The Pulse October 2006 by ACOEP

The PULSE

Osteopathic Emergency Medicine Quarterly VOLUME XXXI NO. 4

OCTOBER 2006

Featured Article Anita Eisenhart, D.O., FACOEP, FACEP

Emergency Department Presentations Following Weight Loss Surgery Introduction Weight loss surgery, as a class known as bariatric surgery, is becoming increasingly popular as treatment for morbid obesity. According to the American Society for Bariatric Surgery, the number of bariatric surgeries performed in the United States has increased from 16,200 in 1992 to 140,640 in 20041. This trend is expected to continue. With a growing population of bariatric surgery patients, emergency physicians in both bariatric centers and community hospitals must be prepared to evaluate and treat complications. Many patients will travel several counties or even across state lines to have their surgery, then present to their local Emergency Department (ED) for post-operative complications. There are several different types of bariatric procedures. The two most common procedures today are the Roux-en-Y (or gastro-duodenal bypass) and the laparoscopic adjustable gastric banding procedure. This discussion will be limited to general concepts of bariatric patients and problems specific to these two procedures. Morbid Obesity Early Complications Morbidly obese patients (defined as a body mass index (BMI) > 40 kg/m2) carry a significant surgical risk, regardless of the surgical procedure being performed. Many

of these risks are related to their co-morbidities that include, but are not limited to, hypertension, non-insulin dependant diabetes mellitus, coronary artery disease, dyslipidemia, obstructive sleep apnea, asthma, obesity-hypoventilation syndrome, peripheral venous insufficiency, thrombophlebitis2, and sedentary life-styles. A national cohort of over 69,000 bariatric surgical patients revealed the most common comorbidities in post-operative complications were hypertension (45%), diabetes (22%), and chronic lung disease (16%). Other important co-morbid conditions included liver disease, congestive heart failure, and renal failure3. Regardless of the bariatric procedure performed, patients may present to the ED early in the post-operative phase with complications related to obesity and co-morbidities. These include, but are not limited to, pulmonary embolus (1 – 2% cases), deep vein thrombosis, wound infections, fascial dehiscence (1% of cases), incisional hernias (10 – 20% of open cases), seromas (40% of open cases)4, and infarction. These should all be evaluated and treated, as each case deems necessary. A retrospective cross-sectional, coroner based study over 2 years described one county coroner’s office experience with bariatric patient mortalities. Fifteen (0.5%) out of 3097 archival cases died following bariatric surgery

The PULSE OCTOBER 2006

(73% of which died within six months of surgery). 80% of these deaths were natural co-morbidities of obesity: cardiovascular diseases (33%), gastrointestinal diseases (20%), acute pulmonary thromboembolism (13%), and acute bacterial pneumonia (13%). Two decedents (13%) died of direct inadvertent / accidental surgical complications5. Tachycardia Tachycardia in a morbidly obese post-operative bariatric surgical patient should be taken very seriously. The most likely reason for the tachycardia is dehydration and may improve drastically with hydration. However, two other diagnoses must be considered. Pulmonary embolus occurs approximately 1 – 2% of cases, but is responsible for 20 – 30% mortality in bariatric surgical patients4. Evaluation and management is the same as would be for a non-bariatric patient. The other serious consideration in the patient who presents with tachycardia is a leak from either the anastomoses or staple line. A leak represents one of the most serious complications and occurs from 1 – 6% of cases of Roux-en-Y surgical patients and is more common in the laparoscopic approach6. Tachycardia and, variably, signs of sepsis may be the only indication of a leak. This populaComplications of Weight-Loss Surgery, continued on page 8

:PV KPJOFE B DP[Z MJUUMF JOEFQFOEFOU HSPVQ BOE OPX ZPV XBOU UP CF UIF EJSFDUPS CVU

"EFORE 9OU #AN "ECOME $IRECTOR 4HREE 0EOPLE 7ILL (AVE TO $IE OR 2ETIRE

"U &.1 ZPV MM IBWF FYDFMMFOU DBSFFS BEWBODF "U &.1 ZPV MM IBWF FYDFMMFOU DBSFFS BEWBODFNFOU PQUJPOT JODMVEJOH BDDFMFSBUFE MFBEFSTIJQ USBJOJOH XIJDI XJMM BMMPX ZPV NFOU PQUJPOT JODMVEJOH UIF PQQPSUVOJUZ UP UIF PQQPSUVOJUZ UP CFDPNF EJSFDUPS PO ZPVS PXO UJNFMJOF CFDPNF EJSFDUPS PO ZPVS PXO UJNFMJOF $BMM ,/08 &.1 &YU OPX UP IFBS

i%PO U (FU 4UVDL w yB EJTDVTTJPO PG UIF BEWBOUBHFT PG DIPPTJOH B DBSFFS QBUI UIBU XPO U MFBWF ZPV TUVDL XJUI OP DIBODF GPS BEWBODFNFOU 5IJT SFDPSEJOH JT QBSU POF PG (PPE %FDJTJPOT "WPJEJOH UIF 'JWF .PTU $PNNPO $BSFFS .JTUBLFT &NFSHFODZ 1IZTJDJBOT .BLF

0S EPXOMPBE UIF BVEJP BOE PS UFYU BU

XXX FNQ DPN BEWBODFNFOU

$SFBUJOH B .PSF 1FSGFDU 1SBDUJDF 5IF #FTU JO &NFSHFODZ .FEJDJOF

The PULSE OCTOBER 2006

Continuing Medical Education Calendar 2006-2007 October 15 ACOEP Committee Meetings Las Vegas Hilton Hotel Las Vegas, NV 16

ACOEP Membership Meeting Las Vegas Hilton Hotel Las Vegas, NV

17 – 20

ACOEP Scientific Seminar Las Vegas Convention Center Las Vegas, NV 25 hrs Category 1A Credit

23–25 Additional Stiles/Laughlin Approaches to Still Functional Techniques Indianapolis, IN 20 hrs Category 1A Credit Call 800-942-0501 for info April 10 – 14

May 4 – 5 Oral Board Review Four Points Sheraton Chicago, IL 10 hrs Category 1A

2007

January 3 – 8

Emergency Medicine: An Intense Review Westin Hotel River North Chicago, IL 40-41 hrs Category 1/1A Credit

August 1 – 4

February 11 – 13 Program Directors Workshop The Siena Casino Spa Resort Reno, NV 10–12 hrs Category 1A Credit 13 – 17

ACOEP Spring Seminar Sheraton Wild Horse Pass Resort and Spa Chandler, AZ 25 hrs Category 1 / 1A Credit

New Frontiers in Toxicology Hotel (TBA) Cleveland, OH 25 hrs of Category 1A

September 14 – 15 Oral Board Review Four Points Sheraton Chicago, IL 10 hrs Category 1A

Core Essentials The Siena Casino Spa Resort Reno, NV 25 hrs Category 1/1A Credit

Table of Contents ED Complications of Weight-Loss Surgery . . . . . . . . . . . 1

Letter to the Editor - Columbus Dispatch . . . . . . . . . . 20

CME Calendar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Governmental Affairs . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Member News . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Guest Column, William Lynch, Jr. . . . . . . . . . . . . . . . . 22

Presidential Viewpoints . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Editorial, Drew Koch, D.O., FACOEP . . . . . . . . . . . . . 23

Student Chapter & Resident Chapter Events . . . . . . . . . 6

Student Chapter Update . . . . . . . . . . . . . . . . . . . . . . . . 24

Executive Director’s Desk . . . . . . . . . . . . . . . . . . . . . . . . 7

Ethics in Emergency Medicine . . . . . . . . . . . . . . . . . . . 25

Money Talk - GWA New Tax Legislation . . . . . . . . . . . 13

Guest Column, Carol Monaco, Deputy Director . . . . . . 26

Guest Column, Levente Batizy, D.O., FACOEP . . . . . . 14

Official Call to Meeting . . . . . . . . . . . . . . . . . . . . . . . . 26

Securing Your Future . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Guest Column, Joseph J. Kuchinski, D.O., FACOEP . . 28

The PULSE OCTOBER 2006

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

Member News James Turner, D.O. Given Significant Honor from NSU’s College of Osteopathic Medicine FORT LAUDERDALE, FL – On August 21, 2006, James Turner, D.O. of Charleston, West Virginia had a significant tribute bestowed upon him when he had an academic society named in his honor during Nova Southeastern University College of Osteopathic Medicine’s (NSU-COM) Academic Societies Kickoff Ceremony. Dr. Turner is the first person in his family to become a physician, and after earning a 3.97 GPA as an undergraduate, chose to pursue a career in osteopathic medicine, graduating from Southeastern College of Osteopathic Medicine (SECOM), the precursor to NSU-COM, in 1988. While at SECOM, he served as class president, which was the start of a career dedicated to service at the community, state, and national level. Currently, the director of the emergency medicine residency at the Charleston Area Medical Center and an emergency physician at New Century Emergency Physicians of West Virginia, Inc., Dr. Turner is an active member of the American Osteopathic Association, American College of Osteopathic Family Physicians, and the American College of Osteopathic Emergency Physicians. He is also the author of numerous publications and lectures, as well as being the recipient of the NSU-COM 1999 Distinguished Alumni of the Year Award.

All NSU osteopathic medical students are assigned to a society composed of approximately 25 students per class and at least two faculty society advisers who act as academic and career advisers. Students remain in their designated academic society throughout their medical school experience, which creates a unique sense of community that students experience from their very first day in medical school. The Student Task Force for Academic Societies spent a considerable amount of time establishing the names of NSU-COM’s new academic societies. The task force felt it was imperative to honor respected individuals associated with NSU-COM, such as Dr. Turner, as well as those who have made a significant contribution to the osteopathic profession. Established in 1979, Nova Southeastern University College of Osteopathic Medicine accepted its first class in 1981. NSUCOM is currently ranked as the 15th largest medical school and the 5th largest osteopathic medical school in the nation. For more information about NSU-COM, please visit http://medicine.nova.edu. NSU is the largest independent not-for-profit institution of higher education in the Southeast and the 7th largest nationally.

Levente Batizy, D.O., FACOEP Honored as Educator of the Year Levente Batizy, D.O., FACOEP was honored by the American Osteopathic Association and the American Osteopathic Foundation when he was presented with the Educator of the Year Award. Annually, osteopathic student and resident physicians nominate an osteopathic physician – trainers who contribute most to their medical education and provide the best role model to them. This award is presented to the physician-educator at the AOA House of Delegates each July. Dr. Levente is currently the Program Director at the Cleveland Clinic – South Pointe Hospital in Cleveland, Ohio, where he practices emergency medicine.

