SPRING 2012
Rational Prescribing
Life after Residency
Button Battery Ingestions
Volume 17, Number 2 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 Karen Estrine, DO • Guest Editor 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
Departments PRESIDENT’Smessage Vidor Friedman, MD, FACEP
3
GOVERNMENTALaffairs Steve Kailes, MD, FACEP
5
CODINGtip Lynn Reedy, CPC, CEDC
6
MEDICALeconomics Ashley Booth Norse, MD, FACEP
7
PROFESSIONALdevelopment Paul Mucciolo, MD, FACEP
9
Features The State of Florida EMS Michael Lozano, MD, FACEP
10
Breathe...SCUBA Diving and Emergency Medicine Karen Estrine, DO
13
Seven Year Old Girl Who Fell From a Swing Frederick Epstein, MD, FACEP John Reynolds, DO; Kelly O’Keefe, MD Andrea Apple, DO; Beth Longenecker, DO
14
Rational Prescription of Controlled Substances from the ED Lynn Welling, MD, FACEP
15
Statewide Emergency Medicine Resident Workforce Prep Day: Life After Residency Workshop Erin S. Berk, MD; Kelly Gray-Eurom, MD, MMM, FACEP
16
Pediatric Button Battery Ingestions Dawn R. Sollee, Pharm.D., DABAT Adam Wood, Pharm.D
18
A New Vision for South Florida: The University of Miami Hospital’s New ED Karen Estrine, DO
21
RESIDENCYmatters
22
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 • Spring 2012 1
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).
PRESIDENT’Smessage
Great Start for Emergency Medicine Vidor Friedman, MD, FACEP President
This year is certainly off to a great start for
others. We had a strong turnout from our
are a number of leadership academy
emergency medicine, from an excellent
residency
great
models throughout the country and we
program at Emergency Medicine Days in
feedback both from the legislators and our
will use those as a starting point for ours.
Tallahassee to getting the SGR patched
future members to be. You'll hear more
It is my hope that your group would be
through the end of the year.
about EM Days and our legislative issues
willing to sponsor one of your members in
in our Governmental Affairs update from
this effort.
Of course none of this would have
programs
and
got
Dr. Kailes.
happened without hard work from many
The future of emergency medicine is very
FCEP members and I wish to send a heart-
All in all, another great job of bringing all
much in flux; this future is being created
felt thanks to all of our members who have
of this together by our Governmental
right now! We have seen again this year
participated in our advocacy and educa-
Affairs and Academic Affairs committees!
that emergency care is frequently taken
tional programs already this year.
for granted by our legislators and our I would like to speak to you about our
So let's look back to the beginning of the
future and the future of emergency medi-
year. The legislative session started early
cine.
this year because of redistricting. FCEP
society in general. It is incumbent upon us, we who provide this essential care to society, to help both
members were in Tallahassee early in
At EM Days the engagement and enthusi-
the lay people and the legislators to under-
January talking with legislators and their
asm of the emergency medicine residents
stand how critical it is that emergency care
staff about our major issues: sovereign
in the state was inspiring. As an organiza-
be supported with adequate resources in
immunity, PIP reform, balanced billing
tion I feel strongly that we continue to
these times of change.
reform, and ongoing Medicaid reform
work hard to facilitate the growth of our
legislation.
future members, for they are truly our
I feel strongly that the development of
future.
future leadership is one of the keys to this
We followed up a few weeks later with a
effort. I look forward to your participation
great EM Days in Tallahassee. For those
As president of this fine organization one
in our leadership development program as
of you who were there, you were treated to
of my goals this year is the creation of a
an attendee or as a mentor.
excellent talks from the likes of the Attor-
Leadership Academy, specifically to help
ney General Pam Bondi; from Robin
those young physicians that are interested
Join us as we move forward into a future
Wescott, the Consumer Advocate; from
in being involved to see all the opportuni-
bright with possibilities!
the Office of Insurance Regulation and
ties for growth within our specialty. There EMpulse • Spring 2012 3
GOVERNMENTALaffairs
It’s Election Year: Where Will We Stand?
Steve Kailes, MD, FACEP Committee Chair
Politics...something often loathed. Decisions are made affecting you whether you like them or not. Politicians project agreement while not truly committing to anything. It is frustrating when I listen to politicians defend their divided positions, lecturing us about "what our founding fathers wanted." I like to read non-fiction. I've read quite a bit about our founding fathers, but I don't think our politicians have. Our country was built on compromise, not on rigid ideology and entrenched positions. A good compromise is one in which both parties are a little satisfied and a little dissatisfied. Our government was designed such that compromise was required to move things forward. Checks and balances, multiple branches of government, and a legislature split between a House and Senate were intended to deny too much power in any one area. Compromise was and is expected of our leaders. What does this have to do with FCEP? Currently it is March, and our State Legislature is in session. Our major goal, for years, has been to get sovereign immunity (SI) protection for providers of EMTALArelated care. This was the year that "the stars would align." The Florida Medial Association told us this was their "number one priority" for this session. It had the support of the Senate and House leadership and the Governor. Yet, as I write this, POOF! it is gone.
Multiple issues were pulled together on a single bill with a compromise such that SI protection is lost due to it being too costly. Optometrists get a "scope of practice expansion" to prescribe some oral medications and medical liability reforms are included. These reforms include allowing the defense to interview the plaintiff’s other treating physicians, allowing physicians and patients to enter into binding arbitration agreements that include a cap on damages, and increasing the burden of proof in cases involving diagnostic testing to a clear and convincing standard of evidence. Were we sold out? I understand compromise but what about principles? We will all come to our own conclusions on this but let's put this in perspective. What did we lose on the SI issue? We have the best caps on non-economic damages in the country and we will benefit from the additional tort reforms included in this deal. We can try for further reforms in the future. Currently, our bigger worry should be the State Supreme Court case challenging the constitutionality of the caps. The case has been heard but the decision is yet to come. This could be a real game changer, so stay tuned. What does the scope of practice expansion really mean? You might disagree with me, but I see such expansions as inevitable. We have a doctor shortage that will worsen
before it improves. Patients lack access to medical providers and specialists for a variety of reasons. Many in the lay public do not see great differences between a podiatrist and a orthopedic surgeon. My point is patients need care and there are not enough of us to provide for all of their needs. Our "leaders" see a long list of affiliated professionals asking to do more. Scope of practice expansions will eventually come at a cost to the public but, given the status quo, many have decided that the benefits outweigh the risks. As to the political reality of the compromise, SI has always faced an uphill battle. With our state budget deficits, this year is no different. For the other battles, the President of the FMA has written, "Strength in the legislative and political arenas is measured by relationships and political resources. In this case, the optometrists have far more political strength than the ophthalmologists. The optometrists have raised $668,499 for their political action committee during the year compared to $46,842 by the ophthalmologists." Was this compromise a lack of principles, caving in, or a crafty deal? What does this mean to you? What would you have done? What have you done already? Eventually, we have to deal with what we have and work to make it better. We CAN make a difference. This takes time, money, and effort. So please help.
