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Welcome New TCEP Members

Tinuola Agbabiaka, DO
Elizabeth Hamilton Arrington, MD
Reece G Baker
Elijah J Bell, III, MD
Michael Brodeur, MD
Matthew Gordon Brooker, DO
Desiree Brooks, MD
Benjamin J Brown, DO
Derek Brown, MD
David W Brunett, MD
Kenneth Chang
Sadie L Cole, MD
Mark Crosby, DO
Sarah Dendy, MD
Jose R Gonzalez, Jr
Aaron Alan Guess, DO
William C Hancock
Duncan Hansing, MD
Brett Anthony Hayzen, MD
Stephen Howard, MD
Darren G Hyams
Michael Jaung, MD
Jae Won Joh, MD
Teshy V John, MD
Edward P Jones, DO
Romeo J Joseph, MD
Kavita B Joshi, MD
Evan Kane, MD
Rachelle M Klammer, MD
Matthew Koger, MD
Dakota R Lane
Joshua Larson, MD
David V Le, MD
James F Leoni, Jr, MD
Mikael Lucas, MD
Jerod L Lunsford, MD

Samuel A McDonald, MD
Matthew McKerley, DO
Faroukh Mehkri
Shahir M Melhem
Su Quoc Nguyen, MD
Ebelechukwu Odiari, MD
Angela B Olson, DO
Edgar Ordonez, MD
Richard Owens, MD
Jessica Petersen, MD
Caleb Andrew Pierce, MD
Brandon Michael Price, MD
Melissa F Ralston, MD
Lindsey Christine Remme, DO
Stephanie C Rhoades, MD
Noam Rosines, MD
Victoria Schneider
Monisha Shah, MD
Joni Shriver, DO
Pankaj Chandra Singhal, MD
Nitin Singla, MD
J Mack Slaughter, Jr, MD
Nastaran Solano, MD
Jessica Solis-McCarthy
Ryan Michael Taube, DO
Adriana Thomas, MD
Jonathan Tull, MD
Nathan Valenti
Avinash Viswanath
Margaret Vo, MD
Greg Wallingford
Ben E Wendell, MD
Jennifer Werner, MD
Ngozi A Wilkins, MD
Robert T Yang
Karin E Zeaton, DO
Patrick S Zelley, MD


TCEP Turns 40

resized__95x94_packardDighton Packard, MD, FACEP

TCEP President 1980-1981; 1989-1990

Where are you currently practicing?

I currently serve as the Chair of the Department of Emergency Medicine Baylor University Medical Center, CMO Envision Health Care (Envision is composed of American Medical Response, EMcare and Evolution Health.)

Tell us about your experiences as TCEP President, and what are some of your most memorable moments in TCEP?

In those days we had no "office". Each president handed down the files (usually in one cardboard carton) to the next one in line. None of us took a long range plan so the change was needed. We decided in my second term that we needed a real office, a real CEO and significant strategic planning.

The second term was most taxing. The CEO (what was really just a secretary was transitioned to a CEO) had to completely rework our bylaws and financing scheme. We had to get those concepts through the Board and supported by the membership.

What was your greatest accomplishment as TCEP President?

Righting the ship and setting the stage for a very successful TCEP.

What has TCEP meant to you through the years?

TCEP and ACEP (I was also on the ACEP Board for 6 years) have given me lasting friendships and knowledge that you simply do not receive without expending the time and energy to run for office and serve. Each year healthcare becomes more complex. By giving TCEP your time you are repaid with knowledge and an understanding of this complexity.


Ron Hellstern, MD, FACEP

TCEP President 1983-1984

Where are you currently practicing?

I ceased clinical practice in 2000 after 29 years. I then served as Chairman of the Board of Medical Edge Healthcare Group (a 500 provider multi-specialty group practice) in Dallas-Fort Worth, Chief Medical Officer for Phytel and Loopback Analytics (population management software companies) and finally as CEO of Ikonopedia, Inc. a medical software development start-up using images to create standardized mammography reports. As of January of this year I am semi-retired and doing part-time practice management consulting for house-based specialties (see www.hospitalpractice.com).

Tell us about your experiences as TCEP President?

Minor Emergency or Urgent Care Centers were a relatively new development when I was President of TCEP and having a foot in both camps at the time I did considerable work toward helping each side understand the other and develop a compromise position on the use of the word "emergency" in a facility's name. I concurrently served on the Board of the Accreditation Association for Ambulatory Healthcare (AAAHC) and developed standards for what were then called freestanding emergency centers in other parts of the country.

