EMpulse (Fall 2017) by Florida College of Emergency Physicians

Volume 24, Issue 3 FALL 2017

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

T he E ver -E volving L andscape O f E mergency M edicine I n F lorida

FCEP Program Aims for Creative Solutions for Payment Reform PHOTOS FROM ALL OUR SUMMER PROGRAMS INSIDE THIS ISSUE!

PHYSICIAN AND LEADERSHIP OPPORTUNITIES NORTH FLORIDA

Fort Walton Beach Medical Center (Ft. Walton Beach) Oviedo Medical Center (Oviedo) Bay Medical Center (Panama City) Bay Medical FSED (Panama City) Gulf Coast Regional Medical Center (Panama City)

CENTRAL FLORIDA

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) Lakewood Ranch FSED (Sarasota) Brandon Regional Hospital (Tampa Bay) Citrus Park ER (Tampa Bay) Largo Medical Center (Tampa Bay) Lutz FSED (Tampa Bay) Mease Countryside Hospital (Tampa Bay) Mease Dunedin Hospital (Tampa Bay) Medical Center of Trinity (Tampa Bay) Northside Hospital (Tampa Bay) Palm Harbor ER (Tampa Bay) Regional Medical Center at Bayonet Point (Tampa Bay) Tampa Community Hospital (Tampa Bay)

SOUTH FLORIDA

Broward Health, 4-hospital system (Ft. Lauderdale) Northwest Medical Center (Ft. Lauderdale) Plantation General Hospital (Ft. Lauderdale) University Medical Center (Ft. Lauderdale) Lawnwood Regional Medical Center (Ft. Pierce) Raulerson Hospital (Okeechobee) St. Lucie Medical Center (Port St. Lucie) Palms West Hospital (West Palm Beach) JFK North (West Palm Beach)

PEDIATRIC EM

Broward Health Children’s Hospital (Ft. Lauderdale) Northwest Medical Center (Ft. Lauderdale) Plantation General Hospital (Ft. Lauderdale) Munroe Regional Medical Center (Ocala) Gulf Coast Medical Center (Panama City) Brandon Regional Hospital (Tampa Bay) Mease Countryside Hospital (Tampa Bay) The Children’s Hospital at Palms West (West Palm Beach)

LEADERSHIP

Aventura Hospital and Medical Center (Miami) Citrus Memorial Hospital (Inverness) Assistant Medical Director Brandon Regional Hospital (Tampa Bay, FL) Assistant Medical Director Brandon Regional Hospital (Tampa Bay, FL) EM Residency Program Director Medical Center of Trinity (Tampa Bay, FL) Assistant Medical Director Regional Medical Center at Bayonet Point (Tampa Bay, FL) Tampa Community Hospital (Tampa Bay, FL)

Call or text: 727.253.5466 Ask about our provider referral program!

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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

Features

FCEP Executive Committee Joel Stern, MD, FACEP • President

Daunting Diagnosis | 6

Joseph Adrian Tyndall, MD, MPH, FACEP • President-Elect Kristin McCabe-Kline, MD, FACEP • Vice President Sanjay Pattani, MD, FACEP • Secretary-Treasurer Jay L. Falk, MD, MCCM, FACEP • Immediate Past-President Beth Brunner, MBA, CAE • Executive Director

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, the Florida College of Emergency Physicians and our advertisers/sponsors. 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 Photo cover courtesy of: © niyazz (https://stock.adobe.com/stock-photo/

Strategies for better AR Management – Maximizing Collections (Sponsored by Martin Gottlieb & Associates) | 9

Using a Distraction “Toolkit” and Other Nonpharmacologic Methods to Manage Pain and Anxiety | 14 Poison Control | 16 Board Certification in the Marketplace | 22 What’s Behind the Growing Interest of Ultrasound Training in Florida Residency Programs? | 23 The Proliferation of Emergency Medicine Residency Programs in Florida: A Trigger to EM Physician Wage Depression | 24 SBS 2017: One of Our Best Yet! | 26 Snapshots from Written Board Review Course 2017| 28 CLINCON 2017 Draws EMS From Across the State of Flroida | 29 North Florida Gains a New EM Residency Program | 30 EM Payment Reform Summit Promotes Tackling Important National EM Issues | 31 SBS 2017 Residency Competition Winners | 32 Focused Assessment with Sonography of Trauma | 32 Musings of a Recently Retired Emergency Physican | 34

concept-of-national-healthcare-system-florida/77449471)

FALL 2017 | VOLUME 24, ISSUE 3

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President’s Message It is a great honor to be installed as the newest FCEP President. There is a long list of many who have served before me. They have achieved many things in promoting and developing our specialty in our state. I have big shoes to fill, and I hope to live up to our history.

Joel Stern, MD, FACEP, FAAEM FCEP President

The transition took place, as it does every year, at Symposium By The Sea. This is our annual marquee event, and this year the CME conference was held at the fabulous Boca Resort and Spa in Boca Raton, Fla. If you haven’t been to SBS yet, I highly encourage you to check it out next year in Sanibel Island. We have many awesome events, including CME programs, LLSA courses, EM resident competitions (like Simwars, CPC and posters) and family friendly events (ike beach volleyball and Casino Night). It’s a great opportunity for networking, and many of our sponsors are recruiting physicians for in-state and national jobs. Registration is free for residents and medical students. This year we had more than 220 attendees, which is a great turnout.

The FCEP Board of Directors also holds a meeting every year in conjunction with the program. At this meeting, newly elected Board members are appointed, as well as Executive Committee officers. Honors and awards are also presented to outgoing Board members, along with people who have made exceptional contributions to the College. We also typically are honored with the presence of several physicians from around the country who are running for positions on the ACEP Board. This year was no exception, as we heard presentations from many qualified candidates for upcoming elections at the ACEP Council meeting in October. I am very proud to note that our own Dr. Vidor Friedman will be running this year for ACEP PresidentElect. Our State Chapter Board plans to actively support his candidacy, and we wish him the best of luck in this endeavor. The ACEP Council meeting will take place in Washington D.C., immediately preceding the ACEP17 CME conference, on October 27 and 28. If you are planning on attending this event, I invite you to spend some time with our delegation. Our next Board of Directors meeting is scheduled for November 16 at the EMLRC office in Orlando. FCEP committees will be meeting on November 15 at the same location. We have several committees, including EMS/Trauma, Medical Economics, Government Affairs, Education & Academic Affairs, Pediatrics, EMRAF, and Membership and Professional Development. All members are encouraged to attend any meetings of personal interest, including Board meetings. We also provide a conference call line, if you are unable to make it to Orlando. In addition, please remember to support our Political Committees and our Foundation. These are separate from NEMPAC and EMF, which are the national organizations. Our PCs are Physicians for Emergency Care (PEC) and Emergency Care for Florida (ECF), and our Foundation is the Florida Emergency Medicine Foundation (FEMF). PC donations can be made with membership renewals, and both PC and Foundation donations can be made online on our website (www.emlrc.org). Foundation donations are 100 percent tax deductible. Finally, I would like to thank you for your membership in our ACEP state chapter. Your support makes these great programs possible and allows us to advocate for the benefit of all EM physicians in Florida.

Approved for AMA PRA Category 1 CreditsTM

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FALL 2017 | VOLUME 24, ISSUE 3

Government Affairs Committee

Damian Caraballo, MD, FACEP Government Affairs Committee Co-Chair

August is a very important month at FCEP, as we map out our legislative strategy for the year. This year, due to early session and Emergency Medicine Days in January 2018, we will be under the gun to get out our priorities and plan our legislative visits. In order to maximize our effectiveness, this year we will be employing a new strategy with FCEP. We will be strategically breaking down Florida into regions, each led by an experienced person who will help facilitate the dispersing of Political Committee funds and setting up contacts with legislature and their aides. The regional “chiefs” will be: Dr. Steve Kailes for Jacksonville/Northeast Florida area; Dr. Kristen McCabe for Daytona Beach/Space Coast area; Drs. Dan Brennan and Sanjay Pattani for the Orlando/Central Florida area; Drs. Joel Stern and Joshua Young for the Miami/South Florida area, Dr. Aaron Wohl for the Fort Meyers/Southwest Florida Florida area; Dr. J. Adrian Tyndall in Gainesville/North Florida area; and myself for the Tampa/West Florida area. Our goal is to recruit newer or unexperienced members to our advocacy efforts and to foster relationships with key legislatures in the given areas. We will also be placing more of an emphasis on strategically targeting government and committee leaders in our efforts.

As for legislative priorities, we once again are seeing insurance companies with abusive practices toward physician groups, particularly if out-of-network. FCEP stands firm in opposing unfair predatory repayment strategies that we are seeing by some health payers in Florida. Through the organization, we have a network of group leaders formulating strategies to standup for physician groups in the face of billion-dollar, conglomerate health insurance companies. We are currently working on a longterm legislative strategy to curtail abusive health insurer practices. FCEP has created a taskforce to intercede on behalf of physician groups who are being taken advantage of in reimbursement, and it is open to all members to join in on the fight for fair physician reimbursement. Rest assured, FCEP is using all avenues, including legislation, regulatory, data collection, and also utilizing ACEP’s vast repertoire of insight and data to ensure fair reimbursement for emergency physicians in Florida. As for other priorities for this legislative year, we will continue to be physician leaders on treating the opioid epidemic which has engulfed our state. We are also looking for members to join a cross-specialty committee on educating the public and the legislature on incorporating Physician Orders for Life Sustaining Treatment (POLST) forms in near end-of-life treatment. Other areas which will require your support include: combatting Personal Injury Protection (PIP) repeal, which would lead to cuts in physician reimbursement; finding more funding for CME and educational grants; opposing the trial bar and improving the malpractice environment of Florida; and tracking/fighting any legislation which strips emergency physicians from autonomy or right to fair reimbursement. In the end, the Florida College of Emergency Physicians is only as strong as our members’ contributions. We continue to face tougher and more cut-throat opponents who will continue to work toward stripping physician autonomy and undermine the physician-patient relationship. It is up to us to band together, meet with legislature, and help formulate legislation which advances our specialty and ability to care for our patients. Finally, I’d be remiss if I did not mention the significance of the FCEP PC. For better or worse, modern politics requires a war chest to combat groups which aim to undermine physicians. Please consider giving just $10 a month to start to help fund our fight against insurers, attorneys and bureaucrats who are working to keep you from fulfilling your medical prerogatives. Because of the power of the doctor-patient relationship, we will always hold the high-ground to these groups. Now more than ever, we need Florida physicians to band together and demand legislative action to improve the quality and lives of Florida patients and physicians.

Approved for AMA PRA Category 1 CreditsTM FALL 2017| VOLUME 24, ISSUE 3

EMpulse | 5

EMS/Trauma Committee I want to begin this EMS/Trauma Committee update with a discussion of DNR law in the State of Florida and how it applies to our prehospital providers. The Florida Department of Health website clarifies “A Do Not Resuscitate Order (DNRO) is a form or patient identification device developed by the Department of Health to identify people who do not wish to be resuscitated in the event of respiratory or cardiac arrest.” In fact, the official statement on the form is “PHYSICIAN’S STATEMENT I, the undersigned, a physician licensed pursuant to Chapter 458 or 459, F.S., am the physician of the patient named above. I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the patient in the event of the patient’s cardiac or respiratory arrest.” Florida Statute 401.45 and Rule 64J-2.018 covers the prehospital use of the DNR form. Endof-life issues are difficult. When time and situation allow for family discussion or for further physician orders, prehospital providers often make every attempt to clarify what a DNR patient’s wishes truly are. However, we must understand that Florida law directs providers to withhold resuscitative care only in the event of cardiac or respiratory arrest.

