Fall 2015 Issue

Fall 2015

Alabama Chapter ACEP

John Campbell, MD, FACEP, President

Leonardo Nasca, MD Editor

Contact us:

Phone: 877.2.ALACEP
Fax: 334.671.168

From the President
John Campbell, MD, FACEP

Dear Alabama Chapter,
Looking back on 40 years of Emergency Medicine, I began my practice of Family Medicine in 1971 but quickly found that Family Medicine was mainly geriatrics, and for me, not very exciting. Realizing that I was an “adrenalin junkie” who was most comfortable in life or death situations, I soon found myself working full time in the Emergency Department of East Alabama Medical Center in Opelika. At that time, the emergency room was just that, a single room in which life-threatening cases were treated. Most were staffed by the hospital medical providers from Surgery, Medicine and pediatrics on a rotating basis. Hospitals were pressured into finding full time providers. Private doctors resented being called from the ED to care for their patients. 
However, early attempts at full time staffing were unsuccessful. Frequently, the hired providers had failed in private practice, because they were either incompetent providing medical care, or they had a history of drug or alcohol abuse. In time, competent physicians were found. With a little more time, Emergency Medicine residencies were developed to provide an adequate number of trained emergency physicians. EM residencies are now among the most popular and command some of the best and brightest of physician trainees. 
It has been my privilege to witness the development of this specialty and to participate in the training of the physicians and paramedics who continue to advance both the art and science of Emergency Medicine.

Chapter Update

Election of Officers results
John E. Campbell, MD, FACEP
President-Elect: Sarah Nafziger, MD FACEP
Secretary/Treasurer: David J. Garvey, MD FACEP
Immediate Past President: Melissa Costello, MD FACEP

AL ACEP Board Nomination Results:

Michael Bindon, MD, FACEP 
Bobby Lewis, MD, FACEP
John M. McMahon, MD FACEP
Sarah Nafziger, MD 

Newly appointed
Hamad Husainy, DO FACEP
Here are the committee changes after evaluating the chapter’s needs:
  1. Government Relations will become Leadership Advisory in Legislation chaired by Jeff Terry. This committee is patterned after to AMA version. It will be an advisory committee acting as a liaison for our chapter’s relations with other state medical societies (such as MASA) and, presenting our needs to the Medicare, Medicaid and other government agencies. We will need a more members to become more affective.
  2. Education will remain as Education to continue to be chaired by Annalise Sorrentino, MD FACEP. She did a wonderful job preparing the educational side of our last annual conference. We will need more members to continue this and up future needs for our profession. 
  3. ITLS will remain as ITLS (International Trauma Life Support) to continue to be chaired by Neil Christen, MD FACEP who will keep our chapter updated on the further needs of  the management and processing of this educational venture with the Illinois Chapter of ACEP. 
  4. Practice Management/Reimbursement Issues will become Practice Management and Government Relations to continue to be chaired by Steven T. Baldwin, MD with the help of Thomas L Arnold, MD FACEP, Michael Bindon, MD, and Stephen Sprayberry, DO. These two entities work closely together on the same issues. 
  5. Communications & Technology will become Communications to continue to be chaired by Lenny Nasca, Jr. MD FACEP
  6. EMS will become Acute Care Services to have as its members, Terry Rivers, MD FACEP, Frank S. Pettyjohn, MD FACEP, John E Campbell, MD FACEP, Michael R. Ambrose, MD, Harold Kim, MD and Neil Christen, MD, FACEP. This committee combine EMS and trauma needs. 
  7. By-Laws & Public Relations will become By-Laws. This committee will be able to acquire information with the assistance of the National ACEP By-Laws Committee. The Public relations portion will be handled by the chapter president
  8. Trauma Systems will no longer exist. As mentioned, above, this will become part of the Acute Care Services.
  9. Women’s Issues in Emergency Medicine will remain as Women’s Issues in Emergency medicine, to have as its members Annalise Sorrentino, MD FACEP and Lauren Walter, MD.
  10. Remember to re-apply for a new password in order to use the new format for the drug queries in the Alabama Prescription Drug Monitoring Program (AL PDMP). You can do this through the website. The more we look up patients, the more we can try to control the narcotic drug-seeking behaviors in this state.
  11. Check out the web site for up to date issues the Medical association for the State of Alabama. You can link to the Legislatures website where a doctor can look up their House and Senate member to contact them with issues. Go online to view the letter “ Medicaid Matters…to ALL Alabamians” by our MASA president , Buddy Smith, MD has sent to the Legislatures
  12. Alabama Health Alert: Psittacosis. The birds infected with Chlamydia psittaci have caused illnesses in people who have visited the aviaries in the Birmingham Zoo. If you have potential cases with symptoms occurring 3-14 days after their exposure, flu-like symptoms with or without organ failure, and having visited an aviary within the last 30 days, please contact Dr. Dee W. Jones at the ADPH Division of Epidemiology 1-800-338-8374 to report symptomatic cases. The surveillance staff will assist you in completing the Psittacosis Investigation Form to be faxed to 334-206-3734 or e-mailed. Lab samples of nasopharyngeal swabs, bronchoalveolar lavage and sputum can be collected for PCR analysis and sent to the Bureau of Clinical Laboratories Emerging Infective Diseases at 334-260-3429.
  13. In an effort to increase relations with our other SEC ACEP Chapters, Several board members have volunteered to be a chapter liaison: Arkansas- Dr. Hamad Husainy, Kentucky- Dr. Michael Bindon, Louisiana- Dr. Bobby Lewis, Mississippi- Dr. Melissa Costello, Missouri- Dr. Bryan Balentine, Tennessee- Dr. Annalise Sorrentino
  14. Mark your calendars for next year’s SEC ACEP Chapter Conference at the Sandestin Golf and Beach Resort in Destin, Florida from June 7 - 9, 2016. There will be a pre-conference ATLS refresher course. Get information from our website.

