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From the President- Merle Hillman, MD
This is my last quarterly President’s Column as my 2-year term is coming to a close at the end of this year. I would like to take a moment and reflect on the state of MNACEP as I see it. When I started my term, I focused on communication, membership and education. While we made strides in these areas, we also were very involved as a chapter with advocacy, reimbursement, and program support (CALS and MN-1 DMAT).
Our successes were directly attributable to the hard work of our board and our members who participated in committees.
Communication. Over the past 2 years MNACEP has issued a quarterly newsletter either by mail initially or e-mail more recently to keep membership informed of chapter activities. I am thankful to the many MNACEP members who have contributed articles and updates to the newsletter. Dr. Topher Obetz, the communications committee chair, developed a website for MNACEP at www.mnacep.org where chapter activities and contacts can be obtained. While there are many ways we can enhance the quarterly newsletter and the website, getting those channels of communication established and maintained is a big step in keeping in touch with our members.
Membership. While MNACEP has traditionally had the support of many Minnesota emergency physicians, there were still many eligible emergency physicians in the state who were not MNACEP members. Membership committee chair, Dr. Christine Kletti identified potential MNACEP members who were approached by either the committee members or by board members. Also, letters were sent to recent EM residency graduates to remind them that their residency membership had expired and inviting them to join MNACEP. As a result of these efforts, our membership has increased significantly.
Education. Over the past two years. MNACEP initiated half-day mini-series in EM education with an update in neurology and LLSA reviews. MNACEP continued to sponsor an annual full-day educational conference alternating between reimbursement and hot topics of emergency medicine. Last year’s reimbursement seminar with Dr. Michael Granovsky was well-attended and received excellent reviews from both physicians and coders. Our Hot Topics in EM is scheduled for December 4, 2009 and promises to be an outstanding conference. I strongly encourage you to attend. These educational events would not occur without the dedication and hard work of the education committee under the leadership of Dr. Terri Gunnarson.
Advocacy. We did not focus our resources on tort reform over the past two years due to the unfavorable make-up of the legislature. However, with the hard work and diligence of our lobbyist, OJ Doyle and of Advocacy Committee co-chairs, Dr. Steve Sterner and Dr. Brent Asplin, we contributed to the passage of the primary seat belt law that went into effect this year, and to the defeat of legislation which would have eliminated no-fault insurance payments to hospitals and physicians. In addition, MNACEP has continued to be active in advocating for emergency medicine during health care reform discussions both on a national and on a local level.
Reimbursement. The reimbursement committee continued to meet quarterly under the leadership of Dr. Tom Combs in 2008 and Dr. Jim Thompson in 2009. This committee continues to provide value to physician groups through education and dialog. If your group is not represented on this committee, I strongly encourage you to choose a physician coding/billing lead that would team up with your coder/biller or business manager to attend as a team.
While MNACEP initially gave support and sponsorship to the CALS program and MN-1 DMAT, both of these initiatives are now doing very well on their own and do not rely on MNACEP for support. We can be proud that MNACEP helped launch these successful programs.
I have been fortunate to have an energetic and hard-working Board of Directors, committed committee members, an outstanding lobbyist in OJ Doyle and a strong executive director, Shari Augustin, with a long track record in the college. Our new President, Dr. Brent Asplin, brings to MNACEP a wealth of knowledge and expertise in emergency medicine and especially in the area of hospital overcrowding. I look forward to his new agenda and initiatives. It has been my privilege to serve as MNACEP President and encourage all of members to stay involved in our chapter.
Sincerely,
Merle Hillman, MD
President, MNACEP
Advocacy Report-
O.J. Doyle, Legislative Consultant, August 2009
Over the past couple of decades, Minnesota’s elected officials have faced some difficult financial challenges, gratefully interspersed with ‘days of plenty’. In speaking with some of the more senior Capitol denizens, we were recalling a legislative session about a decade ago when the commissioner of finance at the time was asked as to the extent of a surplus in the state treasury. He responded that we had “boatloads” of money. That boat has long sailed – or sunk.
Acute ST Elevation Catastrophe
Carlos Morales, MD
Emergency Department Medical Directo, Community Memorial Hospital, Winona MNAortic dissection is only one of many conditions causing acute chest pain. The incidence of acute aortic dissection in the general population is about 3 cases per 100,000 persons per year. The most important predisposing factor for acute aortic dissection is systemic hypertension. It occurs mainly in males between the ages 60–80 years old. Aortic dissection is also seen in Marfan's Syndrome, patients with aortic valvular disease (bicuspid aortic valve and aortic stenosis) and coarctation of the aorta.
