President Obama Launches Medical Malpractice Reform Proposal

President Obama’s budget, discussed at a press conference yesterday, launches a new presidential focus on professional liability laws as they apply to medicine.   He intends to revamp state medical malpractice laws and curb the practice of so-called “defensive medicine.”  The budget specifically calls for $250 million in Justice Department grants to help states rewrite malpractice laws that are consistent with the recommendations made by the bipartisan debt reduction commission last year.  Health and Human Services Secretary Kathleen Sebelius told the Senate Finance Committee yesterday that her agency would advise the Justice Department on grant awards. 

The president’s proposals for professional liability reform include:

• Establishing health courts to deal with medical liability cases.  Health courts would use specially trained judges instead of juries to decide medical malpractice cases.  Awards would be made according to a set schedule.
• Creating a “safe harbor” for physicians who adhere to guidelines for best clinical practices. 
• Creating some protections for physicians who demonstrate acceptable use of an electronic medical record. 
• Providing protections for hospitals and physicians that employ early apology and compensation for medical errors.
• Changing proportionate share laws such that instead of each defendant being held liable for the entire amount of an award in a malpractice suit, each defendant is liable for a percentage proportionate to the responsibility for the harm.  

NOT covered in the president’s proposal is a cap on jury awards.  President Obama has long said that he would not entertain caps as a solution to the professional liability insurance crisis, but has said that he would entertain other options as outlined in his proposal.

President Obama’s debt reduction commission estimates that implementation of the recommendations could save government programs $17 billion by 2020.  Although the cost of defensive medicine is widely debated, conservative estimates start at around $50 billion per year.  The president’s budget does not include any actual savings from the new proposal.   

The Future of Emergency Medicine Summit

Leaders from the major organizations in emergency medicine are meeting to discuss the needs of emergency patients both now and in the future.  Major areas of discussion include workforce, access to care, the daily practice of emergency medicine, and the value of emergency medicine in the emerging era of healthcare reform, with discussion of emergency medicine's role in the formation of accountable care organizations.

Future of EM Summit 2011

Participants in the conference  include:

James G. Adams, MD, FACEP  (AACEM)

Dennis M. Beck, MD, FACEP  (ACEP)

Howard Blumstein, MD  (AAEM)

Marilyn Bromley, RN  (ACEP)

Michele Byers, CAE  (EMRA)

Steven H. Bowman, MD, FACEP  (CORD)

Thomas Brabson, DO, FACOEP (ACOEP)

Gregory Christiansen, DO  (ACOEP)

Theodore A. Christopher, MD, FACEP  (AACEM)

Tammy Crowley  (ACEP)

Nathan Deal, MD  (EMRA)

Angela F. Gardner, MD, FACEP (ACEP)

Marjorie Geist, RN, PhD, CAE  (ACEP)

John Graykoski, PA-C, MPAS  (SEMPA)

Robert Heard, MBA, CAE  (ACEP)

Cherri D. Hobgood, MD, FACEP  (SAEM)

Michelle Hoppes, RN, MS, AHRMQR, DFASHRM  (ASHRM)

Hans R. House, MD, FACEP (ACEP)

Nicholas J. Jouriles, MD, FACEP (ACEP)

Douglas F. Kupas, MD, FACEP  (SAEM)

Douglas L. McGee, DO, FACEP (CORD)

Robert McCurren, MD, FACEP (EDPMA)

Mark Mitchell, DO, FACOEP (ACOEP)

Dighton Packard, MD, FACEP (EDPMA)

AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN  (ENA)

Michelle Parker  (SEMPA)

Randy Pilgrim, MD, FACEP (EDPMA)

John J. Rogers, MD, FACEP (ACEP)

Sandra Schneider, MD, FACEP (Chair of Summit, ACEP)

Donald Stader, MD  (EMRA)

Cary J. Stratford, PA-C, DFAAPA  (SEMPA)

Jim Tarrant, CAE  (SAEM)

Harold A. Thomas, MD, FACEP (Observer only)

Jill Walsh, DNP, RN, CEN  (ENA)

Dean Wilkerson, JD, MBA, CAE (ACEP)

Joseph Wood, MD, FACEP  (AAEM)

Led by Dr. Sandra Schneider, ACEP President, the group will produce a document detailing both the discussions and recommendations in the near future.  

ACEP sends letter to Dr. Berwick, CMS

ACEP sent a letter to newly appointed CMS administrator Dr. Donald Berwick this week.  The letter outlines emergency physician concerns with several health care reform law implementation issues and highlights specific provisions of the new law that affect the delivery of emergency care.  The letter is as presented here:

 July 19, 2010

Donald M. Berwick, MD, MPP, FRCP 

Administrator Centers for Medicare & Medicaid Services

200 Independence Avenue, SW 

Washington, DC 20201

Dear Dr. Berwick:

On behalf of the American College of Emergency Physicians (ACEP) and our 28,000 members, I want to congratulate you on your appointment as Administrator of the Centers for Medicare & Medicaid Services (CMS). We look forward to working with you and your staff during this critical time that the new health care reform law regulations are being promulgated and we believe your clinical and health care policy experience give you a unique perspective on how these rules may impact the delivery of health care in America.

