AJCM Spring 2011

American Journal of Clinical MedicineÂŽ Owned and Published by the American Association of Physician Specialists, Inc. Peer Reviewed. Listed in Google Scholar and BioMedLib

Spring 2011 • Volume Eight, Number Two

SPecial issue: Emergency Medicine 72 Systems Analysis Comparing Physiologic Endpoints of Standard AHA and Compression-Only CPR 77 Section on Research In Medical Education: Emergency Medicine Fellowships in Tennessee 1992-2011 92 The American Academy of Family Physicians Establishes a Forum for Family Physicians in Emergency Medicine 94 A Rare Case of Pneumocystis Pneumonia 98 Emergency Medicine Workforce Issues: Synopsis and Discussion of Presentation by Dr. Carlos Camargo 106 Headache and Spontaneous Internal Carotid Artery Dissection

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A Critica l of ST Ele Appraisal of the Evo vation luti Myoca (STEMI) rdial Infa on Therap y the Cur rcti rent Tre and the Eviden on atment ce Guideline Behind s 40 Ma lignant and Ben Lesions ign Eye in San Francisco lid Study of : a Divers e Urban Popula tion 47 Inv asive Squ of the Cer amous Cel l Carcin oma HPV Imm vix Following unizat Ninete en-Yea ion in a r-Old Wo man 49 Imp act of a Multi-M on Phy oda sici lity Inte in Manag an Knowledge rve and Pra ntion ing He patitis ctice C

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Medical Ethics: Who’s On First?

Mark Pastin, PhD

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Danny Greig, MD, FAAFP Anthony Gerard, MD, FACEP Kim Bullock, MD

In This Issue Systems Analysis Comparing Physiologic Endpoints of Standard AHA and Compression-Only CPR

94 72

James C. Kolb, MD Thomas G. Coleman, PhD Richard L. Summers, MD

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Amy J. Keenum, PharmD, DO Geetha Reddy, MD Luke Rawlings, MD, MPH Jocelyn Wilson, MPH Lorraine Wallace, PhD

Case Report: Headache and Spontaneous Internal Carotid Artery Dissection Liying Chen, MD, PhD Jean-Robert Desrouleaux, MD

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Thomas M. Carr, Jr., MD, FACP, FACEP

Emergency Medicine Fellowship Trained Family Physicians: Outcomes 2000-2008

Sounding Board: A Tsunami and a Meltdown Closer to Home David Lemonick, MD

Gregg Mitchell, MD

Starting an Emergency Medicine Fellowship Program: The First Two Years

Sounding Board: Emergency Medicine Workforce Issues: Synopsis and Discussion of Presentation

by Dr. Carlos Camargo Ellyn Meshel, MD, FAEP Kenneth M. Flowe, MD, FAAEP, MBA

Loren Crown, MD, FACEP

Emergency Medicine Fellowship Strengthens Family Medicine Training Programs

Case Report: A Rare Case of Pneumocystis Pneumonia Swati Sharma, MD Reginald Wills, MD

Research In Medical Education One-Year Fellowships Leading to Board Certification in Emergency Medicine

Sounding Board: The American Academy of Family Physicians Establishes a Forum for Family Physicians in Emergency Medicine

Performance-Based Learning & Competency-Based Testing: Rural Family and Emergency Medicine: Hand Fractures Case #1 Jeremy Draper, MD Justin Arnold, MD

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Case Report: Mild Traumatic Brain Injury in High School Athlete – Novel Method of Evaluating Clinical Progress James G. Laurenzano, MD

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elcome to the American Journal of Clinical Medicine® (AJCM®). This issue is focused on Emergency Medicine. The Journal is dedicated to improving the practice of clinical medicine by providing up-to-date information for today’s practitioners.

The AJCM is the official journal of the American Association of Physician Specialists, Inc. (AAPS), an organization dedicated to promoting the highest intellectual, moral, and ethical standards of its members, and whose diversity incorporates physicians that represent a broad spectrum of specialties including anesthesiology, dermatology, diagnostic radiology, disaster medicine, emergency medicine, family medicine obstetrics, family practice, geriatric medicine, hospital medicine, internal medicine, obstetrics and gynecology, ophthalmology, orthopedic surgery, plastic and reconstructive surgery, psychiatry, radiation oncology, general surgery, and urgent care medicine.

Part of the mission of the AAPS is to provide education for its members and to promote study, research, and improvement of its various specialties. In order to further these goals, the AJCM invites submissions of high-quality review articles, clinical reports, case reports, or original research on any topic that has potential to impact the daily practice of medicine. Publication of a peer-reviewed article in the AJCM is one of the criteria needed to qualify for the prestigious Degree of Fellow in the Academies of Medicine of the AAPS. Articles that appear in the AJCM are peer reviewed by members with expertise in their respective specialties. Manuscripts submitted for publication should follow the guidelines in The International Committee of Medical Journal Editors: “Uniform requirements for manuscripts submitted to biomedical journals” (JAMA, 1997; 277:927-934). Studies involving human subjects must adhere to the ethical principals of the Declaration of Helsinki, developed by the World Medical Association. By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of their article that might create any potential conflict of interest.

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American Journal of Clinical Medicine® • Spring 2011 • Volume Eight, Number TWO

Systems Analysis Comparing Physiologic Endpoints of Standard AHA and Compression-Only CPR James C. Kolb, MD Thomas G. Coleman, PhD Richard L. Summers, MD

Keywords CPR, compression-only, emergency, resuscitation.

Abstract Background Several recent studies suggest that compression only CPR (CCPR) has similar or superior outcomes to the standard AHA guidelines CPR (S-CPR). However, it has been difficult to rigorously study the key metabolic and hemodynamic endpoints in the acute clinical environment. A systems analysis approach employing a mathematical model of human physiology (Guyton/Coleman/Summers model) was used to compare the expected physiologic perturbations of S-CPR and C-CPR strategies.

Methods The computer model contains over 5,000 variables of biologic interactions and encompasses a variety of physiologic processes of interest during the performance of CPR. The model is constructed on a foundation of basic physical principles and mass balances in an integrated scheme connected through algebraic loops and differential equations to create a global homeostatic system. A series of computer simulations recreated the protocols of S-CPR and C-CPR (100 compressions/minute). Critical physiologic endpoints predicted by the model for each of the strategies were compared during the performance of the initial four minutes of simulated high quality CPR.

Results The S-CPR protocol resulted in a 34% lower average systemic blood flow as compared to a C-CPR strategy. The C-CPR produced a small increase in the blood and tissue acid load with a 10% higher serum lactate concentration and 3% lower ventricular tissue pH by comparison. However, the model also predicted that performing S-CPR could result in slightly better blood and tissue oxygen content (4% and 15% respectively).

Conclusions There has been some debate concerning the operational strategy that should be used to optimize the patient’s physiologic condition and potential for a favorable outcome during the performance of CPR. A theoretical systems analysis of the problem using a computer model of human physiology suggests that S-CPR provides slightly better oxygenation but at the cost of increasing the tissue acid burden as compared to C-CPR.

Introduction Traditional cardiopulmonary resuscitation (CPR) methods with a combination of chest compressions and mouth-to-mouth ventilation as outlined by AHA guidelines (S-CPR) have been taught for decades as the unquestioned standard for patients with cardiac arrest.1,2,3 This technique is familiar to many healthcare workers and has demonstrated some improvement in outcomes.3,4 Recently, there has been a call for the adoption of a new standard for cardiopulmonary resuscitation with chest compressions only (C-CPR), also known as cardiocere-

Systems Analysis Comparing Physiologic Endpoints. . .

American Journal of Clinical Medicine® • Spring 2011 • Volume Eight, Number Two

bral resuscitation (CCR), with the goal of increasing the rate of bystander-initiated resuscitation efforts through the use of a simpler technique.5,6,7 The idea remains controversial with some conflicting results reported in the literature when the two techniques are compared head-to-head.7,8 However, most studies seem to suggest that there are little differences in clinical outcomes regardless of which technique is used.9 The basis of the controversy centers on the definition of outcomes and the timing and operator-dependent factors surrounding the initiation of resuscitation efforts by bystanders.10 Regardless of the logistical considerations, what is still unclear is the explicit impact of the two separate techniques on the physiology of oxygen delivery and utilization and the potential resulting biochemical derangements that might prevent the spontaneous return of circulation and lead to an irreversible state. The difficulties in measuring these factors at the organ and cellular level in humans during a clinical setting of cardiac arrest has significantly limited our evaluation of the physiologic differences in the techniques. Computer models and simulation procedures have been proposed as a possible methodology to gain insight into clinical questions of this nature.11,12 The goal of the current study is to compare the outcomes of the two resuscitation techniques (S-CPR vs C-CPR) with regard to specific critical physiologic endpoints predicted for a virtual patient that has been integrated with a detailed computer model of human physiology.

Methods A systems analysis approach employing a virtual patient integrated with a mathematical model of human physiology (Guyton/Coleman/Summers model) was used to predict the expected physiologic perturbations of the S-CPR and C-CPR strategies.13,14,15 The model contains over 5,000 variables of biologic interactions and encompasses a variety of physiologic processes of interest to researchers and clinicians concerned with resuscitation issues. The model is constructed on a foundation of basic physical principles in a mathematical scheme of interconnections with a hierarchy of control that forms the overall model structure. Physiologic relationships derived from the evidencebased literature interconnect the body’s physiologic systems and body organs through feedback and feedforward loops in the form of algebraic and differential equations to create a global homeostatic system. Through simulation studies, the investigators interact with the model using a computational interface that allows for the replication of the conditions of cardiac arrest and CPR interventions (chest compressions and ventilations) and a prediction of critical physiologic variables.

Model Validation Model validation has been generally defined as the confirmation that a computer model possesses a satisfactory range of accuracy within its domain of applicability and is consistent with the intended use.16 This emphasis on accuracy in the context of the clinical state of cardiac arrest and hemodynamic shock is

our approach to validation of the computational platform used in this study. Most important in this process is the comparison of physiologic endpoints that typify and define the clinical state to those predicted by the model. This model has previously undergone extensive validation of global hemodynamic and physiologic variables (of MAP, CO, SvO2, etc) that are generally relevant to the pathologic state under study.13,14 The overall dynamic performance of the model will be quantified by determination of the median performance error (MDPE = median {PE} over all data points as the percent of measured where PE= difference between measured and predicted values).

MDPE has been considered as the measure of the bias and inaccuracy between the model’s predictions and the corresponding experimental observations.17,18

In Silico Investigational Protocol The investigational procedure using the computational platform and computer model involves recreating the experiment for a virtual subject in an In Silico environment.13 This In Silico experiment is intended to simulate the common clinical context of bystanders or first responders performing CPR on a patient that has experienced an out-of-hospital cardiopulmonary arrest.

This process requires a re-enactment of the pathologic event, which included the simulation of an abrupt cardiopulmonary arrest. The virtual subject used in the procedure is considered to be a normal 70 kilogram male with no previous pathology.

The processes of high quality S-CPR and C-CPR were also simulated through the functionality of the model software interface for a period of four minutes. The simulation assumptions and their references origins are listed below.

Simulation Assumptions • 70 kilogram man with spontaneous rhythm cardiac arrest • Compression Rate of 100 compressions/minute19 • Compression Force of 350 newtons20,21 • S-CPR ventilated tidal volume is 500 ml2,22 • S-CPR ventilation rate is 30:2 compressions/ ventilations2 • C-CPR chest tidal volume is 50 ml/compression23,24 In this simulation experiment, the model predicted sequential changes in the prespecified variables, which were recorded during both CPR strategies for the same four-minute time points.

These model-determined endpoints were compared as percentage differences. The blood and body tissue oxygen content, serum lactate levels, and ventricular myocardial tissue pHs were evaluated at the four-minute terminal point of the CPR process as an indicator of the relative effectiveness of the strategies to provide the needed oxygen delivery and support tissue metabolism. The cardiac output values averaged over the entire four minutes of the simulation were used as a comparative measure of the hemodynamic effectiveness.

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Figure 1: Comparison of the model predicted average cardiac output values generated over four minutes of the two simulated CPR strategies (Standard CPR vs Compression-Only CPR). The Standard CPR strategy produced a 34% lower average cardiac output.

Figure 2: Comparison of the model predicted left ventricle myocardial tissue pH and blood lactate levels at the end of four minutes of the two simulated CPR strategies (Standard CPR vs Compression-Only CPR). This represents only a 3% lower tissue pH and 10% higher blood lactate level for the Compression-Only strategy by comparison.

Results The application of the S-CPR protocol to the virtual cardiac arrest patient resulted in a 34% lower average systemic blood flow (cardiac output) as compared to a C-CPR strategy in the same patient (Figure 1). The C-CPR strategy produced a small increase in the blood and tissue acid load with a 10% higher serum lactate concentration and a 3% lower left ventricular myocardial tissue pH in contrast to S-CPR (Figure 2). However,

the model also predicted that performing S-CPR could result in a slightly better blood oxygen saturation (4%) and a mild increase in the overall body tissue oxygen content (15%) as compared to the C-CPR strategy (Figure 3).

Conclusions For many years, the initiation of CPR by bystanders has been shown to have a significant impact on the outcomes of victims

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American Journal of Clinical MedicineŽ • Spring 2011 • Volume Eight, Number Two

Figure 3: Comparison of the model predicted arterial oxygen saturation and pO2, brain tissue pO2, and the mixed venous pCO2 at the end of 4 minutes of the two simulated CPR strategies (Standard CPR vs Compression-Only CPR). This suggests that there is only a small oxygenation advantage for the Standard CPR strategy over the Compression-Only strategy for the short period of the CPR.

of cardiac arrest.1,3,4 However, despite dedicated public initiatives intended to educate the lay population in the techniques, CPR is performed in only about one-third of witnessed out-ofhospital arrests.3,9,10,25 Simplifying the protocol of CPR to include a compressions-only methodology could potentially lower barriers to bystander initiation.25 A move to shift management standards would be even more compelling if there was clear evidence of superior or equivalent outcomes for those patients in which a simpler C-CPR strategy was used. A number of current clinical trials provides evidence to support the use of C-CPR but are confounded by problems of experimental control obviously inherent in such studies.6,7,8 There is also uncertainty with regard to the basic physiologic, hemodynamic, and metabolic advantages of one technique as compared to the other due to the difficulty in experimentally exploring these factors with standard clinical trials. In the current study, we employed the modern methodology of simulations studies using computer models of human physiology to provide some insight into the differentiation of these techniques from the basic physiologic perspective.

