Download May 2012 - California ACEP

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MAY 2012
a forum for emergency physicians in california
What is the
Fair Market Value
of an Emergency Physician’s $ervices
Page 9
TABLE OF CONTENTS |
4
4
9
10
President’s Message
9 What is the Fair Market Value of an Emergency Physician’s Services?
10ADVOCACY UPDATE
Walking Softly, Carrying a Big Stick
15SCIENTIFIC ASSEMBLY
Things to do in Monterey
16 Tattoos and Piercings:
A Review for the Emergency Physician
21 Career Opportunities
12ANNOUNCEMENTS
back cover
Upcoming Meetings & Deadlines
California ACEP
Board of Directors &
Lifeline Editors Roster
2011-12 Board of Directors
Peter Sokolove, MD, FACEP, President
Andrew Fenton, MD, FACEP, President-Elect
Tom Sugarman, MD, FACEP, Vice President
Paul Christensen, MD, FACEP, Treasurer
Michael Osmundson, MD, FACEP, Secretary
Andrea Brault, MD, FACEP, Immediate Past President
Yasmina Boyd, DO
Mathew Foley, MD, FACEP
Marc Futernick, MD, FACEP
Gary Gechlik, MD, FACEP
Alfred Joshua, MD, CAL/EMRA Representative
Cameron McClure, MD
Aimee Moulin, MD, FACEP
Leslie Mukau, MD, FACEP
Mark Notash, MD
Bing Pao, MD, FACEP
Chi Perlroth, MD
Larry Stock, MD, FACEP, At-Large
Andrea Wagner, MD, FACEP
Advocacy Fellowship Program
Mary Bing, MD, Advocacy Fellow
Mathew Foley, MD, FACEP, Advocacy Fellowship Director
Lifeline Medical Editors
Mathew Foley, MD, FACEP, Medical Co-Editor
Richard Obler, MD, FACEP, Medical Co-Editor
Lifeline Staff Editors
Elena Lopez-Gusman, Executive Director
Ryan P. Adame, MPA, Deputy Executive Director
Lucia Romo, Education Coordinator
Callie Hanft, Program Associate
15
WELCOME to new members!
Ranti Bolaji, MD
Carolyn Gates
Vikant Gulati, MD
Jeff D Rodgerson, MD
100% GROUPS
Central Coast Emergency Physicians
Emergency Medicine Specialists of
Orange County
Newport Emergency Medical Group, Inc. at
Hoag Hospital
Pacific Emergency Providers, APC
Front Line Emergency Care Specialists
Tri-City Emergency Medical Group
Loma Linda Emergency Physicians
University of California Irvine Medical Center
Emergency Physicians
Napa Valley Emergency Medical Group
MAY 2012 | 3
PRESIDENT’S MESSAGE |
The California Emergency
Medicine Advocacy Fund (CEMAF)
It’s Your Fund and Your Future
Today’s practice environment is fraught with many challenges.
Unfortunately, these challenges are sometimes caused or
exacerbated by policies implemented by well-meaning,
but often misinformed policy-makers. Be they legislators,
appointed department and agency heads or their staff
members, their actions are far-reaching and impact our ability
to care for patients in ways they simply don’t understand. One
of the very reasons that ACEP and our Chapter exist is to apply
our collective expertise and energies to solving the pressing
policy issues that face emergency medicine. To effectively fight
and safeguard emergency medicine for ourselves, our future
colleagues, and our patients, we must navigate California’s
complex legislature, competing regulatory bodies, thousands
of boards and commissions, and tangled legal system. To be
successful, our Chapter must go above and beyond. Enter the
California Emergency Medicine Advocacy Fund (CEMAF).
You may have heard of CEMAF, and we hope that you’re a part of
one of the nearly thirty groups who contribute, but you may not
know exactly what is, what it funds, or why all emergency medicine
groups need to contribute. So, here it is: all you need to know about
investing in your future through CEMAF.
What is CEMAF?
Think of CEMAF as the ultimate, always-available on-call specialist.
Whether a policy issue presents in the legislative, legal, or regulatory
arena, CEMAF is there to provide a fix. Its sole purpose is to support
legislative, legal and regulatory advocacy on behalf of emergency
medicine in California through funds managed and administered by
California ACEP. CEMAF funds a comprehensive advocacy program
that, beyond the methods already listed, also includes public
relations and media outreach. Whether in the courtroom, legislative
committee meetings, Department of Managed Health Care hearings,
or in the press, CEMAF enables emergency medicine advocacy to
fight effectively and forcefully in any arena. The professional advocacy
services are provided by California ACEP’s full-time advocacy staff,
contract lobbyists, public relations firm, retained attorneys, and
elected representatives of California ACEP.
4 | LIFELINE a forum for emergency physicians in california
How is CEMAF funded?
Contributing groups – which include an impressive number of
single-site groups, in addition to California’s largest groups – support
emergency medicine advocacy by pledging twenty cents ($0.20)
per emergency department visit. Publicly-available emergency
department data filed annually by all licensed hospitals with the
Office of Statewide Health Planning and Development (OSHPD) are
used to determine emergency department visits for contributing
groups. OSHPD data is public, easily accessible and verifiable, and
therefore protects proprietary information regarding group business
practices, in addition to providing a fundamental level of equity:
larger groups pay more, smaller groups pay less, but everyone pays
their share. CEMAF contributors make their investment in increased
advocacy as they see fit, paying annually, quarterly, monthly, or by
whatever method is most convenient.
What does CEMAF do? What has it done?
The simplest answer is that through CEMAF, California ACEP has
become the only physician specialty society that operates on the
same level as the state’s medical and hospital associations. Since
CEMAF’s inception, California ACEP has sponsored two statewide
ballot initiatives; doubled the Medi-Cal fee schedule for emergency
services; tripled the pot of funding for our state’s only-one-inthe-nation program that provides reimbursement for otherwise
uncompensated care (the Maddy EMS Fund, which was also created
through California ACEP-sponsored legislation in the 1980s); and
fought the HMO lobby and a hostile administration to a standstill
over the right of emergency medical groups to set and collect their
fees from non-contracted, risk-bearing organizations, to name a few.
In legislative advocacy, CEMAF monies pay for our contract lobbyist
and in-house legislative team, who review over 2000 pieces of
legislation and amendments introduced each year and lobby on
the hundred or so that most directly impact emergency medicine.
Additionally, we are able to sponsor an average of five pieces of
legislation each legislative session, including an ED overcrowding
solution and the Physicians Orders for Life-Sustaining Treatment
form, and have defeated numerous other bills, including: the balance
billing bans for six years (despite ultimately losing in the courts); the
extension of the balance billing ban beyond HMO products; and
in 2011 reversed a legislative action to eliminate the $100 million
Maddy EMS Fund.
Legal advocacy – CEMAF allows us to advocate on your behalf in
court. California ACEP participates in lawsuits as plaintiffs, files amicus
briefs in critical cases, and coordinates lawsuits by participating
“
...through CEMAF, California ACEP has become the only
“
physician specialty society that operates on the same
level as the state’s medical and hospital associations.
emergency physician groups against underpaying health plans. For
example, we sued the Department of Managed Health Care to stop
their balance billing regulations (unsuccessfully) and the Health and
Human Services agency to stop their proposed provider rate cuts
(successfully).
Regulatory advocacy – California ACEP reviews pending state
agency regulations and files formal comments when they impact
emergency medicine. Occasionally CEMAF funds are used to hire
outside counsel to prepare those comments, most recently when we
opposed CAPG’s petition to have the criteria to determine usual and
customary payments changed to also include contract and public
payer rates. We monitor board, commission, department and agency
hearings and testify on issues important to emergency medicine,
including recently on the delegated model and the financial solvency
of risk-bearing organizations.
Public Relations – CEMAF funds pay for our contract public relations
consultant who directs our media effort including writing letters
to the editor, holding press conferences, and generating media
supporting our advocacy agenda and on behalf of emergency
medicine in general. Since hiring our PR consultant, we have aired
CNN and American Airlines programming about the myths and facts
of emergency care.
By Peter Sokolove, MD, FACEP
health policies they enact converge and impact patient care. We
have toured the leaders of the Senate and Assembly, Chairs of the
Health Committees and Appropriations committees and many other
influential legislators. We have had many proud moments hearing a
legislator argue in committee or on the floor of one of the chambers
on behalf of legislation starting with the phrase “when I toured my
local emergency department last month…”
Advocacy Fellowship Program – CEMAF also helps fund the
training of the next generation of physician advocates through our
fellowship program. Each year two to three physicians complete a
year-long fellowship program providing research and committee
hearing testimony while in return learning how health policy is
made from staff and contract lobbyists. Each year fellows have gone
on to greater leadership roles in the Chapter and in the community
including serving on the California ACEP board of directors.
Does CEMAF support political advocacy?
