Volume 25, Issue 1 SPRING 2018
Official Publication of the Florida College of Emergency Physicians A Chapter of the American College of Emergency Physicians
EM Physician Recounts Parkland Shooting Tragedy
FCEP Visits Tallahassee For Emergency Medicine Days 2018 EM Payment Reform Summit 2018 Brings Together The Best in the Industry
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Chapter Updates President’s Message | 4 EMS/Trauma Committee | 6 Medical Economics Committee | 8 ACEP Board Update | 9 Florida College of Emergency Physicians 3717 S. Conway Road Orlando, Florida 32812 t: 407-281-7396 • 800-766-6335 f: 407-281-4407 www.emlrc.org/fcep
Medical Student Committee | 10 Membership & Professional Development Committee | 11 EMRAF Committee | 13
FCEP Executive Committee Joel Stern, MD, FACEP • President
Residency Matters | 18
Joseph Adrian Tyndall, MD, MPH, FACEP • President-Elect Kristin McCabe-Kline, MD, FACEP • Vice President Sanjay Pattani, MD, FACEP • Secretary-Treasurer
Features
Jay L. Falk, MD, MCCM, FACEP • Immediate Past-President Beth Brunner, MBA, CAE • Executive Director
Daunting Diagnosis | 10 Editorial Board Karen Estrine, DO, FACEP, FAAEM • Editor-in-Chief karenestrine@hotmail.com
Poison Control | 14
Samantha Rosenthal • Managing Editor/Design Editor srosenthal@emlrc.org
All advertisements appearing in the Florida EMpulse are printed as received from the advertisers. Florida College of Emergency Physicians does not endorse any products or services, except those in its Preferred Vendor Partnership. The College receives and distributes employment opportunities but does not review, recommend or endorse any individuals, groups or hospitals that respond to these advertisements. NOTE: Opinions stated within the articles contained herein are solely those of the writers and do not necessarily reflect those of the EMpulse staff, the Florida College of Emergency Physicians and our advertisers/sponsors. Published by: Johnson Press of America, Inc. 800 N. Court St. Pontiac, IL 61764 Phone: 815-844-5161 Fax: 815-842-1349 www.jpapontiac.com
Florida Emergency Medicine Residency Match 2018 | 16 Tragedy at Marjory Stoneman Douglas High School in Parkland, Florida | 24 FCEP Visits Tallahassee For Emergency Medicine Days 2018 | 26 EM Payment Reform Summit 2018 Brings Together The Best in the Industry| 28 Musings of a Recently Retired Emergency Physican | 30
Correction: In the winter 2017-2018 issue of EMpulse, we posted an incorrect corresponding photo with North Florida Emergency Medicine Residency’s update. The mistake was entirely ours, and we regret the error. The staff that works together to put out EMpulse will strive for better diligence regarding attention to minor details. SPRING 2018 | VOLUME 25, ISSUE 1
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President’s Message Death From Firearms: The Next National Health Emergency? As I prepare to compose this issue’s President’s Message, I remain haunted by the recent horrific events in South Florida. Of course, I am speaking of the mass shooting that happened at Marjory Stoneman Douglas High School in Parkland. It has not yet been a month since the massacre on Valentine’s Day as I write these words. It has affected me profoundly, and I feel the need to express my feelings in this column.
Joel Stern, MD, FACEP, FAAEM FCEP President
I worked at Coral Springs Medical Center in the ED from 2003 to 2007. This hospital is just south of Parkland, so I am somewhat familiar with the community. It is considered to be a quiet, somewhat upscale suburban area. One of the things that I noticed when I started working there was that the average patient age was much younger than many of the other places I had worked in South Florida. We had a big pediatric population, and I also saw quite a bit of complications due to pregnancy. I was told the reason was that the city was mainly young families, not retirees as in many other areas in Florida. The schools were considered to be excellent, which was the reason so many young families chose to live there. In fact, many of the physicians at the hospital lived in Parkland.
Perhaps that is why this incident was all the more shocking. Parkland is known as a quiet, nice place to raise a family. A place where your kids can get a great education and live in a nice neighborhood. Not a place where they would be slaughtered at school. Not Parkland. When I saw what happened on the news, my initial thought was “not another one.” I remembered the shooting last year at Fort Lauderdale International Airport: five killed and six injured by a man who has been diagnosed as schizophrenic and is currently awaiting trial. Two years ago, 49 killed and 58 were wounded at the Pulse Nightclub shooting in Orlando, and that shooter was killed by police. Now, 17 more dead and 17 wounded in Parkland. The shooter is in custody and has confessed to the killings. Three mass shootings in three years in Florida. Will there be another one next year? From Wikipedia regarding the Parkland shooting: “Some students began campaigning for gun control and founded the advocacy group Never Again MSD. On March 9, Governor Rick Scott signed a bill to raise the minimum age for buying rifles to 21, establish waiting periods and background checks, allow arming of some teachers and hiring of school police, ban bump stocks, and bar some potentially violent or mentally unhealthy people from possessing guns. The National Rifle Association immediately filed a lawsuit challenging the federal constitutionality of the age requirement clause.” The Republican majority Florida State Government, responding to grassroots advocacy from the students at the school, decided to pass gun control legislation, and now the NRA is suing to stop it. Really! Have they no shame? No sense of responsibility for these tragedies? No feeling for the victims and their families? I feel like some sort of line has been crossed. I am truly stunned and mystified. This is not about constitutional law. This is putting greed and money ahead of human lives. That is the truth. In response to the shooting, ACEP President Dr. Paul Kivela issued a statement, which among other things, included ACEP’s policy regarding guns: “In accordance with its policies, ACEP continues to call for restrictions on the sale and ownership of weapons, munitions, and large-capacity magazines designed for military or law enforcement use. In addition, ACEP has called for increased access to mental health services, expanded background checks, adequate support and training for the disaster response system, as well as increased funding for firearm safety and injury prevention research.” I am proud to be part of an organization that promotes this policy. I am also very proud to be an emergency physician. Undoubtedly, lives were saved during all three of these tragedies by the medical and hospital staff and first responders who attended to the victims. They were all just doing their jobs that day like we all do every day when we show up for work -- 24 hours a day, seven days a week, 365 days a year doing what we are trained to do. I have no answers, only questions. When will this end? What is the solution? If trauma is a preventable disease, as we are taught in ATLS, how do we prevent mass shootings? The opioid crisis has been declared a national health emergency with 60,000 deaths in 2016. Firearm deaths in the same year were estimated at nearly 40,000. Is this our next national health emergency?
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SPRING 2018 | VOLUME 25, ISSUE 1
SPRING 2018 | VOLUME 25, ISSUE 1
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EMS/Trauma Committee First, before we discuss the latest goings on in EMS, I wanted to remind all reading this that one of the most valuable things we have is time. This reminder comes after I recently faced the unfortunate reality of suddenly losing my mother. One of the hardest things to come to grip with was my assumption that there would be more time. My mother, a believer in living life to its fullest and appreciating the experiences that life gives us, always stressed making time for family and loved ones. It is with this sentiment that I implore all those reading this to appreciate the time you have. Send your love and gratitude to those who make your lives better. We must make the best use of the time we have and remember not to assume that there will be more. Secondly, as many of us continue in our clinical roles, let us remember that the patients we care for are not just patients but humans with worries, emotions and frequently have concerned friends and family as well. We should do our best to treat all we encounter not only with top medical care but also with the highest level of compassion and empathy.
Desmond Fitzpatrick, MD EMS/Trauma Committee Co-Chair
Summary from January 2018 FAEMSMD meeting Influenza Season: Worst season in recent memory – should be at the peak. • Vaccine effectiveness limited. • Review/update your highly contagious disease protocols and policies. • Join forces with your local health department, and consider entering into a cooperative agreement to assist with vaccination efforts. • Check the inventory of your resources and supplies. • Recommended to be in disaster mode planning. Stroke Care and the DAWN Trial: Dr. Evan Allen, MBA, Florida State University, College of Medicine, shared the following information: • Study noted it does extend the Large Vessel Occlusion interventional therapy window to 24 hours. • Excellent study in NEJM, subgroups, good number of patients, potentially representative of everyday practice. • Results were noted to be so positive that the study was stopped early. • Functional independence 49% vs 13% for control. NNT = 2.8. • Smell test: Intervention window quadruples (advanced imaging identifies good penumbra/collaterals). Summary of DAWN Study: • This really should extend the window to 22.5-23 hrs in the field for LAMS >4 • The benefit DIDN’T drop the closer you get to 24 hours using advanced imaging to detect patients with good collateral/ salvageable penumbra. • This ISN’T just one research paper. H.R. 304: Protecting Patient Access to Emergency Medications Act of 2017: This bill was passed and signed into law. This is an important bill to EMS daily operations with use of controlled substances in the field by our staff under regular medical direction and protocols. We are now waiting on DEA on rule development and implementation. SB 474: Physician Orders for Life-sustaining Treatment: • An important bill for end-of-life care that would help clarify a lot of the confusion that arises in end-of-life scenarios when treating a patient with DNR in place. • As of February 12, 2018, it was noted that this bill has unfortunately been “temporarily postponed.” • Establishing the Physician Orders for Life-Sustaining Treatment (POLST) Program within the Department of Health -- which would require the Agency for Health Care Administration to establish and maintain a database of compassionate and palliative care plans by a specified date -- would authorize specified personnel to withhold or withdraw cardiopulmonary resuscitation if presented with a POLST form that contains an order not to resuscitate the patient; requiring the Department of Elderly Affairs, in consultation with the agency, to adopt by rule procedures for the implementation of POLST forms in hospice care, etc. • This bill likely needs more people to throw support behind it so it can gain traction. EMS Agenda 2050 Solicits Feedback on Straw Man Document: Comment period is OPEN on second Straw Man Document - Visit this site to download the document: http://emsagenda2050.org/ wpcontent/uploads/2017/03/EMS-Agenda-2050-Straw-ManSeptember-2017.pdf
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EMS systems will be: • Integrated and seamless • Socially equitable • Inherently safe • Sustainable and efficient • Reliable and prepared • Adaptable and innovative • http://emsagenda2050.org/ FirstNet Update Full implementation scheduled for spring 2018 with 24 states and territories, including Florida, that have opted in to the First Responder Network Authority (FirstNet) network, the nation’s first high-speed broadband public safety network. This will assist us in future disaster response.
Medical Economics Committee The Second Annual Emergency Medicine Payment Reform Summit was a great success. Please see EM Payment Reform Summit Co-chair Dr. Jordan Celeste’s summary of the conference in a separate article.
