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The PULSE

Osteopathic Emergency Medicine Quarterly VOLUME XXXI NO. 2

APRIL 2006

Presidential Viewpoints

Paula Willoughby DeJesus, D.O., FACOEP The recent publication of the “National Report Card on the State of Emergency Medicine” by the American College of Emergency Physicians (ACEP) and two articles that appeared in the Chicago Tribune spurred my thoughts about the ongoing crisis in healthcare. The extraordinary effort of ACEP to undertake the task of beginning to look at emergency medicine’s “state of the union” is an opportunity to see the complexity of this issue. The national public release of the document was courageous. This coupled with two Tribune articles heighten my angst. ACEP’s Report Card looked at four areas of care: access to emergency care, quality and patient safety, public health and injury prevention and the medical liability environment. One may have comment with the categories used to create the Report Card, the criteria within these categories, their weighted value, and accuracy of the data or even the interpretation of the results. What is clear is that we have work to do. There is no single solution and the solutions must have multidisciplinary approaches. Issues regarding access to care looked at quantifiable criteria for numbers of departments, visits to the emergency department (ED), Board Certified emergency physicians, nurses, inpatient beds and trauma centers. It queried utilization data such as the per capita spending on hospital care, populations with health insurance, state contributions to coverage programs for chil-

dren, and payments for services by Medicare and Medicaid. This category was weighted most heavily of the four categories because it was seeking to evaluate how well “a state was meeting the emergency care needs of its residents.” It was felt that a “larger bed capacity reduces overcrowding and preserves everyone’s access.” The estimated 45 million uninsured/under insured Americans many times rely on the ED as their only access. On a nightly basis, I rewrite a dozen or more prescriptions for patients already seen by other doctors and other EDs so that people can get their prescriptions filled for free at our institution when they cannot afford to pay for them. This includes routine medications after routine visits to their primary doctors; patients discharged from other hospitals and ED patients from other institutions. Every day we see dozens of patients that can’t wait 4-6 months for a routine office visit in free clinics. Every day we see dozens of patients who tried to wait and didn’t make it and decompensated. They now need inpatient services and many times will require increased resources in hopes of getting the patient back to their baseline status. Every night I see patients as a result of acute alcohol and drug intoxication and will see that same person again before the month is out. A recent report from one San Diego ED and one San Francisco ED estimated the average yearly costs for just one of these individuals was over one million dollars. Who is utilizing your ED? Why are they coming? Is the ED the place that certain health problems should be addressed? I would suggest that there are many common contributors to overcrowding that have nothing to do with the numbers of doctors and nurses in the ED or inpatient beds. I would suggest

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that these issues are responsible for a disproportionate use of per capita spending of health care dollars and resources and do not reassure me in the least that the fact that all of these individuals having access to the ED made things better. What about utilizing current systems and creating new ones that get people access to the right place, in one visit? What about establishing processes that address recidivism? In the January 1, 2005 issue of the Chicago Tribune Magazine, author Kelly Kleiman characterized individuals who insurance companies have declined to cover and would not offer insurance programs to, even though they were willing to pay premiums. Why would this occur, you may ask? Well it has to do with how individual companies choose to do their “underwriting.” “Insurers will try to predict what a condition might cost. If they can have a level of predictability, they’ll cover it. If they can’t or the price for the product might be prohibitively high, then they might not,’ says Mohit Goose, spokesperson for America’s Health Insurance Plan (a trade association in Washington, DC). Debra Chollet sums up the real issue here, “The reason they’re writing insurance is to get premiums to invest; paying medical claims is just an unpleasant corollary.” Insurance is not for the person who is paying the premium to feel assured they will have coverage, it is insurance so that the company is assured they have cash flow to invest in order to make money for its stockholders. This reality is not how the public or health care providers see insurance companies. They see insurance companies as their mechanism to have access to health care. Revisions to how we buy coverage have taken on a new theme.




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Recently, health care savings accounts are being presented as an alternative approach. These are accounts where the consumer sets aside money in a tax-free account to cover expenses, all expenses for health care, preventative, and interventions. They are linked to high deductible health insurance policies that cover expenses when interventions exceed the health care savings accounts. In another article in the February 12, 2006, issue of the Chicago Tribune, William Neikirk, and Judith Graham characterized one person’s satisfaction with their health care savings account. It described an example of how this individual saved a lot on his premiums and touted how he was able to save on interventions by knowing how much something would cost before deciding to do it. He apparently rejected an orthopedist’s recommendation for more physical therapy for his knee arthritis, took the suggestion of a second orthopedist for a “pain killer,” and accepted the generic version of the medication reporting a $610 savings. This was apparently the victory? Patients, like this man will be driven by their conservation of funds in their health care savings accounts and will not always arrive at the best conclusions. Short-term gain in preserving their accounts may not be the best long-term gain for their health. In addition, this program does nothing to address many of the health care issues in crisis today. The long debated national health care approach doesn’t fix it either. It just expands the system like my own institution where health care is rationed, decisions of access will be made for you based on availability and what is authorized. The consequences of this not working will end

up in my ED just like they do right now. Quality and safety of medical care is paramount. The Report Card looked at the number of emergency medicine residents and programs, access to enhanced 9-1-1 systems, proportion of the population with access to Advanced Life Support (ALS) ambulances, access to online medical direction, collection of ambulance diversion data, disaster training and use of preventative health grants. Ambulance utilization is usually very reflective of emergency department utilization. In my own system as many as 15% of our responses are to false calls with no victim being found at the scene. Those same systems to put people in the most appropriate access to care would also impact ambulance utilization. What about including screening at dispatch to direct certain patients to better access points, once available? The uncertain cases could even be referred there after Emergency Medical Services (EMS) is on the scene when EMS interventions are not necessary. In addition, as many as 55% of our EMS calls are not ALS runs. Communities need to look at themselves to determine the right level of care based on need, not just assuming that ALS is the answer. In an internal quality review, my system found that online medical direction took about 2-5 minutes to accomplish and only changed 2% of the care that EMS providers had already performed. Is this the best utilization of time for an already over loaded staff? Does it change outcome? More importantly, what should our outcome and quality performance measures be? This too is not readily developed. For example, something that appears as straightforward

as a response time you would think would be easily defined. It’s numbers. The EMS industry however cannot agree upon the definition of the window of time called a “response time.” Is it from the time the call comes into 9-1-1, the time that the vehicle receives it, or the time the vehicle is en route? Is it to the time the vehicle arrives on scene or the time the EMS providers arrive at the patient’s side? The derivations on the theme of all potential combinations have EMS comparing apples; oranges, pears, and a whole lot more. We are all familiar with those famous P.G. Scores as a measure of emergency medicine and hospital quality. Are these the measures we should be using? A patient’s view or measure of quality will always be different than how the inside guys measure quality. We, as health professionals, will always see and should see quality differently. What about those diversions? Typically, 25% of your ED volume comes from EMS. Why are we turning to EMS as the solution to this problem? If we off load the ED with these processes, we wouldn’t need it. Our system doesn’t allow BLS events to be diverted unless there is an internal disaster in the institution. The public health and injury prevention part of the report looked at traffic accidents and drunk driving, immunizations, prenatal care, and characterized the nature of a state’s injury patterns. These arenas are critical to emergency medicine and EMS. Consequences of behavior need to be reflected to the person making the behavior choice. Use of seat belts, helmets, and operating anything with wheels or motors under the influence, impact our society and medical resources with

Table of Contents Presidential Viewpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Guest Column, Michael Oster, D.O., FACOEP . . . . . . . . . . . . 15

Executive Director’s Desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Domestic Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Research Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Ethics in Emergency Medicine . . . . . . . . . . . . . . . . . . . . . . . . . 18

Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Guest Column, Wayne Jones, D.O., FACOEP . . . . . . . . . . . . . 19

Report of ACOEP Representation at the 2006 AOA Board of

Governmental Affairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Trustees Mid-Term Meeting . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Membership Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Student Chapter Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Court Victory for California Emergency Medicine Physicians . . 10

