January 2010 VOLUME XXXV NO. 1
A Patient's Perception of Quality
Thomas A. Brabson, D.O., MBA, FACOEP
Presidential Viewpoints Let me begin by wishing everyone a Happy and Healthy New Year. By the time you are reading this the holiday season has ended and so have many of our New Year’s resolutions. Regardless, we can all take a moment to reminisce and celebrate all of our personal and professional accomplishments from last year. Then we can plan and set new goals for this coming year. Your Board of Directors will be meeting at the end of January in strategic planning sessions. Our mission will be to evaluate what goals we have achieved over the past two years since our last session. We will then plan for the next two years to help assure that our College will continue to grow, prosper and continue to serve our members. Planning for the future is essential for the success of any operation. The future however, may not be very far away. We all have chosen the profession of emergency medicine. You had to do much planning in your life to overcome the many obstacles on your journey to that goal. Although that
took years, it was well worth the effort in the end. But what about short term planning. When you are driving to a clinical shift, do you try to plan ahead? Remember in my last article, I encouraged each of us to be a ‘Team Leader’. Begin by getting yourself mentally and physically prepared to lead your team during your shift. Once you arrive on shift, identify your team members and understand each person’s role. How is each member of your team going to help you and contribute to the care of your patients? Next plan out how you will handle the patients you will be asked to evaluate. Do you have a good team assembled with all the tools you’ll need to handle just about anything? Although you don’t know their names or chief complaints yet, you do know that the patients are coming. Just like in any other sport, our victories and losses are measured on a scorecard. Number of patients per hour, turn around times, left without treatment, left against medical advice and number of admissions, just to name a few. One scorecard item that sometimes gets emergency medicine physicians fired up is the customer service scores. The cynical physician says that they are not customers, they are patients. Regardless of what term you use, they are first and foremost, people. The people that are our patients, along with their family and friends who are in the emergency department with them, will form an impression of their experience. Instead of getting caught up in potentially negative emotion generating terminology, think of the customer service score as a reflection of the patient’s percep-
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tion of quality. The score that we receive is a reflection of how that person perceived the quality of care that you and your team provided them. In any emergency department there are many different things that can influence someone’s perception. How long did I have to wait to see a nurse or a doctor? How attentive were they to reason I came to the emergency department? Did they work well together to care for me? Were my medical and non-medical needs met to my satisfaction? Did they keep me informed and allow me to participate in my care? Don’t lose sight of the fact that the family and friends in the emergency department will also form a perception and their perception may influence the patient too. So what is a well trained and smart emergency physician to do? Start by remembering that a visit to the emergency department is very anxiety evoking for people. Find ways to identify what may be causing the patient to feel anxious and try to eliminate it. A caring and warm reception when the patient first arrives at the emergency department is a great start. Have you ever had a member of your team stand over a stretcher and say to the EMS crew, ‘Don’t you know we are on divert’? Or try to justify a long wait by saying ”the doctors are very busy and you’ll just have to wait your turn”. These first impressions may create a negative perception that will be very difficult to recover. As the team leader, you’ll need to try to get some service recovery started immediately and re-educate you continued on page 15
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Editorial Staff: Drew A. Koch, DO, FACOEP, Editor Wayne Jones, DO, FACOEP, Assist. Editor Thomas Brabson, DO, MBA, FACOEP Anthony Jennings, DO, FACOEP Janice Wachtler, Executive Director Editorial Committee: Drew A. Koch, DO, FACOEP, Chair Wayne Jones, D.O., FACOEP, Vice Chair David Bohorquez, DO Thomas Brabson, DO, FACOEP 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.
The Pulse An Osteopathic Emergency Medicine Quarterly 142 E. Ontario St., Suite 1500 Chicago, IL 60611-5277
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Me d i c i n e
Q ua r t e r ly
Table of Contents Presidential Viewpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Thomas A. Brabson, DO, MBA, FACOEP Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Drew Koch, DO, FACOEP Executive Director's Desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Janice Wachtler, BA, CBA Members in the News . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Voluntary H1N1 Pediatric Vaccine Recall . . . . . . . . . . . . . . . . . . 7 Nominations Open for Board Positions . . . . . . . . . . . . . . . . . . . . 8 Update on Safe Haven Legislation . . . . . . . . . . . . . . . . . . . . . . . 8 FOEM: Foundation Insights . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 FOEM: Spirited Research Competitions Mark Boston Assembly 10 FOEM: 2009 First Place Posters . . . . . . . . . . . . . . . . . . . . . . . . 12 FOEM: Make a Difference with Charitable Giving . . . . . . . . . . 12
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Emergency Department Ethics . . . . . . . . . . . . . . . . . . . . . . . . . 13 Bernard Heilicser, DO, FACEP, FACOEP
Deadlines for the submission of articles and advertisements are the first day of the month preceding the date of publication, i.e., December 1; March 1, June 1, and September 1. The ACOEP and the Editorial Board of the PULSE reserve the right to decline advertising and articles for any issue.
In My Opinion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Wayne Jones, D.O., FACOEP
©ACOEP 2009 – All rights reserved. Articles may not be reproduced without the expressed, written approval of the ACOEP and the author.
2010 Roth IRA Conversion—Are You Eligible? . . . . . . . . . . . . 18
ACOEP Pursues WADEM Section . . . . . . . . . . . . . . . . . . . . . . 14 New Healthcare Toolbox . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
On the Wild Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 James Shuler, D.O., MA, FACOEP
ACOEP Welcomes New Fellows . . . . . . . . . . . . . . . . . . . . . . . . 19
The PULSE January 2010
Editorial Drew Koch, D.O., FACOEP, Editor
The Pulse 2009 was the year of change for ACOEP. The spring seminar was held in Orlando, Florida. This was a change in venue whereas the last time the spring conference was held in Florida was 1991. ACOEP moved its office in the spring to encompass a floor in the AOA building. Distinguished Fellows were recognized for the first time at the Scientific Assembly. Candidates for the Board of Directors were able to nominate themselves for the first time. The slate for the Board of Directors was completed by self nominators. This process of self nomination appeared to work until one of the candidates withdrew his nomination at the last minute. There were two nominations for the Board of Directors from the floor and both candidates were elected to the Board of Directors. Boston was the site of the Scientific Assembly. ACOEP held their scientific independent of the AOA. This conference was held at different time and location from the AOA fall seminar. This was significant that it was truly the first fall conference that was not held in conjunction with the AOA. Another first was that Boston was the site of this fall’s ACEP Scientific Assembly. ACEP’s seminar commenced as ACOEP’s conference was winding down. The Pulse began the year as part of the Members Services Committee. At the spring conference there was renewed interest in The Pulse and reestablishing the Publication or Communications Committee in the College. The Pulse or the ACOEP Newsletter as it was called had its origins in 1986. The Pulse is published quarterly and relies upon members of the College, ACOEP staff, outside writers and others to submit articles for publication. The publications are mailed to the members of
the college and it is also available electronically. The format of The Pulse has changed over the years and is continually evolving to find articles or topics that members are interested in reading. The Pulse and the Publication Committee rely on volunteers to submit articles. The question asked at the last Publications meeting was, “Does the College want to continue the quarterly publication of The Pulse? The overwhelming answer was yes. ACOEP utilizes The Pulse to provide written communication to members of the college, friends of ACOEP, Osteopathic Emergency Medicine Residents and advertisers. The Publication Committee felt that The Pulse was an integral component of the college and should continue to provide written communication and articles for the membership. The Pulse has changed from a single sheet newsletter that was often mimeographed during its infancy in the late 1980’s to the current 20-24 page newsletter. It has gone from black and white to color on the front page with the last publication and starting with this edition color with the advertisements. This edition will feature 4 pages dedicated to the FOEM Foundation. The Pulse is primarily a publication for the members of ACOEP. The majority of the articles come from members of ACOEP and staff members of ACOEP. The Pulse features articles from the President, the Executive Director, and President Elect. Dr. Bernard Heilicser writes an excellent Ethics column for The Pulse. This has been a mainstay of The Pulse for years. A column on wilderness medicine by Dr. Jim Shulers was added this year. The Pulse has always welcomed articles from members of the college and from friends of the college. Why would the College want to continue their published quarterly publication when there are electronic publications, Facebook, YouTube and Twitter? The AOA just announced that The DO is available as
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an online only publication. This is both for ecological and economic reasons. Social networking sites have become increasingly relevant within the healthcare industry. More and more hospitals utilize social media sites such as Facebook, Twitter, and YouTube. These sites act as helpful networking and marketing tools both for hospitals and physicians and physicians’ groups. ACOEP could have a YouTube channel that features Public Service Announcements. Twitter would be a useful resource for ACOEP and its members. Twitter posts (or tweets) could include Emergency Medicine job opportunities, ACOEP announcements and general news about ACOEP and its members. Facebook would be a tool for physician networking. Other popular media forms of communication for organizations are listserves and Yahoo group. Both the list serves and yahoo groups involve a means of communication within members of a group. With all the change that occurred in ACOEP and with all the new and enhanced technologies that are available to communicate, The Pulse has remained a paper quarterly publication. It is available electronically but a majority of the members want to receive the publication as they have received the publication in the past, by mail. If The Pulse is to continue as the publication of ACOEP it must continue to strive to meet the needs of the members and to publish material that is relevant to its members and to emergency medicine. In order for The Pulse to do this it needs your support and assistance. We need the members to continue to write articles and to tell us what they want to read in their publication. To submit articles to The Pulse, contact the Executive Director at janwachtler@ acoep.org and on the subject line of your email list Article Submission. This will then be forwarded to Dr. Koch and the Editorial Board. Submission deadlines are February 15 (April issue); May 15 (July); August 15 (October) and November 15 (January).
