This issue of EMpulse is dedicated to Dr. Salvatore “Sal” Silvestri, for his devotion and endless support to the emergency medicine community.
Volume 24, Issue 1 SPRING 2017
Official Publication of the Florida College of Emergency Physicians A Chapter of the American College of Emergency Physicians
An O verview of E mergency M edicine Days 2017
A D edication P age to D r . S alvatore S ilvestri INSIDE THIS ISSUE: PHOTOS FROM EM PAYMENT REFORM SUMMIT
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Chapter Updates
President’s Message | 4 Medical Economics Committee | 6 Government Affairs Committee| 7 EMS/Trauma Committee | 8 Leadership Academy Update | 10 Membership & Professional Development Committee | 11
Florida College of Emergency Physicians 3717 S. Conway Road Orlando, Florida 32812 t: 407-281-7396 • 800-766-6335 f: 407-281-4407 www.emlrc.org/fcep
Medical Student Committee | 12 EMRAF Committee | 13 ACEP Board Update | 17 Residency Matters | 18
FCEP Executive Committee Jay L. Falk, MD, MCCM, FACEP • President Joel Stern, MD, FACEP • President-Elect Joseph Adrian Tyndall, MD, MPH, FACEP • Vice President Kristin McCabe-Kline, MD, FACEP • Secretary/Treasurer
Features
Steven Kailes, MD, FACEP • Immediate Past President Beth Brunner, MBA, CAE • Executive Director
Dedication Page to Dr. Salvatore “Sal” Silvestri | 5
Editorial Board Karen Estrine, DO, FACEP, FAAEM • Editor-in-Chief karenestrine@hotmail.com Samantha Rosenthal • Managing Editor/Design Editor srosenthal@emlrc.org
All advertisements appearing in the Florida EMpulse are printed as received from the advertisers. Florida College of Emergency Physicians does not endorse any products or services, except those in its Preferred Vendor Partnership. The College receives and distributes employment opportunities but does not review, recommend or endorse any individuals, groups or hospitals that respond to these advertisements. NOTE: Opinions stated within the articles contained herein are solely those of the writers and do not necessarily reflect those of the EMpulse staff or the Florida College of Emergency Physicians.
Daunting Diagnosis | 9 Poison Control | 15 Florida Emergency Medicine Residency Match 2017| 22 Advocating for Emergency Medicine: A Recap of EM Days 2017 | 23 Snapshots from EM Days 2017 & EM Payment Reform Summit| 24 EM Payment Reform Summit Brings Together EM Leaders from Across the U.S. to Discuss State and Federal Regulations | 25 EM Case Reports | 27 Climate Change: A Health Crisis Call to Action | 28 UCF/HCA Emergency Medicine Residency Program Attends the 58th Presidential Inauguration| 29
Published by: Johnson Press of America, Inc. 800 N. Court St. Pontiac, IL 61764 Phone: 815-844-5161 Fax: 815-842-1349 www.jpapontiac.com
Formation of the FIU-FAST Team | 30 Musings of a Recently Retired Emergency Physican | 31
COVER PHOTO BY: Samantha Rosenthal, FCEP Communications Manager
SPRING 2017 | VOLUME 24, ISSUE 1
EMpulse | 3
President’s Message There really are no words that can fully express the grief and sorrow we feel when we lose a dear friend and member of our emergency medicine community. As emergency physicians, we are painfully aware of how tenuous our existence is as human beings. Every day we see people whose lives are dramatically changed or ended by acute illness or injury, yet we are conditioned by our training to wall off our feelings so that we can perform professionally. And yes, at times the human tragedies we see get to us, and we comfort one another with debriefings and counseling. But the untimely passing of Dr. Salvatore Silvestri on February 26, 2017 has truly shaken us to our core. This is a loss we will feel for a long, long time. “Dr. Sal”, as his EMS colleagues called him, leaves behind a legacy of caring, competence and generosity. His passion for providing the best possible care in the pre-hospital and emergency settings was matched only by his passion for educating the next generation of paramedics and emergency physicians, and his Jay Falk, MD, MCCM, FACEP love for his family. He served as Orange County EMS Medical Director from 2000-2005. His leadership transformed the system into one of the best in the country. Sal was the Program Director of the Emergency FCEP President Medicine Residency Program at Orlando Health since 2005. He created a true family atmosphere in which our residents flourished, while showing them, by example, how to achieve their professional goals. I am writing this column having just attended Sal’s funeral in his old neighborhood Parrish Church in the Bronx. A substantial delegation of faculty and graduates from his ORMC family complemented the large crowd of local family and friends. Several former residents, who had completed the program over a decade ago, attended from distant parts of the country. The priest remarked during the moving mass at how remarkable Sal’s relationships must have been to have so many attend from Florida, despite having comforted the family at visitations in Orlando. Sal was generous with his time to all he had contact with. While being very involved in EMS and EM education nationally (ACEP, CORD and NAEMSP), he made time to be very involved with FCEP and FEMF. Here is a list of work he did for our organizations: FLORIDA COLLEGE OF EMERGENCY PHYSICIANS ACTIVITIES: 1. Medical Editor, FCEP Newsletter, October 1994 – October 1995 2. Chairman, Communications Committee, October 1994 – October 1995 3. Editorial Staff, FCEP Newsletter, July 1992 – October 1995 4. Chairman, Paramedic appeals process Ad Hoc Committee, Florida Association of EMS Medical Directors, 1994 5. Board of Directors, 1997 – 2003 6. Education Committee, July 1999 to present 7. ClinCon 1999 Planning, and ALS Committee, 1999 - 2000 8. EMS Summit 2000 Planning Committee 9. Member, Academic Affairs Section, 2005 to present 10. ClinCon Planning Committee, 2006 – 2009 11. Co-Chair, Education Committee 2015 - present FLORIDA EMERGENCY MEDICINE FOUNDATION: Board of Directors: 2013-present FLORIDA DEPARTMENT OF HEALTH STATE COMMITTEES: 1. State Emergency Medical Services Advisory Council, Florida, 2001 - 2005 term 2. State EMS Education Committee Chairman, January 2004 - July 2005 3. Emergency Medical Review Committee (Pediatric / Neonatal), March 2008 – March 2012 4. Co-Chair, Local Planning Committee, Emergency cardiovascular Care Update (ECCU) 2012. Orlando, FL. September 15, 2012. Sal mentored medical students, residents, fellows and faculty. He had a profound impact on the development of future leaders in emergency medicine and, perhaps most importantly, on the associate program directors at ORMC who will carry on his legacy at our program. Why such a wonderful soul was taken from us so suddenly and prematurely is an unanswerable question, yet here we are. I feel like the lesson is that we need to enjoy our blessings every day. We should focus our time and energy on what matters most to us and pursue these endeavors with passion and love. That’s what Sal did. That’s why he was so happy and fulfilled. That’s why we all loved him.
FCEP President Academic Chairman, ORMC Department of Emergency Medicine
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Be More Like Me To honor me is to be more like me To speak up for those who cannot speak is to be more like me To be humble and to be kind is to be more like me To be patient and considerate is to be more like me To have fun and to be silly is to be more like me To only see the good in others is to be more like me To put others before yourself is to be more like me To eat good food and drink Brunello is to be more like me If you come to a crossroad and cannot decide Be more like me To stay on the path and move from good to great is to be more like me Remember, I’ll always be watching and smiling So try to be more like me Written by Francesca Silvestri in memory of her father, Salvatore Silvestri, MD, FACEP
SPRING 2017| VOLUME 24, ISSUE 1
EMpulse | 5
Medical Economics Committee Sal Silvestri, MD
Despite our usual focus on EM medical economic issues in this space, I wanted to honor the legacy of our colleague and friend Sal Silvestri, MD who passed away on February 26, 2017. As Orlando Health EM Residency Program Director and Orange County EMS Associate Medical Director, Sal most closely impacted the hundreds of EM residents, fellows and paramedics he oversaw during his tenure. However, all who met him knew his definition of friend and family were indistinguishable. His quiet demeanor could not hide his kindness, love and devotion to his trainees. His circle of friends was wide, and his colleagues all have personal memories of his thoughtfulness and selflessness.
Daniel Brennan, MD, FACEP Medical Economics Committee Chair
His impact within FCEP was similar, as co-chair of the Education/Academic Affairs committee and serving on the FCEP and FEMF Boards. Having worked with him the past two decades, I feel lucky to have known him, learned from him, and I was blessed to have him as a colleague, co-Orioles fan, friend and “brother”.
FCEP’s Medical Economics Committee continues to advocate for FCEP EM physicians, meeting on January 25, 2017 in Tallahassee with representatives of the Office of Insurance Regulation (OIR), the Agency for Health Care Administration (AHCA) and Florida CFO’s Insurance Consumer Advocate (ICA). Dr. Duva, FCEP Lobbyist Toni Large and I presented data illustrating the noncompliance of Humana with last year’s balance billing legislation, as well as improper payment clawback attempts we feel violate the preexisting prompt pay statutes. Dramatic reductions in payments by Humana, incorrect out-of-network payment allowables, and aggressive maneuvers to recoup alleged “overpayments” have impacted many EPs throughout Florida. Although AHCA, OIR, and ICA appeared supportive of our concerns to date, no definitive action or plan to address them has been shared. The other key economic issue from last year’s legislative session was the transparency law and the selection of a vendor to build Florida’s consumer healthcare cost database. FCEP strongly advocated for FairHealth, but the RFP process awarded the contract to HCCI/Guroo, what many view as a thinly disguised Ingenix redux due to their support and control by insurers. We will see how the process plays out – thus far it is not clear how the database is envisioned to be used. On the surface, it appears to be more an issue for hospitals than EM providers, but FCEP should encourage the FMA and FHA to get more involved than they were last session on this issue as the database is developed. In terms of economic issues this session, PIP repeal will be the largest issue. Various legislators and the OIR have pushed for repeal of PIP for several years, and last summer, CFO Atwater spent $125,000 for a study of PIP repeal. The study showed PIP reform in 2012 (HB 119) resulted in significant PIP savings1 – with reductions across the board: in PIP costs 17.5 percent, PIP premiums 15.1 percent, claims frequency 10.2 percent, claims severity 10.9 percent, and PIP loss costs 20 percent. Compared to trends outside of Florida which showed 4.1 percent cost increases over the same period, the relative Florida savings were 23.2 percent, in line with the projections expected of 22.7 percent. Despite the fact that the 2012 reforms worked, legislators seem intent on repealing effective reforms in place, citing that the savings are less in the most recent years compared to the first years post reform. Still saving, just not as much. “If it isn’t broken…” does not seem to resonate apparently. For consumers, the repeal of the $10K PIP coverage would save an average of $81 annually. But replacement of PIP with $5,000 of medical payments coverage would cost $72/year, for a grandiose net savings of $9 annually for half the coverage. This is the data their own commissioned report generated, so it is extremely vexing to see PIP repeal still being discussed. From a pure EM perspective, PIP coverage is extremely important to our practices’ ability to maintain coverage, as current PIP coverage provides no fault coverage for drivers, passengers and pedestrians, and provides payments promptly and at adequate rates. PIP payments provide revenue that supports additional safety net care in all EDs and trauma centers. Hopefully, FCEP advocacy will be persuasive, joining the FMA who have pointed that with ACA changes likely nationally, perhaps caution with insurance repeal on the state level would be wise.
Reference: 1. http://www.floir.com/siteDocuments/FLOIRReviewPIP20160913.pdf
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Government Affairs Committee As I write this article, we are less than two weeks away from Emergency Medicine Days. Many of us have planned and prepared for this event, which is the culmination of our advocacy efforts over the past year. There are numerous bills on the agenda, some of which are still in committee. Let’s take a quick overview of those that hit FCEP’s strategic initiatives:
Sanjay Pattani, MD, FACEP Government Affairs Committee Co-Chair
1. HB 3627 Relating to Florida Emergency Medicine Foundation - Education Clearinghouse for Emergency Medical Services (Miller) — The intent is to create funding and utilize EMLRC as a centralized base for statewide EMS education and training. 2. HB 461/HB 1063/SB 156 Motor Vehicle Insurance, Repeals Florida Motor Vehicle NoFault Law & requirements for personal injury protection coverage — FCEP closely watching, anticipating mandatory bodily injury or Med Pay type of amendments. 3. HB 249/HB 61/SB 558 Drug Overdoses, Requiring certain persons to report controlled substance overdoses — FCEP working closely with Legislators, anticipating strike all bill with more HIPAA friendly amendments.
