Presidential Viewpoints Accountability, Emergency

Transcription

July 2010
VOLUME XXXV NO. 3
Presidential Viewpoints
Accountability, Emergency Medicine and Healthcare Reform
Thomas A. Brabson, D.O., MBA, FACOEP, President
1975
The summer of 2010 is finally here after
a long and harsh winter. I hope this issue
of the Pulse finds you healthy, happy and
enjoying the summer fun. Make sure you
take some time to relax and enjoy yourself
with family and friends.
The healthcare reform movement has
been signed into law and now is well on its
way to becoming a reality at a time when our
country’s economy continues to struggle.
Healthcare costs continue to rise and for
the past 30 years, these costs have increased
2.8% above the Gross Domestic Product
(GDP) on an annual basis. Healthcare is
the largest growing expense in the $30,000
- $80,000 income households with the
average family premium being $13,000.
In order for the healthcare reform to take
fully implemented in 2017 with a ‘new
normal delivery system’, much work needs
to be accomplished over the next few years.
There is a proposed timeline in the law but
no detail of how to achieve the goals. In
the first 3 years there are approximately
105 new agencies and programs that need
to be implemented in order to shape the
future of the system. There also must
be coordination between the state and
federal governments and conformity among
the insurance companies. Excise taxes will
be levied on insurance, medical devices,
pharmaceuticals and who knows, maybe
even medical practitioners. To help fund
the system, Medicare cuts will amount to
$439 billion and the American Hospital
Association promised $155 billion. So, we
may be seeing our best reimbursement
from Medicare today than we ever will in
the future. That is not to say however, that
Medicare is the be all and end all.
Accountability is a term that is being
used in many different places these days.
As emergency medicine physicians, we are
accustomed to being held accountable for
good patient care and favorable outcomes.
With the new health care law though, we
will be held accountable for being active
participants in the new model of care. This
new model is proposed to be an integrated
and coordinated model of patient care. It is
proposed to deliver high value with overall
total cost management. There will be new
financial incentives that will not be based on
high cost tests, equipment and procedures.
Efficiency in patient care is what will be
rewarded. The efficiency will come as the
result of a more integrated system for the
delivery of healthcare. As we all witness in
our daily practice of emergency medicine,
one of the biggest contributors to the
inefficiencies in our current system is a lack
of care coordination. We have a system that
The PULSE JULY 2010
allows multiple areas of episodic care but no
formal mechanism to assure that all of the
information about the episodes of care are
gathered and assimilated in one organized
place to be reviewed by a specific person.
An Accountable Care Organization
(ACO) is a new concept that is proposed to
be a step in the right direction to have an
organized continuum of medical care. These
are an expansion beyond the medical home
concept. The ACOs will be responsible
for the clinical care coordination and
integration of medical services for patients.
They will also be responsible for capturing
medical and financial data across the care
continuum. They will be held accountable
for measuring and monitoring costs and the
quality of the medical care delivered. It is
believed that clinical quality and efficiency
will drive better financial performance.
Clinical results will be outcome based and
income will be based on outcomes. This
means that we will be subjected to many
more clinical core measures than we are
today. Evidence based medicine will be
the driving force for the clinical quality
indicators. Appropriate resource utilization
will be key to the success of this initiative.
The emergency department should no
longer be one of the primary entry points for
access to medical care. With this integrated
system, the patient should have ample
opportunity to access the care that they
need based upon the principle that there is
healthcare provider coordination across the
patient’s continuum of care. There will be
continued on page 28
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2
The PULSE JULY 2010
Editorial Staff:
Drew A. Koch, DO, FACOEP, Editor
Wayne Jones, DO, FACOEP, Assist. Editor
Thomas Brabson, DO, MBA, FACOEP
Anthony Jennings, DO, FACOEP
Janice Wachtler, Executive Director
Editorial Committee:
Drew A. Koch, DO, FACOEP, Chair
Wayne Jones, D.O., FACOEP, Vice Chair
David Bohorquez, DO
Thomas Brabson, DO, FACOEP
Joseph Dougherty, DO, FACOEP
Anthony Jennings, DO, FACOEP
William Kokx, DO, FACOEP
Annette Mann, DO, FACOEP
Brian Wiboon, DO
Janice Wachtler, CBA
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THE
The Pulse
An Osteopathic Emergency
Medicine Quarterly
142 E. Ontario St., Suite 1500
Chicago, IL 60611-5277
PULSE
O s t eop a t h i c
Emergency
Me d i c i n e
Q ua r t e r ly
Table of Contents
Presidential Viewpoints . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Thomas A. Brabson, D.O., MBA, FACOEP
Editorial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Drew Koch, D.O., FACOEP
Our History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Executive Director's Desk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Janice Wachtler, BA, CBA
Fellows and Distinguished Fellows Announced . . . . . . . . . . . . . 7
The On Deck Circle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Gregory Christiansen, D.O., M.Ed., FACOEP
Guest Column . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Peter A. Bell, D.O., MBA, HPF, FACOEP-D, FACEP
Guest Column . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Bermard Heilicser, D.O., FACOEP
Emergency Medical Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Gregory Joseph Beirne, D.O., FACOEP
FOEM: 2010 Research Activities . . . . . . . . . . . . . . . . . . . . . . . 14
Foundation Focus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
The Practice of Emergency Medicine/Special Contribution . . . . 16
2010 Student Case Competition Winning Submission . . . . . . . 23
On the Wild Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
James Shuler, D.O., MS, FACOEP, FAWM
Ethics in Emergency Medicine . . . . . . . . . . . . . . . . . . . . . . . . . 27
Bernard Heilicser, D.O., MS, FACOEP
AOBEM Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Members in the News . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
In My Opinion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Wayne T. Jones, D.O., FACOEP
Changes in the Board Announced . . . . . . . . . . . . . . . . . . . . . . 31
Pain Management in the ED . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Steven J. Parrillo, D.O., FACOEP-D
The PULSE JULY 2010
3
Editorial
Drew Koch, D.O., FACOEP, Editor
Acute Exacerbation of Chronic Pain
in the Emergency Department: Part II
1975
In the last edition of the Pulse, I discussed the dilemma that we as Emergency
Medicine Physicians face every day in our
Emergency Departments dealing with
patients who present with an acute exacerbation of chronic pain. We deal with
EMTALA, legal, ethical and social concerns on every patient who presents to the
Emergency Department in pain.
Greg Henry, MD, wrote in a recent article in the Emergency Physicians Monthly
that “we have more pain medication than
you have pain.” Dr. Henry feels that as
Emergency Medicine Physicians we do not
treat pain as well as we can. His emphasis
on adequate pain control coincides with
the Joint Commission and other regulatory
concerns that the Emergency Departments
do no not adequately treat pain.
Oligoanalgesia in the Emergency
Department was coined in 1989 by
Wilson and Pendleton in their article in the
American Journal of Emergency Medicine.
According to their paper, pain is the most
common complaint presenting to the emergency department and that emergency physician have not established themselves as
the champions in treatment of acute pain.
In the 20 years since this paper was written,
it is still perceived that oligoanalgesia in the
emergency department still exists despite
an increased awareness of pain and the
4
increased use of analgesia in the emergency
department.
Opiophobia is the prejudice against the
use of opioid analgesia. This is manifested
in our mores; regulatory and licensing
concerns; concern for drug seeking behavior; concerns for addictions or dependence;
and, the lack of follow up or continuity of
care. Society’s attitudes toward narcotics
at times reflect a moral tone that influences health care providers and the general
public. There are concerns about addiction and abuse with moral aversion for the
pleasures of opioid use and the contempt
for individuals with psychological addiction
to their euphoric effects. These attitudes
towards patients who seek pain relief result
in oligoanalgesia. In the previous article of
the Pulse the topics of addiction and dependence were discussed as were the concerns
regarding legal and regulatory manifestations of opiophobia.
Drug seeking behaviors (DSB) are commonplace in the emergency department.
Many physicians have faced patients with
multiple alleged allergies to narcotics and
other medications who request a medication
that the physician never would have initially thought of prescribing, whose medications were stolen, and who become angry,
threatening, and agitated upon refusal to
refill the stolen prescription-Emergency
Medicine Reports, January 3, 2005.
Pain and the somatic manifestation of
anxiety are the two most common reasons
that individuals seek medical care. Since
the 1990’s prescriptions for and the nonmedical use of opioids have increased. In
2005 there were more prescriptions written
for hydrocodone/acetaminophen combination than any other medication. This was
twice the rate of the second most prescribed
generic and brand prescriptions Amoxicillin
and Lipitor. In 2004 it was estimated that
2.4 million individuals 12 years old or older
who initiated non-medical use of prescription pain relievers during the previous
The PULSE JULY 2010
year. The most abused drugs during 2004
were hydrocodone, codeine, propoxyphene
and oxycodone. The “non-medical use is
defined as the use of a prescription pain
reliever by individuals for whom it was not
prescribed or use only for the experience
or feeling that is produced.” Journal of
Addictive Diseases, vol. 27 (1) 2008. “The
Epidemiology Association between Opioid
Prescribing, Non-Medical uses and ED
Visits.”
The characteristics of drugs of abuse are:
1. Rapid onset of action; 2. High potency;
3. Brief duration of action; 4. High purity;
5. Water solubility (for IV use); and 6. High
volatility (ability to vaporize if smoked).
The opioid that fits these characteristics is
hydromorphone or as per patient request,
Dilaudid. Dilaudid is the drug of choice and
the most requested drug by our patients
with acute exacerbation of chronic pain.
When used in higher doses and given by IV
it produces euphoria that the chronic pain
patients seek.
Patient characteristics of DSB suggest the
following 19 behaviors: escalating use or
over-use of controlled substances; manipulative, demanding behavior to obtain medication; the only possible solution to medical
problem is “controlled” medication and
claims non addictive medications do not
work and they have an allergy to them;
high tolerance to drugs; lost their prescription; ran out of prescription early before
they are “allowed another refill”; selling
or forging prescriptions: using family or
friend’s prescription; pit one physician’s
treatment opinion against another physician’s recommendation; resist non-pharmacological treatment; doctor shop use
greater than 2 doctors; pressure physicians
when physicians initially refuse to write
prescription; history of drug and alcohol
use; old records or pharmacy profiles reveal
an unusual number of prescriptions and
Our History
Introduction: Last summer after arriving
in our new headquarters as we were
unpacking we
found the following
document, titled “Brief History.”
Typewritten on the old stationary and
undated, it contained a concise overview
of how the American College of Osteopathic
Emergency Physicians came to be. The
yellowing document is now preserved in
our historical documents; it is as yellowed
as our older minutes, however it was
obviously written in the early 1980’s as
it recaps the founding of AOBEM and
the first Fellowship Ceremony. Its author
is unknown, perhaps it was an early
staff member or Board member who took
the time to put down, the history of the
College’s founding. Whoever it was did us
a huge favor in preserving dates and people
in our past.
convention in Las Vegas, Nevada, the first
organizational meeting was held at the
Sahara Hotel. During this meeting the first
officers were elected including Dr. Bruce
Horton, President, Dr. Anthony Gerbasi,
Vice President, Dr. Richard Ballinger,
Secretary and Dr. Robert Hambrick,
Treasurer.
BRIEF HISTORY
The American College of Osteopathic
Emergency Physicians was founded and
developed by a few dedicated Osteopathic
Emergency Physicians who believe the
specialty of Emergency Medicine should be
recognized by the American Osteopathic
Association.
In July, 1978, the College was chartered
in Ohio, and the American Osteopathic
Association formally recognized the
American College of Osteopathic
Emergency Physicians.
Following this meeting, appropriate
documents were developed to obtain a
charter for the College.
In February, 1976, the original Board
of Directors of the ACOEP was elected.
They were: Richard Ballinger, D.O., James
Budzak, D.O., Donald Cucchi, D.O., Robert
George, D.O., Anthony Gerbasi, D.O.,
James Grate, D.O., Robert Hambrick, D.O.,
Bruce Horton, D.O., and Scott Swope, D.O.
On October 5, 1975, the committee
for the formation of the American College
of Osteopathic Emergency Physicians
first met in Toledo, Ohio. Present at
that meeting were Bruce Horton, D.O.,
Richard Ballinger, D.O., Anthony Gerbasi,
D.O., Robert Hambrick, D.O., and Robert
George, D.O.
In November, 1978, at the American
Osteopathic
Association
Annual
Convention in Honolulu, Hawaii, the first
Scientific Assembly of the American College
of Osteopathic Emergency Physicians was
held. This was an indication of good things
to come as the program was very well
received by many osteopathic physicians
interested in the specialty of Emergency
Medicine. As a matter of fact, a larger room
was required for the presentation of the
program on each of the four days involved.
In November, 1975, in conjunction
with the American Osteopathic Association
Early in 1979 the Residency Standards
for Training in Emergency Medicine in the
The PULSE JULY 2010
osteopathic profession were developed, and
the first residency programs were initiated
at the Philadelphia College of Osteopathic
Medicine and the Chicago College of
Osteopathic Medicine. At the present time,
there are nine A.O.A. approved Emergency
Medicine residency training programs in
osteopathic hospital across the United
States.
In July, 1980, the American
Osteopathic Association formally recognized
the specialty of Emergency Medicine as a
Board Certified Specialty, and approved
the formation of the American Osteopathic
Board of Emergency Medicine. Following
this recognition the certification process was
established, and there is now a mechanism
for board eligibility status for certification
for the osteopathic Emergency Medicine
physician. Presently more than fifty
osteopathic physicians are certified by the
American Osteopathic Board of Emergency
Medicine.