Executive Directors Desk Janice Wachtler, BA, CBA
Are We Our Own Worst Enemies in the War Against the Infection? As I was cleaning off my desktop, preparing to exchange an 8 year old laptop for a newer, more powerful one, I found varying discarded column ideas. Half worked columns discarded in favor of something else that danced across my consciousness and made for better copy. However, one idea streamed through many of these half-baked columns, and that was about how healthcare workers look and how they dress. Then as I was watching television in the early part of November, a segment featured physician hand-washing habits and I thought maybe this is something that could be a valid article. Physician appearance has been revisited ad nauseum, and for that fact, so has hand-washing techniques, but these discarded columns didn’t address physician appearance, they addressed the out-of-hospital appearance of healthcare workers and, many touched on germ prevention. You see, I’m not looking at this from a researcher’s viewpoint, I’m looking at this from the perspective of some guy on the street who sees this and asks why. My perspective of guy-on-the street is forged in “old school” observations, some personal, others from watching old medical programs, like Ben Casey, Medical Center and, of course, Marcus Welby, MD. But what image was honed in my mind was someone who cared for his or her personal appearance, dressed professionally, washed their hands, and were always neat and clean. Nurses were known by their starched white uniforms, with white stocking and sparkling white shoes. Scrubs were saved for operating room venues and connotated germ-free environments and garments that were worn only in the hospital. This is no
longer the case; or at least it appears so. In any city at any time, healthcare workers are seen in scrubs, clogs and sneakers, walking to work, in fast-food venues, restaurants, shopping malls, you name it. They walk into the hospitals wearing these “uniforms” and proceed to work, however, like your office worker, these healthcare professionals aren’t walking into an office, they are walking into a hospital, “an institution that provides medical, surgical or psychiatric testing and treatment to people who are ill, injured, pregnant, etc., on a inpatient, outpatient or emergency basis.”* Recently, while visiting someone in the hospital, I met a nurse that I walk with from a parking garage near the office, she usually dresses in scrubs and tennis shoes, her hair hanging in her face, I saw this nurse on the floor taking care of patients, looking the same as she did outside and I thought ‘hmmm, I guess that’s why people get infections in the hospital.’ So, are healthcare workers partially responsible for bringing germs in by wearing “outside” shoes? I wonder? We all know about MRSA and other ‘super’ germs and infections that have
occurred in hospitals. Recently we’ve heard that something like 90% of physicians ‘thought’ they washed their hands between patients, when in reality the percentage was much, much less. If, in fact, this is the case and as the University of Maryland is researching through a grant from the Robert Wood Johnson Foundation, could physicians and other healthcare workers be their own worst enemy in fighting the war against infection? Could all the good physicians be brought down by dirty hands? Should healthcare workers step back and study the infection rates between the 1950’s and now to see if some of the laxity in policies regarding wearing clothes and shoes in hospitals effect the supposedly germ-free atmosphere of hospitals? It might be notable to compare the rates of infection to determine if the rates of nosocomial infection to determine if its based on too many antibiotics or if its from the laxity of healthcare workers and their own perceptions of acceptable handwashing and wearing hospital garb both inside and outside of the hospitals. *Webster’s New World Dictionary
Are you interested in serving on Committees of the ACOEP? If you are, now is the time to submit your curriculum vitae and cover letter. Positions are available on all Committees that include the following areas: Communications/Publications • Constitutions & Bylaws CME EMS • Fellowship • Finance Governmental Affairs • Graduate Medical • Education Membership & Credentials • Practice Management Undergraduate Medical Education Please submit your CV and a cover letter to the President-elect indicating your interests. Nominations will be made during the fall. Deadline is July 1, 2010 Submit to: Anthony Jennings, D.O., FACOEP, President-elect ACOEP 142 E. Ontario Street, Suite 1500, Chicago, IL 60611 312-587-9951 (Fax)
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Members in the News ACOEP Member, Joe Heck, D.O., FACOEP has announced his candidacy for the U. S. Congress as a Representative for the 3rd District in Nevada. Dr. Heck is a 1988 graduate of the PCOM who completed his
residency at Albert Einstein Medical Center in 1992. A certified emergency medicine physician since 1993, he has practiced in Nevada since his graduation from residency. His work with EMS has allowed him to gain a certificate of added qualifications in EMS through the AOBEM. Dr. Heck began his public service as
a volunteer Medical Team Manager with Nevada Urban Search and Rescue Team â€“ Task Force 1 and a member of the Las Vegas Metropolitan Police Department (LVMPD) Search and Rescue Team. He continues to serve as a tactical physician with the LVMPD SWAT Team. Called to active duty in 1996 to support Operation Joint Endeavor and in 2003 to support Operation Noble Eagle, Joe continues to serve in the US Army Research having returned from a deployment in Iraq in support of Operation Iraqi Freedom. He currently holds the rank of Colonel and commands a US Army Hospital. In 2006 he graduated from the US Army War College, earning a Masters of Strategic Studies. Previously, Dr. Heck represented the 5th District in the Nevada Senate (2004-08), serving on the Natural Resources, Human Resources and Education and the Commerce and Labor Committees, and as Vice Chair of
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the Transportation and Homeland Security Committee of that body. Dr. Heck has been a member of the ACOEP since 1990 and has served as a member and vice chair of the EMS Committee. He has been a frequent speaker on EMS for the College. We wish him all the best in his run for Congress. Would you like to announce something happening in your professional career? If so, contact Mandy Lundeen, Director of Member Services at mandylundeen@acoep. org, in the subject line list Member News and we will pass it onto the Editorial Board for review.