The PULSE OCTOBER 2006

Presidential Viewpoints Paula Willoughby DeJesus, D.O., FACOEP

Earlier this year the American College of Emergency Physicians (ACEP) released a “National Report card on the State of Emergency Medicine.” It analyzed emergency care in four areas: access to emergency care, quality and patient safety, public health and injury prevention and the medical liability environment. In June 2006, the IOM released three crucial reports from their Committee on the Future of Emergency Care in the United States. The reports are “Hospital-Based Emergency Care At The Breaking Point,” “Emergency Medical Services At the Crossroads” and “Emergency Care for Children Growing Pains.” We clearly know who ACEP is and how they could and would have something meaningful to say about the state of the state in emergency care. Who is the IOM? The Institute of Medicine is the IOM. The IOM was established in 1970 by the National Academy of Sciences. The Academy functions to gather experts in scientific areas to examine policy in matters of public health. The National Academy of Sciences is a private, non-profit organization of scholars engaged in the research to further science and technology for use in society. Congress granted the organizational charter in 1863 and it is mandated to advise the federal government on scientific and technical matters. The Institute of Medicine is under the responsibility of the National Academy of Sciences. It convened in 2003 to examine the state of emergency medical care in the United States and make recommendations on these issues. The results of these deliberations concluded in the three volumes published in June. The Hospital Based Emergency Care report focuses on our practice. It summarizes the issue succinctly by recognizing the emergency department (ED) faces the

“challenge of high demand and inadequate system capacity.” The reports outline the increase in population over the last ten years, increases in hospital admissions and the increase in emergency department volume that is twice that of either of the other statistics. This is in the face of decreasing hospitals, hospital beds, and intensive care beds. According to their findings, patients presenting to the ED are older, sicker, and have needs that are more complex. It recognizes the demand for ED services has increased due to multiple factors. The patients with decreased choices in access decisions; increased use by Medicaid beneficiaries (four times that of insured patients) and in some cases the ED is the sole source for primary care. The report cites concerns of increased costs in providing this care in the emergency department setting. As the number of hospital beds has decreased and admissions have increased, the backlog is squarely placed on the emergency department, further accentuating the load on the ED and its resources. The report quoted one study where 73% of surveyed hospitals were boarding patients in the ED and that it, “was not unusual for patients in a busy hospital ED to be boarded for 48 hours.” This leads to the consequence of ambulance diversion. The report recognized that the ED has been pushed into its position in the health care system. Its clinical sophistication has evolved far more rapidly than the systems and its integration into the spectrum of health care as a whole. It cited a lack of cohesion between the components of healthcare system and its communication. It has also become increasingly difficult for EDs to find certain specialists. This stems from several reasons; lack of payment for their services, increased liability, and increased disruption to their practice and personal life. It was felt there was a lack of disaster preparedness development and real surge capacity capability. Funding for these activities was cited as a significant issue for hospitals to improve their preparedness capability.

The PULSE OCTOBER 2006

The report provides recommendations to these challenges. The recommendations are across all areas related to the issues and clearly recognize the issues are beyond the walls of the ED. The recommendations include the following: 1. It urges chief management officers of the hospital adopt broad institutional strategies to improve quality and efficiency of emergency care. 2. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and the National Committee for Quality Assurance and other stakeholders should develop training in healthcare management and public health disciplines. 3. The Centers for Medicare and Medicaid Services (CMS) should remove current restrictions on the medical conditions that are eligible for separate clinical decision units. 4. The JCAHO should reinstate strong standards that address ED crowding, boarding, and diversion. 5. That the CMS with stakeholders develop standards for measures, implementation, monitoring, and enforcement relative to boarding and diversion. 6. Hospitals should develop robust informational and technology systems to ensure quality care and safety. 7. Congress must appropriate funds to provide funding for hospitals providing uncompensated care and establish funds targeted for a working group to determine future funding allocation recommendations. 8. Increase funding for disaster preparedness and training. 9. Hospitals should regionalize care, oncall, and other resources. 10. Congress should appoint a commission on medical liability.

Presidential Viewpoints, continued on page 29

STUDENT CHAPTER & RESIDENT CHAPTER EVENTS Resident Chapter & Student Chapter Schedule Sunday, October 15 3:00 p.m.-5:00 p.m.

Resident Chapter Meeting Student Chapter Meeting

5:00 p.m. – 7:00 p.m.

Student and Resident ECI Wine & Cheese Reception

Monday, October 16 8:00 am – 10:00 am

Resident Chapter Jeopardy Tournament

9:00 a.m. – 12:00 p.m.

Student Chapter EM Residency Exposition

10:00 am – 4:00 p.m. (break for lunch)

Resident Case Presentation Competition Residents present cases involving a typical presentation of an unusual disease or an atypical presentation of a common disease. Faculty discussants present review and suspected final diagnosis.

10:00 a.m. – 5:00 p.m.

Research Posters on Display in Convention Center

12:00 – 3:00 p.m.

Student Chapter Lecture Series

8:00-10:00 p.m.

Resident Chapter Resident Dinner

Tuesday, October 17 10:00 a.m. – 1:00 p.m.

Resident Lecture Series – Job Panel

2:00-5:00 p.m.

Wednesday, October 18 11:30 a.m.-1 p.m. Thursday, October 19 11:30 a.m. – 1 p.m.

Resident Poster Competition Judging Residents present an interesting case relevant to emergency medicine in a 4’x6’ poster format. The Resident Posters will be on display all day Monday through the end of the day Tuesday. FOEM Research Awards Luncheon Student Case Competition Winner Presentation, presentation of CPC and Poster presentation winners. Winner of the Student Case Competition will also present. Research Oral Abstract Presentations & Luncheon Residents present interesting cases relevant to emergency medicine in an oral presentation.

The PULSE OCTOBER 2006

Executive Directors Desk Janice Wachtler

Of Death and Dying American Medicine has many problems on both the patient and physician ends of care. It struggles with physician liability issues, overcrowding in the Emergency Department, and the use of ancillary personnel to extend physician care in busy surroundings. Both physicians and patients deal with long waits for care and we all deal with death and dying issues like palliative and hospice care. But no matter how hard it tries, medicine and medical providers have problems with dealing with the dying patient and their families. Medical practitioners, be they physicians, nurses, or physician extenders, have a problem telling patient families and patients themselves, that they have exhausted all medicines, all operations and all things that will extend life and that they are dying. They use euphemistic terms like they are “transitioning” or “fading,” but few will come out and tell either their patient or his or her family that they need to face the fact that there is nothing more that medicine can do. This may sound cruel, but it does help the patient and family realize they need to face the fact that their time is limited. Movies dramatize death, and everyone always dies a peaceful death by simply breathing a deep sigh, closing their eyes and slipping from life in a beautiful Kodak® moment. But what of the patient who does not go gently into that good night and rages and burns through every remaining moment? How do we help them? Most often, we recommend Palliative and Hospice care where they are provided with extended care of a nurse practitioner who helps them transition in a supposedly pain-free and peaceful atmosphere. Patients sign Power of Attorney for Health Care documents that delegate health care decisions to family members or trusted friends who supposedly know the patient’s wishes

and will take an advocate role for the patient helping to make those ‘hard to make’ decisions, and may, at the patient’s wish, remove that person from life support and help move the dying process along. Do we prepare them, the advocate, for what happens when life support is removed, and the person goes off of O2, food and glucose? Do we tell them that this may look terrible, but that the patient is not in pain and may be working less hard then when we are force-feeding them? Do we tell them that heavy doses of morphine and Ativan are keeping them pain-free? Do we even help them understand the paper work that they may need to read through after the person dies? I don’t think so. In many cases, the physician visits the dying patient less frequently, or assigns physician extenders to visit the patients in hospitals or nursing facilities and Hospice. Maybe they do it to save a few dollars in insurance costs, maybe because they know that nothing more can be done, or possibly, they cannot deal with losing a patient who has been a patient for a long time. But many times, the patient family relies on this physician who has helped them face many other illnesses to be there as their support to tell them, it will be ok, that the patient is not in pain, and that they need to say that special thing you’ve wanted to say to the dying to ease that passage and to help the surviving family member. While we can’t provide the family with an exact timetable of what we expect will happen or the time frame that it will happen in, the patient’s family needs to know what is happening. Recently, my father died and my family appreciated that his Geriatrician called us to tell us that his systems were failing and he had perhaps thirty days to live. He lived forty-five days after that call. During that time, we worked with him and his staff to put Dad in Hospice care after it became quite evident that he wasn’t going to be here too much longer. Once there, he received higher doses of Morphine and Ativan and was taken off of life sustaining glucose when he protested about

The PULSE OCTOBER 2006

the pain the intravenous needle was causing him. It also gave us a chance to realize that we needed to have conversations with him and tell him things that families sometime take for granted, believing that the patient knows that you love them and miss them. It also gave us time to make appropriate funeral arrangements and to notify family and friends (most of whom are also elderly) that he was dying to lessen the shock of the inevitable phone call. In the event that a patient is terminal, end-of-life specialists need to have counselors available to families to help them deal with the phases of life that Elizabeth Köebler Ross so eloquently described in her book, On Death and Dying, many years ago. The family has to have this help for weeks, if not months, after the death of a family member as emotions may run the gamut of these symptoms over that time. I personally, have problems with the way we sometimes deal with death. Perhaps its too many movie moments, perhaps, it is romanticized in my mind, but I don’t think you should have to undergo days and months of pain and suffering, especially if you, your family, and your medical practitioners, know that there is no cure and no hope. Maybe I’m a wimp, or just a realist, but I would hope that as we look into end-of-life care, medical and legal minds also look seriously into the allowance of assisted death, as in Oregon, as an alternative. I would prefer knowing that someone there would be an advocate for me, that having exhausted all treatments, with systems failing, that I would have the right to end my own life. I am not recommending or advocating that we allow doctors and patient advocates to kill patients willy-nilly just because they are old and infirm, or have a fatal condition and that they are faced with death somewhere down the road. But there should be an option that as people transition into Hospice that they or their advocate can ask that they be provided with this option for death, so that they can die as they lived, making their own decisions and dying with dignity.