As an elected member of the Institute of Medicine (IOM), we're sure you are familiar with the 2006 IOM reports on the "Future of Emergency Care in the United States Health System," which detailed the challenges and concerns this nation faces in maintaining access to emergency medical care. As articulated in the IOM reports, America's emergency medical system as a whole is overburdened, underfunded and highly fragmented. As a result, ambulances are diverted from emergency departments once every minute on average and patients in many areas may wait hours, or even days, for hospital beds causing admitted patients to be boarded in the emergency department and redirecting precious emergency care resources away from incoming patients.

Emergency departments in this country handle more than 120 million patient visits per year and utilization of our services continues to steadily increase. As we have learned from observing the evolution of the Massachusetts medical care system, and its near universal coverage, emergency department utilization has actually increased in that state, rather than decreased, as many projected. We believe this is the result of a number of factors, including the federal mandate applied by the Emergency Medical Treatment and Labor Act (EMTALA), the lack of internal medicine physicians and general practitioners in the state, injuries and illnesses that occur after normal physician office business hours, and the fact that emergency departments continue to be the sole source of access to the health care system for many in that state, despite their insurance status. The one true lesson from Massachusetts is that coverage does not equal access.

Frankly, we are concerned that the combination of health care law reforms and the general delay in producing more primary care physicians could potentially overwhelm America's emergency departments, many of which currently operate at or above capacity on a regular basis. In particular, we would like to focus your attention of the followingprovisions of the "Patient Protection and Affordable Care Act" and the "Health Care and Education Reconciliation Act:"

Patient Protections (§10101) - This measure extends the "prudent layperson standard" to group health plans, or issuers of group or individual health plans, which offer hospital emergency department services, as well as eliminates the need for prior authorization and provides parity in coverage and patient co-payments for in- and out-of-network providers. We urge you to consider expanding these important patient protections to grandfathered health plans as well.

Hospital Value-Based Purchasing Program (§3001) – As this program advances, we want to ensure measures that will improve emergency department efficiencies are considered an essential component of this plan.

Improvements to PQRI System (§3002) – Please assure emergency physician measures continue to be available in the PQRI program and that these measures promote integration of clinical reporting using electronic health records, as well as demonstrate both meaningful use of electronic health records and quality of care furnished to the patient.

Value-Based Payment Modifier (Physician Fee Schedule) (§3007) – As CMS develops its own transparent episode grouper software; it must account for the unique delivery aspects of emergency services. In addition, it is critical that future risk-based measures developed by HHS ensure emergency physician measures are applied only to services that are within the control of the physicians.

Medicare Shared Savings Program (§3022) and Payment Bundling (§3023) – We urge you to recognize the important role emergency physicians play in providing the full continuum of care to Medicare beneficiaries. There must be commensurate recognition of these distinctive services as an integral part of any Accountable Care Organization (ACO) and through the coordination of bundled payments for an episode of care.

Distribution of Additional Residency Positions (§5503) – Due to the statutory obligation to provide at least 75% of the redistributed residency positions to primary care or general surgery, it is even more imperative that CMS provide as many of the remaining slots to emergency medicine residency programs. The expected immediate increase in emergency department visits demands that we accelerate the availability of residency-trained emergency physicians in our communities.

National Health Care Workforce Commission (§5101) – The growing disparity between the increasing number of emergency department visits each year and the decreasing number of emergency departments is alarming and of great concern to us and our constituents. We strongly encourage you to highlight the education and training needs of emergency medicine as the commission proceeds.

Patient-Centered Outcomes Research (§6301) – Due to the integral role of emergency physicians in providing all types of care for elderly patients, we ask that the emergency medicine perspective be represented in the identification of research priorities and the establishment and implementation of the research project agenda.

Extension of Medical Malpractice Coverage (§10608) – The law extends Federal Tort Claims Act liability protections to an officer, governing board member, employee or contactor of a free clinic. This is an important recognition of the unique role of those individuals who provide medical services without requiring compensation from the patient. As you know, the federal mandate of the Emergency Medical Treatment and Labor Act (EMTALA) requires emergency department physicians and many on-call specialists to provide similar, and in fact more comprehensive, services as those provided at free clinics with a substantial burden of uncompensated care. We urge you to review the unique requirements on physicians who provide EMTALA- related services and consider how the Federal Tort Claims Act may be applied to ensure the availability of these emergency and on-call physicians.

