The Pulse (January 2013)

JANUARY 2013 VOLUME XXXVII NO. 5

Presidential Viewpoints Gregory M. Christiansen, D.O., M.Ed., FACOEP

Compromise – It’s a Start

I hope everyone had an enjoyable holiday season and a happy new year. It’s a time to spend with family and friends.

It’s also a time to count one’s blessings. In these uncertain times, there is certainty we will have more uncertainty. This has been a tumultuous year with politics taking center stage as government expansion and the struggling economy have affected nearly every aspect of our professional activity.

Emergency medicine is the bellwether medical specialty for the economic state of the nation. As the safety net, we absorb the ills of the day. Current healthcare policy is fixated on cost containment through reduced physician remuneration. This will hardly cure what ails the health system as the root drivers of medical expenditures are not addressed. They are counting on us to bear the burden. Whatever happens, the eventual ‘fix’ will not be fiscally based on economic policy, but rather political expediency. For this reason most experts are not holding out on physicians avoiding the projected $400 million in ‘unspecified’

Medicare cuts. Our best recourse is to keep involved. We then have an opportunity to achieve our goals. We have recent evidence to base our optimism despite seemingly insurmountable odds. The ACGME story comes to mind as one example where diligence and team work paid off. Allow me to update you on the current progress of this collaborative effort.

In November, the American Osteopathic Association (AOA) briefed the osteopathic community on the status of the negotiations with the American Council of Graduate Medical Education (ACGME). The AOA, ACGME and the American Association of Colleges of Osteopathic Medicine (AACOM) have agreed to the concept of a single, unified accreditation system for all U.S. graduate medical education programs.

As you may recall, over a year ago the AOA learned of the extent of the ACGME proposed common program requirement to restrict future ACGME education systems from the osteopathic community. Under the rule change osteopathic interns could not have their osteopathic post graduate training recognized, residents would be denied ACGME fellowship access and current osteopathic attending educators in allopathic programs would no longer be credentialed by regulatory bodies to provide medical education. Recognizing the myriad of consequences – intended and unintended - ACOEP did its due diligence to identify opportunities for progress in the effort to support osteopathic medical education. The ACOEP was grateful The PULSE JANUARY 2013

for our many friends, colleagues and professional supporters in the emergency medicine community who advocated for our members. We passed on our information and support to the AOA in the effort to educate the ACGME on the value of our professional community.

After several meetings and comment sessions the hard work had a more favorable outcome. The AOA’s Acting Trustee, Boyd Buser D.O., announced an encouraging proposition for our current and future members. The agreement brings constituent organizations together for the purposes of a unified accreditation system. The governance structure will additionally include the following member organizations: the American Medical Association (AMA), the American Hospital Association (AHA), American Board of Medical Specialists (ABMS), American Association of Colleges of Osteopathic Medicine (AACOM) and the Council on Medical Specialty Society (CMSS). Under the structured agreement the AOA would have veto proof protection. For its part, the AOA was able to maintain its domain over graduate medical education, licensing, board certification and Comlex. The AOA secured equal opportunities for training for our graduates and community training sites for primary care. The seven core competencies will remain intact. Fitting with our perspective, the ACGME also gained structural benefits osteopathic continued on page 6

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Editorial Committee: Drew A. Koch, DO, FACOEP-D, Chair Wayne Jones, DO, FACOEP, Vice Chair Julia Alpin, DO David Bohorquez, DO Gregory M. Christiansen, DO, M.Ed., FACOEP Joseph Dougherty, DO, FACOEP Anthony Jennings, DO, FACOEP William Kokx, DO, FACOEP Annette Mann, DO, FACOEP Mark A. Mitchell, DO, FACOEP Erin Sernoffsky Brian Thommen The PULSE is a copyrighted quarterly publication distributed at no cost by the ACOEP to its Members, library of Colleges of Osteopathic Medicine, sponsors, exhibitors and liaison associations recognized by the national offices of the ACOEP. The PULSE and ACOEP accepts 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.

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Articles may not be reproduced without the expressed, written approval of the ACOEP and the author.

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The Pulse Editorial Staff: Drew A. Koch, DO, FACOEP-D, Editor Wayne Jones, DO, FACOEP, Assist. Editor Gregory M. Christiansen, DO, M.Ed., FACOEP Mark A. Mitchell, DO, FACOEP Erin Sernoffsky, Communication Manager Janice Wachtler, Executive Director

O s t eop a t h i c

E m e r g e n c y Me d i c i n e

Q u a rt e r ly

Table of Contents

Presidential Viewpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Gregory M. Christiansen, D.O., M.Ed., FACOEP The Editors's Desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Drew A. Koch, DO, FACEOP-D Executive Director's Desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Janice Wachtler, BA, CBA ACOEP Asks for Inclusion in Primary Care Designation . . . . . .7 In My Opinion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Wayne T. Jones, D.O., FACOEP Taking Care of My Own . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Jeremy A. Lacocque, OMS II Leadership Development and Collaboration . . . . . . . . . . . . . . 10 Mark A Mitchell, D.O., FACOEP, FACEP AOA Endorses an Accreditation System . . . . . . . . . . . . . . . . . . 10 Maintaining Our Identity . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Andy Little, D.O. What Would You Do? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Bernard Heilicser, D.O., MS, FACEP, FACOEP ACOEP Tech Updates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Brian Thommen FOEM: Foundation Focus . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 FOEM: 2012 Gala Pledges . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 FOEM: 2012 FOEM Comeptition Winnners . . . . . . . . . . . . . 16 An Integrated Model of Pallative Care in the E.D. . . . . . . . . . . 19 Mark Rosenberg, Lynne Rosenberg, Ramazan Bahar Residency Spotlight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 ACOEP New Speaker's Bureau . . . . . . . . . . . . . . . . . . . . . . . . 28

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The Editors's Desk Drew A. Koch, DO, FACEOP-D

Thank You, from the Editor

PHYSICIAN OPPORTUNITIES

It was a pleasure serving as the Chair of the Communications Committee and Editor of The Pulse. I became a member of the communications committee in the mid 1990’s to better serve the college and I enjoyed the opportunity to serve the members of ACOEP. Both the committee and The Pulse have endured lean times, however they have grown in size and purpose in the past 15 years.

The committee originally included only written communication but has grown to encompass so much more— the website, social networking, e-marketing and the ACOEP news brief. The Pulse continues to

grow in depth and breadth and is available in both electronic and print version. The committee has formed a Technology Subcommittee to better serve the online needs of the College and its members.

My tenure as chair of the communications committee and editor of The Pulse was not possible without my mentors. Special thanks to my residency program director and friend Edward Sarama, DO, who encouraged me to become active in ACOEP; Ben Fields, DO, who appointed me to my first committee memberships; Peter Bell, DO, who was the Communications Chair and Editor of The Pulse when I joined the committee; Joe Kuchinski, DO, who provided me with the opportunity to be the Chair.

Thanks also goes to members of the communication committee; members of ACOEP’s Board of Directors; past presidents of ACOEP who have supported

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me through their presidencies (Drs. Kuchinski, Scali, Willoughby- DeJesus, Bell, Brabson, and Christiansen); to Wayne Jones, DO, a friend and vice chair of the committee whose support has been invaluable; to Jan Wachtler for her continual support over the years; Erin Sernoffsky, ACOEP Communication Manger and to all the members of ACOEP staff. Most importantly, a special thanks to the members of the college for supporting me over the years as chair of the Communication Committee and Editor of The Pulse.

This is my last article as the editor of The Pulse. Thank you for your continual support over the years. It has been a great honor to serve you and the College.

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Executive Director's Desk Janice Wachtler, BA, CBA

The Future of Osteopathic Training in Emergency Medicine Recently we have all been dealing with the fact that the Accreditation Council for Graduate Medical Education (ACGME) took a shot across the bow of osteopathic medicine by inferring that our programs were somehow not meeting its high standards and therefore AOA credentialed and trained physicians would no longer be considered faculty in its programs beginning on July 1, 2015. This was closely followed by an edict that no osteopathic physician training for even a year would be accepted into allopathic residency or fellowship training beginning on that ominous July 1 date.

This forced everyone’s hand and set forth some historic compromising on the part of this allopathic organization and the American Osteopathic Association.

As part of the settlement, which is not completed as of this writing, all of AOA’s programs that are approved as of July 1, 2015 will be grandfathered into the allopathic system allowing for osteopathic training to be accepted by the allopathic world.

This agreement has provided some angst on our end as we have programs that don’t fit into the allopathic model.

Essentially, this decision eliminates one extra year of training typically given to our residents. You may recall that in 2008 the traditional internship was absorbed into a four-year continuum of training in emergency medicine on the belief that our graduates were better equipped to run an emergency department upon graduating than the lesser trained three year graduate.

Evidently, we were of the minority opinion and must now adapt or cease to exist as a

specialty in this new paradigm.

During my tenure of Executive Director, I have seen our specialty adjust to many changes that have been forced upon emergency medicine in the adapt or die world of medicine. This change will not truly affect the quality of training received by our residents, but it will severely limit their exposure to other specialties that they now receive in their training. These changes raise the question, what do we remove from our curriculum? Do we cut out obstetrics, orthopedics, or perhaps exposure to subspecialties like neurology or hand surgery? That will be hard.

As someone charged to work with many of our talented educators to develop a new model for emergency medicine, I ask what does this new model look like? I don’t truly know.

As a potential patient, just like any other person in the US, I ask what training the ideal emergency medicine physician requires to provide the ultimate care to my family and me. Does it matter if he or she doesn’t have three months of training in general medicine, or three months of surgery? Yes, I think it does. Should he or she have in-hospital family medicine? Not, so much. Does it matter if he or she can diagnose an obstetrical problem, hormone imbalance or a difficult pregnancy? You bet.

