Emergency Physicians and Ity Needed for Our Everyday Lives

FIRST TIME RELEASE Universal BENCHMARKING ALLIANCE ACEP Annual Bending the Financial Report Screening for Suicide? Boarding Curve SEE PAGE 4 SEE PAGE 6 SEE PAGE 9

DECEMBER 2015 Volume 34 Number 12 FACEBOOK/ACEPFAN TWITTER/ACEPNOW ACEPNOW.COM

PLUS A continuing medical education feature of ACEP Now

LOG ON TO http://www.acep.org/ ACEPeCME/ TO COMPLETE THE ACTIVITY AND EARN FREE AMA PRA CATEGORY 1 CREDIT.

THE END OF THE RAINBOW TRICKS OF THE TRADE DO YOUR TOYS OWN YOU? SEE PAGE 12 A Backhanded Approach to Tendon Lacerations Emergency department AIRWAY management of extensor KOVACS’ SIGN M&A CONSOLIDATION IS CHANGING THE tendon lacerations AND OVERHAND RIGHTWARD EMERGENCY MEDICINE LANDSCAPE—BUT WILL by TERRANCE MCGOVERN, DO, TURN THE TREND CONTINUE? MPH, AND JUSTIN MCNAMEE, DO SEE PAGE 15 CONSOLIDATION IN THE HEALTH CARE MARKET isn’t a new trend, he hand is an intricate structure but the frenzy of mergers and acquisitions in the emergency medicine that provides us with the dexter- space make this a top concern for practicing emergency physicians and ity needed for our everyday lives. Unfortunately, we see many pa- EM administrators. Over the next few months, ACEP Now will feature a Ttients in the emergency department who FIND IT ONLINE For more clinical stories and series of articles exploring the effects—both positive and negative—that take this functionality for granted until practice trends, plus commentary consolidation may have on emergency medicine. they lose all or part of it. The attention and opinion pieces, go to: ILLUSTRATION/PAUL JUESTRICH; PHOTOS SHUTTERSTOCK.COM ILLUSTRATION/PAUL spent on flexor tendon injuries is perva- www.acepnow.com CONTINUED on page 5 sive throughout the literature, whereas the more common extensor tendon injuries have not garnered as much attention.1 As emergency physicians, we have the opportunity to decrease the amount SPECIAL OPs of impairment that patients sustain I HEARD IT from these extensor tendon injuries by providing them with the appropriate THROUGH THE treatment that they deserve.

Diagnosing an extensor tendon in- visit our website website our visit

www.wileycustomerhelp.com jury takes a thorough physical exam, If you have changed your address or wish to contact us, please please us, contact to wish or address your changed have you If ‘Grapevine’ with time spent by the provider to iso-

Hoboken, NJ 07030-5790 NJ Hoboken, A novel way of

River Street River

111 111 late each joint and test the range of Journal Customer Services Customer Journal promoting AIDET for motion against resistance. (See “Man-

JOHN WILEY & SONS, INC. SONS, & WILEY JOHN improving experience agement of Extensor Tendon Injuries”

for more on the exam.)2 The potential PERIODICAL of care SEE PAGE 16 impairment that may occur without CONTINUED on page 13 DECEMBER 2015 Volume 34 Number 12

EDITORIAL STAFF MEDICAL EDITOR-IN-CHIEF EDITOR Kevin Klauer, DO, EJD, FACEP Dawn Antoline-Wang [email protected] [email protected]

ART DIRECTOR MANAGER, DIGITAL MEDIA Paul Juestrich AND STRATEGY [email protected] Jason Carris [email protected]

ACEP STAFF EXECUTIVE DIRECTOR DIRECTOR, MEMBER Dean Wilkerson, JD, MBA, CAE COMMUNICATIONS AND [email protected] MARKETING Nancy Calaway L ASSOCIATE EXECUTIVE DIRECTOR, [email protected] sta, F MEMBERSHIP AND EDUCATION ena Vi ke Bu DIVISION COMMUNICATIONS MANAGER rts | La b Reso Robert Heard, MBA, CAE Dianna Hunt ch Clu t & Bea [email protected] [email protected] ’s Yach | Disney 016 -10, 2 PUBLISHING STAFF arch 8 M EXECUTIVE EDITOR/ ASSOCIATE DIRECTOR, PUBLISHER ADVERTISING SALES Lisa Dionne Steve Jezzard [email protected] [email protected]

ADVERTISING STAFF DISPLAY ADVERTISING CLASSIFIED ADVERTISING Michael Lamattina Kevin Dunn Cynthia Kucera [email protected] [email protected] [email protected] (781) 388-8548 Cunningham and Associates (201) 767-4170

EDITORIAL ADVISORY BOARD James G. Adams, MD, FACEP Howard K. Mell, MD, MPH, FACEP James J. Augustine, MD, FACEP Debra G. Perina, MD, FACEP Richard M. Cantor, MD, FACEP Mark S. Rosenberg, DO, MBA, FACEP L. Anthony Cirillo, MD, FACEP Sandra M. Schneider, MD, FACEP Marco Coppola, DO, FACEP Jeremiah Schuur, MD, MHS, FACEP Jordan Celeste, MD David M. Siegel, MD, JD, FACEP Jeremy Samuel Faust, MD, MS, MA Michael D. Smith, MD, MBA, FACEP Jonathan M. Glauser, MD, MBA, FACEP BE READY — Turn Michael A. Granovsky, MD, FACEP Robert C. Solomon, MD, FACEP Sarah Hoper, MD, JD Annalise Sorrentino, MD, FACEP challenging pediatric Linda L. Lawrence, MD, FACEP Jennifer L’Hommedieu Stankus, MD, JD Frank LoVecchio, DO, FACEP Peter Viccellio, MD, FACEP emergencies into Catherine A. Marco, MD, FACEP Rade B. Vukmir, MD, JD, FACEP rewarding ones. Ricardo Martinez, MD, FACEP Scott D. Weingart, MD, FACEP Receive clinical updates that offer the INFORMATION FOR SUBSCRIBERS latest scientific advances 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 $233/year individual. To initiate a paid sub- Gain new skills in our Pre-Conference scription, 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 courses - including procedures and Subscription Services, Inc., a Wiley Company, 111 River Street, Hoboken, NJ 07030-5774. Periodical ultrasound labs and Building Blocks of postage paid at Hoboken, NJ, and additional offices. Postmaster: Send address changes to ACEP Now, Pediatric EM 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 Learn from the most respected names by Cadmus(Cenveo), Lancaster, PA. Copyright © 2015 American College of Emergency Physicians. All rights reserved. No part of this publication may be reproduced, stored, or transmitted in any form or by in pediatric emergency medicine any means and without the prior permission in writing from the copyright holder. ACEP Now, an official ©Disney publication of the American College of Emergency Physicians, provides indispensable content that can be Book your hotel today at Discover products and services for used in daily practice. Written primarily by the physician for the physician, ACEP Now is the most effective acep.org/pem/hotel pediatric EM in our exhibit hall 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 www.acep.org/pemassembly | 800-798-1822, Ext 5 College of Emergency Physicians and Wiley will not assume responsibility for damages, loss, or claims of and 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 REGISTER WITH PROMO CODE PEM16P5 TO SAVE $100 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.

151203 BPA Worldwide is a global industry resource for verified audience data and ACEP Now is a member.

151203-Pediatric EM Assembly.indd 1 10/12/15 12:51 PM

2 ACEP NOW DECEMBER 2015 The Official Voice of Emergency Medicine 4 I IS MERS COMING 8 I A CONVENER OF 10 I SOUND ADVICE 15 I AIRWAY Inside TO AN ED NEAR YOU? EMERGENCY MEDICINE 12 I THE END OF THE RAINBOW 16 I SPECIAL OPs

UPDATES AND ALERTS FROM ACEP NEWS FROM THE COLLEGE

THE NATIONAL EMERGENCY MEDICINE POLITICAL ACTION COMMITTEE (NEMPAC) drew nearly $300,000 in donations during the Council Challenge Oct. 24-25, in Boston. Combined with the thousands of dollars in donations from ACEP members across the country, NEMPAC is on the way toward its $1 million goal set for 2015. ACEP members in seven emergency medicine group practices were recognized for outstanding support: CEP America, EmCare, Emergency ACEP’s 2015–2016 Board of Directors. Medicine Physicians (EMP), Eastside Emergency Physicians (EEP), Florida ACEP15 ROUNDUP LEADERSHIP Dr. Parker, who had served as Board Chair, Emergency Physicians Incoming President Jay Kaplan, MD, FACEP, took is an attending emergency physician with Vis- (FEP), Medical Emergency New leadership, high attendance the reins of ACEP in Boston as Rebecca Parker, ta Health in Waukegan, Illinois. She is sen- Professionals (MEP), highlight Boston meeting MD, FACEP, was elected President-Elect. ior vice president of Envision Healthcare and and Wake Emergency ear-record attendance at ACEP15 in Dr. Kaplan is director of the patient experi- president of Team Parker LLC, a consulting Physicians (WEPPA). Boston brought new leadership, new ence for CEP America in Emeryville, California, group. She is also a clinical assistant pro- NEMPAC advances N faces, and healthy contributions to and a practicing clinician in the emergency de- fessor at the Texas Tech University Health ACEP’s legislative agenda ACEP’s advocacy program and the Emergency partment at Marin General Hospital in Green- Sciences Center at El Paso department of and broadens ACEP’s Medicine Foundation (EMF). brae, California. emergency medicine. visibility in Congress. Attendance at the conference matched the re- The Council reelected two Board members It is the fourth largest cord attendance at ACEP14 in Chicago, although and voted in two new members. Vidor Fried- physician specialty PAC. final numbers are still being determined. man, MD, FACEP, and William Jaquis, MD, A new President-Elect and four members FACEP, were reelected. Christopher S. Kang, of the Board of Directors were elected by the MD, FACEP, FAWM, and Mark Rosenberg, DO, ACEP Council, which also elected its new lead- MBA, FACEP, were also elected to the Board. ership. Contributions to the National Emer- James M. Cusick, MD, FACEP, was elect- gency Medicine Political Action Committee ed Council Speaker, and Col. (ret.) John Mc- Council Speaker James M. Cusick, MD, (NEMPAC) and the EMF also pushed closer to FACEP (left), and Vice Speaker Col. (ret.) John Manus, MD, MBA, MCR, FACEP, was elected THE EMERGENCY the goals set for the year. McManus, MD, MBA, MCR, FACEP (right). Vice Speaker. MEDICINE FOUNDATION (EMF) surpassed its goal for the year with a special Council Challenge ACEP15 LEADERSHIP AWARD WINNERS at ACEP15 in Boston. The Please join ACEP in congratulating the 2015 recipients of the College’s most prestigious awards. challenge drew $210,000 in contributions, surpass- OUTSTANDING CONTRIBUTION JOHN G. WIEGENSTEIN COLIN C. RORRIE JR., PHD, ing the $200,000 IN RESEARCH AWARDS LEADERSHIP AWARD AWARD FOR EXCELLENCE IN goal for the year. HEALTH POLICY • Clifton W. Callaway, MD, PhD, FACEP • Angela F. Gardner, MD, FACEP The average contribu- • Daniel W. Spaite, MD, FACEP • James C. Mitchiner, MD, MPH, tion approached the OUTSTANDING CONTRIBUTION FACEP recommended “Wilcox” level of $500, with record HONORARY IN EDUCATION AWARD numbers of contributors MEMBERSHIP AWARDS • Mel Herbert, MD, FACEP JAMES D. MILLS OUTSTANDING stepping up to become • Marilyn Bromley, RN CONTRIBUTION TO EMERGENCY MEDICINE AWARD major donors and 1972 • Virginia Kennedy Palys, JD COUNCIL MERITORIOUS Club members. SERVICE AWARD • W. Calvin Chaney, JD, CAE • Robert W. Strauss, MD, FACEP EMF is continuing its • Andrew I. Bern, MD, FACEP Pave the Way for the OUTSTANDING CONTRIBUTION DISASTER MEDICAL Future of Emergency IN EMS AWARD JOHN A. RUPKE LEGACY AWARD SCIENCES AWARD Medicine campaign, giving • James V. Dunford Jr., MD, FACEP • Stephen V. Cantrill, MD, FACEP • Carl H. Schultz, MD, FACEP members an opportunity to help build the future of the specialty by donating a WHAT ARE YOU THINKING? personalized brick paver at SEND EMAIL TO [email protected]; LETTERS TO ACEP NOW, P.O. BOX 619911, DALLAS, TX 75261-9911; ACEP’s new headquarters, AND FAXES TO 972-580-2816, ATTENTION ACEP NOW. now under construction.

The Official Voice of Emergency Medicine DECEMBER 2015 ACEP NOW 3 Is MERS Coming to an ED Near You? The 3I tool helps you identify and react to patients who might have Middle East respiratory syndrome by KRISTI L. KOENIG, MD, FACEP, FIFEM Nevertheless, as evidenced by reports from Sau- di Arabia, disease transmission is occurring within nitially described in Saudi Arabia in September health care facilities, and clinicians are at particular- 2012, Middle East respiratory syndrome (MERS) ly high risk of contracting MERS from their infected I has been reported in at least 26 countries. Be- patients. With global travel opportunities, it is es- tween Oct. 26 and Nov. 1, 2015, the National Interna- sential to assess for risk of exposure to transmissible tional Health Regulations Focal Point for the Kingdom infectious diseases for all patients presenting to the of Saudi Arabia notified WHO of seven additional cases emergency department. The modified Identify, Isolate, of MERS coronavirus infection, including one death. Inform (3I) tool (right) is intended for use in manage- As of November 1, 2015, the World Health Organization ment of patients under investigation for MERS. The reported 1,618 cases globally, with at least 579 deaths. algorithm was developed with input from the ACEP The majority of cases have been reported from Saudi Ebola Expert Panel and guidance from the Centers for Arabia. No sustained human-to-human transmission Disease Control and Prevention. has been reported to date. Visit www.acepnow.com/?p=7675 to learn more a Severe illness The vast majority of MERS cases outside of the Ara- about MERS and the 3I tool. b Milder illness c Milder illness (http://www.cdc.gov/coronavirus/mers/case-def.html) bian Peninsula have been in travelers to the region, *Ill patients who do not require hospitalization may be isolated at home while being evaluated for MERS infection. including two unlinked cases in Indiana and Florida DR. KOENIG is director of the University of California, The Identify-Isolate-Inform tool was conceived by Dr. Kristi L Koenig, Director, Center for Disaster Medical Sciences, UC Irvine in May 2014 in patients believed to have been infected Irvine Center for Disaster Medical Sciences and profes- http://wwwnc.cdc.gov/travel/notices/alert/coronavirus-saudi-arabia-qatar while they functioned as health care workers in Saudi sor of emergency medicine and public health at the UC This 3I tool helps emergency departments evaluate and manage Arabia. Both patients were hospitalized and recovered. Irvine School of Medicine. patients under investigation (PUIs) for MERS coronavirus.

ACEP Annual Financial Report for the 2014–2015 Fiscal Year by JOHN J. ROGERS, MD, CPE, FACEP tus of the College for the 2014–2015 fiscal year were candidate members. This represents a ity care, and help control health care costs. (July 1, 2014, through June 30, 2015). This is the 2.9 percent overall increase, with a 1.4 percent Revenue for the fiscal year was more than CEP is a membership organization. As first time this data has been published. growth in active and 7.8 percent growth in can- $33 million, with the majority coming from such, members have a right to know Membership continues to grow. As of June didate members. three activities: dues, ACEP14, and Annals A its financial status. The following is 30, 2015, the College had 34,049 members, of The majority of the College’s assets are in of Emergency Medicine. When looking at a fair and accurate representation of the sta- whom 21,083 were active (regular) and 10,261 cash and investments. Current liabilities are expenses by line of service, the majority is mainly deferred revenue. Equity then stands spent on education and member services. For as $16,956,000, which has grown by $1,121,000 the year, the net income was $1,973,000, of since the previous fiscal year. This buildup in which 60 percent went to equity and 40 per- Did you know that equity will allow the College to reinvest in its cent to staff bonuses. emergency physicians members. It will be applied to the new head- In short, the College is strong financially, have the second highest Physician, quarters, which will give the ACEP staff the membership and equity continue to grow, space it requires and provide areas for meet- and we have sufficient funds for high-cost rate of burnout (just 1% ings that otherwise would need to be held off- projects that will be a significant benefit to less than critical care site. Our finances will also allow us to further our members. physicians) and that Heal Thyself... develop other benefits for our members such burnout has been as our qualified clinical data registry, CEDR, DR. ROGERS is ACEP’s current Vice and explore a national electronic network that President and its immediate past Secretary- shown to negatively will enhance care coordination, promote qual- Treasurer. affect patient care?* Literally.