In addition, we are writing to request your assistance with another matter of significant importance to the coordination and delivery of high-quality medical care in America's emergency departments. Senator Debbie Stabenow (D-MI) has requested a formal response from HHS on her proposal to create a CMS working group that would be responsible for reviewing issues affecting access to emergency care and for developing standards and measures to reduce emergency department boarding and crowding, as well as ambulance diversion. Both of these issues can have dire consequences for patient care and we urge you to develop your response to her request as soon as possible.

Thank you for your consideration of these important issues. As you know, enactment of health care reform was only the first step. We look forward to working with you to ensure the implementation of these laws help our patients receive the best medical care possible, including maintaining access to lifesaving emergency medical services that are so vital to our communities.

Sincerely,

Angela Gardner, MD, FACEP

President

Call for Unity

Today’s health care reform vote on Capitol Hill, while high drama, really only signals the beginning of the work that needs to be done by emergency physicians to improve access to emergency care for our patients and future patients. As I write this, I am watching the floor deliberations via the miracle of technology, and I know that the outcome will disappoint 48% of ACEP members, 48% of all physicians, and 48% of the American public, if polls are to be believed......and that will occur regardless of the outcome.

The greatness of our democracy lies in the ability of our people to freely elect their government representatives and to express themselves fully in the debate over crucial issues. Never in my lifetime has this been more apparent than during the health care reform debate. I believe that almost everyone has an opinion on health care, including many non-Americans, and almost everyone has expressed that opinion at some point.

The real challenge to our democracy, to our specialty, and to our organization is to move forward once today’s vote has been taken. We must have great care not to fall victim to Jefferson’s “tyranny of the minority.” We must move forward to create the greatest health care system in the world, befitting the greatest nation in the world, no matter the outcome of today’s vote.

There is no “win” today for emergency medicine. There is only new illumination on the path to achieving better emergency care. The real work comes as we identify areas that need our skills in innovation and problem-solving and get to work shoring up the nation’s emergency care system. My fervent wish is that emergency physicians will find a common bond in the needs of our patients, and put the rancor and division of the path to health care reform behind us in the interest of better emergency care for everyone.

2010 Council Steering Committee Convenes

Dr. Arlo Weltge, MD, MPH, FACEP convenes the ACEP 2010 Steering Committee today at headquarters in Dallas, Texas. Dr. Weltge, who serves as the Council Speaker, is from Houston, Texas. He is assisted by Council Vice-Speaker Dr. Marco Coppola, DO, FACEP, who practices in Fort Worth, Texas.

The Steering Committee reviews the results of the Council Meeting held in Boston, Massachusetts in October 2009 and makes recommendations to improve future Council deliberations. In addition, the Speaker, Vice-Speaker and Steering Committee supervise the election process for the American College of Emergency Physicians.

The members of the 2010 Council Steering Committee are:

Dr. Ashley Booth Norse, MD, FACEP

Jacksonville, Florida

Dr. Stephen A.D. Grant, MD, FACEP

Aiken, South Carolina

Dr. Theresa Gunnarson, MD, FACEP

Orr, Minnesota

Dr. Kenneth L. Holbert, MD, FACEP

Smyrna, Tennessee

Dr. Kaedrea Jackson, MD, MPH

Brooklyn, New York

Dr. David P. John, MD, FACEP

Dorchester, Massachusetts

Dr. Terry Kowalenko, MD, FACEP

Brighton, Michigan

Dr. Eric E. Maur, MD

Danville, Pennsylvania

Dr. John G. McManus, MD, FACEP

San Antonio, Texas

Dr. William J. Meggs, MD, FACEP

Greenville, North Carolina

Dr. Abhishek Mehrotra, MD, FACEP

Chapel Hill, North Carolina

Dr. John J. Rogers, MD, FACEP

Macon, Georgia

Dr. Peter E. Sokolove, MD, FACEP

Sacramento, California

Dr. Christopher S. Weaver, MD, FACEP

Indianapolis, Indiana

Dr. Jennifer L. Wiler, MD, MBA

St. Louis, Missouri

Dr. James Williams, DO, FACEP

San Antonio, Texas

The American College of Emergency Physicians 2010 Council will have 1429 Councilors from across the nation, who will meet to discuss the issues facing emergency medicine and recommend policy to the Board of Directors. That meeting will take place September 26 – 27, 2010 in Las Vegas, Nevada.

Emergency Medicine in the Health Reform Bills

Work continues in D.C. to produce a health reform package to send the president. Here is a short summary of the provisions that directly concern emergency medicine:

Both the House bill (HR 3962) and the Senate bill (HR3590) contain the following elements:

*Include emergency services as part of an essential health care benefits package.

*Contain emergency care/trauma regionalization pilot project grants.

*Contain trauma stabilization grants.

*Include the HHS demo project to reimburse private psychiatric hospitals that provide EMTALA services to Medicaid beneficiaries.

