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In Case You Missed It: Week of July 25, 2014


“In Case You Missed It” is a weekly roundup of popularicymi healthcare headlines.

Ace your meetings with these tips! Some administrators feel their entire day is filled with nothing but meetings ... click here to continue reading.

Has Patient Satisfaction Gone Too Far? — The Case for Jerks in Healthcare. "Among healthcare leaders, there has been a call to arms of sorts, which has swelled over the last five or so years, to rid medicine of, well, jerks. >> continue reading on

Discovered by Dr. Howie Mell! "The availability of concentrated caffeine powders may mean that we will be seeing more cases of significant overdose. Here are some key take-home points from the discussion - See more here:

Discovered by Dr. Michael Lozano! Physician Leadership Development Hinges on Communication. Read the entire post on

Discovered by Dr. Michael Lozano! How to End Disruptive Behavior that Compromises Patient Safety. "When faced with disruptive behavior, managers at hospitals and other healthcare facilities often will brush it under the rug. They're reluctant to ..." continue at >>

VIDEO! Dr. Al Sacchetti, along with two surprise guests, tell you what to expect when he hosts Day 3:Session 1 of  Essentials of EM 2014 in November.

For more information about EEM 2014, visit their website


Join a facility that has been chosen as one of the 100 TOP HOSPITALS in the United States three years in a row with a new rate increase just announced! We're looking for an ED physician at McAllen Medical CenterLearn more and submit your CV here!


Meeting Planner: Schedule or ambush? Formal or Casual? Ideas for Becoming a Meeting Master


EmCare Director of Clinical Services

clinician hallway meeting Some administrators feel their entire day is filled with nothing but meetings. Physicians can feel this frustration as well and tend do not want to set established meeting times with administrators because of it. If you’re among those frustrated by “over-meeting,” you might want to consider encounters such as phone calls, hallway visits and pre-and post- meeting tags on meetings – these can be less formal and less intense than traditional meetings.

Advantages of “hallway” meetings:

  • Quick, easy and informal – they can set people at ease without anticipation of a “difficult” meeting
  • Allows for more conversations in a given day, since you can conceivably reach many more people and topics in a day. It’s “guerilla warfare,” much like an E.D. environment!
Disadvantages of “hallway” meetings:
  • Administrators might not be prepared for these encounters
  • They can be distractions to what the administrator was previously doing
  • The administrator might be distracted thinking about other projects
  • There is generally more power and meaning in an established, set, scheduled meeting with the administrator.

Advantages of an established meeting with preset agenda:

  • The administrator’s calendar has your name and topic on it, allowing for all involved to be prepared for the discussion clinical meeting
  • You are probably more likely to have the administrator’s full, undivided attention 
  • The administrator will likely be more prepared 
  • You are sending a message that you value the administrator’s time – this can be very important! 
  • You are entering into their comfort zone which may allow them to make better decisions 
  • There is probably more organization to the meeting (especially with a preset agenda). This can better demonstrate your organization skills and professionalism. 
  • It can be easier to take notes. (Watch administrators during meetings...they generally take notes, which is more difficult to do with hallway conversations or phone calls.)

Keys to success of traditional meetings:

  • First, arrive on time. Administrators usually don’t like to wait. Theygenerally also know the value of their medical staff’s time as well and will do everything in their power to show up to your meeting on time themselves.
  • The attention span of an administrator can be extremely short. Keep this in mind when determining the length of the meeting, developing the agenda and managing the agenda. 
  • Know your agenda items: prepare in advance and don’t come in five or ten minutes prior to prepare.
  • Have supporting documents and make copies for the administrator. Take notes on key questions and comments from the administrator and follow up on these items
  • Manage the meeting to end on time. If you are able to wrap up even five minutes early, you could make the administrator’s day! If you find the meeting is going to run over, wrap it up anyway with a comment like “We are running out of time and I want to value your schedule and I would like to continue this discussion prior to our next meeting. Would you like to make another appointment?” You could be met with a response such as, “No, let’s continue the conversation” or “Yes, let’s set up another time.” The administrator may not express immediate gratitude, but may have a sense of respect for your professionalism.