Emergency Physicians sponsors two
educational programs annually to meet
the needs of the membership. The Annual
Scientific Assembly is held in conjunction
with the American Osteopathic Association,
and the Spring program is held each year in
various areas throughout the country.
The first fellowship ceremony was
conducted in Las Vegas, at the Annual
Scientific Assembly of the American College
of Osteopathic Emergency Physicians in
November, 1984. Presently there are ten
osteopathic physicians elected as Fellows
in the American College of Osteopathic
Emergency Physicians.
5
Executive Directors Desk
1975 - A Year in History
1975
As we prepared to celebrate the College’s
35th birthday on October 5th, members
of the Publications Committee thought
that perhaps we need to look at where the
world was when the decision to establish
the College was first formulated. To do
this, William Kokx, D.O., FACOEP and
I started to think about what the world
looked like then.
As you can see from the chart below,
the economics of 1975 were much different than today, but so were society and
lifestyle. For instance, computers weren’t
found in homes or on desktops, telephones
weren’t portable and your tunes were sup-
plied via a transistor radio. Meanwhile, the
US and the world were in turmoil and in
the throes of the end of Vietnam War. We
witnessed Pol Pot and the Khmer Rouge
forces invade and take over Cambodia in
early April leading to the fall of Saigon and
the end of the Vietnam War on April 30th.
The US evacuated its forces from Saigon
and the American public heard words like
Boat People and opened its doors to many
displaced people from Vietnam, Thailand,
and Cambodia. We were also closing
the chapter on the Watergate scandal as
we saw the convictions of John Mitchell,
H.R. Halderman, and John Ehrlichman
sentenced to 30 months to 8 years in jail.
Also in the news were incidents involving
Gerald R. Ford as he made the history books
when he escaped two assassination attempts
in September, once on September 5th by
Lynette “Squeaky” Fromme, in Sacramento,
California, and again on September 22nd in
San Francisco by Sara Jane Moore. And, to
help relieve our dependence on foreign oil,
the U.S. approved the Alaskan Oil Pipeline.
Entertainment made history too, with
the premiere of Saturday Night Live on
NBC. This new fast paced live television
program was aimed solely at the ‘younger
generation.’ We also watched shows like
Upstairs, Downstairs, Barretta and Wonder
Woman. Movies were big in 1975 too, with
classics like One Flew over the Cuckoo’s
Nest (which won the Academy Award for
Best Picture, Best Actor and Best Actress)
and Dog Day Afternoon, Nashville, and
The Man Who Would Be King. Music of
the day was Love Will Keep Us Together
(Captain and Tennille), At Seventeen (Janis
Ian), Lyin’ Eyes (Eagles), The Hustle (Van
McCoy), Where is the Love (Natalie Cole),
and Still Crazy After All These Years (Paul
Simon).
Computers once the domain of only large
corporations like Xerox and IBM, were
made available to consumers for the first
time. People interested in building their
own could do so when Altair Innovations
developed a home computer kit in 1975.
Also movies, once the sole property of cinemas were made available on home video
when, Sony and Mitsubishi went head to
head in this market developing the Sony
Betamax System and Mitsubishi VHS. The
war of home video continued for about a
decade until Betamax succumbed and is
now used mostly for professional recording
studios.
Medicine was not immune to
change in 1975. Like every other area,
medicine was seeing more and more
research being done to produce better
patient outcomes. Three American physicians were granted the Nobel Prize in
Medicine when they developed processes to
follow the interaction between tumor viruses and genetic material in cells. Other physician-researchers working independently in
Russia and France discovered the structure
of biological molecules in antibiotics and
cholesterol. And, in New York City, Interns
and Doctors in 21 hospitals went on strike.
Comparing the world 35 years ago to
today’s standards and norms is difficult, I
mean, who today would even think of not
6
The PULSE JULY 2010
Fellows and Distinguished Fellows Announced for 2010
Emergency Physicians is proud to
announce the physicians named to the
2010 Class of Fellows and Distinguished
Fellows of the College.
Fellowship is granted to physicianmembers of the ACOEP who meet the
following minimal standards: certification
in EM by AOBEM or ABEM; continuous
membership in ACOEP of 5 or more years;
attendance at 2 ACOEP Membership
Meetings and attendance at 2 or more
major ACOEP-sponsored CME meetings
within 5 years of the date of application.
Candidates must also show evidence of
high professional standing in two of the
following areas: publication of scientific or
referenced material in emergency medicine
in a nationally peer-reviewed periodical
with references to the publication in which
the article was published; past or present
membership on an ACOEP committee or
Board of Directors; faculty appointment in
emergency medicine at an accredited college of medicine or college of osteopathic
medicine; active involvement in the leadership and education in EMS, including
but not limited to EMT, First Responder,
EMD and/or paramedic training; service
as a medical director of a community EMS
System, or participation in local disaster
planning and implementation; service as
an emergency medicine residency program
director or faculty; advance degree or fellowship training; past or present service
to the AOBEM or ABEM as an oral board
examiner or a named role in test development; past or present membership on the
Board of Trustees of the Foundation for
Osteopathic Emergency Medicine, and/or
verification of a significant contribution to
the specialty of emergency medicine in the
osteopathic profession. Additionally, each
candidate must be recommended by a current Fellow of the ACOEP. Fellowship is
maintained through continuous membership in the College.
Achieving Fellowship status in
2010 are: Paul J. Adams, D.O. (Fort
Lauderdale, FL); Michael P. Applewhite,
D.O. (Temple, TX); Robert Bazuro,
D.O. (Sandy Hook, CT); Todd A. Bell,
D.O. (Elida, OH); Marc M. Bonin, D.O.
(Greenfield Township, PA); Michele
Butler, D.O. (Lake Havasu City, AZ);
Nikolai Butki, D.O. (Clarkston, MI);
Victoria Camba, D.O. (Wilton Manors,
FL); Stephanie L. Davis, D.O. (Kansas
City, MO); Elaine Diaz, D.O. (Miami, FL);
Joseph J. Fosbinder, D.O. (Bakersfield,
CA); Michele M. Fowler, D.O. (Bixby,
OK); Richard C. Giovannini, D.O.
(Shelby Township, MI); Michael L. Kelley,
D.O. (Hudson, OH); Kyle Kennedy,
D.O. (Joplin, MO); Judith Knoll, D.O.
(Erie, PA); Cindy Yung-Fang Kuo, D.O.
(Express, CA); Michael A. LoGuidice,
Sr., D.O. (Trinity, FL); Daniel Lombardi,
D.O. (Mahopac, NY); Tariq Noohani,
D.O. (Tampa, FL); Joseph R. Peters,
D.O. (Peoria, IL); Katherine J. Pitus,
D.O. (West Bloomfield, MI); Fredric
A. Rawlins, D.O. (Radford, VA); Brian
Risavi, D.O. (Erie, PA); Martha J. Shadel,
D.O. (Harrison Township, MI); Zafar
Shamoon, D.O. (Rochester, NY); Kellee
R. Shea, D.O. (Orlando, FL); Cynthia
Shen, D.O. (Queenstown, MD); Greg
Sorkin, D.O. (West Orange, NJ); Ali
Taqi, D.O. (Troy, MI); Harrison Tong,
D.O. (Clarkston, MI); Susan Watson,
D.O. (Gunnison, CO); Amber D. Weigler,
D.O. (Garden City, MI); James B.
Williams, D.O. (Oklahoma City, OK),
and Shelly Zimmerman, D.O. (Edmond,
OK).
Distinguished Fellowship is
bestowed on physicians who have reached
Fellowship status in the College for a
minimum of 10 years and who have been
recommended by an existing Fellows or
Distinguished Fellows of the ACOEP
because they have been active in the practice of emergency medicine, EMS, disaster
medicine, pediatric emergency medicine
or medical toxicology, on boards or committees of ACOEP, AOBEM or AOA; current or prior involvement in professional
organizations on an international, national,
state, or local levels that concern the above
The PULSE JULY 2010
named practice areas; involvement in past
or current research and/or development
medical curriculum or training programs
in any of the above-named practice areas,
and recognition or awards for excellence
in emergency medicine (or its subspecialty
areas) by a national, state, or local organization.
Achieving Distinguished Fellowship
in 2010 are: Steven Aks, D.O. (Chicago,
IL); Thomas A. Brabson, D.O., MBA
(Media, PA); William R. Fraser, D.O.
(Columbus, OH); Christine G. Giesa,
D.O. (Collegeville, PA); Douglas M. Hill,
D.O. (Thornton, CO); Mary J. Hughes,
D.O. (Dewitt, MI); Joseph C. Hummel,
D.O. (Sewell, NJ); Alan R. Janssen,
D.O. (Fenton, MI)’ Drew A. Koch, D.O.
(Ithaca, NY); Joseph J. Kuchinski, Jr.,
D.O. (Mountain Lakes, NJ); Mark S.
Rosenberg, D.O., MBA (Denville, NJ);
Bryan D. Staffin, D.O. (Buchanan, MI);
Louis C. Steininger, D.O. (Tucson, AZ);
Robert D. Suter, D.O. (Dallas, TX);
David A. Wald, D.O. (Wynnewood, PA),
and Douglas P. Webster, D.O. (Solvang,
CA).
Applications for both types of
Fellowship are available on the College’s
website and are accepted throughout the
year. Evaluation of any application takes
place during the spring meeting of the
Fellowship and Nominations Committee
and are granted annually in the fall.
Please join us in congratulating the
Class of 2010!
Includes the ACOEP Intense Review, COLA
Essentials (2002-2008 only); Oral Board Review;
New Frontiers in Toxicology, Spring Seminar or
Scientific Assembly
7
The On Deck Circle
Gregory Christiansen, D.O., M.Ed., FACOEP
President-elect
Influencing Six Degrees of Separation
I was leaving the hospital and heading home one evening when I ran into
a friend on my way out to the parking
garage. Dr. Abatti was a resident when I
first met him as he rotated through the
Emergency Department. I loved working
with him because he always put forth his
best effort. He has long since finished and
has become an accomplished cardiologist.
We have great respect for each other’s
opinions after having worked through some
very difficult case together over the years.
As we walked I cordially shook his hand
and offered a friendly greeting. He was
escorting a seasoned physician whom I had
overheard speak to days when a resident
meant he or she was really an apprentice
who resided in the hospital. This piqued
my attention because the opinion fits in
well with a project I am working on related
to the cultural changes in resident education that have changed the attitudes of the
newly-minted physicians. Dr. Abatti introduced his friend who said he was a visiting
scientist from the University of Colorado.
I welcomed him to Virginia and asked the
question as only a southern hick could ask,
“What were ya’ll scientisting about?” He
was more then happy to tell me he was
working on interleukins. This really piqued
my attention because that is how I started
my dabble into medicine. Tangentially I
thought to myself of how important that
seemingly trivial work experience has been
to me. I learned self determination and
ingenuity can overcome many obstacles. As
the low man on the totem pole I had to take
the initiative to learn as much about the
subject as possible. I was not satisfied with
a superficial explanation of how PCR, DNA
sequencing or ELISA actually worked. I
remember reading, creating ideas & then
experimenting with the ideas to develop
a deeper understanding of the immune
response process. Eventually the company
created something useful to market – IL-1
& IL-2. My experiences in immune com-
8
plex interactions have since been incorporated into many of my lectures to help
others understand the pathologic process.
As it turns out understanding the immune
response can portend the outcome of many
seemingly unrelated conditions such as heat
stroke (IL-6, IL-18) or acute myocardial
infarction (TNF, Platelet interactions). This
chance encounter brought back so many
thoughts that I had to ask more questions.
He knew the company then called Cistron
– named for the biochemical term related to
DNA sequencing. He also knew the cast of
characters I had worked with – more then
20 years ago. They were still influential
people in their fields, just a bit older. I came
to the realization that this chance encounter
reflected a significant impact on my experiences. My work 20 years ago is still influencing my development today. Additionally,
it appears to becoming full circle with my
new activities in which I am engaged. Most
folks probably do not recognize at the time
of an encounter how profound of an impact
one can have. Simply participating and
being proactive can foster the development
of significant influences.
To give an illustration, one of Albert
Einstein greatest contributions occurred
over a chance encounter. At age four he
watched the needle of a compass move
without anything touching it. He realized
motion did not need direct touch. Other
forces were at work in moving the needle
the same way every time. This was the
beginning of his challenge to Sir Isaac’s
Newtown’s accepted laws of motion and
gravity. An interaction with patent office
boss Friedrich Haller advised him in 1902
to “… think that everything an inventor
says is wrong. Be critical, vigilant and question every premise, challenge everything...”
Following that advice by 1905 he had
written five scientific papers which would
profoundly change our world view. The
Nobel Prize committee was embarrassed
when they passed over Einstein in 1910
The PULSE JULY 2010
and did not recognize him for his insightful,
surreal and masterful theories until 1921.
Einstein’s theory of relativity may have an
extrapolated effect in education. From a
scientific perspective, ‘all movements and
events are in relation to an observer’s frame
of reference’. In life we are shaped by our
relative frame of reference to each other –
that’s how learning occurs.
