Fall 2015 Issue

Fall 2015

Kentucky Chapter ACEP

David (Wes) Brewer, MD, FACEP
President

Ashlee Melendez Executive Director

Contact us:
ky.chapter@acep.org

Phone: 502.852.7874
Fax: 502.852.0066

From the President
David (Wes) Brewer, MD, FACEP

WHAT IS THE VALUE OF ACEP AND KACEP TO YOU?

Not infrequently I am challenged to answer the question “Why should I belong to ACEP?” For this discussion we will consider national and your local chapter one and the same since you cannot belong to one without the other. The state chapter exists to focus on problems unique to our particular environment, while national exists to focus on the big picture. The question posed can be answered from a number of different viewpoints. We can always recite the laundry list of member benefits that you will receive, and while important, the number of goodies that you get are not really valid reasons for membership in any organization. 

I first joined ACEP in the early nineties and for many years it was not really a productive relationship. I received a throw-away journal to read occasionally, a more formal journal that I rarely thumbed through and a host of offerings for insurance or whatever. Once a year I received a dues statement which usually evoked the “what have they done for me lately and why do they charge so much response.” I even dropped out for a couple years because I did not have the vision to see the other side of the coin. It took a long while to realize that this is not a "what can you do for me" organization, it is a "what can we do together" organization.
 
From an organizational standpoint, your time and talents are much more important than your dollars. I firmly believe that only when you make the make the commitment to participate will you begin to see the real potential of membership. ACEP leadership is comprised of some of the best minds in emergency medicine. With a very minimal time commitment, you can work alongside these folks to make your needs own and solve our problems. Please do not wait for someone to swoop in and tell you what works best for you. You did not get where you are today by being passive and waiting for someone to solve your problems. Ours is a team, full contact sport in which you rarely get satisfaction sitting on the sideline. The ability to participate and be a part of the solution is the value of this organization.

Leadership and Advocacy 2015 Meeting

Rand Paul, Wes Brewer, MD, FACEP, KY ACEP President; and Shaun Reynolds, U of L Resident

ACEP Clinical Policy on use of IV tPA
Martin Huecker, MD
Chair, Educational Committee

Unless you are practicing medicine in an underserved rural location in the third world, you have likely heard about the “interim” review of IV tPA. ACEP has approved as of June 2015 an updated policy on the use of IV tPA in stroke patients. The policy is available in manuscript form on ACEP’s site for full review. The purpose here is chiefly to compare the precise changes made since the last iteration. 

In 2012 the policy aimed to give a guideline for decision making regarding patients presenting with stroke symptoms in the 0-3 hour time window and in the 3-4.5 hour window. In 2012 the “answer” to these two questions was combined: 
 
Level A: tPA should be offered to stroke patients with NINDS criteria
Level B: tPA should be considered in patients meeting ECAS III criteria in 3-4.5 hour window
“*The effectiveness of tPA has been less well established in institutions without the systems in place to safely administer the medication” 
Level C: none
 
In 2015 the policy statement now separates the answers to our two questions.
For the 0-3 hour time window:
 
Level A: none
Level B: tPA should be offered and may be given at institutions where systems are in place to safely administer. Risk of ICH should be considered.
Level C: When feasible, shared decision making to discuss benefits and harms
 
For the 3-4.5 hour window:
 
Level A: none
Level B: Despite risk and variability, tPA may be offered and may be given to carefully selected patients ... at institutions where systems are in place.
Level C: Shared decision making …
  • The 2015 statement, whose authors have no relevant industry relationships, notes that the 2012 statement may not have “conveyed the importance of having a discussion” with the patient / family. So we now have the Level C recommendation to have a discussion on risks and benefits regardless of the time window. 
  • The 2015 statement also now includes the consideration of the institution within the sentence on offering tPA to patients. This change could have significant implications for Emergency Physicians practicing in non-stroke centers where they will likely be the only doctor who has evaluated the patient prior to giving tPA. With better transfer availability, most EPs are now in consultation with a stroke Neurologist when ordering tPA. However, the location of the patient at the time of administration of tPA is important. If uncertain whether to give IV tPA to a patient, the threshold to pull the trigger may now be higher when not in a comprehensive stroke center. 
  • For our management of the majority of our patients, this policy statement will not change our practice. But a trend toward more shared decision making and more individualization of therapy is emerging. The guideline clearly states that it does not intend for this statement to represent a legal standard of care for EPs. But with tPA now a Level B recommendation even in the 0-3 hour time window, we may be able to remove the damned if you don’t half of treating ischemic stroke in the ED.

