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by HANS HOUSE, MD, FACEP
It just got easier for emergency physi-cians to obtain medical licenses in
multiple states. For decades, most state medical boards
have tried to improve and simplify their medical licensing process, including de-veloping a universal license application and improving the sharing of information among medical boards. However, the Holy Grail of medical regulation, a portable inter-state license, remained elusive. The barri-ers to this interstate license were numerous. Mostly, medical boards were concerned about losing their autonomy over regulating medicine and supervising the care provid-ed by physicians in their own state. As any-one who has applied to multiple states for licensure can attest, each state has slightly different requirements and processes to-ward granting licensure. A federal medical license covering all the states was not con-
INTERSTATE MEDICAL LICENSURE COMPACT IS LIVEPracticing in multiple states just got easier
TOXICOLOGY Q&A
PRETTY BUT DEADLY
SEE PAGE 9
BREAK ROOM
REMEMBER TO BE GRATEFUL
SEE PAGE 5
STEROIDS FORA SORE THROAT
PEARLS FROM THE MEDICAL LITERATURE
A continuing medical education feature of ACEP Now
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ACEPeCME/ TO COMPLETE THE
ACTIVITY AND EARN FREE AMA PRA
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In addition to our nominal busi-ness of handling true medi-
cal emergencies, typical emergency departments also provide care for many patients with ambulatory med-ical complaints. Whether these pa-tients present due to anxiety over the nature of their condition, to alleviate suffering, or for sheer convenience,
Are we helping or harming with dexamethasone for pharyngitis?
by RYAN PATRICK RADECKI, MD, MS
CONTINUED on page 16
HOOFBEATSMIGHT =ZEBRAS
June 2017 Volume 36 Number 6 FACEBOOK/ACEPFAN TWITTER/ACEPNOW ACePnOW.COM
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PERIODICALCEDR
Leading the Way for EM Quality
SEE PAGE 13
END OF THE RAINBOW
Take Care of Your Heirs
SEE PAGE 17
AHCA UPDATE
How Will AHCA Affect Emergency Medicine?
SEE PAGE 6
EXERTIONAL HEAT STROKE
WHEN THEIR BODY TEMPERATURE RISES TO DANGEROUS LEVELS, IT CAN QUICKLY BECOME A LIFE-THREATENING SITUATION.1
Exertional heat stroke (EHS) is a hyperthermic and hypermetabolic crisis that creates an immediate cascade of CNS and other serious complications. If core body temperatures remain elevated, EHS has been shown to cause long-term neurologic damage and death.1-3
LEARN THE SIGNS. DIAGNOSE IN TIME. VISIT WWW.FIGHTTHEFIREINSIDE.COM
© 2017 Eagle Pharmaceuticals, Inc. All rights reserved. MLR-NON-US-0002 | www.eagleus.com
References: 1. Becker JA, Stewart LK. Heat-related illness. Am Fam Physician. 2011;83(11):1325-1330. 2. Armstrong LE, Casa DJ, Millard- Stafford M, Moran DS, Pyne PW, Roberts WO. Exertional heat illness during training and competition. Med Sci Sports Exerc. 2007;39(3):556-572. 3. Leon LR, Helwig BG. Heat stroke: role of the systemic inflammatory response. J Appl Physiol. 2010;109(6):1980-1988.
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EXERTIONAL HEAT STROKE
WHEN THEIR BODY TEMPERATURE RISES TO DANGEROUS LEVELS, IT CAN QUICKLY BECOME A LIFE-THREATENING SITUATION.1
Exertional heat stroke (EHS) is a hyperthermic and hypermetabolic crisis that creates an immediate cascade of CNS and other serious complications. If core body temperatures remain elevated, EHS has been shown to cause long-term neurologic damage and death.1-3
LEARN THE SIGNS. DIAGNOSE IN TIME. VISIT WWW.FIGHTTHEFIREINSIDE.COM
© 2017 Eagle Pharmaceuticals, Inc. All rights reserved. MLR-NON-US-0002 | www.eagleus.com
References: 1. Becker JA, Stewart LK. Heat-related illness. Am Fam Physician. 2011;83(11):1325-1330. 2. Armstrong LE, Casa DJ, Millard- Stafford M, Moran DS, Pyne PW, Roberts WO. Exertional heat illness during training and competition. Med Sci Sports Exerc. 2007;39(3):556-572. 3. Leon LR, Helwig BG. Heat stroke: role of the systemic inflammatory response. J Appl Physiol. 2010;109(6):1980-1988.
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At its meeting in April, the ACEP Board of Directors was advised by ACEP Coun-
cil Speaker James M. Cusick, MD, FACEP, of the slate of candidates created by the Council Nominating Committee for four available seats on the Board.
The Board of Directors provides day-to-day management and direction to ACEP and serves as its policy-making body. Board members are elected by the ACEP Council and serve three-year terms, with a limit of two consecutive terms. The President-elect also will be chosen by the Council and ultimately serve as ACEP President beginning in October 2018.
For the October 2017 election in Washing-ton, D.C., there are two incumbents and five new candidates on the Board of Directors bal-lot:
• Stephen Anderson, MD, FACEP (in-cumbent, Washington)
• Kathleen Clem, MD, FACEP (AAWEP Section)
• J.T. Finnell, MD, FACEP (Indiana)• Alison Haddock, MD, FACEP (Texas)• Jon Mark Hirshon, MD, FACEP (incum-
bent, Maryland)
• Aisha Liferidge, MD, FACEP (Washing-ton, D.C.)
• Virgil Smaltz, MD, FACEP (New York)Additionally, Carrie de Moor, MD, FACEP
(Freestanding Emergency Centers), has an-nounced her intention to seek nomination from the Council floor for a Board of Directors seat.
For the President-elect position, four cur-rent Board members announced their candi-dacy:
• Vidor Friedman, MD, FACEP• Hans House, MD, FACEP• William Jaquis, MD, FACEP• John Rogers, MD, FACEPCouncil Vice Speaker John McManus, MD,
FACEP (Government Services), is unopposed in his bid for the Council Speaker position. There are three nominees for the Council Vice Speaker position:
• Sabina Braithwaite, MD, FACEP (Mis-souri)
• Andrea Green, MD, FACEP (Texas)• Gary Katz, MD, FACEP (Ohio)
June 2017 Volume 36 Number 6
MEDICAL EDITOR-IN-CHIEF Kevin Klauer, DO, EJD, FACEP
EDITORDawn [email protected]
eDITORIAL STAFF
EXECUTIVE DIRECTORDean Wilkerson, JD, MBA, CAE
ASSOCIATE EXECUTIVE DIRECTOR, MEMBERSHIP AND EDUCATION
DIVISIONRobert Heard, MBA, CAE
DIRECTOR, MEMBER COMMUNICATIONS AND
MARKETING Nancy Calaway, [email protected]
COMMUNICATIONS MANAGERNoa Gavin
ACeP STAFF
PuBLISHInG STAFFEXECUTIVE EDITOR/
PUBLISHERLisa Dionne [email protected]
ASSOCIATE DIRECTOR, ADVERTISING SALES
Steve [email protected]
ADVeRTISInG STAFF
eDITORIAL ADVISORY BOARDJames G. Adams, MD, FACEP
James J. Augustine, MD, FACEPRichard M. Cantor, MD, FACEPL. Anthony Cirillo, MD, FACEPMarco Coppola, DO, FACEP
Jordan Celeste, MDJeremy Samuel Faust, MD, MS, MA
Jonathan M. Glauser, MD, MBA, FACEPMichael A. Granovsky, MD, FACEP
Sarah Hoper, MD, JDLinda L. Lawrence, MD, FACEPFrank LoVecchio, DO, FACEP
Catherine A. Marco, MD, FACEP
Ricardo Martinez, MD, FACEPHoward K. Mell, MD, MPH, FACEP
Mark S. Rosenberg, DO, MBA, FACEPSandra M. Schneider, MD, FACEP
Jeremiah Schuur, MD, MHS, FACEPDavid M. Siegel, MD, JD, FACEP
Michael D. Smith, MD, MBA, FACEPRobert C. Solomon, MD, FACEPAnnalise Sorrentino, MD, FACEP
Jennifer L’Hommedieu Stankus, MD, JDPeter Viccellio, MD, FACEP
Rade B. Vukmir, MD, JD, FACEPScott D. Weingart, MD, FACEP
INFORMATION FOR SUBSCRIBERS
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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NEWS FROM THE COLLEGE
uPDATeS AnD ALeRTS FROM ACeP
ACEP Announces Board, Council Candidates for October 2017 Election
CONTINUED on page 5
4 ACeP NOW JuNE 2017 The Official Voice of Emergency Medicine
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Approved for AMA PRA Category 1 Credit™
Remember to Be Grateful
It was my second shift in the SNICU. She was my third elderly female status post a devastating cerebrovascular accident. My third room overflowing with loved ones, tear-streaked faces, and a palpable fear of the un-known. My third goals-of-care discussion. My words flowed smoother this time as I talked the family through the transition of goals from treatment to comfort. They had reached a “do not resuscitate” decision but were still consid-ering goals of care. Two hours before morning rounds, the patient’s prognosis was confirmed by repeat imaging—cerebral edema and uncal herniation. We revisited her end-of-life wishes and her family requested a transition of goals of care to comfort measures. The third time that shift, I entered comfort care orders.
Two SNICU weeks later, in somewhat of a zombie state, I found it lying open on the ta-ble in our workroom. It was handwritten and addressed to two physicians and two nursing staff. To my surprise, I was one of those physi-cians. My first “thank you” card, from the fam-ily of that patient (see Figure 1). “Thank you for the wonderful care provided. … We greatly ap-preciate your kind and honest interactions with us. We were impressed by the kindness and professionalism of your team.” I felt so good, so satisfied that I met their needs. I was proud that I supported them with a kind and profes-sional demeanor and made a difficult situation a little easier for them. I was grateful for my role as a physician, for my ability to efficiently and effectively connect on a personal level with pa-tients and families in stressful times.
Their expression of gratitude had me re-flecting on my own gratitude and the role it plays in my well-being and experiences as a physician. In our fast-paced emergency med-icine world filled with high rates of burnout, RVUs, and throughput times, we are bombard-ed by patient satisfaction scores—but what about our satisfaction?
Expressions of gratitude offer a path to re-siliency by helping us find reasons to appreci-ate our daily lives and interactions. After this experience, I bought a journal decorated with bees to hold my gratitude list. I named it “Bee Thankful.” When I’m winding down from a shift, I pause and reflect on things from that
day for which I am grateful. I breathe deeply and feel a sense of satisfaction when I write them on the page. My gratitude list reminds me of the positive interactions and opportuni-ties my career offers and provides motivation to start the next day. Our experiences tax us as ever-giving and dedicated physicians, but the simple act of giving thanks can add to our health and vitality. May we all “Bee Thankful” and stay well.