So what unnecessary skills should be removed from training? Does it matter if they can suture someone’s face so that they don’t resemble Frankenstein? Probably, which that brings up the next question: will anyone lobby for caps on legal suits when we fail to diagnose correctly, or a patient has to wait for a specialist because their emergency physician was not trained in all specialty areas? We need advocates on the national level with this allopathic organization.

Years ago allopathic medicine removed practice rights from DOs in California.

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This brought osteopathic physicians together to fight and be recognized. I’m not saying this is another salvo in this political divide. But it is once again an aspersion cast that osteopathic medicine is different and somehow inferior to that of the majority of medicine’s practitioners and the training they receive. When is medicine going to realize that it’s ok to be different and maybe different isn’t so bad?

The change in the program length would have been a natural progression as it becomes too expensive to require our young people to stay in a program just because we want them to have that exposure; in fact, it was being considered long before this agreement was broached.

However, before folding into the norm, it would have been nice to have someone look at medicine as a whole and consider not political and philosophical differences but the patient population and look to a mechanism to even the playing field.

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continued from page 1 programs have already adopted. The OPTI system is a great innovation which would be adopted more broadly into other training programs. In addition, the Clinical Assessment Program (CAP) may serve as a template for the broadened unified accreditation system. If you are not aware the CAP is an osteopathic outcomes data system which assessed resident performance using patient outcomes data. These systems are innovative and it is possible these programs will be incorporated into the ACGME’s future education model called the Next Accreditation System (NAS).

NAS will start in July 2013 and includes goals for accreditation based on education outcomes, peer reviewed systems for preparing physicians for practice, and improve educational efficiency.

You can review the NAS on ACGME’s website. Essentially the NAS system will be a continuum with data captured yearly to demonstrate learning outcomes. Less emphasis will be placed on standardization compliance. Instead the new system is designed to enable innovation and adaptable variability. There will still be a learning environment site visit every 10 years but there will be more emphasis on employing on going self-assessment studies. NAS will incorporate a number of composite studies to demonstrate performance and achievement on a continuum. Achievement of the milestones is the metric to determine preparedness for clinical practice. The emergency medicine milestones are available on the ACGME’s website. The NAS system moves training toward a competency based system. It remains to be seen if this new system will enable adequate patient contacts while providing experiential and contextual learning opportunities for the various learner types. Competency programs in time limited settings tend to accelerate learn objectives too fast thereby meeting on minimal standards. More difficult to measure intangibles like professional development, leadership and professional maturity may be casualties if the system promotes insufficient experience. Higher level learning requirements need better objective outcome measures to determine

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skill competency, the ability to translate skills in new contexts (adaptability) and better structure to promote foundations in patient safety protections. Since these goals and now being considered as minimum standards for certification, then it is very likely that the current four year osteopathic emergency medicine training model may already be the best system for others to emulation.

Osteopathic programs will be incorporated into the new system beginning in July, 2015. They will have up to three years to conform to the guidelines before a formal site visit is made. Current estimates suggest nearly all of our current emergency medicine programs will be able to meet these standards if reviewed on day one. This is a testament to the foresight our professional college and the hard work of the GME committee to have quality at the forefront of our accreditation standards. These changes will demand adaptability from our training models. I believe in the end, the accreditation changes to the education process will highlight our strengths. It is through our innovation and adaptability that we as osteopathic physicians excel.

These programs will demonstrate the strength of our graduates to care for our communities. This success story can only happen if you stay involved and support your mentees, residency programs, colleges and professional organizations. It takes a village and a little determination….

PULSE RESIDENT REPORT DECEMBER 2012 A very Happy Holidays Greetings from the Resident Chapter!

I would like to take this opportunity to introduce you to our newly elected 2012-2013 officers: President: Megan McGrew (Midwestern University) Vice-President: Steven Brandon (St Mary Mercy) Secretary: Andrew Little (Doctors Hospital) Treasurer: Andrew Pacitti (Doctors Hospital) Past President: Justin Arnold (Lehigh Valley) Conference Committee: Brian Ault (Good Samaritan) Jeremy Lott (St John’s Providence) Publications Committee: Danielle Turrin (Good Samaritan) GME Committee: Kim Irvin (Grandview) Members Services Committee: Cara Norvell (Doctors Hospital) Political Affairs Committee: Kade Rasmussen (Ohio Valley) Research Committee: Aimee Washington (Ohio Valley) IT Committee: Patrick Connolly (Ohio Valley) With the above team, we have set many goals for the year ahead, most of which focus at developing “Life After Residency” type resources for the residents to not only take advantage of at the conferences but also from the comforts of their own home!

If you have any interest in participating or assisting with any Resident Chapter events please do not hesitate to contact us! ( msmcgrew@gmail. com ) Thank you kindly, Megan S. McGrew, DO, MBA, MS ACOEP-RC National President ACOEP Board of Directors

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ACOEP Asks For Inclusion in Primary Care Designation At its meeting in October 2012, the Board of Directors of ACOEP, at the request of the Patient/Physician Advocacy Committee, approved a resolution to request that emergency physicians be included in the federal definition of primary care practitioners.

In the 1990s when the definition for primary care was developed, emergency medicine physicians were not included because they are federally mandated to provide care to the American public as the net to catch all patients who may fall through the cracks of society. As we move toward federal healthcare it is important that emergency medicine physicians are included in the definition to ensure reimbursement for the care they provide.

This resolution states that emergency medical care is as essential as that of police and fire departments in any city, and since we provide this patient care on a limitless basis, we should be considered a primary care specialty and asks for inclusion in any federal legislation from this point on.

We will present the resolution to the AOA’s Bureau of Federal Health Programs in January and then will hopefully be added to their legislative agenda for 2013.

As members, you also must advocate for this change in your local and state governments, and to your senators and

representatives. You will need to plant the seed to bring this movement to fruition and we are counting on you. A copy of the resolution appears below and will be on the ACOEP’s website after January 1.

WHEREAS, American healthcare organizations currently recognize five general specialties (family medicine; internal medicine; pediatrics; surgery, and women’s health) as the “Primary Care” specialties; and WHEREAS, the above-named specialties provide general medical and surgical care to the American public on a regional, practice-based basis in which care is limited to patients who are registered with the practitioner and are seen through an appointment basis; and WHEREAS, patient illness is not limited to an appointment-only or care-as-needed basis; and WHEREAS, emergency medicine physicians provide patient care on a limitless basis that is not appointment or condition-based and are the only Federally mandated physicians through EMTALA to provide care for all patients regardless of their ability to pay, access to private or

governmental insurance programs, locality, or time of day; and WHEREAS, this care is as essential as that provided by the police or fire department in any city or region; now, therefore, be it RESOLVED, that emergency medicine be included as a primary service in all future Federal and local legislation regarding primary care services; and be it further RESOLVED, that the specialty of emergency medicine be included as a sixth specialty under the umbrella that is considered as ‘primary care specialties’ by the Federal government.

Explanatory Statement: Currently emergency medicine is not included in the Federal definition of primary care specialties and as such is not eligible for benefits provided to those specialty programs and specialists practicing in the five areas described above.

However, without the existence of emergency medicine practitioners to tend to the American public on a ‘care-as-needed’ basis, the quality of healthcare provided in America would decline and the public would suffer from the decline or disappearance of this specialty and specialist.

“I seek opportunity—not security…I want to take the calculated risk; to dream and to build, to fail and to succeed…I prefer the challenges of life to the guaranteed existence; the thrill of fulfillment to the stale calm of utopia…It is my heritage to stand erect, proud and unafraid; to think and act for myself, enjoy the benefit of my creations, and to face the world boldly and say, this I have done.” ~ Dean Alfange

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In My Opinion Wayne T. Jones, D.O., FACOEP Assistant Editor

The Seldom Heard Message I received a letter a couple of weeks ago that was different than the rest. It was not asking for anything. It was not insulting. It did not allege negligence or harm. It was an apology.

The patient who wrote the letter created quite the stir the night he came in. He generated complaints from nurses, physicians and radiology, all leveled at each other. I never put the two together until I pulled his medical record. Then it all made sense.

I want all of you to read this and recall this patient. You have seen him many times before. I suspect you can recall his breath and defiant demeanor. Remember how he challenged your every decision and spit at the staff? He used ethnic slurs and called you names (things you would never do). Here is his letter in its entirety. Names and dates have been changed.

“To the Emergency Room Staff working the early hours of Sunday October 18th, 2012: Thank You. That’s something I never said. I said a whole lot that night. I swore and was insulting. I was inconsiderate and a general asshole to everyone I encountered. I belittled the doctors, nurses and even the security guards. But, I’m sure you remember that all too well. The way I acted was unacceptable. You guys save lives on a daily basis, even the lives of those who are self destructive and have no respect for anyone in their path.

I’m sure you hear this all the time, but this experience changed me. I’m not sure exactly how yet but I can say that it scared the hell out of me and I want to be a better person. That starts with I’m sorry. I am genuinely very sorry for how I acted toward and treated everyone that night. You were fighting for me to make sure I would be okay and I fought you every step of the way.

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I am so incredibly embarrassed because of how I acted.

I can never really tell you how appreciative I actually am and how regretful I am for my behavior. And I don’t expect more than one person will read this before it ends up with the wastebasket but I felt that I had to try to apologize.

What you do is amazing to me and I know that part of me becoming a better person started waking up the next day and realizing that I had treated the people who were trying to help me like complete shit.

