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  May 2013

From the President

Rick Robinson, MD, FACEP

Welcome to another edition of EMphasis - the official publication of the Texas College of Emergency Physicians. We are all fresh off of another very successful Annual Meeting in which we witnessed our highest attendance in the history of the Chapter. It was a pleasure to see and speak with those of you who attended in Frisco. The Education Committee - under the direction of Dr. Takenaka - organized an outstanding curriculum of clinical and administrative topics delivered by some of our finest local, regional, and national content experts. Resident and Medical Student tracks delivered both quality education and an opportunity to engage in a little constructive competition. Jim Coles secured a record sponsorship for the conference as witnessed by the number and variety of exhibitors on site. Once again TCEP was honored to host many of the ACEP leadership as we shared our world renowned Texas hospitality with our colleagues from around the country.

Annual Meeting is also the time when we review the year behind and look forward to the year ahead.  Dr. Moskow provided the Treasurer's Report which shows the Chapter is in solid financial condition with fiscal year to date net income on a positive note.  Dr. Fisher reported that we gained another Councillor position as Chapter membership reached an all time high of 1711 on December 31, 2012.  Dr. Peckenpaugh provided a concise report of the overall accomplishments of the Chapter during the past year.  Congratulations to all three for their continued leadership and selfless commitment to growing TCEP.

Several of the Committee Chairs including Drs. Dickson, Fisher, Fite, and Takenaka provided reports during the Board Meeting highlighting their individual committee's accomplishments over the past year and shared a few of their goals for the coming year.  I believe it is safe to say that some exciting things are on the horizon in the months ahead.  Our new class of Leadership and Advocacy Fellows are already on the job learning the importance of organized medicine and how each of them will ultimately integrate their individual passions for a better healthcare system into their communities.  The TCEP Residency and Medical School Visit Program has been a conduit of information and mentorship for the next generation of Emergency Physicians for many years.  The program is expected to continue its growth and service in the coming year under the direction of Dr. de Moor and Dr. Knowles.

Election activities are a major part of Annual Meeting.  This is the time we elect Members of the Board of Directors and Councillors.  Those elected this year include:

Chapter President-Elect
Bruce Moskow, MD FACEP

Chapter Treasurer
Angela Siler Fisher, MD FACEP

Chapter Secretary
Shkelzen Hoxhaj, MD FACEP

Regular Members of the Board of Directors
Angela Siler Fisher, MD FACEP
Heidi Knowles, MD FACEP
Heather Owen, MD FACEP

Young Physician Member of the Board of Directors
Gerad Troutman, MD

Candidate (Resident) Member of the Board of Directors
Christine Tracy, DO

Medical Student Member of the Board of Directors
Michael Pandya

Shannon Bagwell, MD FACEP
Diana Fite, MD FACEP
Juan Fitz, MD FACEP
Andrea Green, MD FACEP
Heidi Knowles, MD FACEP
Bruce Moskow, MD FACEP
Heather Owen, MD FACEP
Chet Schrader, MD

Congratulations to all, whether a re-elected incumbent or a newly elected Member of the Board and/or Councillor.  I look forward to working with each of you during the coming year.

It is also important to recognize those who are departing the Board and/or Councillor ranks.  Sincere thanks to those listed below for their years of service in shaping TCEP into one of the strongest Chapters in the College.

Nick Zenarosa, MD FACEP (departing Immediate Past President)
Juan Fitz, MD FACEP (departing Member of the Board of Directors)

A brief summary of projects confirmed or under consideration for the coming year is listed below.  These are research and/or action items the Board and Committees will consider at our annual Board Retreat and Strategy Planning Meeting in July.


