EMpulse Winter 2011 by Jerry Cutchens

WINTER 2011

Emergency Medicine Research in Florida

EMpulse

Volume 16, Number 1

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

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

Research in Florida RESEARCHﬂorida University of Florida College of Medicine - Jacksonville

RESEARCHﬂorida University of South Florida College of Medicine

RESEARCHﬂorida Orlando Health

RESEARCHems Michael Lozano, MD, FACEP

RESEARCHsymposium 2010 Symposium Poster Presentations

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

PRESIDENT’Smessage Amy R. Conley, MD, FACEP and Jay Falk, MD, FACEP

FCEPnominations

GOVERNMENTALaﬀairs Steve Kailes, MD, FACEP

CODINGtip Lynn Reedy, CPC, CEDC

MEDICALeconomics Ashley Booth Norse, MD, FACEP

EMStrauma Michael Lozano, MD, FACEP

PROFESSIONALdevelopment Paul Mucciolo, MD, FACEP

POLITICALfeature The Campaign to Elect Jason Wilson

CLINICALcase A Young African American Man with Respiratory Distress

POISONcontrol Patrick Aaronson Pharm.D

RESIDENCYmatters

DOCTORS’lounge Marlene Buckler, MD, FACEP

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 • Winter 2011 1

Professional PIP Representation

Rutledge M. Bradford, Esq. Board Certified Civil Trial Lawyer by The Florida Bar AV Rated by Martindale-Hubbell EXPERIENCED EMERGENCY ROOM PHYSICIAN REPRESENTATION AGAINST AUTO CARRIERS. WE FOCUS ON PERSONAL INJURY PROTECTION (PIP) LITIGATION SO OUR EMERGENCY ROOM PHYSICIAN CLIENTS CAN FOCUS ON TREATING THEIR PATIENTS. LET MY EXPERIENCE AS A FORMER INSURANCE COMPANY ATTORNEY WORK FOR YOU. •NO FEES OR COSTS IF NO RECOVERY. IF WE PREVAIL AGAINST THE AUTOMOBILE INSURANCE CARRIER IN PIP LITIGATION, PER FLORIDA STATUTES, THE AUTO CARRIER IS RESPONSIBLE FOR OUR FEES AND COSTS. KNOWLEDGEABLE, EXPERIENCED, AND PROFESSIONAL PIP RESPRESENTATION. •LET OUR STRONG PIP EXPERIENCE ASSIST YOUR TEAM.

Attorneys at Law 5210 South Orange Avenue Orlando, Florida, 32809 407-926-8710

PRESIDENT’Smessage

Medical Malpractice Reform: It’s About Basic Fairness Amy R. Conley, MD, FACEP President

Jay Falk, MD, FACEP Board Member

As emergency physicians, we have become weary of the current malpractice climate in which we practice. This is completely understandable and justifiable. We are asked on a daily basis to make critical, potentially life threatening decisions with too little information, at break neck speed with the precision of what would have happened in a “perfect world.” The personal toll that a malpractice lawsuit takes on the individual physician can be devastating. Potential loss of confidence, self esteem, reputation and job security add to the time and financial burdens. Accordingly, the American College of Emergency Physicians and Florida College of Emergency Physicians have worked hard to lobby for malpractice reform. We need to be clear about what it is we seek. The current system is badly in need of reform. It allows for far too many frivolous lawsuits in which a bad outcome with potential for extraordinarily large awards for damages, shared by the plaintiff and his lawyer drive the process, irrespective of whether negligence on the part of the provider occurred or did not. Disingenuous experts can convince juries with “junk science” of almost anything in the theater called a courtroom. This being said, we must also be honest with ourselves. There is no question that some of our patients are injured by negligent acts of omission or commission that occur in our departments. In others, our systems fail us and certain details “fall through the cracks.” In some cases, well trained and well intentioned

providers simply make an honest mistake for a variety of reasons. And sadly, in some cases inadequately equipped practitioners make egregious errors. Accordingly, our push for reforms must take into account the legitimate need of our patients who have been injured through true acts of negligence to be justly and fairly compensated. This can be accomplished in many ways; some current pending proposals in front of the State Legislature will be reviewed below. This year, lawmakers are expected to renew their focus on reforming Florida’s medical malpractice laws. Acknowledging the need for reform, during his recent State of the Union speech to Congress, President Obama pledged to support state reforms of medical malpractice systems to lower health care costs and improve care. To achieve this goal, lawmakers need to carefully consider medical malpractice reforms to ensure that Florida laws continue to protect patients, while removing avenues for trial lawyers to target doctors frivolously. These reforms should be guided by the principles of basic fairness. In Florida, lawmakers are considering legislation that would amend the statutes governing doctors by creating a new section of law for “expert witness certificates.” This provision would require expert witnesses in medical malpractice cases to obtain certification from our state medical board. This provision has been met with enthusiasm by our organized

medical community. The idea is that by requiring certification to be able to testify enables our State medical board to sanction “hired guns” for false testimony which could have ramifications for their ability to practice in their home states. This threat might keep these disingenuous experts from testifying in Florida. There are two problems with this approach. First, if the legislation were effective in preventing plaintiffs from having access to experts it would likely be ruled unconstitutional, since plaintiffs have a right to such access. Second, the likelihood is that legitimate experts (for defense as well as plaintiffs) would likely be unwilling to go through a burdensome credentialing and application process. This could result in the unintended consequence of having “career” experts (hired guns) be the only ones willing to go through the credentialing process. The legislation being considered by lawmakers is also aimed at amending the state’s medical malpractice laws to allow ex parte interview of subsequent treating health care providers. The bill, HB 479, sponsored by Rep. Mike Horner, R-Kissimmee, is a good first step toward providing an avenue for doctors to be able to exchange information and obtain the medical history and condition of a plaintiff in a medical malpractice case. Currently, Florida law prohibits non-party physicians from disclosing a malpractice plaintiff’s medical history and condition to a defendant in a medical malpractice case. Without the ability to exchange this EMpulse • Winter 2011 3

PRESIDENT’Smessage information malpractice defendants are prohibited from discovering relevant information concerning the plaintiff-patient’s medical condition and are therefore stymied in the preparation of a defense. Public policy should allow a defendant in a medical malpractice case to make a thorough investigation and mount an adequate defense by discussing the plaintiff’s allegations regarding damages with his or her treating physicians. The law, of course, would still need to be mindful of federal privacy laws and as such should ensure that a plaintiff‘s execution of a consent waiver needs to be a condition precedent to filing suit. In other words, if a patient is claiming to have been damaged, he must be willing to allow the defendant doctor access to his/her medical records to enable the defendant to scrutinize what these damages are and their relationship to the alleged negligent events. When identifying malpractice reforms that truly drive down the cost of health care, states must also consider clarifying a provision in current law, which allows plaintiffs to sue hospitals for damages caused by doctors who are not employees of the hospital. This expansive provision of law allows vast interpretations that expose hospitals to liability for legal costs and attorneys’ fees when none of its agents have committed malpractice. Another reform Rep. Horner’s bill addresses is the admissibility of reimbursement determinations used by insurers when determining compensation. While these determinations govern how the insurer makes decisions regarding health insurance coverage, payment methodology, and any policies on which reimbursement decisions are based, they should be exempt from being used as evidence of medical negligence. Using these determinations in a courtroom unfairly tips the scales and results in excessive compensation in medical malpractice lawsuits. The proposed legislation would require that medical malpractice insurers allow insured physicians to have the right to

4 EMpulse • Winter 2011

veto settlement offers. Insurance companies often settle cases because it may be less expensive than defending a case, even though the defendant physician was not negligent. Many believe giving physicians greater settlement control in medical malpractice lawsuits, is an important reform that will help curb health care costs. Finally, we hope to see legislation that will address sovereign immunity for all those physicians who provide care on an emergent basis. Sovereign immunity is not an absolute protection from lawsuits in Florida but does provide damage caps on the amount that plaintiffs can recover from hospitals and physicians in a medical negligence action. There is a current proposal in front of the legislature to make certain emergency medicine providers "agents of the state," thereby extending sovereign immunity to acts performed while providing emergency medical care." These proposed reforms along with those already implemented may result in fewer frivolous lawsuits while providing defendant doctors and hospitals with enhanced opportunities for mounting an effective defense. In advocating for reform we must keep what is best for our patients in mind. Remember that harm or damages to a patient is a prerequisite for any legal action. By striving to deliver the best possible care and reducing the number of harm events, we can reduce the substrate from which lawsuits germinate. Ultimately, a totally different system of compensating injured patients is needed. In the meantime, “be careful out there.” As we prepare for Emergency Medicine Days in Tallahassee we must contemplate upcoming legislative concerns and unite in an effort to protect our patients and physicians. Please make every effort to attend March 16-18, 2011. Respectfully Yours, Jay Falk, MD, FACEP and Amy Conley, MD, FACEP * *We would like to thank and acknowledge the input we received from Mary Cayley, MD, JD and numerous legal colleagues throughout the state.

The Annual Meeting of the Florida College of Emergency Physicians August 4-7, 2011 The Naples Grande Resort Naples, FL

SAVE THE DATE www.emrlc.org

FCEPnominations

Call for Nominations for FCEP Board, ACEP Council

FCEP Board Nominations

ACEP Councillor Nominations

Deadline March 31, 2011

Active members of FCEP interested in serving on the Board of

Active FCEP members interested in serving as a Councillor are

Directors are encouraged to submit their nominations to the

encouraged to submit their nomination(s) to the 2011 Nominat-

2011 Nominating Committee for consideration. Five directors

ing Committee for consideration as the Committee develops the

will be elected by the membership through a proxy ballot

slate of candidates.

distributed both online and in the membership magazine, EMpulse. The annual membership meeting where new Board

FCEP has 14 Councillor positions. There are currently 4

members are introduced will be held at the annual Symposium

available positions for a 2-year term.

by the Sea this summer, at the Naples Grande Resort. The FCEP Board of Directors will select the Chapter's CouncilInterested candidates should review the Board criteria (see

lors at its May meeting at the staff office in Orlando. Members

below) and complete and send their nomination, along with a

interested in representing the chapter at the ACEP Annual

copy of the candidate's CV to Beth Brunner at the FCEP office

Council Meeting, October 13-14 in San Francisco, should

(bbrunner@fcep.org, or mail to 3717 S. Conway Rd., Orlando,

submit their name for consideration to Beth Brunner on or

FL 32812). Self nomination and nominations of collegues are

before March 31, 2011, via email (bbrunner@fcep.org). This

both accepted.

year, FCEP will receive 14 Councillor positions, and will elect replacements for the four Councillors whose terms are expiring,

Nominees will be notified if their name has been added to the

as well as four alternate Councillors.

slate of 2011 board candidates. Board candidates are required to submit a brief (up to 300 words) bio on their professional career

Candidates must meet the following criteria:

and a photo for inclusion in EMpulse magazine and on

a) Member of Chapter for at least two years prior to nomination.

www.fcep.org. Candidates must submit their material within one

b) Active involvement in Chapter as evidenced by committee

week of being notified they are on the ballot.

membership. c) Plans to attend Councillor meetings for two-year term.

Board of Directors Criteria a) Member of Chapter for at least two years prior to nomination. b) Active involvement in Chapter as evidenced by committee membership or other activity.

EMpulse â&#x20AC;˘ Winter 2011 5

EM DAYS - TALLAHASSEE, FL 22nd Annual EM Days - March 16-18, 2011 Hotel Duval by Marriott - Tallahassee, FL 32301

Emergency Medicine DAYSâ&#x20AC;&#x2DC;11 2011 EM Days - March 16-18, 2011 Hotel Duval by Marriott 415 North Monroe Street Tallahassee, FL 32301 850.224.6000 - 866.957.4001

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.

GOVERNMENTALaﬀairs

This Election Cycle and Medicaid Reform

Steve Kailes, MD, FACEP Committee Chair

We have just completed the November 2010 elections. Elections are like watching a dog chase its tail. We hear the same rhetoric again and again and feel cynical or frustrated that nothing really changes. Candidates promise us “change,” “hope,” “fiscal responsibility,” and “bipartisanship.” But if any change occurs, it is small and incremental rather than sweeping reforms.

billion or 33.2% of the budget) • limited access to healthcare providers and specialists due to considerably insufficient reimbursement along with high liability risks • lack of control over the quality of services provided • legitimate concerns regarding fraud and abuse of the system

In previous articles, I had suggested that many issues from 2010’s legislative session will likely return for 2011. The Florida houses of Congress have now been refigured into much larger Republican majorities than we have seen in the recent past. Regardless of your political leanings, what this means to all of us is the agenda set by legislative leaders has a very strong chance of passing through both chambers and being signed into law by the governor. From a healthcare standpoint, our elected officials have gone on record stating a reform of the state’s Medicaid program is a high priority. It is widely recognized that the Medicaid system is “broken” due to several reasons, but primarily due to the high costs of providing care and limited state resources despite federal matching dollars. Medicaid’s problems are many, including: • rising enrollment (currently near 3 million recipients) • rising costs (in 1999, Medicaid cost $7.4 billion or 17.8% of the state budget but is anticipated to rise in 2014 to $29.6

Legislative leaders are developing a framework for reform. We anticipate that they might change the entire system to a managed care system, seek flexibility with current federal restrictions, consider use of integrated care systems, and reward healthy behaviors. You might notice that the “elephant in the room” is still the lack of access to providers. None of the changes above address the key concerns of providers: the high costs of providing care (relative to better payers), liability risks, and limited reimbursement. Significantly increasing reimbursement for Medicaid providers might help resolve this access issue. However, given the state’s limited resources, this solution has about the same likelihood of becoming a reality as I have of being named the King of England. The other side of this coin is reducing the liability faced by Medicaid providers. Similar to the various “We Care” programs throughout the state, the legislature is seriously considering applying sovereign immunity (SI) liability protection to Medicaid providers. As EM is the nation’s

safety net, we might finally have some recourse to our unfunded EMTALA mandate. If we consider that the average ED patient payer mix is around 20-30% Medicaid and another 20-30% self-pay, we could have SI protection for approximately 50% of our patients. In addition, FCEP is working with our allies for additional tort reforms. These include: • more stringent requirements for expert witness testimony in medical negligence cases • removing the prohibition of disclosure by a non-party physician to a defendant regarding a plaintiff’s prior medical history and conditions without the plaintiff’s consent • exempting reimbursement of charges for a service that produced a bad outcome from being used as evidence of medical negligence (much like an expression of sympathy is inadmissible) • deleting the prohibition on insured physicians from vetoing settlement offers, admissions of liability/arbitration, and the like, as determined by insurers In closing, please lend us your support. FCEP’s EM Days in Tallahassee will be March 16-18. It is absolutely essential that you contact your state representative and senator to discuss FCEP’s legislative issues. Please also contact us so we can ensure that we as a college stay on message! EMpulse • Winter 2011 7

CODINGtip multiple days in Observation. 99224 – Subsequent observation care – problem focused, low complexity, 15 minutes. 99225 – Subsequent observation care – expanded problem focused, moderate complexity, 25 minutes. 99226 – Subsequent observation care –

New Observation Codes If your ED group also covers for “observation” patients, you have new subsequent day codes for patients staying

detailed, high complexity, 35 minutes.

