EMpulse Fall 2011

FALL 2011

Cave Diving Emergencies

My Heart is in Florida

Scorpion Stings

Volume 16, Number 4 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 Vidor Friedman, MD, FACEP • President Kelly Gray-Eurom, MD, FACEP • President-Elect Michael Lozano Jr., MD, FACEP • Vice-President Ashley Booth Norse, MD, FACEP • Secretary/ Treasurer Amy R. Conley, 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

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: LMC Printing & Packaging Orlando, Florida Tel: (321) 439-7648 www.lmcprinting.com

Symposium by the Sea My Heart is in Florida Interview with ACEP President Dr. David Seaberg

14

New Airway Devices David A. Caro, MD, FACEP

16

Cave Diving in the Florida Springs: The Bends and Other Hyperbaric Emergencies Michael L. Falgiani, MD

18

Tips of the Trade - Auricular Foreign Body Removal Tracy G. Sanson, MD, FACEP

20

The Man with a Red Eye Case Presentation Competition

22

The Girl Whose Skin Might Burst Into Flames Case Presentation Competition

24

Departments PRESIDENT’Smessage Vidor Friedman, MD, FACEP

3

GOVERNMENTALaffairs Steve Kailes, MD, FACEP

7

MEDICALeconomics Lynn Reedy, CPC, CEDC

9

EMStrauma Dagan Dalton, MD

10

PROFESSIONALdevelopment Paul Mucciolo, MD, FACEP

11

General The State of Florida EMS Michael Lozano, MD, FACEP

12

POISONcontrol Treatment of Scorpion Stings in Florida

26

TRAUMAscorecard ENA National Scorecard on State Roadway Laws

29

RESIDENCYmatters

30

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.

EMpulse • Fall 2011 1

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PRESIDENT’Smessage

Let’s Get Started!

Vidor Friedman, MD, FACEP President

Welcome to another year at FCEP! I am honored and humbled to be your president this year. I have lost count of the number of FCEP presidents and pastpresidents that I have worked with over the years and I hope to be able to live up to the tremendous leadership that they continue to show our organization. We have a proud and strong tradition of advocating for EM and this year my goal is to continue to ‘move the ball down the court!’

In Orlando, we are blessed to have tremendous support staff headed by Beth Brunner, who is truly the glue that holds us all together!

Our partnership with the Emergency Medicine Resource and Learning Center has paid tremendous dividends and your leadership is working diligently to ensure that our future together is a bright one.

During this past year, FCEP’s advocacy efforts, in Tallahassee and around the state, have once again served to safeguard our patients and our profession. While our CCE’s (Emergency Physicians of Florida and People for Access to Emergency Care) continue to prosper and serve as role models for other chapters around the country.

Symposium by the Sea was the best ever this year: highlighted by exceptional talks from our own Dr. David Seaberg, President-Elect of ACEP. We were also

treated to an excellent educational program, an amazing Case Presentation Competition, a private concert by "The HOPPEN Bros of ORLEANS," and a Casino Fun night to boot!

In addition to the usual amazing opportunity to meet and network with our peers from around the state, we were honored to have five ACEP Board members and two ACEP BOD candidates attending our symposium. A tradition we hope to sustain long into the future!

Once again we were honored this year by a visit from the President of the Florida Medical Association (FMA), Dr. Miguel Machado, who informed us that his number one legislative priority was to get sovereign immunity for all providers of EMTALA related care! Who would have imagined the day when FMA and FCEP had the same priority legislative goals!

I hope that you and your family were there with us in Naples. If not you missed a great symposium and I hope you can join us next year in Amelia Island for what I am sure will be yet another wonderful Symposium by the Sea! Getting back to moving that ‘ball’ down the court, what do I see for this year?

Well, we need you! Our membership is our greatest asset and we need you, our members, to continue showing up at meetings to give voice to your ideas and concerns. We need you to continue, and

indeed expand, your support of our political advocacy efforts with your time and your dollars; the more resources we have, the more effective we can be for YOU! We have a great relationship with ACEP and that relationship is built on the strength of our member involvement. We currently have one Board member, Dr Andy Bern, who does a great job representing us at the national level, and one alumnus on the ACEP BOD, Dr. David Seaberg President-Elect, who also calls us home.

We are well represented on ACEP and council committees, but we are always looking for the next generation of leaders for our college. Are you ready to get involved? Your leadership is here to assist you. Are you ready to join us?

We must continue to improve and sustain our working relationships with the FMA, the Florida Hospital Association, the various Specialty Societies and the Emergency Nurses Association. Coalition building is our natural strength and we reap tremendous benefits from allying ourselves with the other professionals that we work with every day.

All in all, you have one of the most active and effective ACEP state chapters in the nation! But, yes, there is much to do as always!

Let’s get started…….

EMpulse • Fall 2011 3

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GOVERNMENTALaffairs

The Work Never Ends!

Steve Kailes, MD, FACEP Committee Chair

For Governmental Affairs, the work never

On the liability reform front, recognize that

is accomplished only by shifting those

ends.

The most pressing issue of the

the process has been more about chipping

savings into new costs for the patients,

moment is the fact that the 2003 caps on

away at the rock rather than simply pushing

providers and facilities. For 2012 and into

non-economic

it out of the way.

In 2012, we plan to

the future, we will be continually monitoring

challenged and soon the question of their

continue our push for sovereign immunity

and attempting to correct the problems we

constitutionality will be heard by the Florida

protections. As providers supporting the

and our patients endure.

Supreme Court. We need help to fund our

fragile safety net for all, we believe provid-

advocacy efforts as our coffers desperately

ers of emergency care act as agents of the

Something I am sure you are already aware

need to be replenished.

State in providing care to all who have no

of are the new requirements for prescriptions

other access to care as well as for the many

and dispensing of controlled substances

Please donate and get your peers to donate to

who have inadequate access to meet their

(2011 HB7095/SB818). While dispensing

our CCE’s, Emergency Physicians of

health care needs. The FMA supports this,

these medications is not generally an EM

Florida (for individuals) and People for

and we believe the current legislature and

issue, prescribing them most certainly is,

Access to Emergency Care (for groups).

governor hear this idea with a sympathetic

and we may be facing unintended conse-

You can donate using a credit card by simply

ear.

quences of legislative attempts to rein in the

damages

are

being

so called “pill mills” which have plagued

going to the Government-Advocacy tab on Concerning Medicaid reforms, we are wary

our state. We have begun working to negate

of the changes requiring all patients to be in

any substantially burdensome requirements

The 2012 legislative session and election

a managed care system. Conceptually, the

for EM providers.

campaign are quickly approaching and will

idea works but practically we don’t believe

be unique in many ways. The session is

there is proof the resources exist to

As always, there is too much to cover in too

earlier than usual, so committees will begin

transform the idea into reality. In addition,

little space. Suffice it to say, we need your

work for 2012 soon, probably by the time

we are moving to statewide Medicaid

help to help you. Please contact us with

you are reading this article.

managed care even though the five county

issues or concerns. Please meet with your

Medicaid managed care pilot programs have

legislators so they can have someone they

Significantly, redistricting will occur and is

yet to produce evidence that patients had

can turn to for information and ideas as we

leading to uncertainty for many of the House

access to their care needs.

struggle to make change that matters. Be

our website, www.fcep.org.

involved to be a part of the solutions and,

and Senate seats. This is an opportunity to give our support to candidates who will,

Yes, they may indeed save money for the

please, give your monetary support to fund

ideally, be receptive as our issues are

insurers and even for the state, but I fear this

our advocacy efforts.

presented.

EMpulse • Fall 2011 7

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Emergency Medicine Days in Tallahassee is the premier advocacy event each year for the Florida College of Emergency Physicians. All members are invited each spring to our state capital to spend time face-to-face with their legislators, lobbying for legislation that will provide better access to quality care for our patients. At EM Days, FCEP members gather with their colleagues and lobby for a better emergency medicine climate in Florida. Audience: All Florida EM Residents, FCEP Board Members and other key leaders around Florida.

REGISTER TODAY AT WWW.FCEP.ORG

MEDICALeconomics

Making the Observation Decision Lynn Reedy, CPC, CEDC

Director of Coding Services CIPROMS South Medical Billing

Evaluation and Mangement Codes (only one per day):

99284 Emergency

Presenting Problem:

Key Elements:

High severity:

3 of 3 key components:

Requires urgent evaluation by the physician

A detailed history

HPI = 4+ elements ROS = 2-9 systems

Does not pose an immediate

A detailed examination

EX = 5-7 areas/systems

significant threat to life or

Medical decision making of

Multiple mgmt options

moderate complexity

Moderate data Moderate risk

Dept

If your group faces the decision of providing Observation Services in your hospital, the

Emergency Dept

High severity:

3 of 3 key components:

Poses an immediate significant threat to life or

Within the constraints imposed by the urgency of the patient's clinical condition and/or mental status

physiologic function

A comprehensive history

99218

Low severity

Initial

billed each day, your documentation for the ED E/M Level will roll into the Initial Observation documentation. For a patient staying in your ED for several days while waiting transfer to another facility, adding up the multiple days of Observation Services should increase your reimbursement.

