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Undersea and Hyperbaric Medicine Section Newsletter - September 2008, Vol 15, #3

Undersea and Hyperbaric Medicine

circle_arrow Hyperbaric Medicine Section Meeting
circle_arrow Election of Officers
circle_arrow Message from the Chair
circle_arrow University of Pennsylvania Diving and Hyperbaric Medicine
Fellowship Program
circle_arrow Journal Watch
circle_arrow Case Report Conclusion
circle_arrow Hennepin County Medical Center Undersea and Hyperbaric Medicine Fellowship
circle_arrow Proposed Changes to the Hyperbaric Section Operational Guidelines

Newsletter Index

Hyperbaric Medicine Section


Hyperbaric Medicine Section Meeting


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Join us at Scientific Assembly in Chicago!

The ACEP Hyperbaric Medicine Section meeting has been scheduled for Tuesday, October 28, 2008, from 12:00 pm - 2:00 pm in Room 261 of the Convention Center (McCormick Place- Lakeside Center.)

The educational portion of Scientific Assembly runs from October 27-30. We hope to see everyone there.




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Election of Officers


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The section will be holding elections for Chair-elect, Secretary/Newsletter Editor, and Alternate Councillor. If you have an interest in serving in either capacity, please notify Margaret Montgomery



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Message from the Chair

Christopher J. Logue, MD

Well, it has been a busy summer and it is that time of year again to get ready for the upcoming Scientific Assembly in Chicago on October 27th-30th, 2008. We will have an exciting and busy agenda for our Hyperbaric Section Meeting which will be held on Tuesday, October 28th from 12:00 noon – 2:00pm in Room 261 of the Convention Center.

Once again, we would like to thank Dr. Sorabh Khandelwal and the Ohio State University Comprehensive Wound Care Center for providing us with another superb lunch buffet for our meeting.

I am excited to announce that our guest lecturer will be Keith Van Meter, MD, FACEP from LSU who will present hot-off-the-press research with regard to the use of adjunctive hyperbaric oxygen treatment for resuscitation of selected patients in the emergency department (ED). Also, he will be involved in a discussion of enhancing collaboration between ACEP and the Undersea and Hyperbaric Medical Society (UHMS) in an effort to support clinicians who practice hyperbaric medicine.

Other topics to be discussed at the meeting will include:

  • Changing the name of the section to: Undersea and Hyperbaric Medicine
  • Plans for a winter symposium organized and run by members of the section. Potential topics to be included in the symposium are:
    • Lectures on Diving Medicine
    • A Fellowship Development Seminar
    • Improving Awareness of Hyperbaric Medicine in the General Medical Community
    • Ongoing and Future Research Efforts in Hyperbaric Medicine
    • Recreational SCUBA diving during the trip
  • Plans for a formal Board Review Course organized and run by members of the section to prepare both fellowship trained and practice-plus pathway tract candidates for the UHM Board Exam.
  • The development of a Council of Fellowships in Undersea and Hyperbaric Medicine (CO FUHM’s) in an effort to foster relationships between fellowship programs and encourage collaboration on research projects.
  • A discussion of lack of awareness of hyperbaric medicine in the general medical community and how best to address this.
  • Highlighting community based hyperbaric and wound care centers run by members of our section in the newsletters for the upcoming year.

I look forward to seeing you there. Please, encourage any and all of your colleagues who have an interest in undersea and hyperbaric medicine to come to the meeting, have lunch and discuss exciting plans to improve our section.

Safe Diving!





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University of Pennsylvania Diving and Hyperbaric Medicine
Fellowship Program

Kevin Hardy, MD

The University of Pennsylvania Diving and Hyperbaric Medicine Fellowship is designed to provide licensed physicians the opportunity to be educated and trained in the theory and practice of diving and hyperbaric medicine. Individuals successfully completing the one-year fellowship will obtain sufficient didactic and practical knowledge to work efficiently and competently in a hyperbaric clinical and research environment, to act in a supervisory capacity of a hyperbaric chamber, and meet eligibility requirements to sit for the American Board of Medical Specialists’ certification examination for special competency in Undersea and Hyperbaric Medicine. The fellowship is AGME accredited for two positions.