—Alecia Gende, DOIowa City, Iowai
Comments on Censure
I would like to compliment Dr. Sullivan and the Ethics Committee on their censure of Dr. Rosen. I have practiced emergency medicine for 38 years and had one malpractice case early in my career—about 1984. The expert witness arraigned against me was Dr. Rosen. You have no idea how disheartening that was to a young physician starting out. At the time, rumor had it that he commonly did this sort of work. Luckily, my expert was Greg Henry, and it eventually settled out of court. Dr. Rosen‘s deposition against me was very harsh and judgmental.
Thus, I am heartened to hear him finally called on the carpet, albeit 33 years late.
—Richard C. Frederick, MD
Dr. Peter Rosen remains one of the fin-est fathers of emergency medicine, who elevated the profession from the basements of hospitals to full and equal academic stand-ings, has written countless books and publi-cations, and trained hundreds of emergency medicine residents. His legacy will live on forever in the millions of patients he cared for, the patients his residents saved, and the patients that his residents’ residents will con-tinue to care for.
I remember making monthly payments to buy the Rosen textbook when I was a medi-cal student. When I was face-to-face with the legendary man, he insisted on being called Pe-ter. It wasn’t just me. Medical students, nurses, paramedics, and colleagues all call him Pe-ter. Peter is a humble man, lives a modest life, and is one of the most generous people I have ever met. I think he spends half his earnings on buying meals for students, residents, and friends. For a man who is constantly busy with
Inside 16 I PEARLS FROM THE MEDICAL LITERATURE
15 I SPECIAL OPS
20 I CODING WIZARD
17 I END OF THE RAINBOW
THE BREAK ROOMSenD YOuR THOuGHTS AnD COMMenTS TO
MEMBERS IN THE NEWS
Past President Receives Prestigious Surgeon General‘s Award for Military Academic ExcellenceACEP Past President Robert E. Suter, DO, MHA, FACEP, COL, MC, received the prestigious Major General Lewis Aspey Mologne Award recently in a ceremony held in Qatar. The Army surgeon general selected Dr. Suter to receive the award, which recognizes a balance between outstand-ing leadership in military medicine and leader-ship in academics on a national level.
Dr. Suter, who entered the Army in August
1978 on a four-year ROTC scholarship, has served in a variety of positions in the Medical Service Corps. He was elected and served as president of ACEP from 2004 to 2005 and was president of the International Federation for Emergency Medicine in 2006.
He currently is commander of the 3rd Medi-cal Command (Deployment Support) Forward, U.S. Army Central, and also is the Surgeon General‘s Emergency Medicine Consultant (USAR) and a professor of military and emer-gency medicine at Uniformed Services Uni-versity. He also retains a civilian position as professor of emergency medicine at the Uni-versity of Texas Southwestern Medical School in Dallas.
FROM THE COLLEGE | CONTINUED FROM PAGE 4
Dr. Suter (right) receives the Major General Lewis Aspey Mologne Award.
PHOTO: ACEP
Figure 1: A handwritten thank you note ad-dressed to Dr. Gende and colleagues
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JuNE 2017 ACeP NOW 5The Official Voice of Emergency Medicine
ACEPNOW.COM
ACN_0617_0612_0517
Save These DatesACEP’s Upcoming Educational Meetings Fall 2017-Spring 2018
Oct 29 - Nov 1, 2017ACEP17 Scientific AssemblyWashington, DC
acep.org/acep17
January 22-26, 2018Reimbursement & Coding ConferencesOmni Nashville - Nashville, TN
acep.org/rc
March 13-15, 2018Advanced Pediatric Emergency Medicine AssemblyDisney’s Yacht & Beach Club Resort - Lake Buena Vista, FL
acep.org/pem
November 13-17, 2017Emergency Department Directors Academy - Phase IOmni Park West - Dallas, TX
acep.org/edda REGIST
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February 5-9, 2018Emergency Department Directors Academy - Phase IOmni Park West - Dallas, TX
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May 20-23, 2018Leadership & Advocacy ConferenceGrand Hyatt - Washington, DC
acep.org/lac
by ASHLEY BOOTH NORSE, MD, FACEP
The Affordable Care Act (ACA) reform legislation approved by the U.S. House of Representatives on May 4,
2017, by the narrow margin of 217 to 213 is expected to cause millions of Americans to lose their health insurance, make it much easier to eliminate essential health benefits and protections for people with preexisting conditions, and create instability for these protections in employer-sponsored health plans. Accordingly, ACEP’s Public Affairs team, working in conjunction with the Fed-eral Government Affairs Committee and the Board of Directors, has shifted its focus to the Senate, where the fate of the American Health Care Act (AHCA) is much less certain.
Initial reactions by Republican senators have not been favorable to the AHCA, and not surprisingly, Democrats are unified in their opposition. Senate Majority Leader Mitch McConnell (R-KY) has the unenviable task of trying to craft a bill that can only lose the sup-port of two Republicans from within a caucus of varying ideological beliefs about the ACA, its value to Americans, and whether it needs improvement or outright repeal. If Republi-cans fail to produce a plan that can be ap-proved in the Senate and still have enough support to be passed in the House again within the next couple of months, the effort to modify the ACA, at least using the favora-ble procedural rules of budget reconciliation, will likely die.
On May 24, 2017, the Congressional Budg-et Office (CBO) released its updated analysis of the AHCA. According to the CBO estimate, the bill would result in 23 million more un-insured Americans over a decade while re-ducing the national deficit by $119 billion. Medicaid funding would be cut by $834 bil-lion and cover 14 million fewer people. The AHCA repeals $664 billion in taxes and fees that currently finance the ACA. CBO also esti-mates that in states that do waive some of the “essential health benefits,” premiums would be 20 percent lower by 2026.
ACEP’s team has been meeting with key senators as they prepare their alternative to stress the importance of emergency medi-cine as an essential component of the na-tion’s health care system. Our message has been simple:
Any bill the Senate produces must ensure patients have access to lifesaving emergency care.
We want to constructively work with them to produce a bill that is consistent with ACEP’s Emergency Medicine Health Care Re-form Principles (www.acepadvocacy.org/con-tent.aspx?page=Issues).
Americans overwhelmingly (95 percent) say health insurance companies should cov-er emergency medical care, and ACEP agrees with them.
Patients must be able to receive emergency medical care when and where it is needed,
without seeking preauthorization or fearing that their insurance company will only cover services based on the final diagnosis and not the presenting symptoms.
In addition to our direct meetings with lawmakers on Capitol Hill, we have also used opportunities provided by NEMPAC to attend fundraisers, sent action alerts from ACEP members, and facilitated member visits with senators back home to share our vision for health care reform. We further intend to sup-plement these actions through the Leaders Visit program when ACEP President Rebec-ca Parker, MD, FACEP, travels to Washington, D.C., to meet with key senators in June.
On a related matter, the Trump administra-tion, through the Department of Health and Human Services and the Centers for Medicare & Medicaid Services (CMS), has been placing a great deal of emphasis on state Medicaid
waivers. In fact, CMS is actively promoting waivers and has provided guidance to states as to how to go about applying for them. We are working to ensure the federal Prudent Layperson Standard is not eroded through this process and that emergency medicine patients remain protected from predatory practices. Waivers will continue to be the topic of discussion now and for the foresee-able future by ACEP’s Board of Directors, the Federal Government Affairs Committee, the State Legislative/Regulatory Committee, and the Emergency Medicine Action Fund.
DR. NORSE is chair of ACEP’s Federal Government Affairs Committee, associate professor in the department of emergency medicine at the University of Florida College of Medicine–Jacksonville, and medical direc-tor of the Emergency Medicine Clinical Center.
publications, he makes time for a meal or a game of tennis with anyone who shows an in-terest. That’s his soft side. His tough side is a fearless defender of the medical profession and emergency medicine.
I recently visited Peter in his home in Tuc-son, and at the age of 80, his body showed wear and tear with ecchymosis to his ex-tremities from being on blood thinners and a slowed gait after several joint replacements. He noticed that I glanced at the row of medi-cations on his windowsill. “Those are keeping me alive,” he said. When I inquired about his health, he showed off about his doctors. His
urologist was his intern, he trained his cardi-ologist, and he remembers when his ortho-pedic surgeon was in residency. I recall that I also treated Peter when he came to the emer-gency department for an asthma attack. I was a third-year resident and a bit timid to treat my teacher. He said, “I trust you; I trained you well,” and so I did.
Peter no longer sees patients and has not done legal work for several years. But he still reads tens of articles a day from around the world, is the first screening editor for the Journal of Emergency Medicine, continues to write, and still loves teaching. His mind is as sharp as ever.
His residents and I can attest that he did not just teach us the basics of emergency medicine but how to be good human beings and enjoy life as well. He taught us “get your loving at home” when it comes to seeking to be appre-ciated for a great emergency save, “put your brain in neutral and just do the work” when it comes to avoiding laziness; and “learn from other people‘s f*** ups.” Peter is an eloquent speaker and adds “tobacco sauce” to the Eng-lish language.
The recent publications about Dr. Rosen and ACEP by ACEP Now [September 2016] are an unfair representation of who Peter is, what
he means to so many emergency physicians across the country, and how much he has con-tributed to our specialty. He does not deserve the character assassination based on a dis-puted case of a missed pulmonary embolism that occurred 17 years ago. You can argue the significance of the S1Q3T3 ECG pattern back in 2007, which Peter drilled into his residents, but it will not alter the legacy that Peter leaves to this world and our profession. Peter, get your loving at home—and know your students and residents love you, too.
—Roneet Lev, MD, FACEPSan Diego, California
THE BREAK ROOM | CONTINUED FROM PAGE 5
SenateH
ouse
WASHINGTON UPDATE
House passes American Health Care Act — how will it affect emergency medicine?
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6 ACeP NOW JuNE 2017 The Official Voice of Emergency Medicine
THE NATIONALEMERGENCY MEDICINEBOARD REVIEW COURSE
JULY 24-27, 2017PLANET HOLLYWOODLAS VEGAS, NV
AUG. 11-14, 2017RENAISSANCE BALTIMORE HARBORPLACE HOTELBALTIMORE, MD
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Over 1,700 Participants in 2016 (Over 27,000 Since Inception)
The Course That Has Helped Tens of Thousands of Emergency Physicians Ace Their ABEM/AOBEM
Certifying and Recertifying Exams.
If You Don’t Pass, You Don’t Pay! | Content Updated for 2017
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The Center for Emergency Medical Education (CEME) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Center for Emergency Medical Education (CEME) designates this live activity for a maximum of 34.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the
extent of their participation in the activity.