Non-Safety Related Voluntary Recall of Certain Lots of Sanofi Pasteur H1N1 Pediatric (0.25 mL, for 6-35 month olds) Vaccine in Pre-Filled Syringes Summary: As part of its quality assurance program, Sanofi Pasteur, Inc., performs additional routine, ongoing testing of influenza vaccines after the vaccine has been distributed to health care providers to ensure that vaccines continue to meet required specifications.In recent testing of the amount of antigen in its influenza A (H1N1) monovalent vaccine, Sanofi Pasteur found four distributed lots of single-dose, prefilled syringe pediatric (0.25 mL.) vaccine with antigen content lower than required potency levels. The manufacturer is conducting a non-safety related voluntary recall of these affected lots of vaccine. Background After performing these tests, Sanofi Pasteur notified the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) that the antigen content in one lot of pediatric syringes that had been distributed to providers was later found to have dropped below a pre-specified limit. As a result of this finding, Sanofi Pasteur tested additional lots and found that three other lots that had been distributed also had an antigen content that had fallen below pre-specified limits. This means that doses from these four vaccine lots no longer meet the specifications for antigen content. Recommendations While the antigen content of these lots is now below the specification limit for the product, CDC and FDA are in agreement that the small decrease in antigen content is unlikely to result in a clinically significant reduction in immune response among persons who have received the vaccine. For this reason, there is no need to revaccinate persons who have received vaccine from these lots. Providers are being asked to return any vaccine to the manufacturer in the following lots that remains unused to the manufacturer:
• 0.25 mL pre-filled syringes, 10-packs (NDC # 49281-650-25, sometimes coded as 49281-0650-25): UT023DA UT028DA UT028CB • 0.25 mL pre-filled syringes, 25-packs (NDC # 49281-650-70, sometimes coded as 49281-0650-70): UT030CA These lots were shipped in November and are intended for children 6 months through 35 months of age. Sanofi Pasteur will send directions for returning unused vaccine from these lots to providers. All vaccines are thoroughly tested prior to release and shipping to determine that they meet all manufacturer and FDA standards for purity, potency and safety. The affected vaccine met all specifications at the time of release. CDC and FDA have determined that there are no safety concerns for children who have received this vaccine. Sanofi Pasteur has discontinued distribution of the 0.25 mL syringes of H1N1 pediatric vaccines. The drop in antigen content below the required specification that is described here is specific to Sanofi Pasteur’s pediatric H1N1 monovalent vaccine in 0.25 mL pre-filled syringes. The same vaccine packaged in other forms, such as 0.5 mL pre-filled syringes for older children and adults and multi-dose vials, continue to meet specifications. The antigen content in the affected lots of vaccine is only slightly below the specification limit. The slightly reduced concentration of vaccine antigen found in retesting these lots is still expected to be effective in stimulating a protective response. There is no need to re-administer a dose to those who received vaccine from these lots. However, as is recommended for all 2009 H1N1 vaccines, all children less than 10 years old should get the recommended two doses of H1N1 vaccine approximately a month apart for the
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optimal immune response. So, children less than 10 years old who have only received one dose of vaccine thus far should still receive a second dose of 2009 H1N1 vaccine. For children 6 months of age and older, vaccine is available in multi-dose vials. The vaccine in multi-dose vials is safe and effective vaccine for children. One difference between vaccine in pre-filled syringes and the multi-dose vials is that the multi-dose vials contain a preservative (thimerosal) to prevent potential contamination after the vial is opened. The standard dose for this preparation for administration to infants 6-35 months old is the same as for the pre-filled syringes, 0.25 mL. For healthy children at least 2 years of age, the nasal spray (live, attenuated influenza vaccine) is also an option. The nasal spray vaccine is produced in single units that do not contain thimerosal. For More Information: For Questions and Answers related to the withdrawn vaccine see http://www.cdc.gov/h1n1flu/vaccination/syringes_qa.htm Call CDC’s toll-free information line: 800-CDC-INFO (800-232-4636) TTY: (888) 232-6348, which is available 24 hours a day, every day.
Nominations Open For Board Positions The Fellowship and Nominations Committee of the ACOEP is pleased to announce that nominations for the Board of Directors are currently open for members interested in participating in the nominations process. The qualifications for the Board of Directors positions are as follows: (1) Active membership status for a minimum of 5 years; (2) Fellow status for
a minimum of 2 years; (3) Current of past service to the ACOEP in a leadership role (i.e., Committee Chair or Vice Chair) for a minimum of two (2) years. Physician-members seeking nominations should send a letter outlining their desire to run for the Board and informing the Nomination Committee of how they feel they would best contribute to the Board,
a current copy of his or her CV should be attached to the letter. All nominations should be addressed to Peter A. Bell, D.O., FACOEP-D, Chair, Nominations Committee, ACOEP, 142 E. Ontario Street, Suite 1500, Chicago, IL 60611. Nominations deadline is March 1.
Update on Safe Haven Legislation On January 1, 2010 legal changes will station or emergency room or any designatbe made in regards to regulations for Safe ed “safe haven” location. Safe haven definiHavens for abandoned babies. These laws tions vary from state to state, but generally provide a desperate parent a safe and legal all states recognize these three locations. option to unsafe infant abandonment. Effective January 1 the umbrella has been Previous legislation allowed parents to sur- expanded to cover unharmed children 30 render any unharmed child 7 days old or days old or younger. IfPM youPage have1questions about legislation in younger to a staff member at a fire1or12/2/09 police 3:56 TeamHealth(7x4.75)10-28:Layout
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The PULSE January 2010
Juan Acosta, D.O., MS, FACOEP, President, FOEM
Foundation Insights New directions continue to inspire and challenge those of us involved with the Foundation for Osteopathic Emergency M e d i c i n e (FOEM). In Boston, the ACOEP Board decided to offer FOEM the opportunity to incorporate its publication, the Research Beacon, into every issue of The Pulse. So as we begin a new year, with new directions, let me thank the ACOEP, its Board and its members for allowing us to incorporate research news on a quarterly basis, thus providing you with updated and new information more frequently..I hope you are as excited about this change as I am. Reflecting on the Scientific Assembly in Boston, I must say the research competitions were stellar. I was the coordinator for second year of the FOEM/MedExcel Poster Competition. We accepted 39 Case Study and 26 Research posters in 2009. With so many Case Study posters submitted for judging and with the suggestion that there should be a stronger resident research presence at the Spring Seminar, the FOEM Board concluded that the Case Study portion of the poster competition will become a freestanding event at the 2010 Spring Seminar in Scottsdale, Arizona. So anyone interested in presenting a Case Study poster at Spring Seminar will be required to submit it no later than February 1, 2010. The separation of the two poster sections also means that, effective in 2010, only Research Posters will be accepted
for the newly titled, “Research Poster Competition,” held in conjunction with the Scientific Assembly in late October, 2010 in San Francisco. We believe that separating the current poster competition into two events at different times of the year will enable us to continue to improve the quality of the posters submitted for consideration, the presentations themselves, and the audience experience. Beginning with the Case Study Poster Competition at the Spring Seminar 2010 we plan to provide presenters and their program directors with systematic feedback about their work so that the judging process is transparent and programs can benefit from the judge’s evaluation. Another new initiative coming out of decisions made at the FOEM Board meeting in Boston is the launch of a Board Business Development Committee (BDC). Chaired by Peter Kaplan with members Joseph Kuchinski, D.O., FACOEP and
Sherry Turner, D.O., the Committee will develop a business plan to be presented to the Executive Committee of ACOEP in January. The plan will outline the strategies and tactics for increasing the financial resources of FOEM--and ACOEP-through a campaign of systematic outreach to potential corporate donors. FOEM is taking action to expand its scope to further enhance support for its research agenda and may be calling upon some of you to help identify appropriate corporate contacts. We are also planning to contact Program Directors soon so they can help the Foundation identify Research Directors or others with research knowledge who can assist in development of a “Research Basics” CD that will be disseminated to all residency programs. In future issues, I will continue to provide you with progress reports on these new initiatives of the Foundation.
