EMpulse (Summer 2016)

Volume 23, Issue 2 Summer 2016

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

ACEP discusses diversity in the ED

ACEP Leadership & Advocacy Conference gathers EM leaders in D.C. INSIDE: Photos

from

ABC s

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Celebrating FCEP’s 45th

Anniversary at #SBS2016

Pediatric EMS 2016

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Chapter Updates President’s Message | 4

Medical Economics Committee | 5 Government Affairs Committee| 6 ACEP Update | 7 Membership & Professional Development Committee |8

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

EMS/Trauma Committee | 9 Free-Standing ED Committee | 10 EMRAF Committee | 11 Leadership Academy Update | 12

FCEP Executive Committee Steven Kailes, MD, FACEP • President

FITLS Update | 14

Jay L. Falk, MD, MCCM, FACEP • President-Elect Joel Stern, MD, FACEP • Vice President

Residency Matters | 16

Joseph Adrian Tyndall, MD, MPH, FACEP • Secretary/Treasurer Ashley Booth-Norse, MD, FACEP • Immediate Past President

Features

Beth Brunner, MBA, CAE • Executive Director

Daunting Diagnosis | 5 Coding Tip | 9 FCEP Leaders Attend ACEP’s Diversity Summit | 13

Editorial Board Karen Estrine, DO, FACEP, FAAEM • Editor-in-Chief karenestrine@hotmail.com Samantha Rosenthal • Managing Editor/Design Editor srosenthal@emlrc.org

All advertisements appearing in the Florida EMpulse are printed as received from the advertisers. Florida College of Emergency Physicians does not endorse any products or services, except those in its Preferred Vendor Partnership. The College receives and distributes employment opportunities but does not review, recommend or endorse any individuals, groups or hospitals that respond to these advertisements.

Poison Control | 15 A Look Ahead at the 2016 Election Season| 18 That’s a Wrap!: ABCs of Pediatric EMS 2016| 19 Snapshots of ABCs of Pediatric EMS 2016 | 20 FCEP Visits Washington D.C. for ACEP’s LAC 2016 | 22 Emergency Nurses Visit Washington D.C. to Advocate for Emergency Care| 23

NOTE: Opinions stated within the articles contained herein are solely those of the writers and do not necessarily reflect those of the EMpulse staff or the Florida College of Emergency Physicians.

A Look Ahead: CLINCON 2016 | 24 Symposium by the Sea 2016 Highlights | 26

Published by: Johnson Press of America, Inc. 800 North Court Street Pontiac, IL 61764 Phone: 815-844-5161 Fax: 815-842-1349 www.jpapontiac.com

Celebrating FCEP’s 45th Anniversary | 27 Musings of a Recently Retired Emergency Physican | 28 EM Case Reports | 30

Summer 2016 | Volume 23, Issue 2

EMpulse | 3

President’s Message “...No country can be well governed unless its citizens as a body keep religiously before their minds that they are the guardians of the law and that the law officers are only the machinery for its execution, nothing more.”

- The Gilded Age, by Mark Twain Similarly, our College exists to serve emergency medicine (EM) as a specialty and we have been doing a lot this past year. One of our most important activities is advocating on behalf of the specialty in Florida. It has been a very active year and the coming year promises to not let up.

Steven Kailes, MD, FACEP FCEP President

Among the many issues we have been dealing with is the persistent threat to reimbursement for the services you provide. A 2011 Medicaid reform law directed the Agency for HealthCare Administration (AHCA) to penalize plans if they didn’t raise physician Medicaid rates to Medicare rates after two years of operation. Most of these plans weren’t formed until 2014. AHCA dangled this carrot as patients and providers complained access to care was limited by poor Medicaid reimbursement. Suddenly, and inexplicably, AHCA announced the anticipated increase now applies to only OBGYN and Pediatric specialties. FCEP and the FMA have expressed our disappointment and are exploring our options.

Also, as I have previously written, the law banning balance billing for PPO plans takes effect July 1. While waiting to see how this will affect our reimbursement, we have heard some praise the new law’s language while others expect our reimbursements to go down. We still have much work to do.

At the recent ACEP Leadership & Advocacy Conference (LAC), in an unprecedented move, ACEP announced it is suing the federal government regarding new rules for the reimbursement of emergency services for out-of-network care. In an ACEP press release on the new rule, “This decision essentially allows insurance companies to set whatever prices they want without regard to the consequences to patients, health care providers, and our nation’s safety net of emergency care.”

We are more effective when we have your support. Please offer a little of your time to help these efforts. Build a relationship with your area legislators and invite them to tour your emergency department. As Tip O’Neil quipped, “All politics are local.” These relationships are critical.

Furthermore, please give to your state and federal political action funds.

Advocacy is not all we have been doing. Membership is crucial. If you know emergency physicians who are not members, please encourage them to join. This year we’ll visit all emergency residencies in Florida, including three new residencies established this year! We are engaging EM residents and interested medical students. Furthermore, the blooming Leadership Academy is mentoring and introducing some physicians to the broad array of activities within the College. These physicians may be your future leaders. If interested, please contact us to get involved.

Education is more important to us than ever. Throughout the year we offer a wide array of programs to physicians, nurses, advance practice providers, and the EMS community. Furthermore, in late August we’ll have our Written Board Review Course and we anticipate this year’s course to be even better than before. We are developing an “Innovators Conference” for late next spring. This conference will bring together important topics and information shaping the future of EM. Last, the FCEP Board has been working on a new strategic plan for the college. Our plan is to have this completed by Symposium by the Sea, August 4-7, in Naples, FL. We are trying to be proactive for the future. I have been honored to serve as your president this year. We have many challenges and your president-elect, Dr. Jay Falk, is well prepared to lead the college. Please help us and take advantage of the many ways we serve our specialty.

Mark Twain also said, “I was seldom able to see an opportunity until it had ceased to be one.”

Seize the opportunity.

4 | EMpulse

SUMMER 2016 | VOLUME 23, ISSUE 2

Medical Economics Committee In the aftermath of the 2016 legislative session, the key legislation passed affecting EM was the Out-of-Network Balance Billing bill. The end compromise bill accomplished what FCEP had sought, a payment requirement for OON PPO patients that matches existing HMO law (F.S. 641.513(5)) which requires OON EM bills be paid the lesser of: (1) provider charges (2) The usual and customary provider charges in the community or (3) a mutually agreed rate. Keeping the payment expectation charge-based was important, but inevitably some insurers will interpret “usual and customary charges” in creative ways to avoid the plain English requirement to pay the billed amount, or the community norm of the billed amount. Thus we also successfully pushed to include stronger dispute resolution language in the bill.

We now enter the next phase, where we will be monitoring the process as AHCA spells out new rules and regulations of the Statewide Provider and Health Plan Claim Dispute Resolution Process called for in the new legislation. As this process occurs, FCEP will work with EDPMA / FMA and counsel to assure important Daniel Brennan, MD, FACEP provisions are incorporated – such as requirements for timely review process, the need to review all evidence submitted, the availability of an evidentiary hearing, the prohibition of ex parte communication with either Medical Economics Committee Chair party, the requirement to make a “finding of fact” as to the determination of payment under FS 641.513(5), and finally, the availability to seek judicial review under FS 120.68. Previously the ADR process in FL was rarely utilized – seemingly due to concerns over a flawed process as well as lack of faith in the ADR vendor Maximus – whose contract is up this summer and will be up for bid.

Additionally, it will be important to monitor insurer behavior in terms of contract negotiation. While it appeared public and legislative movements doomed our right to balance bill in the near future on the state (and perhaps federal level), conceding balance billing rights brings concerns that insurers may no longer negotiate contracts in good faith. The main mechanism to assure ongoing good faith is a strong charge-based OON payment requirement, but it remains to be seen how aggressively payors will be in interpreting “usual and customary charges” and hence how aggressive they will be in contract negotiations as the law becomes effective July 1, 2016.

Likewise, the outcome of any ADR filed may influence subsequent postures – so it seems wise to closely monitor the rule development and vendor selection process before choosing an underpaid OON claim to test the revised ADR process. And in terms of aggressive insurer actions, BCBS of GA recently released sent notice to their contracted facilities enlisting the hospitals as enforcers to strong-arm hospital based providers (including EM, radiology, pathology, anesthesia, and hospitalists) to contract with BCBS-Ga at “BCBSGa market rates.”

Furthermore BCBS-Ga attempts to shield itself from any payment pressure by holding itself harmless for any extra costs of non-contracted physicians by passing those costs back to facilities as rate reductions. This is an escalation of the tactics previously used attempting to drive a wedge between the contracted providers and the facilities with which we work.

Given this environment, it is encouraging to see ACEP fight back aggressively on EP’s behalf. The recently filed federal lawsuit seeks court assistance in the battle with CMS over the “greatest of three rule.” Without transparent methodologies to determine “usual and customary” payments can be manipulated by insurers to unreasonably low amounts. The battle for fair payment for EPs is an ongoing one at both the state and federal level. Keep supporting FCEP/ACEP as they support your ability to care for your patients.

References available upon request.

D au n t i n g D iag n o s i s Question: A patient presents unresponsive to the emergency department. His urine fluoresces under the Woods Lamp. What is the diagnosis?

Turn to page 29 for the answer!

Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief SUMMER 2016 | VOLUME 23, ISSUE 2

EMpulse | 5

Government Affairs Committee The Governmental Affairs (GA) committee met at the FCEP office in Orlando on 4/20/16. Our lobbyist, Toni Large, reviewed the health care related bills that had been passed this past session. Our main focus was on the bill regarding balance billing.

After much negotiation, the bill was passed. Effective July 1 of this year, balance billing for emergency services will be prohibited in Florida.

While many feel this was not a perfect outcome, FCEP, working in conjunction with FMA, were able to advocate for many changes to the bill’s original form. These included preserving language referring to charges rather than payments, and a much improved dispute resolution process.

We are hopeful that this will allow EM practices to negotiate for adequate reimbursement from health insurance companies. Time will tell if the bill in it’s current form will achieve those goals.

Joel Stern, MD, FACEP Government Affairs Committee Co-Chair

The PC Board meeting followed the GA committee meeting. This year all House and Senate seats are up for election in Florida due to redistricting. Therefore we will be expected to make more campaign donations than usual.

In anticipation of the ongoing races, we are asking all FCEP members to please contribute to our PC. You will notice a new line item on your annual dues statement this year for our State PC. Annual dues are $100 for active members and $50 for Residents. Please give any amount you feel is affordable. There is also an online option available through our website, as well as recurring monthly donations. Thank you for supporting our State chapter advocacy program.

Finally, please save the date for EM Days 2017. This is the premier EM Advocacy event in Florida. It is scheduled for March 13-15 in Tallahassee.

Our next GA committee meeting will be August 4th at Symposium by the Sea in Naples. Looking forward to seeing you there!

Thanks to all who made contributions to the Political Committees in April and May 2016!

