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MISSOURI EPIC EMERGENCY PHYSICIANS INTERIM COMMUNIQUE Missouri College of Emergency Physicians January 2010 President's Message 1 President's Message The tortuous road leading to significant healthcare reform is be- Current MoCEP Board 3 ing aggressively routed and paved this year. Great political pressure exists in Washington DC to have healthcare reform EMF Grant Information 4 mapped out and a bill signed before the stroke of midnight on New Year's Eve. As we go to press with this newsletter, both MoCEP New Members 5 the Senate and House have pushed their healthcare reform bills out of committee and are now fervently working to reconcile both Battle of the Belt 6 into one bill to send before President Obama. Reconciling each of the 1000+ page bills is not easy. Emergency physicians are Rural Survey Update 6 very fortunate that ACEP has strong powerful resources in PAD Law Passes 8 Washington DC working on both our behalf and that of patients who seek our care. The national ACEP PAC raised over 1 mil- Legislative Issues 9 lion dollars this year making emergency medicine the 4th largest medical specialty PAC in the country. All medical specialties are EM Resident Updates 11 battling to make sure their voice is heard and interests are pro- tected as reform moves forward. Resident Listing 12 & 13 Whether you want reform or not, some iteration will likely be in Open Letter from the ACEP 14 & 15 place before the end of the year. Many of us bring both our pro- President fessional and personal views when we debate what healthcare ShowMeResponse.org 15 reform should ultimately look like. At the national ACEP council meeting in Boston this past October, opinions from all 300+ Resident Research Grant 16 emergency physicians representing their individual states were widely divergent. Much like the general public and politicians, State Advisory Council on 17 EMS emergency physicians can not agree what healthcare should look like in the future. If you read both the Senate and House A Personal Experience in 18 versions of the healthcare reform bills, you notice individual Washington DC states are given great leeway in how to enact key principals of R.R. Hannas Recipients 19 healthcare reform. Thus state politics will likely play an even Disaster; 20 greater role than national politics in how healthcare reform ulti- mately transforms in each individual state. Are We Prepared? Missouri ITLS 21 Missouri emergency physicians will need to come together and play a more active role with state legislators in the future to make Legislative Chart for House 23 sure we have appropriate resources to perform our vital role and Senate Bills Continued on Page 2 Page 2 MISSOURI EPIC Continued from Page 1 in society. Please trust that your MoCEP board of directors and our executive director, Betsy Ledg- erwood have and will continue to carefully monitor Missouri legislative activities that pertain to emer- gency medicine. If you recently received your ACEP annual dues statement, you may have noticed a new voluntary $50.00 Missouri Emergency Physician Political Action Committee billing line. Funds collected allow us as emergency physicians to improve our lobbying and support for Missouri state politicians who support our interests and those of the patients we treat. We compete with much larger PACs such as the trial lawyers, pharmacists, etc. in Jefferson City on many issues each year. These other professional groups often provide their PACs with hundreds and sometimes thousands of dollars on average per individual member. Every dollar that goes to our Emergency Medicine PAC, helps support emergency physician/ medicine advocacy efforts here in the state of Missouri. MoCEP has been busy this past year on many fronts. Reading through this newsletter details only a few of those efforts. You may have noticed on the front page the MoCEP logo has been updated. As we become more involved in political and community activities, it is important to have a logo that brands our organization well. We continue to strongly support the highly successful Missouri Battle of the Belt program. This pro- gram was recently taken over by MoDOT and MoCEP looks forward to continuing our support as a cosponsor of this program. MoCEP recently conducted a study on rural emergency departments here in Missouri. Larry Slaughter M.D., one of our board members obtained a grant from National ACEP to support this effort. We hope to more strongly connect MoCEP with the many rural EDs here in Missouri currently providing invaluable emergency medical services to their local communi- ties. Legislatively over the past year we won a few battles, held steady on some, and lost a few. Al- though the Medicaid (MO HealthNet) payment update, which was to increase another 15% (as part of a multi-year plan to move Medicaid fees to Medicare's level) did not occur, we were able to hold steady and not suffer a reduction as many other medical services/providers did. With monthly state tax revenue still running nearly 10% behind previous year's average receipts, we may see a second round of $500 million in state budget cuts needing to be made in January. Fortunately, Missouri from a deficit spending perspective is not comparable to states like Illinois and California. Compared to the rest of the country, Missouri is aggressive with trying to keep its' budget balanced. This means cuts happen more swiftly and we must always be ready to protect the current funding of emergency medicine in our state. A motorcycle helmet bill allowing any person over the age of 21 to ride a motorcycle without protec- tive headgear unfortunately was passed overwhelmingly by both the House and Senate. Fortu- nately, several state groups, many individuals, along with MoCEP and MSMA (Missouri State Medi- cal Association) lobbied Governor Nixon aggressively to veto this bill…and he did. One of our Mo- CEP members was cited in a newspaper article reporting: Dr. Greg Folkert gave an emotional appeal, talking about losing his own father to a motorcy- cle accident when Folkert was 10 years old. "I was a boy who became a man dogged by never knowing who my father was," said Folkert, a Washington University/Barnes-Jewish Hospital Emergency Medicine resident who finishes his residency in a couple of months. "Please Gov. Nixon, don't repeal this law." Continued on Page 3 MISSOURI EPIC Page 3 Continued from Page 2 MoCEP continues to work on encouraging more physician members to become politically active. At a recent board meeting, it was decided to support matching scholarships, up to $1,000.00 for each of the four residency programs (max $4,000/year), to send residents to the ACEP Leadership and Advocacy conference held in Washington DC each spring. In addition, beginning July 2010, MoCEP is going to trial providing residency programs ½ the cost for their incoming 1st year residents covering a 3 or 4 year ACEP/EMRA/MoCEP membership period. This will cost MoCEP a few thousand dollars each year but will provide an opportunity to all EM residents being trained in Missouri to have MoCEP/ACEP/EMRA membership throughout their residency. Less than half of EM residents being trained in our state are MoCEP/ACEP/EMRA members. We believe this exposure will encourage resident to become more edu- cated on local and statewide emergency medicine initiatives here in Missouri . In addition, we hope to recruit more EM residents to help MoCEP lobby in Jefferson City and advocate for emergency medicine throughout the state. You may have noticed in the papers recently statewide efforts have mounted to overturn the 2005 mal- practice reforms we as physicians fought hard to put in place. In fact, on January 14th, the Missouri Su- preme Court will hear arguments against the constitutional validity of Missouri's current medical malprac- tice tort reform laws. MoCEP recently filed an Amicus Brief for this upcoming Supreme Court trial sup- porting the importance of keeping our current Missouri medical malpractice tort reform laws in place. Time critical diagnosis (TCD) and treatment efforts continue at the state level. Several of our MoCEP members sit on various committees working on state guidelines dealing with care of acute MI, Stroke, and Trauma patients. Under the guidance of the late Dr. Bill Jermyn (a MoCEP board member), legisla- tion was enacted in 2008 to develop statewide coordinated efforts to improve systems and care provided to patients suffering acutely from MI, CVA, and trauma. Current information on efforts behind TCD is available on the MO Department of Health and Senior Services website. Our next board meeting will be held at the MoCEP office in Jefferson City on January 27th at 10:00am. After the meeting, board members will go over to the state capitol and visit with our legislators discussing issues important to emergency physicians. All MoCEP members are invited to attend our board meeting and then make visits with their legislators. We provide talking points on important issues being discussed during the legislative session and can "show you the ropes" with getting around the capitol. Please RSVP to our MoCEP office if you want to attend so we make sure there is adequate room for everyone. Check out the MoCEP website from time to time to keep apprised on your organization's efforts. Please consider becoming more involved with MoCEP and its various activities. Encourage your emergency medicine colleagues who are not current ACEP/MoCEP members to join-about half of eligible EM physi- cians in Missouri are not