  • Review feedback from Annual Meeting 2013
  • Plan curriculum and obtain CME certification for Annual Meeting 2014
  • Recruit sponsorship for Annual Meeting 2014

Emergency Medical Services

  • Plan participation in Texas EMS Conference
  • Research needs and plan preparatory course for EMS Director Certification

Free Standing Emergency Department

  • Monitor and report on FSED specific practice issues
  • Integrate with Practice Enhancement Committee to represent all Chapter members

Government Relations

  • Monitor and report on 83rd Texas Legislative Session
  • Research and recommend TCEP PAC activities
  • Coordinate lobbying efforts


  • Plan for additional membership recruitment and Chapter growth
  • Review and revise Residency and Medical School Visit Program
  • Continue EM Futures Program

Practice Enhancement

  • Participate in Education Committee planning for Annual Meeting 2014
  • Monitor and report on specific Texas EM practice issues that impact our members
  • Integrate with FSED Committee to represent all Chapter members


  • Review and improve communication across various media platforms
  • Track progress of Chapter projects

President's Initiative

  • A new agenda that focuses on a few action items requiring multidisciplinary input.  An example is GME funding.  Meaningful action to support protection and growth of existing GME funding might require input from members of Education, Legislative, Membership, and Practice Enhancement Committees in order to prepare and deliver the type of support needed to ensure a continued stream of well educated and appropriately trained future Emergency Physicians.

Rest assured that the Board and Committees will use EMphasis as a vehicle to keep you posted regarding the status of the projects adopted for action during the coming year.

I want to take a moment to encourage all TCEP members to contribute to the EMRA Legacy Initiative.  This is the most important documentary on emergency medicine ever produced.  It chronicles the history of our specialty through timeless images and recollections of the founders of the one indispensible medical service of the last half century.  Pledging is easy and can be accessed through the TCEP website home page.  Thanks to all of you that have contributed to date.  I encourage those that have yet to contribute to visit the TCEP website today and support this outstanding project.

It is a source of both personal and professional pride to officially announce to our membership that Diana Fite, MD FACEP will receive the prestigious James D. Mills Award for Outstanding Contribution to Emergency Medicine this year during the ACEP Council luncheon at Scientific Assembly in Seattle.  Dr. Fite has been - and continues to be - one of my mentors within organized medicine.  I look forward to applauding her once again in October when the Council recognizes her profound contributions to our specialty.

In closing, I want to recognize our Immediate Past President Dan Peckenpaugh, MD FACEP.  As someone who worked closely with Dan while a member of the Board and Executive Committee, I can honestly say that his dedication to the success of TCEP is genuine, and I look forward to his continued friendship and counsel during my term as President.  Muchas gracias amigo.

Wishing you all the very best until we meet again on the pages of EMphasis.

Rick Robinson, MD FACEP
Texas College of Emergency Physicians

In This Issue:
2013-2014 Board of Directors
Government Relations Committee Report
2013 Annual Meeting Report
News From the Practice Enhancement Committee
Texas Medical Board Chapter 197 Update
Welcome New TCEP Members
News from the Medical Student Committee

2013 - 2014 Board of Directors

TCEP would like to congratulate our new 2013-2014 Board of Directors.  >>>View their information here>>>

Rick Robinson, MD, FACEPboard_bandera_shirt

Bruce Moskow, MD, FACEP

Angela Siler Fisher, MD, FACEP

Shkelzen Hoxhaj, MD, FACEP

Dan Peckenpaugh, MD, FACEP

Shannon Bagwell, MD, FACEP
Carrie de Moor, MD, FACEP
Heidi Knowles, MD, FACEP
Heather Owen, MD, FACEP
Michael Pandya
Patty Short, MD, FACEP
Tim Taylor, MD, FACEP
Christine Tracy, DO
Gerad Troutman, MD

Jim Coles, CAE
Executive Director

Nancy Davis
Executive Assistant
2525 Wallingwood Bldg 13A
Austin, Texas 78746
FAX: 512/329-8943

PO BOX 619911
Dallas, TX 75261-9911
OFFICE: 800/798-1822
FAX: 972/580-2816

Government Relations Committee Report

Diana Fite, MD, FACEP
Chair, Government Relations Committee

The Government Relations Committee met during the TCEP annual meeting with a good attendance and several guests. It is our only face-to-face meeting of the year, and I hope I am not the only person who looks forward to it!!

