ACEP Policy Statement on Emergency Ultrasound by External Entities

Approved by the ACEP Board of Directors, June 2014

The American College of Emergency Physicians (ACEP) believes that certification by non-emergency medicine external bodies, organizations, societies or other medical specialties or upon short course completion is inadequate to demonstrate comprehensive training, knowledge, and skill in the practice of emergency ultrasound.

Emergency ultrasound comprises a set of focused applications utilized to diagnose life-threatening conditions, guide invasive procedures, and treat emergency medical conditions. Both residency-based and practice-based pathways exist for emergency physicians to demonstrate competency in emergency ultrasound as detailed in the ACEP policy statement, “Emergency Ultrasound Guidelines.”

Any non-emergency medicine external certification process would impede the use of this critical clinical skill and adversely affect patient care.

ACEP strongly opposes the use of any non-emergency medicine external certification process to validate competency in the use of emergency ultrasound. Furthermore, any such process should not be utilized as a requirement for hospital privileges or credentialing, nor for reimbursement by accountable care organizations (ACOs), managed care organizations (MCOs), the Centers for Medicare and Medicaid Services (CMS) or other third-party payers.

Philpot on the Australian Organ Donation Register

The Victorian Intensive Care Network (VIN) periodically holds some great meetings featuring great speakers, and they are being released online via the Intensive Care Network podcast. Find out about future VIN meetings here.

Just released is Steve Philpot’s brief, informative talk about how clinicians can use the Australian Organ Donation Register and how to discuss the opportunity for organ donation with families. Steve is an Intensivist at The Alfred ICU and Hospital Medical Director for organ and tissue donation. He also runs Donate Life’s free Family Donation Conversation Workshops held throughout Australia (these workshops are reviewed here). Steve also took part in the panel discussion at smaccGOLD on What is possible? What is reasonable? What is best?

Listen to Steve’s VIN talk here:

You can subscribe to the ICN podcast on iTunes here.


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Are you OK?

Hey folks, I just finished listening to an important podcast from Mitch Thomas and Jess over at the Downstairs Care Out There show.
here is the episode
The cut segement from Jess’s talk on Peer Support and MH

It triggered a memory I had of a patient of mine who suicided quite a few years ago now, when I was working as a rural doctor in a small town. The visiting psychiatrist the next day popped into our clinic and over lunch I brought up the recent suicide. The first thing he asked me was “How are you feeling?” I didnt expect that but I have tried to take that same approach , from them on, when talking to colleagues about traumatic events.

its easy to forget/neglect our emotional responses/reactions to the awful things we often encounter in our line of work in ED, ICU, OT and prehospital.

Jess wrote more on this earlier in the year at the prehospitalresearch blog. Check out her article here.
What CAN happen when we ask our colleagues if they are OK

There have been a lot of talks and materials on inspiring excellence and mental toughness in critical care. A lot of time and energy gets devoted to debating things. Sure some of this is for entertainment and humour. This humour I suspect helps us deal with the existential despair that our work can often invoke.

Here are my ABCs of emergency mental health care FOR EACH OTHER

A = ASK are you ok?
B = BE available to listen
C = CONCERN , express it if you are.

Dr Fleming is a rural doctor from my home state of South Australia. Here he gives an impassioned account of his own journey into addressing the crisis of suicide in his town.
Approach to rural suicide

Thankyou Mitch and Jess for reminding us all, never forget to ask ARE YOU OK?


Filed under: FOAMEd, Interviews of interesting people, Prehospital medicine, Rural medicine

EEM 2014 -Session Host Video- Anand Swaminathan, MD

Next up in our video interview series is Anand Swaminathan, MD.

Anand is the Assistant Program Director of the Department of Emergency Medicine at the NYU Langone Medical Center. Joining Anand for this final session of EEM 2014 are Drs. Kenji Inaba, Haney Mallemat and Billy Mallon. You can count on these boys to bring you the latest info on trauma, trauma and more trauma. Below is the session schedule. The complete EEM 2014 schedule and brochure can be found HERE.

Plan your trip now and REGISTER to join us in San Francisco for the best Emergency Medicine conference ever.