Kentucky Proud: Podcasting
Ryan Stanton, MD, FACEP
Chair, Public Relations Committee

I recently was asked to help develop a podcast for ACEP, which will be called “ACEP Frontline” and will be released around the time of ACEP15 in Boston. This podcast will focus on ACEP policies, practice changing research, as well as the “movers and shakers” of emergency medicine. As I started working on this project, I started thinking about the wealth of podcasting talent here in Kentucky. Over the last several years, a number of podcasters have set up shop in the commonwealth. 

Podcasting has been a great way to spread information and achieve the “lifelong learning” that medicine demands. I have always enjoyed listening to podcasts while traveling, at the gym, or when I’m just sitting around (and Storm Chasers or football isn’t on TV). There are countless formats out there with options from a freebie to quite the premium. There are also options based on the time you have to invest. 
 
With that in mind, I want you to know what is out there (in Kentucky). These podcasts are available on iTunes and many have their own websites/blogs. Listed are the ones that I know of that are focused on emergency medicine. I may not have everyone, and if I leave you out, please let me know and I will give you a shout-out later.
 
Rob Rogers, MD
1) teacher 
2) The Teaching Course Podcast

Matt Dawson, MD
1) Ultrasound Podcast

Jacob Avila, MD
1) 5MinSono

Andy Sloas, MD (Recently moved to TN)
1) PEM ED Podcast

Ryan Stanton, MD
1) Everyday Medicine
2) Everyday Medicine for Physicians(EM-News)
3) ACEP Frontline

The nice thing about the talent in our state is that we cover a wide range of topics. Emergency medicine is one of those specialties that takes constant effort to remain on the cutting edge of practice. We owe it to our hospitals and patients to do everything we can to adopt the most up-to-date, evidence-based practice. I have found that these podcasts seek evidence-based topics and present them in a quick, portable format. As with any information, I advise that you listen to the podcasts and then do your own research to fill in gaps and solidify the information. 

Thus, I ask you to be Kentucky Proud. If you are one that enjoys podcasting and continuing education, check out these locally grown products.

FYI
Can Nurses administer drugs for moderate sedation??

This is a question we have heard from all corners of the state since the advent of sedation (yes there a few of us who have been around since (almost) the discovery of ether).

So, you are in the room ready to reduce the dislocated shoulder or whatever, the patient is connected to every conceivable monitor, every conceivable ancillary service is just outside the door, your carefully calculated dose of the sedative agent of choice is at the bedside. Around this time the nurse hands the syringe to you and says something like “You know that the ‘state board’ does not allow me to administer any sort of sedation drug-- you will just have to push it yourself!”
 
Your eyes roll and you angrily mumble about the dumbness of that rule (not audibly of course!) and then resolve to find out whether or not this is true. It is not.
 
The Kentucky Board of Nursing has issued multiple advisory opinions that the administration of medications for moderate or procedural sedation as well as for RSI (rapid sequence intubation) are within the scope of practice of Registered Nurses (but not LPN’S). The requirement is that each nurse must have appropriate education regarding the drugs and possible complications and side effects. A nurse may not be compelled to administer such a drug if they feel educationally unprepared. In addition each facility must have in place pertinent written policies regarding sedation requirements.

So, the next time you hear “the excuse” have a chat with your nursing leadership to make sure the educational and policy pieces are in place and refer them to the Kentucky Board of Nursing website where the above mentioned advisory opinions are found.

Case Files
Wes Brewer, MD, FACEP
President, KY Chapter of ACEP

Hopefully this is the first of a series of cases submitted by the membership to present interesting and unusual cases. I would ask you to submit cases that you feel would be of interest or educational value to your colleagues. A couple of paragraphs should be sufficient and we are not looking for “journal publication” quality -- just interesting and informative. I invite you to send cases to me. I hope I will be so overwhelmed that I will have to apologize for not being get each and every case in the newsletter.

Thanks,
 
This month’s case represents a condition that is not easily diagnosed and often is missed. The patient is a 34 year old male who presented to the emergency department with a 2 day history of fever up to 103, headache which was described as “behind my eyes”, along with muscle aches, chills and episodes of diaphoresis. He denied nausea or vomiting but his appetite was decreased. He denied cough or upper respiratory symptoms. No sore throat. No urinary symptoms. He was previously healthy with no major illnesses. No routine medications. The systems review was not helpful except as noted above. He was a nonsmoker who worked on a farm.
 
On exam his temperature was 103.2 orally. Pulse 88, resp 20, BP 132/72. For the sake of brevity, I will just say nothing in his physical exam pointed me toward the diagnosis, but he ‘looked sick.’ Oh, and by the way, he was 6 foot 6 inches tall and weighed 378 pounds.
 