Resident's Corner . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

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THE PULSE–AN OSTEOPATHIC EMERGENCY MEDICINE QUARTERLY 142 E. Ontario St., Suite 1250 Chicago, IL 60611 312-587-3709/800-521-3709 Editorial Staff Drew A. Koch, D.O., FACOEP, Editor Paula Willoughby DeJesus, D.O., FACOEP Fred G. Wenger, Jr., D.O., FACOEP Bobby Johnson, Jr., D.O. Janice A. Wachtler, Executive Director Publications Committee Drew A. Koch, D.O., FACOEP, Editor & Chair Fred G. Wenger, Jr., D.O., FACOEP, Advisor Bobby Johnson, Jr., D.O., Vice Chair/Asst. Editor James Bonner, D.O., FACOEP Annette Brunetti, D.O., FACOEP Randall A. Howell, D.O., FACOEP William Kokx, D.O., FACOEP The PULSE is published quarterly (January, April, July, and October) and distributed at no cost by the ACOEP to Members and libraries of Colleges of Osteopathic Medicine by the National Office of ACOEP. The Pulse and ACOEP accept no responsibility for statements made by contributors or advertisers. Display and classified advertising are accepted. Display advertisements should be submitted as camera-ready, pdf, or jpg formats in black and /white art only. Classified advertising must be submitted as typed copy, specifying the size, and number of issues in which the copy should be displayed. The name, address, telephone numbers and E-mail address of the submitting party must accompany advertising copy. Advertisers will be billed for ads following the publication of their advertisements and payments will be due within 30 days of the issuance of the invoice. The deadline for submission of advertising is the first of the month preceding publication, i.e., December 1, March 1, June 1, and September 1. The deadline for article submission is November 15, February 15, May 15, and August 15. ACOEP and the Editor reserve the right to decline advertising and articles for any issue. The PULSE and ACOEP do not assume any responsibility for consequences or response to an advertisement. All articles and artwork remain the property of the Pulse and will not be returned. Subscriptions to the Pulse are available to nonACOEP members or other organizations at a rate of $50 per year.



unbelievable depth. Other personal choices such as smoking or substance abuse penetrate deeply as well. Even choices such as personal habits that adversely affect our health increase the utilization of resources. Many insurance programs do not cover health prevention and health maintenance interventions. Will health care savings accounts further decrease utilization in an effort to make consumers to minimize utilization? Both standard insurance and health care savings accounts function by rewarding those that do not access health care. They say they favor those that are healthy, but how do you stay healthy unless you are engaging in appropriate health prevention and screening? The final area of the Report Card addressed the medical liability environment. It assessed caps, available protection for emergency care, case screening, expert witness criteria, reform initiatives, and professional insurance rate changes. The key is that our medical liability as physicians protected by medical liability insurance. The key problem here again, is insurance. This is the same issue as health insurance. The insurance industry takes premiums for the same use as health care insurance premiums are taken, to have a fund of money to invest to make money for their company. Their solution again, has been to cut their loses by settling the case whether or not it’s in the best interest of the physician to reduce loss to their stockholders. Their follow up is to drop the physician because the physician has “events” and the physician doesn’t have a decision-making role in any of it. These issues are huge. The Report Card is a bold document. It should spur all of us to think. The things that are addressed, not addressed, how they are grouped or

the things we individually perceive as inaccurately addressed, and not indictments of the document or the group that created it. The document begins to show us we have miles to go before we sleep. We need to look closely at the disparity of how the public and we as physicians perceive insurance with how the insurance industry sees the purpose of insurance. The same disparity exists between how patients perceive quality and we perceive. We need to define what the appropriate quality measures are and how they should be measured. Health and injury prevention are not “pie in the sky” or nice to have. Real programs and processes must be put in place to deal with our health care crisis. Dealing with overcrowding in the emergency department has to be dealt with much farther upstream not after it has occurred. The causes and solutions are muti-factorial. Medical liability reform is only a small piece of the issue. Again, the disparity in mission exists between the medical liability insurers and our vision of medical liability insurance. Attitudes of the public toward using lawsuits for conflict resolution need modification. Pre-review of cases before they are filed is essential. Finally, people must be expected to take responsibility for their behavioral choices that impact their health. We need to have discussions that address these issues and many more in real world perspective to make real change in health care in our country. The next important document is the Institute of Medicine’s report on emergency medicine due out in May of this year. I am anxiously awaiting its arrival. Let’s take this on, head on, together and serve as a building block with others in real solutions.

Continuing Medical Education Calendar 2006 April 18 – 22 ACOEP Spring Seminar Wigwam Resort & Golf Club, Litchfield Park, AZ.......25 hrs Category 1 / 1A Credit

October 16 – 20 ACOEP Scientific Seminar Las Vegas Convention Center, Las Vegas, NV....................25 hrs Category 1A Credit

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Executive Director’s Desk Janice Wachtler

The Act of Knowing/The Tact of Telling The following patient walks into your Emergency Department, what do you do and how do you manage the patient, including informing the family of the outcome? A 70 year-old female presents with severe-to-excruciating back pain. The patient’s vital signs are not wonderful; she suffers from COPD and low blood pressure. She is on bronchodilators, and 24 hour O2. She states that she has been in extreme pain for 3 to 4 days and her family physician has had her on high doses of ibuprofen for the pain. Other than the back pain and COPD, she appears to be in good health, although a little jaundiced and has no other outward appearance of anything wrong other than the back pain. Your ED is busy on the day that she appears, but given the status of her pain on the Pain Scale you move her to a bed and take the above history. A cursory evaluation is done and you send her to X-Ray to have her back imaged. The films come back and it shows an excessive amount of arthritis on her spine. However, up until this time, you have done nothing other than evaluate her for the back pain, not any other symptom. You tell the patient that she has arthritis and should continue on the course of ibuprofen and you will inform her family physician what the x-rays show. At this point the patient states that she has had little or no appetite and when she does eat, she eats only a bite or two prior to feeling full and if she forces herself to eat more at the urging of her family she vomits. Her daughter indicates that her mother’s sister has passed away from the complications of stomach cancer within the last 18 months. For the first time, you palpate her abdomen; the patient screams in pain at the slightest pressure. You send her for a CAT Scan. After more than an hour, the scan returns,

however, no radiologist has read the scan, but you look at it and see a 10cm mass situated behind the stomach, pancreas, gallbladder, and liver. What do you do? How do you tell the family your suspicions? In real life, the ED physician stated to the family (not the patient), your mother has pancreatic cancer, she has less than a one percent chance of survival and potentially has six months to live or less. This physician, although potentially correct, had no way of knowing that the biopsy ordered days later was benign, and only surgery could even ascertain if it was a pancreatic tumor or not. Position-wise the chances were fairly good that it was, but how did he know? And his tact in informing the family of an assumption was pathetic. How do you deal with this in a busy ED? Do you blurt out your assumptions to this patient and her family at the bedside where others are nearby to hear not only your guesstimate, but also the family’s reaction or do you put them in a private place to speak with them? Do you call the family physician, and state your assumptive diagnosis and see what they want to do, do they want to come in and speak to their patient themselves or do you give them an overview of what you suspect and what you have told the patient? Do you admit the patient on the basis of her pain measurement, malnourishment, and breathing complications, and call for a consult with an oncologist and the family physician? I am quite sure that all of you have come across a case similar in nature to this one, how did you handle the situation? I am approaching this as a third party; a close friend who was appalled at the way her mother’s case had been disposed of shared this scenario with me. I was appalled at the case history and physical examination that was taken at this busy, urban ED. I felt lots of things were missed, and my first hope was that the attending physician was not one of my members. But as a layperson, placing myself in this physician’s shoes, I would have hoped that I

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would have handled this differently. Let me know if I am wrong. Despite the busy nature of the ED, I would have spoken with either the nursing staff to determine how the family and patient were dealing with the visit. If the family was overwrought as in most cases families are in the ED, I would have informed the patient of the outcome and asked her if I should inform the family. If yes, I would have pulled aside the family and escort them to a private area to inform the family members of my suspicions and explained my suspicions to them. Informing them that based on the placement of the tumor, behind the stomach and near the pancreas, it may, in fact be a pancreatic tumor, and best bets it would be. I would say that such a tumor has a high mortality rate, but in some cases, not many, there is a chance, based on early detection and some radical surgery, mixed with a large amount of luck, that one can survive. However, given the parent’s age and breathing problems it would be a tough surgery. But because I am not an oncologist, I am sending the results to the family physician and an oncologist to have them speak with the family. At that point, the notification has been made to rational members of the family, and it would be up to them to tell you to speak to their parents or wait for further consultation with the family physician or oncologist for the final word. Given the physical status of the patient, if I could, I would admit her to make the testing process easier and to assure that she received at the very least fluids because she was most likely dehydrated. Now, like I said, I’m not a doctor, nor do I plan to be one. But I reflect back to when my own parent was admitted to the ED after suffering a stroke. First, I was relieved to find out that someone I knew was on duty in the ED and glad that he had the wherewithal to evaluate my family’s angst at the situation. He sat us down told us what was going to happen and went to evaluate my Dad. After a




Research Corner

Gregory Rimmer, D.O.

