The Pulse - July 2016 by ACOEP

JULY 2016

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Presidential Viewpoints | John C. Prestosh, DO, FACOEP-D

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The Pulse VOLUME XXXVII No. 3 Editorial Staff Timothy Cheslock, DO, FACOEP, Editor Wayne Jones, DO, FACOEP-D, Assistant Editor Tanner Gronowski, DO, Associate Editor Drew A. Koch, DO, MBA, FACOEP-D, Board Liaison John C. Prestosh, DO, FACOEP-D Christine F. Giesa, DO, FACOEP-D Erin Sernoffsky, Editor Janice Wachtler, Executive Director Thomas Baxter, Graphic Design Manager Editorial Committee Timothy Cheslock, DO, FACOEP, Chair Wayne Jones, DO, FACOEP-D, Vice Chair Drew A. Koch, DO, MBA, FACOEP-D, Board Liaison John C. Prestosh, DO, FACOEP-D Stephen Vetrano, DO, FACOEP John Ashurst, DO John Downing, DO Tanner Gronowski, DO Erin Sernoffsky, Editor Thomas Baxter, Graphic Design Manager The Pulse is a copyrighted quarterly publication distributed at no cost by the ACOEP to its Members, Colleges of Osteopathic Medicine, sponsors, exhibitors and liaison associations recognized by the national offices of the ACOEP. The Pulse and ACOEP accept no responsibility for the statements made by authors, contributors and/ or advertisers in this publication; nor do they accept responsibility for consequences or response to an advertisement. All articles and artwork remain the property of The Pulse and will not be returned. Display and print advertisements are accepted by the publication through ACOEP, 142 East Ontario Street, Chicago, IL 60611, (312) 587-3709 or electronically at marketing@acoep.org. Please contact ACOEP for the specific rates, due dates, and print specifications. Deadlines for the submission of articles are as follows: January issue due date is November 15; April issue due date is February 15; July issue due date is May 15; October issue due date is August 15. Advertisements due dates can be found by downloading ACOEP's media kit at www.acoep. org/advertising. The ACOEP and the Editorial Board of The Pulse reserve the right to decline advertising and articles for any issue. ©ACOEP 2016 – All rights reserved. Articles may not be reproduced without the expressed, written approval of the ACOEP and the author. ACOEP is a registered trademark of the American College of Osteopathic Emergency Physicians.

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TABLE OF CONTENTS Presidential Viewpoints..............................................................................................................................3 John C. Prestosh, DO, FACOEP-D The Editor's Desk............................................................................................................................................4 Timothy Cheslock, DO, FACOEP Executive Director's Desk........................................................................................................................5 Janice Wachtler, BAE, CBA The On-Deck Circle......................................................................................................................................6 Christine Giesa, DO, FACOEP-D Congratulations to ACOEP’s 2016 Award Winners..............................................................8 DO Day on the Hill........................................................................................................................................10 Jon Pazevic, DO, FACOEP What Would You Do?..................................................................................................................................11 Bernard Heilicser, DO, MS, FACEP, FACOEP-D New Physicians in Practice Update...............................................................................................12 Nicole Ottens, DO, FACOEP Board Nominates 6 Physicians for 2016 Slate of Candidates ................................15 Do You Have the Urge to Serve?..................................................................................................... 17 Member News ...............................................................................................................................................19 ACOEP WADEM Brief...............................................................................................................................20 Cameron T. Bubar, MPH, MS-I Woman in a Man’s Role...........................................................................................................................21 Stephanie Davis, DO FACOEP Literature Update Summer 2016 ....................................................................................................23 Amanda Ellis, DO and John Ashurst DO, MSc Osteopathic Physician and Nurse Practitioner Team Promotes Collaboration in Emergency Care ........................................................................25 Brittany Newberry, PhD, MPH, ENP, FNP The Power to Create Real, Effective, and Lasting Fulfillment .................................27 Frank Gabrin, DO The Zika Virus: What the ED Physician REALLY Needs to Know .........................31 R. Scott Taylor, DO; Matthew Pitzer, DO; Sasha Hallett, OMS II and John Ashurst, DO, MSc Foundation Focus........................................................................................................................................33 Sherry D. Turner, DO, FACOEP, MPH ACOEP and FOEM Team Up to Create the ACOEP Emergency Physicians Paradigm Research Group..........................................................38 FOEM Research Network Update..................................................................................................39 Victor J. Scali, DO, FACOEP-D

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Are You Still Enthusiastic? he secret of genius is to carry the spirit of the T child into old age, which means never losing your enthusiasm. — Aldous Huxley

Presidential Viewpoints John C. Prestosh, DO, FACOEP-D

s I have been traveling across our country on behalf of the American College of Osteopathic Emergency Physicians, I have noticed a certain characteristic among students. They possess a genuine excitement and enthusiasm for what they are learning in our Osteopathic medical schools. This characteristic is translated into profuse energy which they use to inform others outside of medicine as to what they are learning. This is evident when I visit the student emergency medicine clubs and speak about the Osteopathic profession and, in particular, ACOEP. The students have many questions which at most times have easy answers; however, other questions demand a definite introspection before providing an answer. One such question posed to me has been, “Are you still enthusiastic about what you do in medicine?” The obvious answer should be “Yes,” but should I give that answer quickly, or do I pause and think before replying in the affirmative? I recently attended DO Day in Washington, DC, and I must say the energy exhibited by the students was palpable. It was awe-

inspiring to see more than 1,000 students in their white coats ready to descend upon Capitol Hill to meet with their congressional representatives. The students were laughing, speaking with colleagues from other schools, taking notes on how to discuss the important issues of the day, and most of all, they were excited. I then observed the physicians who were present for the DO Day activities. I estimated there were about 100-125 DOs in attendance. They too were speaking with friends, enjoying the company of colleagues they may not have seen since DO Day 2015, and were also listening to the “talking points” that would be discussed later that day. Their mere presence at DO Day reflected their enthusiasm for the event. Would it not have made “front-page” news in the Washington papers if 1,000 physicians had been present to join the ranks of the students? I believe practicing physicians need to share their enthusiasm in our profession with peers and spread the word of what Osteopathic physicians represent. DO Day is just one example where our physicians have a platform upon which to stand and raise our voices to bring needed awareness to our profession.

physicians not attending DO Day. It is difficult to arrange coverage and leave busy practices to attend meetings, whether it is a specific event such as DO Day or selected conferences. Realizing the fact that many physicians experience difficulty in attending “outside” functions, I am challenging all our ACOEP physicians to get energized and excited about our profession in our individual emergency departments. We should publicize who we are and get enthusiastic about practicing our Osteopathic philosophy on a daily basis when caring for multiple patients. Something as simple as having their D.O. credentials displayed, (instead of Dr) on your scrubs or lab coats can and will provide an awareness of who you are and foster meaningful interactions between you and your patients. I have introduced my TEAM concept in a previous issue of The Pulse, and kudos to the students; they are utilizing this method. If they are disseminating the tenets of our profession, and so should we. As Emergency Medicine Continued on Page 7

I understand there are a myriad of legitimate reasons for

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Advocating for Fair Coverage e like to go to work and care for our patients. W Unfortunately, the business of medicine and the insurance industry have made this increasingly difficult.

The Editor's Desk Timothy Cheslock, DO, FACOEP

s emergency physicians we see everyone that comes through our doors regardless of their ability to pay for care. It is the right thing to do, it is also the law. Patients expect that when crisis hits we will be there to take care of them. Some emergencies are more serious than others, but all who seek help can be assured that someone will be there to listen, evaluate and provide care for the problem at hand. Recently ACEP launched a campaign to insist on Fair Coverage for patients. This campaign is multifaceted in that it attempts to educate patients as to what their health insurance really provides in the way of coverage for emergency care, brings to the spotlight health insurance companies practices of offering cheap premiums, little coverage and large out of pocket expense to patients, and also encourages legislation to force the insurance industry to provide fair payment for the cost of emergency care delivered by all of us that is mandated by law under EMTALA. This campaign is one that all emergency physicians should support and take part in. We are all advocates for our patients and our profession. Whether it is educating

your patients on the topic, speaking with your legislators or getting involved with the government affairs committee to help draft and support legislation that will bring about the change we seek, any effort on your part will go a long way in making this campaign a success. Most physicians, myself included, are not big on dealing with legislators. We like to go to work and care for our patients. Unfortunately, the business of medicine and the insurance industry have made this increasingly difficult. Insurance companies spend millions of dollars lobbying elected officials each year to gain influence over legislative proposals. We are our own worst enemy when it comes to dealing with the situation. It is no longer a process where we can bury our head in the sand or turn the other way and say that it is not our problem to deal with. It is our problem and our patientsâ&#x20AC;&#x2122; problem that we can no longer afford to ignore. In order to influence the discussion we need members to be involved and we need financial support to highlight our agenda. Involvement in the ACOEP Government Affairs Committee is a great way to be involved in influencing the discussion. ACOEP has recently revamped the advocacy section of the website. Head on over

and take a look to see what topics are trending and what you can do to spread the word. Financial donations are also needed to gain support for our legislative agenda. While ACOEP does not have its own political action committee (or PAC), making a donation to NEMPAC, your state ACEP chapter or OPAC will ensure that your financial support is directed toward supporting a legislative agenda that has your best interests at its core. Taking a small amount of time to speak with our patients about these issues, meeting our legislators and their staff and being knowledgeable about what is happening in our profession and the industry of medicine will make for a much more satisfying and secure career for many years into the future. More information about the Access to Fair Coverage campaign can be found at the ACEP website. There are many resources available on the site to educate yourself and provide additional ways to get involved with this crucial effort to keep emergency care available to all.

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Speaking Patient Remember that people in crisis hear about one-half of what’s being said and comprehend less.

“What medications is he on?”

Executive Director's Desk Janice Wachtler, BAE, CBA

ecently I’ve had several friends bring loved ones to the ED in crisis mode, only to find the doctors intimidating and their communication with the family filled with big medical terms that were hard to understand and quickly explained away by the physician. Come with me on a journey; one that finds you a white or blue collar worker, but not a physician. You speak Polish or Spanish or Greek as a first language, or perhaps you are hearing impaired. You arrive at the Emergency Department via ambulance with a family member who has passed out and is breathing but unresponsive to pain; he or she has no previous medical problems. As you watch your loved one rolled into the ED surrounded by people in scrubs and white coats you are helped out of the ambulance. You are met perhaps by someone in a white coat or scrubs who takes you into an area where you see your family member being hooked up to monitors and now this person is asking you questions in rapid fire order.

As you answer the best you can, the white coat assures you he or she will take care of your family member and leaves you to sit in an over-crowded waiting room. This is foreign territory; people, both sick and well, wait for service; each time someone appears at the door, all look up. A nurse calls your name and hands you a clipboard and pen to fill out paperwork; you ask how things are going, and he or she smiles and says they’ll get back to you. You stare at the clipboard answering questions blindly. Yes, I have Power of Attorney for Healthcare; yes, he has insurance; yes, he’s employed. You sign papers that are glanced over initialing things and trying to make sense out of the legalese on the forms, all the while wondering what’s going on. The white coat re-emerges and asks you to follow. You’re lead to the bedside

of your family member and told he or she has had a stroke. Your mind swirls, you think of nursing homes and wheelchairs, of massive bills and you silently pray for guidance to do the right thing. The white coat says, they can give your loved one a shot called tPA, because they meet the criteria and this will break up the blood clot in their head, but you have to decide now, the stroke clock is ticking down to a three hour deadline. You literally have no time to decide, to consult family members or even look things up on your phone, so you give the ok and wait. This scenario can be one used for many incidences and in many specialties. Is there an inherent risk to tPA? Of course. There are risks to everything. Making it clear that the risk of fatal hemorrhage, Continued on Page 7

“What happened?” “Did this happen before? “Do you know?”

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Zika: The New Summer Virus The symptoms of Zika virus infection typically develop within a week after being bitten by an infected mosquito. Most people do not even realize that they have been infected.

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

h, the endless pleasures of summer afternoons. Well, maybe not endless. The arrival of the Zika virus in the Americas may inhibit some summertime pleasures. It also requires healthcare providers everywhere to be cognizant and vigilant. The Zika virus was first identified in 1947 in the Zika forest in Uganda where British scientists were studying the Aedes mosquito and the spread of yellow fever. Since then there have been sporadic outbreaks of the Zika virus in Africa, Asia, and the Pacific Islands. In May 2015 the first case of Zika virus was confirmed in Brazil, and in February the World Health Organization (WHO) declared Zika virus to be a public health emergency of international concern. In the U.S. there have been at least 346 cases of confirmed travel-associated Zika virus infections, but no locally acquired vectorborn infections.1

responsible for transmission of chikungunya and dengue viruses. These mosquitoes are aggressive daytime biters so preventative measures must be exercised at all times. Zika virus can also be spread by a man to his sexual partners. Of interest is the fact that the virus can be transmitted before, during, and after a man develops symptoms of infection, and the virus persists in semen much longer than in blood. Although a theoretical possibility, there have not been any blood transfusion-associated cases of transmission of the Zika virus. Of utmost concern is passage of the Zika virus from an infected woman to her fetus during pregnancy. Zika virus infection during pregnancy has definitively been linked to the development of fetal microcephaly. 2.

