Acep's First Gentleman

SURVIVING SEPSIS CAMPAIGN ACEP AT 50 YEARS BENCHMARKING ALLIANCE Correlation Does Founding Fathers on Return ED Visits: A Marker Not Equal Causation First National Gathering of Success or Failure? SEE PAGE 11 SEE PAGE 15 SEE PAGE 21 MARCH 2018 Volume 37 Number 3 FACEBOOK/ACEPFAN TWITTER/ACEPNOW ACEPNOW.COM PLUS SHINING A LIGHT ON HUMAN TRAFFICKING FBI expert outlines the LAS VEGAS challenges of helping PATIENT'S PERSPEC- TIVES ON VEGAS trafficking victims SHOOTING: PART 2 uman trafficking is an incred- SEE PAGE 17 PHOTO: ACEP ibly challenging problem to try to Hsolve because it hides in the shad- ows. Not only are traffickers motivated to keep their activities under the radar of law ACEP’S FIRST enforcement, often victims are, too. Is that young woman with the broken arm who was brought to your emergency department by a male “friend” a victim of trafficking? What GENTLEMAN about the shy young man with the black eye and sexually transmitted infection? And if ANTHEM they are, what can you do about it? Matty Parker, husband of ACEP Past President ACEP STANDS UP Cynthia M. Deitle, JD, spent two decades FOR PRUDENT Dr. Rebecca Parker, on standing beside an ACEP leader with the FBI’s Civil Rights program, which LAYPERSON he specialty of emergency medicine is the safety net for our nation’s includes a program to combat human traf- health care system. What—or more important, who—fortifies that ficking. Her experience ranged from work- SEE PAGE 16 T safety net? Emergency medicine is filled with gratification but in- ing on individual trafficking cases to being cludes just as many challenges. Those in our lives serve as the pillars of chief of the Civil Rights unit, giving her a support for us as emergency physicians, the unseen foundation that allows broad understanding of the trafficking prob- EP PILLARS for our return to the trenches day in and day out. This column will highlight lem in the United States and the bureau’s OF SUPPORT the pillars of support in many emergency physicians’ lives. Thank you to efforts to combat it. She recently sat down Honoring the those who support us. with ACEP Now Medical Editor-in-Chief FIND IT ONLINE For more clinical stories and people who To start the series, ACEP Now Medical Editor in Chief Kevin Klauer, Kevin Klauer, DO, EJD, FACEP, to talk about practice trends, plus commentary support us and opinion pieces, go to: some of the challenges she faced while try- www.acepnow.com CONTINUED on page 14 CONTINUED on page 12 A new continuing medical education feature of ACEP Now LOG ON TO http://www.acep.org/ ACEPeCME/ TO COMPLETE THE ACTIVITY AND EARN EM CASES FREE AMA PRA CATEGORY 1 CREDIT. The Golden www.wileycustomerhelp.com visit our website website our visit If you have changed your address or wish to contact us, please please us, contact to wish or address your changed have you If Hoboken, NJ 07030-5790 NJ Hoboken, Hour of ICH River Street River 111 Journal Customer Services Customer Journal JOHN WILEY & SONS, INC. SONS, & WILEY JOHN Management PERIODICAL PAGE 22 PHOTO: SHUTTERSTOC.COM NOW AVAILABLE THE ELIQUIS STARTER PACK Designed to support DVT/PE treatment initiation THE ELIQUIS STARTER PACK OFFERS YOUR PATIENTS: • Their fi rst 30-day supply of ELIQUIS treatment • Refi ll reminder: prompts DVT/PE patients to complete with daily dosing instructions refi ll their ELIQUIS prescription • 2 separate wallets per box No cost to eligible patients when using the − Wallet 1 contains ELIQUIS treatment for days ELIQUIS Free Trial Offer* 1-14 along with directions on how to step down dosing after week 1 For more information, speak to your − Wallet 2 contains ELIQUIS treatment for ELIQUIS Sales Representative days 15-30 or visit hcp.eliquis.com Not actual size. DVT=deep vein thrombosis; PE=pulmonary embolism. *Eligibility Requirements and Terms of Use apply. IMPORTANT SAFETY INFORMATION WARNINGS AND PRECAUTIONS WARNINGS AND PRECAUTIONS (cont’d) DRUG INTERACTIONS (cont'd) WARNING: (A) PREMATURE DISCONTINUATION OF • Increased Risk of Thrombotic Events after Premature Monitor patients frequently and if neurological compromise is 10 mg twice daily, reduce the dose of ELIQUIS by 50% when ELIQUIS INCREASES THE RISK OF THROMBOTIC EVENTS, Discontinuation: Premature discontinuation of any oral noted, urgent diagnosis and treatment is necessary. ELIQUIS is coadministered with drugs that are strong dual (B) SPINAL/EPIDURAL HEMATOMA anticoagulant, including ELIQUIS, in the absence of adequate Physicians should consider the potential benefi t versus the inhibitors of CYP3A4 and P-gp (e.g., ketoconazole, (A) Premature discontinuation of any oral anticoagulant, alternative anticoagulation increases the risk of thrombotic risk of neuraxial intervention in ELIQUIS patients. itraconazole, ritonavir, or clarithromycin). In patients