The Efficacy of B-type Natriuretic Peptide (BNP) for Early Identification Of Blood Loss in Traumatic Injury Introduction In the young traumatically injured patient, current initial non-invasive identifiers of loss of intravascular blood volume such as heart rate are highly inaccurate. B-type natriuretic peptide (BNP) secretion from the myocardium has a direct linear correlation with intravascular volume status and pulmonary artery wedge pressure. Therefore, BNP was assessed as an initial marker for intravascular blood volume depletion in poly-traumatic patients. Methods A series of 14 patients between the ages of 18 and 45 admitted to a Level II trauma center who sustained polytraumatic injury resulting in persistent tachycardia were studied. Each had serial BNP levels and hemoglobin (Hgb) levels

Executive Director's Desk, continued from page 5 thorough evaluation, he returned, informed us on the resolution of some of Dad’s initial symptoms, ordered a CAT scan and talked to us about his possibility with TPA therapy. Unfortunately, he was on the borderline for the criteria for TPA and it was decided that this was not an option, but he spoke with us about rehab possibilities and the fact that as the clot cleared, and motor skills were “booted up” (for lack of a better term), time would be the best judgment for course of action. He at that time called for a specialist consultation and admitted my father. This physician took the time to assess not only the nature of the illness, its severity, but also took time and had the tact enough to tell us what was going on. He did not tell us in front of the patient or other ED patient’s families, but pulled us over to the



obtained on admission, at 8 and 24 hours, and every morning during active fluid resuscitation (greater than 3L/day).

the BL category were volume resuscitated during their hospital course the BNP returned to normal levels.

Results The 14 patients were categorized into two groups based on the change in their Hgb levels over the first 24 hours – clinically significant blood loss (BL) (Hgb drop of greater than 3 gm/dl), or no clinical blood loss (NBL) (Hgb drop of less than 3 gm/dl). The five patients in the NBL category had normal BNP levels (8 – 12 pg/dl) on admission. However, all nine patients who sustained blood loss (BL) had decreased admission BNP levels of less than 5pg/dl reflecting the loss of intravascular volume. Measuring BNP levels on admission had 100% sensitivity for detecting clinically significant blood loss. As the patients in

Conclusion BNP is an easily obtainable, noninvasive objective means of identifying blood loss and monitoring intravascular volume status in the young trauma patient.

side, gave us the facts, and offered viable treatment solutions. This physician had the ability to evaluate, diagnose and the tact needed to tell the family the status of their family member, and offer treatment guidelines. The physician in the first scenario had none of these skills. It is your duty as a physician in the ED to treat not only the whole patient, but also his or her family. You deal with emergency situations on a daily basis, the average person does not, and it is your job to evaluate the mental state of the family members too. I am not saying that it is your duty to diagnose everything perfectly, that’s why you call in consultants, but it is your job to make an effort to treat the whole family with tact and compassion. See Counterpoint to this article in the Editorial

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Gregory Rimmer, D.O., is the Second Place Winner of the Foundation for Osteopathic Emergency Medicine Resident Research Award for 2005. Dr. Rimmer is a PGY2 resident at Genesys Regional Medical Center in Grand Blanc, Michigan. Copies of Dr. Rimmer’s entire paper may be obtained by contacting Dr. Rimmer at grimmer@genesys.org.

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Editorial

Drew Koch, D.O., FACOEP, Editor

Counterpoint The Act of Knowing/The Tact of Telling My first reaction to The Act of Knowing The Tact of Telling was one of angst and disbelief. Our executive director criticized how this emergency physician practiced emergency medicine and conveyed how this patient’s care should have been managed. I sensed betrayal and admonishment from ACOEP’s executive director. I conveyed my discontent with her article in an e-mail and then we talked about me writing a repudiation of her article. I am a full-time practicing emergency medicine physician who practices in a similar environment (a community, teaching, over-crowded inner city hospital) as where the case patient presented. This patient is not dissimilar from patients who present to the emergency department where I work. This patient typifies many patients who present to the emergency department. They are elderly, have chronic medical problems, present with their families at night or on weekends, and who are currently under the care of their private physicians. They present because they have failed outpatient care; they feel their symptoms are worsening; they feel they need to be admitted to the hospital and on numerous occasions end up with a serious illness and are admitted. In a busy ED where patients might be seen in the hallway or at triage or where the patients are experiencing excruciating pain and a complete history and physical is not done; but a limited history and physical, based on their chief complaint, is performed. Ancillary tests are ordered and reviewed and pain medicine administered (if warranted); but it is not until the patient is reassessed that you recognize that you have to start the workup, again. Once the

patient is in a room, changed to a gown, and medicated you perform a complete reassessment; order, hopefully, the appropriate studies; and then make the diagnosis and disposition. This case exhibits what can go wrong when a cursory history and physical are performed. It was not until the physician took a complete history and performed the complete physical that the appropriate test was ordered and the probable etiology of the pain was elicited. The diagnosis of a pancreatic cancer was made by the physician and conveyed to the family. The physician stated to the family that the patient had a high mortality and short life expectancy from this pancreatic tumor. As emergency physicians, we are well aware of HIPAA and its constraints on practicing emergency medicine. As practicing physicians, we are aware that HIPAA has significant penal and financial penalties for violations. HIPAA makes communicating between patients and their families tenuous. EM physicians are not always aware of whom the patient designated to receive information about their health care. It is imperative that physicians communicate with the patients directly and then let the patient communicate with their families. Obviously, minor children and incapacitated adult patients need health care information available to families and/or care providers. This patient and her husband are hard of hearing but this does not negate the fact that all communication about this patient should have been relayed to the patient and not her family. The diagnosis of pancreatic cancer was made by the ED physician based on his interpretation of CAT scan. The official reading from the radiologist was a 10 cm abdominal mass. Diagnosis is still pending. Our society is litigiousness and if we fail to diagnosis, we open ourselves to a malprac-

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tice suit. Telling a patient your suspicions of the worse case scenario is prudent but attempting to predict her longevity is not appropriate. The physical layout of most ED’s that I have encountered over the years, are not conducive to patient privacy. The ED where I am employed has very few private rooms. Most rooms consist of partition walls on three sides with a curtain in the front. The rooms are adjacent to the nurse’s station and afford little privacy. Patients are shuffled between rooms and the hallways. Conversations between patients, their families, and health care providers are for the most part public knowledge. It is refreshing that Jan’s father’s ED visit and the subsequent interaction between the ED physicians, her father and her family were positive despite the severity of his illness and outcome. It does not hurt to mention that the ED physician is a member of ACOEP. Hopefully, he was not afforded special treatment because his daughter is the executive director of ACOEP and his courteous bedside manner is given to all his patients. At first glance, I could not understand what was wrong with this patient’s care in the ED and why our executive director was so fired up! As Emergency Medicine physicians, we make numerous decisions regarding the patients we encountered in the ED. The two most important decisions, I feel, we make about each patient are: does this patient require emergent intervention; does this patient need admission. Clearly, this patient had a life threatening emergency ruled out by CAT scan, a dissecting abdominal aneurysm, and was subsequently admitted to the hospital. So, what is wrong with this case and why was this family so upset? The family was initially upset because the ED physician originally wanted to send the patient home. It was not until




Report of ACOEP Representation at the 2006 AOA Board of Trustees Mid-Term Meeting Representatives: Paula Dejesus Willoughby, DO, President Peter A. Bell, DO, President-Elect (reporting) Janice Wachtler, Executive Director The AOA Board of Trustees MidTerm meeting was held in St Petersburg, Florida February 20th-22nd. Formal written reports were supplemented by the various AOA committees and departments. Of particular interest to ACOEP Members were the approval of a revision in the basic training standards for emergency medicine, which increased the number of patient visits at hospitals applying for new programs from 20,000 Emergency Department visits annually to 25,000 at the base institution and any rotation sites providing additional training to the emergency medicine residents. Existing programs are encouraged to increase their annual visits, but are not effected by this increase. Also approved was a new document that revised the exist-

ing evaluation workbook for evaluations of programs. This document makes the document more objective as deficiencies are ranked and evaluation decisions are based on a point-value scale. This meeting also evaluated various templates for awarding specialty CME to osteopathic physicians. As you may recall, this issue was featured in an October 2005 article, written by Jan Wachtler, titled, the CME Conundrum. The AOA declared a moratorium on the awarding osteopathic category 1A CME (specialty CME) until such time as the various specialty boards and colleges submitted a template to instruct the AOA as to what programs would be recognized. Due to the widespread and varied applications expressed

by the various specialty organizations, the AOA deferred/referred this issue back to the AOA Division of CME and the Bureau of Osteopathic Specialists to work out a template for approval. This is currently being evaluated by the Department of Education at the AOA and we should be hearing about a solution to the problem shortly. Other issues were amendments to the AOA Budget for the FY 2005-06 that adjusted the budget by nearly $200,000 for additional spending; the approval of various educational documents from other specialty areas, and the approval of several changes in governing documents of specialty and state organizations.

