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Medical Humanities Section Newsletter - March 2009, Vol 5, #1

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circle_arrow From the Editor
circle_arrow From the Chair
circle_arrow A Mystery- Solved?
circle_arrow Sodus Bay, NY
circle_arrow Soular Energy
circle_arrow Interview with Jay Baruch
circle_arrow 2008 Creative Writing Award
circle_arrow 2009 Annual Meeting Minutes


Newsletter Index


Medical Humanities Section

 

MUSE – 40th Anniversary Issue – March 2009

From the Editor

Peter J. Paganussi, MD, FACEP
Falls Church, VA

My favorite animals have always been bears. I like all types of bears. I find them fascinating creatures and they have a long, well-documented, evolutionary lineage. All modern bears have evolved from Ursavis elemensis, the earliest bear that lived during the Miocene epoch in sub-tropical Europe.  

One of the most fascinating aspects of bears, to me, has always been hibernation. I have taken this concept to heart with this issue of MUSE. I returned from the ACEP 40th Anniversary Scientific Assembly with such joy! I had an absolute blast in Chicago. It is such an amazing city. I may have actually had too much fun…more fun than most humans should be allowed to have. Which is why I probably went into my own form of hibernation. Like a little child who played too hard, I came home and fell right to sleep. A creative hibernation hiatus as it were.  

Well, from Virginia at least, spring is in the air, with the first whiffs of its sweet, loamy aroma, and it is long past time to wake up. While spring may be in the air, I can still feel Chicago, the last wonderful moments before I began my hibernation. I am partial to the blues, and jazz as well, so Chicago for me is a musical paradise. One trip to Buddy Guy’s Place and I am pretty certain I could convert even a Mozart lover. You have really never heard the blues until you’ve heard them in Chicago, preferably at a real "down n’ dirty" joint like Buddy’s Place. You don’t hear them so much as you feel them. They grab a hold of you and wrap around you like clinging ivy and they never let go. This is a good thing in my book. (Try some Roy Gaines, or Little Milton, Junior Wells, or just Buddy Guy himself…you will not regret it.) So while I spent an evening with some fellow Henry Ford Hospital alums at the aforementioned Buddy’s Place, I also grooved to some fantastic music, as well as live comedy, magic and prose/poetry reading performances by members and friends of our section.  

In the balcony of the truly exquisite lobby of the Chicago Hilton Hotel, for those of us lucky enough to attend, we were treated to a veritable "Best of…" by the Section of Medical Humanities. It was a tour de force all the way around. Lots of laughs, great talent, and the joys of camaraderie, all served up with a healthy slice of Chicago. There are some photos below that capture only a very few of the memories I have. These will have to suffice for now.  

Please enjoy this issue of MUSE. It once again is the backdrop to the prodigious talent of this section. Dr. Hans House has laid much of it out for us in his take "From the Chair." This issue is woven around celebrating ACEP’s 40th anniversary and who we all are as emergency physicians. I am always delighted to be around "ER docs," but I am thrilled when they are like the people who gravitate towards our particular section. As you move your eyes down and scroll your screen up you will be treated to some wonderful delights, beginning with our own chair’s piece on "The Plague of Athens."It is very enjoyable reading. There are photographs of Sodus Bay, NY (located on Lake Ontario) by Dr. Frank Edwards. We have a very well-done interview by Dr. Paul Austin. He interviews section member and director of the ethics curriculum and the medical ethics scholarly concentration at the Warren Alpert Medical School at Brown University, Dr. Jay Baruch. Paul has written and published a book (as Dr. House mentions) that contains some truly special writing. There is a link to his Web site where you may obtain a copy of his book "Something For the Pain." He was the perfect choice to conduct and record such an interview. There is ethereal poetry from Dr. Shay Bintliff. She has also written and published her poetry and prose. Did I tell you there is some good stuff here? Remember to let sleeping bears lie…or hibernate…whatever. Enjoy the works of our colleagues, of whom we can be 40 years proud! 

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From the Chair

Hans House, MD, FACEP
University of Iowa

Late February is always the toughest time to be alive in Iowa. We have been ready for spring for weeks now, and it always seems just around the next corner. There are many things I love about winter: snow-covered forests, warm fires, hot chocolate, cross country skiing, eagles fishing in the river. But it has to end. Soon. 

