Spring 2014

 Spring 2014

President’s Message

Larry Slaughter, MD, FACEP

The Missouri Chapter of the American College of Emergency Physicians is at a transition point. Our membership has increased and we are making the transition from small to medium sized chapter.  With this change we have the need for an increased role and time commitment from an executive director. In the past we’ve had a very limited role for this person. As the board has evaluated the future of our chapter it was felt that we would need someone who could commit more time and energy to pursue the work and goals of the Board and chapter. Subsequently, the board has directed a nominating committee to evaluate bids for a part-time executive director. A number of companies were evaluated and interviewed. The final selection should be made in the next few weeks. With this increased role obviously comes an increased cost. Our plan is to have this new executive director increase our non-dues income and membership with new services. In the immediate future we will cover this cost from reserves and a dues increase. As the board evaluated different funding mechanisms for this part-time position it became apparent that we had not raised dues since 1998. In that timeframe we as a chapter have been quite successful on a number of initiatives. We have increased your Medicaid reimbursement rates. We have been a key voice in supporting the current seat belt and helmet laws. We have been involved in a number of public safety issues including a program we initiated with the emergency nurses association called “Battle of the Belt”. This program teaches high school students about using seat belts and challenges them to compete against neighboring high schools for prizes. In the last year we redesigned our website and established a place in the social media world with both a Facebook and Twitter presence. We have been successful expanding our prior Board member visits at the Missouri Capitol to an Advocacy Day in January. This Advocacy Day included legislative visits, presentations and involvement of a number of residents from the programs at UMKC, St. Louis University, and Washington University. Despite all that we have accomplished, the board also recognized we could do even more if we had more support and an expanded executive director role. I look forward to your comments and questions concerning these issues and hope you will continue to support the work that we are doing with your continued membership with the Missouri College of Emergency Physicians. This is my last presidential article. It has been my honor to represent you and your interests over the last two years. I thank you for your support. We will be having elections for the board at our next meeting, April 5. The candidates in the upcoming elections for our board and officers are imminently qualified and represent the best in emergency medicine. I hope you will join us in St. Louis at the MSMA conference and get to meet your future board members and officers.

MOCEP Education Day and General Meeting

Douglas Char, MD, FACEP

What:  Missouri College of Emergency Physicians Education Day and General Meeting When: April 5, 2014 from 0730-1430 Where: Renaissance St. Louis Airport Hotel Cost:  FREE to MOCEP and EMRA Members MOCEP will be holding our General Meeting in conjunction with the Missouri State Medical Association Annual Meeting on April 5, 2014 at the Renaissance St. Louis Airport Hotel. We have a full day of education and advocacy planned. Come learn about the Emergency Infections and the latest on use of Anticoagulants in NSTEMI and ACS from nationally recognized experts.

We promise to make this years LLSA exam a worry-free experience thanks to tips help from colleagues at Washington University and St Louis University. Hans House, MD (University of Iowa) from the ACEP Board of Directors will share his perspectives on national trends and what ACEP is doing for our specialty.

Best of all this jammed packed day is FREE to members. Once again the MOCEP board has decided to use chapter funds to cover the cost for all attendees. The Renaissance is offering a special rate of $96 for single/double/triple/quad occupancy. Make your reservations by Wednesday March 12th, and be sure to mention MSMA. Find more information online . Send RSVPs to Margie.

*Board of Directors meeting to immediately follow (open to all members) Click here for the MSMA conference information Click here to obtain information for the Renaissance St Louis –Airport Hotel