Counterpoint, continued from page 7

want ED patient flow to improve. They have hired through-put-mangers whose primary focus is to decrease patient’s waiting time not only to be seen but also to decrease patient time in the ED to admission or discharge. The ED physicians are being pushed to move patients out of the ED; so more patients can be seen. Finally, the billing companies want every patient to be a Level 5 and to bill for as much critical care time, as possible. Theoretically, these opposing factors, along with the overcrowding, hinder the amount of time we spend with patients and potentially could lead to a decrease in the quality of patient care. The patient is no longer the focus of the care but is part of the process. This case illustrates that technically what this physician did was correct; he evaluated the patient, found the cause of her pain, and had her admitted. However, he failed to adequately communicate with the patient and express his suspicions of the etiology of her pain in a manner that

was not offensive to the patient and her family. Sometimes, patients and their families have certain expectations of what should occur in the ED and these expectations do not always coincide with what emergency medicine entails. This case, hopefully, teaches us, that when we encounter patients who have a disease with a potential bad outcome and possible poor life expectancy, that we communicate our finding to the patient as privately as possible and in a non-obtrusive manner. As ED physicians, we are pulled in many directions by the patient, their families, the hospital administration, the billing companies, etc. We must not only treat patients, but also communicate to them in a caring and sensitive manner that is not offensive. Editor’s Note: The patient succumbed to complications from her Non-Hodgkin’s Lymphoma one month after her visit to the ED. Our sympathies go out to her family and friends.

the patient was reassessed and had the CAT scan that showed the abdominal mass that the patient was admitted. It also appears the ED physician did not address the patient’s pain and provide any pain management. Finally, the patient’s family was upset with the physician’s bedside manner and communication skills. They were upset with him being so forward with his diagnosis and his prediction of her short life expectancy. As we are all practicing ED physicians, we are well aware that is not so simple as to see a patient and make a diagnosis and disposition. There are opposing forces that hinder our decision-making capacity and put us at odds with not only the patients and their families but also the hospital administration, billing companies and quality of patient care. HIPAA limits our interaction with patient’s families and makes patient discussion with family members almost impossible. Hospital administrators



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Membership Aspects

Donna Verga, Membership Coordinator

ACOEP Mentor Program – The Relaunch “Mentoring is a brain to pick, an ear to listen, and a push in the right direction.” – John Crosby, Executive Director, AOA The benefits of establishing and maintaining a strong mentoring program are immeasurable. The value of mentors for guidance and strength in personal endeavors and professional steps is losing the support it once had. ACOEP hopes to reenergize and rejuvenate the strength of its mentoring program and rebuild a mentoring culture to ensure our next generation of emergency physicians has the guidance they need when entering the field. An ACOEP mentor is defined as an active partner, in an ongoing relationship, who provides support and guidance to a mentee allowing them the chance to better grasp and assess the challenges involved in the osteopathic specialty of emergency medicine. Mentoring, therefore, is a personal enhancement strategy through which one member volunteers their time, energy, and experience to facilitate the development of another member. Through this process, the exchange of resources, expertise, values, skills, perspective, attitudes, and proficiencies combined with the spirit and camaraderie of the specialty are exchanged. The process of learning is built on the identification of an uncertain area and the development of additional required skills and knowledge leading to new confidence in the area. This is a track that is repeated thousands of times in your professional careers. Being a part of the growing mentor program ensures new incoming physicians are prepared for this vital continuance of self-expansion and development. It is obvious how the mentee benefits from this relationship, although a successful developed relationship benefits the mentor and ACOEP as well. This is an exceptional opportunity for you as member to get involved and personally enhance your contribution to the future of the specialty. Along with a feeling of personal fulfillment

from your investment, you may also discover an increased awareness of areas for your own self-improvement. ACOEP encourages the mentoring environment that fosters personal and professional growth of its future. We hope to share your pride when your mentee switches roles and become a mentor to the next professional generation. How does the ACOEP Mentor Program work? A student requests a mentor by completing the Find a Mentor application located at www.ACOEP.org/mentor.htm. A geographic look-up is completed from the list of mentor volunteers. From those closest volunteers, their expectations for the relationship are compared and one is chosen. The mentor is then contacted to ensure they are still able and willing to take on a mentee. The mentee receives notification that a

mentor match has been made and that they will be contacted. It is the responsibility of the mentor to make the initial contact. Both the mentor and the mentee are provided with a guide to help them take the first steps in establish a successful relationship. A follow-up survey is also conducted with the two participants to track their progress and achievements. The ACOEP Mentor Program only provides students the connection to an available mentor. As the program grows in size and experience, the opportunity may be extended to resident members. Do you have what it takes to be an effective mentor? Listed below are some effective and ineffective characteristics of a mentor. Evaluate yourself to determine your readiness to be a mentor.

2006 Neonatal Resuscitation Program Research Grant and Young Investigator Award Call for Applications The American Academy of Pediatrics (AAP) Neonatal Resuscitation Program (NRP) Steering Committee and the Section on Perinatal Pediatrics are pleased to announce the availability of the 2005 Neonatal Resuscitation Program Research Grant and the NRP Young Investigator Award. The awards are designed to support basic science, clinical, or epidemiological research pertaining to the broad area of neonatal resuscitation. Physicians-in-training or individuals within four years of completing fellowship training are eligible to apply for up to $10,000 through the NRP Young Investigator Award. Any health care professional with an interest in neonatal resuscitation can submit a proposal for up to $25,000 through the NRP Research Grant Program. Researchers from Canadian and US institutions are invited to apply. Potential applicants should submit an intent for application to the NRP Steering Committee by Friday, May 5, 2006. All intents will be reviewed and the committee will ask a select group to submit full proposals. Those selected to submit a full proposal will receive the formal application by Friday, June 30, 2006. Completed applications will be due on Friday, September 1, 2006. To obtain the NRP Research Grant or NRP Young Investigator Award Program Guidelines and the Intent for Application, please contact: American Academy of Pediatrics, Division of Life Support Programs, 800/433-9016. Ext. 4798. Or go to www.aap.org/nrp and select the science tab

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COURT VICTORY FOR CALIFORNIA EMERGENCY MEDICINE PHYSICIANS In a major victory for emergency medicine (EM) physicians in California, the Second Appellate District, California Court of Appeal issued an opinion on February 17, 2006 in Prospect Medical Group v. Northridge Medical Group holding that physicians providing emergency services are not prohibited from "balance billing" patients for fees not paid for by a health plan or its contracting independent practice association (IPA). The California Medical Association (CMA) submitted an amicus brief, and the court's opinion was in complete agreement on the points raised by CMA. The court's decision addressed the three following issues: • Whether a California law prohibits non-contracted Emergency Medicine physicians from balance billing individual

ACOEP Mentor Program, continued from page 9 Effective Characteristics • You are able to spot the potential and believe in others. Displaying a positive view greatly increases how much learning you will pass on. • You are held in high regard by your peers and have a network of others you can turn to You may need to rely on this network for information and additional resources. • Display patience and tolerance by understanding mistakes and using them as learning opportunities • You are good at giving encouragement and effectively expressing feedback. You’ll need to be able to build the mentee’s self-esteem and encourage them even if your feedback involves a weakness or area to develop. • The ability to have a larger perspective to bring up points or topics beyond what normally is included. Ineffective Characteristics • Being busy shouldn’t deter you from

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patients for the balance of the physician's fee not paid by a patient's health plan or delegate? The court found that the California law does not prohibit balance billing by non-contracted EM physicians because the law assumes the existence of a voluntarily negotiated contract. • Whether EM physicians must accept the Medicare rate as full reimbursement from a health plan? The IPA asked for a judicial declaration imposing the Medicare rate as the "reasonable rate" for out-ofnetwork EM physicians. The court denied the request, noting that the IPA provided no legal authority for this position. It also noted that California regulations include a six-part test to determine reimbursement for out-of-network physicians, which makes it clear that adopting Medicare, as an across-the-board rate is inappropriate.

