Board Meeting Minutes

American Academy of Emergency Medicine
Minutes of Board of Directors Conference Call
January 9, 2002

IN ATTENDANCE: Robert McNamara, MD; Joseph Wood, MD, JD; Carol Barsky, MD; Howard Blumstein, MD; William Durkin, Jr., MD; Antoine Kazzi, MD; Geoffrey Mitchell, MD; Raymond Roberge, MD, MPH; Tom Scaletta, MD; Leslie Zun, MD. Absent: Drew Fenton, MD; Margaret O'Leary, MD, MBA; Scott Weiner, MD. Guest: Joseph Lex, Jr., MD. Staff: Kay Whalen and Beth Wilson.

Dr. McNamara welcomed everyone to the call including AAEM Education Chair, Joseph Lex, Jr., MD, and turned the Board's attention to the first agenda item.

I. Approval of November 13, 2001 Conference Call Minutes

Dr. McNamara asked if there were any corrections to the draft minutes included in the agenda packet. Dr. Barsky noted that in Section V., the first "Whereas" should read "Whereas typical emergency physicians do not practice inpatient medicine." Dr. Scaletta moved and Dr. Zun seconded that the draft November 13, 2001 Board of Directors conference call minutes be approved with the above change. MOTION PASSED UNANIMOUSLY.

III. Education Committee Report

Dr. McNamara then asked Dr. Lex to give the Education Committee report. Dr. Lex noted that the 2002 Scientific Assembly program had been finalized and that the Education Committee was already beginning to plan the 2003 program.

Dr. Lex then proposed that AAEM purchase LCD projectors which could be used at the Scientific Assembly, Oral Board Review Courses and any other AAEM educational sessions. This purchase would reduce expenses overall due to the high cost of renting these projectors. Dr. Wood moved and Dr. Scaletta seconded that AAEM purchase up to three LCD projectors. MOTION PASSED UNANIMOUSLY.

Next, Dr. Lex asked the Board to consider the proposal to reestablish a Written Board Review Course in the fall of 2002. Sam Kini, MD, has volunteered to serve as course director. A budget for this course was included in the agenda materials. After discussion, Dr. Wood moved and Dr. Durkin seconded that AAEM move forward with reestablishing a Written Board Review Course in the fall of 2002. MOTION PASSED UNANIMOUSLY.

In addition, Dr. Lex asked the Board for input on an AAEM "blitz session" the night before the ABEM written exam. The Board was in favor of AAEM's Education Committee pursuing this initiative.

Finally, Dr. Lex reported that the eMedHome CME program was quite successful. Over 5,000 CME credits had been generated through this mechanism. He asked that the Board consider some type of stipend for Dr. Richard Nunez for this venture. The Board deferred on this discussion at this time.

IX. Joint Sponsorship

Since Dr. Lex was still on the call, Dr. McNamara then turned the Board's attention to the request for joint sponsorship from the organizers of the Naval Conference in San Diego. Dr. McNamara reminded the Board that the Executive Committee had approved this application in 2001, but the Board had some fiscal concerns regarding this program at that time.

After a lengthy discussion, Dr. Barsky moved and Dr. Kazzi seconded that the Executive Committee be empowered to decide if AAEM should partner with the San Diego Naval Medical Center after AAEM has received budget and attendance figures for the 2001 and 2002 meeting. MOTION PASSED WITH DR. DURKIN ABSTAINING.

IV. Scientific Assembly Update

Ms. Whalen reported that as of January 3, 2002, there are 228 registrants for the Scientific Assembly. Dr. Lex reported that all slots for the open mike session were filled within 36 hours of AAEM's e-mail notification to members.

At this point, Dr. McNamara thanked Dr. Lex for all of his efforts on behalf of AAEM in AAEM's educational programming. Dr. Lex then left the call.

II. President's Report

Dr. McNamara then turned the Board's attention to the draft tPA position statement that had been circulated by e-mail. He stated that he had appointed a four-member task force to draft the statement. He also presented an addition to this statement drafted by Dr. Jerome Hoffman.