LP FOR THE LANDMARK CHALLENGEDby MARIA E. CRESPO, MPH, DO; AND ROB-
ERT JONES, DO, FACEP
Lumbar puncture is an essential skill for emergen-cy physicians and the gold standard diagnostic procedure allowing for the rapid analysis of
cerebrospinal fluid (CSF) to rule out dangerous condi-tions such as meningitis, subarachnoid hemorrhage, and other neurologic conditions.1 In our busy depart-ments, lumbar puncture failure can be frustrating and time-consuming and cause added stress to clinicians and patients. A successful lumbar puncture demands an intricate knowledge of anatomy, positioning, and technique. Without this experience and knowledge, we are left to rely on anatomical landmarks that can be misleading in more than 30 percent of people re-quiring the procedure. Obesity is a common challenge we face; it makes landmark acquisition and position-ing difficult if not impossible.2 Additional challenges include age-related anatomical changes, such as the calcification of the interspinous ligaments, which can complicate needle insertion, causing deflection of the needle and increased pain.3
As emergency physicians, we have been trained to always have a backup plan and an alternative ap-proach for all procedures. However, if the midline ap-proach fails at a particular level, most physicians will attempt the procedure using the same technique at another level. If this fails, the patient will frequently undergo a fluoroscopically guided or ultrasound-as-sisted lumbar puncture. This is likely because most emergency physicians have not been trained in an alternative approach to the lumbar puncture.
An alternative method to the traditional lumbar puncture is the paramedian approach. Although scarce in the emergency medicine literature, it has been a successful option that has been performed by anesthesiologists for decades. Advantages of this approach include a larger target through the inter-laminar space as well as avoidance of the supras-pinous and interspinous ligaments. The paramedian approach allows for faster catheter insertion, fewer attempts at needle insertion, and a lower incidence of post lumbar puncture headache.4-5 This approach can be performed in the neutral spine position.3 The paramedian approach is associated with fewer tech-nical problems compared to the midline approach, and because it avoids the supraspinous and inters-pinous ligaments, the procedure is less painful and ideal in elderly patients with calcified ligaments. This approach penetrates the ligamentum flavum directly after passing through the paraspinal muscles.6 First-attempt success rates with the paramedian approach have been reported to be 30 percent to 40 percent higher when compared to the midline approach.3
Paramedian Approach Technique1. Prepare your lumbar puncture kit. You will use
the same equipment, positioning, local anesthe-
sia, and sterile technique as you would for the midline approach. A longer spinal needle may be required since you are approaching the subarach-noid space at an angle.
2. The patient can be positioned in the lateral recum-bent or sitting position. Flexing the patient is not necessary using this approach.
3. Identify the L4 spinous process by using the ili-ac crest as a landmark. Identify the caudal tip of the L4 spinous process and move your finger 1 cm inferior and lateral. Needle insertion will be in a cephalad and medial direction, with the needle angled 10°–15° toward the midline and 10°–15° in the cephalad direction. If contact is made with the lamina, the needle should be adjusted in a ceph-alad direction so that you are walking up the bone until you enter the subarachnoid space and obtain the CSF. (See Figures 1 and 2.)Needle path: skin » superficial fascia » fat
» erector spinae muscle » ligamentum flavum » subarachnoid space.
The paramedian approach to the lumbar punc-ture is a great alternative to the traditional midline approach, and it’s ideal for patients who are difficult to position. Advantages are the larger target of the intralaminar space, avoidance of spinous ligaments, and increased first-attempt success. This procedure does have limitations with obese patients in whom landmarks are not identifiable.
References1. Tintanelli JE. Tintanelli’s Emergency Medicine: A Comprehen-
sive Study Guide. 7th ed. New York, NY: McGraw-Hill Education; 2011:1178.
2. Duniec L, Nowakowski P, Kosson D, et al. Anatomical landmarks based assessment of intervertebral space level for lumbar puncture is misleading in more than 30%. Anaesthesiol Intensive Ther. 2013:45(1):1-6.
3. Rabinowitz A, Bourdet B, Minville V, et al. The paramedian tech-nique: a superior initial approach to continuous spinal anesthesia in the elderly. Anesth Analg. 2007;105(6):1855-1857.
4. Leeda M, Stienstra R, Arbous MS, et al. Lumbar epidural catheter insertion: the midline vs. the paramedian approach. Eur J Anaes-thesiol. 2005:22(11):839-842.
5. Blomberg RG, Jaanivald A, Walther S. Advantages of the parame-dian approach for lumbar epidural for lumbar epidural analgesia with catheter technique. A clinical comparison between midline and paramedian approaches. Anaesthesia. 1989;44(9):742-746.
6. Bapat V, Vishwasrao S. Spinal anaesthesia with midline and paramedian technique in elderly patients. Indian J Appl Res. 2015:5:2249-2555.
DR. CRESPO is an emergency physician at MetroHealth Medical Center in Cleveland. DR. JONES is director of the emergency ultrasound and the emergency ultrasound fellowship at MetroHealth Medical Center and associate professor at Case Western Reserve University School of Medicine, both in Cleveland.
Figure 1 (ABOVE): Posterior view of the lumbar spine.
Figure 2 (BELOW): Lateral view of the lumbar spine.
IMAGES COURTESY OF EMSONO (EMSONO.COM)
Paramedian approach for lumbar puncture
8 ACeP NOW JuNE 2017 The Official Voice of Emergency Medicine
Do you know the dangers of this purple flower?by JASON HACK, MD
QUESTIONS: What is the mechanism by which this flower's chemicals exert effects on the heart?
What ECG findings do you see with poisoning from this plant and similar chemicals?
Are there any animals that produce the toxins seen from this plant?
Pretty but Deadly
sidered an option, as the Federation of State Medical Boards (FSMB) upholds the principle of the 10th Amendment as a core principle that any power not specifically granted to the fed-eral government by the Constitution belongs to the states.
In 2014, FSMB members finally agreed on model legislation to create an interstate com-pact for medical licensure. Interstate compacts regarding licenses are very common; these compacts impart reciprocity from one state to another from a license held by the home state’s citizen. The best example with which we are all familiar is a driver’s license. If you hold a license to drive in Iowa, you can legally use that license in any other state. Why not do the same for practicing medicine? Thus far, 20 states have signed on to the interstate medi-cal compact and have been developing their processes for providing expedited licenses to physicians from other compact states (see Fig-ure 1).
As of April 3, 2017, seven states (Alabama, Idaho, Iowa, Kansas, West Virginia, Wiscon-sin, and Wyoming) are ready to issue compact licenses. In fact, the first interstate medi-cal license was issued on April 20, 2017, to a physician from Wisconsin who was seeking a license in Colorado. The 13 other compact states are coming on board soon. Hopefully, more states will pass the compact legislation and join the growing list.
A compact state will grant an expedited li-cense to a physician from another state. This
means that the physician can get an additional license by completing a short form and paying $700 plus the license fees for that new state. The verification of training, background, and board certification will come from the home state without additional work by the appli-cant.
The medical boards at the heart of this compact have some very specific restrictions
to allow the expedited license. The greatest barrier for most applicants is that you must live and practice at least 25 percent of the time in one of the current compact states. In addi-tion, applicants must be residency trained, be board-certified, and have no criminal history or problems with previous medical licenses. For more information or to apply for a compact license, go to www.imlcc.org.
DR. HOUSE is clinical professor of emergency medicine at The University of Iowa in Iowa City.
LICENSURE | CONTINUED FROM PAGE 1
Figure 1: States that have introduced and en-acted compact legislation (as of May 5, 2017).
ANSWERS on page 10
1 © 2016 Federation of State Medical Boards
2017 State Legislative Status (as of 5/5/17)
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TOXICOLOGY Q&A
A continuing medical education feature of ACEP Now
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Toxins/CompoundDigitoxin and digoxin are cardiac glycosides that bind to the sodium-potassium-ATPase channel to slow and strengthen the beating of the heart ultimately by increasing vagal tone (decreased conduction through the sinoatrial [SA] and atrioventricular [AV] nodes) and intra-cellular calcium concentration.
Symptoms » In overdose, the natural toxin causes nausea,
vomiting, weakness, altered mental status, xanthopsia (yellow vision) and seeing halos, cardiac arrhythmias, very slow heart rates, and death.
» Cardioactive glycoside effects on the heart result in a typical pattern called “digeffect.” This consists of a prolonged PR interval, QTc shortening, and a down-ward slurred ST segment called “Salvador Dali’s moustache.”
» The classic cardiac toxicity seen with cardioactive steroid poisoning (eg, digitoxin and digoxin) is a slow rhythm.
» Almost any rhythm can be seen with this poi-soning (atrial fibrillation, atrial flutter, ventricular tachycardia, ectopy, vari-ous blocks, and, of course, the classic ventricular bigeminy), except a rhythm quickly transmitted through the AV node. The cardioactive glycosides cause an electrical separation of the atria from the ventricles.
» Definitive therapy for digoxin toxicity (and other closely relat-ed cardioactive steroid compounds) is administration of digoxin-specific Fab antibodies.
FactsThere are other poisonous plants that produce cardioactive steroid tox-ins. These include oleander (Nerium oleander), yellow oleander (Thevetia peruviana), lily of the valley (Conval-laria majalis), plants in the squill family (Urginea maritima and Urginea indica), and ouabain (Strophanthus gratus).
Some animals produce cardioac-tive steroids that can act like digoxin and cause toxicity. There is a digoxin-like poison in some species of fireflies. It is called lucibufagin and is found primar-ily in the Photinus species. Some toads—cane toad (Rhinella marina) and Colorado river toad (Bufo alvarius)—also produce bufadienolides poisonous to humans. Typically, this occurs from “toad licking” or attempts to use dried secretions in-correctly as a sexual enhancer.
William Withering introduced digi-talis into the Western apothecary in 1785.
Vincent van Gogh’s yellow period may have been influenced by digitalis thera-py, which at the time was thought to control seizures.
Or, it may have been all the ab-sinthe he was drinking.
DR. HACK (Oleander Photography) is an emergency physician and medi-cal toxicologist who enjoys taking photographs of beautiful toxic, medicinal, and benign flowers that he stumbles upon or grows in his
garden. Contact him at [email protected].
Toxicology Q&A AnswersQUESTIONS ON PAGE 9
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Digitalis purpurea
COMMON NAMES: dead man’s
bells, fairy cap, fairy finger, lady’s thimble, lion’s mouth, throatwort, witch’s bells
10 ACeP NOW JuNE 2017 The Official Voice of Emergency Medicine
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TELEMEDICINE COMING SOON TO AN ED NEAR YOU
Telemedicine can be defined as “the remote delivery of health care ser-vices and clinical information using
telecommunications technology.”1 While tel-emedicine has been gaining traction in other medical specialties, namely stroke care and psychiatry, several emergency departments have developed tele-emergency medicine programs and several more have been explor-ing telemedicine options. A systematic review of the tele-emergency medicine literature in 2015 demonstrated three main categories of applied tele-emergency medicine: telemedi-cine for general emergency medicine care (eg, a rural hospital would use a tele-emergency medicine program for consultations on their patients), direct-to-patient urgent care offer-ings, and telemedicine for special patient populations (eg, stroke or trauma care).2 While many in emergency medicine are familiar with telemedicine use with stroke care, this article highlights three current tele-emergency medi-cine offerings in the United States that focus on direct-to-patient care or direct-to-provider consultation.
