The Pulse: 01-2015 by ACOEP

the

Pulse

January 2015

Osteopathic Emergency Medicine Quarterly

Presidential Viewpoints

| Mark A. Mitchell, DO, FACOEP

Armed with Information: How to Battle the Tough Choices (Page 4)

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VOLUME XXXVI No. 1 Editorial Staff Timothy Cheslock, DO, FACOEP, Editor Drew A. Koch, DO, FACOEP-D, Assistant Editor John C. Prestosh, DO, FACOEP Mark A. Mitchell, DO, FACOEP Erin Sernoffsky, Association Editor Janice Wachtler, Executive Director Thomas Baxter, Graphic Designer Editorial Committee Timothy Cheslock, DO, FACOEP, Chair Drew A. Koch, DO, FACOEP-D, Vice Chair John C. Prestosh, DO, FACOEP Board Liaison/Associate Editor Peter J. Kaplan, Advertising Consultant Stephen Vetrano, DO, FACOEP Andrew Little, DO Erin Sernoffsky, Association Editor Thomas Baxter, Media & Technology Specialist The PULSE is a copyrighted quarterly publication distributed at no cost by the ACOEP to its Members, Colleges of Osteopathic Medicine, sponsors, exhibitors and liaison associations recognized by the national offices of the ACOEP. The PULSE and ACOEP accept no responsibility for the statements made by authors, contributors and/ or advertisers in this publication; nor do they accept responsibility for consequences or response to an advertisement. All articles and artwork remain the property of The PULSE and will not be returned. Display and print advertisements are accepted by the publication through Norcom, Inc., Advertising/ Production Department, PO Box 2566 Northbrook, IL 60065 ∙ 847-948-7762 or electronically at theteam@ norcomdesign.com. Please contact Norcom for the specific rates and print specifications for both color and black and white print ads. Deadlines for the submission of articles and advertisements are the first day of the month preceding the date of publication, i.e., December 1; March 1, June 1, and September 1. The ACOEP and the Editorial Board of The PULSE reserve the right to decline advertising and articles for any issue. ©ACOEP 2015 – All rights reserved. Articles may not be reproduced without the expressed, written approval of the ACOEP and the author.

Pulse

the

The Pulse

Osteopathic Emergency Medicine Quarterly

Table of Contents Presidential Viewpoints...................................................................................................................4 Mark A. Mitchell, DO, FACOEP The Editor's Desk..........................................................................................................................5 Tim Cheslock, DO, FACOEP Executive Director's Desk...............................................................................................................8 Janice Wachtler, BAE, CBA Have You Met That Patient?..........................................................................................................9 John C. Prestosh, DO, FACOEP What Would You Do?..................................................................................................................10 Bernard Heilicser, DO, MS, FACEP, FACOEP-D Pharmaland: A Medical Bedtime Story.........................................................................................12 Janice Wachtler, BAE, CBA Naloxone and EMS: Is it Right for Every Service?......................................................................13 Stephen Vetrano, D.O., FACOEP ACOEP Members in the News....................................................................................................13 Ebola: A Call for Global Health.................................................................................................16 Deborah Lardner D.O., DTM&H Michael Passafaro D.O., DTM&H, FACEP, FACOEP When Good Doctors Feel Bad.......................................................................................................19 Frank Gabin, DO ACOEP Member Spotlight: Christopher Colbert.........................................................................22 Erin Sernoffsky Foundation Focus..........................................................................................................................24 Sherry D. Turner, DO, FACOEP Carbon Monoxide (CO) Toxicity..................................................................................................36 Tanner Gronowski, DO ACOEP-RC President’s Report...................................................................................................37 Andy Little, DO

IN THIS ISSUE Happy New Year! In our first edition of 2015 I hope you will find that The Pulse has been growing and has become a more robust publication. The content we receive for each edition has been excellent! In previewing this quarter’s edition a common theme has emerged: doing what is right for our patients is what we do best as Osteopathic EM physicians. From Dr. Mitchell and Dr. Prestosh’s articles, and my own experience that I share with you this month, it is very evident that we have a unique role in patient care. We see patients at their worst, in desperate times, when all else has failed them. We tend to bear the brunt of their frustration and are expected to make sense of not only their illness, but what we can do to help them move forward. Sometimes those decisions and plans may not be what they want to hear or what their primary care physicians or specialists want us to share with them. We have a unique vantage point being in the Emergency Department. It is how we handle this role that really resonates with our patients. Taking the time to give them a realistic assessment and plan, comforting and caring and providing hope is what we do every day. Dr. Gabrin shares his insight into how this compassionate care can take its toll on our own happiness and what we can do to prevent compassion fatigue. It is a pleasure to have Dr. Gabrin as one of our new regular columnists for The Pulse. We also have updates from within the college by Jan Wachtler and a spotlight on Dr. Colbert, who is chairing the upcoming The Edge: Spring Seminar in Ft. Lauderdale. You will find timely articles on prehospital Narcan for overdose and information on Ebola, along with our quarterly ethics column by Dr. Heilicser also addressing questions regarding the Ebola crisis. We continue to strive to provide you with relevant material and appreciate your feedback. As we move into 2015, continue to watch for more exciting updates and stories in future issues of your publication, The Pulse. - Tim Cheslock, DO, FACOEP

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Armed with Information: How to Battle the Tough Choices recommended a CT of the abdomen. His liver enzymes were all elevated and the CT scan showed extensive metastasis to his liver. In addition, he had a recurrence of a mass in the remaining portion of his pancreas. I called his PCP to review the results and was amazed at the response he gave me. He stated, “Call his oncologic surgeon to see what he wants to do.” I suggested that it was probably time to get Hospice involved to assist the patient and his family during his final days. Nonetheless, I called the surgeon and explained the current status of the patient. Once again I suggested Hospice to him. I was floored when he responded, “Transfer him to us, I may have to take him back to surgery.”

Presidential Viewpoints Mark A. Mitchell, DO, FACOEP

ecently I had the privilege of taking care of a 13-year-old boy named “Robert” who had Burkett’s Lymphoma. He recently received another round of chemotherapy and had a secondary to a fever of 102.8° F. His mother called his pediatric oncologist in St. Louis who told her to go to the nearest ED. The oncologist called the ED prior to the patient’s arrival and gave some recommendations. I was notified and anticipated the patient’s arrival. On arrival, Robert looked scared, but also frustrated. I bonded with his mother and could see the fatigue and fear in her eyes. After a proper work-up we initiated treatment. Lab tests revealed a WBC count of 0.1, Hemoglobin of 8.0, and Platelet count of 20. Antibiotics were given after cultures obtained and the Pediatric Transport Team took the patient to the Pediatric Hospital in St. Louis. The next day I came to work and an 88 year-old gentleman, whom I never met, was introduced to me. “Mr. John” was diagnosed with pancreatic cancer this past summer and underwent an extensive surgical procedure at a hospital about 60 miles away. He came to the ED during the night due to increasing pain in his abdomen and back. The ED physician talked with his primary care physician who

I sat and contemplated, what was the right thing for me to do at this point? I had his PCP and surgeon headed down a course that I honestly didn’t think was in the best interest of the patient and his family. I called his two children and their spouses into the hallway and told them the findings. I explained that, based upon my experience, their 88-year-old father had a condition that was not curable. I then had the conversation with the patient, his wife of 65 years at his bedside holding his hand. He was mentally very alert, but in obvious pain. He looked me in the eye and asked, “Doc, how long do I have?” I answered that I didn’t have any prediction, but that his prognosis was not good. I had another emotional conversation in the hallway with the children and wife and I suggested they give consideration to hospice at this point. They seemed amazed that their husband and father was that bad. I was amazed that I was the first one who had an honest conversation with them about this. The patient was transferred and I never heard the rest of the story. About nine months ago my family faced similar decisions with my father-in-law. He was 87 years old and had lived a wonderful life. I only hope that I can replicate what he was able to do. In his early 80’s he was still riding his bike about 20 miles to the beach in San Diego to eat lunch. However, he couldn’t stay long as he had to get back for his tennis match. He had traveled the world and was completely

physically and mentally competent until the fall of 2013. He had a major cardiac event in 2012 and after that his course headed downhill. My wife left ACOEP’s Scientific Assembly on a plane back to Chicago with her father. That was the last time he would be in San Diego. He moved to an assisted living facility and continued to deteriorate. In the spring of 2014 we had a family conference and made the decision to get hospice involved. It was amazing to see the level of compassion they had in taking care of Dad. I was there at his bedside in his final days. He had a fever and respiratory rate in the 40’s. He was unresponsive as the hospice nurse held his hand and talked to him, “Kevin, it’s me, Mary, your nurse. I’m going to give you something to help your breathing.” She then squirted some morphine under his tongue. What a compassionate way to treat a patient in their final days and hours. For Robert, at age 13 and a whole life in front of him, we spare no resources to get him the care and treatment he needs. However, what is the proper course for an 88 year old with metastatic pancreatic cancer? These are the types of conversations that don’t happen often enough and as emergency physicians we see this all too often. Patients with a terminal condition presents and unfortunately no one has had an honest, compassionate conversation with them and their family about the natural course of their illness. This could be the end stage COPD or “cardiac cripple” with Stage IV CHF. Recently the media covered the story of Brittany Maynard, a 29-year-old woman with an extensive brain tumor. They did an initial resection, but it grew back rapidly and her prognosis was six months to live. As she was Continued on Page 10

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Are You Really Listening to Your Patient? It turns out that the patient, who is a regular patient of the agency who made the report, had called several times the morning of her visit to speak with her counsellor. She was very anxious about a job interview later in the day and her regular therapist was not immediately available. The patient became frustrated that she couldn’t access her provider and voiced her frustration, making a statement somewhat to the effect of, “what do I need to do to speak with someone, take some pills?” That was all the secretary needed to hear. The next thing you know the supervisor was calling the police and EMS to go get her. Now she’s here.

The Editor's Desk

Tim Cheslock, DO, FACOEP

e all like to think that we’re doing what’s best for our patients. We read their complaint and order an array of tests in order to diagnose a condition or ensure their safety for discharge. We base our decisions on a brief interview, sometimes with input from a family member or EMS provider. But are we really listening to what the patient is telling us? Does the physical exam corroborate with what we’re told? I recently encountered a patient brought in by EMS for a potential overdose and presumed involuntary mental health evaluation. Slam dunk, or so I thought. The patient was visibly emotional and EMS reported that the patient called the local mental health provider line stating that she overdosed on her Depakote. As the EMS provider continued her hand off to the nursing staff, the patient became increasingly irate and boisterous insisting that is not what happened. I now have a dilemma to say the least. Do I take the word of the EMS crew, or do I listen to what the patient has to say in her obvious state of distress and emotional breakdown? As I continued to get an earful on each side, I thought it might be prudent to listen to the patient and see what she had to say. I’m glad I did!

Now, another dilemma. Do I pursue the toxicology workup even though this sounds like a big miscommunication? You bet I do, I value my license too much to ignore a potential overdose situation. But what’s more important, how do I interact with the patient? The patient was obviously distraught about not being able to speak with someone about her anxiety. Did she make a potentially suicidal gesture? I’m not sure. She denied being suicidal, rather she wanted to speak with her therapist. Not really an unrealistic request. She told me that the secretary told the patient didn’t have time to deal with her issue and she needed to stop calling. This only infuriated the patient, with a history of mental health issues, even more. I needed to get to the bottom of this situation and hopefully help the patient in the process. After calming the patient down and assuring her that I would try to help her come to terms with her issues, she became much more relaxed and compliant. We did the obligatory tests and observation period. It turns out all her medication was accounted for and she never exhibited any signs of overdose. I spoke with the mental health provider who wanted to know if she was being committed for a 72 hour hold. I explained the situation and they had a plan in place to send a crisis worker to meet with her for a face-to-face visit upon discharge. Deep down I think they realized that the situation was handled poorly and the desired outcome was going to occur regardless of the ED work up. It turns out that if they had just put that plan in place originally, before the patient became irate and infuriated, the whole ED visit and situation

could have been avoided. It just goes to show that you need to be responsive to your patient’s needs and to help provide them with the services they need. It’s important to listen to your patient, for a lot of information can be obtained that may result in an entirely different work up plan. Case in point—I recently had an oncology patient come in for nausea and vomiting. The only thing she required was an anti-emetic and some fluids. The meds she had at home were not helping and she ran into this situation in the past with her chemotherapy. Had I not listened to the patient I would have begun an extensive work up to determine why this patient was vomiting. Was she dehydrated, suffering from a bowel obstruction? Was she merely out of her anti-emetic? A liter of fluids and two doses of Zofran later she was much improved. The family was grateful and the patient disposition was to home with a new script, after her basic chemistry results came back as normal. The family and the patient did not want an extensive work up. No CT needed to be done. They simply wanted help in stopping her vomiting. They just wanted her to feel better. Sometimes more is not better. It is so important in this day and age of patient care that we truly listen and provide what is needed for our patients rather than the knee-jerk reaction to a chief complaint. It saves time, money, and will ultimately result in higher patient satisfaction. It may take a few extra minutes on the front end to hear your patient out, but in the end the payoff will far outweigh the perceived delay. A visit does not always need to be the endless laundry list of tests yielding a non-specific diagnosis. More often than not, a positive outcome can be obtained by listening to the patient and providing what they truly need – an engaged provider, willing to go the extra mile to assist them in finding the solution that they really need.

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Learning to Trust function? Will we be incorporated into another organization, or will we hold our own? These are the questions staff and members are asking, and we have no definitive answer, only that we will be here. And this is where the aspect of trust comes in and plays a big role. ACOEP’s role in this, and in any other advocacy capacity, is to be the hand you hold with confidence that it will advocate for you, your right to practice, learn, and grow in this new environment. Let us be the hand that guides your need for CME and education, and let us be that hand that provides you a safe and secure grip on the practice of emergency medicine.

Executive Director's Desk Janice Wachtler, BAE, CBA

hat exactly is trust? According to Webster’s New World Dictionary it’s the, “firm belief or confidence in the honesty, integrity, reliability, justice, etc., of another person or thing; faith; reliance.” But innately we know that trust isn’t as tangible as we’d like it to be. We’ve all had instances where you put all your faith in someone or something and it backfires. We suffer terribly relearning the ability to trust. So when an organization like the ACOEP says “trust us,” are we looking at someone like Alfred E. Neuman or Albert Einstein? Are we speaking from a position of strength or just making noise?

However, ACOEP needs your hand to be the one it holds to provide it with consistent support for membership, CME, and involvement in the College. ACOEP needs to be able to reach out and know that the hand it is holding will help the organization grow and prosper through involvement in governance for the future, to run for board office, speak at our events and reach past the DO/MD chasm to bring colleagues to our conferences and introduce them to your ACOEP home. ACOEP also needs you to be the hand that heals the nation’s sick; to tend to those who cannot go to that primary care provider because the office hours are not conducive to the working poor; to be the nation’s safety net for those in jeopardy. Your hand can do so much more for the healthcare system than other practitioners but you have to realize and know the hand you are holding of the sick or dying patient is more important in the grand scheme of things than ACA will ever be.

ACOEP, like every other organization, has been on shifting ground since the MOU has been signed developing the Single Pathway for Accreditation, and what we’ve learned in the process is if you’ve seen one RRC, you’ve seen one RRC. What affects one specialty does not affect another; what’s true for your colleagues’ programs, are not true for yours. And so we ask you to trust us. And it’s a scary, tenuous time for all. ACOEP is doing a lot of soul-searching as to where we will be in 2020. Will we still exist? Will we exist in a different form with a different

So working together, member and association, we can support each other through growth, advocacy, healthcare, and disaster. We will be there for you . . . will you be there for us?