BALANCE SHEET INCOME STATEMENT Join ACEP in the first Emergency Medicine Wellness WeekTM and pledge to be healthier by focusing on: Assets Revenue Cash, Equivalents, Dues and Membership $12,812,000 $27,812,000 Investments Products $14,044,000 Physical Health Connections Career Engagement Fixed Assets $6,776,000 Other $6,473,000 Diet, Exercise, Community, Family, Reducing Burnout, Line of Credit $0 Sleep Friends, Spiritual Mindfulness Training TOTAL REVENUE $33,329,000 Deposits $12,000 Other $2,757,000 Expenses and Losses Can you give 100% when your own tank is empty? Education and TOTAL ASSETS $37,357,000 $16,875,000 Membership Sign up online for daily Public Affairs $5,862,000 Liabilities wellness tips, find Policy and Administration $5,621,000 Accounts Payable resources and videos and Accruals $4,075,000 Leadership $2,998,000 about better wellness, Due to Chapters $2,390,000 TOTAL EXPENSES $31,356,000 and share your stories Deferred Revenue $13,936,000 Net From Operations $1,973,000 of improvement. Total Liabilities $20,401,000 WW_AD_AN_0116 Bonus Award $758,000 Member Equity $16,956,000 Contribution to Equity $1,215,000 TOTAL LIABILITIES $37,357,000 Unrealized Gain or Loss –$93,000 acep.org/EMWellnessWeek AND EQUITY Net Change in Equity $1,122,000 * Medscape Emergency Medicine Physician Lifestyle Report 2015 - www.medscape.com/features/slideshow/lifestyle/2015/emergency-medicine#1

WW_AD_AN_0116.indd 1 11/17/15 10:19 AM 4 ACEP NOW DECEMBER 2015 The Official Voice of Emergency Medicine ACEPNOW.COM

M&A | CONTINUED FROM PAGE 1 To start the discussion, ACEP Now editorial board member Ricardo Martinez, MD, FACEP, chief medical officer for North Highland Worldwide Consulting and assistant professor of emergency medicine at Emory University in Atlanta, recently sat down with Jeff Swearingen, managing director and cofounder of Edgemont Capital Partners in New York City, to explore some of the forces driving mergers and acquisitions in emergency medicine. Next month, we’ll highlight some of the mergers and acquisitions topics discussed at the ACEP15 Council Town Hall meeting held Oct. 25, 2015, in Boston.

RM: We’re seeing a lot of activity and tremendous interest in mergers and acquisitions in emergency medicine. What do you see as the main driving forces behind this? JS: First and foremost, there’s a lot of mergers and acquisitions activity throughout health care right now. There is consolidation happening in all four of the main hospital-based specialties: emergency medicine, anesthesia, hospitalist medicine, and radiology. Anesthesia is even more active than emergency medicine in terms of the number of transactions at the moment, if you can believe that. Consolidation is resulting from different types of provider organizations jockeying for position and negotiating leverage as people look to negotiate a larger share of a bundled payment that may be bundled across both the facility and the provider in the future. I think the second reason for consolidation is access to capital. Many of the consolidators that are driving mergers and acquisitions in emergency medicine have far greater access to both debt and equity capital than even a midsized regional group might have. Investment in information technology and other capabilities will be important going forward, especially the ability to

capture data beyond just the three hours in the JUESTRICH; PHOTOS SHUTTERSTOCK.COM ILLUSTRATION/PAUL emergency room episode of care. Emergency physicians in the future may be able to capture standards, and feeling a sense of ownership and RM: We’re seeing this move to consolidate data via call center follow-up with patients to pride in their practice continues to be fostered in a lot of industries. Many of the benefits are make sure that they’re following their discharge and supported. We have seen mergers and ac- back-office benefits: administrative benefits, instructions and that they’re making follow-up quisitions go quite well for several of the groups billing and coding, tracking data, etc. As these appointments with their office-based provid- we’ve represented, but we’ve also seen where types of services become more cloud-based, ers. Envision, the EmCare business, also owns there were some stumbles. At the end of the day, do you see some undoing of the need to con- the large ambulance company American Medi- both of those parties have to live up to the plan solidate? cal Response, and they are using the trained under which the transaction was entered into in paramedics to make follow-up house calls to JS: I certainly believe there’s always going to be a order to make it work. patients discharged from their EmCare-staffed position and presence in the market for independ- emergency rooms. They’re doing this on a test RM: We’ve watched the valuations and the ent groups. That being said, what is going to be basis in some markets, as I understand it. Envi- multiples rise pretty quickly over the last increasingly important for those groups to maintain sion is using those resources to try to reduce few years. Do you see this as a temporary their independence is the ability to access low- readmission cases. That is just one example of situation? cost, high-quality back-office services and be able what may be required of emergency medicine to access, via information technology, the quality providers in the future. To meet these potential JS: I’ll say this: From a relative basis, valuations metrics, the data analytics that they need to dem- requirements, groups will need expertise be- are higher now than they have been at any point onstrate their value in the marketplace. If independ- yond emergency medicine, information technol- in the last five years, maybe even the last 10 or ent groups are determined to stay independent, ogy resources, and access to capital to make more years. Part of that is driven by the fact that, for they absolutely need to be focused on how to best those types of investments. the most part, capital markets are doing very well access those capabilities and services. right now. The large consolidators have access to RM: What do you see as some of the big- RM: In the next five years, where should emer- plenty of debt and equity capital at a relatively low gest challenges for these organizations gency physicians be looking to maximize their cost. Part of that is because of the scarcity value as they begin to merge different entities role in the value chain that’s emerging? [the economic factor that increases an item’s rela- together? tive price based more upon its relatively low sup- JS: It comes back to the importance of being able to JS: I’ll be the first to tell you, having worked ply] of some of the really high-quality groups. In measure your impact on a patient’s health and affect on mergers and acquisitions for 20 years, that the last year or two, we’ve seen several very large outcomes beyond the episode within the four walls there’s absolutely a challenge to making merg- transactions in emergency medicine, like Premier of the emergency room. That could be measured by ers and acquisitions work. Many physicians, Physician Services and Emergency Medical Asso- increased data gathering and quality metrics within whether it’s in emergency medicine or any other ciates of New Jersey. With those very large groups, the acute episode of care in the emergency room specialty, are used to owning their own practice. there’s scarcity value. My general perspective is as well as by the ability to reach that patient and the If they merge with a large organization, it’s criti- that if you’re a seller, valuations are very attractive patient’s follow-up physicians to affect care as [the cal that the culture of hard work, high clinical right now. patients] return to their homes.

The Official Voice of Emergency Medicine DECEMBER 2015 ACEP NOW 5 population in the United States, 38 percent of patients who attempted suicide had a health care visit in the week prior to their attempt; 95 percent had a health care encounter in the year prior.4 Of those visits, primary care and emergency department visits were most common. In a similar study looking at suicide deaths, 80 percent of patients had contact with some type of health care provider within the year prior to their suicide.5 Again, primary care and emergency visits were most common. Approximate- ly 25 percent visited their primary care provider within that year for mental health issues; 65 percent, for other reasons. For the emergency department, 20 percent visited for mental health issues; 35 percent, for other reasons. Have you However, it is not clear that patients who commit suicide would screen positive 12 months been having What does that have earlier during a routine health visit. The same to do with my sprained study also examined visits within the prior four thoughts weeks.5 The percent who visited their primary about killing knee? care provider was 8 percent for mental health issues, 0.7 percent for chemical dependence, yourself? and 21 percent for other reasons. In contrast, except for patients with chemical dependency, patients were less likely to visit the ED, with 7.5 percent going to the ED for mental health, 1.4 percent for chemical dependency, and 12.8 percent for other reasons. While these numbers may give some cre- dence to screening in the ED, it is important to note that patients who commit suicide are more likely to visit primary care providers MADNESS, MANDATE, than the ED. This fact is important since the U.S. Preventive Services Task Force does not recommend screening for suicidality in pri- or Misunderstanding mary care practices.6 The data would suggest

© SHUTTERSTOCK.COM EDs should not routinely screen for suicidality as well. n 2013, more than 41,000 individuals 3. When an individual at risk for suicide Despite the facts, suicide screening is tak- Universal suicide died of suicide in the United States, leaves the care of the hospital, provide ing place in a number of emergency depart- and while that number has been de- suicide prevention information (such as ments, often done by the triage nurse. Suicide screening: saving clining, suicide remains the second a crisis hotline) to the individual and his screening tools are embedded in some elec- leading cause of death among teen- or her family.2 tronic medical records. There is no “best prac- lives or wasting agers and young adults. It is the tenth lead- The NPSG goes on to clarify in the FAQ sec- tice” screening tool. Many use a four-question I 1 ing cause of death for all ages. These deaths tion that screening should occur for “any pa- tool (Are you here because you tried to hurt time? often leave family, friends, and health pro- tient who has a primary diagnosis or primary yourself? In the past week, have you been fessionals with guilt, searching for missed complaint of an emotional or behavioral dis- having thoughts about killing yourself? Have BY SANDRA M. clues and interventions that might have pre- order.”2 The Emergency Nurses Association you ever tried to hurt yourself in the past? Has SCHNEIDER, MD, FACEP vented the untimely, tragic death. Recently, (ENA) states in its “Clinical Practice Guide- something very stressful happened to you in many emergency departments have started line: Suicide Risk Assessment” developed in the past few weeks?).7 Any single positive an- screening all patients for suicide risk. This 2012, “The Joint Commission [NPSG] requires swer is considered a positive screen. A recent practice is not only unnecessary but may not facilities to ‘Conduct a risk assessment that study of this tool in an emergency department be successful and places additional burden identifies specific patient characteristics and setting demonstrated a very high false-posi- on emergency staff. Many emergency department managers and hospi- For the emergency department, 20 percent visited tal administrators falsely for mental health issues; 35 percent, for other believe The Joint Commis- sion requires screening all reasons. However, it is not clear that patients who emergency patients for sui- commit suicide would screen positive 12 months cide risk. In actuality, The Joint Commission National earlier during a routine health visit. Patient Safety Goal (NPSG) 15.01.01 states, “Identify patients at risk for environmental features that may increase or tive rate, though it did appear to be success- suicide.” The NPSG also includes a note that decrease the risk for suicide.’”3 That statement ful in identifying individuals who had suicidal states, “This requirement applies only to psy- may be interpreted to mean that all patients ideation. Overall, nearly 42 percent of all pa- chiatric hospitals and patients being treated need to be screened for suicide ideation. How- tients screened positive, but with secondary for emotional or behavioral disorders in gen- ever, later in that document, the ENA clarifies screening, only 1.5 percent were true positives. eral hospitals.” The elements of performance that screening is only required for patients Among adolescents, 51 percent screened pos- for NPSG 15.01.01 are: seeking mental health care. Therefore, there itive, but only 5 percent were true positives. 1. Conduct a risk assessment that identi- is no requirement to screen all emergency de- Although the numbers screened were low, fies specific individual characteristics partment patients for suicide risk. all patients with mental health complaints and environmental features that may One argument for universal screening is screened positive, but none of them were de- increase or decrease the risk for suicide. the fact that many patients who later com- termined to be suicidal.8 Other tools developed 2. Address the individual’s immediate mit suicide are seen in the ED in the weeks since then and currently under development safety needs and most appropriate set- and months prior to an attempt. In fact, in a now may have better sensitivity and specific- ting for treatment. recent retrospective study on a large patient ity and may be better accepted by providers.9

6 ACEP NOW DECEMBER 2015 The Official Voice of Emergency Medicine ACEPNOW.COM

Screening positive has significant impli- self has been questioned. David J. Knesper, referral systems before universal screening of 6. LeFevre ML, US Preventive Services Task Force. Screening for suicide risk in adolescents, adults, and cations for emergency physicians and staff. MD, of the department of psychiatry at the all patients in the emergency department can older adults in primary care: US Preventive Services Should all patients who screen positive be University of Michigan in Ann Arbor, noted be embraced. Task Force recommendation statement. Ann Intern Med. 2014;160:719-726. cleared by psychiatry? Should all patients “there is no evidence that psychiatric hospi- References 7. Davis KN. Detecting suicide risk in adolescents and adults in an emergency department: a pilot study. Illinois who are discharged receive referral to mental talization prevents suicide” in the immediate 1. Suicide facts. Suicide Awareness Voices of Wesleyan University website. Available at: 10 Education website. Available at: www.save.org/ health resources? Should patients who screen postdischarge period. The stress that led to http://digitalcommons.iwu.edu/jwprc/2004/oral- index.cfm?fuseaction=home.viewPage&page_ pres8/2/. Accessed Oct. 16, 2015. positive, particularly those screening positive the patient’s decompensation is often still pre- id=705D5DF4-055B-F1EC-3F66462866FCB4E6. for more than one question, have 1:1 observa- sent in the community, with the addition of Accessed Oct. 16, 2015. 8. Folse VN, Eich KN, Hall AM, et al. Detecting suicide risk in adolescents and adults in an emergency depart- tion, at least until they can be assessed by the the stigma of being in a mental health facility. 2. Suicide risk reduction FAQs. The Joint Commission ment: a pilot study. J Psychosoc Nurs Ment Health Serv. emergency physician? What are the legal im- There is no necessity for universal screen- website. Available at: www.jointcommission.org/stand- 2006:44:22-29. ards_information/jcfaqdetails.aspx?StandardsFaqId=16 9. Betz ME, Arias SA, Miller M, et al. Change in emergency plications of sending home patients with posi- ing, though screening of “high-risk” popu- 6&ProgramId=47. Accessed Oct. 16, 2015. department providers’ beliefs and practices after use tive screens, particularly if they, sometime in lations is a recommendation of The Joint 3. Brim C, Lindauer C, Halpern J, et al. Clinical practice of new protocols for suicidal patients. Psychiatr Serv. 2015;66:625-631. the future, attempt or complete a suicide? All Commission. Current screening tools are im- guideline: suicide risk assessment. Emergency Nurses Association website. Available at: https://www.ena.org/ 10. Knesper DJ, American Association of Suicidology, of these issues remain unclear. perfect, and referral options for inpatient and practice-research/research/CPG/Documents/Suici- Suicide Prevention Resource Center. Continuity of care deRiskAssessmentCPG.pdf. Accessed Oct. 16, 2015. for suicide prevention and research: Suicide attempts Mental health treatment is not universally outpatient assessment are not able to absorb a and suicide deaths subsequent to discharge from the 4. Ahmedani BK, Stewart C, Simon GE, et al. Racial/ successful. Successful suicides during inpa- large influx of false positives. Treatment, once emergency department or a psychiatry inpatient unit. ethnic differences in health care visits made before 2010. Newton, MA: Education Development Center, Inc. tient mental health treatment are not uncom- available, has limitations. Screening is poten- suicide attempt across the United States. Med Care. 2015;53:430-435. mon. More important, suicide risk is highest tially valuable in high-risk patients. Suicide is DR. SCHNEIDER is director of in the first few weeks after discharge from a an important and serious public health prob- 5. Ahmedani BK, Simon GE, Stewart C, et al. Health care contacts in the year before suicide death. J Gen Intern EM practice at ACEP and a member of the mental health facility. Inpatient treatment it- lem. We need better screening tools and better Med. 2014;29:870-877. ACEP Now editorial advisory board.