members. Together we will continue the advancement of Emergency Medicine to the betterment of all citizens here in Missouri! Happy Holidays! -Rob Poirier M.D., FACEP MoCEP Board Members Officers Name: Board Members: President Robert Poirier, MD, FACEP Douglas Char, MD, FACEP 2009-2010 Vice President Brian Robb, DO, FACEP Chad Boulware, DO Sec/Treasurer Michael Szewczyk, MD, FACEP Charles W. Sheppard, MD, FACEP Past-President Randall Jotte, MD, FACEP Ted McMurry, MD, FACEP Lynthia Andrews, DO, FACEP Resident Board Members: Larry Slaughter, MD, FACEP Jonathan Heidt, MD St. Louis Barry Spoon, DO, FACEP Daniel Baker, DO Joplln Sebastian Rueckert, MD, FACEP Page 4 M I S SO UR I E P IC Emergency Medicine Foundation EMF Grant Applications are Now Available! The Emergency Medicine Foundation is pleased to announce the 2010-2011 on-line grant applica- tions are now available at www.emfoundation.org. Deadline for all proposals is Jan. 12, 2010. Grants range from $2,400 for a medical student grant to a $150,000 two-year fellowship. How do you donate to EMF? Donate On-line To make a secure on-line donation, go to www.emfoundation.org and click on the Donate Now but- ton. Click on Chapter Challenge and type in your chapter's name. Donate via Mail EMF P.O. Box 619911 Dallas, TX 75261-9911 Make sure to note your chapter name. Donate via Phone (800) 798-1822 Ask for Membership Services and let them know you would like to make a donation to EMF in honor of your chapter. A MoCEP Board Meeting is planned at the MSMA Annual Convention for Sat. 3/27/10 at 10am All members are invited to attend M I S SO U R I E P IC Page 5 MoCEP WOULD LIKE TO EXTEND A WARM WELCOME TO ALL OF OUR NEW MEMBERS NEW MEMBERS: ACEP MEMBERS MOVED INTO MO Elizabeth Bassett Robert Honegger, MD Don E. Keen Evelyn W. Young, MD Thaison Paul Tran Justin D. Moody, DO David A. Horwitz Stephen Paul Stewart, MD Roger Charles Merk, MD Stephen Y. Liang, MD Evan Ross Cameron Joseph Spennetta, MD Anthony J. Scalzo, MD Christopher J. Waldschmidt, MD,FACEP Joan A. Veits, MD Ryan C. Jacobsen, MD Laurie E. Byrne, MD Nicholas M. Mohr, MD Scott M. Campbell Brandie Anne Niedens, MD Joshua Stilley Jacob L. Spain, MD Charles P. Coyne, III Bryan Stork, MD Kevin Hardiman Joseph Walline, MD Gilbert Louis Mobley, MD Devin N. Boss, DO Tiffini Battiste, DO Scott Geiger, DO Bernadette Johnson, MD Cassandra Haddox, DO Brandie Anne Niedens, MD Daniel Hagen, DO Tara Schulte, DO Sarah Kennedy, MD Swetha Sridhar, MD Steven A. Lorber, MD Jennifer Watts, MD Jeremiah Ostmeyer, MD Kris Kuhl Peter David Panagos, MD, FACEP Laura E. Marble, MD Jennifer Rupert, MD Samantha Whiteside Maria Scarbrough, MD Andrew Abbeg, MD Kelly R. Brown, MD Joaquin Pascual Guzon, MD James Willis Coker Brett E. Haugen, MD David A George, DO, FACEP Timothy J. Koboldt Stephen Jeremy Perchellet, MD Aalap Mehta, DO Joshua J. Hillen, MD Delwin S. Merchant, MD Roberto A. Moran, MD Chalmer Luke Morris, DO Kimberly Anne Randell, MD Aaron Stavinoha, MD Chris Ellis Bowser, MD Emily Ann Tilzer, MD Phat Luong Randall J. Young, MD Joseph A. Aldrich, III, DO Curtis M. McGeeney, MD Jason D. Meyers, MD Emily Ann Tilzer, MD Alina H. Waring, MD All MoCEP Members are invited to attend MoCEP's next Board Meeting Wednesday, January 27th at 10:00am MoCEP Office, 213 E Capitol Ave., Jefferson City, Terrace Conference Room After the meeting, board members will go over to the state capitol and visit with our legislators dis- cussing issues important to emergency physicians. We provide talking points on important issues being discussed during the legislative session and can "show you the ropes" with getting around the capitol. Please RSVP to Margie 573-636-2144 at our MoCEP office if you want to attend so we make sure there is adequate room for everyone. Let her know if you want an appointment with one of your leg- islator, which she will try to arrange. Page 6 M I S SO UR I E P IC Winners of Battle of the Belt Challenge Announced You're Never Too Cool to Buckle Up. That was the message of the winning video for the 2008 Battle of the Belt challenge. For the third year, more than 125 Missouri high schools competed against each other to increase safety belt use and save lives. STATEWIDE WINNERS: St. Joseph Academy ‐ Highest Overall Seat Belt Usage Blue Eye High School ‐ Most Improved Seat Belt Usage Washington High School – 1st place Video/Public Service Announcement Joplin High School – 2nd place Video/Public Service Announcement Statewide, only 62 percent of Missouri teens report wearing their seat belt. Young drivers between the ages of 15 and 18 comprise 5.4 percent of Missouri's 4.2 million licensed drivers and are in- volved in 15 percent of the traffic crashes in the state. Between 2005 - 2007, 56 teens in mid-Missouri were killed in vehicle crashes. Thirty-eight of those young people were not wearing a seat belt. "Buckling your seat belt only takes seconds and it is one of the easiest and most important things you can do to prevent serious injury or death if involved in a crash," said Matt Myers, central region coordinator for the Missouri Coalition for Roadway Safety. "This is an important message for teens and parents alike." For more information on the Battle of the Belt Program and other winners go to: http://www.savemoyouth.com/getInvolved/BattleoftheBelt.htm Rural Survey Update Recently the Missouri College of Emergency Physicians completed a survey of rural Emergency De- partments in the state. I'd like to thank everyone that participated. Your dedication to serving your communities is evident in your response. Our surveyor reported a response rate 300% higher than average for this type of survey. The survey provided a unique view into the challenges that our rural Emergency Departments face. Lack of an ambulance service, and adequate staffing were concerns raised by many institutions. Many of the challenges are the same as those seen at the biggest institutions in the state such as boarding inpatients, reimbursement, and placement of mentally ill patients. Most importantly the survey has given MoCEP an avenue to communicate with those who serve our rural populations. The Board's hope is that by working together we can advance Emergency care in the state of Missouri. Our plan, in the coming months, is to establish a dialogue to accomplish this goal. We look forward to talking with you. If you have any questions please don't hesitate to contact me at email@example.com Page 8 M I S SO UR I E P IC Public Access Defib Law Passed Legislature PAD passed and has been approved by the Governor. HB 819 was added to HB 103 and became effective Aug. 28, 2009. Congrats to AHA and Bonnie Linhardt. 190.092. 1. This section shall be known and may be cited as the "Public Access to Automated External Defibrillator Act". 2. A person or entity who acquires an automated external defibrillator shall ensure that: (1) Expected defibrillator users receive training by the American Red Cross or American Heart Association in cardiopulmonary resuscitation and the use of automated external defibrillators, or an equivalent nationally recognized course in defibrillator use and cardiopulmonary resuscitation; (2) The defibrillator is maintained and tested according to the manufacturer's operational guide- lines; (3) Any person who renders emergency care or treatment on a person in cardiac arrest by using an automated external defibrillator activates the emergency medical services system as soon as possible; and (4) Any person or entity that owns an automated external defibrillator that is for use outside of a health care facility shall have a physician review and approve the clinical protocol for the use of the defibrillator, review and advise regarding the training and skill maintenance of the intended users of the defibrillator and assure proper review of all situations when the defibrillator is used to render emergency care. [2.] 3. Any person or entity who acquires an automated external defibrillator shall notify the emergency communications district or the ambulance dispatch center of the primary provider of emergency medical services where the automated external defibrillator is to be located. [3.] 