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PLUS
by JARON CHRISTIANSON, MD, MBA, FACEP
Last year, my wife and I put our 1-year-old daughter into daycare for the first time. She developed an upper
respiratory infection and passed it along to me. Despite Tessalon Perles, albuterol, and a variety of over-the-counter reme-dies, I had a hacking, bronchospasm-type cough for a few days. At one point, I was at home watching a sitcom and started laugh-ing and coughing at the same time, which resulted in a twinge in the left side of my neck. I didn’t have any pain but noticed that I would reflexively hold my neck whenever I coughed.
Early the next week, I was in a meeting and developed a left occipital headache. Nothing major but enough to make me take some Tylenol when I got home. The next morning, the headache was back and now was associated with a sunburn-like sensation to my left frontal and parietal scalp. I would also develop a headache in that region whenever I pushed on my neck at the base of my scalp. The pain would go away when I stopped. That night at dinner, I noticed that the sniffing position was now quite uncomfortable for me. Tylenol, Mo-trin, and Robaxin didn’t help, but lying on my side (either side) and either ice or heat did help. I had an early shift the next morn-ing, so figuring I pulled something while coughing, I slapped on some ice and went to bed.
The next day at work, the symptoms per-sisted. I spoke to one of my colleagues, who commented that his brother had something very similar and it turned out to be shingles. That sounded reasonable, so I started Val-trex and prednisone and went about my business. We were leaving for Hawaii the next morning for a friend’s wedding, so I popped over to the barber after work. The pain from the comb through my hair was quite impressive as was the pain from wear-
Cura Te IpsumDissecting a case of physician wellness
NEW SPIN
THE PATIENT IN ROOM 6 HAS
A NAMESEE PAGE 4
EM DOCS
OUR OWN SAFETY NET
SEE PAGE 18
CONTINUED on page 6
THE SUMMA TRANSITIONDirectly from the principalsIn an attempt to provide a venue for vetting the facts, ACEP Now reached out to Summa Emergency Asso-ciates (SEA), US Acute Care Solutions (USACS), and the Summa Health System, based in Akron, Ohio, for their perspectives on Summa Health System’s recent decision to contract with USACS instead of SEA, an important issue affecting our specialty. Both SEA and USACS were approached and consented to interviews with ACEP Now Medical Editor in Chief Kevin Klau-er, DO, EJD, FACEP, on Jan. 10, 2017; questions were provided to them in advance. Summa Health System declined a request for an interview before press time but provided the statement included below. There is no editorial content. This information is directly from the principals of the groups. The ACEP Now editorial advisory board reviewed the finalized transcripts to ensure that the representation of the facts is fair and balanced, representing the viewpoints of those in-terviewed.
Disclosure: Dr. Klauer was formerly employed by EMP from 1999 to 2014. He has no current financial or other relation-ship with EMP and has no current or former relationship with USACS.
CONTINUED on page 14
Jeffrey Wright, MD, president of Summa Emergency Associates
David Scott, MD, FACEP, chief administrative officer for US Acute Care
Solutions
SUITING UP TO COMBAT CONCUSSIONSPAGE 13
PH
OT:
SV
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A Z
AK
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INAUGURATION
Political Junkie Left Disheartened
SEE PAGE 8
FORENSIC FACTS
Forensic Photography for Emergency Medicine
SEE PAGE 22
THE END OF THE RAINBOW
The Value of a Financial Adviser
SEE PAGE 16
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February 2017 Volume 36 Number 2
MEDICAL EDITOR-IN-CHIEF Kevin Klauer, DO, EJD, FACEP
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Subscriptions are free for members of ACEP and SEMPA. Free access is also available online at www.acepnow.com. Paid subscriptions are available to all others for $262/year individual. To initiate a paid subscription, email [email protected] or call (800) 835-6770. ACEP Now (ISSN: 2333-259X print; 2333-2603 digital) is published monthly on behalf of the American College of Emergency Physicians by Wiley Subscription Services, Inc., a Wiley Company, 111 River Street, Hoboken, NJ 07030-5774. Periodical postage paid at Hoboken, NJ, and additional offices. Postmaster: Send address changes to ACEP Now, American College of Emergency Physicians, P.O. Box 619911, Dallas, Texas 75261-9911. Readers can email address changes and correspondence to [email protected]. Printed in the United States by Cadmus(Cenveo), Lancaster, PA. Copyright © 2017 American College of Emergency Physicians. All rights reserved. No part of this publication may be reproduced, stored, or transmitted in any form or by any means and without the prior permission in writing from the copyright holder. ACEP Now, an official publication of the American College of Emergency Physicians, provides indispensable content that can be used in daily practice. Written primarily by the physician for the physician, ACEP Now is the most effective means to communicate our messages, including practice-changing tips, regulatory updates, and the most up-to-date information on healthcare reform. Each issue also provides material exclusive to the members of the American College of Emergency Physicians. The ideas and opinions expressed in ACEP Now do not necessarily reflect those of the American College of Emergency Physicians or the Publisher. The American College of Emergency Physicians and Wiley will not assume responsibility for damages, loss, or claims of any kind arising from or related to the information contained in this publication, including any claims related to the products, drugs, or services mentioned herein. The views and opinions expressed do not necessarily reflect those of the Publisher, the American College of the Emergency Physicians, or the Editors, neither does the publication of advertisements constitute any endorsement by the Publisher, the American College of the Emergency Physicians, or the Editors of the products advertised.
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One patient can remind you why you became a doctor—and show how to become a better one
BY THERESA HSIAO, DO
It was a typical Friday night: The trau-ma bay was full, patients were lined up in hallway beds 1 through 6, and
we were 50 deep in the waiting room. Within an hour of starting my shift, I had a chest pain in Room 4, a pregnant vaginal bleeder in Room 6, an old lady with belly pain in the neigh-boring room, and a colostomy malfunction in Room 13. These descriptions were exactly how I attempted to remember them. I had sys-tematically hit all the right questions for each patient and put in the necessary orders, im-aging was obtained, charts were being typed up, and the attending physician had been noti-fied and had agreed with all my plans. Feeling like I had things under control, I called over to the nurse, “Hey, can you please check on the vaginal bleeder to see how she’s doing?” The nurse stared at me blankly and responded, “You know she has a name, right?”
I was immediately taken aback. To me, she was “Room 6,” 35-year-old female G3 P 0111, newly pregnant with a few days of spotting, mild abdominal cramping, no rebound or guarding, rule out ectopic, and confirm a live intrauterine pregnancy. My face immediately became flushed and warm, and my voice stut-tered. I was unsure how to respond. I had been so consumed with everything else, I honestly hadn’t even glanced at her name. Like a good resident, I had checked on her a couple of times to ensure her abdominal cramping had resolved. I gave her ice water and updated her on the wait time for her ultrasound. Once those
items were marked off my checklist, I went on my way. The nurse proceeded to ask me, “Did you know she and her husband have been try-ing for a year? That she’s had a prior miscar-riage and is worried it might happen again?” My face was now beet red and my heart thump-ing out of my chest from my embarrassment from the unintentional reprimand.
I walked back in, this time more aware, no-ticing more than just the vital signs. In front of me was a woman not much older than me, clearly worried. Her lips were pressed togeth-er nervously, hands clutched tightly, and eyes wide in anticipation of bad news. This was someone seeking reassurance, not just lab val-ues and test results. She was more than just “vaginal bleeder in Room 6.”
As busy physicians, we get so caught up with our endless tasks and algorithms that we often fall prey to practicing cookbook medi-cine. We mechanically run codes, fly through procedures effortlessly, and transition from room to room, chugging through the never-
ending emergency department tracking list. With the practice of medicine becoming so me-thodical, we forget that, on a daily basis, we meet patients who are having the worst day of their life. They divulge to us private details not even their best friends and families are aware of. We forget that we are the privileged few who patients trust with their secrets and stories—what a humbling honor.
“To most physicians, my illness is a routine incident in their rounds, while for me it’s the crisis of my life. I would feel better if I had a doctor who at least perceived this incongru-ity.” —Anatole Broyard, from “Doctor Talk to Me,” The New York Times, Aug. 26, 1990
This challenges those of us in the medical field to remember what it feels like to be on the other end of the stethoscope—to remember that there is a person and not just a pathogen
infecting a host. Let us remember the impor-tance of rekindling and keeping alive the de-sire of service to humankind with which many of us had gone into the medical profession. Caring doctors are better doctors. They prac-tice safer medicine, earn more trust from pa-tients, and get them engaged in their health care, leading to better outcomes. In changing our practice of medicine, it could change our own perspective, too. Perhaps this is a step toward figuring out the antidote to physician burnout.
“Not every patient can be saved, but his illness may be eased by the way the doctor responds to him—and in responding … the doctor may save himself. … It may be neces-sary to give up some of his authority in ex-change for his humanity, but this is not a bad bargain. In learning to talk to his patients, the doctor may talk himself back into loving his work. He has little to lose and everything to gain by letting the sick man into his heart.” —Anatole Broyard, from “Doctor Talk to Me,” The New York Times, Aug. 26, 1990
Thank you to my Room 6, future mom of two, fellow foodie, and wife of her high school sweetheart. Thank you for reminding me that when I chose to go into medicine, I made the commitment to connect with all patients, to be their advocate, to bring compassion to those who are vulnerable and scared in their most vulnerable moments. Thank you for reminding me that the woman in Room 6 has a name.
DR. HSIAO is a PGY-2 emer-gency medicine resident at Einstein Medical Center in Philadelphia.
NEW SPINOPINIONS FrOM eMerGeNCy MeDICINe
Medical Specialty Leaders Meet at ACEP Headquarters
THE SPECIALTY SOCIETIES CEO COA-LITION meets several times a year to discuss issues affecting the nation’s
largest medical specialty societies. In De-cember 2016, this influential group met at the ACEP headquarters near Dallas. Pictured from left are Michael Costelloe, American Society of Plastic Surgeons; Paul Pomerantz, Ameri-can Society of Anesthesiologists; David Hoyt, MD, American College of Surgeons; Susan Holzer, Society of Interventional Radiology; Thomas Stautzenbach, American Academy of Physical Medicine and Rehabilitation; Robert Wynbrandt, The Society of Thoracic Surgeons; Tod Ibrahim, American Society of Nephrology; Martha Liggett, American Society of Hematol-ogy; Dean Wilkerson, ACEP; Saul Levin, MD,
American Psychiatric Association; Kathleen Craig, American Association of Neurological Surgeons; Michael Sheppard, American Uro-logical Association; William Thorwarth, MD, American College of Radiology; Darilyn Moyer, MD, American College of Physicians; Hal Law-
rence, MD, American College of Obstetricians and Gynecologists; Karen Remley, MD, Ameri-can Academy of Pediatrics; David Parke, MD, American Academy of Ophthalmology; and Catherine Rydell, American Academy of Neu-rology.
Members in the News
Charles Pattavina, MD, FACEP, medical director and chief of emergency medicine at St. Joseph Hospital in Bangor, Maine, was elected President of the Maine Med-ical Association. A former
ACEP Board member, Dr. Pattavina received ACEP’s James D. Mills Outstanding Contribu-tion to Emergency Medicine Award in 2010.
WANT TO SHARE THE NEWS ABOUT AN ACEP MEMBER’S
RECENT APPOINTMENT, AWARD, OR ACHIEVEMENT?
Send an announcement within 30 days of the event to
[email protected]. Announcements may be edited for
space and clarity.
“A New Spin” is the personal perspective of the author and does not represent an official position of ACEP Now or ACEP.
The Patient in Room 6 Has a Name
ILLU
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NEWS FROM THE COLLEGEuPDaTeS aND aLerTS FrOM aCeP
Inside 18 I EM DOCS19 I THE FEED
16 I THE END OF THE RAINBOW
24 I CODING WIZARD20 I SPECIAL OPS22 I FORENSIC FACTS
4 aCeP NOW FEBRuARy 2017 The Official Voice of Emergency Medicine
April 3– 5, 2017 | Hilton Orlando, Florida
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Please check the website for updates on CME credits being offered.
KK: How long have you been with USACS?
DS: I’ve been with US Acute Care and its for-mer self, EMP, since 1995.
KK: We’re talking about the transition of the emergency department services at Summa Health from Summa Emergency Associates to USACS on Dec. 31, 2016. I wanted to have a conversation with you to make sure that we heard directly from US Acute Care about exactly what has hap-pened from your perspective. Can you provide some background about USACS?
DS: USACS is a coalition of physician-owned emergency groups (EMP and eight other inde-pendent physician-owned emergency groups) and is now the largest physician-owned emer-gency medicine group in the country.
KK: I think people may not be aware that you’re located right in Akron-Canton, Ohio, and have had business relation-ships with Summa before. Could you speak to your history with Summa? It didn’t just start Dec. 31.
DS: Correct. We have staffed three of the five Summa facilities in the past. We staffed two of them for over a decade prior to them becoming part of Summa, and one was a new build, free-standing, that we started staffing when they built it. We staffed them up until about three years ago when the system put out an RFP and consolidated all five sites into one ER contract [awarded to SEA].
KK: Getting into some of the controversial topics, did the hospital contract with you prior to the end of their agreement with SEA? Some have raised the question of
whether or not Summa had already con-tracted with USACS.
DS: No. Let me give you the timeline. Their contract, from what I understand, was never terminated. Their contract expired at midnight on New Year’s Eve, and it sounds like they had been negotiating with the hospital for some time. There was never an RFP or any sense that we were going to be involved in a transition or that there would be a turnover of this group. We fully expected that SEA would renew. Un-til we got a call on Dec. 24, we knew nothing about this.
KK: Do you think you were contacted as a potential backup plan?
DS: Yes, we were contacted, and I’m told at least one other if not two other national groups were contacted for exactly that reason. They felt they needed a backup plan because they were being told that the doctors were going to walk out at midnight.
KK: But no one was contracted with Sum-ma before the expiration of their contract. Is that correct?
DS: Their contract expired on the 31st. They first reached out to us on the 24th. On the 27th, they said, “We would like a proposal for how you would take over on the 31st if you can,” and they sent that proposal to two other na-tional groups.
KK: From your perspective, do you think they were still negotiating in good faith with SEA at that point?
DS: Absolutely. From what it said in the pa-pers, there were offers to SEA as late as the af-ternoon of New Year’s Eve. What was reported in the paper last week was that they were of-fered a five-year contract or an extension to continue to negotiate, and SEA refused both and walked out at midnight. On the 29th, Sum-ma told us, “If we have to do this, we’re going to do it with you.” They told us verbally they would work with USACS if they still couldn’t negotiate, but they were still negotiating. It wasn’t until the 31st that they said, “SEA has refused our offer of extension and has refused the contract terms that we’ve given to them. You guys need to start tonight.”
KK: How would you respond to the criti-cism that you, as a large group, came in and displaced one of the few remaining independent groups in the area?
DS: We would have wanted to do it differently. We encouraged the hospital to continue to try to get an extension for the sake of the residen-cy and the rapidity of the transition and the disruption that could cause, fully knowing that doing so might have led to SEA working it out. I really don’t see us as having displaced them. I see us filling a void. They left, and there was no one there if we didn’t go in.
KK: What resources or expertise does your group have to run or support a resi-
SUMMA TRANSITION | CONTINUED FROM PAGE 1
CONTINUED on page 7
CONTINUED on page 7
KK: Tell us about the background and history of your group.
JW: Our group is private and independent,
owned and run by the physicians. We’ve been
around for 40 years or so, and we have run
the residency program at Summa Health Sys-
tem since 1980.
KK: How challenging was that for you to begin a training program in emergency medicine, knowing that Akron General was already in place just down the road?