Once this type of meeting takes place on a regular basis, the hallway type meetings become more effective than before.

About Ken Stackhouse:

Ken StackhouseWith more than 30 years of healthcare experience, Ken Stackhouse has been a Divisional Director of Clinical Services (DDCS) for EmCare since 2007 and currently practices as an emergency department (E.D.) nurse practitioner. Prior to joining EmCare, Ken worked as Director of Patient Care and Emergency Services at Corpus Christi Medical Center in Texas and Director of Emergency Services and EMS at Baylor Regional Medical Center in Grapevine, Tex. He has also held such titles as Director of Day Surgery/Endoscopy, Trauma Coordinator, Staff Registered Nurse (R.N.) and Firefighter/Paramedic.

Survival >80 Percent After Valve-in-Valve Implantation

Finding among patients with degenerated aortic valves; worse survival for stenosis as mode of failure

FRIDAY, July 11, 2014 (HealthDay News) -- For patients with failed surgical bioprosthetic valves, one-year survival after transcatheter valve-in-valve implantation is 83.2 percent, according to a study published in the July 9 issue of the Journal of the American Medical Association.

Danny Dvir, M.D., from St. Paul's Hospital in Vancouver, Canada, and colleagues examined the survival of patients after transcatheter valve-in-valve implantation inside failed surgical bioprosthetic valves. Data were obtained from a multinational valve-in-valve registry that included 459 patients (mean age, 77.6 years) with degenerated bioprosthetic valves undergoing valve-in-valve implantation at 55 centers.

The models of bioprosthesis failure included stenosis (39.4 percent), regurgitation (30.3 percent), and combined (30.3 percent). The researchers found that 7.6 percent of patients died within one month following valve-in-valve implantation; 1.7 percent had major stroke; and 92.6 percent of surviving patients had good functional status (New York Heart Association class I/II). There was an 83.2 percent overall one-year Kaplan-Meier survival rate. One-year survival was worse for patients in the stenosis group (76.6 percent) versus the regurgitation group (91.2 percent) and the combined group (83.9 percent) (P = 0.01). One-year survival was worse for patients with small valves (74.8 percent) versus intermediate-sized valves (81.8 percent) and large valves (93.3 percent) (P = 0.001). Having small surgical bioprosthesis (≤21 mm) and baseline stenosis (versus regurgitation) were associated with mortality within one year (hazard ratios, 2.04 and 3.07, respectively).

"In this registry of patients who underwent transcatheter valve-in-valve implantation for degenerated bioprosthetic aortic valves, overall one-year survival was 83.2 percent," the authors write.

Several authors disclosed financial ties to the medical device and biotechnology industries.

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Stroke Incidence, Mortality Down From 1987 to 2011

Prospective cohort study in four U.S. communities showed decrease for blacks and whites

TUESDAY, July 15, 2014 (HealthDay News) -- From 1987 to 2011 there was a decrease in stroke incidence and mortality rates in four U.S. communities, according to a study published in the July 16 issue of the Journal of the American Medical Association.

Silvia Koton, Ph.D., from Tel Aviv University in Israel, and colleagues examined trends in stroke incidence and subsequent mortality in the Atherosclerosis Risk in Communities cohort from 1987 to 2011. The cohort study involved 14,357 participants free of stroke at baseline from four different U.S. communities.

The researchers found that 1,051 participants (7 percent) had incident stroke, including 929 with incident ischemic stroke and 140 with incident hemorrhagic stroke. Over time, stroke incidence decreased in white and black participants (age-adjusted incidence rate ratio per 10-year period, 0.76). The decrease was evident in participants aged 65 years and older (age-adjusted incidence rate ratio, 0.69), but not in those younger than 65 years (age-adjusted incidence rate ratio, 0.97). There was a similar decrease in incidence by sex. Fifty-eight percent of participants with incident stroke died through 2011. Over time there was a decrease in mortality after stroke (hazard ratio, 0.80), with the decrease mainly due to a decrease at younger than age 65 years (hazard ratio, 0.65); the decrease was similar across race and sex.