• Whether health plans may litigate the reasonableness of the amount charged by Emergency Medicine physicians? The court held that the IPA might litigate whether the rates charged by the physicians were reasonable. The court held that payers and physicians both have a right to contest whether an ER physician's out-of-network charge or a health plan's out of network payment for those services is reasonable. CMA is expecting the IPA to appeal. This is a major victory for CMA with national repercussions. Congratulations to CMA! Information on this court decision may be obtained by contacting the AOA’s Washington Office at 800-962-9008

becoming a mentor, but being too busy will kill the relationship. If you are forgetful, don’t have time to return phone calls, are inundated with scheduled items, and wish you had a moment to breathe; you are probably too busy to be a mentor. • If you are criticizing and can always find something wrong. A mentor’s position is not to only point out mistakes. • You do not keep pace with the times and feel you are unaware of some of the current trends and advances available in the field of emergency medicine. Mentees are in pace with what is current and their mentor should be one step ahead. • If you believe a mentee is not capable of driving the relationship.

osteopathic specialty of emergency medicine. With the growth of awareness of the program within the student, we are low on available mentors and have a limited diversity across the country. To effectively cultivate these students, we need more available members to volunteer.

Mentor recruitment. Currently, 44 Active ACOEP members have volunteered to be “on-call” as mentors when a request is made. These volunteers have agreed they are able to commit the personal resources to an individual mentoring relationship. There are an increasingly high number of students interested in the

The mentor application is available at www.ACOEP.org/mentor.htm. Send all questions to donnaverga@acoep.org.

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Your contribution in a mentoring relationship means identifying and encouraging growth with the mentee’s development goals at the center of you activities. However, the benefits of these relationships reflect on you as the mentor and the community of professionals ACOEP is comprised of.


AstraZeneca

is pleased to support the

American College of Osteopathic Emergency Physicians AstraZeneca is one of the world’s leading healthcare companies, providing innovative, effective medicines for serious medical conditions. Skilled research is at the heart of our continuing success and we spend more than $2.7 billion each year on the discovery and development of new and improved medicines. Our track record of innovation includes leading treatments for gastrointestinal disorders, heart disease, cancer, central nervous system (CNS) disorders, respiratory diseases and pain and infection. With US headquarters based in Wilmington, Delaware, we are committed to maintaining a flow of new products around the world which protect and improve human health and quality of life.

www.astrazeneca-us.com Š 2002 AstraZeneca Pharmaceuticals LP

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research and development organization With 100 years of combined experience, scientists at AstraZeneca have discovered and developed several of today’s leading prescription medicines—pharmaceuticals that contribute to a higher quality of life for millions of patients and to a better health economy worldwide. Based in Sweden, AstraZeneca’s R&D organization is international in scope and comprised of approximately 10,000 researchers. Through its own resources and through collaboration with dozens of universities and strategic alliances with numerous research and biotechnology companies, AstraZeneca has broad access to advanced technologies in biomedical research, including genomics, bio informatics, chemical libraries, high throughput screening and product delivery systems.

leading with products

AstraZeneca’s success ratio of bringing new

Priority research is being conducted for the

products to market is among the best in the

development of treatments for high cholesterol,

pharmaceutical industry. The company

blood clot formation, lung cancer and other

produces a wide range of products that make

types of cancer.

significant contributions to treatment options and patient care.

With an R&D pipeline that has been recognized as the best in the industry, the company is well

AstraZeneca has one of the world’s leading

equipped to maintain a flow of high quality

portfolios to treat cancer and gastrointestinal

medicines over the coming years. These

disorders, in addition to the areas of anesthesia

medicines will offer improved health and quality

(including pain management), cardiovascular

of life for patients, better health economics for

disease, respiratory and central nervous system

society and attractive growth for AstraZeneca.

disorders.

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AstraZeneca is a major international research

AstraZeneca operates nine different R&D sites

based pharmaceutical company engaged in the

and has sales activities in over 100 countries

development, manufacture and marketing of

and manufacturing facilities in 19 countries.

ethical (prescription) pharmaceutical products. Our

The Company has a workforce of more than

long heritage of innovation and documented ability

50,000 strong—with over 10,000 employees in the

to develop new concepts in medicine has made us

U.S. alone.

one of the top five pharmaceutical companies in the world. AstraZeneca PLC is headquartered in London with its U.S. headquarters located in Wilmington, Delaware. Wilmington is also the global home for the company’s Central Nervous System (CNS) commercial and research and development efforts.

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leading in the community and the workplace patient assistance program AstraZeneca is acutely aware of the growing costs of healthcare in the United States. The AstraZeneca Foundation Patient Assistance Program (PAP) (formerly the Zeneca Pharmaceuticals Foundation Patient Assistance Program), which has been in existence since 1978, and the

In addition to its products and research and development efforts, AstraZeneca provides health education information, support services and health guidance to millions of Americans through public awareness campaigns including: • National Breast Cancer Awareness Month • Prostate Cancer Awareness Month • Capitol Hill Briefing Program with Asthma and Allergy Foundation of America (AAFA) • National Alliance for the Mentally Ill (NAMI) Helpline Online

AstraZeneca LP Patient Assistance

• NAMI’s Campaign to End Discrimination

Program provide AstraZeneca products

• Migraine Mentors Program with the

free of charge to patients who cannot afford them and who do not have insurance or other programs that can provide the product. Currently there are more than 250,000 patients enrolled in these programs. Over the past year, AstraZeneca donated medicines valued at over $250 million to indigent patients across the United States and Puerto Rico.

National Headache Foundation • Clinical Outcomes Research Initiative (CORI) with the American Society for Gastrointestinal Endoscopy • Nationwide Asthma Screening Program with the American College of Allergy, Asthma and Immunology (ACAAI) • Human Medicine Symposium Series with the Minority Health Institute While AstraZeneca is committed to educating the public, the business’s commitment to its own employees is equally important. AstraZeneca offers onsite breast, prostate, colorectal and skin cancer screenings as well as preventive health programs for employees in all of our therapeutic areas.

www.astrazeneca-us.com © 2002 AstraZeneca Pharmaceuticals LP

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Guest Column

Michael Oster, D.O., FACOEP

Do we always have to use technology and ability? In the past few years, I have experienced some personal moral dilemmas. One involved my wife’s grandmother: she was a 95-year-old farmwoman with previously fair health. She lived with her son and was becoming more and more disabled by arthritis and cataracts. We made plans to go visit her for her birthday. The day before we left to visit her, she suffered a stroke that left her hemi paretic and aphasic with dysphagia. She simply took an aspirin, and within two hours, she was able to speak and take nourishment. However, it was obvious after her stroke that she was not well and didn’t feel like herself. Her son, two of her three daughters, a son-inlaw, two of her grandchildren, and two of her great-grandchildren who were visiting were knowledgeable about medicine and hospitals. She and her family requested no medical intervention. She wanted to sit in the living room, because “dad” had been ill for months and passed in the dining room. She watched TV, listened to her favorite radio shows, and reviewed pictures of her children and grandchildren on digital media and paper pictures interspersed with an occasional nap. We stayed all day and told her we would return in a few days. As I left, she admonished me in that I had verbally said goodbye to her, but did not give her a hug. I hugged her thankful that she was feeling better enough to give me a hard time. When we returned, a visiting nurse was there to evaluate her and let her and her children know what services she could receive. She had been sleeping all week in a lazy boy chair. She appeared to be succumbing to chronic renal failure by the way she looked. Her middle child daughter was going out to drive to the pharmacy. At this time, grandma started having some Cheyne-Stokes respirations. I rushed out

to get the daughter and son-in-law and brought them back in. We gathered around her, reminding her that we loved her. Within 5 minutes, she was gone. I explained to my daughter, then an OMS-1 that she probably had learned more in those two days without medical tests, a stethoscope, or 21st century technology than she would learn in many of her rotations. Another event occurred this year with my own mother. She is 85 and her health is also deteriorating. She was moved from Florida to be near help from her family. She has only been hospitalized once in the past 3 years as opposed to 6 times in one year while in Florida. I believe this is partly due to closer monitoring and communication with colleagues. She was found to have atrial fibrillation with rapid response and replaced on warfarin for TIA/ CVA prophylaxis. Three of the hospitalizations in Florida were from “overdose” of warfarin from polypharmacy and altered mental status from prescribing benzodiazepines, muscle relaxants, and antibiotics that interact with warfarin. After a brief

hiatus from anticoagulation, she developed a vasculitis type rash on the reinstitution of the warfarin. When she developed some pauses in her rhythm, her doctors suggested that she needed a pacemaker. I brought up a point that none of the internists or cardiologists had seemed to consider. I asked, “Isn’t it most people’s wish to die in their sleep? If you give my mother a pacemaker, aren’t you simultaneously removing that option?” They thought about this and asked if we wanted to proceed. We decided not to intervene with the warfarin or pacemaker. With elderly, in my opinion, less is more. We should consider philosophical reasons for our medical arts. I am not saying that placing my mother on warfarin or placing a pacemaker is not medically correct. But, is every medical intervention always a philosophically and morally correct action to take? Send your comments to: moster244@msn.com

Avis, Always Providing New Ways To Save You Time and Money. Your membership in the Avis Association Program entitles you to a host of special Avis services and discounts that can save you lots of time and money. What’s more, you’re eligible for savings up to 10% off Avis Association Select rates and 5% off promotional rates at all participating locations. Shop around. You’ll find Avis has very competitive rates. And with the Avis Wizard System, you can receive our best available rate when you mention your ACOEP / Avis Worldwide Discount (AWD) number: T024500 Isn’t it a relief to know that Avis moves just as fast as you do? For more information and reservations, call 1-800-331-1212. And remember to mention your ACOEP / Avis Worldwide Discount (AWD) number: T024500

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Sav

e th

e Da

te!!

