EDITORIALS American Board of Emergency Medicine - - Progress Update hen I assumed the Presidency of the American College of Emergency P h y s i c i a n s (ACEP), I continued to assign top priority to the goal of a certifying board in emergency medicine, as ACEP presidents have uniformly done. Approximately a year and a h a l f ago, the sponsors of the American Board of Emergency Medicine (ABEM), namely ACEP, the University Association for E m e r g e n c y M e d i c i n e (UA/EM), a n d t h e Section on Emergency Medicine of the American Medical Association (AMA), s u b m i t t e d an application for a p r i m a r y b o a r d to the A m e r i c a n Board of Medical S p e c i a l t i e s (ABMS). This application since then has been the subject of constant negotiations and discussions. As the March meeting of ABMS approaches, I would like to report our current position and our prospects for the approval of ABEM within organized medicine. The initial application was referred to the Liaison Committee o~a Specialty Boards (LCSB). Following two unprecedented public hearings, LCSB recommended the approval of the primary board to its two parent organizations, the A M A Council on Medical E d u c a t i o n and ABMS. In l i n e w i t h s u g g e s t i o n s by LCSB, A B E M amended its Bylaws to add four representatives, from four primary boards. In June of 1977 the Council on Medical Education of the AMA voted, with a two-thirds majority, for the approval" of the application. The~)rderly and rapid progress of the approval process me t its first roadblock at the September 1977 ABMS meeting where the application for a primary board was defeated by a 100 to 5 vote. At the same meeting however, in an apparently rare move, the ABMS voted to encourage the reapplication for a conjoint board in emergency medicine. Since t h a t time the negotiating team continued talks with ABMS and most specifically with seven p r i m a r y boards t h a t are potential sponsors of an emergency medicine board (JACEP 7:117-118 and JACEP 7:287-288). Following this ABMS action, it became abundantly clear to me and, I believe, to many other leaders of the College, t h a t there was no possibility of approval of a primary board in emergency medicine in the foreseeable future. The reasons are many and quite complex and include the current tendency of organized medicine, as well as the public and government, to look askance at further fragmentation and specialization in the field of health care. (Several other groups are awaiting anxiously in the wings for the outcome of the application for ABEM.) In any case, the consensus of the negotiating committee was to apply for a conjoint board that would be a fully operating, functioning certifying board for emergency physicians. In addition, the l e a d e r s h i p of the College and UA/EM directed t h a t the negotiations continue to seek approval of a c e r t i f y i n g b o a r d w i t h i n the a v a i l a b l e mechanisms of organized medicine. These strategies and methodologies were closely reviewed, debated, and eventually approved by the ACEP Council, both at its special meeting in Innisbrook and recently in Houston, Texas. During this period the College was busy putting the finishing touches on the certification examination itself. A criterion-referenced examination was successfully developed and, even more i m p o r t a n t , successfully field tested in October, 1977.
w
8:2 (February) 1979
Another major project of the College related to the specialty certification came into fruition this fall despite being plagued by many problems and unexpected delays: the C o m p r e h e n s i v e Review in E m e r g e n c y Medicine (CREM). The first module, "Cardiovascular-Pulmonary Emergency Medicine," has been given successfully in Chicago and Atlanta. A t h i r d project w i t h i n the specialty development process is the Study Guide in Emergency Medicine which, after overcoming unforeseen delays, is well on its way with the first two sections already shipped to approximately 1,000 subscribers. Another major educational effort is the second edition of the Physicians Evaluation and Education Review (PEER II). A v a i l a b l e since April 1978, almost 1,400 copies have been sold. Meanwhile, through three formal sessions and numerous small and large encounters in person, by telephone, and in writing, the representatives of emergency medicine have been meeting with the representatives of seven major primary boards: American Board of Internal Medicine, American Board of Surgery, American Board of Pediatrics, American Board of Obstetrics and Gynecology, A m e r i c a n Board of P s y c h i a t r y and N e u r o l o g y , American