EX = 8+ systems

Medical decision making of high

Extensive mgmt options

complexity

Extensive data High risk

3 of 3 key components: A detailed or comprehensive

HPI = 4+ elements

history

ROS = 2-9 systems

99219 Initial

Moderate severity

A detailed or comprehensive

EX = 5-7 areas/systems

examination Medical decision making that is

EX + 5-7 areas/systems Minimal mgmt options

straightforward of of low complexity

Minimal data Minimal risk

3 of 3 key components: A comprehensive history

Observation Over

99220 Initial

$65.51

N/A

$109.67

N/A

$145.82

PMFSHx = 3 histories

High severity

A comprehensive examination

EX = 8+ systems Multiple mgmt options

moderate complexity

Moderate data Moderate risk

3 of 3 key components: A comprehensive history

Over

99224 Subsequent

HPI = 4+ elements ROS = 10+ systems PMFSHx = 3 histories

Midnight

99217 Discharge

HPI = 4+ elements

Medical decision making of

Observation

Discharge on other than the initial date of OBS status Stable, recovering, or improving

A comprehensive examination

EX = 8+ systems

Medical decision making of high

Extensive mgmt options

complexity

Extensive data High risk

Report all services provided to a

Problem focused interval history

HPI = 1-3 elements

Problem focused examination

EX = 1 area/system

Responding inadequately

Medical decision making that is

Minimal mgmt options

straightforward or of low complexity

Minimal data Minimal risk

2 of these 3 key components:

to therapy or has

An expanded problem focused

HPI = 1-3 elements

developed a minor

interval history

ROS = 1 system

An expanded problem focused exam

PMFSHx = N/A EX = 2-4 areas/systems

complication

Unstable or has

Subsequent

developed a significant

Observation

complication or a

99234

Medical decision making of

Multiple mgmt options

moderate complexity

Moderate data Moderate risk

2 of these 3 key components: A detailed interval history

Low severity

Same Day

$74.92

PMFSHx = 1 history A detailed examination

EX = 5-7 areas/systems Extensive mgmt options

complexity

Extensive data High risk

3 key components: A detailed or comprehensive

HPI = 4+ elements

history

ROS = 2-9 systems

A detailed or comprehensive exam

PMFSHx = 1 history EX = 5-7 areas/systems

Moderate severity

Same Day

Medical decision making that is

Minimal mgmt options

straightforward of of low complexity

Minimal data Minimal risk

3 key components: A comprehensive history

Admit & Disc

N/A

$135.35

N/A

$176.06

N/A

$218.88

HPI = 4+ elements ROS = 10+ systems

Observation

Same Day

35 minutes HPI = 4+ elements

Medical decision making of high

Observation

99236

$49.99

ROS = 2-9 systems

significant new problem

Admit & Disc

99235

25 minutes

ROS = N/A

Subsequent

Day

$70.48 $28.53

PMFSHx = N/A

Observation

99226

N/A 15 minutes

patient on discharge from OBS status 2 of these 3 key components:

Observation

Day

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

N/A

ROS = 10+ systems

Midnight

99225

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

$174.96

PMFSHx = 1 history

Midnight

Day

VOLUNTARY EMpulse SUBSCRIPTIONS

N/A

HPI = 4+ elements

A comprehensive examination

Over

decision. Because only one E/M Level can be

$119.76

PMFSHx = 2 histories

Observation

The following chart will help with that

N/A

ROS = 10+ systems

biggest questions are “how much more money” and “how much more work.”

2011 Florida

Time Medicare Required: Reimbursement:

PMFSHx = 1 history

physiologic function 99285

Documentation Requirements:

PMFSHx = 3 histories

High severity

A comprehensive examination

EX = 8+ systems

Medical decision making of

Multiple mgmt options

moderate complexity

Moderate data Moderate risk

3 key components: A comprehensive history

Admit & Disc

HPI = 4+ elements ROS = 10+ systems

Observation

PMFSHx = 3 histories A comprehensive examination

EX = 8+ systems

Medical decision making of high

Extensive mgmt options

complexity

Extensive data High risk

EMpulse • Fall 2011 9

EMStrauma

Committee Meeting News

Dagan Dalton, MD Committee Chair

The FCEP EMS/Trauma Committee met

The State Trauma Alert Criteria are now

intent of the law to affect EMS operations.

at the Symposium by the Sea in Naples on

under

state

He further stated that he would have the

August 4, 2011. It was a nice setting for

committee/working group, with nothing

State Attorney’s office review the law for

what is always a great conference and the

new to add at this time. Remember that

opinion, but that the process might take

FCEP Committee meetings were produc-

they can be accessed at any time on

1-2 months. In the meantime, he recom-

tive as well.

myflorida.gov, search Florida Administra-

mended that we meet with our city/county

tive Code under sections F.A.C. 64J 2.004

attorneys to make them aware of the law

and 64J 2.005.

and the pending review by the State’s

At the EMS/Trauma Committee meeting,

final

review

by

the

we approved the concept of Statewide

Attorney’s office, and to come to a

EMS Disaster Protocols and are now

There has been much discussion at both

consensus on the best/safest way to

awaiting the final draft from Dr. Joe

EMS/Trauma Committee meetings and

continue EMS operations.

Nelson for review. Dr. Nelson is sending

FAEMSMD (Florida Association of EMS

the same to the state Public Health

Medical Directors) meetings recently

Remember, approval has been granted for

Preparedness office for their review and

regarding

mill”/controlled

a face-to-face meeting of the EMS Advi-

approval as well.

Dr. Nelson is also

substances legislation, and how that might

sory Council in September 27-28, 2011 at

compiling a list of back-up or assistant

affect us – not only as EPs, but also as

the Fort Lauderdale Airport Hilton, and

State EMS Medical Directors, who are to

EMS Medical Directors.

the next FAEMSMD meeting will be at

be

called

catastrophic

into event

action

if/when

involves

the

“pill

a

that place and time. Also, funding has

several

John Bixler, chief of the Bureau of EMS

been proposed for the same for July, 2012,

regions of the state, communications

for the Florida Department of Health,

and we will keep you posted.

throughout the state are disrupted or his

addressed us at our recent FAEMSMD

unexpected unavailability.

meeting to assure us that it was not the

10 EMpulse • Fall 2011

PROFESSIONALdevelopment

A Taste of Your Own Medicine

Paul Mucciolo, MD, FACEP Committee Chair

After easing into my fourth decade, things have begun to change. My ankles are sore after I run and my back aches for days after cleaning out the garage. On my last visit to the ophthalmologist, he peered into my soul through a series of prisms and lenses and then leaned back to explain that I needed bifocals: “When you start to measure your age in decades, these things happen!”

I have deliberately avoided my primary care physician and I dreaded my annual physical exam. My Italian genes dominate my metabolism and tomato sauce, Pecorino Romano, and Pappardelle have become my personal fuel. I thought this visit was going to be “the talk” and was actually nervous when I saw my physician walk in. I thought the party was over.

However, my doctor cracked a joke, sat at eye level with me, listened, paused, and gave me practical guidance and encouragement. I felt like a weight had been lifted off my shoulders. I learned a lot more on that visit than what I need to do to improve my health.

Be friendly. In EM, the first impression is really the lasting impression. One OB/GYN attending during medical school suggested that we introduce ourselves with a smile, ask the patient how she would like to be addressed, and then turn around to wash our hands. “Give her a

chance to size you up from a few different angles, because that’s how you’re going to be looking at her!”

Be prepared. Preparedness is an indicator of diligence. When a chronic atrial fibrillation patient asks, “What is my INR?” I like to have the exact number in my head for her. Saying that it’s within normal limits doesn’t inspire confidence.

Giving the exact answer and then giving her a copy of the report does.

Be empathetic. When I see a patient on dialysis with heart failure, diabetes mellitus and lupus, I think of how fortunate I am. Medical care consumes this person’s life.

Imagine the indignities this individual endures going from doctor to doctor, being poked with needles, having lancets jabbed into the fingers three times a day before the shots of subcutaneous insulin in the abdomen…

Be patient. Some patients simply cannot formulate a chief complaint. My medicine attending on the first clinical rotation of my third year of medical school opened up Harrison’s (back in the days when we used books!) and pointed out the word “alexithymia”. His advice was to wait for the patient to deliver what he called “the punch line” before starting to ask questions. The chief complaint is in this story somewhere. He warned us that asking too many questions too soon could

lead the patient (and us) astray.

Be reasonable. I find it difficult to remember to take my daily aspirin. Many patients are burdened with the infamous “bag-o-meds” we dread reconciling. Then add on a TID antibiotic, a Q4H nebulizer and BID steroids. The literature may support this regimen, but practicality doesn’t. And how can a patient follow up with his primary care physician tomorrow when it’s Sunday of a holiday weekend?

Be prompt. If it took two hours to get a table at a restaurant, we wouldn’t go back.

