EMpulse Fall 2021 by Florida College of Emergency Physicians

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

FCEP Past Presidents

Celebrate 50 Years

WHAT’S INSIDE: The 50 Years, 50 Voices Project: FCEP’s History New FCEP Leadership & Symposium by the Sea Recap Ultrasound Zoom: POCUS for Shoulder Dislocations The Other Delta: Delta-8, the New THC Derivative

EMpulse Fall 2021

Vol. 28, No. 3 | Fall 2021

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TABLE OF CONTENTS FROM THE COLLEGE 6 FCEP President’s Message By Dr. Sanjay Pattani 8 Government Affairs By Dr. Blake Buchanan 9 EMS/Trauma By Dr. Desmond Fitzpatrick 10 Medical Economics By Dr. Danyelle Redden

12 Pediatric Committee: Use of Monoclonal Antibody to Treat COVID-19 in Children & Adolescents By Dr. John Misdary

Volume 28, Issue 3

33 Medical Student Council By Cristina Sanchez, MS, MS-2

EMpulse Magazine is the official, quarterly publication of the Florida College of Emergency Physicians (FCEP).

11 Membership & Professional Development By Dr. Shayne Gue

EDITOR-IN- Karen Estrine, DO, FACEP, FAAEM CHIEF karenestrine@hotmail.com MANAGING Samantha League, MA & DESIGN sleague@emlrc.org EDITOR

Johnson Press of America, Inc.

FEATURES & COLUMNS 4 2021-2022 FCEP Board of Directors 8 Daunting Diagnosis By Dr. Karen Estrine 14 Happy 50th Anniversary, FCEP By Jonathan Dolan, MA 18 Snapshots from FCEP’s 50th Anniversary Celebration 19 Symposium by the Sea 2021: Annual Family Casino Night 20 Symposium by the Sea 2021: Annual Meeting Recap By Samantha League, MA 22 Symposium by the Sea 2021: Virtual Competitions By Samantha League, MA 32 Remembering Leon L. Haley, Jr., MD, MHSA, FACEP, CPE By Drs. Madeline Joseph, David Caro & David Vukich 34 Immune Thrombocytopenic Purpura vs. Vaccine Induced Thrombotic Thrombocytopenia: Rare but Distinct Conditions Associated with the COVID-19 Vaccines By Drs. Glenn Goodwin, Charles Latimore, Annalee Baker

FALL 2021

24 EMRAF President’s Message By Dr. Elizabeth Calhoun, PGY-3

40 Florida PEDReady and EMSC Update By Drs. Phyllis Hendry & Meryam Jan 41 CLINCON Update; RIP, Linda Swisher, Widow of Bill Shearer By Samantha League, MA 42 Ultrasound Zoom: POCUS for Shoulder Disolcations: Another Weapon in Your Clinical Arsenal By Drs. Naomi Newton & Leila Posaw 46 Critical Care Medicine Specialization and Certification within Emergency Medicine: Past, Present and Future By Dr. Casey Carr 48 Education Corner: Let’s Get Active! Active Learning in Medical Education By Drs. Carmen Martinez Martinez & Caroline Molins 50 Musings from a Retired Emergency Physician: Compassion Fatigue for Vaccine Hesitation By Dr. Wayne Barry

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38 Poison Control: The Other Delta: Delta-8: The New THC Derivative By Drs. Chiemela Ubani, Molly Stott & Dawn Sollee

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Eliot Goldner, MD, FACEP

TABLE OF CONTENTS CONTINUED

UPDATES FROM FLORIDA’S EM RESIDENCY PROGRAMS 25 AdventHealth East Orlando By Dr. Shannon Caliri Florida Atlantic University By Dr. Tony Bruno

26 Orlando Health By Drs. Gregory Black & Brody Hingst Orange Park Medical Center By Dr. Penny Côté

USF at Tampa General Hospital By Dr. Kenneth Dumas

27 Kendall Regional Medical Center By Dr. Kelly Wright UF Gainesville By Dr. Megan Rivera

28 FSU at Sarasota Memorial By Dr. Thomas Cox

29 Jackson Memorial Hospital By Dr. Patricia Panakos Brandon Regional Hospital By Dr. Calixto Romero, III

Meet Florida’s 21st EM Residency Program 30 UCF/HCA Healthcare GME Consortium Emergency Medicine Residency Program of Greater Orlando By Dr. Amber Mirajkar Oak Hill Hospital By Dr. Mohammad Razzaq

31 North Florida Emergency Medicine By Dr. Manna Varghese UF Jacksonville By Dr. Chris Phillips

Mt. Sinai Medical Center By Dr. Daniel Puebla St. Lucie Medical Center By Dr. Nicole Tobin

10 RPg Family Wealth + TEG Advisors 24 E-FORCSE

PRESIDENT Sanjay Pattani, MD, MHSA, FACEP PRESIDENT- Damian Caraballo, MD, FACEP ELECT VICE Aaron Wohl, MD, FACEP PRESIDENT SECRETARY- Jordan Celeste, MD, FACEP TREASURER IMMEDIATE Kristin McCabe-Kline, MD, FACEP, PAST- FAAEM, ACHE PRESIDENT EXECUTIVE Jonathan Dolan, MA DIRECTOR MEMBERS Rajiv Bahl, MD, MBA, MS; Blake

Buchanan, MD, FACEP; Elizabeth Calhoun, MD (EMRAF Representative); Kyle Gerakopoulos, MD; Jesse Glueck, MD; Eliot Goldner, MD, FACEP; Shayne Gue, MD, FACEP; Erich Heine, DO; Saundra Jackson, MD, FACEP; Shiva Kalidindi, MD, MPH, MS(Ed.); Amy Kelley, MD, FACEP; Gary Lai, DO, FACOEP; Dakota Lane, MD, FACEP; Russell Radtke, MD; Todd Slesinger, MD, FACEP, FCCM, FCCP

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Notice of Updated Policy for EMpulse Magazine

PRESIDENT Ernest Page, MD, FACEP

EMpulse Magazine staff have recently reviewed and updated the policy below:

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

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

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EMpulse Fall 2021

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

MD, FACEP*; Jay Falk, MD, MCCM, FACEP*; Cliff Findeiss, MD*; James

V. Hillman, MD, FACEP*; Michael Lozano, Jr., MD, FACEP*; Cory Richter, BA, NREMT-P; David Seaberg, MD, FACEP* *FCEP Past-President

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

FROM THE COLLEGE

FCEP President’s Message By Sanjay Pattani, MD, FACEP, MHSA FCEP President 2021-2022

My fellow FCEP members, I’d like to begin my first letter to you by humbly thanking you for allowing me to represent one of the most talented group of physicians that our healthcare systems are fortunate to have: emergency physicians. It is an honor and a privilege to lead FCEP, one of the strongest and most versatile ACEP state chapters in the nation! I’d also like to thank those of you who could join us at Symposium by the Sea 2021, our first in-person meeting in nearly two years. As we met in Naples and were joined virtually by our colleagues—many of whom, like the rest of us, have been so busy dealing with the latest surge—I am mindful of the service, sacrifice and relevance of all FCEP members to our specialty and patients. I know everyone enjoyed reconnecting with each other after our two-year hiatus, telling stories, laughing, smiling and remembering “the good old days.” This dedication and spirit drives me as I begin my service as your president, especially as we celebrate 50 years as an organization. You know, it’s easy to advocate for emergency physicians. We know what’s up. We treat all people 24/7/365, regardless of race, religion, sexual orientation, gender identity, nationality, socioeconomic class or the ability to pay. We are passionate about our specialty and our patients. We are comfortable with being uncomfortable. We push the limits. We shelter our team members, lead in the darkest of times, and give the homeless guy his sandwich. We are EM physicians. In my mind, we are the best of the best, intellectually, emotionally and spiritually.

My goals as we continue our journey over the next 50 years together address several issues that are top of mind for all of us, and they center on common issues of advocacy, workforce stability, fair payment and mental health. Executing and achieving them is going to be a challenge for all of us. In so doing, we will bring forth the leadership our members expect in government and public affairs, along with delivering the relevant training and education they want and need to pursue professional growth, achieve practice management success and deliver better patient outcomes. Let’s talk about the first area of our continued focus: FCEP will continue to be the most effective advocate for the specialty, while also collaborating with other healthcare associations and leading the House of Medicine whenever needed, on the best possible course. It seems like some issues never stop revolving around the capitol, including the ongoing deliberation over personal injury protection (PIP) law revisions due to the controversy over eliminating the “no fault” provisions and the impact (unknown or negative) to insurance rates. Our 85% solution through amendments to the bill was a solid win. With the veto, we have a no change and a 100% solution, for now. Also signed into law was the correction to the prior session’s glitches with

the pelvic exam consent law. This was a good example of coalition forming with the FMA, and FCEP leading the discussion to amend previous legislation with unintended consequences. The bill regarding parental consent for medical treatment of minors, now signed into law, provides another good example of collaboration. FCEP joined other specialties and the FMA in a veto request, and FCEP successfully placed the needed amendment into the Senate version before this law was passed. As you are familiar with the bill, it allows EM or other physicians who provide lifesaving care to minors be punished with a misdemeanor when treating those minors outside of a licensed healthcare facility without parental consent. So we can do what we do in the ER, but outside of the ER, we are faced with a misdemeanor when we jump into action without a parent around? This poses significant moral and ethical dilemmas for us. We will work with other specialties and the FMA toward a correction early in the 2022 legislative session. Many people ask me, what does advocacy accomplish? Why do we give money to legislators and senators, like Sen. Kathy Passadimo? You are not an N of 1: FCEP builds relationships, understanding and influence so that if we are unsuccessful in enacting or

Joint FCEP-FEMF Board & Committee Meetings November 9, 2021 9:00 am - 3:00 pm Virtual; in-person at EMLRC TBD Stay tuned via email and at fcep.org

EMpulse Fall 2021

killing bills, we can at least amend them to benefit our patients. A second large and ongoing chapter discussion pivots around emergency physician workforce and stability. On April 9, 2021, ACEP and national partner organizations presented findings from their work on the “Emergency Medicine Physician Workforce: Projections for 2030.” Data reveals that, for the first time in history, we are facing a projected oversupply of 6,000-10,000 emergency physicians nationwide over the next decade if we do nothing to mitigate current trends now. FCEP’s next step is to translate the data from ACEP’s eight key considerations to address workforce stability into action plans that will stabilize and strengthen the field of emergency medicine. ACEP acknowledges and FCEP realizes that “there is not one perfect, holistic solution to address market-driven industry instability. Shifting healthcare economics and evolving practice models affect each of you in different ways.” Whether you work for a small private group, academic center or large corporate medical group (CMG), perhaps we can all agree that maybe our collective message needs to be changed. The dialogue with ARNP and scope of practice has been tilted towards access to care. If we do indeed have a surplus, let’s leverage this and fill the perceived gaps ourselves. We need to better organize ourselves and help shape the narrative. Yes, the number of residencies popping up across the state over the past few years can raise anyone’s eyebrow. But my goal as your president will be to help connect each and every one of these young physicians to the intellectual potpourri this College can lend them. Let’s stay organized with one message, marching to one drumbeat. Third, FCEP leaders will continue to fight in the ongoing battles for fair payment. With legacy mandates of EMTALA and prudent layperson standards, we find ourselves in another cycle of third-party “cost shifting.” With companies like United Healthcare threatening to implement automatic downcoding and/or denials

“

Our FCEP tribe has a collective soul, a collective voice, and a collective mind. We are all leaders, each with passion, and each with something to offer at the table.

on emergency medicine bills—and doing so in a retrospective way that removes bedside physician gestalt —we must remain vigilant. This is ironically the result of what we have advocated against in years past: balance billing the patient. Our work in this area will always be difficult as we strive to find solutions that will impact both patients and physicians fairly, as FCEP’s advocacy uniquely places our patients’ needs first. With so many goals for next year, I’d like to comment on one more today: the need for the chapter to provide emergency physicians with the necessary resources to cope with the daily increase in challenges that face us on the front lines. Maintaining our mental health is vital to our longevity in our professional career. We are experiencing stress from every angle, and many may feel like the pandemic is sucking the life out of us. What separates and yet unites us is our common, essential traits that get us through every shift: our resilience, our compassion and our intellectual versatility. We move on from the pediatric code to the end-of-life withhold of care on the 82 DNR. We make things happen under the least favorable of circumstances. We give ourselves every day to our patients, to our staff and to families. We are the anchors that stabilize the healthcare model drift. Yet, we are vulnerable. And we need to embrace this vulnerability: acknowledge our own, and recognize each other’s. We can do a better job providing for those that are in need of help. This is a powerful topic, and one that not many of us are good at discussing. EMpulse Fall 2021

I deliberately did not address the pandemic in great detail since we all live it every shift. But with every challenge we face —whether it is overcrowding/boarding of Covid patients in the ED, nursing staff shortages, or lack of PPE —when things are at their worst, we get better and change the situation around us. When the hour is darkest and trials are their greatest, you elevate yourself to another level and create solutions, because that is what emergency physicians do. FCEP has a promising future. We will continue chapter growth, with subsequent increase in leadership potential and intellectual capital. Together we will continue to maintain vigilance, fiscal responsibility, and advocate for our patients. Today, I would like to make you a promise: to humbly serve you. I will always keep an open mind, lead with objectivity, be nonpartisan and represent all of you; not myself. Although I may be the lead speaker in certain forums and venues, our FCEP tribe has a collective soul, a collective voice, and a collective mind. We are all leaders, each with passion, and each with something to offer at the table. I will look to you over the next year for your counsel and your knowledge, but most importantly, your friendship and your trust. May you have enough happiness to make you sweet, enough trials to make you strong, enough sorrow to keep you human, and enough hope to make you happy. My recently deceased father once said to me: “Your brightest future will always be based on a forgotten past; you can’t go forward in life until you let go of your past failures and heartaches. Embrace them, and embrace each other.” I am so proud to be your president. God bless you, and thank you for being you. ■

COMMITTEE REPORT

Government Affairs By Blake Buchanan, MD, FACEP Former Committee Co-Chair

I know you all have been busy with overcrowded emergency rooms, seeing patients in waiting rooms and hallways. As a result, advocacy has probably been far from the front of your minds. This latest surge of COVID-19 patients has been something I’ll remember for the rest of my career, and I am thankful that as of this writing, it appears to be on the decline. Currently, the FCEP team is preparing as committee weeks in Tallahassee begin for the legislature. We will be monitoring for any legislation that could affect emergency physicians and our practices. We had an eleventh hour victory in late June when Governor DeSantis vetoed the PIP repeal bill. You may remember from my last update over the summer that this bill was a priority of Senate President Simpson and passed through both the House and Senate. Once on the Governor’s desk it was publicly

revealed it would raise premiums and lead to more public controversy and FCEP continued to advocate for its veto. Symposium by the Sea was also a great success, and FCEP presented Senator Kathleen Passidomo with our Legislator of the Year Award. She has been a great friend to emergency physicians and the House of Medicine in general during her time in the legislature. Relationships with leaders like this are cultivated through multiple years of advocacy. These relationships would not be possible without your help, and I want to thank every one of you who have donated to the FCEP PAC. Please continue to help us get our foot in the doors of legislators throughout the halls of the capitol by contributing regularly in the future. I consider it an investment in the future of our specialty.

In the upcoming session, we will likely continue to see bills pushed by nurse practitioners and physician assistants to move goal posts again on scope of practice changes. We will also continue to push to have the arbitration process in the state of Florida function as it was meant to, with mandatory participation when arbitration is needed. If your groups run into any problems with insurers refusing to participate in arbitration through MAXIMUS, we want to know, so contact FCEP immediately. This winter we will be planning a return to Tallahassee for what will hopefully be an in-person EM Days event sometime in late January or early February. Please be on the lookout for more information about this in the future so that you can join us at fcep.org/emdays. ■

Daunting Diagnosis: Q By Karen Estrine, DO, FACEP, FAAEM

Right Image:: Abdominal wall with necrotic tissue

Editor-in-Chief

A 63 year-old female presents to the ED with diffuse abdominal pain and “black discoloration” on her abdominal wall. The patient has a history of ovarian cancer, which was treated in 2014, opiate abuse, and known abdominal hernia. Patient presents febrile and hypotensive. A photograph and CT of her abdomen and pelvis are attached. What clinical condition does the patient have? CONTINUE ON PAGE 46 ▶ 8

Abdominal/Pelvis CT showing extensive fluid collection and development of air-fluid level with extensive amount of gas pockets and severe diffuse subcutaneous edema

EMpulse Fall 2021

Abdominal/Pelvis CT showing 6 cm ventral hernia with protrusion of omental fat

COMMITTEE REPORT

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

“Pandemic flux syndrome” is a nonclinical description coined by the Washington Post that tries to capture the group feeling of “blunted emotions, spikes in anxiety and depression, and a desire to drastically change something about their lives.” This interesting concept encapsulates the difficult-to-describe feeling we hear about from many EM and EMS colleagues. There was an anticipation of relief and “normalcy” heading into the summer. This reality seems to have been broken by what we are now facing. People describe this rapid movement between fatigue, anger, and frustration from the “back and forth” or flux of this pandemic. While sometimes things don’t feel hopeful, a sense of community or collective understanding can develop from the shared struggle of pandemic flux syndrome. Even Forbes magazine has jumped on this term, one we can use to understand and work through these rapid cycles of emotions.

away from work, resist the “Siren Call” of our electronic devices, the chirps of phones, and social media.

It starts with the commitment to regain control and balance over work and what we are doing. Wellness experts at UF are recommending we focus on promoting balance by creating appropriate separation from work. Start with implementing a “transition routine” to switch from work mode to home mode. Listen to music, take a short walk with a pet or to the mailbox. Try and allow your mind to switch modes.

Remember that, not only does what you do matter, but you matter!

