The Pulse April 2011 by ACOEP

APRIL 2011 VOLUME XXXVI NO. 2

Presidential Viewpoints Thomas A. Brabson, D.O., MBA, FACOEP-D, President

We Have a Resounding Voice When It Comes to Emergency Medical Care

Once again spring is finally here. I don’t think there was any place in the US spared from the harsh winter we just experienced. Fortunately though, as osteopathic emergency physicians, we pride ourselves on accepting new challenges, and as we are all aware, there are many new challenges occurring in the world today. Since our last issue, I have had the opportunity to represent the ACOEP at two very important meetings. The first meeting was the second “Future of Emergency Medicine Summit” which was hosted at the ACEP headquarters. Drs. Christiansen, Mitchell and I traveled to Dallas where we joined representatives from ACEP, AAEM, ABEM, AACEM, CORD, ENA, EMRA, SAEM, SEMPA, American Society for Healthcare Risk Management, and the Emergency Department Practice Association. It was a very productive and collegial two days. We discussed the work force issues that challenge the future delivery of emergency medicine.

The issue of how to staff every emergency department with residency trained emergency physicians was again a topic of discussion. This remains a significant difficulty in rural America. We discussed the advanced practice nurses and physician assistants and how they can help to fill the need. Each of these groups has much to offer but they have very few formal training programs specific to emergency medical care. The passage of the Patient Protection and Affordable Care Act has added to our challenges. With the estimated 32 million more people receiving medical insurance, our emergency departments will likely see our volumes soar. The Accountable Care Organization (ACO) provision in the Act also generated much discussion. As I have mentioned before, I believe that the emergency physician should be an active participant in all of the planning of the ACOs. There is a broad consensus that the next phase of reform must slow the growth of health care costs and improve value through payment reforms this will include: bundling of payments, including payments for episodes of acute care. It is thought that some savings will occur as a result of innovative care models including the ACOs, medical homes, transitional care, home care and community-based care. I believe that emergency medical care will be an integral part of all of these innovative care models.

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Therefore, as osteopathic emergency physicians, we must aggressively seek opportunities to participate in the planning and implementation of the innovative models. We need to assure that our role of serving and protecting is maintained while we accept a new role of helping to guide the patient through a new health care system. We currently need to make a decision to admit to the hospital or discharge to home. In the near future, we may be called upon to make the additional decisions to triage a patient to a primary care physician’s office, to a specialty clinic, or even an urgent care center as opposed to being evaluated in the ED. The number of diagnostic studies ordered, specialty consultations, and ‘unnecessary’ admissions will all whittle away at the bundled payment. The question still remains as to who will receive the bundled payment. Many people think that for the hospital based services, the hospital will receive the bundled payment and they will be responsible for the disbursement of the funds. Imagine how that will potentially change the dynamics of the relationship between the physicians and the hospitals. The physicians and hospitals working corroboratively will take on a whole new meaning. We will be partnering for more than just an employment contract, we will be partnering to develop the innovative continued on page 19

OSTEOPATHIC EM RESIDENCY DIRECTOR OPPORTUNITY

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.

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Salary is commensurate with experience

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Signing bonus and relocation

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

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Medical school loan repayment up to $200,000

(toll-free) (fax) (email)

866|356-7662 740|356-7817 AnkromM@somc.org

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THE

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

PULSE O S T E O PAT H I C

Editorial Staff: Drew A. Koch, DO, FACOEP-D, Editor Wayne Jones, DO, FACOEP, Assist. Editor Thomas Brabson, DO, MBA, FACOEP-D Anthony Jennings, DO, FACOEP Janice Wachtler, Executive Director Editorial Committee: Drew A. Koch, DO, FACOEP-D, Chair Wayne Jones, D.O., FACOEP, Vice Chair David Bohorquez, DO Thomas Brabson, DO, FACOEP-D Joseph Dougherty, DO, FACOEP Anthony Jennings, DO, FACOEP William Kokx, DO, FACOEP Annette Mann, DO, FACOEP Brian Wiboon, DO 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 theteam@norcomdesign.com. Please contact Norcom for the specific rates and print specifications for both color and black and white print ads. 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.

EMERGENCY MEDICINE

Q U A RT E R LY

Table of Contents Presidential Viewpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Thomas A. Brabson, DO, MBA, FACOEP-D Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Drew Koch, DO, FACOEP-D Executive Director's Desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Janice Wachtler, BA, CBA Pictures: Impressions That Last a Lifetime . . . . . . . . . . . . . . . . 6 Gregory Christiansen, D.O., M.Ed., FACOEP Governmental Affairs TIPS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Amber Vogt, D.O. ED Voices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Wayne T. Jones, D.O., FACOEP In My Opinion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Wayne T. Jones, D.O., FACOEP WADEM Letter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 FACOEP FOEM: Foundation Focus . . . . . . . . . . . . . . . . . . . . 12 FACOEP FOEM: Foundation Thanks Supporters . . . . . . . . . . 13 FACOEP FOEM: Thanks for 2010 Contributions . . . . . . . . . 14 FACOEP FOEM: Upcoming Events . . . . . . . . . . . . . . . . . . . . 17 ACOEP's Starting Lineup . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 ACOEP Visual Stimulus Competition . . . . . . . . . . . . . . . . . . . 19 Ethics in Emergency Medicine . . . . . . . . . . . . . . . . . . . . . . . . . 20 Bernard Heilicser, D.O., M.S., FACEP, FACOEP At First Look . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

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Editorial Drew Koch, D.O., FACOEP-D, Editor

The only aspect of emergency medicine that is constant is change. The face of emergency m e d i c i n e has changed dramatically over the past two decades and will continue to change over the next, and hopefully last, decade of my career. The job of the emergency medicine physician is simple, we evaluate patients, stabilize the patient and decide to admit, transfer or discharge the patient. That aspect of the job has not changed since completion of my residency over two decades ago. What has changed is how we do our job, the expectations of our job, perceptions of how the patients, community, medical staff and media perceive how we should perform emergency medicine, the dynamics of our job and the complexities of our job. Over the years the emergency departments have become adept and successful in managing the patients who present to our ED this has lead to frustrations by the emergency medicine providers and staff. Since the advent of hospitalists and critical care specialists, the ability to directly admit a patient from the primary care physician’s office has disappeared. The patient is sent to the emergency department for the emergency medicine provider to decide if the patient needs to be admitted or discharged to home. We are the second opinion and the gatekeeper of admissions. The ED is the safety valve for the primary care physicians who are either too busy to see a patient or the patient's condition is complex or too impatient to do an outpatient workup. It is more expeditious to send the patient to the ED for one-stop shopping and complete the bulk of the workup in the ED. Our local law enforcement officers contribute to

our viability by bringing in all the drunks, homeless, and psychiatric patients that have nowhere to go or are causing a ruckus in the community. Patients demand immediate health care when they are not feeling well and present to the ED at the onset of symptoms. Years ago, and even now, our EM providers and staff still question why these patients present to the ED and not their PCP. Patients want immediate access to health care and do not want to wait to see their PCPs. We provide unscheduled health care to all comers regardless of their complaint or their ability to pay. We should be thankful that our patients look to us to provide immediate access to health care instead of complaining about the patients presenting to the ED. Along the same lines of thought, providers and staff should recognize that the PCP’s and LEOs are not dumping on them but respect our expertise in providing care to their patients. On one hand the emergency departments are expected to provide second opinions, call coverage for the PCPs, sort out any problems that patient encounter in the community, become the safety valve for all patients who do not have a PCP and provide medical screening examinations for all patients who present to the ED. On the other hand, the ED is constantly defending itself against the community, medical staff and the administration. Emergency medicine has been a recognized specialty for over 30 years in the osteopathic profession and over 40 years in the allopathic profession. Do the medical staff, community and administration in your hospital recognize EM as a specialty or are the EM providers treated like house staff and not considered valuable members of the hospital, community or medical staff? The former relationship is ideal but does it exist in most communities? In the latter relationship, there is no respect for the EM providers among the medical staff,

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administration and ED. Can the attitudes and behaviors of the medical staff and administration be changed so that there is a collegial working relationship among the medical staff, administration and the emergency department? The culture of the emergency department has changed dramatically over the past 20 years. It is expected that all EM providers provide excellent and quality medical care in a timely and patient-friendly manner. The days of a surly, overbearing provider who provides “quality” care in an abrasive, menacing manner are over. The individual doctor who does not interact well with the staff and patients, who refuse to use order entry sets, has prolonged lengths of stay, low customer satisfaction scores, does not meet CMS indicators, and in general is not a team player, will soon find themselves unemployed in this economy. Although, we still see patients and make decisions on patients but we are being evaluated on many metrics that were not routinely measured in the past. The focus is customer satisfaction, flow and adherence to CMS indicators. This is a lot different than seeing one patient at a time in the order of acuity or in the order of presentation. As a profession, we have changed how we practice EM to fit the needs and demands of our patients and hospitals. As we go forward, we have to change the attitudes and interactions among the ED, medical staff and administration. If you work in an ED that is considered the gateway to the hospital and where there is a collegial working relationship with the medical staff; considered yourself blessed. If not, your ED will have to continually work hard to prove to the medical staff that EM is a viable profession and we do know what we are doing. It will require education and communication and will not be achieved overnight.