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

Lynn Reedy, CPC, CEDC Director of Coding Services CIPROMS South Medical Billing

FCEP, EMpulse VS 3717 South Conway Road Orlando, FL 32812

EAST COAST, FLORIDA

MIAMI, FLORIDA

Outstanding opportunity for an Emergency Physician to

JACKSON HEALTH SYSTEM, a 2,139 bed

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

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

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

MEDICALeconomics

Our 2011 Agenda and More…

Ashley Booth Norse, MD, FACEP Committee Chair

The 2010 elections are over and we must now move ahead with a new Governor, Attorney General, and Congress to ensure a stronger Florida. The Florida legislature opens on March 3, 2011. FCEP’s Medical Economics committee in conjunction with the Governmental Affairs committee met in November and laid out the college’s legislative priorities for the new legislative session. The most pressing issue is Medicaid reform. The new leadership has gone public with its plans for expanding the current Medicaid HMO models. There are also a few proponents of the medical home model. FCEP will be monitoring Medicaid reform closely. FCEP also expects the issue of fair payment to come up again. The bill introduced last year to prohibit “balance billing” of out of network patients did not get much traction. The proposed legislation tried to force contractual agreements between the EPs and insurance companies that are contracted with the hospital(s) at which the EPs practice. I suspect that we will see some version of this bill reintroduced this year. We will continue to monitor and oppose any bill that prevents EPs from receiving fair and equitable payment for treating in-network or out-of-network patients. Another issue discussed was the managed care issue of “usual and customary.” Florida statute states that “reimbursement

for services by a provider who does not have a contract with the HMO 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. Major insurance companies continue to violate this Florida Statute. Four major carriers in Florida have changed their reimbursement policies since 2008 to dramatically reduce reimbursements to EPs who are non-par providers. A recent class action settlement against the Vista Health plan resulted in a change in their reimbursement policy from 120% of Medicare to 200% of Medicare. However, this may still mean up to a 50% reduction from “usual and customary” reimbursement. If this precedence continues it will eliminate the need for carriers to negotiate contracts with providers and will mean considerable reductions in the reimbursement of EPs. FCEP has met with the Agency for Healthcare Administration (AHCA) in the past on this issue. We are currently waiting for the new AHCA secretary to be named and will meet again on this issue. In the meantime what are our options? The first is

class-action lawsuits. We have seen this approach taken with Vista and Aetna. 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 this is a dangerous precedence. The other option is to submit disputed claims to Maximus, the company that AHCA contracts with to resolve disputed claims between providers and payers. Many EPs are fearful of taking their disputes to Maximus because past rulings have not been favorable for the physicians involved. Regarding the Federal Healthcare reform bill, there is much talk and action to repeal and/or de-fund it. The reality is that the current healthcare reform legislation is here to stay in some form and we must start to try to influence the “interpretation” of the legislation. Private practice physicians are concerned about the new payment models in the healthcare reform legislation and how bundled payments and Accountable Care Organizations (ACOs) will affect their practice. We have seen a trend towards more employee physician models so this is a real concern. In closing I want to share a quote by W. Edwards Deming which seems to have more relevance now than ever before. “It is not necessary to change….Survival is not mandatory.” EMpulse • Winter 2011 9

EMStrauma

The State of Florida EMS Part 5 of a Series

Michael Lozano, MD, FACEP

Committee Chair

In the last installment of this series, we covered the essentials of EMS education in Florida by reviewing Strategic Goal 4. Objectives 4.1 through 4.5 sought to improve EMS workforce education, performance, and satisfaction primarily through adoption of the EMS Education Agenda for the Future. The last objective, 4.6, seeks to facilitate pediatric and neonatal educational programs by providing eight hours of relevant education in each Regional Domestic Security Task Force (RDSTF) region annually. Goal 5 seeks to ensure economic sustainability of the state EMS system, and supports the EMSAC as the clearinghouse for EMS legislative issues. The Florida Association of EMS Providers is the lead agency for most of the objectives in Strategic Goal 5. Key to long term sustainability is ensuring revenue in a difficult fiscal environment. Two key performance indicators will measure the percentage of reimbursable calls and percentage of billed charges collected. Most of the EMS in the state is provided by governmental agencies such as fire departments. These will be funded either through property tax millage, independent taxing districts, or general revenue. In addition to these funding streams, municipalities and counties will supplement these revenue streams by direct billing of patient’s insurance. For private providers of EMS, the majority of revenue is provided though insurance, though on occasion there are subsidy arrangements. For elective transports, payment is often 10 EMpulse • Winter 2011

guaranteed ahead of time. This is in contrast to 911 scene calls when EMS run into the same situations that we face in the ED. Patients can call 911 with a reasonable expectation that transport will be available. Method of payment is not requested nor is transport contingent upon a guarantee of payment. This situation is not unique to Florida. Different systems deal with “system abuse” in a variety of ways. Some adopt the “you call, we haul” approach. Some will decline transport either through an explicit policy or the coercion of the patient into an AMA. The latter can lead to risk issues, while the former can lead to public relations nightmares. Public education regarding the appropriate circumstances under which 911 is activated can potentially ease the financial strain on EMS systems, and we have seen efforts in this direction by the Florida Department of Health. Cost savings measures and alternate funding mechanisms are other methods of ensuring long term EMS financial viability. Since many agencies are governmental, an opportunity exists for cutting costs by the identification of best practices for vendor bidding and contract negotiation. Public purchasing procedures can be quite arcane and Byzantine. Evidence of this can be supplied by any of us who have ever responded to an RFP for EMS medical direction. Rules for bidding on public contracts vary between municipalities and counties, but some agencies have had success with programs such as co-operative supply purchases. An

example of this is Bureau of Pharmacy services through the Department of Health. Alternate funding sources include the United Way campaign, private foundations or Federal stimulus money. EMS agencies can provide education programs with a percentage of fees used to subsidize operations. Successful marketing of the EMS system is essential for taking advantage of these opportunities. Whereas Strategic Goal 5 seeks to improve the financial stability of the state EMS system, goal 6 identifies key performance indicators for EMS through benchmarking and partnerships. The objectives are arranged in the same order as one would follow the timeline of a 911 call. Objective 6.1 addresses dispatch systems. Earlier in this series we reviewed the new standards for communicator education and certification. From a systems approach, it is important to determine the proportion of primary Public Safety Answering Points (PSAP) utilizing a nationally recognized emergency medical dispatch (EMD) system. PSAPs are call centers responsible for answering calls for police, firefighting, and ambulance services. When you dial 911, a PSAP fields the call, using some form of EMD. There are three nationally recognized EMDs; Advanced Medical Priority Dispatch System (AMPDS), PowerPhone and the Association of Public-Safety Communications Officials International (APCO). Each of these includes a quality

EMStrauma assurance and improvement component. Part of objective 6.1 includes identification of the challenges and barriers for agencies that currently do not provide EMD QA. The National Association of Air Medical Communication Specialists (NAACS) standards are specific to the air medical transport industry, and adoption of these standards by all air medical communications centers is a goal of this objective. Another opportunity for improving the quality of EMD identified in this objective is to promote EMS Medical Directors involvement in EMD. One of the challenges to accurately tracking EMS response intervals is the lack of standardized definitions. The time of the initial 911 call is fairly easy to track. However, when does the clock start on PSAP processing? Does the time they spend on hold count, or the time it takes to transfer from one PSAP to another? Does “arrival” mean that the unit pulls up to the location, or that they knock on the door? Is it when the EMT or paramedic arrives at the bedside, or when they begin their interview? Objective 6.2 seeks to adopt a standardized model for defining PSAP call processing and EMS response times. Passive collection of these time intervals

via EMSTARS is another objective measure of success. Along those same lines, objective 6.3 seeks to establish a uniform definition of “EMS-hospital turnaround time” and of hospital “diversion” status. Whereas defining the time intervals in responding to the 911 call are somewhat intuitive, turnaround time and diversion status are firmly in the gray area of definitions. A standard definition of diversion is needed when setting up an Emergency System Status Program (ESSP). The Florida DOH, through the Office of Public Health Preparedness, has contracted with Intermedix EMSystemsTM to provide the ESSP function throughout the state through a grant process. Objective 6.3 seeks to promote an Internet based ESSP throughout the state. Such a program is useful not only in dealing with day to day diversion issues, but also to coordinate regional response during a disaster.

1 Following 9/11, Florida divided itself into seven Regional Domestic Security Task Forces. These regions follow the Florida Department of Law Enforcement regions within the State. The goal of the RDSTF is to provide a regional response to any WMD or terrorist incident that may occur within the State. It allows smaller counties that do not have lots of resources to draw from those that do. It also allows these smaller counties to provide assistance to larger metropolitan areas if an event occurs there. Addressing security issues at a regional level also allows for “economies of scale” for homeland security funds, especially in recent years as the amount of DHS funding to the States has decreased. Florida has been routinely hailed as a model for domestic security planning throughout the nation as a result of this regional approach.

In the next installment of this series, we will explore the key performance indicators that will be used to measure the quality of the medical care provided by EMS agencies. Additionally, we will review Strategic Goal 7 – all-hazards coordination and disaster response.

3 Request for Proposal is an early stage in a procurement process, issuing an invitation for suppliers, often through a bidding process, to submit a proposal on a specific commodity or service.

2 EMS Advisory Council

4 www.emsystem.com

EMpulse • Winter 2011 11

PROFESSIONALdevelopment

The Curbside Consultation

Paul Mucciolo, MD, FACEP Committee Chair

“I have a sore throat, would you prescribe a Z-Pack for me?” How many times have you, in the middle of a busy shift, been asked that? Quite a few I bet. EPs practice in a unique setting—the department is designed to protect confidentiality by keeping medical records away from prying eyes and at the same time the physicians are positioned in close proximity to patients. We are committed to helping those in need, but the assistance we render must be documented properly. See: http://www.doh.state.fl.us/ mqa/medical/info_prescribe.pdf Florida Administrative Code §64B8-9.003 requires documented information which identifies the patient, supports the diagnosis, and justifies the treatment. This includes a patient history, examination results, test results, records of drugs prescribed, dispensed or administered, reports of consultations, and hospitalizations. In other words, the “standard” patient encounter should be applied to everyone. The classic Danish proverb “The shoemakers children go barefoot” holds true. Patients who check in through triage have a chart with documentation and treatment. However, the staff member who requests a prescription for amoxicillin for her daughter’s sore throat, whom you’ve never seen and probably never will, is exposing both the patient and you to liability. This patient is receiving medical treatment far below the

standard of care. Controlled substances are another story. Think of the robot on Lost in Space with his arms flailing around: “Danger, Will Robinson! Danger!” Insomnia, dental pain, low back pain and anxiety are at the top of the list of reasons to request controlled substances. This becomes not only a problem with the State, but also with the Federal Government. My repertoire now includes explaining why I can’t prescribe such medications outside the scope of a formal physician-patient relationship and then explaining the problems unique to prescribing controlled substances. “Pill Mills” as they are called in the media are a significant problem. One twenty year-old patient who presented for a medication refill for low back pain told me that his pain management provider was in Fort Lauderdale. He explained that the clinic had an MRI machine on one side of a street where the patients were directed for a scan. No imaging was accepted from any outside source. The next day, the patients would line up to see a physician’s assistant who performed a history and physical on them, carefully correlating the findings on the MRI report with the patient’s complaint. The patient told me that the list of pain complaints documented in his record grew with each subsequent question—as did the number of MRIs ordered. The problem with writing prescriptions

without proper documentation is the lack of information available regarding patient’s prior prescriptions. Many states have systems to track prescriptions for controlled substances. Unfortunately, Florida is not one of them. At a recent Executive Committee meeting where I practice at Halifax Health, the problem of prescription writing was brought up. With the economic crisis upon us, many hospital staff members cannot afford co-pays/doctor’s visits and requests for refills of antihypertensives, diabetes medications and inhalers have become rampant. On further discussion, friends and family faced similar problems. The ED was the first to request guidelines on how to redirect these requests. Surprisingly, five other departments chimed in almost immediately. After much deliberation, two policies were drafted—one for the physicians and one for the staff, which covered both ends of the equation. What about requests for an outpatient CXR, Beta HCG, or MRI of the knee? Nope! Not without a chart. The standard history, physical, differential, diagnostic recommendations and follow-up plan must be in order. When asked “Will you do me a favor, Doc?” think twice. You’re really doing no one a favor by providing substandard care and exposing your license to possible sanctions. EMpulse • Winter 2011 12

RESEARCHﬂorida

University of Florida College of Medicine Jacksonville

Our department of Emergency Medicine’s current research and scholarly work includes:

at Chapel Hill. The study is entitled: Genetic Predictors of Acute & Chronic Musculoskeletal Pain After.

