EMpulse Fall 2010 by Jerry Cutchens

FALL 2010

Photo by Andrew S. Malbin, MD, FACEP

New Healthcare Reform Law

Symposium by the Sea

Gulf of Mexico Oil Spill

EMpulse

Volume 15, Number 5

Florida College of Emergency Physicians 3717 South Conway Road Orlando, Florida 32812-7606 (407) 281-7396 • (800) 766-6335 Fax: (407) 281-4407 www.FCEP.org

Executive Committee Amy R. Conley, MD, FACEP • President Vidor Friedman, MD, FACEP • President-Elect Kelly Gray-Eurom, MD, FACEP • Vice President Michael Lozano Jr., MD, FACEP • Secretary/ Treasurer Mylissa Graber, MD, FACEP • Immediate Past President Beth Brunner, MBA, CAE • Executive Director

Editorial Board Leila PoSaw, MD, MPH, FACEP • Editor-in-Chief editor@fcep.org Jerry Cutchens• Managing Editor jcutchens@fcep.org

Cover Design by Jerry Cutchens / Leila PoSaw Cover Photo by Andrew S. Malbin, MD, FACEP

All advertisements appearing in the Florida EMpulse are printed as received from the advertisers. Florida College of Emergency Physicians does not endorse any products or services, except those in its Preferred Vendor Partnership. The college receives and distributes employment opportunities but does not review, recommend or endorse any individuals, groups or hospitals that respond to these advertisements.

Published by: LynDee Press, Inc. dba Fidelity Press 649 Triumph Court, Orlando, FL 32805 Tel: (407) 297-8484 www.ﬁdelitypress.us

NOTE: Opinions stated within the articles contained herein are solely those of the writers and do not necessarily reﬂect those of the EMpulse staﬀ or the Florida College of Emergency Physicians.

Symposium by the Sea 2010 SYMPOSIUMkeynote Jeﬀrey Bettinger, MD, FACEP

SYMPOSIUMlecture David A. Caro, MD, FACEP

SYMPOSIUMlecture Antonio Marttos, MD

SYMPOSIUMcpc Joshua B. Kaplan, MD

SYMPOSIUMresearch

CONVERsations Sandra M. Schneider, MD, FACEP

SYMPOSIUMphotographs

Departments PRESIDENT’Smessage Amy R. Conley, MD, FACEP

EDITOR’Semergencies Leila L. PoSaw, MD, MPH, FACEP

GOVERNMENTALaﬀairs Steve Kailes, MD, FACEP

CODINGtip Lynn Reedy, CPC, CEDC

MEDICALeconomics Ashley Booth Norse, MD, FACEP

ACADEMICaﬀairs Joseph A. Tyndall, MD, MPH, FACEP

PROFESSIONALdevelopment Paul Mucciolo, MD, FACEP

EMStrauma Michael Lozano, MD, FACEP

ERchronicles Arlen R. Stauﬀer, MD, MBA, FACEP

DOCTORS’lounge Andrew S. Malbin, MD, FACEP

ERmusings Wayne S. Barry, MD, FACEP

POISONcontrol Alexander Garrard, PharmD Patrick Aaronson, PharmD

RESIDENCYmatters

ADVOCACYnow!

36 EMpulse • Fall 2010 1

PRESIDENT’Smessage

Leading by Example

Amy R. Conley, MD, FACEP President

For those of you who were unable to attend this year’s Symposium by the Sea, you missed a truly great event, and it is my hope that it will be in your plans for next year. Symposium by the Sea is a wonderful opportunity to brush up on your emergency medicine knowledge, see colleagues and friends, make new acquaintances, meet potential employers, and become involved in the destiny of EM, all while thoroughly enjoying the relaxed and often entertaining atmosphere of a full service resort. It is our state venue that entices our national leadership and this year was no exception. We were privileged to host Dr. Angela Gardner, President of ACEP, Dr. Sandra Schneider, President-elect of ACEP, and several board members of ACEP including Dr. Andrew Sama, secretary-treasurer, Dr. David Seaberg, and our own Dr. Andy Berns, who each took time to share their wisdom on the current state of affairs at the national level and its impact on our chapter. We have a lot to do, including continued work on health care reform (particularly Medicaid reimbursement), prevention of text messaging while driving, distribution of fair payment rather than the threat of balance billing, insuring appropriate personnel for procedural sedation and the maintenance of EM as an independent practice. All these issues assure quality patient care. I recently had the opportunity, along with other EM colleagues of my area, to contribute to an article in my

“Many other states look to us for advice and progress as a template from which to pattern goals. This is yet one more area where we as a large membership can lead by example.” local newspaper regarding Medicaid reimbursement. It appears that the public has an interest and a knowledge deficit of health care issues. I was permitted to explain the concept of primary care physicians having to limit their practices to smaller numbers of Medicaid supported patients. I went on to explain that this is largely due to the inability to meet their own office needs in order to deliver quality care to their patients. In fact, many of our community physicians report a financial loss with each Medicaid patient visit. Additionally, I commented that this placed an additional burden on our already overcrowded EDs. I also reiterated the words of our esteemed national leader, Dr Angela Gardner, “When these patients get sick but can’t get in to see a physician, they often wait until an illness has worsened to the point that they need care in an emergency department.” Other emergency physicians as well as I cited examples of situations in

which patients wait out common illnesses which if treated early may have permitted quick recovery but instead become life threatening. This delay in presentation actually leads to a heftier burden on taxpayers as the more critically ill patients utilize greater resources. With emergency visits increasing all over the state and indeed the country, we need to maintain and increase our resources and capacity to support this. There must be reimbursement to support quality patient management. It was believed several years ago that ED visits were up in large part due to minor illnesses or injuries. Most recent data demonstrate that this is not the case. In fact, less than eight percent of all visits are non-urgent. We need to grasp every chance to make a difference and gain support on Medicaid reimbursement and other issues important to EM and the delivery of quality care. This can be done by speaking, educating and inviting media, legislators, and non-physician entities into our departments to help them grasp the importance of quality care. I do believe this really helps the public relate and enlists their support. They need to understand that we WANT to care for patients and remain the “safety net “and this can only be done with proper support, financially and legislatively. Many other states look to us for advice and progress as a template from which to pattern goals. This is yet one more area where we as a large membership can lead by example. EMpulse • Fall 2010 3

EDITOR’Semergencies

Many Things Endure and Many Things Change

Leila L. PoSaw, MD, MPH, FACEP EMpulse Editor-in-Chief

With this issue, the EMpulse will change its format from bimonthly to quarterly. We will now bring you a Fall, Winter, Spring, and Summer edition. It is my sincerest hope that what will endure will be the voice of EPs advocating for various causes, speaking up and out on issues that affect EM, clamoring for the well being of the patients we take care of and of our member physicians. I did my first decennial EM board recertification last week and I feel old. Or should I say entrenched and established, part of the woodwork. The examination had not changed much from my first time taking it. There were questions on chomping on electrical cords (never seen one), getting struck by lightning (never seen one), and mushrooms (never seen one). While the examination was not a fair gauge of my depth of EM knowledge, it more than excelled at testing all the EM trivia I had managed to squeeze into my head during my intensive review course. This examination has definitely endured though in a slightly different technologically advanced, computerized format. I look back at the last ten years and my practice too has changed in several ways: percutaneous coronary intervention (PCI) has replaced tPA in cases of STEMI, amiodarone has simplified the ACLS V-fib and pulseless V-tach algorithm, CTA has been a boon to pulmonary embolism diagnos-

tics, Focused Assessment with Sonography for Trauma (FAST) and full body CTs have transformed trauma care. However, the management of hypothermia and heat stroke, hyperthyroidism, diarrhea and such has not changed at all. Funnily, the latter conditions return again and again in tests as tests of the agile emergency physician mind.

In his book Outliers, Malcolm Gladwell suggests that it takes it takes over 10,000 hours of practice and still more practice to master a craft. This might well be so. But what if, as in EM, our clinical shifts and daily practice provide us with sporadic spurts of select conditions and we can’t practice all of what comprises EM. Well, then we have tests!

In a recent survey done by Emergency Physicians Monthly (Schoenberger, August 2010, Volume 17, Number 8) 69% of respondents felt that ACLS certification did not improve care by EPs and 83% of respondents felt that BLS certification did not improve care by EPs. Apparently, many surveyed EPs felt that these are “kindergarten level” and “weekend courses” with weak academic support.

I am resigned to the fact that I might never actually see seizures resulting from an INH overdose, but I can pull out the B6 with a swagger; I might never actually see neuroleptic malignant syndrome, but aha!

So why do these tests exist and why do we acquiescence to do these tests? Consider the following three reasons. I would like to believe that ‘tests’ exist as a means and not an end. They do not measure the absolute knowledge possessed by individual physicians. But it is in the preparation and practice for them that an individual physician regains mastery over the vast, seemingly limitless field of EM which changes over time. In my studies, there were many concepts that I had forgotten which I absorbed like a sponge in anticipation of what might show up on the test and who might show up next in my ED.

I am confident with what to do with lead pipe rigidity; and I am still waiting for Mr. Osborne and Mr. Brugada, but have their EKGs firmly ingrained in my mind for when they show up. In the magical world of tests, my dreams come true: I cardiovert and administer nitroprusside to every patient when given the option. Last but not least, tests are necessary to ensure that our collective knowledge, whether new or old, endures the rites of change. Every EP possesses the same knowledge base and teaches this to new EPs. This ensures continued excellence in emergency care. The standard prevails long after individual physicians retire… to desert climes crawling with coccidiomycosis and aerosolized rodent excreta. EMpulse • Fall 2010 5

Maximize Reimbursement from Auto Carriers! • • • • • • • •

ARE YOUR AUTO CLAIMS NOT PAID IN FULL? IS YOUR STAFF FIGHTING WITH AUTO CARRIERS? ARE YOU TIRED OF DENIALS & REDUCTIONS ON AUTO CLAIMS? DO YOU WANT TO INCREASE YOUR BOTTOM LINE WITH MINIMUM EFFORT AND NO COST? WE HAVE YEARS OF EMERGENCY ROOM PHYSICIAN REPRESENTATION AGAINST AUTO CARRIERS. WE ARE EXPERIENCED, KNOWLEDGEABLE & PROFESSIONAL. WE CAN ASSIST YOUR BILLING COMPANY WITH OUR STRONG LEGAL EXPERTISE. BRADFORD CEDERBERG AND EMERGENCY ROOM PHYSICIANS- AN EXCELLENT FIT!

“Even though our collections process relative to motor vehicle accident claims is both thorough and effective, Attorneys at Bradford Cederberg have still been successful in leveraging the legal means at their disposal to collect impressive dollars that would otherwise have not been realized. The added fire-power of a legal firm who is well-educated in PIP laws and dedicated to insuring proper and full PIP payout, is reaping financial rewards for our clients, with minimal effort on our part and no added cost to our clients. Using Bradford Cederberg’s resources and expertise is a ‘no-brainer’.” Jill Reynolds Chief Operating Officer DUVA ·SAWKO

For more information, contact Jenise Harter at 386-615-7435 or jenise@bradfordlaw.com Attorneys at Law 5210 South Orange Avenue Orlando, Florida, 32809 407-926-8710

EAST COAST, FLORIDA

MIAMI, FLORIDA

Outstanding opportunity for an Emergency Physician to

JACKSON HEALTH SYSTEM, a 2,139 bed

join this 41,000 volume state-of-the-art facility located less than one hour from Orlando. This family-oriented comunity is on the intracoastal and just minutes from the beaches. Double coverage as well as mid-level provides and excellent back-up. Excellent compensation and benefits package. Administration potential. Contact: Robin Lorber at Team Health Southeast, 800-442-3672 ext. 2904 or fax 954-424-3270.

academic system with a public healthcare mission, is presently recruiting for experienced Emergency Medicine Board Prepared/Certified Physicians to join its team.

Position Summary: Our adult emergency department has an annual volume of approximately 80,000 with 126 hours of attending physician coverage per day. In addition, we have midlevel providers staffing Express Care with attending physician supervision. Our physician group and nursing colleagues share a strong collaborative working relationship which have 24/7 specialty back-up in all disciplines. This exciting career opportunity offers a competitive compensation package and one of the best benefit programs anywhere. To inquire about this opportunity, please contact Nathaniel J. Sweet, Senior Talent Acquisitions Specialist at 305-585-6081, or use website to register and apply online at www.jhsmiami.org, requisition 100138. Jackson Health System is an Equal Opportunity Employer.