The House bill contains these elements:

*Quality improvement measures for ED patient through put.

*Statutory authorization for ECCC & ECCC Council of Emergency Medicine.

*HHS annual report to Congress on ECCC activities with focus on ED crowding/boarding and delays in ED care.

*Establishes HHS incentive payments to states that establish medical liability reforms such as Certificate of Merit or early offer.

The Senate bill contains these elements:

*Directs Secretary of HHS to expand emergency medicine research and pediatric emergency medicine research at NIH, AHRQ, HRSA, CDC, et. al.

*Reauthorizes EMSC for five years

*Requires Exchange health plans to provide emergency services without regard to prior authorization or the contractual relationship to the Emergency Physician or the Emergency Physician Group

*Applies the Patient's Bill of Rights and the prudent layperson standard to all health care plans

In addition there was a provision for an HHS working group to develop ED boarding and ambulance diversion standards and to develop quality measures for hospitals to improve ED efficiency and patient flow. This will be addressed administratively, so it is no longer necessary to provide this in the legislative language.

ACEP fought hard for a time extension for Section 1011 (Federal reimbursement of emergency health services provided to individuals not lawfully present in the U.S.) It was not included in the Senate Manager's amendment. It may still be considered as the House-Senate Conference negotiations continue.

As the negotiations continue through the holidays and into the New Year, I'll keep you posted on the latest changes.

Help with Health Care Reform

http://www.youtube.com/emergencycareforyou

Here's how you can help with health care reform.

Senate Stall

Tuesday in the Senate each political party offered an amendment to the chamber’s health reform bill. A partisan floor discussion ensued, delaying actual votes on the amendments. Two-and-a-half days after discussion of the bill began, not a single vote has been taken. One amendment addresses the need for better women’s health screening services and the other eliminates billions of dollars of spending in Medicare cuts.

This is D.C. politics at it’s best. The Republican strategy seems to be to draw out the discussions as long as possible, knowing that the longer the stall, the less chance that any form of health care reform will pass. The Democrats are working on a strategy to overcome the Republican parliamentary tricks. Sen. Tom Harkin (D-IA) confirmed in Roll Call today that one idea under consideration is the motion to table the Republican amendments, this requires only 51 votes instead of the 60 votes needed for cloture.

On this third day of debate without a single vote taken, frustration is mounting in the Chamber as well as among those whose lives and livelihoods are affected by the outcome.

White House Responds to Health Care Reform Questions

In the wake of the recent media coverage of health care reform, the White House has produced several videos addressing common questions. They can be found at http://www.whitehouse.gov/realitycheck/.

The first set of videos addresses a wide scope of topics and debunks some of those common myths:

CEA Chair Christina Romer details how health insurance reform will impact small businesses.

Domestic Policy Council Director Melody Barnes tackles a nasty rumor about euthanasia and clearly describes how reform helps families.

Matt Flavin, the White House's Director of Veterans and Wounded Warrior Policy, clears the air about Veteran's benefits.

Kavita Patel, M.D., a doctor serving in the White House's Office of Public Engagement, explains that health care rationing is happening right now and how reform gives control back to patients and doctors.

Robert Kocher, M.D., a doctor serving on the National Economic Council, debunks the myth that health insurance reform will be financed by cutting Medicare benefits.

In a video first released last week, Linda Douglass from the White House Health Reform Office addresses fears about the end of our private insurance system and reiterates that if you like your current plan you can keep it.

There is also a handy FAQ about health insurance reform.

I suggest that you check some of these out, if for no other reason than to hear what the White House perceives as the most significant issues. In addition, the website has a place for you to comment directly with your concerns about health care reform. Now is your chance to make your voice heard.

Obama's address to the AMA

In the wake of President Obama’s remarks to the American Medical Association on Monday, it seems that everyone has an opinion about what should be done with the healthcare system in America.  Unfortunately, there is no consensus , even within the house of medicine.  The president was very clear about his intent, and very little of it surprised those in the audience.  The president led with a condemnation of the status quo, complete with touching stories of patients struggling with tragic circumstances, both medical and economic.  His arguments were the standards in the healthcare debate – providing medical care is too expensive, too complicated, and too poor in quality to continue.  He did stop short of blaming the current state of affairs entirely upon the physicians, perhaps in deference to the audience.

 

President Obama followed his indictment of the status quo with a description of elements of the reform package that he has long championed:  the electronic health record, comparative effectiveness research, dissolution of healthcare disparities, and universal coverage.  He assured the audience that anyone partaking of a private health insurance plan who was satisfied with that plan would be able to keep it.  However, as he stated long ago on the campaign trail, he supports a government-supported public plan, now called the Health Insurance Exchange.  The president believes that a public option would provide an alternative for Americans who currently cannot obtain affordable health insurance.  He also stated that the public plan would provide “healthy competition” for private insurers. 