The results from this simulation study suggest that despite the very limited ventilation occurring during C-CPR, there is only a comparatively small oxygenation and metabolic advantage obtained through use of the customary S-CPR strategy. The level of oxygenation and metabolic derangement are commonly considered consequential in determining the chances for a spontaneous return of circulation and end-organ damage.26 Therefore, this finding of the simulation study is consistent with the majority of clinical trials suggesting outcomes equivalent for the two techniques and provides support for those advocating a shift in CPR standards to the simpler technique. Systems analyses using the model can be used to help understand the seem-

ing paradox that the ventilations of S-CPR are not required to produce oxygenation similar to that found with compressions alone. Such an analysis reveals several key factors responsible for the results. The additional few compressions performed during C-CPR produce a third greater average blood flow. This technique also results in an uninterrupted continuity in oxygen delivery to vital organs. While the ventilation volumes found to be produced by chest compressions are less than dead space volumes and have limited value to provide oxygen, the blood present in the circulation at the time of cardiac arrest contains a reservoir of oxygen available for delivery over the short time period of the CPR. The simulation suggests that this blood oxygen reservoir may be important, since the tissue oxygenation is very similar for the two strategies. There is some experimental evidence in the literature to suggest that diffusion of oxygen from the dead spaces into the alveoli may find its way into the blood stream of even apneic patients, if there is a moving circulation.27 Blood also provides a great source of buffers against the acidosis (hemoglobin, bicarbonate), and the continuous movement and greater average flow around the cardiovascular circuit of the C-CPR strategy also removes greater quantities of CO2 from the body through the lungs. Evidence of this phenomenon can be seen within the simulation results with nearly identical mixed pCO2 levels for the two strategies despite a somewhat higher blood and tissue acidosis with C-CPR. There are several limitations to this study that should be noted.

While the simulations incorporate the dynamics of a very complex and detailed model of human physiology, it is impossible to be sure that all the critical elements in play during CPR are represented correctly. However, the model has been shown to provide outputs as compared to human experimental studies of

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hemodynamic shock. This suggests that the results should be at least directionally and semiquantitatively accurate for the study of cardiac arrest. The model also does not consider the practical logistical differences between the two differing strategies and assumes optimal high quality CPR. In actuality, delivery of nonstop compressions without fatiguing is quite difficult and could limit the effectiveness of that strategy. Likewise, a directive to provide ventilations could limit bystander engagement in the CPR process. The model also cannot predict the impact of the physiologic derangements on clinical outcomes. Those factors are beyond the intent of the current study and should be studied in clinical trials.

The initiation of bystander CPR is the vital initial link in the chain of survival in advanced cardiac life support (ACLS).

Therefore, it is important that the best strategy is adopted to optimize patient outcomes. A determination of the superior strategy requires a concerted effort to study all the clinical and physiologic factors involved.

James C. Kolb, MD, is Professor of Emergency Medicine, University of Mississippi Medical Center.

Thomas G. Coleman, PhD, is Professor of Physiology and Biophysics, University of Mississippi Medical Center.

Richard L. Summers, MD, is Professor of Emergency Medicine, University of Mississippi Medical Center.

Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. ®

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19. Hallstrom A, Cobb L, Johnson E, Copass M. Cardiopulmonary resuscitation by chest compression alone or with mouth-to-mouth ventilation. N Engl J Med. 2000;342:1546-53.

20. Geddes LA, Boland MK, Pervin R. Taleyarkhan PR, Vitter J. Chest Compression Force of Trained and Untrained CPR Rescuers. Cardiovasc Eng. 2007;7:47–50.

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22. Stallinger A, Wenzel V, Oroszy S, et al. The effects of different mouth-tomouth ventilation tidal volumes on gas exchange during simulated rescue breathing. Anesth Analg. 2001;93:1265–9.

23. Geddes LA, Rundell A, Otlewski M, Pargett M. How much lung ventilation is obtained with only chest-compression CPR? Cardiovasc Eng. 2008;8:145-8.

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Resuscitation. 2007;75:53-9.

25. Katz MH. Increasing bystander CPR rates: the chest compression-only method puts the goal in easier reach. Arch Intern Med. 2011;171:87-8.

26. Crowell JW, Guyton AC. Cardiac deterioration in shock II. The irreversible stage. Int Anesthesiol Clin. 1964;2:171-84.

27. Ramachandran SK, Cosnowski A, Shanks A, Turner CR. Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration. J Clin Anesth. 2010;22:164-8.

Systems Analysis Comparing Physiologic Endpoints. . .

Research In Medical Education: Emergency Medicine Fellowships in Tennessee 1992-2011 

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One-Year Fellowships Leading to Board Certification in Emergency Medicine Loren Crown, MD, FACEP 

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Emergency Medicine Fellowship Strengthens Family Medicine Training Programs Gregg Mitchell, MD 

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Starting an Emergency Medicine Fellowship Program: The First Two Years Thomas M. Carr, Jr., MD, FACP, FACEP 

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Emergency Medicine Fellowship Trained Family Physicians: Outcomes 2000-2008 Amy J. Keenum, PharmD, DO Geetha Reddy, MD Luke Rawlings, MD, MPH Jocelyn Wilson, MPH Lorraine Wallace, PhD 

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One-Year Fellowships Leading to Board Certification in Emergency Medicine Loren Crown, MD, FACEP

For many years the American Board of Physician Specialists has certified graduate training programs (GTPs) in emergency medicine (EM). While programs self-described as “fellowships in emergency medicine” have appeared sporadically since the late 1980s, only a handful have met the rigorous criteria set forth by the American Board of Physician Specialties (ABPS).

This body has created a standard for training in emergency medicine that, when followed, allows a successful candidate to complete a 12- to 24-month track of supervised exposure to emergency medicine that can lead to board certification (see www.abpsus.org for Board of Certification criteria).

dency programs who must have expertise in emergency care.5,6 Emergency Department coverage at the UT site initially was provided by faculty family physicians. They trained students, residents, and recent graduates hoping to acquire skills for delivering emergency medicine services to underserved areas. The program gradually evolved into the prototype for the post-graduate models based on three years of family medicine residency followed by a year of fellowship.7 Three of these programs are described here, and they are consistent with a recently published call for training by the Society of Teachers of Family Medicine.8

Incorporated into the programs are didactics, board review sessions, and journal clubs as well as mentoring and conferencing.

Postings to designated emergency departments as well as rotations at tertiary sites (especially for trauma and pediatrics) and to specialty and/or elective areas (ICU, anesthesia, toxicology, orthopedics) are all potentially available as needed at the particular GTP sites.

It is important to note that these fellowship programs paid for themselves. There was no extra government money involved in producing these educational programs. Literally they paid for themselves. In addition to the negative financial impact of the limited generalist, the model is inadequate for developing countries where needs are similar to rural USA.9

In 2000 a University of Tennessee-Memphis (UTM) site was approved as the first AAPS-certified GTP. The location had been established by faculty as a rural training experience for family physicians with a specific goal of improved skills in maternity care and emergency medicine.1 In response to the declining accountability in US graduate medical education, it was clear that rural and underserved communities would require a different approach.2 Academic center-trained primary care physicians have been gradually abandoning hospital care in favor of lifestyle offices with no night call. Academic medical centers continue to promote this model of limited generalism.3,4 Rural areas suffered due to the demise of aging doctors and from the lack of re-supply by recent graduates. As a result, much of the country relies upon graduates of non-EM resi-

Currently, there are three sites in Tennessee offering such programs: UT-Knoxville, UT-Jackson, and Methodist-North Hospital (http://gsm.utmck.edu/family medicine/emergencymed. cfm, http://www.utmem.edu/UTFamJac/erfellowship.php, www.emfellowship.com). Others exist in California, Texas, and Ohio. Due to enormous lobbying and political pressure by ABEM and ACEP, two of the earlier sites have eliminated the family medicine fellowships and started emergency medicine residencies (Duke and John Peter Smith in Fort Worth).

The high standards of the three current programs are monitored by a review panel that inspects each site prior to designation as a GTP training site. Furthermore, the sites are reviewed on a periodic basis. More importantly, graduates of these programs are accepting committee appointments and serving in positions of academy and board leadership.

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The establishment and maintenance of these programs provide evidence supporting these fellowships as an idea whose time has come.10-12 Given the massive opposition of the current ACGME system, which is invested in maintaining its training cartel, our continued growth is gratifying. The support of the ABPS and BCEM is appreciated. We look forward to training many more graduates as well as approving additional programs in the future. Please check our website in order to obtain information on becoming designated as a GTP in emergency medicine (www.abspus.org for program certification).

Loren Crown, MD, FACEP, is Clinical Professor, University of Tennessee Center for Health Sciences, Memphis.

Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist.

3.

Bullock K. Turf Wars: Emergency Medicine and Family Physicians. Am Fam Physician. 1996 Sept 15;54(4).

4.

Rodney WM, Hahn RG. The impact of the limited generalist (no OB, no procedures, no hospital) model on primary care training and practice. J Am Board Fam Pract. 2002; May-June 15:191-200.

5.

Bullock K, Rodney WM, Gerard T, Hahn R. “Advanced Practice” family physicians as the foundation for rural emergency medicine services (Part II). Texas J Rur Health. 2000:18(2):34-44.

6.

Hall W, et al. Colorado family practice graduates’ preparation for and practice of emergency medicine. J Am Bd Fam Med. Jul/Aug 2000;13(4).

7.

Lee JD, Welsh MJ. Family Medicine/emergency medicine fellowship. Am Fam Phys. 1997;56:383.

8.

Nothnagle M, Sicilia JM, Forman S, Fish J, Ellert W, et al. Required Procedural Training in Family medicine Residency: A Consensus Statement. Fam Med. 2008;40:248-252.

9.

Pust R, Dahlman B. Khwa-Otsyula B, Armstrong J, Downing R. Partnerships creating postgraduate family medicine in Kenya. Fam Med. 2006:38:661-6.

®

References 1.

Rodney WM, Hahn RG, Crown LA, Martin J. Enhancing the family medicine curriculum in maternity care (OB) and emergency medicine to establish a rural teaching practice. Fam Med Dec. 1998; 30:712-719.

2.

Rodney WM, Bullock K. “Emergency Medicine-Introduction” in Rakel RE (editor). Textbook of Family Practice--6th Edition, WB Saunders, Philadelphia, 2002, pp 788-790.

10. Critical Challenges for Family Medicine: Delivering Emergency Medical Care-Equipping Family Physicians for the 21st Century. 2006. http://www. aafp.org/online/en/home/policy/policies/e/emposition.html.

11. Bullock K, Rodney WM, Gerard T, Hahn R. “Advanced Practice” family physicians as the foundation for rural emergency medicine services (Part I). Texas J Rur Health. 2000:17(1):19-29.

12. Taylor AS. Emergency medicine educational objectives for the undifferentiated physician. J.Emerg Med. 1994:12-255.

ABPS Becomes Corporate Partner with NRHA

“We’re pleased to announce the American Board of Physician Specialties® has become a corporate partner with the National Rural Health Association (NRHA),” said CEO William J. Carbone. ABPS’ involvement with NRHA provides a valuable resource to help us proactively identify needs and trends within the rural health care market. “Focusing on the needs of local communities, including those in rural America, helps ABPS and its member Diplomates remain committed to placing patients first.”

The NRHA is a national nonprofit organization with 20,000 members, providing leadership on rural health issues.

“NRHA welcomes ABPS and their desire to provide world-class board certification expertise to physicians and hospitals,” says Brock Slabach, NRHA senior vice-president of member services.

A complete list of NRHA partners is available at http://www.nrhasc.com/connect.

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Emergency Medicine Fellowship Strengthens Family Medicine Training Programs Gregg Mitchell, MD

Family Medicine residency training was established in 1975 as the rural residency program in the state of Tennessee. One purpose was to provide physicians who settled away from the major metropolitan centers. At that time family physicians were commonly assumed to be able to provide hospital and emergency care. State funding was provided with the assumption that private family practice offices would, in conjunction with hospital privileges, provide emergency care. But gradually family medicine changed, and ownership of emergency care frequently was done by contract to the hospital.

Every year upon graduation from the program, at least one resident has chosen to work full time in emergency medicine.

Several residents desired further training and credentialing in emergency medicine to improve their skills and become more competitive in the job market. Jackson Family Medicine residents helped start the credentialing process for the AAPS and finished the process in 2005. Since then our program has benefited in several areas to include our emergency medicine curriculum, recruiting, and increasing faculty workforce.

The Jackson Family Medicine emergency medicine curriculum has undergone many changes since the ACGME duty hour guidelines. We previously had a resident in the emergency room 24 hours/seven days a week working with our emergency medicine physicians. We revised their schedule to complete the required 200 hours but also have our PGY2 residents take calls in our emergency room every night and on weekends. Despite our current resident experience, we have residents who desire further experience and training in managing critically ill patients and improving procedural skills.

Jackson FM-emergency medicine fellows have increased the total number of procedures performed in our emergency room.

We no longer defer to radiology and other specialists for these

skills. The most common procedures for our fellows to perform are intubation, central line insertion, chest tube placement, and lumbar puncture. The residency program has also benefited due to increasing the number of procedures for our residents as well. The fellows perform such a high volume of procedures that, usually after six months of training, they can begin supervising the residents to perform procedures.

Since the inception of the emergency medicine fellowship, Jackson FM has successfully matched eight residents through the NRMP match without having to scramble. This is a change for the better from the era 1999-2005. Jackson has increased the number of applicants and interviews by more than 50% since 2005. Each year we have a significant number of applicants from other medical schools whose primary interest in our program is the emergency medicine fellowship.

Since 2008, Jackson FM plans its match with the intent to specifically choose one to two students each year on the basis of their plan to enter the emergency medicine fellowship. Two Jackson residents will be staying for the emergency medicine fellowship this academic year.

The Jackson FM emergency medicine fellowship curriculum includes two days a month of supervising residents at our family medicine program. These two days have several advantages to the fellows and the residents. First, the fellows are given an opportunity to teach and utilize their outpatient family medicine skills. Second, the fellows are able to follow patients they have seen in the emergency room and schedule their appointments in our clinic on days where they are supervising. Third, the fellows are able to work directly with the family medicine residents and improve their working relationships. The result is an improved relationship in the emergency room and more accessibility for residents to perform procedures. Jackson family

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medicine residents have performed more central line insertions, chest tube insertions, and lumbar punctures since the fellowship started. This is widely perceived as an improvement in the quality of the educational program.

Overall, the emergency medicine fellowship has enhanced the Jackson family medicine residency to become a much stronger and more competitive program. Residents have watched the emergency fellows gain career opportunities that were previously not available. One recent graduate applied for a position at a facility which only allowed ABEM-certified physicians to practice in their emergency department. Due to the quality of his procedure log and experience, the hospital system changed its bylaws to enable family medicine physicians to practice in the emergency department.

The American Board of Physician Specialties certification in emergency medicine has enhanced a family physician’s ability to provide emergency medicine services for patients. Further, it has improved the status and desirability of the family medicine residency program.

Gregg Mitchell, MD, is Associate Professor/Program Director and Fellowship Director for the University of Tennessee Family Medicine, Jackson.

Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. ®

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Starting an Emergency Medicine Fellowship Program: The First Two Years Thomas M. Carr, Jr., MD, FACP, FACEP

Getting Started In 2009 several members of the medical staff of the Emergency Departments (ED) of the adult hospitals in the Methodist Le Bonheur Healthcare System in Memphis, Tennessee, started a non-residency Emergency Medicine (EM) training program to be housed at Methodist Hospital North (MHN) in Memphis.