EMpulse • Spring 2012 5
CODINGtip The following is an excerpt from the
created more than 30 calendar days
Medicare Program Integrity Manual, Pub.
following the date of service.”
100-08, chapter 3, section 3.3.2.5, which
While it is not certain what “give less
addresses Late Entries in the Medical
weight” will mean in an audit situation, it
Documentation:
does establish a standard of 30 calendar days before documentation is going to be
“The MACs (Medicare administrative
viewed as too stale to be credible. Please
contractors), CERT (comprehensive error
keep an eye on the calendar when making
rate testing contractors), Recovery
late-entries to medical records.
Auditors and ZPICs (zone program integrity contractors) shall give less
“Give Less Weight” to Late Late Entries
weight when making review determina-
Lynn Reedy, CPC, CEDC
tions to documentation, including a
Director of Coding Services
provider’s internal query responses,
CIPROMS South Medical Billing
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
MEDICALeconomics
Spring Update
Ashley Booth Norse, MD, FACEP Committee Chair
The 2012 legislative session has ended, and we must move forward with the changes facing healthcare both at a federal level and at a state level. While FCEP members are still digesting what the cuts to hospitals and Medicaid mean to us as emergency physicians, and more importantly as hospital based physicians, let me update you on what the medical economics committee is doing. FCEP’s medical economics committee is still working on the non-par provider reimbursement issues. Florida statute states that “reimbursement for services by a provider who does not have a contract with the PPO shall be the lesser of: a. Provider’s chargers b. The usual and customary charges for the similar services in the community where the services were provided or c. The charges mutually agreed to by the HMO and the provider within 60 days of the submittal of the claim. However, there continue to be insurance companies that violate this Florida Statute. Major carriers in Florida have changed their reimbursement policies since 2008, which has meant dramatic reductions in reimbursements to emergency physicians who are non-par providers. In February, a federal court judge finally cleared the way for releasing payments in the 2009 settlement that ended the historic court challenge against the UnitedHealth Group. Nearly $200 million in awards will be
disbursed to settle claims from physicians for 15 years of artificially low payments the insurer paid for out-of-network health services.
get an estimated out-of-network charge and out-of-pocket expense for that area/procedure. Free searches are limited to 20 per week.
We, emergency physicians in Florida, continue to fight this battle with insurers. FCEP has met with the Agency for Healthcare Administration (AHCA) in the past on this issue. In June of 2011, FCEP leaders and members of the medical economics committee met with the Office of Insurance Regulation (OIR) and asked that an investigation be opened in response to the issue of usual and customary charges being denied by insurers. The medical economics team thought that we had finally made some progress but in January we received notification from OIR that they did not have the statutory authority to investigate. At this time we are trying to work with the Consumer Advocates Office at OIR. Ms. Robin Westcott of OIR met with FCEP during the 2012 EM Days in Tallahassee. In addition, FCEP is once again going to approach AHCA with this issue.
In the meantime what options do we emergency physicians have? The first is classaction lawsuits. We have seen this approach taken with Vista and Aetna as well as others. The down side to a class action suit is that this approach is extremely costly. Also in the past, the trend in the settlements has been reimbursement based on a percentage of Medicare and there is concern that basing reimbursement on a percentage of Medicare is a dangerous precedence to set. The other option is to submit the claim to Maximus for a dispute resolution. For those of you who might not know, Maximus is the company with which AHCA contracts to resolve disputes about claims between providers and payors. Many emergency physicians are fearful of taking their disputes to Maximus because past rulings by Maximus have not been favorable for the physicians involved.
FCEP has also asked ACEP to look into the viability of obtaining data from FAIR Health. FAIR Health is the non-profit agency that took over Ingenix. The state-specific data obtained from FAIR Health could help Florida as well as other chapters in demonstrating usual and customary charges when advocating for fair payment legislation. FAIR Health’s consumer web site is accessible for free (http://fairhealthconsumer.org/medicalcostloo kup/), and anyone can input their zip code and either a CPT code or procedure description and
In addition to usual and customary and fair payment issues, the medical economics committee worked on PIP reform during the 2012 legislative session and is now looking at the cost of psychiatric care in the ED. As always I welcome your thoughts and input so please email me at Ashley.booth@jax.ufl.edu if you have any issues that you would like the Medical Economics committee to discuss.
EMpulse • Spring 2012 7
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PROFESSIONALdevelopment
Access to Care
Paul Mucciolo, MD, FACEP Committee Chair
“I mean, people have access to health care in America. They can just go to the emergency room." — George W. Bush With the presidential election fast approaching, the usual lofty goals are touted: job creation, deficit reduction, national security, healthcare spending, and lest I forget getting the US off foreign oil! If I were to record campaign promises, the song would be unchanged with every election cycle: same story, different actors. We need the basics to survive: food, water, and shelter. Now, healthcare has been added to that list. The healthcare “crisis” is real. As EPs, we know when and which specialist to refer patients to; however, have you ever tried to navigate this maze yourself? I have always enjoyed Dr. Wayne Barry’s interesting stories, and I’m going to take the liberty of telling you mine. Evan Paul Mucciolo was born May 7th, 2009. He was our first child and everyone commented on what a good baby he was. He rarely cried, he smiled, and he ate well. He seemed calm. A little too calm, we were to find out. Dutifully following the “Back to Sleep” recommendations, we laid Evan on his back to sleep. Approaching six months, the back of his head was flat as a board. There was no way he could turn his head to roll over! We were off to the pediatrician, off to the pediatric physiatrist, and off to the brace company for a cranial
remodeling helmet. Then to physical therapy for torticollis and motor delay, occupational therapy to help with grasping and holding, and speech therapy to coax a sound or two out of him. He’s still behind on his milestones, but he’s making progress. What did it take, however, for us to get him there? The helmet was on 23 hours a day. One hour off for bath, cleaning and drying. If my wife noticed a reddened area on his scalp, I got a phone call. Off to Jacksonville the next morning to get the helmet’s liner contoured. Sometimes we could coordinate appointments, but not always. In total, it was 66 trips to Jacksonville for the helmet alone. Add that to the dozen or so physician visits to monitor his progress and tailor his therapy. All of this while I worked full time and my wife ran the house. Whew! How about the cost? Fortunately, my wife and I are healthy and we have rarely had occasion to use our health insurance. This was an entirely different ballgame. My wife and I had to learn how to obtain referrals, pre-approvals, and documentation for Evan. This was an eye-opening experience for us. We occasionally were told that the paperwork was incorrect or had not arrived; we had to pay cash. Fortunately, we managed. Today, Evan’s problems are not over but he is playful and happy. This is certainly not a glamorous story like Dr. Barry’s trip to Haiti. In fact, the