Wait times strongly influence patient satisfaction. Even if the patient knows you’re in a code, ask one of the techs or nurses to apologize on your behalf. The otitis externa case waiting next is certainly not life threatening, but it is very painful.

And it is the only thing on that patient’s mind. If the patient knows that you value his time, he’ll value yours.

Be quiet. Everyone is pressed for time, but let the patient speak. A positive facial expression can encourage a patient to continue when he seems exasperated trying to tell you (the fourth person in twenty minutes to whom he’s had to tell his story) how he dislocated his shoulder.

When the patient is nervous, a smile or nod of the head can ease her tension. After all, what the patient tells you will prove invaluable!

EMpulse • Fall 2011 11

EMStrauma

The State of Florida EMS Part 7 of a Series

Michael Lozano, MD, FACEP

Committee Chair

Last issue we looked at the fourth objective of Strategic Goal Six: Improve performance of key EMS processes through benchmarking and partnerships. This issue will focus in more detail on the quality assurance measures that are central to the medical care provided by EMS systems statewide.

Objective 6.4 addresses airway management as well as cardiac, stroke, trauma, pediatric, and neonatal patients. The cardiac quality measures cover prehospital return of spontaneous circulation (ROSC) reported in out-of-hospital cardiac arrest (OOHCA) patients using the Utstein format, 12-lead EKG performance on patients with suspected cardiac related symptoms, and aspirin administration in suspected cardiac patients.

Do you remember the Utstein Criteria for OOHCA research from journal club in residency? First reported in 19911, and revised in 20042, it provides a standard set of definitions to assist resuscitation researchers in comparing results among different systems of care. The critical importance of a standard definition set was illustrated in a 1991 study by Eisenberg et. al.3 They found that by simply changing the denominator definitions, OOHCA survival rates on a given data set could vary from 16% to 49%. Unfortunately, few EMS systems publically report their OOHCA survival rates using the Utstein template. A 2005 review by the same Seattle research group found that only 35 communities nationwide reported their OOHCA results.4 Their all-cause 12 EMpulse • Fall 2011

survival rate was 8%, while that due to ventricular fibrillation was 18%. Why don’t communities report their data? The answer is multi-factorial, involving a lack of a legislative national reporting mandate, inadequate resources applied to EMS quality assurance, HIPAA-invoked sequestering of data, and lack of political will to disseminate embarrassingly dismal results. Local emergency physicians can help by advocating for transparency with uniform and standardized data reporting as well as encouraging their hospitals to provide EMS with outcomes data on OOHCA cases.

ECG interpretation is taught in most Florida paramedic training programs, and a recent study demonstrated that 12-lead EKG interpretation is a skill that even first year paramedic students can master and retain.9 Older studies have firmly shown that paramedics can produce a 12-lead ECG and accurately appreciate the presence of a STEMI.10,11 Even if the paramedics are not trained to read the ECG directly, the ECG analysis algorithms in the monitor/defibrillators have be shown to have similar sensitivity, specificity, and positive predictive value to cardiologists.12

ACC/AHA guidelines on prehospital chest pain evaluation and treatment recommend that prehospital ECGs be performed on all patients with suspected acute coronary syndrome (ACS) and that aspirin be given to those with suspected STEMI.5 Despite this, early studies have found prehospital ECGs are performed on 8% to 27% of patients with STEMI.6,7 However, feedback reports and other quality improvement efforts improved prehospital ECG performance for patients with acute coronary syndrome and ST-elevation myocardial infarction (STEMI) from 76% to 93%, and 77% to 99% respectively.8 Objective 6.4.1 will look at EMS systems in the state to measure their prehospital ECG usage rates. This is important to the overall health of the population as paramedic initiated ECGs are associated with shorter times to fibrinolysis and PCI in STEMI patients.

Given the high accuracy rates of paramedics in recognizing STEMI on a prehospital ECG, the Florida Association of EMS Medical Directors has advocated the use of standard nomenclature in EMS communications with hospitals regarding STEMI patients. Whereas in the past the term “cardiac alert” was used by many agencies, it was an ill defined term that encompassed STEMI patients, unstable chest pain patients, and those with abnormal heart rhythms. The term “cardiac alert” is being discouraged in favor or the term “STEMI alert” which means a patients with ECG changes consistent with STEMI or a patient with symptoms suggestive of an AMI in the presence of a LBBB. Emergency physicians can assist EMS systems by being cognizant of the “STEMI alert” term, and provide ECG feedback when possible to their EMD providers. With a little bit of interaction, you will discover that with respect to

EMStrauma ECGs paramedics really do know what they are talking about.

In the diagnosis of STEMI, the ECG is one piece of technology that can easily be applied in the prehospital setting. The same does not apply to the prehospital diagnosis of stroke. Until there is an accurate and practical method to image patient’s brains either in their homes or in the back of an ambulance, history and physical exam remain the only tool in the paramedic’s toolkit for acute stroke diagnosis.

National guidelines have been promulgated to promote the integration of EMS into stroke systems of care.13 Just as with angina where the classic presentation is that of a chest discomfort sometimes described as pressure that is provoked by exertion, but atypical presentations abound, the clinical diagnosis can be elusive to pin down. One can simply include those who have an acute onset of a focal neurological deficit, but that would not really capture the universe of stroke patients.

The Birmingham (AL) EMS system uses the following definition: An acute episode of focal neurological deficit can include any combination of the following signs and symptoms : unilateral paralysis, focal numbness, language disturbance (speaking and/or understanding), sudden, severe, unusual headache, visual disturbance, monocular blindness, acute onset vertigo, acute onset double vision, slurred speech, new onset of poor balance.14 Exclusion criteria would include those with significant preceding or accompanying head or spine trauma; intentional or accidental overdose; seizure immediately and clearly preceding the onset of the focal neurologic deficit(s); and of course the great mimicker – hypoglycemia.

The analog to the “STEMI alert” is the “Stroke alert.” In the next installment, we will look at the evidenced-based systems paramedics use to identify acute stroke in the prehospital setting and how that can a role in the regionalization of stroke care in Florida. We will also continue our detailed

look at the EMS system in Florida and the literature evidence that supports prehospital care.

REFERENCES

1. Cummins RO, Chamberlain DA, Abramson NS, et al. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein Style. A statement for health professionals from a task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council. Circulation 1991;84:960-75 2. Jacobs I, Nadkarni V, Bahr J, et al.

Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries. A statement for healthcare professionals from a task force of the international liaison committee on resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation). Circulation. 2004; 110: 3385-3397.

3. Eisenberg MS, Cummins RO, Larsen MP. Numerators, denominators, and survival rates: reporting survival from out-of-hospital cardiac arrest. Am J Emerg Med 1991; 9:544-6.

4. Rea TD, Eisenberg MS, Sinibaldi G, White RD. Incidence of EMS-treated out-of-hospital cardiac arrest in the United States. Resuscitation 2004; 63:17-24.).

5. Antman EM, Anbe DT, Armstrong PW, et. al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the ACC/AHA Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction). J Am Coll Cardiol.

2004; 44: E1–E211.

6. Curtis JP, Portnay EL, Wang Y, et. al.

National Registry of Myocardial Infarction-4. The pre-hospital electrocardiogram and time to reperfusion in patients with acute myocardial infarction, 2000–2002: findings from the National Registry of Myocardial Infarction-4. J Am Coll Cardiol.

2006; 47: 1544–1552.

7. Diercks DB, Kontos MC, Chen AY, et. al.

Utilization and impact of pre-hospital electrocardiograms for patients with acute ST-segment elevation myocardial infarction: data from the NCDR (National Cardiovascular Data Registry) ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry. J Am Coll Cardiol. 2009; 53: 161–166.

8. Daudelin DH, Sayah AJ, Kwong M, et. al.

Improving Use of Prehospital 12-Lead ECG for Early Identification and Treatment of Acute Coronary Syndrome and ST-Elevation Myocardial Infarction. Circ Cardiovasc Qual Outcomes, May 1, 2010; 3(3): 316 - 323.

9. Levis JT. Ability of First-Year Paramedic Students to Identify ST-Segment Elevation Myocardial Injury on 12-Lead Electrocardiogram: A Pilot Study. Prehosp Disaster Med 01-NOV-2010; 25(6): 527-32.

10. Foster DB, Dufendach JH, Barkdoll CM. Prehospital recognition of AMI using independent nurse/paramedic 12-lead ECG evaluation: impact on in-hospital times to thrombolysis in a rural community hospital.

Am J Emerg Med (1994) 12 : pp 25-31.

11. Real-time paramedic compared with blinded physician identification of ST-segment elevation myocardial infarction: results of an observational study. Feldman JA - Am J Emerg Med - 01-JUL-2005; 23(4): 443-8.

12. Clark EN. Automated Electrocardiogram Interpretation Programs Versus Cardiologists' Triage Decision Making Based on Teletransmitted Data in Patients With Suspected Acute Coronary Syndrome. Am J Cardiol December 15, 2010; 106(12); 1696-1702.