By the time you read this report, we will only have about 30 days or less left in this legislative session. The next regular session will not be until 2015, although sometimes the Governor will call a special session which is usually limited to one or more particular items.

Although anything can happen between now and the end of the session, so far this session looks like it will end on a positive note for us and for our patients. Specifically, no bill was filed to try to take away the tort law that specifically applies to emergency patients, in that we have to be found willfully and wantonly negligent rather than a lesser standard of negligence in order to be found guilty of malpractice when caring for emergency patients. This does not apply just to emergency physicians, but to all physicians involved in taking care of an emergency patient. Such a bill to take this tort law away has been filed in past sessions and will always be a threat to us every session in the future, and our lobbyist has to remain vigilant in watching this until the end of session, because items can always be added on to bills as an amendment to another bill, even unrelated bills, at the last minute.

Another good thing about this session is that money for the budget for the next two years came out better than expected, and the legislators are putting back some of the cuts they made two years ago. They are putting money back in for graduate medical education (GME) to fund residency programs; and they are re-instituting loan payment plans in exchange for certain criteria, such as working in underserved areas; and they have said they will replace some of the Medicaid payments that were taken away last session (details not known with certainty yet).

I will give you details about multiple bills in later reports when we know what has happened. Right now we plan to send a blast e-mail to our members if we need you to make contact with your legislators regarding supporting or opposing a particular bill. We will not waste your time, but only do this if critically necessary, so please respond if you get such an e-mail.

There is still time to attend the last "First Tuesday" event, which will be May 7. Let Nancy Davis know if you can come so she can get you registered with the TMA. We will take care of the nominal fee. We meet at 7:00 am in the TMA building first floor which is located at 401 West 15th. If you live too far away to drive in that morning, The TMA has a block of rooms reserved at the Doubletree Suites Hotel in Austin next to the Capitol and across the street from the TMA Building. Their phone number is 512-478-7000 and you cannot make the reservations on line because it will show as full. You must call and ask for the "TMA First Tuesday" block. We will let you know what to do and get you to the Capitol building. You will increase your chance of meeting your actual senator and representative if you make an appointment in advance. But meeting with the health care staff person is really every bit as important as the member because the staff people are usually the ones you make the recommendations to the legislator based on input from constituents. A breakfast snack and a lunch will be provided by the TMA. And bring your white coat because we want the legislators to know that we are physicians.

Just call me or e-mail me if you are thinking about attending but have any hesitation. We all need to know how the legislative process works so we can work with it and not have the governmental process control our practices.

As we always remind our TCEP members, we would appreciate you working one shift per year to give to EMPACT (the political action committee for the Texas College of Emergency Physicians). And larger donations are appreciated, of course. We need to fund EMPACT so that we can give donations to legislators, particularly those in positions of importance to our issues or who have helped us out with our bills or with support of our agenda. Our reports emphasize the importance of having a strong voice when it comes to legislation that affects us so directly. We have to help legislators get elected who understand our issues and help us advocate for our patients. EMPACT needs money to accomplish this. Please send your check to TCEP or call 1-800-TEX-ACEP with your credit card information. You can donate with credit card deductions monthly or quarterly if that is helpful. And you have to renew your donation on a yearly basis. Please call me (713-301-3564) or e-mail me (dianafite@mail.com) or call our executive director, Jim Coles (1-800-TEX-ACEP) or e-mail him (texacep@gmail.com), if you wish to discuss any of the information in this report.