Dr. Barsky moved and Dr. Mitchell seconded that the suggested addition which reads, "Given the cited absence of definitive evidence, AAEM believes it is inappropriate to claim that either use or non-use of intravenous thrombolytic therapy constitutes a standard of care issue in the treatment of stroke." be added to the draft position statement on tPA use. MOTION PASSED UNANIMOUSLY.

Dr. Durkin moved and Dr. Barsky seconded that the tPA position statement which now reads:

Position Statement of the American Academy of Emergency Medicine on the Use of Intravenous Thrombolytic Therapy in the Treatment of Stroke

Submitted to AAEM by the Work Group on Thrombolytic Therapy in Stroke

Background
For many years physicians have been frustrated by the lack of an effective treatment for ischemic stroke. Thus, the introduction of tPA therapy for acute ischemic stroke was met with considerable enthusiasm. Following the favorably reported results of the 1995 National Institute of Neurological Disorders and Stroke (NINDS) trial¹ the Food and Drug Administration approved tPA use for stroke. This therapy was subsequently endorsed by several medical professional societies, including the American Heart Association (AHA) and the American Academy of Neurology. In 2000, the AHA upgraded its recommendation on the use of tPA for acute ischemic stroke from a Class IIb ('optional') to a Class I ('definitely recommended') intervention.^2,3 Despite these endorsements, debate about the efficacy, safety, and applicability of tPA has limited its widespread use. Nonetheless, an increasing number of liability suits are emerging against physicians for not administering tPA based on the assumption that it represents a standard of care. Because of these continuing concerns, the American Academy of Emergency Medicine established a workgroup to study whether or not tPA should be regarded as the standard of care for the treatment of eligible patients with acute ischemic stroke.

Discussion
Efficacy concerns. The NINDS trial was a randomized controlled study evaluating the efficacy and safety of tPA when administered to carefully selected stroke patients within 180 minutes of symptom onset.1 It reported an 11% absolute increase in the number of patients recovering without significant disability at 90 days (number needed to treat = 9).

Though these results appeared promising, the NINDS trial has been criticized for two potential methodological flaws. First, the trial selectively enrolled an equal number of patients treated within 0-90 and 91-180 minutes of stroke onset, with greater benefit shown for those in the former group.4 Such selective enrollment likely skewed the participants toward earlier treatment than would be encountered in clinical practice so that overall results were rendered poorly generalizable. Second, stroke severity in the group treated in the later time strata was greater in the placebo than in the tPA group, again potentially biasing the results in favor of treatment.^4,5

Other thrombolytic trials have demonstrated less encouraging results. To date, seven randomized controlled studies have evaluated the efficacy of thrombolytic therapy for stroke. With the exception of the NINDS trial, none have shown benefit in any of their primary outcome measures.^{1,6,7,8,9,10,11}

Safety concerns. Three trials have evaluated streptokinase for acute ischemic stroke. Each was prematurely terminated due to excessive deaths in the treatment group.^6,7,8 Four trials have evaluated tPA for stroke. Each showed higher rates of intracranial hemorrhage and increases in either short-term or long-term mortality with treatment.^1,9,10,11 In the NINDS trial, treated patients had a 10-fold increase in the incidence of symptomatic intracranial hemorrhage with an absolute increase in risk of 5.8% (number needed to harm = 17). One in 34 tPA-treated patients died as a result of intracranial hemorrhage.

Applicability concerns. The NINDS trial was conducted in expert settings with dedicated stroke teams, designated laboratory, and rapid radiologic imaging resources. This infrastructure allowed rapid identification both of patients having strokes and of those with contraindications to thrombolytic therapy. Issues regarding the need for such resources to ensure appropriate patient selection must be addressed.