13. Acker JE, Pancioli AM, Crocco TJ, et. al,. Implementation Strategies for Emergency Medical Services within Stroke Systems of Care. A Policy Statement from the American Heart Association/American Stroke Association Expert Panel on Emergency Medical Services Systems and the Stroke Council.

Stroke, 2007; 38:3097-3115.

14. Adapted from “Stroke System Entry Criteria” Birmingham Regional Emergency Medical Services System (BREMSS).

EMpulse • Fall 2011 13

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My Heart is in Florida Interview with ACEP President Dr. David Seaberg

David Seaberg, MD, CPE, FACEP

ACEP President / Past FCEP President

How long have you been involved with

state's needs. I am very happy to see the

adequate resources for its four part

FCEP?

growth of residency training programs

mission of clinical care, teaching, research

This year was my 17th Symposium-by-

throughout the state, with seven very

and community service.

the-Sea. I moved to Florida in 1995, first

strong programs. This is great for EM and

develop a new faculty practice plan that

starting

for the citizens of Florida.

currently encompasses the primary care

at

the

University

of

Florida/Shands Jacksonville as Residency

I also helped

specialties. I still love EM and do a couple

Director and then moved to Gainesville,

Why did you leave Florida?

of ED shifts every month and give at least

when we became a Department of EM. I

We loved living in Florida and I loved

one Grand Rounds lecture each month for

was chair of the Gainesville campus until

working with the EPs around the state. I

the EM Residency program.

we moved in 2007. I have been with the

had an opportunity to become the first

University of Tennessee since then.

I

Dean of the Chattanooga campus of the

What do you see are the major issues

continue to serve on the Board of the

University of Tennessee College of Medi-

for EM nationally in the next year?

Emergency

cine. This was a natural growth of my

EM will need to focus on value over the

career path and I was very excited to take

next several years. The government is

on the challenge of developing an

looking at value-based purchasing and

Over the years, how has EM in Florida

academic medical center campus. The

demand quality and lower cost. It will

changed?

Chattanooga campus has over 540 faculty,

accomplish this through the formation of

EM has become one of the premier

170 residents in 9 specialties and 6 fellow-

an integrated healthcare delivery system

specialties in Florida.

Medicine

Learning

and

Resource Center.

FCEP is a very

ships, and has over 220 medical students

and a bundled or capitated payment

active Chapter and the efforts of its mem-

rotate through the campus. I was very

system.

bers have led to many legislative and

happy to start another EM Residency

advocacy successes.

The tort reform

program on the Chattanooga campus, the

EM already provides significant value in

achieved in 2003 was a major accomplish-

only EM program in the University

terms of the care we provide the public

ment for EM and FCEP's continued efforts

system.

and serve as the healthcare safety net,

on behalf of the sovereign immunity bill has garnered support from the FMA.

however we are often viewed as expensive How is your current EM practice differ-

and unnecessary. We need to enhance our

ent from what yours was in Florida?

value-added services to fit into the

Additionally, when I arrived, there were

My position is mainly administrative. My

integrated delivery system.

only two EM training programs in the

main responsibility is to ensure that the

patient-centered medical home being a

state. We trained too few residents for the

academic

great idea in theory only due to the lack of

14 EMpulse • Fall 2011

medical

center

receives

With the

SYMPOSIUMbytheSea

primary care providers, I feel EM could

How do you plan to address these issues

What do you do in your spare time?

serve as a bridge or conduit to better

as President?

I spend as much time with my wife and

integrated care. We have access to over

We need to start preparing for the coming

kids as possible. My two teenage boys are

124 million visits each year, and with the

changes in Medicine. The next three years

very active in High School sports, so I

average 1–1.5 visitors for each patient, we

may very well affect the next 30 years of

spend much of my free time watching

have access to over half the population

practice. We need to get our message out

their games. I also like to go to movies,

each year. We need to use this leverage to

to our members and start advocating for

theater and dancing with my wife, Carol. I

enhance our value.

EM's role in the value equation.

will eventually get back into golf - which I have had to put on the back-burner due to

We already use our Observation Units to

We also need to start working with hospi-

my schedule. That was one nice aspect of

reduce potentially unnecessary admis-

tals and payers to redesign our ED for the

Florida - I loved to play golf there.

sions and avoidable readmissions. Should

new era of emergency health care teams to

we not consider a system to check and

provide

give immunizations; could we not consis-

prevention and wellness counseling that

our members?

tently screen for HIV and alcohol abuse;

will be required in the future.

One must always work to improve your

better

disease

management,

Do you have any words of wisdom for

lot in life. That is true for your practice in

could we not provide counseling on exercise, weight loss, alcohol and smok-

We need to use our resources and advo-

medicine. You need to remain active in

ing cessation; could we not provide better

cacy power in EM, through ACEP and the

FCEP and organized medicine to improve

chronic disease management for conges-

newly

Medicine

your career, specialty and the care for your

tive heart failure, diabetes, COPD to

Advocacy Fund, to position EM as a

patients. Do not leave it for others. You

prevent unnecessary hospitalizations?

solution to enhance quality and reduce

must participate! The best way to predict

cost.

the future is to create it!

as a leader and key contributor in the

What is your favorite personal medical

Are you ever coming back to Florida?

integrated healthcare delivery system.

niche?

We really hope to some day. We loved

The primary care medical home is far

I now focus on Medical Administration

living in Florida.

from providing these services to the popu-

and Medical Education because of my

condo in Jacksonville when we moved to

lation right now, but we in EM could begin

current role and the expertise and value I

Tennessee but we hope to return to the

immediately

feel I can provide in such areas.

First Coast eventually!

formed

Emergency

Just think of how powerful EM could be

through

our

access

to

We sold our beach

patients.

EMpulse • Fall 2011 15

SYMPOSIUMbytheSea

New Airway Devices

David A. Caro, MD, FACEP

Residency Director, Emergency Medicine University of Florida College of Medicine - Jacksonville Emergency airway management has changed significantly over the recent past.

Our 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 firstattempt visualization and ease of intubation. In this article, we will review indirect visualization devices.

These 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 setting 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 (Storz), the Levitan scope (Clarus), and the Shikani scope (Clarus). These 16 EMpulse • Fall 2011

devices combine a light source and fiberoptic camera into the shaft of a semimalleable stylet over which an endotracheal tube is placed. 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. Once the glottis is visualized, the endotracheal tube is guided under video guidance 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.4-6 The videolaryngoscopes include the Glidescope, the C-Mac (Storz), the AirTraq (King), the LMA C-Trach, the McGrath (LMA), and the Airway Scope (Pentax). Most of these devices are shaped like a McIntosh laryngoscope, with some important distinctions. The Glidescope is prototypical of this class of devices 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 for a video 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 to a stand that is wheeled for ease of transport. Importantly, the Glidescope is designed to be used with a rigid stylet shipped with the device. The stylet bends an endotracheal tube in the correct angle to make the 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.7-10 It is wise to gain specific training and simulation experience with any of these devices before using them in an emergency setting. Each device has specific design features that must be understood in order to properly use the device, as well as to be able to immediately correct foreseeable problems that might occur during their use. It is important to know that these devices have been shown to provide superior laryngeal views 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, expect that as these devices become more popular, they will be more frequently employed in US EDs.

SYMPOSIUMbytheSea REFERENCES

1. Cooper, R.M., J.A. Pacey, M.J. Bishop & S.A. McCluskey. (2005). Early clinical experience with a new videolaryngoscope (GlideScope) in 728 patients. Canadian Journal of Anaesthesia = Journal Canadien d'Anesthesie 52, 191-198.

2. 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.

3. Ovassapian, A. (2001). The flexible bronchoscope. A tool for anesthesiologists.

Clinics in Chest Medicine 22, 281-299.

4. 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.

5. 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.

6. 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, 232-237.

7. 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.

8. Cavus, E., J. Kieckhaefer, V. Doerges, T. Moeller, C. Thee & K. Wagner. (2010). The

C-MAC videolaryngoscope: first experiences with a new device for videolaryngoscopyguided intubation. Anesthesia and Analgesia 110, 473-477.

9. 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.

10. 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.

11. 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.

The Annual Meeting of the Florida College of Emergency Physicians

August 2-5, 2012

Omni Amelia Island Plantation Resort | Amelia Island, FL | www.fcep.org

EMpulse • Fall 2011 17

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Cave Diving in the Florida Springs: Michael L. Falgiani, MD

The Bends and Other Hyperbaric Emergencies

Assistant Professor Physician Director of Quality Department of Emergency Medicine University of Florida – Gainesville, FL There are many opportunities for scuba diving in the state of Florida. From the shipwrecks off the panhandle and southern coast to the reefs near the keys to spear fishing in the gulf, Florida is a haven for all types of diving. What most people do not know is that the north central Florida fresh water springs provide some of the most diverse cave diving in the world.

People travel from many different countries to train in and experience these massive cave systems. This is why it is paramount for emergency physicians in Florida to understand diving injuries. The major injuries that can occur in divers include decompression sickness (DCS), arterial gas embolism, nitrogen narcosis and oxygen toxicity.

