Critical Care Medicine Section Newsletter - March 2011
|From the Newsletter Editor - Critical Care Medicine Section Newsletter, March 2011|
|From the Chair - Critical Care Medicine Section Newsletter, March 2011|
|From the Chair Elect - Critical Care Medicine Section Newsletter, March 2011|
|From the Councillor - Critical Care Medicine Section Newsletter, March 2011|
|From the American College of Emergency Physicians - Critical Care Medicine Section Newsletter, March 2011|
|From the Society of Critical Care Medicine - Critical Care Medicine Section Newsletter, March 2011|
|Collaboration Between Sections - Critical Care Medicine Section Newsletter, March 2011|
|Emergency Medicine, Critical Care and Combat - Critical Care Medicine Section Newsletter, March 2011|
|The DO’s of Critical Care - Critical Care Medicine Section Newsletter, March 2011|
|Shock Symposium - Critical Care Medicine Section Newsletter, March 2011|
|Emergency Department Resuscitation of the Critically Ill - Critical Care Medicine Section Newsletter, March 2011|
|Critical Care Emergency Medicine Textbook - Critical Care Medicine Section Newsletter, March 2011|
|Reminder- Newsletters and Access to E-list - Critical Care Medicine Section Newsletter, March 2011|
From the Newsletter Editor - Critical Care Medicine Section Newsletter, March 2011
Brian J. Wright, MD, MPH
Department of Emergency Medicine
North Shore University Hospital
Manhasset, New York
It has been a busy time since the last newsletter, with two national meetings in Las Vegas and San Diego having come and gone. I’d like to extend greetings from the ACEP section of Critical Care Medicine and thank all of the authors for taking the time to submit to the section newsletter. I sincerely hope that you enjoy the newsletter.
Leading off our chair, Dr. Emlet, discusses critical care education and the development of standardized competencies for all intensivists regardless of initial specialty training. Grandfathering is a subject near and dear to the hearts of many section members, but beyond certificates or boards is the important reality that critical care education needs to produce a consistent and reliable intensivist skilled in critical care and able to communicate across multiple disciplines and medical specialties. Dr. Emlet urges the Emergency Critical Care Medicine (Em-CCM) community to play a proactive role in the unification of Critical Care Medicine from silos of “Anesthesia,” “Surgery,” and “Medicine” to a multidisciplinary practice model.
Next Dr. Shiber, our chair-elect, reviews the Society of Critical Care Medicine (SCCM) Congress Lifetime Achievement Award Plenary Session lecture given by critical care giant Luciano Gattinoni this January in San Diego. Dr. Gattinoni is a pioneer in the field of ARDS. I know you’ll enjoy Dr. Shiber’s review of Dr. Gattinoni’s lecture. If you weren’t able to catch Dr. Gattinoni’s talk in San Diego I urge you to check it out online: http://www.sccm.org/Annual_Congress/Pages/CongressDaily.aspx .
Dr. Slesinger, our section councilor, gives us an update from the recent ACEP Council and Board of Directors meeting.
ACEP announced the formation of the Emergency Medicine Action Fund (EMAF). EMAF will help supplement the previously created NEMPAC. The funds collected by NEMPAC can only be used to support political candidates. Health care advocacy goes beyond helping to get the right people elected. EMAF will serve an important role to advocate for emergency medicine physicians and patients among policy makers and regulators. As we enter a new era of “quality” based and “accountable” care, it will be optimal for the clinician at the bedside to have a say in health care policy and regulation. This is also a potential opportunity for the EM-CCM community to extend alliances, and advance the flag of the EM intensivist in the political arena. Stay tuned for more interesting developments on this topic in future newsletters.
Dr. Mayglothling, the chair of our sister section of EM in SCCM, gives a business update from the recent meeting in San Diego. The success of EM-CCM as a specialty will depend on our continued ability to make believers out of our non-EM colleagues in the house of medicine and CCM. It is reassuring to know that our hard work and dedication has not gone unnoticed and we continue to develop alliances with leaders in Anesthesia, Surgery, and Internal Medicine. Collaboration beyond EM-CCM is the key. Get involved on a local, regional, or national level. Finally, consider participating in the National EMCC grand rounds on April 14th.
Dr. Mallemat gives us an update on the collaborations between the CCM and Ultrasound sections of ACEP. Critical Care Ultrasound is a new and exciting field in intensive care medicine. Fortunately, bedside ultrasound is a core skill for the emergency medicine physician and it is for this reason that EM-CCM physicians should lead the way in the development and implementation of new ways to teach and use critical care ultrasound. Dr. Mallemat welcomes you to join in this important collaboration.
Dr. Mallia, a major in the U.S. Army, and an EM Critical Care Fellow, discusses his perspective on EM-CCM and his upcoming role as an intensivist in the U.S. Army. Combat medicine is yet another theater where the EM intensivist model is distinguishing itself; I echo Dr. Mallia’s sentiment that the civilian critical care community follows the militaries lead.
Dr. Axelband provides an osteopathic physicians perspective on board certification, and potential options that the section may want to pursue with our osteopathic colleagues in the struggle for board certification.
Dr. Donnino discusses his upcoming "Shock Symposium" that will be held on May 31st in Boston, right before this year's SAEM meeting. This years conference is sure to be educational and thought provoking and will have speakers from the all disciplines of Critical Care Medicine.
Finally we are introduced to not one but two separate critical care textbooks, collaborated and written with the input of many members of this section. Dr. Winters talks about “ED Resuscitation of the Critically Ill” and Dr. Farcy talks about “Critical Care Emergency Medicine.” Look for each of these texts in the upcoming year.
If you’d like to submit a piece for future newsletters or have any questions, please feel free to contact me .
From the Chair - Critical Care Medicine Section Newsletter, March 2011
Lillian L. Emlet, MD, MS, FACEP
Program Director, Emergency Medicine MCCTP Fellowship
University of Pittsburgh Medical Center
Fellowship Training and the Measurement of Competencies in Critical Care Medicine: Beyond Grandfathering
Is it possible that a training program can train a physician to understand and practice the scope of intensive care provided to a critically ill adult patient? Is it possible that a training program can attest to measuring competence of the entire gamut of critical care medicine, including topics obstetrical, neurological, surgical, medical, and transplant? Is it possible to pool resources from a variety of “silos” of medicine in order to provide patient-centered critical care? When patient survival and functional outcomes reside in the careful coordination of multiple specialists, and understanding the “big picture,” can we afford not to join together to change and improve the training and evaluation of the practice of critical care medicine? Do patients desire streamlined multidisciplinary critical care medicine with consistent communication and coordination from a single dedicated intensivist?