The symptoms of Zika virus infection typically develop within a week after being bitten by an infected mosquito. Most people do not even realize that they have been infected. Only approximately one in five people infected with Zika virus develop symptoms. Symptoms are typically mild and self-limiting. The most common symptoms are fevers; arthralgias, specifically the small joints of the hands and feet; headache; conjunctivitis; and a fine maculopapular rash. Symptoms typically last from two to seven days. Severe disease is extremely rare; however, Guillian-Barre syndrome has been associated with Zika virus infection. The signs and symptoms Continued on Page 13

Zika virus transmission occurs primarily through the bite of an infected Aedes aegypti mosquito. This is the same species of mosquito

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"Enthusiastic?" continued from page 3 physicians we have multiple opportunities each day to tell our patients we are Doctors of Osteopathic Medicine. We can evaluate their responses and answer questions on how we are different. We need to assimilate educational information into our message and then mentor others regarding our profession. The environment of healthcare is rapidly changing and like it or not, we physicians, are in the middle of it. We must create a sense of stability in the midst of what is transpiring. Physicians need to be vocal and take action to provide a proper direction the practice of medicine must travel. This in itself is but one reason attending DO Day is vitally important for the future of medicine, our voices definitely heard by our lawmakers that day. If we fail to provide a road map of where to go, rest assured the government, insurance companies, or both will dictate how to practice our specialty.

"Speaking” continued from page 5 is present, but unlikely, could go a long way in educating the patient. There’s no guarantee the family member will be the same guy he was before the stroke. There may residual effects, not of the medicine but of the stroke itself. What will they be? That depends on where the clot is? Can this happen again? Yes. What if we don’t do anything, can the clot resolve on its own? Yes . . . but . . . Now what if that decision maker has a language barrier, does your institution have a certified translator who can talk in language that can be comprehended by the decision maker? What if the decision maker has someone with them that will translate, will that person sugar-coat or translate information truthfully? What if the family member is hearing-impaired and using ASL, are you familiar with American Sign Language or is someone in the ED to explain these technical things to them.

We, as practicing physicians, need to remember why we do what we do. We were at one time, energized and enthusiastic students, desiring to be human sponges, to learn everything in medicine. As years progress, we understand our education is a daily learning process and we will never know everything. It is relatively easy to get caught up in governmental issues, insurance concerns, RVUs, best practice models, and reimbursement policies. All of these items have a role in our daily practice, but none of these concerns should overrule our basic premise of doing what we do…taking care of our patients with enthusiasm. I believe our patients should never be referred to as consumers or users. If those terms become common everyday usage, I honestly believe we will lose integrity within the patient-physician relationship.

should stop caring for patients. I admit that being around students has aided in keeping my answer positive. Their enthusiasm does radiate and is contagious. I consider myself fortunate my present position in ACOEP allows me to interact with students on a continual basis. How about you? Has the practice of medicine become a hum-drum daily existence, or are you still excited about what you do? Think back to the beginning of your medical career and remember the energy you exhibited. Think about why you entered the Osteopathic profession. I hope that when you reflect upon your early career, you will remember the zest you displayed. I hope you can continue with that enthusiasm and share it with every patient who relies upon your care.

Well, this now brings me back to the question, “Am I still enthused about what I do in medicine?” My answer is yes! The day that answer changes, is the day I

There are a million ‘what ifs’ in everyday life in emergency room and depending where you practice you have to know the vernacular of the area, but when it comes to communicating medical issues, you also need to remember that people in crisis hear about one-half of what’s being said and comprehend less. But every physician needs to be able to explain, in layman’s terms, the disease process, the role of pharmaceuticals in correcting or controlling the issues, and the follow up instructions. But you have to let that decision maker have all the parts of the puzzle before making a decision that can affect their life, the lives of the family and the patient.

Explore ACOEP’s New Online Home!

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

www.acoep.org

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Congratulations to ACOEP’s 2016 Award Winners

COEP’s members change the landscape of emergency medicine on a daily basis. Through their research, commitment to personalized care, dedication to their patients, and support of their fellow medical providers, these incredible professionals save lives, and influence communities in a myriad of ways. Each year, ACOEP’s Nominations Committee recognizes just a small percentage of these skilled, driven professionals who have distinguished themselves. The 2016 class of award winners demonstrates contributions above and beyond what is expected of them and represent the best in emergency medical care across the country. Each winner of these prestigious awards will be honored at ACOEP’s 2016 Scientific Assembly in San Francisco, California. Congratulations to every award winner, and thank you for making our communities safer, and raising the standard of quality care in new and innovative ways.

Victor J. Scali, DO, FACOEP-D has been named the 2016 recipient of the Bruce D. Horton, DO, FACOEP-D – Lifetime Achievement Award. He is the fifteenth recipient of this award The award, named after the ACOEP’s first President, is presented to a physician who has excelled in the field of emergency medicine, is recognized as an expert in the field by their peers and colleagues, and has served the profession both nationally and regionally. Dr. Scali has served in many roles during his service on the Board, including

its President for 2002 – 2004. Dr. Scali has also served as the President of the Foundation for Osteopathic Emergency Medicine, from 2004 – 2006 and continues to serve on its Board as the Director of its Research Network, matching residency programs with pharmaceutical companies as research incubators. He has been the longtime Co-Program Director of the Emergency Medicine Residency program at Rowan University – Kennedy Hospital, and will be moving to an academic teaching position at the university utilizing a problem based curriculum. Duane D. Siberski, DO, FACOEP has been named the 2016 recipient of the Robert D. Aranosian, DO, FACOEP – Excellence in Emergency Medical Services. He is the fourteenth recipient of this award The award, named after the ACOEP’s sixth President, is presented to a physician who has excelled in the service to his community, institution, region or state in the area of emergency medical services (EMS) and is recognized for this outstanding service. Dr. Siberski was recognized for his service to his community of Reading, Pennsylvania and the Region 2 TEMS teams for the eastern region of the state. Additionally, Dr. Siberski is known for his dedication to teaching his peers in various aspects of EMS and is recognized as an expert in the field, much as Dr. Aranosian was during his lifetime. Alexis M. LaPietra, DO, has been named the 2016 recipient of the Innovative Practice Award. She is the second recipient of this award.

The award, developed in 2014, recognizes Dr. LaPietra’s Alternative to Opiates (ALTO) program which creates an environment in which a non-narcotic treatment protocol is established in the emergency department through the utilization of pain medication, other than opiates, and procedures, such as nerve blocks and trigger point injections may be used to alleviate pain. Judith M. Knoll, DO, FACOEP has been named the 2016 recipient of the Benjamin A. Field, DO, FACOEP – Mentor of the Year Award. She is the fourteenth recipient of this award. The award, named after the ACOEP’s tenth President, is presented to a physician who has excelled in their work with students and residents in emergency medicine. Dr. Knoll is being recognized as the inaugural program director for emergency medicine at the Adena Health System in Chillicothe, Ohio and as Chair of the Research Committee of ACOEP. During her five-year tenure on the Committee, she instituted the Research Quality Improvement Initiative which has helped osteopathic emergency medicine residents create and study research strategies and produce excellent, competent, and defendable research projects and papers. Michael P. Allswede, DO has been named the 2016 recipient of the Janice A. Wachtler, BAE, CBA – Educator of the Year award. He is the third physician to be given this honor. Continued on Page 9

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"Awards” continued from page 8 The award, named after the ACOEP’s long-time executive director, is presented to a physician, scientist, professor, or educator at the predoctoral or postdoctoral level of medical education who has excelled in enhancing education for the student, resident, or attending physician in emergency medicine. Dr. Allswede is recognized for his creation and implementation of the Faculty Development Course which brought the tenets and best practices for research in emergency medicine to program directors and core faculty enrolled in the program. He is also a co-editor of a book being reviewed by Oxford University Press that will become one of the 50 Cases Every Physician Should Know series, devoted to emergency medicine and written and edited entirely by osteopathic emergency physicians.

CALL TO MEETING!

Attention: Members of the American College of Osteopathic Emergency Physicians: At the request of the President, John C. Prestosh, DO, FACOEP-D, a meeting of the Membership has been called to provide members with important updates on College business. The meeting will be held in conjunction with ACOEP’s Scientific Assembly in San Francisco, California at the Hilton San Francisco Union Square Hotel on Wednesday, November 2, 2016. The meeting will be in the Continental Ballrooms 1 -4 and will begin at 5:00 p.m. (PDT). For those not attending the meeting, voting for Board candidates will begin on Friday, October 30th and end at midnight on Sunday, October 30th. On-site voting will be available near the registration area from Wednesday, November 2, 2016 at 8:00 a.m. to 4:00 p.m. Members downloading the ACOEP app also will be able to vote with their phones during these hours utilizing an identification code supplied by the member database. This meeting will count towards Fellowship requirements for Active and Resident Members but no CME credit is awarded for participation in the Membership Meeting. Juan A. Acosta, DO, MS, FACOEP-D Secretary

Explore San Francisco with ACOEP November 3, 2016 Hop aboard a vintage fire truck, or explore the sweeter side of the City by the Bay with one of two unique tours for ACOEP attendees and their families!

Vintage Fire Truck Tour

See San Fran from a completely new angle, exploring neighborhoods, highlights, and hidden gems. 12:30 pm - 2:30 pm OR 2:30 pm - 4:30 pm

Best of San Fran Chocolate

Lace up comfortable shoes, and join the sweetest tour in town, indulging in the best of San Francisco chocolate including stops at Dandelion, La Cocina, Recchiutti, Fog City News, and TCHO. 12:30 pm - 4:30 pm

Space is limited! Find out more at www.acoep.org/scientific/sanfran

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DO Day on the Hill Jon Pazevic, DO, FACOEP, Governmental Affairs Chair

O day on the Hill was a first time event for me. As Chairman of the Governmental Affairs Committee for ACOEP, I went with an open mind. It was a well-organized event, with a series of informative topics. The AOA gave every participant a schedule of meeting times with their district’s representatives, senators, or their staffers. There were free Metro passes to get to and from the Hill, and a lunch card to eat there in the congressional cafeteria as well. A new addition to the AOA schedule was a two hour CME breakout for residents and attendings, meaning that attendees can now write this trip off for tax purposes and get a chance to lobby Congress at the same time! The ratio of attendings to students was probably 10 to 1, but I think with the CME, this may change, as it is now a less expensive venture to attend. I was the only attending from the great state of Washington, but I was surrounded by a half dozen excited, passionate osteopathic medical students. The AOA gave us a nice outline of three topics to discuss regarding health policy. The first was prescription opioid abuse, and our support for President Obama’s initiative at curbing this problem. This included a commitment from of over half of the osteopathic medical schools to add additional curriculum regarding this issue, and hopefully the rest will join by the end of the year. Secondly, we asked for support on H.R 4223, POST GRAD ACT, introduced by Representative Judy Chu (D-CA), which would reinstate graduate and professional student eligibility for the in-school interest subsidy for Federal Stafford Loans, which

was eliminated in the Budget Control Act of 2011. Some of the medical students spoke passionately about their financial burdens, with some approaching interest alone of over $100 a day. Lastly, we asked support on HR2417/S.1374, FOREIGN MEDICAL SCHOOL ACCOUNTABILITY FAIRNESS

letter to you representatives in Congress on issues that are important to Osteopathic Medicine, and may also to Osteopathic Emergency Medicine. A perfect example is the H.R.4499, PROP Bill, Promoting Responsible Opioid Prescribing, which decouples the three questions on pain management from

I thoroughly enjoyed my experience at DO Day on the Hill, and now, as a veteran of the event, look forward to my next one. ACT OF 2015. This would hold all foreign medical schools to the same minimum requirements in order to be eligible to receive Title IV federal financial aid. Under the current law, some foreign medical schools are exempt from the same requirements, placing them at an unfair advantage. Dr. John Becher, AOA President, felt that advocacy should be the highest priority of his tenure in the AOA. He encouraged each and every osteopathic physician to go to www.osteopathic.org, and resister, or just enter the site, and go the Grassroots Osteopathic Link (GOAL), to access Active Issues that you can immediately send a

the HCAHPS survey, to help physicians provide the most appropriate care to their patients, without penalties. This separates satisfaction scores from payment decisions. Dr. Becher encouraged all of us to take just three minutes a month to advocate. With just that small amount, we could all make a difference! If we all did this, it would be 20,000 hours a year of advocacy! I’d also like to encourage everybody’s support on an important new bill, introduced by Rep. Trent Franks, R-AZ, H.R. 4771HELP EFFICIENT, ACCESIBLE, LOW-COST, Continued on Page 11

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What Would You Do? Ethics in Emergency Medicine been certified by a physician has lost their rights and must be transported in a secure manner. Our Regional EMS Standing Medical Orders states: ‘Restraints are to be used only when necessary in situations where the patient is potentially violent and is exhibiting behavior that is dangerous to self or others.’”

