EMpulse (Fall 2016) by Florida College of Emergency Physicians

Volume 23, Issue 3 FALL 2016

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

Welcoming Florida's newest EM residency programs Pg. 19

Symposium by the Sea 2016 boasts highest attendance

Corporate Council talks about collaboration in EDs across the U.S. Pg. 13

Pg. 26

INSIDE: PHOTOS FROM CLINCON 2016, SBS 2016 AND WBRC 2016!

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Chapter Updates

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

FCEP Executive Committee Jay L. Falk, MD, MCCM, FACEP • President Joel Stern, MD, FACEP • President-Elect Joseph Adrian Tyndall, MD, MPH, FACEP • Vice President Kristin McCabe-Kline, MD, FACEP • Secretary/Treasurer Steven Kailes, MD, FACEP • Immediate Past President

Features

Beth Brunner, MBA, CAE • Executive Director

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

All advertisements appearing in the Florida EMpulse are printed as received from the advertisers. Florida College of Emergency Physicians does not endorse any products or services, except those in its Preferred Vendor Partnership. The College receives and distributes employment opportunities but does not review, recommend or endorse any individuals, groups or hospitals that respond to these advertisements. NOTE: Opinions stated within the articles contained herein are solely those of the writers and do not necessarily reflect those of the EMpulse staff or the Florida College of Emergency Physicians.

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

FALL 2016 | VOLUME 23, ISSUE 3

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President’s Message It is a pleasure, a privilege, and an honor to serve as your president this year. Despite having held many leadership positions over the years, I feel a bit intimidated by the challenges facing our organization, our specialty, and our profession. My apprehensions are assuaged by knowing the quality and capabilities of our professional staff, and most especially, by our Executive Director of thirty years, Beth Brunner, who this year, was recognized by ACEP as an “Honorary Member.” I am comforted as well, by having a committed and talented board of directors who work so tirelessly for our college. The past presidents of our college continue to provide guidance and expend personal efforts on our behalf. Dr. Steve Kailes, our immediate past president, did an excellent job in all aspects of his tenure, and in passing the gavel, left me with a well thought out strategic plan to be accomplished, in part, during my administration. Finally, I am encouraged by our members, who have given so generously of their time and treasure, to enable the college to accomplish its goals. My philosophy of leadership is to be a “servant leader.” My focus will be to serve the needs of the membership, and to engage and enlist as many of you as possible to help us move our agendas forward. But as Yogi Berra said, “If people don’t want to come out to the ballpark, nobody’s going to stop them.” This is no time for complacency. Membership is the lifeblood of our organization and all of us need to consider ourselves as serving on our membership committee. Please go out and convince your colleagues who are not members of the college to sign up. Membership represents the best investment that practicing emergency physicians can make towards their future professional enjoyment and financial wellbeing.