The rationale for starting a program was the need for EM-trained physicians in the area. Investigating a relationship with AAPS was the logical choice since two of our Emergency Department staff physicians, both of whom are graduates of an AAPS program, staff the ED at MHN. Their levels of competence in performing technical procedures, as well as their abilities to manage critically ill patients and the day-to-day traffic in the ED, reflected well on the AAPS. The group approached the AAPS about how to begin the application process to set up at an EM training program. The actual application process began in January 2008.

As part of compiling the application, ED staff physicians were inventoried about what features of our practice would be key assets of the MHN-based program. After consultation with MHN administrators, the group identified the following as points of strength: • diverse patient population surrounding MHN • large urban location closely surrounded by outlying rural areas dependent on the hospital’s emergency department as its primary healthcare center • large annual patient volume • well-staffed ED area containing a triage area, a designed Fast Track area, a clinical observation unit, and a Joint Commission-certified chest pain center

• Emergency Department (ED) staff made up of 18 board-certified physicians and 20 board-certified Allied Health Practitioners (AHPs) • 24/7/365 double coverage by ED physicians • 24/7/365 hospital-based radiology, anesthesiology, and hospitalist coverage • 24/7/365 sub-specialty coverage and referral • electronic medical record system (EMR) • Right Care Right Place, a program developed to assess and move non-urgent patients to the appropriate care setting • specialized ED equipment, such as diagnostic ultrasound and state-of-the-art intubation equipment • availability of a large number of Level 4 and 5 patients requiring specialized procedures, such as central line placement, lumbar punctures, moderate and deep sedation, intubation, and bedside ultrasound • use of CMS protocols for pneumonia, sepsis, stroke, acute myocardial infarction, and • congestive heart failure • innovative ED programs to reduce length of stay Equally important to the program was the availability of the LeBonheur Children’s Hospital as a resource facility for a pediatric ED rotation and the Elvis Presley Memorial Trauma Center as a resource facility for a trauma rotation.

A physician with experience in teaching residents and fellows was brought on board to incorporate didactics, board review sessions, and journal review, as well as mentoring and conferencing. This physician would also serve as a sounding board for fellow concerns and problems.

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Two categories of candidates for the program were identified: 1) board-certified or board-eligible physicians that had completed a residency in Family Medicine, Internal Medicine, or Surgery and who desired further exposure to and training in EM and 2) board-certified physicians that had been in practice for a period of time and wanted to increase their EM skill levels or wanted to transition to EM. The program was set up to provide these physicians with a 12- to 24-month learning experience treating patients in an appropriate and timely manner, as well as learning the technical and procedural aspects of EM practice. By achieving the above, the physicians coming out of the program would be attractive recruits to ED groups.

Funding for the program was supplied by the Emergency Department physician group which staffs the ED at MHN.

The Survey The application for the training program required that a rigorous set of criteria be met in order to be considered by AAPS. The application was completed in spring 2008 and returned to AAPS. After a timely review of the application, AAPS notified the MHN-based program of an upcoming site survey. The survey team consisted of three members, all with EM experience, who conducted a day-long site visit and review of the MHN facility, as well as site visits to the pediatric and trauma hospitals – a site survey visit similar to a residency review committee visit.

Approximately six weeks later, AAPS notified the program in writing of its approval.

Choosing the Candidates Upon AAPS approval the MHN EM training program began advertising at an online site. Interested candidates applied by mail, online, or in person, and applications were reviewed by the Program Director, the Program Coordinator, and a staff ED physician. Candidates that fit the MHN program profile were invited for onsite interviews with the Program Director, Program Coordinator, and at least one staff ED physician. Candidates were also invited to a lunch or dinner with the Program Director and the current fellows. The first fellow began the program on April 1, 2009, and completed the program March 31, 2010. Fellow candidates are accepted every quarter (January, April, July, and October), which allows for a smooth transition into the training program and an optimal learning experience for all fellows.

Training the Candidates Each fellow starts with an orientation that includes training in EMR. During the first months of the fellowship, the fellow is scheduled as the third physician in the ED, typically with double MD staffing coverage. After 60 to 90 days, the fellow is evaluated on his/her technical skill level, ability to properly diagnose and manage patient care, and patient interaction. After being evaluated, the fellow may remain as the third physician for an additional period of time or, if deemed to have achieved competency and the appropriate skill set, may be moved to a

supporting role to the lead physician, enabling the fellow to hone his/her decision-making and procedural skills along with assuming a leadership role on the ED team. A staff ED physician is always available to the fellow for help and support in managing patients.

During the fellowship, the fellow maintains a log of all procedures performed. Feedback to fellows is provided by the ED staff physician at the end of the shift, and additional feedback is provided based on the results of oral and written evaluations performed regularly throughout the program.

Fellows are expected to staff the ED 12-13 shifts per month with shifts varying between day and evening shifts. The fellow is a part of an ED team consisting of double or triple physician coverage per 12-hour shift as well as Fast Track coverage by two AHPs from 9 am to 11 pm seven days a week.

Realizing the Benefits As of fall 2009 the MHN EM training program gained an affiliation with the University of Tennessee (UT) Department of Family Medicine. Starting soon fellows will spend at least one day a month in an outpatient clinic setting overseeing residents and will also present EM topics at UT Family Medicine conferences.

Through the fellowship program, MHN has added skilled physicians to the hospital staff. The current fellows, all from different areas of the country, have brought their own perspectives of medical practice. These new perspectives and ideas make the MHN program stronger and more innovative. After completion of the program, each fellow will use his/her expertise in an EM setting, helping to meet the nationwide need for EM-trained physicians.

The high level of engagement by the staff physicians with the fellows has sparked staff physicians to remain current on journal readings and keep their procedural competencies well honed.

In Conclusion The first two years of the MHN fellowship program have been a success. The program currently has four fellows with two more fellows accepted to begin in the next several months.

The MHN EM fellowship program continues to seek out highquality motivated candidates for its fellowship program while working to expand its clinical offerings and to meet the high standards placed upon it as an AAPS program.

Thomas M. Carr, Jr., MD, FACP, FACEP, is Program Director, Emergency Medicine Fellowship Program, Methodist Hospital North, Memphis.

Reprints can be obtained from tcarr@bellsouth.net.

Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. ®

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Emergency Medicine Fellowship Trained Family Physicians: Outcomes 2000-2008 Amy J. Keenum, PharmD, DO Geetha Reddy, MD Luke Rawlings, MD, MPH Jocelyn Wilson, MPH Lorraine Wallace, PhD

Keywords Emergency Medicine Fellowship; Rural Emergency Physician work force; Continuing Medical Education: Family medicine physician distribution.

Abstract Context Few emergency medicine residency trained physicians practice in rural areas upon graduation. Family physicians are known to practice in rural locations at a higher rate. The distribution of emergency medicine fellowship trained family physicians from 2000-2008 of one program was examined. The continuing medical education (CME) pursued by these individuals is presently unknown and was explored.

Methods All graduates (n=25) of a one-year clinical emergency medicine fellowship at the University of Tennessee Graduate School of Medicine – Knoxville (UTMCK) were surveyed regarding work location and their CME interests. Determination of the location of current service and the percentage of graduates working in rural areas was compared to present data for emergency medicine residency program graduates. Rurality was estimated by population of county < 10,000, one hospital/county, use of Rural Urban Commuting Area (RUCA) codes over four, and Human Resource and Services Administration (HRSA) designated physician shortage areas.

Findings The response rate was 68%. Four out of 14 respondents (29%) working in emergency medicine worked in rural areas as compared to emergency medicine residency trained physicians who distribute rurally at an estimated rate below 8%. Most of the fellowship graduates working in emergency medicine (11 of 14 [79%]) worked in counties designated by HRSA as physician shortage areas.

Conclusions Our program demonstrated higher rural and underserved distribution rates than is reported in the literature for emergency medicine residency trained physicians. General emergency topics, advanced airway training, and ultrasound training were listed as topics of CME interest for this group.

Introduction There is a shortage of physicians in rural America.1 Emergency physicians are no exception.2,3,4 Emergency medicine residency programs are primarily urban and graduates of emergency medicine residencies generally fail to geographically distribute to rural areas.2,3,4,5,6 Some academic emergency medicine physicians propose rural rotations or rural emergency medicine residency to encourage rural emergency practice.7 Data from these propositions are not yet available to determine if graduates from these programs will distribute to rural areas. Some emergency physicians maintain that the standard way to train emergency medicine physicians is in an emergency medicine residency.8

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Federal funding for a boarded family physician to retrain in an emergency medicine residency is currently unavailable 9,10 This may limit the opportunity for a physician who has completed a family medicine residency from obtaining an emergency medicine residency position. Family medicine physicians are the most likely specialty to distribute to rural America.11,12,13,14,15 A new proposed solution is to graduate physicians from a combined five-year emergency medicine and family medicine residency program.16 As there are not yet any graduates from a combined program, evidence of rural practice is not available.

by Drs. Keenum and Rawlings and was based on a literature search, especially the 2004 West Virginia Workforce Study, and from questions site visitors from the ABPS stimulated during their accreditation site visit. No repeat mailings were sent. A copy of the survey is appendix A.

In 2000, a clinical one-year emergency medicine fellowship was initiated at the University of Tennessee Graduate School of Medicine-Knoxville (UTMCK).17 The training was available to graduates of an accredited three-year family medicine residency by either the American College of Graduate Medical Education (ACGME) or American Osteopathic Association (AOA).18,19 The program was accredited by the American Board of Physician Specialists (ABPS) and provided a pathway to certification in emergency medicine by that board.20 The program was modeled after the Canadian certification of special competency in emergency medicine for family physicians.21 The Knoxville program provided nine months of training in a high-volume level one trauma center emergency department, one month in a high-volume pediatric emergency department, and one-month rotations each in trauma surgery and medical intensive care at UTMCK. Fellows were trained in a location without an emergency medicine residency. Weekly didactic sessions took place reviewing the medical literature related to emergency medicine. Clinical and procedural skills were discussed through faculty, fellow, and resident presentations.

Results

The emergency medicine fellowship was an attempt to develop physicians for rural emergency medical practice. Specifically, the fellowship provided advanced emergency care training following family medicine residency. On admission to the program there were no controls for age, place of birth, or other factors known to influence rural distribution of physicians.22 This paper reflects a subset of eight years of graduates of family medicine physicians after completing an additional year of training in emergency and high acuity care. The purpose of this study was to evaluate the success of the program in locating trained physicians in emergency departments in rural America and to assess their perceived CMS interests.

Methods All those who completed the emergency medicine fellowship between the years of 2000 and 2008 were included in this study.

A one-page survey was mailed to the last known address of all physician graduates of the emergency medicine fellowship.

(Sample of survey included in Appendix A.) Investigation review board approval was obtained. As many doctors work in more than one emergency department, we asked the respondent to reply regarding the department where the graduate worked most of the time. A one-dollar bill was attached in an effort to entice the completion of the survey. The survey was developed

We determined rurality by population of county < 10,000, one hospital per county, use of Rural Urban Commuting Area (RUCA) codes over four, and Human Resource and Services Administration (HRSA) designated physician shortage areas.12,23,24

There were 25 graduates of the program between 2000 and 2008.

There were 17 responses (68%). Fourteen of 17 (82%) respondents declared that they worked 80% or greater in emergency medicine. One respondent stated that his/her time was split 50/50 between emergency medicine and urgent care. Two physicians replied that they worked 20% or less of their time in emergency medicine, spending greater than 80% of their time in family medicine. Only those 14 doctors who listed 80% or greater emergency medicine work were included in further evaluation.

Five of fourteen (36%) of the doctors who worked mostly in Emergency Medicine worked in counties with only one hospital. An estimated four out of 14 respondents (29 %) work in rural areas as compared to emergency medicine residency trained physicians who distribute rurally at a estimated 8% percent.25 Most of the respondents 11 of 14 (79%) listed work location zip codes in HRSA-designated physician shortage areas.24 The locations of practice showed a wide geographic dispersal of graduates (see Figure 1).

Two of fourteen (14%) physicians are Board Certified in Emergency Medicine (BCEM) through the American Board of Physician Specialists (ABPS). None had taken only the written or oral exams in the pathway toward BCEM certification. A surprising eight of the remaining 12 (75%) graduates did not claim to be BCEM-board eligible, although they are eligible to continue the pathway toward boards after completing the fellowship program. One respondent was enrolled in an American College of Graduate Medical Education (ACGME) Emergency Medicine Residency after the fellowship and was American Board of Emergency Medicine (ABEM) board eligible.

Graduates were asked about the physician training requirement to work in their emergency department. The person in the ACGME residency responded that his location required ABEM boards.

The Canadian graduate worked in a department that accepts the Canadian college of family medicine residency with concentration and testing in emergency medicine (CCFP-EM), and the Canadian Association of Emergency Medicine by the Canadian Royal College Residency Graduate (CAEP) boards. All others (88%) responded that primary care boards plus Advance cardiac life support (ACLS), pediatric advanced life support (PALS) and advanced trauma life support (ATLS) were the minimum training requirement to work in their present department.

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Figure 1: Map of geographic distribution of survey respondents

Graduates were also surveyed with regards to CME pursued since completing the fellowship. General emergency medicine was the most common topic listed followed by advanced airway and ultrasound training.

Discussion Most of the graduates of the emergency medicine fellowship completing our survey worked predominantly in emergency care.

A significant percentage of graduates from this program worked in rural areas (29-35%) dependent on the method of assessment of rural practice. A higher percentage of graduates practiced emergency care in rural areas from this program than the percentage of graduates from emergency medicine residency programs, although the data are difficult to compare. An estimated 8% of emergency medicine residency trained doctors is obtained if large rural (6%) and small rural (2%) areas are added together as provided in the article by Ginde, Sullivan, and Camargo, National Study of Emergency Physician Workforce 2008. This point is repeated in the article: the more rural the care the less likely the physician has emergency medicine residency training,25 Our program is small compared to the many physicians in emergency medicine residency training programs across the United States. The locations of practice show a wide geographic dispersal of graduates.

The American Academy of Family Medicine 2009 position paper (AAFP-PP) on delivering emergency care—Critical Challenges for Family Medicine: Delivering Emergency Medical Care-Equipping Family Physicians for the 21st Century—recommends family medicine physicians working in emergency care should maintain CME in emergency care.26

Our study was limited by several factors. The number of graduates was small and some of their contact information was outdated. An increased percentage of returned surveys may have been possible if the authors had sent repeated mailings or utilization of American Medical Association (AMA) or American Osteopathic Association (AOA) registries for the current address of former graduates. Blinding was attempted but was not truly possible because the first author knew many of the fellows personally and could identify some subjects from handwriting samples and last known location. The entire work history was not requested; some graduates may have worked in a rural area and later moved to an urban area or may have worked in the city and later moved to a rural setting.

Table 1: Emergency Medicine (EM) Fellowships* as Listed at ABPS or AAFP Websites in June 2009.