Direct to PatientNew York-Presbyterian/Weill Cornell Medicine in New York City has implemented the Emer-gency Department Telehealth Express Care Service, a direct-to-patient care telemedicine offering. This program aims to quickly see emergency department patients who would typically be seen in low-acuity areas, thus reducing wait times for all ED patients. The
length of stay for patients treated via the Ex-press Care offering is 35–40 minutes as op-posed 2.5 hours in the emergency department. The program is currently offered at two emer-gency departments, Weill Cornell Medical Center and Lower Manhattan Hospital.
The encounter starts with an in-person tri-age by an ED nurse, followed by a medical screening examination performed by an ED physician assistant or nurse practitioner. The patient is then brought into an examination room with a telehealth video cart (see Figure 1) that is linked to an attending ED physician in an office geographically remote from the emergency department. The patient’s visit finishes with a video consultation and dis-charge by the attending. The Express Care program is staffed by emergency physicians and is available 16 hours per day, seven days a week. These patients are billed as ED visits because they receive a full triage and an in-per-son medical screening examination. Since July 2016, the program has had more than 2,000 visits. Patient experience-of-care scores have been in the 99th percentile, and the patients’ ages have ranged from 18 to 99 years old, with approximately 20 percent of these visits from patients older than 60.
Judd Hollander, MD, professor of emergen-cy medicine and associate dean for strategic health initiatives at Sidney Kimmel Medical College of Thomas Jefferson University in Philadelphia, leads his institution’s telehealth offerings. The overall program has had more than 25,000 visits, including on-demand vid-
eo visits for patients, scheduled video visits, remote second opinions, virtual rounds, and Jefferson Neuroscience Network and remote consults. JeffConnect, its direct-to-patient vid-eo-visit program, is currently the only direct-to-patient on-demand video-visit program from an academic center that has 24-7 staff-ing from physicians in a brick-and-mortar ur-gent care and emergency department. As for telemedicine education, not only does Jeffer-son have a telehealth leadership fellowship, it also incorporates telemedicine into its emer-gency medicine residency training. Its resi-dents work with the telehealth physicians to see ED patients in follow-up using video visits, focusing on both clinical reasoning and com-munication skills.
Direct to ProviderIn 2009, Avera eCARE implemented an emer-gency care telemedicine program with its service line eEmergency. The eEmergency program serves rural clinicians in the upper Midwest and nationally. With a touch of a but-ton, an ED clinician has access to a board-cer-tified emergency physician and an emergency nurse. This program allows peer-to-peer sup-port and consultation, including help with dif-ficult cases such as pediatric trauma, strokes, and cardiac arrest. The cameras enable the eEmergency providers to see and hear the pa-tient at the remote site, and with their periph-erals, the eEmergency providers can view an intubation, including the view from the video laryngoscope. Avera eEmergency covers 150
hospitals in 10 states and has consulted on more than 40,000 patients. The eEmergency program has resulted in an estimated cost sav-ings of $29 million and avoidance of more than 4,000 patient transfers.
The Future of TelemedicineAs Rahul Sharma, MD, MBA, CPE, FACEP, the emergency medicine physician-in-chief at Weill Cornell Medicine, states, “Patients want high-quality, efficient health care, and most emergency departments and health care sys-tems will have no choice but to incorporate tel-emedicine in some aspect of emergency care.”
Barriers, including state licensure, reim-bursement, and credentialing requirements, are actively being reconsidered at the state and federal levels. Research is ongoing regarding the outcomes of telehealth programs in emer-gency medicine. A telehealth program will most likely be coming soon to an emergency department near you.
References1. About telemedicine. American Telemedicine Association
website. Available at: www.americantelemed.org/about/telehealth-faqs-. Accessed May 8, 2017.
2. Ward MM, Jaana M, Natafgi N. Systematic review of telemedicine applications in emergency rooms. Int J Med Inform. 2015;84(9):601-616.
DR. HAYDEN is director of telemedicine in the Department of Emergency Medicine at Massachusetts General Hospital in Boston.
Novel telemedicine applications are improving care for patients and providing support for physicians
by EMILY M. HAYDEN, MD, MHPE
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ACEPNOW.COM
A 40-year-old woman presented to our emergency department complaining of left hemiparesis and headache.
She was awake and oriented, and her vitals were unremarkable except for a blood pres-sure of 180/100 without a history of hyper-tension. Past history and medications were negative. No trauma was reported. The optic nerve sheath diameter (ONSD) was measured and showed increased diameter of 0.47 cm bilaterally, demonstrating increased intrac-ranial pressure (see Figure 1). Her level of consciousness decreased dramatically within 30 minutes, and she developed a right-sided gaze. She was intubated and underwent a brain CT showing intracranial hemorrhage in the right basal ganglia with midline shift and intraventricular hemorrhage (see Figure 2). She received a phenytoin loading dose and was taken emergently to the operating room. Fortunately, she survived with an acceptable neurologic outcome.
ONSD can predict increased intracranial pressure effectively. The exact measurement can be achieved by frequent practice. Thus, this approach is being described as an opera-tor-dependent procedure.
Optic Nerve Sheath DiameterThere is no doubt that ultrasonography is a valuable way to evaluate ONSD to determine intracranial pressure, considering that the brain subarachnoid space is continuous with the optic nerve sheath and the pressure should be transmitted.1–4 However, the way to meas-ure the diameter has yet to be determined. Op-tic nerve color Doppler ultrasonography may clarify this measure and change what was previously approved to evaluate the ONSD. Copetti et al noted that the former measures were not compatible with the real anatomy of the optic nerve and proposed a new measure-ment that seems to be more reliable.1 There are two points to be considered:
1. According to the route of optic nerve ap-proaching the globe, the oblique hy-poechoic shadow running medially represents the exact measure of the optic nerve (see Figure 3).
2. Regarding color Doppler ultrasonography of the central retinal artery, which runs within the dural optic nerve sheath to the globe, the new image compatible with the oblique hypoechoic shadow seems more characteristic of the optic nerve.
PurposeThe evaluation of ONSD via bedside ultra-sonography is beneficial in suspected cases of increased intracranial pressure transmis-sion through the optic nerve, which leads to papilledema.
Applicability There are common situations in which intrac-ranial pressure assessment is necessary, but it is not possible to perform fundoscopy. Some examples include ocular media opacities such as cataract formation, hemorrhage, periorbital swelling (eg, palpebral ecchymosis in trauma patients), fixed gaze, and some infectious res-piratory cases that may impose the risk of res-piratory transmission.
IndicationsBedside ultrasonography can be performed in cases of suspected increased intracranial pressure (eg, traumatic brain injuries, various
types of intracranial hemorrhage, space-occu-pying lesions, etc.).
Scanning ProcedureTo measure the ONSD:
1. Place the patient in the supine position.2. Apply sufficient amount of sterile (prefer-
ably) gel on the closed eyelid.3. Place a 6–12 MHz linear probe on the supe-
rior and lateral aspect of the upper eyelid (see Figure 4).
4. Angle the probe slightly medially and cau-dally until the oblique hypoechoic tract of the optic nerve can be visualized with clear margins posterior to the globe. Doppler ca-
pabilities are helpful in assessing the vas-cularity of the optic nerve (see Figure 3).
5. The diameter should be measured 3 mm behind the retina (see Figure 5).5
6. For a more accurate measurement, calcu-late a mean of three measurements.
PitfallsSome reported measurements indicating an anechoic image behind the retina were prob-ably artifacts of lamina cribrosa, the mesh-like bony structure for optic nerve fibers’ passage through the sclera, mimicking the
EMERGENCY OCULAR US FROM TEHRANINTERNATIONAL INNOVATION: MEASURING OPTIC NERVE SHEATH DIAMETER BY OOMAN HOSSEIN-NEJAD, MD; MARYAM BAHREINI, MD; AND FATEMEH RASOOLI, MD
Figure 1 (TOP LEFT): The optic nerve sheath diameter was measured at 0.47 cm, demonstrating an increased intracranial process in our patient.
Figure 2 (TOP RIGHT): Brain computed tomography showed intracranial hemorrhage of the right basal ganglia as well as an intraventricular hemor-rhage and a significant midline shift.
Figure 3 (MIDDLE LEFT): Ocular ultrasound with a 12 MHz linear probe in a normal subject shows a 35 mm optic nerve diameter, identified with color Doppler.
Figure 4 (MIDDLE RIGHT): Optic nerve ultrasound technique. The probe is directed slightly inferiorly and medially with the eyes closed. For better visualization, place the probe on the superior and lateral margin of the orbit.
Figure 5 (BOTTOM): The optic nerve sheath diameter should be meas-ured 3 mm behind the retina.
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12 ACeP NOW JuNE 2017 The Official Voice of Emergency Medicine
As part of its ongoing commitment to as-sist emergency physicians with pro-
viding the highest quality of emergency care, ACEP developed the Clinical Emergency Data Registry (CEDR). This is the first emergency medicine specialty-wide registry at a national level designed to measure and report health care quality and outcomes. It also provides data to identify practice patterns, trends, and outcomes in emergency care. CEDR is an evolv-ing registry that will support emergency physi-cians’ efforts to improve quality and practice in all types of emergency departments even as practice and payment polices change over the coming years. CEDR has re-qualified as a qualified registry by the Centers for Medicare & Medicaid Services (CMS) for 2017 and is wait-ing for CMS to complete its annual required re-view of its 2017 Qualified Clinical Data Registry (QCDR) application.
Instead of physicians being mired in an alphabet soup of reporting requirements, CEDR allows for single data capture to fulfill the requirements of multiple programs, mak-ing physician quality reporting more efficient. The health care environment is transitioning from volume-based to value-based payment for care. The CEDR registry ensures that emer-gency physicians, rather than other parties (eg, payers), are identifying what practices work best for whom.
CEDR was developed under a sophisticated information technology infrastructure and has been phased in over the past few years in terms of the number of participating emergency de-partments, scope, and functionality. After a modest pilot project in 2015 with 13 emergen-cy departments, CEDR grew in 2016 to more than 60 emergency departments with nearly 3 million patient records represented in the registry. The 2,500 physicians participating in CEDR last year had their quality data success-fully reported to CMS, not only protecting their revenue but providing new insights into the quality of their patient care. Sites participat-ing in CEDR for 2016 received a 1,400 percent return on investment, which is a major success for the program. For 2017, CEDR is anticipating
exponential growth, with data for more than 15,000 providers and 20 million patient visits slated to be reported by CEDR to CMS.