Jay Falk, MD, MCCM, FACEP FCEP President

And while we are on the subject, all of us need to consider supporting our PACs, as 100 percent of your board of directors have done. Advocacy is the top priority of the college. We lobby for fair treatment of our patients and ourselves. We continue to convince legislators that we are an essential piece of the “safety net”. Our war chest is small compared to those of the insurance companies and lawyers. Yet, I am very pleased with the outcome of our efforts regarding the balanced billing legislation that absent our efforts could have been catastrophic. We have learned over these last few years that our collective voice can be amplified if we are working collaboratively with the Florida Medical Association (FMA). We are so proud of, and indebted to, Past President Dr. Ashley Booth-Norse who serves on the Board of the FMA and is running for Vice-Speaker next year. FCEP BOD members, Drs. Stern and Pattani have also advanced to leadership roles in the FMA ensuring that EM will be well represented in the FMA moving forward. Dr. Kailes wisely held the Board’s collective feet to the fire to develop a five-year strategic plan for the College. I have already highlighted Advocacy as our number one priority. Our educational mission is an integral part of who we are. As a lifelong academician, I am particularly interested in broadening and deepening our educational platform. Defining the educational needs of our members and our EMS partners, creating new programs and platforms and monetizing these efforts, are top priorities. Our new facility, the EMLRC, enables us to host meetings on site, without the need to pay for space. We are excited to have so many new EM residency programs approved and coming online in our state, and we intend to assimilate their residents and faculty into the field. Our board review course and research consortium enlisted many talented faculty across the state to collaborate on college initiatives. I see this, along with our student groups and EMRA, as a way to ensure our continued health. Membership and Financial Health are the two remaining aspects of our plan, and they go hand in hand. Our goal is to have all practicing emergency physicians in Florida as FCEP members. If we could achieve this, our ability to fulfill our mission would be greatly enhanced. These four parts of our plan – Advocacy, Education, Membership, and Financial Health – are inextricably intertwined. We plan educational activities, like our Emergency Medicine Payment Reform Summit, that will educate and prepare us for the many reimbursement changes about to confront us that will inform our future advocacy efforts (MACRA, etc.). We developed the Leadership Academy to groom future leaders who will become our advocacy champions of the future. We work with our residency programs to join their residents as members and provide them with educational programs, (“Life After Residency”), that will help them thrive as practicing physicians with an appreciation of the value of participation in their specialty organization. And so it goes. I started this report by indicating what a pleasure it is to be able to serve as your President. The fun in all of this is being able to interact with all of you. It is uplifting to work with so many bright, energetic, capable people trying their best to do the right thing for our patients. With your help, I look forward to a productive and fulfilling year.

Medical Economics Committee Balance Billing

Balance billing legislation banning balance billing went into effect July 1, 2016. Elements of the law will require AHCA rule promulgation. FCEP met with AHCA in June 2016 to discuss concerns and provide input in advance of that process. Additionally, we met with the Office of Insurance Regulation to discuss their role in enforcing payor compliance with the new law’s payment provisions. Perhaps most importantly, the dispute resolution process modifications we successfully had included in the legislation were discussed and highlighted as important aspects of the vendor contracting process. Ultimately, we hope that Maximus (the prior vendor and only respondent to the state RFP) will be a better arbiter of disputes given clear rules and guidance to comply with the specifics of the legislation passed. In the meantime, payor behavior in terms of compliance with the charge based payment provisions for out of network care, and in terms of negotiating behavior towards contracting EP’s should be closely monitored by all FL EP groups. Of course, verification that your billing vendors are complying with the OON balance billing prohibition is also critical.

Daniel Brennan, MD, FACEP Medical Economics Committee Chair

Transparency Legislation

Transparency legislation passed in the Spring was primarily focused on facility services and bundled payment data. However criteria for the selection of the All Payor Claims Database (APCD) is critical and was modified to allow FairHealthTM to qualify to bid. This non-payor controlled database is key to independent, verifiable, transparent charge data that would be the best source of data for dispute resolution.

Florida Medical Association

Your FCEP representatives (specialty society as well as county delegates) participated in the FMA House of Delegates at the end of July. There was a lot of discussion about payment reform, MACRA, and MOC. A resolution sponsored by FCEP and authored by Danyelle Redden MD was passed- in final form it would allow AHCA to redefine domestic violence to include human trafficking such that our licensing DV CME requirements could be fulfilled by either topic.

Florida College of Emergency Physicians

The Symposium by the Sea Committee and Board meetings reviewed the above, and also forecast the issue of PIP (Personal Injury Payment) insurance reform as likely 2017 legislative priority. The OIR commissioned a $125K study in May to review the effects of the 2012 PIP revisions, and results due in September will likely direct legislative proposals. The issue of fraud and overall cost are likely to make reform (again) popular, as well as the trial lawyers support for a replacement higher limit bodily injury coverage (and the resultant litigation it would spur vs. no-fault PIP). For EM the $5K set aside protection for providers in the 2012 legislation was key, as well as the charge based reimbursement. Most EDs see a small % of auto injury patients (estimated at about 2 percent) but since these patients reimburse at charges they represent a more substantial source of revenue which can offset the higher cost of trauma care, such as standby costs, and unreimbursed penetrating trauma care.