Executive Directors Desk Janice Wachtler, BA, CBA

Building Leadership

For many years I have been intrigued by the traits that make leaders and the motivation to become a leader. Is it a planned event that makes someone step forward to take charge, is it someone’s own desire for recognition that pushes them to take that step forward? Is it just destiny or fate? As I have looked into leadership, I’ve come to the conclusion that the motivation behind people becoming a leader varies greatly depending on circumstances, as well as desire for recognition, to accomplish something, or personal vision. The thing that doesn’t change is that certain trait that makes someone take that step, whether it’s on their own or at someone else’s urging. But I’ve also found that at times, it is the reluctant leader that makes the most impact. I would like to take several articles over the next year and explore leadership; its definition; the various types of styles; and the drive it takes to take that step forward, the nudge that brings someone from the ranks of Joe Average to Joe Leader. Many great minds have made statements about leadership, but all agree that the basic skill any leader must possess is personal integrity. The motivation that it takes to take the step forward to be a leader is all housed within the person. If the person thinks leadership will somehow enhance his or her fame or fortune; that person will fail as a leader. Why? I think Abraham Lincoln stated it quite profoundly when he said, “Any man can stand adversity, but if you want to test a man’s character, give him power.” This can be said for anyone who has faced a storm and come out standing.

We’ve seen it with people like Donald Trump who has withstood financial doom and has come forward with his character in one piece. He’s now looked at as a leader in business; an icon. Then there is Bernard Madoff, who rose to financial heights, only to fall on his own sword. They both were big personalities, big spenders, high profiles, but what makes the difference? Madoff was working for his own wealth and good; Trump, for the good of his company. While we may not like either man, we respect Donald Trump because he had personal integrity and stood on his principles and his integrity was unquestioned, but he also had as a personal vision for his company. Personal vision is another component; without which, one cannot lead. They see something that needs to be changed and seek to change it. Vision requires the person to (1) identify the problem, (2) set objectives to bring about change, (3) visualize the signs of change, (4) identify working strategies to keep moving toward the change they want, (5) implement the strategies for change, and (6) measure the change over a certain period of time. Real change may require the leader to visit this paradigm over and over until the goal is achieved. As Steve Jobs once said, “Innovation distinguishes between a leader and a follower.” Leadership is also not just bossing people around, anyone can do that. We’ve all seen the person in our office, department or organization that pounds on his desk and orders people to ‘tote that barge and lift that bale.’ People will follow that person to get the job done, but when all is said and done, he or she will be looked at as a “boss” not a leader. I can cite a thousand examples of bad leadership, as you probably can, but why do you think of them as “bosses” and not “leaders?” Because they did not share the passion it takes to lead. When I think about people who have

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personally touched me and impressed me as leaders, I think about people who had a personal passion to achieve a goal. They inspired me to follow them; they sold me on the need for something, and I followed, not blindly, because they told me I would play a part in their plan and while being in the background, I was important to the project. A personal example is a boss that I once had. He was a brilliant man, a recognized educator. A leader? Not so much. He taught me how to write policy, to think along educational lines, to develop goals and objectives for educational purposes, but he shared nothing about where he wanted to take the department or organization. He’d give presentations which were prepared by staff, driven by staff passion, and never recognize the people behind the scenes, so as the movement marched forward taking projects from 1950’s ideas to real-time needs, it was only a job that was over at 5:00 p.m. and no project ever took off and many fizzled due to lack of interest. When I left the position, I vowed that I would not repeat his mistakes, and even though many of my own projects have died because of a lack of interest, those that saw success were those that I had a driving passion for. I would not ask other people to give of themselves, if I could not make the same sacrifice. I made my passion, theirs. Once a person has been identified with integrity and principles, vision and passion, then the person can begin to develop leadership skills. These skills will be discussed in my next article, but to paraphrase Anthony Jay, the only training for leadership is leadership.

Pictures: Impressions That Last a Life Time Greg Christiansen, DO, M.Ed, FACOEP President-elect, ACOEP physicians, we are the difference treated immediately for what was sure to makers. She observed what must come. The EKG confirmed my suspicions. have been unfathomable and He was having a heart attack. His family by his side, I assured them shocking to those unaccustomed to our environment. When I finally my team would do everything possible to confronted her, I needed not say a help him. Without showing the fear in my word. I could see in her eyes that eyes, I knew in the back of my mind that she offered reverence and respect. this task would be daunting. To make the I could only offer my humility point more clear, the family referred to the knowing a picture could not begin patient as father, husband and grandfather. to do justice in testifying to what I am sure you have seen this picture before. We called the catheterization team we, as emergency physicians, see in from home and began our treatment and do on a daily basis. Projecting imagery to our patients algorithms. I kept the family close to and their families has a much the bedside preferring to have the family Picture referenced from the Children’s Cancer Association more lasting impression then we present as much as possible in these may realize. I would contend that situations. In the end, ultimately it is their I love to look at photographs. I most of us do not recognize how much of moment. In the past I have regretted not Greg Christiansen, DO, toM.Ed., appreciate a picture for its ability portray FACOEP an impact we make. It is so intrinsic to offering a family member that chance to be President-elect, ACOEP a moment. It is expressive, detailed and our personality; we hardly notice or may together. I have come to believe offering a tangible. Talented photographers have used not be cognizant of our influence. There chance to say their peace in life was more I love to look at photographs. I appreciate a picture for its ability to portray a moment. It is expressive, adetailed myriad and of media to Talented creativelyphotographers capture are have very few whose members important the care itself. tangible. usedprofessions a myriad of media to creatively capturethan images. These images communicate more more then justhave an so idea; they emotion, depict and project images. These images communicate great an convey impact on someone’s lifea tone While busyanwith our work in expectation. pictures can emotion, be shared and its messages relied to anyone. But what about then just an These idea; they convey experience – yet few ofanywhere us take the time stemming the tidetheof the STEMI, a young message our patients are sending about us and to us. What would a picture of your emergency department, depict a tone project an expectation. toviewed comprehend the significance to the lady informed me the entire family and snapped in anand instant, convey to anyone who its content? thought can thisbetoshared myselfand when a patient boarding in hallway her we cell phone to record my in the waiting room. TheseI pictures messages communities wethe serve. It’s justused the way extended family were interactions with the patients that surrounded her. She was using social media to project perceptions. I was relayed anywhere to anyone. But what are and how we live. So it is no wonder our The pressure was on and I did not have taken aback by the gesture and concerned for the other patientʼs privacy. However, privacy in a county style about the message our patients areatsending influence the perceptions others time access to contemplate emergency department is often odds withactions the need to provide care to the of many who lack to such the fact that so many care. High density on aashoe stringinbudget canmay ill afford luxury. about us and to us. medicine What would picture ways we never such appreciate. were present during this time of crisis. No Unable to deter her, I thought to myself is it that story she finds intriguing to want to document and this information then of your emergency department, snapped in what A familiar beginssowith a typical sooner did she offer share with others? It did not take long for me to recognize her interest. As emergency physicians, we are the an instant, makers. convey toShe anyone who what viewed at been the office and it sounds somethingto those her loved one she called “Dad” went it a difference observed mustday have unfathomable and shocking unaccustomed to our environment. When I finally confronted not sayofaaword. could see in her arrest. eyes that shewas not an instant to content? likeher, thisI needed ... The silence quiet Ishift was V-fib There offered reverence and respect. I could only offer my humility knowing a picture could not begin to do justice I thought this to myself when a patient broken one evening by an older gentleman lose and reflexively I went into ‘code mode.’ in testifying to what we, as emergency physicians, see and do on a daily basis. boarding in the hallway her patients cell phone complained ‘not more feeling good.’ From the corner of my eye, I saw the wife Projecting imageryused to our and who their families has aofmuch lasting impression then we may realize. would contend with that most of us do not recognize hownot much of anthe impact we make. It is so intrinsic to recordI my interactions the patients Although I did know patient, and relatives frantically exit the room. They to our personality; hardly or may not be cognizant of our There are very few that surrounded her.weShe was notice using social I recognized him frominfluence. my many prior could notprofessions bear to watch and I did not have whose members have so great an impact on someoneʼs life experience – yet few of us take the time to media to project patients the we sense the time to offer comprehend the perceptions. significance Itowas the taken communities we who serve.left Itʼs me just with the way are of and how we live. So itthe is comfort they needed. no wonder actions theforperceptions of others in ways we may aback by theour gesture andinfluence concerned the impending doom. I have beennever downappreciate. the I was too focused on doing the very thing I familiar story begins with a privacy typical day‘road at thetooffice and it sounds like this ... The other Apatient’s privacy. However, the code’ before. something We all have. wanted to silence do whenofI began my career as an a quiet shift was broken one evening by an older gentleman who complained of ʻnot feeling good.ʼ Although I in stylethe emergency my my mind I began preparewho for left the meemergency physician; dida county not know patient, Idepartment recognizedis himInfrom many prior to patients with the sense of provide emergency impending I have downcare the ʻroad to the of codeʼ before. –We have. In my mind beganlady to stayed on and silently often at oddsdoom. with the need been to provide eventuality a calamity myallproverbial care. TheIyoung prepare for the eventuality of atocalamity proverbial to the many who lack access it. High– myblack cloud. black cloud. observed the team frenetically working to The nurses attempted to walk the patient from triage to a treatment room. All the while they struck fear density medicine on a shoe budget The attempted to walk was the atbring him back to the living. in my heart. I jumped in to string address my concerns thatnurses an impending catastrophe hand. This patient should not be walking as if he needed a stress test from stafftobuta rather treated immediately for what was my check list and can ill afford such luxury. patient fromthe triage treatment room. I went through sure to come. The EKG confirmed my suspicions. He was having a heart attack. Unable to deter her, I thought All the while they struck fear in my heart. organized my team so we would not let His family by his side, I assured them my team would do everything possible to help him. Without to myself,thewhat sheI knew finds insothe Iback jumped to address mytask concerns down the next team showing fear isin it mythat eyes, of myinmind that this would that be daunting. To make the in line – the Cath point moretoclear, family referred to the patient as father, husband and am sure you have intriguing want the to document and share an impending catastrophe was grandfather. at hand. ITeam. They had already been summoned seenothers? this picture before. with It did not take long for me This patient should not be walking as if he and I needed to keep him alive long We called the catheterization team in from home and began our treatment algorithms. I kept the family to recognize her interest. As emergency stress test theasstaff but rather enough for them close to the bedside preferring to have theneeded family apresent asfrom much possible in these situations. In the to do their miracle.