Board of Family Practice and the American Board of Orthopaedic Surgery. The most recent negotiation meeting occurred in Chicago on November 16, 1978. W h a t a p p e a r s to be the final draft of the Bylaws of ABEM was agreed upon at t h a t meeting. The conjoint board, which will retain the name of ABEM, will consist of 12 representatives of emergency medicine and seven representatives of major p r i m a r y boards. Thirteen votes will be necessary to pass on general business of the board and 15 votes will be necessary to pass changes in the Bylaws, t r a i n i n g s t a n d a r d s and evaluation standards. Plus, a proposed change would have to be presented to the sponsors at least 180 days prior to the vote on each issue. It was agreed t h a t at least one member of the ABEM Executive Committee and at least one member of the Credentials Committee of ABEM will be from the representatives of the primary sponsoring boards. I believe t h a t the support of the seven p r i m a r y boards is serious and genuine. The American Board of Orthopaedic Surgery continues in full support; however, it is reconsidering its position as one of the sponsoring boards. The American Board of Otolaryngology now appears to have expressed interest in being a sponsoring board. A meeting of the negotiating team and the representatives of the seven primary boards will take place in Chicago F e b r u a r y 1. Meanwhile, LCSB will consider the application for the conjoint board at its meeting on February 16. Final statements of support of the seven p r i m a r y boards are yet to come in writing. The American Board of Internal Medicine has serious reservations concerning prior t r a i n i n g of emergency physicians in the field of internal medicine as well as the need for assurance of the continuing ability of residents in internal medicine to function in the educational setting of the emergency department. The next possible benchmark is the March ABMS
JACEP
88/67
meeting. The logistics and the t i m e table of t h e negotiations, the most recent a d j u s t m e n t s , and the final draft of Bylaws j u s t recently a g r e e d upon, made it impossible to submit our revised application to ABMS in t i m e to be placed on the M a r c h a g e n d a 120 days in advance, as t h e ABMS Bylaws require. However, consideration is being given to h a v i n g one of the sponsoring boards m a k e a motion to set aside t h e Bylaws and vote on our a p p l i c a t i o n at the forthcoming ABMS m e e t i n g in Chicago. F a i l i n g t h a t , an a t t e m p t will be m a d e to e l i c i t a s t r a w vote among the ABMS m e m b e r s h i p to d e m o n s t r a t e two-thirds majority support. This evidence of support would m a k e it clear t h a t the long a w a i t e d approval will occur at the next r e g u l a r m e e t i n g of ABMS in September of 1979. W i t h e i t h e r of the above eventualities, A B E M will proceed to a c t i v e l y involve t h e r e p r e s e n t a t i v e s of the seven p r i m a r y boards in its actions, d e l i b e r a t i o n s and p r e p a r a t i o n s for t h e c e r t i f y i n g e x a m i n a t i o n . It is conceivable, b u t highly unlikely, t h a t n e i t h e r r e a l support or expression of support by an adequate m a j o r i t y of ABMS will be shown in the March meeting. In this case, A B E M should be in a position to proceed with its own e x a m i n a tion w i t h i n an a p p r o p r i a t e t i m e period. Yet, I feel confident t h a t with t h e support of t h e
seven major p r i m a r y boards we should have A B M S approval of our application by S e p t e m b e r of 1979 at the latest. I believe t h a t the o t h e r m e m b e r s of the n e g o t i a t i n g t e a m s h a r e this opinion. As I have expressed previously to the A C E P Council, I feel strongly t h a t we m u s t continue our e n d e a v o r to receive approval of certifying boards in e m e r g e n c y medicine, b u t w i t h i n the f r a m e w o r k of organized medicine. An i m p o r t a n t a d d i t i o n a l consideration is t h a t as problems of the t h i r d p a r t y r e i m b u r s e m e n t emerge, in my j u d g e m e n t , it will be i m p o r t a n t for e m e r g e n c y medicine to h a v e a recognized specialty certifying board. Readers should keep in m i n d t h a t despite w h a t appears to be a prolonged period of w a i t i n g and negotiating, all t h e other specialties who have sought the s a m e result, have required a s u b s t a n t i a l l y longer period of time to achieve it. I a m looking f o r w a r d to the auspicious event of the approval of A B E M as our College e m b a r k s on a second decade of life.