In Emergency Medicine, we began our training and practice to understand and coordinate a broad range of patient care, organized by acuity and severity of presentation of chief complaint.1 We have had the luxury and privilege of interacting with all providers in the house of medicine and know no differently than to coordinate and provide a variety of care for the acutely ill. While many of us in this ACEP Section of Critical Care Medicine eagerly await the ability to access a method of certification via the ABEM-ABIM agreement,2 the next step beyond grandfathering into critical care medicine will be the contribution that EM provides towards unifying the practice of CCM. With the increased growth of EM physicians pursuing sub-specialty training and practice in CCM, more of us will be afforded leadership opportunities for the improvement of patient care, education, administration, and research. These opportunities for improving EM and CCM transcend the traditional locations and “silos” of medicine, as the majority of us seek to improve collaboration in training, research, and practice between EM and CCM.
Advancing the ACGME Milestone concept
The next generation of ACGME competency based medical education (CBME) via the “Milestone Project” will refine each specialty’s competencies and define performance standards, and identify methods to assess trainees.3 As the specificity with which we teach, monitor, and assess the development of medical trainees increase for all specialties, this is an ideal time for the subspecialty discipline of critical care medicine to develop its own “entrustable professional activities” (EPAs) that define the scope of practice of critical care medicine.4,5,13 EPAs are the critical activities that constitute a specialty, as they reflect that most important outcome of graduate medical training: the ability of a trainee to independently perform their professional activities.6
As has been pointed out by several leaders and educators in critical care, the time is now for an integrated approach to CCM training.7 Rather than separate discussions within the specialties of Internal Medicine, Anesthesia, Emergency Medicine, and Surgery, a unified approach to defining the expected practice traits of intensivists is required. This is similar to what has already been done for the European Union with the Competency-Based Training in Intensive Care Medicine (CoBaTrICE) program. As the ACGME moves forward with each specialty defining EPAs for each specialty, we hope that the educators in Surgical Critical Care, Anesthesia Critical Care, Internal Medicine Critical Care include Emergency Medicine Critical Care together to identify and merge the EPAs into one unified expectation for intensive care training and practice in the US.
Towards a Consistent Intensivist Product
We are all here to learn the practice of critical care medicine, no matter our prior strengths that our primary discipline brings to fellowship training. The paradigm of the future of critical care medicine training reverberates back to the initial founding principles, where care of the critically ill was only defined by the “special competence and involvement in emergency and long-term resuscitation...as a multispecialty endeavor that crosses traditional…specialty barriers.”8 Competency is defined as the ability to perform a professional task, with its inherent required knowledge, skills, and attitudes, at a level sufficient for unsupervised, independent practice.6
In 2004 and 2005, the Framing Options for Critical Care in the United States (FOCCUS) and subsequent Prioritizing the Organization and Management of Intensive Care Services (PrOMIS) Conferences highlighted the need for regionalized “tiered” critical care system and explicit professional competency definitions, amongst other problems.9 To define critical care medicine as a separate primary specialty would require significant work by the ACGME and ABMS. A more feasible solution would be to merge the currently described competencies and allow co-sponsorship of a certifying exam, similar to Hospice and Palliative Medicine.10
Who better to teach a cricothyrotomy than a Surgeon? Who better to teach pharmacology of sedation, analgesia, and catecholamines than an Anesthesiologist? Who better to teach triage and crisis management than an Emergency Physician? Who better to teach the differential diagnostic skills required to manage a septic, neutropenic, immune suppressed patient with acute-on-chronic renal failure than an intensivist trained in Internal Medicine? Despite general strengths of primary discipline, all of these skills are eventually encompassed within an intensivist, and the goal of training is equalizing the product of our fellowship programs. We have been lucky here at the University of Pittsburgh, where physicians from a variety of primary specialties have been able to train equally along-side each other in our ICUs with a breadth of medical and surgical patient exposure from a breadth of faculty representing all 4 disciplines. Inter-Departmental collaboration can be successful in pooling resources to develop new training programs, as seen by a rapid growth in non-standard programs that are joint initiatives.11,12
Pooling faculty resources at an individual institution is a solution to improve the quality of fellowship training. Perhaps the best solution is partnership within institutions/ health care systems to ensure the exposure to niches in critical care medicine (Trauma, Cardiothoracic, Medical, Neurosurgical) is best utilized. Standardizing training programs across the entire spectrum of critical care medicine will require including and expanding upon currently established ACGME fellowship requirements.
The blurring of the line between medical and surgical intensive care needs to begin in training, where the true mandate of the training program is to provide a robust, broad patient care exposure and teaching. The beginning will be with definable EPAs for critical care medicine that merges the current accredited program definitions for competency-based education in critical care medicine, with inclusion of neurocritical care into primary required content. However, the depth and scope of neurocritical care may eventually best be seen as a subspecialty of critical care medicine. We look towards a future where the breadth of intensive care medicine practice, leadership, and educational leadership, from obstetrical to neurosurgical, cardiothoracic to transplant, medical to surgical, is achievable for all trainees and intensivists.
- Hockberger RS, Binder LS, Graber MA, et al. American College of Emergency Physicians Core Content Task Force II. Ann Emerg Med. 2001; 37(6): 745-70.
- American Board of Emergency Medicine and American Board of Internal Medicine. Critical Care Medicine Joint Statement. www.abem.org, www.abim.org. Last accessed February 13, 2011.
- Nasca TJ. Next accreditation system focus of CEOs speech at 2010 ACGME Annual Education Conference. www.acgme.org. Last accessed February 13, 2011.
- Ten Cate O. Entrustability of professional activities and competency-based training. Med Educ. 2005; 39: 1176-1177.
- Ten Cate O. Trust, competence and the supervisor’s role in postgraduate training. BMJ. 2006; 333: 748-751.