This is the time of the year when our minds are numbed by the months of cold. We are less active. We procrastinate. We’re lazy. We promise ourselves we’ll get around to cleaning the garage "when it gets a little warmer." And we don’t get messages out to the membership of the section like we should. 

As the seasons cycle through the year, so does activity in this section. We gather steam through the summer and hit our peak in time for the Scientific Assembly every October. But this is time of the year for our nadir. And as section chair, it is my fault.  

So let’s crack open our first chardonnay of the spring (allow me to recommend the 2005 Frank Family Napa Valley- drink it now, it’s perfect) and here’s to more writing, photographing, reading, singing, and storytelling. Some of our members have some wonderful material out there right now. Dr. Paul Austin’s book, Something for the Pain (http://www.paulethanaustin.com/PaulEthanAustin/Home.html) is both moving and troubling. Dr. Shay Bintliff published a heartwarming collection of poetry collection called Soular Energy (available on amazon.com) dedicated to her granddaughter who lost a battle with cancer at 11. And our Open Mic maven Dr. Liz Mitchell has her debut album Not the Whether of Summer (http://www.lizmitchellmusic.com/).

This is also the time of the year to start scheduling your conferences and workshops. I have a few suggestions. The Examined Life (http://www.medicine.uiowa.edu/osac/examinedlife/) a conference focused on creative writing in Medicine, will be held at the University of Iowa April 29th- May 1st. Section members Dr. Jay Baruch and Dr. David Sklar will be attending- why not join us? Later this summer, both the University of Iowa (http://www.continuetolearn.uiowa.edu/iswfest/html/welcome/) and Sarah Lawrence College (http://www.slc.edu/summer/Writers_Seminar.php) in New York will be putting on their summer writing programs. These are great ways to improve your craft and network with some other very creative minds. Finally, my favorite conference that I have never attended is the Creativity and Madness (http://www.aimed.com/sf09.html) program held annually in Santa Fe, New Mexico in August. It focuses on the interplay between art, creativity, disease, and healing. Wow- how cool. Just thinking about being in Santa Fe in the peak of opera season is helping me shake off these late winter doldrums. 


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A Mystery- Solved?

Hans House, MD, FACEP
University of Iowa

I have often pondered the Plague of Athens. OK, now I know I have lost most of you. Yes, I really am that much of a geek. I actually care about what killed thousands of Athenians 2500 years ago. I am completely fascinated by this story for a couple of simple reasons. First, it had a huge impact on the development of western civilization, effectively ending Athens’s golden age. Second, the cast of characters related to the events before and after the plague reads like a who’s who of classical literature: Euripides, Pericles, the 300 Spartans at Thermopylae, the running 26 miles from the battle of Marathon, Asclepius, and even our old friend from med school graduation: Hippocrates. Third, and most importantly, the etiology of the Plague of Athens is one of the most enduring and perplexing mysteries in all of medicine.  

For over 2000 years, with every paradigm shift in the science of medicine, scholars have postulated on the cause. In the last 150 years, the germ theory has led writers to try to pin an infectious microbe as the culprit. This mystery is ever more tantalizing because we have a meticulous description of the disease from an eyewitness historian named Thucydides (although there is some evidence that parts were written 20 years after the fact). He describes in rather horrifying detail the course, symptoms, signs, and mortality rate that fails to match exactly to any known infectious disease.  

No less than 27 theories have been proposed to explain the Plague of Athens, by a wide range of authors. All the papers conclude with the same epitaph: since no remains from plague victims exist, we will never know for sure. Just this month, however, I learned of a startling development in the greatest of medical mysteries. In 1998, when crews were upgrading Athens’s public transportation in advance of the 2004 Olympics, they stumbled upon a previously unknown mass grave. The bodies at the bottom (the oldest) were arranged carefully, set next to funeral pottery. The pottery gave the site an age: 430 BC. The summer of the plague! 

As more victims were added to the pile, the arrangement became more haphazard. Funeral rites were neglected. By the time the newest bodies entered the grave, they were not laid; they were dumped and allowed to land in any way they fell. Imagine the situation: the city is at war with Sparta and the enemies are clawing at the gate. To protect the citizens, Pericles calls for everyone to take refuge within the city walls. The population surges with people and their livestock from the surrounding farms. Then a plague breaks out in Piraeus, the port connected to Athens by the long Themistoclean walls. Men, women, and children all perish following the appearance of fever, blisters, cough, and diarrhea. The city panics and descends into chaos as the epidemic roars on.  