Third Annual Robert D. Aranosian, D.O. Trauma Symposium Tuesday, May 16, 2006 Marriott Centerpointe, Pontiac, MI redits CEU C es s for Nur ics med & Para CME icians s y h P r fo

"The Special Patient" TOPICS:

- Mechanism of Injury - Pain Management - Volume Resuscitation - Hands-On Trauma Experiences

Registration Fee: (1 Day Course) $50/day Oakland County EMS Providers $50/day POH Staff $75/day Non-Oakland County EMS Providers $75/day Non-POH Healthcare Providers

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Registration Deadline: May 1, 2006 50% Refund for cancellations before May 5, 2006 No Refunds after May 5, 2006 For more information, contact: Denise DeLisle e-mail: denise.delisle@pohmedical.org Office: (248) 338-5327

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Domestic Preparedness

William Bograkos, D.O., FACOEP, Col, USA The “1st Interpol Global Conference on Preventing Bioterrorism” took place on 1 and 2 March 2005 in Lyon, France. More than 500 delegates attended from 155 countries. It was the largest meeting of police ever (in terms of countries participating).1 Under the leadership of Ronald K. Noble, Secretary General of Interpol, Law Enforcement professionals, scientists, clinicians, researchers, planners, and other global citizens came together to communicate, cooperate, and collaborate in the face of global terrorism and the threat of “deliberate epidemics.”2 In an “Outbreak Scenario,” it is essential to contain and control the Public Health Crisis3 and this will require cooperation and strengthening of bridges between cultures and disciplines such as Law Enforcement and Health. During a Public Health Emergency of International Concern4, clear coordinated communication between Interpol and World Health Organization (WHO) will be essential. This is the basis of a Unified Command Structure. Communication, coordination, commands, and control is the essence of the Operational Plan. Common language is also the essence of any Operational Plan. This is quite a challenge for our global community. The Interpol initiative brought cultures together from both the Health and Law Enforcement communities. There were opportunities to discuss anti-terrorism (hardening of targets) and counter-terrorism (prevent, deter, respond). Most presentations are posted on the Interpol website www.interpol.int As a member of the World Association for Disaster and Emergency Medicine (WADEM) let me take this opportunity to share a few “lessons learned” from the conference. Lets begin with using ” common language.” Health uses the term surveillance as the “ongoing systematic collection, analysis, and interpretation of data in order to plan, implement and evaluate public health interventions.” 5 This is medical intelligence. As Health professionals, we think of active and passive surveillance. To address the “prevent” in Bioterrorism we need to collaborate, coordinate, and communicate on relevant topics

through BT Fusion Centers. It is through fusion that analysis and interpretation of significant data or information takes place and becomes valuable. Health has a valuable role in fusion centers designed for the purpose of analyzing, linking, and disseminating (BT) intelligence. This not only has great implications for deliberate epidemics and training but also addresses the medical threat to all of those who serve and protect our citizens. This also sets the foundation for GIS. Geographic Information Systems should be tied to Public Health Epidemiology. Law Enforcement seems to do a much better job utilizing GIS with “violent crimes,” than local and regional Public Health does with communicable disease. I realize medical information and intelligence reflects on social stability but if we view “Outbreak” like a forest fire, and each infected or contagious patient as a flame, utilizing GIS in the Emergency Operational Center brings Emergency Management, Law Enforcement and Health together to contain and control the epidemic as it burns across geographic boundaries. In addressing “deter” in Bioterrorism rather than focus on grams of “agent,” I feel and stated that it is important for Law to address the concept of BioCrimes. We all realize that there is more money in moving people (Human Trafficking) than moving “dope” (drugs). Every global physician knows this as does every Law Enforcement Officer. We also know that current attention is on explosives, nuclear/radiation dispersal devices, and chemical hazards crossing borders and boarding transportation. IHR outlines that events detected by national surveillance system such as “a case of the following diseases: Smallpox, Influenza with pandemic potential”, and “an event involving the following diseases shall always lead to utilization of the (IHR) algorithm, because they have demonstrated the ability to cause serious public health impact and to spread internationally: Pneumonic plague, Cholera, VHF (Ebola, Lassa, Marburg)”. These contagious diseases shall be notified to WHO under the International Health Regulations.

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I am not a lawyer, however, I am a physician who believes that Human Trafficking is a crime against humanity as is narco-trafficking. Both may constitute Public Health concerns and cause a serious public health impact. When we focus on grams of “Bio Agents,” we have a different vision. When we strengthen the bridges and foundations of Law Enforcement / Health Cooperation we see and act more clearly. By discussing BioCrimes as criminal activity that poses serious Public Health threat Law Enforcement Officers can respond at many different levels within their agencies and cooperate with appropriate Health professionals. This cooperation begins locally but extends globally just as the medical threat extends globally. When I use the term “Health” I refer to clinicians, researchers, teachers in the field of agriculture as well as animal and human health. The illegal movement of people and goods that pose a threat to Public Health deserves greater attention of government leadership. Discussion of BioCrimes should continue with discussions of Bio Warfare, Asymmetrical Warfare, and Bioterrorism. 1 www.interpol.int/Public/BioTerrorism/ Conferences/Final Communique.asp 2 WHO preparedness for Deliberate Epidemics www.who.int/csr/delibepidemics/en/ 3 A situation where there is a (actual/potential) risk of a major exposure to a usual serious health hazard for a community (for which is perceived as such). Rather than an acute disproportion between these and resources, a public health crisis is characterized by: inadequate information: scientific uncertainty, and/ or public worry about causes, character, or dimensions of a usual health problem. (Source WADEM, Education Committee Working Group, 30th July 2004) 4 IHR 2005 defines it as an extraordinary event, which is determined by the IHR 2005 to constitute a public health risk to other Nations through the international spread of disease, and potentially require a coordinated international response www.who.int/gb/ebwha/pdf_files/ WHA58/58_55-en.pdf 5 Source: Communicable Disease Control in Emergencies- A Field Manual, WHO 6 http://wadem.medicine.wisc.edu/

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Emergency Department Ethics

Bernard Heilicser, D.O., MS, FACEP, FACOEP

Ethics in Emergency Medicine: What Would You Do? In this issue of The Pulse we will review the case of the 50 year-old female who was brought to the Emergency Department for evaluation of severe dog bites, was determined to lack decision-making capacity and was admitted to the hospital, and soon after was allowed to sign out AMA, but then was returned to the ED by Security. This case was presented in Volume XXXI, January 2006. This patient was attacked by a pit bull and sustained severe extremity lacerations. She is a non-insulin dependent diabetic and refused inpatient IV antibiotics after initially agreeing to admission. She could not remember the risks of being discharged even though just described to her. Because of questionable decision-making capacity she was coercively admitted. Within 20 minutes of leaving the ED for the medical floor, she was found leaving the hospital by Security, and for some reason brought back to the ED. The patient had told the floor nurse she wanted to go home and was allowed to sign out AMA. It appears the floor nurse did not question the safety of this action or its consequences. We contacted the admitting physician who stated he had been led to believe by the floor nurse that the patient fully understood the risks. What would you do? This case presented a rather perplexing situation. The patient had already been formally discharged from the hospital. Should she be forcibly readmitted for her own safety? Would we even have a right to do this? We again spoke at length with the patient, again explaining the risks of infection, especially compounded by her diabetes. The patient had had a breath alcohol of 0.083. The patient continued to have intermittent acceptance of admission followed by stating she was going home. At no time could/would she acknowledge the risks of her condition, nor would she

18

give a rationale for this. We did learn, however, that her initial ED nurse had been somewhat condescending towards the patient and this had upset her. The patient’s body language was passive and she was not making any aggressive attempt to leave. A different nurse was assigned, and after only brief conversation, our patient calmly agreed to be readmitted. We will never know if a more compassionate individual soothed the initial conflict, or our patient simply gave up after all our badgering. Nevertheless,

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the situation had a favorable outcome. But, what if? I would suggest that if a patient or other is in our house (ED) and has a significant condition threatening life or limb, and that person lacks decision-making capacity for refusing appropriate treatment, then we must be an advocate on their behalf. If you have any cases in your practice that you would like to present or have reviewed in The Pulse, please Fax them to us at 708-915-2743. Thank you.