Again, I’m so sorry and thank you so much – Tom” He was wrong, I shared this with

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everyone. The staff smiled and a few even laughed.

We all suspect this was step 9 and 10 of the 12 step process for recovering alcoholics. But it was still appreciated. In my 10 years of administration, this was a first. Not the first thank you for a job well done, but an apology for the patient’s own behavior. This letter still sits on my desk. I read it now and then, because, every now and then, we all need a little thank you.

All of you are good people, all of you do a good job, you save lives and you all deserve a thank you. Thank you. Wayne

Taking Care of My Own

Jeremy A. Lacocque, OMS II Chicago College of Osteopathic Medicine I strive to treat patients as I would treat a loved one. Congestive heart failure, heart attacks, depression, appendicitis, Alzheimer's, they’re all part of my family history if I look hard enough. So, I remind myself that when a patient comes in with one of those problems, it could easily have been someone I love in their place. Every patient is part of some kind of family and community, and I see the trust the person and their loved ones place in me as a healthcare provider as a privilege and an honor, and in an attempt to return the sentiment, I treat them as I would treat a family member or close friend.

This perspective became uncomfortably relevant when a 60 yearold, retired man came to a community hospital’s emergency room I was doing some clinical time in on Chicago’s North Side. We’ll call him John. It was a warm Monday evening in August, and I had just finished a short but tiring day of school filled with material from microbiology.

A few hours before I met John in the ED, John’s son brought him to his primary care physician because he wasn’t able to walk as far as he used to without losing his breath. After half of a block, he became exhausted and gasped for air, according to John’s son. At his appointment, his primary care physician noticed shortness of breath, some elevated creatinine, troponin, white blood cells and liver enzymes as part of his work up and decided to send him to the ED for further evaluation.

John seemed comfortable, but fatigued as he lied in bed with his eyes halfway closed. He was joined by his son and daughter-in-law. His family appeared like they were straight from the 70’s, his son with big, sepia-colored glasses and a fluffy mustache and a pin-striped, blue dress shirt and corduroys.

Joe and his son wrangled through his medical history of clotting disorders, pneumonia, congestive heart failure, and a couple MI’s. His history concluded with a description of his bipolar disorder. During his depressive episodes, John, frustrated by his inability to walk very far, would

lose his appetite and stay in bed for days.

His family, who lived with him, was also frustrated by what they called a rapid decline in his health.

After ruling out an embolism and an MI, we whittled down John’s differential diagnosis to community acquired pneumonia, in accordance with his abnormal lung sounds and poor oxygenation, even while lying in bed relaxed. He was admitted to the ICU. Despite aggressive antibiotic and supportive therapy, his health deteriorated during the next couple of weeks. He was intubated and fell into septic shock. He succumbed to his illness just 18 days after I met him in the emergency room.

Why did all this make treating him like a family member uncomfortably relevant? My mother, the same age as John, was in a different hospital on the north side recovering from septic shock, precipitated by salmonella. She was on a ventilator in the ICU for two weeks. Being in shock, her entire body was blue. Not just her finger tips, but her forehead, her arms, everything. If diagnosis relied on touch alone, she would be pronounced dead. She was cold, and her blood pressure too low to feel a pulse. The feeling of her cold hands and the sound of the ventilator pushing air into her in the otherwise silent room is just as vivid in my memory now as it was three months ago. No amount of experience, preparation, reasoning or medical knowledge could ever lessen the fear and hopelessness I felt in that room with her. My identity as a medical student waned, leaving me as nothing but a scared child of a sick mother. I didn’t care what her cardiac enzymes were, or that her creatinine was finally getting lower; she looked lifeless, and at the mercy of a machine.

The staff, especially the nurses, that took care of my mother made the sleepless nights much more bearable. They treated my family just as much as they treated my mother. I will never forget the first night my mom was in the ICU, a nurse brought up a desk and chair, and sat in my mom’s

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room. She sat there, the entire night.

She just watched my mom, adjusting things intermittently, making my mom as comfortable as possible, from 7p to 7a. Her entire shift was spent in my mom’s room.

This spoke both to the dedication of the staff, but also to the severity of my mom’s condition.

My mother was lucky enough to slowly recover and she managed to defeat her massive, systemic infection, but I remember every day that she could have ended up like John. It’s been four months now, and her brush with death is still brought up almost daily. Her voice is still slurred from what we think is a result of a global stroke, as her blood pressure dipped to almost nothing a few times. Everytime I feel the warmth of my mother’s hand, I’m reminded of what a recovery she has made, and that others, like John, are not always as lucky. The entire experience is a reminder that life isn’t just something that usually lasts until 80, and is filled with school, a job, and retirement, but it’s something that happens from one minute to the next, and can stop at any moment. While I’ve always heard that, seeing my mom on a ventilator one evening and smiling and hugging me the next, made this statement less trite and more meaningful than I expected at my young age.

The whole experience helped me realize connecting with another human being and treating him or her as the suffering person he or she is, is not something that requires 45 minutes and an armchair in a psychiatrists office. It requires a momentary smile and eye contact, words of reassurance and understanding, patience, and just taking the time as a healthcare provider to realize that there isn’t just a “septic patient in room 14” but there is the mother, sister, daughter, and wife of a distraught family, next door in the waiting room. It can be emotionally taxing to completely empathize with every patient you see, but I believe there is a balance worth striving for that makes all the difference to you and the patient’s family, as it did with ours.

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Leadership Development and Collaboration Mark A. Mitchell, D.O., FACOEP, FACEP

The delivery of healthcare continues to evolve and recent and impending changes make for evermore challenges for those in leadership positions. These challenges are not only felt in large healthcare organizations, but transmit all the way to the individual patients we see on a daily basis. We are faced with issues and questions like never before. * Does this patient meet criteria for admission or observation? * Can I arrange for prompt outpatient follow up? * Has this patient been admitted within the last 30 days for AMI, CHF, or pneumonia? * Have I met all the Core Measures and PQRS? * Is my utilization pattern (lab, x-ray, CT, medications) make me an outlier that someone is watching? *What is going to happen to the ED volume with the healthcare reform?

*What will my ED do if the volume goes up another 10 to 20%?

These are just a few of the myriad of questions and issues that we face each and every shift. In order for your department to run smoothly you need a leader who addresses these issues and creates an environment that minimizes stress. The role of the Emergency Department Medical Director is vital and the departments that run the smoothest generally have a great leader.

We at ACOEP want to make sure we are creating opportunities for medical directors to share their ideas, frustrations and solutions with their peers. Therefore, at the ACOEP Emerge conference in Denver we had an interest meeting of medical directors simply to see if there was sufficient interest to move forward with something more formal. Within a few minutes of the meeting it was obvious that the answer was a resounding yes.

Therefore, beginning with the ACOEP Spring Conference in 2013 we will have two hours dedicated to our Medical Directors in a separate session.

This is a development in process and the format will be modified to meet the needs of those in attendance. The concept is to share experiences and knowledge among the diverse medical directors in the group.

We will begin this spring with addressing two topics that many are facing: • Transitions of Care • Integration of Electronic Medical Records (EMR) If you are currently an Emergency Department leader as Medical Director, Assistant Medical Director, EMS Director, Director of Operations, or any other role we invite you to join us. This is an open meeting that anyone will be invited to join this group. Look for more details as we get closer to the Spring Conference.

AOA Endorses a Single, Unified Graduate Medical Education Accreditation System

The American Osteopathic Association (AOA), along with the Accreditation Council for Graduate Medical Education (ACGME) and the American Association of Colleges of Osteopathic Medicine (AACOM), have entered into an agreement to pursue a single, unified accreditation system for graduate medical education programs in the United States beginning in July 2015.

This move comes about after the ACGME proposed two policies (Common Program Requirements) about a year ago. One policy would limit the ability for AOA-trained DO’s to enter a second year of training in an ACGME program.

The other policy would no longer recognize completion of an AOA-accredited residency program for entry into an

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ACGME fellowship.

“Americans deserve a health care system where continuously improving quality of care and the health of our patients is the drive force,” stressed AOA President, Ray E. Stowers, D.O. “A unified accreditation system creates an opportunity to set universal standards for demonstrating competency with a focus on positive outcomes and the ability to share information on best practices.”

A unified accreditation system will preserve access to the ACGME residency and fellowship programs for DOs and formally recognizes AOA training and board certification for DOs wanting to serve, and currently serving as ACGME faculty. In addition, OPP/OMM core competencies will remain intact in osteopathic-focused

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training programs with the new system strongly encouraging AOA board certification for DOs. Over the coming months, the three organizations will work toward defining a process, format, and timetable for ACGME to accredit all osteopathic graduate medical education programs currently accredited by the AOA. As developments and details unfold, information for the osteopathic family can be found at www.osteopathic.org/acgme.

There, you can find answers to frequently asked questions, the AOA’s joint press release, a timeline of the issue, and other resources.

SOURCE: American Osteopathic Association

Maintaining Our Identity Andy Little, D.O.

I will always remember October 24th, 2012 as a day that changed our profession.

Whether this change will be for the good or the bad, the verdict is still out, but it will be etched forever in osteopathic history.

Since that time I have stewed over what exactly I could do in response to the news of "universal standards for demonstrating competency” instituted by ACGME. The steps taken by the American Osteopathic Association (AOA) were bold and game changing, but to what exact end? I have to admit, I was initially very skeptical of what this would all mean and felt as if this will be the end of osteopathy as I know it.

However, like many other aspects of life, I can't control what has happened; I can only control how I will react to it.

Our role as osteopaths in emergency medicine will be not to find ways to change what we do, but find the ways in which we can continue to maintain our identity and values in this new process. I remember the extensive research I performed prior to applying to medical school, and similar study I performed before residency applications. The first thing that came to my mind was where and how we train.