Drs. Luten, Hendry, Joseph, Godwin, and Kalynych along with residents Drs. Fawsett and Journey are completing work on the Pediatric Emergency Care Safety Initiative (PECSI) which is a 2 year, $470,000 grant from the Florida Medical Malpractice Underwriters Association. The goal of this project is develop an educational website on pediatric patient safety issues.

Drs. Booth-Norse, Schauben, and Kalynych are working with residents Drs. Bogle and Fox in regard to a study on the Effective Use and Efficacy of Alkalinization in Overdose.

Dr. Robert Wears was recently awarded a Robert Wood Johnson Foundation grant with the University of Michigan to study the history of patient safety as a social movement, focusing on how it has changed and been transformed by its interaction with healthcare. Dr. Sima Patel, along with Drs. Hendry and Kalynych are completing a pilot study in regard to a brief intervention on thirdhand smoke in the pediatric ED and its impact on caregiver’s smoking policies and/or cessation efforts. Dr. Sabato along with residents Dr. Baker and Elliot are working on three projects regarding Therapeutic Hypothermia within the pre-hospital and hospital settings. Drs. Hendry and Kalynych are working on a multi-centered NIH funded study through the University of North Carolina

13 EMpulse • Winter 2011

Dr. M. Joseph is serving as Chair and Co-Principal Investigator of the American College of Emergency Physicians’ DHS funded project All Hazards Preparedness Training for Children and Adults Through Interactive Web-based Games. Drs. Sollee, Schauben, Kalynych, Kunisaki, Booth-Norse, and Westenbarger are participating on the clinical trail: A Comparison of Anavip [Crotalinae (pit viper) equine immune F(ab)2] and CroFab® (Crotalidae Polyvalent Immune Fab, ovine) in the Treatment of Patients with Crotalinae Envenomation: A Randomized, Prospective, Blinded, Controlled, Comparative, Multicenter Study. Drs. Simon and Kalynych along with resident Dr. McCann completed a joint study with Naval Hospital San Diego physicians entitled: Ultrasound Evaluation of Cranial and Long Bone Fractures in Cadaver Models. Dr. Godwin is a Co-Principal investigator along with Drs. Haan, Zenni, and Genuardi in regard to a study looking at patient safety training along with simulation. The

study is entitled: Perception of Simulation as an Educational Modality for Teaching Pediatric Emergency Medicine to Emergency Medicine Residents. Drs. Caro, Morrissey, and Kalynych along with resident Dr. DJ Williams are completing a study entitled: Quantitative Capnometry: the Next Vital Sign? For more complete information on these studies and additional studies in our department, please visit our website at: http://www.hscj.ufl.edu/medicine/researc h-affairs/search/?p=department&view=d

RESEARCHﬂorida

University of South Florida College of Medicine

The USF Emergency Medicine Division of Research continues to be very active with a number of projects underway and even more in the works. Our mission is to promote and facilitate high quality studies in the areas of medical, surgical and traumatic emergencies while maintaining scientific integrity. The core team consists of newly appointed Director of Research, R. Gentry Wilkerson, MD, Clinical Research Coordinator, Daryl DeNittis, R.N., M.S., Assistant Research Coordinators Erin Stirling, PharmD and Gayatri Nair, BS as well as the Chief Resident of Research, Scott Stirling, MD. We look forward to the addition in the near future of Assistant Directors of Research Aaron Osborne, MD and Jason Wilson, MD. We are excited to be a part of the ProCESS (Protocolized Care for Early Septic Shock) Study. This is a multi-center trial funded by the National Institutes of Health (NIH) grant and is coordinated by the University of Pittsburgh's Departments of Critical Care Medicine (CCM) and Emergency Medicine. This effort hopes to forward our knowledge of severe sepsis and septic shock that was initiated by the landmark Early Goal Directed Therapy study by Rivers in 2001. ProCESS is a prospective, randomized, open-label, three-arm parallel-group trial of alternative resuscitation strategies for early septic shock, looking at not only clinical efficacy but also biologic mechanisms and cost effectiveness. We are currently enrolling patients in a study evaluating the effectiveness of IRRISEPT, a long-acting antimicrobial agent used in the irrigation of skin and soft

tissue infections. The solution is pre-packaged in a self-contained manual irrigation device that delivers 7-8 PSI of pressure as recommended by current ACEP guidelines. Beriplex® P/N is a prothrombin complex concentrate used in many countries around the world as an alternative to fresh frozen plasma in reversing oral anticoagulantinduced coagulopathy. We are part of an open-label, randomized, multicenter phase IIIb study to assess the efficacy, safety and tolerance of Beriplex® P/N compared with plasma for rapid reversal of coagulopathy induced by Vitamin K antagonists in subjects requiring an urgent surgical or urgent invasive procedure. With the winter months upon us we anticipate the resumption of our Tamiflu (Oseltamivir) study. This is a randomized, multi-center parallel-group double-blinded study of Tamiflu in patients with influenza. Adult and adolescent patients will be randomized to receive either 100 mg or 200 mg of study drug intravenously every 12 hours. The primary outcome measure is safety of the study drug. Safety will be assessed by adverse events, vital sign monitoring and electrocardiogram comparison from days 1, 3 and the end of the study period. Secondary outcome measures include pharmacokinetics and vial load and shedding. Other studies include an educational program in conjunction with the US Department of Veterans Affairs (VA) for the treatment of mild traumatic brain injury and evaluation of potential markers of sepsis.

The Ultrasound Division headed by Charlotte Derr, MD, RDMS, has a number of studies underway in that exciting and burgeoning field. We are busy adding to our repertoire with additional studies on medical simulation headed by Brad Peckler, MD, electrocardiogram analysis, early markers of renal function, biomarkers in traumatic brain injury, d-dimer utility and on the insertion of nasogastric tubes. At the recent Scientific Assembly held by ACEP in Las Vegas, USF was represented in the research presentation by second year resident Veronica Tucci, MD who presented: Is There a Sex Bias In Descriptions of Applicants In Standard Letters of Recommendation for Emergency Medicine Residencies? and Do Male Emergency Physicians Focus on Different Personal and Professional Traits In Writing the Standard Letters of Recommendation for Fourth Year Medical Students Than Their Female Colleagues? Chief Resident Jason Wilson, MD presented Boarding Times and Patient Safety: A Generalizable Quantitative Model. Ray Merritt, MD another second year resident presented Ultrasonography Evaluation of the Effect of Head Rotation on the Relationship of the Internal Jugular Vein and Carotid Artery. Dr. Peckler, our medical simulation guru, presented Teamwork In the Trauma Room Evaluation of a Multimodal Team Training Program for the Trauma Room. As this year ends and the new one begins we are excited about the direction of research at the University of South Florida!

EMpulse • Winter 2011 14

RESEARCHďŹ&#x201A;orida

Orlando Health

In 2010, we had several publications, posters, and abstracts. Our publications are as follows: 1. Krauss B, Silvestri S, Falk JL. Carbon Dioxide Monitoring (Capnography). UpToDate, January 2010. 2. Leech S, Silvestri S, Daugharthy J, Zigrossi D. Novice Paramedics Can be Trained to Perform FAST Examinations in Real Time Using Videoconferencing Technology. Prehosp Emerg Care 2010;14(Suppl 1):34. 3. Porter J, Rosenberg M, Van Dillen C, Parrish A, Vasquez V, Ralls GA, Papa L, Silvestri S. Can Electrocardiograms be Transmitted Quickly and Reliably Via a Cell Phone Camera From the Field to an Emergency Department? Prehosp Emerg Care 2010;14(Suppl 1):26-27. 4. Van Dillen C, Silvestri S, Ralls GA, Papa L. The Impact of Elimination of Diversion on Emergency Medical Services Unit Off-load Time. Prehosp Emerg Care 2010;14 (Suppl 1):37. 5. Leech SJ. Chapter 24 Emergency Ultrasound, In: The Atlas of Emergency Medicine. Kevin Knoop, Ed. [Textbook] 6. Papa L, Akinyi L, Liu M, Pineda J, Tepas JJ, Oli MW, Zheng WR, Robinson G, Robiscek S, Gabrielli A, Heaton S, Hannay J, Demery J, Brophy G, Layon J,

15 EMpulse â&#x20AC;˘ Winter 2011

Robertson C, Hayes RL, Wang KKW. UCH-L1 is a Novel Biomarker in Humans for Severe Traumatic Brain Injury. Crit Care Med. 2010 Jan;38(1):138-44 7. Liu MC, Akinyi L, Scharf D, Mo J, Larner SF, Muller U, Oli M, Zheng W, Kobeissy F, Papa L, Lu XC, Dave JR, Tortella FC, Hayes RL, Wang KK. Ubiquitin-C Terminal Hydrolase as a Novel Biomarker for Ischemic and Traumatic Brain Injury in Rats. Eur J Neuroscience Feb;31(4):722-32. 8. Thundiyil JG, Modica RF, Silvestri S, Papa L. Do United States Medical Licensing Examination (USMLE) Scores Predict In-Training Test Performance for Emergency Medicine Residents? J Emerg Med 2010 38(1):65-9. 9. Thundiyil JG, Porter JA, Williams J. Drug- and Toxin-induced Seizures. Emerg Med Reports March 2010;31(6). 10. Mondello S, Robicsek S, Gabrielli A, Brophy G, Papa L, Tepas III J, Robertson C, Buki A, Scharf D, Jixiang M, Akinyi L, Muller U, Wang KK, Hayes RL. Alphall-Spectrin Breakdown Products (SBDPs): Diagnosis and Outcome in Severe Traumatic Brain Injury Patients. J Neurotrauma Apr 21 EPub. 11. Clark MC. Approach to the Child with a Limp. Chapter in www.UptoDate.com Updated Limping

Child Diagnostic Algorithm and Acute Hip Diagnostic Algorithm. May 2010. 12. Wang KKW, Zhang Z, Svetlov SI, Glushakova O, Prima V, Kobaissy F, Liu MC, Robertson CS, Papa L, Lewis LM, Formisano R, Bossu P, Ciaramella A, Barba C, Catani S, Gabrielli A, Robicsek S, Wagner A, Mondello S, Hayes RL. Discovery and Translational Utilities of Acute, Subacute and Chronic Brain Injury Biomarkers. Brain Injury24(5): May 2010 13. Whittle JS, Parrish GA, Rosenberg MS, Sand ME. Complications of Prosthetic Heart Valves in the Emergency Department. Emerg Med Rep 2010;31:37-48. 14. Bullard TB, Rosenberg M, Ladde J, Papa L. Quality of Neuroimaging Obtained Using a Cell Phone and Neurosurgical Transfer Decisions. Acad Emerg Med May 2010 17(5) Suppl 1. [Abstract] 15. Papa L, Lewis L, Silvestri S, Giordano P, Mondello S, Falk JL, Sawyer S, Akinyi L, Demery J, Brophy G, Robinson G, Hunter C, Tortella F, Hayes RL, Wang KK. Ubiquitin C-terminal hydrolase (UCH-L1): A Potential Serum Biomarker for Mild and Moderate Traumatic Brain Injury. Acad Emerg Med May 2010 17(5) Suppl 1. [Abstract] 16. Hunter C, Silvestri S, VanDillen C, Rosenberg MS, Papa L, Falk JL.