EM Fellowship Name

Location

Sparks Health System

Ft Smith, AR

Premier Health Care Services

Dayton, OH

University of Tennessee

Jackson, TN

University of Tennessee

Knoxville, TN

University of Tennessee

Memphis, TN

Premier Health Care Services

Huntington, WV

*Following Family Medicine residency training. www.aafp.org/fellowships/other.html www.abpsus.org/certification/emergency/eligibility.html

There are similar programs to the one described here. The University of Tennessee presently sponsors programs in three locations: Knoxville, Jackson, and Memphis. These three programs are accredited by the ABPS and links are provided from the

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ABPS web site. Other programs are listed on AAFP website for fellowships. They are listed in Table 1.

Discussion of this method of physician training would be incomplete without discussing the complexity of funding such a program. The issues are well described and referenced in the AAFP-PP.26 Rodney et al first published this model in 1998.27 The lack of a certificate of added qualification (CAQ) prevents funding this training by indirect medical education (IME) and direct medical education (DME) in the manner most family medicine and emergency medicine residencies are funded.9, 10 Fellowships in geriatrics and sports medicine are funded by IME and DME as they lead to a certificate of added qualification (CAQ).

create any potential conflict of interest. The authors have stated that no such relationships exist.

References 1.

Brooks RG, Walsh M, Mardaon RE, Lewis M, Clawson A. The roles of nature and nurture in the recruitment and retention of primary care physicians in rural areas: a review of the literature. Acad Med. 2002;77:790-789.

2.

Moorhead JC, Asplin BR. Distribution of emergency medicine residency graduates. Ann Emerg Med. 1998;32:509-510.

3.

Handel DA, Hedges JR. Improving Rural Access to Emergency Physicians. Acad Emerg Med. 2007;14(6)562-565.

4.

Williams JM, Ehrlich PF, Prescott JE. Emergency Medical Care in Rural America. Ann Em Med. 2001;38(3)323-327.

5.

Peterson LE, Bazemore A, Dodoo MS, Phillis RL. Family physicians help meet the emergency care needs of rural America. American Family Physician. 2006;March 1 edition.

6.

Peterson LE, Dodoo M, Bennett KJ, Bazemore A, Phillips RI. Nonemergency Medicine-Trained Physician Coverage in Rural Emergency Departments. Workforce Issue. J Rural Health. 2008;24;(2)183-188.

7.

Wadman MC, Muellerman RL, Hal D, Tran TP Walker RA. Qualification discrepancies between urban and rural emergency department physicians.

J Emerg Med. 2005;28:273-276.

8.

Camargo CA, Ginde AA, Singer AH, Espinola JA, Sullivan AF, Pearson JF, Singer AJ. Assessment of Emergency Physician Workforce Needs in the United States, 2005. Acad Emerg Med. 2008;15(12).

In conclusion, we offer a small but tested solution to the problem of emergency physician care in rural America. The data represent a period of time for a pilot study. The problems are well understood, but most proposed solutions are untested. Our program illustrates cooperation between emergency medicine residency trained physicians and family medicine residency trained physicians. Higher rural and underserved distribution rates are achieved with the Emergency Medicine Fellowship than are reported in the literature for emergency medicine residency trained physicians. Many of the graduates provide rural emergency care or care in underserved areas after completion of one year of additional training following family medicine residency.

9.

Tuohy E. GME Funding and Specialty Choice, Part I. JAMA. 1999;282(23)2268.

Amy J. Keenum, PharmD, DO, is Associate Professor, Family Medicine, and Emergency Medicine Fellowship Director, University of Tennessee, Knoxville.

15. Specialty and physician workforce. What influences Medical Student and Resident Choices? Document by the Robert Graham Center. http://www. grahamcenter.org/online/etc/medialib/graham/documents/publications/ mongraphs-books/2009/rgcmo-specialty-geographic.Par.0001.File.tmp/ Specialty-geography-compressed.pdf page 26. Accessed May 14, 2009.

The emergency medicine fellow’s clinical work generates clinical dollars. The clinical dollars are generated in a separate setting from where the graduates, in most cases, eventually work.

If clinical dollars can be donated to the program in the form of an educational grant, fiscal viability of the program is possible.

Similar programs designate the training fellows as family medicine faculty and pay them from the funds created from clinical care the fellows provide, as they are board eligible or board certified in family medicine when they begin the emergency medicine fellowship.

Geetha Reddy, MD, was an ER Fellow when this article was prepared.

Luke Rawlings, MD, MPH, is Assistant Medical Director, Emergency Department, Mercy Medical Center, Redding, CA. Jocelyn Wilson, MPH, was an MPH student at the University of Tennessee, Knoxville, when this article was prepared. She is currently a medical student at East Tennessee State University.

Lorraine Wallace, PhD, is Associate Professor of Family Medicine, The Ohio State University Medical Center, Columbus.

Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might ®

10. Tuohy E. GME Funding and Specialty Choice, Part II. JAMA. 1999;282(24)2366.

11. Casey MM, Wholey D, Moscovice IS. Rural emergency department staffing and participation in Emergency Certification and Training Programs. J Rural Health. 2008;24(3):253-262.

12. Bennett P, Tadros A, Davis SM, Hobbs GR. The 2004 West Virginia Emergency Medicine Workforce. West Virginia Medical Journal.

2007;10-13.

13. Keenum AJ, Blake. Primary Care Distribution in Tennessee. Tenn Med. 2003;96(3)133-4.

14. Bullock KA, Pugno PA, Gerard, A. The role of Family Physicians in Delivering Emergency Medical Care. AFP. 2008;January 18 edition.

16. ACGME Web site listing combines Emergency Medicine – Family Medicine residency programs. http://www.acgme.org/adspublic/.

Accessed May 14, 2009.

17. University of Tennessee Knoxville Family Medicine – Emergency Medicine Program Description http://gsm.utmck.edu/family_medicine/ emergencymed.cfm. Accessed May 14, 2009.

18. ACGEM family Medicine Program Requirements http://www.acgme.org/ acWebsite/RRC_120/120_prIndex.asp. Accessed May 14, 2009.

19. ACOFP Family Medicine Program Requirements http://www.acofp.org/ membership/pds.aspx. Accessed May 14, 2009.

20. ABPS Board Eligibility http://www.abpsus.org/certification/emergency/ eligibility.html Accessed May 14, 2009.

21. Shepard LG, Burden JK. A survey of one CCFP-EM programs graduates their background, intended type of practice and actual practice. CJEM.

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shortage. Accessed May 19, 2009.

2005;7(5)315-320.

22. University of Tennessee Policy of nondiscriminatory hiring practices. http://hr.utk.edu/employment.shtml. Accessed May 14, 2009.

23. Ginde AA, Sullivan AF, Camargo CA. National Study of Emergency Physician Workforce. 2008. Ann Emerg Med. 2009;54(3)349-359.

24. Rural-Urban Commuting Area Codes (RUCA Codes). http://depts. washington.edu/uwruca/index.html. Accessed May 19, 2009.

25. Health Resources and Services Administration.

http://bhpr.hrsa.gov/

26. AAFP Position Paper Critical Challenges for Family Medicine: Delivering Emergency Medical Care- Equipping Family Physicians for the 21st Century. http://www.aafp.org/online/en/home/policy/policies/e/ emposition.html. Accessed May 14, 2009.

27. Rodney WM, Hahn RG, Crown LA, Martin J. Enhancing the family medicine curriculum in maternity care (OB) and emergency medicine to establish a rural teaching practice. Fam Med. Dec 1998;30:712-719.

Appendix A: Sample of Survey of Emergency Medicine Fellowship Graduates August 2008

UT EM Fellowship Graduate Survey Year of Graduation (from EM Fellowship)_______________________________________ How many hours per week, on average, are you working as a physician?_____________________________________________ % in EM_ _________________________________ % other medicine _ _______________________________ (specify) What is the population of your town? (circle one)

less than 10,000

10,000-20,000

20,000-50,000

greater than 50,000

What is the zip code of the ED where you work the most hours?_ __________________________________________________ Number of hospitals in your county?_________________________________________________________________________ Number of Emergency Departments in your county? ____________________________________________________________ Number of Emergency Department locations you work in (average per month)?_______________________________________ Does the Emergency Department where you work have a physician opening? (circle one) Yes

No

If yes, how many physicians are needed?______________ What are the basic qualifications for a doctor to work in your primary ED? (check all that apply) ______ BCEM ______ ABEM ______ AOBEM ______ Primary care boards plus ACLS, ATLS, PALS _____other, please specify_________________________________________________________________________________ Number of physicians in your EM department who are not board eligible for either ABEM, AOBEM or BCEM?_____________ Are you board certified by the AAPS? (circle one) Yes No Have you taken the AAPS written exam? (circle one) Yes No Are you board certified by the ABEM? (circle one) Yes No

Oral Exam? (circle one) Yes No BCEM board eligible? (circle one) Yes No

What education have you pursued since completing the EM Fellowship? (Check all that apply) ________ Completed ACGME accredited Emergency Medicine Residency ________Airway Advanced Training________Ultrasound Training ________General Emergency Medicine________Other, please specify______________________________________________ What educational suggestions would you have for the EM fellowship year that could enhance your practice skills today? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________

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M e d i c a l E t h i c s Without the Rhetoric Cases presented here involve real physicians and patients. Unlike the cases in medical ethics textbooks, these cases seldom involve cloning, bizarre treatments, or stem cell research. We emphasize cases more common to the practice of medicine.

Most cases are circumstantially unique and require the viewpoints of the practitioners and patients involved. For this reason, I solicit your input on cases discussed here at councile@aol. com. Reader perspectives along with my own viewpoint are published in the issue following each case presentation. We are also interested in cases that readers submit. The following case looks at one of the questions that frequently arises in the practice of disaster medicine.

Mark Pastin, PhD Mark Pastin, PhD, is president and CEO of the Council of Ethical Organizations, Alexandria, VA. The Council, a non-profit, nonpartisan organization, is dedicated to promoting ethical and legal conduct in business, government, and the professions.

case N IN E

W h o ’ s On F i r s t ?

You are called to the emergency room of a nearby community hospital in response to a horrible accident. The drunk driver of an 18-wheeler crashed head-on into a full school bus carrying parents to a sports event. There are dozens of patients in need of care when you arrive and are the first physician on the scene. The triage nurse points in the direction of the semi driver, who is singing “99 Bottles of Beer on the Wall” to himself. While he is seriously injured, you are confident that immediate attention will save him. But you see among the injured a fellow physician and parent, who is more seriously injured. You think the chances of saving him are about 50 – 50 or with immediate attention. If you attend to the physician immediately, you may lose both the truck driver and the physician. But it is hard for you to attend to the drunken perpetrator of this disaster, while ignoring a colleague known as a great parent and dedicated practitioner. When you turn to treat the physician, the triage nurse scolds, “You are not allowed to play favorites.” While you understand that triage decision should be made on the basis of medical considerations, you just think it is the wrong answer in this case. Who is right? The triage nurse or the physician?

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M e d i c a l E t h i c s Without the Rhetoric CASE EIGHT AN ALY SIS

n e v e r t o o o l d f o r lo v e

Our case from the last issue concerns at 82-year-old male who is in excellent physical condition - except that he needs a kidney. His 60-year-old wife would qualify as a donor possibly excepting her age. The individuals are wealthy enough to pay for the procedure. Our question: Legal issues aside, is it ethical to perform the transplant?

This was a divisive case among readers. Most refused to address the case in isolation.

Many opined that the procedure was a poor use of medical resources. This line of reasoning assumes that performing this procedure on our 82-year-old means that someone else will be deprived of a needed medical service. But this is not how supply and demand work. If old people buy a lot of new cars just because they can afford to, it does not mean that there will be too few cars for younger people. And so it is with healthcare. When a medical procedure becomes popular, such as breast augmentation, it does not mean that Johnny may have to go without a tonsillectomy.

Does the fact the patient may get the procedure because he is wealthier than others mean that the procedure should not be performed? I don’t think this makes a difference either. Should I not send my kids to college because other kids cannot even afford to go to grade school?

Most of the objections to this procedure share the assumption that the supply of medical services is fixed or at least limited. But while there are never enough medical services for everyone who wants or needs them, the supply of medical services grows daily. So I think it is not only ethically permissible to perform the procedure; I think the arguments against doing so are suspect.

This is an actual case. Of course, there are any number of complicating circumstances and additional details; but please address the case on the basis of the information provided.

There will be an analysis of this case and a new case in the next issue.

Your input is requested. Email your responses to: councile@aol.com. © 2011 Council of Ethical Organizations

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sounding board

The American Academy of Family Physicians Establishes a Forum for Family Physicians in Emergency Medicine Danny Greig, MD, FAAFP Anthony Gerard, MD, FACEP Kim Bullock, MD

Family Physicians remain critical to the system of emergency care in this country. This conclusion is supported by the Institute of Medicine report on the state of emergency care in the United States.1 The data collected by Dr. Camargo2,7,8 further support this. In most rural or suburban emergency departments in this country, patients will find Family Physicians doing what they have always done, stepping up to meet the needs of their communities in whatever capacity is necessary. Most of us have dedicated large portions of our careers to providing high quality and readily accessible emergency care to our communities.5,6 Many of us have undergone the rigorous process of achieving additional certification through the BCEM. Many of us remain active members of ACEP, but we have seen the support once afforded us by organized emergency medicine erode rapidly over the last two decades.

The AAFP, however, remains strongly supportive of the well trained Family Physician’s right to practice the full spectrum of emergency medicine according to his/her documented training, experience, and/or proven ability. With this background, the AAFP created the Special Interest Group in Emergency Medicine (SIG-EM), which held its inaugural meeting at the 2010 AAFP national meeting. The meeting was well attended and membership of the SIG-EM stated their desire to make real and positive changes in the status of FPs who provide emergency care in this country. In eight months of existence the SIG-EM has established an Emergency Medicine/Urgent Care online community through AAFP, amended the AAFP workforce statement3 to include clear language about the necessity of Family Physicians in Emergency Medicine, and established a yearly presence at the AAFP scientific assembly.

The importance of a forum for communication between Family Physicians in Emergency Medicine cannot be overstated.9,10 For a long time FPs in EM have felt isolated and without a mechanism for professional support. The EM/UC online community helps meet this need, and I encourage any eligible member of AAFP to sign up and become active on this valuable resource. The SIG-EM will continue to bring concerns and policy initiatives to the AAFP’s leadership in keeping with our mission. We also hope to help facilitate communication/ collaboration between interested parties (AAFP, ACEP, ABFM, ABEM) to continue to strengthen the support network for those FPs who chose to provide emergency care.

We are at a tipping point in the evolution of emergency care in this country with one group that clearly wants the exclusive right to work in the nation’s emergency departments, regardless of their inability to staff them and another, much larger, group that recognizes the harm that would come to patients who would be unable to access emergency care due to a shortage of providers, if those who advocate exclusivity were to prevail.

Interdisciplinary discussion and collaboration is the only way to address the persistent shortage of EPs if we are to keep the health care needs of the public as our primary focus.