What are some of your most memorable moments in TCEP?

Perhaps, I have early Alzheimer's but I don't remember any memorable moments.

What was your greatest accomplishment as TCEP President?

My greatest accomplishment was to be appointed as the Emergency Medicine representative to the Texas Trauma Technical Advisory Committee, representing both TCEP and the TMA, and thereby be able to help design and write the Texas Trauma System's Rules and Regulations.

What was the state of Emergency Medicine during the time of your presidency?

Emergency Medicine was still at the bottom of the political pecking order when I was TCEP president. In fact, I would estimate that fewer than half of Texas EDs were independent departments. What a sea change to see the brightest residents flock to Emergency Medicine.

What has TCEP meant to you through the years?

TCEP played an integral role in establishing Emergency Medicine's legitimacy and reliability in Texas, especially in the early years. And the group of worker bees was quite small so that political burnout was just as big a risk as clinical practice burnout, and this in the days when 18 twelve-hour shifts was the norm. Several of this early group served more than once as TCEP President to keep it going. TCEP today bears almost no resemblance to TCEP in my term as president when we were lucky to fill up a small conference room for our annual meeting.

resized__95x95_Wayne_1Wayne Schuricht, DO, FACEP
TCEP President 1987-1988

Where are you currently practicing?

I currently live in Fort Worth where I practiced for 30 years. I am currently retired, completely!

Tell us about your experiences as TCEP President?

Obviously serving as President of TCEP (TxACEP back then) was and is a great honor and responsibility. At that time Ruth Dean was our administrator and we held our meetings in the ACEP national headquarters. During that time, Ruth resigned, and we hired the dynamic, Kathy Dykgraaf as our new administrator and moved our office out of the ACEP building. Our Annual Meeting that year was held in Fort Worth and was, I believe the last time we held a joint meeting with the Emergency Nurses and Paramedics. I had a wonderful time as President supported by Past Presidents Dighton Packard and David Prentice along with President-Elect Ken Sherman. I believe I had the honor to name Dighton as the "God Father of Emergency Medicine in Texas"! We also hosted a major planning meeting to facilitate our future needs and plans.

What are some of your most memorable moments in TCEP?

I was privileged to serve TCEP as a Councillor for 9 years at the ACEP Scientific Assembly, during which time much of the future of Emergency Medicine was formulated.

What was your greatest accomplishment as TCEP President?

During those mid 80's years, probably the most important thing the Board did was to recognize the need for us to be politically active on the state level, and we hired our first lobbyist (which is not a 4 letter word). We actively worked for, supported, and had the state legislature pass the motorcycle helmet law for Texas. During that time I appeared on a national television show, Sonya, live from Hollywood, in which I debated the head lobbyist for the motorcyclist organization on the obvious need to have such a law. His name was Roland Rolloff. I then had the honor of witnessing Governor Bill Clements sign the law into effect at the state capitol. Sad to say, it wasn't too long before it was repealed. I believe that I hosted the first President's dinner, which I understand has become a nice yearly tradition.

What was the state of Emergency Medicine during the time of your Presidency?

Needless to say, we had just progressed out of infancy into toddler-hood and were learning to walk. We had to prove to the medical world that we belonged in that world as a recognized medical specialty and to stand alone in that capacity. And thank goodness that has been accomplished. I frequently refer people to the terrible shooting that took place in 1966 at UT in Austin. I am quick to point out that in 1966 the Capitol City of Texas had NO EMS system in place. No ambulances, just funeral parlor hearse style body transporters, no paramedics, and no Emergency Medicine trained physicians. We've come a long way, baby!!

What has TCEP meant to you through the years?

I joined ACEP as an EM Resident in Jacksonville, Florida in 1978. I arrived in Fort Worth to work and serve my commitment to the USAF in August of 1980, and immediately joined TxACEP. I have always considered ACEP/TCEP as the home of Emergency Medicine, and am so proud to have been a member for 35+ years. I am also ever so proud to see how the subsequent leaders of ACEP/TCEP have led and developed our specialty into its rightful place in the medical world!

resized__95x118_fiteDiana Fite, MD, FACEP
TCEP President 1995-1996

Where are you currently practicing?

I am currently a private attending physician at Methodist Willowbrook Hospital in Houston, Christus St. Catherine's Hospital in Katy, Emerus 24 HR ER in Tomball, and The Emergency Room at Katy Main Street in Katy.

Tell us about your experiences as TCEP President?

