The Pulse October 2007 by ACOEP

The PULSE

Osteopathic Emergency Medicine Quarterly VOLUME XXXII NO. 4

October 2007

Presidential Viewpoints Peter A. Bell, D.O., FACOEP

Forging Ahead Once again congratulations are in order. The ACOEP is now the second largest specialty college. In addition, we are proud to support 42 residency programs, and in 2008 will have approximately 900 residents in training (the largest osteopathic training program is family practice with over 1000 residents). Every month, individuals interested in establishing new emergency medicine residency programs approach us. Likewise, the student chapters across the country continue to grow, and serve to drive the interest in new residency programs. Concurrent with these milestones is the expenditure of the President’s discretionary funds to send board members to the student chapters. Next year the student chapter visitation plan will be an official line item in our budget, thus completing another objective in our strategic plan. A comprehensive update on all the President’s Objectives were presented at the Fall 2007 convention. For those unable to attend, the information will be available on our website. The ACOEP is going through many changes. Some of these were outlined in the Summer 2007 President’s Message. The Board of Directors has been working diligently to address the concerns of the

membership, and formulate action plans to best serve your needs. These initiates were derived from surveys of and meetings with the membership. Despite your vote of approval, some members of our AOA family have misunderstood our intentions. The following is an overview of issues under consideration and a public reaffirmation that we are osteopathic physicians who are loyal to the profession and will remain part of the AOA. In March the Board of Directors announced a change in the ACOEP’s participation at the annual AOA Convention. This decision drew concerns from the AOA Bureau of Conventions and AOA leadership. My response was an analogy that I believe holds true for a lot of growing organizations. We are part of a large family. We respect our parents (the AOA) and desire to have a positive relationship, but we have matured. It is time for adulthood. With this come necessary changes in the family relationship. While a grown child may agree to a joint vacation with mom and dad, they need their own space, and as well as they need to manage our own finances. Like that proverbial child ACOEP needs this same space. In May, the ACOEP Board of Directors submitted a resolution to the AOA House of Delegates recommending an independent accreditation agency be established to manage all postgraduate medical education. This concept had been discussed in many circles, and was privately supported by

The PULSE october 2007

many specialty colleges, academic administrators, and various osteopathic leaders. The intent was to discuss the current process openly and improve our current system. Again, this drew concerns from the AOA leadership. Discussions ensued. It was evident that our actions were misunderstood. In order to avoid the possibility of further miscommunication, I also shared that the ACOEP is planning to expand operations (in large part due to the growth expressed in my first paragraph). Our current lease at the AOA building expires at the end of next year. We are exploring space options both inside and outside the AOA building. These three issues precipitated a meeting with the AOA executive leadership at the July House of Delegates. Our growing pains had commonality with many of the other specialty colleges. In order to avoid misunderstanding of intent between parent and child, the AOA proposed a Summit of ALL the specialty colleges to discuss EVERYONE’S needs and concerns. As in any family, sometimes the path to unity is fraught with poor communication and apprehension. A family meeting is the perfect solution! I have great expectations for our specialty and our profession. Addressing issues in an open, transparent, and inclusive forum is my desire. We are going places, some with our family, and others on our own, to destinations yet to be determined. As always I welcome your feedback.

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The PULSE october 2007

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

Is the Grass Greener on the Other Side? Part II Is the grass greener on the other side? My last editorial in The Pulse broached this subject. Now it is time to answer this question. Since the last publication of The Pulse, I have decided (with my family’s encouragement) to see if the grass is really greener on the other side! So, what compels an individual to resign from their current job and move their family 250 miles north to another state (that has fierce winters)? Is it midlife crisis, adventure, opportunity, finances and change reasons that people seek employment and residence in different locales? In my case some of these factors come into play, but the overriding impetus is a sense of unhappiness and uncertainty that have prompted me to seek employment and fulfillment in another location. Is a midlife crisis a possibility? I guess, but I usually associate that concept with a new, young significant other (mistress), a manic change in spending habits or a self centered indulgence of the world. I have not acquired any of these traits and my

family is excited about moving to another community that is not only closer to our families but presents my children with excellent educational and recreation endeavors. Life is an adventure but not at my age! I do not relish the idea of moving just to move and to have my family’s life disrupted so that they can experience how people live in a different community and environment. This relocation provides me with the opportunity to not only change my location but to change my focus as well as what I do. I will continue to practice Emergency Medicine that I still enjoy but I will be involved in the decision-making processes of the Department. What does all this mean? It means I am becoming a working director! Money is not the driving force behind my relocation because my current employer (I had to give a 120 day notice before my resignation) continues to compensate the emergency physicians well, provides a competitive benefit package and a desirable work schedule. I will no longer be a salaried employee but a limited liability partner, who is responsible for providing my own benefits. Several questions that were brought up during the job interviews include: Why this location and why now; and what are

you running from? Both of these questions required a tremendous amount of soul searching and honesty on my part. During my interviews I am not sure if I answered these questions appropriately but since then I contemplated these questions and hope that my answers justify relocating. Why was I so unhappy with my current job and why did I feel uncertain about the future? As stated in the last edition of the Pulse, my frustration and dissatisfaction with the delivery of Emergency Medicine is that the patient is not as important as the process and we are more concerned with throughput. My new job has low patient satisfaction scores and throughput needs improvement. So why will I tolerate the new job and not my current job? One is that I will be part of the decision making process and second is that the patient “appears” to be at the forefront of improving throughput. It appears not to be process driven but patient driven and hopefully there will be a balance between moving the patient through the ED and ensuring that the patient is what drives the throughput process. Hopefully, once the length of stays in the Emergency Department decrease the patient satisfaction scores will increase!! My uneasy feeling about my current