Complications of Weight-Loss Surgery, continued from page 1

tion may have little or no abdominal pain, nor tenderness upon palpatory examination (given the size of the abdomen). They may also have limited manifestations of fever or significant leukocytosis. Leaks occur from the time of surgery to 7 – 10 days post-operative. If undiagnosed, leaks may lead to sepsis, renal and respiratory failure4. Acute respiratory failure should raise the suspicion of an intra-abdominal leak7. If a leak is suspected, a good preliminary study is a Gastrografin upper gastrointestinal series. This does not, however, definitively rule out leaks. Abdominal CT scans are better for finding leaks further down the gastrointestinal tract. A low threshold to return a patient to the operating suite should remain in these cases with unexplained tachycardia and suspicion of a leak4. Some leaks may be managed conservatively with bowel rest, parenteral nutrition, and CT-guided aspiration of the intra-abdominal abscess / fluid collection followed by re-evaluation for a self-healing leak4. There are two recent case reports of thyrotoxicosis shortly post-operative bariatric surgery presenting as tachycardia8 9. One of these cases resulted in a negative laparoscopy under the suspicion of a postoperative leak8. Late Complications A long-term complication well described in patients with a rapid, large-volume weight loss is gallbladder disease. Gallstone development after bariatric surgery occurs in 3 –30% of cases. Several mechanisms have been proposed. Researchers studying bile content before and after bariatric surgery found that mucin (a crystallization-promoting compound) is important in cholesterol crystals and gallstones in bariatric patients. This may be related to defective gallbladder emptying during rapid weight loss10. Another group found a correlation between the apolipoprotein-E genotype and the risk of developing cholelithiasis following bariatric surgery. These authors suggest pre-operative evaluation for the Apo-E3/E4 genotype and consider prophylactic cholecystectomy during the bariatric procedure in patients with the Apo-E genotype11.

Many bariatric patients are placed on ursodiol for six months following the surgery to prevent gallstone formation4. Roux-en-Y Procedure Description The Roux-en-Y gastric bypass surgery is the most common bariatric surgery performed in the United States and worldwide today. It is both a restrictive and a malabsorptive procedure and may be performed either laparoscopic or open. The laparoscopic technique results in a shorter hospital stay, improved post-operative comfort level, decreased skin scarring, and fewer ventral hernias. The open technique has fewer leaks, hemorrhages, anastomotic strictures, internal hernias, and bowel obstructions2. The procedure involves separating a small gastric pouch (10 – 30 ml) at the proximal stomach from the gastric remnant (left to lay dormant and vascularized in the abdomen). This pouch is anastomosed end-to-side to a mobilized loop of jejunum, called the afferent loop. The Roux limb, or efferent loop, is anastomosed side-to-side with the proximal jejunum to allow digestion with biliary and pancreatic secretions. This results in 95% of the stomach and the entire duodenum taken out of the digestive pathway. In the super obese patients (BMI > 50 kg/m2), the surgeon may elect to bypass 30 – 150 cm of the jejunum as well, resulting in a greater malabsorptive condition and more dramatic weight loss6. Figure 1: Roux-en-Y

Diagram by Janie McDowell Gastrojejunal strictures occur in 3 – 27% of Roux-en-Y patients and presents 4 weeks to several months post-operative. Presenting symptoms include intolerance of solid foods, then liquid intolerance with

The PULSE OCTOBER 2006

daily vomiting and minimal to no abdominal pain. The diagnosis is usually made by endoscopy. The diagnosis may also be made by a contrast media swallow. Management is usually performed during the diagnostic endoscopy with pneumatic balloon dilators. Strictures may also be managed by fluoroscopically guided bougies, or, rarely, by surgical revision (either open or laparoscopic). Endoscopic pneumatic balloon dilation may need to be performed multiple times over the course of several months12 and does not usually require hospital admission unless significant dehydration is found. There are two recognized types of fistulas following the Roux-en-Y. A gastrogastric fistula is one that forms from the new gastric pouch to the dormant gastric tissue. This usually occurs from a staple gun failure and its incidence is about 3%. This may be accompanied by a gastro-jejunostomy site leak (as described above). In the absence of peritonitis, a gastro-gastric fistula does not require surgical intervention. This fistula does, however carry an added risk of a marginal ulceration and poor weight loss (as the large, dormant stomach is now being utilized)6. An entero-cutaneous fistula is often a result of an anastomotic leak and will be obvious upon physical examination. Abdominal CT will define the track clearly6. Adhesions are far more common in the open technique Roux-en-Y and may lead to a small bowel obstruction (as would any laparotomy). Most of these patients may be managed conservatively, without surgical intervention. Bowel obstruction occurs at least 2 – 3% of cases4. There is one type of obstruction, a closed loop obstruction, which carries a high mortality if not treated within 36 hours. A closed loop obstruction occurs when a length of small bowel is obstructed at both ends. This leaves a segment that is unable to be decompressed and can, specifically, occur in Roux-enY patients because of a long adhesive band or internal hernia. The incidence of strangulation is high with a closed loop obstruction because the loop is free to rotate upon itself. The abdominal CT will show distended “C” or “U” shaped fluid-filled loops with engorged mesenteric vessels6. An internal hernia may occur at the efferent Roux loop. This carries a risk of volvulus. Abdominal CT is the most sensi-

tive pre-operative method of diagnosing an internal hernia6. One author recently reported three cases of superior mesenteric artery syndrome that all presented as gastrointestinal obstructive complications following laparoscopic Rouxen-Y. This is a vascular compression of the third portion of the duodenum. Two of their cases underwent laparoscopic duodeno-jejunostomy and the third was treated with hyperalimentation. All three recovered fully within 4 – 18 months13. These authors suggest this diagnosis be considered in laparoscopic Roux-en-Y patients who present with rapid extensive weight loss and atypical, recurrent obstructive symptoms not attributable to more common causes such as internal hernias or adhesions. Another author reported a case of a 43year-old man with a superior mesenteric vein thrombosis ten days after a Rouxen-Y. His symptoms were abdominal pain radiating to the back. He was found to be hypercoagulable and responded successfully to anticoagulant therapy14. An additional mechanical issue is vomiting secondary to improperly, incompletely chewed food. The newly formed pouch has little ability to grind and digest. The Rouxen-Y patient is instructed pre-operatively to always chew completely. Even a small piece of food will feel very uncomfortable and cause chest pain and vomiting until the mass has either passed distally or is vomited. These vomiting episodes are generally tolerated well15. Metabolic Complications / Presentations Nearly every Roux-en-Y patient experiences dumping syndrome. Early on, these patients may present to the ED with their symptoms, which is also frequently accompanied by significant fear and anxiety. Dumping syndrome is an intentional side effect of the bypass surgery. When foods, particularly those high in sugar content or high osmotic activity, are ‘dumped’ directly into the small bowel, transit time is increased as an osmotic diuresis occurs. Dumping syndrome is a vasomotor and neuroendocrine response initiated by rapid emptying of foods into the jejunum. The hyperosmolarity of the sugars causes an influx of fluid16,17. Symptoms of dumping syndrome include nausea, sweating, bloating, abdom-

inal pain, cramping, and lightheadedness. Signs may include tachycardia and hypotension. Flushing, syncope, and diarrhea may also ensue. Symptoms are relieved with fasting and generally last about an hour. Dumping syndrome serves as a deterrent to overeating and eating ‘the wrong foods’16,17. In time, the Roux-en-Y patient learns to prevent dumping syndrome with diet modifications. Additionally each event is better tolerated than the last. Because the Roux-en-Y has both restrictive and malabsorptive properties, several metabolic derangements may occur. Early in the post-operative phase, dehydration is common. The Roux-en-Y patient is given several dietary instructions prior to surgery to optimize their nutrition. 1.) During the meal, eat the protein portion first, and at least half the meal should be protein. 2.) Drink plenty of fluids (however, avoid fluids just before, during, and just after a meal). 3.) The following are life-long supplements: a. Multivitamin b. Calcium c. Iron (ferrous fumarate coupled with ascorbic acid). Ferrous fumarate is the only form of iron that does not require the stomach and duodenum for absorption. d. B12 parenterally (either sublingual or intra-muscular). Adherence to these rules markedly decreases the incidence and severity of nutritional complications. Iron deficiency is one of the most frequently encountered metabolic deficiencies following the Roux-en-Y with the incidence ranging from 14 – 52% and microcytic anemia up to 74%, depending on the Roux limb length. Adolescents and women of childbearing age are at particular risk for iron deficiency and microcytic anemia18. This can be prevented or treated with high dose iron coupled with ascorbic acid. Calcium deficiencies may also occur as calcium is maximally absorbed in the duodenum and proximal jejunum. If the Roux arm is long, a vitamin D deficiency may also ensue. These carry a risk, long term, of osteoporosis18 and osteomalacia19. Hyperparathyroidism is also well described in the literature following bypass surgery,

The PULSE OCTOBER 2006

and generally responds well to vitamin D administration15. Protein-calorie deficiencies are a goal of bariatric surgery. This often results in low energy and at least 25% of weight lost is fat-free-mass18. Most patients experience significant hair loss around three to five months post-operative and should be reassured of re-growth with proper nutrition. B12, folate, and thiamine deficiencies all occur secondary to decreased intake and absent duodenal absorption (especially thiamine). B12 deficiency is present (with or without symptoms) 12 – 33%18. Most of the clinical relevance to these deficiencies involves central and peripheral neurologic derangements. In a literature review of 96 case reports of neurologic complications after bariatric surgery, peripheral neuropathy was seen in 60 cases, encephalopathy in 30. Neurologic emergencies included Wernicke’s encephalopathy, rhabdomyolysis, and Guillain-Barré syndrome. These researchers found a 1.3% rate for neurologic complications in 18 surgical series20. Wernicke’s encephalopathy following bariatric surgery is well described in the literature20,21,22,23,24. The classic triad of inattentiveness, ataxia, and ophthalmoplegia may present as early as six weeks after a Roux-enY procedure. Parenteral thiamine administration often results in a full recovery. A controlled study of peripheral neuropathy following bariatric surgery revealed a rate of 16% (71/435 patients in the series). The clinical patterns were polyneuropathy (n=27), mononeuropathy (n=39), and radiculoplexus neuropathy (n=5). Nerve biopsies showed prominent axonal degeneration and perivascular inflammation. These authors go on to site malnutrition as the most important risk factor for peripheral neuropathy24. A syndrome known as acute post-gastric reduction surgery (APGARS) neuropathy has recently been introduced. In a survey administered to bariatric surgeons, with a respondent bariatric caseload of 168,010 patients, 109 cases were reported to have neuropathies with 99 believed to represent APGARS. APGARS is a poly nutritional, multisystem disorder characterized by proComplications of Weight-Loss Surgery, continued on page 11

chose ECI “Ibecause they help me to schedule all the important things in my life.