Orlando PULSE

As a prime example of the importance of adequate resources, the Pulse shooting tragedy in June hit close to home, with 44 victims treated in our ED. There was a complete team effort – EP’s (Attendings, fellows, residents, APP’s), trauma surgeons (also attendings/residents/fellows), anesthesia, radiology, intensivists, critical care physicians, RN’s, RTs, techs, business office, environmental, security, police/EMS, chaplains, administrators - literally hundreds contributed to the incredibly successful response to the tragedy. In addition to the resource burden of the event, the barricades and traffic in the area led to a noticeable drop in ED volume for a few weeks afterwards. To date, no local, state or federal funds have been provided for the EP care provided, nor does it appear likely any will. This is only mentioned to highlight the importance of adequate payment for daily services we provide, so that this community resource is available and qualified staff is there when we are needed. At the end of the day, we should be incredibly proud of the work we do and vocal in our advocacy for the public that the safety net be maintained.

D au n t i n g D iag n o s i s Question: A 25-year-old female presents to the ED stating that she has developed small black “spots” on her tongue and lips for a day. She states she feels weak. Her tongue is pictured below. What is the diagnosis, and how is it treated?

Turn to page 13 for the answer! Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief FALL 2016 | VOLUME 23, ISSUE 3

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Government Affairs Committee I am honored to be the new Chair of the Government Affairs Committee. FCEP is very fortunate to have leaders from around the state who really take ownership of individual issues we face each year in our legislative/regulatory platform. This organizational commitment to advocacy was epitomized during this past 2015 legislative session on the controversial issue regarding balance billing. I believe we had a minimum of eight individuals who were working non-stop with monitoring, crafting legislation, meeting with legislators, attending legislative sessions and answering texts from legislators 24/7 to ensure FCEP’s position was heard. Throughout our discussions and relentless hard work, our diligence always focused on the main beneficiary from our efforts—our patients.

Sanjay Pattani, MD, FACEP Government Affairs Committee Chair

• • • •

We have some big priorities on our plate coming up in 2017, starting with the elections. The redistricting and staggered term limits reveal many new races and proves challenging as many of us are meeting with individual legislators to provide them with our campaign support. These pre-session “casual encounters” are essential because many of the incoming 2017 legislators will be freshman. I’m so proud that more than 50 FCEP members are involved with these individual meetings in their home town/city, and establishing new relationships and friendships with their local representatives. Currently, the legislators are not addressing any “hot topics” due to election season. However, soon after November, and before session rolls around March 2017, FCEP has its eyes on a few blips on the radar screen:

Waiting and watching for the draft rules to be published on transparency and balance billing. Just as soon as these draft rules are released, we will gather our leaders to review and provide specific recommendations back to AHCA. This is so very important that the rules do match the intent of the legislation that was passed. Workers Comp will likely return for 2017. It’s in the news now and lawmakers definitely want to “fix” the problem for their individual constituents. PIP will most likely resurface again. FCEP will explore common ground with the FMA in order to address and preserve emergency services care. Let’s not forget about ARNP scope of practice expansion, opiod antagonist issues, CON law, etc.

As we are on the brink of another exciting legislative advocacy season, I would like to acknowledge that it’s an honor to work with so many FCEP leaders on what many around the country consider the most active chapter in the area of policy and innovation. I serve on the ACEP State Legislative Committee – along with 5 other FCEP leaders – so we do have considerable presence with significant input on many of the federal issues as well. Please remember to mark your calendars for November Government Affairs Committee (November 16, 2016) and Emergency Medicine Days 2017 (March 13-15, 2017). Additionally, I would like to specially thank FCEP’s Lobbyist Toni Large. Toni spends countless hours in Tallahassee and continuously educates us and takes us to new territories of the legal and regulatory EM world. Finally, thank you for taking the time to keep abreast of our legislative advocacy efforts. I encourage and welcome your involvement with the governmental affairs committee.