MOCEP Bylaws Amendment – Vote

Rob Poirier, MD, FACEP

The MOCEP General Membership Meeting will take place April 5, 2014 during MOCEP’s Education Day at the Missouri State Medical Association meeting. Dr. Larry Slaughter, MOCEP President will provide an update on chapter status and activities. In addition, membership will be asked to consider an amendment to the bylaws to expand the Board of Directors from 14 to 16 persons. (Article VI, Section 2): The Board of Directors shall be composed of 16 voting directors including the officers. Article VI Section 2 currently states the Board of Directors shall be composed of 14 voting directors. MOCEP membership continues to grow and currently stands at over 500 members. We have more interest from members wanting to be on the Board of Directors. Several MOCEP members asked for the number of Board of Directors to be increased so the General Membership will vote on this bylaw change. The current MOCEP bylaws can be found under the member’s only section of our website by clicking here. The bylaw change will be voted on first at the General Membership meeting. If passed, the General Membership will then elect five board members to open seats. If you are interested in serving on the Board, please email Larry Slaughter, M.D. so you can be added to the nomination slate. Nominations will also be taken from the floor at the General Membership meeting. The membership present at the General meeting will elect three councillors who will serve three years and attend the ACEP Council meeting held annually in the fall. Our state chapter will send six voting representatives to Chicago this year, an increase from the previous five. If you are interested in serving as a MOCEP councillor, please email Larry to be added to the nominee slate. If you have any questions or need further information about the upcoming elections, recommended bylaws change, or councillor responsibilities, please contact MOCEP Treasurer Rob Poirier, M.D. There is no cost to MOCEP members to attend the upcoming Education and General Membership meeting. Please RSVP to Margie  so that we can get a head count for lunch.

First MOCEP Annual Advocacy Day 2014

Jonathan Heidt, MD

This past January, MOCEP hosted our first Annual Advocacy Day! A total of 25 emergency medicine physicians and residents from around the state gathered in Jefferson City to discuss legislative topics with our representatives and senators that are important to our patients and our specialty. It is easy to dismiss advocacy as simply “politics” or efforts best left to lobbyists. However, as emergency physicians, we practice advocacy every day. Every time we stand up on behalf of a vulnerable patient, or struggle to obtain the resources we need to provide quality emergency care for our communities we are acting as an advocate.

Unfortunately, the challenges that we must face in order to provide high quality care for our patients goes beyond our local emergency departments and hospitals. Laws such as EMTALA, HIPAA and the Affordable Care Act impact our practice on a daily basis. As emergency physicians, we must work together to insure that safe and high quality emergency care continues to be available to our patients – wherever and whenever we are needed!

As a group we met with Dr. Keith Fredrick and Rep. Kevin Engler to discuss our current issues of medical malpractice reform, a prescription drug monitoring program, and Medicaid expansion. After several interesting and lively discussions, our participants then had the opportunity to meet with their own representatives and senators. Overall the event was a huge success and we are already planning for next year! If you have any questions or would like more information, please contact Jonathan.

Missouri’s Time Critical Diagnosis System – Update

Brian Froelke, MD    Missouri State EMS Medical Director, Department of Health and Senior Services

In May 2008, just one day after the death of its visionary Dr. John William (Bill) Jermyn III, the success of Missouri House Bill 1790 marked the start of Time Critical Diagnosis (TCD) in our state. Dr. Jermyn was a past President of MOCEP and the state’s first full-time EMS Medical Director. He realized that the level of care available to injured and sick patients depended on where in the state you lived. He envisioned changes to pre-hospital and emergency care so that every citizen had access to the best possible care. TCD focuses on creating a Stroke, Trauma, and STEMI care system that delivers “the right patient to the right place in the right time and provides the right care.” Modeled after the trauma system, TCD creates a network of care from EMS triage and transport, to public education, to several levels of state designated specialty care centers. For several years statewide and national partners gathered together to build the infrastructure for this “evidence based” approach to patient care that understands that “minutes matter” in these diagnoses and follows the patient throughout the entire medical experience looking for areas of improvement in accuracy and efficiency.

The statutory regulations supporting TCD were completed and submitted to the Department of Health and Senior Services last year. Each of the state’s six EMS regions has been working to develop implementation plans for Stroke, Trauma and STEMI. Hospitals have to decide what level of care they can provide (Level 1 to 4) and preparations are underway to meet those new requirements at many facilities.

Currently we are accepting applications for Missouri Stroke Center designations and are in the process of reviewing the over 40 we have received. While this rollout is occurring, we remain hard at work on the internal review of the trauma regulations as well as preparations for STEMI Center application acceptance. In the midst of these projects we are also working with our beta test sites on several database and registry updates to meet the new TCD Registry needs. We welcome support from our partners in assisting with professional training and continue our public education efforts. Resources for such efforts, as well as public service announcements, may be found at this website.