Decompression sickness is also referred to as Caisson’s disease or the bends. Often people with DCS have pain in the joints of the knees and hips and bending over helped to relieve some of their pain, hence the name “the bends”. DCS occurs when a diver ascends to rapidly causing tiny nitrogen bubbles come out of the bloodstream and obstruct blood flow.

Typically divers ascending from a dive ascend slow enough that the nitrogen 18 EMpulse • Fall 2011

bubbles stay in the blood and travel to the lungs and are exhaled safely and the diver ascends. DCS is dependent on depth and duration of dive. The longer and deeper the dive, the more time that diver must spend ascending to allow the lungs to exhale all of the nitrogen that has accumulated in the body tissues during the dive.

There are two types of DCS. Type I DCS involves the skin and joints and occurs within 1 to 12 hours after surfacing from a dive. Pain is usually felt in the shoulders or knees. Type I DCS is treated with recompression therapy in a hyperbaric chamber. Type II DCS is much more serious. Type II involves the central nervous system. Nitrogen bubbles form in the low pressure venous plexus and impede venous outflow from the spinal cord.

This allows more nitrogen bubbles to form in and around the spinal cord. The symptoms seen in Type II DCS include an ascending paralysis, autonomic dysfunction, ataxia, numbness, tingling and fatigue. Both a motor and sensory loss is usually present. Since multiple bubbles may form, this will not present in a typical dermatomal distribution or stroke pattern.

Type II DCS is also treated in a hyperbaric

chamber. Table 6 of the US navy recompression tables is used and the treatment is approximately 4 hours and 45 minutes in the hyperbaric chamber.

There are many factors that predispose a diver to getting the bends. Divers who have had a prior DCS event are more likely to have another. Divers in extreme conditions, such as cold water, and those pursuing more strenuous dives with higher exertion during the dives are more prone to DCS. Females are more likely than their male counterparts to develop DCS, although the exact reason for this is unknown. Other risk factors include increased age, obesity and dehydration.

Another injury that occurs upon ascent is air-gas embolism (AGE). AGE occurs when divers rapidly ascend without exhaling. The volume of air in a diver’s lungs expands as the diver rises to the surface resulting in a rupture of the lung parenchyma and embolization of air into the arterial circulation. Risk factors for AGE include asthma, COPD and congenital pulmonary cysts.

Symptoms of AGE include chest pain, dyspnea, coughing, pink frothy sputum, syncope, seizure and stroke-like symp-

SYMPOSIUMbytheSea toms. The air that escapes into the arterial circulation can also travel to the coronary arteries causing chest pain that mimics acute coronary syndrome. In contrast to decompression sickness, AGE symptoms occur immediately upon surfacing, are not dependent upon depth or duration of the dive and neurologic findings are strokelike and follow a vascular distribution.

Treatment of DCS and AGE includes: ABC’s, oxygen via non-rebreather mask at 100%, hydration with IV fluids, pain control and ultimately recompression in a hyperbaric chamber. Avoid high altitude transfers (helicopter preferred over fixed wing) whenever possible.

Descent injuries include oxygen toxicity and nitrogen narcosis. As the partial pressure of oxygen increases during descent, the likelihood of cerebral oxygen

toxicity increases. Cerebral oxygen toxicity presents with nausea, paresthesias, dizziness and seizures. An oxygen toxicity seizure can be deadly if experienced underwater.

Symptoms of oxygen toxicity can occur suddenly without prodrome. Nitrogen narcosis occurs as more nitrogen is dissolved into the bloodstream and other tissues as the diver descends. Symptoms include loss of fine motor skills and higher order mental processes. Unlike oxygen toxicity, nitrogen narcosis is a gradual process and for most begins around 100 feet of depth. Nitrogen narcosis is a euphoric feeling and is similar to the effects of alcohol. Divers call this the “Martini Law” which states that every 33 feet you descend on air is equivalent to drinking one martini on an empty stomach. As with alcohol, nitrogen narcosis

affects every diver differently.

In summary, both decompression injury and air-gas embolism are life threatening conditions that may present to your emergency department. Decompression injury usually presents several minutes to hours after the dive and can affect the skin, joints, and central nervous system.

Air-gas embolism occurs immediately upon surfacing and presents with symptoms mimicking a heart attack or stroke.

The treatment of both entities is similar with airway, breathing and circulation being paramount. After initial resuscitation, oxygen and IV hydration, recompression therapy is the treatment of choice.

I hope this helps to shed some light on life threatening diving injuries and hope to see you around the springs of north central Florida.

EMpulse • Fall 2011 19

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Tips of the Trade Auricular Foreign Body Removal Tracy G. Sanson, MD, FACEP

Associate Professor, Education Director Division of EM, University of South Florida The most common foreign bodies in the ear are beads, plastic toys, pebbles, insects (especially cockroaches), popcorn kernels, earrings, paper, peas, cotton, pencil erasers, and seeds.

INSECTS Kill the insect before attempting to remove it with Mineral oil, lidocaine (2%), or isopropyl alcohol. (Suggest baby oil, isopropyl alcohol, or cooking oil if patient is frantically calling the ED.) Insecticidal activity of common reagents for insect foreign bodies of the ear Antonelli PJ, Ahmadi A, Prevatt A, Laryngoscope.

2001;111:15-20

Conclusion: Many agents commonly available in the EMS may be used to kill insect foreign bodies in the ear canal.

Antiseptic agents and microscope oil were the most effective against the most common insect foreign body, the cockroach. Ticks were the most resistant to all agents tested.

Comment: What is the best agent to grab when you have a distraught patient severely agitated by the presence of a live insect in the ear? Mineral oil has been commonly recommended, but it tends to create a gooey mess, making foreign body removal more difficult. Isopropyl alcohol would be my drug of choice. Although it is only number 2 on the quick-kill list, it is probably more readily available than the number 1–ranked ethyl alcohol. Liquid anesthetics are a nice thought, but take at least 3 or 4 times longer to achieve the desired lethal effect on the bug.

20 EMpulse • Fall 2011

Methods of Removal ● Irrigation: The simplest method of removal provided the tympanic membrane is not perforated. Use an irrigation syringe or standard syringe and angiocath or butterfly tubing cut short. Direct the stream along the wall of the ear canal and around the object, flushing it out.

Do not irrigate: - Hygroscopic objects such as vegetables, beans, and other food matter - may swell.

- Button Batteries: Avoid nasal and otic drops. These electrolyte-rich fluids enhance battery corrosion, leakage, generation of an external current, and local injury. ● Suction: If the object is light and moves easily, attempt to suction it out with a small catheter, a standard metal suction tip or specialized flexible tip. ● Alligator forceps are best for grasping soft objects like cotton or paper. ● Super Glue or cyanoacrylate. Place the glue material on the end of a cut cotton-tip applicator, avoiding the side of the ear.

Contact with the object through the otoscope, and hold for ~ 15 seconds. Then remove.

Pediatr Emerg Care. 1989 Jun;5(2):135-6. A new technique for removing foreign bodies of the external auditory canal. Pride H, Schwab R.

Conclusion: “Cyanoacrylate adhesive (Super Glue) was used successfully to remove a soy bean in a 16-year-old male.

The glue was placed on the blunt end of a

cotton swab, which was then introduced into the canal to make contact with the bean. Removal was easy, safe, and effective.”

Emerg Med J. 2002 Jan;19(1):43-5. Comparative prospective study of foreign body removal fromexternal auditory canals of cadavers with right angle hook or cyanoacrylate glue. McLaughlin R, Ullah R, Heylings D.

Conclusion: “The authors feel that cyanoacrylate impregnated cotton buds are as effective at removing impacted foreign bodies as a right angle hook but the process takes longer. It is believed that patients could tolerate this longer time as the cyanoacrylate method is in theory less traumatic.”

METALLIC OBJECTS Using a metal forceps, place a magnet on the end outside the ear. Touch the magnetized forceps to the object and remove. ● Styrofoam: Instill the organic solvent acetone or ethyl chloride.

Ann Emerg Med. 1994 Mar;23(3):580-2. The use of acetone to dissolve a Styrofoam impaction of the ear.

White SJ, Broner S.

Conclusion: Styrofoam can be particularly problematic because it can be compressed and become tightly impacted in an ear canal. Furthermore, Styrofoam is friable and tends to fragment with usual removal methods. Instillation of the organic solvent acetone into the ear canal was well-tolerated and caused rapid and nearcomplete dissolution of the Styrofoam impaction. This is the first reported case of

EMERGENCYultrasound organic solvent dissolution of an otic foreign body.

BATTERIES Remove immediately to prevent corrosion or burns. A delay of only an hour or two or a missed diagnosis of a battery in a nose or ear may lead to a very severe outcome. On contact with most tissue, this type of alkaline battery is capable of producing a liquefactive necrosis extending into deep tissues. Do not crush battery during removal. Avoid nasal and otic drops.