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

The following ethical dilemma was referred to us by an Emergency Department EMS Coordinator. “As many hospitals are experiencing, we have had a high volume of behavioral health patients in our facility. Some are admitted and some are transferred to hospitals or other facilities that can accommodate them. We have always utilized private ambulance companies to transfer out patients to another facility. An unfortunate incident happened enroute to another facility, from our hospital. Some of our administration believes any patient that has been petitioned and certified, and is being transferred to another facility, must be placed in restraints for the journey. I asked if this included the calm and cooperative patient, they said yes, anyone who has

The EMS Coordinator was uncomfortable with the administration’s dogmatic approach. She further states that approach was “before the advocacy of patient rights groups, especially for behavioral health protocols.” How should this be approached? What, if any, policies are out there? Does the legal (cover your rear-end) perspective have greater merit than a more principled ethical consideration for patient’s real needs? What would you do? Please send your thoughts and ideas to ThePulse@acoep.org. Every attempt will be made to publish them when we review this dilemma in the next issue of The Pulse.

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

"DO Day” continued from page 10 TIMELY HEALTHCARE (HEALTH) ACT OF 2016. This Bill supports a $250,000 cap on non-economic damages, Maximizes patient recovery of damages by limiting lawyer fees in larger lawsuits, gives full liability to health care providers not to be named in any lawsuits for any product/medicine licensed or cleared by the FDA for use. If just one of these three components was passed, it would significantly help all physicians. Call, text, email, or write your congressional representative to co-sponsor and support this bill. The more traction we can get behind it, the better some or all of the bill has to pass. We all know that capping noneconomic damages, giving more money to the patients instead of the attorneys, and dispensing with frivolous lawsuits will decrease overall health care costs. Here’s a great opportunity for you all to practice your three minutes of advocacy. Go to the ACOEP Governmental Affairs website, to find your congressman, or go to www.house.gov/representatives/find/ and enter your zip code to take you to your representative, and send him a message regarding this bill. This week, I just sent a few emails, thanking the staffers and Senator for meeting with us, and reminding them of the support we would like in Congress. It didn’t take long. And, it just might make a difference. I thoroughly enjoyed my experience at DO Day on the Hill, and now, as a veteran of the event, look forward to my next one. I’d like to encourage each and every member of the ACOEP to consider going as well—if you can make time for one or two days next April, you’ll get a chance to feel like you might make a difference, and, get a feeling of pride and reinvigoration, seeing all those medical student white coats around you, knowing our osteopathic profession is growing stronger each and every day.

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y e f G i g q y h i

o m o d F d f P f p R “ b W D H A P

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New Physicians in Practice Update Nicole Ottens, DO, FACOEP

he New Physicians in Practice Committee (NPIP) congratulates the graduating 2016 residents! Your hard work has paid off and soon you’ll be attending physicians! We are so excited for you. We have lots of great tips for you in the newly updated Membership Guide on the ACOEP website as well as in the graduation packet were sent to all graduating residents in June. If you have questions about any of the changes coming your way, don’t hesitate to contact us, we’re here to support you through this transition into “the real world.” The NPIP Committee is busy developing our Scientific Assembly Lecture Track to make it the best ever! NPIP will meet on Thursday, November 3rd from 1-3pm during ACOEP’s Scientific Assembly in San Francisco. We will host a luncheon and dedicated speaker’s track again this year, focusing on the issues and needs of New Physicians in Practice who are transitioning from resident to attending. Our current program includes: “Navigating Life After Residency,” by Chris Colbert, DO, FACOEP; “High Risk Cases in Emergency Medicine,” by Kevin Klauer, DO, FACEP; “Finding Your Work/Life Balance,” by William Frasier, DO, FACOEP-D; “Working with Residents: How to Succeed at Bedside Teaching,” by Alan Janssen, DO, FACOEP-D; and “Asset Protection,” by Legally Mine.

Part I Written Exam Date Change It is our goal to provide you with the most up-to-date information to assist you with your transition out of residency. Therefore, we wanted to be one of the first to alert you to the recent AOBEM changes to the dates for the Part I Written Exam. Starting in 2017, you will no longer be able to take Part I in March prior to graduation. You will apply by April 1st of your final year for a September 12th testing date. Currently the deadline to register for Part II Oral Boards will be July 1st (exactly one year after you graduate) for a November/ March testing date. ACOEP’s Spring Seminar For those of you who missed out on the fun, the Spring Seminar in Arizona allowed us to have a great social gathering, poolside of course! We had almost 30 people in attendance and enjoyed the time socializing and networking. It was so much fun we plan to do another event like this next spring. A big thank you to the ACOEP for sponsoring the food and drink at this fun event! Are you social? Do you like networking? Can you SnapChat, Instagram or Tweet with the best of them? Are you savvy with

Facebook and other communication tools? We need your help! The NPIP is looking for someone to be our Communications Subcommittee Chair to keep us engaged with our current and potential members. If you would like to help, please contact Gina Schmidt at gschmidt@acoep.org and she will get us connected! See You in San Fran! SAVE THE DATE: November 3rd, 2016

SAN FRANCISCO, CALIFORNIA

New Physicians in P ractice Lecture Track 9:00 am 9:30 am 10:30 am 11:00 am 11:40 am

Navigating Life After Residency (Chris Colbert, DO) High Risk Cases in Emergency Medicine (Kevin Klauer, DO) Finding Your Work/Life Balance (Bill Fraser, DO) Working with Residents: How to Succeed at Bedside Teaching (Alan Janssen, DO) Asset Protection (Legally Mine)

During this event you will have access the following opportunities:

• • • • •

1-A CME CREDITS FREE LUNCH FREE PROFESSIONAL HEAD SHOTS COMRADERIE / MENTORSHIP INSIDERS TIPS TO BOARD RECERTIFICATION

(Schedule and speakers subject to change)

New this year, NPIP members will be provided with free access to professional photographs (head shots) to make any CV have that professional look! Watch your emails, mail box, Facebook and the ACOEP website for more details. Hope to see you there!

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"Summer ” continued from page 6 of Zika virus infection are nonspecific and may mimic other flavivirus virus infections such as West Nile virus, dengue fever, chickungunya, and yellow fever. Of these viruses, dengue is the most serious and may be life-threatening. Although dengue virus causes symptoms of fevers, arthralgias, and headache, it is not associated with a rash. The presence of a rash can help distinguish Zika virus infection from dengue fever. Zika virus titers are the highest in the blood during the first week after the onset of symptoms. A definitive diagnosis of infection can be made by a positive reverse transcriptase polymerase chain reaction (RT-PCR) of the serum during the first week after the onset of symptoms. Patients with symptoms of infection in geographic areas also known to harbor dengue or chickengunya viruses should also have appropriate serologic testing performed for these viruses. Treatment is typically supportive and consists of rest and hydration. Acetaminophen is recommended for the treatment of fever and joint pain. The use of NSAID’s or aspirin in patients with unconfirmed Zika virus infection should be avoided. These medications can increase the risk of hemorrhage in patients with undiagnosed dengue fever. Patients infected with these viruses should remain under mosquito netting to prevent further mosquito transmission of infection to other individuals. Pregnant women with exposure to the Zika virus should undergo laboratory testing. They should also have fetal ultrasounds to evaluate for the presence of microcephaly and/or intracranial calcifications. If fetal intracranial findings are detected on ultrasound, an amniocentesis should be performed and RT-PCR testing for Zika virus should be performed on the amniotic fluid. Since the onset of the Brazilian outbreak of Zika virus in May 2015, Brazil has witnessed an alarming increase in infants born with abnormally small heads with resultant serious brain defects. On April 13,

2016, the CDC issued a statement that Zika virus definitely causes microcephaly.2. This causative effect has serious implications worldwide and makes prevention all the more important. The best method to prevent disease is to avoid travel to areas with active infection. Other preventative measures include mosquito control and avoiding mosquito bites. People in areas of active infection should wear long sleeved shirts and long pants treated with permetherine. They should apply DEET containing insect repellant to their skin. Insect repellant is safe to use on children two months of age and older, but it should not be applied to the child’s hands or mouth. Mosquito bed netting should be used to prevent contraction of disease, as well as, transmission of disease from infected individuals.

a country with active Zika virus infection where they could contract infection and transmit the virus when they return to their home countries thus resulting in more widespread disease? In February, the U.S. Olympic Committee issued a statement that athletes and staff can opt out of attending the games if they are concerned about contracting the Zika virus.3. Women who are pregnant or considering becoming pregnant are strongly cautioned against attending the Games. Men who have a pregnant partner and are traveling to the Games are urged to abstain from sexual relations or to use condoms for the duration of pregnancy. 1. http://www.cdc.gov/zika/ (April 6, 2016) 2. http://www.cdc.gov/media/releases/2016/ s0413-zika-microcephaly.html (April 13, 2016) 3. http://www.cdc.gov/media/releases/2016/

The CDC recommends the following timeframes for waiting to get pregnant after a possible Zika virus exposure.

s0226-summer-olympic-games.html 4. http://www.cdc.gov/zika/pregnancy/ thinking-about-pregnancy.html

Suggested time to wait before trying to get pregnant4 Possible exposure via recent travel or sex with a man without a condom WOMEN

MEN

Zika symptoms (sx)

Wait at least 8wks after sx onset

Wait at least 6 mos after sx onset

No Zika symptoms (sx)

Wait at least 8wks after exposure

Wait at least 8 wks after exposure Talk with health care provider

People living in areas with Zika WOMEN

MEN

Zika symptoms (sx)

Wait at least 8 wks after sx onset

Wait at least 6 mos after sx onset

No Zika symptoms

Talk with health care provider

The presence of Zika virus in Brazil has raised serious concerns regarding the Summer Olympic and the Paralympic Games scheduled later this summer. Should countries send their best athletes to Rio de Janeiro? Should thousands of athletes and training staff converge on

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Board Nominates 6 Physicians for 2016 Slate of Candidates

t its meeting in April, the Board identified six physicians for the 2016 slate of candidates for the three positions available on the Board. This year, all candidate bios, as well as a video from each individual and voting instructions, can be found at www. acoep.org/boardcandidates beginning on September 1st.

Online voting is open to members from September 1st until October 30th, and on-site voting will occur on Tuesday, November 1st at the ACOEP’s Scientific Assembly, closing at 3 p.m.

Your 2016 Candidates Juan F. Acosta, DO, MS, FACOEP-D, FACEP Dr. Acosta is currently completing his first term on the ACOEP Board of Directors and serves as Secretary of the College, a position to which he was elected last fall. He also represents the emergency medicine profession on ACGME’s Osteopathic Principles Committee, and the Commission on Osteopathic College Accreditation and Council on Continuing Medical Education. Dr. Acosta has a strong background in graduate medical education through his experience as core faculty at the St. Barnabas Hospital in the Bronx, New York, and has extensive undergraduate experience at NYCOM, Weill Medical College of Cornell University, and Pacific Northwest University of Health Sciences. A strong supporter of the Foundation for Osteopathic Emergency Medicine, Dr.

Acosta served as President for two terms and now sits on the Foundation as its Immediate Past President. He continues to support and conduct research for the Foundation and often acts as a judge in its competitions. Presently, Dr. Acosta works in Yakima, Washington as the Medical Director of the Emergency Department and as the Regional Vice President for Medical Affairs for The Schumacher Clinical Partners. Active in EMS, serving as the Yakima County EMS Medical Director and sits on the Washington Osteopathic Board for Medicine and Surgery. When asked about continuing service on the Board, Dr. Acosta replied, “I hope that I get re-elected because I feel my job isn’t complete on the Board. It’s such a privilege to be on the Board and have the opportunity to represent our members on the West Coast and know that my voice is heard by the organization. I am proud to be an osteopathic emergency physician and to represent the ACOEP and its members.” Gregory Joseph Beirne, DO, FACOEP Dr. Beirne is a current member of the ACOEP Board, completing his first term. Dr. Beirne, who goes by Joe, has served as the Chair of the Emergency Medical Services Committee and on the Undergraduate Medical Education Committee, but his real passion is EMS. Dr. Beirne began his medical career as a paramedic for a hospital-based EMS system in St. Louis. He eventually became

2016

a shift supervisor and a paramedic program instructor. He did his medical training at the Midwestern University, Chicago College of Osteopathic Medicine and did an emergency medicine residency at Des Peres Hospital in St. Louis, Missouri. After graduation he stayed on as core faculty and then moved to his current position as an attending physician and EMS Medical Director and EMS Education Director at Missouri Baptist Medical Center in St. Louis. His history with EMS has come full-circle as he is now also the Medical Director for St. Louis Community College EMS program and EMS Medical Director for Respond Right EMS Academy, a privately owned EMS training program. Dr. Beirne also serves the people of St. Louis as a member of the Metro Area Advisory Council of EMS, which consists of medical directors who work to continuously improve the quality of pre-hospital care in the metropolitan St. Louis area. Dr. Beirne’s goal is to represent the interests of all ACOEP members and to provide his experience, knowledge, and leadership to the students and residents, who are the future of our College. “Working with the student chapter the last years has been one of the most rewarding experiences of my career. I also consider it an honor to represent all of the members of this college as we continue to advance the profession of osteopathic emergency medicine.” Stephanie L. Davis, DO, FACOEP Dr. Davis is currently Vice Chair of ACOEP’s Emergency Medical