Fellows will evaluate elective and emergency patients under the guidance of the Undersea and Hyperbaric Medicine faculty of the Institute for Environmental Medicine. The mechanism we have followed over the years for this activity allows for the fellow to assume a primary role in the management of each case. Whether the patient is seen on the inpatient floors, in the ED, or as an elective consult in the treatment facility in the Institute for Environmental Medicine, the fellow sees the patient first. The fellow then communicates the patient’s history and physical findings to a faculty physician on duty along with the fellow. The faculty member will then directly evaluate the patient, and the faculty physician and fellow will together develop a treatment plan. As the fellow matures through the year-long training, less interaction with the faculty member will be required to make management decisions and also monitor hyperbaric therapy. In this way, fellows are assured of being confident of their clinical decision-making skills prior to completing their training. We have an active service with patient referrals from all over the Delaware Valley. Fellows will have nearly daily contact with referral physicians, which will allow them to hone the skills required for a successful practice. Telephone inquiries from physicians will be taken initially by the fellow so as to allow them to ‘field’ questions. Depending on the acuity of the patient, the fellow may tell the referring physician that he will discuss the case with an attending and call the referring physician back, or simply place the physician on hold, make a rapid contact with a faculty member, and then proceed with treatment recommendations (such as initiating rapid transport to our facility if an emergency condition exists). As there is always an attending physician on call, and in the hospital with a fellow, a fellow always performs a ‘sign-out’ on their cases with a staff member.

Fellows will participate in the Hyperbaric Medicine clinical service, or related clinics 4-5 days/week during at least 10 months of the training period (they may choose to participate in up to two, one-month electives). Elective hyperbaric oxygen therapies occur from 7:30 AM to 4:30 PM. The Institute for Environmental Medicine operates a multiplace hyperbaric chamber complex. The largest chamber can accommodate up to eight patients and an inside attendant. There are several chambers devoted solely to research and one back-up clinical chamber that can accommodate 3 patients and an inside attendant. Up to four two-hour elective therapy sessions are conducted six days per week (Monday – Saturday). Sunday treatments are scheduled for patients who have clinical condition that cannot tolerate a gap in treatment (e.g. acutely compromised skin flap or graft). Fellows always practice with a staff physician in attendance. Initially, the staff physician will provide primary supervision to elective treatments, with the fellow acting as an observer. Typically, within a month on service, fellows develop their knowledge base and comfort so they assume more of the role as primary supervisory physician. Again, however, a staff physician will still be present on site to co-sign all documentation and oversee clinical decision-making. Fellows will be on call for emergency cases after hours on an every-third-day basis. Staff physicians will be in attendance in the institution when a fellow is called to come to the hospital to evaluate or to treat a patient.


The fellow will take a primary role interacting with the support personnel operating the hyperbaric chamber regarding technical issues such as length and depth (pressure) of the treatment. Fellows will perform day-to-day examination and monitoring of elective patients with the staff physician acting as advisor. At times when patients are so numerous that the treatment schedule would be slowed if just one physician performs examinations, the staff physician assists with these responsibilities. When urgent consults on new patients must be performed on hospital floors, the fellow will make the initial contact and the staff physician will remain in the Institute for Environmental Medicine to monitor the elective treatments. Similarly, when fellows are unavailable due to attendance at one or more lectures or an academic meeting, the staff physician is always available to assume a primary clinical role.


The Clinical Hyperbaric Medicine Service at the University of Pennsylvania sees an average of 300 new consults per year and performs approximately 4000 patient treatments annually. Emergency hyperbaric oxygen treatments supplement the clinical experience for the fellow and approximately 100 cases per year are treated. This includes treatment for carbon monoxide poisoning, necrotizing fasciitis, gas gangrene, arterial gas embolism, decompression illness and crush injuries. In addition, fitness to dive evaluations are performed regularly as the faculty members are certified by the Undersea and Hyperbaric Medical Society and the Diver’s Alert Network as Diving Medical Examiners.