Desmond Fitzpatrick, MD EMS/Trauma Committee Co-Chair

If a patient is critical but not in cardiac or respiratory arrest and further orders cannot be obtained, providers have a duty to act. In certain cases, providers may be able to safely delay more aggressive treatment, such as an advanced airway. However, there are circumstances where immediate treatment is necessary. A DNR does not mean do not treat. Physicians, due to training and licensure, often have the luxury of making a more advanced determination based on patient factors and discussions with families. Our prehospital providers don’t have this luxury. We must work together to further our understanding of these issues and push our legislature toward bringing more advance orders into our state, like POLST (physician’s orders for life sustaining treatment), which allow for a clearer understanding of our patients’ wishes.

FAEMSMD (Florida Association of EMS Medical Directors) July State Meeting Update

Stroke Systems of Care Update: A new designation for “acute stroke ready centers” has been created for hospitals wishing to be part of the stroke care system but not meeting primary stroke center status. This update for FS 395 also requires hospitals to provide information and data about stroke care at their center. See FS 395.3038 for further details. Status Update on “H.R. 304: Protecting Patient Access to Emergency Medications Act of 2017”: This is an essential bill regarding patient’s access to prehospital pain control and DEA legislation. The bill has passed the House of Representatives without any opposition. It now is in the Senate with some support but needs advocacy to ensure that it does not fall by the wayside. Please call or write your senators in support of this bill (SB 916). Medication Shortages: Medication shortages often disrupt our ability to provide optimal care to our patients. Thankfully, more attention is being paid by lawmakers and agencies, such as the FDA. The FDA has recently announced expiration extensions on certain critical medicines such as atropine, D50 and epinephrine. Please see the FDA website for further information on medications included in this extension. Lastly, I would like to applaud some groundbreaking research and protocols coming from the South Florida medical director group of Scheppke, Antevy and Pepe. Their work includes a “Head-Up CPR” trial and a novel approach to breaking the cycle of overdose abuse.

Daunting Diagnosis Question: A 39-year-old male presents with left arm pain after lifting a heavy box. The patient felt a “pop” at his medial arm. He has mild weakness, but he is able to flex, extend, supinate and pronate his arm. What is the diagnosis?

Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief

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Turn to page 25 for the answer! FALL 2017 | VOLUME 24, ISSUE 3

Medical Student Committee Article by Alicia Bishop, FCEP Medical Student Committee Secretary-Editor Medical students from across the state gathered at the Boca Raton Resort & Club earlier this month for FCEP’s annual Symposium by the Sea (SBS). SBS 2017 provided several exciting opportunities for students: to attend high-yield lectures in EM topics, present their research, meet like-minded peers and network with professionals from around Florida. From a broad pool of submissions, several students were chosen to showcase their research during the Research Poster presentations, giving attendees a glimpse into all the inspiring academic work Florida students conduct in EM. Congratulations to Emily Welch, a second year student from the University of Florida College of Medicine, whose presentation “Disparities in ED Recidivism Rates by Gender, Race, Age, Health Literacy, and Payer Status in Evaluation of Low-Risk Acute Coronary Syndrome Patients” was selected as the “Best Medical Student Poster” this year. Quinn Frier, an MS2 from Florida State University College of Medicine who also had the chance to present his project “Removal of LBBB as a STEMI Criteria Does Not Affect Patient Outcomes”, shared that he particularly enjoyed this year’s Medical Student Forum and several of the lectures.

(L-R) Hannah Gordon, Dr. Robyn Hoelle, Misty Coello and Benjamin Banapoor at the Medical Student Forum at SBS 2017. Photo courtesy of Alicia Bishop

“This event has been so valuable — from the session with residency directors to the lectures — for helping not only to see how to actually fulfill your dream of becoming an ER doctor, but also to help you get a feel for the field and make sure this is something you’re truly interested in,” Frier said. A particularly exciting part of this year’s SBS was welcoming the inaugural classes of three new Florida emergency medicine residency programs. Students in attendance had the chance to learn more about the resources each of these unique learning environments will offer. This was a great opportunity for those hoping to stay in state. “It was fantastic to see such a large turnout from both students and program directors,” FCEP Medical Student Committee Cochair Hannah Gordon, an MS3 from Florida International University’s Herbert Wertheim College of Medicine, said. “The Medical Student Forum this year was a clear indicator that Florida is growing into an EM training powerhouse. We are lucky to be in a state with so many opportunities for students.”

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ACEP B oard U pdate It was great to see so many old friends and new faces at Symposium By The Sea in Boca Raton. Another Great FCEP annual meeting. Kudos to all the hard-working volunteers and staff! As for me, it has been quite a busy summer for your ACEP Board member! I have had the opportunity to make several chapter visits this summer, and it is great to see the level of engagement and activity across the country.

Vidor Friedman, MD, FACEP FCEP Board Member, SecretaryTreasurer of American College of Emergency Physicians

Unfortunately, most of the chapters are also struggling with many of the same issues that we are wrestling with here in Florida: out-of-network payment and MOC being at the top of the list.

These issues were also prominent at the ACEP BOD meeting in June, where we approved the ACEP/EDPMA Joint Task Force Model Legislation for Out of Network Services and the supporting document “Guiding Principles and Annotations of OON Model Legislation”. We also reviewed our strategic plan regarding OON/BB legislation. We also met with the ABEM Board leadership regarding the concerns many members have raised regarding the MOC process. Since June, the ACEP Executive Committee has met with the ABEM Executive Committee several times, and we have had excellent dialogue on ABEM’s plan going forward to address these controversies. I am sure that we will hear more on this at the Council meeting in October. While I understand some of the angst out there regarding MOC, I personally have significant concerns with “legislative” solutions to these issues, which the FMA has been touting. It has been my experience that the legislature doesn't really understand medical practice and tends to create even more onerous requirements then what we all ready have. Board certification and recertification has served to create higher standards for specialty physicians, and board certification has justified higher reimbursement by payers. If you have not read Brian Zink MD’s book Anyone, Anything, Anytime, a History of Emergency Medicine, it speaks quite eloquently regarding this issue. It is my fervent hope that we can resolve this “in house” working with ABEM. At our June board meeting, we also approved our annual budget for ACEP. The budgeting process this year was fairly stressful for all involved. For the past decade, ACEP’s finances have been quite robust with a significant growth in member equity. ACEP built a new headquarters, which like here in Florida, was essential for the ongoing work of the organization. ACEP is also being tasked with taking an ever-larger role in the business of the emergency medicine, and this is requiring significant investment on the College’s part. Consider the development of CEDR, our qualified clinical data registry, which has involved investment by the College of more than $5 million over several years. If ACEP did not take this on, the vast majority of our members would face a very real decline in reimbursement in a few years. ACEP’s financial situation is quite strong, but I foresee a few years where ACEP will need to be in an investing mode instead of focusing on building member equity. Actually, I consider this very positive for the organization. After all, we built up member equity to use in a fiscally responsible manner for our members, and that is exactly what the ACEP Board of Directors is doing! I hope to see many of you in Washington, D.C. in October for the ACEP Council meeting from October 26-28 and at ACEP2017 from October 29-November 1. It will be a fun and exciting time! Bring your white coats and join us for White Coat Day on the Hill on November 1, 2017, which is a great opportunity for emergency medicine to share our stories and concerns with our U.S. Congressional representatives. See you in D.C.!

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FALL 2017 | VOLUME 24, ISSUE 3

Strategies for better AR Management – Maximizing Collections Article by Shanna Howe, VP of Operations

In this everchanging healthcare industry, Emergency Medicine providers are constantly looking for ways to maximize collections and resolve Accounts Receivable sooner. Meanwhile, payors do not make this easy; so, working the “exceptions” has become more important than ever. First, study your claim filings and file electronically wherever the opportunity exists. It is important to understand each individual payor’s claim filing requirements and file correctly the first time. In addition to filing electronically, work with the payors to setup EFT/ACH payments as well as ERA/835 remits, as this will help to expedite receipt of the funds and remittance advice. Even when following best practices, there are always claims that don’t pay or pay incorrectly the “exceptions”. For those exceptions, analyze your AR in detail, and by pay specific attention to responsibility. Handling patient responsible payments requires its own plan. Here, we’ll focus on Insurance Responsible AR. • Start by reviewing unadjudicated claims by AR Aging by Payor Class – This allows you to focus on any potential issues early on based on each individual Payor Class. • Next, take look at denials by Payor Class – Focus on the top denials by Payor Class, and drill down to each individual payor as needed, and focus on the denials that have opportunity for resolution with the payor. • Technology makes the job easier, so use your resources wisely, and check claim status online via payor’s websites or send & receive 276/277 EDI Claim Status transactions. Make phone calls only when necessary, as payor wait times and procedures may allow you to accomplish little for the amount of time spent. • Protect your bottom line by verifying that contracted payors are paying according to the reimbursement terms of your managed care contract – payors often times may neglect to load contract renewals/annual escalators in their system, or may load and process claims incorrectly. Reviewing your overall Days in AR will help you to determine your practice’s overall AR performance in terms of how quickly you are paid. However, depending on your self-pay/ uninsured process, the Days in AR statistic can vary greatly from one practice or billing company to another. Get to know your average Days in AR and be alerted of changes – with the use of Business Intelligence tools available to us today, being alerted of changes or potential issues will allow you to focus on those last dollars.

Leadership Academy Update The annual Symposium by the Sea (SBS) conference in August signifies many things for the Florida College of Emergency Physicians. As we usher in new officers and Board members, we also see a lot of new faces, great ideas and work to facilitate projects that begin during our annual conference. One area of particular interest and excitement is FCEP's Leadership Academy. The Leadership Academy exists to promote participants to pursue the highest quality emergency medical care and education, while empowering our emergency physicians to better protect the patients they serve across our great state.

Pat Agdamag, MD, FACEP

FCEP Board Member; Chair of FCEP’s Leadership Academy

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 the ability to exercise individual’s organizational and educational skills through unique leadership experiences -- all from some of our most influential EM leaders across the state Florida and ACEP! Some of the venues Leadership Academy members will take part in this year include: FCEP's Board of Director meetings, FCEP's Committee meetings, Tallahassee state legislature meetings during Emergency Medicine Days 2018, and ACEP national assembly meetings.

For those not familiar with FCEP's Leadership Academy, it combines elements of mentoring, organization and guided experiences to selected Academy applicants 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. At Symposium by the Sea, the journey begins. 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 events attended include FCEP Board and Committee meetings, Emergency Medicine Days, Symposium by the Sea, and ACEP's Leadership and Advocacy Conference in 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, or even introduction of new legislation during our annual Emergency Medicine Days conference in Tallahassee. This year at Symposium by the Sea in Boca Raton, we took the time during our Board of Directors meeting to recognize our incoming and outgoing classes of the Leadership Academy for their efforts and dedication toward a search for growth in leadership : • Graduating: Drs. Ray Merritt (Tampa - project: New EM Clerkships for out-of-state Osteopathic medical students) and Saundra Jackson (Jacksonville - project: ED US Image storage with Right to bill) • Alum Update: Two of our previous year's graduates -- Drs. Gary Lai (Weston, FL ) and Kristi Staff (Tampa, FL) -- have both attained FCEP Board positions. • The 2017-2018 class that was ushered includes three outstanding EM physicians with instinctive and diverse leadership qualities: Drs. Kirk Szustkiewicz (Brandon), Laura Hummel (Tampa) and Ryan McKenna (Jax to Tampa). As FCEP's current Chair of the Leadership Academy, I can personally attest to the quality of candidates selected. It is a highly competitive process statewide with careful selection. This will no doubt be a springboard for more growth in their leadership experiences already attained. Once again, please join me in congratulating all of these individuals for their honor and distinction!