Pictures: Impressions That Last a Life Time

end, ultimately it is their moment. In the past I have regretted not offering a family member that chance to be together. I have come to believe offering a chance to say their peace in life was more important than the care itself. While busy with our work in stemming the tide of the STEMI, a young lady informed me the entire family 6and extended family were in the waiting room. The pressure The PULSE wasAPRIL on and2011 I did not have time to contemplate the fact that so many were present during this time of crisis. No sooner did she offer this information then her

We worked until we got a viable rhythm and fortunately the patient awoke from his death. We rushed to take him to the catheterization suite and in my harried state I glanced over and saw the woman still standing to the side and watching with deep concern. She had experienced the gamut of emotions but appeared relieved. I accompanied the patient to the Cath Lab and handed off the patient to my trusted cardiology colleague. His procedure was successful. The cardiologist reported the patient had a completely obstructing RCA clot and 100% atherosclerotic occlusion of his left main. His disease state and postcath report gave clarity as to why I had to deal with so many rhythm complexities during a complicated treatment process. When I returned to the Emergency Department I was greeted by the young lady who stayed in the ED during the entire episode. She informed me that she was a nurse and understood the details of what we had done. But she had one other piece of information to share. It was her wedding night and she was grateful the memory would be a happy one. She did not want the joy of her wedding to also mark the anniversary of her new father-in-law’s death. She did not want her holiday with her family and her new husband’s family to be a reminder of a catastrophic image of being in my emergency department that night. Although the staff knew we were fortunate to cheat death, we had only a tacit understanding of what we did. We were successful at our jobs and for that we were happy and ready to move forward. But beyond our limited level of understanding we were the difference to an entire family. The nurse, bride and daughter-in-law offered a different and more global perspective of the impact we made in just one ‘case’. To her this wasn’t just a case, it was her family. In our environment we rarely are offered such sincere words by someone who understands such complexities so well. However, it is enlightening to realize what we do means so very much more than we might imagine. In another, less dramatic and more subtle event, I was approached by a fellow College member prior to her lecture at one of our conferences. She was enthusiastic

and confident. She had a message to offer and wanted to teach our members. I offered her my assistance if she needed it and she then stopped me. She was about to speak to a packed lecture hall and changed her entire train of thought to let me know of an event that we shared more than 15 years earlier. She took the time to tell me I was the part of the reason she was here to speak to our College today. She asked me if I remembered the time I offered to help another colleague. I was on-call as the floor intern doing my night call; she a student following another intern who also was on-call. I could not remember the experience and I was dependent on her recollection to know the story. She said I stopped to help her intern address a perplexing case. The ward patient needed help and was becoming more acutely ill as time passed. Her intern was stymied by a complex EKG and the stress of the situation made her more frantic in trying to provide the needed care for the patient. There wasn’t anybody she could use as a resource and she was relieved that I was there to bounce ideas from in order to create a plan. Apparently, I helped work through a complex EKG which allowed her intern to chart a course of action for her patient. She said that moment of mentorship and teaching gave her the confidence to care for the patient independently. In that moment of chaos tempered with a calm security in observing my attentive behavior inspired her to become an emergency physician. I was grateful for the kind words and tried to be cognizant that she still had a lecture

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to give. I was struck by how an innocuous occurrence in my mind could have such a profound effect on someone else. She was a gifted observer and used these talents to become an outstanding emergency physician. I took solace in knowing she is an inspiration to our college and I was grateful for the chance to hear her share her ideas. Given these images, I would like to leave you with some parting words. You are truly a valued member of our College. Despite all that may go on in our day-today struggle to meet the demands of our practice, we mean something to someone else. We make a difference to many more people then we are aware of. We are grateful you chose to be an inspiration to your patients, family and colleagues. When we meet again to learn from each other, I hope you will share your pictures. They mentor our future leaders and give us time to reflect on our motivations. A picture can say a thousand words but also touch a thousand hearts and last a life time.

Governmental Affairs TIPS Amber Vogt, DO 2010-11 TIPS Fellow Midwestern University/CCOM

Prescription Drug Monitoring Programs Get Involved In recent years, the diversion and abuse of prescription medication has become increasingly problematic. In 2005, an estimated 33 million people had used pain relievers non-medically in their lifetime, and this number continues to grow. The number and percentage of current nonmedical users of psychotherapeutic drugs in 2009 (7 million) were higher than in 2008 (6.2 million).1 According to the 2007 NSDUH, over 70 percent of prescription drug abusers got their medications free from a friend or relative. These medications were received from a single physician 80% of the time.2 We feel this impact in the emergency department. In 2009, there were nearly 4.6 million drug-related emergency department visits of which approximately one half (2.3 million) were attributed to adverse reactions to pharmaceuticals and almost one half (2.1 million) were due to drug misuse or abuse.3 With recent overcrowding problems, changing this trend is an important factor in improving ED disposition. Prescription drug monitoring programs (PDMP) have been in existence for 70 years to help combat misuse and diversion, but with little effect. The State of California developed the original PDMP in 1939 to contend with the rising prescription drug abuse in its state. Today, there are 34 states that have operational PDMPs that have the capacity to receive and distribute controlled substance prescription information to authorized users. There are an additional 10 that have programs in place that are not yet fully functional.4 These programs are state, not federally controlled, and therefore have various governing organizations and standards as to who can access this information. Fortunately, in recent years legislative

bills have made a push to strengthen existing programs and create new ones that will hopefully lead to increased surveillance. The expectation would be to create a nationwide drug surveillance program in which information could be shared across state lines. Currently, only Ohio and Kentucky have a program in place for this. At present, there are only two federal funding programs available to state PDMPs. The first program to provided federal funding to states was the Harold Rogers Prescription Drug Monitoring Program (HRPDMP) administered by the U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Assistance. HRPDMP provides three categories of grants: planning, implementation, and enhancement. To be eligible for funding, the state must already have a statute or regulation permitting the establishment of a PDMP. Since its inception in 2002, it has awarded over 100 grants worth $48 million.4 The second source of federal funding is the National All Schedules Prescription Electronic Reporting Act (NASPER) administered by the U.S. Department of Health and Human Services (HHS). This grant program enables states to create a PDMP database or to enhance an existing one. Fiscal year 2009 was the first year state grants were available. The appropriations are approximately $2 million per year.5 There was a third prospective source of funding, HR bill 5710, that never came to fruition. It would have amended NASPER Act of 2005 and provided $15 million in fiscal year 2011 and $10 million a year for fiscal years 2012 and 2013 to eligible states.6 While this bill passed the House, it was not approved in the Senate before the recent change in Congress.