GOVERNMENTALaﬀairs

Need Your Insights. Need your Help!

Steve Kailes, MD, FACEP Committee Chair

Frustrated? Angry? Worried? Hopeful? Most of us share some combination of these feelings when thinking about health care reform and the future of our specialty. We need to remain engaged in the process to help guide this massive ship through the storm. Recently at the Symposium by the Sea in Boca Raton, various guests and speakers were present, allowing for excellent dialogue about issues facing emergency medicine, both nationally and on a state level. While everyone is still trying to grasp what is occurring or will occur, we know the process will be dynamic. In each article I ask for your help, and this will be no different. As we continue our work, we need your input to help guide us to the issues needing to be addressed. As of this writing, we are waiting to see who will be in play for the fall elections after the coming primary elections are over in late August. Who will be governor and what seats are held in the legislature may have a huge influence over issues important to us. Republican or Democrat is not always as important as it is to know the individual candidates, since members of both sides of the aisle can be supporters of EM causes. If you know of a candidate we should or should not support, let us know. Politics is

most influential at the local level, so your insight is invaluable to our cause. Issues definitely on our radar screen include liability reform, ensuring fair payment for our provided services, establishing guarantees that future board certification indicates specialty specific training in EM, patient safety issues, and improving access to care for our patients (which includes all specialties, but with a separate focus on what can be done to improve mental health services availability). Furthermore, we are monitoring areas like the future reorganization of the Department of Health, plans for Medicaid reform, and influences from other areas (like the Board of Nursing proposed rules change that would impact our delivery of procedural sedation). As always, we strive to help make the practice of EM better for both you and your patient. Please go to www.fcep.org under the “Government - Advocacy” tab and donate to our efforts through our Committees of Continuous Existence (CCE). These donations are absolutely critical to the success of our advocacy efforts. We need funds now to support candidates sympathetic to our causes. We’re all in this boat together so, please grab an oar and help us row. EMpulse • Fall 2010 7

CODINGtip 276.69 – Other fluid overload 724.03 – Spinal stenosis, lumbar region, with neurogenic claudication 780.33 – Post traumatic seizures 784.92 – Jaw pain 786.30 – Hemoptysis, unspecified

VOLUNTARY EMpulse

799.50 – Unspecified signs and

SUBSCRIPTIONS

symptoms involving cognition 970.81 – Poisoning by cocaine

New ICD-9 Codes begin 10/1/2010

970.89 – Poisoning by other central nervous system; stimulants

We have several new diagnoses codes!

Lynn Reedy, CPC, CEDC

Document the appropriate details for

Director of Coding Services

your coders to assign these codes.

CIPROMS South Medical Billing

Contribute $20 or more to help defray the publishing and mailing costs of EMpulse. Check payable to: FCEP, EMpulse VS 3717 South Conway Road Orlando, FL 32812

MEDICALeconomics

Accountable Care Organizations Will Redefine How We Practice! Ashley Booth Norse, MD, FACEP Committee Chair

“The Patient Protection and Affordable Care Act” (PPACA) sets into motion sweeping and far reaching changes to our healthcare delivery system. We must understand how this will impact and redefine our practice. A new government board will play a role in tightening physician payment rates. In 2012, Accountable Care Organizations (ACO) will begin to emerge. Emergency physicians will be forced to participate in the Physician Quality Reporting Initiative (PQRI) or suffer decreased payments in five years. In 2015, the Centers for Medicare and Medicare Services (CMS) will start to phase-in a "value-based payment modifier" to the physician fee schedule which will be based upon both outcomes and utilization. For the first time, each state Medicaid program will utilize Recovery Audit Contractors (RAC) to audit providers and identify improper Medicaid payments. ACOs will redefine how we practice emergency medicine. A hospital(s) and a set of physicians will accept joint responsibility for the quality and cost of care that patients belonging to an ACO receive. This hopes to ensure health care that improves clinical outcomes, enhances quality and decreases cost. This concept is currently embodied by systems like Mayo and Geisenger but for most of the country they are administratively too complex to form and too difficult for CMS to adminis-

ter. Medicare pays a lump sum to private insurers and holds them accountable for all the medical care the beneficiary needs. So, why doesn’t Medicare just use the current Medicare Advantage program to accomplish these goals? There are differences between ACOs and HMOs. In ACOs the “accountability” rests with the providers. Providers or provider groups, rather than insurance companies, are evaluated on the quality and efficiency of care. Also there is direct contracting with provider organizations without reliance on a health plan intermediary. ACOs also allow for flexibility in the type of organization. Some regions may prefer independent practice associations while others may prefer a physician-hospital organization. The physician-centered organization makes more sense to many policymakers because the resources that flow from “doctor-patient” based decisions account for a major portion of overall health care costs regardless of where the care actually takes place. There are many questions still to be answered. How is CMS going to fund and administer these? CMS could pay ACOs with a “gainsharing” mechanism in which the fee-for-service payment structure remains, but a portion of patient cost savings gets passed to the physician. On the other hand, CMS could institute a

partial capitation scheme, in which the ACO gets a flat rate per person but risk corridors limit the ACO’s potential losses should the plan happen to experience higher than expected utilization and costs. CMS could also institute full capitation models which would put physicians in the position of being risk managers. Other obstacles include possible Federal Trade Commission and Department Of Justice moves to quash ACOs on anti-trust grounds. Additionally there are tort issues. There is shared risk and shared liability in ACOs. For example, in a physicianhospital organization, the hospital and physician group will share liability for outcomes, and in multi-specialty independent practice associations, physicians from different specialties will share risk. State and Federal laws regarding insurance regulation, anti-trust, as well as organizational and professional liability will have to change in order to make ACOs a viable option for most physicians. A cartoon in the New Yorker stated “These New Regulations Will Fundamentally Change the Way We Get around Them." In all seriousness though, the key to success and preservation will be physician leadership. Physicians will have to learn to work in teams to coordinate care and physicians must be the leaders of those teams. Emergency physicians will be in a better position than most: they usually make good team players and leaders. EMpulse • Fall 2010 9

ACADEMICaﬀairs

Beyond Symposium 2010

Joseph A. Tyndall, MD, MPH, FACEP Committee Chair

Symposium by the Sea is always a highlight of academic affairs activity for FCEP and a proud moment for EMRAF and the EMLRC. Symposium 2010 in Boca Raton was no disappointment, and those who attended witnessed another outstanding program that included the participation of both the incoming and outgoing Presidents of ACEP. This success was due in part to another outstanding CPC competition and a robust judged research poster presentation that featured 20 posters from programs across the State. The slate of high quality preconference presentations and lectures rounded off a terrific gathering of colleagues. Please be sure to view the abstract submissions (including the winning abstracts) as well as the CPC competition cases published in this issue. I would like to thank EMRAF for their outstanding planning efforts and members of the academic affairs committee as well as all the staff at FCEP and EMLRC for another great year in education for FCEP. Also a special thank you to Dr. Sandra Schneider, ACEP President Elect, and Dr. David Seaberg, Dean of the College of Medicine at the University of Tennessee in Chattanooga, for judging the research posters. Thanks also to them for participating in the CPC competition judging along with Dr. Gary Goodman. Thank you to the program sponsors who were all essential in making the conference possible and 10 EMpulse • Fall 2010

again, a special thanks to Dr. Fred Epstein for his continued and tireless commitment to the outstanding CPC program. One of the most important driving forces behind any successful effort is the collaboration and collegiality of the participants. In moving forward with the goals and missions of the academic affairs committee, partnership amongst institutions, teaching programs and individuals will be invaluable to the progression of academic affairs activities. In an update written almost a year ago I highlighted our goals to create educational networks that foster individual academic growth and promotion within our respective organizations. We also discussed the creation of a network for the purpose of sharing information, creating vital research activity and establishing conduits for extramural funding. Dr. Schneider, for example, worked towards the creation of such a network in the State of New York. We were fortunate to have Dr. Schneider share her successful experiences with the FCEP Board. We can do the same in Florida. With our major academic medical centers hosting emergency medicine residency programs, and with the combination of patient care encounters reaching hundreds of thousands of patients annually, we have an enormous opportunity to make an impact; whether in creating evidence for policy positions impacting emergency

medicine or expanding individual and institutional projects to access the vast deposits of clinical information that can be provided by our combined efforts. I remain convinced that this is an opportunity we should not let go of. Here is a call for individuals and members of institutions to join FCEP’s academic affairs committee to drive us to the next level of opportunity. Again, my hope is that the participation of individuals, especially from programs where such participation matters in promotion and recognition of service, will be robust and enthusiastic. As we look towards our future planning, please feel free to contact me through the FCEP offices should you be interested in participating.

PROFESSIONALdevelopment

The Changing Complexion of Emergency Medicine

Paul Mucciolo, MD, FACEP Committee Chair

When you decided to become an EP did you have any idea how many other roles you would assume as part of your professional obligation? Some of the hats we wear our day-to-day practice include detective, teacher, advocate, healer and administrator. Sometimes we need to do detective work to diagnose a patient’s condition and at other times we have to teach patients how to best take care of their health. Sometimes we have to guide families through different treatment options as when addressing end-of-life issues. All the while, we have to maintain the flexibility to adjust to dynamic patient volumes, alter our practices to meet quality measures and also try to deliver all-important customer service in a competitive health care environment. Since I started practicing EM in 1997, my responsibilities as an EP have grown steadily. Core measures, based on CMS requirements and evidence based practices, touted to improve patient outcomes for myocardial infarctions, strokes and pneumonia are enforced as standards of care. The final straw is our ever increasing role as perhaps the only primary care provider for the majority of ED patients. I was the youngest of seven children. My parents took us to the doctor only when we

were truly “sick” and mom’s remedies like the “tincture of time” were ineffective. We almost never went to the ED. Do you remember the days when the doctor’s office would be open after hours? Complaints like “Lortab refill,” “I need a referral to a gastroenterologist” and “Web MD said I should go to the ER immediately—I have a ruptured aneurysm in my brain” were unimaginable then. Now they are daily occurrences. Busy shifts are particularly frustrating and this is understandable. Repeat visits for psychosomatic or psychosocial problems are increasing in prevalence. Our prevailing culture programs people to rush to the ED whenever they cough, sneeze, or vomit. In the words of Sir William Osler: “One of the first duties of the physician is to educate the masses not to take medicine.” Despite the advertisements, there is no magic bullet. The fable of Chicken Little can be traced to Buddhist scriptures: A hare startled by falling fruit believes that the earth is coming to an end and starts a stampede of other animals. A lion halts the stampede. He investigates the cause of the panic and restores calm. The necessity of reason as taught in this fable is important in our practice as well. The EP’s enemy is not only disease but

also media sensationalism. Media stories are ratings driven and they tend to be embellished and exaggerated. Global warming, oil in the gulf, bird flu, health care reform, and the economic crisis are all going to get us. Unfortunately, our patients fall prey to this. How did the generations before us survive? If our patients have a cramp, it’s appendicitis and a CT scan. If they have a cough, it’s pneumonia and an X-ray. Most patients we see need reassurance. This is difficult to deliver in a busy ED. Consider the healthy 17 year old young man who presented with back pain after moving boxes. His examination was completely normal, but his mother called from Wisconsin and demanded an MRI: “I don’t know what type of medicine you practice down there, doctor, but that [MRI] is the standard of care up here!” I had to track down the young man’s family physician (who fortunately was a friend of his family) on a Saturday afternoon who concurred that the mother’s request was “…ridiculous.” The sun will rise, the sky won’t fall, and we will continue to do our best as providers of emergency care for the legions of patients who depend on us. This is a daunting task, but one which we are uniquely positioned and equipped to handle. EMpulse • Fall 2010 11