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FCEP Leadership Academy Chair Dr. Patrick Agdamag (center) presents Drs. Saundra Jackson (left) and Ray Merritt (right) with awards at SBS 2017 upon graduating from the Leadership Academy. Photo courtesy of FCEP Communications Manager Samantha Rosenthal

FALL 2017 | VOLUME 24, ISSUE 3

Membership & Professional Development Committee Our most recent meeting took place at Symposium by the Sea (SBS) 2017 in Boca! Were you there? Although we were all excited about being at SBS, there is always the business of the organization to attend to, and we were able to get a lot accomplished. A few things that we were able to celebrate is that our membership is growing. Over the past years, there has been a steady increase in our membership, largely due to you. Thank you for continuing to support your organization and for encouraging your colleagues to do the same.

Rene Mack, MD, RDMS Membership & Professional Development Committee Chair

I have mentioned in other issues that we have a growing number of medical students and residents who are an integral part of our organization. We are encouraged that the younger generation is as enthusiastic about emergency medicine as we are. In an effort to bolster their understanding of EM and assist their quest for more information, we have developed an FCEP Medical Student Mentoring Program. If you are interested in helping to further the education and foster an enriching learning environment for medical students interested in EM, please get in touch with us and we will get you connected with an eager medical student. Also, if you have novel ideas of how we can continue to nurture and encourage our medical students and residents, please reach out to us.

The fifth class of the FCEP Leadership Academy was inducted at SBS 2017. We welcome Drs. McKenna, Hummel and Szustkiewicz, and look forward to showing them the inner workings of FCEP and ACEP. Have you been interested in “getting more involved” but don’t know where to start? The FCEP Leadership Academy is a great place to start. You will take part in the Council meetings at ACEP Assembly; this is a notable opportunity as you will be representing our membership. The Council meetings are where the resolutions affecting ACEP, and therefore FCEP, are voted on. Being an active part of our democratic process is only one part of the Leadership Academy. You will also gain insight into the local, state and national involvement of EM and how integral we are to the process. We have a rolling application cycle so jump in anytime. We recognize that it is vitally important that all areas of our specialty are well represented, and we are continually mindful of this and intentionally seeking ways to incorporate all our members. We have had an increase in our non-academic members, and we have been better for it! Having a better understanding of the needs of our members in various practice styles improves the outcome for the entire group. Do you work in a community hospital, clinic or rural area and would like to have some input on how we can better represent you? Send in your ideas -- we would appreciate hearing from you about how we can better serve you and the rest of the community. There are numerous tasks that FCEP takes charge of in order to provide the most meaningful and productive return for our members. Luckily, we have an organization that is run by us and for us, so we more readily understand what is needed by the members. Despite our understanding of what we need, we still need you! Without input from all of us, we can’t be sure that we are representing the whole community to the best of our ability. I encourage you to get involved with FCEP and/or ACEP -- the experience is enriching and well worth it. Our next committee meetings will take place on November 15, 2017 at the FCEP office in Orlando. The Board of Directors meeting will take place on November 16, 2017 also at the FCEP office in Orlando. You’re not able to make it in person? We have a conference call line, and we encourage you to call in. I’ll be there -- will you? See you soon!

FALL 2017 | VOLUME 24, ISSUE 3

EMpulse | 11

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EMRAF Committee Article by Shayne Gue, MD, Former EMRAF President, Florida Hospital Chief Resident (PGY-3) I am honored to have had the opportunity to serve as your EMRAF President over the past year. More so, I’m excited to turn over the reins to a great resident, colleague and friend Dr. Jesse Glueck. Jesse is a senior resident at Orlando Health and has been an active member of EMRAF during my tenure. I know he has big plans for the upcoming year, and I’m thrilled to help him move forward on each. Our August meeting took place at this year’s Symposium by the Sea at the Boca Raton Resort and Beach Club. We were entertained and educated by colleagues in the SimWars, CPC and Research Poster Presentation competitions. Special congratulations to all those who participated and our winners listed below: SimWars Champions: Florida Hospital Runners Up: Orlando Health Case Presentation Competition Best Presenter: Allyson Best, MD (Orlando Health) Best Discussant: Eli Kennedy, MD (Florida Hospital) Best Program: Orlando Health Research Poster Presentation Outstanding Medical Student: Emily Welch, MS1, University of Florida, Gainesville Outstanding Resident: Tushar Gupta, MD, PGY-3, University of Florida, College of Medicine, Jacksonville Outstanding Fellow: Ryan Queen, MD, Orlando Health 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. We are seeking to expand our membership this year 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 programs. As with all FCEP Committees, we meet quarterly in conjunction with the FCEP Board of Directors meeting at the EMLRC in Orlando and during Symposium by the Sea. We hope to have an increased presence and involvement this year in the planning/ organization of FCEP’s Emergency Medicine Days and Symposium by the Sea. We currently have 14 resident representatives from seven Florida residency programs (Florida Hospital, Orlando Health, UF Gainesville, University of South Florida, Aventura Medical Center, Osceola Regional and UF Jacksonville). Our objective for the 2017-2018 year is to increase our membership to a minimum of 20 resident members from all 14 Florida residency programs. If you are interested in serving as an EMRAF Liaison for your program, please contact me at shaynegue@hotmail.com.

A Welcome Message From the Newly Appointed EMRAF President Article by Jesse Glueck, MD, EMRAF President, Orlando Health Emergency Residency (PGY-3) I would first like to take this opportunity to thank Shayne for his great leadership over the past year. He has dedicated himself over his tenure as EMRAF president to the EM residents, ensuring that we as a whole are directly involved in shaping the future of emergency medicine training and practice in the State of Florida. I also want to personally welcome all of this year’s new residents, especially those from the newly created programs, to the family that is Florida Emergency Medicine. This is an exciting time of growth here in Florida, and we at EMRAF look forward to advocating on your behalf and working with you all to ensure that you get the same great resident centered training the State of Florida has always been known for. I would also like to echo what Shayne stated about increasing our membership this year to include representatives from all 14 of the residency programs in our state. The only way we can guide our training and future practice environment is by directly being involved in the processes that shape them. I am looking forward to all of the exciting things that we can accomplish together over the next year FALL 2017 | VOLUME 24, ISSUE 3

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EM p u l s e F e at u r e Using a Distraction "Toolkit" and Other Nonpharmacologic Methods to Manage Pain and Anxiety Article by Phyllis Hendry, MD, FAAP, FACEP; Sophia Sheikh, MD, FACEP; and Raina Davidman, MBA, LPN, EMT

America’s Painful Epidemic DID YOU KNOW?

• The Joint Commission released new pain management standards effective January 1, 2018 that include provision of non-pharmacologic pain treatment modalities. • Veterinary schools require more pain education than medical schools; however, that is changing. *Expect to see a new emphasis on pain education in medical and other health professional schools. • Conversation alone can reduce anxiety and pain through distraction. *Up to a 25% reduction.

Pain is a common presenting complaint to emergency departments (EDs) and can be acute, chronic or procedure related. Most emergency providers receive limited training in pain management, let alone in nonpharmacologic techniques such as distraction, imagery or comfort positioning. Additionally, EDs and EMS rarely have access to nonpharmacologic-trained specialists or child life professionals. In light of the opioid epidemic, overcrowding, and patient safety issues surrounding sedative and analgesic medications, EDs are searching for new methods of managing pain. Nonpharmacologic approaches are more commonly used in pediatrics; however, these concepts also apply to adults. Nonpharmacologic interventions have the potential to decrease or eliminate opioids, improve patient/ family response, and decrease procedure time and adverse events. The Distraction Toolkit Project is a component of the free access Pain Assessment and Management Initiative (PAMI).

Pilot Course on Nonpharmacologic, Child Life & Distraction Toolbox Techniques

On April 21, 2017, PAMI held a pilot course tentatively named New Approaches to Pain: Exploring Nonpharmacologic, Child Life & Distraction Toolbox Techniques for Pain Management in Emergency and Acute Care Settings. Attendees included physicians, students, residents, pharmacists, paramedics, EMT’s, nurses, child life specialists, medical assistants, respiratory therapists and music therapists, representing Northeast/Central Florida and South Georgia. Course topics included the basics of pain management, benefits of nonpharmacologic management, a stepwise approach to pain management that incorporates pharmacologic and nonpharmacologic measures, therapeutic language, comfort positioning, coaching, distraction, guided imagery, and other physical/psychosocial modalities. A variety of case scenarios, distraction tools, resources, videos, and apps were reviewed and all attendees received a resource packet and their own Distraction Toolbox! Attendees recommended expanding to a four-hour course to allow for skill stations and more time for case discussion. Physical (Sensory) Interventions Comfort Positioning Cutaneous stimulation Nonnutritive sucking Pressure, massage Hot or cold treatments Pacifier +/- sucrose solution

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WHAT’S IN A DISTRACTION TOOLBOX? Choose a toolbox item appropriate for the situation and developmental age • Hot or cold packs • LED animal keychain • Wikki Stix • Bubbles • Mad Libs • Games/Videos • I Spy wands

• • • •

Music/Apps Stress balls Pin Wheels Pacifier: with or without sucrose solution • Therapeutic language

For more information on PAMI’s Distraction Toolkit visit: http://pami.emergency.med.jax.ufl. edu/resources/new-approaches-topain-course/ Scan here to be taken directly to the site!

Cognitive-Behavioral Interventions Psychologic preparation, orienting information, and coaching Distraction (passive or active): movies, games, apps, phone or tablet, toys with light or sound Relaxation techniques (breathing, meditation, etc.) Music and singing Guided imagery Conversation and therapeutic language FALL 2017 | VOLUME 24, ISSUE 3

The Who, What, Where and Why of a Distraction Toolkit

A distraction toolkit can be a bag, backpack, toolbox, cart or even a room that contains “tools” used to distract patients during painful or stress provoking situations such as procedures, imaging, fracture reduction, burn care or management of chronic pain. Safety first! Tools and techniques are based on the setting, situation and developmental stage of the patient. It is important to pick a tool that is developmentally appropriate for the patient and to be aware of small parts and younger siblings in the room. Infection control is also a factor to consider, Can the tool be sanitized and used again, or is it a singleuse tool that can be given to the patient or thrown away? There are many benefits of using distraction in conjunction with other pain management therapies to facilitate ED or EMS triage and management: • Improves initial assessment and vital sign interpretation • Often decreases the analgesic dose or need for medications • Decreases fear and anxiety for the patient, as well as for the caregiver and the healthcare provider • Consider community partners to fund tools that can be given to patients to keep PAMI Distraction Toolkit components include: • Original course PowerPoint (April 21, 2017) • Responses to Pain by Age & Development • Suggested Language • Autism Tips • Bravery Boost poster • Toolbox Components • Resources (apps, videos, and more) • Course Bibliography • Kansas EMSC Communication Cards Visit http://pami.emergency.med.jax.ufl.edu/resources/new-approaches-to-pain-course/ to download your own toolkit. For additional information or questions email: emresearch@jax.ufl.edu or call 904-244-8617.

To work to perfect our physicians’ ability to practice medicine, every day, in everything we do. FALL 2017 | VOLUME 24, ISSUE 3

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Poison Control What

to use when sodium bicarbonate is on shortage â&#x20AC;&#x201C; a toxicology perspective Article by Dawn Sollee, Pharm.D., DABAT, FAACT Assistant Director, Florida/USVI Poison Information Center â&#x20AC;&#x201C; Jacksonville Associate Professor, UF College of Medicine, Department of Emergency Medicine â&#x20AC;&#x201C; Jacksonville Patrick Aaronson, Pharm.D., DABAT Emergency Medicine Pharmacist, UF Health Jacksonville

Drug shortages are an everyday occurrence in healthcare. One such shortage affecting toxicologists is the decreased availability of sodium bicarbonate. This is not the first time for sodium bicarbonate to be included on the FDA shortage list. In 2012, a similar shortage occurred and practitioners had to evaluate the use of other modalities to provide alkalinization of the urine or serum including IV sodium acetate or oral administration of citrate or bicarbonate. The current shortage seems to be due to delays in manufacturing along with demand surpassing supply from Hospira Inc. Importation from Australia by Athenex Inc. has approval from the Food and Drug administration (FDA) through the duration of the domestic shortage to help mitigate the severity; however, challenges remain.1 Toxicologists and physicians rely on the administration of sodium bicarbonate to alkalinize the serum (i.e. cyclic antidepressant toxicity) and the urine (i.e. salicylate, phenobarbital, and methotrexate toxicity) as well alter fast sodium channel activity (i.e. cocaine, quinidine, flecainide, and diphenhydramine toxicity). Alternatives to IV sodium bicarbonate are necessary during the shortage in order to manage patients appropriately. Some of the options are described in Table 1 (see next page).