In the background, members of ACEP’s CEDR committee, led by Stephen Epstein, MD, MPP, FACEP, have been building a large set of quality measures and methods to col-lect required data from emergency department patient care records. Dr. Epstein has been the ACEP leader of the development of this registry for seven years.
In addition to Dr. Epstein, more than 100 ACEP members have provided guidance to the construction of CEDR through CEDR sub-committees. The CEDR Committee is work-ing hard to create a robust organizational structure to guide the future of this rapidly growing registry. The four subcommittees (re-search, measures, education, and outreach) have been active in making CEDR a valued partner in physician quality endeavors. High-lights of current subcommittee activities in-clude:
1. Developing a research infrastructure and protocols to allow researchers access to the de-identified CEDR database.
2. Working with the ACEP Quality and Patient Safety Committee, continuing to refine the CEDR measure sets with emergency medicine–relevant report-ing measures that can be used across all payers, one of the major advantages of a QCDR like CEDR in quality reporting to CMS.
3. Implementing Maintenance of Certifica-tion (MOC) Part IV for our ABEM diplo-mates. That’s correct: ABEM diplomates will be able to complete their MOC Part IV requirements right from their CEDR dash-board. Beta testing is scheduled to begin for this feature soon, and it will be ready to roll out in late autumn this year.
The CEDR Committee is supported by the new Quality Division within ACEP, which is developing an array of analog and digital programs to assist ACEP members in their practice.
The CEDR team wishes to thank the ded-
icated support of ACEP members who guide CEDR in providing the highest value of report-ing for all participants in this quality journey. For more information about CEDR, or if you
are interested in participating in the registry, please email [email protected].
DR. GOYAL is associate executive director for quality at ACEP.
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Leading the Way for EM QualityAn update on ACEP’s Clinical Emergency Data Registry
by PAWAN GOYAL, MD
JuNE 2017 ACeP NOW 13The Official Voice of Emergency Medicine
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A ZEBRA IN YOUR ED
Ovarian vein thrombosis is a rare but potentially dangerous diagnosis
by S. TYLER CONSTANTINE, MD
The CaseYou’re getting in that first sip of coffee at 7:05 a.m. as your colleague continues his sign-out. “Room 24 is a 38-year-old healthy
female with right lower quadrant abdominal pain. Pelvic ultrasound was negative. Labs
were normal: no leukocytosis, normal basic metabolic panel and liver function tests. Pregnancy test and urinalysis were negative; she had her tubes tied last year. She’s awaiting a CT to rule out appendicitis,” he says.
“Slam dunk,” you think. Follow up the CT, reassess the patient, and dispo accordingly. No problem!
An hour later, the CT returns: no appendicitis, no in-flammatory changes. As you prepare the discharge, a quick skim of the radiology report reveals, “Long segment of thrombus in the right ovarian vein.”
You reassess the patient, and she is still having pain but is feeling better overall after a tiny dose of morphine. Her abdominal exam is reassuring, and her vitals remain normal. You politely advise her that you will get back to her and her husband shortly with the treatment plan.
What on earth do you do about ovarian vein throm-bosis?
BackgroundIf you haven’t seen a case of ovarian vein thrombosis (OVT), that’s because it is exceedingly rare, especially in its idiopathic form. The diagnosis was first identified in 1956, published in a case report by Austin.1 Our colleagues in obstetrics should recognize this condition more read-ily. They see it in the peripartum period (most commonly postpartum) as well as in patients who have had recent gynecologic (or abdominal) surgery, pelvic inflammato-ry disease, or gynecologic malignancy.2 Outside of these conditions, the diagnosis of OVT is considered idiopathic and tends to be picked up incidentally, as in this case. The exact prevalence of idiopathic OVT is uncertain; it is only reported in case series. In one study, investigators uncov-ered six cases of OVT in the 2.5-year study period. Two of those cases were discovered incidentally.3
PresentationOVT most commonly presents with an acute onset of ab-dominal or flank pain. Literature suggests that the pain will be on the right side 90 percent of the time, theoreti-cally owed to the right ovarian vein following a longer course with incompetent valves.4 This laterality makes the condition a mimicker of more common etiologies such as acute appendicitis, renal colic, pyelonephritis/urinary tract infection, and inflammatory bowel disease.5 In the case of peripartum disease, the patient may frequently present with fever and leukocytosis in a similar manner as endometritis. In postpartum patients, expect a higher
frequency in cesarean section patients (1–2 percent) than in those following vaginal delivery (0.05–0.18 percent).6
DiagnosisOVT is at risk of becoming lost in the long differential di-agnosis for abdominal and flank pain in the emergency department, especially when fever and/or sepsis physiol-ogy are present. Clearly, the emergency physician will be on the lookout for the more common etiologies mentioned above. In this case, the emergency physician was appro-priately suspicious for acute appendicitis. Although not useful in idiopathic cases, which will usually be tricky, a careful history may help elucidate some risk factors. Consider OVT in the recent postpartum patient (although endometritis is far more likely), after recent hysterectomy or other gynecologic surgery, or when there is a concern for undiagnosed malignancy. Physical exam findings may reveal fever, tachycardia, abdominal tenderness, and signs of peritonitis, all of which are nonspecific for this condi-tion. A detailed pelvic examination may reveal findings of pelvic inflammatory disease, which may be the cause of OVT, as well as adnexal mass.
The emergency physician may be unlikely to diagnose OVT based on the history and physical examination alone. Fortunately, contrast-enhanced CT scanning of the abdo-men and pelvis provides excellent sensitivity (100 percent) and specificity (99 percent) for the condition.7 It may also be diagnosed on MRI or with pelvic ultrasound but with markedly decreased sensitivity. In this case, pelvic ultra-sound with Doppler did not detect OVT or any signs of ovarian vascular congestion or enlargement.
ManagementWhen the patient with OVT presents in overt sepsis, empir-ic antibiotics, fluids, labs, and appropriate cultures are the mainstay as well as cross-sectional imaging to rule out vari-ous causes of intraabdominal pathology. When OVT is de-tected in this fashion, inpatient management should also include systemic anticoagulation, typically with heparin.
There are no standard or specialty society guidelines for the management of these patients as data are limit-ed. There is a theoretical risk that the patient will develop signs of sepsis, but perhaps the most worrisome compli-cations are inferior vena cava extension and subsequent embolization (ie, pulmonary embolism). Estimates (from all causes of OVT) put the risk for pulmonary embolism at an alarming 25 percent, with an associated mortality of 4 percent.7 Clearly, this suggests a need for anticoagulation to help reduce this risk. Historically, systemic anticoagula-tion has been initiated with heparin, followed by bridging to warfarin until a therapeutic international normalized ratio is achieved.7 The increasing popularity of direct oral anticoagulants offers a potentially useful alternative. How-
ever, the efficacy of these drugs for the treatment of OVT has not been studied.
Disposition for these patients will likely depend on pa-tients’ presentation, laboratory and imaging results, symp-tom control, and provider discretion. Patients with sepsis physiology will require admission and gynecological or surgical evaluation. In patients with an incidental find-ing whose symptoms are controlled and have a reassuring workup, disposition may depend on the anticoagulation plan and ability to secure follow-up and outpatient referral.
Expert consultation for nonsurgical patients may pose a challenge. Recently delivered patients should be evaluated by their obstetrician. However, in non-peripartum patients without acute gynecologic pathology, a gynecologist may or may not manage the condition. Patients will likely require hematology referral or evaluation for consideration of an underlying hypercoagulable state and to both monitor and determine the duration of anticoagulation.
Case ResolutionThe patient’s pain continues to improve with oral acetami-nophen. Given her normal vital signs, labs, and otherwise benign CT scan as well as established outpatient follow-up, you make a shared decision with the patient and her husband to manage her OVT in the outpatient setting us-ing a direct oral anticoagulant. You consult hematology over the phone, screen the patient for her bleeding risk on anticoagulation, and provide relevant education. The pharmacy helps start the patient on a 30-day starter kit of rivaroxaban, and you reinforce the importance of early follow-up and to return for worsening symptoms. The pa-tient will see her primary care doctor in one week, with subsequent hematology referral.
References1. Austin OG. Massive thrombophlebitis of the ovarian veins; a case report.
Am J Obstet Gynecol. 1956;72(2):428-429.2. Harris K, Mehta S, Iskhakov E, et al. Ovarian vein thrombosis in the
nonpregnant woman: an overlooked diagnosis. Ther Adv Hematol. 2012;3(5):325-328.
3. Quane LK, Kidney DD, Cohen AJ. Unusual causes of ovarian vein thrombosis as revealed by CT and sonography. AJR Am J Roentgenol. 1998;171(2):487-490.
4. Ortín X, Ugarriza A, Espax RM, et al. Postpartum ovarian vein thrombosis. Thromb Haemost. 2005;93(5):1004-1005.
5. Prieto-Nieto MI, Perez-Robledo JP, Rodriguez-Montes JA, et al. Acute appendicitis-like symptoms as initial presentation of ovarian vein thrombo-sis. Ann Vasc Surg. 2004;18(4):481-483.
6. Heavrin BS, Wrenn K. Ovarian vein thrombosis: a rare cause of abdominal pain outside the peripartum period. J Emerg Med. 2008;34(1):67-69.
7. Kodali N, Veytsman I, Martyr S, et al. Diagnosis and management of ovar-ian vein thrombosis in a healthy individual: a case report and a literature review. J Thromb Haemost. 2017;15(2):242-245.
DR. CONSTANTINE is an EMS fellow and junior faculty at Carolinas Medical Center in Charlotte.
14 ACeP NOW JuNE 2017 The Official Voice of Emergency Medicine
The Maine ThingPatient flow improvements can increase efficiency even in small emergency departments by SHARI J. WELCH, MD, FACEP
The emergency department at Houlton Regional Hospital (HRH) in Houlton, Maine, wanted to take its operational
performance to the next level. This Critical Ac-cess Hospital (CAH) seeing 11,000 visits a year struggled with patient surges. As is the case in many CAHs, HRH was challenged with recruit-ing new physicians, especially hospitalists, who are so critical to ED flow. (Approximately 25 percent of Americans choose to live in ru-ral areas, while only 10 percent of physicians choose to practice there.) Further, the emer-gency department has only single coverage, and was easily overwhelmed by one critically ill patient. Finally, HRH struggled to manage the behavioral health burden in its nine-bed emergency department.
CEO Tom Moakler, ED Medical Director Bri-an Griffin, and Nursing Director Tricia Murray wanted to re-engineer patient flow in their de-partment during peak flow times to improve efficiency. They began with an ambitious change package:
• Redesign intake• Repurpose triage as a rapid treatment
unit (RTU) (low-acuity service line)• Re-engineer patient flow for high-flow/
low-flow times of the day• Develop a night plan with the hospitalists
Redesign IntakeThe emergency department had continued to use traditional nurse triage and booth registra-tion, followed by traditional ED patient flow. This did not serve it well during peak arrival times. The leadership did a number of things that help expedite intake and patient care in the single-covered emergency department.1 Traditional triage was replaced with an ab-breviated triage and a “pull-to-full” model to bring the patients, provider, nurses, and reg-istration to the bedside.2 This takes all of the steps of intake and conducts them in parallel instead of in series, which is inarguably more efficient.
