The Pulse- Summer 2018

JULY 2018

MASS CASUALTY INCIDENTS

PREPARING TO PREPARE PG 9

PRESIDENTIAL VIEWPOINTS

ACOEP PRESIDENT’S DOINGS PG 3

WHEN TRAGEDY STRIKES AT HOME PG 19

NATURAL DISASTERS TAKE AN UNNATURAL TOLL PG 22

The Pulse VOLUME XL No. 3

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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

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Christine F. Giesa, DO, FACOEP-D Erin Sernoffsky, Editor Janice Wachtler, Executive Director Gabi Crowley, Digital Media Coordinator EDITORIAL COMMITTEE Timothy Cheslock, DO, FACOEP, Chair Drew A. Koch, DO, MBA, FACOEP-D, Board Liaison John C. Prestosh, DO, FACOEP-D Stephen Vetrano, DO, FACOEP Kaitlin Bowers, DO Tanner Gronowski, DO Dominic Williams, DO Erin Sernoffsky, Director, Media Services

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TABLE OF CONTENTS 3

PRESIDENTIAL VIEWPOINTS Christine Giesa, DO, FACOEP-D

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THE EDITOR'S DESK Timothy Cheslock, DO, FACOEP

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EXECUTIVE DIRECTOR’S DESK Janice Wachtler

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ON DECK CIRCLE Robert Suter, DO, MHA, FACOEP-D

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MASS CASUALTY INCIDENTS – PREPARING TO PREPARE Duane D. Siberski, D.O., FACOEP-D, FACEP, PHP

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THE LAS VEGAS MASS CASUALTY INCIDENT Michael P. Allswede DO

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IMMERSIVE MCI TRAINING IN CHICAGO AS CLOSE TO THE REAL THING AS POSSIBLE Gabi Crowley

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WHEN TRAGEDY STRIKES AT HOME Nicole Ottens, DO, FACOEP

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NATURAL DISASTERS TAKE AN UNNATURAL TOLL Azer Wael

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PHYSICIAN POST TRAUMATIC STRESS DISORDER Christine Giesa, DO, FACOEP-D

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EMERGENCY DECONTAMINATION: WHAT YOU NEED TO KNOW Bernard Heilicser, D.O., M.S., FACEP, FACOEP-D

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SWEET HOME CHICAGO! Erin Sernoffsky

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COMMITTEE CORNER

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ETHICS IN EMERGENCY MEDICINE: WHAT WOULD YOU DO? Bernard Heilicser, D.O., M.S., FACEP, FACOEP-D

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FOEM FOCUS

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AUTO-BREWERY SYNDROME - TREATING THIS RARE DISEASE Christine Giesa, DO, FACOEP-D

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he core of my work as your ACOEP President and Board member is to represent you and ACOEP to the broader medical community. Your Board has been hard at work advancing our agenda and working toward positive change in emergency medicine.

Here are just some of the ways in which I have worked to represent you in recent months.

EDPMA SOLUTIONS SUMMIT: Lead from Where You Are I attended the EDPMA Solutions Summit. Topics of discussion included how to fight back when insurers are increasingly implementing reimbursement policies that may violate laws that protect patients and providers, such as the Prudent Layperson Standard, the Emergency Medical Treatment and Labor Act. I participated in a panel discussion “The Future of Emergency Medicine.”

Panel discussants included Andrea Brault, MD, chairman of EDPMA and Paul Kivela, MD, President of ACEP. We explored the impact on ED volume by the loss of Level 1 and 2’s to urgent cares and mini-clinics. Within the next 10 years there will be an abundance of emergency physicians—how do we extend our practice? Should we incorporate the hospitalist services under our auspices? We can be a leader in telemedicine. Emergency physicians need to remember that we are the specialists in unscheduled care. We need to be creative.

Finally, we should not wait for government and others to take action.

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PRESIDENTIAL VIEWPOINTS

THE EDITOR’S DESK

Christine Giesa, DO, FACOEP

Timothy Cheslock, DO, FACOEP

ACOEP PRESIDENT’S DOINGS

ADAPTING MILITARY MEDICAL TRAINING TO THE CIVILIAN ENVIRONMENT

Others are already taking action on their own. Emergency medicine should look for creative partnerships and unite: ACEP, ACOEP, AAEM, PFC, and EDPMA. All of us are the future of emergency medicine

ACEP LAC 2018 I attended the ACEP Leadership and Advocacy Conference in Washington, DC. ACOEP President-Elect Bob Suter, DO FACOEP, and I had the opportunity to represent ACOEP at the Federal Government Affairs Committee Meeting. The topics of discussion for the Solutions Day were treatment approaches used in the opiate free ED and the use of ED- initiated Medication Assisted Treatment (MAT) and other support services. Appropriate endof-life care, such as building clinical protocols into geriatric emergency care, incorporating payment incentives into value-based payment models, and bringing emergency care and follow up palliative care to the patient outside of the hospital, were also key topics.

ACOEP Statement on Drowning With the coming of spring, postings in the news and on social media began to again appear regarding “dry drowning” and “near drowning.”

ACOEP was asked to write a statement dispelling the myths of “secondary drowning” and “near drowning.” A synopsis of ACOEP statement is as follows: ACOEP defines drowning in three ways—fatal drowning; non-fatal drowning with injury or illness, and nonfatal drowning without injury or illness.

ACOEP urges the media and public to abandon the use of the terms ‘near drowning’, ‘dry drowning,’ and ‘secondary drowning’ when speaking, or writing about the medical sequelae of drowning, as these are not actual medical terms and often lead to confusion Drowning deaths do not occur due to unexpected deterioration days to weeks later without proceeding symptoms. A drowning patient who initially appears normal but develops respiratory symptoms or altered mental status more than eight hours after the event, should seek care.

The physician should consider other diagnoses than primary drowning in these patients. Other diagnoses to be considered include spontaneous pneumothorax, chemical pneumonitis, bacterial or viral pneumonia, head injury, asthma, heart attack, or other serious injury.”

Visit www.acoep.org/newsroom for the full statement, as well as a downloadable graphic explaining this statement that can be shared with patients, families, and other medical professionals.

RSO Strategic Planning I was invited to attend the RSO Strategic Planning Session in May. I am enthusiastic about the future of the RSO, and ACOEP with these enthusiastic, talented young leaders taking on new responsibilities and spearheading new initiatives. I’m very excited to see what heights these leaders take the RSO to!

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mergency medicine derived many of its treatments and innovations from some type of military research and training.

Several of the devices and medical products we use today had their origins in the military, for example TXA for hemorrhage and quick clot.

A few recent medical products have been proven on the battlefield and adapted to civilian EMS and Emergency Departments around the country. Therefore, it is reasonable and prudent to consider that some of the military protocols can be modified and adapted for civilian mass casualty or active shooter events in our communities.

Gone are the days when emergency departments and trauma centers were the defined starting point for care. In recent mass casualty events we have seen how often lives have been saved with immediate care given promptly by professionals in the field.

It has also been shown in such largescale events, even the most prepared facilities can quickly become overwhelmed, demanding innovative and novel approaches to provide rapid stabilization to preserve life. In many cases, non-medical personnel or ordinary citizens have performed heroically to assist in saving lives.

The Trauma Combat Casualty Care Course (TCCC) is an excellent resource provided to military medical providers in preparation for deployment to a war zone. I had taken part in this training prior to my deployment to Afghanistan with the US Army. Its emphasis is on care under fire, rapid assessment

and hemorrhage control, rapid identification of life threatening injuries and prevention of hypothermia.

The course is both academic and situationally challenging as you learn or review critical skills that have been proven to save lives on the battlefield.

The TCCC course is offered by a variety of training organizations throughout the United States.

Many are staffed by former military members and have excellent practical exercises tailored to potential threats in your community designed not only to make you think outside the box regarding how you will perform, but also how to prepare your facility if you should be unfortunate enough to have to deal with this type of situation. Many

control, use of tourniquets and basic triage may be difference between success and failure in a large-scale event.

Too often hospitals are resistant to providing the training necessary to prepare for the worst case scenario. I think it is obvious that we can no longer leave this to chance.

Participation in your hospitals emergency preparedness committee or other groups within the hospital that deal with all hazard preparation is key to securing funds and resources to train your staff in the event of a mass casualty situation. Providing planners with a realistic scenario and injury pattern is critical to making practice scenarios real. As emergency

TOO OFTEN HOSPITALS ARE RESISTANT TO PROVIDING THE TRAINING NECESSARY TO PREPARE FOR THE WORST CASE SCENARIO.” tactical EMS and law enforcement units already make TCCC part of their training curriculum.

It would be of great benefit to also engage the providers in your own emergency department to do the same. Many facilities can easily be overwhelmed by as few as five or ten major trauma patients. Imagine if there were 50 or 100 or more. Providing all your staff, from physicians and advanced practice providers to nursing and ancillary staff, with some degree of competence in hemorrhage

physicians, we know more than most of what can come through that door and how well we are prepared or not to handle it. By advocating through your hospital committees, you can do a lot to enhance the preparedness of your own facility for the future.

Disclaimer: Dr. Cheslock is a Lieutenant Colonel in the Florida Army National Guard. His opinions are strictly his own and are not to be representative of the DOD, US Army or any other entity.

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bout 25 years ago, a television show premiered that focused on the daily activities of a group of physicians, nurses, and nurse’s aids in one emergency room in Chicago.

ER was a great hit for nearly 10 years and in one episode it chronicled one attending physician’s encounter with a patient’s family who accosted him and left him broken and bleeding.

Recently, a nurse at a hospital in Chicago was shot and wounded by a patient’s family member who felt she did not provide the patient with appropriate care. The article in the Chicago Tribune called the emergency department a war zone, in which emergency department workers were often spat upon, accosted, and verbally or physically abused. The wounding of this nurse was just the tip of the iceberg at this hospital.

So, is it time for all the emergency medicine associations to come together and insist that emergency department personnel be better protected? Should we all stand by and let these talented and dedicated physicians, nurses, PAs and NPs, be afraid to go to work, or even leave work? Will we see people leave the field because they are not safe in the workplace? So, let this be a first step in demanding that institutions step up and act.

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EXECUTIVE DIRECTOR’S DESK

THE ON-DECK CIRCLE

Janice Wachtler, BAE, CBA

Robert Suter, DO, MHA, FACOEP-D

PHYSICIAN WELLNESS: A BILL OF RIGHTS

ORGANIZING CHAOS

Emergency Physician’s Bill of Rights 1. It is the right of emergency physicians and other emergency personnel to work in an environment that is well-equipped, clean and safe.

2. It is the right of the emergency physician and emergency department personnel to be protected from violence brought upon them by upset family members, friends or others by the institution in which they work.

3. It is the right of the emergency physician and emergency department personnel to have counsellors and family advocates employed by the institution to act as intermediaries to mediate disputes, and act to defuse tense situations and appease family members or others.

4. It is the right of the emergency physicians and emergency department personnel to have a safe, well-lit location in which to park their cars or wait for public transportations before and after shifts that is protected and patrolled by security personnel employed by the institution.

5. It is the right of the emergency physicians and emergency department personnel to have a safe, comfortable, secure lounge, where they may rest during their shift.

This is just a beginning, let me know if you have other suggestions and we will present and raise flag of awareness of these issues to the media, institutions and government.

Visit www.acoep.org/pressroom to add your thoughts to the Emergency Physician’s Bill of Rights!

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his month’s issue of The Pulse has a Mass Casualty Incident (MCI) theme, to highlight and show respect for the great work done by many of our colleagues over the years during MCI responses.

It is also gives a nod to increasing awareness of our MCI Exercise plans the day before the ACOEP Scientific Assembly in Chicago this Fall.

Of course, as a military guy I must point out that the original approaches to MCI response were initially developed by military medicine.

Subsequently, they have been improved by both civilian and military providers, especially since the advent of the specialty of emergency medicine and the development of the organized cadre of EMS and disaster specialists that have developed among us.

Just like soldiers in combat operations, it is important for physicians in MCI situations to either lead, follow, or get out of the way.

Both types of operational systems are designed to function reliably in high-risk situations by incorporating structure, organization, and hierarchy.

These elements create order out of chaos. An MCI or disaster situation is not the time to be debating or perfecting processes; rather is the time for everyone to be harmoniously executing the previously planned processes.

Great MCI teams use the lessons learned from each event to make improvements before the next incident. They know that the time to focus on perfecting tasks and refining operations is during the planning

LEAD, FOLLOW, OR GET OUT OF THE WAY!” GENERAL GEORGE S. PATTON processes, and not in the heat of the moment.