CEMAF does not engage directly in political advocacy (e.g.,
contributing to candidates for elected office). However, a portion of
each group’s contributions to CEMAF is transferred to the Emergency
Medicine Political Action Committee (EMPAC), a separate legal entity,
ED Tour Program – Each year your advocacy team partners with
emergency physicians to lead tours of 15-20 key legislators through
emergency departments in their legislative districts. These tours
are a unique opportunity to spend an hour or two of undivided
time with legislators showing them a day
in the life of an emergency physician
and to witness how the all the varied
MAY 2012 | 5
PRESIDENT’S MESSAGE |
which does engage in direct political advocacy. EMPAC is proud to
boast the largest specialty PAC in California. At a half a million dollars,
it is the largest specialty PAC in California and enjoyed a 90% success
rate with candidates we supported in the last election cycle.
Who determines how CEMAF funds are spent? Is there
transparency?
The budget for CEMAF is overseen by the California ACEP board of
directors and is reviewed and discussed at every board meeting. All
board meetings are open to all California ACEP members, who are
very welcome to attend. The Government Affairs Committee (GAC)
recommends legislative priorities and positions on specific bills
to the to the board of directors, which votes on all bill positions in
open session. Interested California ACEP members can join GAC and
participate on conference calls. Finally, groups that contribute to
CEMAF are invited to the annual CEMAF meeting held in conjunction
with the Scientific Assembly (in Monterey this year).
What are the tax implications for my group?
Based upon the advice of California ACEP’s accountant, the amount
of the contribution retained within CEMAF (currently 80%), may be
tax-deductible by the emergency medicine group as a business
expense (subject to the consultation and advice of each group’s own
tax advisor). The portion of the contribution sent to EMPAC (currently
20%) is a political contribution and, therefore, pursuant to current
law, is not tax-deductible.
I already give to other “causes”, why should I give to
CEMAF?
It’s important to remember that CEMAF isn’t just another cause, it’s
OUR cause. I understand well the financial pressures emergency
physicians are facing and how everyone’s paycheck has gotten
smaller in recent years. But this is precisely why we all need to support
CEMAF. CEMAF is not a charity, it’s a wise business investment as
emergency medicine’s last line of defense against further cuts by
public and private payers. In the last year alone, OUR cause, OUR CEMAF funds were responsible
for successfully stopping a $100 million elimination of the Maddy
EMS Fund as well as suing to block Medi-Cal physician rate cuts. The
successful reversal of the Maddy Fund elimination is a tremendous
financial victory for emergency physicians. Because of OUR cause, the emergency physicians at one Los Angelesarea hospital received an estimated $500,000 last year for treating
the uninsured. These funds were directly attributable to the efforts
of the Chapter and were reimbursed because of CEMAF. Without
CEMAF, those funds would have been eliminated last year, resulting
in even lower reimbursement. I’m a salaried emergency physician, how does CEMAF
affect me?
Just because you are paid a salary doesn’t make you immune to the
will and actions of California’s legislators and regulators. Through
CEMAF funding, the Chapter addresses many important issues
affecting your daily practice, such as ED crowding, psychiatric patient
transfers, and scope of practice issues. Such issues are critical to your
6 | LIFELINE a forum for emergency physicians in california
practice environment and the integrity of our specialty. California
ACEP is currently working on a regulatory/administrative action
involving procedural sedation and the administration of propofol,
where once again our practice autonomy and ability to most
effectively care for patients are under threat. Academic emergency
physicians will appreciate that California ACEP successfully sponsored
legislation (SB 1188 in 2001 and SB 1187 in 2010) permitting use in
California of the federal process for exception to informed consent
for research in emergency care settings. Without that law, many
important emergency medicine research studies would not have
been possible, and patients would have been unable to benefit from
enrollment. These are just a few examples of the many issues that
affect ALL emergency physicians, regardless of their group affiliation
or reimbursement structure.
In addition, it is naive to believe that compensation of salaried
physicians is unrelated to compensation of those who are not
salaried. How do you think salaries are determined? Medical groups
that employ physicians perform annual compensation surveys of
reimbursement in the community to guide their salary structure.
If non-salaried emergency physicians are hit with a 25% cut in
reimbursement, do you really believe that salaried physicians will
be insulated from this? A number of years ago, California ACEP Past
President Paul Kivela wrote a great Lifeline article about “Freeloaders”.
When I was a residency program director, I gave that article to all of
my incoming interns at orientation, because it emphasized that we
all need to be members of California ACEP and cannot freeload off of
the contributions of others. Similarly, what we accomplish through
CEMAF affects all emergency physicians, and this is why we all should
contribute.
Why don’t our California ACEP dues cover this?
California ACEP dues are only $295 per member – less than other
large Chapters, including: Michigan, Illinois, Florida, Ohio, Texas,
and even West Virginia – and cover member benefits such as our
Scientific Assembly, Emergency Medicine in Yosemite, Lifeline, cosponsorship of the Western Journal of Emergency Medicine and some
lobbying. However, as the attacks on emergency medicine have
increased and our opponents have grown in strength, we too have
needed to grow to be able to mount a defense. CEMAF has enabled
us to hire an additional lobbyist, hire a PR consultant, increase the size
of our PAC, expand our ED tours program, and fund lawsuits against
the state blocking Medi-Cal rate cuts. CEMAF is truly the muscle of
our advocacy program.
It’s your future, it’s your fund
The bottom line is that our specialty, our practices, and ultimately our
patients depend upon our broad involvement and support. It is YOUR
future that is at stake, and one organization and one fund have been
more successful than any other in California at protecting, promoting
and advancing emergency medicine: California ACEP and CEMAF. If
your group does not contribute to CEMAF, don’t sit on the sidelines
any longer, please join your colleagues and contribute today.
For more information on contributing to CEMAF, contact our office at
(916) 325-5455 or [email protected]. n
Camaraderie.
It starts
with knowing
the people you work
with have your back.
It grows stronger
when you see spirits
lifted and performance
acknowledged
and rewarded.
It arrives when you
find you’re looking
forward to seeing
the people you work
with everyday in the ED
– around a campfire.
Join us.
Call Ann Benson at 800-828-0898 or visit emp.com. Opportunities in 60 locations across the USA. AZ, CA, CT, HI, IL, MI, NV, NY, NC, OH, OK, PA, WV
CEMAF
Donors
The California Emergency Medicine Advocacy Fund
(CEMAF) has transformed California ACEP’s advocacy
efforts from primarily legislative to robust efforts in
the legislative, regulatory, legal, and through the
Emergency Medical Political Action Committee, political arenas. Few, if any, organization of our size can boast of
an advocacy program like California ACEP’s; a program that
has helped block Medi-Cal provider rate cuts, stop the $100
million raid on the Maddy EMS Fund, and fight for ED overcrowding solutions – and that’s just the last year! The efforts
could not be sustained without the generous support from
the groups listed below, some of whom have donated as
much as $0.25 per chart to ensure that California ACEP can
fight for emergency medicine. Thank you to our 2011-12
contributors (in alphabetical order):
• Acute Care Medical Group of Orange County
• Alvarado Emergency Medical Associates
• Antelope Valley Emergency Medical Associates
• Beach Emergency Medical Associates
• Centinela Freeman Emergency Medical Associates
• CEP America
• Chino Emergency Medical Associates
• Culver City Emergency Medical Group
• EMP
• EMS Management
• Montclair Emergency Medical Associates
• Napa Valley Emergency Medical Group
• Orange County Medical Associates
• Pacifica Emergency Medical Associates
• Riverside Emergency Physicians
• San Dimas Emergency Medical Associates
• San Francisco Medical Associates, Inc.
• Santa Cruz Emergency Physicians
• Sherman Oaks Emergency Medical Associates
• South Coast Emergency Medical Group, Inc.
• Tarzana Emergency Medical Associates
• Team Health
• Tri-City Emergency Medical Group
• Valley Emergency Medical Associates
• Valley Presbyterian Medical Associates
• West Hills Emergency Medical Associates
(Southern California)
JOB OPPORTUNITIES
•
Excellent Opportunities for Emergency
Physicians
• Very Competitive Compensation
• Pleasant Work Environment
• Hospitals include Arcadia Methodist &
Glendale Memorial (Top heart programs).
• Available practice settings in the Greater
Los Angeles area.
Contact Debbie Corn for more information.
(909) 634-3172 or fax CV to (909) 629-8755
Email: [email protected]
PaAC
Board EP
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PaACE
P Boa
August 9-12, 2012
Sept.10-15
ABEM
ConCertExam
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Board Review
rd Rev
iew
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A 7-1
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If you are taking the Board Certification Exam for the first time or taking
it for recertification, PaACEP’s Board Review will meet your needs
• Afocused3½daycourse—shorterthanmostreviewcoursesbutprovidesthe
informationneededtopasstheexam!
• Nationallyrecognizedfaculty,allrecertifiedwithinthelastfouryears
• Peerrecommended
• Freepracticebookwith1,300questions*—Mirrorstheformatoftheexamfor
extrapreparation(*newly revised for 2012)
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More information available online at www.paacep.org. Contact
Nancy Miller toll-free at (877) 373-6272, or email [email protected].
TheAmericanCollegeofEmergencyPhysiciansdesignatesthisliveactivityfora
maximumof52.75AMA PRA Category 1 Credits™.Physiciansshouldclaimonly
thecreditcommensuratewiththeextentoftheirparticipationintheactivity.