- Ten Cate O, Scheele F. Competency-based postgraduate training: Can we bridge the gap between theory and clinical practice? Acad Med. 2007; 82: 542-547.
- Kaplan LJ, Shaw AD. Commentary: Standards for education and credentialing in critical care medicine. JAMA. 2011; 305(3): 296-7.
- Safar P, Grenvik A. Organization and physician education in critical care medicine. Anesthesiol. 1977; 47: 82-95.
- Napolitano JM, Fulda GJ, Davis KA, et al. Challenging issues in surgical critical care, trauma, and acute care surgery: A report from the Critical Care Committee of the American Association for the Surgery of Trauma. J Trauma. 2010; 69: 1619-1633.
- Certification in HPM. http://www.aahpm.org/certification/default/index.html. Last accessed February 13, 2011.
- Kroboth FJ, Zerega WD, Patel RM, et al. Nonstandard programs: The University of Pittsburgh Medical Center’s next frontier in graduate medical education. Acad Med. 2011; 86(2): 180-186.
- Ellender TJ, Emlet LL, Hou PC, et al. A National review of critical care medicine fellowships with established emergency medicine pathways. Submitted for publication.
- Jones MD, Rosenberg AA, Gilhooly JT, et al. Competencies, outcomes, and controversy-linking professional activities to competencies to improve resident education and practice. Acad Med. 2011; 86: 161-165.
From the Chair Elect - Critical Care Medicine Section Newsletter, March 2011
Joseph Shiber, MD
Director Emergency Medicine Critical Care
Baylor College of Medicine
Synopsis of SCCM Congress Lifetime Achievement Award Plenary Session
ARDS Therapy in 2011: Moving Forward, Looking Back
Luciano Gattinoni, MD, FRCP
University of Milan, Italy
This article will attempt to summarize the presentation by Dr. Gattinoni from the Society of Critical Care Medicine’s Critical Care Congress held recently in San Diego. The speaker started out describing the history of Acute Respiratory Distress Syndrome (ARDS) starting in the early 1970’s when he began his career in Critical Care, and made the suggestion that “just as Critical Care was born from ARDS it may also be that ARDS was born from Critical Care”. He described that the standard manner of treating ARDS patients at that time using 12-15 cc/kg of tidal volume (TV) and 5-10 cm H2O of positive end-expiratory pressure (PEEP), based on a recent New England Journal of Medicine article, resulted in many patients developing pneumothoracies; he joked that since it was so common, with patients often requiring bilateral thoracostomy tubes, that intensivists all learned how to do the procedure on these patients. It was also in the early 1970’s that the first case report of the successful use of extra-corporeal membrane oxygenation (ECMO) in an adult was published. Shortly thereafter was the first clinical trial using ECMO versus mechanical ventilation in ARDS patients, which resulted in 90% mortality in both groups.
Despite this failure and subsequent studies showing not much better success with ECMO, Dr. Gattinoni still believes the concept of “lung rest” makes physiologic sense and gives the examples of casting a broken leg or not moving an inflamed joint until healed. He stated that extracorporeal treatment could be useful particularly for ARDS patients where ventilation to maintain normocarbia was the main problem; in these cases, true ECMO would not be required since adequate oxygenation could be achieved by conventional mechanical ventilation but CO2 clearance was still problematic. A much lower blood flow (1L) is required to maintain normal CO2 clearance compared to a higher blood flow (5L) in order to achieve extracorporeal oxygenation. The simplistic breakdown is that the efficiency of dissolved CO2 clearance is high and requires a low blood flow but high fresh gas flow; since oxygen is bound to hemoglobin, a volume of blood can only deliver a fixed amount of O2 so that a high flow of blood is necessary to satisfy the tissue oxygen requirements. This type of “membrane lung” as the speaker calls it, is less complex than ECMO since it can be accomplished with much smaller vascular catheters and has been compared to the level of invasiveness as renal replacement therapy.
Dr. Gattinoni proceeded to go into more detail on pulmonary physiology, stating that previously the idea was that in ARDS there was lower lung compliance due to increased pathologic “stiffness” of the lung parenchyma. That concept has been identified as erroneous; the amount of lung tissue inflated and available for ventilation is simply reduced and has been named “the baby lung”. The remaining aerated lung has the same intrinsic compliance and physiologic properties, it is simply smaller than the initial normal total lung volume; the change in compliance will be proportional to the change in percentage of lung available for ventilation. It was only with the advances of high resolution computed tomography (CT) scanners in the late 1980’s that clinicians were able to visualize the reduction in “ventilatable” lung parenchyma in ARDS. The lungs in ARDS also have increased water weight compared to healthy lungs due to increased endothelial capillary permeability so that there is more weight pressing down on the lung tissue under the force of gravity. This means that when a patient is supine there is a hydrostatic column pressing downwards onto the most dependent tissue equivalent to the amount of tissue (water) above it. The example that Dr. Gattinoni gave was that of “a sponge when dry has holes all of approximately the same size but when the sponge is wet and set down, the holes at the bottom are compressed so are smaller than the holes above it”. Again, on CT scan ARDS patients have the majority of collapsed, non-ventilated tissue on the posterior segments of their lungs while supine; the use of prone positioning and increased levels of PEEP are intended to oppose these forces and allow recruitment of some of these collapsed lung units.
Dr. Gattinoni mentions that over the last 20 years there has been a steady decrease by about 0.5 cc/kg per year of the recommended TV for ARDS patients, initially at 15 cc/kg and now at 6 cc/kg. He brings up the question of whether there is a continuum of volumes which cause ventilator induced lung injury (VILI) with 6 cc/kg better than 7 which is better than 8 and so forth up to 15 cc/kg; or conversely is there a threshold value which below there is no risk of VILI? His opinion is that there is a unique threshold value of TV for each ARDS patient based on the actual size of their “baby lung”, and if that value is exceeded continually over an extended time period then VILI occurs.