Two studies have shown that patients with stroke mimics were frequently misdiagnosed with strokes.^12,13 Administration of tPA to such patients would carry all of the bleeding risks without any of the potential benefits. A separate study assessing clinicians' ability to interpret CT scans showed an alarming rate of misread CT's, with emergency physicians identifying only 73% of hemorrhages.¹⁴ Only 52% of radiologists in this study were able to identify all cases of hemorrhage on five cranial CT scans. Post-marketing registries and regional databases have yielded conflicting results regarding the effectiveness of this therapy in clinical practice, making it difficult to determine the true impact of widespread implementation of thrombolytic protocols.^15,16

Conclusion
It is the position of the American Academy of Emergency Medicine that objective evidence regarding the efficacy, safety, and applicability of tPA for acute ischemic stroke is insufficient to warrant its classification as standard of care. Until additional evidence clarifies such controversies, physicians are advised to use their discretion when considering its use. Given the cited absence of definitive evidence, AAEM believes it is inappropriate to claim that either use or non-use of intravenous thrombolytic therapy constitutes a standard of care issue in the treatment of stroke.

be adopted. MOTION PASSED UNANIMOUSLY.

VI. Membership Report

Ms. Whalen reported that AAEM currently has 718 paid full voting members for 2002 compared to 567 paid full voting members at this point last year.

Next, the Board turned its attention to the request for emeritus membership status from two full voting members. Dr. Wood moved and Dr. Roberge seconded that Jack Henriquez, MD, be granted emeritus status. MOTION PASSED UNANIMOUSLY.

Dr. Wood moved and Dr. Kazzi seconded that John W. Bell, II, MD, be granted emeritus status. MOTION PASSED UNANIMOUSLY.

VII. AMA Representation

Dr. McNamara reminded the Board that AAEM had applied for membership in the AMA's Specialty and Service Society in the past, but had failed to meet the requirement for number of AAEM members who belong to the AMA. He reported that the Executive Committee recommended that we once again apply for membership and encourage our own members to join the AMA. Dr. Wood moved and Dr. Durkin seconded that AAEM once again apply for membership in the Specialty and Service Society of the AMA. MOTION PASSED UNANIMOUSLY.

VIII. T-System Advertising

Dr. McNamara indicated that recent T-System ads that offended some emergency physicians was on the agenda to determine if AAEM should write an official letter to T-System protesting the campaign. Dr. Roberge reported that he had written a letter as an individual physician expressing his concern. Dr. Wood moved and Dr. Roberge seconded that AAEM not take official action by sending a letter of protest to T-System. MOTION PASSED 9-1.

X. New Business

Dr. McNamara then reported that the Executive Committee had selected the following award recipients for 2002:

Young Educator Award - Amal Mattu, MD
Resident/Fellow of the Year - David Huang, MD
James Keaney Award - Joseph Lex, Jr., MD
Peter Rosen Award - Jerris Hedges, MD
David K. Wagner Award - James Roberts, MD

Dr. McNamara then reported that CAL/AAEM was requesting that its Board members need not be board-certified if they were residency graduates who had not yet taken their exams. After much discussion, Dr. Wood moved and Dr. Roberge seconded that CAL/AAEM be allowed to accept residency-trained individuals who were not yet board-certified to hold a position on the CAL/AAEM Board for one cycle (two years). MOTION PASSED 7-3.

At this point, Drs. Wood and Roberge left the call.

Dr. Kazzi reported that the Student Rules of the Road was under way. Ms. Whalen reported on printing estimates for the book. The Board felt it best to wait until the March Board meeting to determine how this publication would be disseminated.

Dr. Barsky reported that she had been in contact with the president of the AAEM-India society and he was willing to change the organization's name. She would meet with him again during our Scientific Assembly.

Dr. McNamara polled those on the call to see if they would be available for a brief Board meeting at the conclusion of the Scientific Assembly. Due to the difficulties flying east, this did not seem feasible. Dr. McNamara suggested that this be considered for subsequent meetings.

There being no further business, the conference call meeting was adjourned.

Respectfully submitted,

Kay Whalen
Organizational Director