"In a multicenter cohort of black and white adults in U.S. communities, stroke incidence and mortality rates decreased from 1987 to 2011," the authors write.

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Smoking Has Negative Impact on Success of ACL Reconstruction

Negative effect on subjective and objective outcomes of anterior cruciate ligament reconstruction

THURSDAY, July 10, 2014 (HealthDay News) -- Cigarette smoking is associated with a negative impact on anterior cruciate ligament (ACL) reconstruction outcomes, according to a study published in the June 18 issue of The Journal of Bone & Joint Surgery.

Sung-Jae Kim, M.D., Ph.D., from the Yonsei University College of Medicine in South Korea, and colleagues conducted a retrospective review of 251 patients who underwent unilateral ACL reconstruction with use of bone-patellar tendon-bone autograft from January 2002 to August 2009. Preoperative values and 24-month postoperative findings were compared for nonsmokers, current smokers, and former smokers.

The researchers found that the three groups differed significantly in terms of postoperative mean side-to-side anterior knee translation (P = 0.003), mean Lysholm score (P < 0.001), and mean International Knee Documentation Committee (IKDC) subjective score (P < 0.001); there was no minimal clinically important difference seen in the difference in IKDC subjective score. Pack-years of exposure correlated with postoperative anterior translation (P = 0.015) and IKDC objective grade (odds ratio, 1.083; P = 0.002) in a dose-dependent manner. There was a significant difference for light, moderate, and heavy smokers in anterior translation (P = 0.038) and in the proportion of cases by IKDC objective grade (P = 0.013).

"Cigarette smoking appeared to have a negative effect on subjective and objective outcomes of ACL reconstruction, and heavy smokers showed greater knee instability," the authors write.

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Ecstasy Use May Lead to Posterior Spinal Artery Aneurysm

Case report describes PSA aneurysm in teen with neck stiffness, headaches after 'Ecstasy' use

MONDAY, July 7, 2014 (HealthDay News) -- Use of 3,4-methylenedioxymethamphetamine, "Ecstasy," can trigger intracranial hemorrhage, subarachnoid hemorrhage (SAH), and possibly de novo aneurysm formation and rupture, according to a case report published online July 3 in BMJ Case Reports.

Jeremiah Johnson, M.D., from the University of Miami Miller School of Medicine, and colleagues describe the case of a teenager presenting with neck stiffness, headaches, and nausea after ingesting Ecstasy.

The researchers note that a brain computed tomography (CT) was negative for SAH, but cerebral vasculitis was suggested by CT angiogram. SAH was indicated on a lumbar puncture, but a cerebral angiogram was negative. Abnormalities on the dorsal surface of the cervical spinal cord were identified on a spinal magnetic resonance angiogram, and a subsequent spinal angiogram demonstrated a left posterior spinal artery (PSA) 2 mm fusiform aneurysm. The aneurysmal portion of the PSA was excised during surgery and without postoperative neurological sequelae.

"'Ecstasy' can lead to neurovascular inflammation, intracranial hemorrhage, SAH and potentially even de novo aneurysm formation and subsequent rupture," the authors write.

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Article Address Ethical, Legal Issues of Sports Concussion

Report explores ethical concerns for docs during evaluation, management of concussed athletes

WEDNESDAY, July 9, 2014 (HealthDay News) -- The ethical and legal issues surrounding evaluation and management of patients with sports-related concussions are addressed in a position paper published online July 9 in Neurology.

Matthew P. Kirschen, M.D., Ph.D., from the University of Pennsylvania in Philadelphia, and colleagues examined the ethical and legal issues for physicians during treatment of athletes with sports-related concussions, and offered guidance for physicians.

The researchers reviewed and compared elements of sports-related concussion laws, including education, removal from play, and clearance for return to play. They also suggested ways for physicians to overcome the challenges presented by privacy laws in relation to provision of care for concussed athletes. Ethical considerations relating to the evaluation and management of concussed athletes were addressed via a framework that included considerations such as professionalism, informed decision-making, patient autonomy, and conflicts of interest.