George Podgol;ny, MD President, ACEP President, ABEM
Prehospital Cardiac Arrest and Resuscitation: Evaluation and Alternative Strategies v a l u a t i o n of medical care is surely one of the most challenging, if not painful, duties of the h e a l t h professional. The e v a l u a t i o n of resuscitation from prehospital cardiac a r r e s t is no exception. In '~Epidemiology of Cardiac A r r e s t a n d Resuscitation in a S u b u r b a n Comm u n i t y " (8:2-5, 1979) E i s e n b e r g et al a n a l y z e d the resusc i t a t i o n s a t t e m p t e d by 33 s e p a r a t e g r o u p s in K i n g County, W a s h i n g t o n , to begin to develop a ~gold-standard" t h a t could be used as a m e a s u r e of the effectiveness of p a r a m e d i c p r o g r a m s in t r e a t i n g p r e h o s p i t a l cardiac arrest. Over an 1 8 - m o n t h period, 649 cardiac a r r e s t s occurred ( a n n u a l incidence 7.2/10,000). P r i m a r y h e a r t disease was found to be t h e cause in 81% and v e n t r i c u l a r fibrillation was p r e s e n t in 57%. Based on the success rate of Cobb et aP in c o n v e r t i n g p r e h o s p i t a l v e n t r i c u l a r fibrillation, E i s e n b e r g e s t i m a t e d t h e m a x i m u m incidence of lives saved to be 2/10,000 annually. This, then, was offered as a goal for successful resuscitation for an efficient p a r a m e d i c program. The p r i m a r y s u r v e i l l a n c e tool used to collect d a t a was a questionnaire. An e l e m e n t a l question in e v a l u a t i n g the results of h e a l t h care is w h e t h e r the d a t a base used to develop the "goal" will provide a s t a n d a r d t h a t will be applicable and acceptable elsewhere. E i s e n b e r g et al seemed satisfied with the e x t e n t to which t h e i r questionnaire m e c h a n i s m reflected t h e r e a l i t i e s of cardiac a r r e s t and r e s u s c i t a t i o n in K i n g County, and felt t h e i r d a t a and approach would be applicable to o t h e r s u b u r b a n communities. Yet, approaches to d a t a collection as well as differences in study p o p u l a t i o n s and access to medical care for cardiac c o m p l a i n t s m a y differ Substantially. For example, Cobb et a l l , 2 e s t i m a t e d t h a t n e a r l y One t h i r d of 18,000 requests for medical assistance in Seattle were from patients with cardiovascular disease while only 71 of 1,771 p a t i e n t s consecutively t r a n s p o r t e d by Pozen et al 2 had ischemic h e a r t disease. E s t i m a t e s have p u t the incidence of ~heart a t t a c k " d e a t h s at 28.6/10,000 in a ~'standard g e n e r a l population. ''3 Since more t h a n h a l f of these will t a k e place in the c o m m u n i t y , we m i g h t expect a n incidence of prehosp i t a l cardiac a r r e s t a b o u t twice t h a t observed by Eisen-
E
68/89
berg et al. However, the researchers did point out t h a t t h e i r study population included only those patients for whom the emergency system was activated. D a t a has been offered to suggest t h a t successful resuscitation from p r e h o s p i t a l cardiac a r r e s t is related to 1) n u m b e r s of laypersons t r a i n e d in resuscitation; 1 2) frequency of layperson (bystander) s u p p o r t of the cardiac a r r e s t victim, 1 and 3) q u a l i t y of CPR provided by the bystander, s Lay persons m a y be - - or r a t h e r , m u s t be - - an i n t e g r a l p a r t of t h e p r e h o s p i t a l r e s u s c i t a t i o n effort. Successful r e s u s c i t a t i o n has been reported in 61% of cases in which CPR was i n i t i a t e d by a lay person w i t h i n one m i n u t e of cardiac arrest. ~ D a t a from a decade ago on t h e f r e q u e n c y of successful p r e h o s p i t a l r e s u s c i t a t i o n showed t h a t success r a t e s were often 10% or less. 7 The contribution of t h e l a y m a n m a y vary from one emergency care system to a n o t h e r while the competency of the prehospital care system m a y be e n t i r e l y comparable. How is one to account for this variable? To w h a t e x t e n t w i l l c o m m u n i t y e d u c a t i o n in the signs and symptoms of h e a r t a t t a c k and the importance of p r o m p t entry into t h e e m e r g e n c y care s y s t e m influence t h e frequency of prehospital cardiac a r r e s