ApprovedbytheAmericanCollegeofEmergencyPhysiciansforamaximumof
52.75hour(s)ofACEPCategoryIcredit.
NotaffiliatedwithABEMorAOBEM.
Westin BWI Hotel, Baltimore, MD
What is the
?
Fair Market Value
of an Emergency Physician’s $ervices
By Myles Riner, MD, FACEP
Trying to define the market value of someone’s professional services is difficult when those services are typically paid at vastly different
rates, depending on the payer, especially when the party paying is usually not the direct recipient of the service. So when an emergency
physician provides clinical services to a patient, how are those services valued by different payers, and what does that say about the
reasonable market value of those services?
F
or example, let’s say that you come to the emergency
department with an acute asthma attack: you can’t breath
well, and your inhaler hasn’t helped to break the attack. A
pretty straight-forward case, really: your ER doc does a history
and physical exam, orders up some oxygen and a few respiratory
therapy treatments, some steroids, perhaps an IV to rehydrate you
and get access in case your condition worsens and you need IV meds,
and returns to re-evaluate you every 15 minuets to make sure the
treatments are working. Two hours later, you are able to go home
with a script for three days of Prednisone and a refill for your Ventolin
inhaler as the one you have is running low. You get instructions on
how to care for yourself at home, when to see your primary care
doctor, and what you should do if the wheezing comes on again
despite the treatment. Chances are, you will likely get a charge for
this service from the physician for 99284 level care for around $320,
give or take, if you live, let’s say, in central California.
If you had HMO coverage, but had to go to a closer out-of-network
ER, your HMO would pay the ER doc between $140 and $250.
If you didn’t have insurance, you would be expected to pay the full
charge. Unfortunately, many patients can’t afford to pay; or could
afford to pay but are just irresponsible, and don’t pay anything.
If the patient pays nothing, the emergency physician may be able
to recover about $45 from the EMS Fund, a tobacco settlement
funded program that pays on average about 15% of the emergency
physician’s fee.
So, what’s the real market value for an emergency physician’s services?
I would argue that it is the full amount that the emergency physician
charges, as long as these charges aren’t significantly higher than what
other emergency physicians in the same area charge, but then I just
paid a heating technician $175 for 10 minutes of maintenance on our
furnace. Others would argue differently, but their estimate would be
based on their particular agenda: protecting those living in poverty,
reducing costs for the employer, dealing with government budget
deficits, or making higher profits for the insurer. Unfortunately, none
of these advocates actually provides emergency care to anyone.
However, if you were uninsured with a family income at or below
350% of the federal poverty level; or you are insured and have
incurred high medical costs (greater than 10% of family income
over the prior 12 months) with a family income at or below 350%
of federal poverty, and you submitted a request for a discount; you
would (by virtue of California law) only have to pay 50% of median
billed charges of a nationally recognized database of physician
charges, probably around $150.
If you were covered by your County’s new Low Income Health
Program (a family of 4 making less than $41,000/year), the county
may pay the emergency physician about 30% of the Medicaid rate,
or a whopping $21.
If you had PPO coverage, the plan would pay between $175 and
$240, minus any co-insurance payment, and you would have to pay
the rest up to the $320 charge.
So, for a $320 emergency physician service, the emergency physician
might receive anywhere from the full $320 down to $21, and about
10% of the time – nothing. The average emergency physician in
California provides about $140,000 a year in unreimbursed care.
Of course, in order to provide these services, the emergency physician
has to spend $10 to pay for malpractice insurance, $30 for billing
services, and additional costs for other overhead amounting to a total
of about $55 for every ED patient treated (even if the payment is $0)
By the way, if you were suffering from a heart attack or serious injury,
and the emergency physician (and his team) actually saved your life
(it happens hundreds of times every day), the emergency physician’s
charge would be around $800 to (rarely) $2000. So, what’s the real
market value of YOUR life?
This article was also published on the blog:
The Fickle Finger www.ficklefinger.net/blog/ n
If you were covered by California’s Medi-Cal program, one of the
lowest paying Medicaid programs in the country: $68.
If you were covered by Medicare: the federal program would pay
about $125.
MAY 2012 | 9
Walking Softly,
Carrying a Big Stick
ADVOCACY UPDATE |
By Elena Lopez-Gusman, Callie Hanft & Ryan P. Adame
Priority Legislation 2012
When it comes to lobbying and politics, clichés abound. The legendary Assembly Speaker Jesse M. Unruh was veritable treasure trove of tried
and true quips like: “Money is the mother’s milk of politics”, said with respect to campaign contributions; and, with respect to lobbyists: “If
you can’t eat their food, drink their booze, screw their women and then vote against them, you have no business being up here”. “Big Daddy”,
as the former Speaker, State Treasurer, and would-be Governor (losing to Ronald Reagan in 1970) was known, was unapologetic about the
business of politics. While we here at California ACEP have no doubt experienced the side of politics the late Speaker spoke about, we prefer to
accomplish our business with considerably less bravado.
I
n that spirit, this month’s update focuses
on a less-hearlded, but no less important
side of the legislative process: killing bills.
Hopefully, you’re well-aware of our efforts
in the sponsorship of legislation – see
previous issues of Lifeline – but a less visible
mark of a lobbying operation’s effectiveness
is its ability to stop and/or alter (amend)
legislation which is deemed against our
interests, or which could be improved.
Below is a detailing of bills that the Chapter
helped amend and/or kill thanks to our
long-standing relationships, influence, and
political effectiveness in the Capitol.
AB 2394 (Nielsen) Emergency
Medical Services: Commission on
Emergency medical Services
California ACEP Position: Oppose
Unless Amended
AB 2394 would have altered the membership
of the Commission on Emergency Medical
Services, which was created by a 1980
law sponsored by California ACEP (SB
125 – Garamendi, Chapter 1260, Statutes
of 1980), by eliminating one of two seats
designated for board-certified emergency
physicians. One of those seats is specifically
designated for California ACEP, and has
been occupied for a number of years by
Chapter Past President Ramon Johnson.
The other emergency physician seat is one
appointed by the Speaker of the Assembly.
AB 2394 would have replaced the Speaker’s
emergency physician appointment with
a member designated by the California
Association of Air Medical Services
(CAAMS).
While we have a great appreciation
for the services provided by all of the
professions that compose the 18 member
Commission, California ACEP vigorously
opposed this change. However, wanting to
be constructive and solution-oriented, the
Chapter offered amendments which would
have allowed for the seat to be designated
for the CAAMS, provided that their designee
was a board-certified emergency physician.
While discussions about the amendment
were ongoing with CAAMS before the bill’s
scheduled hearing, Assembly Member
Nielsen decided to withdraw his bill from
the Committee. Due to legislative rules
and deadlines, the withdrawal of the bill
effectively killed it.
10 | LIFELINE a forum for emergency physicians in california
AB 1862 (Logue) Health FacilitiesFree Standing Emergency
Departments
California ACEP Position: Oppose
AB 1862 would have permitted the
creation of free-standing emergency
departments (FEDs), using existing hospital
licenses, in any community in California.
While California ACEP strongly supports
expanded access-to-primary care and other
necessary components of patient accessto-care, including community clinics, AB
1862 would have seriously jeopardized
the financial stability of the precariously
situated emergency care safety net, to
say nothing of the potentially disastrous
consequences for patient care. Upon
review by the advocacy team and the Board
of Directors, there was a strong sentiment
that the construction of FEDs would likely
lead to: confusion among patients as to the
range of services provided in an FED versus
an ED attached to a hospital; the potentially
negative health outcomes for patients
being transferred from an FED to a hospital
for a higher level of care, who wouldn’t
have necessarily required transfer had they
sought care in a traditional ED; as well as
the potential for patient cherry-picking
and/or seeking higher reimbursement from
patients in areas with higher concentrations
of commercially insured patients, with dire
financial consequences for remaining EDs.
Thus, California ACEP strongly opposed the
bill and lobbied the author and committee
members heavily to address our concerns.
Ultimately, due to the pressure put on the
committee members by the Chapter’s
efforts, Assembly Member Logue elected
not to have his bill heard in the Assembly
Health Committee, where, like AB 2394
it died due to legislative deadlines, and
without a hearing.
AB 2552 (Torres) Driving Under
the Influence Reporting
California ACEP Position: Oppose
AB 2552 would have required that
emergency physicians report to law
enforcement, any patients with injuries
sustained in what the physician suspected
was an alcohol- or drug-related vehicle
accident. While California ACEP supports
certain mandated-reporting requirements
– suspected child abuse, for instance –
the Chapter felt strongly that this type
of reporting would seriously damage
the physician-patient relationship by
potentially deterring or delaying patients
from seeking treatment out of fear of being
reported to law enforcement. The effect
would be detrimental to the patient’s health
outcomes, and would undermine the basic
trust between patient and provider, a trust
which should only be breached in the rarest
of instances.
The Chapter’s insistence on amendments
to remove the reporting requirement
were successful, and Assembly Member
Torres amended her bill in the Public Safety
Committee.
The effect of the Chapter’s efforts on all of
these bills is a strengthening of emergency
physicians’ stature and influence in the
Capitol, as well as the emergency care
safety net as a whole. Killing bills is not,
perhaps, as “sexy” as championing them,
but the policy effect is no less important.