2013 Annual Meeting Highlights

Jim Coles, CAE
TCEP Executive Director

The TCEP Annual Meeting was held on April 11-14, 2013 at the Westin Stonebriar Hotel in Frisco, Texas.  With over 318 attendees, this was the largest Annual Meeting to date.  There were 150 Active Members,

54 Resident Members and 114 Medical Students in attendance.  In addition, EMRA sponsored the Annual Meeting and promoted a regional EMRA presence in conjunction with the Residency Fair. ACEP Council Speaker, and TCEP member, Dr. Marco Coppola was in attendance. There was attendance from the following ACEP Boardowp_4756 Members - Drs. Andy Bern,  Michael Gerardi,  Hans House, Jay Kaplan, Becky Parker and Alex Rosenau. In addition, ACEP Executive Director Dean Wilkerson, JD, CAE and ACEP Executive Assistant Sonja Montgomery, CAE were in attendance.

There was a golf tournament on Thursday, April 11, 2013 with 35 golfers that took on the challenging Stonebriar Country Club course.  Thanks to all the Hole Sponsors for the tournament, but especially to the First Choice Emergency Room for their sponsorship of the gourmet sandwich lunch.

emcareboothThe President's Reception was held on Friday, April 12, 2013 to honor outgoing TCEP President Dr. Dan Peckenpaugh, President-Elect Dr. Rick Robinson and the rest of the TCEP Board of Directors, past TCEP Leaders and ACEP leaders were also in attendance.  Thanks to EmCare and TMLT for their sponsorship of the reception.

owp_4783The Exhibit Hall had 65 exhibitors who displayed their products and services on Friday, April 12, and half a day on Saturday, April 13, 2013.  This was one of the largest Exhibit Halls to date.  In addition to the exhibitors, there were eight residency programs represented alongside EMRA.  The Opening Reception was held on Friday, April 12, 2013 from 5:00 - 6:30 pm with over 250 people, which included the  attendees, residencies and exhibitors. 

The Annual Business Meeting was held on Saturday, April 13, 2013 with College business matters being discussed.  One of the most important activities was to recognize award winners and elect Board Members and Councillors.  The Award winners that were recognized were:  James E. Hayes Award - Dr. Arlo Weltge;  Michael Wainscott Legacy Award - Dr. Ije Akunyili;  Best Abstract Award - Dr. Anant Patel, JPS Health Network     ;  Medical Student Awards - Margaret Vo, Texas Tech University Health Sciences Center; Paul C. Foster, School of Medicine at Ft. Worth/Texas College Osteopathic  Medicine;  Zachary Gibson, University of North Texas Health Science Center; Bryan Wilson, University of Texas Health Science Center San Antonio; Emily owp_4761Turner, University of Texas Houston Health Science Center;  Brian Allgaier, TX A&M Health Science Center College of Medicine; Cole Livingston, Texas Tech Health Sciences Center School of Medicine;  Sara Andrabi, Baylor College of Medicine; Mack Slaughter Jr., University of Texas Southwestern Medical Center; James Adam Moore, University of Texas Medical Branch Galveston. Retiring Board Members  included Dr. Juan Fitz and  Dr. Nick Zenarosa.

shannon tim jim_1Board Members that were elected or re-elected were - Regular Board Members Dr. Angela Siler Fisher; Dr. Heidi Knowles; Dr. Heather Owen.  Young Physician Member - Dr. Gerard Troutman;  Candidate Member - Dr. Christine Tracy;  Medical Student - Michael Pandya.   Elected Councilors for 2013 were Drs. Shannon Bagwell, Diana Fite, Juan Fitz, Andrea Green, Heidi Knowles, Bruce Moskow, Heather Owen and Chet Schrader.

bobby_jim_lynnThe Board of Director's Meeting was held on Sunday, April 14, 2013 from 8:30 - 11:30 am.  The highlights of the Board Meeting included elections of the 2013-2014 Officers.  These included Chapter President Dr. Rick Robinson;  Chapter President-Elect Dr. Bruce Moskow; Chapter Treasurer Dr. Angela Siler Fisher; and Chapter Secretary Dr. Shkelzen Hoxhaj.  Dr. Robinson outlined his goals and objectives for the upcoming year. Other actions and discussions included -  The 2013-2014 TCEP Budget was adopted; a discussion on supporting EMRA Film Project, Heroes of Emergency Medicine; discussion of membership totals and trends in Texas and nationally; an ACEP Update from several ACEP Board Members and the ACEP Council Speaker Dr. Marco Coppola; and committee reports from the TCEP and ACEP Committees.