The DO school I attended is located in a town of around 20,000 people in a severely underserved area, rather than a large metropolitan city. Instead of spending my 3rd and 4th years of medical school at large inner-city trauma and academic centers, I spent hour upon hour in a small community hospital and physicians offices located in community settings. Although many of our residencies are located in

larger cities, many are in rural, community hospital settings. This diversity, although common to osteopathic schools and their graduate medical education, are foreign ideas to the majority of our allopathic colleagues.

Second, we can offer another modality to our patients: hands that have been trained in osteopathic manipulation manipulation (OMM). I know that there have been a few studies based on surveys that have shown that osteopaths who practice in emergency medicine are bad at or don't use OMM, and I would tell you that I've never received one of those surveys to affirm that I do use OMM on a daily basis. This is something I spent extra time learning and something I have seen work time and time again, better than a shot, better than a pill. Now if I was to tell you I did it to my STEMI patient and suddenly his LAD was no longer 95% occluded, that would be false. But on those low back pain and headache patients I see on a daily basis, I have found that it is not only as effective as medication, it allows me an opportunity to connect with my patients in a way that a "hands off" approach could not. So rather than having the attitude of "we don't have time" or "it’s not effective," we need to find ways to embrace OMM and include it in our practice.

I will always remember that we, as a profession, are a close family. I remember my first exposure to ACOEP. In the fall of 2008 a few of my fellow OU students and I got off a plane in Las Vegas and headed to Caesars’ Palace to take part in the Student

Chapter’s fall conference. Over the next two days I met and interacted with people that have helped define who I am today.

There I met my mentor that helped guide me through the application and match process. At later conferences I met fellow students and other physicians with whom I would build strong relationships, even name one of my children after. We have a great thing, where anyone who wants to belong can. We need more of this, we need this sense of family to continue and that begins with each of us.

I could go on about what we are good at, but my final thoughts are of the first when I read the email outlining the AOA's new accreditation process. When is DO Day, and when is the AOA House of Delegates? These are two days, which are March 14th, 2013 and July 16th-18th 2013, are important events in which we need to be involved. Like the old voting commercials said, "if you don't vote, you don't get a say," if you don't advocate, you won’t get a say. Having been to both of these meetings in the past I have seen how the real impact we can have on what is currently happening and what can happen in the future.

So as the new accreditation process moves closer, my hope is that we, as members of this college and of the osteopathic profession, continue to do what we do best. That we take advantage of this as a time to find a solution, a time to band together, not only to maintain our identity, but to increase our effect on society.

“Just because things are not going perfectly does not mean they are not going well.” ~ Al Groh

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What Would You Do? Ethics in Emergency Medicine Bernarnd Heilicser, D.O., M.S., FACEP, FACOEP In this issue of The Pulse we will review the case of the 50 year-old male with metastatic cancer who attempted suicide at home. This case was presented in the October 2012 issue.

The patient had called his son, asking him to come home. When the son arrived, he found his father unresponsive in a car in the garage with the motor running and called 911. The patient’s wife was out shopping. A suicide note was present.

In the ED it was determined that the patient had taken a Halcion overdose. The patient was intubated and resuscitated. The wife wanted life support removed and to allow the patient to die. However, the son wanted everything done. The attending ED physician was going to honor the wife’s request, but was countermanded by the ED Medical Director, supporting the son.

The patient had an uncomplicated

Brian Thommen

construed to lack decision-making capacity, and consequently, we are obligated to act in their best interest. In the ED, we don’t have all the information. Nevertheless, we have the responsibility to resuscitate the patient, as decided by the ED Director.

A subsequent psychiatric consultation, and perhaps hospice placement would be appropriate.

What if the patient’s wife was the Power of Attorney for Health Care? That would certainly complicate the issue.

Would you have then honored her request?

One could frame this situation either way and probably justify either decision (some light thinking for a while).

If you have any cases that you would like to present or be reviewed in The Pulse, please fax them to 708-915-2743. Thank you.

ACOEP Tech Updates

ACOEP has always strived to keep up with advances in technology and information delivery, this past year being no exception. If you have attended any of the recent ACOEP conferences you are well aware of our new conference application (www.emergemeetings.com) which delivers up-to-the minute schedule changes; lecture and handout information; meeting agendas; speaker evaluations and more, all conveniently delivered via the web directly to your notebook, tablet or smart phone.

You may have also noticed the ACOEP Go Green initiative which has seen the bulky binders full of paper conference materials replaced with convenient ACOEP-branded flash drives. We also provide dedicated conference websites that can be accessed 24/7 on free Wi-Fi service now provided to members at all ACOEP meetings.

ACOEP is also pleased to announce that we had a higher percentage of member participation this year’s annual Board Elections than in its entire history.

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hospital course and was discharged home.

Two days later, the patient sustained a fatal self-inflicted GSW to the head. The ED Medical Director is doubting his decision.

This troubling case was very difficult for all involved. We are presented with a patient with a terminal illness who wants to die. He makes the attempt, but we still resuscitate him. Was this right?

A patient has the autonomous right of self determination. However, suicide does not come under our societal acceptance of this right. Consequently, we attempt to resuscitate the patient, often questioning ourselves during the process. However, we often do not have the opportunity to determine the patient’s psychiatric circumstances at the time of the event.

Was the patient clinically depressed? Many suicidal patients are, but not always. A clinically depressed patient can be

These elections, which have taken place online since 2011, not only make it more convenient for members to cast their vote at their convenience, but allow more of the members to participate as previously only members attending the Fall meeting could vote. These are just a few of the changes we have recently made to better serve our members and meet their needs with the power of today's devices and services.

Despite these changes, ACOEP is continuously looking for new ways to evolve and adapt to the ever-changing technology and this year will again be no exception! In the coming months you can expect to see a revamped website featuring a more streamlined interface and layout, broader compatibility with today's devices such as iPads, tablets, and smart phones, and more content dedicated student and resident interests. Speaking of content for our members, much like The Beat newsletter, you are also be able to get The Pulse in its new online format as it becomes

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a true online publication able to be conveniently viewed on a variety of devices simply by visiting the Pulse webpage (www. acoep.org/pulse.htm). As we move forward we will also be converting the entire Pulse library into this new format which will be available for just in case you missed an issue or want to look back on the many years of this quality publication! We are currently rolling these changes out as we speak, so be sure to keep checking the ACOEP website (www.acoep.org) regularly as we anticipate all of these changes to be completed and live by Feb. 1st.

Again, these are just a few highlights of the changes we've made and some of the exciting new things we have planned!

As always we welcome feedback from our membership as some of our truly best ideas have come from you our members! If you have any suggestions, comments or ideas please feel free to contact the ACOEP IT Director, Brian Thommen via email at bthommen@acoep.org with your input.

Juan Acosta, D.O., MS, FACOEP, President, FOEM

Foundation Focus 2012 FOEM Legacy Gala Dinner and Awards Ceremony

Presented by TeamHealth Friends: Premier Physician Services and Schumacher Group On October 16, 2012 the Foundation for Osteopathic Emergency Medicine hosted its second annual Legacy Gala Dinner and Awards Ceremony. The Foundation’s signature soiree, the night consisted of recognizing the top donors and researchers of the American College of Osteopathic Emergency Physicians and The Foundation for Osteopathic Emergency Medicine. The attendees were dazzled by the professional DJ, emcee, elegant dining experience, and fun on the dance floor that continued well into the night. To top it all off, the guests recognized the Foundation’s charitable mission by contributing an outstanding amount of over $18,000 in just one night! Thank you so much to all who attended, and who were recognized as supporting FOEM all year long. We look forward to seeing you all again in 2013!

For more pictures of the 2012 FOEM Legacy Gala, check out FOEM on Facebook.

2012 FOEM Legacy Gala Honorees FOEM President’s Circle Award: Presented to donors achieving lifetime donation level of $10,000 - $24,999.

• • •

Juan Acosta, D.O., MS, FACOEP Beth Longenecker, D.O., FACOEP-D Sherry Turner, D.O., and James Turner, D.O., FACOEP

The representatives of TeamHealth dressed to impress

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FOEM Foundation Pillar Award: Presented to donors achieving lifetime donation level of $5,000 - $9,999.

• 1st Place: Good Samaritan Hospital Medical Center in West Islip, NY- $24.00/resident (Dave Levy, D.O., FACOEP pictured above accepting the award).

• 2nd Place: Ohio Valley Medical Center in Wheeling, WV $20.00/resident • 3rd Place: Kennedy University Hospital in Stratford, NJ $14.00/resident

FOEM Research Flame Award: Presented to the ACOEP Residency Program that has achieved the highest average score for Senior Research Papers in 2012. Scores are determined by the ACOEP Research Committee.

• • • •

Mark Foppe, D.O., FAAEM, FACOEP Victor J. Scali, D.O., FACOEP-D Douglas Webster, D.O., FACOEP-D Bruce Whitman, D.O., FACOEP (Not pictured)

100% Program Challenge Winner: Presented to the ACOEP Residency Program that has raised the most funds per resident in 2012. To qualify, 100% of the residents must contribute at least $5.00.

• Henry Ford Macomb Hospital in Clinton Township, MI (Jennifer Stevenson, D.O. and Anthony Affatato, D.O., FACOEP pictured above accepting the award).

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2012 Legacy Gala Pledges

FOEM Board Thank you to the following people for making a pledge at the 2012 FOEM Legacy Gala. Together we raised over $18,000! Special thanks to Paula DeJesus D.O., MHPE, FACOEP (Dist) and Joseph Kuchinski, D.O., FACOEP-D for picking up the microphone and rallying the troops!