So, what caused it? Time to call in the folks from "CSI." 

In 2006, Greek researchers published their results from a DNA probe of a tooth of plague victim.1 They compared the genotype to a number of the infectious diseases blamed for the plague. And they got a match: Salmonella species, closely related to S typhi

Typhoid fever? Really? Are you sure? 

Many features of the Plague of Athens are consistent with typhoid fever. Epidemiologically, the disease flourishes in summer when water supplies run low and refugee populations are crowded together. The persons in Athens died after 7 – 9 days, finally succumbing to high fever, abdominal pain, and diarrhea. But there are also elements that don’t fit so well. Consider this passage from Thucydides’s history.2

"After which came sneezing and hoarseness, and in not much time the pain descended into the chest, and produced a severe cough. . . . Externally, the body was not very hot to the touch, and was not pale, but reddish, livid, and flowering with small blisters and wounds." 

Cough is not a known symptom in typhoid fever. And the famous "rose spots" that accompany the infection are faint and fleeting. It is hard to imagine an observer characterizing them as "livid" and "flowering with small blisters and wounds" (although the flowering metaphor for rose spots is tempting!) 

So again, as so often with histories of the Plague of Athens, we are left with an incomplete and unsatisfying answer. Although I would like to probe for a more final answer, I also recognize the pleasure in allowing some things to remain in the realm of the unknown. I am a big fan of the television show "Lost." It is the most addicting TV show in history for science fiction aficionados like me. What makes "Lost" great is that they introduce one or two mysteries for each one they solve. You get the satisfaction of learning an answer, but the new mystery gets you even hungrier for the next solution. For now, I will be happy that the mystery of the Plague of Athens is the "Lost" of the ancient world. It is a mystery that I don’t really want solved. Maybe. 

  1. Papagrigorakis, M.J., et al., DNA examination of ancient dental pulp incriminates typhoid fever as a probable cause of the Plague of Athens. Int J Infect Dis, 2006. 10(3): p. 206-14.
  2. Cunha, B.A., The cause of the plague of Athens: plague, typhoid, typhus, smallpox, or measles? Infect Dis Clin North Am, 2004. 18(1): p. 29-43. 

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Sodus Bay, NY

Frank Edwards, MD, FACEP
Sodus, NY

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Soular Energy

Shay Bintliff, MD, FACEP
Kamuela, HI

Deep in the depths of Mother Earth
Come waves of energy giving forth to life.
    Fierce
        Magical
            Mystical
Is my soul the celestial liquid
Poured from eternity’s endless well?

Where do I find myself?
As if I know where I belong.
    A path
        A journey
            A calling
Brings my soul’s rest from living
That burdensome reality called life.

Questions..Oh, so many questions!
What powers will protect me?
    Mental
        Physical
            Spiritual
Can this adventuresome journey
Be safe, easy, yet challenging?

My past will blend with the future
As guidance for my next journey.
    Look
        Listen
            Learn
Just as the new moon, a sliver, a promise
Of fullness yet to come.

How will I wear my soul?
Do these wrinkles mark the wisdom I’ve earned?
    Live
        Life
            Fully
As the stream will smooth rough rocks
Making its way to Mother Ocean’s arms.

The Soul’s energy generates from within
Yet reaches out for all with
    Creativity
        Hope
            Passion
Giving fire, light and magic
That flow as the hot lava from Kilauea.

I will search in the quiet space
Of life’s richest moments, and live with
    Congruence
        Confidence
            Compassion
For living such a life is the way
To know and find the self. 


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Interview with Jay Baruch

Paul Austin, MD
Durham, NC

Interview with Jay Baruch: An emergency physician and faculty member at Brown Medical School, and author of Fourteen Stories: Doctors, Patients, and Other Strangers.  

Paul: Jay, your book, Fourteen Stories: Doctors, Patients, and Other Strangers, published by Kent State University Press, has been well received within the literary community, as well as the medical community. Did writing the book change the way you practice medicine? 

