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

Back to the Future: The Greek Tragedy

Happy New Year and I hope your holiday season was a safe and memorable one. The holiday celebrations offer a time to be with family and friends. It is a time to reflect on the year’s blessings we have been fortunate enough to receive. It is also a time to reminisce where we have been as time progresses. It is a time to learn what worked and what needs more of our attention to be successful. A retrospective look lets us peer into the future. The road map of the past helps us to plot the course for our future. Much of our specialty’s immediate outlook will be shaped by future political events. By this time next year we will have had a national election, the provisions in the Patient Protection and Affordable Care Act (PPACA) will be ramping up and the Supreme Court will have heard arguments regarding PPACA. We might even find out what will happen to the SGR by then. Looking forward with the perspective of a telescopic lens we can get a glimpse into our future. This brings me to my next consideration. Do your patients ask you to predict the

future? I get asked that question nearly every time I work a shift. They ask, “How long do I have to stay?” Or, “how long will this take?” Sometimes they even ask, “How long do I have, Doc?” The famous physicist, Niels Bohr, remarked on his perspective on fortune telling, “Prediction is very difficult, especially about the future.” I tell my patients that if I could predict the future I would have the lottery ticket right now. My augury is so limited that I am still pondering the significance of the Braille key pad on my local drive-up ATM machine. I thought to myself that there must be a logical explanation to have a code dotted on an ATM. With a little detective work I found the source for the genesis of the policy. It was a government regulation that required mobile disability interface compliance. The foresight of the policy was matched by the penalties imposed for noncompliance. Lesson learned: regulation created a potential revenue source for the government and offer little if any benefit to the public. I could quickly relate as I grappled with new terms in the PPACA like Meaningful Use, ACO’s (Accountable Care Organization), HAI (Health Care Acquired Infections). At face value the terms sound good and might offer the utopia we are looking for. But how would these terms affect my practice and are they really logical steps in improving health care in this country? Alternatively, are they just another means at couching everything together in mass confusion while producing price controls with fines? What does this


future hold? I took my dilemma to my patients by asking them for their insight. I turned the tables to see if they had an idea of how the PPACA will affect them. This is particularly interesting because many of these patients were using the emergency department as the preferred alternative to the multitude of deficits in primary care health system. Some patients had no idea what to expect from the PPACA or had given the topic little thought. Others were fearful of what the PPACA may bring but hadn’t investigated the facts from fiction. However, every once in a while you come across someone with experience and insight who can offer a cogent opinion. I met such a uniquely qualified couple who stopped by for treatment of a respiratory condition. He was a chemist and was well into his 90’s. She was an economist and had a thick European accent. They had survived the German invasion in World War II and the Soviet expansion that followed. They had lived in several countries with various health systems and at their endowed age, they were not shy in offering their opinion on what they thought about the PPACA. They quietly but sternly said they had already lived through the future of health care once and were not interested in reliving it again. It was part of the reason they left Europe for America in the first place. Being an intellectually gifted person with an analytical pension he offered the following observation. I’ll encapsulate his remarks. continued on page 4



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Editorial Staff: Drew A. Koch, DO, FACOEP-D, Editor Wayne Jones, DO, FACOEP, Assist. Editor Gregory M. Christiansen, DO, M.Ed., FACOEP Mark A. Mitchell, DO, FACOEP Erin Sernoffsky, Communication Manager Janice Wachtler, Executive Director Editorial Committee: Drew A. Koch, DO, FACOEP-D, Chair Wayne Jones, DO, FACOEP, Vice Chair Julia Alpin, DO David Bohorquez, DO Gregory M. Christiansen, DO, M.Ed., FACOEP Joseph Dougherty, DO, FACOEP Anthony Jennings, DO, FACOEP William Kokx, DO, FACOEP Annette Mann, DO, FACOEP Mark A. Mitchell, DO, FACOEP Erin Sernoffsky Brian Thommen Janice Wachtler, CBA The PULSE is a copyrighted quarterly publication distributed at no cost by the ACOEP to its Members, library of Colleges of Osteopathic Medicine, sponsors, exhibitors and liaison associations recognized by the national offices of the ACOEP. The PULSE and ACOEP accepts no responsibility for the statements made by authors, contributors and/ or advertisers in this publication; nor do they accept responsibility for consequences or response to an advertisement. All articles and artwork remain the property of the PULSE and will not be returned. Display and print advertisements are accepted by the publication through Norcom, Inc., Advertising/Production Department, PO Box 2566 Northbrook, IL 60065 ∙ 847-948-7762 or electronically at Please contact Norcom for the specific rates and print specifications for both color and black and white print ads.



The Pulse An Osteopathic Emergency Medicine Quarterly 142 E. Ontario St., Suite 1500 Chicago, IL 60611-5277




Table of Contents

Presidential Viewpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Gregory M. Christiansen, D.O., M.Ed., FACOEP Executive Director's Desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Janice Wachtler, BA, CBA Exciting Changes on the ACOEP Board . . . . . . . . . . . . . . . . . . 8 ACOEP Spring Seminar Registration Open . . . . . . . . . . . . . . . . 8 ACOEP Mentor Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Erin Sernoffsky Op-Ed - Tell Us Your Thoughts . . . . . . . . . . . . . . . . . . . . . . . . . 9 Jan Wachtler, BA, CBA The On Deck Circle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Mark A. Mitchell, D.O., FACOEP How Many Patients Do Hospitals Have? . . . . . . . . . . . . . . . . . 11 Wayne Jones, D.O., FACOEP, Assistant Editor FOEM: Foundation Focus . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Juan Acosta, D.O., MS, FACOEP FOEM: Thanks its 2011 Donors . . . . . . . . . . . . . . . . . . . . . . . 17 Brimonidine Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Kelly Bray, D.O. Ethics in Emergency Medicine: What Would You Do? . . . . . . 21 Bernard Heilicser, D.O., MA, FACEP, FACOEP Resident Prospective: Is it Crazy Enough? . . . . . . . . . . . . . . . . 22 Justin Arnold, D.O., MPH WestJEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Letter to the Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Fred Sabol, D.O., FACOEP

Deadlines for the submission of articles and advertisements are the first day of the month preceding the date of publication, i.e., December 1; March 1, June 1, and September 1. The ACOEP and the Editorial Board of the PULSE reserve the right to decline advertising and articles for any issue. ©ACOEP 2011 – All rights reserved. Articles may not be reproduced without the expressed, written approval of the ACOEP



On the topic of healthcare, extrapolating the economics of today to what one can expect from the future apparently doesn’t take an advanced degree in economics from a prominent university. Look at the example of those folks with the prestigious pedigrees (referring to Goolsbee, Summers, Romer, Volcker, among others) who have impotently advised the President on economic solutions and who have since retreated into their ivory towers. I took that comment to mean he lacked confidence in the political decisions based on gestalt. He went on to say, “The idyllic policies failed when tested in the real world.” They remarked that the PPACA is a repeat of history and cited numerous first hand examples of the short comings. At that point she leaned over and propped up her glasses to offer her intuitive familiarity with the system. She asked me if I knew the history of Greece? I did not answer because I wasn’t sure if this was an intended riddle of substance, or if this was just a headline reference of the day. I considered her, in my brief encounter, to be wise, so I took her at face value. I had a good idea she did not mean ancient Greece. She managed to jog an old memory from my family’s Greek origins. My great uncle was a Greek physician whose family fled the conflict in Cyprus during the early 70’s to stay with my mother who had already immigrated to the US. She must have seen my reminiscing mind and then cautioned me against the infinite wisdom of our leaders who hold fast to these system ideals. She then predicted another rework of the law due to its destined flaws. They had little faith in the infinite wisdom that created our current economic or health care policies having seen this all before. They then reminded me of the wisdom of Albert Einstein who also escaped from Germany’s wrath. He said, “Only two things are infinite, the universe and human stupidity, and [he] wasn’t sure about the former.”

different. It doesn’t really cost $5 for two aspirin unless you factor in the liability risk. The national cost of health care services has ballooned to 17 % of GDP and will rise even further. The economy and the health system are intricately intertwined. On the economic side, the failure of the debit ceiling debate was followed by a credit rating downgrade. The failure of the super committee format is threatening yet another credit downgrade. The US economy is trillions of dollars in debt and has too few jobs to reduce the deficit. Social programs like Social Security openly state by 2016 the program will be upside down and will pay out more than it can take in. 10,000 baby boomers are now reaching retirement age each day and for every retiree only two to three workers are paying into the system. Based on the November 2011 report of the Bureau of Labor and Statistics, 13,863,000 men and women are out of work sensationalizing the headline figure of 9% unemployment. Another 8.4 million are under-employed with only part time work and more than 2.8 million have dropped out of the market to reveal a real unemployment rate of 17%. This adds up to over 25 million Americans who lack the resources to pay their bills. To offer some perspective, only 13 million American were out of work during the Great Depression. Further masking the problem is the new way of reporting economic statistics and job reports which hide the real impact. When 120,000 jobs are filled and at the same time 300,000 people are dropped from the expiring unemployment benefits, the unemployment rate should go up. However, despite having almost three times as many jobs lost as gained, those who are dropped from the equation actually cause the unemployment rate to go down. It makes for good politics but has real implications for emergency medicine as it increases the demand on the safety net services. The real threat to our economy and health system is the lack of honesty from all parties involved.

Exploring the economic side of their argument did not take the clairvoyance or mystical tea leaves to figure out. The economic predictions and clues to the health system failures have been circulating for many years – we as a nation just have been procrastinating or flat out ignoring the consequences. Many people saw the abuse and corruption by misguided economic policies which were further reinforced by an abetting press. Healthcare is no

Many patients are disingenuous with their healthcare and have expectations that are not aligned with their behavior. The principle upon which guides good health practices is strikingly similar to a strong stock market. Poor choices eventually demand a correction. To offer a medical analogy, our current economy is not unlike the downward cycle of heart failure. Heart disease is the leading cause of death in this country and billions of dollars have been

continued from page 1



poured into this cash cow of disease. Despite the enormous effort in education, patients are shocked at the news of having heart disease after reporting a life of indulgent behaviors like smoking, substance abuse and gluttony. The risk factors and life style choices take their toll on the heart. The cardiac output declines and the ability to perform is impaired. Modulation of hormones, blood pressure and contractility and even surgical interventions like valve replacement and implants eventually reach a point of futility. Once perfusion reaches a critical level, then cardiovascular collapse is inevitable. Even with all the obvious evidence of an impending disaster, the hospitalist who at one patient per hour still hates to admit (no pun intended) anything, will apply a sternal rub to the patient and fail to see the dire situation. For his part he will tell you the pain is reproducible. His evidence is backed by his statement, “You just are not pressing hard enough.” This action seems to satisfy everyone involved that the pain we speak of must be true and that any other source of pain is a falsehood or anomaly. This is the classic example of confirmation bias. This sounds strikingly similar to how our economy is failing as well. There is plenty of blame to go around as we have dishonesty in the economic system ranging from government policy (providers), to the consumers (patients). The curious analogy of the couple’s foreshadowed argument brings me to the discussion of the Greek health system. This piqued my interest because it followed my belief that a good physician learns from his mistakes, but a great physician learns from someone else’s mistakes. I looked into their logic to see if I could learn a lesson or two. I’ll outline the Greek economic backdrop to give a reference of the country’s situation. Greece is a country of just over 11 million people. It is now racked with high unemployment and inflation. The country is saddled with crushing debt now at 115% of GDP and the public has responded with outrage. But their anger appears misplaced as they continue to advocate for policies that have resulted in the dependency they currently find themselves. They now have a new government that was not elected but rather appointed by external interests. The socialist government was replaced last month by an appointed national unity government headed by a European Central Bank technocrat – Prime Minister Lucas Papademos. This action in itself reminded me of the warning by Thomas