t and therefore t h e n u m b e r of p o t e n t i a l l y r e s u s c i t a t a b l e cardiac a r r e s t v i c t i m s ? We r e c o g n i z e t h a t a r r h y t h m i c d e a t h s occur e a r l y in t h e course of m y o c a r d i a l i n f a r c t i o n and t h a t m a n y are p r e v e n t a b l e w i t h e a r l y t r e a t m e n t . Since an effective education p r o g r a m m a y reduce p r e h o s p i t a l cardiac arrest, the success r a t e for p r e h o s p i t a l resuscitation by a n efficient p a r a m e d i c s y s t e m m a y also be reduced a n d an efficient p a r a m e d i c s y s t e m m a y a p p e a r to be doing its job less well. Surely an accounting of total cardiac arrests m i g h t avoid such a p o t e n t i a l m i s i n t e r p r e t a tion, but this merely underlines the reality that an overly simplistic index m a y be m i s l e a d i n g . O b v i o u s l y , t h e r e a s o n for t h e e x i s t e n c e of c o m m u n i t y - b a s e d m e c h a n i s m s for d e a l i n g with cardiac e m e r g e n c i e s is the fact t h a t b e t t e r t h a n half, p e r h a p s b e t t e r t h a n 65%, of those who die suddenly, p r e m a t u r e l y a n d unexpectedly do so in t h e k i t c h e n s , churches and shopping centers of t h e i r communities, not in the coron a r y care u n i t ) , s
JACEP
8:2 (February) 1979
w
8:2 (February) 1979
Another major project of the College related to the specialty certification came into fruition this fall despite being plagued by many problems and unexpected delays: the C o m p r e h e n s i v e Review in E m e r g e n c y Medicine (CREM). The first module, "Cardiovascular-Pulmonary Emergency Medicine," has been given successfully in Chicago and Atlanta. A t h i r d project w i t h i n the specialty development process is the Study Guide in Emergency Medicine which, after overcoming unforeseen delays, is well on its way with the first two sections already shipped to approximately 1,000 subscribers. Another major educational effort is the second edition of the Physicians Evaluation and Education Review (PEER II). A v a i l a b l e since April 1978, almost 1,400 copies have been sold. Meanwhile, through three formal sessions and numerous small and large encounters in person, by telephone, and in writing, the representatives of emergency medicine have been meeting with the representatives of seven major primary boards: American Board of Internal Medicine, American Board of Surgery, American Board of Pediatrics, American Board of Obstetrics and Gynecology, A m e r i c a n Board of P s y c h i a t r y and N e u r o l o g y , American Board of Family Practice and the American Board of Orthopaedic Surgery. The most recent negotiation meeting occurred in Chicago on November 16, 1978. W h a t a p p e a r s to be the final draft of the Bylaws of ABEM was agreed upon at t h a t meeting. The conjoint board, which will retain the name of ABEM, will consist of 12 representatives of emergency medicine and seven representatives of major p r i m a r y boards. Thirteen votes will be necessary to pass on general business of the board and 15 votes will be necessary to pass changes in the Bylaws, t r a i n i n g s t a n d a r d s and evaluation standards. Plus, a proposed change would have to be presented to the sponsors at least 180 days prior to the vote on each issue. It was agreed t h a t at least one member of the ABEM Executive Committee and at least one member of the Credentials Committee of ABEM will be from the representatives of the primary sponsoring boards. I believe t h a t the support of the seven p r i m a r y boards is serious and genuine. The American Board of Orthopaedic Surgery continues in full support; however, it is reconsidering its position as one of the sponsoring boards. The American Board of Otolaryngology now appears to have expressed interest in being a sponsoring board. A meeting of the negotiating team and the representatives of the seven primary boards will take place in Chicago F e b r u a r y 1. Meanwhile, LCSB will consider the application for the conjoint board at its meeting on February 16. Final statements of support of the seven p r i m a r y boards are yet to come in writing. The American Board of Internal Medicine has serious reservations concerning prior t r a i n i n g of emergency physicians in the field of internal medicine as well as the need for assurance of the continuing ability of residents in internal medicine to function in the educational setting of the emergency department. The next possible benchmark is the March ABMS