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Though a nationwide program would be beneficial in many situations, it is not without some negative consequences. According to the American Chronic Pain Association, approximately 75 million people in the United States suffer from severe pain—50 million of this group experiencing chronic pain.7 PDMPs have had a negative impact on some patients’ access to needed therapies. This is especially prevalent to patients with opioid prescriptions. It not only affects our patients, but also physicians. PDMPs have emerged as powerful tools for investigators to establish that patients’ unlawful activities could be determined with a simple inquiry. All prescribing physicians should assume government investigators will use data accessible from the PDMP to evaluate a physician’s actions following a negative event.8 So what can we do as physicians? While we want to adequately treat our patients with both chronic and acute pain, we must be stewards in stopping prescription drug abuse. As we all know, it is a frequent encounter in emergency departments around the country. We can expect to face increased scrutiny as prescription drug abuse amplifies. Many physicians are not even registered users within their state. The simplest answer to all of this is to become a member of your PDMP if you have not already done so. As emergency physicians, we are adept at using every resource available to us. This is an important tool to put in our armamentarium. Once you have signed up, use it. It is guaranteed to help you in your future practice.

1. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality (2010). Results from the 2009 National Survey on Drug Use and Health: National findings. Rockville, MD. Retrieved from http:// oas.samhsa.gov/NSDUH/2k9NSDUH/ MH/2K9MHResults.pdf. 2. Office of Applied Studies. (2008). Results from the 2007 National Survey on Drug Use and Health: National findings (DHHS Publication No. SMA 08-4343, NSDUH Series H-34). Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://oas.samhsa.gov/p0000016.htm.

3. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (December 28, 2010). Rockville, MD. 4. State prescription drug monitoring programs. (2010). Retrieved March 1, 2011 from http://www.deadiversion.usdoj. gov/faq/rx_monitor.htm. 5. Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. (2007). National All Schedules Prescription Electronic Reporting Act of 2005: A Review of Implementation of Existing State Controlled Substance Monitoring Programs.

Retrieved March 1, 2011 from www.dpt. samhsa.gov/doc/NASPER%2009142007. doc. 6. National All Schedules Prescription Electronic Reporting Reauthorization Act of 2010. (2010). Retrieved from http://www. gpo.gov/fdsys/pkg/BILLS/111hr5710rfs/ pdf. 7. American Chronic Pain Association. (2011). Retrieved from http://www. theacpa.org/default.aspx. 8. Knight, P. (2010). Prescribing opioids during the diversion crackdown. Wisconsin Medical Journal. 109:291-294.

ED Voices Wayne T. Jones, D.O., FACOEP Assistant Editor

Meaningful Use The time is well upon us. If your facility has not yet implemented an electronic health record (EHR), it will. The Government is dangling money in the face of every physician and health center in the U.S. in an attempt to soften the implementation of these systems. In order to be paid, you just need to meet “Meaningful Use Criteria”. Actually, it sounds very reasonable. I would think we all would want meaningful use from our EHR. Why else would we undertake such a task? But, what is meaningful use? Meaningful use for my razor is to shave my face. Meaningful use for my car is to get me from point A to point B. You don’t think the Government would make EHR use un-meaningful, do you? The overreaching Health Outcome Policy Priority is to improve quality, safety, efficiency and reduce health disparity. This comes to us from the HIT Policy Committee. So far, so good. As you migrate from the Care Goals to the Objectives to the Measures (each one more prescriptive) your heart begins to sink. I would think meaningful use would mean something to me as a practitioner,

or as a medical director, or as a facility administrator. No, it is meaningful as a big brother, the one who will adjust what they consider “health care”. To be meaningful, CMS would like you to have a system that can report how many patients have diabetes, hypertension, elevated LDL’s and who smokes. They would prefer BMI and the number of mammograms performed rather than trending of medical errors. Did you get your flu shot, your aspirin or smoking cessation counseling? This is great information for the First Lady, but totally useless to me as a front line clinician. Eleven years ago, the Institute of Medicine (IOM) published To Err is Human. The report made a public statement that 98,000 patients die needlessly in our nations hospitals. We were taken aback as the public became enraged. Did much change? Will these governmental mandated Meaningful Use Criteria improve the system? If not, are they really meaningful? If we accept that little has changed, then 1 million patients have died since the first government report. For all the outrage of the lives lost in the Afghanistan and Iraq war, I see little anger here.

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The IOM defined a medical error as the failure of a Plan of Action to be implemented, or the use of a wrong plan or to achieve an aim. There were other specific errors such as administration of treatment, or to employ indicated testing. Does the reporting of insurance types sound like a preventable error? There have been calls for transparency. Hospitals are instituting the Just Culture Model for error reporting and system change. Medical Boards are implementing new and innovative ways of continuous certification; and hopefully improved patient care. None of this is included in meaningful use. We as clinicians have medication errors, thought processing errors, system errors, and onerous medical legal oversight. We have more big brothers than are genetically possible. Though, I do believe that a portable flexible medical record can aid us in error prevention and communication, I am not sure the Government understands Meaningful Use.

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

Manifest Destiny By the late 1700’s we had won our independence from Great Britain. The British Crown relinquished the land west of the original thirteen states to include the Mississippi River in the 1783 Treaty of Paris. Spain was allowed to retain Florida and some land spreading west, crossing the Mississippi River limiting our access to inland areas. In 1803, we purchased a large expanse of land from France called the Louisiana Purchase. This did not include just Louisiana but parts of 14 current states spreading as far north as present day Canada and as far west as Montana. The Florida Territory was seen as an irritant to the United States. Swamp-filled and infested with yellow fever it was not the prize of any nation. In 1819, Spain agreed to sell the land for debt owed to U.S. citizens. We were building a great nation. Our Nation had gained a great deal in a very short time and how we saw ourselves began to change. We entered this country seeking certain freedoms. We established our own governance on the principles that church and state must be allowed to exist independently but in concert with one another. We said that all men must be free, at the same time realizing that slavery and servitude was a custom that flew in the face of this fabric. Our Nation tried to ignore this tear but it was a tear that could ruin us if left un-mended. Texas was claimed by the French, Spanish and Mexican governments until the late 1600’s when the Spanish established firm control. The Spanish government allowed U.S. citizens to immigrate and establish residency. In 1821, when Mexico declared independence from Spain, the Texas territory under Mexico’s control became part of that new nation. Mexico also encouraged U.S. immigration expanding the American mix in this northern region. Provoked by the Mexican Government, the 1836 Texas Revolution created a new country - the Republic of Texas.

The Republic of Texas, though independent, consisted of mostly U.S. citizens. The U.S. wanted to annex Texas but concerns over the expansion of slavery stalled the approval by Congress. In the July, 1845 edition of the Democratic Review, a gentleman by the name of John O’Sullivan published an essay entitled “Annexation” which called on the Congress to admit Texas into the Union. O’Sullivan argued that the U.S. had a divine mandate to expand throughout North America, writing “our manifest destiny to overspread the continent allotted by Providence (God) for the free development of our yearly multiplying millions.” Texas was annexed soon after, but it would not be until the second publication by O’Sullivan containing the phrase “manifest destiny” that this phrase would change the nation forever. Standing on the Rocky Mountains and looking westward, our appetite would not be satisfied until we owned all lands from ocean to ocean. President Polk declared war on Mexico, determined to take that land west of the Rockies. We reimbursed the Mexican Government 15 million for their loss. Had we now satisfied our manifest destiny? We were now entering the Civil War. Our Nation would be torn apart and rebuilt with a loss greater than its riches. Our attention turned within. Mostly unnoticed by the American public was the battle amongst newspaper publishers, notably Joseph Pulitzer of the New York World news and William Randolph Hearst of the New York Journal. They struggled to be the top news publisher. To attain this, they understood the value of a sensational headline. This type of journalism would become known as Yellow Journalism. The articles contained little or no legitimate news and instead used eye-catching headlines. Today we are so immune to this style of writing that we actually expect this type of coverage; however it was new and exciting to read these

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articles of injustice and violence occurring around us, and it sold newspapers. It also, probably, sold us the Spanish-American War— a war to create an independent Cuba. What were we doing? We were now using our manifest destiny to spread our vision of righteous independence around the world. This was also by Providence. Not only did our government rule with manifest destiny to the benefit of others, but also, yellow journalism empowered our government (with our blessing) to benefit whoever they saw as needing assistance. Who recalls this quote; “One Small Step For Mankind”? Sensational! Yellow? Manifest Destiny? It had been a race for the moon. Outside of saying 'we did it', what did we gain? But, we really wanted it. Why? Land (or holdings) has always been a part of the manifest destiny argument. Yellow journalism acted as a catalyst for sealing the deal. Let me give you one more example. Healthcare. How comfortable does that feel? Manifest destiny has always dealt with some tangible asset. Something you can feel in your fingers. Now there is little land left to own. There remains that great valuable un-captured resource called healthcare. Yellow journalism is an easy bed partner. Public sentiment is easy to acquire. The problem with healthcare is that all the beds, all the medications, all the buildings are nothing without the knowledge to use them. You and I are not land or holdings. We are educated professionals. We are not owned and reallocated. We are not someone’s manifest destiny. We need to tear away from these constraints. Sound outlandish? I read a lot of history, and this one sounds like it’s in the books.