”

ThE naTIon’s prEmIEr, prIvaTEly-ownEd sTaffIng and managEmEnT Company. founded by physicians • owned by physicians • physicians managing physicians

800.253.1795 / www.eci-med.com

The PULSE OCTOBER 2006

Complications of Weight-Loss Surgery, continued from page 9

tracted post-operative vomiting, hyporeflexia, and muscular weakness. B12 and/or thiamine deficiencies were noted in 40% of the cases23. Laparoscopic Adjustable Gastric Banding Description Laparoscopic adjustable gastric banding is the second most common form of weight loss surgery worldwide and has grown significantly since its inception in the early 1990â&#x20AC;&#x2122;s2. It is especially attractive to older patients and those with a lower pre-operative BMI as it carries less overall risk than the Rouxen-Y and has a decreased expected weight loss7. Unlike the Roux-en-Y, gastric banding is purely a restrictive procedure without the malabsorptive properties. A ring is placed at the proximal end of the stomach, just below the junction of the stomach and the esophagus, forming a virtual pouch of about 15 ml. A port for inflation and deflation of the band is secured onto the rectus fascia of the anterior abdominal wall. Adjustments are made up to six times annually for complete weight loss management2. Figure 2: Laparoscopic Adjustable Gastric Banding

Diagram by Janie McDowell

Complications Several complications following band surgery have been readily identified. These include esophageal injury, wound infections, band slippage, pouch dilatation, persistent vomiting, acid reflux, band erosion, band leaking, and outlet stenosis7. One series of band patients showed a 54% complication rate requiring hospitalization.

30% had esophagitis, 21% had obstruction due to slippage / pouch dilatation, 9% had incisional hernia, and 9% had band erosionn25. Band erosion is a serious complication with a rate of 1 â&#x20AC;&#x201C; 10%. Erosion presents with vomiting, abdominal pain, bleeding, intra-abdominal abscess, or fistula. Diagnosis is generally made by endoscopy and usually requires surgical management7. Bland slippage can be life threatening if not diagnosed and treated in a timely fashion. Slippage may present to the ED within two to three days with complete dysphasia and dehydration. More concerning symptoms of progressive epigastric pain and signs of peritonitis from ischemia of the gastric pouch may develop. If band slippage is diagnosed (generally by a gastro-intestinal swallow study) immediate deflation should occur, followed by surgical intervention and supportive therapy26. The rate of band slippage varies in each series. One series of 1,480 patients in one center with laparoscopic adjustable gastric banding described 125 (8.4%) patients with band slippage (56% of which had to have band removal and 44% had band repositioning)27. Other Bariatric Procedures Two additional bariatric surgical procedures may be encountered and deserve mention, although their frequencies are markedly decreased from the Roux-en-Y and the laparoscopic adjustable gastric band. The biliopancreatic diversion and duodenal switch are truly malabsorptive procedures with far less of a restrictive component as they are given a much larger gastric pouch. These patients carry a tremendous risk of long-term nutritional complications2. An older banding technique, known as vertical banded gastroplasty, may be encountered. This was first introduced in the 1970â&#x20AC;&#x2122;s and has nearly been replaced by the laparoscopic adjustable gastric band. This is a more invasive technique and is usually performed open. Complications are generally related to other restrictive surgeries, as described above2. Summary The bariatric post-operative patient may present to the ED with various complaints

The PULSE OCTOBER 2006

and concerns. A careful history as to the type of surgery (restrictive, or restrictive and malabsorptive, or purely malabsorptive) that was performed is paramount in their evaluation. Routine ED laboratory investigations will illuminate most metabolic derangements, including dehydration. If a mechanical complication is suspected, appropriate radiographic studies and early surgical consultation are warranted. Particular attention should be paid to the tachycardic patient. While dehydration and anemia are the most likely diagnoses, pulmonary embolus and leaks must be considered, as they are the diagnoses associated with the most morbidity and mortality. Additionally, a post-operative bariatric patient may have an abdominal complaint unrelated to their surgery and the usual differential diagnosis for their complaint must be considered. One author described a case of a patient with a ruptured appendicitis after a recent Roux-en-Y. This patient had tachycardia, fever, and leukocytosis and absence of abdominal pain. A negative upper gastro-intestinal series was also noted. The diagnosis was eventually made on abdominal CT28. With a rapidly growing population of bariatric patients in the United States, the emergency physician must be cognoscente of the mechanical and metabolic compliComplications of Weight-Loss Surgery, continued on page 12

MICHIGAN-Southeast

ER-One is currently hiring BP/BC Emergency Physicians for their Southeast Michigan locations. ER-One Physicians enjoy: Highly competitive wages, paid benefits, CME allowance, paid malpractice, 401k, employee stock option program, flexible scheduling, and more!

To learn more about this opportunity, please visit our website: www.er-one.org, or contact: Deanna Jones Phone: (800) 465-6052 Fax: (734) 632-0182 Email: djones@er-one.org

Complications of Weight-Loss Surgery, continued from page 11

cations that often arise. Early diagnosis and management is crucial in minimizing morbidity and mortality in this high-risk patient population. References 1. A merican Society for Bariatric Surgery: www.asbs.org 2. Buchwald H: Consensus conference statement. Bariatric surgery for morbid obesity: Health implications for patients, health professionals, and third-party payers. J Am Coll Surg 2005;200:593-604 3. Poulose BK, Griffin MR, Zhu Y, et al: National analysis of adverse patient safety events in bariatric surgery. Am Surgeon 2005;71:406-13 4. Livingston EH: Complications of bariatric surgery. Surg Clin N Am 2005;85:853-68 5. Omalu BI, Luckasevic T, Shakir AM, et al: Postbariatric surgery deaths, which fall under the jurisdiction of the coroner. Am J Forensic Med Pathol 2004;25(3):237-42 6. Sandrasegaran K, Rajesh A, Lall C, et al: Gastrointestinal complications of bariatric Roux-en-Y gastric bypass surgery. Eur Radiol 2005;15:254-62 7. Ukleja A, Stone RL: Medical and gastroenterologic management of the post-bariatric surgery patient. J Clin Gastroenterol 2004;38(4):1-8 8. Lynch BA, Dolan JP, Mann M: Thyrotoxicosis after gastric bypass surgery prompting operative re-exploration. Obes Surg 2005;15(6):883-5 9. Carneio JR, Macedo RG, Da Silveira VG: Thyrotoxicosis after gastric bypass. Obes Surg 2004;14(5):699-701 10. Gustafsson U, Benthin L, Granstrom L, et al: Changes in gallbladder bile composition and crystal detection time in morbidly obese subjects after bariatric surgery. Hepatology 2005;41(6):1322-8

11. Abu Abeid S, Szold A, Gavert N, et al: Apolipoprotein-E genotype and the risk of developing cholelithiasis following bariatric surgery: a clue to prevention of routine prophylactic cholecystectomy. Obes Surg 2002;12(3):354-7 12. Goitein D, Papasavas PK, Gagne D, et al: Gastrojejunal strictures following laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Endosc 2005;19:628-32 13. Goitein D, Gagne DJ, Papasavas PK, et al: Superior mesenteric artery syndrome after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Obes Surg 2004;14:1008-11 14. Sonpal IM, Patterson L, Schreiber H, et al: Mesenteric venous thrombosis after gastric bypass. Obes Surg 2004;14(3):419-21 15. Fujioka K: Follow-up of nutritional and metabolic problems after bariatric surgery. Diabetes Care 2005;28(2):481-4 16. Pandolfino JE, Krishnamoorthy B, Lee TJ: Gastrointestinal complications of obesity surgery. Medscape General Medicine 2004;6(2):15 17. Frichtel CM: Bariatric surgery: A brief primer for primary care physicians. The Permanente J 2004;8(3):10-13 18. Alvarez-Leite J: Nutrient deficiencies secondary to bariatric surgery. Curr Opin Clin Nutr Metab Care 2004;7:1-7 19. Collazo-Clavell ML, Jimenez A, Hodgson SF, et al: Osteomalacia after Roux-en-Y gastric bypass. Endocr Pract 2004;10(3):195-8 20. Koffman BM, Greenfield LJ, Ali II, et al: Neurologic complications after surgery for obesity. Muscle Nerve 2005;epub

21. Loh Y, Watson WD, Verma A, et al: Acute Wernicke’s encephalopathy following bariatric surgery: Clinical course and MRI correlation. Obes Surg 2004;14(1):129-32 22. Escalona A, Perez G, Leon F, et al: Wernicke’s encephalopathy after Roux-en-Y gastric bypass. Obes Surg 2004;14(8):1135-7 23. Chang CG, Adams-Huet B, Provost DA: Acute post-gastric reduction surgery (APGARS) neuropathy. Obes Surg 2004;14(2):182-9 24. Thaisetthawatkul P, Collazo-Clavell ML, Sarr MG, et al: A controlled study of peripheral neuropathy after bariatric surgery. Neurology 2004;63(8):1462-70 25. Martikainen T, Pirinen E, Alhava E, et al: Long-term results, late complications and quality of life in a series of adjustable gastric banding. Obes Surg 2004;14(5):648-54 26. Kriwanek S, Schermann M, Ali Abdullah S, et al: Band slippage – a potentially lifethreatening complication after laparoscopic adjustable gastric banding. Obes Surg 2005;15:133-6 27. Keidar A, Szold A, Carmon E, et al: Band slippage after laparoscopic adjustable gastric banding: Etiology and treatment. Surg Endosc 2005;19(2):262-7 28. Mehran A, Liberman M, Rosenthal R, et al: Ruptured appendicitis after laparoscopic Roux-en-Y gastric bypass: Pitfalls in diagnosing a surgical abdomen in the morbidly obese. Obes Surg 2003;13(6):938-40