National ACEP

In June, the Board of Directors for ACEP has adopted two policies, “Anonymous Expert Physician Testimony for the State Medical Licensing Board” and “Anonymous Complaint to State Licensing Boards by Third Parties” in an effort to curtail the practice of some states enabling anonymous allegations against physicians. Such testimony does not provide the accuse physician the ability to respond appropriately to the accuracy of allegations nor the credibility of the expert. 
Our state will have members to represent us as councillors for ACEP15. They are Dr. Melissa Costello, Dr. Hamad Husainy, and Dr. Lisa Bundy. Alternates will be Dr. David Garvey and Dr. Annalise Sorrentino. 
The Fellows from Alabama to be inducted this year at National ACEP are;

Alan J. Babcock, MD Jinyue Li, MD
Melanie R. Barnhart, MD Alexander Lo, MD 
James Scott Burrow, MD James B. McLester, MD
Ashley R. Cole, MD Jeffrey D’Von Milner, MD
Josiah Daily, MD Patrick Joseph O’Hare, MD
R. Scott Everett, MD, PharmD Angelyn L. Ramsey, MD
Damon Fierro, MD Derek Adam Robinett, MD
John P. Gullett, MD Steven Sprayberry, DO
Alex Trent Hunt, MD Deborah J. Trujillo, MD
John Clinton Jacobs, V, MD Richard Andrew Vann, MD
Jenna Lynn Johnson, MD Kristi Caple Witcher, MD
Nicholas Kimpel, DO  Matthew D. Wolfe, MD

EMS Corner
Dr. John McMahon

The national issue of bystander Narcan continues to be brought up to be included into the basic EMTs, EMT-Ps, sheriffs, and police officers to be able to give intranasal doses. 
CPAP has been added to the states EMS protocols.
Stroke TPA rate is at 16% statewide.
MedStar EMS received the AHA Gold Star Award for having 80% of their STEMI patents EMS first encounter to PCI balloon within 60 minutes for 3 years in a row.
ADPH and the State Office or EMS and Trauma are working together on the means for transport of confirmed cases of Ebola to Grady Hospital in Atlanta per CDC.
Spice, also known as K2 and Green Giant, with the synthetic marijuana derivative of cannabicyclohexanol (for short), has created a 1200 spike in the number of EMS calls from January to June. The highest volume of calls came during April and May. Mobile had 500. 
Get ready for the new and dangerous version of bath salts. Flakka, also known as alpha-PVP, is alpha-pyrrolidinovalerophenone. This is the new synthetic psychoactive drug related to the cathinones, the amphetamine like stimulant compounds.