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Have You Met That Patient? about her age, she appeared closer to 80. I introduced myself, shook her hand, and she informed me that she knew who I was. I was fairly certain that we had never met, so I asked how she knew me. She told me she had worked in our hospital for more than 25 years and although we never met, she had heard my name mentioned numerous times and felt she already knew me. After a few moments of friendly talk and even laughing about how two people could work in the same hospital for so many years and never meet, I asked her what was wrong. As she began to explain her story, I had the beginnings of a very deep sinking feeling in the pit of my stomach.

vital signs were stable; however, I continued to have a sense that we were heading into a bad scenario. I ordered some basic lab tests, a urinalysis, and a chest radiograph. I asked her if she needed anything while she waited for the results. She said she was fine and apologized for taking my time with such a trivial complaint when the department was so busy with sick patients. Her initial laboratory results came back rather quickly and other than a mild anemia, everything else was fine. However, the chest radiograph was not normal; there were two very

be kind, for everyone " Aislways fighting a hard battle." – Plato

The On-Deck Circle

John C. Prestosh, DO, FACOEP, President-Elect

mergency medicine physicians see various types of patients during every shift. We see the depressed, confused, extremely ill, the not-so-ill, and those who just need to talk to someone. We accept each encounter with our patients, hoping to remedy their complaints and concerns, and maybe even be a teacher in some fashion. After all, the word doctor comes from the Latin “docre,” which means, “to teach.” We have so many opportunities to teach our patients, but so little time in the confines of our busy departments. This leads me to “that” patient. It was not a good day in the department. We were holding patients, triage was backed up, and it seemed as though every patient had at least one complaint about their wait and the care they received. It was a really bad day!

She said that for the past three or four months she had a nagging cough, and it bothered her so much she was losing her appetite. She believed this was the reason for a 30 pound weight loss over that time period. She had just completed her work shift and felt too tired for the drive home so she wanted to stop in the emergency department to see if she should have some blood tests drawn. She quickly added that she was sure she just needed some vitamins and maybe a short vacation to restore her strength. She had no significant past medical history, took no medications other than a daily 81 mg aspirin, had never been a smoker, and very rarely drank alcohol. Her family history was noncontributory. Her physical exam, other than her frail appearance, was unremarkable. Her

I picked up the chart for the next patient and noticed the chief complaint was fatigue and weakness. My first thought was, “here’s another patient who will have a myriad of complaints, will require an extra length of time just to talk about things, and then reiterate complaints about her wait like everyone else.” I entered the room to find a very pleasant, although somewhat frail, 64 year-old woman who was smiling and said hello to me. My first thought was that there had to be a mistake

small nodular appearing densities in her right lung. My heart sank as I reviewed the film. I had already informed her of her anemia, and she was pleased to hear that so far the anemia was her only abnormality, but now I had to inform her of the chest x-ray. She asked me if this could be serious, and what it could be. I explained to her that these nodules could be serious, and she should have a cat scan of her chest to gather more information. She asked if the test could be done now since she was here. I agreed that we could do the test at this time. She again apologized and said I should be taking care of others and not her. The radiologist called me about 45 minutes Continued on Page 10

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"Tough Choices" continued from page 4 an educated woman she did extensive research on her condition and came to the conclusion that there were no viable treatment options either in the US or abroad. Therefore, she made the decision to live life to the fullest in the time she had. She traveled with her husband and spent time with her family. However, she did something that many would think unheard of—she planned her own death. She knew what the final stages of her disease would be like—seizures, severe headaches, loss of bodily functions, and eventually become less responsive. She made the decision that she didn’t want that for herself or her family. She determined that on November 1, 2014 she would bring her life to an end with her family beside her. She moved to Oregon, where it is legal to prescribe 100 capsules of secobarbital, which she dissolved and drank. This highly publicized case brought about lots of discussion and debate. My opinion is that she was informed and given the right to make her own decision. Death is as real as life. Open, honest conversations between healthcare providers and their patients assist families in the final days. While many physicians may not feel comfortable having these discussions, they should at least make sure the patients and their families are directed to the proper resources. Our country is faced with a crisis as more and more of the federal budget is spent on providing healthcare. Nine of ten Medicare patients die of chronic disease, and caring for them in their final six months of life absorbs one-third of all Medicare dollars. During that time, more than a third of chronically ill Medicare patients are treated by 10 or more doctors. Nearly 70% of Americans die in a hospital, nursing home, or long-term-care facility. Yet, seven out of 10 Americans say they would prefer to die at home. Also, 70% of patients with chronic disease say they want to avoid hospitalization and ICU when they are dying. We must be part of the solution in helping to ensure that the dollars are spent appropriately and more importantly that patients have a choice in end of life decisions. No, I am not advocating for death panels. However, providing patients with information in a compassionate manner empowers them to be a part of their own destiny. As emergency physicians we are at the forefront of these issues and have an opportunity to be a voice of reason, compassionate communicators, and ensure that overall healthcare dollars take care of more individuals.

"That Patient" continued from page 9 later and informed me that my pleasant 64 year old patient had metastatic lung disease. I was not surprised to hear his report, but I was extremely upset. I considered how to tell her this information. I probably delayed going into her room by about 15 minutes because I did not want to be the bearer of her diagnosis. I finally summed up enough courage and entered her room to again find her smiling, and she asked about the result of the scan. I guess she could tell by my facial expression that it was not going to be good news. I pulled up a chair, sat as close to her bedside as I could, and placed my hand into hers. I told her the spots on her lung were indeed cancer and represented metastatic disease. I explained that further testing would have to be done to confirm the primary site of her cancer. I had a difficult time looking into her eyes with this information. I apologized for having to give her this terrible report. She startled me when she abruptly said, “Doctor, look at me! It’s OK, this is not your fault; you did not cause this problem.” I was truly taken aback by her words, and I immediately looked at her. She was smiling and then said the words that I will never forget. She softly said, “Thank you for your kindness and concern.” I asked if there was anything I could do for her, and she said nothing else was necessary. She asked for a phone to call her husband to come pick her up and drive her home. I offered her admission to the hospital to get her work-up started quickly but she declined and said she would call her family doctor in the morning to arrange further testing. I went back to the emergency department’s kitchen and reflected about what had just transpired during the past few hours. I was supposed to be the doctor, the “teacher” to this patient; however, in reality I was the one being taught. I experienced a very valuable lesson with “that” patient. I was having a bad day and was feeling upset about a lot of things happening in the department that I had no control over. However, I had just been in contact with a patient who truly had a terrible day and was consoling me! I realized that there was a person having a much worse day than me and was trying to make me feel better. I learned a lesson that day and I learned it from “that” patient. No matter how bad you may feel, always be kind and attempt to comfort every patient under your care. The next individual you meet may well be having a day that in comparison would make yours look great.

What Would You Do? Ethics in Emergency Medicine

Bernard Heilicser, DO, MS, FACEP, FACOEP-D

ith the recent concerns, and some would say hysteria, over the Ebola outbreak reaching the United States, many ethical questions have been posed. The following dilemma was presented by Chris Fishback, RN, Manager of Urgent Aids, Ingalls Hospital. The resuscitation status regarding an Ebola patient has been debated. Our professionalism and duty to care would mandate that every patient be resuscitated (coded) in the event of a cardiopulmonary arrest. Of course, a patient or appropriate surrogate may autonomously request a Do Not Resuscitate (DNR) status, however, in our society, resuscitation is otherwise presumed. The current guidance would say to protect the healthcare worker and not code the patient, unless appropriate personal protective equipment (PPE) is already donned. The rush to properly don PPE for a coding patient would be considered too risky. Our dilemma relates to the questionable, but not confirmed, Ebola patient who crashes in front of you on presentation to your hospital. Should you attempt resuscitation? What is your legal or ethical obligation to treat this patient? How would you substantiate not coding this unconfirmed possible Ebola patient? What would you do? Please send your thoughts and ideas to WhatWouldYouDo@acoep.org. Every attempt will be made to publish them when we review this dilemma in the next issue of The Pulse. If you have any cases that you would like to present or be reviewed in The Pulse, please email them to us at WhatWouldYouDo@acoep.org Thank you.

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Committed Physicians Interested in Serving on College Committees ACOEP's most valuable resource is our incredible membership base. Your experience, expertise, and insight are an indispensable tool in shaping the future or emergency medicine! Share your vies by becoming involved in one of our dynamic committees! Visit www.acoep.org/committees to learn what opportunities are available! Committees are open to any physician and we encourage interested physicians to sit in on meetings of Committees that you are interested in being appointed to. Appointees must attend 66% of all meetings, conference calls and must participate in the activities of the Committee. Failure to do so will cause the appointee to be removed from the committee. Send your information to: Jan Wachtler, Executive Director, ACOEP, 142 E. Ontario St., Suite 1500, Chicago, IL 60611

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Pharmaland: A Medical Bedtime Story Janice Wachtler, BAE, CBA

ar away, in a land called Pharma, people were concerned. A cry went out across the land; no longer would the Pharmers have direct access to the providers to market its wares! No longer would they be able to give providers cups and pens and do-dads with their logos on to remember the products they made. There was concern that providers may be using products just because their pen had the name of a product on it. Worried, they called a meeting of the largest conglomerates to resolve its marketing issues. In the largest city of Pharma, in a huge glasswalled building, the heads of the largest producers sat. There was Mexaltrexate and Latuda - Cialis and Eliquis - Pristiq and Breo . . . all concerned about the best way to market their goods to their consumers. Mexaltrexate, a large, strongwilled Pharmer stood and addressed the group, pounding on his chest as he spoke. “These laws will change our marketplace! How can we get to the people that use our products if we can’t leave a pen, or a cup, or a pad of paper with our name on it? How will they know our products exist if we can’t give CME cruises, sponsor programs, and put our logos on signs and giveaways? How will the users know that we even exist? This is outrageous!” he stormed. Latuda put her hand on his hand as he sat down; his face reddened from his outburst. “It will be all right we just have to find another way,” she said calmly. Next to speak was Breo, “If we can’t market directly to those who provide and promote our goods, how will the consumer know what we do ... or worse what if the providers chose the generics? They will wreak havoc upon our profit – they will cause us to lose money! They will drive our economy down – pharmers will be out of work!” “What do you care?” yelled Cialis. “Your product is always needed, but my product is a product of choice – if we can’t get it to the provider, they may not know it’s out there.” The meeting went on for hours, pitting pharmer against pharmer, when suddenly Pristiq

ow can we get to the people that use our " Hproducts if we can’t leave a pen, or a cup, or a pad of paper with our name on it? " stood up and quietly said, “Let’s market directly to the users. If we can’t provide goodies to the provider, let’s give the information directly to the user and they can make recommendations to the provider for what they want.” Suddenly, the yelling ceased as pharmers sat rubbing their chins and contemplating how to do just that – get the information to the user.

billboards and screensavers, on tee shirts and underwear, but how can they get to the people they needed to? Finally, a small voice from the table cleared its throat and said quietly, “Let’s get to the kids – if we make stories and dolls and cartoons we can do away with the bathtubs and bladders and make stories of those names sitting around the table.”

Years passed and Pharma again was happy land, no providers were being given tokens and mementoes regarding the products pharmers made and users were now bringing suggestions to the providers. Users were being greeted with all sorts of advertising for this product or that to lower one’s blood pressure, bring back romance into one’s life, or stop frequent bladder urges. The commercials and advertising were cute sometimes, other times reminiscent of times gone by and users ate up these print and video ads. But again complaints were heard throughout the lands beyond Pharmaland.

“We can tell tales of Metheltrexate, and how he slew cancer and arthritis . . . we can tell tales of Cialis and how he came from his bathtub to bring romance back into the life of the lovelorn and lonely . . . we can tell of careers helped by Aricept by bringing back clear thinking. Yes, we can do this!” he declared, “We can sell to kids, and they will bring these names and products to life and make them everyday names in the vocabulary of millions!”

Providers were now questioning and complaining, “how can a user know what’s good for them?” yelled one. “I can’t give a user a product just because they saw it on TV?” called another. And, again Pharmaland convened a meeting of officials. They sat around the familiar table, each pharmer wondering how best to meet the needs of employees, revenue and the users, especially. If providers were getting tired of users coming to them and asking for specific products, how can they bring the information into the homes and lives of the users? How best for them to maintain market share in an already tightening and competitive market? They met for days ... thinking ... discussing ... wondering ... how? They spoke of endorsements, of putting logos on race cars and jackets, on

And so it came to pass that Mexeltrexate became a hero slaying dragons made up of cancer cells and psoriatic patches with his friend Xarelto fighting the villainous blood clot warriors, and Cialis became the romantic hero of countless romance novels, and slowly the lingo of the nation was changed to accommodate the marketing trends. Providers shrugged their shoulders and did what they always did, gave the users what the provider thought they needed and users continued to ask, and all the pharmers lived happily ever after. - The End -

the PULSE | JANUARY 2015

Naloxone and EMS: Is it Right for Every Service? Stephen Vetrano, D.O., FACOEP ACOEP EMS Committee Chair

arcotic drug abuse is a hot topic these days, and thanks to it, states have changed scope of practice of EMS providers in some fashion to allow the administration of naloxone to reverse opiate overdose. In some states, it extends even further, with non-medical law enforcement officers and civilians being granted permission to use naloxone. As emergency physicians, we are the ones dealing with EMS providers and law enforcement officers on a fairly regular basis. You may be asked by representatives of these agencies for assistance with, or opinions on, the carrying and use of naloxone. There are some things to keep in mind. First and foremost, know what you are getting into. Is the agency looking for a medical director, or just someone to sign a purchase authorization form? Remember, for any EMS agency to purchase a prescription drug, they need physician authorization. Signing authorization for an agency to purchase sterile water and saline for irrigation is one thing (yes, that needs physician signature too, they are drugs), but signing for something like naloxone is another. You should talk to the agency and gage how responsible they are and if you and the agency seem to get along with each other, such that you can be the overall medical director, assuming you are interested in becoming an EMS medical director. Also be aware of where the authorization comes from. In my home state of New Jersey, this all came about because a law was passed allowing civilians to use naloxone. BLS could not; as the law stated it could not change a scope of practice. However, police officers, not having a scope of practice, fell under the civilian aspect of the law and would be allowed to administer it. When it became known that BLS could not give a drug that the police could, the New Jersey Commissioner of Health issued a waiver allowing naloxone to be in the scope of practice. Your state may do it similarly via waiver, or by passing law or regulation, or through a civil access model. You need to know the route of administration. Is your state allowing BLS providers to give

e are the ones dealing with EMS " W providers and law enforcement officers on a fairly regular basis. " injections? Or are they allowing an auto injector or the intranasal route? This becomes important as ultimately, you will have to provide some type of training. Do you need to train for IM injections? Does your state allow intranasal administration of medications? This requires additional purchases: the mucosal atomization device, to turn your naloxone injection into a nasal spray. Should your EMS agency carry naloxone? You need to work with your agency leadership on this. Do you have a significant opiate overdose problem in your service area? Will the pubic expect you to carry this drug? What if you don’t, how will you respond to the public? Can your agency bill for the service, or do you have eat the cost because of payment regulations, or by law (the public access law in NJ forbids the user of naloxone to bill for the service).

If you are working with a police department, what level of training do they have? Are they required to maintain CPR Certification or Emergency Medical Responder training? Do you have to worry that they will administer naloxone when they should be administering oxygen and ventilations? After all, no one dies from lack of naloxone in an opiate overdose, they die from lack of oxygenation and ventilation. Shouldn’t we be emphasizing that in our training? While seeming like a quick fix to the problem of narcotic abuse, the addition of naloxone to the scope of practice of basic level EMS providers, police officers or civilian population carries its own set of issues. Thankfully, as emergency physicians, we are equipped to handle most of these issues. It does require careful thought and discussion between you and your agency leadership.