Enhancing Older Adult Emergency Care: Introducing the American College of Emergency Physicians/American Geriatrics Society/Emergency Nurses Association/Society for Academic Emergency Medicine Geriatric Emergency Department Guidelines

Christopher R. Carpenter, MD, MSc (Chair, ACEP Geriatric Section)

In October 2013, the American College of Emergency Physicians and Society for Academic Emergency Medicine Boards of Directors officially approved the Geriatric Emergency Department Guidelines. These guidelines represent recommendations for geriatric adult emergency care and add to those previously provided by the British Geriatrics Society entitled The Silver Book. The guideline authors are practicing emergency physicians and the intent of this work is to help nurses, clinicians, hospital administrators, and health care systems to optimize geriatric emergency care within their institution based upon patient needs and available resources. We anticipate many questions and concerns related to these recommendations so this introduction is meant to help ICEG members to understand these new recommendations.

1. Why now?
2. How were these guidelines derived?
3. What are the GED Guidelines?
4. What is next?

Emergency Geriatrics – The United States Experience In 1990 America, emergency medicine had no geriatric emergency care interest groups, textbooks, or dedicated mentors. Very little research existed to understand the unique needs or ED management related outcomes of this population. The demographic imperative of a rapidly aging baby-boomer society was sluggish to awaken change in geriatric emergency medicine. During this period, the John A. Hartford Foundation decided to focus on improving geriatric health care outcomes. Recognizing the cross-disciplinary role of emergency medicine, they approached UAEM, the precursor of SAEM with a challenge to develop a body of expertise in geriatric emergency medicine education, research, clinical operations, and policy-making. This resulted in the formation of the first Geriatric Emergency Medicine Task Force in 1991 and an entire issue of Annals of Emergency Medicine dedicated to geriatric emergencies in 1992. These manuscripts described the current state of affairs for geriatric emergency care while outlining an agenda for future research and educational initiatives. The energy and productivity of this first Task Force led to a larger grant from the Hartford Foundation in 1993 that ultimately led to the first textbook (Emergency Care of the Elder Person in 1996), as well as multiple research projects that further defined the epidemiology of geriatric syndromes in the ED (falls, delirium, dementia, polypharmacy). In 2000, the Geriatric Interest Group (now Academy for Geriatric Emergency Medicine) was born at SAEM followed soon thereafter by the ACEP Geriatric Section in 2003. These geriatric emergency medicine groups came to the realization that abstract presentations, traditional CME lectures, manuscripts, and textbooks alone were insufficient to align emergency care of older adults with geriatric management principles. Emergency medicine needed a structured document containing best practice recommendations from geriatric emergency care health care providers, researchers, and advocates. Consequently, work on the GED Guidelines began in 2011. Deriving the GED Guidelines Leaders within the ACEP Geriatric Section and AGEM identified representatives from ACEP, AGS, ENA, and SAEM organized a series of teleconferences during the years 2011 and 2012. The 14 GED Guidelines co-authors split into two working groups: “structural and staffing” and “clinical/operational”. Each group reviewed the literature and provided best-evidence recommendations for essential geriatric emergency care. Between October 2013 and February 2014, ACEP, SAEM, AGS, and ENA Boards of Directors officially approved the guidelines and on February 14 2014, they were posted online for ICEG members.   Components of the GED Guidelines – Perceptions and Realities The Geriatric ED Guidelines consist of 40 specific recommendations in six general categories: Staffing, Transitions of Care, Education, Quality Improvement, Equipment/Supplies, and Policies/Procedures/Protocols. The GED Guidelines are not intended for every community in the world to open geriatric-only EDs. Most health care systems lack the financial resources, staffing levels, or patient volumes for stand-alone geriatric EDs to be feasible. The guidelines are not an authoritarian dictate for every ED to develop and sustain all of these elements. However, every ED that provides emergency care for geriatric adults ought to be aware of these guidelines, the rationale for the recommendations, and the resources available to transition from theory to implementation. The Future of Geriatric Emergency Care These guidelines represent a two-year effort from multiple organizations and individuals committed to optimizing the emergency care delivery model for geriatric adults. We believe that the geriatric adult in the ED represents the “canary in the coal mine” for our health care system. If we can successfully navigate the challenges that this vulnerable population presents to 21st Century medicine then all age groups will benefit from a reliably available, compassionate, and efficient emergency care system. However, we fully recognize that the GED Guidelines are a beginning not an end so the authors lay out a plan forward that includes dissemination, implementation, adaptation, and refinement.