Intravenous Sodium Acetate (Serum and Urinary Alkalinization)

Neavyn et al, in 2013, published a review article on the use of sodium acetate as an alternative to sodium bicarbonate to help provide information to toxicologists during shortages and concluded that sodium acetate is an inexpensive and apparently safe option.2 Also in 2013, Osterhoudt published 4 cases of successful utilization of sodium acetate to alkalinize the serum in 4 pediatric patients (all with different ingestions).3 In 2015, Alrabiah et al, published the results of their retrospective comparison of sodium acetate and sodium bicarbonate for alkalinization of the urine in methotrexate administration.4 They found no significant difference in the time to urine pH of >/= 8, length of stay, or increases in serum creatinine but did have a small sample size.4 To obtain successful alkalinization utilizing sodium acetate, the dosing/administration is the same. One-two milliequivalents of sodium acetate is administered intravenously as a bolus (however, it should be over 15-20 minutes), after which 150 mEq of sodium acetate is placed in a liter of 5% dextrose and started intravenously at maintenance rate. If performing urinary alkalinization, the goal urine pH is 7-8 and if performing serum alkalinization, the goal serum pH is 7.45-7.55.

Enteral Sodium Bicarbonate and Sodium Citrate (Urinary Alkalinization)

No known studies have described serum alkalinization with enteral sodium citrate or sodium bicarbonate. However, Cohen et al. described urinary alkalinization with oral sodium bicarbonate for nine subjects and achieved a mean urine pH exceeding 7.4 in approximately 2 hours after the first dose 4 g (~50 mEq).6 Enteral dosing regimens for urinary alkalinization in adults described in the literature include: sodium bicarbonate 4 g (~50 mEq) orally followed by 2 g (~25 mEq) by mouth every 4 hours7 or 4 g (~50 mEq) orally every 8 hours.6 Another option is sodium citrate, 30 mL (30 mEq) of 500 mg / 334 mg per 5 ml by mouth every 4 hours.7 If you have any questions concerning alternatives to sodium bicarbonate for urinary or serum alkalinization, please contact your local poison center toll free at 1-800-222-1222.

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Table 1

Alkalinizing agent comparison chart5,7 Alkalinizing agent

How supplied*

mEq

50 mEq

Sodium Bicarbonate IV (MW: 84 g/mol)

8.4% 4.2%

1 mEq / mL

50 mL

Sodium Acetate IV (MW: 82 g/mol) Sodium Bicarbonate tablets

~8.4% ~4.2% 650 mg tablet

1 mEq / mL

50 mL

8 mEq / 650 mg

~ 6 tablets

Sodium Citrate (Bicitra®) suspension

500 mg / 334 mg per 5 ml (30 ml cup)

1 mEq / mL

50 mL

* Commonly supplied, IV (Intravenous), MW (Molecular weight), mL (milliliter), mEq (milliequivalent)

References

1. Thompson CA. Sodium bicarbonate shortage found to affect hospitals’ daily operations. Am J Health-Syst Pharm 2017:74(16): 1208 2. Neavyn MJ, Boyer EW, Bird SB, Babu KM. Sodium acetate as a replacement for sodium bicarbonate in medical toxicology: a review. J.Med. Toxicol. 2013;9:250-4. 3. Osterhoudt KC, Trella J, Henretig F. Sodium acetate substitution for sodium bicarbonate in pediatric poisoning: a case series (Abstract). Clinical Toxicology 2013;51(7):592. 4. Alrabiah Z, Luter D, Proctor A, Bates JS. Substitution of sodium acetate for sodium bicarbonate for urine alkalinization in high-dose methotrexate therapy. AJHP 2015;72(22):1932-4. 5. Rouch, JA, Burton, B, Dabb, A et al. Comparison of enteral and parental methods of urine alkalinization in patients receiving high-dose methotrexate. J Oncol Pharm Practice 2017:23(1): 3-9 6. Cohen B, Laish I, Brosh-Nissimov T, et al. Efficacy of urine alkalinization by oral administration of sodium bicarbonate: a prospective open label trial. Am J Emerg Med 2013(31) 1703-1706 7. Gold Standard, Inc. Sodium Bicarbonate / Sodium Citrate. Clinical Pharmacology [database online]. Available at: http://www. clinicalpharmacology.com. Accessed: August 11, 2017.

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R e s i d e n c y M att e r s See what our emergency medicine residency programs have been up to. The Emergency Medicine Residency at Florida Atlantic University is off to a great start. Our first class of six residents started their journey in July. Four out of our six residents have called Florida home for quite some time, while the other two traveled from Pennsylvania and California to join us. They have all settled in nicely and are making a smooth transition from student to resident. We look forward to a wonderful year together.

Florida Atlantic University Lisa Clayton, DO, MBS, FACOEP Assistant Program Director

This July we also welcomed a new CORE faculty member and our Director of Quality Improvement and Patient Safety Dr. Joshua Solano. Dr. Solano was born and raised in South Florida. He completed medical school at the University of Florida and residency at Beth Israel Deaconess Medical Center – Harvard Affiliated in Boston where he stayed on as residency faculty and an assistant program director for two years. He is excited to return to his hometown, and we are excited to welcome him to our team!

Greetings from UCF/HCA Emergency Medicine Residency Program of Greater Orlando. We would like to formally welcome our class of 2020: Drs. Bawany, Chiang, Craen, Fusco, Hanna, Pollak and Tsau. We also welcome our new Pediatric Emergency Medicine faculty Dr. Ariel Vera to the OsRMC family. There are many exciting updates we would love to share with all of you. We had the opportunity and pleasure to participate this year at Symposium by the Sea in Boca Raton. Drs. Webb (PGY-2) and León (PGY-2) competed in the CPC competition, and Drs. Amico and Walker presented at the conference as well. Furthermore, we are proud to say that we have six abstracts that have been accepted and will be presented this year at ACEP in Washington, D.C. by UCF HCA of Greater Orlando Abhishek Roka, MD and Drs. Kramer (PGY-2), León (PGY- 2), Roka (PGY-2), Singh (PGY-2), Amico, Ballinger, Banerjee, Dub, Leoh N. Leon II, MD Ganti, Lebowitz and Rosario. Abstracts are as follows: “Sepsis fun facts: A simple way to increase PGY-2 sepsis bundle compliance”, “Septic shock patients more likely to be admitted to ICU from floor”, “Procalcitonin Trend Predicts Discharge to Home in Severe Sepsis and Septic Shock Patients”, “Early Transport versus On-Scene Management of Pediatric Out-of-Hospital Cardiac Arrest”, “Who gets tPA? Beyond the basic demographics”, and “Predictors of good outcomes after pediatric cardiac arrest”. Lastly, we would like to extend our deepest condolences to the Kissimmee Police Department and families after the tragic loss of Officer Matthew Baxter and Sgt. Richard “Sam” Howard. Both were part of the OsRMC family and are very much missed. Our thoughts and prayers are with you during this difficult time. Another year gone by and another class graces the department, full of energy and eager to learn. Outside the ED doors that were installed decades ago, steel support beams and concrete pillars surround our current department, a daily reminder of the new state-of-the-art emergency department and surgical tower that will be completed next year.

Mt. Sinai Medical Center Matthew Brooks, DO PGY-3

We were well represented at Symposium by the Sea by Drs. Justin Burkholder and David Kinas who presented original research and interesting cases. Speaking of research, new studies are constantly getting approved by the IRB, and our program has never had as much original academic research as it has now -- from quality improvement studies to ultrasound-guided procedure-based studies.

On a more solemn note, the Mount Sinai family suffered a devastating blow with the passing of one of our beloved attendings. Dr. Daniel Gurr is no longer with us, although he will always be remembered for his completely selfless attitude, love for storytelling, teaching, and running a calm and caring emergency department. Every shift he worked instilled a sense of tranquility throughout the room, and his unexpected passing is an incredible loss for the entire Mount Sinai organization. He will be greatly missed.

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The last quarter at UF Jacksonville has been marked with pride at the accomplishments of our faculty and residents, and yet tremendous sadness after the death of Dr. Robert Wears, a professor of Emergency Medicine.

University of Florida, Jacksonville Jason Arthur, MD, MPH PGY-3

Dr. Wears was a world-renowned expert in patient safety, a brilliant emergency physician and a family man. He was a titan in the research, academia and emergency medicine communities. He was a mentor and role model for our residents and a friend to everyone he met. Dr. Wears received his undergraduate and medical degrees from Johns Hopkins, a Masters in Computer Sciences from the University of North Florida, and a PhD in Industrial Safety from the Crisis and Risk Research Centre at the Ecole des Mines de Paris. He completed his residency in emergency medicine at UF Jacksonville and joined the faculty here in 1986. He was a professor at Imperial College of Medicine (London), Institute for Health Innovation at Macquarie University (Sydney) and at the University of Southern Denmark.

He sat on the editorial boards of 10 different journals and was a reviewer for 38 more. He served on the Board of Directors of the Emergency Medicine Patient Safety Foundation. He was an associate editor of the Annals of Emergency Medicine. He served on the editorial board of Human Factors and Ergonomics, the Journal of Patient Safety, and the International Journal of Risk and Safety in Medicine. He published more than 400 papers, books and chapters on patient safety, resilience in healthcare and emergency medicine. He received a Robert Wood Johnson Foundation Investigator Award in Health Policy Research to write a definitive history of the patient safety movement. He was also a Life Fellow of the American College of Emergency Physicians and worked clinically continuously since graduating from residency. He is survived by his wife Dianne, whom he met as a medical student; his children Matthew and Sarah; his six grandchildren; and nearly 40 years worth of emergency medicine residents to whom he was a surrogate father and grandfather. Associate Professor of Emergency Medicine and Medical Director for the UF Jacksonville Emergency Department Dr. Ashley Norse has been elected Vice Speaker of the Florida Medical Association (FMA). Dr. Norse obtained her medical degree from Louisiana State University in New Orleans and completed her residency at UF Jacksonville. She completed a fellowship in healthcare policy before serving as the youngest FMA delegate to the AMA, DCMS President and, ultimately, FCEP President. Rockstar senior resident Dr. Tushar Gupta won first place in the Resident Poster Presentation at Symposium by the Sea for his poster â&#x20AC;&#x153;Influence of the SOFA score in predicting inhospital mortality: does the type of organ failure matter?â&#x20AC;? In July, we started an online Ultrasound Journal Club (US JC). The aim of the US JC is to provide continual ultrasound education for visiting students, residents and faculty. Each month senior residents review an article and share some pearls while ultrasound faculty shepherd a discussion about the paper, its utility and the use of ultrasound in our practice. By being based online, participants can join anywhere they please and we can include different departments that might be interested in the article. Lastly, UF Jacksonville is excited to announce that our Emergency Ultrasound Fellowship will launch in July 2018. Applicants interested in training in a fast-paced, resuscitation-centered program should contact Fellowship Director Dr. Andrew Shannon at Andrew.Shannon@jax.ufl.edu. Another academic year is upon us, and our newest class of talented interns have begun rotating through the department. UF welcomes Drs. Lindsay Beamon (Boston University), Mike Chami (Michigan State University), Julia Eidelmen (Philadelphia College of Osteopathic Medicine), Weedley Funeus (Wake Forest), Bethany Johnston (UT Southwestern), Kemba Mark (George Washington University), Brynne McAlpine (Med College of Georgia), Thuyen Nguyen (Baylor), Austin Reed (University of Florida), Danielle Roberts (Ross University), Laura Scieszka (Marshall University), Tierra Smith (Morehouse), Garrett Snipes (University of South Carolina- Greenville), and Dacia Ticas (UT Southwestern). We are also honored to have our chairman Dr. J. Adrian Tyndall here with us as he begins his tenure as FCEP President-Elect. We are excited to work with our colleagues across the state to support policy initiatives on behalf of ED physicians everywhere. We had representation from every class at this year's Symposium by the Sea in Boca Raton, and a great time was had by all in attendance. Looking forward to another great year! FALL 2017 | VOLUME 24, ISSUE 3