EMStrauma

The State of Florida EMS Part 4 of a Series

Michael Lozano, MD, FACEP

Committee Chair

Objectives 4.4 and 4.5 of the EMSAC Strategic Plan tackle state-wide educational issues. These interrelated objectives address universal certification of all training centers through the Committee on Accreditation of Educational Programs for the EMS Professions (CoAEMSP) by January 1, 2013 and the initial adoption of the EMS Education Agenda for the Future: A Systems Approach.1 The need for a comprehensive approach to EMS was first recognized in 1992 by the National Association of EMS Physicians (NAEMSP) and National Association of State EMS Directors (NASEMSD). The National EMS Education and Practice Blueprint (1993)2 (‘the Blueprint’) was produced by multi disciplinary panel led by NHTSA which established standard knowledge and practice expectations for four levels of EMS personnel: first responder, emergency medical technician (EMT)-B (basic), EMT-I (intermediate), and EMT-P (paramedic). Under the directorship of EP Dr. Ricardo Martinez, NHTSA funded and published the EMS Agenda for the Future3 in August 1996. Commonly referred to as ‘the Agenda’, its intent was to create a common vision for the future of EMS. The Agenda addressed 14 attributes of EMS, including education. The report emphasized the need to develop national core content for curricula for providers at various levels and asserted that all EMS education must be conducted with the benefit of qualified medical direction. 12 EMpulse • Fall 2010

As a follow-up to the Agenda, The EMS Education Agenda for the Future: A Systems Approach (2000), called for the development of a system to support the education, certification and licensure of entry-level EMS personnel that facilitates national consistency. The EMS Education Agenda proposed a system with five integrated primary components: Core Content, Scope of Practice Model, Education Standards, Training Program Accreditation, and Certification. The National EMS Core Content was completed in 2005 and consists of a list of skills and knowledge necessary for the practice of EMS. The National EMS Scope of Practice Model was released in 2006 and identified the core content for the four newly defined levels of EMS providers: Emergency Medical Responder, Emergency Medical Technician, Advanced EMT and Paramedic. The scope of practice document identifies minimum knowledge and skills for providers at each level. The National EMS Education Standards were released in 2009, and replaces the National Standard Curricula. National EMS Education Program Accreditation is applied to all nationally recognized provider levels and is universal. Accreditation is the major mechanism for verifying educational program quality for the protection of students and the public. Accreditation enhances the consistency of the evaluation of instructional quality.

The National EMS Certification document is scheduled to be released in the future. The plan is that certification would be available for all nationally recognized provider levels and be universal. Certification involves a standardized examination process and contributes to the protection of the public by ensuring the entrylevel competence of EMS providers. Under the proposed system, in order to be eligible for National EMS Certification, a student must have graduated from an accredited program. In addition to the Education Agenda, the Institute of Medicine’s (IOM) EMS At the Crossroads (2006) also recommended a single national EMS accrediting agency for the country as part of a process of standardization in EMS education. EMS is one of the few, if not the only, allied health care professions that does not require its educational programs to be accredited. The overall certifying body is called the Commission on Accreditation of Allied Health Education Programs (CAAHEP), with its reviewing body, the Committee on Accreditation of Educational Programs for the EMS Professions (CoAEMSP). The lead for this part of the strategic plan is the EMSAC Education Committee, with assistance from the Florida Association of EMS Educators, the EMSAC Legislative Committee, and Florida Association of EMS Providers. One of the first tactics to be completed is a survey of stakeholders and providers to ascertain

EMStrauma which scope of practice levels would be supported (EMR, EMT, AEMT, and Paramedic). Although in Florida, EMT and Paramedics have been defined in rule and statute for many years, the same is not true across the country. The initially defined levels from the Blueprint of First Responder, EMT-B, EMT-I, and EMT-P have morphed over time as individual states have either stayed within the NHTSA framework, or defined their own levels between EMT and Paramedic. Changes to the National Standard Curricula in 1985 and 1999 led to the development of EMT-I/85 and EMT-I/99 respectively. When looking nationwide, there are something in the order of 40 different levels between first responder and paramedic. Clearly, the new approach will lead to a

degree of uniformity and allow for reciprocity across states. Once the EMSAC has identified the levels to be adopted, the Legislative Committee will seek their adoption through legislation. The more difficult and complex process will be defining a statewide transition from National Standard Curricula to the new Education Standards. This will require adjustment of the Department of Educationâ&#x20AC;&#x2122;s curriculum frameworks to match the adopted scope of practice levels and education standards.

-------------------------------------------------1 NHTSA. 2000. Emergency Medical Services Education Agenda for the Future: A Systems Approach. Washington, DC: Department of Transportation. www.nhtsa.gov/people/injury/ems/EdAge nda/final/index.html NREMT (National Registry of Emergency Medical Technicians). 1993. National Emergency Medical Services Education and Practice Blueprint. Columbus, OH: NREMT 2

NHTSA (National Highway Traffic Safety Administration). 1996. Emergency Medical Services Agenda for the Future. Washington, DC: Department of Transportation. www.nremt.org/nremt/ downloads/EMS%20Agenda%20for%20t he%20Future.pdf 3

Additionally, there will need to be an adoption of the national test for each approved provider level. While the goal is to have this all accomplished by 2013, this complex process may well extend into the next strategic plan.

EMpulse â&#x20AC;˘ Fall 2010 13

SYMPOSIUMkeynote

The New Health Care Reform Law Jeffrey Bettinger, MD, FACEP

Bettinger, Stimler, Schultz & Associates, LLC

After nearly a century of failed attempts, comprehensive health care reform was enacted on March 23, 2010, when President Barack Obama signed the Patient Protection and Affordable Care Act (PPACA). It is crucial that all EPs understand the ramifications of the PPACA. Numerous provisions within the 2,000 plus pages will affect reimbursement for emergency services. Emergency physicians need to maintain an attitude of calm diligence to develop a strategy to avail themselves of the opportunities within PPACA, and to prepare for the threats posed by various provisions of the law. Although most of the substantive reimbursement provisions of PPACA do not take effect until 2014, some effects will be felt well before then. As with most laws designed in the past substantially to change the social fabric of our society, modifications to the law and development of interpretive regulations will occur over the next decade. Mandates Although there are many specific provisions about payment to physicians and organization of their practices, the biggest impact of the reforms will likely come from insurance mandates. Starting in 2014, all U.S. citizens – employed and unemployed - will be required to have health insurance. Additionally, all employers of more than 50 employees must provide health insurance to their employees.

14 EMpulse • Fall 2010

To achieve these mandates, the PPCA provides carrots and sticks. Individuals and families who earn less than 400% of the Federal Poverty Limit (“FPL”) are eligible for sliding scale subsidies of their health insurance premium. • Those earning less than 400% of the FPL are eligible for financial assistance related to cost-sharing provisions for their medical bills. • Penalties of up to $695 per individual, and $2,085 per family, will be assessed if health insurance is not obtained. • Further, individuals earning less than 133% of the FPL will be eligible for Medicaid. (Numbers will increase in Florida, where current Medicaid eligibility is limited to those earning less than 100% of the FPL). • While employers of less than 50 employees are not mandated to offer health insurance to their employees, employers of more than 50 employees will pay a penalty of $2,000 per employee if they do not offer health insurance (the first 30 employees are exempted from the penalty calculation). • Beginning in 2010, small employers having between 10 and 25 employees may be eligible for a 35% tax credit should they elect to offer health insurance. Insurance Reforms PPACA contains numerous provisions that will change the eligibility and benefits of health insurance. • Beginning in 2010, eligible dependents up to age 26 can be covered under their

parents’ health insurance policies. • Over the next few years, lifetime policy limits will be rescinded, premium increases will be more closely scrutinized, policy rescission will be limited to instances of fraud, and insurers will be mandated to spend 80 to 85% of premium dollars on medical losses. • Beginning in 2014, insurers will be mandated to offer insurance to individuals without regard to an individual’s health history (pre-existing condition prohibition). Although rating - or charging a higher premium - will not be permitted based on health history or gender, insurers will still be allowed to increase premiums due to age, tobacco use, and locality. Health Insurance Exchanges Beginning in 2014, each state will offer health insurance through an exchange. • A “public option” will not exist, meaning the health insurance companies participating in the exchange will all be private firms. The federal government will attempt to coordinate regional exchanges that cover multiple states, but each state exchange will be required to offer a minimum of two insurers. • There will be exchanges for both individual policies and small employers’ policies. • Each insurer on the exchange will be mandated to offer four tiers of coverage, with the least expensive tier having the highest cost-sharing provisions. • Each tier must contain an “essential benefits package.”

SYMPOSIUMkeynote • Care providers will not be required to sign participation agreements with exchange insurers. Essential Benefits Package By 2014, all health insurance policies, whether offered through the exchanges, purchased privately, or provided by an employer, must contain a certain set of minimum benefits. • Importantly for emergency medicine, emergency services are part of the essential benefits package. Fortunately, and due in large part to ACEP, PPACA contains provisions that state that no prior authorization is required for emergency services. • The provisions also allow for “prudent layperson” type definitions of emergency care. • Insurers are prohibited from charging higher deductibles and co-pays for care rendered by non-participating providers. Medicare Provisions Although the basic Medicare physician fee schedule was not addressed within the law, PPACA contains provisions that will influence many aspects of physician Medicare payments. • For the time being, Congress will need to continue to address the issue of “Sustainable Growth Rate” reductions to the physician fee schedule. • Ideally, Congress will enact a long-term fix to the SGR problem, rather than continuing to take the temporary band-aid approach favored over the last few years. • The PQRI reporting bonus program will shift over the next few years to a penalty program for non-reporting. • In addition, a budget neutral “quality care” modifier will be introduced to physician payments in 2015. As regulations are developed over the next few years, emergency physicians will have more clarity about how “quality care” will be measured, and what impact it will have on physician reimbursement. Two pilot programs that Medicare will introduce over the next few years have the potential of seriously impacting reimbursement for emergency physician services, while also affecting the

financial relationship between emergency physician groups and their hospital partners. • In 2012, Accountable Care Organizations (“ACOs”) will be created. ACOs are groups of providers who sign agreements to care for more than 5000 Medicare beneficiaries. Payments for Part A and Part B are via the usual fee-for-service model; however, any cost savings that Medicare experiences because of more efficient medical care will be shared with the ACO. • Beginning in 2013, voluntary pilot programs will begin bundling hospital and physician payments for select conditions. These bundled payments will include reimbursement for all hospital fees, and all physician fees for services starting three days prior to hospitalization and extending thirty days post-hospitalization. Opportunities for Emergency Medicine The two provisions of PPACA that have an obvious benefit for emergency medicine are: • The enhanced coverage for a majority of currently uninsured Americans, and • The mandating of emergency services (including beneficial provisions that limit cost sharing for non-contracted insurers). • Actuarial studies have predicted that two-thirds of the currently uninsured population will obtain insurance coverage. • For the typical community hospital emergency department, the potential exists that most patients who currently fall in the “self-pay” category will be covered by health insurance. • Depending on the typical fee paid by the insurers of these newly insured, and depending on the cost sharing responsibility born by these newly insured, emergency physicians stand to gain significant new revenue from previously uninsured patient visits to the emergency department. Threats for Emergency Medicine The two most prominent threats faced by emergency medicine under PPACA are: • The potential erosion of current payment rates by commercial insurers, and

• The possibility that emergency physician reimbursement will be closely tied to hospital reimbursement for a segment of the Medicare population. • Depending on the financial class mix of patients seen in the emergency department, various amounts of revenue are obtained from patients covered under traditional health insurance (i.e., HMOs, PPOs, and other forms of commercial insurance). Whether the emergency physician participates in these plans or not, the potential exists under PPACA that the new exchange-based insurance payment rates for emergency physician services will have the effect of lowering the overall physician payment rates paid by current insurers. • Political economic trends - such as the potential for bans on balance billing - may further compound the downward pressure on fees paid to emergency physicians. The two PPACA pilot programs - Accountable Care Organizations and bundled payments - may have a profound effect on traditional fee-for-service revenue for emergency physicians. Emergency groups should follow these two areas closely as rules and regulations are developed over the next few years. Emergency groups will need to be receptive to the financial needs of the hospitals they staff, and develop clinical guidelines and payment formulas that align incentives between the emergency group and the hospital. Summary While the coverage expansions that are at the center of health care reform will likely boost practice revenues for many EPs, those aspects of health reform that are included as part of the effort to make the system more efficient and less costly could have financial consequences that would not be welcomed by many physicians. While most of these provisions will not be implemented until 2014, EPs should begin their strategic planning now in order to prepare for these changes. EPs and emergency groups will be well served to learn the pertinent provisions of PPACA, and be ready to implement required changes to their clinical and billing practices.

