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July 2014

Osteopathic Emergency Medicine Quarterly

Presidential Viewpoints

Mark A. Mitchell, DO, FACOEP

Sitting at the Crossroads


here is so much change going on in healthcare it makes it difficult to keep up. The most obvious change is the ramifications as a result of the continued rollout of provisions of the Affordable Care Act, i.e. “Obamacare,� that was signed into law in 2010. Then we have the Sustainable Growth Rate (SGR), the funding mechanism for Medicare that appeared to be an acceptable method when it was passed into law, but is now recognized to be flawed. Our healthcare system is now the patient that needs diagnosis, treatment, and time to heal. continued on page 4

Presidential Viewpoints Page 4

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Executive Director's Desk Page 6

2014 Board Candidates Page 18

FOEM Foundation Focus Page 28

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VOLUME XXXV No. 3 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, Communications Manager 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 Kenneth Argo Todd Thomas Andrew Little, DO Danielle Turrin, DO Julia Alpin Peter A. Bell, DO, FACOEP-D David Bohorquez, DO Anthony Jennings, DO, FACOEP Matthew McCarthy, DO, FACOEP Erin Sernoffsky, Communications Manager 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 2014 – All rights reserved. Articles may not be reproduced without the expressed, written approval of the ACOEP and the author.





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...........................................................................................6 Janice Wachtler, BAE, CBA What Would You Do?..................................................................................................7 Bernard Heilicser, DO, MS, FACEP, FACOEP-D ACOEP, Don’t Look Back…..................................................................................... 8 John C. Prestosh, DO, FACOEP A Tribute to a Mentor................................................................................................10 Juan F. Acosta, DO, MS, FACOEP-D ACOEP Honors Practice Excellence......................................................................11 Attention AOBEM Candidates applying to take Part I in March 2015 Donald Phillips, DO, FACOEP...............................................................................13 Navajo Culture............................................................................................................14 Mark Rosenberg, DO, MBA, FACOEP-D Tactical EMS................................................................................................................16 Steve Vetrano, DO, FACOEP Tax Fraud Hits Many Physicians..............................................................................17 Janice Wachtler, BAE, CBA 2014 Board Candidates .............................................................................................18 Janice Wachtler, BAE, CBA Book Review: Back from Burnout by Frank Gabrin, DO.......................................21 Tim Cheslock, DO, FACOEP His Right Upper Quadrant Abdominal Pain is from What?...............................22 Michael Schick, DO, and Anne Klimke, MD Doing a Disservice to the Deserved.......................................................................24 Gregory M. Christiansen, DO, FACOEP-D FOEM Foundation Focus.........................................................................................28 Sherry D. Turner, DO, FACOEP Resident Wrap Up.......................................................................................................34 M. Steven Brandon, DO Embracing Change.....................................................................................................35 Andrew Little, DO Residency Spotlight.....................................................................................................36

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Presidential Viewpoints


Mark A. Mitchell, DO, FACOEP "Crossroads continued from page 1 As Emergency Physicians we sit at the crossroads of the “inpatient” and “outpatient” worlds. We see firsthand the effects of patients who don’t have access to good primary and preventative care. That can be the hypertensive or diabetic patient who frequents our doors when they run out of their medications and simply needs a refill, or someone who put off medical care due to lack of access that shows up with a critical condition and hospital admission. It is hard to comprehend that the cost of one ED visit and hospitalization is more than would have been required for years of outpatient management of the disease. And what is this “Medical Home” that is constantly being talked about? It seems many of our patients don’t have a medical home and even those that do, have trouble getting into it. I sure am glad that my wife doesn’t lock the door and not answer the phone after 5 p.m. and on weekends and holidays. Shouldn’t a medical home be a place that the patient has access to almost 24/7? When the home is locked or not accessible, where is the patient to go for care other than the Emergency Department? We also know firsthand the crisis our country is facing because of the lack of adequate psychiatric services. There is more and more publicity about this giving the public

T and government representatives a better understanding of the magnitude of the issue. This is not new news to us, we’ve been boarding many of these patients in our ED’s as they await proper placement, evaluation, and treatment. The stories of patients staying in an emergency department for days while awaiting a bed to become available is certainly not new news to us. I bring out some of the many issues we face in Emergency Medicine not because I am upset or depressed about the current state of our healthcare system. Instead, I see this as a golden opportunity for us. We are in a great position to assist in being a major part of solution. As we have large volumes of patients (about 130 million visits a year) that present for care, and about 70% of all hospital admissions begin their care in the ED, we are in a pivotal position. As the funding for healthcare is reduced, and shifting from pay for volume to pay for outcomes we will find ourselves having the attention on many stakeholders. Our hospital partners will be subject to payment structures that may include an Accountable Care Organization (ACO) which has a capitation payment system in place. When this occurs they will be looking for ways to decrease the cost of care and yet maintain good outcomes. Historically hospitals have

looked to the ED to fill the inpatient beds. Many times we have found ourselves caught in the middle. Our colleagues on the medical staff have wanted us to discharge patients and avoid admissions, while hospitals need admissions to stay afloat. This could be a major paradigm shift as hospitals will be looking to us for alternatives to admissions. This will place us in a great position to be able to advocate for our patients in ways such as the following: • Physical space and personnel to have a wellfunctioning observation unit. • Case Management and/or Social Services available in the ED 24/7. • Ability to schedule a follow-up visit with the PCP within 48 hours of ED discharge. • Reliable call back system to check on patients to insure follow-up or encourage them to return to the ED for additional evaluation. Now is the time that local leadership needs to take advantage of the changes in healthcare and advocate for our departments, providers, and most importantly, patients. If you don’t step up and take the lead, you will be in a position to follow others; in doing so you will lose the ability to have a strong voice in your own fate.

ACOEP Staffing Updates Already 2014 has been a year of incredible changes! We have welcomed two new staff members as well as developed new departments to better accommodate our ever-growing membership. 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 Executive Director Janice Wachtler, BAE, CBA 312.445.5705 Development Director Stephanie Whitmer 312.445.5712 Executive Assistant Geri Phifer 312.445.5700 Manager of Education Services Kristen Kennedy, M.Ed. 312.445.5708

Administrative Assistant, FOEM and Member Services Gina Schmidt 312.445.5701 MEETINGS AND CONVENTIONS Manager of Meetings and Conventions Adam Levy 312.445.5710 Senior Meetings Coordinator Lorelei Crabb 312.445.5707 Education Services and Meetings Assistant Andrea Jerabek 312.445.5703

MEMBER SERVICES Director of Member Services Sonya Stephens 312.445.5704 Sr. Coordinator of Member Services Jaclyn Ronovsky 312.445.5702 MEDIA AND TECHNOLOGY Communication Manager Erin Sernoffsky 312.445.5709 Media Technology Specialist Tom Baxter 312.445.5713

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The Editor's Desk

Tim Cheslock, DO, FACOEP

Reality Check! disposition issues and the constant pressure to satisfy everyone. Functioning in that situation day after day has led many to the one thing we all dread and often don’t recognize: burnout! At some point in time we will all feel it. It is how we handle it that will determine if we forge forward and adapt, or if we decompensate and go from a situation of health to one of distress.


very now and then I think it is important to step back and perform a reality check. This can mean many things to many people. In this aspect I would like to look at it from a perspective of job satisfaction and wellness. July is typically an anniversary date for many physicians, as most start a new job upon completion of residency or maybe made a change after that first job out was really not what you thought it would be. For others, maybe you have been in the same job for many years. Whatever the case, we all need a nudge sometimes to pause and take inventory of our life and job satisfaction. Are you happy in your present situation? If you are, that’s admirable. If you are not, then it is even more import to take inventory to determine why. It’s import to see where you lie on the spectrum of happiness and ultimately wellness. As emergency physicians, we all like to think that we work hard and play hard. The images of pit docs on TV lead the general public to believe we are in constant motion and thrive on the adrenalin rush. We can go for 24 without sleep and still enjoy time with our family and friends, all without breaking stride. There is no stopping us and we are invincible. In some regards, they are at least partially correct. Emergency Physicians are a special breed. We do work in a fast-paced environment and have to deal, not only with critically ill patients, but also the social issues of our patients,

The reality of the work is not going to change and by many accounts will only continue to become more burdensome. So how do you deal with it? What does your group do to support you in your practice of emergency medicine? There will surely be a variety of responses to this. There is not one correct answer. Each of us requires different things to keep us happy, grounded and satisfied with our job. Maybe it is having scribes to assist us with documentation, or maybe eight hour shifts and overnight docs to make the schedule tolerable. Is there enough time off to spend with your family and flexibility to attend those special events at school? Most large groups have similar packages these days. So what is it that draws someone to a particular group or facility? I truly believe that it is the people and what they are motivated to accomplish. That’s right; it’s your co-workers, directors and administrators, the people you work with every day who go a long way to keep job satisfaction high. In doing my own self inventory of my job over the last year I can honestly say that I am very happy with my current situation and my overall job satisfaction is higher than it has been in a while. I am surrounded by colleagues that are supportive, of a similar practice pattern, and all have a genuine concern for making the work environment the best it can be. It says a lot for a group that can retain their physicians. Low turnover is surely a key indicator of a well satisfied group, especially in today’s era of job hopping. In addition to the physicians I work alongside, the administrative team at our office is outstanding. I can’t ask for any better. The last thing that I found is really special about this group is the family support. There is a social activities committee that provides opportunities to bring together our spouses and children for events. It is efforts like these that make a group more than a group. It truly becomes a second family. Above and beyond that, each and every family event or crisis has the support of our group if

needed. What better way to help ensure your sanity? Now this may sound like a recruiting pitch, it is not. It merely highlights what I have come to believe has helped me develop as a well grounded emergency physician and I am thankful for the ability to work in that situation on a daily basis. What does it take for you to be happy and high-functioning? Only when we are happy and grounded in our situation can we perform at our peak. Only then can we meet the demands of providing that level of care which our patients not only expect, but deserve. Only then can we shift the metrics into the green and keep them there. Take a few minutes and ask yourself, what makes you happy? Are you able to find that happiness in your current situation? Are your priorities where they need to be in regards to your work, family and home situation? Keeping yourself healthy in the broad sense of the term takes some work. Do you have enough time off, are you able to get a good night sleep, do you take out time to exercise? Is your family or personal life in order? All of these are components of wellness. Addressing all of these concerns can help assure that we are at our peak and able to fully engage in our job. Wellness is a topic that often time is not given enough coverage and seen as a passing fancy. I challenge you to make it a bigger priority in your practice and your life. If you are feeling challenged in your current environment, your colleagues are likely feeling it too. Only by confronting the issues head

What does it take for you to be "happy and high-functioning?" on and making a dedicated effort to overcome will you be successful. We are all in it for the long haul, so let’s do it together and make it the best it can be! I would be interested in hearing from our membership as to what keeps you grounded. What gives you satisfaction in your work? What can we do to help make your life as an emergency physician more satisfying? Feel free to email me your comments. I look forward to hearing from you!

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Executive Director's Desk Janice Wachtler, BAE, CBA

Strange Bedfellows Now fast-forward to medicine today. Most patient care is done in high-density doctors’ offices and hospitals, utilizing well-trained physicians who routinely use antibiotics and high-cost alternatives to care for patients. While the patient outcomes are good, these high-cost methods tax its payers, e.g. government and private insurance. Additionally, patients are dissatisfied with being treated in this atmosphere, where they feel they have no rapport with the doctors. In the end, you have over-worked physicians and dissatisfied patients.


veryone has known friends who suddenly announce their engagement or marriage, and all you can do is scratch your head and murmur aloud, “Who would have thought?” Well, that’s been my interpretation of the Single Pathway Proposal announced a few years ago and apparently is now waiting for approval by the AOA House of Delegates. As we go down this road, I murmur, “Who would have thought?” But I think I know why and here’s my take on things. Looking back at the foundations of medicine, osteopathic medicine was a late-comer on the medical scene. The Healing Arts date back to time immemorial, but formal medical training began in the US in 1765, prior to then medicine was an apprenticed-trained profession. In the late 1800s, AT Still, an apprenticedtrained physician, came on the scene, pressed into service as a hospital steward by the Civil War. His talents made him, in his own words, a ‘de facto surgeon.’ Following the war, he went onto to other things, and it wasn’t until his own children became sick and died from spinal meningitis that he became certain the medicine of his day was flawed. He began to seek out different treatment modalities to avoid medicines of the day, which often caused more harm than good. Believing alternate treatments caused fewer side effects, and surgery done in more sanitary conditions with fewer medicines, patients would have a better outcome.