Jay: I think so. A challenging part of writing for me involves tapping the appropriate voice to tell a particular story. In my collection, adapting the point of voice of others, whether it’s nurses, patients, family, and even an ED janitor, means being attuned and sensitive to those around you. By doing this work in my writing, I find the mental muscles bending that way in my clinical work. I tend to think through difficult clinical situations as if a pivotal part of a story. I try to remove myself as much as possible (though I sometimes fail). I try to ask narrative questions. How did we get here? How might this situation be perceived differently? Am I asking the right questions? What are the possible outcomes? How can I make a positive impact, and just as importantly, are there gasoline gestures, things I might do or say that make the entire encounter go puff?

Paul: You have a history of working in the medical humanities for quite some time. What do the medical humanities offer the trench dog who is just moving the meat in the ER? 

Jay: Practicing emergency medicine means trading in uncertainty. I tell students that the core part of my practice in the ED involves listening to patients’ stories. We get bombarded with stories. And patients aren’t always reliable storytellers. I can’t blame them. Most patients haven’t been to medical school, and don’t know what we consider important or unimportant information. Plus, they’re sick or injured and scared and forced to wear silly, unattractive gowns that may or not fit. My emergency medicine skills prepare me to process and respond to what I hear. Many cases are more straightforward and place less narrative demands on us as listeners. But there are many other clinical situations where it’s imperative that emergency physicians be narrative experts as well.

Medical humanities is such a broad and diffuse concept, and it might mean different things to different people. The humanities includes music, art, dance, theater, not only literature and writing. People use it differently. I’ve wanted to write since I was a little kid. It wasn’t a conscious decision. The medical humanities movement has given what I do some legitimacy, for which I’m grateful.

For the trench doc, medical humanities can function at several levels: a tool for practice; an instrument for personal growth and expression; an occasion to allow yourself to reflect and think expansively; and let us not forget enjoyment and entertainment.

One way people connect and develop compassion for others is through the stories they tell. The many pressures of working in the ED can distract us from the fact that people wait hours to tell us very personal stories. I’ve written elsewhere that practicing medicine is an emotional contact sport, and I believe that fact is amplified multifold in the ED. I can’t speak for others, but for me, writing and reading has helped me process and disentangle these complicated experiences.

Paul: Thus far, you've not written any narrative nonfiction about your experiences as a doctor. Why is that? 

Jay: I recently posted an essay, "The Story Always Comes First" on the NYU Literature, Arts, and Medicine blog where I explained my personal discomfort writing nonfiction narratives. (http://medhum.med.nyu.edu/blog/?p=146) I’m particularly sensitive to patient privacy and confidentiality issues. I don’t feel confident that I can change identifiable details enough. I’m also concerned about doctor-patient trust, and should patients know about my other life, I don’t want them to withhold important information out of fear that I might use it for creative use. I want patients to be secure that I consider them the subject, not the object, of my attention. And finally, I find that fiction allows me the imaginative freedom to probe emotional truths that might be restricted by an obligation to reality. These are my personal opinions. Others disagree with me. They have persuasive counterarguments. I’m fascinated by this debate.

Paul: Your book, Fourteen Stories, along with Frank Huyler's book The Blood of Strangers, and David Sklar's book, La Clinica, offer a modern take on the practice of medicine, in the same tradition of The Doctor Stories, by William Carlos Williams. Books such as The House of God, and TV shows such as "ER," and "Scrubs," seem to offer a different perspective. Would you consider The House of God, "ER," and "Scrubs" to be part of the medical humanities?  

Jay: I’m still trying to wrap my hands around what is meant by "medical humanities." The House of God has been praised and criticized, but it’s an important and iconic work. My contribution to a recent anthology of essays on this book argues how the book is unflinchingly honest about certain aspects of doctoring which might make readers uncomfortable.

"ER" and "Scrubs" connect with audiences in profound and original ways. Movies, television, even medical thrillers are entertainment, but they also provide a lens through which the public has learned about medicine, doctors, and emergency medicine. 

Paul: Nowadays it seems like every doc with a laptop wants to write a book.

What advice would you give to the ER docs out there who have a great idea for a book, but are unsure of how to start? 

Jay: It depends on the purpose of your writing and the type of writing. The simple answer is this: if you want to write, start writing. Someone once said you can’t edit a blank page. It’s best if you have someone you respect to critique your work. Local writers groups, writing workshops, and writing workshops specific targeted for health care providers are out there. 

Paul: Did you take any classes or go to any lectures, when you were first starting out as a writer? 