Strive to take some quality break time throughout the day. There is mounting evidence about taking one-to-fiveminute breaks to stop, separate yourself from the distractions, and take deep, controlled breaths. It can decrease stress and cortisol levels and lower blood pressure for longer than just the few minutes you participate in the activity. Also, when it is your time

After the recent State Surgeon General executive order allowed EMS to administer Regeneron, Dr. Ken Scheppke and other state of Florida health officials have been trying to expand the access to this medication during our most recent COVID spike. These infusion sites are viewed as a way to alleviate some of the burden on our emergency departments

The Forbes article recommends “practicing self-care, tak[ing] breaks, go[ing] outdoors and get[ing] some sunlight.” Create ways to strengthen your resiliency and recharge with hobbies, and arrange time off. Plan and take a vacation. Strengthen yourself physically and mentally with running, gym time, yoga, or walks in a park. They also recommend “reduc[ing] your time on social media and avoid[ing] arguing with strangers online.” Their last bit of advice is, “Don’t do anything rash, such as hastily quitting your job. Try practicing a little meditation to decompress and chill yourself out. Make sure you get enough—but not too much—sleep. Try to avoid excessive amounts of alcohol, drugs, and junk foods. Seek out professional help.”

A special thanks to FCEP’s own Dr. Cristina Zeretzke-Bien for the inspiration for this article. Want more information? Scan the QR codes at the end of this article.

EMS and Trauma Committee Update:

EMpulse Fall 2021

and hospitals by trying to stave off admissions in appropriately selected patients. For more information, reach out to Melissa Keahey (mkeahey@emlrc.org) or go to floridahealthcovid19. gov/monoclonalantibody-therapy. The Central Florida Disaster Medicine Coalition and the region five trauma agency completed its Virtual MCI Trauma Coordination Center Plan Functional drill on August 13, with excellent attendance. It was a solid educational experience for all who attended. A special thanks to Dr. McPherson, Dr. Pappas, Matt Meyers, Lynne Drawdy and all who helped put this together. More resources can be found at centralfladisaster.org. And last but not least, major congratulations to our very own Dr. Scheppke for being named the 2021 NAEMT/BoundTree EMS Medical Director for the Year. Fantastic work! ■ Vel ma voles vellest, consequam repe re nullenis qui ut estiatemped ea conseque necerfe ritatibus mod modisque remolupis ipit, ipictur, solupta ssinulpa volupta temodit omnimol oribus eiusdae ratio odia quos ducipiderum qui corereni alia as estiis atis dis core non ratur ad quidest doluptiora volo officab oratum re perum es nat quidit, volori core eum que volor sedicipsam, te volest imusaectis ulpa in est que di dolorio eseditis dolor aceati dolupti dolorepresti offictur a prorro quatur sam, a con pro conse volupta tistem ut magnam lab il is re occusa debistiur? Puditatent molor ariam quide derspid magnim idem eicipsum reptata tquaecea perferion expla commolor si resti ipiti de expedic totam que volorer roreper chillab orepudae. UtAd qui dolor sequodit labo. Itatem santia 9

COMMITTEE REPORT

Medical Economics By Danyelle Redden, MD, FACEP Committee Co-Chair

New and evolving payor policies continue to threaten fair reimbursement for emergency physicians. Three such policies by Cigna and United Healthcare are outlined below. ACEP and FCEP are actively monitoring the reimbursement landscape and fighting inappropriate payor behavior. In order for us to maintain a robust defense, it is essential that physician groups recognize and report the details of inappropriate denials they are experiencing. It is also more important, now than ever, for physicians to understand the importance of accurately reflecting the complexity of medical decisionmaking and care provided within the chart, including the final impression. When applicable, this may involve including multiple final diagnoses.

Cigna downcoding policy Cigna recently announced a downcoding policy that will go into effect on November 14, 2021. The policy involves down coding charts from a 99285 (level 5) or 99284 (level 4) to a 99283 (level 3) when a “single, noncomplex diagnosis” is submitted. Cigna

has not released a list of diagnoses that are considered “non-complex.” ACEP is aware of this policy and is working to stop its implementation, as it clearly violates the federal prudent layperson standard, which requires insurers to cover an emergency department visit based on symptoms, not final diagnosis. Similar policies have been enacted by other insurers in recent years, including Blue Cross Blue Shield, Anthem and United Healthcare.

UHC “non-emergency” denial policy A plan by United Healthcare to implement a policy to retroactively deny emergency care facility charges was postponed indefinitely after backlash from the medical community, including a vigorous response from ACEP. The policy would have involved review of level 4 and level 5 ED claims in order to assess whether the ED visit constituted an emergency. Factors assessed would have included “the presenting complaint, the intensity of diagnostic services performed and other complicating factors.” If a claim was denied, providers would have been able to complete an attestation

“if the event met the definition of an emergency consistent with prudent layperson standard.”

UHC downcoding policy A United Healthcare policy to downcode level 4 and level 5 claims based on an algorithm was delayed in May 2020 and August 2020. The policy involves using the Optum E/M Pro tool to downcode based on final diagnosis. While there has not been a formal announcement that the policy has been enacted, there have been reports from physician groups in multiple states suggesting that it (or a similar policy) is being tested.

State IDR Since the passage of legislation banning out of network balance billing in Florida, a few cases have been submitted to the state independent resolution process (administered by MAXIMUS). The cases were decided in the favor of emergency physicians. However, insurers are still claiming that their participation in the process is voluntary, thus limiting the usefulness of the system. ■

PLAN WELL INVEST WELL LIVE WELL Providing Investment Advice & Planning to FCEP Members since 2005

EMpulse Fall 2021

Mitch Goldfeld | Bill Eaton Senior Managing Directors teg@rpgfamilywealth.com 781-328-0255

COMMITTEE REPORT

Membership & PD Committee By Shayne Gue, MD, FACEP, FAAEM Committee Co-Chair

The topic is burnout. As we begin to emerge from yet another peak in the number of COVID-19 hospitalizations in Florida, we must take time to reflect and bring focus to our personal wellness. What does it mean to be “well” in medicine? What do we do when we feel the effects of burnout? Little more than a year ago, our society was literally applauding healthcare heroes each night. We were risking our lives, fighting an unknown virus, with little information and limited resources. One year later, we are armed with the knowledge and tools (vaccines) to actually win this battle against COVID, yet widespread fear mongering and misinformation propaganda continue to allow this virus to wreak havoc on our society. I, for one, am frustrated and tired. And I know that many of you feel the same. We are starting to speak on the topic more often, but now, more than ever, it’s important to practice what we preach: looking out for one another and making wellness an everyday

priority. Burnout is on the rise. Physician suicide is at an all-time high. We must be better at supporting one another, recognizing the signs of burnout, and taking steps to mitigate its effects. ACEP boasts many resources and services,1 and every ACEP member has access to at least three free counseling sessions.2 Take advantage of these free resources and don’t ever hesitate to reach out to us for help. On a happier note, we were so thankful to have had the opportunity to come together in person for Symposium by the Sea 2021 in Naples. It was a weekend of friendship, fellowship, advocacy and education. We celebrated together the success of FCEP’s 50-year history, including many generations of past, current and future leaders in our specialty. The entire weekend was safe and successful due to our hardworking FCEP staff and the many physicians in attendance. We are already looking forward to next year, so be on the lookout for more information coming your way!

continued dedication to the specialty we all practice and love. The times have been trying, but you have all shown resilience, compassion and strength throughout. FCEP is here for you, and we are all here for each other. I look forward to seeing you all in happier circumstances very soon. Keep up the good fight! ■

ACEP RESOURCES 1. ACEP Wellness Services acep.org/corona/covid19-physician-wellness

2. ACEP Counseling Services acep.org/life-as-aphysician/ACEPWellness-andAssistance-Program

As always, we thank you for your

OCT 24-27, 2021 EMpulse Fall 2021

COMMITTEE REPORT

Pediatric Committee: Use of Monoclonal Antibody to Treat COVID-19 in Children & Adolescents By John Misdary, MD, FACEP Committee Co-Chair

In November 2020, the US Food and Drug Administration (FDA) provided Emergency Use Authorizations (EUA) for virus-neutralizing monoclonal antibody therapies for the treatment of mild to moderate COVID-19 in high risk groups of adolescents 12-17 years old and adults. Multiple studies have shown that this treatment significantly decreased the risk of subsequent ED visits and hospitalizations in adult patients over 18. It has become a game changer in the treatment of adult patients. In the first waves of the pandemic, a relatively small proportion of COVID-19 infections occurred in pediatric patients, thereby limiting the experience with monoclonal antibody therapy in patients 12-17 years of age. A press release was put out June 10, 2021 by Children’s Hospital of Philadelphia (CHOP). They no longer recommend routine use of investigational monoclonal antibody products in children, adolescents, or young adults given the lack of pediatric safety and efficacy data. Further, children and adolescents with COVID are hospitalized at a significantly lower rate than older adults and the potential benefit of these therapies in younger age groups are unclear. If one of the nation’s top pediatric hospitals is publicly stating they are not recommending it due to a lack of evidence, how should we as EM and PEM physicians proceed? I performed a literature search using both PubMed and Google Scholar and found only one single article on the use of monoclonal antibody therapy in the pediatric population. The Journal of the Pediatric Infectious Disease Society published an article May 2021 titled “Initial Guidance on 12

Use of Monoclonal Antibody Therapy for Treatment of Coronavirus Disease 2019 in Children and Adolescents.” A panel of pediatric experts from 29 institutions was convened to develop guidelines based on review of the best available evidence and expert opinion. The group found that there is no high-quality evidence supporting the safety and efficacy of monoclonal antibody therapy for treatment of mild to moderate COVID-19 in children and adolescents. They did find evidence for potential harm associated with infusion reactions or anaphylaxis.The panel suggests against routine administration of monoclonal antibody therapy for treatment of COVID-19 in children or adolescents, including those designated by the FDA as being at high risk of progression to hospitalization or severe disease. There has been no evidence to refute this, and CHOP has been the only major children’s hospital to publicly release information on its institution’s use of monoclonal antibody therapy for COVID-19 in the pediatric population. The most recent NIH guidelines for COVID-19 therapy in children that was updated in April 2021 gave an AIII recommendation that most children with mild or moderate disease can be managed with supportive care alone. The recommendations reiterated that there is currently no data available to determine which high-risk pediatric patients defined in the EUAs will likely benefit from these therapies. Consequently, there is insufficient evidence for the NIH to recommend either for or against the use of these monoclonal antibodies in children and adolescents with mild to moderate COVID-19 who are at high risk of severe disease and/or hospitalization, EMpulse Fall 2021

and monoclonal antibody therapy should not be considered routine care. This recommendation is primarily based on the absence of data assessing efficacy or safety in children or adolescents, limited data with which to identify children at the highest risk of severe COVID-19, as well as the low overall risk of progression to serious disease in children, and the potential risk associated with infusion reactions. Finally, there is limited published evidence on the co-administration of monoclonal antibody therapy with pediatric vaccines by interfering with the immune response. Monoclonal antibody–vaccine interaction studies are generally not required by regulatory authorities to support licensure indicating the lack of necessity or clinical relevance of such evaluations. This is reflected in FDA regulatory guidelines. According to guidelines, live viral vaccines should be administered at least three weeks before or three to eleven months after an injection of intravenous immunoglobulin depending on the dose. While specific studies investigating the co-administration of monoclonal antibodies with vaccines have not been performed, concerns could be raised. This means that the use of monoclonal antibody for COVID-19 in pediatric patients with chronic diseases could lead to a delay in vaccination, with a reduction in coverage for routine vaccines in the most fragile pediatric population. These concerns can have important implications in a historic moment such as this in which vaccination coverage has dropped significantly because parents skipped the vaccine appointment of their children as they were afraid of COVID-19, or

vaccination centers postponed the appointments because they were closed. On the other hand, COVID-19 vaccines could actually represent the best option for vulnerable children and adolescents because of their cost-effectiveness, and the use of monoclonal antibody for COVID-19 treatment could negatively affect the immune response to the COVID-19 vaccines. The criteria currently used for monoclonal antibody therapy against SARS-CoV-2 are very broad and allows individual clinicians or institutions to use these agents on a case-by-case basis. Several questions need to be addressed before their routine use in pediatric clinical practice, including what their associated benefit-to-risk ratio in children and adolescents is, who the patients are that could really benefit from their use, and if there is an interference with monoclonal antibody therapy on recommended vaccines. While we wait for answers to these questions from well-conducted research, an effective and safe COVID-19 vaccine for vulnerable pediatric patients remains the best strategy to prevent COVID-19 and represents the priority for public health. Other than supportive care, therapeutic interventions for children and adolescents with mild to moderate COVID-19 are limited. Parents/caretakers will be concerned and scared when their child is diagnosed with COVID-19 and will want some therapeutic intervention. Many people have heard of monoclonal antibody therapy for COVID-19 and may ask about the option. With the limited data supporting use of monoclonal antibody therapy in children and adolescents, a serious discussion about the risks, benefits and shared decision-making with the parents/caretakers may be the best path forward. ■

Thank You, PAC Donors The success of FCEP’s advocacy efforts is dependent upon our ability to fund those efforts. Thank you to the individuals who donated in April - June 2021: Nicole Abdo

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Donate online at: fcep.org/support 13

THE 50 YEARS, 50 VOICES PROJECT

Happy 50th Anniversary, FCEP By Jonathan Dolan, MA Executive Director Dear Members, Just before I have the privilege of completing my first year as your Executive Director, FCEP will celebrate 50 years as a chapter of the American College of Emergency Physicians. No specialty has done more in those five decades to define and treat the needs of the patient and address their acute undifferentiated care needs, anytime, anywhere, and without regard for the ability to pay. I know the past two years have been exceedingly difficult and often disheartening. Please know, however, that so many people appreciate what you do and the difference you make in the lives of your patients, families and community. From the early days of the specialty to these challenging times of this global pandemic, you have much to be proud of and look forward to in the bright years ahead. Many of you have been so kind to comment on the success of the “50 Years 50 Voices” campaign. Some have asked, “how did you come up with the idea?” As I began my service to you last fall, the first surge was on the move, and I was in the office far more than I could be with you. My days and nights were occupied with learning about FCEP and emergency medicine. But files, pictures and emails can only go so far. So, in thinking about what to do for the 50th anniversary, and as I began to learn these amazing stories, I thought of the project. Then we planned and executed it by hitting the road and coming to you. The objective was to hear your story and listen to your

voice. And, from young to old, east to west and north to south, members welcomed me in, made the difference and told the story. The presentation of the 50 Years 50 Voices compilation video at Symposium by the Sea 2021 was very impactful for all who attended. Linking it and adding the mini episodes you can view on our website and YouTube, has enabled all our member physicians and their families, as well as our many collaborators, to share in our journey and experience our joy. Thank you to our FCEP leadership for supporting the project and all who participated by returning the questionnaires and/or sitting for an interview. A special thank you to our videographer Ryan Bale of The Rescue Company 1 for filming and editing so diligently to make it perfect. A very special thanks to Samantha League, Director of Communications. Her exceptional talent in production by watching, transcribing and choosing the footage was the best, most graceful and inclusive handling of “your story” anyone could ask for, and made this the most impactful and outstanding project possible. For me, it was just what a new leader needs to see, hear, learn and feel. I will take your priceless stories and meaningful lessons with me as I serve you over what I am confident will be many more successful decades for FCEP. Happy 50th Anniversary! ■

EMpulse Fall 2021

Episode 1: FCEP’s 50th Anniversary Tribute to Emergency Medicine Debut: August 6, 2021 at SBS 2021 Featuring: Rajiv Bahl, MD, MBA, MS; Ashley Booth-Norse, MD, FACEP; Daniel Brennan, MD, FACEP; Elizabeth Calhoun, MD; Damian Caraballo, MD, FACEP; Jordan Celeste, MD, FACEP; Bill Davison, MD, FACEP; Arthur Diskin, MD, FACEP; Jay Edelberg, MD, FACEP; Caral Edelberg, CPC, CCS-P; Jay Falk, MD, FACEP; Kelly Gray-Eurom, MD, MMM, FACEP; Erich Heine, DO; Phyllis Hendry, MD, FACEP; Saundra Jackson, MD, FACEP; Steven Kailes, MD, FACEP; Wayne Lee, MD, FACEP; Michael Lozano, MD, FACEP; Kristin McCabe-Kline, MD, FACEP; Ernest Page, MD, FACEP; David Orban, MD, FACEP; Russ Radtke, MD, FACEP; John Stimler, DO, FACEP; Josef Thundiyil, MD, MPH, FACEP; Chrissy Van Dillen, MD, FACEP, FAEMS; David Vukich, MD, FACEP; Frederic Wurtzel, MD, FACEP

Episode 2: FCEP’s Leadership Academy Episode 3: The ALS/BLS Competition at CLINCON Episode 4: The Evolution of Critical Care Episode 5: Advocacy at Emergency Medicine Days

Scan to watch online at fcep.org/50years

“In the past, we the practice of emergency medicine did not exist.” -Dr. Richard Slevinski (FCEP President 1983-85)

OUR HISTORY: 1968: ACEP is founded by eight physicians & recruits its first 29 members, including Dr. William Haeck (first FCEP President 1971-72; ACEP President 197475)

October 15, 1971: The Florida Chapter of ACEP is established. “Bill drove throughout Florida and literally knocked on ER doors to recruit our first members,” says Dr. Cliff Findeiss (FCEP President 1975-76) 1972: “I decided to organize and manage a series of annual conferences to address the severe lack of emergency physician training and skills,” says Dr. Findeiss. “Under the banner of FCEP, I found support from the University of Miami medical school. The physician demand for training was so great that our basic EM annual conferences drew up to 1,000 attendees each year for several years. These conferences created revenue for FCEP, which enabled us to hire Garry Briese as our first chapter executive and rent office space in Orlando.” 1974: FCEP hires its first executive director, Garry Briese

1968: ACEP founding members

1971: Dr. Bill Haeck (left) accepting FCEP’s charter

An early Florida Chapter of ACEP Board Meeting (date unknown)

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“When we first started, nobody knew our specialty. We had to go out and show them what we did.” -Dr. John Stimler (FCEP President 1997-98) 1975: The first emergency medicine residency program is established at UF Health Jacksonville

Dr. Stimler in 1977

1976: ACEP establishes the American Board of Emergency Medicine (ABEM) 1977: Dr. John Stimler (FCEP President 1997-98) is part of the first class to graduate from Florida’s first emergency medicine residency program at UF Jax 1979: The independent ABEM receives specialty board approval as the 23rd medical specialty in the U.S. from the American Board of Medical Specialties (ABMS) – but as a conjoined board 1980: ABEM certifies its first emergency medicine physicians