Danyelle Redden, MD, MPH, FACEP FCEP Board member & Medical Economics Committee member
FCEP continues to monitor reimbursement trends and attempts by some insurers to undermine fair payment. We have seen underpayments and claw back attempts by Humana since the 2016 balance billing legislation was enacted. Several insurers have announced new policies that will require close scrutiny. Florida Blue announced a new policy last year that claims submitted with higher level E&M codes may be denied if the level billed is inconsistent with the diagnosis. Centene, which administers Sunshine Health Medicaid plans, announced in January that ED visits billed at level 4 or 5 with “a lower level of complexity or severity” will be reimbursed at Level 3. FCEP is working to get further clarification of these policies and to determine the impact they are having on our members.
At the national level, insurer underpayments have been prominent in the news recently. Anthem Blue Cross Blue Shield enacted a policy in several states in which the insurer denies claims that it deems in retrospect were not emergencies. Senators Claire McCaskill (D-MO) and Benjamin Cardin (D-MD) have requested that the policy be investigated by HHS and the Labor Department due to violation of prudent layperson standard. It is encouraging to see these dangerous policies garnering criticism. UnitedHealth has also announced a policy to down code or reject higher E&M claims it doesn’t believe are justified. 2018 marks the second year of the Merit-Based Incentive Payment System (MIPS). The quality measures are different for 2018 than those for 2017. It is essential that emergency physicians are familiar with these measures. The adjustment potential for Medicare reimbursement has increased from 4 to 5 percent. Also, a composite performance score of 15 points will be required to avoid a negative adjustment, as compared to just 3 points last year. More information can be found at www.CMS.gov.
Thanks to all who made contributions to the Political Committees in December 2017, January 2018 & February 2018! Juan Carlos Abanses Mark Attlesey Ian Backstrom David Ball Brian Baxter Roberto Betancourt Evan Bishop-Rimmer Jerry Thomas Brooks Carlos Castellon Jordan Celeste Kristen Dunlap Michael Estep Stephen Scott Feilinger Michelle Fox-Slesinger Kimberly Gressick Omar Hammad Manning Hanline Brian Scott Hartfelder Brooke Hensley Jeffrey Edward Ingeman Frederick Michael Keroff Jeffrey Glenn Laoang
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John Patrick Astkhik Mangasarian Michael McCann Melissa McCarthy Phillip Daniel McConnell Raymond McLane James David Melton Pamela Miller Jamie Mullis Jeremy Helmick O’Shea Sweha Patel Victor Sasson Mary Elizabeth Schmieder Sergio Segarra Sarah Spelsberg Joel Stern Andrea Catherine Suen Robert Tober Jon Van Heertum Courtney Verboncoeur Emily Laura Wolfe
THANK YOU TO OUR 2018 CORPORATE PARTNERS! The success of the Florida Emergency Medicine Foundation (FEMF) and the Emergency Medicine Learning & Resource Center (EMLRC) is due in large part to our corporate partners that provide annual sponsorship support for our educational programs and events. Thank you to our 2018 corporate partners for believing in our mission and helping us to provide life-saving education to life savers!
SPRING 2018 | VOLUME 25, ISSUE 1
ACEP B oard U pdate It has been another busy first quarter for ACEP and emergency medicine. I thought I would make this update a bit different this time around. I am going to share some of the issues that we have been working on these first three months of the year. Some of these may issues may be a bit controversial. American Society of Anesthesia guidelines regarding Moderate Sedation The ASA came out with these new guidelines in January, and, frankly, we do not believe that they should apply to emergency medicine. We had representation amongst the drafting committee and raised multiple concerns that this policy only addresses Elective Sedation and not Emergent Sedation, and our input was not reflected in the final policy. We have also had discussions with CMS regarding the scope of these guidelines, CMS has published the following pertinent guidelines regarding “Anesthesia Services”: Vidor Friedman, MD, FACEP FCEP Board Member, Vice President of American College of Emergency Physicians
• CMS FAQs for Revisions to Hospital Anesthesia Services Interpretive Guidelines state that “emergency medicine trained physicians have very specific skill sets to manage airways and ventilation that is necessary to provide patient rescue. Therefore, these practitioners are uniquely qualified to provide all levels of analgesia/sedation and anesthesia (moderate to deep to general).”
• According to CMS, hospitals must specify the qualifications for each category of practitioner who administers analgesia, and their supervision requirements. These policies must be based on “nationally recognized guidelines.” CMS guidance states that such guidelines are “issued by a national organization that has appropriate expertise and which has used consensus-setting process of professionals with appropriate expertise in developing its guidelines.” • CMS includes in its listed examples of such organizations the American Society for Anesthesiologists (ASA) and the American College of Emergency Physicians (ACEP). • The agency’s FAQs note that a hospital may use multiple guidelines, “for example, ACEP for sedation in the emergency department and ASA for anesthesia/sedation in surgical services, etc.” In response, Dr. Kivela has created a working group to rapidly develop a set of ACEP guidelines for Emergency Sedation to help our membership meet our patient needs. Anthem/ UHC attack on the Prudent Layperson Standard While this is not a new issue (Anthem states they started to pilot this in 2015), it has been recently expanded and implemented in multiple states. ACEP has pushed back very successfully with both effective advocacy efforts (Laura Wooster and our DC team) and a compelling public relations campaign. Recently, Senator Cardin (D-MD) and McCaskill (D-MO) sent a letter, crafted with help from our ACEP team, to the HHS Secretary asking CMS to explore these policies and uphold Federal Law regarding PLS. On March 5, 2018, a number of America’s Hospitals and Health Systems wrote a letter to Anthem urging them to “abandon these policies immediately, to ensue that patients receive high-quality, appropriate, timely care.” You can view that letter here: https:// www.dropbox.com/s/1qunr4vhvah6bcn/Anthem%20HALO%20letter%20final%20030518.pdf?dl=0 In February, Congressman Lujan (D-NM) sent a letter to UHC asking for more information regarding their policy of retroactive ED care denials as well. We will continue to keep the heat on them! ACEP involvement in two bills introduced in Congress The first bill, the “Alternatives to Opioids (ALTO) in the Emergency Department Act” (H.R. 5197), would provide $30 million, over three years, to help establish a demonstration program to test alternative pain management protocols to limit the use of opioids in the ED. The House bill is sponsored by Reps. Bill Pascrell (D-NJ), David McKinely (R-WV), Diana DeGette (D-CO), and Scott Tipton (R-CO). The Senate companion is sponsored by Sens. Cory Booker (D-NJ), Shelley Moore Capito (R-WV), Mike Bennet (D-CO), and Cory Gardner (R-CO). A shout out to Dr. Mark Rosenberg for his efforts regarding this. The second bill, the “Preventing Overdoses While in Emergency Rooms Act of 2018” (H.R. 5176), would provide $50 million (over five years) in grants to establish policies and procedures for administering Medication-Assisted Treatment (MAT) in the ED to overdose patients with subsequent referral to community providers, as well as develop best practices for care coordination and integrated care models for long-term treatment and recovery options. Clearly ‘the devil is in the details,’ however both these bills could provide us with some better options then we currently have regarding pain management, and treatment of Opioid Abuse. Next time someone asks “What has ACEP done for me lately,” I hope this fills in some of the blanks. Please let me know if this is useful/interesting to you; and as always I appreciate your thoughts and feedback.
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Medical Student Committee Article by Alicia Bishop, FCEP Medical Student Committee Secretary-Editor Emergency Medicine Interest Groups across Florida have been hard at work preparing events for their classmates and communities throughout this academic year. This issue’s student update will highlight their efforts. NOVA’s ACOEP Emergency Club, led by president Leena Owen and vice president Maja Magazin, hosted its first splinting clinic in October 2017. Medical students and PA students worked with local emergency physicians and residents to apply their first casts. Several members also participated in a simulation lab with the emergency medicine program at Mount Sinai. Attendees were able to practice suturing, inserting central lines, performing intubations and using ultrasound. NOVA is currently planning an ultrasound clinic which will focus on the FAST and LE DVT exams, as well as their first ever Match Panel in late March. FSU’s EMIG, led by president Conley Diaz-Gomez (outgoing president Alicia Bishop), hosted a Procedures Night in December 2017 with assistance from Tallahassee Memorial NOVA’s ACOEP Emergency Club. Photo courtesy of Alicia Bishop Hospital emergency physicians, FSU COM PA program faculty, and Leon County EMS. Thirty-five medical and PA students had the chance to practice intubation, central line placement, ECG lead placement and chest tube insertion. FSU is also excited to be planning a Disaster Preparedness Day in late March that will train students regarding basic techniques for providing care in a mass casualty scenario. Finally, FSU will be hosting a dinner for women who are interested in pursuing EM, as well as providing ride-along opportunities with Leon County EMS throughout this spring. FIU’s EMIG, led by co-presidents Astrid Casin and Hayley Musial, hosted a Workshop Week in the fall, featuring a full week of procedural training for students. Skills included chest tube insertion, ultrasound and ECG, a Knot Tying Olympics, and central line placement. Several M4s also gathered for a panel to advise younger students looking to pursue EM. Other fall events included a lecture by Dr. D. Kaufman on abdominal emergencies, an introduction to EM for first-year students, and a talk by faculty adviser Dr. R. Levine on the Florida Advanced Surgical Transport Team and their role in handling recent disasters such as Hurricane Irma. Early this semester, FIU also hosted a wilderness workshop. LECOM’s EMIG, led by president Veronica O’Neil (outgoing president Clairisse Hafey), hosted an emergency physician for a lecture on drugs of abuse in the fall, as well as several meetings with area emergency physicians focusing on how students can be successful during their EM rotations. In October 2017, LECOM also held an ultrasound clinic and students had the chance to learn basic exams from five local emergency physicians. FAU’s EMIG, led by president Jordyn Cohen (outgoing president Jeff Katz), hosted a talk in fall 2017 on EMS field medicine. They also held a talk with a toxicologist on trends in drugs of abuse in Florida.
D a u n t ing D i a gn o s i s Question: A 30-year-old female presents with right hip flexor pain s/p trip and fall two days prior. Patient has been ambulatory since the fall, but states the pain persists. Her plain film is to the right. What is her diagnosis?
(Answer on page 15) Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief
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Membership & Professional Development Committee By the time you get this, we would have already celebrated ACEP Wellness Week from March 11-17. ACEP Wellness Week focuses on the Wellness Wheel, which has a seven-spoke approach: Occupation, Emotional, Physical, Financial, Spiritual, Social and Intellectual Wellness. How many of these did you address? I really appreciate that ACEP has dedicated this week to recognizing how important yet fragile our well-being is to our professional and personal longevity. It is important that we all pay close attention to our levels of wellness as they can significantly affect us, either negatively or positively.