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

The PULSE OCTOBER 2006

MoneyTalk Monica H. Masters, Financial Advisor, Smith Barney

Most Expiring Tax Rules Are Extended Under New Tax Legislation Changes October 2006 President Bush recently signed the Tax Increase Prevention and Reconciliation Act of 2005 (TIPRA) into law, creating many new opportunities, and unexpected challenges, especially for individuals saving for retirement or a child’s education. The TIPRA legislation includes dozens of new provisions. Following are four of the most important: • Capital gains and dividends: The previous tax law’s lower rates on capital gains and dividends have been extended through 2010, rather than expiring after 2008 as originally scheduled. • Alternative minimum tax (AMT): Taxpayers who benefit from certain provisions of the tax law may have to pay an additional tax called the alternative minimum tax. In 2006, an exemption of $62,550 for married couples and $42,500 for single taxpayers will be allowed in calculating the AMT. The exemption is phased out at higher levels of income. In addition, TIPRA allows taxpayers to use certain tax credits, such as the dependent care credit, the credit for the elderly and disabled, energy-saving credits, tuition credits and some homeowner credits, to reduce the AMT. • “Kiddie” tax: Effective immediately, TIPRA expands the reach of the Kiddie tax by making it applicable to children under the age of 18 (rather than the prior age of under 14). The “Kiddie” tax is the tax paid on a child’s unearned income that is calculated at the parent’s highest marginal tax rate. • Roth IRA conversions: In 2010, individuals who earn more than $100,000 in modified adjusted gross income will be able to convert a Traditional IRA to a Roth IRA. Previously, only individuals

who made $100,000 or less were eligible to convert to a Roth IRA. An attractive advantage of a Roth IRA is that you can take tax-free withdrawals after five years if you meet certain requirements. Favorable Tax Rates Are Extended The reduced rates on capital gains and dividends were scheduled to expire at the end of 2008. TIPRA extends for the 2009 and 2010 tax years the 0% and 15% rates on adjusted net capital gains and dividends. Here are a few actions investors may want to consider: • Investors seeking current income with some growth opportunities may want to consider shifting a larger percentage of their portfolios to high-quality equities that pay substantial dividends. • Distributions from tax-deferred accounts such as 401(k) s and IRAs are typically taxed as ordinary income. If you’re withdrawing income from your retirement accounts, consider favoring fixed-income investments in these accounts and moving growth equities to your taxable accounts. • If you are heavily invested in highly appreciated securities, now may be the ideal time to realize your gains at the lower capital gains rate and diversify your portfolio. AMT Income Limits Rise and Tax Credits are Available One of the consequences of the current tax law is that many taxpayers are at risk for triggering the AMT, an alternative to ordinary income tax that has ensnared more and more taxpayers every year. The AMT forces many taxpayers to give back some of the deductions they can take against their regu-lar income tax, such as certain home equity loan interest, real estate and state and local taxes. For 2006 only, TIPRA increases the amount of the AMT exemption for mar-

The PULSE OCTOBER 2006

ried couples fil-ing jointly to $62,550. (The AMT exemption was $58,000 for 2005 and was scheduled to go down to $45,000). The exemption for single taxpayers is raised to $42,500. (It was $40,250 for 2005 and was scheduled to go down to $33,750.) The exemption is phased out at higher levels of income. Note that this is a 1-year “fix” and Congress will need to revisit the issue. To be sure that you’re taking advantage of the newly created benefits, and avoiding the pitfalls, be sure to speak with your tax and financial advisors.

Monica Masters is a Financial Advisor with Smith Barney located in Chicago, Illinois and may be reached at (800) 621-2842 ext.3338. "This article is based, in whole or in part, on information provided by the Planning Services Department of Smith Barney." Smith Barney is a division and service mark of Citigroup Global Markets Inc. Member SIPC. Citigroup Inc., its affiliates, and its employees are not in the business of providing tax or legal advice. These materials and any tax-related statements are not intended or written to be used, and cannot be used or relied upon, by any such taxpayer for the purpose of avoiding tax penalties. Taxrelated statements, if any, may have been written in connection with the “promotion or marketing” of the transaction(s) or matter(s) addressed by these materials, to the extent allowed by applicable law. Any such taxpayer should seek advice based on the taxpayer’s particular circumstances from an independent tax advisor.

Guest Article Levente Batizy, D.O., FACOEP

Lost Innocence Give purple medicine for tummy aches. Give red medicine for fever. Give green medicine for St. Patrick’s day. Give kisses for aches and pains. Give hugs for Peter when you miss him. Give one pinch to grow an inch on your birthday.

must fight to survive and to hold on to your innocence. Remember where you came from and why you are here. Levente G. Batizy, D.O. is the Director, Graduate Medical Education / Program Director, Emergency Medicine at South Pointe Hospital in Cleveland, Ohio.

Dr. Olivia Mancisia 3/12/06

As I was preparing my speech to the graduates of South Pointe Hospital, I came across a verse written by an 8-year-old daughter of a friend. When I read the verse, I knew that I had to share it with someone. Take a moment to read the verse and reflect on the contents. Read the words, but feel the “essence” of what and by whom it was written. First, it represents the innocence that is only present in the mind of a child and maybe in the mind of a pre-med student who is full of love toward humanity and is willing to undergo a grueling commitment to become a public servant and a champion for those who are too sick to care for themselves. As you read the verse, it is full of trust and love, just as we were when we started medical school. Something happens to all of us as we go through medical school, internship, and residency. We lose our innocence. Maybe it is the long work hours. Maybe it is the realization that even modern medicine has its limits. Maybe it is the constant cynicism that surrounds you as you try to “make a difference.” Eventually you start emulating your peers and your co-workers. You too become a cynic. A cynic whose “Ideals” tarnish. You become a worker clad in protective armor who is on a survival mission. Every patient becomes a disease. Workups of patients become a minefield, a trap

- A trap that you must navigate to avoid lawsuits. The challenges are clear - your fight is on. It is your love of humanity and hunger for knowledge versus a health care system that is rich in resources and technology, but poor in “caring” and humanity. In a paradigm where the system is more important than the caregivers or the patient it serves, where non-profit institutions care most about the bottom line, you

ACOEP has recognized Monica H. Masters

Financial Advisor Financial Planning Specialist (800) 621-2842, ext. 3338 As a Financial Advisor for: Investments, Lending, Insurance and Financial Planning. Three First National Plaza, Suite 5100, Chicago, IL 60602

© 2006 Citigroup Global Markets Inc. Member SIPC. Smith Barney is a division and service mark of Citigroup Global Markets Inc. and its affiliates and is used and registered throughout the world. CITIGROUP and the Umbrella Device are trademarks and service marks of Citigroup Inc. or its affiliates and are used and registered throughout the world.

4.25 x 5.5

The PULSE OCTOBER 2006

AstraZeneca

is pleased to support the

American College of Osteopathic Emergency Physicians AstraZeneca is one of the worldâ&#x20AC;&#x2122;s leading healthcare companies, providing innovative, effective medicines for serious medical conditions. Skilled research is at the heart of our continuing success and we spend more than $2.7 billion each year on the discovery and development of new and improved medicines. Our track record of innovation includes leading treatments for gastrointestinal disorders, heart disease, cancer, central nervous system (CNS) disorders, respiratory diseases and pain and infection. With US headquarters based in Wilmington, Delaware, we are committed to maintaining a flow of new products around the world which protect and improve human health and quality of life.

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

The PULSE OCTOBER 2006

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

leading with products

AstraZeneca’s success ratio of bringing new

Priority research is being conducted for the

products to market is among the best in the

development of treatments for high cholesterol,

pharmaceutical industry. The company

blood clot formation, lung cancer and other

produces a wide range of products that make

types of cancer.

significant contributions to treatment options and patient care.

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

AstraZeneca has one of the world’s leading

equipped to maintain a flow of high quality

portfolios to treat cancer and gastrointestinal

medicines over the coming years. These

disorders, in addition to the areas of anesthesia

medicines will offer improved health and quality

(including pain management), cardiovascular

of life for patients, better health economics for

disease, respiratory and central nervous system

society and attractive growth for AstraZeneca.

disorders.

The PULSE OCTOBER 2006

AstraZeneca is a major international research

AstraZeneca operates nine different R&D sites

based pharmaceutical company engaged in the

and has sales activities in over 100 countries

development, manufacture and marketing of

and manufacturing facilities in 19 countries.

ethical (prescription) pharmaceutical products. Our

The Company has a workforce of more than

long heritage of innovation and documented ability

50,000 strongâ&#x20AC;&#x201D;with over 10,000 employees in the

to develop new concepts in medicine has made us

U.S. alone.

one of the top five pharmaceutical companies in the world. AstraZeneca PLC is headquartered in London with its U.S. headquarters located in Wilmington, Delaware. Wilmington is also the global home for the companyâ&#x20AC;&#x2122;s Central Nervous System (CNS) commercial and research and development efforts.

The PULSE OCTOBER 2006

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

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

AstraZeneca LP Patient Assistance

• NAMI’s Campaign to End Discrimination

Program provide AstraZeneca products

• Migraine Mentors Program with the

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

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

The PULSE OCTOBER 2006

Securing Your Future Arnold Bender, CPA, GCG Insurance

Protect Yourself With Disability Insurance Carrying the Right Kind of Coverage Can Provide You With an Adequate Income If an Accident or Illness Occurs. The U.S. Census Bureau estimates that you have a 20% chance of becoming disabled for a long time as a result of an accident, illness, or debilitating condition. Yet, 80% of Americans have inadequate or no long-term disability coverage to protect themselves. Don’t be caught short; protect yourself and your family by purchasing the right type of coverage. Protecting Your Paycheck Short-term disability coverage provided through state funds or your employer generally runs only three or six months. If your disability is long term (you have a physical or mental condition that can be expected to last indefinitely and prevents you from engaging in any "substantial gainful employment" or results in death you may be eligible for coverage under Social Security, but payments from this source may not be adequate for your needs. You should carry long-term disability coverage to pay you a sufficient monthly benefit if you cannot work. What you’ll pay for this insurance depends not only on the company you buy it from but also on: • How long benefits continue. Payments continue for the period fixed in the policy—the longer this is, the higher the premiums. Generally, policies pay for

five years, ten years, or until you reach, full retirement age for collecting Social Security benefits, assuming you remain disabled for this period. • Amount of monthly benefits. The greater the benefits, the higher the premiums. Benefits under the policy are usually capped at a certain percentage of your regular monthly income (e.g., 50% or 66.67%). Monthly income for this purpose is pre-tax (the gross amount you receive without regard to tax withholding and other payments). • Definition of disability. The more liberal the definition, the higher the cost of the policy. If you are covered in the event you are unable to perform the usual duties of your current occupation (“your own occupation” definition), you’ll pay more than you would for coverage that will allow you to collect only if you cannot work at any job (“any occupation” definition). • When benefits begin. The longer you wait after becoming disabled to collect (called the elimination period), the lower your premiums. For example, you’ll pay more to collect after 31 days of disability than if you wait six months to begin receiving benefits. The typical elimination period is 90 days. Inflation adjustment. If your policy can run

for many years (e.g., you buy one to cover you until you reach full retirement age), consider adding a cost-of-living feature that adjusts your benefits to reflect the impact of inflation. There is an additional cost for this feature. Premium waiver. Make sure the policy doesn’t require you to pay premiums once disability has persisted for 90 days or longer (most policies automatically include this benefit). Caution: Despite your desire to purchase long-term disability coverage, you usually cannot do so if you are currently pregnant, unemployed or are required to carry a weapon on your job.