RESEARCHďŹ&#x201A;orida Relationship Between End-tidal Carbon Dioxide and Lactate in Emergency Department Patients with Suspected Sepsis. Acad Emerg Med May 2010 17(5) S133. [Abstract] 17. Whittle JS, Weber K, Thundiyil JG, Ladde J, Blue R, Giordano P, Ralls GA, Silvestri S. Prevalence of Methicillin-Resistant Staphylococcus Aureus in EMS Personnel. Acad Emerg Med May 2010 17(5) S135. [Abstract] 18. Leech SJ, Flach F, Papa L, Vu C, Giordano P. A Randomized, Controlled, Crossover Trial of Video Glasses as an Adjunct for Ultrasound-Guided Vascular Access. Acad Emerg Med May 2010 17(5) Suppl 1. [Abstract] 19. Ladde J, Baker S, Wan M, Lilburn N, Vasquez V, Papa L. The LOOP Trial: A Randomized Prospective Study Comparing the Efficacy of a Novel Skin Abscess Drainage Technique Versus Traditional Incision and Drainage in the Emergency Department. Acad Emerg Med May 2010 17(5) Suppl 1. [Abstract] 20. Leech SJ, Flach F, Papa L. Inter-Rater Reliability of a FAST Competency Assessment Tool. Acad Emerg Med May 2010 17(5) Suppl 1. [Abstract] 21. Brophy G, Mondello S, Gabrielli A, Robicsek S, Papa L, Hayes RL, Wang KW. Ubiquitin C-terminal Hydrolase (UCH-L1): Correlations Exist Between Biofluid Kinetics and Clinical Outcome in Severe Traumatic Brain Injury Patients. J Neurotrauma May 2010 27(5). [Abstract] 22. Mondello S, Gabrielli A, Robicsek S, Papa L, Brophy G, Hayes RL, Wang KW. Necrotic and Apoptotic Cell Death Processes in Severe Traumatic Brain Injury Assessed by Sandwich ELISA-based Analysis of all-Spectrin Breakdown Products in Cerebrospinal Fluid - Clinical Significance and Temporal Profile. J Neurotrauma May 2010 27(5). [Abstract]

23. Mondello S, Robicsek S, Gabrielli A, Brophy G, Papa L, Tepas III J, Robertson C, Buki A, Scharf D, Jixiang M, Akinyi L, Muller U, Wang KK, Hayes RL. Alpha II-Spectrin Breakdown Products (SBDPs): Diagnosis and Outcome in Severe Traumatic Brain Injury Patients. Eur J Neuroscience 2010; 27(7): 12031213. 24. Balmes J, Thundiyil JG, et al. Prevalence of Beryllium Lung Disease Among Nuclear Workers. JOEM 2010 Jun; 52(6): 647-652. 25. Thundiyil JG, Rowley F, Papa L, Olson KR, Kearney TE. Risk Factors for Complications of Drug-Induced Seizures. J Med Toxicology EPub 07/28/10 26. Weber K, Denney C, Thundiyil J, Giordano P. Prevalence and Predication of Deterioration After Drowning in the Emergency Department. Ann Emerg Med September 2010, Vol 56(3): S2. [Abstract] 27. Ramirez J, Thundiyil J, CrammMorgan KJ, Papa L, Dobleman C, Giordano P. MRI Utilization Trends In a Large Tertiary Care Pediatric Emergency Department. Ann Emerg Med September 2010, Vol 56(3): S18. [Abstract] 28. Rosenberg MS, Thundiyil J, Greenberger S, Rawal A, Latimer-Pierson J. Does Physician Estimates of Pediatric Patient Weights Lead to Inaccurate Medication Dosages. Ann Emerg Med September 2010, Vol 56(3): S47. [Abstract] 29. Rosenberg MS, Bullard T, Ladde J, Papa L. Can Digital Photographs of CT Images Obtained and Transferred by Cell Phone Be Used to Predict the Need for Transfer to Tertiary Care Center. Ann Emerg Med September 2010, Vol 56(3): S57. [Abstract] 30. Cassidy DD, Papa L, Reimer F, Ritter CL, Williams DA, Townsend CS. Implementation of a Multifaceted

Electrocardiogram Screening Policy In the Emergency Department and Its Impact on ST-Elevation Myocardial Infarction Percutaneous Coronary Intervention Times. Ann Emerg Med September 2010, Vol 56(3): S60. [Abstract] 31. Bullard TB, Papa L, Nickolenko P. Factors Impacting Hospital Consumer Assessment of Health Care Providers and Systems Scores. Ann Emerg Med September 2010, Vol 56(3): S85. [Abstract] 32. Blue R, Whittle JS, Thundiyil JG, Silvestri S, Ralls G, Sirotkin L, Ladde J, Weber K, Giordano P. Prevalence of Methicillin Resistant Staphylococcus aureus in Out-of-Hospital Health Care Providers. Ann Emerg Med September 2010, Vol 56(3): S87. [Abstract] 33. Semmons R, Whittle JS, Thundiyil JG, Silvestri S, Ralls G, Sirotkin L, Blue R, Ladde J, Weber K, Giordano P. Methicillin Resistant Staphylococcus aureus in Ambulances. Ann Emerg Med September 2010, Vol 56(3): S88. [Abstract] 34. Ladde J, Bullard TB, Rosenberg M, Papa L. Can Cell Phone Digital Images Alter Neurosurgical Decisions to Transfer Patients Referred to a Level 1 Trauma Center? Ann Emerg Med September 2010, Vol 56(3): S127. [Abstract] 35. Van Dillen, CM, Silvestri S, Ralls G, Haney M, Papa L. The Evaluation of Acute Wound Characteristics for Alternate Medical Treatment Site Disaster Planning. Ann Emerg Med September 2010, Vol 56(3): S136. [Abstract] 36. Hunter CL, Silvestri S, Dean M, Falk J, Papa L. End-Tidal Carbon Dioxide Levels Are Associated With Mortality In Emergency Department Patients With Suspected Sepsis. Ann Emerg Med September 2010, Vol 56(3): S151. [Abstract]

EMpulse â&#x20AC;˘ Winter 2011 16

RESEARCHems

EMS Research: A Call To Arms

Michael Lozano, MD, FACEP Committee Chair

In applying emergency medicine to the EMS setting, the medical director is faced with several challenges. One of these challenges is the very nature of EMS systems in the US. As illustrated in the IOM report, “Emergency Medical Services at the Crossroads,” EMS is fragmented across the nation with multiple jurisdictions, and multiple levels of educational preparation and levels of care.1 This variability in practice makes it difficult to generalize the results of any pre-hospital studies published in the medical literature. Another related challenge is the application of emergency medicine across both time and distance. In this aspect, EMS shares many aspects with public health.

is still “art” in the science of medicine.

When an ED medical director develops a clinical policy for their staff, it is generally a consensus statement derived by the same independently licensed practitioners who will be carrying it out. Even then many directors will agree that it's difficult to get unanimity of opinion among ED physicians. Similar challenges face the EMS medical director. Implementing a new protocol in an EMS system where you have a handful of units is a totally different matter from a system with dozens of stations and three shifts of 24 hours each.

While there is certainly more EMS research activity occurring in Florida, there is no central clearinghouse where one can easily look up these studies. EMS systems that participate in these trials are often directly associated with the academic site conducting the study. Growing the body of EMS research will require cooperation on both sides.

While we all would like to say that we strive to employ evidenced-based medicine into our practices, there is simply not enough evidence in the literature to cover every single case that presents to our emergency departments. That is why there 17 EMpulse • Winter 2011

In the field of EMS, the medical director is further shackled by a lack of evidence that can be generalized to his own system. While we in EMS all aspire to worship at the altar of evidenced-based medicine, we end up drinking in the lounge of anecdotal based care. That is not to say that there is not a growing body of EMS research. In fact, several important trials that contributed to EMS research in the field of AMI treatment,2 airway management,3 and refusal of care4 occurred in Florida, and a large pre-hospital cardiac arrest trial involving a site in Florida is ongoing.5

Doubtless there are academicians with hypotheses to test, and EMS systems with plenty of patient contacts and a desire to expand the boundaries of science. FCEP's Academic Affairs committee and EMS/Trauma Committee are exploring avenues that would promote this sort of cross disciplinary collaboration. If any FCEP members would like to assist, please contact the respective committee

chairs for Academic Affairs and EMS/Trauma: Adrian Tyndall, MD, FACEP (tyndall@ufl.edu) or Dagan Dalton, MD (dr@dagan.md). 1 Committee on the Future of Emergency Care in the United States Health System—Institute of Medicine of the National Academies, Future of Emergency Care: Emergency Medical Services at the Crossroads. Washington, DC, The National Academies Press, 2007. 2 Cannon CP, Sayah AJ, Walls RM. ER TIMI-19: testing the reality of prehospital thrombolysis. J Emerg Med. 2000 Oct;19(3 Suppl):21S-25S. 3 Silvestri S, Ralls GA, Krauss B, et. al. The Effectiveness of Out-of-Hospital Use of Continuous End-Tidal Carbon Dioxide Monitoring on the Rate of Unrecognized Misplaced Intubation Within a Regional Emergency Medical Services System. Annals of Emerg Med 1 May 2005; 45(5):497-503. 4 Silvestri S, Rothrock SG, Kennedy D, et. al. Can paramedics accurately identify patients who do not require emergency department care? Prehospital Emergency Care October-December 2002; 6(4):387390. 5 A Randomized Controlled Study Comparing Autopulse To Manual CPR In A CPR-First Protocol For Out-OfHospital Cardiac Arrest. Clinical Trial.gov identifier: NCT00597207

RESEARCHsymposium

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

Accuracy of ECG Interpretations by Emergency Medicine Residents and the Efficacy of Immediate Feedback by EM Attendings Mohsen Akhlaghi, MD, Terrell Swanson, MD, Dustin Brimblecom, MD, Robert Wears, MD, MS, Colleen Kalynych, MSH, EdD, Vivek Kumar, MD, MPH, and Michelle Lott, BSH, CHES UF COM Department of Emergency Medicine OBJECTIVE The objective was to determine the efficacy of an immediate feedback loop program in ECG readings among residents and attendings while working in a busy academic, urban ED. METHODS This IRB approved prospective observational study consisted of a convenience sample of residents, attendings, and patients. Data was collected in the ED ICU on Tuesdays, Wednesdays, and Fridays during all shifts. Once an ECG was performed, the results were interpreted by the resident and indicated on the data sheet. The ECG was read by the attending, who discussed their opinion with the resident and provided feedback. A separate group of ED physicians served as the quality assurance (QA) team. Lastly, the Cardiologist’s interpretation was recorded. The effectiveness of the feedback loop program was assessed via resident surveys. RESULTS Patient population (n=271) comprised of 47% males and 53% females, the majority were African Americans (58%) with 39% Whites. Sixty four percent of the population was between the ages of 41-70 yrs. EM PGY1s read 29% of the cases, EM PGY2s read 25%, and PGY3s read 44% cases. EM attendings agreed with residents’ EKG readings 86% of the time. The Cardiologist agreed with EM residents’ EKG readings 71% of the time; leaving 29% disagreement between Cardiologist readings and EM resident interpretations. On an agreement Likert Scale ranging from Strongly Agree to Strongly Disagree, 50% agreed their interpretation skills improved with the QA 18 EMpulse • Winter 2011

system, 31% were neutral and 13% disagreed. Forty four percent agreed the QA system increased their confidence in reading ECGs, however, 38% were neutral, and 13% disagreed. Fifty seven percent also strongly agreed or agreed that the QA system would assist in providing better patient outcomes. CONCLUSION The agreements vs. disagreements between residents, attendings, and cardiologist show a positive trend towards the level of accuracy of ECG interpretations with increasing level of training. This trend signifies the appropriateness of the medical education received by the residents. However, there is a clear discrepancy between the cardiologist and the EM attending agreements on resident interpretations of a Normal Sinus Rhythm, although this may not be of consequential importance. In reviewing the Feedback loop and the QA system, nearly half of the residents agreed the QA system increased their level of confidence while interpreting ECGs; however, a similar percentage had no opinion about the system or disagreed to its usefulness. Further evaluation is needed to determine barriers in providing consistent feedback while in the ED in regard to ECGs. -----------------------------------------------------------------------------Emergency Physicians Using An Online Immunization Registry Perform Fewer Blood Screens For Occult Bacteremia On Children Aged 6-24 Months Who Present To ED With Fever Without a Source Cristina M. Zeretzke, MD, 1Mark S. McIntosh, MD, MPH, 1Todd Wylie, MD, MPH, 1Colleen J. Kalynych, MSH, EdD and 2David Wood, MD, MPH University of Florida COM/Jax 1Dept of EM, 2Dept of Pediatrics 1

OBJECTIVE The primary objective of this study was to determine if utiliza-

RESEARCHsymposium tion of the Florida SHOTS immunization registry to validate completion of the primary conjugate vaccine series would reduce the screening for OB in children ages 6-24 months who present with FWS in the ED. METHODS Two convenience samples of children aged 6-24 months who presented to the pediatric ED were enrolled in the study. The first sample of patients included those who presented with fever (>39oC) without a source of infection, and the second was a comparison group who presented with conditions other than FWS. In both sample populations, children’s immunization status was checked in Florida SHOTS. For those children with FWS, the treating physician documented the “pre-registry” work-up plan to be performed based on information gathered from clinical history including immunization status and physical examination. After accessing Florida SHOTS, a “post-registry” work-up plan was determined. Other data collected for both populations included age, gender, race, primary care physician, and immunization status based on immunization card if present, caregiver report, and/or Florida SHOTS. For those children with FWS, temperature and CBC and blood culture for hold was also recorded. RESULTS Ninety-seven children aged 6-24 months presented to the pediatric ED with FWS. “Pre-registry” work-up plans recorded by physicians indicated a screening blood draw for CBC and a blood culture (for hold) was indicated for 94% (n=91) (95% CI 89-98) of the children to screen for OB. However, after accessing Florida SHOTS, 54% (n=53) (95% CI 48-68) of the children were found to have received the primary immunization series. Emergency practitioner’s access to the registry reduced the percentage of screens for OB in children aged 6-24 months with FWS from 94% (n=91) (95% CI 89-98) to 39% (n=38) (95% CI 29-48), (p< 0.0001, S= 53.0). The Kappa statistic suggested very low agreement between “pre-registry” and “post-registry” work-up plans(κ= .08); signifying a significant change in “post registry” work-up plans after accessing Florida SHOTS. Of the 261 children aged 6-24 months who presented to the pediatric ED with conditions other than FWS, 52% (n=137)(95% CI 46-59) had documented evidence in Florida SHOTS of receiving their primary immunization series. CONCLUSION This study suggests that in the post conjugate vaccine era, EM practitioners who utilize a state online immunization registry to validate completion of the primary series of 3 Hib and 3 PCV7 vaccines are able to perform fewer blood screens for OB in children aged 6-24 months with FWS. ------------------------------------------------------------------------------

Incidence and Recognition of Elevated Triage Blood Pressure in the Pediatric Emergency Department Tracy Ricke, MD, Phyllis Hendry, MD, Colleen Kalynych, MSH, EdD, Vivek Kumar, MD, MPH, Colby Redfield, BS University of Florida COM/Jax Dept of EM OBJECTIVE To determine the incidence and recognition of elevated BP in pediatric emergency patients. METHODS A random selection of patients seen in a large academic pediatric ED over 1 year was identified for retrospective chart review. Triage and subsequent BP measurements were recorded and categorized as normal or elevated (90th, 95thor 99th percentile plus 5 mm Hg). Physician recognition and evaluation of elevated BP, training level and specialty were collected. Demographic information and possible confounding variables (weight, pain, medications, etc.) were analyzed. Exclusions included known hypertension or related conditions and those without triage BP. RESULTS Of 978 charts reviewed, 910 were included for the study (50% male, 50% female; 77% Black, 16% White, 7% other). Fiftyfour percent (487) had elevated BP (>90th percentile) with only 6 recognized by providers as abnormal. Further, 39% (189) of the 487 had a BP >99th percentile with only 2 recognized by providers. Pain and BP were not positively correlated (r= -0.155, n= 487, p= <0.01). CONCLUSION In this study, elevated BP’s (> 90th percentile) were not recognized by ED providers regardless of specialty or experience. Early recognition of elevated pediatric BP‘s offers referral opportunities for the diagnosis of hypertension and related disorders. -----------------------------------------------------------------------------ED Documentation Training In The Face Of ED Overcrowding Ben Lenhart, M.D.; Kelly Gray-Eurom, M.D.; David Caro, M.D. University of Florida COM/Jax Dept of EM OBJECTIVE To evaluate if resident education in improving coding and documentation could decrease deficiencies in documentation performance and chart completion in conjunction with decrease the length of stay delays.