Repurpose Triage as an RTUThe former triage area is now the RTU area, which serves as a place to care for low-acuity patients rather than placing them in a tradi-tional bed. In the old flow model, low-acuity patients often suffered long waits and delays because no resources were dedicated to them. This new low-acuity zone cannot support its own provider, but it can have nurses and staff dedicated to the rapid processing of patients. In addition, nurses are empowered to begin standardized, chief complaint–driven order sets. This has long been recognized as a best practice, particularly in single-coverage de-partments, so that patients are always mov-ing along their patient flow journey.
Re-Engineer Flow for High Flow and Low FlowThe leadership also articulated a process for times of the day when all nine beds are full (high flow).3 During these times, the provider sees new patients in the RTU (one specified chair) until beds are available. Diagnostic test-ing is started, and patients are managed in the waiting room until treatment spaces open up. Emergency Severity Index 1 and 2 patients are accommodated in the main emergency depart-ment by moving less-acute patients out.
Develop a Night Plan with the HospitalistsFinally, like many rural hospitals, the depart-ment struggled with on-call coverage at night. The heavy lifting was being done by the hospi-talists, who admitted the majority of patients. However, the hospitalists were working seven days straight and were wearing out quickly. The hospitalists needed to have a few hours on the night shift to get sleep, but the emergency department wanted to get its patients bedded down on the inpatient units. The solution was the implementation of “holding orders,” also known as “bridge orders” or “timed-out or-ders.”4
The before and after data in Table 1 are very impressive.
Hats off to the Houlton Regional leaders. When you think you can’t take your emergen-cy department to the next level of operation-al performance, just remember "The Maine Thing."
References1. Welch S, Davidson S. Exploring new intake models
for the emergency department. Am J Med Qual. 2010;25(3):172-180.
2. Augustine J. 'Pull to full' speeds up flow. ED Manag. 2011;23(3):30-31.
3. Welch S, Savitz L. Exploring strategies to improve emergency department intake. J Emerg Med, 2012;43(1):149-158.
4. Traub SJ, Temkit M, Saghafian S. Emergency depart-ment holding orders. J Emerg Med. 2017; pii: S0736-4679(17)30110-5.
Table 1: Houlton Regional Hospital Metrics Before and After Implementing Patient Flow Changes in November 2016
2016DOOR TO DOCTOR
TIME (Minutes)OVERALL LENGTH OF STAY (Hours)
LENGTH OF STAY, ADMITTED (Hours) ELOPEMENT %
NUMBER OF VISITS
August 44 3.6 5.9 3.3 923
September 43 3.3 5.2 3.4 888
October 45 3.5 5.3 2.8 858
November 31 2.7 5.1 1.2 819
December 32 2.8 5.0 0.5 807
2017
January 31 2.9 6.6 1.3 850
February 33 2.5 6.1 1.9 765
March 29 2.6 5.9 1.4 915
ABOVE: CEO Tom Moakler, ED Medical Director Brian Griffin, and Nursing Director Tricia Murray (left to right).
BELOW: Houlton Regional Hospital’s rapid treatment unit area serves as a place to care for low-acuity patients.
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JuNE 2017 ACeP NOW 15The Official Voice of Emergency Medicine
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
these non-emergencies may prove just as chal-lenging. Acute pharyngitis, for example, rep-resents more than 1 million visits annually to US emergency departments. This presenting complaint rarely requires or benefits from an-tibiotics, yet the desire to provide our patients with at least some token of relief is frequently strong enough to overcome the rationality of antibiotic stewardship. Estimated appropriate prescribing rates for pharyngitis, accounting for group A strep prevalence, are 10 percent to 20 percent, but antibiotics are prescribed in roughly 60 percent of cases.1
What alternative might we have to our ill-conceived antibiotic prescriptions? How about systemic steroids?
It follows logically that if pharyngitis is as-sociated with inflammation of the pharynx, perhaps strong anti-inflammatory immu-noregulation might prove beneficial. We have seen our otolaryngology colleagues prescribe steroids postoperatively for edema and pain. Should we use them for uncomplicated phar-yngitis in our ambulatory population?
Examining Steroid Use for Sore Throats In fact, it’s a little facetious to even ask such
questions, considering many physicians al-ready routinely incorporate consideration for oral steroids into their treatment options for pharyngitis. Most frequently, these are given as a one-time dose, either oral or intramus-cularly, of dexamethasone or prednisone. However, for such a common treatment, the evidence is weaker than one may expect.
The largest examination of systemic ster-oids for acute pharyngitis comes in the form of a Cochrane Review.2 Unfortunately, despite be-ing the largest review, the evidence base con-sists of a mere eight studies and 743 patients. These studies include patients from all over the globe; evaluate varying doses, types, and routes of steroids; mostly include adjuvant antibiotics; and measure all manner of dif-fering outcomes. Despite the mostly consist-ent results favoring steroids, the only reliable conclusion is the need for a more robust trial.
This leads us to the 2017 publication in JAMA of the Treatment Options without An-tibiotics for Sore Throat (TOAST) trial.3 This trial randomized 565 patients with acute sore throat to either 10 of oral dexamethasone or identical placebo. Patients were eligible for en-rollment provided clinicians did not prescribe immediate antibiotics, but clinicians were al-lowed to provide antibiotics for delayed use if symptoms did not improve.
A long story made short, this is a negative trial. There was no statistically significant dif-ference in complete symptom resolution at the 24-hour primary outcome. The difference be-tween groups, 22.6 percent resolution in the dexamethasone group versus 17.7 percent reso-lution in placebo, was much smaller than ex-pected based on the results from prior trials in which nearly three times as many patients in the dexamethasone group experienced symp-tomatic relief.
No long story can truly be made short. An-ecdotally, most clinicians reading these data found they reinforced their preexisting opin-ion, whether they felt steroids were beneficial or not. For those clinicians who have been us-ing dexamethasone with positive effects in their practice, these data are viewed through the lens of their experience and the prior re-search. In this view, the statistically negative result is a feature of inadequate sample size,
and all the secondary outcomes consistently tilt toward dexamethasone. Symptom relief at 48 hours favored dexamethasone by 8.7 percent, a number needed to treat of 12, and almost all the quality-of-life and resource uti-lization outcomes likewise show small benefi-cial effects.
Oral dexamethasone is universally inex-pensive, and the preponderance of evidence suggests it’s helpful, so why is this poten-tially controversial? Why were any clinicians taking the opposing viewpoint that this treat-ment should not be routinely adopted? This is likely because the intervention has likely been downgraded from “harmless” to “most-ly harmless.”
The Risks of SteroidsIn certain patients, the deleterious effects of systemic steroids are obvious and avoidable. However, we expect most healthy young pa-tients to tolerate short low-dose courses of steroids without ill effects. A recent publica-tion in BMJ, unfortunately, suggests serious adverse outcomes are substantially more com-mon from steroid exposures.4
These authors reviewed a commercial in-
surance database and a final cohort of more than 1.5 million patients to examine for associ-ations between short-course steroid exposure and sepsis, venous thromboembolism, and fractures. As compared with patients without exposure to steroids, patients prescribed ster-oids had roughly double the risk for sepsis, a 60 percent increase for venous thromboembo-lism, and a 25 percent increase for fractures in the five- to 90-day period following exposure. The numbers needed to harm for each of these conditions range from approximately 3,000 for sepsis to 800 for fractures. The harms were not equally distributed across ages, with lower risks for younger patients and increased risks for those older. However, the risks remained substantially increased. These increases in ad-verse events also held true for short courses and low doses of steroids.
So where does that leave us? Steroids prob-ably do provide some benefit in symptomatic relief of pain from acute pharyngitis but not to the magnitude reflected in earlier trials. At the same time, this treatment is probably not quite as risk-free as previously thought. Ideally, evi-dence from trials would be robust enough to show signals of which patients were more like-
ly to benefit from steroids, but with just a few hundred in each treatment group, nothing re-liable can be gleaned. Ultimately, we will have to wade into a realm of some uncertainty and make individualized assessments of the value of potential benefit as well as of the likelihood of benefit and rare but important harms.
References1. Barnett ML, Linder JA. Antibiotic prescribing to adults
with sore throat in the United States, 1997-2010. JAMA Intern Med. 2014;174(1):138-140.
2. Hayward G, Thompson MJ, Perera R, et al. Corticoster-oids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev. 2012;10:CD008268.
3. Hayward GN, Hay AD, Moore MV, et al. Effect of oral dexamethasone without immediate antibiotics vs placebo on acute sore throat in adults: a randomized clinical trial. JAMA. 2017;317(15):1535-1543.
4. Waljee AK, Rogers MA, Lin P, et al. Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. BMJ. 2017;357:j1415.
DR. RADECKI is assistant professor of emergency med-icine at The University of Texas Medical School at Houston. He blogs at Emergency Medicine
Literature of Note (emlitofnote.com) and can be found on Twitter @emlitofnote.
PEARLS | CONTINUED FROM PAGE 1
Steroids probably do provide some benefit in symptomatic relief of pain from acute pharyngitis but not to the magnitude reflected in earlier trials. At the same time, this treatment is probably not quite as risk-free as previously thought.
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Acute pharyngitis in an adult patient, showing reddening and inflammation of the pharynx.
16 ACeP NOW JuNE 2017 The Official Voice of Emergency Medicine
Take Care of Your HeirsWhat you need to know about estate planning by JAMES M. DAHLE, MD, FACEP
Q. What do I need to know about estate plan-ning before I meet with an estate planning attor-ney?
A. Estate planning is a chore that most of us put off whenever possible. Not only do physicians usually find it uninteresting, expensive, and even worse, it can force us to face our own mor-tality. However, it is an important aspect of financial planning and, when done poorly (or not at all), can really cause a mess for heirs.
There are three purposes to estate planning:• Ensure our minor children, our things, and our money go
where we wish them to go at the time of our death. • Minimize the amount of our assets that have to pass
through the expensive, time-consuming, and public pro-cess of probate.
• For a select few, estate planning is also done to minimize the amount of estate and inheritance taxes paid at the time of death.
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.
CONTINUED on page 18 PH
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JuNE 2017 ACeP NOW 17The Official Voice of Emergency Medicine
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Badar Afzal Kkhan, MD - Karachi, Pakistan
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Minor ChildrenWhile it can be frowned upon to try to rule the lives of your heirs from the grave, one time when everyone agrees it would be wise to pro-vide some direction is when you have minor children. The most important function of a will is to name the person (guardian) who will take care of your children in the event of your death. Your will should also name the person who will manage your assets (including life insurance benefits) on their behalf. While this can be the same person, naming a different person allows you to draw on the talents of dif-ferent family members or friends and provides some checks and balances.