We are also closely monitoring changes in bills dealing with: • ARNP scope of practice laws • Certificate of Need repeal • Any Willing provider legislation to allow for out of network care • Trauma center designation and certification Our continued desire to educate legislators on the potential pitfalls of using HCCI instead of Fair Health Database will be bolstered by using ACEP’s press release in the New England Journal of Medicine: "Surprise” Gaps in Health Insurance Coverage Need Solutions; ACEP Calls for Fair Coverage. FCEP will also educate our legislators on the NORC report that depicts a study from 2014 that was commissioned by CCIIO in order to assess available sources for charge databases: • • • •
The conclusions of the study were favorable toward FAIR Health. CCIIO did not initially make this report publicly available. ACEP only learned about it as a result of its inclusion in the administrative record related to our litigation. It is now a public document.
There is a feeling of anxiety, yet energy in the air. I hope to see you in a couple of weeks. This is where the rubber hits the road, and our time and investments spent through our PC will hopefully pay off. I look forward to our visit to Tallahassee.
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EMpulse | 7
EMS/Trauma Committee We all have people that significantly impact us throughout our lives. Unfortunately, our community has suddenly lost a dear friend who undoubtedly had a profound impact on medicine, EMS, paramedics, EMTs, residents, fellows and patients. Salvatore Silvestri was a role model, not only as a physician and leader but also as a father, brother, friend and mentor. I am who I am today because of his influence. Thank you Sal for all the guidance, fun and food. Your memory and legacy will live forever in all of us. As 2017 progresses and the weather gets warmer, we will likely see a decrease in the presentation of patients with viral illness and influenza. We can then expect an increase in outdoor activities along with related trauma and heat-related illness. It is never a dull moment for EMS in Florida!
FAEMSMD (FLORIDA ASSOCIATION OF EMERGENCY MEDICAL SERVICE MEDICAL DIRECTORS) UPDATE FROM JANUARY 2017
Christine Van Dillen, MD, FACEP EMS/Trauma Committee Co-Chair
State Trauma Criteria
Integration of the CDC criteria into the Florida Trauma scorecard Methodology continues to be on hold at this time, pending additional rule workshops and discussion. There are already plans to utilize the new EMSTARS version 3.3 to assist the State of Florida in the review trauma outcomes and utilization of this information to improve our guidelines and transport destination decisions.
Stroke
On January 17, 2017, the Department of Health legislative committee met with the American Heart Association regarding stroke systems across the state, focusing on issues as they pertain to EMS. There is potential to soon see new legislation to update the Florida Stroke Act. Another one of the main considerations is to develop and promote widespread use of a tool to identify risk of large vessel occlusion (LVO) stroke in the field. Currently, stroke evaluation is done differently across the state with several different tools. Most of the stroke evaluation tools include a bilateral strength exam in the extremities and evaluation for facial droop along with speech, but when differentiating between a LVO and a small vessel occlusion (SVO) cortical signs (gaze, agnosia, neglect) must be added.
DEA Update
H.R: Protecting Patient Access to Emergency Medications Act of 2017 focuses on how Emergency Medical Service agencies and personnel obtain, store and administer controlled substances on a regular basis. As discussed in our last update, this bill passed on January 9, 2017 and went onto the Senate committee on January 10,2017.
Protocol Database
FAEMSMD has an exciting update regarding their website and tools for members. The Florida EMS Protocol Database is in its finally testing phases, and it should be up and running within the next month. This is a password-protected database, where protocols are categorized by the various counties in Florida. This could be very useful for the medical directors across the state.
POLST-Physician Orders for Life Sustaining Treatment
There is another bill in the senate: SB 228: Physician Orders for Life Sustaining treatment. It was effective by July 1, 2017 but the last action was noted on January 12, 2017 in the Senate where it was pushed to the judiciary Appropriations Subcommittee on Health and Human Services. Also, there is currently no House companion. POLST, if approved, would be extremely helpful in following our patients’ wishes for their care at the end of life. It specifies many forms of treatment other than just do not resuscitate after a pulse has been lost. Use of this form has been accepted by many other states across the U.S. This provides limited immunity for legal representatives and healthcare providers who act in reliance with these forms. FAEMSMD and FCEP EMS/Trauma Committee members are in support of this form being adopted in the State of Florida. There have been proposed changes for workshops at the state level to eliminate details currently required in the contracts for EMS Medical Directors in Florida. FAEMSMD and FCEP EMS/trauma Committee plan to create a position paper to communicate our concern regarding replacing these requirements either in another rule or statute. The American Board of Emergency Medicine recently accepted EMS as a subspecialty, created accredited fellowships and offered a certification exam to become EMS certified. We feel this is an important movement for EMS across the US and the world to standardize training of EMS physicians and improve quality of care provided in the field.
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To work to perfect our physicians’ ability to practice medicine, every day, in everything we do.
D au n t ing D iagn o s i s Question: A 23-year-old female presents to the emergency room after four doctor visits for joint pain. She has now developed a rash on her lower extremities. What is her diagnosis? Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief
Turn to page 10 for the answer!
Thanks to all who made contributions to the Political Committees in December 2016, January 2017 & February 2017! Ian Backstrom Jacqueline Kay Barnes Laurie Boge Jerry Thomas Brooks Timothy Bullard Mark Edward Caputo Carlos Castellon Jordan Celeste Roland Clark Steven Eccher Michael Estep
Robert Allen Farrow Stephen Scott Feilinger Manning H Hanline Stanley Wayne Janasiewicz Steven Kailes Frederick Michael Keroff Thomas Leonard Margarita S Martino Raymond McLane Pamela Miller Ricardo Santayana
SPRING 2017 | VOLUME 24, ISSUE 1
Mary Elizabeth Schmieder Joel Stern John Stimler Robert Tober Jon Van Heertum Janessy Vasquez Juan Felipe Villegas Therese Marie Whitt Joshua Young
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Leadership Academy Update The annual Emergency Medicine Days conference in Tallahassee signifies many things for our Florida College of Emergency Physicians. As we gather to meet with Florida legislators at the annual conference, we realize there is still much work to be down in the ways of educating the public and advocacy for our specialty. This is best accomplished by having all hands on deck and reaching out to new members, EM residents and medical students alike. One area of particular interest and excitement is FCEP's Leadership Academy. For those of you not familiar, the Leadership Academy exists to promote participants to pursue the highest-quality emergency medical care, education, and empowerment of emergency physicians to better protect the patients they serve across our great state. The Leadership Academy typically selects only two to four candidates each year across the entire state of Florida. It combines elements of mentoring along with a high level of organizational & educational skills, and leadership experiences - all from some of our most influential EM leaders across the state Florida and ACEP nationally.
Pat Agdamag, MD, FACEP
FCEP Board Member; Chair of FCEP’s Leadership Academy
Some of the venues they will be taking part in include: FCEP's Board of Director meetings, FCEP's Committee meetings, as well as Tallahassee state legislature meetings (Emergency Medicine Days) and ACEP national assembly meetings. For those not familiar with FCEP's Leadership Academy, it combines elements of mentoring, organization, and guided experiences to carefully selected Academy participants who want to grow in their interest area(s) of emergency medicine. The Academy brings all the ingredients needed to grow leaders in our field, while harnessing their targeted areas of interest.
The time commitment for the Academy fits nicely with the hectic schedules we have in our busy lives and practices. Our gatherings center around three to four large conferences and our quarterly Board/Committee meetings. The cost of attendance for the Academy program itself is free, and group practice sponsorship is encouraged to help cover any costs for travel and attending conferences. The typical venues include FCEP Board and Committee meetings, state legislature meetings in Tallahassee, Symposium by the Sea, and ACEP's Leadership and Advocacy conference in Washington D.C. One requirement for graduation from the Academy is completion of an administrative project. This can be working toward a medical directorship, research project, administrative or leadership position, and even introduction of new legislation during Emergency Medicine Days in Tallahassee. Our current class is represented by two outstanding U.S. fellows with much experience: Drs. Saundra Jackson (Jacksonville) and Ray Merritt (Tampa). They both attended Emergency Medicine Days and soaked in the unique experiences we face with our specialty in Florida. As FCEP's current Chair of the Leadership Academy, I can attest to the quality of candidates selected. The Academy will no doubt be a springboard for more growth in leadership experiences already garnered and much more. On behalf of FCEP, I once again, would like to personally welcome you to a journey, which reveals a path to progress, growth and opportunity. Visit EMLRC.org for information and to apply to be a part of the this amazing opportunity.
D a u n t ing D iagn o s i s Answer: This patient has classic erythema nodosum, which manifests as tender inflammation of the subcutaneous fat. The red, painful and tender “lumps” are most commonly located on the shins but can affect upper extremities. Multiple etiologies such as medications (sulfa, OCP), fungal diseases, mononucleosis, sarcoidosis, IBD and etc. can cause erythema nodosum. It is usually self-limiting in a period of weeks to months. It is treated with NSAIDS, not steroids. It is most important to understand the etiology of the erythema nodosum in order to treat the underlying cause — although some cases are idiopathic. Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief
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(Question on page 9) SPRING 2017 | VOLUME 24, ISSUE 1
Membership & Professional Development Committee FCEP Goes on the Road! By the time you receive this issue of the EMPulse, FCEP will have visited all of the active (FAU starts July 2017) residency programs in Florida! That’s right, FCEP took our message on the road. Although this is not a new endeavor but with the doubling of EM residency programs in Florida, we felt it was necessary to strengthen our commitment to the established programs and welcome the new ones to the FCEP family. We were able to share with the programs the various ways that FCEP is heavily invested in the health and strength of our residency programs. Residents are always encouraged to participate in the various FCEP events and as such have their own committee within FCEP, the Emergency Medicine Residents’ Association of Florida (EMRAF) and serve as a member of the FCEP Board of Directors.
Rene Mack, MD Membership & Professional Development Committee Chair
Our commitment to members, of course, doesn’t end there. We are available to the entire membership for various levels of communication as individuals or as groups. Are you interested in having your group become a member of the ACEP 100% Club? If you have any questions, please contact the FCEP office or ACEP, and we’ll be glad to help.
It’s not only the FCEP leadership that is portable, many of our programs are mobile, online or rotate around the state. One of the goals of FCEP is to enhance your professional development in a multitude of ways. We have resources ranging from Webinars, recertification courses (e.g., ATLS/PALS/ITLS) and conferences. One of our most notable rotational events is our annual Symposium by the Sea, which is taking place this year at the lovely Boca Raton Resort & Club August 3-6, 2017 (yes, I realize that was a shameless plug). Although we are FCEP, we are committed to the enrichment of the entire emergency medical community, including but not limited to: EMS, nurses, APPs and administrators. Have you ever been to (or asked your EMS professional about) CLINCON? CLINCON is our annual EMS conference, drawing hundreds of participants from around the country, that focuses on strengthening practical skills and enhancing clinical knowledge to optimize patient care. How about the Advanced Practice Providers (APP) Skills Camp? This course is designed by local emergency medicine professionals to enhance the knowledge and skills set of individuals caring for patients in the emergency department, an urgent care setting or for any professional wanting to brush up on their emergency medicine skills. Due to popularity, we have increased this course from an annual offering to several times a year; in fact, the April 2017 course sold out in February 2017!
FCEP Immediate Past-President Dr. Steven Kailes and FCEP Leadership Academy Fellow Dr. Saundra Jackson presenting at the University of Florida - Jacksonville Emergency Medicine Residency Program.