EMS Children's Corner

There was $13K left over in the budget from last year to help purchase atomizers for EMS use. You are on duty in the ED, when a rescue unit calls and they would like orders for 3 year old child who is having their first seizure? 
As you pull out your Alabama EMS Patient Care Protocols for reference, you recall that febrile seizures are the most common seizure disorder in children affecting 2-5% of children between the ages of 6 months and 5 years. You make sure to tell your nurses to get a rectal temperature and an accurate weight on the child (in kilograms) on arrival, but in the mean time you know you will need to help the EMS providers as their anxiety levels are likely high. 
Pediatric prehospital seizure management is characterized by variability in care related to providers’ infrequent exposure to children, difficulty maintaining skills, and limited knowledge of pediatrics. Prehospital providers may have more difficulty in rapidly obtaining intravenous access in children relative to adults, and the stress of managing critically ill children poses an added challenge. In attempt to help with some of their anxiety and stress, any information you can provide will be welcome.
You can estimate the child’s weight as 15 kg, based on prior PALS training. You ask that the providers begin timing the seizure as you know most febrile seizures are short lived and self-limited. A true simple febrile seizure lasts less than 15 minutes and is characterized as generalized tonic-clonic in nature. You quickly think about other common causes of pediatric seizures and your list includes:
  • Febrile seizures
  • Ingestions or toxins
  • Head injury and/or child abuse
  • Infections, particularly meningitis
  • Prior history of seizure (has the patient missed doses of their medication?)
The Alabama EMS Patient Care Protocol for Seizures (3.30) recommends obtaining an IV, but this may be difficult in the pediatric patient. Encourage the EMS personnel to move forward with obtaining a finger-stick glucose and treat according to the Hypoglycemia Protocol (3.21) if it is less than 60 mg/dL (4 cc/kg of D25 IV or 0.5 mg glucagon IM with online medical direction). If the patient continues to have a seizure for greater than 5 minutes, use medications to stop the seizure as described in the protocol (these will need online medical direction). Recent studies suggest that non-IV routes may be the best option in pediatrics with one study showing that IM midazolam was not inferior to IV diazepam. So when the call comes consider your options: midazolam 0.2 mg/kg IM maybe as good as an option as diazepam 0.1 mg/kg IV. Recent literature also indicates that IN midazolam (0.2 mg/kg) is preferred over PR diazepam.
Once the patient arrives in your ED, your work is just beginning, or really it may be done if you determine this is a simple febrile seizure. This is a seizure accompanied by fever (before, during or after) 100.4° F or 38 C, without central nervous system infection, metabolic disturbance or history of previous seizure disorder. For a simple febrile seizure no routine labs, EEG, CT scan, or referral to a neurologist is necessary. A lumbar puncture is not necessary if the patient is fully immunized and has not been pretreated with antibiotics. Locating the source of the fever (maybe a viral infection) and ensuring the child returns to a normal baseline is necessary. Nearly all of these children may be safely discharged after educating the families about febrile seizures.
Seizure Medication Choices
No IV - Midazolam 0.2 mg/kg IN/IM (may also be given buccal)
IV – Midazolam 0.1 mg/kg over 30 sec
Diazepam 0.1 mg/kg over 30 sec
Lorazepam 0.1 mg/kg over 30 sec
PR - Diazepam 0.5 mg/kg
Hypoglycemia (glucose < 60 in pediatrics)
D25W: IV 2-4 cc/kg 
Glucagon: IM 0.5 mg (Will need on-line medical direction)
The Alabama EMS for Children program is here to help. Please contact us if you would like to more information on how you can be the children’s champion for your hospital:
Ann E. Klasner, MD, MPH
Alabama EMS for Children Medical Director
Alabama EMS for Children Project Director
1. Silbergleit R, Durkalski V, Lowenstein D, et al. “Intramuscular versus intravenous therapy for prehospital status epilepticus”, N Engl J Med. 2012;366(7)591-600.
2. Carey JM, Shah MI “Pediatric Prehospital Seizure Management” Clinical Pediatric Emergency Medicine. 2014;15(1)59-66.
3. Subcommittee on Febrile Seizures. “Clinical Practice Guideline-Febrile Seizures: Guideline for the Neurodiagnostic Evaluation of the Child with a simple febrile seizure.” Pediatrics 2011;127:389-394.