So here we are in 2014, we have a big medical group (MDs) and a not-so-big group (DOs) who practice medicine in the US. Both groups have accrediting powers; the MDs through ACGME and the AOA. Both are funded by the government to train their residents to meet the nation’s demand for qualified physicians; but they train in different realms. Allopathic physicians generally train in a university based system; osteopathic physicians, OPTI-based programs. Both physician training models produce welltrained physicians, who take similar certification and licensing examinations; but one physiciantype produces its physicians with less cost and its physicians are just as good as the other. Now, you’re the government: you pay for the training of the nation’s physicians; not its dentists, or veterinarians, just its physicians, and you’re paying for two different agencies to train physicians, who have the same outcomes, similar if not the same treatment modalities, why? Both groups, the ACGME and AOA want to continue to train physicians, but know that pretty soon, the governmental agency responsible for paying for physician education will, scratch its proverbial head and wonder why are we paying for two different training models? Let’s choose one and pay for that.

shake hands, but both are somewhat suspicious of each other’s motives. But they work out a way to make the government happy to sustain both of their existences. That basically is what’s happened with the Single Pathway. Sure, the ACGME has more clout and makes bigger noise, but their main goal is the same as AOA’s—to produce a quality product, a physician, who can make patients well, have good outcomes, and who reflects well on whatever route he or she trains in. Is it always fair? Probably not. Will it make osteopathic physicians more MD-like? Probably not. Will it open doors to equal footing for DOs? Probably, and that’s what it’s all about. Are MDs jumping for joy? No, they’re just as suspicious of DOs as some DOs are of MDs. Why? Because in most realms DOs are the minority; some physicians have never worked with DOs and remember the 1960s when they were removed from the State of California, not because they were bad doctors, but because they posed a threat to the MD minority in the State. We will have to make this change now or later for the survival of medicine in America. We will all do what we for the good of the state, but we will survive. Each specialty will have to make changes; each will have representation, but each will change. It will be up to the physicians representing each specialty to ensure that your rights as physicians are included in the standards. ACOEP will represent your rights, will fight for the individual recognition of AOBEM certification to become a program director and will ensure that our training is not eroded. We will need time and your backing to do so.

So both groups get told by the government to make changes to solve a funding issue and a care issue; they get told there must be one pathway. The bigger guy wants it their way; the little guy acquiesces. Why? For survival. The two meet,

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Ethics in Emergency Medicine

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

What Would You Do? Please send your thoughts and ideas to Every attempt will be made to publish them when we review this dilemma in the next Pulse. If you have any cases that you would like to present or be reviewed in The Pulse, please email them to us at Thank you. Which one would you choose to offer a ride to, knowing that there could only be one passenger in your car?


n this issue of The Pulse, we will present a theoretical “Killer Question.� Although this is not specifically medically related, we would like to make ourselves think. This question was posed by Mr. Michael Nussbaum of Homewood, Illinois. You are driving along in your two-seater sports car on a wild, stormy night. You pass by a bus stop, and you see three people waiting for the bus: 1. An old lady who looks as if she is about to die. 2. An old friend who once saved your life. 3. The perfect man (or) woman you have been dreaming about.

This was a moral/ethical dilemma that was once actually used as part of a job application. You could pick the old lady, because she is going to die, and thus you should save her first; or you could take the old friend because he once saved your life, and this would be the perfect chance to pay him back. However, you many never be able to find your perfect dream lover again. What would you do?

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The On-Deck Circle

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

ACOEP, Don’t Look Back… logical, easier choice; after all, we are familiar with this route! Change is unsure and unknown; but challenging! It appears likely that ACOEP will travel the road named Change. This is the road all medical education will be following. We need to ensure that when we see the outline of the single accreditation pathway provided by ACGME, we have the capability to make a positive impact. We have outstanding emergency medicine residencies and have graduated excellent residents to work in the healthcare system. We have always followed an “apprentice” structure of teaching, and it has served us well. We have trained residents not only in large teaching institutions, but also the majority in smaller community settings. The results have been the same; we have mentored extremely capable residents. This is not an aspiration; this is reality. This model of education is something we have consistently improved. We can demonstrate to the ACGME a different style of training that has worked for us and would work for them. However, Osteopathic training programs must remain vigilant and continue to provide educational opportunities that remain on the forefront of medical training. The ACGME has also chosen to travel the road named Change. While we travel the same road together, Osteopathic

training programs must continue to excel in order to remain in existence. ACOEP must prove to the government that our style of training residents not only works, but is cost efficient. We have been able to provide training in our residencies at a far less cost than those in allopathic training programs. While it is true that we have depended on many “volunteer” hours from core faculty in the past, we must advocate for better faculty reimbursement while still maintaining lower budgetary needs than ACGME programs. We should continue to focus on the best training

e know what we are. But know "W not what we may be. " – William Shakespeare


COEP, don’t look back…is the ACGME pursuing you to procure you as part of their domain?

ACOEP, don’t look back…is the government approaching you to show you they cannot afford your four year training programs? ACOEP, don’t look back…are the houses of medicine clamoring to have you surrender into their fold? ACOEP, don’t look back…are students and residents leaving you and seeking memberships in other medical organizations?

length for programs to graduate well-rounded and capable residents. All the Osteopathic program directors have long believed that a four year program is the necessary time frame to achieve that goal, and ACGME now has approximately 35% of their programs also utilizing that time frame. ACOEP recognizes that in the future, government may dictate three year training programs due to funding constraints. Be assured that we will be ready to face that dictum if it should ever come. While four years of training remains better-suited to provide well-rounded patient care, we can

ACOEP, don’t look back…the past you cannot change; it is history. ACOEP, do look forward…the future is what you can shape, and shape it you must! The training of Osteopathic emergency medicine physicians has truly come to a crossroad, and the direction we travel is vitally important to our future. One road is named “Tradition” and is wide, paved, and straight. The other road is named “Change” and is not wide, not paved, and rather uncharted. Which road will Osteopathic training programs take? Tradition seems to be the

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ACOEP is a dedicated and vibrant organization. Members of our college meet regularly with representatives from ACEP, AAEM, SAEM and CORD. Although we do not have as many members as those organizations, we are considered equals. We will continue to participate in multiple ventures with these groups and offer our opinions to help shape the future of emergency medicine. We should not fear being engulfed by them, but rather see them as our partners in creating quality, cost-effective care for our patients. ACOEP is a recognized stake-holder within the house of emergency medicine. ACOEP has always had a strong relationship with our students and residents. A reflection of this is exemplified by their representation on our Board of Directors. The student and resident representatives sit at the table for all board meetings, both open and executive sessions. They are free to state their concerns and needs. The board has always listened and collaborated with these individuals. We will continue to foster solid relationships with students and residents as they are the future flagbearers for our Osteopathic profession. The ACOEP Board of Directors has committed

to visit every Osteopathic emergency medicine student chapter either with face to face meetings or through electronic media. The board understands the importance of being more active in reaching out to our residents and impressing upon these young physicians that their continued presence in ACOEP is vital to our future. I have personally committed to visit all Osteopathic emergency medicine residencies (last count listed 50 programs) by the time my presidency will be completed in 2017. The present leadership of our college appreciates our valued history. Our past leaders and mentors created a college of which we can be proud. They forged ahead at a time when emergency medicine was extremely young and not a vital specialty in medicine. They had the foresight to see the need emergency medicine would fill. They directed their energy to fulfill that goal. We must now look to the future. Emergency medicine does fill a critical role in the practice of medicine. We are at a crossroad, and ACOEP will likely proceed along the road called Change. Change is difficult and uncertain, but can offer unforeseen advantages that may strengthen the future of the ACOEP. While it is true we cannot have control over all aspects of our future, we must be ready to prove ourselves and thereby be an essential factor in shaping the road named Change.



and will provide excellent three year training programs if necessary.

Osteopathic Emergency Medicine Quarterly

We Want to Hear from You! ER Physicians do incredible things every day and we want your stories! Send your story ideas to, we would love to share your experience with our members. We also encourage you to email 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.


Read current articles and view back issues from your laptop, desktop, tablet or mobile device.

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A Tribute to a Mentor


Juan F. Acosta, DO, MS, FACOEP-D


s a medical student, I was very interested in emergency medicine because it is closely related to being a paramedic. When applying to emergency medicine programs, I was very eager to apply to one that not only gave me a great education but also had faculty and a program director that would offer me a great experience. I never got a chance to tell my program director the important role he played in my life. With life’s demand, people often become very busy and with difference career opportunities, drift apart due to distance. One of the many lessons I learned from this individual was to always treat patients with the utmost respect and care, no matter

where or how they came to the emergency department. Respect was also extended to patients’ family members. Using the excuse that your emergency department was too busy, thus giving you a “free card” to disrespect someone was not an option. Taking your personal problems out on someone that needs your help was also not an option. We have a duty to care for our patients. It has now been thirteen years since graduating from residency and I can still hear those words of encouragement and compassion that he would use when providing care. He once told me “One day we will all be on one of those stretchers as a patient, hoping that the doctor in charge of your care will treat you as a human being”.

I wanted to bring this forward not only to gives thanks, but also to challenge all of you to step back, exam your compassionate and caring meter and decide if it needs refueling because it may be you that will be taking care of me. It is also important to remember what an influence we may have on the students and residence that we help to train. Our work to encourage and guide them has ripple affects on the patients they treat, and their families. Our experiences are valuable. Please consider becoming a mentor in ACOEP’s mentor program. Visit for more information on the program and how to become involved, or email Jaclyn Ronovsky at

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ACOEP Honors Practice Excellence


e all know physicians who are role models for their peers. They may be excellent teachers, wonderful mentors, excel in their field of practice, or provide our profession through a lifetime of service. ACOEP has recognized physicians for years for just that and this year is no different as we recognize five physicians for their practice excellence and service not only to the ACOEP but the Osteopathic profession. On the top of the list is the Bruce D. Horton DO FACOEP Lifetime Achievement Award. The awards, named after our first president, is awarded to a physician-member who has excelled in emergency medicine throughout his lifetime by serving as a role model to his or her peers and working to better the profession. This year, the award is being presented to the Honorable Joseph Heck, Jr, DO, FACOEP, Congressman from the Third District in the State of Nevada. Dr. Heck has spent more than 25 years in public service as a physician, Army Reservist, Community volunteer, State Representative for Nevada and now Congressional Representative. He served in Operation Iraqi Freedom and served on active duty three times. He has also been a volunteer firefighter and ambulance attendant, Search & Rescue team member, and SWAT physician. Dr. Heck is a 1988 graduate of PCOM and completed his residency at Albert Einstein Medical Center in 1992. In 2003, the College lost two Past Presidents, Benjamin A. Field, D.O., FACOEP and Robert D. Aranosian, D.O., FACOEP. These physicians had major impact on our College and profession. Dr. Field was an avid believer that it was the physician’s duty to teach but also mentor those medical students, residents and young physicians that would make up the next generation of physicians. To that end, ACOEP created the Benjamin A. Field, D.O., FACOEP Mentor of the Year Award. It is awarded annual to the physician who believes in the same principles that Dr. Field so steadfastly believed in. This year, the award is being presented to Joseph Dougherty, D.O., FACOI, FACOEP, emergency

medicine program director of the Ohio Valley Medical Center, Wheeling, West Virginia. Dr. Dougherty has held this position since 2006, during this period he brought forth his ability to train residents in his program as well as mentor his core faculty in the educational building blocks to bring quality and pride to his graduates. Additionally is a determined believer in the tenets set forth by Dr. Field and has devoted himself to mentoring residents and medical students at his program on healthy lifestyles and success in their careers. Robert D. Aranosian, D.O., FACOEP was dedicated to Emergency Medical Services and he dedicated his life to making EMS an important function within the profession. He knew the importance of service to his community and was devoted to providing his community around Pontiac, Michigan with these services. Like Dr. Bob, Murry B. Sturkie, D.O., FACOEP has been a steadfast proponent of EMS in the State of Idaho, and so he is the recipient of the Robert D. Aranosian, D.O., FACOEP Excellence in EMS Award. Dr. Sturkie is a graduate of the Pontiac Osteopathic Hospital program and knew Dr. Bob well. Dr. Sturkie, like Dr. Bob, has worked as a paramedic and firefighter in his early career and has served as the Medical Director of many fire district within his home state, served as Chair of the Idaho State EMS Physician Commission, the Board of Directors of the Idaho Simulation Network-Steering Committee and as a Liaison Representative to several EMS agencies for the ACOEP.

documents during this time, working to redesign educational curriculum for the AOA’s residency training programs. In 1992, ACOEP lured her to its executive office and since then she has written numerous educational documents, as well as increased our educational base, educating residents, program directors and members with a quiet voice and steady hand. The Janice A. Wachtler Educator of the Year Award is awarded to educators in the field of emergency medicine who, like Jan, have made major impact not only in the educational arena but by expanding the scope of emergency medicine education through innovative techniques and challenges that they have shared with their fellow physicians, students, residents, coordinators and the public. We are proud to award the inaugural winner of this award, Alan R. Janssen, D.O., FACOEP-D of Genesis Regional Medical Center in Grand Blanc, Michigan. Dr. Janssen has been involved in the creative teaching of residents throughout his career, challenging and improving their skills. Additionally, Dr. Janssen has worked on the creation of educational policies through his chairmanship and membership on the Committee on Graduate Medical Education as well as the Board of Directors of the American Osteopathic Board of Emergency Medicine.