We probably do not recognize the impact
we have relative to each other. My coworker’s mentoring is responsible in part to
my interpretation and reaction to events I
experienced more then 20 years ago. Those
actions back then have helped to shape
my thinking today. This realization brings
home the point that especially in the field
of medicine, we all need mentors to help
us succeed. As mentors, we have to extend
ourselves to make that happen. Stepping
back and acknowledging how the whole
conversation got started, I thanked the visiting scientist for his influence and hoped to
cross paths with him in the future… I am
looking forward to the experience.
This quirk of an encounter made pause
to consider the significance of our influential experiences. The theory of ‘6 degrees
of separation’ regarding social networking
suggests our relative experiences influence
each other. I recalled my short interaction
with a medical student at DO Day on
Capital Hill. We were making our way to
the congressional offices when we struck
up a conversation. I was thrilled to see him
among so many students getting involved
in the political process. They recognized the
changing landscape of medicine demands
political involvement. In superficially conversing about some contemporary issues
as we walked, I noticed he echoed the
thoughts and mindset of what others wanted him to believe. He did not recognize
how he was influenced in his ideas or how
he shaped his decision making. The relative
simplicity of his understanding of the issues
made me question how we are teaching
our students. Do they learn how to think
critically? What is their experience with
concepts of evidence based medicine that
demands inquiry? Do they question ideas
which may sound good at face value but if
challenged for validity, then can not with
stand the scrutiny? I did not press him on
his ideas - learning is relative and has to be
taken from the perspective of the learner.
Once a learner recognizes that he does not
know something, then it creates a conflict
from within. He will have to either confirm
the idea’s validity or accept the notion without challenge. Validity takes work, but it is
an active process which promotes discovery
of new ideas and interpretations. Mezirow
called this transformation learning because
the internal conflict forced a change in our
perceptions. It has been said that, “the eyes
can not see what the mind does not know.”
The last office visit of the day did not
yield the presence of a single senator or
congressman. In meeting with legislative
aids a group of student mirrored the exact
thoughts they were told to reflect. This
pleased the legislative aid because there
were no dissents, challenges or attempts
to confirm the validity of the legislative
agenda. However, a spark in the group
came from a student hailing from the West
Virginia College of Osteopathic Medicine.
Her view allowed her to look through the
mirrored thought and recognized it as
simply a one-way mirror. She was being
manipulated to think one way and she
politely questioned the effect of the proposal. Mathematically, the espoused plan
did not add up. It lacked validity and could
not make sense. I was so proud of her for
her willingness to be a leader and recognize
truth. She used her critically thinking skills
to question. She empowered herself to bring
up more questions and she synthesized new
coherent thoughts in her attempt to seek
solutions. The legislative aid was clearly
holding back information and offered no
explanation to her questions.
My experience with DO Day drove home
several points.
1. We as a profession need each other to
do our part if we are to be successful. Our
many student participants in DO day are
a sign of a healthy profession, but we need
more participation from our seasoned professionals. Our success as a profession now
demands legislative involvement from all
of our members. Not only does our voice
become a whisper when we lack participation, but we fail to model and mentor the
next generation as well.
2. We need to think critically. If we don’t
wrestle with the ideas then we won’t be
able to establish an understanding or our
position to provide effective change. The
AOA offered town hall meetings to help
foster dialogue to debate the ideas. We
need to teach our future doctors to think
critically. This is a key requirement in
developing leaders for the profession. These
leaders need to step forward and offer their
expertise.
3. Valid arguments are truthful and therefore do not need to be hidden. The profession will not fractionate if the profession
stays true to its ideals and focuses on the
patients we serve.
4. We will cross paths again – Einstein’s
concept of ‘spacetime’ suggests we are
connected and function relative to each
other. Hopefully will cordially greet each
other and reflect on our influence with one
another. We have much to learn from our
relative positions and could do more to help
each other succeed.
Wish you
were here.
~EMP
Emergency Medicine Physicians has just added two new
hospitals to over 60 hospitals served in the United States:
Brookhaven Memorial Hospital Medical Center in Long Island
and Mercy Hospital – Anderson in Cincinnati. We’re looking
for emergency medicine physicians who are dedicated to
delivering the best in emergency medicine to fill immediate
openings. If you’re interested in joining a democratic group
that offers equal equity, leadership opportunities and a
schedule you make your first year, call or write back today.
800-828-0898 | [email protected]
Opportunities across the USA.
EMP has a number of osteopathic hospital locations including three
with osteopathic EM residency training programs.
The PULSE JULY 2010
9
Guest Column
Peter A. Bell, D.O., MBA, HPF, FACOEP-D, FACEP
Editor Emeritus
Scholarly Activity: A Road to Higher Ground
In 1973
the number
one hit on the
U.S. Hot Soul
Singles chart
was ”Higher
Ground” by
Stevie Wonder.
It addressed
the ongoing
struggles and
recurring challenges of man. It expressed
a second chance to remake one's life and
achieve something better than what was
commonplace. It offered hope. It was
inspirational. It focused on faith and a
commitment to reaching farther, achieving
more, and ascending to higher ground. It
also had attitude. "Gonna keep on trying till I reach my highest ground … No
one's gonna bring me down". During this
same era, and with the same tenacity, the
specialty of emergency medicine was established. Early goals were to codify a body of
knowledge specific to the practice of emergency medicine and to that end, to train
others to be specialists in the discipline.
In order to accomplish these goals,
emergency medicine had to gain the
respect of the other specialties within the
house of medicine. The standards for training in emergency medicine were set high.
The requirements for board certification
were extensive. Emergency medicine was
also the first specialty to require ongoing
certification. Scholarly activity and lifelong
learning was a prerequisite.
Today, emergency medicine has
very well defined standards for training
residents in emergency medicine. These
include an extensive appendix of topics,
diseases, and procedures encountered in
the emergency department. In addition the
appendix has been weighted with both frequency and acuity so as to better direct the
10
learners’ studies.
Certification through the American
Osteopathic Board of Emergency Medicine
requires a three-step process: the assessment of medical knowledge through a
written exam, analysis of common scenarios through an oral/practical exam, and
assessment of practice through a quality
assurance review of charts. In addition,
continuous medical education must be
achieved over a three-year cycle, assuring
that at least 25 hours per year are completed in the specialty of emergency medicine.
The concept of ongoing, continuing, or
maintenance of certification was pioneered
by emergency medicine. Both AOBEM
and ABEM require a series of literature
reviews annually with examination that
qualifies the physician to recertify every 10
years. Most recently, the bar was raised by
national authorities, to incorporate a quality improvement project into the recertification process. This requirement was
inspired by the current core competency
required by all AOA and ACGME training
programs:”Practice-Based Learning”.
So who is a scholar? Merriam- Webster
defines a scholar as a person who attends a
school or studies under a teacher, or a person who has done advanced study in a special field: “a learned person". http://www.
merriam-webster.com/dictionary/scholar In
our pursuit of excellence, we are encouraged to develop as scholars of emergency
medicine.
Today scholarly activity in emergency
medicine is abundant. Like any financial
portfolio, it is desirable to have diversity
and balance. The ACGME defines scholarly activity for residents as:
“An opportunity for residents/fellows and
faculty to participate in research, as well as
organized clinical discussions, rounds, journal clubs, and conferences. In addition, some
members of the faculty should also demonstrate
The PULSE JULY 2010
scholarship through one or more of the following:
peer-reviewed funding; publication of original
research or review articles in peer-reviewed journals or chapters in textbooks; publication or presentation of case reports or clinical series at local,
regional, or national professional and scientific
society meetings; or participation in national
committees or educational organizations.”http://
www.acgme.org/acWebsite/about/ab_
ACGMEglossary.pdf
Specific to the emergency medicine standards, it further states that:
"1. The curriculum must advance residents’
knowledge of the basic principles of research,
including how research is conducted, evaluated,
explained to patients, and applied to patient
care.
2. Residents should participate in scholarly
activity.
The curriculum should include resident
experience in scholarly activity prior to completion of the program. Some examples of suitable
resident scholarly activities are the preparation
of a scholarly paper such as a collective review
or case report, active participation in a research
project, or formulation and implementation of an
original research project; and,
The program must teach residents to have
an understanding of basic research methodologies, statistical analysis, and critical analysis of
current medical literature.
3. The sponsoring institution and program should allocate adequate educational
resources to facilitate resident involvement
in scholarly activities.” http://www.
acgme.org/acWebsite/downloads/RRC_
progReq/110emergencymed07012007.pdf
The AOA guidelines for training in
emergency medicine state similar goals
for osteopathic residents. STANDARD II:
EDUCATIONAL PROGRAM GOALS
AND OBJECTIVES are rather extensive.
They require faculty to be involved in
research and academic pursuits such as
publication in peer review journals, participation in textbook chapters, local or
specialty publications, formal lectures (on
a national basis), visiting professorships,
or active involvement in national emergency medicine organizations within the
past five (5) years. http://www.acoep.org/
uploads/2007-07-EmergencyMedicine.pdf
Scholarly activity can be demonstrated
in many forms.
Research
- Collaboration w/ basic scientists for bench research
- Clinical research
o case-based paper with literature search
o comprehensive literature search with paper i.e. collective review
o pilot studies
o abstract proposals/research pro
posals (comprehensive IRB ready)
o Survey
o Pharmaceutical or procedure/
practice comparisons: assess the effica
cy of one drug or procedure versus another
Writing
- Faculty development
o train the trainer
o adult education concepts
o patient education concepts
- Peer reviewed
o online journals
o journal articles
o textbook chapter
o curriculum development
o editorials
o specialty publications
o training manuals
o grant writing
Speaking
- national, state, or regional presenta
tions
o papers
o abstracts
o posters
o case competition
o lecture
o literature reviews (niche)
o keynote address (inspire others to a purpose or cause based on expertise and mentorship)
-
-
-
Grant reviewer
IRB member
Research department
o methodology
o statistics/metrics
o writer/reviewer
Education
- Advanced degrees
- Certificate programs
- Honorary titles (criteria defined with peer approval)
- Accolades acknowledging scholarly achievement
The five-year plan
Research, Writing, Speaking, Serving,
and Education are the elements of your
portfolio. We all can add to the body of
emergency medicine knowledge during
the course of our careers. Start by selecting
something from each of the 5 categories.
Serving
Each selection must capture your interest
- Editorial board
and be achievable. Next, define a 5 year
- Colleges, societies, associations (Board plan to accomplish each item. Once you
and committee work)
begin the journey, many new opportunities
o OPTI
may present themselves, adding depth and
o ACOEP
often unexpected resources that expedite
o ACEP
your plan. The five years will go quickly,
o AAEM
and you may have to modify your origi
o SAEM
nal plan, but don’t lose sight of the goal.
o WADEM
Remember, as an osteopathic emergency
o IFEM
physician, you are a scholar. Keep reaching
- Visiting professorships
for higher ground.
o COMs
o International
Editorial, continued from page 4
large quantities prescribed over a short
time; multiple providers writing prescriptions; symptoms that markedly deviate
from objective evidence; use the ED as primary care; and, PCP is on vacation. These
characteristics are suspicious for DSB but
not proven behaviors.
The professional patient also exhibits
DSB.
These are patients who exploit
chronic medical conditions; feign illness;
persuade providers to diagnose by history;
taint urine specimens with blood; bring
own diagnostic work-up; control interview;
apply psychological pressure; refuse workup; and leave before treatment is completed. How many times have we seen the
professional patient, gave into their requests
and did not realize we were duped until
after the patient left the ED? We all have
fallen victim to these patients and do not
readily recognize that we have been had.
The question arises, how do we treat
patients with an acute exacerbation of
chronic pain who presents to the ED? Do
we concede to the patient’s request? This
is the path of least resistance but now you
have fed the bears and they will keep coming back for more. EMTALA requires a
medical screening exam on all patients.
Once your medical screening exam is completed, do you provide the patient with
analgesia or do you refer the patient to their
The PULSE JULY 2010
PCP or the pain clinic for management of
their pain. Many EDs have policies that
deny patients with DSB behaviors any controlled substances after completion of their
medical screening exam. Other EDs have
treatment options that employ non-narcotic
medications and adjunctive therapies for
their chronic pain patients. These are difficult patients to manage and time and labor
intensive and there is no easy solution on
how to deal with them.
11
Guest Column
Bernard Heilicser, D.O., FACOEP
The Real Reality
We have just arrived in Port-AuPrince, 2 ½ weeks have passed since the
earthquake. Words cannot describe what
one sees, hears and smells. The images
we have seen are bad, but this is beyond
comprehension. The devastation is everywhere. This can’t be real. But, it is.
Working the ED at the large Hospital
De L’Universite D’état D’ Haiti, or
General Hospital, the human misery is
beyond description. They come by the
hundreds, many still emergently from
the earthquake, others having never
seen a physician before.
The ED is three tents, each with
12 mesh cots with three hundred to
five hundred each day, most between
7 a.m. and 6 p.m. The injury and illness is difficult to fathom. Bones are
not meant to create such angles, open
wounds displaying so much anatomy
is a thing for a dissection lab in medical school. Malaria, dengue fever and
typhoid should only be Board questions. Tetanus is a fatal disease.
An “inpatient” ward of 360 patients
is adjacent to the ED; under the trees.
Pre-Op and Post-Op are also in tents, as is
the TB “isolation”. Surgery is in hallways.
ICU is in a collapsed building, mostly on
the floor with occasional electricity. There
is no CT, only minimal lab and simple
x-ray, if you wait 2 to 4 hours. Sterility
is fiction. Dunk the needle driver in
Betadine and start suturing, again. The
12
only sheets are the ones in the tent cities.