process is boring and mundane and here lies the significance of Evan’s story. This is what our patients endure in varying degrees. Think about the patient who comes in for a cough and weight loss, and we find a mass. Then what? It’s off to the oncologist for consultation, to the imaging center for CTs and a PET scan, and maybe a trip to the pulmonologist or cardiologist for pre-operative clearance with a stop at the surgeon for a port. Then it’s chemotherapy and follow-up blood tests. Throw in referral paperwork, pre-authorization forms, medical records releases, and co-pays and our patient’s entire life is monopolized by the same medical care which is supposed to save his life. Where I practice at Halifax Health, we have case managers available twenty-four hours a day who help patients navigate the system. However, when it takes a physician several hours making phone calls and doing paperwork to get medical care for his son, something is wrong. Evan’s care was never delayed, because if the paperwork was not in order, I paid the bill at the time of service. However, what happens to the majority of our patients (and the estimated forty-five million Americans) who are less fortunate, who are uninsured or underinsured? With this election cycle, perhaps we should all consider the difficulties our patients and their families encounter accessing healthcare. EMpulse • Spring 2012 9
EMStrauma
The State of Florida EMS Part 8 of a Series
Michael Lozano, MD, FACEP
Committee Chair
In this issue we will examine pre-hospital stroke care. In the State EMS Strategic Plan, Goal 6, Objective 4.2 addresses the percentage of time that a Stroke Alert is initiated based upon primary or secondary impression. Stroke Alert is analogous to STEMI and Trauma Alerts. It serves to facilitate care by communicating valuable patient information between pre-hospital and hospital. The system goal is to have more effective care delivered to the patient. The Florida Stroke Act1 went into effect July 1, 2005, and was the first pieces of legislation nationwide that specifically addressed stroke care and tried to promote a state-wide stroke system of care. It tied the designation of hospitals as primary (PSC) or comprehensive (CSC) stroke centers to the criteria set by The Joint Commission on Accreditation of Healthcare Organizations (TJC). Under both statute and rule, hospitals can attest that they are either certified by TJC or that their stroke program meets the TJC criteria for stroke centers.2 Florida specific criteria for stroke center can be found in Florida Administrative Code.3 The law calls for AHCA to establish and maintain a list of primary and comprehensive stroke centers in the state. Currently there are 116 PSC and 19 CSC in Florida. The list is posted online.4 In addition to distributing the list of stroke 10 EMpulse • Spring 2012
centers, the Department of Health (DoH) was tasked with developing a stroke-triage assessment tool to be used by pre-hospital personnel. EMS medical directors must use the stroke-triage assessment tool provided by the DoH or one that is substantially similar. Additionally EMS medical directors must develop and implement stroke specific protocols that address the assessment, treatment, and transportdestination stroke patients. The intent of these protocols is to assess, treat, and ultimately transport these patients to the most appropriate hospital. Stroke is certainly a disease process amenable to pre-hospital intervention. Up to 2% of all EMS calls are stroke related, and recent data indicate that 29% to 65% of patients with signs or symptoms of acute stroke access their initial medical care via local EMS.5 Eligible patients who arrive via EMS are more likely to be treated with t-PA than if they self presented.6 In developing an evidenced-based protocol, an EMS medical director needs to first decide which tool to use to identify the presence of a stroke. Several assessment tools have been developed and prospectively validated for use in the pre-hospital setting. The first of these was the Los Angeles Prehospital Stroke Screen (LAPSS).7 Training for the LAPSS involves a short video that takes less than an hour. It has a sensitivity of 93% and a specificity of 97%. The Cincinnati
Pre-Hospital Stroke Scale (CPSS) was derived from elements of the NIS Stroke Scale used in hospitals.8 It takes about ten minutes to train a paramedic in its use, and it takes about a minute to apply the test. For anterior circulation strokes, its sensitivity is 88% and specificity is 97%. In Florida the CPSS remains one of the most commonly used assessment tools. Two other prospectively validated tools are the Face Arm Speech Test and the Melbourne Ambulance Stroke Screen.9,10 All these assessment tools have been found to improve the accuracy of paramedics in appreciating the presence of a stroke. Another commonly used tool in Florida is the Miami Emergency Neurologic Deficit (MEND) Prehospital Checklist.11 It consists of the CPSS with additional questions to refine the diagnosis of stroke and provide a better assessment of the severity of the stroke. Other tools to assess the severity of stroke are the Los Angeles Motor Scale (LAMS) and the LAG Scale.12,13 These supplemental scales are especially useful if the system has several destination options available. Besides stroke identification and determination of its severity, documenting critical historical points is paramount for pre-hospital providers. The last date and time that the patient was known to be normal or at their neurologic baseline (LKN). In order to minimize confusion,
EMStrauma LKN should be expressed in hours and minutes, and not simply relative to EMS arrival. For example, LKN should be expressed as “2/25/2012 6:02 PM” and not "30 minutes ago." All reasonable and expedient methods shall be used to ensure that LKN time is as accurate as possible. The name and contact information for any witness who can communicate with the destination facility regarding the patient’s baseline and acute medical condition. If at all possible, it should be allowable to transport the reliable witness to the destination hospital. The patient’s medications, or an accurate list, should be brought to the hospital. Particular attention should be paid to identifying anticoagulant (both oral and injectable), antiplatelet, and antihypertensive drug use. Pre-hospital treatment for stroke should be geared toward stabilization of the ABCs and rapid transport to the closest appropriate hospital. A common challenge for EMS educators and medical directors alike is convincing paramedics that the hypertension seen in the peri-stroke period is actually protective. Limiting the administration of dextrose containing fluids unless the patient is hypoglycemic seems prudent and is recommended in most consensus guidelines.5 Transport decisions center on mode of transport as well as destination. Given previous research that has documented the improved outcome of patients who receive in-hospital care at facilities specializing in stroke care, it is prudent to deliver all stroke patients to a stroke center assuming that one is in the EMS system’s catchment area.14 In some well defined circumstances, air medical transport may be preferred to ground transport.15 Such cases would include situations when the transport time by ground exceeds 60 minutes, or where ground transport would pose an undue burden on the EMS system’s ability to respond to other emergency calls.16
When given the choice between equidistant PSC and CSC, EMS systems need to take into account the LKN time, and be cognizant not to overwhelm CSCs with patients who fall within the 3-hour or 4½-hour time windows and who could have been treated at a PSC. Overall, the stroke system of care that has evolved in Florida is first rate as evidenced by a notably lower per capita morbidity and mortality rate compared to other states in the stroke belt. Ongoing efforts at EMS education in the area of stroke care need to be supported, as well as efforts to meaningfully integrate EMS into PSC and CSC quality assurance programs. Emergency physicians can play a significant role both as EMS advocates in their facilities and as EMS medical directors.