This year the College has honored its longtime Executive Director, Janice Wachtler, with an education award named after her. Jan began her career as an elementary school teacher in the public and private sectors in Chicago. When teacher burnout set in she sought a change for a summer and came to work for the AOA on a summer job that lasted 13 years. During her career at the AOA, she ran the Committee on Postdoctoral Training, a committee that set educational policies and procedures as well as reviewed and recommended approval of resident education. She wrote numerous

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A a M

Is There Someone in Your Professional Life that You Would Like to Honor? You can do this by nominating them for an award from the ACOEP, and here’s how:


Bruce D. Horton, D.O., FACOEP, Lifetime Achievement Award is awarded to a member of the American College of Osteopathic Emergency Physician who had made contributions to the College and/or emergency medicine through his or her actions, dedication and deeds over his or her career.


F I C t y a p

Benjamin A. Field, D.O., FACOEP, Mentor of the Year Award is awarded to a member of the American College of Osteopathic Emergency Physician or emergency medicine community who had made contributions to teaching emergency physicians, residents and students. Robert D. Aranosian, D.O., FACOEP Excellence in EMS Award is awarded to a member of the American College of Osteopathic Emergency Physician or emergency medicine community who had made contributions to the field of EMS that furthered the operation, teaching or development of the specialty through his or her actions, dedication and deeds.

a p f m

Honorary Membership is awarded to physicians and lay people alike who have contributed to the success of the American College of Osteopathic Emergency Physician or emergency medicine community through his or her actions, dedication and deeds.


Janice A. Wachtler Educator of the Year is awarded to an educator who has made significant contribution to emergency medical education. The nominee should constitute the caliber of educator who has achieved a pinnacle level and is considered a consummate role model to the emergency medicine community, through inspired and motivated teaching encourages others to achieve their greatest potential; has made contributions for the advancement of emergency medicine education through innovative instruction or design, or has created a compelling vision for the future. Practice Innovation Award is presented to nominee(s) who have developed an innovative process through which the practice of emergency medicine is improved by the implementation of this process. The innovation must improve the efficiency, patient safety and/or quality of care in the emergency department and be easily transferrable to other emergency department settings, sustainable over the long term and demonstrates collaboration between the emergency department and hospital team. Nominations are accepted annually through March 1 and must include a cover letter explaining why the nominee should be considered, a recent CV and, picture of the nominee. Nominations should be sent to the Chair, Nominating Committee, ACOEP, 142 E. Ontario Street, Suite 1500, Chicago, IL 60611

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Attention AOBEM Candidates applying to take Part I in March 2015 Donald Phillips, DO, FACOEP


ffective June 3, 2014, applications and credentials submission for Part I are available using a web-based system. From go to the "Exam Info and Application" link from the "Part 1 Certification Requirements" page (available in the left hand navigation column), this will take you to that system. Login using your AOA account. The login page will provide a link for password reset, etc.

Step 1

Handwritten paper applications will be accepted, but are discouraged. If you require paper submissions, please contact the office for these. Submitting your application on paper may delay credentialing for the examination. The deadline for completing your application is September 1, 2014

Step 2

Step 3

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Navajo Culture Mark Rosenberg, DO, MBA, FACOEP-D


t ACEP in 2013, I had an opportunity to lecture on a topic near and dear to my heart, that of Palliative Medicine and Geriatric Emergency Medicine. The lecture was received extremely well and a significant group of those who listened came to the front of the lecture room to ask me questions and comment on the material. One individual was my friend from residency days who now lives and works on the Navajo Reservation in Window Rock, Arizona. We didn’t have much time to talk but several months later I received a text from him asking if I would be interested in discussing palliative care with the traditional healers and caregivers on the reservation. Of course, I agreed. Without question, I agreed. I knew nothing about the Navajo culture and traditions regarding elderly and palliative care. I was under the mindset that all cultures have the same quest for relief of pain and suffering in common. In my palliative and geriatric practice at Saint Joseph Regional Medical Center (SJRMC) in Paterson, New Jersey I frequently talk to many people regarding death and dying in one of the most ethnically diverse communities in the country. We have dozens of different languages spoken and it is home to most of the world’s religions. In the Emergency Department we need to constantly be aware of the nuances of this culturally diverse population. Within a short time, I received a call from Julianna, the program coordinator who introduced herself as a family medicine physician at Tsehootsooi Medical Center in Fort Defiance, Arizona. This was an Indian Hospital on the Reservation which was one of seven Indian hospitals providing care to more than 330,000 people - mainly Native Americans. Julianna wanted to discuss a little more about her goals for this project and discuss my presentation. I made a critical error in judgment. I spoke before I fully understood. I explained my plans and how I would talk about making a case for Palliative medicine at the hospital. I talked nonstop for 15 minutes about how people want to die at home or in familiar surroundings. And how symptom

was starting to realize that my Navajo "Iexperience was going to be one of total education for me. " management was common to all cultures, and there was silence on the other end of the phone. As I stopped talking, Julianna said that she was Navajo and wanted to improve care for the circle of life that all Navajo lived. She wanted to do it for her people. She explained that most Navajo have a strong belief in the spirit world. The spirit of death is present with the dying family member and as a result family members don’t die at home. It possibly could endanger other members of the family. Instead, a terminally ill Navajo would stay in their house during their illness but would possibly be left outside to die rather than have the spirit of death in the house. Many patient die in the hospital to avoid dying in the home. Julianna continued to explain the magnitude of the crisis. This time I just listened in amazement. I was starting to realize that my Navajo experience was going to be one of total education for me.

Mexico and drive several hours to Window Rock, the Head of Government of the Navajo Nation. I was staying on the reservation at the hospitality house that was in the housing subdivision where all hospital workers, nurses and doctors lived. It was reservation housing for non-Navajo hospital workers. The housing was basic and lovely. I stayed there with two other physicians who were part of our team to help enlighten the caregivers, practitioners, and the healers or Medicine Men, about the benefits of Palliative Medicine. Before we were able to even discuss dying we were going to have a ceremony in a Hogan to ask the spirit world for permission to have such a discussion. Julianna explained what was expected and how to participant in this ceremony. The Hogan was an eight-sided wood log building which had a clay or mud roof and

Now I want to explain that this is an article about my experience and what I have learned and observed. This is not a study or research paper of Navajo traditions and cultures. It is my experience, from the point of view of an emergency physician practicing EM with a specific interest in Geriatric and Palliative medicine. As I prepared for my trip, I would fly into Albuquerque, New

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15 a hole in the center for the chimney to come out. There were no windows and a dirt floor. The only door faced east. We were asked to walk in clockwise along the perimeter and to walk between a small fire of hot embers and the Medicine man who sat on the far west wall. As I approached the Medicine Man, I handed him an offering of Mountain Tobacco and I was asked to sit to his left. Being one of the presenters I sat next to Julianna and the Medicine man. About fifty people came in for this ceremony which included a young woman nursing her baby, the very old and the very young. As we all sat on the floor, the ceremony continued in English and Navajo, including chanting and sermon-like discussion. The entire time ingredients were added to the ember pit and the Hogan remained densely smoke-filled. The ceremony lasted for two hours and we all introduced ourselves as we exited the Hogan walking out toward the west. That evening we had a wonderful pot luck dinner and early to bed. As I tried to sleep, I thought back on the day and evening. I have never felt so spiritually connected to a people in my life. The Hogan was scary for me. I found myself completely chanting and rocking back and forth. I was for the first time in my life, physical emotionally and spiritually connected. That frightened me, just letting myself connect. I don’t know how else to explain it. Actually as

I write this I still don’t know how to explain the intense connection I felt. The next two days were lectures, workshops and discussions on Palliative Medicine. Many of the elders discussed elder care and all of the medicine men discussed and debated the approach to bring Palliative Medicine to the reservation. Of course the entire program ended with another session in the Hogan to thank the spirit world for permission to discuss this difficult topic. I learned much during these few days on the reservation. Geriatric care is coordinated at the hospital and seniors come in and have a full day assessment. During that preventative visit the senior is screened for delirium, dementia, depression, as well as a nutritional and falls assessment. They also get a cardiovascular and neuro assessment. The program is being revamped but the concept of proactively managing senior health is far superior to our reactive practice in my hospital even with our geriatric ED. The Medicine Men take care of the entire patient family. They look at the whole family and treat them as a unit.

There is zero cost for all medical care including medication. Access is difficult, however, because of some inherent problems with language and transportation. Within the Navaho population, the traditional healers (Medicine Men) agree, it is okay to talk about palliative care and dying even if you are afraid. It is the Life Cycle. I think there is much to learn about caring and end of life that we can learn from the Navajo. I went to the reservation to teach and to help people deal with death and dying but instead I was immersed in another culture for a short time and gained insight into perhaps another dimension of palliative care. However, there are also many needs and shortcomings to medicine on the reservation. Our help in staffing and providing medical care is needed and welcomed. Change is a slow process and these are a proud people. They make no demands. I would propose that most people living in America are unaware of the living conditions and health care available to Native Americans. I strongly encourage all of you to schedule a visit and instead of doing mission work in some far off land, come to the Rez (reservation) and help yourself grow mentally and culturally right here in our own country.

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Tactical EMS


Steve Vetrano, DO, FACOEP



s emergency physicians, we need to be prepared to treat the victims of mass casualty events, both man-made and natural disasters. One of the more high-profile responses remains the active shooter event. Caring for the victim of a shooting event, whether a gang fight, police gun battle, or the mass shooting, hasn’t changed. The principles of managing the ABCs that we have all learned in medical school, residency or as street EMS providers hasn’t changed, but there have been some tweaks. Law enforcement has now taken a more militaristic stance with special operations teams (SWAT) by partnering with EMS to place medical personnel up front or even as part of the team. While the primary mission of “SWAT medics” is to provide medical support to the law enforcement unit, having EMS personnel on site to treat any injuries is beneficial to all. One of the mainstays in training military medics is the Tactical Combat Casualty Care (TCCC) course which now has a civilian counterpart. The mantra of this training is to “Stop the bleeding, start the breathing.” This is taught as maintaining the “XABCs”, where X is eXanguinating hemorrhage. When deaths from gunshot wounds, specifically combat gunfire, is examined, there are some deaths that occur immediately. These are wounds that instantaneously kill: specific head shots or torso shots that hit brainstem or the left ventricle or the aorta. Short of being shot in the presence of the appropriate surgeon in the OR, these are not survivable. The next group of deaths from gunfire is related to exsanguinating hemorrhage: wounds that are bleeding out. In an extremity, the immediate life-saving intervention for exsanguinating hemorrhage is the placement of a tourniquet. Classically, two cravats and a stick, the traditional tourniquet taught for the Boy Scouts of America first aid merit badge, works incredibly well. Commercial tourniquets should work on the same “windlass” mechanism as this.