He further defines the force acting upon the lung, the transpulmonary pressure (PL), which is the airway pressure minus the pleural pressure. He gives examples of when the airway pressure may be high but the pleural pressure is also high, so that the transpulmonary pressure is low and there is little risk of VILI; he compared that to an example of when the airway pressure is the same high value but the pleural pressure is low, so that the transpulmonary pressure is high and will result in significant risk of VILI. He also gives the definition of Stress as the forces developing in the lung due to the transpulmonary pressure, and Strain as the deformation of the lung relative to its resting state due to inflation with a TV. Stress has the same units of measurement as pressure (cm H2O) with the Plateau Pressure used as the surrogate; while strain has no specific units of measurement, it is defined by the change in volume caused by the TV inflation divided by the original volume in the resting state (deltaV/Vo), with the surrogate being the cc/kg of TV delivered. Dr. Gattinoni does admit that “these are bad surrogates but are better than nothing” when attempting to estimate these forces in order to make decisions on ventilatory strategies.
Stress and strain are almost linearly related within physiologic limits, so that:
Stress = K x Strain and PL = K x (deltaV/Vo)
with K being the specific elastance of lung tissue; elastance is defined as pressure/volume (P/V). Dr. Gattinoni offers that the specific elastance is the transpulmonary pressure where the TV is equal to the resting volume, so that the lung volume doubles. Experimental and clinical data show that the specific elastance of healthy lungs and ARDS lungs is the same = 13 cm H2O, since to reiterate the lungs in ARDS are not stiffer merely smaller. As an editorial point, I will mention that the speaker is referring to the acute stages of ARDS and not the subsequent healing stage where scarring may occur. He then returns to the idea that there is a strain threshold for VILI which is the TV resulting in greater than maximal lung volume capacity. When the total lung capacity is exceeded (whether in healthy lungs or the “baby lung” of ARDS) the fibrous skeleton of the lung made of elastin and collagen fibers reach their limits of stretch and unfolding, respectively. After this limit, tissue rupture and gross baratrauma occurs (pneumothorax, pneumomediastinum, air embolism). Even without causing tissue rupture, high strain promotes the release of proinflammatory cytokines and recruitment of white blood cells resulting in inflammation, known as biotrauma.
The forces that act upon the lung only interact on ventilated regions, not on consolidated or collapsed regions, so that VILI can only occur in ventilated areas. Forces act upon homogenous tissue evenly, as all tissue equally support and distributes the force. Since the lung in ARDS is not homogenous, as fully aerated regions may be neighbored by partially aerated and collapsed regions, the forces are not evenly distributed. Dr. Gattinoni makes the point that as ARDS worsens, the lungs become less homogenous. Stress is then amplified at the interfaces of normal and abnormal (collapsed) tissues; these amplifications of forces are known as “stress risers” and focus the strain onto the remaining “baby lung”. It is for this reason that the TV at which VILI occurs, that is the strain at which the maximal lung volume is exceeded, is unique to each patient. A TV of 6 cc/kg may be safely below that threshold for one patient, but may be over the limit for another patient if the amount of lung available for ventilation is very small. Dr. Gattinoni suggests that CT scanning with differential tissue density mapping maybe able to estimate the degree of non-homogeneity, so that it may be possible to predict the amount of recruitable lung. His final point is that there are some patients who have such degree of lung non-homogeneity (their “baby lung” is so small) that they cannot be safely ventilated, even using PEEP and proning for recruitment, and using lung-protective strategies; they simply do not have enough ventilated tissue to support their CO2 clearance and mechanical ventilation will merely incite VILI and progress their ARDS. These patients could be identified early in order to start extracorporeal CO2 clearance and avoid the further risks of VILI. He concludes by saying that this strategy of extracorporeal “lung rest” may also be valid for severe asthma and COPD exacerbations and that he predicts in the next decade we will see a major change in the way we treat ARDS.
For more information please see the articles in the October 2010 CCM Supplement.
- Gattinon L, Protti A, Caironi P, et al. Ventilator-induced lung injury: the anatomic and physiologic framework. Crit Care Med. 2010;38(Suppl):S539-548.
- Pesenti A, Patroniti N, Fumagalli R. Carbon dioxide dialysis will save the lung. Crit Care Med. 2010;38(Suppl):S549-554.
- Del Sorbo L, Ranieri M. We do not need mechanical ventilation any more. Crit Care Med. 2010;38(Suppl):S555-558.
From the Councillor - Critical Care Medicine Section Newsletter, March 2011
Todd L. Slesinger, MD, FACEP, FCCM
Department of Emergency Medicine
North Shore University Hospital
Manhasset, New York
Let me start by saying that it has been a pleasure serving you as Councillor again. This year, there were 330 Council members representing all 53 chapters, 30 ACEP sections of membership, the Emergency Medicine Residents' Association, and the Association of Academic Chairs in Emergency Medicine. ACEP’s membership is now at a record high exceeding more than 29,700 members. The 2010 ACEP Council considered 34 resolutions. Of those, 23 were adopted (including 3 memorials and commendations), 5 were not adopted, and 6 were referred to the ACEP Board of Directors. The Board voted to accept the resolutions adopted by the Council.
The entire list of resolutions and actions can be found on acep.org under About Us > Leadership > Council
Of note, ABEM announced at the council meeting that the subspecialty of EMS has been approved by ABMS. Our EMS brothers have also fought for a very long time for board certification, and they are now faced with the task of standardizing their training and qualifications. Congratulations!
Congratulations to the New College Leaders
At its 2010 meeting, the ACEP Council elected two new members to the Board of Directors and re-elected two incumbents, as well as choosing the next President-Elect and Council officers. Congratulations to the new ACEP leaders:
Congratulations to all the new leaders elected and appointed during Scientific Assembly.
Board of Directors
Sandra M. Schneider, MD, FACEP - President
David C. Seaberg, MD, CPE, FACEP - President-Elect
Ramon W. Johnson, MD, FACEP - Chair of the Board
Andrew E. Sama, MD, FACEP - Vice President
Alexander M. Rosenau, DO, FACEP - Secretary-Treasurer
Jay Kaplan, MD, FACEP - EMF Chair-Elect
Elected Board Members
Andrew I. Bern, MD, FACEP (incumbent)
Paul D. Kivela, MD, FACEP
Robert E. O'Connor, MD, FACEP
Andrew E. Sama, MD, FACEP (incumbent)
I would like to remind the membership that NEMPAC is now the 3rd largest medical PAC. If you are ever going to make a contribution, this is the year!