EMpulse • Fall 2010 15

SYMPOSIUMlecture

New Airway Devices

David A. Caro, MD, FACEP

Residency Director Emergency Medicine UF, Jacksonville

Emergency airway management has changed significantly. Technological advances have included the use of neuromuscular blockade, the conversion from blind nasal intubation to direct oral intubation, and more recently, the advent of a number of alternative airway devices designed to improve first-attempt visualization and ease of intubation. We’ll review one class, indirect visualization devices, in this article. The indirect visualization devices specifically include videolaryngoscopes and intubating stylets. Multiple variations exist and are worth review. All depend on video input from internal cameras as well as lighting from an internal light source, and all are designed for oral intubation use. Multiple studies have demonstrated superior Cormack-Lehane views of the larynx compared to direct laryngoscopy with a standard laryngoscope.1,2 What has not been described is the performance of any of these devices in the presence of blood, vomit, or significant airway secretions, all of which have been shown to impair bronchoscopic video system performance.3 The intubating stylets include the Bonfils stylet (Karl Storz GmbH & Co. KG), the Levitan scope (Clarus Medical, LLC), and the Shikani scope (Clarus Medical, LLC). These devices combine a light source and fiberoptic camera into the shaft of a semi-

16 EMpulse • Fall 2010

malleable stylet over which an endotracheal tube is placed.

to a stand that is wheeled for ease of transport.

The stylet is shaped by the manufacturer to allow the practitioner to place the tip of the stylet around the tongue with minimal force and minimal mouth opening, bringing the glottis into almost immediate view either through an eyepiece or via a cable attachment to a videoscreen.

Importantly, the Glidescope is designed to be used with a rigid stylet shipped with the device. The stylet bends an endotracheal tube to the correct angle to make an acute angle around the tongue into the airway. It is essential to use this stylet to ensure intubation success with this device. Other videolaryngoscope systems have been recently introduced to compete with the Glidescope.7,8,9,10

Then the endotracheal tube can be guided into the airway. The intubating stylets have had proven track records in the operating room and appear to be solid choices as primary or difficult airway devices.4,5,6 The videolaryngoscopes include the Glidescope (Verathon Inc.), the C-Mac (Karl Storz GmbH & Co. KG), the AirTraq (King Systems), the LMA C-Trach (LMA North America, Inc.), the McGrath (LMA North America, Inc.), and the Airway Scope (Pentax of America Inc.). Most of these devices are shaped like a McIntosh laryngoscope, with some important differences. The Glidescope is prototypical of this class of device and is one of the most established.1 Its handle has a tip that is angled at 60 degrees compared to the McIntosh blade, allowing a view that is angled around the curvature of the tongue, more “anteriorly” directed. It is attached to a small videoscreen by cable, and the screen is attached

It is wise to gain specific training and simulation experience with any of these devices before using it in an emergency setting. Each device has specific design features that must be understood in order to use the device properly. It is important to know that these devices have been shown to provide superior laryngeal views compared to direct laryngoscopy, and that they have been shown in some studies to improve intubation success rates in difficult airway settings.1,11 In contrast, we do not have data on their use in the “wet” (blood, vomit, secretions) airway. However, we can expect that as these devices become better known, they will be more frequently employed in U.S. emergency departments. -------------------------------------------------Cooper, R.M., J.A. Pacey, M.J. Bishop & S.A. McCluskey. (2005). Early clinical experience with a new videolaryngoscope 1

SYMPOSIUMlecture

(GlideScope) in 728 patients. Canadian Journal of Anaesthesia = Journal Canadien d'Anesthesie 52, 191-198. Savoldelli, G.L., E. Schiffer, C. Abegg, V. Baeriswyl, F. Clergue & J.L. Waeber. (2008). Comparison of the Glidescope, the McGrath, the Airtraq and the Macintosh laryngoscopes in simulated difficult airways*. Anaesthesia 63, 1358-1364. 2

232-237. van Zundert, A., R. Maassen, R. Lee, R. Willems, M. Timmerman, M. Siemonsma, M. Buise, et al. (2009). A Macintosh laryngoscope blade for videolaryngoscopy reduces stylet use in patients with normal airways. Anesthesia and Analgesia 109, 825-831. 7

Cavus, E., J. Kieckhaefer, V. Doerges, T. Moeller, C. Thee & K. Wagner. (2010). The C-MAC videolaryngoscope: first experiences with a new device for videolaryngoscopy-guided intubation. Anesthesia and Analgesia 110, 473-477. 8

Ovassapian, A. (2001). The flexible bronchoscope. A tool for anesthesiologists. Clinics in Chest Medicine 22, 281-299. 3

Greenland, K.B., G. Liu, H. Tan, M. Edwards & M.G. Irwin. (2007). Comparison of the Levitan FPS Scope and the single-use bougie for simulated difficult intubation in anaesthetised patients. Anaesthesia 62, 509-515. 4

Turkstra, T.P., D.M. Pelz, A.A. Shaikh & R.A. Craen. (2007). Cervical spine motion: a fluoroscopic comparison of Shikani Optical Stylet vs Macintosh laryngoscope. Canadian Journal of Anaesthesia = Journal Canadien d'Anesthesie 54, 441-447.

Arslan, Z.I., T. Yildiz, Z.N. Baykara, M. Solak & K. Toker. (2009). Tracheal intubation in patients with rigid collar immobilisation of the cervical spine: a comparison of Airtraq and LMA CTrach devices. Anaesthesia 64, 1332-1336. 9

Byhahn, C., S. Nemetz, R. Breitkreutz, B. Zwissler, M. Kaufmann & D. Meininger. (2008). Brief report: tracheal intubation using the Bonfils intubation fibrescope or direct laryngoscopy for patients with a simulated difficult airway. Canadian Journal of Anaesthesia = Journal Canadien d'Anesthesie 55, 6

Suzuki, A., Y. Toyama, N. Katsumi, T. Kunisawa, R. Sasaki, K. Hirota, J.J. Henderson, et al. (2008). The PentaxAWS((R)) rigid indirect video laryngoscope: clinical assessment of performance in 320 cases. Anaesthesia 63, 641-647. 10

Maassen, R., R. Lee, B. Hermans, M. Marcus & A. van Zundert. (2009). A comparison of three videolaryngoscopes: the Macintosh laryngoscope blade reduces, but does not replace, routine stylet use for intubation in morbidly obese patients. Anesthesia and Analgesia 109, 1560-1565.

VOLUNTARY EMpulse SUBSCRIPTIONS Contribute $20 or more to help defray the publishing and mailing costs of EMpulse.

Check payable to: FCEP EMpulse VS 3717 South Conway Road Orlando, FL 32812

EMpulse â&#x20AC;˘ Fall 2010 17

SYMPOSIUMlecture

Disaster Management Telemedicine Projects Antonio Marttos, MD

Director Trauma Telemedicine Department William Lehman Injury Research Center University of Miami The trauma telemedicine department at William Lehman Injury Research Center/Ryder Trauma Center has been working for the past four years on developing tele-trauma solutions, in different areas of the trauma care theater. Using state of the art technologies we aim at extending the reach of urban trauma center physicians, improving performance during mass casualty incidents, and increasing trauma care education opportunities.

So far 4 Trauma Centers (Orlando, Gainesville, Pensacola and Miami) are connected to 8 remote hospitals. Ultimately we seek to create a statewide tele-network between all 21 Florida trauma centers and their surrounding community hospitals. Tele-trauma A diminishing workforce and the increas-

Florida’s shortage of surgeons and its susceptibility to natural disasters prompted state authorities to strive to develop and implement a telemedicine network which would cover the entire state, to improve care at remote locations, alleviate personnel shortages in mass casualty scenarios and allow better allocation of resources.

Furthermore, use of a robot would allow complete mobility in the trauma resuscitation area enabling the remote physician to be immersed in the environment, to interact with fellow clinicians and patients, in order to extract as much information as possible from any situation.

The network was initiated by providing teleconference capabilities to all trauma centers involved, and by identifying the community hospitals with the highest number of transfer patient to the trauma centers.

18 EMpulse • Fall 2010

Tele-trauma was used 113 times from April 2008 to July 2009. Most remote physicians were able to see all of the patient’s injuries clearly (4.58) and were able to see screens and monitors presenting patient information and vitals (4.83). Remote physicians felt able effectively to communicate with staff (4.66) and that the staff was able to understand their questions and comments (4.79). They also felt that having access to a remote physician at all times would be beneficial (4.95).

Florida Trauma Network

In the case of Ryder Trauma Center a connection was first established with Lower Keys Medical Center, in Key West. We have just started live connection with EMS in Key West and Marathon.

thereby extending the reach of trauma care specialists, allowing them to be involved in the care of the trauma patients regardless of their physical location.

Mass Casualty Triage

ing regionalization of care have caused trauma resources to become ever scarcer throughout the country. Tele-trauma is the provision of trauma care from a distance,

Effective response to a disaster situation (e.g., a mass casualty explosion) requires that healthcare systems be able to manage the ‘surge capacity’ created by the sudden increase in demand for care. Unfortunately, in these situations, appropriate triage is delayed due to

SYMPOSIUMlecture non-availability of trauma specialists, or is performed by non-trauma clinicians. Telemedicine allows a remote expert to perform triage, freeing up local personnel to provide much needed care to the most acute patients. Our research investigated the effectiveness of telemedicine in triaging victims during several mass casualty exercises performed in collaboration with Jackson Memorial Hospital, the US Army and Holmes Regional Medical Center, using a combination of commercially available products.

Key West; Universidad Militar, Colombia; University of Amazonas, and University of Sao Paulo, Brazil; Hospital Universitario Dr. Negrin, Canary IslandsSpain; Hospital Buen Samaritano, Puerto Rico). Each week, prior to grand rounds, a tele-conference between the organizing faculty members discusses the upcoming presentation and finalizes arrangements. Trauma cases are then presented at grand rounds, and all participants discuss patient management step by step.

Within hours a connection with Miami was established, which facilitated logistics discussions pertaining to much needed supplies and patient transfers, and allowed physician consultations. The volunteers also could stay in touch with their own families, a much needed stress relief. In the weeks subsequent to the earthquake, Ryder Trauma Center attending physicians were able to perform tele-rounds with the UM Hospital in Haiti, an essential component of the relief efforts.

This confirmed that telemedicine is effective for remote triage of mass casualty victims. The technology utilized is simple, inexpensive and rapidly deployable with little training.

These Trauma Grand Rounds through video-conferencing are rated by students, residents, fellows and attendings to be an outstanding tool for education, and sharing of expertise between medical centers.

Trauma Tele-Grand Rounds

Haiti

Valuable lessons were learned from this use of telemedicine in an actual disaster situation.

Ryder Tele-Trauma Center, in association with several distinguished institutions, has set out to modernize Grand Rounds, one of the most important and time-honored traditions in medical education.

On January 12, 2010 Port Au Prince, Haiti, experienced an earthquake of 7.0 on the Richter scale.

The telemedicine connection was limited by accessibility to a stable high-speed satellite connection.

The University of Miami started a large relief effort sponsored by its faculty, staff, and generous benefactors, one of the first institutions to provide aid to the wounded.

We also learned what should be included in a mobile telemedicine kit and what sort of protocol should be set for consultations with remote physicians.

We have been conducting bimonthly tele-conference grand rounds for over two years. We connect to a net of participating institutions (Walter Reed Army Medical Center, Washington D.C; University of Florida, Gainesville and Jacksonville; Holmes Regional Medical Center, Melbourne; Lower Keys Medical Center,

It also helped set a platform whereby telemedicine would become part of the standard of care in UM/Project Medishareâ&#x20AC;&#x2122;s Haiti hospital.

Within hours of the disaster a team of physicians on a humanitarian mission flew to Port Au Prince. Communication with anyone outside of Haiti was almost impossible; there was no electricity, phones, or running water. Critical patients were sent back to Miami. However, clinicians at the receiving hospitals had no idea how many patients were to come, or the nature of their injuries. Something had to be done to establish a communication link. On the Saturday following the earthquake, only 96 hours later, Dr. Antonio Marttos boarded an airplane armed with two portable satellite dishes and two mobile telemedicine kits.