Ratchet style mechanisms are also acceptable. One very common piece of equipment used every day as a “tourniquet” is the blood pressure cuff. The mechanism of a pneumatic tourniquet also works well, but the one caveat to using a manual BP cuff is you need to clamp the tubes. Hence, “Stop the bleeding.” The next spike in deaths from gunshot wounds is from tension pneumothorax. Here is where we “start the breathing.” The emergency management from tension pneumothorax is needle decompression; the definitive management is chest tube placement. Needle decompression is best accomplished in the second intercostal space, midclavicular line, with a large-bore iv catheter. A 14-gauge catheter is preferred. There has been significant discussion and concern regarding the appropriate catheter length, specifically with regard to the increase in obesity in the United States. You may need longer catheters for larger patients. The definitive management is tube thoracostomy, or chest tube placement. This is best accomplished at the 4th-5th intercostal space, mid-axillary line. Tube size is variable. Pure pneumothorax may need smaller tubes such as a 28-french. If there is concern for hemothorax or hemopneumothorax, a larger tube, such as a 34 or 36-french tube should be used.

hemorrhage and tension pneumothorax are accomplished, or if their presence has been ruled out, attention may be turned back to the conventional ABCs. In the actual tactical environment, however, there are some modifications. Laryngoscopy for intubation may be deferred, as the light source may provide a tactical disadvantage. Basic life support airway adjuncts or supraglottic airway devices may be placed initially for the tactical environment. Oxygenation may also be deferred as the logistics of carrying an oxygen bottle into the tactical environment are difficulty; as well as a significant risk placed to the tactical team should an oxygen tank be ruptured by gunfire. Lastly, CPR may not be performed, again related to the logistics of tying up tactical medical providers for such work, as well as exposing those providing CPR to gunfire There are numerous resources on the web and in print regarding tactical medicine. Most of them are derived from TCCC or similar programs. Additionally, there are a number of tactical medicine courses, some do provide physician CME. While these courses are designed for the tactical medicine provider, the approach to the patient wounded from gunfire that these courses provide will serve you well in preventing death in an otherwise potentially salvageable patient.

Small pneumothoraces can be treated with oxygenation and expectant management; or with placement of a pigtail catheter. These kits are sold commercially and allow for placement of a pigtail catheter into the pneumothorax via a Seldinger technique. Location would be the same as a chest tube. of

Once the treatment exsanguinating

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H p a


Tax Fraud Hits Many Physicians Janice Wachtler, BAE, CBA


ecently, Krebs on Security, an online source of in-depth security news and investigation, reported that many physicians are being informed by the Internal Revenue Service (IRS) that their income tax has already been filed for 2013 and they were victims of tax fraud. No one quite knows the extent of the problem or even where a security breach has occurred but it is assumed that National Providers Identification (NPI) numbers have been obtained through this breach.

The incident was first reported by the New Hampshire Medical Society which stated that physicians who were filing their tax returns around April 15th received notifications of

previous filings. Since then other state medical societies have reported similar occurrences. It should be noted that ACOEP does not house any NPI information and all physicianmember information is stored on a secure system protected by redundant firewalls. Theories abound on how these numbers were obtained, whether hackers somehow acquired Social Security numbers or NPIs from a government, state or national medical society or from an unknown source. The online source states that, according to a Treasury Inspector General’s office, in 2012 the IRS issued nearly $4 billion in fraudulent refunds to people who stole Social Security numbers and other personal information and then filed bogus tax returns.

We want to make you aware of this scheme as several members of ACOEP reported that they too have been notified of duplicate tax returns and refunds being made. If this happens to you make sure you report this to the IRS at the Identity Protection Specialization Unit, 1-800908-4490 so that steps can be taken to secure your account and obtain an IRS PIN number to protect further filings. There are specific IRS forms that you will need to complete. Source: http//

Are You Making the Most of your Membership? Visit to see the exclusive offers ACOEP members receive from these great partners!

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2014 Board Candidates Janice Wachtler, BAE, CBA


t’s election season again! Time to select the newest members of the ACOEP Board of Directors. Some of ACOEP’s brightest, most energetic and experienced members are running for a position. Take a moment to familiarize yourself with the candidates. Voting instructions will be sent to all qualified members this summer and the new board members will be announced at The Edge: Scientific Assembly 2014!

Shan Ahmed, D.O. is a board certified emergency medicine physician who would be an asset to the college as an established leader, active member, and well respected colleague in the field. He first became involved with ACOEP by becoming a leader within the Resident Chapter. His main goal was to provide our future DO’s better insight to the world of emergency medicine, and pursued this goal by enhancing both the resident and student chapters. He established the annual Emergency Medicine Jeopardy Tournaments for the residents, as well as introducing the concept of having routine hand-on workshops for the students. Dr. Ahmed has not only performed numerous workshops, but also helped organize the resident and student Suture Lab, Ultrasound Workshop, and the multifaceted Procedure Labs which are still currently run by both chapters. In addition, he continues to give lectures and assist in numerous activities for both the residents and students on a local and national level. During his membership with ACOEP, he has been a part of several committees including the Undergraduate Medical Education Committee, which he now serves as the Chairperson and has done so for the past two years. Dr. Ahmed is a proud graduate of the New York College of Osteopathic Medicine. He remains an active member of his medical college where he serves as an assistant professor, and lectures at the regional osteopathic conventions. He completed his training in osteopathic emergency medicine at Good Samaritan Hospital Medical Center in New York where he was chief resident. After graduation from residency, he became a part of the core faculty and subsequently Assistant Residency Director of the Emergency Medicine program. Following

his time at Good Samaritan, Dr. Ahmed became the Assistant Medical Director at St. Charles Hospital and afterwards was promoted to Medical Director at St. Joseph Hospital, both of which were are in New York. At St. Joseph Hospital, he was involved in many aspects of hospital functions such as spearheading the sepsis initiative and creating the first Emergency Department Concussion Program in New York. Dr. Ahmed is also passionate about EMS. He volunteers his time as the Medical Director for multiple agencies in his catchment area, and serves on the physician advisory committee for Nassau County EMS. Currently, Dr. Ahmed works as the Regional Medical Director for Island Medical Physicians P.C. on Long Island New York and in addition to clinical shifts, oversees operations at 3 emergency departments on Long Island and several others in the North East. In his seven years as a physician in emergency medicine, Dr. Ahmed has certainly achieved a great deal, not only in his personal career and life, but also with all the volunteer work that he does for EMS, the local college and on the national level with ACOEP. He has not only brought great ideas and concepts to the college, but has initiated various workshops and programs that the college holds dear today. His belief in college and member unity along with promoting mentorship and leadership from the grass root level has been his goals for the college then, now and for the future. “I believe it is my time to give back as a Board Member of the ACOEP. As a member of the college since my residency, I’ve had the privilege of many great mentors contributing to my academic and personal growth and thus enabling me to develop into a confident and competent emergency medicine physician. I am truly honored to be nominated to the board and have the opportunity to serve the college that has helped me become the person I am today.” Gregory J. (“Joe”) Beirne, D.O., FACOEP, FACEP, is a 1997 graduate of the Chicago College of Osteopathic Medicine and a 2001 graduate of Des Peres Hospital emergency medicine residency. After graduating, he stayed on as core faculty for the residency program until 2003. Since 2003, he has

worked as an attending physician in the emergency department at Missouri Baptist Medical Center in St. Louis, Missouri, and is EMS medical director and EMS education director. He also serves as medical director for St. Louis Community College EMS Programs and as medical director for Respond Right EMS Academy, a privately owned EMS training program. Joe was certified in emergency medicine by AOBEM in 2003, and received fellowship status from ACOEP in 2005 and ACEP in 2004. As a member of the college, he has served on the undergraduate medical education committee and on the EMS committee, initially as a member in 2004, then became EMS committee chair in 2009, a position he currently holds. Joe is also ACOEP liaison to CECBEMS (Continuing Education Coordinating Board for EMS) and a member of the Metro Area Advisory Council of EMS in St. Louis, a group of local EMS medical directors who continually improve the quality of prehospital care in the metropolitan St. Louis area. Joe began his career many years ago as a paramedic for a hospital-based EMS system in St. Louis, eventually becoming a shift supervisor and paramedic program instructor. After completing medical school and residency training, he became actively involved in the EMS community that mentored him early in his career and has been a leader in EMS education and training for the entire St. Louis area. As a member of ACOEP, Joe has been actively involved with the student chapter, serving as a mentor for the student leadership academy projects at the spring conference, as well as lecture and lab sessions for the fall conferences. I appreciate the opportunity to introduce myself to the members of the college and ask for your support as I seek a position on the ACOEP board of directors. Having served the college over the last 10 years as a committee chair, lecturer and student mentor, I have found the experience incredibly rewarding. My goal is to represent the interests of ALL the members of the college, and to provide my experience, knowledge and leadership to the students and residents, who are the future of our college. I am actively involved at multiple levels locally and nationally supporting the future of emergency medicine as the “front door” to health care and that we, as emergency physicians, are the critical link in any healthcare model and

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19 know how best to provide care for the patients in that system. Lastly, we need to continue to cultivate an environment of mentorship with our students and residents to prepare them for their professional careers, as well as provide them with the leadership skills and knowledge to become the next generation of leaders of our college. In closing, I would like to thank you for the opportunity to introduce myself and ask for your support and your vote as I seek a position on the ACOEP board of directors. If elected, I pledge to continue my work to represent your interests and advance the specialty of emergency medicine. Thank you for your time and your support!! Christine F. Giesa, D.O., FACOEP-D Dr. Christine F. Giesa has spent more than two decades striving to exemplify excellence and professionalism in her medical care, her instruction, and her professional affiliations. A graduate of the Philadelphia College of Osteopathic Medicine, Dr. Giesa completed her residency in emergency medicine at Albert Einstein Medical Center in Philadelphia, Pennsylvania. Following her residency, Dr. Giesa was a clinical instructor for the Albert Einstein Emergency Residency Program until 2011, when she made a career change. She now works in the emergency department at Delaware County Memorial Hospital which is a community hospital in the suburbs of Philadelphia. In addition to her clinical duties she also serves as the program director of a traditional osteopathic rotating internship and is the osteopathic DME for the Crozer- Keystone Health System. Dr. Giesa has been a dedicated member of the American College of Osteopathic Emergency Physicians since 1991 and has been an active member of the Continuing Medical Education Committee since 1997. She attained fellowship status in 1998 and in 2014 received the honor of distinguished fellow for longstanding service to the college. Upon joining the CME Committee, she was appointed vice-chair of the Spring Seminar and ultimately became chairman. She worked to help establish the concept of “updates” as the theme for the Spring Seminar and devised a 5-year rotation schedule for core topics. Dr. Giesa has been vice-chair and chair of the CME Committee and was instrumental in developing the COLA Seminar. Dr. Giesa takes her responsibilities for the College seriously and says that she still enjoys participating in the COLA seminar. Dr. Giesa was asked several times to consider running for the Board of Directors, but did not

accept the invitation until the CME Committee had strong leaders in place to work effectively to continue the standard of excellence that past and present CME Committee chairs have worked so hard to establish. Dr. Giesa is currently finishing her first term as a member of the Board of Directors and says ”it has been an honor to have served on the board for the past three years and to be nominated to continue to serve our college.” As a member of the Board, Dr. Giesa has had the opportunity to serve as a mentor for the Student Chapter and she is currently vice chair of the finance committee. The Board of Directors has made it their mission to promote osteopathic emergency medicine and to reach out and mentor all of the student chapters. This past year Dr. Giesa was assigned to be the board mentor to the emergency medicine clubs at the Lake Erie College of Osteopathic Medicine and the Lake Erie Bradenton campus. Her close proximity to PCOM also allowed her to visit their emergency medicine club. Dr. Giesa says “serving as a member of the Board of Directors for the ACOEP has been a very enlightening and humbling experience. I would very much like to be given the opportunity to continue serving our membership as a member of the Board of Director.” Brandon Lewis, D.O. is a graduate of Texas A&M University and the University of North Texas Health Science Center-Texas College of Osteopathic Medicine. He completed his Emergency Medicine residency at Lehigh Valley Health Network in Allentown, PA. He served in the U.S. Air National Guard for 10 years as a flight surgeon and was activated several times including a deployment to Iraq in 2007. Dr. Lewis is a partner and member of the Board of Managers at Emergency Service Partners, LP, a physician owned Emergency Medicine partnership group which staffs 25 emergency departments across the state of Texas. Dr. Lewis currently practices at St Joseph Regional Health Center, a 300 bed community hospital in Bryan, TX. He currently serves as both Medical Director and Chair of the Emergency Services Department which sees 65,000 patients per year. Under his direction, the Emergency Department, in cooperation with other departments, earned the hospital national recognition six consecutive years for excellence in stroke and cardiac care. The facility was designated as a certified stroke center and selected by CMS to serve as a test site for Comprehensive Stroke designation criteria for community hospitals. His facility achieved Cycle IV Chest Pain Center accreditation, and increased its trauma designation