Tax Issues There are two tax-related considerations with disability insurance: whether premiums are deductible and whether benefits received under the policy are tax-free. Understanding the tax rules and planning ahead can ensure the more favorable tax treatment for you. Premiums. If your employer pays the premiums for your disability policy, the company, and not you, can deduct them. But you receive the benefit of coverage tax-free. If you pay the premiums personally, you cannot deduct their cost. This is viewed as a nondeductible personal expense.

2nd Annual Residency Exposition Hosted by ACOEP-Student Chapter Students are invited to attend and network with representatives from AOA-Approved Emergency Medicine Residency Programs Monday, October 16th 8:00 a.m. to Noon Las Vegas Convention Center in Las Vegas, NV

The PULSE OCTOBER 2006

Letter to the Editor The Columbus Dispatch

On Thursday June 15th, buried on page D6 of the Metro Section was an article on the release of the Institute of Medicine’s report on the Future of Emergency Care. This report highlights in grim detail a national crisis in emergency care, a crisis that affects citizens of every community in Ohio. Given the importance of this issue, the national TV networks ran it on the “front page.” Are we less concerned in Columbus? Emergency departments provide the health care safety net for everyone, the insured and the uninsured. Unfortunately, the number of hospital emergency departments is declining, while the number of patient visits has increased. Between 1993 and 2003, Emergency Department visits rose by nearly 14 million. Who goes to the emergency department? Insured patients referred by their family physician because of the need for testing or because it is after normal business hours. Emergency transports by 9-1-1 response; the un- and under-insured who simply have no other option for health care. Some of these uninsured visits are not for non-emergent conditions. Indeed, the lack of primary health care means that these folks often wait until it is an urgency or true emergency before seeking the health care they need, thus stressing the system even further. The federal Emergency Medicine Treatment and Active Labor Act (EMTALA) requires the assessment of any individual seeking treatment in an emergency department in the United States. Anyone-anywhere-anytime! With no required compensation for the emergency physician providing the service, emergency physicians provide more charity care than any other medical provider. This means your emergency department is crowded; ambulances are diverted; and while full or understaffed hospitals board patients in the ED, the emergency situation is stretched to a breaking point. Most hospital emergency departments, viewed and utilized by our public as an essential public service, are strapped to provide the service for which they exist without delay during normal operations. A catastrophic

vehicle crash can quickly absorb any surge capacity that might exist. There is simply no preparation or readiness for a natural or manmade disaster. America's most missioncritical hospital resources are struggling to meet daily demands, much less the additional burden of an epidemic. In fact, only a tiny fraction of federal funding for emergency preparedness has been spent on medical preparedness, although emergency service providers— EMS and hospital emergency departments –are a crucial part of the response to any disaster! State and federal governments must recognize the role of emergency physicians, nurses, and EMS in responding to disasters and allocate funds accordingly. In Ohio, Homeland security and other dollars continue to target non-medical issues. The recent announcement of $41.3 million in Homeland Security Funds for Ohio earmarks just $1.3 million for the metropolitan medical response system. No state agency is truly engaged in medical preparedness. The summary work and accomplishments of the State of Ohio Security Task Force, established in the wake of 9-11, do not even address the role of medicine. http://www. homelandsecurity.ohio.gov/taskforce.htm The Department of Health currently oversees Ohio’s public health response, a role clearly identified in the pandemic flu response plan, which is a public health plan encompassing mostly prevention-surveillance-education and containment. There is no medical response plan! There is a Medical Surge Committee but with no state authority over hospitals, no state chief medical officer, and no dollars targeted towards medical response. The only real agreement among everyone is that in the face of a pandemic flu, in this particular case, there will be a critical shortage of resources and hospital capacity will be greatly compromised. This issue affects everyone. This is not just another national report. This report is a wake up call to Ohio and the nation to recognize emergency care as an essential community service that must be funded. This must include dedicated funding for

The PULSE OCTOBER 2006

the emergency medical system for disaster preparedness, and reimbursement for emergency physicians and departments for the uncompensated emergency and trauma care. A possible national solution is proposed in the Access to Emergency Medical Services Act (HR 3875 and S 2750). Emergency physicians need your support and your call to your Congressman or Senator advocating support of the Access to Emergency Medical Services Act. This Act addresses the growing lack of resources in emergency care by recognizing emergency medicine as an essential community service; addresses the growing physician shortage by extending limited liability protection to physicians caring for patients in emergency departments; and provides financial incentives to hospitals to end the practice of ‘boarding’ patients. I urge your thoughtful consideration and support for timely resolution of this crisis in emergency care. Sincerely Peter A. Bell, DO, FACOEP, FACEP President Ohio Chapter, American College of Emergency Physicians Columbus, Ohio

Peter A. Bell, DO, FACOEP, FACEP President Ohio Chapter, American College of Emergency Physicians 3510 Snuffer Rd Columbus, Ohio 43235 Office 614-792-6506 614-544-5834 bell@exchange.oucom.ohiou.edu www.ohacep.org

Governmental Affairs Raul J. Garcia-Rodriguez, D.O., FACOEP, Chair

It’s Time to Become Active in Your College Imagine if we had a college where all members were active in Governmental Affairs and we actually made a difference in the shape of healthcare for years to come. That is the chance we have now. All of the headlines point to a gloomy future in healthcare; a future where the Government tells you exactly how to treat your patients to the extent of what labs, X-rays, and medicine to use on each patient. To add insult to injury, you will be paid less for your services. The Centers for Medicare and Medicaid Services have proposed to cut physician payments 5.1% across the board for 2007. These changes will affect all of us as of January 1st, 2007. Specialties like Radiology will suffer a

14 to 16 % cut. These cuts will inevitably affect us at each hospital that tries to cut every department’s share on an equal basis. The Government is trying to initiate new ways to eliminate cost of laboratory, radiological, and other medical studies ordered every day by Emergency Department physicians. Now is the time to act. Get involved. Let’s not let it get to the point where one has to choose whether to not order studies to keep one’s job, but at the same time open yourself to lawsuits. Become a participant of the ACOEP’s Governmental Affairs Agenda. • Donate fifteen minutes a month to call your congressman and senators; OR

• Donate fifteen minutes a month to write to your congressman and senators; OR • Donate one day a year and come to Washington to talk to your congressman and senators at DO Day on the Hill; OR • Join us on the Governmental Affairs Committee and act monthly on ACOEP projects. For more information, please contact us acoepgov@acoep.org.

Winning Resident Paper Announced The Foundation for Osteopathic Emergency Medicine (FOEM) is proud to announce the awarding of the 2006 Resident Paper Award to Sandra Munsters, D.O. of POH Medical Center. Dr. Munsters paper, titled, Prospective Analysis on the Correlation Between Traumatic Hyperglycemia and Patient Outcomes, was judged to be the best submitted this year. For her entry, Dr. Munsters will be presented with an award of $1500 at the Foundation Awards Luncheon at the Las Vegas Convention Center on Wednesday, October 18th, where she will present her paper. The ACOEP has also recognized Chad Stadheim, a second year medical student at the Midwestern University, Chicago College of Osteopathic Medicine, for his winning submission, titled, Rapid Progression of Ataxia and Dysphagia in a Developmentally Challenged Boy Presenting to the Emergency Department.

Student Dr. Stadheim’s submission to the 2006 Student Case Competition will be presented with an award of $1000 for his submission to the Competition. The Foundation is pleased to announce that these two papers will be featured in its premiere issue of its research supplement to The Pulse in January 2007. Additionally, the Foundation will feature the abstracts of all poster and oral presentations in this issue. Also highlighted will be abstracts of two papers dealing with resident opinions on linked residencies and on resident opinions on training selections. These papers, submitted as part of the Research Competition were chosen to be important to the emergency medicine community and the Foundation wished to present them in its premiere issue. The papers, titled, The Driving Factors that Influence Graduating Osteopathic Physicians to Choose Allopathic

The PULSE OCTOBER 2006

Emergency Medicine Residency Programs, by Chantelle L. Thurow, D.O. and Michigan Osteopathic Intern and Resident Perspectives on Linking Internship to Residency, by J. Michael O’Hargan, D.O., both of Genesys Regional Medical Center, were excellent papers illustrating the interests of resident researchers in emergency medicine. We thank all of the participants in this competition for their excellent efforts in research in emergency medicine. The Foundation will be unveiling its newly revamped applications for the 2008 competitions in late January. Please refer to our website at www.foem.org or through the “Links” section of the ACOEP’s website.

Guest Column William Lynch, Jr.

The “Mystery” of Hotel Roles For the past number of years, our firm NHS has represented ACOEP in securing group contracts for the multiple meetings that the college conducts. During that time, the “hotel market” has witnessed significant transition and is currently on a major upswing with hotel companies like Marriott, Starwood, and Hilton reporting record profits. For nearly two years after September 11, overall demand for guest rooms dropped significantly and as a result some hotel rates were down by more than 60%. During that time, very few hotels were built and the number of individuals traveling on business and for vacation dropped significantly. Beginning in early 2004, Americans began to travel again in record numbers and this precipitated a sustained rise in hotel room rates. For doctors that live in a “scientific world” the method of hotel pricing does not follow logical principles but traditionally a short-term capitalist model. Most major hotels have a person called a “revenue manager” responsible for setting rate guidelines in conjunction with the Director of Group Sales responsible for contracting groups like ACOEP. The primary factors that determines group rates are the time of year the meeting occurs, (peak season vs. off-season), the size of the group, overall spending for group meals and activities, and the date of arrival and departure. These variables are looked at with the number of individual or social guest that traditionally uses the resort over those dates. In addition, if the group “leverages” all of their meetings with a hotel chain they can secure significant savings as ACOEP has done with Starwood Hotels – the management company of Westin, Four Points, and The Wigwam Resort. The resorts and downtown hotels also factor in “city-wide” conventions or sporting events like NASCAR that impact the demand for rooms. In addition to the

overall rate, the staff of ACOEP has been instrumental in negotiating discounts on food & beverage, audio-visual and securing a number of complimentary rooms that save on the overall budget. The landscape for hotel rates is fluid and with a significant number of new hotels and resorts being built, the laws of supply and demand always come into play. The older hotels must continually put capital into their properties to keep

the level of quality up or the smart buyers will not utilize their facilities. We highly recommend that you sign up for the hotel frequent guest programs that can help you receive “VIP” treatments and be made aware of special offers.