Potential ways to address the problem are many. In the longer term dual training and certification in both EM and FP may help address the shortage; a few of these programs already exist, but it has yet to become a popular choice for medical students. The Canadian model of different pathways to certification is also something that may be on the table. In the Canadian system, a physician may achieve certification either through an EM resi-

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sounding board dency or through an FM residency with additional experience in EM. This has been a very successful model for adequately staffing emergency departments across Canada. Even if we cannot exactly mirror this approach, we can certainly learn a great deal from their successes. Many continue to fight for official recognition of BCEM, which has seen some limited success. As we approach these issues, it is important that we work together and across disciplines, giving us a much stronger voice. We already have the high ground in that our focus is for all Americans to have access to quality emergency care. This model was supported by the conclusions of the Institute of Medicine’s report on the state of emergency care in the United States.

Anthony Gerard, MD, FACEP, is Staff Physician, Lebanon Emergency Physicians, and Assistant Clinical Professor of Family Medicine, Pennsylvania State – Hershey.

We have seen recent positive moves from ACEP regarding support for FPs in EM, including recognition of anyone in ACEP as an Emergency Physician regardless of specialty training. While it leaves a large number of non-ABEM boarded physicians out, this recognition may represent an opportunity for further interface with ACEP with a view toward achieving common goals.

In fact AAFP and ACEP leadership have recently met to discuss this and various other topics. It is precisely this type of cross disciplinary communication that will allow us to move forward as partners rather than antagonists as we see health care reform posing one of the greatest challenges to the emergency care system we have seen in our lifetimes. Both ACEP and AAFP have endorsed health care reform, but both are also acutely aware of stresses it will place on an already inadequately staffed emergency care system. Surely we can achieve a mutually acceptable solution if we work with, instead of against, each other.

References

The recently approved AAFP workforce statement incorporates much of the AAFP position paper on FPs in EM4 into a document that establishes a framework for a rational approach to the workforce issues we face. As I have outlined, we now have several large professional organizations willing to be at the table with us. We have reached this point because it is no longer intellectually honest to deny the need for FPs in our nation’s emergency departments, but we are also here, in no small measure, due to the tireless efforts of those of you in BCEM, AAFP, ACEP, and IOM who have continued to look for a way forward when many had given up. The hope of the SIG-EM is that we have now reached a time and an environment where real recognition can be achieved for the sake of our fellow FPs in the ED trenches and, most importantly, for the health and wellbeing of the communities we serve.

Danny Greig, MD, FAAFP, is Emergency Room Physician, Mid-Michigan Medical Center, Midland, MI, and Assistant Clinical Faculty, Mid-Michigan Medical Center Family Medicine Residency.

Kim Bullock, MD, is Director, Ambulatory Emergency Services, Providence Hospital, and Clinical Associate Professor Department of Family Medicine, Georgetown Medical Center, Washington, DC. Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. ®

1.

Institute of Medicine. The Future of Emergency Care in the United States Health System, Hospital Based Emergency Care: At the Breaking Point.

The Emergency Care Workforce. June 2006:p.165. http://www.iom.edu/.

2.

Camargo CA Jr, et al. Assessment of Emergency Physician workforce needs in the United States 2005. Academic Emergency Medicine. Oct. 2008.

3.

Workforce Reform -- Policy & Advocacy -- American Academy of ...

Description: AAFP policy on physician workforce reform. www.aafp.org/ online/en/home/policy/policies/w/workforce.html69k.

4.

Critical Challenges for Family Medicine: Delivering Emergency ...

Description: The AAFP’s policy on delivering emergency medical care. www.aafp.org/online/en/home/policy/policies/e/emposition.html97kk.

5.

Graham Center One-Pager. Petereson LE et al. Family Physicians Help Meet the Emergency Care Needs of Rural America. AFP. April 1, 2006,73:7.

6.

Rodney WM. The FP’s role in emergency medicine. Family Practice Management. 1995:2(7),23.

7.

Sullivan AF, Ginde AA, Espinola JA, Camargo CA Jr. Supply and demand of board-certified emergency physicians by U.S. state, 2005. Acad Emerg Med. 2009 Oct;16(10):1014-8. Epub 2009 Aug 31.

8.

Ginde AA, Sullivan AF, Camargo CA Jr. National study of the emergency physician workforce, 2008. Ann Emerg Med. 2009 Sep;54(3):349-59.

Epub 2009 Apr 24. Erratum in: Ann Emerg Med. 2009 Dec;54(6):793.

9.

Bullock K, Rodney WM, Gerard T, Hahn R. “Advanced Practice” family physicians as the foundation for rural emergency medicine services (Part I). Texas J Rur Health. 2000;17(1):19-29.

10. Bullock K, Rodney WM, Gerard T, Hahn R. “Advanced Practice” family physicians as the foundation for rural emergency medicine services (Part II). Texas J Rur Health. 2000;18(2):34-44.

Other Resources: 1.

Holliman CJ, Wuerz RC, Chapman DM, Hirshberg AJ. Workforce projections for emergency medicine: how many emergency physicians does the United States need? Acad Emerg Med. 1997 Jul;4(7):725-30.

2.

Counselman FL, Marco CA, Patrick VC, McKenzie DA, Monck L, Blum FC, Borg K, Coppola M, Gerard WA, Jorgenson C, Lazarus J, Moorhead J, Proctor J, Schmitz GR, Schneider SM. A study of the workforce in emergency medicine: 2007. Am J Emerg Med. 2009 Jul;27(6):691-700.

The American Academy of Family Physicians Establishes a Forum. . .

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Case Report A Rare Case of Pneumocystis Pneumonia Swati Sharma, MD Reginald Wills, MD

Abstract Pneumocystis jirovecii pneumonia (commonly called Pneumocystis pneumonia or PCP) is an opportunistic infection that occurs in immunocompromised individuals. Although Human Immunodeficiency Virus (HIV) infected patients with a low CD4 (cluster of differentiation 4) count are at highest risk of PCP, it is a significant cause of pneumonia in other immunodeficient patients. Non-HIV patients at risk are those with cancer, particularly hematologic malignancies, patients receiving glucocorticoids, chemotherapeutic agents and other immunosuppressive medications, hematopoietic stem cell and solid organ transplant recipients, patients with primary immunodeficiencies, and severe malnutrition. Only a few cases have been reported in patients without any known immunodeficiency. We report the unusual case of pneumocystis pneumonia in a previously healthy non-HIV patient who was not on any immunosuppressant.

the-counter ibuprofen for pain and denied smoking, alcohol, or use of illicit drugs. She was single, educated till twelfth grade, and unemployed.

Case Report A 32-year-old female with no significant past medical history, who immigrated from Ethiopia four years prior to presentation, came to the emergency department with fever, dry cough, and generalized abdominal pain for three weeks. Patient was admitted with provisional diagnosis of dehydration and gastroenteritis. Patient also reported nausea and vomiting for three weeks. She had non-bloody diarrhea which lasted for four days and had resolved. She denied any sick contacts or recent travel.

On further review of systems, she denied any dysuria or abnormal vaginal discharge. Her last menstrual period was six days before admission. She reported appetite loss, fatigue, generalized body ache, and ten-pound weight loss in previous three weeks. She had no known allergies. She was taking over-

Figure 1. Chest x-ray showing prominent septal lines and interstitial disease.

On physical examination, her temperature was 100.6 Fahrenheit (F), pulse was 133/min, blood pressure was 93/60 mm Hg, and respiratory rate was 20/min. She was saturating 99% at room air, and her body mass index was 14.9. On exam, cachexia and generalized abdominal tenderness were noted. No other abnormalities were identified on multi-systemic exam.

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In the first hospital week, patient had persistent fever with a maximum temperature of 103.4 F. Repeat chest x-ray showed bilateral infiltrates and effusions (Figure 2 & 3). Computed tomography of chest showed bilateral lower lobe infiltrates, bilateral mild pleural effusions, and few mediastinal and hilar lymph nodes. She was started on vancomycin, piperacillintazobactam, caspofungin, and metronidazole after an infectious disease consultation. Bone marrow biopsy demonstrated mild hypercellular marrow and trilineage hematopoeisis but no evidence of granuloma or malignancy. On consultation with the pulmonary team, bronchoscopy was recommended, but patient refused initially.

Figure 2. Bilateral pleural effusions and lower lobe infiltrates seen on chest x-ray.

In the second hospital week, patient continued to have fever on broad spectrum antibiotics. She consented for bronchoscopy finally but developed shortness of breath the following day. Her saturation at room air was found to be 64% and chest x-ray showed worsening of bilateral infiltrates and effusions, with right side more severely involved than left (Figure 4). Therapeutic thoracentesis was done. 850 ml fluid was drained from right side and 550 ml from left side. Pleural fluid was transudative, and cultures were negative. AFB and silver stains were negative, and there were no malignant cells.

Figure 4. Lateral decubitus chest x-ray demonstrates layering of effusion on right and bilateral consolidation.

Figure 3. Bilateral pleural effusions and lower lobe infiltrates seen on chest x-ray.

Laboratory work-up showed leukocytes of 4400/cm but a bandemia of 28% and an elevated sedimentation rate of 65 mm/ hr. Initial chest x-ray showed prominent bilateral septal lines, which was reported as interstitial disease vs. viral pneumonia (Figure 1). Tuberculin skin test was positive (21 mm), but three acid-fast bacilli smears (AFB) were negative. Pan-cultures and influenza, HIV antibody and viral load, hepatitis, malaria, parvovirus, Epstein-Barr virus, and histoplasma tests were all negative. Syphilis, neisseria gonorrhoeae, and chlamydia tests were negative.

After thoracentesis, her hypoxia resolved and bronchoscopy was done. Bronchial washings were positive for Pneumocystis Jirovecii. Testing for malignancy and AFB was negative.

Treatment for PCP was started with Trimethoprim-sulphamethoxazole (TMP-SMX) and prednisone. Autoimmune and rheumatologic work-up was done. Anti-nuclear antibody was positive with a nucleolar pattern of 1:80. Anti-phospholipid and scleroderma antibodies were also positive. Rheumatoid factor and serum angiotensin-converting enzyme level were both normal. Anti-deoxyribonucleic acid, anti-smith, and anti-sjogren’s antibodies were negative. Rheumatology consult service considered overlap syndrome as one of the possibilities. Patient

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showed clinical and radiological (Figure 5) improvement and was discharged with instructions to complete twenty-one days treatment with TMP-SMX. She was counseled to follow-up in our out-patient clinic and with rheumatology clinic. Since then, she has been seen at our clinic twice and is in a fair state of health. She has not followed with the rheumatology clinic.

Figure 5. Normal chest x-ray.

Discussion PCP is a potentially life-threatening infection that occurs in primarily HIV patients with CD4 below 200, but also in non-HIV patients with immunosuppression. The common underlying factor is presence of cellular immunodeficiency. Approximately one to two percent of patients with rheumatologic diseases develop PCP, usually in the setting of immunosuppressive therapy, particularly combined therapy. In the case discussed, the patient was HIV negative with CD4 of 384. She had a rheumatologic disorder but was not on any immunosuppressant. The relationship between autoimmune rheumatic disorders and opportunistic infections is a potential area of research. One hypothesis is that chronic infections, such as mycoplasma infections, may be present in a variety of autoimmune diseases, and these chronic infections can compromise the immune system, permitting opportunistic infections by other bacteria, viruses, fungi, and yeast.1 There have been reports of PCP in people who had no known predisposing conditions. Therefore, this pneumonia can manifest in patients with normal CD4 count, and in these cases, PCP is probably associated with qualitative alterations of the cellular immune system.2 Diagnosis of pneumocystis can be difficult, because it cannot be cultured. It is classified as a fungus on the basis of its genomic

characteristics. Though still widely referred to as pneumocystis carinii, the extracellular parasitic organism responsible for infection in humans was renamed pneumocystis jirovecii in 1999. The name is after the Czech parasitologist, Otto Jiroveci, thought to be the first to describe the organism in humans.3 The designation, pneumocystis carinii, is now reserved for the species infecting only rats.

Pneumocystis infection is usually, but not exclusively, confined to the lungs. Fever, non-productive cough, and exertional dyspnea are the typical features.4 Physical findings are usually non-specific. Chest x-ray typically shows bilateral interstitial pattern. It can be normal in at least one-third of the cases. Elevated LDH has high sensitivity, and the degree of elevation may provide evidence of severity of illness. Sputum induction is the current standard screening tool for pneumocytis. Polymerase chain reaction assays for induced sputum can increase the diagnostic yield over conventional staining.5 If induced sputum is negative and index of suspicion is high, bronchoscopy with broncho-alveolar lavage (BAL) is the diagnostic method of choice.6 BAL has more than 95% sensitivity and an even higher specificity. TMP-SMX orally or intravenously is the drug of choice for treatment for PCP in both HIV and non-HIV patients.

Patients with severe PCP who have a contraindication to TMPSMX should receive intravenous pentamidine. Patients should receive 21 days of therapy. Systemic corticosteroids should be administered within the first 72 hours of starting treatment; if partial pressure of oxygen in arterial blood (PaO2) is less than 70 mm Hg or alveolar-arterial oxygen gradient is more than 35 mm Hg. The rationale is that dying organisms trigger an inflammatory response which can deteriorate oxygenation and hence steroids can play an important role in recovery. TMPSMX is also the first line agent for prophylaxis. The other drugs that can be used for prophylaxis are dapsone, atovaquone and aerosolized pentamidine.

Most studies on PCP have looked only at HIV patients, so information on non-HIV patients is limited. The organism burden and diagnostic yield of modalities, such as induced sputum and BAL, is higher in HIV patients as compared to those without HIV. The course of PCP in non-HIV patients is fulminant and has higher mortality.7 In HIV patients, the course is more indolent, and the prognosis is improving due to early prophylaxis.

In our patient, the index of suspicion for PCP was very low, as there was no obvious cause for immunosuppression. Bronchoscopy should be pursued if infection fails to resolve in a patient without impaired host defenses or if unusual pathogens are suspected.8 Bronchoscopy was the key to the diagnosis in our case.

Swati Sharma, MD, is Family Medicine Resident, Howard University Hospital, Washington, DC. Reginald Wills, MD, is Associate Professor, Department of Community & Family Medicine, College of Medicine, Howard University, Washington, DC. Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might

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create any potential conflict of interest. The authors have stated that no such relationships exist.

2.

Cano S, Capote F, Pereira A, Calderon E, Castillo J. Pneumocystis carinii pneumonia in patients without predisposing illnesses. Acute episode and follow-up of five cases. Chest. 1993;104;376-381.

Conclusion

3.

Bennett NJ, Gilroy SA. http://emedicine.medscape.com/article/225976overview. Updated March 29, 2011.

This is a rare case of PCP in a non-HIV patient not on any immunosuppressive therapy. This case points out that PCP can occur in patients who apparently show no immunosuppression.

It brings forward the possibility of a relationship between rheumatic diseases and opportunistic infections. It also illustrates the role of bronchoscopy with BAL as an important diagnostic tool for non-resolving pneumonia and, in particular, for PCP.