University of Florida, Gainesville Travis Murphy, MD PGY-2

EMpulse | 19

The 2017 academic year is getting off to a great start for the Florida Hospital Orlando Emergency Medicine Residency program. We welcomed our EM class of 2020 on July 1, and, so far, they are doing a great job adjusting to intern life. Our two amazing chiefs Drs. Shayne Gue and Julian Trivino have been an integral part of that process. We are lucky to have them as our leaders. We also have some exciting news to report that we are again the winners of the 6th Annual SimWars Competition at the most recent Symposium by the Sea. Also, congratulations to my fellow secondyear Dr. Eli Kennedy for winning “Best Discussant” at the Case Presentation Competition (CPC) at this year’s Symposium by the Sea. Looking forward to what lies ahead for our residency! Florida Hospital Katie Laun, DO PGY-2

To begin, we want to wish all of our colleagues throughout the southeast, affected by Hurricane Irma a quick and painless recovery. Through adversity comes strength and bonding, and our hospital leadership, faculty and residents demonstrated this throughout the course of the storm. Our residents exemplified leadership dedication and poise in a time of crisis, for which we are deeply impressed and grateful. As we begin to prepare for our third interview season, we reflect on how much we’ve accomplished and also the ways we can further develop our program. Our faculty continues to mentor our residents with scholarly work. Dr. Baker has co-authored many publications with the second year class. PGY-2 Dr. Yang authored an EMDocs article, which was a thorough review of post-colonoscopy complications. It was one of the most viewed articles on the website. Dr. Yang was also elected to Aventura Hospital be one of the inaugural MDCalc Fellows. In this role, he works to create evidence-based decision Emergency Medicine tools for the website, most recently the Canadian Syncope Risk Score. Under the leadership of our Residency Staff Simulation Director Dr. Jessica Cook, our residents and faculty participated in a multi-institution, high-fidelity, simulated Mass Casualty Incident at Broward Health Simulation Center. Numerous hospitals, local fire rescue and EMS, and the School of Nursing all helped create an extraordinary and educational experience. Our faculty are dedicated to furthering their academic and scholarly achievements. Dr. Marra presented at the Mediterranean Emergency Medicine Conference in Lisbon, Portugal on geriatric opiate prescribing in September. Dr. Slesinger published Preliminary Performance on the New CME Sepsis-1 National Quality Measure: Early Highlights From the Emergency Quality Network (EQUAL). Dr. Dubensky presented a webinar titled “Sepsis Resuscitation: Challenging Cases and Exceptions” through the ACEP EQUAL Network. Finally, we would like to extend a warm welcome to the extremely accomplished Dr. Andre Pennhardt, who will be joining us as Associate Program Director in October 2017. Dr. Pennhardt is currently a professor of emergency medicine at Medical College of Georgia and has an extensive military and tactical EM background. He is fellowship trained in EMS and Austere and Wilderness Medicine.

Greetings from sunny, hot and humid Miami. We were thrilled to welcome our second class of EM residents this June, a vastly talented group of young individuals from all across the country. They represent a diverse mix of backgrounds, experiences and interests. Our action-filled orientation month included summer theater at the Adrienne Arsht Center for the Performing Arts, a baseball game at Marlins Park, our department chair’s fantastic welcome event by the water, SIM sessions at the renowned Gordon Center, as well as BLS, ACLS, ATLS, and PALS, in addition to jumping right into the action of the emergency departments both at Jackson Memorial and at Holy Cross Hospitals. Jackson Memorial Hospital Emergency Medicine Residency Staff

As we continue to evolve our dynamic didactics curriculum, we have introduced a new concept of expert panels, whereby the residents read up on curriculum topics and ask a panel of EM attendings specific questions that elaborate on management principles and different scopes of practice. This is on top of our mix of SIM labs, oral board preparation, short-focused lectures, ultrasound education and newly incorporated Emergency Medicine Foundations small groups. There is clearly plenty to keep our core faculty and residents occupied. On a side note, we are ecstatic to report that one of our interns -- Dr. Desiree Delgado -- has been accepted to present at MEMC in Portugal in September. Congratulations! Finally, we were honored to welcome Dr. Jessica Smith, EM program director at Brown University and University of Miami Alum, as our Grand Rounds Speaker and Faculty Development Leader at the end of August. We look forward to seeing everyone at ACEP this October.

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FALL 2017 | VOLUME 24, ISSUE 3

“Welcome to the family!” “Congratulations!” These two phrases have been heard on countless occasions throughout the USF EM Residency Program this summer. As always, our summer in Tampa opened with everyone’s celebration of advancement in position and welcoming of the new intern class. The intern class hit the ground running, but not after starting off with our July “Welcome Pool Party”, where each intern was “patched” into the USF family. In August, our residency had a strong showing at the 2017 FCEP Symposium by the Sea in Boca Raton, FL where we participated in both SimWars and CPC, as well as showcasing many of our resident’s research endeavors. The month of July marked another huge milestone for USF — the official change in our program leadership. Congratulations to Dr. Charlotte Derr for officially being named the new USF EM University of South Florida program director, Dr. Rachel Semmons for being promoted to associate program director, and Dr. Darrell “Clay” Ritchey Jr, MD, MSHCA, MSEd Andrew Thomas for being named the new fourth year clerkship director. In addition, we would like PGY-2 to welcome Dr. Ryan McKenna, coming to us from UF Jax, as the new USF EM simulation director. Also, we would like to welcome back to USF EM graduates Drs. Beth Mannion, who has begun her attending career with us as our EMS Fellow, and Allison DeRespino, as our Ultrasound Fellow. We would like to continue the celebration by extending a welcome to our new USF EM recruits. Congratulations to new parents Josiah and Brianna Hill on the arrival of their son Kai Gabriel Hill, and to Dominic and Katie DiDomenico on the arrival of their youngest son Leonardo Cruz DiDomenico. Lastly, we would like to thank Drs. Kelly O’Keefe, Tabitha Campbell and Ashley Grant for all of the support, leadership and guidance that you have provided to those associated with USF EM. We are extremely grateful for all you have done to help make USF EM the program it is today. We wish you all the best on your new endeavors. We look forward to seeing everyone at ACEP in October! This is quite an exciting year for the St. Lucie Emergency Medicine Residency program as we bid a bittersweet farewell to our beloved class of 2017, welcome the new class of 2020 and see many positive changes to our curriculum. To our incoming class -- Drs. Alexandra Chitty, Christine Gonzalez, Oliver Morris and Kevin Summers – we are blessed to have you, and we welcome you all with open arms! Our program achieved initial ACGME accreditation in April 2017, which has been the catalyst for many changes. Starting this year, our residency program will be three years long, and we will be taking six new residents for the upcoming year. Our lecture series has been restructured to include intensive oral board preparation, case reviews and an outstanding weekly EKG conference lead by ACEP Fellow Dr. Sarah Fowles. St. Lucie Medical Center Thomas Adams, DO

We have enjoyed several resident team-building activities over the past few years, including an airboat tour of the Everglades, a day at the Florida Atlantic University Ropes Course and recently a day at the Ballpark. We look forward to having more fun while cultivating our knowledge over the next year! We are off to an exciting start this year. All PGY classes have transitioned well to their new roles at the hospital. We are proud that our interns are doing such a fantastic job representing the emergency department on their different rotations. We are especially proud of how well our program performed at Symposium by the Sea. Chief Resident Dr. Allyson Best and PGY-2 Dr. Brandon Herb helped secure first place in the Case Presentation Competition; PGY-3 Dr. Jesse Gluek was elected President of the Florida Chapter of the Emergency Medicine Residency Association; and several of our residents were able to showcase their research during the poster session. We can’t wait to meet and share ideas with residents from all over the country at ACEP this year. We have been looking forward to attending ACEP since our intern year -- we are just so sad that Dr. Silvestri won’t be there with us, but we know that he will be there in spirit.

#LiveLikeSal FALL 2017 | VOLUME 24, ISSUE 3

Orlando Health Shari Seidman, MD & Erich Heine, DO PGY-3

EMpulse | 21

EM p u l s e F e at u r e Board Certification in the Marketplace Article by Michael L. Carius, MD, Immediate Past-President of the American Board of Emergency Medicine

Florida is a rapidly evolving environment for Emergency Medicine (EM). Florida has always had strong, respected leadership in the specialty, and there is every sign that Florida’s star is rising. The state’s number of EM residencies recognized by the Accreditation Counsel for Graduate Medical Education (ACGME) is burgeoning. This change could potentially affect job opportunities and career stability for emergency physicians. Amidst this shifting milieu, one of the competitive edges that a physician can possess is certification by the American Board of Emergency Medicine (ABEM). There currently are 35,161 ABEM-certified physicians, of whom 31,722 (90.2 percent) are EM residency trained (of these, 2,057 are located in Florida). There are an additional 3,867 physicians certified by the American Osteopathic Board of Emergency Medicine (AOBEM). That’s more than 39,000 board-certified emergency physicians! Michael L. Carius, MD Immediate Past-President of the American Board of EM

A study by Marco et al.[1] showed that emergency physicians found career benefits associated with ABEM certification, such as greater job opportunities, increased income and added peer recognition. The 2014 ACEP/Daniel Stern physician compensation survey also showed that board-certified physicians received, on average, nearly $7,000 per year in additional total compensation.[2] There are many other advantages to ABEM certification, such as high-value CME opportunities associated with Lifelong Learning and Self Assessment (LLSA) activities. The American Medical Association also provides up to 60 CME credits when a physician re-certifies with ABEM. ABEM provides a distribution of the types of CME (trauma, stroke, pediatrics) associated with LLSA tests and the ConCert™ Examination. LLSAs have an indirect benefit as a patient safety program. LLSA readings emphasize high-risk medical conditions for which there are a disproportionate number of medical malpractice cases. A final benefit is that to obtain Fellow status within ACEP, a physician must be ABEM or AOBEM certified. In Florida’s dynamic job marketplace, board certification becomes more important. A more crowded workforce magnifies scope of practice issues, especially with advanced practice clinicians (APCs). The high standards of ABEM certification, including maintaining that certification, can be held out as a distinguishing feature between board-certified physicians and APCs. An additional strength of the credential is in the ongoing struggle with medical merit badges. ABEM, along with every other major EM organization, is campaigning to eliminate medical merit badges (such as ACLS courses for routine emergency department privileges) and state-imposed, condition-specific CME requirements for board-certified emergency physicians. Making ABEM certification as strong a credential as possible helps to convince government regulatory agencies that there is an advantage to providing additional benefits to physicians who are board certified. In the first few years of the Affordable Care Act, ABEM and other American Board of Medical Specialties (ABMS) member boards were able to negotiate a provision that added $4 million in reimbursement for emergency physicians. ABEM is currently working with the ABMS to persuade CMS to modify the implementation of MACRA. We are seeking an increase in the credit for the Clinical Practice Improvement Activity (CPIA) in calculating a physician’s composite score. Currently, Maintenance of Certification contributes 3.75 percent; ABEM hopes to have this increased to the maximum 15 percent, which would represent a significant benefit to board-certified physicians. As the workforce in Florida is undergoing transformation, one of the best competitive edges a physician has is ABEM certification. It will help ensure job and career stability as well as position EM in a strong leadership position among the various medical specialties. Florida is emerging as a destination state for training in our specialty. Having a strong alignment between the medical specialty societies such as FCEP and ABEM benefits physicians, our specialty and our patients.