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Journal Watch

Reviewer:  Marvin Heyboer III, MD, FACEP
Co-secretary, Hyperbaric Section - ACEP

Xue L, Yu Q, Zhang H, et al. Effect of large dose hyperbaric oxygenation therapy on prognosis and oxidative stress of acute permanent cerebral ischemic stroke in rats.Neurol Res. 2008;30(4):389-393.

This is a study out of Beijing Tiantan Hospital in Beijing, China. It is a prospective randomized control trial animal study of 114 male rats. Researchers caused acute permanent middle cerebral artery occlusion (MCAO) in the rats. The rats were then randomized to 1 of 3 arms. The first arm received hyperbaric oxygen (HBO) treatment for 9 hours after occlusion. This was initiated 3 hours after MCAO at 2 ATA with HBO at the first, third, fifth, seventh, and ninth hours and compressed air at the alternating hours. The second arm received HBO treatment for 18 hours after occlusion. This was also initiated 3 hours after MCAO at 2 ATA with HBO at the first, third, fifth, seventh, ninth, eleventh, thirteenth, fifteenth, and seventeenth hours and compressed air at alternating hours. The third arm was the control group that received no treatment. Outcomes were measured by (1) the Garcia neurological grading system, (2) measurement of cerebral infarct volume by pathological staining and NIH Image J software 24 hours and 120 hours after occlusion, and (3) measurement of levels of reactive species in ischemic brain tissue 18, 48, and 120 hours after occlusion.

Results demonstrated improved neurobehavioral outcome in the rats treated with HBO for 9 and 18 hours post-occlusion compared to the control group (p<0.01). Also, decreased cerebral infarct volume in rats treated with HBO for 9 hours (decreased 63-64%) and 18 hours (decreased 51-66%) compared to the control group when measured at 24 hours and 120 hours. Further, the measurement of reactive oxygen species demonstrated a decrease in both HBO groups compared to controls in both superoxide dismutase (SOD) at 18 and 48 hours (p<0.01 and p<0.05) and malondialdehyde (MDA) at 18 hours (p<0.05). NO levels were actually elevated in the HBO groups at 18 and 48 hour time points (p<0.01) with levels being equal at 120 hours.

This study demonstrated that HBO therapy was effective in improving neurobehavioral outcome and decreasing cerebral infarct volume. Studies done in multiple disease processes have demonstrated that HBO therapy attenuates ischemia-reperfusion injury. Intuitively, one would expect HBO therapy to improve survival of the penumbra (resulting in improved clinical outcome) in acute ischemic stroke. This topic warrants prospective human clinical trials.


Reviewer: Christopher J. Logue, MD

Bennett PB, Marroni A, Cronje FJ, et al. Effect of varying deep stop times and shallow stop times on precordial bubbles after dives to 25 msw (82 fsw). Undersea Hyperb Med. 2007;34(6):399-406.

Within the past several years, there has been a change in the recreational diving culture with the addition of the "deep stop." SCUBA training agencies have now been recommending that on deeper dives one should stop at ½ of their maximum depth and stay for 1-2 minutes prior to continuing the ascent and performing the traditional 3-5 minute safety stop at 15-20 FSW.

The rationale for this change originated from a paper published by these same folks at Duke University in 2004 (Undersea Hyperb Med. 2004;31(2):233-243.). In this original paper, dives were performed to 25 MSW (82 FSW) and a stop at 15 MSW (50 FSW) for 5 minutes was incorporated into the decompression profile along with the usual 3-5 minute safety stop at 6 MSW (20 FSW). The added deep stop significantly reduced precordial Doppler detectable bubbles (PDDB) detected within 90 minutes of surfacing after the dive. This new paper takes a closer look at the issue in an effort to determine the ideal amount of time to stop at the deep stop.