4.

Wilkin A, Feinberg J. Pneumocystis carinii Pneumonia: A Clinical Review. American Family Physician. October 15, 1999.

5.

Thomas CF, Limper AH. http://www.uptodate.com/contents/ epidemiology-clinical-manifestations-and-diagnosis-of-pneumocystispneumonia-in-non-hiv-infected-patients. Updated January 4, 2011.

6.

Kovacs JA, et al. New insights into transmission, diagnosis, and drug treatment of Pneumocystis carinii pneumonia. JAMA. 2001;286:2450-60.

7.

Russian DA, Levine SJ. Pneumocystis carinii pneumonia in patients without HIV infection. Am J Med Sci. 2001; 321(1):56-65.

8.

Niederman MS. Bronchoscopy in Nonresolving Nosocomial Pneumonia.

Chest. 2000;117; 212S-218S.

References 1.

Nicolson GL et al. Rheumatoid Arthritis, Multiple Sclerosis, Lupus, Inflammatory Bowel Diseases, Scleroderma and other Autoimmune and Degenerative Diseases. Autoimmune Illnesses and Degenerative Diseases. Medical Sentinel. 1999;4:172-176.

Do you know a qualified physician who is in need of board certification or a Diplomate needing to recertify?

The American Board of Physician Specialties (ABPS), the official certifying body of the American Association of Physician Specialists, Inc. (AAPS), provides medical specialty certification and recertification in the following specialties: • • • • • • • • •

Anesthesiology Dermatology Diagnostic Radiology Disaster Medicine Emergency Medicine Family Medicine Obstetrics Family Practice Geriatric Medicine Hospital Medicine

• • • • • • • •

Internal Medicine Obstetrics and Gynecology Ophthalmology Orthopedic Surgery Psychiatry Radiation Oncology Surgery Urgent Care

More Innovative Boards of Certification Under Development

 Eligibility requirements include advanced training, significant experience, good moral character, and successful completion of a specialty written and/or oral examination.  In order to maintain certification, every physician is required to complete re-certification every eight years.  ABPS also provides recertification for eligible Diplomates from Member Boards of ABMS and AOABOS. See Complete Requirements at http://www.abpsus.org/certification/index.html.

For additional information, contact the ABPS Certification Department at 813.433.2277

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sounding board

Emergency Medicine Workforce Issues: Synopsis and Discussion of Presentation by Dr. Carlos Camargo Ellyn Meshel, MD, FAEP Kenneth M. Flowe, MD, FAAEP, MBA

We had the pleasure of attending the lecture by Carlos Camargo, MD, DrPH, on emergency medicine workforce issues on June 25, 2011, at the AAPS Annual Meeting. Dr. Camargo, an academic emergency physician from Massachusetts General Hospital and Harvard Medical School, delivered this data-rich presentation. He has published multiple studies related to the emergency medicine workforce shortage within his research focus of public health.

The reality of the healthcare environment is a shortage of emergency physicians. Others1 have suggested that there is not now, or may even never be, an adequate supply of ABEM/AOBEM certified, emergency residency-trained physicians to meet the needs of all emergency departments in the country. Rural communities have enough trouble attracting emergency physicians without limiting the workforce further. His studies confirm this view. The data strengthen not only the belief that there is an ongoing need for non-emergency medicine residency-trained, non-ABEM/AOBEM certified physicians to help staff emergency departments for the foreseeable future, but also the belief that there must be a sound alternative certifying board.

Readers should explore the workforce calculator on the Emergency Medicine Network website, http://www.emnet-usa.org/ nedi/workforce.html2, to see how the different computations do not lead to the stated goal of covering all emergency departments anytime soon or possibly ever. While at the site, also click on the 2009 NEDI-USA link (http://www.emnet-usa.org/ nedi/nedi_usa.htm) to see the makeup of ED visit volumes in your state. The most interesting disparity is the makeup of states in regard to high vs. low volume emergency departments.

Massachusetts is an example of a state that has very few low volume EDs, while Texas, North Carolina, and Montana have a significant number of low volume EDs. The message is that leaders in Emergency Medicine may have very skewed personal experiences – consider the difference in distributions in Massachusetts (Figure 1) versus Montana (Figure 2) and how neither correspond well to the country as a whole (Figure 3). Dr. Camargo and EMNet staff are currently further refining these data, in nine states, to document the capabilities of the facilities in addition to their annual visit volumes.

The EMNet workforce study was a cross-sectional analysis of the 2008 AMA Physician Masterfile. Although this database includes all physicians who have ever obtained a medical license in at least one US state, the information is based on self-reporting from the participating physicians to their state board(s).

There was also exclusion of BCEM and AOBEM with the definition of board certification being ABEM certified only.

Some interesting facts from the 2008 workforce study are outlined below: • 39,061 emergency physicians practice in the United States.

• 22,314 (57%) were emergency medicine board certified by ABEM. • 26,826 (69%) were emergency medicine trained or emergency medicine board certified by ABEM. • 12,235 (31%) were neither emergency medicine trained nor emergency medicine board certified by ABEM.

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Figure 1. Numbers of emergency departments of varying annual volumes in 2009, Massachusetts, from http://www.emnet-usa.org/NEDI/ MA.htm, accessed 6/28/2011.

Figure 2. Numbers of emergency departments of varying annual volumes in 2009, Montana, from http://www.emnet-usa.org/NEDI/ MT.htm, accessed 6/28/2011.

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Figure 3. Numbers of emergency departments of varying annual volumes in 2009, entire United States, from http://www.emnet-usa.org/ nedi/USA.htm, accessed 6/28/2011.

• 16,822 (75%) ABEM board-certified emergency physicians had emergency medicine training preceding emergency medicine board certification.

We extrapolate from these data that approximately 5% of the 2008 workforce was BCEM certified (approximately 2,000 in 2008) and approximately 4% was AOBEM certified (1,746 in 2008, per Dr. Camargo’s article).

Some facts regarding the non-emergency medicine trained/ ABEM certified emergency physicians: • More than double the proportion were in smaller population and rural areas compared with emergency medicine trained or ABEM board certified emergency physicians.

be ABEM certified, and to have graduated training in the past five years.

Nearly all (98%) of emergency physicians who graduated within the past five years were emergency medicine trained or ABEM certified compared with only 44% among those emergency physicians who graduated 20+ years ago.

The state of the emergency physician workforce in rural EDs is quite concerning but is of great interest to AAPS. Of the emergency physicians who graduated within the previous five years, only 1% are currently practicing in small rural areas and only 5% in any rural area. This is compared with 5% and 15%, respectively, for emergency physicians who graduated 20+ years ago.

• Among all emergency physicians 7,433 (19%) reported that emergency medicine was their secondary specialty.

Until there are sufficient numbers and distribution of emergency medicine-trained, ABEM/AOBEM certified emergency physicians, there will remain a population of non-emergency medicine-trained, ABEM/AOBEM certified emergency physicians who provide clinical coverage for EDs. These emergency physicians provide a valuable service, because they often fill gaps in access to emergency care, such as in rural EDs that are unlikely to be staffed by emergency medicine-trained, ABEM/ AOBEM certified emergency physicians.

Those from small rural areas were much less likely than urban emergency physicians to have emergency medicine training, to

To summarize the current workforce status: Two-thirds of clinically active emergency physicians are now emergency medi-

• Family medicine and internal medicine were the most common residency training backgrounds.

• Most graduated from residency 20+ years ago (69%).

• More than half reported that emergency medicine was their primary specialty.

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sounding board cine trained or ABEM/AOBEM certified. One-third (12,235) non-emergency medicine-trained, ABEM/AOBEM certified emergency physicians still provide clinical coverage of EDs and are approaching the end of their careers. Furthermore, large geographic disparities in the emergency physician workforce exist, with fewer emergency physicians in Middle America and in rural areas. Finally, demand for all emergency physicians will likely continue for several decades, and the shortage of emergency physicians may even increase in rural areas.

One solution to these workforce shortages that Dr. Camargo discussed was the trend of hospitals using unsupervised mid-level providers (MLPs) in emergency departments – a common strategy being used to stretch the supply of all types of emergency physicians. Indeed, this autonomy is advertised heavily in job postings and is highly sought. But, is it safe? Dr. Camargo presented a recent study of 63 urban EDs comparing adherence to national asthma guidelines when patients were seen by physicians, supervised MLPs, and unsupervised MLPs.3 The guidelines used were administration of inhaled beta agonists within 15 minutes of arrival, prescribing systemic corticosteroids, and avoiding the prescribing of inappropriate antibiotics. The results showed that the unsupervised MLP concordance score was significantly lower than the physician only or supervised MLP scores. MLPs provided unsupervised care in 2% of these patients, but other studies show how this is quickly increasing, with nearly 5% of total ED visits being managed independently

by MLPs in 2005.4,5 This sacrifice of quality of care is disturbing. If funds permit, Dr. Camargo’s research group would like to do further studies of the care delivered by these different care models (physicians, supervised MLPs, unsupervised MLPs); they would examine other common illnesses as well as clinical outcomes.

Lastly, Dr. Camargo advised the audience about ACEP’s definition of an emergency physician, published just the previous week. The definition was exclusionary to the non-emergency residency trained, non-ABEM/AOBEM physician. The policy definition is: “An emergency physician is defined as a physician who is certified (or eligible to be certified) by ABEM or AOBEM or an equivalent international certifying body recognized by ABEM or AOBEM in emergency medicine or pediatric emergency medicine, or who is eligible for active membership in the American College of Emergency Physicians. It should be noted that residents in an ACGME or AOA approved residency in emergency medicine are emergency medicine resident physicians.” Dr. Camargo does not endorse this definition and will continue to use the term “emergency physician” for all physicians who have chosen to focus their careers on emergency care.

also discussions about how insurance companies could use this information to deny coverage in the future and how MLPs are making gains while we continue with our infighting within emergency medicine. Fortunately, Dr. Camargo will continue further unbiased and independent studies on the workforce issue that will help define the continued need for our member physicians and other non-EMRT, non-ABEM/AOBEM physicians despite ACEP’s exclusionary policies. We owe him and the EMNet research team a debt of gratitude for their groundbreaking studies, particularly in view of the fact that most of their workforce studies have been completely unfunded. If you feel that this research is valuable, individuals can donate money to help fund future workforce studies. Please see the EMNet website for details on how to make a tax-deductible donation: http://www.emnet-usa.org/give.htm.

Ellyn Meshel, MD, FAEP, is Emergency Room Attending at Tuomey Regional Medical Center, and Partner, Midlands Emergency Physicians, PA. Kenneth M. Flowe, MD, MBA, FAAEP, is Chief Medical Officer and Emergency Department Medical Director, Person Memorial Hospital, Roxboro, NC. Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. ®

References 1.

E.g., Institute of Medicine; Future of Emergency Care in US Health System. Ann Emerg Med. August 2006;48:2:pp 115-120.

2.

The majority of the data presented from Dr. Camargo’s lecture is reproduced on the Emergency Medicine Network website at http://www. emnet-usa.org/confirmed by linkage on June 30, 2011. Dr. Camargo is a contributor to this site, and the site mission is “to advance public health objectives through diverse projects in emergency care, particularly through clinical research.”

3.

Tsai C, Sullivan AF, Ginde AA, Camargo CA. Quality of emergency care provided by physician assistants and nurse practitioners in acute asthma.

Am J Emerg Med. May 2010;28:4:pp 485-491.

4.

Ginde AA, Sullivan AF, Camargo CA. National Study of the Emergency Physician Workforce 2008. Ann Emerg Med. September 2009;54:3:pp 349-359.

5.

Ginde AA, Sullivan AF, Blum CF, Camargo CA. Use of midlevel providers in US EDs, 1993 to 2004: implications for the workforce. Am J Emerg Med. Jan 2010;28:1:pp 90-4.

A discussion ensued about how the new ACEP definition could be used to our disadvantage in the future as a good number of AAEP members would not meet the criteria. There were

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A Tsunami and a Meltdown Closer to Home David Lemonick, MD

Has anyone visited the emergency department recently? I know I’m preaching to the choir here, but it seems to me that increasingly the emergency department (ED) is the “canary in the coalmine” of America’s health care. And because I’ve made my living in EDs during the past 25 years in a number of states, in a variety of hospitals, and in different types of jobs, I’ve had the privilege and misfortune of seeing some of the best, and the worst, of health care, human nature, and, I fear, our nation’s future. Full disclosure: some of my observations may be pessimistic.

Let’s start with this observation: The ED is packed, and so is the waiting room. The number of easy shifts I’ve worked in recent memory is few. And this is reflected by some statistics.

Between 1996 and 2006, the annual number of ED visits jumped from 90.3 million in 1996 to more than 119 million in 2006, a 32% increase. During the same period, the number of EDs decreased by 9%, and hospitals have closed 198,000 beds.1,2 And as the number of emergency departments declines, EDs have become the main source of health care for a growing segment of the U.S. population that lacks access to primary care services. Of the approximately 100 billion outpatient visits annually, just over one-third are for acute care. Only 42% of these acute care visits are to the patients’ primary physician.

EDs (which account for only 4% of the physician workforce) handled 28% of acute care visits. And EDs treated a disproportionate share of uninsured patients compared with other sites.3 This dramatic increase in emergency department use during the past several years has been driven, in large part, by the chronic shortage of primary care physicians, according to a 2009 study.4 Increasing numbers of uninsured patients are presenting to the ED, and uninsured patients lack access to primary care. And available data also show that care in the ED is more expensive than office-based care.5

The critical condition of primary care has been well described.6 A report by the American Academy of Family Physicians states that in order for the country to have sufficient family physicians to meet the demands of the population, accredited family medicine residency programs must immediately increase their residency positions, and that they must also recruit diverse candidates who will most likely serve rural, underserved, and elderly patients. The AAFP predicts that the shortage of family physicians will reach 40,000 by the year 2020.7 Similarly, primary pediatric care is in a state of crisis. There is an insufficient number of pediatricians, an increasing demand for their services, and inadequate funding for medical education. This lack of available care harms children and families and produces expensive alternatives to primary care.8 In a 2006 report, the American College of Physicians stated that, while there is a growing demand for primary care due to growth in the number of people with chronic diseases and long-term care needs of an aging population, there has been a decline in the number of medical students entering primary care. The authors of the report opine that primary care, “the backbone of the nation’s health care system, is at grave risk of collapse due to a dysfunctional financing and delivery system.” To avert a crisis, the authors recommend a number of policies, including implementation of the advanced medical home, reforming of reimbursement policies, and creating financial incentives for improving quality and efficiency.9 Compounding the problem of shifting of the setting of primary care to EDs is the profound national shortage of emergency physicians. Has anyone checked out the classified ads recently?