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Services Committee, and as the EMS representative on the Committee on CME she is working to bring a unique experience to the Scientific Assembly in 2016 – an Active Shooter Workshop. As a trauma physician in a rural setting, she has expertise in not only emergency medicine and trauma, but also emergency medical services. Dr. Davis is currently developing a Stroke Center at her hospital, Cameron Regional Medical Center in Missouri. She has extensive EMS experience working with several ambulance services and serving as Medical Director to several others. She is also an active member of ACOEP’s Council for Women in Emergency Medicine. As a Board member she will bring her unique skills as a rural emergency physician to the College, as well as her perspective of handling a wide range of cases and injuries not seen in urban or university-based programs. She is a graduate of the Henry Ford Bi-County Hospital in Michigan and of the University of Health Sciences, College of Osteopathic Medicine in Missouri. Nicole Y. Ottens, DO, FACOEP Dr. Ottens is the current New Physicians in Practice Publications Subcommittee Chair and in the last five years on this committee helped it grow from a special interest group to a committee with a subcommittees and an educational track at ACOEP’s Scientific Assembly. She is also a member of the Continuing Medical Education Committee. Dr. Ottens has served as an ACOEP Student Board Member, the American Osteopathic Association Board of Trustees Resident Member, Chair of the Council of Interns and Residents within the AOA, and has been a delegate to AOA’s House of Delegates. She has served as a board member for the Illinois Osteopathic Medical Society (IOMS) as a student, resident and

district trustee for two different districts. She has also chaired the IOMS Education Committee. Dr. Ottens is a physician at the Sarah Bush Lincoln Health Center in Mattoon, IL. She is boarded in emergency medicine and family medicine. She’s an ACOEP fellow and a Clinical Affiliate Faculty Member at the Chicago College of Osteopathic Medicine. She is a wife, and mom to Brady, Bailey and Olivia. In her spare time, she is a runner and triathlete. Jeremy D. Tucker, DO, FACOEP, FACOI Dr. Tucker is the current Chair of the Practice Management Committee and also represents ACOEP on ACEP’s Emergency Medicine Practice Committee. He is the Vice President of the Mid-Atlantic Region, as well as National Medical Director for Patient Safety for US Acute Care Solutions. His passion is to grow healthcare companies by focusing on process, company culture, efficiency and team building. He has expertise on clinical practice, leadership development, patient safety, quality, and risk mitigation. Technology is an important tool and he has expertise on leveraging technology to solve healthcare problems. Dr. Tucker is on the board of Fruit Street Health, PBC, Co-Founder of Medssenger and board of trustees for US Acute Care Solutions PAC, and is currently involved with multiple tech start-ups. Dr. Tucker is a graduate of the emergency medicine/internal medicine residency program at Midwestern University and is certified in both specialty areas. He has numerous publications on practice management and has lectured widely on these topics.

Christopher P. Zabbo, DO, FACOEP, FACEP Dr. Zabbo is currently the Program Director of the Emergency Medicine Residency Program at Kent Hospital in Warwick, Rhode Island. He has a Clinical Associate Professor of Emergency Medicine faculty appointment at UNECOM. He has been a member of the ACOEP’s Committee on Graduate Medical Education since 2011, and now serves as the Vice Chair. He is also the current President of the Rhode Island Chapter of the American College of Emergency Physicians. Dr. Zabbo has extensive leadership experience having served on the Board of Directors for Healthcentric Advisors and Toll Gate Indemnity. Dr. Zabbo graduated from the Emergency Medicine Residency at The Warren Alpert Medical School of Brown University in Providence, RI. As a physician he has an extensive background in research, publishing numerous papers and projects during and since the end of his training in 2008. Dr. Zabbo is dedicated to emergency medicine education at both the undergraduate and postdoctoral levels. He believes that with the impending move toward single accreditation for graduate medical education, it is imperative to strengthen our relationship with medical students to stimulate enduring membership in our College. Continuing to raise our College’s educational events to the next level remains one of Dr. Zabbo’s goals. His advocacy efforts to improve GME funding and increase emergency medicine residency positions are ongoing. Only ACOEP members in good standing are eligible to vote for ACOEP’s Board. Voting is easy online and later in the summer all qualified members will receive voting instructions. If you are uncertaing of your membership status, please email sstephens@acoep.org.

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Do You Have the Urge to Serve?

COEP is looking for physicians interested in serving on its Board of Directors beginning in 2017. At that time there will be three positions available on the Board. To be considered for a position on the Board you must meet the following three requirements: (1) You are an Active, Fellow, or Distinguished Fellow members are eligible to serve on the Board of Directors. (2) You have been an ACOEP membership for a minimum of five years. (3) You have an established record of service to the profession of emergency medicine or in a leadership status as a Committee or Subcommittee Chair or Vice Chair for two years.

The Nominations Committee of the College will conduct interviews with interested physicians who meet the above criteria on Tuesday, November 1 from 11:00 a.m. to 4:00 p.m. at the Hilton San Francisco Union Square Hotel in California. Interviews are by appointment only. Interested parties should send their current CV and a letter outlining their interest in serving the College to: ark A. Mitchell, DO, FACOEP-D M Chair, Nominating Committee ACOEP 142 E. Ontario Street, Suite 1500 Chicago, IL 60611 Or to janwachtler@acoep.org, please mark â&#x20AC;&#x153;Nominations Committeeâ&#x20AC;? in the subject line.

Au Sa N D Te Br

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EM Jobs in Texas! Austin San Antonio Northeast Texas Dallas/Fort Worth Texas Hill Country Bryan/College Station

Search our current job openings online at

www.eddocs.com/careers

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Member News

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

COEP members are incredible and Freya Dittrich, DO is no exception! In June she competed in NBC’s Spartan, Ultimate Team Challenge by the producer of American Ninja Warrior. Hosted by the NFL’s Dhiani Jones, Spartan, is an intense physical challenge. According to NBC’s website, “Groups of friends, families, co-workers and more must work together as they race across specially designed Spartan courses engineered to

test their determination, endurance and will. Teams of five compete on one the most demanding courses ever devised and have to push through the pain to win $250,000.”

the grueling Boston Marathon this year, and with the Fargo Marathon in May, she’s just finished her 15th. In the past year Sonya has run the Reykjavik Marathon, the Riga Marathon, and is registered to run the 2016 Budapest Marathon in October.

Congratulations Dr. Dittrich! ACOEP’s own Sonya Stephens, Director of Member Services and Gina Schmidt, Senior Coordinator of Data Management, have been busy pounding the pavement! Both of them have participated in many endurance running events including the Napa Valley Marathon, where they both ran personal bests. Gina completed

Alexis LaPietra, DO, has spearheaded an initiative to drastically reduce opioid use as a response to common conditions. At her program, St. Joseph’s Regional Medical Center in Paterson New Jersey, opioids are no longer the first tool used when treating kidney stones, musculoskeletal pain, sciatica, headache, or extremity fracture and joint dislocation. Dr. LaPietra will lecture at the upcoming Scientific Assembly where she will also receive the Innovative Practice Award.

C W b a t l a r S O t p

ACOEP Needs You!

Calling all physicians who have experienced the trials of medical school, the stress of residency, and the excitement of becoming an attending physician. We’re looking for everyone who has dealt with difficult patients, had to deliver tragic news, has worked through the confusing web of getting finances in order, has experienced daunting job searches, and has survived to tell the tale!

ACOEP’s Mentorship Program Needs You! ACOEP’s members have valuable experience and perspective to share and to pass along to the next generation of emergency physicians. Becoming a part of ACOEP’s Regional Mentorship Program is an exciting way to give back to the medical community and to help up-and-coming doctors find their way in the ever-changing landscape of emergency medicine. The Regional Mentorship Program, is an exciting initiative that provides all osteopathic medical schools with a team of mentors dedicated to passing on lessons that can only be learned in the trenches. Each mentor team, consisting of one board member, one regional mentor, and multiple supporting mentors, provides honest, individual advice, insight and guidance. Students can approach mentors individually to ask questions about everything from board examinations to residency programs.

For more information, visit: www.acoep.org/mentorship

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World Association of Disaster Emergency Medicine News Brief Cameron T. Bubar, MPH, MS-I

his year, the first student club representing World Association for Disaster and Emergency Medicine was established at University of New England College of Osteopathic Medicine. UMEâ&#x20AC;&#x2122;s WADEM club establishes a platform that brings the resources of WADEM to the up and coming health professionals of Maine, training this generation of providers on large-scale evens that effect communities all over the world. Club members include representatives from the colleges of Social Work, Public Health, Pharmacy and Osteopathic Medicine with the initiative to recruit additional health profession programs.

This year the club hosted discussions on disaster medicine tools such as, Incident Command Systems and Hazard-Vulnerability Assessments as well as topical issues like the impact of viral outbreaks. Next year, members will be participating in an emergency pharmaceutical dispensing Point of Distribution (POD) exercise and attending the international WADEM Congress on Disaster and Emergency Medicine in Toronto.

are an ever-increasing priority.Â While traditional emergency medicine serves a critical role during disaster response and recovery, training well-rounded, multidisciplinary physicians who understand the dynamics of the four stages of disaster planning will help improve the resiliency of our society and healthcare infrastructure, and undoubtedly improve the field of disaster medicine. This is our hope for the future; starting now with the UNE COM student club.

Current events conti n ue to demonstrate how disaster medicine and preparedness

From left to right: John Levasseur, OMS II; Sam Broder, OMS II; Dr. Bill Bograkos; Victoria Huckestein, OMS I; Cameron Bubar, OMS I; and Dr. Stacey Thieme. (Photo credit: Natalya L Gorsky, Staff Assistant, IPEC).

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Woman in a Man’s Role Overcoming double standards in leadership in the ED Stephanie Davis, DO FACOEP

s female physicians in this generation, we work in a male-dominated field. Although as we see the trends of medicine, and particularly emergency medicine, changing, we still work in an environment and with individuals who have become accustomed to interacting with male physicians. The way in which we not only communicate, but portray confidence can often be perceived as being arrogant, cocky or frankly down right bitchy. I recently had an experience with my emergency department nursing director taking a complaint about my behavior to not only the nursing director, but also the CEO of the hospital (aka my boss). I was shocked when I was called before them questioning my behavior over the past six months to a year. You see I work in a small rural hospital. It is me and 2-3 other nurses at one time. Each of these nurses I know on a personal basis. I know their children, their husbands, even their birthdays. I have often socialized with several of them outside of the workplace. In time that my behavior had been in question, not once did any of my nursing staff come to me with concerns. Research supports a strong link between confidence and perceived competence. Women suffer for our lack of confidence. We are more susceptible to social fear. When we react, speak or behave in the same manner as our male colleagues, we are evaluated negatively for using the same confident language and assertive style. When women are acknowledged to have been successful, they are less liked and more personally

I am a woman in a man’s world. I do not have the privilege of being an ass. — The Imitation Game. derogated than equivalently successful men; being disliked can have careeraffecting outcomes, for overall evaluation and advancement, salary and bonuses, not to mention the shear complexity added to the work environment. Everything said must be said in some way – in some tone of voice, at some rate of speed, and with some intonation and volume. We may consider what to say when speaking, but rarely do we consider how to say it. Research tells us that communication styles of men and women differ dramatically. Women’s language tends to be more indirect and subtle than men’s language. As women we tend to tag declarative answers by adding yes/ no rising intonations that make statements sound like questions. We use hyperpolite forms that may involve more word usage, and very often avoiding definitive statements. All of these subtleties lead to a general notion of uncertainty or hesitancy in female speech. We are taught to be non-assertive, uncertain, polite, and proper in our speech and if we don’t comply, we are seen as aggressive or masculine. Research among women physicians highlights gender-related communication problems. Some doctors reported that nurses wouldn’t do for women doctors what they do for men. Men can be authoritarian without loss of service, but women cannot operate in the same way. When I was a young female physician

I had fought to portray, and honestly to have, the confidence that would have nurses and staff and other physicians take me seriously. The impression we must give when entering a patient room must instill almost instantaneous confidence in our abilities to assess and take care of them. As such, I learned to carry myself as if I knew where I was going. Not only did it portray confidence, but eventually this bestowed confidence in myself as well, a valuable trait in our field. I learned to stay calm and collected during stressful adrenaline-provoking situations. All of which, again, portrayed the confidence I wished to emanate as did my male counter parts. I do not aspire to be a “nice” girl. I aspire to practice excellent, confident, emergency medicine. I am inspired by the quote, “I realize that there is nothing as useless and inconsequential as a ‘nice girl,’” SLuckettG, Canadian emergency medicine resident, April 7, 2016. What I didn’t realize in the short time I had been at my little rural hospital is that I do not have the privilege of being an ass. I almost never raise my voice. I almost never shout orders or demands. I am often self-sufficient and independent, doing anything and everything to help the nursing staff (my friends) make their jobs easier. While my male counter parts can be demanding, irritable, edgy, and downright disrespectful, and frankly on the