Rest assured that your advocacy team
continues to monitor hundreds of bills and
amendments throughout the year and
will continue to act quickly, decisively and
effectively on your behalf.
For more information, or questions on
legislation, please contact us at advocacy@
californiaacep.org or by calling the California
ACEP office at (916) 325-5455. n
MAY 2012 | 11
ANNOUNCEMENTS |
2012 CAL/EMRA E-lection
2012 Chapter Awards Recipients
The Chapter will host the CAL/EMRA E-lection during the Chapter
Board E-lection, May 1-15, 2012. Residents will elect the CAL/
EMRA President and successor to the CAL/EMRA Representative
on the California ACEP Board of Directors. Voting will be online at
www.californiaacep.org.
Each year California ACEP recognizes members and non-members
alike who have made significant contributions to the Chapter,
emergency medicine, and/or to their communities. This year
the Chapter has the great privilege to recognize the following
individuals at the Awards Ceremony during the President’s Gala
on the evening of Friday, June 22, 2012 at the Scientific Assembly
in Monterey. Congratulations to:
For more information, please contact the Chapter office at
[email protected].
2012 Chapter Board E-lection
The Chapter Board E-lection will be held May 1-15, 2012. Voting
will be conducted online only, at www.californiaacep.org. Only
Active, Honorary and Life members, who were members as of
February 1, 2012, are eligible to participate pursuant to the
Chapter Bylaws. Voters will need an e-mail address and their ACEP
ID number to participate.
If you have any questions regarding the E-lection, to locate your ACEP
ID number, or your eligibility, please contact the Chapter office at
[email protected].
Bylaws Revisions
After a review by ACEP, one last round of revisions and approval
by the Board of Directors, the Chapter’s final revised Bylaws will
be distributed by e-mail vote to the membership May 16-31, 2012.
The revisions must be approved by no less than two-thirds (2/3) of
current Chapter members responding to the ballot.
If you have any questions regarding the Chapter Bylaws or the balloting
process, please contact the Chapter at [email protected].
Recipient
Award
Samuel H. Ko, MD, MBA
CAL/EMRA Award
Thomas J. Sugarman, MD,
FACEP
Chapter Service Award
(Physician)
Desiree Webb
Chapter Service Award (NonPhysician)
Jeffrey Tabas, MD, FACEP
Education Award
James V. Dunford, MD, FACEP
EMS Achievement Award
Alexis Leiser, MD
House of Medicine Award
Thomas J. Lee, MD
Humanitarian Award
Garen Wintemute, MD, MPH
Injury Prevention Award
David M. Strumpf, MD, FACEP
Key Contact Award
Anthony York
Media Award
Assembly Member Das
Williams
Senator Kenneth L. Maddy
Political Leadership Award
William K. Mallon, MD, FACEP
Walter T. Edwards Meritorious
Service Award
California ACEP
12 | LIFELINE a forum for emergency physicians in california
ANNOUNCEMENTS
The National Conference on Wilderness and Travel Medicine,
Squaw Valley*
August 22-26, 2012
Lake Tahoe, California
Info: (888) 995-3088
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Wilderness and Travel Medicine* (International)
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1. A
pril 23 – May 10, 2012
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River, California
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ENDURING MATERIALS - ONLINE CME
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Workshop*
June 21-23, 2012
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Monterey, California
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Yosemite Conference
January 16-19, 2013
Yosemite Lodge
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Patient Safety Risk Solutions* Enduring Materials - Webinar
Jointly sponsored by California ACEP and the American College of
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Info: www.psrisk.com
Advanced Wilderness & Expedition Provider (AWEP)*
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May 26 – June 3, 2012
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• The Dilemma of the Psychiatric Patient in the Emergency
Department
July 23 – 29, 2012
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• Treating Stroke in the ED; and the Standard of Care Is…
August 20 – 26, 2012
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26th Annual Wilderness Medicine, Big Sky*
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• August 2012, Risk Management Monthly/Emergency
Medicine
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Info: (310) 315-2828
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• SonoSim Ultrasound Training Solution
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MAY 2012 | 13
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Web: www.fastresponse.org
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Medical Center
Lyne Jones, Administrative Assistant
department of Emergency Medicine
11234 Anderson St., A108
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Phone: (909) 558-4344 x 0
Fax: (909) 558-0102
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Web: www.llu.edu
Medic Ambulance
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Web: www.medicambulance.net
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National College of Technical Instruction
Lawson E. Stuart, RN, CEN, EMT-P
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Phone: (916) 960-6284 x 105
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Oakland Fire Department
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47 Clay Street
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Phone: (510) 238-6957
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PHI Air Medical, California
Graham Pierce, Course Coordinator
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Riggs Ambulance Service
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Phone: (209) 725-7010
Fax: (209) 725-7044
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Web: www.riggsambulance.com
Mendocino Lake Community College
Patrick Magee, MA, EMT-P
1000 Hensley Creek Road
Ukiah, CA 95482
Phone: (707) 467-1047
Fax: (707) 467-1011
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Web: www.mendocino.edu
Santa Rosa Junior College
Public Safety Training Center
Bryan Smith, EMT-P, Course Coordinator
5743 Skylane Blvd.
Windsor, CA 95492
Phone: (707) 836-2907
Fax: (707) 836-2948
Email: [email protected]
Web: www.santarosa.edu
Napa Valley College
Cori Carlson, EMS Director
2277 Napa Highway
Napa CA 94558
Phone: (707) 256-4596
Email: [email protected]
Web: www.winecountrycpr.com
WestMed College
Brian Green, EMT-P
5300 Stevens Creek Blvd., Suite 200
San Jose, CA 95129-1000
Phone: (408) 977-0723
Email: [email protected]
Web: www.westmedcollege.com
Northern California Medical Education
Scott Rebello, Course Coordinator
6617 Madison Avenue, #12
Carmichael, CA 95608
Phone: (916) 724-0830
Email: [email protected]
Web: [email protected]
EMREF is a proud sponsor of
California ITLS courses
Please call 916.325.5455 or E-mail Lucia Romo: [email protected] for more information.
Things To Do in
| SCIENTIFIC ASSEMBLY
Monterey
After the lectures and labs - or even before - don’t miss the myriad things to
do in scenic Monterey. Below are some suggestions, but contact the Monterey County
Convention & Visitors Bureau at (877) MONTEREY or at www.seemonterey.com.
IC HOP
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A&UL 21-2 ncy liforn
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Cannery Row
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Fisherman’s Wharf
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• A ten minute bike ride from the Hyatt
Pebble Beach
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California ACEP’s Scientific Assembly &
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Hyatt Regency Monterey Hotel & Spa
Regional, State and Federal Parks
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Scenic Drives
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Historic Sites
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Special Events
• Seasonal festivals include: Monterey Jazz Festival, Carmel Bach
Festival, Monterey Auto Week and more!
• seemonterey.com/calendar n
MAY 2012 | 15
REVIEW
Tattoos and Piercings: A Review for the
Emergency Physician
Michael Urdang, MD*
Jennifer T. Mallek, MS†
William K. Mallon, MD, DTMH*
* University of Southern California, Department of Emergency Medicine,
Los Angeles, California
†
University of Southern California, Keck School of Medicine, Los Angeles,
California
Supervising Section Editor: Sean Henderson, MD
Submission history: Submitted March 28, 2011; Revision received April 21, 2011; Accepted April 22, 2011
Reprints available through open access at http://escholarship.org/uc/uciem_westjem
DOI: 10.5811/westjem.2011.4.2268
Tattoos and piercings are increasingly part of everyday life for large sections of the population, and
more emergency physicians are seeing these body modifications (BM) adorn their patients. In this
review we elucidate the most common forms of these BMs, we describe how they may affect both the
physical and psychological health of the patient undergoing treatment, and also try to educate around
any potential pitfalls in treating associated complications. [West J Emerg Med. 2011;12(4):393–398.]
INTRODUCTION
Tattoos and piercings (T&P) are ancient practices of body
modification. The word tattoo comes from Polynesia and was
first described by Captain Cook in 1769. The art form was
named for the tapping noise made by a tattoo needle on the
skin, which in the native tongue was tatau or tatu.1 Piercing,
including the ear lobe, is also an ancient process, defined as the
insertion of a needle to create a fistula for decorative
ornaments. First recorded in the Middle East more than 5
thousand years ago, the practice is mentioned in Genesis 24:22
when Abraham asks his older servant to find a wife for his son
Isaac. One of the gifts given to Rebecca, Isaac’s new wife, by
the servant was a golden earring. Since then, ear piercing has
become so well accepted that most scientific literature excludes
the ear lobe in the definition of body piercing.