ACOEP Members in the News Congratulations to William Bograkos MA, DO, FACOEP, FACOFP, who has just been named President-Elect of the American Osteopathic Academy of Addiction Medicine. Among his many professional accomplishments, Dr.Bogorokas is a colonel in the United States Army, and has served in the Department of Defense for for 28 years, most recently as the Chief of the Warrior Transition Division, Clinical Operations at the North Atlantic Region Medical Command. Dr. Bograkos served on the Maryland Brain Injury Association Board of Directors and has been an active Advanced Trauma Life Support (ATLS-I) instructor at Cowley

Shock Trauma, in Baltimore, Maryland. He currently serves as a consultant to the “Psychiatric Continuity Service,” Walter Reed National Military Medical C e n t e r, a n d t o “ H O M E M I N D ” t h e Danish Wounded Warrior Project.

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the PULSE | JANUARY 2015

Ebola: A Call for Global Health Deborah Lardner D.O., DTM&H Michael Passafaro D.O., DTM&H, FACEP, FACOEP

ith Dr. Spencer’s case of Ebola now resolved in New York City, our specialty is reminded how we remain on the front lines of outbreaks. His humanitarian service in Africa might have caused an outbreak in a heavily populated, urban travel hub. If he had not been as vigilant as he was, he could have been patient zero for disaster. Fortunately, the patient survived and our infrastructure was able to trace and isolate the disease with appropriate measures. It appears we have successfully contained a deadly virus. But his case highlights bigger problems: the isolationist mentality of many Americans in regards to international health and disease burdens as well as the misconception that diseases stay within the confines of country borders. A recent statement from the American Society for Tropical Medicine and Hygiene dated October 30, 2014, has reluctantly agreed to comply with the Louisiana Department of Health and Hospitals requirement that members from affected areas are not allowed to report to its annual meeting in November. 1 Unfortunately, this legislation has prevented local experts from sharing important scientific information with colleagues that might mitigate the outbreak in the future. And although the field has changed from travel medicine to tropical medicine to global health, it is still relevant for all medical specialties. By understanding diseases in their appropriate context, we will enhance our ability to give effective healthcare in our increasingly diverse American population. Our patients, especially in major metropolitan areas like New York City, are arriving from all over the world. In an age of modern transportation where aircrafts can reach almost any major city around the globe in less than 24 hours, the United States is at particular risk for importing a potentially disastrous disease like Ebola. This is in sharp contrast to the turn of the 18th century when long-distance travel was primarily with tall ships and a trip from England to Australia could take almost one year. Today, larger jumbo jets carry several hundred passengers and cruise lines traveling around the world have been known to carry over 3000 passengers and crew. The

ur patients, especially in major metropolitan " Oareas like New York City, are arriving from all over the world."

U.S. Department of Transportation reports that 443,969,603 passengers traveled on U.S. airlines and on foreign airlines in 2014.2 In addition, mass gatherings, such as the Haj pilgrimage in Saudi Arabia which brings approximately 2 million pilgrims together every year or the millions of spectators at the World Cup football matches held every four years, are becoming commonplace. 3

Since the age of European imperialism, epidemiologists have long recognized the interaction between disease and travel. The development of the new specialty of Tropical Medicine in the late 1800s in England was considered an essential component to the economic and social authority of the British Empire by Joseph Chamberlain, then British Secretary of State for the Colonies (1895 –1903). He asserted that regular trade, efficient administration and agricultural productivity were seriously hampered in the colonies by previously unknown diseases particularly between the Tropics of Cancer and Capricorn. East and west trade lines were drawn in Africa based on clinical manifestations now known as African sleeping sickness (Trypanosomiasis brucei rhodesiense and gambiense respectively) In India, epidemic diseases like plague, leprosy, cholera and malaria were major financial burdens to the British Raj. Malaria was of particular interest since British officers were at increased risk as they created water irrigation and the transcontinental rail system. This left many fresh water reservoirs for future propagation of mosquitoes in its wake. The use of Quinine chemoprophylaxis in the 1840s, often mixed with gin, probably made the whole British experience tolerable as they steamed across the continent. 4 Ironically, it was these very same colonialists who made significant contributions to the study of infectious disease. Protagonists like Ronald Ross of the Indian Medical Service

were able to discover the complete life cycle of plasmodium. Patrick Manson, another medical officer to the colonial office reported on the causative agent of lymphatic filariasis and was instrumental in our understanding of tropical disease transmission. Their ideas and those of other returning physicians were presented as a series of lectures on “Tropical Medicine” while on home leave in England. Through continued support of Chamberlain, these lectures became more formalized and what was to become the London School of Hygiene and Tropical Medicine was established. Today, this specialized research center is considered by most in the international community to be the leading program in tropical disease training, where Dr. Peter Piot, the co-discoverer of Ebola, continues to lecture. Fortunately, the field of Tropical Medicine has changed to be more inclusive and less colonial in philosophy. A more acceptable, collaborative term of “global health” continues in the modern public health arena. There are many similarities between the American Institute of Medicine “convergence” model for infectious diseases and global health. This model examines factors from a variety of angles. For example, changes in human demographics, ecological and environmental degradation, vector expansion through climate change, agricultural practices as well as social and political influences all contribute to the disease burden. Together, they create a larger picture from which one can better understand disease that affect not only individuals but populations. For example, urban areas are major epicenters of disease. The urban population of the world has grown rapidly from 746 million in 1950 to 3.9 billion in 2014. 5 The United Nations report on population notes that “mega-cities” with 10 million inhabitants or more are fast increasing. There are presently 28 mega-cities worldwide, sixteen are located in Asia, four in Latin America,

the PULSE | JANUARY 2015

three each in Africa and Europe and two in Northern America. 6 Diseases like Polio that are considered controlled but still appear in the background of urban populations potentially can resurface in overcrowded areas facilitating transmission. Social behavioral interactions may both enable or impede outbreaks leading to more complicated diseases such as drug resistant HIV or Tuberculosis. Urban areas can quickly outgrow their infrastructure capacity and become a source of political instability. All of these factors together create the metaphor of the “urban crucible”, first proposed by Nash. 7 This concept asserts that urban environments result in the restructuring of social groups, the redistribution of wealth, labor, politics and ultimately health. Another change in the global health perspective includes the study of ecological balances. Human populations are encroaching on natural habitats of potential disease carrying vectors or hosts. This is seen in the presumptive index case for the current Ebola outbreak where a child living on the fringes of the rainforest Meliandou in Guéckédou prefecture in Guinea died on December 6, 2013. 8 Environmental interactions are central in medicine and we often forget to “listen” to it in our modern chaotic life. The concept of a “silent forest” was described by Belfour in the Lancet in 1914 as the howler monkeys in the rainforest in Trinidad, West Indies died off in the forest cycle of yellow fever. This silence was a predictor for outbreaks of yellow fever as humans who were clearing the forest contracted yellow fever as the mosquito vector looked for a possible host. 9 Environmental influences of global warming have allowed diseases like Dengue, Chagas disease and West Nile virus into the continental United States. The vector habitats and breading sites are expanding resulting in greater disease potential. Our interaction with other mammalian species have always been know causes of disease like plague or rabies, but often forgotten is our human interaction with livestock. As agricultural practices develop internationally, infectious disease threats from agriculturally based livestock are predicted to become increasingly important. The unfortunate paradox is that modern agricultural practices and

loss of traditional farming ultimately reduces food security and can contribute to outbreaks such as Taenia, Cysticercosis, Brucellosis, Bovine Tuberculosis, Avian Influenza and Cholera. Finally, global health also examines disease burdens in their social and political context. Outbreaks in countries with collapsing, overburdened infrastructure can lead to social instability. Country sovereignty and selfdetermination can confuse the issues. A research study by Harvard University estimated that more than a third of a million South Africans were needlessly infected because of president Thabo Mbeki’s government’s HIV policies. 10 His assertion that the cause of AIDS was poverty, bad nourishment and general ill-health, not a virus, allowed for the dissemination of the disease to endemic proportions. The result is that now HIV is embedded in South Africa. As thousands of people are newly infected, their health systems become overburdened and the country is forced to rely on international aid contributions. In the past, the United States humanitarian response to natural or medical disasters has been generous in financial support. But unfortunately it is often in countries with weak, inefficient health care systems, double burdened by political corruption. Consensus in the global health community now recognizes a country that relies solely on international aid will inevitably collapse. Vulnerable populations will be at greater risk, perpetuating the cycle of more aid. A recent book by Linda Polman entitled “The Crisis Caravan” 11 recounts the problem with humanitarian aid and how well-meaning interventions have been known to backfire. The generosity of our humanitarian service, embodied in Dr. Spencer’s verses the humanitarian puzzle of preventing self-reliance is the conundrum. How we should be spending our efforts is only entangled with the politically charged aspect of where. For example, sustainable capacity building in communities through local staff training is an investment with positive returns. The relevant current example is the quick response of Nigeria, which had one Ebola patient who directly contaminated 20 others.

The New York Times reports that the outbreak was quickly contained by internationally trained medical professionals qualified in epidemiology for HIV and polio control. Those patients and their contacts totaled almost 900 people, and were personally and effectively monitored with face to face contacts. Virtually all contacts passed the 21-day incubation period without falling ill. 12 Understanding the complexity of these issues through the study of global health will better prepare us for effective interventions like this one. Continued medical involvement will create more effective partnerships and not just crisis management. True collaborations are the next obstacles in global health as we increasingly recognize that they are often one sided. Are developed nations medical voyeurs? Are we helicoptering down to communities which will no longer be able to support our efforts once we leave? Or are we creating a sustainable positive change? Although we like to focus on the exotic disease just as they did in Victorian times, there are many other targets that should not be neglected. Preventable disease like pneumonia, malaria and diarrhea still continue to kill millions of children around the world. Complicated diseases like multi-drug resistant Tuberculosis and HIV are a continued threat to our own national health security. The reallocation of resources to prevent transmission of these diseases should still be the ultimate focus of our humanitarian effort. Unfortunately, Ebola is an unwitting evil character in the latest news story. But just like the incubation period, once time has passed, it will fall out of the headlines, and the public will have moved on to the latest, mediatrending disaster. Only our continued advocacy, training and international service will prepare us for future imported outbreaks and global health, once a historical detail, again will resurface as we enter this new era of medicine. References

1. American Society for Tropical Medicine and Hygiene, October 30, 2014, [press release] UPDATED: To Stop Ebola Outbreak, Virus Must Be Contained in West Africa. retrieved from http://astmh.org//Content/NavigationMenu/ Publications/IntheNews/EbolaStatement-updated_v3.pdf 2. The Research and Innovative Technology Administration (RITA) retrieved from; http://www.transtats.bts.gov/Data_

Continued on Page 18

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"Ebola" continued from page 17

Elements.aspx?Data=2 3. Fédération Internationale de Football Association World Cup retrieved from: http://www.fifa.com/aboutfifa/ worldcup/ 4. Muhammad Umair Mushtaq, Public Health in British India: A Brief Account of the History of Medical Services and Disease Prevention in Colonial India, Indian J Community Med. Jan 2009; 34(1): 6–14. 5. United Nations Department of Economics and Social Affairs, Population Division. Population Facts: Our Urbanizing World, August 2014, retrieved from: http:// www.un.org/en/development/desa/population/ publications/pdf/popfacts/PopFacts_2014-3.pdf 6. United Nations DESA. World’s population increasingly urban with more than half living in urban areas. July 10 2014, New York retrieved from: http://www.un.org/en/ development/desa/news/population/world-urbanizationprospects-2014.html 7. Nash, G. B. (1979). The urban crucible: Social change, political consciousness, and the origins of the American Revolution. Cambridge, Mass: Harvard University Press. 8. Baize, S et al, Emergence of Zaire Ebola Virus Disease in Guinea, N Engl J Med 2014; 371:1418-1425October 9, 2014DOI: 10.1056/NEJMoa1404505 9. Simpson D. Arbovirus infections. In: Cook GC, editor. Mason’s Tropical Disease. 1996. pp. 143–56 10. Chigwedere P1, Seage GR 3rd, Gruskin S, Lee TH, Essex M. Estimating the lost benefits of antiretroviral drug use in South Africa. J Acquir Immune Defic Syndr. 2008 Dec 1;49(4):410-5. 11. Polman, L., & Waters, L. (2010). The crisis caravan: What’s wrong with humanitarian aid? (1st U.S. ed.). New York: Metropolitan Books. 12. Donald McNeil Jr (Sept 30, 2014) Nigeria’s Actions Seem to Contain Ebola Outbreak, The New York Times, and Retrieved from: http://www.nytimes.com/2014/10/01/health/ebolaoutbreak-in-nigeria-appears-to-be-over.html?_r=0

EMERGENCY Intensive on Immersi ce Experien

2015 dates March 6–8 Orlando March 27–29 Las Vegas

ACOEP’s Young Physicians in Practice Committee ACOEP is proud to unveil the Young Physicians in Practice Committee, a special group dedicated to addressing the specific needs of physicians in their first five years post residency! The transition from resident to attending physician is a difficult one, filled with hurdles at every point. From work-life balance, to contract negotiations, to financial concerns, to legal issues, these five years are challenging for all physicians as they set out to build a rewarding, impactful career. The Young Physicians in Practice

Committee will hold meetings in conjunction with The Edge: Spring Seminar, and Scientific Assembly. These meetings will include a rapid-fire lecture track that will offer CME hours, social and networking opportunities, and much more! To learn more about this incredible initiative, and to download a Young Physicians Membership Packet, visit www.acoep.org/pages/newphysicians. You can also find more information on Facebook at https://www.facebook.com/ acoepnp.

We Want to Hear from You! ER Physicians do incredible things every day and we want your stories! Send your story ideas to ThePulse@acoep.org, we would love to share your experience with our members. We also encourage you to email ThePulse@acoep.org to share your thoughts on specific articles that you read here. We want to keep the conversation rolling, whether you agree or disagree with a point of view represented in our articles, we want to highlight various perspectives from our diverse membership.

April 24–26 Boston June 5–7 St. Louis Oct. 2– 4 Washington, D.C. Nov. 20 – 22 San Diego Advanced Education in Difficult & Failed Airway Management

the PULSE | JANUARY 2015

When Good Doctors Feel Bad Frank Gabin, DO

hink about who we are as a group. We’re hyper-intelligent, highly motivated, disciplined people who “get it” in an instant and have a strong desire to care and make a difference for others. We chose emergency medicine, because we know that what we do, can make the biggest impact on the survival and quality of life of our patients. Yet, we’ve come to accept the fact that, as physicians, we’ll eventually succumb to some form of compassion fatigue or burnout. There is a huge paradox here. Intuitively we know that helping others should feel good. How can caring for others actually cause us to feel bad? I propose that it’s our current understanding of empathy that is the root cause of our problem. With a deeper look at the science of empathy and how it affects us, we’ll better understand where our stumbling block is. Identifying the source of our emotional exhaustion as caregivers will show us what we can do to change things. This will allow us, almost immediately, to begin to feel better. Recent studies show that 70% of us are suffering from compassion fatigue or burnout. We’re uniquely affected. Of interest is that the more educated you are, the more protected you are from burnout, unless you’re a physician! What is happening to us happens in no other educated segment of the world’s population. Compassion fatigue and burnout are considered forms of secondary post traumatic stress disorder. As emergency physicians, we exhibit the same emotional symptoms exhibited by survivors of abuse and severe trauma. How can it be that just doing our specific jobs can cause most of us to suffer emotionally? Our human physiology is the culprit. I’ve come to understand how the model of care we’ve have been taught as physicians is in conflict with our most basic survival physiology. Think of our situation as being like a computer’s; our hardware (physiology) and our software (our current model of care) are incompatible. They don’t work well together,

caring for others actually cause " Husowto can feel bad?" and combined they don’t produce good results, especially for us doctors.

that additional distance, we’ll actually make mistakes.