Rene Mack, MD, RDMS Membership & Professional Development Committee Chair
There has been an annual increase in physician dissatisfaction and burn out with EM physicians, unfortunately, toward the head of the pack. Burnout is described in several ways with the general consensus recognizing a triad of: 1.) emotional exhaustion, 2.) depersonalization and 3.) reduced personal accomplishment. These feelings can be a result of numerous factors including: medicallegal, work-life balance, poor sleep hygiene, financial concerns and strained work environment. There are a variety of strategies available to help mitigate and/or resolve the concerns, but the most important aspect is that we have to begin a personal self-analysis to identify where the issue(s) lie.
If you think you may have any of these signs of burnout or maybe you recognize them in a colleague, please reach out to ACEP and/or FCEP for some EM-specific strategies. In addition, please get in touch with your company’s EAP, a local counselor, or at least a close friend or relative who can help you to develop a personal plan for addressing the concerns. In addition to recognizing and celebrating our wellness endeavors, I also want to celebrate you! Another great recognition is that we continue to grow our membership base, and we’re currently at just over 1,900 members! This increase places us as one of the top five largest state chapters, especially considering that at this time last year we had approximately 1,700 members. I am especially proud because this means that the EMPs in Florida recognize the importance of standing together to create change within our specialty and medicine as a whole. So who do we have to thank for this? You, of course! Many thanks to your continued outreach to our colleagues and discussing the many benefits of ACEP/FCEP membership with them. We also have several groups who have committed to having 100 percent ACEP membership. Are you a part of one of these groups? If not, consider having a discussion with your colleagues to join the 100 Percent Club. Visit the ACEP/FCEP website for more details on group discounts and other group benefits. So we have wellness and membership participation covered, are you ready to learn more about your specialty and the various avenues available to become more involved? Are you interested in finding out where your non-clinical passion for emergency medicine lies? Consider joining the FCEP Leadership Academy (LA). The LA was developed to give EMPs low-stress insight into the various areas where FCEP and ACEP work to create and promote a thriving EM specialty and community. Enrollment in the LA is now on a rolling basis, so we encourage you to contact us at any time. I look forward to seeing you at our next committee meeting on April 11, 2018 at the FCEP office in Orlando. As always if you have any questions, reach out to FCEP, we’re here to help.
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EMpulse | 11
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EMRAF Committee While I typically use this column to highlight what the EMRAF Committee is working on, I felt that with the events in Parkland this past February it was more appropriate to share a letter I wrote to the governor after the shooting. I share this with you to illustrate the importance that no matter what side you take on any political issue, it is imperative to make sure your voice is heard. Dear Mr. Governor, You may not remember me but after the Pulse nightclub shooting, we spent some time together in an elevator at Orlando Regional Medical Center. I was an emergency medicine intern on my trauma rotation, and it was the week of June 12, 2016. I was on my way upstairs to check on one of the Jesse Glueck, MD victims of the shooting who had begun spiking high fevers. The source was likely the infected wound EMRAF President, Orlando in his back that was so large I could fit my fist into it, a wound created by a high-velocity round fired Health EM Resident (PGY-3) from a Sig Sauer MCX rifle. I introduced myself and you handed me a medal of recognition. Your photographer made sure to capture us as I hesitantly accepted what I had hoped was a token of a Governor’s appreciation for treating his constituents during one of the darkest moments in his State’s history and not just a photo-op. I put the medal in my back pocket and when I was done seeing my patient I headed down to the trauma bay where more than two days after the shooting the room, despite being impeccably clean, still had the ironic smell of blood hanging in the air. I pinned it to a corkboard since I alone deserved no special recognition and went about my day. It wouldn’t stay there very long. If the medal had still been hanging on that wall, I would have taken it down and mailed it to you with this letter. However, later that day I saw a replay of a press conference you had held the day before. When you were asked if the shooting would spur you to take any action to help prevent another shooting your response was, and I quote “…this is a time to pray…and there will be plenty of time to come together.” You didn’t even have the decency to answer the question. So I walked down to the trauma bay, pulled the medal off the wall and threw it in the garbage, as something so hollow did not belong in what I considered a hallow room. Mr. Governor, you had almost two years between Pulse and Parkland to do something, anything in an effort to prevent senseless murder in our state. Instead, you have responded with sound bites like “the second amendment has never shot anyone.” Not only have you failed to act, but you have again and again signed legislation that makes it easier for Floridians to purchase and carry firearms. You even tried to pass legislation that would make it illegal for a pediatrician to ask if a parent had a firearm in the home so he or she could provide guidance on proper safe storage of guns much like we do regarding prescription medications. The shooting at Marjory Stoneman Douglas High School shows us, just as the shooting at Sandyhook and the shooting in Las Vegas did, what awaits those who fail to act. You failed to act, and now Florida is home to two of the deadliest mass shootings in this country’s history. What you and other politicians have yet to realize is that everyday more and more members of my generation, the generation that was in elementary school during the Columbine shooting; the generation that witnessed in horror as our politicians stood idly by, impotent to do anything after 20 kindergartners were murdered; the generation that includes those brave, fearless students who stood feet from Senator Rubio the other night and called him out for doing what you have done, nothing, turn eighteen everyday and earn the right to vote. We are a generation fighting for change and fighting for our lives. Politicians who hope to represent us must be willing to fight along side us, and those who are not will soon find themselves without a job.
Poison Control Physostigmine’s Role in Anticholinergic Toxicity Article by Emily Jaynes Winograd, PharmD Clinical Toxicology/Emergency Medicine Fellow Florida/USVI Poison Information Center – Jacksonville
Blind as a bat. Hot as a hare. Dry as a bone. Red as a beet. Mad as a hatter. Full as a flask. This classic mnemonic refers to the symptoms associated with anticholinergic toxicity: mydriasis, hyperthermia, dry skin and mucous membranes, flushing, altered mental status, and urinary retention. Tachycardia, hypertension, and diminished bowel sounds are also common components of the anticholinergic toxidrome. Myriad prescription drugs, over-the-counter medications, and plants cause anticholinergic symptoms when ingested (Table 1).1 Table 1. Select classes and substances with anticholinergic effects
Physostigmine salicylate (Antilirium®) is a reversible, carbamate acetylcholinesterase inhibitor originally derived from the Calabar bean.2 Historically, it was included as a component of the “coma cocktail” to reverse anticholinergic toxicity, including anticholinergic symptoms generated by tricyclic antidepressant (TCA) overdose. However, following two case reports of asystole in patients receiving physostigmine for TCA toxicity, use of this therapy became much more judicious.3 Acetylcholinesterase is the enzyme responsible for degrading the neurotransmitter acetylcholine in cholinergic synapses, allowing for the cessation of cholinergic stimulation and cellular recycling of acetylcholine. Inhibition of acetylcholinesterase by physostigmine prevents acetylcholine breakdown, thus increasing synaptic availability of this neurotransmitter. In anticholinergic toxicity, physostigmine promotes accumulation of acetylcholine in the synapse in order to competitively overwhelm the cholinergic blockade causing the patient’s symptoms. Other acetylcholinesterase inhibitors like neostigmine are not used for the reversal of anticholinergic toxicity because they do not penetrate the blood-brain barrier and therefore will not address neurologic symptoms. While benzodiazepines remain the treatment of choice for agitation and delirium secondary to undifferentiated toxicity, there is evidence to support the use of physostigmine over benzodiazepines when anticholinergic toxicity is suspected. Burns and colleagues conducted a retrospective chart review of 52 patients who received physostigmine, benzodiazepines, or both for the management of agitation or delirium caused by anticholinergic toxicity. Physostigmine controlled agitation in 96 perecent of patients and reduced delirium in 87 percent of patients. Benzodiazepines controlled agitation in only 24 percent of patients, and were not effective in addressing delirium. Patients given physostigmine had a shorter time to recovery, though incidence of side effects and hospital length of stay were comparable between the two groups. The presence of an anticholinergic agent was confirmed by laboratory testing in 77 percent of cases, and included a wide variety of agents such as diphenhydramine, atropine, scopolamine, amitriptyline, doxylamine, benztropine, and cyproheptadine.4 The Florida Poison Information Center Network (FPICN) recommends reserving physostigmine administration for the following moderate to severe indications in the setting of anticholinergic toxicity: • • • •
Status epilepticus refractory to benzodiazepines Ventricular dysrhythmias Severe or prolonged psychosis Other significant anticholinergic effects not controlled by benzodiazepines
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Per the package insert, physostigmine salicylate use is contraindicated in patients with known or suspected cyclic antidepressant poisoning, asthma, gangrene, diabetes, cardiovascular disease, mechanical obstruction of the intestine or urogenital tract, any vagotonic state, and in patients receiving choline esters (e.g. depolarizing neuromuscular blocking agents like succinylcholine).5 It is especially important to obtain and analyze an electrocardiogram before administering physostigmine. Patients with QRS or QT prolongation, or other signs of TCA toxicity, should not receive physostigmine due to the risk of worsening conduction disturbances, bradycardia, asystole, and seizures.6 In adults, administer 0.5 – 2 mg physostigmine salicylate IM or via slow IV push (no faster than 1 mg/minute). This dose can be repeated every 10 – 30 minutes for persistent, life-threatening symptoms such as dysrhythmias or seizures. Pediatric patients should receive 0.02 mg/kg physostigmine salicylate IM or via slow IV push (no faster than 0.5 mg/minute). This dose can be repeated every 5 – 10 minutes up to a maximum dose of 2 mg. Following physostigmine administration, monitor patients for resolution of anticholinergic symptoms (e.g. resolution of dysrhythmias or convulsions, improvement in mental status, decrease in heart rate and blood pressure). Physostigmine adverse effects include muscarinic symptoms such as hypersalivation, bronchospasm, and bradycardia, and nicotinic symptoms like weakness and paralysis.7 Physostigmine can also precipitate seizures, especially when given too quickly or at high doses.6 Like most pharmacologic therapies, physostigmine administration is not without risk. However, when used in a carefully selected patient population, it can be a life-saving antidote. FPICN toxicologists are available 24 hours a day at 1-800222-1222 to assist emergency physicians in the treatment of all toxic exposures, including determination of appropriate physostigmine use for anticholinergic poisoning. References: 1. Manning BH. Chapter 13. Anticholinergics. In: Olson KR. eds. Poisoning & Drug Overdose, 6e New York, NY: McGrawHill; 2012. 2. Nelson LS, Goldfrank LR. Plants. In: Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank LR. eds. Goldfrank’s Toxicologic Emergencies, 10e New York, NY: McGraw-Hill; 2015. 3. Pentel P, Peterson CD. Asystole complicating physostigmine treatment of tricyclic antidepressant overdose. Ann Emerg Med. 1980 Nov;9(11):588-90. 4. Burns MJ, Linden CH, Graudins A, Brown RM, Fletcher KE. A comparison of physostigmine and benzodiazepines for the treatment of anticholinergic poisoning. Ann Emerg Med. 2000 Apr;35(4):374-81. 5. Physostigmine salicylate [package insert]. Lake Forest, IL: Akorn, Inc; 2008. 6. Kearney TE. Chapter 223. Physostigmine and Neostigmine. In: Olson KR. eds. Poisoning & Drug Overdose, 6e New York, NY: McGraw-Hill; 2012. 7. Howland M. Antidotes in Depth. In: Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank LR. eds. Goldfrank’s Toxicologic Emergencies, 10e New York, NY: McGraw-Hill; 2015.