On a more solemn note, most of us have heard by now about the passing of Dr. Salvatore “Sal” Silvestri. He was a prominent figure and humanitarian who helped to shape the Orlando Health EM Program over the past two decades. He was also a distinguished figure in the EMS arena and strove to bridge the gap between pre-hospital and in-hospital care, even extending his efforts to the international arena. His effortless ability to lead and promote humility, professionalism and engagement was a rare combination. As a graduate of the Orlando Health Program, Sal was more than just a Program Director. He was a friend, a mentor and a role model. He will be greatly missed. I will challenge us all to find or further define our purpose. Hopefully, the path leads you toward personal and global enrichment. If you hit a stumbling block or are looking for a partner for the journey, reach out to FCEP — we’re here for you.
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M e di c a l S t u d e n t C o m m i t t e e This edition of FCEP’s Medical Student Committee quarterly update features Florida International University’s Emergency Medicine Interest Group and Nova Southeastern University’s Wilderness Medicine Club. On January 21, 2017, the South Florida Wilderness Medicine Association kicked off its second annual Wilderness Medicine Skills Development Workshop at Taylor Birch State Park. Medical students from all of Florida and the Caribbean had the opportunity to Hannah Gordon practice various skills, including bleeding Secretary-Editor of the FCEP control, treating environmental emergencies Medical Student Committee (such as heat, cold and lightning injuries) and improvised splinting. There was a scene size up station that discussed basic triage and how to run through an assessment as an emergency first responder. The Eckerd College Emergency Response Team ran the stations. This year the event was coordinated by Florida International University medical students Bianca Alvarez, Stephanie Fernandez, Hayley Musial and Alexandra Dadrat, and Nova Southeastern University medical student Jarryd Reed. “We are excited to see how the program has grown over the past two years” FIU medical student Stephanie Fernandez said. “Student interest for wilderness med programs is definitely there. Bianca, Jarryd and I are excited to be leaving something behind when we graduate.” More than 50 students attended, and the program concluded with a mass casualty drill so realistic that concerned bystanders came over to offer help. We would like to extend a special thank you to the Eckerd College Emergency Response Team, Drs. Ben Abo, Darren Kaufman and Jason Mansour, for providing their expertise and support in planning and managing the event.
FCEP Recognizes 100 Percent Membership! We would like to acknowledge the EM groups and hospital that have 100 percent membership in FCEP and ACEP. Thank you for your involvement in both FCEP and ACEP!
All Childrens Emergency Center Physicians Athens-Clarke Emergency Specialist Emergency Medical Professionals , PA Emergency Physicians of Central Florida LLP Florida Emergency Physicians Kang & Associates Florida Regional Emergency Associates Southwest Florida Emergency Physicians Tampa Bay Emergency Physicians UF Department of Emergency Medicine Group University of Florida Jacksonville
EMRAF Committee By the time you’re reading this, Emergency Medicine Days will be complete and we will have matched our new interns for the Classes of 2020 across the state! EM Days saw the involvement of residents from six different programs around the state. We had the opportunity to work closely with the EM leaders around our state to meet with our elected officials and advocate for the best interest of our patients. I highly encourage your support and participation with this exciting event in the future. Additionally, Match Day 2017 will see the biggest intern classes in Florida EM history. With a record 12 EM programs matching new residents, our specialty continues to grow in the Sunshine State – and with it new opportunities for education, leadership and advocacy. Be sure to get your new interns on board with all FCEP and ACEP have to offer and get them involved from the start. Shayne Gue EMRAF President, Florida Hospital EM Resident
On a somber note, we send our love and condolences to the Orlando Health family on the unexpected passing of their program director, and mentor to so many, Dr. Sal Silvestri. Your Florida EM family is thinking about you and praying for you in this time of hardship.
As always, the role of EMRAF within FCEP is to empower residents to learn about all aspects of emergency medicine and to provide a unified voice of emergency medicine residents in the State of Florida. Our primary goal is to increase resident engagement and facilitate the development of a more well-rounded EM resident. This year we are seeking to expand our membership by actively recruiting more resident representatives from around the state. Program representatives are tasked with serving as a liaison between the EMRAF Committee and their respective residency program. As with all FCEP Committees, we meet quarterly, in conjunction with the FCEP Board of Directors at the EMLRC in Orlando and during Symposium by the Sea. We currently have 13 resident representatives from six Florida residency programs (Florida Hospital, Orlando Health, UF Gainesville, University of South Florida, Aventura Medical Center and Osceola Regional Medical Center). Our objective for the 2016-2017 year is to increase our membership to a minimum of 20 resident members, including all 11 Florida residency programs. If you are interested in serving as an EMRAF Liaison for your program, please contact me at shaynegue@hotmail.com.
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EMpulse | 13
FLORIDA
Opportunities
Love your location!
EmCare is seeking physicians in Florida and nationwide. Join our team today! NORTH FLORIDA
Destin Emergency Room (Destin) Fort Walton Beach Medical Center (Ft. Walton Beach) Lake City Medical Center (Lake City) Oviedo Medical Center (Oviedo) Bay Medical Center (Panama City) Bay Medical Sacred Heart Beach ER (Panama City) Gulf Coast Regional Medical Center (Panama City)
CENTRAL FLORIDA
Blake Medical Center (Bradenton) Oak Hill Hospital (Brooksville) Englewood Community Hospital (Englewood) Munroe Regional Medical Center (Ocala) Emergency Center at TimberRidge (Ocala) Poinciana Medical Center (Orlando) Brandon Regional Emergency Center (Plant City) Fawcett Memorial Hospital (Port Charlotte) Bayfront Punta Gorda (Punta Gorda) Central Florida Regional Hospital (Sanford) Lakewood Ranch FSED (Sarasota) Brandon Regional Hospital (Tampa Bay) Citrus Park ER (Tampa Bay) Medical Center of Trinity (Tampa Bay) Northside Hospital (Tampa Bay) Palm Harbor ER (Tampa Bay)
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SOUTH FLORIDA
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LEADERSHIP
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PEDIATRIC EM
Broward Health Children’s Hospital (Ft. Lauderdale) Plantation General Hospital (Ft. Lauderdale) Pediatric Medical Director and Staff Northwest Medical Center (Margate) Mease Countryside Hospital (Tampa Bay) Brandon Regional Hospital (Tampa Bay) Pediatric Medical Director and Staff The Children’s Hospital at Palms West (West Palm Beach)
Full-time, part-time and per diem opportunities. Ask about our EmBassador Travel Team Opportunities!
Poison Control Poison Center Public Health Initiatives Article by Emily Jaynes Winograd, PharmD, Clinical Toxicology/Emergency Medicine Fellow, Florida/USVI Poison Information Center – Jacksonville; Jay L. Schauben, PharmD, DABAT, FAACT, Director, Florida/USVI Poison Information Center – Jacksonville, Clinical Professor, Department of Emergency Medicine, University of Florida Health Science Center – Jacksonville; and Patrick Leffers, PharmD, Clinical Toxicology/Emergency Medicine Fellow, Florida/USVI Poison Information Center – Jacksonville
Most emergency medicine physicians recognize the core mission of the Florida Poison Information Center Network (FPICN) in their provision of emergency poisoning triage and consultation advice. What may not be as well-known are the public health surveillance and disaster support services also provided by Florida’s poison control centers and their impact on Florida’s public health initiatives.
Public Health Surveillance
While we document required patient care data during our conversations with emergency physicians, this information serves a critical secondary purpose for public health surveillance. These efforts allow for the detection, tracking and mitigation of case clusters relevant to a wide range of public health problems. In addition to automated upload and detection algorithms running on our de-identified data sent to both the Florida Department of Health ESSENCE bio surveillance system and the American Association of Poison Control Center’s National Poison Data System, FPICN Heroin time series over three years as viewed by FPICN’s “What’s Trending” dashboard. has developed its own core of surveillance efforts, geared toward quickly funneling such data back into the local clinical arena to facilitate street insight into Florida’s emergency departments. Likewise, FPICN’s foray into developing newer, better surveillance techniques has resulted in Florida having some unique capabilities within its poison control centers. This surveillance is not limited to “drug overdoses” but includes environmental and occupational exposures, bites and stings; food/waterborne diseases; adverse effects of medications; and, of course, trends in street drug abuse. If FPICN has knowledge of trends in your specific area, we attempt to alert the emergency departments pre-emptively. Should you have any questions or concerns on trends in your area, please feel free to contact the poison center to ask or discuss. As you can predict, the surveillance efforts are only as good as the data coming in. Hence, we continue to ask you to work with us.
Disaster Support and Surge Capabilities
FPICN receives ASPR funding through the State of Florida to maintain the capability for providing the Florida Department of Health and the State of Florida with disaster support and immediate surge capabilities during an event of “public health significance”. In the past, when you dialed the Florida Flu (H1N1) Hotline, the BP Deep Water Horizon Hotline, the New England Compounding Fungal Meningitis Hotline or the Blue-Green Algae Hotline, your calls were answered by FPICN staff in disaster/surge mode. Ongoing since February 2016, Florida’s poison control centers operate the Florida Zika Virus Hotline for the Florida Department of Health and has since fielded more than 10,000 requests for Zika virus information from throughout the United States and abroad. During the August 2016 peak of Zika virus concern, the FPICN continued to manage poison exposure calls while also assimilating Zika information requests in excess of 60% percent of our average call volume. This kind of support was possible due to the surge capabilities that have been integrated into the FPICN’s infrastructure. Public health surveillance activities, disaster support and surge capabilities are a part of everyday operations within FPICN. The system developed leverages the expertise of FPICN’s healthcare professionals (nurses, physicians, pharmacists) directly in the center of both these arenas. To learn more about poison control in Florida, and to access poisoning resources for health care providers, please visit: http://floridapoisoncontrol.org/ https://www.facebook.com/FloridasPCC/ https://twitter.com/FloridaPoison SPRING 2017 | VOLUME 24, ISSUE 1
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ICD-10 Documentation Tip: Key to Documenting Fractures • Laterality: Left/ Right • Site of FX: Proximal/ Shaft/ Distal • Displaced vs. Non-Displaced • Mechanism of Injury: How it happened • Etiology of fracture: Traumatic/ Pathologic/ Osteoporosis/ Neoplastic Disease • Closed or Open • Type: Comminuted/ Greenstick/ Oblique/ Segmental/ Spiral/ Transverse/ Compression Burst/ Salter Harris
ACE P B o ard U pda t e The ACEP Board has met twice in person since my last update. Time does fly! We had our annual retreat this past December in Tucson. The retreat is supposed to be a bit less intense than our Board meetings, but in recent years, the agenda has grown to include more business and a bit less brainstorming. This year we started with a review of the election, and its potential impact on the legislative and regulatory environment in Washington DC, which is a discussion that is clearly still ongoing.
Vidor Friedman, MD, FACEP FCEP Board Member, SecretaryTreasurer of American College of Emergency Physicians
Healthcare is front and center of the raging debate in Congress, and it is vital that we marshal our members to influence this conversation. Emergency services and Prudent Layperson standards, are essential community services as defined by EMTALA, and we must do all we can to ensure that they survive the “repeal and replace” process. It would be tragic if the replacement for the Patient Protection and Affordable Care Act left the patient out of the equation.