from Level III to Level II. He also oversaw the consolidation of regional EMS services under a single medical director for better standardization and cooperation and implemented a successful clinical research program in the Emergency Department. He has received awards from Texas Trauma Region-N Regional Area Council and St Joseph Regional for his service and achievements. Dr. Lewis also serves as Vice President of Medical Affairs for the St Joseph Health System. Dr. Lewis began his administrative career serving in a Medical Director role at a 7000 volume rural hospital ED and later, at a hospital affiliated freestanding ED seeing 12,000 patient per year. Dr. Lewis has been an active member of the ACOEP since joining as a student in 1998. He served in several leadership positions during medical school and residency including President of both the Student and Resident Chapters. One of his more notable achievement during that period was authoring a resolution that eventually led to the AOBEM changing their rules to allow 4th year residents the opportunity to sit for Step 1 of their Emergency Medicine Boards. He is currently a member of the Graduate Medical Education Committee, the Members Services Committee, and is the current and founding Chair of the Young Physicians Special Interest Group. He has also been a speaker on several occasions for the Student Chapter at the annual Scientific Assembly. Dr. Lewis also serves on the Steering Committee for the FOEM Research Network. He is active with the Emergency Medicine Practice Management Association, a conglomerate of Emergency Medicine organizations which advocate on behalf of the specialty on legislative and regulatory issues. Dr. Lewis has also been very active in his state medical society, the Texas Osteopathic Medical Association having served on several committees and three terms, as a student, a Young Physician, and as a regular elected member on its Board of Directors. Having served previously as both a student and resident, Dr. Lewis feels very honored to have been nominated for a position on the ACOEP Board of Directors. If elected, he would bring the viewpoint of an experienced physician working in a community hospital, who is actively engaged with the residents and newer members of the College. He would relish the opportunity to offer his experience and proven leadership skills in continued service to the College as a member of the Board of Directors. Robert E. Suter, DO, MHA, FACOEP-D, FIFEM. It is an incredible honor to have had the opportunity to serve the membership of my College for the past three years on your ACOEP

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20 Board. By electing me to my first term you made an investment in me that I hope to repay by continuing to have the opportunity to serve you into the future. As a member of ACOEP for over 25 years, it has always been the place that I feel most comfortable. I joined as a student, served as the President of my school’s EM club, and was a founding member of both the national Student and Resident Chapters. As a graduate of the St. Louis University EMTParamedic program and Washington University in St. Louis, who worked full time in EMS and EMS education prior to receiving my DO and MHA degrees from Des Moines University, I was singled out by my residency leadership at Brooke Army Medical Center in San Antonio, Texas to run for EMRA President. I did so and was elected, becoming the first DO to be elected to a national emergency medicine office outside of the AOA. I also was on the first executive committee of the American Association of Osteopathic Postgraduate Physicians which the AOA evolved into a Council. Following residency I became board certified by both American Osteopathic Board of Emergency Medicine and the American Board of Emergency Medicine with a CAQ in Emergency Medical Services from both organizations. During this time I was also elected to the Board of the Government Services Chapter of ACEP, participated in numerous state and national committees, including in the ACOEP, lectured at ACOEP and other venues, and served as the liaison to several organizations In subsequent years, I served over two decades as an EMS Medical Director at the local and regional level and was the physician Co-Chair of the federal project EMS Agenda for the Future published in 1995. In 1998 I was given the Wackerle Founders Award, EMRA's highest recognition of service to emergency medicine and emergency medicine residents, and in 2000 the highest award of the Continuing Education Coordinating Board for EMS for many years of contributions to advancement of EMS education. A member of the ACEP Council from 1991, in 1999 I was elected to ACEP Board of Directors for the first of two terms, becoming the first osteopathic physician to serve as ACEP President in 2004-05. I was also the first osteopathic physician on the Board of the International Federation for Emergency Medicine, and served as its President in 2006, continuing to serve on or chair a number of important committees and task forces of IFEM, and was awarded the Order of the IFEM in 2008, and in 2009 was given the John G. Wiegenstien Leadership Award, ACEPs most coveted honor.

nearly every imaginable academic and private practice setting, including the U.S. military, as a Colonel in the U.S. Army Reserve. My full time private practice experience includes serving as a medical director, staff physician, regional medical director, and partner in a democratic group. Before moving to my current position at the American Heart Association as a Vice President responsible for all Quality Programs around the globe, I was a full-time Professor of Emergency Medicine at the University of Texas-Southwestern leading efforts in Professional Development, and was Chief of the Practice Management, Health Policy, and International Emergency Medicine Sections. I continue to practice emergency medicine 12 hours a week at Parkland and Children’s Hospitals in Dallas, and also hold appointments as a Professor at the Medical College of Georgia, Des Moines University, and the Uniformed Services University of the Health Sciences. My military service includes time in Iraq with the 1st Cavalry and 3rd Infantry Divisions, as the Army Reserve Consultant to the Surgeon General for Emergency Medicine, and command of the 94th Combat Support Hospital. My long-term commitment to clinical excellence, teaching, and research in EMS and emergency medicine has included a passion for sharing the specialty of emergency medicine and the osteopathic profession with EMS and physician colleagues around the world. I have authored or co-authored scores of studies, papers, and textbook chapters in emergency medicine, and

given hundreds of presentations worldwide. My academic efforts have centered on being integrative scholar, especially in the areas of Evidenced-Based Practice, EMS, Practice Management, Quality, and Health Policy and preserving the Global History of Emergency Medicine. Most importantly, however, have been my efforts to serve the profession. In addition to higher profile service in the AOA early in my career, and years of ACOEP lecturing and serving on ACOEP committees, in 2010 joining the board of the Foundation for Osteopathic Emergency Medicine, and the ACOEP Board in 2011. I have also served on the Des Moines University Alumni Board of directors since 1998, currently serving as President. All of these roles and the associated liaison and other work have allowed me the opportunity to be a better Board member and to begin to repay the ACOEP and the osteopathic profession by bringing to the ACOEP Board the many experiences and expertise that I have been fortunate to have obtained over the past twenty years. This includes my military and other experiences that would be otherwise underrepresented. It is my hope that I will continue to have the opportunity to serve you in the coming years to bring my unique knowledge to ACOEP for consideration by my amazing colleagues on the Board in our shared decision making process. Thank you for your past and future support of me and our College.

Board Election FAQs

Each fall ACOEP holds elections for available positions on Board of Directors. Here are some frequently asked questions to remind you of how the process works: Who’s eligible to vote? All categories of Active, Retired, and Life members of ACOEP are eligible to participate in the election process for the Board of Directors. The following membership categories are considered Active members categories: Active First Year Fellow Member Life Member Life Charter Member Active Member Retired Member Distinguished Fellow Member When does voting begin? Voting will open on August 1, 2014 and will close one hour before the Membership Meeting at the 2014 Scientific Assembly at 4 PM Pacific Time. Can I vote on that day? Voting can be done only when eligible members pay their dues. The earlier you pay your dues, the earlier you can vote. Voting remains open until 4:00 p.m. PST on Sunday, October 12, 2014. How will I know when I’m eligible to vote? As dues payments are received and entered, Sonya Stephens, Member Service Director, will send paid members an email with the link and instructions. Can I vote at the Scientific Assembly? Yes, Voting will remain open until 1 hour prior to the General Membership Meeting at the 2014 Scientific Assembly in Las Vegas (on Sunday October 12, 2014, 5-7 PM). At the conference, voting kiosks will be available on the day of the Membership Meeting and a link will be available on the conference app. Eligible Members, who have not already done so, may vote on-site using computers at these kiosks or your own laptop or tablet.

My emergency medicine practice has spanned

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21 Book Review:

Back from Burnout by Frank Gabrin, DO Tim Cheslock, DO, FACOEP


t’s not too often I get to do book reviews anymore. When I was asked to review a book sent to the ACOEP office I was hesitant at first. What I came to find from the experience though is that you should never turn down a challenge and you might even come out better for it in the long run. Back from Burnout, by Frank Gabrin, DO, is very pertinent to the daily practice routine in which we all find ourselves. It is no secret that if you practice emergency medicine long enough you will at some point in time exhibit signs of burnout. Whether it is disrupted sleep, agitation, problems with alcohol or substances or relationship strain, almost every one of us will go through a rough patch in our career. We tend to become apathetic to what is going on around us. Our patients can sense that we don’t care. Our satisfaction scores suffer and this reflects poorly on us and our practice. Worse yet, the risk of litigation becomes more substantial and the potential for a malpractice case becomes exponential. All because we are not happy, overworked and have lost sight of why we used to really love the practice of medicine. Dr. Frank Gabrin shares his personal journey of coming back from burnout and how it took some pretty vivid patient encounters to make him realize that there was a lot more going on in his life than he realized. We see a physician who, just like us, dealt with the daily hustle and bustle of a busy ED and all the frustrations that accompany it. Patient satisfaction scores, HCAHPS scores, patient holding, and frustrated coworkers are part of the daily routine. Work faster and harder, but make sure the patient gives us a five as they walk out the door. It’s not hard to imagine myself in the same situation as I read the opening chapters. Every person has a transforming event in their life. For Frank Gabrin that event was beating cancer, not once but twice. He shares how his battle with cancer changed him and gave a unique perspective to him from both sides of the stethoscope. Eyes are opened when

suddenly you are the one on the receiving end of this great system we call healthcare. There are many other personal stories included from his life as well. We all have those patients that touch our lives for some reason or other. The young injured child, the elderly patient taking their last breath, the behavioral health patient seeing purple cows. Yes, I said purple cows. That was a teaser. Another reason to read the book!

What is even better is being given the chance to regain that feeling of satisfaction that you once enjoyed. I would highly recommend this to all EM physicians and any healthcare provider that seeks to reconnect with the reason that they decided to become a care provider. It is well worth your time!

Why should you read the book? This book will help you get back what you have lost in your daily routine. How to truly care. He defines True Care and provides a way to reconnect with our patients and give them what they really want. All while in the process, giving ourselves what we really want—to once again be happy and fulfilled in our career. It is always interesting to see inside another’s journey, one not so dissimilar from your own. In some instances I found myself asking, how could he have been there on my last shift? It was almost eerie, some of the similarities.

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His Right Upper Quadrant Abdominal Pain is from What? Michael Schick, DO, and Anne Klimke, MD

Introduction Right upper quadrant (RUQ) pain can be related to multiple etiologies. Bedside ultrasound can rapidly rule in and out a number of life threats. It is typically utilized in the emergency department to rule out cholilithiasis and/or cholecystitis. It may also discover unusual anatomy or pathology. This article highlights and reviews causes of RUQ pain other than gallbladder disease that may benefit from a bedside ultrasound. Case Report A 57-year-old male presented to the emergency department (ED) from home with RUQ and epigastric abdominal pain. It began 6-7 days ago as dull epigastric discomfort that radiated to the back that per the patient initially felt like a flare of his chronic pancreatitis. He went to an outside hospital ED where lab work was done and he was discharged with oxycodone without a definitive diagnosis. He now states the pain is localized mostly in his RUQ with no radiation of the pain. He notes the pain is worse with lying flat. He denies nausea, vomiting, black or bloody stools. He had a normal bowel movement two days ago. He denies fevers, chills, or other constitutional symptoms. He denies weight loss. He acknowledges a long history of alcohol abuse, but his last drink was four months ago. Recent endoscopy demonstrated esophageal varices. Recent colonoscopy was unremarkable.

guaiac negative. Otherwise his physical exam is unremarkable. Given the patient’s location of pain and vital signs consistent with a systemic inflammatory response syndrome there was primarily a concern for an infectious or inflammatory process. The chest x-ray demonstrated an elevated right hemi-diaphragm. It was unclear whether this represented a large pleural effusion or perhaps a mass in the RUQ of the abdomen.