Jefferson. He said, “banking institutions are more dangerous to our liberties than standing armies.” How prophetic, yet it happened in the democracy called Greece. Prime Minister Papademos is charged with keeping Greece from going bankrupt. As part of the Eurozone, he has to institute an austerity package or face expulsion from the union. The thought of severe spending cuts and tax hikes prompted workers to revolt and strike. Curiously, the labor strikes included physicians. It wasn’t always this way and I can offer a little history to illustrate. The Greek island of Cyprus was invaded by Turkey after a Cypriot military coupe took over the government. The island remains divide to this day. I vividly remember the ire of the Cypriots toward then President Jimmy Carter. I also recall the loss of my great uncle’s home to the Turks as it became a command center for military operations. My refugee relatives eventually moved to Athens. Greece then developed a restorative democracy in 1974. The country had growing health system problems with large gaps in coverage, particularly in rural areas, which prompted a call for change and reforms. With the rise of the socialist party in 1981 the then active Association of Hospital Doctors of Athens and Piraeus (EINAP)passed law 1397/83 which created the Greek national health care system (ESY). The ESY system was created and formed from private and public elements. It was designed for universal coverage and access. It centered on the development of a primary care system which was provided mainly through public systems. The compulsory insurance program rested under the jurisdiction of the Ministry of Employment and Social Protection analogous to the Centers for Medicare and Medicaid Services(CMS). The Ministry of Health and Social Solidarity (formally known as the Ministry of Health and Welfare) was responsible for planning of the ESY system and is analogous to our Health and Human Services agency. The design was to create a unified health system to cope with inefficiencies. Change was instituted to develop publicprivate partnerships through a centralized administration system, accompanied by additional pharmaceutical reforms. Every aspect of the health care expenditure was controlled by the health ministry in a system analogous to the new created Independent Payment Advisory Board (IPAB) under

the PPACA. Professional hospital management over time was abolished as government sought to increase its control over expanding health expenditures. Low reimbursements, retrospective reimbursements and unrealistic budget constraints failed to meet costs. The incentives to improve efficiencies with increased regulation resulted in clientelism. A black market emerged and was reported on in 1994 due in part to irrational pricing, poor planning and limited referral coordination analogous to our current EMTALA regulations. Physicians demanded cash to make up the difference in deficit payments under the social system despite regulations making such demands illegal. Fair financing and equity in access gave way to private expenditures as public waiting list grew for services. The government instituted new reforms and exhaustive studies resulting in increased emphasis on hospital services. The transfer of power from primary care occurred because health care personal lacked the influence to argue their position with the government. Additionally, they lacked motivation and incentives for improvement having been burdened with bureaucratization. In response the government created ‘Afternoon Clinics’ for direct payments to doctors in private practice in an attempt to stem the tide of black markets and tax evasion. Patients were given choice but with increasing inequalities in access. The Ministry of Health and Social Solidarity grew in size over time to include two Deputy Ministers and three General Secretaries. There are five Directorates Generals under the Ministry which cover 1)General HealthServices ( primary care), 2) General for Health ( professions and civil servants), 3) General for Administrative Support and Technology Infrastructure, 4) General for Public Health (Pharmacy), 5) General for Social Solidarity ( family protection and welfare groups). There are six additional ministries with subordinate authorities to cover elements such as undergraduate education, national finance, medical devices, military and merchant marine medical services, etc. Sadly only 25% of the Greek population has confidence in their physician. 42% of citizens admitted to making a payment to the physician out of fear of receiving substandard care. Out of pocket expenditure accounted for over 37% of the health expenditure and this is on top of social health insurance (31+%) and tax


costs (29+%). Private insurance makes up only 2% of the health expenditure. If you are interested in reading more about national health systems then review the Health Systems in Transition Report from the World health Organization Institute which outlines the health systems of each country in the Eurozone. It does not take a leap of faith to see we have much in common with the systems across the pond. The ideology and leadership recite the same principles. The solutions to universal problems toward access and expenditures are copied from like systems. We are moving to this type of socialized system and our future is apparent. We are so close to what has already happened in Greece. Just in writing this article I counted during my shift a dozen patient transfers to my institution based on financial disincentives of the treating physician and failures of EMTALA. We can also expect to fight with our colleagues under the bundled payment system. The government plan has been overtly stated to increase public participation in government controlled insurance. As explained to me by a high ranking government bureaucrat, once the public insurance rate reaches three in five consumers (patients) it will have control of the market and will be able to dictate reimbursement rates otherwise known as price controls. For example, if a consumer (patient) breaks her hip the likelihood that she will be a Medicare recipient is high. Standard practices will dictate the orthopedic expenditure bundle which will be distributed between the hospital, orthopedist, radiologist and emergency department. The orthopedic physician will have to decide if the potential for readmission or HAI is worth the reimbursement in relation to the regulatory risk. The radiologist and emergency physician will fight over what is left. Currently radiology services average about half of the emergency department fees. How long do you think that process will sit well with emergency physician groups? Add the fact that advanced imaging payments are being reduced significantly beginning in 2013, the search for more revenue will increase the frustration and agitation with the system. There are some opportunities worth embracing in the PPACA. We need to continued on page 6


continued from page 5 advocate for quality care concepts and realistically priced services. Currently, it is a guessing game when a patient enters a hospital for service. Patients and staff have little idea of pricing or market rates. As a result much of what we do is defensive medicine because it is the climate we live in. We also need a unified effort to demand a sensible tort system. We can move toward more efficient service and limit duplication of services if we have a rational and consistent legal climate. Expanding access to patient records will also go a long way to improve efficiency. In Japan patients can swipe a card and get their lab test from a kiosk. How novel to let the patient have their own medical record immediately accessible. Right now the information management sector is the most over rated component to the PPACA and hinders the effectiveness of medical service. Exorbitant, expensive systems and poor designs trap ‘providers’ and create havoc with record management. The Accountable Care Act is without 1 11/28/11 1:21 PM a4M_SmallPulseAd_Layout doubt the most influential legislation

to impact the health care industry. The implications are enormous and we are doing what we can through the Emergency Medicine Action Fund (EMAF) for favorable solutions. There are many issues in need of a solution that we as physicians can impact for the better. We can address end of life issues. This is the low hanging fruit and every chronic care, cancer patient, and nursing home patient should be approached by their doctor on this issue. We can also advocate for smarter reimbursement. It is ridiculous to have higher reimbursement rates for cerumen dissipation than other more cognitively complex services. It is also ridiculous to endow substance abusing patients with unlimited resources at the public’s expense, yet mandate rationed care to a middleclass, employed patient. I personally have treated patients who have used the local ambulance service without paying a bill at a tune of one million dollars a year, yet the same transport service will charge an employed patient $400 for the same complaint. The result is often the employed patient declines the ambulance service to avoid personal cost pressures and instead chooses Page 1 to drive him or herself to the hospital.

Emergency Medicine Opportunities

One of the most important lessons to take away from the Greek experience is absolute necessity to protect the doctor patient relationship. Doctors are not ‘providers’; they are doctors. The only providing I do is to provide for my family with provisions. Language is important because it shapes our perspective and it is being used coercively. Therefore, patients are not consumers, health units or expenditures. Patients are people. It is a tenant that must be restored if there is any hope of improving the system. Otherwise, the Hippocratic Oath from ancient Greece will have only historical significance and the greased palms of providers will look more like the MF Global CEO, the honorable Jon Corzine. You can guess what the initials MF stand for and I would not dignify his actions as honorable. The current physician culture of passive involvement in health policy will absolutely result in a Greek archetypal health system. If there is anything to learn about our future it is to get involved now. Watching physicians demonstrate with rioters in the streets of Athens is a sign of a missed opportunity to make meaningful use of change. Be an advocate for your patients and start making an impact on the politicians who have ignored the predictions and symptoms for far too long. What have you got to lose?

References: Physician owned and operated, 4M Emergency Systems has over 15 years of experience management and staffing emergency departments and urgent care centers. We are now looking for qualified physicians at the following locations. Geneva, Ohio: If balance is what you’re looking for in life, Geneva has it! Located on the shores of Lake Erie in Ohio’s wine country region, Geneva is situated 55 miles from the Pennsylvania state line and 45 minutes north of Cleveland! Beautiful settings, fishing, boating, swimming and wonderful park facilities can be part of your life! Annual volume 15,000. 12-hour shifts. Outstanding compensation/ benefit package includes partnership opportunity, a generous stipend, paid malpractice with tail, health, 401K retirement plan, paid long/short term disability, life, and an additional incentive plan. Candidates should be board-certified emergency medicine or primary care with solid EM experience.

Austintown, Ohio: Brand new free-standing ED located just outside Youngstown is seeking a dedicated and confident emergency medicine physician. Annual volume 28,000; physician assistant double coverage; 15 beds; flexible 12-hour shifts. The outstanding partner plan includes a generous stipend, health, paid malpractice with tail, 401K retirement plan, paid long-term disability and life, an additional incentive plan, business spending accounts, sign-on bonus & referral bonus program! Call us for more information about this exciting opportunity and others. Erin Waggoner, (888)758-3999; or e-mail

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US Bureau of Labor and Statistics 2011. World health Organization 2010, on behalf of the European Observatory on Health Systems and Policieshttp:// Economou C. Greece: Health system review. Health Systems in Transition, 2010, 12(7):1–180. dictionary/ Tanner, Michael D. (2008) “The Grass Is Not Always Greener: A Look at National Health Care Systems Around the World” Cato Policy Analysis no. 613

Executive Director's Desk Janice Wachtler, BA, CBA

Lighting the Way John F. Kennedy was an inspiration to me when I was a kid. Besides being the first president who I can remember that didn’t look like my grandfather, in 1963 he was very close to my father’s age. He was also the first president I ever saw on television. I remember the Kennedy/ Nixon Debates and I remember how enthralled my parents were at a presidential candidate who was their peer. As we watched and listened to his “Ask not what your country can do for you; ask what you can do for your country,” we were inspired by his challenge. He called for a nation to get moving, to get out from under the mantle of World War II thinking and the heavy burden it placed on the world, and he challenged all Americans to get involved with their government, the world and their communities; I became a believer. Following his challenge, he offered the nation ways in which to get involved. He offered goals he saw for the United States and its citizens: to fly in space, to land on the Moon, to help the world, and Americans flocked to universities to become involved in projects that would see us prosper and grow in areas that would allow us to go to the moon, to make strides in medical care, to grow our nation in ways that had never been tried before.

