EMpulse Fall 2020 by Florida College of Emergency Physicians

Official Publication of the Florida College of Emergency Physicians A Chapter of the American College of Emergency Physicians

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RESILIENT �Florida Balance Billing Out-of-Network Dispute Resolution Summary

� Don’t be Blind to the Risk of Contaminated Hand Sanitizers

Plus: Introducing Florida’s 19th emergency medicine residency program

� Point-of-Care Ultrasound in Pulmonary Embolism

Vol. 27, No. 3 | Fall 2020

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TABLE OF CONTENTS COMMITTEE REPORTS 6 FCEP President’s Message By Dr. Kristin McCabe-Kline

7 ACEP President’s Message By Dr. William Jaquis

10 Pediatric Education By Dr. Todd Wylie

11 GovernmentA‹airs By Dr. Blake Buchanan 13 Membership & Professional Development By Dr. Shayne Gue

14 Medical Economics: Florida Balance Billing Out-of-Network Dispute Summary By Dr. Daniel Brennan & Shanna Howe

15 EMS/Trauma

By Dr. Desmond Fitzpatrick

20 EMRAF President’s Message By Dr. Elizabeth Calhoun, PGY-2 32 Medical Student Council

By Dan Schaefer, MPH, MS-3

FEATURES & COLUMNS 4 Highlights from FCEP’s Annual Board Meeting By FCEP Staff

10 Daunting Diagnosis By Dr. Karen Estrine

12 Cover Story: Resilient, but not Invincible: Physician Suicide Awareness By FCEP Staff

16 Virtual SBS Recap By FCEP Staff

33 Life After Residency Recap By Rajiv Bahl, MD, MS

34 Sponsored: Hospice is a Valuable COVID-19 Resource for Overburdened EMS Professionals By Lilian Valeron

35 The Show Must Go On: Medical Education in the Face of COVID-19 in Florida

By Carmen J. Martinez, MD, MSMEd, FACEP, FAAEM & Caroline M. Molins, MD, MSMEd, FACEP, FAAEM

36 Poison Control: Don’t be Blind to the Risk of Contaminated Hand Sanitizers

FALL 2020

Volume 27, Issue 3 EMpulse Magazine is the official, quarterly publication of the Florida College of Emergency Physicians (FCEP). EDITOR-IN- Karen Estrine, DO, FACEP, FAAEM CHIEF karenestrine@hotmail.com INTERIM MANAGING Melissa Keahey EDITOR mkeahey@emlrc.org DESIGNER Samantha League, MA PUBLISHER Johnson Press of America, Inc.

800 N. Court St. Pontiac, IL 61764 jpapontiac.com

NOW ONLINE: fcep.org/empulse

By Chiemela Ubani, Pharm.D & Anthony DeGelorm, Pharm.D.

38 Sponsored: Practice Optimization Opportunities By Shanna Howe

39 Ultrasound Zoom:

By Dennis D’Urso, MD, PGY-3; edited by Leila Posaw, MD, MPH

42 Musings: Leadership in Crisis By Dr. Wayne Barry

Advertise in or Write for EMpulse NEXT DEADLINES: Dec. 4: Ad insertion orders & payment due ‘Intent to Submit an Article’ form or email due for Fall articles Dec. 14: Articles and ad designs due Jan. 8-22:

FEEDBACK REQUESTED

EMpulse Fall 2020 in mailboxes

EMpulse Print & Digital Readership Survey EMpulse Magazine is published four times a year and mailed to current FCEP members as a complimentary, member benefit. Thanks to membership growing substantially over the past decade, along with active participation from members who submit articles, EMpulse has evolved into a robust magazine and journal—but without steady advertisements, our print distribution model will not be sustainable. We are considering a few different options, such as converting EMpulse to a digital-only publication or reducing the number of print editions. Please take a moment to answer a brief survey about EMpulse and help us plan for the future. Scan the QR code above to take the survey now EMpulse Fall 2020

Scan to learn more » fcep.org/about-empulse

All advertisements in EMpulse are printed as received from advertisers. The Florida College of Emergency Physicians does not endorse any products or services unless otherwise stated. FCEP receives and distributes employment opportunities but does not review, recommend or endorse any individuals, groups or hospitals that respond to these advertisements. Opinions stated within articles are solely those of the writers and do not necessarily reflect those of the EMpulse staff, the Florida College of Emergency Physicians and our advertisers/sponsors. 3

2020-2021

BOARD OF DIRECTORS

MEMBERSHIP NEWS

Kristin McCabe-Kline, MD, FACEP, FAAEM, ACHE PRESIDENT

Sanjay Pattani, MD,

MHSA, FACEP PRESIDENT-ELECT

Highlights from FCEP’s Annual Board Meeting ByFCEPSta‹

Damian Caraballo,

MD, FACEP

VICE PRESIDENT

Elizabeth Calhoun, MD EMRAF REPRESENTATIVE

Erich Heine, DO

2021 (1ST TERM)

Aaron Wohl, MD, FACEP SECRETARY TREASURER

Jordan Celeste, MD, FACEP

2021 (2ND TERM)

Saundra Jackson, MD, FACEP 2022 (1ST TERM)

J. Adrian Tyndall, MD, MPH, FACEP

IMMEDIATE PASTPRESIDENT

Vidor Friedman, MD, FACEP ACEP BOARD

William Jaquis, MD, MSHQS, FACEP ACEP BOARD

2022 (1ST TERM)

Daniel Brennan, MD, FACEP

Jesse Glueck, MD

Shayne Gue, MD

Rajiv Bahl, MD, MBA, MS

2022 (1ST TERM)

2021 (2ND TERM)

2022 (1ST TERM)

Given the unique challenges surrounding the COVID-19 pandemic, the FCEP BOD unanimously voted to re-elect the 2019-20 officers to their respective positions. We'd like to thank the FCEP Executive Board for their leadership during this unprecedented time, and look forward to working together to accomplish this year's goals. Congratulations to our returning and newly elected Board Members:

• Todd Slesinger, MD,

Shiva Kalidindi, MD, MPH, MS(Ed.), FAAP, FACEP

Amy Kelley, MD, FACEP

2023 (1ST TERM)

2023 (2ND TERM)

FACEP, FCCM, FCCP, FAAEM • Shiva Kalidindi, MD, MPH, MS(Ed.), FAAP, FACEP • Amy Kelley, MD, FACEP • Dakota Lane, MD And a special congratulations to:

• Dr. Steve Kailes for

receiving the Martin Gottlieb Advocacy Award • Beth Brunner, MBA, CAE for receiving the William Haeck Member of the Year Award Gary Lai, DO, FACOEP

2022 (2ND TERM)

Dakota Lane, MD, FACEP 2023 (1ST TERM)

Russell Radtke, MD

2022 (2ND TERM)

Danyelle Redden, MD, MPH, FACEP

2021 (2ND TERM)

Todd Slesinger, MD, FACEP, FCCM, FCCP 2023 (2ND TERM)

RESIDENCY PROGRAM UPDATES 27 NORTH FLORIDA:

21 SOUTH FLORIDA: Florida Atlantic University By Dr. Tony Bruno, PGY-1 Mount Sinai Medical Center Dr. Stephanie Fernandez, PGY-3 Kendall Regional Medical Center Ibrahim Hasan, MD, Kristina Drake, MD & Sara Zagroba, MD, PGY-3s St. Lucie Medical Center By Shelby Guile, DO, PGY-2 Aventura Hospital Dr. Scarlet Benson Jackson Memorial Hospital Program Staff

UF Health Gainesville Dr. Christopher Purcell, PGY-3 UF Health Jacksonville By Rick Courtney, DO, PGY-2 UCF/HCA North Florida Regional Dr. Jayden Miller, PGY-2 Orange Park Medical Center Cody Russell, MD, PGY-2

29 CENTRAL FLORIDA: UCF/HCA Ocala By Dr. Caroline Smith, PGY-3; Emily Clark, MD, PGY-2 & Jean Laubinger, MD, PGY-2 UCF/HCA of Greater Orlando Dr. Amber Mirajkar, PGY-3

24 WEST FLORIDA: USF Health Dr. Mikhail Marchenko, PGY-3

Orlando Health By Gregory Black, MD, PGY-2; Brody Hingst, MD, PGY-2 & John Atiyeh, MD, PGY-3 AdventHealth East Orlando By Tyler Mills, MD, PGY-1

Brandon Regional Hospital Dr. Cecilio Padron, MD, PGY-2 Oak Hill Hospital Ryan Johnson, MD, PGY-1 & Mohammad Razzaq, DO, PGY-1 FSU at Sarasota Memorial Dr. Courtney Kirkland, PGY-2

Stay in Touch: /fcep.org @fcep @fcep_emlrc /emlrc.org @emlrc /emlrc

Newsletters: • Every Wednesday: EMNews Now delivered • Biweekly/Monthly: PEDReady PEARL delivered • Every quarter: Partner Broadcast delivered

MEMBERSHIP NEWS

A Special Announcement By Karen Estrine, DO, FACEP, FAAEM EMpulse Editor-in-Chief

Florida Emergency Medicine Foundation Board of Directors: PRESIDENT Ernest Page, MD, FACEP

With so much joy, we are thrilled to announce the birth of our daughter, Ellie Love Turesky

VICE Roxanne Sams, MS, ARNP-BC, MA PRESIDENT

Born 9/8/2020 8:58 PM 7lbs, 9 oz 20 inches long

SECRETARY- Maureen France TREASURER MEMBERS Dick Batchelor; Arthur Diskin,

MD, FACEP*; Jay Falk, MD, MCCM, FACEP*; Cliff Findeiss, MD*; James V. Hillman, MD, FACEP*; Michael Lozano, Jr., MD, FACEP*; Cory Richter, BA, NREMT-P; David Seaberg, MD, FACEP*

All our love, Karen, Derek, & Ellie

*FCEP Past-President

QUICK LINKS:

ACEP/FCEP EngagED (online community)

MyACEP Portal

Donate to FCEP’s PAC (not taxdeductible)

Donate to FEMF’s Capital Campaign (tax-deductible)

(update your address, etc.)

EMpulse Fall 2020

The Florida College of Emergency Physicians (FCEP) and Florida Emergency Medicine Foundation (FEMF) are nonprofit organizations dedicated to advancing emergency care through education and advocacy. Both are headquartered at the Emergency Medicine Learning & Resource Center (EMLRC) at 3717 S. Conway Rd., Orlando, FL 32812. 5

COMMITTEE REPORTS

FCEP President’s Message By Kristin McCabe-Kline, MD, FACEP, FAAEM, ACHE FCEP President ’19-21

Peace.

It does not mean to be in a place where there is no noise, trouble, or hard work. It means to be in the midst of those things and still be calm in your heart. -Unknown

As emergency medicine physicians, we are taught to take control. Patients come to us in need and we treat, triage, work up, and disposition them. We battle illness and injury wielding dangerous instruments and medications. We face some of our greatest professional challenges and are at the greatest risk of burnout when we experience losses of control. One of the most difficult concepts for us to embrace is the fact that most often, control is an illusion. For years, emergency physicians have had to accommodate regulatory and billing requirements, health system C-Suite agendas, electronic health records, disease states or injuries that are beyond modern medicine’s capability to treat, changes in contracts with health systems, or even politics within our own organizations. During the last six months, there have been even more circumstances beyond our control due to changes in emergency department

volumes, higher than ever before acuity levels, and politicization of COVID-19 underscored by public fear. Our resilience continues to be tested in ways we might not have ever imagined 10 years ago. However, when we take a step back, we realize that when we focus on the areas where we do not have control, we thwart the opportunity to effectuate change within our sphere of influence. My uncle, Hugh West, is an emergency physician whose career spanned nearly 50 years. When he retired from his position as a teaching attending at UCSF, he still truly loved his chosen profession. Throughout my career, I have trusted him with some of my most difficult feelings that I didn’t think I should have at the time: fear, sadness, anger, and the worst of all—shame. We have shared stories of intellectually challenging cases, amazing catches, miraculous survivals, and indescribable tragedies. We have shared the burden of suffering together in our storytelling of cases remote and recent, taking turns when one of us felt the weight of a poor outcome weighing down our soul while the other offered comfort and reassurance. One of the phrases my Uncle Hugh has used often throughout the years is one I challenge us to use now: “Change your headset.” What he has asked me to do from time to time is alter the tone and words I use in internal dialogue so that they do not reflect the paradigms of what others have told me I should feel or how I should respond. Removing the tracks playing in the background that are automatically triggered by

EMpulse Fall 2020

previous teachings has allowed me to experience my feelings as they come and be kinder to myself. The resulting experience is the ability to relate to others more authentically. Throughout our careers, we will have opportunities to support our colleagues by sharing our stories and hearing theirs. When we are vulnerable to each other, we help our colleagues heal as we, in turn, are healed. We are also far better able to embrace opportunities to offer healing to our patients when we allow them to be vulnerable to us. Emergency physicians are well positioned to meet all patients where they are and have genuine interactions that inspire hope. In my opinion, this is the heart of resilience: peace. Peace that comes from accepting our lack of control, driving change within our sphere of influence, relating authentically, and experiencing the hope derived from lives lived in service to others while allowing ourselves to be healed. ■

Peace I leave with you; my peace I give you. I do not give to you as the world gives. Do not let your hearts be troubled and do not be afraid.

-John 14:27

COMMITTEE REPORTS

ACEP President’s Message By William Jaquis, MD, FACEP ACEP President ’19-20

The years are short, but the days are long. This is my last article to FCEP as the ACEP President… and my last speech to Council is coming up soon. I have been thinking quite a bit, not only of this year, but the three decades of both being an emergency physician and the 30-year mark I recently hit as an ACEP member. If you spare me the comments on age, I will spare you the long retrospective look into my career. To begin, I would like to share an overview of one of the major events of the last few months: the Summit on Preparing for the Next Pandemic. I am humbled and gracious for the many hours of preparation ACEP staff put into this summit, and the tremendous knowledge exchange from many of our experts in emergency care. I truly believe the efforts of the dozens of people involved will serve as a blueprint for many activities in emergency medicine for years to come. To summarize, the summit’s eight sessions included discussions on: • Communications: What breaks down often in a crisis is communication. How does the information get communicated within ACEP, within our communities and from the different perspectives of the roles we serve? We need an organized plan to reach everyone who needs to know: health care systems, emergency teams and other stakeholders.

• Data and Analysis: This pandemic

has brought an unprecedented flow of information through traditional and non-traditional channels. In a very dynamic environ-

ment, the noise must be minimized to find the signals. How do we stay informed on rapidly changing standards of practice, and how can we raise awareness more quickly? We need verifiable data systems that interconnect at the local, state, regional and national levels. As an aspiration, the interconnections at an international level would allow more coordinated responses.

• Deployment and Distribution

of Physicians and Other Health Care Workers: Saturation of the workforce in highly affected communities leads to more demand than capacity and rapid burnout of the health care system. Strategies to move the workforce to the need, not only intra-specialty but inter-specialty, were necessary and can be improved.