Stroke: Delays To Presentation And Emergency Department Evaluation. Ann Emerg Med. 1999;33(1):3–8. 7. Kidwell CS, Starkman S, Eckstein M, et. al. “Identifying Stroke In The Field. Prospective Validation of The Los Angeles Prehospital Stroke Screen (LAPSS).” Stroke 2000 Jan;31(1):71-6 8. Kothari RU, Pancioli A, Liu T, et. al. “Cincinnati Prehospital Stroke Scale: reproducibility and validity.” Ann Emerg Med 1999 Apr;33(4):373-8. 9. Harbison J; Hossain O; Jenkinson D; et. al. Diagnostic Accuracy of Stroke Referrals From Primary Care, Emergency Room Physicians, and Ambulance Staff Using the Face Arm Speech Test. Stroke. 2003;34:7176. 10. Bray JE. Paramedic diagnosis of stroke: examining long-term use of the Melbourne Ambulance Stroke Screen (MASS) in the field. Stroke - 01-JUL-2010; 41(7): 1363-6
1. Fla. Stat. § 395.3037-3041
11. http://www.strokesite.org/stroke_scales/MEND_Checklist_Pre hospital.pdf
2. Joint Commission on Accreditation of Healthcare Organizations: Disease-Specific Care Certification Manual, 2nd Edition, Oakbrook Terrace, IL; ©Joint Commission Resources, 2005.
12. Nazliel B, Starkman S, Liebeskind DS, et. al., A Brief Prehospital Stroke Severity Scale Identifies Ischemic Stroke Patients Harboring Persisting Large Arterial Occlusions. Stroke. 2008 Aug;39(8):2264-7.
3. F.A.C. 59A-3.2085(15)
13. Singer OC, Dvorak F, Mesnil de Rochemont R, et. al., A Simple 3-Item Stroke Scale. Stroke, 2005;36:773-776.
REFERENCES
4. http://ahca.myflorida.com/mchq/health_ facility_regulation/Hospital_Outpatient/form s/StrokeCentersList.pdf. 5. Adams HP, del Zoppo G, Alberts MJ, et. al. Guidelines for the Early Management of Adults With Ischemic Stroke: A Guideline From the American Heart Association/ American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: The American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007;38:1655-1711.
14. Langhorne P, Williams BO, Gilchrist W, et al. Do stroke units save lives? Lancet. 1993;342:395–98. 15. Rymer MM, Thrutchley DE. Stroke Team At The Mid America Brain And Stroke Institute. Organizing Regional Networks to Increase Acute Stroke Intervention. Neurol Res. 2005; 27 (suppl 1): S9–S16. 16. Crocco TJ, Grotta JC, Jauch EC , et. al. EMS Management Of Acute Stroke– Prehospital Triage (Resource Document to NAEMSP Position Statement). Prehospital Emergency Care 2007;11:313–317.
6. Kothari RU, Jauch E, Brott T, et.al. Acute EMpulse • Spring 2012 11
Presents:
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EMpulsefeature
Breathe… SCUBA Diving and Emergency Medicine Karen Estrine, DO
Associate Professor of Clinical Medicine University of Miami Miller School of Medicine
“Breathe. Breathe, Karen, breathe.“ I chanted these words in my head as I took my first breath with a SCUBA regulator during the initial day of my open water dive certification. To my profound relief, it actually worked, and I was fine. I have always wanted to become SCUBA certified, but fear of going from an air to water environment always got the best of me. This fear was further exacerbated at the tender age of nine when my parents, both avid SCUBA divers, went on a dive trip. I missed them at first, but I was overjoyed when they came home a week early. Shortly thereafter, I learned that the reason for their early return was secondary to a horrific dive accident from which my mother suffered. On their trip to the Pacific, my mom was caught in a triple-current, spiral vortex which dragged her deeper underwater. This inhibited her ability to normally ascend to the surface and she ran out of air! As she realized what was happening, she managed to craw hand-over-hand up a coal wall to the surface. Since she was out of oxygen, she could not breathe in, however, she could exhale, and that vital step saved her life. My mother tells me that she reminded herself, “Don’t panic, your lungs will feel like they have oxygen in them: The air in your lungs expands as you surface. Just exhale slowly and keep exhaling.” Hypoxia set in as she crawled up the coral wall to the surface. The diving physicians with whom she was traveling speculated that she had suffered an air gas embolism (AGE), and for reasons of prophylaxis, she spent hours in a hyperbaric chamber. She discontinued diving for the remainder of the trip. Retrospectively, this was a near-drowning, hypoxic event. I am so thankful that she survived. Twenty-two years later, I decided it was time to get over my fears and explore an incredible world that covers seventy-one percent of the earth’s surface. I dutifully studied from my dive book, and I took the written test. Then, I put
faith in my dive master, I took my first breath underwater, made my first decent, and I completed my first dive! In the years between my mother’s dive accident and my own SCUBA certification, I trained as an emergency medicine resident in Detroit and subsequently moved to Florida when I became an attending physician. Emergency medicine has its “bread and butter” chief complaints. Florida has been interesting, though, as my medial cases now include beach near-drownings, fish hook injuries, jellyfish and Portuguese man-of-war stings, along with various other poisonous marine invenomations. Most interesting of all these marine-related injuries are the two that crossed my chart-rack in the past few months. In a matter of two weeks, I had two separate male patients with potentially severe injuries from SCUBA diving. Both injuries were quite similar, presented in the same fashion, and were secondary to breaking the number one rule of SCUBA diving: ALWAYS BREATHE. Both patients were young men who were SCUBA certified, but each held their breath on ascent. One was lobster hunting, and perhaps he did not have enough air in his tank to get that one last lobster. So, he took the last breath from his tank, went 20 feet in depth, neglecting to exhale on the way up. The other patient, as well, did not exhale on ascent. Both men presented with dyspnea, chest pain, throat tightness, and anxiety. Before I even said hello to them, they each knew they had subjected themselves to a dangerous dive injury---and so did I. On auscultation, both had clear and equal breath sounds, so I was not as concerned about a pneumothorax… rather, something worse. Both patients had subcutaneous emphysema throughout their upper chests and necks. They were speaking and protecting their airways, but I knew that something horrific had happened…and I told myself, “Breathe, Karen, breathe.” It was my responsibility to take care
of these patients and save their lives. On spiral CT scan, both had extensive pneumomediastinum. Again, if they had just exhaled on their ascents, the pressure in their lungs would have been severely reduced and they would not have sustained their injuries. I maintained them on supplemental oxygen, as intubation was not warranted at the time. Ironic, though, was the possibility that I could have transitioned them from their SCUBA respirators to our hospital respirators. I called a nearby medical center to speak with the physician who runs their hyperbaric chamber. I thought it was a good possibility that “diving” them in the compression/hyperbaric chamber could potentially reduce their respective pneumomediastinums. The physician in charge of the chamber said that hyperbaric oxygen therapy in their particular cases was unnecessary since it could possibly cause more harm, so they were not transferred. Ultimately, both men went to the ICU for days of observation, and their healing was left up to them—for their own bodies to re-absorb their subcutaneous air and the large volume of air in their mediastinums. They eventually felt better and were discharged. During my open water dives, I remembered my mother and these two patients. I thought to myself, “follow the rules and always breathe… inhale and exhale.” So I did. And not only was I safe, but I saw a world I had never seen before. A world teeming with life—fish, marine mammals, and plants--all with their own natural Self Contained Underwater Breathing Apparatuses. It was amazing; I breathed underwater… We spend the great majority of our lives on the other twenty-nine percent of the earth’s surface, however, the same lessons I have learned underwater and through my emergency medicine training still apply: remembering to take a deep breath and letting out a big exhale is sometimes all that is necessary to manage and survive a tough situation.