D a u n t ing D i a gn o s i s Answer: This patient was found to have a 6 x 3 c.m. lytic focus at the right intertrochanteric region with associated pathologic fracture. In this case, surgery was postponed by orthopedics, in order to obtain a hematologic work-up, as surgery could potentially metastasize a malignant bone lesion. Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief
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F l o ri d a E m e rg e n c y M e d i c in e Orlando Health
Florida Hospital
John Atiyeh, MD Eastern VA
Yasmany Cartaya, MD University of Cincinnati College of Medicine
David Bailey, MD Univ of HI Mark Bender, MD USF Jordan Bjerke, MD Wright State Beulah Castor, MD UF Michael Clemmons, MD LSU New Orleans Danielle DiCesare, MD Tufts University Agnieszka Gaertig, MD Morehouse University Justin Kittedge, MD Albany Medical College Tucker Maute, DO Lake Erie College of Osteopathic Medicine
Misty Coello, MD Florida International University Herbert Wertheim College of Medicine Elizabeth Janevski, MD Loma Linda University School of Medicine Thomas Lawyer, MD University of Utah School of Medicine Samuel Muniz, MD Florida State University College of Medicine - Pensacola Jon Risovas, MD Loma Linda University School of Medicine
Keegan Mullins, MD Marshall University Olivia Munizza, MD Penn State University Christiaan Myburgh, MD FIU Gustavo Rey, MD FSU Mark Schattschneider, MD USF Geraldine Uy, MD Howard University Alexander Williams, MD Texas Tech University
University of South Florida
University of Florida Gainesville
University of Florida Jacksonville
UCF/HCA
Nicole Abdo, MD USF Health Morsani College of Medicine
Kathryn Dasburg, MD Florida International University Herbert Wertheim College of Medicine
Javier Ayo, MD Florida State University College of Medicine
Maria Chamorro, DO Lake Erie College of Osteopathic Medicine
Kyle Barfield, MD University of Central Florida College of Medicine
Emily Slone, MD Southern Illinois University
Thomas Bloom, MD Pennsylvania State University College of Medicine Morgan Dufresne, MD Ross University School of Medicine Johnathon Elkes, MD Medical University of South Carolina College of Medicine Martin Gaccione, MD The University of Toledo College of Medicine Kelsey Hundley, MD USF Health Morsani College of Medicine Adam Koby, MD University of Florida College of Medicine Mikhail Marchenko, MD University of Central Florida College of Medicine Brian Samuels, MD USF Health Morsani College of Medicine Lauren Shapiro, MD Charles E. Schmidt College of Medicine at Florida Atlantic University
Terri Davis, MD West Virginia University School of Medicine William DeMayo, MDGeisinger Commonwealth School of Medicine Martin Dun, MD University of Cincinnati College of Medicine Caitlyn Emigh, MD University of Texas Southwestern Medical Center Southwestern Medical School Lauren Fisher, MD University of Arkansas for Medical Sciences College of Medicine Aaron Frankel, MD New York Medical College Tareyn Morris, MD Texas A&M Health Science Center College of Medicine April Pinto, MD Ohio State University College of Medicine Joseph Pompa, DO West Virginia School of Osteopathic Medicine Christopher Purcell, MD Virginia Commonwealth University School of Medicine Shannon Robinson, MD University of North Carolina at Chapel Hill School of Medicine Priscilla Shen, MD USF Health Morsani College of Medicine Chanteil Ulatowski, MD Oakland University William Beaumont School of Medicine
Ryan Brandt, MD Medical College of Georgia Michael Carpenter, MD University of Florida College of Medicine Shivani Deopujari, MD Virginia Commonwealth University School of Medicine Christine Gage, DO Arizona College of Osteopathic Medicine of Midwestern University Adam Greeley, MD University of Tennessee Health Science Center College of Medicine Andrew Grozenski, MD Michigan State University College of Human Medicine Shaunn Hussey, MD University of South Florida Morsani College Bradford McGuire, MD Florida State University College of Medicine Yoldez Meroueh, MD University of Florida College of Medicine Eamon Olwell, MD University of Arkansas for Medical Sciences College of Medicine Jessica Ryder, MD University of Queensland School of Medicine Andrew Sellinger, MD Florida State University College of Medicine Tyler Tantisook, MD University of Tennessee Health Science Center College of Medicine Jesse Zadell, MD Virginia Commonwealth University School of Medicine
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Michelle Hernandez, MD Florida International University Keegan McNally, MD University of Central Florida Amber Mirajkar, MD University of Florida Mary Slome, MD State University of New York Sherwin Thomas, MD Wayne State University
North Florida Emergency Medicine
Ashley Barash, DO Nova Southeastern University College of Osteopathic Medicine Emmanouil Kiriakopoulos, DO Liberty University College of Osteopathic Medicine Shelby Martin, MD University of Louisville School of Medicine Joshua Middleton, MD University of Florida College of Medicine Mollie Powell, DO Marian University College of Osteopathic Medicine Robert Skinner, MD University of Tennessee Health Science Center College of Medicine Joseph Tran, MD Oakland University William Beaumont School of Medicine Jessica Yap, DO Campbell University Jerry M. Wallace School of Osteopathic Medicine
R e s i d e n c y M at c h 2 01 8 PBCGME/St. Lucie Medical Center
Mt. Sinai Medical Center
Jackson Memorial Hospital
Kendall Regional Medical Center
Aventura Hospital & Medical Center
FAU at Bethesda Health
UCF/Ocala Regional Medical Center
Drew Brooks, DO University of Pikeville – Kentucky COM
Nicholas “Nick” Boyko, DO Rowan University School of Osteopathic Medicine
Nathan Boin, MD Icahn School of Medicine at Mount Sinai
Ibrahim Hasan MD Northeast Ohio Medical University
Busko Alexander, MD University of Miami
Jonathan Wacht Brandon, MD University of California, San Francisco, School of Medicine
Kelly Galzer MD Florida Atlantic University College of Medicine
Ioana Stroe, MD Florida State University College of Medicine - Ft. Pierce
Nathan George, MD University of Illinois College of Medicine Peoria
Michael Drechsler, DO Lake Erie COM Shelby Guile, DO Edward Via COM – Carolinas Campus Jerome Daniel, DO Touro University Nevada COM Abby Regan, DO William Carey University COM Ashkahn Zomorrodi Nova Southeastern University COM
Stephanie G. Fernandez, MD Florida International University Herbert Wertheim - College of Medicine Fenil Chirag Patel, MD University of Alabama School of Medicine Rahul Paul, MD USF Health Morsani College of Medicine Kevin Sigler, MD Rutgers New Jersey Medical School Jenna Lynn Varner, DO Nova Southeastern University - College of Osteopathic Medicine Ethan Zimmerman, DO Lake Erie - College of Osteopathic Medicine
Mitchell Evan Brown, MD Keck School of Medicine of the University of Southern California Samuel Thomas Cochran, MD Medical College of Georgia at Augusta University Dennis D’Urso, MD Sidney Kimmel Medical College at Thomas Jefferson University Christopher Blair Gaines, MD University of South Alabama College of Medicine Brittney Alexis Giuffre, MD Lewis Katz School of Medicine at Temple University Joseph Paul Greene, MD University of Miami Leonard M. Miller School of Medicine
Anthony Peters DO NOVA Southeastern University College of Osteopathic Medicine Nicholas Rosende MD New York College of Medicine Kristina Drake MD Medical University of South Carolina College of Medicine Matthew Mattioli DO Edward Via College of Osteopathic Medicine Virginia Campus Anton Gomez DO NOVA Southeastern College of Osteopathic Medicine Sara Zagroba MD Jacobs School of Medicine and Biomedical Sciences at the University of Buffalo
Ludwig Sebastian Koeneke-Hernandez, MD Sidney Kimmel Medical College at Thomas Jefferson University
Boris Rybatsev MD State University of New York Upstate Medical University
Ryan Daniel Lynch, MD Lewis Katz School of Medicine at Temple University
Jennifer Eells DO NOVA Southeastern University College of Osteopathic Medicine
Athena Areti Mikros, MD University of Illinois College of Medicine
Joseph Clemons MD Southern Illinois University School of Medicine
Yijia Mu, MD University of Pittsburgh School of Medicine Michael Osinski, MD Lewis Katz School of Medicine at Temple University
Hieu Van Duong, MD University of Alabama School of Medicine Kristina Eastman, MD Ross University School of Medicine Tuan Quang Ha, MD University of Texas Medical Branch School of Medicine at Galveston Andrew Morris, MD Drexel University College of Medicine Manuel Alejandro Obando, MD Florida International University Herbert Wertheim College of Medicine Laura Pumarejo Gomez, MD San Juan Bautista School of Medicine
Hatoum Zachariah, MD George Washington University Khan Mohsin, DO Nova SE School of Osteopathic Medicine
Stephanie Iken, MD Central Michigan University College of Medicine Kimberly Johnson, MD University of Oregon
Klein, Danielle, MD Florida Atlantic University COM
Raza Kazmi, MD Virginia Commonwealth University
Mirza Zuheir, MD University of South Florida Anabelle Taveras, MD University of Illinois
Caroline Smith, MD McGovern Medical School at the University of Texas Health Science Center at Houston Nicholas Titelbaum, MD Icahn School of Medicine at Mount Sinai Aaron Umansky, MD Mercer University School of Medicine
Eva Ryder, MD Unversity of Sydney, Sydney Medical School Daniel Samet, MD Florida International University Herbert Wertheim College of Medicine Shuai Zhao, MD University of Minnesota Medical School
Richard Boccio MD Ross University School of Medicine
Shahnaz Rashid, MD University of South Carolina School of Medicine Daniel Felipe Rivera, MD University of Illinois College of Medicine
SPRING 2018 | VOLUME 25, ISSUE 1
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R e s i d e n c y M at t e r s Our emergency medicine residency programs say goodbye to a great year! Hello from Boca Raton, Florida. We are exceptionally pleased with our applicant pool this past interview season and are eagerly awaiting the results of the match. It seems the applicant pool grows stronger and stronger each year, serving to highlight the increasing interest and expanding field of emergency medicine at both our program and in Florida as a whole. Good luck to all in the match! Over these past three months, we have had the pleasure of hosting several noteworthy Grand Rounds speakers. The list of speakers included Dr. Eric Bruno, who is the clinical medical educator at the University of Tennessee, who lectured on “Operational Emergency Medicine;’’ Dr. Edward Sloan from the University of Illinois, who lectured on “Optimization of the ED Acute Stroke Patient;” and Dr. Christopher Amato from Morristown Medical Center, who lectured on “Pediatric Head Trauma.” Florida Atlantic University Jeff Klein, MD PGY-1
Unfortunately, in light of the frequency of mass casualty situations, we will be launching our inaugural FAU EM Disaster Day. This training event is currently scheduled in April and will involve not only EM residents, but also residents from general surgery and the nursing staff from affiliated hospitals. It will first provide a background on START (Simple Triage And Rapid Treatment) and the basics of EMS. This will be followed with three different simulation scenarios where a team of residents and nurses will have to apply the knowledge learned in the first portion of the day to rapidly triage, treat and move a large number of victims to a casualty containment area. Although this simulation will provide a vital learning experience that we are looking forward to, it will be performed with the victims of the Parkland shooting and their families in mind. It has been one year since the passing of our beloved program director Salvatore Silvestri, MD. Even with his loss, his teachings and wisdom remain with each one of us at Orlando Health, and we all strive to #LivelikeSal. Our program recently hosted the second annual Salvatore Silvestri, MD Memorial Ballgame, which many current residents and alumni gathered to honor Dr. Silvestri. It was a beautiful day filled with laughter, reflection, food and family. We are pleased to announce our fellows for the upcoming 2018-2019 academic year. We are lucky enough to have four graduates matriculating on to fellowships here at Orlando Health! Drs. Drew Bienvenu and Cole Feffer will become our Ultrasound fellows. Dr. Jesse Glueck will matriculate to our Pediatric Emergency Medicine Fellowship. Dr. Erich Heine will matriculate to our Simulation/Medical Education Fellowship. Congrats to all! And congratulations to our soon-to-be graduating fellows Ryan Queen, MD (ultrasound), and Stacy Miller and Alex Rodriguez (EMS). As graduation day approaches for our PGY-3 residents, we prepare to celebrate their journey over the past three years. A huge congratulations to our PGY-3 residents: Allyson Best, MD; Aytana Alvarez-Ambas, MD; Brian Buning, MD; Christopher Mills, MD; Cole Feffer, MD; Drew Bienvenu, MD; Erich Heine, DO; Jesse Glueck, MD; Mohammad Jaffar, MD; Morgan Snavely, MD; Nicole Mailloux, MD; Shari Seidman, MD; Stephanie Dunlop, MD; and Tessa Stamille, MD.