BETTER TOOLS BETTER RESULTS

SUREVENT ™

GRANDVIEW ™ NOW AV AILABLE ! p

Adult Dis

The SUREVENT not only improves the quality of care you deliver everyday, it is ideal for disaster preparedness. Weighing only 4 oz., this single-use device makes it simple and affordable to ventilate large numbers of patients anywhere, anytime. Selected by rural and metropolitan departments alike, the SUREVENT provides a solution to be prepared. Are YOU?

osable V ersion

Known as the tongue tamer, the GRANDVIEW Laryngoscope Blade provides a clear and unobstructed view to the cords. The wider blade surface and brighter lamp design make it ideal for all emergency care providers. See for yourself how a little innovation can increase your intubation success rate. Don’t delay. Call us today.

1-800-633-5900 Creating Quality Products for Life 6352 Corte del Abeto, Suite J • Carlsbad, CA 92011-1408

The PULSE OCTOBER 2006

www.HartwellMedical.com

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

Half-A-Century This past spring when I celebrated my birthday, my 8-year-old son informed me that I was half-acentury old!! At the time, I did not feel like I was fifty! I thought I felt pretty good, overall, except for this chronically swollen, painful, locking, and non-bending knee. While a first-year medical student at PCOM, I was diagnosed with a torn cartilage in my knee and surgery was performed to remove the damaged cartilage. The cause of this injury was unknown at the time, but I am certain it had nothing to do with me playing rugby, doing power squats or the running that I was partaking at the time!!! For about 18 years, I as fairly active as a runner, I did squats and played recreational sports like golf (cart riding eschewed), volleyball, hiking, and racquetball. Five years ago I experienced pain and swelling with any physical activity. One year later, I had an arthroscopy and house cleaning of my knee. I was told at that time I had extensive osteoarthritis of my knee and would probably need a knee replacement in the future. My running career was over but I was still able to do my beloved squats until 2 years ago. Two years ago, I experienced severe knee and leg pain with swelling, locking, and decreased range of motion. Three Synviscus injections (one injection weekly for three weeks) in my knee afforded me about 8 months of relief and a return to increased physical activity. I was taking glucosamine and chondroitin in the hopes that theses medications would prevent any further degeneration of my knee. However, the knee started acting up again to the point that I not only had pain, swelling, locking, and decreased range of motion, but I developed sciatica, as well. My second Synviscus injection series at the end of last

year provided minimal relief and lasted less than one month. This past winter I was miserable! Walking and sitting at work exacerbated the pain and swelling and driving my forty minute commute was unbearable. I just could not find that comfortable position while driving and sleeping. The activities of daily living like showering and dressing were cumbersome. Setting the parking brake on my car was impossible to accomplish with my left leg and usually done by hand or with my right leg. The elliptical machine not only increased the pain and swelling in my knee but made the sciatica flare up. NSAIDS and Tylenol were providing minimal or no relief. There was no respite from the severe pain or swelling. It was recommended that I undergo total knee replacement by my orthopedic surgeon. He stated normally he would postpone the surgery until I was sixty, but felt that there was no other option available that would provide me with pain relief for the next ten years. There is no good time to have surgery. I did not want to wait until the winter to have the knee replacement and run the risk of slipping and falling on the ice. Spring and fall are busy times at home with school, sports, cub scouts, PTA and other activities that my family are involved in that would make it difficult to provide transportation and any other assistance that I would require. It was decided to have the knee replacement this past June and my hospital was able to fulfill my schedule with moonlighters and new hires. I never utilized any sick time in the past or had any major surgery that required missing work. It was a different experience receiving health care rather than providing health care. The whole experience of being a patient was very positive. It gave me insight into what it is like being a patient and hopefully will allow me to be a better and more empathetic physician. Overall, I was very satisfied with the care I received in the hospital and as an outpatient. The only

The PULSE OCTOBER 2006

shortcoming or disappointment I encountered, as a patient was both the inpatient and outpatient physical therapy. My only concern or drawback to my physical therapy was the assumption that because I was a physician that I know all about physical therapy and the therapy rendered was not individualized enough to fit my specific disability. At my 12 week post op check-up my orthopedic surgeon was happy about my range of motion and felt that eventually I would obtain 0 degrees of extension and 120 degrees of flexion. I need to improve my extension by 1-2 degrees and need about 10 or so degrees of increased flexion. I had 8 weeks of physical therapy and my routine did not change from the first session through the 26th session. Any adjustments made to my program either by increasing the weights or increasing the time on the exercise bicycle or elliptical machine was done by me on truly a trial and error process. The majority of the exercises done at physical therapy and at home were geared specifically for extension and not flexion. I need to improve my flexion and, hopefully, with the new exercises given to me by my orthopedic surgeon this will happen. Before the surgery, I thought I would be out of work for 8 weeks and when I went back to work, the pain and swelling will have subsided. I return to work this week after being out for 12 weeks and I am still experiencing some pain, decreased range of motion and swelling. Even though I am not happy with my range of motion at this time, it has improved significantly since the surgery. This past spring at the ACOEP conference, I hiked Piestewa Peak and each step was an experience with increased instability, pain, and swelling. I was amazed that I was able to hike Piestewa Pike and not injure myself!! At 10 weeks post-op, while on vacation in the Adirondacks, we hiked up Baker Mountain that was listed as an easy climb (moderate or difficult is more appropriate definition) and my knee Half-a-Century, continued on page 29

Student Chapter Update Joshua Linebaugh, MSIV, National Chapter President

Greetings once again from the Student Chapter!! I hope this update finds the membership of the ACOEP doing well now that the summer is over, and itsâ&#x20AC;&#x2122; extreme heat is hopefully behind you. The update below is written to give the membership a status report on progress that the Student Chapter has made on achieving our goals previously stated in the February Pulse. The goals set forth by the Student Chapter for the year were three-fold: Improving communication between students on a national scale, finding ways to give back to the ACOEP membership as a whole, and promoting the many quality Osteopathic Emergency Medicine residency programs to our students. Communication between those students interested in Emergency Medicine and the national Student Chapter has always been challenging and will increasingly become more difficult because of the growing number of Osteopathic Medical Schools. Therefore, we devoted much of our time this year to the development of the website, www.acoepsc.org. The website has been met with great enthusiasm and approval by the students, and we anticipate that this communication tool will become more valuable as itsâ&#x20AC;&#x2122; functional scope expands. Giving back to the ACOEP membership was our focus at the Spring Seminar held this past April in Phoenix, Arizona. The Student Chapter sponsored two events with the membership specifically in mind. First, we took a group of physicians and their families to watch the Arizona Diamondbacks take on Barry Bonds and the San Francisco Giants. The second event was a student-run OMM clinic for the physicians and their families. Both events were received very well, and the Student Chapter has decided to make the OMM clinic an annual event at the Spring Seminar. Do not hesitate to take advantage of this opportunity next year at the Wild Horse Pass Resort. Promoting the many quality Osteopathic Emergency Medicine residency programs will be the focus of the Student

Chapter at the upcoming AOA Convention held in October in Las Vegas, Nevada. In an effort to do this, the crux of our events in Vegas will be the 2nd Annual Osteopathic Emergency Medicine Residency Expo. We have gone to great lengths to promote this event to students across the country, to the residency programs, and to the AOA as a whole. Our expectation is to have a great turnout of students and programs at the Expo! This is an exciting time for medical students across the nation as we experience the many transitions that accompany the beginning of the new academic year. For some, we are finishing our board preparation and apply for residency; others are now experiencing clinical rotations for the first time, and still others, are renewing their

The PULSE OCTOBER 2006

focus to spend time in the classroom trying to get a handle on the basic sciences that lay a foundation for their lives as a clinician. With these many transitions, come many uncertainties. Therefore, I encourage you to become involved in our Mentor Program. This is an opportunity to use your experience and expertise to shape the lives of those future physicians that will someday become your colleagues. If you have any questions, concerns, or you would like more information about working with the Student Chapter, feel free to contact me at acoepsc_pres@hotmail.com. Thank you once again for your continued support of the Student Chapter.

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

What Would You Do? In this issue of The Pulse, we will review the case of the 30 year-old female who presented to the Emergency Department for evaluation of suicidal ideations. She had stated that 18 years ago, her cousin had concealed a pregnancy, delivered the baby, and then they placed the baby in a plastic bag and buried it. The viability of the baby was unknown. Our patient had struggled with depression ever since. The dilemma related to the responsibility of Emergency Department, if any, to notify the police. This case was very troubling to all involved. The medical staff was torn between concerns for police involvement vs. the well being of the patient. What would notification of the police accomplish after 18 years (if this scenario was even true)? How would the patient react to this public opening of her problem? Did we indeed have an affirmative responsibility to notify the police? What about patient confidentiality? The hospital’s legal department was contacted and a decision to honor patient confidentiality within the doctor-patient relationship was decided. This determination was amenable to all involved, and the patient received psychiatric care. 5/2/06 5:21 PM Page 1 like to present or have reviewed in The Pulse, please fax them to us at (708) 915-2743. If06-EM-471 you have any cases in your practice that you would

career

Your is moving. We’ll make sure it’s direction. in the

right

The best practice begins at EmCare. If there’s one thing your job has taught you, it’s that your training never ends. At EmCare, we make professional development and continuing education a priority for physicians. Programs like the EmCare Leadership Institute and our Internet Training System enable you to open new doors and further your career. And that is one very valuable lesson.