EMpulse • Spring 2012 13
CLINICALcase
Seven Year Old Girl Who Fell From a Swing CPC Chair: Frederick Epstein, MD, FACEP Case Presentation: John Reynolds, DO; Kelly O’Keefe, MD University of South Florida Case Challenger: Andrea Apple, DO; Beth Longenecker, DO This is the case of a seven-year old female brought in as a trauma alert by helicopter. Per paramedic report the patient was playing on her swing when she fell backwards landing on a pile of mulch. When paramedics arrived they found the patient unable to move the right side of her body. Her vital signs were normal and stable en route to the hospital, and a point of care glucose was reported as normal. The past medical history was limited, but it was known that the patient had Down’s syndrome and had had open heart surgery.
of the left cerebral hemisphere which was concerning for ischemia. A CT angiogram of her neck and head was also obtained which was consistent with Moyamoya syndrome. While in the ED the stroke team was consulted and the patient was admitted to the Pediatric Intensive Care Unit. The patient underwent rehabilitation and was eventually discharged home with her family.
When the patient arrived to the trauma bay, initial assessment included ABC’s, a FAST exam, and a secondary survey. She was nonverbal, with no airway difficulty, and an intact gag reflex. Bilateral breath sounds were present and 2+ pulses in all extremities were felt. Her abdomen was soft and there were no long bone fractures observed. The FAST exam was negative. The neurologic exam revealed a nonverbal female with nystagmus and a left sided gaze preference. She had a flaccid paralysis of the right side of her body, and did not respond to placing intravenous lines or to other painful stimuli on the right side. While in the trauma bay the patient was given lorazepam and midazolam with no change in her neurological exam. She was taken to CT scan which showed a large area of hypo-attenuation
DISCUSSION Moyamoya syndrome is a condition that must be considered in all young adults and children presenting with stroke symptoms. It is classically described in the literature as affecting Asians, but has been found in all ethnicities. Other conditions associated with the disease include Down’s syndrome and Sickle Cell Disease. A preliminary diagnosis can be made with CT angiography or MRA of the brain. Confirmation of the disease can be done with four vessel angiography. Treatment for this disease is primarily supportive and definitive therapy consists of anastomosing the blood vessels around the diseased arteries. Indications for surgery include worsening ischemia, recurrent strokes and seizures. The surgery should be done at a later time after the acute event when the patient is more stable. Preventive measures usually include anti-platelet drugs and exchange transfusion for patients with sickle cell disease.
14 EMpulse • Spring 2012
EMpulsefeature
Rational Prescription of Controlled Substances from the Emergency Department Lynn Welling, MD, FACEP Commanding Officer Naval Hospital Jacksonville
It’s 10 p.m. Friday night. The ED is hopping. “Migraine” is the chief complaint on the next chart you pick up. When you walk in the room, the patient on the bed is sleeping with his coat over his face. You wake him up and he starts moaning, “Doc, I need something for my headache.” As you do your H&P, he repeatedly asks for something for the pain. As you explain you will treat his pain and that you have to find out what is causing it, he becomes more agitated and demanding. You explain that you are going to start an IV and do a physical exam. He is quick to point out that he is allergic to all forms of NSAID’s, reglan, phenergan, imitrex, etc. And he says that his doctor’s office is closed with no answering service and they usually get something that starts with a “d” and ends with “ol.” We’ve all been in similar situations. Plus, we often hear things like: “I just moved to town and haven’t had time to get a new doctor to refill my oxycodone for my back pain” or “I lost my hydrocodone prescription.” While each of us wants to provide the best medical care available–to include taking care of painful conditions–the ED is seen by many drug-seeking patients as a primary provider for non-medical use of controlled prescriptions. Just about everyone–from the president and the governor to the Centers for Disease Control and Prevention–has recognized that abuse of prescription medications is an epidemic, with Florida leading the way. With the recent passage of prescription drug bill HB 7095, Florida is taking a multipronged approach that supports the four arms brought out in the President Obama’s Prescription Drug Abuse plan: education, monitoring, proper disposal and enforcement. Based on approaches to address the epidemic abuse of prescription medications such as the program that the Swedish Medical Center Seattle implemented in its ED at its Cherry Hill campus, the Quality Collaborative of Northeast Florida approved a project called the Rational Prescription of Controlled Substances from the Emergency Department (RPCS). Representatives from 15 private and public health care organizations in Northeast Florida (including emergency medicine groups, hospitals, pharmacies, pain clinics, substance abuse clinics, rehabilitative medicine, and the Duval County Medical Society) came together in the RPCS working group to develop a regional response to address the misuse of controlled substances in EDs. We focused on developing evidence-based guidelines for the
rational prescribing of controlled substances for chronic, non-malignant pain that would not become barriers for patients who needed medical care, that all institutions would agree on, that physicians would follow, and that local health systems CEO’s would make policy. We also addressed all four arms in the president’s plan. Our collaborative approach, coupled with the CEO backing, made it easy for ED physicians to maintain their ability to treat patients as medically necessary while avoiding confrontation with those looking to abuse or misuse controlled medications. While primarily focused on EDs, our guidelines can easily be implemented in acute care clinics as well as used by private practice doctors and dentists. The RPCS working group products consist of provider education papers (including policy and references), patient education posters/handouts, patient brochures and patient notification forms to be signed with the ED registration packet. The Naval Hospital Jacksonville and Orange Park Medical Center rolled out the guidelines on Oct. 1, 2011, followed shortly by Northeast Florida health systems Baptist Health, Mayo Clinic, St. Luke’s Hospital, St. Vincent’s Healthcare and University of Florida at Shands – all in Jacksonville. While the program has only been operational for a short period, initial response from ED doctors and nurses is positive. The biggest concern expressed by doctors coming onboard with the program is the potential for a drop in patient satisfaction–something that has not been reported. While Swedish did note an initial drop after its program launch, it was followed by a rise in both patient and staff satisfaction. Swedish attributed this to a decline in drug-seeking patients which decreased wait times and reduced agitation in the EDs. Customizable templates for all the products can be obtained by contacting me at lynn.welling@med.navy.mil. While EDs like ours will continue to prescribe appropriate pain medications for acute pain, we hope these voluntary guidelines will make it easier for all ED physicians to reduce controlled substance dependence, abuse, misuse and diversion.