Thank you so much for inviting the Past Presidents to answer these questions. I was honored to be the first female President of TCEP. That does not sound unusual these days at all but was still a bit unusual eighteen years ago!

What are some of your most memorable moments in TCEP?

When I began my year as President, the United States House of Representatives had just undergone a takeover by the Republicans under the leadership of Speaker Newt Gingrich, who had campaigned with his "Contract with America". He had a list of ten things that the House would pass immediately if the Republicans were elected to the majority, and he carried around that list on a laminated card that he kept in his front pocket. So I made a list of ten items that I called my "Contract with TCEP", and I laminated it and carried it in my white coat front pocket. I referred to at least one item on the list for every one my President articles in EMphasis.

What was your greatest accomplishment as TCEP President?

My Contract with TCEP was: 1) Unite emergency physicians; 2) Tort reform; 3) Expert witness reality check; 4) Domestic violence and child abuse recognition; 5) Unfunded mandates (COBRA medical screening exam); 6) Advise ways to prevent unwanted ED contract acquisitions; 7) Encourage emergency physicians to run for elected offices; 8) Increase TCEP/ACEP meeting attendance; 9) Reverse the "just say no" attitude; 10) Escalate realization that emergency medicine is the most essential medical specialty.

What was the state of Emergency Medicine during the time of your presidency?

I will elaborate briefly on a few of the items I worked on during my presidency and I believe this information answers the question about regarding the state of emergency medicine during my time as President, which was 1995-1996. Under item 1, the AAEM organization had just been created and there was growing contention about emergency physicians being board certified or not, with Texas having a very large number of non-board certified and/or non-residency trained EP's since our area of the country was so far behind in getting residency programs approved. Texas was one of the few states that did not vote unanimously in favor of changing the ACEP rules that as of the year 2000, all new members (other than students or residents) would have to complete a residency in EM. Under item 2, regarding tort reform, we were in an awful mess with many malpractice suits being filed. We did achieve a small degree of tort reform in 1995 but nothing compared to what was accomplished in 2003! Many of us had more than one malpractice suit back then. Item 3 was related, regarding expert witnesses, because the rules were loose and it was very easy to find someone who was not an emergency physician and who had not been practicing whatever their specialty was for years to say negative false things about the emergency physician on behalf of the plaintiff side, and that was allowed!

What has TCEP meant to you through the years?

One of my personal favorite items was #9, which was about reversing the "just say no" attitude. "Just say no" seemed to be the buzz phrase at that time, trying to get people to not be so involved and busy in their everyday lives. However, I think emergency physicians can handle a lot of things going on at the same time. That is what we do!! So I stated that 99% of emergency physicians can make the time to be on a committee or attend a meeting or call a legislator or all of the above. I fully understand that family time and personal time are important, so combine all that by being on a committee call while on vacation, or teaching your partner to also make that call to the legislator, and bring the kids along to the meetings and add an extra day or two for fun time together. It's NOT "get a life". This IS our life!

resized__95x96_zachariahBrian Zachariah, MD, FACEP
TCEP President 2001-2002

Where are you currently practicing?

I'm not currently in clinical practice. I am the Chief Medical Coordinator for the Illinois Department of Financial and Professional Regulation, the agency which licenses and regulates physicians in Illinois. My position is analogous to that of Medical Director for the TMB.

Tell us about your experiences as TCEP President?

It was the best of times; it was the worst of times. Okay, really just the best of times.

What are some of your most memorable moments in TCEP?

I think I remember the Annual Meetings the most. Not necessarily the sessions, although I'll never forget those years on the TEB Panel, but the hallway conversations, networking and social events where friendships and professional relations are forged and much of the real work of the organization is done.

What was your greatest accomplishment as TCEP President?

The staff does such an excellent job with the day-to-day running of TCEP that the President's greatest accomplishment in that sense is to stay out of their way and let them do their job. In other contexts it's hard to claim any single accomplishment as one's own. I was proud to be part of several excellent Boards, both before and after my presidency. I think we represented the unique needs of Texas emergency physicians well in Austin and to ACEP and met their needs for quality educational programs and networking opportunities.

What was the state of Emergency Medicine during the time of your presidency?

In a lot of ways it was simpler then. Emergency Physicians practiced in EDs attached to hospitals. Urgent Care clinics were generally a lower tier of health care and were not considered by either the public or professionals as a substitute for the ED and free-standing EDs were just starting in other states.

What has TCEP meant to you through the years?