Interested in Research? The Foundation for Osteopathic Emergency Medicine is looking for physicians interested and/or involved in research to serve on the Committee on Research and the Academic Awards Review Committee. Committees are forming now. Please submit your letter of interest and a recent CV outlining your research experience or interests to the Executive Director, Carolyn Swallow
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Carolyn Swallow, Ph.D., Executive Director, FOEM
Spirited Research Competitions Mark Boston Assembly For the second year, the participants of the FOEM/MedExcel Poster Competition enjoyed the format adopted last year for presenting posters. This format provided the audience with the ability to view the poster being discussed allowing the audience to experience a visual and auditory poster review simultaneously. Thirty-nine Case Study and 26 Research Posters were accepted for the competition. The Case Study section of the competition was won by Jeff Sarata, DO, MSU/ EM Residency Lansing, MI, First Place, for his poster “Septic pulmonary emboli secondary to cutaneous abscess.”; Marianna Karounos, DO, St. Joseph’s Regional Medical Center, Paterson, NJ, Second Place; presented “Brugada Syndrome: A life saving catch.” Julie Sanicola-Johnson, DO, St. Joseph’s Regional Medical Center, Paterson, NJ, won Third Place for “Unusual presentation of abdominal pain in an adult: 32-year-old female with intussusceptions.” The Research Poster section was won by John Rimmer, DO, St. Barnabas Hospital, Bronx, NJ, First Place; for “The non-traumatic red eye—A systematic approach to clinical teaching and diagnosis.” Christopher Hill, DO, Good Samaritan Hospital Medical Center, West Islip, NY, won Second Place for “A comparison of three ways to measure blood pressure: A novel ultrasound color flow Doppler method, a traditional audible Doppler method and the traditional auscultatory method.” Kelly Klocek, DO, Ohio Valley Medical Center, Wheeling, WV won Third Place for “Systematic prophylactic antibiotics in epistaxis treated with anterior nasal packing.” Look for the abstracts of the First Place posters in this section of The Pulse; second and third place winners’ abstracts will be re-printed in future issues of The Pulse. Judging the posters in the narrow timeframe allowed is a grueling process and we couldn’t do it without passionate physician volunteers. This year’s crew includ-
ed Bernadette Brandon, D.O., FACOEP, Douglas Hill, D.O., FACOEP, Mark Mitchell, D.O. FACOEP, Daniel Olsson, D.O., FACOEP, Catherine Polera, D.O., FACOEP, Murry Sturkie, D.O., FACOEP and Brian Wiley, D.O., FACOEP Thank you, poster judges.. Again in Boston, the FOEM/Schumacher Group CPC Competition had enthusiastic participation by residents and attending physicians as well as its large audience. Fourteen residency program cases were accepted for the competition this year. Mark Foppe,DO, FACOEP organized and coordinated the event. First Place winners were resident Dennis C. Mays III, DO, Ohio Valley Medical Center, Wheeling, WV and attending Beth Longenecker, DO, FACOEP, Mount Sinai Medical Center, Miami, FL. Second Place winners were resident Matthew Turner, DO, Henry Ford Macomb, Macomb, MI and attending Michael D’Ambrosio, DO, FACEP, Kennedy Health System, Stratford, NJ. Third Place winners were resident Virginia Stoll-Tyrell, DO, Charleston Area Medical Center, Charleston, WV and attending John Herrick, DO, Christus Spohn Hospital, Corpus Christi, TX. We look forward to as lively a CPC Competition in San Francisco in 2010. CPC judges included Mark Foppe, D.O., FACOEP, Gerald Maloney, D.O., FACOEP, Michael Oster, D.O., FACOEP and Gary Willyerd, D.O., FACOEP. Thanks to them for their service. Traditionally the most prestigious resident research competition is the FOEM/ EMP Research Paper competition that is judged in advance of the Scientific Assembly. The judges carefully evaluated the eighteen papers submitted. The winners were: Tameem S. Husain, DO, First Place for “Comparison of the cardio-toxic effects of reacemic albuterol vs levalbuterol in treatment of acute airflow obstruction.”; Captain Kamal S. Kalsi, DO, Second Place for “High frequency users of the Emergency
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Department: A descriptive study,” and Tamara Moise, DO, Third Place, for “Patient analysis as a function of mode of arrival to the Emergency Department.” Each winner presented their research at the well-attended FOEM/EMP Research Paper Award Luncheon. Dr. Husain’s abstract is re-printed in this section of The Pulse. The abstracts of Drs. Kalsi and Moise will be re-printed in future issues of The Pulse. Your fellow physicians judging the papers included Juan Acosta, D.O., FACOEP, Gary Beasley, D.O., FACOEP, Anthony Guarracino, D.O, FACOEP, Robert Suter, D.O., ACOEP, Gary Willyerd, D.O., FACOEP and Valerie Woodmansee, D.O., FACOEP.. We thank them for spending their valuable time on this service to the Foundation. The final competition at the Scientific Assembly was the FOEM/EmCare Oral Abstract Competition and Luncheon. The First Place winner was Annie Gharapetian, DO, St. John Oakland Hospital and St. John Hospital, Oakland, MI for “Pediatric alcohol related injuries. . . Does insurance matter?” The Second Place winner was Alfredo Rabines, DO, St. Barnabas Hospital, Bronx, NY for “Resident satisfaction with translation and interpretation methods in an urban hospital setting.” Shimbul Shah, DO, St. Barnabas Hospital, Bronx, NY was the Third Place winner for “What factors are important when selecting an emergency medicine residency? The perspectives of medical students versus recent residency graduates.” Judges included Juan Acosta, DO, FACOEP; Mark Foppe, DO, FACOEP; Mark Mitchell, DO, FACOEP, and Murry Sturkie, D.O., FACOEP. Thanks to them for providing their services for the final competition of the Scientific Assembly. We look forward to another lively set of competitions next October in San Francisco—see you there!