EMpulse • Spring 2012 15
EMpulsefeature
Statewide Emergency Medicine Resident Workforce Prep Day: Life After Residency Workshop Erin S. Berk, MD Kelly Gray-Eurom, MD, MMM, FACEP University of Florida-COM Jacksonville
This year, the University of Florida Department of Emergency Medicine/Jacksonville hosted the first statewide resident workforce preparation workshop. The two-day Life After Residency Workshop had been an annual local event for the Jacksonville EM residents since 2001, but this year, with the help of numerous sponsors, the event became a statewide conference. Dr. Kelly Gray-Eurom was the Event Coordinator and spearheaded the workshop. Dr. Erin Berk was the Education Program Coordination, and Dr. Kendall Webb was the AV-IT Coordinator for the Conference. The event was held on August 31st and September 1st at the Hyatt Regency Riverfront in Jacksonville. The program was designed to help prepare EM residents and pediatric EM fellows for transition into the workforce of Emergency Medicine. Over 100 people attended, including residents and fellows from the University of Florida-Jacksonville, the University of FloridaGainesville, Florida Hospital, Mt. Sinai Medical Center, and the University of South Florida. The event began with a cocktail social followed by dinner and reception on August 31st.
16 EMpulse • Spring 2012
Several emergency medicine employers and financial agencies served as sponsors for the workshop. Both the participants and sponsors had a great time interacting and talking about EM opportunities and programs in the state of Florida. The formal workshop took place on September 1st. The event started with a lecture by Dr. Alexander Berk, University of Florida-COM, Jacksonville, on “Finding the Right Job.” He encouraged residents to begin thinking about the job search process, and highlighted the differences among community based, academic, and various governmental jobs. He also provided the residents with a comprehensive list of questions to ask during job interviews and pointed out common pitfalls new graduates make when taking their first job. The next sessions focused on legal and financial matters confronting new graduates. First, Mark A. Addington, Esq. from Addington Law in Jacksonville gave a lecture on “Emergency Medicine Contract Negotiation.” He discussed a variety of contract issues including differences between being an independent contractor and an employee.
EMpulsefeature Next, Daniel J. D’Alesio, Jr., JD and Charles Portero, MS-RMI, CPHRM discussed Medical Malpractice Litigation Prevention & Insurance in Florida. Both have extensive experience in claims litigation through the University of Florida and offered a valuable perspective on the state of malpractice in Florida.
from the Mt. Sinai Medical Center program; Fred Blind, MD, FACEP, a 2008 graduate from UF-Jacksonville; Michael Falgiani, MD, a 2009 graduate from UF-Jacksonville; and Christopher Maguire, MD, a graduate from the University of South Florida program
The final lecture of the day was given by Mitchell A. Goldfeld, CIMA. He discussed Financial Planning, the importance of debt reduction, student loan repayment, and planning for retirement.
The panel provided an opportunity for senior residents and fellows to ask candid and specific questions of the recent graduates about their first jobs and their interview process. Overall, the workshop was a huge success and a great networking opportunity for residents, faculty, and EM provider groups. Evaluations from participants were overwhelmingly positive, and we hope to make this statewide conference an annual event.
Finally, and perhaps most informative, was a panel discussion with recent EM graduates who are all now practicing in Florida. The panel discussants were Jenny Zagaria, DO, a 2010 graduate
EMpulse • Spring 2012 17
POISONcontrol
Pediatric Button Battery Ingestions Dawn R. Sollee, Pharm.D., DABAT Assistant Director
Adam Wood, Pharm.D
Clinical Toxicology Fellow Florida/USVI Poison Information Center – Jacksonville
Battery ingestion in the pediatric population is a common occurrence. The American Association of Poison Control Centers reported that in 2009, there were a total of 5,403 cases of battery exposures in patients under the age of five years. Four of these exposures led to mortality, making battery exposures the second highest cause of death in this age group, second only to analgesics.1 Most button battery ingestions are benign as they will usually pass through the entirety of the gastrointestinal tract without incident. Unfortunately, this may take up to 14 days in some instances. Complications from these ingestions typically occur when the battery becomes lodged in the esophagus. Possible complications include localized tissue necrosis, tracheoesophageal fistula formation, esophageal burns, and cases of perforation through the bowel and aorta.2 Injury from button batteries lodged in the esophagus is thought to occur through
several mechanisms listed in order of clinical importance: a. Generation of an electrical current that causes electrolysis of esophageal fluids at the negative pole. This electrolysis produces sodium hydroxide which can cause significant chemical burns. b. Leakage of alkaline substances from degradation of the battery. This is thought to be less clinically significant with lithium batteries since they only contain a mildly irritating electrolyte. c. Mechanical force exerted on the tissue in contact with the battery. This alone does not cause significant injury. An article in Pediatrics published in 2010, reported that the incidence of ingestion of large-diameter (≥ 20 mm) lithium disc batteries is on the rise and that this is associated with increased morbidity and mortality. Data for this article was reviewed from a number of sources including the National Poison Data System (NPDS), National Battery Ingestion Hotline (NBIH), and other medical literature. These investigators found that there was a 6.7 fold increase in the percentage of button battery ingestions with major or fatal outcomes from 1985 to 2009 reported by the NPDS. Additionally, they
18 EMpulse • Spring 2012
found that ingestion by children under the age of four years and ingestion of largediameter lithium batteries (≥ 20 mm) were associated with worse outcomes, including death. Complications such as esophageal burns were also seen to occur in as little as 2-2.5 hours post ingestion in some reports.3 Based on these findings there have been revisions to the recommendations for management of button battery ingestions:3 a. Urgent initial radiographs are recommended for most battery ingestions. This may be waived if it is known that the battery is ≤ 12 mm in an a symptomatic child > 12 years of age. Younger children require a radiograph since 36% of cases with batteries lodged in the esophagus are initially asymptomatic.