• Disparities and Vulnerable Pop-

ulations: We have long known that health outcomes are worse in vulnerable populations and where there are disparities in access to care. Outcomes in patients with COVID have certainly shown the same trend. As with any coordinated plan for an unexpected event, we need specific plans to alert and support these populations and their caregivers.

• Information Flow: Events such as

these create different experiences in different communities based on many factors. How can and did we share that information effectively across those communities and stakeholders so that we can be better prepared? We need to develop plans that will enhance community trust.

• Research: Good discussion on

pretty much the same research

EMpulse Fall 2020

questions as any – what happened, why did it happen (and what confidence do we have that these answers are “correct”), and what do we still need to learn. We need to build these networks now in anticipation of the next event.

• Supply Chain: One of the biggest

and ongoing stories of our experience is the inability to manufacture and distribute goods that we need related to health care delivery. Understanding the supply chain helps us define the barriers and demand new solutions for emergency care.

• Workforce Support and Sustain-

ability: Physicians in general are experiencing significant burnout and depression. Especially in the context of this year, emergency physicians express an even greater level of those conditions. How can we support them starting at even the ground level of physiologic and safety needs? We need the systems that support our colleagues, reducing the barriers that currently exist which prevent them from getting the help they need.

In one of my favorite quotes, Sir Isaac Newton stated that “if I have seen a little further, it is by standing on the shoulders of giants.” My presidency began chronologically last October, but in reality it began when I started emergency medicine about 30 years ago. I often think of the growth of emergency medicine as having some very distinct periods of rapid change. The first, of course, is the pioneers who had a vision to create a better system of care in our emergency rooms. Taking risk and ridicule, they Continue on page 8 » 7

« Continued from page 7 initiated that change. The next distinct period is the initiation of the educational components and a Board to codify and memorialize those efforts. We have difficulty, even today, trying to explain what we do and the value we provide. Imagine being one of those earlier pioneers who had to develop and explain the context and the content. None of those accomplishments could have been advanced without a vision and a strategy, with enough confidence in the outcome that those barriers along the way were shoved away. We are stronger by their experiences. Our time is now. We are the shoulders that current and future generations of emergency physicians will stand on, and a sea of change is underway. All of the work initiated by these summits, let alone the other work of emergency medicine, requires the same intention. Even though we have the verbal acknowledgement, we need to change the support to execution and outcomes. Despite a pandemic and holding the care of so many communities in our hands, we still also face questions on our labor force, our wellness and our reimbursement, which affect access for our patients. As importantly if not more so, we are often an integral part of those communities where disparities are the most significant. These changes will require us to do what those before us have done: find a shared vision, have a strategy, and shove away the barriers that prevent us from doing so. I will close with a quote, and by telling you that you are more important than you think. Thank you for all that you do. ■

Without realizing it, we fill important places in each other’s lives. It’s that way with the guy at the corner grocery, the mechanic at the local garage, the family doctor, teachers, neighbors, coworkers. Good people who are always “there,” who can be relied upon in small, important ways. People who teach us, bless us, encourage us, support us, uplift us in the dailiness of life. We never tell them. I don’t know why, but we don’t. And, of course, we fill that role ourselves. There are those who depend on us, watch us, learn from us, take from us. And we never know. You may never have proof of your importance, but you are more important than you think. There are always those who couldn’t do without you. The rub is that you don’t always know who. ― Robert Fulghum, All I Really Need to Know I Learned in Kindergarten 8

THANK YOU, PAC DONORS The success of FCEP’s advocacy efforts is dependent upon our ability to fund those efforts. Generous donations to our political action committees (PACs) are always needed and greatly appreciated. Thank you to those who donated in March-June 2020: Christopher Adams Nadia Ashlee Adside Timothy Bruce Allison Olyn A Andrade Brooke Aileen Arrington Mark G Attlesey Corinne Ballard Spencer Elliott Barela Steven M Barrett Tyler Bean Matthew A Beattie Jeffrey D Bettinger Drew Bienvenu Nataly Blanco Michael A Borunda Mitchell Bourne Mark W Brodeur Blake Buchanan Victoria Ruth Cardieri Jordan Celeste Gianluca Cerri Ethan Adair Chapin Lawrence Chen Frederick Chu Ian Paul Ciesielski Dane E Clarke Joel Brian Collins Garret David Cudmore John Moore Day Timothy De Ocejo Alex T Doerffler Becca Dupree Robert B Fulton Zackary M Funk Tisha Gallanter Donna Gartner Jessyca Christine Gibson Gary W Gillette Courtney Grace Omar Hammad John Hammock Brian Scott Hartfelder Julie A Heger Saundra A Jackson

Steven B Kailes William Korey David Krahm Gary Lai Jon E Lamos Mark Maguire Christopher T Martin H Lynn Massingale Meghan McCallister Ryan T McKenna Alicia Nassar David A Nateman Michaela Anne O’Driscoll Jadthiel Oliva Cecilia Margarita Paez Venugopal Palani Matthew Parrish Rachel Pray Dumi Presuma Nicolas Rubel Reginald Saint-Hilaire Andrew I Schare Donna Schutzman-Bober Matthew A Schwartz Jason Sevald Brooke M Shepard Abdul-Aziz Adewale Shittou Sara Oliveira Sims John Caleist Soud Aisha Subhani Will Forrester Taber Lisa Townsend Farid N Visram Joshua A Walker Bruce S Whitman Caitlin Ann Williams Jason Wilson Fredric C Wurtzel Jennifer A Yorke Daneil Nathan Young Larry S Zaret John Zelahy Tony Zitek

DONATE NOW: Text “FCEPPC” to “41444” or EMpulse Fall 2020

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COVID-19 Patients in Your ED? Refer Them to VITAS for Hospice Care. Most patients who face the challenges of an advanced illness prefer to receive end-of-life care at home, surrounded by familiarity, comfort, and loved ones. VITAS® Healthcare provides high-acuity care to hospice-eligible COVID-19 patients in their preferred care setting: private residence, nursing home, or assisted living facility. Refer patients directly from your ED to VITAS for: • Complex modalities for patients requiring high-acuity care for COVID-19 or other comorbidities • Safety-compliant protocols for direct patient care, supported by telehealth for virtual care, education, and bereavement • Interdisciplinary care that addresses physical, emotional, and spiritual needs • Grief support for families and front-line healthcare workers Like your ED, VITAS is available 24/7/365. What determines hospice eligibility? Call 800.93.VITAS, visit VITAS.com, or download the VITAS hospice app for clinicians. SINCE 1980

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COMMITTEE REPORTS

Pediatric Committee By John Misdary, MD, FACEP Pediatric Committee Co-Chair

With everything going on regarding COVID-19, the pediatric emergency medicine committee has been trying to keep Florida’s emergency physicians up to date regarding pediatric care. We started in early April with putting together a handout with all the information we had at that time regarding the coronavirus in the pediatric population. As things developed with the coronavirus, we too had to keep the emergency medicine community updated. As a committee, we were able to put together an additional information guide in June regarding a multisystem inflammatory complex that results as a sequela of coronavirus. As a committee, we will continue to keep the emergency physicians of Florida updated regarding any further changes or any new disease processes. The pediatric emergency medicine committee has had a virtual summer. Typically, the summer months are filled with conferences and speaking engagements. This year, we had to move everything to virtual. We started with CLINCON, putting together a series of lectures and virtual simulations regarding what

to do with altered sensorium in the pediatric population. Though it was difficult moving to this format, like everything else going on, we had to move forward, adapt, and change to something that we may have to continue to do in order to reach the necessary audience. Overall, it was a success, and made us better prepared and organized for when Symposium by the Sea went virtual as well. Though we were planning on continuing with the theme of the altered sensorium, like everything else, we had a change in plans, and made it an opportunity to engage with Florida’s emergency physicians, providing more information regarding the coronavirus and pediatric population. As we move into fall, we will see what the combination of the coronavirus and influenza have in store for the pediatric population, and we will keep you abreast of any changes. Despite everything going on in the emergency medicine community with coronavirus, we have not lost sight of our mission, which was to continue to raise the level of pediatric knowledge and awareness in emergency medicine for the

Daunting Diagnosis: Q By Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief A 42-year-old unvaccinated male presents to the ED as a referral from the dental clinic. He was treated for a “right dental abscess” without resolution. The patient presents with right facial swelling and erythema. Labs and a facial CT are obtained. What is the patient’s diagnosis? Continue on page 31 »

EMpulse Fall 2020

state of Florida. Our own Dr. Shiva Kalidindi has taken it upon himself to create a committee to build a Florida-based pediatric emergency medicine curriculum. This was done to improve access to high-quality pediatric emergency medicine expertise with just-in-time learning for EM training programs across the state of Florida. They have already conducted a needs assessment that was performed by Dr. Carmen Martinez and Dr. Phyllis Hendry. It is evident that there is a need to augment the actual education across the state. Dr. Swan and Dr. Zeretzke volunteered to help conduct a more targeted needs assessment, and I will be developing an assessment tool. The plan is to develop a curriculum addressing the identified needs sometime in spring of 2021. For this upcoming year, FCEP’s own Dr. Trisha Swan will be the chairperson for the pediatric emergency committee for national ACEP. We wish her the best in this challenging position and know that she will bring continued success to this committee the same way she did in the state of Florida. ■

COMMITTEE REPORTS

Government Affairs By Blake Buchanan, MD

Government Affairs Committee Co-Chair

Unless you’ve gone on complete media blackout, you are likely aware there is an upcoming election. With early voting possibly underway by the time you are reading this, and mail-in voting ongoing, we can really think of this as an election season instead of just election day on November 3. As emergency physicians, the issues important to us and our patients transcend party lines, and no matter your political views or those of your representatives, I encourage each of you to advocate and contact your legislators regularly about the issues important to emergency medicine. We cannot expect to have an effect on the outcome by simply standing on the sidelines.

At FCEP, your political committees have been working hard to support pro-medicine candidates up and down the ballots across the state on both sides of the aisle. This next session will begin a new era of leadership in Tallahassee with the new Speaker of the House, Chris Sprowls, and a likely new Senate President, Wilton Simpson. We will also likely see a major focus on budgetary changes given the drastic changes to Florida’s economy that have occurred due to the COVID-19 pandemic. Finally, we are working to put together an “Insurance Summit” with other state-level specialty groups to highlight insurers behaving badly

and not appropriately reimbursing emergency care in the state of Florida. Multiple other medical groups have already signed on, and I encourage any of you who are having problems with insurers refusing to appropriately reimburse emergency care to reach out to us at FCEP and let us know. Remember to vote this season as we continue to advocate for promedicine candidates and educate those in power on the issues important to emergency physicians. If you are able, I encourage you to donate to the FCEP PAC so that we can continue being your unified voice throughout the state. ■

Regular Session begins

March 2, 2021

DONATE TO OUR PAC NOW: Text “FCEPPC” to “41444” or

Donate online at: fcep.org/donate

EMpulse Fall 2020

We are

resilient,

but not

invincible. Every day, an American physician commits suicide.

National Physician Suicide Awareness (NPSA) Day was September 17, 2020. This annual event serves to commemorate colleagues lost to suicide and raise awareness about mental wellness.

Ways to Create Awareness: Create a safe, supportive work environment • Sometimes the best support can come from those who know exactly what you’re going through each day.

• Sharing your story can help others feel more comfortable about sharing theirs. • Be vulnerable and be a role model for your colleagues and trainees.

Physician suicide is a tremendous issue in healthcare today: the relative risk of committing suicide is 2.27 times greater among women and 1.41 times greater among men versus the general population. Each physician suicide is a devastating loss affecting everyone— family, friends, colleagues, and up to 1 million patients per year. It is both a very personal loss and a public health crisis.

Find some time for self-care “Do you recognize your stress warnings? Take some time to learn your personal triggers, then work on ways to help reduce them. Start with a 2-minute ‘breath break’ to refocus before reengaging.” -René Mack, MD, RDMS; FCEP Membership & Professional Development Co-Chair

This year, raising awareness is more important than ever. The coronavirus pandemic has placed unprecedented strains on the health care workforce, bringing new and unforeseen concerns. And being an emergency physician carries with it a unique set of stressors that can eventually take a toll.

CORD Wellness Resources

ACEP Wellness & Assistance Program ACEP members get exclusive access to three free counseling or wellness sessions in partnership with Mines & Associates. Sessions are available 24/7 by phone, text or online messaging, or you schedule a face-to-face appointment.

Physician Suicide Podcasts & Videos EMpulse Fall 2020

Suicide During Residency Resources

Blogs & Messaging

COMMITTEE REPORTS

Membership & Professional Development By Shayne Gue, MD

MPD Committee Co-Chair

2020 has felt like the longest year of my life... but as emergency medicine physicians—and the entire world— have grappled with an array of new challenges, there have also been opportunities for creativity, innovation and wellness amidst the obvious struggles. Here at FCEP, one major challenge was continuing our various annual educational conferences, including CLINCON, Symposium by the Sea and Life After Residency. I’m happy to say that not only were we able to continue these highly-lauded programs, but in fact, they went better than anyone could have imagined! The virtual environment was not without impediment, but our dedicated staff and program planning committee members worked tirelessly to provide you with the same great education and fellowship you have come to expect! Even better, the virtual platform allows us to offer these awesome CME credits for up to one year (so register now even if you missed out on the live event for SBS, only $105 for more than 20 AMA PRA Category 1 CreditsTM)! Although we now feel better prepared to take on the next virtual challenge, we are all anxiously awaiting the time we can safely be together again.

On the membership side of things, our chapter continues to see growth thanks in large part to our emergency medicine residency training programs! Thanks to this increase in membership, Florida will be well-represented by 22 councillors during this year’s Council Meeting at the Scientific Assembly, ACEP20 Unconventional. Additionally, we are looking forward to beginning our annual residency outreach program (now in a virtual forum). If you are a part of a Florida EM residency program and are interested in scheduling a “visit” and virtual presentation, we are looking forward to the opportunity to connect with each of you! On the professional development end, we have several exciting ideas and concepts in various stages of planning. We recognize that the first few years upon graduation from residency are vital to your development as a physician and to your career longevity. We continue to promote the fantastic resources of the Young Physician Section of ACEP (included in your first year attending dues). For Florida specifically, we are thrilled to announce the creation of the Early Career Physicians section, which will be led by Dr. Dakota Lane,

EMpulse Fall 2020

and will develop a forum for career development, mentorship, fellowship and non-clinical advising. If you are a soon-to-be graduating resident or newly-minted attending and interested in learning more, please reach out! Lastly but most importantly, don’t forget to find time for YOUR wellness. Your mental and physical wellbeing are the most important factors in allowing you to provide the high-quality, patient-centered care that only emergency physicians can provide. We are discussing and implementing several ideas and programs to support you in this arduous task, but we need your help. How can FCEP assist you? Please reach out and let us know what’s important to YOU! How can we expect to care for others if we can’t take care ourselves? We want to help you in any way we can. Finally, I hope to see you all (virtually) at our next Board and Committee meetings, which are open to all FCEP members. Until then, keep up the phenomenal work as you continue to care for our most vulnerable population and provide the highest quality emergency care! ■

COMMITTEE REPORTS: MEDICAL ECONOMICS

Florida Balance Billing Out-of-Network (OON) Dispute Resolution Summary By Daniel Brennan, MD, FACEP Medical Economics Committee Co-Chair

On July 1, 2016, Florida’s HMO balance billing ban for emergency services was extended to PPO’s and EPO’s (Fla Co. 627.64194 (5)). As a result of advocacy efforts, the regulation requires that insurers must reimburse OON emergency providers at the lesser of: (1) the physician’s charges; (2) the usual and customary charge for similar services in the community where the services were provided; or (3) the mutually agreed upon charge between the physician and the insurance company (Fla Co. 641.513 (5)). This language was designed to protect emergency medicine providers from payors making the unilateral decision to pay according to the payor’s usual and customary rates or other reimbursement methodology. The Agency for Health Care Administration (AHCA) is contracted with MAXIMUS Federal Services, an independent dispute resolution organization, to provide assistance to health care providers and health plans in order to resolve claim disputes. Maximus is considered the second level appeal process, with the first level appeal being directly with the payor. Maximus has been accepting claim disputes for Florida’s managed care line of business since May 1, 2001. Historically this was not a successful dispute resolution process; however, with the amended regulation it was noted that this was a “new and improved” Maximus.