The specific model of care I’m referring to is that of ‘keeping our professional distance.’

Some research even suggests that if physicians could “down-regulate” their empathetic response, doing so may weaken the negative effects empathy has on our brains, thus freeing up more cognitive resources that are necessary for completing complex clinical tasks. Why is it that empathy has a negative effect on our brains and weakens our cognitive abilities? Continued on Page 20

Research is proving that the reasoning behind this model no longer fits with the emerging understanding of our human physiology and the neural mechanisms involved with our personal survival and care of our species. Before going into this research, let’s discuss why the idea of keeping our distance is so prevalent in our profession. Traditionally we’ve been taught and warned not to get too close with our patients; that staying objective and keeping a safe clinical distance is good for the patient and ourselves. Surprisingly, the idea of professional distance isn’t clearly defined anywhere, yet it permeates all of medicine. The message is clear; getting too close or involved with our patients is bad for both parties. Empathy has been singled out as the reason. Research done just a few years ago tells us that too much empathy actually impedes the delivery of quality medical care. This information shows that repeated exposure to the suffering of others causes doctors to experience personal distress leading to compassion fatigue and burnout. Worse yet, these emotional conditions are associated with negative medical outcomes for our patients. It seems that the experts are saying that experiencing empathy with our patients leads to poor-quality healthcare and an increased risk of medical errors. Since making a mistake is our worst fear it’s no wonder why we always feel threatened. We’ve been taught to put up a wall so that these things don’t affect us, and now it appears they’re telling us to distance ourselves even further, injecting even more fear that without

the PULSE | JANUARY 2015

"Feel Bad" continued from page 19 Think about it for a second. Empathy is defined as a state where we feel the suffering of the person in front of us. Who’s at their best when they’re suffering? No one. No wonder we react like victims of trauma and abuse and develop the post traumatic stress disorder of burnout. Herein lies the conundrum. If empathy is the problem and keeping our professional distance isn’t the solution, what is? To find the answer, let’s look at some basic neuroanatomy and human physiology involved in our situation. What I’m about to show you is so powerful that if we apply this understanding to what we’re already doing, we could completely eliminate compassion fatigue and professional burnout from the landscape of medicine and nursing today. Our physiology is based in survival. Survival of the individual, and of the species, evolutionarily dictated that our ancestors be hyper-vigilant of danger, conflict and loss. As a result, our bodies and brains evolved complex systems that cause us to preferentially look for danger, react intensely to it and and then quickly store the experience in a neural structure. This way, if the same threat appears again, we’ll

recognize and react to it even more quickly and intensely. These systems, linked to our personal safety and survival, are powerfully tied to our emotions. They’re especially active when we perceive any threat (even if the threat is merely making a mistake). They were designed to get our attention so that we feel it physically and/ or emotionally. These are the basest of human needs and get top priority, run under our conscious awareness, and are active at all times. We can’t turn them off. Our limbic system, amygdala, MNS [Mirror Neuron System], interior insula and medial prefrontal cortices all work together to generate our visceral experience (our gut reaction). The limbic system is closely tied to our five senses and contains the amygdala – the primary danger detector for physical threats to our personal safety and the safety of our tribe. The MNS is responsible for the process of mimicry, which forms the basis of our empathetic connection. Our MNS is a bit like a high-definition camera that observes and records every detail of people’s facial expressions, body language, pupil movements and even vocal tones. Our MNS (with the help of the motor and premotor cortices) through the process of

Excellent Opportunity for Full-or Part-time ABEM/AOBEM BC/BE Emergency Medicine Physician Exciting opportunity for full-or part-time ABEM/AOBEM BC/ BE emergency medicine physician to join our well-established single hospital group located in Dothan, Alabama. Annual ED volume 60,000. Equitable scheduling with 7-day block off each month. 420-bed Level 2 trauma center serves 600,000+ as the area’s regional referral center. Excellent subspecialty and hospitalist support. Big city medicine in a congenial small-town community, low cost of living, excellent family-oriented quality of life. Active outdoor recreation area; beautiful Gulf beaches within 75 miles. Current opportunities to teach medical students; be part of planning for future residency training. Competitive hourly rate with productivity bonus and malpractice allowance. Educational loan repayment available. Contact Sarah Purvis, SAMC Physician Recruiter @ sbpurvis@ samc.org or 1-800-248-7047 ext. 8145 1108 Ross Clark Circle Dothan, AL 36301

mimicry, makes us feel what others in our environment are feeling. This system is capable of recognizing seven universal emotions(the same across all of the world’s cultures); anger, fear, sadness, disgust, surprise, contempt and happiness. To better understand how this works within us, let’s look at the effects of happiness, the only positive emotion recognized by our MNS. Think of the universal experience we’ve all had with a newborn. Whenever we’re introduced to a newborn infant, we do whatever it takes to have the baby smile back at us. Why? What exactly are we looking for? We know the baby can’t see very well and can’t talk. Yet as adults, we work hard to get the baby to mimic us; we make funny faces and talk baby talk just to win the smile and excitement from the baby. When we see and feel that baby’s smile. Our MNS causes us to automatically and unconsciously mimic the baby’s expression, and that same pleasure the baby feels ultimately washes over us as well! Very powerful, right? The dark side is that this works the same way with the other six negative emotions. We feel what they feel, and just as powerfully, whether we realize it or not. It turns out that the MNS is a big deal, especially for us. What it does is connect us. Since we can’t turn it off, we’re always connected. This means empathy is not a static condition. It is part of a larger process that is not entirely under our conscious control. The big flaw in our model of care is trying “not” to connect. We can’t! It’s impossible! This is why keeping our distance does not work. We can’t fight against our central nervous system. It has been designed by six hundred million years of planetary evolution that was based on survival, personally and collectively as a species. Our physiology requires that we sync up and connect with other humans in our immediate environment. This is so important that, by design, the process is buried beneath our conscious awareness so that we can’t stop it from happening. Connection is of paramount importance to our survival and the survival of our species! While the process of mimicry makes us automatically feel what others are feeling, there is a second, conscious piece to the process. The first part is responsible for what science is now calling “affective empathy”. This is primal and happens unconsciously almost at the level of the brainstem. The second half happens in the frontal and prefrontal cortices where we have some conscious control. It is responsible for what is referred to as “cognitive empathy”, where we move from feeling to understanding by putting ourselves in another’s

the PULSE | JANUARY 2015

shoes. Cognitive empathy can help us feel better emotionally while giving care. It’s here that we can begin to unravel the solution to our problem. If unaddressed “affective empathy” is what’s making us emotionally ill. Conversely then “cognitive empathy”, where we consciously try to understand another’s pain, is where we find the key to unlock our pain. Our MNS causes us to feel pain when we see pain. We work in a profession where we’re constantly surrounded by pain and suffering all the time. This pain, which is now ours, slowly overwhelms our emotions. We may try to keep our distance from this pain, but we’re already unconsciously connected; it’s the emotional and physical effects of this unconscious connection that cause compassion fatigue and ultimately burnout. Until now, we had no idea that we were unconsciously connected to their pain. In fact, by purposely keeping our distance, we shut down the rest of the process and can’t move past the point of affective empathy. We change our experience when we move from “feeling” how bad things are and consciously enter the state of cognitive empathy. We experience some relief just by trying to understand what it would be like to be in another’s shoes. However, when our experience of cognitive empathy shifts into the state of compassion (where we actively want things to be better for them) everything really begins to change. Compassion is not empathy. Compassion, as part of a larger process that we control, is what relieves us from the post traumatic stress disorder we’ve all unconsciously experienced. Compassion can heal all of us. What’s the effect of moving from cognitive empathy and into compassion? Let’s look at some eloquent and exciting neuroscience from researchers Matthieu Ricard and Tania Singer. They show us, using the MRI scanner, that when we empathize with a person who’s suffering, the area of our brain that registers suffering is activated in the same way and at the same location as the brain of the person we’re empathizing with. This is the state we’re in when we’re faced with a suffering patient and we’re feeling bad, sad and thinking how awful it is for him or her. This state is our automatic affective empathy, born out of the primal need for survival of our own species. Clearly, if we stay in the experience of affective empathy, we suffer too. According to Ricard (who also happens to be a buddhist monk dubbed the happiest man on

the planet by Time magazine), with compassion, every atom of suffering becomes soaked with loving kindness and the experience—physical and emotional—transforms into something much different. The change shows up in our brain too: when compassion is activated, all the areas in the prefrontal cortex and limbic system that handle distress, fear and pain are deactivated and the dopamine-rich wholesome centers, the ones that generate positive emotional states, kick in. Compassion, actually makes us feel good. Science is showing us that compassion, like happiness, makes us better at almost everything a human can do: mathematical calculations, spacial perception, logical reasoning, physical strength- just about all of our capacities are enhanced or augmented by compassion. Therefore, experiencing compassion when we’re actively connected to our patient will actually enhance our cognitive abilities, and the fear of mistakes and bad clinical outcomes that is associated with affective empathy will obviously disappear. This is why the process of keeping our “professional distance” is flawed: it looks at empathy as an isolated event instead of seeing its role in the process of connection. While “affective empathy” does hurt—and leads to burnout simply because we get stuck in it— it is in activating our compassion and our desire to care, that we move past the pain and into feeling good as our intuition tells us we should. Compassion doesn’t fatigue! Compassion can only enlarge, engage and empower the one who feels compassion for another. I firmly believe that the antidote for compassion fatigue is compassion itself. We need to dismantle medicine’s big lie, the myth that we’ve been taught and incorporated into our practice. Keeping our professional distance does not make us better doctors. Keeping our distance actually diminishes our cognitive powers.

What can we do, right now, to start feeling better because of the amazing work we all do every day? We can let go of the myth of keeping our distance and then enter more deeply into the connection to our patients and their families. After all, it is already happening, so why not cause something good to come out of it? Try using this six step formula for mindfully generating the care that you and your patient both deserve: • Get present • Fully connect • Focus on your patient’s needs • Move from affective Empathy to Cognitive Empathy • Generate compassion • Take action Learn more about the delivery of true care in my free book Care 101, or by reading my weekly blog called Shot of Satisfaction; both are available at my website www.clear2care.com. You could also read Back From Burnout, available at Amazon.com. Until next time, Go Care, Make a Difference and Change Our World!

Your EssEntial rEsourcE for EmErgEncy mEdicinE Board rEviEw

With this new understanding we’ll build the new reality where instead of working against our physiology, by trying to keep our distance, we’ll override our automatic basic survival physiology by consciously choosing to move into the state of compassion in order to enhance our cognitive abilities and provide better care. We override it not by stepping back, but rather, by stepping forward and into a deeper connection with the hurting human in front of us. By doing so, we’ll engage in the process of cognitive empathy and then move into the state of compassion which will cause healing on both sides of our stethoscope.

Ohio

ACEP

American College of Emergency Physicians Advocacy

Education

Leadership

www.ohacep.org (614) 792-6506

the PULSE | JANUARY 2015

ACOEP Member Spotlight: Christopher Colbert Erin Sernoffsky

that the caliber of speakers and topics " Iheknow will bring together will reflect his years of experience and fresh ideas. I’m really looking forward to Fort Lauderdale!

– Nilesh Patel, D.O., FACOEP

as treating Hemorrhagic fever in Kosovo, and Leshmeniasia in Iraq. He has also managed high altitude sickness as individuals attempt to climb Mount Fiji in Japan.

Christopher Colbert

or as long as he can remember, Christopher Colbert wanted to be a physician. “It was always my calling,” he says. “I always believed that osteopathic physicians maintained a more personal relationship with their patients.” Born in Washington, D.C., the father of three has always had a strong sense of service, both to the patients he treats, as well as to the American people. Like the two generations before him, Dr. Colbert took this calling very seriously and enlisted as a Major in the United States Army. Through this service, he has been deployed to combat regions such as Kosovo and Iraq. “The military has afforded me the opportunity to travel the globe and practice medicine in amazing places, meeting great people, incredible friends, and practice international medicine.” These opportunities not only include meeting celebrated military physicians and soldiers during his time at Walter Reed Medical Center, but also have provided Dr. Colbert with experiences such

Dr. Colbert has taken these experiences and applied them, not only to his practice at Provident Hospital in Cook County, but to his role as an educator. He is the Course Director of Emergency Medicine at Midwestern University where he is also a Clinical Associate Professor of Emergency Medicine. In his most prominent ACOEP leadership role yet, Dr. Colbert takes the helm of The Edge: Spring Seminar 2015! “Chris is absolutely the right man for the job,” says Nilesh Patel, D.O., FACOEP, and chair of the CME Committee. “He’s always been a popular speaker and he brings a unique perspective to the job. I know that the caliber of speakers and topics he’ll bring together will reflect his years of experience and fresh ideas. I’m really looking forward to Fort Lauderdale!” His dedication to others, as well as commitment to medical education, specifically osteopathic emergency medicine, led him to ACOEP in the first place. An active member of the Continuing Medical Education Committee, Dr. Colbert distinguished himself in 2011 when he became the course chair of the Oral Board Review Course. As the chair, Dr. Colbert made the meeting incredibly successful by rewriting cases, streamlining the entire conference, and improving the overall course outcomes. This meeting sells out and has become an incredibly valuable resource to ACOEP’s members. “Dr. Colbert’s involvement in the Oral

Board Review Course has been integral in making this course more closely mirror the exam itself, and our attendees are reaping the benefits,” says Jan Wachtler, ACOEP Executive Director. “He’s gathered an excellent team of examiners together and every year the class gets stronger.” In addition to the Oral Board Review, Dr. Colbert has also lectured at numerous conferences, including as faculty at ACOEP’s EMS Track at the Spring Seminar, Intense Review, and the Scientific Assembly where he has also served on the planning task force. His diverse lists of lecture topics include EMS in Iraq, psycho behavioral disorders, updates on the evaluation of pediatric neck masses, Lymphadenopathy, and bariatric emergencies. He received excellent reviews on his lectures, and in an evaluation one ACOEP member commented that he is “one of the best new speakers for the College!” Additionally, he earned the title of Outstanding Lecturer of the Year from Midwestern University in 2010. These experiences have prepared him for his new role as Course Chair, and have given him an excellent framework for what conference attendees expect, as well as inspiration for new opportunities and offerings. “I’m excited for this new challenge!” says Dr. Colbert, “I want to give back to ACOEP in a big way. We’re expanding the EMS Track, the FOEM 5K, the competitions! The topics and the team that we’re putting together will be really informative for our members. We’re bringing back old favorites and are excited to introduce our members to new speakers.”

the PULSE | JANUARY 2015

ACOEP Staff Contact List

Below is an updated list of ACOEP staff along with their contact information. Feel free to call or email our staff with any questions, concerns, or needs that you may have. EXECUTIVE

EVENTS (continued)

Executive Director Janice Wachtler, BAE, CBA Direct Line: (312) 445-5705 Email: janwachtler@acoep.org

Education & Events Assistant Andrea Jerabek Direct Line: (312) 445-5703 Email: ajerabek@acoep.org MEMBER SERVICES

Director, Affiliate Management Stephanie Whitmer Direct Line: (312) 445-5712 Email: swhitmer@acoep.org