We had a great presentation from EMRA updating us on all that they are doing. ACEP and EMRA have a great partnership, and both organizations are stronger then ever. We also had a lengthy discussion regarding CEDR, ACEP’s qualified clinical data registry, and how we plan to grow this rapidly over the next few years. While many things may be on the table in the debate about healthcare, the “Pay for Quality” movement is alive, well and is here to stay. One of the difficult things about this program is that the “results” do not happen for two years, so in 2019 your reimbursement for care in 2017 will be affected. If you report no data in 2017, in 2019 you will receive a 4 percent cut on all your Medicare reimbursements. For most of us, that is 30 percent of our volume, and probably 40 percent of our reimbursements since we lose money on 50 percent of our patients. As the program matures, more and more of our reimbursement will be tied to “quality metrics”. My advice is to get on board as soon as possible. It takes time and energy to make this happen, but in the end ,I assure you it will be worth it. We also had presentations regarding our Diversity Initiatives, the roles and duties of a Board member, and had our annual review of the Strategic Plan. To finish up, we had a robust discussion regarding ACEP’s potential involvement in accreditation of EDs. We are doing our due diligence on this, but if not us, then who? Who else would we want to do this? While this is a controversial issue, I believe that we are better off controlling our own practice environment. This is about accrediting the department, not the provider. In early January 2017, we met again in Dallas for our first formal Board meeting of the new year. If you would like to view a summary of all the items that we reviewed, approved and discussed, please contact me and I can provide you with a Drop Box link that has a document that reviews all the items that were on the agenda. Of all the items that we discussed at the Board meeting, the most challenging was how we, the ACEP Board, should respond to the transition that occurred at the Summa Health Emergency Medicine Residency. As we are all too aware, there was a firestorm of social media activity surrounding the abrupt transition that, unfortunately, occurred at this program. ACEP is a nondenominational organization; we have/had members on all sides of this situation. Our primary concern was that the residents in the program be taken into consideration, and that their needs, fears and concerns be addressed. ACEP will be developing a white paper regarding best practices for contract transitions. When completed, it will not only be disseminated to ED groups and the emergency medicine community, but also to hospitals and their administrators. We will be publicizing to our members the availability of existing resources regarding ED contract provisions, negotiations and other related materials. We welcome the input of our members and others as we develop supportive resources. As always, I welcome your feedback, guidance and counsel.
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R e s id e n c y M a t t e r s A new year has begun! See what our emergency medicine residency programs have been up to so far. Winter is now behind us and spring has arrived! Nonetheless, we had a wonderful time during this past winter here at Florida Hospital East. Our residency program hosts a yearly Christmas event with a trip to ICE! at the Gaylord Palms. ICE! is an indoor winter wonderland, and this year’s theme was a Charlie Brown Christmas. Our residents enjoyed walking through this Charlie Brown Christmas-themed attraction, which featured 2 million pounds of hand-carved ice sculptures and displays. All this was kept at a chilly 9 degrees Fahrenheit.
Florida Hospital Day Zayas, MD PGY-2
With all the excitement during these past holiday months, our residents continued to study hard as we prepared for the emergency medicine in-training exam that was scheduled in late February 2017. However, after the exam was finally over, we celebrated being finished by heading over to the Great Escape Room, which is a fun Sherlock-themed escape adventure in which players are locked in a room and have to use elements in the room to solve a series of puzzles with a goal to escape within a set time limit. The game was definitely challenging, but we worked very well as a team and were able to solve many of the puzzles thrown at us allowing us to come extremely close to escaping. We loved our time there so much that we hope to plan another trip soon for a second shot!
Aside from all the fun, we continue to work hard in the department, learning each day from every patient encounter and tackling challenging cases. Interviews have also come to an end, and we have met great potential future residents. We look forward to announcing soon who the newest additions to our team will be.
With the end of the academic year rapidly approaching, residents and program directors met a few weeks ago for our annual retreat to review the many qualified applicants that interviewed this season. It was a time to eat, relax and have residents give their input as to which applicants we felt would be a good match for our residency. Soon, we’ll be finding out the next group of interns who matched at UF to fill the 14 available spots but welcoming the new interns means saying goodbye to the seniors. This year, more than half of the senior residents have decided to stay in Florida, which is a big change as over the last couple of years most of the past graduates have signed in Texas. Dakota Lane and Ideen Zeinali will be staying at UF as fellows in Ultrasound and EMS/Ultrasound/ International Medicine, respectively. Taylor Zeglam is staying in Gainesville to continue at UF. Hasaan Rasheed is going to the Tampa area; Julie Estrada is heading to the Treasure Coast at Indian River. I will be heading south to Miami. Jordan Bell is going back to the great state of Texas, which is no surprise to anyone who knows him, and Sarah Graham is heading to Tennessee.
University of Florida, Gainesville Merisa Kaplan, MD, MPH PGY-3
Best of luck to all! Greetings from Mt Sinai Medical Center in Miami, Fla. We are currently at the tail end of our “winter season”, and instead of snow flurries, we were blessed with endless amounts of snow birds. I am happy to report that we have made record numbers in the amount of patients our relatively small ED has triaged, treated and properly dispositioned this season, demonstrating that hard work and training can surmount sheer volume even in these “code black” situations. Our long awaited ultrasound rotation has begun which will train MSMC EM residents in arguably the newest and most invaluable tool that is sure to be ubiquitous in our field. Instead of online modules, we will be physically ultrasounding all types of pathology and presenting our findings to the rest of the residency during conferences. All of this will be done under the supervision and instruction of a U.S.-trained attending. Mt. Sinai Medical Center Matthew Brooks, DO PGY-2
As expected with the creation of three new EM residencies in the South Florida area, we have interviewed and ranked more candidates than ever before this year. Luckily, the caliber of applicants has continuously risen year by year, and we are happy to report that our handpicked class of 2020 will be rockstars at the very least.
We are currently preparing to present all types of case reports and original research at the 2017 FLAAEM Scientific Assembly that will be held at the Fontainebleau April 22. Not only is the venue famous and gorgeous in its own right but the quality of relevant EM material present is what will make the trip truly special, so plan your MIA trip soon! That’s it for this EMPulse residency update. I wish the best to my fellow Florida EM colleagues. If I don’t see you at our quarterly consortium lectures, I hope to see you on Miami Beach in April for FLAAEM!
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In the past quarter, UF Jacksonville hosted the Southeastern SAEM Conference. The conference had around 80 participants in attendance. The keynote address was given by Vice Chairman of Emergency Medicine at Massachusetts General Dr. Ali Raja. The conference culminated in a Zombie Olympics, which tested critical skills and knowledge for the practice of emergency medicine. Outgoing Chief Resident Dr. Adnan Javed has accepted a position as an assistant professor at University of Massachusetts Wooster.
University of Florida, Jacksonville Jason Arthur, MD, MPH PGY-2
We would like to recognize our newly elected chief residents for 2017-2018: Drs. Lauren Page Black, Hannah Fox and Shehzad Muhamed. Drs. Black and Muhamed went to medical school at the University of Florida, while Dr. Fox went to Virginia Commonwealth University. We’re also eagerly anticipating the opening of our North Hospital, which is anticipated to open in May 2017.
Arrrggghhh! It be the time for Ye Ole Krewe O Pirates to take back the Tampa Bay! Here in Tampa, we all know that the New Year typically brings Gasparilla with legions of Pirates and hordes of marathoners, as well as beer week for those who are particularly crafty about their beer. This year was extra special as we hosted the NCAA Football National Championship. It has been the perfect time of year around these parts, with beautiful weather, a festival every weekend and an extraordinarily busy emergency department! We are extremely excited about a new ultrasound project, which our very own second-year resident Dr. Mike Butterfield has just begun in our ED. He has been at the forefront of ultrasound ED use and ultrasound research since the beginning of his residency. Now that the project is off the ground and rolling, we couldn’t be happier for him. Additionally we’d like to announce the upcoming grand opening of Tampa General’s first stand-alone satellite emergency department. Many of our terrific attending physicians have been working hard to put this project together and it will be opening and fully operational by the end of March. The main Tampa General campus is growing too! Recently we’ve added three new attending physicians. We would like to extend the warmest of welcomes Drs. Gamble, Jameson and Moseley, who will be sharing their vast knowledge and helping to mold us into the excellent independent physicians that we are all striving to become.
University of South Florida Jeffrey Hoida, MD PGY-2
It is with tremendous sorrow that we conclude this quarter’s letter with heartfelt condolences to all of “the family” of the late Dr. Sal Silvestri. Although he ran the program in Orlando, you’d be hard pressed to find an ED physician here at TGH that wasn’t affected by his wonderful influence. Many of our residents rotated with his program and many more of our attending physicians trained directly under his leadership and all have the fondest memories of their time learning from him. He has a one-of-a-kind, once-in-a-lifetime-type of personality, which has warmly touched so many of our lives. We will choose to celebrate his memory with the same jubilee in which he lived his life, and we will strive to better our profession everyday in honor of how he always did. We’ll miss you Sal. It is with great sadness that we announce the passing of our beloved program director Dr. Salvatore Silvestri. The Orlando Health residency program, the emergency medicine community, and the greater community as a whole has lost a great leader, mentor and friend. We ask that your thoughts and prayers are with his family. Dr. Silvestri was the type of program director who inspired each of his residents to realize their full potential, and he will live on as a reminder of our inner strengths. Most recently, he worked closely with our residents on 14 of 51 research projects presented at our Quality Retreat Research Symposium with topics including EMS; end-tidal CO2; traumatic brain injury; stroke; sepsis; and education. Two research projects were awarded first and second place, and a third an honorable mention.
Orlando Health Shari Seidman MD & Erich Heine, DO PGY-2
The lessons that Dr. Silvestri left with us are ones of kindness, empathy, self-empowerment and love. As the match moves closer, and we look to the future, we will use his guidance to continue his vision: not simply a residency program that develops the greatest of emergency medicine physicians, but a family that is with you for life. Even in the sorrows of saying goodbye, there is great hope too, that our residency program will continue to make the future brighter with the beautiful family Dr. Silvestri helped to build.
Now that we are over half way through our first year and have completed our first full interview season, the Kendall Regional Medical Center Emergency Medicine Residency is excited to expand our multidisciplinary training opportunities. After a successful joint residency simulation competition with the Emergency Medicine Residency Program at Aventura Hospital and a real-time disaster drill with trauma surgery in our emergency department, we look forward to our busy spring ahead. We have continued to work collaboratively with Aventura and will be having our first mass casualty drill during EMS Week 2017 this spring at Broward Community College. This fantastic learning opportunity will include emergency medicine, surgery and anesthesia residents; EMS; and nurses as active participants. SPRING 2017 | VOLUME 24, ISSUE 1
Kendall Regional Medical Center Kendall Regional Medical Center Emergency Medicine Residency Staff
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Match time is right around the corner, and we are excited for our first class of emergency medicine residents to start in July 2017! Meanwhile, we are in the final stages of fine-tuning the rotation schedules and didactic curriculum for our incoming residents. Our EM Research Group has kept busy with several recent publications. Below are a listing of some of these recent publications.
Florida Atlantic University Lisa Clayton, DO, MBS, FACOEP Assistant Program Director
1. Alter SM, Infinger A, Swanson DR, Studnek JR. Evaluating clinical care in the prehospital setting: Is Rapid Emergency Medicine Score the missing metric of EMS?. Am J Emerg Med 2017; 35(2): 218-221. 2. Benda B. The Year in Review. Sad!. Integr Med (Encinitas) 2017; 16(1): 64. 3. Shih RD, Walsh B, Eskin B, Allegra J, Fiesseler FW, Salo D, Silverman M. Diazepam and Meclizine Are Equally Effective in the Treatment of Vertigo: An Emergency Department Randomized Double-Blind Placebo-Controlled Trial. J Emerg Med 2017; 52: 23-27. 4. Wolf SJ, Maloney GE, Shih RD, Shy BD, Brown MD, and the American College of Emergency Physicians Clinical Policies Committee. Clinical Policy for Critical Issues in the evaluation and management of adult patients presenting to the emergency department with acute carbon monoxide poisoning. Ann Emerg Med 2017; 69: 98-107.
The Emergency Medicine residency at St Lucie Medical Center is pleased to announce the results of the 2017 match for the class of 2021. We are happy to welcome future Drs. Alexandra Chitty, Christine Gonzalez, Oliver Morris and Kevin Summers. The EM residents have been keeping busy as usual and performed well on the in-service examination. Program residents also participated in a ropes challenge course on the Florida Atlantic University campus. Fortunately, no residents required any trips to the ER.
Aventura Hospital Todd L. Slesinger, MD, FACEP, FCCM, FCCP Program Director
St. Lucie Medical Center The inaugural class of the Aventura Hospital and Medical Center Emergency Rege Turner, DO Medicine Residency has truly found its stride. The residents are actively engaged in their clinical rotations and becoming involved with numerous academic endeavors. Dr. Akinradewo will be presenting “Knowledge and Risk Perceptions of Zika Virus among Attendees of the 2016 Summer Olympic Games” at AAEM in Orlando, as well at local and regional venues. Dr. Yasavolian was the second author on “Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial”, which was a truly practice-changing article. Dr. Castaneda-Guarderas continues her involvement in SDM research and collaborated in “Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial” published in the December issue of BMJ. Drs. Elkhayat and Yang participated in the 2017 Ultrasound Point of Care course sponsored by Yale University. Dr. Hamilton had the opportunity to work with ParaDocs, providing medical coverage for the Winter Party in Miami. Dr. Arandi co-authored with Dr. Baker an article on AAA, which has been accepted for publication in the 2017 EMRA Pressor-Dex handbook.