PROBLEM

When the expanded Florida Balance Billing law went into effect, most ED groups across the state immediately experienced a significant decrease in OON reimbursement, equal to 100% of Medicare, from at least one major 14

By Shanna Howe Gottlieb, LLC

payor. Because the reimbursement was not in compliance with the regulation, the appeals process began. Appealing directly with the payor was the first step and is always important as you want to show that you have done your due diligence to resolve the issue with the payor directly and allow the payor the opportunity to respond. Appeals were submitted, and the payor upheld their original decision, indicating in the written appeals response that reimbursement was in accordance with the payor’s maximum allowable rate. Aside from the payor’s reimbursement being non-compliant with the regulation, data was available to show that prior to the expansion of the law taking effect, the payor was reimbursing at an amount at least twice of the reduced reimbursement. Appeal responses and data were compiled and presented to the Office of Insurance Regulation on at least two occasions, in an attempt to resolve the matter before moving forward with Maximus, to no avail. This was now our opportunity as an emergency medicine community to test the “new and improved” dispute resolution process facilitated by Maximus. This historically has not been a very user-friendly process, being labor and time intensive on the ED provider group and revenue cycle management companies. Additionally, the Maximus process can be costly, which deters many provider groups from initiating the process. Gottlieb, LLC, a Florida-based emergency medicine revenue cycle management company and one of FCEP’s corporate sponsors, filed an initial submission on behalf of an EMpulse Fall 2020

independent ED group. Gottlieb used the initial submission as a test case of the Maximus process, submitting only the minimum required variance amount of $5,000. Gottlieb’s initial submission and the subsequent two submissions were successful, and Maximus ruled in favor of the ED group. As the non-prevailing party, the payor was ordered by AHCA to pay the ED group for the variance amount claimed, as well as the Maximus costs. These three submissions accounted for roughly an additional $55,000 in return for the ED group. While the results were favorable to the ED group, and the results showed that the Maximus process had improved, there were challenges with enforcement of the final order as illustrated below.

CHALLENGE

AHCA claims that while they issue the order, they have no ability to ensure compliance with the order. There have been instances where the plan paid out on the final order and then subsequently filed overpayment recovery notices and recouped the funds. Most recently, we received a response from the payor regarding two additional submissions. Payor has indicated that Maximus should immediately dismiss the request because the payor does not wish to participate in the process. The law indicates that the process is voluntary for both parties; however, we believe this was intended to mean that either the payor or the group can voluntarily submit a request for Maximus review, and was not intended to mean that the payor can simply decline to participate and get the case dismissed. Gottlieb, LLC is currently working with an FMA attorney to address the process gaps that currently allow for this dismissal to take place. ■

COMMITTEE REPORTS

EMS/Trauma By Desmond Fitzpatrick, MD, FACEP EMS/Trauma Committee Co-Chair

“Just do the next right thing.” While the parents or Disney fans of this group will know this purposely veiled reference, the statement is an exceedingly complex one but an important one nonetheless. 2020 has been a year of confusion and upheaval. 2020 has shown us that even knowing what the next right thing is often challenging. When it comes down to patient care, we should break it down to “if it’s good for the patient, do it; if it’s not good for the patient, don’t do it” (credit: Dr. Mitchell, ICU Indian River). Even more complicated is relating this concept to self-care and safety. The idea of “safety third” has emerged as a reminder of the self-care and protection concept. Initially coined by Mike Rowe of “Dirty Jobs” fame but adapted for EMS by Ben Abo, D.O. and his group with the Carolina Wilderness Medicine, “Safety Third” deals with the reality that “no scene is fundamentally ‘safe’ for first responders and no scene can ever truly be secure, but first responders have a duty to act, balanced by an obligation to assess relative risk.” This fact is especially true during at-risk situations such as house fires, providing care in areas of violence, or during outbreaks or a pandemic. This concept also addresses the fact that we need to plan and prepare for modifiable risks. We need to protect ourselves throughout patient care. As COVID continues to spread, let us focus not only on providing highquality patient care, but also on taking care of ourselves. We must remember to address not only our physical needs (PPE, masks, etc.), but also our mental needs. We need to identify safe outlets for decompressing and self-care. We need to reach out when help is needed and try and reach out to others in need. We cannot take care of others to our fullest if we don’t take care of ourselves. Always remember, what you do matters!

Education Committee, 3) enhance technology and resources with the Resources Committee, and 4) lead and support legislation, policy and advocacy efforts that impact EMS with the Government Affairs & Legislative Committee. State EMS Medical Director Dr. Kenneth Scheppke relayed that due to COVID, some projects are on hold, including the development of state resuscitation criteria and the resuscitation academies. There is, however, renewed interest in other projects involving EMS, including vaccine delivery. More information on prehospital vaccination efforts was recently distributed to members by Melissa Keahey (mkeahey@emlrc.org). Dr. Scheppke also discussed COVID care-related information, including interesting COVID care impacts on resuscitation, noting a trend of less shockable cases, less AED use, less public cases, and more EMS TOR in the field. He also noted the state website for COVID data related information: floridahealthcovid.gov The Region V Trauma Agency report by Dr. McPherson discussed five priority areas for Trauma Agency EMS guideline protocols: 1) pediatric trauma, 2) prehospital administration of TXA, 3) spinal immobilization, 4) geriatric TBI patients taking anticoagulation medications, and 5) COVID-19 management of severe trauma patients. Final drafts will be sent to the RDSTF-5 trauma advisory board executive committee for review. They also just completed a regional virtual tabletop disaster training on September 24, 2020. ■

Now on to the EMS/Trauma Committee update: Congratulations to Dr. Chrissy Van Dillen for being elected President of the Florida Association of EMS Medical Directors. Dr. Van Dillen has outlined four main goals of the group and created committees to address these goals, including: 1) increase active membership and engagement with the Membership Committee, 2) increase membership value through education, collaboration and partnerships with the EMpulse Fall 2020

VIRTUAL

2020

by the

Thank You Faculty Innocent Akujuboi, MD

Anti-Racism Allyship and Dialogue: Moving on from “What Can I Do?”

Brandon Allen, MD, FACEP UF GAINESVILLE

Are You Ready for High Sensitivity Troponin in Your ED?

Patty Ambrosio, DO, FAAP, FACEP ARNOLD PALMER HOSPITAL FOR CHILDREN

Pediatric Status Epilepticus Simulation

Yaritza Arriaga, MD SCP, ADVENTHEALTH

Anti-Racism Allyship and Dialogue: Moving on from “What Can I Do?”

Mitchell Barneck, MD ORLANDO HEALTH

Intubation Guidelines in Critically Ill Patients, So I Have a Great Innovation Idea, Now What?

Lauren Black, MD, MPH UF JACKSONVILLE

Septic Shock Epidemiology within the One Florida Data Trust Cohort

Ashley Booth-Norse, MD, FACEP

ADVENTHEALTH

Post ED Care of the Critical COVID patient: What happens in the ICU doesn’t always start in the ICU UF JACKSONVILLE

LLSA for Today

Mark Clark, MD, FACEP, FAAP ARNOLD PALMER HOSPITAL FOR CHILDREN

UF JACKSONVILLE

Continuous COVID Education: Latest Literature on a Novel Disease; AntiRacism Allyship and Dialogue: Moving on from “What Can I Do?”; Protest Medicine: Caring for a Cause

LLSA for Today

Shayne Gue, MD FCEP

SBS CO-CHAIR

Douglas Haus, DO, FACEP ADVENTHEALTH

Ocular Ultrasound Basics and Advanced

Arthur Diskin, MD, FACEP

Erich Heine, DO

QUALITY MEDICAL MANAGEMENT, LLC AND QUALITY MEDICAL RISK MANAGEMENT, LLC

Risk Management Pitfalls and Pearls: An Analysis of 300+ Claims

Marie Carmelle-Elie, MD, FACEP, FCCM, RDMS UF GAINESVILLE COVID-ready Communication in the Era of the Pandemic

Nicolas Erbrich, MD, FAAP NEMOURS CHILDREN’S HOSPITAL

Pediatric Rapid Fire Cases

Andrea Brault, MD, MMM, FACEP

3 Tools to Combat Burnout; EM TownHall Session Panelist

Understanding the Trajectory of Federal Legislation to Ban Surprise Medical Billing

Dakota Lane, MD

PEM Visual Diagnosis

Vidor Friedman, MD, FACEP

BRAULT

Steven Godwin, MD, FACEP

Welcome to Symposium by the Sea 2020; SBS 2020 Virtual Journey Wrap-Up

David Caro, MD

UF JACKSONVILLE

LLSA for Today

Bob Cambridge, MD

FCEP

Trivia Night: EM Style

Robyn Hoelle, MD, FACEP NORTH FLORIDA REGIONAL MEDICAL CENTER

Ed Gaines, JD, CCP ZOTEC PARTNERS, LLC,

2020 EM Reimbursement and Regulatory Updates from D.C. to Tallahassee and Beyond

Andy Little, DO ADVENTHEALTH

ENT Emergency Tips and Tricks

Tracy Macintosh, MD UCF/HCA ORLANDO

Anti-Racism Allyship and Dialogue: Moving on from “What Can I Do?”

René Mack, MD, FACEP, RDMS

Mommy, will we be OK? Talking with your Family about the Pandemic; FCEP EM Resident Panel

Self-Care for the Essential Worker

Jennifer Jackson, MD, FACEP

Carmen J. Martinez, MD, MSMEd, FACEP, FAAEM

UNIVERSITY OF MIAMI

FCEP

SBS CO-CHAIR

ADVENTHEALTH

Florida EM Resident Quick Fire Case Presentation Competition

The Show Must Go On: Medical Education in the Face of COVID

Shiva Kalidindi, MD, MPH, MS(Ed.), FAAP

Thomas Matese, Jr., DO, FACP, FACEP

NEMOURS CHILDREN’S HOSPITAL

Pediatric Track: Child with Altered Sensorium

TEAMHEALTH

GEMA

Jay Ladde, MD ORLANDO HEALTH

Metrics and Morale: How to Balance the Hospital’s Demand for Metrics with the Residents Need for Wellness

EMpulse Fall 2020

ST. LUCIE MEDICAL CENTER

Life Long Learning: The Deliberate Practice Paradigm

Kristin McCabe-Kline, MD, FACEP, FAAEM EMERGENCY MEDICINE PROFESSIONALS

Emergency Medicine Townhall Session FCEP PRESIDENT

John Misdary, MD ST. JOSEPH’S CHILDREN’S HOSPITAL

COVID Presentation in Children

Caroline Molins, MD, MS Med Ed, FACEP

Todd Slesinger, MD, FACEP, FCCM, FCCP AVENTURA HOSPITAL & MEDICAL CENTER

Critical Care Emergency Medicine for the Covid-19 patient

ADVENTHEALTH

Tricia Swan, MD, M.Ed., FAAP, FACEP

Diana Mora, MD

COVID-19 and Kids: What do I Need to Know?, Approach to Child with Altered Sensorium

The Show Must Go On: Medical Education in the Face of COVID NORTH FLORIDA REGIONAL MEDICAL CENTER

Ultrasound for the Evaluation of Pulmonary Embolism

Melissa Parsons, MD

Meredith Thompson, MD UF GAINESVILLE

Reflective Practice: “What, So What, Now What?”

Alfredo Tirado, MD, FACEP

Amit Patel, MD

Role of Point of Care Ultrasound to Optimize Care During COVID Pandemic Crisis

NEMOURS CHILDREN’S HOSPITAL

Pediatric Rapid Fire Cases

Vanessa Perez, MD, FAAP NEMOURS CHILDREN’S HOSPITAL

Pediatric Rapid Fire Cases

Joyce Perfetti, D.O. U.S. ACUTE CARE SOLUTIONS, ADVENTHEALTH, TAMPA

Drop It Like It’s Hot: Identification, Treatment & Tips for Heat Stroke in the ED

Mark Rosenberg, DO, MBA, FACEP, FAAHPM ACEP

OAK HILL HOSPITAL

Veronica Tucci, MD/JD, FAAEM, FACEP OAK HILL HOSPITAL

A Whole New Level of Crazy: Emergency Psych in the Era of COVID

George Willis, MD, FACEP, FAAEM UNIVERSITY OF MARYLAND DEPARTMENT OF EMERGENCY MEDICINE

Pearls and Pitfalls in the Diagnosis and Management of Aortic Dissection

EM Townhall Session Panelist

Jason Wilson, MD, MA, FACEP

ACEP PRESIDENT-ELECT

USF

Tracy Sanson, MD, FACEP

Aaron Wohl, MD, FACEP

Kenneth Scheppke, MD, FAEMS

COVID Presentation in Children

Opioid Update During the Pandemic

Todd Wylie, MD UF JACKSONVILLE

EM Townhall Session Panelist

Cristina Zeretzke, MD, FAAP, FAAEM, FAC

Christopher Scott, MD, CPE, FACEP ENVISION

Hiring in Today’s Environment

Approach to Child with Altered Sensorium; Multisystem Inflammatory Syndrome- What it is and How to Treat it?

Jesus Seda, MD, FACEP

Tony Zitek, MD

KENDALL REGIONAL MEDICAL CENTER

Bites That Suck

GOLD

Socially Situating COVID-19

Women In Medicine: Cocktails and Conversation; Anti-Racism Allyship and Dialogue: Moving on from “What Can I Do?”