News From the Practice Enhancement Committee

Rob Dickson, MD, FACEP
Practice Enhancement Committee

TCEP Annual Meeting Expert Panel Summary:
The business track was headlined this year by several expert panel discussions of Pain management in the ED and Strategies for EPís to thrive in the ACA Obama care era. Both panels had a mix of academic talents, input from the C suite and veteran ED directors. For those of you not lucky enough to join us in Frisco have a review of both discussions along with some helpful links in the upcoming issues of Emphasis.

Expert Panel on Pain Management in the ED
Moderator: Arlo Weltge, MD FACEP
Panelists: John Dipasquale MD FACEP, Bruce Moskow MD, FACEP, Patty Short MD, FACEP, Ron Short MBA, Knox Todd MD, James d'Etienne, MD, and Monica Wattada, MD

The session began with a historical synopsis pain management in the ED by Dr. Todd. He reviewed the current opiate abuse and misuse epidemic in the US. According to Dr. Todd EP's should be more concerned about what we send patients home with rather than our acute treatment of pain in the ED. On Acute ED pain treatment he is a proponent of nurse driven protocols (see below)and stressed the need for individualized care plans for super users with pain related complaints. The panel discussed options for acute ED pain treatment and debated the use of nurse driven protocols of which Dr. Todd is a proponent. There was some controversy among the audience and panelists regarding the impact of pain management on patient satisfaction scores. Mr. Short pointed out that pain management is not in the top concerns of patients who complete patient satisfactions scores and there was some audience feedback citing literature suggesting otherwise.

Good Shepherd Medical Center ED 1+1 Acute Pain Protocol:
Physician assesses patient and determines need for IV analgesia. Physician clicks on Medhost order box labeled "Pain Protocol". 1mg of Hydromorphone is administered IV to adult patients age 21-64. The patient must be on a monitor with pulse oximetry ongoing. At 15 minutes after administration, nursing assesses patient and asks "Do you need more pain medication?" If the answer is "yes" then an additional dose of Hydromorphone 1mg is given IV per protocol. PRN Benadryl 25mg IV and PRN Zofran 4mg IV is included in the protocol for itching and nausea if reported by the patient. This is to be administered by nursing without the need for additional physician consent. In any incidence of severe respiratory depression with oxygen saturations less than 90%, Narcan 0.1mg IV is to be administered to patient by nursing with physician being notified.

Exclusion Criteria: Pain greater than 7 days duration, initial O2 sats of less than 95%, weight less than 100 pounds, systolic BP less than 90, drug or alcohol intoxication, a chronic pain syndrome (fibromyalgia/SCD)

Ann Emerg Med. 2011 Oct;58(4):352-9. doi: 10.1016/j.annemergmed.2011.03.003. Epub 2011 Apr 19.
Randomized clinical trial comparing the safety and efficacy of a hydromorphone titration protocol to usual care in the management of adult emergency department patients with acute severe pain


Chronic pain patients:
On the issue of chronic pain and the use of opiate pain medications in the ED there was expert advice on how we deal with these patients. The short answer is commented on above but worth repeating that we should focus our efforts on prescriptions we send patients home with and not focus all of our energies on withholding opiates for use in the ED. Texas has a prescription database that EP's can register for and access the opiate prescription history. This can be an important tool for EPís to access critical information that will help in managing these patients.