The classical presentation of aortic dissection is severe, sharp often unremitting pain radiating to the back, between the scapulas. The International Registry of Acute Aortic Dissection (IRAD) reported chest pain was more sharp than tearing in about 70% of the cases. IRAD reported the following ECG changes during Aortic dissection causing chest pain; normal in 31 percent, nonspecific ST and T wave changes in 42 percent, ischemic changes in 15 percent and acute MI in 5 percent. The right coronary artery is the one most commonly involved.Daily, many patients are seen in the Emergency Rooms across the nation with chest pain suspicious for an acute coronary syndrome. Early recognition of ST elevation myocardial infarction is critical since early reperfusion is the goal of treatment because it limits infarct size and improves survival. The American Heart Association guidelines recommend Percutaneous Coronary Intervention (PCI) as the preferred method to establish reperfusion when readily available. If PCI is not available or will take more than 90 minutes fibrinolytic therapy is the recommended option.
When the decision is made to use fibrinolytic agents to establish reperfusion beware that aortic dissection patients may present with symptoms or signs consistent with an acute myocardial infarction, usually ST elevations in II, III and aVF consistent with an inferior MI. Some of the complications related to administration of thrombolytics to patients with aortic dissection are severe cardiovascular collapse due to hemorrhage, cardiac arrest with electromechanical dissociation due to cardiac tamponade and even acute cerebral infarction or other neurological deficits.
In an attempt to minimize this risk before administering thrombolytics: get bilateral upper extremities blood pressure (usually a differential of >20 mmHg in systolic blood pressure between the arms), carefully auscultate the heart with special attention for a diastolic murmur suggesting aortic regurgitation, palpate for reduced peripheral pulses, and obtain a chest x-ray to evaluate for a widened mediastinum. Pulse discrepancies, widened mediastinum on chest x-ray and murmur of aortic regurgitation are suggestive but not diagnostic of aortic dissection. If aortic dissection is suspected or even considered, it should be evaluated with either a chest CT with contrast, a transesophageal ECHO or an angiogram.
Aortic dissection is a rare but catastrophic condition causing chest pain and ECG chances that could be mistaken for ST Elevation Myocardial Infarction (STEMI). When untreated, 35% of the patients with aortic dissection die within 24 hours, 80% die within 2 weeks. It does not need to be further complicated by administration of thrombolytics. STEMI fast track management is a great tool in the setting of an acute coronary syndrome; “less time to reperfusion means more cardiac muscle preserved”. However, less time to examine and evaluate the patient can lead to a catastrophe when patients with chest pain due to aortic dissection receive thrombolytics.
Minnesota Statewide Trauma System
Bruce Arvod, MD
Director, Emergency Services at Chippewa County-Montevideo HospitalMinnesota’s statewide trauma system was established in 2005. The system designates hospitals as level I, II, III or IV trauma hospitals. Participation remains voluntary. However, no major trauma patient can be transported to a hospital not participating in the statewide trauma system unless no trauma hospital is available within 30 minutes' transport time. The goal of the trauma system is to decrease injured patients' time to definitive care by ensuring that patients' medical needs are appropriately matched with hospitals' resources.
For many years Minnesota has had level I and II-verified trauma hospitals located in metro areas. Level I and II trauma hospitals in Minnesota obtain verification by the American College of Surgeons (ACS) then apply to MDH to be recognized as a trauma hospital. To obtain a level III designation, a hospital may use the same route as I and II, or it may apply for designation directly through the MDH trauma program. Level IV trauma hospitals may only achieve designation through the MDH Trauma Program. The hospital must first establish a trauma program within their facility that meets the required criteria, complete the application and then a site visit must be completed for Level III applicants. Level IV applicants have a site visit within the three-year designation period. During the site visit, MDH trauma program reviewers will tour the facility and evaluate the trauma program components.
The main criteria needed for a level IV designation are: commitment of the facility, physician advisor, and RN program coordinator, 24 hour coverage by physician, blood bank and lab, a designated trauma team and transfer protocols and agreements, a trauma team protocol, appropriate trauma training for physicians and nurses, a performance improvement process, trauma registry, and required equipment. The main upgrades for level III are: surgical coverage, common orthopedic capability, radiology, respiratory therapy, and involvement in community trauma prevention. A level II facility needs to have all the resources needed to provide definitive emergency care. A level I facility needs to have the ability to handle the most complex of cases and be a regional leader in emergency care and education.
One of the main barriers of becoming a level IV trauma system is the administrative costs and man hours needed. There is a definite reward for that cost in the improved care of trauma patients by the increased level of preparedness and organization. There is some resistance because of the protocol that every defined high risk trauma patient needs to be transferred. That protocol, though, gets everyone working more efficiently on transfers. Overall, most of Minnesota’s rural hospitals are becoming level IV and are benefiting from the process. In those hospitals that would have the possible resources to become level III, the surgeon group buy-in is usually the deciding factor. Some surgical groups don’t have the resources to be able to commit to coming in on every major trauma call. Some regional facilities have remained at level IV status.
According to the MDH, trauma is the third leading cause of death in Minnesota. On average, trauma claims the lives of 2,400 Minnesotans annually. A comprehensive statewide trauma system has been responsible for increasing survival rates by 15 to 20 percent in states where it has been implemented. Wide-scale participation will ensure that a statewide, cooperative effort is in place to care for seriously injured patients. More information on the Minnesota Statewide Trauma System is available at the Minnesota Department of Health web site at www.health.state.mn.us/traumasystem.