POISONcontrol b. Batteries found in the esophagus must be removed within two hours. c. Any co-ingestion with a magnet requires prompt removal due to the risk of tissue ischemia and necrosis should the two become attached with tissue between them. Conclusion: The incidence of clinically significant outcomes with large diameter lithium batteries (≥ 20 mm) has been increasing. Due to the risk for esophageal injury, battery ingestions require prompt
localization via radiograph and removal within two hours if the battery is found lodged in the esophagus. For further questions regarding battery exposures, contact your local Poison Information Center at 1-800-222-1222 or the National Battery Ingestion Hotline at 202-6253333. REFERENCES 1. 1. Bronstein AC, Spyker DA, Cantilena LR, Green JL, Rumack BH, Giffin SL. 2009
Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 27th Annual Report. Clinical Toxicology. 2010;48: 979-1178. 2. Disc Battery Ingestion. In: POISINDEX® System [Internet database]. Greenwood Village, Colo: Thomson Reuters (Healthcare) Inc. Updated periodically. 3. Litovitz T, Whitaker N, Clark L, White NC, Marsolek M. Emerging BatteryIngestion Hazard: Clinical Implications. Pediatrics. 2010;125:1168-1177.
EMpulse • Spring 2012 19
EMpulsefeature
A New Vision for South Florida: The University of Miami Hospital’s New ED Karen Estrine, DO
Associate Professor of Clinical Medicine University of Miami Miller School of Medicine
The wait is over… The University of Miami Hospital Emergency Department is being reshaped with new physicians and a new vision. Formerly titled Cedars of Lebanon Hospital from 1961, when it was founded as a 100- bed facility, until 2007 when the University of Miami purchased the hospital, it is now a 560-bed, multi-specialty facility. In the words of Dr. Kathleen Schrank, the University of Miami Hospital is the “flagship of UHealth.” It is the pinnacle of the University of Miami Health System (uhealthsystem.com) with over 1,000 physicians from all specialties including community physicians and the University of Miami Miller School of Medicine (UMMSM) staff. In the fall of 2011, Dr. Kathleen Schrank, Professor of Clinical Medicine and longtime Chief of the Division of Emergency Medicine, announced that the Miller School of Medicine was dramatically expanding their academic endeavors and Emergency Medicine Faculty. In the process, Dr. Schrank decided to pass the torch to a new leader. To father the flagship, Dr. Schrank, with the help of Mark Halman, the Vice Chair for Administration, hired a long-awaited physician to captain the enterprise. Dr. Robert Levine has been hired as the new Chief of the Division of Emergency Medicine within the Department of Medicine. Dr. Levine completed his emergency medicine residency at Emory University in Atlanta. He went on to complete an internal medicine residency at Albert Einstein College of Medicine in New York, and further, a critical care fellow-
ship at the University of Pittsburgh. He maintains all three boards today. Subsequently, Dr. Levine did a resuscitation research fellowship under the auspices of Dr. Peter Safar, one of the founders of modern CPR. After fellowship, his career started at the University of Pittsburgh. He continued on to the Baylor College of Medicine in Houston, the Cleveland Clinic in Ohio, and finally the University of Texas School of Medicine at Houston prior to his new move to Miami, Florida. Throughout his busy career, Dr. Levine has worked clinically in both emergency medicine and critical care medicine, performed clinical research, and helped established a critical care fellowship while also wearing many hats such as that of Chief of a Division of Critical Care at The University of Texas where he was a Professor of Critical Care and Emergency Medicine. The new Emergency Department is in its infancy but growing fast with an almost completely new group of physicians. The vision is to establish an academic program in South Florida, including an emergency medicine residency program with fellowships in all the sub-specialties of emergency medicine, create research programs in collaboration with cardiology, neurology, and other specialties for cardiac arrest and resuscitation, cardiovascular disease, traumatic brain injury, and acute stroke, and to integrate medical students and residents from other specialties into the Emergency Department. Already, the University of Miami Hospital is a high acuity emergency department with an active role in medical education, research involvement, and most impor-
tantly, service to the community. As part of a large conglomeration of medical facilities, the University of Miami Hospital sits on a campus with the Bascom Palmer Eye Institute, Jackson Memorial Hospital, the Sylvester Comprehensive Cancer Center, the Miami Veterans Administration Medical Center, and numerous other centers for clinical activities and research. As a whole, the medical campus has goals to improve its operations. Speaking about this, in his words to the University of Miami’s faculty and staff in mid March, 2012, the Chief Operating Officer, Dr. Jack Lord commented: “I wanted to share with you the leadership structure that will help the Miller School of Medicine and UHealth advance through a period of great change – and reach the top ranks of the Nation’s academic medical centers, becoming a top 20 medical school by 2020, and a medical destination for all patients of South Florida and beyond. To achieve these goals, we are sharpening our focus on the key functions of the medical center in our core areas of health care services, research and education…” As one of the new emergency medicine attending physicians in the new University of Miami Hospital Emergency Department, I see amazing change underway already, and the excitement is brewing. Like Jedi master Yoda’s famous saying, “Do or do not… there is no try,” the University of Miami Emergency Department is prepared to implement the changes needed to establish a first rate Emergency Medicine program to serve South Florida and beyond! EMpulse • Spring 2012 21
RESIDENCYmatters
University of Florida, Gainesville David Nguyen, DO
Florida Hospital Jill Ward, MD
University of South Florida Nicholas N. Healy, DO
Greetings from Gainesville!
Florida Hospital’s Emergency Medicine Program has been busy as the close of the interview season has come. We are very proud of our soon-to-be new residency class.
Our residency program is excited to hail the arrival of several babies! Congratulations to Dr. Wilkerson, Dr. Fucarino, Drs. Abrahamsen and Toraño, Dr. Payor and Dr. Repasky. We bid a very fond farewell to Dr. Gentry Wilkerson and Dr. Michael Omori. Dr. Wilkerson joined the team in 2010 and transformed our research department. His fresh approach to journal club created a fun and efficient way to learn research fundamentals while appraising hot topics. Dr. Omori began working at Tampa General in 1984 and was one of our core faculty members when the residency program was launched in 2003. In 2000, he was featured in the television documentary Trauma: Life in the E.R. Dr. Omori is passionate for technology and will be pursuing an advanced degree in Medical Informatics. We continued to lobby for our patients and our profession in Tallahassee at the annual EM Days. We met with state representatives, senators and their staff to discuss sovereign immunity, fair payment, automobile insurance fraud, and changes to our Medicaid program. We were encouraged by our conversations and optimistic that we will ultimately have the support we need to gain sovereign immunity someday. In December, we headed out to a trampoline dodge-ball arena in Tampa to build esprit de corps and challenge our cardiovascular limits. With multiple residents having had athletic experience at the collegiate and Olympic-level, the competition was intense. We look forward to updating you next time on the results of our in-service exam and our latest published and presented research.