ACEP Policy of Opiate Prescribing from the ED:


Texas Prescription Program:


Rob Dickson, MD FACEP
Correspondence to swimdoc5271@gmail.com


Texas Medical Board Chapter 197 Update

Ira Nemeth, MD, FACEP

The Texas Medical Board (TMB) made changes to Chapter 197 Ė Emergency Medical Service effective as of January 2, 2013.  The changes revolve around Off-line Medical Director responsibilities.  Here are the significant changes:

  • Notify the board at time of licensure registration or renewal of your position as medical director and the names of all EMS transport agencies for whom you are off-line medical director.
  • One of the following three initial educational requirements must be completed within 2 years of notification to the board
o    12 hours of formal continuing medical education (CME) in the area of EMS medical direction; or
o    ABMS Board certification in EMS or AOA Certificate of Added Qualification in EMS; or
o    A Department of State Health Services (DSHS) approved EMS medical director course.
  • Every 2 years an additional hour of formal CME must be completed.
  • You cannot be medical director for more than 20 EMS transporting agencies at one time without a waiver from TMB.
DSHS has not established the process for approving medical director courses and TMB has not described how waivers can be obtained.  As more information becomes available, TCEP will provide updates.


Welcome New TCEP Members

Stephen Hamilton, MD

Zachary Hardy

Michelle Hong

Jose Loaiza, MD

Ashley Rider

Jeffrey Smith

Dustin Staloch

Briana Tully


Baylor College of Medicine Students Get Educated On Human Trafficking

BCM TCEP Liaisons Zheng Ben Ma, MSIII, and Ronnie Kuo Ren, MS II

Ben_MaOne of the unique aspects about Emergency Medicine is that it reaches a diverse cross section of people within a community. It requires its physicians to provide emergency medical care for all, regardless of race, socioeconomic status, or background. This nature of EM attracts and develops physician leaders because it places them in a unique position to identify and advocate for patients in extraordinary situations. Students at Baylor College of Medicine have taken a particular interest in the situation of human trafficking, a major social issue in the city of Houston. BCM's Emergency Medicine Interest Group (EMIG) believes that EM physicians should take the lead in advocating for these human rights victims because of their unique position in the medical field

A form of modern-day slavery human trafficking is prevalent in many countries around the world. It is also a growing social concern in the United States, especially in Houston. In fact, Houston is considered the hub of human trafficking in the US because of its strategic location on the coast, its diverse immigrant-heavy population, and its abundant interstate highway corridors.

ronnie_Kuo_RenHuman Trafficking, as defined by the Trafficking Victims Protection Act of 2000, is the recruitment, harboring, transportation, provision or obtaining of a person for labor or sexual services through the use of force, fraud or coercion. The victims of this crime can be of any age, sex, ethnic and socioeconomic background. Because this crime is rapidly growing in Houston and the victims are themselves the commodities, we believe that physicians, especially emergency physicians, are in a unique position to identify and help rescue these victims.

The students at BCM have taken a great interest in fighting against this rapidly-growing criminal enterprise. A critical first step is promoting awareness and education. After all, one cannot fight an enemy if one does not know the enemy, or even worse, of its existence.

A new elective course was created in the fall of 2012 entitled "The Hidden Aspects of Medicine." Under the guidance of a forensic pediatrician with expertise in human trafficking who is also on faculty with Texas Children's Hospital, this elective explored several difficult social issues affecting patients' health. Additionally, several student groups at BCM have partnered with the local organization Houston Rescue and Restore Coalition (HRRC) to provide introductory and advanced level training for medical professionals to better recognize these victims. BCM's EMIG hosted one of these training sessions in December 2012 and explored several specific cases of trafficking.

While these are only some of the beginning steps in the fight against human trafficking at BCM, the hope is that these efforts will spark passion in the hearts of future physicians to take on this cause to end modern-day slavery. BCM EMIG believes that in the future, emergency physicians should be in the forefront of the effort to rescue people, bring healing, and ultimately change the city, the country and the world.

Additional information and resources on human trafficking can be found at:
Children at Risk: http://childrenatrisk.org/research/child-trafficking/
Houston Rescue and Restore Coalition: http://www.houstonrr.org/
Polaris Project: http://www.polarisproject.org/




Texas College of Emergency Physicians
2525 Wallingwood Drive, Bldg. 13A | Austin, Texas 78746
Phone: 512.306.0605 | Toll Free: 800.TEX.ACEP | Fax: 512.329.8943

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