Brevard Physicians Associates Florida Emergency Physicians, Inc. Ademola Adewale Alexander Garcia Gonzalez Alfredo Tirado-Gonzalez Alkesh Brahmbhatt Bianca E Alvarez Amabel J. Cabatu Ashley Norse Laurie Boge Bradford J. Bowls Brian A. Nobie Caroline Molins Clifford J. Denney Dale S. Birenbaum Damian Caraballo Danyelle Redden David A. Goldman David Sarkarati Dennis A. Hernandez Ernest Page II Floriano Putigna

6 | EMpulse

Holtzclaw, Stephen G Jaime L. Massucci Jason Porter Javier Gonzalez Jay Falk Jesse Caron Jill Ward Jordan Johnson Jordan Celeste Jorge J. Lopez Joshua Young Kahang Chan Katia M. Lugo Kendall Webb Ketan Pandya Kristin McCabe-Kline Leonardo Cisneros Lisa M. O’Grady Marc Santambrosio Maritza Rodriguez Mark Kruger Max Baumgarndner

SUMMER 2016 | Volume 23, Issue 2

Miguel A. Acevedo-Segui Pamela C Miller Omaryra L. Mansfield Patricia Nichols Patrick Agdamag Paul Blake O’Brien Paul DePonte Ramon H. Nunez Regan A. Schwartz Rene Mack Robyn Hoelle Caitlin Sandman Sanjay J. Pattani Sookie bong Steven Kailes Vanessa C. Peluso Vicki Friend Vidor E. Friedman Vincent Valente Wayne Friestad Weylin C. Sing William Randall Poole

ACEP Update In my last note I shared with you what the ACEP Board of Directors focused on in our last Board meeting in April. By the time this hits the presses, we will have met again in June, and recently, we convened at the Leadership and Advocacy conference in Washington. By the way, this years’ L&A conference was our largest every with over 600 attendees, and many felt it was one of the best ever!

I think the biggest news from ACEP is that we have taken the unprecedented step of initiating a lawsuit against the Department of Health and Human Services (HHS) and the Department of Treasury (DOT) regarding the ‘final rule’ that they published in November of 2015 regarding out of network payments.

It is not every day that we sue the Federal Government!

I believe this is one of the most significant actions that ACEP has taken on behalf of it’s members, in our history. How did we get here?

In June of 2010, HHS & DOT (the Departments) issued an interim final rule to implement the ACA’s out-ofnetwork emergency services provisions. The interim final rule established a “greatest of three” methodology for determining payment for out-of- network emergency services in which the insurer must pay the greatest of the following:

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

1) the insurer’s in-network amount; 2) the usual, customary, and reasonable amount (“UCR”); or 3) the Medicare amount. In almost all instances, the highest of these three amounts will be the UCR amount. However, insurers have historically understated and prevented public verification of the UCR amounts.

Over the course of the last four years. ACEP made repeated requests that the Departments require insurers to determine UCR amounts using transparent, publicly verifiable data. The Departments refused to modify the regulation and issued the rule in final form on November 18, 2015 without requiring transparent, verifiable data to calculate UCR amounts.

They also exacerbated the adverse impact of the Final Rule on patients and emergency physicians by adding a provision stating that the minimum payment requirement does not apply in states that prohibit billing patients more than the amount covered by insurance (“balance billing”).

As it stands now, the Departments have virtually ensured that emergency physicians will be underpaid for out-of-network emergency services because insurers have proven by their past behavior that they will manipulate UCR amounts downward if given the chance. Moreover, the Final Rule leaves out-of-network emergency physicians with no minimum payment protection in states that prohibit balance billing.

The ACEP BOD felt that The Departments’ regulation is arbitrary, capricious, anabuse of discretion, and contrary to statutory law because it fails to ensure a reasonable payment for out-of-network emergency services as required by the ACA. ACEP has filed this suit on behalf of emergency physicians and patients in an effort to have this ‘rule’ reconsidered; to protect our patients, and ourselves, from the predatory business practices of some health insurers.

Membership & Professional Development Committee The summer season is officially here! In Florida, the translation usually brings on the heat! Although is officially summer, one of Florida’s greatest selling-points is that we are able to enjoy sunshine year round. In spite of this, the summer is definitely a time that we tend to become more active and interactive. This time of year, especially, FCEP and the EMLRC strive to provide you with numerous venues to learn, share and engage in some well needed wellness activities.

As the name indicates, the goal of this committee is to provide us, the membership, with access to the tools needed to help you through the various stages of your career, including education, networking and wellness.

Hmmm, where can we fulfill all those desires? Symposium by the Sea (SBS), that’s where!

Rene Mack, MD Membship & Professional Development Comittee Chair

Yes, it’s that time of year again when we all get together and enjoy a long weekend full of education (FREE CME!!) and entertainment, for you and the whole family. There is still time to register, but remember that as a member of ACEP/FCEP there is no registration fee. This year, SBS will take place at the Naples Grande Beach Resort August 4-7, 2016 and has added a Pediatrics Track and a reformatted educational series that allows for more interactive learning.

So what else is going on this summer? Are you a new grad or facing an upcoming recertification exam or want to update your knowledge base? FCEP recognized this need within our membership and have answered this need by creating a highly informative Written Board Review Course. Now, there is no need to travel out of the state for this much needed educational opportunity. This year’s session of our annual Written Board Review Course will take place from August 22-25, 2016 in Orlando at the Rosen Plaza Hotel on the famous International Drive (I-Drive).

Whether you’re preparing for the qualifying exam or the CONCERT, the process of preparing for these board exams can become overwhelming.

The course has received great reviews from the previous participants and this year promises to provide the same high caliber of quality, pertinent medical knowledge needed to excel at these required exams. Also, from the time you receive this issue of EMPulse, you will still have a few days to receive a discount for registering by July 16, 2016. Join your colleagues from across the country for a valuable educational opportunity!

This is also the time for a new academic year and we have much to celebrate in Florida! If you have not heard, we have welcomed 6, yes 6, new programs to the Florida ACGME educational programming! The new programs are: University of Central Florida/HCA at Osceola Regional Medical Center, Florida Atlantic University College of Medicine (starting class 2017), Aventura Hospital and Medical Center, Jackson Memorial Health System and Kendall Regional Medical Center. Mount Sinai Medical Center is an established osteopathic program that has transitioned to the recently formed single accreditation ACGME system.

Please join us in welcoming these programs into the important arena of educating future EM physicians. We will all be involved in educating these young doctors on the various aspects of academic, community and rural medicine; in addition, educating them (and ourselves) of the need to remain actively involved in non-clinical medicine, to help improve the future of emergency medicine.

I hope that you will take a few minutes to chat with me while you’re at Symposium and let me know how else FCEP can improve your career and well being as we fight to improve the healthcare for our patients. See you at Symposium!

EMS/Trauma Committee Well, here we are.

We began this journey years ago, well before my arrival here, when the EMS leaders and Trauma leaders in the state of Florida were meeting with the Florida Department of Health (FDOH), and together were hammering out the proposed statutes and rules for EMS and Trauma in the Sunshine state. At that time, Florida became and has remained a leader in EMS and Trauma, but we have since noted more and more that there are areas in which we should improve.

One of them has been a true state-wide Trauma system. We had (and have) great Trauma Centers, but the idea of a state-wide Trauma system of care was one that had been discussed, worked on, but not fully developed and implemented. Also, in the mix came the CDC Field Trauma Triage Guidelines, which were somewhat different from our Trauma Alert Criteria listed in Florida Rule 64J. And then to add more to the mix, we had a number of hospitals pursuing Trauma Center (TC) status at almost the same time.

Dagan Dalton, MD, FACEP

Because of legal challenges on both sides, FDOH had to address the TC issue first. A state working group was EMS/Trauma Committee Co-Chair already meeting and reviewing CDC criteria vs. Florida Rule 64J. After many Rule Development Workshops and petitions and discussions, FDOH proposed a new rule for new TCs, and this was reviewed and upheld by an Administrative Judge. Then the State Surgeon General, himself a Trauma Surgeon, recommended a review of Florida’s Trauma System, a state of the state, by the American College of Surgeons Committee on Trauma; they, in turn, made many recommendations, only one of which was a review of Florida’s EMS System by NHTSA. This was done, with the result of many more recommendations. These recommendations are each being considered and some of them now being implemented. Patience. It’s AGS: average government speed.

The most important recommendations, in the opinion of many, are those that move us towards a true statewide Trauma system: where the non TCs receive a Trauma Alert patient and effectively and efficiently triage, stabilize, and transfer that patient to a TC. The same for EMS field crews and a Trauma Alert patient. And that the TCs are closely involved with the non TCs in terms of QA, feedback, Trauma training and education, and partnering with Community outreach for Trauma awareness and prevention, within their service area.

I recently changed employment from a Provisional Level 2 TC to a relatively small, rural Critical Access Hospital. I also recently recertified in ATLS (for the 8th time). The current Rule in Florida is that emergency department physicians at TCs be current in ATLS, but not required of those at non TCs. I’m not in favor of merit badges, but the concept here is backwards. Rural emergency department docs need that training and re-training more than the TC docs. The history and evolution of the ATLS course is consistent with this: the poor trauma care an orthopedic surgeon and his family received at a rural E.D. after a private plane crash.

Here we are. It’s time to move forward, and we are. Just at AGS, be a little patient, but be involved! A true statewide Trauma system of care involves every single one of us.

Coding Tip ICD-10 Codes That Can Never Be Primary

Provided by Lynn Reedy, CPC, CEDC, Director of Coding Services, Tampa Bay Emergency Physicians By now we are gaining a new understanding of the specificity of this new code set. The best feedback you can get will come from the people handling your denials.

Some diagnoses require a primary diagnosis for the underlying condition that causes them: B97.4 Respiratory syncytial virus (RSV) as the cause of diseases classified elsewhere I46.2 Cardiac arrest due to underlying cardiac condition I46.8 Cardiac arrest due to other underlying condition I46.9 Cardiac arrest, cause unspecified; Asystole R65.10 Systemic inflammatory response syndrome (SIRS) R65.20 Severe sepsis without septic shock R65.21 Severe sepsis with septic shock Other diagnoses require a primary diagnosis that identifies the toxic element: G92 Toxic encephalopathy H10.219 Acute toxic conjunctivitis I can hear your response, “we would never have that information in the Emergency Department.” Correct, but this new code set still requires that further primary diagnosis. When you don’t have the underlying condition or cause, help your coders and the billers handling the denials by providing a symptom that can be used primary.

SUMMER 2016 | VOLUME 23, ISSUE 2

EMpulse | 9

Free-Standing ED Committee The Freestanding ED: Coming Soon to a Neighborhood Near You Article by Patrick Agdamag, MD, FACEP, FCEP Board member Even if you’ve never worked in a Freestanding Emergency Department (FSED), you probably have been hearing more about them from your colleagues or others in your practice. There’s a good reason for that: they’re experiencing rapid growth in Florida and around the country. But, before we get into stats and numbers, I would like to take a moment to give our new article section its proper introduction.

Defining the Landscape

Whenever someone unfamiliar with FSEDs asks about them, I typically hear a response that contains at least some version with the term “urgent care center” mentioned. This couldn’t be further from the truth. ACEP defines the term by the following: A freestanding emergency department (FSED) is a facility that is structurally separate and distinct from a hospital and provides emergency care.

There are two basic types of FSEDs: a hospital outpatient department, also referred to as an off-site hospital-based emergency department, and independent freestanding emergency centers (IFECs or FSEC). In most states, hospitals wanting to expand need a certificate of need to build a new hospital at a particular site. Expansions on current properties can be complex and limited by physical space. Enter the FSED which, depending on the size, typically is half the cost to build.

FSEDs are strategically built in areas or communities that have patient populations with higher commercial insurance. So for the hospital system (or individual practice/owner) this is a way to throw a cast net for their market catch, or plant a seed for a future medical center location down the line. Another new trend is dual use for outpatient services the hospital can offer a select patient population specific services-- more to come on this one later.

Services Provided

My very first shift out of residency training was at a FSED, so it felt like everyone was high acuity that day. Depending on the location, the acuity is typically lower at FSEDs than their main hospital counterparts. However, services offered must be full menu. EMTALA and CMS regulations, state hospital based FSEDs must all offer the same comprehensive emergency services - 24/7 - as their main hospital ED counterparts. This includes, but is not limited to, comprehensive lab services, CT/US, and pharmaceuticals, materials, and on-call specialty coverage. CMS regulations state the credentialing of emergency providers at the FSED - must be the same as for the emergency physicians and APPs who work at the main hospital.

In addition, medical staff privileges and organizational structure should be as inclusive, along with on-call specialty coverage.