Go to acep.org under Advocacy > NEMPAC
Also please read carefully the article on the new Emergency Medicine Action Fund. We all need to contribute to both.
From the American College of Emergency Physicians - Critical Care Medicine Section Newsletter, March 2011
Emergency Medicine Action Fund Announced
ACEP's New grassroots effort aims to influence health care reform’s regulatory implementation.
With changes in the health care system already underway, a new initiative is looking to positively impact the regulations that will be written and implemented under this sweeping reform.
The Emergency Medicine Action Fund, launched by ACEP in February, will pool contributions from individual emergency physicians and groups, ACEP Sections of Membership, and anyone else interested in advancing emergency care to provide financial support for advocacy activities in the regulatory arena.
“This is probably the most important, defining moment for emergency medicine in our lifetime,” said ACEP President Dr. Sandra Schneider. “The decisions that are made now will set the course for us for years to come and we must positively influence the regulatory agenda. This Action Fund will help us do that and create a practice environment we can thrive in.”
The Emergency Medicine Action Fund will pursue a regulatory agenda that supports emergency physicians and quality emergency care. For example, evolving practice models and demonstration projects, such as accountable care organizations and bundled payments, are two areas of the Patient Protection and Affordable Care Act where the Action Fund might be able to wield some influence.
“We need to be out there with the rule writers, working to ensure that emergency medicine’s perspective is valued,” said Dr. Angela Gardner, ACEP Past President who first proposed a national grassroots initiative focused on federal regulatory affairs. “It is critical that we be involved in these decisions regarding the formation of the future of health care delivery. This is our opportunity to be part of it.”
The following organizations have been invited to designate representatives to the initial Board of Governors – American Academy of Emergency Medicine (AAEM), Association of Academic Chairs of Emergency Medicine (AACEM), American College of Osteopathic Emergency Physicians (ACOEP), Emergency Department Practice Management Association (EDPMA), Emergency Medicine Residents’ Association (EMRA), and Society for Academic Emergency Medicine (SAEM).
One of the unique features of the Emergency Medicine Action Fund is that multiple Sections can band together to form coalitions that would be eligible to have a seat on the Board of Governors. Or Sections can organize their individual members for collective representation. The first 10 groups of contributors at $100,000 will be granted seats on the Action Fund’s Board of Governors.
“We are encouraging Sections, chapters and small to mid-sized groups to combine their resources,” Dr. Schneider said. “This is intended to be an inclusive effort, and everyone’s contributions are needed.”
The Emergency Medicine Action Fund is modeled on a successful initiative sponsored by CAL/ACEP, CAL/AAEM, EDPMA, and rural emergency physicians in California that has raised several million dollars for state advocacy since 2004.
Wes Fields, chair of the California Emergency Medicine Advocacy Fund, said their program doubled the size of the CAL/ACEP advocacy staff, increased the number of lobbyists and consultants, and engaged in legal activities related to physician payment practices. He has been appointed by Dr. Schneider as the founding chair of the new national Action Fund.
“I view this as the best form of free speech on behalf of emergency physicians and our patients,” Dr. Fields said. “It is not partisan. It is not political.
“The rule writers and the policy makers will hear emergency medicine speaking with one voice, with one set of goals, one approach,” he added. “We need wide and deep support, even from those who are not members of the College.”
CEP America, the nation’s largest emergency medical partnership, will be the inaugural donor to the Emergency Medicine Action Fund, pledging $100,000.
Activities planned by the Emergency Medicine Action Fund are intended to enable participants to make contributions that would be tax-deductible business expenses (tax deductibility can be determined only by participants’ tax advisors).
NEMPAC, the National Emergency Medicine Political Action Committee of the ACEP, gives contributions to candidates who have listened to the needs of emergency medicine and made a positive change. However, NEMPAC may be used only to support candidates.
The Action Fund can enhance regulatory advocacy with policy makers to ensure emergency physicians receive fair payment for their services. It can also fund numerous meetings with regulators to help guarantee that patients receive the best care, and provide funding for studies to demonstrate the value of emergency medicine.
“With the new Congressional session upon us, it is as important as ever to be active on both the legislative and regulatory fronts,” Dr. Schneider said. “We will depend on all of these funds to make our case. This will be the year we ask everyone to dig a little deeper. In these challenging times, we need contributions to both the Action Fund and NEMPAC.”
Find out more about the Emergency Medicine Action Fund at www.acep.org/EMActionFund.
How is the Emergency Medicine Action Fund Different from NEMPAC?
Both are valuable tools that need our continued support, but the Emergency Medicine Action Fund serves a different purpose than NEMPAC.
EM Action Fund
Gives campaign contributions to Congressional candidates
Funds meetings with regulators and policy makers
Enhances emergency medicine advocacy efforts
From the Society of Critical Care Medicine - Critical Care Medicine Section Newsletter, March 2011
Julie Mayglothling, MD
Chair, SCCM Section of Emergency Medicine
Department of Emergency Medicine
Department of Surgery, Division of Trauma/Critical Care
Virginia Commonwealth University
Update from SCCM EM Section
We had another great turnout for this year’s SCCM Annual Congress in San Diego. Over 40 people attended the EM Section meeting and we had great discussion about short term and long term goals for our section and our growing specialty.
One of the highlights of this year’s Congress came when Dr. Pamela Lipsett, the incoming president of SCCM, publically declared her support for emergency physician intensivists during her Presidential Address. She reiterated the projected shortage of intensivists and clearly supported emergency physicians as a part of the solution. She urged the audience to rethink the traditional boundaries of critical care medicine training and to support the idea of uniform standards across all specialties. We had the opportunity to thank Dr. Lipsett personally and she reiterated her commitment to critical care board certification for emergency physicians. It was a reminder that we have several strong supporters in important leadership positions that continue to work on our behalf, both behind the scenes and in public forums.
This year we will continue our section project of a National EMCC Grand Rounds. This project serves several purposes. It is a great opportunity to take controversial topics and have a review of the literature and a discussion of how different institutions practice. In addition, it keeps us in contact with each other outside our two major meetings a year. Our next scheduled webcast is Thursday April 14th from 3:30 to 4:30. We will be discussing hemodynamic monitoring techniques. If your institution would like to participate, please email Joe Zito to find out how to link to the webcast. Our second section project is looking at critical care education for emergency medicine residencies. Our hope is to first assess what different residencies are teaching, then come up with recommendations for a suggested critical care curriculum for all EM residencies. If you would like to participate, please contact me .