EMpulse â&#x20AC;˘ Fall 2010 19

SYMPOSIUMcpc

The Somnolent Alcoholic with Low Blood Pressure CPC Chair: Fred Epstein, MD, FACEP Case Presenter / Discussant: Joshua B. Kaplan, DO University of Florida - Gainesville A 62 year old Caucasian male presented to Shands at the University of Florida with the chief complaint of “not feeling well”. The patient had called EMS, but the call was soon disconnected and EMS found the patient lying outside his house, intoxicated. On arrival, the patient appeared somnolent but was arousable to verbal stimuli and was oriented to person and place. Initial vital signs were: blood pressure (BP) 70/33, heart rate (HR) 100, respiratory rate (RR) 27, saturation 96% on room air, temperature 31.7 C, and blood glucose 220. Two liters of warm NS were infused, a Bair Hugger was placed and 4L of oxygen were administered by nasal cannula. The patient provided limited history due to his somnolence and intoxication; however, he reported shortness of breath for 2 days, not feeling well, and a subjective fever a few days prior. He admitted to drinking unknown quantities of alcohol. He denied chest pain, abdominal pain, nausea/vomiting, cough or headaches, and denied trauma. Repeat vital signs 40 minutes later were: BP 83/49, HR 88, RR 21, saturation 100% on 4L oxygen, and temperature 33.5 C. From prior records, the patient’s past medical history included cirrhosis, chronic alcoholism, and HTN. Also from prior records, he was not taking any medications, had no allergies, and had no contributory family history. The patient drank 7-8 beers/day and did not smoke. On physical exam, the patient was somnolent, intoxicated with a disheveled appearance. He had dry mucous membranes. His skin was cool and dry. He was tachycardic, but had equal/palpable pulses throughout. He was mildly tachypneic, and lung sounds were clear bilaterally. The abdomen was soft, non-distended, non-tender, without rebound or guarding, had normal bowel sounds, with no obvious ascites. He was moving all extremities with no focal weakness. The neurologic exam was limited, however no focal deficits were 20 EMpulse • Fall 2010

appreciated. His Glasgow Coma Score was 14. Point of Care labs showed: H/H of 11.2/33.7, Na 144, K 3.1, Cl 114, HCO3 10, BUN 8, Cr 1.2, INR 1.3, Lactic acid 9.8, and VBG 7.08/31/35/9. Chest X-ray was unremarkable. EKG revealed sinus tachycardia. FAST exam showed fluid in Morison’s Pouch, the splenorenal and pelvic recesses; UA was unremarkable. Formal labs showed: WBC 10.2, H/H of 10/28.9, PLT 321, mildly elevated LFTs and Lipase, Lactic acid of 11.13, elevated D-Dimer, slightly low Fibrinogen, normal cardiac enzymes, EtOH 168, ABG 6.98/41/158/10. A central venous line and an arterial line were placed; blood and urine cultures were sent; and Timentin and Vancomycin was started empirically. Repeat vital signs 30 minutes later showed: BP 148/93, HR 117, R 17, Sat 100% NRB, Temp 33.9 C. The patient’s mental status deteriorated and he was intubated and started on a Versed drip. Repeat vitals 30 minutes later showed: BP 50/37, HR 121, RR 12, saturation 100%, and temperature 34.4 C. The patient was given 2L of NS and 2 amps of NaHCO3. The Versed drip was stopped and Dopamine was administered, followed by a Levophed drip titrated to 25mcg/min. Steroids were also given. Repeat vital signs 20 minutes later showed: BP 71/43, HR 127, RR 12, saturation 100%, and temperature 34.5 C. The patient was taken for a CT of the head, chest, abdomen, and pelvis (Figure 1). The patient was brought back to the resuscitation bay and a further test confirmed the diagnosis. CASE DISCUSSION This patient presented to the ED intoxicated, somnolent, complaining of not feeling well. He was hypotensive, tachycardic, tachypneic, and hypothermic. His physical exam findings reflected these vital sign abnormalities, and otherwise were fairly unremarkable. He had a worsening lactic acidosis, slightly wors-

SYMPOSIUMcpc ening anemia, essentially normal electrolytes (with the exception of low bicarbonate), and a normal white count. He had a history of cirrhosis with ascites, and had a positive FAST exam. His BP initially responded to IVF, but then continued to drop even after the addition of pressors. He was covered with antibiotics in case this was a presentation of septic shock.

initiated and surgery was consulted. The patient was taken to the OR and a celiotomy with hepatic packing was performed. The following day, the patient had successful embolization to control the hemorrhage. A biopsy of the liver mass confirmed the mass as hepatocellular carcinoma (HCC). The patient was discharged 6 days later.

The CT scan of his abdomen revealed a large mass in the left lobe of his liver. Furthermore, the CT scan showed “blushing” of IV contrast dye in and around this mass suggesting active hemorrhage. The patient was brought back to the resuscitation bay and a 19 G needle was inserted into the abdomen with US guidance. Frank blood was aspirated. The fluid seen on the FAST exam and on CT was not ascites, but blood.

Risk factors for developing HCC include: ascites, cirrhosis, and hepatitis. It is the most common primary tumor of the liver. Symptom onset is typically late which leads to a poor prognosis. Many patients are asymptomatic at the time of diagnosis, while 2-10% present with rupture. Risks for rupture include: Male sex, left liver lobe involvement, and close proximity to the liver surface. Management of ruptured HCC typically consists of arterial embolization. Overall mortality of ruptured HCC is 60-70%.

A repeat H and H was 7/20. A mass transfusion protocol was

Figure 1

EMpulse • Fall 2010 21

SYMPOSIUMresearch

2010 Resident Case Presentation Competition (CPC) Top Research Poster Presentations Presented at the Symposium by the Sea 2010 July 29 - August 1, 2010 . The Boca Raton Resort & Club

END-TIDAL CARBON DIOXIDE LEVELS ARE ASSOCIATED WITH MORTALITY IN EMERGENCY DEPARTMENT PATIENTS WITH SUSPECTED SEPSIS Christopher L Hunter, MD, PhD, Salvatore Silvestri, MD, Matthew Dean, Jay Falk, MD , Linda Papa, MD Orlando Regional Medical Center Emergency Medicine Residency University of Central Florida College of Medicine OBJECTIVE Recently, exhaled end-tidal carbon dioxide concentration (ETCO2) was demonstrated to correlate with clinical measures of organ failure and lactate levels in febrile patients. This study assessed whether levels of ETCO2 were associated with inhospital mortality and examined the correlation with serum lactate levels in patients presenting to the ED with signs of SIRS, sepsis, or septic shock. METHODS We conducted a prospective observational cohort study of septic patients presenting to an urban tertiary care center ED with an annual volume of 70,000. Adult patients who presented with suspected infection and two or more of the following SIRS criteria: temperature >38C or <36C, heart rate >90 beats/min, and respiratory rate >20 breaths/min were eligible. The following data was collected: ETCO2 via nasal cannula, serum lactate level, blood cultures, the need for pressors or mechanical ventilation, and disposition. Our primary endpoint was the association between ETCO2 (mmHg) and inhospital mortality. Our secondary endpoint was the correlation between ETCO2 and serum lactate (mMol/L). RESULTS There were 147 patients enrolled over 15 months with a mean age 63 years (range 18-99), 57% were male, 33% were admitted to the ICU, 20% were put on pressors, 31% were blood culture positive, and 18% were intubated. The mean length of stay was 22 EMpulse â&#x20AC;˘ Fall 2010

9 days (range 1-54) and inhospital mortality was 14%. Overall mean levels of ETCO2 and lactate in all patients were 31.7 (range 8-81) and 3.0 (range 0.4-15.0) respectively. Mean ETCO2 levels in patients who survived to hospital discharge was 32.6 (95%CI= 30.8-34.4) and in patients who did not survive it was 26.5 (95%CI= 21.9-31.1) (P=0.012). Mean levels of lactate in patients who survived to hospital discharge was 2.6 (95%CI= 2.1-3.1) and in patients who did not survive it was 5.8 (95%CI= 3.6-8.0) (P=0.008). There was a significant inverse relationship between ETCO2 and lactate levels with a correlation coefficient of -0.462 (P<0.001) - so as lactate levels increased ETCO2 levels decreased. CONCLUSION There was a significant association between levels of ETCO2 and inhospital mortality in emergency department patients with suspected sepsis. Additionally, ETCO2 levels were significantly and inversely correlated with lactate levels in these patients. With future studies it may be used as a potential risk and non-invasive stratification tool for predicting sepsis severity in this patient population. -----------------------------------------------------------------------------THE LOOP TRIAL: A RANDOMIZED PROSPECTIVE STUDY COMPARING THE EFFICACY OF A NOVEL SKIN ABSCESS DRAINAGE TECHNIQUE VERSUS TRADITIONAL INCISION AND DRAINAGE IN THE EMERGENCY DEPARTMENT Jay Ladde MD, Sara Baker MD, Michelle Wan MD, Natalie Lilburn MD, Vanessa Vasquez, Linda Papa MD Orlando Regional Medical Center OBJECTIVE The LOOP technique has been used as an alternative abscess drainage technique to the traditional I&D for skin abscesses in

SYMPOSIUMresearch the ED but its large-scale utility has yet to be determined. This study assessed treatment failure in these two drainage techniques; as well as ease of procedure and pain scores in patients of all ages presenting to the ED. METHODS This prospective randomized controlled study of adults and children was conducted at both a Level I Adult and Level I Pediatric Trauma Center. Patients were eligible if they presented to the ED with a skin abscess necessitating drainage in the ED. Patients were excluded if the abscess was located on face, hand, or foot abscesses or if the patient required admission or operative intervention. The main outcome was proportion of failures at 10-day follow-up as defined by requiring admission, IV antibiotics or repeat drainage. Secondary outcomes were measured initially and at 36 hours using a 10cm VAS scale and included ease of procedure (EOP) (0=effortless to 10=very difficult)and pain scores (0=no pain to 10=worst pain). RESULTS Over an 8 month period, there were 115 patients enrolled: 35 (27%) children and 94 (73%) adults. The overall mean age was 25 yrs (SD16) with 24 (SD17) yrs in the LOOP group (LG) and 26 (SD17) yrs in I&D group(IDG) (P=0.49). There were no significant differences between the groups with respect to sedation (p=0.82), size (p=0.77), location (p=0.14) presence of cellulitis (p=0.75) or antibiotic use (0.87). Overall failure occurred in 17 patients (14.8%) with 13.8 % in LG and 15.8% in the I&D group (P=0.80). Initial EOP was rated as 3.24 (SD1.9) in the LG and 3.15 (SD1.9) in the IDG (p=0.81). Initial pain scores were 4.84 (SD2.8) and 4.78 (SD2.5) in the LG and IDG’s respectively (p=0.91). At 36 hrs EOP was rated as 1.72 (SD2.0) in the LG and 2.98 (SD2.5) in the IDG (p=0.05) and pain scores were 2.57 (SD2.6) and 3.74 (SD2.7) in the LG and IDG respectively (p=0.02). CONCLUSION The LOOP technique appears comparable to traditional I&D in the treatment of abscesses in the ED. Larger samples will be required to determine efficacy in this ongoing trial. -----------------------------------------------------------------------------STABILIZATION AND TREATMENT OF DENTAL AVULSIONS AND FRACTURES BY EMERGENCY PHYSICIANS USING JUST-IN-TIME TRAINING Mark McIntosh, MD, MPH; Jason Konzelmann, MD; MS, Jeffrey Smith, DMD; Colleen Kalynych, MSH, EdD; Robert Wears, MD; Howard Schneider, DDS, MSD; Todd Wylie, MD, MPH; Anne Kaminski, MD, Madeline Matar-Joseph, MD

University of Florida COM/ Jacksonville Department of Emergency Medicine Florida State College at Jacksonville OBJECTIVE The objective of this investigation is to use a dental simulation model to compare splinting and bandaging methods for managing tooth avulsions and fractures, as measured by dentist evaluators for quality and time to complete each stabilization procedure. METHODS This was a randomized crossover study comparing 3 splinting techniques for managing a traumatically avulsed tooth (periodontal pack, wire, and bondable reinforcement ribbon) and 2 bandage techniques for managing a fractured tooth (calcium hydroxide paste and light-cured composite). After viewing a Just-in-Time training video, a convenience sample of emergency physicians performed the 5 stabilization techniques on dental models containing extracted teeth embedded in clay to simulate a segment of the human dentition. Data collected included time to complete each procedure, the evaluation of dentists about whether the procedure was performed satisfactorily or unsatisfactorily, and the ranking of dentists’ and participants’ preferred technique. RESULTS Twenty-five emergency physicians participated in the study: 17 residents, 2 pediatric emergency medicine fellows, and 6 attending physicians. Reported median time, as well as minimum and maximum times to complete each splinting technique for an avulsed tooth, was as follows: periodontal pack 4.4 minutes (2.5 to 6.5 minutes), wire 8.6 minutes (5.8 to 12.9 minutes), and bondable reinforcement ribbon 8.9 minutes (5.6 to 15 minutes). Median time (and minimum and maximum times) to complete each protective bandaging technique for a fractured tooth was calcium hydroxide paste 4.6 minutes (3 to 9.6 minutes) and light-cured composite 7.1 minutes (5.5 to 14.1 minutes). When asked to choose a preferred splinting and bandaging technique according to the performance of the physicians, the dentists chose the bondable reinforcement ribbon 96% (24/25) and the light-cured composite 100% (25/25) of the time. Study participants had no measurable or agreeable preference for a particular splinting or bandaging technique. CONCLUSION The results of this study suggest that of the stabilization procedures completed by emergency physicians, dentists preferred the bondable reinforcement ribbon for managing an avulsed tooth and the light-cured composite technique for managing a fractured tooth over the commonly taught and more frequently used procedures in emergency medicine.