Social acceptability of these practices varies widely from
culture to culture. Catholicism and Judaism have banned the
practice of tattooing.2 Esthetics, personal expression, religious
views, communication, and style are all motivations for
obtaining a tattoo or a piercing. Once relegated to the margins
of society (bikers, military, sailors), tattoos and piercings are
now common across all ages and both genders in what has been
described as an epidemic. For the emergency physician (EP),
tattoos and piercings have become important nonverbal clues
about the patient’s lifestyle and, furthermore, are increasingly
the cause of an emergency department visit.3,4
This review provides EPs with the tools to be able to assess
Volume XII, NO. 4 : November 2011
16 | LIFELINE a forum for emergency physicians in california
the lifestyle or social background of their patients, to be able to
understand the medical complications that may arise as a result
of body modification, and to have a deeper understanding of
the psychologic associations of tattooing and, when necessary,
the relevance of the body modification to the current chief
complaint.
EPIDEMIOLOGY
Within Western society there has been a shift from the
stereotype of the tattooed sailors, who used tattoos to
communicate their travel and services, the outsider biker of the
1960s (Hell’s angels), and the gang members of the 1980s to the
ornamental tattoo, which is now part of a collection of body
modifications among women as much as men. Recent surveys
completed in 2002 and again in 2006 have shown an increase in
prevalence in tattoos within the US population.5,6 In 2002, a
Harris poll showed a tattoo prevalence of 16%, whereas in 2006
a North American survey of 18 to 50 year olds found that 24%
had tattoos and 14% had body piercings (excluding the ear).
The surveys found that those who were tattooed were more
likely to be less well educated, to have a high recreational drug
use, and were less likely to show any religious affiliation.
Tattooing can be used to camouflage intravenous drug
abuse, where it involves the antecubital fossa, and has an
important place within generalized medical therapy. Its use is
seen as a camouflage for dermatologic disease, can be added as
a final stage in many plastic reconstructive procedures, and is
393
Western Journal of Emergency Medicine
Tattoos and Piercings
Urdang et al
Table 1. Piercing terminology.9
show that persons who get piercings are more likely to partake
in risky activities, including drug taking and sexual
promiscuity, and have a higher risk of incarceration. The
educational status and income of persons with T&P are
generally lower, although these educational and economic
disparities are lessening as T&P becomes more mainstream
(Table 1).8,9
Ampallang: horizontal through the penis
Antitragus: ear and cartilage
Barbell: type of jewelry composed of a straight bar with bead on
each end (found anywhere)
Christina: mons pubis
Conch: adjacent to external auditory canal
MEDICAL RELEVANCE FOR THE EMERGENCY
PRACTITIONER
There are several ways that T&P are relevant to the
practicing emergency practitioner (Table 2).
Finger web
Frowney: lower lip
Guiche: male perineum
Hafada: lateral scrotum
Labret: lips
Madonna: labret upper lip
Prince Albert: transurethral piercing from urethral meatus to below
glans penis
Reverse Prince Albert: ring exits on top of penis
Smiley: upper lip frenulum
Triangle: clitoral hood
also used for guidance in radiation therapy, endoscopic surgery,
and ophthalmologic procedures.
Studies, which have looked at the epidemiology of
piercings, have found that 2% of Americans report having
piercings (not including the ear lobe) and that females get more
piercings than men. Among young adults who have piercings
there is a high rate of associated eating disorders.7 Studies also
Table 2. Medical relevance of tattoos and piercings (T&P)
Relevance of T&P
1. Interpretive: understanding the patients and medically relevant
aspects of their lifestyle
Interpretive Relevance
For the EP, T&P presents a window to the lifestyle and life
experience of the patient. Many questions relevant to the
history can be answered by a review of the T&P present.
Figures 1 through 4 show examples of information obtained
from T&P. While interpretation is not as simple as it was 30
years ago, when sailors, military members, and gangs had the
most tattoos, relevant information is often within reach of the
observant EP.
Complications of Tattoos
Tattoo complication rates show a prevalence of
approximately 2% to 3%. Table 3 summarizes the complications
associated with tattoos, many of which will be encountered by
EPs. Most complications are related to infection that can be
traced back to individual tattooist practicing a nonsterile
technique. In particular, the jail and intravenous drug-using
population is at risk for hepatitis B and C and methicillinresistant Staphylococcus aureus infection.10–12. Even syphilis has
been transmitted by a tattoo artist licking the tattoo needle.13
Failure to recognize a tattoo as the source of a complication leads
- Incarceration
- Drug use
- Sexual orientation
- Gang allegiance
2. Complications of T&P, resulting in the ED visit
- Embedded
- Infectious
- Trauma
3. Relevance to the medical work-up in the ED
4. Psychiatric association
5. Procedural related
- Airway
- Magnetic resonance imaging
- Plain films
ED, emergency department.
Western Journal of Emergency Medicine
Figure 1. ‘‘LW’’ is a gang affiliation meant to be seen when wearing
sandals.
394
Volume XII, NO. 4 : November 2011
MAY 2012 | 17
Tattoos and Piercings
Urdang et al
Figure 2. Mi vida Loca ¼ My crazy life also seen as [ in many
patients; in this case, ‘‘LOWCA’’ is a reference to low riders and the
automotive culture associated with them. The gang is ‘‘Lowell
Street,’’ indicating a traditional Hispanic ‘‘turf gang’’ that is ‘‘loco’’—
crazy or brave.
to incorrect therapy. In many cases the tattoo is not correctly
linked to the medical problem because the patient may have
multiple risky behaviors.
Complications of Piercings
Complications of piercings are more common than those
of tattoos and studies show rates as high as 9%. The types of
complications include local or systemic infections, traumatic
Figure 4. ‘‘Brown Pride’’ for racial identity as Hispanic or Latin; the
anticubital fossa tattoos often cover intravenous drug abuse tracks,
and the woman (right arm) is often the woman who ‘‘waits for him’’
during jail time. Yolanda is his girlfriend, and the left anticubital fossa
tattoo is a tribute to a family member in the military, killed in service
with ‘‘R.I.P.’’, or rest in peace, noted above.
insertion, poor cosmesis, and rejection of foreign body, as
well as migration and embedding.14 These are summarized
in Table 4.
Jewelry is mainly body-site specific and made from metal.
Metals used include stainless steel, gold, titanium, and various
alloys. When these alloys contain nickel, there are associated
allergic skin reactions and contact dermatitis. Specific
Figure 3. Jiminy Cricket shown (a derogatory reference to the Crips, when called crickets or crabs), with the lipstick mark from a woman
who loves him. The N and the E probably refer to northeast and the Chinese characters are of uncertain reference.
Volume XII, NO. 4 : November 2011
18 | LIFELINE a forum for emergency physicians in california
395
Western Journal of Emergency Medicine
Tattoos and Piercings
Urdang et al
Table 3. Medical complications of tattoos.15
Table 4. Medical complications of piercings and pocketing.23,25
Tetanus17
Hepatitis B and C infection26
Skin infection (MRSA)
Pressure necrosis
18
Ludwigs angina27
Sepsis
Contact dermatitis28
Mycotic and viral infection
Verruca vulgaris
Abscess
19
Tuberculosis cutis
Hematomas
Molluscum contagiosum20
Aspiration
Syphilis
Dental trauma
14
Chancroid
Sarcoid granulomas
Psoriasis
Argyria (silver pigmentation of skin)
Magnetic resonance imaging burns
Toxic shock syndrome29
Endocarditis21
Keloid formation30
Dermatitis
Traumatic avulsion
Lichen planus
Embedding and migration
Lupuslike reaction
Perichondritis31,32
Urticaria
Trigeminal neuralgia33
Photosensitivity
Nasal septal hematoma
Tumor induction—including melanoma and carcinoma
Thrombophlebitis
Human Immunodeficiency Virus14,22
Condom failure
Granulomas
Airway compromise
Impetigo
Appendicitis34
Endocarditis15,16
MRSA, methicillin-resistant Staphylococcus aureus.
complications relevant to the EP are summarized in Table 5.
Rarer complications of piercings include bacterial endocarditis,
tetanus, piercing migration with embedding, and even a case
reported of appendicitis from a swallowed piercing that
occluded the appendiceal aperture.15–18
Psychologic Associations of Body Modifications
The EP should be more concerned about illnesses and
suicidal behavior in those with body modifications. Tattooing
correlates with the perception of decreased mental health, and
tattooing and body piercing together correlate highly with
increased ‘‘sensation-seeking’’ behavior.19 A study of young
tattooed Korean males conducted in Korea, where body
modification is considered part of counterculture, used the
Minnesota Multiphasic Personality Inventory personality test
and found high scores in items of psychopathic deviance and
schizophrenia, suggesting that those with tattoos were
impulsive, hostile, and prone to delinquent behavior.20 A data
analysis of 4,700 individuals who responded to a Web site
(www.bmezine.com) for body modification found a high
frequency of abuse in the background of those who
participated. This survey also found that 36.6% of the males
had suicidal ideation and 19.5% had attempted suicide. For the
females, a statistically significant higher suicidality rate was
found, with percentage values of 40.8% and 33.3%
Western Journal of Emergency Medicine
respectively.21 Skegg22 noted that piercing was more common
among women rated as having low constraint or high negative
emotionality and was less common among those with high
positive emotionality. Therefore, one can conclude that body
piercing and tattoos, especially in females, could be a sign of
suicidal behavior. However, no association has been found with
eating disorders.7
Some authors have attempted to show positive association
for these body modifications. In a study of women with eating
disorders, the authors suggested that body piercing could be
seen as reflecting a positive attitude towards the body, an
expression of care.23 In addition people with piercings are more
likely to give attention to their physical appearance and are less
likely to be overweight than people without piercings.22
REMOVAL OF TATTOOS AND PIERCINGS
Burris and Kim24 found that 50% of persons with tattoos
express regret and wish for tattoo removal. The quest for tattoo
removal reflects earlier poor decision making and an
embarrassing stigma often perceived by the age of 40 years.