Orlando Health Shari Seidman, MD & Erich Heine, DO PGY-3
With every graduating class, there comes a new academic year. Match day is just weeks away, and we are thrilled to discover which bright new interns will be joining the ORMC EM family in March. Our class size expands to seventeen this year -- our largest class yet. Hello everyone! Time is definitely flying by for us at Florida Hospital East Orlando. As my colleagues and I eagerly anticipate Match Day next month, we are reminded again of how fortunate we are to be a part of such a great residency! Although we only have six residents per year, we have seen a record number of patients at Florida Hospital East Orlando with some days up to more than 450 patients checked in within 24 hours (thanks in a large part to the flu). However, we have banded together, worked hard, and have seen and treated patients in a timely manner. I am very proud of my team, and I am constantly grateful to be a part of such an amazing training facility with the best residents, attendings, and staff.
Florida Hospital Katie Laun, DO PGY-2
The residents at Florida Hospital East Orlando have also been working hard to study for the yearly Inservice Traning Exam (ITE) on February 28. Our attendings have been incorporating review sessions though our weekly conference to review pertinent material. It has been very helpful, and we all anticipate doing well on the exam.
Although we work hard, we also play hard and are looking forward to our yearly “Wellness Day” after the ITE, which often includes participating in a fun activity such as Top Golf, Escape Room or bowling. Our Wellness days are always a great way to unwind and hang out with each other along with the faculty as well. Can’t wait to see what the rest of the year has in store for FH East Orlando!
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The Emergency Medicine Residency at the University of Florida – Jacksonville has several commendations to announce. First, we would like to recognize the addition of our newest faculty members. Drs. Rosemarie Fernandez, Jennifer Fishe and Amanda Crichlow have recently joined our program and are already making meaningful contributions as they settle in as part of our family. We are also happy to announce that senior resident Dr. Warren Sher will remain at our institution as an assistant professor beginning in July, and former chief resident Dr. Alexandra Mannix will be returning as an assistant program director after completing a simulation fellowship and teaching at Rush University in Chicago. University of Florida, Jacksonville Corey Dye, MD PGY-1
The program has also established two new fellowships in ultrasound and research to be respectively filled by graduating seniors Dr. Christopher Kumetz and current chief resident Dr. Lauren Page Black. Dr. Kumetz, along with senior Dr. Jason Arthur, have been fundamental in expanding ultrasound education in Jacksonville with their monthly ultrasound journal club.
We would also like to recognize assistant program director Dr. Melissa Parsons who continues to be actively engaged in FeminEM and has been elected to speak at the upcoming October conference, as well as Dr. Luis Rios who remains heavily involved in relief efforts deploying with the U.S. Disaster Medical Assistance Team to Puerto Rico after hurricane Irma. To all the students who rotated and interviewed with us – we wish you the best for a happy and successful upcoming match! This has been a very busy first few months of the year for the UF Emergency Medicine residency in Gainesville! We were present for EM Days with a share of residents and our chairman, and we lobbied for common-sense opioid legislation and other FCEP priorities along with EM docs from across the state. We were also able to help host a discussion about medical record integration with representatives from the legislative and technical sides, which provided good insight into the work our state has already put into integration among EMRs and hospital systems and provided some initial targets for future projects. Our Quality Improvement curriculum continues. Projects such as focusing on minimizing discrepancies in discharge instructions and make safer sign-outs continue with the help of Dr. Holland. We are excited to hear that other institutions are interested in quantifying the impact of redundant testing on patients transferred due to the current inability to share labs, imaging and documentation in real time from other hospital systems.
University of Florida, Gainesville Travis Murphy, MD PGY-2
As an offshoot of this project, we are working with our Burn colleagues to develop an internal telemedicine consultation method, with hopes to expand to our satellite sites (and who knows, maybe even other hospitals in the future?!) to safely save patients the expense of transport all the way to Gainesville. Our EMS fellow Dr. Becker has led the way in creating the Cardiac Arrest Research Team -- a multidisciplinary group with representatives from Emergency Medicine, Cardiology, Neurology, Critical Care and Cardiothoracic Surgery -- that is investigating factors that affect outcomes in resuscitation. With rank lists submitted and the In-Training exam behind us, we are gearing up for new chief elections and the annual PGY-2 trip to SAEM. Looking forward to seeing you in Indianapolis! It’s 2018 and we at St. Lucie Medical Center are having an outstanding year! In just a few days, our residency program will be participating in our very first ACGME match. After an exciting rotation and interview season, our match list is finalized and we are thrilled to welcome this July’s incoming class. Best of luck to all who are participating in the match this year!
St. Lucie Medical Center Thomas Adams, DO
As a residency program, we have enjoyed several recent wellness activities. In December of 2017, we participated in the Ropes Course at Florida Atlantic University – a well-renowned outdoor course that emphasizes confidence building and teamwork. We also ran our yearly 5K run at Classics by the Sea in Jupiter, Florida. Once again, our beloved Program Director Dr. Matese took home the gold. Our program is looking forward to our next annual “Resident’s Day Out” event that will occur this Spring.
We are also proud to say that we have participated in several beach clean-up activities, Habitat for Humanity and many of us volunteered at the Treasure Coast Marathon. We at St. Lucie Medical Center wish you all a wonderful and productive year. We look forward to seeing you all at the next conference! SPRING 2018 | VOLUME 25, ISSUE 1
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With Match Day upon us, Aventura Hospital will soon have a full complement of emergency medicine residents. The 2017-2018 interview season brought a diverse group of exceptional applicants to Aventura, and faculty and residents are excited to welcome our third class. Meanwhile, current residents and faculty are thriving. In December, AHMC hosted SoFlo Grand Rounds, a combined conference with all of the South Florida Emergency Medicine GME programs. More than 120 faculty and residents gathered at Aventura to hear presentations from Drs. Erin Marra, Jennifer Jackson, and keynote speaker Dara Kass. In January, Simulation Director Dr. Jessica Cook presented a workshop course at the national IMSH conference (International Meeting on Simulation in Healthcare) entitled “Evaluation Made Simple: Checklists, Global Rating Scales, Milestones and Competencies” to help educators begin using simulation for evaluation of trainees.
Aventura Hospital
Annalee Baker, MD In February, several faculty presented at the Seventh Annual FLAAEM Scientific Assembly in Miami Assistant Program Director Beach. Program Director Dr. Todd Slesinger spoke on a panel, and Ultrasound faculty Drs. Guarav Patel and Huy Tran presented original lectures. The Aventura Sim Team, (Drs. Thomas Yang, Katie Peterson, Mitali Mehta and Matthew Yasavolian), led by Dr. Cook, took first place in the FLAAEM SIMWARS competition! While prepping for SIMWARS, PGY-2 resident Dr. Thomas Yang also found time to publish the Canadian Syncope Risk Score on MD Calc (https://www. mdcalc.com/canadian-syncope-risk-score).