Thanks to all who made contributions to the Political Committees in June, July & August 2016! Brevard Physicians Associates Emergency Resources Group Florida Emergency Physicians, Inc. Adam Sienkiewicz Ariana Wilkinson Austin C Reed Bianca E Alvarez Blaire Laughlin Caitlin Sandman Carlos H Castellon Christine N Diiorio Christopher Kumetz Danielle M Christiano Danyelle Redden Ian C. Backstrom

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Javier Gonzalez Jay Falk Jeffrey D Bettinger Jesse Walck Joel Stern Jordan Celeste Jordon Johnson Kathryn Dasburg Kendall Webb Laurie Boge Manning H Hanline Maria S Bristol Mark C Johnson Martin Johann Pontasch Max Baumgarndner

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Michael C Tracy Michael G Maxwell Michael Lozano Michael T Schultz Omaryra L. Mansfield Pamela Miller Patrick Agdamag Paul A. Andrulonis Robert Allen Farrow Stephen Holtzclaw Stephen N George Steven Kailes Thomas K Leonard Vincent Valente

EMS/Trauma Committee As the summer months have come to an end and the humidity lingers on, we look back on an eventful summer for EMS. Within our own state and, for many of us, our home city, Orlando experienced one of the deadliest terrorist attacks since 9/11. This attack on June 12, 2016, at Pulse nightclub left 49 dead and wounded 53 additional people. Our hearts were crushed for all the young victims who were so full of life and potential as well as for all the families who were left to mourn them. Our deepest condolences to those who lost loved ones in this tragedy. We were also able to see the local EMS, SWAT, law enforcement, Level I Trauma center and additional surrounding hospitals put to the test. Through all the evil and tragedy, these agencies and the community came together, worked hard, and did a phenomenal job under such pressure. Thank you to all those who responded in this dark hour. Your hard work is deeply appreciated.

Christine Van Dillen MD, FACEP

EMS/Trauma Committee Co-Chair From this event, and other shooting and terrorist events, there were some lessons learned, which included readiness to respond. There has been a focus on go bags ready to respond in areas where there may be large groups congregated. In the Journal of Trauma Acute Care surgery in March of 2015, they discussed the use of tourniquets during the Boston bombing. In total, 243 patients were treated, with 152 of those presenting to the ED within 24 hours. Twenty-seven had non-commercial tourniquets applied; there was an overall mortality rate of zero. The conclusion was made that an “effective, prehospital extremity hemorrhage control posture should be translated to all civilian first responders in the US and should mirror the military's posture toward extremity bleeding control. The prehospital response to extremity exsanguination after the Boston Marathon bombing demonstrates that our current practice is an approach, lost in translation, from the battlefield to the homeland."

We also enjoyed the education that was provided at CLINCON in July and Symposium by the Sea in August. Thank you, EMLRC, for your continued hard work!

FAEMSMD UPDATE

At the most recent meeting in July 2016, FAEMSMD held officer elections for the 2016 – 2018 term. The results are as follows: President: John Milanick Vice President: Chris Hunter Secretary/Treasurer: Brooke Shepard Members at Large: Dave Meurer and Chrissy Van Dillen The next FAEMSMD meeting is scheduled in conjunction with the EMSAC meetings in Palm Beach Gardens at the Double Tree Hotel on October 19, 2016.