Spring is the time to get involved in SCCM. Applications for committee memberships open in the next several weeks. Apply to get involved with a committee for SCCM- anyone who applies is guaranteed at least one committee appointment. It’s a great way to get involved and meet people throughout the organization. The deadline for committee applications is May 1st. Applications can be found at http://sccmwww.sccm.org/membership/volunteers/committee_application/application.asp
And finally, we are still keeping up out database of dual trained EM-Critical Care physicians. If you have done fellowship or are currently enrolling in fellowship, let me know so you can be counted! Email me your name, contact information and where you are doing fellowship.
Collaboration Between Sections - Critical Care Medicine Section Newsletter, March 2011
Haney Mallemat, MD
Department of Critical Care and Emergency Medicine
University of Maryland Medical Center
Despite the incredible skill and expertise that EM-CCM physicians bring to the specialty of critical care, physicians with combined training are still awaiting the opportunity to gain board recognition from the ACGME. As such, EM-CCM physicians must continue to demonstrate the expertise they add to the field. Leading the growing field of critical care ultrasound is a significant way this can be accomplished.
Although critical care ultrasound has been around for several years, it is only recently that it is gaining popularity among intensivists. Despite both the ACCP and SCCM having recommendations for critical care physicians, ultrasound has not had the same success as the ACEP ultrasound guidelines that are part of an EM resident’s competency. Although the reasons for critical care ultrasound’s slow growth is unclear, some have speculated that lack of local expertise is part of the problem.
As Emergency Medicine physicians increasingly enter critical care fellowships, they bring expertise in ultrasound and thus have the potential to emerge as leaders in critical care through ultrasound education, research and mentoring. This leadership can demonstrate why EM-CCM physicians should be granted ACGME certification. Recognizing this potential, members of the ACEP-Critical Care and ACEP-Emergency Ultrasound sections have come together to discuss strategies to move EM-CCM physicians to the front-line of critical care ultrasound.
If you have ideas you would like to contribute or would like to collaborate with other EM-CCM ultrasound physicians please contact us at: firstname.lastname@example.org. However you choose to participate we look forward to hearing from you soon.
Emergency Medicine, Critical Care and Combat - Critical Care Medicine Section Newsletter, March 2011
Anantha K. Mallia, DO
MAJ, Medical Corps, United States Army
Fellow, Emergency Medicine-Critical Care
North Shore University Hospital, Manhasset, NY
Versatility and adaptability are two key virtues that the military demands of its service members and that a nation, in turn, demands of its military. Certainly, in times of war, the need for versatility and adaptability becomes essential and often urgent. Perhaps no other aspect of military operations has had to adapt so dramatically to war as the field of military medicine. The urgencies of past and current wars have necessarily led to the employment of untested and/or experimental principles and methods into the practice of combat medicine. Time and again, from the Civil War to Operation Enduring Freedom, the lessons and experiences of combat have transformed many of these untested principles and methods into significant advances that revolutionized the practice of medicine as a whole, to eventually become standard of care in the civilian world. From casualty evacuation to damage control surgery, the way we practice medicine in theater has shaped the way we practice medicine at home.
In 2008, the United States military officially approved a critical care medicine (CCM) fellowship track for Emergency Physicians (EPs) to help address an urgent need for intensivists to support combat operations in the Middle East that were growing, well, more “intense.” This need for military intensivists would possibly outpace the supply gained from the traditional CCM tracks (Medicine, Surgery and Anesthesia). Not only does this new track address a developing intensivist shortage in the military, but it serves to enhance the versatility of an already formidable combat medicine arsenal. The EP-intensivist will not only add depth of perspective and experience to the fields of military CCM and Emergency Medicine (EM), but will also bring the unique capability to effectively treat critically-ill patients throughout various diverse stages of casualty care—from the battlefield and pre-hospital setting to the emergency/trauma bay to the intensive care unit. In short, the military EP-intensivist will exemplify the virtues of versatility and adaptability.
Fellowship training in CCM has no doubt made me a better physician and will allow me to contribute so much more to the care of injured Soldiers, Marines, Sailors and Airmen wherever I encounter them, downrange and back home. It is certainly my hope that the military’s employment of this new track of critical care training and practice will hasten the rightful transformation of EM-Critical Care in the civilian world from an “experiment” to standard of care.
The views expressed in this article are those of the author and do not reflect the official policy of the Department of Army, Department of Defense, or the U.S. Government.
The DO’s of Critical Care - Critical Care Medicine Section Newsletter, March 2011
Jennifer Axelband, DO
Department of Medical Critical Care
Department of Emergency Medicine
St. Luke's Hospital
In the United States, two nationally recognized board certification pathways exist for emergency medicine residency graduates—ABEM and the AOBEM. As emergency medicine physicians pursuing recognition and certification for our training and practice of critical care, we have embarked upon a journey in the allopathic medical community both educating and negotiating with those individuals and groups with the authority to grant us this “official recognition.” Perhaps it is time to approach the osteopathic medical community as well.