Irrigate the infected wounds and stumps,
and welcome the next patient to the cot.
Privacy is nonexistent. Bodily functions are performed on, or squatting
beside, the adjacent cot. There are no partitions. Rashes are demonstrated for all to
see.
Supplies are present, at times. Today
we have normal saline, yesterday we ran
out by 11 a.m. How often do we use the
third indicated antibiotic for a given infection? Atrial fibrillation is a clinical (pulse)
diagnosis, and treated for results and discharge in a similar manner. There may
not be insulin for that patient with DKA
today; hopefully normal saline is available.
How do you tell a mother to give
her child the amoxicillin twice a day with
water; there is no water. Apply this lotion
The PULSE JULY 2010
for the endemic rash and then wash or
bathe; with what, sewer water? Placebo
medicine is the standard of care. Tylenol,
Motrin and Benadryl are all wonder drugs.
Really, the arm around the patient with
encouragement, reinforcement and a smile
is the true medicine.
The children are the hardest. What
did they do to deserve this? The 2 month
old about to die who, thank God, is resuscitated with 2 intraosseous lines. The
2 week old is probably better off with
her Maker. Children should grow up
with all their extremities.
There is no time to cry.
The simple scalp laceration patient
who decided to charge his cell phone
in the tent by disconnecting the fan
(it went up to 107˚in the tents). He
is upset that you make him leave; so
much for our Press Ganey’s.
The people of Haiti are appreciative
and caring. The children are well
dressed and loved. “Merci” is always
voiced. They are proud and resilient.
Their emotional and physical strength is
inspiring. They were most appreciative of
the medical care, but we should be more
appreciative of what they taught us.
There are two realities in this world.
The material reality we selfishly desire,
pursue and protect; that is our reality.
And the reality that is Haiti; the REAL
REALITY.
Emergency Medical Services
Gregory Joseph Beirne, D.O., FACOEP
What's New, What's on the Horizon?
Greetings from
St. Louis! It appears
summer has arrived
here with a vengeance, with temperatures this week
(May 24) already in
the 90’s, with that
lovely humidity we
are famous for. It seems like just last week
that all of us were together at the Kierland
Resort in Scottsdale. It was an enjoyable
week for me, allowing me to catch up with
friends and colleagues. As chair of the EMS
committee, one of the ideas I had proposed
to the other committee members was for
our committee to have an article in each
issue of THE PULSE. With that in mind,
I would like to provide updates from our
recent EMS committee meetings to the
membership, as well as my own experiences as a new EMS medical director. At our spring 2009 meeting in
Orlando, we welcomed several new members and began work on an ambitious
project to review position papers that
are on NAEMSP (National Association
of EMS Physicians). We are in the final
stages of this project, and will be providing recommendations to the ACOEP
Board of Directors regarding these papers,
hoping to provide a link to NAEMSP on
the ACOEP website. Many of our college
members are actively involved in EMS and
also members of NAEMSP. We also began
work on the creation of an EMS section on
the ACOEP website, a project that is still
ongoing at this time. We hope to have this
finalized within the next by spring 2011.
This section would provide the membership with resources for EMS issues, questions/answers, legal updates, and hopefully
a blog for members to provide information
for ideas, cases, etc. I will keep you updated on the status of this ambitious project.
At our fall 2009 meeting in Boston,
we continued work on the NAEMSP
papers, and also discussed the creation of
an online EMS fellowship. Many of our college members, myself included, completed
an emergency medicine residency, but did
not have the chance to pursue an EMS fellowship. After working as attending physicians, we became actively involved in EMS
and realized that an EMS fellowship would
have provided us with a tremendous educational opportunity. Currently, there are
two AOA/AOBEM approved EMS fellowships, Lehigh Valley Medical Center and
Albert Einstein Medical Center. Most of
us, as you know, do not wish to uproot our
families, or give up our current positions
and responsibilities, to pursue this type of
additional training. With that in mind, the
EMS committee discussed the creation of
a “distance-based” online learning module,
similar to University of Phoenix or Kaplan
University. This would allow ACOEP
members who are interested in EMS fellowship certification to complete the
training while enabling them to continue
working as attending physicians in their
current location. At the present time, we
are continuing our dialogue with the AOA
and AOBEM to develop a curriculum for
their consideration.
At our most recent meeting in
Scottsdale just a few months ago, we continued our work on the NAEMSP position
papers, as well as continued discussion
about the EMS fellowship project. We also
welcomed new members, both students
and residents, and also had a guest from
WADEM (World Association of Disaster
and Emergency Medicine), Jerry Overton,
who is the section chief for International
EMS. Jerry spoke about his mission with
WADEM and international EMS, and we
hope to have him speak at the scientific
seminar in San Francisco this fall. Dr.
Bograkos, one of our EMS committee
members, spearheaded the campaign to
have ACOEP become the foundation for
the osteopathic section of WADEM. We
hope to reach out to other osteopathic
physicians who are involved in EMS and
The PULSE JULY 2010
disaster medicine at the fall 2010 scientific
seminar. All ACOEP members may join
WADEM. (http://www.wadem.org)
This brings me to some final
thoughts about EMS and my experiences
as a medical director. I am the director
of EMS Education for Missouri Baptist
Medical Center in St. Louis, Director of
EMS Programs for St. Louis Community
College, and Medical Director for Respond
Right, a privately owned EMS education company in St. Louis. In addition, I
have recently become co-medical director
for two fire departments in suburban St.
Louis. Our emergency department is in
a suburban, community-based hospital
with an annual volume of approximately
40,000-45,000. We are a level 2 trauma
center. We were approached in 2008
about becoming medical control by two
fire departments in our area. One of these
is a city-based fire department with an
annual volume of 4000 calls for 2009.
Geographically, it is a unique environment, as the coverage area abuts the city
of St. Louis on its eastern border, and
several affluent suburbs on its western and
southern borders. The call volume includes
many medical emergencies, motor vehicle
trauma and the “knife and gun club”. This
particular department has many new paramedics and many veteran paramedics, all
of whom are eager and dedicated to providing excellent patient care. I met with
all of the crews last June, while the contractual process for becoming their medical
control was being finalized. Many of them
were colleagues I worked with during my
tenure as a paramedic. During our discussions, many of the crews expressed frustration about their past experiences with
other hospitals that had been their medical
control over the years, as well as the lack
of educational programs. I assured them
that we were going to provide a unique
medical control program for them and that
13
Juan Acosta, D.O., MS, FACOEP, President, FOEM
2010 Research Activities
As we move
forward in our
plans to expand
and increase
the research
activities in
osteopathic
emergency
medicine, the
Foundation
is pleased to
announce that
the Spring Case Poster Competitions were
very successful and we had 19 entries into
this event. The event was well attended
and we were happy to see so many
attendees participate in this event and give
support to our presenters.
The winning case posters were:
1st Place: Marianna Karounos
from St. Joseph’s Regional Medical Center
for her poster titled
“Dizziness and Brugada Syndrome
in an Urban Setting.”
2nd Place: Alexandre Pierrot
from St. Barnabas Hospital for his poster
titled “Rapidly Expanding Non-Traumatic
Pericardial Effusion with Tamponade.”
3rd Place: James Rodriguez
from Botsford Hospital for his poster titled
“Isoniazid Toxicity.”
Beginning this fall, the Foundation
will host its events in conjunction with
the ACOEP’s Scientific Assembly at the
San Francisco Hilton Hotel, Union Square
on Monday, Tuesday, and Wednesday,
October 25, 26, and 27th. The session
14
will lead off with the CPC on Monday,
Healthcare Professionals.”
beginning at 7:00 a.m. and ending at
As we continue to bring you more
approximately 3:30 p.m. Research posters information on research being conducted
will also be presented on Monday during
by emergency physicians, we urge you to
the same time period. The Oral Abstract
get involved in the Foundation, not only as
Competition will start the day Tuesday
a donor, but a participant. We need judges
at 6:00 – 7:30 a.m. and our events will
to review posters, CPC presentations, and
finish off with the Resident Research
oral abstracts, and to serve as reviewers of
Paper Luncheon on Wednesday at 11:30
resident research. If you are interested,
a.m. Winners will not be announced until
please contact Stephanie Whitmer,
Wednesday at the end of the Luncheon.
Executive Secretary for the Foundation and
If you are interested in participating in she will gladly help you with finding the
any of these programs, we urge you to visit appropriate venue for you.
our website, www.foem.org, and download
the application form and
remember all applications
must be submitted to the
OHIO: OSTEOPATHIC
Foundation by July 15th.
EMERGENCY MEDICINE
We have also supplied
RESIDENCY
PROGRAM DIRECTOR
copies of the Handbook
to the program directors
This is an exciting opportunity to lead a program
and residents to keep
from inception, as well as participate in the dethem informed of the date
velopment process. Qualified candidates must be
changes and to encourage
ABOEM certified and residency trained in Osteotheir participation in these
pathic Emergency Medicine with prior experience
programs.
as a program director or assistant director. Adena
We are also happy to
Regional Medical Center is a full-service hospital
announce the continuance
with an annual ED volume of 41,000. Located 45
of research at all levels.
miles directly south of Columbus and 90 miles
This year, James Turner,
northeast of Cincinnati. Chillicothe is surrounded by
D.O., and his team
history, recreation, and scenic beauty.
at Charleston Area
We offer a highly appealing package that includes
Regional Medical Center,
competitive remuneration, excellent benefits, and
Charleston, West Virginia,
equity ownership eligibility within an established,
were awarded an $11,000
democratic group.
David A. Kuchinski
Memorial Grant for
Contact Amy Spegal, Premier Health Care Services
research being done on
phone: (800)726-3627, ext 3682,
“Posttraumatic Stress
email: [email protected]
Disorder, Work Stress,
fax: (937)312-3683
and Burnout among
The PULSE JULY 2010
Foundation Focus
Janice Wachtler, BA, CBA, Executive Director
Fickle Finances
For most of us, this past year was sort
of topsy-turvy especially when it came to
finances and investments. We’ve watched
as banks have failed and large investment
companies have had to have government
help because they over extended themselves. Associations and Foundations have
watched from the sidelines, just like you
have and have ridden the various waves of
good news and cringed as bad news was
laid on your desk with each morning’s
newspapers.
And like you, the Foundation has felt
the pinch of diminishing returns, but while
you could depend on the steady stream of
patients and income, we could not.
To adjust to the fact that donations
fell to an all time low in 2009, we charged
for the CME provided at the various
research events at the Scientific Assembly
last fall and will do this again in 2010.
We also had to move the events away from
anything involving a meal function just to
maintain costs. We have relied heavily on
the ACOEP, our regular core of donors and
sponsors to continue to promote research,
and we’ve had to limit the grants being
funded. We’ve also relied heavily on the
Board and Staff members, who in many
cases waived travel and hotel reimbursement to lighten the load. Staff has been
cut even though we now have two parttime staff positions, one is minimally funded and one is a volunteer position. We
will continue in this leaner fashion until
we can be assured that we can continue as
a research entity, and that will depend on
you.
Philanthropic development is individual and most people develop the tendency
and frequency of donating to a cause early
in their professional career. Also, people
tend to donate in causes they believe in
and are personal. Generally speaking if
you adopted pet from a shelter, you will
support that shelter for the life of the pet
and will probably return to the shelter to
adopt another pet. Likewise, if you had
a friend or relative with a specific disease,
you will donate to that particular charity
more frequently than any other. Other
people feel strongly about a specific cause,
wildlife, gun control, animal habitat, or
whatever and they will support that cause
on a long-term basis. So what we’re asking
is to support the group that supports you
and osteopathic emergency medicine, and
that is the Foundation for Osteopathic
Emergency Medicine.
Right, you say, and how can I help,
I’m strapped too. Well, we know that, but
. . . here’s how you can help.
Each year the ACOEP sends out
its dues notices, and each year there is a
“negative check off ” on it for $50 for the
Foundation. Many of you have provided
us with this amount and more, most have
not. This $50 is 100% tax-deductible for
you and each donation is acknowledged
so you can claim it on your income taxes.
If all of the ACOEP members left this
on their dues statement, we could raise
upwards of $100,000 annually. If residents
donated annually, that would add another
$50,000 annually. Do you know what we
could do with that? Help you in so many
ways fund your residency research, help
you teach research and do research at levels
that we can only imagine. But it won’t
happen in a year, or even in two, it will
happen gradually as we gain your support
and show you what we can do.
The PULSE JULY 2010
So as you fill out that form, and write
that check remember the Foundation
and whether you’re a resident or attending, a student or a retiree, remember the
Foundation and its mission to support
osteopathic emergency physicians doing
research. We’ve come a long way in 10
years and we have a long way to go, but
you have to take the first step to support
us and keep up the pace for us to continue
to help you. We have to work as a team, so please
join us – we can’t do it without you.
RESEARCH
OPPORTUNITY
Opportunity exists to participate in a Multi-Center
Research Project
We are looking for additional
Emergency Residents interested in participating in
our perspective,
multicenter research of MRSA
skin infections.
For more information, please contact:
Judith M. Knoll, D.O. FAAEM
Hamot Medical Center, Erie, PA
[email protected]
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21
Executive Directors Desk,
continued from page 6
mean, who today would even think of not
having a lap top or home computer at the
very least? But it’s true the world then was
much different than it is now.