Juan Acosta D.O. , M.S., FACOEP Anthony Affatato D.O. FACOEP Michael Allswede D.O. Justin Arnold D.O. , M.P.H. Nick Bair D.O. Jacob Bair D.O. Jennifer Bantley-Wilson D.O. Peter Bell DO, MBA, HPF,FACOEP-D Jessica Bennett Rudolph Bescherer D.O., FACOEP Thomas Brabson DO, MBA, FACOEP-D Bernadette Brandon D.O. FACOEP April Brill D.O. Dale Carrison D.O., FACOEP Anthony Catapano D.O. Stephanie Cheslock D.O.

Timothy Cheslock D.O. Gregory Christiansen D.O. FACOEP Mark Damon D.O. Daniel Defeo D.O. Paula DeJesus D.O., MHPE, FACOEP-D Adrian Dews D.O., MS Anita Eisenhart D.O. FACOEP Mark Foppe D.O., FAAEM, FACOEP Howard Friedland D.O. FACOEP Christine Giesa D.O. FACOEP-D Joseph Ginejko D.O. Christopher Gooch D.O. Ashley Guthrie Kristopher Hart D.O. Kimberly Irvin D.O. Andrew Kalnow Peter Kaplan Elizabeth Kassapidis D.O. Kristen Kennedy Patrick and Kelly Klocek D.O. Joseph Kuchinski D.O., FACOEP-D Richard Lartey D.O. David Levy D.O. FACOEP Jennifer Liu D.O. Beth Longenecker D.O. FACOEP

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Ralph Love D.O. Bill Lynch NHS Manjushree Matadial D.O. FACOEP Mark Mitchell D.O. FACOEP Andrew Pacitti D.O., MS Nilesh Patel D.O. Jeremy Petrosino John C. Prestosh D.O., FACOEP Jaclyn Ronovsky Otto Sabando D.O. FACOEP Steven Schwartz D.O. Erin Sernoffsky Isaac Sernoffsky Joseph Sorber Student Sonya Stephens Jennifer Stevenson D.O. Robert Suter D.O., MHA, FACOEP, FACEP, FIFEM Brian Thommen Jim Turner D.O., FACOEP Sherry Turner D.O. Stephen Vetrano D.O., FACOEP Jan Wachtler Kristin Wattonville Douglas Webster D.O. FACOEP-Dist

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2012 FOEM Competition Winners Research Paper Competition Sponsored by EMP •

1st Place Jill Donofrio, D.O., MPH from Kent Hospital in Warwick, RI Carotid Ultrasound and the Emergency Department Physician: A Validation Study

•

2nd Place Amanda Miller, D.O. from Edward W. Sparrow Hospital in Lansing, MI CT Scan Detection of Injuries Without Signs or Symptoms of Injury in Stable Blunt Trauma Patients

• 3rd Place Michael Mesisca, D.O. from

Arrowhead Regional Medical Center

in Colton, CA Clinical Research Pilot Study: Thiamine Deficiency Among Adult Patients with Diabetic Ketoacidosis Presenting to the Emergency Department

Research Study Poster Competition Sponsored by MedExcel •

1st Place Catherine Ippolito, D.O. Midwestern University in Chicago, IL

•

2nd Place Kelly Koenig, D.O. Integris Southwest Medical Center in Oklahoma City, OK

•

3rd Place Laura Fil, D.O. Good Samaritan Hospital Medical Center in West Islip, NY

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Clinical Pathological Case (CPC) Competition Sponsored by Schumacher Group •

1st Place Resident Michelle Ischayek, D.O. Aria Health in Philadelphia, PA

•

1st Place Faculty Steve Hollosi, D.O. Charleston Area Medical Center in Charleston, WV

•

2nd Place Resident Anne Newbold, D.O. Midwestern University in Chicago, IL

• 2nd Place Faculty

Chris Steinacker, D.O. POH Regional Medical Center in

Pontiac, MI • 3rd Place Resident

Jeffery Hirschi, D.O. Edward W. Sparrow Hospital in

Lansing, MI •

3rd Place Faculty Nicole Maguire, D.O. Newark Beth Israel Medical Center in Newark, NJ

Oral Abstract Competition Sponsored by EmCare •

1st Place Shannon Weinstein, D.O. Good Samaritan Hospital Medical Center in West Islip, NY

•

2nd Place Merkeza Grant, D.O. St. Joseph’s Regional Medical Center

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in Paterson, NJ

•

3rd Place David Zimmerman, D.O. Newark Beth Israel Medical Center in Newark, NJ

Winning Abstracts Research Paper Competition Sponsored by EMP 1st Place Jill Donofrio, D.O., MPH Kent Hospital in Warwick, RI Carotid Ultrasound and the Emergency Department Physician: A Validation Study Principal Investigator (s): Jill Donofrio DO, MPH, Christopher Mozdzanowksi DO, Douglas Kuxhausen DO, Carla Dugas DO, Christopher Zabbo DO Abstract This study aims to determine whether Emergency Department (ED) physicians can use an abbreviated bedside ultrasound protocol to accurately evaluate the condition of the carotid arteries. Our primary outcome was the accuracy with which the ED study predicted a category of stenosis as compared to the degree of stenosis based on a formal carotid ultrasound. The secondary outcome was the accuracy with which the ED physician measured peak systolic velocity (PSV) as compared to the measurements obtained during a formal ultrasound study, the current gold standard.

We trained four emergency medicine residents and one emergency medicine attending physician to perform an abbreviated carotid ultrasound protocol

which measured the peak systolic velocity (PSV) of the internal carotid artery (ICA) and the common carotid artery (CCA) bilaterally and requires the practitioner to calculate the ratio of the two (PSV ICA/ PSV CCA). Forty-five adult patients > 55 years old were enrolled from December 2010 to January 2012, presenting with chief complaints of TIA, syncope, or nearsyncope within 24 hours of their emergency room visit. The measurements and ratios obtained by our emergency physicians compared to those obtained by the formal ultrasound study all had p-values > .05, and thus were not statistically significant.

This pilot study was meant to be a preliminary look carotid disease in the emergency setting. Our findings confirm that properly trained emergency physicians are capable of performing the abbreviated carotid ultrasound protocol accurately.

Research Study Poster Competition Sponsored by MedExcel 1st Place Catherine Ippolito, D.O. Midwestern University in Chicago, IL Emergency Physician Use of Bedside Ultrasound Abstract Objective: The use of bedside ultrasound in the emergency department has become an increasingly important diagnostic and therapeutic tool. The use of ultrasound is becoming commonplace in many community emergency departments. In this survey study, we will look at the utilization of bedside ultrasounds in community emergency departments. Our

goal is to evaluate the most common uses of ultrasound (diagnostic and therapeutic) in the emergency department and the accuracy of bedside exams compared with formal radiological studies. We also wish to evaluate the percentage of cases that involve a resident vs. attending and how that affects use/accuracy.

Methods: Survey of emergency department attending and resident physicians who are utilizing bedside ultrasound in the emergency department and asking the following questions: 1) Why was ultrasound utilized? Procedural, diagnostic or both?

2) Did the patient have a formal ultrasound or other definitive imaging?

3) If so, did the radiology findings match the bedside ultrasound findings?

4) What is the level of training of the emergency physician?

5) What is the age and gender of the patient’s being studied?

PERSONNEL: Data sheets will be available in the emergency departments that are being studied, which are select training sites for Midwestern University’s Emergency Medicine Residency Program.

SUBJECT RECRUITMENT: This is a voluntary survey which is open to any and all emergency department attending and resident physicians. Since this is a voluntary survey, completion of a survey constitutes the physician’s consent to participate in this survey study. This survey serves only to assess the normal and usual practice of the studied emergency physicians and as such does not seek to initiate or utilize diagnostic or therapeutic ultrasound in a situation where it would not have been otherwise utilized. It is anticipated that once approved by the Midwestern University IRB, we will commence with

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the survey with a goal of obtaining 150200 completed surveys.

INCENTIVES: No incentives are being offered to encourage physicians to participate in this study.

INFORMED CONSENT: There is no informed consent needed from the patients as this is a survey of physician practice and will not impact patient management. In addition, since this is a voluntary survey, all physicians that participate are doing so of their own choice and by completing a survey they are consenting to being a part of this study. In addition, there will not be any unique physician identifiers (only level of experience/training).

CONFIDENTIALITY: There are no unique personal identifiers being obtained from the patients or any identifying information (outside of level of training) about the physicians studied in this survey.

RISK TO SUBJECTS: None. This is a survey of physician practice only and as such seeks only to assess current use of diagnostic and therapeutic ultrasound and not guide diagnostic or therapeutic decision-making.

DATA COLLECTION AND ANALYSIS: Surveys will be available in all study emergency departments and there will be a separate folder for completed surveys.

Once all data has been collected it will be organized in an Excel spreadsheet for data analysis.

Results: 203 studies were completed 155 (76.4%) were completed by residents 185 (91.1%) were performed for diagnostic purposes, 44 (21.9%) were FAST exams 137 (67.5%) had formal imaging obtained

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119 (86.9%) had matching results between bedside and formal radiological studies

Oral Abstract Competition Sponsored by EmCare

Conclusions: Bedside ultrasound was found to primarily be used by emergency medicine residents for FAST examinations. It was concluded that overall, emergency medicine (resident and attending) physicians are more that 85% accurate in their detection of disease processes with bedside ultrasound. It was also determined that ultrasound is likely being underutilized for the purpose of common ED procedures such as central line placement.