The outcome measure of this study was PDDB following dives to 25 MSW (82 FSW) for 25 minutes (or 20 minutes on a repetitive dive) with variations in the stop times at 15 MSW (50 FSW) and at 6 MSW (20 FSW). In terms of preventing PDDB, the ideal deep stop time at 50 FSW is 2.5 minutes during decompression from a dive to 82 FSW. Shorter deep stop times (ie, one minute) tended to produce the highest PDDB. In addition, lengthening the traditional shallow stop did not provide any appreciable reduction in PDDB (at least lengthened to as long as 10 minutes).

Therefore, the final recommendation is that the ideal deep stop time at 50 FSW following a dive to 82 FSW should be 2.5 minutes. Staying for any shorter or longer period of time at that depth is not beneficial in reducing PDDB. In addition, the authors recommend performing the deep stop in addition to the customary 3-5 minute safety stop at 20 FSW.




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Case Report Conclusion

Marvin Heyboer III, MD, FACEP
Co-secretary/Newsletter Editor

During our last newsletter we presented the case of a 44-year-old gentleman who completed scuba diving 2 days prior to presentation with rather acute onset of pain, paresthesias, and swelling to the left forearm and hand. His dives were well within no-decompression limits. There was further report by the patient of similar previous episodes in the past following diving.

The decision was made to treat the patient with a trial of hyperbaric oxygen. The symptom onset was temporally related to the completion of scuba diving, and there was no other clear explanation for his presentation. He was given the presumptive diagnosis of decompression injury (DCI), and he was treated with a US Navy TT6. The patient reported no initial change in his symptoms upon arrival to 2.8 ATA. He did report gradual improvement in the pain, paresthesias, and edema as the treatment progressed. The nurse reported some improvement in the edema also. The improvement remained even with decompression to 2 ATA and final decompression to 1 ATA. He had only slight residual pain/paresthesias and significant resolution in the edema after completion of treatment. He was contacted the next day, and he reported continued symptomatic improvement. The wrist pain gradually resolved, no sensory complaints, minimal residual pain along the dorsal surface of the index finger MC contiguous with the extensor tendon. The soft tissue swelling was almost completely resolved.

The patient was instructed to follow-up in 2-4 weeks with us or another dive medical examiner. He was instructed not to dive in the interim. The patient also followed up with a hand surgeon. He obtained xrays and an MRI. Bilateral wrist x-rays showed a large cyst involving the radial distal half of the left lunate at the radial aspect and a large cyst involving the distal half of the right scaphoid. Left wrist MRI demonstrated that the cyst was fluid filled with some diffuse fluid around the extensor tendons. He followed this up with a bone scan. Bilateral wrist bone scan demonstrated scattered foci of intense uptake within the wrists bilaterally, with slight intense uptake near the right distal radius-ulnar joint and near the left lunate. The radiologist’s impression included ‘Question Caisson’s Disease given the clinical history of pain following diving.’

The hand surgeon diagnosed the patient with interosseous ganglion of the left lunate and right scaphoid. He had high concern for micro fractures resulting from nitrogen expansion on decompression or related directly to increased external pressure. This would lead one to think that the cysts were preexisting, and the actual trauma was the result of direct pressure changes.

Several weeks later the patient dove again (on an extremely conservative profile of 50 fsw for approximately 20 minutes) and experienced similar symptoms including pain and swelling in both his hands and wrists (left greater than right). His hand surgeon referred him back to us. Since he was one week out from his most recent SCUBA dive and his symptoms were again gradually improving he was not re-treated with hyperbaric oxygen. We recommended that the patient be screened for other forms of arthritis and referred to a rheumatologist. His Rheumatoid factor was strongly positive and a diagnosis of Rheumatoid Arthritis was made. The patient was referred to a rheumatologist and we recommended that the patient refrain from further diving as he made his living as an aviation mechanic and his hands and wrist function are vital to his livelihood.

Final Diagnosis:
Previously undiagnosed rheumatoid arthritis exacerbated by compression/decompression stress from recreational SCUBA diving.