"Physicians caring for concussed athletes have an ethical obligation to ensure that their primary responsibility is to safeguard the current and future physical and mental health of their patients," the authors write. "Including concussion evaluation and management training in neurology residency programs, as well as developing a national concussion registry, will benefit patients by the development of policies and clinical guidelines that optimize prevention and treatment of concussive head injury."

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In Case You Missed It: Week of July 18, 2014


“In Case You Missed It” is a weekly roundup of popularicymi healthcare headlines.

Famous Face Praises Quality Care He Received while Filming Movie in Arizona. This actor credits care he received at Tucson Medical Center for his speedy recovery from health scare. Watch the video here: 

EmCare-affiliated doc, Dr. Howie Mell, shares his thoughts on the new crop of freestanding ERs in this New York Times article:

Baylor Scott & White made the list of Best U.S. Hospitals by U.S. News & World Report. Read this article to learn what that means for patient care: 

The latest updates to the "Two Midnight Rule" Explained. Click here to learn about new changes: 

eventsAre you attending the 22nd Annual Health Forum and American Hospital Association Leadership Summit? Stop by booth 203 to meet the EmCare team!

Back-alleys? Craigslist? This doctor reveals all of the illegal ways her patients have admitted to getting their prescriptions. Read the article on Have you ever heard of any unique measures patients take to get prescription drugs? Tell us in the comments!


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Famous Face Praises Tucson Medical Center for Providing Quality Care during a Health Scare!


Actor Thomas Haden Church well-known for his role in the popular 90’s sitcom, Wings, recently praised the team at Tucson Medical Center, for the role they played in his recovery from pneumonia. Church contracted pneumonia from propane exposure during a film shoot. The Tucson team “really pulled me out of a bad situation,” Church said.

Tucson Medical Center is also the facility that boasts the winner of EmCare’s 2014 Commitment to Care Award for Emergency Medicine, Dr. Richard Rosenthal. You Learn more about what makes  Dr. Rosenthal and the Tucson Medical Center so special, here.

Congratulations Tucson Medical Center for another instance of quality care!

Watch the clip below to see Church give kudos to the Tucson Medical Center team!


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Coyle’s Conundrums: Sepsis Early Detection is the Best Direction


By Dr. John Coyle, EVP, EmCare Physician Services

Hippocrates claimed that sepsis was the process by which flesh rots, swamps generate foulsepsis airs, and wounds fester.1 In an early study of sepsis it was postulated that the systemic pathogen spread was the primary cause. Even with advancement of antibiotic therapy, that concept did not fully explain the pathophysiology behind the morbidity and mortality rates of the disease process.

The term “sepsis” was more formally defined in 1992 by an international consensus panel as a systemic inflammatory response to infection (systemic inflammatory response syndrome, or SIRS), noting also that septicemia (commonly thought of as the presence of “positive blood cultures”) was neither a necessary condition nor a useful term.2 Patients could be minimally ill with “positive blood cultures” or in the ICU in shock without “positive blood cultures”.  Speaking of septic shock, this is defined as severe sepsis complicated by either hypotension that is refractory to resuscitation or hyperlactemia (lactate level > 4).3 Since signs of hypotension and tachycardia are seen in other presentations they should be considered a contributing sign rather than defining signs.

The number of cases of sepsis in the United States exceeds 750,000 per year with pneumonia being the most common cause, followed by intra-abdominal and urinary tract infections.4  The infectious process, if not treated, can lead to hypoperfusion  followed by a cascade of responses by multiple organ systems. Hypoperfusion is manifested by oliguria, hypoxemia, altered mental status and elevated serum lactate levels. The final stages of sepsis include end organ damage followed by end organ failure and death.

Early manifestations of the body’s response to an infectious agent’s systemic spread can be nonspecific and include fever, lethargy, fatigue, chills, nausea and vomiting.  These signs and symptoms may be subtle, especially in the very young and older population. Since these patients at the extremes of age (the young with immature immune response, and the elderly with diminished immune response due to age and disease) are more vulnerable to systemic manifestations, a higher index of suspicion for early sepsis is prudent in the differential diagnosis.