I met most of my professional mentors, role models and personal friends through TCEP. Leaving Texas and TCEP behind was one of the hardest things I've ever had to do.

resized__95x95_seayTim Seay, MD, FACEP
TCEP President 2007-2008

Where are you currently practicing?


Tell us about your experiences as TCEP President?

It was a great experience. Outside of my own group, this was the best leadership challenge I had ever had. It truly prepared me for a number of endeavors.

What are some of your most memorable moments in TCEP?

FINALLY getting the Annual meeting to somewhere besides Galveston, Austin or San Antonio!

What was your greatest accomplishment as TCEP President?

We grew everything, setting records for membership, dollars, annual meeting etc.

What was the state of Emergency Medicine during the time of your presidency?

Greatest specialty in the world, coming into adulthood.

What has TCEP meant to you through the years?

Best part, hands down, is getting to know well many others that I now count as friends.

zenarosaNick Zenarosa, MD, FACEP
TCEP President 2011-2012

Where are you currently practicing?

I currently live in the DFW area.
My current role is Physician leader and administrator.

Tell us about your experiences as TCEP President?

TCEP offers a great forum to share both clinical and nonclinical challenges facing EM in Texas.

What are some of your most memorable moments in TCEP?

My most memorable moment was the successful implementation of tort reform.

What was your greatest accomplishment as TCEP President?

I am most proud of restructuring contracts to align staff incentives with TCEP goals.

What was the state of Emergency Medicine during the time of your Presidency?

We have been in an upward swing to a state of a performance based professional organization. 

What has TCEP meant to you through the years?

TCEP provides a forum for all practicing Texas Emergency Physicians to collaborate despite at times being corporate competitors.


September 2013

Dear TCEP Member:

The Texas College of Emergency Physicians was chartered in June 1973. This marks the 40th anniversary of the most active medical specialty society in Texas. TCEP has a rich history of advocacy. Our Members have been on the front lines of medical education, patient advocacy, and healthcare delivery since TCEP was born. That tradition continues today. As part of our year-long celebration TCEP will publish a series of Presidential Reflections intended to provide our Members with a glimpse of the state of Emergency Medicine in Texas over the past forty years. Stories of the friends we made and the battles we fought to ensure a bright future for the next generations of Texas Emergency Physicians will be told. Those of us on the 40th Anniversary Commemorative Committee hope you enjoy reading these articles as much as we enjoy researching and presenting them.

Message From the President

Rick Robinson, MD, FACEP

TCEP President

Welcome to another edition of EMphasis - the official publication of the Texas College of Emergency Physicians. As this issue is under development we find ourselves at the start of another academic year. This is always a bittersweet time for those of us that work in graduate medical education. Graduating seniors leave our programs to begin to hone their craft and at the same time the fresh faces of new interns arrive on campus eager to earn their places as members of the one indispensible medical specialty of the last fifty years. Many Texas Emergency Physician Groups - both academic and community - are welcoming most of those recent graduating seniors into new clinical environments to begin their careers. About 20 percent of graduating Texas seniors will continue to serve their military families both in Texas and elsewhere around the globe. As the JPS, UTHSCSA, and UTSW-Austin programs begin graduating their first classes over the period 2014-2016 we will see a minimum of 135 new Emergency Physicians joining the workforce each year. Most will remain in Texas. Some will carry on the tradition of training the next generation of Emergency Physicians. TCEP is proud to remain a partner in this generational training process.

The celebration is officially on.

Speaking of generational processes … TCEP celebrated its 40th anniversary as a Chapter of the American College of Emergency Physicians in June. As the TCEP Board reflected on this during our July meeting we came to the only conclusion possible - celebrate the moment Texas style. Annual Meeting 2014 will host the TCEP 40th Anniversary Celebration at Moody Gardens Resort on Galveston. The planning committee is currently at work organizing the venue and events to commemorate this milestone in our history. Carrie de Moor, MD FACEP is chairing the committee. She is assisted by fellow BOD members Heidi Knowles, MD FACEP and Heather Owen, MD FACEP who are leading subcommittees to ensure the success of this project. An important piece of the anniversary celebration is a special feature series of Presidential Reflections that will be included in EMphasis over the next six months. The first installment appears in this issue. These reflections are intended to both honor our Past Presidents and provide insight into our history and growth as a professional organization. Additional information regarding commemorative activities will appear in EMphasis and other scheduled notices as we approach Annual Meeting 2014. Anyone wishing to participate in the planning activities should contact Nancy Davis at texacep@gmail.com.