EMpulse • Winter 2011 19

RESEARCHsymposium METHODS An educational presentation was given during one of the residency’s planned weekly didactic sessions. Chart documentation educational review was then initiated. Departmental billing specialists forwarded coding downgraded charts to the department’s Medical Director. A brief chart documentation educational review was then performed, which included missing documentation, what level the chart should have been billed as compared to the level of medical service provided, what level the chart was actually billed at, and what revenue loss occurred due to this downgrading. This chart documentation education review was then sent to the resident provider for reassessment and education, especially in systems based practice and practice-based learning and improvement competencies. This data has been collected for quality review and is analyzed monthly during ED operations analysis. RESULTS Data revealed that despite length of stay and overall ED patient volume being relatively consistent, the average charge per resident chart during the 5 months before and after this educational activity increased from $313.44 to $394.76. Residents seem satisfied with this educational component covering an educational aspect that is often insufficient during residency but expected after graduation. This review provides another method of training and assessment for departments whose attending physician coverage is at times stretched and detailed analysis of charts and discussion of the details of documentation from a business perspective can sometimes be difficult to perform. CONCLUSION A combination of didactic training and real-time Continuous Quality Improvement (CQI) review both improved resident physician mean charges per chart and E&M coding levels, even in the setting of extended length of stay in a crowded ED. This process provides a method of competency-based training and assessment for emergency residencies in the setting of ED overcrowding targeting an educational “hole” in the EM Model Curriculum that is currently in need of further training. In particular, it focuses on practice-based learning, systems based practice, and written communication skill competencies. -----------------------------------------------------------------------------Effect of a Rapid Response Team Utilizing Proactive Rounding In Reducing Hospital Mortality Benjamin Lenhart, MD1, Steven A. Godwin, MD1, Joseph Sabato, MD, Robert L, Wears, MD1, MS, Cynthia Gerdik, BSN2, Colleen Kalynych, M.S.H., EdD1 1University of Florida COM/Jax Dept of EM; 2Shands Jacksonville

20 EMpulse • Winter 2011

OBJECTIVE The objective of this study was to determine the effect of an RRT with a proactive component in reducing overall hospital mortality, non-ICU cardiopulmonary arrests, and unexpected ICU transfers. METHODS A prospective cohort study was performed on all adult and pediatric patients admitted to UF & Shands Jacksonville’s Clinical Center and Pavilion, who experienced a cardiopulmonary arrest, unexpected ICU transfer, or RRT consult. The pre-intervention time period was January 2006-June 30, 2007; 18-months (no Rapid Response Team implemented) and post-intervention time was 18 months (implementation of the RRT) July 1st, 2007 to March 1st, 2009. Primary outcome measures included overall hospital mortality, non-ICU cardiopulmonary arrests, and unexpected ICU transfers. Secondary measures included the number of non-ICU cardiopulmonary arrests that expired. RESULTS There were a total of 2,543 RRT activations during the 18 month period post implementation of the rapid response team with a proactive rounding component. During this timeframe, the overall hospital mortality rate decreased by 27.8% (p<0.0005). Non-ICU codes decreased from a mean of 21.3 per month to 11.6 per month (95% CI on the difference 5.6 to 13.9). And while the rate of ICU bounce-backs did not significantly change from a mean of 16.3 per month to 14.1 per month (95% CI on the difference -.95 to 5.4), the rate of non-ICU cardiopulmonary arrests that expired decreased by 66% (p<0.0005). CONCLUSION Rapid response team implementation with a proactive rounding component effectively decreased overall hospital mortality, non-ICU cardiopulmonary arrests, and survival of non-ICU cardiopulmonary arrests without significantly affecting unexpected ICU transfers. Future studies may wish to compare RRTs without proactive rounding with those RRTs with proactive rounding to further isolate the proactive rounding intervention. -----------------------------------------------------------------------------Can cell phone digital images alter neurosurgical decisions to transfer patients referred to a Level I Trauma center? Jay Ladde MD, Tim Bullard MD, Marcy Rosenberg MD, Linda Papa MD Orlando Regional Medical Center OBJECTIVE Improving triage of patients in need of neurosurgical care could optimize outcomes and resource allocation. The purpose of this

RESEARCHsymposium study is to assess if and how digital images from a cell phone can alter neurosurgical transfer decisions. METHODS This cross-sectional study was conducted at an urban Level I Trauma Center and identified all patients transferred from outside facilities with reported intracranial pathology who had accompanying imaging archived in our system from 1/1/2007 to 12/31/2007. Archived images of the transferred patients were displayed on a digital image monitor. A cell phone was used to digitally photograph 1 to 3 images of each case depending on the nature of the lesion. The cell phone images and a brief clinical history (age, gender, neuro exam, vitals) were emailed to two independent neurosurgeons (NA, NB) blinded to both the purpose of the study and to the clinical outcome of the patients. The main outcome measure was whether the image changed the decision to transfer and how the decision was altered based solely on the addition of cell phone images. RESULTS There were 88 cases that met eligibility criteria and were included in the study. The mean age of patients was 70 yrs (range 25-95) and there were 51 (58%) males, 18 (21%) were traumatic injuries. Based on clinical data alone NA would have transferred 64 (73%) patients and NB 39 (44%). After images were provided NA would have transferred 67 (76%) and NB 49 (56%). The availability of the image altered the transfer decision by NA in 25 (28%) of cases (p=0.024) and by NB in 28 (32%) (p<0.001). Using clinical data only, NA and NB agreed on their decision to transfer in 53% of cases (kappa 0.11, p=0.20). After images were provided, the level of agreement between NA and NB increased to 75% (kappa 0.47, p<0.001). CONCLUSION In this study, cell phone images had a significant impact on neurosurgical transfer decisions. Despite variations in neurosurgical practice, digital cell phone images improved the agreement among the transferring physician in their decisions to transfer. -----------------------------------------------------------------------------Ultrasound Guided Intra-Articular Analgesia in Anterior Shoulder Dislocations John Lissoway, MD, David Caro, MD, Colleen Kalynych, MSH, EdD, Vivek Kumar, MD, MPH University of Florida COM/Jax Dept of EM OBJECTIVE To determine the effectiveness of using bedside US in visualizing and injecting the glenohumeral joint with intra-articular lidocaine for analgesia in anterior shoulder dislocations.

METHODS A convenience sample of 10 patients presenting to a large academic ED with anterior shoulder dislocations was collected over six months. After radiographic confirmation of anterior shoulder dislocation, the glenohumeral joint was visualized with US and subsequently injected with lidocaine under direct visualization. Using a visual analog scale, pain scores were obtained prior to injection, 10 minutes post-injection, and following shoulder relocation. Ease of reduction and time spent between injection and discharge were also recorded. RESULTS The glenoid was visualized by US in 10/10 patients. The average pain score prior to injection was 9.2 (8-10) (10=agonizing, 0=none), post-injection 6.5 (0-10) and post-relocation 2.9(0-10). Eight physicians participated. Physicians rated the ease of administering analgesia using US at 3.7 (2-5) (1=difficult, 3=neutral, 5=very easy). Average time between the US guided lidocaine injection and discharge was 81 minutes (37-117). CONCLUSION This case series suggests US is an effective adjunct in visualizing the glenohumeral joint to guide IA injection of lidocaine prior to reduction of shoulder dislocations in the ED. Further study is needed to validate these findings. -----------------------------------------------------------------------------Can EKGs Be Transmitted Quickly and Reliably Via a Cell Phone Camera From The Field To An Emergency Department? Christine Van Dillen, MD1, Marcy Rosenberg, MD2, Jason Porter, MD3, George Ralls, MD2, Vanessa Vazquez, MD4, Andrew Parrish, Linda Papa, MD2, Salvatore Silvestri, MD2 1 University of Florida, Department of Emergency Medicine, Gainesville, Florida 2Orlando Regional Medical Center, Department of Emergency Medicine, Orlando, Florida 3Florida Hospital, Emergency Medicine, Orlando, Florida 4Johns Hopkins University and Medical Center, Emergency Medicine, Baltimore, Maryland OBJECTIVE We sought to determine the speed and reliability of cell phone transmission technology of 12-lead EKG images from an out-of-hospital location to the ED. METHODS The study setting was a large urban regional EMS system. A smartphone was used to take an image of a 12-lead EKG from an out-of-hospital location. Transmission of the EKG occurred from a site where a recent patient transport had originated. Up to

EMpulse â&#x20AC;˘ Winter 2011 21

RESEARCHsymposium two addresses were randomly selected from the 911 call log from 62 different fire station first due jurisdictions. The cell phone image was transmitted in real time from the out-ofhospital site origin to a dedicated web address at the ED, where a study investigator received the image. The study investigator calculated the success of transmission as well as the transmission time. The transmission time recording was stopped when an interpretable 12-lead was available on the web site. Descriptive and comparative statistics will be used to evaluate the data using Microsoft Excel, SAS, and STATA. RESULTS Images were obtained from 109 different 12-lead EKGs from 109 different out-of-hospital locations and transmitted to the study ED. The initial attempt transmission rate was 100%, with 100/109 (91.7%) transmitted in < 2 minutes, 7/109 (6.4%) transmitted in 2-4 minutes and 2/109 (1.8%) transmitted in > 4 minutes. The mean transmission time (+/- SD) was 1.33(+/0.54) minutes, with a range of 0.58-to-5.04 minutes. CONCLUSION In the out-of-hospital setting we evaluated, transmission of 12-lead EKG images is quick and reliable. Future studies should focus on the impact of real-time use of EKG transmission via cell phone technology. -----------------------------------------------------------------------------Does a dedicated Pediatric Trauma Center reduce Door to Operating times at a Level I Trauma Center? Renee Campbell MD, Jay Ladde MD, Kurt Weber MD Orlando Regional Medical Center OBJECTIVE We sought to identify if moving the trauma receiving area to the pediatric emergency department (ED) at a level 1 trauma center would decrease door to operating room (OR) times. METHODS This is a retrospective cohort review of all pediatric trauma victims seen between August 2006 to July 2008 at level 1 pediatric and adult trauma centers. 2 reviewers abstracted data from our institutionâ&#x20AC;&#x2122;s state-mandated trauma center database on variables including sex, age, injury severity score (ISS), hospital length of stay (LOS), and ED and OR time-points. Pediatric trauma victims, <17 years of age, who required emergent surgical intervention were included. Patients discharged home or transferred to floor were excluded. The primary outcome measure was transit time between emergency department and operating room. Students t-test and chi square analysis were used to analyze continuous variable and population means respectively.