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edge of being completely inappropriate, I was not allowed this privilege. I was told that it was “not like me.” How then can we as female physicians communicate directly, confidently without seeming obnoxious, aggressive or arrogant? As strong women is it inevitable to be perceived as difficult? Do we necessarily have to communicate differently than our male counter parts? I answer that you can be strong and not be obnoxious.

boiled down to a simple conversation about comparing myself to another physician. The nurse felt that because I had acted offended at her comments that I had indeed become upset with her. From that point forward for several months any interaction we had she had read into my comments, behavior or demeanor. She noted my sarcastic or humorous comments as less than humorous from her perception. The number one rule: don’t personalize things that aren’t personal. In the emergency department we are

about the length of stay, the time of decision to admit, the time to antibiotic administration, or even the Press Ganey Score. It’s about the people! The better you understand people- not just your patient but the staff, nurses, your boss, and your colleagues- the more successful you will be. The key is to realize they are really not that complicated. People like to be praised, not criticized. Praise energizes us and makes people feel capable. Criticism makes us feel bad and uncertain. Be generous with praise and careful with criticism. Words carry a huge amount of

The question then is how? Here are some tips I have learned through my experience. First, focus on being respected, not liked. Often as females we are prone to seek this affirmation that we are liked, especially by other females. As a physician it is far more important to be respected. There is also a crucial difference between the two. You cannot control if someone likes you. It is simply out of our control. However, if you conduct yourself in such a way that demands respect, staff respond to it. Interestingly, when you focus less on being liked and more on being respected, guess what, they tend to like you more. Score! Second, watch the fine line between friendly humor and sarcasm. As professionals, we must watch our sarcastic comments that can often be perceived as disrespectful or derogatory. It is best to be straightforward, saving the humor and sarcasm for appropriate times. Nurses will respect the fact that they understand exactly what you are trying to communicate. If you think to yourself, “will this be perceived as offensive,” it more likely will be. In my experience, what had triggered this major concern over my behavior

like family. We work closely day in and day out, depending on each other’s strengths, weaknesses and abilities. We are thrown into close intimate relationships with people we may not often have anything to do with. And just like family, we are set up for failure, for conflict. Don’t personalize. When we treat each interaction as if there is no personal component we not only prevent ourselves from over-reacting, we also diffuse any personal conflict.

weight, so choose and use them carefully. I am a women in a man’s world. I am a confident, competent female emergency medicine physician. I don’t aspire to be a nice girl, but I hope to be perceived as so. I aspire to practice good, confident emergency medicine, and to inspire the next generation of female physicians to aspire to the same.

At its most basic level, medicine isn’t

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

Title: Is TMP/SMX useful in treating uncomplicated skin abscesses?

Title: Rethink the chest radiograph after ultrasound guided RIJ CVC

Article: Talan DA, Mower WR, Krishnadasan A, et al. TrimethoprimSulfamethoxazole versus Placebo for Uncomplicated Skin Abscess. N Engl J Med. 2016. 3 ;374(9): 823-32.

Article: Hourmozdi JJ, Markin A, et al. Routine chest radiography is not necessary after ultrasound guided right internal jugular vein catheterization. Crict Care Med. 2016; Epub ahead of print.

What we know: ED visits for skin abscesses are on the rise with more than 50% being credited to MRSA in some studies. Greater than 80% of all skin abscesses will resolve with incision and drainage alone.

What we know: Until now, the standard of care was to routinely evaluate for placement and complications of internal jugular venous catheter placement with a chest radiograph.

Article Review: This was a randomized double blind control trial of 1247 patients either given TMP/SMX or placebo for an uncomplicated skin abscess after incision and drainage. The primary outcome was clinical cure 1 to 2 weeks post completion of treatment. In a modified intention to treat analysis, a cure rate of 80.5% and 73.6% was found in the TMP/SMX and placebo groups respectively (p=0.005). TMP/SMX was also found to decrease subsequent surgical drainage procedures (3.4% vs 8.6%), skin infections at new sites (3.1% vs 10.3%) and infections of household members (1.7% vs 4.1%) as compared to placebo. Commentary: While success rate is still very high with incision and drainage of skin abscesses, it is important to note that the use of TMP/SMX may be of benefit to patients to prevent treatment failure and secondary complications.

Article Review: In this study, authors conducted a retrospective chart review of 1322 US guided RIJ CVC attempts at an academic tertiary care hospital over a 1 year period. The overall success rate was 96.9% with an average of 1.3 attempts. There was only one pneumothorax (0.1% 95% CI 0-0.4%) and the rate of catheter misplacement requiring reposition was 1% (95% CI 0.6-1.7%). Multivariate regression analysis showed no correlation between high-risk patient characteristics and complication rate. Commentary: This study suggests that routine use of chest radiography when using US guidance for CVC may not be necessary. US guidance offers real time verification of line placement and can be used to detect a pneumothorax at the patientâ&#x20AC;&#x2122;s bedside.

Title: Video laryngoscopy may be superior to direct laryngoscopy when cervical spine is immobilization is required. Article: Foulds LT, McGuire BE, and Shippey BJ A randomised cross-over trial comparing the McGrath(ÂŽ) Series 5 video laryngoscope with the Macintosh laryngoscope in patients with cervical spine immobilisation. Anaesthesia. 2016 Apr;71(4): 437-42. What we know: It is important to maintain immobilization while intubating a patient with a suspected cervical spine injury as even slight movement may cause catastrophic spinal cord injury. However, maintaining cervical spine immobilization limits positioning for direct laryngoscopy which may decrease first attempt success rates. Article Review: This was a randomized cross over trial comparing video laryngoscopy using the McGrath Series 5 vs direct laryngoscopy with a Macintosh laryngoscope in 49 patients placed in cervical spine immobilization. The primary outcome was view obtained while the secondary outcome was time to tracheal intubation, success rate, and complications. Using video laryngoscopy, the view was better but there was no significant difference in time to endotracheal intubation. There were no failed intubations in the video laryngoscopy group and 28% in the direct laryngoscopy group (p<0.02). Commentary: Although this was a small study, it does demonstrate that video laryngoscope maybe a safer option for intubation when the cervical spine requires immobilization.

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Title: Throwing the kitchen sink at cardiac arrest, does it matter whatâ&#x20AC;&#x2122;s in that sink? Article: Kudenchuk PJ, Brown SP, Daya M, et al. Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest. N Engl J Med 2016. 5;374(18): 1711 â&#x20AC;&#x201C; 22. What we know: Amiodarone and lidocaine are commonly used medications for pulseless V-tach and V-fib that is refractory to shock. However, there is limited data demonstrating their utility or lack-there-of. Article review: This was a randomized double-blind placebo controlled trial with 3026 patients who experienced out-ofhospital atraumatic cardiac arrest, and shock refractory v-fib or pulseless v-tach. From 10 North American sites, paramedics enrolled patients who were randomly assigned to amiodarone (974) lidocaine (993) or saline (1059) arms. The primary outcome measured was survival to hospital discharge with a secondary outcome being favorable neurological outcome at discharge. Of the three arms, there was no statistically significant difference in survivability at discharge (amiodarone 24.4%, lidocaine 23.7%, and placebo 21%) and neurologic outcomes were similar between the three groups.

Title: NSAIDs best for Renal colic pain control? Article: Pathan SA, Mitra B, Straney L, et al. Delivering safe and effective analgesia for management of renal colic in the emergency department: a double-blind, multigroup, randomised controlled trial. Lancet. 2016 Mar 15 Epub ahead of print. What we know: Pain management for renal colic can very difficult to address. Previous studies have been attempted to determine appropriate and timely analgesia but have been limited due to difficulties with blinding, small sample size, and difficulty with measuring appropriate outcomes. Article Review: This was a double blind randomized control trial with three treatment groups. Adult patients with moderate to severe renal colic were randomized to a treatment block of diclofenac, paracematol, or morphine. The primary outcome was a 50% reduction in pain 30 min after treatment. This study included 1644 patients with 1316 patients having a renal calculi detected. A

total of 68% of the patients who received diclofenac had 50% reduction in pain after 30 min while 66% and 61% of those who received paracematol and morphine respectively reached this outcome. When compared with morphine, diclofenac was superior to achieving the primary outcome of pain reduction by 50% within 30 min of treatment (p=0.0187). More adverse events were noted in the morphine group as compared to the diclofenac group (4% vs 1%; p=0.0088). Commentary: Treatment of pain in a timely manner when a patient presents to the ED with renal colic is crucial. This study demonstrates that diclofenac has superior reduction in pain control when compared to morphine without the associated side effects. Therefore it seems reasonable to start with diclofenac as the first line analgesic when patients present with renal colic.

Commentary: This study demonstrates that there is no statistically significant difference between using amiodarone, lidocaine or placebo when looking at survival to discharge and neurological outcomes in patients who experience atraumatic, shock refractory v-fib or pulseless v-tach cardiac arrest.

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Collaboration in Emergency Care Brittany Newberry, PhD, MPH, ENP, FNP

t Indian Path Medical Center in Kingsport, Tennessee (TN), K. Kay (KK) Moody, DO is championing collaborative practice in the Emergency Department (ED) where she serves as Department Chair. For Dr. Moody, this is not a new model of care. “I have always practiced with Physician Assistants (PA) and Nurse Practitioners (NP) in the ED so I would not know any other way. This is probably true for most recently trained EM Docs - this is the new norm.” Along with Angela Deschner, FNP and Heather “Nikki” Williams, FNP, this trio seems to have mastered collaborative practice for the benefit of patient care and work-life balance. Repeatedly in the interviews, each one says in her own words that patient care is strengthened when physicians and advanced practice providers (APPs) work collaboratively to provide emergency patient care. After years of working together, this group shares practical insights and their own experiences with collaborative care models. Interviewer: How has working in a collaborative practice impacted your patient care and/or the patient’s perception of care? Angela Deschner, FNP (AD): - “… Collaborative relationships provide a great service to the patients. In my environment there is a nonjudgmental/team work atmosphere. I am still fairly new in the ED… [The physicians] are eager and willing to help out and the patient receives the care of two providers. Cases are sometimes

discussed among all providers present making it a true team approach to care.” Heather “Nikki” Williams, FNP (NW) – “Working collaboratively in the ED gives my patients the reassurance and comfort of knowing that they are receiving the best care from our team when they see that we are working together collaboratively.” Interviewer: What are the benefits of working in a collaborative practice?

an especially hard shift.” NW – This model provides “every patient we see the knowledge and expertise of many different aspects of care for our patients…Often times it is this collaboration that can help in difficult decisions and treatments of our sicker patients to assure a better outcome in their care”. Interviewer: What are some of your biggest challenges working in a collaborative practice? KK – “Proximity. The ideal practice is close proximity of the physician with the advanced practice provider. Sitting in the same general area allows for co-management of higher acuity patients with easy and open communication. We are actively re-designing our ED’s to allow a combined space.”

K. Kay Moody, D.O. (KK): “As ED volumes continue to increase, APPs, especially experienced, well trained NPs and PAs, are worth their weight in gold.”

AD – “This is probably the hardest question for me to answer because the benefits overshadow any challenges. I guess I would have to say that there is a bit of a challenge when a new physician enters our group. The act of just learning how that provider likes things and their style of practice can provide a short-term challenge until we become familiar with each other and that relationship is formed.”

AD – “There’s a lot of respect for the [APPs] in this practice… a level of trust from the physicians that has not come so easily in other practices. I often receive encouragement and praise from my attending physician after I have endured

NW – “I think my biggest challenge at times working in a collaborative practice is the diverse amount of backgrounds and experiences that each has. With new physicians entering the practice it often takes time for that trust and reassurance

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in our skills and knowledge of patient care to build.” Interviewer: Why did you choose this particular practice group? KK – “My husband and I researched the entire country for the ideal place to live and practice. We evaluated everything from weather patterns to school systems and decided that East Tennessee would be our ideal place to raise our children. We were impressed with the kindness of the people in this area and with the contract group and with supportive administration.” AD – “I had worked with physicians from this group at a different facility and had received the same respect as a nurse and hospitalist that I now enjoy as an NP. I was familiar with their work ethics and practice and was eager to become part of the team.” NW – “Emergency medicine has always been where my heart is. This team has given the autonomy and confidence to be the best practitioner I can be… The collaboration we have within this group helps to keep our emergency room running smoothly and the patient turnover at a steady pace. The physicians in our group are great to recognize that a successful patient outcome is a collaborative experience.” Interviewer: What do you enjoy outside of the ED that helps you keep a work/life balance? KK – “We love our farm! {It offers wellness} through daily chores, feeding and caring for the many animals as well as planting hundreds fruit trees, blueberry bushes and edible plants. We hike up the mountain in our back yard and sit by the creek that runs through the pasture. There is something incredibly healing about the sound of running water, roosters crowing, and farm animals.” AD – “I try to spend my down time de-stressing by making time to give back to the community animal shelter. My

s ED volumes continue to increase, APPs, especially A experienced, well trained NPs and PAs, are worth their weight in gold. passion is dogs so I will frequently get a couple of bags of dog food and dog snacks and spend time at our local animal shelter playing with/walking the dogs there. I make time to do at least one thing I really enjoy during a shift off as I truly believe that my personal wellness is reflected in the care I provide others.” NW – “Family is very important to me. Other than watching my kids in sports, fishing is a pastime that everyone in my family enjoys as well. I love being outside and nothing makes my day more complete than being on a ball field watching my kids or on the lake with my husband enjoying the fresh air and watching him catch fish.