JW: Both are very good programs. Both have
won international awards, do well recruiting
each year, and put out a very good product,
well-trained residents. We have residents go
all over the country every year. We have 10
residents a year; it’s a three-year program.
KK: The program has a great reputation and provides great training. What really happened, from your perspective, with this transition?
JW: Basically, our most recent contract [with
Summa Health System] was a three-year con-
tract started in 2013. At that time, there was
an RFP because Summa wanted one group
for six emergency departments. One has
since closed, so now it’s five emergency de-
partments. It was us and many other groups
vying for that contract. We won the contract in 2013 and picked up three other emergency
departments within the system.
KK: Was this negotiation in 2016 differ-ent?
JW: We had dealt with similar administra-
tions for multiple years. Some members of the new team have been here for one to three
years. The negotiations didn’t get started, un-
fortunately, until mid to late November. We
saw the first contract on Nov. 26. It was about
an 80-page contract. The biggest issue was
that it was never about quality, timeliness of
service, or meeting any metrics. We do fan-
tastic on the metrics. The residency does very
well on the medical education side. When we won the RFP three years ago, we picked up three new emergency departments within Summa. All three are underperforming either financially and/or by volume.
Two weeks before we took over the Wads-worth contract, the hospital decided to get rid of inpatient beds; it took out 36 percent of the volume within that ER. The groups that were in there before us had asked for stipends or assistance. We did those contracts for three years and lost between $8 million and $9 mil-lion. It cost us more to staff them, bill them, and malpractice them than we were receiving in revenue. There was nothing to cut from our end. We offset the losses with other depart-ments that we run.
Five senior residents this year wanted to stay with the group. All five had to sign with competitors because I could not offer them the type of package needed for them to pay back the $350,000 in medical student loans.
KK: So the math is simple. You can’t compensate people and pay your bills if they’re more than you can bring in in revenue.
JW: Correct. I’ve been head of our group for 15 years, and even before I was president of the group, we never had any financial as-sistance from the hospital, but those in resi-dency roles got graduate medical education money. In our counterproposal to Summa, we didn’t even ask for financial assistance. We said, “Can we get out of two of these three ERs? Can we close them? Can we make them urgent cares?”
KK: Was there anything extraordinary beyond meeting your losses with the stipend you were looking for?
JW: No. Initially, we didn’t even want a sti-pend, but when it was discussed, it was ac-tually significantly less than what we were losing. Basically, our group, doctors, and corporation were giving [Summa] a stipend the last three years, and my doctors were tak-ing less.
KK: In effect, you were subsidizing the hospital. Did you decide to withdraw, or did they terminate your contract?
JW: The contract was over Dec. 31 at 11:59 p.m. I had requested face-to-face meetings with emails saying, “Guys, let’s get together and get this worked out.” We got the contract on Nov. 26 or 28. Our first and only face-to-
JEFFREY WRIGHT, MD President of Summa Emergency Associates
DAVID SCOTT, MD, FACEP Chief Administrative Officer for uS Acute Care Solutions
SUMMA WEIGHS IN“It was Summa’s intention to complete a long-term contract with our former emergency services provider. When presented with multiple offers of extension to reach an agreement over a holiday weekend, our former group declined. This forced Summa into a position to execute a contingency plan involving US Acute Care Solutions. USACS stepped in to serve our five emergency departments, and our EM residency, under extraordinary circumstances and has performed admirably.” —Valerie Gibson, Summa Health chief operating officer
Our residency director and core faculty were willing to continue to educate the residents and even provide a weekly conference without getting paid until a transition was laid out. That was never taken up.
There were no patient safety issues … Some of the low-acuity patients experienced slightly longer waits because the physicians weren’t as facile with the EMR, but there were no patient safety issues.
6 aCeP NOW FEBRuARy 2017 The Official Voice of Emergency Medicine
face meeting was Dec. 26. We thought the attorneys could get this worked out. We con-tinued to talk, and our last conversations were Dec. 31 at about 4 p.m. I had submitted a term sheet on what I thought could work out. Summa offered us a three-year contract that decreased our residency funding and offered no financial assistance for the underperform-ing EDs. We countered with a 15-year contract and made adjustments to the residency fund-ing. I figured we would negotiate that some-where between the three years they offered and the 15 [the offer was rejected on Dec. 14, with Summa offering a 60-day extension]. Eventually, I offered a five-year contract with a revenue assurance the first year. That was rejected on that Saturday [Dec. 31].
KK: Did the contract expire, or did Sum-ma or SEA terminate the agreement?
JW: The contract was going to expire at mid-night; it just expired. KK: It sounds like they may have had a backup plan in place?JW: Well, they had actually talked to US Acute Care Solutions on Dec. 24 before we had our face-to-face meeting on Dec. 26.
KK: I have heard that your group has been offered employment opportunities
with USACS. Is that true?
JW: I want to clarify. We did not walk away from any patient care. We took care of all the patients the way we were supposed to, completed the workups that we had already started, and we did appropriate turnover and checkouts for the physicians coming on. Some of our physicians were offered con-tracts by US Acute Care Solutions. Some of the contract language is vague and more of a short-term offer than long-term. We are a group that believes in the independent prac-tice of medicine without a lot of the corporate involvement.
KK: I assume none of them have taken the offers.
JW: We had one part-time physician who is now working for the new group, but the other 65 are not.
KK: Well, I admire your solidarity, that’s for certain. Some people have been criti-cal on both sides about the transition of the training program. Tell me, from your perspective, what transition plan you had in place to protect the residents.
JW: That was one of our biggest concerns. The residents [250 residents] within Summa
dency training program?
DS: We either run or are involved in support-ing nine other residency programs across the country. We have a lot of resources in the way of faculty and teaching physicians, and we are bringing all of those resources to bear to sup-port and to continue this really tremendous training program at Akron, which has a great reputation and a great history.
KK: Some have raised issues about pa-tient safety, electronic medical record (EMR) proficiency by the physicians, even the physicians being non-residen-cy trained and/or board-certified in emer-gency medicine. Can you clarify?
DS: You can’t get credentialed to be on staff at Summa in the emergency department if you’re not a board-certified emergency physician; all of our physicians who have worked there and are on staff are board-certified in emergency medicine. There was a rumor out there at some point about an internal medicine–trained doc-tor. That’s untrue.
KK: What about patient safety issues that might have been created because of the transition?
DS: There were no patient safety issues. We
had all of the shifts covered, and we have qualified physicians. Some of the low-acuity patients experienced slightly longer waits be-cause the physicians weren’t as facile with the EMR, but there were no patient safety issues. Within two days, all of the wait times were back to baseline.
KK: Did you ever have to use a different documentation system other than the EMR system that was in place?
DS: The first two days, the hospital used their downtime procedures, which do involve the physician documentation being on paper. The nurses were using the EMR for some of their charting, but they did use their downtime pro-cedures for the first approximately 40 hours. They didn’t have enough trainers to do the transition that quickly, but within 40 hours, we were back on the EMR. This was the hos-pital’s plan for the transition.
KK: There’s been a lot of conversation and discussion about the optics of con-flict-of-interest with friends or family members who may or may not have been involved with some of the negotiations. Any thoughts or comments?
DS: We all know in medicine that there are conflicts of interest at times. The issue in my
SUMMA TRANSITION
CONTINUED on page 15 CONTINUED on page 15
WRIGHT | CONTINUED FROM PAGE 6 SCOTT | CONTINUED FROM PAGE 6
FEBRuARy 2017 aCeP NOW 7The Official Voice of Emergency Medicine
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by L. ANTHONY CIRILLO, MD, FACEP
As a self-professed political junk-ie, I will admit that attending a presidential inauguration
has been on my bucket list for a long time. As I “approach” middle age at the age of 56 (my definition of middle age) and since in-augurations only happen every four years, I decided that this would be the year to head to Washington, D.C., to attend the inaugura-tion of Donald J. Trump as the 45th president of the United States. I will admit that, given the unconventional nature of the entire presi-dential campaign and the controversy that surrounds President Trump, I drove to D.C. with my son Connor and with a mixed emo-tional bag of excitement and trepidation. The weekend experience in D.C. was enlightening, but honestly, it was more disheartening. When I left D.C. and headed back home to Rhode Is-land, I kept asking myself, “Who is America?” While in D.C. and in the days since I got back home, I keep feeling that I am not part of the America that I saw at the inauguration or at the Women’s March on Washington the following day. Since I have been involved in politics and advocacy for a while, I was not naive enough to believe that everyone in D.C. was going to sing "Kumbaya" just because it was inauguration weekend. On the other hand, I did not expect to witness Americans disrespecting the office of the president, the United States as a nation, and mostly one other.
Inauguration Morning
We took the Metro and made it to Union Sta-tion by 8 a.m. Upon leaving Union Station, there were already protests happening, but given the presence of law enforcement every-where, we felt very safe and walked up to the Capitol. We were fortunate and had been given seated tickets by U.S. Rep. Jim Langevin (D-RI). I will give kudos to Sen. Roy Blunt (R-MO), who served as chair of the Inauguration Commit-tee, and the entire team of folks who did the planning and logistics for the inauguration. Despite the complexity of the event, this was well choreographed and orchestrated.
So if the day was so easy, then when I did get so disheartened? Well, it wasn’t the official ceremony part of the whole day but, honestly, the people there. Look, I had no illusions that this wasn’t going to be a pro-Republican and pro-Trump crowd. If you made the trip to the inauguration, you were probably on the “right-er” side of the aisle in terms of political lean-ing; I get that. However, the people around us
weren’t just happy about their guy winning. They actually seemed to revel more in taunt-ing and jeering the outgoing president, the first lady, and, of course, Hillary Clinton, who could have taken a pass on the whole day and avoided the crowd. There was real vitriol and disdain for people who had served the nation, which went beyond disagreeing with a politi-cal point of view. I was really taken aback by this. Maybe I am naive, but an important part of politics for me is separating someone’s is-sues from that person’s value as a human be-ing. In all my years in politics and advocacy, I
have yet to find a politician or poli-cymaker who I agreed with on every issue. That’s why you don’t fall on your sword on any one issue because tomorrow is another day, another issue, and another vote. That’s why you build relationships based on mutual respect and finding common ground rather than focus on what divides us. In all honesty, the crowd really took something away from the importance and significance of this event, which has happened only 58 times in the his-tory of our nation.
The president’s speech was, in a word, “Trumpian.” He was very clear that under his administration things were going to be dif-ferent and that the old ways of doing things weren’t going to continue. He spoke about the inauguration being about giving power back to the people, which seemed a little unusual for a man who pretty much has never been a man of the people. I would have to imagine that his comments were also awkward for all the current members of Congress and all the ex-presidents who were in attendance (Jimmy Carter, Bill Clinton, George W. Bush, and Ba-rack Obama). The crowd certainly got excited by President Trump’s speech, but the enthusi-asm quieted quickly as people left.
After the actual swearing in ceremony, we got back to the place we were staying only to find that every—and I mean every—news chan-nel was covering the “anarchists” in the streets of D.C. Even though this was a small group of about 100 people, they got, essentially, all the news coverage of the day. It was disappointing that the media made breaking windows and setting a few trash cans and newspaper ma-chines on fire more important than discussing the importance of living in a democratic and free nation where we have a peaceful transi-tion of power every four or eight years. Friday night was pretty mellow at one of the unoffi-cial inaugural balls.
The Women’s March
Then came Saturday, which was the day of the Women’s March on Washington. Again, from my political junkie perspective, I give kudos to Teresa Shook, Evvie Harmon, Fontaine Pear-son, Bob Bland, and others who created the concept on Facebook and worked to make it
NEW SPINOPINIONS FrOM eMerGeNCy MeDICINe
CONTINUED on page 10
Dr. Cirillo and his son Connor join the crowd at the inauguration.
“A New Spin” is the personal perspective of the author and does not represent an official position of ACEP Now or ACEP.
“NOT MY AMERICA”
Attending the 2017 presidential inauguration left this political junkie disheartened
8 aCeP NOW FEBRuARy 2017 The Official Voice of Emergency Medicine
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A Diverse Future for Emergency Medicine
MORE DIVERSITY AND INCLUSION ENHANCEMENTS UNDER WAY
More than a year ago during its re-treat, the ACEP Board of Directors discussed the importance of di-
versity and inclusion and agreed that mak-ing improvements in these areas would be a multi-year project. The Board made one of the 13 objectives within ACEP’s strategic plan to “promote and facilitate diversity and inclu-sion and cultural sensitivity within ACEP.” ACEP President Rebecca Parker, MD, FACEP, hosted a summit in April 2016 and appointed the diversity and inclusion task force, led by Aisha Liferidge, MD, to welcome this genera-tional shift in diversity, which is directly tied to ACEP's future success. Here are a few initia-tives ACEP is currently undertaking:
• Annals of Emergency Medicine has pub-lished "Why Diversity and Inclusion Are Critical to ACEP’s Future Success," written by Dr. Parker; Steven J. Stack, MD, FACEP, an emergency physician and past Presi-dent of the American Medical Association; and Sandra Schneider, MD, FACEP, direc-tor of EM practice at ACEP. This "burning platform" paints the current landscape of diversity in emergency medicine and its patient populations, describes how studies show that embracing diversity and inclusion can improve patient care, and outlines research that shows inclu-siveness benefits organizations and even companies. Read the article at www.ann-emergmed.com.
• ACEP and its chapters are taking a hard look at ensuring that the faculty members at our educational conferences represent a
variety of races, religious affiliations, cul-tural identities, sexes, gender identities, and other forms of diversity far beyond the obvious visual distinctions. Expanding the opportunities for faculty and course topic selection improves the well-being and re-siliency of members while also improving
patient care.• A Diversity Leadership Task Force, led by
Dr. Stack, will help broaden the diverse representation among ACEP leadership. This approach will potentially attract, re-tain, and engage new members; develop new leaders; and build upon the expertise
of current members. Diversity and inclu-sion of leadership positions will help many to overcome collective biases and nurtures creativity of thought, collaboration, and problem solving.
• Dr. Liferidge’s task force has developed ob-jectives to guide its activities over the next several years. The task force has identi-fied five focus groups: age, gender, race/ethnicity, sexual orientation, and religion. It recognizes there are additional groups to pursue in the future. The task force has outlined three objectives:
· Engage the specialty of emergency medicine on diversity and inclusion.
· Identify obstacles to advancement within the profession of emergen-cy medicine related to diversity and inclusion and develop ways to over-come those obstacles.
· Highlight the effects of diversity and inclusion on patient outcomes and identify ways to improve those out-comes.
This task force is developing tactics to ac-complish each of these objectives. Upcoming projects for the task force include ongoing con-ference calls and an in-person meeting during the ACEP Leadership & Advocacy Conference in March, as well as the development of pro-posals for consideration by the ACEP Board and Council Steering Committee, a webinar on bias and cultural competence, a social media campaign, and more.
a worldwide event. Effective advocacy is all about tapping into passion, and the coordina-tors of the march did so extremely well. It was impressive to see the diversity of issues that were being championed. Reproductive rights, immigration reform, religious discrimination, LGBTQ rights, gender and racial inequalities, workers' rights, and environmental issues were all part of the official platform. Although not part of the official platform, there was an anti-Trump sentiment that pervaded the event. For me, this is where the event lost something. Signs saying “Not My President” were some of the nicer ones. Madonna’s “F-bomb” rant and talk about blowing up the White House went beyond exercising one’s right of free speech and into a realm of hate and intoler-ance, which is what the protest was supposed to be rallying against.