Winding down from a busy and productive winter, the Aventura faculty hosted a holistic wellness day for the residency, highlighted by hot yoga, wellness journaling and tai chi, as well as a nutrition presentation and relaxing lunch. The Aventura family is now relaxed, recharged and ready for a beautiful spring. Greetings from The Magic City! We are very pleased to be able to provide updates on some of our residents’ recent academic achievements. At this year’s FLAAEM, Dr. Henry Zeng presented a poster on Lomotil toxicity; Dr. Chris Sweat presented a case of unintentional acyclovir overdose; and Dr. Timothy Montrief presented a photo poster on traumatic vision loss as well as a case report on loperamide toxicity, the latter of which won an award for best case presentation. Congratulations to Drs. Emily Ball and Anwar Ferdinand for their involvement in a project titled “Opt-out Emergency Department Screening of HIV and HCV in a Large Urban Academic,” which Jackson Memorial Hospital was chosen for an oral presentation at the next AAEM Scientific Assembly in San Diego. It will Mark Supino, MD also be published in the Western Journal of Emergency Medicine: Integrating Emergency Care with Associate Program Director Population Health. Dr. Laura Scheidt collaborated on a project entitled “Longitudinal, SimulationBased Disaster Response Curriculum Culminating in an Inter-professional Large-Scale Response Exercise for MD/MPH Students” that was just recently presented by our very own Dr. Motola, guru of SIM, at the International Meeting on Simulation in Healthcare in L.A. Finally, we commend Dr. Ariana Weber for serving as an instructor for the EMS Point of Care ultrasound course for Monroe and Miami-Dade County Air Rescue flights medics and nurses. Having recently finished a grueling but exciting recruitment season, and we look forward to Match Day to find out which talented individuals will be joining us to finally form the full complement of our residency program. It’s really amazing how quickly three years can fly by. Finally, we are looking forward to hosting the quarterly South Florida Emergency Medicine Consortium on March 28 at which time we will be welcoming Dr. Hilarie Cranmer, who is the director of global disaster response at Massachusetts General Hospital. Before we know it, we’ll be knee deep in orientation for our new residents, soon followed by the (re)opening of ERAS, and then interviews. Lather, rinse, repeat! Greetings from the University of South Florida, or more appropriately -- arrrggghhh! New Year in Tampa brings Gasparilla with various crews of pirates along with marathoners wishing to test their endurance. Many from our residency felt that it was only appropriate to form a crew of pirates and celebrate this yearly tradition together. The month of February not only is the month for the in-service exam, but it is also the time of year for USF EM’s Annual Residency Alumni Lunch. During this time, former and current residents along with current faculty gathered to discuss current EM trends and provide advice to current residents. We would like to extend a “Thank you” to Dr. K. Kay Moody of ‘EM DOCS’ for taking time out of her schedule to come visit us and be our guest keynote speaker. She spoke to our residency about defining wellness and how to maintain self-wellness throughout an EM career. We would like to welcome our newest USF EM recruit. Congratulations to new parents Lin and Angela Poff on the arrival of their son, Franklin A. Poff IV. For those who have lost count, we have welcomed three new recruits over this past year with two more on the way over the next few months. Lastly, with interview season complete and Match Day right around the corner, we would like to extend best wishes to all applicants. We would also like to extend a welcome to those who match with USF EM. Enjoy your time before residency, and we look forward to working with you all soon!
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University of South Florida Darrell “Clay” Ritchey Jr, MD, MSHCA, MSEd PGY-2
It has been a great summer and fall at Kendall, and there have been a lot of great changes! We have continued to grow in our ability to provide a strong educational experience for all of our trainees. First, I want to introduce the new core faculty who have joined the team. Dr. Astrid Sarvis is a pediatric residency-trained and pediatric emergency medicine fellowship-trained physician. Dr. Sarvis will work with current pediatric emergency fellowship-trained faculty to help design the best training program possible so that our residents learn how to care for sick children. Dr. Jesus Seda brings with him a wealth of experience as a clinician and former chief resident, and he will be helping us ramp up our critical care training. Drs. Valori Slane and Matt Slane have also joined the faculty. As associate program director, Dr. Valori Slane has become an integral part of the program. She brings with her experience as a medical director and fellowship-trained global health expert. Dr. Matt Slane now heads the residency orthopedic rotation. His years of experience as a leader in the military and in mountain and tactical medicine have helped him transition into his new role rapidly and effectively. Dr. Joseph Zitek is our new research director. He has years of experience as an associate research director, multiple publications and with his guidance we will be able to further grow our research mission.
Kendall Regional Medical Center Kendall Regional Medical Center Emergency Medicine Residency Staff
There are other exciting changes to the program that we want to let everyone know about. This past summer, we opened a new simulation center at the hospital which allows us to provide high-fidelity multidisciplinary simulation in-situ. We have also been developing our own longitudinal curriculum, which links directly with our off service rotation educational content. This will ensure that our residents get the best foundation to their didactic experience no matter where they are. There are also plans to offer our senior residents specialized tracks in the areas of Ultrasound, EMS, and simulation to start. The residents will be able to choose their own journey and develop their skills and interests, thus putting them in a great position for fellowship training after graduation. Finally, our ultrasound longitudinal training program has been successfully launched. This has allowed our senior residents to work collaboratively with our interns, increasing the senior residents ability to teach and supervise while obtaining scanning experience. In only a few short months, the residents have been able to record thousands of scans. Add to this the two new ultrasound machines that will be arriving shortly, the ultrasound program is ready to really take off! Greetings from UCF/HCA Emergency Medicine Residency Program of Greater Orlando! It’s hard to believe that it is time to welcome our class of 2021 to our EM family! The upcoming interns will allow us to have all three classes and one step closer to a resident-run emergency department, and we cannot be excited enough!
UCF HCA of Greater Orlando Abhishek Roka, MD and Leoh N. Leon II, MD PGY-2
Next, residents and faculty will be representing our program the upcoming SAEM 2018 in Indianapolis. We have abstracts including: “Accuracy of Prehospital Triage to Identify Large Vessel Occlusion Strokes;” “Accuracy of Prehospital Triage to Identify Large Vessel Occlusion Strokes;” and “Incidence and Trends of Pediatric Clonidine Ingestions over the Last Fifteen Years.” We also will be participating in didactic sessions which include: “The Assembly Line Model, a Novel Approach to Residency Education;” “Developing an Infrastructure for Emergency Medical Services/Prehospital Research;” “Improving Outcomes in Pediatric Cardiac Arrest;” and “New Frontiers: Management of Acute Ischemic Stroke in the Extended Time Window (Up to 24 Hours).” Lastly, we have an IGNITE sessions on “How to run the perfect code – beyond the ACLS card,” “Stop the Bleed!” and “ Non-Opioid Analgesia.”
Furthermore, we continue to be very proud of the hard work and dedication from all of the faculty and residents. Congratulations to all the residents on taking your In-Service exam! We had the opportunity to have our wellness day at Top Golf after the exam, and we had an amazing time with our EM family. Finally, we are extremely thrilled to announce our newly appointed chief residents of our inaugural class: Drs. Kramer and Roka. They are extremely eager to continue to demonstrate excellent leadership and will strive to make our program grow. Congratulations to those who matched, and good luck on your upcoming journey!
THOUGHTS, COMMENTS OR FEEDBACK ON EMpulse? WE WOULD LOVE TO HEAR FROM YOU! EMpulse IS STARTING “LETTERS TO THE EDITOR.” PLEASE SEND ANY ARTICLES TO INFO@EMLRC.ORG. SPRING 2018 | VOLUME 25, ISSUE 1
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North Florida Regional Emergency Medicine (NFEM) residency program is full-steam ahead with the first class establishing the groundwork for the upcoming residents. We had the opportunity to meet many promising future EM leaders and cannot wait to meet our new class! NFEM was one of five residencies represented at EM Days, lobbying to Florida legislators for policies that will benefit our field and patients. Our own Dr. Christopher Libby traveled to Washington to meet with various representatives, including Neal Dunn, along with discussing interoperability issue, Emergency Departments are facing, with CMS administrator Seema Verma. North Florida EM Residency Zaza Atanelov, MD & Collin Bufano, DO PGY-1
Not only are we in the forefront of policy, but we are also tapping into the depths of research. Residents have already submitted multiple case reports, and some have already been published. With the guidance of EMS director Dr. Amit Rawal, we are actively coalescing data into an EMS database for future larger scale studies.
Conference days are ramped up with faculty constantly coming up with innovative adult learning, including Dr. Jonathan Journey holding the first ever “Duck Pond Journal Club.” Meanwhile, simulation director Dr. Evan Stern has is constantly challenging residents with realistic and complex cases. He even bought us pig tracheas for Valentine’s Day, so we could hone our cricothyrotomy skills. As the harsh Florida winter comes to an end, North Florida EM has continued with the same momentum thanks to the support and enthusiasm of our faculty. Congratulations to Dr. Mora who is continuing to teach POCUS while expecting her second boy, as well as Dr. Zaza Atanelov for his future addition to the North Florida Family. Finally congratulations to Dr. Dakota Lane, the new addition to our outstanding Ultrasound faculty.
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WE’D LIKE TO CONGRATULATE ALL CLASS OF 2021 EMERGENCY MEDICINE RESIDENTS IN THE STATE OF FLORIDA! CHECK OUT PAGES 16-17 FOR A LIST OF ALL 2018 MATCHED EM RESIDENTS!