Jay: I took a few writers workshops. I went to many readings by writers. I read many books on writing, and I read many great books. But mostly I sat down and wrote a lot of terrible stuff. Two novels worth of garbage, a stack of equally lousy short stories. In the end, I understood enough about my writing to recognize certain weaknesses and sought the help of a freelance editor who was ruthless with me. I still have a long way to go. I think there are easier paths than the ones I hacked through.

Paul: How do you find time to write? 

Jay: Between my clinical duties and academic duties at the medical school, and home life, finding time is a challenge. For several years I made decisions regarding my medical career to favor more writing time. After marrying and having a son, I focused on family responsibilities. I also became more involved in medical education, medical ethics in particular. I’m far behind my present project, and when I’m not writing, that frustration reveals itself as extra bumps in my already bumpy personality.

Paul: Who are some of the writers that you read for fun? 

Jay: There are so many, but writers I go back to include Anton Chekhov, William Carlos Williams, Isaac Babel, Alice Munro, Michael Ondaatji, George Saunders, Kurt Vonnegut, Lorrie Moore, Raymond Carver, Tim O’Brien, Andrea Barrett, Stuart Dybeck, Walker Percy, Ethan Canin, to name only a few. There is also this Paul Austin book that I enjoyed tremendously.

I love to read—OK, I’m addicted to it-- but with time so short, reading usually comes at the expense of writing. I listen to books on tape while running or in the car. Recent books that I loved include Lush Life by Richard Price and Unaccustomed Earth by Jumpa Lahiri (a stunning writer).

Paul: Who are some of the writers that you read to improve your own writing? 

Jay: See above. Also some mind-blowing short story writers that I’ve been reading recently include Amy Hempel, Tobias Wolff, and Andre Dubus.

Paul: You are a member of the medical humanities section of ACEP. Why did you join, and how has the section helped you as a doctor, and as a writer? 

Jay: This section is remarkable for several reasons. People gravitate towards kindred spirits, and my medical world and creative world has been distinct and separate most of my career. Through the humanities section, I’ve met similarly nutty people. They are dedicated physicians and talented artists who take their art seriously. The section, by its mere presence, provides a creative community where people at all levels of expertise can comfortably come out of the dark and strut their stuff. Michael Burg, Hans House, Seth Hawkins, Liz Mitchell and others should be applauded for their efforts. The College is better for it. 

Paul: Thanks again for taking the time for this interview. Any final thoughts on the role of humanities in emergency medicine?

Jay: I hope the section keeps medical humanities personal, clinically relevant, and in the trenches. Personal definitions of medical humanities aside, I think narrative skills are essential tools for taking care of patients. Developing interesting curricula in this area might be valuable to ACEP members…and hopefully, fun.

I want to thank my colleagues for taking time from their busy schedules to read this, and thank you, Paul, for interviewing me. I’m honored. 

Jay Baruch is the author of Fourteen Stories: Doctors, Patients, and Other Strangers (Kent State University Press, 2007), along with multiple literary essays and essays on emergency medicine and medical humanities. He is an emergency physician in the Department of Emergency Medicine at the Warren Alpert Medical School at Brown University and director of the ethics curriculum and the medical ethics scholarly concentration at the medical school.

Paul Austin is the author of Something For the Pain: One Doctor's Account of Life and Death in the ER. His essays have appeared in Turnrow, Ascent, The Gettysburg Review, Creative Nonfiction, and The Southeast Review.  


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2008 Creative Writing Award

The American College of Emergency Physicians (ACEP) Section of Medical Humanities recently announced the winner of its second annual Creative Writing Award.  

The 2008 Creative Writing Award was presented to Peter J. Paganussi, MD, FACEP, at the section’s meeting in Chicago during the ACEP Scientific Assembly

Dr. Paganussi’s essay entitled "Outside the Box, Inside the Box, and Generally All Boxed Up" won the top honor in this annual contest. The essay was first published in Virginia ACEP’s EPIC newsletter. 

All creative writings published in the 2007-2008 interim between Scientific Assemblies were eligible. Competition was especially tight this year, with judges split in many cases between different submissions. "The competitiveness of the award this year reflects the increasing number of emergency physicians who are producing very high quality creative writing," notes Seth Hawkins, MD, an organizer of the award competition.  

Applications for next year’s award will be solicited in July 2009.