Today I am not sure that I belong to either of the Americas that I witnessed in D.C. I am not far right or far left on any issue. I believe that I am part of the true majority in this country, those who live somewhere within two stand-ard deviations on the bell curve of social and economic issues. I know that effective democ-racy and debate can’t be just about talking—there has to be a listening part, too. This nation was founded by people who disagreed about
many things, including whether we should have even become a separate nation. Howev-er, through all of our troubled times, we have remained one nation, one America, even after being nearly torn apart by a “civil” war. Our greatest moments in history have been real-ized when we put aside our differences and faced our enemies and challenges together. I am concerned that we are now becoming a “pendulum nation,” swinging wildly back and forth to political extremes as politicians in both parties attempt to garner the support of the loyalists on either side. The media, which should be a voice of reason and a vehicle for education, has become a morass of pandering sound bites, trying to win the “gotcha” arms race. America is not strengthened by rhetoric and name-calling by anyone on either side of a political issue. America will prosper when we listen to and respect each other as people, as Americans.
DR. CIRILLO is director of health policy and legislative advocacy for US Acute Care Solutions in Canton, Ohio, and chair of the ACEP Federal
Government Affairs Committee.
INAUGURATION | CONTINUED FROM PAGE 8
Dr. Cirillo and his son Connor at one of the unofficial inaugural balls.
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10 aCeP NOW FEBRuARy 2017 The Official Voice of Emergency Medicine
The International Liaison Com-mittee on Resuscitation (ILCOR) appointed a task force in 2013 to prepare recommendations re-garding first-aid care by trained
or untrained rescuers. The recommenda-tions were released with the 2015 American Heart Association Guidelines Update for Car-diopulmonary Resuscitation and Emergency Cardiovascular Care. The goal was to provide an evidence base for the initial care provided by laypersons, EMS, and physicians outside of the office or hospital setting.
ACEP Now has partnered with three emer-gency medicine residency training programs (Wake Forest School of Medicine, Winston-Sa-lem, North Carolina; Mayo School of Gradu-ate Medical Education/Mayo Clinic, Rochester, Minnesota; and Warren Alpert Medical School of Brown University, Providence, Rhode Is-land) to review 15 of these recommendations following the PICO (Population, Intervention, Comparator, and Outcomes) analytic format utilized by the recommendation authors.
Panel Commentators• Howard Mell, MD, MPH, CPE, FACEP,
assistant professor, Wake Forest Baptist Medical Center, Department of Emergency Medicine
• Jessica L. Smith, MD, FACEP, associate professor (clinical), Warren Alpert Medical School of Brown University, and program director, Emergency Medicine Residency
• Jason Stopyra, MD, FACEP, assistant pro-fessor, Wake Forest Baptist Medical Center, Department of Emergency Medicine
• Matthew Sztajnkrycer, MD, PHD, FACEP, associate professor, Mayo Clinic, Depart-ment of Emergency Medicine
Reference: Singletary EM, Charlton NP, Ep-stein JL, et al. Part 15: first aid: 2015 American Heart Association and American Red Cross guidelines update for first aid. Circulation. 2015;132(suppl 2):S574–S589.
OPEN CHEST WOUND (FA 525)Recommendation Author: Anuradha Ga-napathy, MDDr. Ganapathy is a member of the emergency medicine residency training class of 2018 at the Warren Alpert Medical School of Brown Uni-versity.QUESTION: Among adults and children with open chest wounds outside of the hospital (P), does use of occlusive dress-ing (I) compared to non-occlusive dress-ing (C) change outcomes (O)?
Results: One animal study (deemed very-low-quality evidence) addressed the PICO question of use of occlusive versus non-occlusive dress-ings in open chest wounds for respiratory ar-rest and to improve oxygen saturation. Vented and unvented chest seals were placed serially on open chest wounds in eight pigs, and onset of tension pneumothorax and deterioration of respiratory parameters were measured upon serial air injections into the pleural cavity.Outcomes: There was benefit from use of non-occlusive devices for the outcomes of respira-tory arrest, oxygen saturation, tidal volumes, and respiratory rate. There was no significant benefit in terms of mean arterial pressure, sur-vival, or cardiac arrest. Discussion: Tension pneumothorax is a life-threatening complication in open chest wounds. The task force recognized the lim-ited evidence addressing this but noted that both evidence and the medical practice of treating a tension pneumothorax by creating an open wound to allow communication be-tween it and the ambient air justified the ben-efit of non-occlusive dressings in open chest wounds. Further research into non-occlusive dressings is required due to the concern that they may inadvertently occlude open chest wounds, causing life-threatening complica-tions. Recommendation: First-aid providers should not apply occlusive dressings or de-vices in patients with open chest wounds. Note from Dr. Smith: In the first-aid setting,
occlusive dressings should not be placed on open chest wounds due to the possibility of doing harm by creating a tension pneumo-thorax.
HYPOGLYCEMIA (FA 795)Recommendation Author: Derick D. Jones, MDDr. Jones is a member of the emergency medi-cine residency training class of 2018 at the Mayo School of Graduate Medical Education/Mayo Clinic.QUESTION: Among adults and children with symptomatic hypoglycemia (P), does administration of dietary forms of sugar (I) compared with standard dose (15–20 g) of glucose tablets (C) change time to resolution of symptoms, risk of complications (eg, aspiration), blood glu-cose, hypoglycemia, or hospital length of stay (O)?
Results: Three randomized control studies and one observational study that addressed the PICO were identified. All four studies were downgraded for risk of bias and imprecision. The three randomized studies were deemed low-quality evidence, while the observational study was deemed very low quality. Outcomes: No study showed that any form of dietary sugar or glucose tablets improved the blood glucose before 10 minutes. The obser-vational study showed fewer diabetic patients demonstrating a 20 mg/dL increase in blood glucose level 20 minutes after treatment when treated with dietary sugars compared to glu-cose tablets. Pooled data from the three ran-domized trials showed a slower resolution of symptoms 15 minutes after diabetic patients were treated with dietary sugars compared with glucose tablets. No studies assessed the risk of complications or assessed hospital length of stay.Discussion: The current analysis evaluated glucose supplementation from glucose tablets
CONTINUED on page 12
Reviewing ILCOR Guidelines on Chest Wounds, Hypoglycemia, Positioning, and Oxygen UseDissecting the evidence behind the recommendations
Editor’s Note: This is part three of a four-part series.
International Liaison Committee on
Resuscitation
FEBRuARy 2017 aCeP NOW 11The Official Voice of Emergency Medicine
ACEPNOW.COM
ACEP Clinical Policy on Acute Carbon Monoxide Poisoningby STEPHEN J. WOLF, MD, FACEP
InOctober 2016, the ACEP Board of Direc-tors approved a clinical policy on the eval-uation and management of adult patients
presenting to the emergency department with acute carbon monoxide (CO) poisoning. There are approximately 50,000 ED visits per year as a result of CO poisoning. Acute poison-ings have extremely varied presentations, from minimal symptomatology to unrespon-siveness, hypotension, severe acidemia, or acute respiratory failure. CO poisoning is also known to be associated with longer-term mor-bidity and mortality.
CRITICAL QUESTIONS AND RECOMMENDATIONS
QUESTION 1: In ED patients with suspected acute CO poisoning, can noninvasive car-boxyhemoglobin (COHb) measurement be used to accurately diagnose CO toxicity?
Patient Management Recommendations
• Level B: Do not use noninvasive COHb measurement (pulse CO oximetry) to di-agnose CO toxicity in patients with sus-pected acute CO poisoning.
QUESTION 2: In ED patients diagnosed with acute CO poisoning, does hyperbaric ox-ygen (HBO2) therapy, as compared with normobaric oxygen therapy, improve long-term neurocognitive outcomes?
Patient Management Recommendations
• Level B: Emergency physicians should use HBO2 therapy or high-flow normo-baric therapy for acute CO-poisoned pa-tients. It remains unclear whether HBO2 therapy is superior to normobaric oxygen therapy for improving long-term neuro-cognitive outcomes.
QUESTION 3: In ED patients diagnosed with acute CO poisoning, can cardiac test-ing be used to predict morbidity or mor-tality?
Patient Management Recommendations
• Level B: In ED patients with moderate to severe CO poisoning, obtain an ECG and cardiac biomarker levels to identify acute myocardial injury, which can pre-dict poor outcome.
DR. WOLF is an associate professor and vice chair for academic affairs in emergency medicine at the University of Virginia School of Medicine in Charlottesville.
compared with dietary sugars at equivalent doses of 15–20 g. Alternative dietary sugars and glucose gels/pastes may be effective. This study does not look at adverse effects of ad-ministering more sugar than needed. Recommendation: In conscious individu-als with symptomatic hypoglycemia, glucose tablets should be administered (strong recom-mendation, low-quality evidence). If glucose tablets are not available, dietary sugars can be used (weak recommendation, very-low-quality evidence). Note from Dr. Sztajnkrycer: Although 15–20 g dietary-equivalent glucose tablets were iden-tified as the best first-aid option based on four studies, lack of availability should not deter the use of other sugars, despite the weak rec-ommendation, in a symptomatic hypoglyce-mic patient who is conscious, able to follow commands, and able to swallow.
POSITIONING (FA 517)Recommendation Author: Sean O’Rouke, MDDr. O’Rouke is a member of the residency train-ing class of 2018 at Wake Forest School of Medi-cine.QUESTION: Among adults who are breathing and unresponsive outside of a hospital (P), does positioning in a lateral, side-lying recovery position (I) compared with supine position (C) change overall mortality, need for airway management,
stridor, the incidence of aspiration, the likelihood of cervical spinal injury, com-plications, or incidence of cardiac arrest (O)?
Results: Eight observational studies that ad-dressed the PICO were identified but were all deemed very-low-quality evidence.Outcomes: There is limited evidence to sug-gest the lateral decubitus position improves morbidity or mortality, with very-low-quality evidence to suggest a lower incidence of as-piration, increased total lung volume, or de-creased stridor. Several studies have identified different positioning methods with very-low-quality evidence of benefit from these alterna-tive positions.Discussion: On arrival to a scene with injured or ill persons, first responders must protect these individuals from continued harm. Actions to safely position patients are guided by several variables. In a person who is unresponsive and breathing normally without evidence of serious injuries, consider placing the person in the lateral decubitus position. If a person is unresponsive and not breathing normally, re-suscitation efforts should begin immediately. Furthermore, if there is concern for neck, back, hip, or pelvic injury, the person should be left in the position in which they were found to avoid further injury.Recommendation: Although there is lit-tle evidence to suggest the optimal recovery
position, consider placing the unconscious person who is breathing normally in a lateral decubitus position.Note from Dr. Stopyra: This is one of those common-sense recommendations. If unin-jured, place the patient in a position that makes it easy to clear their airway should they vomit. A different recommendation debunks the “feet-elevated” position for shock (FA 520).
OXYGEN USE IN FIRST AID (FA 519)Recommendation Author: Shannon Mum-ma, MDDr. Mumma is a member of the residency train-ing class of 2018 at Wake Forest School of Medi-cine.QUESTION: Among adults and children who exhibit symptoms of shortness of breath, difficulty breathing, or hypoxia outside the hospital (P), does adminis-tration of oxygen (I) compared with no administration of oxygen (C) change sur-vival with favorable outcomes, shortness of breath, time to resolution of symptoms, or therapeutic endpoints (O)?
Results: One retrospective study presents very-low-quality evidence that there is no ben-efit of supplemental oxygen administration for reducing death, the need for assisted ventila-tion, and respiratory failure for patients with acute exacerbation of chronic obstructive pul-monary disease. One randomized controlled
trial presents low-quality evidence showing the benefit of supplementary oxygen admin-istration for treatment of shortness of breath in cancer patients with dyspnea and hypoxemia. A meta-analysis and four randomized con-trolled trials present low-quality evidence of no benefit for advanced cancer patients with dyspnea without hypoxemia for shortness of breath. Oxygen administration was found to have a positive effect on oxygen saturation. Outcomes: No evidence was found for or against routine administration of supplemen-tal oxygen by first-aid providers. Supplemen-tal oxygen administration has been found to be of some benefit in specific circumstances, including advanced cancer patients with dysp-nea and hypoxia as well as individuals with decompression injuries. Oxygen provided to patients with hypoxemia helped them reach normal oxygen levels. Discussion: There is no recommendation for the use of supplemental oxygen as the evi-dence is conflicting and too low quality to recommend a change to current practice. The use of supplemental oxygen should be limited to individuals with specific training in oxygen administration.Recommendation: No recommendation.Note from Dr. Mell: Providing supplemental oxygen does not appear to improve outcomes for patients with dyspnea. Emergency physi-cians do not need to routinely carry oxygen as part of first-aid kits.
ILCOR | CONTINUED FROM PAGE 11
Visit ACEPNow.com and search for “carbon monoxide poisoning” to read the full guideline summary.
MOre ONLINe
12 aCeP NOW FEBRuARy 2017 The Official Voice of Emergency Medicine
Join Us for EDPMA’s Solutions Summit!The Solutions Summit is the premier conference for those in the business of emergency medicine.
The Emergency Department Practice Management Association (EDPMA) is the national trade association representing Emergency Physician Groups, Billing, Coding, and other Supporting Organizations serving the nation’s Emergency Departments. EDPMA members deliver (or directly support) health care for about half of the 136 million patient visits to U.S. Emergency Departments each year.
www.edpma.org l www.solutionssummit.org
ALL HANDS ON DECKSailing through the Changing Tides of Emergency Medicine
APRIL 25–28, 2017 OMNI SAN DIEGO HOTEL
SUITING UP TO COMBAT CONCUSSIONS
From peewee leagues to the NFL, football is a national obsession in the United States. However, recent re-search into football-related injuries is starting to illumi-
nate the grave neurologic toll the sport can take on its players. Paul S. Auerbach, MD, MS, FACEP, MFAWM, FAAEM,
Redlich Family Professor in the department of emergency medicine at Stanford University School of Medicine in Cali-fornia, and coauthor William Waggoner decided to combine the current research on sports-related concussions with their knowledge of football to suggest a series of rule changes that could help protect players’ brains.1
ACEP Now Medical Editor in Chief Kevin Klauer, DO, EJD, FACEP, recently sat down with Dr. Auerbach to discuss what inspired him to write this opinion piece and what he hopes football organizations will take away from it. Here are some highlights from that discussion.
KK: Let’s talk about your very provocative, interesting, and forward-thinking editorial about concussions that came out Sept. 27, 2016. What prompted you to write this?
PA: I got interested in this largely because of my experience as a team physician for a local high school and observing a lot of concussions in football players. I also want to give credit to my coauthor, Bill Waggoner. He was a high school coach and an outstanding collegiate player.
A few years ago, I was involved in a study to look at a noninvasive device to diagnose concussions. We discovered that it took a minimum of four to six weeks for the concussed players to get back to a baseline measurement. I discussed this finding with other investigators in the field who had used other methods to diagnose concussions and who had found the same result. That flew in the face of what commonly oc-curs with players, who get returned to play anywhere from 24 hours to about a week. That exposes them to what is com-monly referred to as second-impact injury, which most peo-ple believe is far worse than the initial injury.
Tom Talavage, PhD, at Purdue University and other inves-tigators have highlighted the fact that, with objective MRI techniques, subconcussive injuries—meaning injuries in
which players don’t become clinically sympto-matic in the same way that do persons who have an acute injury altered enough to be recognized at that moment—are prevalent. There is an enor-mous number, reasonably in the range of 10 to 20 percent, of players who are being injured.
KK: I love the quote from your article, “With or-thopedic injuries, athletes, players, and coach-es readily accept a four- to six-week recovery period. It is astonishing that they show so much less respect for the brain.” Do you have some sta-tistics regarding football and concussions that you can share with readers?