TOUGH Conversations Resources for discussing a suicide attempt in the family with children | BY MELISSA MCHARG

he Rocky Mountain Mental Illness Research, Education • Addresses mental illness and and Clinical Center potentially co-occurring conditions T such as substance use (MIRECC), located at the Denver and Salt Lake City Veterans • Promotes elements of resiliency and Affairs medical centers, offers building resilient coping skills in clinicians and communities children and families educational resources to help • Familiarizes parents/caregivers with navigate the rare but critical developmental concepts that increase instances when a person with their capacity to recognize behaviors suicidal ideation or behavior that may follow traumatic events, with arrives at the emergency depart- suggestions for how to support each ment for care. A small working developmental stage following such group in MIRECC’s education an event core, led by Douglas Gray, MD, a • Provides information on recognizing © SHUTTERSTOCK.COM child and adolescent psychiatrist, signs of emotional or mental distress The "How to Talk to a Child About a Suicide Attempt in Your created the “How to Talk to a Child About that may necessitate intervention by a Suicide Attempt in Your Family” booklet and Family” booklet and video can help emergency physicians with tough conversations with families in the ED. a mental health professional video (available online at www.mirecc.va.gov/ visn19/talk2kids/index.asp). The group aims to charge from ED.2 Among the recommendations THE VIDEO OFFERS THE BENEFITS arm emergency medical personnel with profes- for better continuity of care were positive family ABOVE, PLUS: sionally developed resources to support suicidal involvement and caring emergency physician– patients and their families. • Visual demonstration of principles in patient interactions. This educational resource was developed to motion, with professional actors as well The “How to Talk to a Child” booklet and video support parents or caregivers who have recently as graphic presentations of key supply emergency physicians with a readily experienced a suicide attempt by a family mem- approaches and takeaway concepts available resource that helps meet the most ber and for professionals who provide crisis and • Illustration of how a suicide-related common needs expressed by family members. immediate follow-up care for suicidal individuals. conversation might unfold, showing how The booklet and video are available in Spanish While the first priority in a mental health emergen- open-ended inquiries and responsive- and English and may be downloaded or ordered cy is to stabilize and ensure patient safety, suicidal ness to children’s individual concerns at no cost. The booklet features a full-color individuals and their family members also have criti- guide the course of the interaction visual presentation that focuses on tools for cal needs for immediate follow-up care. speaking with three developmental groups When faced with this situation, providers must For more information about the Rocky (preschool, school age, and teenager), with manage multiple challenges such as limited staff Mountain MIRECC mission and to learn tips for responding to concerns and challenges time and resources while balancing these realities more about other educational resources unique to each group. with the need to address patient and family needs available to clinicians, visit and concerns. A large-scale survey conducted via www.mirecc.va.gov/visn19. THE BOOKLET: the National Alliance on Mental Illness highlighted References specific areas where family needs could be best met • Offers tips for parents/caregivers on introduc- 1. Cerel J, Currier GW, Conwell Y. Consumer and family experiences in by emergency departments, including communicat- ing concepts related to depression, hopeless- the emergency department following a suicide attempt. J Psychiatr ness, self-directed violence, and suicidality Pract. 2006;12:341-347. ing better about discharge planning and providing 2. Knesper DJ, American Association of Suicidology, Suicide Preven- written materials and information on other support • Builds understanding of why it is important tion Resource Center. Continuity of Care for Suicide Prevention and Research. Newton, MA: Education Development Center, Inc. 2010. resources.1 A Suicide Prevention Resource Center to speak to children about difficult and publication also focused on patient follow-up traumatic topics, what to share, how much MELISSA MCHARG is a program specialist at needs subsequent to a suicide attempt and dis- to share, and when Rocky Mountain MIRECC.

The Official Voice of Emergency Medicine DECEMBER 2015 ACEP NOW 7 A Convener of Emergency Medicine President Dr. Barry Heller on the ABEM’s role as a supportive hub for the emergency medicine community

The American Board of Emergency Medicine’s (ABEM) improvements to its Maintenance What is your vision for ABEM, es- us. Furthermore, the role models I encoun- of Certification (MOC) program may not grab national headlines, but the board has taken pecially as it impacts other organi- tered in the ED, people such as Bob Roth- a methodical and diplomate-focused approach to the evolution of MOC, spearheaded zations? stein, MD, our first emergency department by leaders who are also active members of the field of emergency medicine. chair [at Harbor-UCLA Medical Center in ABEM President Barry N. Heller, MD, a practicing emergency physician and assistant BH: There are so many challenges fac- Torrance, California], made an even bigger clinical professor of medicine at UCLA David Geffen School of Medicine, brings a passion ing the specialty and plaguing emergency impression and convinced me that this spe- for the specialty to his work at the organization. Elected President in August, Dr. Heller physicians. I believe that our specialty is cialty was the best match for me. is no stranger to the ABEM. He has been a member of the Board of Directors since July made stronger by working in collaboration My initial impression of ABEM was 2008 and has served on the Executive Committee since 2012. with the various membership organizations when I took the oral exam; it was a remark- He recently shared with ACEP Now his objectives for his presidency and his vision for serving our specialty. We all need to find able examination. I was impressed with the the future of the organization. ways to work in harmony with one another sophistication of the examination structure and not waste time bickering over differ- as well as the logistics of its administration. ences. When that happens, we lose, the It was clear to me that ABEM was focused What are your goals during your I recognize that the MOC program is specialty loses, and ultimately, our patients on quality, and I wanted to learn more about term as ABEM President? not perfect. We, the ABEM Board of Di- do not get the best that our specialty has the Board. I also wanted to give something rectors, are continually looking for ways to offer. ABEM can serve as a convener of back to the specialty that had served me Dr. Heller: First and foremost, I want to to improve the value, relevance, cost, the emergency medicine community, much so well. I had two great mentors who en- continue ABEM’s commitment to deliver- and meaning to our diplomates. As one as we have done with the EM Model Task couraged me, Howard Bessen, MD, and ing the best possible physician assess- prong of this approach, we are watch- Force. More recently, we brought together Bob Hockberger, MD. They are two great ment for initial and continuous certification. ful of changes made by other boards to every key EM organization for an MOC leaders in our field, and both served on the ABEM multiple-choice question examina- their MOC programs. For example, we are summit to explore ways of improving the ABEM Board of Directors. My connection tions focus on complex cognitive skills closely watching how the American Board program and had a similar summit on the with ABEM started in earnest when I be- such as clinical synthesis and diagnostic of Anesthesiology is changing from an issue of board eligibility last fall. came an oral examiner. Advancing through processing, not purely fact recall. This em- every-10-year exam to weekly online quiz- ABEM works to promote its mission the organization has been a professionally phasis carries over into the design of the zes. If this pilot is successful, we could see to ensure the highest standards in emer- rewarding experience. In-training Examination and the ConCert how this approach might be applied in the gency medicine. It has been energizing to (Continuous Certification) Examination. ABEM MOC program. collaborate with so many organizations in Where do you see ABEM heading? After nearly a decade of development and emergency medicine. For example, ABEM the commitment of substantial financial appreciates the opportunity to work with BH: As medicine changes, especially in resources, ABEM recently introduced the “I also want to explore ACEP on the development of clinical qual- the area of physician quality reporting, Enhanced Oral Certification Examination ity measures that are relevant and are ABEM needs to create a relevant, sen- (eOral) format. The eOral format creates a ways to increase the aligned with the ABEM MOC program. sible way to help physicians stay current more authentic experience to the current value of ABEM’s MOC The potential for working with ACEP to and to assure the public that emergency oral examination. The amount of effort the program to our dip- participate in the Clinical Emergency Data physicians are doing so. One attribute that ABEM Board, its hundreds of volunteers, Registry in order to reduce the reporting I bring to ABEM is the perspective of the and ABEM staff have expended on this lomates. When you requirements for Part IV Practice Improve- community physician. I’ve been clinically project has been herculean. The psycho- examine the cost and ment activities is quite exciting. If we can active at the same community hospital for metric rigor of the process and the enthusi- time commitment build the appropriate interface, reviewing 32 years. ABEM has over 32,000 diplo- asm with which the eOral format has been and reacting to one’s clinical performance mates, and most of them do not work in received have been very encouraging. emergency physicians reports would automatically be reported a residency program. It is important to re- I also want to explore ways to increase spend in MOC, it’s fairly to the ABEM MOC program. This would member the challenges that all of our dip- the value of ABEM’s MOC program to our lomates face in trying to deliver the best modest.” obviate the need for a separate attesta- diplomates. When you examine the cost tion and aligns with ABEM’s desire to care possible and demonstrating their and time commitment emergency physi- lessen the burden of MOC reporting for continuing competency and commitment cians spend in MOC, it’s fairly modest. our diplomates. to improvement. The annualized cost of MOC is $265, I see ABEM continuing its refinement as which is about $5 per week. ABEM has What initially drew you to the spe- the gold standard in certification and apply- kept the cost of the Lifelong Learning and cialty of emergency medicine and ing best practices to every type of physician Self-Assessment (LLSA) activity fixed for assessment. The transition from an episodic ABEM, in particular? the past four years and the ConCert Ex- physician testing organization to one of con- amination unchanged for the past three BH: I was lucky enough to have been in tinuous physician assessment will be ongo- years. ABEM’s participation in the Physi- a traditional rotating internship, with one ing. The most important goal for ABEM is cian Quality Reporting System (PQRS) month in obstetrics, neurosurgery, emer- to be true to our mission statement: to en- MOC bonus program through the Centers gency medicine, and so on. I say I was sure the highest standards in the specialty for Medicare & Medicaid Services added lucky because I think the loss of opportu- of emergency medicine. I also hope that nearly $4 million in available revenue for nities to see all these different disciplines we can continue to improve our specialty emergency physicians. ABEM also pro- significantly complicates the decision to so that, in addition to being the best in our vides low-cost CME opportunities with choose a specialty in today’s environment. field, we can always end our shifts with the the LLSA through ACEP and the American After several months working on different feeling that we have done something use- Academy of Emergency Medicine (AAEM). services, I came to the emergency depart- ful. By listening to physicians and creating All of the revenue from the CME activity ment, and I was amazed at how much I better links with the tremendous organiza- goes to ACEP and AAEM as the accred- enjoyed the many aspects of emergency tions supporting our specialty, I think we ited CME providers. Dr. Heller speaking at ACEP15 in Boston. medicine that make it so attractive to all of can achieve our mission.

8 ACEP NOW DECEMBER 2015 The Official Voice of Emergency Medicine ACEPNOW.COM

JAMES J. AUGUSTINE, MD, FACEP, is director of clinical operations at EMP in Canton, Ohio; clinical associate professor BRINGING DATA BENCHMARKING of Emergency Medicine at Wright State University in Dayton, TO THE BEDSIDE Ohio; vice president of the Emergency Department Benchmarking ALLIANCE Alliance; and on the ACEP Board of Directors. Bending the Curve Opportunities to reduce boarding time that will improve the care and service of all emergency patients by JAMES J. AUGUSTINE, MD, FACEP © SHUTTERSTOCK.COM

few years ago, emergency depart- ED boarding times for the years 2012, 2013, leadership needs to focus its efforts on the ment leaders were given a valuable and 2014 are summarized in Table 1. Re- ADDITIONAL nursing administration to link rapid flow of A gift. The Joint Commission and then porting the data by cohort gives ED leaders inpatients to nursing incentives. These may be the Centers for Medicare & Medicaid Servic- a much more precise comparison based on financial (credit for nurse worked hours going es (CMS) identified hospitals reducing the ED volume and patient population served. READING to the inpatient unit rather than the ED), com- boarding of admitted patients as a priority The highest number is found in adult EDs munication enhancement (timesaving patient • Wiler JL, Welch S, Pines J, et al. for safety and quality of care. This was an and those EDs seeing between 80,000 and Emergency department perfor- turnover methods from ED to inpatient nurs- opportunity to bend the curve on the amount 100,000 patients per year. These EDs have mance measures update. Acad es), and/or recognition (award programs for of time patients spent in the ED, a curve that boarding times of around 160 minutes. The Emerg Med. 2015;22:542-553. competing nursing units). had been on an upward trajectory for years in low-volume EDs, seeing fewer than 20,000 On the physician side, most EDs now ad- many hospitals. This time interval, referred patients, have boarding times that average 65 mit the majority of patients to hospitalists or • Rosenau AM, Augustine JJ, to in the ED literature as “boarding time,” minutes, nearly a 100-minute difference. The group practices, including resident teams. The Jones S, et al. The growing requires management by ED leaders and hos- boarding time median of 119 minutes in 2012 emergency physicians have the opportunity to evidence of the value of emer- pital administrators. Both groups promoted has been decreased to 112 minutes in 2014. negotiate with those services regarding the el- gency care. Acad Emerg Med. measures with The Joint Commission that re- But in many EDs, and in particular those 2015;22:224-226. ements of improved patient service and path- duced boarding time. They wrote standards in the 20,000 to 60,000 cohorts, the board- way compliance. Many admitting physicians that emphasized the importance of ED flow ing time has actually increased over the three want a patient to be completely “worked up” to minimize ED boarding. years measured. There is clearly an opportu- by the time that patient will reach the floor Then in 2011, CMS published a set of per- nity gifted from CMS and The Joint Commis- and have the most important therapies start- formance measures that highlighted the ED. sion to allow ED leaders the traction needed to ed. The emergency physician can offer those “ED-1, Admit Decision Time to ED Departure negotiate better hospital flow for admitted pa- elements if the admitting service will provide Time for Admitted Patients” was an impor- tients. More ED physicians and nurses need to a timely response to emergency physician tant measure. The CMS defined the measure engage in the efficient processing of patients dissatisfied ED staff, frustration, and turno- calls, a rapid concordance on the need for in a positive fashion: median time from ad- needing inpatient services. In most hospitals, ver at all levels. Overwhelmed EDs also lack admission, and the timely delivery of an “or- mit decision time to time of departure from this will primarily be focused on patients be- the capacity to respond to community emer- der to admit.” The emergency physician also the emergency department for emergency ing admitted to the same hospital, which on gencies and disasters. needs to facilitate the work of the admitting department patients admitted to inpatient average is 17 percent of overall ED volume. But The timely processing of patients who are physician with an organized and complete status. The rationale for this measure was the processes will also facilitate the movement of admitted to the hospital or transferred for history and physical exam on the patient re- opportunity for emergency physicians to inpatients to admission units of other hospitals admission to another hospital improves the cord and transition-of-care communication fluence behavior by hospital administration when transfers are necessary, which is about overall flow rate of all ED patients. This leads that is clear and concise. and the admitting medical staff of the hospi- 2 percent of patients in the average ED. to a culture of timeliness and satisfaction for The work of the emergency physicians tal. As the measure states, “Reducing the time Boarding of inpatients in the ED leads all patients who arrive for ED service and re- and nurses together will lead to a process of patients remain in the emergency department to crowded conditions, lack of patient care duces walkaway rates. effective care and communications and then can improve access to treatment and increase areas, insufficient staff to process all ED ar- Where have EDs had success in improving reduce blocking behaviors by staff in the ad- quality of care. Reducing this time potentially rivals, and then a deadly cascade. The cas- admission flow? Primary work is done outside mitting areas of the hospital. improves access to care specific to the patient cade will typically include prolonged patient of the ED, with the global recognition that re- There are a growing number of sources to condition and increases the capability to pro- waiting times, increased suffering for those duced boarding times are associated with use for best practices in the admission provide additional treatment.” waiting for service, unpleasant treatment en- reduced overall hospital length of stay, im- cess. It is the opportunity to use them to bend The measure was implemented in 2012 vironments, ambulance diversion, and poor proved quality of care, and closer adherence the curve of boarding time that will improve and was subject to public reporting in 2013. patient outcomes. The cascade then leads to to established hospital pathways. ED nursing the care and service of all ED patients. The simple definition and explanatory lan- guage became a very complicated process for Table 1. Boarding Time in the EDBA Data Survey Through 2014 many hospitals. The challenge was to define “admit decision time.” The Emergency De- partment Benchmarking Alliance (EDBA) ED BOARDING TIME, ED BOARDING TIME, ED BOARDING TIME, ED TYPE asked its 1,100 ED leaders to describe the MEDIAN MINUTES, MEDIAN MINUTES, MEDIAN MINUTES, time marker that had been implemented in 2012 2013 2014 their hospital. The reported definitions in- cluded actions by the ED clerk (placing a bed All EDs (N=1,105) 119 115 112 order), the ED charge nurse (contacting the Under 20K 83 73 65 bed coordinator), the admitting physician (writing an admission order), and the emer- 20–40K 80 101 96 gency physician (changing status to admit- 40–60K 122 128 124 ted in the ED information system). From the 60–80K 144 131 128 hundreds of answers to this question, it was apparent that there were wide variations in 80–100K 161 153 168 the definition of this time stamp. Over 100K 161 174 149 The EDBA initiated collection of the per- Pediatric EDs 97 96 98 formance measure in 2012. Unlike CMS, which reports all EDs as one group, the EDBA Adult EDs 175 161 154 reports the measure by cohorts. The median