4. Any person who [has had appropriate training, including a course in cardiopulmonary re- suscitation, has demonstrated a proficiency in the use of an automated external defibrillator, and who] gratuitously and in good faith renders emergency care [when medically appropriate] by use of or provision of an automated external defibrillator[, without objection of the injured victim or victims thereof,] shall not be held liable for any civil damages as a result of such care or treatment, [where the person acts as an ordinarily reasonable, prudent person would have acted under the same or similar circumstances] unless the person acts in a willful and wanton or reckless manner in provid- ing the care, advice, or assistance. The person or entity who provides appropriate training to the person using an automated external defibrillator, the person or entity responsible for the site where the automated external defibrillator is located, the person or entity that owns the automated exter- nal defibrillator, the person or entity that provided clinical protocol for automated external defibrilla- tor sites or programs, and the licensed physician who reviews and approves the clinical protocol shall likewise not be held liable for civil damages resulting from the use of an automated external defibrillator[, provided that all other requirements of this section have been met]. Nothing in this section shall affect any claims brought pursuant to chapter 537 or 538, RSMo. M IS S O U R I E P I C Page 9 Legislative Issues of Interest July 2, 2009—Gov. Nixon vetoes bill to repeal Missouri helmet law; cites increased health care costs to taxpayers, public safety as primary concerns JEFFERSON CITY, Mo. - Gov. Jay Nixon today vetoed Senate Bill 202, legislation that would have re- pealed Missouri's helmet law for motorcycle riders. In vetoing the bill, Gov. Nixon cited two primary concerns: the significantly increased health care costs that could have resulted from the repeal, and the safety of Missouri's motorcycle riders. "In terms of lives and of dollars, the cost of repealing Missouri's helmet law simply would have been too high," Gov. Nixon said. "By keeping Missouri's helmet law intact, we will save numerous lives, while also saving Missouri taxpayers millions of dollars in increased health care costs. Keeping our helmet law in place was the safe and cost-effective choice for Missouri." Universal helmet laws, such as the law Missouri has had since 1967, require all motorcycle riders to wear a helmet at all times while riding. According to data from the National Highway Traffic Safety Ad- ministration (NHTSA), the economic consequences of repealing such a law are clear. When Florida re- pealed its universal helmet law in 2002, the cost to treat patients diagnosed with head injuries as a re- sult of motorcycle accidents doubled, reaching a total of $44 million. [Traffic Safety Facts, NHTSA, 2008] Nationally, one academic study estimated that the total cost to treat motorcycle accident victims who were not wearing a helmet is $250,231,734 a year more than the cost of treating victims who were wearing a helmet [Economic Impact of Motorcycle Helmets: From Impact to Discharge, Journal of Trauma-Injury, Infection & Critical Care, 2006] Data from health care providers and insurance compa- nies indicate that the taxpayers ultimately must pay for a significant portion of these increased treat- ment costs. After the Florida repeal, 16 percent of injured motorcyclists admitted to a hospital for treat- ment were either under-insured or uninsured, and the costs for another 21 percent of those admitted were billed to either charitable or public sources, such as Medicaid. [Traffic Safety Facts, NHTSA, 2008] The public safety implications of eliminating or weakening a universal helmet law also are devas- tating. The NHTSA reports that helmets reduce the likelihood of a motorcycle fatality by 37 percent; but without a helmet law, riders more often choose not to wear protective headgear. As a result, when states repeal their helmet laws, motorcycle fatalities skyrocket. [Traffic Safety Facts, NHTSA, 2008] Ac- cording to an NHTSA report, in the 30 months following Florida's repeal of its universal helmet law in 2002, the number of motorcycle fatalities jumped sharply. That year, the state had projected 242 motor- cycle fatalities in light of increased registration of motorcycle riders. In fact, however, 301 motorcycle riders died in Florida in 2002 - 24 percent more than expected. For the two years before and after Flor- ida's repeal, fatalities per 10,000 motorcycle riders increased 21 percent in that state, compared with 13 percent nationally. [Evaluation of the Repeal of the All-Rider Motorcycle Helmet Law in Florida, Na- tional Highway Traffic Safety Administration, 2005] In other states where universal helmet laws have been repealed, the trend is similar. According to the NHTSA, fatalities increased by 31 percent in the year following the repeal of the Texas helmet law in 1997. When Arkansas repealed its helmet law the same year, fatalities increased by 21 percent. [What Happens When a Helmet Law is Repealed? Traf- fic Safety Facts, NHTSA, 2008] In addition to Senate Bill 202, the Governor vetoed four other pieces of legislation today. Those bills, along with their subject matter, are listed below: * Senate Committee Substitute for Senate Bill 542, relating to the state treasurer; * House Bill 373, relating to the general educational development revolving fund; * House Bill 306, relating to certain hotel and motel taxes; and * House Committee Substitute for House Bill 89, relating to traffic violations. The Governor's veto messages on these bills can be viewed at http://governor.mo.gov/actions/. Page 10 MI S S O U R I E P I C M I S SO U R I E P IC Page 11 EM Resident Updates The Emergency Medicine Resident Association (EMRA), which represents over 9000 members, holds biannual council meetings in conjunction with the ACEP Scientific Assembly in the fall and the SAEM meeting in the spring. These meetings allow the gathering of resident representatives from various pro- grams around the country to discuss issues that are of importance to residents and to vote on resolutions which pertain to these matters. During the ACEP Scientific Assembly in Boston, several resolutions were debated – including live animal use in training, and the new Institute of Medicine recommendations on work hour regulations. A new board of directors was also chosen during this meeting. Each residency program is allowed one representative to vote on resolutions at the council meetings. If you are inter- ested in more information, please email the EMRA regional representative at firstname.lastname@example.com. The Missouri College of Emergency Physicians allows a resident to represent each program at the Board of Directors meetings. Increasing resident involvement in emergency medicine policy issues at both the national and state level have become a priority. As the national debate on healthcare reform evolves, it is becoming quite evident that the environment future leaders in medicine are currently practicing in will become drastically altered. It is essential that residents are trained and educated on how to become ac- tive participants in the legislative process rather than allow change to occur without their involvement. As the health care debate continues to evolve, residents in Missouri are very fortunate to have a Board of Directors who are committed to resident training in advocacy and health policy. The MoCEP Board of Directors will soon be providing all Emergency Medicine residents with a copy of the EMRA Advocacy Handbook. This handbook was written by residents and published this past spring at the ACEP Leader- ship and Advocacy conference. The book is intended to serve as a primer for advocacy training. A PowerPoint lecture series based on the handbook is being developed and is currently under review by the EMRA Health Policy committee. The MoCEP Board of Directors has established annual grant funding for Missouri EM residency pro- grams providing up to $1,000.00 matching funds for each program in support of resident travel/housing to the Leadership and Advocacy (L&A) conference in Washington DC. The experience obtained at the L&A conference is outstanding, inspiring future emergency medicine leaders here in Missouri. Finally, the MoCEP Board of Directors has committed 3 years of funding to pay 50% of the cost of a 3 or 4 year resident membership to ACEP/MoCEP/EMRA for new interns starting in July if the individual pro- gram also commits 50% funding. By exposing residents early to the activities of ACEP, EMRA, and Mo- CEP, it is anticipated that young physician involvement and awareness of legislative awareness will im- prove. Through this commitment, MoCEP membership is expected to grow, resulting in a greater voice for Missouri on the national stage. The emergency medicine residents in Missouri are thankful for these opportunities and are looking forward to the year ahead! Page 12 M I S SO UR I E P IC Washington University/Barnes-Jewish/Children's Hospital 2009 Emergency Medicine New Resident Listing Name: Coming from: PGY-1 Thomas Belanger St. Louis University School of Medicine PGY-1 Joseph Burkett Wayne State School of Medicine PGY-1 Sarah Hoper University of Iowa, Carver College of Medicine PGY-1 Steven Katz University of Tennessee, Memphis PGY-1 Sarah Kennedy University of Virginia School of Medicine PGY-1 Albert Kim Northwestern University, Feinberg School of Medicine PGY-1 Nicholas Krehbiel University of Kansas, School of Medicine PGY-1 Peta-Gay Laird University of Michigan Medical School PGY-1 Sreeja Natesan Saint George's University PGY-1 Melanie Sutter Washington University School of Medicine PGY-1 Neda Tahmasebi Washington University School of Medicine PGY-1 Molly Tran Washington University School of Medicine Washington University/Barnes-Jewish/Children's Hospital 2009 Emergency Medicine Residency Graduate Locations Name Where they have gone: Erica Casey Duke University, International Medicine Fellowship, Durham, NC Sara Cross Shawnee Mission Medical Center, Shawnee Mission, KS Gregory Folkert St. Joseph's Hospital West County, Barnes-Jewish West County, St. Louis Michael Fullenkamp Premier Medical Group, Omaha, NE Alisa Hayes University of Missouri Hospital, Columbia, MO Ryan Petersen Mercy Hospital, Roseburg, OR Evan Schwarz University of Texas, Southwest, Toxicology Fellowship, Dallas, TX Alan Taylor Methodist Hospital, Memphis, TN Jose Vega Kaiser Permanente, San Diego, CA Brian Weisenberg St. Anthony's Medical Center, St. Louis, MO Brian Wessman Washington University School of Medicine, Critical Care Fellowship, St. Louis Inaugural Emergency Medicine Resident Class at St. Louis University Name Where they are from PGY-1 Andrew (Andy) Abbeg, D.O. Nova Southeastern University College of Osteopathic Medicine PGY-1 Tina Khosla, M.D. University of Missouri Kansas City School