Now it’s time that we challenge the medical community to get involved in their own world; to make medicine better and grow our opportunities. We are confronted with many problems, a citizenry in which many have no or insufficient coverage to pay for their medical needs, an aging population requiring expanded care, and insufficient physicians to cover the need. As practitioners you have seen healthcare reform reduce your reimbursement, insurance that restricts the pharmaceuticals that can be utilized to give the best patient outcomes and proposals coming down that will restrict your practices further. At the same time, medical professionals have gotten lethargic and rely too often on groups to advocate for its rights and needs. Although AOA has done a phenomenal job representing osteopathic concerns, only emergency physicians can represent emergency medicine’s needs. You are the only physicians who can tell legislators the problems you face on an hourly basis. Only you can articulate the problems of overcrowded emergency rooms; overextended staff and insufficient staffing; insurance coverage that now may curtail payments for emergency department visits and not pay for medical care dispensed to these people. While groups like AOA, ACEP, EMAF and ACOEP can do the rounds on a local and national level, and advocate for you, we cannot know the intimacy of your particular practice scenario. So I challenge the members of the American College of Osteopathic Emergency Medicine to help us petition

Washington, DC to look at healthcare reform not from a 90,000 foot level, but on a personal, ground level. How can you do this? You can participate in the AOA’s DO Day on the Hill on March 8th. For too long our members have been a tacit voice in governmental issues, except to complain. So, rather than to complain to us, complain to those who truly make a difference and plan to attend the event. Too often we have blown off this opportunity to meet our legislators and their staffs and we have failed to make our voice heard. Students, residents, and 12 board members and staff members cannot adequately voice your concerns. But think if we had 150 or 200 members attend the event with all the students, residents, and staff all advocating for emergency care – what an impression we would make. Over the next several months we will be posting information on our website providing you with mechanisms to become informed on healthcare issues being considered by Congress. We will hold a special meeting prior to the DO Day on Hill activities so that the Patient and Physician Advocacy Committee can prepare our physicians to advocate our specific healthcare issues. So I will light the first candle to light the way to Washington; I challenge you to light your candle and stand beside me. Together we can create a light that will be seen nationwide and we will make an impression on the one group that can change healthcare to benefit you.

Join Us for DO Day on the Hill Thursday, March 8, 2012



Exciting Changes on the ACOEP Board If the past years are any indication, 2012 will be a time of great growth and innovation for ACOEP, led by an enthusiastic Board of Directors. Not only are experienced Board members taking on new roles, ACOEP’s Board also welcomes four new members to its ranks. A successful association draws on the experience of veteran members as well as fresh voices and ideas and, the ACOEP Board relies heavily on a mix of both. This year Gregory Christiansen, DO, FACOEP, assumes the office of the President, leading the College as it continues to grow and evolve. At his side, veteran Board member Mark Mitchell, DO, FACOEP, is named the president-elect. John Prestosh, DO, FACOEP has been selected to become the secretary and James Turner, FACOEP will serve as the treasurer. The Board also welcomes new members to its ranks. Christine Giesa, DO, FACOEP-D transitions to this new leadership role, bringing with her years of experience as the Chair of the CME Committee and 20 years of ACOEP membership. The Pennsylvania native had planned to become a pathologist until six months before graduation, when a rotation with Dr. Tony DiPasquale changed her course.

“By the end of the month I was hooked. Tony is the reason I went into EM,” recalls Dr. Giesa. “I wanted to be a Board member so I could continue to serve the College in a higher capacity. ACOEP is a strong, independent force in the Osteopathic community. It does not hesitate to make hard decisions and has been a very vocal advocate for osteopathic physicians.” Joining Dr. Giesa on the Board is Robert Suter, DO, FACOEP, a native of Decatur, IL who now resides in Dallas, TX. A graduate of Des Moines University, Dr. Suter has been a member of ACOEP since 1986 when, as a first year medical student, he helped to create the Student Chapter. “The success of the Student Chapter, and the Resident Chapter which followed, is one of the things that brings me absolute joy to see,” says Dr. Suter. “My desire is to bring my experience and networking in other areas of organized medicine to the table as a resource to the Board and the College.” Resident Chapter President Justin Arnold, DO, MPH is a third year resident at Lehigh Valley Health Network in Allentown, PA. A six-year Student and Resident member, Dr. Arnold is excited to become further invested in the College and

its future. “My decision to pursue osteopathic emergency medicine was due to a few close mentors before medical school, however my involvement with ACOEP is really what let me know this is the niche for me,” says Dr. Arnold. “The College supports its students, residents and members in a unique way. My friends and mentors at ACOEP have truly become a second family.” Joseph Sorber is a third year medical student at West Virginia School of Osteopathic Medicine and joins the Board as the ACOEP Student Chapter President. Dr. Sober is eager to contribute to the growth of the Student Chapter and providing excellent services to up-and-coming professionals. “The greatest single benefit for the student membership is the access ACOEP provides to their residency programs at the spring and fall conferences,” Dr. Sober says. “The ACOEP Board of Directors are dedicated to their student population and provide a wonderful student-centered conference environment.” ACOEP sincerely welcomes the new members to its Board and looks forward to another year of progress and development.

ACOEP Spring Seminar Registration Open!

and conference materials as ACOEP’s meetings enter a new era.

Registration is now open for the 2012 Spring Seminar in beautiful Scottsdale, Arizona, April 10-14! Members may notice a change in the look of the brochure


Bold thinking and emerging ideas have fueled the American College of Osteopathic Emergency Physicians from the start. There was no roadmap in 1975 when a small group of physicians came together to create this organization. They relied on their vision and willingness to chart new territory – a spirit that continues to shape ACOEP today. In that vein,


we've branded our Spring Seminar and Fall Scientific Assembly under the theme "Emerge." This powerful new identity, with its bold, dynamic logo, conveys the vital and growing role of these meetings in advancing our profession. It also indicates the exciting offerings to come in 2012. Join us this spring for innovative didactic sessions, improved and exciting competitions, the 2012 COLA review, EMS track, and even a 5K race! The ACOEP Spring Seminar promises unparalleled opportunity for education, networking, relaxation, and more!

ACOEP Mentor Program Launches Nationwide

by Erin Sernoffsky

Experience is an invaluable teacher. With this in mind ACOEP Member Services Department proudly unveils the ACOEP Mentor Program, an exciting new initiative linking veteran residents and physicians with medical students who are navigating the difficult transition from classroom to emergency room. This unique member benefit fosters relationships where students can reap the benefit of their mentor's knowledge, insight and guidance. “Building a bridge between medical students and experienced osteopathic physicians and residents is not only an integral component to training successful DO’s, but it also contributes to the overall quality of care,” says ACOEP Board President Gregory Christiansen, DO, FACOEP. “This program strengthens the osteopathic emergency medicine community and is an easy way to make a significant contribution

to our colleagues and the patients we care for.” Students can expect an honest dialogue with people who understand the personal and professional challenges that face them in this exciting and daunting time. This one-on-one approach allows mentees to ask specific questions, address unique fears, and receive dedicated advice to individual situations. Mentors and mentees can explore all aspects of becoming a successful physician, including work-life balance, residency opportunities and expectations, board examination preparation, strategies for approaching rotations, financial obligations, and the future of healthcare in the United States. Participants need only to commit to two or three hours per month and will be free to establish their own best means of communication, topics of discussion, and partnership goals.

“I can think of no better resource in becoming a successful physician than the osteopaths who have already made it,” says Joe Sorber, ACOEP Student Chapter President. “The ACOEP Mentor Program fosters a strong community of doctors and offers a kind of support that we can’t find anywhere else.” Practicing physicians or residents in at least the third year are invited to share their experience and insight as mentors. Mentors must also be active ACOEP members, and commit to sharing their experience and observations openly and honestly. For more information, or to register for this exciting new network, visit http:// or contact Jaclyn Ronovsky, ACOEP Member Services Assistant, at 312.445.5704 or email

Op-Ed - Tell Us Your Thoughts

by Janice Wachtler, BA, CBA We’ve all heard the rumors and innuendos regarding the ACGME and recommendations to not accept DO’s into allopathic residency programs and, in fact, these are discussed by the ACGME and AOA as this will have a severe impact in the entire landscape of medical education. So the question is how can the osteopathic profession create the needed residency training positions in less than five years? Anyone who knows me, knows that I enjoy brainstorming so let me throw these ideas out and invite your opinion. You can share your thoughts through a special link on our website, under “Newsletter.” We will publish any responses received by March 1st. Scenario 1: What if an institution in an area with few osteopathic emergency physicians approached the AOA and ACOEP and said that they have the facilities, vol-

ume, OPTI approval and have all their program documentation in order. The one thing they are lacking is DO faculty, however they have MD’s on staff who have the credentials for core faculty. To supplement the lack of DO role models the OPTI has developed a visiting professorship to visit the facility on a monthly basis to provide the necessary osteopathic component in the residency. Would this meet the need to train osteopathic residents? Scenario 2: A rural area is in need of physicians in all specialty areas in order to serve their population, however, there are no institutions large enough to train physicians. The town hierarchy approaches a training institution to propose paying for positions to train the needed physicians; in return, the residents promise to return to the town and stay for five years following their residency program and perhaps estab-


lish a home in the area. Could this be possible in today’s medical funding paradigm? Scenario 3: What if we opened osteopathic emergency medicine residency programs to MDs by creating a program that would provide the MD trainees with three additional components within their training programs that taught them osteopathic philosophy, osteopathic patient approach and treatment, as well as osteopathic manipulation. At the end of their program would they be able to sit for board certification through AOBEM and AOA? Would this dilute the profession? Today is not the time to color within the lines. We need to be creative and to think outside the box. So tell us, what do you think?


The On Deck Circle Mark A. Mitchell, D.O., FACOEP President-Elect

Emergency Medicine - Remember the "Why" Close your eyes and take yourself back to those days in medical school or even before. Remember what it was that drove you to pursue a career in medicine. What was it for you? I imagine that for many it was the desire to provide a service to our fellow citizens; to be there and make a difference. We get great satisfaction in knowing that we can play such a vital role in our communities each and every day. While we may not have all the answers, many times just our mere presence and taking the time to listen and show compassion is healing in and of itself. We get the opportunity to take care of such a wide variety of clinical presentations from in utero issues, to those who are at the end of life. However, the practice and delivery of medical care today is not what it used to be. The complexities we face are incredible as we deal with topics such as thinking about medico-legal issues that actually have nothing to do with the care of patient’s

needs. We have to make sure we consider quality metrics such as Core Measures and PQRS. In 2012 and beyond we will encounter measures that are time based and we will have to rely upon our hospital partners to ensure we have the support required to meet these metrics. Hospitals can’t afford to have patients boarded in the ED as this will affect their reimbursement. We are faced with administrative teams that hold the ED providers accountable for patient satisfaction and often we work in environments that are conducive to this. Many providers even have compensation that is at risk based upon patient satisfaction scores. Even though we have made great strides in the recognition of emergency medicine amongst our medical peers, we still find ourselves fighting for equality. We are the providers of “inconvenience” as no one looks forward to the call from the ED in the middle of the night, during a busy day in the office, or operating room,

on weekends or over holidays. Yet, our mission is to take care of patients regardless of when their crisis arises, their financial situation, or other circumstances beyond control. I am proud of what emergency physicians do and we do it 24/7. We do it without prejudice and give outstanding care to everyone. Thus I want you to remember the “why” you decided to get into medicine in the first place. We can’t let all the issues and struggles that we face in the complexity of medicine distract us from our “why”. Take a deep breath before you walk into the next patient’s room and remember why you are there. Enjoy the opportunity you have to make a difference in one more life. The difference may be large, such as making a critical diagnosis, or the difference may be small, such as just taking the time to sit down and listen; but the impact you can have is up to you.