Trauma

State acceptance of the CDC adult criteria for the Trauma scorecard was placed on hold as there were two rule workshops, yet this was not well received in some areas. Regional trauma agencies are in the process of being set up based on statute 395.4015. The proposal suggests using department of Security Task Force (RDSTF) regions, as they are already regions which are designated around the state. Peter Pappas, a key leader in the pilot project in Region V, came to discuss his success and continued efforts in his trauma agency. The National Academies of Science, Engineering, and Medicine came out with a very well-written report, A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury (2016), which can be found on www.nap.edu. Within this report were important recommendations to include EMS as both part of the care system as well as part of the data collected and reported.

Out of Hospital Cardiac Arrest (OHCA)

The DOH is considering funding a position to support EMSTARS data exchange with CARES. As this has been a goal for FAEMSMD, this would allow us to anonymously compare data with each other across the state as well as with other EMS agencies who report to CARES across the nation.

DEA Update "Protecting Patient Access to Emergency Medications Act of 2016" (H.R. 4365)

This legislation will clarify that the current practice of physician EMS Medical Directors overseeing care provided by paramedics and other emergency medical service practitioners via “standing orders” is statutorily allowed and protected. H.R.4365 on 2/03/2016; this bill was referred to the Subcommittee on Crime, Terrorism, Homeland Security, and Investigations. S.2932 Protecting Patient Access to Emergency Medications Act of 2016 Related bill CRS0 on May 16, 2016 was read twice and referred to the Committee on Health, Education, Labor, and Pensions.

Continued on page 8

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Continued from page 7

State EMS plan discussion

1.1.3 Reduce EMS medical errors — By December 31, 2018, our goal is to implement an anonymous statewide EMS medical error data collection tool and processes. 2.1.2 Improve patient care quality and the following outcomes (by December, 2018): • Increase the percent of non-traumatic cardiac arrest patients who receive bystander CPR from 16% to 20% • Increase the percentage of non-traumatic cardiac arrest patients who develop a Return of Spontaneous Circulation (ROSC), both prehospital and upon arrival to ED, from 16.32% to 20.34% • Increase the percentage of STEMI alert events in which the on-scene time is less than or equal to 15 minutes from 61% to 90% • Increase the percentage of STEMI alert patients that were transported to a Level I or Level II Cardiovascular Hospital from 68% to 90%. • Increase the percent of stroke alert events in which the on-scene time is less than or equal to 15 minutes from 67% to 90% • Increase the percentage of stroke alert patients that were initially transported to a primary or comprehensive stroke center from 69% to 90% by December 2018 • Increase the percentage of trauma alert events in which the total on-scene time is less than or equal to 10 minutes from 40% to 90% by December 2018 • Increase the percentage of trauma alert patients who were initially transported to a trauma center from 57% to 75% 6.1.2 Promote the ethical and professional practice of prehospital medicine in Florida • Decrease the number of administrative complaints pertaining to patient care/violation of protocols by 40% from 5 per year to 3 per year by December 2017 • FAEMSMD Involvement • Medical Error Prevention • Cardiac Arrest • STEMI • Stroke • Trauma • Pediatric Care • Protocol Violation related complaints

General Clinical Discussion

A question was asked to the group regarding the use of D10 versus D50 for hypoglycemic emergencies in the field. Several medical directors in the state of Florida have already switched to D10 and feel that this works well, with good feasibility specifically based on data from EMS agencies across the nation. This data included no increase in time to effect and no change whether or not hypoglycemia reoccurred after administration. A repeat assessment clinically and chemically with a repeat glucose is extremely important and required when using D10. Repeated dosing should also be in the protocol for as-needed purposes. The next part of our discussion used another hot topic: narcotic overdoses and the use of Narcan. It was reported that Manatee County spent $8,000 – $9,000 in one weekend due to high usage of laced heroine. There were concerns about how higher doses are being administered initially, as well as concerns over agitated patients and risk of pulmonary edema as a result. Law enforcement is usually on scene first and therefore needs to be provided with training regarding appropriate dosing in those who are fully unresponsive or partially responsive as well as waiting for other medical personnel prior to administration.