of Medicine PGY-1 Aalap Mehta, D.O. Kirksville College of Osteopathic Medicine PGY-1 Maria Louisa Scarbrough, M.D. University of Illinois College of Medicine PGY-1 Brett Haugen, M.D. University of Iowa Roy J. and Lucille A. Carver College of Medicine PGY-1 Emily Tilzer, M.D. University of Missouri Kansas City School of Medicine PAGE 13 Page 13 Truman Medical Center/University of Missouri-Kansas City School of Medicine Emergency Medicine Residency Name Coming From PG-1 David Biller University of Kansas School of Medicine (Kansas City) PG-1 Michael Donohue University of Minnesota School of Medicine (Minneapolis) PG-1 Sarah Farnan University of Missouri-Kansas City School of Medicine PG-1 Sandeep Guttikonda University of Missouri-Kansas City School of Medicine PG-1 Aaron Kaus University of Kansas School of Medicine (Kansas City) PG-1 Antoinette Koomson University of Illinois College of Medicine (Chicago) PG-1 Julie Rowell University of Louisville School of Medicine PG-1 Jennifer Rupert University of Missouri-Kansas City School of Medicine PG-1 Ted Sibley University of Minnesota School of Medicine (Minneapolis) PG-1 Jennifer von Fintel University of Kansas School of Medicine (Kansas City) Graduate Class of 2009 Name Where they have gone Aaron Barksdale, MD Truman Medical Center-Hospital Hill, Kansas City, MO Alison Benson, MD North Kansas City Hospital, KCMO Community Practice Tim Chilcote, MD Shawnee Mission Medical Center, Shawnee Mission KS Community Practice Shawn Cox, MD St. Luke's Hospital, Kansas City, MO Community Practice Brandon Farmer, MD Central Texas Medical Center, San Marcos, TX Community Practice Megan Glenn, DO Truman Medical Center-Lakewood, Kansas City MO Community Practive Ryan Jacobsen, MD Truman Medical Center-Hospital Hill, Kansas City MO Academic Practice Dawn Lewis, MD Charlie Norwood VA Medical Center, Augusta, GA Community Practice Brandon Shirai, MD Hawaii Medical Center, Honolulu, HI Community Practice Freeman Health System Joplin, MO 2009 Graduates: Name Where they have gone Coye McMillian, DO Hillcrest Baptist Medical Center. Waco, TX Current Residents: Name Coming from PGY4 Amanda DeTar, DO Kansas City University of Medicine and Biosciences PGY4 Eric Hogan, DO Oklahoma State University College of Osteopathic Medicine PGY3 Daniel Baker, DO Kansas City University of Medicine and Biosciences PGY3 Matthew Grounds, DO Kansas City University of Medicine and Biosciences PGY2 Jason Kent, DO Kansas City University of Medicine and Biosciences PGY2 Michelle Parlett, DO Kansas City University of Medicine and Biosciences PGY2 Tiffani Battiste, DO Oklahoma State University College of Osteopathic Medicine PGY1 Sam Brewer, DO Kirksville College of Osteopathic Medicine PGY1 Scott Geiger, DO Touro College of Osteopathic Medicine Make sure the American people and Congress get the facts about emergency care and address these issues in health care reform legislation. Spread the word to your family, friends and colleagues and ask them to send this message to everyone they know. An Open Letter from America's Emergency Physicians As the physicians on the front lines of emergency care, we see the tragic problems of a failing health care system. We care for people who are ravaged by untreated disease; help worried mothers on weekends with sick children, unable to access a system that's open 9 to 5, weekdays only; and treat the victims of heart attack, stroke and injuries whose very lives depend on our care. The role of emergency medicine has been badly misrepresented during the health care reform debate. The American College of Emergency Physicians supports comprehensive reform, including universal coverage. But it is vitally impor- tant that reform legislation not be based on erroneous perceptions, but instead address the critical problems harming emergency patients. It is time to debunk the myths, focus on the real problems and outline solutions to ensure that health care reform will protect and enhance everyone's access to quality, timely emergency care. Myth: Emergency medical care is expensive and inefficient. Reducing emergency care will "bend the cost curve" on our nation's rising health care costs. Fact: The 120 million annual visits made to emergency departments account for only 3% of all health care spending. In addition, emergency departments are equipped with state-of- the-art diagnostic equipment and highly trained physicians who can draw on many hospital resources quickly, providing coordinated, efficient patient care. The fixed costs of being open 24/7 are high, but the variable costs for seeing patients in the emergency department are the same as anywhere else care is provided. Myth: Emergency departments are crowded with patients seeking non-urgent care. Fact: Only 12.1% of emergency patients have non-urgent conditions that could wait 2 to 24 hours for medical care, according to the Centers for Disease Control and Prevention (CDC). While this percentage may be slightly higher in some hospitals, the reality is that crowded conditions and longer wait times are primarily caused by patients being "boarded," or forced to stay in the emergency department - often on gurneys lining the hallways - long after they have been seen and admitted to the hospital. Myth: Your local emergency department will always be there when you need it. Fact: Hundreds of emergency departments have closed nationwide because of an overburdened emergency care system. Those remaining must accommodate an average increase of 3 million more patient visits each year. Every 60 seconds emergency care is delayed when an ambulance is diverted to a distant hospital because a nearer one is unable to accept more patients. In addition, 75% of emergency department directors report significant problems getting needed on-call specialists, such as neurosurgeons and orthopedists, to provide vital on-call services to emer- gency patients. Myth: The need for emergency care will decrease when health care reform is enacted. Fact: With a growing and aging population, our role in providing care to the sick and injured any time day or night, and our front line responsibility in responding to natural and man-made disasters, will be in even greater demand in the future. Since enacting its universal health care legislation, Massachusetts has experienced an increase in emergency department patients. Emergency medicine is an essential community service that is vitally im- portant to our nation's health care system. To help ensure our country has a strong emergency care system, the American College of Emergency Physicians sup- ports comprehensive health care reform that includes: • Every person in America must have meaningful and affordable health insurance coverage provided through a combination of employer and individually mandated insurance. It should be means-tested, allowing those in need to receive coverage or financial support to buy insurance. A combination of private sector and govern- mental solutions may be needed to achieve universal coverage. America is experiencing a dramatically rising tide of Continued on Page 15 Page 15 M I S SO UR I E P IC Continued from Page 14 uninsured and underinsured patients. Emergency physicians are the only doctors in the country required by federal law to treat all patients regardless of their ability to pay. It is a responsibility we embrace proudly, but many emergency de- partments and physician groups are closing under the burden of uncompensated care. • Health care costs must be reduced. Significant medical liability reform is needed to eliminate unnecessary, expen- sive tests known as "defensive medicine." Liability reform can also help increase the availability of critically needed on- call specialists. Widespread adoption of electronic health records could substantially cut costs and improve patient care if there were complete integration of data between the emergency department and other medical settings. Administrative and overhead costs must be reduced. • Quality and patient safety must be improved by eliminating the practice of "boarding" admitted patients in emergency department hallways until they are transferred to an in-patient hospital bed. This can be achieved by establishing quality standards that define how quickly admitted patients are moved to their appropriate care settings, with such information reported and available to the public. • A national surge capacity plan must be developed and resources provided to prepare our nation's hospital emergency departments for public health crises such as the H1N1 pandemic, a terrorist attack or other catastro- phes. With so much at stake, America can no longer ignore the crisis in its emergency medical care system or make health reform decisions based on myths. Go to www.acep.org/realities for information on protecting your access to quality, timely emergency care. We must act now. Nick Jouriles, MD, FACEP President American College of Emergency Physicians Disasters Call for Heroes. Answer the Call. The Missouri Department of Health and Senior Services is pleased to announce Show-Me Response, a Registry of Volunteer Healthcare Professionals www.ShowMeResponse.org The Missouri Department of Health and Senior Services, Center for Emergency Response and Terrorism (CERT), announces the December 1, 2008 activation of Show-Me Response, an online registration pro- gram for healthcare professionals who are interested in volunteering in the event of a natural disaster or other large-scale public health crisis in Missouri. During a public emergency, healthcare volunteers are essential to