1st Place -Shannon Weinstein, D.O. Good Samaritan Hospital Medical Center

Co-Investigators: Catherine Ippolito D.O. PGY2 John Hall D.O. PGY3 Elham KellerShabrokh D.O. PGY2 Primary Investigator: Thomas Green D.O., Attending Physician – Emergency Department – Saint James Hospital – Olympia Fields and Chicago Heights, IL. Assistant Professor – Department of Emergency Medicine – Midwestern University – Chicago College of Osteopathic Medicine.

Institutions: Swedish Covenant Hospital - Chicago, IL St. James Hospital - Olympia Fields and Chicago Heights IL St. Anthony’s Hospital - Crown Point, IN St. Margaret Mercy Hospital Hammond, IN

Will the Use of Osteopathic Manipulative Treatments on Patients with Headache in the Emergency Department Result in Decreased Pain on a 100 Point Scale?

Genevieve McGerald DO, Ronald Dvorkin MD, Jacob Bair DO, Laura Fil DO, Doni Marie Segerivas DO, Shannon Weinstein DO Abstract Introduction: Headache is the fifth most common reason for seeking treatment in the emergency department (ED), representing two million visits per year1.

Currently, pharmaceutical therapy is the primary management in the ED. As osteopathic physicians we are trained to utilize manipulative therapies to treat many musculoskeletal and systemic ailments including headaches.

Objective: To evaluate the utility of osteopathic manipulative treatments (OMT) on patients presenting to the ED with headache.

Hypothesis: Patients receiving OMT are more likely to have a decreased level of pain compared to those patients receiving a placebo osteopathic treatment.

Methods: The study was conducted at a suburban academic adult ED that sees approximately 50,000 patients of the total 100,000 annual census. Included in the study were both male and female patients 19 years of age or older who presented

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to the ED with the chief complaint of a headache. The patient was asked to rate their pain level on a 100-point scale by the attending physician. A resident physician, not directly involved in the care of the patient, would then enroll the patient into the study. Envelopes were randomized with either “Osteopathic Manipulative Treatment” or “SHAM Osteopathic Manipulative Treatment”. The resident that enrolled the patient would then open the envelope and perform the selected treatment. Treatments were performed prior to any analgesic administration. If the ‘osteopathic treatment’ was selected, the resident would perform three standardized osteopathic manipulations to the patient.

If the ‘SHAM osteopathic treatment’ was selected, the resident would perform three standardized placebo treatments. The study was terminated if any patient was unable to tolerate the treatment or if the nurse entered the room to administer medication. At the end of the treatment the resident would ask the patient to again rate their pain level on a 100-point scale.

Results: We expect that patients who receive OMT are more likely to have a greater decrease in pain level as compared to those patients who receive the placebo treatment. The study is expected to be completed by September 15, 2012.

1. Head Wise magazine, volume 2, issue 2, 2012

An Integrated Model of Palliative Care in the Emergency Department Mark Rosenberg, DO, MBA, Lynne Rosenberg, PhD, Ramazan Bahar, RN, MSW, LSW Medicine was first recognized by the American Board of Medical Specialties as the 23rd medical specialty on September 21, 19791. In a relatively short span of time, the practice of Emergency Medicine has grown to include the subspecialties of Medical Toxicology, Pediatric Emergency Medicine, Sports Medicine and Undersea and Hyperbaric Medicine2. Hospice and palliative medicine is the newest subspecialty of Emergency Medicine evidenced by the American Board of Emergency Physician's certification. This subspecialty concentrates on life threatening illnesses whether they are curable or not with palliative medicine representing "the physician component of the interdisciplinary practice of palliative care"3.

Published work on palliative care in the ED is limited yet promising. Countries such as Canada have prioritized palliative and end of life care research, recognizing that acute care settings do not translate into quality care for patients in this cohort4, 5. However, palliative care programs utilizing additional home care services did not provide evidence that consistently supported a decline in ED visits during the last weeks of life4, 5, 6. In the United States, quality of care and allocation of medical resources is part of the overall healthcare reform debate. Research supports the use of palliative care interventions early in the disease trajectory to promote quality of life as well as reduce costs associated with treatments 7, 8, 9, 10. A recent study has shown that lung cancer patients who received palliative care generally chose less aggressive treatment and lived approximately three months longer than those patients receiving standard treatment 8.

The ability to change the existing paradigm of care for chronic disease is an opportunity for palliative medicine - specifically palliative care in the ED - to alter the in-house plan of care.

There are many ED palliative care delivery systems as providers draw on their experience to design programs to meet the needs of diverse stakeholders resulting in three recurring models of palliative medicine/care in this area: ED-palliative care partnerships; ED palliative care champions; and ED hospice partnerships11.

The Life Sustaining Management and Alternatives (LSMA) program discussed below illustrates the ED palliative care champion model.

Palliative Care Initiative The LSMA program at St. Joseph's Regional Medical Center (SJRMC) in Paterson New Jersey is the result of the efforts of the ED Chairperson, boarded in EM and palliative medicine, who championed the palliative care initiative.

SJRMC is a major academic tertiary medical center and state designated trauma center with 651 beds and an annual ED volume of over 135,000 visits. The primary goal of the LSMA program was to identify those patients who might benefit from palliative care interventions upon entry into the healthcare system. The use of a trigger sheet (Table 1) assists the staff in indentifying patients for real-time palliative consults in the ED. Early in the LSMA program, it was recognized that a distinction was needed between palliative care and end of life as the staff used both terms interchangeably.

This same phenomenon has been noted in the literature12, 13, 14 representing a barrier to research striving to improve care and support during this time of life14.

The LSMA program defines palliative care as providing palliative treatment while curative treatment is continued and is inclusive of end of life care. This is in contrast to hospice programs in which patients have less than a six month life expectancy. Palliative care focuses on the disease trajectories of terminal illness

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(e.g. cancer) organ failure (e.g. congestive heart failure) and frailty (e.g. Parkinson's' disease).

The LSMA program adheres closely to the World Health Organization's (WHO) definition and principles for palliative care, intervening as early as possible in the disease process to identify a plan of care that prolongs life while prioritizing the individual patient's goals15. End of life care, a component of the palliative care program, is defined as the care provided during the last likely hospitalization. It is impossible to know when a person is dying hence the difficulty in defining end of life leaving the concept to regulatory interpretation rather than scientific evidence14. However, end of life care usually encompasses a chronic disease with a progressive downward trajectory14.

The LSMA Program The Chair of the ED and a nurse coordinator initiated the LSMA program within an informal framework, identifying patients for palliative consults when they were working in the ED. The ED staff has been responsive to multiple initiatives, such as the geriatric ED, resuscitation center, and the toxicology referral center to name a few, which have developed into successful programs, yet there was minimal interest in a palliative care program. Barriers to palliative care in the ED have been well documented and include staff resistance due to the stereotypical association with death as well as financial barriers from insurance companies 11, 16, 17.

In response, the LSMA program at SJRMC evolved slowly, using each patient's unique situation to help build the necessary foundation for the acceptance, transition and success of the ED palliative care program. The ED Chair set out to expand the role of the ED by identifying continued on page 20

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continued from page 19 patients that would benefit from palliative care allowing the plan of care to be decided at the front end of the hospital stay. It has been recognized that it is beneficial to all for palliative care to start early - preferably on the first day of admission which may mean starting in the ED itself 3, 18.

The LSMA program officially started in 2010 when the first ED palliative consult resulted in a male patient being discharged from the ED with home hospice in place. The following month, there were six consults in the ED resulting in five admissions to medical/surgical units, and one discharge from the ED with home hospice in place. As interest in the program grew, any ED staff member could ask for a palliative care consult (Table 1) resulting in 76 LSMA consults in the ED for 2010 (Table 2). There have been 55 consults in the ED as of July 2011 with additional consults performed in-house at the request of the medical staff.

Table 1: See Below Table 2: See page 23 The LSMA program includes a core team of one emergency physician and one master's prepared nurse coordinator for the initial consult. Additional member involvement from the interdisciplinary team is determined by the plan of care. Other key members may include nursing, medicine, nutritionists, chaplains, psychologists, social workers, physical therapists, occupational therapists, and

other disciplines as required meeting the needs of each patient and family.

Distinguishing itself from most other ED palliative programs, the LSMA program is open to all ages including children.

SJRMC has a pediatric ED with vast resources available to this population with a special focus on cancer trajectories.

Initial consultations range from a general introduction to in-depth communications regarding advanced directives and treatment plans. Of utmost importance is the determination of the patient goals as early as possible18 including discussions of Do Not Resuscitate (DNR) status as appropriate to the individual patient. The LSMA program has not had an impact on the number of inpatient consultations for the inpatient palliative care service at SJRMC. This may suggest that the implementation of the LSMA program has identified a new subset of patients reflecting similar experiences noted in the literature 19.

Positive benefits of the LSMA program have been numerous extending beyond the patient and their families to the ED and hospital staff. First and foremost, the patient's wishes are supported and carried out throughout the plan of care.

The interdisciplinary team focuses on open communication to attain symptom management, choice of interventions and the treatment plan. General benefits include reducing hospital length of stay (LOS) and reduction of overall cost which 3 is well documented in the literature 20, 21. Specifically, the LSMA program has provided benefits related to resuscitation

Table 1.

Triggers for ED palliative care consult.

Arriving at the ED: From SNF/LTC with DNR status established or requested Actively dying in pain and discomfort.

Currently enrolled in a hospice program.

Previously discharged from SJRMC inpatient Palliative Care Program.

Two or more hospital admission within three months with same symptoms consistent with a terminal or degenerative chronic medical condition.