But, before you get excited about the idea of being able to tell your favorite Urology or Orthopaedic colleague - they now have an extra ED to cover when their on-call - just remember based on the typical locations and market areas FSEDs are built - there is typically more upside for their practice than first expected. Admissions processes are the same as main ED, except the patient now needs a ride to get there. The admission rates coming out of FSEDs hover around the 7-10% range (as opposed to your main hospital’s 25%). This means more of the specialty referrals coming from FSED are outpatient referral follow-ups with patients that typically have commercial insurance. And for admissions, FSED patients who are in need of specialty consultation - can many times have it take place when your patient arrives to their floor/or unit over at the main hospital. Once your Urology and Ortho colleagues realize that this is more frequently the scenario with patients from your FSED, they may instead be looking forward to your phone call.

The Sunshine State

It should be no surprise to you that Florida has been experiencing rapid population growth over the last decade. The overcrowding and high volumes are real. You’ve seen it and felt it, after long shifts and visiting snow birds flocking endlessly now. Florida emergency department visits alone have seen a near 15% growth in visits since 2011.

In our state, there is currently only one type of FSED: hospital based FSEDs. Which means they are all owned, and operated by a hospital system. They must provide emergency services which are comparable to the main hospital ED. This differs widely from the great state of Texas, where both independent centers and hospital-based models are in co-existence. Some of you may have heard from your colleagues in Texas who share tales of the wild, wild west surrounding FSEDs. In a simple explanation - this is because Texas has both models and has created a fierce market competition in this growth model. To give you an idea of how the saying “ everything’s bigger in Texas” holds true - consider this: There are approximately 500 FSEDs across the United States. Almost half (200+) of these - are located in the great state of Texas. Florida’s first freestanding emergency department opened back in 2002 was Munroe Regional Medical Center at Timberidge, located in Ocala, FL. As of April 2016, the official count lists 24 freestanding emergency departments in our state. However the number is misleading as many are close to hatching, but have not made it to AHCA’s official tally as of yet.

Assuming current trends continue, by the time you are reading this article; there’s a good chance Florida will reach close to 30 FSEDs. With many more ready to break ground. Whether you are ready or not, there’s a good chance a FSED will be coming soon - to a neighborhood near you. I look forward to healthy growth that enhances our practice opportunities, and provides new environments for us to care for Florida’s ever growing patient population.

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SUMMER 2016 | VOLUME 23, ISSUE 2

EMRAF Committee Article by Merisa Kaplan, MD, MPH, FCEP Board of Directors Representative for EMRAF

Who says you can’t have it all?

When Dr. Randy Katz joined TeamHealth, he wanted to be part of a group with national resources, physician-focused management, a network of respected peers, long-term stability and a formalized leadership training program.

He also wanted to protect cherished time for his family and hobbies. With TeamHealth, he got it all.

During our last meeting in April, I’m happy to report that we had representatives present from most of the Florida EM programs, either in person or via phone. During this meeting, we discussed the EMRAF scholarship (application deadline in June 15). Additionally, we discussed the importance of resident-centered events at the upcoming Symposium by the Sea conference. Finally, we again addressed our main goal of obtaining support and buy-in from program directors to allow residents time off to attend FCEP/EMRAF meetings.

After our last meeting in April, an email went out to all the program directors in Florida with a draft version of a standardized method for residents to demonstrate what they do at the FCEP/EMRAF meetings to justify time off from clinical work/conference meetings. The document utilizes metrics from the CORDEM 2013 model pertinent to resident/physician tasks. The goal is to obtain feedback from program leadership to help establish a format for residents to show the value in attending these meetings.

At this time, we are still accepting feedback, so I ask all program directors to please review the previously sent document to see if they have any suggestions for the standardized document. Additionally, I request that all EMRAF board members speak to their Residency Program Directors regarding the form so that we can have an updated version available at the next meeting for review.

The next EMRAF Board meeting will be held at this year’s Symposium by the Sea conference in Naples, scheduled August 4-7th, 2016. It is our hope that residents from all the Florida programs will be represented at the meeting as residents usually attend the conference to participate in the SimWARS session and case presentation competition.

Visit TeamHealth.com to find the job that’s right for you.

888.861.4093 physicianjobs@teamhealth.com

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I highly encourage all current EMRAF members to reach out to incoming interns (if they have not done so already) to find out who is interested in being a board member so they can be in attendance; however, as always, all residents, regardless of board member status, are welcome to attend the meeting. With the recent approval of additional emergency medicine residencies in Florida, hopefully we will have more residents than ever present our August meeting, board members and leadership will be elected.

Do you want to advertise in EMpulse?

Contact EMpulse Managing Editor Samantha Rosenthal at srosenthal@emlrc.org.

Leadership Academy Update A Call for new Candidates - A Call for new Leaders Article by Patrick Agdamag, MD, FACEP, Chair of FCEP’s Leadership Academy TUMULTUOUS TIMES

As healthcare continues to evolve, we as emergency physicians, must also rise to this challenge. We have to deftly maneuver and navigate - ever rising tumultuous waters of the changing healthcare climate. We should do so as one effort. We must do it with loyalty and integrity. In order to ensure our practice of EM survives the storm - intact and emboldened - emergency physicians must organize our efforts.

(L-R) FCEP Leadership Academy Chair Pat Agdamag, MD with Leadership Academy members Kristi Staff, MD; Cesar Carralero, DO; and Gary Lai, MD at the 2015 Council meeting in Boston.

The climate of EM, particularly in the state of Florida, will be influenced not just by the Affordable Care Act, or other changes at the federal and state level. But it will also be impacted by individuals who can continue momentum already obtained - and elevate efforts to the next level. So when changes occur - we can respond in strength. When emergency physicians come together and organize with each other; something special happens - a positive synergistic effect resulting in benefit for all in our specialty.

The work FCEP has done, and paths established - have provided gathered momentum and safeguards for all who practice emergency medicine in Florida.

Despite past victories, it will take new individuals - new leaders to move and initiate plans into action. Fresh ideas and new leaders are continuously needed to step out into the battle and lead our efforts. Simply put: New leaders aren’t just welcome, they’re a necessity.

HIDDEN TALENT - IN PLAIN SIGHT

Take almost any group of practicing emergency physicians and APPs - at any hospital - and within the walls of the ED - you will likely find at least one, if not a field of potential leaders. Our specialty is truly a gold mine of underutilized/undeveloped talent. We must recognize it and assist those individuals into attaining roles and leadership positions - that work for our greater good. The path to get there, however, may not always be simple. Several factors can play into establishing and creating a proper path for an individual seeking to take on a leadership role.

For those interested in stepping into a leadership position, a common misconception is a limited field view of available or attainable roles they seek to step into - in their immediate practice surroundings (role within group, medical directorship, or hospital committee, etc). For some, depending on which hospital system you work at, how your group is structured, or the climate of your local medical staff organization; those who are wanting to take on more - may not have an avenue to do so. Add to this, the concerns of taking additional time to pursue a leadership opportunity, outside of our already busy work and life schedules - can look daunting. Despite this, I believe we have more than ample opportunity for leadership roles when compared to our colleagues in other specialties. With an even greater natural ability for leadership, than other physicians specialties - because of who we interact with on a daily basis , and the management decisions we make. Everyday. During every shift.

FCEP’S LEADERSHIP ACADEMY OPENS DOORS

FCEP’s Leadership Academy is a year long program of leadership exposure and development within the college. It is tailored to the individual looking to find a leadership role that matches their interests and discover avenues not once seen. Our goal as a Board was to have the Academy combine elements of mentoring, organization, and guided experiences to selected Academy participants who wanted to grow in their interest area of EM. The idea is to graceful exposure to various networking and leadership experiences spanning across the state of Florida and beyond. Three main goals that are achieved for graduates are networking, mentorship, and ultimately taking on an administrative project of their own.

TIME REQUIREMENT: LESS THAN YOU THINK

The Academy experience allows participants to develop leadership without sacrificing significant time in doing so. So, whether an upcoming Written Board exam you are studying for , LLSA test you procrastinated on, obligatory In-law family event, or any important commitment you have: We will respect that time and work with you. The time commitment for the Academy schedule is customized to fit the hectic schedules we have in our busy practices. We recognize personal and family commitments and will work with you to ensure they are not disrupted. Basically, expected attendance and participation is centered around 2 annual conferences and 2 quarterly Board/Committee meetings. The cost of attendance for the Academy program itself is free, and group practice sponsorship is encouraged to help cover any costs for travel and attending conferences.

The typical venues include FCEP Board and Committee meetings; state legislature meetings in Tallahassee, Symposium, and ACEP’s Leadership and Advocacy Conference in D.C. The upcoming application process and selection for 2016 -2017 Academy class is still open. FCEP is once again opening the call to applicants who are ready to take the next step as leaders. Visit EMLRC.org to fill out an application today, or email any direct inquiries to pagdamag@gmail. com or agdamagp@usacs.com.

On behalf of FCEP, I welcome all who have made the commitment to their practice of emergency medicine today, and those who desire to be leaders tomorrow. Please step forward - the Leadership Academy welcomes you.

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SUMMER 2016 | VOLUME 23, ISSUE 2

EM p u l s e F e a t u r e FCEP Leaders Attend ACEP’s Diversity Summit Article by Sanjay Pattani, MD, MHSA, FACEP, FCEP Government Affairs Commitee Co-Chair Emergency Medicine is one of the most unique specialties within the House of Medicine, serving a patient population that is not biased by payor mix, diagnosis, or daily scheduling conveniences. Our patients are diverse, in age, gender, race, religion, LGBT (Lesbian, Gay, Bisexual, Transgender), and geography characteristics. Each of these patient groups increasingly require a highly diversified, culturally sensitive, and intellectually flexible clinical approach from our emergency care workforce.

Recognizing a potential mismatch between patient needs and the current ED provider composition/preparation, ACEP’s Board of Directors has added an objective to its Strategic Plan “to promote and facilitate diversity and cultural sensitivity within ACEP.” Key questions for ACEP include how does our specialty address the challenges associated with the landscape of clinical patients that changes by the minute? How do we prepare ourselves to improve the quality of clinical emergency medicine within the proposed cultural paradigm shift?

On April 14th, 2016 ACEP’s Diversity Summit was the launch of ACEP’s focus on diversity and inclusion. Twenty emergency physicians from across the country attended the summit, many of whom with publications or leadership roles in diversity and inclusion. I had the honor of attending and participating in the Summit.

Lets face the reality--patients feel more comfortable communicating and interacting with physicians and other providers who look like them and have similar life experiences. Diversity and inclusiveness has the potential to improve not only the patient’s experience of care, but actual patient care and increased compliance with medical recommendations. Diversity among providers also creates a better opportunity to investigate strategies to reduce disparities in health care.

Additionally, fostering real diversity and inclusiveness will enhance the reputation of ACEP internally within our specialty and externally to policy makers, the media, and the public. Diversity elicitis diverse viewpoints and new perspectives. It leads to creativity of thought, collaboration, and effectiveness in solving problems, and expansion into new markets. Organizations have the opportunity to overcome collective biases as they bring diversity of thought into their discussions.

According to ACEP President-Elect Rebecca Parker, “forward-thinking leaders of emergency departments and ED groups must ensure they have every advantage in delivering the best patient care possible not only because it is the right thing to do, but also to ensure better reimbursement, minimize liability risk, and attract and retain the best talent. Focusing on promoting diversity and inclusiveness has the potential to attract new members, to retain those members, to engage with them, and give them opportunities in leadership and to pursue their interests. This is important for the long-term growth and stability of the organization.”

Although many organizations have addressed diversity, nobody (especially within the House of Medicine) has a clear strategy or directive towards it. We have a great opportunity to strengthen and promote best emergency medicine health care practices, improve the member experience through inclusion initiatives, and enhance the perception of FCEP/ACEP as being a great place to network no matter who you are or where you come from. We are embarking on a transformational change in our organizational culture.