 

There were two things that I noticed today that were a change from the president’s usual discourse on health system delivery.  First, he stated today that all Americans would be required to purchase health insurance of some kind.  In the past, especially during his campaign, he only espoused a requirement  for insurance for children.  Secondly, he stated that he is opposed to caps on damages recovered in malpractice litigation, but that he is “open to consideration of” any number of other methods to  appease physician concern over professional liability.  He said that he has drawn criticism from members of his party over his willingness to consider any changes to the tort system. 

 

No doubt the president is looking to trade vague, lukewarm promises to consider changes in the tort system for some Republican support of his health system reform plans.  Will it be enough?

Tap Water Medicine?

"Tap Water Healthcare" is a term coined by Dr. Arthur Kellerman, MD, FACEP, Professor and Associate Dean for Health Policy, Emory School of Medicine.  It is the concept of a basic health plan that is the equivalent of community tap water.  The goal of community water treatment plants is to provide safe drinking water for the entire community.  In recent years, many have decried the taste of mass purified water, the low standards for solutes, and the lack of easy portability.  For these reasons, many people prefer to purchase bottled water.  Some even prefer fancy bottled waters from "natural" springs, from foreign countries, or with special additives like flavor or bubbles.  

     As the debate over health care proceeds, is it possible to develop basic health coverage that resembles tap water - available, inexpensive, and safe?

Representative Cuellar Signs On HR 1188

Gordon Wheeler and I met with Representative Henry Cuellar (D-TX) this morning, and he agreed to become a co-sponsor of HR 1188.  Representative Cuellar is actively involved in the current healthcare reform efforts, and was very receptive to our comments about the importance of emergency medicine in the lives of all Americans.  Thank you, Representative Cuellar, for your support. 

Swine flu

The American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA) today issued a joint statement about the cases of swine flu in the United States and offered recommendations to the public about when to seek emergency care.

Saying the nation’s emergency departments are on the front lines of any public health emergency, the two organizations urged the public to apply the “prudent layperson standard” to any illness or injury: If the average prudent person would think you have the symptoms of a medical emergency, then you need to seek emergency care.

“Emergency physicians and nurses are specially trained to assess your symptoms and treat you, and if you have any doubts about your medical condition, we are there for you,” said Dr. Nick Jouriles, president of ACEP.  “While news reports about the swine flu may have raised alarm, remember there are still very few actual cases of the illness in the United States.  And if you have no symptoms, then you do not need to seek emergency care.  If you do not have a fever or cough, it is extremely unlikely that you have the swine flu.”

Emergency physicians and nurses in different parts of the country are seeing people who do not have symptoms, but are simply seeking information and reassurance that they are not ill, which both organizations say is understandable, given the widespread news coverage.  To help people understand this disease and get the information they need, the Centers for Disease Control and Prevention (CDC) is maintaining up-to-date web pages about the symptoms of swine flu and when to seek immediate medical care (www.cdc.gov/swineflu).

“If you have symptoms that would not ordinarily take you to the emergency department but are considering going because you are afraid you have swine flu, you probably do not need to go,” said Bill Briggs, RN, president of ENA.  “Remember that many illnesses – not just swine flu – are transmitted in public places and very often the best way to avoid the spread of disease is to stay home until your symptoms subside.”

In the current push for health care reform, policymakers must recognize the unique role that emergency physicians and emergency nurses play, especially in times of crisis.  Emergency departments are the nation’s safety net, a point driven home this week with the threat of pandemic swine flu filling ERs with patients fearing they are infected.  The safety net is under extraordinary stress in the best of times, never mind the worst.

“Even those ‘worried well’ who have primary care physicians are being directed to the emergency department because of our specialized expertise,” said Dr. Jouriles.  “We stand on the front lines of any disaster and when all other doors are closed, our doors are always open.  That is why true health care reform must strengthen America’s health care safety net – emergency departments.’

ACEP is a national medical specialty society representing emergency medicine with more than 27,000 members. ACEP is committed to advancing emergency care through continuing education, research and public education. Headquartered in Dallas, Texas, ACEP has 53 chapters representing each state, as well as Puerto Rico and the District of Columbia. A Government Services Chapter represents emergency physicians employed by military branches and other government agencies. 

ENA is the only professional nursing association dedicated to defining the future of emergency nursing and emergency care through advocacy, expertise, innovation and leadership.  Founded in 1970, ENA serves as the voice of 37,000 members and their patients through research, publications, professional development, injury prevention and patient education.  Additional information is available at ENA’s website www.ena.org.

Swine Flu Outbreak

The United States has seven confirmed cases of Swine Influenza A/H1N1, five in California and two in Texas, and nine suspect cases.  All of the seven confirmed cases had mild Influenza-Like Illness (ILI).  No deaths have been reported. 