Guest Column

Wayne Jones, D.O., FACOEP

The Dwindles As part of my job at Saint Vincent Medical Center in Erie, Pennsylvania, I investigate and respond to complaints originating in the Emergency Department. Most of the time, it involves patient-physician interaction; and most of the time, it involves the same physicians. The latest complaint was fairly benign but still needed to be handled. A family was upset because the physician told them that their wife, mother, and grandmother (87 years old) had the “dwindles.” The daughter was a nurse and had never heard of anything so ridiculous. Instead of admitting and treating this condition (as the family expected), the patient was sent home. The family called the hospital CEO (yes, the same person who keeps a watchful eye over hospital utilization) and instantly she was admitted with an apology and a complaint referral to me. Yes, thanks to the CEO, my job was now made easy; explain myself, and my physician’s language (which must be flawed, since the CEO of my own hospital felt it was wrong). Now I must admit, I have used the slang term “dwindles” in the past. Not usually in front of patients and their families, but to other physicians. Even though many physicians did not know what I was saying, I did. It’s that patient that has nothing clinically wrong but has, well, the dwindles. I polled my colleagues in the ED and found all of them had heard the term. So now, onto the family. On my way to the floor I stopped by the library and did a Google search for “the dwindles” (hey, it’s what the patient reads). I found links to dwindling ice caps, churches dwindling, patient ID information system hopes dwindling, revenue dwindling, interest dwindling, dwindling Sumatran tigers and even Netscape was dwindling; but no patient dwindling. Finally, I did the noble thing and turned to Pub Med, and there it was, The dwindles: failure to thrive in older patients. Nutrition Review, 1996 January; 54(1Pt 2): S25-30. Turns out it was in the literature. Wow.

I found my way to the patient’s room only to discover the entire family quietly standing around the bed. There laid a tiny, cachectic woman, nonverbal, motionless with the exception of breathing, not interacting with anyone in the room. The family lamented that she had not eaten since arriving in her hospital room yesterday. She suffered a condition I had seen numerous times in my career. A debilitating disease that was mostly incurable. My consult had ended, this woman clearly had “the dwindles.” I listened and apologized, as would any good steward of a health center. “We don’t want her to dwindle,” said the family, “we want her to be normal again.” It was their loss they felt, not hers. Using a term traditionally reserved for infants, failure to thrive (FTT) evolved to be an adult diagnosis. The dwindles then became defined as a constellation of failure to thrive symptoms in the older adult. Usually, the literature will sight three elements: (1) deterioration in the biologic, psychologic, and social domains; (2) weight loss and under nutrition and (3) lack of any obvious explanation for the condition. As early as 1971, a physician studying the population of Glasgow, noted that a high proportion of all deaths in old age were preceded by a period of “pre-death” where, it was felt, the person had outlived “the vigor of their bodies and the wisdom of their minds.” Since this paper, numerous other studies have looked at the diagnosis and have attempted to identify a single causative factor to treat. The symptom complex, though, was inconsistently described and did not conform to any accepted model of disease such as diabetes or gastrointestinal bleeding. Was it truly a single entity or, as described, a constellation of numerous illnesses and end of life syndromes? Was it a meaningful diagnosis or should it be abandoned due to its heterogeneity? Withstanding these arguments it was granted an ICD-9 code in 1979. In 1991, the National Institute on Aging took a final stance and described FTT as a

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syndrome of weight loss, decreased appetite, poor nutrition, inactivity, dehydration, depressive symptoms, impaired immune function, and low cholesterol (I think that should cover it). It has been suggested, in recent literature, that the term should be abandoned. The stigmatizing label distracts clinicians from a systemic evaluation of interacting deficits. In a retrospective study involving 132 veterans from a Veterans Affairs Medical Center in Portland, Oregon, age 65 years and older (a mean of 76 years, 98% male) admitted with a diagnosis of FTT, the following characteristics were found: 83% were admitted from home; 82% were dependent in at least one ADL; 36% were cognitively impaired; 30% had a diagnosis of cancer; 18% had underlying infection; 13% had dehydration; and 12% had depression. At discharge, only 46% were discharged home while 34% went to nursing homes. Fourteen percent died during hospitalization; 11% died within 30 days of discharge; and an additional 32% died within 1 year of discharge (a total of 57% mortality at one year). The patients with a diagnosis of cancer and/or infection saw the greatest mortality rate. The study also found a large degree of subjective variation in how physicians applied the term FTT, due to the absence in consensus over diagnostic criteria. The key to treatment is invariably the same, early recognition of any precipitating factors and intervention, early enough to stop the progression. Whether the disease is identified as single or multifactorial, the diagnosis carries a high mortality and poor end of life alternatives. Yes, our patient had the dwindles, but maybe we should have told the family she had outlived ‘the vigor of her body and the wisdom of her mind’.

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Governmental Affairs Raul Garcia, D.O., FACOEP

Calling for all of our members to be a part of our future Most of us sit in our respective Emergency Departments questioning how to solve the overcrowding problems or how we can change the way Healthcare is today. The truth is that there are many ways to go about making a difference. One of them is coming to Washington D.C., on April 27 to join our colleagues at DO Day on the Hill. DO Day on the Hill is a day when the profession comes together and meets Congress to express our views and interests. For all those of you that have never been at DO Day on the Hill, this should be your first experience. ACOEP is the fastest growing college in the osteopathic profession and there is no reason to not make it known for its legislative involvement in our profession. For one day a year, DOs come to Washington to sit with our Congressmen and Senators and explain our views and beliefs. There is a lot to discuss and our profession needs as many of us to show up and show a united push for better healthcare. Today we enjoy a freeze on Medicare cuts largely in part to the effort of our Council on Federal Health Programs and the support of many DOs that fought to keep our Medicare reimbursement from being cut. Today we have tougher challenges ahead such as resolving the formula for physician reimbursement in the future, professional liability reform, volunteer faculty, student loans, and more. Whether you are a student, a resident, a physician that just started practice, or one that has practiced for many years, you are welcomed in DC. Our government affairs committee will meet there on Wednesday evening the 26th. You are all welcomed to participate in our meeting. Come and make ACOEP the most involved college in governmental affairs. Legislative Update Medical Liability Reform The White House has made a Medical Liability Reform a priority for its Health

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Care Agenda. President Bush has placed the issue at the top of his domestic agenda. The House of Representative passed HR 5 (Help, Efficient, Accessible, Low Cost, Timely, Healthcare Act of 2005) last July 28th making it the fourth time that it votes favorably for Medical Liability Reform. Unfortunately the Senate has yet to develop a bipartisan compromise and bring a bill to a vote. There is hope that with pressure from the White House, the House, and us, the Senate can reach a vote on the floor this spring. Medicare Physician Payments Reform of the Medicare physician payment formula, specifically, the repeal of the sustainable growth rebate formula, is one of the AOA’s top legislative priorities. The formula is unpredictable, inequitable, and fails to account for physician practice costs. Physicians are the only Medicare providers that are subjected to the flawed SGR formula. We must stop any further cuts and replace the SGR formula with one that lets Medicare beneficiaries access to physician services.

Trauma Centers The Trauma Care program that provides grants to support the development and improvement of trauma care centers suffered a $3.4 million dollar cut. Senator Frist introduced a bill (S.265) that will bring funding back to trauma development. Emergency Medical Services for Children (EMSC) EMSC is a federal program directed to develop emergency equipment and training for use on children. The program actually gained one million dollars to bring it to twenty million for the fiscal year 2006. National Health Service Corps (NHSC) NHSC awards scholarships and loan repayment awards to doctors in exchange for a placement n areas with a shortage of health providers. The program was cut by $4 million dollars for the fiscal year 2006.

Membership Meeting Notification Thomas A. Brabson, D.O., FACOEP, Secretary of the American College of Osteopathic Emergency Physicians invites all members of the College to attend its Spring Membership Meeting on Friday, April 21, 2006 at the Wigwam Resort and Spa in Litchfield Park, Arizona. The meeting will convene at 12:30 p.m. and should adjourn at 1:30 p.m. Activities of the College Board of Directors and Committees will be reported. At this meeting, members will be provided with the opportunity to interact in question and answer sessions with the Board to determine future direction of the College.