Announcements

October 28, 2016 -- Intubation Rodeo

Membership & Professional Development Committee In case you haven’t heard, this is FCEP’s 45 year anniversary, and there were many things to celebrate at SBS 2016! Among the celebration, worthy events that took place include SBS 2016 which had the highest registrant numbers to date. This registrant increase coincides with another noteworthy event--our current membership is the highest since inception of the Florida College! We have also been recognized by ACEP as having one of the highest percentages of renewal/retention of our resident members. I think this is all due to the great work that you, our membership, has been doing to continuously inform your colleagues about the numerous benefits of membership in our national and local organization. While at SBS 2016, I was reminded that although we are all concerned about making sure we remain up to date on our clinical skills, it is also important that we develop and enhance our leadership and other non-clinical skills. What areas of non-clinical medicine are you interested in? Is it advocacy, teaching, research, etc? Maybe you feel that you don’t have the time to dedicate to this other area of your career? Luckily, FCEP has many opportunities available for you to become involved that can be augmented to fit any busy EM physician schedule. If you are interested in advocacy, fighting for the rights of your patients and your colleagues, there are many local and national opportunities available. Most notable, locally, is EM Days, an annual FCEP event that will take place March 13-15, 2017 in Tallahassee. EM Days is the main advocacy event in Florida when EM physicians meet with the legislatures of our state to discuss the status of healthcare and the effects of the upcoming legislation on our local communities. This is a great opportunity to share our particular perspective with those who will be making the decisions that affect us all. On a national level, ACEP hosts the annual Leadership and Advocacy Conference in Washington DC on March 12-15, 2017. This conference is similar to EM Days except you are discussing the issues with our national legislators in the Congress and Senate. Rene Mack, MD Membership & Professional Development Committee Chair

Perhaps you would like to explore grant writing or other research-related topics? Are you interested in learning more about documentation and reimbursement? These areas can be ambiguous and learning the proper methods can be time consuming and detailed. Luckily, ACEP and FCEP have the resources to help guide you through the questions and concerns we are faced with on a daily basis. If you have any questions, contact the FCEP office, or visit the FCEP/EMLRC website at: EMLRC.org, which will lead you to the numerous resources we have available. The ACEP resources can be accessed via acep.org or contacting the FCEP/ACEP offices directly. While there are many areas of nonclinical medicine available for exploration, all that is needed for you to become involved in one, or several areas, is to contact the FCEP office and allow us to help you with your journey. As our membership grows, we appreciate the continued support and look forward to serving you in numerous ways in the future. As always, I look forward to seeing you at our next committee meeting on November 16, 2016.

FEMF Update Article by Michael Lozano Jr., MD, FACEP; FEMF President This year’s Symposium by the Sea was particularly special for me. I was honored by my fellow Florida Emergency Medicine Foundation Board members by election to the position of Board President. I thought back to when I first joined the board in 2014, but then realized that my association with, and the impact of the Florida Emergency Medicine Foundation (FEMF) on my professional life started way before then. I moved to Florida in 1994 after my EMS fellowship. I had been involved with EMRA back in New York, so naturally I wanted to connect with the emergency medicine community in my new state. I was pleasantly surprised by the wide range of EMS related offerings from FCEP. I attended the Disaster Management and ClinCon conferences on a regular basis. I later became involved with ITLS (then it was BTLS), and the ALS/BLS Competition. For all of these I received CME, and I noticed that the certificate always said FEMF. Later the name changed to the Emergency Medicine Learning and Resource Center, but still FEMF was a part of my professional life. Michael Lozano Jr., MD, FACEP I started attending Symposium by the Sea. It’s not only a conference; for us it’s become a family tradition. My FEMF President daughters are in college and law school, and they still text, “When and where is Symposium this year?”