Table of Contents Presidential Viewpoints, Peter A. Bell, D.O., FACOEP . . 1

Governmental Affairs, Leann Fox . . . . . . . . . . . . . . . . . 12

Editorial, Drew Koch, D.O., FACOEP . . . . . . . . . . . . . . 3

Emergency Department Ethics . . . . . . . . . . . . . . . . . . . 12

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

History of EMS, Part III, Wayne Jones, D.O., FACOEP . . 13

ACOEP Members in the News . . . . . . . . . . . . . . . . . . . 7

Finanacial Edge, Dave Muti, JD, RMA . . . . . . . . . . . . 17

Resident Research, Christopher Michael Gooch, D.O. . . . 9

CME Calendar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Guest Column, Wayne Jones, D.O., FACOEP . . . . . . . 11

The PULSE october 2007

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 Wayne Jones, D.O., FACOEP, Asst. Editor Peter A. Bell, D.O., FACOEP Gary Bonfante, D.O., FACOEP Duane Siberski, D.O., FACOEP Janice Wachtler, Executive Director Communications Subcommittee Drew A. Koch, D.O., FACOEP, Chair Wayne Jones, D.O., FACOEP, Vice Chair Gary Bonfante, D.O., FACOEP, Advisor James Bonner, D.O., FACOEP, Advertising Bobby Johnson, Jr., D.O., FACOEP William Kokx, D.O., FACOEP Annette Mann, D.O., FACOEP The PULSE is a copyrighted quarterly publication distributed at no cost by the ACOEP to its Members, libraries of Colleges of Osteopathic Emergency, sponsors, and liaison agencies 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 email address of the submitting party must accompany advertising copy. Advertisers will be billed for ads prior to the publication of their advertisements and payments will be due within 30 days of the issuance of the invoice. The deadline for submission of articles and advertising is the first day of the month preceding publication, i.e., December 1, March 1, June 1, and September 1. ACOEP and its Editorial Board reserve the right to decline advertising and articles for any issue.

Editorial, continued from page 3 employer is not only perceived by myself but by other physicians, as well. There have been 5 resignations of physicians in the past six months with several other physicians cutting back on their employment status. Most of the physicians working in the Emergency Department at my current employer have been together for many years! Why are physicians leaving? I cannot vouch for the other doctors but for me, it is the direction of patient care away from the patient and the sense of uncertainty about employment. So, why am I relocating to another hospital at this time? Timing and location are key components to any relocation. It is the appropriate time in my career for me to shift gears away from being 100% clinical, to being both clinical and administrative. My original intent was to remain as a shift worker until I retire, but after being exposed to committee work (including chairperson)

at ACOEP for the past 11 years and serving a term on the Medical Executive Committee at my current hospital has increased my desire to be more than just a factory worker! I am relocating to a college town that offers tremendous educational and recreational activities for my family and allows us to be closer to our families. College towns are vibrant and full of activity! I will no longer be commuting over 30 miles each way to work. I will be working at a community hospital that is devoid of house staff. I will sorely miss working with the Emergency Medicine Residents and the medical students and physician assistant students. I am excited about relocating and my new job. I realize that I will be working more and will have to be available 24/7 and will no longer have paid vacations and benefits, but I need a change in venue to restore my inner sanctuary. Is the grass really greener on the other side? I doubt it, but sometimes in life all we need is change!

ACOEP has recognized William Mencke, Jr.

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

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. © ACOEP 2007 - All Rights Reserved. Articles may not be reproduced without the expressed written approval of the ACOEP and the author.

© 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.

Executive Directors Desk Janice Wachtler

The "Meaning" of America We all know what it means to be an American and this column will not address our rights as citizens of our great Country; but it does address our actions as its people. It appears, at least to me, that the tenor of our Country has become much more angry in the past decade than ever before in my memory, and to make it worse, we seem to have become mean both in our approach to things and in our speech patterns. An example of this mean-spiritedness occurred during the summer when a conservative Commentator made a rash comment about a Democratic Candidate running for President. The Candidate and Commentator had obviously clashed before during the previous election, but on this one particular occasion the Commentator made a very sarcastic and very negative comment about the Candidate’s family. Normally, not much would have been made about this mud slinging, but this time, the Candidate’s wife was listening to the interview and fired back with a call into the talk show on which the Commentator was being interviewed. The Candidate’s wife basically stated that politics were politics; but family was offlimits. The media outlets, both print and video picked up this confrontation and each person was interviewed on the morning talk shows and the Commentator was not sorry for the comment and never expressed her apologies to the family of the Candidate. Of course, this caused a fury of rhetoric and vitriol to be expressed by each side and soon the world intervened and life went on. But what was the need to make the comment in the first place? For laughs or press? We will probably never know, but it just seems that this type of mean-spirited jibes are appearing more and more often in political commentary, campaigns and just in