22 EMpulse â&#x20AC;˘ Winter 2011

RESULTS 1728 cases were identified. 1455 cases were excluded for disposition home or admission to floor leaving a study population of 273 cases. Of these, 109 were admitted through the adult trauma center (August 2006-July2007) and 164 were admitted through the pediatric trauma center (August 2007-July 2008). Between these groups, the baseline characteristics of sex (male sex 65% v. 68%, p=0.89), age (8.7 vs. 7.8 years, p= 0.35), and ISS score (6.6 vs. 8.0) were not statistically different. The average transit times from the emergency department to the OR were 61 and 68 minutes, respectively (P=0.65). The average hospital LOS were 3.86 and 5.18 days, respectively (p=0.35). CONCLUSION Moving the geographical location of the pediatric trauma receiving area from the adult trauma center to the pediatric hospital did not seem to alter transit time to the OR for those trauma patients requiring emergent surgery in this study. Further studies relating to dedicated pediatric trauma receiving areas based on specific injuries and outcomes may be useful. -----------------------------------------------------------------------------Do Perceptions of Effective Distractive Driving Public Service Announcements (PSAs) Differ Between Adults and Teens? Barbara J Solomon, MD, 1Phyllis Hendry, MD, 1Colleen Kalynych, MSH, EdD, 2Pam Taylor, MSN, RN, 3Joseph J. Tepas III, MD University of Florida COM/Jax 1Dept of EM, 3Dept of Surgery; 2Shands Jacksonville 1

OBJECTIVE This study was designed to determine whether perceived effectiveness of public service announcements (PSAs) differed between teens and adults. We hypothesized that adult derived intent differs from teen perception. METHODS A committee of mostly adults evaluated six PSAs designed by high school students to address adolescent vehicular safety. High school students attending a safety exposition were also asked to rank the PSAs on an agreement Likert scale assessing interest, understandability, believability and potential effect on driving behavior. Students also graded their agreement with published driving distracters. RESULTS Of the 330 surveys collected, 201 students aged 14-19 selected at least one choice and 181 ranked-ordered more than one PSA. Teens selected PSA (#1) 34% of the time and PSA (#3) 33% of the time. Adult judges ranked PSA 3 first, and although PSA 3

RESEARCHsymposium was chosen by both groups, PSA 1 was not considered effective by the adult judges. Student age, race, grade, or gender did not produce statistically significant differences. A cohort of 186 teens responded to nationally noted driving distracters with more than 86% in agreement. Eating and applying cosmetics were additional distracters noted by students. CONCLUSION Preventative media messages should include teen stakeholder review. Components of effective adolescent safety messages continue to require further study. -----------------------------------------------------------------------------MRSA prevalence in EMS Transport Vehicles Rachel Semmons, Jessica S. Whittle, Josef G. Thundiyil, Salvatore Silvestri, George Ralls, Leela Sirotkin, Rebecca Blue, Jay Ladde, Kurt Weber, Philip Giordano, Orlando Health, Orlando, FL Orlando Regional Medical Center, Orlando, FL OBJECTIVE This study sought to evaluate the prevalence of MRSA on various surfaces in ambulances and to compare the cleaning method and last known time of cleaning of each vehicle. METHODS This study was conducted at an urban tertiary referral level 1 trauma center emergency department which receives approximately 60 EMS transports per day. The study population consisted of a convenience sample of EMS ambulances used in transportation of patients to the facility, belonging to any of 14 regional EMS agencies. Samples were consecutively taken upon ambulance arrival to the emergency department in a single day. Samples were obtained by a researcher using a Dacron swab moisturized with sterile saline swab the steering wheels, stretcher hand rails, supplemental oxygen control knob, and the inside rear door handle of the ambulances. Swabs were plated onto BBL CHROMagar MRSA plates (Becton Dickinson) and growth was recorded at 24, 48 and 72 hours. RESULTS 25 ambulances from 6 different EMS agencies were sampled. Overall, 8% (8/100) samples were positive and 28% (7 of 25) of ambulances had at least one positive MRSA culture. One ambulance had two sites which were positive for growth. Positive cultures were obtained from the following sites: one from a steering wheel, one from stretcher railings, four from supplemental oxygen knobs, and two from the inside rear door handle. According to the EMS personnel surveyed, all of the ambulances are routinely cleaned by spraying exposed surfaces with an antibacterial solution and manually wiping surfaces dry.

The time since last cleaning was reported to be greater than eight hours for nineteen ambulances, two to eight hours for six ambulances, and none of the vehicles were cleaned within two hours prior to sampling. CONCLUSION These data suggest that EMS vehicles are contaminated with MRSA and may pose some risk for patient or personnel exposure. Further studies determining the extent of these risks and identifying optimal cleaning strategies are indicated. -----------------------------------------------------------------------------Prevalence of Methicillin Resistant Staphylococcus aureus in Prehospital Healthcare Providers Rebecca Blue, Jessica S. Whittle, Josef G. Thundiyil, Salvatore Silvestri, George Ralls, Leela Sirotkin, Jay Ladde, Kurt Weber, Philip Giordano. Orlando Regional Medical Center Orlando, FL OBJECTIVE This study sought to determine the prevalence of MRSA colonization in EMS personnel. METHODS This study was conducted at an urban tertiary referral level 1 trauma center emergency department which receives approximately 60 EMS transports per day. The study population consisted of a convenience sample of EMS personnel transporting patients to the facility, belonging to any of 14 regional EMS agencies. Subjects were consecutively enrolled on a voluntary basis upon arrival to the emergency department over a 3 day period. After receiving instructions, subjects used standard Dacron swabs to culture their nares under the supervision of a researcher. Swabs were plated onto BBL CHROMagar MRSA plates (Becton Dickinson) and growth was recorded at 24 and 48 hours. Subjects also completed a survey regarding demographic factors, occupational factors and potential risk factors for MRSA exposure. Data was evaluated using descriptive statistics and chi-squared and z-statistics to compare the MRSA prevalence rate of our sample population to previously published healthcare provider and emergency department worker prevalence rates. Further, we compared the EMS workers with positive cultures to those without to evaluate for occupational risk factors. RESULTS 100 subjects from 7 different EMS agencies were enrolled. Mean age was 31.9 years and 78% of subjects were male. Overall, 17% (95%CI 9.7-24.4%) of subjects had positive MRSA cultures. 13 cultures were positive at 24 hours, 4 were positive at 48 hours. Univariate analysis of multiple potential risk factors was performed. None of the variables including

EMpulse â&#x20AC;˘ Winter 2011 23

RESEARCHsymposium gender, transport type (interfacility v. emergency response), hours worked per week, frequency of patient contact, history of previously drained abscess, EMS agency, level of training, and showering at the workplace were significantly associated with MRSA colonization. CONCLUSION This is the largest study to date to assess the prevalence of MRSA in EMS personnel. In this study, the MRSA prevalence in EMS personnel, 17%, is comparable to that of ED personnel (16%) and higher than that seen in the general population (1%). These data suggest that EMS personnel share a similar occupational risk for MRSA colonization as other healthcare providers. -----------------------------------------------------------------------------The Evaluation of A Telemedicine Model in Acute Wound Management: Initial Phase of an Alternate Medical Treatment Site Disaster Plan Marisa Haney, MD; Christine Can Dillen, MD; Salvatore Silvestri, MD; George Ralls, MD; Christian Zuver, MD; Dave Freeman, EMT-4; Linda Papa, MD Departments of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida; The University of Florida College of Medicine, Gainesville, FL; The University of Wisconsin, Madison, WI; The Office of the Medical Director, Orange County EMS, Orlando, FL OBJECTIVE We assessed the feasibility of evaluating acute wounds via a live web-based video by comparing wound characteristics and management of video images to an actual bedside evaluation. METHODS This prospective observational study was conducted in the ED of an urban Level I trauma center. Adult patients with acute wounds of various severities to the face, trunk and/or extremities presenting to the ED within 24 hours of injury were enrolled. Research assistants transmitted web-based teleconferenced images of the wound to the attending or senior EM resident prior to performing their bedside assessment using 2 laptop computers. The evaluating physician completed a standard wound assessment data form of the video image and at bedside. The primary outcome measure was the correlation between the video and bedside evaluations as assessed by contingency coefficients, and Kendall’s tau. RESULTS There were 173 wounds evaluated; 57% on extremities, 27% on face, 10% on scalp, and 7% on trunk. Patients were mean age 42 (SD20) years, 84% male and mean time to presentation was 3.1 (SD3.4) hours. Mechanism of injury: 40% cut by an object, 20%

24 EMpulse • Winter 2011

falls, 15% MVC, 6% pedestrian struck, 6% assaults, 5% direct blows, 4% motorcycles, and 4% gunshots. The correlation coefficient between video and bedside assessments was 0.96 for wound length, 0.85 for depth, 0.99 for location, 0.82 for degree of bleeding, 0.82 for shape, 0.90 for contamination, 0.77 for vascular compromise, 0.89 for neurologic compromise 0.89, and 0.72 for tendon injury (p<0.001 for each). For management decisions: need for closure was 0.83, for suture material 0.81, for closure method 0.74, for anesthetic 0.80, and for irrigation 0.82 (p<0.001 for each). Management of the wound would have been the same in 94.2% of cases. CONCLUSION Based on these data, wound characteristics and management decisions appear to correlate well between video and bedside evaluations. These results have implications in disaster management. -----------------------------------------------------------------------------EMTALA Knowledge Among Emergency and Medicine Residents: A Need to Become Educated! Alexander J. Scumpia DO, MSc, Jennifer A. Fernandez DO, Jerry Cajina DO, Beth Longenecker DO, David A. Farcy MD Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, FL 33140 OBJECTIVE This study looked at emergency medicine (EM) residents and internal medicine (IM) residents at one community teaching hospital to assess their knowledge of EMTALA, and to determine if there is a need for the implementation of specific core lectures about EMTALA to all house staff. METHODS A multiple choice test of 15 questions was given to a convenient sample of residents at a private, Trauma Level II community teaching hospital of 955 beds. The study asked if the resident had any previous formal EMTALA training or lecture. IRB approval was obtained for this study. RESULTS All questionnaires were collected and scored to compare pre versus post-test results. There are 27 EM residents and 40 IM residents at the tested institution. On the day that the tests were administered, 22 pre-tests and 17 post-tests were completed by EM residents. Additionally, 12 pretests and 10 post-tests were also completed by IM residents. The average score for the EM residents’ EMTALA knowledge pre-test was 60%. In contrast, the IM residents achieved a 49% pre-test score. As expected, we saw a significant improvement in post-test scores after the lecture. The EM residents’ average post-test was 86%, and the

RESEARCHsymposium IM residents’ average post-test was 82%. The study additionally revealed that 66% of IM residents had no previous knowledge of EMTALA, whereas only 32% of ER residents identified the same. CONCLUSION This study showed limited awareness and knowledge regarding EMTALA. EMTALA training should be integrated into the educational program of all residencies. The incorporation of this training will help to spread awareness of the law, reduce patient morbidity/ mortality, reduce potential for future liability and help the relationship between emergency physicians and their specialty consultants. -----------------------------------------------------------------------------Does Rib Raising Increase Peak Flow in Healthy Volunteers?

CONCLUSION This study demonstrates that rib raising produced a clinical effect greater than could be expected by chance. While there was no significant change in peak flow among the control arm, 39 patients receiving rib raising had statistically significant changes in peak flow. Interestingly, 59% had an increase in peak flow while 41% had a worsening of peak flow. Explanations for this dichotomy may have been: 1) The use of EMS and day laborers as test subjects. These subjects may have been in an enhanced sympathetic state prior to enrollment do to the nature of their work. 2) Possible variance in technique between the 2 osteopathic physicians conducting the rib raising. While this study does show impressive statistics it is necessary to further this research and reach out to larger sample sizes and closer monitoring of the patients pre and post treatment to further explain the dichotomy of these results.

Michael Devarona, DO; Mija Vail, DO; Jenny Zagaria, DO, Gabriel Suciu, M.S.P.H., Ph.D., Beth Longenecker, DO Mount Sinai Medical Center Miami Beach, FL OBJECTIVE To clarify the effect of rib raising on pulmonary function as determined by peak flow measurements. METHODS This study was a blinded two-arm randomized trial approved by the IRB. It was conducted in a single institution at Mount Sinai Medical Center in Miami Beach, Florida in May 2010. The study included 80 healthy volunteers between the ages of 20 and 65. The volunteers were randomized into one of two treatment arms: true rib raising and a sham rib raising technique in a 1:1 ratio. The primary endpoint was the percent of mean change in peak flow between pre and post intervention. The average of 3 pre and 3 post-treatment peak flows were recorded for each volunteer. The data was collected and then analyzed. We used parametric paired t-test when the normality conditions were not violated or nonparametric tests for the paired comparisons when the normality conditions were violated. Other comparisons were based on the same rule of normality versus non-normality, established from the Shapiro-Wilk’s test. All comparisons were two-sided with a maximum error level of 0.05. RESULTS There were 81 patients enrolled in the study, with one disqualified due to age. There was no statistically significant change in peak flow in the control group. 59% of the patients in treatment A had an increase of 4.8% in their peak flow measurements with a p-value of less than .0001. 41% of patients in Treatment group A had a statistically significant worsening of their peak flow measurements post rib raising. The decrease was 7.7% with a p-value of .0001.

FLORIDA PARTNERSHIP OPPORTUNITIES Coastal North Florida to Panhandle Control your financial future with Titan's productivity based compensation! Titan Emergency Group is an equity based group owned and operated by our physician members, managed on principles of equality and democracy for over 20 years. Titan is currently seeking top quality BE/BC Emergency Medicine residency trained physicians to staff Florida facilities, all within minutes of the coast and local attractions. ED volumes ranging between 31,000-75,000 visits annually. Partner from day one, excellent compensation including productivity bonuses, health 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.

EMpulse • Winter 2011 25

POLITICALfeature

The Campaign to Elect Jason Wilson

During each clinical shift, I repeat the phrase: “Hi, I’m Dr. Wilson. What brings you to the emergency department today?” I pose this question at least twenty times a day. In return, I expect an answer about a fever, belly pain, chest pain, vomiting, back pain, bleeding, or something else from a myriad list of common complaints. In reality though, this is a loaded question. The reason a specific patient shows up to the ED can only be understood by placing that patient in a broader healthcare system context that leaves us managing all types of medical problems 24 hours a day. Problems exist when there is nowhere else for a patient to go or no other physician available. In addition, the way in which we manage our patients is partially dictated by our clinical experiences, evidence, and training. And don’t forget to couple these factors with funding issues, fear of litigation, a lack of follow-up, and an absence of access to the already confusing healthcare system. We want to do what is right for our patients, and we strive to give each person the best care. However, we also complain about the increasing difficulty to make autonomous decisions in the interest of our patients because of external factors supposedly beyond our control. At the end of the day, many physicians go home frustrated and too tired to advocate for change. Many return the next day only to complain that lawyers and politicians are ruining medicine.