EMpulse • Fall 2010 23

CONVERsations

Up Close And Personal

Sandra M. Schneider, MD, FACEP ACEP President-Elect

Tell us a little bit about yourself? I was born in an immigrant suburb of Pittsburgh full of wonderful salt of the earth people. A lot of people did not go to college. As a young child people would ask me what I wanted to do. I would say I wanted to be a doctor. My mother would correct me and say “No, she means a nurse.” And I would say “No, I really want to be a doctor.” I went to the University of Pittsburgh Medical School. After I finished my residency there, I received a US Public Health Service scholarship to go to Kentucky, where I spent 3 ½ yrs as an internist and an EP. I then returned to the University of Pittsburgh and the Montefiore Hospital for 13 yrs as its ED Director. The hospital merged and downsized and I ended up being offered the Chair at the University of Rochester. I keep bouncing back and forth to Pittsburgh but Rochester has been my home for 17 yrs and will be for a while longer. My daughter is moving to Dallas in 2 weeks, so who knows? What are your hobbies? Oh my goodness! I am a scuba diver. That’s not a great hobby to have because you can’t do it very often, it’s very expensive, and you’ve got to lug around a lot of equipment, but I love underwater photography – I don’t do much photography above water. My other hobby is sewing and I know this sounds strange. I got back into sewing 24 EMpulse • Fall 2010

after many years and got this embroidery machine as a gift to myself when I was elected president. You basically pick out something on these little machines and push a button and it sews right in front of you! The most wonderful things in the world! Deep in my soul, I am a creative person. Unfortunately, outside, I have no talent. So, inside my soul I am a dancer, but I can’t dance. So sewing is my creative outlet: my daughter has a pony and I have been making these saddle pads and embroidering polo wraps for her. She likes skull and crossbones and bats and all sorts of crazy things and we have been having a blast! My other creative outlet is Chinese cooking. My secret ambition is to be on “Iron Chef, America”. But just like dancing, I’m probably never going to get there. What message would you like to give to emergency physicians of Florida? Get involved. Join a club. ACEP has been a wonderful club to join. I have also been involved with SAEM and AAEM. I think getting involved is great, and then when you have joined a club, get more involved! I tell people “Go the opening reception, meet people, volunteer for a committee, volunteer to do something on the committee, and then actually do it. Volunteering to do something and then actually doing it is shocking for people. Get involved nationally and advocate for your patients. You will see your work in a much broader

context and you also have an outlet for some of the things that irk you. One of the main reasons I got involved with ACEP was because I was upset that we didn’t have a presence in the NIH. And when I went on the ACEP board, they asked “What would you like to accomplish?” I said “I would like to have a meeting with the NIH some time in my 6 years.” And 6 months later, there we were, in the NIH. That was all I wanted to accomplish, and it was done in 6 months. Now, if we could do this in 6 months, surely we can stop the practice of boarding. This is a little harder and it will take a lot more time, but the power of ACEP is incredible. What is also amazing is all the friends I have made. My daughter was going to New York City on the day after we started bombing Iraq. I was scared to death. I wrote down the names of all the EPs I knew in NYC and told her that if anything happened, she was to go an ER and ask “Do you know any of these doctors?” When I rang most of these people later, they said “Sandy, if your daughter had come in, I would have stopped, made sure that your daughter was taken care of, and then I would have gone back to work”. Every time I fill out my ACEP dues form, I think about that moment, and I think that I don’t pay enough. However expensive ACEP dues may be, the friendships are worth much, much more.

Baby 911 provides peace of mind...

Important health information for the first year of your baby’s life

That’s what you’ll experience with the invaluable health and emergency information you need to care for your new baby at your fingertips. You’ll know how to care for your precious infant even during the most stressful emergency or routine healthcare situations. Baby 911 is a DVD educational guide that gives you comprehensive, helpful advice and gentle reminders on how to care for your bundle of joy, from the moment you are released from the hospital until your baby’s first birthday.

Richard S. Slevinski, M.D., developed the concept and content of Baby 911 based on 30 years of caring for families in the Emergency Department. He was the EMS Medical Director for the State of Florida for many years, leading the way in Emergency, Trauma and Disaster care. He currently practices at Sacred Heart Hospital in Pensacola Florida, a Level 2 adult and Pediatric Trauma Center.

Important health information baby’s life

Emergency Medicine Learning and Resource Center (EMLRC) is a nonprofit organization for the first year of your dedicated to promoting and advancing emergency medicine, disaster management, prehospital emergency care, and public health through annual medical education conferences and research activities. As a leader in medical simulation education and training, EMLRC continues to explore and define new methods and © EMLRC technological formats for classroom and distance learning. Learn more at www.emlrc.org.

As you view Baby 911, you will learn how to: • Administer rescue breathing and CPR • Relieve congestion with nasal suctioning • Accurately take your baby’s temperature • Handle dehydration related to vomiting and diarrhea • Care for your newborn’s umbilical cord • Tips for soothing a fussy baby • Introduce the family pet to baby • Identify and address postpartum depression • Plus much more

Developed by:

Supported by:

Important health information for the first year of your baby’s life

Peace of mind – that’s what you’ll experience with the invaluable health and emergency information you need to care for your new baby at your fingertips. You’ll know how to care for your precious infant even during the most stressful emergency or routine healthcare situations.

Important health information for the first year of your baby’s life

ORDER

www.baby911.org

Developed and provided by the Emergency Medicine Learning & Resource Center www.emlrc.org.

ERchronicles

# 37: The Elevator Doors Closed Arlen R. Stauffer, MD, MBA, FACEP

“You look awfully pale, Brad,” Sylvia said to her husband as he dropped firmly into the recliner. After 45 years with this man, she knew instantly that something wasn’t right. Sylvia stared in wide-eyed disbelief as this strong man staggered from the chair and toppled against the wall. She ran to his side. He moaned. “He’s still breathing,” she said out loud, and then she grabbed the phone a punched 9-1-1 into the keypad. -------------------------------------------------“Medic 33 here. We’re two minutes out with a 68-year-old male who passed out.” The paramedic’s nervous voice on this radio call told the ER staff that there likely was more to this story than just passing out. She continued her report. His wife says he complained of abdominal and back pain earlier, and then he just slumped down. His initial BP was 70 over 30. We’ve got saline running wide open. I think I can feel a mass pulsing…” Three emergency nurses looked up at each other. They all knew what was coming. “OK, folks! Let’s get a spot ready for this guy.” Emergency physician Tammy Cortez spoke the obvious. “Sounds like a triple-A!” The nurses were already preparing Critical

26 EMpulse • Fall 2010

Care Room 2, and Cortez released a deep sigh. She knew that a lot of things would need to go right on this Saturday evening for this to have a good outcome. She was not in her usual work place at the big medical center, but had volunteered to cover this vacant shift for her friends here at the small community hospital 35 miles away. Extra bags of saline were stacked on the table, the lab tubes were bunched in the ready position, and the monitor was turned on as Brad was rolled through the ambulance entrance. “Do we have someone on vascular call tonight here?” Cortez asked with a hopeful tone. “I’ll check.” As Brad was pulled from the ambulance stretcher onto the Critical Care bed, Cortez noticed that his eyes were wide open. Fear was obvious. “Hi, Sir. I’m Dr. Cortez. Are you still having pain in your belly?” Not knowing how long this patient may remain awake, Cortez fired questions rapidly to Brad as the nurses flew into action all around the bed. “Do you have any medicine allergies? Have you had any heart or blood pressure problems in the past? Tell me what medicines you’re on.”

Cortez heard, “His pressure’s 78 over 40.” She glanced at the tachycardia on the monitor. As she continued firing questions at Brad, her hands were probing his flanks and abdomen. Yes, there it was…..the pulsatile mass. “Is there a vascular call doc?” She shouted toward the ER secretary as she silently prayed for an answer in the affirmative. “Yeah, Miller’s on tonight.” “Get him….NOW!” Then, remembering all the “no-vascular-surgery-call” days on this hospital’s ER schedule, she whispered under her breath in Brad’s direction. “It may be your lucky day, buddy.” The blood was on its way to the lab, and Cortez was finishing a quick physical exam while she looked at the EKG. “Call the OR and tell ‘em we’ll have one coming up….soon!” The clock was ticking. Cortez leaned into Brad’s field of vision. “Sir, you have an aneurysm in your belly that has ruptured, and you’ll need immediate surgery. We’re getting fluids into you now, and you’ll be getting some blood in a few minutes as we get you ready for the OR.”

ERchronicles Can I see my wife?” Brad asked weakly. “Sure.” Sylvia was ushered through the bustle towards Brad. What was actually a flurry of organization seemed chaotic to her as she approached his side. “Brad?” For the first time, the reality of the seriousness of this hit Sylvia. “Hi, Baby.” Brad swallowed hard. “They say…..I need……surgery.” His voice was soft now, and he felt like he

rupture an aneurysm like this don’t make it through,” she said as she looked Sylvia straight in the eyes. Sylvia didn’t know what to say. As she turned back toward Brad, she heard a nurse call out. “Pressure’s dropping a bit!” “You should call your children,” Cortez whispered in Sylvia’s ear, “and let them know what’s going on.” Vascular surgeon Jim Miller darted past the two women and called out as he

and the ER tech, rolled smartly toward the elevator for its direct ride to the OR. Sylvia’s hand slipped up Brad’s arm and off his shoulder. She stood motionless, and, although surrounded by several people, felt very alone. She stared down at her feet. The elevator doors closed. -------------------------------------------------Abdominal aortic aneurysms are most common in males over the age of 60 and in smokers, and there is a genetic predisposition. Ninety percent are infrarenal in location. The major complication of an AAA is rupture, which can be fatal in nearly half of these patients in the peri-operative period. Death is often due to cardiac complications. Some advocate screening individuals at risk for AAA, and performing elective repairs when the aneurysm reaches a larger size, indicating higher risk of rupture. Mortality rates for elective repairs are considerably less than the rates for patients with an AAA rupture.

was going to fall asleep.

jumped on the OR elevator.

Cortez touched Sylvia’s shoulder. “We’re getting the OR ready now, and Dr. Miller, the vascular surgeon, should be here in a minute.”

“Get him up to the OR…..NOW! I’ll be scrubbed in within a minute.”

Sylvia backed away from the bed and motioned silently with her head toward Cortez.

“Sylvia,” Brad whispered as he struggled to lift his hand from the bed. “Sylvia.” His voice trailed off. Sylvia reached between nurses for Brad’s hand.

“Is this pretty serious?” she whispered. Cortez also spoke softly; only Sylvia could hear her now. “It’s very serious.

Many people who

Brad’s bed was starting to roll.