It’s the simple things in life that mean the most to me.” (Editor’s note: For KK, who is actively involved in leadership positions among national medical and hospital organizations, a commitment to physician wellness inspired her to develop a website promoting work-life balance (http://www.physicianwellnessstore. com). Additionally, she has developed a Facebook page for APPs in emergency care which seeks to connect physicians and APPs for resource sharing.)

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The Power to Create Real, Effective, and Lasting Fulfillment Frank Gabrin, DO

s you may already know from my previous article, I was visited by a catastrophic and unexpected health problem recently. During the months that I couldn’t work and was hospitalized, I really missed being a doctor. When I was released from the hospital, still too sick to go back to work, I considered all of my options, including not returning to the emergency department. It was through this introspection that I realized not being an emergency room doctor in this lifetime was inconceivable. All I’ve ever wanted to be, for as long as I can remember, is a good doctor. I love being a doctor. I worked with a recruiter and found a new position closer to home. Before my illness, I’d been doing locums work and traveling nonstop. Moving forward, I needed to invest more energy into better self-care. As the passing days moved me closer to my first shift, I found myself, despite my thirty years of experience, extremely anxious and nervous. I found myself thinking “Am I good enough?” Am I smart enough, fast enough, and physically well enough? Am I rusty or is it really “just like riding a bike?” What about my clinical skills, procedural skills, and interpersonal skills? Would I be able to rise to any clinical emergency? Was I really up to being the attending in the emergency department and all the responsibility that title includes? “What if I’m not good enough?” And what about the nursing and ancillary staff I’d be working with and the attending staff that I’d be consulting with? Would

they be gracious or would they be oppositional? Would they support me or challenge me?

I want my peers and co-workers to feel competent and respected. I want them to know that I appreciate their hard work. I want them to know that I’m open to their

ur current practice of medicine is almost O guaranteed to ruin our emotional health and destroy our personal lives. I wondered if I’d find the work fulfilling. When it’s all said and done and my first shift was over, would I walk out the door with that feeling of personal and professional accomplishment? Would I feel successful? Would I find happiness in this place where I want to care for others and make a tangible difference in their lives? Most importantly I wondered, “Would I love it again?” First impressions are so important in our line of work and there are no do-overs. I asked myself what sort of first impression I wanted to create. What’s my end game? What do I really want and what can I do to create that reality? I want to care for others and feel good doing it. I want to feel good about who I’m as a doctor and the clinical work that I do. I want to be a great diagnostician and a great clinician. I want my patients to feel better both physically and emotionally. After being on the other side of the stethoscope for the past seven months, I really want the staff I work with and the patients that I care for to understand how deeply I care about their overall wellbeing.

suggestions. I want, through my words and actions, to help empower everyone to create positive change for their patients, their peers and themselves. I attribute the bad behaviors of some of my nurses and doctors that resulted in not so wholesome experiences for me as a patient, to the professional burnout that’s so prevalent in health care today. I can’t judge them. I remember what it was like for me when I was severely burned out. Many of my patients at that time did not feel that I cared at all. My own personal journey back was long and arduous. It took me several years to find my way back to a reasonably healthy emotional condition. I know first-hand that many doctors and nurses are really suffering. That’s why I’m fascinated by the research that Dr. Tait Shanafelt and his colleagues are doing at the Mayo Clinic. When you look at his work, alongside the supportive information from several surveys done by Medscape, it’s easy to see WHY the problem of burnout is rapidly getting worse for us. The rate of burnout in doctors climbed from 45% in 2011 to a rate of 54% in 2014. That’s a 10% increase in just three years. It could

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continue to rise for, as of yet, there’s no prevalent cure or solution. Dr. Shanafelt shows us that burnout is a clinical syndrome where physicians experience severe emotional exhaustion, loss of meaning in work, feelings of ineffectiveness, as well as the depersonalization of other people. This has profound personal consequences for both physicians and their families. It also may effect quality of care and physician turnover. More than half of us are deeply affected. Burnout can become so overwhelming, that some of us have found suicide to be the only option. The fact that one in two US physicians has symptoms of burnout implies that the origins of this problem are rooted in our professional environment and our care delivery system rather than in the personal characteristics of individuals. Evidence indicates that this dis-ease will ultimately affect each and everyone of us, either directly or indirectly, unless we find the solution to this problem and make changes to the way we behave in our delivery of care. Shanafelt’s research reveals that physicians not only are not all that happy, they’re even unhappier while at work. Clearly we’re not being fulfilled by what we do and, for me personally, this is really sad. I truly believe, in the bottom of my

heart, that practicing medicine should be the most emotionally rewarding career on the planet. That’s just not the case today. Our current practice of medicine is almost guaranteed to ruin our emotional health and destroy our personal lives. The bulk of our workforce, more than half of us are suffering in a sort of emotional hell that’s ambiguous and difficult to articulate to others. Unless we do something differently, our medical practice will destroy our interest in life itself and leave us in abject misery. While the research continues to look for a cure, Shanafelt’s findings showed that there’s one thing we can begin do right now that can substantially blunt the effects of, and may actually provide a permanent solution for burnt out physicians. What is it you ask? It’s mindfulness-based stress reduction training which involves self-awareness, focus on the present and intentionality in thoughts and actions. This could be a game changer for us. And I know it can, because I’ve experienced it first-hand. At age 57, I was about to start all over again at a new place and I had some major anxiety about this because I wanted to really love what I do and not ever want to suffer from burnout again. I wanted to get it right.

When starting work someplace new, my mentality, and likely yours too, is to project an air of confidence and authority so the staff will respect and trust us. We cling to the mantra “never let them see you sweat!” “I got this!” After all, we’re held to a standard of care where we’re expected to be right all the time. Is it really possible for any human to be right all the time? There’s real paradox in our situation. Part of the problem is that there’s a very fine line between confidence and arrogance. If our attitude is brash, it can alienate the staff that we work shoulder to shoulder with. When we act as if we don’t need help, no one will offer to help! No one will spontaneously offer us important clinical information we may not be aware of. No one will feel free to give us helpful suggestions. We create a situation where we have to “go it alone,” and feel disconnected from those around us. So I asked myself, do I want to be right or do I want to be happy and fulfilled? I want both! I do want to be right and I want to feel good about who I’m and what I do. More than anything else, I want to enjoy what I do and have the power to create lasting fulfillment for myself and others in the Emergency Department. Because this is what I want, I decided to try a different approach: a little humility. I

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decided to drop the idea that I did not ever want the staff to see me sweat and to be mindful of my thoughts, share my fears and vulnerability with the staff, and ask for help. In his new book, The Power Paradox, Dacher Keltner, whose extensive research for the past two decades looks at the ways that power is distributed in groups, shares with us practical information that can help us to use mindfulness to rise above the effects of burnout and be more effective as physician leaders. It’s all about real power. His research shows that power is not something we can grab through

coercive force, strategic deception and the undermining of others. Real power is given to individuals by the group they’re in. He tells us that our ability to make a difference in the world is shaped by what other people think of us. That’s why first impressions and the first day of work are so important to our own happiness and sense of fulfillment.

their lives better, or worse. When we receive power from others, it feels like a vital force that surges through our brains and bodies. This surge propels us forward in pursuit of goals. We experience higher levels of excitement, inspiration, joy and euphoria which enable purposeful goal directed action. Depending on our consciousness or intent, this experience of power propels us forward in one of two directions: • Toward corrupted, abusive, impulsive, unethical and self-serving actions • Toward benevolent behavior that

advances the greater good Power makes us feel less connected and dependent on others so we begin to focus on our own personal goals and desires. Keltner’ research shows that this kind of power can corrupt us in four different ways: Cause deficits in empathy and morality.

Our capacity to influence others depends on their trust in us. Our ability to empower others depends on their willingness to be influenced by us. Our power is constructed in the judgments and actions of others and when they grant you power, they increase your ability to make

Induce self-serving impulsivity. Generate disrespect and insensitivity where our words and deeds are completely void of human dignity

Lead to narratives of exceptionalism. The self-centered abuse of power is always costly in many different ways to both the individual who has been given power and the group of people who gave it to them. Trust in the community declines, performance at work is compromised and our health fades away. For those who abuse power, their egocentric and selfish intentions lead to outcomes where both the powerful individual and the group feel that their overall situation is diminished or depreciated. This is a losing situation for everyone involved. The group will always diminish the ranking or standing of those who abuse their power by behaving selfishly. The group will no longer give power to those who are no longer interested in advancing the greater good for the group. On the other hand, when our primary intention is to add value to others, Keltner’s experiments revealed that our words and deeds will automatically advance the greater good of the entire group. In turn, and in all circumstances, the group will reward us with enduring power allowing us to enjoy lasting fulfillment and satisfaction. Keltner’s work consistently proves that individuals who were given power by the group because they remained kind and focused on the overall wellbeing of others, enjoyed enduring power and long lasting fulfillment along with higher levels of excitement, inspiration, joy, and euphoria. This makes good sense in light of what Keltner has shown through his research: Groups give power to individuals who advance the greater good and they diminish the standing of those who stray from this principle. In a short adaptation from his book, Keltner gives us five ethical guidelines that we can use to mindfully do the business of caring for others. His advice is spectacular and is roughly paraphrased below: 1. Be aware of your feelings of power. The feeling of power is like a vital force

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moving through our body, involving the acute sense of purpose that results when we stir others to effective action. This feeling will guide us to the thrill of making a difference in the world. People who excel in their power— the physician who improves the health of dozens of people a day, the high school teacher who inches her students toward academic success, the writer whose piece of fiction stirs others’ imaginations—they all know this. They feel the rush of dopamine and vagus nerve activation in the purest moments of empowering others and lifting up the greater good. If we remain aware of this feeling and its context, we’ll not be entrapped by myths that power is money, or fame, or social class, or a fancy title. Real power means enhancing the greater good, and our feelings of power will direct us to the exact way we’re best equipped to do this. 2. Practice Humility. See your power as a gift from others and the chance to make a difference in the world. People who are humble enjoy more enduring power. The paradox here is that the more we approach our power and capacity to influence others with humility, the greater our power is. 3. S tay focused on others and give. The most direct path to enduring power is through generosity. Give resources, money, time, respect and power to others. These acts of giving will empower others and enhance our own ability to change the game and make a difference in the world. Empowered individuals are happier. 4. P ractice Respect. When we direct respect towards others, we dignify them and elevate their standing. This empowers them. Love your neighbor as yourself, treating others with human dignity is an ancient wisdom that transcends all religion and spirituality. We can express this principle at work

and in our day to day lives through respect. Ask questions and listen with intent and be curious about others. Acknowledge them, compliment them and praise them with gusto. Express your gratitude.

interactions among strangers, friends, work colleagues, families, and community members that are defined by commitment to the greater good, where the benefits people provide one another outweigh the harms they cause.”

5. Change the psychological context of powerlessness by applying the first four guidelines above. Pick one aspect of powerlessness in the world and change it for the better: Attack the stigma that devalues women. Confront racism. Create opportunities within your workplace that empower those who don’t feel powerful.

As the time for me to work my first shift drew ever closer, I kept all this in mind. Although my anxiety made it rough to sleep before showing up, I’m happy to tell you that I successfully and mindfully completed my first shift in the emergency department. I really enjoyed myself. I loved the staff and my patients. I felt both confident and humble. It felt really good to practice medicine again.

Incorporating these five mindfulness practices in our day to day can begin to create real change for yourself and those you work with. In Keltner’s words: “In every interaction, we have the opportunity to practice empathy, to give, to express gratitude, and to tell unifying stories. These practices make for social

As long as I can stay humble and focused on others, I truly believe that creating lasting fulfillment and escaping the clutches of burnout is possible. I’m excited about returning for the next shift. Until next time, go care, make a difference and change (y)our world!