Fever, tachycardia, tachypnea, hypotension and leukocytosis with bandemia, are the criteria and hallmarks for SIRS. The physical exam must be thorough and include searching for any potential sources of infection. Those would include the 3 W's (wind, water and wound): pneumonia, urinary tract infection and wound infection. Additional physical signs such as a cardiac friction rub or murmur (endocarditis), abdominal findings consistent with acute abdomen or pelvic inflammatory disease, and unexplained pain (osteomyelitis and necrotizing fasciitis) should also be considered in the initial physical assessment.

According to the latest evidence and information on best practices, initial workup, at the discretion of the treating physician, may include CBC, chemistry including lactate and liver function tests, coagulation studies, and cultures of blood and any potential sources or sites of infection.  Various studies have shown that less than 33% of patients with sepsis have “positive blood cultures.”5  Chest radiograph, EKG, appropriate CT scans, ultrasound, joint aspirations, and lumbar puncture may also be considered in the search for sources of infection.  

Treatment modalities include support of ABC's with supplemental oxygen and fluid resuscitation, which may be vigorous, particularly in the presence of hypotension, which if persistent may lead to or worsen hypoperfusion of critical organ systems and at the cellular level.6  Fluid resuscitation is a cornerstone of therapy and should be aggressive with isotonic crystalloid.  Additional adjunctive therapy should be considered if fluids alone cannot adequately and consistently maintain mean arterial pressure (MAP) between 65 and 70. Adjunctive pressor agents such as dopamine, dobutamine, or norepinephrine may be considered. Broad-spectrum antibiotics, based on suspected sources of infection, should be administered early in the emergency department after appropriate cultures are obtained, but not delayed for culture procurement if the patient is severely ill. If an internal infectious process amenable to surgical intervention is suspected, urgent surgical consultation should be sought. Debridement of external sources with appropriate sterile techniques should include removal of any foreign bodies.

In summary, as is the case with most diseases, early detection and treatment is the cornerstone to improving patient outcomes. A higher index of suspicion for early sepsis must be employed especially for those on either end of the age spectrum. There is no one specific sign of early sepsis; however, common findings of fever, tachycardia, tachypnea and hypotension, if not addressed, can lead to development and/or worsening of SIRS. If undiagnosed or inadequately treated, the inflammatory cascade will likely continue resulting in end organ damage and possibly organ failure and death. Aggressive fluid resuscitation, oxygenation and ventilation, the use of broad-spectrum antibiotics, and continuous monitoring (invasive if indicated in an ICU setting) will help mitigate further extension and help improve outcomes.


1 Manjong. The Acient riddle of sigma eta psi iota (sepsis). J Infect Dis 1991;163:937-945

2 Bone RC, Sibbald WJ, Sprung CL. The ACCP-SCCM Consensus Conference on sepsis and organ failure. Chest 1992; 101: 1481-1483

3 Derek C. Angus, M.D., M.P.H. and Tom Van der Poll, M.D., PhD. N Engl J Med 2013; 369: 840-851 2013 Aug 29

4 Lagu T, Rothberg MB, Shieh MS, Pekow PS, Steingrub JS, Lindenauer PK. Hospitalization, costs, and outcomes of severs sepsis in the United States 2003 to 2007. Crit Care Med 2012; 40: : 754-756{Erratum, Crit Care Med 2012;40:2932

5 Andre Kalil, M.D., M.P.H.; Chief Editor:  Michael R. Pinsky M.D., CM, Dr hc, FCCP, MCCM , Medscape 2014 Mar 31

6 Asfar P. Meziani F. Hamel JF, etal; SEPSISPAM investigators. High versus low blood - pressure target in patients with septic shock N Engl J Med. 2014; 370: 1583-1593 April 24, 2014



John CoyleDr. John Coyle is the Executive Vice President of EmCare Physician Services. Dr. Coyle is a member of the American Osteopathic Association, the American College of Osteopathic Emergency Physicians, the Florida Osteopathic Medical Association, the American College of Emergency Physicians and the American Heart Association.  He is certified in Advanced Trauma Life Support and serves as an instructor for Advanced Cardiac Life Support. In addition to his commitment to patient care, Dr. Coyle has dedicated much of his career to mentoring and developing physician leaders and supporting medically underserved areas.


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