Figure 1. PA and lateral upright chest radiograph demonstrating an apparent elevated right hemi-diaphragm versus pleural effusion. A bedside ultrasound demonstrated a large fluid collection within the capsule of the liver. It was concerning for a subcapsular hematoma or abscess. Gallstones and a thickened gallbladder wall were also appreciated, concerning for cholecystitis. Surgery was consulted at this time and the patient was put in for a computed tomography (CT) scan of the abdomen and pelvis.

The CT scan demonstrated possible cholecystitis, a large subcapsular fluid most likely a hematoma, cirrhosis of the liver, and a 4x2 cm pancreatic mass encasing the porta hepatis.

Figure 4. Coronal and transverse cuts from an IV contrast enhanced CT scan of the abdomen demonstrating a large superior subcapsular fluid collection, most likely hematoma.

Figure 5. Coronal cut from the same CT scan demonstrates a 4x2 cm pancreatic mass.

The patient’s past medical history includes pancreatitis, hepatitis, cholelithiasis, alcohol abuse, and schizophrenia. The patient takes sucralfate, nadolol, and pantoprazole. On physical exam, the patient’s vital signs were as follows: blood pressure 111/62, heart rate 99, respiratory rate 16, pulse oximetry is 97% on room air and a rectal temperature of 38.9 °C. He is alert, in no acute distress, but appears uncomfortable. His abdomen is soft, non-distended, with normal bowel sounds. He has moderate tenderness to palpation in the RUQ without rebound and mild voluntary guarding. His rectal exam demonstrates external hemorrhoids, yellow stool that is

Figure 3. RUQ ultrasound demonstring hyperechoic gallstones with shadowing, thickened gallbladder wall.

Figure 2. RUQ bedside ultrasound demonstrating a large complex fluid collection within the capsule of the liver.

Surgery evaluated the patient and believed the gallbladder wall thickening was likely secondary to the patient’s underlying liver disease. The patient was admitted for further evaluation and management. Discussion There are numerous etiologies for RUQ abdominal pain. Traditionally emergency ultrasound has been utilized to evaluate for gallbladder pathology. However, there are many more etiologies of RUQ abdominal pain that can be discovered by bedside ultrasound.

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Subcapsular fluid collections of the liver can be from blood, bile, or pus. The etiology may be infectious, obstructive, traumatic or spontaneous. Risk factors include: coagulopathy, pregnancy, liver disease, biliary disease, and malignancy. They are often subacute and related to another underlying process. Pathology in the right lower chest can present with right upper abdominal pain. This pain may be pleuritic or constant. A consolidation in the right lower lobe (RLL) of the lung may be easily visualized by bedside ultrasound. Consolidations may be secondary to infection, malignancy, atelectasis, contusion or pulmonary infarction. Pleural effusions are also easily visualized by bedside ultrasound. Pleural effusions have many possible etiologies that include infection, heart failure, cirrhosis, renal disease, pancreatitis, pulmonary infarction and malignancy. Pleural effusions are more likely to be simple anechoic fluid in contrast with a consolidation from pneumonia which will be complex. Hepatic abscesses may be divided in two categories, pyogenic or parasitic. Patient’s often present with fever, RUQ abdominal pain and jaundice. Pyogenic abscesses are uncommon and are typically associated with another site of infection such as biliary or bowel. There are often multiple abscesses present and immuncompromised patients are at particular risk. Parasitic abscesses include: amoeba, echinoccocal, protozoan and helmiths. Amebic abscesses are common worldwide with possibly 10% of the world population infected. However, amebic abscesses are

found in only 1-2% of liver abscesses in the US. Echinoccocal, protozoan and helmiths are very uncommon in the US, but common in developing regions. Hepatic abscesses are typically poorly demarcated and range from primarily hypoechoic to hyperechoic. Hepatomegaly can be present in multiple disease states that cause RUQ abdominal pain including: hepatitis, right heart failure, systemic volume overload states, infiltrative disease and carcinomas. Hepatomegaly can be detected by measuring the liver longitudinally. Greater than 12-14 cm is considered abnormal. Additionally, when using the Morison’s pouch view, extension of the right lobe of the liver beyond the inferior pole of the kidney indicates probable hepatomegaly. Malignancy can present as RUQ abdominal pain and be associated with nausea, vomiting, jaundice and weight loss. The most common etiology of hepatic mass is metastasis from another primary malignancy. However, the etiology of RUQ abdominal pain can be due to primary malignancy of the liver, gallbladder or pancreas. Gallbladder carcinoma is uncommon, representing 5% of all cancers found at autopsy. Ultrasound is more sensitive than CT in identifying gallbladder carcinoma. Pancreatic carcinoma has a dismal 5-year survival rate of 4%. Risk factors include chronic alcoholism, chronic pancreatitis, and diabetes. Early detection is paramount and complete resection is the only effective treatment, which was not possible for this patient because of the complexity of the mass and its location.

References • Chen CJ et al. Clinical Presentation and Outcome of Hepatic Subcapsular Fluid Collections. J Formos Med Assoc. 2009;108(1):61-8 • Lichtenstein, et al. The BLUE-points: three standardized points used in the BLUEprotocol for ultrasound assessment of the lung in acute respiratory failure. Crit Ultrasound. 2011:3(2):109-110. • Ma J, Mateer J, Blaivas M. Emergency Ultrasound, 2nd edition. McGraw-Hill Companies, Inc. 2008 • Marx et al. Rosen’s Emergency Medicine Concepts and Clinical Practice, 7th edition. Elsevier Inc. 2010 • Parlamento et al. Evaluation of lung ultrasound for the diagnosis of pneumonia in the ED. The American Journal of Emergency Medicine. 2009;27(4):379-84 • Volpicelli G, Elbarbary M, Blaivas M, et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med. 2012 Apr;38(4):577-91. Epub 2012 Mar 6. • Xirouchaki et al. Lung ultrasound in critically ill patients: Comparison with bedside chest radiography. Intensive Care Med. 2011;37(9):1488-93.

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Doing a Disservice to the Deserved Gregory M. Christiansen, DO, FACOEP-D


he story that broke on CNN on April 23, 2014, was nothing new to many emergency physicians, especially those who worked in the VA system of hospitals or were familiar with care being given to veterans. America’s dirty little secret was now big news - our veterans are dying in a dysfunctional medical system and social media outlets have been buzzing with commentary on the inevitable analogy between the non-functioning VA system and the Accountable Care Act. Does this surprise anyone? No, this happens in a large government-run system with lots of red tape and lots of users. The story about the VA’s use of false records in multiple states broke while we were at the Spring Seminar and more information was brought forth when we returned to our lives. The British tabloid, The Guardian, reported that America’s veterans were waiting more than 167 days for treatment and that the VA doled out more than $36,000,000 in settlements with veterans and their families to date. So you may ask why this is just being brought to life now, well that’s another story in itself. To get the real story, it’s important to review history. The VA system is a centralized system with all of the challenges and obstacles that come with massive bureaucracy. It was intended to serve the veterans who served our country. Since its conception in 1811, veterans would be entitled to life-long medical support. By 1988 nearly 1/3 of the US population was eligible for benefits from the VA. The VA continued to grow from an independent agency into a cabinet level department with direct access the President. It is a large system with facilities in most states; it serves 9 million veterans and has 85 million visits per year. It’s a rigid system to maintain consistency and in doing so it lacks the ability to adjust to the rapid changes in medicine; I know I worked there. In looking back over the last 50 years, the casual observer could easily see the system is arcane and slow. When faced with a massive influx of wounded soldiers from Vietnam, the VA was overwhelmed by the type and variety of condition it was mandated to

manage. It simply fell short in meeting the needs of our soldiers. Just check your media history and you’ll see what happened. Movies like “Born of the 4th of July” and “Coming Home” set in the era of the 1970’s chronicle the difficult conditions our service members endured from some VA hospitals. My very limited experience in the VA was consistent with what you would expect from a large top-down system. The credentialing process took months. I waited in long lines, just like the veterans I was to serve, to get my sanctioned blood tests and x-rays. I had to work through multiple cumbersome computer systems which could not integrate information. Only one person could work on a chart at a time because that is how the system functioned. Efficiency in the system took a backseat to the layered bureaucracy. Adjustments, adaptability and opportunities for change were and still are very difficult to initiate. Look at how long it has taken the government to address the issues of limited services, record improprieties and clearly identified unmet health conditions like depression. Just to offer some contrast - there were two MERS cases in the US and the national media immediately told the public how those cases were being address by their respective treating hospitals. What would happen in your shop if you faced on average 22 suicides/ day in your system? There have been 1,892 suicides from January 1, 2014 to the end of March and I am guessing you haven’t heard how this issue is being confronted by the hospital system. This is very sobering information. I would argue complacency settles for accepting the idea that you get what you get in a big bureaucracy. So imagine the frustration as a board certified emergency physician of not being allowed to intubate in the emergency department. This experience is not unique as I had to be credentialed through a training rotation and signed off by the anesthesiologist to seek this privilege. These kinds of system mandates were constantly consuming physician time to maintain credentials. The VA facility could not attract certified emergency physicians to work in the emergency department because of the

unyielding bureaucracy. This flaw nearly cost the life of one veteran that I can personally attest to. In the VA hospital emergency department I had worked, attending physicians typically were not emergency medicine trained. On one random weekend shift, I worked the swing shift with my non-EM trained colleagues. A patient had just come from dialysis was carried into the ED by his son who was visibly panicked. The veteran was diaphoretic, tachycardic, incoherent, and bleeding profusely from his shunt. The access graft was torn and the patient was slipping into irreversible shock. The covering non-EM trained doctor was clearly out of his element. So I jumped in and was fortunate enough to be able to control the hemorrhage while starting the resuscitation. The covering doctor had never treated uncontrolled hemorrhage and never performed a baseball stitch to sew up the tear. It was not part of his residency training experience. He graciously thanked me for getting involved and the patient lived. I would like to say this was an anomaly in the VA system, but it’s not. When you have serious concerns and question the system to provide safeguards to improve patient outcomes, the normal reply is because “it’s the VA.” It’s a culture that would not be tolerated in private settings where physician pressure would force the question and best practice would be put in place to safeguard patient care and outcome. After all, no one would go to a civilian hospital or clinic if wait times were measured in days and months, not in hours and minutes. The civilian system is now is the same boat. If you look across the pond it’s the same story. Tiny little Scotland’s single payer list did the same thing as the VA. 7,000 patients planned for surgery were conveniently removed from the list to make it look like metrics were being met. England’s National Health Service averages 8 weeks to get admitted to the hospital for a medical condition. In 2013 Canadians waited more than nine months for orthopedic treatment and neurosurgery cases waited at least four months. In the system I am most familiar with, Virginia Commonwealth University

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25 Medicaid, patients could expect on average to wait nine months to a year before getting into any of the specialty clinics. Since these patients can’t get into the system, where do you think these patients went for care? The same place the VA patients went—the ED. Remember in 2006 when an ED doctor was charged with homicide for a death in the clogged waiting room of an Illinois hospital? What part of the Obamacare system changed to correct this event from being repeated? Unfortunately, this is likely to happen again and the system has even less ability to adapt to the regulatory pressures. I am aware of two hospital systems in my region which are succumbing to those pressures as they prepare to close their doors. The other regional hospital will be expected to pick up the additional volume even though their margins are too thin to adjust in a substantial way. So I will close with this story. A colleague who practices internal medicine tried to get services for his elderly parents. His parents had no idea on how to navigate the system and pleaded for his help. It took him half the day to get to the right people just to get the appointment approved. He said they would have never been able to figure it out. He said his father would have just given up. So as frustrating as the system is, you can make a difference to your patients in trying to have patience. They may have desperate situations you probably can’t fix. But if you advocate for them you can never go wrong. Our service men and women deserve all of us to be advocates for them.

world/2014/may/18/obama-madder-thanhell-va-allegations • news/2014/may/18/obama-warned-aboutva-wait-time-problems-during-20/ • AD/DC. Dirty Deed Done Dirt Cheap, Australia 1976. • us/2014/05/18/whistleblower-websitelaunched-to-expose-va-wrongdoing/ • reports/1993/11/a-guide-to-the-clintonhealth-plan • flashback-the-healthcare-debate-of-1994#. U3pCq_ldVZs •

nation/2014/05/18/fort-collins-va-clinicwhistleblower/9258309/ • h ttp:// • article/378233/lessons-va-scandal-john-fund • B32a8NPv.dpbs • va-study-finds-more-veterans-committingsuicide/2013/01/31/1092b330-5a68-11e29fa9-5fbdc9530eb9_story.html • politics/2014/03/commemorating-suicidesvets-plant-1892-flags-on-national-mall/ • MERS/INDEX.HTML

 eferences & Web site R locations: • http://www.cnn. com/2014/04/23/ health/veteransdying-health-caredelays/ • http://www. dcclothesline. com/2014/05/19/ left-dieadministration-runamok/ • http://www.