help coordinate and deliver services for medical assessment and treatment, medication dis- pensing, immunization, counseling, special needs sheltering, and more. When volunteers register for Show-Me Response, they make themselves available for contact in the event of a disaster should their area of expertise be needed. Once contacted, each volunteer will be able to choose the type and level of participation. The system is safe and secure, and any information a volun- teer provides will be privacy protected. Show-Me Response will collect and check licensing and credential information so data can be readily available for the Missouri Department of Health and Senior Services staff to assist in the notification and activation of qualified medical volunteers. Healthcare professionals can register as volunteers on the Show-Me Response web site at www.ShowMeResponse.org. For additional information, please contact firstname.lastname@example.com or contact: Carole Schutz, MS, RN, Program Coordinator PO Box 570 Jefferson City, MO 65102-0570 Office 573-526-0577 Page 16 MISSOURI EPIC Three are Recipients of the Resident/Student Research Grant The goal of the Missouri College of Emergency Physicians' Medical Student/Resident Research Grant is to facilitate the academic growth and research expertise of medical students/residents in emergency medicine and to promote research in emergency medicine. After review of the submissions by a panel appointed by the Missouri College of Emergency Physi- cians Board of Directors, there were three that qualified for partial funding of their research from the Missouri College of Emergency Physicians' Resident Grant. The recipients are: Jonathan Heidt, MD from Washington University for his project "Geriatric Syndrome Screening in Emergency Medicine: A Prospective, Home-Based Reliability Assessment." The objectives are: "1) To validate the MMSE screening results in the ED by re-testing subjects three-weeks after ED dis- charge when recovering from the presenting illness.; 2) To conduct an observational pilot trial of Geriatric Technician case-finding for occult cognitive dysfunction, visual deficits, frailty, or deficient immunization status for geriatric emergency department patients.; 3) To quantify EM physician re- sponse to cognitive dysfunction screening results using documented recognition of informed physi- cians compared with uninformed physicians.: Stacey House, MD. PhD from Washington University for her proposal "Role of Heparins on the In Vitro Bioavailability and Cardioprotective Properties of Human Recombinant Fibroblast Growth Fac- tor 2: Development of a Novel Therapeutic for Acute Myocardial Infarction." She writes that "This re- search will provide valuable evidence necessary for the development of FGF2 as a potential novel therapeutic agent for acute myocardial infarction. This study will be the first to elucidate the cardio- protective efficacy of human recombinant FGF2 when given during early reperfusion in an in vitro model of acute myocardial infarction. In addition, this study will be the first to determine the tissue distribution of human recombinant FGF2 given intravenously, and will provide valuable information as to the effect of heparins on this tissue distribution. The cardioprotective efficacy of human recom- binant FGF2 when co-administered with heparins will also be investigated. These studies are abso- lutely necessary to develop FGF2 as a treatment for acute myocardial infarction." T. Paul Tran from University of Missouri-Kansas City School of Medicine for his proposal entitled "Influence of Socioeconomic Status upon Post-Myocardial Infarction Outcome Disparities, within Separate Black and White Patient Cohorts." He writes that "This is an ongoing study being re- searched at St. Luke's Hospital in Kansas City with Drs. Gary Gaddis, John Spertus, and Mike Weaver that I have the privilege of working on." "The object of our study is to examine socioeco- nomic status as an independent variable when examining post-MI outcomes and to see if there re- mains a disparity among black and white patient cohorts. Past studies have examined SES in rela- tion to health outcomes, but not with the same parameters we are using to approach the issue. We look specifically at SES with regards to access to healthcare and affordability of healthcare. It is our hope that with our data we can better utilize healthcare resources in improving post-MI outcomes in all patients." For more information on the Missouri College of Emergency Physicians Resident/Student Grant please go to www.mocep.org MISSOURI EPIC Page 17 From the State Advisory Council on EMS: The Time Critical Diagnosis regulations continue to be reviewed. The Trauma Regulations that are in effect now will be reopened for updates only. The addition will be the Level IV hospitals and defi- nitions to make the trauma regulations match the Stroke/STEMI regulations. One of the trauma sur- geons questioned the fact that emergency boarded physicians did not have to keep current ATLS credentials to work in the Level IV hospitals. In the previous trauma regulations, board certified emergency physicians did not have to repeat ATLS certification once they (emergency physicians) had taken the ATLS course. As of this time, this piece of the regulation will remain the same, board certified emergency physicians are not required to take ATLS once they are certified. The trauma surgeon questioned this very closely and made the offhand comment that some board certified emergency physicians were not providing adequate trauma care to their patients. The surgeon would not comment further, but this is a serious remark and in discussing this with the surgeon, he would not give specific case but continued to cast the impression that there are board certified emer- gency physicians that are not adequately treating trauma patients. This is the kind of remark that surfaces during regulation discussions and could very well be used later to reverse the ATLS re- quirement for emergency physicians. The regulation packages for Stroke and STEMI are also well on the way and should be published and start the approval process in the spring. Emergency physicians will be key partners in all of these endeavors and should read and understand the regulations and the effects on the pre-hospital and emergency department patient care. These regulations will have outcome reviews to make sure that all the participants are meeting the requirements of the regulations at their designation levels (Level I, II, III, IV). If any emergency physicians have time to participate in the Time Critical Diagnosis discussions please call Beverly Smith at DHSS, 573-526-0723 to be put on the list serve for notification. Lindy Andrews, MD MAKE PLANS NOW TO ATTEND THE 2010 LEADERSHIP AND ADVOCACY CONFERENCE MAY 16-19, 2010 WASHINGTON, DC FOR MORE INFORMATION GO TO WWW.ACEP.ORG Page 18 MISSOURI EPIC A Personal Experience in Washington DC The following is an account by Chet Schrader, M.D. one of the emergency medicine chief residents at Barnes-Jewish Hospital/Washington University School of Med. This summer, the idea of Health Care reform turned into action while I was in Washington, DC, tak- ing a month to do an internship with the American College of Emergency Physicians. In July, I traveled to the nation's capitol to assist individuals who speak on Emergency Physicians' behalf on a regular basis: Gordon Wheeler, Associate Executive Director; Hilary Smith, Congres- sional and Political Affairs Assistant; Angela Franklin, Quality Measures/HIT Director, Lupe Gonza- les, DC Operations Manager; Laura Gore, Public Relations Director; Brad Gruehn, Congressional Affairs Director; Pamela Jay, Public Affairs Administrative Assistant; Julie Lloyd, Public Relations Manager; Elaine Salter, Public Relations Coordinator; Jeanne Slade, Political Action Director; and Barbara Tomar, Federal Affairs Director. My first exposure to the legislative workings of DC began with MoCEP partly sponsoring myself and three other resident colleagues, allowing us to attend ACEP's Leadership & Advocacy Conference. Throughout the conference in April 2009, we learned skills that allowed us to spend time with our Congressional leaders and ask for their support on ACEP's foremost legislative priority – the Access to Emergency Medical Services Act of 2009. The Access bill set out to address three main components: (1) Bipartisan Commission on Access to Emergency Medical Services: Following the recom- mendation of the IOM, the bill creates a commission that will examine factors, such as emergency department crowding, the availability of on-call specialists, and medical liability issues, which affect delivery of emergency medical services. (2) Emergency/Trauma Physician Payments: Authorizes an additional payment through Medicare to all physicians who provide EMTALA-related care, including on-call specialists whose services are needed to stabilize the patient. The additional funding would help ensure emergency and other phy- sician specialists are able to continue providing care to the growing Medicare population. These payments would neither increase Medicare beneficiaries' co-payments nor negatively impact any other physicians' Medicare payments. (3) Emergency Department Boarding/Diversion: CMS would develop hospital boarding and di- version standards, working through consensus-based organizations such as the National Quality Fo- rum (NQF) and Hospital Quality Alliance (HQA). With the emphasis this summer on health care reform, the time spent in DC