Dr. Edelberg in 1982

1982: Dr. Jay Edelberg becomes the first FCEP president (1982-83) to be trained by an emergency medicine residency program 1986: The federal Emergency Medical Treatment & Labor Act (EMTALA) is enacted 1987: The first Symposium by the Sea conference, offering free CME and hosting the annual Board meeting of elections, was held in Marco Island. Beth Brunner begins her 33-year career as FCEP’s executive director

Beth Brunner, Dr. Cliff Findeiss, Lt. Governor Buddy MacKay, Dr. David Orban and Dr. Harvey Rohlwing at an EM Days in the 1990s

1989: A decade later, ABEM is granted “Primary Board Status” by ABMS and can now pursue the development of subspecialty certifications

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1980 Clincon

1991: In its 20th anniversary year, the Florida Chapter of ACEP closes on its first office building, becomes the first chapter to change its name to the Florida College of Emergency Physicians, and creates the the Florida Emergency Medicine Foundation (FEMF) as a separate entity from FCEP to house educational and research initiatives

1996: FEMF receives ACGME accreditation as a primary sponsor of continuing medical education for physicians

Dr. Eileen Weimerskirch (1988-89) and Dr. Emmett Ferguson (1991-92) outside of FCEP’s first office building

2001: In its 30th anniversary year, FEMF becomes the third organization to receive accreditation from the CECBEMS (now CAPCE) to provide CEU’s to pre-hospital care providers across the nation. The Capital Campaign for a proposed new building is also revealed

2006: FCEP celebrates its 35th Anniversary at the SBS Past-Presidents’ Luncheon

Past Presidents’ Luncheon (2006)

2013-14: “After many years of planning, we finally picked up shovels and broke ground on the new building. The old space was full of memories of good times spent together, but its useful days had run out.” – Dr. Michael Lozano, Jr. (FCEP President 2013-14) January 2015: FCEP moves into the Emergency Medicine Learning & Resource Center (EMLRC). “My year was also memorable for the tremendous growth in the educational programs offered by the college and the foundation.” – Dr. Ashley Booth-Norse (FCEP President 2014-15)

EMLRC Groundbreaking Ceremony (2014)

This is a condensed version of the timeline that originally debuted at Symposium by the Sea 2021. Find more online at fcep.org/50years EMLRC Grand Opening Ceremony (2015) EMpulse Fall 2021

Snapshots from FCEP’s

50th Anniversary Celebration August 6, 2021 at Symposium by the Sea 5:30 pm - 7:30 pm | Naples Grande Beach Resort

6 1) Event attendees watching the 50 Years, 50 Voices Anniversary Tribute. 2) FCEP President Dr. Sanjay Pattani welcoming attendees. 3) “A History of EM in Florida” outlined on signage. 4) Immediate Past-President Dr. Kristin McCabe-Kline with ACEP President-Elect, Gillian Schmitz. 5) FCEP staff: Kim Palm, Director of Finance; Samantha League, Director of Communications; Jonathan Dolan, Executive Director; Melissa Keahey, Director of Development & Operations; and Reana DePass, Accounting & Education Assistant. 6) Jonathan Dolan introducing the 50 Years, 50 Voices Project at the event.

EMpulse Fall 2021

ANNUAL FAMILY CASINO NIGHT August 7, 2021 | Naples Grande Beach Resort Presented by DuvaSawko & EMPros

Scan to view & download photos by Greg Hunter

EMpulse Fall 2021

August 5-7, 2021 | Naples Grande Beach Resort | Naples, FL

ANNUAL MEETING RECAP On August 5, the Florida College of Emergency Physicians held its annual meeting at the Naples Grande Beach Resort before Symposium by the Sea 2021 officially began. This meeting hosts the transition of the guard for FCEP leadership, along with the conferring of awards. FCEP Officers Installed:

• President: Sanjay Pattani, MD,

FACEP • President-Elect: Damian Caraballo, MD, FACEP • Vice President: Aaron Wohl, MD, FACEP • Secretary-Treasurer: Jordan Celeste, MD, FACEP • Immediate Past-President: Kristin McCabe-Kline, MD, FACEP, FAAEM A special congratulations was given to Dr. McCabe-Kline for her outstanding leadership as president during an unexpected two-year tenure in the midst of a pandemic. New FCEP Board Members Elected: • Blake Buchanan, MD • Eliot Goldner, MD, FACEP • Kyle Gerakopoulos, MD, MBA • Stephen Viel, MD Also Appointed: • Erich Heine, DO Outgoing Board Members: • Daniel Brennan, MD, FACEP • Danyelle Redden, MD, MPH, FACEP • J. Adrian Tyndall, MD, MPH, FACEP

FCEP also recognized the following award recipients: FCEP Legislator of the Year Award Recipient: Senator Kathleen Passidomo The Leigislator of the Year Award recognizes a state legislator who has demonstrated a significant commitment to pro-medicine and healthcare policies.

Martin J. Gottlieb Advocacy Award Recipient: Blake Buchanan, MD, FACEP The Martin L. Gottlieb Award for Outstanding Advocacy in Emergency Medicine was created in honor of Marty Gottlieb and recognizes a leading FCEP advocate who has mae a significant contribution to the advancement of emergency medicine issues and advocacy in Florida over the past year.

William T. Haeck Member of the Year Award Recipient: Daniel Brennan, MD, FACEP The Bill Haeck Member of the Year Award is named after our first president and recognizes an individual who has performed a significant level of service that spans years and has positively impacted the field of emergency medicine over that time, noted or unsung.

Cliff Findeiss Emergency Medicine Legacy Award: J. Clifford Findeiss, MD, FACEP The new Cliff Findeiss Legacy Award will honor an individual who has demonstrated a similar steadfast commitment to advancing emergency medicine over the course of their lifetime like Dr. Cliff Findeiss did over the course of his.

Special Sponsor Recognition Award: Dr. Charles “Chuck” Duva

EMpulse Fall 2021

The following FCEP members were also recognized for their national achievements, which will formally be recognized at ACEP’s Scientific Assembly in Boston this month: John A. Rupke Legacy Award: Jeffrey D. Bettinger, MD, FACEP Policy Pioneer Award: Jordan GR Celeste, MD, FACEP Innovative Change in Practice Management Award: Matthew Rill, MD, FACEP National Emergency Medicine Faculty Teaching Award: Elizabeth DeVos, MD, FACEP Finally, the following transitions within committees were announced: Government Affairs Committee: Drs. Caraballo & Buchanan will be stepping down as Chairs of the Government Affairs Committee. Drs. Saudnra Jackson and Russell Radtke will be the new Chairs. EMRAF Committee: Dr. Elizabeth Calhoun, PGY-3 will remain the EMRAF representative on the Board of Directors for an additional year. Symposium by the Sea Planning Committee: Dr. Rene Mack announced that, after a decade of serving as Co-Chair of the SBS Planning Committee, she is stepping down. She is still Co-Chair of the Membership Committee.

Thank You Sponsors

Thank You Faculty Yaritza Arriaga O’Neill, MD, FAAEM Sarah Baker, MD

Platinum Level Sponsors

Andrew Barbera, MD Mitchell Barneck, MD Kamal K. Chavda, MD, FAAP Nicholas Cozzi, MD, MBA Nicholas Erbrich, MD, FAAP Ricardo Hernandez, MD Sarah Johnson, MD Shiva Kalidindi, MD, MPH, MS, FAAP, FACEP

WiFi Sponsor

John Kiel, DO, MPH, CAQ-SM Sarah Kirby, MD, FACEP Andrew Little, MD, FACEP Trevor Lofgran, DO Carmen Martinez, MD, MSMEd, FACEP, FAAEM Nettie McFarland, RHIT, CCS-P, CHC

Gold Level Sponsors

Sarah Melendez, MD Jan Meryam, MD John Misdary, MD, FACEP, FAAEM, FAAP Camilo Mohar, DO

Silver Level Sponsors

Caroline Molins, MD David Orban, MD, FACEP Sanjay Pattani, MD, FACEP Joseph Ray, MD Gillian Schmitz, MD, FACEP Richard Shih, MD, FACEP, FAAEM Tricia Swan, MD Erica Warkus, MD, PhD George Willis, MD, FACEP, FAAEM Kyle Wiser, MD, MBA Todd Wylie, MD Cristina Zeretzke-Bien, MD, FAAP, FAAEM, FACEP

Planning Committee Rene Mack, MD CO-CHAIR Shayne Gue, MD, FACEP, FAAEM CO-CHAIR Miguel Acevedo, MD, FACEP Sara Baker, MD Erich Heine, DO Michael Lozano, MD EMpulse Fall 2021

Virtual 2021

Emergency Medicine Research Competition BEST MEDICAL STUDENT PROJECT Efficacy of High-Sensitivity Troponin I Assay for Ruling in Acute Coronary Syndrome in End-Stage Renal Disease Patients Over a One-Year Period by Kelly Perryman, BS15, Elizabeth Warren, RN15, Brandon Allen, MD, FACEP15

Emergency Medicine Analytics of Big Data from Research on Burnout in Medicine by Thomas Cox, MD1,3, Sagar Galwankar, MD1,3, Ankit K Sahu, MD1,3, Praveen Aggarwal, MD1,3

BEST CASE REPORT

ALL ENTRIES: Medical Student Category ‘E’ For Emergent: An Analysis of the Use of Prehospital Red Lights and Sirens (RLS) and Time to Antibiotic Administration in Sepsis Alert Patients

by William Taber, BS3, Nicholas Caputo, B.S.E, NRP8, Erica Warkus, MD, PhD3, Marshall Frank, DO, MPH, FACEP, FAEMS3

Assessing the Factors Related to False Positive HIV Testing in the Emergency Department by Rebecca Haber, BA7,13,18,

Nicholas Lewis, BA7,13,18, Onyeka Acholonu, BA, BS7,13,18, Heather Henderson, MA, CAS7,13,18, Jason Wilson, MD, MA, FACEP7,13,18

Efficacy and Safety of High-Sensitivity Troponin I Assay for Ruling Out Acute Coronary Syndrome Over a One-Year Period by Kelly Perryman, BS15, Elizabeth Warren, RN , Brandon Allen, MD FACEP

Evaluation of Medical Student Learner and Gamer Types at a South Florida Medical School: A Study by Shatz CD,

COVID-19 Vaccine Hesitancy Among Healthcare Providers by Derrick Huang, MD9,14, Latha Ganti, MD9,14

Intentional Ingestion of Oleander in Self Harm Attempt, a Growing Trend? by Vincent Costers, MD18

Rhabdomyolysis and Hypokalemic Periodic Paralysis, A Rare Case by Obianuju Eziolisa, DO, PGY-310, Muhammad Khan, MD, PGY-310

Ultrasound for Abdominal Pain in the Emergency Department: Recent Trends and Effects on Disposition by Derrick

Mixed-Methods Analysis of Uncontrolled Diabetes and Potential Causes of Health Inequity in NonHispanic Black Patients in the Emergency Department by Lucy

Huang, MD9,14, Leoh Leon, MD9,14, Latha Ganti, MD9,14

Nucleic acid-based HIV viral load testing in the Emergency Department

Volumetric Densities of Emergency Medicine Focused Meta-Analytical Research in Clinical Medicine by

by Nicholas Lewis, BA , Akhil Tumpudi, BS7, Heather Henderson, MA13, Marci O’Driscoll, MS13ww, Onyeka Acholonu, BA, BS13, Jason Wilson, MD, MA, FACEP13,18 17

by Emily Wheeler, MD3; Jeremy Lund, PharmD3; Casey Chaney, DO3; Stephanie Murphy, MD13, Sagar Galwanker, MD3

Mixed Methods Analysis of NonFatal Gunshot Wound Patients in the Emergency Department by Apoorva

Garner18, Jason Wilson, MD, MA, FACEP13,18

Clam Calamity: Five concurrent cases of neurotoxic shellfish poisoning with varying presentations following ingestion of clams from ocean water contaminated with Karenia brevis

MS216, Jackson JS, MD4,16, PoSaw LL, MD MPH6

by Allison Dombroski11,17, Enola Okonkwo, MD13,18, Jared Senvisky, MD13,18, Tiffany Pleasent, MD13,18, Jason Wilson, MD13,18

Ravichandran, BS18; Rebecca Haber, BA7; Alfredo Ortega-Cotte, BS18; Benjamin Kailes18; Emily Holbrook, MA18; Roberta Baer, PhD18; Jason Wilson, MD, MA, FACEP13,18

BEST RESIDENT PROJECT

Implementation of a Stroke Imaging Protocol: Improving Stroke Imaging Selection in the Emergency Department

Time to Treatment: Characterizing the Current Landscape of Intracranial Hemorrhage Management in Patients on Oral Anticoagulation and the Role of Interfacility Transport Leading to Potential Delays in Care by Allison

Loeffler, OMS-II17, Grant Yatzkan, MS-II18, Jason Wilson, MD13,18

Resident Category A simulated exercise on Phase Zero’s platform to capture user experience and feedback on electronic data capture by Dr. Josh Pavlik, PGY-II3; Dr. Sagar Galwankar3; Dr. Vivek Chauhan5; Kevin Yee12; Ngoc Le12

An Uncommon Cause of Acute Hyperkalemia with Hemodynamic Instability by Wesley Priddy, MD18,

Lance Lewis, MD18, Samuel Harris, MD18, Matthew Vasey, MD13

Analysis of Traumatic Intracranial Hemorrhage in Patients with Isolated Head Injury on Anticoagulation/ Antiplatelet (ACAP) Therapy by Kevin

Raymond, DO1,3, Amit Agrawal, MD1,3, Alexander Sterling, DO1,3, Mary Roberts, DO1,3, Reuben Holland, MD1,3, Sagar Galwankar, MD3

EMpulse Fall 2021

Unusual Renal Ultrasound in Ill Elderly Male by Jillian Kiely, MD, MPH, PGY-218,

Allyson Hansen, DO18, Charlotte Derr, MD, RDMS, FACEP18

Thomas Cox, MD3, Sagar Galwankar, MD3, Ankit K Sahu, MD1; Sanjeev Bhoi, MD1

When physical fitness isn’t enough: evaluation of SWAT officer physical performance after medical-related stressors by Lindsay W. Wencel, MD11, Jay Ladde, MD11, Jesus V. Roa, MD11, Chadwick Smith, MD11

Worth the Wait? A survey investigating patient’s perceptions regarding acceptable waiting times in the emergency department by Stephanie Murphy, MD, PGY-23; Emily Wheeler, MD, PGY-23; Kevin Raymond, DO, PGY33; Sagar Galwankar3; Alice Rogan, BSc (Hons), MBChB3; Brad Peckler, MD, FACEP, FACEM3

Attending Category Esmolol, vector change, and dosecapped epinephrine for prehospital ventricular fibrillation or pulseless ventricular tachycardia (EVADE VF) by

Marshall Frank, DO, MPH3; Kyle Stupca, PharmD3; Nick Scaturo, PharmD3; Eileen Shomo, PharmD, BCCCP3; Tonya King, PhD3

INSTITUTIONAL AFFILIATIONS:

Virtual 2021

1. All India Institute of Medical Sciences, New Delhi, India 2. FAU Schmidt College of Medicine 3. FSU at Sarasota Memorial Hospital 4. Holy Cross Hospital 5. Indira Gandhi Medical College, Shimla, H.P. India 6. Jackson Memorial Hospital 7. Lake Erie College of Osteopathic Medicine 8. Nova Southeastern College of Osteopathic Medicine 9. Ocala Regional Medical Center 10. Orange Park Medical Center 11. Orlando Health 12. Phase Zero, Boston, MA 13. Tampa General Hospital 14. UCF Department of EM 15. UF Gainesville 16. UM Miller School of Medicine 17. University of New England College of Osteopathic Medicine 18. USF Morsani College of Medicine

THANK YOU, PLANNING COMMITTEE & JUDGES: Competition Chair: Jason Wilson, MD, FACEP Judges:

In FCEP’s annual Case Presentation Competition, EM residents from selected programs will virtually deliver discussions of the initial approach, differential diagnosis and final impression of an unknown ED case from one of the other programs. The program that submitted the case then completes the case conclusion with the actual patient outcome. Thank you to all who attended and participated in FCEP’s Virtual Case Presentation Competition (CPC) on September 1, 2021! Best Resident Presenter: Naomi Newton, MD, PGY-2 from UM/Jackson Memorial Hospital Best Resident Discussant (tie): Michael Buchko, MD, PGY-3 from USF Geoffrey Wade, MD, PGY-3 from FSU at Sarasota Memorial Hospital Best Overall Program: UM/Jackson Memorial Hospital

All Participating Institutions: FSU at Sarasota Memorial Hospital Orange Park Medical Center Orlando Health UM/Jackson Memorial Hospital USF Emergency Medicine

Jennifer Jackson, MD, FACEP Steven Nazario, MD, FACEP Richard Shih, MD, FACEP

THANK YOU, PLANNING COMMITTEE & JUDGES: Judges:

Competition Chair:

Dakota Lane, MD, FACEP

Jennifer Jackson, MD, FACEP

Tami Vega, MD, FACEP Scan to watch winning presentations here:

Roxanne Sams, MS, ARNP-BC, MA

fcep.org/sbs/research

EMpulse Fall 2021

Scan to watch the entire CPC online:

COMMITTEE REPORT

EMRAF President’s Message By Elizabeth Calhoun, MD, PGY-3 Committee Chair

At Symposium by the Sea, and as we celebrate our 50th anniversary, we have heard from 50 voices in emergency medicine, and we are reminded that working through adversity has been our hallmark since our initiation. As residents who trained through the pandemic, we have been a vital part of our hospitals’ disaster management, signing up to help with last-minute plan changes, managing ICU holds and overwhelmed waiting rooms. At our summer meeting, EMRAF residents created plans for spreading awareness of FCEP, exploring what we can do to directly help our growing number of Florida EM residents.