The journey will be challenging, but promoting this diversity initiative will enhance our future success in delivering high-quality, culturally sensitive patient care. It was a pleasure working and learning from many of the leaders at the Summit, and I solicit your concurrent and forever bound attention to inclusion and diversity.

Florida International Trauma Life Support Update Para-medicine: Making the Choice

Article by Jeffery D. Gilliard, NRP/CCEMTP/FPM, BS, FITLS Chapter Coordinator/Affiliate Faculty In May of 1983 I began my adventure into the world of para-medicine by attending the paramedic program at Brevard Community College in Cocoa, Florida. And with the patience, mentoring and butt kicking from our instructors we all made it. At the time I was working part-time as an EMT with Herndon Ambulance in Orlando Florida and was pretty convinced that I was going to extend my training into civilian para-medicine.

When the opportunity came I jumped at it with excitement and started to prepare myself mentally for the commitment. I was not at all hesitant to expand my knowledge of emergency medical care but I was surprised to see what was going to be required in my new adventure. Everything from cellular structure, acid base balance, acute medical conditions, multi-traumatic injury and how they all tie together. It was astonishing and a bit overwhelming to say the least. To be able to look at an ECG strip and understand what each deviation of the line represents was mindboggling and exciting at the same time. I would never had imagined it would lead me to be able to determine what is going on with a patient’s heart and how to fix or facilitate the beginning of the healing process.

During the first few weeks of my journey I learned how the human body is designed, or supposed to be designed, and how it is supposed to work under normal conditions. I was especially fascinated with the way a body reacts to stress and trauma. I was aware of many of these processes but breaking them down to a cellular level gave more clarity as to why our bodies require balance to maintain life. We learned what organ systems do, what cells they are made of, what they require, and how they change with age. How life is sustained in the most critical of events and how simple solutions can have the biggest impact on maintaining life.

We also learned that in the paramedic field you can’t rely on everything being a cut and dry situation. Anything can happen and it will be up to you to determine how, what and why it’s affecting your patient, then start fixing or reversing it. One way to compare today’s paramedic is the old west “Town Doctor.” They came into the streets to aid those shot in a gunfight or to the home of the ill or injured.

Paramedics are making decisions and acting upon them in an instant, in the most uncontrollable of environments, no fluff here! We are the field decision makers, we diagnose, treat, maintain, revive, then pass onto a facility to continue what we have started.

Paramedics are equipped with tools and knowledge in order to determine how to assess a person’s body. Even with no information provided we can sniff out a good idea of what is going on with a patient and start to comfort, end suffering and facilitate healing. The Body is a well-oiled machine, and like anything else needs attention from time to time. Requiring electricity, fuel, and rest the body is resilient and with the paramedic’s assistance can survive the worst of conditions. It is up to us to determine where the aberrant conditions take place and support their return to normality. Each of us have a plumbing, disposal, defense, and storage systems and don’t always take care of them. We are like small walking cities with our own infrastructure and management processes. Having the ability to make critical decisions is paramount for the paramedic. So many of our situations are high stress and can have no room for error or delay. We also bear witness to our efforts not having positive outcomes. We then have to overcome feelings of sadness, doubt and stress by realizing we could not change those individual’s fates. This can be very stressful and cause extreme ripples in or job, home life and relationships.

Ultimately causing us to lose focus, when we need to remain ready to act and do our best for our next patient. In our careers we are subjected to being exposed to many dangers and situations that will affect us for years and years or may even take our life.

Paramedics are committed to serve the human race and do no harm to those we are called upon to treat. Our eyes see humanity with two distinct differences only, Woman and Man. Each of us are blind to color, sexual identity or preference and respect all human ideas, religions and cultures equally. We are the ears, eyes, and the first line of care for the community and expected to do the right thing in all situations. The public holds all of public safety in high regard and standard, we are a vital part of a society to maintain health and life in people from all backgrounds and races. We are judgment free and can be the difference of life and death with one decision.

Pretty serious stuff if you ask me. Knowing that we make decisions for the sick and injured that may cause them to die or suffer greatly is a lot to carry. Each of us has an unwritten mandate to stay educated and continue our mission of reducing mortality and morbidity to the communities we serve. My goal, to be the oldest paramedic on the planet, still teaching and hopefully mentoring to those who will listen!

We should always strive to be humble in our roles in paramedicine, thou sometimes it can be trying. As mentors we can give life and career shaping advice to future emergency responders in our community. We are all here for one reason, that’s to help all people maintain life and reduce suffering while here on this precious earth. We may be called upon at any time, even when away from the job.

Our creed demands us to be ready to serve those who call with the respect, dignity and humbleness that we hope a responder will do for us when we call. Cheers!

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SUMMER 2016 | VOLUME 23, ISSUE 2

Poison Control Now We Got Bad Blood: Novel Oral Anticoagulant Reversal Kellie Rodriguez, PharmD, BCPS PGY2 Emergency Medicine Pharmacy Resident UF Health Jacksonville Novel oral anticoagulants (NOACs) are comprised of two drug classes based upon their targeted factor in the coagulation cascade. Factor Xa inhibitors include rivaroxaban (Xarelto®), apixaban (Eliquis®) and edoxaban (Savaysa®), while dabigatran (Pradaxa®) is the only oral direct thrombin inhibitor (DTI) available in the U.S.1-4 The most distinctive characteristic of NOACs is the lack of routine monitoring required. Additionally, these agents do not reliably affect many of our available coagulation assays, such as the activated partial thromboplastin time (aPTT) or international normalized ratio (INR), making identification of patients at risk of toxicity more difficult. Studies have shown, however, that the dilute thrombin time (dTT) has a linear response to dabigatran concentrations and the anti-factor Xa assay has a similar response to factor Xa inhibitors, offering providers with parameters to quantitatively measure the effects of these agents.5-6 The drawback of these assays is that they are not widely available in the U.S. Until recently, there had also been a deficit of antidotes to reverse these agents. The approval of Idarucizumab (Praxbind®) in late 2015 marked the start of a new era in reversal of NOACs. Idarucizumab is recombinant humanized antibody fragment that targets dabigatran with approximately 350 times more affinity to dabigatran than dabigatran’s affinity to thrombin.7 In an interim analysis of the REVERSE-AD trial, a prospective cohort study in dabigatran-treated patients with life-threatening bleeding or requiring an urgent procedure, idarucizumab, dosed as a 5 g IV bolus, achieved reversal of the studied coagulation assays in 88-98% of all patients and a median time to clinical bleeding cessation of 11.4 hours in bleeding patients.8 Notably, over 50% of patients required additional blood products, such as fresh frozen plasma (FFP) and packed red blood cells (PRBCs). Thrombotic events occurred in five patients and may have been due to delay in re-initiation of dabigatran after reversal. Major considerations of this trial include the small sample size of 90 patients; lack of randomization, blinding or a control group; limited availability of laboratory assays studied; and a prolonged time to cessation of bleeding of ~11 hours despite use of additional required blood products. Furthermore, the average wholesale price for the FDA-labeled dose of 5 g of idarucizumab is $4200, making cost an important consideration as well.9 Andexanet alfa is a recombinant, modified factor Xa molecule that serves as a decoy to target both direct and indirect factor Xa inhibitors.10 Andexanet alfa, dosed as an IV bolus followed by a 2-hour continuous infusion, was studied in 145 healthy volunteers receiving either apixaban (ANNEXA-A) or rivaroxaban (ANNEXA-R) in standard doses until steady state was reached and compared to placebo.10 In both treatment arms, the study drug demonstrated a significant decrease in anti-factor Xa activity when compared to placebo and no serious adverse or thrombotic events. Limitations of this study include a healthy volunteer study population and a lack of assessment of clinical outcomes. This agent is currently undergoing phase 4 clinical studies and has not yet been FDA-approved.

Aripazine, also known as PER977, is a small molecular antibody with activity against Xa inhibitors, DTI, low molecular-weight heparin and unfractionated heparin.10 This agent is currently undergoing phase 2 studies, however has shown promising results in a placebocontrolled randomized trial in healthy patients, reversing effects of edoxaban and sustaining these effects for over 24 hours with mild adverse effects.11 With the recent approval of idarucizimab for dabigatran reversal, and other target-specific reversal agents coming down the pipeline, the management of NOAC reversal will be revolutionized. It is, however, imperative to consider the level of evidence

SUMMER 2016 | Volume 23, ISSUE 2

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R e s i d e n c y M at t e r s Catch up with our Emergency Medicine Residency Programs and see what they’ve been up to.

Florida Hospital Jessica Aun, DO PGY II

It is hard to believe summer is already here!! We’re so excited for the arrival of our new interns. We have a great group of newcomers graduating from the University of South Florida, Lake Erie College of Osteopathic Medicine, East Tennessee State University, and William Carey University College of Osteopathic Medicine. Unfortunately, with the coming of the interns, we will be saying goodbye to our senior residents. It is always bittersweet to attend the graduation of our third year residents (featured in the picture). Fortunately, five out of our six, will be staying local to Orlando, with the sixth resident moving to California. We’ve had several great events over the past several months including our Annual Program Evaluation Retreat with a day at Universal Islands of Adventure. Recently several residents and members of our faculty attended SAEM in New Orleans where there was tons of learning, amazing beignets, and great Creole food. Our residency looks forward to an exciting summer full of many learning opportunities and interesting cases.

As another academic year comes to an end, it’s once again time to look back at an exciting year of big steps for the UF EM program. Earlier this year, the residency was approved to increase from eight residents a year to fourteen. Then in March, we had a successful match, filling all fourteen spots with worthy candidates who will be starting with us in July. Please join us in welcoming: Jason Argran, Josh Altman, Brittany Beel, Chacey Bryan, Alicia Buck, Chris DeFreitas, Nicole Hardy, Kevin Hord, Spencer Johnson, Travis Murphy, Ryan Roberts, James Sanstead, Catherine Uthe, and Joseph Violaris.

We also want to send a warm welcome to the youngest member of our family, Baby Zach Zeglam, our own PGY-2 Taylor Zeglam’s first child.

Some of our own senior residents will be staying with us a little longer, much to the other residents’ pleasure.

Dr. Hwang, one of our current chief residents, will be staying to fulfill an EMS fellowship, and Dr. Mora will be staying for the ultrasound fellowship. Dr. Kikukawa will be staying close and practicing at the Kanapaha ED, a standalone ED affiliated with UF Health. Dr. Bucciarelli and Dr. Adarsh Patel will both be going to Clearwater to practice at Morton Plant. Dr. Moore and Dr. Pawlowicz are heading to Dallas to work with Questcare Partners.

Dr. Pratik Patel will be in Orlando working for EMPros.

University of Florida, Gainesville Merisa Kaplan, MD, MPH

Finally, a big congratulations goes out to Dr. Rasheed and Dr. Bell, our 2016-2017 chief residents, and Dr. Zeglam and Dr. Estrada, our 2016-2017 academic chief residents. While they have some big shoes to fill, we have no doubt they will all do an excellent job in their new positions.

St. Lucie Medical Center Rege Turner, DO PGY-III

The residency at St Lucie Medical Center is about to part ways with their senior class. Dr. Chantelle Dufresne will be practicing at Good Samaritan Medical Center in West Palm Beach, Florida. Dr. Rick Carlson will be practicing at Good Samaritan Medical Center in Lafayette, Colorado. Dr. John Collins will be joining Martin Memorial in Stuart, Florida. Dr. Brant Hinchman will be joining Martinsville Memorial Hospital in Martinsville, Virginia. We are pleased to announce that all four residents passed their written boards. We will be sad to part ways with such a stellar group of physicians, but are excited to welcome the class of 2020 this upcoming June, which will be composed of Austin Hudson, Michael Gulenay, Blaire Laughlin, and Jeremy McCreary.