Director Sonya Stephens Direct Line: (312) 445-5704 Email: sstephens@acoep.org

Executive Assistant Geri Phifer Direct Line: (312) 445-5700 Email: gphifer@acoep.org

Senior Coordinator, Member Services Jaclyn McMillin Direct Line: (312) 445-5702 Email: jronovsky@acoep.org

EDUCATION

Director Kristen Kennedy, M.Ed. Direct Line: (312) 445-5708 Email: kkennedy@acoep.org

FOEM & Membership Database Coordinator Gina Schmidt Direct Line: (312) 445-5701 Email: gschmidt@acoep.org MEDIA AND TECHNOLOGY

Webinar Coordinator George Reuther Direct Line: (312) 445-5714 Email: greuther@acoep.org

Association Editor Erin Sernoffsky Direct Line: (312) 445-5709 Email: esernoffsky@acoep.org

EVENTS

Director Adam Levy Direct Line: (312) 445-5710 Email: alevy@acoep.org

Media and Technology Specialist Tom Baxter Direct Line: (312) 445-5713 Email: tbaxter@acoep.org

Senior Meetings Coordinator Lorelei N. Crabb Direct Line: (312) 445-5707 Email: lcrabb@acoep.org

FOEM Beacon | January 2015 masthead_Layout 1 4/18/13 10:24 AM Page 1

• A FOUNDATION DEDICATED TO RESEARCH IN OSTEOPATHIC EMERGENCY MEDICINE

Foundation Focus Sherry D. Turner, DO, FACOEP President ACOEP’s elite presented dozens of awards, and by the end of the night, over $30,000.00 was raised in support of FOEM’s mission. Thank you to all who attended and donated, and congratulations to our 2014 Honorees! President’s Circle Award ($10,000 and above Lifetime Donor) Robert E. Suter D.O., MHA, FACOEP-D, FACEP, FIFEM Pillar Award ($5000 and above Lifetime Donor) Joseph J. Calabro D.O., FACOEP-D Mark A. Mitchell D.O., FACOEP Bryan Staffin, D.O., FACOEP-D

Supporting Sponsor:

Friend Sponsors:

n October 13 the Foundation for Osteopathic Emergency Medicine held its annual Legacy Gala: Dinner & Awards Ceremony in the spectacular ballroom of Caesar’s Palace in Las Vegas, NV. Not only did the glittering event feature genuine Las Vegas showgirls, a multi-media awards show, private gaming tables, a red carpet, and a professional photographer, there was also reason to celebrate: a room full of donors, supporters, and researchers. FOEM and

Partner Level ($2,500 and above Lifetime Donor) Fahim Shan Ahmed D.O., M.S., FACOEP, FACEP Rudolph D. Bescherer D.O., FACOEP Donald G. Beyer D.O., FACOEP Thomas Brabson D.O., MBA, FACOEP-D Bernadette P. Brandon D.O., FACOEP Gregory M. Christiansen D.O., M.Ed., FACOEP-D Jack B. Field D.O. Christine F. Giesa D.O., FACOEP-D Drew A. Koch D.O., MBA, FACOEP-D William Lynch Steven J. Parrillo D.O. FACOEP-D Jon Pierre Pazevic D.O., FACOEP John C. Prestosh D.O., FACOEP Theodore A. Spevack D.O., FACOEP-D 100% Program Challenge Ohio Valley Medical Center

FOEM Research Flame Award McLaren Medical Center – Macomb FOEM Research Study Poster Competition Sponsored by: 3 rd Place: Richard Welch D.O of Edward Sparrow for “The accuracy of emergency medicine resident physicians to correctly interpret commuted tomography imaging by level of training” 2 nd Place: Ashley Debarba, D.O. of Midwestern for “the correlation of need for physical restraints and involuntary parenteral medications with psychiatric patient boarding times in the ED” 1 st Place: Jeremy Kadish D.O. of St. Luke’s for “STABCric (Surgical technique against bougie cricothyrotomy” FOEM Clinical Pathological Case Competition Sponsored by: 3 rd Place Faculty: Nicole Maguire, D.O., FACOEP of Newark Beth Israel Medical Center 3rd Place Resident CPC: Karan Parmar, D.O. of St Barnabas Hospital 2 nd Place Faculty: Blanca Grand, D.O. of St Barnabas Hospital 2nd Place Resident: Mathiew Weigand, Continued on Page 26

Annual Run for Research

& 1-Mile DO Dash

Wednesday, April 8, 2015

Join the Foundation for Osteopathic Emergency Medicine at The Edge: Spring Seminar 2015 in Fort Lauderdale, FL! Annual Run for Research 5K and 1-Mile DO Dash Wednesday, April 8, 2015 at 6:00 a.m. Get up early and get the blood flowing for a good cause! All conference attendees and their families – from walkers and novice runners, to seasoned marathoners – are welcome to join the FOEM 5K Run for Research!

RATES • Early bird rate: $40 • Early bird rate for students, residents and family: $20 • One Mile D.O. Dash Rate: $15 • Regular rate after February 1, 2015: $50 for attending physicians. $30 for Students, Residents, and Family. All rates include a t-shirt!

If running a 5K isn’t your speed, take part in the 1-mile DO Dash, new this year! Runners and walkers alike will all receive a dry-fit race shirt.

All Proceeds will benefit FOEM! For more information or to register for an event, please contact Stephanie Whitmer at swhitmer@foem.org or 312.587.1765

Case Study Poster Competition Wednesday April 8, 2015 From 12:30 – 5:00 p.m. The Foundation for Osteopathic Emergency Medicine is proud to present the annual Case Study Poster Competition, in which students and residents present interesting or unique cases that have presented at their hospital. Winners receive certificates, cash prizes, and recognition in FOEM publications throughout the year. The deadline for submission of applications and abstracts is January 31, 2015. For more information on how to participate, please contact Stephanie Whitmer at swhitmer@foem.org or 312.587.1765

FOEM Beacon | January 2015

"Foundation" continued from page 24 D.O. of Henry Ford Macomb 1 st Place Faculty: Jennifer Axelband, D.O., FACOEP of St Luke’s Hospital 1st Place Resident: Neeraja Murali, D.O. of McLaren Oakland FOEM Oral Abstract Competition 3rd Place: Deep Desai, D.O. of Newark Beth Israel for “Urinary Tract Infection Resistance in Newark and Treatment Efficacy” 2 nd Place: Michelle Ischayek, D.O. of Aria Health for “Comparison of Serum Specific Pancreatic Amylase vs. Serum Lipase in the Diagnosis of Acute Pancreatitis” 1 st Place: Sammie Margaritas D.O. of Midwestern University for “The Effect of Psychiatric Patient Boarding Times in the Emergency Department Following Closure of a Public Psychiatric Hospital” FOEM Research Study Paper Competition Sponsored by:

3 rd Place (tie): Mikaela Bowers, D.O. of Midwestern University for “Comparison of the Number of Admissions of Psychiatric Patients from the Emergency Department to State-Operated Facilities Before and After the Closing of Various State-Funded Facilities within a Large Metropolitan Area: a Retrospective Chart Review” J onathan Taylor, D.O. of St. Vincent Hospital for “Factors Associated with Delayed Evaluation of Patients with Potential Stroke in United States Emergency Departments” 2 nd Place: Andrea Skye Drenguis, D.O. from St. Vincent Hospital for “GlideScope Versus C-MAC for Awake Upright Laryngoscopy” 1 st Place: Brian Taylor, D.O. of Lakeland Regional Medical Center for “TIMI Reliance in a General Emergency Department Chest Pain Unit (TRIAGED CPU)” Winning Abstracts Research Study Poster Competition Sponsored by: “STABCric (Surgical Technique Against Bougie Cricothyrotomy”

Jeremy Kadish D.O. of St. Luke’s Hospital for STABCric: Surgical Technique Against Bougie Cricothyrotomy Introduction: Performing a surgical airway is a last resort heroic measure when a physician cannot ventilate nor intubate a patient. This observational study examines if the bougieassisted cricothyrotomy is easier to learn and faster to perform than the classically taught open surgical method. Methods: This is a single center randomized observational cross-over study comparing the traditional surgical to bougie assisted cricothyrotomy methods. This study was reviewed by the St. Luke’s University Hospital IRB and found to be exempt. Twelve medical students (MS3 and MS4) volunteered and were randomized to one of the two techniques prior to watching an educational video describing and demonstrating that specific technique. After the video, each student performed their assigned cricothyrotomy method on a pig trachea. These pig tracheas were obtained fresh and inspected for appropriate anatomy prior to use. An appropriately sized section of fresh pig skin was sutured to the trachea to more realistically represent a human neck. After a four-week washout period, the same students were brought back to watch the video of the remaining technique and then perform it on a pig trachea. We measured video viewing times as individuals were allowed to rewind and watch the video for as long as they felt necessary for competence. We also measured time for correct endotracheal tube placement and recorded bronchoscopic video of the procedure to assure correct tube placement. After each successful endotracheal tube placement, the pig trachea was dissected by a single trained investigator then inspected for incision entrance point and tracheal wall damage. The primary outcome measure was time to correct endotracheal tube placement. We are also reporting the time spent to learn each technique, an important secondary outcome measure. Results: Our sample size was twelve including seven MS3 level students and five MS4 level students. Data was entered into SPSS v22 (IBM Corporation, Armonk NY) for analysis. Wilcoxon signed rank test was chosen to compare time to endotracheal tube placement as well as time spent learning each technique. Median time to placement for open surgical vs bougie-assisted was 310.5 seconds (IQR 235.75 – 418.5) vs 195.5 seconds (IQR 162.75 – 284.5) respectively. This was found to be significantly different; p=0.034. Median time to learn for open surgical vs bougie-assisted technique was 339 seconds (IQR 287.25 – 436.75) vs 249.5 seconds (IQR 166.75 – 300.75) respectively. This was also found to be significantly different;

p=0.005. Conclusion: This novel bougie-assisted method is both more rapidly learned as well as more rapidly performed by novice learners compared to the traditionally taught open surgical cricothyrotomy. While this is a small pilot study, our results suggest that the bougieassisted technique should be the preferred technique to teach to novice learners who may be required to perform an emergent cricothyrotomy during their career. A larger study which is sufficiently powered will be required to verify these conclusions. Oral Abstract Competition 1st Place: Sammie Margaritas D.O. of Midwestern University for “The effect of psychiatric patient boarding times in the emergency department following closure of a public psychiatric hospital” Abstract Title: The effect of psychiatric patient boarding times in the Emergency Department following closure of a public psychiatric hospital Authors: Samantha Margaritis, BS, OMSIII; Ryan Misek, DO; Ashley DeBarba, DO; April Brill, DO FACOEP Objective: Recently, a 75-bed state operated inpatient psychiatric hospital closed near our hospital system. We analyzed the effect of closing this public mental health facility on psychiatric patient boarding times in the Emergency Department (ED). Methods: We performed a retrospective multicenter cohort study of all patients assessed to require inpatient psychiatric hospitalization at two community EDs from July 1, 2010 through May 10, 2013. All patients requiring inpatient psychiatric hospitalization were included. Exclusion criteria consisted of patients under 18 years of age, patients over 65 years of age, patients requiring medical stabilization prior to transfer, pregnant patients, and patients discharged from the ED prior to transfer to a psychiatric facility. A total of 1,108 patients qualified and time of arrival, time of disposition and time of transfer were collected along with insurance status and accepting facility type. Using SPSS software, a two-sample t-test with correction for unequal variance analyzed boarding times before and after the psychiatric hospital closure on July 1, 2012. Results: We found a statistically significant difference in the boarding times of patients transferred to a private psychiatric facility

FOEM Beacon | January 2015

following closure of the public psychiatric hospital (t= -3.086, P=0.002, df= 666.134). There was no significant difference between patient boarding time before and after closure when transferred to either a public or private psychiatric hospital (t= -.133, p= .894). The mean number of minutes before and after the closure was 752.46 and 758.36 respectively. Subgroup analysis identified a statistically significant increase in boarding time of patients with private medical insurance (t= -2.530, P=0.012, df= 251.429) and Medicaid/Medicare (t= -2.087, P=0.037, df= 470) following closure. There was a statistically significant difference in boarding times before transfer to public versus private psychiatric hospitals both before (t=17.276, P=0.000, df=661) and after (t=-13.795, P=0.000, df=440) the hospital closure. Conclusion: Although there was no statistically significant difference in overall psychiatric patient boarding in the ED following closure of a public mental health hospital, we did find that patients who were transferred to private psychiatric facilities experienced longer ED boarding times following the closure. We also identified a statistically significant correlation of increased boarding times in both Medicaid/Medicare and privately insured patient groups following closure of the state funded hospital. This study highlights the significant impact that the closure of a single inpatient psychiatric facility can have on nearby emergency departments. We hope to bring attention to the need for increased psychiatric services during a time when there is a nationwide trend towards the reduction of available inpatient psychiatric beds. Research Paper Competition Sponsored by:

assessed whether TIMI risk scores obtained by ED providers in the setting of a busy ED differed from those obtained by trained research investigators. Methods This was an ED-based prospective observational cohort study comparing TIMI scores obtained by 49 ED providers admitting patients to an ED chest pain unit (CPU) to scores generated by a team of trained research investigators. Provider type, patient gender, and TIMI elements were examined for their effects on TIMI risk score discrepancy. Results Of the 501 adult patients enrolled in the study, 29% of TIMI risk scores determined by ED providers and trained research investigators were generated using identical TIMI risk score variables. In our low risk population the majority of TIMI risk score differences were small, however 12% of TIMI risk scores differed by two or more points. Conclusion TIMI risk scores determined by ED providers in the setting of a busy ED frequently differ from scores generated by trained research investigators who complete them while not under the same pressure of an ED provider. ED providers should not be expected to produce TIMI scores identical to those of trained research investigators. Keywords: acute coronary syndrome; standard of care; cardiology; TIMI score; chest pain unit INTRODUCTION

TIMI Reliance in a General Emergency Department Chest Pain Unit (TRIAGED CPU) Brian Taylor, DO; Michelino Mancini, DO ABSTRACT Objective Several studies have attempted to demonstrate that the Thrombolysis in Myocardial Infarction (TIMI) risk score has the ability to risk stratify Emergency Department (ED) patients with potential acute coronary syndromes (ACS). Most of the studies we reviewed relied on trained research investigators to determine TIMI risk scores rather than ED Providers functioning in their normal work capacity. We

ECG results, biomarker assays, patient history and clinical acumen, 0.4-5% of patients with acute myocardial infarction are inadvertently discharged from the ED.7-14 Absence of ECG changes, biomarker assays, or history of heart disease does not entirely exclude the diagnosis of Non-ST-elevation ACS. In an effort to improve outcomes in patients with acute coronary syndromes, researchers have developed numerous risk stratification tools.15-57 Of all the risk stratification systems developed, the Thrombolysis in Myocardial Infarction (TIMI) risk score is the most studied, supported and utilized.3,7,58,59 A patient’s TIMI risk score is determined by assigning a value of 1 for each of seven equally weighted prognostic variables with the total score determining a patient’s risk of adverse cardiac outcome (death, MI, severe recurrent ischemia requiring revascularization) within 14 days of presentation. TIMI risk score variables include a patient’s age, presence of known coronary artery stenosis, aspirin use in the past week, frequency of angina episodes, ECG and cardiac marker changes, and risk factors for coronary artery disease (hypertension, diabetes, family history of premature coronary artery disease, elevated cholesterol, and smoking). The TIMI risk score was originally derived from a retrospective analysis of a relatively high-risk population of patients with known unstable angina/NSTEMI.15 In this patient population the TIMI risk score was associated with 4.7% to 40.9% (or greater) risk of adverse cardiac outcome (Figure 1).15 Following the development of the TIMI risk score tool, several studies were performed validating the tool’s ability to stratify risk among patients with cardiac disease.16,60-62