Medicine, especially, osteopathic medicine was very different too. In 1975, doctors working the emergency department
were not “specialists” in the new field of
emergency medicine. Much of the work
done in the ED was done by either moonlighting physicians or physicians trained
in other specialty areas. Allopathic medicine, had declared Emergency Medicine
a specialty in the late 1960’s and there
were only a few accredited allopathic residencies in allopathic medicine by 1975.
Osteopathic physicians in any specialty area
were almost all trained in a small network
of osteopathic hospitals, many of which
were required by their state to have the
word “osteopathic” in their name. But on
October 5th 1975, nine physicians joined
forces to develop what became known
as the American College of Osteopathic
Emergency Physicians. They were: Richard
Ballinger, D.O., James Budzak, D.O.,
Donald Cucchi, D.O., Robert George, D.O.,
Anthony Gerbasi, D.O., James Grate, D.O.,
Robert Hambrick, D.O., Bruce Horton,
D.O., and Scott Swope, D.O. (See related
article, “Our History” for the exact information). From their efforts the specialty of
osteopathic emergency medicine was developed and nurtured.
Many take for granted the work and
sacrifice that these physicians went through
developing the Articles of Incorporation
in the State of Ohio; a Constitution and
Bylaws by which to operate under; appearing before the AOA Board to inform them
of the need for this specialty and then to be
recognized, as not only a specialty affiliate,
but a medical specialty within its organization. The actual recognition did not occur
for three more years.
During the three-year period between the
founding of the College and the recognition
as an affiliate and specialty area, the Board
had to recruit interested physicians to make
a specific number of interested parties in
this new specialty. The “founders” had to
market this new area. The AOA required
that a specific number of physicians show
interest in any area under consideration as
a “new specialty.” Additionally, they had to
be ready to have training programs set up
to train physicians interested in emergency
medicine, and to do that they needed to
recruit physicians working in the ED who
were interested in teaching. And, even
more important they had to develop basic
training standards for the specialty. The
group of nine increased exponentially to
recruit physicians who could fit the bill and
medical students and interns who would be
interested in the specialty.
In summer of 1978, the specialty of emergency medicine and its specialty college
were officially recognized by the American
Osteopathic Association; in the fall, the
residency training standards were approved
as were two residency programs at CCOM
and Hospital of PCOM were approved and
training began in the fall of 1979. The first
osteopathic emergency medicine resident
was Gerald E. Reynolds, D.O. at HPCOM.
Today, osteopathic emergency medicine
programs train about 1,000 residents each
year in 44 residency programs; there are
currently 504 fellows and distinguished fellows of the ACOEP and more than 3,000
members of our association.
Looking back, it’s amazing to see what 9
determined people can set in motion. And,
even more amazing is seeing the fruits of
their labor and the support of the dedicated
members of ACOEP can take the College in
the next 35 years.
We can always look back to see where
we’ve been but we must never lose sight
of where we want to go, so we continue to
encourage your participation and support.
OFFICIAL CALL
To the Officers and Members of the American College of Osteopathic Emergency
Physicians:
You are hereby notified of the ACOEP's Fall Membership Meeting on Monday, October 25,
2010, at the Hilton San Francisco Union Square Hotel in San Francisco, California. The
meeting will begin at 5:00 p.m. A "Meet and Greet" Session to introduce members to Board
Candidates will begin at 4:00 p.m.
Voting for new Board Members will occur at this meeting. All classes of Active Members, Life
Members and Retired Members will be provided with ballots at the time they sign into the meeting. New Board Members will be sworn into office at the Fellowship and Awards Ceremony
immediately following the meeting. Candidate information will be included in your dues notice in
August and will be made available on www.acoep.org after August 15th.
Janice A. Wachtler, CBA, Executive Director
22
The PULSE JULY 2010
2010 Student Case Competition
Winning Submission
Joshua Craig Poles, OMS III
Kansas City University of Medicine and Biosciences - Class 2011
I. Case Report
A. Chief Complaint: Persistent ventricular
fibrillation after induction of therapeutic
hypothermia and high dose vasopressor
therapy.
B. History of present illness: A previously
healthy 36-year-old man was brought
to the emergency department (ED) by
ambulance after coworkers witnessed him
suddenly collapse and stop breathing.
Coworkers called 9-1-1 and initiated CPR.
An on-site automated external defibrillator
utilized by the man’s coworkers delivered
one shock. EMS arrived approximately
4 minutes later and found the patient in
asystole. Paramedics performed minimally
interrupted cardiac resuscitation. The
patient received a total of 2 mg intravenous epinephrine and 2 mg intravenous
atropine and had return of spontaneous
circulation 11 minutes into the field resuscitation without further defibrillation.
He remained unconscious and was orally
intubated with a standard 8.0 endotracheal
tube. Paramedics administered a 100 mg
i.v. lidocaine bolus followed by a 2 mg/min
lidocaine drip. Upon arrival in the ED, the
patient was unconscious with stable vital
signs and the EKG demonstrated normal
sinus rhythm (NSR).
Therapeutic hypothermia (TH) was
induced while the patient was in the
ED through a closed-loop i.v. catheter
and a Coolgard 3000™ fluid circulator
(Alsius, Irvine, CA) 2 hours after the initial collapse. Intravascular temperature
was maintained at 33.5°C. Propofol was
administered for sedation and 10mg of
vecuronium was administered to prevent
shivering.
The patient was transferred to the
intensive care unit with a core temperature
of 33.5°C. Three hours after collapse the
patient began experiencing recurrent epi-
sodes of ventricular fibrillation (VF). The
following i.v. medications were initiated:
5 µg/min of epinephrine, 8 µg/kg/min of
dobutamine, and 8 µg/kg/min of dopamine. Bedside delivery of extracorporeal
membrane oxygenation (ECMO) support
and the placement of an intraaortic balloon
pump were required. A left heart catheterization was performed and demonstrated
normal coronary anatomy without evidence
of an obstructive lesion. A bedside 2-D
echocardiogram demonstrated septal and
ventricular akinesis with an ejection fraction of 15%. Over the course of 9 hours in
the ICU, ventricular fibrillation recurred
persistently with just brief intervals of
NSR. He received 122 defibrillations at
settings between 200 and 300 J of biphasic energy. During the ongoing 9-hour
resuscitation, totals for the following i.v.
medications were administered: 4.4 mg of
epinephrine, 164 mg of dobutamine, 120
mg of dopamine, 795 mg of amiodarone,
and 64 mg of procainamide.
Twelve hours after arrival, the patient
was transferred to another facility to be
evaluated for potential heart transplantation. He arrived at the receiving hospital
in persistent VF with a core temperature
of 33.5°C. It was proposed by the receiving physicians that either the considerable
dosages of cardiac medications or TH was
causing refractory VF. All vasoactive and
beta adrenergic agents were abruptly discontinued and TH was withdrawn. The
patient was again defibrillated with 200 J
of biphasic energy and he converted to and
remained in NSR.
C. Past medical and surgical history: Patient
has seasonal allergies. No other past medical or surgical history.
D. Medications and allergies: Claritin-D as
needed for seasonal allergies. No known
drug allergies.
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E. Review of systems: Per the patent’s wife:
1. General/Constitutional- No recent illness. There had been no weight changes.
The patient had been in excellent general
state of health with good strength, ability to conduct usual activities, and strong
exercise tolerance. He played tennis 3 days
per week. No fatigue. No chills. No night
sweats.
2. Skin- No rashes, changes in pigmentation, bruising or petichiae.
3. Head/Eyes/Ears/Nose/Mouth/ThroatPositive for recent mild seasonal allergy
symptoms. No recent headaches. No
vertigo or lightheadedenss. No change
in vision. No history of head injury. No
epistaxis or ginigival bleeding. No neck
stiffness.
4. Cardiovascular- No precordial pain. No
substernal distress. No palpitations. No
syncope. No dyspnea on exertion, orthopnea, or nocturnal paroxysmal dyspnea.
No edema. No cyanosis. No known heart
murmurs.
5. Respiratory- No shortness of breath,
wheezing, stridor, or cough. No hemoptysis, respiratory infections, tuberculosis (or
known exposure to tuberculosis).
6. Gastrointestinal- Normal Appetite. No
dysphagia, indigestion, abdominal pain,
heartburn, nausea, vomiting, hematemesis,
jaundice, constipation, or diarrhea. No
abnormal stools or recent changes in bowel
habits.
7. Genitourinary- No urgency, frequency,
dysuria, nocturia, hematuria, polyuria,
oliguria, stones, infections, genital sores,
discharge, or venereal disease.
8. Musculoskeletal- No Pain, swelling,
muscular weakness, atrophy, or cramps.
9. Neurologic/Psychiatric- Denies seizures,
tremor, incoordination, parathesias, difficulties with memory or speech, sensory/
motor disturbances, or muscular coordination. Also denies emotional problems, anxiety, depression, previous psychiatric care,
23
or hallucinations.
10. Endocrine- Denies heat/cold intolerance, excessive sweating, polyphagia, thyroid problems, or diabetes.
F. Physical exam: This was 36 year old,
well-developed, caucasian male. No cephalic deformities, lacerations, or evidence of
trauma was noted. The pupils were equal
and reactive to light. There was no hemorrhage from the auditory canal. There was
no jugular venous distention. There was no
evidence of tongue laceration. The chest
was clear to auscultation; examination
of the heart revealed clear heart sounds
without rubs, gallops, or murmurs. Rigid
posturing of the extremities was noted on
neurological examination.
G. Vital signs: On arrival in the ED, the
patient’s vital signs were blood pressure of
115/60 mm Hg, heart rate of 127 beats/
min, core temperature of 37.0°C (98.6°F),
and oxygen saturation of 100% while
being bag-valve-mask ventilated.
H. Emergency department head-to-toe format by
system:
1. HEENT- Normocephalic and atraumatic. Pupils equal, round, and reactive to
light. No jugular venous distension.
1. Neurological- Bilateral upper extremities were in slight decorticate (flexion)
rigidity. Patient was unresponsive. Glasgow
coma scale score of 4.
2. Pulmonary- 8.0 endotracheal tube in
place. Mechanical ventilator programmed
in assist control. Lungs were clear to
auscultation bilaterally without wheezes,
rhales, or rhonchi.
3. Cardiovascular- S1S2, were audible, regular rate and rhythm. No murmurs, rubs,
or gallops appreciated. Capillary refill < 2
seconds in upper extremities. No jugular
venous distension appreciated. No pedal
edema. Radial and dorsalis pedis pulses
+2/4 bilaterally.
4. Gastrointestinal- Abdomen soft, nondistended. No masses. No organomegally.
Normal bowel sounds in all 4 quadrants.
Nasogastric tube in place. No bright red
blood per rectum. Stool in vault.
5. Genitourinary- Foley in place with yellow urine draining.
6. Extremities- no clubbing, cyanosis, or
edema. Positive abrasion on right hand and
24
knuckles.
I. Laboratory and ancillary data:
EKG- Sinus tachycardia at 120 beats/min.
No ST wave changes.
Chest radiograph- Portable chest radiograph
showed clear lung fields with normal heart
and mediastinal silhouettes.
Labs:
Arterial blood gas- pH: 7.38 pCO2: 37
pO2: 346 HCO3: 21.5.
CBC- WBC: 9.6 Hgb: 16.1
Hct: 45.7 Platelets: 319
Chem-7: Na+: 140 K+: 3.5
Cl-: 110 HCO3: 16 BUN: 11
Cr: 1.4 Glucose: 202
Creatine Phosphokinase- 155
CPK-MB- 3.8
Troponin I- 0.10 ng/mL
Urine drug screen- negative.
Urinalysis- normal
J. Diagnostic impression:
1. Out-of-hospital cardiac arrest with
return of spontaneous circulation.
2. Persistent ventricular fibrillation secondary to excessive dopamine and dobutamine
during therapeutic hypothermia.
K. Plan of disposition: On hospital day 2,
his ejection fraction had increased to 75%.
On day 3, after ECMO support and the
intraaortic balloon pump were removed,
sedation was discontinued and he was successfully extubated. He remained in NSR.
Upon regaining consciousness the patient
had impaired short-term memory which
gradually resolved over the next 7 days.
On hospital day 10, an automatic implantable cardioverter defibrillator (AICD)
(Medtronic, Minneapolis, MN) was placed
and the patient had a full neurological
recovery and was discharged home.
This patient underwent cardiac
magnetic resonance imaging, myocardial
biopsy, channelopathy genetic screening,
and evaluation for dysrhythmogenic right
ventricular dysplasia, all of which were
normal. Several months after discharge he
is back at work full-time. The AICD has
not fired and the patient has had not subsequent episodes of ventricular fibrillation.
The PULSE JULY 2010
2. Discussion:
Etiology of Persistent VF in This
Patient
Based on published evidence, I believe that
the cause of persistent VF in our patient
was excessive dopamine and dobutamine.
At intermediate doses (2–5 μg/kg/min),
dopamine stimulates β-receptors, producing
positive inotropic effects (1). The adverse
effects are associated with excessive sympathomimetic activity and include dysrhythmia, tachycardia, hypertension, anginal
pain, nausea, vomiting, and headache
(2). Dobutamine stimulates myocardial
β1-adrenergic receptors at doses with a positive inotropic effect (2.5–10 µg/kg/min)
(1). The major side effects of dobutamine
are dysrhythmia and excessive tachycardia
(1). The Heart Failure Society of America
guidelines recommend that if worsening
tachydysrhythmias develop during administration of dobutamine, discontinuation
or dose reduction should be considered (3).