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Hennepin County Medical Center Undersea and Hyperbaric Medicine Fellowship

Robert E. Collier, MD FACEP, Director

The Hennepin County Medical Center Undersea and Hyperbaric Medicine Fellowship is an ACGME accredited one year program. Fellowship graduates fulfill the requirements to sit for the American Board of Medical Specialists’ certification examination for special competency in Undersea and Hyperbaric Medicine. The program is approved for one fellow at this time with the possibility of expansion. Applications are being accepted for the 2009-2010 Academic Year.

The primary teaching hospital, Hennepin County Medical Center (HCMC), Minneapolis, MN is the major referral center for all hyperbaric emergencies for western Wisconsin, the eastern Dakotas and all of Minnesota. HCMC is a Level I Trauma Center with the Regional Burn Center, the Regional Poison Center, and a Center of Excellence in Trauma, Medical Critical Care, and Renal Medicine.

The HCMC facility has three large multiplace chambers plus a fourth small lock-in/out chamber. Our monoplace chamber is used currently for research on traumatic brain injury. A small chamber is also available for research. Our very experienced hyperbaric staff includes all CCRN/CHRN certified nurses and chamber operators who are all NBDHMT certified hyperbaric technologists. Our facility is UHMS accredited as of 2006. We are in the process of building a ten million dollar facility to replace the historic but aging 1965 chambers built by Dr. Claude Hitchcock. Dr. Hitchcock did groundbreaking research on HBO and necrotizing infections and performed open heart surgery in a hyperbaric environment before bypass was developed. Our central spherical chamber originally was appointed just like a full operating suite. Currently we can treat up to twelve patients at a time. Our acute care chamber has the capability of being pressurized to 6 ATA and has all monitoring capability necessary to provide critical care.

Our EM/HBM certified faculty has many years of experience in Hyperbaric Medicine. The fellowship is under the auspices of the Department of Emergency Medicine and operates within the framework of the nationally recognized HCMC Emergency Medicine Residency Program. HCMC is also the main EM teaching hospital for the Department of Emergency Medicine at the University of Minnesota School of Medicine.

The hyperbaric service provides out-patient, in-patient, and critical care hyperbaric medicine. All of the major UHMS indications for hyperbaric oxygen therapy are represented in our hyperbaric patient population. Our department gives more than 3000 hyperbaric treatments per year at the training site. We treat approximately 210 to 220 patients per year with 60% of our dives being emergency patients. Because of our environment and demographics, we see a large volume of carbon monoxide poisonings, necrotizing infections and acute ischemia problems. Our chronic patients mostly have radiation injuries and non-healing, problem wounds.

The fellow masters the entire spectrum of hyperbaric and diving medicine including multiplace and monoplace hyperbaric chamber operations. A scholarly, research activity is required. The fellow attends two weekly clinics during which all the patients undergoing hyperbaric oxygen treatments are seen and monitored for complications. Wound healing patients are evaluated and their wounds debrided and dressings changed as indicated. The fellow sees both inpatient and outpatient consults and sees all emergency consultations presenting to the emergency department including diving injuries, air embolism, carbon monoxide poisoning and cases of necrotizing fasciitis and gas gangrene. The fellow supervises the hyperbaric oxygen treatments under the direction of the attending faculty. Two weeks of the 12 month program are spent at the UHMS/NOAA Dive Physicians Training course.

Applicants are expected to be board certified in an ABMS specialty and must have excellent critical care training and skills. ABEM certified fellows will be scheduled for shifts in the ED to keep up their primary board practice skills.











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Proposed Changes to the Hyperbaric Section Operational Guidelines

The Section ofUndersea and Hyperbaric Medicine Sectionis chartered by the Board of Directors ("the Board") of the American College of Emergency Physicians ("the College") to provide a forum in which members of the College with special interests in hyperbaric medicine can develop a knowledge base, share information, receive and give counsel and serve as a resource to others interested in this area of emergency medicine.