Members in the News! Stephen A. Roskam, DO, FACOEP-D was recently honored by Midwestern University for his service to his alma mater, the Chicago College of Osteopathic Medicine (class of 1980), as this year’s recipient of the prestigious OSTEE award. The award is granted in recognition for his Outstanding Service in Teaching and Educational Excellence during his 28 years as a faculty member in the residency program in emergency medicine at CCOM. As the residency program director Dr. Roskam diligently championed an excellent clinical and didactic experience as the program grew to be the second largest of all the osteopathic and allopathic programs in the country with as many as 68 residents at


a time under his direct supervision. Steve continues as a professor of emergency medicine and full time emergency physician working alongside residents at Provident Hospital of Cook County. Congratulations friend of ACOEP and frequent speaker, Kevin Klauer, DO, who was recently elected as ACEP Council Vice Speaker! Attendees of ACOEP 2011 Scientific Assembly will remember Dr. Klauer’s popular presentations, High Risk Cardiovascular Cases, and Career Ending Mistakes in Medicine. He also serves as the Director of Center for Emergency Medical Education (CEME) and the Chief Medical Officer for Emergency Medicine Physicians. Dr. Klauer has received the


ACEP National Faculty Teaching Award and the EMRA Robert J. Dougherty Teaching Fellowship Award. Congratulations, Dr. Klauer! Do you have exciting news, accomplishments or developments to share? Please send them to We would love to include them in an upcoming issue of The Pulse.

How Many Patients Do Hospitals Have?

Wayne Jones, D.O., FACOEP Assistant Editor So let’s say you have a 300 bed hospital that sees 60,000 patients in the ED. Assuming an admission rate of 20%, the hospital admits 12,000 a year. Assuming that this represents 70% of all admission, the hospital will house approximately 16,000 patients in a year. Again, assuming a five-day length of stay, the health center will utilize 219 beds per day, or have a 73% occupancy rate. It may sound low, but this mirrors most hospitals. So, how many patients does this hospital have? The answer is the same everywhere… none. Physicians have patients; hospitals have beds. We have accepted a big responsibility by becoming a physician. The cost of healthcare, along with the health of our patients, are only 2 endpoints. Patient behavior, patient demands and rates of infection are a few more. Hospital efficiency and survival also belong to us. I question if we really understand this concept. Physicians are in the drivers’ seat of medicine. We as physicians need to be responsible and clean up our act. We need to start being reasonable practicing physicians. We need to police our own ranks. We have allowed hospital and governmental attempts to do this for us. Well, it doesn’t work. Think about it. Who entices patients

to develop drug-seeking behaviors? We do. Who packs the ED full of patients? We do. Who allows lawyers to run among us throwing out litigious allegations? We do. And who orders too many tests because of legal and patient pressures? Ok, you get it. Now I understand it’s not all of us all the time, but it is all of us some of the time. Yes, even me. I have had those weak moments when I prescribed antibiotics for the not-really-ill patient. I order the d-dimer, knowing all along it will be negative. I get the head CT, because the parent is angered, by the thought of taking a brain-injured child home. We spend way too much money for every patient we see, we delay discharges for convenience and we promise to provide more. We are being benevolent. There is plenty for everyone, so why not give everyone everything? Because, we are running out of “plenty”. Now we are going to be beat with our own stick. Since patients are accustomed to Chinese takeout (a term I use to describe the nature of them asking for the care they expect, not require), CMS is following suit by asking the patients if they like the service they receive. Now, I find it counter intuitive that CMS wants to save money, but will pay healthcare based on customer satisfaction. In other words, we need to do more to make the patient happy to get

better scores. Does this save money? Not for CMS. Does this make patient care better? Doubt it. CMS pays for the treatment of a diagnosis. Hospitals, then, are incentivised to discharge patients as early as possible to make more money per-patient, perday. If that patient returns in 30 days for the same diagnosis, the hospital eats the bill. So was the first admission good care? Was readmission better care? Maybe the method of payment just bought the wrong treatment. But, remember, as physicians, neither the hospital nor CMS own the medicine we practice. We do! So why are we following their lead? When physicians begin to compete for Medicare dollars, i.e. payments based on patient outcomes, non-compliant patients will be discharged from practices so that practices can improve their scores. Where will these patients go? That’s a great question. The answer should be nowhere! As physicians, we need to stand up to Medicare and say stop. Physicians need to take control of medicine and remove all insurers from demanding their own Chinese takeout. In medical school, you learned disease processes. In residency, you learned how to treat disease. As a mature physician, you need to learn to practice medicine.

Do you want to make a mark on emergency medicine? Do you have a calling to lead your peers? If you do ACOEP wants you! Applications are currently being sought for candidates for potential membership on the Board of Directors of the American College of Osteopathic Emergency Medicine. Check the “What’s New” section of the ACOEP’s website for the application and complete the form, attach your photograph and current and up-to-date CV and return it to Dr. Brabson, Chair of the Nominations Committee. Conference Call interviews will be arranged during February and March. If you have any questions, please contact or call at 312-445-5705 for further information.



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

Foundation Focus 2011 FOEM Pinnacle Award

2011 FOEM Foundation Pillar Award

2011 Inaugural Honors Dinner and Awards Ceremony There is no denying that 2011 was a transformative year for the Foundation for Osteopathic Emergency Medicine, capped off by the FOEM 2011 Inaugural Honors Dinner and Awards Ceremony presented by Schumacher Group. This spectacular evening gave the Foundation an opportunity to publicly acknowledge and thank those who have supported us through the years. • Joseph Kuchinski, D.O. , FACOEP-D

• Juan F. Acosta, D.O., MS, FACOEP, FACEP • John W. Becher, D.O., FACOEP-D • Peter J. Kaplan, Norcom, Inc. • Beth Longenecker, D.O., FACOEP • Robert E. Suter, D.O., MHA, FACOEP-D, FACEP, FIFEM • James M. Turner, D.O., FACOEP and Sherry Turner, D.O. • Janice Wachtler, BA, CBA

2011 FOEM President’s Circle Award

• • • •

Mark Mitchell, D.O., FACOEP of Schumacher Group and his wife Laura enjoying the VIP Reception

EmCare Emergency Medicine Physicians (EMP) MedExcel Schumacher Group

For more pictures and stories from this event, check out FOEM on Facebook!

2011 Inaugural Honors Dinner and Awards Ceremony sponsors

• Paula Willoughby DeJesus, D.O., MHPE, FACOEP-D Sponsor: • Anita Eisenhart, D.O., FACOEP

• Presenting Corporate Schumacher Group • Silver Level Sponsor: TeamHealth • Supporting Sponsors: Premier Health Care Services and Morningstar Emergency Physicians


2011 FOEM Corporate Champion Awards


FOEM Competitions The Foundation for Osteopathic Emergency Medicine held four competitions at the ACOEP Scientific Assembly, and 2011 showcased some of highest quality of research and presentation skills to date! Attendees of the Research Study Poster Competition, the Research Study Paper Presentations, the Oral Abstract Competition, or the Clinical Pathological Case (CPC) competition can testify that these events are more riveting and educational than ever. Thank you to all our participants, judges and attendees for making these events so successful! 2011 FOEM Resident Research Paper Competition sponsored by EMP • 1st Place: Lionel Lee, D.O. from Arrowhead Regional Medical Center o Comparison of Short-Term Seizure Control with Itravenous vs. Oral Phenytoin Loading in the Emergency Department • 2nd Place: Elizabeth Placzek, D.O. from St. Joseph’s Regional Medical Center o Contrast Nephrophathy: a Literature Review and Retrospective Pilot Study for Risk, Prophylaxis, and Diagnosis Following Exposure for Urgent Radiographs • 3rd Place: Eric Grube, D.O. and Nick Van Malderen, D.O. from Doctor’s Hospital o Prospective Study of Bedside Ultrasound in Determining Presence or Absence of Blood Flow in Patients with Testicular Pain 2011 FOEM Research Poster Competition sponsored by MedExcel • 1st Place: Alexis Davison, D.O. from St. Joseph’s Regional Medical Center o A Comprehensive Study on Resident Accuracy in the Performance

and Interpretation of Focused Bedside Emergency Ultrasonography • 2nd Place: Adam Schwartz, D.O. from Good Samaritan Hospital o The Osteopathic Emergency Resident In-Service Exam as a Predictor of Success on the American Osteopathic Board of Emergency Medicine Part 1 Certifying Exam

2011 FOEM Clinical Pathological Case (CPC) Competition sponsored by Schumacher Group: •

Faculty 1st Place: (tie with PERFECT SCORES) Angela Cheers, D.O. from POH Regional Medical Center and Stacey Barnes, D.O. from St. Joseph’s Regional Medical Center

• 3rd Place: (tie) Randall Grant, D.O. from St. Barnabas Hospital and Eric Schmeiser, D.O. from OU-HCOM: Affinity Medical Center o Venous Blood Gas Testing vs. the Standard Basic Metabolic Panel for the Measurement of Potassium. Are VGB Potassium Levels Accuarate Enough to be Used to Make Critical Decisions Regarding Medical Management in an Urban Emergency Department? o Ultrasound Investigation of Leg Position Enhancing Femoral Vein Exposure for Cannulation

• Faculty 3rd Place: Annahieta Kalantari, D.O. from Aria Health

2011 FOEM Oral Abstract Competition sponsored by EmCare

Research Study Paper Competition sponsored by EMP

1st Place: Olphabine Authouriste, D.O. from St. Luke’s Hospital o Effect of Nebulized Furosemide in Treating Dyspnea Associated with Congestive Heart Failure

2nd Place: Joanne Rousseau, D.O. from Midwestern University: CCOM o Effects of Having a Physician in Triage on Patient Walkout Rates, Patient Satisfaction and Emergency Department Hours on Ambulance Diversion.

• 3rd Place: Julie Sanicola-Johsnon, D.O. from St. Joseph’s Regional Medical Center o A Look into ED Physicians’ Attitudes and Experiences with End of Life and Palliative Care, and the Effect of Palliative Care Teams and Formal Education in the Emergency Department.