References 1.

Marco CA, Wahl RP, Counselman FL, Heller BN, Harvey AL, Joldersma KB, Kowalenko T, Coombs AB, Reisdorff EJ. The American Board of Emergency Medicine ConCert examination: emergency physicians’ perceptions of learning and career benefits. Acad Emerg Med 2016;23:1082-5.

ACEP/Daniel Sterns 2014 National Emergency Medicine Salary Survey: Clinical Results. http://bookstore.acep.org/acep-daniel-stern-compensationreports

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EM p u l s e F e at u r e What’s Behind the Growing Interest Residency Programs?

Ultrasound Training

Florida

Article by Saundra Jackson, MD, RDMS, FACEP, Emergency Ultrasound Director, Emergency Resources Group

The use of bedside point-of-care ultrasound (POCUS) has increased tremendously over the past decade, with an initial measurable increase in interest and growth taking place in the early 21st century.2 Emergency ultrasound (US) is a versatile tool that is used in a variety of environments and clinical situations. We routinely employ this technology in our adult and pediatric EDs, but with the advancement of technology and the ability to manufacture more compact, portable units, the routine utilization of this technology has extended to settings outside of hospital: EMS, military battle fields, more austere and remote environments both in the United States and abroad, and disaster situations. 2,3 It provides critical real-time information, serving as both a diagnostic tool that can identify the potential etiology of the condition and then serve as an instrument to monitor the resuscitation. With the growing attention surrounding emergency US use in clinical practice, there has come the push to standardize education, particularly in the case of residents, through the establishment of formal curricula.3 The Council of Residency Directors (CORD) met in 2008 to devise guidelines Saundra Jackson, MD, RDMS, FACEP that aimed to assure resident competency in what they established to be core applications: FCEP Leadership focused assessment with sonography for trauma (FAST), intrauterine pregnancy determination in Academy graduate early pregnancy, focused echocardiography, evaluation of abdominal aorta, and use of bedside ultrasound to help guide procedures. Since that time, the list of these named studies has expanded to include other applications, such as ocular, biliary, renal, deep venous thrombosis, thoracic and soft tissue/musculoskeletal.3 Proficiency in the performance of the aforementioned applications is necessary in order to successfully complete emergency medicine training today. CORD created several guidelines that have affected the growth of emergency ultrasound nationally, as well in the state of Florida. Among the most important of which mandates that each residency program designate full-time faculty dedicated to providing US education via both didactic and hands-on scanning, each program is to deliver the appropriate equipment necessary to provide this education.2,3,4 Thus, central to the increasing ultrasound interest in Florida is the increase in the number of new residency programs sprouting up throughout the state. These programs are using formal lecture in conjunction with scanning shifts completed during a mandatory US rotation, or other dedicated time, in a resident’s education. These recommendations have led to “colorful” competition between residency programs as they proudly strut their talents during SimWars, which is as famous for the team names and costumes, as it is for the level of ultrasound knowledge and skill demonstrated by its participants. The American College of Emergency Physicians (ACEP) defined clinical US in 2014 as a diagnostic modality separate from that of the physical exam, not merely as an adjunct or extension to the physical exam.5 This has paved the way for recognition of the training and skill needed to become proficient in POCUS and establish the legitimacy of this skill as it relates to image acquisition and images interpretation by emergency physicians independently. This position statement by ACEP highlights the expansion of education beyond residency and criteria (150 scans split between the core competencies) that will enable older physicians in academic and private community practices to gain the same level of proficiency.1 National and international interest in US is increasing. Ultrasound, with its versatility and minimal-to-no ionizing radiation risk, is making a strong comeback as a premier form of functional imaging. It is providing a benefit as it improves the expedience and quality of care that is delivered to patients we serve. Emergency medicine physicians are leading the charge and slowly becoming more recognized as the leading expert in its use. In this vain, graduates from emergency ultrasound fellowships are becoming highly desirable as the subspecialty experts leading the charge in developing and implementing clinical ultrasound programs around the country. According to the Emergency Medicine Residency Association Ultrasound Division, there are now more than 25 fellowships in North America (including a program in Toronto), five of which are in our home state.6 I anticipate the number of fellowship programs to expand secondary to the number of new residency programs opening up around the state. We are now also starting to see ultrasound being taught formally in medical school curricula with emergency medicine physicians leading the front.

References 1. 2. 3. 4. 5. 6.

ACEP Policy Statement. Emergency Ultrasound Imaging Criteria Compendium. April 2006. Tayal, V. ACEP Updates Emergency Ultrasound Guidelines. March 2009. Akhtar et al. CORD Consensus Statement for Residency Training. Acad Emerg Med. 2009; 16:S32-S36 Ahern, M et al. Variability in Ultrasound Education among Emergency Medicine Residencies. West J Emerg Med. 2010; 11(4): 314-318. ACEP. Definition of Clinical Ultrasonography. January 2014. EMRA Ultrasound Division. Accessed 17 August 2017. https://www.emra.org/committees-divisions/ultrasound-division/

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EM p u l s e F e at u r e The Proliferation of Emergency Medicine Residency Programs A Trigger to EM Physician Wage Depression

Florida:

Article by David J. Orban, MD, FACEP, Former FCEP Board member

Imagine my surprise one April 2016 morning as I scrolled through my email and read an ACEP News Brief that reported seven new U.S. emergency medicine residency programs had been accredited by the RRC-EM – and five of them were in Florida! How could that possibly be? After all, the number of EM ACGME-approved residency programs had only grown to five since Jacksonville inaugurated the first in 1976. One year later, the RRC had approved 25 new EM residency programs nationally, four more in Florida, creating concerns for me about an oversupply of EM physicians in Florida. I remembered a time 20 years ago when the Anesthesiology RRC created too many residency positions and their graduates couldn’t find jobs. The popularity of the specialty plummeted among U.S. medical school graduates while right-sizing occurred, which resulted in the demise of some programs. David Orban, MD, FACEP Associate Professor & Director, Division of Emergency Medicine USF

With the approval of the new allopathic programs and integration of the existing osteopathic programs into the ACGME, Florida now has 14 ACGME-accredited EM residencies – up from only five ACGME-accredited programs in 2015. With the addition of several new programs which are still in the application pipeline, Florida could easily reach 200 EM graduates per year by 2022.

At present, Florida has approximately 2,400 physicians engaged in the full-time practice of emergency medicine. Two national EP workforce studies during the past 12 years estimated the attrition rate for emergency physicians is about 3.5 percent per year due to retirement, death, burnout or leaving the specialty for other careers such as administration and teaching. Assuming Florida would graduate 200 EM physicians a year, the number is several times that needed to replace the annual attrition, estimated to be about 85. Physicians tend to practice where they complete their residencies, meaning a surplus in Florida is not be expected to resolve shortages in rural locales, such as Nebraska, Iowa and Oklahoma. So what motivated this sudden, unprecedented expansion, and what does it mean for our specialty in Florida? What will happen to job opportunities in five to 10 years when the tsunami of graduating residents begins? My research found the expansion ultimately emanated from a new 2013 Florida law – as usual, follow the money!

Where did the funding for the new residencies come from?

Most of the funding for the country’s 100,000 residency slots traditionally came from the federal government as part of Medicare funding. However, the 1997 Balanced Budget Act placed a cap on such graduate medical education (GME) spending, effectively freezing it at 1997 levels. More recently, new funds became available for certain hospitals, which can motivate pursuing EM residency programs as a revenue and manpower source, absent any consideration of the regional workforce needs. While the federal government is the sole administrator of Medicare, the state-federal partnership inherent in Medicaid programs provides room for innovation. The Florida Department of Health and AHCA, inspired by actions taken in Ohio to reallocate Medicaid GME spending to reflect local health workforce priorities, proposed regulatory changes to address the shortage of primary care residency positions in the state. In 2013, the Florida Legislature passed a law providing funding for the expansion of highly trained primary care physicians statewide, which included emergency medicine. The law provides for payments to historically non-teaching (virgin) hospitals and to other qualified institutions for graduate medical education associated with the Medicaid program. This system of payments is designed to generate federal matching funds under Medicaid and distribute the resulting funds to participating hospitals. Florida used this unique approach to fund GME expansion. While other states have used these funds for traditional primary care, Florida also funds emergency medicine for reasons that are unclear. While the EM scope of practice includes primary care, Florida does not have a shortage of emergency physicians. The Florida Statewide and Regional Workforce Analysis (posted on the AHCA website) estimated the current and future supply of physicians. It concluded the EM physician surplus was 150 physicians in 2013, which is expected to grow to a surplus of 700 physicians (supply over demand) by 2025 which is a 22 percent surplus. This calls into question why state and federal funds are being invested in expanding EM training

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when a statewide shortage does not exist and a large surplus is forecasted. Under the new law, if a non-teaching community hospital receives approval from the RRC-EM, the hospital can apply for a change in scope of services to include incremental resident-related costs. If approved, the State issues enhanced payments to cover the incremental costs of the residency program. The estimated cost per resident per year is approximately $150,000. Of this, $75,000 goes directly to resident salary and benefits, and $75,000 is paid to the hospital as indirect costs. At $150,000 perresident-head-per-year, it is understandable why many community hospital administrators have been interested in the opportunity to be paid to increase their ED manpower. Hence, the proliferation of emergency medicine residency programs in Florida appears to emanate from State policy that funds EM training despite the expectation that it will contribute to a large surplus – good news for entities that will profit from the anticipated EM physician wage depression.

Seeking a Remedy to Oversupply

At the CORD 2017 Academic Assembly, I asked Chair of the RRC-EM Dr. Phil Shayne and Senior VP for Hospital-based Accreditation at ACGME Dr. Louis Ling whether any attempt had been made to match the location of the new EM residency programs with the emergency physician manpower needs in the U.S. Both were somewhat apologetic and said they understood “the Florida Problem”, but there was nothing either could do since the RRC-EM’s only responsibility is to accredit programs that meet standards. This differs from the RRC-EM of the mid-1990s, which didn’t approve a single new program for five years while ACEP analyzed emergency medicine manpower “oversupply” issues. Many other medical specialties today have used their RRCs to control the number of specialists trained in order to avoid oversupply and wage depression.

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Consequently, a national remedy to avoid a surplus is not on the horizon, so “the Florida problem” (forecasted surplus followed by wage depression) is ours to resolve.

D a u n ti n g D ia g n o s i s Answer: This patient has a partial biceps tendon tear. These tears damage the soft tissue but do not completely sever the tendon. Injuries occur when the elbow is forced straight against resistance. On physical exam, this patient has ecchymosis and a bulge in the upper part of the arm created by the recoiled, shortened biceps muscle.

Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief

Orthopedics should be consulted. In this case, the patient was first evaluated by soft tissue ultrasound and was then referred for MRI evaluation.

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EM p u l s e F e at u r e SBS 2017: One Of Our Best Yet! Wow! Symposium by the Sea 2017 has come and gone. It was, as usual, a great experience. We met at the lovely Boca Raton Resort and Club August 3-6. Were you there? If not, I’ll give you a brief summary of the great events that took place. Even if you were there, maybe you didn’t realize all that was taking place; this way you have a primer for next year.

Rene Mack, MD, RDMS Symposium by the Sea 2017 Chair

We started with our committee meetings which are the foundation of our organization. We had several discussions regarding the state of EM not only in Florida but in the nation. Please check out the individual committee update articles for more detailed information. The Board of Directors (BOD) also had transitions of the officers and members. Dr. Joel Stern is our current president, and I’m off the board after serving for my maximum six years. Involvement on the FCEP Board of Directors has been an integral part of my involvement in FCEP, and I greatly appreciate the opportunity and strongly encourage others to join the BOD during your career.