PA: Yes. There is beginning to be a bit of a surge of a response. I’ve gotten communications from the Na-tional Collegiate Athletic Association (NCAA), from independent writers, and from researchers who are interested in this field, and the consensus is that commentaries like we published will hopefully ignite activity to prevent these injuries. I’ve also received responses from parents citing their dis-tress at what’s going on with children.
There are statistics that I've seen from the years 2002 to 2012; there was a 200 percent increase in the number of emergency de-partment visits for concussions among 8- to 13-year-olds and the number of reported concussions of children 14 to 19 years old. In 2012, emergency departments treated 325,000 teens for concussion. That is just the tip of the iceberg because those are the pa-tients that seek care. The Centers for Disease Control and Prevention published statistics on the number of children who take part in some sports in the United States, and we’re talking about tens of millions of adolescents.
Emergency physician attempts to reduce football-related head injuries by changing the rules
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FEBRuARy 2017 aCeP NOW 13The Official Voice of Emergency Medicine
ACEPNOW.COM
ing a baseball cap. Over night, the headache worsened and
settled into a persistent pre-orbital pain along with my neck pain. It was still better when I was on my side. The shingles rash that I was expecting had yet to materialize. I was having no other symptoms. By the afternoon, I was becoming a bit more concerned and called my emergency department and spoke with a doctor. If I came in, based on what I’m saying, would she do any imaging? She didn’t think so, and in her shoes, I wouldn’t either. I still figured I pulled something while coughing, though I couldn’t really link that to the neu-ralgia symptoms. That evening, I was texting with another emergency physician, and she matter-of-factly diagnosed me with a vertebral artery dissection (VAD). Thanks, I said, but I’ll stick with rash-less shingles and muscle strain with secondary neuralgia.
I actually slept well that night, and things seemed to be getting better. However, by the time I got downstairs in the morning, the pain was back and worse. What worried my wife most was that we needed to be out the door in 15 minutes and I had crawled back into bed. We had a plane to catch, so I slapped on an ice pack and loaded up the car, and we were out the door. About 10 minutes into the car ride, my wife noticed that I had my seat completely reclined, and we both came to the realization that getting on the plane probably wasn’t a great move. She got off the freeway, and we de-cided to swing by my emergency department to get told everything was fine, and then we’d be on our way.
Emergency Department WorkupAt the emergency department, I had a normal exam, and everyone agreed that this was mus-cular. My colleague even found a nice trigger point that exacerbated my symptoms. He sug-gested a trigger point injection, which I was agreeable to on the condition that I would get a CT angiogram of my neck if it didn’t help. Deal. I got the injection; it didn’t help. I got the CT angiogram, and about 30 minutes later, I was in an ambulance to our neuro tertiary-care center for my long-segment VAD. No Ha-waii for me.
The overnight stay in the neuro ICU was pretty uneventful. I got a little morphine, more for the cough than the pain. I was started on Plavix and aspirin. My MRI of the brain was normal. Transcranial Doppler showed no em-boli. I puked up a dose of Norco, but other-wise, the night was uneventful. After seeing the intensivist, neurologist, and neurosur-geon, it was decided that I would lay low for six weeks, continue the antiplatelets, and start lisinopril and Lipitor.
Little did we know that the day I left the hospital was the first day of boating season in Seattle, and our route home was from one side of Lake Washington to the other. After about an hour in the car (for a 10-mile drive), I was carsick and made it to within a half mile of my house before I vomited. This led to a marked increase in the headache that was not im-proved with position, ice, Zofran, or tramadol. Of course, my wife thought I was doing fine, so she popped over next door to chat with the neighbors. When she got home, apparently I looked like death, so back to the emergency department we went. I guess the nurses agreed with my wife’s assessment; they put me in a resuscitation room. Now my blood pressure
was 230/120, and I was dripping in sweat. For-tunately, a repeat CT angiogram showed no change in the dissection, and I did not have a subarachnoid hemorrhage. After about eight hours in a room, two liters of fluid, IV Dilau-did, Zofran, Compazine, Benadryl, and Ativan, I was as good as new.
Long Road to ResolutionSadly, I spent the next three weeks on my back, needing narcotics and benzos to control the pain. I finally went in to see the neurosurgeon, who wasn’t thrilled that I was incapable of sit-ting upright in the waiting room. He promptly got the neurointerventionalist from next door, who sent me down to interventional radiology and performed a diagnostic angiogram, which showed a pretty ragged artery with lots of thrombus. The options were: 1) stay on Plavix and hope for the best, or 2) sacrifice the artery that I really didn’t need anyway. I chatted with a few people, but it was pretty clear that the second choice was the best option. The next day, I had a second angiogram and had six
platinum coils placed. As an aside, it was not-ed that I had some extravasation of blood into the soft tissue. I went home that evening with a Medrol dose pack, and by the next morning, I was nearly pain free and have been so since.
I was back at work and feeling great at my six-month follow-up for angiogram number three. To my dismay, this showed that the ex-travasated blood had managed to work itself into a dural arteriovenous fistula (AVF). The recommendation was to do a fourth angio-gram and squirt a little surgical glue (Onyx) in there and just be done with it. The down-side of a persistent dural AVF is myelopathy, which is obviously best avoided. This sound-ed like a fantastic plan until the physician told me that the risk of the procedure was the glue going where it shouldn’t, causing an im-mediate spinal artery stroke and quadriple-gia. I spoke to my neurosurgeon and then a colleague neurosurgeon, who both thought an open approach, if even needed, was better, so I got an MRI (normal) and saw a specialist outside of the system who did these for a liv-
ing. He wanted to wait another six months, repeat the MRI, and then do his own angio-gram. The repeat MRI was normal. His angio-gram showed decreased blood flow through the AVF. Apparently, a few of these just slow down and shut off on their own. It was decid-ed to wait a year and repeat the angiogram. If the flow remains low, then there won’t be much more to do. If there is still a problem, then the next step would be a multilevel spi-nal fusion—which definitely beats a spinal artery stroke!
In the meantime, I feel great and have no symptoms. I’ve diagnosed a good number of VADs in the meantime, and my group’s CT uti-lization rate has skyrocketed. I have come to the conclusion that VADs are not that uncom-mon.
DR. CHRISTIANSON is program director of emer-gency services at Group Health Permanente in Seattle.
VERTEBRAL ARTERY DISSECTION | CONTINUED FROM PAGE 1
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X-ray of a vertebral artery dissection.
14 aCeP NOW FEBRuARy 2017 The Official Voice of Emergency Medicine
KK: The 325,000 number I heard a little bit differently, and this caught my attention. In 2012, those 325,000 who came into the emergency department for concussions equaled about 40 an hour. That put it in context for me.
Do you think there is a specific age group that is more at risk than others?
PA: What I’ve read suggests to me that youth players, meaning children under high school age, are more prone to these injuries than are other players. So this starts in the youth leagues, and it’s cumulative. They start injur-ing themselves the minute they start banging heads, and given what we know about concus-sions and what happens down the road, in my opinion, that’s unconscionable.
KK: What is your perspective on the cur-rent return-to-play recommendations?
PA: The current return-to-play recommenda-tions are not adequate. Subjective tests, writ-ten tests, and the combination of motor skills that are used for evaluation can be manipu-lated by the players. They very likely under-estimate the brain health of the player. The concept that the players should be cleared by a knowledgeable health care provider is certainly a step in the right direction, but it doesn’t go far enough because, in many cases, those health care providers aren’t fully aware of the duration of time it takes to heal from a concussion.
KK: I think it’s going to be hard for people to adopt these recommendations.
PA: Well, I didn’t expect the football establish-ment in this country to say, “Thank you. We will do exactly what you said.” But I think the conversation had to start somewhere, empha-sizing the fact that my goal isn’t to abolish the sport—it is to get the people who have reason-able data to step forward and say we need to do something. I fully expect the NFL to be the most resistant. Colleges will be less resistant, and youth football will be most amendable to make these changes because of enlightened parents and coaches.
KK: Tell me about the reception you’ve gotten for the article, especially from the football establishment—have you gotten season tickets anywhere?
PA: No season tickets. The people I’ve heard from have offered an overwhelmingly positive response. They've said, “We agree that some-thing needs to be done.” I made a very impor-tant point at the end of the article about why critics might protest. They wouldn’t want to change because it would change the game in an unacceptable way and it wouldn’t be foot-ball any more. I wanted to make it clear that we live in a free society and people can make in-dividual choices, but that change would even-tually come about because of necessary rule changes. Parents have contacted me about how to get their coaches and, in some cases, family members to accept and adopt this ap-
proach. I’ve heard from folks who want to spread the word through their organizations and a group of ex-NFL players who want me to talk to them about what I’m proposing.
KK: You mentioned the rules, and the name of your article is “It's Time to Change the Rules.” What are you pro-posing?
PA: The rule changes we propose were based on our best understanding of how concussions occur. Based on the work of others, we know that down linemen hit each other in the head innumerable times in practice and games, and they sustain the subconcussive injuries that only on occasion turn into acute clinical manifestations that would pull someone off the field. We know that these linemen have been studied and their brains are affected in a bad way. The most common time they hit heads is at the snap of the ball. Why can’t they be hands-on-knees in an upright position and not firing off and hitting heads? In addition, I think it’s fairly obvious that if someone leads with the top of their head to tackle, that’s a bad thing. We did our best to define what that meant and create a rules infraction if they did it.
The next rule is no forearm shivers to the head, which happen every time that some-one comes up with their forearm and smacks somebody in the head. That’s like boxing in football—just get rid of that. It should be not-ed that the Ivy League is experimenting with no-contact practices. Next, in terms of concus-
sions and return to play, there are many physi-
cians who are not aware of the fact that there is
a four- to six-week minimum time for recovery.
What we tried to do was pick a number that
was sensible in terms of combining safety and
all the reasons why people want to return to
play. For kids, there’s just no reason why youth
football players should be hitting heads ever;
there’s just no reason. Tackle football should
be abolished at that level.
KK: Don’t you also think that the presence of a helmet gives a false sense of confi-dence?
PA: One of the first responses I received from
someone who read the article was his opinion
that the way to solve the problem with football
was to take the helmets away. If you take the
helmets away, you’ll see the head injuries go
away. What we recall is that the reason hel-
mets were put in the game and why they added
face masks was to prevent head and face inju-
ries. Although, as you said, helmets provide a
false sense of security because they aren’t de-
signed to prevent concussions. They actually
encourage players to strike heads with greater
force, and the deceleration injury is not pre-
vented by a helmet.
Reference1. Auerbach PS, Waggoner WH 2nd. It’s time to change the
rules. JAMA. 2016;316(12):1260-1261.
AUERBACH | CONTINUED FROM PAGE 13
Health System wrote a letter to us, and the
Residents Council wrote a letter to the board
of directors with a vote of no confidence in
the hospital leadership. Our biggest concern
was the continued education of our residents.
Our residency director and core faculty were
willing to continue to educate the residents
and even provide a weekly conference with-
out getting paid until a transition was laid
out. That was never taken up.
KK: We’ve heard that you sent the resi-dents home to take a month off. Can you speak to that decision?
JW: No. The residents are back in the de-
partment. Our concern was with the staffing
levels and the credentials of the new physi-
cians (never shown to either us or our resi-
dency director). The residents (only those
on an ED rotation) did not work for two or
three days. They were put on administrative
elective, basically a study month for their in-
service exam. They have since gone back to
their normal routine.
KK: Who told them to come back to work?
JW: They were pressured by [two members
of Summa Health System’s senior leader-
ship]. They were told that they could poten-
tially lose their jobs if they didn’t come back
into work.
KK: Did you have concerns that there was any undue influence over the negotiation process by those who might have had a conflict of interest?
JW: Absolutely that was one of our biggest
concerns. The initial hospital contract team
was the COO, who was new to her position
within the last year or two. The biggest con-
cern was the CMO of the hospital, who is the
wife of the USACS CEO. She was directly in-
volved with contract negotiations.
KK: So from your perspective, she was in-volved with the negotiation? It’s not just that she works there?
JW: No, no, no. She was directly on the hos-
pital’s contract negotiations team. The first
conversation we had about the contract took
place in November, and included me and
the [Summa Health System] CMO and COO,
about two to three weeks before we got the
contract [Nov. 26]. We turned in our coun-
terproposal on Dec. 12. They reviewed it on
Dec. 14, and she was directly involved with
that meeting.
mind is how they are dealt with. In this case, the conflict had been disclosed in the past and was well-known. The person that we’re talking about, [the wife of the USACS CEO], has been on the board of [Summa] hospital in the past, and she’s the CMO currently. That conflict had been disclosed. She was recused from any part of this decision making. In fact, there was no decision. As we said, we didn’t get notified until the 24th, so the idea that this was some type of a plan just simply isn’t true. She was recused from the negotiations and any part of that conversation. Clearly, the hospital knew that this was an issue that would be brought up, and they handled it as any large organiza-tion handles potential conflicts. I don’t have any concerns about it.
KK: Are you fully staffed, and what does your staffing plan look like?
DS: We have fully staffed all of the shifts. We have a group of partners with us who travel. We’re using them. We have a lot of volunteers from our partners across the country, and we’re actively hiring. We also are actively staff-ing the residency program. Scott Felton is the interim program director. We have Chris Lloyd as the associate program director. We have the rest of the 10 core faculty named, some of whom are interim; we continue to look for
permanent core faculty.
There have also been some comments about how this group was displaced and doesn’t have jobs. They are great doctors, so we’ve obviously reached out to them multiple ways, multiple times, and would love for them to stay with Summa and continue to provide great care to the community, which they care about. I want to make sure that it’s not por-trayed that we aren’t interested in them com-ing back. We would love to have them as part of our team.
SUMMA TRANSITION
WRIGHT | CONTINUED FROM PAGE 7 SCOTT | CONTINUED FROM PAGE 7
THE ACEP BOARD OF DIRECTORS WEIGHS INUnderstanding the importance of this issue to our members and our spe-cialty, the ACEP Board of Directors met on Jan. 19, 2017, and discussed this topic extensively. We are com-mitted to protecting the interests of our specialty, patients, members, residents, and training programs. Your input as we develop support-ive resources is welcome. We will to continue to communicate with you on this and other important issues.
FEBRuARy 2017 aCeP NOW 15The Official Voice of Emergency Medicine
ACEPNOW.COM
Pick the Right Adviser from the CrowdDeciding to use a competent, low-cost adviser or to function as your own financial planner by JAMES M. DAHLE, MD, FACEP
Q. Is there any value to hiring a financial ad-viser?
A. Many emergency physicians wonder if they should spend their hard-earned money on financial advisory fees. The answer to this question, like much in life, is, “It depends.” The key is comparing the value received from the adviser to the price you pay the adviser. When hiring a financial adviser, it is absolute-ly critical, despite the difficulty of doing so, that you get good advice at a fair price.
Many doctors hire a financial adviser be-cause they are too busy and would rather pay someone else to deal with the hassle. The im-pression might be that it isn’t worth the doc-tor’s time and is similar to hiring someone to take care of the lawn and clean the house so you can spend your time making the big bucks practicing medicine. Unfortunately, the truth is that doing financial planning and manag-ing your investments is likely the very best use of your time.