Our faculty continues to be involved in academics. Dr. Marra presented at talk on opioid prescribing in older adults at the National Updates on Behavioral Health Emergencies in Las Vegas. Dr. Slesinger published two chapters in the second edition of Critical Care Emergency Medicine. Also, Drs. Dubensky and Slesinger reviewed and discussed the new definitions for SEPSIS-3 for the ACEP Quality and Improvement Patient Safety section. Our emergency room expansion is almost finished and scheduled to open May 1, 2017, which will bring 14 new exam rooms, two isolation rooms, five behavioral health rooms, and a new ultrasound room. The new facility will allow us to provide better clinical care to our expanding patient census, and offer a new and expanded space for enhanced clinical education and bedside teaching. The 2016-2017 interview season is completed; we interviewed 165 amazing applicants. Good luck to everyone on Match Day! Finally, we will like to thank Gary Lai, DO who came representing FCEP and gave a talk about advancing emergency medicine. For more information, please contact Residency Program Coordinator Angela Taylor at angela.taylor2@hcahealthcare.com. Greetings from the Jackson Health System/University of Miami Miller School of Medicine Emergency Medicine Residency Program! It has been a beautiful winter here in South Florida. The residency hosted the third South Florida EM Consortium at Jackson on Febuary 8, 2017. We had a great showing with residents and faculty from the South Florida EM Residencies at Aventura, Kendall and Mt. Sinai. We were honored to have Dr. Mark Reiter, the Past President of AAEM and Program Director at University of Tennessee-Murfreesboro/Nashville, discuss the business of EM and EM myths and facts. Our residents are preparing to attend AAEM this year in Orlando. We are excited to have all the residents protected from clinical duties for this educational opportunity. We are looking forward to the residents and faculty spending time at this great conference here in Florida this year.
Jackson Memorial Hospital Chris Freeman, MD Associate Program Director
Also in our own backyard, we are happy to welcome CORD to Fort Lauderdale in April as the official social chairs. We hope to see you all there.
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Greetings from UCF/HCA Emergency Medicine Residency Program of Greater Orlando! We are proud to continue sharing with you the many great memories and upcoming events throughout our journey as interns. As you all know, Match Day is around the corner, and we are all looking forward to welcoming the new members of our EM family! Congratulations to all fellow residents on completion of our in-service exam! Thank you to our faculty and staff, as well as those from Florida Hospital, for your wonderful lectures and support in preparation. Furthermore, our faculty has been working very hard to put together a great variety of options for our elective rotations next year, including topics such as simulation, ultrasound, research, safety and quality, clinical informatics, and many more.
UCF-Osceola Abhishek Roka, MD and Leoh N. Leon II, MD PGY-1
Drs. Ballinger and Rubero along with Drs. Benzing, Webb, and Singh had the opportunity to provide medical care during the 2017 presidential inauguration in Washington D.C. We encourage you all to read Dr. Benzing’s article about this unique and exciting event.
Lastly, we would like extend our deepest condolences to the Orlando Regional Medical Center EM program after losing a much loved Program Director Salvatore Silvestri, MD. Our thoughts are with you during this difficult time.
THANK YOU TO OUR 2017 CORPORATE PARTNERS! The success of the Florida Emergency Medicine Foundation (FEMF) and the Emergency Medicine Learning & Resource Center (EMLRC) is due in large part to our corporate partners that provide annual sponsorship support for our educational programs and events. Thank you to our 2017 corporate partners for believing in our mission and helping us to provide life-saving education to life savers!
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Florida Emergency Medicine Residency Match 2017 Orlando Health
Florida Hospital
University of Florida - Gainesville
University of Florida - Jacksonville
UCF/HCA
Matthew Beattie, MD; USF Health Morsani College of Medicine
Lindsay Beamon; Boston University School of Medicine
Steven Chadwick, DO; Alabama College of Osteopathic Medicine
Sheila Bawany, MD; USF Health Morsani College of Medicine
Ashley Gregory, MD; Tulane University School of Medicine
Maram Bishawi, DO; Nova Southeastern University College of Osteopathic Medicine
Michael Chami; Michigan State University College of Human Medicine - Flint
Cory Clugston, MD; University of Florida College of Medicine
James Chiang, MD; Loma Linda University School of Medicine
Elizabeth Kim, MD; Loma Linda University School of Medicine
Megan Calabrese, MD; State University of New York Upstate Medical University
Julia Eidelman; Philadelphia College of Osteopathic Medicine
Jessica Dalton, MD; University of Florida College of Medicine
Alexandra Craen, MD; USF Health Morsani College of Medicine
Stacey Geryak, MD; University of Florida COM
Ambar Marín López, MD; Ponce Health Sciences University School of Medicine
Dominic DiDomenico, DO; West Virginia School of Osteopathic Medicine
Weedley Funeus; Wake Forest School of Medicine of Wake Forest Baptist Medical Center
Roseline Desvaristes, MD; James H. Quillen College of Medicine East Tennessee State University
Nicholas Fusco, DO; Lake Erie College of Osteopathic Medicine
Brian Guetschow, MD; University of Iowa Roy J & Lucille A. Carver COM
Bradley Parrish, DO; Nova Southeastern University College of Osteopathic Medicine
George Gulenay, MD; University of Central Florida COM
Mohammad Ramadan, DO; Kansas City University of Medicine and Biosciences
Innocent Akujuobi, MD; Howard University COM Mitchell Bameck, MD; Oregon Health & Science SOM Laura Cook, MD; University of South Carolina of Medicine Greenville
Shannon Armistead, DO; West Virginia School of Osteopathic Medicine
University of South Florida
Jonathan Kennedy, MD; University of Miami Leonard M Miller SOM Kirsten Kepple, MD; Medical College of Georgia at Augusta University Joshua Koplon, MD; University of Alabama SOM
Kyle Friez, MD; Medical College of Georgia at Augusta University Josiah Hill, MD; USF Health Morsani College of Medicine
Bethany Johnston; University of Texas Southwestern Medical Center Southwestern Medical School
Alicia Nassar, MD; USF Health Morsani College of Medicine
Kemba Mark; George Washington University School of Medicine and Health Sciences
William Pearce, MD; USF Health Morsani College of Medicine
Rebecca “Brynne” McAlpine; Medical College of Georgia at Augusta University
Diego Riveros, MD; University of Florida College of Medicine
Thuyen Nguyen; Baylor College of Medicine
Jacob Stritch, MD; University of Florida College of Medicine
Austin Reed; University of Florida College of Medicine Danielle Roberts; Ross University School of Medicine
Ian Little, MD; University of Tennessee Health Science Center COM
Laura Scieszka; Marshall University Joan C. Edwards School of Medicine Tierra Smith; Morehouse School of Medicine
Virginia Owens, DO; Midwestern University Arizona College of Osteopathic Medicine
Garrett Snipes; University of South Carolina School of Medicine Greenville
Caitlin Parks, MD; Florida State University
Dacia Ticas; University of Texas Southwestern Medical Center Southwestern Medical School
Katie Pearson, MD; University of Texas SOM San Antonio
Blake Duke, MD; Mercer University School of Medicine Corey Dye, MD; Leonard M. Miller School of Medicine University of Miami Michael Gast, MD; Louisiana State University Rebecca Lacayo, MD; Lewis Katz School of Medicine Temple University
Andrew Hanna, MD; USF Health Morsani College of Medicine Akiva Pollak, MD; StonyBrook University School of Medicine Joshua Tsau, MD; McGovern Medical School at University of Texas, Houston
Sean McAlister, MD; Tulane University School of Medicine Tanner Miles, MD; Oakland University William Beaumont School of Medicine Kimberly Rose Papa, MD; University of Florida College of Medicine Michael Schneider, MD; Wright University Boonshoft School of Medicine Brett Schubert, MD; Florida State University College of Medicine-Tallahassee Theodore Strom, MD; Florida State University College of Medicine-Daytona Beach Nandini Verma, MD; Leonard M. Miller School of Medicine University of Miami
Monty Putman, MD; University of Louisville SOM Anne Richardson, MD; University of Florida COM Margaret Story, MD; Medical College of Georgia at Augusta University
St. Lucie Medical Center
Mt. Sinai Medical Center
Kendall Regional Medical Center
Aventura Hospital & Medical Center
Alexandra Chitty, DO; West Virginia School of Osteopathic Medicine
Mauricio Baca, MD; University of Central Florida
Sumit Arora; St. Louis University School of Medicine
Ramsey Ataya, MD; Northeast Ohio Medical University
Ulrika Andersson, MD; Linkaping University Faculty of Medicine and Health Sciences
Sean Argo, MD; University of South Florida
Christine Gonzalez, DO; Nova Southeastern University COM
Chandelle Raza, DO; Lake Erie College of Osteopathic Medicine at Bradenton
Emily Ball; University of New Mexico School of Medicine
Spencer Elliott Barela, MD; American University of the Caribbean School of Medicine
Frederick Chu, MD; University of Illinois College of Medicine - Peoria
Damien Carracedo, MD; Florida Institute of Technology
Oliver Morris, DO; Nova Southeastern University COM
Zach Gimbel, MD; University of Miami School of Medicine
Emerson Franke, MD; Ross University School of Medicine
Jeffrey Klein, MD; Florida Atlantic University
Kevin Summers, DO; Edward Via COM-Carolinas Campus
Waroot “Shay” Nimjareansuk, DO; Nova Southeastern University
Jaskirat Gill, MD; State University of New York Upstate Medical University
Benjamin Mazer, MD; Medical College of Georgia August University
Natasha Brown, MD; Sackler University School of Medicine New York state American Branch Elizabeth Rubin, MD; David Geffen School of Medicine UCLA Blake Guillory, DO; Lake Erie College of Osteopathic Medicine at Bradenton
Jackson Memorial Hospital
John Combs; University of California - Irvine School of Medicine Desiree Delgado; University of Illinois at Chicago College of Medicine Matthew Dybas; University of Illinois at Chicago College of Medicine Paul Eugene; Louisiana State University School of Medicine Anwar Ferdinand; Morehouse School of Medicine Christina Gutierrez; Texas A&M Health Science Center
Sarah Lynn Dichter, MD; American University of the Caribbean School of Medicine Nikkitta Christine Georges, MD; Emory University School of Medicine Karla Lorraine Guzman Melero, MD; Ponce Health Sciences University School of Medicine Amanda Kaye Haan, MD; Indiana University School of Medicine Colin J Allen Hagen, MD; Central Michigan University College of Medicine
Kristina Jacomino; Vanderbilt University School of Medicine
Arvinder Singh Jandu, MD; University of Iowa Roy J and Lucille A Carver College of Medicine
Matthew Kwon; University of Pittsburgh School of Medicine
Andrew Brett Napier, MD; USF Morsani College of Medicine
Timothy Montrief; University of Miami Miller School of Medicine
Jasminia Magtoto Nuesa, MD; Saba University School of Medicine
Dumi Presuma; Temple University School of Medicine
Daniela Patricia Valenzuela, MD; Ponce Health Sciences University School of Medicine
Michael Traum; University of Maryland School of Medicine Kelsey Wolfe; Albany Medical College
Jessica Wire, MD; Loma Linda University School of Medicine
Karl Yousef; University of Arizona College of Medicine
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Mitali Mehta, MD; Morehouse School of Medicine Matthew Mungo, DO; Nova Southeastern University College of Osteopathic Medicine Katherine Peterson, MD; Keck School of Medicine of the University of Southern California Jennifer Reyes, DO; University of North Texas Health Science Center at Fort Worth/Texas College of Osteopathic Medicine Ricardo Rodriguez, MD; Michigan State University College of Human Medicine Nicole Rodriguez Perez, MD; San Juan Bautista School of Medicine
FAU at Bethesda Health
Daniel Parks, DO; Lake Erie College of Osteopathic Medicine Matthew Wallace, MD; Ross University
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EM D ays 2017
As usually is the case, 2017 saw a flurry of legislative activity as FCEP members descended on Tallahassee. Despite seeing slightly decreased numbers from coinciding with the ACEP Leadership and Advocacy conference, those in attendance stepped up to represent emergency physicians throughout Florida. Key issues this year included replacing Florida’s current Auto-Insurance Personal Injury Protection (PIP) in exchange for Bodily Injury Insurance, funding for mental health, addressing the growing opiate epidemic, addressing medical transparency, establishing mediation in order to protect physicians from unfair health payer behaviors, the cutting of Medicaid funding by $1 billion dollars, and the expansion of scope of practice by nurse practioners independent of physicians. The conference kicked off with FCEP’s lobbyist Toni Large, updating members on the rapid movement of bills through committee in the second week of session. It was followed by a special lecture by FCEP member Rep. Cary Pigman (R-Avila Park), who gave attendees a special behind-the-scenes look on how Florida legislature really works and provided hints on how to best advocate for our specialty. We also saw special guest Mayor of Tallahassee and gubernatorial candidate Andrew Gillum on Monday evening; he gave a lecture during the EMRAF meeting. The night concluded with the FCEP Board meeting, followed by a friendly happy hour night with our colleague anesthesiologists from the FSA.