As of December 2009, a total of 23,005 osteopathic physicians were certified by the American Osteopathic Association (AOA) with a total 25,326 combined primary board and certificate of added qualification (CAQ) in active status. The American Osteopathic Board of Emergency Medicine (AOBEM) is the third largest osteopathic certifying body of the 18 specialties. AOBEM has consistently grown in its annual number of first time board certified emergency medicine physicians from 120 in 2005 to 152 in 2009, over 30% growth in certifications in a 5 year period. As of 2009, 1860 osteopathic emergency physicians are board certified by the AOA. CAQ in toxicology, sports medicine, emergency medical services and most recently pediatrics are available for osteopathic emergency physicians with appropriate training in these subspecialty fields via conjoint or shared boards.1
Currently the AOA recognizes anesthesia, surgery and internal medicine with CAQ in critical care. Of these primary disciplines anesthesia has a total of 562 board certified members with only 5 CAQ in critical care. No CAQ have been awarded since 2005. Eight hundred and sixty one osteopathic general surgery board certifications are active as of 2009 with 37 CAQ in surgical critical care. Since 2005 the average number of yearly awarded CAQ in surgical critical care is 7. As of 2009, the AOBIM actively certifies 2824 physicians with 116 CAQ in critical care. The average yearly number of critical care CAQ awarded by the AOBIM is 4.6 with 10 awarded in 2005, 7 in 2006, 3 in 2007, 0 in 2008 and 13 in 2009. Of the primary specialties with CAQ in critical care, anesthesia offers 2 fellowship programs with a total of 2 positions (1 per program), surgery offers 3 fellowship programs 1 year in duration for a total of 7 positions and internal medicine offers 4 critical care medicine fellowship programs 2 years in duration for a total of 9 positions and 7 pulmonary critical care fellowship programs with a total of 24 positions available.1,2
The American College of Osteopathic Emergency Physicians (ACOEP) members number over a thousand. Informal conversations with the current president of ACOEP Thomas Brabson, DO, FACOEP were positive and encouraging in support of osteopathic emergency physicians pursuing a CAQ in critical care. As in the allopathic medical community, the osteopathic community must navigate through the appropriate channels in pursuit of certification as well. The process involves a petition for CAQ requiring 25 signatures of interested osteopathic board certified emergency physicians. Once the petition is completed the next step requires drafting formal letter addressing the ACOEP board of directors regarding the CAQ. The ACOEP board of directors would then approve or decline the CAQ motion. If the motion to pursue a CAQ is approved the next communication is from the AOBEM liaison on the ACOEP board of directors to AOBEM. If AOBEM approves the motion communication will begin with the American Osteopathic Association Bureau of Osteopathic Specialists (BOS) which oversees the 18 specialty certifying boards. As the process approaches the level of the BOS communication with specialties already approved for CAQ will begin and further discussions will be conducted with final approval or decline resting with the BOS.
In preparing to write this piece for the newsletter, while gathering information regarding the specialties with CAQ in critical care, conversations with various osteopathic associations has lead to interesting and encouraging possibilities. Bert Bez, DO executive director of the American Osteopathic College of Anesthesiologists (AOCA) expressed interest in the concept of a conjoint board for a CAQ with anesthesia and emergency medicine. It has also been reported, although not confirmed, that Gary Slick, DO AOBIM executive director may be willing to discuss this concept as well. No communication with surgery has been established to date. Lastly, in researching the osteopathic policies and bylaws, The American Osteopathic Association Policy Compendium 2010 was reviewed. Of specific interest was the section regarding “Admitting MD’s onto osteopathic graduate medical education programs.” This sections states, “ The American Osteopathic Association endorses the recommendations of the attached white paper developed by representatives of the American Association of Colleges of Osteopathic Medicine (AACOM) and the AOA’s Bureau of Osteopathic Education (BOE) and recommends that through 2015, the osteopathic profession annually review the impact of the projected 30% additional LCME MD graduates entering ACGME training programs. The review would include analysis of federal legislation affecting the number of graduate medical education positions, before making a final decision on whether or not to support a new policy that would permit osteopathic graduate medical education programs to admit MDs”3 In summary this report has those in favor and those not in favor of this policy change based on survey results from “key stakeholders” that were identified by the Medical Education Summit Progress Task Force. The final recommendation was to re-evaluate this possible policy change yearly until 2015. Thus bringing up and additional possibility that if the osteopathic medical community is in favor of a CAQ in critical care for emergency medicine, can this encompass both osteopathic and allopathic physicians? It appears, as stated earlier, perhaps it is time to approach the osteopathic medical community.
- Ayres RE, Scheinthal S, Gross C, et al. American Osteopathic Association Specialty Board Certification. JAOA. 2010 Mar; 110:184-92.
- Opportunities.osteopathic.org [Internet], Chicago; c 2003-2010 [cited 2011 Feb 13]. Osteopathic medical internships and residencies. Available from: http://opportunities.osteopathic.org/
- American Osteopathic Association [Internet], Chicago; c 2001-2010 [cited 2011 Feb 13]. AOA Positions and Policies, American Osteopathic Association Policy Compendium 2010. Available from: http://www.osteopathic.org/inside-aoa/about/leadership/Pages/aoa-policy-compendium.aspx
Shock Symposium - Critical Care Medicine Section Newsletter, March 2011
Michael Donnino MD
Beth Israel Deaconess Harvard Medical School
This year's "Shock Symposium" will be held on May 31st at the Joseph B. Martin Conference Center in Boston, MA sponsored by Beth Israel Deaconess Medical Center/Harvard Medical School. The symposium is a multi-disciplinary conference organized by two emergency medicine/critical care physicians with speakers from the fields of emergency medicine, emergency medicine/critical care, anesthesia/critical care, surgery/critical care, and medical/critical care. Featured speakers include Robert Berg who is a pediatric intensivist and head of the American Heart Association's Basic Life Support Guidelines Committee - he will speak on the new 2010 AHA cardiac arrest guidelines. Julie Mayglothling (emergency medicine/critical care physician with a special expertise in trauma) will be speaking on the paradigm shift toward non-operative management of trauma. Mark Walsh, an emergency physician who created his own mini-anesthesia training program in order to provide anesthesia in Haiti will be discussing the potential usage of I/Os for shock and cardiac arrest patients illustrated by patients he managed in a Cholera outbreak in Haiti. Dr. Walsh will show applications both for ED physicians practicing in the US and for those considering international work.
Additional speakers include other emergency medicine/critical care physicians (Michael Donnino/Michael Cocchi) who will be speaking on uncommon causes of shock and management of a post-arrest patient. Other speakers include Samuel Goldhhaber who is one of the foremost authorities on massive pulmonary embolism, Carl Hauser (surgeon) who is introducing a novel concept of the role of mitochondrial injury in shock, Nate Shapiro (emergency physician) introducing the concept of microcirculatory dysfunction and monitoring in shock, and many others. The multi-disciplinary nature of the conference is perhaps best exemplified by a session on massive gastrointestinal hemorrhage in which speakers from emergency medicine, critical care, gastroenterology, interventional radiology, and surgery form an expert panel to tackle tough management questions. The conference conveniently falls one day prior to SAEM in Boston, making attendance easier for those traveling from outside the Boston area.