Though not originally designed for ED use, several additional studies have attempted Chest pain is the second most common to demonstrate the TIMI risk score’s complaint of patients presenting to emergency ability to stratify risk among real-world ED departments (ED) in the United States, populations.7,17-21,63-68 As a result of these accounting for approximately seven million 1 visits annually. Early deter mination of TIMI risk Risk at 14 days of death, MI, or severe whether a patient’s chest score recurrent ischemia requiring urgent pain origin is cardiac versus noncardiac is revascularization imperative. Patients 0-1 4.7 % diagnosed early with 2 8.3 % acute coronary diseases (ACS) may benefit from 3 13.2 % early interventions. 2-6 4 19.9 % A missed diagnosis 5 26.2 % of ACS may result in wrongful discharge, 6-7 at least 40.9 % myocardial infarction Figure 1. TIMI risk score. and sudden death. (Table adapted from Antman et al.)15 Despite utilization of

FOEM Beacon | January 2015

studies, the TIMI risk score tool has made its way into the protocols of Emergency Departments and hospitals around the world, often determining whether a patient is admitted to a hospital, observation unit or discharged home.64 The TIMI risk score is promoted for being simple to remember, easy to determine using data readily available during an acute presentation, and for its ability to be applied early in a clinical course.4,64,69 In addition to assisting with triage and disposition decisions, the TIMI risk score improves the exchange of information between ED physicians and cardiologists.65,70 Importance For many reasons, complete and accurate TIMI risk scores can be difficult to obtain when patients present with chest pain to a busy ED. Several studies have demonstrated how interruptions, distractions, and workload affect an ED provider’s ability to maintain thought flow and increase the likelihood of errors occurring.71-74 Pines et al75 suggest that patients presenting to the ED during times of increased ED crowding are at greater risk for adverse cardiovascular outcomes. Inaccurate TIMI risk scores may result in inaccurate risk stratification, as well as ineffectual or inappropriate management of patients with nonspecific chest pain. Most studies validating the utility of the TIMI risk score among ED populations utilized trained research investigators or a combination of trained researchers and ED providers to generate TIMI risk scores.7,17,18,20,23,63 Trained research investigators do not work under the same time constraints and in the same distracted environment as a working ED Provider. Trained research investigators have the benefit of spending more time interviewing patients, reviewing medical records, scrutinizing ECG patterns, and reviewing their own scores for errors and clarification.7,17 Unfortunately, the ED provider does not usually have a trained research investigator at his or her disposal to determine accurate TIMI risk scores. Our review of the literature found very few prospective studies utilizing ED Providers exclusively as assessors for the TIMI risk score. In the select studies where ED providers assessed TIMI risk scores, their scores were not compared against those of trained study investigators for accuracy or validity.64,65 Current guidelines from the American College of Cardiology, American Heart Association, and National Institute for Health and Clinical Excellence strongly encourage the use of early risk stratification tools such as the

TIMI risk score when patients present to health care providers with chest pain.2-4,76 In addition, Gallegher et al77 suggests the possibility of medicolegal pitfalls by providers not utilizing risk stratifying tools when assessing patients for evidence of ACS. As a result, the TIMI risk score tool is increasingly being used by ED providers as a basis for therapeutic decisionmaking despite a lack of supporting studies using ED provider-obtained data. Outcomes of Interest

• Patients with ST-elevation acute myocardial infarction (STEMI) • Positive Cardiac Biomarkers suggestive of myocardial injury • ECG changes • Unrelenting chest pain • Coronary Revascularization in the last 60 days • Abnormal vital signs • New dysrhythmia (any run of ventricular dysrhythmia is not a candidate for the CPU) • Aortic dissection • Pneumothorax • Pneumonia • Esophageal rupture • Pulmonary Embolism • Pericardial tamponade • CHF • Uncontrolled diabetes

• Electrolyte abnormalities that cannot be cared for with PO The primary goal electrolyte replacement of our study was to • Psychiatrically unstable determine if TIMI risk • Patients unable to perform activities of daily living scores obtained by ED providers in the setting • Pleural effusions of a busy ED differ • Renal failure requiring dialysis during their time in the CPU substantially from those • Any diagnosis meeting admission criteria obtained by trained research investigators who complete them Figure 2. LRMC Chest Pain Unit exclusion criteria. while not under the same pressure of a working ED provider. In because the data collected was normal data addition, we evaluated whether ED provider already being obtained and charted during the type or patient gender had any effect on TIMI normal course of an ED provider’s work, and risk score discrepancy, which aspects of the could be collected anonymously. TIMI risk score most frequently differ between assessors, and whether lower TIMI risk scores Study Setting and Population (i.e., 0-3) or higher TIMI risk scores (i.e., >3) more frequently match research investigator LRMC is an academic-based community scores. hospital with an annual ED census of approximately 50,000 patients. The hospital’s This is the first study we are aware of 6 bed CPU opened in 2010 and is situated that evaluates how closely TIMI risk scores adjacent to the ED. The CPU is under generated by ED Providers obtained in the the direct supervision of ED providers. All normal course of their work match those ED providers admitting patients to the CPU obtained by trained research investigators, from October 27, 2012 until July 28, 2013 specifically when applied to patients admitted were included in the study. Participating ED to a hospital’s chest pain unit (CPU). providers included 18 Attending Physicians, 21 Resident Physicians and 10 Midlevel Providers METHODS (Physicians Assistants and Nurse Practitioners). No ED providers were excluded from the study. Study Design Patient inclusion criteria included all comers presenting to the ED with non-traumatic chest This was a prospective observational cohort pain suggestive of ACS who were admitted study comparing TIMI scores obtained by to our hospital’s CPU, irrespective of age. At ED providers admitting patients to the CPU our institution, ED providers independently at Lakeland Regional Medical Center (LRMC) determine who is to be placed in the CPU. to scores generated by trained research TIMI risk scores are not typically used in the investigators. The Lakeland Healthcare decision to place patients in the CPU. Patient Institutional Review Board approved the study exclusion criteria for study enrollment mirrored without need for written informed consent CPU exclusion criteria as set by the hospital’s

FOEM Beacon | January 2015

• Age • Presence of known coronary artery stenosis ≥50%* • Prior cardiac catheterization with known disease • Prior MI, CABG, angioplasty, or stent • Aspirin use in the preceding 7 days • At least 2 episodes of severe chest pain within last 24 hrs • ST changes ≥0.5mm on admission ECG • Initial serum cardiac biomarker elevation (Troponin I above normal range) • At least 3 of the following risk factors for Coronary Artery Disease (CAD): • High blood pressure (≥140/90 or on antihypertensive medicine) • Diabetes, prediabetes, or hyperglycemia • Family history of premature CAD or MI (CAD in male 1st-degree relative, or father <55, or female 1st-degree relative or mother <65) • Elevated LDL (≥100), reduced HDL (≤40for men, <50 for women), elevated triglycerides (≥150) • Smoking in the past 5 years** • ED provider type (Attending Physician, Resident Physician or Midlevel Provider) • Confirmation of blinding to ED provider TIMI risk score * Similar to Pollack et al65, this parameter was expanded in our study because actual cardiac catheterization reports were not always available in the ED. ** 5 years was chosen as a cut-off because risk associated with smoking has been found to diminish after 5 years.78-80 Figure 3. Variables assessed by research investigators. Chest Pain Center Door-to-Balloon Committee in accordance with recommendations from the Society of Cardiovascular Patient Care (Figure 2). The CPU is open 24 hours a day, 7 days a week and on holidays, with research investigators available 24 hours a day to enroll patients. Study Protocol Research investigators consisted primarily of nurses already trained to care for CPU patients. Prior to data collection, these research investigators received additional training on how to obtain TIMI risk scores. Their standardized training involved handouts, Microsoft Office PowerPoint presentations, and one-on-one training with clarification

to ensure unambiguous collection of data. Research investigators were instructed to use all resources available to them including a patient’s hospital record, accessible outside records, labs, prior cardiac catheterization reports, cardiology notes, and patient reported responses. Research investigators routinely evaluated the patient and assessed TIMI risk score variables within 24 hrs of a patient’s presentation to the ED (Figure 3). In situations where patients were unaware or unable to answer questions concerning pertinent medical history (for example, an adopted patient unaware of his or her family history), patients were not given any points for those variables. Our goal for the research investigator was not to obtain 100% infallible TIMI scores, but

rather to generate scores as close as possible to scores assigned by research investigators performing similar TIMI risk score validation studies. Separately, ED providers assigned TIMI risk scores to all patients admitted to the CPU at the time of CPU admission per hospital protocol and the ED provider’s normal routine (typically following the results of initial ECG and biomarker tests). No additional TIMI training or education was provided to ED providers prior to data collection. ED provider TIMI scores were recorded electronically in the patient’s EpicCare electronic health record in a location research investigators were told not to access. In addition, research investigators confirmed blindness by recording whether or not they had prior knowledge of the ED provider’s TIMI risk score for each patient. Research investigator data was hand written on a standardized data collection form and placed in a secure folder in the CPU area inaccessible to ED providers. In this way, research investigators and ED Providers were blinded to one other’s TIMI risk scores throughout the study. Data Analysis Upon completion, the pertinent data was extracted from patient charts and data collection forms and entered into a database using Microsoft Office Access 2007. The data was then exported into a Microsoft Office Excel 2007 spreadsheet. We used SPSS software to make comparisons of TIMI risk scores obtained by research investigators and ED providers. Where significance testing was reported, variables were analyzed using the Pearson Chi-Square test. RESULTS

TIMI Score

Researcher n

ED provider n

ED provider score matches researcher score

Range of TIMI Discrepancy

54 (56.3%)

-4

-3

0.8

130

121

48 (36.9%)

109

34 (37.0%)

33 (37.1%)

38 (53.5%)

5 (22.7%)

1 (100%)

0 (100%)

Total Patients

501

213 (42.5%)

% of Total scores

-2

5.4

-1

125

25.0

0 (Matching)

213

42.5

103

20.6

5.0

0.8

Total

501

100

Table 2. Discrepancy between ED Provider and Researcher TIMI scores.

Table 1. Research investigator and ED provider TIMI scores.

FOEM Beacon | January 2015

Age ≥65

Researcher n (%)

ED provider n (%)

166 (33.1%)

167 (33.3%)

Positive n (ED/R)

Negative n (ED/R)

p value

Age ≥65

166/166 (100%)

334/335 (99.7%)

0.000

104/149 (69.8%)

338/352 (96.0%)

0.000

Known CAD

149 (29.7%)

118 (23.6%)

Known CAD

ASA use

239 (47.7%)

254 (50.7%)

ASA use

181/239 (75.7%)

189/262 (72.1%)

0.000

207 (41.3%)

126 (25.1%)

Angina

59/207 (28.5%)

227/294 (77.2%)

0.147

9 (1.8%)

7 (1.4%)

ECG Changes

2/9 (22.2%)

487/492 (99.0%)

0.000

21 (4.2%)

10 (2.0%)

Elevated Trop

7/21 (33.3%)

477/480 (99.4%)

0.000

190 (37.9%)

274 (54.7%)

173/190 (91.1%)

210/311 (67.5%)

0.000

Angina ECG changes Elevated Trop CAD risk factors

Table 3. Incidence of TIMI variables.

The patient population consisted of 543 patients who presented to the ED with symptoms suspicious for cardiac chest pain and were admitted to the CPU. Research investigators provided all variables used to form the TIMI risk score for 543 patients. ED providers provided the necessary variables for 501 patients. Because some ED providers did not record TIMI scores for every patient, we only have complete data for 501 patients. Of these 501 patients, 277 were female and 224 were male. The mean age of the patient study population was 59 (ages 18 to 94), median age 57. Though the frequency distributions for research investigators and ED providers were similar, the two scores often did not match for a given patient (Table 1). In fact, of the 501 patients in the study with complete data, ED provider and researcher TIMI risk scores matched for only 213 patients (42.5%). Of the 213 patients with the same TIMI scores, only 147 scores were determined using identical TIMI variables. For example, one patient was given a TIMI score of 1 by both the research investigator and ED provider. On further analysis, however, the research investigator gave a point for aspirin use over the past 7 days, while the ED provider gave a point for having 3 or more risk factors for CAD. Further breakdown of TIMI scores revealed that scores differed by 1 point for 228 patients (45.5%), 2 points for 52 patients (10.4%), and 3 points for 8 patients (1.6%). No scores varied by more than 3 points (Table 2). Table 3 shows the incidence of TIMI variables as reported by research investigator and ED provider. The frequencies of several variables were similar, such as “Age ≥65”, “Aspirin use”, “ECG changes”, and “Elevated Troponin”. Research investigators reported a greater incidence of “Known CAD” and “Angina”, while ED providers reported a greater prevalence of “CAD Risk Factors”.

CAD Risk Factors

(ED= ED provider, R=Research Investigator) Table 4. TIMI variable agreement (ED provider variable matched research investigator variable for the same patient). Our analysis shows that salient disagreements in TIMI variables exist between ED providers and research investigators. For example, ED providers reported the incidence “Angina” in only 59 of 207 patients (28.5%) determined by research investigators to have had “Angina”. Additionally, ED providers reported “Angina” as being present in 67 patients not reported by research investigators. Table 4 shows how often research investigators and ED providers agreed on reported variables, with their relative significance. Additional analysis was performed based on ED provider type assessing the TIMI score (Attending Physician, Resident Physician or Midlevel Provider). Attending Physicians determined the scores for 183 patients, Resident Physicians scored 225 patients, and Midlevel Providers scored 93 patients. Overall TIMI risk score determinations were similar across all provider types. TIMI scores matched 43.2% of researcher scores for Attending Physicians, 42.7% for Resident Physicians, and 40.9% for Midlevel Providers (Table 5). When discrepancies occurred, Attending Physicians and Midlevel Providers reported slightly lower TIMI scores, while Resident Physicians reported slightly higher TIMI scores (Figure 4). Further analysis shows that gender has little effect on TIMI score differences. ED provider scores agreed with research investigator scores for 112/277 female patients (40.4%) and for 103/224 male patients (46.0%). Because the CPU at our institution is utilized to screen a population of patients at low-risk for ACS, far more low TIMI scores (TIMI 0-3) were generated. Based on the scores obtained by research investigators, 407 patients presenting to the CPU had TIMI scores 0-3, while only 94 had TIMI scores >3. There was no difference in the frequency of ED provider scores matching researcher scores on the basis of the number of variables involved (Table 6).