We have been fortunate to have as colleagues a number of osteopathic physicians who have recently excelled in the heat of mass casualty situations. From Richard Jadick, DO who was dubbed “Hero MD” on the cover of Newsweek magazine, to our colleagues who performed brilliantly during the more recent Las Vegas massacre, as well as others around the country - we salute you.

The innovations that you helped plan before and executed during these incidents saved hundreds of lives. This knowledge will play an important role in mitigating the dangers of our world and in protecting our loved ones.

Inspired leadership combined with selfless service and teamwork allows MCI providers to overcome obstacles, making sure that teammates are in the right place when needed to support patients and each other.

To have achieved these results we have certainly had to live Patton’s axiom by either leading, or following.

Getting out of the way was not an option, and not a path to success.

The nature of MCIs reminds us that we have chosen wisely in entering a specialty where we give a good measure of our time and talent in service to others. The need to serve others has never been greater. Money and position may not always follow,

but satisfaction will always be there when we have a purpose in life that is beyond position and money. Emergency medicine provides us that purpose.

As emergency physicians we intuitively understand that while we need to be prepared for emergencies and disaster situations, we should not create them. Whether in our own emergency departments or within ACOEP, we aspire to maintain stable, predictable, and drama-free operations. We do this by preparation and planning, while always being open to thoughtful, timely input from all members during the planning process.

It is has been my great privilege to “follow” on the ACOEP Board for the past six years, only rarely needing to “get out of the way.” Now I get to utilize these experiences as a follower to improve my skills in my relatively new role on the leadership team of this great organization. My pledge to you is that just like our great MCI leaders we will listen to you, incorporate your concerns within our planning and decision making, making sure that when it is time to perform under pressure that you get the highquality leadership that you deserve.

I look forward to seeing you in Chicago this Fall. In the meantime, thank you for your support and for the leadership that you provide to our emergency departments nationwide every day.

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ACOEP-RSO PRESIDENT AND DIRECTOR OF STUDENT AFFAIRS REPORT Dhimitri Nikolla, DO, PGY-3 ACOEP-RSO President AHN Saint Vincent Hospital Erie, PA RSOPresident@acoep.org

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C H I C AG O Celebrating ACOEP’s 40th anniversary in our hometown

Christina Powell, OMS-3 ACOEP-RSO Director of Student Affairs LECOM – Bradenton Bradenton, FL RSOStudentDirector@acoep.org

elcome to the Summer edition of The Pulse! The RSO has had a busy spring!

First, Spring Seminar was a huge success!

On April 6th, we held our student symposium and received overwhelmingly positive feedback. The day began with rapid-fire lectures featuring pearls on ventilator management, common toxicology emergencies, EKGs, and applying to residency. We had a tremendous ultrasound lecture from Dr. Eva Tovar Hirashima, Emergency Medicine (EM) and Ultrasound Faculty at UC San Diego. The EKG and ultrasound workshops were a huge success as well!

Next, on April 22nd, Kaitlin Bowers, DO (RSO PastPresident), Kristen Kennedy, M.Ed. (ACOEP Director of Education Services), and participated in the first All EM Resident Organizations and Students (AEROS) Meeting at the CORD Academic Assembly in San Antonio, TX. Representatives from eight national EM resident and student organizations attended. Multiple vital topics pertaining to residents and students were discussed including standardized video interviews and overapplication to residency.

On May 15-16th, we held our annual RSO Executive Board Strategic Planning meeting. We spent almost two full days finalizing plans for Scientific Assembly, planning changes to our website, bylaws, advocacy section, leadership development, and member benefits. ACOEP

has prioritized resident benefits and some exciting offers are in the works! So, keep an eye out for updates in in your email and on our Twitter and Facebook pages. In addition, due to feedback from the fall, there will be some proposed changes to our bylaws; for example, prepare to vote at Scientific Assembly on residency program voting rights. We are considering allotting every residency program present their own vote no matter how many residents in the program are ACOEP members.

We hope that this will improve voter efficacy among members in programs with fewer ACOEP members.

Our next student symposium will be “Deadly Misses” held at Lakeland Health on Saturday, September 8th. Tell your students to register soon before space runs out!

Lastly, Scientific Assembly will be October 21-25, 2018 in Chicago, IL. RSO Events will be held Oct 21-22nd including an airway competition, Tox Wars, the EMRA Quiz Show, and our first-ever, So You Think You Can Teach? Competition. The Student Leadership Academy, Student Residency Expo, and Swipe Right Resident and Recruiter Lunch are planned as well. As always, all RSO members are welcome to attend the ACOEP main conference lectures!

The RSO Board has a busy summer ahead! We are looking forward to seeing you all at Scientific Assembly!

AOA AND AOBEM ANNOUNCE CHANGES TO CME October 21 – 25, 2018 Chicago Marriott Downtown Magnificent Mile Visit acoep.org/scientific for more information

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As you may be aware the AOA and AOBEM have worked together to institute changes to CME accreditation, scheduled to take place in 2019. According to the AOA’s statement, “the requirement for category 1 or 2, A or B, classification will be eliminated.”

As we finish this CME cycle we are excited to celebrate ACOEP’s 40th Anniversary in Chicago with Scientific Assembly, re-envision the Written Board Prep, expand our online courses, introduce an exciting new partnership with HippoEM, and so much more.

While this change will have some effect on the CME landscape, we remain very confident in our educational programming and optimistic that the growth we have enjoyed over the past decade will continue.

For more information please visit www.acoep.org.

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PROGRAMS AND IMPLEMENTATIONS Run, Hide, Fight The Office of Homeland Security authored the Run, Hide, Fight video with accompanying information display literature in 2012. Designed for the workplace, it has been adapted to the school environment with ALICE: Alert-Lockdown-Inform-CounterEvacuate. With the video’s emphasis on the three options, it covers the reality of an active shooter event with data pertaining to the random victim choice, short duration and need for heightened awareness. The training is aimed at maximizing survival during an event in the workplace. It can be viewed by interested citizens and has been taught by police departments and private entities across the country.

MASS CASUALTY INCIDENTS

PREPARING TO PREPARE M

By Duane D. Siberski, D.O., FACOEP-D, FACEP, PHP

American public sentiment and awareness ebbs and flows after MCIs occur. The need for an integrated system with well-trained providers responding to mass casualty incidents truly exists. Critiques of MCIs bring to light shortcomings; communication failure, remote staging of vehicles, incident command without unified command or system integration and more.

Problems identified without definitive monetary support to impact system-wide changes.

Education and training in preparation of MCIs exist for first responders and the public. Implementation of programs varies across the country and in each state with many ACOEP members currently involved in these initiatives. Creativity in the implementation of training programs aids in success.

The first question to answer often is when and how do I start? While not a template for all areas, these are examples of programs and their utilizations.

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Realization of the probability for education site violence is bringing to light the need for training in schools.

There has been a trend toward an attitude of “it can happen here” from the previous “it’ll never happen here” lately. By utilizing the guidelines set forth in the Run, Hide, Fight and ALICE programs, schools can be better prepared. School administrators, local government, and first responder agencies could be resources to plan such training.

TARGET AUDIENCE:

edia coverage of the latest mass casualty incident [MCI] has decreased. Parkland High School is in the record book. Remembrances of previous MCI events tribute the victims ceremoniously. The Academy of Country Music awards show dedicated to the Route 91 victims, #RunBoston spelled out the city’s name with a course route along the city streets, a Massachusetts’s moment of silence at 2:49 PM occurred five years after the bombing, the National Park located at a plane crash site in Pennsylvania, the corollary New York City memorial and museum with a $44 admission ticket price, an empty field devoid of the removed Amish one room schoolhouse all stand as reminders to previous MCI events.

The common denominator in all of this is the Emergency Department [ED]. Optimal MCI victim care is a team approach, with challenges ranging from victim transportation, training, logistics, and issues that vary from hospital to hospital.

easier with each scenario. Other athletic trainers had to confront their fear response resulting in freezing in place, unable to make decisions or protect themselves.

OPTIMAL MCI VICTIM CARE IS A TEAM APPROACH, WITH CHALLENGES RANGING FROM VICTIM TRANSPORTATION, TRAINING, LOGISTICS, AND ISSUES THAT VARY FROM HOSPITAL TO HOSPITAL.”

Training for the Berks County Athletic Trainers Association in Pennsylvania used the ALICE curriculum which brought the need for combined education and scenario-based practice to the forefront. Utilizing starter pistols, mannequins, and screaming, moulage victims created a chaotic environment for the practice, and providers made decisions to rescue victims, shelter in the lockeddown classroom, or evacuate.

Some participants found their response to the active threat became

Athletic Trainers – high school and college based CHANGE:

Action plan for improved survivability in education site violence event FUNDING:

Education budget – Berks County Athletic Trainers Association TIME:

12 hours over past 3 years, 3 training session

Tactical Emergency Casualty Care Authored by the National Association of Emergency Medical Technicians [NAEMT], the Tactical Emergency Causality Care [TECC] course covers management of trauma victims in austere conditions. The curriculum teaches rendering care to victims while in direct threat (under attack), indirect threat (when hostile threat is suppressed but can reemerge), and evacuation care (while moving victims from the incident scene).

The military version, Tactical Combat Casualty Care, developed by the U.S. Department of Defense Committee on TCCC, is adapted to battlefield casualties care. While some TCCC guidelines may not be applicable to civilian application, [e.g. return fire and take cover], the techniques and management are evidence-based for providing life-saving care on the battlefield for victims.

Integrating TECC care into current pre-hospital operations requires accepting the paradigm change from “the scene is safe” to “the scene is as safe as it can be.” Providers utilize a Rescue Task Force [RTF] model to access victims. Differing from Tactical EMS or SWAT EMS which proceed with law enforcement into the highrisk area, the Hot Zone, providers of the RTF are escorted, and move as a group with law enforcement to access victims in the lower risk area, the Warm Zone. Utilizing rapid assessment, techniques to treat limited life-threatening injuries of victims at the point of wounding, while maintaining situational awareness, the RTF moves from victim to victim.

This style of access to victims is a change from operational dogma in EMS. Cooperative maneuvers with law enforcement in unsecured,

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but lower threat areas require preplanning and practice between providers. Adaptation of more aggressive responses by non-SWAT law enforcement to hostile threats began after 1999 and the Columbine event. The FBI recognizes this change as life-saving. While staging EMS at a safe distance, the Cold Zone, is the most common, more EMS agencies are adopting the TECC training and RTF model with local law enforcement.

The Eastern PA Regional EMS Council, Orefield, PA, hosted several TECC courses for providers. Most recently, a TECC course was grant-funded to provide training for 50 providers on the campus of Penn State Health – St. Joseph Medical Center, Reading, PA. Participants attended didactic sessions with skills stations practice.

Moulage victims, law enforcement officers for escort, and ballistic protective gear provided the realistic practice during scenario evolutions.

Although TECC training and RTF are not the current standard in Pennsylvania, the Pennsylvania Department of Health-Bureau of EMS currently has the Hostile Threat Work Group. This task force is evaluating the state-wide implementation of a TECC/RTF plan.

TARGET AUDIENCE:

Pre-hospital providers – police, fire, EMS CHANGE:

Action plan for pre-hospital providers to decrease preventable deaths in the civilian tactical environment FUNDING:

Pennsylvania EMS education grant, provider funded TIME:

24 hours TECC, 120 hour Hostile Threat Work Group

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Active Shooter Drill Staging a drill to allow law enforcement, EMS and Fire department personnel allows the practice of techniques for providers involved in the preparation phase of an event. Pre-planning for such an event can help to minimize and mitigate risk, but not prevent it. Multiagency practice drills can help to coordinate each discipline’s roles and responsibilities when responding to an event. Each program, whether Run, Hide, Fight/ALICE, TECC/TCCC, RTF, or ALERRT: Advanced Law Enforcement Rapid Response Training is designed for the specific groups in response to the same threat.

Scheduling between multiple agencies begins months in advance.

Schools tend to prefer in-service days for staff education events, municipal agencies require needs assessments for budget approvals, instructors, evaluators, Department of Health observers, victims, and food vendors will all need time for scheduling. Receiving facilities cannot predict activity levels in flu season.

Aeromedical units are weather dependent. The coordination of each entity together resembles a combination of cat wrangling and Jello juggling.

Organizing an active shooter training drill can be a large-scale event when planned to incorporate training programs for a high school, municipal police and fire departments, local EMS agencies, receiving hospital, aeromedical service, instructors, victims, and the news media. School staff utilize ALICE training, law enforcement divides manpower to the different activities required of contact team or RTF escort team, fire and EMS assemble RTF teams, casualty collection points, triage and transport staging areas, the unified command system maintains communication and incident control with each component seamlessly working together.