“Let’s go!” Cortez shouted loudly. “The OR’s ready!” Brad’s bed, surrounded by three nurses

The annual rupture risk for an AAA that is 4-5 cm in diameter is nearly 5%, and that annual risk increases to more than 10% when the AAA reaches a diameter of 6 cm. -------------------------------------------------The author is a long-time emergency physician from New Smyrna Beach, a former FCEP Board member and EMpulse editor, and current Director of Inpatient Services for Halifax Health Hospice. This is a revised version of one of the “Chronicles” that ran in several Florida newspapers a few years ago. Contact: stauffer911@gmail.com. EMpulse • Fall 2010 27

DOCTORSâ&#x20AC;&#x2122;lounge

The Underwater World of Dr. Andrew S. Malbin

Andrew S. Malbin, MD, FACEP is a board certified emergency physician who resides in Tampa, Florida. He practiced EM full time in the Tampa area from 1980 - 1999. He now works part-time as a fixed-wing air ambulance medical director and flight physician as well as does part-time consulting work. Dr. Malbin graduated from Boston University School of Medicine in 1978. He did his post graduate training at the University of Florida, Jacksonville from 1978-1980. Besides the Florida College of Emergency Physicians, Dr. Malbin is a member of the ACEP Air Medical Transport and Undersea & Hyperbaric Medicine Sections, member and former Secretary of the Undersea and Hyperbaric Medical Society, and a member of the Florida Society for Critical Care Medicine, American

28 EMpulse â&#x20AC;˘ Fall 2010

Association of Professional Ringside Physicians, and the AMA. Dr. Malbin began taking underwater photographs in the early 1980s. What began as a hobby has evolved into a true passion. Dr. Malbin has shot underwater photographs in a variety of locales around the globe including; Hawaii, Australia, Turks and Caicos, the Cayman Islands, Dominica, and Micronesia to name a few. Currently he is shooting digital images with a Nikon D300 in Aquatica housing. He continues to look forward to the new underwater photo opportunities that await him around the world. To order a print or view more pictures from Dr. Malbin's underwater adventures, visit his website at www.oceandoctorshots.com

ERmusings

Reminiscences of an Aging ER Doc

Wayne S. Barry, MD, FACEP I was recently “Facebooked” by a handsome 40 year old African American lady named Terri. “Was I the doctor who delivered babies in Cleveland in 1969 and then moved to Cockeysville, MD?”

rooms, and I attended the delivery of Terri! The delivery was complicated by a mild case of amnionitis and I wonder if she had been right about her water breaking!

Who could this lady be? Aha! Terri was the baby of a pregnant clinic Mom I met in Cleveland as a first week medical student at Case Western Reserve.

In my next 2 preclinical years, I met Terri and her mother every time she had a pediatric appointment. Afterwards Terri’s mother and I corresponded by mail each Christmas until Terri was about 14. The family then moved deep into Appalachia and we lost track of each other.

On a clinical rotation in medical school, I met the elegantly shy and quiet Mom in the OB clinic when she was very pregnant. At a home visit several weeks later, the mother excused herself to the bathroom and came back muttering “I think my water just broke.” Of course I had NO IDEA but she told me she needed to be checked at the hospital. Her husband Johnnie pointed ruefully to their disabled family car “up on blocks” in the yard. Unhesitatingly I offered to drive her to the hospital in my brand new, 1900 dollar, 1969 Volkswagen Beetle that my grandmother had given me as a college graduation present. At the hospital a cynical Ob/Gyn resident declared that the patient was not in labor and I drove her home again. I was criticized by an ancient OB physician who led our freshman seminar about the liability I could have incurred had I crashed my car with the patient in it. During class the next morning a page directed me to the Labor and Delivery

I am very excited about re-finding Terri on Facebook and we are trying to arrange a meeting. She lives with her 10 year old daughter and her mother in Jacksonville, a mere 110 miles from my home in Debary. Her father has passed away and her mother has remarried. Last spring I reconnected with a former patient I have known since 1975 when I was a resident on the Oncology Service at Johns Hopkins Hospital. Mildrene was the wife of a recently retired Air Force General then working for the power company in Northern Virginia. Normally a very vigorous person in her early 50’s she began to feel tired all the time. At the Andrews Air Force Base hospital she was told she had untreatable DeGuglielmo’s syndrome or ErythroLeukemia. Undaunted, Mildrene and her husband researched 3 medical centers that were

willing to treat her with experimental protocols and Baltimore was closer than Seattle or Houston. Her husband worked every day and drove 90 miles through traffic jams to be at her side for the entire month she lay hospitalized. I was devastated that month as every single patient on the ward died, most of them waiting for bone marrow transplants. But Mildrene and her husband kept me going. We poisoned her with twice the now recommended doses of chemotherapeutic agents. Somehow she made it and started an enduring correspondence with me. Hearing she was going to be in my neighborhood last spring, I changed my schedule to meet her. She came to my home on the way to the airport, and we embraced each other with a special feeling that transcended the doctor patient relationship. Though her husband died from renal failure after 2 failed kidney transplants and dialysis, she has been in remission all of these years. I am blessed to have had experiences like these during my 37 year medical career. It is truly an honor and a privilege to take care of people like Mildrene and Terri and her Mom. I hope the rest of you enjoy similarly rewarding patient encounters during your careers. I am sure that you will!

EMpulse • Fall 2010 29

POISONcontrol

Deepwater Horizon: The Gulf of Mexico Oil Spill Alexander Garrard, PharmD

Florida/USVI Poison Information Center-Jacksonville

Patrick Aaronson, PharmD

Emergency Medicine Pharmacist, Shands Jacksonville napthenes, aromatics, and asphaltics.3

shoreline arrival.6

Toxicity from hydrocarbons is directly related to their physical properties including: surface tension, volatility, chemical activity of side chains, solubility, and

The rig burned for approximately 36 hours, before sinking on April 22, 2010, coming to rest on the seafloor bed 5,000 feet below the water surface.

Studies that directly examine the acute and psychological symptoms of oil spill disasters from super tankers such as Exxon Valdex, Braer, Sea Empress, Nakhodka, Erika, Prestige, Tasmin Spirit, and Hebei Spirit have been described.7 Many of the studies were cross-sectional without a control group and found that the more the contamination of shorelines increased, the more likely residents were to engage in clean-up efforts, thus increasing the exposure to crude oil.

The well continued to spew approximately 184 million gallons of crude oil into the Gulf Mexico making this the worst environmental and oil disaster in the history of the United States.1,2

Acute symptoms (within one-two days) of petroleum exposure included: headache, itchy eyes, throat irritation, dermatitis, dizziness, nausea, fatigue, rash, and limb paresthesias.

On April 20th, 2010, an explosion occurred on an ultra-deepwater offshore oil drilling rig named Deepwater Horizon (DWH) in the Gulf of Mexico. The explosion killed eleven of the 126 crew members on board and caused a massive fireball that could be seen 35 miles away.

As the well hemorrhaged into the Gulf of Mexico for 85 days, concerns have been raised regarding the health and well-being of DWH response workers, of citizens living along the affected coast line, of workers in the Bay such as fishermen and service workers for the oil industry, and of healthcare professionals who have been treating these persons.2 Crude oil or petroleum is a mixture of hydrocarbons found beneath the Earthâ&#x20AC;&#x2122;s crust. This mixture can consist of gases, such as methane, propane, butane, and pentane, and other liquids and solids. The chemical composition by types of hydrocarbons may contain paraffins, 30 EMpulse â&#x20AC;˘ Fall 2010

viscosity. The pulmonary system, specifically aspiration, is most commonly involved in severe hydrocarbon toxicity. Viscosity (resistance to flow) is the chemical property most associated with aspiration risk.4

Acute psychological symptoms were increases in generalized anxiety disorder and depression.7-8

Measured in Saybolt Seconds Universal (SSU), substances with low SSU (examples < 45 include gasoline, kersosene, lighter fluid) are associated with an increased chance of aspiration.

According to the American Association of Poison Control Centers, there were 4,625 exposures to motor oils, of which 98% of cases resulted in none to minor acute adverse outcomes.9

On the other hand, crude oil viscosity is on average > 300 SSU.5 Some of the most toxic components of crude oil come from polycyclic aromatic hydrocarbons (PAH) causing mucus membrane inflammation which may increase the risk of respiratory infections such as pneumonia; however, much of the PAHs are vaporized prior to

Given the predominant hydrocarbon composition of natural crude oil, an occasional exposure or brief contact with oil is unlikely to cause adverse effects. Individuals who have had brief contact with oil can wash the exposed area with a grease dissolving liquid such as hand

POISONcontrol dishwashing detergent and water. Sensitive individuals may develop a rash or skin irritation. People who are exposed to crude oil for a longer period of time, such as response workers, run the risk of erythematic skin, swelling, and burning. Wearing proper protective equipment such as gloves, eye protection, and clothing that covers the arms and legs can minimize the extent of exposure. Inhalation of crude oil vapors or smoke from burning crude oil can cause minor respiratory irritation; however, persons

result in significant toxicity aside from dermal irritation. Response workers, who are continuously exposed to high levels of oil dispersants, may develop central nervous system (CNS) concerns such as drowsiness, in addition to renal and hepatic impairment, blood dyscrasias, and sensation of metallic taste. Supportive care, including removal of the worker or citizen from the source of exposure, is the primary management modality. Unfortunately there is no litmus test or lab that can be performed to confirm an expo

health issues that may arise. FPICN can be contacted via the national poison center number at 1-800-222-1222. -------------------------------------------------1. Jervis, R., Levin, A. (2010, June 28). Obama, in Gulf, pledges to push on stopping leak. USA Today. 2. Long C., Weber HR. (2010, July 16). BP plugs Gulf oil spill to test cap. The Florida Times-Union. 3. Hyne NJ (2001). The Nature of Oil and Gas. In N.J. Hyne, Nontechnical Guide to Petroleum Geology, Exploration, Drilling and Production (pp. 1-4). Tulsa: PennWell Corporation. 4. Seymour FK, Henry JA. Assessment and management of acute poisoning by petroleum products. Human Exposure Toxicology. 2001;20(11):551-562 5. Maximizing the Refinery Process. (2009). Retrieved July 21, 2010 from Colfax Article: http://www.colfaxcorp.com/oilandgas/doc s/6870-refinery_process_1/pdf. 6. Schenkman L, Gulf oil disaster: No ‘Smoking Gun’ for killer oil. Science 2010;328(5983):1214-1215 7. Aguilera F, Mendez J, Pasaro E, et al. Review on the effects of exposure to spilled oils on human health. Journal of Applied Toxicology. 2010;30:291-301

with a history of asthma or congestive obstructive pulmonary disease (COPD) may have an exaggerated response to the fumes. Oil dispersants have been used in the clean-up effort in an attempt to minimize the surface area of oil that could coat wildlife and the coast line. Broken down crude oil is easier to denature than a large oil slick. The two oil dispersants being used include Corexit EC9500A and Corexit EC9527A,10 which are comprised of organic acid salts and propylene glycol. As with exposure to crude oil, brief contact with oil dispersants is unlikely to

sure or to gauge the degree of crude oil toxicity. Some components such as benzene can be measured in exhaled air; however, this does not correlate with level of toxicity accurately. The Florida Poison Information Center Network (FPICN) in collaboration with the Department of Health is tracking all DWH exposures, is deeply involved in patient management and care. The FPICN has access to the latest information regarding the oil spill and new

8. Lee CH, Kang YA, Chang KJ, et al. Acute health effects of the Hebei oil spill on the residents of Taean, Korea. Journal of Preventative Medicine and Public Health 2010;43(2): 166-173 9. Bronstein AC, Spyer DA, Cantilena LR. 2008 Annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 26th Annual report. Clinical Toxicology 2009; 47: 1034 10. Dispersants. (2010, June). Retrieved July 20, 2010, from EPA Response to BP Oil Spill in Gulf of Mexico: http://www.epa.gov/bpspill/dispersants.ht ml#general2 EMpulse • Fall 2010 31

SYMPOSIUMphotographs

Symposium by the Sea 2010 The Annual Meeting of the Florida College of Emergency Physicians July 29 - August 1, 2010 . The Boca Raton Resort & Club

Symposium by the Sea 2011 The Annual Meeting of the Florida College of Emergency Physicians

August 4-7, 2011 . Naples Grande Beach Resort . Naples, FL

Free for all FCEP Members!!