The Official Voice of Emergency Medicine DECEMBER 2015 ACEP NOW 9 DR. LIEU and DR. RIVER are DR. MANTUANI is assis- DR. NAGDEV is director of emergency ONE MORE REASON ultrasound fellows at Highland tant director of emergency ultrasound at Highland Hospital and NOT TO ORDER SOUND Hospital, a member of Alameda ultrasound at Highland assistant clinical professor (volunteer) of AN X-RAY Health System, in Oakland, Hospital. emergency medicine at the University ADVICE California. of California, San Francisco. How to Perform Ultrasound-Guided Subclavian Vein Cannulation Part 1: The supraclavicular approach With the by CHARMIANE LIEU, MD, GERIN RIVER, MD, DANIEL MANTUANI, MPH, MD, AND ARUN NAGDEV, MD supraclavicular entral venous catheter placement is or femoral vein cannulation as an essential procedure in emergency well as attain proficiency with in- POTENTIAL PITFALLS approach, the medicine, with the internal jugular plane needling technique. C • This approach may be more SCV is often vein (IJV) the most commonly accessed site. However, in certain situations such as ab- Anatomy difficult in patients with higher BMI or short necks since it’s more normal neck anatomy, presence of a cervical The SCV runs from lateral to medi- shallow and difficult to probe and needle into the collar, IJV thrombosis, or active cardiopulmo- al under the clavicle, just anterior supraclavicular notch. easily visualized nary resuscitation, the subclavian vein (SCV) to the subclavian artery (SCA). As as compared to may be a better option.1,2 Also, because of the it approaches the heart, the SCV • Always clearly visualize the needle SCV’s fixed position under the clavicle, size is joined by the IJV, forming the tip with the in-plane technique and the infraclavicular variations are less common (unlike the often brachiocephalic vein. The supra- remember that the SCV is anterior to collapsed IJV noted in patients with severe clavicular approach attempts to the SCA. approach, making dehydration or sepsis). Cannulation of the cannulate the portion of the SCV • For more advanced sonographers, for an ideal site SCV may also improve patient comfort while just lateral to the clavicular head color Doppler can be used to discern reducing rates of infection and thrombosis of the sternocleidomastoid mus- between SCV and SCA. for central venous when compared to the IJV and femoral vein.3,4 cle.8 The right SCV is preferred to Classically, landmark-based SCV can- the left since it forms a straighter cannulation. nulation is performed below the clavicle. In angle with the IJV, offering a shorter distance Figure 3A). Slowly trace the IJV caudally (to- contrast, ultrasound guidance allows cannu- for wire passage into the superior vena cava, ward the chest) into the supraclavicular fossa lation to occur both via the infraclavicular (at avoiding proximity to the thoracic duct, which until the probe abuts the clavicle (see Figure the junction of the axillary vein and SCV) and drains into the left SCV (see Figure 1). 3B). While visualizing the most promximal/ supraclavicular (where the SCV meets the IJV caudal aspect of the IJV, angle the probe an- to form the brachiocephalic vein) approaches. Procedure teriorly to visualize the confluence of the IJV When compared to landmark techniques, ul- Set Up and SCV (see Figure 4). At this proximal loca- trasound guidance reduces the rates of arte- As with all central venous access, standard tion, the SCV lies anterior to the SCA, and the rial puncture, pneumothorax, brachial plexus sterile technique should be followed to mini- operator should dynamically fan the probe injury, and hematoma formation.5–8 With the mize infection (sterile ultrasound probe cover from a posterior to anterior position to iden- supraclavicular approach, the SCV is often and gel, drapes, etc.). Place the patient in a tify both vessels. shallow and easily visualized as compared to supine position and the ultrasound machine A clear view of the often shallow and large the infraclavicular approach, making for an contralateral to the patient (eg, left side of the SCV can make for a relatively simple access ideal site for central venous cannulation.9,10 patient for right SCV cannulation) to allow site. Unfortunately, variation in vascular anat- Our two-part series will discuss both the for visualization of the screen and needle in a omy always exists, and in some patients, clear supraclavicular and infraclavicular approach- similar line of sight (see Figure 2). SCV visualization can be difficult. es to ultrasound-guided SCV cannulation. Before attempting either of these more chal- Survey Scan Ultrasound-Guided SCV Cannulation lenging ultrasound-guided SCV cannulations, Place a high-frequency linear transducer (eg, After clear ultrasonographic visualization of we recommend novice sonographers obtain 13–6 MHz) on the lateral neck just above the the SCV is obtained, place a small skin wheal comfort with both the ultrasound-guided IJV clavicle to locate the IJV and carotid artery (see just lateral to the ultrasound transducer. Un-

Figure 2. For a right SCV cannulation, the operator has placed the ultrasound system on the contralateral side. This ergonomic position allows Figure 1. Surface anatomy of the right subclavian vein (SCV). Note the confluence of the SCV for direct view of the ultrasound screen and site and internal jugular vein (IJV) to form the brachiocephalic vein. of needle entry without change in visual axis.

10 ACEP NOW DECEMBER 2015 The Official Voice of Emergency Medicine ACEPNOW.COM

Figure 3. Figure 4. Figure 5. Figure 3. (A) In a transverse plane on the neck, locate the thyroid, IJV, and carotid artery (CA) deep to the sternocleidomastoid (SCM) muscle. (B) Slide the transducer down the IJV into the supraclavicular fossa until the subclavian artery (SCA) is noted.

Figure 4. Angle the probe like the classic ultrasound-guided IJV cannulation, and finally enters the SCV. Confirmation of venous SCV cannulation may be ideal in certain scenarios anteriorly (solid SCV cannulation will require the use of in-plane tech- access is performed in a similar manner to other and safer than the landmark-based SCV central line yellow arrow) to visualize the SCV 2,3,11 nique (see Figure 5). central venous cannulation sites (checking for non- placement. We recommend this access site as an as it joins the bra- Enter the skin just lateral to the transducer at pulsatile dark blood, ultrasound-guided visualiza- alternative for providers comfortable in procedures chiocephalic vein an angle that will intersect the SCV at the desired tion of the guidewire, etc.). A postprocedure chest requiring in-plane needle visualization. Using a (BCV). The external jugular vein (EJV) location (this angle will depend on patient body radiograph will determine the location of the cath- pragmatic ultrasound-based approach to central may be seen join- habitus and probe size). Slowly advance the needle eter tip and identify most pneumothoraces. venous cannulation that relies on visualized patient ing the SCV at this under ultrasound guidance, gently aspirating the anatomy, operator skill, and the clinical scenario al- location. syringe for flashback and ensuring that the needle Summary lows emergency physicians to become adept at an tip is clearly visualized as it transverses soft tissue The supraclavicular approach to ultrasound-guided often challenging aspect of emergency care. Figure 5. An in-plane technique will be used with the References 4. O’Grady NP, Alexander M, Burns LA, et al. patients: a prospective randomized study. vian venous catheterization: greater success Healthcare Infection Control Practices Advisory Critical Care Med. 2011;39:1607-1612. rate for less experienced operators using needle entering 1. Mallin M, Louis H, Madsen T. A novel technique Committee (HICPAC): guidelines for the preven- ultrasound guidance. Crit Care Med. the skin just lateral 7. Lalu MM, Fayad A, Ahmed O, et al. Ultrasound- for ultrasound-guided supraclavicular subclavian tion of intravascular catheter-related infections. 1995;23:692-697. guided subclavian vein catheterization: a to the ultrasound cannulation. Am J Emerg Med. 2010;28:966-969. Clin Infect Dis. 2011;52:e162-e193. systematic review and meta-analysis. Crit Care 10. Stachura MR, Socransky SJ, Wiss R, et al. A com- transducer. The op- 2. Gorchynski J, Everett WW, Pentheroudakis E. A 5. Brass P, Hellmich M, Kolodziej L, et al. Ultrasound Med. 2015;43:1498-1507. parison of the supraclavicular and infraclavicular erator should use modified approach to supraclavicular subclavian guidance versus anatomical landmarks for sub- views for imaging the subclavian vein with ultra- the nondominant vein catheter placement: the pocket approach. clavian or femoral vein catheterization. Cochrane 8. Patrick SP, Tijunelis M, Johnson S, et al. sound. Am J Emerg Med. 2014;32:905-908. Supraclavicular subclavian vein catheterization: hand to stabilize Cal J Emerg Med. 2004;3:50-54. Database Syst Rev. 2015;1:CD011447. 11. Parienti, J, Mongardon, N, Mégarbane B, et al. the forgotten central line. West J Emerg Med. the transducer on 3. Ouriel K. Preventing complications of central 6. Fragou, M, Gravvanis A, Dimitriou V, et al. Real- Intravascular complications of central venous 2009;10:110-114. venous catheterization. N Engl J Med. time ultrasound-guided subclavian vein cannula- catheterization by insertion site. N Engl J Med. the patient’s neck. 2003;348:2684-2686; author reply 2684-2686. tion versus the landmark method in critical care 9. Gualtieri E, Deppe SA, Sipperly ME, et al. Subcla- 2015;373:1220-1229. SCV; IJV; BCV.

What’s Hot ICD-10: Lesson Learned for 2016 During the First 90 Days BEGIN YOUR JOURNEY WITH PHASE I February 8-12, 2016 | DALLAS, TX Alternative Payment Are you a current Director Models of the or aspiring to be one? Future Join us for ACEP’s ED Directors Academy, to hear from veteran practitioners and management experts offering you tried-and-true solutions Avoid Big January 11-15, 2016 to dealing with difficult staffing issues, Penalties – New Orleans, LA creating patient satisfaction, and Navigate PQRS preventing errors and malpractice. complexities www.acep.org/rc Learn why so many see this as the must 800-798-1822, ext. 5 attend conference for ED directors and those aspiring to become director.

151202-EDDA Phase 1.indd 1 10/12/15 12:47 PM 151201-Reimbursement Coding.indd 1 10/12/15 12:46 PM The Official Voice of Emergency Medicine DECEMBER 2015 ACEP NOW 11 DR. DAHLE is the author of The White Coat Investor: A Doctor’s PROTECT YOUR Guide to Personal Finance and Investing and blogs at http://white POT OF GOLD FROM THE END OF THE coatinvestor.com. He is not a licensed financial adviser, accountant, BAD ADVICE or attorney and recommends you consult with your own advisers RAINBOW prior to acting on any information you read here. Avoiding the Hedonic Treadmill Steps toward saving may be tough, but you’ll thank yourself in the long run by JAMES M. DAHLE, MD, FACEP did earlier in life as mortgages are paid off, YEARS TO tax burdens decrease, children leave home SAVINGS FINANCIAL Q. I know you have recommended that attending physicians RATE INDEPENDENCE and finish their educations, work-related ex- should be putting about 20 percent of their gross income penses disappear, and the need for life and 0% Infinite disability insurance is eliminated. And ob- toward retirement. My spouse and I have found this to be viously if you work and save until you’re 80, 5% 65 very difficult, both early on and now that we’re in our mid you probably won’t need your portfolio to last 10% 50 careers. I am a bit embarrassed to say this, but I don’t see as long as an early retiree will. But the point 15% 42 of the chart remains the same—increased how we could spend much less than we currently do without 20% 36 savings simultaneously increase portfolio a dramatic change in our lifestyle. What should we do? size and decrease the need for income from 30% 27 the portfolio. A. Just as the time required to perform a chore Since you can always spend your entire 40% 21 There are some practical steps that can be seems to expand into the time available, so income and then some, the secret to financial 50% 16 taken in order to get off the hedonic treadmill. does our spending naturally expand until it independence always lies primarily on the Everyone has heard about how important it is 60% 12 consumes our entire income. For most peo- spending side of the equation. As a rule of to live on a budget. What they don’t tell you, ple, it requires a conscious and sometimes thumb, financial independence means you 70% 8 however, is that living on a budget is really a difficult effort to avoid this process. It is also have a level of assets that is approximately 80% 5 temporary process. A budget is a training tool, a truism of personal finance that decreas- 25 times your annual spending requirements. 90% 3 and once you’ve trained yourself to spend at a ing spending is far more psychologically The less you spend, the sooner you will be- sensible level, you can actually quit the physi- painful than increasing spending is pleas- come financially independent and the less 100% 0 cal act of budgeting. Most financially success- urable. To make matters worse, many of us you will have to save to reach that point, ful people can generally get to that point with find ourselves on the “hedonic treadmill,” which also means you will need to take less toward fighting it. Understanding the conse- a few months or years of careful budgeting. also known as “hedonic adaptation.” As risk with your investments. The easiest way quences of a low savings rate (ie, out-of-con- Track your spending by initially writing down you make more money, your expectations to avoid the hedonic treadmill is to never get trol spending) is also helpful. Saving more every dollar you spend, then make sure you and desires rise in tandem, resulting in no on it in the first place. However, for most of money each year not only increases the size are actually spending your money in accord- permanent gain in happiness. Thus, you us, a conscious effort is required to get off of your nest egg, it also reduces the size of the ance with your values. For example, if you work harder and harder, spending more the treadmill or at least limit its effects on nest egg required to maintain the same life- find you value vacations with your children and more, and then find you are no happier our financial lives. style in retirement. The math behind financial and having a nice home the most but dis- making and spending $500,000 a year than Financial literacy can pay great dividends independence is surprisingly simple. You can cover you are spending a large percentage you were making and spending $100,000 a in this respect. If you have never heard of he- make a chart with a 0 percent savings rate at of your money on education, eating out, and year. To make matters worse, the increasingly donic adaptation, chances are that you are one end and a 100 percent savings rate at the auto payments, then you need to realign your progressive tax burden on that additional in- already on the treadmill. Recognizing this other. Then using some simple basic assump- spending with your values. As a typical phy- come can further destabilize your finances. completely natural tendency goes a long way tions (ie, 5 percent real investment return and sician, you can generally buy anything you a 4 percent real withdrawal rate) want but not everything you want. Spend your and ignoring the effects of pen- money on what makes you the happiest. sions and Social Security, you can Some people find it easiest to boost their determine how long you need to savings rate by “saving their raises.” Every work for any given savings rate. time their income goes up, they simply keep For example, if you make spending the same way they did on a lower $200,000 per year and save 50 income. This technique, however, does not percent of your income, then you work as well for most emergency physicians, only need your investments to pro- who generally reach peak earnings relatively vide $100,000 in income, and you early in their career. can reach that point after about Studies have shown that spending cash 16 years. But if you only save 10 is psychologically more painful than using percent of your income, then you a debit card, which, in turn, is more pain- need your investments to provide ful than using a credit card. This behavioral $180,000 of income, and it will re- tendency, combined with the convenience of quire 50 years to reach that point. cards, means that we generally spend more Obviously everyone’s financial when using credit cards. So if you aren’t sav- situation differs, and if someone ing as much as you would like, consider going inherits significant assets early in to a cash-spending plan. Psychological stud- life, then they have the potential ies also show that our willpower is limited. We to become financially independ- are only able to deny ourselves so many times ent much earlier. But whether you before giving in. However, it turns out it takes start saving and investing at age 20 the same amount of willpower to decide not to or 40, it still takes just as long to buy a BMW as to avoid buying a latte. Use your reach financial independence, limited willpower where you can get the most and that amount of time is most bang for your buck—on the big-ticket items. dependent on your savings rate. Recognizing the behavioral pitfalls that Now, this chart overstates the lead to out-of-control spending can help case quite a bit, as most retirees keep you off the hedonic treadmill. Practic- will not only have some Social ing emergency medicine is far more enjoya- Security but also naturally spend ble when you do not have to do it for financial

ILLUSTRATION/PAUL JUESTRICH; PHOTOS SHUTTERSTOCK.COM ILLUSTRATION/PAUL much less in retirement than they reasons.

12 ACEP NOW DECEMBER 2015 The Official Voice of Emergency Medicine ACEPNOW.COM

DR. MCGOVERN is an DR. JUSTIN MCNAMEE PRACTICAL TIPS emergency medicine resident is an attending physician FOR THE TRICKS OF at St. Joseph's Regional at Emergency Medicine PRACTICAL DOC Medical Center in Paterson, Professionals in Ormond THE TRADE New Jersey. Beach, Florida.