Laboratory evaluation revealed normal white cell count, mild thrombocytopenia at 140,000. AST, ALT and ALK PHOS were mildly elevated. Bilirubin normal. Sed Rate was elevated at 75. CXR no infiltrate. UA negative. Head CT yielded no useful information. Blood cultures were obtained (and were ultimately no growth).Lactate was less than 2. Lumbar puncture attempted but abandoned after unsuccessful attempts (see weight above!!) when no plus size spinal needles were to be found in this small rural facility in the middle of the night.
 
The patient was admitted to his internist who empirically started IV ceftriaxone. Over the next day the patient developed a harsh nonproductive cough and was progressively more dyspneic. Approximately 20 hours after initial presentation, a repeat chest x-ray demonstrated fluffy, diffuse bilateral infiltrates concerning for the development of ARDS. More antibiotics were added and the patient ultimately required intubation and then was transferred to a tertiary care center where a diagnosis was made on clinical grounds. He was started on doxycycline and recovered uneventfully.
 
One little snippet of information that I did inquire about is just what type of farming he did. Having grown up on a farm, I know full well that farming encompasses a wide variety of activities. But I did not ask this fellow if he handled goat placenta, it was just not in my usual repertory of inquiries. Turns out that he had a herd of over 100 goats, and that during the birthing season he frequently assisted in the delivery.
 
Those of you who were screaming Q fever early in the presentation are correct. The causative organism, Coxiella burnetti, is frequently found in the placenta and amniotic fluid of sheep, goats and cows and is easily aerosolized. The organism is very difficult to grow thus blood cultures are usually negative. PCR and IgG IFA on paired sera 2 weeks apart are diagnostic but take too long to be clinically useful. The diagnosis is thus based on clinical grounds and a high index of suspicion. Doxycycline is the drug of choice even in children down to age 8 and is most effective if begun within 3 days of symptom onset. Children younger than 8, pregnant women, or those allergic to doxycycline, can be given trimethoprim / sulfa.

News from National

Chapter Grant Applications
We want to remind you that chapter grant applications are due at the national office no later than Monday, November 2, 2015. For more information and the chapter grant application, go to our website

Don't miss ACEP15! This year the meeting is in Boston--October 26-29, 2015. Course reservations are BACK this year, so be sure and register for the courses you want. For more information, and to register go to ACEP's website.  
 
All Chapter Audio Conference
If you would like to listen to the recording of the All-Chapter Audio Conference that was held on August 18, it is now available on our website
 
Fellow Status
Earning the designation of Fellow of the American College of Emergency Physicians (FACEP) is reserved for an elite group of emergency physicians. They have demonstrated a commitment to their specialty through board certification, volunteerism, leadership, community service, and continued membership in their specialty society.   Chapter, community, and hospital committee leadership count toward the FACEP application requirements.  For more information on becoming a Fellow of the College, please visit our website or contact the ACEP Member Care Center at 800/798-1822, ext. 5, or membership@ACEP.org.
 
“Pave the Way” For the Future of Emergency Medicine
You’ve built your career in emergency medicine—now is your chance to build the future of the specialty.
 
In 2016, ACEP is moving to a dynamic new headquarters in Irving, TX. To ensure that emergency medicine research always has a home in ACEP’s new building, you can donate to the EMF Plaza, a beautiful collection of personalized brick pavers in the courtyard.
 
By donating, you will have an enduring symbol of your commitment to emergency medicine and will literally lay the groundwork for future research projects that bring about the highest quality care for your patients.
 
Immortalize your commitment
Recognize a colleague in memoriam 
Thank a mentor or friend
 
Find out more at our website.
 
Residency Visits 
To help you and your faculty prepare residents for the future, ACEP offers fully funded visits by emergency medicine leaders to your residency program.
 
Designed to bring ACEP leaders face-to-face with faculty and residents, these visits engage the future of the specialty in a wide variety of discussions from ever-changing legislative and regulatory landscapes, to practice management issues, to career advice and preparation. To schedule a visit and see the current list of speakers, visit our website
 
Research Forum 
Emergency medicine’s premier research event has been elevated to new heights in 2015, with a brand new electronic showcase, additional networking opportunities, and more original research than ever before.
Research Forum, October 26-27, is the opportunity to view and discuss original research at the world’s largest gathering of researchers, teachers, and practitioners of emergency medicine.
 
Meet, confer, and network in a highly supportive environment, where you can review the latest advances on a wide variety of emergency medicine topics. And best of all, access to the Research Forum is FREE as part of your ACEP15 four-day registration! To see the schedule or to register, visit our website.
 