Tattoos may cause immediate and delayed hazard to health and
are not easy to remove. Delayed complications include
development of allergic, hypersensitivity, or granulomatous
reactions that require tattoo removal.25 On average, tattoo regret
396
Volume XII, NO. 4 : November 2011
MAY 2012 | 19
Tattoos and Piercings
Urdang et al
Table 5. Summary of specific piercing and/or pocketing complications by anatomic location.
Oral piercings
Airway compromise following tongue swelling or jewelry obstruction. Dental trauma: 10% of those with tongue
piercings experience enamel trauma.35
Ear piercings
Complications are particularly associated with high piercings (above the ear lobe), of which 77% will have some
minor infection and 43%, an allergic reaction. Perichondritis, in particular with pseudomonas, can be difficult to
treat and may result in permanent disfigurement.36
Nasal piercings
Are either through the alar or septum, leading to septal hematoma or a perichondritis of the nasal septum.
Nipple piercings
These have a 2- to 4-month recovery time and cause local abscesses, cellulitis, and may interfere with the ability
to lactate.
Genital piercing
In men, can result in priapism, paraphimosis, and urethral strictures and in women can cause bleeding, infections,
and scarring.23 The genital piercing of both sexes interferes with all barrier contraceptive methods and has been
shown to cause the local spread of sexually transmitted diseases.37
occurs 14 years after tattooing and has spawned a whole new
industry. Nonprofit organizations also provide tattoo removal to
gang members wishing to remove their tattoos (www.
homeboy-industries.org). Tattoos can be removed by
mechanical, chemical, or thermal methods.
Alternatives to permanent tattoos include the Indian
technique of staining the skin with henna. This will fade over a
period of 7 to 10 days. In the past year there has been the
development of nonpermanent tattoo ink. This technique uses
ink-containing beads that are deployed in the same method as
used previously. However, the ink can be fully removed by
single-pass laser treatment (www.freedom2ink.com) that
dissolves the bead, allowing the dye to be exposed to enzymes,
laser, and UV rays.
SUMMARY
Tattoos and piercings have become widespread practices
that enjoy greater social acceptance than ever before. Body
modification is important to the EP because it provides
information about the ‘‘patient.’’ The physician can learn a great
deal about these patients via their body modification, including
information of immediate relevance to their medical evaluation.
Secondarily, T&P are directly responsible for an increasing
number of emergency department visits due to both immediate
and delayed complications. The EP armed with knowledge about
T&P/body modifications can forge more functional doctorpatient relationships, obtain critical historical data, and provide
better treatment and referral for this patient population.
funding sources, and financial or management relationships that
could be perceived as potential sources of bias. The authors
disclosed none.
REFERENCES
1. Tattoos By Design. History of tattoos. Tattoos By Design Web site.
Available at: www.tattoos-by-design.co.uk/history.html. Accessed April
23, 2008.
2. Gennaro J. A brief tattoo history. Religious Tattoos Web site. Available
at: www.religioustattoos.net/tattoos-history/index. Accessed April 23,
2008.
3. Scheinfeld N. Tattoos and religion. Clin Dermatol. 2007;25:362–365.
4. Vassileva S, Hristakieva E. Medical applications of tattooing. Clin
Dermatol. 2007;25:367–374.
5. Laumann A, Derick A. Tattoos and body piercings in the United States: a
national data set. J Am Acad Dermatol. 2006;55:413–421.
6. Sever J. The Harris Poll No. 58, October 8, 2003. Harris Interactive Web
site. Available at: http://harrisinteractive.com/harris_poll/printerfriend/
index.asp?PID¼407. Accessed April 23, 2008.
7. Preti A, Pinna C, Nocco S, et al. Body of evidence: tattoos, body
piercing, and eating disorder symptoms among adolescents. J
Psychosom Res. 2006;61:561–566.
8. Armstrong ML, Roberts AE, Koch JR, et al. Investigating the removal of
body piercings. Clin Nurs Res. 2007;16:103–118.
9. Panconesi E. Body piercing: psychosocial and dermatologic aspects.
Clin Dermatol. 2007;25:412–416.
10. Samuel MC, Doherty PM, Bulterys M, et al. Association between
heroine use, needle sharing and tattoos received in prison with hepatitis
B and C positivity among street-recruited injecting drug users in New
Address for Correspondence: Michael Urdang, MD, University of
Southern California, Department of Emergency Medicine, 1200 N
State St, Rm 1011, Los Angeles, CA 90033-1029. E-mail:
[email protected].
Mexico, USA. Epidemiol Infect. 2001;127:475–484.
11. Zeuzem S, Teuber G, Lee JH, et al. Risk factors for the transmission of
hepatitis C. J Hepatol. 1996;24:3–10.
12. Stemper ME, Brady JM, Qutaishat SS, et al. Shift in Staphylococcus
aureus clone linked to an infected tattoo. Emerg Infect Dis.
2006;12:1444–1446.
Conflicts of Interest: By the WestJEM article submission
agreement, all authors are required to disclose all affiliations,
Volume XII, NO. 4 : November 2011
20 | LIFELINE a forum for emergency physicians in california
13. Long GE, Rickman LS. Infectious complications of tattoos. Clin Infect
Dis. 1994;18:610–619.
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piercing, tattooing, and self-injuring in eating disorders. Eur Eat Disord
36. Simplot TC, Hoffman HT. Comparison between cartilage and soft
Rev. 2004;13:11–18.
tissue ear piercing complications. Am J Otolaryngol. 1998;19:305–
24. Burris K, Kim K. Tattoo removal. Clin Dermatol. 2007;25:388–392.
310.
25. Stirn A. Trauma and tattoo-piercing, tattooing and related forms of body
37. Gokhale R, Hernon M, Ghosh A. Genital piercing and sexually
modification between self-care and self-destruction of traumatized
Tattoos
and Piercings
individuals. Psychotraumatologie. 2002;2:45.
Urdang et al
transmitted infections. Sex Transform Infect. 2001;77:393–394.
26. Van Sciver AE. Hepatitis from ear piercing. JAMA. 1969;207:2285.
14. Meltzer DI. Complications of body piercing. Am Fam Physician.
2005;72:2029–2034.
27. Perkins CS, Meisner J, Harrison JM. A complication of tongue piercing.
15. Ochsenfahrt C, Friedl R, Hannekum A, et al. Endocarditis after nipple
Br Dent J. 1992;182:147–148.
placement in a patient with bicuspid aortic valve. Ann Thorac Surg.
28. Fischer T, Fregert S, Gruvberger B, et al. Nickel release from ear
2001;71:1365–1366.
piercing kits and earrings. Contact Dermatitis. 1984;10:39–41.
16. Lick SD, Edozie SN, Woodside KJ, et al. Streptococcus viridans
29. McCarthy VP, Peoples WM. Toxic shock syndrome after ear piercing.
endocarditis from tongue piercing. J Emerg Med. 2005;29:57–59.
Pediatr Infect Dis J. 1988;7:741–742.
17. O’Malley CD, Smith N, Braun R, et al. Tetanus associated with body
30. Lane JE, Waller JL, Davis LS. Relationship between age of ear piercing
piercing. Clin Infect Dis. 1998;27:1343–1344.
and keloid formation. Pediatrics. 2005;115:1312–1314.
18. Hadi HI, Quah HM, Maw A. A missing tongue stud: an unusual
31. Turkeltab SH, Habal MB. Acute Pseudomonas chondritis as a sequel to
appendicular foreign body. Int Surg. 2006;91:87–89.
ear piercing. Ann Plast Surg. 1990;24:279–281.
19. Stuppy DJ, Armstrong ML, Casals-Ariet C. Attitudes of health care
32. Hanif J, Frosh A, Marnane C, et al. Lesson of the week: ‘‘High’’ ear
providers and students toward tattooed people. J Adv Nurs.
piercing and the rising incidence of perichondritis of the pinna. BMJ.
1998;27:1165–1170.
20. Kim JJ. A cultural psychiatric study on tattoos of young Korean males.
Yonsei Med J. 1991;32:255–262.
2001;322:906–907.
33. Gazzeri R, Mercuri S, Galarza M. Atypical trigeminal neuralgia
associated with tongue piercing. JAMA. 2006;296:1840–1842.
21. Hicinbothem J, Gonsalves S, Lester D. Body modification and suicidal
34. Hadi HI, Quah HM, Maw A. A missing tongue stud: an unusual
behavior. Death Stud. 2006;30:351–363.
appendicular foreign body, Int Surg. 2006;91:87–89.