daily life. And to tell you the truth, I find it very annoying and immature. People make off the cuff statements about others they encounter in their daily life and they probably always will. After all, we know that Mrs. Jones is really annoying when she has a bit too much to drink at social gatherings, or Mr. Smith makes passes at all the young girls in his office. So why do we have the urge to broadcast our feelings about them and why do we seem to always make it an attack on their personalities through nasty remarks? I guess to some extent it empowers the maker of the comment in some way or another – it may even draw attention away from them by making the target of the comment the center of attention. It may debase or demean a potential adversary before they get a foothold or an advantage over the commentator, or it may simply be to break the tension in a particularly hot conversation, but whether for laughs or defense, these snippets of conversation are meant to hurt the person about whom the comment is made. We deal with these comments in many ways. We may obsess over them, especially if they are made about us. We try to ignore them; we may even expound upon them, pounding our chests in righteous indignation. But ultimately it is just a few words

strung together – a lot of sound and fury signifying nothing. It is only with experience that we learn several things. First, there are always people ready to make comments about our actions and second, that only you can control how you are judged. You must remember that reputations are made and maintained not by a single deed or action. Reputations are made by a lifetime of hard work, accomplishments and most of all consistency of character. However, like most things, reputations can be affected by what happens during that lifetime and effected by harmful comments of others. You have to select how you want your individual life’s reputation to be established. If, like that Commentator, you wish to be remembered by the mean-spiritedness of comments and deeds, that’s one thing; if you would prefer to be remembered as someone who cares about others feelings, that’s another. As for the People out in America today who feel that the only way to prosper is at the expense of others, I say, “forgive them; for they know not what they do”1 and hope that all the people to whom these comments are directed go on to bigger, better things in their lifetime than the small-minded people ever thought they could or would do. 1 The Bible, King James Version, Luke 23:34

Attention ACOEP Members Interested in Pediatric Research Opportunities Emergency Medical Services for Children National Resource Center Executive Director Tasmeen Singh MPH, NREMT-P has presented an excellent opportunity for first time researchers to obtain funding for research in pediatric emergency medicine. ACOEP members with an interest in developing a project, or participating in a project involving pediatric emergency medicine pre-hospital should contact: Mark Foppe D.O. FACOEP Coordinator of the Research Consortium ACOEP at DocFop@aol.com. The purpose of the consortium is to offer assistance in getting a multi-centered project started, however, this source of funding is specifically seeking first time researchers. Any one who is interested in participating in research is encouraged to contact the ACOEP to hear about available projects. Any questions about the EMSCNRC can be sent to tsingh@emscnrc.com or faxed to 202-884-6845.

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ACOEP Members in the News Daniel Dickriede, a graduate of the Cleveland Clinic/South Pointe Hospital, Warrensville Heights, Ohio has been presented OUCOM Phillips Medical of Public Service. Dr. Dickriede is the first Ohio Alumni to receive this prestigious award. The Phillips Medical of Public Service was first awarded by OUCOM in 1976 and is named for Jody Galbreath Phillips and her late husband, Wallace Phillips, to acknowledge their contributions to the University and the people of the State of Ohio. The Award is presented to outstanding individuals for medical practice exemplifying the best traditions of the osteopathic profession; administration exemplifying the best tradition of humane, concerned administration and public involvement; and for public policy leadership exemplifying the best traditions of democratic concern for the public good and the public welfare. Dr. Dickriede was presented this award for his work with Doctors Without Borders, as one of the first Americans to volunteer for this service with which he has served in Somalia, Afghanistan, and Rwanda. John J. Kelly, D.O. was awarded the prestigious Albert Einstein Medical Center Physician Leadership Award for 2007 in July. The award, granted to one physician annually from within the staff of the hospital, is voted on by senior leadership and department chairs at the institution. Dr. Kelly is the Associate Chair of the Department of Emergency Medicine at the hospital as well as an Associate Professor of Emergency Medicine at Jefferson College of Medicine in Philadelphia. He is an active researcher in quality improvement, airway, asthma, and pneumonia as it relates to emergency medicine.

Tanguay, D.O. of the Midwestern University / CCOM for their acceptance as Fellows in the Training in Policy Studies (TIPS). The program trains young physicians in healthcare policies through the New York College of Osteopathic Medicine.

Pontiac, Michigan and current resident of Waterford, Michigan passed away suddenly in April 2007. Our sympathies go out to Dr. Pflaum’s family. Dr. Pflaum has been a member of the ACOEP for more than 10 years. Congratulations go out to Stephen Cluff, ACOEP/ThePulse_Location D.O. and Carrie Lotenero, D.O. of Henry Ford Hospital of Macomb (MI) and Jason

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The PULSE october 2007

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Resident Research Christopher Michael Gooch, D.O.