Consider a typical financial advisory re-lationship for a doctor. Perhaps the doctor is paying an “industry standard” 1 percent of portfolio assets to the adviser each year and has a portfolio worth $2 million, so the cost of the advice and service is $20,000 per year. Particularly after the initial financial planning and setup of the investments and investment accounts, the adviser may only be spending five to 20 hours a year dealing with this physi-cian’s investments. By doing that without an adviser’s help, the doctor would be “earning” (saving) $1,000–$4,000 per hour, and that’s an after-tax figure! I know many emergency physicians make good money, but I don’t know any doing that well. Perhaps the most impor-
tant reason many physicians choose to be their own financial planner and investment manag-er is the substantial cost of hiring someone to do it for them, especially considering the ease of doing so compared to learning to practice medicine safely. You see, whereas an emergen-cy physician needs to know almost everything about emergency medicine and a competent, experienced financial adviser ought to know almost everything about financial planning and investing, if you are functioning as your own adviser, you need only understand the portions of personal finance, investing, and the tax code that actually apply to you, which is a small fraction of what an adviser needs to know.
Just because real financial advisers are very expensive, many advisers are actually com-missioned salespeople in disguise. Chances are good that competent, low-cost advisers can provide more value than their cost, espe-cially early in your career.
First, consider the costs. There is little rea-son to pay the “industry standard” or “av-erage” level of fees given how many good advisers out there are willing to do it for less. Many advisers working under an Asset Under Management fee model will work for less than 1 percent, especially as the size of your portfo-lio grows. However, you can also simply pay an hourly rate for your initial financial planning and investing plan design and then a flat, rela-
tively inexpensive (a few thousand dollars per year) ongoing asset-management fee. If you are spending a five-figure amount on adviso-ry fees each year, chances are very good you can lower your cost while maintaining or even improving the quality of your advice, service, and after-fee investment performance.
Second, consider the many ways in which an adviser can add value. The most useful thing an adviser can do for you is to help you develop an initial financial and investment plan. That means educating you on what matters when it comes to finances, helping you better define your goals, and generating a written plan on what you should do with the money you have now and will earn in the fu-ture in order to maximize your happiness and reach your goals. Even after the plan has been designed and implemented, the adviser serves another important function: helping you stick with the plan. Investors, especially physician investors, are notorious for performance chas-ing and behavioral biases that cause self-in-flicted financial catastrophes, such as buying high and selling low. In addition, the adviser can function as a financial coach, remind-ing you of your goals and encouraging you to save enough of your income to reach them. Of course, the adviser also takes care of the necessary portfolio chores, such as opening accounts, typing buy and sell orders into the computer, and generating periodic reports
about asset allocation, investment perfor-mance, and progress toward goals. Finally, an adviser provides an important backup func-tion. For most couples, one person is far more interested in personal finance than the other. The presence of an adviser provides a bit of insurance that if something happens to the in-terested partner, the financially naive partner will have someone to ensure the finances are managed in some reasonable way.
Each of these functions that a competent, low-cost adviser can provide has significant value. However, that value is different for eve-ry investor. For an investor who already has a written financial and investing plan and has the interest, knowledge, and discipline re-quired to maintain the plan, that value is like-ly to be much lower than the substantial cost. However, an investor who has none of those things can easily justify paying significant fees to a financial adviser as money well spent.
Even the least competent physician inves-tor who desires to fully rely on a full-service financial adviser needs to learn a few things. These include understanding what a fair price is for advice as well as learning what high-quality financial advice and portfolio manage-ment look like. I know of no better way to find out whether your adviser is giving you good advice than to go get a second opinion from another experienced, fee-only adviser at a separate firm. That second opinion may be the best financial advisory fee you will ever pay.
In summary, a competent, low-cost advis-er can provide substantial value, but whether that value is more than the price depends both on the price and on how ready and willing you are to function as your own financial planner and investment manager.
THE END OF THE RAINBOW
PrOTeCT yOur POT OF GOLD FrOM
baD aDVICe
DR. DAHLE is the author of The White Coat Investor: A Doctor’s Guide to Personal Finance and Investing and blogs at http://white coatinvestor.com. He is not a licensed financial adviser, accountant, or attorney and recommends you consult with your own advisers prior to acting on any information you read here.
Even after the plan has been designed and implemented, the adviser serves another important function: helping
you stick with the plan.
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16 aCeP NOW FEBRuARy 2017 The Official Voice of Emergency Medicine
n Acute and Chronic Back Pain in the ED n BRUE in Low Risk Infants: AAP Guidelines n SEPSIS, SOFA, So What? n Sore Throat: 2017 Sate-of-the-Art n Imaging in Chest Trauma n Myths in Emergency Medicine n Poisoning / Overdose 2017 n ED-Related “Choosing Wisely” - Part 1 n ED-Related “Choosing Wisely” - Part 2 n Gastrointestinal Pearls n ACLS Literature Update - Part 1 n ACLS Literature Update - Part 2 n Unusual Antibiotic Side Effects n The Dilemma of PE Overdiagnosis n The Challenges of Physician Variability n Assessing Suicide Risk n TIAs in the ED n Clinician Burnout: 2017 Update n Getting to Know Tranexamic Acid n Management of CPR Survival - Part 1 n Management of CPR Survival - Part 2 n SAH Ongoing Diagnostic Challenges n Minor Head Trauma: Special Cases n Ongoing Challenge of Managing Pediatric UTI n Steroids: Uses and Misuses in EM n Topics in COPD 2017: Is Anything New? n Visual Diagnosis Challenges - Part 1 n Visual Diagnosis Challenges - Part 2 n Important Recent EM Literature - Part 1* n Important Recent EM Literature - Part 2* n Diagnostic and Therapeutic Controversies* n Challenging ED Scenarios*
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*Topics listed with an asterisk (*) are 90-minute faculty panel discussions; all other topics are 30 minutes.
by K. KAY MOODY, DO, MPH
EM Docs has gone global. Our 10,800-plus members are teaching and
learning from other physicians practicing emergency medicine in some areas with ex-tremely limited resources. We have quite an international reach! Our members are living and practicing on every continent (except Ant-arctica). We are represented in North America in the United States, Puerto Rico, and Canada; in South America in Chile and Honduras; in Africa in Egypt; in Asia in India, Japan, Saudi Arabia, Taiwan, and Singapore; in Australia in Australia and New Zealand; and in Europe in Sweden, United Kingdom, and Norway, among others.
We Are EMPOWR’dWe are empowered by other EM Docs. Practic-ing emergency medicine is hard. It has always been and will always be hard—that is the rea-son most of us chose it! We have disruptions to our sleep with odd shift times. We sometimes see people at their worst as they yell and blame and call names. We finish a code, deliver ter-rible news to a family, and walk into the next room with a plastic smile and the lingering knowledge of what just happened. We cover the “code brown” after the disimpactions with deodorizers and cover our heartaches after we lose the ones who came in too late. We com-partmentalize our lives so we can function in-side and outside the emergency department. Occasionally, we realize our family member is saying, “Are you listening?” as our mind drifts to the 15-year-old with a gunshot wound. We work with empty stomachs and full bladders. We drive home with the images of broken anat-omy and aching souls. How do we answer our families when they ask, “How was your shift?” We titrate our own emotions to a professional level and manage our own frustrations despite the fact that we are human. To deal with the unrealistic expectations on us, some use sar-casm and dark humor or alcohol. Many of us exercise and get outdoors! EM Docs tend to have an amazing sense of adventure and love for extreme sports.
We empower each other. We understand each other like no one can. We speak the same language and share the same culture of caring like a tribe. We have always been the safety net for our communities. Now EM Docs are the safety net for their colleagues. Working a holi-day or a nightshift seems a little more bearable when we know so many of our colleagues are also out there doing the same. On EM Docs, we have a night shift/holiday shift “roll call” to identify colleagues working that shift, and we share favorite songs that we play on the way in to a shift or that we sing in our minds when we walk into a shift or when the “brown stuff” hits the fan. “Welcome to the Jungle” seems to be a favorite, along with “I Gotta Feeling,” “Highway to Hell,” and “Crazy Train.”
We share and discuss cases. We inspire one another to stay current on evidence-based medicine. We laugh at ourselves and each oth-er. “JAFERD” is a nick name that some EM Docs have taken on as an inside joke after one mem-ber told a story of a patient who was angry with her for refusing to fill his opioid prescription. She said that this unnamed patient walked out and said to her, “You are just another f***ing ER doctor.” She abbreviated it to JAFERD and it stuck. “Own it,” many said. Another member made T-shirts, and some even put it on their car license plates. We fight among ourselves on some issues, but we stand up for our profes-sion and for each other. We are out of isolation and have a united voice now.
Heated DiscussionEM Docs survived the election with mostly re-spectful discourse. There continue to be oc-casional heated discussions that allow us to learn from one another on (usually) divisive topics such as abortion, gun control, gender is-sues, and the Affordable Care Act. Some mem-
bers participate in the discussions, and many more follow it. Even when the discussions get a little dramatic, all sides are heard.
The connection and communication be-tween the bedside physicians and our profes-sional organizations are faster now. It helps the fiercely passionate bedside physicians be heard, and it helps our trailblazers in leader-ship know our most pressing struggles so that emergency medicine can better address our challenges right away.
MetricsOne EM Doc, who will remain anonymous, posted about door-to-doctor time, door-to-disposition time, patient satisfaction scores, and similar measures, stating that these met-rics have unintended consequences such as “encouraging physicians to sign up before they are really ready for a new patient just to stop the clock,” which “does nothing to actu-ally improve patient flow.” The member dis-cussed how patient satisfaction scores “can lead to inappropriate medications and tests.
Performing to timed metrics may lead to poor charting and increased risk for errors. The end result is physician dissatisfaction and fewer EM Docs willing to serve in leadership positions.” “Time to take back control of our profession,” another EM Doc said, but from whom—the Centers for Medicare & Medicaid Services, government intrusion, third-party payers, corporate medicine?
One commented that door-to-doctor time was originally designed to assess adequate ED coverage, not measure individual physicians. Times for individual physicians can be affect-ed by the shifts they work. Wait times go up, and satisfaction scores go down. Physicians are frustrated by nonclinical leadership that sees only multicolored charts and graphs that do not represent what truly happens at the bedside. One EM Doc cited a New York Times article from January 2016, “How Measurement Fails Doctors and Teachers .”
One argued that “to improve, we must
Our Own Safety NetEMPOWR, Share Knowledge, Inspire #PhysicianWellness
CONTINUED on page 31
STreNGTH IN NuMberS
DR. MOODY, founder of the EM Docs Facebook group, is president of the Tennessee College of Emergency Physicians and former emergency department chair for Mountain States Health Alliance.
EM DOCS ON SOCIAL MEDIA
EM Docs enjoy a variety of outdoor activities.
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18 aCeP NOW FEBRuARy 2017 The Official Voice of Emergency Medicine
Regulatory TwitterTweets of a different tone
by JEREMY SAMUEL FAUST, MD, MS, MA
In the past few years, major hospitals, health organizations, and prominent
leaders in health care have hopped onto Twit-ter. Now, just about every major healthcare and medical entity, from the New England Journal of Medicine (@NEJM) to the Mayo Clinic (@MayoClinic), has an official Twitter feed. For the most part, tweets that are offi-cially representing a prestigious organiza-tion or prominent person in the field tend to reflect that fact. Translation: The tweets are usually boring. No one takes a stand. No one says anything interesting. For the most part, official Twitter accounts associated with medi-cine and health care organizations are echo chambers for well-established ideas that are not interesting to medical professionals. Sure, there’s the occasional tweet about some med-ical innovation or recent research. However, those are usually self-promoting and not ready for prime time. At worst, even well-respected med-ical centers’ Twitter ac-counts are in the habit of tweeting out poorly writ-ten health and medicine stories from local and na-tional mainstream media or, regrettably, spouting pseudo-wisdom from ce-lebri-docs and self-styled health and medicine gu-rus who are more style than substance. Part of the problem is that these accounts are frequently not managed by medical professionals but rather by young public re-lations professionals just entering the medi-cal field who don’t distinguish between Vivek Murthy (the much-beloved Surgeon General of the United States, @Surgeon_General) and Deepak Chopra (decidedly not the Surgeon General of the United States, Twitter handle withheld.)
Enter Andy Slavitt. Mr. Slavitt has been the acting administrator of the Centers for Medi-care & Medicaid Services (CMS) since 2015. While Mr. Slavitt has come under some scru-tiny from some conservative news outlets and other critics for his work while at the helm of CMS, his personal Twitter feed is simply awe-some. Mr. Slavitt (@ASlavitt) brings a refresh-ing honesty to the medium. Yes, he’s partisan,
but he owns it. He’s also not afraid to mix it up with random people and accounts online. Usu-ally famous or “well-known” people on Twitter ignore snarky comments from “normals” (ie, everyday people without any particular claim to fame trying to bait a prominent person into a Twitter battle). Not Mr. Slavitt! He’s just as apt to tweet official news about major govern-ment initiatives, such as MACRA, as he is to dispel rumors and myths about the Affordable Care Act (ACA) put forth by everyday tweeps (ie, you and me). One anonymous but politi-cally tied Twitter account accused Mr. Slavitt of not knowing the difference between getting insurance and obtaining real medical care, a critique of the ACA. Most government officials at Mr. Slavitt’s level would let a tweet like this slide and simply ignore it. Instead, Mr. Slavitt swung back, tweeting that “unnamed people often lob clichés at you in the job … highest rates of regular [doctor] visits, script fills, and avoided deaths, notwithstanding.”
In fact, Mr. Slavitt’s Twitter persona is not ran-dom. It’s part of a plan. Mr. Slavitt has said that his Twitter presence is spe-cifically being cultivated in order to demystify the large and often opaque government agency that he runs. Doing so, he says, “scares the crap out of my colleagues” at CMS, who aren’t used to such a frank and occasionally brusque approach to online PR. This reflects precisely why Mr. Slavitt’s tweets are so
informative. When a government agency has a real person responding in real human ways, things may indeed get a little messy, but peo-ple feel like they can be a part of the process. Even critics are more likely to engage. The 12,000-plus followers Mr. Slavitt has amassed in just a few months seem to agree.
Also in agreement is health care reporter Dan Diamond (@DDiamond) of Politico.com, who invited Mr. Slavitt to be the first guest on his new weekly podcast, “Pulse Check,” which is available online or on iTunes. In that first interview published in April 2016, Mr. Dia-mond somewhat affectionately branded Mr. Slavitt as “remarkably liberated to weigh in on
CONTINUED on page 25
DR. FAUST is an attending physician at Brigham and Women’s Hospital and a clinical instructor at Harvard Medical School, both in Boston. He is co-host of FOAMcast and tweets about emergency medicine and classical music @jeremyfaust.
THE FEEDSerVING uP THe beST eM TWeeTS
I do not believe there has ever
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FEBRuARy 2017 aCeP NOW 19The Official Voice of Emergency Medicine
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Pushing Fast Forward in the EDThe Miriam Hospital’s FAST FORWARD>> program regains lost patient flow efficienciesby SHARI WELCH, MD, FACEP, FACHE
The Miriam Hospital is a 247-bed com-munity hospital affiliated with the Warren Alpert School Medical School
of Brown University in Providence, Rhode Is-land. The emergency department sees 68,000 visits annually in its 61 treatment spaces, which include 21 lounge chairs for vertical flow. The emergency department has had a long reputation for efficiency and service quality. The ED physicians and staff have al-ways been proud of their performance met-rics and empty waiting room. However, after crossing the 60,000-visit volume band, the de-partment began to falter operationally, and its wait times increased. The new normal includ-ed an often full waiting room. The emergency department, which effectively operates as a geriatric emergency department (more than 30 percent of its patients being older than age 65), often found itself with Emergency Sever-ity Index (ESI) 2 patients being placed back in the waiting room, a situation that did not please staff.