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• Easily earn CME online • A ccess hundreds of hours of lectures from ACOEP conferences and events • C u st o m i ze d l e c t u r e s f or a tt e n d i n g physicians, residents and students • Discounts available for ACOEP members

Available at: www.acoep.org/classroom

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The Zika Virus: What the ED Physician REALLY Needs to Know R. Scott Taylor, DO; Matthew Pitzer, DO; Sasha Hallett, OMS II and John Ashurst DO, MSc Arizona College of Osteopathic Medicine, Midwestern University Duke Lifepoint Memorial Medical Center

The Zika virus is expected to continue to spread, so it is imperative that emergency medicine providers are aware of the virus and are able to recognize possible signs and symptoms of the disease. As the virus spreads and while more studies are being conducted, emergency medicine providers must keep current in order to offer preventative information to patients and provide quality health care, as they encourage research efforts to create a vaccine. Epidemiology The Zika virus was first described in a sentinel rhesus macaque from the Zika forest of Uganda in 1947 with the first human case being reported in Nigeria when three individuals fell ill in 1953. Over the next 50 years, the virus dwelled in relative obscurity until 2007 when 5,000 of the 6,700 inhabitants of the Federated States of Micronesia became infected. In March 2015 the virus reached the Americas and on February 1, 2016 the World Health Organization declared the virus to be a Public Health Emergency of International Concern. As of this writing, 58 countries and territories have reported transmission of the virus.

blood, urine, semen, saliva, CSF, amniotic fluid as well as breast milk. Non-mosquito borne transmission can occur through a variety of means. Sexual transmission to partners can occur in those who have been infected with the virus. More concerning, however, is that mother to fetus transmission has also been noted. This mode of transmission has been linked to adverse fetal outcomes, most notably microcephaly. Although no cases have been reported of blood transfusion related infection, the emergency physician must be aware of this risk in the future. Clinical Picture The vast majority of those infected with the virus are asymptomatic with only 20% of those infected exhibiting the signs and symptoms of the virus. Characteristic clinical findings are acute onset of fever with a maculopapular rash, arthralgia or conjunctivitis. Other commonly reported symptoms are myalgia and headache. The disease is typically mild, with symptoms lasting approximately 7 to10 days. The likelihood of severe disease requiring hospitalization and fatality is low.

traveling to an endemic area. Laboratory diagnosis is accomplished by testing serum or plasma to detect for viral nucleic acid or virus specific immunoglobulin M and neutralizing antibodies. In those suspected to be infected with the virus, evaluation for co-infection with Dengue Fever and Chikungunya virus should be obtained given the similar geographic distribution and symptomatology. Treatment Treatment is largely supportive. There is no specific antiviral treatment available for the Zika virus. The best treatment, however, continues to be the prevention of contracting the Zika virus, especially for the immunocompromised patient populations. Travelers should be instructed on using mosquito repellent, treating clothing with permethrin, sleeping in bed nets and using window screens. References • Petersen LR, Jamieson DJ, et al. Zika Virus. NEJM 2016; 374(16): 1552 – 1563. • Centers for Disease Control and Prevention. Zika Virus. http://www.cdc.

Diagnosis

gov/zika/index.html • Zika Virus. TheBMJ. February 2016. http://

Transmission The Zika virus is a single-stranded RNA virus of the Flavivirdae family. Two types of human transmission occur in the wild: mosquito and non-mosquito. Human viral transmission is primarily through the bite of an infected Aedes mosquito. Once infected, the virus has been detected in the

Diagnosis is largely is based off clinical suspicion, travel history as well as the patient’s clinical features. Clinical suspicion for Zika virus should be raised with patients exhibiting two or more of the following in those who present to the emergency department: low grade fever, maculopapular rash, arthralgia and conjunctivitis coupled with a history of

www.bmj.com/freezikaresources • Z ika Virus Resource Centre. The Lancet. http://www.thelancet.com/campaigns/ zika • Z ika Virus. The World Health Organization. http://www.who.int/ mediacentre/factsheets/zika/en/

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Assistant/Associate Residency Program Director

The Emergency Medicine Department at Penn State Milton S. Hershey Medical Center seeks energetic, highly motivated and talented physicians to join our Penn State Hershey family. Opportunities exist in both teaching and community hospital sites. This is an excellent opportunity from both an academic and a clinical perspective.

Emergency Medicine Core Faculty

As one of Pennsylvania’s busiest Emergency Departments with 26+ physicians treating over 70,000 patients annually, Penn State Hershey is a Magnet® healthcare organization and the only Level 1 Adult and Level 1 Pediatric Trauma Center in PA with state-of-the-art resuscitation/trauma bays, incorporated Pediatric Emergency Department and Observation Unit, along with our Life Lion Flight Critical Care and Ground EMS Division.

Pediatric Emergency Medicine Faculty

For additional information, please contact: Susan B. Promes, Professor and Chair, Department of Emergency Medicine, c/o Heather Peffley, Physician Recruiter, Penn State Hershey Medical Center, Mail Code A590, P.O. Box 850, 90 Hope Drive, Hershey PA 17033-0850, Email: hpeffley@hmc.psu.edu

We offer salaries commensurate with qualifications, relocation assistance, physician incentive program and a CME allowance. Our comprehensive benefit package includes health insurance, education assistance, retirement options, on-campus fitness center, day care, credit union and so much more! For your health, Hershey Medical Center is a smoke-free campus. Applicants must have graduated from an accredited Emergency Medicine Residency Program and be board eligible or board certified by ABEM or AOBEM. We seek candidates with strong interpersonal skills and the ability to work collaboratively within diverse academic and clinical environments.

The Penn State Milton S. Hershey Medical Center is committed to affirmative action, equal opportunity and the diversity of its workforce. Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled.

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• A FOUNDATION DEDICATED TO RESEARCH IN OSTEOPATHIC EMERGENCY MEDICINE

Sherry D. Turner, DO, FACOEP, MPH President

Foundation Focus

he Foundation for Osteopathic Emergency Medicine hosted several exciting events at ACOEP’s Spring Seminar in Scottsdale, AZ. Kicking off the week was the FOEM Case Study Poster Competition, which boasted over 30 unique and interesting cases presented by residents and a few ambitious students. The quality of the presentations was exceptional. Congratulations to the top three winners are as follows: 1 st - Olivia Reed, DO Intermittent Dysarthria in the Face of Intracranial Bleeding Norman Regional Health Systems Norman, OK 2nd - Laura Mader, DO First case of survival in refractory ventricular fibrillation following “dualaxis cardiac defibrillation” and esmolol administration. St Mary Mercy Hospital West Islip, NY

Next up on the docket was the FOEM 5K Run for Research. A perfect spring sunset and cool breeze made this year’s event the perfect running environment. Donning their bright yellow 5K t-shirts, more than 70 runners participated in the charity event, which raised funds to advance the Foundation’s mission. The winners of this year’s race were: Men’s Bracket 1st – John Sillery, DO (15 min.; 10 sec.) 2nd – Jake Current, DO (19 min.; 29 sec.) 3rd – Adam Sadowski, DO (19 min.; 36 sec.) W omen’s Bracket 1st – Marge Peddit, DO (20 min.; 49 sec.) 2nd – TIE – Lauren Warner, DO and Veronica Coppersmith, DO (27 min.; 19 sec.)

3rd – Alyssa Johnson, DO (28 min.; 18 sec.) Last, but not least, the Foundation had the pleasure of teaming up with the Las Vegas Convention and Visitors Authority and National Hotel Sales to host the Clean the World Event. The event took place at the Welcome Reception of the Spring Seminar, and consisted of hundreds of ACOEP members and their families taking the time to pack hygiene kits for the homeless. These kits added up to over 20 huge boxes that were promptly donated to the local homeless community in Scottsdale. Thank you to all of the kindhearted volunteers that made this event so successful!

3rd - Moises Moreno, DO A Case of Hip Pain, Masquerading a More Serious Etiology Good Samaritan Hospital Medical Center Livonia, MI

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Thank You for Supporting a Medical Mission Trip to the Philippines The Foundation isn’t just fulfilling its mission on site at meetings, but all throughout the year through a variety of grants and programs. One such grant that we are particularly proud of is the funding of the medical supplies for a mission trip to the Philippines, which took place in March of 2016. It is so rewarding to see the tangible value of our work. Please enjoy this letter of appreciation from grant recipient and ACOEP Student Chapter President Cameron Meyer.

the surgeries, imaging, and/or procedures they needed. The local government was kind enough to let us use a local hospital/clinic for ten days. Each day people from all around the island were bused to our clinic. Our clinic started each day at 8:00 AM and ended after everyone was seen. Our team consisted of 2 physicians, 4 medical students, 2 nurses, and a handful of volunteers. Over the course of 10 days we were able to provide care for 1400 people. The second part of our mission trip

ue to the generous donation by FOEM we supplied D these clinics with Infant and adult scales, wheelchairs, a stretcher, air conditioners, and many other items. “Like many places around the world the island of Guimaras, in the Philippines, is full of thousands of underserved individuals in need of basic medical attention. On February 20th we embarked on a mission trip to serve this population. There were two parts to this trip. The first was to setup a clinic where locals could come and receive medical attention. In this clinic we were able to diagnose and treat a variety of pathologies including skin infections, urinary tract infections, rheumatic fever, pneumonias, otitis media, and many others. We also performed procedures including incisions and drainages, and wound debridement. The countless children that visited our clinic received wellness exams and expecting mothers were given prenatal vitamins. Another part of our clinic was screening for diabetes and hypertension. Once patients with these diseases were identified, we provided education about their disease process and lifestyle modifications. Some patients we saw had needs that we were not able to treat given our limited resources. These individuals were provided with transportation to another island and financial assistance to pay for

was made possible by the Foundation for Osteopathic Emergency Medicine. The hospital we worked at and another clinic on the island were in dire need of supplies. Due to the generous donation by FOEM we supplied these clinics with Infant and adult scales, wheelchairs, a stretcher, air conditioners, and many other items. The item they were most excited to receive was a Doppler ultrasound. In the US this is considered a vital piece of equipment in obstetrics and vascular pathologies, but this labor and delivery clinic had never had one before. This will allow the providers of this clinic to significantly enhance the prenatal care they provide to expecting mothers. Also members of the ACOEP Board of Directors were kind enough to donate money for supplies to allow us to more fully equip these clinics. Our mission trip was a great success. We are grateful for all the assistance we received especially from the Foundation for Osteopathic Emergency Medicine and the ACOEP members who donated to our trip. Due to the overwhelming success of our trip, we will be doing a similar trip in 2 years. We greatly appreciate your continued mentorship and support as we

continue our efforts to provide excellent care to those who need it most. Sincerely, Cameron Meyer OMS IV ACOEP-SC Past President Timothy Bikman OMS III ACOEP-SC President”

2016 Case Study Poster Competition Winning Abstracts 1 st - Olivia Reed, DO Intermittent Dysarthria in the Face of Intracranial Bleeding Norman Regional Health Systems Norman, OK Authors: Olivia Reed, DO, PGY-1, Emergency Medicine Resident, Norman Regional Hospital Robin Mantooth, MD, Chief of Staff Elect, Norman Regional Hospital Introduction: This case describes a patient who presented to the emergency department with complaints of difficulty speaking that only occurred during times of extreme emotional stress. Despite complete resolution of her dysarthria and an unremarkable neurological exam, CT demonstrated a left temporal lobe parenchymal hemorrhage with left temporoparietal subarachnoid hemorrhage. This case demonstrates an unusual presentation of a life threatening process. Case Description: A 63 year old Caucasian female with a past medical history of hypertension presented to the emergency department with complaints of difficulty speaking. Her dysarthria had started one hour prior to arrival and had completely resolved prior to examination. She described her dysarthria as “difficulty finding the right words and slurred speech.” The patient stated her dysarthria had been occurring intermittently over the previous three days when she was Continued on Page 36

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Fall Research Competitions FOEM Research Study Poster Competition

Sponsored by WEDNESDAY, NOVEMBER 2, 2016 7:30 am – 11:00 am

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

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

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

FOEM Oral Abstract Competition WEDNESDAY, NOVEMBER 2, 2016 12:00 pm – 2:00 pm

FOEM Resident Research Paper Competition Sponsored by WEDNESDAY, NOVEMBER 2, 2016 2:00 pm – 3:30 pm

This is FOEM’s most prestigious event. Participants submit their full research papers for review by a panel of physician experts. The panel identifies the top 5 papers prior to conference, and the winning resident-authors face off to determine the top 3 winners.

The deadline to apply to the Foundation’s Fall Research Competitions is 31, 2016. Apply now at www.foem.org 35 FOEM BEACON | July JULY 2016 FOEM-2016-Comps-R3.indd Pulse-07-2016-R6.indd 35 1

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"Foundation" continued from page 34 under extreme emotional stress. The first episode occurred while she was planning her father’s funeral. The second episode occurred while she was upset looking through family photos, and the third episode occurred while at her father’s funeral. Each episode lasted approximately one hour and spontaneously resolved without any residual deficit. The patient’s history also provided the provider with a mixed acute versus chronic presentation because she believed she had experienced a similar episode one year ago while under emotional stress. Her dysarthria was not accompanied by any other neurological complaints. An extensive neurological and physical exam was benign. Her review of symptoms did demonstrate a mild headache that was neither the worst headache of her life or sudden in onset. The differential diagnosis at this time included partial seizures, complex migraines, conversion syndrome, transient ischemic attack, ingestions, and head injury. A CT head without contrast was obtained and demonstrated an area of parenchymal hemorrhage involving left temporal lobe with left temporoparietal subarachnoid hemorrhage. At the time of evaluation neurosurgery was not available and the patient was transferred to a center with the capacity to provide surgical evacuation. She remained in stable condition with appropriate hemodynamic management during evaluation and transport. The patient did have a positive outcome. Discussion: This patient’s atypical presentation of primary intracerebral hemorrhage could have had devastating consequences had providers not promptly utilized diagnostic CT imaging. The estimated 30 day mortality of primary intracerebral hemorrhage is between 35% and 52%, with only 20% of patients expected to make a full recovery at six months.