Returning to reality, organizing and running multi-agency drills will expose organizational and operational short-comings, system downfalls, unchecked egos of personnel, and heated debates in the hot-wash

with associated after-action report for process improvements. The news media will edit to a favorable 30 second video clip with a short extemporaneous blurb by a drill participant or organizer. Ultimately, providers will accept the need for improvement and will have had the benefit of skills practice.

TARGET AUDIENCE:

First responders – law enforcement, fire, EMS, school staff CHANGE:

Action plan and practice in coordinated multi-agency event to minimize and mitigate risk for improved survivability FUNDING:

Agency dependent ranging from budgeted to donated HOURS:

250 in planning, 10 in drill, 1 hour – confession and penance for lying to parochial high school principal that no participant would be armed [six law enforcement officers as security detail for drill protection were all armed]

Stop the Bleed In October of 2015, the Office of Homeland Security initiated the Stop the Bleed Campaign. Intended to “encourage bystanders to become trained, equipped, and empowered to help in a bleeding emergency before professional help arrives,” it addresses treatment at the site of wounding by non-professionals. With a goal of the lay public providing care to victims prior to the arrival of professional care, as the name implies, it targets uncontrolled hemorrhage.

An EMS outreach program from Penn State Health – St. Joseph Medical Center in Reading, PA brings the Stop the Bleed program to over 110 schools in Berks County kicked off on March 1, 2018. The program provides a stocked

Stop the Bleed box for each school.

Training in the 90-minute program for school staff utilizes ED physicians, nurses and medics and school athletic trainers. On-going training will be provided at in-services for newly hired staff. Restocking of the Stop the Bleed box will be done by the hospital in the event there is a need to use the supplies.

Berks County school superintendents embraced the program and although the program’s planning required several months, it was coincidentally implemented shortly after the Parkland event, coincidentally.

TARGET AUDIENCE:

School staff CHANGE:

Action plan to provide hemorrhage control prior to professional care arrival FUNDING:

Hospital advertising budget TIME:

24 hours past 6 months, on-going for next 3 years

ACOEP-RSO – EM RESIDENCIES AND EMERGENCY MEDICINE CLUBS Emergency medicine training curriculum, whether GME or UGME, does not specifically include tactical care. While military medicine has an obvious need for such training, the majority of physician and physiciancandidates may not receive any exposure to this sub-specialty. Efforts to provide such exposure occurs though several options.

The St. Luke’s Health University Health Network Emergency Medicine Residency, Bethlehem, PA, has hosted several “Tactical Day” trainings as part of the educational component of residency. Members of the Region 2 TEMS Team, including Rebecca Pequeno, MD, chairman of SLUHN Emergency Service and co-medical of R2TEMS, provide didactic, skills stations, and practical evolutions for EM residents. Donning ballistic vests and helmets, residents crawl to access victims and provide care under austere conditions.

ACOEP’s RSO and other programs have also taken on this educational

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of perpetrator or culprit or offender lightly gauze the true identifier not used in presentation.

need. The University of New England College of Osteopathic Medicine’s Emergency Medicine Club, Biddeford, ME, brought the topic of Tactical Medicine to its members.

Members of the Region 2 TEMS presented the program to UNECOM EM club. After a didactic presentation, the club members rotated through skill stations to practice tourniquet application, wound packing, chest decompression, digital intubation and surgical airway techniques. Energy, enthusiasm, and smiles emanated from helmets, body armor, and gas masks as future physicians took turns treating mannequin casualties and cutting pig tracheas.

Tailoring a presentation to specific audiences can be an artform. While program core content remains unchanged, variations in presentation can be adapted to each audience.

Many CPR instructors supply students with helpful metronomes to maintain 100 BPM. Their utilization of songs for this task truly is audience dependent: The Bee Gees or Queen.

Start Preparing to Prepare

TARGET AUDIENCE:

Emergency medicine residents, Osteopathic medical students CHANGE:

Provide exposure to tactical medicine FUNDING:

None found yet, pig tracheas with lungs - $10 each, offset by lobster chowder $12 a cup TIME:

36 hours

ACOEP CME – Spring Seminar, Scientific Assembly The CME committee of the ACOEP organize the Spring Seminar and Scientific Assembly. The programs provide excellent CME through a variety of venues, including lecture topics of casualty care, MCI event reviews, and handson practicals. Presentations by providers involved in MCI events have been well attended and attendees receive information and opinions germane to EM practitioners rather than news reports.

The ACOEP EMS Committee, working with the CME Committee, has provided break-out session tracks covering the topic of Tactical Medicine and Tactical Medical Command. An increasingly popular addition to the conferences has been the Active Shooter Training. SWAT Physician John Dery, DO and Fire Chief Michael Roman spoke to a packed room of ACOEP course participants in San Francisco, CA, prior to skills session and scenario evolution where a hotel conference room was turned into a mock ED with multiple shooting victims. Members of the Resident Student Organization [RSO] provided moulage victims for the single coverage EM physician, Kevin Loeb, DO, to treat in his department. Other course attendees fulfilled roles in the ED as nurses, ward clerks, and techs.

In Bonita Springs, FL an EMS track with sessions covering the Pulse nightclub MCI, skills session at the conference hotel and, after a short bus ride, training at the county’s fire training grounds was well attended and provided lifesaving information. Working with members of fire, EMS and law enforcement, program attendees practiced as members of the RTF to attend to victims and move with the law enforcement escort. Skills stations practice next to fire and EMS professionals filled the time between practice evolutions in the buildings with victims for the RTF maneuvers. Riding the bus back to the hotel, sweaty, dirty, tired, and a bit sore, course participants had seen the aspects of training expected of first responders to prepare for an MCI. This fall at the Scientific Assembly, attendees will have a chance to register for an MCI Simulation on an unprecedented conference scale. An MCI event, field hospital, surge patients, transportation issues, treatment strategy and much more. See the article on page 17 for a full description.

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TARGET AUDIENCE:

ACOEP Conference attendees CHANGE:

Provide experience in large-scale MCI drill FUNDING:

CME budget TIME:

Worth every minute spent

Prepare to Prepare Barriers MCIs will occur. Low-frequency, high-risk events have no predictability. While there has been a trend away from the denial attitude, proactive training still can meet with resistance. Some barriers to education may be encountered.

Political correctness tends to be a line some instructors will not cross, while others trip over this line regularly. The latest TECC course included an explanation from an instructor that phrases like “neutralize the threat” have been felt to be too graphic a description of the law enforcement activities to locate, contain, or kill the threat from a homicidal perpetrator and have upset some people in other classes. Although the instructor’s term modification to “bunny hugs and candy kisses” can be used as code words, the magnitude in presentations of sensitive material must sometimes include a warning to the audience.

Pre-lecture instructions are given to be non-judgmental if another participant leaves the program during the presentation. Preemptive apologies for language, germane to the topic but upsetting to some, does not decrease post-lecture complaints, but is included. Descriptive terms

Preparation for MCIs involves many aspects. Educational programs which focus on improved survivability for victims exist for first responders and the public. Available programs have content ranging from self-preservation in a workplace to military tactic recommendations. Some programs target the MCI timeline from the onset of the event until arrival of first responders. Other programs are designed for the specific provider and their roles and actions. Some programs are scalable to the different disciplines of first responders; law enforcement, fire, or EMS. Which program is the best in your locale?

MCI victims will arrive in an ED, during and after an event.

Improving the training of the “other team” to care for victims of MCIs is an important aspect in preparation. Empowering bystanders and improving first response can save lives.

The need to prepare for MCIs is obvious. Organizing training is difficult. However, opportunities exist, and while no one may feel they have the time or resources to invest in such trainings, this qualifies now as a priority.

Visit www.acoep.org/news for links to these and other valuable resources.

REFERENCES: “Run, Hide, Fight”, U.S. Department of Homeland Security, Washington, D.C. https://www.dhs.gov/active-shooter-emergency-action-plan-video “Dealing with Workplace Violence: A Guide for Agency Planners”, U.S. Office of Personnel Management, Washington D.C. www.opm.gov/ Employment_and_Benefits/Worklife/OfficialDocuments/HandbooksGuides/ “Stop the Bleed”, U.S. Department of Homeland Security, Washington, D.C. https://www.dhs.gov/stopthebleed, October 2015 “Active Shooter: How to Respond”, U.S. Department of Homeland Security, Washington, D.C. http://www.dhs.gov, October 2008 “Active Shooter: What You Can Do”, U.S. Department of Homeland Security, Washington D.C. http://training.fema.gov/EMIWeb/IS/IS907.asp, October 2008.

Tactical Emergency Casualty Care, National Association of Emergency Medical Technicians, Clinton, MS, naemt.org

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THE LAS VEGAS MASS CASUALTY INCIDENT

By Michael P. Allswede, DO

“That music is going to keep me up all night.”

Without realizing the irony of my words, I went to bed at 2100 on October 1st. My phone started ringing around midnight with the words “every available physician report to Sunrise for a mass casualty event.” I responded to Sunrise Hospital & Medical Center in Las Vegas for duty at 0020 and walked into one of the largest mass shooting events in our country. My most enduring memory of that night was the strong smell of blood that permeated the ambulance entrance and throughout the emergency department.

The Las Vegas mass casualty incident began a bit after 2200 on October 1 at the Harvest Festival Concert. The terrorist had planned his assault by reserving a room on the 32nd floor of a high-rise hotel with a view of the concert venue. The terrorist had assembled an arsenal of 27 weapons with hundreds of rounds of ammunition. His intent appears to have been indiscriminate mass killing. Over the course of 11 minutes, he rained down over 1,100 rounds in 12 volleys of bullets on the

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unsuspecting crowd of over 10,000 country music fans. The barricaded terrorist killed himself as law enforcement closed in on his location.

Over 500 people were injured with 59 deaths on that evening, 35 of which were pronounced at the scene, and 24 at area hospitals. The majority of these injuries, and all of the deaths, were from 5.56 mm and/ or 7.62 mm military gunshot wounds. 16 Las Vegas hospitals were involved in the response with significant resource sharing between proximity hospitals and non-involved sister facilities. Sunrise Hospital was the closest trauma center to the event and received the majority of the casualties due to victim self-triage. Sixteen victims died at Sunrise, either pronounced dead upon arrival or after heroic resuscitation attempts.

At the time of my arrival, the on-duty physicians had implemented the “Code Triage” disaster plan and the emergency department functioned as an airway and hemorrhage stabilization station. “Red” casualties were stabilized and sent on to the operating rooms, or the intensive care units where definitive management was

MY MOST ENDURING MEMORY OF THAT NIGHT WAS THE STRONG SMELL OF BLOOD THAT PERMEATED THE AMBULANCE ENTRANCE AND THROUGHOUT THE EMERGENCY DEPARTMENT.”

accomplished by specialists.

The majority of the victims had arrived by self-triage and were not dispatched by scene command.

My assignment was to re-triage over 100 “Yellow” casualties.

Each treatment room contained between three and six victims, some of them family and friends, some of them strangers, all of whom were providing self-aid due to the overflow of patients. And so my night began.

After several hours of work, we realized that our rate limiting feature was registration and radiology. Because of the physician surplus at 0400, I left to return in a few hours and relieve the overnight crew. When I returned, the majority of victims had been dispositioned with a few remaining victims still needing care. However, family members of the victims had begun arriving and 16 families were told the most devastating of news. The hospital responded with a team

of nursing, pastoral care, social work and physicians to assist the family members. Las Vegas is a vacation destination and many of the victims were celebrating engagements, marriages, birthdays, or reunions. The sudden shift from joy to tragic loss was excruciating for all of us.

The Las Vegas MCI was yet another example of terrorism in the United States. While the U.S. murder rate has diminished over the previous 10 years, both the rate and size of mass casualty events has increased. There are few barriers to the acquisition of firearms and a high vantage point over a crowd. Whether the terrorist chooses a firearm, a bomb, or a motor vehicle, mass casualty events are now a public health concern and should be treated as such. It is time for emergency medicine to take its place in advocating for data driven civilian hospital preparations for events such as these.

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IMMERSIVE MCI TRAINING IN CHICAGO AS CLOSE TO THE REAL THING AS POSSIBLE

By Gabi Crowley

F

rom shootings, to train derailments, to bombings, to plane crashes, headlines regarding mass casualty incidents have become all too familiar on the front pages of our newspapers. In most mass casualty scenarios, the amount of injuries outweighs the amount of resources available, therefore presenting greater challenges for first responders.