We are a resilient and adaptable workforce, and together we can promote ourselves. This is part of the FCEP mission: to empower emergency physicians. We are here for you. As our families and communities reemerge out of our homes and back into the hustle and bustle of life, we have been forced to acknowledge, and even confront, what home means to each of us. It has been said that home is not a place but instead who you are with; home is not where you live, but rather where they understand you. But home can be both. Because our environment contributes to our

All Florida Chapter of Emergency Physicians members are encouraged to take this FREE course, through CE Broker or through the FMA.

character, our physical experiences in emergency medicine help to shape us. This is why EMRAF in FCEP can be that home for our new Florida residents, through our shared experiences. We are part of a story, and FCEP, through its 50 years of history, advocacy and education, has gone into the making of our role. EMRAF interest is building, but there is so much more residents can benefit from this year. If you have not yet signed up to receive updates, click Subscribe to Announcements at the bottom of fcep.org, or send me an email at ecalhounmd@gmail.com. ■

1.25 HOURS CE

Improving Best Practices for Patient Care: Optimizing Use of the PDMP Database COURSE OBJECTIVES

•

Discuss the E-FORCSE® database and the role of the Florida PDMP Foundation

•

Understand disciplinary actions related to the PDMP requirements

•

Review laws and rules surrounding the prescribing and dispensing of controlled substances

•

Understand the value of PDMP database information

•

Discuss prescribing information technology Information Technology Solu-

•

Review of the best practices for PDMP utilization The course can be accessed via CE Broker at https://tinyurl.com/adcvzfmw OR via the FMA at https://tinyurl.com/28m6jcra

2012-2013

The Florida PDMP Foundation produced this course with funding through the Cooperative Agreement Number 6NU17CE925020 from the Centers for Disease Control and Prevention. Prescription Drug Monitoring Program Annual Its contents are solely the responsibility of the authors (FL) and do Report not necessarily represent the official views of the Centers for Disease Control and Prevention. Rick Scott Governor

John H. Armstrong, MD, FACS RICK SCOTT State Surgeon General & Secretary Governor Rebecca Poston, BPharm, MHL J O H N H . AManager RMSTRONG, MD, FACS Program Surgeon General & Secretary Florida Department of Health

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EMpulse Fall 2021

December 1, 2013

Updates from Florida’s

Emergency Medicine Residency Programs

AdventHealth East Orlando By Shannon Caliri, DO, PGY-1 Hello, everyone! I am Shannon Caliri, one of the new “baby docs” here at AdventHealth East Orlando. Us interns are currently in our third month of residency and are trying to get acclimated to life as an ED resident. There are many obstacles to overcome and many, many new things to learn; but it is such an exciting time. We are doing procedures, rotating through different specialties, and learning from each and every one of our patients. We are all incredibly thrilled that we are now a part of such a great team and we are all striving to improve so we can make it even better. This month the ED has been packed with COVID patients, and ICU beds are filling up fast with the most recent surge. The waiting room is consistently filled because of the many bed-holds preventing us from seeing new patients. Please, please, please get vaccinated, tell your loved ones to get vaccinated, and continue to wear your mask during these times. We need everyone to participate to win this battle. Currently, our residency podcast is going through a rebranding process, and we will be up and running again soon. This podcast will aim at providing high quality EM content, board review and journal clubs, as well as highlighting our program. We will post an update once the podcast is ready to go! Stay safe! ■

Florida Atlantic University By Tony Bruno, DO, PGY-2 The sweet days of summer are flying by in Southeast Florida. Big congratulations to all of our first-year residents on completing their first few months of residency! Our program remains impressed with how they have jumped in feet first. We have been extremely busy the last few months. First off, we extend our program director Dr. Clayton a huge congratulations as she recently won the Health Care Educator Hero Award. This award is presented by the Palm Beach County Medical Society and is presented to those who are notably making a difference in healthcare. We are very fortunate to have Dr. Clayton leading our residency. Our very own Dr. Daniella Lamour, PGY-2 and Dr. Thomas Peterson, PGY-3 were highlighted in an interview feature on NBC WPTV. The interview focused on the COVID-19 pandemic resurgence and the toll it has taken on ED physicians. Their eloquent and heartfelt representation of the situation we are all facing made us very proud. Read now by scanning the QR code. EMpulse Fall 2021

Despite working incredibly hard in the hospitals, we are still making time to enjoy ourselves and recharge. At one of our first in-person wellness events since the COVID-19 pandemic, we enjoyed an exciting game of kickball. This was a great event set up by Dr. Ali Syed, PGY-3 and faculty attending Dr. Benda. The game may have not been the most competitive, but the laughs and exercise made it an afternoon to remember. Our residency has also continued to contribute to research and academia. Drs. Alter, Shih and Solano co-authored several commentaries regarding COVID-19 treatment. Meanwhile, recent graduate Dr. Alexander Busko, in association with Drs. Alter, Solano, Clayton, Hughes and Shih, presented a poster regarding the role of thromboelastography in treatment of geriatric traumatic brain injury patients. This was presented at the 2021 International Conference on Emergency Medicine. There were also multiple presentations given at the SAEM annual meeting and the American Geriatrics Society Annual Meeting. ■

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

Orange Park Medical Center By Penny Côté, MD, PGY-2

Orlando Health

By Drs. Gregory Black and Brody Hingst, PGY-3s Happy fall from Orlando Health! The new academic year is in full swing here at Orlando Regional Medical Center (ORMC). Drs. Lindsay Maguire, Timothy Bullard, and Linda Papa published a systematic review in The American Journal of Emergency Medicine that was recently featured on EM:RAP’s Emergency Medical Abstracts. It investigates the role of ketamine in alleviating treatmentresistant depression as well as suicidal ideation. Additionally, Drs. Mitchell Barneck, Linda Papa, Jay Ladde, Linh Nguyen, and Josef Thundiyil published a prospective cohort study in the Journal of the American College of Emergency Physicians. It investigates the utility of transcutaneous carbon dioxide measurements in the emergency department. Well done to each of you! We have been honored to have such an exceptional group of medical student rotators these past few months. We enjoyed working with each and every one of you, and wish you the best during the upcoming interview season you all will thrive! Amidst our very best vaccination efforts, Orlando Health is now offering RegenCOV (casirivimab and imdevimab) by home health to patients with a diagnosis of COVID-19 ≤ 10 days who do not require hospital admission/O2 and are at risk for progression to serious illness. We have also been providing home health kits to these patients which include a pulse oximeter among other useful items. So far we have received overwhelmingly positive feedback from our patients. Lastly, it was great getting out there for Symposium by the Sea this year and seeing everyone again! Hope you all are staying safe and not feeling too bad after that third Pfizer shot. ■ 26

In July, our EM residency became complete as we welcomed our third class of residents into our program. The interns are settling in well and making us proud, despite the continuing challenges of the pandemic. Our entire emergency department continues to adapt and work as a team to fight the COVID-19 pandemic. Our PGY-3s volunteered to add additional medical ICU coverage in response to unprecedented numbers of patients suffering from COVID-19. We welcomed a new group of medical students into our department to complete their EM rotations. We are gearing up for another interview season and are looking forward to meeting all the candidates. Despite the constraints of the pandemic, we are collaborating with nearby programs to plan joint ultrasound training events. Many of our residents and faculty are looking forward to attending (hopefully inperson) ACEP in Boston in October. In the research world, we welcomed

Dr. Wegman to our core faculty group. He will be leading our resident-faculty research efforts. Dr. Bosely, PGY-3 will be presenting his scholarly project with the help of faculty member Dr. Davis at the International Meeting on Simulation in Healthcare in January. Dr. Lofgran, PGY-3 was recently awarded a grant to support his research on the effects of NSAIDS on hypothermia in rats. Drs. Côté and Baker, PGY-2s, participated in FCEP’s Case Presentation Competition and are looking forward to competing again next year. On the horizon, OPMC has begun plans for construction of a new simulation center! We recently welcomed ultrasound fellowshiptrained faculty, Drs. Hoffman and Carr, who are both certified in resuscitative transesophageal echocardiogram. With their help, we are training all three resident classes in resuscitative TEE. All in all, it has been a busy and exciting start to this new academic year! ■

USF at Tampa General Hospital By Kenneth Dumas, PGY-2 Greetings from the EM family here at USF/TGH. We have some exciting updates to share.

to better reach our underserved population through mobile vaccination opportunities.

We are very proud of our residents and faculty who have been working hard facing the most recent Covid surge. TGH has been on the forefront of treating patients with monoclonal antibody therapy and has several active Covid-19 research trials including being selected as a site for ACTIV-6, a large clinical trial that will investigate repurposed medications. We are currently looking at ways

Additionally we’re very proud of two of our very own residents, Dr. Buchko and Dr. Costers, who participated in FCEP’s Case Presentation Competition, with Dr. Buchko tying for 1st place as Best Resident Discussant.

EMpulse Fall 2021

As always follow along with us at our blog for the most up to date news: usfemergencymedicine.org/blog ■

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

Kendall Regional Medical Center By Kelly Wright, MD, PGY-3

Emergency Medicine Chief Resident

Hello again from Miami! It’s been a great start to another academic year here at Kendall. We welcomed our newest residents to the Class of 2024, and we held our annual Intern Welcome Party where our residents and faculty had the opportunity to meet and mingle before the official start of the new academic year. Our Ultrasound Fellowship also welcomed their newest class of fellows, Dr. Nicholas Rosende and Dr. Jose Batista. Along with the ultrasound fellows, several residents and all our

interns had the opportunity to attend the annual Ultrasound Course in Miami Beach. We are looking forward to working closely with the fellows again this year as we gain knowledge on using POCUS in the emergency department through hands-on practice, weekly didactics and weekly tape review sessions. Our Administration Fellowship also welcomed their newest fellow, Dr. Anton Gomez, who is working closely

with our Emergency Department’s Medical Director and Assistant Medical Directors to learn what is needed to run an emergency department efficiently while also serving on several hospital committees. We would also like to announce the newest member to our core faculty, Dr. Sabina Modelska. She is a great addition to help our residency continue to grow with her experience in both EMS and SIM. ■

UF Gainesville By Megan Rivera, MD, PGY-2

Hello from Gainesville! While it remains hot in the Swamp, the return of college football has signaled the beginning of fall. Gainesville has reawakened with a sea of orange and blue tailgates, as many are ready to get back to a postCOVID normalcy. With fall festivities in full swing, our residents have kept busy. The most recent wave of new COVID cases has led to an explosion of both volume and acuity within our ED. We welcomed 14 new interns this July, and they’ve hit the ground running. Our entire team came together to create new care spaces and improve flow and quality within the department.

Despite the many unknowns during this pandemic, one thing has always remained true: residents rise to the occasion. We’ve had a great start to the new academic year with core faculty lectures, interesting case presentations, evidence-based medicine discussions and M&M. This included our annual Fellowship Day with presentations from UF’s various programs: neurological critical care, critical care, administration, sports medicine, EMS, simulation and ultrasound. Pediatrics will be added to this list as we are excited to host our first PEM fellows as early as July 2022. EMpulse Fall 2021

Additionally, residents engaged in an Emergency Neurological Life Support course to help improve their skills with some of the department’s most critically ill patients. To maintain proper balance, we’ve kept wellness on the schedule. Residents recently enjoyed a day at the beach, and we’ve been giving plenty of business to our local breweries after conference. These events, along with great support from our faculty, have helped keep morale up despite this COVID wave. And although there is still a lot of uncertainty with what fall will bring, we remain optimistic that there are better days ahead. ■ 27

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

Mt. Sinai Medical Center Daniel Puebla, MD, PGY-2

FSU at Sarasota Memorial Thomas Cox, MD, PGY-3 Hello from Sarasota! It has been a long summer, and our residents continue to set a high standard of excellence for our community. In particular, we congratulate Dr. Geoffrey Wade on his performance in the Case Presentation Competition as one of the Best Discussants. For the Emergency Medicine Research Competition, we recognize Dr. Emily Wheeler for winning Best Case Report, and Dr. Thomas Cox for winning the Best Resident Project. In addition, we congratulate all the residents, medical students and attendings who participated in this year’s competitions. Under the instruction of Dr. Ashley Grant, Ultrasound Director, we continue to sharpen our ultrasound skills by teaching and helping our medical students and internal medicine colleagues. In addition, we have started a new study comparing the efficacy of and pain reduction for the Pericapular Nerve Group Block (PENG) vs. Facia Iliaca Compartment Block in the emergency department. In addition, our residency has welcomed our newest interns and hasgrown to its full size. Our own Dr. Kevin Raymond, PGY-3, also welcomed to the world a new baby girl, growing our residency family. Lastly, we thank all the healthcare workers, medical staffing, housekeepers and anyone who works in the healthcare industry for your hard work as this pandemic persists. ■

Hello from Miami Beach! Our 2021 academic year is well underway and we’re extremely proud of the progress our intern class has made over the last few months. In July, our interns joined other Florida residencies at the South Florida Ultrasound Conference where they honed their sono skills through lectures and interactive stations, surely providing useful skills for the years to come. Our residency is proud to have Drs. Stephanie Fernandez and Michael Shalaby join our ranks this year as the inaugural class for our Advanced Ultrasound Fellowship. We’re excited to have them on our team as we grow together and learn the ins and outs of sonography. Welcome to Miami Beach, Drs. Fernandez and Shalaby! On the research front, we’d like to give a shout out to Drs. Jiodany Perez, Stephanie Sorenson and Michael

Rosselli for publishing an interesting case report in the British Medical Journal, utilizing musculoskeletal ultrasound in the evaluation of septic arthritis in a patient who presented to the ED with fever during the COVID-19 pandemic. Drs. Grethel Miro, Paige Swalley, Michael Dalley, Tony Zitek and David Farcy also published a prospective study on comparing the two monoclonal antibodies for COVID-19 in the Journal of Emergency Medicine. We’d also like to acknowledge Drs. Daniel Puebla and Robert Farrow for publishing an article on how to perform ultrasound-guided arthrocentesis in StatPearls. Finally, we’d like to give a warm welcome to our new core faculty members: Dr. Antoinette Golden, Assistant Program Director; Dr. Tony Zitek, Director of Research; and Dr. Nicole Warren, Medical Student Clerkship Director. ■

St. Lucie Medical Center By Nicole Tobin, DO, PGY-2 As we are sure is the case with everyone else, the chaos has continued down at St. Lucie. We are seeing upwards of 160 patients a day, which is much greater than our normal average for this time of year. It is keeping all of us residents busy and pushing us all to see more and more patients. While hectic, our senior residents are rising to the challenge, knowing that this is what we will be facing alone in just a few months. We couldn’t ask for better prep. We have also been watching our new interns get used to life in the ER. With an increase in patient volume and the number of critical patients, it probably isn’t quite what they expected to walk into when they graduated from medical EMpulse Fall 2021

school just a few short months ago. It’s exciting to see them fall into a routine in the ER as they try to navigate the life of a resident. Unfortunately, with the rise in COVID cases, we have gone back to virtual conferences. We are hopeful that at least our interns will get the chance to experience SIM lab soon, even if we cannot all be there together. We are very appreciative of our chief, Dr. Tran, for scheduling virtual guest lectures so that we can continue expanding our knowledge base. All of us at St. Lucie hope that the light at the end of the tunnel is coming soon and wish all of our fellow residents well in these crazy times! ■

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

Jackson Memorial Hospital By Patricia Panakos, MD Greetings from Miami! We can’t believe it’s fall already. It seems like just yesterday that we were hosting our orientation month and the yearly intern welcome BBQ at Dr. Diskin’s house. Now we are sipping on Starbucks’ PSL, watching football and keeping our fingers crossed against hurricanes. The 15 members from the Class of 2024 came from all over the country, bringing a breadth of diversity and experiences. They quickly settled into life in Miami and hit the ground running as they began caring for the sickest patients due to COVID-19 cases rising again in South Florida. We are hopeful that the peak has passed, and our residents have remained compassionate and resilient as we continue to serve our community in this time of need. In fact, Dr. Juhi Varshney, PGY-1 was so moved by her experience that she wrote a piece in the Miami Herald on COVID-19

through the eyes of an EM physician. We are so proud of her for her heartfelt and inspirational article. Accolades are also in order for Drs. Kristopher Hendershot and Naomi Newton, PGY-2s, who competed in FCEP’s 2021 Virtual Case Presentation Competition (CPC) and brought home the trophy for the best program for the 5th consecutive year! Dr. Naomi Newton was also recognized as the overall best discussant. We would like to congratulate them on all their dedication, hard work and success. Before we know it, recruitment season will be here, so the planning for the next virtual interview season has already begun. We can’t wait to meet stellar new medical students interested in training at Jackson! We hope to see everyone live at ACEP21! ■

Meet Florida’s 21st emergency medicine residency program:

By Dr. Calixto Romero III, MD, PGY-3 Chief Resident

The new academic year has been progressing very well. Our new class has been a wonderful addition to the Brandon Regional EM family. We are all very excited to see them progress throughout the year. Our PGY-2 and PGY-3 classes have been working hard at making the transition into residency as smooth as possible for them. Although we are back in virtual classroom for academic half-day sessions due to COVID 19 surges, we have a stellar curriculum that is progressive and inclusive of the residents, faculty and guest speakers. This change back to virtual classroom has highlighted the resiliency of our residents and faculty alike. Both individually and collectively, our program has been invested in advancing our wealth of knowledge and understanding for our practice. The Class of 2022 is actively preparing for post-residency life. A significant portion are completing interviews for fellowships in emergency ultrasound, EMS, and critical care medicine. Some have already secured attending physician jobs after the completion of their residency training.

Westside-Northwest Emergency Medicine Plantation, FL

• Total positions: 39 • Positions per class: 13 • Accreditation date: Aug 27, 2021 • Inaugural class: July 2022

Brandon Regional Hospital

Program Director: Matthew Slane DO, FACEP, FAAEM

DON’T FORGET TO SHARE ONLINE Access the online version of each residency program update at fcep.org/empulse or on your residency program’s fcep.org landing page. Follow FCEP’s social media channels to share in realtime!