FLORIDA DOH

PLATINUM

UNIVERSITY OF FLORIDA

UF JACKSONVILLE

LLSA for Today

Thank You Sponsors

UF GAINESVILLE

SILVER

FIU

Evidence-Based Approach to Vaginal Bleeding

by the

2020

12th Annual Emergency Medicine Research Poster Awards 1-hour Sepsis Bundle: Mitchell Bourne,

OUTSTANDING MEDICAL STUDENT POSTER Evaluation of European Society of Cardiology 0/1-H Algorithm in the Early Diagnosis of MI at UF Health:

Comparing rates of skull fractures in female versus male geriatric patients: A prospective study: Michelly Gonzalez,

Medical Student Education Through Virtual Rotations During COVID-19:

Diagnostic Accuracy of Point-Of-Care Cardiac Ultrasound in Identification Of Pericardial Effusions: Caitlin Premuroso,

Midventricular Takotsubo: Jon J Risovas,

Justin Raman, MS2,19 Jacob Sammon, BS,19 Elizabeth Warren, RN,19 Brandon Allen, MD19

OUTSTANDING RESIDENT POSTER Missed Opportunities for Adolescent HIV Diagnosis: Targeted Testing vs. Routine Screening in a Pediatric Emergency Department (PED): Naomi

Newton, MD, PGY-1,6,21 Colleen K. Gutman, MD,3,6,19 Elizabeth Duda, MD,6,24 Ryan Alevy,10 Katherine Palmer,6,23 Martha Wetzel, MSPH,6 Janet Figeroa, MPH,6 Mark Griffiths, MD,3,6 Atsuko Koyama, MD, MPH,3,6,22 Lauren S. Middlebrooks, MD,3,6 Harold K Simon, MD, MBA,3,6 Andres Camacho-Gonzalez, MD,3,6 Claudia R. Morris, MD3,6

OUTSTANDING CASE REPORT From Chest Pain to Osteomyelitis/ Discitis: Jon J Risovas, MD, PGY-3,1 Fahad Uddin, MS2, Katia Lugo, MD, Douglas Haus, DO1 1

MS, Scott M. Alter, MD, MBA, Joshua J. Solano, MD,7 Richard D. Shih, MD7 7

ALL ENTRIES Actinic Keratosis: Diagnostic variance based on hospital status?: Lauren

Karsh, MD,13 Steven Warrington, MD, M.Ed,13 Jennifer Chapman, MD,13 Shannon Overholt, MD,13 Blake Robbins,13 Karthik Krishnamurthy, DO13

An Evidence-Based Management Algorithm for Acute Chloroquine and Hydroxychloroquine Toxicity:

Alessandra Della Porta, MS, EMT-B,21 Kasha Bornstein, MSc Pharm, EMT-P,21 Mehruba Anwar Parris, MD21

Asymptomatic Patients Often Have Abnormal Urinalysis Results: Adam Shir, MS3,12 Tony Zitek, MD,9,12 Ramsey Ataya, MD,9 Liuba Santos9

Blood Culture Results and Overtreatment of Patients with a

Alison Ohringer MPH, MS,21 ,Jennifer S. Jackson, MD21

Janae Fry, DO,13 Shilpa Amin, MD,13 Steven Warrington, MD, M.Ed,13 Matthew Cannon, DO4 MD, PGY-3,1 Katia Lugo, MD1

MD,14 Mitchell Barneck, MD,14 William Waite, MD,14 Jillian Davison, MD,14 Steve Leech, MD14

One and Done? A Single High Sensitivity Troponin to Safely Rule-Out MI: Jacob Sammon, BS,19 Justin Raman,

Electrocardiographs Revealing Epsilon Waves Following Use of Hormone Supplements in Young Cardiac Arrest Patient: Enola Okonkwo, MD,25 James

Allen, MD19

Bower, MD,16 Brian Samuels, MD,25 Dany Sayad, MD,25 Bryan Hyman, MD,25 Christian Schuetz, BS25

Emergency Department “Provider Discharge”, A Quality Project: Cody

Russell, MD,13 Steven Warrington, MD, M.Ed,13 Steven Goodfriend, MD13

Emergency Medicine Applicant Preferences for Faculty Fellowship Training: Trevor Lofgran, DO, PGY-2,13 Steven Warrington, MD, M.Ed,13 Terrel Swanson, MD13

ESI Triage Accuracy in Rural Florida Emergency Departments: Matthew

Casarico MS4,8 Conley Diaz-Gomez, MS4,8 Gerald Megna, MS4,8 David Yi, MBA8

Irukandji Syndrome in Fort Lauderdale, a Case Report: Andrew T. DiZenzo,21

MS-3,12 Tony Zitek, MD,9,12 Joshua Raber, MS-3,12 Adam Shir, MS-3,12 Boris Ryabtsev, MD9,12

False positive HIV Screening Test Results in the Tampa General Hospital Emergency Department: Victoria

Sands,25 Heather Henderson, MA,25 Jason W. Wilson, MD25

Gap Analysis: Attitudes, Confidence, and Knowledge of Emergency Ultrasound Minimal Imaging Criteria in Six Florida Emergency Medicine Residency Programs: Nisha Puri,21

Kerry O’Sullivan,21 David Kinas, DO,11 Vu H. Tran,2 David Hotwagner, MD,17 Javier Rosario, MD,15 Andrew Shannon, MD,20 Leila Posaw, MD,21 Andrew T. DiZenzo21

Glasgow Coma Scale as a Predictor of Intracranial Hemorrhage in Geriatric Head Trauma Patients: A Prospective Study: Scott Russo, MD,7 Scott M. Alter,

MD, MBA,7 Joshua J. Solano, MD,7 Richard D. Shih, MD7 EMpulse Fall 2020

MS2,19 Elizabeth Warren, RN,19 Brandon Planned Versus Actual Disposition: Does it Affect Readmission Rates in Sepsis Patients?: Kristin Smith, MS4,19

Faheem Guirgis, MD,20 David Holden, BSH, CPT,20 Morgan Henson, MPH, CPH, CCRP, CPT,20 Lauren Page Black, MD, MPH,20 Elizabeth DeVos MD, MPH19

Point-of-care Ultrasound Use in the Emergency Department Does Not Decrease Resident Productivity:

Mitchell Barneck, MD,14 Caitlin Premuroso, MD,14 Jillian Davison, MD,14 Stephen Leech, MD14

Rapidly Expanding Neck Mass: Nizar Osmani,21 Emily Prince-Ralby,21 John Beach, MD,21 Jennifer S. Jackson, MD21

The Epsilon Wave, More than ARVD:

Rachael Chaska, BA, NRP,25 Maram Bishawi, DO,25 Bryan Hyman, MD,25 Ryan McKenna, DO,25 Christian Schuetz, BS,25 Enola Okonkwo, MD25

Unusual Presentation of Hip Pain in a Man on Low Molecular Weight Heparin: A Case Report: Joshua Goldstein, MD,21 Patricia De Melo Panakos, MD,21 Peleg Y,21 Leila Posaw, MD21

Using a Quantitative Point-of-Care Test to Confirm HCV Viral Load in an Emergency Department Setting: Ryan

Sawyers,25 Luke Djavaherian,25 Heather Henderson, MA,25 Michael Buchko, MD,25 Jason W. Wilson, MD25

What is the level of proficiency after performing 25 supervised transvaginal ultrasound examinations?: Johnathon

Elkes, MD,25 Charlotte Derr, MD, RDMS,25 Alan Shteyman,25 Yuanyuan Lu,25 Ashley Grant, DO, RDMS,8 Tabitha Campbell, MD,18 Saundra Jackson, MD5

13th Annual

When Lightning Strikes Twice: SCJ Septic Arthritis and Hairy Cell Leukemia: Kyla Rakoczy, BS,21 Alessandra Della Porta, BS,21 Laura Eliseo, MD,21 Jennifer S. Jackson, MD21

AUTHOR AFFILIATIONS 1. AdventHealth East Orlando (Orlando, FL)

2. Aventura Hospital & Medical Center (Aventura, FL)

3. Children’s Healthcare of Atlanta (Atlanta, GA)

4. Edward Via College of Osteopathic Medicine – Carolinas Campus (Spartanburg, SC)

5. Emergency Resources Group (Jacksonville, FL)

6. Emory University School of Medicine (Atlanta, GA) 7. FAU Charles E. Schmidt College of Medicine (Boca Raton, FL) 8. FSU Sarasota College of Medicine (Sarasota, FL)

9. Kendall Regional Medical Center (Miami, FL)

10. Morehouse School of Medicine (Atlanta, GA)

11. Mt. Sinai Medical Center (Miami, FL) 12. Nova Southeastern University (Ft. Lauderdale, FL)

13. Orange Park Medical Center (Orange Park, FL)

14. Orlando Health (Orlando, FL) 15. Osceola Regional Medical Center

Quick Fire Winners: AUGUST 26 WINNERS

AUGUST 27 WINNERS

Best Presenter: Joshua Goldstein, MD, PGY-121

Best Presenter: Christine Gage, DO, PGY-320

Best Overall: University of Miami – Jackson Memorial Hospital21

Best Overall: UF Jacksonville

Best Discussant: Andrea Alvarado, MD, PGY-221

Best Discussant: Joseph Ray, MD, PGY-21

The CPC trophy will have both Jackson Memorial Hospital and University of Florida Jacksonville listed as this year’s overall winners.

(Kissimmee, FL)

16. Sanger Heart & Vascular Institute (Charlotte, NC)

17. St. Lucie Medical Center (Port St. Lucie, FL)

18. TeamHealth (Knoxville, TN) 19. UF Gainesville (Gainesville, FL) 20. UF Jacksonville (Jacksonville, FL) 21. UM—Jackson Memorial Health System (Miami, FL) 22. University of Arizona, College of Medicine (Phoenix, AZ) 23. University of Colorado (Boulder, CO) 24. University of Washington (Seattle, WA)

25. USF—Tampa General Hospital (Tampa, FL)

EMpulse Fall 2020

COMMITTEE REPORTS

EMRAF President’s Message By Dr. Elizabeth Calhoun, PGY-2 EMRAF President ‘20-21

Welcome to a new academic year. I am your incoming EMRAF president, and I am looking forward to reinvigorating resident involvement. The Emergency Medicine Residents’ Association of Florida (EMRAF) is the designated state committee for emergency medicine residents. Greatly expanding the number of residency programs in Florida over the last few years has led, unfortunately, to more distancing and sometimes less familiarity amongst residents in EMRAF. However, it also brings generous opportunity for collaboration with now 19 programs statewide! During this season, I will continue to

reach out individually with the goal of establishing a Residency Representative for each program with whom we can coordinate and disseminate information about upcoming FCEP programming. To my fellow residents, now more than ever, your voice in this organization is vital. You represent a variety of academic residency program designs with various perspectives, and the patients you care for belong to the many diverse regions of Florida. Through FCEP events and committee meetings, you have an opportunity to contribute that perspective and guide our state’s chapter of ACEP.

Additionally, involvement brings networking, leadership and advocacy opportunities, and fun! Please reach out to your program coordinator or to me directly for more information. Are you already receiving FCEP’s latest news updates? If not, please visit fcep.org/emnews-now and simply click the orange Subscribe to Announcements button in the bottom right to receive periodic emails with latest EM news and reminders about upcoming events. ■

WE’RE ALL IN THIS TOGETHER 888-311-8760

www.duvasawko.com The current global crisis is not without its challenges, but together, with unity and solidarity, we will prevail, and we will rise together. Our team here at DuvaSawko will be by your side through it all, because together,

we are stronger.

EMpulse Fall 2020

SOUTH FLORIDA EM RESIDENCY PROGRAMS

Florida Atlantic University By Dr. Tony Bruno, PGY-1 Here in sunny South Florida, we continue to blend work with pleasure, whether during off-shore boating adventures, intracoastal cruises, or lazy beach days (socially distancing, of course). We have welcomed medical students back to the ED post-Covid sabbatical, and are continuing with in-hospital ultrasound shifts on a weekly basis, while attending virtual sessions to review our scans. Educational opportunities abound, as covering three contrasting hospitals can be both intense and amazing. The trauma service, in particular, has continued to be busy at both Delray Medical Center and St. Mary’s Medical Center, both level 1 trauma centers with very different and unique patient populations. Monthly SIM Lab sessions have resumed, and we continue to hone procedural skills such as US-guided central lines, intubations (including fiber optic, direct laryngoscopy and GlideScope approaches), suturing and managing trauma cases. While we are always blessed with fantastic Grand Rounds speakers, we were recently honored to host Dr. Ammal Mattu, who gave an engaging and informative discussion on emergency cardiology. The 2020-21 academic year is now in full swing, with first year residents firing on all cylinders. Our weekly didactic conferences, while virtual at the moment, are still as engaging and interactive as ever, and our medical students impress us daily. We are very excited to say that we will resume in-person conferences, with face-to-face discussion resuming on October 13. Our faculty and residents offer a big congratulations to new chief residents, Dr. Danielle Klein and

Dr. Zachariah Hatoum. They are thriving in their new roles and have added immense value to the program through their hard work and leadership. Although the COVID-19 pandemic continues to present a challenge in all areas of medicine, our program is very fortunate to have all of the PPE we need to care for our patients, thanks to tenacious governance within both our program and our hospital systems. Even though we all want the pandemic to end, we are viewing it as a unique time in history, offering academic and clinical challenges that will better prepare us as well-rounded physicians. Our program has continued its scholarly ascent with our very own Dr. Josh Solano having published two articles. The first, “Quality Assurance in the Emergency Department,” published in EM Clinics of North America, provides an overview of current national frameworks and organizations that help define emergency department quality standards, as well as the process required to accredit physicians in the emergency department. The second, “Public Health Strategies Contain and Mitigate COVID-19: A Tale of Two Democracies,” published in The American Journal of Medicine, elucidates some of the factors that led to the significant differences in EMpulse Fall 2020

both case rates and deaths between the USA and South Korea during the COVID-19 pandemic. Additionally, program director Dr. Lisa Clayton, assistant program director Dr. Patrick Hughes, former program director Dr. Richard Shih, research director Dr. Scott Alter, and recently graduated resident, Dr. Daniel Parks, published: “Rescue Intubation in the Emergency Department After Prehospital Ketamine Administration for Agitation,” in Prehospital and Disaster Medicine (2020:1-5. doi:10.1017/S1049023X20001168). Drs. Shih and Alter published an editorial together, “The Menacing Assaults on Science, FDA, CDC, and Health of the US Public,” in EClinicalMedicine (in press). And Dr. Shih published a second editorial, “ Hydroxychloroquine for Coronavirus: The Urgent Need for a Moratorium on Prescriptions,” in Am J Med. (2020;133(9):1007-1008. doi: 10.1016/j.amjmed.2020.05.005. PMID: 32502485). Overall, our four-yearold program has published over 100 articles in peer-reviewed journals. Last but not least, we are very excited to announce that we have launched our own Twitter handle. Give us a follow @FAUmedEM to stay up to date with us! ■

SOUTH FLORIDA EM RESIDENCY PROGRAM UPDATES

Mount Sinai Medical Center By Stephanie Fernandez, MD, PGY-3 We are happy to report that the 2021 academic year is off to a great start. Despite a tumultuous year, our intern class has taken to the Emergency Department with enthusiasm, and we are proud of the progress they have made over the past few months. Senior residents have transitioned into their leadership roles seamlessly and continue to grow as lecturers and mentors. As we continue to adapt to challenges put forth by the pandemic, we have transitioned to an online interviewing platform. We look forward to meeting our future colleagues this interview season! Lastly, we’d like to give a warm welcome to our new core faculty members: Dr. Oren Mechanic, and Sinai alums, Drs. David Kinas and Robert Farrow! We are excited to see what the remainder of the year has in store. ■

St. Lucie Medical Center By Shelby Guile, DO, PGY-2 The academic year is now in full swing, and we continue to learn every day as we adjust to the “new normal.” We have been staying safe by using our respirators and doing almost all virtual didactics. While almost everything is online these days, our intern class was able to kick off their education with a hands-on ultrasound lecture hosted by our ultrasound director, Dr. Hotwagner, after they watched a livestream lec22

Kendall Regional Medical Center By Ibrahim Hasan, MD, Kristina Drake, MD & Sara Zagroba, MD, PGY-3s Emergency Medicine Residency Co-Chiefs Kendall Regional EM Residency started the academic year with our annual Airway Course, taught by Dr. Solis, and Ultrasound Course, taught by Dr. Moreno. It was definitely no hocus POCUS! With the new Ultrasound Fellowship in place, our interns were able to get oneon-one teaching from the fellows and early hands-on experience. The Ultrasound Fellowship has brought depth to the program with weekly ultrasound didactics and tape review, and even the mystery ultrasound case of the month. More exciting, Kendall Regional EM is now offering an Ultrasound Clerkship rotation for medical students, which has been a success with our first set of medical students rotating this past summer. We would like to thank our fellows, Drs. Nikkitta Georges and Harold Gomez, for all the teaching they have done so far.