Advanced disease with frequent infections.

Nutritional complications with albumin of less than 2.5mg/dl.

Primarily bed bound with advanced dementia process.

Advanced disease with enteral feeding in place.

Disease Triggers: Aspiration Pneumonia Bone Mets COPD Heart Failure Hemorrhagic Stroke Malignant Neoplasm Renal Failure Septicemia Trauma Table 2.

LSMA 2010 consults in the ED Month Consults Admitted/Unit 20 ED CCU MS February 1 1 March 6 1 5

Disposition Hospice The PULSE JANUARY 2013DNR Home Rehab LTC Expired 1 1 1 4 1 1 1 1

rates, intensity of care and patient satisfaction. SJRMC successful cardiac resuscitation rates have increased from 1% to 20% as the medical center is no longer resuscitating people with "end of life" diagnosis; these patients are now DNR. Along with this finding there are cost savings attributed to decreased intensity of care. ICU costs are associated with approximately 20% of overall hospital costs 10.

InterQual 2011 level of care criteria for acute care was applied to all patient consults in the LSMA program. Over half (57%) of all patients admitted to medical surgical units met criteria for a higher level of care, identified as either critical care or stepdown.. Of those patients discharged from the ED, 62% met admission criteria; with 50% of this cohort meeting critical care admission criteria. This was in accordance with the patient's stated goals of care and advanced directives.

Essentials for an ED based Palliative Care The LSMA program grew from existing hospital resources. Currently, the program continues with the Chair and Nurse Coordinator providing ED and in-house consults. These two professions are considered essential to the development of any ED based program. An advocate of the palliative care program is needed (preferably an ED physician) who possesses the ability to work behind the scenes educating, recruiting, addressing barriers and promoting inclusion and continuity of the program within the individual hospital structure. It is essential to know the staff and community as well as nuances of the hospital in terms of leadership, internal politics and resources before designing an ED based palliative care program.

Education and certification of staff is an ongoing necessity including continual review of the literature. The development and maintenance of a data log are required to provide statistical evidence for oversite review, board and committee updates and to identify quality indicators for monitoring. Lastly, it is recommended that any ED-based program provide real time consults which has been a large part of the success of the LSMA program. As noted in the literature 22, contact with the patient and family on the first date of service provides the best opportunity to impact the plan of care.

Future Directions The LSMA focus has been on identifying patients for the palliative care program, providing both end-of-life and palliative consults. In the future, the emphasis will be on palliative care for the purpose of providing continuity. A mechanism to follow-up with each ED palliative consult needs to be developed in which each patient will be revisited in 48 hours to define the plan of care. For this transition to occur, the role of the ED physician 21 is being examined in terms of actual versus expected outcomes in relation to the palliative care patient. The staff will need to identify the main reason for ED visits for those in palliative care, which studies suggest are related to symptoms of pain, nausea, vomiting, constipation and shortness of breath 23. EMS protocols, time trial therapy and heart failure patients specifically will be monitored. Above all, each palliative care team member is an advocate for this vulnerable population reaching out to discover innovations and advancements in this growing specialty of care.

References History of Emergency Medicine http:// atlantichealth.hodesiq.com/Job_Search. asp?User_ID= Accessed September 3, 2011.

Recognition of Subspecialty Boards in Emergency Medicine. http://www.acep. org/content.aspx?id=34884 Accessed September 3, 2011.

Quest, T., Marco, C., Derse, A., (2009) Hospice and palliative medicine: New subspecialty, new opportunities. Annals of Emergency Medicine, 54, 94-101.

Seow, H., Barbera, L., Howell, D., Dy, S., (2010). Did Ontario's end-of-life care strategy reduce acute care service use?

The need to use quality indicators for improvement. Healthcare Quarterly, 13, 93-100.

Lawson, B., Burge, F., McIntyre, P., Field S., Maxwell, D., (2009). Can the introduction of an integrated service model to an existing comprehensive palliative care service impact emergency department visits among enrolled patients? Journal of Palliative Medicine, 12, 245-251.

O'Mahony, S., Blank, A., Simpson, J., Persaud, J., Huvane, B., McAllen, S., Davitt,

M., et al., (2008). Preliminary report of WHO Definition of Palliative Care. http:// a palliative care and case management www.who.int/cancer/palliative/definition/ project in an emergency department for en/\ Accessed September 2, 2011. chronically ill elderly patients. Journal of Kenen, J., (2010). Palliative care in the emergency department. Annals of Urban Health, 85, 443-451.

Lamba, S., Quest, T., (2011). Hospice Emergency Medicine, 56, 17A-19A. care and the emergency department: Smith, A., Fisher, J., Schonberg, M., Pallin, Rules, regulations and referrals. Annals of D., Block, S., Forrow, L. et al., (2009).

Am I doing the right thing? Provider Emergency Medicine, 57, 282 - 290.

Temel, J., Greer, J., Muzikansky, A., perspectives on improving palliative care Gallagher, E., Admane S., Jackson, V., in the emergency department. Annals of et al., (2010). Early palliative care for Emergency Medicine, 54, 86-93. patients with metastatic non-small-cell Waugh, D., (2010). Palliative care project lung cancer. The New England Journal of in the emergency department. Journal of Palliative Medicine, 13, 936.

Medicine, 363, 733-742.

Quest, T., Asplin, B., Cairns, C., Hwang, Beemath, A., Zalenski, R. (2009). Palliative Resuscitating U., Pines, J., (2011). Research priorities emergency medicine: Annals of Emergency for palliative and end-of-life care in the comfort care? emergency setting. Academic Emergency Medicine, 54, 103-104.

Ciemins, E., Blum, L., Nunley, M., Lasher, Medicine, 18, e70 - e76.

Penrod, J., Deb, P., Dellenbaugh, C., A., Newman, J., (2007). The economic 3 Burgess, J., Zhu, C., Christiansen, C., and clinical impact of an inpatient palliative Luhrs, C., et al., (2010). Hospital-based care consultation service: A multifaceted palliative care consultation: Effects on approach. Journal of Palliative Medicine, hospital cost. Journal of Palliative Medicine, 10, 1347-1355.

Table 1.

Barbera, L., Taylor, C., Dudgeon, D., 13, 973-976.

Triggers for ED palliative care consult.

(2010). Why do patients with cancer visit Grudzen, C., Stone, S., Morrison R., Arriving at the ED: the emergency (2011). The palliative care model for status From SNF/LTC with DNR established department or requestednear the end of Actively dying in pain and discomfort. life?

Canadian Medical Association Journal, emergency department patients with in a hospice program.

182, 563-568. advanced illness. Currently Journal enrolled of Palliative Previously discharged from SJRMC inpatient Palliative Care Program.

Meier, D., Beresford, L., (2007). Fast Medicine, 14, 945-950.

Two or more hospital admission within three months with same symptoms is key to medical partnering with the Reid, C., (2011). consistent Palliativewith care is not a terminal or response degenerative chronic condition. emergency department. Journal of Palliative Advanced with frequent infections. same as end of life care.

BMJ,disease 342:d2735.

Nutritional complications albumin of less than 2.5mg/dl.

10, 641-645.

Chan, G. (2006). End-of-life and palliative withMedicine, Primarily bed bound with advanced dementia process. care in the emergency department: A Sean Morrison, R., Penrod, J., Cassel, Advanced disease with enteral feeding in place. call for research, Disease education, policy and J., Caust-Ellenbogen, M., Spragens, L., Triggers: Meier, D et al., (2008). Cost savings Aspiration improved practice in this frontier area.Pneumonia Mets associated with US hospital palliative care Journal of Emergency Nursing, 32,Bone 101-103. consultation programs. Archives Internal National Institutes of HealthCOPD State-ofHeart Failure Medicine, 168, 1783-1790. the-Science Conference Statement on Hemorrhagic Stroke Improving End-of-Life Care, Malignant (2004).Neoplasm Renal Failure http://consensus.nih.gov/2004/2004EndO Septicemia fLifeCareSOS024html Accessed September Trauma 10, 2011.

Table 2.

LSMA 2010 consults in the ED Month Consults Admitted/Unit ED CCU MS February 1 1 March 6 1 5 April 7 3 4 May 7 1 1 5 June 6 2 4 July 7 4 3 August 8 1 1 6 Sept 10 1 2 7 Oct 5 5 Nov 7 1 1 5 Dec 12 3 9 Totals 76 10 13 53

Disposition Home Rehab LTC Expired 1 4 1 1 1 6 5 1 2 2 1 3 4 3 5 1 2 2 3 1 4 3 2 4 1 2 4 4 4 33 5 10 28

Hospice

DNR

1 1

1 1

1

4 2 1 3 6 1 3 9 30

2 1 1 2 1 1 12

The LSMA program includes a core team of one emergency physician and one master's prepared nurse coordinator for the initial consult. Additional member involvement from the interdisciplinary team is determined by the plan of care. Other key members may include 21 The PULSE JANUARY 2013 nursing, medicine, nutritionists, chaplains, psychologists, social workers, physical therapists, occupational therapists, and other disciplines as required meeting the needs of each patient and family. Distinguishing itself from most other ED palliative programs, the LSMA program is open

Residency Spotlight ACOEP is proud to continue casting a spotlight on the outstanding residency programs available!