Although the BOD is excited about the 40th anniversary we are also keeping our finger on the pulse of medical practice in Texas. Gil Shlamovitz, MD FACEP - a TCEP member on staff at Baylor College of Medicine - advocated to the Texas Medical Disclosure Panel (TMDP) that moderate (procedural) sedation consent language be separated from that of monitored anesthesia care on the uniform consent form. The process began in November, 2012. The issue ultimately made its way to a hearing of the TMDP in early summer 2013. As the hearing date approached Dr. Shlamovitz requested TCEP sponsorship of his proposal. The BOD quickly reviewed the matter and voted to support the proposed modification. TCEP L&A Fellow Nate Deal, MD provided supporting testimony on behalf of the proposal at the TMDP hearing. TCEP BOD member Carrie de Moor, MD FACEP was prepared to provide testimony as well. In a letter from TMDP Chair Dr. Appel TCEP was informed in early August that the proposal was adopted. This is an excellent example of TCEP advocacy for all practicing Texas Emergency Physicians and demonstrates the BOD's ability to mobilize resources on behalf of our members and patients. TCEP appreciates the hard work of Dr. Shlamovitz in recognizing this opportunity and advocating for its implementation.

Manish Shah, MD - a TCEP member on staff at Texas Children's Hospital - is working with the Pediatric Readiness Project and approached TCEP requesting a recommendation for an appointment to the EMS for Children Advisory Committee which meets quarterly in conjunction with GETAC. The TCEP EMS Committee recommended member Dominic Lucia, MD who is Pediatric Emergency Medicine trained and board certified and currently holds the appointment of Medical Director of the Pediatric Emergency Department at Scott and White in Temple. Dr. Lucia brings a level of training and experience to this appointment that is certain to benefit one of the most vulnerable groups we serve.

TCEP L&A Fellow Sandra Williams, DO who is on staff at Baylor College of Medicine was formally recognized by the Texas Medical Association for her leadership in developing the very successful Emergency Medicine CME program presented at TexMed in San Antonio during May 2013. Attendance at the Emergency Medicine track was 65% greater than that of other tracks on average. Dr. Williams developed a program that featured a mix of academic and community Emergency Physicians who provided both individual lectures and panel discussions. The Emergency Medicine lecturers and panelists were scored higher than lecturers in other tracks on average. Congratulations Dr. Williams and Team EM.

TCEP member Jonathan Larson, MD (San Antonio, Bexar County) and Arthur Lim, MD JD MBA (Houston, Harris County) were recently appointed to the TMA Leadership College (TMALC) Class of 2014. The TMALC mentors young physicians by introducing them to organized medicine in much the same way as the TCEP L&A Fellowship does.  TCEP congratulates Dr. Larson and Dr. Lim on their appointments as we continue to partner with our TMA colleagues in other specialties by representing the interests of our shared patients and their access to care.

TCEP was invited to participate in the TMA Choosing Wisely Project. Choosing Wisely is a national initiative that aims to promote conversations between physicians and patients by helping patients choose care that is supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary. ACEP is partnering at the national level and now TCEP is partnering at the state and regional levels. Young Physician BOD member Gerad Troutman, MD will serve as TCEP liaison to TMA on this matter. Dr. Troutman has considerable experience with TMA committees to date and will serve TCEP and its members well in his expanded BOD role as this project is fully developed.

As mentioned above the TCEP BOD met July 25-26 at ACEP headquarters in the DFW area. Standing Committee activities for the prior quarter were reviewed. We conducted our annual strategic planning meeting and assigned critical actions for the coming year. Sustained membership growth and retention remains one of these actions. A companion initiative to this will be a survey to ascertain TCEP value perception among current members. This tool is now under development and should be rolled out prior to distribution of the next EMphasis. I encourage all members to provide your feedback when you receive the survey. The BOD is committed to ensuring your membership is meaningful and provides measurable value. Our next BOD meeting is scheduled for September 26-27. We will once again meet at ACEP headquarters as we focus on the upcoming Council meeting. As a reminder TCEP Board meetings are open to all members so join us if your schedules permit. Those of you that are unable to attend can 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 current year.

The TCEP road show kicked off a new season of Residency visits in July. To date we enjoyed excellent turnouts as we visited JPS, UTSW, and a combined BCM/UT-Houston program. These visits are intended to provide individual lectures and panel discussions under the general umbrella of the business of Emergency Medicine. Topics such as career development, billing/coding, risk management, advocacy, and personal wellness comprise the average program. These visits are attended by TCEP members serving as lecturers, panelists, and ambassadors of their respective organizations. We are frequently joined by ACEP and EMRA leadership at one or more locations each season. TCEP members interested in participating in Residency and Medical School visits should contact Nancy Davis at texacep@gmail.com.