EMpulse Fall 2021

We also want to welcome a new core faculty member, Dr. Gomez, to our family. Dr. Gomez completed fellowship in emergency ultrasound and has joined the staff as emergency ultrasound faculty. As a group, we wish that all other residency programs in the state are faring well with the circumstances surrounding the pandemic. We hope that all of our colleagues are staying safe and continuing to care for their wellness. ■ 29

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

UCF/HCA Healthcare GME Consortium Emergency Medicine Residency Program of Greater Orlando By Amber Mirajkar, MD Research Fellow

This academic year started off with a bang as Florida saw the worst COVID-19 surge in our state since the pandemic began. This, in turn, prompted our new interns to start the year off running. We are very happy to welcome Drs. Abigail Alorda, Taylor Cesarz, Natalie Diers, Robert Pell, Mitchell Voter, Alexa Ragusa and Bridget Schevek to our program. In July, they completed their intern bootcamp and attended the MSMU Ultrasound Conference in Miami. Now they are already aiding in resuscitations, performing procedures, and taking on a heavy patient workload, rising to the occasion to care for our very sick patient population. We also welcomed our newest class of fellows. Dr. Michelle Hernandez, former chief resident, will be one of two ultrasound fellows at our program, and she will be joined by Dr. Thomas Lawyer who is coming from AdventHealth East Orlando’s EM Residency. Drs. Maria Chamorro and Amber Mirajkar have stayed on

as the academic and research fellows, respectively. Dr. Chamorro attended the ACEP/CORD Teaching Conference in August in Fort Worth, TX, returning with a plethora of ideas on how to further enhance our didactics. She looks forward to attending the second part of the conference in Spring 2022. At the ACEP 2021 Research Forum Special Edition: COVID on August 4, several members of our residency presented original research. Drs. Amber Mirajkar and Mark Rivera, PGY-3, presented “Racial Disparities in Patients Hospitalized for COVID-19,” and EMS Director, Dr. Ayanna Walker, presented “Impact of virtual simulation to teach paramedics respiratory failure management during the COVID-19 Pandemic.” To continue the tradition of research, Dr. Parth Patel, PGY-3, is presenting “The A to E (ABCDE) Pit Crew Model: A Novel Approach to Team Based Cared of Critical Patients in the Prehospital Setting” at the ACEP21 Research Forum in October. We look forward to seeing everything

there and comparing ideas and findings. While we love presenting research at conferences, virtual or in-person, we have been publishing research, too. Drs. Mark Rivera, PGY-3, Jesse Wu, PGY-3, and Larissa Dub, Associate Medical Director of the Emergency Department, published “Rare Presentation of Deep Vein Thrombosis and Submassive Pulmonary Emboli due to Hypercoagulable State with Supratherapeutic Anticoagulation.” Additionally, Drs. Fernando RiveraAlvarez, PGY-3, Marvi Gul, PGY-2, Ayanna Walker and Anines Quinones, EM Faculty, published “Aortic Dissection as a Seizure.” We have many more publications in the works and cannot wait to submit them! Despite the new wave of the COVID-19 pandemic and returning to virtual didactics, our commitment to education and training has never waned; we have just become more creative. ■

Oak Hill Hospital By Mohammad Razzaq, DO, PGY-2

WEST FLORIDA

Greetings from Oak Hill! What a busy summer we’ve had. Just when we thought we were finally getting over COVID-19, it came back and hit us with a vengeance.

nurses, techs and other staff from the floors that have temporarily accepted assignments in our department. We appreciate their help during these exceptional times.

As we are sure is the case for many of our fellow residents around the state, we have had to revert to many of our infection control measures from earlier in the pandemic. A tent has gone back up outside to handle the surge, and is seemingly never empty. That being said, everyone in our department has risen to the challenge. We would like to express our gratitude to the

We would like to extend a warm welcome to the Class of 2024! They have done an amazing job of stepping up to the plate during this uncharacteristically busy summer. We are grateful to have them as part of our team, and though they haven’t been with us long, we can already see their positive impact. Our interns also acquitted themselves well at our recent EMpulse Fall 2021

Field Day, integrating into our teams to challenge senior residents and faculty alike. We are happy to say that despite the radical changes in the 2020 interview season, we have an excellent group of new residents. Our expansion in GME is also proceeding well! This move comes with the opportunity for residents to set up part of the new space to fit our needs. Currently the two ideas in highest contention are a resident gymnasium or an expansion and upgrade of our current sim lab. Stay tuned for more updates and stay safe out there! ■

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

North Florida Emergency Medicine By Manna Varghese, MD, PGY-2

North Florida EM has had a busy, yet exciting summer. The previous PGY-3 class had their graduation ceremony in June. It was incredible to hear stories of how these physicians had grown over the past few years in residency. We are so proud of how far they have come and are excited to see them continue to excel as fellows and attendings in their respective jobs. A few weeks later, we welcomed our new intern class for orientation and then their first day of residency! Throughout the entire month of July, interns participated in EM intern bootcamp, learning the basics of EM ultrasound, common procedures and basic foundations.

Our residents and faculty had to rise to the challenge of the spike in COVID cases we experienced this summer. We saw record-breaking volumes of patients across all of our sites, including the main ED and our freestanding EDs. While this was a difficult time for many of us, it has been incredible to watch each person step up and tackle the challenge head-on. Our faculty has also provided incredible support for residents during this time, ensuring that each resident’s concerns are heard and everyone continues to have an excellent learning experience.

months, our program has emphasized resident wellness. The PGY-2 class had their wellness retreat for four days at the Margaritaville Resort in Orlando. We also had our program’s annual summer Wellness Day at Ginnie Springs at the end of August. Both of these events were great chances to rest and recharge while spending time with our co-residents. We’re looking forward to the last few months of the year and are hopeful that we will be able to continue gathering in-person for didactics and other events outside of work as COVID cases start to downtrend and vaccination rates increase. ■

Despite the difficulties of the past few

UF Jacksonville By Chris Phillips, MD, PGY-2 We were incredibly saddened to hear that Dr. Leon Haley, our dean and CEO, passed away after a tragic accident in South Florida. He was an incredible leader and a beloved son, father, friend and colleague. Dr. Haley will be sorely missed as not only the leader of our organization but also as a tremendous friend and mentor to our specialty. This latest COVID surge has not been easy on anyone and I’m so proud of everything we’re doing as a department to address the rising tide of patients. As with the rest of Florida, our ICUs are at capacity. In order to create more ICU beds and help with ED boarding, we turned our observation area into an ICU led by critical care trained EM physicians. Everyone is doing an amazing job in extremely challenging circumstances. In particular, our interns have hit the ground running and have done a fantastic job of transitioning from medical students to resident physicians. They are an amazing, fun and hardworking class who are already making our program better.

Our department was happy to welcome back medical students on away rotations this year. We had a lot of excellent students who we hope to work with next year! We wish you all the best of luck during interview and match season. In order to help medical students learn more about the program here at UF Jax, we have continued our successful online lecture series, EM Sneak Peak, that was started last year. It’s a way to get to know the residents, ask questions about the program, and learn about awesome EM topics including beach medicine, sports medicine, women in EM, EM critical care and POCUS. Our residents recently attended a conference day at Jacksonville Beach with our beach/surf medicine expert, Dr. Andrew Schmidt. We learned about drowning, diving emergencies, marine envenomations, and had the chance to practice hands-on scenarios, including in-water rescue training with the lifeguards. Our residents also EMpulse Fall 2021

participated in the yearly Difficult Airway Course, which allowed us to reinforce our airway management skills. We are lucky to have some of our faculty as directors for this nationally-recognized program! Our department had many achievements over this past quarter. First, we’d like to congratulate Dr. Joy Turner, PGY 2, who won the resident Haiku competition at the Clinical Decision Making in Emergency Medicine conference. We’ve also had many faculty achievements, including Dr. Kelly Gray being appointed to Governor DeSantis’ Commission on Mental Health and Substance Abuse. In our research department, Dr. Lauren Black received the prestigious NIH K23 award on her first submission! In addition, Dr. Faheem Guirgis was appointed to co-director of the UF KL2 CTSI Program. We’re proud of everything we have accomplished so far this year and look forward to seeing what the rest of this year has in store for us! ■ 31

FEATURE

Remembering Leon Haley, Jr., MD, MHSA, FACEP, CPE

FCEP/ACEP member Leon L. Haley Jr., MD, MHSA, FACEP, CPE died unexpectedly on July 24, 2021 at the young age of 56. A leader both locally and nationally, Dr. Haley became the first Black CEO of UF Health Jacksonville in January 2018. He led by example during the COVID-19 pandemic, becoming the first person in Jacksonville to receive the Pfizer vaccine and going out of his way to bring comfort and joy to sick patients. Dr. Haley also served on the Florida Hospital Association’s board of trustees, on the ACGME’s board of directors, and as a board member of the Florida Safety Net Hospital Alliance and American Board of Emergency Medicine, among many other civic institutions. Scan the QR code provided at the end of this article to read more about his rich legacy. The following are submissions by fellow FCEP members as they share memories of their time with Dr. Leon Haley:

By David Caro, MD, FACEP

By Madeline Joseph, MD, FACEP, FAAP Associate Dean for Inclusion and Equity & Professor of Emergency Medicine and Pediatrics, UFCOM-Jacksonville From my first meeting with Dr. Leon Haley at our EM Holiday Party in December 2017, I knew he would be a different type of Dean to the UF College of Medicine in Jacksonville (UFCOM-Jacksonville). He came to the party before he started his job in January 2018, and a few minutes after meeting many of our faculty, residents and staff, he was leading the dance line. I knew right then he would be a hands-on type of Dean, both personable and engaged. I had the great fortune of working with Dr. Haley very closely on diversity, inclusion and equity matters as he established the inaugural Associate Dean for Inclusion and Equity position at UFCOM-Jacksonville and appointed me to serve. I looked forward to the Monday morning Deans’ meeting where he brought the leadership team together. He conducted those 30-minute meetings in such a way that left you motivated to do and serve more. He was intentional in

Dr. Leon L. Haley Jr. Photo from UF Health Jacksonville

helping leaders see the big picture and did not get caught up in their silos. Dr. Haley talked the talk and walked the walk, and did that with style, authenticity and dignity. We had many conversations during our monthly meetings on how to close the gaps in health disparities and how to change the culture to more of an inclusive excellence, where everyone has the opportunity to reach their potential. He knew when to let me run with my ideas, when to provide sound advice, and when to provide the forum to turn ideas into reality. What I discovered since his tragic death is that my story and experience were not unique and that many of us felt the same way. He honored each person’s gifts and brought out the best in us! Dr. Haley, you will be missed greatly as a fierce leader, a colleague and a friend but your smile and spirit will continue to motivate us to uphold your legacy to achieve health equity. We will be Haley Strong! Rest in peace.

EMpulse Fall 2021

Disaster Medical Officer, UF Health Jacksonville; Associate Chair of Education & EM Residency Program Director, UFCOM-Jacksonville I first met Dr. Haley at our department’s annual Christmas party in 2017, after he had accepted the job as the new dean for the UFCOMJacksonville. What still stands out to me was his presence: he didn’t seek out attention, and spent time in conversation with as many people as he could. He was gracious and kind, yet in talking with him, I couldn’t help but recognize the steady confidence, the characteristic poise that we all later came to rely on, and the ability to relate both with the individual as well as with a large group. Importantly, he wasn’t a wallflower. By the end of that evening, he was head of the party’s conga dance line, leading the entire department through the banquet room in a display of what would be one of his many “best” character traits: steady, down-to-earth, realistic leadership that included everyone he potentially could get involved, and feel good about doing it. He was one of the best “bridge-builders” I’ve ever

met. He did his job day-in and day-out, never got out-worked, and his legacy with UF Health Jacksonville will be his servant leadership that drove UF Health Jacksonville and the UFCOM Jacksonville to continue its path of growth and community involvement in a way that few could.

By David Vukich, MD, FACEP FCEP Past-President 1998-1999; Professor & Senior Associate Dean for Hospital Affairs; Senior Vice President and Chief Medical Officer, UF Health Jacksonville *Editor’s Note: On July 15, 2021, a week before Dr. Haley’s tragic death, Dr. David Vukich was interviewed for the 50 Years, 50 Voices Project. The following is a transcript of what he said about Dr. Haley during his interview, lightly edited for readability:

“I was chairman of the search committee that found Dean Haley. He was up at Emory at the time, and he was just a perfect fit! He didn’t see the ad. I just cold called him and said, “hey, can you come down and interview for this job? We have an inner-city hospital; it’s a little bit like Grady (Memorial Hospital),” which is where he cut his teeth, and he said, “sure, I’ll do it.” So one thing led to another; he interviewed, and he’s a star. I’ve had seven or eight CEO’s since I’ve been here, and to be sure, he’s the most capable. He’s caused the most advancement here, and he’s an emergency physician! So when we have our meetings, there’s this secret handshake or what not — half of what goes on is not verbal, because we’ve shared so many experiences. Compared to me, he’s a youngster... I’m probably a lot older than him, but he’s probably a lot wiser than I am.” ■

Dr. Leon Haley Jr. receiving the Pfizer vaccine. Photo from UF Health Jacksonville

Scan to read more about Dr. Haley on UF Health Jacksonville’s website:

COMMITTEE REPORT

Medical Student Council By Cristina Sanchez, MS, MS-2

MD Candidate, Florida State University FCEP Medical Student Council Secretary-Editor

The FCEP Medical Student Council has transitioned into new leadership and is eager to get some exciting events up for interested future physicians. Please welcome our new officers: Veronica Abello (NSU) as our new chair, Christopher Day (FIU) as our new advocacy chair, and Cristina Sanchez (FSU) as our new secretary-editor. This year’s annual FCEP “Symposium by the Sea” was held in person in Naples, Florida, from August 5-8. The event took place at the Naples Grande Beach Resort and brought together both current and aspiring emergency medicine physicians in a successful event for all. Aspiring physicians from the whole state of Florida are grateful to have had the opportunity to attend this live event. Continuing to navigate

the SARS-COV-2 pandemic has brought many unexpected challenges. Medical students face uncertainty on a daily basis on how their education or programs of interest may change. Additionally, students are continuing the process of becoming accustomed to having much of their medical school careers take place virtually, and are grateful for the opportunity to attend some live events, such as the symposium. We are still uncertain if EM Days, an event which typically takes place in Tallahassee, will be held virtually or live in-person. Despite this uncertainty, students continue to look forward to learning about advocacy and government relations. We will be providing more information as the dates approach.

EMpulse Fall 2021

The Medical Student Council is taking the current pandemic into account and is working hard to bring students what they most need. Likewise, we continue our dedication in keeping all students interested in emergency medicine up-to-date with any events, both virtual and in-person. Similar to last year, we are planning to have virtual information sessions led by program directors and practicing EM physicians this year. We hope these information sessions will help students to more easily navigate the interview season. Sessions will be recorded (with permission from participants), and those sessions will be posted at a later date. We are excited to be serving as the new Medical Student Council and eager to see what the next year brings us all. ■ 33

FEATURE

Immune Thrombocytopenic Purpura vs. Vaccine Induced Thrombotic Thrombocytopenia: Rare but Distinct Conditions Associated with the COVID-19 Vaccines By Glenn Goodwin, DO, PGY-2 Aventura Hospital & Medical Center

While the COVID-19 vaccine has surely saved thousands, if not millions of lives, there appears to be rare sequela of vaccinations that are as unique as the Sars-CoV-2 viral infection itself. One of the more worrisome adverse effects is the emergence of COVID vaccineinduced thrombotic thrombocytopenia (VITT). While superficially appearing to be closely related to COVID vaccineinduced immune thrombocytopenic purpura (ITP), the distinction is critical when determining a treatment strategy.