focused on a different approach. With the release of the Senate HELP Committee and House Tri-Committee bills, we pri- marily focused on reviewing the bills and making sure the interests of emergency physicians and the patients we treat, are protected and advanced. Continued on Page 19 MISSOURI EPIC Page 19 Continued from Page 18 By working with members of the House Energy & Commerce Committee, our group was able to in- troduce an amendment to the legislation including language to authorize the Emergency Care Coor- dination Center (ECCC) and the Council on Emergency Care within the ECCC. This amendment would help establish emergency care regionalization pilot projects; support and expand emergency medicine and pediatric emergency medicine research; and provide financial support to economically challenged trauma centers. The legislation already had contained a quality provision that focused attention on ED crowding and boarding. Health care reform is far from finished. When I left DC this summer, we were still advocating for the same provisions to be included in the Senate Finance Committee Bill. In a meeting, with Senator Stabenow's (D-MI) staff, we were encouraged that the same amendment placed in the House bill would be offered. However, we were surprised to learn that they were unsure of the overall support of an amendment, because those legislators on the Finance Committee "were not hearing from Emergency Physicians". Lobbyists are very important to ACEP and its' members, but it is even more important that ACEP members regularly contact their state legislators on issues pertinent to them. The amendments offered by ACEP still have to make it through multiple stages of bill reconciliation, but we're hopeful all amendments go through. Nevertheless, it was an exciting time in DC, and one that will serve as invaluable experience for me in future state, local, and national endeavors. Meeting with Congressional staff, representing ACEP at CMS briefings, and even participating in the constant rumor-mill of DC was quite an eye-opening experience – one that I'd recommend to all who could find the time to do it. 2009 R.R. Hannas, M.D., Award Recipients Christopher Watkins Kansas City University of Medicine & Biosciences Samuel Brewer A.T. Still University of Health Sciences Ketan Patel St. Louis University Brandon G. Gaynor University of Missouri – Kansas City School of Medicine Laurel Beth Barrett Washington University School of Medicine Kari Cooper University of Missouri – Columbia School of Medicine The award, entitled the R. R. Hannas, M.D. Emergency Medicine Award, is named after Dr. Han- nas, one of the "founding fathers" of Emergency Medicine, who has practiced Emergency Medi- cine in Kansas City on and off for approximately thirty years. Dr. Hannas was chairman of the committee that originally founded the American Board of Emergency Medicine (ABEM). He served on the Board for twelve years and was the organization's fourth president. He was instru- mental in helping to organize the fifth Emergency Medicine program in the country at Northwest- ern University, and he is also a past president of the American College of Emergency Physicians (ACEP). The award consists of a certificate suitable for framing and $250.00. The Medical School Dean, at the recommendation of the Director of Emergency Medicine, select award winners. MoCEP is proud to be able to provide this award to a senior medical student at graduation. Page 20 MISSOURI EPIC Disaster; are we prepared? Recent times have made preparation for disasters of all types paramount for the protection and well being of our communities and loved ones. The best method of protecting ourselves and others is to prepare for the worst in advance. As emergency physicians we are all aware of the emergency preparedness drills that our hospitals have in place by mandate. We may have even sat in a formative meeting or been contacted by phone during the drill. This is a necessary step in the development of disaster preparedness. As emergency physicians, we need to recognize that our role is by definition, the forefront of prepara- tion for disaster management. If and when anything occurs, we will be called to assist in managing all areas of the disaster including providing direct medical care. Recently, I had the opportunity to interview several of my colleagues and discovered that, outside the basic tenets of our training, and the hospital's established disaster management plan, our roles as emergency medicine physicians were not clear or established. Other than being notified, the next step or action was unclear. Certainly all of us stand ready to respond to the call, and do what is asked of us. What we need to do next is unclear. The mechanics of disaster preparedness and management are numerous and extensive. The first step is recognition of the situation and identification of its potential damage. The next steps include management, containment, and informative interaction with the public though most of us, as emer- gency medicine physicians have had some training in these areas, time and sophistication of terror- ism has somewhat blurred our training and methods. The question to all of us, is how many of us can recognize all or most of the modern agents of mass concentration? How many of us have been recently trained in decontamination protocols? How many of us are skilled in handling the media and preventing mass hysteria? Recently, I had the opportunity to take a course which provided training in these areas with an over- view of the newest biological and chemical agents of destruction. The course lasted 4 days. The first 2 days involved basic disaster life support, tenets, reviewing of all hazards, including recogni- tion, distribution patterns and management techniques. The course continued through the delinea- tion of a disaster paradigm and the methodology of mass triage. Time was spent on refreshing the participants in nuclear and radiologic events. All areas were explored both through lecture, power point and small group discussions. The next course involved the psychosocial aspects of terrorism and disaster, which included a discussion on debriefing and exposure management of self and staff. The first and best section of the course was an outstanding didactic preparation for the most likely disaster or mass casualty events. It allowed us to recognize potential threats and to initiate available resources. The section clearly showed that these events can impact any of our cities' or emergency department regardless, of size. It illustrated the need for all of us, as emergency physicians to be trained and proficient in disaster management. The second section of the course was a much more hands on approach addressing, decontamina- tion, fit testing, hazmat suits, and closed space rescue situations in full gear. A full scale rescue was reenacted in a darkened school auditorium with over 60 mangled victims. Marked secondary explo- sion incendiary devices, needed to be addressed, along with the triage and evacuation of all team members and victims. This was one of several scenarios addressed in the course, which could oc- cur at any one of our local hospitals, churches or schools, at any given time. Continued on Page 21 MISSOURI EPIC Page 21 Continued from Page 20 As emergency medicine physicians we will be and need to be in the front line of those managing and providing care in those situations. As horrifying as the thought of a mass casualty incident or disas- ter, be it of natural origin (the new Madrid fault line) or of a terrorist origin (domestic or alien), we must recognize that it is all too possible and assume our leadership role by participating and prepar- ing for the worst. We need to check our hospital decontamination rooms, review our hospital disaster plans, and dou- ble check our own fit masks. Our role will be in the front lines whether we choose it or not, by the very definition of our profession. Now is the time for us to plan for the potential disaster, either by attending the basic disaster life support/Advanced disaster life support courses, ourselves by send- ing someone from the department or by sending someone. Every day brings the possibility that is will be needed. We at least need to become more involved in the disaster planning strategies of our hospitals and communities, so that if called upon we may assume our anticipated position as lead- ers. The first portion of the course, "Basic disaster life support" is actually provided on-line. The ad- vanced disaster life support is attendance only. Looking on-line I found over 10 pages of available disaster management courses. I believe that our best solution to prepare for disaster lies in familiarizing ourselves with our re- sources. We should regularly attend scheduled planning meetings with local EMS, hospital admini- stration and community leaders. This is truly a situation in which an ounce of prevention will out- weigh a pound of care. ADLS has been endorsed by the American College of Emergency Physicians as "The gold standard in all-hazards training for medical response to mass casualty incidents." For further information on these courses, please see the NDLSF (National Disaster Life Support Foundation) website at www.ndlsf.org. Robert B. Smith, MD, JD Missouri ITLS 2009 As the new year begins, we celebrate another successful year in Missouri ITLS. International Trauma Support Inter- national is a global organization dedicated to improving Trauma care. The course, originally known as BTLS, was modeled after the ATLS, when