The FOEM/MedExcel Poster Competition participants were residents in AOA/ ACOEP sponsored residency programs. The Foundation is grateful to MedExcel for this their second year of sponsoring the monetary awards for this event This year over 65 posters were accepted. For the second year, each resident’s poster was projected in a PowerPoint format as the residents presented research. Because of the large number of submissions, each resident had less than 10 minutes for presentation and questions. Juan Acosta, M.S., D.O., FACOEP, President of the Foundation for Osteopathic Emergency Medicine (FOEM), coordinated the Poster Competition. He worked with volunteer judges who used predetermined criteria to evaluate the posters and decide First, Second and Third Places Abstracts of the First Place Research and Case Study poster are re-printed below. 2009 Research Poster Winner First Place John Rimmer, D.O. St. Barnabas Hospital, Bronx, NY The nontraumatic red eye: A systematic approach to clinical teaching and diagnosis BACKGROUND: The nontraumatic red eye is the most common ocular complaint in Emergency Department, the etiology of which ranges from benign to sight-threatening conditions. The ability to differentiate between these conditions and recommend initial therapy falls to emergency physicians. When polled, graduating residents often feel uncomfortable with eye complaints. Training regimens in the red eye are varied, and there’s no standardized strategy for approaching a red eye in emergency
medicine training curriculums. Past work in the area has produced several opinion papers on suggested management but no systematic, validated approach. Emergency medicine has often benefited from such structured algorithmic approaches, such as with the NEXUS criteria for cervical spine injury or Ottawa Ankle Rules. We propose a similar approach to the nontraumatic red eye, a system by which the clinician can practice with a streamlined method, offering patients better ocular care and appropriate consultation. OBJECTIVE: To create and validate a clinically structured approach to the nontraumatic red eye. We propose an introduction of this approach through two phases, an educational phase followed by clinical validation, the first of which we will accomplish with this study. METHODS: We first polled residents and attending physicians in emergency and internal medicine on their perceived importance of presenting ocular signs and symptoms. Next a set of six yes/no questions were developed by attending ophthalmologists as an algorithmic guideline which enables the clinician to proceed down a pathway that emphasizes important elements in the history and physical exam. These can then be used to formulate a diagnosis or acuity level of presenting complaint and determine the need for appropriate consultation. Following this we randomized emergency and internal medicine residents into two groups and had them take a ten question visual quiz on sample red eye cases. Quizzes were given via a secure website and included a brief history, images of red eyes and slit-lamp exams. Examinees were asked to submit a diagnosis, and need for consultation as urgent or routine. Half of the residents had prior access to the algorithm and half did not. Scores were statistically
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analyzed for value of the algorithm in obtaining a correct diagnosis. RESULTS: Data collection is ongoing and will determine if a structured approach will aid non-ophthalmologist clinicians in arriving at a correct diagnosis and need for ophthalmologic consultation. CONCLUSION: We theorize a structured algorithmic approach to the nontraumatic red eye will aid in organizing a clinician’s approach to ocular complaints, providing for improved clinical acuity, disposition, and appropriate consultation. Once determined, the approach will need to be clinically validated with patient encounters in a multi-center large-scale trial. References
1. Dart JKG. Eye Diseases at a community health centre. BMJ 1986; 293:1477-1480 2. Galor, A. Red eye for the internist: When to treat, when to refer. Cleveland Clinic Journal Med 2008; 75: 137-143 3. Leibowitz HM. The red eye. N Engl J Med 2000; 343:345-351 4. McDonnell, PJ. How do general practioners manage eye disease in the community? British Journal of Ophthalmology 1988; 72: 733-736 5. Shapiro MB, Croasdale CR. The red eye: A Clinical Guide to Rapid and Accurate Diagnosis. In Krachmer JH, Mannis MJ, Holland EJ. Cornea. St Louis: Mosby, 1997: 438-45.
2009 Case Study Poster Winner First Place Jeffrey Sarata, D.O. MSU EM Residency, Lansing, MI Septic pulmonary emboli secondary to cutaneous abscess At first glance this would appear to be two separate disease entities in a patient with a history of asthma. She entered the emergency department complaining of a cutaneous abscess in her axilla and dyspnea that felt like an
asthma exacerbation. A high degree of clinical suspicion prompted further evaluation with a chest x-ray revealing a pulmonary nodule. The ensuing clinical workup led to the diagnosis of septic pulmonary emboli secondary to the cutaneous abscess. Left untreated or undiagnosed, this could have been a fatal disease entity. HPI: A 51 year-old female presented to the Emergency Department complaining of a painful, swollen area in her right axilla. She had been treated for an abscess at an urgent care clinic 4 days prior but no drainage was performed. Incision and drainage was performed and she was discharged home. She returned 2 days later for removal of packing and also complained of dyspnea which felt like an asthma exacerbation. Chest x-ray revealed a pulmonary nodule so follow up CT was obtained. CT
demonstrated a large pleural effusion and multiple septic emboli. Chest X-ray may show multiple poorly defined round opacities, pleural effusion, or non-nodular alveolar or interstitial infiltrate. Confirmation is based on computerized tomography. Smaller septic emboli may resolve with antibiotic and heparin treatment. Larger emboli may require operative intervention to control the source. Adequate antibiotic coverage is the mainstay of treatment with therapy directed empirically toward the extra-pulmonary infection. The patient improved on antibiotic therapy and follow up CT demonstrated resolution of the effusion and many of the nodules.
with Septic Pulmonary Emboli. J Emerg Med, 2008.12.029 2. Cook RJ, Ashton RW, Aughenbaugh GL. Septic Pulmonary Embolism. Chest 2005;128:162– 6. 3. Lin, Jung-Chung and Chang, Feng-Yee, Pyogenic Liver Abscess Associated with Septic Pulmonary Embolism. J Chin Med Assn 2008, 71, 603-4. 4. Lin, M.Y.and Rezai, K. Septic Pulmonary Emboli and Bacteremia Associated with Deep Tissue Infections Caused by Community-Acquired Methicillin-Resistant Staphylococcus Aureus. J Clin Microbiology. 2008, 46, 1553-5. 5. Dale, D.C. Infectious Diseases: The Clinician’s Guide to Diagnosis, Treatment, and Prevention. WebMD, 2007.
1. Kruse, T.B. and Vadeboncoeur, T.F. MethicillinResistant Staphylococcus Aureus Sepsis Presenting
Make A Difference With Charitable Giving More than ever before, charities depend on people like you to support their important work. But how can most of us make a difference, especially when we’re so busy planning for your other financial goals? The answer may be a life insurance policy. A life insurance policy can transform a small giver into a substantial donor, and serve as a great replacement vehicle for your heirs if you gift other assets to charity during your lifetime. There are two main options you can use to structure your charitable gift using life insurance as the funding vehicle: the Life Insurance Endowment Option and the Asset Replacement Option. The Life Insurance Endowment Option The Life Insurance Endowment Option is easy to establish: your favorite charity is simply named beneficiary of a life insurance policy on your life. Through this technique, both you and the charity can reap important benefits. You benefit because you can make a
major gift for a few dollars a year. When the charity is the Policy owner and beneficiary of the policy, the premium payments may be income-tax-deductible for you. Finally, your gift is self-executing and proceeds are paid promptly. The charitable institution benefits, too. They’re assured of a source of future income. The amount of the gift is certain. There may be possible access to the cash surrender values, and they have total control of the program if they own the policy. The Asset Replacement Option With this option, you make a tax-deductible gift to charity (cash, stocks, bonds, real estate, or other assets). Then you purchase a life insurance policy, naming your heirs as beneficiaries, to replace the property you “gifted.” The money you save from the income tax deduction could help fund the policy premium. You benefit, because your gift may qualify for a current income-tax deduction. You can
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also place the gift in a trust to provide you with income while you’re still alive. Plus, your gift may escape estate taxes after your death. And finally, after you’re gone, your heirs receive insurance benefits equal to the value of the asset you gifted. Likewise, the charitable institution benefits because the amount of the gift is certain. If you opted to place the gift in a trust, the charity can control the asset during your lifetime by serving as trustee and they’re assured of a source of income. For more information, please contact: Sheldon R. Bender, Vice President (847) 457-3012 GCG Financial, Inc. 3000 Lakeside Drive, Suite 200 South Bannockburn, IL 60015 This information should not be considered tax or legal advice. You should consult your tax and legal advisor regarding your own situation. Insurance products offered by Minnesota Life Insurance Company, Securities offered through Securian Financial Services, Inc. Member NASD/SIPC. GCG Financial, Inc and Securian Financial Services, Inc. operate under separate ownership.
Emergency Department Ethics Bernard Heilicser, D.O., MS, FACEP, FACOEP
Mass Casualty Situation in Your ED, What Would You Do? In this issue of The Pulse we will review the hypothetical posed as to the appropriateness of giving placebo medication in a mass casualty event. This was presented in October 2009. What would you do to maintain operations in an emergency department if it was being overwhelmed by an influx of patients? In the event of a mass casualty, weapon of mass destruction or infectious etiology (i.e. H1N1) situation, and your ED was â€œgoing underâ€? or at risk for physical attack from a frightened or hostile community, would you give a placebo to a stable (worried well) patient with instruction to return at a later date? This dilemma really challenges our ethical approach to patient care. Essentially,
placebos are not considered appropriate for treatment (although, more studies appear to demonstrate how our minds affect medical outcomes). How could we rationalize giving a placebo? Two philosophies exist in ethics, and really how we approach patient care. If we consider a deontological approach, or rules-based paradigm, every patient gets the appropriate indicated diagnostics and treatment. Altruistic, but is this practical in a disaster situation? Applying the concept of utilitarianism, or the greatest good for the greatest number, would a placebo then be appropriate? If we allow a mob panic to create a situation where patient care was interfered with
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or halted, we have certainly contradicted the greatest good. More people will suffer and be jeopardized if this was to occur. I would support the justification for administration of a placebo to keep my ED open and safe. I acknowledge this should be an absolute last resort. Let us hope this is more of an intellectual exercise and never a real life challenge. However, thinking ahead about potential issues and ethical dilemmas is an integral part of preparedness. If you have any cases in your practice that you would like to present or have reviewed in The Pulse, please fax them to (708) 9152743. Thank you.