Anand Session


EEM 2014 Session Host D4S1 Anand Swaminathan

ACEP Clinical Policies Committee to Develop Independent tPA Policy

The ACEP Board Directors accepted a recommendation last week from its Clinical Policies Committee to begin working on a tPA policy exclusive to ACEP instead of a joint project with the American Academy of Neurology.

The 2013 Council had asked that ACEP reconsider its current “Clinical Policy: Use of Intravenous tPA for the Management of Acute Ischemic Stroke in the Emergency Department,” which had been developed with the AAN and published in February 2013.

After an open 60-day comment period in early 2014 and a subcommittee review of the comments and literature findings, the Clinical Policies Committee recommended to pursue an independent policy, which will include updated evidence and grading criteria. The Board unanimously approved this recommendation.

Once the draft is developed, it will be available for members to review and comment for 60 days prior to the Committee’s presentation to the Board. An estimated timeline was not available.

Additionally, the Board confirmed its commitment to the clinical policy development process and agreed to add three methodologists to the committee, additional meetings, and another staff person to ensure a robust review process.

Tasty Morsels of EM 040 HSV in Kiddies

[Featured Image: Ben Tillman, Wikimedia Commons]

Another review from the EB Medicine series of publications. Remember this comes free with EMRA membership if you’re a trainee. Along with EM:RAP, Emergency Medical Abstracts and lots of other good stuff. This time it’s Paeds:

Pediatric Herpes Simplex Virus Infections: An Evidence-Based Approach To Treatment. Paediatric Emergency Medicine Practice. 2013 Dec 24;:1–20.

Sorry it’s a bit longer than usual but I found a lot of important stuff in here, a lot of new to me.

  • CytoMegalo Virus, Varicella and Epstein Barr are all types of herpes virus
  • HSV can be transmitted even without visible lesions
  • HSV-11 tends to reside within the trigeminal ganglion, while HSV2 commonly resides in the sacral ganglia which makes sense with the clinical distribution of oral HSV-1 and genital HSV-2
  • Lifelong latency and periodic recurrences are hallmarks of HSV infections. As Mark Crislip might say, Herpes is for life not just for Christmas…
  • in herpes encephalitis 1/3 is primary, 2/3 are reactivation. Just because they don’t have a cold sore doesn’t mean it’s not HSV encephalitis
  • HSV-1 prevalence is 90% by old age
  • HSV encephalitis has 2 peaks: <20 and >50. Virtually all are HSV-1
  • most neonatal HSV (non-encephalitis) is HSV-2
  • peripartum HSV in 3 categories:
    1. disseminated (think signs of sepsis, respiratory collapse, liver failure, disseminated intravascular coagulopathy, and pneumonitis.)
    2. CNS disease (with or without lesions. think seizures, irritability, a bulging fontanel, and temperatures either high or low. Most of these will have skin lesions at some point)
    3. disease limited to skin eyes and mouth
  • mortality for untreated disseminated disease is 85% and even if treated it remains high
  • common differentials for the rash include
    • erythema toxicum or pustular melanosis
    • It is important to note that both of these present in the first few days after birth, unlike disseminated HSV which typically presents after at least 10 days or so. I remember seeing pustular melanosis as a paeds doc doing baby checks and being almost as freaked out as the parents were. Reassurance from the boss was all both of us needed.
  • in CNS HSV 5-10% of LPs can be normal initially. How on earth do you even make the diagnosis in these kids then?
  • they note that LFTs might be useful as they are typically quite abnormal in babies with disseminated disease. I’m not sure this is fit as a rule out but in the crashing infant with crappy LFTs it might prompt you to consider it in addition to the usual bacterial sepsis.
  • if you’re looking for CNS disease with imaging then the temporal lobes are where the money is and MRI is the test to see it. However you will sometimes see it on CT, and i’ve seen it missed on CT by those who sit in dark rooms for a living.
  • the first drug for this was something called vidarabine. When aciclovir came out they did a randomised trial between the two and found no difference. And aciclovir rules the day due to its apparent favourable side effect profile (ring a bell for amiodarone v lidocaine or verapmail v adenosine anyone?)
  • Kaposi-Juliusberg Varicelliform Eruption – you’ve all heard of that right? It’s important and potentially life threatening so get on it!
  • Some others
    • herpes gladiotorum – typically athletes getting HSV-1 through abraded skin
    • herpetic whitlow – the one on the finger that looks like a paronychia but isn’t

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