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

Foundation Focus The Foundation for Osteopathic Emergency Medicine (FOEM) has been busy during the first quarter of 2011. The 2011 FOEM Case Study Poster Competition received a record high of 74 applications! This is a vast increase in number from 2010 when we received less than 20 submissions. We are so happy to see that residents are taking advantage of the opportunities FOEM has to offer, and that program directors are stepping up and distributing information and helping their residents turn in quality research and case studies. One of the prime purposes of FOEM is to improve the quality of research and

education in emergency medicine, and we are so thrilled that the ACOEP membership base is acknowledging and supporting us. Thank you! To continue this positive trend, FOEM has been consistently updating its website so that program directors, residents, potential donors, sponsors, and the general public have one place to find the answers to their questions regarding the Foundation, its programs and supporting its premise. As the year continues, we encourage you to check out our website at www.foem.org and send any comments or suggestions to Stephanie Whitmer at swhitmer@foem.org. She is always listening and making changes to meet the needs of our supporters. Another exciting technological development occurred this year as well – FOEM is now on Facebook and Twitter! “Follow” @TheFOEM or “like” us on Facebook

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to receive updates and information that may not necessarily be on the website or available to the general public. We might also be holding raffles and competitions online to keep things exciting and fresh (hint hint)! Lastly, the Foundation will be hosting its First Annual FOEM Awards Banquet in Las Vegas during the ACOEP Scientific Assembly this fall. This black tie event is a must for everyone interested in honoring our top donors, award winners, and sponsors or to just enjoy a savory meal while networking with your fellow osteopathic emergency physicians in a more formal setting. We are honored to have such loyal supporters and look forward to showing our appreciation in style! Once again, FOEM thanks you for your involvement and support. Have a wonderful spring!

Foundation Thanks its Supporters for Their Involvement in Fall Events In October of 2010, FOEM launched its first-ever fund raising raffle during the ACOEP Scientific Assembly in San Francisco. With prizes such as an Apple iPad, an iPod with speakers, a laptop, travel certificates and more, it is easy to see why the raffle made over $5000 in just four days. The funds raised will go towards FOEM’s mission of supporting research and education in osteopathic emergency medicine. FOEM will hold another raffle at the FOEM booth at the ACOEP Spring Seminar in Fort Lauderdale and looks forward to similar success. Stop by to support our cause and maybe even win some money! At this time, we would like to acknowledge those that supported the raffle in the fall. Thank you for supporting the Foundation for Osteopathic Emergency Medicine! Juan Acosta, DO, MS, FACOEP Anthony Affatato, DO, FACOEP Amy Aldrich, DO Arash Armin, DO – WINNER Gary Beasley, DO, FACOEP Rudolph Bescherer, DO Suzana Bogdanovska, DO David Bohorquez, DO Nader Boulas, DO Genevieve Boulos, DO Thomas Brabson, DO, FACOEP-D David Branch, DO, JD, FACOEP Bernadette Brandon, DO, FACOEP Tiffany Brown, DO Joseph Calabro, DO, FACOEP Victoria Camba, DO, FACOEP Melissa Carter, DO Anthony Catapano, DO Timothy Cheslock, DO Bill Cole - WINNER

Paula DeJesus, DO, FACOEP-D Bill DiCindio, DO Joseph Dougherty, DO, FACOEP Greg Frappier, DO, FACOEP William Fraser, DO, FACOEP-D Howard Friedland, DO, FACOEP Stuart Friedman, DO Aaron Garret, DO John Graneto, DO, FACOEP Greg Gray, DO William Halacoglu, DO, FACOEP Valerie Hart, DO, FACOEP James Hill, DO Christopher Hill, DO Brady Husky, DO, FACOEP George Hutchins, DO Alan Jannsen, DO, FACOEP-D Stephen Kaiser, DO, FACOEP Peter Kaplan John Kasper, DO arcin Kociuba, DO Brenda Koegler, DO Nancy Kragt, DO Paul Kramer, DO Michael Kuchinski Andrea Kuchinski Dottie Landau David Lang, DO, FACOEP Tavi Madden LeDuc, DO David Levy, DO, FACOEP Andrew Little, DO Kevin Loeb, DO, FACOEP Daniel Lombardi, DO, FACOEP

Beth Longenecker, DO, FACOEP John Lyman, DO Dave Malicke, DO, FACOEP Fanny Mantilla, DO Brian McGrath, DO Mark Mitchell, DO, FACOEP Gary Moorman, DO, FACOEP-D Allen Morini Terrance Mulligan, DO, FACOEP Paul Numsen, DO Michael Oster, DO, FACOEP Steve Parrillo, DO, FACOEP-D Dana Parsons, DO, FACOEP Micheal Passafaro, DO P. Marvin Pustinger, DO Shawn Quinn, DO Daniel Rizzo, Alex Rosenau, DO, FACOEP Mark Rosenberg, DO, FACOEP-D Charles Ross, DO Noelle Rotondo, DO David Ruby, DO Otto Sabando, DO, FACOEP - WINNER Victor Scali, DO, FACOEP-D Victoria Selley, DO Jeremy Selley, DO - WINNER Marty Shadel, DO, FACOEP Ron Sheer, DO David Sheraga, DO George Shervanick, DO Duane Siberski, DO, FACOEP Bruce St. Amour, DO Murry Sturkie, DO, FACOEP Paul Toete, DO Jim Turner, DO, FACOEP Jan Wachtler Pat Wachtler Pamela Walters, DO, FACOEP Doug Webster DO FACOEP - WINNER Nike Whitcomb, CFRE - WINNER Brian Wiley, DO, FACOEP Thomas Wills, DO, FACOEP Gary Willyerd, DO, FACOEP-D

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FOEM Thanks its 2010 Contributors Due to deadlines for the January 2011 issue of The Pulse, the previous 2010 list was incomplete. This is the complete 2010 list of donors to the Foundation for Osteopathic Emergency Medicine. We so graciously thank our supporters and ask that you follow their lead in supporting research and education in emergency medicine. * Although we strive for accuracy, if there are any errors in our records, please contact me at swhitmer@foem.org and I will be quick to remedy the problem. Thank you. Will you help FOEM reach its fundraising goals in 2011? $7,500 and Above EmCare Emergency Medicine Physicians (EMP) Schumacher Group $2,500 - $7,499 Joseph Kuchinski, DO, FACOEP-D Robert E. Suter, DO, FACOEP-D James Turner DO, FACOEP and Sherry Turner, DO $1,000 - $2,499 Juan Acosta, DO, MS, FACOEP Anita W. Eisenhart, DO, FACOEP Mark A. Foppe, DO, FACOEP William Lynch, Jr. MedExcel, USA Janice Wachtler, BA, MBA Douglas Webster, DO, FACOEP-D Gary Willyerd, DO, FACOEP-D $500 - $999 ACOEP Peter A. Bell, DO, MBA, FACOEP-D T.Brabson, DO, MBA, FACOEP-D Gregory Christiansen, DO, FACOEP John Everett, DO Peter J. Kaplan Beth Longnecker, DO, FACOEP Steven Parrillo, DO, FACOEP-D John C. Prestosh, DO, FACOEP Duane Siberski, DO, FACOEP Bruce Whitman, DO, FACOEP $250 - $499 Anthony Affatato, DO, FACOEP Regina Hammock, DO Stephen G. Kaiser, DO, FACOEP Judith Knoll, DO, FACOEP

Drew A. Koch, DO, FACOEP James Morosco, DO Jamie Adamski, DO $100 - $249 Gaiti Bakhsh, DO, FACOEP Gregory Boris, DO Dale Carrison, DO, FACOEP Glenn DeLong, DO, FACOEP Kenneth Doroski, DO, FACOEP Nate Drexler, DO Mark Edwin, DO Clifford Fields, DO Calixto Garcia, DO Christine Giesa, DO, FACOEP-D William Gluckman, DO Kyle Groom, DO Patricia Guntern, DO William Halacoglu, DO, FACOEP Valerie Hart, DO, FACOEP Ira Brady Husky, DO, FACOEP-D Alan R. Janssen, DO, FACOEP-D Julie Johns, DO, FACOEP David Kraus, DO, FACOEP Helene Labonte, DO Robert McJennet, DO Mark A. Mithcell, DO, FACOEP Nilesh Patel, DO Jon-Pierre Pazevic, DO, FACOEP Christopher Posey, DO, FACOEP Stephen Pulley, DO, FACOEP Fred Rawlins, DO, FACOEP Otto Sabando, DO, FACOEP Victor J. Scali, DO, FACOEP-D Jeremy Selley, DO Jane Sennett, DO, FACOEP Michael E Sheehy, DO, FACOEP Robert M. Sidwa, DO Murry Sturkie, DO, FACOEP