It’s never easy to think that something so horrific could happen in a place so close to home, but unfortunately that’s the harsh reality we’re faced with, and ACOEP wants to be sure you are prepared.

This fall, we are proud to partner with the local agencies in an immersive mass casualty incident training, unlike anything you have ever seen.

“This event is so important as we have seen in the past several years alone with Las Vegas, Sandy Hook, the church shooting in Sutherland, Texas, the high school massacre in Parkland, Florida and many others that mass casualty incidents are becoming more and more common. Often physicians and hospitals are not prepared,” ACOEP’s Director of Education, Kristen Kennedy said. “We know preparation is key and this training allows for physicians to practice and hone their skills for such incidents.”

Expect hands-on practice in surge control, limited supplies, moulage victims, and the overall chaos and panic of civilians, all designed to be as close to a real-life event as possible. But also expect to be kept guessing. In a real MCI, you won’t know what’s coming, and the same is true

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THE PHYSICIANS WILL WORK AS A TEAM TO EVALUATE AND TRIAGE THE PATIENTS AS THEY ARRIVE. THEY WILL HAVE TO ASSESS, TRIAGE, TREAT, AND THEN TRANSFER TO DECOMPRESS THE ED.” for ACOEP’s simulation. Attendees won’t be told before the event what’s going to happen, or what injections and collateral damage will take place.

Participants will be given an MCI response plan to familiarize themselves with in advance, and then will work together to staff a fully-equipped field hospital somewhere in Chicago before being surged by hundreds of moulage victims.

“The physicians will work as a team to evaluate and triage the patients as they arrive. They will have to assess, triage, treat, and then transfer to decompress the ED,” ACOEP’s EMS Committee member, Stephanie Davis, DO said. “They will

be very active participants in every aspect of patient care.”

Attendees of this event will be working out of a mock off-site hospital in an undisclosed location in the city, while medical students from Midwestern University will volunteer as victims.

Per ACGME Standard IV.A.6.c, residents must have experience in emergency preparedness and disaster management, and this upcoming training will be an excellent training to meet this standard.

lecture and hands-on training course.

To register, please visit acoep.org/ scientific for more information.

Space is extremely limited for this unique event!

Physicians who register for the event will have the opportunity to earn up to 6 hours of CME in this combined

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When Tragedy Strikes at Home

By Nicole Ottens, DO, FACOEP

W

hen I completed residency, I looked for a job in a rural community. After spending nine years training in the Chicago area, my husband and I were ready to settle down in nice, quiet small town. Medicine is based on relationships and having a connection to my patients is important to me. There is an added level of enjoyment and job satisfaction when you take care of your neighbor during his heart attack or your son’s first grade classmate when she needs stitches in her eyebrow. It is not uncommon for me to receive a phone call or text message asking me those three important words: Are you working? Those words signify a relationship and a level of trust that comes from knowing the people I take care of in my ED. However, there is one slight problem with being so connected—the stakes are higher when things get bad.

Last September, our sleepy little Midwestern town joined the ranks of so many other towns who didn’t expect it to happen to them. We had our own school shooter.

Around lunchtime, EMS called to give us a heads up that they were outbound to a shooting at the high school. Within minutes, the shift in our department was intense and the stress level palpable as we prepared for the worst. Critical rooms were emptied, OR rooms held open, a slew of administration and additional physicians descended on our department and everyone was glued to the radio and police scanner as the scene

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unfolded. This was the real deal. Shots fired.

Kids fleeing in every direction. Lockdown in place. Every police car and ambulance in the area was headed to the high school. My first thought (and only phone call) was to my best friend because her son was in that cafeteria and I could feel the swell of panic building in me. What if it was her kid that got shot?

How could I possibly stay calm and focus if he is truly hurt? She has to know. I have to tell her and prepare her. My phone call to her was less than 20 seconds. She already knew. He had called her and he was safe. I relaxed a bit and turned my attention back to the radio. The swell grew again. I knew the voices of those men on scene. Those police officers and EMS providers were knee deep in a potential mass casualty incident and it was their kids in that school. You could hear the added level of fear in their voices, not knowing who was shot and where the shooter was located. The helicopter was landing on our helipad, called preemptively.

The updates kept coming. Two known victims—a hand injury grazed by a bullet, refusing care and one male student, shot in the chest. EMS was bringing him here with diminished breath sounds, chest pain and needle decompression done prehospital. An ER physician and a general surgeon were already in the room waiting his arrival. How many more? Pediatrics and anesthesia were now down in our department, a rare sight. My phone went off—a robocall telling me what I already knew. More radio traffic from the

scene. Buses are coming to take the cleared children to a secure location.

The injured patient arrives, more stable than anticipated.

Our eyes scan the EMS crew. They are shaken. This isn’t just another gunshot wound. How many more? They don’t know. Their description of the scene plays out like a recap on the local news channel. Frightened kids running in every direction, hiding in the local neighborhoods and fields. Frantic parents coming to the area, searching for their children. Law enforcement and EMS being stretched to capacity to keep control of the scene. Tactical crews, bomb squads and state troopers were already there. Word spreads quickly. My best medics, the tough guys who have seen it all, are shaken. While trained for it, this is so much worse than any drill. This is our town. Our school. Our kids.

Finally, we hear it. They have him in custody. A lone shooter has been apprehended. A hero gym teacher, my subdivision neighbor whose oversized dogs walk her every evening, has done what needed to be done to save a cafeteria full of kids. Later, we would learn how she didn’t even hesitate when tackling him and securing his weapon, forcing his shots to miss most of those in the room and putting an end to a potentially large number of casualties.

Slowly the department returned to normal that day as we were allowed to stand down from the heightened state we were in. The number of extras in our department dissipated and gradually our work flow returned to normal. But the conversation in the halls and at the desk was constant.

More details would emerge, more people would find out, the news crews would arrive and Facebook would explode with streams of people sharing, caring, grieving, speculating, and searching for comfort. Plans were made for a vigil and the community hunkered down to support

one another. Local restaurants provided food for the event and town windows were filled with “Mattoon Strong” signs. Local churches and youth groups lent support and counseling to those who needed it. Rival schools wore our school colors and played our school theme song at their next home football games. It was the best of times and it was the worst of times. It would take months before the community would recover from the shock and pain of what almost happened to our children. But the wonderful thing about small towns is that we were all in this together and the collective support went much further than the t-shirts and bracelets that were sold as a reminder of our solidarity.

In retrospect, allow me to pass along the tidbits of firsthand experience that we gleamed from it:

1) We all know the way to triage- whether you use the Red/Yellow/Green/Black color system, SALT (Sort, Assess, Lifesaving Interventions, Treatment/ Transport) or START (Simple Triage and Rapid Treatment) systems, we get how to assess the injured. But it never hurts to review this and keep it fresh so when things get chaotic, your fundamentals kick in. In our own department, we were ready. From the moment we heard what was about to take place, our 25 bed ER morphed quickly. We did our in-house triage of those already in rooms and those in the lobby. We shuffled the stable chest pains and pneumonia patients out of our trauma beds and from the front rooms where they had initially been placed. We moved the ankle sprains and corneal abrasions into chairs in the hallway and out of rooms they really didn’t need. I sent our rotating health sciences student to go room to room closing the doors of patients we couldn’t evacuate while gravely warning them about what might be coming and asking for their patience.

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Not one person complained. We updated our lobby and told them what we were doing behind the closed doors where it may seem someone had forgotten them. We held two OR’s from their elective cases, just in case we needed them. And thankfully, there was a peer review meeting going on during lunch that day, which allowed us to pull extra doctors into our department just in case. We tripled our provider staffing before the first patient ever left the scene. The helicopter was called and brought over during the outbound of EMS. This was one time that we didn’t mind calling ahead and everyone was glad when they were no longer needed. We were ready. When most of your physician staff lives less than 20 min from hospital, it makes it easy to call people in. But having an on call list or sending out a mass text/message to have your extra providers available from the moment you know what might be happening is crucial. Don’t wait until you’re overwhelmed with bodies to call for help. Better to call them in and send them home as a “false alarm” than to need them when you’re overtaken with sheer volume and then have to wait for them to arrive.

2) Be sure your EMS/law enforcement officers know to create a bigger perimeter around the location. There were only two streets in town that led to the high school. We needed those streets. But children, in a panicked state, had ran. They ran blocks and blocks.

They ran into fields and came out the other side. I’m told it looked like ants flooding out of an anthill. It is hard to account for numbers and names when they are going everywhere. Add in modern technology with kids all having their own cell phones and frantically calling their parents to come get them and now you have a real mess.

We had one car literally run into the ambulance who was responding, creating a new accident less than 2 blocks from the school. It was hard to keep distraught parents away, understandably. Containment of the chaos is key. A bigger boundary to keep your inlet/outlet open makes for easier transport.

3) Be aware of post traumatic stress disorder (PTSD). Our culture in emergency medicine is to pull yourself together and keep going, to compartmentalize.

And while we cannot delay patient care or ignore our responsibilities, these type of situations are traumatic. Even though we didn’t have any serious injuries from our brush with an active shooter, just the sheer experience of it was traumatizing. The not knowing and anticipation of potentially hundreds of our kids being hurt rocked us to our core. I cannot imagine the angst our EMS and police felt pulling up to that scene knowing kids could be hurt. Potentially their own kids. There were hundreds of frightened kids, running for their lives. The children and school staff were

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supported immensely in the aftermath and rightly so. But what of our own? What about the paramedic who had to needle decompress that child in the field after assessing his chest injury? This wasn’t just another chest wound or gunshot wound. This was a child, shot by another child and at the time he was assessing that wound, he didn’t know if he had the shooter or a victim. He didn’t know if he would have to leave this child for another that might have been more critical. He might have had to go back for more after transporting this one. As the dust settled, EMS and police lingered in our department for hours, even without more victims. They didn’t know what else to do. How do you unwind from that? How do you just go back to the station and wait for the next call? They need a time and place to debrief also. YOU need a time and place to debrief. I went to the vigil that night. I went to support my community and my best friend whose child hurdled a cafeteria table, climbing over other frightened kids in an effort to get out alive. He was at the table next to the shooter when it began. It would be weeks before loud noises didn’t panic him again. I went to the vigil to let out the fear and angst I’d felt that day and to mourn what our children won’t ever forget. And to try to make sense of the senseless. It was cathartic. Be aware of how these events effect your staff and can continue to affect them for days and weeks after. Tactical debriefs afterwards are important to assess what you did well and what could have been done better.

But at the end of the day, don’t forget to debrief the experience and emotions and to watch for PTSD in those involved. We deal with sick and hurt people all day long.

But mass casualty incidents are a whole different beast.

They amplify what we see daily into something much more taxing. Have a system in place to help your staff heal and watch for burnout and signs of The second point is regarding PTSD. Just as a reminder, PTSD symptoms include flashbacks or unwanted memories of a traumatic experience. This could include nightmares or avoidance of situations that bring back those memories. Also included symptoms would be heightened arousal, anger, depressed mood, trouble sleeping, agitation, fear, irritability, social isolation, anhedonia, guilt, mistrust, loneliness and emotional detachment. Watch for these in your crew and in yourself.

Make sure help is provided. Get help if you are struggling.

In order to heal others, you have to be healthy too.

Like anything else, practice makes perfect. Keep up your MCI training. Have a local MCI to test your own system.

You never know when you might need it. It can happen anywhere, even in sleepy little towns like mine.

NATURAL DISASTERS

TAKE AN UNNATURAL TOLL

By Azer Wael

W

hen a natural disaster strikes, so much attention is focused on the immediate aftermath. In the emergency department, we know this is just the beginning. We must be prepared to manage large numbers of casualties related to major incidents including natural disasters like the tornado that devasted the Southwest Georgia community in January 2017.

Tornadoes are the most lethal atmospheric condition; they have caused 9000 deaths over the past 50 years in the United States About 700 tornadoes touch down in the USA each year, but only 3% cause casualties.

Tornado-related causes of death include craniocerebral trauma and crush injuries of the chest and trunk. Fractures are the most common nonfatal injury. Wind speeds can cause debris to deeply impale the body, which frequently causes infections. Those who live in mobile homes are 40 times more likely and those in cars are five times more likely to be killed or injured than those in fixed structures (FEMA, 2000).

January 21–23, 2017 saw a deadly winter tornado outbreak that occurred across the Southeast United States. Lasting just under two days, the outbreak produced a total of 80 tornadoes, cementing its status as the second-largest January tornado outbreak and the third-largest winter

tornado outbreak since 1950. Furthermore, it was the largest outbreak on record in Georgia with 42 tornadoes confirmed in the state.