UAB Residents Corner
Sean Vanlandingham

Summer has been a busy and exciting season for the UAB Emergency Residency Program. We are very proud of our PGY3 class that just graduated. Nine out of ten of the class will be staying in the Southeast region to practice, and five will be staying in Alabama for the coming year. We welcome Joel Hamm and Browning Wayman as they begin a fellowship in International Medicine here at UAB. We also welcome Whitney Turner and Therese Medalle who will be working at the UAB Highlands Emergency Department.
We are especially thankful to ALACEP for their sponsorship of the Class of 2015’s graduation ceremony, which was held on June 25th. This was a special time for residents and their families to celebrate and share memories from the past three years at UAB.
As we honor the outgoing PGY3’s, we are equally excited about the arrival of our new intern class. The Class of 2018 shows tremendous potential, bringing us some of the very brightest medical school graduates from Georgia, Florida, Texas and Alabama.
We had a strong resident showing in San Diego, CA in May at SAEM 2015. David Page (PGY3) presented his research on “Community-Acquired, Healthcare-Associated and Hospital-Acquired Severe Sepsis Epidemiology in the University Health System Consortium”. We also fielded our first team for the annual ultrasound “Sonogames” with a very strong rookie performance. Brian Bauerband (PGY3), Max Thompson (PGY2) and Sean Vanlandingham (PGY3) competed with teams from 50 other residency programs, placing first in the initial “quiz show” round. The team advanced to the second round with nine other teams and competed in novel “hands-on” challenges including an ultrasound Pictionary game and building an underwater Lego castle using only ultrasound imaging. Next year we hope to do even better and win the grand prize.
The 2015-2016 academic year is full of promise and we look forward to sharing our many successes and stories with you in the coming year.

CRNP Corner
Robin Lawson, CRNP, DNP, ACNP-BC, NP-C, CCRN
Professor, University of South Alabama College of Nursing

Collaborative Rule Changes Effective August 6, 2015
Significant changes in collaborative practice regulations became effective August 6. Among several changes, the new rules include these provisions: 
  • Eliminate 10% on-site collaboration time for CRNPs and CNMs who have two or more years collaborative practice experience consistent with physician’s practice specialty. 
  • Increase physician’s full-time equivalent (FTE) limit from three to four full-time CRNPs/CNMs/ PAs, or combination of part-time positions, up to 160 scheduled work hours. 
  • Allow a transitional full-time position (40 hours) so a new CRNP/CNM/PA may join a practice and overlap up to 45 days for orientation with a departing CRNP/CNM/PA. With the 40-hour transitional allowance, a new CRNP or CNM may have 6 weeks overlap for orientation before the current employee leaves the practice. The physician’s written request for this allowance must specify the starting date.
  • Define parameters for prescribing “off-label” and in authorized clinical trials. 

Physicians are required to submit the “Commencement of Collaborative Practice” form and fee to the BME. The physicians must notify the BME within 14 days of the date of termination of the collaboration. 