Any pain on A BACKHANDED APPROACH TO TENDON LACERATIONS | CONTINUED FROM PAGE 1 proper treatment is reason enough to have Figure 1. Extensor injury zones.3 extension or a low threshold to treat these patients for a extension lag at tendon injury if there is any doubt in your mind. Even a small discrepancy in your exam the proximal may indicate a partial tendon laceration that can progress to a complete laceration if not interphalangeal treated appropriately. Kleinert and Verdan ZONE I developed a classification system for exten- joint on presen- sor tendon lacerations that divides the dorsal part of the hand into eight different zones tation to the ZONE II (see Figure 1).3 This classification system is ED should raise used below as a reference point to provide emergency physicians guidance in treating ZONE III your suspicion their next extensor tendon injury. for potential Extensor Tendon Injuries central slip and Lacerations ZONE IV Zone I: This zone encompasses the distal rupture. interphalangeal (DIP) joint and the remain- ing part of the finger distal to the joint. Most ZONE I ZONE V commonly, these injuries are closed and require immobilization in hyperextension of ZONE II the DIP for six to eight weeks and outpatient ZONE III follow-up with the hand surgeon.4 Besides outpatient follow-up with a hand surgeon, patients are truly responsible for how well ZONE IV these injuries will heal because it’s been ZONE VI shown that compliance with the splint is the biggest factor affecting successful treatment.5 For open injuries, hand surgeons use another classification method where zone I is split up into four different types.2 For our purposes, we will focus on open inju- ZONE VII ries with an associated tendon injury that you have identified on exam. If the injury results in physical loss of part of the tendon ZONE VIII or significant avulsion of the skin, the surgeon will likely need to take the patient to

the operating room for a possible graft, and JUESTRICH; PHOTOS SHUTTERSTOCK.COM ILLUSTRATION/PAUL we should cover them with antibiotics in the ED. However, if there is only loss of tendon continuity, we can suture the tendon back ED should raise your suspicion for potential of extension, the metacarpophalangeal joint together, splint only the DIP in mild hyper- central slip rupture. These patients should be (MCP) in 15° of flexion, and the PIP in the extension, and have the patient follow up as placed in a dorsal or volar splint that keeps neutral position with outpatient follow-up an outpatient with the hand surgeon.6 For the PIP in extension while allowing for full with a hand surgeon.10 these tendon laceration repairs, you may range of motion of the DIP.9 The complexity want to use a roll stitch, or dermatoteno- of the extensor mechanism surrounding the Zone IV: Once you start to enter zone IV, the desis, that incorporates both the overlying PIP requires the training of an orthopedic tendons become larger and easier to repair. skin and tendon using 4-0 or 5-0 nonabsorb- surgeon for repair of open lacerations of the Fortunately, there are not many instances of able sutures as detailed in Figure 2. tendon. For an extensor tendon laceration closed tendon injuries from zone IV and the identified within the ED, we can suture the more proximal zones. For tendon lacerations Zone II: This zone consists of the middle pha- overlying laceration, splint the wrist in 30° that are greater than 50 percent of the ten- lanx, and closed injuries can be placed in an don, we can repair the tendon with the modi- extension splint for three to four weeks if there fied Kessler technique detailed below in the Figure 2. Roll stitch for extensor is only minimal weakness on extension. How- suturing technique section.8 Similar to zone tendon laceration repair in zones ever, significant extensor lag will need to be III injuries, these should also be splinted in I and II.7 explored by a hand surgeon on an outpatient a volar splint and should follow up with the basis.8 Open tendon lacerations overlying the hand surgeon on an outpatient basis.10 middle phalanx can be repaired primarily in the ED using a roll stitch as described above Zone V: This zone is where we frequently en- in zone I, splinting the DIP in extension with . 1986;4:217-225. counter the “fight bites” that patients don’t outpatient follow-up with the hand surgeon. always willingly admit. With the high possi-

J EMERG MED bility of subsequent complications, any open Zone III: The most well-known closed injury injury in this region should be treated as a of zone III is perhaps rupture of the central fight bite until proven otherwise. After exten- slip, which results in the commonly tested sive irrigation of the wound, we can suture Boutonniere deformity typically two to three the tendon if possible. However, leave the weeks after the injury. Any pain on exten- skin open for hand surgeons to do a delayed sion or extension lag at the proximal inter- closure in their office. This is in addition to

phalangeal (PIP) joint on presentation to the REPRINTED WITH PERMISSION FROM CONTINUED on page 14

The Official Voice of Emergency Medicine DECEMBER 2015 ACEP NOW 13 TRICKS OF THE TRADE | CONTINUED FROM PAGE 13

Using the modified Bunnell technique and 4-0 nonabsorbable sutures, we can repair these lacerations in the ED. Patients can then be splinted (wrist in 30° of extension, MCP neutral, DIP and PIP joints free) and follow up with a hand surgeon.

placing a splint (wrist in 45° of extension, equately irrigated and debrided and that the References 6. Carl HD, Forst R, Schaller P. Results of primary extensor tendon repair in relation to the zone of injury and pre- MCP in 20° of flexion) and starting patients patient’s tetanus status is updated. For the 1. Tuncali D, Yavuz N, Terzioglu A, et al. The rate of upper- operative outcome estimation. Arch Orthop Trauma Surg. on prophylactic antibiotics, such as Augmen- majority of these injuries, you can approxi- extremity deep-structure injuries through small penetrat- 2007;127:115-119. ing lacerations. Ann Plast Surg. 2005;55:146-148. tin.5 If patients aren’t going to see the hand mate the overlying skin laceration, splint, 7. Calabro J, Hoidal CR, Susini LM. Extensor tendon 2. Griffin M, Hindocha S, Jordan D, et al. Management of surgeon the next day, it may be prudent to and have the patient follow up with the hand repair in the emergency department. J Emerg Med. extensor tendon injuries. Open Orthop J. 2012;6:36-42. 1986;4:217-225. have them come back to the ED for a wound surgeon in the next couple of days. These in- 3. Kleinert HE, Verdan C. Report of the Committee on 8. Hanz KR, Saint-Cyr M, Semmler MJ, et al. check in the next 24 hours. juries can be repaired as late as one week af- Tendon Injuries. J Hand Surg Am. 1983;8:794-798. Extensor tendon injuries: acute management and ter the initial injury.9 Instead of waking up 4. Anderson D. Mallet finger—management and patient secondary reconstruction. Plast Reconstr Surg. 2008;121:109e-120e. Zone VI: This zone encompasses the major- the orthopod at 3 a.m. for someone’s drunken compliance. Aust Fam Physician. 2011;40:47-48. 9. Newport ML. Extensor tendon injuries in the hand. ity of the dorsum of the hand. The broad, stupor–fueled flight through a pane of glass, 5. Handoll HH, Vaghela MV. Interventions for treating mallet finger injuries. Cochrane Database Syst Rev. J Am Acad Orthop Surg. 1997;5:59-66. well-defined tendons in this area make it, just take matters into your own hands. 2004;3:cD004574. 10. Chapter 11: Hand. In: Simon RR, Sherman SC, eds. arguably, the easiest tendon repair we can Emergency Orthopedics. 6th ed. New York, NY: do in the ED. Using the modified Bunnell WATCH NOW McGraw-Hill Medical; 2011:207-211. technique and 4-0 nonabsorbable sutures, 11. Rosh AJ, Kwon NS, Wilburn JM, et al. Extensor Visit ACEPNow.com to watch videos of the modified Kessler tendon repair. Medscape Web site. Available at: we can repair these lacerations in the ED. and modified Bunnell stitches. http://emedicine.medscape.com/article/109111- Patients can then be splinted (wrist in 30° of overview. Accessed Nov. 16, 2015. extension, MCP neutral, DIP and PIP joints free) and follow up with a hand surgeon.10 Figure 4. Summary diagram for repair of extensor tendon lacerations.

Zones VII and VIII: Once you have an extensor laceration in the wrist or forearm, the musculotendinous junctions and muscle bel- ZONE I lies become more involved, which is outside Roll stitch, DIP of the scope of what we can repair in the ED. splint We should repair the overlying skin and put in a volar splint (wrist in 20° of extension, ZONE VIII MCP neutral). Our hand surgeon colleagues are going to need to repair these injuries.10 Suture overlying ZONE II skin, splint wrist Roll stitch, DIP Tendon-Suturing Techniques in 20° ext, MCP splint As described above, there are a number of neutral, ortho different ways to repair tendon lacerations. primary repair ZONE I Typically, the tendon should be repaired with 4-0 or 5-0 nonabsorbable sutures. Two of the more commonly described repairs are ZONE II the modified Kessler and modified Bunnell stitches. Figure 3 provides a schematic of the repair. ZONE III

Figure 3. The modified Kessler (left) ZONE VII ZONE IV ZONE III and modified Bunnell (right) stitches Suture overlying Suture overlying for tendon repair.11 skin, splint wrist skin; splint wrist in in 20° ext, MCP ZONE I ZONE V 30° ext, MCP 15° neutral, ortho flex, and PIP neu- primary repair ZONE II tral; ortho primary repair ZONE III

ZONE IV ZONE VI

ZONE VI ZONE IV Modified Bunnell ZONE VII Modified Kessler repair, splint repair if >50% of wrist 30° ext, ZONE VIII tendon lacerated, MCP neutral, splint wrist in 30° JUSTIN MCNAMEE DIP/PIP free ext, MCP 15° flex, and PIP neutral Summary ZONE V Far too often, we become reliant on our con- Assume fight bite, sultants for relatively simple procedures that Augmentin, repair tendon can be done safely and efficiently in the ED. if possible, leave overlying Figure 4 provides a quick reference for repair- skin open, splint wrist ing these extensor tendon injuries in the ED; 45° ext and MCP neutral it is assumed that all of these injuries are ad-

14 ACEP NOW DECEMBER 2015 The Official Voice of Emergency Medicine ACEPNOW.COM

DR. LEVITAN is an adjunct professor of emergency medicine at Dartmouth AIRWAY ESSENTIALS College's Geisel School of Medicine in Hanover, New Hampshire, and a FOR TODAY’S visiting professor of emergency medicine at the University of Maryland, EMERGENCY Baltimore. He works clinically at critical care access hospitals in rural PHYSICIAN AIRWAY New Hampshire and teaches cadaveric and fiber-optic airway courses. Kovacs’ Sign and Overhand Rightward Turn Two pearls when using a hyperangulated video laryngoscope by RICHARD M. LEVITAN, MD, FACEP Figure 1 (Left). Blade position- ing and Kovacs' sign. In the upper image (ideal placement), yperangulated video laryngoscopes the cricoid ring is not seen. have blade shapes with a curvature There is more room beneath more acute than a standard Macin- the posterior larynx on the H monitor screen, which is criti- tosh blade. Commercial products include the cal for observing tube delivery. GlideScope, Storz D-Blade, and McGrath X In the lower image, the cricoid blade. In the course of teaching use of these ring and the internal aspect devices, I have often been told, “I had a great of the criothyroid membrane view but had trouble delivering the tube.” are visible between the vocal cords, indicating over-insertion Hyperangulated blades look around the cur- of the hyperangulated blade vature of the tongue very well, but their perspec- and a steep angle of approach. tive on the larynx, looking upward at it from the base of the tongue, can lead to difficulty in tube Figure 2 (Right). Schematic representation of the angle delivery. If the blade is inserted too deeply, the of approach. The top image video-imaging element gets very close to the lar- shows ideal placement of a ynx, and the view will be great, but the angle hyperangulated blade—in this case, a GlideScope Titanium of approach is consequently very extreme. This blade—compared to overinser- creates difficulty with tube delivery through tion (bottom image). Note that three mechanisms. First, it steepens the up an- the approach angle is more gle to the larynx; second, it shortens the tube acute and that there is less room for tube delivery between delivery area (distance from blade tip to larynx); the blade and the larynx. and third, it reduces the area on the screen for observing tube delivery. Operators must be careful that they look in the mouth when inserting a hyperangulated stylet, then carefully observe Verathon offers the GlideRite stylet to help Figure 3. GlideRite stylet has an it coming into view on the monitor. Jamming a with tube insertion. It is a rigid stylet with a approximate 70-degree angula- tion and a side-to-side long-axis rigid hyperangulated stylet into the posterior 70-degree angle and a nifty proximal end, al- dimension exceeding 2 inches pharynx (off screen) can cause injury to the soft lowing the thumb to pop the stylet up (see Fig- (far larger than the diameter of palate, tonsils, or hypopharynx. ure 3). A GlideRite stylet exceeds 2 inches in the human trachea). George Kovacs, MD, MHPE, an emergency side-to-side dimension; this exceeds the di- physician from Halifax, Nova Scotia, and direc- mensions of the human trachea. Accordingly, tor of the Airway Interventions & Management it is a tube delivery device (around the tongue in Emergencies (AIME) courses, recently showed and into the larynx), not a tracheal introducer. me a simple way to determine if the angle of ap- By partially removing the stylet after insertion proach using a hyperangulated blade is exces- through the cords, the tracheal tube can be ad- Figure 4. Right-turn overhand sive. I have labeled this “Kovacs' sign” and now vanced downward into the trachea. This ma- technique for hyperangulated stylet insertion into the tra- incorporate it into my instruction with hyperan- neuver, however, doesn’t address issues with chea. By turning the stylet and gulated blades (see Figures 1 and 2). If the blade the inclination of the trachea and the corruga- tube 90 degrees, the tube an- is overinserted, the cricoid ring becomes visible tion of the tracheal rings. gles downward, aligning with between the vocal cords. This indicates a very An easy maneuver, which can be done the inclination of the trachea. Note that the tube can be ad- steep angle of approach and will likely make tube gradually by the operator with no assistance, vanced in small increments off introduction difficult. Conversely, when the an- is turning the GlideRite stylet and tube 90 the stylet using the right hand gle of approach is not so steep, the cricoid ring is degrees to the right after insertion through only as long as an overhand not seen, there is more room between the blade the cords (see Figures 4 and 5). The operator grip is used at the top of the tube and stylet. tip and the larynx, and there will be more space should use an overhand grip at the top of the on the inferior aspect of the monitor to observe stylet and tube. After insertion through the tube delivery. cords, the tube and stylet are turned right- The second piece of the puzzle with a hyperan- ward, to the corner of the patient’s mouth, gulated video blade is getting the tube to drop into while making sure the tip is through the lar- Figure 5. Turning the the trachea. One cannot merely advance the stylet, ynx. The thumb is then used to slide the tube tube right improves as the curvature used to get around the tongue cre- off the stylet in a series of gradual advance- interaction with trachea rings (corruga- ates a side-to-side dimension that exceeds the di- ments. By turning the stylet and tube, the tion and inclination) ameter of the human trachea. The trachea is only tube now points downward, overcoming the with a left-bevel tube. 15–20 mm in males and 14–16 mm in females. Ad- inclination problem. Turning 90 degrees also Whenever inserting ditionally, if the hyperangulated stylet is simply rotates the bevel of the tube upward, which trachea tubes with a left-bevel tube, rotated upward through the cords, the direction prevents the tube tip from catching on the cor- if resistance is felt the tube and stylet points is upward, while the tra- rugation of the tracheal rings. beneath the vocal chea has a downward inclination. Finally, there Try the overhand turn and make sure to cords, a gentle right- are the tracheal rings, which can prevent tube watch for Kovacs' sign on your next use of a hy- ward turn will solve the problem in most advancement when using a standard asymmet- perangulated video laryngoscope. These are instances. ric left-beveled tracheal tube. simple tips that will improve your practice!

The Official Voice of Emergency Medicine DECEMBER 2015 ACEP NOW 15 DR. WELCH is a practicing emergency physician with Utah Emergency TIPS FOR Physicians and a research fellow at the Intermountain Institute for Health BETTER Care Delivery Research. She has written numerous articles and three books PERFORMANCE SPECIAL OPs on ED quality, safety, and efficiency. She is a consultant with Quality Matters Consulting, and her expertise is in ED operations. I Heard It Through the ‘Grapevine’ Texas hospital finds novel way to improve patient experience using AIDET

by SHARI WELCH, MD, FACEP committed to the AIDET system to take ACKNOWLEDGE these measures to the next level.2 Gordon Warm smile and number of communication strat- Aalund, MD, and Dahlia Hassani, MD, friendly greeting egies have evolved over the past presented their novel approach in a post- INTRODUCE A decade to improve the patient en- er at the 2015 Innovations in Emergency “Manage up” counter and experience of care. One mod- Department Management conference in yourself and others’ el that is promoted by the Studer Group, Orlando, Florida, February 24–26.3 competence to the and employed by many health systems, is Staff members trained in AIDET are person(s) called the AIDET system.1 What is AIDET? encouraged to use the words “excellent” T It is a composite of five behaviors to use and “thank you” liberally. Some of the A I D E DURATION in every patient/staff interaction to antici- particular habits or behaviors that can STANDS FOR: Provide others with pate, meet, and exceed expectations of promote the AIDET philosophy include: time expectations patients, coworkers, and visitors. AIDET ✔ ACKNOWLEDGE—Show a positive is used to decrease the anxiety of patients attitude and put others at ease. EXPLANATION and their families and to improve patient • Anticipate needs. Update the person(s) satisfaction. • Greet the person, provide eye con- about what Baylor Regional Medical Center in tact, and smile. to expect from you Grapevine, Texas, is a 269-bed hospital • Follow the 10 and 5 Rule: at 10 feet, and others that sees almost 50,000 emergency depart- look up and acknowledge, make THANK YOU ment visits. Already performing well in pa- eye contact, and smile; at five feet, Thank them for tient satisfaction measures (according to verbally greet and offer assistance choosing your U.S. News & World Report, 80 percent of if necessary. facility patients would recommend the facility to ✔ INTRODUCE—Give your name ILLUSTRATION/PAUL JUESTRICH; PHOTOS SHUTTERSTOCK.COM others), the emergency physician group and role.

Add the authority of Tintinalli’s Special to your teaching, practice, and study offer for ACEP members!

Presented in full color, Tintinalli’s Emergency Medicine is the most practical and clinically relevant reference of its kind. It covers virtually every condition for which patients seek emergency department care in a concise and easy-to-read manner. The most widely used textbook in emergency medicine, Tintinalli’s is the preferred study guide for in-training and board examinations and recertification.