Our highly anticipated and attended LLSA course, including the Patient Safety, is a staple. Even better, the participants were able to take the test(s) and complete the requirement(s) before leaving the course. If you were not able to take part in our Pediatric course, it was likely because it was at maximum capacity. Our Pediatric Committee runs this course and gave us another high-quality session on dealing with critical pediatric patients. We are already planning for SBS 2018, so stay tuned. The critical care course? Also highly attended and delivered the high-yield critical care information we’re all looking for in easily digestible doses. The residency programs in Florida are growing; we’re now up to 14! The Florida Hospital program won the SimWars Competition and the Orlando Health program won the overall CPC award. The Aventura and UCF/HCA (Greater Orlando) programs are two of our new programs that participated this year and gave a great showing at the SimWars and CPC competitions. We are proud of our residency programs and look forward to hosting the other programs at SBS in the years to come. Florida weather in the summer can be unpredictable but the weather cooperated and gave us plenty of sunshine and warmth for our Annual Volleyball Game. Residents versus attendings, program versus program -- there were many configurations of teams but the common thread was the camaraderie enjoyed by all. Casino Night, sponsored by DuvaSawko, has again lived up to its reputation and provided all in attendance, especially the kids, with another opportunity to dance the night away while enjoying each other’s company. We had a new component this year -- our New Speaker Series -- that has garnered great interest and will likely be returning for SBS 2018. A panel of advisors was also available to give real-time feedback for our participants, which was greatly appreciated. Would you like to take part in the series next year? Get in touch with us at the office and we will give you some more information about the process. Thank you so much to all that attended and participated in making this year’s SBS a great success. We look forward to hosting our next SBS on August 2-5, 2018 at the Sanibel Harbour Marriott Resort in Ft. Myers, Fla. See you there!

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All Symposium by the Sea 2017 photos by Samantha Rosenthal, FCEP Communications Manager FALL 2017 | VOLUME 24, ISSUE 3

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Snapshots from Written Board Review Course 2017 Article brief and photos by Samantha Rosenthal, FCEP/EMLRC Communications Manager

Florida Emergency Medicine Written Board Review Course 2017 took place August 21-24 at the Rosent Plaza Hotel in Orlando, Fla. Established faculty from all over Florida presented various review topics to help prep attendees for their upcoming exams. Attendees enjoyed the in-depth lectures, hands-on ultrasound skills lab and the question-and-anwer sessions each day. Weâ&#x20AC;&#x2122;d like to thank our program sponsors: DuvaSawko, EMPros and Envision Physician Services. We would also like to thank program chair Dr. J. Adrian Tyndall for his hard work in putting this wonderful program together.

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EM p u l s e F e at u r e CLINCON 2017 Draws EMS From Across the State of Florida Article and photos by Samantha Rosenthal, FCEP/EMLRC Communications Manager

This year’s CLINCON 2017 drew in EMS professionals from across the state of Florida. With national speakers, a surprising twist to our Bill Shearer International ALS/BLS Competition and fun sponsored social events, it was one of the best years yet. Co-chaired by Felix Marquez, EMT-P and Dr. Benjamin Abo, this year’s program focused on delivering lectures on relevant topics, including: street drugs, PTSD, active shooter/MCI response tactics, sepsis, pediatric care and so much more. The first day kicked off with three pre-conferences that focused on different learning topics, like POC ultrasound 2017 Bill Shearer International ALS/BLS Competition Finals for EMS and active shooter response. On Tuesday, we saw the official kickoff to CLINCON 2017 with a special dedication during the Opening Ceremony to the late Dr. Salvatore Silvestri. The day continued with more lectures, EMS State meetings and ended with Excellence in EMS Awards Ceremony hosted by the Florida Department of Health. The awards ceremony aims to recognize outstanding achievement throughout the state to individuals and organizations that are advancing and providing innovative EMS care to the community.

Attendees at the Red, White & Brew Block Party.

With a slight schedule change this year, the ALS/BLS Competition Preliminary Round was held on Wednesday, July 12. This year 34 teams competed with Boca Raton B, Coral Springs / Parkland, Hallandale Beach, Margate Coconut Creek, Miami Dade Fire Rescue A and Pembroke Pines moving on to the ALS Finals the next day. Thursday morning began bright and early for many, including our finalists for the ALS competition. The final competition scenario saw all five teams competing side-by-side to a mass casualty incident at a concert. The run-through team was utilized as the first wave of first responders to arrive on-scene but were victims of a secondary explosion onsite. It was very fast paced and exciting to see all five final teams tackling the finals scenario at the same time. The winners were announced later that evening with Coral Springs/Parkland finishing in third place, Pembroke Pines finishing in second place and Margate-Coconut Creek placing first in the 2017 Bill Shearer International ALS/BLS Competition. We’d like to thank Star & Shield Insurance for providing the cash prizes for the top three final teams. A sponsor (AirMethods) talking with a program attendee.

Dr. Paul E. Pepe, who is a prominent EMS academic professional, presented multiple lectures on July 13, including: Event Medicine: An Evolving Subspecialty of Emergency Medical Services Practice; PHETI; and EBM vs EBM: Why We Need Both Evidence-Based and Experience-Based Medicine. All of his lectures saw a full house, and many attendees left very satisfied with the amount and quality of information he reviewed. The fun started in the early evening with the Red, White & Brew Block Party. Attendees came dressed in their best patriotic-themed attire, and we gave away prizes courtesy of our program sponsors. A big thank you to AirMethodsfor sponsoring the event.

Margate-Coconut Creek receives check from Star & Shield Insurance aftering being announced the winners of the 2017 Bill Shearer International ALS/BLS Competition.

We would like to thank all CLINCON 2017 sponsors and exhibitors for their support. Our exhibit hall, which was open Tuesday, Wednesday and Thursday, had strings of attendees visiting the various EMS companies’ booths. We would like to also thank our education and competition planning committees for all their hardwork in making this year’s conference one of the best. As this year program ends, so we begin the planning for CLINCON 2018! Don’t forget to mark in your calendars the dates for CLINCON 2018 (July 10-14, 2018), which will be held once again at the Caribe Royale in Orlando, Fla. We thank all of our attendees from this year, and we look forward to seeing you next year! Approved for AMA PRA Category 1 CreditsTM

EM p u l s e F e at u r e North Florida Gains a New EM Residency Program Article by Robyn Hoelle, MD, North Florida EM Program Director and Tami Vega, MD, North Florida EM Associate Program Director

North Florida Emergency Medicine Residency has started! Starched white coats walking the halls, frantic faces digging through clean holding to find the 4-0 suture, excited newbies scribbling bathroom codes on the back of name badges… a new year has begun, but here at North Florida it is not just a new year it is THE beginning. We are primarily a community hospital in the heart of North Florida. As a team, our faculty has made the commitment to educate residents to be competent, caring and to be “well” physicians. Our faculty has been learning, growing, designing and implementing a whole new approach to residency. We’ve had to learn the way we old folks did it (uphill-in- What airway lecture is complete without balloons? Photo courtesy of Dr. Robyn Hoelle the-snow-with-bleeding-ulcers) may not always the best way to do it. We are implementing Adult Pedagogy methods and flipped classrooms. I had to learn how to tweet! Not to mention physician wellness curriculum, retreats and strategies, oh my! Our facility and infrastructure has been preparing as well with expansions. We are developing a state-of-the-art Simulation Center at our facility, including highfidelity Laerdal manikins like SimMan 3G Trauma, Sim Junior and BabySim. Dr. Evan Stern will serve as our Simulation Director as we complete the new facility build out. We will have six simulation bays, including a dedicated Pediatric bay and a dedicated simulation coordinator. Dr. Diana Mora is fellowship-trained and will serve as our Ultrasound Director, and we have two brand new ultrasound machines in our department with uploading capabilities. We also have a robust EMS presence with local, rural and air EMS in which both residents and students will actively participate. Dr. Amit Rawal directs and co-directs three surrounding systems. We also have a dedicated research team comprised of a coordinator, scientific writer Associate Program Director Dr. Tami Vega introduces Sim Man Trauma. and a biostatistician. Projects Photo courtesy of Dr. Robyn Hoelle already underway include sepsis, emergency medical system and cardiac marker research. We also have started a new medical student clerkship, which includes an EMS experience, an ultrasound experience, paired attending shifts and an opportunity to interview (and receive coaching on interview skills) during their rotation to save them traveling later.

North Florida Emergency Medicine Residency’s first class of residents. Photo courtesy of Dr. Robyn Hoelle

We couldn’t be more proud and excited of our founding residents. They all took the plunge and moved to Gainesville, putting their faith in us. Our residents are an extremely fun group with diverse personalities. They hail from all over the country, including New York, California, Illinois, South Carolina, Oregon, Virginia, Massachusetts and, of course, Florida. They have already made a reputation with our consultants as a conscientious, hardworking group. One of our residents, Chris Libby, has already been elected to the Florida Medical Association Board of Governors; Zaza and Collin have already become EMRA reps. Impressive! Come visit or reach out to us. We are looking forward to introducing our residents to you at the next conference!

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EM p u l s e F e at u r e EM Payment Reform Summit Promotes Tackling Important National EM Issues Article by Jordan Celeste, MD, FCEP Board member, EM Payment Reform Summit 2018 Co-chair

In February 2017, the first EM Payment Reform Summit was held at the FCEP offices in Orlando. This immersive, twoday event drew emergency medicine leaders from all across the country who are leaders in both healthcare delivery and payment reform. The conference format, with both scheduled talks and robust panel discussions, allowed for an unmatched level of interaction between these leaders and attendees. Last year’s conference focused on the already-in-process and the future changes coming to emergency medicine reimbursement, as well as on how to be successful under the new value-based care strategies. Highlights included discussion of Affordable Care Act regulations aimed at decreasing the cost of care – yes, this is the alphabet soup that we have been hearing about for years (MACRA, MIPS, QRUR, etc). Another acronym that was also discussed indepth was APM, or Alternative Payment Model. Since Florida is not alone in its fight, the topic of out-of-network payments and “balance bills” (or rather, the more preferred, “surprise bills”) was discussed on an in-depth level. Taking the topics of change and innovation to the level of care, discussions also focused on what can be done by emergency department management, with particular attention to patient flow, transitions of care, and coordinated care. “Big data” and what it can do for us, including satisfying reporting requirement, was covered in depth, with a detailed explanation of ACEP’s Clinical Emergency Data Registry, or CEDR. Expanding on the theme of maximizing resources to also benefit patient care, innovations in EMS and Telemedicine were explored as well. This year’s meeting will continue to focus on the ongoing challenges that Emergency Medicine faces in the evolving payment environment, with a particular focus on continued innovation and collaboration. Planned topics include updates on federal rules and regulations, CEDR and quality data reporting, and APMs, as these issues did not go away in a year. No meeting on emergency medicine payment challenges would be complete without a discussion of out-of network billing, but this year’s conference is also going to be focusing on emergency medicine-specific messaging and PR surrounding the issue. Also slated for discussion is yet another way that insurers are disrupting coverage for our patients, by challenging the prudent layperson standard and issuing retroactive payment denials. Great effort has been made this year to bring in renowned, expert speakers who also are emergency physicians. Topics that are slated to be covered by such folks include: developments in emergency medicine billing and coding, working collaborative with hospitals, aligning incentives with hospital administration, and palliative care. Free-standing emergency departments and other innovative care delivery will be covered, as well as specific issues facing academic programs. This year’s meeting is sure to continue the robust discussions that were begun last year, and to take participants even further into the future of emergency medicine as the true leader in care innovation and collaboration. Emergency physicians are famed for performing well under pressure, and finding solutions to the most pressing problems. These two days will capitalize on having many folks with those desirable traits in one room. Mark your calendars for February 22 and 23, 2018, and check www.emlrc.org /empaymentreformsummit in the coming weeks for more details.