PHYSICIAN AND LEADERSHIP OPPORTUNITIES NORTH FLORIDA
Fort Walton Beach Medical Center (Ft. Walton Beach) Bay Medical Center (Panama City) Bay Medical FSED (Panama City) Gulf Coast Regional Medical Center (Panama City)
CENTRAL FLORIDA
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EM p u l s e F e a t u r e Tragedy at Marjory Stoneman Douglas High School, Parkland, Florida Article by Mark Lieberman, MD, FACEP
It was Valentine’s Day, Ash Wednesday and Frederick Douglass’ (sad name coincidence) birthdate. I was working in my home office. It seemed like a quiet day, like any usual weekday in Parkland. Typing away on my laptop, I was listening to NPR. My son, an FSU student in Tallahassee, called and informed me that he saw on Twitter there was an active shooter at Marjory Stoneman Douglas High School. I was sort of disheveled, in my basketball shorts and wrinkled T-shirt and had important timesensitive work to complete — but, none of that mattered. Immediately, I went to my garage, grabbed an old pair of sneakers and without tying the laces, ran out my back door, through my back yard and over the berm. I live five houses from the high school, and once on the sidewalk, I entered mayhem. I ran to the intersection at the corner of the school and was stopped by the police. I explained to the officer that I was an emergency physician, and, without hesitation, he let me through. At that point, I was recognized by many of the Coral Springs Fire Rescue paramedics that I have known for the last 20 years. They pointed me out to the EMS Division Chief Juan Cardona, and I offered my assistance. He was happy to see me there, as I was the first physician to arrive. He told me to wait with him. The scene at that point was quite disturbing and overwhelming. There were dozens of police cars and Fire Rescue Units from five local cities. Helicopters were noisily hovering around, and bystanders/parents with shocked and distraught looks were massing. Several fathers were (L-R) Dr. Mark Lieberman and EMS Division Chief of the Coral Springs-Parkland Fire Department Juan Cardona assisting thousands of students as they staged held back, trying to get past the police barriers or trying in desperation a walkout from their respective schools to Marjory Stoneman Douglas High School to pay their respect to the victims. Both men helped treat about half to obtain any information. There was a blue tent completely enclosed, a dozen victims the day of the Parkland high school shooting. Photo courtesy of Dr. Lieberman the contents of which were too sad to think about. Amid this chaos, was controlled coordination carried out by the Coral Springs Fire Rescue Command. Their stellar effort along with all the first responders on the scene saved lives, no doubt. I had grabbed some gloves, placed protective arm cover sleeves on, and started tying my sneakers, when a Margate Fire Rescue Unit pulled up. They had just scooped two teenagers from the front of the high school. One of the teenagers had five gunshot wounds (GSWs) and appeared to be in serious condition. There was a possibility that the patient could have had penetration of his right chest and possibly a hemopneumothorax. I jumped into the ambulance, and we departed to the Trauma Center at Broward Health Medical Center (about 27 miles away). I prepared to perform needle decompression, if deemed necessary. En route to the trauma center, I assisted the paramedics and assessed and reassessed this injured teenager. The other teenager was very stable with an extremity GSW, so most of my attention was on the more seriously wounded student. He was alert with a stable blood pressure but tachycardic. His oxygen saturation was good. I had borrowed the paramedic’s stethoscope, and his breath sounds seemed diminished on the right. I soon realized that this stethoscope was not the best quality and limited my assessment. His breath sounds appeared to be the same on the left. The paramedics were excellent -- two IVs were started, and IV Normal Saline was running wide open. The patient was alert, fully oriented and strangely calm. I believe internally he was nervous, but he did not show it at all. His blood pressure remained stable, his tachycardia improved, and he had no signs of tension pneumothorax. I borrowed one of the medic’s cellphones and contacted his parents to update them. It struck me how calm they were and how that calmness in the face of uncertainty was handed down to their son. When asked his pain scale, without hesitation it was a 6. In the ED, it seems everyone’s pain is a 9 or 10, and here, this boy had five GSWs and his pain was a 6. After hanging up the cellphone with his parents, I remembered my wife had no idea I left the house. I had not even taken my
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phone or wallet. I called her to let her know what was going on. She informed me that my niece, who is a freshman student and cheerleader at MSD, had just left the school 15 minutes before the shooting for a doctor’s appointment. I was so relieved. It was at that point, I realized my little hidden city in the northwest corner of Broward County was going to be national news and forever changed. The traffic was very heavy during the 30-minute trip with lights and sirens. This boy was stabilizing, and I just held his hand for the last 10 minutes of the ride. We arrived at the pediatric trauma unit, where the boy was whisked into the trauma bay, as we gave report to the trauma surgeon, and the staff took over. He was rapidly assessed and preparations were being made to take him to the operating room. The ambulance that I came with was then rushing back to the school to re-assist with the mass causality situation, so I returned with them. On the drive back, as we were cleaning up and preparing for more trauma victims, we heard that the assailant was captured. When we returned, I waited expectantly for several hours, but the trauma event was essentially over. The police and FBI were canvassing the school. The deceased, unresuscitatable victims were being identified. Frantic parents were still trying to contact their missing children, five of which were not notified of their child’s passing until 3 a.m. the next morning. I commiserated with the medics, the fire chiefs, the Mayor of Parkland Christine Hunschofsky and several fellow emergency physicians. Dr. Peter Antevy, the medical director of Coral Springs Fire Rescue, had attempted heroically to revive a critically injured teenager. Subsequently, I attended the vigil the following night, as well as the funeral service and grieving house of 18-year-old Meadow Pollack. Her picture remains on my work desk. I take evening walks to the memorials at the school and talk with friends and strangers alike while there. I volunteered my services to assist Coral Springs Fire Rescue when several thousand students staged a walk-out from their respective schools to MSD to pay their respect to the victims and protest against assault weapons. Thankfully, the two students that I rode with are doing fine and will have complete physical recoveries. The City of Coral Springs and Coral Springs Fire Rescue put on an event this last Sunday that I was able to attend. I met other injured teen survivors and their families and chatted with many of the paramedics that attended. Several of the medics have been mentally and thus physically affected by the horror of that day. I have three children, all in college now, who graduated from MSD. For the first week after the horrid event, I had recurrent nightmares that something happened to my daughter. I can’t possibly imagine the unfathomable anguish of these heartbroken parents. In closing, I nervously laugh when people suggest that I was heroic. I know that any one of my fellow emergency physicians would have done exactly the same as I did in this situation. It’s in our ED DNA. I don’t think my participation really changed an outcome. However, I was honored to be able to render my assistance. There were real heroes -- those paramedics that day -- particularly Laz Ojeda, who made a life-saving decision. I would like to thank my fellow telecommuter coworkers, about 120 RNs and physicians, for their kind thoughts and support from all over the country. I want to thank all the Fire Rescue personnel including Chief Frank Babinec, Chief Juan Cardona, Chief John Whalen and Chief Robert Bertone. I want to especially thank the Margate Crew, for allowing me to contribute with the medical care in their ambulance. I have written and sent a letter of commendation to their chief. They are Paramedics Charlie Gandia, Jackie Maurico and Nick Lopez. Lastly, I want to thank my wife Lisa, and my children Monica, Blake and Lance (who all are on a path in medicine) for their love and support. Hug your children everyday, God bless, and help heal Parkland.
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EM p u l s e F e a t u r e FCEP Visits Tallahassee For Emergency Medicine Days 2018 Article by Damian Caraballo, MD, Emergency Medicine Days Co-Chair January marked another successful FCEP EM Days. For three days, FCEP leaders throughout the state met with legislative leaders to advocate for emergency medicine physicians. This year we focused our strategy to prioritize meeting with key legislative committee members. After a whirlwind week of meeting with legislators to advocate for emergency physicians and our patients, testifying to strike down false-narratives pushed by outside special interests, and fighting for physician and patient-rights which impose on our autonomy, our hard work seems to have paid off--every single bill we opposed this year (at present writing) appears to have been defeated. Florida Legislative session came early this year, in January. The three main issues in this year’s EM days were opioid legislation, PIP repeal, and expansion of practice, this year in the form of a bill which would (L-R) FMA Vice Speaker Dr. Ashley Booth-Norse; FCEP Board member Dr. Aaron Assistant Deputy Secretary for Medicaid Policy and Quality (AHCA) Shevaun have allowed pharmacists to diagnose/treat influenza and strep-throat. Wohl; Harris; and Assistant Secretary for Substance Abuse and Mental Health (DCF) John Bryant answer questions on an opioid panel moderated by EM Days Co-chair Dr. The surprising bill saw pharmacists moving in on scope of practice, by Sanjay Pattani. Photo courtesy of Samantha Rosenthal proposing a bill which would allow pharmacists to diagnose and treat the flu in pharmacies, without physician intervention. FCEP testified against this practice, given that influenza kills more than 65,000 people per year and pharmacists essentially have no diagnostical training in pharmacy school. It passed on the House side, but was killed in the Senate side in committee. This will be a bill and movement to closely track in future years (it’s no wonder House Health and Human Services chairman, Representative Jaime Grant, joked at the beginning of the committee meeting, “HHS committee, also known as who wants to play doctor this year.”) Over the next few years, expect to see an unprecedented number of unqualified entities (pharmacists, naturopaths, chiropractors, etc.) move in on medicine’s turf and try to start practicing medicine on patients. It’s more important than ever that physicians unite to fight this dangerous encroachment. While not an issue as well publicized as scope of practice, tort reform, or Balance Billing, the HB 19 (Grall) /SB150 (Lee) Personal Injury Protection bill, which would have eliminated PIP in Florida in exchange for Bodily-Injury insurance. We currently have a Medical-Pay carve out where physicians who see MVA patients in the ED can use the Auto-insurance PIP as primary insurance to reimburse medical care. The new bill would eliminate this med-pay set-aside, and instead the at-fault party would be forced to pay for medical bills in a car accident. Because this would open up litigation for car accidents to determine fault, it could take years before Emergency physicians were paid for car accident patients they see in the ED (think about how many MVA’s you see on a daily basis, whether major trauma or neck pain secondary to a fender-bender). Basically, you would wait three years or more to be reimbursed by many of these patients, and current law capped repayment at a multiple of Medicare. By ORMC FCEP Residents and medical students meet together at EM Days 2018 to discuss important topics and legislation concerning emergency medicine. Photo courtesy data-projections, if the House Bill had passed as written, it would have of Samantha Rosenthal cost Emergency Medicine groups in Florida as high as 5 percent of revenue. Fortunately, through our relationships in the Senate, we were able to help kill the bill in committee. We will undoubtedly see this bill return, as it did in 2018, and it will set up future battles between the House and Senate to have a mandatory Medpay set-aside for EMTALA physicians who treat MVA victims. Without a doubt, the biggest issue in EM Days this year was HB 21 (Boyd)/SB 8 (Passidomo) for the control of opioid prescribing. FCEP has been one of the leaders on combatting the opioid epidemic. We met with both co-sponsors of the bill, Senator Passidomo and Representative Boyd to give our solutions for the opioid crisis. Our opioid expert Dr. Aaron Wohl led a panel which crafted a manifesto on ways to combat the opioid epidemic. It’s key theme was that we “have an addiction problem, not an opioid problem.” Our main recommendations included increasing access to Medication Assisted therapy (MAT), increasing funding for behavioral health, and increasing first-provider access to Naloxone. The Legislature, though sympathetic, unfortunately seemed to focus on
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reducing the amount of opioids physicians can write. As of this writing, next year expect a hard cap on the number of opioids we can write for out of the ED to three days, and mandatory checking of the PDMP (eg E-FORSCE, which will change to another drug database vendor this year) prior to prescribing and scheduled substance. The law would also require two years of Opioid CME for licensure, as well as further fund drug-rehabilitation centers and increase the supply of Naloxone. We will continue to try to work on legislature to use this as an opportunity to push for an EHR-sharing system such as EDIE, which would connect unrelated healthsystem ED’s data and make for a “push” PDMP which integrates automatically into your EHR (imagine a system where one click on your EHR shows a patients scheduled narcotic prescriptions in the year, and populates the note with the mandated “I checked the state PDMP system.”) While I was initially pessimistic in our talks with legislature during EM-Days, it appears our hard work and alliances with other physician groups such as FMA have paid dividends. While many physicians cynically decree, “what have you done for me lately,” it was FCEP who took the state lead on the Balance Billing ban and the PIP-repeal, which, if the bills had passed as originally written, would have cost Emergency Physicians in Florida somewhere between 25 to 35 percent of their revenue (in real numbers, if the average salary for an EM physician in Florida is currently around $300,000, everyone EM physician in Florida would be making up to $105,000 less if these bills had passed as originally written.) FCEP provides a real, monetary benefit to every emergency physician in Florida. I cannot stress enough how important it is to become involved with physician advocacy, and become a member of the FCEP PAC. I really believe EM FCEP residents and EM Days 2018 participants attend the EMRAF Reception at Andrews Downtown. The event was sponsoredby DuvaSawko and EMPros. Photo Days is our most important event at FCEP. Next year it will be in March courtesy of Samantha Rosenthal in Tallahassee—the stronger showing we have from our members, the more forceful our voice becomes in passing pro-physician Florida laws. If you’d like more information on how to become involved in advocacy, please contact Sanjay Pattani or me for ways to get involved. We hope to see you all at next EM Days 2019 in March of 2019.