26 EMpulse • Winter 2011

With this in mind, I have decided that this approach is not fully acceptable. In order to best care for our patients, we must have a conversation on the healthcare system that dictates why patients show up in our department, why they have no primary care physician, why they wait until they are very sick to seek treatment, and why we feel it is necessary to order studies defensively, fearing the very patient we try to help. I want to serve our patients past the bedside and beyond the hospital walls. I want to build a community of ownership for our department, for our specialty, and for all physicians. We can be a part of something in medicine and in our community that is bigger than our shift and bigger than ourselves. I am entering a world outside of my formal training in order to bring our patients’ voices to the political conversations regarding health care, the economy, high unemployment, and the future of my city – because all of those things dictate the ED census, the patients I see, and the types of chief complaints that show up on the tracker. I take care of people from all walks of life, from every area of the city, while they are at their worst. As the medical safety net for the community, an ED physician is the natural advocate for all constituents. We are also the natural advocates for the house of medicine within society at large -- as we interact with every physician specialty as well as nursing and ancillary support.

What we do matters! We need to voice that to the world by speaking up for the marginalized patients we care for every day. We need to also speak for the colleagues who are busy slinging charts in the pit and those who are doing their best for their patients from shift to shift. It may not benefit you directly today if I am elected to a City Council seat. My advocacy will, however, benefit a patient. And in the future, your investment in me will make a difference – imagine having an emergency physician represent you at the city level, or perhaps the state level? How about in the U.S. House or Senate? I might be Apple stock before iPod, and now is the time to buy. We are going to need your help to run against a political machine that is well funded and highly polished. I will need your advocacy in order to advocate for your patients, for you, and for protecting the privilege of practicing medicine. When you finish this article, take the time to get involved with our campaign for the Tampa City Council Citywide District 3 seat or get involved in a race yourself – but please, do not think that physicians can continue ignoring the politics that dictate so much of our profession. To learn more about the Campaign to Elect Jason Wilson to Tampa City Council, visit www.voteforwilson.org Follow us on Twitter @voteforwilson and on Facebook.

CLINICALcase

A Young African American Man with Respiratory Distress CPC Chair: Fred Epstein, MD, FACEP Case Presenter: Scott Sterling, Kelly O’Keefe, University of South Florida Challenger: Courtney Dobleman, Sal Silvestri, ORMC A 27 year old African American male presented to Tampa General Hospital Emergency Department with shortness of breath, fever, a productive cough and abdominal pain. The patient had a past medical history for systemic Lupus, renal failure, and respiratory failure and was brought in by ambulance from a skilled nursing facility. Per the nursing staff at the outside facility the patient had a two day history of productive cough, fevers up to 103 degrees F and was “not acting like himself.” There was a history of several prior admissions to the ICU for respiratory failure. On exam the patient was tachycardic at 136, mildly hypertensive at 145/87, and febrile at 39.3○C. He was in severe respiratory distress with O2 saturations of 84%RA and was breathing at 42 bpm. He was using his accessory muscles to breathe and had a

28 EMpulse • Winter 2011

tracheostomy and G-tube present. The remainder of the lung exam demonstrated rales along the entire right side and scant rales on the left side. Cardiovascular exam demonstrated a sinus tachycardia with no murmurs and no JVD. The patient was diffusely tender in his abdomen with active bowel sounds. The patient was able to follow commands. No focal neurological deficit was demonstrated. The patient’s extremities were soft, symmetric, and non tender and there was no rash noted. The patient was immediately placed on a non-rebreather mask with a flow rate of 15L/min. Pan cultures were obtained prior to starting Vancomycin and Piperacillin/Tazobactam. Lab work showed a white cell count of 17,000 with 11% bands, creatinine of 3.3 mg/dL (baseline was 2.1), and a lactic acid of 1.2mmol/L.

CLINICALcase ECG showed sinus tachycardia.

Discussion

CT abdomen/pelvis showed ascites and a CXR showed diffuse infiltrates worse on the right side. Unfortunately at this point, the patient developed frank hemoptysis and desaturated to 55% while still on the 15L non-rebreather mask. The patient was immediately connected to a bag mask ventilation system via his tracheostomy tube.

DAH has many causes which range from autoimmune (Goodpasture’s Syndrome, SLE) to infectious to iatrogenic (Coumadin). The diagnosis is often only made through bronchoscopy and bronchoalveolar lavage in which continued hemorrhage is present after lavage. However, a CXR and a strong clinical suspicion can lead the astute clinician to suspect DAH without bronchoscopy. Steroids and supportive airway/respiratory management are first line treatments. Patients with severe DAH will often require intubation and mechanical ventilation. If there is an inadequate response to steroids and supportive management, plasmapheresis should be instituted. There is limited evidence supporting the use of plasmapheresis in DAH, 1,2 however it may be a life saving procedure in severe refractory DAH.3

Immediate consultation was placed to the MICU team. The MICU team agreed to an immediate bronchoscopy given the patient’s deteriorating condition. Bronchoscopy showed diffuse alveolar hemorrhage (DAH) greater on the right lung than the left. High dose pulse steroids were started (500mg IV of methylprednisolone). Given the patient’s prior history of DAH, prior lack of response to steroids and grave clinical situation plasmapheresis was performed. Four hours post plasmapheresis, the patient was saturating 97% on 2LNC. Pulse steroids, antibiotics and plasmapheresis were continued in the MICU. The patient was discharged in good condition on day five.

1. 2. 3.

Goldman: Cecil Medicine. Approach to Medicine. Saunders. Chicago, 2007 23rd Edition. Mason: Murray & Nadel's Textbook of Respiratory Medicine, McGraw-Hill. 4th ed. 2007 Picard C etal. Diffuse alveolar hemorrhage in the immunocompetent host: diagnostic and therapeutic management. Presse Med. 2009 Sep;38(9):1343-52. Epub 2009 May 15.

Excellence in Emergency Medical Care

11th annual symposium on emergency medicine and acute care, standards of care 2011. Enjoy Orlando This Spring! April 18-21, 2011 Rosen Shingle Creek Hotel Orlando, FL Sponsors: Florida Hospital and Florida Emergency Physicians This four-day intense course will provide you with a unique opportunity to learn State of the Art Diagnostic and Clinical Information from faculty representing major academic medical centers located throughout the U.S. Faculty has been personally chosen for their ability to practice the “Art of Medicine” and who specialize in patient care and use of clinical evidence.

Fee: $695.00 Early bird fee $645.00 before March 1, 2011 To register or to request a brochure, please contact: (407) 875-0555 www.floridaep.net Rosen Shingle Creek Hotel Excellent room rate: $122.00 per room, per night! Reserve before March 4, 2010 (407) 996-9840

POISONcontrol

Methamphetamine: Unintended Consequences Patrick Aaronson Pharm.D. Emergency Medicine Pharmacist, Shands-Jacksonville

Methamphetamine (“ice”, “crystal”, “meth”, “crank”, “tina”, “speed”) is a synthetic central nervous system (CNS) stimulant with a high potential for abuse and addiction. Geographically, Florida has an estimated 0.4% of the total population reporting methamphetamine use compared to 2% (Nevada) and 0.06% (Connecticut).1 Pseudoephedrine (PSE) or ephedrine found in over-the-counter (OTC) common cold medications (i.e. Sudafed®) is the main precursor ingredient that is sought after for the production of meth. The removal of one oxygen molecule (benzylic beta hydroxyl group) is all that separates PSE from meth. According to 2008 System to Retrieve Information from Drug Evidence (STRIDE) data, the price per gram of meth is $238.00 (purity of 52%).2 The raw materials are inexpensive; $100.00 spent at a pharmacy or hardware store can buy ingredients for an ounce (30 grams) of meth worth up to $7,000. The production of meth has a negative impact on the environment, in addition to the human exposure to various hazardous waste chemicals. Since 1996, Federal regulations have attempted to restrict the procurement of PSE and major ingredients involved in the production of meth (i.e. iodine, red phosphorous, hydrochloric gas); however, this seems to be the catalyst for creative meth precursor acquisition, manufacture methodology, and trafficking changes.3 30 EMpulse • Winter 2011

Impact on the ED In 2009, there were 81 cases of methamphetamine-related deaths in Florida compared to 114 in 2008.4 Methamphetamine-related emergency department (MRED) visits is ranked fourth nationally behind cocaine, marijuana, and heroin of all illicit drug visits seen in the ED.5 MRED accounts for 2.4% (50% patients have no insurance) of all visits seen in a Pacific Northwest ED for approximately $130,000 per week in total hospital charges. The major methamphetamine associated medical conditions described are mental health (18.7%), trauma (18.4%), skin infections (11.1%), and dental diagnosis (9.6%).6 MRED can present in the ED as an acute sympathomimetic toxidrome (i.e., hypertension, tachycardia, hyperthermia, rhabdomyolysis, agitation, and seizures), trauma, suicide, psychosis, skin infections, acute coronary syndrome, skin burns from chemical exposure during production, intracranial hemorrhage, cerebrovascular accident, and withdrawal symptoms.6 Unique visual clues of a chronic methamphetamine user may include: dental decay (selective to the anterior maxillary teeth due to xerostomia, vasospasm, and poor dental hygiene), skin picking marks (formication), bruxisim and repetitive movements.6 State and Federal Legislation The Combat Methamphetamine Epidemic Act (CMEA) of 2005 is a federal regulation that limits the amount of OTC meth-

amphetamine precursor sales (ephedrine, PSE) to 3.6 grams per day or 9 grams (7.5 grams mail-order) in a 30-day period.7 CMEA also requires retail sellers to place the products behind the counter or in locked cabinets and check the purchaser’s identity and maintain a log of each sale. In addition to CMEA, the Florida Legislature passed Senate Bill 1050 in 2010 to control the sale of PSE and ephedrine in with mandatory enforcement beginning January 2011. This bill will require Florida retailers to electronically submit purchaser transaction into a statewide database; National Precursor Log Exchange (NPLEx).8 The federal law was successful in reducing the number of clandestine methamphetamine laboratories in the State of Florida; 337 in 2005 to 125 in 2008.9 In contrast, large amounts of precursor chemicals are now obtained by engaging in numerous small transactions below legal thresholds to avoid triggering reporting mechanisms (smurfing). In fact, when Oklahoma implemented their electronic monitoring system, smurfing and meth lab incidents increased. This unintended consequence gave rise to massive numbers of smurfers and multiple fake IDs to circumvent reporting mechanisms.10 Trafficking Changes Historically, the major source of methamphetamine was transported into Florida from Mexican drug trafficking conduits. However, this has decreased now that Mexico prohibits importation and bans the

POISONcontrol use of PSE all together.2 Due to the recent U.S. and Mexican legislation changes, reports of smurfing large-scale PSE in the southwest is now stabilizing supply to laboratories in the Southeast region.2 Thus, a recent trend of highly pure crystal meth from Atlanta into Northern Florida destined for South Florida’s club scene has seen a significant increase.9 Manufacturing Changes Drug Enforcement Association (DEA) estimates over 300 ways to manufacture meth.11 However, a handful are used regularly. Methamphetamine street “cooks” learn synthetic procedures through underground sources and the Internet. Poor synthesis technique, facilities, chemical ignorance can lead to potentially toxic by-products. Prior to recent legislation, several methods of production were able to provide large amounts of methamphetamine. These included Phenyl-2-propanone (P2P) Method, Red Phosphorus / Matchbook Method, and the Nazi /Birch Method.12 These methods are burdensome and involve heating the mixture yielding toxic fumes. The following recent manufacturing methods have emerged: One Pot Method, Shake-and-bake: Surfaced in the late 2007 allows the drug to be made quickly frequently such as inside cars. Primary chemicals include: PSE, anhydrous ammonia (fertilizer) or ammonium nitrate (cold compress), and lithium (batteries). Methamphetamine is accomplished by pouring all ingredients into a 2-liter soda bottles and in as little as 30 minutes have small amount of meth. Law enforcement officials are finding the left over ingredients containers on the roadside creating an environment and health hazard. Although this method is quick and produces little in the way of noxious odors, a flash fire can occur when the lithium is introduced. As a result, the container needs to be “burped” on a regular basis; otherwise, the container may fail, exposing the ingredients to the air. In addition to flying metal, the lithium in the air presents a further explosive danger. 12-13

Electro-organic Production: Application of direct current (DC) charge through an electrolyte containing the precursors to produce the drug from electromechanical drug synthesis. In this process, palladium or platinum has a DC current passed through it to produce hydrogen at the surface of the cathode, which is then used to convert ephedrine or PSE to methamphetamine.13 Fish Tank, Cold Cook Method: Growing methamphetamine crystals on strings (string dope). Primary chemicals include: PSE, red phosphorous (matches),

activated charcoal, gun bluing (selenious acid, copper nitrate), and aluminum shavings. Ingredients are mixed and layered in a container (fish tank or five gallon bucket), buried in the ground or kept dark for up to 28 days until crystals grow on strings suspended above the chemical solution.14 Crime lab chemists and the DEA are reporting this method as an “urban legend” as the chemical resulting from this method does not appear to be methamphetamine. However, individuals report that they are using this drug and integrated this into drug networks. There is a growing concerning for problematic