Chinese Emergency Medicine in Transition
Austin Indritz, MD
During a recent trip to mainland China to participate in medical mission work, I had an opportunity to visit a municipal hospital and view current emergency medical care in rural China.
Background
Emergency medical care is rapidly changing as China experiences huge growth economically and technically. Emergency care is primarily composed of physicians from other disciplines (internal medicine, pediatrics, surgery, etc.). Emergency medicine residencies exist in China, although distribution of these specialized graduates remains small because of low numbers.Presently, most hospitals are divided into municipal and provincial or regional medical centers, each with varying levels of service and care. Several large cities (Beijing, Shanghai, Guangzhou) are developing different models of emergency care to provide pre-hospital treatment and distribution of care and services throughout their municipalities.
The pre-hospital care system is primarily provided by ambulance teams composed of driver, physician, nurse, and patient carrier; formal training of paramedics in China is in early stages. Transport is usually to the closest hospital and in many hospitals, there are dedicated emergency departments that assess and treat patients.
Emergency Medical Service Observed in Lanxi
Municipal emergency department service consisted of patient registration, physician’s visits, diagnostic studies, and treatment. Each level was carried out in separate departments requiring a prepayment at each stage for the patient to receive the necessary services. Patients were seen promptly by physicians, underwent careful examination, and appropriate tests and/or treatments were ordered.
Based on test results and physician re-evaluation, initial medication treatment frequently included intravenous (IV) therapy. This municipal hospital had a large intravenous treatment room (over 150 patients, easily) with most seats filled with patients receiving intravenous medication from poles hanging from the ceiling. Subsequent discharge with oral medication was then arranged.Conclusion
As a country of 1.3 million people, China is advancing rapidly to provide prompt and appropriate medical care for its population. Distribution of dedicated emergency care physicians and services remains a challenge as need for emergency medical service at all levels is expanded.Reference
Shao JF, Shen HY, Shi XY. Current state of emergency medication education in China. Emergency Medicine Journal. 2009;26:573-575.
Clinical News
Balance Billing Ban in California Could Have National Impact
The California Supreme Court's decision in January to ban "balance billing" in that state will force emergency care providers to dispute literally millions of underpaid claims in court, emergency medicine experts warned. And, although balance billing regulations vary by state, the influential Golden State's ruling could trigger similar shifts elsewhere.
Read the entire article.Women Have Fewer Complications, Better Survival Following Trauma
Women are less likely than men to experience complications following acute trauma, which may account for their apparent survival advantage, according to a retrospective study of almost 700,000 patients. However, women who do experience complications from traumatic injuries are more likely to die as a result.
Read the entire article.FDA Takes a Closer Look at Xigris Bleeding Event
The Food and Drug Administration said on Feb. 4 that it is working with Eli Lilly and Co. to review the incidence of serious bleeding events and mortality in patients receiving the company’s sepsis drug drotrecogin alfa (Xigris). The drug was initially approved in the United States in 2001 and received an updated warning in 2005. At that time, the label was amended to state that the therapy might not be appropriate for patients with single organ dysfunction and recent surgery. The FDA began its most recent review after publication of a 73-patient retrospective study that found that patients with risk factors for bleeding had a significantly higher risk of a serious bleeding event with Xigris.
Read the entire articleHypothermia Makes Gains in Cardiac Arrest
There has been a major shift in the use of therapeutic hypothermia (TH). We've seen a substantial increase in interest," so that at the start of 2009 there is generally at least one large center routinely using TH for cardiac arrest patients in virtually every major U.S. metropolitan area, said cardiologist Dr. MaryAnn Peberdy, professor of medicine and emergency medicine at Virginia Commonwealth University in Richmond, and one of the authors of a consensusstatement on post-cardiac arrest syndrome.
Read the entire article
CALS
The Comprehensive Advanced Life Support program (http://www.calsprogram.org/home.aspx ) or CALS began in 1996. Minnesota ACEP has been a sponsor of CALS from the beginning and aided in lobbying efforts to secure permanent funding from the Minnesota State Legislature. These efforts were successful and today CALS has trained over 3600 health care professionals.
CALS was initially developed and implemented by Dr. Ernie Ruiz, former Chief of Emergency Medicine at Hennepin County Medical Center. Dr. Ruiz was concerned that rural health providers were inadequately trained to anticipate, recognize and treat life-threatening emergencies. The CALS curriculum consists of three components: 1) home study, 2) two-day interactive, scenario based provider course and 3) the skills lab.
CALS is currently being utilized by many MN emergency physicians to fulfill the Minnesota State Trauma System (http://www.health.state.mn.us/traumasystem) training requirements. The MN State Trauma System will accept either CALS or ATLS as appropriate educational training.
MN ACEP is working to further strengthen its relationship with CALS and its educational efforts. Numerous states around the nation are working to implement the CALS curriculum. MN ACEP applauds the efforts of CALS and others to improve rural critical care patient management. We look forward to working closely with CALS in the future.
Bill Heegaard, MD