2,300 pp | 8 ½ x 11 Special ACEP 2,000+ illustrations Regular Price Bookstore price: 978-0-07-179476-3 Item #479966 $249 $237

Available November 2015

Special member price available at bookstore.acep.org

ABS_AD_TEM_MGHP_1015

ABS_AD_TEM_MGHP_1015.indd 1 10/8/15 2:50 PM 16 ACEP NOW DECEMBER 2015 The Official Voice of Emergency Medicine ACEPNOW.COM

• Name: self, skill set, experience cooperation or assistance and support. • Department: coworkers, other depart- Each provider is audited on two to five • Thank the person for giving you an op- ments, physicians patients by scribes during an assigned portunity to help. ✔ DURATION—“How long will this take?” The group of emergency physicians in • Under-promise and over-deliver. shift ... the [AIDET] tool is used to give Grapevine has found another way to utilize • Give a time expectation that will surely scribes: as observers of physicians’ practices. be met and follow up if unable to meet performance feedback to the provider. While there is a growing body of literature expectations. demonstrating that scribes in the emergency • There are two types of time: real and per- department can improve efficiency, patient ceived. Understand both. satisfaction, and staff satisfaction, scribes ✔ EXPLANATION—“What will you be • Give explanation of purpose, the “why.” ✔ THANK YOU—Let them know you have were used in Grapevine to facilitate their AID- doing and why?” • Ask the person if they have any questions enjoyed helping or working with them. ET model. The department providers utilized • Explain step-by-step what will happen. or tell them to feel free to ask later. • Thank the person for communication and CONTINUED on page 18

CLASSIFIEDS

Texas - Texarkana Medical College of Wisconsin Earn up toTexas $450,000 - Texarkana plus partnership opportunity in as little as one year! Academic,Medical College VA, and of Community Wisconsin Earn up to $450,000 plus partnership Busy, high-acuity ED, tort reform, and Opportunities for MDs, DOs, and APPs opportunity in as little as one year! Academic, VA, and Community no state income tax -- no wonder our The best of both worlds – physiciansBusy, high-acuity love working ED, tortat CHRISTUS reform, and OurOpportunities Level I Adult ED for atMDs, Froedtert DOs, andHospital APPs is no state income tax -- no wonder our AcademicThe bestA and of bothGREAT Community worlds – EM completing an expansion in January 2016. St. Michael, a beautiful, award-winning Our Level I Adult ED at Froedtert Hospital is physicians love working at CHRISTUS Academic and Community We are recruiting for two faculty to complete hospital with a 33-bed, 60,000-volume completing an expansion in January 2016. St. Michael, a beautiful,ED. award-winning our Froedtert coverage in the Clinician/ We are recruiting for two faculty to complete hospital with a 33-bed, 60,000-volume Mercy Medical Center, an academically Educator Path. Our Department is also Enjoy scribes andED. NP/PA support. our Froedtert coverage in the Clinician/ initiating weekday coverage at the VA ED in affiliatedMercy Medicalcommunity Center, hospital an academicallyin downtown Educator Path. Our Department is also WonderfulEnjoy scribes mid-sized, and NP/PA family-friendly support. Milwaukee. We are recruiting for two faculty. community is an outdoor-lover’s dream. Baltimoreaffiliated is lookingcommunity to add hospital a Board in Certifieddowntown initiating weekday coverage at the VA ED in Wonderful mid-sized, family-friendly Emergency Physician. Additionally,Milwaukee. we We are are actively recruiting recruiting for two faculty.for six communityEmergency is Servicean outdoor-lover’s Partners, L.P. dream. Baltimore is looking to add a Board Certified faculty for our new, freestanding community is a respected, Texas-based, 100% EmergencyCAREER Physician. Additionally, we are actively recruiting for six Emergency Service Partners, L.P. ED, which opens in July, 2016. physician-owned group. faculty for our new, freestanding community is a respected, Texas-based, 100% Contact Ashley Ulbricht today at Mercy is a major community teaching affiliate AllED, faculty which opensmembers in July, could 2016. have clinical physician-owned group. [email protected] for more details, responsibilities at one or more sites. Contact Ashley Ulbricht today at Mercyof the is University a major community of Maryland teaching School affiliateof All faculty members could have clinical and mention job # 264830-11. HITS ALL THE [email protected] for more details, Medicine,of the University with all medical of Maryland students, School and of Weresponsibilities are also seeking at one PAs or and more NPs sites. for our new, and mention job # 264830-11. residents from multiple departments, rotating Froedtert ED 14-bed Clinical Decision Unit. Medicine, with all medical students, and We are also seeking PAs and NPs for our new, regularly.residents Thefrom Emergency multiple departments, Department rotating has TheFroedtert Department ED 14-bed of ClinicalEmergency Decision Medicine Unit. a long history of educational excellence, at MCW is nationally and internationally Texas - Houston Vicinity regularly. The Emergency Department has The Department of Emergency Medicine providinga long history regularHIGH of rotations educational for Emergency excellence,NOTES recognized in Resuscitation Research, Injury at MCW is nationally and internationally GleamingTexas - new Houston and expanded Vicinity Prevention and Control, EMS, Toxicology, emergency department opened Medicineproviding residents, regular rotationsmedical students,for Emergency and recognized in Resuscitation Research, Injury Global Health, Ultrasound, Medical Education, in September,Gleaming new just andone expandedhour from residents in other specialties. Prevention and Control, EMS, Toxicology, Medicine residents, medical students, and and Process Improvement. emergencyHouston! department opened Global Health, Ultrasound, Medical Education, in September, just one hour from residents in other specialties. Interestedand Process applicants Improvement. should submit a Full-time and PRNHouston! openings in Bellville, EMA – The Power of Blue TX for Family Medicine physicians with curriculum vitae and letter of interest to Dr. The DepartmentWhether sees it’s aover great 56,000 song or adult a great visits EM career, when Interested applicants should submit a Full-timeEmergency and Medicine PRN openings experience, in Bellville, as Stephen Hargarten, Department Chairman, at TX for Family Medicine physicians with annually with an additional 7,500 pediatric curriculum vitae and letter of interest to Dr. well as EM-boarded physicians. As part The Departmenteverything sees is perfectly over 56,000 aligned, adult it’s music visits to your ears. [email protected]. of Emergencythe Bryan-based Medicine St. Joseph experience, Health as patients seen primarily by pediatricians in Stephen Hargarten, Department Chairman, at well as EM-boarded physicians. As part annually with an additional 7,500 pediatric [email protected]. System, enjoy excellent specialty an adjacentJoin aarea. passionate 24 to group36 hours of physicians of daily PA and partner with of thebackup Bryan-based and easy St. transfers. Joseph Health patients seen primarily by pediatricians in System, enjoy excellent specialty coveragean adjacenta practice augments area. powered 24 54 to hours 36 by hours amazingof attending of daily support, PA technology, Flexiblebackup scheduling and easy andtransfers. paid physician coverage. A collegial medical Ohio - Canton malpractice. coveragebenefits augments and compensation, 54 hours of equitableattending scheduling, and Flexible scheduling and paid staffphysician provides coverage.extensive specialty A collegial coverage. medical Unique opportunityOhio to - joinCanton an independent, Work as few asmalpractice. 6 days per month and coaching/mentoring for career development and growth. top-quality, democratic, well-established become a true partner in your practice Thestaff department provides extensive houses aspecialty Sexual Assaultcoverage. Unique opportunity to join an independent, withWork Emergency as few as Service 6 days Partners,per month L.P. and Forensic Exam program that is the primary and physician-owned group with an become a true partner in your practice The departmentEmpowering houses you to havea Sexual a voice Assault in the practice while openingtop-quality, for andemocratic, ABEM or AOBEMwell-established BC/BE referral site for Baltimore City. We share close and physician-owned group with an Contactwith Emergency Jeff Franklin Service at jeff@eddocs. Partners, L.P. Forensic Exam programmaking that is thehealthcare primary work better. physician. com and mention job # 266643-11. relationships with nearby Health Care for the opening for an ABEM or AOBEM BC/BE Contact Jeff Franklin at jeff@eddocs. referral site for Baltimore City. We share close Starkphysician. County Emergency Physicians com and mention job # 266643-11. relationshipsExploreHomeless emergency with and nearby Baltimore Healthmedicine City. Care and for theurgent care staffs a 65,000+ volume ED and a Homeless and Baltimore City. 35,000+Stark Countyvolume UrgentEmergency Care. Physicians The ED opportunities in NJ, NY, PA, RI, NC and AZ. isstaffs nationally a 65,000+ recognized volume as the ED first-ever and a 35,000+ volume Urgent Care. The ED Exceptional Emergency Medicine Mercy is ranked by US News and World accredited chest pain center in the US, is Opportunity ais multi-year nationally recipient recognized of the as HealthGrades the first-ever ReportMercy the #2is ranked hospital, by and US theNews #1 andcommunity World accredited chest pain center in the US, is Exceptional Emergency Medicine Emergency Medicine Excellence award, AntelopeOpportunity Valley, California hospital, in Maryland. Becker rates it as a a multi-year recipient of the HealthGrades Report the #2 hospital, and the #1 community and is also a level II Trauma Center and Tophospital, 100 Hospital. in Maryland. Sponsored Becker by ratesthe Sisters it as a StrokeEmergency Center. Medicine Excellence award, AntelopeAntelope Valley Valley,Emergency California Medical and is also a level II Trauma Center and Associates (AVEMA) seeks: Topof Mercy, 100 Hospital. we are an Sponsored independent, by thefiscally Sisters Antelope Valley Emergency Medical strong hospital, located six blocks north of EquitableStroke Center. and flexible scheduling. (1) Experienced,Associates board (AVEMA) certified seeks: Emergency of Mercy, we are an independent, fiscally Excellent provider staffing levels. Newly Baltimore’s Inner Harbor, equidistant between Equitable and flexible scheduling. PhysicianLearn for morefull-time/part-time about career work with opportunities: IC Callstrong 866.630.8125 hospital, or locatedview openings six blocks at www.ema.net/careers north of renovated ED. Great work-lifestyle (1) Experienced, statusboard certified Emergency theBaltimore’s University Inner of Maryland Harbor, and equidistant Johns Hopkins between balance.Excellent Clearly provider defined staffing levels.equal-equity Newly Physician for full-time/part-time work with IC renovated ED. Great work-lifestyle (2) PAs or NPs withstatus EM/Acute Care the University of MarylandHospital. and Johns Hopkins partnership track (including equity experience interestbalance. inClearly an independent defined equal-equitybilling Hospital. partnership track (including equity (2) PAs or NPs with EM/Acute Care company). Student loan reduction Hourly compensationexperience is among the highest in program.interest Generousin an independent benefits includebilling Southern California. Salary and benefits are competitive. company). Student loan reduction Hourly compensation is among the highest in 100% employer-funded retirement plan, AVEMA is a stable,Southern independent, California. democratic MercySalary is an Equaland benefits Employment are competitive. Opportunity BE/CMEprogram. account, Generous PLI benefitsinsurance withinclude 100% employer-funded retirement plan, group that has staffed the ED for over 40 Employer. corporate tail, and HSA-based health AVEMA is a stable,years. independent, democratic Mercy is an Equal Employment Opportunity insurance.BE/CME account, PLI insurance with group that has staffed the ED for over 40 Employer. corporate tail, and HSA-based health Antelope Valley Hospitalyears. is a public, not for insurance.Contact Frank Kaeberlein, MD at profit hospital in Lancaster, California, with 115,000Antelope ED Valleyvisits. Hospital We have is trauma, a public, stroke, not for Interested candidates should submit their Contact(330)-489-1365 Frank Kaeberlein, or MD at STEMI,profit EDAP, hospital and in chestLancaster, pain centerCalifornia, status. with curriculum vitae to Scott A. Spier, MD, Chief Full115,000 specialty ED visits.call panel We 24/7. have Also:trauma, Scribe stroke, Interested candidates should submit their [email protected](330)-489-1365 or coverageSTEMI, forEDAP, all physicians/NPs/PAs, and chest pain center efficient status. curriculumMedical Officer, vitae to MercyScott A.Medical Spier, Center,MD, Chief FullEHR, specialtywww.ema.net radiologist call real-time panel |24/7. [email protected] reading Also: of Scribeall | 3 Century Drive, Parsippany,[email protected]. NJ 07054 | 866.630.8125 [email protected] imaging,coverage paid for malpractice,all physicians/NPs/PAs, housing between efficient Medical Officer, Mercy Medical Center, shifts,EHR, excellent radiologist nurses real-time and medical reading staff. of all [email protected]. imaging, paid malpractice, housing between As theshifts, community-training excellent nurses siteand for medical the UCLA/ staff. OVMC EM residency program, residents The Official Voice of Emergency Medicine Asare the in community-trainingthe ED most days. siteUCLA for faculty the UCLA/ DECEMBER 2015 ACEP NOW 17 appointmentOVMC EM is residency possible forprogram, our attendings. residents are in the ED most days. UCLA faculty appointmentThis is an is amazing possible opportunity! for our attendings.

We lookThis forward is an amazing to hearing opportunity! from you.

WeContact: look forward Thomas to hearing Lee, MD, from you. [email protected] Contact:323-642-7127 Thomas Lee, MD, [email protected] 323-642-7127 SPECIAL OPs | CONTINUED FROM PAGE 17 the AIDET tool but struggled with a process the use of the AIDET validation tool. Each Scribe-implemented AIDET validation References to validate each individual provider’s per- provider is audited on two to five patients by was an effective tool to evaluate and im- 1. Putnam JB Jr, Kennedy J. Teaching physician-pa- formance for feedback purposes. In an early scribes during an assigned shift. The tool is prove provider communication. Can you tient communication (AIDET) for results in all pillars. Studer Group Web site. Available at: http://www. trial, they used another provider to validate easily completed by the scribes in the course see the possibilities? Scribes have the po- studergroupmedia.com/WRIHC/presentations/ the use of AIDET, but that proved costly and of the workflow, and the tool is used to give tential to become partners in emergency de- teaching_physician_patient_communication_(aidet)_for_results_in_all_pillars_vanderbilt_putnam_ required providers to be available on a shift performance feedback to the provider. The partment quality and safety initiatives and kennedy_0028.pdf. Accessed Nov. 10, 2015. for which they weren’t previously scheduled feedback is unique in that it is nearly done provide another opportunity to align the 2. Baylor Regional Medical Center. U.S. News & World (not a popular proposition!). in real time, which allows physicians to im- goals of the entire health care team. Great Report Web site. Available at: http://health.usnews. com/best-hospitals/area/tx/baylor-regional- The need to identify another method for prove in real time. The results are provided job in Grapevine! medical-center-6741739/details. Accessed Nov. monitoring AIDET in practice led to utiliza- routinely with no increased departmental PS: According to Grapevine Medical Di- 10, 2015. tion of departmental scribes for the auditing costs. Providers discuss results at depart- rector and Chairman Robert Risch, MD, they 3. Aalund G. AIDET validation using scribes in the ED. Poster presented at: Innovations in Emergency project. All providers receive AIDET train- mental meetings. Coaching is tailored for have used scribes to help with hand washing Department Management conference, Feb. 24–26, ing. Scribes are also trained on AIDET and individual providers. and several other lean projects. 2015; Orlando, Florida.

CLASSIFIEDS

Physician and Leadership OPPORTUNITIES

EmCare leads the way in Making Healthcare Work Better™, especially for physicians. We provide the resources you need so you can focus on what’s truly important - patient care. Whether you are considering full-time, part-time or independent contractor opportunities with EmCare, you can rest assured you will be working for an industry-leader who delivers a vast array of benefits unmatched within the industry. Come join our team, contact us today!