Damian Caraballo, MD, FACEP FCEP Board member; Emergency Medicine Days Co-Chair
The second day kicked off the meetings with local legislature. FCEP members met with leaders of the House and Senate in order to advocate for our specialty. A hot topic was the repeal of Florida PIP insurance in auto accidents. EM physicians in Florida currently have $5,000 set aside in our auto-insurance laws, which reimburses EM doctors who evaluate MVC patients. The current House version of repeal does not include a set aside for EMTALA providers — failure to do so could negatively affect emergency physicians by a decrease in revenue of up to 14 percent, as according to FCEP’s Medical Economics Committee Chair Dr. Daniel Brennan. We worked hard to talk to state leaders, including bill sponsors Senator Brandes and Representative Grall, to explain to them the importance of having a physician set aside for EMTALA providers and how their current bills threatened specialist access for Florida’s EDs. Another hot topic discussed was last year’s balance billing ban, and the need for mediation and healthcare transparency for both physicians and Floridians. We met with leaders from the Office of Insurance Regulation (OIR) and Agency for Healthcare Administration (AHCA), where we learned rules for the new mediation system, MAXIMUS, will be released April 1, 2017. FCEP emphasized the importance of establishing a fair Usual and Customary Rate (UCR) based on average charges. FCEP is concerned insurances are currently trying to manipulate the UCR through a recently passed healthcare transparency law, which uses a database HCCI to tell Floridians healthcare costs. We learned insurances are trying to use the database to publish insurance allowables, rather than the real cost of care. Such an attempt would be significantly lower than actual cost of care and could inversely impact our UCR reimbursement physicians negotiate with insurances for contracted rates. Our physicians were quick to pounce on this potential “Trojan-Horse” bill placed by insurances, and legislature and health agencies were educated on how to set-up a fair system. Through the leadership of FCEP Board member Dr. Aaron Wohl, we were also able to change some well-intended, but poorly written, bills which would have required EM physicians to ask for consent to call family of opiate overdose victims. We educated legislature on the best ways to combat the opiate epidemic and hammered home the need for better mental health funding to help treat the current drug epidemic which we are seeing nationwide. Led by the research of Dr. David Orban, we showed Florida leaders the importance of funding mental health laws we helped pass during last session. On the third and final day, we met with leaders of the Florida Hospital Association, OIR and FMA President Dr. David Becker. We held a townhall with Dr. Becker, FCEP President Dr. Jay Falk and FSA President-Elect Dr. Kurt Jones. We learned that physicians every where are being backed into a corner by both regulators and politicians. As a silver-lining, we are now seeing physicians band together to advocate for better patient care. Perhaps the most important lesson learned at EM Days 2017, much like our roles in the ED, is that physician advocacy is a 24/7- and 365-day job. It is only through relationships that we make after session, and in the fundraising we do for legislature through the FCEP PC, that we can truly make a difference in bills that affect Florida physicians. Last session, it was through these relationships that we were able hold back a big push by health insurances to cap basically all reimbursement at 200 percent of Medicare — a change which would have resulted in a 25 to 35 percent cut in salaries for all EPs in Florida. We are at a crossroads in American medicine, where the decisions decided the next few years will determine the remainder of how we see patients and are reimbursed over the rest of our careers. If you are looking to get involved, please contact one of your FCEP leaders. We will work with our members in setting up meetings with local legislative leaders once session ends. Also, please donate to the FCEP PC, which combats the deep pockets of rival Insurance, lawyer, and even Nursing PACS. Finally, please be a part of the solution to our current ills in medicine and plan on attending FCEP’s Emergency Medicine Days next January in 2018. SPRING 2017 | VOLUME 24, ISSUE 1
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S napshots
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EM D ays 2017
Photos by Samantha Rosenthal, FCEP/EMLRC Communications Manager
Snapshots from EM Payment Reform Summit Photos by Samantha Rosenthal, FCEP/EMLRC Communications Manager
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SPRING 2017 | VOLUME 24, ISSUE 1
EM p u l s e F e a t u r e EM Payment Reform Summit Brings Together EM Leaders From Across the U.S. to Discuss State and Federal Regulations FCEP/FEMF’s EM Payment Reform Summit was held on February 9-10, 2017 and discussed critically important reimbursement issues due to both Federal and State legislation and new regulations. The conference was held in Orlando at the Emergency Medicine Learning & Resource Center. Rapid changes in laws and regulations are scheduled to permanently change the clinical and business aspects of the practice of emergency medicine, including reimbursement and workload requirements. Conference attendees included physician group leaders, clinicians and billing companies. Knowledgeable speakers, including ACEP members/leaders and independent policy advisors, covered a myriad of pertinent topics including: new law and reimbursement regulations, documentation requirements, and ramifications of the regulations. Innovations to cope successfully in the future were presented by creative, successful ED management leaders. Clifford Findeiss, MD EM Payment Reform Summit Co-Chair; Former FEMF President
All conference attendees and faculty members themselves learned a great deal from each other. This article will share some of the key information we learned related to pertinent changes in the business and clinical aspects of emergency medicine.
Commercial insurance carriers are succeeding in squeezing physician reimbursements by aggressively pursuing "narrow hospital networks”, via tough contracts, to increase their profitability to the detriment of physicians and hospitals. Some carriers, following implementation of Florida’s balance billing legislation in July 2016, are arbitrarily applying Medicare rates or rates they determine to be usual and customary. Physician groups are being pushed to execute unfavorable contracts, whereby they agree to reimbursement rates set by the insurers, with the backing of State legislatures, as full payment for services. Insurers are, in most states, obtaining new statutes beneficial to carriers, which de-facto have the upper hand in controlling physician and hospital reimbursement. Providers are, to large degree, losing their rights to collect fees greater than the rates determined by states and/or insurers. State-by-state, powerful insurance lobbies are effectively maneuvering physicians and hospital systems to agree to payment rates pegged to decreased ratios of Medicare rates, which are dropping lower than past norms. Reimbursement to hospitals alone by Medicare and Medicaid have been insufficient to support their operational costs, so commercial insurance reimbursement is a keystone to financial strength for hospital systems. In summary, providers who bill usual and customary fee-for-service rates to patients and insurers today are under siege and are certainly not winning this battle. FCEP Lobbying: ACEP and other Chapters across the country are actively lobbying their legislators on many reimbursement issues. FCEP members gathered in Tallahassee again this year during Emergency Medicine Days on March 13-15, 2017 to educate Florida Senate and House members regarding the dangers to EM patients and Florida emergency physicians. FCEP has lobbied to mitigate narrow networks and “balanced billing” limitations, and has met with Florida legislators to advocate for an acceptable appeals mechanism to balance the scale. The ultimate ramifications of this trend of curtailed reimbursement options, such as unfair limitations on reimbursement for emergency physicians, is that quality of patient care will very likely be negatively affected, as less well-trained providers fill slots where physicians are replaced. FCEP leaders are also actively engaged with the Office of Insurance Regulation (OIR) to seek their assistance in correcting problems with certain insurers reimbursement practices. HHS and Medicare to make matters worse, under concurrent federal regulations promulgated by the Department of Health and Human Service and the Affordable Care Act (Obamacare), physicians are required to submit loads of documentation, including patient care data, to comply with Federal regulations. Physicians and their groups are required to report various types of data to qualify for reimbursement. HHS/CMS has a lust for big data, with a noble vision to define evidenced-based best practices and to do other types of research. Submission of data regarding HHS “quality measures” by physician specialty is required to comply with reimbursement regulations. For emergency physicians, hospital electronic medical records (EMRs) must be accessible to the physician group and its billing entity to submit patient care records and data. This data must be secured under HIPPA requirements to avoid data breaches. The complexities of the required demands are challenging at the least. To comply with Federal rules, independent emergency medical group practices need to collaborate and share data through the hospital’s EMR. How and who will manage, store and control data at various levels, which will be a challenge and create uncertainty within many organizations? Who will shoulder the costs of management? Who will bear the responsibility for security breaches?
Continued on page 26
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Continued from page 25 ACEP has developed “CEDR”, a secure and centralized cloud-based data bank designed to accommodate the needs of emergency medicine practices. CEDR was developed to be a secure repository focusing on CMS/HHS data reporting requirements. The data sources for CEDR will be fed from EMRs. The Quality Payment Program: HHS creates Medicare regulations under health care law, currently the Affordable Care Act (Obama Care.) The current elephant in the room is the HHS “Quality Payment Program,” which is modifying physician reimbursement in a big way. The Quality Payment Program is tied to the ACA, legislation called MACRA and HHS regulations (e.g. MIPS and APMs.) MACRA is the acronym for “Medicare Reform Law and CHIP Re-authorization Act”, which was passed by Congress in 2015 replacing SGR (the “Sustainable Growth Rate” law). MIPS and APM regulations were created by HHS for Medicare. MIPS, the “Merit based Incentive Payment System”, and APMs, the “Advanced Alternative Payment Models”, are HHS/Medicare regulations for reimbursement to modify and control Medicare metrics for fee-for-service reimbursements. The results of the above developments are that Medicare now offers physicians two new tracks for physician reimbursement: (1) MIPS or (2) APMs. APMs created by HHS for Medicare incentivize physician groups to decide to: 1) either accept lower reimbursement levels, a penalty for non-participation with one of the Quality Payment Programs; or 2) alternatively, choose options for participation in various APM risk/reward programs to potentially gain increased reimbursement by outperforming peers and receiving performance bonuses. These Medicare risk/reward plans are budget neutral to CMS; therefore, there will be winners and losers. For those who choose not to participate in an APM, and do not participate in MIPS, Medicare will assess penalties. In 2017, for example, a 4 percent payment penalty is scheduled to be assessed for non-participation. Many physician groups are choosing not to participate and eat the 4 percent penalty so that they will not have to spend precious time and money on data gathering and reporting. For EM groups, as hospital-based practices, non-participation will be extremely difficult to avoid. More hospitals systems may decide that they need to employ emergency physicians to manage not only data collection and submission, but also to improve coordination of care among related medical services. As we all know healthcare costs in America are, in fact, out of control. Key contributors to excess costs, inefficiency in patient care and unacceptable outcomes for patients are clearly a result of the lack of effective coordinated patient care. Duplicative management of patients’ care — consisting of repetitious testing, lack of medical record data sharing among specialist colleagues, excess reliance upon ED care, conflicting drug prescriptions and excess admissions to hospitals — are all detrimental to patients. Physicians understand that better coordination of care would improve the quality of care for our patients. I believe the architects of Federal laws and regulations have their hearts in the right place and are trying to encourage coordination of quality care. However, the Federal government “solutions” for physicians and hospitals are discouraging at best and may be DOA due to labor intensive, and time consuming mandates and penalties. There are a paltry number of systems across the country managing coordination of care models achieving cost savings while accomplishing the long-term outcomes patients deserve. There are logical ways that coordinated patient care can be achieved, but the solutions will require integrated networks among insurers, hospitals and physician organizations. Integrated care management is the Holy Grail — coordinated care under capitation payment models with Medical Home philosophies. Our federal government can’t successfully re-design and manage this conundrum on its own, but sadly, it will continue to cut healthcare costs and decrease revenue to providers to the detriment of our citizen’s well-being. The private sector will be innovative and hopefully find solutions!