By Charles Latimore, MD, PGY-2 Aventura Hospital & Medical Center

infection, there has been conflicting and concerning data regarding the dangers of the spike protein itself. Emerging evidence suggests that the spike protein generated by our intramuscular and endothelial cells following administration of the COVID-19 vaccines may up-regulate a pro-thrombotic pathway via platelet factor 4 (PF4); the same molecule known to cause Heparin Induced Thrombocytopenia (HIT). Additionally,

By Annalee Baker, MD, FACEP

Residency Program Director & Associate Professor of EM, NYU Grossman School of Medicine

it is theorized that the lab-engineered lipid nanoparticle covering of the mRNA may lead to unpredictable absorption rates in the central nervous system, resulting in various neurological side effects. Since initiating COVID-19 vaccination of healthcare workers and the general population, rare occurrences of anaphylaxis have occurred. As of January 2021, only 21 cases of

Figure 1. Diagnosis of Vaccine Induced Thrombotic Thrombocytopenia

Currently, there are three COVID-19 vaccinations approved by the Food and Drug Administration (FDA) for use in the United States: PfizerBioNtech, Moderna and Johnson & Johnson (J&J), with J&J being the only single-dose formulation. While the J&J vaccine uses a traditional adenovirus vector, the other two vaccines are the first vaccines to use long-studied messenger RNA (mRNA) technology to deliver the immunogenic material to the host. The mRNA is translated to an endogenous version to the coronavirus spike protein, which engenders an immune response and is then quickly degraded, prior to being incorporated into the nucleus. This mRNA technology has actually been in existence for many years, employed in the treatment of certain cancers and genetic diseases. Although production of endogenous spike protein cannot cause an active 34

Image obtained from the Expert Hematology Panel on COVID-19 VITT with express written consent from the authors, Parvord et al. EMpulse Fall 2021

anaphylaxis have been recorded in the 1.8 million doses of PfizerBioNTech vaccine given so far (11 cases per million). What has not been reported by the CDC and the vaccine manufacturers yet, are the unquantified incidence of other lifethreatening reactions. Unfortunately, there does seem to be an emergence of rare side effects from these vaccines, centered on the coagulation cascade and resulting in both thrombotic and bleeding events. Although the pathogenesis of the syndrome VITT is not yet fully defined, certain findings have been consistently seen. In almost every patient with COVID-19 associated VITT, high levels of antibodies to PF4–polyanion complexes were identified. In patients with HIT, heparin binds to PF-4, forming a complex that binds and activates platelets and monocytes, resulting in profound thrombosis and inflammation. In VITT, it is the spike protein that binds to PF-4, resulting in the same platelet activation, thrombosis and destruction. There is also not yet enough data on COVIDVITT to determine mortality and morbidity, but the similarities to the HIT pathway are extremely concerning when one considers the 20% mortality seen in HIT. Differentiating between COVID vaccine-induced ITP from VITT can be challenging but the distinction becomes imperative when considering initial management. The key distinguishing feature is the presence or predilection for thrombosis. Clinical signs of thrombosis, however, may be subtle. Fortunately for physicians, there exists an extremely sensitive tool perfectly tasked for this: the D-dimer. In the absence of overt or indirect signs of thrombosis, VITT can be screened by D-dimer levels, which are typically available on a timely basis in any emergency department. D-dimers of >2000 ng/ml with strong clinical suspicion, or dimer of >4000 ng/ml makes a strong case for VITT. Although minor elevations in D-dimer may be seen in ITP, values are typically orders of magnitude lower and thrombosis is rarely seen. If D-dimer is grossly elevated in patients with thrombocytopenia, even those seen up to 42 days post-COVID-19

Table 1. Management of COVID-19 Vaccine-Related ITP vs. VITT COVID-19 Vaccine-Related ITP Platelet count >30,000/μL and no bleeding: • Observation Platelet count <30,000/μL and no bleeding: • IV corticosteroids • Add IVIG if steroids contraindicated or refractory to steroid treatment Platelet count <30,000/μL and bleeding or high risk of bleeding: • Corticosteroids + IVIG • Considering adding anti-D (WinRho SDF, Rhophylac) or thrombopoietin receptor agonists (TP-RAs) Platelet count <50,000/μL with critical bleeding or platelet count <10,000/μL: • IVIG + steroids + platelet transfusion • Splenectomy if refractory to IVIG + steroids + platelet transfusion For patients refractory to all treatments: • Romiplostim (Nplate) and Eltrombopag (Promacta)

COVID-19 VITT Platelet count <100,000/μL with no evidence of thrombosis: • IVIG (≥1 dose) • Consider adding: • IV Corticosteroids • Direct oral anticoagulants (DOACs), • Fondaparinux, Danaparoid, or • Argatraban for thromboprophylaxis *Balance risk of bleeding / thrombosis Platelet count <30,000/μL or evidence of thrombosis: • IVIG (≥1 dose) • IV Corticosteroids • Anti-coagulate with non-heparinbased therapies such as the DOACs, Fondaparinux, Danaparoid, or Argatraban • *Balance risk of bleeding / thrombosis Platelet count <30,000/μL with extensive thrombosis OR refractory to DOACS + IVIG + steroids: • Plasma exchange For patients refractory to all above treatments: • Add Rituximab For patients with cerebral venous sinus thrombosis: • Skip IVIG and go straight to plasma exchange + high dose steroids + neuroradiaology/neurosurgery consult **For all VITT cases: Give fibrinogen concentrate or cryoprecipitate to keep fibrinogen level >1.5 g/L

Table constructed using papers put out by the Expert Haematology Panel (EHP) on COVID-19 VITT and commonly used ITP Emergency Medicine Guidelines.

vaccination, one can reasonably begin treatment for VITT while awaiting more definitive diagnosis. VITT can be subsequently definitively diagnosed with a PF4 ELISA assay, though most emergency clinicians will not have immediate access to this laboratory test. Additionally, one should not rely on the rapid assays that are often used to detect HIT unless they have been EMpulse Fall 2021

specifically validated for VITT, given the potential differences in antigenic target or sensitivity. Fibrinogen levels should also be checked in all patients with suspected VITT. While not recommended for diagnostic criteria, fibrinogen levels may be low in patients with VITT, and therapy should Continue on next page ▶ 35

◀ Continued from previous page

be adjusted accordingly (see Figure 1 and Table 1 on previous page). Determining whether a patient has COVID-19 vaccine-induced ITP vs VITT changes the treatment strategy, which in the case of VITT, must target both bleeding and thrombosis, or the risk thereof. As outlined in the table below, treatment algorithms and lab cutoffs for each condition differ in notable ways. There is not yet enough evidence to fully substantiate these treatment options, but the algorithm represents the best current consensus guidelines from experts in hematology, and may provide a good starting point until additional evidence is obtained.

Conclusion It must be emphasized that despite

these rare hematologic complications, the overall safety and benefits of the COVID-19 vaccine are tremendous. The vaccines have already prevented thousands, if not millions of infections, and continue to save many lives. Emerging side effects, while concerning, are extremely rare. Clinicians advising patients on initial vaccination must consider the dangers and susceptibility of their patients to COVID-19 infection weighed against specific risk factors for side effects from the vaccines. Patients with a history of ITP or other hematologic disorders should consult their hematologist. The incidence of symptomatic thrombocytopenia post vaccination is generally well below the risk of death and morbidity from SARS‐ CoV‐2 infection. In the emergency department, most physicians have become all too familiar with the ravages of infection by

SarsCoV2. It behooves all emergency clinicians to also learn about the serious (albeit rare) complications of COVID-19 vaccination. As with most studies and findings related to the novel virus, much more research is needed to establish more categorical guidelines and recommendations regarding VITT and other postvaccination phenomena. There have not been nearly enough cases to definitively substantiate the interventions above, but the algorithms represent the best guidance currently available from experts in hematology. It is critically important that emergency physicians are aware of the distinct entity of VITT to initiate a proper diagnostic and therapeutic strategy. In the absence of much-needed additional data and randomized controlled trials, these intervention pathways may serve as an adequate starting point in consultation with hematology. ■

REFERENCES 1. Silverman MA. Immune Thrombocytopenia (ITP) in Emergency Medicine. Accessed June 22, 2021, 2021. https://emedicine. medscape.com/article/779545overview#a6 2. Cines DB, Bussel JB. SARSCoV-2 Vaccine-Induced Immune Thrombotic Thrombocytopenia. N Engl J Med. 06 2021;384(23):22542256. doi:10.1056/NEJMe2106315 3. Johnson & Johnson’s Janssen COVID-19 Vaccine Overview and Safety Updated June 1, 2021. Accessed June 15, 2021. https:// www.cdc.gov/coronavirus/2019ncov/vaccines/different-vaccines/ janssen.html 4. Pfizer-BioNTech COVID-19 Vaccine Overview and Safety. Updated May 27, 2021. Accessed June 15, 2021, 2021. https://www.cdc.gov/ coronavirus/2019-ncov/vaccines/ different-vaccines/Pfizer-BioNTech. html 5. Moderna COVID-19 Vaccine Overview and Safety. Accessed June 15, 2021. https://www.cdc.gov/ coronavirus/2019-ncov/vaccines/ different-vaccines/Moderna.html 6. Schoenmaker L, Witzigmann D, Kulkarni JA, et al. mRNA-lipid nanoparticle COVID-19 vaccines: Structure and stability. Int J Pharm. May 2021;601:120586. doi:10.1016/j. ijpharm.2021.120586 7. Heublein M, Gandhi M, Chiu C,

Okamoto E, Karginov T, Williams P. The Curbsiders. #253 COVID-19 Vaccines with Dr. Monica Gandhi https://thecurbsiders.com/episodelist 8. Pavord S, Lester W, Makris M, Scully M, Hunt B. Guidance from the Expert Haematology Panel (EHP) on Covid-19 Vaccine-induced Immune Thrombocytopenia and Thrombosis (VITT). 2021:7. 28 May 2021. Accessed 21 June 2021. https://b-s-h.org.uk/media/19718/ guidance-v20-20210528-002.pdf 9. Kowarz E, Krutzke L, Reis J, Bracharz S, Kochanek S, Marschalek R. “Vaccine-Induced Covid-19 Mimicry” Syndrome: Splice reactions within the SARS-CoV-2 Spike open reading frame result in Spike protein variants that may cause thromboembolic events in patients immunized with vector-based vaccines. Research Square2021. 10. Lu L, Xiong W, Mu J, et al. The potential neurological effect of the COVID-19 vaccines: A review. Acta Neurol Scand. Jul 2021;144(1):3-12. doi:10.1111/ane.13417 11. Greinacher A, Thiele T, Warkentin T, Weisser K, Kyrle P, Eichinger S. A Prothrombotic Thrombocytopenic Disorder Resembling HeparinInduced Thrombocytopenia Following Coronavirus-19 Vaccination. Research Square2021. 12. Greinacher A, Selleng K, Mayerle J, et al. Anti-SARS-CoV-2 Spike Protein EMpulse Fall 2021

and Anti-Platelet Factor 4 Antibody Responses Induced by COVID-19 Disease and ChAdOx1 nCov-19 vaccination. Research Square2021. 13. Arepally GM, Padmanabhan A. Heparin-Induced Thrombocytopenia: A Focus on Thrombosis. Arterioscler Thromb Vasc Biol. 01 2021;41(1):141152. doi:10.1161/ATVBAHA.120.315445 14. Immune Thrombocytopenia. Accessed June 22, 2021, https:// rarediseases.org/rare-diseases/ immune-thrombocytopenia/#:~:text=The%20incidence%20 (how%20 many%20people,is%209.5%20 cases%20per%20100%2C000. 15. Zeller B, Helgestad J, Hellebostad M, et al. Immune thrombocytopenic purpura in childhood in Norway: a prospective, population-based registration. Pediatr Hematol Oncol. 2000 Oct-Nov 2000;17(7):551-8. doi:10.1080/08880010050122816 16. Dominguez M. Immune Thrombocytopenia. Updated 09/25/2019. Accessed June 15, 2021, 2021. https://step1.medbullets.com/ hematology/109040/immunethrombocytopenia-itp 17. Patriarcheas V, Pikoulas A, Kostis M, Charpidou A, Dimakakos E. Heparin-induced Thrombocytopenia: Pathophysiology, Diagnosis and Management. Cureus. Mar 2020;12(3):e7385. doi:10.7759/ cureus.7385

THREE GREAT COMPANIES Managing over 9 million Emergency Medicine visits annually Serving over 13,000 providers Working within more than 40 health systems Delivering optimal results to over 330 private practice clients

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VentraHealth.com EMpulse Fall 2021

POISON CONTROL

THE OTHER DELTA: Delta-8: The New THC Derivative By Chiemela Ubani, Pharm.D.

Clinical Toxicology/EM Fellow, Florida/USVI Poison Information Center - Jacksonville

What is delta-8 tetrahydrocannabinol? Delta-8 tetrahydrocannabinol (THC), or “Weed Light,” is an analog of delta-9 THC with potential antiemetic, anxiolytic, appetite-stimulating and analgesic properties.1 Delta-8 THC is found naturally in extremely low concentrations in hemp, but it can also be chemically derived or genetically altered from hemp. The genus Cannabis has three different species: sativa, indica and ruderalis. Hemp is a subspecies of C. sativa that contains low concentrations of delta-9 THC (the psychoactive component responsible for the “high” effects) and high amounts of cannabidiol. Hemp has been cultivated for years to commercially produce ropes, textiles, shoes, food and even paper. The structural difference between delta-8 and delta-9 THC is the location of the double bond, which is found on the 8th carbon instead of the 9th carbon. Because of this difference, it has milder psychoactive properties2 and potentially has fewer adverse effects. 38

By Molly Stott, Pharm.D.

Clinical Toxicology/EM Fellow, Florida/USVI Poison Information Center - Jacksonville

Is delta-8 THC legal? Under federal law, delta-8 THC is considered legal. The United States Agriculture Improvement Act of 2018 (2018 farm bill) removed hemp from the federal list of controlled substances, allowing the sale and use of hempderived products that contain no more than 0.3% delta-9 THC.3 However, this law does not address delta-8THC necessitating some states to take action and successfully ban this compound’s use and sale. In Florida, there is no existing legislation to ban or deter the sales of delta-8 THC. According to the Florida Department of Agriculture and Consumer Services, hemp or hemp extract products offered for sale in Florida must comply with all labeling requirements and have a certificate of analysis that shows delta-9 THC content less than 0.3%.4 Therefore, since delta-8 THC can be derived from hemp, it is considered legal as long as the hemp used for its production meets these requirements. (Hemp derived products are considered a dietary supplement and are not required to be proven safe prior to marketing). EMpulse Fall 2021

Edited by Dawn Sollee, Pharm.D., DABAT, FAACT Director, Florida/USVI Poison Information Center- Jacksonville, UF Health Jacksonville

Would delta-8 THC cause a positive on a marijuana screen? Delta-8 THC is very structurally similar to delta-9 THC, resulting in crossreactivity on some assays. Therefore, even if a laboratory assay is not capable of determining between delta-8 THC and delta-9 THC, it will still likely produce a positive marijuana screen result.

Why is there such a craze behind delta-8, and what is the mechanism of action? Delta-8 THC is also known as “legal weed,” and users can take it recreationally without worrying about breaking the law with its consumption. Unlike delta-9 THC, medical marijuana cards are not needed for its purchase and delta-8 THC is readily available at smoke shops, gas stations, dispensaries, online storefronts, etc. Delta-8 THC binds to the cannabinoid G-protein coupled receptor CB1 located throughout the body, but especially in the central and peripheral

nervous system.1,5 Users report that it offers the same medical benefits as delta-9 THC with a milder high and a reduction of the negative side effect intensity of anxiety, paranoia, confusion, impaired motor or cognitive function.

What are the risks of using delta-8 THC? The primary risk of using delta-8 THC is the lack of regulation by the FDA. While delta-8 THC is considered legal from a federal standpoint, it is not subject to the safety and efficacy standards set by the FDA.3 This lack of regulation leaves a high margin of error due to variations in manufacturing processes and a lack of analysis for adulterants in the final product. Furthermore, because of the absence of regulation, and delta-8 THC existing in a “legal grey area,” there are no age restrictions on the sale of delta-8 THC, therefore allowing children to purchase these products.7 According to a report published by the United States Cannabis Counsel (USCC) in June of 2021, the sale of unregulated delta-8 products “presents a public health risk of potentially wider impact than the vape crisis.”8 The USCC conducted a study where 16 delta-8 THC products purchased from California, Florida, Nevada,

Texas, Michigan, Massachusetts, North Carolina and Indiana were tested for ingredient accuracy.8 The results of these tests found varying amounts delta-8 THC and delta-9 THC, as well as heavy metals and pesticides. In addition to these adulterants, dichloromethane was found in many of the samples. Dichloromethane is used in the extraction process of delta-8 THC but can emit highly toxic fumes when exposed to heat.3,8 Regardless of the lack of regulation and high probability of adulterants, delta-8 THC can produce many unwanted effects. Of note, cannabinoid hyperemesis syndrome (CHS), which is characterized by cyclic vomiting, is one of the most severe effects. Delta-8 THC can also produce psychotropic effects similar to the ones produced by delta-9 THC, albeit, delta-8 THC’s effects are said to be milder.4,9 Exposure to delta-8 may impair cognitive function and other neurologic functions such as driving a car, operating heavy machinery or completing other tasks that require a high level of focus. Additionally, delta-8 products are available to all age groups, including children. Similar to delta-9 THC, delta-8 THC can cause more pronounced and persistent symptoms in pediatrics.10

How do we manage the adverse effects? Since delta-8 THC is a relatively new hemp derivative, little is known on exact treatment strategies for adverse effects. As with delta-9 THC, the mainstay of treatment for adverse effects associated with delta-8 is largely symptomatic and supportive care.10 There has been one well defined case of delta-8 THC induced CHS in which the patient was treated with capsaicin cream. Additional possible treatments for CHS include warm showers, haloperidol, benzodiazepines, and IV fluids for volume loss.4 Antiemetics are usually not effective in CHS. The only definitive treatment for CHS is cessation of cannabis use. Any patient, especially a pediatric patient, with persistent symptoms of CHS or neurologic/cognitive dysfunction should be admitted for further observation and supportive care.10 Health care professionals at the Florida Poison Information Center Network are available at 1-800-222-1222 to answer questions concerning, or assist in the management of, this or any other toxic exposure. ■ Photo Credit: Dr. Chiemela Ubani

REFERENCES: 1. National Center for Biotechnology Information (2021). PubChem Compound Summary for CID 638026, delta8-Tetrahydrocannabinol. Retrieved August 16, 2021 from https://pubchem.ncbi.nlm. nih.gov/compound/delta8Tetrahydrocannabinol 2. Razdan RK. Structure-activity relationships in cannabinoids. Pharmacol Rev. 1986;38(2):75-149. 3. Abernethy, A. (2019, July 25). Hemp production and the 2018 farm bill. U.S. Food and Drug Administration. https://www.fda.gov/newsevents/congressional-testimony/ hemp-production-and-2018-farmbill-07252019. 4. Rosenthal J, Howell M, Earl V, Malik M. Cannabinoid Hyperemesis

Syndrome Secondary to Delta-8 THC Use [published online ahead of print, 2021 Jul 31]. Am J Med. 2021;S00029343(21)00486-1. 5. Delta 8. Florida Department of Agriculture and Consumer Services. Title XXXV. Statute 581.217; State Hemp Program. https://www.fdacs. gov/content/download/94040/file/ Delta8.pdf. 6. Zou S, Kumar U. Cannabinoid Receptors and the Endocannabinoid System: Signaling and Function in the Central Nervous System. Int J Mol Sci. 2018;19(3):833. Published 2018 Mar 13. 7. The increasing popularity of Delta 8 raises concerns. Addiction Center. (2021, July 29). https://www. addictioncenter.com/news/2021/07/ increasing-popularity-delta-8/.

EMpulse Fall 2021

8. US Cannabis Counsel. The Unregulated Distribution And Sale Of Consumer Products Marketed As Delta-8 THC; The Health Risks of Delta-8 THC and What’s Needed Now. Executive summary. 2-24. Retrieved August 19, 2021. USCC Delta-8 Kit.pdf (cdn-website.com) 9. Toxicology rounds: Your ed patients are likely using... : Emergency medicine news. LWW. (n.d.). https:// journals.lww.com/em-news/ Fulltext/2021/08000/Toxicology_ Rounds__Your_ED_Patients_Are_ Likely.17.aspx 10. Plants-Marijuana. In: IBM Micromedex POISINDEX (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: www. micromedexsolutions.com/ (cited: August 19, 2021).