It is such an exciting part of the year at ORMC. All of the third years are graduating, and the second years are taking over leadership for the program. Congratulations to the new chiefs – Rich Brown, Stacie Miller, and Mihail Stojanovski. You all are sure to be great leaders for the residency. Another congratulations to the new quality officers Ryan Queen and Alexa Rodriguez. We couldn’t be more excited for this group and all they will bring to the program.

It was another successful year at SAEM. We are proud of our Ultrasound Team who had a great showing and represented ORMC well.

We would like to extend a Big Welcome to all the new incoming interns that will be joining us in July. Enjoy this last month of freedom, before Dr. Falk puts you to work. Another big congratulations to all the graduating seniors, most of whom are staying in or around Orlando. One is even having a baby – congratulations James Brown! In addition best wishes to Matt Dean on his recent marriage to former ORMC graduate Danielle Dragoo.

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SUMMER 2016 | VOLUME 23, ISSUE 2

Orlando Health Tory Weatherford, MD

Greetings from sunny South Florida! While sitting by the pool surrounded by picturesque views of Biscayne Bay, sipping an iced coffee during a much enjoyed yet seemingly infrequent lull in the fast paced EM residency schedule, no other welcome (although quite cheesy) seems appropriate. Another year passed, although not without accomplishments, personal triumphs, educational milestones, and residency progress that cannot go without being highlighted.

As formerly the only emergency medicine residency in South Florida, Mt. Sinai Medical Center will join others for the 2016/2017 academic year, this time as a fully accredited ACGME residency. We will start the year with seven new residents, handpicked from a record number of astonishingly talented applicants. As seven are gained, five of our seniors will continue on in their careers with extraordinary opportunities that represent the very definition of “light at the end of the tunnel.” The majority of our seniors will continue to bask in the Florida sun; Drs. Gina Petrakos, Harrison Borno and Bobby Betancourt will become attendings at Martin Memorial, Mount Sinai Matthew Brooks, DO Westside Regional, and Homestead Hospital respectively. Dr. Benjamin Abo with continue his passion for being a first responder in an EMS fellowship at the University of Florida in Gainesville, and Dr. Akash Mehta will enjoy a change in scenery at West Los Angeles Medical Center.

The emergency medicine residency at Mt. Sinai will continue into its 18th year full speed ahead with an increasing emphasis on cutting edge up-to-date medical practice. This is in addition to our already proven excellence in patient care for the entire population of full time residents and tourists of the coastal resort city of Miami Beach. Not being a tertiary care center, our residents become incredibly comfortable handing procedures and cases normally managed by trainees in the respective subspecialties. This proves to be invaluable in our goal of producing well rounded attendings that are comfortable managing any emergency that presents itself. We continue to participate and excel in academic research (ie. REBOA, Sepsis, US), SimWars, conferences, and any and all of the various GME opportunities presented to us, all the while churning out some of the most well-versed emergency medicine residents in the state of Florida. From all of us, work hard, play harder, and we will see you at the beach!

The last three months at UF Jacksonville have been busy, to say the least. Clinically, the UF-Jax Faculty continues to expand with the addition of Dr. Kim Fredericksen and Dr. Michael Mohseni at the UF North campus.

Academically, UF Jax was well represented at SAEM. Dr. Christina Cannon presented a poster on sepsis protocols and reducing inpatient mortality, Dr. Chris Zernial gave an oral presentation on medical student education, and Dr. Adnan Javed gave an oral presentation on predictors of death from severe sepsis. Drs. Lexie Mannix, Amanda Young, Melissa Parsons, and Ryan McKenna (a graduate of our program and current Simulation Fellow at the Mayo Clinic-Jax) participated in Sim-Wars.

Our own Dr. David Caro went above and beyond to help ensure Sim-Wars was both entertaining and educational.

Our Sono Games team included Drs. Lexie Mannix, Christina Cannon, and Bryant Lambe, led by Drs. Petra Duran-Gehring and Andrew Shannon. From a residency administration perspective, rising PGY-3’s Lexie Mannix, Adnan Javed, and James Barr began their duties as Chief Residents in May.

University of Florida, Jacksonville Jason Arthur, MD

We also want to thank Drs. Christina Wieczorek, Caleb Powell, and Bryant Lambe for their service as Chiefs this past year, and congratulate both Drs. Wieczorek and Powell and their families, who are both expecting babies this summer, and offer our congratulations.

Lastly, the UF-Jax Family would like to thank Dr. Lisa Jacobson for her years of service as Associate Program Director. Dr. Jacobson is beginning an exciting new chapter in her career in Hawaii, one we hope is accompanied by a very comfortable couch on which Residents can crash when we visit.

Greetings from the University of South Florida! We are well on our way into the spring season here in Tampa, and gearing up to welcome our incoming intern class. They have some big shoes to fill as our current seniors head out to academic positions, community positions and fellowships throughout the country.

Recently, doctors Juliana Lefebre, Elizabeth Mannion, and Talor Matthews, presented posters at FLAAEM in Miami.

Doctors Lefebre and Matthews were awarded two of the top four prizes for their posters and accompanying oral presentations. Congratulations to our ultrasound team who competed at SonoGames at SAEM in New Orleans.

They won best team costume for the second year in a row! They worked incredibly hard in the weeks leading up to the competition and we are proud of their effort and commitment.

University of South Florida Talor Matthews, MD

Finally, we bid a happy retirement to one of our long-favorite attendings, Dr. Cathy Carrubba. In 30 years of practice, she influenced enumerable medical students and residents in the pediatric emergency department.

Her tireless efforts as Medical Director of Tampa Fire Rescue will leave a lasting legacy in pre-hospital care in the Tampa Bay Area and beyond. Thank you, Dr. Carrubba, for always pushing us to be better!

SUMMER 2016 | VOLUME 23, ISSUE 2

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EM p u l s e F e a t u r e A Look Ahead at the 2016 Election Season Article by Damian Caraballo, MD, FACEP, FCEP Board member, Co-Chair of PEC & EPF This election season appears to be a wild one. We’ve all heard about the circus surrounding the presidential elections. Not to be outdone, Florida is undergoing re-districting for its state legislative seats. For the first time in years, seats that once were an easy win with little opposition for both republicans and democrats now will be shaken up, placing many legislatures in an election day fight for the first time in years. Further, many familiar faces in the House will be running for senate, further shaking up the legislative power in Tallahassee.

With this looming change in power structure, the FCEP PAC will need your help more than ever to make sure we continue to support our friends of medicine in the Florida legislature. Without support, legislature will turn to other groups such as the insurance and trial-lawyer lobby to fund their campaigns. In doing so, we will concede our influence over laws which will strip away at the autonomy and rights of Florida emergency physicians, putting further strain on our already over-taxed emergency departments.

Damian Caraballo, MD, FACEP

The upcoming 2017 political picture looks to have new fights to be fought on behalf of emergency doctors, FCEP Board member including the threatened end of the Personal Injury Protection (PIP) Insurance. PIP is in place as part of the no-fault auto-insurance in Florida, which assures all Florida drivers are covered for $10,000 in bodily harm in an auto accident for the first month of treatment in an automobile accident. This includes an ear-marked $5000 for physician bills. Auto Insurances such as All-State have all ready started to decrease reimbursement under PIP, by paying less than Usual and Customary Charges.

Completely abolishing PIP could place undue pressure on Emergency Physicians, as traditionally PIP insurance reimburses quickly and at a favorable rate for Emergency Physicians. With all the motor vehicle accidents seen in ED’s throughout Florida, any threat for timely payment will threaten the viability and access to emergency physicians and specialists in Florida’s busy emergency departments.

FCEP will continue to fight for Florida’s emergency physicians. This prior session, FCEP fought off a brutal insurance attack at fair physician reimbursement in the battle over balance billing. Had the law passed as originally written by insurances, Florida EM Physicians would have seen drops in revenue as high as 30-40%, while facing continued increasing patient volumes and ever-threatening malpractice claims. Through the help of FCEP’s members and PAC, we were able to strike a compromise which assured Florida’s emergency physicians that we receive usual and customary charges at local market rates for out-of-network insurance providers.

It is through the hard work of FCEP staff and your continued support for the FCEP PAC that we are able to fight off the ever-present influence of insurance companies and trial lawyers. Insurance companies contribute more money to campaigns in Florida than any other industry. Without financial support to pro-physician PAC’s, such as FCEP’s PAC, we face an unwinnable battle versus heavily funded groups whose self-interests counter the best interests of Florida Emergency Physicians.

Please support the FCEP PAC—it is our only chance to continue our well respected position with Florida Legislature to assure we can wield influence on pro-physician policies. Without support, legislature will turn elsewhere for advice and for bills, and rest assured any Trial-lawyer or insurance Bill will certainly hamper your ability to best care for patients and be reimbursed in a fair and appropriate manner.

Many doctors complain about the current loss of autonomy and outside influence on their practice of medicine. By giving to the FCEP PAC, you are assuring your voice is heard in Tallahassee, and are working to arm emergency physicians with the power and voice needed to take back control over patient care.

Please give today—visit www.emlrc.org/fcep-pac-donations to donate.

Emergency Medicine Days 2017 SAVE THE DATE Advocacy in Action!

DATE:

March 13-15, 2017

LOCATION:

Hotel Duval Tallahassee, Florida Stay tuned to EMLRC.org for more information about the EM Days 2017!

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SUMMER 2016 | VOLUME 23, ISSUE 2

EM p u l s e F e a t u r e That’s a Wrap!: ABCs of Pediatric EMS 2016 Article by Jennifer Thelen, RN, BSN, CEN, CPEN, 2016 ABCs of Pediatric EMS Chair Pre-hospital pediatric care is a vital component in the treatment of the ill or injured child. In emergencies EMS providers are often the ones that initiate life saving and directed medical care of the pediatric patient. However, pediatric emergencies represent only a small portion of the total amount of calls to which EMS providers respond. Furthermore, within this small percentage of calls, pediatric patients range in size and age from newborn to teenage children. These two factors play a huge part in the unfamiliarity of pre-hospital providers with pediatric patients. In order to improve pediatric care in the pre-hospital setting, more training needs to be done for our EMS providers.

In order to help improve the care of pediatrics in the field, ABCs of Pediatric EMS conference was launched three years ago. The goal of this program is to provide EMS providers with increased knowledge and skill on how to care for the pediatric patient. On May 26, Orlando Health hosted the 3rd annual ABCs of Pediatric EMS conference. Approximately 80 EMS providers, representing various agencies from all of Central Florida, were in attendance.

The conference consisted of both lectures and hands on skill labs. Lecture topics included Special Needs Children, Pediatric Transport, Pediatric Trauma, and Pediatric Pain Management. Skills Lab Stations included Pediatric Transport, Pediatric Trauma, Airway Management, and the Special Needs Child. Those in attendance showed great enthusiasm and were eager to practice their skills during our simulations in the skills lab portion of the day. The faculty for this conference consisted of physicians, paramedics, and nurses from all three children’s hospitals in the Orlando area. My hope is to continue to provide pre-hospital personnel with the knowledge and skill required to appropriately care for the pediatric population in our surrounding communities.

Not only is it crucial to properly prepare EMS for pediatric emergencies. It is also important to prepare parents for medical emergencies that involve a child. One of the most critical components to this is the prevention of an injury to occur. On May 18, we celebrated EMS for Children Day as part of Healthcare week.

Tina Wallace, the Trauma Coordinator for Arnold Palmer Hospital for Children, played a huge part in making this day successful in our community. Tina, along with members of the local fire department, visited some of the local Orlando preschools. Fun education was done with the children on being safe around water. Educational resources on water safety were also sent home to the parents. The children were allowed to explore the fire engine and get up and personal with the firefighters and EMS personnel. They were taught that firefighters are there to help them even if they look intimidating in their funny outfits.