Earlier this fall, our residents enjoyed a treat by undergoing a simulation training for transvenous pacers. Yet the true simulation skill test will be at the upcoming SimWars competition in October, at the Broward College Simulation Lab, with Aventura’s EM Residency. We hope to defend our SimWar title once again! FInally, we’d like to welcome our new Program Director, Dr. Valori Slane. We thank Dr. Emilio Volz for being our fearless leader and creating so many opportunities for the program. We wish him well in his future endeavors. We also welcome new family members to the Kendall EM Family, including Arthur, son of Dr. Antoinette Golden; Amelia, daughter of Dr. Nicoles Aviles; and Vicky, daughter of Dr. Moshe Yatzkan. ■

ture series in July. In September, we all virtually attended the “Adena Thought Leaders Summit - Mock Trial” about litigation in the emergency department. The mock trial featured expert witness, Amal Mattu, to provide a thoughtful discussion on standard-of-care in acute coronary syndromes. All of us were fortunate enough to be able to do a socially-distanced SIM lab at FAU in Boca Raton. We worked through a variety of different cases while utilizing masks and small groups. We also learned and reviewed basic procedures, including EMpulse Fall 2020

lumbar punctures, central lines and different methods of intubation. We were all happy to be able to continue our quarterly SIM lab visits as they are a valuable learning opportunity to experience and review rare cases. We hope that everyone is continuing to stay mentally and physically healthy at this time! ■

SOUH FLORIDA EM RESIDENCY PROGRAMS

Aventura Hospital By Dr. Scarlet Benson

Assistant Clinical Professor We have been busy preparing for the unchartered territory of virtual medical student interview season by participating in online meet and greets through the EMRA Residency Program Fair at the end of September. Dr. Kristina Eastman, PGY-3 compiled several video montages highlighting the perks of joining the Aventura EM team, with the assistance of several co-residents as well as our ultrasound gurus, Drs. Huy Tran and Guarav Patel. Clerkship Director Dr. Annalee Baker created a stellar online booth for the program fair, in addition to stealing the show as a medical expert on two national news interviews with CNN and Newsy Reports, providing her insight and perspective regarding the coronavirus pandemic. Dr. Jessica Cook, Simulation Director, starred in a virtual tour demonstrating the ins and outs of our stateof-the-art simulation program at Broward Simulation Center. She also mentored our rising star, Dr. Nicolas Ulloa, PGY-2, in publishing two articles: “A clinical challenge in the emergency department: a case of Klebsiella infective endocarditis presenting with splenic abscess” in the Cureus Journal, as well as “Altitude induced pulmonary hypertension” with StatPearls. Dr. Benjamin Pirotte, PGY-2 co-wrote and published “Refusal of care” in StatPearls with his

mentor, Assistant Clerkship Director, Dr. Scarlet Benson. Dr. Benson also co-wrote and edited a FOAMed article with emdocs.net with Dr. Ioana Rider, PGY-3 titled, “Evidence-based disposition in acute heart failure.” Dr. Laura Tortora, Toxicology Director, was not only awarded Teaching Attending of the Year by the graduating senior class of 2020, but also had two posters accepted for cases submitted to virtual toxicology conferences: “Beads from snow: a case of cerebral vasospasm from cocaine use,” for the Annual Scientific Meeting of the American College of Medical Toxicology, and “Antimuscarinic toxicity due to lupini bean ingestion,” with Education Director, Dr. Laurence Dubensky, and former resident, Dr. Ulrika Agnew, at the North American Conference of Clinical Toxicology. We are excited about this interview season, although we expect there will be unique challenges associated with the need for virtual interviews and limited socialization, and recognize the additional stress this might place on medical students, as well as the interviewing residents and faculty. We look forward to working together as a team with our residency and hospital, as well as our fellow EM community, to overcome this challenge, as resilience is one of the strong points within our specialty! ■

Introducing Florida’s 19th emergency medicine residency program:

Memorial Healthcare System Pembroke Pines, FL

• 10 categorical positions for PGY-1 • Participating in NRMP match for 2021–22 academic year

• Application deadline: Dec. 1, 2020

Program Director: Jonathan Rose, MD, MBA

Jackson Memorial Hospital ByEMResidencyProgramSta‹ It has been an interesting summer in Miami. We have welcomed our class of 2023—another fantastic class who come from all over the country, bringing a breadth of diversity, experiences and insight. We are excited to welcome them to Jackson and get them started on their careers as EM physicians. This onboarding has been during our second peak of COVID in South Florida. We hit our apex at the end of July and have been managing it well as a community, hospital system and residency. Faculty and residents from the University of Miami/Jackson Health System were excited to attend, participate and present at this year’s virtual Symposium by the Sea (SBS). We were very excited by our residents, Drs. Joshua Goldstein and Andrea Alverado, who competed in the clinical pathology competition at SBS. Dr. Goldstein won the award for the best presenter while Dr. Alvarado won best discussant, and we were selected as the best overall team. Dr. Naomi Newton won an award for her research at the poster competition as well. Congratulations to them for their hard work and well-deserved victory. Otherwise, we are preparing for our first virtual recruitment season and are excited to start interviews in November. We are also preparing for influenza/COVID returning in the fall/winter, and looking forward to post-COVID life. Stay safe everyone, and thank you for all that you do. ■

Associate Program Director: Leon Melnitsky, DO

EMpulse Fall 2020

WEST FLORIDA EM RESIDENCY PROGRAM UPDATES

USF Health By Mikhail Marchenko, MD, PGY-3 Greetings from Tampa and the USF Emergency Medicine Residency! We are excited to introduce our new website: usfemergencymedicine.org It is an awesome place for the most up-to-date information about the USF emergency medicine residency program. Not only will medical students interested in the program find useful information, but with our growing blog, residents from our program and other programs can learn a thing or two. During these times of social distancing, it may be difficult to find accurate information about residency programs when you cannot visit residency programs in person. That is why we have put in extra effort to share our experience as residents at TGH and USF on social media. Medical students and residents can follow us along on Instagram @usfemergencymed. We hope that other programs can follow along too, making these new times a little bit easier for the medical students in their difficult decisions in choosing the best residency program for themselves. We wish all of the 4th year medical students good luck in their search, and although we are a little biased, USF EM is definitely the best. ■

Brandon Regional Hospital By Cecilio Padron, MD, PGY-2 We are undergoing post-graduate training in one of the most challenging and interesting times in U.S. history. The pandemic has forced academic programs across the country to adapt quickly and effectively, a situation that characterizes the very nature of the field of emergency medicine. Brandon Regional has risen to the challenge in the midst of starting the new academic year. We welcomed our new class of 2023 with 15 residents, and although we were not able to host our usual EM orientation month, we successfully restructured the beginning of their residency training with a combination of live Webex lectures and shadow shifts. This being the first year that we have three classes of residents at BRH, the class of 2023 made a seamless addition to the team and were managing airways on critical patients within their first month. The BRH class of 2023 has already become an integral part of adapting to residency training during these unique times. They have taken it upon themselves to lead the development of Brandon Regional’s online presence to communicate effectively with future generations of residents and our colleagues in other programs. We’ve created an active Instagram page that is regularly updated showcasing some of our faculty, residents, resources, and training. We’ve hosted live online Q&A sessions with faculty and residents for medical students applying to residency next cycle. Currently, we are building a personalized website to act as a resource to connect with the medical EMpulse Fall 2020

community across the country. During these past few months, Brandon Regional, under the guidance of ultrasound faculty Drs. Eric Kalivoda and Grabriel Cabrera, has published many great publications showcasing the strength of our ultrasound program. Drs. Keyon Shokraneh and Jordan Johnson published a case report on bedside ultrasound of gastric volvulus. Drs. Melissa Bacci and Roli Kushwaha published a case report on bedside ultrasound of pneumoperitoneum. Drs. Patrick Hsu, Caroline Shepherd, and Keyon Shokraneh published a case report of a flail mitral leaflet on bedside echo. We’ve had many other recent publications, and a few more in progress. Lastly the addition of faculty member Dr. Martin Kim, who is fellowship-trained in simulation training, has proven to be an invaluable tool during these unprecedented times. Dr. Kim wasted no time upon his arrival to BRH, aggressively developing our simulation program while maintaining safe practices, including masking and distancing. We have successfully been able to convert one of our larger ED treatment rooms into a fully functional, in-house, simulation training room. This has allowed us to engage in weekly simulation training in cohorts, which is sharpening our skills in critical case presentations and developing our comradery with our new fellow residents. We look forward to seeing the development of our program over the course of the academic year. ■

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WEST FLORIDA EM RESIDENCY PROGRAM UPDATES

FSU at Sarasota Memorial By Kevin Gil, MD, PGY-1

I think we can all agree that our most exciting update is our intern class! Our new group joins us from all across the country, from Texas to Hawaii, with a diverse mix of backgrounds. As a new intern and former student at FSU’s Sarasota campus, I have been lucky enough to watch the program grow from its inception. I remember attending the program’s very first Wednesday conference as a student and being so impressed with the quality of the residents and of the educational sessions, which have continued to improve over time. Along with being the second class at FSU Sarasota’s EM residency program, the class of 2023 will also be remembered for beginning

residency during a historic worldwide pandemic. Although we have all had our graduations, match ceremonies and other celebrations canceled, our program leadership has been as enthusiastic as ever in making us feel welcome and supported. With the overall number of active COVID cases in Florida and Sarasota County dropping, we are finally starting to feel a new sense of normalcy. As a program, we have found ways to responsibly gather by taking advantage of the outdoors at our world-renowned Siesta Key Beach. Most importantly, as of this writing, we do not know of anyone in our program that has tested positive. For that and so much more, we feel lucky and are

cherishing the opportunity to serve our community while learning from the many lessons the pandemic has given us. Finally, we are looking forward to the upcoming virtual application season. We normally love showing off our beautiful hospital, weather and city, but we are also excited about our latest digital recruiting projects. We are expanding our social media efforts, building a new website, creating a virtual tour, and are actively involved in recruiting events including the EMRA Residency Fair. Wishing good luck to all the programs and applicants during this unique and unprecedented application cycle! ■

Oak Hill Hospital By Ryan Johnson, MD, PGY-1 & Mohammad Razzaq, DO, PGY-1

Greetings from sunny Spring Hill. With the addition of our newest intern class, we are excited to finally have a full cohort of residents. The interns are adjusting to resident life and have been integrating well into both the department and the surrounding community. We recently received exciting news regarding our new emergency department: the construction which had been postponed due to the pandemic has been scheduled to resume. We’re very excited for the expansion. Hopefully this is a sign of both a return to normalcy and exciting opportunities for the future.

As we are sure is true with many other programs across the state and the nation, COVID-19 continues to be a challenge in our ED. Luckily our leadership has been understanding of the challenges this unprecedented time created and has been very supportive of our residents. We are all hoping for things to improve as quickly as possible. Interview season is quickly approaching. Although we are sad we won’t get to greet prospective residents in person, we nevertheless look forward to meeting potential additions to our program. This will certainly be an unprecedented

EMpulse Fall 2020

interview season, and we wish each applicant the best of luck. Now with two classes below them, our seniors are transitioning into leadership and teaching roles. They have been taking on greater responsibility in the department and are working closely with the interns to aid in their transition into residency. We are all excited for our seniors as they pursue job and fellowship opportunities. We wish them the best as their graduation grows closer. ■

NORTH FLORIDA EM RESIDENCY PROGRAMS

UF Gainesville

UF Jacksonville

By Christopher Purcell, MD, PGY-3

By Dr. Rick Courtney, DO, PGY-2

Annual airway day and mechanical ventilation day closed out our summer conference series. For airway day, we learned about the difficult airway algorithm and then put it to the test with challenging live simulations involving impending airway failure scenarios. After familiarizing ourselves with various airway adjuncts, residents were able to work on improving fiberoptic skills. We closed out the day with an “airway rodeo,” where teams competed in a relay race that had stations including foreign body obstruction, digital intubation, utilizing the tomahawk approach, and more. Mechanical ventilation day came the following week and allowed us to learn the intricacies of ventilators alongside our respiratory therapists in the simulation lab.

Hello from Jacksonville! The last few months have been an exciting time of growth for everyone within our program. Our interns have done a fantastic job of transitioning from medical students to resident physicians during these unprecedented times of Covid-19. The beginning of the new residency year brought new roles and additional responsibility for our PGY 2’s and 3’s. Our senior residents continue to share their vast medical knowledge with junior residents and with the students we have slowly started welcoming back into the hospital for educational opportunities.