Under the new rules, the physician’s limit on CRNPs and CNMs in collaboration and PAs under the physician’s supervision increases to four FTEs (160 hours weekly). 
There are several long-awaited changes in the Requirements for Collaborative Practice for CRNPs and CNMs with more than two years (4,000 hours) of collaborative practice experience. All CRNPs/CNMs must meet with the collaborating physician at least quarterly, but CRNPs/ CNMs with qualifying experience are no longer required to be on-site with the collaborating physician for 10% of their practice hours. In the case of a CRNP/CNM practicing in a remote site, the collaborating physician must visit the remote site at least twice per year. 
On-site time with the collaborating physician is required for (a) CRNPs and CNMs with fewer than two years (4,000 hours) collaborative practice experience and (b) CRNPs/CNMs with qualifying experience who are moving to an unfamiliar medical specialty. They must be on-site with the physician for 10% of scheduled hours while accumulating two years (4,000 hours) of practice. In other words, if the experienced CRNP enters a new collaboration and does not have clinical experience consistent with the physician’s clinical specialty, the “experience clock” resets to zero. 
The revised rule for quality monitoring requires “a meaningful sample” of medical records. Quality outcome measures should be determined within the practice. The physician and CRNP/ CNM should review the results of the record review and summarize the findings. 
Prescriptions and Medication Orders have new parameters for off-label prescribing if the collaborating physician agrees with the therapy, the pharmaceutical option is consistent with the current standard of care for treating a disease or condition, and supported by evidence-based research (from the ABN E-News).

Visit NPsights.com

PA Corner
DJ Bonds, PA-C, MPH

Visit SEMPAC.com. Become involved. There are meetings to meet and greet others in your field and get continuing education credits.

News From National

Chapter Grant Applications
We want to remind you that chapter grant applications are due at the national office no later than Monday, November 2, 2015. For more information and the chapter grant application, go to our website

Don't miss ACEP15! This year the meeting is in Boston--October 26-29, 2015. Course reservations are BACK this year, so be sure and register for the courses you want. For more information, and to register go to ACEP's website.  
All Chapter Audio Conference
If you would like to listen to the recording of the All-Chapter Audio Conference that was held on August 18, it is now available on our website
Fellow Status
Earning the designation of Fellow of the American College of Emergency Physicians (FACEP) is reserved for an elite group of emergency physicians. They have demonstrated a commitment to their specialty through board certification, volunteerism, leadership, community service, and continued membership in their specialty society.   Chapter, community, and hospital committee leadership count toward the FACEP application requirements.  For more information on becoming a Fellow of the College, please visit our website or contact the ACEP Member Care Center at 800/798-1822, ext. 5, or membership@ACEP.org.
“Pave the Way” For the Future of Emergency Medicine
You’ve built your career in emergency medicine—now is your chance to build the future of the specialty.
In 2016, ACEP is moving to a dynamic new headquarters in Irving, TX. To ensure that emergency medicine research always has a home in ACEP’s new building, you can donate to the EMF Plaza, a beautiful collection of personalized brick pavers in the courtyard.
By donating, you will have an enduring symbol of your commitment to emergency medicine and will literally lay the groundwork for future research projects that bring about the highest quality care for your patients.
Immortalize your commitment
Recognize a colleague in memoriam 
Thank a mentor or friend
Find out more at our website.
Residency Visits 
To help you and your faculty prepare residents for the future, ACEP offers fully funded visits by emergency medicine leaders to your residency program.
Designed to bring ACEP leaders face-to-face with faculty and residents, these visits engage the future of the specialty in a wide variety of discussions from ever-changing legislative and regulatory landscapes, to practice management issues, to career advice and preparation. To schedule a visit and see the current list of speakers, visit our website
Research Forum 
Emergency medicine’s premier research event has been elevated to new heights in 2015, with a brand new electronic showcase, additional networking opportunities, and more original research than ever before.
Research Forum, October 26-27, is the opportunity to view and discuss original research at the world’s largest gathering of researchers, teachers, and practitioners of emergency medicine.

Meet, confer, and network in a highly supportive environment, where you can review the latest advances on a wide variety of emergency medicine topics. And best of all, access to the Research Forum is FREE as part of your ACEP15 four-day registration! To see the schedule or to register, visit our website.
Teaching Fellowship 
Experts in instructional design and academic 
emergency medicine have taken this very popular and successful program and updated it to meet the needs of today’s emergency physician. This program is designed for faculty in residency programs who want to improve their skills, residents interested in an academic career, and other physicians who have responsibility for teaching emergency medicine. Registration is limited and are filled on a first-come, first-serve basis so call today to have your name placed on the waiting list. To find out more info about the course or to register, visit our website
Emergency Medicine Basic Research Skills (EMBRS) Workshop
The (EMBRS) Workshop was designed by a task force of experienced investigators to help the physician with an interest in emergency medicine research get started. Participants will learn how to identify clinical research opportunities and become familiar with clinical research and outcomes, injury prevention, health care delivery and effectiveness research. Also, the course includes an introduction to statistics and statistical software and sessions on publishing and presenting your research. 
Registration is limited so that each can receive individual attention and instruction. Don’t put off your decision! Call today to have your name or your program name added to the waiting list. To find out more information or to register, visit our website.