In alignment with the mission and future goals of the EMSC, May was full of successful events. Both ABCs of Pediatric EMS conference and EMS for Children Day were helpful in both the primary prevention of injury in children as well as improving pediatric knowledge among EMS providers.

TURN TO PAGE 20 FOR PHOTOS OF ABCs OF PEDIATRIC EMS 2016!

Snapshots of ABCs of Pediatric EMS 2016 All photos taken by Samantha Rosenthal

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SUMMER 2016 | VOLUME 23, ISSUE 2

EMLRC’s EMS Leadership Program

Coming Fall 2016

NEW EMERGENCY MEDICINE RESIDENCY PROGRAM

The University of Central Florida College of Medicine and Hospital Corporation of America are excited to announce a new Emergency Medicine Residency program at Osceola Regional Medical Center.

Stay tuned for more details

ucfemergencymedicineresidency.org U N I V E R S I T Y O F C E N T R A L F LO R I DA

College of Medicine

SUMMER 2016 | VOLUME 23, ISSUE 2

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EM p u l s e F e a t u r e FCEP Visits Washington D.C. for ACEP’s LAC 2016 Article by Jordan Celeste, MD, FCEP Board member Photos courtesy of the Florida College of Emergency Physicians This year, ACEP members convened in Washington, DC to discuss the most pressing health policy topics facing our specialty. Over four days of meetings provided attendees with a survey of the landscape, as well as thoughts about what the future holds for emergency medicine in the rapidly evolving healthcare environment.

Apart from the formal sessions, many committees and workgroups met as well to address issues such as alternate payment models (APMs), quality measure development and implementation, sobering centers, and freestanding emergency departments. The conference also saw the meeting of the Emergency Medicine Foundation (EMF) Board of Trustees, who approved a budget with over $1.7 million dollars in grants – a record for the organization.

The formal educational content kicked off on Sunday, though, with EMRA and the Young Physician Section (YPS) of ACEP holding another immensely successful half day of programming entitled Health Policy Primer – a must-attend event for anyone new to advocacy. Featured speakers included Michael Granovsky, Douglas McGee, and Brendan Carr, and covered topics from payment issues to GME funding and beyond.

Monday’s content did not disappoint, with the bulk of it centering around the alphabet-soup-like environment that we find ourselves in. Following the ACA and then the repeal of the SGR, we are left dealing with issues such as MACRA and how ACEP’s CEDR can be used for MIPS… (head to acep.org for more information about these as well as other pertinent issues facing emergency physicians). Another huge issue facing our specialty is how exactly emergency medicine might fit into APMs, and this is being explored via a task force with EDPMA as well as through other avenues.

AMA President Dr. Steve Stack (second from the right) with FCEP members Drs. Todd Slesinger, Jay Rao and Danyelle Redden at ACEP’s Leadership & Advocacy Conference in Washington D.C.

A clear highlight of the educational content was the talk regarding out-ofnetwork and balance billings led by Ed Gaines, Dr. Alison Haddock, and our very own Dr. Steven Kailes, FCEP President. Mr. Gaines focused on the issue at a federal level, while Dr. Haddock took it down to the states. Dr Kailes provided a wonderful overview of the not-always-wonderful experience that we recently had in Florida. The topic of out-of-network payments continues to be incredibly pertinent, as ACEP has launched its Fair Coverage initiative surrounding the issue, and has now moved to sue the federal government regarding the “greatest of three” language found in a CMS regulation.

Following the educational content of Monday were the actual hill visits Tuesday. ACEP members met with members or staff of the House and Senate, focusing discussion on current legislation to protect EMS’ ability to use controlled substances to treat ailments such as seizure and severe pain, to expand mental health resources, to develop protections for EMTALA-related care, and to address the opioid epidemic. The Florida group had very positive experiences meeting with the legislators and/or their staff and believe that our voices were heard, although the real work of advocacy must continue year-round. Part of that work includes contributing to both NEMPAC as well as FCEP’s PAC, as your dollars can contribute to the cause even if you are not able to lend your actual voice.

The final day of the meeting centered around the topic of leadership – delving into such matters as diversity, burnout, and generational issues in the workplace. An all-star panel of speakers led the sessions, including Dr. Steven Stack, AMA President, Dr. Paul Auerbach, Dr. Robert Strauss, and Dr. Tracy Sanson. The final day of the Leadership and Advocacy Conference continues to develop FCEP leaders with U.S. Congressman David Jolly during a private tour of the capital into a wonderful day of programming, and all should consider at ACEP's LAC16. extending their stay to attend this CME content.

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EM p u l s e F e a t u r e Emergency Nurses Visit Washington D.C. to Advocate for Emergency Care Article by Kevin Captain, RN, NREMT-P and Terri Repasky MSN, RN, CNS, CEN, EMTP The national Emergency Nurses Association (ENA) strongly advocates for legislative issues that affect emergency care. Three Florida Emergency Nurses’ Association (FENA) members recently visited Washington DC to attend “Day on the Hill, learn more about government affairs and to visit legislators. Penny Blake (West Palm Beach), Brenda McCarthy (Clearwater), and Kevin Captain (Daytona Beach), participated in the ENA’s Day on the Hill, a program orchestrated by the ENA designed to educate and support nurses interested in Government Affairs. After the formal program, these nurses visited the DC offices of Representative David Jolly, Jeffrey Nowill (Rep. Patrick Murphy), Becca Brown (Rep. Ron DeSantis), and Alyssa Wang (Senator Bill Nelson).

ENA’s Day on the Hill is an important, often unrecognized, activity that promotes national advocacy for emergency care. Many are not aware how much difference one individual can make when it comes to sitting down and communicating issues with their congressional representative or state senator, who, contrary to popular belief, really do listen to constituents. Congressional members may not be aware of or have working knowledge of the issues faced by emergency providers. Nurses, by providing this information, can greatly influence whether a politician sponsors or co-sponsors a bill. This is the golden opportunity for emergency nurses to educate politicians on healthcare issues that ultimately affect their own personal lives as well. After completing the Day on the Hill program, speaking to a congressional representative or their staffing liaison(s) is not a formidable experience; the ENA provides comprehensive preparation to ensure each encounter is emotionally memorable, effective, and change-evoking for the legislative parties.

The Florida nurses mentioned above advocated for several pending bills that will affect emergency care and emergency medical systems in Florida. Primary focus was on two bills: H.R.2646 (Helping Families in Mental Health Crisis Act) and H.R. 4365 (Protecting Patient Access to Emergency Medications Act).

The mental health bill(s) are designed to improve funding and reimbursement for mental health services with the intent to decongest emergency departments and better facilitate patient transfers for appropriate mental health treatment. The bills also assist by adding grant funding for mental health providers and allowing same-day billing for both medical and mental health services. The FENA members related “real life” stories and situations illustrating the need for mental health funding.

The Protecting Patient Access to Emergency Medications Act is a proactive bill that has been created in an effort to preserve today’s EMS practice of administering controlled medications, such as narcotics and benzodiazepines under the EMS medical director’s standing orders. This practice is not currently recognized under the U.S. Drug Enforcement Agency’s Controlled Substances Act, a set of rules authored in 1970, long before the development of Emergency Medical Services. Without legislation EMS personnel will not be allowed to administer controlled substances as part of standing orders/protocols.

Overall, the Florida congressional visits were very positive and the nurses recognized prevailing opportunity to increase interaction with and influence representatives in Washington. They look forward to advocating for Emergency Care along side with FCEP in the future.

Florida ENA Board Member Recognized During Nurses’ Week On May 8, 2016 during nurses’ week the Gainesville Sun published a special edition “Salute to Nurses” and recognized nurses for a job well done. Member of the community nominated nurses for recognition and Ms. Paula Davis, the Secretary of Florida ENA State Council was one of the nurses.

Paula works at the Gainesville Veterans Affairs Medical Center; her nominator wrote “Besides being a joy to know and work with, Paula exemplifies what a nurse is all about.

Her primary focus is always on the patient. She has gone above and beyond so many times to make sure the patient gets the best care possible. She also does her best to make sure her co-workers get the assistance and training they need in order to do their jobs.”

Congratulations Paula! FENA and FCEP are proud of you!

EM p u l s e F e a t u r e A L o o k A h ea d : C l in C o n 2016 Article by Rachel Semmons, MD; 2016 CLINCON Co-Chair By the time this article reaches your mailbox, CLINCON 2016 will be less than a week away. Each year we challenge ourselves to bring new innovations and cover the hot topics in prehospital medicine. As a result, even though the conference has existed for more than forty years, the privilege of preparing lectures and skills labs to arm our prehospital providers never grows old.

As one of the members of the planning committee, I feel it is one of the most valuable events that the EMLRC has the opportunity to host.

I’m excited to share with you what I believe to be some of the highlights of the upcoming conference. The event will take place at the DoubleTree by Hilton near the entrance to Universal Studios in Orlando. Planning this year centered on the development of learner tracks that will engage both the beginning prehospital provider, as well as those with more experience who are looking to develop their critical care management skills. We are also pleased to present a new track this year that explores mobile integrated health. The faculty roster includes speakers from throughout the state as well as visiting lecturers. As in years past, the conference will include the Bill Shearer ALS/BLS Competition. Who doesn’t enjoy some intense, spirited competition?

The first morning of the conference will open with a lecture by Dr. Brent Myers on the future of EMS. Dr. Myers is medical director of Wake County EMS and is well known in prehospital circles for his innovative approach to prehospital care. His talks are always engaging, and I’m looking forward to hearing what changes he sees coming to our field.

From there, the provider track will cover a variety of topics from management of rural trauma to concussions to EKG interpretation. Day one of the provider track will culminate with a discussion of new street drugs of abuse from emergency physician and toxicologist Dr. Josef Thundiyil. His tips for the management of patients with spice ingestion are sure to be helpful. During that same time, the critical care track will cover cardiovascular emergencies in obstetric patients (taught by Dr. Kathleen Shrank of Miami Fire Rescue), heart failure management (taught by FCEP President-Elect Dr. Jay Falk), and the use of noninvasive and invasive ventilation strategies for acute respiratory failure.

At the end of the day, EMS fellows from Orlando Health, University of Florida, and University of South Florida will gather together to teach an obstetrics skills lab. High risk obstetrics is a topic that proves daunting even to many experienced emergency physicians, and our expectation is this lab will provide the education and experience to bolster confidence when addressing these risks in the field.

One of the highlights of day two of the conference will be Dr. Phyllis Hendry’s lecture on prehospital pediatric analgesia. Her insights into managing this frequently overlooked, but important aspect of our care, are sure to be practice-changing. On the last day of the conference, I’m looking forward to the group presentation on lessons learned from active shooter scenarios.

I know our prehospital providers will also be excited to participate in a high fidelity procedure lab that offers experience in adult and pediatric intubation as well as surgical cricothyrotomy. On days two and three, our Mobile Integrated Health track will provide practical how-to advice for those looking to develop this health care platform in their own system.

These are just a few highlights of the event. I hope to see you there.

ICD-10 Documentation Tip: Key to Documenting Fractures • Laterality: Left/ Right • Site of FX: Proximal/ Shaft/ Distal • Displaced vs. Non-Displaced • Mechanism of Injury: How it happened • Etiology of fracture: Traumatic/ Pathologic/ Osteoporosis/ Neoplastic Disease • Closed or Open • Type: Comminuted/ Greenstick/ Oblique/ Segmental/ Spiral/ Transverse/ Compression Burst/ Salter Harris

HIGHLIGHTS OF SYMPOSIUM BY THE SEA 2016: • FCEP’s 45th Anniversary Celebration and Casino Night sponsored by Duva-Sawko/EmPros • The Past Presidents’ Volleyball Tournament • SimWARS 2016 • Research Poster Abstract Presentation • EM Residents’ Case Presentation Competition 2016 • Past Presidents’ Luncheon

It’s that time of year again when we all get together and enjoy a long weekend full of education and entertainment, for you and the whole family.