These electrolyte-rich fluids enhance battery corrosion, leakage, generation of an external current, and local injury After removal, the canal should be irrigated to

remove alkalai residue.

Objects which are difficult to remove and warrant referral are spherical objects, objects in contact with the TM and in the ear > 24 hours.

Otolaryngol Head Neck Surg. 2002 Jul;127(1):73-8.

Pediatric external auditory canal foreign bodies: a review of 698 cases. Schulze SL, Kerschner J, Beste D.

Conclusion: “Attempts under direct visualization had lower success rates with removing spherical objects, objects touching the tympanic membrane, and objects in the canal for more than 24 hours. Failed removal attempts resulted in higher complication rates. These cases should be

referred directly to otolaryngologists for otomicroscopic removal.” www.bestbets.org Ear Foreign Body Removal B Fennessy October 2004. Search strategy: Medline 1966-09/04.

Conclusion: There is no evidence in the current literature for choosing any particular method over another in the removal of foreign bodies from the ear, and many different techniques are applicable.

Clinical bottom line: No studies have been undertaken on comparing the different techniques to determine success. It is therefore advised that cases are treated individually.

EMpulse • Fall 2011 21

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The Man with a Red Eye CPC Chair: Fred Epstein, MD, FACEP Case Presenter: Christopher Mann, MD David Caro, MD, FACEP

University of Florida, Jacksonville

Case Challenger: Jonathan DeGroat, MD

University of Florida, Gainesville

Mr. D is a 31 year old male who presented to the ED with a chief complaint of dizziness and right eye redness for one day duration. Mr. D admitted to alcohol use the previous night that lead to an altercation with an unknown assailant. He states he was struck in the face multiple times with a closed fist and had some minor pain and bleeding after the incident but went home that night without any concerns.

When he woke up the next morning, he noticed that his right eye was swollen, reddened and aching, but denied any visual changes. He also denies any loss of consciousness but states he could not remember many of the events of the previous night. His past medical history was significant for a prior inferior orbital floor fracture and a closed maxillary angle fracture that was non-operatively managed. Past surgical history was significant for a repair of a previous facial fracture but further details were not known.

Family history was non-contributory.

On admission his vital signs were stable (BP 124/78, HR 80, RR 16, O2 Sat 100%), his physical exam was remarkable for abrasions to his upper lip and face, inferior ecchymosis of the right eye. His ocular exam was significant for bilateral exophthalmos, chemosis (most prominent on the right) and conjunctival erythema. He was unable to abduct his right eye past midline, and his visual acuity was 20/40 bilaterally. His pupils were equal, round, and reactive to light and accommodation, visual fields were intact, and his intraocu22 EMpulse • Fall 2011

lar pressures were mildly elevated at 22mmHg in the left and 23 mmHg in the right. On slit lamp exam the anterior chamber was difficult to visualize given his conjunctival erythema and chemosis but no obvious cells, flare or hyphema were noted. On fundoscopic exam no papilledema or retinal hemorrhage was noted. Under fluorescein exam no focal areas of uptake were noted however there was diffuse punctate uptake. At this point a brief differential diagnoses included intracranial hemorrhage, orbital compartment syndrome, tumor, and carotid

cavernous sinus fistula or aneurysm. The decision was then made to obtain a CT of the head to evaluate for any intracranial pathology.

SYMPOSIUMbytheSea Computed axial tomography exam of the revealed hyperdense and enlarged cavernous sinuses bilaterally with findings of exophthalmos and prominence of the right superior ophthalmic vein. These findings were concerning for a potential carotid cavernous sinus fistula. Given these findings a CTA and CTV were recommended to further evaluate the pathology of the above findings.

CTA/CTV revealed a direct carotid cavernous sinus fistula due to a dissection of the left internal carotid artery. Given these findings consultations were obtained from neurosurgery and radiology who recommended the patient be transferred to a facility which has interventional neuroradiology services. The patient was then transferred to an outside facility and underwent a successful endovascular repair with subsequent resolution of his symptoms.

Traumatic carotid cavernous sinus fistulae are a rare but potentially fatal complication of maxillofacial trauma, with a reported overall incidence of less than 1% of all patients with cranial facial trauma.

They can present as either direct or indirect fistulas. Direct fistulae, secondary to trauma, cause shearing of the internal carotid artery from its dural connections.

These shearing mechanisms can result in either carotid artery dissection, pseudoaneurysm or occasionally rupture of the internal carotid artery. The shunting of blood from the carotid artery into the cavernous sinus causes a high flow state in the cavernous sinus which rapidly increases pressure. This increase in pressure is manifested clinically as chemosis, proptosis, elevated intraocular pressures, decreased ocular movements and occasionally a pulsatile ocular bruit.

Direct fistulas generally require emergent surgical repair either open or more commonly via an endovascular approach.

Approximately 75% of direct CCSFs are a result of antecedent trauma (usually associated with a basilar skull fracture), the remaining 25% are acute ruptures of the carotid artery due to atherosclerosis or hypertension. Complications of direct CCSFs include massive life-threatening

epistaxis, subarachnoid hemorrhage, ischemic infarction of the brain, ocular ischemia and blindness in the affected eye.

Most CCSFs are not immediately life-threatening unless further complications occur. The treatment of choice for acute direct high-flow CCSFs is balloon embolization of the culprit lesion. Spontaneous closure in high-flow states is unlikely. In low-flow states, spontaneous closure via thrombosis of the cavernous sinus rarely necessitates the need for operative repair. Indications for repair would include evidence of severe proptosis, ischemia to the globe, glaucoma, diplopia or intolerable symptoms.

REFERENCES

1. Fabian TS, Woody JD, Ciraulo DL, et al.

Posttraumatic carotid cavernous fistula: frequency analysis of signs, symptoms, and disability outcomes after angiographic embolization. J Trauma 1999;47:275–281 2. Corradino G, Gellad FE, Salcman M. Traumatic carotidcavernous fistula. South Med J 1988;81:660–663 3. Mullan S. Carotid cavernous fistulas and intracavernous aneurysms. In: Neurosurgery.

Wilkens RH, Rengachary S (eds). New York, McGraw-Hill, 1985, pp 1483–1494 4. Albers SA, Latchaw RE, Chapter 136 – Interventional Neuroradiology of the Skull Base, Head and Neck. In: Cummings Otolaryngology: Head & Necksurgery 5th ed. Flint, PW et al. (eds). Missouri, Mosby, 2010, pp 1940-1943 5. Fattahi, T., Brandt, M., Jenkins, W., & Steinberg, B. (2003). Traumatic carotidcavernous fistula: Pathophysiology and treatment. Journal of Craniofacial Surgery, 14, 240–246.

EMpulse • Fall 2011 23

SYMPOSIUMbytheSea

The Girl Whose Skin Might Burst Into Flames CPC Chair: Fred Epstein, MD, FACEP Case Presenter: Jillian Davison, MD; Sal Sylvestri, MD, FACEP Orlando Regional Medical Center

Case Challenger: Jill Ward, MD

Florida Hospital - Orlando

A 28-year-old female presented to the ORMC Emergency Department complaining of a painful, diffuse rash. It started three days prior, gradually expanded, and was intensely painful. The lesions were erythematous, circular, non-raised, and located on the abdomen, flank, and left leg. The patient stated, “It feels like my skin is going to burst into flames.”

Her past medical history revealed no chronic medical conditions. She had a similar rash two months ago while incarcerated that was resistant to topical steroids and Benadryl - it resolved spontaneously after one week. She had no surgical history, took no medications, and had no allergies. Her family history was unremarkable. The patient smoked 1 pack/day, drank a moderate amount of alcohol, and used both cocaine and marijuana on a regular basis. She was a former pet groomer, and lived with her mother in Orlando. She was bisexual with multiple sexual partners and was released from jail one month prior to presentation.

The patient denied recent travel, sick contacts, or new medications.

On physical exam, the patient was noted to be a white female appearing disheveled, non-toxic, and slightly uncomfortable.

Her vital signs were within normal limits.

She had mild edema to both hands and a small effusion of her left knee. A rash was present on her abdomen, flank, and left leg that was non-blanching, tender, and purpuric with necrotic centers ranging from 1-5 cm in diameter with clearing 24 EMpulse • Fall 2011

near the edges. There were no vesicles or blisters, and no involvement of the palms, soles, or mucous membranes.

Initial work up showed an unremarkable CBC, CMP, coagulation panel, chest x-ray, and urinalysis. A urine drug panel was positive for THC and cocaine. Rapid HIV was non-reactive. Her ESR and CRP were elevated at 53 and 3.8, respectively.

Her RPR returned at 1:256.

After admission, treponemal IgM and IgG were both positive.

Skin biopsies confirmed the presence of spirochetes, and histopathology was consistent with

gummata/Lues Maligna. The patient was treated with IM Penicillin, and the lesions immediately improved.

She was discharged with instructions to complete outpatient treatment. The patient returned three weeks later with recurrence of rash.