Clinical News

New Oral Vaccine May Protect Children from H. pylori Infection
August 6, 2015 - Will Boggs, MD 
A new oral recombinant vaccine protects children against infection with Helicobacter pylori, researchers from China report. At least half the world’s population is affected by H. pylori, and so far none of several H. pylori vaccine candidates have proven effective in humans.
Read More

Patient-Controlled Analgesia Works in the Emergency Department
Megan Brooks
July 23, 2015 - Megan Brooks (Reuters Health)
Patient controlled analgesia (PCA) can be used effectively in emergency department patients dealing with moderate or severe pain, according to results of the Pain Solutions in the Emergency Setting...
14 Tips to Improve Clinical Efficiency in Emergency Medicine
Kevin M. Klauer, DO, EJD, FACEP 
14 Tips to Improve Clinical Efficiency in Emergency Medicine. The more complex the delivery of emergency medical care becomes, the more critical it is that we find ways to become lean, mean EM machines. 
Read More

Getting the Most Out of Your Annals of Emergency Medicine Podcasts

One of the key benefits of ACEP membership is a subscription to Annals of Emergency Medicine. The subscription includes not only the print journal, but complete access to all of the journal's online and digital features. One of the key features is free access to Annals podcasts.

Annals Podcasts — Not Another Boring Lecture
Since February 2009, every issue of Annals of Emergency Medicine has featured podcasts that introduce and discuss a number of articles in the journal. The podcasts cover not only a broad range of topics, but also offer an engaging discussion of their importance and relevance to emergency medicine. 
Are They Any Good?
The podcasts are an easy-to-use source of information from the journal. One listener said the podcasts “… dive into why the article is important. I feel smarter after hearing you ask questions about the research.” Another reader said that “What I love about your podcast is that it is very casual and you explain why certain studies are important and what they did well/poorly. You do this better than any other journal summary I’ve ever listened to.”
Who Does the Podcasts? 
David H. Newman, MD, and Ashley E. Shreves, MD are the creators of the podcasts. Dr. Newman teaches at Columbia University in the Department of Biology and is an emergency physician with the Department of Emergency Medicine at the Icahn School of Medicine at Mount Sinai in New York. He is an Evidence-Based Medicine editor at Annals of Emergency Medicine, authored the critically acclaimed Hippocrates' Shadow, and is widely published in both scientific and popular media journals. He also edits the SMART EM and The NNT.com web resources. Dr. Shreves is a board certified and practicing emergency and palliative medicine physician, works as faculty in both the ED and palliative medicine departments with the Icahn School of Medicine, and will soon be the associate program director for the Mount Sinai-St. Luke’s/Roosevelt Hospital EM residency.
“For us it feels like a chance to chat about the latest studies and to have some fun,” said Newman. “And if it helps Annals connect with the global community, well that’s icing on the cake.”   

Free, Easy, Fast Access

The podcasts are free and easily accessible through multiple formats:
  1. Play on your computer by clicking on any of the individual podcast files on the Annals Web site.
  2. Easily download to your mp3 player.
  3. Subscribe to the Annals of Emergency Medicine podcasts at the iTunes Music Store and have the podcast automatically download to your iTunes each  month.
  4. Use your RSS reader for automatic delivery of content of each issue.
Annals Podcasts—More Than What You Expect
Annals Podcasts.  One of a multitude of journal features available to all ACEP members. Smart, engaging, relevant. Easy to listen to while exercising or driving to your shift. Come and hear what you’ve been missing.