Please register on line by visiting the Shock Symposium website at http://cme.med.harvard.edu/cmeups/custom/03124125/index.htm. You can also register by mail by going to the website and printing the mail in registration form.
Emergency Department Resuscitation of the Critically Ill - Critical Care Medicine Section Newsletter, March 2011
Michael Winters, MD, FACEP
Director, Critical Care Education
Co-Director, Combined EM/IM/Critical Care Program
Assistant Professor of Emergency Medicine and Internal Medicine
University of Maryland School of Medicine
By Michael Winters MD, Peter DeBlieux MD, Evadne Marcolini MD, Michael Bond MD, and Dale Woolridge MD
Managing critically ill patients in the emergency department is an essential skill for emergency physicians—perhaps the defining skill. Emergency physicians must be ready to provide needed therapies for patients who are in extremis. Written and edited by experts in emergency medicine, this book covers all aspects of resuscitating and managing the critically ill ED patient. Every chapter highlights “Key Points” and “Pearls,” calling your attention to essential information. Many also offer management algorithms for quick reference. Among the chapters in this book are: The Patient with Undifferentiated Shock, The Crashing Ventilated Patient, Fluid Management in Critically Ill Patients, Cardiac Arrest Updates, Post-Cardiac Arrest Management, Severe Sepsis and Septic Shock, Bedside Ultrasonography in the Critically Ill Patient, and Resuscitation of the Critically Ill Neonate. Additional chapters cover the difficult airway, aortic catastrophes, emergency transfusions, deadly arrhythmias, cardiogenic shock, pulmonary embolism, gastrointestinal hemorrhage, poisoned patients, trauma, intracerebral hemorrhage… and more.
This book is an essential resource for the initial resuscitation of an emergency physician’s very sickest patients and for the ongoing management that can be necessary when inpatient beds are in short supply.
Look for it in your ACEP Bookstore Summer 2011.
Critical Care Emergency Medicine Textbook - Critical Care Medicine Section Newsletter, March 2011
David A. Farcy MD, FACEP
Medical Director of the Surgical Intensivist Program
Director of Emergency Department Critical Care
Mount Sinai Medical Center
Miami Beach, FL
Critical Care Emergency Medicine, 1st Edition
Senior Editor: David A. Farcy, MD
Editors: William Chiu, MD; Alex Flaxman, MD; John Marshall, MD
It is with great pleasure that we announce publication by McGraw-Hill of the first textbook on critical care emergency medicine. Initially, I was working on a pocket guide to be published by the Emergency Medicine Residency Association (EMRA). However, as that project developed it became clear that more than a handbook was needed. I had asked Dr. Alex Flaxman, who at the time was starting his fellowship at Shock Trauma to assist me. Dr. Flaxman and I proposed such a textbook to McGraw-Hill who undertook publication and invested in the project. The editors and publisher both felt that having a surgeon who was familiar with our cause and supportive of emergency physicians doing critical care would be beneficial to the project. Dr. William Chiu is the Fellowship Director of Trauma / Critical Care at Shock Trauma. Dr. Chiu is a great supporter and was the ideal candidate, and it was an honor to have him join as an editor. We also wanted a non-critical care emergency physician to guarantee the content was easy to understand but thorough. Dr. John Marshall is the Chairman of the Department of Emergency Medicine at Maimonides Medical Center and has been involved with teaching for a decade. Having him accept the challenge as the fourth editor was not just an honor but also added credibility to the project.
First, we had to define and decide who comprises our audience, those for whom the textbook was to be written. Emergency Physicians are at the front line, and their care is essential, given the ever-increasing incidence of critically ill and injured patients presenting to the Emergency Department (ED). Challenged by problems such as ED overcrowding (the number one reason reported is boarding of ICU patients; Lamb et al. noted a 59% increase of ED critical care volume with an 8% decrease in non-urgent patients). This is mirrored nationally with 23% of ED patients triaged as requiring immediate or emergent (within 15 minutes) care. One of every 10 patients hospitalized from the ED is directly admitted to the ICU.
Underscored is the clinical reality that emergency medicine physicians are seeing a higher volume of patients, with more patients severely ill than in the past. Emergency physicians are forced to perform critical care in the ED. Aggressive, appropriate care delivered in the ED for critically ill patients has been shown to decrease mortality and morbidity. Rivers et al. showed that early goal-directed therapy care of the septic and septic shock patient resulted in a 28 % mortality reduction. Recently the AHA made hypothermia a class one medical recommendation for patients with spontaneous return of circulation after cardiac arrest.
Thus this textbook was written for the physicians who are delivering critical care in the emergency department and who wish to improve their critical care knowledge and delivery of care. This textbook keeps in mind that the audience includes those who are not critical-care certified physicians. The majority of chapters were written by an EM physician trained in the practice of critical care and most chapters were co-authored by a Critical Care Fellowship trained practitioner in EM, IM or surgery.
- Office USGA. Hospital Emergency Departments - Crowded Conditions Vary Among Hospitals and Communities. Report to the Ranking Minority Member. In. Edited by Committee on Finance US; 2003.
- Lambe S, Washington DL, Fink A, et al. Trends in the use and capacity of California's emergency departments, 1990-1999. Ann EmergMed. 2002;39(4):389-396.
- McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2002 emergency department summary. Adv Data. 2004(340):1-34.
- Rivers EP, Nguyen HB. Goal-directed therapy for severe sepsis. Reply. N Engl J Med. 2002;346(13):1026-1026.
Reminder- Newsletters and Access to E-list - Critical Care Medicine Section Newsletter, March 2011
If you have not received your newsletter or are unsure if your section membership is current you can access your member profile on line. Go to the Home page on the ACEP website www.acep.org and click on My ACEP. If you have any questions or need assistance the Member Services staff are available at (800) 798-1822 Monday through Friday from 8 am to 5 pm Central time or email@example.com to answer questions about section membership, ensure that your preferences for receiving emails and publications is up to date and that the email address on record is accurate. You must provide a valid e-mail address to receive section newsletters.
Residents and medical students receive complimentary membership to one section of choice.
Section officer elections will be held electronically prior to Scientific Assembly and we want to make sure you receive your ballot at that time.
Scientific Assembly is in San Francisco this year Oct. 15 – 18.