We are excited to welcome Dr. Colleen Gutman to our pediatric emergency medicine faculty. She recently graduated from her PEM fellowship at Emory University and started working with us this summer. She is a great addition to our already strong longitudinal pediatric EM experience. An unconventional recruitment season is now in full swing. This year, creativity is paramount as we work to increase the visibility of our program in novel ways. We recently launched our new Instagram (@ufemergencymed) and Twitter (@UF_EM), which highlight various aspects of our program and spotlight individual faculty, fellows and residents. We have also been hosting online meet and greets via Zoom with faculty and residents, which invites prospective applicants to become more familiar with our program. ■

Many thanks are in order to our faculty, who have done a wonderful job of keeping resident education at the top of their priorities while having to adjust our usual way of life with all of the Covid precautions taking place. We have all become masters of Zoom. Finally, a big congratulations to our own Dr. Christine Gage, PGY-3, who won Best Presenter and Best Overall CPC Presentation at virtual Symposium by the Sea this year for her presentation on a tetanus case. ■

UCF/HCA North Florida Regional By Jayden Miller, MD, PGY-2 We’ve been “zooming” through 2020 here at North Florida (pardon the pun!). As with many other programs, our didactics have stayed virtual for months now. We took the opportunity to open our conference to M4s around the country and state who are interested in North Florida, or have limited ED exposure at their home sites. We’ve had so many new faces! ACEP is around the corner, we’re excited to have a team representing SIMWARS. Similarly, Dr. Marcos Marugan-Wyatt, PGY-2 is presenting at CaseCon. He will be sharing a case of pyogenic extensor tenosynovitis visualized and diagnosed with bedside ultrasonography — a great case to represent the exemplary ultrasound education Drs. Diana Mora and Dakota Lane provide for our residents. Learn more about North Florida EM at northfloridaem.com or follow us @northfloridaem on Instagram and Twitter! ■

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NORTH FLORIDA EM RESIDENCY PROGRAM UPDATES

Orange Park Medical Center By Cody Russell, MD, PGY-2

The last few months have been a time of extraordinary growth for our program. Not only did we expand as a residency by welcoming our second class into the ED, but we are also in the process of literally expanding our hospital as we near the completion of a three-story addition to increase our available inpatient bed space. We have also begun rotating our residents at a third ED for our program at Normandy Park ER, giving our residents another environment to learn and train.

include our program competing in our first FCEP Case Presentation Competition. Dr. McKeny and myself came home empty-handed, but our program livestreamed all the presentations, learned a ton, and became even more eager for a chance at the title next year. Similarly to all programs, we’ve tried to adapt to the times. We’ve been offering a “virtual rotation,” allowing medical students to stream into our Thursday conference and get more involved with our residents each week. Dr. Fry and Dr. Descallar have led this initiative to assist medical students struggling to arrange rotations due to COVID as an additional opportunity to stay involved in the EM community. We have also begun working with our partner medical school, Mercer College of Medicine, and will be hosting a simulation day at their campus giving medical students a chance to

In the research realm, we are working towards multiple industry grants as well as continuing our multi-disciplinary research in collaboration with our dermatology residency. Our second-year class has begun putting in the groundwork on some other exciting projects involving our local EMS agency and point-of-care ultrasound. Other academic updates

have some hands-on scanning time, learning basic bedside ultrasound skills with our ultrasound guru, Dr. Euwema. To take a break from it all, we are getting together as a program with all our residents and family members to go to a socially-distanced Jacksonville Jaguars game together, where we will see our very own Dr. Deaton on the sidelines as the airway physician for the Jaguars. Our residency has also encouraged adventurous elective rotations to get away, including a wilderness medicine elective recently completed by Dr. VanderVelde and Dr. Lofran, which involved them rappelling from large downtown buildings with our local EMS and search & rescue colleagues. In summary: it’s been a rather exciting year of growth at Orange Park Medical Center. ■

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EMpulse Fall 2020

CENTRAL FLORIDA EM RESIDENCY PROGRAMS

UCF/HCA at Ocala Regional By Emily Clark, MD, PGY-2, Jean Laubinger, MD, MPH, PGY-2 & Caroline Smith, MD, PGY-3

Fall has kicked off differently this year in Ocala due to the global pandemic: we resumed in-person conferences at the Emergency Operations Center (EOC) in Ocala. While gathered in the very room where disaster planning and response meetings take place, we discussed the history, organization and role emergency medical services (EMS) plays in our community. Although our residency conference looked different with facemasks and social distancing, we were all thrilled to gather together again.

Despite physical distancing, our collaborations in research have not slowed down. We have initiated a program to help our emergency department patients with substance use disorder bridge the gap to community resources. The program, started by Captain Jesse Blaire of Ocala Fire Rescue, brings together local mental health facilities, rehabilitation services, and community programs to provide medical treatment and social support for patients with substance use disorder. Through our core faculty member and Ocala Fire Rescue EMS director, Dr.

Frank Fraunfelter, our residents have worked with Capt. Blaire to provide research support for the program. In our busy emergency department, we are fortunate to treat a wide variety of patient conditions that have led to several case report publications. Our residents have recently published reports on consumptive coagulopathy following Eastern diamondback rattlesnake bites, aortic dissection presenting as leg pain, and managing intermediate risk pulmonary emboli in patients on Pradaxa. ■

UCF/HCA of Greater Orlando By Amber Mirajkar, MD, PGY-3

It is the beginning of another academic year and, like so many other programs, we have seen our Emergency Department changed by the COVID-19 pandemic. However, it has not stopped our intern class from embracing the challenge. Drs. Marvi Gul, Jonathan Littell, Jeffrey Adams, Jovans Lorquet, Martin Morales-Cruz, Adam Oswald, Mihir Tak have hit the ground running, and we are excited to have them on our team. In addition to new residents, we have new fellows. Our ultrasound fellows, Drs. Nicholas Fusco and Roberto Marrero, and our academic emergency medicine fellow, Dr. Cherian Plamoottil, have started as well. We are grateful to have them teaching in our ED. While we do not know how long the pandemic will linger, we are committed to quality patient care and education of our current and

future doctors. Despite COVID-19, our research interests remain strong. Drs. Gideon Logan, Emily Drone, Larissa Dub, and Latha Ganti published a case series detailing hypercoagulability in COVID-19. The residents created a new protocol detailing steps for a COVID-19 cardiac arrest resuscitation. In continuing education, alumni and faculty published a mass casualty curriculum. Congratulations to Drs. Joshua Tsau, Nicholas Fusco, Ayanna Walker, and Latha Ganti on their published article, “Development of an interactive curriculum and trainee-specific preparedness plan for emergency medicine residents” in the International Journal of Emergency Medicine. We have many more publications in the works!

thusiastically participating in them. From Symposium by the Sea to ACEP, COVID-19 is not holding us back. While the virtual platform is a new frontier for most, our technology committee, Drs. Keegan McNally, Parth Patel, Javier Rosario, and Ariel Vera, are working hard to map it for us. They are exploring new ways to not only improve weekly conferences via Zoom, but also make the interview experience unique as the interview season starts. We hope everyone stays safe in these uncertain times, but we are also looking forward to a promising new academic year. Best of luck to all those applying to fellowship! ■

Although many events are entering the virtual world, we are still enEMpulse Fall 2020

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EMpulse Fall 2020

CENTRAL FLORIDA EM RESIDENCY PROGRAMS

AdventHealth East Orlando By Tyler Mills, MD, PGY-1

Orlando Health By Gregory Black, MD, PGY-2, Brody Hingst, MD, PGY-2 & John Atiyeh, MD, PGY-3 Happy Fall! We at Orlando Health have stayed busy these past few months. We were excited to participate in FCEP’s annual Symposium by the Sea. Thank you to all our colleagues around the state who worked tirelessly to pull this off virtually despite countless barriers. The symposium was perfect, and you are rockstars. We would like to congratulate some of our own presenters for their fantastic presentations: Mitch Barneck, Erich Heine, Jesse Glueck, Patty Ambrosio, Evelyn Ramirez and Brody Hingst. Way to go! As COVID-19 continues to impact our community, we remain ever vigilant. Dr. Kurt Weber and several of our residents are hard at work investigating the prevalence of SARS-CoV-2 among team members with different work exposure risks. This is part of a large, nationwide, multicenter study. We are proud to be participating and look forward to seeing the data! Finally, this year’s interview season will be unprecedented, as both programs and applicants adapt to a virtual venue. Although this is not ideal, EM physicians are trained to adapt and overcome. We are working around the clock to make this application cycle as gentle as possible for so many phenomenal M4 students. We are all in this together! We hope this finds you safe and well, Your Friends at Orlando Health ■

It was a busy summer at AdventHealth East Orlando! The interns have settled into their new roles and are an integral part of the team. Senior residents have their eyes on the future with many considering fellowship, and many had the opportunity to explore career options further at the annual Symposium by the Sea conference. The entire program attended the first ever virtual Symposium by the Sea, which went off without a hitch, thanks in part to our very own Dr. Shayne Gue who serves as co-chair of the event. In addition to career and networking opportunities, this year’s virtual sessions offered lectures on a variety of topics by physicians from across the Sunshine State, including some of our faculty at East Orlando. Dr. Haus shared his expertise on ocular ultrasound, while Dr. Little educated his virtual audience on ENT emergencies. Drs. Molins and Martinez teamed up for their presentation titled: “The Show Must Go On” to discuss the unprecedented impact of the pandemic on medical education and provide solutions. All

three lectures were well attended. Advent East dazzled in the residency competition portions of the event, featuring Drs. Muniz, Risovas and Ray. Dr. Risovas, PGY-3 participated in the Case Presentation Competition and won first prize for his poster submission. Dr. Ray, PGY-2 also brought home the hardware—much to the delight of his co-residents— with a dominant performance in the discussion part of the competition. Congratulations, gentlemen! Looking ahead, our interview process at AdventHealth looks different this year. The goal of recruiting strong intern classes to join our family in East Orlando, however, has not changed. Committed to that tradition, dedicated residents like Drs. Janevski and McGillicuddy have graciously volunteered their time conducting virtual interviews and information sessions with applicants and prospective students. We are thankful for their efforts and confident they will deliver yet another great class! ■

Daunting Diagnosis: A By Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief Continued from p 10 The facial CT demonstrated subcutaneous fat stranding adjacent to the parotid gland with concern for acute parotitis. There was diffuse cervical lymphadenopathy and no drainable fluid collection. ENT was consulted and diagnosed the patient with viral vs. bacte-

EMpulse Fall 2020

rial parotitis. Given the patient’s progressive condition, ENT recommended admission to the hospital and infectious disease consultation. ID agreed that the patient had acute parotitis. A respiratory viral panel and mumps serology were obtained. The patient’s labs were later confirmatory for mumps. ■

COMMITTEE REPORTS

Medical Student Council By Dan Schaefer, MPH, MD Candidate – M3 Secretary-Editor, FSU College of Medicine

The Florida College of Emergency Physicians Medical Student Council (FCEP MSC), like the rest of the world, is still getting used to operating during the COVID-19 pandemic. However, we are excited to talk about what we have accomplished in the past few months and our plans for the future! We were happy to have a great turnout of medical students intently listening to and posing excellent questions to current residents of Florida EM programs at the Residency Panel during Virtual Symposium by the Sea back in August. With the entire traditional interview process changing drastically due to COVID-19, medical

students have been eager to gain as much up-to-date information as possible regarding residency applications, interviews and lifestyle. The MSC is currently preparing for EM Days during the next legislative session. We are also excited for ACEP 2020 and its EMRA events that will be especially useful for all of the 4th-year medical students in Florida. Lastly, we are always pondering new events and ideas to help medical students on their path to emergency medicine during this tumultuous time. The Emergency Medicine Interest Groups (EMIGs) at medical schools

across the state have risen above all challenges presented by the pandemic and have been actively engaging their students in emergency medicine education and activities. Some notable examples are NOVA’s pediatric emergency medicine case presentations, FIU’s EM basics on topics such as ECGs, IV fluids and FAST scans, FSU’s aerospace medicine and gun violence lectures, and LECOM’s COVID in the Emergency Department talks. As always, if you are interested in more information on what FCEP MSC is up to, please check us out on Facebook at “FCEP Medical Student Group.” ■

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EMpulse Fall 2020

EVENT RECAP

Life After Residency: Thriving Beyond Medicine By Rajiv Bahl, MD, MBA, MS FCEP Board Member

No one expected 2020 to take the turn it has, but the Florida College of Emergency Physicians took the complications of this pandemic head on – like any emergency physician would. The Life After Residency: Thriving Beyond Medicine program was designed to help residents of all levels understand the next step after residency. Much of what is taught during residency is based on clinical practice and understandably, many aspects of physician life and personal success go beyond the bedside. The Life After Residency program was developed to help residents make a smooth and educated transition into being attendings. This year, the program was split into two parts: a live program that was hosted virtually as well as a robust virtual program for additional content and resources. It was my pleasure to be involved in the planning process and work alongside planning chairs Dr. Robyn Hoelle and Dr. Todd Slesinger. This year, Dr. Jay Falk led a panel with Drs. Damian Caraballo, Jordan Celeste and Aaron Wohl, discussing the things they wish they knew in residency. This engaging conversation covered financials, contracts, changing jobs and advocacy. The state of emergency medicine is quickly changing, and the additional demands that are placed upon new attendings is growing. With their experienced perspective, residents received a purview on life just outside of one’s training years.

Life After Residency would not be the same without Dr. Tracy Sanson, who has provided thoughtful lessons to this program for several years. Her engaging discussion of selfcare moved beyond the understood mantras of doing yoga and taking time for yourself and into the deeper realm of what self-care truly means. Without a doubt, emergency medicine has stressors that test every one of us and she took us beyond the surface, introducing new ways to not only look at ourselves but how to also remain resilient against the pressures we face as clinicians.

With positive resident engagement, the virtual events this year were a success. But we are excited to bring the program back to the beach next year at the Sirata Beach Resort in St. Pete Beach! ■

Thank You Sponsors Platinum Level

One of the most successful talks is our financial wellness discussion. This year we featured Shayne Ruffing, who engaged our residents over some of the nuances of financial freedom, from student loans to retirement. Residency programs are busy teaching the academics of emergency medicine, and we were fortunate to have him extend this to our residents. With the policies surrounding patient care continually changing, understanding those changes can be difficult. FCEP Lobbyist Toni Large spoke with our residents about the pressing issues of the day—which are many of the issues FCEP fights for at EM Days in Tallahassee. Although we all have faced many unexpected challenges this year, FCEP and the Life After Residency committee are still committed to providing the highest quality content and education to our members, residents and students. EMpulse Fall 2020

Silver Level

Hospice is a Valuable COVID-19 Resource for Overburdened EMS Professionals By Lillian Valeron

VITAS® Healthcare

The COVID-19 stories of our nation’s first responders and emergency departments (ED) are both personally and professionally wrenching. Yet many similar medical, logistical and emotional challenges have defined the standard of care for hospice and palliative medicine specialists for more than 40 years. Florida’s EDs, emergency medicine professionals and hospitals can find solutions to the pandemic’s challenges by partnering with a local hospice provider to secure appropriate healthcare for seriously ill patients while accomplishing key goals:

• Identify hospice-eligible patients

early and refer them quickly to an appropriate setting of care whether at home, in an inpatient hospice unit, or at a care facility capable of handling COVID-19 patients. This rapid-response approach to hospice eligibility reduces hospital and ED admission/readmissions, provides care in the most appro-

priate setting, and frees ED/hospital beds for non-COVID care.

• Leverage telehealth technology

to evaluate and admit patients seamlessly from the ED to hospice care at home or another setting. Telehealth enables simpler patient monitoring while supporting the education of caregivers and healthcare professionals about end-of-life care.

• Engage in timely goals-of-care

conversations in the ED to help patients and families identify and document their preferences for end-of-life care—a “soft skills” activity that can also be hosted via telehealth to support timely transitions out of the ED.