Dopamine is contraindicated in patients
with uncorrected cardiac dysrhythmias,
including ventricular fibrillation or ventricular tachycardia (4). Dopamine and
dobutamine are primarily metabolized by
catechol-o-methyl transferase and monoamine oxidase, which are in highest concentration in the liver and kidneys (1).
The effect of TH on the clearance
of exogenous catecholamines and cardiac
life support medications has not been specifically evaluated, however, studies have
demonstrated diminished liver metabolism
by enzymes such as cytochrome P-450 during TH (5-7). Tortorici et al. described four
medications found in higher-than-expected
concentrations in patients cooled within
the therapeutic range (6). Additionally,
animal studies have demonstrated reduced
glomerular filtration, leading to reduced
excretion of parent drugs or their metabolites during TH (8).
Therapeutic Hypothermia
Therapeutic hypothermia is a relatively
new treatment modality for many practitioners (9). In 2005, it received the status
of guideline therapy by the American
Heart Association; however, details regarding its potential complications and interactions with other therapies need further
delineation (10). To date, the literature
demonstrates that a core body temperature
<32°C is associated with refractory VF,
whereas mild TH at 32–34°C is not (1112). Several studies have demonstrated no
evidence that TH poses a higher risk for
dysrhythmias than normothermic therapy (11,13-14). The Hypothermia after
Cardiac Arrest group performed a blinded
assessment of 275 patients who were either
maintained at a normothermic temperature
or treated for 24 hours with mild TH at
32–34°C. There was no statistically significant difference between the two groups in
the rate of dysrhythmias: 32% (44/138) in
the normothermic group compared to 36%
(49/135) in the group treated with mild
TH. In this study, TH was discontinued
to mitigate dysrhythmias in 3/137 cases
(15). Bernard et al. studied 77 patients
who were assigned to treatment with TH
at 33°C for 12 hours vs. normothermia.
Although numerical data were not published, the authors assert that clinically
significant dysrhythmias did
not develop as a result of
TH (11).
Idiopathic Ventricular
Fibrillation
Idiopathic ventricular fibrillation (IVF) is defined
as cardiac arrest in the
absence of structural
heart disease or identifiable causes of VF (11).
It occurs in 1–9% of
out-of-hospital cardiac
arrest survivors (16).
The mean age is 35–40
years, and 70–75% of
the patients are male
(16). IVF is a diagnosis
of exclusion, making
it necessary to rule out
all possible causes of
VF (17). AICDs are
currently the treatment of
choice, and ongoing annual
evaluations for cardiomyopathy are recommended (9,16).
Persistent Ventricular
Fibrillation
One of the major challenges in persistent VF is
that patients resuscitated
from a VF arrest are at risk
of refibrillation by a variety
of mechanisms (18). Initially,
focal ionic and metabolic
changes create electrical myocardial heterogeneity, leading to slow conduction and
micro-reentry circuits (19). These conditions can be further complicated by hyperkalemia, increased cyclic adenosine monophosphate, disturbed calcium metabolism,
and disrupted electrical coupling between
cells (19). Myocardial stunning as a result
of numerous defibrillations, as occurred
with our patient, also makes termination of
the ventricular dysrhythmia progressively
more difficult (20). Ventricular fibrillation
in this patient eventually terminated after
the simultaneous cessation of both TH and
cardiac life-support medications, making it
difficult to determine which factor was the
primary cause.
This patient benefited from an integrated system of care encompassing all
links in the AHA chain of survival, includ-
The PULSE JULY 2010
ing the newest link, therapeutic hypothermia.
As therapeutic hypothermia becomes
more commonly accepted and utilized in
clinical practice its interactions with other
therapies and substantial benefits will
become better understood.
Figures:
1. Rhythm strip from the AED used by the
patient’s co-workers demonstrating ventricular fibrillation and one shock.
2. 12-lead EKG upon arrival in the emergency department demonstrating normal
sinus rhythm.
3. 12-lead EKG from ICU show one episode of recurrent ventricular fibrillation.
25
On the Wild Side
James Shuler, D.O.,MS, FACOEP, FAWM
Medical Support of Endurance Events: Part 2
So you’ve
decided to
medically support an “endurance event.”
Excellent! Now,
comes the big
question: What
medical supplies
do you need to
bring? That’s a
tough question.
Taking the time to consider the full range
of situations you might encounter may
well make the difference for your participants. With this in mind, give thought to
the following considerations: What challenges will the participants face during the
event? Where will the event take place
and will “altitude” be a factor? What sorts
of weather might you expect? How many
participants will there be? Does the very
terrain pose any consideration?
Start by putting yourself in your
potential patient’s situation. For example,
imagine you stepped through your bike
and cut your leg on the gear-sprocket.
You’re bleeding and need help. Would you
prefer to receive an appropriate “wound
treatment” there on the road-side so that
you can get back on your bike and moveon? Or do you want a trip to the emergency department with a $200 co-pay and
a 2-6 hour wait for the same treatment?
As an emergency physician you have the
opportunity to make someone’s day.
What you bring with you will of
course depend on the location and type of
event you’re supporting. What type of
weather, temperatures, incidents/accidents,
numbers of participants, etc. are all considerations to keep in mind, so be sure to get
specific details about the type of event you
will be supporting.
Let’s imagine some other scenarios.
Should you anticipate a female urinary
tract infection on the second day? YOU
BET! Are you prepared? What about
altitude illness on the arrival at the reg-
26
istration booth of the 2-day walk in the
mountains of Colorado? Are you prepared? What if there is a cycle crash during a 2-day event, leaving one participant
with a simple laceration and the other with
a suspected clavicle fracture? How about a
fall with a “cracked” helmet? In the emergency department, you are prepared for
all of the scenarios, but what about when
you’re “out there” supporting the participants and you don’t have an entire hospital
full of “stuff ” and staff to support you?
Are you prepared?
What a tall order. In these situations
you have two choices: 1) hope like heck
your cell phone has enough bars to call
911, or 2) “fix” the problem. True, not
every injury can be fixed at the scene, but
a bunch can. Again, put yourself in the
shoes of the event participants and think
through every scenario you can imagine.
That’s the single best way to prepare.
Most events like these share the common theme of endurance. That carries
with it many predictable occurrences.
Initially, “wear-and-tear” injuries like the
expected blisters will occur along with the
unexpected accidents. Later in the event,
“over-use” injuries will ensue, like strains,
bursitis and tendonitis. Be forewarned!
There will be more injuries than you
expect, as not all participants will come
to the event with the proper equipment,
experience, and knowledge. You will need
to overcompensate by preparing, yourself,
for those who are woefully underprepared.
The larger the event, the more unprepared
participants there will be. (Be afraid. Be
very afraid…)
Next you get to deal with the complications of the climate. Do you anticipate heat, cold, wet, dry, and what about
“terrain” conditions? One year I asked if
we had enough blankets for riders during a July two-day ride in Colorado. The
committee looked at me as if I were from
another planet. However, they acquiesced
and added a bunch with the thought
they’d give me an “I told you so.” Guess
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what? A flash storm soaked 1500 riders who were dressed for the 90ºF sunny
weather with a drop in temperature to the
upper 50’s… Of all the supplies, the riders were most thankful for the truckload of
blankets I had requested.
Be afraid again? Nope, be prepared
for the unexpected. Any event like this is
truly a “controlled” disaster, so you must
truly think in the mind-set of disaster preparedness.
That said; ensure there are adequate
stations appropriately spaced. There is
little research on this, but walking events
usually have a minimal hydration stop
every 1.5 miles with a “full” rest area at
every 3rd mile. That will include individuals to prepare/serve hydration and
nutrition with a medical specialist there.
The medical individual may be an EMT
or paramedic or nurse who needs to be in
contact with you via phone or HAM radio
(which is a favorite of ours on the long
bike-rides).
During these events you will encounter a wide-range of problems. I’ll address
specific problems later. First, you may
encounter an individual that is light-headed, nauseated and tachycardic, an overall
“I don’t feel well.” Is this dehydration,
an electrolyte imbalance or altitude illness
(which can occur at altitudes as low as
4,000 feet)? To separate this, a few questions can sort this out. First, if they are
regularly urinating clear urine at each stop
it is not dehydration. It is either altituderelated or an electrolyte disorder, most
commonly hyponatremia. Research has
shown that the body knows what it wants.
Subsequently, every “full station” should
include fruit, fat (like peanut butter), carbohydrates and salt, like potato chips or
pretzels. Additionally, hydration stations
must include both water and an electrolyte
replacement solution like Gatorade®. If
it’s hot and dry and pretzels look good, eat
them. If they are urinating infrequently
and the urine is dark, it’s likely a hydration
issue. If you are at “altitude” and every-
thing seems appropriate then you must
consider altitude illness, generally accompanied by a headache. Although vital
signs are important you must consider the
context, these people are working hard,
look at your patient’s “whole picture.”
As far as what to bring medically,
every full station should have sun block
and general wound-care items such as bandaging, Adaptic®, irrigation and cleaning
materials like SureCleans®. Additionally,
IV capabilities with normal saline and an
individual capable of starting an IV should
be present along with shade and a cot for
the individual to lie in comfort. With
respect to medications I always bring oral
and injectible medications like epinephrine, diphenhydramine, Ondansetron, IV
Solumedrol®, and a host of antibiotics to
cover the unexpected like UTI’s and bronchitis (insure this isn’t exercise-induced
asthma, for which I carry albuterol). I also
carry a couple suture sets with a variety of
suture materials. I can’t tell you how often
I’ve done a repair at the road-side allowing
an individual to complete their objective
without having to go to the ED.
Regarding blisters, there is a great
medical “myth” out there that says “never
‘pop’ a ‘blood-blister’” Phooey! There is no
evidence to support this and it should be
treated like a blister/abrasion. Drain and
cover as you would any other blister/injury.
When it comes to the standard blister,
drain and cover with felt-padding or other
padded adhesive materials available. There
are also blister-prevention materials available through many organizations; SAM
Medical Products produces Blist-O-Ban®
which is available at www.blistoban.com.
Additionally they have many other medical
solutions for “out there” situations.
The bottom-line is that I carry situation-specific medications with me on these
events and rely on the fact that each “aidstation” is well equipped. HAM operators
are excited to help you if you call them
early enough, if unavailable the cell-phone
can keep you in touch with the event control.
Finally, educate participants as to the
problems that can occur. Over the years
I’ve done these events it has incredibly
paid-off. We get minor complaints earlier
before a real problem exists. If a “hotspot” starts, pad it early.
I only hope you take part in events
like this locally for whatever the cause. It
pays nothing but you or your organization
may get a sponsorship logo. Most importantly, it’s the most rewarding work you
can do. Should you have any questions,
please reach me at [email protected].
Ethics in Emergency Medicine
Bernard Heilicser, D.O., MS, FACOEP
What Would You Do?
In this issue of The Pulse we will
review the hypothetical case of the three
victims trapped in the rubble of a collapse.
The first victim is blocking the access to
the other two victims. Victim 1 will not
be able to be extracted without an above
the knee amputation. Unfortunately,
Victims 2 and 3 cannot be accessed without extraction of Victim 1. Victim 1
understands the need for the amputation,
and that it will be his only hope of survival. He states he would rather die intact,
and refuses the amputation. However, this
refusal will prevent probable successful
extraction of Victims 2 and 3, resulting in
their deaths.
This has been a lengthy, difficult and
dangerous rescue mission, putting you and
your task force at risk.
Does Victim 1 have the right to refuse
his own life saving procedure, and does he
have the right to have this decision result
in the death of others?
What would you do?
I raised this question at a FEMA Medical
Specialist Class on January 12. Ironically,
the devastating earthquake in Haiti
occurred later that afternoon. The relevance of this question was only intensified.
The first question presents a very
difficult dilemma for the rescue personnel. After all your heroic effort, can the
patient refuse the amputation? One could
say the patient has the autonomous right
to make his own medical decision and
refuse the amputation. Of course absolute
medical decision-making capacity with full
informed refusal would be needed. In the
scenario described, can decision-making
capacity truly be present? The presence of
possible dehydration, hypothermia, hypoglycemia, and electrolyte imbalance could
certainly be invoked. This might equivocate the patient’s decision-making capacity.
In of itself, the dilemma may allow
for the principle of beneficence to trump
the patient’s autonomy. Our intellectual
honesty may be called into question, but
to error on the side of life in such a drastic
situation may have credibility.
Now, with two other victims condemned to death by Victim 1, would you
The PULSE JULY 2010
accept his refusal? Again, at the risk of
questionable ethical consideration, what
would/should we do?
Individuals have a right to make
informed decision for themselves. This
may include a refusal of standard life saving treatment or procedures (i.e. on religious grounds). However, when others
will die because of these decisions, how
much standing do we give autonomy?
I respectfully understand that others
may disagree, but I would find it extremely difficult to accept the presence of Victim
1’s decision-making capacity. Therefore,
appropriate sedation and pain control, following by life-saving procedures would be
initiated.
We would welcome any additional
comments on this presentation.
If you have any cases in your practice
that you would like to present or have
reviewed in The Pulse, please fax them
to us at 1-708-915-2743. Thank you for
your participation.
27
AOBEM Update
Mark J. Stone, DO, FACOEP, Secretary
AOBEM would like to announce new
improvements to the certification/recertification processes. Beginning in 2012,
those diplomats entering the recertification
process will be required to pass 8 COLA
exams in order to be eligible for the Formal
Recertification Examination. If a diplomat
fails a COLA exam three times, he/she will
be given the opportunity to re-register
and pay the fee for that COLA exam. At
that point, the diplomat has another three
attempts to pass the COLA exam.