• Resident 1st Place: Dennis Heard, D.O. from Mount Sinai Medical Center • Resident 2nd Place: Inna Kovelman, D.O. from Lehigh Valley Health Network • Resident 3rd Place: Tamara Boots, D.O. from Aria Health Winning Abstracts

1st Place: Lionel Lee, D.O. from Arrowhead Regional Medical Center Comparison of short-term seizure control with intravenous vs. oral phenytoin loading in the emergency department AUTHORS Evan Houck, DO, Lionel Lee, DO, Thomas Minahan, DO, and Andy Lowe, PharmD Introduction Phenytoin remains one of the oldest and most commonly prescribed anti-epileptic medications currently in use today. Intravenous (IV) and oral phenytoin are commonly used for loading phenytoin in the emergency department (ED). Unfortunately, there is a paucity of data continued on page 12


continued from page 11 concerning the clinical efficacy of oral versus intravenous loading. Our objective was to investigate if IV phenytoin loading compared to oral phenytoin loading led to a decreased level of seizure activity within 48 hours of being seen in the ED. Methods We obtained the pharmacy records of all patients given phenytoin in a large, urban ED from October 2008 – October 2009. These records were then reviewed and organized to determine which patients met inclusion or exclusion criteria. The study was done in a retrospective fashion. These patients were then called by phone and questioned about their seizure activity in the 48 hours following their ED visit. Patients were then placed in to one of four groups: IV loading seizure present, IV loading seizure free, oral loading seizure present, and oral loading seizure free. All patient data was kept confidential throughout the process and an institutional review board approval at Arrowhead Regional Medical Center was obtained prior to study initiation. Results There were a total of 290 loading doses of phenytoin given to 247 patients during the study period. The average patient age was 40 years and the average loading dose administered was 797.9 mg (200 mg – 1500 mg). There were 168 IV doses and 122 oral doses and there were 166 males and 81 females. Out of the 170 patients remaining in the study group after application of the inclusion and exclusion criteria, 90 patients received oral loading and 80 patients received IV loading. Of the oral study group patients, 35 patients were able to be contacted and included in the final analysis. Of these 35 patients, four patients (11.5%) reported having a recurrent seizure event within 48 hours of leaving the ED.


Of the IV study group patients, 39 were able to be contacted and included in the final analysis. Of these 39, nine patients (23%) reported having a recurrent seizure event within 48 hours of leaving the ED. When analyzed using a 2 x 2 contingency table and Fisher's exact test, the P-value was found to be 0.1567 between the two groups reporting a recurrent seizure within 48 hours.

country, and emergency medicine residency programs must include ultrasound training as a mandatory part of the emergency medicine curriculum. The purpose of this paper is to review all resident performed bedside ultrasound scans in our emergency department, and compare the accuracy of the resident’s findings to that of widely accepted gold standards such as, CT scan, ultrasound, x-ray, etc.

Conclusion Phenytoin continues to be a commonly used medication in the ED for controlling seizures. Moreover with seizures representing a common disease seen in the emergency department and accounting for 1 out of every 100 adult ED visits, perhaps this study will examine our management of seizures. Although the study has its limitations, the clinical and financial significance should be reviewed for further research.

Methods: Residents were asked to perform focused emergency bedside ultrasound scans on any patient with a clinical indication for the study. The residents’ interpretation of the bedside scan and the confirmatory test results were recorded on a Quality Improvement (QI) sheet. A value of “1” was given if the bedside US findings agreed with the confirmatory study; a value of “2” was given if they were in disagreement. The scans were further sub-divided into “A”, “B”, “C”, or “D.” A value of “A” was given if the focused bedside and confirmatory study both had positive findings. A value of “B” was given for a negative focused bedside scan but a positive confirmatory study. A value of “C” was given for a positive focused bedside scan but a negative confirmatory study. A value of “D” was given if both focused bedside scan and confirmatory studies were negative, indicating no pathology.

Research Study Poster Competition sponsored by MedExcel 1st Place: Alexis Davison, D.O. from St. Joseph’s Regional Medical Center

A Comprehensive study on Resident Accuracy in the Performance and Interpretation of Focused Bedside Emergency Ultrasonography. Hung Dang, D.O, Jasmine Thomas,D.O, Alexis Davison, D.O., Nader Boulos, M.D., Vincent A. Debari, PhD. Objective: The use of ultrasound is rapidly becoming the new standard of care in many emergency departments throughout the


Results: A total to 2167 QI sheets collected from July 2007 to April 2010 were reviewed for this study. Six hundred and eight QI sheets met our inclusion criteria and 1559 were excluded. The majority of the scans performed were done on the gall bladder (188/608), which showed an agreement of 91%, Kappa 0.81, Z score 11.3 and 95% confidence interval of 0.720.90. Pelvic ultrasounds were the second most performed (177/608), with 96% agreement, Kappa 0.83, Z score 11.1, 95% CI of 0.71-0.95. We had a total of eightythree FAST exams that had an 89.2% agreement, Kappa 0.69, Z score 6.69, 95% CI 0.52-0.87 with confirmatory studies. Bedside renal ultrasound studies produced

a total of 53/608 with confirmatory studies showing an agreement of 86.8%, Kappa 0.73, Z score 5.35, 95% CI of 0.55-0.92. Conclusion: It is our conclusion that with basic didactic and hands on training, residents are able to competently perform and accurately interpret focused bedside ultrasounds with a high degree of accuracy as compared to confirmatory tests. Oral Abstract Competition sponsored by EmCare 1st Place: Olphabine Authouriste, D.O. from St. Luke’s Hospital Effect of Nebulized Furosemide in Treating Dyspnea Associated with Congestive Heart Failure Objective Furosemide, a calcium-channel blocking loop diuretic, is given IV and orally in the treatment of CHF. To our knowledge, nebulized furosemide for the treatment of congestive heart failure has not yet been studied. However, using furosemide in an aerosolized form has been shown to be successful in treating other diseases known to induce dyspnea such as end-stage cancer, COPD, and asthma (1, 3, 5-8). There are several case reports and small, uncontrolled studies describing a positive relief of dyspnea in patients with endstage cancer uncontrollable by standard therapy (1, 2). Moreover, two doubleblind, randomized, crossover study have demonstrated inhaled furosemide alleviates the sensation of experimentally induced dyspnea and air hunger respectively (4, 9). Nebulized furosemide may potentially provide a bridge to relieving dyspnea in patients with CHF until other standard medication can take effect. The primary outcome of the study is improvement in dyspnea via change in the VAS scores and a secondary outcome is an improvement in the vitals specifically oxygen saturation and respiratory rate.

Methods Single center, double-blind randomized prospective study of approximately 50 patients seen in the emergency department with known or suspected CHF by clinical history with the chief complaint of dyspnea. A power analysis was conducted prior to initating the study with a suggested enrollement of 30 patients to achieve statistical significance of p<.05. The hospital Instutional review Board requested an FDA investigational new drug (IND) approval prior to patient recruitment due to the planned administration of furosemide. An IND number was approved and interim reports were filed as per FDA request. While in the Emergency Department, all potential subjects were briefly interviewed by an attending or resident physician to determine eligibility. If the patient met inclusion criteria and consent was obtained, participants were then asked to rate the amount of dyspnea using a 100 mm visual analogue scale(time zero). The study medication was delivered via a nebulizer with flush 02 via facemask or inhalation aparatus as per patientâ&#x20AC;&#x2122;s ability to comply with respiratory treatment. Patients assigned to the treatment group received 40 mg furosemide diluted with 1 mL normal saline solution to a total volume of 5 mL. Patients assigned to the placebo group received 5 mL normal saline solution. The treatment was given over 15 minutes. The patient then completed a second VAS and a second set of vitals recorded. At 30 minutes a third and final VAS was completed and a 3rd set of vitals recorded as well. During this intervention all participants received standard medical treatment with oxygen, diuretics, nitroglycerine and morphine and diagnostics for congestive heart failure. A treatment algorithm was provided for the treating physicians to limit deviations in standard practice of management of congestive heatfailure. Changes in a patientâ&#x20AC;&#x2122;s perception


of dyspnea were evaluated by a mixed randomized-repeated measures analysis of variance conducted to compare changes in mean VAS over time between furosemide and placebo groups. The between-subjects effect was group (furosemide vs placebo) and the within subjects effect was VAS values over time (T0-T30). A p-value < .05 denotes statistical significance. Secondary outcomes were evaluated with independent samples t-test or Mann Whitney rank sums test if required due to a wide distribution of data point variables. Results Fifty participants were enrolled into the study with 25 patients randomized to the furosemide group and 24 to the placebo group. One patient in the placebo group did not have appropriate data documentation. The participants range in age from 47 years to 96 years with a mean age of 79 in the treatment group and 76 in the placebo group. The majority of participants are caucasian, of the 50 enrolled particpants 7 patients were of non-caucasian background. Males and females were comparably distributed between the groups. Mean oxygen requirement on initial evaluation was 3.8L/min in the furosemide group and 3.2 L/min in the placebo group. Thirty-six of the participants are prescribed home furosemide with doses ranging from 20mg to 160 mg daily, of these 17 patients were randomized to the placebo group and 17 to the furosemide group. All 17 patients in the placebo group on furosemide took their home diurtic prior to evaluation, 13 patients in the furosemide group medicated prior to evaluation. Three patients in the placebo group were given intravenous furosemide by EMS prior to arrival, no patients received prhospital furosemide in the study group. The mean VAS for the furosemide group at T0, T15 and T30 were 4.38mm, 2.86mm and 2.18mm respectively. The mean VAS continued on page 18


FOEM thankS thE SpOnSOrS OF thE 2011 FOEM inaugural hOnOrS DinnEr anD awarDS CErEMOny

The commitment and support of these organizations assisted the Foundation for Osteopathic Emergency Medicine produce the largest gathering of osteopathic emergency physicians in the Foundation’s 13-year history. We are grateful for your continued belief, support, and participation with FOEM. Juan Acosta, D.O., MS, FACOEP, FACEP President, FOEM

142 E. OntariO StrEEt, SuitE 1500 • ChiCagO, illinOiS 60611 16


The Foundation for Osteopathic Emergency Physicians thanks its 2011 donors! (For purposes of space, designations were limited to D.O.)

*Special thanks to Peter Kaplan, NORCOM, Inc. for his incredibly generous in-kind donations that defrayed the promotional and design costs of the 2011 Inaugural Honors Dinner and Awards Ceremony. Thank you, Peter! $2,500 and above Juan Acosta, D.O. Joseph Kuchinski, D.O. $1,000 - $2,499 William Lynch, Jr. Beth Longenecker, D.O. Robert E. Suter, D.O. Sherry Turner, D.O. Douglas P. Webster, D.O. $500 - $999 Donald Beyer, D.O. Gregory Christiansen, D.O. Peter Kaplan, NORCOM, Inc. James Turner, D.O. Janice Wachtler Michael Ward, D.O. $250 - $499 Michael Dâ&#x20AC;&#x2122;Ambrosio, D.O. William DiCindio, D.O. Anthony DiPasquale, D.O. James Espinosa, D.O. Dennis Guest, D.O. Iscovich Foundation Gary LaPolla, D.O. Francis L. Levin, D.O. David Levy, D.O. Jon Pierre Pazevic, D.O. John C. Prestosh, D.O. Patrick Sullivan, D.O. Bruce Whitman, D.O. $100 - $249 Fahim Shan Ahmed, D.O. Michael Allswede, D.O. Victor Almeida, D.O. Thomas Brabson, D.O.