50% off all ACEP Members!!

Who Should Attend Emergency Physicians, Physician Assistants, Nurses and other Health Care Professionals.

FCEP Membership Benefit Registration for the Symposium by the Sea general conference is FREE to all FCEP Members. Join the Florida College of Emergency Physicians prior to Symposium by the Sea and your registration will be refunded upon receipt of your application and payment of your first year's dues. For further information, contact the FCEP office at (407) 281-7396 or by email at info@fcep.org.

Symposium by the Sea 2011 is an educational opportunity designed for the busy emergency physician, resident, nurse, PA, and allied health professional who demands cutting edge information regarding their ever-changing practice environment. In addition to the educational sessions, the conference provides: Symposium General Educational Sessions* Preconferences available for ED Administrators, Medical Directors & Nurses; Satellite Educational Symposia; Florida Emergency Medicine Resident's Case Presentation Competition (CPC); Wine & Cheese Reception with Exhibitors; Ferguson Memorial Volleyball Tournament; EMRAF Job Fair; A Night with Orleans - Saturday Evening Private Concert. *All except the preconferences are no charge for FCEP Members and 50% off for ACEP Members!

Conference Date & Location

August 4-7, 2011 . Naples Grande Beach Resort . 475 Seagate Drive . Naples, Florida 34103 Reservations (888) 422-6177 . www.naplesgranderesort.com . Mention Symposium by the Sea Guest Room Reservations Cut-Off Date: July 21, 2011 . Reserve your room early!

Exhibit/Sponsorship Opportunities Visit www.emlrc.org/sbs2011.htm or contact Jerry Cutchens at jcutchens@emlrc.org. The Exhibit/Sponsorship Prospectus is available directly at www.emlrc.org/pdfs/ sbs2011prospectus.pdf.

More Information

Visit www.fcep.org or call (800) 766-6335 EMLRC . 3717 S. Conway Road . Orlando, FL

www.orleansonline.com

A Night with Orleans - Saturday Evening Private Concert

technology The Florida College of Emergency Physicians is proud to present a private concert for you by the legendary band Orleans at the 2011 Symposium by the Sea Conference at The Naples Grande Resort in Naples, FL, Saturday August 6, 2011. Orleans will be performing such favorites as Dance with Me (1975), Still the One (1976) and Love Takes Time (1979) and many more!! Be sure not to miss this night to remember by signing up for the 2011 Symposium by the Sea Conference today!!

Presented by Emergency Medicine Learning & Resource Center (www.emlrc.org) in conjunction with the Florida College of Emergency Physicians (www.fcep.org).

RESIDENCYmatters

University of Florida, Gainesville David Nguyen, DO

Florida Hospital Vu Nguyen, MD

University of South Florida Jason W. Wilson, MD

Greetings from Gainesville! We are now in full swing in the new residency year. This year, our program initiated an orientation-type month for the interns. During July, they had EM lectures from our faculty in the morning and had short shifts in the ED in the afternoon. They also had hands-on procedure labs at our dedicated simulation lab. This orientation month has eased our interns into the program and they have quickly adjusted to our emergency department. We even had a city-wide scavenger hunt and pool party to welcome and congratulate the class of 2013 for surviving their first month!

Greetings from Florida Hospital. I am excited about this month’s update because it has been a little time since the last one and there have definitely been some positive changes since then.

On August 25, our program hosted the first annual Florida Emergency Medicine Resident Day in Tampa, Florida.

Our new faculty has also adjusted well to our department. Drs. Borenstein, Stead, Elie, Falgiani, Falgiani, Flach, Van Dillen, and Marchick are all enthusiastic teachers and mentors for our growing program and department. Thank you and welcome!

Drs. Breckon Pav and Javier Gonzalez have recently returned from the Symposium by the Sea where they represented our program in the CPC. They did an excellent job and we thank them for their hard work.

Residents Josh Kaplan, Beth Nealon, Justin Bennett and Bill Jackman recently attended the FCEP’s Symposium-ByThe-Sea conference in Boca Raton. Drs. Kaplan and Nealon represented our program in the state CPC competition. We are proud to announce that Dr. Kaplan was 2nd runner up for best case presenter, and Dr. Nealon was the winner of the best case analysis. These outstanding presentations gave us the highest composite score (case presentation and case analysis) and therefore bring the 2nd Annual Bud Ferguson CPC Award and trophy to Gainesville!

Our ED has recently undergone a small but significant interior remodeling. This has provided us with a larger working space and has reduced crowding, while allowing more direct surveillance of patients. This was a much needed expansion for our growing number of providers.

Congratulations and Go Gators!

34 EMpulse • Fall 2010

First off, let me again welcome our intern class. With their inauguration, our program has a full roster for the first time since our inception in 2008. They have quickly adapted to their new roles as physicians and are doing a great job in learning and delivering patient care. We are very proud of them.

Dr. Bethany Ballinger has recently joined us at Florida Hospital East Orlando (our main training facility) as a core teaching attending. We are all looking forward to working with her in the clinical arena. She is a great asset to have in our ED.

Thanks to the sponsors and to our Program Director and Education Director, Drs. O'Keefe and Sanson respectively, the day was a success! Residents from USF, Mt. Sinai, and Florida Hospital were present along with a plethora of state wide ED leaders, including numerous medical directors, recruiters, FCEP members and program directors. The focus of the program was on preparing senior residents for the job hunt and the eventual transition to life as an attending physician. After the formal portion of the day, we had a great time retreating to our Program Director’s house for tennis, food and, of course, a couple of beers as well. What an awesome time to meet residents and attending physicians from other programs in a laid back atmosphere. Hopefully the success of this day will grow next year with an even bigger and better event!

RESIDENCYmatters

The Annual Meeting of the Florida College of Emergency Physicians

Univ. of Florida, Jacksonville Oscar D. Espetia, MD

Mount Sinai Medical Center Marshal A. Frank, DO

Congrats to all programs across the sunshine state and we hope the new academic year is treating you well. Our interns here are busy learning the ropes and we look forward to their developing into great emergency physicians. Our departmental Research Day was held on March 25th and was a huge success. As part of the research celebration, we held our journal Club at the River City Brewing Company on the evening of the 24th.

The new academic year has begun and we are off to a smooth and fresh start.

August 4-7, 2011 The Naples Grande Resort Naples, FL

Our two new chief residents, Dr. Mezeda Meze and Dr. Daniel Padron, are clearly going to be great leaders.

SAVE THE DATE www.emrlc.org

On Research Day, our graduating residents and fellows presented their scholarly projects. Guest speaker, Dr. Ricardo Martinez of the Schumacher Group, gave an inspirational address on leadership in emergency medicine and he challenged all in attendance to contribute their best efforts in life. Drs. John Lissoway and Ben Lenhart won the departmental resident research award. Thanks to all who assisted in making Research Day a success. Three abstracts were accepted and published in the DCMS Northeast Florida Medicine 2010 Resident Research issue: - Pupillary Response after Neuromuscular Blockade by Steven Andescavage (Caro, Akhlaghi, Kalynych); - Use of Broselow Tape to Determine an Optimal Dosing Weight in Overweight Patients by Jason Lowe (Luten, Kalynych, Hanna); and - ED Documentation Training in the Face of ED Overcrowding by Ben Lenhart (Gray-Eurom, Caro).

All the current returning residents are excited to have advanced in their training as future emergency physicians. We are happy to welcome 5 new interns to our group. Recently, some of our residents presented posters at the Symposium-by-the-Sea in Boca Raton, at the annual meeting of the Florida College of Emergency Physicians. Dr. Josephine Matthai presented a great CPC and we eagerly await the results. More, two residents will present their research at the ACOEP conference in San Francisco. Congratulations to Dr. Erin Connor on her recent election to the role of Resident Representative of the Florida Chapter of the American Academy of Emergency Medicine. Congratulations are also in order for Dr. Alex Scumpia on becoming an uncle. His brother Phillipâ&#x20AC;&#x2122;s wife gave birth to a healthy baby boy in Los Angeles. We are all revved up about this new academic year, as we progress in our careers as emergency physicians. EMpulse â&#x20AC;˘ Fall 2010 35

ADVOCACYnow!

 PAEC

People for Access to Emergency Care Emergency medicine is the leader in promoting patient access and safety. In order to achieve our goal of taking emergency medicine to the next level of policy influence in Tallahassee, the Florida College of Emergency Physicians has formed an advocacy entity called “People for Access to Emergency Care” (PAEC). PAEC provides a means for our friends in the business world, such as billing companies, physician groups and other organizations, to assist FCEP in supporting legislative leaders and policy makers, and it ensures that emergency medicine has a seat at the table with key leaders in the Florida House and Senate. PAEC allows FCEP and its partners in emergency medicine to act with a unified voice in Tallahassee. Its members are

groups and organizations dedicated to promoting emergency medicine in Florida and providing better access to quality emergency care to our patients. In order to be successful at securing emergency medicine’s place at the table, we need you to join People for Access to Emergency Care and joining is easy.

To find out more about contributing to PAEC, or to join our 2010 contributors, contact Beth Brunner at: bbrunner@fcep.org. 2010 Platinum Members: Emergency Physicians of Central Florida Florida Emergency Physicians, Inc.

There are three levels of membership: • Platinum $15,000 per year • Gold $10,000 per year • Silver $5,000 per year

Titan Emergency Group

PAEC’s goal is to raise $200,000 for the 2010-11 legislative cycle. With these funds we will be able to help elect candidates who support your issues. This will enable us and your organization to participate in the decision-making process.

Comprehensive Medical Billing Solutions

2010 Silver Members:

Martin Gottlieb & Associates, LLC Southwest FL Emergency Physicians, PA Tampa Bay Emergency Physicians, PL

 EPF

Emergency Physicians of Florida Emergency Physicians of Florida (EPF), formerly known as the Florida College Political Action Committee (FLACPAC), is one of the primary advocacy tools that enables individual physician members of FCEP to make a difference at the legislative and regulatory level. In order for us to have a positive influence on our legislators, both at home and in Tallahassee, we need your help. Please consider “giving a shift” from personal funds. You can even donate online at: fcep.org/flacpac.htm. Thank you to all who have donated since the October 1, 2009! 36 EMpulse • Fall 2010

Dr. Casey A. Corbit Mrs. Brenda Jones William H. Knibbs, M.D., P.A. Dr. Gary N. Mendelow Mrs. Kathryn E. Frisch Dr. Linh Tung Le Mr. Mitchell David Brantley Dr. Wayne S. Friestad Dr. Gary N. Mendelow Dr. Paul Lewis Petersen Dr. John J. Valentini Steven R. Newman, M.D., P.A. Mr. John Prairie Dr. John Tilelli Dr. Bryce R. Tiller Dr. Wayne S. Barry Dr. Claire H. Simpson Mrs. Delby L. West Dr. Ronald Krome Dr. Steven B. Kailes

Dr. Joel Stern Dr. Thomas L. Schaar Dr. Gary Gillette South Miami Criticare, Inc. Dr. Miguel Acevedo Dr. Dale Birenbaum Dr. Bradford Bowls Dr. Ka Hang Chan Dr. Leonardo Cisneros Dr. Paul Deponte Dr. Vidor E. Friedman Dr. Vicki Friend Dr. Wayne S. Friestad Dr. Brent F. Gardner Dr. David Goldman Dr. Rodney Kang Dr. Mark Kruger Dr. Jorge Lopez-Ferrer Dr. Steven Nazario Dr. Patricia Singh Nichols

Dr. Biran Nobie Dr. Lisa M. O'Grady Dr. Ernest Page, II Dr. Ketan Pandya Dr. Vanessa Peluso Dr. W. Randall Poole Dr. Cheryl Reynolds Dr. Maritza Rodriguez Dr. Marc Santambrosio Dr. David D. Sarkarati Dr. Regan Schwartz Dr. Weylin Sing Dr. Sivapragasm Sivanesan Dr. Mylissa Graber Dr. Steven B. Kailes Dr. Vu Hoang Nguyen Dr. Michael Lozano Dr. Larry Hobbs Mr. Daniel Woodard

FCEP|

Florida College of Emergency Physicians

3717 South Conway Road, Orlando, FL 32812

NONPROFIT ORGANIZATION US POSTAGE PAID PERMIT NO. 2361 ORLANDO, FL