Hospital President Arthur Sampson and ED Medical Director Gary Bubly, MD, decided to undergo a comprehensive ED operations as-sessment conducted by an objective third par-ty. The assessment identified opportunities for improvement. The leaders were committed to improving the emergency department but needed a road map of where to start. After the assessment, Dr. Bubly, along with his associ-ate director, Ilse Jenouri, MD, and his nursing counterparts, Denise Brennan, nurse director of emergency services, and Bob Boss, clinical manager, decided to trial a change package with a set of complementary improvements that would commence simultaneously.
Using data, interviews, and observation, the ED operations experts argued that the emergency department had the space and personnel to manage the volumes. Their as-sessment revealed that intake was cumber-some, with many delays as most steps were conducted in series. Further, though the Miriam emergency department had just be-gun patient streaming and treating patients in chairs, there was no improvement in wait times because the streaming was not decisive and most geographic zones were mixed-acuity service lines. This made it hard to move low-acuity patients through the system quickly. Other patient flow and housekeeping issues were identified. Using data the leadership team developed, the emergency department implemented the flow model in Figure 1 us-ing the major care/minor care concept used in Great Britain.
The leadership team cleverly dubbed the
CONTINUED on page 21
DR. WELCH is a practicing emergency physician with Utah Emergency Physicians and a research fellow at the Intermountain Institute for Health Care Delivery Research. She has written numerous articles and three books on ED quality, safety, and efficiency. She is a consultant with Quality Matters Consulting, and her expertise is in ED operations.
SPECIAL OPsTIPS FOr beTTer
PerFOrMaNCe
Figure 2: Miriam’s New Triage Process
QUICK REG
Quick LookTRIAGE
Full TRIAGE
Physician Assessment
ALL BEDSIDE ORDERS
FULL REG
Figure 1: The Miriam Flow Model
ALLARRIVALS
TEAM TRIAGE
ESI 1, 2
ESI 3, 4, 5
ESI 4, 5
Vertical ESI 3
Horizontal ESI 3
VERTICAL CARE
Fast Track
MAJOR CARE
Team 5Team 1 Team 7
The Miriam Hospital emergency department’s vertical treatment area.
20 aCeP NOW FEBRuARy 2017 The Official Voice of Emergency Medicine
change package “The Miriam: FAST FOR-WARD>>.” It connotes the overarching theme of trying to regain lost efficiencies. The chang-es included:
1) Team triage, which made the most of the physical layout.
2) A patient flow coordinator (PFC) to moni-tor flow into the department and, where possible, load-level the various zones.
3) Low-acuity patient streams (fast track and vertical flow), which place lower-acuity patients into cohorts depending on resource need.
4) A housekeeping improvement initiative to rectify the problem of empty but dirty rooms.
The leadership crafted a new triage process that has many steps now happening in paral-lel (see Figure 2).
The physician contact is now very early in the ED encounter, and lab testing is initiated at triage. The physician can decide which zone is most appropriate for the patient, but the PFC assigns the room.
The PFC is a role that is growing in popu-larity, especially in emergency departments seeing more than 50,000 visits per year. The PFC manages incoming ambulances and has the 30,000-foot view of the workload in each area. As emergency departments get busy with increased numbers of geographic zones, an overview is lost unless someone is dedicated
to monitoring and managing flow. This role works best when it is in addition to the charge nurse role, which was becoming unmanage-able in terms of scope of duties. The charge nurse and PFC work as a team and are in con-stant communication (cellphones with speed dial) to share information for flow manage-ment. The charge nurse now focuses on one
area with attention to outflow, admissions, and discharges. The charge nurse can inform the PFC as to workload in the back, the status of patients, and which patient is likely to be moving next. Together, they manage overall patient flow.
Patients were grouped according to acuity and resources needed. This allowed for the re-
alization of new efficiencies, and many fast-
track patients were turned around in under an
hour! Housekeeping fine-tuned its processes
to decrease the downtime of most rooms.
The results were astonishing and unequiv-
ocal. After four rapid-cycle tests of change,
the leaders and stakeholders had ironed out
the bugs and were ready to turn on their new
ED processes for good. Compare their results
where they were underperforming relative to
the Academy of Administrators in Academic
Emergency Medicine and Emergency Depart-
ment Benchmarking Alliance cohorts before
and are now top performers (see Table 1).
There are some take-home messages that
are important to all ED leaders and manag-
ers reading this story. You will need to change
your processes as your volumes grow. In par-
ticular, as you jump a volume band, what
has worked before no longer works at the in-
creased volumes. Parallel processing, patient
streams that segment patients according to the
time and resources they will need, and push-
ing the provider to the front of the encounter
are all forward-thinking ED flow strategies. For
The Miriam Hospital emergency department,
this change package helped get its mojo back!
Once again, the ED members are top perform-
ers in their system. From now on, they will
continue moving their patients fast forward
and achieving higher levels of performance
and great success!
SPECIAL OPS | CONTINUED FROM PAGE 20
PERFORMANCE METRIC
THE MIRIAM HOSPITAL AAEM 60-80K
EDBA 60-80KBEFORE AFTER
PPD 182 198 193 164
D2D 41 17.7 30 33
LOS Overall 264 232 300 201
LOS Admitted 341 326 486 336
LOS DIscharged 228 189 264 181
LOS Fast Tracked N/A 118 N/A 128
LBTC 4.72% 1.8% 4.4% 3.1%
LWBS 2.9% .61% 2.6% N/A
Definitions: PPD, patients per day; D2D, door-to-doctor time; LOS, length of stay; LBTC, left before treatment com-plete; LWBS, left without being seen; AAAEM, Academy of Administrators in Academic Emergency Medicine; EDBA, Emergency Department Benchmarking Alliance.
Table 1: Miriam’s Performance Before and After Intervention Compared to Benchmark Data
FEBRuARy 2017 aCeP NOW 21The Official Voice of Emergency Medicine
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What’s a Picture Worth?Forensic photography for emergency medicine by RALPH J. RIVIELLO, MD, MS, FACEP
The Case: You are called to testify in court for a domestic violence assault case. You saw the patient three years ago; she had sustained multiple bodily injuries. In addition to pro-viding medical care, you took photographs of her injuries. While on the stand, you are shown the picture in Figure 1 and are asked to describe the location and size of the wound. How would you answer that question?
DiscussionIn the case, the photograph does not allow the viewer to accurately know which body part is being depicted. Also, the size cannot be de-scribed. Photography has become an impor-tant documentation tool for injuries. It is used in documenting child abuse, elder abuse, do-mestic violence, sexual violence, and assault cases. In some departments, forensic nurse ex-aminers (FNEs) are called upon to take photo-graphs and document the findings. However,
a FNE may not always be available, requiring the emergency provider to take the pictures. A few helpful hints will allow you to take pho-
tographs that actually represent the finding you identified.
Forensic photography supplements the medical forensic history and physical find-ings. It allows the viewer to see the injuries that the provider saw at the time of evalua-tion. The advent of digital photography has had a great impact on forensic photography. Several advantages of digital image capture in-clude instant review of photo for quality and composition, no need for film or film devel-opment, and ease of storing and transfer of images. Prior to taking photos, there should be a department policy addressing the use of photographs. The policy should cover topics including consent, secure storage of images, and transfer of images. Risk management, in-formation technology, and the medical records departments should be involved in policy de-velopment.
Patients should consent to have their pho-tographs taken. A separate photographic con-sent form should be used. Patient have the
right to refuse image capture of certain inju-ries or body parts. Also, the consent should address the release of images to law enforce-ment and/or district attorney’s offices. Imag-es should be stored on a secure server and/or within the electronic health record.
The medical record should reflect that pho-tographs were taken as well as the number tak-en and how they were stored. Transferring the images to a CD-ROM and storing the CD with the medical record or in a separate secure loca-tion or using a separate memory card for each patient are acceptable. Photographs depict-ing genitalia should be stored with particular sensitivity.
Some Photographic TipsEquipment: Expensive equipment is not nec-essary. A good-quality point-and-shoot cam-era takes sufficient images. The camera should capture images of at least six megapixels and have macro lens capabilities. Macro lenses al-
CONTINUED on page 23
FORENSIC FACTSDR. RIVIELLO is professor of emergency medicine and vice chair of clinical operations at Drexel Emergency Medicine in Philadelphia.
be a MeDICaL DeTeCTIVe—
bONe uP ON yOur FOreNSIC SKILLS
Figure 1 (Left): Suboptimal quality photograph of an injury from a domestic violence assault.
22 aCeP NOW FEBRuARy 2017 The Official Voice of Emergency Medicine
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† You will qualify for $100 bonus cash rewards if you use your new credit card account to make any combination of Purchase transactions totaling at least $500 (exclusive of any fees, returns and adjustments) that post to your account within 90 days of the account open date. Limit one (1) bonus cash rewards offer per new account. This one-time promotion is limited to new customers opening an account in response to this offer. Other advertised promotional bonus cash rewards offers can vary from this promotion and may not be substituted. Allow 8-12 weeks from qualifying for the bonus cash rewards to post to your rewards balance.
By opening and/or using these products from Bank of America, you’ll be providing valuable financial support to American College of Emergency Physicians.
This credit card program is issued and administered by Bank of America, N.A. Visa and Visa Signature are registered trademarks of Visa International Service Association, and are used by the issuer pursuant to license from Visa U.S.A. Inc. BankAmericard Cash Rewards is a trademark and Bank�of�America and the Bank of America logo are registered trademarks of Bank of America Corporation.
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The BankAmericard Cash Rewards™ credit cardfor American College of Emergency Physicians.
To apply visit: newcardonline.comUse Priority Code VACN53.
Earn more cash back for the things you buy�most.
$100cash rewards bonus
after qualifying purchase(s).†
2% and 3% category rewards bonuses apply on up to $2,500 in combined quarterly spend in those categories.▼
3% cash back on gas
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For information about the rates, fees, other costs and benefits associated with the use of this Rewards card, or to apply, go to the website listed above or write to P.O. Box 15020, Wilmington, DE 19850.
▼ The 2% cash back on grocery store and wholesale club purchases and 3% cash back on gas purchases applies to the first $2,500 in combined purchases in these categories each quarter. After that the base 1% earn rate applies to those purchases.
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By opening and/or using these products from Bank of America, you’ll be providing valuable financial support to American College of Emergency Physicians.
This credit card program is issued and administered by Bank of America, N.A. Visa and Visa Signature are registered trademarks of Visa International Service Association, and are used by the issuer pursuant to license from Visa U.S.A. Inc. BankAmericard Cash Rewards is a trademark and Bank�of�America and the Bank of America logo are registered trademarks of Bank of America Corporation.
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low close-up shots and are represented by the “tulip” icon on most cameras. A built-in or sep-arate flash is also required. Other essentials in-clude spare batteries, media cards, computer cable, reference scales for measuring length, cleaning supplies, and the camera manual. A tripod or monopod may also be helpful.
For most applications, the camera can be kept in automatic mode, which will choose the correct settings and capture desirable images. For close-ups, the mode dial should be set to the macro setting. For initial settings, file for-mat should be set to JPEG, image quality to fine, and image size to largest.
Prior to taking photographs, a picture of the patient’s identifying information should be taken. This should include the patient name, medical record number, date, and time. A hos-pital ID sticker is ideal. Next, a picture of the photographer’s ID should be taken.
A facial image or full-body image can be taken to identify the patient. When taking pic-tures of an injury or other finding, a “forensic series” of images should be taken:
• Overview (includes two anatomic land-marks for orientation)
• Mid-range (closer, includes one anatomic landmark)
• Close-up (one with and one without a ref-erence scale)
The overview and mid-range shots may include more than one finding. However, the close-ups should each include a single injury.
A reference scale should always be used. The most popularly used scale is the American Board of Forensic Odontology scale (ABFO-2). This has the advantage of showing the distor-tion of the photograph. If an ABFO scale is not available, a small ruler or coin can be used. The scale should not obscure the finding(s) and should be positioned on the same plane as the finding and at an equal distance from
the camera.
Make sure your camera is oriented 90 de-
grees to the injury. This ensures the most ac-
curate representation of the injury. Also, make
sure the background is free of clutter.
Take as many pictures as needed to best
represent the finding. Never delete a picture no
matter how bad it is. Also, photographs should
not be manipulated, and if photographic soft-
ware is used to enhance an image, the original
image should be saved, and for each altered
image, documentation of how it was altered
should be provided.