ARKANSAS OPPORTUNITIES NORTH FLORIDA OPPORTUNITIES KANSAS OPPORTUNITIES SOUTH CAROLINA TENNESSEE OPPORTUNITIES Sparks Medical Center (Van Buren) Lake City Medical Center Menorah Medical Center OPPORTUNITIES Horizon Medical Center (Dickson) (Lake City) (Overland Park) McLeod Health, 3 hospital system Erlanger Baroness (Chattanooga) CENTRAL FLORIDA Gulf Coast Medical Center Overland Park FSED (Shawnee) (Dillon, Loris, Seacoast) Level 1 Trauma Center. Academic OPPORTUNITIES (Panama City) Medical Director Medical Director and Staff Department Chair Citrus Memorial (Inverness) Galichia Heart Hospital (Wichita) TEXAS OPPORTUNITIES Erlanger North Hospital Largo Medical Center SOUTH FLORIDA OPPORTUNITIES Wesley Medical Center (Wichita) CHRISTUS Spohn Hospital - Alice (Chattanooga) (Indian Rocks) Broward Health, 4-hospital system (Alice) ParkRidge Medical Center Leesburg Regional Medical Center (Ft. Lauderdale) Adult and Pediatric KENTUCKY OPPORTUNITIES CHRISTUS Hospital - St. Elizabeth (Chattanooga) (Leesburg) Northwest Medical Center Greenview Regional Minor Care (Beaumont) Sequatchie Valley Munroe Regional Medical Center (Ft. Lauderdale) (Bowling Green) Conroe Regional Medical Center Emergency(Dunlap) (Ocala) Adult and Pediatric Fishermen’s Hospital (Marathon) Murray-Calloway County Hospital (Conroe) Medical Director Physicians Regional Medical Poinciana Medical Center Raulerson Hospital (Okeechobee) (Murray) CHRISTUS Spohn Hospital - Center (Knoxville) (Orlando) Fawcett Memorial Hospital Shoreline (Corpus Christi) Turkey Creek Medical Center Brandon Regional Emergency (Port Charlotte) LOUISIANA OPPORTUNITIES East Houston Regional Medical (Knoxville) Center (Plant City) St. Lucie Medical Center FSED CHRISTUS St. Patrick Hospital Center (Houston) Medical Director Skyline Medical Center (Nashville) Bayfront Punta Gorda (Port St. Lucie) (Lake Charles) West Houston Regional (Houston) Level 2 trauma Center (Punta Gorda) Palms West Hospital CHRISTUS Highland Medical CHRISTUS Jasper Memorial Southern Hills Medical Center Central Florida Regional Hospital (West Palm Beach) Center (Shreveport) Hospital (Jasper) Medical Director (Nashville) (Sanford) West Palm Hospital and Staff Stonecrest Medical Center Doctor’s Hospital of Sarasota (West Palm Beach) MISSOURI OPPORTUNITIES CHRISTUS Spohn Hospital - (Nashville) (Sarasota) Belton Hospital (Belton) Kleberg (Kingsville) TriStar Ashland City (Nashville) Sebastian River Medical Center GEORGIA OPPORTUNITIES Golden Valley Memorial Hospital Pearland Medical Center University Medical Center (Sebastian) Doctor’s Hospital of Augusta (Clinton) (Pearland) (Nashville) Bayfront Spring Hill & Brooksville (Augusta) Centerpoint Hospital CHRISTUS Hospital - St. Mary Erlanger Bledsoe Hospital 2 hospital system (Spring Hill) Murray Medical Center (Independence) Level 2 trauma (Port Arthur) (Pikeville) Oak Hill Hospital (Spring Hill) (Chatsworth) center CHRISTUS Santa Rosa Hospital - Northside Hospital (St. Petersburg) Fairview Park (Dublin) Westover Hills (San Antonio) VIRGINIA OPPORTUNITIES Medical Center of Trinity (Tampa Piedmont Fayette Hospital NEW HAMPSHIRE OPPORTUNITIES CHRISTUS Alon/Creekside FSED Henrico Doctors’ Hospital, Bay) Medical Director and Staff (Fayetteville) Parkland Regional Hospital (San Antonio) 5 campuses (Richmond) Citrus Park ER (Tampa Bay) Coliseum Medical Center (Macon) (Portsmouth) CHRISTUS Santa Rosa - Alamo Brandon Regional Hospital South Georgia Medical Center Heights (San Antonio) (Tampa Bay) (Valdosta) Medical Director and Staff PENNSYLVANIA OPPORTUNITIES Metropolitan Hospital (San Tampa Community Hospital Smith Northview Urgent Care Lancaster Regional Medical Antonio) (Tampa Bay) Center (Valdosta) Center (Lancaster) Northeast Methodist (San Antonio) The Villages Regional Hospital Mayo Clinic at Waycross Heart of Lancaster Regional Medical Director and Staff (The Villages) (Waycross) Medical Center (Lancaster) Methodist TexSan (San Antonio) Florida Hospital, 3-hospital system (Lake Placid, Sebring, Wauchula)

FULL TIME, PART TIME AND PER DIEM ASK ABOUT OUR TRAVEL OPPORTUNITIES! [email protected] Quality people. Quality Care. Quality of LIFE. 727.437.3052 • 727.507.2526

18 ACEP NOW DECEMBER 2015 The Official Voice of Emergency Medicine CLASSIFIEDS WE’RE UNITING. YOU’RE WINNING.

COMING TOGETHER TO IMPROVE THE WORLD OF HEALTH CARE.

Schumacher Group and Hospital Physician Partners are joining forces. With our combined clinical services

and expertise, we’ll be able to provide more advantages

than ever to our providers, hospital partners, and patients. PATIENTS PROVIDERS

STATES HOSPITALS

www.schumachergroup.com www.hppartners.com ADVANTAGE:

Emergency Medicine

Don’t just join another ED. Emergency Physicians Join a system of opportunity! (Faculty Positions) The Department of Emergency Medicine at Rutgers Robert Wood Johnson Medical School is currently recruiting Emergency Physicians to join our growing 20 Hospitals in Long Island, Queens, Staten academic faculty. Island, Manhattan and Westchester County Robert Wood Johnson University Hospital serves as the medical school’s primary teaching affiliate. The Hospital is a 580-bed Level 1 Trauma Center and New Academic, Administrative & Research Settings Jersey’s only Level 2 Pediatric Trauma Center with an annual ED census of greater than 90,000 visits. Whether you are just starting out as an Emergency Physician or have decades of experience, the North Shore-LIJ Health System has the career opportunity The Department has a well-established three-year residency program and an you want today. We can also help you plan for tomorrow with ﬂexible options Emergency Ultrasound fellowship. The Department is seeking physicians who can for scheduling or transferring to diff erent locations as your goals and needs contribute to our clinical, education and research missions. Qualified candidates must be ABEM/ABOEM certified/eligible. change. So, don’t just plan your next move. Plan your career. Salary and benefits are competitive and commensurate with experience. Please send a letter of intent and curriculum vitae to: Robert Eisenstein, MD Interim Contact Andria Daily to learn more: Chairman, Department of Emergency Medicine, Robert Wood Johnson Medical 844-4EM-DOCS School, 1 Robert Wood Johnson Place, MEB 104, New Brunswick, New Jersey, [email protected] 08901; Email: [email protected]; Phone: 732-235-8717; Fax: 732- nslijemphysicians.com 235-7379.

We are an equal opportunity/AA employer: F/M/Disability/Vet Rutgers, The State University of New Jersey is an Affirmative Action/Equal Opportunity Employer, M/F/D/V.

ACEP NOW TO PLACE AN AD IN ACEP NOW ’S CLASSIFIED 12/1/2015ADVERTISING SECTION PLEASE CONTACT: 10001399-NY11885 Kevin Dunn: [email protected] NOW | Cynthia Kucera: [email protected] | Phone: 201-767-4170 11/1/2015, 12/1/2015 UMDNJX 10000957-NY11193 4.875” x 5” NORSHL Gabrielle Mastaglio v.5 The Official Voice of Emergency Medicine4.875” x 5” DECEMBER 2015 ACEP NOW 19 Ellen Aronoff v.2 CLASSIFIEDS Aloha

As Hawaii’s oldest and largest ED physician group we are dedicated to nurturing the next generation of quality emergency physicians and meeting the ever-changing healthcare challenges. Contact JD Kerley at (877) 379-1088 or email your CV to [email protected].

TRUE PARTNERSHIP OPPORTUNITY

Providence Health Center Brody School of Medicine • Busy 86,000-volume ED EMERGENCY MEDICINE FACULTY • Scribe coverage & NP/PA support • Certified stroke and chest pain center ◊ Clinician-Educator ◊ Clinical-Researcher ◊ Critical Care Medicine ◊ • BC/BP in Emergency Medicine required ◊ Pediatric Emergency Medicine ◊ Ultrasound ◊

The Department of Emergency Medicine at East Carolina University Brody School of Medicine seeks BC/BP emergency physicians and pediatric emergency physicians for tenure or clinical track positions at the rank of assistant professor or above, depend- ing on qualifications. We are expanding our faculty to increase our cadre of clinician-educators and further develop programs in pediatric EM, ultrasound, clinical research, and critical care. Our current faculty members possess diverse interests and expertise leading to extensive state and national-level involvement. The emergency medicine residency is well-established and includes 12 EM and 2 EM/IM residents per year. We treat more than 130,000 patients per year in a state-of-the-art ED at Vidant Medical Center. VMC is a 960+ bed level 1 trauma center and regional referral center. Our tertiary care catchment area includes more than 1.5 million people in eastern North Carolina, many of whom arrive via our integrated mobile critical care and air medical service. Our new children’s ED opened in July 2012, and a new children’s hospital open in June 2013. Greenville, NC is a fast-growing university community located near beautiful North Carolina beaches. Cultural and recreational opportunities “Providence is a busy hospital where I can see high are abundant. Compensation is competitive and commensurate with qualifications; acuity in a fast-paced environment. Leave work and excellent fringe benefits are provided. Successful applicants will be board certified or prepared in Emergency Medicine or Pediatrics Emergency Medicine. They will possess Waco offers attractive real estate with great schools outstanding clinical and teaching skills and qualify for appropriate privileges from and the best sports teams in the Big 12 (Sic ‘Em ECU Physicians and VMC. Bears!). I have access to all that I would want in a big city without the hassles of traffic and crowds.” Confidential inquiry may be made to: Theodore Delbridge, MD, MPH —Nicholas Steinour, MD Chair, Department of Emergency Medicine ED Medical Director [email protected]

ECU is an EEO/AA employer and accommodates individuals with disabilities. Applicants must comply with the Immigration Reform and Control Act. Proper documentation of identity and employability required at the time (512) 610-0316 of employment. Current references must be provided upon request. [email protected] www.ecu.edu/ecuem/ 252-744-1418

20 ACEP NOW DECEMBER 2015 The Official Voice of Emergency Medicine CLASSIFIEDS

What has your career done for you lately?

As facility medical director, Dr. Karen Kriza relies on TeamHealth to manage the administrative duties associated with operating an efficient emergency room. Thanks to TeamHealth’s support with scheduling, recruiting, insurance negotiations and risk management, Dr. Kriza has more time to focus on her patients and family and enjoy the luxuries of living by the water.

Text CAREERS to 411247 for latest news and info on our job opportunities! Visit teamhealth.com to find the job that’s right for you.

Featured Opportunities:

Hamilton Medical Center Grays Harbor Charleston Area Medical Dalton, GA Community Hospital Center General Hospital 63,000 volume Aberdeen, WA Charleston, WV Medical Director 35,000 volume 36,000 volume Medical Director Memorial Hospital College Station Martinsville, VA St. Joseph’s Medical Center Medical Center 43,000 volume Stockton, CA College Station, TX 65,000 volume 25,000 volume Northwest Healthcare Florissant, MO Hilton Head Hospital Hillside Hospital 58,000 volume Hilton Head, SC Pulaski, TN 23,000 volume 12,000 volume WCA Hospital Jamestown, NY Abrazo Arrowhead Campus Waterbury Hospital 36,000 volume Glendale, AZ Waterbury, CT 36,000 volume 55,000 volume