Assets and ProbateAnother function of a will is to determine who gets your stuff and your money when you die. If you die “intestate” (ie, without a will), the probate judge will follow the laws of your par-ticular state to determine who inherits your es-tate. Basically, if you don’t have a will, the state will make one for you. Typical intestate rules indicate that your spouse has first claim on your assets, then your descendants, followed by your parents, and then your siblings. How-ever, each state has slightly different rules, and you should read them before deciding whether they are in line with your wishes. If they are not, then even if you have no minor children, you need a will. If your family, de-sires, and financial situation are very simple, you may be just fine with an inexpensive will purchased through an online service. As your assets grow or your family situation becomes more complicated, a consultation with a quali-fied estate planning attorney becomes more and more valuable.
The process of probate involves a judge reading the will (or following intestate laws in the absence of a will) and determining who gets what. This process is public, which re-veals to the world what you owned. It can also be expensive, costing as much as 15 percent of the value of the estate! Finally, it can be time-consuming. It might take a year or more for your heirs to receive what is coming to them.
TrustsAn important aspect of estate planning is minimizing how much of your assets must go through probate. This is primarily accom-plished through beneficiary designations and secondarily through revocable trusts. Retire-ment accounts, life insurance policies, an-nuities, and many other types of financial accounts allow you to name beneficiaries. All of those assets pass outside of the probate pro-cess quickly, inexpensively, and without pub-lic knowledge. Payable-on-death accounts at a bank may also allow you to have additional FDIC coverage on your assets.
Revocable trusts are trusts that are used to pass assets outside of the probate process. Many wealthy people, particularly elderly ones, have their homes, vehicles, and even financial accounts owned by their revocable trust. Since it is revocable, they have full ac-cess to the assets at all times and can remove them from the trust if needed. But when they die, the assets are passed in accordance with the terms of the trust.
TaxesA lot of doctors worry about the “death tax” (ie, estate and inheritance taxes). However,
the truth is that under current law, few phy-sicians will have to worry about estate tax-es. They simply do not earn enough, save enough, or invest well enough to build their estate to an amount greater than the federal exemption amount. In 2017, the federal ex-emption before the estate tax applies is $5.49 million. As long as the total value of your es-tate is below that amount at your death, you will not owe any federal estate tax. The ex-emption amount is doubled if you are mar-ried. The exemption amount is also indexed to inflation under current law, so it should double every 20 years or so. Unfortunately, some states have their own estate tax and often with a lower exemption amount than the federal law. These states include Con-necticut, Delaware, Hawaii, Illinois, Iowa, Kentucky, Maine, Maryland, Massachusetts, Minnesota, Nebraska, New Jersey, New York, Oregon, Pennsylvania, Rhode Island, Ver-mont, Washington, and the District of Co-lumbia. Maine, Massachusetts, New Jersey, Oregon, and the District of Columbia have particularly low exemption amounts ($1 mil-lion or less).
If you are fortunate enough to have a fed-eral estate tax problem or unfortunate enough to live in a state with a low exemption amount, it may be worthwhile to address this with some formal estate planning. The main strategy is to give away amounts above the estate tax ex-emption limit prior to death.
This can be done directly by giving away up to $14,000 per year ($28,000 if you are married) to anyone you like without using any of your estate tax exemption. This is a great way to decrease the size of your estate to an amount below the exemption limit. If you have three married children, each with three married children, that’s 24 people you, together with your spouse, can give $28,000 per year to ($672,000 total) without any estate (gift) tax implications. You can also give mon-ey to charities through various structures that may also provide you substantial income tax deductions. If you are not comfortable giv-ing assets to your heirs at this time, you can use an irrevocable trust. The money is then out of your estate but can only be used by heirs in accordance with the rules of the trust. If you expect to owe estate taxes at death, a consultation with a competent estate plan-ning attorney in your state could be worth hundreds of thousands or even millions of dollars to you.
Be aware that some methods of simplify-ing your estate planning can have unforeseen consequences. For example, placing your chil-dren’s name on the title of your investment account or home can keep those assets from passing through probate. However, they may also cause the heir to owe a lot more in capital gains taxes than they otherwise would due to the loss of the step up in basis at death.
Estate planning is a process whereby you can ensure your wishes are met, probate is avoided, and estate taxes are minimized. Phy-sicians need a will in place as soon as they have children or begin to acquire significant assets. Most will also benefit from scheduling a visit with an estate planning attorney by the time they reach mid-career.
END OF THE RAINBOW | CONTINUED FROM PAGE 17
18 ACeP NOW JuNE 2017 The Official Voice of Emergency Medicine
CLASSIFIEDS
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, 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
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optic nerve route, which does not follow the vascular pattern of the central retinal artery on color Doppler.1
Another pitfall is measuring the ill-defined non-clear shadow, probably the previously discussed shadow superimposed on the real ONSD. This can be prevented by carefully an-gulating the transducer medially and caudally to visualize the oblique ONSD with clear mar-gins.
ONSD measurement with this method has yet to be determined in settings such as various races, different disease acuities, eye angulations, etc. Some researchers defined
various measures for the ONSD. The median
normal and elevated ONSD was measured at
0.42 cm (IQR 0.37–0.48 cm) in accordance
with the median invasive intracranial pres-
sure measurement that was 12 mm Hg (IQR
9–19 mmHg) and ≥ 0.48 cm for the intracra-
nial pressures > 20 mmHg, respectively.5 The
median intracranial pressure was measured
by intraparenchymal external ventricular
catheters. However, getting the view of the
oblique hypoechoic tract of the optic nerve
provides lower normal measures, around 0.35
cm, that need to be validated.
References1. Copetti R, Cattarossi L. Optic nerve ultrasound:
artifacts and real images. Intensive Care Med. 2009;35(8):1488-1489.
2. Aduayi OS, Asaleye CM, Adetiloye VA, et al. Optic nerve sonography: a noninvasive means of detecting raised intracranial pressure in a resource-limited setting. J Neurosci Rural Pract. 2015;6(4):563-567.
3. Ochoa-Pérez L, Cardozo-Ocampo A. Ultrasound ap-plications in the central nervous system for neuroanaes-thesia and neurocritical care. Colombian J Anesthesiol. 2015;43(4):314-320.
4. Dubourg J, Javouhey E, Geeraerts T, et al. Ultrasonog-raphy of optic nerve sheath diameter for detection of raised intracranial pressure: a systematic review and meta-analysis. Intensive Care Med. 2011;37(7):1059-1068.
5. Rajajee V, Vanaman M, Fletcher JJ, et al. Optic nerve ultrasound for the detection of raised intracranial pres-sure. Neurocrit Care. 2011;15(3):506-515.
DR. HOSSEIN-NEJAD is assistant professor of emer-gency medicine at the Imam Khomeini Hospital of Tehran University of Medical Sciences in Tehran, Iran.
DR. BAHREINI and DR. RASOOLI are assistant profes-sors of emergen-cy medicine at
the Sina Hospital of Tehran University of Medical Sciences.
US OPTIC NERVE | CONTINUED FROM PAGE 12
JuNE 2017 ACeP NOW 19The Official Voice of Emergency Medicine
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Palms West Hospital (West Palm Beach) JFK North (West Palm Beach)GEORGIACartersville Medical Center (Cartersville) Newton Medical Center (Covington) Habersham Medical Center (Demorest) Fairview Park (Dublin) Piedmont Fayette Hospital (Fayetteville) Coliseum Medical Center (Macon) Eastside Medical Center - South Campus (Snellville) Memorial Satilla Health (Waycross) INDIANA Terre Haute Regional Hospital (Terre Haute) KANSASMenorah Medical Center (Overland Park) Overland Park Regional Medical Center (Overland Park) KENTUCKYGreenview Regional (Bowling Green) TJ Health Cave City Clinic (Cave City) Frankfort Regional (Frankfort) Pavilion Urgent Care Clinic (Glasgow) TJ Samson Community Hospital(Glasgow) Murray-Calloway County Hospital (Murray) LOUISIANACHRISTUS 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 (Independence)Research Medical Center Brookside (Kansas City)Liberty Hospital (Liberty)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) 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 Southeast Texas Outpatient Center - Mid County (Port Arthur) CHRISTUS Alon/Creekside FSED (San Antonio) Methodist Texan (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) VIRGINIA Spotsylvania Regional Medical Center (Fredericksburg)
LEADERSHIP OPPORTUNITIESGreenview Regional (Bowling Green) Oak Hill Hospital (Brooksville) Golden Valley Memorial Hospital Clinton, MO) Northwest Medical Center (Ft. Lauderdale, FL) Assistant Medical Director CHRISTUS Jasper Memorial Hospital (Jasper, TX) Coliseum Medical Center (Macon, GA) EM Residency Program Director Aventura Hospital and Medical Center (Miami) HealthOne Emergency Care Fairmont (Pasadena, TX) Brandon Regional Hospital (Tampa Bay, FL) Assistant Medical DirectorBrandon Regional Hospital (Tampa Bay, FL) EM Residency Program Director Citrus Park ER (Tampa Bay, FL) Assistant Medical Director
Medical Center of Trinity (Tampa Bay, FL) Assistant Medical DirectorTerre Haute Regional(Terre Haute, IN) Mayo Clinic at Waycross (Waycross, GA) PEDIATRIC EM OPPORTUNITIESBroward Health Children’s Hospital (Ft. Lauderdale, FL) Northwest Medical Center (Ft. Lauderdale) Plantation General Hospital (Ft. Lauderdale, FL) Clear Lake Regional Medical Center (Houston, TX)Coliseum Medical Center(Macon, GA) Kingwood Medical Center(Kingwood, TX) Centennial Medical Center(Nashville, TN)Gulf Coast Medical Center(Panama City, FL) Overland Park Regional Medical Center (Overland Park, KS) Brandon Regional Hospital (Tampa Bay, FL) Mease Countryside Hospital (Tampa Bay, FL) The Children’s Hospital at Palms West (West Palm Beach, FL)
FULL-TIME,PART- TIME,
PER DIEMAND TRAVEL
OPPORTUNITIES!
Ask about our referral bonus program. Refer a provider.
Receive a bonus!It’s that simple.
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.
IN-HOUSE EMERGENCIESby BETTY ANN PRICE, BSN, RN
Question: What do I need to know about billing for a consultation on an in-house emergency?