FEATURE

Florida PEDReady and EMSC Update By Phyllis Hendry, MD, FAAP, FACEP

Florida EMSC Medical Director

Florida EMSC Advisory Committee Presentations and materials are now available on the PEDReady website! Visit emlrc.org/flpedready for the latest materials. The goal of Florida PEDReady is to enhance pediatric emergency care and “readiness” in Florida’s emergency departments and EMS agencies. Email us at pedready@jax.ufl.edu to be added to the FL PEDReady listserve.

Pediatric Disaster Preparedness: JumpSTART The JumpSTART (Simple Triage and Rapid Treatment) pediatric MCI triage tool was created in 1995 by Dr. Lou Romig, a Florida pediatric emergency and disaster physician. A modification of JumpSTART was published in 2001. JumpSTART is the most used pediatric mass casualty triage algorithm in the U.S. Florida EMSC is excited to announce that the FL PEDReady website will become the hosting site for JumpSTART in collaboration with Dr. Romig! New JumpSTART badge buddies have been designed in collaboration with Dr. Romig, Chief Julie Downey (DOH EMS Disaster Response Committee), Dr. Phyllis Hendry and members of the

Meryam Jan, MD Research Fellow

FL EMSC Advisory Committee. The PEDReady website disaster section will be updated soon with new pediatric disaster resources. Email us at PEDReady@jax.ufl.edu to request badge buddies. Consider joining the National Pediatric Disaster Coalition (npdcoalition.org) listserv by emailing nationalpedicoalition@gmail.com. Child Life Disaster Relief has created a new resource on child development and disasters for parents, guardians, organizations, and communities. Illinois EMSC also has online Pediatric Disaster Courses.

Child Life Disaster Relief Resources

National EMSC Resources to Make Your ED or EMS Agency PEDReady: EIIC Prehospital Pediatric Readiness Toolkit and Checklist

EIIC Pediatric Readiness for EDs: Interactive Checklist

New JumpSTART badge buddies for pediatric MCI triage 40

EIIC Pediatric Readiness for EDs: Regular Checklist

EMpulse Fall 2021

Pediatric EMS Asthma Research Study The “Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial,” or “EASI AS ODT” study, is a pragmatic trial using a stepped wedge design, where each site introduces the intervention at a different period in time, rather than all at once. Using this approach, the study is looking at pediatric patient outcomes before and after EMS agencies introduce an oral steroid option for the treatment of asthma attacks. The study is led by Principal Investigator Jennifer Fishe, MD, a pediatric emergency medicine physician and pediatric EMS medical director from the University of Florida College of Medicine-Jacksonville, and is funded by a five-year National Heart, Lung, and Blood Institute K23 award. Dr. Fishe is a member of the FL EMSC Advisory Committee. The study comprises of seven sites, including five EMS agencies in Florida, Texas Children’s Hospital, and the Houston Fire Department from PECARN’s CHaMP node.

PECARN Study: Exploring Oral Steroids for Asthma in Ambulance Setting

Farewell to Melia Jenkins Melia Jenkins is retiring soon after working as a Florida DOH Social Services Manager and EMSC Project Director since 1997! Thank you Melia for your dedicated service to the children of Florida — you made a difference! ■

CLINCON & Bill Shearer ALS/BLS Competition 2021 Postponed Indefinitely Based on recent and unforeseeable information on case counts, hospitalizations and breakthrough cases, the EMLRC has been forced to indefinitely postpone CLINCON and its prestigious Bill Shearer ALS/BLS Competition. This was another difficult decision to make in these challenging times – we know how badly you all want to come back together and see the next winning team raise Dr. Eugene Nagel’s trophy above their heads with pride! But despite our best efforts, we ultimately cannot put our EMS workforce at risk of COVID-19 infection or exposure, not only for their own health and safety, but for the general public’s health and safety, too. Registration fees have been refunded, and hotel reservations should be cancelled directly and immediately to avoid penalties. The Florida Department of Health EMS Meetings are moving forward as planned on Sept. 28-30, 2021 at the Caribe Royale; please check their website for more information. We are grateful for everyone’s support and commitment to the ALS/BLS Competition, which has been a tradition and rite of passage for paramedics for over 40 years. Stay tuned for information on next year’s event at emlrc.org/clincon.

RIP Linda Swisher, Widow of Bill Shearer Linda Wertz Swisher, 78, passed away on August 19, 2021. She was preceded in death by her husband, Bill Shearer, and is survived by her son, Sam Swisher, Jr.; her daughter, Amanda Veigh; and three grandchildren. Even after Bill’s passing, Linda remained a part of the Bill Shearer International ALS/ BLS Competition, held annually during CLINCON. She served as a national advanced trauma life support educator for the American College of Surgeons, where she taught ATLS to emergency room physicians and trauma surgeons throughout the U.S., and was appointed by Florida Governor Jeb Bush as a member of his Emergency Medical Services Advisory Council. In 1999, she was the Florida Association of EMS Educators Program Director of the Year. Learn more about Linda’s life and service to the emergency medicine community at www.legacy.com/us/obituaries/ heraldtribune/name/linda-swisher-obituary?pid=199945898.

EMpulse Fall 2021

Linda Swisher addressed the 2019 ALS/BLS competitors during the Awards Ceremony at CLINCON 2019, speaking about what this competition meant to her late husband. The EMLRC was so grateful to host her one last time.

ULTRASOUND ZOOM

POCUS For Shoulder Dislocations: Another Weapon in Your Clinical Arsenal By Naomi P. Newton, MD, PGY-2

University of Miami / Jackson Health System

Introduction I have always been an “in the trenches” kind of person. While the acuity, adrenaline rush, and hands-on aspects of emergency medicine certainly hold their appeal, I love this field because it so beautifully straddles both the most dramatic and the most humbling aspects of the medical profession. Emergency medicine is messy, both literally and figuratively. We see everything, and we see it before anyone else in the hospital. We often meet patients when they are in their most vulnerable states, and we wade daily through a sea of trauma, injustice, poverty, substance use, homelessness, mental health disorders, and other complex medical and societal issues. We are constantly investigating, teaching, advocating, stabilizing and treating—all while seeking the best and most efficient disposition for our patients. However, life “on the front lines” of the healthcare system can also be physically, mentally, emotionally and even spiritually grueling, especially given the unique time constraints under which we work. Successful physicians navigate these challenges by charging toward the battlefield, armed with every weapon at their disposal. Point-of-care ultrasound, or POCUS, is one of the most versatile and advantageous tools in the emergency medicine armamentarium.

Shoulder Dislocations: The Clinical Problem I have heard some seasoned attending physicians remark that they have grown increasingly weary of the procedural aspects of emergency medicine over the course of their 42

Edited by Leila Posaw, MD, MPH

Emergency Ultrasound Faculty, Jackson Memorial Hospital

careers. They view procedures, such as shoulder reductions, as time and resource-heavy endeavors that add to the existing burden of life “in the trenches.” From a purely clinical perspective, shoulder dislocations are quite straightforward; they usually present with an obvious shoulder deformity, and they are treated with joint reduction techniques. However, in practice, the diagnosis and treatment of shoulder dislocations can be tedious and can send the emergency room workflow to a screeching halt. When a patient’s presentation is suspicious for a shoulder dislocation, one generally begins by obtaining x-rays to confirm the diagnosis and rule out concomitant fractures. After each reduction attempt, one must then obtain more films to determine whether the procedure was successful. In my bustling and often chaotic urban, public hospital, where my colleagues and I work with limited staff and resources, we often encounter delays in obtaining timely imaging—even for portable films. Delays in obtaining the initial diagnostic x-rays can worsen the patients’ muscle spasms, making any attempted reductions more difficult. Additionally, obtaining multiple x-rays for shoulder dislocations–especially if several reduction attempts are required—further consumes time, staff and medical supplies, and increases the costs associated with the emergency room visit. It also exposes patients to more radiation, which can be particularly problematic if they are pregnant, if they are children, or if they have other contraindications to irradiation. Furthermore, many shoulder reductions are performed EMpulse Fall 2021

under procedural sedation, which requires additional staff and supplies at the bedside before, during and after the procedure.

The POCUS Advantage POCUS is a wonderful weapon for more efficiently managing shoulder dislocations, even during the most tumultuous of shifts. POCUS spares the patient from radiation and provides real-time information about the success of a procedure at the bedside.

Shoulder POCUS or Traditional Radiograph? How does shoulder POCUS compare with traditional radiographs, in terms of diagnostic accuracy? Can shoulder POCUS completely replace x-rays in the diagnosis and management of shoulder dislocations, or will it miss clinically relevant, concomitant fractures, which are known to occur in about a quarter of all shoulder dislocations? Only a few small, prospective, observational studies have compared the diagnostic accuracy of POCUS and x-rays in the setting of shoulder dislocations & reductions. Although the sensitivities and specificities for diagnosing dislocations with POCUS ranged from the high 80s to 100% in nearly all the studies, the data cannot be generalized, due to both the heterogeneity of the study designs, and the level of ultrasound training among clinicians participating in the studies (ranging from POCUS-trained physicians to college students, who had completed a shoulder POCUS crash course). However, other studies

have shown that the three main risk factors for concomitant fractures include older age, first time dislocating the joint, and a traumatic mechanism. If all three risk factors are absent, the negative predictive value for associated fractures is nearly 97%. Taking all of this into account, we cannot yet eliminate shoulder x-rays altogether, although some physicians might consider skipping a pre-reduction radiograph in favor of shoulder POCUS in a patient without major risk factors for concomitant fractures. However, POCUS is an excellent alternative to radiographs in determining the success of a reduction at the bedside, especially if multiple attempts are required, as this will save time, resources, and additional radiation. In other words, shoulder POCUS is more of a highpowered firearm than a military tank; it does not completely take us out of the clinical trenches, but it can help us fight our battles more efficiently.

Anatomy Shoulder POCUS is quick and easy— even for a novice sonographer! It simply requires a functional ultrasound machine and a sound understanding of the anatomy of the glenohumeral joint. Frank Netter’s illustration (Figure 1) depicts the muscles and bony structures surrounding and overlying the glenohumeral joint in the posterior view. You will notice that the deltoid normally covers the supraspinatus, as well as parts of the other rotator cuff muscles that all attach laterally to the humeral head. The scapular spine is the bony demarcation of the supraspinatus and infraspinatus (located superiorly and inferiorly, with respect to the scapular spine), and it extends to the

Shoulder POCUS To-Go:

acromion posteriorly and the coracoid process anteriorly. A sound knowledge of these anatomic landmarks allows for seamless scanning.

POCUS of the Normal Shoulder There are both anterior and posterior approaches to examining the shoulder with POCUS, but I have found the posterior approach to be the easiest to perform. Additionally, in several studies, the posterior approach has had slightly better sensitivities and specificities, when compared to the anterior approach. To perform shoulder POCUS via the posterior technique, it is best to use a curvilinear probe, although a linear probe may suffice, if the patient’s body habitus allows. Hold the probe in the transverse position, just over the scapular spine, with your probe marker directed to the patient’s right side (Figure 2). Move laterally until you see both the glenoid and the humeral head. Remember that all bony structures will appear hyperechoic, or white. Muscular structures will be more echogenic (i.e., somewhere in between grey and black), and any fluid will appear anechoic, or completely black. In the posterior approach, the patient’s back (posterior) will be in the near field and the patient’s front (anterior) will be in the far field. As demonstrated in Figure 3, the scapular spine will be more medial, and the attachments of the rotator cuff muscles on the humeral head

Fig 1: Posterior Shoulder muscles, as demonstrated in Netters’ Anatomy–cited accordingly, with additional labels, as follows: A) Deltoid. B) Infraspinatus. C) Scapular Spine. The dashed ellipse indicates the posterior view of the glenohumeral joint.

Fig 2: In this schematic for ultrasound probe orientation in the posterior shoulder POCUS view, the black box represents the curvilinear probe in the transverse orientation. The blue circle represents the marker/indicator on the ultrasound probe. The arrows are reminders to hold the probe in the transverse orientation, with the probe marker to the right, regardless of the shoulder you are examining; this is ultrasound convention.

Continue on next page ▶

Shoulder POCUS - Posterior View: 1) Hold the curvilinear probe in the transverse orientation.

Stick in your wallet. Reference on-the-go.

2) Place the probe over the posterior shoulder, just over the scapular spine. (Probe marker is ALWAYS towards the patient’s RIGHT, no matter which shoulder you’re scanning.)

Courtesy of authors Leila Posaw, MD, MPH and Naomi Newton, MD

4) Intraarticular block: Inject 15-20 cc lidocaine/bupivacaine when the hyperechoic needle is in the joint space.

3) Move laterally until the glenoid fossa, humeral head, and scapular spine are visualized in 1 image.

EMpulse Fall 2021

◀ Continued from page 43 will be more lateral. Fanning the probe caudally, you will first see the deltoid muscle, followed by the infraspinatus as it attaches to the humeral head. You will then see the humeral head and the glenoid fossa. You may also see the hyperechoic scapular spine in the medial aspect of your image.

POCUS of Anterior & Posterior Shoulder Dislocations How does one identify shoulder dislocations, using the posterior POCUS approach? In an anterior dislocation (Figure 4), the humerus will be visualized closer to the far field, as it will be displaced more anteriorly, or further from the ultrasound probe. Therefore, the humeral head will appear to be below the scapular spine. A posterior dislocation (Figure 5) will show opposite image—the humeral head will be closer to the near field, as it will be displaced more posteriorly, or closer to the ultrasound probe. Therefore, the humeral head will appear to be above the scapular spine. Some studies have attempted to quantify the exact degree of anterior and posterior displacement on POCUS views, but these data are limited and not yet generalizable; at this time, it is probably best to compare your pre-reduction POCUS image with your post-reduction POCUS image to determine if your reduction attempt was successful. Note that the ability to visualize external rotation of the shoulder joint on the ultrasound also indicates that your reduction was successful. I recommend watching a video by Dennis D’Urso, MD, a

Normal Shoulder

former chief resident of my residency program, which demonstrates external glenohumeral joint rotation after a shoulder reduction (Video 1).

POCUS for Pain ControlIntraarticular Block Pain control also plays a major role in the success of a reduction procedure. While procedural sedation with intravenous medications is commonly used for shoulder reductions, several studies have explored the role of ultrasound-guided intraarticular blocks as alternatives to the time-consuming, costly, and often more complicationridden procedural sedation techniques. The data are sparse: limited to a few, small randomized controlled trials that were heterogeneous in design, thus limiting their generalizability to emergency department care. Additionally, systematic reviews of these data have not shown any difference in the success rates of shoulder reductions with either technique. However, POCUSguided blocks have been shown to significantly reduce the time, cost and complications associated with the procedure. Therefore, one should consider a POCUS-guided shoulder block in the right patient and setting. Using the posterior POCUS approach to the intraarticular glenohumeral block (Fig 6a & 6b), first sterilize the skin over the shoulder. Next, find the glenoid and humeral head, using the previously discussed posterior POCUS approach. Next, simply inject 15-20 cc of 1% lidocaine into the joint space, visualizing your hyperechoic needle tip and the “bubbles” of hypoechoic anesthetic fluid in real time on the machine. (You can also use 2%

Anterior Dislocation (with attempted Intraarticular Block: Needle indicated by arrow)

Fig. 3: In this view of a normal shoulder, one can identify the following structures in their proper anatomic locations: A) Deltoid, B) Infraspinatus attaching to the Humeral Head, C) Humeral Head, D) Glenoid Fossa, & E) Scapular Spine.

Fig. 4: An anterior dislocation is visualized when the humeral head appears to be below the scapular spine & glenoid fossa (i.e., more anterior, or closer to the far field), as indicated by the dashed arrow. Note the abnormal space in the joint, indicating the lack of articulation between the humeral head and the glenoid fossa. A) Deltoid. B) Infraspinatus. C) Humeral Head. D) Glenoid Fossa.

Video 1: UltrasoundGuided Intraarticular Block for Anterior Shoulder Dislocation Courtsey of Dennis D’Urso, MD

lidocaine or bupivacaine, depending on what is easily available in your ED.) After waiting about 10-20 minutes, you can attempt to reduce the joint without procedural sedation. Dr. D’Urso’s video

Posterior Dislocation

*Use anatomic landmarks to distinguish between anterior vs. posterior and medial vs. lateral orientations on the machine. 44

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also demonstrates an ultrasoundguided intraarticular block in real time (Video 1).

Take-Home Points

Fig. 5: A posterior dislocation is visualized when the humeral head appears to be above the scapular spine/glenoid fossa (i.e., more posterior, or closer to the near field), as indicated by the dashed arrow. Note the abnormal space in the joint, indicating the lack of articulation between the humeral head and the glenoid fossa. A) Deltoid. B) Infraspinatus. C) Humeral Head. D) Glenoid Fossa. E) Scapular Spine.

The next time that you find yourself managing a patient with shoulder pain and an obvious upper extremity deformity while grappling with a particularly hectic shift, remember that shoulder POCUS is in your emergency medicine arsenal. Current evidence suggests that in most cases, you should still start by obtaining a plain radiograph to assess for concomitant fractures (unless your patient lacks the aforementioned risk factors). If fractures are not demonstrated on the initial x-ray, take up your gauntlet—I mean, probe—and capture a POCUS image of the patient’s dislocated shoulder. After employing your favorite

reduction technique, reach for your probe again. Does the shoulder look reduced? If not, you can try again, as often as is necessary. You can track your progress in real time with the ultrasound, rather than pausing to hammer-page your radiology tech for additional scans, or to redose analgesics while waiting for the portable film. Additionally, in the right patient, a POCUS-guided intraarticular lidocaine block may provide pain control without the need for procedural sedation during reduction attempts. Using shoulder POCUS, your patient will likely be ready for disposition much sooner, and you will have saved time, energy and resources—all of which you can dedicate to the other battles that you valiantly continue to fight each day on “the front lines.” ■

REFERENCES: Fig. 6a: This is the setup for a POCUSguided intraarticular block in the posterior view. The curvilinear probe is placed on the patient’s posterior shoulder, with the probe marker pointing toward the patient’s right side, as indicated by the arrow.