To reiterate a point that appeared in both the May and July EMphasis I want to take a moment to once again 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 Emergency Medicine. Pledging is easy and can be accessed through the TCEP website home page through September 30. 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.

Our very own Angela Siler Fisher, MD FACEP will receive the 2013 Joseph F. Waeckerle Founder's Award in Seattle during ACEP13. This is the highest award presented by the Emergency Medicine Residents Association (with over 10,000 members). Dr. Siler Fisher emerged the winner from a very competitive field of national EM leaders; a testament to her unwavering support and mentorship of Emergency Physicians in training around the country. The EMRA Fall Awards Reception will take place at the Seattle Sheraton Hotel on October 16.  The awards program will begin at 3:30pm local time.  I encourage all TCEP members whose schedules permit to attend the awards ceremony in support of Dr. Siler Fisher's achievement.

In closing I want to recognize a TCEP family member. Nancy Davis just celebrated her 20th anniversary as TCEP Executive Assistant. It has been a real pleasure to work with Nancy during my nine year tenure with TCEP. Whether organizing the day-to-day headquarters operations in Austin or coordinating events at Annual Meeting and Scientific Assembly Nancy keeps the TCEP machine moving forward. And she always does it with a smile on her face. During our time together I have come to regard Nancy as a trusted colleague and friend. On behalf of all TCEP members over the past twenty years I want to express our thanks and appreciation to Nancy for her commitment to serving TCEP and its mission of advocacy for our members and patients. Feliz aniversario y muchas gracias amiga.

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

Government Relations Committee Report

Diana Fite, MD, FACEP

Chair, Government Relations Committee

In the last Emphasis Government Relations Committee report, I mentioned that there was one bill in the last session that affects us but we did not get a chance to weigh in on it before it was too late.

That bill was SB 1191, introduced by Senator Wendy Davis, regarding sexual assault evidence collection and treatment of victims. For many years, emergency physicians had been the usual physicians to treat sexual assault victims, and the ED nurses or techs would generally collect all of the evidence (scrapings under the nails, pulling of scalp hair and pubic hair, oral swabs, collection of loose hairs and other debris from genital area) and the emergency physicians would collect the evidence obtained from the pelvic exam and when applicable, from the rectal exam. Over time, the sexual assault nurse examiner (SANE) course was developed so that trained nurses could complete all the evidence collection, and they would administer treatment related to the assault under the emergency physician's oversight. Of course, the emergency physician would evaluate any injuries or other medical problems. In order to adhere to chain of custody or chain of evidence rules, one person other than the victim would have to stay in the exam room with the evidence collection from start to finish, then have to either hand the evidence kit over to the police or keep it locked up until the police could receive it.

Evidence gathering techniques are now more sophisticated and the best collection methods will include using colposcopes to look for evidence of injuries. It had become evident that conviction rates were improved with thorough collection techniques and improved knowledge about adherence to chain of custody procedures, so about 15 years ago, a legislative change occurred in Texas that required victims to be examined by a SANE examiner if at all possible, or at least at a facility designated for treatment of sexual assault survivors. This meant following EMTALA regulations and transferring the patients after acceptance by the receiving facility. Most transferring facilities insisted upon transfer by ambulance, which meant the survivor/victim had to leave their means of transportation behind. This legislative change was welcomed wholeheartedly by emergency physicians who were finding it more and more difficult to have time to participate in the evidence collection, and often could not see the patient in a timely manner as evaluation and treatment of the more serious patients had to take precedence over these survivors.

Apparently one or more victims complained to Senator Davis about having to be transferred far from where the car had been left and having major difficulty getting back to their car, and multiple victims did not understand why they had to be transferred in the first place. Senator Davis sought to amend the Health and Safety Code so that as of September 1, 2013, the health care facility that is not designated for treating sexual assault survivors must inform the survivor that the facility is not the community's designated facility, must provide the survivor with the name and location of the designated facility, but must inform the survivor that the survivor has the option to receive care, including collection of evidence, at the current facility.