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northeast ohio We are now looking for excellent EM physicians to join our stable, well established group at the following locations:  UH Richmond Medical Center Richmond Heights, OH - 22k UH Bedford Medical Center Bedford, OH - 20k UH Geneva Medical Center Geneva, OH - 14k

UH Ahuja Medical Center Beachwood, OH - 24k UH Conneaut Medical Center Conneaut, OH - 13.5k UH Twinsburg Medical Center Twinsburg, OH - 16k

EXTREMELY COMPETITIVE COMPENSATION Incentive Plan HSA Contribution Signing Bonus Life Insurance Company Funded 401K Malpractice Insurance  with Tail  Short/Long Term Disability Group Health Plan  UH Geauga Medical Center Chardon, OH - 19k St. Joseph's Health Center Warren (Eastland), OH - 38k Howland, OH - 13.5k (urgent care)

St. Elizabeth Health Center Boardman, OH - 43k Austintown, OH - 31k Youngstown, OH - 41k St. Joseph's Family Medical Center Andover, OH - 7.5k

Warren, OH - 11.5k (urgent care)

To learn more about joining our practice, contact Erin Waggoner at or Jeff Mirelli at

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Call to Meeting Membership Meeting Sunday, October 12 5:00-7:00pm Caesars Palace 3570 Las Vegas Blvd, Las Vegas, NV 89109 The biannual ACOEP Membership Meeting provides you with the opportunity to learn the most recent news of the College, including the latest on the proposed single pathway development, the results of the Board elections, and CME opportunities! Attendance is credited toward applications for fellowship by submitting an attendance form at the conclusion of the meeting.

Save the Dates!

Thank You to EmCare, ACOEP’s 2014 Prime Partner!

ACOEP is already planning exciting opportunities for 2015! Mark your calendars for these conferences: Intense Review and Oral Board Review January 13-19, 2015 Westin River North Chicago, IL The Edge: Spring Seminar 2015 April 7-11, 2015 Marriott Harbor Beach Ft. Lauderdale, FL The Edge: Scientific Assembly 2015 October 18-21, 2015 Loews Portofino Bay Universal, Orlando, FL

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Foundation Focus Sherry D. Turner, DO, FACOEP President


he Board of Trustees of the Foundation is thrilled to welcome two new members. Aimee Blagovich, D.O. and Shelly Zimmerman-Damon, D.O., FACOEP have been actively involved with FOEM for many years, and we are honored to have them on our team. To learn more about the FOEM Board of Trustees, please visit our website at I would also like to announce the Competition Handbook has been updated, and available to students and residents wishing to participate in the fall competitions.. Applications are due by July 31! Lastly, don’t forget to sign up for the Faculty Development Track that will debut in October 2014. The Faculty Development Course has been designed to assist current and future emergency medicine core faculty with skills required to meet the new standards for research in the new basic standards that will govern the profession under the Single Pathway for Accreditation. This course has been designed to provide participants with basic knowledge they will need to develop research, assist their residents to develop research during their residency, and remove the trepidation physicians have about undertaking a research project. FOEM's Recap of The Edge: Spring Seminar 2014 2014 FOEM 5K Run for Research Back for its 3rd year, the FOEM 5K Run for Research was as successful as ever! Participants were delighted to join together at the spectacular Westin Kierland Resort & Spa golf course for a bonding experience they would not soon forget.

ACOEP Immediate Past-President, Gregory Christiansen, D.O., FACOEP-D wore his usual eccentric running attire – this year an orange mohawk with a matching orange plastic mustache. ACOEP Board Secretary John Prestosh, D.O., FACOEP-D joined in the fun, donning a shiny orange wig that made it look as though his head was on fire as he ran. The rest of the group was happy to wear their official race t-shirts, and everyone had a great time zig-zagging through the scenic Arizona golf course as the sun rose. The winners of the race were: • 1st Place Male: Peter Lundy, D.O. • 2nd Place Male: James Hensel, D.O. • 3rd Place Male: Timothy Bickman • 1st Place Female: Danielle Cross, D.O. • 2nd Place Female: Stacy Kindell, D.O. • 3rd Place Female: Anjali Patel (wife of Nilesh Patel, D.O.) Thank you to all that came out and

congratulations to our winners! The 2014 FOEM 5K Run for Research would not be possible without the support of its corporate sponsors. Thank you! 2014 Case Study Poster Competition Sponsored by

The Case Study Poster Competition was another highlight of the Spring Seminar. Both residents and students provided what judges called “the best quality case presentations to date.” The event was generously sponsored for the 2nd year in a row by Premier Physician Services – we thank them for their support! The winners were: • 1st Place: Karan Parmar, D.O. of St. Barnabas Hospital continued on page 27

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THE 2014


MONDAY, OCTOBER 13 Caesars Palace, LasVegas, Nevada Supporting Sponsor:







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Core Faculty Academic and Research Skills Development Course Join FOEM for the brand-new Faculty Development Track, at the 2014 The Edge—Scientific Assembly! This one-day course will provide you with insight into how best to take advantage of FOEM’s new Research Quality Improvement Initiative, implement new common core standards, enrich research, and network with other institutions and organizations to improve osteopathic research across a broader spectrum! Topics will include research design, grant writing, orientation to the FOEM Research Network, tips on getting published and more!

Who should attend? The Core Faculty Academic and Research Skills Development Course is open to core and prospective core faculty members with an interest in improving research and academic teaching skills.

When are the seminars given? The Faculty Development Track will debut on October 12, 2014 at the ACOEP Scientific Assembly and run for four consecutive spring and fall meetings.

What is the cost? $50 per session for faculty, and free to residents nominated by their Program Director.

To find out more, contact Stephanie Whitmer at

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FOEM | BEACON "Foundation Focus" continued from page 24 • 2nd Place: Christine Goss, D.O. of Good Samaritan Hospital Medical Center • 3rd Place: Joshua Batt, D.O. of Arrowhead Regional Medical Center Winning Abstracts • 1 st Place: Karan Parmar, D.O. of St. Barnabas Hospital  eep Cool and Carry On: Rapid Cooling in K Heatstroke with Cerebral Edema ucky Ferozan DO, Karan Parmar DO, Edith B Szabo DO Introduction Heat Stroke (HS) is defined as rectal temperature greater than or equal 106°F (41.1°C) along with change in mental status ranging from confusion, delirium, stupor to coma and/or convulsions.1HS accounts for hundreds of deaths in United States annually, with 80% of the victims age 50 years and older.2 A study showed 54% increase in heat related deaths where hyperthermia was included as a contributing factor to death, between 1993 and 2003.3 Heat related deaths are preventable and mortality decreases with public health and healthcare workers preparedness.4,5 Here we discuss HS in a septic patient with an initial core temperature of 108.5°F who developed cerebral edema (CE) and was successfully resuscitated. To our knowledge, this is the first case report of a favorable outcome of a HS patient with concomitantCE. Case Presentation We present a case of a 55 year old diabetic female who was brought in by EMS after being found unresponsive by her husband for an unknown amount of time on a late July afternoon in Bronx, NY. EMS reported that their apartment, located on the 7th floor, was scorching hot. Husband reported that there was no air conditioning in the apartment and that the last time he saw her was earlier that morning, when she complained only of a cough. Vitals on triage: rectal temperature of 108.5°F, pulse 139, blood pressure 88/61 mmHg, SpO2 86% on room air and finger stick glucose 182 mg/dL. Primary survey showed no gross signs of trauma, GCS 7 (E1V2M4), 2 mm pupils with corneal reflex, diffuse rhonchi in the lung fields with tachycardia and warm dry skin. Patient was intubated immediately; central venous access established for cold IV fluids along with ice water bath immersion. Rectal probe was inserted to monitor temperature continuously along with a Foley catheter to monitor urine output and cold water lavage. Chest x-ray showed a right lower lobe infiltrate so the patient was started on empiric antibiotic coverage. Approximately 25 minutes

from arrival, the rectal temperature was 101.5°F at which point ice water bath was discontinued. Subsequent CT brain showed white matter effacement concerning for CE. Neurology was consulted with recommendations to maintain normothermia, cautious hydration to prevent osmotic neuronal damage, aggressive sepsis treatment (however, lumbar puncture was withheld, per neurology, due to concerns of elevated intracranial pressure secondary to CE) and to start mannitol if worsening signs of cerebral herniation, such as pupillary dilation, or worsening 24 hour repeat CT brain. Blood work showed WBC: 27,000 u/L, Lactic Acid: 4.8mmol/L, creatinine: 1.8mg/dL, CPK: 1683 IU/L, urine drug screen was negative along with serum toxicology screen including acetaminophen and salicylic acid. Further history from the husband revealed that she did not take any psychiatric medications, which decreased the likelihood of neuroleptic malignant syndrome or serotonin syndrome. Patient’s temperature was 100.4°F approximately 45 minutes after arrival, and soon after was transferred to the ICU. 24-hour repeat CT brain showed stable white matter effacement without signs of increasing CE. Patient’s resuscitation was continued with IV antibiotics and IV fluids with white count, lactic acidosis, acute kidney injury and elevated CPK resolving within 48 hours. CE noted to be resolving on 48 hour repeat CT brain without the need to use mannitol. Sputum and blood cultures grew ESBL Klebsiella and CT chest showed right lobe lung abscess. Patient was extubated on day 10 of her hospital stay and post­intubation showed signs of dysmetria, though subsequent MRI only showed a small lacunar infarct. Patient was discharged to short­term rehab with complete recovery. Discussion Response to heat stress is a dynamic balance between the mediators of inflammation, including endothelial cells, leukocytes, inflammatory cytokines, and endotoxins. Proinflammatory cytokines identified in HS include tumor necrosis factor (TNF); interleukin (IL)-2, -6, -8, and -10; interferon­α and –β.6 In a study of 18 HS patients, circulating cytokine levels correlated with clinical HS severity index.7 Additional in vitro studies show that cooling delays the release of IL-1B, IL-6 and TNF.8 The brain is the most heat­ sensitive organ in the human body10. It has been shown that irreversible changes of neural cells start at approximately 40°C (104°F)11-14. The most important consequence of these changes are destruction of endothelial cells of the brain and leakage of serum proteins across the brain­ blood barrier resulting in brain edema the most


hazardous acute complication of pathologic brain hyperthermia9, 14. Additional studies show, a strong relation between heat­ induced neuronal damage and edematous areas of the brain16. Other experiments reveal that neurons can tolerate low temperatures of at least 30°C (86°F)16,17,18. Although there is limited human data, animal models have illustrated that halting early gene expression of proinflammatory genes and excitatory neurotransmitters via rapid cooling and maintaining therapeutic hypothermia (TH) [defined as core body temperature less than 35°C within 6 hours of hospitalization] plays a central role in preventing neuronal cell death7. Further, TH also stabilizes the blood brain barrier and reduces CE by decreasing permeability to inflammatory cytokines and potential harmful substances such as free radicals and thrombin8,9. Conclusion To our knowledge, this is the first documented case of a successful outcome involving heat stroke complicated by cerebral edema that can be attributed by early aggressive rapid cooling measures. To date, evidence supports the use of hypothermia treatment in cardiac arrest patients and neonatal hypoxic­ischemic encephalopathy19,20. However, hypothermia has not been proven to show benefit in patients with stroke and traumatic brain injury21. Our patient was induced into a hypothermic state within 1 hour of presentation to our emergency department. As a result, future investigational studies involving other neurological injuries (i.e. stroke, traumatic brain injury, heat stroke) should investigate a possible relationship between neurological outcome and duration of timing for inducing a hypothermic state. • 2nd Place: Christine Goss, D.O. of Good Samaritan Hospital Medical Center  itle: A Case of Palytoxin Poisoning in a T Home Aquarium Enthusiast and His Family Authors: Christine Goss, DO, David Levy, DO  ood Samaritan Hospital Medical Center, Dept. G of Emergency Medicine, West Islip, NY 11795 Introduction: Palytoxin is highly toxic and has been isolated from species of Zoantharia coral that are available commercially to home aquarium enthusiasts. In this case a 53 year old male presented to the Emergency Department (ED) with dyspnea, starting shortly after cleaning his exotic coral species from his home aquarium which he identified as Zoantharia. A literature review identified only a limited number of cases of inhalational exposure, although there are an continued on page 29