Kevin Clark, D.O. Bevin Clayton, D.O. Glenn DeLong, D.O. Kenneth Doroski, D.O. Anita W. Eisenhart, D.O. Clifford Fields, D.O. Bryan T. Fitzgerald, D.O. Gregory Gray, D.O. Ira Brady Husky, D.O. Stephen G. Kaiser, D.O. Ned Magen, D.O. David T. Malicke, D.O. Stephen Mifsud, D.O. Mark A. Mitchell, D.O. Thomas Mucci, D.O. Steven Parrillo, D.O. Benjamin Paschkes, D.O. Nilesh Patel, D.O. Christopher Posey, D.O. Victor J. Scali, D.O. Donald Sefcik, D.O. Brian S. Silverman, D.O. James Thomas, D.O. John A. Tyrell, D.O. Below $100 Anthony Affatato, D.O. Rohit Agrawal, D.O. David Alexander, D.O. Siddhartha Al-Hashimi, D.O. Leonardo Altamirano, D.O. Kelly Anderson, D.O. Richard Anderson, D.O. Adam Ankrum, D.O. Alwin Arendse, D.O. Amy Arnold, D.O. Gerard Ashbeck, D.O. Dale Askins, D.O. Brian Ault, D.O. Jacob Bair, D.O. James Bajo, D.O. Michael L. Baker, D.O. Mark Banas, D.O.


Chandler Tracy Barber, D.O. Jane Barnes, D.O. S.B. Bashor, D.O. Robert Bazuro, D.O. S. Addison Beeson, D.O. Robert Beight, D.O. Joseph Gregory Beirne, D.O. Luke Bertorelli, D.O. Charles Black, D.O. Craig Black, D.O. Brian Blaustein, D.O. Richard Blubaugh, D.O. Wojciech Bober, D.O. Susan Lessner Boesler, D.O. Suzana Bogdanovska, D.O. William Bograkos, D.O. James M. Bonner, D.O. Charles Boothby, D.O. Thomas Borgstedte, D.O. Gregory Boris, D.O. Melinda Boye-Nolan, D.O. Matthew Boyer, D.O. Joshua Bozek, D.O. Alvin Jay Bradford, D.O. Wallace Broadbent, D.O. Sharla Bryan, D.O. Kyland Burden, D.O. Russell E. Burkett, D.O. Kristie Busch, D.O. Nikolai Butki, D.O. Jeffrey Butler, D.O. Ronald Cable, D.O. Joseph J. Calabro, D.O. Arthur Calise, D.O. Terrence Callahan, D.O. Victoria Camba, D.O. Carla Cameron, D.O. Terry L. Carr, D.O. Dale Carrison, D.O. Melissa Carter, D.O. Thomas E. Carter, D.O. Jason Everett Cheatham, D.O. Dale Chisum, D.O. Mark E. Cichon, D.O.


Kelly Clifford, D.O. Stephen R. Cluff, D.O. Eric Clymer, D.O. Michael Coleman, D.O. Samuel Coleridge, D.O. Brian Collins, D.O. Jonathon Conard, D.O. John Conlon, D.O. Duane Corsi, D.O. Jeffrey Couturier, D.O. Kevin Cranmer, D.O. Thomas Culver, D.O. John Current, D.O. Alan Daar, D.O. Mario D'Alessandro, D.O. Frederick Davis, D.O. Phillippe De Kerillis, D.O. Douglas Dero, D.O. David Didur, D.O. Matthew Dikin, D.O. Freya Dittrich, D.O. Jean Emmanuel Dorce, D.O. Stephen P. Dubos, D.O. Aleksandr Dubrovoskiy, D.O. Julie Dunlop, D.O. Nana Dwomoh, D.O. Michael C. Eastman, D.O. Harry J. Emmerich, D.O. Randy Engelman, D.O. Warren Entwistle, D.O. John Everett, D.O. Robert Faber, D.O. Carter Fenton, D.O. Michael Ferraro, D.O. Jack B. Field, D.O. Laura Fil, D.O. Michael Filart, D.O. Donald Findlay, D.O. C.H. Fowlkes, D.O. William E. Franklin, D.O. J. Gregory Frappier, D.O. Nathan Fredrick, D.O. Darryl Lawrence Friedl, D.O. Joseph Frontino, D.O. Karen Gaber-Patel, D.O. Michael Gable, D.O. Steven Gable, D.O. C. Wayne Gallops, D.O. Aaron Garret, D.O. Timothy Genetta, D.O. Christine Giesa, D.O. Elizabeth Gignac, D.O. Richard C. Giovannini, D.O. Bernadette Gniadecki, D.O. Antonio Gonzalez, D.O. Stephanie Goodwin, D.O. Michael Goodyear, D.O. Sheryl Gottlieb, D.O.


Dwynn Greenfield, D.O. Jeffry Greenlee, D.O. Raymond Griffith, D.O. Kyle Groom, D.O. Joseph Guarnaccia, D.O. Anthony Guarracino, D.O. Regina Hammock, D.O. Robert Harper, D.O. Bernard Heilicser, D.O. Todd Helfman, D.O. John Herrick, D.O. Ralph Hess, D.O. Edwin M. Hinton, IV, D.O. Bradford Hoffman, D.O. Timothy Holt, D.O. Susan Horling, D.O. Roger Howell, D.O. Philip Howren, D.O. Lisa Hrutkay, D.O. Donald G. Hudson, D.O. Heather Hughes, D.O. Raymond Hughes, D.O. Joseph Hummel, D.O. Robert L. Hunter, D.O. Scott Kanagy, D.O. Dmitry Katkovsky, D.O. Steven Keehn, D.O. Sara Kelly, D.O. Lenard Kerr, D.O. Howard Kessler, D.O. Thomas C. Kickham, D.O. Jeffrey Kinyon, D.O. Thomas E. Klie, D.O. Judith Knoll, D.O. Drew A. Koch, D.O. Matthew Kramp, D.O. David Kraus, D.O. Arnold S. Kremer, D.O. Jay Kugler, D.O. John Kulin, D.O. Michael Kupon, D.O. Elizabeth Lacy, D.O. Sheera Lall, D.O. James E. Lambros, D.O. Paula Lange, D.O. Catherine Langston, D.O. Matthew Larrew, D.O. Richard Lartey, D.O. Ronald Joe Leckie, D.O. James Lee, D.O. Thomas Licata, D.O. Jean Liu, D.O. Kevin Loeb, D.O. Michael LoGuidice, D.O. Hollis London, D.O. Aaron Love, D.O. Lisa Henning Low, D.O. Freda Lozanoff, D.O.


Sean Ludlow, D.O. Khoa C. Luong, D.O. Rose Mack, D.O. Mary E. Malcom, D.O. G. Edward Mallory, D.O. Raymond Malta, D.O. Michelino Mancini, D.O. Thomas Marchiando, D.O. Carmen Massey, D.O. James Massimilian, D.O. Manjushree Matadial, D.O. Robert Mathews, D.O. Michelle M. Maureau, D.O. Ronald McAdam, D.O. Raymond McCarthy, D.O. William E. McConnell, D.O. James W. McCorry, D.O. Eric McDowell, D.O. David McKelway, D.O. James Mead, D.O. Roger Meadows, D.O. Andrew Mersky, D.O. Brian Miller, D.O. Terrall Moore, D.O. Gary Moorman, D.O. James Morgan, D.O. Robert A. Mott, D.O. Darlene Myles, D.O. Kevin P. Neenan, D.O. Joe A. Nelson, D.O. Oanh Clark Nguyen, D.O. Paul Numsen, D.O. Joseph Obebe, D.O. Price Paul Omondi, D.O. Gary Osborn, D.O. Chantel O'Shea, D.O. Nicole Ottens, D.O. Diane M. Paratore, D.O. Edmond Pasternak, D.O. Punam Patel, D.O. Sandeep Patel, D.O. Celine Paulus, D.O. Amanda Pearce, D.O. Arthur Pecora, D.O. Katherine J. Pitus, D.O. Scott Plasner, D.O. Amy Poholski, D.O. Catherine Polera, D.O. James D. Polk, D.O. J.A. Poplawski, D.O. Robert Prahl, D.O. Stephen Pulley, D.O. Abdulrahman Qabazard, D.O. Shaila Quazi, D.O. Narasinga Rao, D.O. Jason Ravanzo, D.O. Fred Rawlins, D.O. Gregory Reinhold, D.O.

Craig Reynolds, D.O. Omer Richman, D.O. Karen Rickert, D.O. Saul E. Rigau, D.O. Alexander Riss, D.O. Brian J. Robb, D.O. Samuel Robles, D.O. Mark S. Rosenberg, D.O. Charles S. Ross, D.O. John W. Rubin, D.O. Scott Russo, D.O. Matthew Rutman, D.O. Mariusz Rybaltowski, D.O. Richard Saalborn, D.O. David Sarkarati, D.O. Cary Schneider, D.O. Henry Schuitema, D.O. Adam Schwartz, D.O. Sandra Schwemmer, D.O. Edmund Sciullo, D.O. Jennifer Scott, D.O. John Scranton, D.O. Monte Sellers, D.O. Czar Medical Services, D.O. Marty Shadel, D.O. Thomas Sharp, D.O. Michael E Sheehy, D.O. Ashwin Shetty, D.O. Jeffrey Shipkey, D.O.

Merlin L. Shriner, D.O. James Shuler, D.O. John Siekerka, D.O. Doni Marie Sigarivas, D.O. Kerrilene Sinapi, D.O. Steven A. Smith, D.O. Gregory Smolin, D.O. Janene C. Sparks, D.O. John E. Sparks, D.O. Peter Spence, D.O. Theodore Spevack, D.O. Bryan Staffin, D.O. Daria Starosta, D.O. Robyn Steenstra, D.O. John Stepanek, D.O. Ronald Sterrenberg, D.O. Jennifer Stevenson, D.O. Jay A. Stiefel, D.O. Murry Sturkie, D.O. Aisha Subhani, D.O. John F. Sullivan, Jr., D.O. Mark Tang, D.O. Marcus Teng, D.O. Brandon Thomas, D.O. Haley Todsen, D.O. Paul Toote, D.O. Jeffrey Trager, D.O. Lyncean Ung, D.O. Dinesh Verma, D.O.