Since sections are considered a subcategory of membership of the College, sections will not have separate bylaws or formal incorporation documents, and their existence and operations shall be subject to the terms and conditions stated in Policy on Sections of Membership, as adopted and/or amended by the Board.

These Operational Guidelines have been drawn up to facilitate operation of the Section. They shall conform to the Constitution and Bylaws of the College, and the activities of the Ssection to the decisions of the Board. Projects in the areas of education, internal governmentgovernance, legislation, or public relations shall be undertaken only with the advice and consent of the Board. The activities of the Ssection shall be intimately coordinated with those of the College.


1 Name
  The name of this section shall be the Section ofUndersea and Hyperbaric Medicine Section. 
2 Objectives
  In addition to the general objectives of the College as set forth in the Constitution, the objectives of this Ssection shall be:
  2.1 Provide a forum to disperse and discuss different treatment modalities. Specific columns can be dedicated to different areas, such as diving medicine, toxicology, infectious disease, and wound care.
  2.2 Develop training sessions for emergency medicine residents; this will offer exposure to the field. More importantly, research development will be stimulated.
  2.3 Provide assistance in developing new programs for ACEP members. This will address both safety and efficacy of unit operations.
  2.4 Network with the Undersea and Hyperbaric Medicine Society to ensure uniform development of a curriculum in diving medicine and hyperbaric medicine.
  2.5 To develop a section of hyperbaric medicine where all ACEP members who are interested in hyperbaric medicine can share and develop a broad base of knowledge.
  2.6 To promote collegiality and cooperation among the physicians who practice emergency medicine and hyperbaric medicine.
  2.7 To serve as a resource to the College president, Board of Directors, College committees, and ACEP members on issues relating to emergency medicine.
  2.8 To coordinate activities with other organization involved in hyperbaric medicine at the invitation of the President and/or Board of Directors.
3 Membership
  3.1 The membership of the Section ofUndersea and Hyperbaric Medicine Sectionshall consist of physicians who have a special interest or expertise in hyperbaric medicine, who are interested in contributing toward the objectives of the Ssection, and who fulfill membership requirements as defined in the ACEP Bylaws. Section members may vote on Ssection matters and be officers of the Ssection.
4 Section Executive Committee
  4.1 The governing body of the Ssection shall be composed of four officers of the Ssection: chairman, chairman-elect, immediate past chairman,  and secretary.
  4.2 Nominees for officers shall be members of the Ssection presented by the Ssection's Nominating Committee to the Ssection membership through its newsletter or through the section e-list at least 30 days prior to the Ssection's annual meeting, which will be held in conjunction with the College's annual Scientific Assembly ("Scientific Assembly"). If elections are held during the annual meeting,Nnominations from the floor will also be accepted at the time of the Ssection annual meeting. If elections are held via e-mail or U.S. mail, write-in candidates will be accepted.
  4.3 The election cycle of the Ssection's officers will coincide with the dates of the Scientific Assembly.
  4.4 Unless otherwise scheduled via e-mail or U.S. mail ballot, the election of officers shall be by a majority vote of the section members present and voting at the annual meeting. The election of officers shall be by a majority vote of the Section members present and voting at the annual meeting. The Ssection will elect a chairman-elect and a secretary. If the current chairman-elect cannot serve as chairman, the Ssection will also elect a chairman.
5 Officers
  The officers of the Ssection shall at a minimum be the chairman, the chairman-elect, the immediate past-chairman, and secretary. The officers shall be members of the Ssection and serve for a term of one year. Following the chairman's term of one year, there will be an additional one-year term designated as immediate past-chairman. Officers may not serve more than two consecutive terms.
  5.1 Duties of the chairman of the Ssection:
    5.1.1 He shallMay be appointed by the College President to serve as a voting member of a related College Committee if one exists.
    5.1.2 He mMay attend ACEP Board of Directors meetings at his own expense; and he will receive minutes of meetings of the Board, Council, Steering Committee, etc. of the College.
    5.1.3 He sShall keep the Board of Directors and Executive Director informed of Ssection activities via copies of correspondence, agenda, minutes of meetings, etc.
    5.1.4 He willShall submit an annual report to the College President and Executive Director. This shall consist of a list of achievements and activities of the past year and goals and objectives for the coming year.
    5.1.5 He sShall submit to the Board of Directors for approval all section plans, goals, objectives, budgets and meetings before they are implemented by the Ssection.