The bill requires that the person performing the collection of evidence must have basic collection training, or "equivalent education and training", which should cover emergency physicians. However, one problem with this is that the physician might end up being the only person allowed to collect any and all of the evidence, including pulling hairs from the scalp and other evidence collection that has not required a physician in the past, if other providers have not taken the "basic collection training". The bill requires all health care facilities that have emergency departments to submit to the Department of State Health Services (DSHS) a plan for complying with the provisions that must be provided to sexual assault survivors. The bill also requires the facilities to develop a plan to train personnel on collection of sexual assault forensic evidence.

We now have many emergency physicians in Texas who have never performed the evidence collection for a "rape kit" and this could present a major problem with this bill. Even more worrisome is that many emergency departments are so crowded now that there is no way a physician will be able to stay in the exam room for the time it will take to perform the rape kit, especially when only one emergency physician is on duty. The same problem will be present for the nurses. We need to make the point that we are not "evidence collectors". The physicians evaluate and treat patients. We should not be expected to collect evidence for the police. We must encourage the hospitals to provide SANE education to the nurses or set up a plan for the sexual assault nurse examiners to be able to enter the facility for purposes of collecting the forensic evidence. The bill is actually directed toward the health care facility rather than toward the emergency physicians, although the hospital may try to interpret that differently.

All our members need to be aware of this bill so that the group can decide how to handle these changes or be prepared to help the hospital understand the facility is responsible for providing the personnel to collect evidence for the police. We will keep our members informed of further information about this legislation.

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.

News From the Practice Enhancement Committee

Zachary Goldman, MD

For this issue I wanted to address CPR and CPR in conjunction with critical care. We will leave the larger issue of critical care for a later discussion.

CPR has its own specific code and so it is a separately billable procedure along with the E/M level generated. CPR involves the provision of cardiac life support including chest compression and ventilation. It is important to note the provider does not have to directly perform the CPR to bill for it, they can be directing the activities while others perform the actual process. The time doing CPR has no bearing on billing so it could be one minute or 100 minutes or on and off for an hour and it is all the same.

Code 92950: 5.38 RVUs

As one might imagine these patients are acutely ill and would meet criteria for critical care. The question is what transpires during the course of the visit. Just like any other separately billable procedure that time must be subtracted from the critical care time. Take the case of a patient arriving in cardiac arrest via EMS with CPR in progress. The patient arrives and you continue CPR and intubate the patient. You continue CPR for 30 minutes while you talk with family and after 35 minutes you call the code. In this case you can bill for the CPR and the intubation but if you subtract out the time for the CPR and intubation there is less than 30 minutes of independent critical care time involved. You may still document that critical care was performed but not 30 minutes of independent critical care. In this case you would most likely bill for CPR, intubation, and an E/M Level 5 visit. There are instances when both critical care and CPR can be billed. The patient presenting with CPR in process and ultimate return of spontaneous circulation that is then admitted to the ICU. In this case CPR was performed and can be billed and at the time of return of spontaneous circulation the critical care clock can start and if there is greater than 30 minutes of total critical care time after subtracting out time spent on CPR and other procedures (intubation, central line etc.) then both can be billed. Another common occurrence could be intermittent return of spontaneous circulation. In these cases each time CPR is restarted the time of CPR must be subtracted out. In these cases if the time interval is greater than 30 minutes between successive  CPR activities and other billable procedures then again critical care can be considered.

Please note this is the same for a code you may be called to manage on the floor. While you might not be able to bill for critical care you can still bill for the CPR and for the EM Level which in almost all of these cases should come out to an E/M Level 5 if you both perform and document the necessary components for a Level 5 chart. In this case do not be afraid to use the history caveat statement unable to obtain secondary to… (Respiratory failure, CPR in progress etc.).

Example: CPR (5.38) + intubation (3.22) + E/M level 5 (4.93) = about 13.53 RVUs
CPR (5.38) + intubation (3.22) + critical care (6.40) = about 15 RVUs

*** these may not reflect RVUs in your practice******

The take home message is making sure if CPR is performed that you are documenting that it is being done and that you are billing for it. Also, make sure in those situations where CPR is performed and there is return of spontaneous circulation with greater than 30 minutes critical care rendered apart from separately billable procedures that you document critical care time also. Finally, even if there is not greater than 30 minutes of critical care time, do not be afraid to document less than the 30 minutes of critical care time as that will add to medical decision making.

Psychiatric Boarding: How does Texas Stack Up?

Laura Medford-Davis, MD

Chief Resident, Baylor College of Medicine

TCEP Leadership and Advocacy Fellow 2013

Boarding, the time between decision to admit and when a patient leaves the emergency department (ED), is a growing problem for all patients, but psychiatric patients remain in the ED 3.2 times longer than non-psychiatric patients. Boarding lasts so long that in one study each bed occupied by a psychiatric boarder could have turned over to see 2 additional patients, increasing crowding and wait times for all ED patients.