West Virginia Stroke Pilot Study: A Resident’s Perspective On a summer day on a retreat in the middle of the rolling hills of West Virginia, I was among a group of health care professionals from all over the state. From emergency medical transport personnel to nurses to physicians, we had all gathered to discuss stroke care in the State. This stroke “think-tank” had a monumental goal: to implement a system to provide quality stoke care in West Virginia. As we learned about how devastating strokes are in the U.S., I was reminded of my own personal encounter with stroke and its injurious effects on the human body and mind. When I was a young boy, my grandfather was found slumped over in a car. No miracle clot busters were available at the time, but only rehabilitation and hope for the best. Having already suffered injuries to his right side in World War II, this stroke involved that same side along with his speech. He came home to us about one week later. For over eleven years, my family and I cared for him. I saw firsthand how debilitating strokes can be and the gradual decline of function over the years. Through the years, stroke care has transformed from simple supportive care to systemic thrombolytic therapy to clot retrieval or clot-directed TPA. In 1992, eight emergency departments in Houston, Texas examined their own management of stroke care in an attempt to identify deficiencies or delays in the system that could be negated by a rapid response team. With this study, they looked at onset of stroke to Emergency Department (ED) arrival time, ED arrival to physician examination time, and ED arrival to CT scan time. They found that most hospitals’ evaluation and care of acute stroke patients were slow but the presence of a stroke team significantly shortens treatment times. Advancements in computers have

greatly aided in the diagnosis and treatment of stroke with the development of telemedicine with teleradiology networks such as NeuroLink®, Systems such as these have proven to show that their use cuts costs and allows more appropriate transfer of patients requiring neurosurgical care. In 2000, the Journal of the American Medical Association (JAMA) printed a consensus statement recommending the establishment of primary stroke care centers which include the availability and interpretation of computed tomography (CT) scans 24 hours a day. The American Stroke Association five years later published recommendation for the establishment of stroke systems of care. These mainly consisted of coordinated efforts from Emergency Medical Services (EMS) personnel to ED staff to rehabilitation teams in dealing with stroke and its after-effects. The Brain Attack Coalition also published their consensus on recommendations for comprehensive stroke centers that highlighted once again the need for trained health care professionals in providing quality stroke care. It is from these studies that the West Virginia Coalition for Quality Health Care Stroke Pilot Study is based on. Our goal is to design and implement a system to improve the quality of stroke care in West Virginia. Every aspect of the health care delivery system is involved from the paramedics who transport a suspected stroke patient to the hospital to the physical therapist that delivers post-stroke rehabilitation therapy. At this retreat, representatives from the health care community came together to reflect how in their own sphere of influence the deal with stroke and how their institutions can be more efficient and effective in their treatment and patient care. A consensus statement from across the board could be formulated: we are not

The PULSE october 2007

up to par, but we can do better. To accomplish this monumental task would take the cooperation of everyone involved to provide better stroke care to not only the resident of West Virginia but to every American. Utilizing a “hub-spoke” model, the pilot hospitals would form groups of smaller hospitals (spokes) teamed with larger hospitals (hubs) to provide stroke care. These relationships would allow “one-call” transfer of patients, when necessary. These sites would employ teleradiology along with telemedicine. The “spoke” Emergency Room (ER) physician would have access to a “hub” neuroradiologist to confer on patients and determine the appropriate treatment of stroke patient. In partnership, both facilities would be able to confer with one another in a timely, organized fashion to ensure that the patient receives the highest quality and appropriateness of care. Whether this patient has a stroke in a metropolitan center or lives in a rural area, we hope stroke victims fare better with this model that is currently being utilized in a pilot project. At my own facility, we are creating a “stroke team.” From the emergency room physician to the coronary care unit nurse to the medicine resident on call, each team member is paged when a suspected stroke patient presents to the emergency room or has neurological changes on the inpatient floors. Each team member has their role and duty clearly defined to make certain that we provide quality treatment to our patients. By including critical healthcare professionals that will be caring for the patient from arrival to the ED to admission to our coronary care unit, continuity of care is preserved to help our patients recover from a life-changing stroke. Being part of this project has been a great educational experience, not only

Resident Research, continued from page 9 clinically, but also crucial in understanding the intricacies involved in such an undertaking. Each person is a vital component of the project. However, there are great obstacles to be surpassed to get individuals working together for a common good. A recurrent theme I found prevalent during our retreat and subsequent meetings was a feeling of resistance to change current practices. During breakout sessions, each hospital group met with others to discuss their approach to stroke care. After the sessions, we gathered together as a group to share respective stroke care plans. It was at that moment each participant realized that we had our work cut out for us. The comments began to turn into statements of doubt and questions about how such a study can be accomplished. I thought to myself is this how most projects start with such self-doubt and negativity. Fortunately, the comments changed from “we can’t” to “we can do this.” Ideas transformed into action plans. Each group went back to their institution to work within their system to organize and implement this task. Currently, we are in the pilot phase of the project and gathering data for our study. As we begin the pilot project, we hope that we can create a network of healthcare facilities and trained personnel to deal with stroke and its other complications that afflict everyone in the State of West Virginia. Beginning with greater public awareness that “time is brain” to using CT perfusion scan technology to building stronger alliances between hospitals, stroke care will be revolutionized with West Virginia leading to change. If successful, our project could be used nationwide to help everyone. Stroke knows no gender, race or creed; it affects everyone. Thus, only together we will be able to not only deal with it but to fight it.