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6TH ANNUAL SIMWARS COMPETITION WINNERS:

Florida Hospital Emergency Medicine Residency Program COMPETITION CHAIR: Ademola Adewale, MD, FAAEM; Chair, FCEP Sim Committee Director of Research and Medical Simulation Assistant Program Director Florida Hospital Emergency Medicine Residency COMPETITION JUDGES: Nicole Aviles, MD, Kendall Regional Medical Center Jill Davison, MD - Orlando Health Karen Estrine, DO, FACEP, FAAEM - Jackson Memorial Hospital

9TH ANNUAL SYMPOSIUM RESEARCH POSTER PRESENTATION OUTSTANDING MEDICAL STUDENT POSTER: Emily Welch, MS1; Disparities in ED Recidivism Rates by Gender, Race, Age, Health Literacy, and Payer Status in Evaluation of Low-Risk Acute Coronary Syndrome Patients; University of Florida, Gainesville OUTSTANDING RESIDENT POSTER: Tushar Gupta, MD, PGY3; Influence of Sequential Organ Failure Assessment component score in predicting in-hospital mortality from sepsis: Does the type of organ failure matter?; University of Florida, College of Medicine, Jacksonville OUTSTANDING FELLOW POSTER: Ryan Queen, MD; Introducing Resident Quality Officers: A Unique Niche for Emergency Medicine; Orlando Health COMPETITION CHAIR: J. Adrian Tyndall, MD, MPH, FACEP; Chairman, Department of Emergency Medicine; University of Florida College of Medicine, Gainesville; Chief of Emergency Services, UF Health Shands COMPETITION JUDGES: Allison Haddock, MD – Baylor College of Medicine Paul Kivela, MD, FACEP – ACEP President-Elect

FLORIDA RESIDENT CASE PRESENTATION COMPETITION BEST PRESENTER: Allyson Best, MD, PGY-3 – Orlando Health BEST DISCUSSANT: Eli Kennedy, MD, PGY2 – Florida Hospital BEST PROGRAM: Orlando Health Emergency Medicine Residency COMPETITION CHAIR: Jennifer Jackson, MD; Assistant Professor, Emergency Medicine Associate Medical Student Clerkship Director, Emergency Medicine University of Miami Miller School of Medicine COMPETITION JUDGES: Richard Shih, MD, FACEP – EM Residency Program Director; Florida Atlantic University Kelly Medwid, MD – Assistant Program Director and Co-Simulation Director; Kendall Regional Medical Center Tami Vega, MD – Associate Program Director, UCF College of Medicine HCA GME Consortium at North Florida Regional Medical Center

Graphic created by Lindsay C. Ballard, FIU Herbert Wertheim College of Medicine, MD Candidate, Class of 2018

Congratulations to all Symposium by the Sea 2017 Competition winners!

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!

Thanks to all who made contributions to the Political Committees in May to August 2017! Omar Hammad Manning Hanline Angel Harper John Haughey Alexandra Heyes Matthew Hughes Laura Hummel Saundra Jackson Mark Johnson Steven Kailes Steven William Kamm Joseph King William Korey Ken Krabacher Thomas Leonard Margarita Martino Kristin McCabe-Kline Ryan McKenna Daniel McMicken Adam Memon Scott Meyer Pamela Miller Pia Myers Karen Oldano William Osborn Paul Perry Marc Steven Plotkin Russell Radtke David Ragbeer Wayne Ramcharitar Andrea Ramirez Jayant Rao Robert Andrew Raybin

Anthony Richa Ricardo Rodriguez Alvin Ruangsomboon Adam Rubin David Ian Sack Reginald Saint-Hilaire Charles Sand, I Kathleen Schrank Michael Schultz Jason Sevald Brooke M Shepard Michael Simpson Roman Edward Skylar Mark Jeffrey Slepin Nathaniel Stephens Aisha Subhani Andrea Catherine Suen Kirk Charles Szustkiewicz Daniel A Thimann Bryce Tiller Thang X Tran Jon Van Heertum Onier Villarreal Alejandro Farid N Visram David A Wein Timothy E Whalen Susan D Wilcott David Thomas Williams Scott Robert Scott Tammy G Windisch Stephanie K Wood Joshua Young John Zelahy

FALL 2017 | VOLUME 23, ISSUE 3

EMpulse | 33

Musings Of a Recently Retired Emergency Physician Will We Have Healthcare When We Retire? Article by Wayne Barry, MD, FACEP

The roller coaster car has limped to an anti-climactic stop at the station. The U.S. healthcare brouhaha has subsided for the moment. The Republican dominated Legislature and the Executive Branch failed to craft and pass a healthcare bill satisfactory to their side only since the Democratic legislators were completely boycotted from the process for fear they would prevent the repeal and replacement of “ObamneyCare”. Instead, the Republicans inadvertently managed to thwart their own effort all by themselves! The way I see it there are at least four reasons why this happened:

Wayne Barry, MD, FACEP

1. Neither the Congressional Republicans nor the White House constructed an alternative plan to ACA that was palatable to their own partisans. 2. The plan(s) that were designed were not only undesirable, but some said (including President Trump) they were “mean” to the American people. 3. President Trump failed to do what President Obama and most presidents before them both have done, which is to stump around the country to sell his “Big Ideas” (in this case healthcare) to his constituency, namely the pseudo vast majority of the population who voted for him. 4. Finally, there were enough Republican partisans who realized that the healthcare plans attempted to be passed were just plain heartless and cruel to many segments of the U.S. population, such as the poor, chronically ill and aging citizens who are being priced out of the private insurance market and depend so heavily on the current Medicaid Program to provide some kind of coverage for their medical needs.

So what is to be done now? I shudder to sound like one of those “I told you so people”, but if only the flaws and outright mistakes encoded in the ACA had been addressed and fixed over the past seven and half years by both sides of the aisle in the U.S. Congress, we wouldn’t be in this scary and embarrassing mess. The Big Bad Insurance companies are threatening us again with rising premiums due to the uncertainty of the future for healthcare. President Trump’s approach is to let the ACA implode under its own ineptness. I find this approach rather childish on his part, and he risks alienating the many millions of American citizens who may be adversely affected by this tact. Fortunately, there are hints that some Republican Congressmen want to shore up the deficiencies of ACA which are causing some marketplace premiums to rise unacceptably high and fast. They may even *gasp* want to consult with those across the aisle to help craft a healthcare bill which won’t harm the American people and may even help a lot of them. Perish the thought! Now let’s try to bring this discussion around to the world of emergency medicine. To me, our loftiest goal is access to care for everyone. While this is a complex issue with many complicated components and nuances, it seemed clear that under ACA, access to care for patients who visit the ER was not for the most part diminished. I believe that Access to Care is one of the names of the enormous elephant sitting in the room of any discussion conducted about Repeal and Replace ObamaCare. There is no way to care for many American citizens. Whether there is a reduction in the Medicaid Program, reduction in subsidies provided by the government to low wage earners to procure healthcare coverage, the mandate for coverage for care itself, and finally ensuring coverage for pre-existing illness, one of the unintended benefits of ACA I believe was to incur less medical debt on many of our ER visitors. I am still bristling at the now-apocryphal story about some unnamed elected official who declared, it was during the George W. Bush Administration I think, that anybody without medical coverage can just go to the ER for their medical care. How naïve and misguided is that idea? And yet, I believe that many Republican lawmakers today, as well as the President believe, precisely the same thing. How many times have we heard this before? And how distensible do “they” think the “Safety Net” for the broken American Medical Care Delivery is? You would think that as I near the age of 70, my concerns about healthcare coverage should be comfortably minimal in view of the fact that I am almost five years past Medicare eligibility and projections about Medicare running out of funds will probably not come true until after I am inhabiting the other side of the dirt. In the short term, I am very worried about my “trophy wife” of 30 years who will not turn 65 for another one-and-a-half years. I am trying to start a countdown to retirement from one or both of my current enjoyable, but too time consuming jobs, namely Urgent Care and Hospice and Palliative Care Medicine. I depend on the decent healthcare coverage provided by the one job, and I am afraid to stop working less than full time for fear of forfeiting the medical coverage which my wife and I both enjoy. I am quite frankly afraid to expose her to the tumult and raging seas of “Is it ACA or not ACA”. With that being said, I will keep “pulling through the plough” for another year and a half, and I hope that my health holds up to support this decision. By then, my wife and I will both be able to enjoy the fruits of Medicare, one of the most popular entitlement programs ever passed into law. My fond hope is that Medicare can be saved for the rest of all of us so that all American citizens present and future can partake in some thoughtful wisdom which came from the late-President Lyndon B. Johnson and fellow legislators of that time.

34 | EMpulse

FALL 2017 | VOLUME 24, ISSUE 3

Patrick Agdamag, MD, FACEP Daniel Brennan, MD Damian Caraballo, MD Jordan Celeste, MD Jay L. Falk, MD, MCCM, FACEP Immediate Past-President Vidor Friedman, MD, FACEP - ACEP Board of Directors Jesse Glueck, MD - EMRAF Representative Shiva Kalidindi, MD, MPH, MS(Ed.) Gary Lai, DO, FACOEP René Mack, MD Kristin McCabe-Kline, MD, FACEP Vice President

Joe Nelson, DO, MS, FACOEP, FACEP Sanjay Pattani, MD, MHSA, FACEP Secretary-Treasurer Russell Radtke, MD Danyelle Redden, MD, MPH, FACEP Todd L. Slesinger, MD, FACEP, FCCM, FCCP Kristine Staff, MD Joel Stern, MD, FACEP - FCEP President Joseph Adrian Tyndall, MD, MPH, FACEP - President-Elect Jill Ward, MD Kendall Webb, MD Aaron Wohl, MD, FACEP

Florida College of FCEP | Emergency Physicians

2017-2018 FCEP Board of Directors

3717 South Conway Road, Orlando, FL 32812

We’d like to welcome all new and already-established FCEP Board members, FEMF Board members, FCEP Councillors and FAEMSMD Executive Board members!

2017-2018 FEMF Board of Directors Ernest Page, MD, FACEP - FEMF Secretary-Treasurer Cory Richter, BA, NREMT-P (CR) Roxanne Sams, MS, ARNP-BC, MA FEMF Vice President Sandra Schwemmer, DO, FACOEP-D, FACEP, FAAOE, LHRM David C. Seaberg, MD, FACEP

2017-2018 FCEP Councillors and Alternates Dr. Ashley Booth-Norse Dr. Jordan Celeste Dr. Jay Falk Dr. Kelly Gray-Eurom Dr. Kristin McCabe-Kline Dr. Danyelle Redden Dr. Joel Stern Dr. Adrian Tyndall Dr. Andrew Bern Dr. Amy Conley Dr. Larry Hobbs Dr. Steven Kailes

Dr. Michael Lozano Dr. Ernest Page Dr. Sanjay Pattani Dr. Todd Slesinger Dr. Kristi Staff Dr. Kendall Webb ALTERNATES Dr. Clifford Findeiss Dr. Kevin King Dr. David Orban Dr. Tracy Sanson

2016-2018 Florida Association of EMS Medical Directors Executive Board President: John Milanick, MD, MPH (Putnam County EMS) Vice President: Christopher Hunter, MD, PhD (Orange County EMS) Secretary-Treasurer: Brooke Shepard, MD (Temple Terrace Fire Department) Member at Large: Christine Van Dillen, MD (Alachua County EMS) Member at Large: David Meurer, MD (ShandsCair)

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

Dick Batchelor Arthur Diskin, MD, FACEP (PP) Cliff Findeiss, MD (PP) Maureen France (CR) James V. Hillman, MD, FACEP (CR) Michael Lozano, Jr, MD, FACEP FEMF President