• More research. The empiric basis for our recommendations are based on rather weak research evidence in most cases so sustainable funding opportunities are needed to enhance the evidentiary basis of these protocols, as well as the pool of future geriatric emergency medicine thought leaders.
• Prioritization. The 40 recommendations need stratification into essential and non-essential domains so that hospital administrators, payers, and research funders can develop a systematic approach to local implementation.
• Raising Awareness. Emergency medicine clinicians, hospital administrators, patient advocacy leaders, and patients should be aware that the GED guideline exists. However, adult learning theory and implementation science indicate that hands-on learning is simultaneously more desirable for learners and effective in terms of sustained practice change. Therefore, the guideline group is also developing a “Geriatric Emergency Department Boot Camp” program in which geriatric emergency medicine leaders bring the recommendations, a toolbox of resources, pragmatic examples from their own institutions, and mentorship to interested programs so that nurse- and clinician-providers do not need to travel and essential ancillary providers like social work, case management, consultants, hospital administrators, and payers can also participate. The intent is for participants in the boot camps to devise quality improvement projects with which the boot camp faculty will assist and for which one-year outcomes will be assessed.
• Refinement. The boot camp concept also provides a tangible test tube to evaluate the feasibility, acceptability, and barriers to existing GED Guideline recommendations – knowledge that will be used to refine the 2nd Edition of GED Guidelines in coming years.

Super Utilizers – cutting the Gordian Knot of Health Care Spending

Randy Jotte, MD, FACEP

As healthcare reform advances from legislative buildings and insurance corporate headquarters to hospitals and emergency departments, we increasingly hear about “Super-Utilizers,” also known for years by those in clinical departments as Frequent Fliers. Who exactly are these “Super-Utilizers” and why so much attention now? Super-Utilizers are patients you may think you know quite well. You also may be surprised. Perhaps “Wally” is in your ED for the 5th time this month, found once again on the ground at the bus stop with an ethanol level of 356 but remarkably awake. Neither labs nor an intravenous line are necessary, just a stretcher and some time. Sober at daybreak, he again is on his way. While to ED staff “Wally” is a “Super-Utilizer,” he is not necessarily so to the health care system. A more subtle but true Super-Utilizer would be “Janice” with chronic abdominal and back pain, diabetes, and congestive heart failure. Although she presents to an ED about once a month, she almost uniformly is admitted. While inpatient she is evaluated by cardiologists, neurologists, surgeons and neurosurgeons with stress tests, CT scans, endoscopies, MRIs and more. Often, a week or two later she is discharged with no significant intervention or changes in her health. In the health care policy discussion on Super-Utilizers, patients like “Janice” are the center of attention. Super-Utilizers are defined both by frequency of encounters with emergency departments, often 10 or more per year, AND use of costly health care resources. These patients often have chronic medical conditions such heart failure, diabetes, or renal disease as well as psychiatric diagnoses and substance abuse. Aggregate spending patterns are striking. The federal Agency for Healthcare Research and Quality reports that the top 1% of health care utilizers in the U.S. population consumes 21% of the $1.3 trillion health care budget in 2010. Among Medicaid populations, this 1% consumes 30% of the Medicaid Budget. These Super-Utilizers nationwide are spending nearly $88,000 in health care per person annually. Some may be experiencing an acute and severe illness, such as multi-system trauma, sepsis or cancer. Many, however, are chronically ill but stable, receiving redundant testing and fragmented care. The top 5% accounts for 50% of all health-care expenditures. In contrast, the bottom 50% of health care utilizers account for only 2.8% of healthcare spending in 2010. 15.4% of the population spent absolutely nothing on health care in 2010. These resource utilization patterns exist in the Medicaid, Medicare and Commercial Insurance populations In Missouri, the current legislative assembly and Governor’s office have focused significant attention on Super-Utilizers. The MO HealthNet (Medicaid) 2014 Division Budget of $7.4 billion supports care for approximately 850,000 Medicaid beneficiaries. The top 1%, or 8,500 patients, consumes up to $2.2 billion or nearly $260,000 per patient. With health care consuming an ever-increasing portion of federal, state, corporate and household budgets, we know “savings” will be identified. Most of us are familiar with the annual SGR “crisis” regarding double digit percentage reductions in Medicare reimbursement rates, legislated “efficiencies” in care delivery and incremental patient financial responsibility in their health care costs. Super-Utilizers are a patient subset in which prudent and informed care management may allow the right care at the right time with substantial savings. Emergency physicians are essential to the management of Super-Utilizers in two regards. First, working as “gatekeepers” of the healthcare system we decide whether a condition is chronic and stable, merits a limited, or perhaps an extensive evaluation and admission. Access to particular information, including recent diagnostic studies, pain contracts, or case managers and primary care physicians allows us to tailor our care to the patient’s, and systems, best interests. Second, emergency physicians care for these Super Utilizers frequently and often are more familiar with such patients than any other providers. We know the “drivers” of their frequent presentations and can quickly focus on the problem at hand. MOCEP members are working closely with the Missouri’s elected legislators and directors of MO HealthNet to facilitate care management programs of Super-Utilizers in Missouri. Pilot projects have been proposed to demonstrate how a robust and effective care management program for these patients can be a win: win for all.