22. Skegg K, Nada-Raja S, Paul C, et al. Body piercing, personality, and
35. Maheu-Robert LF, Andrian LE, Grenier D. Overview of complications
sexual behavior. Arch Sex Behav. 2007;36:47–54.
secondary to tongue and lip piercings. J Can Dent Assoc. 2007;73:327–
23. Claes L, Vandereycken W, Vertommen H. Self-care versus self-harm:
331.
piercing, tattooing, and self-injuring in eating disorders. Eur Eat Disord
36. Simplot TC, Hoffman HT. Comparison between cartilage and soft
Rev. 2004;13:11–18.
tissue ear piercing complications. Am J Otolaryngol. 1998;19:305–
24. Burris K, Kim K. Tattoo removal. Clin Dermatol. 2007;25:388–392.
310.
25. Stirn A. Trauma and tattoo-piercing, tattooing and related forms of body
modification between self-care and self-destruction of traumatized
37. Gokhale R, Hernon M, Ghosh A. Genital piercing and sexually
transmitted infections. Sex Transform Infect. 2001;77:393–394.
individuals. Psychotraumatologie. 2002;2:45.
Western Journal of Emergency Medicine
398
Volume XII, NO. 4 : November 2011
CAREER OPPORTUNITIES |
Anaheim Regional Medical Center
ANAHEIM, CALIFORNIA | Anaheim Regional
Medical Center’s well established ED Physician group has an immediate part time
opportunity for a Board Certified or Board
Prepared Emergency Physician. We have a
busy, high acuity department with 44,000 annual visits; we have a “state of the art” Critical Care Center with computerized tracking
system and physician order entry. Shifts are
9-10 hours long with double coverage during
peak hours. We offer a competitive salary and
paid malpractice.
Interested physicians E-mail your CV and
references to [email protected] and
[email protected] or call us at 714-999-3887.
Well-Established ER Physician Group
SAN FRANCISCO / EASTBAY | Wellestablished ER physician group seeking fulltime/part-time, experienced, board certified
ER MD in busy 50,000 patient/year department, double coverage, fee for service.
Please send your CV to Carolyn Campbell/
Western Journal of Emergency Medicine
David Orenberg, MD, Fremont Emergency
Medical Group, Inc., email address: femginc1@
gmail.com or call 510.791.5376.
Make a Difference in Your Life
and in the Lives of Our Troops!
The Watsonville Emergency
Medical Group
Humana Military Healthcare Services
is seeking Full Time or Part Time Board Certified/Board Eligible EM, IM, FP, or PD emergency medicine trained physicians to provide
services at Weed Army Community Hospital;
Fort Irwin (outside of Barstow, CA). Attractive remuneration & malpractice insurance
provided. The service hours of these excellent positions are 12 hour shifts between
the hours of 8:00 a.m. and 8:00 p.m., rotating
days/nights, holidays, weekends. Qualified
candidates shall have completed any primary
care residency and possess a minimum of 1
year part time recent ED experience within a
similar or higher lever ED (level 3, low acuity).
Current licensure in any one of the U.S. States
and possession of BLS, ACLS, ATLS, and PALS
certifications is required. Candidates must be
U.S. citizens.
MONTEREY BAY AREA | The Watsonville Emergency Medical Group has a full time position
available at our community hospital. We are
a single group, single hospital, fully democratic group at our hospital for over 30 years.
We are a well respected group and serve on
most committees at the hospital. The shifts
are 8-9 hours with daily PA support. Rapid
full partnership is available based on hours
worked. Must be BC/BE in emergency medicine. New adult hospitalist and pediatric hospitalist programs started this past year with
Lucille Packard Hospital/Stanford affiliation.
We believe in flexible scheduling to enjoy the
redwoods and surfing in beautiful Santa Cruz
County on your time off.
Contact [email protected] or
Dr. Stan Hajduk 831-818-6358.
Contact Michelle Sechen at 1-877-202-9069,
forward CV via email to [email protected],
or by fax at 502-322-8759.
398
Volume XII, NO. 4 : November 2011
MAY 2012 | 21
21ST CENTURY MEDICINE:
21 CENTURY MEDICINE:
ST
Utilizing Point-of-Care Ultrasound to Optimize
Patient Care, Safety, and Satisfaction
ENROLLMENT APPLICATION
21st Century Medicine: Utilizing Point-of-Care Ultrasound
to Optimize Patient Care, Safety, and Satisfaction
June 7, 2012 & September 27, 2012
Please register by completing this application form or by registering
online at http://cme.stanfordhospital.com. Applications must be
completed online, faxed or postmarked 3 weeks prior to the course
date. Registration fee includes Continental Breakfast, refreshment
break, lunch, course materials, and certificate of attendance. Tuition
may be paid by check, Visa, Amex or MasterCard.
Utilizing Point-of-Care Ultrasound to Optimize
Patient Care, Safety, and Satisfaction
STATEMENT OF NEED
The American Medical Association has recognized the utility of
ultrasound; it recommends training and education standards are
developed by each physician’s respective specialty. It has been
proven that bedside ultrasound allows the treating physician to
more quickly determine the cause of life-threatening illness. If
Juneprocedures
7th, 2012
& performed,
September
2012
invasive
must be
they can27,
be done
under
ultrasound guidance (instead of using blind landmark techniques),
The Immersive
Learning
decreasing
the risk of complications.
ThisCenter
has been recommended
byat
theLi
Agency
for
Healthcare
Research
and
Quality as a key
Ka Shing Center for Learning
intervention. Emergency Medicine was an early adopter of point of
and
Knowledge,
Stanford,
California
care
ultrasound
due to the need
for rapid evaluation
of critically ill
patients. Now other specialty organizations, including critical care,
A Continuing Medical Education Conference presented
surgery, internal medicine, ob-gyn, and pediatrics are starting to
by theultrasound
Department
of Surgery,
of Emergency
include
during
residencyDivision
training. However,
many curMedicine
at the
Stanfordtrained
University
of Medicine
rently
practicing
physicians
beforeSchool
ultrasound
training was
available. This course will provide strategies on how to use point of
care ultrasound as well as provide hands-on training on ultrasound
techniques important to practicing attending physicians who did
their training before ultrasound was widely available.
PROGRAM
TARGET AUDIENCE (subject to change)
This national conference is designed to meet the educational
needs
of physicians
across all specialties in the
hospital and teach7:15-7:30
Registration/Continental
Breakfast
ing settings.
7:30-8:15 OBJECTIVES
Intro to the US Machine: Physics/Knobs
LEARNING
Faculty
At the conclusion of this activity, participants should be able to:
• Utilize strategies on the use of point of care ultrasound as part of
8:15-9:15
The FAST/E-FAST exam (Focused
patient care.
Assessment
with Sonography
in Trauma,
• Utilize ultrasound
when performing
invasive procedures
such
including
Extendedthoracentesis,
FAST (E-FAST)
placing central
lines, paracentesis,
and arthrocenAssessment of the Chest for Pneumothorax)
tesis.
Faculty
• Implement evidence-based
ultrasound strategies in diagnosing
and interpreting emergency conditions including sepsis,
9:15-9:30
Break
acute abdominal
pain and both traumatic and non-traumatic
hypotension.
9:30-10:15
POC-US: Emergency Aorta, Biliary, Renal
ACCREDITATION
Faculty
The Stanford University School of Medicine is accredited by the
Accreditation
for Continuing
Medical
Education (ACCME)
10:15-11:00 Council
POC-US:
Emergency
Echo
to provide continuing
medical education for physicians.
Faculty
CREDIT DESIGNATION
11:00-11:45 The RUSH Exam (Rapid Ultrasound in
Stanford University School of Medicine designates this live activity
Shock)
for a maximum of 8.0 AMA PRA Category 1 Credit(s)TM. Physicians
Faculty
should claim only
the credit commensurate with the extent of their
participation in the activity.
11:45-12:30 Lunch
CANCELLATION POLICY
12:30-1:30
Ultrasound-Guided
Refunds
must be
requested in writing 3Procedures
weeks prior to the course
All Faculty
and will be subject
to a $75 administrative fee. No refunds will be
made on cancellations received after this date. Program materials
1:30-4:15
Hands-On
Lab is received less than
cannot
be guaranteed
if enrollment
Faculty
3 weeks prior All
to the
course. Stanford University School of Medicine reserves the right to cancel this program; in the event of can4:15-4:30
cellation,
courseQuestions/Wrap-up
fees will be fully refunded.
All Faculty
ACCOMMODATIONS
For lodging near the Stanford campus, please view our lodging guide
for Q&A
will be provided at the conclusion of
atOpportunities
the following URL:
http://www.stanford.edu/dept/visitorinfo/plan/
each presentation
lodging.html
22 | LIFELINE a forum for emergency physicians in california
SELECT THE DATE YOU ARE REGISTERING TO ATTEND:
June 7, 2012
September 27 , 2012
Please type or print:
____________________________________________________________
NAME/DEGREE
____________________________________________________________
SPECIALTY
____________________________________________________________
MEDICAL LICENSE NUMBER (REQUIRED FOR CME CREDIT)
AFFILIATION
____________________________________________________________
STREET ADDRESS
____________________________________________________________
FACULTY
CITY
STATE
ZIP
____________________________________________________________
BUSINESS PHONE
EVENING PHONE
All
faculty are affiliated with Stanford
University School of
Medicine
unless otherwise noted.