 


 

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2008 Annual Meeting Minutes

American College of Emergency Physicians
Section of Medical Humanities
October 28, 2008
Chicago, IL 

MINUTES

Participating in all or part of the meeting were: Hans R. House, MD, DTMH, FACEP, Chair; Paul E. Austin, MD, FACEP; Arthur R. Derse, MD, JD, FACEP; Seth C. Hawkins, MD, FACEP; Catherine A. Marco, MD, FACEP; Elizabeth Mitchell, MD; Peter J. Paganussi, MD, FACEP; David P. Sklar, MD, FACEP, ACEP Board Liaison; Katrin (Kay) Takenaka, MD, FACEP; Mary Wilger, DO, FACEP 

Others participating: Tracy Napper, ACEP staff liaison. 

Agenda

  1. Call to Order
  2. New Business

A. "Open mic" discussion

B. Select chair for art gallery for 2009

C. Membership

D. Web site development/newsletter expansion

E. Review/approval of operational guidelines

F. Writing Award for 2008  

Major Points Discussed

  1. The meeting was called to order by Hans R. House, MD, DTMH, FACEP, section chair.  
  2. New Business 

A. "Open Mic" – Dr. Mitchell encouraged everyone to attend the Open Mic Night on Tuesday, October 28. She acknowledged that there are challenges every year for this event. She had several new performers due to a mass e-mail that Susan Morris of ACEP sent. This year food will be offered at Open Mic, using the 15% section dues allocation from 2007. Dr. Mitchell agreed to organize the event in 2009 in Boston. The EMF Event on Monday, October 27 was a great success. Several musicians performed and art was provided by section members for the silent auction. Dr. Sklar also donated copies of his books to EMF. The EMF staff would like to do this again next year. Ms. Napper will meet with her ACEP colleagues to discuss future partnership opportunities. 

B. Art Gallery for 2008 – Dr. Hawkins has agreed to again organize the gallery for 2009. This year the gallery was in the ACEP Resource Center which was a great location. However, there were fewer pieces of art, because the EMF-donated pieces were only showed at the EMF event. Ms. Napper will investigate partnering with the EMF booth next year and exploring ways to showcase all art on all exhibit days. Dr. Hawkins suggested having more multimedia options in the gallery. The Section of Wilderness Medicine photo contest was again displayed in the gallery using a digital frame. We will pursue doing this again in 2009. 

C. Membership – Dr. House is concerned about membership numbers. He reminded section members to sign up their residents, as residents are allowed 1 free section membership. Dr. Mitchell suggested advertising the section in ACEP News, as many members still do not know this section exists. Dr. Hawkins suggested creating an online survey to gauge member interests and needs. Dr. Paganussi suggested finding the department heads of major humanities departments and using them as targets for communication.  

D. Web site development/Newsletter expansion –Dr. Paganussi suggested adding more links to our Web site, including a succinct yet comprehensive definition of medical humanities. He asked members to submit items for the Web site and newsletter. Dr. Hawkins has an article he plans to rewrite for inclusion on the Web site. Dr. Austin will conduct an e-mail interview with Dr. Jay Baruch and submit it for the newsletter. Ms. Napper gave Dr. House a certificate for the newsletter award of distinction for 2006-2007; Dr. Burg and Dr. McGee were not in attendance to receive their certificates. 

E. Review/approval of operational guidelines – The revised guidelines were approved for submission to the ACEP Board of Directors for review. 

F. Dr. Hawkins said that this year’s recipient of the Creative Writing Award is Peter Paganussi, MD, for his piece "Outside the Box, Inside the Box, and Generally All Boxed Up." Articles will be solicited for the third annual award in July 2009. More advertisement of the award needs to be done next year as well as expanding the panel of judges and blinding the submissions. 

The meeting was adjourned. 


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This publication is designed to promote communication among emergency physicians of a basic informational nature only. While ACEP provides the support necessary for these newsletters to be produced, the content is provided by volunteers and is in no way an official ACEP communication. ACEP makes no representations as to the content of this newsletter and does not necessarily endorse the specific content or positions contained therein. ACEP does not purport to provide medical, legal, business, or any other professional guidance in this publication. If expert assistance is needed, the services of a competent professional should be sought. ACEP expressly disclaims all liability in respect to the content, positions, or actions taken or not taken based on any or all the contents of this newsletter.

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