EPs are in great demand. A recent study by Dr. Carlos Camargo of the Harvard Medical School and the Harvard School of Public Health found that the supply of emergency physicians might never reach the increasing demand for their services.10 Making

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sounding board several clearly unrealistic assumptions, such as a zero attrition rate and an ideal geographic distribution of EPs, Dr. Camargo estimates that the supply of EPs may meet the demand by the year 2019. But if the assumptions are changed to be more realistic, supply will never meet the need. In 2009, the American College of Emergency Physicians released the “National Report Card on the State of Emergency Medicine” and in the category “access to emergency care,” the United States received a “D.” The reason for this dismal grade is the fact that the nation has too few emergency departments to meet the needs of a growing and aging population.11 The Institute of Medicine has concluded that emergency departments and ambulatory services are overburdened, underfunded, and highly fragmented.

Patients face long waits in overcrowded emergency rooms, and they often need on-call specialists who are not available. A significant contributing factor is that more and more patients are turning to emergency departments for care because they lack insurance, they need after-hours care, or because of their limited medical options in rural communities.12 Regardless of how you may feel about President Obama and The Patient Protection and Affordable Care Act (PPACA) that was signed into law on March 23, 2010, the provision of health insurance is not the same as the delivery of health care. PPACA is intended to allow 32 million previously uninsured Americans to get regular care from physicians. But an unintended, if not unanticipated, consequence of the PPACA is that it will likely result in further overcrowding of EDs. This is because PPACA increases health insurance coverage, without increasing access to medical care, especially with an aging population combined with physician shortages and maldistribution. EDs will continue to be increasingly crowded under the PPACA. Insured patients visit EDs at the same rate as the uninsured. The newly insured will continue to face obstacles to primary care. About half of the newly insured will be covered under Medicaid, and many primary care physicians do not accept this insurance.

A case in point: EDs remain crowded in Massachusetts after mandated health insurance for all. ED visits there rose 7%, and ED costs rose 17% over two years. And EDs continue to close despite increasing visits. PPACA requires insurers to cover costs of emergency visits, whether in- or out-of-network, to stop requiring prior authorization for emergency services, and to provide “prudent layperson” coverage. Thus, it is anticipated that ED waiting times will continue to rise above the already unsafe levels.13 Leigh Vinocur, MD, an assistant clinical professor at the University of Maryland School of Medicine and a spokesperson for the American College of Emergency Physicians, said the average emergency department wait continues to hover around four hours.14

Health care is also breaking the bank. As healthcare spending in the U.S. rose above $2.5 trillion in 2009, the percentage of the GDP spent on healthcare jumped to 17.3% from 16.2% in 2008 – the largest one-year increase since 1960. At this rate of growth, healthcare costs are expected nearly to double to $4.5 trillion in 2019. At that point, they will account for 19.3% – almost a fifth of our GDP. Government health spending is growing much faster (8.7%) than spending by private payers (3%), largely because of people losing their jobs and ending up on Medicaid. And if Congress restores planned Medicare reimbursement cuts to doctors, it is predicted that the federal and state governments will be funding the majority of healthcare by next year. This increasing reliance on government programs is a bad sign. State governments are already cutting back on Medicaid, with inevitable bad results not only for patients, but also for America’s primary safety net providers, its emergency departments. And when extra federal Medicaid subsidies come to an end, that trend should accelerate.

By comparison, in Australia the total health expenditures as a percentage of GDP is about 9%; in Austria 9.5%, Belgium 10%, Canada 10%, Denmark 8.5%, Finland 7%, France 10%, Germany 11%, Iceland 10.5%, Ireland 7%, Italy 8.5%, Japan 7.5%. According to Reuters, “the United States spends more on healthcare than any country in the world but has higher rates of infant mortality, diabetes, and other ills than many other developed countries.” So we’re paying more for healthcare, but we’re not getting more. This is a problem which we, as consumers, would not tolerate in almost any other part of our lives.

Medicare’s hospital fund is still projected to go bankrupt in 2017, and, unless healthcare spending is controlled, bankruptcy of the whole government is possible. Thus, if government funds the majority of healthcare, and if it is forced to cut back or go bankrupt, physicians, hospitals, other healthcare providers and, ultimately, patients themselves will suffer irreparably.

So we have a “perfect storm:” increasing demand for primary care, with shifting demand toward emergency department utilization, associated with inadequate supplies of residency-trained primary care and emergency medicine-trained physicians, increasing public funding of health care, decreasing certainty of the future for such funding, and a prohibitive percentage of the GDP diverted toward a haphazard, inefficient, and patchwork system of care.

As is often the case in a crisis, critical challenges provide the impetus for new opportunities and for creative solutions. The Board of Certification in Emergency Medicine (BCEM) is one existing and proven solution. Through both its practice track and fellowship programs, BCEM offers specialty certification

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sounding board in emergency medicine to physicians who are originally board certified in another ABMS primary care specialty residency.

Similarly, the American Academy of Family Physicians has published a position paper that outlines the role of family physicians in the future of emergency medicine. The paper states that, “Family physicians are qualified to provide emergency care in a variety of settings. In rural and remote settings, family physicians are particularly qualified to provide emergency care.

Emergency department credentialing should be based on training, experience, and current competence; fellowships in emergency medicine or additional course work may be of added benefit.” Combined residency programs in family medicine and emergency medicine, or additional training, may be beneficial.

Another potential solution to the workforce shortage is to increase the total number of ABMS-approved residency-training slots. This would require an increase in graduate medical education funding, which, in turn, would probably require funding of most specialties’ training slots. If, as has been estimated, an average EP spends one-third of his or her work hours on administrative duties, increasing the percentage of time spent on patient care would also be beneficial.

Mid-level providers are another vital physician-extension resource that has grown from a participation in 3-5% of emergency care visits in the late 1990s to close to 20% of visits today.

How these mid-level providers are optimally used and what, if any, supervision is needed for them, are questions that will need to be answered. Scribes have been investigated and in many cases confirmed anecdotally to be efficiency-amplifiers in some emergency departments. The benefit of electronic medical records and of computerized physician order entry is less apparent. Telemedicine is another potential method to relieve the mal-distribution of specialists, especially in rural settings.

Data for 2008 show that there were 10.3 EPs per 100,000 population in urban areas versus 2.3-5.3 for rural settings.15 Loan forgiveness and combined residencies in EM-primary care (e.g., EM-IM, EM-FM, EM-pediatrics) might ameliorate the problem of mal-distribution.

Finally, as any EP well knows, there is a significant use of the nation’s EDs for trivial, non-emergent, and convenient care (read: “inappropriate ED utilization”). It is quite politically incorrect to use the term “inappropriate visit” to describe any patient care in the ED, but clearly there is a disconnect between the concept of “emergency” that is held by the EP and his or her patient. The Kaiser Health Plan of Colorado has estimated that 20% of its 72,000 ED visits per year are “unnecessary.”16 After the completion of a medical screening exam that shows that no

emergency medical condition exists in a patient who presents to an ED, several options may be useful. A separate waiting room, a “triage out” program, and a dedicated social worker or case manager may be employed to redirect these patients.

Conclusions As I’ve watched the steady stream of humanity passing through my ED over the past two and a half decades, I know that my purpose there is to “help people.” After all, that is why I became a physician in the first place. But, Houston, we have a problem. Dallas, too. And Topeka, Presque Isle, Biloxi, Walla Walla, Pascagoula, and Punxatawny. If you or someone you know has worked in, has been treated in, or has otherwise been near an ED recently, or plans to be in an ED in the foreseeable future, you will recognize that something has gone terribly wrong there. Primary care is collapsing. Health expenditures are exploding and threaten to undercut any potential for economic recovery. The cost of health care delivery is sapping the vitality out of our nation’s financial security and world leadership. The “medical home” is a pipe dream for many, and the nation’s EDs have become the de facto medical home for many.

Supplies of EPs and other primary specialists cannot keep up with demands for their services. While emergency departments close, the number of visits to the remaining departments and the waiting times rise. Care becomes more expensive and increasingly fraught with medico-legal risk. Tough decisions are ahead of us with regard to emergency care. Dithering is not an option.

David Lemonick, MD, is Attending Emergency Physician, Armstrong County Medical Center, Kittanning, PA, and Vice President, American Academy of Emergency Physicians.

Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. ®

References 1.

Pitts SR, Niska RW, Xu J, et al. National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary. CDC. Division of Health Care Statistics National Health Statistics Reports. Number 7.

August 6, 2008.

2.

Kellermann AL. Crisis in the emergency department. N Engl J Med. 2006 Sep 28;355(13):1300-3.

3.

Pitts SR, Carrier ER, Rich EC, et al. Where Americans get acute care: increasingly, it’s not at their doctor’s office. Health Aff. 2010 Sep;29(9):1620-9.

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sounding board 4.

Prasad S, Klingner J. Uninsured Patients and Emergency Department Use in the United States. JAMA. 2009;301(11):1124.

5.

Newton MF, Keirns CC, Cunningham R, et al. Uninsured Adults Presenting to US Emergency Departments: Assumptions vs Data. JAMA. 2008;300(16):1914-1924.

6.

Center for Workforce Studies. Association of American Medical Colleges.

Recent Studies and Reports on the Inadequacy of the U.S. Physician Supply. November 2010. 7. AAMC. Available at:https://www.aamc.org/ download/.../recentworkforcestudiesnov09.pdf. Accessed April 13, 2011.

7.

American Academy of Family Physicians “Family Physician Workforce Reform: Recommendations of the American Academy of Family Physicians.” December 2006.

8.

Expert Work Group on Pediatric Subspecialty Capacity. “Recommendations for Improving access to Pediatric Subspecialty Care through the Medical Home” December 2007.

9.

American College of Physicians. “The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care.” January 30, 2006 available at: www.acponline.org/advocacy/ events/state_of.../statehc06_1.pdf. Accessed April 13, 2011.

11. The National Report Card on the State of Emergency Medicine. Evaluating the Emergency Care Environment State by State. 2009. American College of Emergency Physicians. Available at: http://www.emreportcard.org.

Accessed April 13, 2011.

12. Institute of Medicine. Hospital-Based Emergency Care: At the Breaking Point. June 13, 2006. National Academy of Sciences. Available at: http:// www.iom.edu/Reports/2006/Hospital-Based-Emergency-Care-At-theBreaking-Point. Accessed April 13, 2011.

13. Hospital Emergency Departments: Crowding Continues to Occur, and Some Patients Wait Longer than Recommended Time Frames GAO-09347 April 30, 2009 Available at: http://www.gao.gov/products/GAO-09347. Accessed April 13, 2011.

14. Benton E. As ED Waits Grow, Experts Point to Crowding and Access.

Emergency Medicine News. April 2011-Volume 33-Issue 4 - pp 1,50-51.

15. Talley BE, Moore SA, Camargo CA, et al. Availability and Potential Effect of Rural Rotations in Emergency Medicine Residency Programs.

Academic Emergency Medicine. 18:3.297–300, March 2011.

16. Hellstern R. Are you sending your patients home? You should be.

Emergency Physicians Monthly. 18(4) p. 27. April 2011.

10. Camargo CA, Ginde AA, Singer AH, et al. Assessment of Emergency Physician Workforce Needs in the United States. Academic Emergency Medicine. Volume 15, Issue 12, pages 1317–1320, December 2008.

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Case Report Headache and Spontaneous Internal Carotid Artery Dissection Liying Chen, MD, PhD Jean-Robert Desrouleaux, MD

Introduction Dissection of the extracranial carotid arteries is increasingly recognized and is a common cause of stroke in young patients.

In the absence of a traumatic trigger, spontaneous internal carotid artery dissection (CAD) may be related to various welldefined pathological processes.1 It is likely to be multifactorial, including environmental exposures, infections, and nonspecific inflammation of the arterial wall.1 A wide spectrum of sports and different physical activities has been reported to precede spontaneous CAD.6,7 However, most frequently, the etiology remains undefined as in the present case.

Case Report A 32-year-old female was brought by her friend to the emergency room (ER) after she had severe headache and near-syncope event at her work place. As per her friend, the patient’s headache started the night before; it was gradually getting worse to this point. In the ER, she became more lethargic and was noted to have left facial droop. Immediately, she developed respiratory distress and was intubated.

Patient’s histories were systematically screened and ruled out migraine, trauma, and infections during the two weeks before the headache onset. No fever (temperature≥38°C) or any other typical symptoms (cough, rhinitis, hoarseness, sneezing, vomiting) with onset of the headache.

She has no history of alcohol, cigarettes, and illicit drug use. She had bilateral ovarian tube ligation and no use of contraceptive pills.

The patient was sedated. Blood pressure was 120/70 mmHg, heart rate 65 beats/minute, oxygen saturation 100% on ACVentilator (500/12/70), and temperature 37° C (98.6° F). There were no heart murmurs, rubs, or gallops. There were no carotid bruits. Right-side weakness was accompanied by decreased sensation and positive Babinski sign.

Results of basic metabolic panel, CBC, cardiac enzymes, and coagulation panel were normal. Urine analysis and urine drug screen were negative for infection or illicit drug. CT scan of the brain revealed large left middle cerebral artery (MCA) territory acute infarct but no bleeding.

The patient was admitted to the Intensive Care Unit (ICU) for respiratory failure secondary to acute stroke. Neurology and neurosurgery were consulted. Aspirin was given. An MRI of the brain done 24 hours later confirmed the result of brain CT and expected progression (Figure 1). MR angiography of brain and neck revealed patent left middle cerebral artery (Figure 2) but severe dissection at the left carotid bulb (Figure 3). According to the neurosurgeon, any attempt toward intervention at revascularization of the left internal carotid artery was not encouraged because of the risk of hemorrhagic conversion with regard to the stroke. Given the large size of the infarct, the neurosurgeon recommended continuing low-dose aspirin and subcutaneous heparin 5,000 units every eight hours for deep venous thrombosis (DVT) prophylaxis.

To determine the cause of the stroke, a transthoracic echocardiogram was performed and shown negative for the possibility of endocarditis, with no cardiac cause for an embolism. The other results, including hypercoagulopathy panel, rheumatoid

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factor, lipid profile, C-reactive protein (CRP), anti-nuclear antibody (ANA) and ESR, were all within normal limits.

Figure 1. MRI of the brain revealed large left middle cerebral artery (MCA) territory acute infarct, as indicated by the arrow.

Figure 3. MR angiography revealed severe dissection at the left carotid bulb. Please note the bleeding interrupted lumen indicated by the arrow.

Discussion Naggara et al studied 29 consecutive patients with CAD by high resolution of MRI. They reported that symptomatic spontaneous internal CAD was more frequently associated with the presence of periartery soft tissue edema compared with traumatic CAD. Their study and the others5,6,7 also indicated that biological markers of inflammation are significantly correlated with the imaging finding in patients with spontaneous internal CAD. 4

Figure 2. MR angiography of brain revealed left middle cerebral artery was patent.

According to the history, the patient in this case had no history of neck injury, any provoking physical activities, or sickness before this event. Although high resolution MRI was not performed during hospitalization, the inflammatory biomarkers were negative. In agreement with Naggara’s group, in order to define the etiology in a larger population of CAD, we encourage the use of high resolution MRI to explore vasculopathies other than atherosclerosis. Further studies with more specific proinflammatory markers related to systemic vasculitis; i.e., IL-6 and IF-g, are warranted to corroborate the role of inflammation in spontaneous CAD.