____________________________________________________________
EMAIL
FAX
Sarah R. Williams, MD, FACEP, FAAEM
Associate
Residency
Director,
REGISTRATION
FEES:
$649 Stanford/Kaiser Emergency
Medicine Residency Program
Type of payment:
Co-Director,
Emergency Ultrasound Fellowship
Check made
payableDivision
to Stanford
University School
of Medicine
Department
of Surgery,
of Emergency
Medicine
Credit
Card (Check one:
Visa
Master Card
Amex)
Course
Director
Anne-Sophie
Beraud, MD
____________________________________________________________
Clinical
Instructor
CARD NUMBER
EXPIRATION DATE
Department of Medicine, Division of Cardiovascular Medicine
____________________________________________________________
NAME (AS IT APPEARS ON CARD)
Laleh
Gharahbaghian, MD, FACEP, FAAEM
Director,
Emergency Medicine Ultrasound
____________________________________________________________
CARDHOLDER’S
SIGNATURE Ultrasound Program and Fellowship
Director,
Emergency
Department of Surgery, Division of Emergency Medicine
Please register online at www.cme.stanfordhospital.com
Zoe
Howard,this
MDform and remit with payment to:
OR complete
Emergency Ultrasound Fellow
Stanford Center
for Continuing
Education
Department
of Surgery,
Division ofMedical
Emergency
Medicine
Attn: Jean Hengst
John
MDRoad, Suite 230, Palo Alto, CA 94304
1070 Kugler,
Arastradero
Clinical
Professor
Medicine
Phone: Assistant
(650) 497-8554
Fax: of
(650)
497-8585
Department
of
Internal
Medicine
Email: [email protected]
Faculty
Disclosure
Stanford
University School of Medicine is fully ADA compliant.
The Stanford
University
School
of Medicine
adheres to ACCME
If you have
needs that
require
special accommodations,
Essential
Areas,
Standards,
and
Policies
regarding
industry
including dietary concerns, please contact [email protected]
support of continuing medical education. Disclosure of faculty
and
commercial relationships
bequestions
made prior
activity.
about to
thethe
symposium,
CONFERENCE
LOCATION willFor
The Immersive Learning Center
SPONSORED
BY Center
THE
at Li Ka Shing
for Learning
STANFORD
UNIVERSITY
and Knowledge
SCHOOL
OF MEDICINE
291 Campus
Drive, Ground Floor
Stanford, CA 94305
http://lksc.stanford.edu/
please contact Cassandra Alcazar,
CME Conference Coordinator,
Stanford Center for Continuing Medical
Education at (650) 724-5318 or email
[email protected].
To
To register
register and
and pay
pay online,
online, visit
visit www.cme.stanfordhospital.com
www.cme.stanfordhospital.com
21ST CENTURY MEDICINE:
Utilizing Point-of-Care Ultrasound to Optimize
Patient Care, Safety, and Satisfaction
STATEMENT OF NEED
The American Medical Association has recognized the utility of
ultrasound; it recommends training and education standards are
developed by each physician’s respective specialty. It has been
proven that bedside ultrasound allows the treating physician to
more quickly determine the cause of life-threatening illness. If
invasive procedures must be performed, they can be done under
ultrasound guidance (instead of using blind landmark techniques),
decreasing the risk of complications. This has been recommended
by the Agency for Healthcare Research and Quality as a key
intervention. Emergency Medicine was an early adopter of point of
care ultrasound due to the need for rapid evaluation of critically ill
patients. Now other specialty organizations, including critical care,
surgery, internal medicine, ob-gyn, and pediatrics are starting to
include ultrasound during residency training. However, many currently practicing physicians trained before ultrasound training was
available. This course will provide strategies on how to use point of
care ultrasound as well as provide hands-on training on ultrasound
techniques important to practicing attending physicians who did
their training before ultrasound was widely available.
ENROLLMENT APPLICATION
21st Century Medicine: Utilizing Point-of-Care Ultrasound
to Optimize Patient Care, Safety, and Satisfaction
June 7, 2012 & September 27, 2012
Please register by completing this application form or by registering
online at http://cme.stanfordhospital.com. Applications must be
completed online, faxed or postmarked 3 weeks prior to the course
date. Registration fee includes Continental Breakfast, refreshment
break, lunch, course materials, and certificate of attendance. Tuition
may be paid by check, Visa, Amex or MasterCard.
SELECT THE DATE YOU ARE REGISTERING TO ATTEND:
June 7, 2012
Please type or print:
____________________________________________________________
NAME/DEGREE
____________________________________________________________
SPECIALTY
____________________________________________________________
MEDICAL LICENSE NUMBER (REQUIRED FOR CME CREDIT)
STREET ADDRESS
____________________________________________________________
CITY
LEARNING OBJECTIVES
At the conclusion of this activity, participants should be able to:
• Utilize strategies on the use of point of care ultrasound as part of
patient care.
• Utilize ultrasound when performing invasive procedures such
placing central lines, paracentesis, thoracentesis, and arthrocentesis.
• Implement evidence-based ultrasound strategies in diagnosing
and interpreting emergency conditions including sepsis,
acute abdominal pain and both traumatic and non-traumatic
hypotension.
EMAIL
CREDIT DESIGNATION
Stanford University School of Medicine designates this live activity
for a maximum of 8.0 AMA PRA Category 1 Credit(s)TM. Physicians
should claim only the credit commensurate with the extent of their
participation in the activity.
CANCELLATION POLICY
Refunds must be requested in writing 3 weeks prior to the course
and will be subject to a $75 administrative fee. No refunds will be
made on cancellations received after this date. Program materials
cannot be guaranteed if enrollment is received less than
3 weeks prior to the course. Stanford University School of Medicine reserves the right to cancel this program; in the event of cancellation, course fees will be fully refunded.
ACCOMMODATIONS
For lodging near the Stanford campus, please view our lodging guide
at the following URL: http://www.stanford.edu/dept/visitorinfo/plan/
lodging.html
AFFILIATION
____________________________________________________________
TARGET AUDIENCE
This national conference is designed to meet the educational
needs of physicians across all specialties in the hospital and teaching settings.
ACCREDITATION
The Stanford University School of Medicine is accredited by the
Accreditation Council for Continuing Medical Education (ACCME)
to provide continuing medical education for physicians.
September 27 , 2012
STATE
ZIP
____________________________________________________________
BUSINESS PHONE
EVENING PHONE
____________________________________________________________
FAX
REGISTRATION FEES: $649
Type of payment:
Check made payable to Stanford University School of Medicine
Credit Card (Check one:
Visa
Master Card
Amex)
____________________________________________________________
CARD NUMBER
EXPIRATION DATE
____________________________________________________________
NAME (AS IT APPEARS ON CARD)
____________________________________________________________
CARDHOLDER’S SIGNATURE
Please register online at www.cme.stanfordhospital.com
OR complete this form and remit with payment to:
Stanford Center for Continuing Medical Education
Attn: Jean Hengst
1070 Arastradero Road, Suite 230, Palo Alto, CA 94304
Phone: (650) 497-8554 Fax: (650) 497-8585
Email: [email protected]
Stanford University School of Medicine is fully ADA compliant.
If you have needs that require special accommodations,
including dietary concerns, please contact [email protected]
CONFERENCE LOCATION
The Immersive Learning Center
at Li Ka Shing Center for Learning
and Knowledge
291 Campus Drive, Ground Floor
Stanford, CA 94305
http://lksc.stanford.edu/
For questions about the symposium,
please contact Cassandra Alcazar,
CME Conference Coordinator,
Stanford Center for Continuing Medical
Education at (650) 724-5318 or email
[email protected].
To register and pay online, visit www.cme.stanfordhospital.com
lifeline
PRSRT STD
US POSTAGE
California Chapter, American
College of Emergency Physicians
PAID
CPS
1020 11th Street, Suite 310
Sacramento, CA 95814
Upcoming Meetings & Deadlines |
For more information on upcoming meetings, please e-mail us at [email protected];
unless otherwise noted, all meetings are held via conference call.
june 2012
May 2012
juLY 2012
May 1st – 15th
Chapter Board of
Directors Election
June 4th at
2:30 pm
Practice Management
Committee
July 2nd at
2:30 pm
Practice Management
Committee
May 3rd at
10:00 am
Government Affairs
Committee
June 13th at
2:00 pm
Education Committee
July 10th at
9:00 am
Reimbursement
Committee
May 7th at
2:30 pm
Practice Management
Committee
June 20th
July 19th at
10:00 am
Government Affairs
Committee
May 8th at
9:00 am
Reimbursement
Committee
Chapter Board of
Directors
Hyatt Regency
Monterey Hotel & Spa,
Monterey
May 20th –
23rd
ACEP Leadership &
Advocacy Conference
June 21st –
22nd
TBA
Education Committee
(Contact office for
details)
Ultrasound Workshop
Hyatt Regency
Monterey Hotel & Spa,
Monterey
June 21st –
23rd
Scientific Assembly
Hyatt Regency
Monterey Hotel & Spa,
Monterey