800-EmCare1 (800-362-2731) recruiting@emcare.com www.emcare.com/opportunitywatch

The PULSE OCTOBER 2006

Guest Column Carol Monaco, Deputy Director Division of Regulatory Affairs, AOA Washington Office

Prepare for National Provider Identifier (NPI) “Getting an NPI is free; not having one is costly,” is the new slogan to get physicians and other providers to apply for the standard identifier as soon as possible. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandates the adoption of a standard unique health identifier to replace provider identifiers currently in use with health plans, including Medicare, Medicaid, and all other private and public payers. HIPAA-covered physicians and healthcare providers, whether they are individuals or organizations, must obtain an NPI. When a physician applies for an NPI, he/she must include all legacy identifiers such as PINs, UPINs, Medicaid number, etc. (To apply, go to https://nppes.cms.hhs.gov/ NPPES/Welcome.do) However there’s more to the NPI than just applying for a number. Without proper preparations, practices may see a disruption in cash flow next year. A physician practice must contact all of its health plans to determine the plans’ NPI implementation timeline. The actual

compliance deadline is May 23, 2007 (May 23, 2008 for small health plans). For its part, the Centers for Medicare & Medicaid Services (CMS) released its timeline for using the identifier. CMS currently accepts claims with the NPI, but an existing legacy Medicare billing number also must be on the claim, otherwise, Medicare will reject it. According to CMS’ tips on NPI, a practice must contact its vendors, business associates, and colleagues to see if they are ready to deal with the new identifier and when they will begin accepting it. Office staff also must be trained on using the NPI such as: how and when to disseminate it, how to protect it, and when to collect it from other providers for use in HIPAA standard transactions. In addition, a practice should develop a plan to ensure that the NPI is kept up to date; plus educate staff on how NPIs from other organizations or peers will be collected and validated for use in HIPAA standard referral transactions. Staff must know what to do if another physician’s NPI is needed in a

HIPAA standard transaction (i.e., ordered or referred service), but the NPI is unknown. HIPAA standard transactions include: claims and encounter information, coordination of benefits, claims status inquiries/ responses, eligibility inquiries/responses, payment and remittance advices, enrollment/ disenrollment in health plans, and referrals. With less than a year before mandated compliance, CMS plans to hold NPI roundtable discussions via conference calls to help physicians and other providers with the implementation process. CMS suggests that physicians obtain their NPIs at least six months before the compliance deadline to allow time for preparation and testing. NPI products and resources are available through the CMS web site: www.cms.hhs. gov/NationalProvIdentStand/.

OFFICIAL CALL To the Officers and Members of the American College of Osteopathic Emergency Physicians: You are hereby notified of the ACOEP’s Fall Membership Meeting on Monday, October 16, 2006 at the Las Vegas Hilton Hotel in Las Vegas, Nevada. The meeting will begin at 5:00 p.m. A “Meet and Greet” Session to introduce members to Board Candidates will begin at 4:00 p.m. Active, Active-Exempt, Life and Retired Members will be allowed to vote for members of the Board of Directors and new Board Members will be announced at this meeting. The Presidential Inauguration and swearing in of newly elected Board Members will occur at this meeting at 6:30 p.m. The location of this meeting is N 109-111 at the Las Vegas Convention Center. Thomas A. Brabson, D.O., FACOEP, Secretary

The PULSE OCTOBER 2006

Guest Article Joseph J. Kuchinski, D.O., FACOEP

November Elections Never have "off-year" elections for Congress meant so much to healthcare! Several "national" issues such as " the war with Saddam Hussein and now the insurgents" (our conflict has never been with the people of Iraq) and support for the President will directly affect the fate of incumbents this fall. One only has to look to the results of the Connecticut Democratic Primary to see this direct effect. However, there are two critical issues for healthcare, which are not getting as much national press. The liability crisis looms as large as ever. A few states have been successful in the tort reform arena. Now they will need to withstand judicial scrutiny. Finally, the issue of flawed Medicare physician payment formula must be fixed! Physicians are slated to take a 5.1 percent cut in January 2007 and total decreases of more than 30 percent over the next 8 years.

The ACOEP and AOA have been working diligently to remedy this flawed system. Several ACOEP Board members joined me in Washington DC for the AOA "fly-in" to advocate for our profession (see the www.ACOEP.org for an update). Now we need your support: 1) Join GOAL and find out how easy it is to be an advocate for your patients (25 percent of new Medicare patients are finding it difficult to find a physician) and our profession. Register online at www.capwiz.com/aoa-aoia/mlm/ 2) Get to know your candidates for the House and Senate now and build the groundwork for a successful partnership in the future! Visit the Candidates & Elections page of the D.O. Advocacy Action Center at www.capwiz.com/ aoa-aoia/e4/.

3) VOTE! Many have sacrificed for all of us to have this right. Whether it means registering for an absentee ballot or relieving a partner for part of a shift, all of us must vote! Register to vote or request an absentee ballot online at the D.O. Advocacy Action Center at https://ssl.capwiz.com/aoa-aoia/e4/nvra/ ?action=form&state=. 4) Talk to your patients about these critical issues - there are resources available to get them involved. 5) Support your candidates by anyway you feel comfortable: volunteering, contributing, holding or attending a fundraiser. Find out how to get involved today! Contact Leann Fox at (800) 962-9008 or lfox@osteopathic.org. It's never too late!

ACOEP Welcomes two new staff members The ACOEP is pleased to announce the hiring of two new employees to the positions of Executive Assistant and Meetings Marketing Coordinator. Yvonne Treacy joined the ACOEP as its Executive Assistant immediately following the Spring Seminar. As Executive Assistant, her duties will include providing support to the Executive Director, assisting the development of Committee and Board agendas and providing Committee assistance to several different Committees. A native of Ireland,

Yvonne is the first voice you will hear when you call into the ACOEP. Her valuable skills in member relations combined with a wideranging background in office administration and support have made her a valuable addition to our staff. Amanda Lundeen joined us as Membership Marketing Coordinator in September 2006 A recent graduate of Augustana College her Bachelor of Arts degree in Speech Communication is a valuable benefit to the membership area. Combined with her strong verbal and writ-

The PULSE OCTOBER 2006

ten communication skills Mandy has excellent people skills and is a highly motivated and organized person. Stop by and introduce yourself to Mandy and Yvonne at the ACOEP booth in Las Vegas!

Presidential Viewpoints, continued from page 5

11. Rural hospitals should link and develop relationships with academic centers. 12. The Department of Health and Human Services and other stakeholders convene to develop evidence-based indicators of emergency care systems performance. 13. Congress should establish demonstration programs to promote regionalization and coordination, and accountable emergency care systems. 14. Congress should establish a lead agency within the Department of Health and Human Services for emergency and trauma care and report within two years. The strength of this report is that it recognizes the state of emergency care is not solely an emergency department problem but that it is the symptom of the bigger issue. The challenges in these issues and these recommendations are monumental

but solvable. We did not get to this point in an instant. It has not been a sudden inciting event, but a slowly building and smoldering crisis that has been brewing for years. In order for this to be successful, the recommendations must be coupled with real healthcare reform answers. We must take the recommendations seriously and have the tough discussions they

Half-a-Century, continued from page 23

replacement worked fine. I had no problems with my knee during the ascent or descent of the mountain; however, I did develop pain and swelling in my knee the next day which lasted for about a week. This was a minor setback but proved to me that knee replacement was okay and I probably was not ready for that climb. The pain I experience since the surgery is usually relieved with pain medication and is not as

disabling as it was before the surgery. I am resigned to the fact that I will continue to require pain medicine on a PRN basis until my knee is totally healed. My orthopedic surgeon assures me that the pain will eventually “burn out” but it might take as long as 1 year. The quality of my life has definitely improved since my knee replacement and I no longer feel like I am a half-centuryold!! Note: I want to thank everyone for his or her support and help during my recovery. Thanks to my wife, Sandy, and my sons Joe, Mikey, and John, who without my recovery would have been impossible. Special thanks to Jan Wachtler and Wayne Jones, D.O., FACOEP for their encouragement and thoughtfulness and to Jed Seitzinger, D.O. for manipulating the work schedule.

Find the right EM practice, at the right time, with the right people Athens, TX - Just south of Dallas. Level III Trauma Center with 30K patient volume. 32 hours of physician coverage. Potential annual income of $300,000. Other nearby opportunities range from 6 to 24K volume. Call Ronnie at ext 1345 “The Valley”, McAllen, TX - This facility is among the top 3 percent of all hospitals in the nation. Designated as a Level IV trauma center with formal triage, this facility cares for 25K patients annually. Potential annual income of $300,000. Call Kim at ext 1389 Roswell, NM - Truly a land of enchantment. With double physician coverage PLUS NP Fast Track--this ED has one of the lowest patients per hour you will ever see. Potential annual income of $333,000. Call Pam at ext 1234 Tampa Area - Brand new 20 bed ED that cares for over 17K patients annually. A dynamic staff and overall team atmosphere make this EM opportunity worthwhile. Call Teresa at ext 1378 Biloxi, MS - Be involved in rebuilding this community. 26K ED volume with double physician coverage. Rotating trauma call with other facilities on the coast. Stable core group of physicians. Call Carl at ext 1217

Stop by and see us at AOA booth # 337 in Las Vegas The time is right to come join us in making a difference in emergency medicine.

800.893.9698 fax: 337.262.7298 | physician_jobs@tsged.com | www.tsged.com

The PULSE OCTOBER 2006

Build a better future. For you. For your patients. Premier Health Care Services believes every emergency physician deserves to work in a stable environment that richly rewards you for your skills and passion, while providing you with full benefits, including incentive compensation and malpractice coverage. At the same time, we believe you should be given opportunities for lifelong growth and career expansionâ&#x20AC;&#x201D; board member positions, committee participation, medical directorships, and even chairperson seats. At Premier Health Care Services, our goal is to provide you with a rewarding career as an emergency physician. With a physician retention rate of more than 90%, weâ&#x20AC;&#x2122;re providing physicians with careers that can last a lifetime. As a physician-owned and managed company, we understand the value of stability and have since 1987. To learn about a rewarding career with Premier Health Care Services, Inc., call our Physician Services Department at (800) 406-8118.

Physician Owned and Managed Since 1987 Dayton, Ohio z (800) 406-8118 z www.premierhcs.net The PULSE OCTOBER 2006

Is your career as a physician as fulfilling as you always hoped it would be?

TeamHealth offers more.

You’ve wanted to be a physician for as long as you can remember. Whatever your goals—to serve on a national specialty task force, to reach out to mentor residents, to serve as an ED medical director, or to have the flexibility to enjoy life outside of work—TeamHealth provides the resources and support to help you be the kind of physician you’ve always wanted to be. Leave behind the administrative hassles of managing a physician practice and let TeamHealth support you in

is your career all you dreamed it would be?

providing exceptional patient care. Isn’t that why you became a physician in the first place?

If your career isn’t all you dreamed it would be,

call TeamHealth today.

800.818.1498

ACOEP NEWSLETTER

Presorted Standard U.S. Postage

PAID

Chicago, IL Permit No. 2177

142 E. Ontario Street, Suite 1250 Chicago, Illinios 60611

www.teamhealth.com

The PULSE OCTOBER 2006