Secondly, all oral examinations (certi-
fication and re-certification) will be video
recorded for security and quality control
measures.
The AOA Bureau of Osteopathic
Specialists has approved the Practice
Performance Improvement component
of our recertification process which will
be formalized in 2012. The Practice
Performance component involves the diplomat identifying a target area for growth of
Emergency Medicine skills. The diplomat
will review the care given to patients with
that particular issue. The diplomat then
develops and implements a practice performance plan to improve care, based on evidence based guidelines or expert consensus
data. He/she will review the care given to
patients after the program is implemented
for clinical improvement.
In conclusion, AOBEM is seeking
diplomats who would like to become item
writers for the examination process. Please
contact Ms. Josette Fleming at aobem@
aol.com for further information.
Presidential Viewpoints,
our issues with our respective members
of the House and Senate. I personally
enjoyed speaking with Congressman Joe
Sestak as he was walking back to his office
from the Capitol building. I encourage
every member of the ACOEP to consider
participating next year. More importantly
though, I strongly encourage you to stay
actively involved in the many State and
Federal issues that effect our practice of
medicine and ability to deliver care to
our patients. All it takes is a phone call
or email for you to be heard by your
elected officials. The more voices speaking
in unison, the stronger the message will be
received. Silence or a low voice signifies
lack of interest and importance.
In this issue of The Pulse, we have been
given permission from ACEP to print a copy
of a manuscript that will also be published in
the August Annals of Emergency Medicine.
We appreciate ACEP allowing us to do this
because it is important for you as a member
of the ACOEP to witness the fruits of your
College’s labor and see that we are actively
working with the other organized bodies
in emergency medicine to help shape the
future of our profession.
In closing, I want to thank Tony
Jennings for all of his support and assistance
as we worked very closely together over
the past few years. His unfortunate illness
came at a very inopportune time for him
personally and professionally. Becoming ill
is a personally devastating and humbling
experience, especially if you are a physician.
I have continuously been inspired by the
strength, maturity and resilience that Tony
has demonstrated throughout his diagnostic
dilemma and subsequent treatment.
Although he has chosen to step down from
our Board, you should rest assured that I
shall continue to use him as a valued advisor
as I continue to lead our College and now
work with Greg Christiansen as Presidentelect.
a very significant emphasis on primary care
and the role of the primary care provider
will change dramatically over the next
several years. The benefit to the emergency
physician should be that we are no longer
the primary entry point into the healthcare
system and we have efficient ways to make
patient dispositions that are effective and
efficient and not dependant on unnecessary
testing or admission to the hospital because
there is not a better alternative.
On a different note, your College has
remained very active since the spring
conference. We sent a letter to the CMS
expressing our concerns about the adverse
impact their new rule concerning Propofol
and procedural sedation will have on
emergency physicians and emergency
medicine residency training. We also had a
strong showing at DO Day on the Hill. The
weather was perfect and everyone enjoyed
the camaraderie and opportunity to discuss
28
The PULSE JULY 2010
Member News
Joseph W. Stella, D.O., FACOEP
long time member of the American
College of Osteopathic Emergency
Physicians, Past President of the
American Osteopathic Association and
the Pennsylvania Osteopathic Medical
Association passed away on Saturday,
May 22, 2010 at his home in Allentown,
Pennsylvania surrounded by his family. Dr.
Stella was the Founder of the emergency
medicine residency program at St. Luke’s
Hospital, formerly Allentown Osteopathic
Hospital, in Bethlehem, Pennsylvania. He
practiced both emergency medicine and
family medicine from 1963 to 1985. Dr.
Stella was a graduate of the Kirksville
College of Osteopathic Medicine, Class of
1943. He served in the Navy following
graduation and then entered postdoctoral training at Allentown Osteopathic
Hospital in 1946. He was actively
involved in the Pennsylvania Osteopathic
Medical Association and served on many
AOA Committees, Bureaus and its Board
of Trustees and served as President of
the American Osteopathic Association in
1986. Dr. Stella was a mentor to many
osteopathic physicians in emergency medicine and family medicine and will be sorely
missed for his gentle ways, smart gover-
The PULSE JULY 2010
nance and infinite patience.
Congratulations go out to Victor
Almeida, D.O., FACOEP; Peter Alamia,
D.O.; Mark Rosenberg, D.O., MBA,
FACOEP; Lauren Trattner, D.O., and
Jennifer Waxler, D.O., FACOEP who
have been elected to the Board of Directors
of NJ-ACEP. Dr. Almeida will assume the
Presidency of the Board in 2011.
Congratulations also go out to
Joe Heck, D.O. who secured the
Republican nomination for Nevada’s Third
Congressional District race by garnering
68.8% of the vote.
29
In My Opinion
Wayne T. Jones, D.O., FACOEP
The Next Generation's ED
1975
So, what year was it that:
Saturday Night Live debuted with host
George Carlin,
One Flew Over the Cuckoo’s Nest swept
the Oscar’s
VCR’s were introduced by Sony
New York City avoided bankruptcy by
obtaining a $2 billion federal loan
The Vietnam War ended
The US saw its first “Doctors Strike” by
NYC residents and interns
Jimmy Hoffa disappeared
Elton John sings “Lucy in the Sky With
Diamonds”
The FTC sues the AMA for restricting
physician advertising
And the ACOEP was founded
Yes, it was 1975. Unemployment was
above 9%, gas was 44cents a gallon, and
Foster Grants cost $5.00. We didn’t have
AIDS, we had herpes. We soon discovered
the difference between love and herpes
(herpes is forever).
We drove Gremlins, Pacers and
Firebirds. We wore bell-bottoms with halter-tops while standing on platform shoes.
Our hair was Shag, Mullet and Afro with
sideburns. We were cool!
We became the first “generation” to
make debt a lifestyle. During this time,
we began seeing ourselves as individuals;
30
we learned that “I’m OK, You’re OK”;
we became more self-indulgent and questioned everything. We were out to change
the world. And we did.
I began my career as a medic, serving the rural lake coast of northwest
Pennsylvania, first as a volunteer and then
paid. ACLS was a new science allowing a
panacea of medications and interventions.
The science of medicine was defined as
medicine itself. What we did was what was
supposed to be done. We never questioned
if a therapy would benefit a person; if it
was available, then there must be some
proven benefit.
How many of you remember rotating
tourniquets? We used them for CHF, to
reduce preload. You would place a cuff on
each of the proximal extremities and inflate
the cuff to reduce venous return in three of
the four limbs. On a scheduled basis you
would “rotate” to another extremity. Did it
work? Damn right it worked! (Really . . . I
don’t know.)
Can you recall the first three drugs
given in a patient with ventricular fibrillation? Edison-Medicine of course. Three
stacked shocks. If a little was good, more
was better. Back then there were no
attachable pads, just jelly. We burned a lot
of flesh (and one or two medics).
Ok, can you recall the next three
drugs? Epinephrine, bicarb and calcium.
You had better flush the line well between
meds though. Did it work? You bet!
Being way ahead of our time, we
used a device called the Thumper. It was
a piston compression device hooked up to
a compressed air cylinder, which delivered
cyclic cardiac compressions. This made cardiac arrests easy. Oh, and it also worked.
Remember MAST trousers. Sure you
do. They were cumbersome, expensive and
had exact instructions in application and
use. I never really saw the utility in them,
but I was told they worked.
The esophageal obturator airway was
a blind insertion device used by paramedics and EMTs. You shoved it into the apnic
The PULSE JULY 2010
patient’s mouth and ventilated through
one of two holes. Which one you ask?
The one that worked, of course. It fell out
of favor a few years later due to concerns
it was dangerous (really?). Of course, it
returned with a new name and sales pitch.
Now there are a couple devices with the
same old (new) technology (really?).
The demand valve ventilator rounded
out the pack. Push the trigger and you got
air filling those lungs. How much should
you give? Sort of like the last question…
enough. Ok, you held the trigger until
the chest started to rise. But, you know,
you do need to blow off the CO2 that the
IV bicarb created, so… more was better
right? Yeah!
As a medic we always ended up in
the same place... the ED. The emergency
department was a place, not a career. Any
physician could be an emergency physician. It was a training ground; a place to
make some money; a way to support your
real career. Almost daily we would meet
the “new” ED Doc. They were cool, but
not always very good. It was exciting and
uncontrolled. Did it work? Not very well.
Emergency medicine grew and
changed with the needs of patients. We
looked at ourselves as a safety net. We
were much like the community clinics,
serving those with nowhere else to go and
those who needed care without an appointment. We did not see ourselves as a service
industry, but as an industry that serves.
Withstanding these arguments, we were
different enough to become a specialty.
We initially focused on technique,
skills and broad based medical knowledge. What we missed was service design.
Waiting was a given. Triage (through
careful design) became an art form rationalizing why patients had to wait. We
struggled to break free from the grip of
triage as it became not just an evaluation,
but a place we called “triage” (Ok, key in
Changes in the Board Announced
At the College’s Spring Membership
Meeting, the Board of Directors
announced that due to an unexpected illness, Dr. Anthony Jennings removed himself from the position of President-elect to
take a general position on the Board. Dr.
Jennings stated that a recent diagnosis prevented him from assuming the all duties
related to the governance duties required
of this office and thus would not be able
to assume the Presidency as anticipated in
October 2010.
At a special meeting of the Board,
a recommendation was made and duly
acted upon that will allow Dr. Brabson to
remain in the Presidency of the College
for an additional year (October 2011)
and the Board voted to elect Gregory
M. Christiansen, D.O., M.Ed, FACOEP
to the position of President-elect. Mark
A. Mitchell, D.O., FACOEP the current
Treasurer of the College will maintain his
position as Treasurer and in accordance
with the Bylaws Ms. Wachtler who will
assume the temporary duties of Secretary
under Dr. Mitchell’s supervision until
the October meeting of the Board when
elections will be held for the positions of
Treasurer and Secretary.
Normally, terms of office for Officers
are two years in length, during which
physicians undergo intensive orientation
into the processes of governance not only
of the ACOEP but the AOA. Officers in
the positions of President and Presidentelect participate in executive functions of
the College as well as act as representatives
of the College at AOA functions. During
this process, Dr. Christiansen, who has
served the College in the role of Treasurer
and Secretary, will be in the Office of
President-elect for eighteen months during
which he will play a pivotal role in representing the ACOEP at the AOA’s House
of Delegates and at its various Board of
Trustees meetings.
When Dr. Jennings feels that his
health will allow him to participate, he will
again be eligible to run for an open position on the Board. Whatever he chooses,
we are all pulling for him to make a full
recovery and expect to see him in the fall.
In My Opinion
Get well soon, Tony, we miss you.
Open Letter to the Membership
from Anthony W. Jennings, D.O., FACOEP
It is with regret that I am announcing that
I will not seek re-election to the Board
of Directors. My current state of health
prohibits me from being able to continue
at a level I feel necessary to meet the obligations required for performance of the
duties of a board member. I will continue
to improve my health and will hopefully
return in the future to serve the ACOEP
once again. My time with ACOEP and its
members, staff and the affiliated organizations has been very valued and cherished.
I wish you all the best!
The PULSE JULY 2010
the singing angels and bright lights). Did
it work?
We allowed other service industries to
define our process. Lab and x-ray made us
call, request, page and almost grovel for
service. We were ranked behind the ICU,
OR, morning floor STAT labs and smoke
breaks. We could wait… because our
patients could wait (see a trend here?).
Consultants made us conform to their
practice style. We would hold patients for
OR, endoscopy and admissions. If the ED
was not full, then we could wait. They
could wait.
Well, it’s time we changed the world
again. The ED is not an office or a lab
waiting area… it’s the ED. It’s our ED. It’s
the next generations’ ED.
31
Pain Management in the ED
Steven J. Parrillo, FACOEP-D
So what
is "pain?"
Fishman says,
“Pain is what
a patient says
it is.” The
International
Association
for the Study
of Pain (IASP)
defines it as “an
unpleasant sensory and emotional experience associated with actual or
potential tissue damage.”
We see patients every day in the ED.
Study after study has made it clear that
we don’t do a good job managing that
pain – for a variety of reasons. One of
the most common is the fear that we will
either contribute to a drug problem or create one. Patients present with a history
of “chronic pain” and we wonder whether
that is actually true. We wonder if we are
being scammed.
But there is a difference between
“addiction” and “physical dependence.”
Addiction implies that use of an agent has
an effect – usually adverse – in a patient’s
ability to function. That may mean that
he argues more often with his wife than
he did before. It may mean that she does
not do as well at work as before. These
patients have a problem that needs to be
addressed, but you may be surprised at
some of the statistics below.
On the other hand, physical dependence is the physiologic requirement for
the agent and that absence of that agent
would induce withdrawal. The true chronic pain sufferer worries that he will not be
taken seriously – largely because that is
exactly what happens.
Pain management has made major
strides in the last decade. Clinicians now
attempt to deal with the cause of the pain
whenever possible. Migraine, for example,
is usually treated first with triptans or
other serotonergic medications and narcotics are held in reserve for rescue.
So why do patients come to the ED
for management of pain? If a patient
32
presents with a headache, she is coming for
one of two reasons: pain relief or diagnosis
(or both). But Trainor and Minor showed
that 25-50% of such patients receive no
medication and only 1/3 of those who do
receive medication obtain adequate pain
relief. Yes, I know that headache is one of
the complaints drug seekers use, but read
on.