 

Mexico reports three separate event locations – Mexicali, San Luis Potosi, and the Federal District of Mexico.  The government of Mexico began surveillance of ILI March 18, 2009.  Since then, 854 cases of pneumonia have been reported in Mexico City, with 59 deaths.  San Luis Potosi, in central Mexico, reports 24 cases of ILI, with three deaths.  Mexicali, near the border with the United States, has had four cases of ILI, with no deaths.  The majority of these cases have been in healthy young adults.

 

Of the Mexican cases, 18 are confirmed Swine Influenza A/H1N1.  Twelve of the 18 are identical to the Swine Influenza A/H1N1 viruses isolated from the patients with confirmed cases in California.  Swine flu viruses do not normally infect humans.  However, sporadic human infections have occurred in persons with direct exposure to pigs and in health care workers caring for persons with swine flu.  The Centers for Disease Control and Prevention (CDC) report 12 cases of human infection with swine flu between December 2005 and February 2009. 

 

The Swine Influenza A/H1N1 viruses isolated in this outbreak appear to be a strain not previously detected in pigs or humans, although these reports are preliminary.  Because there is reported spread of an animal virus in humans, and because of the geographical spread of multiple community outbreaks, these events are of concern, and the CDC is working to further characterize the viruses and provide guidance for treatment and prevention.

 

The symptoms of swine flu in humans are expected to be similar to the symptoms of seasonal human influenza, and include fever, malaise, lack of appetite, and coughing.  Some patients with the swine flu have reported runny nose, sore throat, nausea, vomiting, and diarrhea.  The H1N1 swine flu viruses are antigenically different from human H1N1 viruses, and vaccines for the human seasonal flu are not expected to provide protection from the swine flu viruses. 

 

To diagnose swine influenza A infection, a respiratory specimen must be collected and sent to the CDC for testing.  The specimen must be collected in the first 3-4 days of the illness, when the virus is shedding.  Testing may require an additional 3-4 days.  The CDC has not yet made recommendations for treating patients with an antiviral medication while the testing is pending, although these recommendations are expected later today. 

 

There are four different antiviral medications available for use in the United States for influenza:  amantadine, rimantadine, oseltamivir and zanamivir.  The most recent swine influenza viruses isolated from humans are resistant to amantadine and rimantadine.  At this time, the CDC recommends the use of oseltamivir or zanamivir for the treatment of infection with swine influenza viruses. 

 

The outbreak of “swine flu” in North America is a growing cause of concern in the World Health Organization (WHO) and in scientists worldwide concerned with pandemic prevention.  Recent improvements in pandemic preparedness may be tested by this emerging threat.   

 

 

 

HAPPY 100TH EPISODE!

This is my 100^th blog for the American College of Emergency Physicians.  For television shows, the 100^th episode is a cause for celebration.  One hundred broadcast episodes means that the show is a success for everyone involved, the producers, the sponsors, the actors, AND the writers. 

 

I began this “blogging” project in November of 2006, as the first official “blogger” for the American College of Emergency Physicians.  It was my idea that the leadership of the college should investigate ways to reach out to younger physicians using newer technologies and communication media.  Having a blog seemed so hip, so young, so whatever-the-word-of-the-moment is.

 

It has been a learning experience.  I learned how to host a blog.  I learned to write without an editor.  I learned that writing without an editor means everyone feels entitled to offer advice on your writing, both style and substance.  I learned that the harshest critics did not want to criticize me in the “comment” section, where others could see, but wished to make their views known via email.  I learned that being a blogger for an organization means that everyone has your email address.

 

I learned that producing three to five hundred coherent, intelligent-sounding words that will live in cyberspace forever on a consistent basis is a challenge not unlike rearing children - tedious, relentless, and unimaginably joyful.

 

I learned the distinct joy of trying on, trying out, and wearing out new technologies.  I have “pages” on every social network imaginable. I facebook, myspace, pulse/plaxo, link-in and now, I tweet on twitter.  (Writing without an editor also allows me to create brand-spanking-new verbs.)  I have thousands of friends-of-friends.  I actually believe that epidemiologists could learn a thing or two about communicable diseases from observing the spread of information through social networking devices.  I have even appeared on youtube more than once, and more than Mom watched it........or else Mom spent most of the last few months clicking and reclicking.

 

So, to my several hundred loyal readers, my occasional readers, and even my first-time readers, I say thank you.  Thank you for the chance to learn, to grow, to express myself, and to be a part of something much, much larger than myself.  Thank you for allowing me just another mature adult trying to stay connected to a rapidly changing world.  Most of all, thank you for birthing the inevitable result of 100 hundred successful episodes.......a spin-off!

 

ACEP now has bloggers from all walks of the (emergency physician) profession expressing themselves on The Central Line.  Check it out now at thecentralline.org.