As I became more involved with the Florida College, I came to better understand the rather unique relationship between FCEP and FEMF/ EMLRC. To the best of our research, we are the only ACEP chapter with a separate non-profit foundation. You may not know that in the past five years, we have provided training on life saving and other critical medical topics to over 5,000 physicians, 500 nurses and 10,000 emergency responders. This is something that we all need to be proud us. We are a vital and essential organization providing educational resources to the Florida medical community. In my first year as president of FEMF, I want to be able to make the case and highlight those times when FEMF makes a difference. We are a great organization that works closely with FCEP, and are worthy of your financial support. I look forward to communicating these success stories to you, and to make the case for FEMF as your foundation, and a valuable asset for your professional development. FALL 2016 | VOLUME 23, ISSUE 3

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Free-Standing ED Committee Spotlight on FL's newest Off-site ED: Palm Harbor ER Article by Patrick Agdamag, MD, FACEP; FCEP Board Member For those that didn't get a proper introduction of the FSED world in my last EMpulse article update, I foretold of Florida's rapid growth in the number of new FSEDs and that soon one may be coming to a neighborhood near you. Well if you live anywhere near the Tampa Bay area, you now have yourself a star addition to the lineup of Florida's ever growing Free Standing/Off-site ED roster: Palm Harbor Emergency Room. The super-sized, 24-bed FSED will provide comprehensive emergency services to Pinellas and Pasco County area residents in greater Tampa Bay. It will no doubt be a trailblazer as being Florida Hospital's very first off-site ED in the Tampa Bay area. As its name would suggest - it is situated in Palm Harbor, FL - a family oriented community in the northwest corner of Tampa Bay. Residents of this area of Tampa Bay can enjoy both beach access and lake access and still be only 30 minutes from downtown. The new facility will be located on the area's busiest thoroughfare in Pinellas county - US Highway 19 - and is situated just under 8 miles from it's main hospital site, which is located in the historical city of Tarpon Springs, FL. It is here where Palm Harbor will be affiliated with its main campus: Florida Hospital North Pinellas.

Pat Agdamag, MD, FACEP FCEP Board Member With excellent rated schools and access to both fresh water and the Gulf, the community of Palm Harbor's has seen

significant growth and expansion.

The new 24-bed facility will have all the coveted bells and whistles, one would expect. Not mention of course, the FSED basics - such as on-site X-ray, ultrasound, CT-scan, and laboratory services. The ED will be primed and ready to handle STEMIs, Strokes, and just about any emergent health need for it's residents in the surrounding community. With the opening of this FSED, the north portions of Pinellas County and nearby south Pasco county communities will have improved access to emergency care. This is area of Tampa Bay sees large seasonal volumes swings and mounting flocks of snow bird residents each winter; existing EDs in this area routinely experience large bursts of visits during season, even compared to the rest of the Bay area. Ever increasing age and acuity in these residents generate high inpatient and ED volumes, many times causing other hospital ED's in the area to utilize EMS diversions, or bypass for hours or days at a time. Palm Harbor is on pace to open its doors by the end of November 2016 and is expected to fulfill a critical role in the community this winter, just when it's needed. By the time some of you are reading this article, there's a good chance you will be able to go pay a visit!

Freestanding ED Brief: UF Health Emergency Center – Kanapaha Brief submitted by Wendy A. Swan, BSN, RN, SANE-A; Nurse Manager at UF Health Emergency Centers - Springhill & Kanapaha UF Health is opening its second freestanding Emergency Dept. on October 1, 2016 in Gainesville, Florida. The UF Health Emergency Center – Kanapaha is located in the SW area of Gainesville, just off of Archer Road. Kanapaha will feature 10 exam rooms, one trauma/resuscitation room, and 3 fast-track beds to provide care to the patients in Gainesville and the surrounding area. Since opening the Springhill Emergency Center, with Zachary Wilson, MD as its Medical Director, on August 1, 2013, thousands of patients have been seen and treated at that location. Both Kanapaha and Springhill ED’s will offer services in-line with our main Emergency Department, including CT, X-Ray, ultrasound, an on-site laboratory, and highlytrained emergency staff and physicians. The opening of Kanapaha is the fourth option for the Gainesville-area in terms of UF Health’s Emergency Services: The main campus South Tower ED/Level 1 Trauma Center, the north tower Pediatric Emergency Dept., the Springhill Emergency Center, and the Kanapaha Emergency Center. Medical Director for Kanapaha: Matthew Shannon, MD Nurse Manager (Kanapaha & Springhill locations): Wendy Swan, BSN, RN, SANE-A