Symposium by the Sea (SBS) provides FCEP members and attendees with access to the tools needed to help you through the various stages of your emergency medicine career, including education, networking and wellness.

This year, SBS will take place at the Naples Grande Beach Resort August 4 - 7, 2016 and has added a Pediatrics Pre-conference and a reformatted educational series that allows for more interactive learning.

There is still time to register! Remember that as a member of FCEP, registration is FREE.

• Emergency Medicine Town Hall Session

I hope that you will take a few minutes to chat with me while you’re at Symposium and let me know how else FCEP can improve your career and well-being as we fight to improve the healthcare for our patients.

See you at Symposium!

• LLSA For Today

Sincerely,

• ACEP presentations • EMRAF Networking Reception

• Pediatric Emergencies Pre-conference • Wine, Beer & Cheese with Vendors event

Celebrating FCEP’s 45 th Anniversary

Visit www.emlrc.org/symposium-by-the-sea for more information about the upcoming event!

Celebrating FCEP’s 45 th Anniversary In honor of FCEP’s 45th Anniversary, here are some quotes from our Past Presidents highlighting key events during their term: “In 1976, my year as President of FCEP, emergency medical care was a twinkle in some eyes and shaky at best. Docs in 1970’s ERs were anything but mainstream physicians. I worked with Dr. Bill Haeck to survive as we strived to create a modicum of professionalism for our adopted ‘specialty.’”- J. Clifford Findeiss, MD (1975-1976) “During my term as FCEP president, the chapter laid the ground work to become a recognized specialty. I became the first Emergency Physician to sit on the FMA Specialty Council. Nationally, our chapter councilors wrote and lobbied the motion presented to a special meeting of the ACEP Council ( at Innisbrook) that allowed ACEP to continue to seek Specialty status within the family of medicine through ABMS ( American Board of Medical Specialties) Our resolution passed after a long floor fight, and eventually lead to ABEM.”- Frederic C. Wurtzel, MD, FACEP (1978-1979) "I was the first EM trained doc to be President, and I was so committed to ‘spreading the gospel’, that I drove around parts of the state and got uninvolved docs to think of FCEP as their organization. Jim Kitaif and Don Johnson came on board and became active board members. I visited some of the docs in Tallahassee hoping they would get involved. I enjoyed watching the specialty flourish and FCEP grow as an organization. I'm very proud of the great leaders we had in FCEP, year after year."- Jay W. Edelberg MD, FACEP (1982-1983) “In the past we the practice of Emergency Medicine did not exist. As an early Board Member and President of Florida ACEP I had the privilege of helping to define our practice, to change the structure of Medicine. We developed the concepts of EMS Medical Direction, Trauma Centers, our Board Exams and we earned respect from our specialty colleagues. These were hard fought battles. We spent our own time and money to define the political and intellectual boundary's of Emergency Medicine as it is today. I am so proud and lucky to have been a part of this.”- Richard S. Slevinski, MD, FACEP (1983-1985) “During my presidency we were struggling financially, and felt that I felt we were doomed to stay in the ‘sandlot’ leagues if we didn't raise the dues (I believe it was $150 at the time)....the Board agreed, and we doubled the dues to $300. Everyone not happy, but I believe we took the right path.”- Wayne Lee, MD, FACEP (1985-1987) “My presidency was during the early days of active legislative involvement, and I remember numerous trips to Tallahassee to lobby for various issues. It was also around that time that we started the Symposium by the Sea. For me, FCEP (or ‘Florida ACEP’ as it was then known), was a lasting learning and growing experience and gave me the chance to make friends and interact with other EPs in what was then still a very young specialty. I believe we hired Beth around the time that I was VP or president elect, which was probably our greatest accomplishment.”- Luis Quintero, MD, FACEP (1987-1988) "From my perspective Florida ACEP was critical during my presidency to educating legislators about the need for access to evaluation and treatment for all who presented for care.From my perspective Florida ACEP was critical during my presidency to educating legislators about the need for access to evaluation and treatment for all who presented for care. I remember working the night shift then driving to MCO for a flight to Tallahassee to lobby on more that one occasion.”- Eileen Wright, MD, FACEP (1988-1989) “In 1992, during my presidency, we closed on the new office building for the Florida Chapter of the American College of Emergency Physicians. During that year, we changed our name to the Florida College of Emergency Physicians so that our constituency and our issues would be clearer to Florida legislators and staff in working in Tallahassee when we went there to lobby. We were the first chapter in the U.S. to do that, and many other states followed suit.”- David J. Orban, MD (1990-1991) “The Florida College of Emergency Medicine has been for the last forty-five years a consistent, cohesive and effective entity representing the interest and core values of the emergency physician in Florida.”- James V. Hillman, MD, FACEP (1992-1993) “The two things I remember being most significant were the issue of CHEC funding for EM residencies and Managed Care denial of payment for ED visits/prudent layperson standard. This was the year that we finally passed the HMO law - thanks to all of FCEP leaders - and to our champion Rep./Dr. Ben Graber.”- Harvey Rohlwing Jr., MD, FACEP (1995-1996) “FCEP was one of the national leaders in EMS and I wanted to learn from the best.”- John G. Shedd, MD, FACEP (1996-1997) “The most important issues during my presidency centered around legislative language for managed care organization payments. This language set a minimum payment between 1. The charge of the provider. 2. The usual and customary payment for each service and 3. What negotiated between the provider and the insurer and 3. Medicaid fee schedule for Medicaid managed care plans. No mention of tying any payments to Medicare or multiple thereof.”- John E. Stimler, DO, FACEP (1997-1998) “FCEP stood behind me while I was president of the college and, although we failed ultimately in stopping the helmet law repeal, FCEP was instrumental in combining our efforts with the FHA so that our voice could be heard by as many as possible. They also stood with us against the insurance industry reference non-payment of bonafide emergencies due to a non-emergency final discharge diagnosis. FCEP provided all emergency physicians in the state a means of expression, communication and comradery that was so important to all of our careers and sense of well-being in our tough profession.”- Robert B. Tober, MD, FACEP (1999-2000) “FCEP was (and remains) the premier Florida medical professional society because it continuously identifies, mentors, supports and empowers exceptional physician/staff leaders.”- William Colgate, MD, FACEP (2000-2001) “FCEP was about the people and relationships built and working toward common goals to improve Emergency Medicine. I have always valued my membership in FCEP and the friendships I have made.”- David C. Seaberg, MD, FACEP (2002-2003) “At the young age of 45, FCEP continues to be a powerful voice for emergency medicine, the patients we serve, and a model for the rest of organized medicine. Wiser because of the work of those who served before me, my presidency was highlighted by the continued struggle to maintain malpractice reform, assuring access to on call specialists, raising public awareness of what we do in emergency medicine, and above all the great leaders among the FCEP staff, Board Members, and Committee Members I had the proud privilege of working with. As we say in Italian: ‘Cent’ Anni’ !”- Michael J. Zappa, MD, FACEP (2003-2004) “I remember my year as President very well. My son was born and I would rock him with my foot while writing my editorials. My year was memorable for supporting significant malpractice reform legislation while holding our own against managed care. We worked closely with Debbie Wasserman-Schultz to pass the pool fencing bill. I also felt it was important to establish sections for pediatrics and academic providers - which we did.”- Arthur L. Diskin, MD, FACEP (2004-2005) “We expanded our membership focus and kicked off the inaugural year of the Florida Leadership Academy. We became the 7th largest chapter and sent 15 Councillors to represent the interests of Florida emergency physicians to the annual Council Meeting at the ACEP Scientific Assembly in Denver this October.”- Kelly Gray-Eurom, MD (2012-2013) “During the 18 months I served as President, FCEP was instrumental in helping me significantly improve our political relationship with the FMA. This was critical as we broadened our political influence to secure legislation for liability protection for all emergency physicians.”- Larry Hobbs, MD, FACEP (2007-2008) “The proudest time for me as FCEP president was establishing the leadership academy and getting our up and comers involved in leadership. I also am always amazed at the significance of our legislative presence in Tallahassee and with all of the other members of the House of medicine. Right now I’m trying to represent FCEP on the ACEP Board to keep our momentum going.”- Vidor Friedman, MD, FACEP (2011-2012) “After many years of planning, this is the year when we finally picked up shovels and broke ground on the new building. The old space was full of memories of good times spent together, but its useful days had run out.”- Michael Lozano, Jr, MD FACEP (2013-2014) “While it was the work of so many presidents that came before me as well as countless others, my year was defined by the opening of FCEP’s new building. My year was also memorable for the tremendous growth in the educational programs offered by the college and the foundation, most notably, FCEP’s first annual board review course.”- Ashley Booth-Norse, MD (2014-2015)

Musings Of a Recently Retired Emergency Physician Silly Season

Article by Wayne Barry,MD, FACEP As some of you may know, I am a NASCAR nut. About midway through the 36 race NASCAR season-- there comes a time when some of the drivers change race teams for the next year. This may be due to their personal driving fortunes rising or falling.

Sometimes the race teams themselves have waxing or waning conditions which provoke these driver changes. This time is affectionately called “Silly Season.” Similar phenomena occur in other sports none has such a delightfully descriptive term as NASCAR’s Silly Season The US election season is certainly a “Silly Season” this year. Many of us cannot believe what has happened in the Republican Party during the recent primary elections, and there is a “revolutionary” movement with the Democrats as well.

Wayne Barry, MD, FACEP

There will probably be some scholarly essays in this edition of EMPulse about the impact on Medicine in general and Emergency Medicine in particular with respect to a Republican verses a Democratic victory in the fall Presidential election.

Please let me provide you with a disclaimer that the following thoughts (or musings) are based less on fact checking and more on my gestalt as I handicap Silly Season this year.

First of all I feel it necessary to tell you that I read an article about Donald Trump about 5 years ago. The article concentrated on the fact that he definitely does not like doctors! He thinks he is smarter than we are, and so he wonders what good are we?

He wants to repeal Obamacare, but like his other fellow Republicans he has not offered a comprehensive vision for health care in the future….except that he laudably wants everyone to have some.

This sounds a little like Bernie Sanders, whose vision of comprehensive health care is a single payor Medicare for everyone which will apparently carry an astronomical price tag.

I was simply amazed at how Donald Trump dispatched his Republican rivals during this “Silly Season.” In fact the expert manner in which he employed, name calling, bullying, and character assassination prompted me to think of the name of this piece.

I am personally a Democrat by heritage and a sometimes Republican by practice, and I clearly favored Jeb Bush for the Republication nomination (and general Presidential election for that matter).

I thought he was a very credible governor of our state of Florida. Even though I do not agree with a number of his positions such as his stand on abortion, gun control, and some others, I found him the class of the Republican candidate field. I would have rather preferred it if he were President than his brother George, but such will not be the case for the Bush family legacy.

The way Donald Trump eliminated the remained of the Republican Primary field may be a subject for teaching in political science graduate school. My opinions about some of them are as follows: 1. Jeb Bush: He was so vulnerable to the personal personality attacks hurled at him by Trump, that he even folded in the face of similar blows from his Florida rival Marco Rubio. There goes $100,000,000 worth of Super Pac money down the drain. We at ACEP could have made better use of at least some of that money!

2. Marco Rubio: He disappointed me as a Floridian when he at first portrayed himself as a Tea Party favorite, and then ended up flip flopping so badly on Immigration that I cannot tell whether he was for it or against it. I am sorry, but I do not understand why Rubio would be against immigration (legal or not) of folks from South and Central America like his parents who obviously came to this country and participated positively to the American Dream!