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This patient’s benign presentation is particularly daunting given her subarachnoid extension of the primary

bleed, which is associated with poor outcomes. Despite finding an intracerebral hemorrhage, the source of her intermittent symptoms remained unknown. It was felt that in addition to a primary ICH, this patient was likely experiencing simple partial seizures that accounted for her intermittent symptoms. This case demonstrates the ED provider’s responsibility to detect life threatening disease processes despite uncharacteristic presentations. nd - Laura Mader, DO 2 First case of survival in refractory ventricular fibrillation following “dualaxis cardiac defibrillation” and esmolol administration. St Mary Mercy Hospital West Islip, NY Authors: Laura Mader, DO St. Mary Mercy Hospital (SMMH); Kevin Boehm, DO SMMH; Daniel Keyes, MD, MPH SMMH; Michelle Moccia, DrNP, APN, RN SMMH. Introduction: Refractory ventricular fibrillation (VF) is unresponsive to standard medications (epinephrine and amiodarone) and 3 or more attempts at defibrillation and has a very high mortality. Defibrillation along two different axes and administration of esmolol has recently been advocated. We present the first case of a patient with out-of-hospital survival using this novel approach. Case report: December 26, 2015, a 67-year-old man with prior LAD stenting transported via EMS to the emergency department (ED). He complained of “numbness in his left arm radiating into his chest.” He took 325 mg of aspirin 20 minutes prior to EMS arrival. Pain relieved by nitroglycerin. EMS ECG showed 1 mm ST elevation in anterior leads and T wave inversions in II and AVF. On arrival to ED, he “felt funny” and with upper extremities shaking, he became apneic and pulseless. He was in VF. ACLS care began, including biphasic defibrillation at 200 J. First intubation attempt failed and ventilation resumed using bag-valvemask. Resuscitation continued with epinephrine 1 mg intravenous (IV) every

5 minutes; 4 total doses given. A total of 450 mg of amiodarone administered. The patient received 4 defibrillations at 200 J and a fifth at 300 J. It was decided to attempt dual axis defibrillation and IV esmolol. The paddles of a second defibrillator were placed in a bilateral midaxillary line, each approximately 6 cm below the axillae. Defibrillation at 300 J simultaneously delivered from each device on “count of 3.” The patient remained in VF; CPR continued. A bolus of 80 mg of esmolol IV push and 0.1 mg/ kg/hr was initiated. The next rhythm check continued in VF. A second simultaneous dual defibrillatory shock was delivered in the same manner as the first, this time with return to spontaneous circulation (ROSC). With a second attempt at intubation he stated, “stop that!” Post resuscitation ECG demonstrated atrial fibrillation with 2-5 mm ST elevations in leads I, AVL, and V2-V6 and reciprocal inferior changes. Heparin bolus and drip were given. He was taken for catheterization and found to have a mid left anterior descending (LAD) lesion and underwent placement of a drug eluting stent. The patient was discharged on hospital day 4 and seen one week later in outpatient cardiology clinic. He had some chest “soreness,” and mild dyspnea on exertion, but felt “well.” He provided permission for this case report. Discussion: Hoch et al described successful double sequential external shocks for refractory v-fib in 1994. In 90 patients with refractory VF, Driver et al, in 2014 reported increased survival with IV esmolol for adrenergic hyperstimulation known as “electrical storm.” In 2015, Cabañas et al reported ten cases of refractory VF treated with double sequential external defibrillation in the prehospital setting, three with ROSC, but none survived to discharge. In 2015, McGovern and McNamee proposed dual defibrillation followed by esmolol, and then a repeat dual shock. This case report describes the first successful use of dual-axis defibrillation and esmolol administration with the patient surviving to

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hospital discharge and outpatient follow up. rd - Moises Moreno, DO 3 A Case of Hip Pain, Masquerading a More Serious Etiology Good Samaritan Hospital Medical Center Livonia, MI

and drainage of the psoas abscess. Culture of the abscess grew Klebsiella pneumoniae. Intravenous antibiotics were continued for several days. The patient recovered well. Discussion: Psoas abscess is an uncommon etiology of hip pain that is easy

to overlook due to its rarity. CT confirmed the diagnosis of psoas abscess, thought to be secondary to the foreign body. Physicians need to maintain a high index of suspicion for a psoas abscess as its signs and symptoms are highly non-specific and delaying the diagnosis may be fatal.

Authors: Moises Moreno DO, Sanford Glantz MD

Emergency Medicine Residency Program, Good Samaritan Hospital Medical Center, West Islip, NY Introduction: A psoas abscess is a rare condition with high morbidity and mortality. The clinical manifestations are often variable and nonspecific, which make it difficult to diagnose at the initial visit. This is an unusual case of a patient who presented to the emergency department (ED) with left hip pain. Case Description: A 66-year old woman presented to the ED with progressively worsening left hip pain that started 5 days prior to arrival. The pain was associated with chills and anorexia. She had progressive difficulty ambulating secondary to pain. On examination, she was in no acute distress. Her vital signs were significant for a temperature of 100.2°F orally. She had left lower quadrant abdomen tenderness without distention or guarding. There was no costovertebral angle tenderness. Her pain was greatest with active range of motion of the left hip. The remainder of her physical exam was unremarkable. Due to her left lower abdominal tenderness, a CT of the abdomen and pelvis was obtained. The CT revealed a 3.9 cm fine linear foreign body within a loop of small bowel in the upper pelvis that appeared to extend through the lateral wall and abutting the adjacent left psoas, causing a psoas abscess. The patient suspected the foreign body was a fish bone. The patient was started on ertapenem. She was taken for an exploratory laparotomy and had extensive lysis of adhesions, a small bowel resection,

To learn about • F OEM Research Competitions • F OEM Research Grants • F OEM Research Network and much more, visit: www.foem.org/research

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ACOEP and FOEM Team Up to Create the ACOEP Emergency Physicians Paradigm Research Group

he Foundation for Osteopathic Emergency Medicine (FOEM) is proud to launch the American College of Osteopathic Emergency Physicians Paradigm Research Group (ACOEP-PRG), a multi-level, longitudinal study aimed at evaluating residency training, outcomes, satisfaction, academic performance and associated costs as medical training moves toward a single accreditation pathway. Led by Michael Allswede, DO, this study will provide valuable and vital information to program directors, lawmakers, administrators, and residents as to what’s working in emergency medical training, what’s not, and how successful the single pathway is for American communities. “The purpose of this landmark project is to quantify the impact of the ACGME evaluation and certification system upon 62 emergency medicine residencies,“ says Dr. Allswede. “To my knowledge no other specialty is undertaking a project of this scope or magnitude and I’m incredibly proud that ACOEP and FOEM are so proactive in uncovering what’s working and how we can grow, to do better by our residents and ultimately our patients.” The ACOEP-ACGME realignment creates an opportunity to evaluate ACOEP residency performance within the new ACGME accreditation paradigm, as well as a chance to assess the costs and benefits of the ACGME Milestone paradigm itself. The ACOEP-PRG project will collect and analyze both objective and subjective data on a year to year basis through data

Among the 62 programs, approximately 500 core faculty members and 1,500 residents will simultaneously make this transition. The ACOEP Paradigm Research Group (ACOEP-PRG) endeavors to collect both objective and subjective data prior to and during the transition. Maintaining an osteopathic identity is of the upmost importance as these changes take place. The PRG project will also identify best practices to support osteopathic residencies engaged in this paradigm shift in the following areas: solicitations, surveys, and standardized testing. This gives researchers a chance to chart the changes as we move through the process. The data includes: • costs associated with adoption of the ACGME paradigm, • resident performance on standardized testing, • resident satisfaction, • core faculty academic performance, • core faculty satisfaction, • program director/assistant director performance, and • program director/assistant director satisfaction In 2016, 62 emergency medicine residencies, previously accredited by ACOEP will make application to the American Council on Graduate Medical Education (ACGME). Not only will these residencies administratively re-align with the ACGME to create a single accreditation system, but these residencies will simultaneously adopt the ACGME Milestones project.

• development of academic research programs, • implementation of program evaluation and resident review committee structures, • the role of the Osteopathic Postdoctoral Training Institution (OPTI), • the role of allopathic affiliation, and • financial and organizational support of academic physicians in compliance with new responsibilities and performance expectations. Programs participating in this data collection will have access to the data, giving them hard facts on the successes and drawbacks of the new training standards, measured at various points along the way. The face of medical training is changing, and hard data is a vital tool in continuing improvement, avoiding pitfalls, and adjusting to new challenges.

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FOEM Research Network Update Victor J. Scali, DO, FACOEP-D Chair FOEM Research Network (FRN) Steering Committee

uring the last 10 years, ACOEP has witnessed a dramatic transformation in the development of a resident research culture with widespread interest and productivity. This renaissance is due in large part to the adoption of a mandatory research requirement and demonstration of competency for residency graduation. A competitive spirit among residencies developed, driving quality research and productivity in the resident annual paper competition, oral presentations, posters, and abstracts, presented at the ACOEP Scientific Assemblies and Spring Seminars. When the FOEM Research Network (FRN) was originally formed three years ago, its mission was two-fold. The first mission is to provide opportunities for multi-center studies developed by our residents and core faculty research teams in a single institution. The FRN enabled more rapid acquisition of quality data to residency programs across the country. The second mission is to promote clinical research by forming a multi-residency network that enhances our ability to access pharmaceutical company (Pharma) grant funding for Phase III and post-market clinical studies directly from the industry leaders or indirectly through Contract Research Organizations (CROâ&#x20AC;&#x2122;s).

cost effective study site selection tool offered to pharmaceutical companies and contract research organizations (CROâ&#x20AC;&#x2122;s) free of charge for the first year of use. It provides unlimited access to the site selection databases of our 48 member network of emergency medicine residencies which are all aligned with medical schools and which treat an aggregate of more than two million annual ED patients. The FOEM Research Network also allows smaller residencies with less capital resources to benefit in several ways by their participation. These residencies are able to participate in clinical studies that they could not have acquired if they solicited them as a single residency applicant. Their residents benefit by a structured research program that is enhanced by residents participating in national protocols. Please be assured that the FRN will not negatively impact residency programs with established research grant pipelines, but will rather serve to enhance their revenue, and productivity with additional research opportunities.

The Hospital Emergency Department (ED), under EMTALA has evolved into the safety net for the insured and the uninsured populations alike. It acts like an epidemiologic window to the community by triaging and treating large numbers of patients in a captive setting. This unique interface allows the ED to perform disease incidence screening that potentially could have a long-term effect on overall community health, disease prevention, and health promotion. The NIH is interested in giving grants for translational research involving large population-based studies. In 2015, our first proof of concept contact with a major pharmaceutical company was testing a reversal agent for dabigatran, a well-known novel oral anticoagulant. The pharmaceutical company chose 14 sites from our site selection database with nine sites going on to meet study entry criteria. The great potential of the FOEM Research Network was further recognized in October 2015 by the American Heart Association/ American Stroke Association (AHA/ASA) with the signing of an official partnership

During a time when our healthcare system faces a shrinking financial base, a more cost effective, austere approach to clinical research has developed within the pharmaceutical and medical device industries resulting in less research funding availability. The FOEM Research Network represents a very attractive,

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agreement. This agreement has already Over 48 EM residencies have already FRN offers an early opportunity for both provided priority access to current joined the network and the ultimate organizations to collaborate on resident stroke studies, MaRISS and ARAMIS for strength of the organization will best be research and accelerate the process of several of our current 48 FRN member served by 100% participation. Thank you validating our database and treatment organizations. In addition, our partnership for your support and anticipated interest protocols. has given our member residencies super in FOEM. The FRN has great potential in If your residency program is not currently user status access to the AHA patient providing the financial strength needed to a member of the FRN but you are interested database for the conducting of original fund more resident research projects in studies. The AHA the future. contracts with 2000 hospitals We are excited T he FOEM Research Network also allows smaller and ambulatory to think what the residencies with less capital resources to benefit in clinics enrolling FRN will look like over 11 million in the next three several ways by their participation. inpatient/ years with the close outpatient collaboration of the in joining, please contact, Stephanie cardiovascular patient records through ACOEP and ACGME residencies jointly Whitmer, MNA, Executive Director of their quality improvement databases as conducting multicenter prospective FOEM, at swhitmer@acoep.org and a follows: Get with the Guidelines, Mission studies initiated by residents and core research site database will be sent to you in Lifelines, The Guideline Advantage, and faculty or by participating in large web-based format for ease of completion. Hospital Accreditation /Certification. As prospective multicenter trials that are Also, be sure to inform Stephanie if you are the American Osteopathic Association generating funding for individual residency interested in a position on the FRN Steering and the ACGME work toward a single educational enhancements and faculty Committee or possess the unique skills to accreditation system for post graduate development programs. fill one of several administrative positions training in Emergency Medicine and that are still recruiting. other specialties by the year 2020, the

ACOEP Digital The ACOEP Digital app is your hub for conference information, course materials, and more! It’s custom tailored to fit your digital life! Available for all smartphones and tablets, this free app allows you to access current and past course materials, create custom schedules, explore didactic topics, and much more!

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

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