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John A. Tyrell, DO James S. Walker, DO Susan Watson, DO John D. Weilbacker, DO, FACOEP Stephanie Whitmer Anthony D. WilkoDO, FACOEP Under $100 Anonymous Fahim Shan Ahmed, DO,FACOEP Steven Aks, DO, FACOEP-D Michael Allswede, DO Sean Al-Salman, DO, MSHcA Leonardo Altamirano, DO, FACOEP Adam Ankrum, DO Eric Applebaum, DO Amy Arnold, DO Sarah Arzt, DO Dale Askins, DO, FACOEP Larry Bachle, DO, FACOEP R. Scott Baeder, DO Fred Bailor, Jr., DO, FACOEP Michael L. Baker, DO William Barone, DO Gary Batten, DO Robert Bazuro, DO, FACOEP Gary Beasley, DO, FACOEP S. Addison Beeson, DO Joseph Gregory Beirne, DO, FACOEP Donna Bell, DO Sheldon Bender David Berg, DO Craig Black, DO Brad Blaker, DO, FACOEP Janice Blau, DO Brian Blaustein, DO, FACOEP Daniel Bommlje, DO Charles Boothby, DO Thomas Borgstedte, DO

Wallace Broadbent, DO Billy Bryan, DO Kyland Burden, DO Russell E. Burkett, DO Jeffrey Butler, DO, FACOEP George Sarkis Caleel, DO Arthur Calise, DO, FACOEP Brett A. Call, DO Carla Cameron, DO Nicholas Cardinal, DO Terry L. Carr, DO Melissa Carter, DO Thomas E. Carter, DO Jason Everett Cheatham, DO, FACEP Stephen Chester, DO Mark E. Cichon, DO, FACOEP-D Kevin Clark, DO Ryan Coates, DO Jeffrey Cohan, DO Andrew Cohen, DO Brian Collins, DO, FACOEP Michael S. Cone, DO Elizabeth Cook, DO Jeffrey R. Cotner, DO Jeffrey Couturier, DO, FACOEP Kevin Cranmer, DO Joseph D. Crum, DO Eric Csernyik, DO, FACOEP Thomas Culver, DO John Current, DO Melissa Cusumano, DO Mario D'Alessandro, DO, FACOEP Stephanie L. Davis, DO Phillippe De Kerillis, DO John Deagle, DO Louis DeMicco, DO Stephen DeWitt, DO, FACOEP William DiCindio, DO, FACOEP David Didur, DO Freya Dittrich, DO Anamika Doma, DO Jean Emmanuel Dorce, DO Joseph Dougherty, DO, FACOEP William Downs, DO Joseph A. Drasba, DO Paul Dubiel, DO, FACOEP Stephen P. Dubos, DO Kevin Durell, DO, FACOEP Michael C. Eastman, DO Francis C. Eaton, DO Jeffrey Evans, DO

Robert Faber, DO Kathleen Faccio, DO, FACOEP Andrew Felsted, DO Michael Ferraro, DO Michael Filart, DO Donald Findlay, DO Jerry Fitzgerald, DO Patrick Flaherty, DO James J. Flowers, DO, FACOEP William S. Folley, DO Matthew Font, DO, FACOEP C.H. Fowlkes, DO Gregory R. Frailey, DO, FACOEP Kevin Franks, DO J. Gregory Frappier, DO, FACOEP William R. Fraser, DO, FACOEP-D Joan M. Gable, DO, FACOEP Steven Gable, DO Raul Garcia-Rodriguez, DO, FACOEP Tressa Gardner, DO, FACOEP Michelle Gebhart, DO Timothy Genetta, DO Mary Gessner, DO Tara Gleeson, DO, FACOEP Keischa Glenn, DO Bernadette Gniadecki, DO Sodi Goldstein, DO Greg Gray, DO Brian Greenberg, DO Jeffry Greenlee, DO, FACOEP Raymond Griffith, DO, FACOEP David Grinbergs, DO Joseph Guarnaccia, DO, FACOEP Anthony Guarracino, DO, FACOEP John Havlick, DO Bernard Heilicser, DO, FACOEP David Hess, DO Ralph Hess, DO Gregory Higbee, DO Douglas Hill, DO, FACOEP Edwin M. Hinton, IV, DO Bradford Hoffman, DO, FACOEP Eric Hogan, DO Dorene Hojnicki, DO Susan Horling, DO Evan Houck, DO Darrin Houston, DO Randall Howell, DO, FACOEP Donald G. Hudson, DO Anwer Hussain, DO, FACOEP Ali Jamehdor, DO

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Raymond James, DO Michael Jarzabek, DO Tabitha Jeffers, DO Gregory Jones, DO Risty T. Kalivas, DO, FACOEP Scott Kanagy, DO Jonathon Karol, DO, FACOEP Jessica Kasirsky, DO Elizabeth Kassapidis, DO Dmitry Katkovsky, DO Sophie Kay, DO Gloria Kayfan, DO Kenneth Keller, DO Sara Kelly, DO Thomas C. Kickham, DO Wendy Anne Kissinger, DO Thomas E. Klie, DO William Kokx, DO, FACOEP Joseph Kovacic, DO Michael Kovalick, DO Jay Kugler, DO Christ Kyriakedes, DO, FACOEP Sheera Lall, DO Catherine Langston, DO, FACOEP Gary LaPolla, DO, FACOEP Richard Lartey, DO Ronald Joe Leckie, DO Shi-Wen Lee, DO James Leonard, DO Francis L. Levin, DO Robert Linkenheimer, DO, FACOEP Kevin Loeb, DO Michael LoGuidice, DO, FACOEP Carrie Loterno, DO Lisa Henning Low, DO Freda Lozanoff, DO, FACOEP Sean Ludlow, DO Rose Mack, DO Mary-Lyn Magarelli, DO, FACOEP Mary E. Malcom, DO, FACOEP David T. Malicke, DO, FACOEP Gerald Maloney, DO, FACOEP Michelino Mancini, DO Thomas Marchiando, DO, FACOEP Christopher Martella, DO, FACOEP Bruce A. Marts, DO Mihaela E. Matei, DO Robert Mathews, DO Michelle M. Maureau, DO Ronald McAdam, DO Maureen McCarville, DO

James McClay, DO James W. McCorry, DO, FACOEP James McMullen, DO James Mead, DO Michael Mendola, DO Bryan Menges, DO Andrew Mersky, DO Midstate Medical , Scott T. Miekley, DO, FACOEP Julie Mills, DO Anna Milman, DO Eric Mohr, DO Jeffrey Moldovan, DO Gary Moorman, DO, FACOEP-D Andrew E. Morrison, DO Robert A. Mott, DO Robert D. Mullins, DO Michelle Naegele, DO Samuel Namey, DO Craig Nattkemper, DO Kevin P. Neenan, DO Joe A. Nelson, DO, FACOEP Matthew Nerland, DO Dzung-Young Nguyen, DO Matthew Nickerson, DO David J. Niles, DO Daniel E. Oberdick, Sr., DO, FACOEP Julia Ann O'Brien, DO Price Paul Omondi, DO, FACOEP Robert Ormanoski, DO, FACOEP William E. Osborn, DO Diane M. Paratore, DO, FACOEP Neelesh Parikh, DO Malsuk Park, DO, FACOEP Ernest Patti, DO, FACOEP Arthur Pecora, DO Scott Plasner, DO James D. Polk, DO, FACOEP Valerie A. Pollard, DO J.A. Poplawski, DO Sean Quinn, DO Carol Rahter, DO, FACOEP Narasinga Rao, DO, FACOEP Jody Rein, DO Craig Reynolds, DO, FACOEP William Richardson, DO Vincent Rimanelli, DO Alexander Riss, DO Samuel Robles, DO, FACOEP Alexander Rodi, DO Chadwick Ross, DO