Brantina P, Greenberg L, Pasteur W, Grotta JC. Current Emergency Department Management of Stroke in Houston, Texas, Stroke. 1995; 26:409-414. 2 Bailes JE, Cooper-Poole C, Hutchinson W, Maroon JC, Fukushima T. Utilization and Cost Savings of a Wide-Area Computer Network for Neurosurgical Consultation. Telemedicine Journal. 1997; 3:135-139. 3 Bailes JE, Neurolink: A Neurosurgical Wide-Area Computer Network.Neurosurgery. 1994; 35:732-736. 4 Alberts MJ, Hademenos G, Latchaw RE, Jagoda A, Marler JR, Mayber MR, Starke RD, Todd HW, Viste, KM, Girgus M, Shephard T, Emr M, Shwayder P,

The authors of this article are Christopher Michael Gooch, D.O., Joseph Dougherty, D.O., FACOEP, Kristin Smith, D.O., Kristine Midcap, D.O., and Daryl Trusty, D.O. Ohio Valley Medical Center, Wheeling, West Virginia. Dr. Gooch is an OGME III Resident.

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Walker MD. Recommendations for the Establishment of Primary Stroke Centers, JAMA. 200; 283:3102-3109. 5 American Stroke Association’s Task Force on the Development of Stroke Systems. Recommendations for the Establishment of Stroke Systems of Care. Stroke. 2005; 36:690-703. 6 Brain Attack Coalition. Recommendations for Comprehensive Stroke Centers: A Consensus Statement from the Brain Attack Coalition. Stroke. 2005; 26:1597-1616.

Guest Column Wayne Jones, D.O., FACOEP

Life Boat Ethics It's Not Just Pandemic Flu “So here we sit, say 50 people in our lifeboat. To be generous, let us assume it has room for 10 more, making a total capacity of 60. Suppose the 50 of us in the lifeboat see 100 others swimming in the water outside, begging for admission to our boat or for handouts. We have several options: we may be tempted to try to live by the Christian ideal of being "our brother's keeper," or by the Marxist ideal of "to each according to his needs." Since the needs of all in the water are the same, and since they can all be seen as "our brothers," we could take them all into our boat, making a total of 150 in a boat designed for 60. The boat swamps, everyone drowns. Complete justice, complete catastrophe.” So began the 1974 treatise By Garrett Hardin, Ph.D. Garrett was a theorist rooted in ecology and microbiology. His thrust was in dissecting the moral dilemmas encountered in societies, nations and the world in regards to ecology, food sources and the demand of differing classes of people. While his thoughts were challenged, the undertow of the reality was pervasive. In his writings a common thread emerges. How do we pick the next ten; and the next ten; and so on? How do we decide who goes without? Should people be cast from the lifeboat once they have already been seated in it? How do we deal with social standing, relationships, benefice and justice? It recognizes not only the “right” to the resources we share but also the inequities inherent in all societies. Out of this would come three choices: 1. Limit the use of the resource. But this rightly denies access to all. 2. Rotate the use of the resource. This can create competing interests. 3. Close the use of the resource temporarily. This can allow for recovery but hurts anyone needing the resource during this time.

Last week I had the opportunity to sit in on a teleconference regarding the allocation of ventilators during a pandemic flu crisis. It was sponsored by the New York State Department of Health. They rolled through the obvious mechanisms to combat surges; delay onset of infectivity by shutting down places of mass gathering such as schools; surveillance and quarantining of travelers; rapid diagnostic testing; and typical surge planning such as stopping elective admissions and surgeries, discharging stable patients and expanding available numbers of beds. Then they got to the real rub; limiting life saving measures, especially the utilization of ventilators. A scarce commodity for many hospitals. They employed the SOFA criteria (sepsis organ-related failure assessment) to decide who should be allowed on a ventilator. SOFA assesses the function of six key organs and organ systems: lungs, liver, brain, kidneys, blood clotting, and blood pressure. Using these criteria, patients would be triaged into categories of 1) medical management only, 2) highest need, 3)

intermediate need and 4) no need presently but needs reassessed. Patients who were provided ventilator support are reevaluated in 48 hours and again in 120 hours. If the patient shows a decline, withstanding the ventilator support, they may be removed if there is another patient requiring the same support. This sounds great and it has taken many man-hours to create this model. But are we prepared to throw people out of the lifeboat so others may survive? There is no litigation protection in my state even in the face of a disaster. Just last week, a physician from New Orleans was finally released on manslaughter charges for allowing three patients to die after delivering palliative care during a disaster. This took two years of his life. I am sure he had many sleepless nights and tearful days. Are any of us willing to withstand this? Would you pull a viable patient from a ventilator to give it to another (no less needing) patient? Would you allow a family member to be removed during a time of frailty? Would you pull the tube? It may be easier to stay in the water.