Jason N. Vieder, D.O. Sanford Vieder, D.O. Karen Vincent, D.O. Sarah Vitello, D.O. S. Robin Von Haven, D.O. Peter Wachtel, D.O. Brett D. Wagner, D.O. James S. Walker, D.O. Joseph Warren, D.O. John D. Weilbacker, D.O. Shannon Weinstein, D.O. John Wells, D.O. Fred G. Wenger, D.O. Eric Wernsman, D.O. Thomas Wigboldy, D.O. Elaine Lombardi Wilk, D.O. Anthony D. Wilko, D.O. Adrienne Brooks Williams, D.O. John Williamson, D.O. Thomas Wills, D.O. Courtney Wilner, D.O. Jennifer B. Wilson, D.O. Melissa Winger, D.O. Robert J. Wise, D.O. William Wixom, D.O. Michael Yangouyian, D.O. John Zambito, D.O. Michael E. Zielinski, D.O. Faizah Zuberia, D.O.


Brimonidine Case Study

by Kelly Bray, D.O. & Keri Robertson, D.O. Introduction: Brimonidineis an alpha-2 agonist used for the treatment of glaucoma in adults. Toxicity of brimonidine is similar to that of clonidine. Symptoms include drowsiness, bradycardia, hypotension, and respiratory depression [1]. This case highlights the accidental ingestion of a very small amount of brimonidine by a 22-month-old male. Case Report: A 22-month-old male with no past medical history presented to an emergency department for apneic episodes after being found sucking on his grandfather’s new bottle of brimonidine ophthalmic. The mother found her child in his grandfather’s bedroom sucking on the eye drops as if it were a bottle. Twenty minutes after the ingestion, the mother stated that the child kept falling asleep, even with tactile stimulation. She tried feeding the child orange juice without success. The mother called the poison center and was told to bring the child to the emergency department. In the emergency department, the child arrived via EMS with a temperature of 36.6, pulse 124, respirations 32, blood pressure 112/58, a pulse ox of 100% on a 100% non-rebreather mask, and fingerstick glucose of 177. Initially, he was awake and crying loudly. The child’s physical exam was within normal limits other than his tachycardia. Eight minutes later, the child was noted to have several episodes of apnea and bradycardia. His respiratory rate was as low as 6 breaths per minute and his heart rate decreased to the 90s; the patient was subsequently bagged. An IV was placed and the patient received a 20cc/kg normal saline bolus and the poison center recommended naloxone 0.5 mg IV for the apneic episodes, which was administered without improvement. Twenty minutes later,the child was still noted to have the apneic episodes, and he was subsequently intubated with versed and rocuronium. CBC, BMP, pCXR, and urinalysis were within normal limits. The patient was started on a fentanyl/versed drip and transferred to the nearest PICU. The patient remained intubated in the PICU for two days and then was success-


fully extubated on day three. He was discharged home after another day of observation and sent home without sequella. The PICU team measured the amount of missing brimonidine eye drops, and only 0.5 ml were missing from the 5 ml bottle, which equates to 1mg of brimonidine. Discussion: Brimonidine is an alpha-2 agonist used for the treatment of glaucoma. The manufacturer does not recommend its use in children under 2 years old due to the toxic side effects that can come from ocular usage [2]. Brimonidine is chemically similar to clonidine but is safer because it is less lipophilic and more polar than clonidine, which limits its ability to cross the blood brain barrier. Therefore, there are less CNS effects [1,3]. In earlier literature, past case reports reported altered mental status, miosis, bradycardia, hypotension, apnea, respiratory depression, and hypothermia with clonidine toxicity in toddlers. Interventions of naloxone, atropine, fluid resuscitation, or intubation were performed with clonidine ingestion [4]. In another study, a 5 year old was started on a naloxone drip for 25 hours and successfully avoided intubation for his clonidine overdose [5]. Brimonidine toxicity is similar to clonidine toxicity with symptoms of drowsiness, ataxia, pallor, irritability, hypotension, bradycardia, miosis, and respiratory depression. These symptoms can be from ocular or oral exposure [1]. An 11-day-old infant with glaucoma became lethargic and had apneic episodes after 1 drop of brimonidine to the eye; the symptoms resolved on their own [6]. Another case highlights a 24-day-old infant who had episodic lethargy and apnea one hour after administration of ophthalmic brimonidine that also resolved on its own [7]. Brimonidine has been implicated in oral toxicity as well. A 2-year-old male ingested 2ml of Brimonidine 0.2% ophthalmic solution and 20 minutes later became pale and lethargic with shallow respirations. These symptoms resolved spontaneously, without intervention [10]. A 19-month- boy was given activated charcoal after ingesting brimonidine. His symptoms included apneic


episodes and bradycardia. His symptoms resolved after 4 hours with supportive care [11]. A retrospective study over 9 years showed 176 brimonidine unintentional poisonings. 11 received naloxone, 28 were hospitalized, and only 2 were intubated. This study recommended that more studies be done in regards to naloxone as a treatment for brimonidine poisoning [1]. Another study recommended tactile stimulation as a non-pharmacologic intervention as a means of treating brimonidine poisoning, and if this doesn’t work, then intubate the patient [3]. Conclusion: This case report highlights a very small amount of brimonidine ingested by a 22 –month- old which resulted in apneic episodes,bradycardia, and subsequent intubation. This proves the point that a very small amount of brimonidine can cause serious consequences in pediatrics. This case highlights that aggressive triage to an emergency department needs to be done with any child with a small amount of brimonidine ingestion [12]. References 1. Becker ML, Huntington N, Woolf AD. Brimonidine Tartrate Poisoning in Children: Frequency, Trends, and Use of Naloxone as an Antidote. Pediatrics. 2009; 123(2):305-311. 2. Shannon MW, Borron SW, Burns M. Haddad and Winchester’s Clinical Management of Poisoning and Drug Overdose. 4th ed. Philadelphia, PA: Saunders Elsevier; 2007. 3. Rangan C, Everson G, Cantrell FL. Central [alpha]-2 Adrenergic Eye Drops: Case Series of 3 Pediatric Systemic Poisonings. Pediatric Emergency Care. 2008 March; 24(3) 167-169. 4. Fiser DH, Moss M, Walker W. Critical care for clonidine poisoning in toddlers. Critical Care Medicine.1990 Oct; 18(10): 1124-1128. 5. Romano MJ, Dinh A. A 1000-Fold

continued on page 21

Ethics in Emergency Medicine Bernard Heilicser, D.O., MS, FACEP, FACOEP

What Would You Do? In this issue of The Pulse we will review the case first published in October 2011 exploring an ambulance transporting a psychiatric patient with non life threatening issues. The ambulance driver decided to divert and follow an erratically driven vehicle while attempting to contact law enforcement. The ambulance crew was successful in alerting law enforcement and the erratically driven car was stopped without any problem. The patient was then transported to the initial intended emergency department. Was this an acceptable decision by EMS? On one hand, the public may have been

continued from page 15 for the placebo group for T0, T15 and T30 were 4.38mm, 2.86mm and 2.18mm respectively. A statistically significant decline in the VAS for both groups from T0 to T30 (p<0.0001) was apparent. In comparing the decline in VAS between the furosemide and placebo group, there was not a significant difference in the magnitude of change over time (p=.39). Heart rate, systolic blood pressure and oxygen saturation were not statistically different from T0 to T30 both within and between the furosemide and placebo groups (all p > .2). Diastolic blood pressure did significantly decrease from T0 to T30 in the furosemide group (p =.04) but did not differ significantly between the furosemide and placebo groups. Results revealed a statistically significant group difference in median respiratory rate at T30 (p = .04) with a mean rate of 21 in the placebo group and 18 in the furosemide group. Median hospital length of stay was 5 days for the furosemide group and 6 days for placebo (p=.46). Neither group had any adverse effects reported.

spared a disastrous event by halting a potentially destructive vehicle. However, was the patient being transported subjected to a dangerous deviation of protocol? What if this seemingly non-emergent transport was to have changed and the patient now required immediate intervention? Conceptually, focusing on the greater good, the decision by EMS is given credibility. That could be commendable. However, the immediate needs of the dedicated patient were put in jeopardy. When EMS has been activated to respond and a patient relationship has been established, not following accepted protocol is potentially abandonment. It would be very difficult to defend the action by EMS if a bad outcome was to have occurred. If the

Conclusion Furosemide was well tolerated without adverse events when administered in nebulized fashion. A statistically significant difference between nebulized furosemide and placebo was apperent with a decreased respiratory rate in the nebulized furosemide group despite the VAS not demonstrating a statistically significant subjective change in dyspnea.

continued from page 20 Overdose of Clonidine Caused by a Compoundin Error in a 5-Year-Old Child with Attention-Deficit/Hyperactivity Disorder.Pediatrics. 2001 Aug; 108(2)471472. 6. Carlsen JO, Zabriskie NA, Kwon YH, Barbe M, Scott WE. Apparent Central Nervous System Depression in Infants After the Use of Topical Brimonidine. American Journal of Ophthalmology. 1999 Aug; 128(2): 255-256. 8. Bowman RJC, Cope J, Nischal KK.


ambulance was to have been involved in a motor vehicle crash, or the patient suffered an adverse event, the perspective of this decision would certainly be different. Emergency medical services is often placed in a difficult ethical situation. Obviously, who gets treated first at a mass casualty event is the epitome of this dilemma. However, in a single patient situation, the care of that patient has priority over a possible or theoretic situation. If you have any cases that you would like to present or be reviewed in The Pulse, please fax them to 708-915-2743. Thank you.

Ocular and systemic side effects of brimonidine 0.2% eye drops in children. Eye.2004; 18:24-26. 9. Vanhaesebrouck S, Cossey V, Cosaert K, Allegaert K, Naulaers G. Cardiorespiratory depression and hyperglycemia after unintentional ingestion of brimonidine in a neonate. Eur J Ophthalmol.2009 Jul-Aug; 19(4):694-695. 10. Hoffmann U, Kuno S, Franke G, Fusch C, Haas J. Adrenoceptor agonist poisoning after accidental oral ingestion of brimonidine eye drops. Pediatric Critical Care Medicine.2004 May; 19(3):282-285. 11. Soto-Perez-de-Celis E, Skvirsky DO, Cisneros BG. Unintentional Ingestion of BrimonidineAntiglaucoma Drops: A Case Report and Review of the Literature. Pediatric Emergency Care. 2007 Sept;23(9):657-658. 12. Lai MW, Woolf A. National U.S. trends in brimonidine exposure 19972004. Clinical Toxicology. 2005 Oct; 43(6): 722-723.