ITLS Founder John Camp- bell, MD took the new ATLS course in 1980. He went back to Alabama and with the support of Alabama ACEP, founded the organization in 1982. Since that time, tens of thousands of EMT's Paramedics, Nurses, PA's and Physi- cians have been trained worldwide. Missouri Delegation at ITLS in Charlotte, NC 11-8-09 Facing L-R, Bob Page, Brandon Kennall, Missouri Chapter was started in 1986 with the help and Janet Taylor, Doug Cunningingham support of Missouri ACEP, a relationship that still exists today. ITLS is a 16 hour trauma assessment and manage- ment course. ITLS courses are administered by chapters, most sponsored by ACEP chapters. ITLS is constantly revising to keep up with the latest in technology and science to optimize education and patient care. The current lineup for ITLS is ITLS basic and advanced, Pediatric ITLS, ITLS Access, a course designed to show providers how to gain access to trapped victims without the use of heavy hydraulic tools. Continued on Page 22 Page 22 MISSOURI EPIC Continued from Page 21 Missouri holds over 50 classes annually and has coverage all over the state's trauma regions. Courses are administered locally through training entities by ITLS Instructor/Coordinators with over- sight from Affiliate faculty with a Physician medical director at the course or readily available. ITLS holds a trauma conference each year to learn the latest, roll out new information and do the work of the business. This year in Charlotte, NC, one of our own, Brandon Kennall, ITLS Access Instructor from Springfield, was presented with the Harvey Grant award for outstanding Access in- structor. Missouri is in the top 10 chapters worldwide in students trained and we have been trending upward the past 5 years. Missouri Chapter was selected to Pilot a new offering called E-Trauma. The content and didactic material are delivered online. After completion of the online course, participants then complete a one day "completion course" to get their certification. The completion course includes all physical skills and critical thinking scenarios. This course was successful as we had 19 of 19 completed the online component and the completer course. It should save money and time but the information is still de- livered. Furthermore, the online material can be taken stand alone for nationally recognized CEU's. I wish to personally thank the MoCEP Board and membership, especially Dr's Spoon, Szewczyk, and Margie Wilson, for their active leadership and support of trauma training for Missouri. With your continued support, we train even more providers. Bob Page, AAS, NREMT-P, CCEMT-P, I/C MO ITLS Coordinator MISSOURI EPIC Page 23 American College of Emergency Physicians Annual Scientific Assembly 2010 September 28-October 1 Mandalay Bay, Las Vegas, NV For more information go to www.acep.org This chart details key provisions as they relate to emergency medi- cine in both the House and Senate bills, House Senate Health Care Reform Provisions HR 3961 HR 3962 HR 3590 Include emergency services as part of essential health care benefits pack- X X age Quality improvement measured by ED patient through-put X Statutory authorization for ECCC & ECCC Council of Emergency Medicine. HHS annual report to Congress on ECCC activities w/focus on ED crowd- X ing/boarding & delays in ED care following presentation. Emergency care/trauma regionalization pilot project grants X X Trauma stabilization grants X X Reauthorize EMSC for 5 years X HHS incentive payments to states that establish medical liability reforms X (Certificate of Merit/early offer) HHS demo project to reimburse private psych hospitals that provide EM- X X TALA services to Medicaid beneficiaries Require Exchange health plans to provide emergency services w/out re- X gard to prior authorization or EPs contractual relationship Medicare physician payment reforms: * 2010 update based on MEI *X * -- * Rebase SGR *X * -- * Exclude non-physician items from spending target *X * -- * Allowable future growth for E&M services GDP +2% *X * -- * Increase 2010 payment by 0.5%/Decrease 2010 payment by 0.5% * -- *X HHS working group to develop ED boarding & ambulance diversion ** Provision was included in meas- standards & quality measures for hospitals to improve ED efficiency ure approved by the Senate Fi- & patient flow nance Committee. Will be ad- dressed administratively (no longer necessary to include in legislation). PAGE 24 MISSOURI EPIC 213 E. Capitol Avenue, Suite 200 Jefferson City, MO 65101 M IS S O URI EP IC Contact us at: MoCEP PO Box 1865 Jefferson City, MO 65102 Phone: 573-636-2144 Fax: 573-635-6258 www.mocep.org MARK YOUR CALENDAR NOW!!!! The 2010 Combined Clinical Conference on Emergency Care Conference Dates: August 10-13, 2010 at Tan Tar A, Lake of the Ozarks Sponsored by: Missouri College of Emergency Physicians; Missouri Emergency Nurses Association; Missouri Emergency Medical Services Association; Missouri Ambulance Association
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|E6 6b
Rockfax Description
FA. Andy Barker 1980
Ticklists: ROCKFAX Eastern Grit: Top 500, Burbage, Millstone and Beyond Routes Graded List, Peak Rock/16/Eighties Gritstone :The Shape of Things to Come, Mike and Connors 2 year plan, Pete's 150 Peak Extremes.
Photo: Jim Pope's first trad route, Nosferatu (E6 6b) © Simon Wadsworth

subset: commoncrawl


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Professional Services
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A bunch of sounds recorded from my kitchen in my student days, pretty good recording quality.
Reading newspaper looking for news
Cutting paper with scissors
Me ripping up a piece of paper.
several rocks shaking inside two cups
hojas de papel pasando. Sheets
Small Bobsleigh fast passby - 3 times
Recording of various steps on Gravel
a recording of flipping through pages of a book and a leaflet.
Short sound of paper being handled. Part of a percussive kit with paper-sounds.
recordings of various rustling sounds with a stereo Audio Technica 853A
Just having some fun with the 6 inches of snow that we received. The first part of this is me ...
Pebbles falling into various containers, plastic, a paper cup, and ceramic/glass. Meant to simulate fertiliser being poured into a container. ...
A bunch of sounds recorded from my kitchen in my student days, pretty good recording quality.
Small stone avalanche caused by dislodging some rocks from an overcrop. Recorded with a Zoom H2 with 90° dispersion.


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Everybody invited . . . except those in TIME-OUT or who would be missing a hot date! We reserve the right to limit service to anybody too serious or wearing too many clothes!
questionWeaver 56-60, M 10 Answers 4 Jan 18, 2013 in Friendship
Is Playboy pyjamas and a heart print dressing gown too casual? lol
Best Answer
lol thanks!!!! I hope thats memorable i na good way!!!
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Thanks lol
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dress casual and to impress! -- is that really fair?
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News & Public Affairs
Immigrant rights group to protest in Tampa against deportations listen06/19/15 Seán Kinane
MidPoint with WMNF News Friday Listen to this entire show:
Tags: immigration, Deportation, Raices en Tampa, immigrants, Marisol Marquez
In Tampa Friday evening, immigrant-rights activists will protest deportations; the rally is called #FightForLegalization and will begin at 6:00 p.m. at La Mexicana store at 2002 East Fletcher Avenue.
WMNF interviewed Marisol Marquez, an organizer with the group Raices en Tampa.
<iframe width="640" height="360" src="https://www.youtube.com/embed/pVa06vzi00s" frameborder="0...Be the first to comment
May Day rally for labor and immigration rights in Ybor City05/04/15 Seán Kinane
MidPoint with WMNF News Monday Listen to this entire show:
Tags: May Day, Raices en Tampa, SDS, Students for a Democratic Society, Labor Day, labor, unions, workers, immigration, immigrants
Friday was May First – it was celebrated around the world as May Day, also known as International Workers Day or Labor Day. About 30 people rallied on a sidewalk along 7th Avenue in Ybor City Friday evening chanting about labor rights and immigration rights.
WMNF spoke with an organizer, Alicia Gazga, a member of Raices en Tampa.
<iframe w...Be the first to comment
Immigration panel Saturday in Tampa listen02/12/15 Seán Kinane
MidPoint with WMNF News Thursday Listen to this entire show:
Tags: Marisol Marquez, immigration, Raices en Tampa, Tampa, immigrants
Comprehensive immigration reform remains elusive in Congress; but here in Tampa, local activists are calling attention to the need to stop deportations.
This Saturday several groups are hosting a panel on immigration called Stop the Heartbreak.
WMNF spoke with Marisol Marquez, an organizer with the group Raices en Tampa.
<iframe width="640" height="360" src="https://www.youtube.com/embed/iG8C4STMoqY" frameborder="0" allowf...Be the first to comment
Tampa Dream Defenders criticize Governor Scott for vetoing bill to make it easier to get licenses listen06/06/13 Seán Kinane
WMNF Drive-Time News Thursday Listen to this entire show:
This week Florida Governor Rick Scott vetoed a bill passed by the Legislature to make it easier for undocumented Floridians to get identification documents like driver's licenses.
Thursday afternoon the Tampa Dream Defenders held a press conference to criticize Gov. Scott for his veto.
I interviewed Marisol Marquez about her concerns.