• Provide complex modalities for

hospice patients who require high-acuity, comfort-focused care at home or outside of the hospital, including supportive respiratory therapy and non-invasive ventilation, comfort-focused cardiac care, pain management, wound care, and more.

VITAS® Healthcare, a Florida hospice provider since 1978, has partnerships with EMS providers throughout the U.S. to pre-identify and pre-enroll hospice patients in hospice revocation reduction programs that prevent hospital and ED readmissions. VITAS trains dispatchers and paramedics in homebased, end-of-life care, so when a hospice patient calls 911, VITAS and EMS teams work together in real time to provide supportive care and modalities at home to keep patients in crisis out of the ED and hospital. Transition your COVID-susceptible, hospice-eligible patients to their preferred care setting, relieving burdens on your staff and ED and freeing your acute-care beds. Download the VITAS mobile app for referrals, locations, and hospice eligibility guidelines (Android and iOS), call 800.93.VITAS (available 24/7), or visit VITAS.com.

SPONSORED CONTENT

EMpulse Fall 2020

FEATURE

THE SHOW MUST GO ON:

Medical Education in the Face of COVID-19 in Florida By Carmen J. Martinez, MD, MSMEd, FACEP, FAAEM

Over the years, medical educators have faced educational challenges that have resulted in innovations and strategies.1 Each pandemic has taught us important lessons and changed our medical education process. For example, during the HIV/ AIDS outbreaks, the learning environment was challenged with fear of personal safety and ethical obligations regarding patient care. Educators had to clarify learning goals by consolidating care and creating new care models for affected patients.1 Now, COVID-19 and the mandate for social distancing also created its own challenges, and new educational strategies are beginning to emerge. Interested to know how other residencies approached their educational challenges, we surveyed all the Accreditation Council for Graduate Medical Education (ACGME) accredited emergency medicine (EM) residency programs in Florida. The survey asked residency programs to describe their experience about the mandatory didactic activities before and after the pandemic began in March 2020, specifically asking about video conferencing platforms, learning management systems, the use of asynchronous learning or individualized interactive instruction (III),

By Caroline M. Molins, MD, MSMEd, FACEP, FAAEM

and resident/faculty engagement. Twelve of the 18 programs surveyed responded, with a mix of residencies from large academic tertiary centers, trauma centers, and small community programs. Most programs were using either Cisco©WebEx, Microsoft® Teams or Zoom as their digital platform, and used a variety of software to prepare quizzes such as Google Forms, Microsoft® Word and Microsoft® Forms. Since the beginning of the didactic lecture transformation, one quarter of the respondents have incorporated III, 17% have cancelled in-person simulation, and 17% have incorporated small group learning or workshops. The educational experiences have become more diverse with the incorporation of asynchronous activities, more interactive virtual experiences, and three programs have even utilized pre-recorded lectures into their didactic programs. The essence of being virtual has also fostered an environment of collaboration with national emergency medicine web-based resources. Residency programs reported using a combination of the following: EMRAP, Foundations of Emergency Medicine©, EM Fundamentals©, EMpulse Fall 2020

ACEP Virtual, AliEM©, The Center for Medical Education© National Board Review Course, Metasin™ EMCrit Podcasts, HippoEM© and RebelEM©. Collaboration between other EM programs and other residency specialties was also reported (17%). All the programs reported using an EM Board Review question database with all using ROSH Review©. In addition, six programs also used HippoEM© and three used EMCoach©. Surprisingly, more than half the programs reported no change in the level of engagement from the residents or faculty. Only one-third of programs found an increase in faculty engagement, and two reported an increase in resident engagement. Meanwhile, two and three programs felt their faculty and residents, respectively, were less engaged. Six months later, most of us continue our didactic time behind digital platforms, which has changed our education methods for the better, we hope. As we continue this virtual journey, some best practices are emerging. During virtual conferences, it is imperative to understand your personal connection to the internet (Ethernet, WiFi, cellular), use Continue on page 43 » 35

POISON CONTROL

Don’t be Blind to the Risk of

Contaminated Hand Sanitizers Chiemela Ubani, Pharm.D.

Anthony DeGelorm, Pharm.D.

Clinical Toxicology Fellow at Florida/USVI Poison Information Center-Jacksonville

With the international emergence of the SARS-CoV-2 virus, the Centers for Disease Control and Prevention (CDC) has updated its infection control guidance to place more emphasis on the use of personal protection equipment (PPE), hand washing, social distancing and alcohol-based hand rubs to prevent the spread of the virus.1 Alcohol-based hand rubs, such as hand sanitizers, are inexpensive, readily available and easy to use, thereby making them a staple product to have on hand. Most hand sanitizers contain ethyl alcohol (ethanol) or isopropyl alcohol (isopropanol) as active ingredients. These are generally safe when used topically and are known to inactivate the virus at concentrations between 65-90%.1 A growing need for hand sanitizer 36

Clinical Toxicology Fellow at Florida/USVI Poison Information Center-Jacksonville

products has led to a spike in mass production and a lack of quality control, allowing items with contaminants to reach the market. Substances like methanol, which are normally removed in the ethanol manufacturing process, are left in the products due to haphazard and hasty distilling techniques.7 Methanol is not an U.S. Food and Drug Administration (FDA) approved ingredient for hand sanitizers and is known to be quite toxic. Due to multiple cases and deaths from the ingestion of these contaminated products, the FDA issued a warning in June 2020 about nine hand sanitizers manufactured by Eskbiochem SA de CV in Mexico that reached the U.S. market.2 The FDA has now expanded that list to over 75 products.2 With hand sanitizers becoming increasingly important in EMpulse Fall 2020

preventing transmission of the SARSCoV-2 virus and an increasing number of products coming to market, it’s essential for healthcare providers to become familiar with the signs and symptoms of methanol toxicity. Methanol, also known as wood alcohol, has been around for centuries and was used as a component of embalming fluid as far back as ancient Egypt.5 Methanol is considered a “toxic alcohol,” which refers to alcohols that are not intended for human consumption. Methanol-containing products commonly encountered include windshield washer fluid, gas line antifreeze, solid cooking fuel and photocopying fluid. Methanol can be absorbed via oral, inhalation and dermal routes. Ingestion can occur accidentally with children or inten-

tionally in patients with a history of substance abuse or mental illness, using it as a substitute for alcohol. Dermal absorption can potentially lead to toxicity, but the absorption depends on several factors including the duration of contact, concentration of methanol, amount and the surface area of exposed skin.4 There is little data showing the effects of chronic dermal exposure of methanol, but case reports identify skin dryness as a result of repeated exposure.3,4 Another report documents a few patients developing visual disturbances after application of denatured alcohol as hand sanitizer three to five times a week for more than 6 months.3 Like ethanol, methanol can cause inebriation and is metabolized by alcohol dehydrogenase (ADH). When absorbed, it is slowly metabolized by ADH to formaldehyde and subsequently by aldehyde dehydrogenase to formic acid (undissociated form) and formate (dissociated form). Both forms act as a mitochondrial toxin that inhibits cytochrome oxidase, producing oxidative phosphorylation interference.5 The exact mechanism is not well understood, but optic nerve cells and neurons in the basal ganglia appear to be uniquely susceptible, leading to ocular and

neurologic toxicity.5 Ocular toxicity is responsible for visual impairment, often described as "snowfield vision," and can ultimately progress to blindness. Neurologic toxicity can lead to abnormal mental status, focal deficits, muscle spasms and parkinsonism.5 Accumulation of formic acid produces end organ damage and is responsible for the anion gap metabolic acidosis seen in these patients.5 When evaluating a patient with possible methanol exposure, a methanol level can confirm the presence (although it is not readily available at most institutions). If there is early clinical evidence of a possible methanol exposure (central nervous system depression, high serum osmolarity, and an unexplained osmolal gap), providers should be thinking about treatment with an ADH antagonist such as fomepizole. Fomepizole competitively inhibits ADH, preventing the metabolism of methanol to its toxic metabolites. If fomepizole is not readily available, ethanol can be used instead. Ethanol will compete with methanol for binding to ADH, preventing formation of toxic methanol metabolites. Maintaining a serum ethanol level of at least 100 mg/dL will ensure adequate blockage of methanol metabolite formation.8 The endpoint of both therapies

FPICN toxicologists are available 24 hours a day, free of charge, at 1-800-222-1222 to answer any questions regarding potential exposures.

is the resolution of the unexplained osmolal gap. Adjunctive therapies to ADH inhibition are folate and sodium bicarbonate. Folate offers a theoretical advantage of enhancing the elimination of formate by converting it to carbon dioxide and water, while sodium bicarbonate shifts the equilibrium formation to favor formate, the less harmful mitochondrial toxin. Patients with late evidence of methanol toxicity (new vision deficits, acidosis, seizures) should undergo dialysis.6 With the growing list of contaminated hand sanitizers present on the FDA website and the increased use of hand sanitizers due to SARS-CoV-2, understanding the presentation and management of methanol toxicity is key. Your local poison control center is available if a health care provider suspects a methanol exposure or to answer any questions regarding other potential exposures. ■

REFERENCES 1. Centers for Disease Control and Prevention. Hand Hygiene Recommendations. https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene. html. Accessed August 27, 2020. 2. Center for Drug Evaluation and Research. FDA updates on hand sanitizers consumers should not use. https://www.fda.gov/drugs/ drug-safety-and-availability/fda-updates-hand-sanitizers-consumersshould-not-use. Accessed August 27, 2020. 3. Chan, A., & Chan, T. (2018). Methanol as an Unlisted Ingredient in Supposedly Alcohol-Based Hand Rub Can Pose Serious Health Risk. International journal of environmental research and public health, 15(7), 1440. https:// doi.org/10.3390/ijerph15071440

4. Batterman SA, Franzblau A. Time-resolved cutaneous absorption and permeation rates of methanol in human volunteers. Int Arch Occup Environ Health. 1997;70(5):341-351. doi:10.1007/ s004200050228 5. Wiener SW. Toxic Alcohols. In: Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS. eds. Goldfrank’s Toxicologic Emergencies, 11e. McGraw-Hill; Accessed August 27, 2020. https://accesspharmacy. mhmedical.com/content.aspx?bookid=2569&sectionid=210275462 6. Roberts DM, Yates C, Megarbane B, et al. Recommendations for the role of extracorporeal treatments in the management of acute methanol poisoning: a systematic review and consensus statement. Crit Care Med. 2015;43(2):461-472. doi:10.1097/ CCM.0000000000000708

EMpulse Fall 2020

7. Difford S. Distillation. The science of distillation. Difford’s Guide - the home of discerning drinkers. https:// www.diffordsguide.com/encyclopedia/198/bws/distillation-the-science-of-distillation. Published March 27, 2014. Accessed September 1, 2020. 8. Howland M. Ethanol. In: Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS. eds. Goldfrank’s Toxicologic Emergencies, 11e. McGraw-Hill; Accessed September 15, 2020. https://accesspharmacy. mhmedical.com/content.aspx?bookid=2569&sectionid=210263617

We focus on optimizing revenue so physicians can focus on whatâ&#x20AC;&#x2122;s important.

Practice Optimization Opportunities By Shanna Howe, Vice President of Emergency Medicine, Gottlieb

Today, more than ever, it is a necessity to simplify and improve the financial experience for healthcare providers and patients. Here are some of the ways in which you can optimize your practice. Every practice is unique, and all of these ideas may not work for yours, so it is important to test an opportunity before deciding. I. Managed Care Contracting Strategy: Partner with an expert negotiator for managed care contracting assessment, strategic planning, negotiations/renegotiations, and contract compliance and adherence. On average, ED practices have the opportunity to increase reimbursement by approximately 15% when maximizing managed care contracting efforts. II. Clinical Documentation Education: Align with an industry professional to research latest trends in emergency medicine and insurance markets; monitor provider documentation during coding process to capture deficiencies electronically; identify lead provider in your practice to share documentation feedback at least once monthly; provide proactive provider documentation education and tips to new providers as part of the on-boarding process. III. Reimbursement Strategies: Find solutions to minimize the negative financial impact to your practice of being the debt collector for deductibles and other patient cost-share. Get involved in the industry through advocacy and fight bad payor behavior, downcoding, and balance billing laws. Use all appeal, dispute resolution, and arbitration options available to you. IV. Alternative Care Models: Consider alternative care models such as Observation, Telehealth, Ultrasounds. V. Practice Management: Every Emergency Medicine group must deal with multiple complex business issues, due to many fluid parts and ever-changing details. Ongoing practice management assistance such as physician compensation plans, staffing models, and practice expenses can make a big difference in achieving superior business performance of the practice. We understand that each group is unique in its group structure, annual volume, communities they serve, and hospital partner relationships. Additionally, each group has its own unique set of challenges and opportunities. That is why it is so important to partner with an expert in RCM and Practice Management, like Gottlieb, so you can focus on what matters most â&#x20AC;&#x201C; providing the highest level of care to patients.

Weâ&#x20AC;&#x2122;ve Got This.

Gottlieb.com

ULTRASOUND ZOOM

Point-of-Care Ultrasound in Pulmonary Embolism By Andrea Alvarado, MD, PGY-2 Jackson Memorial Hospital

Are you concerned about your patient who is short of breath? Is your patient hypotensive, tachycardic and too unstable for the “donut of truth” (also known as the CT scanner)? I know—I have been there. Identifying the etiology of shock can be nerve-racking in unstable patients, and when it is pulmonary embolism (PE), it can be scary as a large percentage of patients end in sudden death. We as emergency physicians need to be empowered to diagnose and manage such patients at bedside in the emergency department, and one of the best ways to do that is with point-of-care ultrasound. Our strategy needs to be directed towards examining the heart, lungs and lower extremity veins. Read on for my technique and tips!

TECHNIQUE A. Cardiac Probe: Phased array probe

Fig. 1: Summary of sensitivities and specificities Sign

Sensitivity Specificity

RV Dilatation

80%

McConnell

22%

97%

D-Sign

26%

95%

TAPSE

64%

61%

Edited by Leila Posaw, MD, MPH

Emergency Ultrasound Director, Jackson Memorial

Pre-set: Cardiac Patient position: Supine position with left arm over the head; left lateral decubitus may help bring the heart closer to the chest wall in order to achieve a better apical four-chamber (AP4C) view. Technique: If the display marker is on the left, the probe marker will point to the left hip for the parasternal long axis view (PSLAX), the right hip for the parasternal short axis view (PSSAX), and the right flank for the sub-xiphoid (SX) and AP4C.

B. Lung Probe: Curvilinear probe or Linear probe Pre-set: Thoracic (Lung) Patient position: Sitting upright or lying supine with elevated torso. Technique: The probe is placed perpendicular to the ribs in order to acquire a view of the pleural space between two rib shadows. The 12-view examination is performed bilaterally at the anterior thorax mid-clavicular line, lateral thorax at the mid-axillary line, and posterior thorax, with a close inspection of the costophrenic angles for pleural effusion.