Toxicity of Common Chemicals Involved in Methamphetamine Production Highly Toxic: may result in rapid progression of symptoms from respiratory failure, coma, and death. Sodium / Potassium Cyanide Solid Skin, Eyes, Ingestion Hydrogen Cyanide Gas / Liquid Skin, Eyes, Ingestion Vapor of volatile corrosives: irritation to mucus membranes, pulmonary edema, headache, dizziness, nausea, and anxiety Anhydrous ammonia (dermal Agrochemical Gas Skin, Eyes, burns) sources Inhalation Hydriodic Acid Mineral Acids + Liquid Skin, Eyes, Iodine crystals Inhalation Hydrogen Chloride Gas Sulfuric Acid + Gas Skin, Eyes, NACL (table salt) Inhalation Kerosene (flammable) Liquid Skin, Eyes, Inhalation Gasoline (flammable) Liquid Skin, Eyes, Inhalation Methylamine (flammable) Pesticides Gas, Liquid, Skin, Eyes, Solid Inhalation Low concentrations: irritation of mucus membranes High concentrations: loss of consciousness Acetone (flammable) Paint Thinners Liquid Skin, Eyes, Inhalation Benzene (flammable, Paint Strippers Liquid Skin, Eyes, carcinogen) Inhalation Ethyl Ether (explosive) Engine Starter Liquid Skin, Eyes, Inhalation Isopropanol (flammable) Liquid Skin, Eyes, Inhalation Methanol (flammable, vision Gasoline Additive Liquid Skin, Eyes, damage) Inhalation Trichloroethane (flammable) Gun Scrubber Liquid Skin, Eyes, (degreasing agent) Inhalation Toluene (flammable, acute renal Brake Cleaner Liquid Skin, Eyes, necrosis) Inhalation Metal Salts: minimal potential for exposure, may be corrosive in the presence of moisture Red Phosphorous (explosive) Matches, Road Solid Skin, Eyes Flairs Iodine Veterinary sources Solid Skin, Eyes Mercuric Chloride (corrosive) Dry Cell Batteries Solid Skin, Eyes Lead acetate (CNS, peripheral Hair dyes Solid Skin, Eyes nerves, kidneys, and hematopoietic toxicity)

EMpulse • Winter 2011 31

POISONcontrol toxic and health effects that should be further investigated.2 Hazardous by-products Various stages of methamphetamine production have a significant risk of explosion and/or fire. Some of the chemicals used to produce methamphetamine have independent toxicity (Table 1).15 Every pound of meth produced can yield up to five pounds in toxic waste. The cost of cleaning up methamphetamine labs has been dropped dramatically, due to improved technology and support from the DEA. DEA estimates that the average direct cost to clean up a lab several years ago was about $17,000, but is now $2,000 to $3,000 per lab.16 If one should encounter or suspect hazardous chemicals associated with methamphetamine manufacture, the law enforcement or DEA9 should be contacted. The Florida Poison Information Center is available to assist with clinical guidance in the event there is a human exposure (1-800-222-1222). References

6. Hendrickson RG, Cloutier R, McConnell KJ. Methamphetamine-related emergency department utilization and cost. Acad Emerg Med 2008; 15:23-31 7. FR Doc 06-8194 [Federal Register: September 26, 2006 (Volume 71, Number 186)] [Rules and Regulations] [Page 56008-56027] From the Federal Register Online via GPO Access [wais.access.gpo.gov] [DOCID:fr26se06-8] Available at: http://www.deadiversion.usdoj.gov/fed_regs/rules/ 2006/fr0926.htm. Accessed October 2,2010 8. Florida Department of Law Enforcement: Florida methamphetamine precursor electronic monitoring system. Available at: http://www.fdle.state.fl.us/Content/getdoc/cf5f675 9-df71-43f5-8cf9-2ea8f20847dc/methlaw.aspx. Accessed October 2, 2010 9. U.S. Drug Enforcement Association: Florida 2008. January 2008 Available at: http://www.justice.gov/dea/pubs/state_factsheets/f lorida.html Accessed October 2, 2010 10. Pray S. Pseudoephedrine: stricter controls in the future? U.S. Pharmacist 2010;35(1): 17-19 11. DEA (Drug Enforcement Administration). 1998. NNIC Report on the supply of illicit drugs to the United States. http://www.usdoj.gov/dea/pubs/intel/nicc97.htm

1. National Survey on Drug Use and Health: State estimates of past year methamphetamine use for 2002 – 2005. December 2008 Available at: http://oas.samhsa.gov/2k6/state Meth/stateMeth.htm. Accessed October 2, 2010

12. National Drug Intelligence Center Pennsylvania drug threat assessment: Methamphetamine. June 2001. Available at: http://www.justice.gov/ndic/pubs0/670/meth.htm. Accessed September 30, 2010.

2. National Drug Intelligence Center: Methamphetamine. http://www.justice.gov/dea/ concern/18862/ndic_2009.pdf Accessed October 2, 2010.

13. Fire Engineering: Firefighting in clandestine drug labs. June, 2008. Available at: http://www.fireengineering.com/index/articles/dis play.articles.fire-engineering.volume-161.issue-6.f eatures.firefighting-in-clandestine-drug-labs.html. Accessed October 3, 2010

3. Gahlinger P. Amphetamines. In: Gahlinger P. Illegal drugs: a complete guide to their history, chemistry, use, and abuse. New York: Penguin; 2004: 203-221 4. Florida Department of Law Enforcement: 2009 Medical Examiners Commission Drug Report. June 2010 Available at: http://www.fdle.state.fl.us/Content/getdoc/742e21 62-c1de-4ecd-bce4-857a32c6f42e/2009Drug-Report.aspx. Accessed October 2, 2010 5. Drug Abuse Warning Network: National estimates, drug –related emergency department visits for 2004 – 2008. December 2009 Available at: https://dawninfo.samhsa.gov/ data/default.asp?met=All. Accessed October 2, 2010

32 EMpulse • Winter 2011

14. Boeri M, Gibson D, Harbry L. Cold cook methods: An ethnographic exploration on the myths of methamphetamine production and policy implications. Int J Drug Policy 2009;20:438-443 15. Drug Enforcement Administration: Guidelines for law enforcement for the cleanup of clandestine drug laboratories. 2005 http://www.stopmethinflorida.org/documents/redb ook.pdf. Accessed October 2, 2010 16. U.S. Drug Enforcement Association: Environmental impacts of methamphetamine. March 2010 Available at: http://www.justice.gov/dea/concern/meth_environ ment.html. Accessed September 30, 2010

Tripp Contracting Corporation State of Florida Licensed General Contractor for 25 Years Lic. # CGC 038777 Specializing in Interior Build Out, Home and Office Remodeling, Renovations and Additions. References available. No Job Too Large or Too Small Phone 407-467-8108 Email Carlisst@earthlink.net

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

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

Free for all FCEP Members!!

50% off all ACEP Members!!

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

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

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

Conference Date & Location

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

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

More Information

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

www.orleansonline.com

A Night with Orleans - Saturday Evening Private Concert

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

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

RESIDENCYmatters

University of Florida, Gainesville David Nguyen, DO

Florida Hospital Vu Nguyen, MD

University of South Florida Jason W. Wilson, MD

Greetings from Gainesville!

Greetings from Florida Hospital!

November 1, 2010 marked the one year anniversary of our new Emergency Department. During this past year, we have seen a record number of patients. As we have grown more comfortable in our new surroundings, we have turned our department into a fine-tuned, efficient machine. Although there is always room for improvement, the new space has truly enhanced our ability to provide quality patient care.

It is hard to believe how much time has elapsed since our last update and we are in the middle of the Holiday Season. This means more pleasant ER patients of the season.

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

The fall season also kicked off another year for resident applicants. In preparation for the interview season, we revamped our website which now includes a resident perspective video as well as a video tour of our Emergency Department. This has also been a record year of the number of applicants applying to our program. A total of 797 medical students applied to our program. This year, we are interviewing 134 for our 8 slots. We are all very excited to meet all of these potential members of our Gator family! In other news, attendings Dr. Marchick and Dr. Challapalli recently welcomed new additions to their families. Good luck to both of these first-time parents! Also, attending Drs. Van Dillen and Flach were recently engaged, while Dr. Nealon, one of our senior residents, got married in October. Congratulations to all! Go Gators!

34 EMpulse • Winter 2011

Recently, Florida Hospital proudly hosted a historic event: an assembly of all living Surgeon Generals, past and current. It was indeed a meeting of great minds and the FHEM Residency was fortunate to be a part of it. The speakers provided much encouragement and guidance in the midst of the national atmosphere of healthcare reform. We are also very excited about the growth and maturity of our program. Foremost, we congratulate Dr. Brittany Thomas, one of our senior residents, for her recent publication in the November issue of Clinical Journal of Sports Medicine, on her work with Dr. Ryan McCorkle. In November we started the interview season and we hope our interviewees are as happy as we are about the changes we made to the interview process. Until next time, have a great start to 2011!

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

Hello from UFCOM-Jacksonville!

In October, at the ACOEP Scientific Assembly held in San Francisco, residents Michael DeVarona, Daniel Padron, Jeremy White, and Alex Scumpia, competed against 13 teams and won 3rd place in the Medical Jeopardy Tournament. Michael DeVarona also won 2nd place in the oral abstract contest for his presentation on "Does Rib Raising Increase Peak Flow in Healthy Volunteers?” The study included 80 participants, half of which underwent true rib raising manipulation while the remaining half underwent sham manipulation techniques.

Greetings from Orlando!

As 2010 comes to a close another has flown by!! Our interns are in full swing and making great progress, the second years having been taking on more of a leadership role while our seniors are preparing for life out in the real world. The annual meeting of the ACEP was held September 26-28th in Las Vegas, NV. Our Assistant Program Director, Dr. Morrissey was recognized as an outstanding academician by the ACEP Academic Affairs Committee. He was one of ten physicians who were awarded the ACEP National Faculty Teaching Award. Now the nation knows what we have already known: Dr. Morrissey is truly one of the best teachers in the country! In an attempt for a threepeat, our SimWars team led by Drs. McCann, Kirpalani, Baker and Elliot performed very well; we lost, but barely. A big congrats to one of our chief residents, Andrew Vihlen, and his wife who recently welcomed their new son Landon into the world. As we begin the New Year and continue to grow, so does our program. One of our attendings, Dr. Duran, has become our Ultrasound guru and created an excellent curriculum as well a great interactive website that has great case reports, images and review topics. Thanks to her, our residents are becoming very proficient in US.

Senior resident Marshall Frank's article, "Ectopic Glandular Breast Tissue in a Lactating Young Female: A Clinical Correlation”, was accepted by the Journal of Emergency Medicine. Congratulations to Chief Resident, Mezeda Meze, who officially became a U.S. citizen on November 10, 2010. Dr. Meze was born in Haiti and later moved to Guadeloupe before coming to the United States in 1992. Congratulations also to resident Cameron McDow (PGY-2) on the birth of his daughter – Hazel Aurelia McDow – born on October 28, 2010.

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 • Winter 2011 35

DOCTORSâ&#x20AC;&#x2122;lounge

Greetings from Wellington, New Zealand! Marlene Buckler, MD, FACEP

I am sitting at the waterfront overlooking Chaffer's Marina on a sunny summer's eve (down under, you know) watching people strolling and jogging by, listening to music on my iPod, reading Christopher Hitchens and sipping Chardonnay. This has to be one of the best ways to relax, appreciate life, and put things into perspective. Tomorrow morning duty calls again in the ER at Hutt Valley Hospital, but for now, absorbing the sights, tropical breezes and warm sun of Wellington's dynamic waterfront is just what the doctor ordered. A few boats are out on the harbour including one lone sailboat. The Royal Port Nicholson Yacht Club (which I joined a mere 5 days after arriving in town in late November) has been closed over the Christmas season and sailing races resume later this week. I can't wait to get back out on the water with the Kiwis who welcomed me, a novice sailor, with open arms and immediately put me to work crewing. Their friendliness and penchant for socializing at the club gives even the Canadians a run for their money. There's a casual, laid-back feeling to New Zealand. Perhaps its geographical location in the South Pacific as well as its island status has something to do with it. The beauty of its varied topography is rivaled by few other places on the planet. One can literally be alpine skiing in the morning and be basking on a beach in the afternoon on the same day. New Zealand's population of a little fewer than 4.4 million lives mostly in its major cities. Much of the country, especially on the South Island, is sparsely populated and one can drive for miles through stunning landscapes and encounter few other people. Some of the most beautiful beaches I have seen (and I live in Florida!) are in New Zealand. Ancestors of the Maori, New Zealand's indigenous people, traveled here by sea from Polynesia less than 1000 years ago. It is doubtful that the islands were inhabited by humans before that time. The first Europeans, the Dutch, arrived in 1642. They received a less-than-friendly welcome and it was 1768 before 36 EMpulse â&#x20AC;˘ Winter 2011

other Europeans ventured here. Though people of European descent represent the majority of the population, the Maori presence is everywhere, especially in Wellington, the country's capital, where the indigenous language is still spoken. The Wellington harbor is surrounded by hills with magnificent vistas. Over the years New Zealand has welcomed people of other nationalities and one can hear many different languages, especially at the Sunday morning farmers' market. The festive atmosphere, abundant and varied produce and the exceptionally good prices, along with the fact that it is a 10-minute walk from my apartment, keep me going back every week. While sitting on the waterfront this evening, I noticed a young family with a small girl of about 8 years, who was missing a leg, yet walked sprightly with the aid of crutches. A couple hours later, along came the same family heading in the opposite direction. I had been sitting near a series of large, raised wooden planks that children frequently run along, jumping from one to the next. The one-legged girl came up to those planks. I'm guessing that since she was not using a prosthetic limb she was likely a recent amputee. She exuded energy and pleasure as she jumped, tripodstyle, from one plank to the next. As she arrived where I was just clearing my belongings, she vaulted over the gap with a look of sheer delight on her face, despite her mother's admonition to be careful. "She's doing great!" I said aloud to her and her parents, as she passed. More than anything else I saw today, this one little child represented the spirit of New Zealand. If you're looking for a place to visit, that will rekindle your love of nature, recharge your batteries, and renew your trust in mankind may I humbly suggest a port-of-call in New Zealand. Cheers, Marlene Buckler, MD, FACEP

FCEP|

Florida College of Emergency Physicians

3717 South Conway Road, Orlando, FL 32812

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