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Claire and Robin's Romantic Greek Wedding


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IBISWorld's Data Management & Query Software Procurement Research Report provides the latest price data and the factors underpinning price movements, such as input costs and external demand drivers. The report identifies the leading suppliers of Data Management & Query Software and offers a strategic analysis of the key factors influencing the way the procurement market works. Data forecasts also accompany our analysis so your company can make purchasing decisions with confidence.
During the three years to 2015, the price of data management and query software has been rising slowly at an estimated average annual rate of 1.1% to $1,392 per license. Mounting downstream demand, thanks to higher business expenditures on technology and the growing amount of internet-based data, has driven the minimal increase primarily. After the recession, corporate profit rebounded quickly... purchase to read more
The total cost of ownership for data management and query software is medium. Because buyers can purchase a variety of package options from suppliers, thus buyers should be aware of the inclusions and potential additional costs that could arise with each option. For example, unlimited licenses cost significantly more upfront and can deter buyers from making purchases. Limited licenses (e.g. those... purchase to read more
This report is intended to assist buyers of data management and query software. These products include categorization; clustering; customer relationship; database management, reporting and user interface; query; data mining; information retrieval; metadata management; object oriented database management; portal server; transaction server; and business intelligence and data analysis software. Clients of this software are businesses that need to store and retrieve data electronically on local or remote servers. Software can be installed on a buyer's servers or hosted outside of the buyer's network through a software as a service (SaaS) model.
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Price Drivers
Input Cost Drivers
External Demand Drivers
Recent Price Trend
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Product Life Cycle
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Related Goods
Subsitute Goods
Quality Control
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Supply Chain Risk
Geographic Locations
Competitive Environment
Geographic Locations
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Cost Structure Benchmarks
Switching Cost
Buying Basics
Buying Lead Time
Selection Process
Buying-Decision Scorecard
Key RFP Elements


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Birth by grandpatoenailWatch
©2012-2015 grandpatoenailMature Content
A pic for my fic 'Change'. PLEASE COMMENT!
What's this fic? I think I would like to read it.
not to be funny but you gave him a really big..........ya know LOL but this is very good drawing...........i scared for ichigo LOL sorry but im a yaoi fan girl and him and ichigo are perfect for each other
lolz yeeeeah. that's how most people are reacting. XD and DA can say shit about it! >:-D it's not erect and it's not an erotic pic...well, it's not the them. XD fangirls are much different i guess.
Oh my sweet lord I know this isn't supposed to be erotic but...... * nosebleed *
hahaha! no worries you wouldn't be the first to have taken it that way. *hands tissue* lol
Oh shit.it's big!!!!!! Good job
Hum... If he look that way when he is sleepy... I want to know how he look when he is "fully awake" *3*
Great art
Great art
i can draw that he's not really sleepy just has no clue wtf going on XD daaaazed
haha nuff said i guess?
Nice view ~


text:
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Boston, MA - Temporary The Role: Copywriter The Job: We?re looking for an experienced copywriter that understands branding, can create effective, innovative and inspiring copy in a collaborative environment. What You?ll Do: Collaborate with art director, senior graphic6/2/2015 Boston, MA Save This Job
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at Delphix (View all jobs) Boston, MA . Description: The Delphix team is looking for exceptional computer scientist to join our engineering team to develop distributed platforms and services that scale. Our core java platform is responsible for connecting everything together,6/2/2015 Boston, MA Save This Job
Boston, MA - Full Time The Role: Channel Marketing Analyst The Job: The channel marketing analyst will own all aspects of one or more marketing channels. They will be a part of a fast paced cross-capability team that values new ideas and learning as much as possible as6/2/2015 Boston, MA Save This Job
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OUR MISSION IS TO BRING THE CERTAINTY OF SCIENCE TO THE ART OF BRAND MARKETING. At Tremor Video, we?re transforming the video advertising experience across all screens for the world?s leading brands. Our proprietary brand-performance technology, VideoHub, offers advertisers,6/1/2015 Boston, MA Save This Job
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OUR MISSION IS TO BRING THE CERTAINTY OF SCIENCE TO THE ART OF BRAND MARKETING. At Tremor Video, we?re transforming the video advertising experience across all screens for the world?s leading brands. Our proprietary brand-performance technology, VideoHub, offers advertisers,6/1/2015 Boston, MA Save This Job
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OUR MISSION IS TO BRING THE CERTAINTY OF SCIENCE TO THE ART OF BRAND MARKETING. At Tremor Video, we?re transforming the video advertising experience across all screens for the world?s leading brands. Our proprietary brand-performance technology, VideoHub, offers advertisers,6/1/2015 Boston, MA Save This Job
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'The Atlantic' Can Add 'Scientology Propaganda' to Its Proud History of Journalistic Excellence
Advertising is famously tricky business. Plenty of magazines have run ads that don't necessarily represent their brand, but you like to think there's still some standard, particularly for magazines of repute. The Atlantic is one of America's prouder publications, running articles from such fine authors, historically, as Martin Luther King Jr., Mark Twain and Edith Wharton. As of Monday evening, they're also running a "sponsored content" article praising the many virtues and victories of the Church of Scientology. The piece (screengrab here) lauded David Miscavige, who is called "ecclesiastical leader of the Scientology religion" and who "has led a renaissance for the religion itself, while driving worldwide programs to serve communities through Church-sponsored social and humanitarian initiatives." Coincidentally (sure), this comes just ahead of New Yorker staff writer Lawrence Wright's voraciously anticipated Scientology exposé, Going Clear: Scientology, Hollywood and the Prison of Belief. Following Internet backlash, The Atlantic pulled the ad, saying, "We have temporarily suspended this advertising campaign pending a review of our policies that govern sponsor content and subsequent comment threads" ...
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2 Comments
Hmm. We have better things to do than religion bashing.
'Scuze me Sarah?? Are you seriously saying Scientology is a religion? I personally know a former Sea Org officer...and it's no religion. Totalitarian mind control is an accurate term....religion...no.


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I am new hackintosher,
After following a few tutorials, guides, google and trial and error i managed to install 10.6.3 and update it to 10.6.7 via iAtkos method perfectly functional(i tried the guide here but didnt work for me) now when i try to update to 10.6.8 and i restart computer boots and runs extremely slow and now usb but 10.6.7 is fully stable hackintoshed about 10 times using multiple methods but result is always the same any help would be appreciated my system specs and methods i have tried below
Dell Optiplex gx620
Intel pentium d 3.4 ghz processor
3gb memory
500gb sata(use for mac) and 80gb sata
gma950 2772 device id integrated graphics
Wmp54gs wlan card(airport) 10.6.3 but 10.6.8 doesnt take even after reinstalling old kext)
Iatkos s3
Nawcom boot cd(##### legacy wont boot my computer keeps restarting) w/ myhack 1.1
Please help no kp only a slow machine i have all kext files that make it work just very slow and no usb
Help with dell gx620
Started by izzy5708, Mar 17 2013 06:23 AMSnow Leopard 10.6.8 iAtkos Hackintosh Slow system Dell optiplex gx620
2 replies to this topic
Posted 17 March 2013 - 06:23 AM
Posted 19 March 2013 - 04:15 AM
use this guide http://www.insanelym...age__hl__ gx620
Posted 19 March 2013 - 05:18 AM
Do as Cerastez advised: It's the safest and wisest choice.
But as a side note, and if you are willing to try, your CPU+GPU can work just fine with one of Bronzovka's latest Lion kernels for AMD. People tend to overlook it, since it's poorly advertised, but these kernels work wonderfully on legacy Intel CPUs such as the Pentium D. There's no tested guide for your machine under Lion, but if you manage to set it up properly using the resources available in the AMD development section, your reward will be running 10.7.5 with your machine, with the possibility of getting modern features such as iCloud (if you have access to a Mac or vanilla Intel hack to set it up, but then it's another battle). Cool, isn't it?
All the best!
Also tagged with one or more of these keywords: Snow Leopard, 10.6.8, iAtkos, Hackintosh, Slow system, Dell optiplex gx620
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The Fortress, The Spyder and The Diesel - all new Flash Drives from OCZ.
Originally Posted by liratheal
God I hope they release it as 'bullet proof'.
I want to see some gun nuts shooting it with a .50 or something :D
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