C. Lower Extremity Veins Probe: Linear probe Pre-set: DVT Patient position: Reverse Trendelenburg with external hip rotation and approximately 30 degrees of knee flexion. Technique: Compression is applied EMpulse Fall 2020

at the common femoral vein (sapheno-femoral junction), the superficial femoral vein, and the popliteal vein. Lack of compression (with pressure sufficient to cause tenting of the artery) is indicative of thrombosis.

POCUS SIGNS A. Cardiac

Based on a meta-analysis published by Fields et al. in 2017, undefined right heart strain is a common ultrasound finding in PE with a sensitivity of 53% (95% CI, 45%-61%) and a specificity of 83% (95% CI, 74%-90%). Multiple other ultrasonographic signs, including ventricle size ratio, paradoxical septal motion, tricuspid regurgitation, 60/60 sign, McConnell’s sign, right heart thrombus, right ventricle (RV) hypokinesis, pulmonary hypertension, RV end-diastolic diameter, tricuspid annular plane systolic excursion, RV systolic pressure, and early systolic notching, have been identified. Due to variable specificities and sensitivities (Fig. 1), no single sign is sufficient to exclude PE. Although, visualization of a clot in transit is the most specific sign. The following six signs (three related to size and three related to function) are simple to perform and suggest acute right heart strain. Continue on page 40 » 39

Fig. 2: TAPSE. Courtesy of Michael Traum, MD

Continued from page 39 Size: (1) RV dilatation, (2) McConnell’s sign, and (3) D-Sign Function: (4) TAPSE, (5) S’, and (6) FAC 1. Right Ventricular Dilatation Significance: RV dilatation is suggestive of acute RV strain. Technique: RV end diastolic diameter should be measured at the midlevel in the AP4C view. A diameter greater than 35mm is suggestive of RV dilatation. Alternatively, obtaining a ratio of RV to LV enddiastolic diameter greater than 0.6 is considered abnormal. 2. McConnell’s Sign Significance: McConnell et al. compared RV dysfunction in patients with acute PE with patients with chronic pulmonary hypertension, and found that the cardiac echocardiogram in patients with acute RV strain had an akinetic RV free wall while the apex had normal contractions. McConnell’s sign is 94% sensitive for acute right heart strain. In subsequent studies, this sign has been found in patients with acute RV infarct and 17% of chronic pulmonary hypertension,

and thus is far from definitive proof of PE. Technique: McConnell’s sign is visualized best in the AP4C view. 3. Paradoxical Septal Motion (D-sign) Significance: Septal wall flattening or deviation toward the left ventricle (LV) is another marker of RV dysfunction that can clue us into identifying the presence of right heart strain. D-sign is suggestive of elevated RV pressure. Technique: Paradoxical septal motion is assessed in the PSSAX view. Abnormal septal motion is characterized by flattening of the septum and deviation towards the LV during diastole.

4. Tricuspid Annular Plane Systolic Excursion (TAPSE) (Fig. 2) Significance: RV function has been shown to correlate with the RV free wall excursion, or TAPSE. Preliminary studies also suggest that the use of TAPSE in tachycardic and hypotensive patients increases the sensitivity for identifying acute PE. A normal value is >20 mm, and excursion of less than 16mm is considered abnormal, and suggestive of RV systolic dysfunction and, consequently, RV strain. Technique: The goal is to measure the movement of the tricuspid annulus from the end of diastole to the end of systole using M-mode. Step 1: Obtain the A4C view. Step 2: Place the M-mode marker through the lateral tricuspid annulus. Step 3: Measure the distance from the peak to the valley.

POCUS-PE.to.go

• Cut along the dotted border of the table below, fold along the bold line and stick in your wallet to reference onthe-go. Courtesy of authors Leila PoSaw, MD and Andrea Alvarado, MD, PGY-2

POCUSPE Cardiac probe

Is there RV dilatation?

Is there a D-sign?

Is the TAPSE < 17 mm?

Is there a McConnell’s sign?

Are there A-lines?

Is there a DVT?

Are there sub-pleural consolidations?

Curvilinear probe Linear probe

Figure on PPT

POCUS -PE

EMpulse Fall 2020

Figure on PPT

Fig. 3: S’. Courtesy of Michael Traum, MD

5. Systolic Excursion Velocity (S’) (Fig. 3) Significance: The S’ is a measure of RV systolic function, and a velocity less than 10 cm/s is suggestive of depressed RV function. Technique: Step 1: Obtain the A4C view. Step 2: Turn on the TDI mode. Step 3: Place the PW Doppler on the lateral free wall near the tricuspid annulus. Step 4: Measure the velocity of the S’ wave. 6. Fractional Area Change (FAC) (Fig. 4) Significance: FAC is another measure of RV systolic function. Values greater than 32% of change are indicative of normal RV systolic function. FAC <30% is mild, <24% is moderate and <17% is severe depression of the RV systolic function. Technique: This is performed in the A4C view by tracing the RV cavity to calculate the area at the end of diastole and at the end of systole. FAC is a function of the change in area divided by the end-diastolic area.

B. Lung (Fig 5)

The thoracic ultrasound is not the single best imaging modality especially if used alone. However, if abnormal or when used in conjunction with the cardiac or lower extremity (LE) venous ultrasound, the lung ultrasound may be extremely helpful. The association of a normal (A-profile) lung POCUS with a positive LE venous scan has been shown to favor the diagnosis of PE. Recently, several lung abnormalities have been described for PE, including the (1) presence of multiple lesions, (2) rounded, polygonal or wedge shaped lesions, (3)

Fig. 4 FAC. Courtesy of Brittney Giuffre, MD

(DA - SA)/DA %

Fig. 5: Normal lung and sub-pleural consolidation

Normal lung

Sub-pleural consolidation

associated pleural effusions, (4) right lung affectation more than left, (5) and posterior lower lung findings. In patients presenting with dyspnea, thoracic ultrasound can help rule out other etiologies of respiratory distress such as pneumonia, pulmonary edema, pneumothorax, or COPD/asthma. Sub-pleural consolidations Thoracic ultrasound seeks to evaluate the pleural line for subpleural consolidations that may be representative of pulmonary infarction. The majority of findings occur in the posterior and inferior areas of the lung. Some studies suggest that pleural lesions between 0.5cm to 3cm are more indicative of PE. EMpulse Fall 2020

C. Lower Extremity Veins

In patients undergoing clinical evaluation for PE, a LE ultrasound with positive findings for deep venous thrombosis increases the pre-test probability of the patient having a PE. In the right clinical context, POCUS has the power to quickly raise or lower clinical suspicion for PE. It is important to keep in mind that POCUS is a rule-in test for PE. While the specificities of these exam findings are high and help us rule in the diagnosis, these findings have poor sensitivities and cannot be used to rule out the Continue on page 43 » 41

MUSINGS FROM A RETIRED EMERGENCY PHYSICIAN

Leadership in Crisis By Wayne Barry, MD, FACEP FCEP Member

Sixty-two years ago, when I was in the 5th grade, I decided I wanted to study science. Through my personal journey of studying biology, chemistry, physics and math in high school, pre-med biology in college, medical school and residency training inspired by gifted researchers and clinicians, I never encountered such a barrage of attacks on the truth that is science as I have experienced during the past 3.5 years. There is climate change denial, relentless relaxation of pollution control regulation, endorsement of the use of coal and the preservation of fossil fuel energy sources, the de-emphasis of renewable energy use, and finally, the catastrophic refusal to listen to the counsel of some of our country’s wisest and most astute scientists and public health officials with respect to the current Covid pandemic crisis. These are all examples of the repudiation of basic scientific facts, which have become contaminated by the base agendas of politicians. I have followed the career of Lasker Award winning Dr. Anthony Fauci (who is not that much older than I), and I am appalled at politicians and pundits who call him confused and unnecessarily pessimistic about the progress of the coronavirus epidemic. Fox News’ broadcast host, Tucker Carlson, called Dr. Fauci a “fraud and the buffoon of the professional class.” Senator Rand Paul, a physician himself, who even contracted the coronavirus, does not consider Dr. Fauci an authority on Covid-19 issues, even though he is the head of the National Institute of Allergy and Infectious Diseases. Sen. Paul believes in herd immunity at the 21% population infection rate in places such as New York City. He did not believe there would ever be a surge of cases, and he is not so sure that a vaccine is our hope for ending the 42

crisis. He must have slept through his public health classes during medical school! More important than ‘which political pundit disparaged which accomplished and distinguished scientist’ is the tragedy of over 200,000 dead Americans as a result of Covid. Did this really need to happen? Failure to recognize the seriousness of the pandemic soon enough by the leadership in our country is largely to blame. Then, the attempts to place favorable, political spins on the consequences of the epidemic paralyzed U.S. leadership into a disjointed and politicized response, which served no good purpose. I am still trying to figure out why the richest and most technologically advanced country in the world leads all countries in both the number of cases and deaths due to the coronavirus. The first mistake in my opinion was putting the economy above the safety of the American people. Failure to close down high risk activities in the community, reopening too soon, and then politicizing mask wearing vs. non-mask wearing has resulted in needless extra numbers of dead Americans. Case in fact is the Sturgis, South Dakota motorcycle rally where nearly nobody wore a mask: 250 of the 500,000 attendees contracted Covid, and then caused 250,000 infections in the 11 states they went home to! More scandalous is the nationwide lack of PPE for healthcare workers. The Trump Administration has always maintained that we have always had enough PPE to keep our healthcare workers safe, and that we have access to unlimited stockpiles of this equipment. You, the readers of this article, working Florida’s EDs, may know best whether this is true or not. Over 1,200 healthcare workers have died from Covid since March EMpulse Fall 2020

in this country. The lack of a widespread uniform procedure for testing the U.S. population in order to more accurately gauge the extent of infectivity among the population as a whole, and not making a sufficient number of coronavirus tests available with quick turnaround results, is regrettable. I am thankful that I am tested every two weeks and that the result takes only three days to come back. Meanwhile, my adult children in Texas and Tennessee have never been tested! It doesn’t take rocket science to listen to the advice of public health experts. Other countries seem to have handled the coronavirus crisis more efficiently and safely for their populations. Germany, for instance, who has tested many more of their people than the U.S., is one such country. Their rate of deaths is 9.24/100,000 people, while that in the U.S.—with probably far fewer tested people — is 24.66/100,000. In order to deal with the economic fallout of the pandemic, Germany instituted a nationwide program called “Kurz Albeit,” which in German means “short work.” The German government spent lots of money (not unlike the multi-trillions of dollars the U.S. has spent) to pay all laid-off workers and businesses required to close between 60-80% of their usual pay. I like the idea of giving temporary government subsidies to ensure that employees and employers of pandemic-closed businesses stay economically viable while keeping everybody safer. Thanks to the Federal Reserve, interest rates are so low that leveraging huge debt for the future is a little less unpalatable.

Continue on the next page »

Articles continued: MUSINGS FROM A RETIRED PHYSICIAN: LEADERSHIP IN CRISIS

THE SHOW MUST GO ON: MEDICAL EDUCATION IN THE FACE OF COVID IN FLORIDA

Continued from page 42

Continued from page 35

If General Motors can turn their assembly lines into making ventilators, I see no reason why other U.S. industrial sites could not turn themselves into super PPE manufacturing sites to ensure sufficient supply of this commodity for healthcare worker safety. Finally, there should be a nationwide strategy led by public health experts to conduct widespread and regular virus testing in order to more precisely guide therapeutic and quarantine measures. Let us hope that the winner of the upcoming election can help us right the course of our misguided nation during this pandemic, and that a safe FDA- and CDC-approved vaccine will soon be able to save us from this deadly scourge. ■

multiple screens as often as possible, assign a moderator to monitor chat features, incorporate scheduled breaks, have shorter lecture topics/ time, and make each conference as interactive as possible. Other recommendations center around assigning a “technology” champion (faculty or resident) to help others, evaluate your program’s use of a learning management system, use the asynchronous chat feature of digital platforms to continue the learning and foster a positive learning environment beyond the didactic sessions, and collaborate with others (this is the best time to get national speakers to lecture to your residents!). As we journey forward, we can look back and see how undergraduate

and graduate medical education has metamorphosed. The medical students have returned with limitations, yet how will they learn the full scope of emergency medicine with this limited view? Medical education is no different and has been forever changed by the COVID-19 pandemic. Our eyes are fixed on screens, from TVs to smartphones and computers— but remember to take a moment and look up and to the future. Now is the time to use the challenges that were thrust upon us to create innovation and scholarship. Let us join together as we catapult ourselves into a forward-thinking medical education community within emergency medicine and the state of Florida. ■

REFERENCES: 1. Russell SW, Ahuja N, Patel A, O'rourke P, Desai SV, Garibaldi BT. Peabody's Paradox: Balancing Patient Care and Medical Education in a Pandemic. Journal of Graduate Medical Education. 2020;12(3):264-268

ULTRASOUND ZOOM: POINTºOFºCARE ULTRASOUND IN PULMONARY EMBOLISM Continued from page 41 presence of PE. Nonetheless, POCUS is an invaluable skill that facilitates the early diagnosis and management of PE, and is worthy of consideration in your next patient in shock. ■

RV Function RV Dilatation

McConnell’s Sign

D-Sign

TAPSE

Lung

DVT

REFERENCES: 1. Fields JM, Davis J, Girson L, et al. Transthoracic Echocardiography for Diagnosing Pulmonary Embolism: A Systematic Review and Meta-Analysis. J Am Soc Echocardiogr. 2017;30(7):714723.e4. doi:10.1016/j.echo.2017.03.004 2. Haller EP, Nestler DM, Campbell RL, Bellamkonda VR. Point-of-care ultrasound findings of acute pulmonary embolism: McConnell sign in emergency medicine. J Emerg Med. 2014 Jul;47(1):e19-21. doi: 10.1016/j. jemermed.2014.01.032. Epub 2014 Mar 27. PubMed PMID: 24685451. 3. Avila, J. 2020, Feb 14. Right Heart Strain. Retrieved from https://www. coreultrasound.com/right-heartfunction/ EMpulse Fall 2020

The success of the Florida Emergency Medicine Foundation (FEMF)/Emergency Medicine Learning & Resource Center (EMLRC) is due in large part to our corporate partners who provide annual sponsorship support for our educational programs and events. Thank you to our corporate partners for believing in our mission and helping us provide lifesaving education for lifesavers, even in an unprecedented pandemic.

3717 S. Conway Road, Orlando, FL 32812 www.emlrc.org/fcep | (800) 766-6335

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Non-Profit Org. U.S. POSTAGE PAID Pontiac, Illinois PERMIT NO. 592

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EMpulse Fall 2020

Articles inside

The Show Must Go On: Medical Education in the Face of COVID-19 in Florida

Ultrasound Zoom

EMS/Trauma

Sponsored: Practice Optimization Opportunities

Poison Control: Don’t be Blind to the Risk of Contaminated Hand Sanitizers

Sponsored: Hospice is a Valuable COVID-19 Resource for Overburdened EMS Professionals

Life After Residency Recap

Medical Student Council

Virtual SBS Recap

Medical Economics: Florida Balance Billing Out-of-Network Dispute Summary

ACEP President’s Message

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