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Emergency Department Ethics Bernard Heilicser, D.O., MS, FACEP, FACOEP

What Whould You Do? Our patient is an elderly female who is scheduled to be transported from a tertiary medical center to her home. The private ambulance company contacted the EMS System Medical Director because of concerns over the disposition of the patient on arrival to her home. It appears the patient was going home to die. She was on a ventilator and lacked decision-making capacity. Her family was taking her home and requested that EMS

discontinue the portable ventilator when they arrived at the home. This presented an ethical dilemma for the crew. Was it appropriate for them to comply with the familyâ&#x20AC;&#x2122;s wishes and remove the ventilator? Consequently, they contacted the Medical Director for direction. Is this an appropriate function for EMS? If not, how would you accommodate the family?

What would you do? Please send us your thoughts and ideas (fax 1-708-915-2743). Every attempt will be made to publish them when we review this case in the next Pulse. If you have any cases in your practice that you would like to present or have reviewed in The Pulse, please fax them to us.

Governmental Affairs Leann Fox AOA Washington Office

Tamper-Resistant Prescription Pads Implementation Date Looms On August 17, the Centers for Medicare and Medicaid Services (CMS) issued a guidance letter to State Medicaid Directors concerning the new requirements for prescription drugs pads. REQUIREMENTS: By October 1, 2007, prescription pads must contain one of the following characteristics to be considered tamper-resistant. Prescription pads must have features to prevent: 1) Unauthorized copying; 2) Erasure or modification of the prescription; and 3) Use of counterfeit prescription forms. NOTE: All existing state laws [Is your state compliant?] and requirements for tamperresistant prescriptions are deemed to meet or exceed the CMS standard. States that

provide the pads to physicians at no cost can treat the expenditure as a Medicaid administrative cost. Prescription pads are expected to meet all three characteristics by October 1, 2008. EXEMPTIONS: The requirements also contain exemptions for nursing facilities, intermediate care facilities for the mentally retarded, and other specified institutional and clinical settings. The tamper-resistant pad requirement also doesnâ&#x20AC;&#x2122;t apply to refills of written prescriptions presented at the pharmacy before October 1, 2007. In addition, the requirement does not apply to e-prescriptions, faxed prescriptions, or prescriptions communicated to the pharmacy by telephone by a prescriber. Prescriptions paid for by a managed care entity also are exempt.

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EMERGENCIES: CMS guidance does not restrict emergency fills of non-controlled or controlled dangerous substances for which a prescriber provides the pharmacy with a verbal, faxed, electronic or compliant written prescription within 72 hours after the date on which the prescription was filled. With guidance coming less than two months before implementation, the AOA supports a delay in the October 1, 2007 compliance deadline. If you have specific questions or concerns relating to the implementation of tamper-resistant prescription pads, please submit them to Carol Monaco at cmonaco@osteopathic.org. This information will assist the AOA with further discussions with CMS on this issue.

History of EMS Third in a Series Wayne Jones, D.O., FACOEP

The Civil War Experience Our nation was ill prepared for one of the largest casualty laden wars in our history. Nearly 620,000 Americans would die on our own soil while countless others would lie wounded. Diseases in the form of dysentery and malaria would take more lives than any bullet. Most medical officers were career soldiers, entrenched in “traditional” military medicine, unable and to some extent, unwilling to change military procedure. Triage, treatment and transport all needed restructuring. While a medical system resembling Larrey’s Napoleonic ambulance volante was used, transport personnel were less than qualified. It would become the duty of the most unfit soldier to man the medical wagon and retrieve wounded from the battlefield. If they could not fight then maybe they could be made to drive a wagon. Since whiskey was the most common medicinal in the field, it was also the most abused. These wagon drivers would sample the medicinals and rarely complete their patient care duties. It was said that drunkards and thieves staffed the ambulance corps. It was not until the 1862 appointment of Dr. Jonathan Letterman that military medicine was reorganized. He secured a charter from Major General George McClellan allowing whatever was necessary to improve the system. Letterman set out to establish forward first aid stations, mobile field hospitals and an efficient ambulance corps. He maintained strict oversight under the control of medical personnel, not the Quartermaster Department. The greatest single casualty count would come in July of 1863 at the Battle of Gettysburg. 50,000 soldiers would lie dead or wounded by the end of the threeday siege. 8,000 soldiers and 3,000 horse carcasses would require internment. Of interest, there would be only one civilian death; twenty-year-old Ginnie Wade would be struck and killed by a stray bullet while she baked bread.

The army was intent on military equipment recovery. The job of sanitation and clearing the battlefield of soldiers landed directly on the shoulders of Jonathan Letterman. This would be the first true test of Dr. Letterman and his new system. To deal with the large numbers of wounded soldiers, a vast medical encampment was created southeast of Gettysburg, called Camp Letterman. It was said that the stench of war was still in the air as President Abraham Lincoln delivered his Gettysburg Address some four months latter. Lincoln would dedicate the battlefield as the Soldiers National Cemetery and would re-dedicate the Union to the war effort. Letterman’s system became known as the Letterman Ambulance Plan and gained such favor as to be implemented

as General Order Number 106: Uniform System of Ambulances in 1864 by an Act of Congress. Letterman resigned from the army in 1864 and relocated to San Francisco, where he served as coroner. After the death of his wife, Mary, he became severely depressed and eventually died. Jonathan was only 48 years old. In his honor, the army hospital at the Presidio was named Letterman Army Hospital. He was buried at Arlington National Cemetery. The inscription reads: Medical Director of the Army of the Potomac, June 23, 1862 to December 30, 1863, who brought order and efficiency in to the Medical Service and who was the originator of modern methods of medical organization in armies. His wife is buried at his side.