National surveys in 2008-2010 of the extent of the problem found that 60% of psychiatric patients in 86% of hospitals experience long boarding times: 24-48 hours in 50% of hospitals and 5 days or more in 21% of hospitals. Providers cite a lack of inpatient beds as the biggest contributor to boarding.3 There were 400,000 public beds in 1970 and only 50,000 in 2006, an 89% decline in publicly-funded beds compared to the 62% decline in all beds from 1970-2003.5 The minimum standard for inpatient psychiatric beds is 50 beds per 100,000 population, but the US currently provides just 28% of those required, 14.1 per 100,000 population in 2010, no increase from the 14 per 100,000 that existed in 1850 when inpatient psychiatric treatment first began. Although Texas did not close any beds between 2005 and 2010, Texas has only 8.5 per 100,000, placing it among the fifteen states that have less than 10 per 100,000, and 41st in the nation. Total public spending nationwide on mental health services decreased 30% from 1955 to 1997, and Texas ranks 49th nationally in per capita mental health expenditure. While Bexar and Harris Counties have innovative jail diversion and crisis response systems, there is little investment in long-term care to prevent crisis.

To address the boarding crisis, EDs can provide psychiatric assessment and de-escalation training to staff and providers who may have only minimal psychiatric training yet are finding themselves on the front lines of treatment. Quiet areas for psychiatric patients separate from the main ED prevent further deterioration of psychiatric crises, while protocols that initiate psychiatric treatment in the ED can improve patients' illnesses while they wait.1 Case managers that proactively locate and schedule outpatient mental health services and other resources can halt the revolving door that keeps ED patients returning in crisis after crisis.5,6,9

However EDs cannot solve the problem alone since they do not control all of the issues that affect psychiatric boarding such as ED crowding, inpatient and outpatient psychiatric service availability and financing, and local laws and regulations regarding mental health. EDs, the community, and the government must take joint ownership of the problem. HB-245 was proposed during the recent Texas legislative session promoting the authority of ED and EMS providers to hold and transfer psychiatric patients without waiting for a warrant or court order, but it did not make it out of the public health committee. Other states have taken steps to address psychiatric boarding that might be helpful here. To match boarded patients to available inpatient beds more quickly, some states including Virginia and Maryland are creating state-wide electronic dashboards where ED staff can view all available beds simultaneously, rather than calling each psychiatric facility individually as they do currently. Such systems leverage technology to allow more efficient use of existing psychiatric beds and ED staff time, and could also be helpful if applied to outpatient psychiatric services.9 Montana guarantees access to short-term inpatient psychiatric care regardless of insurance status, and some states reimburse treatment of psychiatric disease for the uninsured.6,10 Get involved with First Tuesdays and other advocacy efforts next legislative season to push for HB-245 and other bills to improve Texans’ access to psychiatric care.

1 Manton, A. "Psychiatric patients in the Emergency Department: The dilemma of extended lengths of stay." March 2010. American Psychiatric Nurses Association.

2 Falvo T, Grove L, Stachura R, et al. "The opportunity loss of boarding admitted patients in the emergency department." Acad Emerg Med 14.4 (2007): 332-7.

3 ACEP. "ACEP Psychiatric and Substance Abuse Survey." 2008. 

4 Schumacher Group. "Emergency Department Challenges and Trends 2010 Survey of Hospital Emergency Department Administrators." 2010. 

5 Bender D, Pande N, and Ludwig M. "A literature review: Psychiatric boarding." US Department of Health and Human Services, 2008. 

6 Bender D, Pande N, and Ludwig M. "Psychiatric Boarding Interview Summary." US Department of Health and Human Services, 2009. 

7Appelbaum, P. "The 'quiet' crisis in mental health services." Health Affairs 22.5 (2003): 110-6.

8 Treatment Advocacy Center. "No room at the inn: Trends and consequences of closing public psychiatric hospitals." 2012. 

9Alakeson V, Pande N, and Ludwig M. "A plan to reduce emergency room 'boarding' of psychiatric patients." Health Affairs 29.9 (2010): 1637-42.

10 National Alliance on Mental Illness. "Grading the States 2006: A report on America's health care system for serious mental illness." 2006. 

11 Maryland Hospital Association. "Mental Health: Strengthen the fragile infrastructure." 2012.


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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