Again her HIV was negative and RPR was positive, but titers had decreased from 1:256 to 1:128. This new rash was thought to be secondary to cocaineinduced vasculitis given the patient’s rich social history, and could easily be confused with her initial syphilitic rash.

Lues Maligna is also known as malignant or ulceronodular syphilis. It differs from other forms of secondary syphilis in its morphology and location. It can present as pustules, nodules, or ulcers with or without mucosal involvement.

The hallmark skin findings are multiple, well demarcated round or oval lesions that may have a lamellar crusting to the edge. The diagnostic criteria include a strongly positive RPR titer, a severe JarischHerxheimer reaction, characteristic gross and microscopic morphology, and rapid resolution of lesions with antibiotics.

Despite the fact that the patient may have returned with cocaine-induced vasculitis, an initial diagnosis of syphilis should never be missed in the ED. Syphilis is a vital diagnosis to make in the ED because it is easily treatable, yet devastating if left undiscovered. This patient illustrated the importance of always including “the great masquerader” on the differential of an unknown rash in the ED and to always keep a high clinical suspicion of syphilis in mind.

Symposium by the Sea 2012 The Annual Meeting of the Florida College of Emergency Physicians

August 2-5, 2012 . Omni Amelia Island Resort . Amelia Island, FL

REGISTER @ WWW.FCEP.ORG Conference Overview

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 2012 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 2-5, 2012 . Omni Amelia Island Platation Resort . 6800 First Coast Highway, . Amelia Island, Florida 32034 Reservations (904) 261-6161 . Mention Symposium by the Sea Guest Room Reservations Cut-Off Date: July 2, 2012 . Reserve your room early!

Exhibit/Sponsorship Opportunities

Visit www.emlrc.org/sbs2012.htm or contact Jerry Cutchens at jcutchens@emlrc.org.

The Exhibit/Sponsorship Prospectus is available directly at www.emlrc.org/pdfs/ sbs2012prospectus.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 2012 Symposium by the Sea Conference at The Naples Grande Resort in Naples, FL, Saturday August 4, 2012. 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 2012 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).

POISONcontrol

Treatment of Scorpion Stings in Florida Rachel O’Geen, Pharm.D. Clinical Toxicology Fellow

Dawn R. Sollee, Pharm.D., DABAT Assistant Director

Adam Wood, Pharm.D

Clinical Toxicology Fellow Florida/USVI Poison Information Center – Jacksonville Scorpion stings account for a large number of calls to poison control centers nationwide. In 2009, there were 17,154 scorpion exposures reported to the American Association of Poison Control Centers. Of these, 1,625 were treated in a health care facility with 50 cases resulting in major outcomes.1 In that same year, the Florida Poison Information Center Network received reports of 585 scorpion stings with no major effects.2 To improve treatment of severe scorpion stings, the FDA approved Anascorp® on August 3, 2011. It is the first equine derived F(ab’)2 anti-venom specific for scorpion envenomation in the United States.3 Most scorpions found in the US are of the Centruroides genus and produce primarily neurotoxic venom. The severity of envenomation will vary depending on the species of the scorpion. The principle site of toxicity is the sodium channel where the venom causes continuous firing of axons. This leads to initial symptoms consisting of pain, tingling, and burning at the site of the sting which might lack signs of inflammation.

When symptoms progress past the initial site, common manifestations include pain in areas distal to the site and subjective complaints of dysphagia. Severe cases may develop symptoms of cranial nerve and somatic motor dysfunction including rotatory eye movements, tongue fasciculations, and respiratory arrest. Patients may also develop uncontrollable muscle move26 EMpulse • Fall 2011

ments that can be mistaken for anything from restlessness to seizures. While adults are more often stung by scorpions, children under 10 years of age are more likely to develop severe symptoms requiring treatment.4 When considering treatment for scorpion envenomation it is important to determine which species was responsible for the sting. Of the scorpions indigenous to the United States, only Centruroides exilicauda (also referred to as Centruroides sculpturatus, the Arizona bark scorpion) is able to deliver enough venom with its sting to produce potentially life-threatening effects in humans. This species is native to Arizona but is also found in parts of New Mexico, Nevada, and California. Although there have been reports of travelers unknowingly transporting scorpions in their personal belongings or people keeping one as a pet, they are not likely found outside the southwestern region of the US.4 There are three species of scorpions indigenous to Florida (C. gracilis, C. hentzi and C. guianensis); fortunately, none are expected to cause systemic effects.6 Most people with history of a scorpion sting will not manifest systemic symptoms and can be managed sufficiently at home.6 Prior to the availability of anti-venom, treatment of severe scorpion envenomation consisted of intensive supportive care including benzodiazepines for

muscular manifestations and intubation as needed for respiratory support. Boyer, et al evaluated the efficacy of Anascorp® in 15 Arizona children with systemic manifestations of scorpion stings. All patients receiving antivenom experienced a complete resolution of symptoms within 4 hours of administration compared to only 14% of patients in the placebo group (p = 0.001). In addition, patients treated with anti-venom received an average cumulative midazolam dose of 0.07 mg/kg prior to discharge compared to 4.61 mg/kg in the placebo group (p = 0.01).7 Treatment of scorpion stings in Florida should involve symptomatic and supportive care similar to that of other insect bites. Patients who have been exposed to a scorpion native to Florida will generally only develop pain at the site. Although hypersensitivity reactions to the venom may occur, symptoms are not generally expected to progress systemically.

Patients may find cold compresses and analgesics helpful in the management of local symptoms. Use of anti-venom may be considered in patients in Florida presenting with systemic symptoms who have history of recent travel to the southwestern US or who have come into contact with a pet scorpion from this area.

Recommended dosing consists of 3 vials of Anascorp® given intravenously over 10 minutes. Each vial is reconstituted with 5 mL of normal saline and swirled, as to not denature the proteins. The contents of the

POISONcontrol 3 vials are then combined and further diluted with normal saline to create a total volume of 50 mL. Additional vials, if needed, may be given following a period of 30-60 minute observation. Common adverse effects include vomiting, fever, rash, pruritus, and headache. Hypersensitivity reactions including anaphylaxis are possible when using Anascorp®. Particular caution is advised in patients who have a known allergy to horse proteins or those who have previously received equine derived anti-venom. Patients should be counseled on the risk of serum sickness, which may present as delayed flu-like symptoms (rash, fever, and arthralgias).8 Feel free to contact your local poison center toll-free at 1-800-222-1222 with questions regarding general management of patients with scorpion stings or the use of Anascorp® anti-venom.

REFERENCES

5. Koehler PG and Oi FM. Stinging or Venomous Insects and Related Pests.

University of Florida IFAS Extension website. Published October 1994. Revised March 2003. http://edis.ifas.ufl.edu/IG099.

Accessed September 1, 2011.

2. Florida Poison Information Center Network Query (2009). Scorpions.

6. Gibly R, et al. Continuous intravenous midazolam for Centruroides exilicauda scorpion envenomation. Ann Emerg Med. 1999 Nov; 34(5): 620-625.

1. Bronstein AC, et al. 2009 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 27th Annual Report. Clin Toxicol. 2010 Dec; 48(10): 979-1178.

3. FDA approves the first specific treatment for scorpion stings. Food and Drug Administration website. http://www.fda.gov/NewsEvents/Newsroom/ PressAnnouncements/ucm266611.htm.

Accessed September 1, 2011.

4. Curry SC, et al. Envenomation by the scorpion Centruroides sculpturatus. J Toxicol Clin Toxicol. 1983-84; 21(4 & 5): 417-449.

7. Boyer LV, et al. Antivenom for critically ill children with neurotoxicity from scorpion stings. N Engl J Med. 2009 May; 360(20): 2090-2098.

8. Anascorp® [package insert]. Franklin, TN: Rare Disease Therapeutics; 2011.

EMpulse • Fall 2011 27

TRAUMAscorecard

ENA National Scorecard on State Roadway Laws Terri M. Repasky RN, MSN, CEN, CNS, EMTP Clinical Nurse Specialist, Emergency / Trauma President Elect Florida ENA

The Emergency Nurses Association (ENA) invites FCEP to join us in injury prevention efforts in our state.

According to the Centers for Disease Control and Prevention, a person is taken to an ED to be treated for a vehicle crash-related injury every 10 seconds. That translates into approximately 3.8 million emergency department visits a year from vehicle crashes alone. Every 12 minutes, someone in the United States dies from a vehicle crash. Study after study show that injury and death can be prevented when states pass and enforce laws that protect citizens from roadway related injury.

The ENA has created a tool and report to empower ENA members and others to engage in collaborative efforts that encourage lawmakers to pass research-based laws protecting people from roadway-related injuries.

The 2010 National Scorecard on State Roadway Laws: A Blueprint for Injury Prevention examines roadway safety laws in all 50 states and the District of Columbia and assigns scores on 14 legislation based criteria. Of the 14 possible criteria Florida scored 7. This report is current as of October 11, 2010.