FORENSIC FACTS | CONTINUED FROM PAGE 22
FEBRuARy 2017 aCeP NOW 23The Official Voice of Emergency Medicine
ACEPNOW.COM
CLASSIFIEDS
NORTH FLORIDA Destin Emergency Room (Destin) Fort Walton Beach Medical Center (Ft. Walton Beach) Lake City Medical Center (Lake City) Oviedo Medical Center (Oviedo) Bay Medical Center (Panama City) Gulf Coast Regional Medical Center (Panama City) CENTRAL FLORIDABlake Medical Center (Bradenton) Englewood Community Hospital (Englewood) Munroe Regional Medical Center (Ocala) Emergency Center at TimberRidge (Ocala) Oak Hill Hospital (Ocala) Poinciana Medical Center (Orlando) Brandon Regional Emergency Center (Plant City) Fawcett Memorial Hospital (Port Charlotte) Bayfront Punta Gorda (Punta Gorda) Central Florida Regional Hospital (Sanford) Doctors Hospital of Sarasota (Sarasota) Brandon Regional Hospital (Tampa Bay) Citrus Park ER (Tampa Bay) Medical Center of Trinity(Tampa Bay) Northside Hospital (Tampa Bay) Palm Harbor ER (Tampa Bay) Regional Medical Center at Bayonet Point (Tampa Bay) Tampa Community Hospital (Tampa Bay) SOUTH FLORIDA Broward Health, 4-hospital system(Ft. Lauderdale) Northwest Medical Center (Ft. Lauderdale) Westside Regional Medical Center (Ft. Lauderdale) Aventura Hospital and Medical Center (Miami) Raulerson Hospital (Okeechobee)
St. Lucie Medical Center (Port St. Lucie) Palms West Hospital (West Palm Beach) JFK North (West Palm Beach)GEORGIA Cartersville Medical Center (Cartersville) Newton Medical Center (Covington) Habersham Medical Center (Demorest) Fairview Park (Dublin) Piedmont Fayette Hospital (Fayetteville) Coliseum Medical Center (Macon) Mayo Clinic at Waycross (Waycross) KANSAS Menorah Medical Center (Overland Park) KENTUCKY Greenview Regional (Bowling Green) TJ Health Cave City Clinic (Cave City) Frankfort Regional (Frankfort) Murray-Calloway County Hospital (Murray) LOUISIANA CHRISTUS St. Frances Cabrini Hospital (Alexandria)Terrebonne General Medical Center (Houma) CHRISTUS St. Patrick Hospital (Lake Charles)CHRISTUS Highland Medical Center (Shreveport) MISSOURI Belton Regional Medical Center (Belton) Golden Valley Memorial Hospital (Clinton) Centerpoint Medical Center (Kansas City)Liberty Hospital (Kansas City)Lafayette Regional Health Center (Lexington)Western Missouri Medical Center (Warrensburg)
NEW HAMPSHIREParkland Medical Center (Derry)Portsmouth Regional Hospital (Portsmouth) Portsmouth Regional Hospital Seabrook ER (Seabrook) SOUTH CAROLINA McLeod Health, 4 hospital system (Dillon, Little River, Manning, Myrtle Beach) TEXAS CHRISTUS Spohn Hospital - Alice (Alice) CHRISTUS Spohn Hospital - Beeville (Beeville) CHRISTUS Hospital - St. Elizabeth (Beaumont)CHRISTUS Hospital - St. Elizabeth Minor Care (Beaumont) CHRISTUS Spohn Hospital - Memorial (Corpus Christi) CHRISTUS Spohn Hospital - Shoreline (Corpus Christi) East Houston Regional Medical Center (Houston) CHRISTUS Jasper Memorial Hospital (Jasper) CHRISTUS Spohn Hospital - Kleberg (Kingsville) Kingwood Medical Center (Kingwood) Pearland Medical Center (Pearland) CHRISTUS Hospital - St. Mary(Port Arthur) CHRISTUS Santa Rosa Medical Center (San Antonio) CHRISTUS Santa Rosa Hospital - Westover Hills (San Antonio)CHRISTUS Alon/Creekside FSED (San Antonio) CHRISTUS Santa Rosa - Alamo Heights (San Antonio) Metropolitan Methodist (San Antonio) Northeast Methodist (San Antonio)
TENNESSEE Horizon Medical Center (Dickson) ParkRidge Medical Center (Chattanooga) Hendersonville Medical Center (Hendersonville) Physicians Regional Medical Center (Knoxville) Tennova Hospital - Lebanon (Lebanon) Centennial Medical Center (Nashville)Natchez Freestanding ED (Nashville)Southern Hills Medical Center (Nashville) Stonecrest Medical Center (Nashville) Bledsoe Hospital (Pikeville) VIRGINIASpotsylvania Regional Medical Center (Fredericksburg)
LEADERSHIP OPPORTUNITIESGreenview Regional (Bowling Green) Golden Valley Memorial Hospital (Clinton, MO) Parkland Medical Center(Derry, NH) Northwest Medical Center (Ft. Lauderdale, FL) Assistant Medical DirectorColiseum Medical Center (Macon, GA) EM Residency Program Director Twin Cities (Niceville, FL) Poinciana Medical Center(Orlando, FL) Oviedo Medical Center (Oviedo, FL) Gulf Coast Regional Medical Center (Panama City, FL) HealthOne Emergency Care Fairmont (Pasadena, TX) Brandon Regional Hospital (Tampa Bay, FL)Assistant Medical Director
Citrus Park ER (Tampa Bay, FL) Assistant Medical Director Medical Center of Trinity(Tampa Bay, FL)Northside Hospital (Tampa Bay, FL) Assistant Medical DirectorTerre Haute (Terre Haute, IN) Mayo Clinic at Waycross (Waycross, GA) Palms West Hospital (West Palm Beach, FL)
PEDIATRIC OPPORTUNITIESBroward Health Children’s Hospital (Ft. Lauderdale, FL) Clear Lake Regional Medical Center (Houston, TX)Coliseum Medical Center (Macon) Centennial Medical Center (Nashville, TN)Kingwood Medical Center (Kingwood, TX) Mease Countryside Hospital (Tampa Bay, FL) Brandon Regional Hospital (Tampa Bay, FL)Pediatric Medical Director and StaffThe Children’s Hospital at Palms West (West Palm Beach, FL)
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Editor’s Note: Cutting through the red tape to make certain that you get paid for every dollar you earn has become more difficult than ever, particularly in our current climate of health care reform and ICD-10 transi-tion. The ACEP Coding and Nomenclature Committee has partnered with ACEP Now to provide you with practical, impactful tips to help you navi-gate through this coding and reimbursement maze.
GET PAID FOR YOUR INTERPRETATIONby HAMILTON LEMPERT, MD, FACEP, CEDC
Question: Can I bill for my interpretation of ECGs and X-rays?Answer: Yes, you are permitted to bill for interpretation of ECGs and X-rays, but certain criteria must be met. First and foremost, an “interpretation” is different than a “review.” If you independently visualize or review a diagnostic test, this work is incor-porated into the level of medical decision making. If you perform an interpretation,
the written report should be similar to what a specialist in the field would prepare. It must be your interpretation, not someone else’s. Medicare and some other pay-ers have stated that they will pay for interpretations that contribute to the diagnosis or treatment of patients but usually only one interpretation. Some payers do reim-burse for both contemporaneous and final (QA) readings. Therefore, you might con-sider having discussions with other services that may want to bill for concurrent or delayed readings. Some institutions require credentialing in order to “officially” inter-pret certain studies. For more information, see ACEP’s FAQ on this topic at www.acep.org/content.aspx?id=32164&list=1&fid=2292. Brought to you by the ACEP Coding and Nomenclature Committee.
DR. LEMPERT is chief medical officer, coding policy, at TeamHealth, based in Knoxville, Tennessee. Dr. Lemanski is associate professor of emergency medicine at Baystate Medical Center/Tufts University School of Medicine in Springfield, Massachusetts, and chair of the ACEP Coding and Nomenclature Committee.
NaVIGaTe THe CPT MaZe,
OPTIMIZING yOur
reIMburSeMeNT
CODING WIZARD
24 aCeP NOW FEBRuARy 2017 The Official Voice of Emergency Medicine
CLASSIFIEDS
Rapid expansion in Greenville, SC due to new EM Residency Program starting 2017 and community hospital growth.Greenville Health System (GHS) seeks BC/BE Emergency Physicians to become faculty in the newly established Department of Emergency Medicine. Successful candidates should be prepared to shape the future Emergency Medicine Residency Program and contribute to the academic output of the department.
GHS is the largest healthcare provider in South Carolina and serves as a tertiary referral center for the entire Upstate region. The flagship Greenville Academic Department of Emergency Medicine is integral to the patient care services for the:
• Level 1 Trauma Center• Dedicated Pediatric Emergency Department within the Children’s Hospital• Five Community Hospital Emergency Departments • Accredited Chest Pain Center • STEMI and Comprehensive Stroke Center• Emergency Department Observation Center• Regional Ground and Air Emergency Medical Systems• Accredited 3 year Emergency Medicine Residency Program
The campus hosts 15 other residency and fellowship programs and one of the nation’s newest allopathic medical schools – University of South Carolina School of Medicine Greenville.
Emergency Department Faculty enjoy a flexible work schedule, highly competitive salary, generous benefits, and additional incentives based on clinical, operational and academic productivity.
Greenville, South Carolina is a beautiful place to live and work. It is one of the fastest growing areas in the country, and is ideally situated near beautiful mountains, beaches and lakes. We enjoy a diverse and thriving economy, excellent quality of life, and wonderful cultural and educational opportunities.
CURRENTLY SEEKING PHYSICIANS FOR THE FOLLOWING ROLES:
• Clinician Educator • Observation Medicine• Medical Toxicology • Advanced Practice• Prehospital Medicine • Research
*Public Service Loan Forgiveness (PSLF) Program Qualified Employer*
Qualified candidates should submit a letter of interest and CV to: Kendra Hall, Sr. Physician Recruiter, [email protected], ph: 800-772-6987.
GHS does not o�er sponsorship at this time. EOE
CLINICAL & ACADEMICEMERGENCY PHYSICIANS
South Carolina
Emergency Physicians of Tidewater (EPT) is a physician-owned, physician-run, democratic group of ABEM/AOBEM eligible/certified EM physicians serving theNorfolk/Virginia Beach area for the past 40+ years.We provide coverage to 5 hospital-based EDs and 2 free-standing EDs in the area. Facilities include a Level 1 trauma center, Level 3 trauma center, academic medicine and community medicine sites. All EPT physicians serve as community faculty to the EVMS Emergency Medicine residents. EMR via EPIC. Great opportunites for involvment in administration, EMS, ultrasound, hyperbarics and teaching of medical students and residents. Very competitive financial package and schedule. Beautiful, affordable coastal living.
Please send CV to [email protected] or call (757) 467-4200 for more information.
the issues of the day” on Twitter (said with a chuckle). In other words, he called Mr. Slavitt out on being unexpectedly “real” on Twitter. Mr. Slavitt agreed and acknowledged that it was part of a plan to get ahead of problems and to have a “good offense” when it comes to policy rollout at the federal level. Whether you agree with CMS policy, I believe the strategy has been effective. Thanks to Mr. Slavitt, and the medium itself, I do not believe there has ever been a time when average people have had more access to a high-level government administrator.
Speaking of Mr. Diamond, his health care coverage on Politico has gotten enormous and well-deserved attention lately. His daily blog, “Politico Pulse,” is becoming must-read mate-
rial for anyone looking to keep up with what is happening in the world of health care policy, politics, and business. Each day, Mr. Diamond gives updates on public health (eg, the latest
on Zika) and what’s going on in Washington (eg, will Medicare expand or contract in the incoming administration?), and he tracks ma-jor movements in the pharmaceutical indus-try, with recent special attention to mergers and what they mean. Finally, Mr. Diamond’s brief list of “what we’re reading” provides dai-ly links to important medicine, science, and health care policy articles in the mainstream press as well as online.
Do you have other must-follow Twitter ac-counts and blogs? Let me know, and I’ll high-light some of them here on “The Feed.”
THE FEED | CONTINUED FROM PAGE 19
DO YOU HAVE ANY FAVORITE FOAMED RESOURCES THAT ACEP NOW READERS SHOULD KNOW ABOUT VIA THE FEED? TWEET AT ME @JEREMYFAUST OR EMAIL TO [email protected]
FEBRuARy 2017 aCeP NOW 25The Official Voice of Emergency Medicine
ACEPNOW.COM
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Honolulu, Hawaii
The Emergency Group, Inc. (TEG) is agrowing, independent, democratic groupthat has been providing emergencyservices at The Queen’s Medical Center(QMC) in Honolulu, Hawaii since 1973.QMC is the largest and only traumahospital in the state and cares for morethan 65,000 ED patients per year. QMCopened an additional medical center inthe community of West Oahu in 2014,which currently sees 50,000 ED patientsannually.
Due to the vastly growing community in the West Oahu area, TEG is actively recruiting for EM Physicians BC/BE, EM Physicians with Pediatric Fellowship who are BE/BC and an Ultrasound Director. Physicians will be credentialed at both facilities and will work the majority of the shifts at the West Oahu facility in Ewa Beach, Hawaii.
We offer competitive compensation,benefits, and an opportunity to sharein the ownership and profits of thecompany. Our physicians enjoyworking in QMC’s excellent facilities andexperience the wonderful surroundingsof living in Hawaii.
For more information, visit our websiteat www.teghi.com. Email your CVto [email protected] or callthe Operations Manager at 808-597-8799.
For more information, visit www.RCLCareers.com
INTERESTED IN ACAREER AT SEA?We're looking for caring
Doctors and Nursesto join our team.
WASHINGTON, Olympia: Full-time, partnership track
opportunity for residency trained BC/BE emergency physician. Established, independent, fee-for-service democratic group.
Annual volume 70,000+. State-of-the-art department located on
the scenic Puget Sound.
Send CV to Kathleen Martin, 413 Lilly Rd. NE.,
Olympia, WA 98506 or [email protected]
TO PLACE AN AD IN ACEP NOW ’S
CLASSIFIED ADVERTISING SECTION
PLEASE CONTACT:
Kevin Dunn: [email protected]
Cynthia Kucera: [email protected]
Phone: 201-767-4170
Exciting Academic Emergency Medicine Opportunities
The Baylor College of Medicine, a top medical school, is looking for academic leaders to join us in the world’s largest medical center, located in Houston, Texas. We offer a highly competitive academic salary and benefits. The program is based out of Ben Taub General Hospital, the largest Level 1 trauma center in southeast Texas with certified stroke and STEMI programs that has more than 100,000 emergency visits per year. BCM is affiliated with eight world-class hospitals and clinics in the Texas Medical Center. These affiliations, along with the medical school’s preeminence in education and research, help to create one of the strongest emergency medicine experiences in the country. We are currently seeking applicants who have demonstrated a strong interest and background in medical education, simulation, ultrasound, or research. Clinical opportunities are also available at our affiliated hospitals. Our very competitive PGY 1-3 residency program currently has 14 residents per year.
MEDICAL DIRECTORThe program is searching for a dedicated Medical Director for the Ben Taub General Hospital, The Medical Director will oversee all clinical operations at Ben Taub, with a focus on clinical excellence. The successful candidate will be board certified and eligible for licensure in the state of Texas. The candidate will have a solid academic and administrative track record with prior experience in medical direction. Faculty rank will be determined by qualifications.
Those interested in a position or further information may contact Dr. Dick Kuo via email [email protected] or by phone at 713-873-2626. Pleases send a CV and cover letter with your past experience and interests.
Service § Education § Leadership
EMERGENCY MEDICINERESIDENCY PROGRAM
Emergency Medicine FacultyThe Department of Emergency Medicine at Rutgers Robert Wood Johnson Medical School, one of the nation’s leading comprehensive medical schools, is currently recruiting Emergency Physicians to join our growing academic faculty.
Robert Wood Johnson Medical School and its principal teaching affiliate, Robert Wood Johnson University Hospital, comprise New Jersey’s premier academic medical center. A 580-bed, Level 1 Trauma Center and New Jersey’s only Level 2 Pediatric Trauma Center, Robert Wood Johnson University Hospital has an annual ED census of greater than 90,000 visits.
The department has a well-established, three-year residency program and an Emergency Ultrasound fellowship. The department is seeking physicians who can contribute to our clinical, education and research missions.
Qualified candidates must be ABEM/ABOEM certified/eligible. Salary and benefits
are competitive and commensurate with experience. For consideration, please send
a letter of intent and a curriculum vitae to: Robert Eisenstein, MD, Interim Chair, Department of Emergency Medicine, Rutgers Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, MEB 104, New Brunswick, NJ 08901; Email: [email protected]; Phone: 732-235-8717; Fax: 732-235-7379.
Rutgers, The State University of New Jersey, is an Affirmative Action/Equal Opportunity Employer, M/F/D/V
ACEP NOW 9/1/2016, 10/1/2016, 11/1/201610004208-NY16624UMDNJX4.875” x 5”Gabrielle Mastaglio v.5
26 aCeP NOW FEBRuARy 2017 The Official Voice of Emergency Medicine
CLASSIFIEDS
SEEKING THE BEST EM PHYSICIANSEmBassador Travel Team
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Fast track to future leadership opportunities
FOR MORE INFORMATION:
Alan W. [email protected]
FEBRuARy 2017 aCeP NOW 27The Official Voice of Emergency Medicine
CLASSIFIEDS
TH-10168 Practice Made Perfect brand ad size: 9.875 x 7 island pub: ACEP Now (FEB 2017)
Join our team
teamhealth.com/join or call 855.615.0010
FEATURED OPPORTUNITIES
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Mountainview HospitalLas Vegas, NV78,000 Volume
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LOS ANGELESCALIFORNIADOWNTOWN LOS ANGELES:
Quality STEM Stroke Center, good Metrics, paramedic receiving (no peds inpatients). Physician coverage 38-40 hrs/day with NP & PA 12-20 hrs/day. 1.9 pts/hr, stable 26yr contract, core
group physicians average 23 years tenure. Require Board certi-fied or Board eligible (residency trained) with experience. Day &
night shifts (max 5 nights/mo.). Salary competitive.
TUSTIN – ORANGE COUNTY:New ER opening December, parametic Receiving, 110-bed
hospital, 9 bed ER, Anticipate 600-900 visits/mo. Base + Incentive (patient volume + RVU) 24 hr. Shifts
LOS ANGELES:Low volume 700/mo. urgent care non-Paramedic receiving, less
stress, 20 yr. contract w/stable history. Patients 1/hr. Base + incentive
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history stable. $110/hr. 24hr shifts available
FAX CV to 213-482-0577or call 213-482-0588, or email
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TEXARKANA!CHRISTUS St. Michael Health System
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(512) [email protected]
28 aCeP NOW FEBRuARy 2017 The Official Voice of Emergency Medicine
CLASSIFIEDS
BY DAVID BIRDSALL, MD VICE PRESIDENT & EMERGENCY MEDICINE PARTNER
To read more about the importance of culture and how CEP America enacted change, visit: go.cep.com/yourculture
WHAT IS CULTURE AND WHY DO I NEED IT?