    5.1.6 He sShall preside at the annual meeting of the Ssection and at any other meetings of the Ssection. In his absence, he shall assign this function to the chairman-elect.
    5.1.7 He sShall appoint chairmen and members to any standing and special committees of the Ssection to carry out Ssection activities.
    5.1.8 He sShall have the privilege of recommending to the President the appointment of Ssection members to Committees of the College.
    5.1.9 He sShall be a member ex officio of all standing and special committees of the Ssection.
    5.1.10 Shall review all section grant proposals developed by their section members. Those developed section grant proposals that are determined to be appropriate for submission are then signed and submitted to the appropriate committee or task force assigned to manage the Section Grant Program.
  5.2 Duties of the chairman-elect:
    5.2.1 He sShall serve as an officer of the Ssection.
    5.2.2 He sShall assist the chairman in his duties for the Ssection as designated by the chairman.
    5.2.3 He sShall serve as chairman in the absence of, resignation, or death of the chairman.
  5.3 Duties of the immediate past-chairman:
    5.3.1 He sShall serve as an officer of the Ssection.
    5.3.2 He sShall serve as chairman of the Ssection Nominating Committee.
    5.3.3 He sShall assist the chairman in his duties for the Ssection as designated by the chairman.
  5.4 Duties of the secretary:
    5.4.1 He sShall take the minutes of the annual meeting of the Ssection and submit to the appropriate section communication vehicle.
    5.4.2 He sShall provide the Board of Directors the names of the elected Ssection officers.
    5.4.3 He sShall assist the Ssection chairman in the preparation of an annual meeting and the chairsmen of other committees of the Ssection, as requested.
    5.4.4 He sShall distribute to the membership via the Ssection newsletter or other communications vehicle: The minutes of the annual meeting of the Ssection. Such information as shall from time to time be of interest to members of the Ssection.
    5.4.5 He sShall notify members regarding their appointment to any committees of the Ssection and shall send copies of such notification to the Executive Director of the College.
    5.4.6 He sShall give due notice of all meetings of the Ssection and the Executive Committee of the Ssection to the membership of the Ssection and the Board of Directors of the College.
    5.4.7 He sShall carry out such other duties as are assigned by the chairman of the Ssection and the Board of Directors of the College.
    5.4.8 Shall serve as editor of the section newsletter unless otherwise appointed by the chair.
6 Councillor
  6.1 The Section shall elect a councillor and an alternate councillor to represent the Ssection to the Council of the College ("the Council"). Term of office is two years, with the alternate councillor becoming the councillor at the end of his/her two-year term. If he cannot serve as councillor, the Ssection shall elect a member to fill both positions and resume normal progression from alternate councillor to councillor. If the councillor and alternate councillor are unable to represent the section at theCouncil prior to an election at the annual meeting the chair will appoint a section member to serve as councilor.
  6.2 Duties of the councillor and alternate councillor:
    6.2.1 He sShall represent the Ssection at the Council meeting.
    6.2.2 He willShall have the duties, obligations, and privileges as designated by the Bylaws and procedures adopted by the Council.
    6.2.3 He willShall keep the Ssection informed of all Council activities before, during, and between sessions and report to the Ssection, in its newsletter, and/or other communication vehicles, all important matters considered.
    6.2.4 He willShall bring resolutions to the Council from the Ssection, if any are developed.
7 Standing and Special Committees
  7.1 The chairman shall appoint a Nominating Committee as a standing committee and designate the Immediate Past Chairman to serve as chairman. From time to time, the Section chairman shall appoint special committees when indicated.
  7.2 The Nominating Committee shall consist of three members appointed by the chairman of the Ssection for a term of one year. In addition, the Immediate Past Chairman will chair the Committee.
  7.3 Other standard committees: 1) Education Committee; 2) Certification of added qualifications; and 3) Membership Drive Committee. From time to time, the section chairman shall appoint special committees when indicated.
8 Meetings
  The annual meeting of the Ssection will be held during the annual Scientific Assembly of the College and will consist of two portions:
  8.1 A professional program open to all members of the College, professionals, paraprofessionals and guests invited by the Ssection.
  8.2 A business meeting open to all members of the College with voting limited to section members.
  8.3 At their own expense, sections may hold special meetings at other ACEP functions.
  8.4 Sections may seek outside funding support for their meeting as long as it is not in conflict with the College’s fund raising activities associated with Scientific Assembly.