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SPRING 2017 | VOLUME 24, ISSUE 1
EM C a s e R e p o r t s Mycotic Aneurysm Article by Nathan Bach, DO; PGY-3 at UF Health Jacksonville Emergency Medicine Residency Program
Case
A 75-year-old male with PMH of gout, hypertension, possible malaria infection in the Philippines during WW II and diabetes mellitus II presented with chest pain and fatigue. He reportedly had a recent chest X-ray done by his PCP showing concern for a widened mediastium for which he was referred to the emergency department. He describes the left-sided chest pain as intermittent, sharp and non-exertional over the last three years, and endorses increasing fatigue and decreased appetite over the last two weeks. He reports he was seen for this same pain when it began three years prior and was told he may have a “bone tumor� by a previous PCP. The patient was mildly hypertensive, but all other vital signs were within normal limits, afebrile. On exam, he was in no acute distress, without any abnormalities on neurologic/cardiovascular/pulmonary/ abdominal/skin exam. AP chest X-ray in the ED showed a prominence of the aortic arch. Labs were only remarkable for a glucose of 270 mg/dL, WBC 11.4 thous/mm3 with 89% neutrophils. Troponin, lactic, Mg, Phos, and remaining CBC and BMP were within normal limits. EKG shows normal sinus rhythm with mild LVH and no signs of ischemia. CTA chest was obtained which showed aortic wall thickening from the left subclavian artery to mid thoracic aorta with significant peri-aortic gas and aneurysmal dilation. The patient was started on IV vancomycin and zosyn, cardiothoracic surgery and the Nathan Bach, DO medical ICU were consulted. During his hospital admission, his blood cultures grew out clostridium septicum. He PGY-3 at UF Health was hospitalized for eight days then discharged on long-term antibiotics. CT surgery plans to place endograft to Jacksonville Emergency Medicine Residency Program aneurysm post sterilization of aorta, given patient being very high risk for repair with open thoracotomy
Discussion
Aortic aneurysms are one of the deadly diagnoses emergency physicians must rule out when working a patient up for chest/abdominal/ flank pain. The majority of aortic aneurysms are due to trauma, connective tissue disorders, genetics and chronic health conditions. A small percentage of aneurysms can be due to infectious sources, which are referred to as mycotic aneurysms. Some pre-existing aneurysms may become secondarily infected while the large majority of mycotic aneurysms are primarily caused by degeneration due to an infectious source. Risk factors for mycotic aneurysm include arterial injury, atherosclerosis, a preceding infection (pneumonia, endocarditis, osteomyelitis, soft tissue infection, etc.), immunocompromise and pre-existing aneurysm. Mycotic aneurysms can be found anywhere but are more commonly found in the intracranial arteries, visceral arteries, abdominal aorta, iliac arteries, extremities and very rarely in the thoracic aorta. Organisms most commonly isolated are staphylococcus (MRSA predominant) and salmonella spp. However, streptococcus pneumoniae; gram negatives; and less commonly mycobacterium, treponema pallidum (syphilis), anaerobes, other gram-positive organisms and fungal sources have been identified. Presenting signs and symptoms are similar to typical aneurysms (pulsatile mass, chest/abdominal/flank pain) along with systemic signs of infection, although some studies show over half of patients had no fever on presentation. Untreated mycotic aneurysms can lead to complications such as hemorrhage, thrombosis, sepsis, osteomyelitis and heart failure. Diagnosis is critical and relies on history and physical, imaging (CTA or MRI) and blood cultures. There are no strict guidelines for treatment; however, most cases are treated with IV antibiotics (initially vancomycin + piperacillin-tazobactam, ceftriaxone or a fluoroquinolone) and surgical interventions, which range from debridement to excision with reconstruction.
SPRING 2017 | VOLUME 24, ISSUE 1
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EM p u l s e F e a t u r e
Climate Change: A Health Crisis Call to Action “Climate change is the biggest global health threat of the 21st century,” according to a 2009 Lancet report. Unfortunately, this call to action is slow to catch the attention of healthcare professionals. The American Medical Association and American Academy of Pediatrics have both made recent statements that health is inextricably linked to climate change, and that clinicians need to understand this relationship to better recognize and anticipate climate-associated health effects and advocate for health-protective public policy. While the effects of a warming planet are felt by all, the impact is more profound on children, minority populations, the elderly, the homeless, those that are socially isolated, and those with disabilities and chronic diseases including mental illness. The World Health Organization estimates that 88 percent of the diseases and deaths tied to climate change in the world now occur in children who are younger than 5 years old. They suffer disproportionately from climate-sensitive diseases and are exposed longer to the damaging health effects posed by climate change. As emergency room doctors, you will be on the frontlines of providing care for those harmed by the effects of climate change today and in the years and decades to come. Sea level rise is already affecting our low-lying coastal regions, like Miami and the Gulf Coast, which will only get worse in the coming decades. NOAA projects a sea level rise of 4.1 to 6.6 feet by 2100, with a two-foot rise as early as 2048 and three-foot rise by 2063. More than two-thirds of Florida’s 20 million residents live in coastal counties. To understand more about the health impacts Lynn Ringenberg, MD of climate change, visit: http://www.psr.org/environment-and-health/climate-change/. Post-traumatic stress disorders, anxiety and Emeritus professor of depression are common following disasters — often a major part of the health burden. Increased rates of substance abuse and pediatrics at USF Health and board member of PSR/Florida interpersonal violence, especially intimate partner violence against women, have been observed following weather-related disasters; and immediate past-president events likely to show up in the emergency department. of national PSR
Climate-related increases in ozone and pollution in the atmosphere is worsening respiratory and cardiovascular problems, allergies, and asthma exacerbations. Increasing temperatures lead to earlier and longer pollen season. According to the CDC, asthma rates are increasing every year in the United States. Extreme heat is the leading cause of environmental deaths in the United States, killing more people than hurricanes, lightning, tornadoes and floods. Predictive modeling studies estimate that future summer heat-related mortality will increase several-fold in the United States by 2050 with the elderly, infants, outdoor laborers, homeless and socially isolated populations at higher risk. According to the American Academy of Pediatrics, studies show that high school athletes and infants younger than 1 year old are at an increased risk of heat-related illness and death. The 1995 massive heat wave in Chicago killed about 700 people, and the 2003 European heat wave killed between 45,000-70,000 people and created a host of stressors — anxiety and depression — in those that survived. Warmer temperatures also are expanding the regions where vector-borne diseases occur — like Lyme disease, Dengue fever, West Nile virus and now Zika virus — causing devastating and life-long disabilities in newborn babies. Waterborne diseases, like Giardia, Cryptosporidium, noroviruses and enteroviruses, are expected to worsen with continued warming. We’re already seeing an increase in, once rare, amoebic meningoencephalitis due to Naegleria fowleri infections. Children born this year will be 33 years old in 2050 and 83 years old in 2100; these may be your children and grandchildren. How will Florida and our world look then? “How will the probable rise in temperature (3.6 to 7.2 degrees,), rising sea levels, and the increasing likelihood of extreme weather affect the course of their lives and the lives of their children?” asks a recent journal article published by The Future of Children, a joint project between Princeton University and the Brookings Institution. This is unchartered territory, so no one really knows. I think about those same questions, and I feel a responsibility to get educated on the science of climate change and how it is effecting my patients’ health and their future. It compels me to roll up my sleeves to work for change, and I hope you will join me. Even though scientists say we are too late to stop the Earth’s warming, we do still have a chance to slow the warming process and create a more sustainable and livable planet for those that follow us. A 2015 Lancet article states that “tackling climate change could be the greatest global health opportunity of the 21st century.” We must advocate for changes in our communities right now, including: measures like energy-efficient design, more green space, cleaner and improved public transportation, safer areas to walk and bicycle, renewable energy (like solar and wind), and climate resilience policies in our communities. The Lancet report challenges us by saying that “health professionals have an essential role in the achievement of planetary health; working across sectors to integrate policies that advance health and environmental sustainability, tackling health inequalities, reducing the environmental impacts of health systems, and increasing the resilience of health systems and populations to environmental change.” The threats are great, and the time to act is short, but by amplifying our voices as trusted health professionals, we can help turn the tide for a healthier and more peaceful world. For more information, visit PSR Florida’s website: http://www.psrflorida.org/, or email Dr. Ringenberg at ring46@me.com. References: 1. www.thelancet.com Vol 373 May 16, 2009 2. Downloaded From: http://jama.jamanetwork.com/ on 09/23/2014 3. www.thelancet.com Published online June 23, 2015 4. http://dx.doi.org/10.1016/S0140-6736(15)60854-6 1 5. WHO. Climate change and human health— risks and responses. www.who.int/global- change/publications/cchhbook/en/print. html. Accessed September 2, 2008 6. http://seagrant.noaa.gov/Portals/0/Documents/what_we_do/climate/Florida%20Report%20on%20Climate%20Change%20and%20SLR.pdf 7. PEDIATRICS Volume 136, number 5, November 2015 8. file:///Users/ring46/Desktop/CLIMATE/PsySR:%20Climate%20Change%20and%20Mental%20Health.webarchive 9. file:///Users/ring46/Desktop/A%20Physician’s%20Guide%20to%20Climate%20Change,%20Health%20and%20Equity%20-%20Center%20for%20 Climate%20Change%20and%20Health.webarchive 10. www.futureofchildren.org
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SPRING 2017 | VOLUME 24, ISSUE 1
EM p u l s e F e a t u r e UCF/HCA Emergency Medicine Residency Program Attends Presidential Inaugration
the
58th
Article by Drs. Adam Benzing, PGY-1, and Bethany Ballinger, UCF HCA GME Consortium Emergency Medicine Residency Program of Greater Orlando Program Director Over the past few decades, event medicine has become an increasingly recognized subcategory within the broad scope of emergency medicine practice. The complexities of our legal and healthcare systems, demographics of an aging population, and security concerns have all contributed to the integration of medical support and contingency planning as pre-requisite for large public gatherings. January 20, 2017 marked the 58th presidential inauguration, and the UCF/HCA Emergency Medicine Residency Program had the unique privilege of sending a team to the nation’s capital to provide medical support. Drs. Bethany Ballinger (PD), Jose Rubero (APD), Adam Benzing (PGY1), Amninder Singh (PGY1) and Amanda Webb (PGY1) made up our clinical team, and Michelle Stevenson (Residency Coordinator) provided patient tracking.
The clinical team from UCF/HCA Emergency Medicine Residency Program that attended the 58th presidential inauguration.
A presidential inauguration has unique considerations for medical and support planning that include:
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Security: One factor of particular relevance is security. All personnel providing support required security background checks months in advancek, and layers of security and screening on the day of that create significant logistical issues for patient transportation and provision of medical care.
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Multi-Agency and Jurisdictions: Resources mobilized were both local and federal, drawn from all over the country. Numerous federal agencies and assets working side by side with local government and personnel. The scale of resources deployed in support of the inauguration made the event a truly unique experience, while also creating significant logistical and planning hurdles.
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Size and Demographics: Presidential inaugurations draw large crowds anticipated in the hundreds of thousands, if not millions. While this inauguration did not meet the scale of previous years, any gathering of such magnitude has the potential for significant strain on local EMS systems. Likewise, demographics of any event must be considered during planning, with inauguration crowds often trending toward older demographics.
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Weather: The inauguration is an outdoor event on the National Mall in January. The realities of both weather and security result in large numbers of people standing for long hours in cold weather with strict security screening that inhibits their ability to easily access shelter and resources.