ADVERTISEMENT
WHAT IS CULTURE?Like an iceberg, culture is largely invisible. If you ask your nursing or medical staff to describe your hospital’s culture, they’d probably have a hard time. However, it’s likely that everyone in your organization shares an unspoken understanding of the rules and their place in the pecking order.
“Culture represents your organization’s core, its true self.”
It’s expressed continuously by what your people do and say. For this reason, it can’t be faked or changed through directives. It has to be changed through hearts and minds.
CULTURE IS MISSION CRITICALDeveloping and maintaining a positive culture probably isn’t in your job description as a leader. But make no mistake, it’s one of the most important things you can do.
Culture touches everything in your organization. It influences behavior, relationships, decisions and ultimately, effectiveness. A survey of top supply chain executives found that they viewed culture (or lack thereof) as the number one barrier to business success. Culture has elevated many ventures — and crushed many more. On the positive side, the best and the brightest minds compete to work for culture-conscious companies like Google, Twitter, Facebook and even the fully unionized Southwest Airlines. On the negative side, we have the culture of unchecked greed that tanked Enron. Glaring cultural differences made the $35 billion Sprint Nextel merger a disaster.
CULTURE & HEALTHCARELet’s talk about what this all means for hospitals and health systems.
As a vice president and former regional director of CEP America, it’s been enlightening to work with dozens of hospitals over the years.
Very often, when a department is struggling, team members will point out why their department is different. Maybe they’re in a part of the country where recruiting top-notch providers
CULTURE IS TRENDING
You can’t open a magazine or read an article lately without a reference to culture. But what is it, really, and why do organizations need it?
and staff is difficult. Maybe the facilities are outdated, cramped and uncomfortable. Or maybe they have high patient volumes, high acuity or a challenging population.
Granted, these difficulties are real. But I also think these departments are underestimating the role culture plays.
In my day, I’ve seen hospitals with every advantage struggle with staff retention, patient satisfaction and quality. And I’ve seen hospitals with stark disadvantages excel at all of the above.
Performance areas directly impacted by culture include: Patient Satisfaction, Provider Satisfaction, and Medical Staff Alignment.
FEBRuARy 2017 aCeP NOW 29The Official Voice of Emergency Medicine
CLASSIFIEDS
The Emergency Medicine Department at Penn State Health Milton S. Hershey Medical Center seeks energetic, highly motivated and talented physicians to join our Penn State Hershey family. Opportunities exist in both teaching and community hospital sites. This is an excellent opportunity from both an academic and a clinical perspective.
As one of Pennsylvania’s busiest Emergency Departments treating over 75,000 patients annually, Hershey Medical Center is a Magnet® healthcare organization and the only Level 1 Adult and Level 1 Pediatric Trauma Center in PA with state-of-the-art resuscitation/trauma bays, incorporated Pediatric Emergency Department and Observation Unit, along with our Life Lion Flight Critical Care and Ground EMS Division.
We offer salaries commensurate with qualifications, sign-on bonus, relocation assistance, physician incentive program and a CME allowance. Our comprehensive benefit package includes health insurance, education assistance, retirement options, on-campus fitness center, day care, credit union and so much more! For your health, Hershey Medical Center is a smoke-free campus.
Applicants must have graduated from an accredited Emergency Medicine Residency Program and be board eligible or board certified by ABEM or AOBEM. We seek candidates with strong interpersonal skills and the ability to work collaboratively within diverse academic and clinical environments. Observation experience is a plus.
Assistant/Associate Residency Program Director
Emergency Medicine Core Faculty
Pediatric Emergency Medicine Faculty
Community-Based Site Opportunity
The Penn State Health Milton S. Hershey Medical Center is committed to affirmative action, equal opportunity and the diversity of its workforce. Equal
Opportunity Employer – Minorities/Women/Protected Veterans/Disabled.
For additional information, please contact: Susan B. Promes, Professor and Chair, Department of
Emergency Medicine, c/o Heather Peffley, Physician Recruiter, Penn State Hershey Medical Center, Mail Code A590,
P.O. Box 850, 90 Hope Drive, Hershey PA 17033-0850, Email: [email protected] OR apply online at www.pennstatehersheycareers.com/EDPhysicians
30 aCeP NOW FEBRuARy 2017 The Official Voice of Emergency Medicine
CLASSIFIEDS
4/C Process Family–career ad 10.875˝ x 15˝
Family life. Amazing EM career. You can have both.
Founded by ESP, ERGENTUS, APEX, TBEP, MEP, EPPH and EMP
Own your future now. Visit usacs.com or call Darrin Grella at 800-828-0898. [email protected]
US Acute Care Solutions values family, and the diverse ways families are born. As physician owners, we are one family, united in our mission to care for patients and each other. When a clinician in our group decides to have a child by birth or adoption, the rest of us rally around to ensure they receive the time they need to pursue their dream of family, and the support they need to continue excelling in their careers as physicians and leaders. At USACS, we’re living life to the fullest, together.
measure.” Many said that most of the metrics are not under our control. One said that some of the most important things we do in emer-gency medicine—practice compassion and empathy—cannot be measured nor should they be. There are only demerits given for “lost efficiency” when spending time with grieving families. Some of the most important parts of what we do include reassurance for the souls who come to us scared and hurting. It is up to us to advocate for our patients with the admin-istrators and policymakers.
ZDoggMD at LACZDoggMD, an internal medicine physician who is known for music videos, parodies, and comedy sketches about medical issues and working as a physician, is coming to the ACEP Leadership & Advocacy Conference, March 12–15, 2017, in Washington, D.C. He is the only non-emergency physician on EM Docs, voted in by the membership because of his advo-cacy efforts for the practice of medicine. Now he has a better understanding of emergency medicine challenges and he will be meeting us in D.C. to help us advocate for real solutions to the opioid crisis and to discuss social media, resiliency, and how to be a leader in Health 3.0 that we are building together.
Subgroups Since we have a no-advertising and a no-recruiting policy, with only emergency physicians on EM Docs, we have a few free subgroups:
• Doc to Doc Rental and Homes for Sale: (multispecialty) for vacation rentals or when one of our colleagues is relocating.
• Doc to Doc Job Connect: (multispecialty) no recruiters are allowed on this page, but we allow physicians to connect with one another when there is a need to fill a po-sition or when someone is considering a career change.
• EMDOCS Mentoring Medical Students Interested in EM: when they match, they can stay on as mentors and also join the main EM Docs group.
• Physician Entrepreneur: a place where we can support our colleagues who have created a useful tool or service.
• EM Docs Education: where conferences, board review courses, books, and educa-tional opportunities can be announced and discussed.
EMPOWR EventsEM Docs are getting together outdoors through EM Physician Outdoor Wellness for Resil-iency (EMPOWR). Have your local event! Just make it happen and take photos to encourage others to do the same.
EM Docs Meet-ups/EMPOWR eventsAt ACEP16, we met at 6 a.m. for group runs, and we had the outdoor terrace area designated for EM Docs at the Opening Party in Las Vegas.
Plans for face-to-face meet-ups (EMPOWR events) so far in 2017 include:
• March 12–15, 2017: ACEP Leadership & Advocacy Conference meet-ups include a wellness room for 6 a.m. yoga and ballet and group outdoor runs/walks before lec-tures.
• May 16–18, 2017: At Essentials of EM, we will have daily outdoor events specifical-ly for members of EM Docs as well as EM
Docs designated VIP rooms.• Summer 2017 (date TBD): Meet-up in
New Mexico for hiking in the Pecos Wil-derness.
• Nov. 3–5, 2017: Meet-up in Arkansas for a free cattle drive and barbecue at my family ranch.
If you want to be included in the conversa-tion, ask a colleague to add you to the Face-book group—chances are, someone in your department is on EM Docs. Send a private Facebook message to the admin page for EM Docs with proof that you are an emergency physician, for example, a photo of your ID badge or diploma, etc.
EM DOCS | CONTINUED FROM PAGE 31
ZDoggMD will be speaking at this year’s Leadership & Advocacy Conference.
FEBRuARy 2017 aCeP NOW 31The Official Voice of Emergency Medicine
ACEPNOW.COM
Seqirus USA Inc. King of Prussia, Pennsylvania 19406 © 2016 Seqirus USA Inc. September 2016 US/RIV/0816/0069
RAPIVAB™ (peramivir injection), for intravenous useInitial U.S. Approval: 2014
BRIEF SUMMARY OF PRESCRIBING INFORMATIONThese highlights do not include all the information needed to use RAPIVAB safely and effectively. See full prescribing information for RAPIVAB.
----------------------------------INDICATIONS AND USAGE--------------------------------RAPIVAB is an influenza virus neuraminidase inhibitor indicated for the treatment of acute uncomplicated influenza in patients 18 years and older who have been symptomatic for no more than two days.
Limitations of Use:• Efficacy based on clinical trials in which the predominant influenza virus type was
influenza A; a limited number of subjects infected with influenza B virus wereenrolled.
• Consider available information on influenza drug susceptibility patterns andtreatment effects when deciding whether to use.
• Efficacy could not be established in patients with serious influenza requiringhospitalization.
---------------------------------DOSAGE AND ADMINISTRATION------------------------• Administer as a single dose within 2 days of onset of influenza symptoms.• Recommended dose is 600 mg, administered by intravenous infusion for a minimum
of 15 minutes.• Renal Impairment: Recommended dose for patients with creatinine clearance 30-49
mL/min is 200 mg and the recommended dose for patients with creatinine clearance 10-29 mL/min is 100 mg.
• Hemodialysis: Administer after dialysis.• RAPIVAB must be diluted prior to administration.• See the Full Prescribing Information for drug compatibility information.
-------------------------------DOSAGE FORMS AND STRENGTHS------------------------Injection: 200 mg in 20 mL (10 mg/mL) in a single-use vial.
------------------------------------CONTRAINDICATIONS-----------------------------------
--------------------------------WARNINGS AND PRECAUTIONS---------------------------•
•
---------------------------------ADVERSE REACTIONS--------------------------------------Most common adverse reaction (incidence >2%) is diarrhea.
To report SUSPECTED ADVERSE REACTIONS, call 1-844-273-2327 or contact FDA at 1-800-FDA-1088 or www.fda.gov/medwatch
---------------------------------------DRUG INTERACTIONS---------------------------------Live attenuated influenza vaccine (LAIV), intranasal: Avoid use of LAIV within 2 weeks before or 48 hours after administration of RAPIVAB, unless medically indicated.
--------------------------------USE IN SPECIFIC POPULATIONS---------------------------• Pregnancy: Use if benefit outweighs risk.• Nursing mothers: Caution should be exercised when administered to a nursing
woman.Revised: 8/2016
Patients with known serious hypersensitivity or anaphylaxis to peramivir or any component of RAPIVAB.
Cases of anaphylaxis and serious skin/hypersensitivity reactions such as Stevens-Johnson syndrome and erythema multiforme have occurred with RAPIVAB. Discontinue RAPIVAB and initiate appropriate treatment if anaphylaxis or serious skin reaction occurs or is suspected.Neuropsychiatric events: Patients with in�uenza may be at an increased risk of hallucinations, delirium and abnormal behavior early in their illness. Monitor for signs of abnormal behavior.
Important Safety Information Rapivab® (peramivir injection) is indicated for the treatment of acute uncomplicated influenza in patients 18 years and older who have been symptomatic for no more than 2 days.• Efficacy of Rapivab was based on clinical trials in which the predominant influenza
virus type was influenza A; a limited number of subjects infected with influenza B virus were enrolled.
• Influenza viruses change over time. Emergence of resistance substitutions could decrease drug effectiveness. Other factors (for example, changes in viral virulence) might also diminish clinical benefit of antiviral drugs. Prescribers should consider available information on influenza drug susceptibility patterns and treatment effects when deciding whether to use Rapivab.
• Efficacy could not be established in patients with serious influenza requiring hospitalization.
ContraindicationsRapivab is contraindicated in patients with known serious hypersensitivity or anaphylaxis to peramivir or any component of the product. Severe allergic reactions have included anaphylaxis, erythema multiforme, and Stevens-Johnson syndrome.Warnings and Precautions• Rare cases of serious skin reactions, including erythema multiforme, have been reported
with Rapivab in clinical studies and in postmarketing experience. Cases of anaphylaxis and Stevens-Johnson syndrome have been reported in postmarketing experience with Rapivab. Discontinue Rapivab and institute appropriate treatment if anaphylaxis or a serious skin reaction occurs or is suspected. The use of Rapivab is contraindicated in patients with known serious hypersensitivity or anaphylaxis to Rapivab.
• Patients with influenza may be at an increased risk of hallucinations, delirium, and abnormal behavior early in their illness. There have been postmarketing reports (from Japan) of delirium and abnormal behavior leading to injury in patients with influenza who were receiving neuraminidase inhibitors, including Rapivab. Because these events were reported voluntarily during clinical practice, estimates of frequency cannot be made, but they appear to be uncommon. These events were reported primarily among pediatric patients. The contribution of Rapivab to these events has not been established. Patients with influenza should be closely monitored for signs of abnormal behavior.
• Serious bacterial infections may begin with influenza-like symptoms or may coexist with or occur as complications during the course of influenza. Rapivab has not been shown to prevent such complications.
Adverse ReactionsThe most common adverse reaction was diarrhea (8% Rapivab vs 7% placebo).Lab abnormalities (incidence ≥ 2%) occurring more commonly with Rapivab than placebo were elevated ALT 2.5 times the upper limit of normal (3% vs 2%), elevated serum glucose greater than 160 mg/dL (5% vs 3%), elevated CPK at least 6 times the upper limit of normal (4% vs 2%) and neutrophils less than 1.0 x 109/L (8% vs 6%).Concurrent use with Live Attenuated Influenza VaccineAntiviral drugs may inhibit viral replication of a live attenuated influenza vaccine (LAIV). The concurrent use of Rapivab with LAIV intranasal has not been evaluated. Because of the potential for interference between these two products, avoid use of Rapivab within 2 weeks after or 48 hours before administration of LAIV unless medically indicated.
You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.References: 1. Rapivab [package insert]. Durham, NC: BioCryst Pharmaceuticals, Inc; 2014. 2. Kohno S, Kida H, Mizuguchi M, Shimada J; S-021812 Clinical Study Group. Ef� cacy and safety of intravenous peramivir for treatment of seasonal in� uenza virus infection. Antimicrob Agents Chemother. 2010;54(11):4568-4574. doi:10.1128/AAC.00474-10.
RAPIVAB is a registered trademark of BioCryst Pharmaceuticals, Inc. All other trademarks herein are the property of their respective owners.
Seqirus USA Inc. King of Prussia, Pennsylvania 19406 © 2016 Seqirus USA Inc. September 2016 US/RIV/0816/0069
For flu patients in the emergency department who may not be appropriate for oral treatment1,2
Go to www.rapivab.com to learn more and view full Prescribing Information.
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• Only one 15- to 30-minute IV infusion required• Treats acute uncomplicated influenza in patients 18+ who have been
symptomatic for no more than 2 days• Appropriate for many patients, including those who cannot tolerate or may
be noncompliant with oral flu treatment and those requiring IV hydration• Can be used with OTC supportive therapies
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