 

.....and stay tuned for next season’s premiere.

 

 

 

Disclaimer:  Because I do believe in telling the truth, I have to admit that The Central Line is not my project.  It was lovingly crafted by very skillful ACEP staffers, and is written by a host of VERY talented emergency medicine professionals.  They are allowing me to link to the site and to claim credit for the idea because THIS IS MY BLOG AND THEY CAN’T STOP ME!  Seriously, they are allowing me to post to The Central Line during the debut at the Legislative and Advocacy Conference in Washington D.C. this week.  Check it out......and thanks for stopping by.     

Health Reform must include emergency medicine

ACEP members will demand that emergency medicine be addressed during health care reform.

Nearly 400 emergency physicians from across the country will be converging on the nation's capital April 19-22 to advocate for greater patient access to lifesaving emergency medical treatment. As part of their visit, these medical specialty leaders will meet with key policy and lawmakers on Capitol Hill to educate them about the nation's emergency care crisis, which was recently documented in ACEP's National Report Card on the State of Emergency Care.  The report, issued in December, assigned the nation an overall grade of C- for its support of emergency care and a D- in access to emergency care. 

Emergency physicians will urge their elected officials to hold hearings on and enact the Access to Emergency Medical Services Act (H.R. 1188 and S. 468), a bill that outlines measures to strengthen access to emergency care for patients. The meetings are part of the 2009 Leadership and Advocacy Conference of the American College of Emergency Physicians (ACEP), a key component of which is to urge members of Congress and the administration to include an array of critical emergency care issues in the discussions of health care reforms.

Invited conference speakers include former Clinton Administration senior health care advisor Chris Jennings, Rep. Pete Stark (D-Calif.), political pundit Charlie Cook, executive director of Families USA Ron Pollack and executive vice president for government affairs of the U.S. Chamber of Commerce R. Bruce Josten (final confirmations pending)

Thank You Tennessee!

Thank you to the Tennessee College of Emergency Physicians for inviting me to speak and hosting me at their annual meeting in Chattanooga, Tennessee.  My special thanks to my dear friend Sandy Herman, who organized the excellent program, and was generous enough to include me.  I gave an update on health care reform, and in a separate lecture provided a review of the latest literature affecting wilderness medicine.  My favorite part of the meeting, though, was participating in a luncheon panel discussion with Greg Henry, Todd Taylor, and David Seaberg, moderated (refereed?) by Sandy Herman.  None of are shy, and the ensuing debate was lively.  (....and just for the record, Greg, you ARE wrong.)

 

I also would like to express my appreciation to David and Carol Seaberg, who invited me into their home, treated me to wonderful food and great company, and took me to Rock City.   The Seaberg’s sons, Ryan and Tyler, showed me the secrets of the boulders atop Lookout Mountain with all the energy and enthusiasm that teenage boys have.  Who could resist the dare to follow a narrow path, appropriately named “Fat Man’s Squeeze,” between two giant boulders on the way up the mountain?  I stood near the top of that mountain, in front of a green waterfall, and saw seven states.  It doesn’t get any better than that.

 

I spoke with representatives of the Tennessee Emergency Management Agency, who expressed dismay that Tennessee ranked 51^st in disaster preparedness in the recently released National Report Card on the State of Emergency Medicine.  They presented the Tennessee disaster preparedness program to the group, vigorously defending their preparedness and their integration with physicians and hospitals.  My defense of the Report Card is based on the methodology.  Tennessee received the ranking based on the metrics chosen by a group of emergency medicine experts, and based on the data available at the time from public sources.  Their presentation revealed a disaster plan that appears cohesive and well-considered, and does have some physician involvement.  If nothing else, the controversy caused by the Report Card led to a better dialogue and a better working relationship between TEMA and the emergency physicians of Tennessee.  If the result is better disaster planning, then the Report Card has served its purpose.

 

Again, I thank the Board of the Tennessee College of Emergency Physicians, their president, Dr. Kenneth Holbert, and my many old friends from Tennessee – John Proctor, Bob Roth, Sandy Herman, Harry Severans, Jim Creel, David Seaberg, and too many others to name – for a wonderful experience.  Tennessee Rocks!

 

 

 

  

 

A Day at NASA

I had the pleasure of spending a day at NASA this week.   I met Dr. Joseph P. Kerwin, M.D. (Captain, MC, USN, Ret.), the first physician astronaut to serve with the National Aeronautics and Space Administration.  Dr. Kerwin has had a long and varied career.  He logged 4500 hours flight time as flight surgeon before being selected by NASA in 1965.  He served as science-pilot for the Skylab 2 (SL-2) mission, and subsequently managed the on-orbit branch of the Astronaut Office, where he coordinated astronaut activity involving rendezvous, satellite deployment and retrieval, and other Shuttle payload operations.  He later served as Director of Space and Life Sciences at the Johnson Space Center, Houston.  In that capacity he was responsible for direction and coordination of medical support to operational manned spacecraft programs, including health care and maintenance of the astronauts and their families; for direction of life services, and for managing Johnson Space Center earth sciences research, light experimentation projects, and scientific efforts in lunar and planetary research. 