Toxicology: It’s a croc!

Evan Schwarz, MD FACEP Assistant Professor Medical Toxicology Fellowship Director Division of Emergency Medicine Washington University School of Medicine

Diversion of prescription medications is a major health concern. Efforts including better recognition, changes in prescribing practices, and the use of prescription drug monitoring (at least in every other state besides Missouri) have attempted to curb this epidemic. However, as we have worked to decrease prescription drug diversion, the use of heroin has increased, most notably seen with the recent death of the well-known actor Philip Seymour Hoffman. Given this re-emergence of heroin, another opioid, Krokodil, has gained attention due to concerns that it will become a drug of abuse in the United States. Krokodil first became prevalent in Russia and the Ukraine. The active opioid in Krokodil is Desomorphine, a derivative of codeine. Desomorphine is approximately 10 times as potent as morphine and was used as a medicinal agent in the United States in the 1930s. Codeine is dissolved in solvents, such as paint thinner and gasoline, and combined with other chemicals including red phosphorous (match books) and iodine to make Krokodil, which is then injected. Users are reported to develop severe and disfiguring soft tissue infections following its use. In fact, it is called Krokodil because some liken the skin changes to the scales of a crocodile. The media has referred to it as the “flesh-eating zombie drug” due to the skin changes associated with its use.     Over the past year, there are multiple reports of Krokodil emerging in the United States. It was first reported in Arizona. Since then, there have been reports of it in Illinois, Ohio, and even Missouri. The first published report in the medical literature was written by physicians practicing in a St. Louis area hospital. The case report was subsequently pulled before being re-published as a letter to the editor. Reports have focused on the fact that either the users admitted to using Krokodil or had skin lesions consistent with using the drug. The one constant between all these reports is that Desomorphine was never actually confirmed in any of these patients. As such, we have no idea if any of them actually used Krokodil or not! While it’s possible that the drug was not found due to low concentrations or it being metabolized, it is also possible that the users were mistaken and developed soft tissue lesions and infections from using dirty needles or injecting non-sterile substances…like gasoline.     In Russia, heroin is very hard to obtain. Until recently, codeine was available for over-the-counter purchase. Drug treatment centers are scarce and there is still a severe stigma associated with drug use in Russia. This is different in the United States. These differences, along with the fact that the drug is associated with devastating tissue injuries, make it unlikely that Americans will choose to use Krokodil. In fact, you could say the concerns are likely a croc.

ACEP Now

If you haven’t seen ACEP’s new publication, ACEP Now, you’ve missed an Affordable Care Act Roundtable discussion with emergency medicine leaders, an article about pain posters in the ED, a pro-con piece on protecting your assets from litigation and much, much more. ACEP has partnered with a new publisher and added new medical editor in chief, Kevin Klauer, DO, EJD, FACEP, to give the monthly member benefit a content boost and revamped artistic presentation. Don’t worry. All the clinical topics and news emergency physicians expect from ACEP’s official publication are still there. You’ll get tips on using Ultrasound, legal advice and opinions on the latest emergency medicine issues. Don’t miss the new ACEP Now.