ATTENTION EMERGENCY PHYSICIANS INTERESTED IN PEDIATRIC EMERGENCY MEDICINE CAQ AOBEM is pursuing the development of a certificate of added qualifications in Pediatric Emergency Medicine. A prerequisite to the approval by the AOA of a new CAQ is the Bureau of Osteopathic Standards requirement that every new CAQ must have as a minimum of five physicians willing to serve as subject matter experts as well as 25 individuals willing to take the examination. AOBEM is soliciting individuals who are willing to serve as a subject matter expert or individuals interested in taking a Ped EM CAQ. Subject matter experts must be willing to commit in writing to the construction of a table of specificity and a CAQ examination. Subject matter experts will not be eligible for the initial examination. Individuals wishing to qualify for a CAQ examination in pediatric emergency medicine must have completed an AOA approved fellowship in pediatric emergency medicine or have had significant, ongoing experience in pediatric emergency medicine. The practice track eligibility component will be open for a period of 5 years. The tentative eligibility requirements can be forwarded to interested individuals by contacting the AOBEM office.

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Financial Edge Dave Muti, JD, RMA

So Many Types Of Mortgages: What Is The Best Choice For You? Unlike past generations, today we have many different options when trying to decide on a mortgage for our home. As recently as the mid 90’s we still only had 4 or 5 different types of mortgages, but today if you can dream up the “type” of mortgage you want it probably exists. Rather than advocate one option over another this article will explain different types of mortgages as well as their different working components. But before we begin looking at the different programs available, we need to understand how life today is much different than it was for our parents and grandparents and how this change in habits affects our mortgage and financial wellbeing. Today we live the “I have to have it now” lifestyle while trying to keep up with the Jones’. This could be one reason the national average of home ownership is roughly 7 years and the typical mortgage lasts only 4.2 years. It could also explain why the average household has in excess of $25,000 in credit card debt and less than $27,000 set-aside in retirement accounts. Prior generations had a more stable lifestyle: one job, one pension, one house and one mortgage. Today, pension plans seem to be a thing of the past and most Americans will hold 5 or more jobs throughout their careers. My experience indicates that most of us will have 4 homes throughout our adult lives. A starter home, a move up home (both of which we’ll own 3 to 7 years); then our dream home where we will live the longest through much of our working career and while the kids get through college; and finally, a smaller home where we will downsize as “empty nesters” or to enjoy retirement. Depending upon what stage of your life you are facing you need to choose the mortgage that best suits your situation, maximizing your cash flow and taking both your short and long-term financial goals into consideration.

Now let’s review different types of mortgage products available. They can all be broken down to fit within 5 basic categories: Interest Only, Amortized, Fixed, Adjustable and Balloon. With each type of mortgage there are advantages and disadvantages, as well as many different options, which are beyond the scope of this article. Your mortgage planner should explain them in consultation with you so together you can choose the most appropriate program. The information provided in this article should give you a better understanding of the choices you have today but it is not meant to be comprehensive. Before any program can be recommended, a thorough discovery session must be completed to fully understand the circumstances and goals of each client before prescribing the right mortgage program. After all, the type of mortgage you choose will directly impact your ability to retire. Interest Only loans are exactly that. Your monthly payments consist only of the interest portion of the money borrowed. In essence, you are only paying for the “cost” of the money and nothing towards the principal. You do have the option of sending in “principal payments” but they are not required. Interest Only loans may be the best use of your cash flow in conjunction with a comprehensive mortgage plan. These types of loans are typically used for Cash Management Strategies to build long-term wealth. An amortized loan means that your monthly payment is comprised of both principal and interest. Initially the vast majority of the payment is interest while a small portion goes towards paying down the balance of the loan. Fifteen years into a 30-year fixed rate mortgage you would still have 71% of the original balance remaining. If you remain in this loan the principal component of your monthly payment really