 

We compared notes on our respective fields, and on the progress that has been made in medicine in the past 50 years.  Dr. Kerwin told me, “The only difference between your specialty and mine is that I made house calls.”  I guess that’s true, but I think most people would consider a house call thousands of miles away in space an adventure.  Dr. Kerwin is the co-author of “Homesteading Space:  The Skylab Story,” a compelling tale of the Skylab from the near-disastrous launch to the descent into the Indian Ocean. 

 

I had the opportunity to tour the historic Mission Control, and I admit to developing a lump in my throat at the thought of the teams who labored tirelessly and risked their personal safety to send human beings into space.  Every mission was an exercise in learning......learning the tasks necessary to live in a weightless environment, learning the mechanical skills to manage spacecraft, learning the nuances of flight.    In the early days of the space program every person had a singular focus – get a man on the moon.  Today NASA has a new program known as Constellation.  The Constellation Program is focused on carrying a new generation of explorers to the moon, and then to Mars. 

 

In these troubled days of challenges in healthcare, economic depression and worldwide warfare, there is a bright spot in the form of Orion, NASA’s first Constellation Program vehicle.  Orion is a reminder that whatever the challenges, the human spirit will continue to seek knowledge and understanding beyond what is currently known.   

 

Thank you, Joe. 

Too big to fail: the malpractice industry?

“I will pursue tort reform in America until every state enjoys the same success as Texas,”  announced Texas Governor Rick Perry to a group of physicians gathered in Washington D.C.  In a speech eerily reminiscent of another Texas governor, Perry detailed the successes of the tort reform movement in Texas, stating, “We need tort reform, and we need it now!”  Unsurprisingly, the group of physicians gathered for the American Medical Association’s National Advocacy Conference greeted the remarks with a standing ovation. 

 

Since the passage of Proposition 12 in September 2003, Texas has transformed from one of America’s “judicial hell-holes” into the land-of-milk-and-honey for physicians.  Neurosurgeons, obstetricians, and emergency physicians flocked to the state, seeking shelter from the litigation wars in Florida, Ohio, and Mississippi.  Malpractice insurance rates have declined by 23% overall.  There is a 2,300 case backlog for the Texas State Board of Medical Examiners, struggling to provide licensure for the litigation refugees of other states.  Seventy-two counties in sparsely populated west Texas boast physicians where there were none 5 years ago. 

 

As the debate for health care reform heats up in Washington D.C., the focus is appropriately on accessible, affordable, high-quality medical care.  Policy-makers struggle to find an economic model that will pay for the kind of care that Americans want and deserve.  Physicians make up a very small percentage of those serving as elected officials in Washington.  Perhaps that explains why lawmakers, who overwhelmingly come from another line of work, fail to see the blunt truth that is right in front of them.

 

Americans could provide the highest quality medical care to everyone in the country, conveniently and affordably, by eliminating defensive medicine. 

 

Of course, the economic cost would be borne by those involved in the litigation industry, which includes far more people than the the much maligned plaintiff attorneys.  Also securing monetary gain from the pursuit of malpractice litigation are defense attorneys, malpractice insurance companies, professional (I mean, expert) witnesses, arbitrators of all types, professional and paraprofessional case reviewers, settlement structure analysts, actuarials , courthouse personnel, and purveyors of advertising.  In fact, perhaps tort reform is not a part of health care reform discussions because the entire malpractice industry is too big to fail?

Congratulations, Dr. Jeff Runge

I am in Washington D.C. this week participating in the discussions about health care reform.  Last night I had the honor of being invited to participate in honoring one of emergency medicine’s own, Dr. Jeff Runge.  

 

Dr. Jeffrey W. Runge, MD, FACEP, received the Dr. Nathan Davis Award for Outstanding Government Service in a ceremony last evening.  Dr. Runge practiced emergency medicine for 25 years, and was assistant chairman of the Department of Emergency Medicine at the Carolinas Medical Center in Charlotte, North Carolina when President Bush appointed him administrator of the National Highway Safety Administration.  While there he implemented a combination of legislative and law enforcement initiatives, including the “Click It or Ticket” program.  Dr. Runge went on to serve as chief medical officer within the Department of Homeland Security (DHS), working as an advisor on medical and bioterrorism issues.  While there Dr. Runge founded the Office of Health Affairs, providing oversight of the Department’s biodefense and medical readiness programs.  Dr. Runge now acts as a consultant in the areas of disaster medicine, bioterrorism defense and homeland security technology.