The Scorecard ranks states based on 14 types of legislation that address: seat belt use; child passenger safety; graduated driver licensing for teens; all-rider motorcycle helmet requirements; ignition interlock devices to prevent drunk driving; entering, sending, reading, or retrieving data for all drivers using cell phones or other interactive wireless communication devices; and the authority to develop, maintain and evaluate a state trauma system.

The full report is available online at www.ena.org.

EMpulse • Fall 2011 29

RESIDENCYmatters

University of Florida, Gainesville David Nguyen, DO

Florida Hospital Vu Nguyen, MD

University of South Florida Jason W. Wilson, MD

Greetings from Gainesville! With the start of a new academic year, we have had to say goodbye to our former senior residents. The class of 2011 has spread its Gator pride as far as Arizona! This exceptional class has set high standards with their excellent patient care, hard work, and dedication. We wish them well in their future careers.

Greetings from Florida Hospital! We hope everyone is having a great summer.

The transition that occurs during this time of year always brings excitement. We proudly graduated our inaugural class in June. We wish them the best of luck in their new endeavors.

The USF EM Residency Program had a great presence at the recent ACEP Scientific Assembly in Las Vegas.

We also welcome the class of 2014.

During July, the new interns went through an ED orientation month. Not only did they have shifts in the ED, but also had daily EM lectures and hands-on procedure labs at our dedicated simulation lab. This orientation month eased our interns into the program, and they have quickly adjusted. To celebrate the completion of their first month, we had a city-wide scavenger hunt, an epic paintball battle, and a pool party!

On July 1, the new Pediatric Emergency Room at Shands Hospital for Children at the University of Florida opened, becoming north central Florida’s first ED specifically geared toward kids. It is staffed by seven board-certified/ board-eligible Pediatric EPs and 22 Pediatric-trained EM registered nurses. We will be able to treat up to 24,000 patients a year.

At the Symposium by the Sea CPC, Residents Justin Bennett and Jonathan Degroat looked to defend our title of the Bud Ferguson award. We are proud to announce that we are back-to-back champions! Justin Bennett placed 3rd for his case presentation of Ehrlichiosis and 30 EMpulse • Fall 2011

Taking their place are six fresh faces from all over the country. Our intern class has hit the ground running and is quickly assimilating to their new roles.

We congratulate our four residents who represented our program in the AAEM Sims Wars and placed third in the competition. Our second year residents, Drs. Troy Mostaan and Jill Ward placed 2nd and 3rd place respectively in individual CPC case presentations at the Symposium by the Sea. FHEM Residency is proud to be part of the movement of FH becoming a large academic hospital.

Until next time: we hope to see everyone at the ACEP Meeting.

Jonathan DeGroat won 1st place for best case discussion of carotid-cavernous fistula. Their combined score won the overall highest score! Also at the Symposium, resident Brandon Allen took home second place for his fantastic poster presentation investigating return visits within 72 hours. Congratulations to all our residents for representing our program so well… and Go Gators!

There were five research posters from residents and attendings, two attending speakers as well as a return of the popular Slit Lamp Course taught by senior residents and attendings from our program.

Thanks to residents Veronica Tucci, Ray Merrit, Larry Land, Alonso Osorio and attendings Kelly O’Keefe, Charlotte Derr and Brad Peckler for representing our program so well in the Sin City.

The trip, of course, was not all work and no play during the conference. The entire PGY-3 class attended the conference – and even made it to a few lectures each day – giving us a chance to spend time together hiking around Red Rock Canyon, visiting the Hoover Damn, and playing some Black Jack prior to dispersing into the “real world”.

We have returned with renewed vigor to finish up our senior year and will be submitting more abstracts for the AAEM conference just 80 miles down the road in Orlando this coming spring.

RESIDENCYmatters

Univ. of Florida, Jacksonville Travis Smith, DO

Mount Sinai Medical Center Nicole Campfield, DO

Orlando Regional Medical Center Rebecca Blue, MD

Greetings from Shands!!!! Just like everywhere around the state and across the nation, we are welcoming our new interns to the craziness we like to call the "The Shands."

Another exciting year has begun for our residency program at Mount Sinai. The installation of our new electronic records system (EPIC) is underway and has provided a novel challenge for the department. With new technology comes new faces, and the ED would like to formally welcome its new interns: Ashley Lisiewski, Kirsten Ritchie, Roberto Fernandez, Aaron Mickelson and Daniel Aronovich.

We would also like to welcome our new attending, Dr. David Edwards, to the Sinai family. They are already proving to be quite an asset to our program!

Greetings from Orlando!

We all remember the steep learning curve during our first months in the ED. Our seniors are doing a great job in the new transition. The next big step is our transition to EPIC in the next few months.

In an effort to integrate online medical education into our didactics, we have introduced a new awesome online educational resource for the residents. It was created by our resident selected faculty teacher of the year Dr. Alex Berk and by me. Check it out at jaxem.squarespace.com.

Look forward to seeing everyone at ACEP.

Mount Sinai Medical Center Roberto Fernandez, Ashley Lisiewski, Aaron Mickelson, Kirsten Ritchie & Daniel Aronovich

Last month heralded the success of the First Annual FLAAEM Scientific Assembly, held at the Grand Beach Hotel in Miami Beach. Our own Dr. David Farcy holds the position as 2011 President to the FLAAEM Association, while Dr. Erin Connor (PGY-4) holds the title of Resident Representative. Two days of lecturers were followed by resident poster presentations.

Dr. Richard Giroux (PGY-2) presented an interesting poster on “Sudden Cardiac Arrest”, Dr. Michael DeVarona (PGY-2) presented a poster on “Spontaneous Tracheal Rupture” and Dr. Nicole Campfield (PGY-2) delivered a case presentation poster on paraphimosis. The posters will be showcased at subsequent conferences throughout the year.

Lastly, sincere congratulations go out to our program director, Dr. Beth Longenecker, on her wedding last month!

It’s been busy as we geared up for another interview season! Our first candidates have come and gone. Thanks to all of the residents who contributed to recruitment and preparations – the caliber of candidates is outstanding, and the support of the residents and faculty is sure to make this an amazing year!

Orlando Health is exploring an exciting ED expansion goal. While planning is still underway, initial recommendations include expanding the department to approximately 70 beds, with over 30 beds in the pediatric emergency department.

We’re looking forward to final blueprints – it looks like we’ll have plenty of room to grow!

Orange County EMS is teaming up with Orlando Health to study the incremental benefit of 12-lead transmission on-scene for STEMI patients, specifically benefits of 12-lead transmission on the time-toreperfusion in STEMI patients. It is an exciting study, and both EMS teams and our physicians are dedicated to the project.

Congratulations to everyone involved in this partnership!

It seems like this year is racing by! Our intern class is performing far beyond expectations, and our upper classmen are providing excellent guidance as they continue to demonstrate their skills.

EMpulse • Fall 2011 31

EMERGENCY MEDICINE OPPORTUNITY JACKSONVILLE, FLORIDA Come Live on Florida’s Coast! Described as one of the nation’s most dynamic and progressive cities, Jacksonville’s miles of beaches and waterways are some of its most alluring assets. Home of the Jacksonville Jaguars, the city boasts a sports and entertainment complex, a major symphony orchestra, diverse cultural and recreation opportunities along with abundant natural resources. Due to its convenient location, mild climate and reasonable cost of living coupled with a high quality of life, Jacksonville is one of the top 15 fastest growing cities in the US.

EAST COAST, FLORIDA Outstanding opportunity for an Emergency Physician to join this 41,000 volume state -of –the- art facility, located less than one hour from Orlando. This family-oriented community is on the intracoastal and just minutes from the beaches.

Double coverage as well as mid level

providers and excellent back-up. Excellent compensation and benefits package.

Contact: Robin Lorber at

Team Health Southeast, 1-800-442-3672, ext. 2904. FAX (954) 424-3270.

Titan Emergency Group, an equity based group owned and operated by our physician members, is currently seeking an Emergency Medicine Physician for a full partnership opportunity in Jacksonville, Florida. Candidate must be BE/BC ABEM/AOBEM certified to work in our facilities.

Memorial Hospital is a 353-bed tertiary care hospital offering a breadth of services including the new state-ofthe-art CyberKnife Cancer Center and innovative Memorial Neuroscience Center. The ED is comprised of 33 beds with a 12 bed fast track and sees 72,000 patient visitors annually.

Orange Park Medical Center has a fully accredited 255-bed hospital that is currently seeking a Level II Trauma designation and has recently added Open Heart Surgery to its comprehensive heart care services. The ED has 24 beds with a 12 bed fast track and is under renovation to double its size.

At Titan, you have the ability to capitalize on performance based compensation!! We offer competitive compensation that includes both an hourly rate as well as productivity bonuses. Further we have a very comprehensive benefits package that includes heath and disability insurance, generous 401K retirement plan, CME and professional expense funding as well as malpractice and tail coverage.

For more information, contact Alisha Lane at (904) 332-4322 or a.lane@titandoctors.com.

College of FCEP|Florida Emergency Physicians 3717 South Conway Road, Orlando, FL 32812

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