3. Chris Chistie: He was another one of my luke warm favorites until he self repudiated and took up with the Donald.

4. Ted Cruz: This is the scariest guy of all to me. Between his pseudo evangelical persona and his antigovernment actions which financially injured many fellow Americans, I cannot tell whether he secretly wants to be a white supremacist anti Federalist or a TV Evangelist in sheep’s clothing!

5. Carley Fiorina: She was admirable as the only female Republican Presidential hopeful. However she lost her only election to public office to a veteran liberal Democrat in California, and she was apparently not very successful as the CEO of HP. The she jumped on board with Ted Cruz. Did I say I thought he was scary?

6. John Kasich: He was my second choice after Jeb Bush. Unfortunately he will be known more nationally as yet another unsuccessful

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opponent of the Donald and not a pretty decent Governor of Ohio.

7. Ben Carson: What a turn around from a street punk in Detroit as a kid, then a world famous neurosurgeon at Johns Hopkins! Who would have thought that he would turn another 180 degrees and be anti abortion, anti gun control, and almost an anti vaxer??? I severely doubt if he practiced as President what he preached as a primary contestant that American Medicine would be any better off than it is today. I believe that he is as bad a politician as he is as good a physician!

On the Democratic side we have the true dyed in the wool liberal if not revolutionary Bernie Sanders who isn’t even a true Democrat up against the seasoned Hillary Clinton. I think many of us admire the remarkable fight that Bernie has waged. It is probably a good thing that he is dragging Mrs. Clinton’s pragmatic ideas to the left. But he looks and sounds so old and tired that it is hard to imagine that he would have the strength to continue campaigning on the bottom end of Clinton ticket for President!

Hilary on the other hand is right up there with the Donald in high disapproval ratings among the voters. It is hard to forget her fiasco with Bill Clinton’s attempt to overhaul the Medical Establishment. Does anyone remember Ira Magaziner and the secret room full of 100 equally smart people …none of who had MD or DO after their names? I am sorry that she has fallen out as the first likely lady US President because her entitlement attitude and grey legal activities make her a poor standard bearer for her gender in my opinion.

So now it looks like a Presidential race between Donald Trump and Hillary Clinton. While there are a few people like my 22 year old daughter who lives and works in Austin, Texas, the blue spot in the red state of Texas who is boarding a plane to Germany to join her new husband who is already there on a business trip for IBM. She tells her mother and I she may never come back to the US because she is so horrified that Donald Trump is the Republican Presidential nominee!

Most of the rest of us are collectively sighing that here comes yet another Presidential election in which we have to choose between the lesser of 2 evils. While I am personally astounded that a show business con artist like Donald Trump can win the nomination of one of the 2 major political parties by virtue of the rampant dissatisfaction over Congress, the Government, politics and politicians, I am trying to remain philosophical.

Because of the chronic dysfunctional behavior in Washington these days, does it really matter in the end the US President is?

He or she will accomplish very little in the face of intense political gridlock. And does it really matter whether a professional con artist acting as the Commander-in-Chief pisses off our friends and foes in the world today? As it happens they are all chronically pissed off at the US anyway.

So as Silly Season comes to a close, let the Games Begin!

D a u n t i n g D ia g n o s i s Question: A patient presents unresponsive to the emergency department. His urine fluoresces under the Woods Lamp. What is the diagnosis?

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

(Question

Answer: Urine fluoresces under the Woods Lamp with ethylene glycol (antifreeze) ingestion.

Following ingestion, patients will have metabolic acidosis, intoxication, cardiovascular dysfunction, and vomiting as primary symptoms. Patients can be treated with ethanol or fomepizole in addition to emergent hemodialysis to prevent calcium oxylate crystals from forming in the kidneys that could cause permanent renal failure.

o n pa g e

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EM C a s e R e p o r t s Understanding the Zika Phenomenon Article by Naureen Farook, MS4, and Jennifer Jackson, MD

Within the last several years, each year has carried with it a notorious virus that sweeps the continents and demands the expeditious intervention of domestic and transnational public health entities. The medical community remembers most of 2014 and 2015 for the explosive threats of Ebola and Dengue. Before the wake of 2016, yet another outbreak has taken the world by storm, but this time, Zika virus has revealed itself as the source of a previously unsuspecting but severe consequence in newborns.

What is Zikavirus?

Naureen Farook, MS4 University of Miami Miller School of Medicine

Zikavirus, cousin to other flaviviruses such as Dengue and Chikungunya, causes a mosquito-borne illness transmitted by the Aedes aegypti mosquitoes. Prior to the dramatic rise in incidence in the Americas, primarily in Brazil, major epidemics with Zika were reported in French Polynesia, New Caledonia, the Cook Islands, and Easter Island in 2013 and 2014. In the most recent update, 42 countries in Central and South Americas as well as the Caribbean have recorded active, local transmission.

Tranmission

While the virus is predominantly transmitted by mosquitoes, with humans wedged as its augmenting hosts, its vertical transmission has concerned physicians and public health officials the most. The surge in cases of microcephaly in newborns over the past year has strongly linked Zika virus to pregnancy-related fetal malformations. The Ministry of Health in Brazil has informed that the prevalence of microcephaly spiked 20-fold since the Zika virus outbreak. The Director of the CDC has recently confirmed there is conclusive evidence that Zika causes microcephaly—the first time a mosquito-borne virus has been directly affiliated to congenital brain defects.

Most cases of Zika virus in the U.S. have been travel-associated. However, the CDC has issued a warning that local mosquitoes can feed on those already infected with Zika virus and disseminate it to others. More importantly, there have been several locally acquired cases of the viral illness via sexual contact with a person who recently traveled to an area with reported Zika prevalence. A recent CDC’s Morbidity and Mortality Weekly Report (MMWR) verified male-to-male sexual transmission of Zika, which is notable as all other cases to this point have described transmission via vaginal intercourse.

Jennifer Jackson, MD Assistant Professor, Emergency Medicine University of Miami Miller School of Medicine

Nonetheless, all such incidences have been described primarily in persons experiencing active symptoms of Zika infection. It is still unclear how long a person can transmit the virus after a recent infection, but preliminary data suggest exposures potentially occur immediately before or after the initial appearance of symptoms in the traveler—the time when viremia is highest.

Clinical Picture of Zikavirus

One of the hindrances of this epidemic remains rooted in its generally uncharacteristic clinical presentation. The symptoms of Zika fever are self-limited and can be within the spectrum of most mild illnesses, including fever, maculopapular rash, arthralgia, conjunctivitis, myalgia, headache, retro-orbital pain, and vomiting. However, 80% of individuals infected are asymptomatic, and hospitalization due to Zika is rare, with a handful of cases linking Guillain-Barre as a neurological sequelae. Even if mild symptomatology is noted, the diagnostic challenge persists when attempting to distinguish from diseases such as Dengue, while keeping in mind a lingering possibility of coinfection.

The most alarming complication of the Zika epidemic has been its association with microcephaly, a rare congenital malformation. Several reports have also revealed ophthalmologic findings in these newborns, presumably due to intrauterine Zika infection. In an autopsy analysis with confirmed RT-PCR positivity for Zika, the CDC recently tested newborn and fetal tissues, including brain and placenta, using formalin-fixed paraben-embedded (FFPE) assays for the virus.

All newborn brain samples demonstrated substantial histopathologic changes, including parenchymal calcifications, microglial nodules, gliosis, and cellular degeneration and necrosis. The two placental tissue samples indicated some varied results; one showed heterogeneous chorionic villi with calcification, fibrosis, and perivillous deposition, while the other displayed relatively normal-appearing chorionic villi.

However, a number of case reports confirmed focal calcifications in the villi and decidua as well as the presence of the virus in amniotic fluid, lending credence to Zika’s intrauterine infectivity and placental damage.

Present evidence suggests that in newborns, the viral changes are predominantly limited to the brain and eyes alongside a consistent picture of vertical transmission. It is yet to be determined how Zika affects maternal and fetal outcomes at different gestational ages.

Though further research is necessary to understand the pathophysiology of this disease, the teratogenic effects of Zika cannot be ignored and has thus necessitated diligent surveillance of the infection.

Continued on page 32

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Continued from page 30

Diagnosis in the ED

As previously mentioned, the nonspecific clinical presentation of Zika fever impedes the diagnostic work-up. More importantly, there are currently no commercial tests available for Zika. A recently published retrospective study demonstrated MRI and ultrasound findings, such as low cerebellar biometry, occipital subependymal pseudocysts, polymicrogyria with laminar necrosis and operculum dysplasia, and absent or hypoplastic corpus callosum in fetuses with confirmed Zika infection. While these may indirectly corroborate a clinical suspicion of Zika infectivity, they represent nonspecific radiologic findings. This renders it even more important to understand the travel histories of sick patients and pregnant women. The most recent Florida Health Department guidelines emphasize how a brief history regarding any recent travel, specifically in the previous 2-3 weeks, is a crucial inquiry to identify patients who may be experiencing Zika fever. All suspected cases should be reported immediately to the local health department. Pertinent information to include is 1) time of initial presentation and 2) recent travel, especially to country(ies) endemic to Zika.

If there is a strong suspicion of Zika, samples of serum, saliva, and/or urine can be sent to the state Department of Health for testing using PCR. However, these specimens must be collected during the first 3 weeks after the onset of the illness. If testing a pregnant woman, an ultrasound may be considered to determine if microcephaly, intracranial calcifications, or other aforementioned findings are present in the fetus.

Immunohistochemistry is also available for samples collected at ≼4 days after symptoms began, but due to the cross-reactivity of the antibodies with other flaviviruses, such as Dengue, the results are not as reliable.

Treatment/Precautions

Consistent with most viral infections, treatment for Zika fever is primarily supportive. Because of the risk of co-infection with Dengue, physicians should avoid recommending aspirin or other non-steroidal anti-inflammatories. For pregnant women experiencing fever, the only acceptable treatment option is acetaminophen.

As of now, the first-line preventive strategy involves taking appropriate control measures. While travel has not been banned, the CDC highly recommends avoiding or postponing travel to South America and other Zika-prevalent countries (Table 1), especially for women who are pregnant or trying to become pregnant.

Cases of sexual transmission to date have alarmed health officials, suggesting that this route of transmission may be more common than previously reported. It is hypothesized based on a handful of semen analyses that seminal shedding of Zika may extend several days to weeks after the resolution of symptoms. While the CDC prepares to issue proper guidance to prevent sexual transmission, the agency strongly advises men and women to avoid semen exposure from men who may have been exposed to Zika or to consistently use condoms. To prevent further spread, persons who have suspected Zika illness should restrict mosquito exposure to avoid infecting local mosquitoes. Otherwise, the public health advisory consists of staying indoors as much as possible and if outdoors, use appropriate mosquito protection. Until more research can be gathered to elucidate the true impact of Zika’s potency, the best approach stands to mobilize public health efforts that will counter the spread of the virus.

References available upon request.

TABLE 1 - List of Countries with Increasing or Widespread Transmission of Zika OCEANIA/PACIFIC ISLANDS American Samoa Fiji Kosrae (Federated States of Micronesia) Marshall Islands New Caledonia Samoa Tonga AFRICA Cape Verde

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AMERICAS Aruba Barbados Belize Bolivia Bonaire Brazil Colombia Costa Rica Cuba Curacao Dominica Dominican Republic Ecuador El Salvador French Guiana Guadeloupe Guatemala SUMMER 2016 | VOLJUME 23, ISSUE 2

Guyana Haiti Honduras Jamaica Martinique Mexico Nicaragua Panama Paraguay Puerto Rico Saint Lucia Saint Martin Saint Vincent and the Grenadines Sint Maarten Suriname Trinidad and Tobago U.S. Virgin Islands Venezuela

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