DISCUSSION This study demonstrated that a majority of TIMI scores as determined by ED providers in the setting of a busy ED differ from scores generated by trained research investigators who complete them while not under the same pressure of an ED provider. In our study only 29.3% of TIMI scores were calculated using identical TIMI risk score variables. The majority of TIMI risk score differences were either negligible (same TIMI risk score obtained despite differing TIMI variables used) or diverged by no more than 1 point in our low risk patient population; however, 12% of patient scores differed by two or more points. We have shown that ED provider type has little effect on the likelihood of TIMI risk scores matching TIMI scores obtained by trained research investigators. Neither the patient gender nor the quantity of positive variables had a significant effect on TIMI risk score differences. Patient age was the variable most agreed upon by TIMI risk score assessors with only one instance of an ED Provider incorrectly giving a point to a 57 y/o for being ≥65 y/o. TIMI variables requiring more active investigation showed greater variation. Researchers reported greater incidence of known CAD, possibly due to having more time available to review patient records and interview the patient. ED providers were apt to report a greater incidence of ≥3 CAD risk factors. Confirmation bias (or myside bias) is one potential reason for this. For example, in ascertaining the presence of multiple CAD risk factors (a time consuming task), an ED provider might assume that when one or two risk factors are present, such as smoking and hypertension, other risk factors are likely present as well. Unfortunately, the TIMI risk score recorded in the electronic medical record by our ED providers simply shows when ≥3 CAD risk factors are present

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Range of TIMI Discrepancy from Researcher Score

Attending Physician n

Resident Physician n

Midlevel Provider n

-3

2 (1.1%)

2 (0.9%)

0 (0.0%)

-2

15 (8.2%)

7 (3.1%)

5 (5.4%)

-1

50 (27.3%)

47 (20.9%)

28 (30.1%)

0 (Matching)

79 (43.2%)

96 (42.7%)

38 (40.9%)

31 (16.9%)

54 (24.0%)

18 (19.4%)

6 (3.3%)

15 (6.7%)

4 (4.3%)

0 (0.0%)

4 (1.8%)

0 (0.0%)

Total Patients Scored

183

225

Table 5. Range of TIMI score discrepancy from research investigator by ED provider type and does not further categorize which CAD risk factors were recognized by the ED provider. ECG changes and biomarker elevations were seldom present in our study, likely reflecting the low-risk nature of our CPU study population. Research investigators reported a few more instances of ECG and biomarker changes than were reported by ED providers, though not statistically significant (p = 0.000). Both ED providers and research investigators reported similar numbers of aspirin users among our population, however only 75.7% of these patients matched. 73 patients recognized by ED providers as having taken aspirin went unrecognized by our research investigators. Likewise, research investigators reported an additional 58 patients who ED providers said had not taken aspirin. Similar to aspirin, there was a discrepancy in the reporting of angina episodes. Researchers, who had the benefit of spending more time with patients, reported far more occurrences of angina than ED providers (207 to 126 occurrences). ED providers only recognized 59 of the 207 patients (28.5%) designated as having had angina by research investigators. Interestingly, ED providers reported angina as being present in 67 patients who research investigators did not feel met criteria for angina. There are many barriers to obtaining accurate histories from patients.81-83 Patients who present to the ED in chest pain often do so under great duress, likely compounding the already difficulty job of extracting accurate history. Studies have shown that patients in stressful situations have impairments in cognition, memory and verbal recall.84-85 Many clinicians recognize the phenomenon of the contradictory account, where the second person to interview a patient obtains an entirely different story. Perhaps in recognition of this, Hess et al17 excluded patients with unreliable history from his prospective study on TIMI

45 40

30 % Patients

Attending Physicians

Resident Physicians Midlevel Providers

15 10

-3

-2

-1

TIMI Variation

Figure 4. Range of TIMI score discrepancy from research investigator

Further analysis showstype that gender has little effect on TIMI score differences. ED provider by ED provider scores agreed with research investigator scores for 112/277 female patients (40.4%) and for 103/224 male patients (46.0%).

score validity in the ED. The variability of LIMITATIONS Because the CPU at our institution is utilized to screen a population of patients at low-risk for patient reported responses in the ED suggests ACS, far more low TIMI scores (TIMI 0-3) were generated. Based on the scores obtained by a need for risk stratification which 407 place Someto the researchers have researchtools investigators, patients presenting CPU had TIMI scoressuggested 0-3, while onlythat 94 had TIMI scores >3. Therecan was no difference in the biomarker frequency of ED providershould scores matching greater weight on objective variables which ECG and indices carry researcher scores onwith the basis number ofweight variablesininvolved (Table 6). be assessed independent of interviews theof the greater risk stratification scores.17,40 Modified TIMI risk scoring tools have been patient. Table 6. TIMI risk score divergence by range. developed which assign more points to ECG 17,40 Matching TIMI score risk the idea Researcher ED provider matches Because so few and biomarker variables. Many ED providers TIMI support of score n researcher TIMI with identical ECG and biomarker changes were present in utilizing a clinical prediction rule for the Range score variables difficult identification of ACS among 0 to 3 patients with407 our study it is169 (41.5%)to make generalizations 116 (28.5%) 44 (46.8%)ability to recognize 31 (33.0%)and chest discomfort in hopes4 toof6 offering early 94 on the ED providerâ&#x20AC;&#x2122;s Total86 A few recent501 assign a proper 213 147 those TIMI risk score for discharge to low risk patients. studies have suggestedDISCUSSION that a rapid TIMI risk variables. Though not significant, the few ECG score protocol can be to safely andofbiomarker recognized in our instudy This employed study demonstrated that a majority TIMI scoreschanges as determined by ED providers the setting of a busywith ED differ from scores generated by trained research investigators who complete discharge low risk ED patients chest were slightly underreported by ED providers, underThough the same pressure of anmay ED provider. study only of TIMI 22,23,86 discomfort home fromthem thewhile ED.not which reflect Inaour degree of 29.3% selection bias scores were calculated using identical TIMI risk score variables. The majority of TIMI risk score the TIMI risk score device has the potential to or simply differences in interpretation. It is differences were either negligible (same TIMI risk score obtained despite differing TIMI stratify risk among ED populations, our study possible that ED providers under-report some suggests that it may depend on how and by aspects of the TIMI risk score (such as angina, whom the TIMI risk score data is obtained. It ECG and biomarker changes) since they have is important that these studies, as well as any already deemed a patient low risk and not likely study suggesting validity and broad applicability suffering from true ACS by virtue of placing the of a risk stratification tool for regular use in the patient in the CPU. In addition, ED providers ED, be examined closely to determine if the may be less likely than research investigators to working data was obtained by ED providers report a Troponin I level at the very edge of the while working in their normal environment. We cutoff as â&#x20AC;&#x153;positiveâ&#x20AC;?, especially in a patient with commend validation studies such as Chase et known chronic renal insufficiency, for example. al64 and Pollack et al65 for using ED providers to determine risk scores and call for more similar We asked our research investigators to obtain studies. We also question the applicability of scores within 24 hours of patient presentation. studies which rely on data largely obtained by This was done in order to improve the trained research investigators in place of ED likelihood of obtaining complete data for the providers. majority of patients. We recognize that research investigators in other studies may have had TIMI risk score Range

Researcher n

ED provider matches researcher TIMI score

Matching TIMI score with identical variables

0 to 3

407

169 (41.5%)

116 (28.5%)

4 to 6

44 (46.8%)

31 (33.0%)

Total

501

213

147

Table 6. TIMI risk score divergence by range.

FOEM Beacon | January 2015

additional time to perform their investigations. While CPU nurses are capable and trainable, most CPU nurses have minimal experience participating in research and may not have performed to the same standard as professional research investigators. Research investigator TIMI risk score ECG interpretation was performed by our trained research investigators and not physicians well-versed in ECG interpretation. Many TIMI risk score validation studies include a patient cut-off age for enrollment, such as ≥30 years old.15 Because we were performing a comparison of risk scores and not examining patient outcomes, we did not feel that excluding patients by age was necessary. Although pertinent patient history was occasionally obtained directly from a patient’s cardiologist by phone or when visiting the CPU, we did not routinely obtain data in this manner. Most data was acquired using information readily available to the research investigator in the CPU setting, which is similar to what is available to the ED provider. Midway through the project some cardiologists released online access to their outpatient clinical electronic medical records including catheterization lab reports, providing additional means of data acquisition to researcher investigators. Prior to obtaining access to these records, data in question could sometimes be obtained via fax or telephone during regular business hours. As mentioned earlier, our researchers were not focused on obtaining infallible data. Where data was unknown and could not easily be produced we gave no points for those variables. Patient demographics may have also contributed to some study variation. Though predominantly English-speaking, our geographic area does contain some non-English speaking individuals which could have impeded an assessor’s ability to obtain a reliable history. Our study examined a specific cohort of low risk patients presenting to the ED with chest pain. CPU patients do not make up the entirety of patients presenting to the ED complaining of chest pain. Many times high risk patients with ACS are admitted directly to the hospital or cath lab, and patients with noncardiac etiologies of chest pain (such as trauma or rash) are discharged home. The results of our study may not be generalizable to all populations of patients presenting with chest pain to the ED, however there clearly exists a discordance of TIMI risk scores between ED providers and trained research investigators. CONCLUSION

Several studies and guidelines have been published suggesting that TIMI scores obtained in ED populations are valid.2-4,7,63,65,66,68,76 Our study demonstrates that there is discordance between TIMI scores generated by trained research investigators and busy ED providers. Our study questions the reliability, validity, and applicability of TIMI risk score validation studies where scores were ascertained predominantly by trained research investigators. ED providers should not be expected to produce TIMI scores identical to those of trained research investigators and until more validation studies are available, should continue to use sound clinical judgment in patients presenting to the ED with evidence of ACS. Areas for future research may include comparing time spent by ED providers and research assistants determining risk stratification scores, reliability of patient reported history in an ED environment, difficulties associated with access to outside medical records, effects of ED crowding and ED provider staffing on job efficiency, accuracy, and capacity for risk stratification, further risk tool validation studies using ED provider-obtained data, and studies evaluating all patients presenting to the ED with chest pain, not just CPU patients. Competing Interests

Correspondence Michelino Mancini, DO, Department of Emergency Medicine, Lakeland Regional Medical Center, 1234 Napier Ave, Saint Joseph, MI, 49085. REFERENCES 1.

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None to declare. Acknowledgements We thank Jerome Thayer, PhD, at Andrews University for assistance with the statistical analysis used in this study and Tim Taylor, MA, at Sacramento City College, for database development and technical support. We also thank the Chest Pain Unit nursing staff at Lakeland HealthCare for their assistance in making this study possible. Contributors BT and MM were responsible for conception and design of this study. BT conducted the literature search and article review, as well as acquired, managed, analyzed and interpreted the data, trained research investigators, and wrote the manuscript. MM supervised the project, reviewed the manuscript and approved the final version submitted for publication. Funding This study was funded by a grant from Michigan State University – College of Osteopathic Medicine, Statewide Campus System Research Mini-Grants Program for Resident Research Projects.

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34. Christenson J, Innes G, McKnight D, et al. A clinical prediction rule for early discharge of patients with chest pain. Ann Emerg Med. 2006; 47:1-10. 35. Campbell CF, Chang AM, Sease KL, et al. Combining Thrombolysis in Myocardial Infarction risk score and clear-cut alternative diagnosis for chest pain risk stratification. Am J Emerg Med. 2009; 27:37-42. 36. Rubinshtein R, Halon DA, Gaspar T, et al. Usefulness of 64-slice cardiac computed tomographic angiography for diagnosing acute coronary syndromes and predicting clinical outcome in emergency department patients with chest pain of uncertain origin. Circulation. 2007; 115:1762-8. 37. Hollander JE, Chang AM, Shofer FS, McCusker C, Baxt W, Litt H. Coronary computed tomographic angiography for rapid discharge of low-risk patients with potential acute coronary syndromes. Ann Emerg Med. 2009; 53:295-304. 38. Hollander JE, Chang AM, Shofer FS, et al. One year outcomes following coronary computerized tomographic angiography for evaluation of emergency department patients with potential acute coronary syndrome. Acad Emerg Med. 2009; 16:693–8. 39. Hoffmann U, Bamberg F, Chae CU, et al. Coronary computed tomography angiography for early triage of

patients with acute chest pain: the ROMICAT (Rule Out Myocardial Infarction using Computer Assisted Tomography) trial. J Am Coll Cardiol. 2009; 53:1642-50. 40. Body R, Carley S, McDowell G, et al. Can a modified thrombolysis in myocardial infarction risk score outperform the original for risk stratifying emergency department patients with chest pain? Emerg Med J. 2009; 26:95-9. 41. Gatien M, Perry JJ, Stiell IG, Wielgosz A, Lee JS. A clinical decision rule to identify which chest pain patients can safely be removed from cardiac monitoring in the emergency department. Ann Emerg Med. 2007; 50136-143. 42. Kim JH, Jeong MH, Ahn Y, Kim YJ, Chae SC, Seong IW, Kim CJ, Cho MC, Seung KB, Park SJ, et al. A novel risk stratification model for patients with nonST elevation myocardial infarction in the Korea Acute Myocardial Infarction Registry (KAMIR): Limitation of the TIMI risk scoring system. Chonnam Med J. 2011 April; 47(1):20-26. DOI: 10.4068/cmj.2011.47.1.20. 43. Carmo P, Ferreira J, Aguiar C, Ferreria A, Raposo L, Gonclaves P, Brito J, Silva A. Does continuous ST-segment monitoring add prognostic information to the TIMI, PURSUIT, and GRACE risk scores? Ann Noninvasive Electrocardiol. 2011; 16(3):239-249. 44. Gonclaves PA, Ferreira J, Aguiar C, Seabra-Gomes R. TIMI, PURSUIT, and GRACE risk scores: sustained prognostic value and interaction with revascularization in NSTE-ACS. European Heart Journal. 2005; 26:865872. DOI: 10.1093/eurheartj/ehi187. 45. Bracco C, Melchio R, Sturlese U, Pomero F, Martini G, Poggi A, Cena P, Severini S, Castagna E, Brignone C, Serraino C, Dutto L, Veglio F, Fenoglio L. Early stratification of patients with chest pain and suspected acute coronary syndrome in the Emergency Department. Minerva Med. 2010 Apr; 101(2):73-80. 46. Zairis MN, Lyras AG, Makrygiannis SS, Beldekos DJ, Mainas KA, Patsourakos NG, Ampartzidou OS, Adanopoulou EN, Prekates AA, Argyrakis SK, Foussas SG. Continuous 12-lead electrocardiographic ST monitoring adds prognostic information to the Thrombolysis In Myocardial Infarction Risk Score in patients with non-ST-elevation acute coronary syndromes. Clin Cardiol. 2005; 28:189-192. 47. Manenti ERF, Bodanese LC, Camey SA, Polanczyk CA. Prognostic value of serum biomarkers in association with TIMI risk score for acute coronary syndromes. Clin Cardiol . 2006; 29:204-210. 48. Eagle KA, Lim MJ, Dabbous OH, et al., GRACE Investigators. A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry. JAMA. 2004; 291:2727-33. 49. Boersma E, Pieper KS, Steyerberg EW et al. for the PURSUIT Investigators. Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of 9461 patients. Circulation. 2000; 101:2557-2567. 50. Kurz DJ, Bernstein A, Hunt K et al. Simple point of care risk stratification in acute coronary syndromes: The AMIS model. Heart. 2009; 95:662-668. DOI:10.1136/ hrt.2008.145904. 51. Piombo AC, Gagliardi JA, Guetta J et al. A new scoring system to stratify risk in unstable angina. BMC Cardiovascular Disorders. 2003; 3(8).