Is it Crazy Enough? Justin Arnold, DO, MPH ACOEP-RC President ACOEP Board of Directors In 1958, Niels Bohr, the famous Danish physicist muttered to his colleague “we all agree that your theory is crazy, but is it crazy enough?” The theory he was talking about has little bearing on our day-to-day work in the ED; that is unless you commonly employ the nonlinear field theory on elementary particles (I don’t). But what rings true about his statement was that to push a field forward, you have to think about things a little differently to make positive and progressive changes. The Resident Chapter has been developing a very proactive and engaging position in participating within the ACOEP and we hope you’ve noticed. We strive to be, not only active, but engaged members of the college. We want to make a difference for osteopathic emergency medicine residents across the country while at the same time making real contributions to both the college and emergency medicine as a whole. We have a theory that, well, may sound crazy. We theorize that with support from the membership and the Board and with active participation within the college, we can continue to grow the Resident Chapter to one of the most active portions of ACOEP. Yes, that’s right – the residents. Now, residents traditionally have not been known to spend what little free time we have thinking about how to take on more responsibility. Between clinical shifts, grand rounds, Rosen’s club, journal club, simulation, and family life – there are simply not that many hours left in the day. But what we have seen over the last few years has been a shift in attitude. Residents

want to be more involved. We want to resident members across the country who participate in committees and really make are interested in working alongside the an impact on our profession. We want membership to really make a difference in emergency medicine to be everything we the emergency medicine community. More dreamed it would be – for both ourselves importantly, these members have chosen to as well as our patients. And, if you do so through the ACOEP because they look around the ACOEP, you will have believe in the fellowship, collaboration, and undoubtedly noticed spirited and energetic virtue that is exemplified by the ACOEP. residents stepping up on committees, We have a great group of residents research initiatives, and in the mentorship that need your support to make this work. of the student chapter members. I encourage everyone to share your niche Specifically, the Resident Chapter has – your specialty – with the residents. hit the ground running this year. Our Engage us. Enlist us. Entrust us. Get Scientific Seminar in Las Vegas was our more involved with the college and join most successful meeting to date. We us in creating a critical mass of passionate had 139 residents attend lectures, CPC emergency physicians that can help make competitions, poster presentations, and our specialty everything it deserves to be. Resident Jeopardy! All but two osteopathic Our vision and goals aren’t that crazy after emergency medicine residencies were all – or maybe they really are just crazy represented. Resident members attended enough! and participated on every committee possible. Residencies from across the country are represented on the newly elected Resident ™ Chapter Board. Finally, we have set an In te n si ve ambitious agenda for Im m er si on E xp er ie n ce this year that focuses on activity in government affairs, research, “Amazing opportunity membership services, to see and do it all in and collaboration with FOEM, EMRA, airway management.” WESTJEM, AOA CIR, – Micheyle L. Goldman and the Student Chapter. DO, Florida I am proud to represent so many 2012 dates April 20 – 22, Las Vegas

September 21 – 23, Seattle

May 18 – 20, Boston

October 26 – 28, Atlanta

June 8 – 10, Chicago

November 16 – 18, Las Vegas

Intensive and hands-on. Focusing on the difficult and failed airway. Challenging Code Airway scenarios.

Register at or (866) 924-7929

Evidence-based. Comprehensive. Expert Faculty.





Western Journal of Emergency Medicine To the Membership, The Western Journal of Emergency Medicine (WJEM) is now the official journal of the ACOEP. It is an open source journal and can be accessed online at In October, I attended the WJEM Advisory Board meeting as your ACOEP representative. They were THRILLED to have us on board. Emphasis will be on original research and scholarly activities. The journal will also accept photographs, videos (for on-line version) and case studies. Here is an overview of opportunities for our members. 1. We need a SECTION EDITOR (or two) for the new â&#x20AC;&#x153;Musculo-Skeletalâ&#x20AC;? medicine section. a. Candidates need to be highly motivated individuals who have published in the past. It is preferable that the publications be pertinent to musculo-skeletal medicine. Topics may include (for example) orthopedics, trauma, osteopathic diagnosis and treatment, and bone pathologies. b. Candidates can expect to review a dozen or so articles per year for POSSIBLE publication.

c. Interested candidates may submit their Curriculum Vitae with a letter of intent to: Janice Wachtler, Executive Director A C O E P, 2. Other sections are also available for section editorship. They include: Behavorial Emergencies, Disaster Medicine, Emergency Cardiac Care, Geriatrics, and Trauma. a. All section editors will need to have an established publication track record  and will be significantly involved with offering pre-decisions on manuscripts. b. Interested candidates may submit their Curriculum Vitae with a letter of intent to: Mark Langdorf, MD, Editor In-Chief, 3. We need our members to volunteer to be REVIEWERS for any of the sections. a. Reviewers can expect to review 3-6 articles/year for POSSIBLE publication. b. The reviewers will need to have a few publications or enough so  as to feel comfortable commenting on whether a manuscript deserves publication. Identifying its flaws and  ways to improve it are essential to the review process.

c. Instructions on how to review a paper are on the website. d. Interested candidates may submit their Curriculum Vitae with a letter of intent to: Mark Langdorf, MD, Editor In-Chief,

4. We need our members to submit IRB approved studies, photographs, and case studies. a. Instructions on how to format and submit an article are included on the website. b. Submission is FREE. If accepted, the price of printing is $300 (which  is VERY inexpensive). If a department gets a subscription for $600/year AND a member of that department gets an article accepted, then there is no printing fee!! In fact, a lot of departments have submitted several articles/yr, and gotten more than two published making this a very cost effective option! Questions regarding your engagement with WJEM can be sent to me at Peter A. Bell, DO, MBA, HPF, FACOEPDist, FACEP President ACOEP 2006-2008

Join Our Team of Contributors! We are always looking for fresh insight, interesting cases, new developments, or exciting programs. If you are interested in contributing articles to The Pulse. Please contact Erin Sernoffsky, Communication Manager at or call 312.445.5709.



Letter to the Editor I would like to comment on Dr. Koch’s editorial in the October 2011 edition of The Pulse. First, I would like to thank him for writing the article and to pass on to him how interesting I found it. I’ve been doing Emergency Medicine since 1985 and what a shock it was when I was first made to work with a mid-level! Let me state right now that I personally don’t believe mid-levels should be in any ED! I feel strongly about this based on my experience and the mistakes that they have made in the near-disasters that I have been involved with them. It isn’t their fault! They aren’t physicians … it’s that plain and simple. It is the system’s fault and the public’s fault! It’s politically correct! Mid-levels were developed to work in physician’s offices and somehow they ended up in an area where anything can happen and can happen immediately and what is done or not done can mean life or death or prolonged suffering.

It has been my experience that the more tests that are ordered by mid-levels the better and basically they don’t have any differentials that are considered. “We’ll just check it to be sure” is what I commonly hear. Another problem is that hospitals and ER companies don’t have any standard way of handling mid-level charts. Some hospitals/companies have every chart signed by the ER doc with whom they are working; some don’t. Some ED’s have a supervising physician that signs all midlevel charts at some time or other. There just isn’t any standard across the country on how the mid-levels should be supervised! Is it right to sue the physician who signed the chart and never saw or discussed the patient with the mid-level, when something goes wrong? I kind of chuckled part about “fast-track!” that physicians don’t do and whoever came up

must have been in an altered state of consciousness! Fast-track to calamity is how I think of it. One could go on and on about TAT, provider-productivity, patient/customer complaints, decreased provider costs, etc, etc, ad infinitum about the current problems in medicine, but the bottomline is the safety and well-being of that human being on the bed! Nothing more. Physicians are the ones completely training to teach another human being! Thank you for your time in reading this opinion. Fred Sabol, D.O., FACOEP Kegley, WV

when I read the Please remember triage; nurses do, with “fast-track”

Making Your Voice Heard The Editorial Committee of the ACOEP would like to hear from its members and provide feedback to issues discussed in its communication vehicles. Readers may enter their opinions, submit potential articles or provide us with feedback on any issues discussed in The Pulse at any time by logging into our website, www.acoep. org, and clicking on the Submit icon on the right side of the screen. You will have the ability to submit your opinion or article by clicking on the link to either source “My Opinion” or “Article Submission” section.

Your article will be sent to the appropriate editorial team to review the article for relevance, need, and content. Other teams will be responsible for grammatical correction. Authors will be informed as to when or if it will be published and you will be asked to submit biographic information on yourself, including but not limited to a current photograph, curriculum vita and email address. If you wish to comment on any article, we ask you to list the name of the


article, author, and the issue in which article appeared. This will be sent to the Editorial Staff, reviewed and placed in a pdf format to be sent to the author for comment. Opinion articles will not be edited for anything except for grammar. ACOEP does have the right not to print the comment if it contains inappropriate personal comments about the author. We look forward to hearing from you.


Exciting Staff Changes for ACOEP In our on-going quest to serve our members better, ACOEP is pleased to begin 2012 with many exciting changes to the staffâ&#x20AC;&#x201D;the creation of new positions, and the arrival of energetic professionals to swell our ranks. Although we were sad to bid farewell to Mandy Ward and Brittani Eckhardt, the Member Services Department has continued to grow, welcoming Jaclyn Ronovsky, Member Services Assistant, in March, and Sonya Stephens, Member Services Manager, in July. This December, Lorelei Crabb hit the ground running as the new Meetings Assistant, as Erin Sernoffsky transitioned into her new role as Communication Manager. Finally, we are thrilled to announce that Matt Bohney has joined the staff as the IT Assistant. Below, please find contact information for our entire team, and do not hesitate to call the office with any questions or concerns!

Geri Phifer Executive Assistant 312.445.5707

Jaclyn Ronovsky Member Services Assistant La Grange Park, IL 312.445.5702

Jan Wachtler Executive Director Chicago, IL 312.445.5705

Kristin Wattonville Director of Meetings and Conventions 312.445.5710

Matt Bohney IT Assistant 312.445.5701 Erin Sernoffsky Communication Manager 312.445.5709

Lorelei Crabb Meetings Assistant 312.445.5707


Brian Thommen Director of IT Services 312.445.5703


Stephanie Whitmer Development Director 312.445.5700

Sonya Stephens Member Services Manager 312.445.5704


Osteopathic EM Residency Director SOMC is looking for an osteopathic boarded Emergency Medicine physician to lead our osteopathic EM residency program after the retirement of the current director. The position offers:

About SOMC We are a 222-bed regional medical center located in the beautiful valley of southern Ohio. SOMC recently completed a 100 million dollar expansion focusing on a renovation of the Emergency Department, expanding it from a 24 bed facility to 43. The expansion also included a Heart & Vascular Center, a four-story tower providing medical/surgical private rooms and 12 new surgical suites (nine general, one vascular and two cardiothoracic). Southern Ohio Medical Center has something very unique. We offer a stateof-the-art facility with the best technology – all while maintaining a small town atmosphere. The city of Portsmouth is a family-oriented community with a progressive school system, a local university, and a young physician population, which makes this an excellent place to practice and raise a family. Portsmouth is two hours south of Columbus and east of Cincinnati, with easy access to major metropolitan areas in the tri-state region.

Salary is commensurate with experience

Signing bonus and relocation

For more information, please contact Missy Ankrom in our Physician Recruitment Department:

Medical school loan repayment up to $200,000

(toll-free) (fax) (email) The PULSE JANUARY 2012

866|356-7662 740|356-7817


Presorted Standard U.S. Postage


Chicago, IL Permit No. 2177 142 E. Ontario Street Suite 1500 Chicago, Illinios 60611



The Pulse January 2012