The 2017 tornado outbreak is a prime example of why we should always be prepared. Only 26 tornadoes in the U.S. from 1995 through 2015 had a maximum width larger than the Albany tornado (1.25 miles wide). As I later watched the news reports of the aftermath and spoke with close physician friends, and those who were affected by the tornado, I was touched by the untold story of fellow physicians, nurses and hospital staff’s sacrifice during the disaster. There were physician mothers and fathers who were forced to take multiple nights of call without relief because backup could not reach the hospital due to road closures as a result of the storm. Others still were separated from their family, leaving a spouse or aging parents to fend for themselves.

Medical staff had to make preparations to continually take care of patients, all the while hoping the plans they put in place for their own families were sufficient in their absence.

It is a difficult time in these scenarios. Every day, physicians manage the medical needs of our patients, which by itself requires a high level of emotional investment. However, during natural disaster and crisis, this demand increases exponentially. We struggle with how we take care of

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MEDICAL STAFF HAD TO MAKE PREPARATIONS TO CONTINUALLY TAKE CARE OF PATIENTS, ALL THE WHILE HOPING THE PLANS THEY PUT IN PLACE FOR THEIR OWN FAMILIES WERE SUFFICIENT IN THEIR ABSENCE.” ourselves, and our own families, while meeting the needs of those around us.

What the public never realizes is that these physicians sometimes have little lead time to prepare.

As we think about the importance of evacuation and disaster planning, how do we, as health care providers, address our own immediate needs and those of our own families, so we can effectively provide patient care?

You may need to continue patient care for a longer period without relief than you have done in the past. Have a plan for your own family in case of natural disaster. You will likely feel the same level of anxiety as your patients about your home, children, pets, and life, so make time to take a breather. When you leave for your shift or call, pack as if you may not return for some time.

In our case, physician and hospital staff colleagues stepped up for each other. Those who lived closer to the facilities took coverage for those who were further away. Others opened their homes or found strategic and safe ways to relieve their colleagues. They checked in on the families of colleagues who were stranded at the hospital.

There should be an organized, professionally-conducted debriefing for staff within 24 -72 hours after the occurrence of the emergency

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incident to assist with coping and recovery. Provide access to mental health resources and improve work performance. Also establish a postdisaster employee recovery assistance program according to staff needs; counselling and family support services.

Our hospital’s emergency preparedness command center addressed needs to ensure the care was available throughout our community. Emergency protocol was activated and diverted patients from the main & north emergency centers in order to receive those with storm-related injuries to treat the incoming 45 emergent-need patients impacted by the storm. Mobile care stations were set up onsite in the most devasted neighborhoods for localized care. Staff members volunteered to work overtime to help with storm-related care. While our staff rose to the need for our community, the health system likewise rose to meet the needs of more than 400 Phoebe employees affected by the storms.

GENERAL REFERENCES Federal Emergency Management Agency, (2000).

Retrieved from http://www.fema.gov on May 22, 2018.

Virgil, N.B. (2017). 5-way doctors can cope when natural disorder strikes. MedPage Today’s

Temporary housing was provided for more than 20 employees and their families at one of our hospital locations.

Nearly 2,000 complimentary meals were provided to employees. $20,000 given to Phoebe Family members who suffered catastrophic losses 100 flashlights, 40 battery-powered lanterns, 96 blankets and many batteries handed out 131 items donated by employees through registry FEMA registered 121 employees for potential government disaster assistance in one day In total, $50,000 in cash andsupplies were given to Phoebe employees impacted by the storm

PHYSICIAN POST TRAUMATIC STRESS DISORDER

By Christine Giesa, DO, FACOEP-D

P

art of the excitement of emergency medicine is that we never know what will roll through our doors next. Since the beginning of our training we have been exposed to devastating illness, violence, unexpected death, and trauma. We have personally suffered abuse from our patients, and all of us have experiences so horrible that we have chosen to “forget.”

Our home, the ED, is a highly stressful environment. Despite this, we like what we do. Emergency physicians report a high level of career satisfaction, but they are also experience a significant amount of burn out. The high level of burn out in emergency physicians indicates that perhaps we do not handle these stressors as well as we think.

When we think of victims of posttraumatic stress disorder (PTSD), we usually think of combat veterans, victims of a violent crime, and victims who have suffered a severe physical or psychological trauma. Recent mass casualty incidents include multiple high school shootings and the Las Vegas concert shooting.

Victims of these tragic events, as well as, the emergency personnel that care for these victims, may develop PTSD. Symptoms of PTSD include emotional numbing or feelings of detachment, difficulty concentrating, hypervigilance, flashbacks, nightmares, and an exaggerated startle response. Left untreated, these symptoms can lead to depression, substance abuse, suicide, and burnout.

Why are physicians at risk for developing PTSD? The DSM-5 had added new symptomatology that captures the emergency physician experience: “repeated or extreme exposure to aversive details of a traumatic event(s), which applies to workers who encounter the consequences of traumatic events as part of their professional responsibilities.”

Emergency physicians work in a stressful environment and are repeatedly exposed to violence, unexpected death, and trauma.

We need to recognize that these daily micro exposures may have a cumulative effect and put us at risk for developing PTSD. Following a traumatic event, it is important that we take a brief time out and deal with our emotions surrounding the event and not just “power through.” Briefly gathering the medical team and giving everyone a chance to express their thoughts and emotions regarding the event can be a very powerful tool in helping the team start to heal.

Physicians with PTSD experience higher rates of anxiety, depression, and burnout. PTSD is also associated with higher rates of suicide. Physician suicide is increasing at an alarming rate and public awareness campaigns estimate that 400 physicians commit suicide each year. Recognizing the overlap between depression, anxiety, burnout, suicide and PTSD, raises the question whether PTSD is the missing link in the successful treatment of these illnesses.

There needs to be an increased awareness that unrecognized and untreated PTSD most likely exists among emergency physicians.

Although the majority will not develop PTSD, a physician who is struggling with symptoms of anxiety, depression, burnout, and/or suicidality needs to be aware that they may be suffering from PTSD and seek the appropriate treatment. There is no stigma associated with seeking treatment and taking time off to heal.

IF YOU OR SOMEONE YOU KNOW IS AT RISK OF PTSD OR SUICIDE DO NOT HESITATE TO REACH OUT. THERE IS STRENGTH IN REACHING OUT. National Suicide Prevention Lifeline 1-800-8255 American Foundation for Suicide Prevention www.afsp.org Black-Bile Website dedicated to fighting depression in physicians. www.black-bile.com

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EMERGENCY DECONTAMINATION:

WHAT YOU NEED TO KNOW

By Bernard Heilicser, DO, MS, FACEP, FACOEP-D Medical Director & Medical Manager, IL-TFI USAR

W

e often talk about decontamination as something accomplished prior to a patient arriving at our emergency department. Fortunately, this is usually what occurs. However, in our chaotic and disturbing world, we cannot always rely on this to have been adequately or fully performed, nor the probability of self-presenting patients from the scene. Additionally, to be best, and safely, prepared, we truly need to know what is happening in the field, or our driveway, before we see the patient.

With the multitude of dangerous chemicals traversing our highways and train tracks on a daily basis, the potential for hazardous material and other contaminants becoming clinical events cannot be overlooked. The easy availability of these new weapons, by terrorists, adds to our concerns.

Here is a brief overview of decontamination as practiced by trained responders at an operational level.

If we define decontamination as the process of removing and/ or neutralizing contaminants, then

we understand how the potential for secondary contamination determines the need and selection of emergency decontamination in the first place.

Why decontaminate? To protect first responders, our citizens, and to minimize the spread of hazardous materials. The rapid identification of contaminants is essential. We need to know what we are dealing with so as to avoid inappropriate, if not harmful, treatments. Lack of information, contact with contaminants and inadequate decontamination may be disastrous. Primary decontamination in the field may have been relatively inadequate. Successful decontamination mandates a written plan. This should identify and address the different types of decontamination:

Emergency – may be simply spraying

equipment should be clearly indicated and used.

There are two general types of decontamination: physical removal and chemical (or in combination). Physical removal of contaminants includes loose materials and may be sufficient. Chemical removal involves neutralization, rinsing and disinfection and sterilization. The needed equipment should be known and readily available.

All first responders to a decontamination event need to be made aware of the circumstances. This is especially true for emergency medical services. Every individual must participate in a job briefing, chiefly addressing safety. Emergency activations and all contingencies must be known. Additionally, the nature of the problem should be stated, specific duties should be defined, and any criminal or terrorist activity presented. Respective agency participation and function should be clear. All personnel must state their understanding of the plans and the goals.

Actual decontamination scene set-up is beyond the scope of this article. However, consideration of locations, wind direction and speed, approaching weather, available resources and logistical locations are essential. Defining, marking and enforcing the hot zone, warm zone and cold

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When planning for a decontamination event, it should be remembered no one plan will cover every eventuality.

Training and practice is paramount.

In the emergency department we must be vigilant. We have all done that disaster drill, or actually experienced, an organophosphate exposed patient brought in, not recognized, and has now effectively shut down our department, or worse. We must ask, how do I identify the contamination, when is decontamination necessary, where should it be set-up, and how do we handle emergency decontamination?

The mantra of plan, prepare, practice is certainly true. I would add, don’t practice until you get it right, practice until you get it right every time.

With appreciation to the Illinois Mutual Aid Box Alarm System Division 24 Haz Mat Team.

EMERGENCY DEPARTMENT PRACTICE MANAGEMENT ASSOCIATION

JOIN EDPMA TODAY and get membership rates for the Solutions Summit next year!

the exposed individual or placing them in a shower

Advocacy

Formal – time to set up the more

News Alerts

sophisticated equipment, including pools, showers, sprays and scrubbing

Committee Involvement

Mass – multiple exposed which may include ambulatory and non-ambulatory

Networking

Fine – more detailed and specific

Industry News

contaminant removal

Best Practices

The appropriate personal protective

Solutions Summit

VISIT: www.edpma.org 25

zone is imperative. How will confinement be maintained?

Confinement tarps, water supply, entry from the hot zone, washing and rinsing pools, drying line, removal of wet and dry personal protective equipment, all require coordination.

Workshops

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GET READY FOR NEW LABS AND TRACKS SUCH AS: Mass Casualty Incident Training Saturday, October 20th 7:00am-2:00pm Price: $300 Active shooter. Train derailment.

Explosive device.

SWEET HOME CHICAGO!

You’ve never been to a training on this scale before. Manage a surge of hundreds of patients, while simultaneously balancing triage, treatment, and transportation at the Mass Casualty Incident Simulation.

ACOEP joins forces with local agencies to create this immersive, true to life event. Earn 6 Hours of CME while you gain the skills to handle anything at your ED.

ACOEP’s Leadership and Medical Directors’ Academy

40 years ago ACOEP’s first Scientific Assembly took place. In the ensuing decades this conference has grown to be the flagship of a thriving association. In honor of ACOEP and Scientific Assembly’s 40th Anniversary we are taking over ACOEP’s home base, the Windy City!

On this exciting year, Scientific Assembly features breakout sessions, hands-on skills labs, renowned speakers, an epic mass casualty simulation, and even CME at Sea—two breakout sessions aboard a cruise of the Chicago River.

From the New Physicians in Practice Track, to the Women in Emergency Medicine Track, to the favorite Tachy Track, there is truly something for every emergency medicine professional.

An incredible roster of speakers is headlined by keynote speaker Melissa Stockwell—Purple Heart and Bronze Star recipient and 2016 Paralympic medalist. Kick off an incredible conference at Chicago’s famed House of Blues for a private concert by hometown favorite Rod Tuffcurls and the Bench Press. Families are invited!

There’s so much going on this year that, for the first time, ACOEP is offering a limited amount of All Access Passes— save money and save your spot in Advanced Ultrasound, Critical Care, the Opioid or Stroke CME Boat Cruise, and the Second City Communication courses. Only 25 passes are available, so get yours before they’re gone!

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Also new this year is Emergentalks, your chance to present at a national conference and share your stories of life in the ED. Every emergency department is full of stories of real life drama—including tales of healing and inspiration.

We are looking for new and emerging speakers to share their stories from the ED. Check www.acoep.org/scientific for guidelines on how to apply and, if selected, you could be sharing your story at Scientific Assembly!

Saturday, October 20, 2018 8:00am-5:00pm and Sunday, October 21 8:00am-12:00pm Price: $500 If working as a Medical Director is a career goal, this is a can’tmiss course. Taught by seasoned veterans of the ED, you’ll gain new skills in leadership, operations, reimbursement, utilization and interprofessional collaboration.