Fred G. Wenger, DO, FACOEP Timothy Rossi, DO Thomas Westenberger, DO David P. Ruby, DO Jeffrey Wheeler, DO Arthur Ruediger, DO Erik White, DO Brandon Russell, DO Kenneth Scott Whitlow, DO Fred E. Sabol, DO, FACOEP Stacy J. Williams, DO, FACOEP Cary Schneider, DO, FACOEP Jennifer B. Wilson, DO Marie Schreiber, DO Warren Wisnoff, DO Michael Schreiber, DO Maury Witkoff, DO, FACOEP John Scranton, DO, FACOEP William Wixom, DO, FACOEP Donald Sefcik, DO, FACOEP Michael Yangouyian, DO, FACOEP Shane Serfling, DO Michael E. Zielinski, DO Regina Sexton, DO Troy Shaffer, DO Ashwin Shetty, DO, FACOEP Merlin L. Shriner, DO, FACOEP James Shuler, DO, FACOEP Sheryl Gottlieb Siar, DO Purabi Mehta Simon, DO Steven A. Smith, DO, FACOEP J. Keith Speed, DO Theodore Spevack, DO, FACOEP-D John Stepanek, DO Douglas D. Stern, DO Ronald Sterrenberg, DO Jennifer Stevenson, DO John F. Sullivan, Jr., DO, ™ FACOEP Matthew Swayze, DO In te n si ve Edith Szabo, DO Im m er si on E xp er ie n ce Ben Tapper, DO Laurie Taylor, DO Marcus Teng, DO, “Amazing opportunity FACOEP to see and do it all in James Thomas, DO Timothy Thompson, DO, airway management.” FACOEP – Micheyle L. Goldman Michael Todd, DO DO, Florida Harrison Tong, DO Jeffrey Trager, DO Craig Steven Turner, DO April 8 – 10, Las Vegas September 23 – 25, Seattle Erwina Ungos, DO October 28 – 30, Atlanta May 13 – 15, Boston Sazanne Vass, DO Sanford Vieder, DO, November 18 – 20, Las Vegas June 10 – 12, Chicago FACOEP Sean Vitale, DO Intensive and hands-on. Focusing on the difficult and failed Darrel Vlachos, DO airway. Challenging Code Airway scenarios. Peter Wachtel, DO, Register at www.theairwaysite.com or (866) 924-7929 FACOEP Brett D. Wagner, DO Lisa M. Ward, DO Evidence-based. Comprehensive. Expert Faculty. John Palmer Weddle, DO

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FOEM's Upcoming Events! FOEM Case Poster Competition This annual competition takes place during the ACOEP Spring Seminar and is open to students and residents that experienced an interesting case that took place in their hospital. Date of Competition Wednesday, April 27, 2011 Deadline: For Application January 31, 2011 Deadline: For PowerPoint March 31, 2011 Top 3 posters are awarded $500, $250, and $125 respectively.

FOEM/MedExcel Research Poster Competition

This annual competition takes place during the ACOEP Scientific Assembly and is open to students and residents that have completed a research project and would like to present it as a poster summarizing their findings. Date of Competition Tuesday, October 11, 2011 Deadline: For Application July 31, 2011 Deadline: For PowerPoint September 30, 2011 Top 3 posters are awarded $500, $250, and $125 respectively.

FOEM/Schumacher Group Clinical Pathological Case Competition (CPC)

FOEM/EMP Resident Research Paper Competition

This exciting annual competition pits residents against faculty in diagnosing a difficult case. It takes place during the ACOEP Scientific Assembly. Residents submit the case without final diagnosis, and the faculty member is given a few weeks to develop a diagnosis. Both residents and faculty submit PowerPoint presentations. Each program must have a resident and faculty member in order to participate. Date of Competition Tuesday, October 11, 2011

This is FOEMâ&#x20AC;&#x2122;s most prestigious event. Participants submit their research papers (already required to complete residency training) for review by a panel of physician experts. The panel identifies the top 3 papers and the resident-authors present their findings at the Annual FOEM/EMP Research Luncheon that is held during the ACOEP Scientific Assembly. Research is mandatory, so SUBMIT YOUR PAPERS TO FOEM and win some cash! Date of Competition Thursday, October 13, 2011

Deadline: For Application July 31, 2011 Deadline: For PowerPoint September 30, 2011 Fee: $100 per program, per case submitted

Deadline: For Application & Submission of Paper: July 31, 2011

Top 3 presentations are awarded $500, $250, and $125 respectively for both residents and faculty members.

FOEM/EmCare Oral Abstract Competition

This competition is the same as the Case Poster Competition, but instead of a poster, the student or resident must create a PowerPoint slideshow to present during the ACOEP Scientific Assembly. Date Of Competition Wednesday, October 12, 2011 Deadline: For Application: July 31, 2011 Deadline: For PowerPoint: September 30, 2011 Top 3 presentations are awarded $500, $250, and $125 respectively.

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FOEM will award up to $3500 annually for the best research papers. Typically the top 3 winning papers awarded $2000, $1000, and $500 respectively, however, FOEM reserves the right to withhold funds if quality PowerPoint presentation is not submitted. FOEM may also divide the money between 2 papers or give it to one winner depending on the circumstance.

For more information, please contact: Stephanie Whitmer Executive Secretary 142 E. Ontario Suite 1500 Chicago, IL 60611 312-445-5700 swhitmer@foem.org

ACOEP's Starting Line-up by Erin Sernoffsky It’s the most wonderful time of the year! Baseball season is in full-swing, ushering in warmer weather and filling our brains with thoughts of double headers, sunshine and hotdogs. As major league teams make trades and find their starting rotations, ACOEP also has some exciting changes to our lineup. Here’s the roster of veteran players and rookies who make up our squad heading into the new season! Brittani Eckhardt Position: Former Member Coordinator Hometown: East Moline, IL Years in Organization: 2

Services

ACOEP fans will be sad to learn that free agent Eckhardt has decided to take her talents to the Quad Cities, where she is getting married this spring. The entire organization will miss her dearly and wishes her well!

Geri Phifer Position: Administrative Assistant Hometown: Columbus, MS Months in Organization: 3 Number: 312.445.5707 gphifer@acoep.org

Phifer, no longer the new kid on the block, is ACOEP’s utility infielder. Phifer makes an excellent teammate to the Executive Director, assisting in all areas of administrations. Familiar with ACOEP for many years, the organization is thrilled to find her a spot on the starting rotation this season!

Jaclyn Ronovsky Position: Member Services Assistant Hometown: La Grange Park, IL Months in Organization: 1 Number: 312.445.5702 jronovsky@acoep.org

Ronovsky is the latest addition to the 2011 recruiting class. This rookie assists with all

membership duties, from applications and dues payments, to Student and Resident Chapter concerns and the mentorship program.

Erin Sernoffsky Position: Meetings Assistant Hometown: Akron, OH Years in Organization: 2 Number: 312.445.5709 esernoffsky@acoep.org

Sernoffsky, a recruit out of Ohio, assists the meetings department in preparing for conferences. She can be contacted for questions about COLA credit and certificates, Oral Board Review information, exhibitor and sponsorship coordination, and concerns pertaining to ACOEP’s new social media initiatives.

Brian Thommen Position: Director of IT Services Hometown: Chicago, Illinois Years in Organization: 8 Number: 312.445.5703 bthommen@acoep.org

Number: 312.445.5704 mandyward@acoep.org

As Membership Captain, Ward handles any issues pertaining to dues, fellowship, the Career Center, member benefits, Undergraduate Medical Education Committee, Member Services Committee, and Practice Management Committee. She is also the team leader on ACOEP’s database and can assist with any log-in problems.

A veteran Meetings Director, Wattonville is adept at fielding questions related to meeting registration and agenda information, as well as any CME issues. She is the go-to player for the CME Committee and is the direct link to all conference chairs and speakers.

ACOEP’s IT heavyweight, Thommen is the point-man for technical responsibilities including the development and launch of ACOEP’s new website. He can also be called upon for assistance with AV and presentations at all conferences.

Jan Wachtler Position: Executive Director Hometown: Chicago, IL Years in Organization: 19 Number: 312.445.5705 janwachtler@acoep.org

Coach Wachtler has fielded a promising team. A veteran of the College, this hometown favorite is the source of all ACOEP institutional information. Mandy Ward Position: Director of Member Services Hometown: Minooka, IL Years in Organization: 5

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Kristin Wattonville Position: Director of Meetings and Conventions Hometown: Rockford, Illinois Years in the Organization: 4 Number:312.445.5710 kwattonville@acoep.org

Stephanie Whitmer Position: Executive Assistant at ACOEP, Executive Secretary for FOEM Hometown: Chicago, Illinois Years in Organization: 1.5 Number: 312.445.5700 swhitmer@acoep.org

After years away, Whitmer returns to ACOEP where she can answer any general College inquiries including those regarding payment and billing information. Whitmer is also the team’s go-to player for all things FOEM, encompassing competitions, grant and award applications, and charitable contributions.

ACOEP Announces Visual Stimulus Competition ACOEP is in the process of establishing a new electronic database to collect visual stimuli for the purposes of medical education for its membership, particularly for use at the Intense Review and Oral Board Review Courses. To bolster involvement in this undertaking, we would like to present a new competition! By submitting your original visual stimuli to the Visual Stimulus Competition you could win prizes of $1000 $500 and $250 for the top three submissions. This work will also be considered a scholar activity for those participating in resident education. All content will be controlled by the College through the Continuing Medical Education Committee. The initial phase will gather material for the main educational programs of ACOEP, namely the Intense Review and Oral Board Programs. The next phase will become an annual competion that will be showcased at the Fall Scientific Assembly. These photographs of patients, EKGs, radiographic studies or other visual stimuli demonstrating classic or unique findings will be used to enhance the education of the prac-

tioning emergency physician, and then be added to a developing web-based database for the general membership to access for their own review.