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FOEM | BEACON "Foundation Focus" continued from page 27 abundance of self-reported exposures found on the internet. Case Description: A 53 year old male presented to the ED with chief complaint of dyspnea with associated non-productive cough, fever, chills, and body aches. He stated that these symptoms began that afternoon after cleaning exotic coral from his home aquarium. The patient’s wife and daughter had both been present in the home at that time, and presented to the ED with similar symptoms. Examination was initially significant only for tachycardia and bilateral expiratory wheezes. There was no reported history of cardiac or pulmonary disease in the patient or his family. He was placed on oxygen by nasal cannula for hypoxia and treated with nebulized Albuterol in the ED. Initial chest x-ray was normal, showing no evidence of pulmonary infiltrates. He was admitted to the hospital for respiratory distress. During the first 24 hours of hospitalization, the patient’s condition worsened with the onset of hemoptysis and worsening hypoxia. Serial chest X-rays revealed the development of bibasilar pulmonary infiltrates. Following a seven day hospital course the patient was discharged home requiring portable oxygen. Discussion: Palytoxin exposure is a rare cause for presentation to the ED, but it is important that physicians be aware of the symptoms of exposure in order to illicit a thorough history. Although there is currently no definitive test to diagnose palytoxin exposure, a similar constellation of symptoms and laboratory findings have been described in previously reported inhalational exposures attributed to Zoantharia coral species. • 3rd Place: Joshua Batt, D.O. of Arrowhead Regional Medical Center

Intracranial Hemorrhage following Bath Salt use: a Case Report  mber Widenski, DO, Josh Johnson, DO, Jamshid A Mistry, DO, Anh Nguyen, MD, and Michael Neeki, DO Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, CA A 42 year old male arrived to the emergency department via ambulance for reported altered mental status, right sided weakness, slurred speech, blurry vision and dizziness. On evaluation in the emergency department, the patient complained of a persistent headache and dizziness, reporting resolution of any focal weakness or slurred speech prior to arrival. The patient admitted to using “bath salts” via nasal insufflation multiple times prior to symptom onset, with his last use being a few hours prior to arrival. A Head CT scan showed a left-sided thalamic intracranial hemorrhage with brain stem extension and blood tracking into the 4th ventricle, causing obstructive hydrocephalus, requiring an emergent ventriculostomy that was placed by the neurosurgery service. The patient was subsequently admitted to the neurosurgical intensive care unit, and after 4 days was extubated. At that time, the patient demonstrated a disconjugate gaze and speech impairment, later requiring a ventriculoperitoneal shut 9 days after hospital admission. The patient continued to improve throughout the rest of his hospital stay and was later discharged into the care of his family with continued outpatient rehabilitation therapy. With names such as White Ice, Ivory Wave, Ocean Snow, Lunar Wave, and Vanilla Sky, the dangerous consequences from the increasing

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use of bath salts are easily foreshadowed. Reports on morbidity and mortality due to bath salts have sharply increased in recent years. In 2011, The American Association of Poison Control Centers reported 6,138 calls for related bath salt use, up from only 304 calls in 2010, and as of February 2012 had already received over 400 calls. Bath salts contain derivatives of cathinone, isolated from the East African plant Catha edulis, which share structural similarities to methamphetamines and MDMA (ecstasy). Since the mid-2000s, unregulated cathinone derivates have appeared in American and European drug markets. According to the Drug Enforcement Agency, the most common compounds that comprise bath salts and are responsible for most of their effects are MDPV (3,4 – Methylenedioxypyrovalerone) and Mephedrone (4 – Methylmethcathinone). Their consumption via various routes leads to a toxidrome similar to the combined effects of ecstasy and methamphetamines, believed to work by both direct agonist activity and re-uptake inhibition of norepinephrine, serotonin, and dopamine. The product is usually in powder or crystal form, with a white or tan brown color, and often carries the label “not for human consumption” on their packaging to subvert government control. Most users will nasally insufflate the powder form or smoke the crystalline form, but oral ingestion, rectal suppository, intramuscular, and intravenous forms are also reported. More and more articles and case reports have been published in recent years after the rising use of bath salts for their euphoric and sympathomimetic effects. However, as of April 2012, no prior reported cases of intracranial hemorrhage due to bath salts abuse have been reported.



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Resident Wrap Up

M. Steve Brandon, DO ACOEP Resident Chapter President

Most of us are creatures of habit. We naturally become accustomed to and comfortable with our surroundings, even when we recognize they might not be the most ideal. Any change in our lives is met with some degree of anxiety. Earlier this year it was announced that the AOA, AACOM and ACGME intended to merge into a “single accreditation system for graduate medical education.” From the minute I first read that announcement email questions have abounded from those with whom I interact. What would this mean for me? Will my program go away? What about board certification? Is this the end of DOs? Reactions have ranged from optimistic to apocalyptic, and everywhere in between. I definitely find myself leaning more toward optimistic. The fact is that right now we do not know all of the details, but what do we know? We know there is a merger, but how it will all play out is yet to be seen. Since the announcement, the AOA has been publishing and updating information about this merger on the AOA website. I encourage you to each check it out, it actually is quite informative and will answer many of your questions. Due to changes in the ACGME system, we also know that this merger had to happen. Without it many of our – Arnold Bennett graduates would be excluded from post-graduate training that is unavailable within OGME. The results of this would have been disastrous. We also know that the AOA’s first priority is the well-being of the osteopathic community. This should provide us with the greatest solace. I am certain the AOA would never enter into an agreement that would be detrimental to its own survival, and this provides me some anxiolysis even when I don’t know how it will all play out.

change, even a change for the "Any  better, is always accompanied by drawbacks and discomforts. "

I see this as an opportunity for growth. For too long has the osteopathic community demanded equality while also maintaining strict exclusivity. This is a step in the right direction, but it must force us to self-reflect. The ACGME has recognized our training programs as being equivalent to theirs, otherwise they would not have agreed to this. Yet, this is also a call for us to step up our game. We must focus on maintaining relevance as the MD and DO worlds grow even closer. As a specialty college, we (the ACOEP) must focus on the value that we provide our membership. This may cause some discomfort as we change and grow, but I am confident we are up to the challenge and look forward to all that we will accomplish. Thank you,

Steve Brandon, DO ACOEP Resident Chapter President ACOEP Board of Directors Emergency Medicine Resident, St. Mary Mercy Hospital, Livonia, MI

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Embracing Change Andrew Little, DO


hange: it's the one thing guaranteed to happen. Whether it's the clothes we wear, the cars we drive, the houses we live in, or where we work, it will happen. It's the one thing that emergency physicians are trained to deal with, not only in the turnover of patients and staff, but in the rapid change of patient health status during a visit to our emergency departments. In being trained to deal with change we are taught to be calm, direct, learning to cope while trying to keep things together. We are taught to think of the patient first, of their family first, of our staff first, thinking little of ourselves in the process. On a daily basis I am amazed as I see my fellow residents, my supervising physicians, and others deal with change almost effortlessly.

One major change that we are in the midst of is the single pathway for GME/ residency programs. Through this change, I have watched, waiting to see how people will react. I have been amazed at how many have forgotten how to deal with change. I have heard people angry, throwing their hands in the air, looking to make sure they are taken care of. They seem to be forgetting the focus of this conversation; the residents, the patients, the public. Forgetting their training, and the idea that we cannot control change, but we can control how we act during change. Over the next four to five years there will be great changes to the landscape of how and where residents in emergency medicine

train. We cannot control it, but we can shape it, work with the ACGME to make sure the foundation off what makes our programs unique and special are upheld. We can also use this as an opportunity to rise, improve and come out better. Like many of you, I don't know what the upcoming changes exactly mean, and if someone says they do, I wouldn't believe them. But I do know that these changes should not be viewed as changes for the worst, but opportunities to improve. An opportunity for the best of us, the best we have to offer to be brought to light.

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Residency Spotlight Program: South Pointe Hospital / NOEM Consortium Address: 20000 Harvard Road City/State/Zip: Cleveland, Ohio 44122

Program: Lehigh Valley Health Network Address: 2545 Schoenersville Road City/State/Zip: Bethlehem, PA 18017

Hospital Information: Type (Community, rural, urban): Community

Hospital Information: Type (Community, rural, urban): community Trauma Level: 1 Number of Hospital Beds: >1000 Number of ED Beds: 58 at Cedar Crest / 38 at Muhlenberg

Trauma Level: Number of Hospital Beds: 250 Number of ED Beds: 28 EM Program Information: Phone: (216) 491- 7460 Website: Total Number of EM Residents: 22 Residents to Attending Ratio Working Clinically: 2:1 Accepts Medical Student Rotations? Yes EM Program Curriculum: Highlights: South Pointe Hospital is a Cleveland Clinic Hospital, South Pointe is a certified Stroke Center, >85% of lectures given by attendings, 2 skills labs a year, 2 Live ATLS procedures labs a year, US Curriculum, Trauma rotation at Metro Health in Cleveland followed by a month of Lifeflight in which the resident functions as a Flight physician on a aero-medical helicopter. Residents able to rotate through as many as 5 EDS, each with different patient populations, Ohio University – Heritage College of Osteopathic Medicine opening a satellite medical school at South Pointe with first class matriculating in 2015. Prefers COMLEX Scores of: First time pass Interview Dates: October - December Number of Letters of Recommendations and who can write the letters: 2 letters

EM Program Information: Phone: 484.884.2888 Website: Total Number of EM Residents: 56 Residents to Attending Ratio Working Clinically: 1:1 Accepts Medical Student Rotations? yes EM Program Curriculum: PGY 1: 6 blocks ED, 1 block ICU, 1 block ortho, 1 block OB, 1 block Pediatric ED, 1 block medicine, 2 blocks m/s PGY 2: 7 blocks ED, 1 block ICU, 1 block cardiology, 1 block anesthesia, 1 block inpatient pediatrics, 1 block imaging, 1 block trauma PGY 3: 6 blocks ED, 1 block ICU, 1 block Pediatric ED, 1 block trauma, 1 block neurology, 1 block toxicology, 2 blocks elective PGY 4: 9 blocks ED, 1 block !CU, 1 block admin/EMS, 1 block pediatric ICU, 1 block elective EM Program Application Information: Dates applications are accepted: July 1 Prefers COMLEX Scores of: >80 Interview Dates: Nov 12 & 19, Dec 3, 10 & 17, Jan 7 & 14 Number of Letters of Recommendations and who can write the letters: Require 2 SLOE’s completed by clerkship director

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Check out the recently redesigned online publication

The new version of The Fast Track is more robust, with a combination of both anecdotal experiences, thought provoking articles, and peer reviewed research articles that will propel ACOEP to the next level in the student and resident publication arena.

Here are some articles featured in the Summer 2014 issue: • Snake Bites • The Lifesaving Skills of EMS • Perspectives on the AOAACGME Merger • Spirituality in the ED • The Future of Backboards

You can view The Fast Track online by going to:

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The Pulse 07-2014  

The July 2014 issue of The Pulse