ACOEP Pursues WADEM Section William Bograkos, D.O., FACOEP At the Scientific Assembly, the ACOEP Board gave approval to pursue the development of a section within the World Association for Disaster and Emergency Medicine – WADEM. Under the leadership of WADEM Board member William Bograkos, DO, FACOEP, a group met and wrote tentative mission and vision statements for what we plan to call the “Osteopathic Section of the WADEM”. This action follows the Board approval for the ACOEP to be an Affiliate Member of WADEM. That took place after the Spring meeting. A brief summary of that action appears in a previous edition of the Pulse. Mission Statement – The mission of the “Osteopathic Section of the WADEM” is to pursue academic excellence in international disaster preparedness, response, recovery, development, prevention and mitigation. Vision – To expand the role of the Osteopathic physician in Global Health and Humanitarian Assistance So why has the College decided to make this move? The intent is to have a way for all osteopathic physicians in the US and abroad – regardless of specialty - to inter-
face with like-minded people around the world. Many of our members already are heavily involved in disaster preparedness and response. For many, that is at the local level. For others it involves deployment on DMATs, USAR teams. For others it means lending a hand abroad when disasters strike. Emergency Medicine is the discipline that should continue to lead the way in this critically important area. To that end, the College submitted a proposal to the AOA for a fellowship in Disaster Medicine. If you are a DO and a member of WADEM, we need to know. A section requires a minimum of 10 members, but we would like many more than that. If you do not belong to WADEM and have an interest in disaster medicine, consider joining. Since the College is an Affiliate, the yearly dues are only $120. There will be no other financial commitment. From our Mission and Vision statements you can see that we will have an educational focus. This interface with WADEM will help us to liaison with world experts and should open doors for interested residents to obtain EMS and disaster medicine rotations in parts
of the world they might otherwise never experience. Osteopathic physicians will have a way to meet and talk with world experts. We may be able to collaborate in research that has never before been feasible. WADEM works closely with the World Health Organization. Once we have enough interest from College members, we will write bylaws and distribute drafts to section members for discussion, review and approval. Officers will probably be appointed initially from the group that met in Boston, but future leaders will be elected from the membership. Once the Section is established, leadership will notify the AOA and solicit interest from other DOs. If you are interested or would like more information, contact Bill Bograkos at email@example.com or Steve Parrillo at firstname.lastname@example.org. You may apply for WADEM membership by going to www. wadem.org. We are excited about this new venture. Please join us!
New Healthcare Toolbox Website Helps Providers Manage the Emotional Side of Trauma Everyday, children and families face serious illness or injury. The newspaper headlines read, “Brother and Sister Hit by Car While Crossing Street” or “7-Year-Old Girl Awaiting Transplant” or “Ten Teens Hospitalized with H1N1 virus.” Up to 80% of pediatric patients and their families report experiencing some traumatic stress following illness, injury, hospitalization, or painful medical procedures. Left untreated, traumatic stress reactions can negatively impact medical adherence, treatment, and recovery. The Healthcare Toolbox and the Pediatric Medical Traumatic Stress Toolkit guide medical professionals in effectively assessing and treating medical traumatic stress in their patients and families. Armed with these tools, providers can address the emotional, as well as the physical side of trauma. The Health Care Toolbox (www.healthcaretoolbox.
org) is a web-based compendium of practical assessment and intervention tools that providers can use with traumatized children and families, at different points along the continuum of care. The website contains a wealth of background information about medical traumatic stress, downloadable patient education handouts, and teaching materials. The Toolbox also highlights the D-E-F Protocol for trauma-informed care, which helps providers respond to Distress, offer Emotional support, and ensure Familycentered care for traumatized children and families. The D-E-F protocol and other materials are also available in published format as part of the Pediatric Medical Traumatic Stress Toolkit. The trauma of childhood illness and injury may be unavoidable, but health care providers are in a unique position to make
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a difference in the lives of their patients and families. The Pediatric Medical Stress Toolkit and the Health Care Toolbox provides them with the tools to effectively assess and manage the emotional side of trauma. For further information or a complementary copy of the PMTS Toolkit, please contact: Erin E. Falk, RN, BSN Healthcare Outreach Coordinator Center for Pediatric Stress The Children’s Hospital of Philadelphia 34th and Civic Center Blvd. Room 1493, CHOP North (3535) Philadelphia, PA 19104 Phone: 1-267-426-7950 Email: email@example.com Or visit our website at www.healthcaretoolbox.org or www.chop.edu/cpts
In My Opinion Wayne T. Jones, D.O., FACOEP
Do we create studies to prove our experiences? It is late on a Saturday night when you see a twenty-year-old female with pelvic pain. Your exam suggests it may be appendicitis, although you cannot totally exclude an ovarian source. You perform a CBC and CT of the abdomen. The CBC reveals a total WBC of 11,500 and the CT states “appendix is not identified”. You relent and add a pelvic sonogram to evaluate the adnexa. The sono shows a small right ovarian cyst along with minimal fluid in the pelvis. The young lady states that she is now feeling better. You decide she may have suffered a ruptured ovarian cyst and discharge her. What percent chance do you think exists that she really has an appendicitis? Twenty five percent? Fifty percent? What if I tell you that you run into her PCP the following week and discover she is doing just fine? Ok, twenty-five percent it is. What if the PCP tells you that she suffered a ruptured appendicitis at the hospital across town? Ok… Maybe it was a seventy-five percent chance of appendicitis. If the first scenario were to occur, you may self “teach” yourself that the original diagnosis of ruptured ovarian cyst may be closer to a seventy-five percent certainty. Of course, if the latter were true, next time, you would not be as assured an ovarian cyst could be the culprit. In fact, you would be quite certain that the outcome was inevitable given the circumstances. This tendency to perceive outcomes based
on hindsight as inevitable has been termed “creeping determinism”. Creeping determinism has been used when discussing things like the predictability of a war, political elections and the reasons a sexual predator behaves as they may. It has been nurtured in social and societal settings. But, if it exists there, it must also exist in our world of medicine. So, do we use creeping determinism to design our studies? Do we accept our experiences as “inevitable diagnoses and outcomes” and only truly wish to prove these outcomes? Think about many of the decision rules we now have. They are based on an –if this, then that- analysis. However, we fill in the “this” piece. We try to self predict the “ultimate” outcome based on another piece of artificial hindsight. What if our diagnosis is wrong using the decision rule. Well, we always pad the decision rule with what we have labeled sensitivity and specificity disclaimers. Maybe it was the application of the criteria by you or just a weakness of the rule. Either way, we say, it was a predictable outcome given our now lucid hindsight. Why do I think this is so important to understand? Because, as clinicians, we are challenged everyday with missed diagnoses. We may assign blame. We present, mentor, discipline and dismiss our fellow caregivers based on creeping determinism. Moreover, we may not realize that maybe, at the time
they saw the patient, they made a good decision. On the other hand, maybe, they were trying to rely on self-taught experiences. Do you still need clarity? Ok, what is the difference between lumbar strain and an aortic dissection? Chest wall pain and a pulmonary embolism? I was once told by an internist that you cannot have a pulmonary embolism without hypoxemia and tachycardia. Is this bad information, self-taught experience or decision rules? If we use Kline and colleagues PERC decision rule, we find our internist to be correct. This decision rule eliminates patients whose age is less than 50, heart rate below 100, pulse oxymetry greater than 95%, no hemoptosis, no estrogen use, no trauma or surgery within 4 weeks, no DVT history and no unilateral leg swelling. So, maybe our internist is correct (but only if a pulmonary embolism is not present). It’s not easy. Not by a long shot. Retrospective diagnoses may be a product of creeping determinism and not bad thought processes. Or maybe they are. Lawyers love this. They can make the best clinician dance on the stand. We know the weakness of many of our decision processes. We just need to make certain that the studies we design do not rely on creeping determinism.