Practical Ultrasound for The EM Doctor Saturday, October 20, 2018 12:00-4:00pm Price: $250 Ultrasound is an invaluable tool in rapid diagnosis and this course gives you hands-on practice, and the technical knowledge to bring this ever-changing technology to your ED. Space is limited!

The Comprehensive Critical Care Workshop: Airway, Pediatrics and OB/GYN Emergencies Sunday, October 21, 2018 8:00am-12pm Price: $285 This highly interactive, hands-on course gives you the strategies and techniques needed to treat the critically ill pediatric, adult, and OB/ GYN patient. Become an expert through demos, hands-on practice and lively discussion. Space is limited!

Improvisation, Communication, and Comedy in Your Practice: A Workshop with Chicago’s World Famous “The Second City” Theater Company Sunday, October 21, 2018 5:00-8:00pm Price: $250 Join members of Chicago’s famed

improv troupe for a deep dive in to ways to be a better communicator through humor and quick thinking.

This incredibly fun event is not CMEeligible, but you will leave better able to connect with your patients. Space is limited!

Opioid and Stroke Workshops River Cruise Tuesday, October 23, 2018 6:00-9:00pm Price: $300 Fight the opioid epidemic or learn the latest in stroke treatment while sailing on the stunning Chicago River.

Choose from Stroke Neuro Cruise: Sail Away with TIAs, CVAs and tPA or Opioid Cruise: Turning the Tide on the Opioid Epidemic, and enjoy dinner, two hours of CME learning, and one hour of the lovely Chicago skyline.

Space is limited!

Networking and Empowerment Luncheon with ACOEP’s Council for Women in EM (Presented by US Acute Care Solutions)

Wednesday, October 24, 2018 12:30-2:30pm Price: Free, RSVP Required Enjoy a networking luncheon with leaders in EM, and celebrate the accomplishments of trailblazing women in EM.

Visit ww.acoep.org/scientific for registration and more details on everything Scientific Assembly has to offer.

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VOTE IN THE 2018 ACOEP BOARD ELECTIONS! Election season is once again upon us as ACOEP

Tim Cheslock, DO, FACOEP is a graduate of the Lake

members are invited to select peers to serve as the

Erie College of Osteopathic Medicine and the Saint Vincent Health System Emergency Medicine Residency. He has been very active with ACOEP for 15 years, serving as a Board member, committee chair, and Past President of ACOEP’s Resident Chapter. As the chair of the Publications Committee, a member of the EMS Committee, and consultant with the CME committee, Dr. Cheslock has his finger on the pulse of ACOEP. He also serves as a member of the AOA’s Committee on Continuing Medical Education.

In addition to his current involvement in the ACOEP, he is a graduate of the Physician Leadership Development Course in conjunction with Florida Hospital in Orlando.

guiding body for ACOEP. The 2018 slate of candidates is a robust group of active, visionaries all of whom have shown a dedication to ACOEP’s growth.

Read the bios below to familiarize yourself with the candidates below. Voting instructions will be emailed soon and can be found on the ACOEP website.

Jennifer Axelband, DO, FACOEP completed her residency in emergency medicine in 2005 and subsequently completed a fellowship in critical care. Since then, she has been practicing as both an EM physician and an intensivist. Dr. Axelband credits ACOEP as being an integral part of her growth and achievements as an osteopathic physician and is ready to “pay it forward.”

As a new graduate of emergency medicine and critical care, Dr. Axelband sought guidance in a few board members on how to pursue recognition of osteopathic EM physicians as intensive care physicians. Because of the support the ACOEP Board provided, new EM/CC graduates are becoming certified and hired for positions in both disciplines. She has had the opportunity to become involved with committees and speak at conferences for ACOEP, is a strong supporter of education, and values her role as a clinical physician educator for medical students, residents, and now fellows.

Dr. Axelband hopes to become involved in the leadership of ACOEP to learn more about the processes and decision making that paves the path to the future, to provide direction and support to both new and seasoned EM physicians, and to be a part of a Board that looks to maintain ACOEP’s mission while embracing changes that will improve our osteopathic community.

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He has served on the board of a non-profit association in the past as the treasurer and a board member at large for the Spaatz Association, made up of current and former Civil Air Patrol Members that achieved the Cadet Programs highest achievement, the General Carl A. Spaatz Award.

During his tenure Dr. Cheslock maintained the books for the organization and filed the annual tax reports. The primary mission was to foster comradery and provide scholarships and mentoring to current CAP cadets. The size of the organization was small in comparison to ACOEP, but the experience gained was invaluable.

Dr. Cheslock currently works for Florida Emergency Physicians of Team Health. He is chairman of the Department of Emergency Medicine, Assistant Facility Medical Director and an attending physician at Florida Hospital Waterman in Tavares, Florida. He has been a member of the Army National Guard for 20 years, serving a tour in Afghanistan. He completed the Army Command and General Staff College and continues to serve as a Lieutenant Colonel in a medical support battalion for the Florida Army National Guard.

Drew Koch, DO, MBA, FACOEP-D, graduated from

Megan McGrew Koenig, DO, MBA, FACOEP has been

the Philadelphia College of Osteopathic Medicine. He completed both his internship and residency in Emergency Medicine at Memorial Hospital in York, PA. Dr. Koch is board certified in Emergency Medicine. He is a Distinguished Fellow in the American College of Osteopathic Emergency Physicians (ACOEP). He received the Meritorious Service Award in 2003 and the Excellence in Emergency Medical Service Award in 2010 from ACOEP.

involved with the ACOEP since 2006. She has held a variety of leadership positions consistently throughout this time frame, including serving on both the Student and Resident Chapter Boards, to most recently being a member of the CME Committee and serving as the New Physicians in Practice Committee Chair. Involvement in this College has always been a priority to Dr. Koenig; from a networking and mentorship perspective to advocacy and national representation.

Dr. Koch has been a member of ACOEP since 1987 and has served on the following ACOEP committees beginning in 1996: EMS; Fellowship; Members Service; Nominations, and Publications. He has served as the Chair of Fellowship and Publications Committees, the Editor of the Pulse from 2004 to 2014, and has been the Vice Chair of Nominations Committee from 2011-2014. Dr. Koch was elected to the Board of Directors of ACOEP in 2012 through 2018 and served as Treasurer from 2015-2017.

Dr. Koch has been practicing Emergency Medicine since 1989. Before relocating to Ithaca, New York, in 2007 where he continued practicing Emergency Medicine and served as Chair of the Emergency Department, he practiced Emergency Medicine at the Pinnacle Health System in Harrisburg, Pennsylvania. While in Ithaca, he was actively involved as the Medical Director of the local EMS agencies; served as Chair of the Hospital Peer Review Committee, was a member of the hospital Medical Executive and Credential Committees and served as President of the Medical Staff. He is currently practicing Emergency Medicine at Guthrie Health Care System in Sayre, Pennsylvania.

Dr. Koenig has sat on the Board previously as the Student and Resident Chapter Presidents (2008-2009, 2012-2013).

She looks forward to the opportunity to be a part of the Board again during such a pivotal time as we transition towards the single accreditation system, as she feels “new physician” representation would be a great asset to the current team. Her passions within the college lie in mentorship towards the younger members, as well as improving the quality of conference programming.

Duane D. Siberski, D.O. FACOEP-D, FACEP has been an American College of Osteopathic Emergency Physicians Board of Directors member since 2012, and has been an active member of ACOEP since serving as National Vice President of the Student Chapter of ACOEP in the early 90’s. He is an attending physician at Penn State Health St. Joseph Medical Center in Reading, Pennsylvania. He currently serves as the hospital’s EMS medical director.

Dr. Siberski serves as a Pennsylvania State Regional EMS Medical Director in Pennsylvania’s Eastern Region.

Dr. Siberski is an active member of Regional and State Medical Advisory Committees where he works with the Regional Communications Committee to oversee the nine dispatch centers in the Eastern Region’s six county area.

His activities as a Medical Director for the Region 2 Tactical Emergency Medical Services team include involvement with multiple SWAT teams and the Pennsylvania State Police Special Response Team. Locally, he is the Medical Director for multiple fire departments and Muhlenberg Area Ambulance Association and rides the trucks as a prehospital Physician.

Dr. Siberski has worked on numerous ACOEP committees including By-Laws, GME, EMS, and Member Services. Prior to his election to the Board of Directors, he served as the National Advisor to the Student Chapters of the ACOEP. He has represented the College as Liaison to the American College of Emergency Physicians and has promoted dialogue between our organizations allowing open lines of communication. Dr. Siberski is currently serving on a task force to plan ACOEP’s October Mass Casualty Incident Scenario Simulation in Chicago.

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ACOEP’S COUNCIL FOR WOMEN IN EM

By Angie Carrick, DO, ACOEP

E

xciting things are happening with the Women’s Committee! First, we are now officially a committee within ACOEP versus a council or special interest group. As a committee we work closely with a staff member from ACOEP, have dedicated funds and are working to have our own section on the ACOEP web page. We will continue our Facebook posts and articles in The Pulse as means of communicating important updates regarding all things “fem” in ACOEP. We just held our first women’s lecture track at the 2018 Spring Seminar. Dr. Jaime Hope gave an incredible talk on the topic of imposter syndrome. For those unfamiliar, imposter syndrome is a phenomenon that affects highly achieving people (usually women). The person believes they are a fake and are fooling others into believing they are smart and successful, but that eventually they will be exposed for their true capabilities. This syndrome is highly common and has affected famous individuals such as Meryl Streep and Maya Angelou.

Dr. Hope energetically explained this and gave fantastic ideas on how to battle our own tendencies to negate our personal achievements. If you missed hearing her talk in person be sure to catch it when it comes out online! It was highly impactful to all in attendance.

I was intrigued by Dr. Hope’s lecture and had the chance to speak more with her about it.

Here is what she had to say.

A: Dr. Hope, why did you become passionate about speaking on Imposter Syndrome?

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J: Dr. Carrick, thanks for allowing me to be a part of this! You are doing such important things and I appreciate it! I remember role call on the first day of medical school. As they were reading names, I suddenly had this fear that mine wasn’t going to be called.

That they would tap me on the shoulder and tell me they made a mistake and a more qualified student would be taking my seat.

Of course, that didn’t happen, but to be in a room with such outstanding students, all with long lists of impressive accomplishments affected me. Instead of feeling like I was rising up to the challenge, I felt like an imposter! I had never discovered a new chemical, I had not opened orphanages in 3rd world countries, how did my application make it through? At the time, it was hard to see the awesomeness in my own accomplishments because they were familiar and what other people had done sounded new and exciting. I worked hard in my training and generally enjoyed it, but occasionally my mind would wander back to wondering if I belong. It wasn’t until I was an attending that I heard the words “Imposter Syndrome” and started to read about it.

I cautiously started chatting with others about it and lo and behold, I wasn’t the only one! In fact, it was way more common than I realized. Objectively successful people like Sheryl Sandberg, Albert Einstein, and Emma Watson have publicly discussed imposter feelings. I didn’t want anyone to feel alone like I did, as if they have to hide some awful secret. I have learned the signs and symptoms and I am dedicated to helping others fight them like I have!

IT TAKES PRACTICE BUT REPLACING THE SELF-NEGATIVITY AND MEANNESS WITH APPRECIATION AND GRATITUDE WILL CHANGE YOUR LIFE!” A: How did you develop the ways to fight ‘automatic negative thoughts’ about personal successes?

J: The first step was to recognize that they exist. Those things that pop into your head before you realize it is happening. For example, if you are self-conscious about a particular part of your appearance, your eyes will go to that part in the mirror or in pictures in a nanosecond. If you are uncomfortable accepting compliments, your auto-reply with be a deferment or self-deprecating comment. You do these things in your head and out loud. I challenge anyone to spend three days being very conscious of (and even writing down) the first thing that pops into your head when you look in a mirror or at a picture, when someone gives you a compliment, and when you are met with a challenge. You will be surprised when you realize this autopilot voice has been running the ship.

Once you recognize that, it’s time to take back control. You are the boss of your thoughts!

It takes practice but replacing the self-negativity and meanness with appreciation and gratitude will change your life! Also, keep a ‘greatest hits’ folder, either a physical folder or a

computer file. Fill it with lists of your accomplishments and achievements, thank you letters you’ve received, and other things that you have earned.

You will have mountains of objective evidence that you have done great things, and you can refer to it anytime you are feeling doubts. Lastly, talk to others! I can’t emphasize this enough!

This syndrome exists because it lurks in the dark. Have an “ANT” buddy to help each other continue to recognize and eradicate these junk thoughts.

A: Do you feel like you are overcoming Imposter Syndrome yourself?