FOEM Beacon | January 2015

52. Singh M, Reeder GS, Jacobsen SJ et al. Scores for post-myocardial infarction risk stratification in the community. Circulation. 2002; 106(18):2309-2314. 53. Morrow DA, Antman EM, Giugliano RP et al. A simple risk index for rapid initial triage of patients with ST-elevation myocardial infarction: an InTIME II substudy. Lancet. 2001; 358(9293):1571-1575. 54. Soderholm M, Deligani MM, Choudhary M, Bjork J, Ekelund U. Ability of risk scores to predict a low complication risk in patients admitted for suspected acute coronary syndrome. Emerg Med J. 2012; 29:644e649. DOI:10.1136/emermed-2011-200328. 55. Chandra A, Lindsell CJ, Limkakeng A, Diercks DB, Hoekstra JW, Hollander JE, Kirk JD, Peacock WF, Gibler WB, Pollack CV, on behalf of the EMCREG i*trACS Investigators. Emergency Physician High Pretest Probability for Acute Coronary Syndrome Correlates with Adverse Cardiovascular Outcomes. Academic Emergency Medicine. 2009 Aug; 16(8):740748. DOI: 10.1111/j.1553-2712.2009.00470.x 56. Diercks DB, Hollander JE, Sites F, Kirk JD. Derivation and Validation of a Risk Stratification Model to Identify Coronary Artery Disease in Women Who Present to the Emergency Department with Potential Acute Coronary Syndromes. Academic Emergency Medicine. 2004 June; 11(6):630-634. DOI: 10.1197/j.aem.2004.01.001. 57. Hoekstra JW, Pollack Jr CV, Roe MT, Peterson ED, Brindis R, Harrington RA, Christenson RH, Smith SC, Ohman EM, Gibler WB. Improving the Care of Patients with Non-ST-elevation Acute Coronary Syndromes in the Emergency Department: The CRUSADE Initiative. Academic Emergency Medicine. 2002 Nov; 9(11):1146-1155. Article first published online: 8 JAN 2008, DOI: 10.1197/aemj.9.11.1146.

Emerg Med. 2006; 48:252–9. 65. Pollack CV, Jr, Sites FD, Shofer FS, et al. Application of the TIMI risk score for unstable angina and non-ST elevation acute coronary syndrome to an unselected emergency department chest pain population. Acad Emerg Med. 2006; 13:13–8.

78. Critchley JA, Capewell S. Smoking cessation for the secondary prevention of coronary heart disease. Cochrane Database of Systematic Reviews. 2003; 4(CD003041). DOI: 10.1002/14651858.CD003041. pub2.

66. Hess EP, Agarwal D, Chandra S, Murad MH, Erwin PJ, Hollander JE, Montori VM, Stiell IG. Diagnostic accuracy of the TIMI risk score in patients with chest pain in the emergency department: a meta-analysis. CMAJ. 2010 July; 182(10):1039-1044. DOI:10.1503/ cmaj.092119.

79. Anthonisen NR, Skeans MA, Wise RA, et al. The effects of a smoking cessation intervention on 14.5-year mortality: a randomized clinical trial. Ann Intern Med. 2005; 142:233.

67. Lee B, Chang AM, Matsuura AC, Marcoon S, Hollander JE. Comparison of cardiac risk scores in ED patients with potential acute coronary syndrome. Crit Pathw Cardiol. 2011; 10(2):64-8. DOI 10.1097/ HPC.0b013e31821c79bd. 68. Lyon R, Morris AC, Caesar D, Gray S, Gray A. Chest Pain presenting to the Emergency Department—to stratify risk with GRACE or TIMI? Resuscitation. 2007 Jul; 74(1):90-93. Epub 2007 Mar 13. 69. Pollack CV, Roe MT, Peterson ED. 2002 Update to the ACC/AHA Guidelines for the management of patients with unstable angina and non–ST-segment elevation myocardial infarction: implications for emergency department practice. Ann Emerg Med. 2003; 41:355–69. 70. Pollack CV Jr, Braunwald E. 2007 update to the ACC/ AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: implications for emergency department practice. Ann Emerg Med. 2008 May; 51(5). DOI:10.1016/j.annemergmed.2007.09.004.

58. Vadeboncoeur A, Dankoff J, Lang ES. Chest pain, in evidence-based Emergency Medicine. Oxford, UK: Wiley-Blackwell. 2009. DOI: 10.1002/9781444303674. ch16.

71. Chisholm CD, Collison EK, Nelson DR, Cordell WH. Emergency department workplace interruptions: are emergency physicians “interrupt-driven” and “multitasking”? Academic Emergency Medicine. 2000; 7(11):1239-1243.

59. Dunham M, Challen K, Walter D. Risk stratification of patients with acute chest pain without a rise in troponin: current practice in England. Emerg Med J. 2010; 27:461e464. DOI:10.1136/emj.2008.068163.

72. Chisholm CD, Dornfeld AM, Nelson DR, Cordwell WH. Work Interrupted: a comparison of workplace interruptions in emergency departments and primary care offices. Ann Emerg Med. 2001 Aug; 38(2):146-51.

60. Morrow DA, Antman EM, Snapinn SM, et al. An integrated clinical approach to predicting the benefit of tirofiban in non-ST elevation acute coronary syndromes: application of the TIMI risk score for UA/NSTEMI in PRISM-PLUS. Eur Heart J. 2002; 23:223-229.

73. Laxmisan A, Hakimzada F, Sayan OR, Gree RA, Zhang J, Patel VL. The Multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care. Int J Med Inform. 2007 Nov-Dec; 76(11-12):801-11. Epub 2006 2006 Oct 23.

61. Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor Tirofiban. N Engl J Me. 2001; 344:1879-1887.

74. Rivera AJ, Karsh BT. Interruptions and Distractions in Healthcare: Review and Reappraisal. Qual Sal Heath Care. 2010 Aug; 19(4):304-312. DIE:10.1136/ qshc.2009.033282.

62. Aragam KG, Tamhane UU, Kline-Rogers E, et al. Does simplicity compromise accuracy in ACS risk prediction? A retrospective analysis of the TIMI and GRACE risk scores. PLoS One. 2009; 4:e7947. 63. Weisenthal BM, Chang AM, Walsh KM, Collin MJ, Shofer FS, Hollander JE. Relation between Thrombolysis in Myocardial Infarction Risk Score and one-year outcomes for patients presenting at the Emergency Department with potential acute coronary syndrome. Am J Cardiol. 2010 Feb 15; 105(4):441-4. DOI: 10.1016/j.amjcard.2009.10.015. Epub 2010 Jan 5. 64. Chase M, Robey JL, Zogby KE, Sease KL, Shofer FS, Hollander JE. Prospective validation of the Thrombolysis in Myocardial Infarction Risk Score in the emergency department chest pain population. Ann

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75. Pines JM, Pollack Jr, CV, Diercks DB, Chang AM, Shofer FS, Hollander JE. The association between Emergency Department crowding and adverse cardiovascular outcomes in patients with chest pain. Academic Emergency Medicine. 2009 July; 16(7): 617-625. First published online: Jun 22, 2009, DOI: 10.1111/j.1553-2712.2009.00456.x. 76. Camm J, Gray H, Antoniou S, et al. Unstable angina and NSTEMI: the early management of unstable angina and non-ST-segment-elevation myocardial infarction. NICE Clinical Guideline 94, (2010). National Institute for Health and Clinical Excellence Web site. Available at: http://www.nice.org.uk/nicemedia/ live/12949/47988/47988.pdf. Accessed March 8, 2014. 77. Gallagher S, Knight C, Wragg A. Medicolegal pitfalls in the management of chest pain. Clin Risk. 2010;

80. Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ. 2004; 328:1519. 81. Yoon PW, Scheuner MT, Peterson-Oehlke KL, Gwinn M, Faucett A, Khoury MJ. Can family history be used as a tool for public health and preventive medicine? Genetics in Medicine. 2002; 4(4):304-310. 82. Daelemans S, Vandevoorde J, Vansintejan J, Borgermans L, Devroey D. The Use of Family History in Primary Health Care: A Qualitative Study. Adv Prev Med. 2013; 2013:695763. Published online 2013 July 14. DOI: 10.1155/2013/695763. 83. Fuller M, Myers M, Webb T, Tabangin M, Prows C. Primary care providers’ responses to patient-generated family history. Journal of Genetic Counseling. 2010; 19(1):84-96. 84. Olver JS, Pinney M, Maruff P, Norman TR. Impairments of Spatial Working Memory and Attention Following Acute Psychosocial Stress. Stress Health. Published online Jan 3, 2014. DOI: 10.1002/smi.2533. 85. Hidalgo V, Almela M, Villada C, Salvador A. Acute stress impairs recall after interference in older people, but not in young people. Horm Behav. Published online Jan 6, 2014. PII: S0018-506X(13)00251-1. DOI:10.1016/j.yhbeh.2013.12.017. 86. MacGougan CK, Christenson JM, Innes GD, Raboud J. Emergency physicians’ attitudes toward a clinical prediction rule for the identification and early discharge of low risk patients with chest discomfort. CJEM. 2001; 3:89-94.

To learn about • FOEM Research Competitions • FOEM Research Grants • FOEM Research Network and much more, visit: www.foem.org/research

FOEM Beacon | January 2015

Thank You!

Thank you to everyone who made the 2014 FOEM Legacy Gala: Dinner and Awards Ceremony such a memorable evening! Congratulations to all of the award and competition winners. Thank you especially to everyone who made a donation. In the coming year you will see your money hard at work as we launch new initiatives, expand competitions, and foster a community of medical research that will affect the quality of healthcare across the country.

the PULSE | JANUARY 2015

Carbon Monoxide (CO) Toxicity

We are pleased to offer you a sneak-peak at the excellent work produced by the team at The Fast Track, ACOEP's Student and Resident Publication. To see more of the in-depth articles and studies published, visit www.acoep.org/fasttrack

Tanner Gronowski, DO

very winter there is an increase in the number of cases of patients with carbon monoxide (CO) toxicity compared to the rest of the seasons. CO is the leading cause of morbidity and mortality from poisoning in the United States. Although CO poisoning is treatable, usually the most difficult part of a carbon monoxide case is first considering it as a diagnosis. Carbon monoxide is a colorless and odorless gas that is formed from the incomplete combustion of carbon containing compounds. CO binds to hemoglobin with almost 200 times the affinity of oxygen, thus beating out oxygen when competing for hemoglobin binding sites. CO also causes a leftward shift in the oxyhemoglobin dissociation curve, decreasing the ability of oxygen to offload to tissue. An exposed patient will have an adequate supply of oxygen, however it is not able to be transported or used. In essence, CO works to decrease the amount of oxygen that can bind to hemoglobin as well as hinder the release of that oxygen to tissue, thus leading to a functional asphyxiation. Although CO exposure is a year-round concern, the cold winter months usually create some additional ways for your patients to

O is the leading cause of morbidity and " Cmortality from poisoning in the United States. be unintentionally exposed. Exposure may occur when your patient tries to warm their house up with an unconventional method such as bringing a gas grill into the house or using propane heaters. An indoor fire in a fireplace without proper ventilation is another way CO may accumulate in the home. CO exposure is commonly linked to emissions from automobiles despite the implementation of catalytic converters in the 1970â&#x20AC;&#x2122;s. Patients may also run into trouble when they warm their cars with the garage door closed. Patients with elevated carboxyhemoglobin (COHb) levels may present with a myriad of vague complaints ranging from a mild headache or nausea to more severe symptoms such as altered mental status, coma and even cardiac arrest. Patients with elevated COHb levels may also present with flu -like symptoms, which may trick many clinicians during flu season. Table 1 is a guide to the types of symptoms to be expected at various COHb levels. However, it is important to note that these levels are

Carboxyhemoglobin Level (% Blood Saturation)

Symptoms

0-10

None

10-30

Headache, pulsating temples

30-40

Severe headache, nausea, vomiting, blurred vision, dizziness

40-50

Symptoms as above with increased severity. Possible syncope, increased respiratory rate and tachycardia.

50-60

Coma with intermittent convulsions.

60-70+

Coma with intermittent convulsions. Depressed heart and respiratory rate. Possible cardiac arrest.

Table 1

guidelines and that patients may present with different symptoms at different levels. Aside from mortality, the other major concerns for CO poisoning is delayed neurologic sequelae as most patients do not have neurologic symptoms at presentation. Impairments in concentration and learning, cog-wheel rigidity, dementia, amnesia and depression occur in 23-76% of patients several days to weeks after poisoning. Considering CO toxicity in your patients is of utmost importance, because a serum COHb level is how CO toxicity is diagnosed. You may also have access to a co-oximeter in your emergency department which is not as accurate, but may be used to rule out an elevated COHb level. A normal COHb level is between 0-5%. If the patient is a smoker a normal level could be up to 10%. A special consideration is with the pregnant patient where studies have shown that even low COHb levels may have deleterious effects on the fetus. Therefore, it is

Type of Oxygen Exposure

Half life of Carboxyhemoglobin

Room Air

5 hours

100% Non-Rebreather

1 hour

Hyperbaric Oxygen (at 2.5 atmospheres)

20 minutes

Table 2

the PULSE | JANUARY 2015

prudent to treat a pregnant patient even with a low COHb level. If your patient has an elevated COHb level, you must then make the decision of how to treat them. Keep in mind that if a patient was removed from the source of CO the percentage of COHb has had time to drop so they may have had a much higher level. You may be able to back-calculate the level using Table 2. Treatments include using a 100% non-rebreather or sending the patient to the hyperbaric oxygen chamber. All patients who are symptomatic or with elevated COHb levels should be considered for hyperbaric therapy. Patients with the following may be at increased risk for delayed neurologic sequelae: syncope, seizure, altered mental status or confusion, age >36 years, carboxyhemoglobin level > 25%, prolonged CO exposure >24 hours, abnormal cerebellar function or fetal distress during pregnancy. Finally, with any CO case it is wise to discuss the case with the toxicologist on staff at your hospital or a local poison center.

ACOEP-RC President’s Report

t the start of my term as the new Resident Chapter President, I would like to thank the resident chapter and the college for allowing me to serve. I'm excited for what my fellow officers and I will be able to do over the upcoming year. We are thankful for the efforts of those that have come before us, for helping us be in the place we are now, giving up the opportunity to move forward. Over the next year we will refocus our efforts to make sure that our offerings are valuable. We will spend time recruiting new benefits, enlisting staffing companies for funding, and make sure we are giving members the best opportunities possible.

References: 1. Goldfrank, Lewis R. “Carbon Monoxide.” Goldfrank’s Toxicological Emergencies. 9th ed. New York: McGraw-Hill Medical, 2011.

Andy Little, DO ACOEP Resident Chapter President

2. Goldbaum, Leo. “Mechanism of the Toxic Action of Carbon Monoxide.” Annals of Clinical and Laboratory Science 6.4 (1976): 372-76. 3. Thom, Stephen R., Veena M. Bhopale, and Donald Fisher. “Hyperbaric Oxygen Reduces Delayed Immune-mediated Neuropathology in Experimental Carbon Monoxide Toxicity.” Toxicology and Applied Pharmacology 213 (2006): 152-59.

First and foremost, we are pleased to announce that printed copies of The Fast Track are being delivered to each residency program and medical school so that members will have the opportunity to read this wonderful resource.

Finally, I would like to invite our resident members to join us for our offerings at The Edge: Spring Seminar in Ft. Lauderdale, April 7th-9th, 2015. We will offer our Critical Care Ultrasound Lab, and introduce a Junior Resident Boot Camp focusing on the transition to being a leader within your own program. Thank you,

Andy Little, DO ACOEP National Resident Chapter President ACOEP Board of Directors

the PULSE | JANUARY 2015

Thanks for Making The Edge: Scientific Assembly 2014 a Memorable Event!

the PULSE | JANUARY 2015

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One decision, one career, one life.

One on the dance floor, EMP physicians and guests at the EMP party during ACEP SA, Chicago.

How are you going to live it? You could work for a giant machine that’s owned and operated by stuffed shirts who don’t know auscultation from a conference call. Or you could join EMP. A group that’s owned and managed by emergency medicine physicians who are passionate about working together to care for patients – and each other. Don’t be a number, be a part of our family. There’s only one you and there’s only one real team. EMP.

Become one. Visit emp.com/jobs

or call Ann Benson at 800-828-0898. abenson@emp.com

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