Presidential Viewpoints, continued from page 1
actually did. Before you leave the room, tell the patient what you are thinking and what you plan to do for them. Then ask if there is anything else they need before you go. A few simple words and gestures that will go a long way in making a patient feel more at ease and less anxious. A patient who leaves your emergency department with a perception that he/ she received good quality medical care will want to come back when they are ill or injured again. They will also want to share their experience with their family and friends. Word of mouth advertising a
positive experience is the best marketing. A patient advertising a bad experience could be detrimental marketing that you may have a difficult or impossible time trying to correct. I can easily say that we all chose this profession with the intention of doing our best to help the ill and injured patient that come to our respective emergency departments. The science of emergency medicine is what people expect us to have mastered. It is the art of emergency medicine though that often shapes their perceptions.
team members. The message should always be that you were expecting the patient you just weren’t sure when they would arrive. Body language is just as important as the spoken word. Even though you may work in a very busy emergency department with many high acuity patients, all that matters to the individual patient is how important they think you consider them. Studies have shown that simply sitting down with a patient causes them to perceive that you spent much more time with them than you
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On the Wild Side James Shuler, D.O.,MS, FACOEP, FAWM
Accidental Hypothermia Commuting to work over a threeday period that set Colorado’s record for the largest snowstorm in October, thus making it the snowiest October in Colorado history, I feel compelled to write about the cold. Oddly enough, I am doing so from the medical clinic on the private Bahama yacht club island of Cat Cay located 80 miles southeast of Fort Lauderdale. In most countries, primary hypothermia is classified as an accident, homicide, or suicide, while secondary hypothermia is usually classified as a natural complication of a systemic disorder. Secondary--or “accidental”--hypothermia occurs in various locations and in all seasons and has a predilection toward those over 65 years of age. Surprisingly, one multicenter study showed that 69 of 428 annual deaths due to accidental hypothermia occurred in Florida! Unfortunately death by this means is difficult to quantify as no reliable histologic criteria exist to confirm hypothermia as the cause of death. There are two or three book chapters’ worth of physiologic stressors that can jeopardize thermostability by either decreasing heat production or increasing heat loss. Age extremes, overall health, nutrition, hydration status, fatigue and sleep deprivation, type of exposure/immersion and a wide variety of intoxicants can affect heat loss through conduction, convection and radiation while impeding compensatory responses. Adding insult to injury, as the CNS cools, speech, motor skills, memory and judgement become impaired. Oddly enough, paradoxical “undressing” by the hypothermic patient is common. EEG’s become abnormal at 33.5°C (92.3°F), about a degree below where most individuals demonstrate neurologic findings of dysarthria, amnesia and poor judgement, and
most become comatose below 30°C (86°F). Beyond being cold, hypothermia can confound laboratory work-up results. Initially respiratory rates increase leading to a respiratory alkalosis, followed by respiratory depression leading to acidosis. As temperature decreases, the solubility of serum carbon dioxide increases. Further shivering increases serum lactate, and, as the organs cool, metabolism and acid clearance become reduced. The buffering capacity of blood is markedly impaired. At 28º C (82.4º F) a 10mm Hg drop in PaCO2 decreases pH by a whopping 0.16, double the 0.08 of the normothermic individual. Overall this leads to a mixed bag. One study found 30% of hypothermic patients to be acidotic while 25% were alkalotic. Hematologically, a number of interesting things happen. The hematocrit increases 2% (from volume depletion) with each 1º C (1.8º F) drop in temperature. The white blood cell count is lowered through several mechanisms and may cause you to miss an underlying infection. Serum potassium tends to lower as the ion shifts into cells and kaliuresis ensues. Hypokalemia is more profound in those chronically hypothermic. Supplementation can lead to potassium toxicity when the patient becomes normothermic. Numerous enzymes elevate during hypothermia and CPK levels can be quite elevated; levels over 200,000 IU have been observed, often accompanied by rhabdomyolysis. Blood urea nitrogen and creatinine are often elevated through a decrease in nitrogenous waste clearance and cold dieresis and are thus a poor guide for volume status. As membrane transport slows, glucose utilization decreases and insulin activity is markedly impaired with a reduction in temperature to 30º C (86º F) where insulin becomes inactive and subsequently should not be administered to a patient until the temperature is above 32º C (89.6º F). Initially this leads to an increase in serum glucose fueled by catecholamine-induced
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glycogenolysis. Prolonged hypothermia is often associated with hypoglycemia as stores are depleted and can confound recovery, so this must be closely followed. Another study of urban hypothermic patients found pancreatitis to be present in 50% of the patients. As the abdominal exam on a hypothermic patient is often unreliable, pancreatic enzymes should be checked.Additionally, all hypothermic patients should be handled very carefully and be placed on a cardiac monitor as even minor trauma/rough handling can lead to ventricular fibrillation. As most hypothermic patients are volume depleted, moderate to large amounts of fluid may be required to resuscitate the patient. Standard saline solutions, possibly with 5% dextrose if indicated should be used. Avoid Ringer’s lactate as the cold liver is unable to metabolize lactate. As we’ve all been trained, there are many rewarming options. At the core (excuse the pun) there are passive external and active external and internal techniques that can be undertaken. The passive techniques are those that allow the hypothermic patient to rewarm themselves. The active techniques imply that some rewarming technique is being actively applied or administered. External techniques include “Bear Huggers” and other external heat sources, immersion, and negative pressure rewarming. Core measures include heated infusions, inhalation, “cavity” lavages like peritoneal etc., extracorporeal measures and cardiopulmonary bypass. First-hour rewarming results varied little between external and internal techniques in most studies, but were clearly better than passive. Core rewarming using mask inhalation or endotracheal tube and nasotracheal tube rewarming appear to be superior with an added 0.5-1º C rewarming per hour. As with many things in medicine, simpler is often best. The more invasive methods carry with them higher complication rates and no true proven efficacy. One unique advantage is that peritoneal lavage carries
with it the ability for dialysis which can be useful for detoxification but carries with it the caveat that it can worsen hypokalemia. That said, no evidence exists to date that invasive measures increase survival rates, and complications like DIC, pulmonary edema, hemolysis and ATN do exist. With respect to survival, the jury is out and anything can happen. The lowest documented infant survival is 15.2º C (59.4º F) and the adult is 15.2º C (56.8º F). With that in mind, during resuscitation, the catecholamines tend to worsen outcomes with their administration. Epinephrine should be withheld and dobutamine seems to be useful in low-dose amounts, keeping in mind that it can exacerbate Hypokalemia. Additionally, procainamide can increase the incidence of VF whereas quinidine has been found useful. The use of lidocaine is unresolved at this time. Again, the laboratory evaluation of sepsis is confounded making cultures paramount. The biggest negative predictors of survival include asphyxia, slow rate of cooling, invasive rewarming, asystole and pulmonary edema. Positive predictors include rapid cooling, presence of VF during arrest, and narcotic or ethanol intoxication. Further reading on this subject can be found in P. S. Auerbach’s Wilderness Medicine, 5th ed. By Mosby. I wish you a warm winter season and look into Smartwool™ products to keep you warm. Again, I welcome any comments at firstname.lastname@example.org.