Must-read/must-view sources in bold 1. Bafuma, P. (2016, Mar 22). Clinical Question: How effective is intraarticular lidocaine for shoulder reduction? Canadiem. www. canadiem.org/boring-questioneffective-intra-articular-lidocaineshoulder-reduction 2. D’Urso, D. Ultrasound-Guided Intraarticular Block for Anterior Shoulder Dislocation. [Video]. YouTube. Accessed August 2021. www.youtube.com/ watch?v=gDfVnWZY03o 3. Hansen, JT. Netter’s Anatomy Flash Cards: Companion Atlas of Human Anatomy 6th Edition. 4th Edition. Elsevier/Saunders, 2014.

Fig. 6b: In this patient with an anterior shoulder dislocation, a lidocaine block was used prior to reduction. Visualizing the hyperechoic needle tip (indicated by the arrow) in the joint space and watching for “spreading” or “bubbling” of the anechoic lidocaine in this space ensures that the examiner anesthetizes the right area. A) Deltoid. B) Infraspinatus. C) Humeral Head. D) Glenoid Fossa. E) Scapular Spine.

Image Credits: • Dennis D’Urso, MD, courtesy of the UM/Jackson Health System EM residency ultrasound database. • All other images are either freely available on the internet, for public viewing, or cited accordingly in the references section.

4. Gottlieb, M, et al. Point-of-care ultrasound for the diagnosis of shoulder dislocation: A systematic review and meta-analysis. American Journal of Emergency Medicine 37: 757-761. 2019. www.elsevier.com/ locate/ajem 5. Gottlieb, M, and Russel, F. Diagnostic Accuracy of Ultrasound for Identifying Shoulder Dislocations and Reductions: A Systematic Review of the Literature. West JEM. 2017. DOI: 10.5811/ westjem.2017.5.34432 6. Lahham, S, et al. Pilot Study to Determine Accuracy of Posterior Approach Ultrasound for Shoulder Dislocation by Novice Sonographers. West JEM. 2016. DOI: 10.5811/ westjem.2016.2.29290. 7. Nagdev, A. Ultrasound-Guided Glenohumeral Joint Evaluation and Aspiration. (2016, June 15). ACEP Now. www.acepnow.com/article/ EMpulse Fall 2021

ultrasound-guided-glenohumeraljoint-evaluation-aspiration/2 8. Richardson, L. (2018, Aug 4). POCUS Triage Shoulder Dislocation. Emergency Medicine St. John. www.sjrhem.ca/rcp-pocus-triageshoulder-dislocation 9. Rich, C. (2016, Nov 30). POCUS: Shoulder Dislocation. Brown Emergency Medicine: Orthopedics, Procedures, Trauma, Ultrasound. www.brownemblog.com/blog1/2016/11/30/pocus-shoulderdislocation 10. Riguzzi, C, Mantuani, D, and Nagdev, A. (2014, Feb 12). How to Use Point of Care Ultrasound to Identify Shoulder Dislocation. ACEP Now. www. acepnow.com/article/use-pointcare-ultrasound-identify-shoulderdislocation/?singlepage=1 11. Seyedhosseini, J, et al. Accuracy of point-of-care ultrasound using low frequency curvilinear transducer in the diagnosis of shoulder dislocation and confirmation of appropriate reduction. Turkish Journal of Emergency Medicine 17:132-135. 2017. www.elsevier.com/locate/TJEM 12. Sherman, SC, et al. (2020). Shoulder dislocation and reduction. UpToDate. Retrieved 15 March, 2021, from www. uptodate.com/contents/shoulderdislocation-and-reduction 13. Tin, J. (2018, Jan 8). US Probe: Ultrasound for Shoulder Dislocation and Reduction. emDOCS. www. emdocs.net/us-probe-ultrasoundfor-shoulder-dislocation-andreduction/ 45

FEATURE

Critical Care Medicine Specialization and Certification within Emergency Medicine: Past, Present and Future Casey Carr, MD Assistant Professor; Director, Student and Resident Critical Care Education; Co-Director, Cardiac Arrest Programs; Division of Critical Care, Department of Emergency Medicine, UF

THE PAST Historically, there has been a consistent link between emergency medicine (EM) and critical care medicine (CCM). The specialties have significant clinical overlap – shock, respiratory failure and airway management are common threads between the two fields, and there are obviously many more. Certification of emergency medicine physicians to practice critical care medicine similarly has a long, and somewhat controversial, history.

certification of emergency medicine, the American Board of Emergency Medicine (ABEM) sought a pathway for emergency physicians who completed critical care postgraduate training to become board-certified. This lack of access to certification was almost certainly based on inter-specialty agreements during ABEM efforts to become a ABMS recognized specialty board—all EM-based certificates that were considered “hospital based” were removed after reported considerable political backlash.

For more than two decades after American Board of Medical Specialties (ABMS) approved of the board

The result of this lack of certification pathway led CCM trained EM physicians to seek the European

Diploma in Intensive Care Examination, which was used as a surrogate for certification after completing fellowship training.

THE PRESENT In 2011, decades of advocacy led to fruition. The American Board of Internal Medicine (ABIM) and ABEM agreed to co-sponsor board certification in CCM. In 2012, the American Board of Surgery (ABS) followed suit, and the American Board of Anesthesia (ABA) followed soon after in 2013. Neurocritical Care certification via the United Council for Neurologic Subspecialties (UCNS) had long allowed emergency physicians to complete

Daunting Diagnosis: A By Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief ◀ CONTINUED FROM PAGE 8

The CT scan shows extensive inflammatory changes of the abdominal wall including an air-fluid level and subcutaneous gas concerning for superimposed infection with a gasforming bacteria. The inflammatory changes are associated with a large, incarcerated ventral hernia and bowel perforation. The patient was hemodynamically unstable, requiring sepsis protocol and emergent general surgery consultation. The patient underwent an initial

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exploratory laparotomy for a necrotizing soft tissue infection, and multiple subsequent surgeries including resection of the transverse colon, multiple debridements of the anterior abdominal wall, open cholecystectomy, multiple wound wash-outs, and wound vac placement. The patient additionally underwent hyperbaric treatment. Hematology was consulted for further treatment of her ovarian cancer. The patient’s prognosis is poor.

board certification by that point. Currently, emergency physicians have multiple pathways into critical care medicine, as illustrated by the many governing boards allowing co-sponsorship. Each pathway has its own benefits, career implications and training nuances. All fellowships in CCM are two years in length, and each pathway has its own application process and prerequisites. There is also considerable variation between programs regarding curriculum, educational requirements and application timing. Despite the approval of a CCM certification pathway for EM physicians, there is still significant controversy. There are significant training requirements asked of EM residents that are not required of graduates of other fields. ABIM applicants are required to have 3 months of non-ICU internal medicine rotations; if this is not completed prior to matriculation, the applicant must complete these rotations during

fellowship. The first year of ABS training is considered a “preliminary surgical year” where an EM applicant is expected to gain experience in non-ICU surgical patients. Graduates of surgical or anesthesia programs complete only one year of a critical care fellowship; EM graduates are required to complete two years. Unfortunately, the reasons for these differences in prerequisites, curriculum and training length are likely due to compromises made during the integration of EM into the world of CCM.

THE FUTURE As ICU patient boarding within the emergency department continues to worsen nationally, institutions across the country have begun to implement ED ICUs – areas of the emergency department dedicated to caring for the ICU patient that remains in the ED. Frequently, these ED ICUs are staffed by emergency medicine intensivists. The model of ED ICU care varies, with some hospitals allocating a physical space with accompanying

staff, whereas others employ an “open” ED ICU model, where a resource intensivist consults and advises on boarding ICU patients. There certainly seems to be significant merit to this model, especially in the context of the Covid-19 pandemic and soaring rates of ED overcrowding – in fact, recent literature suggests the presence of an ED ICU improves patient oriented outcomes. In 2018, the Society of Critical Care Medicine released a joint statement calling for change in critical care training. Specifically, this white paper calls for the establishment of critical care as a primary specialty, a unified training process, and a unified certification process, rather than the fragmented, multi-specialty pathways that exists currently. This remains a goal of the organization, and discussions regarding curriculum, prerequisites and training duration are on-going. In the future, all candidates, regardless of training, may enter the same training program and complete the same certification exam. ■

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EDUCATION CORNER

Let’s Get Active!

Active Learning in Medical Education By Carmen J. Martinez Martinez, MD, MSMEd, FACEP, FAAEM

As educators, each of us recognizes that maintaining learners’ engagement during a presentation can be challenging. We know how to use a traditional teaching model to deliver new information by using passive didactic lectures, but we also know that it may not always be the best way to get the information across. This is the moment when we reach for active learning tactics as an educator. This article defines active learning, discusses the evidence and learning theory behind it, and briefly summarizes different active learning strategies that medical educators can adopt to improve learner engagement. Malcolm Knowles emphasizes that it is through watching, exploring and studying behavior that adults begin to learn. In other words, when the learner

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

is more than a passive recipient of the information and has active involvement, the information is integrated at a higher level of cognition. Traditional teaching models consist of a long lecture format. The educator delivers the information, and the student passively listens with minimal critical thinking skills being used and little engagement of the learners. Adult learners have an attention span of 15 to 20 minutes; therefore, they may be considered ineffective if lectures are longer than this. In contrast, active learning is recognized as a learnercentered approach in which information is presented in a way that engages, motivates, promotes discussion and uses critical thinking skills. Learners are required to partake in purposeful learning activities and ponder on the things they are involved in.

Active learning is based on the theory of human constructivism, which states that knowledge is built rather than passively acquired. Active learning has four main components: triggering prior knowledge, including student participation, encouraging student metacognition and delivering feedback about student’s learning. Scaffolding is the process in which teachers build upon prior learning and, through progressive learning, add layers of complexity to the topics which promote independent learning. Building this takes critical thinking and reasoning skills and allows students to further assimilate new knowledge, adding to existing knowledge and skills. Although each individual teaching strategy has a specific learning theory at its root for existence, the overarching components are exemplified.

Simple — Less Time

Figure 1: Active Learning Strategies

Minute Paper

Large Group Discussion

Pause for Reflection

Informal Groups

SelfAssessment

Group Evaluations

Think-PairShare

Peer Review

Triad Groups

Adapted from Chris O’Neal & Tershia Pinder-Grover, Center for Research on Learning and Teaching, University of Michigan 48

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In practice, incorporating active learning into didactic teaching should be considered when possible. It must be well thought and aligned with the desired learning outcome. For example, if you wish to discuss communication skills, creating a role-play scenario may be helpful. Next, you should gauge your learner’s level of knowledge on the topic and the amount of time allotted for your session. Some basic concepts may need to be taught or reviewed before gaining additional knowledge. If you have an extended period of time, you can teach

Case Studies

Brainstorm

first then incorporate active learning. In contrast, assigning the learners to review key concepts by using reading or asynchronous activities may be more beneficial for a short period of time. The planned learning session can be focused on an active strategy during your allotted time.

a lofty goal that takes time, patience and persistence, but its benefits to the learners outweigh this strife. The challenge for each of us is to try something new the next time you teach. ■

Implementing active learning strategies can be challenging. Learners might be reluctant to participate in active learning activities. But explaining to them the purpose and value of the strategy has shown to decrease resistance. Last, do not be afraid of trial and error inevitably, there will be a learning activity that goes well and those that do not. Keep trying as you perfect your active teaching skills.

REFERENCES:

Active learning in medical education can be achieved through many different techniques and teaching practices. Employing active learning is beneficial for both the learner and the educator. It immerses the learners in the process through writing, reading and discussions. It results in improving knowledge retention, creates a deeper understanding, and encourages selfdirected learning. Therefore, it promotes the development of critical thinking and an analytical approach to problemsolving. However, understanding these concepts is just the beginning. Striving for active learning as an educator is

Role Playing

Hands-On Technology

Jigsaw Discussions

Game Sessions

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1. Prince, M. (2004), Does Active Learning Work? A Review of the Research. Journal of Engineering Education, 93: 223-231. https:// doi.org/10.1002/j.2168-9830.2004. tb00809.x 2. Torralba, K. D., & Doo, L. (2020). Active Learning Strategies to Improve Progression from Knowledge to Action. Rheumatic diseases clinics of North America, 46(1), 1–19. https://doi. org/10.1016/j.rdc.2019.09.001 3. Yang, C. (2021). Active Learning: Techniques to Improve Learner Engagement. https://accelerate. uofuhealth.utah.edu/leadership/ active-learning-techniques-toimprove-learner-engagement. Accessed August 27, 2021. 4. Wolff, M., Wagner, M. J., Poznanski, S., Schiller, J., & Santen, S. (2015). Not another boring lecture: engaging learners with active learning techniques. The Journal of emergency medicine, 48(1), 85–93. https://doi. org/10.1016/j.jemermed.2014.09.010 5. Center for Research on Learning and Teaching. (n.d.). Introduction to Active Learning. https://crlt.umich. edu/active_learning_introduction. Accessed August 27,2021.

Experiential Learning

Simulations

Inquiry Learning

Complex - More Time

Active learning does not necessarily mean altogether abandoning the lecture format, but incorporating a range of different activities. Integrating opportunities for engagement will aid in the retention of information, thereby promoting a higher level of cognition. As a result, engaged learners are more likely to look for other opportunities to learn beyond the classroom setting. Active learning strategies range from simple activities such as pausing for reflection or large group discussion, to simulation and experiential learning. In preparation and planning for including these strategies, the educator must consider the timing of the strategy. Some strategies will take more time than others. Figure 1 shows the continuum of some active learning strategies arranged by complexity and time commitment.

MUSINGS FROM A RETIRED EMERGENCY PHYSICIAN

Managing Compassion Fatigue for Vaccine Hesitation By Wayne Barry, MD, FACEP Former FCEP Board Member

I have recently endured a rough week where several of my home hospice teammates came down with COVID. Astonishingly, most were unvaccinated individuals. The teammates consist of a case manager RN, a chaplain, a patient care secretary in the office, and a home health aid. Several hospice patients who were cared for by this team came down with COVID, and one patient died of COVID-related illness. Failing to achieve herd immunity against COVID-19 has resulted in the appearance of mutant variants, including the most recent and infectious one, the Delta variant, which is infecting large numbers of people across the world and in the U.S., including fully vaccinated individuals in “breakthrough” infections. The victims are generally younger and less vulnerable, due in large part because the U.S. was successful in vaccinating a large proportion of older and more vulnerable members of the population. Fortunately, breakthrough infection victims rarely get very sick and end up in hospitals on the verge of death. Yet hospitals are being overrun, and ER and ICU beds are running dangerously short. Blog posts and news contain numerous reports of exhaustion and compassion fatigue among EM and ICU docs. Make no mistake: the current resurgence of COVID-19 Delta is a disease of the unvaccinated.

hesitant. The first and most astonishing group of vaccine hesitant people are healthcare workers. While 96% of physicians are vaccinated, up to 50% of other healthcare workers, including nurses, CNA’s respiratory techs, pharmacists, medical assistants and hospital administrators, are not. There have already been some landmark court decisions upholding the right for hospitals to require that their employees be vaccinated in order to work in their facility. The courts have held that this principle is a safety issue with respect to the patients for whom they provide care. EMT’s and paramedic personnel are another reservoir of first responders with a relatively high degree of COVID vaccine hesitancy. Atlantic reporter Derek Thompson recently broke down vaccine hesitancy into four categories: #1) Vaccine dissenters are concerned about taking vaccines in general, no matter what disease they are designed to protect. These people may be unaware or refuse to believe that vaccines have saved more millions of lives during the past century than all other modern medical technology advances combined. #2) The deliberation crowd wants to wait and see if the vaccines are really safe and are awaiting final approval by the FDA, which in the case of the Pfizer vaccine, has already happened.

So how do those of us in healthcare manage compassion fatigue for the unvaccinated? First of all, we can pray that more unvaccinated people get vaccinated. Vaccination numbers are increasing in large part due to the terror of rising COVID infections in younger, healthier people.

#3) Distrust is found among individuals who are skeptical of medical advice coming from the government because of past cultural or community experience with less than honest programs, such as the Tuskegee syphilis treatment experiments.

Let’s look again at the groups of people who are generally vaccine

#4) The indifferent cohort is just not seriously concerned about COVID in EMpulse Fall 2021

their area. While all healthcare workers join civilian non-healthcare workers in belonging to these above described groups, EMT’s and paramedics have an additional cultural barrier of being risk-takers, which enables them to run into burning buildings and pick up injured and sick victims in safetycompromised settings. Dr. Edwin Leap and others advise that compassionate and sensitive discussions based on friendship and trust among our colleagues is the best way to sway medical healthcare workers who are COVID-vaccine hesitant. A relatively large proportion of vaccine hesitaters are convinced that their personal freedoms and bodily autonomy are being violated. These people need to be educated and reminded that the health and safety of others trumps enforcing personal freedoms in times of a pandemic when huge numbers of lives and personal health conditions are at stake. Again, these people need to be talked to by their friends, neighbors and colleagues in whom they trust, because the national dialogue has been perverted by misinformation in the public and social media. Yet we who come down on the right side of these issues must resist frustration, which leads to anger and then depression about those whom we know and love who do not yet believe in the efficacy and safety of mitigating tactics. We must continue to do our jobs without being judgmental towards our non-vaccinated patients, and exercise the opportunity to conduct compassionate and informative discussions with those who trust us who may not yet feel comfortable with COVID vaccination or see the merit in mask wearing or social distancing. ■

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Articles inside

Musings from a Retired Emergency Physician: Compassion Fatigue for Vaccine Hesitation

Critical Care Medicine Specialization and Certification within Emergency Medicine: Past, Present and Future

CLINCON Update; RIP, Linda Swisher, Widow of Bill Shearer

North Florida Emergency Medicine

Florida PEDReady and EMSC Update

Immune Thrombocytopenic Purpura vs. Vaccine Induced Thrombotic Thrombocytopenia: Rare but Distinct Conditions Associated with the COVID-19 Vaccines

Ultrasound Zoom: POCUS for Shoulder Disolcations: Another Weapon in Your Clinical Arsenal

Jackson Memorial Hospital

Medical Student Council

FSU at Sarasota Memorial

Orlando Health

FCEP President’s Message

AdventHealth East Orlando

EMS/Trauma

Membership & Professional Development

Symposium by the Sea 2021: Annual Meeting Recap

Kendall Regional Medical Center

Happy 50th Anniversary, FCEP