JACEP
88/67
meeting. The logistics and the t i m e table of t h e negotiations, the most recent a d j u s t m e n t s , and the final draft of Bylaws j u s t recently a g r e e d upon, made it impossible to submit our revised application to ABMS in t i m e to be placed on the M a r c h a g e n d a 120 days in advance, as t h e ABMS Bylaws require. However, consideration is being given to h a v i n g one of the sponsoring boards m a k e a motion to set aside t h e Bylaws and vote on our a p p l i c a t i o n at the forthcoming ABMS m e e t i n g in Chicago. F a i l i n g t h a t , an a t t e m p t will be m a d e to e l i c i t a s t r a w vote among the ABMS m e m b e r s h i p to d e m o n s t r a t e two-thirds majority support. This evidence of support would m a k e it clear t h a t the long a w a i t e d approval will occur at the next r e g u l a r m e e t i n g of ABMS in September of 1979. W i t h e i t h e r of the above eventualities, A B E M will proceed to a c t i v e l y involve t h e r e p r e s e n t a t i v e s of the seven p r i m a r y boards in its actions, d e l i b e r a t i o n s and p r e p a r a t i o n s for t h e c e r t i f y i n g e x a m i n a t i o n . It is conceivable, b u t highly unlikely, t h a t n e i t h e r r e a l support or expression of support by an adequate m a j o r i t y of ABMS will be shown in the March meeting. In this case, A B E M should be in a position to proceed with its own e x a m i n a tion w i t h i n an a p p r o p r i a t e t i m e period. Yet, I feel confident t h a t with t h e support of t h e
seven major p r i m a r y boards we should have A B M S approval of our application by S e p t e m b e r of 1979 at the latest. I believe t h a t the o t h e r m e m b e r s of the n e g o t i a t i n g t e a m s h a r e this opinion. As I have expressed previously to the A C E P Council, I feel strongly t h a t we m u s t continue our e n d e a v o r to receive approval of certifying boards in e m e r g e n c y medicine, b u t w i t h i n the f r a m e w o r k of organized medicine. An i m p o r t a n t a d d i t i o n a l consideration is t h a t as problems of the t h i r d p a r t y r e i m b u r s e m e n t emerge, in my j u d g e m e n t , it will be i m p o r t a n t for e m e r g e n c y medicine to h a v e a recognized specialty certifying board. Readers should keep in m i n d t h a t despite w h a t appears to be a prolonged period of w a i t i n g and negotiating, all t h e other specialties who have sought the s a m e result, have required a s u b s t a n t i a l l y longer period of time to achieve it. I a m looking f o r w a r d to the auspicious event of the approval of A B E M as our College e m b a r k s on a second decade of life.
George Podgol;ny, MD President, ACEP President, ABEM
Prehospital Cardiac Arrest and Resuscitation: Evaluation and Alternative Strategies v a l u a t i o n of medical care is surely one of the most challenging, if not painful, duties of the h e a l t h professional. The e v a l u a t i o n of resuscitation from prehospital cardiac a r r e s t is no exception. In '~Epidemiology of Cardiac A r r e s t a n d Resuscitation in a S u b u r b a n Comm u n i t y " (8:2-5, 1979) E i s e n b e r g et al a n a l y z e d the resusc i t a t i o n s a t t e m p t e d by 33 s e p a r a t e g r o u p s in K i n g County, W a s h i n g t o n , to begin to develop a ~gold-standard" t h a t could be used as a m e a s u r e of the effectiveness of p a r a m e d i c p r o g r a m s in t r e a t i n g p r e h o s p i t a l cardiac arrest. Over an 1 8 - m o n t h period, 649 cardiac a r r e s t s occurred ( a n n u a l incidence 7.2/10,000). P r i m a r y h e a r t disease was found to be t h e cause in 81% and v e n t r i c u l a r fibrillation was p r e s e n t in 57%. Based on the success rate of Cobb et aP in c o n v e r t i n g p r e h o s p i t a l v e n t r i c u l a r fibrillation, E i s e n b e r g e s t i m a t e d t h e m a x i m u m incidence of lives saved to be 2/10,000 annually. This, then, was offered as a goal for successful resuscitation for an efficient