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begins to increase in the second half of the term while the interest portion decreases. This would also hold true for a 15 or 20year fixed rate mortgage. Fixed rate mortgages will have a fixed percentage rate and a fixed monthly payment for a certain number of years. They typically carry higher rates than other types of mortgages but they offer the security and certainty of knowing your monthly payment and interest rate will not change for the term of the loan. The most common are 30 and 15 year, but 10-year and 20-year have been around for a while, and recently a 40-year and even 50-year have become available. However, these longerterm mortgages work slightly differently in that after the initial 30 years there may be a balloon payment. This means the longer term is used to calculate your monthly payment, which will be lower than a 30-year fixed, but if you remain in the loan for longer than thirty years you may have a lump sum payment due. Adjustable Rate Mortgages (ARMS) have an interest rate that will adjust over time and monthly payments that are recalculated on a scheduled basis to reflect changes in the “market” interest rate. Interest rates for ARMS are typically lower than the rates in fixed-rate mortgages. ARMS allow you to fix the interest rate for the length of time that you plan to hold the loan without paying a higher cost for interest rate protection during a time when you will not need it. When you know for certain that you will only have a particular mortgage for a certain number of years these types of loans are the best choice. Balloon mortgages, like adjustable rate mortgages have a fixed-interest rate and payment for a certain number of years. The big difference here is when the initial period expires the entire balance of the loan becomes due. You must pay back the

remaining loan balance after the initial term. This is usually accomplished either by refinancing your loan or selling the property. The payments are typically calculated on a 30-year amortized schedule but the loan is due in full after the certain number of years is over. A variant of ARMS, Option ARMS are very complicated mortgages and should only be used by financially savvy clients. They are also commonly referred to as a Cash Flow Mortgage or Pick-A-Payment. When used correctly, this type of mortgage can be the best financial tool available to manage your cash flow, re-direct monthly expenditures towards retirement and college planning, as well as build long term wealth. They were designed for higher income earners who desired the flexibility of making the minimum payments to free up cash for other investments. These types of loans seem complicated at first but a qualified mortgage planner should be able to break them down into pieces that are easily understandable. This type of mortgage provides you with up to 4 payment options each month to choose from and each one has a higher monthly payment as you move down the list. They are:

1. Minimum payment option – this is a “discounted rate” that is typically less than even the interest only payment. By making this payment your loan balance will increase each month. 2. Interest Only Payment Option (if available). 3. Fully Amortized 30 year Payment Option. 4. Fully Amortized 15 year Payment Option. Unlike what the mass media would like you to believe, choosing a mortgage today is much more complicated than “what’s the interest rate?” Here are seven questions to ask yourself before you call any Mortgage Professional. • Is this a starter home or your long-term home? • Do you have (or plan to have) children? If yes, will you have to pay for a college education and/or a wedding? • Do you have student loans and other debt you need to pay off? • Over the next 30 years do you think that you might lose your job and incur some debt as a result?

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• Do you have elderly parents who might require long-term health care? • Do you want to put on an addition or upgrade your kitchen? • Will your income change dramatically in the next 3 to 5 years? If you answered yes to most or all of these questions, an ARM may prove to be a better choice for you than a fixed rate mortgage. All of those situations trigger the “need” to refinance and the “interest rate” will not be the driving force. When people decide to refinance, only a small percentage of them refinance to lower their interest rate. Our experience has been that most people refinance for reasons such as those suggested above. When you are deciding on what type of mortgage is right for you, make sure that your Mortgage Planner is versed in all of these areas. They should not be just an order taker. A good Mortgage Planner should take the time to meet with you personally to investigate what the best option for YOU is. You might be thinking, “It’s only a mortgage”. But for most, a mortgage is the largest financial decision you will ever make. The type of mortgage

you choose will directly impact your ability to retire at any age. Don’t make that type of decision in a couple of minutes over the phone or worse over the Internet through one of the mortgage portals that sells your information to several lenders at once. Your financial well being depends on it. Take the time to research all the products available and then sit down with a Mortgage Planner to review. Your goal at this meeting is to ensure he/she is knowledgeable on all products and is interested in YOU as a client. He should be able to design a mortgage plan that will maximize your

monthly cash flow while taking your longterm retirement goals into consideration. About the author: David Muti, JD, RMA, is the President of Forgotten Equity, Inc and a Senior Mortgage Planer with Millennium Home Mortgage, LLC based in New Jersey. He writes for several magazines and has been a keynote speaker for financial conferences. He can be reached via email at dave@forgottenequity.com. You can learn more about mortgages and how to use them to create wealth by visiting www.forgottenequity.com.

CME Calendar 2007 October 1 – 4 ACOEP Scientific Seminar San Diego, CA 25 Category 1A Credit 7 – 9

green EMERGENCY SOLUTIONS, PC

To learn about our Emergency Medicine practice opportunities contact Amy Inter, Physician Recruiter at:

www.emergencysolutions.com amy.inter@emergencysolutions.com

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26th Annual Winter Update Crowne Plaza Hotel at Union Station Indianapolis, IN Indiana Osteopathic Association 800-942-0501 20 Category 1A credit anticipated

2008 January 9 – 14 Emergency Medicine: An Intense Review Westin Chicago River North Hotel, Chicago, IL 40 – 42 Category 1A Credit 40 – 42 Category 1 Credit February 5 – 9 COLA Essentials Marco Island Hilton Hotel Marco Island, FL 25 Category 1A Credit 25 Category 1 Credit (pending) March 25 – 29 ACOEP Spring Seminar Doubletree Paradise Valley Hotel Scottsdale, AZ 25 Category 1A Credit 25 Category 1 Credit (Pending) May 2 – 3 Oral Board Review Sheraton Four Points Hotel Chicago, IL 10 Category 1A Credit

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