The Section may recommend to the Board of Directors of the College a dues increase, if members feel it necessary to support their activity. A dues increase recommendation must be approved by a majority of Section members present during their annual meeting.The dues for the section are established by the Board of Directors of the College.

10 Additional Funding for Activities
  10.1 To increase its funds, the Section may apply for: 1) An allocation of 15% of its total dues collected during the previous year; or 2) A one-time per project voluntary special assessment.
  10.2 The Section may raise funds from outside entities such as corporations. All such fundraising must be approved in advance by the College and meet the criteria established by the College.
  10.3 The Section may apply for a Section Grant. Projects can be funded which benefit individual sections as well as advance emergency medicine and educate the public.

Parliamentary Authority

The parliamentary authority for all proceedings of the Ssection shall be the parliamentary authority approved for use for proceedings of the College. However, should conflicts or inconsistencies arise between the parliamentary authority and this instrument, this instrument shall govern.

12  Voting         
  12.1 Voting on any issue, except amendments to these Operational Guidelines, may be accomplished either during the annual meeting, or via a mail ballot. Mail ballots can be electronic and/or U. S. mail. The Chair shall determine which method is appropriate for each item coming before the Section.

For e-mail and U.S. mail ballots, the voting membership will be defined as the section membership on the date the ballot is sent. The majority of dues paying section members (based on the number of dues paying members on the day the ballot is sent) must approve any item in order for the item to be approved.

For e-mail and U.S. mail ballots, write-in candidates will be accepted.

    12.2.1 Voting by E-mail
      Snap Survey software will be used to e-mail the ballots and to tally the results.
      Two e-mail notices will be sent, seven days apart, to all section members regarding the upcoming ballot.
      Seven days after the second notification email, the ballot will be e-mailed once to all section members with a due date for return by e-mail in 10 days.
    12.2.2 Voting by U.S. Mail
      Mail ballots shall be distributed to members through the section newsletter or the section e-list a minimum of thirty (30) days prior to the voting deadline. The ballot will also be sent once via U.S. mail to all section members with a due date for return in 10 days. Executed mail ballots will be forwarded by e-mail or U.S. mail to the section staff liaison.



Any member of the Ssection membership may originate a proposed change in these Ssection operational guidelines. Proposed amendments to the operational guidelines must be submitted in writing by the approved communication vehicle to the Cchairman in care of the Ssection’s staff liaison at the College at least ninety (90) days prior to the scheduled annual meeting.

  13.2 Proposed amendments will be published in the Ssection newsletter or e-mailed via the section e-list immediately preceding the annual meeting of the Ssection, and will be placed on the agenda of the Ssection annual meeting. Any proposed amendment must be approved by two-thirds of the members present and voting during the annual meeting or the section will follow the procedures for electronic voting.

Adopted amendments will be reviewed by the Section Executive Committee and the Board of Directors of the College. Amendments approved by the Board of Directors of the College will be published in the Ssection newsletter preceding the next annual meeting of the Ssection.

12 Neutral Gender
  Wherever the pronoun "he" appears, it shall be read as gender-neutral.
Approved by ACEP Board of Directors, October 4, 1991



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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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