One of the gurus of ED pain management, James Ducharme, showed that pain
is the presenting symptom approximately
80% of the time. Yet many receive nothing to relieve that pain during the visit.
When asked, 42% said that would have
liked to receive something. The point is
that no one asked until after the disposition had been determined!
So what about that ubiquitous “pain
score” we are mandated to record? Many
suggest that we do what must do, but
treat the patient rather than the score. In
a fascinating 2008 Annals study, nearly
half the group with an average score of
7.8 out of 10) did not want an analgesic.
Once again, we need to ask.
So you might be asking, “Why is
everyone in such ‘severe’ pain?” Many
authorities point out that those with mild
pain stay home. (I can hear you snickering…) Many patients know from experience that we don’t believe them, so they
change their behavior to convince us that
they need analgesia. They know we often
do not believe them if they just say they
are in pain or give a low pain score.
So think back to the last patient in
pain who was watching TV, eating, playing Nintendo. Surely those behaviors
prove that the pain is exaggerated, right?
Actually, studies have shown that these
are all ways patients try to distract
themselves from their pain. It does not
mean they are not really in pain.
How about that patient who has a
normal BP and heart rate? Several have
documented that vital signs are not a good
way to determine if pain is truly present.
What to do, what to do.
Start by questioning all of your painrelated management. Then work together
with your staff to standardize your
The PULSE JULY 2010
approach to pain. Question every step of
the process. If something you do (or order
done) hurts a patient, you have chosen to
let it hurt. Sometimes there is no choice.
Most times you can minimize or eliminate
pain.
Starting IVs in children (or adults for
that matter) is a good example. There
are ways to prevent or minimize the pain
including needle-free jet injection or intradermal injection of lidocaine, nitrous oxide
inhalation, topical EMLA® etc.
What’s the worst thing (in terms
of pain) we often do to our patients?
Hands down – it is NG tube insertion.
(“Can’t you put me to sleep for this, doc?”
“No, I never do that. You’ll be fine. Just
swallow this hose and don’t choke or
inhale it or I will have to start over.”) This
is a very painful procedure, with many
studies recording VASs between 80 and
100.
Take 5 minutes for local anesthesia.
Do a neb with lidocaine. Apply lidocaine
gel. Atomize some lido or tetracaine. You
might even consider a small dose of IV
midazolam.
Initiate pain management at arrival,
possibly in triage. Splint the sprain or
fracture. Apply topical tetracaine for eye
pain. Paramedics give IV fentanyl for fractures and burns. Surely we could do the
same in triage or shortly after coming into
the treatment area. And do it before getting the films!
But is it safe to do this? A 1999
Australian study looked at the safety of a
nurse-managed, titrated analgesia protocol for the management of severe pain in
the emergency department. The authors
showed that nurses could initiate IV opioids for pain control without attracting
drug seekers. Additionally, there were
no patients who left the triage area after
receiving analgesia.
How long do you think it takes
you to address a patient’s pain?
Another Australian study that allowed
nurses to titrate intravenous opioid analgesia showed that doing so reduces time
to analgesia for selected painful conditions.
The range was ½ to one hour. The aver-
age time to administration of analgesia in
the US is 2 hours. (That figure is 6 hours
in the UK). There were no adverse events.
ED nurses are now allowed to do this by
protocol down under.
Be honest. Have you ever given analgesia without first seeing a patient? Of
course you have!
Suppose you are the only doctor, you
are treating someone critical and the
nurse says, “There’s a patient in 3
writhing from a kidney stone.” Maybe
it’s time to consider a titrated opiate policy.
“Wait!” you say, “how about my sickle
cell patients? I see them every day. Surely
there is a problem here. They abuse the
ED.” Not so fast…
A 2008 Annals study found that only
35.5% of SSC patients were found to be
high ED utilizers. That subset had lower
hematocrit levels, required more transfusions, had more “pain” days, more pain
crises, higher mean pain and distress, and
worse quality of life. After controlling for
severity and frequency of pain, high ED
utilizers did not use opioids more frequently than other sickle cell disease patients.
Others have shown that sickle cell
patients reported at least some pain on
more than 50% of days. They reported
pain > 5/10 on 16% of days. They did not
see any provider on 79% of those painful
days. A staggering 30% reported experiencing pain on at least 95% of days. Only
14% reported that they experience pain
<5% of days.
The message . . . we see them when
the pain flares.
Have you ever heard a nurse say this?
“Can I give that patient Dilaudid? The
morphine just isn’t working.” The correct
starting dose of IV morphine is 0.1mg/kg.
Only half of all patients will get pain relief
with that dose. Repeat doses can be given
every 5-10 minutes. An average dose for
pain control will be about 0.16mg/kg. In
order to control pain for 4 hours, many
patients will require 0.4mg/kg.
If you don’t want to start an IV, consider an oral regimen. (Yes, IM opiates do
work, but those injections hurt). A 2008
AEM study compared 0.1mg/kg morphine
with 0.125mg/kg oxycodone in suspension. Oxycodone was given faster – 8.5
vs. 20.5 minutes for the IV group. While
there was a larger VAS change at 10 and
20 minutes for IV group, there was no difference at 30 and 40 minutes. Satisfaction
was higher with IV medication
Yes, it is difficult to change attitudes.
The PULSE JULY 2010
Don’t believe that? Think back to when
you first started ordering morphine in
doses of 6-10mg IV. Didn’t your nurse say
something like, “Okay, but I’m going to
give it 2mg at a time so I don’t kill your
patient, you stupid cowboy.”
Why are we so reluctant to
believe patients are in pain? What
would you want? Do you question dyspneic patients? Basic pain management
relies on our beliefs and our attitudes, less
on our knowledge. Here are more facts
born out in the literature. Eighty percent
of our patients are in moderate to severe
pain. Yes, up to 12% of our patients have
addiction or dependency issues, but the
majority (88%) is actually in pain.
So here is the proverbial bottom line.
Pain is a common complaint in the ED.
Only a small number of patients are drug
seekers. We should do as much to relieve
pain as we do to relieve dyspnea. You are
not going to make someone an addict
by giving him a narcotic in the ED.
You are not going to cure addiction by
denying analgesia in the ED.
I extend my personal thanks to James
Ducharme MD for sharing his knowledge
and literature base for this brief discussion.
33
Emergency Medical Services,
this would be a tremendous opportunity
for both sides. Over the last year, I have
found the process of being a medical director quite challenging, but exciting. During
any given ED shift, I typically see at least
three or four of the crews, and am able to
stay current with their practice patterns,
answer their questions, give them feedback on patients they have transported to
our ED, provide them with educational
updates, or sometimes just “shoot the
breeze” with them. It is enjoyable working
with EMS providers who are so devoted
and passionate about their job. Currently,
I am visiting the firehouses to ride with
all of the crews so I get to know each one
of them. I am also trying to recruit our
ED nurses to ride with the crews as well,
since the fire department has extended the
opportunity to them. We also invite the
paramedics to come to the ED for “shadowing” opportunities if they wish.
Lastly, what’s on the horizon in EMS?
We hope to bring the EMS fellowship to
fruition in the future, as this really is an
exciting educational opportunity for all of
the ACOEP members. I have some EMS
research and educational projects coming
up with our two fire departments, including use of video laryngoscopy for field
intubation, and use of Cardizem for prehospital rate control of atrial fibrillation.
I hope to have updates for all of you on
these projects in future issues of The Pulse.
Thanks for allowing me to share this
with you. If you are interested in joining
the EMS committee, please feel free to
contact me ([email protected]).
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fibrillation. Arch Mal Coeur Vaiss 1999;92:29- 36.
18. Boddicker KA, Zhang Y, Zimmerman MB, et
al. Hypothermiaimproves defibrillation success and
resuscitation outcomes fromventricular fibrillation.
Circulation 2005;111:3195–201.
19 Opie LH. Electricity out of control: arrhythmias. In: Heart physiology. Philadelphia: Lippincott
Williams & Wilkins; 2004:607–10.
20 Sandroni C, Sanna T, Cavallaro F. Myocardial
stunning after successful defibrillation. Resuscitation
2008;76:3– 4.
21. Poles JC, Vadenboncouer TF, Bobrow BJ, et al.
Persistent ventricular fibrillation during therapeutic
hypothermia and prolonged high-dose vasopressor
therapy: case report. Jour Emerg Med 2009;05.027.
2010 Student Case Competition,
References:
1. Brunton LL, Parker K, Blumenthal D, et al.
Goodman & Gilman’s manual of pharmacology and
therapeutics. New York: McGraw-Hill, Inc; 2008.
2. Shin DD, Brandimarte F, Luca L, et al. Review
of current and investigational pharmacologic agents
for acute heart failure syndromes. Am J Cardiol
2007;99:4A–23A.
3. Adams KF, Lindenfeld J, Arnold JM, et al. HFSA
2006 comprehensive heart failure practice guideline. J
Card Fail 2006;12:32.
4. Clinical Pharmacology Online. Dopamine.
Available at: http:// www.clinicalpharmacology-ip.
com/Forms/Monograph/monograph.
aspx?cpnum_206&sec_moncontr. Accessed December
8, 2008.
5. Carmona MF, Malbouisson LM, Pereira VA, et al.
Cardiopulmonary bypass alters the pharmacokinetics
of propanolol in patients undergoing cardiac surgery.
Braz J Med Biol Res 2005;38:713–21.
6. Tortorici MA, Kochanek PM, Poloyac SM. Effects
of hypothermia on drug disposition, metabolism, and
response: a focus of hypothermiamediated alterations
on the cytochrome P450 enzyme system. Crit Care
Med 2007;35:2196–204.
34
The PULSE JULY 2010
Emergency Medicine Opportunities
Physician owned and operated, 4M Emergency Systems has over 15 years
of experience management and staffing emergency departments and urgent
care centers. We are nowlooking for qualified physicians at the following locations.
Warren, Ohio
Austintown, Ohio
St. Joseph Health Center in Warren, Ohio, conveniently located
between Cleveland and Pittsburgh, seeks a confident and dedicated
emergency medicine physician. Annual volume 34,000; level III
trauma center; 12-hour shifts; EM residency program; flexible
schedule; physician/physician assistant double coverage! Extremely
competitive compensation and benefit package including partner
plan, health plan, 401K, malpractice, life and long-term disability.
For more information about this position, contact Erin Waggoner,
4M Emergency Systems, telephone 888-758-3999; or email
[email protected].
Brand new free-standing ED located just outside Youngstown is
seeking a dedicated and confident emergency medicine physician.
Annual volume 28,000; physician assistant double coverage; 9 beds;
flexible 12 hour shifts. e outstanding partner plan includes a
generous stipend, health, paid malpractice with tail, 401K retirement
plan, paid long term disability and life, an additional incentive plan,
business spending account, sign on bonus & referral bonus program!
[email protected].
Youngstown, Ohio
Andover, Ohio
4M Emergency Systems is seeking a board certified emergency
physician to join our well-established stable group at St. Elizabeth
Health Center. Conveniently located between Cleveland and
Pittsburgh, this Level I Trauma Center has a volume of 41,000 with
36 hours/day of physician coverage. With full specialty back-up, this
facility has an excellent clinical mix as well as strong support from the
attending medical staff, administration and nursing staff. Extremely
competitive compensation and benefit package including partner plan,
health plan, 401K, malpractice, life and long-term disability. Sign on
bonus! Call us for more information about this exciting opportunity
and others.
[email protected].
If balance is what you’re looking for in life, Andover has it! Located in
the Pymatuning Valley Region, which is situated in Northeastern
Ohio only a few miles from the Pennsylvania state line and sixty miles
north of Cleveland, Andover is a nature lover’s paradise! Beautiful
settings, fishing, boating, swimming and wonderful park facilities can
be part of your life! Andover is a free-standing emergency department
with an annual volume of 6,500. e outstanding compensation/benefit
package includes partnership opportunity, a generous stipend, paid
malpractice with tail, health, 401K retirement plan, paid long term
disability and life, and an additional incentive plan. Candidates should
be board-certified in emergency medicine or primary care with solid
EM experience.
[email protected].
Boardman, Ohio
Brand new, full service emergency department with full service
hospital! e ED sees 38,500K patients annually with 36 hrs of
physician coverage & 12 hr of physician extender coverage daily.
Nice patient mix with attentive nursing and medical staff. Boardman
is an upscale, affluent community in a growing demographic area that
is ideal for beginning and/or raising a family. e outstanding partner
plan includes a generous stipend, health, paid malpractice with tail,
401K retirement plan, paid long term disability and life, and an
additional incentive plan. Candidates should be board-certified in
emergency medicine or other primary care specialty with solid
EM experience.
[email protected].
To learn more about joining our practice,
please contact Erin Waggoner at
1-(888) 758-3999 or via email at
[email protected]
The PULSE JULY 2010
GREAT CAREER. GREAT LIFE.
35
Presorted
Standard
U.S. Postage
PAID
Chicago, IL
Permit No. 2177
142 E. Ontario Street
Suite 1500
Chicago, Illinios 60611
Celebrating 35 years of supporting the
Osteopathic Emergency Medicine Community
(1975-2010)
Join our celebration!
San Francisco, October 2010
36
The PULSE JULY 2010

Presidential Viewpoints Accountability, Emergency

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