J: It is a work in progress! I look at it like recovery. I’ll be doing well for a while and then occasionally slip back into the negative self-deprecating thoughts. I definitely practice what I preach! I use mantras, fight my ANTS, shake off comparisons, and stop should-ing all over myself when I feel my confidence getting low. It will never be perfect…nor should anyone want to aspire to this unattainable ideal. I’ve become much more accepting of my flaws and finally have given myself permission to embrace the good. And I love helping others do the same!

A: Are there any references you recommend reading on Imposter Syndrome for someone wanting more information?

J: Some of my favorite books (I usually listen to the audiobook version, so easy to get some good reading in while I’m driving, exercising, and doing chores like laundry). I read a lot!

• You Are a Badass by Jen Sincero • Mastering your Mean Girl by Melissa Ambrosini • Women Don’t Ask, Negotiation and the Gender Divide by Linda Babcock and Sara Laschever • Presence by Amy Cuddy • The Miracle Morning by Hal Elrod • The Secret Thoughts of Successful Women by Valerie Young • The Confidence Gap by Steven Hayes A huge thanks to Dr. Hope for taking time to answer all these questions so eloquently!

Since our women’s lecture series was such a hit we are doing another track this fall in Chicago. It will be expanded with more lecturers and new topics.

We look forward to seeing all of you there!

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COMMITTEE CORNER

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

What Would You Do? Ethics in Emergency Medicine

ACOEP’s Committees are not just a great way to get involved with the ACOEP community, they are an incredible opportunity to make valuable contacts, impact real change on a local, state and national level, and learn a great deal about the medical community.

Members at every level are invited to explore what ACOEPs committees have to offer, and to bring their unique talents and viewpoints to the table.

From this point on, each issue of The Pulse will include a brief spotlight on various committees and we invite you to attend a meeting, to reach out, or to try and learn more!

Member Services

Research Committee

Help ACOEP make a stronger community, brainstorm ideas for new member benefits, and create the EM home you envision. This committee meets twice a year with staff liaison and Director of Member Services Sonya Stephens. Sonya says, “since ACOEP is a pretty diverse group of emergency medicine professionals, the committee’s membership should reflect the diversity within the College to best represent all interests.

The member services committee welcomes new members and ideas in order to achieve that goal.”

“Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has” -Margaret Mead

Interested members who have questions can reach out to Sonya at SStephens@acoep.org.

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The purpose of the ACOEP research committee has changed in 2018 from supporting the ACOEP resident research requirement to supporting the Foundation for Osteopathic Emergency Medicine (FOEM) new request for proposal (RFP) strategy in support of the Accreditation Council on Graduate Medical Education faculty research requirement. Working with WestJEM and other publications, the ACOEP research committee will develop a grant strategy to exploit strengths within the ACOEP membership and create larger, statistically valid research.

Building on the history of resident research paper review and advisement, the ACOEP research committee will

now make its research paper reviewers available to advise and assist resident and faculty research papers prior to submission to journals.

Today is an exciting time of change for the ACOEP. As an organization, the ACOEP is only as strong as its member involvement. By taking an active role at the research committee, members can earn scholarly credits as well as take a leadership role in bringing our specialty into the Single Pathway paradigm.

If you are interested in making a difference, please email Dr. Allswede and discuss taking a role in making the ACOEP of the future at pittdoc@gmail.com.

In this issue of The Pulse we will review the dilemma presented in the April, 2018 issue, referred to us by a frustrated paramedic.

The situation involved a 70-year-old female patient being transferred from an urgent aid to an affiliated hospital emergency department. The patient had sustained a fall injury and struck her head. She was on anticoagulant medication.

The EMS crew noted the patient to be “a little restless …complaining of a headache”. Although, initially alert with normal vital signs, she became disoriented. The paramedic asked the physician if he would consider transferring the patient to a Trauma Center, concerned for a possible intracranial bleed. The physician told him to run it by the accepting ED for medical control. Diversion was denied. En route, the patient became nonverbal and responsive only to pain. Diversion was again denied. The same crew was later called to transfer the patient to a different trauma center that had an arrangement with the initial receiving hospital. The diagnosis: Intracranial Bleed.

What could the EMS crew have done to change this frustrating scenario?

What would you do?

This case demonstrates the ethical problems that have been created by hospital affiliations and competition. We know hospitals want to keep patients within their “system,” especially the well insured. A 70-year-old patient, with blunt trauma, would probably be in that category. Our EMS crew demonstrated good assessment acumen and advocated for the patient.

They were twice denied.

How could they circumvent this situation? Outright ignoring the transfer orders would be too precarious, although possibly admirable. They could have attempted to contact their Medical Director for an override, a reasonable alternative. Or while en route to the initial receiving hospital, the radio communication could have “too much static and you are breaking up,” necessitating a decision to act in the patient’s best interest in the absence of medical control. (Please do not let my medics know I said this!)

These patient care issues and dilemmas will continue to become more complicated. As emergency physicians and EMS medical directors, we must transcend the politics and financial motivations and continue to do what we have always done, be advocates for our patients.

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

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FOEM FOCUS SAVE THE DATE TUESDAY, OCTOBER 23RD 2018

W

e’d like to thank all who attended the 2018 Spring Seminar and participated in the various FOEM events that took place! Take a look at the winners of the FOEM Case Study Poster Competition and the FOEM 5K below.

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Congratulations to the winners of the FOEM 5K! WOMEN:

1st place: Christina Powell 2nd place: Michelle Preston 3rd place: Nancy Goodwin MEN:

2018 FOEM Case Study Poster Competition Winners *Winning abstracts featured below

1st place: Jeffrey Lin 2nd place: Timothy Bikman 3rd place: Gary Bonfante

Congratulations to the winners of FOEM’s 2018 Case Study Poster Competition! Thank you to all that participated.

FOEM Case Study Poster Competition

1st Place: Samantha Margaritas, DO from Midwestern University in Downers Grove, IL for her case Time for a Change of Pace.

2nd Place: Jacob Smith, DO from Doctor’s Hospital in Columbus, OH for his case May Thurner Syndrome: An Uncommon Cause of a Frequent Diagnosis.

Celebrate FOEM’s 20th Anniversary at the FOEM Legacy Gala: Dinner and Awards Show!

FOEM 5K Winners!

3rd Place: Kevin McLendon, DO from Merit Health Wesley in Hattiesburg, MS for his case Old Timer’s Toxin: Caramel Kalemia.

Winning Abstracts 1st Place: Samantha Margaritas, DO from Midwestern University in Downers Grove, IL for her case Time for a Change of Pace.

TITLE:

Time for a Change of Pace

AUTHORS: Samantha Margaritis, DO, Rodney Fullmer, DO, Midwestern University, Downers Grove, IL; Swedish Covenant Hospital.

INTRODUCTION: Hypertrophic cardiomyopathy (HCM) causes enlargement of the cardiac myocardium, mitral valve abnormalities, and obstruction of the outflow tract leading to lethal arrhythmias, often

leading to sudden cardiac death. The gold standard of treatment for HCM is septal myotomy (SM) with mitral valve (MV) repair. Common complications of SM with MV repair include LBBB, aortic regurgitation and ventricular septal defect. Literature on MR rupture post SM is scant and with varying presenting symptoms. When patients with history of HCM present in unstable arrhythmia, MR rupture needs to be considered as a life threatening cause. This is a unique case as it is an uncommon complication of a disease requiring emergent intervention.

CASE DESCRIPTION: 65 y/o M physician brought into the ED externally paced for third degree heart block. Initial history obtained through EMS as patient was A&Ox1-2. Pt was rounding when he had a syncopal episode at a nursing home. An AED noted v-fib and delivered a shock, CPR followed.

EMS EKG strip showed a-flutter with variable conduction, v-tach and v-fib with a second shock delivered. Pt then had third degree heart block and was paced externally by EMS. While transferring the patient, transcutaneous pacemaker was dislodged and patient lost consciousness with a heart rate of 10. A transvenous pacemaker (TVP) was required for stabilization and placed emergently at bedside.

Subsequent ECG showed LBBB. Troponin elevated to 0.09. After TVP

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placement, patient’s mental status improved and provided history that he had a SM for HCM and MR repair 2 months prior. Three days PTA, patient had a syncopal episode and was admitted to another hospital and diagnosed with MR rupture. Patient requested to be discharged home on Eliquis that morning with plan to return following day for MR repair. Also, the patient had occipital abrasion on exam and subsequent CT head showed traumatic SAH. This case involved addressing a cascade of three life threatening conditions related to one initial event, with few similar case reports. Our patient presented with two rare complications of a routine treatment as one study found that 0.8% of patients who had SM with MV repair had subsequent MV rupture1. Another study demonstrated that only 43/482 patients had complete heart block requiring pacemaker after SM with MVR3. In ER setting, it is prudent to immediately place external pads and keep a broad differential of potential causes. Maintain a wide knowledge base and a high index of suspicion for MV rupture in patients with HCM presenting in labile arrhythmia.

In our practice, it is imperative to maintain proficiency in infrequently performed procedures such as emergent TVP placement to prevent death. This also demonstrates importance of completing a primary and secondary survey of patients to evaluate the full extent of injuries. Had we focused solely on the cardiac problem presented, we would have missed the diagnosis of traumatic SAH. Recognize that patients with history of HCM are likely anticoagulated and have a low threshold to do head CT.

DISCUSSION:

RESOURCES 1.

Iacovoni A, Spirito P, Simon C, et al. A contemporary European experience with surgical septal myectomy in hypertrophic cardiomyopathy. European Heart Journal. 2012;33(16):2080-2087. doi:10.1093/eurheartj/ehs064.

2. Kotkar KD, Said SM, Dearani JA, Schaff HV. Hypertrophic obstructive cardiomyopathy: the Mayo Clinic experience. Annals of Cardiothoracic Surgery. 2017;6(4):329-336. doi:10.21037/acs.2017.07.03.

3. Rastegar H, Boll G, Rowin EJ, et al. Results of surgical septal myectomy for obstructive hypertrophic cardiomyopathy: the Tufts experience.

Annals of Cardiothoracic Surgery. 2017;6(4):353-363. doi:10.21037/ acs.2017.07.07.

2nd Place: Jacob Smith, DO from Doctor’s Hospital in Columbus, OH for his case May Thurner Syndrome: An Uncommon Cause of a Frequent Diagnosis.

TITLE: May Thurner Syndrome: An Uncommon Cause of a Frequent Diagnosis AUTHORS:

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Resident, Doctors Hospital, Columbus, OH Andrew Little, DO, Core Faculty, Doctors Hospital, Columbus, OH This case describes a young patient who presented to the ED with the complaint of leg pain and swelling after suffering a fall 2 weeks prior. She was found to have a large multi-vessel DVT in this leg. What is unique about this patient’s case is the cause of her DVT. Patient was found to have findings consistent with May-Thurner Syndrome, a nonthrombotic iliac vein lesion.

INTRODUCTION:

CASE DESCRIPTION: 28-year-old Caucasian female with history of seizures and IVDA presented to the emergency department with left leg pain and swelling after a fall 2 weeks prior. She had increasing pain and swelling in her left leg and shortness of breath with productive sputum and subjective fevers. She also had generalized abdominal discomfort with nausea. She admitted to ongoing skin popping of heroin. She had no additional VTE risk factors.

Physical exam revealed a heart rate in the 100s and blood pressures in the mid to low 90s. She was noted to have diffuse left lower quadrant tenderness and a palpable cord in the left inguinal region. She also had 1+ pitting edema of the left lower extremity with intact pulses and sensation.

She underwent radiologic and laboratory testing revealing evidence of dehydration. Left lower extremity duplex revealed acute DVT’s in the left external iliac vein, common femoral, proximal femoral, and mid femoral vein. Patient additionally had a CT chest, abdomen, pelvis revealing extensive bilateral multifocal nodular consolidations and extensive thrombus within the left iliac vessels with extension of subocclusive thrombus into the IVC secondary to compression of the left common internal iliac vein via the right common internal iliac artery.

Patient was discussed with vascular surgery and admitted to stepdown. She underwent a pharmacomechanical thrombectomy, IVC filter placement and angioplasty of the left external iliac vein. Blood cultures also confirmed streptococcal viridans bacteremia. Unfortunately, patient signed out on POD #1 after completion thrombectomy, and her final outcome, although improved at disposition, is unknown.

DISCUSSION: May-Thurner syndrome manifests as obstruction of the left common iliac vein due to the overlying right common iliac artery. This occurs due to either direct compression or intimal hypertrophy of the iliac vein due to pulsatile trauma. This occurs in 2% to 5% of patients with lower extremity venous disorders. Incidence of lower extremity DVT is higher on the left side than on the

right and within these patients, 18-49% of these cases are due to May-Thurner syndrome. This predominantly occurs in women (8:1) of childbearing age with long periods of immobility or pregnancy.