International Trauma Life Support (ITLS) Program Aims to Improve Trauma Care, Training Worldwide

ITLS is a global training program dedicated to preventing death and injury from traumatic injuries through education and trauma care. While many of you might be familiar with ITLS, you may not be aware of its history or connection with ACEP. Founded in 1985 as Basic Trauma Life Support, it was funded from an ACEP Chapter Grant to the Alabama Chapter. The course was originally developed by John Campbell, MD, FACEP who was given the first ACEP Outstanding Contribution in EMS Award in 1989. The course has been endorsed by ACEP since 1986.  ITLS is now an independent not-for-profit organization. Since 1994 it has been managed by the Illinois College of Emergency Physicians. Many ACEP Chapters sponsor and manage ITLS Chapters for their state as well, including Ohio, Florida, New York, Virginia, West Virginia, California, Illinois, Alabama, Colorado, Texas, Arizona, Louisiana, and Missouri ITLS has grown to be an international standard with 95 chapters and training centers in 36 countries. Chapters and training centers are located on all continents except Antarctica. To date, ITLS has trained more than 600,000 trauma care professionals in 70 countries worldwide. ITLS courses combine classroom instruction with hands-on skill training and scenario assessment stations to challenge the students to expand their knowledge and skills in trauma care. ITLS has become accepted internationally as the standard for training pre-hospital professionals in trauma care. It is taught both as a continuing education course but also as part of many initial EMT and paramedic training programs. ITLS also offers eTrauma which is an online educational program that provides the didactic portion of the ITLS Provider course. It can be taken for CEU credit only or followed by an ITLS Completer course for skills and testing for ITLS certification. ITLS can be taught at two levels: Basic and Advanced. ITLS Basic provides the core knowledge and skills for all levels beginning at the EMT-Basic and first responder levels. ITLS Advanced builds on this knowledge and skills to address advanced procedures for paramedics, trauma nurses, and physicians. Other related ITLS courses include ITLS Access, ITLS Pediatric and ITLS Military. ITLS Access trains EMS crews with the skills they need to access, stabilize, and extricate trapped patients. ITLS Pediatric continues the training of the Basic and Advanced courses with an emphasis on trauma in children. And ITLS Military is a custom edition of a stand-alone military edition designed for military personnel. To learn more information about ITLS, to arrange for a class, or set up a training center, visit our website.

Leadership and Advocacy Conference

Learn how to maximize your impact as an emergency medicine advocate during ACEP’s Leadership and Advocacy Conference, May 18-21, in Washington, DC at the Omni Shoreham Hotel. You can register for the conference and the hotel on ACEP’s website. During this dynamic conference, you will gain skills in media relations and networking for influence, meet with members of Congress and other key policy makers, and identify your role in advancing key issues facing emergency medicine. See the video of members enjoying last year’s conference.

Careers Section Longevity and Tenure Award Applications Due July 18

Cathey Wise, Director, EMF

The ACEP Section of Careers in Emergency Medicine is soliciting nominations for an award for emergency physicians in the following two categories:

• A Longevity Award for the physician with the longest active career in emergency medicine.
• A Tenure Award for the physician with the longest active career in the same emergency department.

Recognition is also given to those physicians who are still actively practicing emergency medicine after 20, 25, 30, and 35 years. The deadline is July 18. Eligibility Criteria To be eligible, physicians must have worked an average of 1,000 or more hours per year in emergency medicine practice or teaching; hours for residency training and administration are not included. They must be a current ACEP member. Previous applicants may apply every year; however, they may not win the same award within a 5-year period. Information is attached and can also be found on our website.

Clinical News

Stroke Risk Jumps After Head, Neck Trauma Eleven of every 100,000 patients younger than 50 years who were seen for traumatic injury developed an ischemic stroke within 4 weeks, a study of data on 1.3 million people found. Read the full article Imaging No-NosTop List of Avoidable Tests in Emergency Medicine Imaging studies take four of the five slots in a newly unveiled list of unnecessary tests and procedures commonly performed in the emergency department, with CT scans in low-risk trauma cases earning particular censure. Read the full article

Biphasic Reaction Risk Rises with Severity of Initial Anaphylactic Attack The more severe an anaphylactic reaction, the more likely that a child will have a second reaction within several hours, according to data from a review of more than 400 children. The findings were presented at the annual meeting of the American Academy of Allergy, Asthma, and Immunology. Read the full article

Welcome New Members

Erik DeLaney

Nolan Gartin

Jeremy M. Horak

Leslie A. Marshall

John D. Owen, MD

Abigail Shniter, MD

Gregory C. Thompson

Barry I. Ungerleider, DO