Emergency Medicine Program Director Position Announcement Grandview Hospital located in Dayton , Ohio is currently seeking a new Program Director for the Emergency Medicine Residency Program. The successful candidate should possess ethical leadership and management experience, a commitment to education, advanced understanding of healthcare technologies utilized in the ED, and the ability to build constructive relationships with multiple constituents at that national, state and local levels. The Program Director will report directly to the Director of Medical Education and should be willing to actively participate in the Postgraduate Medical Education Committee. The Program Director will be responsible for: • Providing overall leadership to the EM Residency Program • Coordinating and participating in the Didactic Program for the EM Residency Program • Managing the Clinical Curriculum for the EM Residency Program • Participating in the Budget Development Process with the Department of Post-Graduate Medical Education • Coordinating the recruitment, interview, and selection process for the EM Residency Program • Adhering to the AOA and ACOEP basic documents First consideration will be given to applicants who meet the following qualifications: • Willing to become board-certified physician licensed to practice in the state of Ohio • An active member of the American College of Osteopathic Emergency Physicians (ACOEP) • An experienced educator with five years of practice experience preferred • Enthusiasm for creating and maintaining an EM Residency program that is ranked among the highest in the osteopathic profession. • Willing to maintain personal growth through continuing medical education and his/her selected field of certification. • Possess excellent management, organizational and leadership skills Interested applicants should direct inquiries to Robert Cain, D.O., DME at 937-723-3248 or Bradley Hobbs at Bradley.Hobbs@khnetwork.org. For additional information on Grandview Hospital and the Kettering Health Network, please visit: www.khnetwork.org
The deadline for submitting your Curriculum Vitae is November 15th, 2009
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2010 Roth IRA conversion – you are eligible?
Effective January 1, 2010, everyone is eligible to convert his or her Traditional IRA to a Roth IRA. Not only have income limits been stripped out, but any taxes due can be spread over tax years 2011 and 2012. In the past, if you had an adjusted gross income above $100,000, you could not convert a Traditional IRA to a Roth. Period. End of discussion. Also, if you were eligible to make the conversion, all income tax owed had to be paid in the tax year of the conversion. However, thanks to the Tax Increase Prevention and Reconciliation Act of 2005, the income restriction no longer applies, starting January 1, 2010. Plus, for conversions made in 2010, any money owed to the IRS could be split between the years 2011 and 2012, so the final payment would not be due until April 15, 2013. Why consider converting to a Roth IRA? • Non-deductible contributions. The money you put into a Roth IRA comes from aftertax income. With a traditional IRA, contributions are generally deductible, based on your income and other factors. This makes
the Roth attractive to taxpayers in lower tax brackets or individuals who do not need the deductions so long as they believe that their tax rate is lower now than what it would be when they take distributions. • Completely tax-free earnings and distributions. You pay zero income taxes on the money at retirement provided you meet distribution requirements, generally 59 1/2 and 5 years after the conversion. With a traditional IRA, all or a portion of your distributions may be taxable. The Roth vs. Traditional decision often depends on what you believe your tax rate will be in the future. • Tax-free and penalty-free early withdrawals of contributions. Because contributions to a Roth IRA are made with after-tax dollars, early distributions of earnings are subject to tax and penalty; however, you can withdraw your contributions at any time. • Contributions after age 70½. Unlike traditional IRAs, you are not required to start taking mandatory distributions upon reaching age 70 1/2. If you plan to
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retire before that time, either a Roth or Traditional IRA may work well. However, if you see yourself working beyond age 70, a Roth IRA will let you continue to put aside money (that can be used for your future or eventually be distributed to family members at your death), and delay withdrawals until you decide the time is right. The bottom line: The Roth IRA is a dynamic, flexible tool. Is it right for you? Would a Traditional IRA be better? Or should you have a combination of both? Where to start: Contact me today, and together we can identify your needs and review your options. There is no cost or obligation. For more information, please contact: Sheldon R. Bender, Vice President (847) 457-3012 GCG Financial, Inc. 3000 Lakeside Drive, Suite 200 South Bannockburn, IL 60015
This information should not be considered tax or legal advice. You should consult your tax and legal advisor regarding your own situation. Insurance products offered by Minnesota Life Insurance Company, Securities offered through Securian Financial Services, Inc. Member NASD/SIPC. GCG Financial, Inc and Securian Financial Services, Inc. operate under separate ownership.
ACOEP Welcomes New Fellows at Fall Meeting The ACOEP was honored to award and recognize its 2009 Fellows at the Fellowship Ceremony held in conjunction with the Scientific Assembly in Boston last October. 2009 was the first year that the ACOEP recognized its members who have g o n e above and beyond the service level expected of Fellows and recDistinguished Fellows 2009 ognized these physicians “Distinguished Fellows.” These physicians, like their younger counterparts, began their journey to this recognition many years prior to this designation when they dedicated their careers to medical education, hospital administration, community or political service, and taken a portion of their Fellows 2009 time to devote to these endeavors. In some instances these physicians honored at the Ceremony were pioneers in the field of emergency medicine practice and training, and so it was with honor that we recognized these physicians. Included in the 2009 Class of Distinguished Fellows are: John W. Becher, D.O., FACOEP-D, Newtown Square, Pennsylvania; Darryl A. Beehler, D.O., FACOEP-D, Detroit Lakes, Minnesota; Peter A. Bell, D.O., MBA, FACOEP-D, Hilliard, Ohio; Mark Cichon, D.O., FACOEP-D, Park Ridge, Illinois; Paula Willoughby DeJesus, D.O., MPH, FACOEP-D, Chicago, Illinois; Dennis Guest, D.O., FACOEP-D, Yardley, Pennsylvania; Joseph T. Imbesi, D.O., FACOEP-D, Holmdel, New Jersey; Gary L. Moorman, D.O., FACOEP-D, Toledo, Ohio; Thomas J. Mucci, D.O., FACOEP-D, Poland, Ohio; Daniel J. Olsson, D.O., FACOEP-D, Manlius, New York; Steven J. Parrillo, D.O., FACOEP-D, Plymouth Meeting, Pennsylvania; Stephen A. Roskam, D.O., FACOEP-D, Oak Park, Illinois; Victor J.
Scali, D.O., FACOEP-D, Springfield, Pennsylvania; Theodore A. Spevack, D.O., FACOEP-D, Brewster, Massachusetts, and Gary L. Willyerd, D.O., FACOEP-D, Bloomfield Hills, Michigan. The ACOEP also had the honor of recognizing physicianmembers who met the criteria for Fellowship within the College. These physicians have all met service and membership criteria for this honor. It is our privilege to welcome the following physicians as Fellows of the American College of Osteopathic Emergency Physicians: Leonardo Altamirano, D.O., FACOEP, Freeport, New York; Chad Borin, D.O., FACOEP, Edmond, Oklahoma; Thomas Boyle, D.O., FACOEP, Elmhurst, Illinois; Jeffrey Davies, D.O., FACOEP, La Quinta, California; Clifford Fields, D.O., FACOEP, Providence, Rhode Island; William Franklin, D.O., FACOEP, Milwaukee, Wisconsin; Joseph Guarnaccia, D.O., FACOEP, Windham, New Hampshire; Brandon Lewis, D.O., FACOEP, College Station, Texas; Gerald Maloney, Jr., D.O., FACOEP, Bay Village, Ohio; Merlin L. Shriner, D.O., FACOEP, Bowie, Texas, and Yvette Wirta-Clarke, D.O., FACOEP, Stuart, Florida. We encourage anyone interested in gaining Fellowship or Distinguished Fellow status to visit the College’s website at www. acoep.org or call the ACOEP Office/Membership Division for an application.
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