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Frequently Asked Questions Katie Cavaretta ACOEP Meetings Coordinator

This is a new feature article that will appear periodically to address questions frequently asked of the ACOEP. Each article will address specific areas like membership, aspects of meeting planning, board activities and so forth. The first of these articles address several areas of specific meetings that we have gleaned from feedback provided to us by meeting participants at various meetings. Please feel free to provide us with other questions that we can address in future articles. You may contact us at the addresses provided at the end of this article.

1. Why don’t you serve us lunch daily at the Intense Review? Each year, participants at the Intense Review ask why we do not serve lunch. The reason is economics, as you will see. In 2006, the course was held at the Westin River North. A box lunch, which happens to be the most inexpensive lunch they offer, is $31.00 per person. This includes a sandwich, bag of chips, pasta salad, cookie, and appropriate condiments. After you add in gratuity (20%) and Illinois sales tax (10.94%) and Chicago sales tax (3%) – all of which are standard for any hotel in any location – each participant box lunch is over $50 per day. To cover ACOEP’s cost, each registration fee would need to be increased by at least $200 just for the addition of a sandwich each day! We would rather you had a chance to leave the hotel, stretch your legs a bit and have a break from those long lecture sessions. 2. Why is the Intense Review in Chicago in January? This is a simple one. The first year, 1994, it was held in Scottsdale, after the morning sessions of the Spring Seminar. Being such a long day, not many people lasted until the evening hours in lecture. Most made it out to the pool or the golf course. In 1995, the decision was made to make Intense Review an independent course in Chicago in January relieving participants of the temptation to leave and go golfing or sunbathing. This way, they are getting a full board review course for 40 hours. 3. What about the continental breakfast? I’m so sick of muffins and bagels everyday! To keep your registration fees as low as possible, we work on a moderate food and beverage budget. As in question one;

there are many add-ons to hotel food and beverage costs and our normal breakfasts average between $20 - $30 per person plus taxes and gratuities, so the costs escalate to per person costs accordingly. To maintain the Board of Directors and the Committee on Continuing Medical Education commitment to provide low cost CME with high educational value, we are always trying to work with the hotel to find menus that will allow us to have variety within our budget. 4. Why do we keep going back to Arizona? How do you pick hotels and locations? Course locations are selected based upon the results of your membership surveys. Specifically, Spring Seminar has been held in the Arizona area for 16 years. In 2003, 79% of members stated that they wanted to be at resort locations and 67% desiring to be in a warm weather destination. Once the Spring Seminar was held in Scottsdale, nobody ever wanted to leave! We are currently looking at new sites in Scottsdale, New Mexico, Tucson, Florida, and California. We hope to develop a rotation to meet the needs of everyone. Also, because of the size of our group, arrangements are generally made 3 to 4 years in advance, so your input to the 2006 survey will be incorporated after 2008. A hotel is selected for several reasons. First, the hotel size has to be comparable to our group. If it’s too big, we get lost in the shuffle; too small, there is often not enough staff to service our needs. If the meeting space is not conducive to learning, we must look at other options. When inspecting a property, the meeting space is the most important item on our “checklist,” because it is the most important aspect to our continuing medical education meetings.

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Second, the property needs to be close to an international airport for easy accessibility. Your time is valuable, and it certainly helps to have only one flight to your destination. The ACOEP Staff also must consider room rates, food and beverage costs, as well as audio-visual costs. A good majority of the membership has expressed their desire to return to Scottsdale. The College has always done a great job at negotiating room rates under $200, but if we return to Scottsdale at a respectable meeting hotel, you may see these rates in the $200-300 range. 4. Why is the meeting room always so cold? January in Chicago is cold. April in Phoenix can be over air-conditioned for our mostly eastern and Midwestern participants. However, because the ACOEP staff is not in the meeting space at all times, we are often not aware of temperature changes or other issues (such as the microphone malfunctions and lighting). If any of these are a problem, please report them to a staff member, and we will do everything in our power to make sure it is taken care of immediately! No room temperature is perfect for everyone, so our general advice is to bring a sweater, especially if the lecture day is more than 4 hours long. To submit questions to the ACOEP you can contact Jan Wachtler at 800-521-3709 or janwachtler@acoep.org and she will have various staff members answer your specific questions.

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Student Chapter Update

Josh Linebaugh, ACOEPSC National President, ACOEP Board of Directors Greetings from the Student Chapter! This is an exciting time for the students as we prepare for the years’ events. The driving force behind all of our activities this year is our desire to positively impact the future of the ACOEP. Therefore, we have decided to dedicate our focus this year to three themes. The first theme for the year is communication. With the recent creation of new Osteopathic Medical Schools, it is becoming increasingly more important for the National Student Chapter to find more effective ways to communicate with local Emergency Medicine chapters. Our new website, www.acoepsc.org, is the tool that will make this communication possible. We look forward to the possibilities the website will afford us to be a stronger voice for the students across the nation. The second theme for the year is to find ways to serve the ACOEP and its’ membership. Over the years, the support for the students from the membership has been

overwhelming and we are dedicated to find ways to show our gratitude. With this in mind, we have decided to host a studentrun OMM clinic for all those who attend the ACOEP Spring Convention in Arizona. We have blocked off a three-hour window from 1-4pm on Wednesday, April 19, 2006 at the WigWam Resort for the clinic. These services provided are intended for physicians and their families. We will have a sign-up sheet for treatment times located at convention registration. The students are excited about this opportunity to give back to the ACOEP membership by utilizing our osteopathic manipulative skills. Our third theme for the year is important for the future of the ACOEP as well as the Osteopathic profession as a whole. The Student Chapter has committed itself to promoting the many quality Osteopathic Emergency Medicine Residency Programs available to our students. In an effort to ensure that the most talented Osteopathic Medical Students continue

their medical training at an Osteopathic Residency Program, we have created a forum for these students to meet face to face with our residency programs. The 2nd Annual Osteopathic Emergency Medicine Residency Expo will be held at the 2006 AOA Convention in Las Vegas, Nevada this coming October. The expo will give our residency programs a venue to highlight their strengths to students who attend the convention from across the country. The Student Chapter has high hopes for recordsetting student participation at the convention because after all, what student doesn’t want to go to Vegas! Thank you for your continued support of the students. Your participation in the mentor program continues to overwhelm us. For those not yet participating in the mentor program that have interest, please contact me at acoepsc_pres@hotmail.com. We look forward to your continued support.

institutions that possess interactive websites, flashy pictures, and easily accessible information. We are right in the middle of the application season, and it appears, secondary to ERAS, there has been an increase in Osteopathic applicants to our programs. Unfortunately, many of them are blindly clicking on the mouse pad, without current knowledge of the programs. Our website listed on our hospital’s page has information that is over 5 years old. Everything from salary to ED volume is incorrect. We at the Residents chapter of the ACOEP are working to change this deficiency. The Communications Committee took on the task of developing the ACOEP website to alleviate the aforementioned issues. This will take time, and also cooperation from the individual programs. Please raise the issue with your Residency Director/DME if you do not have an official website. Now that we have easy access to our applicants, we must give them easy access to us. We

hope to bring our websites to the level of those found at allopathic programs, and capture those applicants on the fence between Osteopathic and Allopathic training programs. If you have questions, comments, or concerns, please direct them to Michael Kubek at icecoldkubek@yahoo. com. Thank you for your time, and good luck with the Match.

Residents Corner Michael Kubek, D.O.

Hello to all, and a belated happy Holidays as well. As chair of the Communications Committee, I would like to focus on our current task, internet accessibility. The AOA made a huge move this year to link up with the previously Allopathic ERAS system of residency application. This lifted a huge burden from the medical students’ shoulders. Now a click of a button and only the effort of one application creates an efficient dissemination of applicant information. However, applicants to Osteopathic programs still lack the ability to research residency training sites on line. Obviously, our main concern lies in the lack of accessible ACOEP approved Emergency Medicine websites. I raised this issue at the Orlando meeting, and met with resounding agreement from all residents in attendance. To date, on the ACOEP website none of the listed Residencies have links to their websites. Unfortunately, we are competing with large well-funded Allopathic

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Editor’s Note: At this time, the ACOEP is under contract for renovation with anticipated changes occurring over the next year. Anticipated changes will include a Members Only Section that should debut in August 2007. Additionally, the issues raised about mandatory updates by residency programs are currently being incorporated into ACOEP policies and will also go into effect as changes are being incorporated into the site. We hope that this will alleviate some of the angst our Resident and Student Members are encountering.


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The Pulse April 2006  

The Pulse - Osteopathic Emergency Medicine Quarterly

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