Presidential Viewpoints, continued from page 1

the osteopathic educational system and provides recommendations to reengineer and streamline the certification, continuing medical education, and postdoctoral process. Prior to the meeting, I solicited input from our CME, GME, and Executive Committees. I then submitted written comments prior to the meeting to the committee chairman. Dr. Christiansen and I attended a special meeting that reviewed each one of the committee’s recommendations. I took full advantage of the opportunity to voice the concerns of the ACOEP. Our goal was to publically express our desire to maintain the integrity, financial viability, and exceptional quality of all of our emergency medicine residency and CME programs. I believe our concerns were heard along with those of many of

be partnering to develop the innovative and cost effective patient care initiatives. At the conclusion of the meeting in Dallas, Dr. Christiansen and I flew to Phoenix, AZ for the AOA Board of Trustees (BOT) mid-year meeting. I have always found the BOT meeting to be a great opportunity to discuss ACOEP issues with some of the Board members in a relaxed and neutral environment. This meeting was no exception. The subject that was most important to us was the Report of the Education Policy and Procedure Review Committee III (EPPRC III). The Committee Report presented the current structure of

Visual Stimulus Competition Format

Only original visual stimuli will be considered for presentation, this includes photographs of patients, EKGs, radiographic studies or other visual stimuli demonstrating classic or unique findings that will enhance the education of the practioning emergency physician. A minimum of two different photographs should be submitted for each individual case. Please submit digital JPEG image by an email attachment (resolution of at least 640 x 480) to bthommen@acoep. org and almeidavic@aol.com and be sure to mark them “ATTN: Visual Stimulus Competition.” Each submission must abide by the following convention: a case review with the ensuing elements: 1) chief complaint, 2) history of present illness, 3) focused physical exam, 4) pertinent laboratory data, 5) two questions asking the student to identify the diagnosis or pertinent finding(s). This case review will be typed on a single 8.5” x 11” page document

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in Microsoft Word® for Windows. On a separate page, please list the answer(s) and brief discussion of the case, including an explanation of any key features or aspects. This two-page document will be mounted adjacent to the photographs on the 2’ x 2’ board. The case review is limited to 250 words. Submissions will be selected based on their educational merit, relevance to emergency medicine, quality of the photograph and the case history. Accepted submissions will be notified via email and will be instructed when to set-up and dismantle their case. Patients, patient identifiers and hospital specific information should be appropriately concealed. If accepted for display, ACOEP reserves the right to edit the submitted case. Participants must attest that written consent and release has been obtained for all photographs, with the exception of isolated diagnostic studies such as EKGs, radiographs, etc. Authors will be responsible for bringing their photograph(s) and case review (2 pages with case review and answer) to the Scientific Assembly. Authors of all photos submitted by July 30, 2011, will receive a notification of acceptance or rejection by August 30, 2011. the other specialty colleges. The EPPRC III committee will be processing our input and there is more work to be done. I thank everyone for all of the support that you continue to provide me and the ACOEP this year. I encourage each of our members to take an active role in your membership and serve on a committee, mentor a student or resident, share our message with elected officials, or simply send us your thoughts and ideas of how we can serve you better and help you get you involved. Active participation in a career in emergency medicine goes far beyond the walls in a hospital. Thank you.

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

What Would You Do? Our patient is an elderly male amputee with a history of diabetes. He weighs 375 pounds and cannot support himself on his good leg. He lives at home with his frail wife who weighs 98 pounds. The patient has a lifeline device that he uses to call 911 for fire department assistance to adjust him in bed or to go to the bathroom. His wife is unable to help and there is no other family. Additionally, the patient has recently sold the hospital bed he obtained for free.

I think we all know where this is going. The patient calls 911 many times each day. He invariably refuses transport to the hospital, requesting only the daily living need described. The local fire department is getting frustrated at what they perceive as abuse of the EMS system. They come to you for guidance. What would you do?

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Please send your thoughts and ideas to (fax 708-915-2743). Every attempt will be made to publish them when we review this case in the next Pulse. If you have any cases in your practice that you would like to present or have reviewed in the The Pulse, please fax them to us.

At First Look At First Look Presentation: Case 1:34 y/o WM arrives to the ER with fever, chills and a painful lesion in the tip of his left middle finger. These symptoms started four days ago. Vitals:Presentation: BP: 140/90 34 HR: 110 RR: 22 O2Sa: 96 % RAfever, Temp: 101.5 y/o WM arrives to the ER with chills and a painful lesion in the tip of his left middle finger. These symptoms

started four days ago.

Hx: The patient works in construction. He thought that this painful lesion might have been caused by a piece of metal that penetrated his finger during work. He did not think much of it. However, the fever persisted, and he decided to come to the ER.

Vitals: BP: 140/90 HR: 110 RR: 22 O2Sa: 96 % RA Temp: 101.5

PE: A tender red to purple nodule was noted in the pulp space of the terminal phalange of the left middle finger. The patient was The patient works in was construction. this painful lesion might have been caused by a piece of metal that febrile.Hx: A holosystolic murmur heard at He the thought apex of that the heart. Whenpenetrated asked, the denied everHebeing told thatmuch he has his patient finger during work. did not think of it. However, the fever persisted, and he decided to come to the ER. murmur, even on his last physical exam which was about a month ago. The remainder of the physical exam was within normal limits. A tenderare red to purple noted in the space of the terminal phalange of the left middle finger. The patient ThesePE:images given to nodule you was based from thepulp patient presentation. was febrile. A holosystolic murmur was heard at the apex of the heart. When asked, the patient denied ever being told that he has

At First Look

murmur, even on his last physical exam which was about a month ago. The remainder of the physical exam was within normal limits. These images are given to you based from the patient presentation.

Presentation: 34 y/o WM arrives to the ER with fever, chills and a painful lesion in the tip of his left middle finger. These symptoms started four days ago. Vitals: BP: 140/90 HR: 110 RR: 22 O2Sa: 96 % RA Temp: 101.5 Hx: The patient works in construction. He thought that this painful lesion might have been caused by a piece of metal that penetrated his finger during work. He did not think much of it. However, the fever persisted, and he decided to come to the ER. PE: A tender red to purple nodule was noted in the pulp space of the terminal phalange of the left middle finger. The patient was febrile. A holosystolic murmur was heard at the apex of the heart. When asked, the patient denied ever being told that he has murmur, even on his last physical exam which was about a month ago. The remainder of the physical exam was within normal limits. These images are given to you based from the patient presentation.

Question: Can you describe the image above and do you know what is going on with the patient? (Are you also able to name the finger lesion?)

Question: youabove describe theknow image above Question: Can you describe Can the image and do you what is going and do you know what is going on with the on with the patient? (Are you also able to name the finger lesion?

patient? (Are you also able to name the finger lesion?)

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So What Have You Been Looking At? Case 1 Answer: This patient presented with fever, chills and painful lesion on his finger (Osler node). CBC showed leukocytosis with left shift. X-ray of the left hand was normal. The new regurgitant heart murmur led us to ordering the echocardiogram. As shown, vegetation on the mitral valve was noted. The diagnosis of Sub acute infective Endocarditis was made. The patient was admitted for two days where he received high dose IV antibiotics. He was then discharged with a six weeks course of antibiotics, and was instructed to follow up with a cardiologist and have a repeat echo at the end of the six weeks.

At First Look - Answer

Osler Nodes: These nodes are infrequent due to earlier diagnosis and Rx. Nodes are described as red-purple, slightly raised, tender lumps, often with a pale centre. The cause of the lesions is due to immune complexes. Biopsies of the lesions have been shown to find bacteria that are coherent with the cause of the endocarditis. Answer: This patient presented with fever, chills and

Many thanks to Farook Taha OMS III UNDMJ-SOM for submitting this case.

painful lesion on his finger (Osler node). CBC showed leukocytosis with left shift. X-ray of the left hand was normal. The new regurgitant heart murmur led us to ordering the echocardiogram. As shown, vegetation on the mitral valve was noted. The diagnosis of Sub acute infective Endocarditis was made. The patient was admitted for two days where he received high dose IV antibiotics. He was then discharged with a six weeks course of antibiotics, and was instructed to follow up with a cardiologist and have a repeat echo at the end of the six weeks.

The PULSE APRIL 2011 Many thanks to Farook Taha OMS III UNDMJ-SOM for submitting this

O R lu t t e

M c

Valley emergency medicine residency of modesto New eM ResideNcy PRogRaM diRectoR waNted!

ew Emergency Medicine Residency Program Director wanted for program at large teaching hospital in Modesto, California starting in 2012. Must meet all requirements for Program Director position as stated by the ACOEP. Great opportunity, great salary and benefits, great location and working conditions and educational environment. Please contact Dr. Peter Broderick, CEO/DIO, Valley Consortium for Medical Education, affiliated with Midwestern University OPTI.

209-576-3528 (office) | 209-404-7160 (cell) Email: peter.broderick@valleymeded.org

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