Our team was invited to support the event through the D.C. Department of Health and worked side by side with the George Washington University Medical Reserve Corps to staff a central referral station. The medical support model used for the event involved multiple ALS-capable medical aid stations located across the mall, with two higher-level treatment and triage stations established to receive patients requiring higher levels of care or for those requiring further assessment before disposition. In contrast to previous years when EMS transportation was conducted directly from each medical aid station, the purpose of this new model was to reduce the burden of unnecessary transports on the EMS system by providing more centralized and definitive care. Although we were fortunate not to experience any significant burden in terms of acuity or volume, the opportunity to participate in an event of this scale and magnitude was truly a unique experience — a highlight of which was meeting and working beside personnel from virtually every military branch and law enforcement and disaster response agencies.
Photo taken by the UCF/HCA Emergency Medicine Residency Program at the 58th presidential inauguration ceremony in Washinton D.C.
The UCF/HCA EM Residency Program would like to extend our gratitude to the D.C. Department of Health for inviting us to participate in such a truly unique opportunity. SPRING 2017 | VOLUME 23, ISSUE 4
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EM p u l s e F e a t u r e Formation of the FIU-FAST Team
Article by Robert Levine, MD; Steve Williams, RN; and Ruben D. Almaguer, MA In late 2014, Dean of the Herbert Wertheim College of Medicine (HWCOM) of Florida International University (FIU) Dr. John Rock asked me to work with Assistant Vice President of Disaster Management for FIU (former Director of Emergency Management for the State of Florida) Ruben Almaguer to form a Disaster Medical Response Team serving FIU and our surrounding community. As the Chancellor of LSU’s School of Medicine, Dr. Rock lived through the devastation of Hurricane Katrina. Our goal was to create a team capable of supporting FIU, the fifth largest university in the nation, and the South-Florida tri-county area to avoid the preventable human suffering and deaths seen after Hurricane Katrina. Having representatives from Emergency Medicine and Disaster Management, we added Dr. Aileen Marty, who was a former U.S. Navy and expert in infectious disease to our group. With contacts in academia, medicine, emergency management and now the U.S. military, we began to explore currently available local resources. After preliminary meetings on campus, we met with two local teams: an Urban Search and Rescue Team Florida Task Force 1 belonging to Miami-Dade Fire Rescue Department, and the State of Florida’s Florida Advanced Surgical Transport Team (FAST) in April 2015. During these meetings, we had the opportunity to review their equipment caches, as well as learn about their level of training, staffing, operations and previous deployments. We found that there was significant overlap in personnel from the various medical teams, and some teams around the state and/or country have difficulty maintaining readiness for deployment due to inadequate funding, personnel and training. We continued to meet with the FAST team to observe their overall operations and quickly realized that we could work together. Through local philanthropy, FIU was able to purchase additional equipment — such as Western Shelters base of operations tents, a mobile water purification system and etc. — to support the FAST team so that the team could expand its functionality in austere disaster environments. In addition, we recruited additional medical professionals to help support the primary medical care mission of the team. As an outcome of our excellent and ongoing working relationship, FAST leadership signed a Memorandum of Understanding (MoU) in February 2016 to bring the FAST team under the auspices of the FIU College of Medicine, possibly creating the first university-sponsored team of this type in the U.S. A brief history of how and why the FIU-FAST team came about and recapitulation of more recent events that FIU-FAST has participated in follows: During Hurricane Katrina, several hundred people died, including 70 in intensive care units (ICU) possibly due to the inability to support and rapidly evacuate the patients. In 2006, the State of Florida Bureau of Preparedness & Response, not wanting to have to rely on a possibly delayed federal response in the future, established the State Medical Response System (SMRS). The goal of the SMRS is to provide State-based services and resources for medical surge support to communities impacted by disaster or to help in a pre-storm evacuation. The SMRS includes six State Medical Response Teams (SMRT’s), similar to DMAT’s, and one critical care transport team (FAST Team) based in Miami. The FAST team is comprised of about 75 physicians, nurses, paramedics and other clinical staff supported by a team of six logistics professionals. Current leadership is under Steve Williams, RN; Paul Allen, who is a paramedic; and Ruben Almaguer, who is a paramedic. Dr. Jeff Scott, who is an emergency medicine physician, serves as the medical director. The FAST team provides a 10-bed mobile ICU with ventilator support that can be established within 60 minutes of arrival at the disaster location. FAST is one of the few civilian teams in the U.S. whose entire vehicle and equipment cache is certified by the U.S. Air Force to fly on military transport aircraft. The team regularly conducts joint training exercises with the U.S. Air Force to practice loading on C5, C17 and C130 aircraft. FAST also works with the U.S. Coast Guard, flying on their C130 and HC144 aircraft. The most commonly represented specialties on the team include emergency medicine-critical care, family medicine and surgery. Recent additions include pediatrics-EM, neonatology and OB-GYN. Membership of the team is drawn from leading medical disaster responders in South Florida, many of whom have been deploying to disaster scenes, like wild land fires, hurricanes and earthquakes, since the 1990s. In 2010, team members deployed to the Haiti earthquake for six weeks as part of the U.S. Federal Government response. More recently, members of the team deployed in response to Hurricane Matthew. Our latest deployment was to Puerto Barrios, Guatemala as part of a joint mission with the U.S. Navy. The eight members of the team included three emergency medicine physicians, one neonatologist, one OB-GYN, an infectious disease specialist, one OB-GYN nurse and a paramedic. With a small group of Navy physicians (family medicine, pediatrics, radiology, OB-GYN, dermatology, optometry, psychiatry and orthopedics), physician assistants, nurse practitioners, Corpsmen, dentists, pharmacists and a large group of support personnel, we saw about 600 patients a day — 6,000-7,000 patients during the nearly two-week deployment. Patients were evaluated in a large gymnasium that was converted into small examination areas with separate areas for triage, adult, pediatrics, dentistry and etc. Private examination rooms were provided for gynecologic and dermatologic complaints. Several physicians performed consultative work in local hospitals on a rotating basis. From Zika-babies through leishmaniosis, the groups worked collaboratively with rapid interaction among the various specialties resulting in better care and a terrific work environment and team. Security and coordination with other organizations was generously provided by the Guatemalan government. Translators and other support personnel were also provided by the local government. Funding for the mission was provided by private funding for the FIUFAST Team. Future local, domestic and international training and humanitarian missions help the team refine our equipment needs, level of training requirements and processes with after-action reports leading to improved preparation for our next mission. Medical personnel and support (ops/logistics) people should feel free to contact us for additional information about joining the team.
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SPRING 2017 | VOLUME 24, ISSUE 1
Musings Of a Recently Retired Emergency Physician What’s a K Kay?
Article by Wayne Barry, MD, FACEP K Kay is a person, namely Dr. K. Kay Moody. She is a very special to emergency medicine, and I wanted to use my “soapbox” to give her a “shout out”. Perhaps some of you know K Kay already. If you don’t you should get to know her. It’s really easy. She created a Facebook blog in 2013 “to share the joys and challenges of Emergency Medicine”. In her Facebook blog EMDOCS, she declares we are a tribe representing every race, gender, ethnicity and 20 different countries. “We are a group of souls who respect each other.” We stand united with our patients ready to overcome adversity, be it in the “pit” struggling with our EHR, feeling the unrealistic oppression of improving dashboard metrics, or just battling incomprehensible disease processes in some ridiculously sick patients making split-second life saving and limb saving decisions for their benefit.
Wayne Barry, MD, FACEP
In addition to her Superwoman of EMDOCS personna, K Kay is actually a really nice person. She is an emergency physician married to another emergency physician and together they are raising their family of children (5) and animals while living on a picturesque working farm in Eastern Tennessee. She is a “bent arrow”, which means she did other things before attending osteopathic medical school. I have met K Kay exactly one time less than a year ago at ACEP 16 in Las Vegas, but I feel like I have known her for many years. She does not look a day over 30, but I figured she must be little older than that with five children, some of whom look like they are approaching their teenaged years. I found out how old she really was when she responded to a cornucopia of well wishes for a birthday she enjoyed In January, and she in fact spilled the beans as to her age.
To me K Kay is the Statue of LIberty and the Peter Max (present day icon of the Pop Art world) of emergency medicine. Like the Statue of Liberty, K Kay carries the torch for our tribe of emergency physicians leading us toward self awareness with respect to wellness, professional satisfaction and fighting for the rights of our patients to see us in our ERs (access to care). Like Peter Max, she is prolific and tireless in her quest to achieve these goals. She is like a breath of fresh air in that she has infused us with a self pride in her designs of clothing, pins and activities, all which celebrate membership in our tribe and our positive feelings about what we do in the “pits” and the “trenches” we call our worksites. Oh by the way, she has immersed herself into as many ACEP and Tennessee ACEP Committees as she can possibly fit into her busy schedule. I believe she is serving as the President of the latter organization this year. She is the posterchild for ACEP involvement and advocacy. She writes and speaks emergency medicine-related issues are her passion. But then I see another side to her while following her on Facebook: She was on a snowy Washington State trip with her husband scoping out some land suitable for establishing a wellness spa for tired out ER docs who need rejuvenating and others.
Photo of Dr. K. Kay Moody. Provided by Wayne Barry, MD, FACEP
Her blog is a fascinating melange of interesting entries. I can read where she or others have had a trying shift in the ER. There are countless nuggets of useful clinical tips as readers share their experiences with problem solving and “tricks of the trade”. There are discussions about the current state of healthcare in America. She exhorts our colleague blog participants to be decorous with respect to each other’s feelings and general propriety. She organizes forums (fora) to discuss wellness, how to survive a malpractice lawsuit and how to prevent professional burnout. As far as I am concerned K Kay occupies a place in my personal pantheon of Heroes of Emergency Medicine. Some of these are Rick Bukata, Jerry Hoffman, Greg Henry, Dennis Whitehead, Louise Andrew, Judith Tintanelli, Marsha Ford, Jack Allison, Linda Lawrence, Mark DeBard, Peter DeBlieux, Diane Birnbaumer, Billy Mallon, Marco Coppola, Corey Slovis, Amal Mattu, Arjin Chamugam, Marian Gausche Hill, Michael Gerardi, Dave Seaberg, Angela Gardner, Peter Vicellio, Kevin Klauer, George Moltzen, Cliff Findeiss, Andy Berger, Jorge Lopez, Ernie Page, Kelly Gray Eurom, Steve Kailes, Melissa Graber, Beth Bruner, James Mills, Collin Rorie, Steve Stack, Bob Solomon and the many others I may have forgotten to name. Before I close, I want to tell you about my one and, so far, only encounter with K Kay. As I mentioned above, it took place during ACEP 16 in Las Vegas this past fall. I remembered that she broadcast in EMDOCS a time and a place to meet during one of the evening receptions, so I made a point to show up at the Terrace at Caesar’s Palace at the appointed time. I first ran into an old buddy Chuck Henrichs from North Carolina and bounced my plan to meet K Kay off him. He thought it was a great idea and joined me in looking for her. We turned around and there she was “holding court” with some of her many friends. We, two old guys, inserted ourselves easily into the gaggle and had a great time meeting and embracing K Kay as she greeted us both like long lost friends. After spending a few minutes of delightful chit chat with her, we moved on so that others could take our places in the gaggle. Since I was hungry, I sat down on a railing to sip my beer and munch shrimp canapes where I found myself sitting next to a guy with an interesting looking hat, but he looked rather forlorn. I studied his hat and then caught his glance, and he spoke to me stating that he was lonely and bored because he didn’t know anybody at the reception. Without thinking I told him about my meeting with K Kay minutes before. As luck would have it, I looked up, and there she was about 50 feet away from where we sat. I dragged Dave over to meet her, we both chit chatted some more with her before turning to reclaim our seats. Photo of Dr. K. Kay Moody. Provided by Wayne Barry, MD, FACEP
Dave looked at me with his eyes wide open and there was a big smile on his face, and he said thank you for making my evening by introducing me to K Kay! Well my friends, that says it all! SPRING 2017 | VOLUME 23, ISSUE 4
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