Teaching Fellowship 
Experts in instructional design and academic 
emergency medicine have taken this very popular and successful program and updated it to meet the needs of today’s emergency physician. This program is designed for faculty in residency programs who want to improve their skills, residents interested in an academic career, and other physicians who have responsibility for teaching emergency medicine. Registration is limited and are filled on a first-come, first-serve basis so call today to have your name placed on the waiting list. To find out more info about the course or to register, visit our website
 
Emergency Medicine Basic Research Skills (EMBRS) Workshop
The (EMBRS) Workshop was designed by a task force of experienced investigators to help the physician with an interest in emergency medicine research get started. Participants will learn how to identify clinical research opportunities and become familiar with clinical research and outcomes, injury prevention, health care delivery and effectiveness research. Also, the course includes an introduction to statistics and statistical software and sessions on publishing and presenting your research. 

Registration is limited so that each can receive individual attention and instruction. Don’t put off your decision! Call today to have your name or your program name added to the waiting list. To find out more information or to register, visit our website.

Clinical News

New Oral Vaccine May Protect Children from H. pylori Infection
August 6, 2015 - Will Boggs, MD 
A new oral recombinant vaccine protects children against infection with Helicobacter pylori, researchers from China report. At least half the world’s population is affected by H. pylori, and so far none of several H. pylori vaccine candidates have proven effective in humans.
Read More

Patient-Controlled Analgesia Works in the Emergency Department
Megan Brooks
July 23, 2015 - Megan Brooks (Reuters Health)
Patient controlled analgesia (PCA) can be used effectively in emergency department patients dealing with moderate or severe pain, according to results of the Pain Solutions in the Emergency Setting...
 
14 Tips to Improve Clinical Efficiency in Emergency Medicine
Kevin M. Klauer, DO, EJD, FACEP 
14 Tips to Improve Clinical Efficiency in Emergency Medicine. The more complex the delivery of emergency medical care becomes, the more critical it is that we find ways to become lean, mean EM machines. 
Read More

Getting the Most Out of Your Annals of Emergency Medicine Podcasts

One of the key benefits of ACEP membership is a subscription to Annals of Emergency Medicine. The subscription includes not only the print journal, but complete access to all of the journal’s online and digital features. One of the key features is free access to Annals podcasts.

Annals Podcasts — Not Another Boring Lecture
 
Since February 2009, every issue of Annals of Emergency Medicine has featured podcasts that introduce and discuss a number of articles in the journal. The podcasts cover not only a broad range of topics, but also offer an engaging discussion of their importance and relevance to emergency medicine. 
 
Are They Any Good?
The podcasts are an easy-to-use source of information from the journal. One listener said the podcasts “… dive into why the article is important. I feel smarter after hearing you ask questions about the research.” Another reader said that “What I love about your podcast is that it is very casual and you explain why certain studies are important and what they did well/poorly. You do this better than any other journal summary I’ve ever listened to.”
 
Who Does the Podcasts? 
David H. Newman, MD, and Ashley E. Shreves, MD are the creators of the podcasts. Dr. Newman teaches at Columbia University in the Department of Biology and is an emergency physician with the Department of Emergency Medicine at the Icahn School of Medicine at Mount Sinai in New York. He is an Evidence-Based Medicine editor at Annals of Emergency Medicine, authored the critically acclaimed Hippocrates' Shadow, and is widely published in both scientific and popular media journals. He also edits the SMART EM and The NNT.com web resources. Dr. Shreves is a board certified and practicing emergency and palliative medicine physician, works as faculty in both the ED and palliative medicine departments with the Icahn School of Medicine, and will soon be the associate program director for the Mount Sinai-St. Luke’s/Roosevelt Hospital EM residency.
 
“For us it feels like a chance to chat about the latest studies and to have some fun,” said Newman. “And if it helps Annals connect with the global community, well that’s icing on the cake.”   

Free, Easy, Fast Access

The podcasts are free and easily accessible through multiple formats:
  1. Play on your computer by clicking on any of the individual podcast files on the Annals Web site.
  2. Easily download to your mp3 player.
  3. Subscribe to the Annals of Emergency Medicine podcasts at the iTunes Music Store and have the podcast automatically download to your iTunes each  month.
  4. Use your RSS reader for automatic delivery of content of each issue.
Annals Podcasts—More Than What You Expect

Annals Podcasts.  One of a multitude of journal features available to all ACEP members. Smart, engaging, relevant. Easy to listen to while exercising or driving to your shift. Come and hear what you’ve been missing.