already including ELIQUIS, increases the risk of thrombotic events. events. An increased rate of stroke was observed during the • Prosthetic Heart Valves: The safety and effi cacy of ELIQUIS taking 2.5 mg twice daily, avoid coadministration of ELIQUIS If anticoagulation with ELIQUIS is discontinued for a reason transition from ELIQUIS to warfarin in clinical trials in atrial have not been studied in patients with prosthetic heart valves with strong dual inhibitors of CYP3A4 and P-gp. other than pathological bleeding or completion of a course fi brillation patients. If ELIQUIS is discontinued for a reason and is not recommended in these patients. • Strong Dual Inducers of CYP3A4 and P-gp: Avoid of therapy, consider coverage with another anticoagulant. other than pathological bleeding or completion of a course of • Acute PE in Hemodynamically Unstable Patients or concomitant use of ELIQUIS with strong dual inducers of (B) Epidural or spinal hematomas may occur in patients therapy, consider coverage with another anticoagulant. Patients who Require Thrombolysis or Pulmonary CYP3A4 and P-gp (e.g., rifampin, carbamazepine, phenytoin, treated with ELIQUIS who are receiving neuraxial anesthesia • Bleeding Risk: ELIQUIS increases the risk of bleeding and can Embolectomy: Initiation of ELIQUIS is not recommended as St. John’s wort) because such drugs will decrease exposure to or undergoing spinal puncture. These hematomas may cause serious, potentially fatal, bleeding. an alternative to unfractionated heparin for the initial apixaban and increase the risk of stroke and other result in long-term or permanent paralysis. Consider these – Concomitant use of drugs affecting hemostasis increases treatment of patients with PE who present with hemodynamic thromboembolic events. risks when scheduling patients for spinal procedures. the risk of bleeding, including aspirin and other antiplatelet instability or who may receive thrombolysis or pulmonary • Anticoagulants and Antiplatelet Agents: Coadministration Factors that can increase the risk of developing epidural agents, other anticoagulants, heparin, thrombolytic agents, embolectomy. of antiplatelet agents, fi brinolytics, heparin, aspirin, and or spinal hematomas in these patients include: SSRIs, SNRIs, and NSAIDs. ADVERSE REACTIONS chronic NSAID use increases the risk of bleeding. APPRAISE-2, – Advise patients of signs and symptoms of blood loss and to a placebo-controlled clinical trial of apixaban in high-risk • use of indwelling epidural catheters • The most common and most serious adverse reactions report them immediately or go to an emergency room. reported with ELIQUIS were related to bleeding. post-acute coronary syndrome patients treated with aspirin or • concomitant use of other drugs that affect hemostasis, Discontinue ELIQUIS in patients with active pathological the combination of aspirin and clopidogrel, was terminated such as nonsteroidal anti-infl ammatory drugs (NSAIDs), hemorrhage. TEMPORARY INTERRUPTION FOR SURGERY early due to a higher rate of bleeding with apixaban compared platelet inhibitors, other anticoagulants – There is no established way to reverse the anticoagulant AND OTHER INTERVENTIONS to placebo. • ELIQUIS should be discontinued at least 48 hours prior to • a history of traumatic or repeated epidural or spinal effect of apixaban, which can be expected to persist for at elective surgery or invasive procedures with a moderate or PREGNANCY CATEGORY B punctures least 24 hours after the last dose (i.e., about two half-lives). • There are no adequate and well-controlled studies of ELIQUIS in A specifi c antidote for ELIQUIS is not available. high risk of unacceptable or clinically signifi cant bleeding. • a history of spinal deformity or spinal surgery ELIQUIS should be discontinued at least 24 hours prior to pregnant women. Treatment is likely to increase the risk of • Spinal/Epidural Anesthesia or Puncture: Patients treated hemorrhage during pregnancy and delivery. ELIQUIS should be • optimal timing between the administration of ELIQUIS elective surgery or invasive procedures with a low risk of with ELIQUIS undergoing spinal/epidural anesthesia or used during pregnancy only if the potential benefi t outweighs and neuraxial procedures is not known puncture may develop an epidural or spinal hematoma which bleeding or where the bleeding would be noncritical in location and easily controlled. Bridging anticoagulation the potential risk to the mother and fetus. Monitor patients frequently for signs and symptoms of can result in long-term or permanent paralysis. during the 24 to 48 hours after stopping ELIQUIS and prior neurological impairment. If neurological compromise is The risk of these events may be increased by the to the intervention is

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