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EM p u l s e F e a t u r e EM Payment Reform Summit 2018 Brings Together The Best in the Industry Article by Jordan Celeste, MD, FACEP, EM Payment Reform Summit Co-Chair
In late February, leaders in emergency medicine payment and policy convened at the EMLRC offices in Orlando, Fla. for the second annual EM Payment Reform Summit. Faculty flew in from across the country to discuss ongoing and upcoming changes to the payment landscape, and ways for emergency medicine to lead the way in the future of American medicine. Day one focused on the legislative and regulatory climate that has brought medicine to its current state, and that promises (or threatens) to continue to reshape the environment in which we practice. Mr. Ed Gaines, Chief Compliance Officer for Zotec Partners’ emergency medicine division and Chair of the ACEP/EDPMA Joint Task Force on Reimbursement Issues, provided updates regarding the ongoing fight to preserve the prudent A group of EM Payment Reform Summit 2018 participants mingle in layperson standard and prevent inappropriate downcoding of emergency between program session. Photo courtesy of Samantha Rosenthal medicine claims. Emergency medicine billing and collections was expertly covered by Dr. Michael Granovsky, who serves as Director of ACEP’s Coding and Reimbursement Conference, who also provided real life examples of attempted downcoding, and reviewed steps that you can take to ensure that your claims have a high first-pass success rate. Another battle – this one against insurance companies’ portrayal of emergency physicians as greedy doctors who are burdening patients with “surprise bills” – was led by Dr. Paul Kivela, current ACEP President and practicing emergency physician. A panel discussion was also held about this topic, with particular attention to advocacy efforts at the state level. Dr. Daniel Brennan, FCEP’s Medical Economics Committee Co-Chair, provided a review of the Florida experience with out-of-network billing legislation. MACRA was extensively reviewed by Mr. Robert Jasak, who serves as the Vice Preisdent for Coverage and Payment Policy with the DC consulting firm Hart Health Strategies, and then Dr. Steve Epstein further refined the Michael Granovsky, MD, FACEP; Ed Gaines, JD; Jennifer Wiler, MD, discussions with particular attention to how ACEP’s Clinical Emergency (L-R) MBA, FACEP; and Robert Jasak, JD participate in a panel session for EM Payment Reform Summit 2018. Photo courtesy of Samantha Rosenthal Data Registry (CEDR) is designed to help practices not only meet, but potentially benefit from, these regulations. Dr. Jennifer Wiler from the University of Colorado and part of ACEP’s RUC team, specifically reviewed the pertinent information regarding Alternate Payment Models, and gave an update about how the Physician-Focused Payment Model Technical Advisory Committee (PTAC) process has been working so far. Fortunately, in the room were both Dr. Randy Pilgrim who is Co-Chair of ACEP’s Alternate Payment Models Task Force, and Dr. Tony Cirillo, who is chair of one of the workgroups, so there was discussion regarding ACEP’s proposed APMs as well. Panel discussions allowed for more interaction between faculty members, as well as conference attendees. Topics included some future directions that payment models may take, how emergency medicine may fit into these models, and how attribution of costs and risk adjustment might work. Much attention was paid to positioning emergency medicine as a leader and a partner in the APM space, and working to avoid the often-used logic that an ED visit is a “failure” of any system.
(L-R) ACEP Vice President Vidor Friedman, MD, FACEP; EM Payment Reform Summit Co-chair Dr. Clifford Findeiss; EM Payment Reform Summit Cochair Dr. Jordan Celeste; and ACEP President Paul Kivela enjoying the program in Orlando, Fla. Photo courtesy of Samantha Rosenthal
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Two relatively new transplants to Florida, Dr. William Jaquis who is the Senior Vice President for the East Florida Division of Envision Physician Services, as well as current ACEP board member, and Dr. Kathleen Clem, who is serving as Executive Vice President and Chief Clinical Ofiicer for the Adventist Health System, participated in a panel along with Drs. Epstein and Kivela that further discussed how EM can be a potential partner. SPRING 2018 | VOLUME 25, ISSUE 1
Day two took discussions even further, with a particular focus on EM as a center of innovation. Former FCEP and ACEP President Dr. David Seaberg covered ways in which to make your emergency department viewed favorably by your C-suite, and also later gave an in-depth talk on challenges facing academic and residency programs. Dr. Randy Pilgrim, who is with Schumacher Clinical Partners, discussed specific ways that you can collaborate with your hospital to obtain better patient outcomes, and make everyone happy in the process. Even though the emergency department is often described as the “front Robert Jasak, JD speaks to two program attendees about lines” of medicine, that line was pushed out even further by Dr. Kenneth (center) his session “Updates on Affordable Care Act Rules and Regulations.” Photo courtesy of Samantha Rosenthal Scheppke, as he gave an overview of the work is being done to combat the opioid crisis in Broward County, which includes specific EMS training, medical-assisted therapy (MAT), and community centers and support. Following the idea that we can transform how emergency medicine can serve its patients and the community, a talk by Dr. Mark Rosenberg, Chair of Emergency Medicine at St. Joseph’s Healthcare System in Paterson, New Jersey, concerning end-of-life and palliative care brought into focus the critical role that we can be playing during potentially stressful times in our patients lives, as well as in their deaths. The conference concluded with a panel discussion about the continually evolving role of telemedicine, which also featured Dr. Timothy Bullard, who serves as the Chief Medical Officer, Business Development and Innovation at Orlando Health. Over the course of two information-filled days, conference attendees were able to learn from some of the best speakers in their respective fields, and have access to them for additional questions and dialogue. While the agenda was robust, there was still time for networking and interaction amongst conference attendees as well, making for an ideal educational and innovative learning environment. Special thanks must be given to Dr. Cliff Findeiss, former FCEP President and current FEMF Board Member, for taking the initiative to create this conference, and having the dedication to see it executed so well. Check back later this year for information about next year’s course.
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Musings Of a Recently Retired Emergency Physician A void P hysician B urnout Article by Wayne Barry, MD, FACEP
I saw a tweet from an emergency physician friend of mine, expressing her elation over the fact that her medical director backed her up during an inquiry about a patient complaint lodged against her because she did not treat one of her patient’s pain with a narcotic analgesic. Kudos for her medical director for not “throwing her under the bus” for this alleged infraction. I guess this means that maybe she has been “thrown under the bus” before for similar situations. Who out there has felt the sting of the deeper meaning of her elation because she DIDN’T get thrown under the bus during the investigation of a groundless patient complaint? Been there, done that, right? Physician burnout is a hot topic these days. Admirably Steven Stack, MD an emergency physician and recent past-president of the AMA made physician burnout one of his key issues. I am not sure what was actually accomplished through his efforts. Events like the above occur not infrequently during the career lives of virtually every emergency physician I have ever known during 32 years Wayne Barry, MD, FACEP of work in emergency medicine. Some of us encountered the above more than others, but none of us has escaped the humiliation, distress, regrets, or just plain despondency that such an event engenders. Please do not mistake my remarks about this subject as though I do not believe that patient satisfaction, and customer (oops... I mean “patient”) service is of paramount importance in our work and the work of any and all physicians. I have admired and envied those physicians who rarely come up against this trial and tribulation. God love them, they aren’t always the brightest bulbs in the EM Caduceus either. But HCAPS, Press Gainey, and Harris Polling results take a tremendous bite out of the satisfaction and gratification of working in the ER. Then there are the malpractice lawyers circling the chum of bad medical outcomes regardless of whether there are medical errors or not. Would you believe that one of my most memorably triumphant “saves” (arguably life saving that is) in a desperately sick child resulted in a settlement for the plaintiff among 4 different entities of which I ( the life saver) was one! I know most of you have heard this stuff before, and so rather than belabor the beating of dead horses, I would like to propose 2 thinking points for your supratentorial evaluation. No. 1: Hospital Administrators and Malpractice Lawyers have Contributed to the Current Opioid Epidemic I retired from the ER before the spate of guidelines and opiate prescribing rules became plentiful in our nations’ ER’s. I remember feeling the sting of being constantly reminded by the Joint Commission as far back as 2001 that “Pain is the 5th Vital sign). This increased the stress of constantly dealing with drug seekers and addicts in the ER. Each one of us had to develop his or her own personal approach to this dilemma. My routine approach to excruciating acute pain problems in the ER was # 20 lortab 5’s and prayer that there would be follow up other than the ER. I figured that it was unlikely that I would be creating addiction with a post surgical number of narc pills, and if I were successfully gamed by a seeker….well so be it!.. Local pharmacies in my neighborhood were so familiar with my narc prescribing habits that they would call me up if a prescription written by me had any other number (like 200 instead of 20) designated looking for forgery. In this way I felt I was buffered against answering to the Hospital CEO’s crowd to patient complaints like the one above, and no malpractice lawyer could accuse me of violating the Joint Commission commandment….oops….I meant to say guideline. Then one day a popular ER tech troubled with a quasi clandestine drug abuse problem came in coded to the very ER in which he worked. Needless to say we were all emotionally crushed by this tragedy, and narcotic prescribing guidelines issued forth quickly from the medical director. I must say I felt very comfortable adhering to these guidelines, and if a patient pressed me to prescribe outside thee guidelines I had some ammunition (HIPPA compliant of course) to explain my position. No. 2: Physicians Bring Economic Health to Our Communities 736,873 physicians provide patient care in the US. 12.6 million jobs are supported by physicians. $2.3 trillion in economic activity is generated by physicians yearly. So why are we the “patsies” of Social Political forces in this country? Burnout can be defined as a state of emotional or mental exhaustion combined with doubts about your competence and the value of your work. Another way of defining physician burnout is unremitting stress caused by lack of control over decision making which leads to frustration, depression, and finally burnout. Physicians seem to be incapable of organizing in a way that would lead to taking their $2.3 trillion war chest to Washington D.C. and kicking some ass. Not going to happen. Some would say physicians are so self absorbed in their own practice pursuits, that all of the insurance companies, medicare regulators and State Medical Boards just sneaked up on us and “picked us off at the pass.” Many of us are too altruistically involved with trying to help people that we do not have time to stick up for ourselves in the ugly corrupt world of politics. I remember a
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brief but former FCEP administrator who formerly worked for the Florida Medical Association stated that trying to direct the physician constituency was like trying to herd cats. She found it refreshing when she transitioned to ACEP where she found a large number of smart and like minded physicians laser focused on issues such as improving access to health care and public safety issues. My intention is not to present to you a scholarly treatise on physician burnout and how to avoid it because this is an increasingly complex issue containing many scholarly works worth paying close attention to. Work family balance issues, health and wellness, financial planning are just parts of this complicated subject. There are ACEP position papers, ACEP Committees, and ACEP Sections which I encourage you to explore for your own personal safety and well being. I just wanted to drop a few curmudgeonly thoughts in your direction for your deliberation. Until next time be well!
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Florida College of FCEP | Emergency Physicians
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