Treatment options include endovascular thrombolysis followed by venous dilation and endovascular stent placement as well as even left common iliac vein bypass.

Emergency providers should be aware of additional causes of VTE such as anatomic etiologies as May-Thurner’s as these are not amenable to traditional treatment therapies such as long-term anticoagulation. With increased pressures to decrease hospital admissions including patients with VTE, providers must take note to ensure that anticoagulation alone is the appropriate therapy for each case to prevent further clinical problems.

REFERENCES 1.

Zhou, Q., Lee, B., Lee, R., & Stewart, M. (2015). An atypical cause of extensive left-lower-extremity DVT: May-Thurner syndrome. Radiology Case Reports,10(2), 1019. doi:10.2484/rcr.v10i2.1019

2. Mousa, A. Y., & Aburahma, A. F. (2013). May–Thurner Syndrome: Update and Review. Annals of Vascular Surgery, 27(7), 984-995. doi:10.1016/j. avsg.2013.05.001 3. Durack, J. C., & Kohi, M. P. (2011). Venous Anatomy of the Abdomen and Pelvis. In Cardiovascular imaging(pp. 1005-1018). St. Louis, MO: Elsevier Saunders.

4. Durack, J. C., & Kohi, M. P. (2011). Venous Anatomy of the Abdomen and Pelvis. In Cardiovascular imaging(pp. 1005-1018). St. Louis, MO: Elsevier Saunders.

5. Demir, M. C., Kucur, D., Çakır, E., Aksu, N. M., Onur, M. R., Sabuncu, T., & Akkaş, M. (2016). May-Thurner syndrome: A curious syndrome in the ED. The American Journal of Emergency Medicine,34(9). doi:10.1016/j. ajem.2016.02.045 6. Kaltenmeier, C. T., Erben, Y., Indes, J., Lee, A., Dardik, A., Sarac, T., & Chaar, C. I. (2017). Systematic review of May-Thurner syndrome with emphasis on gender differences. Journal of Vascular Surgery: Venous and Lymphatic Disorders. doi:10.1016/j.jvsv.2017.11.006

3rd Place: Kevin McLendon, DO from Merit Health Wesley in Hattiesburg, MS for his case Old Timer’s Toxin: Caramel Kalemia.

Case Report Abstract TITLE:

Old Timer’s Toxin: Caramel Kalemia

AUTHORS: Kevin McLendon, D.O., Matthew Wiggins, M.D., Alex Gauthier, D.O., Deepu Thoppil, M.D., Jacob Fenster, D.O.

Hyperkalemia is a laboratory diagnosis with devastating consequences. In the Emergency Department we often focus on the initial stabilization of a patient found to have irregular potassium levels and may easily overlook the

INTRODUCTION:

cause of the electrolyte imbalance. We focus on the EKG, calcium administration, and our immediate efforts to return potassium to a safe level. However, for our patients’ health it is imperative that we discover the cause of their ailments in efforts to best prevent them from recurring.

Potassium regulation is controlled by the kidneys and often clinically significant changes require more than a single source or influence. Impaired excretion, increased intake, and/or intracellular shifts are the root causes of hyperkalemia. The clinical manifestations are not an effect of the absolute elevation of potassium, but acuity of the elevation.

Without treatment hyperkalemia may lead to cardiac irritability with subsequent dysrhythmias and death.

An 84-year-old Caucasian male presented to the emergency department with one day of nausea/vomiting and severe diffuse abdominal pain. He notes intermittent diarrhea over the last month that resolved one week prior and he was in usual health until his onset of abdominal pain and cramping. He reports his vomitus looked just like the tea he regularly drinks. He likens his pain to his previous peritonitis; however, it is much better than when he awoke and spontaneously resolves in the ED. He denies any associated symptoms of fever, chills, weakness, or body aches. He is compliant with medications and regularly follows with his nurse practitioner.

CASE DESCRIPTION:

Review of diet discovered the patient eats approximately 10 pounds of Werther’s weekly, along with a daily 1-gallon intake of Chrystal Light Peach Iced Tea. It is estimated that the patient was consuming a daily additional 2.8g of Potassium from the Werther’s alone, plus a minimum 16 servings of potassium-based sweetener in his tea. During an office visit in December he was switched from Lasix to Spironolactone and had been encouraged to decrease his sugar intake. After which he incidentally switched to sugar-free Werther’s (1/800th the potassium content). His use of enalapril with spironolactone was stable as reported by his visit to his NP in mid-January. When he returned to Werther’s Originals he rapidly developed hyperkalemia within a week.

DISCUSSION:

AUTO-BREWERY SYNDROME

TREATING THIS RARE DISEASE

By Jan Wachtler

I

magine a 46-year-old male presents to your Emergency Department (ED), exhibiting symptoms of intoxication and slurring his words. He complains his thoughts are foggy, and he’s dizzy, as well as having symptoms of irritable bowel syndrome with episodic vomiting and diarrhea. He also informs you that because of his Type II Diabetes he has not had a drink of alcohol in more than 20 years. You take his blood pressure and do a complete work-up; his stomach is distended and spongy. You do a routine blood test and find that his BloodAlcohol Concentration (BAC) is 0.37g/dL. What’s your diagnosis?

If you thought he was intoxicated, you’d be correct, except that he did not consume any alcohol. The man in question could be suffering from a rare gastroenterological syndrome called Auto-Brewery Syndrome or ABS. ABS is a rare but increasingly common diagnosis for people presenting with symptoms like those described above. Patients with ABS are sometimes arrested for DUI or classified as ‘frequent flyers’ when they return repeatedly to EDs across the world with the same symptoms.

I first learned about ABS in an email from Michelle Giannotto, volunteer patient advocate for the Auto-Brewery Syndrome Support Group.

To be honest, when I saw the message title on the email I thought, ‘why is someone sending us something about making beer?’ But after reading her email and an attached article from the Staten Island Advance (www.silive.com) from

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August 18, 2017, I began to look up information on this odd syndrome.

The article describes Donato Giannotto’s case and what had happened to him over a period of fourteen months preceding his diagnosis.

Donato would be fine, eat dinner and then exhibit symptoms of impairment, with slurred speech, blackouts, and bloating. In fact, over just a few months he had to be put on oxygen 24/7 because of the excessive swelling contributing to a 60-pound weight gain. Mr. Giannotto had been to the ED at least once a month and was admitted to the hospital each time for uncontrolled blood sugar, high BAC levels and twice to ICU due to seizures caused by complications of ABS. Mr. Giannotto’s family members, Dr. Cynthia X. Pan, Chief, Division of Palliative Care and Geriatrics at NY Presbyterian Hospital, and Dr. Darrell Sandel, Emergency Medicine at South Nassau Hospital, had witnessed Mr. Giannotto’s health decline and after listening to his symptoms, realized he was suffering from ABS; a yeast overgrowth caused by antibiotics.

Dr. Pan had just attended a seminar for Rare and Unusual Conditions where ABS was one of the topics.

Armed with a possible diagnosis Mr. Giannotto was admitted to Robert Wood Johnson University Hospital in New Brunswick New Jersey, where a team of medical professionals conducted the 24-hour testing as outlined by the case study published in the International Journal

of Clinical Medicine; “A case study of Gut Fermentation Syndrome (Auto-Brewery) with Saccharamyces cerevisiae as the Causative Organism” by Barbara Cordell and Justin McCarthy. It was during the 24-hour testing he was finally diagnosed.

Upon confirmation of the diagnosis, it would take four more months to locate a team of doctors from Richmond University Medical Center (RUMC) in Staten Island New York willing to take the case. Three doctors at the hospital; Jessie Saverimuttu, MD, an infectious disease specialist; Prasanna Wichremesignhe, MD, a gastroenterologist; Seshadri Das, MD, an endocrinologist at Mount Sinai Hospital, and a licensed clinical nutritionist, Dr. Christopher Napoli all began the search for an answer to Mr. Giannotto’s problem.

They learned his symptoms developed after receiving a course of antibiotics after a surgical procedure; that was followed by another course of antibiotics for a dental problem, and that, it seems led to the perfect storm. The antibiotics killed off the good bacteria in his gut allowing other organisms to take over. They identified the yeast through performing an endoscopy and colonoscopy with cultures, and sensitivity tests. The strain of brewer’s yeast identified was Candida Intermedia; a yeast not identified in any other published case. This strain of yeast was resistant to the powerful oral anti-fungal medication Mr. Giannotto had been receiving. After selecting another broad-spectrum anti-fungal that was introduced through a PICC line daily for eight weeks, he was cured.

Unfortunately, Mr. Gionnotto’s case isn’t the only one diagnosed in hospitals around the country and the

world, and more frequent presentations are becoming common. So what causes this and how best to cure it?

Large dosages or long-term use of antibiotics is the culprit that wipes out almost all bacteria in the gut.

Doctors have stated that patients on an antibiotic regime should take probiotics at bedtime, since the antibiotics are generally taken with meals. The probiotic should replace some of the bacteria needed to process foods in the intestines. Also, patients with this syndrome should avoid alcohol and maintain a low glycemic index diet until the symptoms are gone and stool samples or colonoscopy/endoscopy cultures come back negative.

Other physicians and nutritionists have recommended a paleo diet which requires the intake of higher protein and lower carbs, and stresses the use of non-starchy vegetables and fruits, with a moderate to high fat intake as well as a higher potassium and lower sodium intake. This type of diet generally shuns the pre-processed food with higher sodium and throws back to the Stone Age where our hunter-gatherer ancestors ate more protein and fiber.

Auto-Brewery Syndrome is also referred to as Gut Fermentation Syndrome. There is information and case studies at www.autobrewery.info. The Auto-Brewery Syndrome support group which can be contacted through the website has doubled in size since 2017, and record numbers are joining in 2018.

Our thanks to Michelle Giannotto for taking the time to bring this rare syndrome to our attention.

1. Black, Andrew, Rare Gut Fermentation Syndrome Creating a Buzz, Rare Disease Report, August 2, 2016. http://www.raredr.com/mews/rarealcohol-making-disease.

2. Roberts, Catherine, The 8 Ins and Outs of the Paleo Diet, Active Beat, www.activebeat.co/diet-nutrition/the8-ins-and-outs-of-the-paleo-diet/3/

LARGE DOSAGES OR LONGTERM USE OF ANTIBIOTICS IS THE CULPRIT THAT WIPES OUT ALMOST ALL BACTERIA IN THE GUT.”

OTHER RESOURCES Gut Fermentation Syndrome, Endocrinology Advisor, April 4, 2014/ https:www.medicalbag.com/profile-in-rare-diseases/gut-fermentationsyndrome/article/47431/.

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ACOEP JOINS

COALITION TO ADVOCATE FOR EMERGENCY PHYSICIANS AND PATIENTS

Where you live is a reflection of who you are.

Over 200 locations and growing.

IN TEXAS

T

his Spring ACOEP joined forces to speak out against Blue Cross Blue Shield of Texas and their dangerous decision to limit coverage for emergency care.

Alongside the American College of Emergency Physicians, Emergency Department Practice Management Association, the National Association of Freestanding Emergency Centers, and others, ACOEP co-signed a letter strongly condemning these actions.

Not only does this policy endanger Texas patients, the plan is unclear with very little information available online.

BCBS-TX does little to clearly lay out how their policy will be enacted, and if out-of-network refers to the hospital or the physician treating the patient.

Furthermore, it is uncertain how a member’s claims and symptoms will be taken in to account as to whether their visit will be covered.

The coalition of organizations sending the letter believes that this action taken

by BCBS-TX violates federal and state state standards, asking patients to “self diagnose” whether or not they have an emergency medical condition.

Dealing with insurance, payment and reimbursement is difficult enough as it is. Actions like these by insurance

companies not only unnecessarily complicate medical care, but put patients at risk.

If the cosigned letter is not adequately addressed, ACOEP and the rest of this coalition will seek a meeting with Blue Cross Blue Shield of Texas to advocate for this policy’s immediate change.

Visit www.acoep.org/news to download the letter sent to Dan McCoy, MD, President of Blue Cross Blue Shield of Texas.

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August 18 - 22, 2018 October 12 - 16, 2018

Fast Facts Emergency Medicine Board Review August 23 - 25, 2018

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www.ohacep.org (614) 792-6506

Own your future now. Visit usacs.com or call Darrin Grella at 844-863-6797 careers@usacs.com

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