855.615.0010 | [email protected] | www.teamhealth.com

TH-9713 The Official Voice of Emergency Medicine DECEMBER 2015 ACEP NOW 21 Global branding campaign ad size: 9.875 x 13.875 full bleed pub: ACEP Now (DEC) Texas - Texarkana Medical College of Wisconsin Earn up to $450,000 plus partnership opportunity in as little as one year! Academic, VA, and Community Busy, high-acuity ED, tort reform, and Opportunities for MDs, DOs, and APPs no state income tax -- no wonder our The best of both worlds – Our Level I Adult ED at Froedtert Hospital is physicians love working at CHRISTUS Academic and Community completing an expansion in January 2016. St. Michael, a beautiful, award-winning We are recruiting for two faculty to complete hospital with a 33-bed, 60,000-volume ED. our Froedtert coverage in the Clinician/ Enjoy scribes and NP/PA support. Mercy Medical Center, an academically Educator Path. Our Department is also affiliated community hospital in downtown initiating weekday coverage at the VA ED in Wonderful mid-sized, family-friendly Milwaukee. We are recruiting for two faculty. community is an outdoor-lover’s dream. Baltimore is looking to add a Board Certified Emergency Physician. Additionally, we are actively recruiting for six Emergency Service Partners, L.P. faculty for our new, freestanding community is a respected, Texas-based, 100% ED, which opens in July, 2016. physician-owned group. Contact Ashley Ulbricht today at Mercy is a major community teaching affiliate All faculty members could have clinical [email protected] for more details, responsibilities at one or more sites. of the University of Maryland School of and mention job # 264830-11. Medicine, with all medical students, and We are also seeking PAs and NPs for our new, residents from multiple departments, rotating Froedtert ED 14-bed Clinical Decision Unit. regularly. The Emergency Department has The Department of Emergency Medicine Texas - Houston Vicinity a long history of educational excellence, at MCW is nationally and internationally providing regular rotations for Emergency recognized in Resuscitation Research, Injury Gleaming new and expanded Prevention and Control, EMS, Toxicology, emergency department opened Medicine residents, medical students, and Global Health, Ultrasound, Medical Education, in September, just one hour from residents in other specialties. and Process Improvement. Houston! Interested applicants should submit a Full-time and PRN openings in Bellville, TX for Family Medicine physicians with curriculum vitae and letter of interest to Dr. The Department sees over 56,000 adult visits Emergency Medicine experience, as Stephen Hargarten, Department Chairman, at well as EM-boarded physicians. As part annually with an additional 7,500 pediatric [email protected]. of the Bryan-based St. Joseph Health patients seen primarily by pediatricians in System, enjoy excellent specialty an adjacent area. 24 to 36 hours of daily PA backup and easy transfers. coverage augments 54 hours of attending Flexible scheduling and paid Ohio - Canton malpractice. physician coverage. A collegial medical staff provides extensive specialty coverage. Unique opportunity to join an independent, Work as few as 6 days per month and top-quality, democratic, well-established become a true partner in your practice The department houses a Sexual Assault and physician-owned group with an with Emergency Service Partners, L.P. Forensic Exam program that is the primary opening for an ABEM or AOBEM BC/BE Contact Jeff Franklin at jeff@eddocs. referral site for Baltimore City. We share close physician. com and mention job # 266643-11. relationships with nearby Health Care for the CLASSIFIEDS Stark County Emergency Physicians Homeless and Baltimore City. staffs a 65,000+ volume ED and a Texas - Texarkana 35,000+ volume Urgent Care. The ED is nationally recognized as the first-ever Medical College of Wisconsin Earn up to $450,000 plus partnership Exceptional Emergency Medicine TexasTexasMercy -- TexarkanaTexarkana is ranked by US News and World accredited chest pain center in the US, is Opportunity opportunity in as little as one year! a multi-year recipient of the HealthGrades MedicalMedical College College of of Wisconsin Wisconsin EarnEarn up up to Reportto $450,000 $450,000 the plus plus #2 partnership partnership hospital, and the #1 community Academic, VA, and Community opportunityopportunityhospital, in in as as little little in as as Maryland. one one year! year! Becker rates it as a Busy, high-acuity ED, tort reform, and Emergency Medicine Excellence award, Academic,AntelopeAcademic, VA,Valley, VA, and and CaliforniaCommunity Community Opportunities for MDs, DOs, and APPs Busy,Busy, high-acuity high-acuity ED, ED, tort tort reform, reform, and and no state income tax -- no wonder our The best of bothand is worldsalso a level II Trauma– Center and OpportunitiesOpportunities for for MDs, MDs, DOs, DOs, and and APPs APPs Top 100 Hospital. Sponsored by the Sisters Antelope Valley Emergency Medical nono state state income income tax tax -- -- no no wonder wonder our our TheThe bestbest ofof bothboth worldsworlds –– Our Level I Adult ED at Froedtert Hospital is physicians love working at CHRISTUS Academic andStroke Community Center. OurOur Level LevelAssociates I IAdult Adult ED ED (AVEMA) at at Froedtert Froedtert seeks: Hospital Hospital is is physiciansphysicians love loveof Mercy,working working at atwe CHRISTUS CHRISTUS are an independent, fiscallyAcademicAcademic andand CommunityCommunity St. Michael, a beautiful, award-winning completingcompleting anan expansionexpansion inin JanuaryJanuary 2016.2016. St.St. Michael, Michael, a a beautiful, beautiful, award-winning award-winning completing an expansion in January 2016. hospital withstrong a 33-bed, hospital, 60,000-volume located six blocks north of hospital with a 33-bed, 60,000-volume Equitable and flexible scheduling. (1)WeWe Experienced, are are recruiting recruiting boardfor for two two certified faculty faculty to to Emergencycomplete complete hospital with a 33-bed, 60,000-volume We are recruiting for two faculty to complete Excellent provider staffing levels. Newly Baltimore’sED.ED. Inner Harbor, equidistant between ED. Physicianourour FroedtertFroedtert for full-time/part-time coveragecoverage inin thethe work Clinician/Clinician/ with IC MercyMercy MedicalMedical Center,Center, anan academicallyacademically our Froedtert coverage in the Clinician/ renovated ED. Great work-lifestyle EducatorEducator Path.Path. statusOurOur DepartmentDepartment isis alsoalso EnjoyEnjoy scribes scribes and and NP/PA NP/PA support. support. Mercy Medical Center, an academically the University of Maryland and Johnsaffiliatedaffiliated Hopkins communitycommunity hospitalhospital in in downtowndowntown Educator Path. Our Department is also Enjoy scribes and NP/PA support. balance. Clearly defined equal-equity initiatinginitiating weekdayweekday coveragecoverage atat thethe VAVA EDED inin WonderfulWonderful mid-sized, mid-sized, family-friendly family-friendly affiliated community hospital in downtown Milwaukee.Milwaukee.(2) PAs orWe We NPs are are recruitingwith recruiting EM/Acute for for two two Care faculty. faculty. communitycommunity is is an an outdoor-lover’s outdoor-lover’s dream. dream.Hospital. BaltimoreBaltimore isis lookinglooking toto addadd aa BoardBoard CertifiedCertified initiating weekday coverage at the VA ED in Wonderful mid-sized, family-friendly partnership track (including equity experience EmergencyEmergency Physician.Physician. Milwaukee. We are recruiting for two faculty. community is an outdoor-lover’s dream. Baltimore is looking to addinterest ain Board an independent Certified billing Additionally,Additionally, we we are are actively actively recruiting recruiting for for six six EmergencyEmergency Service Service Partners, Partners, L.P. L.P. Hourlyfacultyfaculty compensation forfor ourour new,new, freestandingisfreestanding among the communitycommunity highest in isis a a respected, respected, Texas-based, Texas-based, 100% 100% Emergency Physician.company). Student loan reduction physician-ownedphysician-owned group. group. Additionally, we are actively recruiting for six Emergency Service Partners, L.P. program. Generous benefits include ED,ED, which which opens Southernopens in in July, July, California. 2016. 2016. Salary and benefits are competitive. ContactContact Ashley Ashley Ulbricht Ulbricht today today at at MercyMercy isis aa majormajor communitycommunity teachingteaching affiliateaffiliate AllAll facultyfaculty membersmembers couldcould havehave clinicalclinical faculty for our new, freestanding community is a respected, Texas-based, 100% 100% employer-funded retirement plan, [email protected]@eddocs.comMercy is forforan more more Equal details, details, Employment Opportunity physician-owned group. AVEMAresponsibilitiesresponsibilities is a stable, at at one one independent, or or more more sites. sites. democratic ofof thethe UniversityUniversity ofof MarylandMaryland SchoolSchool ofof ED, which opens in July, 2016. BE/CME account, PLI insurance with group that has staffed the ED for over 40 andand mention mention job job # # 264830-11. 264830-11.Employer. Medicine,Medicine, withwith allall medicalmedical students,students, andand Contact Ashley Ulbricht today at Mercy is a major communitycorporate teachingtail, and HSA-based affiliate health WeWe are are also also seeking seekingyears. PAs PAs and and NPs NPs for for our our new, new, residentsresidents fromfrom multiplemultiple departments,departments, rotatingrotating All faculty members could have clinical insurance. FroedtertFroedtert ED ED 14-bed 14-bed Clinical Clinical Decision Decision Unit. Unit. [email protected] for more details, of the University of Maryland School of Antelope Valley Hospital is a public, not for regularly.regularly. TheThe EmergencyEmergency DepartmentDepartment hashas responsibilities at one or more sites. TheThe DepartmentDepartment ofof EmergencyEmergency MedicineMedicine a long history of educational excellence, and mention job # 264830-11. Contact Frank Kaeberlein, MD at profit hospital in Lancaster, California, with TexasTexas - - Houston Houston Vicinity Vicinity a long history of educational excellence, Medicine, with all medical students, and 115,000atat MCWMCW ED is visits.is nationallynationally We have andand trauma, internationallyinternationally stroke, Interested candidates should submitprovidingproviding their regularregular rotationsrotations forfor EmergencyEmergency We are also seeking PAs and NPs for our new, recognizedrecognized in in Resuscitation Resuscitation Research, Research, Injury Injury residents from multiple departments,(330)-489-1365 rotatingor STEMI, EDAP, and chest pain center status. GleamingGleamingcurriculum new new and and expanded expandedvitae to Scott A. Spier, MD,MedicineMedicine Chief residents,residents, medicalmedical students,students, andand Froedtert ED 14-bed Clinical Decision Unit. FullPreventionPrevention specialty andand call Control,panelControl, 24/7. EMS,EMS, Also: Toxicology,Toxicology, Scribe emergencyemergency department department opened opened regularly. The Emergency Department has GlobalGlobal Health, Health, Ultrasound, Ultrasound, Medical Medical Education, Education, inin September, September,Medical just just one one Officer, hour hour from from Mercy Medical Center,residents residents inin otherother specialties.specialties. [email protected] coverage for all physicians/NPs/PAs, efficient Houston! The Department of Emergency Medicine a long history of educational excellence, andandEHR, Process Process radiologist Improvement. Improvement. real-time reading of all Houston! [email protected]. Texas - Houston Vicinity imaging,InterestedInterested paid applicants applicantsmalpractice, shouldshould housing submitsubmit between aa Full-timeFull-time and and PRN PRN openings openings in in Bellville, Bellville, at MCW is nationally and internationally TXTX for for Family Family Medicine Medicine physicians physicians with with providing regular rotations for Emergency shifts,curriculumcurriculum excellent vitaevitae andnursesand letterletter and ofof medical interestinterest staff.toto Dr.Dr. TheThe DepartmentDepartment seessees overover 56,00056,000 adultadult visitsvisits recognized in Resuscitation Research, Injury Gleaming new and expanded EmergencyEmergency Medicine Medicine experience, experience, as as StephenStephen Hargarten, Hargarten, Department Department Chairman, Chairman, at at wellwell as as EM-boarded EM-boarded physicians. physicians. As As part part annuallyannually withwith anan additionaladditional 7,5007,500 pediatricpediatric Prevention and Control, EMS, Toxicology, emergency department opened Medicine residents, medical students, and [email protected]@mcw.edu. the community-training site for the UCLA/ OVMC EM residency program, residents ofof the the Bryan-based Bryan-based St. St. Joseph Joseph Health Health patientspatients seenseen primarilyprimarily byby pediatricianspediatricians inin Global Health, Ultrasound, Medical Education, in September, just one hour from residents in other specialties. System,System, enjoy enjoy excellent excellent specialty specialty anan adjacentadjacent area.area. 2424 toto 3636 hourshours ofof dailydaily PAPA are in the ED most days. UCLA faculty backupbackup and and easy easy transfers. transfers. and Process Improvement. Houston! appointment is possible for our attendings. coveragecoverage augmentsaugments 5454 hourshours ofof attendingattending FlexibleFlexible scheduling scheduling and and paid paid physicianphysician coverage.coverage. A A collegialcollegial medicalmedical Interested applicants should submit a Full-time and PRN openings in Bellville, This isOhio Ohioan amazing - - Canton Canton opportunity! malpractice.malpractice. TX for Family Medicine physicians with staffstaff providesprovides extensiveextensive specialtyspecialty coverage.coverage. curriculum vitae and letter of interest to Dr. The Department sees over 56,000 adult visits UniqueUnique opportunity opportunity to to join join an an independent, independent, WorkWork as as few few as as 6 6 days days per per month month and and Emergency Medicine experience, as top-quality,top-quality,We look forwarddemocratic,democratic, to hearing well-establishedwell-established from you. becomebecome a a true true partner partner in in your your practice practice TheThe departmentdepartment houseshouses aa SexualSexual Assault Assault Stephen Hargarten, Department Chairman, at well as EM-boarded physicians. As part annually with an additional 7,500 pediatric andand physician-ownedphysician-owned groupgroup withwith anan withwith Emergency Emergency Service Service Partners, Partners, L.P. L.P. ForensicForensic ExamExam programprogram thatthat isis thethe primaryprimary [email protected]. of the Bryan-based St. Joseph Health patients seen primarily by pediatricians in openingopening Contact:for for an an ABEM ABEM Thomas or or AOBEM Lee,AOBEM MD, BC/BE BC/BE ContactContact Jeff Jeff Franklin Franklin at at jeff@eddocs. jeff@eddocs. referralreferral sitesite forfor BaltimoreBaltimore City.City. WeWe shareshare closeclose physician.physician. [email protected] comcom and and mention mention job job # # 266643-11. 266643-11. relationshipsrelationships withwith nearbynearby HealthHealth CareCare forfor thethe System, enjoy excellent specialty an adjacent area. 24 to 36 hours of daily PA 323-642-7127 backup and easy transfers. StarkStark CountyCounty EmergencyEmergency PhysiciansPhysicians HomelessHomeless andand BaltimoreBaltimore City.City. coverage augments 54 hours of attending staffsstaffs aa 65,000+65,000+ volumevolume EDED andand aa Flexible scheduling and paid physician coverage. A collegial medical 35,000+35,000+ volumevolume UrgentUrgent Care.Care. TheThe EDED Ohio - Canton malpractice. isis nationallynationally recognized recognized asas thethe first-everfirst-ever MercyMercy isis rankedranked byby USUS NewsNews andand WorldWorld accreditedaccredited chest chest pain pain center center in in the the US, US, is is ExceptionalExceptional Emergency Emergency Medicine Medicine staff provides extensive specialty coverage. OpportunityOpportunity Report the #2 hospital, and the #1 community Unique opportunity to join an independent, Work as few as 6 days per month and aa multi-year multi-year recipient recipient of of the the HealthGrades HealthGrades Report the #2 hospital, and the #1 community hospital, in Maryland. Becker rates it as a top-quality, democratic, well-established become a true partner in your practice The department houses a Sexual Assault EmergencyEmergency MedicineMedicine ExcellenceExcellence award,award, AntelopeAntelope Valley, Valley, California California hospital, in Maryland. Becker rates it as a andand is is also also a a level level II II Trauma Trauma Center Center and and TopTop 100100 Hospital.Hospital. SponsoredSponsored byby thethe SistersSisters and physician-owned group with an with Emergency Service Partners, L.P. Forensic Exam program that is the primary AntelopeAntelope Valley Valley Emergency Emergency Medical Medical StrokeStroke Center. Center. AssociatesAssociates (AVEMA) (AVEMA) seeks: seeks: ofof Mercy,Mercy, wewe areare anan independent,independent, fiscallyfiscally opening for an ABEM or AOBEM BC/BE Contact Jeff Franklin at jeff@eddocs. referral site for Baltimore City. We share close strongstrong hospital,hospital, locatedlocated sixsix blocksblocks northnorth ofof EquitableEquitable and and flexible flexible scheduling.scheduling. (1)(1) Experienced, Experienced, board board certified certified EmergencyEmergency physician. com and mention job # 266643-11. relationships with nearby Health Care for the ExcellentExcellent provider provider staffing staffing levels.levels. NewlyNewly PhysicianPhysician for for full-time/part-time full-time/part-time work work with with IC IC Baltimore’sBaltimore’s InnerInner Harbor,Harbor, equidistantequidistant betweenbetween renovatedrenovated ED.ED. GreatGreat work-lifestylework-lifestyle statusstatus thethe UniversityUniversity ofof MarylandMaryland andand JohnsJohns HopkinsHopkins Stark County Emergency Physicians Homeless and Baltimore City. balance.balance. Clearly Clearly defined defined equal-equityequal-equity (2)(2) PAs PAs or or NPs NPs with with EM/Acute EM/Acute Care Care Hospital.Hospital. staffs a 65,000+ volume ED and a partnershippartnership tracktrack (including(including equityequity experienceexperience interestinterest inin anan independentindependent billingbilling 35,000+ volume Urgent Care. The ED company).company). StudentStudent loanloan reductionreduction HourlyHourly compensation compensation is is among among the the highest highest in in is nationally recognized as the first-ever Mercy is ranked by US News and World program.program. Generous Generous benefits benefits includeinclude SouthernSouthern California. California. SalarySalary andand benefitsbenefits areare competitive.competitive. Exceptional Emergency Medicine 100%100% employer-fundedemployer-funded retirementretirement plan,plan, MercyMercy isis anan EqualEqual EmploymentEmployment OpportunityOpportunity accredited chest pain center in the US, is Opportunity AVEMAAVEMA is is a a stable, stable, independent, independent, democratic democratic Report the #2 hospital, and the #1 community BE/CMEBE/CME account,account, PLIPLI insuranceinsurance withwith groupgroup that that has has staffed staffed the the ED ED for for over over 40 40 Employer.Employer. a multi-year recipient of the HealthGrades corporatecorporate tail,tail, andand HSA-basedHSA-based healthhealth years.years. Emergency Medicine Excellence award, Antelope Valley, California hospital, in Maryland. Becker rates it as a insurance.insurance. AntelopeAntelope Valley Valley Hospital Hospital is is a a public, public, not not for for and is also a level II Trauma Center and Top 100 Hospital. Sponsored by the Sisters profitprofit hospitalhospital in in Lancaster,Lancaster, California,California, withwith ContactContact Frank Frank Kaeberlein, Kaeberlein, MD MD at at Interested candidates should submit their Stroke Center. Antelope Valley Emergency Medical 115,000115,000 ED ED visits. visits. We We have have trauma, trauma, stroke, stroke, Interested candidates should submit their Associates (AVEMA) seeks: of Mercy, we are an independent, fiscally (330)-489-1365(330)-489-1365 or or STEMI,STEMI, EDAP, EDAP, and and chest chest pain pain center center status. status. curriculumcurriculum vitaevitae toto ScottScott A. A. Spier,Spier, MD,MD, ChiefChief FullFull specialty specialty call call panel panel 24/7. 24/7. Also: Also: Scribe Scribe Equitable and flexible scheduling. strong hospital, located six blocks north of [email protected]@cantonmercy.org coveragecoverage for for all all physicians/NPs/PAs, physicians/NPs/PAs, efficient efficient MedicalMedical Officer,Officer, MercyMercy MedicalMedical Center,Center, (1) Experienced, board certified Emergency EHR,EHR, radiologist radiologist real-time real-time reading reading of of all all [email protected]@mdmercy.com. Excellent provider staffing levels. Newly Physician for full-time/part-time work with IC Baltimore’s Inner Harbor, equidistant between imaging,imaging, paid paid malpractice, malpractice, housing housing between between shifts,shifts, excellent excellent nurses nurses and and medical medical staff. staff. renovated ED. Great work-lifestyle status the University of Maryland and Johns Hopkins balance. Clearly defined equal-equity TO PLACE AN AD INAsAs the theACEP community-training community-training NOW site site forfor’S the the UCLA/ UCLA/ (2) PAs or NPs with EM/Acute Care Hospital. OVMCOVMC EM EM residency residency program, program, residents residents partnership track (including equity areare in in the the ED ED most most days. days. UCLA UCLA faculty faculty experience appointmentappointment is is possible possible for for our our attendings. attendings. interest in an independent billing CLASSIFIED ADVERTISING SECTION company). Student loan reduction Hourly compensation is among the highest in ThisThis is is an an amazing amazing opportunity! opportunity! Southern California. Salary and benefits are competitive. We look forward to hearing from you. program. Generous benefits include PLEASE CONTACT:We look forward to hearing from you. 100% employer-funded retirement plan, AVEMA is a stable, independent, democratic Mercy is an Equal Employment Opportunity Contact:Contact: Thomas Thomas Lee, Lee, MD, MD, BE/CME account, PLI insurance with [email protected]@ucla.edu group that has staffed the ED for over 40 Employer. 323-642-7127323-642-7127 corporate tail, and HSA-based health years. insurance. Antelope Valley Hospital is a public, not for Kevin Dunn: Contact Frank Kaeberlein, MD at profit hospital in Lancaster, California, with [email protected] 115,000 ED visits. We have trauma, stroke, Interested candidates should submit their (330)-489-1365 or STEMI, EDAP, and chest pain center status. curriculum vitae to Scott A. Spier, MD, Chief Full specialty call panel 24/7. Also: Scribe Cynthia Kucera: [email protected] coverage for all physicians/NPs/PAs, efficient Medical Officer, Mercy Medical Center, EHR, radiologist real-time reading of all [email protected]. [email protected] imaging, paid malpractice, housing between shifts, excellent nurses and medical staff. Phone: 201-767-4170

As the community-training site for the UCLA/ OVMC EM residency program, residents are in the ED most days. UCLA faculty appointment is possible for our attendings. 22 ACEP NOW DECEMBER 2015 The Official Voice of Emergency Medicine This is an amazing opportunity! We look forward to hearing from you. Contact: Thomas Lee, MD, [email protected] 323-642-7127 EPPH joins US Acute Care Solutions. Welcome trailblazer.

We’re glad you don’t turn away from adventure. That you chose to align with the innovators to secure and grow your territory. As a founding partner of US Acute Care Solutions, we’ll give you the muscle you need to compete, and the resources you need to expand your horizons. You’ll maintain your identity under the security of the powerful group we’re forming together. Physician strong, we will remain majority physician owned. We won’t be traded or sold. We’re not a commodity. We’re US Acute Care Solutions. We own our future.

Start your future now. Visit usacs.com Founded in 2015 by EMP | From New York to Hawaii or call Ann Benson at 800-828-0898. [email protected]

4/C Process EPPH announcement ad 10.875˝ x 15˝ 66825A RAPID RHINO Epistaxis Journal Ad ACEP NOW.pdf 1 9/17/2015 3:26:17 PM

RAPID RHINO™ Epistaxis Products

For epistaxis events, there’s only one right answer: RAPID RHINO product by Smith & Nephew.

CMY

• Easy placement • Lubricated removal • Anterior and posterior options

Reach for RAPID RHINO Epistaxis Products.

Contact your local sales representative or call 1.800.797.6520. www.smith-nephew.com/ent Supporting healthcare professionals for over 150 years.