Michigan State University – Genesys Regional Medical Center 1 Genesys Parkway Grand Blanc, MI 48439 Hospital Information: Type: Non-profit, community Trauma Level: 2 Number of Hospital Beds: 410 Number of ED Beds: 47 EM Program Information: Phone: (810)606-5980 Website: www.gensys.org Total Number of EM Residents: 27 Residents to Attending Ratio Working Clinically 1:1 (2:1 overnight) Accepts Medical Student Rotations? Yes, 4th years only EM Program Curriculum: PGY 1: EM (4 months), Peds EM, IM, Anesthesia/Ophthalmology (2 weeks each), ICU, Ob, General Surgery, Block nights (ICU/ house call) PGY 2: EM (7 months), Orthopedic Surgery, Ultrasound/EMS, Obs/EM, Radiology/Anesthesia (2 weeks each), ICU PGY 3: EM (6 months), PICU, ICU, Toxicology, Cardiology, Neurology/Neurosurgery (2 weeks each), Elective PGY 4: EM (8 months), EM administration, Trauma, Elective (2 months) EM Program Application Information: Dates applications are accepted: Prefers COMLEX Scores of: Interview Dates: October-December Number of Letters of Recommendations and who can write the letters: 2 letters of recommendation and Dean’s letter

Conemaugh Valley Memorial Hospital – Emergency Medicine 1086 Franklin St Johnstown PA 15905 Hospital Information: Type: Trauma Level: 1 Number of Hospital Beds: 552 Number of ED Beds: 37

22

EM Program Information: Phone: 814-534-3745 Website: http://www.conemaugh.org/education/gme/ Total Number of EM Residents: 16 Residents to Attending Ratio Working Clinically 1:1 to 1:3 Accepts Medical Student Rotations? yes EM Program Curriculum: PGY 1: EM(4); IM(1); IM-ICU(1);FP(1);Surgery(1);Anes(1); Trauma(1);OBGYN(1);EM-PEDS (1) PGY 2: EM(5); IM-ICU(1);Ophth(.5);Trauma(1); PICU(1); ORTHO(1);Research(1);Cardiology(1);Plastics(.5) PGY 3: EM(7);ICU(1);EM-PEDS(1);EMS(1);Research(1); Selective(1) PGY 4: EM(9); EMS(1);Selective- Mini Fellowship(2) EM Program Application Information: Dates applications are accepted: Sept 1 Prefers COMLEX Scores of: >500 Interview Dates: Consecutive Thursdays in the months of October, November and December Number of Letters of Recommendations and who can write the letters: 3 letters of recommendations, preferably with one being from an Emergency Medicine Physician.

Marietta Memorial Hospital 401 Mathew Street Marietta, Ohio 45750 Hospital Information: Type: Community Hospital Trauma Level: Trauma III Number of Hospital Beds: 199 Number of ED Beds: 30 EM Program Information: Phone: (740)568-5669 Website: www.mmhopsital.org/gme Total Number of EM Residents: 16 Residents to Attending Ratio Working Clinically 1 to 1, at times 2 to 1 Accepts Medical Student Rotations? Yes 2 per month EM Program Curriculum: PGY 1: EM – 6 months, Surgery, Anesthesia, OB/GYN, ICU *out rotation, ENT/Ophthalmology, Radiology/Ultrasound PGY 2: EM – 6 months, Orthopedics , IM – 2 months, Cardiology, Peds EM * out rotation, Elective PGY 3: EM – 6 months, Research/Admin, Trauma level 1

The PULSE JANUARY 2013

*out rotation, SICU *out rotation, Pulmonology , Urology, Elective PGY 4: EM – 6 months, EMS, PICU *out rotation, Plastic/Hand Surgery *out rotation, Toxicology, Elective, Neurosurgery EM Program Application Information: Dates applications are accepted: July 1 Prefers COMLEX Scores of: 450 and greater Interview Dates: September 1 thru Dec 15th.

Number of Letters of Recommendations and who can write the letters: 3 and at least 1 from an ER physician.

Good Samaritan Hospital Medical Center 1000 Montauk Highway West Islip, NY 11975 Hospital Information: Type: Community, ~100,000 volume Trauma Level: 2 Number of Hospital Beds: 437 Number of ED Beds: 100 EM Program Information: Phone: 631/376-4163 Website: www.good-samaritan-hospital.org Total Number of EM Residents: 24 Residents to Attending Ratio Working Clinically: 1:1 Accepts Medical Student Rotations? yes

PGY 3: PGY III: Emergency Medicine - GSHMC 22 Emergency Medicine - EHC 4

Pediatric Emergency Medicine 6

Cardiac Care Unit 4 Emergency Medical Services

2 Trauma Surgical Service 4 Toxicology 4 Elective 2 Vacation 4 PGY 4: PGY IV: Emergency Medicine - GSHMC 24 Emergency Medicine - Level I 4

Pediatric Emergency Medicine 4 Pediatric ICU 4 Research / Administration

2 Trauma Surgical Service 4

Elective/Selective

6

Vacation 4 EM Program Application Information: Dates applications are accepted: July 1st Prefers COMLEX Scores of: >500 Interview Dates: Begins in October Number of Letters of Recommendations and who can write the letters: need 3, one of which must be from an EM physician, for application to be complete

EM Program Curriculum: (13 @ 4-week blocks annually) (numbers listed are # of weeks) PGY 1: PGY I: Emergency Medicine - GSHMC 22 Internal Medicine 4 Medical Intensive Care Unit 4 General Surgery 4 OB/GYN 4 Pediatrics 4 Anesthesia/Radiology 2 Orthopedics 4 Vacation 4 PGY 2: PGY II: Emergency Medicine - GSHMC Emergency Medicine - EHC

Pediatric Emergency Medicine

Surgical Intensive Care Unit

Emergency Medical Services Emergency Ultrasound 2 Ophthalmology 2 Otolaryngology 2 Research / Administration

2 Vacation 4

24 4 6 4 2

The PULSE JANUARY 2013

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Member Benefits from PEPEID EM

Join the ACOEP Journal Club!

Are you taking advantage of the many benefits of ACOEP Membership? The Member Center on the ACOEP homepage has a complete listing of ACOEP Member Benefits, including a 15% discount on a PEPEID EM subscription for one electronic device, and a 50% discount on a second device.

ACOEP is proud to announce the formation of a Journal Club! The purpose of this group is to share interesting, valuable and informative articles, studies, abstracts, cases and more with ACOEP Members at large. By sharing information and encouraging discussion in online forums, the ACOEP Journal Club aims to enrich the practices of our diverse members. Topics will range from clinical studies, to best practices, administration, government, and more.

PEPID EM provides emergency personnel an electronic medical information resource that includes a differential diagnosis generator, enabling a quick diagnosis by entering patient symptoms, while simultaneously checking for drug interactions and dosing information. PEPID EM designed specifically for emergency personnel, is made easily accessible, at your fingertips in the “heat of battle” environment of emergency medicine. PEPID EM is the only point-of-care tool that truly supports emergency personnel in making decisions and can improve patient safety and speed of care.

Membership is simple, and requires minimal time commitment. If you are interested in joining, please contact Erin Sernoffsky at ESernoffsky@ACOEP.org.

PEPID EM is available on iPad, iPhone, Blackberry, Android, PalmPre, Windows Mobile and Online; making everything emergency personnel need available to support efficient, high-quality care without leaving the patient's side.

SAVE THE DATE Planning for ACOEP’s 2013 Emerge Scientific Assembly is already underway!

The conference will be held October 6-9 at the brand new Hilton San Diego Bayfront.

The conference will include cutting-edge didactic section, a large exhibit floor, competitions, committee meetings, and the 3rd Annual FOEM Legacy Gala and Awards Ceremony.

Registration will open this spring so stay tuned to ACOEP e-blasts and website for up-to-date conference information.

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ACOEP New Speaker's Bureau In an effort to secure new speakers for the College’s major CME conferences, ACOEP will be sponsoring a New Speaker’s Bureau. This opportunity will be open to members of the college to display their speaking skills and become involved with lecturing on a national level. The first annual competition will take place at ACOEP’s upcoming EMERGE Spring Seminar, which will be held April 2-6 at the Marriott Harbor Beach in Fort Lauderdale.

Rules: • Candidates must submit the following by Monday, March 4: 1) Faculty Profile 2) CV 3) Proposed Title of Presentation 4) (3) Learning Objectives The Faculty Profile form can be found on the ACOEP website (http://www.acoep.org/speakers.htm) •

Please submit the above items to Lorelei Crabb at lcrabb@acoep.org by March 4. The ACOEP CME Committee will conduct a CV review to select the most qualified candidates. You will be contacted by email if you are selected for the competition.

•

Speakers must give a 12-minute power point based lecture before a panel of judges from the ACOEP CME Committee on a topic relevant to Emergency Medicine. This time allotment is strict, speakers running over the 12-minute time period will be stopped. There will be a 2-minute period for questions following the presentation.

•

Speakers are required to bring their presentations to the audition. Presentations must be preloaded onto the ACOEP laptop in advance. You will not be allowed to your own computer for presentation. Your presentation must be compatible with the college’s computer as their will be no time to switch computer’s between presentations.

•

ACOEP will provide a wireless microphone and laser pointer with slide advancer for the speakers.

•

Speakers must be registered for the Spring Seminar and are responsible for their own travel arrangements and expenses.

•

Judges will select one winner from the speakers. The winner will be offered the opportunity to lecture either the 2014 Spring Seminar or Scientific Assembly.

Call for Nominations

Physicians interested in working with the Board of Directors of the American College of Osteopathic Emergency Physicians should submit their most recent CV with a letter detailing their credentials and reasons for wanting a seat on the Board to: Thomas A. Brabson, D.O., MBA, FACOEP-D Chair, Nominations Committee ACOEP 142 E. Ontario Street, Suite 1500 Chicago, IL 60611 312-587-9951 (fax) janwachtler@acoep.org (Subject Line Title: NOMINATION) Deadline: March 1, 2013

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