Serial CT scans showed stabilized infarct and reduced edema.

Patient was extubated on third day of her hospitalization. At discharge, the patient was switched to a full dose of aspirin and Plavix for four to six weeks and then aspirin for rest of her life time. Patient was transferred to acute rehabilitation center.

The principal mechanism of carotid artery dissection is thromboembolism.8 Endovascular repair and surgery are justified as an alternative therapeutic approach to achieve a sufficient restoration of the vessel lumen. In a nonrandomized study,9 the data suggested that frequency of new cerebral ischemic events

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in patients with spontaneous CAD is low and probably independent of the type of antithrombotic treatment (aspirin or anticoagulants). Given the unfavorable results of surgery associated with the possible hemorrhagic conversion of the stroke in the present case, we started antithrombotic treatment with aspirin and Plavix.

References 1.

Rubinstein SM, Peerdeman SM, van Tulder MW, Riphagen I, Haldeman S. A systematic review of the risk factors for cervical artery dissection.

Stroke. 2005;36:1575-1580.

2.

Garry D, Forrest-Hay A. A headache not to be sneezed at. Emerg Med J. 2009;26:384-385.

3.

Dharmasaroja Pornpatr and Dharmasaroja Permphan. Sports-Related Internal Carotid Artery Dissection Pathogenesis and Therapeutic Point of View. The Neurologist. 2008;14:307-311.

4.

Neggara O, Touzé E, Marsico R, Leclerc X, Nguyen T, Mas JL, Pruvo JP, Meder JF, Oppenheim C. High-resolution MR imaging of periarterial edema associated with biological inflammation in spontaneous carotid dissection. Eur Radiol. 2009;19:2255-2260.

5.

Volker W, Besselmann M, Dittrich R, Nabavi D, Konrad C, Dziewas R, Evers S, Grewe S, Kramer SC, Bachmann R, Stogbauer F, Ringelstein EB, Kuhlenbaumer G. Generalized arteriopathy in patients with cervical artery dissection. Neurology. 2005;64:1508-1513.

6.

Forster K, Poppert H, Conrad B, Sander D. Elevated inflammatory laboratory parameters in spontaneous cervical artery dissection as compared to traumatic dissection: a retrospective case-control study. J Neurol. 2006;253:741-745.

7.

Genius J, Dong-Si T, Grau AP, Lichy C. Postacute C-reactive protein levels are elevated in cervical artery dissection. Stroke. 2005;36:e42–e44.

Jean-Robert Desrouleaux, Department of Emergency Medicine, Mercy Medical Center, Rockville Centre, NY.

8.

Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist.

Benninger DH, Georgiadis D, Kremer C, Studer A, Nedeltchev K, Baumgartner RW. Mechanism of ischemic infarct in spontaneous carotid dissection. Stroke. 2004; 35:482- 485.

9.

Georgiadis D, Arnold M, von Buedingen HC, Valko P, Sarikaya H, Rousson V, H.Mattle P, Bousser MG, Baumgartner RW. Neurology.

2009;72;1810-1815.

Conclusion CAD accounts for up to 10% of ischemic stroke events in young adults. Although the long-term recurrence rate of symptomatic dissection is low, patients should be informed about warning symptoms of dissection and to obtain screening vascular imaging. Failure to make a precise early diagnosis and start appropriate treatment may result in long-term neurologic sequelae or death. Based upon the mechanism of the disease, antithrombotic treatment with anticoagulatives or aspirin remains the first-line treatment and disease control.

Liyeng Chen, MD, is Attending Physician (hospitalist MD), Mercy Medical Center in New York.

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Headache and Spontaneous Internal Carotid Artery Dissection

American Journal of Clinical Medicine® • Spring 2011 • Volume Eight, Number Two

Performance-Based Learning & Competency-Based Testing

Rural Family and Emergency Medicine: Hand Fractures Case #1 Jeremy Draper, MD Justin Arnold, MD

Physicians need to refresh their skills in commonly occurring injuries. In many places, subspecialist help is not available or affordable. These basic skills reflect the reality of community medical practice for a variety of specialties staffing rural emergency rooms, primary care offices, and mission hospitals.1 For younger physicians, academic medicine teaches a curriculum of “Refer to Ortho.” Many fractures can be managed conservatively while maintaining quality in the community.2 The trick is to know which ones require surgery.

non-angulated fracture. Spiral fractures, which are more unstable than oblique fractures, result from the bone twisting apart.

A spiral break is visible on x-ray and can be distinguished from an oblique fracture by a component parallel to the long axis of the bone.2

A 23-year-old Latino construction worker injured his left hand in an arm wrestling contest two days ago. He is otherwise completely healthy. His vital signs are normal, and he is in no acute distress. He is right-handed. The left hand is swollen mainly on the dorsum and the proximal phalanx with maximal point tenderness on the third proximal phalanx. He has no insurance and speaks only Spanish. The image is shown on the right.

1. Adjectives for this fracture would include all but one of the following: a. Transverse b. Oblique c. Non angulated d. Spiral Suggested Answer – B. This is an oblique fracture of the proximal phalanx. Oblique fractures are slanted fractures in which the line of the break runs obliquely to the long axis of the bone. Transverse fractures run perpendicular to the long axis of the bone. Angulation refers to the angle of the distal fragment measured from the proximal fragment. This is an example of a Rural Family and Emergency Medicine: Hand Fractures Case #1

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Performance-Based Learning & Competency-Based Testing 2. In terms of one fragment being displaced from the other, which statement best describes this situation? a. Although the fracture fragments are apart, there is sufficient proximity that union is likely without surgery. b. These fracture fragments are displaced to the point that surgery is the only choice for a good result. c. Since the fracture fragments are apart, nonunion is likely and the patient should be counseled to expect significant disability even if surgery is performed. d. Since the fracture segments are apart, nonunion is likely and the patient should be counseled to expect significant disability without surgery.

a. The fracture is clearly comminuted. b. There is insufficient evidence to conclude that the fracture is comminuted. c. Comminution improves the stability of the fracture. d. Comminution promotes rapid healing.

Suggested Answer – B. This is a simple fracture of the proximal phalanx, not a comminuted fracture. A comminuted fracture has greater than two bone fragments.1 Due to the multiple lines of fracture and multiple bone fragments comminuted fractures are more difficult to reduce, more unstable than simple fractures, and require longer healing time (on average one to two weeks longer).

Suggested Answer – A. Phalangeal fractures that are nonangulated, nondisplaced, or stable following reduction are amenable to closed treatment with splinting and early rehabilitation. Indications for operative treatment of phalangeal fractures include: open fractures, irreducible fractures, unstable fractures, failed closed reductions, and displaced intra-articular fractures. Early finger mobilization and functional casting help prevent disability.3 3. If the patient decides on surgery, which statement describes the time surgery should be scheduled? a. Surgery should be scheduled for today. b. Surgery should be performed in the next 3-10 days. c. Surgery can be performed up to three weeks later. d. Surgery can be performed up to six weeks later.

Suggested Answer – B. Pain and swelling begin to resolve 1224 hours after an initial fracture, and often surgery is not performed during this initial period. Surgery should be performed in the next 3-10 days, once swelling has improved, and prior to bone healing and remodeling. Performing surgery three to six weeks after a fracture is not recommended, as healing and remodeling may be almost complete, and permanent disability may occur if the rotation and alignment are not obtained and maintained during healing.3 To gain a better understanding, a second view of the hand is obtained.

4. From this additional image, the physician should conclude that the best conclusion is:

5. Fractures that are comminuted are best described as: a. Needing surgery for optimal outcome. b. Managed variably dependent on location and nature of the fracture.

Rural Family and Emergency Medicine: Hand Fractures Case #1

American Journal of Clinical Medicine® • Spring 2011 • Volume Eight, Number Two

Performance-Based Learning & Competency-Based Testing c. Requiring Vitamin C 500mg PO TID to avoid complex regional pain syndrome.

6. The best statement describing the impact of the lateral image on the management of this case is: a. Comminution is clearly seen on this view and surgery is indicated.

d. More painful than fractures that are not comminuted.

Suggested Answer – B. Stability of phalangeal fractures depends on location, fracture orientation, and degree of initial displacement. Comminuted fractures are managed variably depending on location and nature of the fracture. For example, comminuted fractures with an intact periosteal sleeve and no initial displacement are usually stable and can be managed without surgery. Comminuted fractures are not necessarily more painful than simple fractures. Size, time since initial injury, and fracture location are all variables that can determine associated pain.3 A consultant is contacted by telemedicine. He requests a lateral image seen below.

b. Comminution is not present and surgery is not required. c. The view adds nothing to the diagnosis and management. d. Medicolegal liability is reduced through the presence of a lateral view.

Suggested Answer – C. There is no evidence of a comminuted fracture on the lateral view. Anteroposterior and oblique views are sufficient to manage this fracture; the addition of a lateral view adds no additional information. Because no additional information is obtained by adding a lateral view, medicolegal liability is not reduced.

Jeremy Draper, MD, is a third-year Family Medicine Resident, University of Tennessee Family Medicine Department.

Justin Arnold, MD, Department of Orthopedics, University of Tennessee, Chattanooga.

Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. ®

References 1.

Rodney WM, Hahn RG. Extended flexible sigmoidoscopy vs. colonoscopy: a family medicine perspective. Am J Clin Med. 2010;7:105-108.

2.

Rodney WM, Rodney JRM, Arnold KM. Xray Interpretation. Pfenninger J, Fowler G (editors). Primary Care Procedures. 3rd Edition. Philadelphia: Elsevier Mosby. 2010;1583-1592.

3.

Henry MH. Fractures of the Proximal Phalanx and Metacarpals in the Hand: Preferred Methods of Stabilization. J Am Acad Orthop Surg.

2008;16:586-595.

Rural Family and Emergency Medicine: Hand Fractures Case #1

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Case Report Mild Traumatic Brain Injury in High School Athlete – Novel Method of Evaluating Clinical Progress James G. Laurenzano, MD

The patient was a local high school male soccer player who was seen by me at a local urgent care center shortly after he was injured. This teenage male was accompanied by his mother.

He had been struck in the head after colliding with another player while competing in a high school soccer game. There was no loss of consciousness surrounding the impact. The patient had a complaint of a headache on his initial presentation.

There was no nausea, vomiting, or unusual behavior.

His initial neurologic function showed a GCS of 15 with no focal neurologic deficits. He was a bright, inquisitive teenager with high intellectual function. There were no focal deficits on his examination. The patient could perform rapid alternative movements with no focal cerebellar deficits. The only significant motor/cerebellar abnormality: the patient could stand less than five seconds on each leg with his eyes closed (right and left leg standing times were symmetric). Also, during and after the examination, the patient would ask me to repeat instructions several times, with the repetition of instructions being the only unusual aspect of his examination.

The clinical diagnosis of mild traumatic closed head injury was made. No imaging studies were deemed warranted. I explained my decision to not CT image the patient due to the history of the injury and the examination showing no evidence of a focal structural neurologic defect, plus the significant radiation load of CT imaging on this patient’s developing brain. The mother and the patient were comfortable with this decision not to proceed with radiologic neurologic imaging.

The patient wanted to know when he would be able to return to competitive sports. On reflecting on how to answer the patient’s question, I was searching for an objective measure to

show the patient and his mother that his cognitive function was not optimum now (believability/“buy in” by the patient and his mother). Also, any objective measure of cognitive function would ideally be easy to perform, easy to repeat, low in cost, and easy to independently monitor. Finally, when the patient’s testing had returned to normal pre-injury optimal testing, any testing should have some reasonable correlation with clinical improvement so the patient could return to competitive athletics safely with respect to accepted clinical guidelines.

I asked a few more questions of the teenage male, and I was pleased (but not surprised based on his age) that he was an avid gamer on his computer at home. Again, his mother confirmed how avid he was. Not being current gamer (my own clinical exposure ended with PacMan in the last millennium with occasional clinical exposure from enthusiastic nieces and mostly nephews soundingly thrashing me in video games scores by orders of magnitude), I realized the complex cognitive mental tasks required of most modern video games is extensive requiring concentration and interaction of higher cortical functions.

I asked the patient to go home and monitor his score on his most popular video game. I asked him to report at the time of his re-evaluation how much his top score had decreased and if his score had improved with time. This bright patient was very agreeable to this as was his mother.

On scheduled re-evaluation with me, the patient told me that his score had dropped off 30% the evening of my initial evaluation with marked difficulty in even attempting to play the game.

The finding of a marked decrease in performance plus the extraordinary effort to even try to play a video game, which was previously effortless, was quite startling to both the patient and his mother.

Mild Traumatic Brain Injury in High School Athlete

American Journal of Clinical Medicine® • Spring 2011 • Volume Eight, Number Two

Over the next two weeks, his video game score continued to improve as his headaches decreased and his concentration improved. At the two-week timeframe for his scheduled re-evaluation, he showed his mother that his video game skills had returned to premorbid levels with commensurate improvement in his video games scores to his premorbid level. He felt able to return to competitive sports and his mother agreed.

My evaluation two weeks after his injury showed his concentration had improved and this was confirmed by his mother. His neurologic examination was normal. He could now stand more than 10 seconds on each leg with his eyes closed (right and left sides were the equal).

My recommendation at this point was to return him to normal activities. Both the patient and the mother were very comfortable with this. The patient was released from any specific follow up unless there was any return of symptoms. There has been no need for follow up since he was last seen four weeks ago.

PubMed and general Google searches yielded no results concerning mild traumatic brain injuries and evaluation of clinical progress using computer-based video games in lieu of formalized neuropsychological testing.

The advantage to this potential approach to clinical evaluation is there is an antecedent pre-traumatic scored evaluation for a great number of patients, such as this one, in a cohort of young

athletes (i.e., most patients, especially males, have played video games on the computer, and there is a recorded score), the computer system is already in place so no extra costs are incurred, the testing can be done on an as-needed basis, the patients will readily participate in this means of testing, and the video tests are usually quite interactive requiring long periods of concentration and mental processing (brain functions normally effected by mild blunt traumatic brain injury that is normally not imaged well). For young athletes who are not video gamers (perhaps female athletes), another activity having antecedent scoring and easily followed might be cell phone messaging in a month, but further study would likely be warranted.

Unfortunately, the limitations of this case study are: first, I forgot to ask which video game he played. I assume there are differences in levels of interactivity, but to this mature medical (but non-video) practitioner, all video games are interactive beyond any level of play I could ever get out of them.

James G. Laurenzano, MD, is Medical Director, Doctors Express Urgent Care Center, Springfield, MA. Potential Financial Conflicts of Interest: By AJCM policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The author has stated that no such relationships exist. ®

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Call for p r e s e n tat ion s and posters

2012 house of delegates & annual scientific meeting The American Association of Physician Specialists, Inc., welcomes your proposals for presentations and posters at the 60th House of Delegates and Annual Scientific Meeting at The Ritz-Carlton, Marina del Rey, Los Angeles, California, June 25-29, 2012.

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