Another interview season is in the books! We had a record number of applicants this year, and the quality of the applicants year after year continues to amaze us. Our applicants also had the chance to meet our newly installed residency leadership group. Our new Program Director, Dr. Bobby Desai, Associate Program Director, Dr. Lars Beattie, and Assistant Program Director, Dr. Matt Ryan have been an integral part in the continued growth and success of our residency program. Congrats to all! A congratulatory shout also goes out to one of our Chief Residents, Henry Young, who recently won the University of Florida resident teaching award. In international news, Dr. Kevin Ferguson lead a group of medical students and staff on his annual medical mission trip to Thailand that took place at the end of February. He has worked hard setting up fundraising events and gathering supplies for the two week trip. In Thailand, his group traveled to local clinics and provided medical exams and vaccinations. They had a wonderful experience and safely returned home. 22 EMpulse • Spring 2012
The Walt Disney Children’s Hospital Emergency Department expanded from an 8-bed facility to a full 16-bed facility with a new trauma bay. It now has more lively room features including a color changing room, Disney movies on-demand, and interactive walls for children! Florida Hospital has once again teamed with Orlando Health for our annual in-service exam review, helping bring together the two residency programs. It has been a great learning experience and fun to see our friends there too. This year’s AAEM in San Diego, California was attended by Jill Ward, PGY 2, sitting on three committees. Florida Hospital presented a poster at AAEM as well. Many residents attended this year’s SAEM in March, including Lauren Py, who represented us as a board member. For other academic conferences, the entire second year class will attended Florida Emergency Physician’s Risk Management Symposium, and the intern class will attended Florida Emergency Physician’s Acute Care Symposium in March.
RESIDENCYmatters
Univ. of Florida, Jacksonville Travis Smith, DO
Mount Sinai Medical Center Nicole Campfield, DO
Hello to all...We are doing great in Jacksonville as we just made the big leap to EMR in January of 2012. We have finally switched over to EPIC, and thanks to our great faculty, Dr. Gray-Eurom and Dr. Webb, things could not have gone any better. We have been eagerly getting used to this new system of electronic medical records.
The residency program at Mt. Sinai Medi-
The month of February had been extra busy as we were all getting ready for the in-service exam, which was on February 29th. For our preparation, we had weekly reading assignments and board review questions on our website: www.jaxem.org. We were excited to host the Southeastern SAEM at the end of February. We had guest lecturers and 5 hours of board review. Not only did we present a lot of posters and oral presentations, some of our faculty also hosted STUD-wars-- a student version of SIM wars. This was made up of teams of 3-4 students from UM, UF, FSU and LECOM who competed in real life pre-hospital scenarios. The goal was to introduce them to pre-hospital emergencies so as to assist them into their clinical rotations. We hope the in-service went well for everyone, and we hope to see some of you at SAEM.
cal Center is focusing on airway management techniquest at the present time. We recently underwent a special conference focusing on cricothyrotomy, with lectures given by ACEOP President, Dr. Gregory
Christiansen,
an
expert
in
difficult airway management. Dr. Victoria Garrett was also kind enough to provide a simulation lab with mannequins and pig tracheas for our practice. This was a unique experience and it provided the opportunity for us to become prepared should the eventual need arise for a surgical airway. We thank Drs. Christiansen, Garrett and the Cook Critical Care representatives. We have met our match! We would like to formally welcome our new intern class: Benjamin Abo,
Roberto
Betancourt,
Harrison Borno, and Gina Petrakos. We are very excited to have them join us in July of 2012, and we look forward to great things from them in the future!
Robert Fernandez (PGY-1) and Mount Sinai residents practicing on trachea specimens.
EMpulse • Spring 2012 23
RESIDENCYmatters
Orlando Regional Medical Center Rebecca Blue, MD
St. Lucie Medical Center Sarah Fowles, MD
The year has definitely flown by! We had an exciting interview season, and match day went well. A thank-you is extended to all of our residents, attendings, and administrators who made this interview season both effective and fun! The pool of applicants was impressive and we cannot wait to have the newest members of our family come on board.
This has been very exciting time for the St. Lucie Medical Center Emergency Medicine Program. As a member of the consortium, Palm Beach Centre of Graduate Medical Education, we have smoothly integrated ourselves into some of the programs and conferences already in place, and we are diligently working on perfecting our own emergency medicine activities.
In March, a group of residents along with two attendings traveled to Tallahassee for EM Days. The lectures explaining pertinent legislation were informative, and gave us important insight into political bills which will change our practice of medicine in the years to come. After becoming literate in legislative issues, we were fortunate to have the opportunity to meet our representatives and senators and discuss pertinent issues in emergency medicine. The people we met were very receptive to our views and we certainly felt like we made a difference. In addition, it was good to get to know residents from other residency programs and work together to get the ball rolling for next year’s Symposium by the Sea. Our third year residents have secured positions for next year and we could not be more proud of them. Some residents are entering fellowships and others will be joining practices throughout Florida and in South Carolina. Enjoy the spring! 24 EMpulse • Spring 2012
With increasing resident participation our weekly lectures have evolved immensely. We are especially grateful for the weekly newsletter published by Morgan Garrett to keep both the residents and the attendings abreast on the upcoming lecture topics, reading assignments, and social outings. Residents of our program have recently prepared and presented posters at venues including the 2011 CEME Scientific Research Poster Competition and the February 2012 FOMA Research competition. Additionally, we would like to congratulate Jeanette Roberts, one of our first year residents, for winning the Resident Jeopardy contest at the annual ACOEP Fall Scientific Assembly. Some of the social gatherings in which we have participated include: a canoe trip, a 5K run, and even a ropes course for team/confidence building. Later this spring, we look forward to the residents’ day out. We are also happy to have matched four of our top medical student candidates and greatly anticipate them becoming part of our family in July. As we move toward the third year of our program and come another year closer to maturity, we rejoice that things are constantly changing for the better and look forward to a bright future.
The Annual Meeting of the Florida College of Emergency Physicians August 2-5, 2012 Omni Amelia Island Plantation Resort - Amelia Island, FL
REGISTER TODAY! www.fcep.org
College of FCEP|Florida Emergency Physicians 3717 South Conway Road, Orlando, FL 32812
NONPROFIT ORGANIZATION US POSTAGE PAID PERMIT NO. 2361 ORLANDO, FL