Answer: When you are called to the floor for a code or other emergency, remember to document each of the procedures performed and the services you provide. You may be able to bill for an initial consult if your expertise is required beyond that of the attending service and the attending or other designee has requested your exper-
tise. Be sure to document the name of the person who requested your consulta-tion. A written order for your consult is required. It is important to know whether the patient status is inpatient or outpatient (eg, observation). Alternatively, more than 30 minutes of time may support critical care when the time claimed is exclusive of separately billable procedures. Otherwise, you may be able to code for subsequent inpatient hospital care, which may be contingent upon whether you are credentialed with admitting privileges. Include in your note participation in CPR, endotracheal intu-bation, arterial/central venous/intraosseous line insertions, paracentesis, chest tube thoracostomy, etc. Peripheral IV insertion requiring physician skill might be captured with documented medical necessity (eg, multiple unsuccessful attempts by nursing staff). Brought to you by the ACEP Coding and Nomenclature Committee.
Ms. Price s president and CEO of Professional Reimbursement & Coding Strategies, Inc., and a member of ACEP’s Coding & Nomenclature Advisory Committee.
nAVIGATe THe CPT MAZe,
OPTIMIZInG YOuR
ReIMBuRSeMenT
CODING WIZARD
20 ACeP NOW JuNE 2017 The Official Voice of Emergency Medicine
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Page 2 of 2
Davis Advertising Inc.Phone: 610-227-0400
Confirmations:Phone: 610-227-0400
E-mail: [email protected]
Insertion Order #: 903998This is a classified display advertisement.
The image shown below is scaled to fit this space and is provided for reference only.The production version of this advertisement is included in a separate attachment.
Einstein Healthcare Network (EHN) in Philadelphia is seeking full-time, board-certified/board-eligible physicians to join our growing regional Emergency Medicine program. We are looking for:
• Attending Physicians
• Associate Residency Program Director
• Medical Student Clerkship Director
• Faculty in the Division of EMS
• Faculty in the Division ofUltrasonography
Our EM department covers Einstein Medical Center Philadelphia, Einstein Medical Center Elkins Park and Einstein Medical Center Montgomery with over 40 board-certified faculty and over 20 Physician Assistants. EHN has the region’s largest Emergency Medicine Residency Program and is dually accredited by the ACGME-RRC and AOA.
The successful candidate would be interested in joining a lively, energetic and committed group of ED physicians providing quality emergency care to our patients and solid
evidence-based education to our residents, medical students and PA trainees. We welcome ED physicians interested in being involved in all aspects of Emergency Medicine, including trauma, pediatric care, toxicology, EMS, education, ultrasonography, research, quality and safety, simulation and observation medicine.
EHN offers a competitive salary, sign-on bonus, relocation assistance, CME allowance, defined benefit pension plan, excellent health insurance and other benefits. Academic appointments are through the Sidney Kimmel Medical School of the Thomas Jefferson University and are commensurate with candidate experience.
Philadelphia is an affordable, walkable, large city with a diverse population and world-class educational institutions, medical facilities, museums, entertainment/sports venues and restaurants.
Applicants must be board-certified or board-eligible in Emergency Medicine and have or be eligible for a Pennsylvania medical license.
Emergency Physicians
EOE
Please send curriculum vitae to: Kim Hannan, Physician Recruiter, Einstein Healthcare
Network, Recruitment and Placement Center, Phone: 267-421-7435, [email protected]
Wenatchee, WAWenatchee Emergency Physicians is seeking BC/BE emergency physicians to join our long-standing, democratic group due to expansion and retirement transitions. Central Washington Hospital is our primary facility with a volume of ~40,000. We also staff a Moses Lake, WA facility and a Wenatchee urgent care clinic. Income is highly competitive, and there is a short partnership track.
Wenatchee is a family-oriented community on the Columbia River at the base of the sunny/dry side of the Cascade Mountains, 2.5 hours from Seattle. The area has instant access to skiing, mountain biking, road cycling, wineries, water sports, hiking, climbing, and fishing. Search “We are Wenatchee” videos Parts I, II, and III.
Contacts:
Eric Hughes, [email protected] or Kirk Willett, [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
JuNE 2017 ACeP NOW 21The Official Voice of Emergency Medicine
CLASSIFIEDS
TH-10329Practice Made Perfect brand adsize: 9.875 x 7 islandpub: ACEP Now (JUN 2017)
Join our teamteamhealth.com/join or call 855.615.0010
FEATURED OPPORTUNITIES
Physician Led, Patient Focused.
West Valley Medical CenterCaldwell, ID34,000 volume
Rome Memorial HospitalRome, NY30,000 Volume
Metroplex Adventist Hospital Assistant Medical DirectorAustin, TX48,000 volume
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.
MetroHealth Medical Center Correctional Health Program
Seeking ER/FP physician to join MetroHealth Correctional Health Care program serving the Cuyahoga County Correctional Center in beautiful downtown Cleveland.
Join exceptional health care team in the growing specialty of correctional medicine, which encompasses a broad procedural skill set.
Comprehensive correctional health program includes full laboratory, pharmacy, digital imaging, ultrasound, and telemedicine services for annual patient census of approximately 30,000.
Consistent with national trends, aging patient population presents with multiple medical/surgical/acute care needs.
Complete range of consultation, emergency medical and surgical services provided by MetroHealth Medical Center, a Level I trauma center.
Qualified candidates should be board certified or board eligible in emergency medicine or family medicine with ER experience. Competitive MetroHealth salary and extensive benefit package.……………………………………………………
Send CV and inquiries to [email protected]. Thomas A Tallman, DO, MMM, FACEP, Medical Director, MetroHealth Correctional Health Program, 216 704 4296.
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
22 ACeP NOW JuNE 2017 The Official Voice of Emergency Medicine
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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
NORWALK:Low volume 600/mo. Paramedic receiving. Patients 8/hr. 10-year
history stable. $110/hr. 24hr shifts available
FAX CV to 213-482-0577or call 213-482-0588, or email
Emergency Physicians of Tidewater (EPT) is a physician-owned, physician-run, democratic group of ABEM/AOBEM eligible/certified EM physicians serving the Norfolk/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 opportunities for involvement 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.
Discover the heart of the Golden State.
The Permanente Medical Group, Inc.
Central
California
EMERGENCY MEDICINE PHYSICIANSCentral California (Modesto/Manteca)Robust Salary + $350,000FORGIVABLE LOAN PROGRAM THE PERMANENTE MEDICAL GROUP, INC. (TPMG)Our Central Valley Service Area is currently seeking BC/BE Emergency Medicine Physicians to join our department in Modesto and Manteca, California.
• Physician-led organization–career growth and leadership • Professional freedom• State-of-the-art facilities• Multi-specialty collaboration and integration• Technology driven• Mission driven, patient care-centered and one of the largest progressive medical groups in the nation!
EXTRAORDINARY BENEFITS• Shareholder track • Unparalleled stability–70 years strong• Shared call • Moving allowance• No cost medical and dental • Malpractice and tail insurance• Three retirement plans, • Home loan assistance including pension (approval required)• Paid holidays, sick leave, education leave (with generous stipend)
Life is good in the Central Valley: an hour from the Bay Area, an hour from the ski slopes, minutes from world-class wineries, excellent public schools, and affordable real estate (yes, in California).
Please send CV to: [email protected]
EMERGENCY MEDICINE PHYSICIANSCentral California (Modesto/Manteca)Robust Salary + $350,000FORGIVABLE LOAN PROGRAM THE PERMANENTE MEDICAL GROUP, INC. (TPMG)Our Central Valley Service Area is currently seeking BC/BE Emergency Medicine Physicians to join our department in Modesto and Manteca, California.
• Physician-led organization–career growth and leadership • Professional freedom• State-of-the-art facilities• Multi-specialty collaboration and integration• Technology driven• Mission driven, patient care-centered and one of the largest progressive medical groups in the nation!
EXTRAORDINARY BENEFITS• Shareholder track • Unparalleled stability–70 years strong• Shared call • Moving allowance• No cost medical and dental • Malpractice and tail insurance• Three retirement plans, • Home loan assistance including pension (approval required)• Paid holidays, sick leave, education leave (with generous stipend)
Life is good in the Central Valley: an hour from the Bay Area, an hour from the ski slopes, minutes from world-class wineries, excellent public schools, and affordable real estate (yes, in California).
Please send CV to: [email protected] are an EOE/AA/M/F/D/V Employer. VEVRAA Federal Contractor
Physicians (Emergency Medicine) Openings in Tucson, Arizona
The Southern Arizona VA Health Care System (SAVAHCS) is offering an exceptional opportunity for full time Emergency Medicine providers to join our winning team.
We are currently seeking skilled physicians holding an active and clear state medical license. Live where the country vacations in the winter. Home of the University of Arizona. This is an exceptional opportunity for experienced Emergency physicians to provide care for Veterans. See acutely ill patients with complex medical problems who have served their country. All backup specialties available, including neurosurgery, ENT and GYN. We offer 10 hour shifts, double and triple coverage. The ED PA sees less acute patients in triage. Our physicians perform clinical duties in the 19-bed Emergency Department which operates 24/7 for the current 26,000 patients seen annually. There are teaching and administrative opportunities available. We offer a competitive salary and generous 401k matching program. A Federal pension is available after only five years of service. Successful candidates must be eligible for a faculty appointment at the University of Arizona. The University of Arizona EM residents and medical students rotate within the department. The physician is required to maintain ACLS/BLS/ Intubation proficiency and certification. Preferred experience: board certified or board eligible in Emergency Medicine. Clinical Contact: Dr. Randall Bennett, MD, FACEP, Emergency Dept. Director, 520-904-3221, or [email protected].
Offering competitive salary and benefits, including… * 26 Vacation Days * 13 Sick Days * 10 Holidays* Many Health Plan options * Vision and Dental plans * Federal Retirement
* Recruitment/Relocation Incentive may be authorized
For detailed information on these positions, go to https://www.usajobs.gov/ , and enter the control number 458777500 in the Keyword select to view the announcement and to apply for this position. This is a wonderful opportunity to service those who have served. Applications must identify their current citizenship/Visa status. A current unrestricted medical license in any U.S. state/territory is required. Candidates must apply on line by submitting a current CV, with three (3) professional references, and complete the on-line questionnaire. The HR point of contact is David Tweedy, (520) 792-1450, ext. 6213.
The Department of Veterans Affairs is an Equal Opportunity Employer.
JuNE 2017 ACeP NOW 23The 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
24 ACeP NOW JuNE 2017 The Official Voice of Emergency Medicine
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Own your future now. Visit usacs.com or call Darrin Grella at 800-828-0898. [email protected]
We believe in physician ownership.
Physician ownership matters. At US Acute Care Solutions, physician ownership is the key to loving what we do. It empowers us to make a difference in the lives of our patients by keeping clinical decisions in the hands of clinicians. We believe in the high level of ideas and dedication that ownership creates. That’s why every full-time physician in our group becomes an owner. We believe that discovery, camaraderie and the pursuit of excellence don’t end when your residency does. If you’re looking for an exciting home for your career, we believe you’ll find it at USACS. #ownershipmatters
USACS is made up of over 1,900 physician owners and growing.
4/C Process We Believe Ad 10.875” x 15”