p a r a m e d i c program. The p r i m a r y s u r v e i l l a n c e tool used to collect d a t a was a questionnaire. An e l e m e n t a l question in e v a l u a t i n g the results of h e a l t h care is w h e t h e r the d a t a base used to develop the "goal" will provide a s t a n d a r d t h a t will be applicable and acceptable elsewhere. E i s e n b e r g et al seemed satisfied with the e x t e n t to which t h e i r questionnaire m e c h a n i s m reflected t h e r e a l i t i e s of cardiac a r r e s t and r e s u s c i t a t i o n in K i n g County, and felt t h e i r d a t a and approach would be applicable to o t h e r s u b u r b a n communities. Yet, approaches to d a t a collection as well as differences in study p o p u l a t i o n s and access to medical care for cardiac c o m p l a i n t s m a y differ Substantially. For example, Cobb et a l l , 2 e s t i m a t e d t h a t n e a r l y One t h i r d of 18,000 requests for medical assistance in Seattle were from patients with cardiovascular disease while only 71 of 1,771 p a t i e n t s consecutively t r a n s p o r t e d by Pozen et al 2 had ischemic h e a r t disease. E s t i m a t e s have p u t the incidence of ~heart a t t a c k " d e a t h s at 28.6/10,000 in a ~'standard g e n e r a l population. ''3 Since more t h a n h a l f of these will t a k e place in the c o m m u n i t y , we m i g h t expect a n incidence of prehosp i t a l cardiac a r r e s t a b o u t twice t h a t observed by Eisen-
E
68/89
berg et al. However, the researchers did point out t h a t t h e i r study population included only those patients for whom the emergency system was activated. D a t a has been offered to suggest t h a t successful resuscitation from p r e h o s p i t a l cardiac a r r e s t is related to 1) n u m b e r s of laypersons t r a i n e d in resuscitation; 1 2) frequency of layperson (bystander) s u p p o r t of the cardiac a r r e s t victim, 1 and 3) q u a l i t y of CPR provided by the bystander, s Lay persons m a y be - - or r a t h e r , m u s t be - - an i n t e g r a l p a r t of t h e p r e h o s p i t a l r e s u s c i t a t i o n effort. Successful r e s u s c i t a t i o n has been reported in 61% of cases in which CPR was i n i t i a t e d by a lay person w i t h i n one m i n u t e of cardiac arrest. ~ D a t a from a decade ago on t h e f r e q u e n c y of successful p r e h o s p i t a l r e s u s c i t a t i o n showed t h a t success r a t e s were often 10% or less. 7 The contribution of t h e l a y m a n m a y vary from one emergency care system to a n o t h e r while the competency of the prehospital care system m a y be e n t i r e l y comparable. How is one to account for this variable? To w h a t e x t e n t w i l l c o m m u n i t y e d u c a t i o n in the signs and symptoms of h e a r t a t t a c k and the importance of p r o m p t entry into t h e e m e r g e n c y care s y s t e m influence t h e frequency of prehospital cardiac a r r e s t and therefore t h e n u m b e r of p o t e n t i a l l y r e s u s c i t a t a b l e cardiac a r r e s t v i c t i m s ? We r e c o g n i z e t h a t a r r h y t h m i c d e a t h s occur e a r l y in t h e course of m y o c a r d i a l i n f a r c t i o n and t h a t m a n y are p r e v e n t a b l e w i t h e a r l y t r e a t m e n t . Since an effective education p r o g r a m m a y reduce p r e h o s p i t a l cardiac arrest, the success r a t e for p r e h o s p i t a l resuscitation by a n efficient p a r a m e d i c s y s t e m m a y also be reduced a n d an efficient p a r a m e d i c s y s t e m m a y a p p e a r to be doing its job less well. Surely an accounting of total cardiac arrests m i g h t avoid such a p o t e n t i a l m i s i n t e r p r e t a tion, but this merely underlines the reality that an overly simplistic index m a y be m i s l e a d i n g . O b v i o u s l y , t h e r e a s o n for t h e e x i s t e n c e of c o m m u n i t y - b a s e d m e c h a n i s m s for d e a l i n g with cardiac e m e r g e n c i e s is the fact t h a t b e t t e r t h a n half, p e r h a p s b e t t e r t h a n 65%, of those who die suddenly, p r e m a t u r e l y a n d unexpectedly do so in t h e k i t c h e n s , churches and shopping centers of t h e i r communities, not in the coron a r y care u n i t ) , s
JACEP
8:2 (February) 1979