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FALL 2016 | VOLUME 23, ISSUE 3

ADDRESS: 7405 S.W. Archer Road Gainesville, FL 32608 OFFICE: 352-627-0500

EMRAF Committee Article by Shayne Gue, MD; EMRAF President I am humbled and honored to be serving as the EMRAF President for the upcoming academic year. We plan to “hit the ground running” and work to further the progress made in outreach and involvement by our Past-President Dr. Merisa Kaplan. With the addition of several new residency programs this year and next, we are looking forward to higher membership and more involvement than ever before! Our August meeting took place at this year’s Symposium by the Sea at Naples Grande Beach Resort. We were entertained and educated by colleagues in the SimWars, CPC, and Research Poster Presentation competitions. Special congratulations to all those who participated and our winners listed below: SimWars Champions: Florida Hospital and University of South Florida Case Presentation Competition Best Presenter: Chasi Skinner, DO (Florida Hospital) Best Discussant: Burr Fong, DO (Mount Sinai) Best Program: Florida Hospital Research Poster Presentation Outstanding Medical Student: Stephanie Winslow (University of Florida – Gainesville) Outstanding Resident: Larissa Mueller, MD (University of South Florida) As always, the role of EMRAF, within FCEP, is to empower residents to learn about all aspects of Emergency Medicine and to provide a unified voice of Emergency Medicine Residents in the State of Florida. Our primary goal is to increase resident engagement and facilitate the development of a more wellrounded EM resident. This year, we are seeking to expand our membership by actively recruiting more resident representatives from around the state. Program representatives are tasked with serving as a liaison between the EMRAF Committee and their respective residency programs. As with all FCEP Committees, we meet quarterly, in conjunction with the FCEP Board of Directors at the EMLRC in Orlando and during Symposium by the Sea and EM Days in Tallahassee. This year, we hope to have an increased presence and involvement in the planning/ organization of FCEP’s Emergency Medicine Days and Symposium by the Sea. We currently have 10 resident representatives from 5 Florida residency programs (Florida Hospital, Orlando Health, UF Gainesville, University of South Florida and Aventura Medical Center). My primary objective for the 2016-2017 year is to increase our membership to a minimum of 20 resident members including all 11 Florida Residency Programs. If you are interested in serving as an EMRAF liaison for your program or you’re a program director and do not see your program listed above but would like to have your residents get involved, please contact me at shaynegue@hotmail.com.

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

Leadership Academy Update Article by Patrick Agdamag, MD, FACEP; FCEP Board Member The annual Symposium by the Sea (SBS) conference in August signifies many things for FCEP. As we usher in new officers and Board members, we also see a lot of new faces, great ideas and work to facilitate projects that begin during our annual conference. One area of particular interest and excitement is FCEP's Leadership Academy. The Leadership Academy exists to promote participants to pursue the highest quality emergency medical care, education, and empowering of emergency physicians to better protect the patients they serve across our great state. The Leadership Academy typically selects only two to four candidates each year across the entire state of Florida. It combines elements of mentoring along with a high level of organizational/educational skills and leadership experiences - all from some of our most influential EM leaders across the state Florida and ACEP nationally. Some of the venues they will be taking part in include: FCEP's Board of Director meetings, FCEP's Committee meetings, Tallahassee State legislature meetings and ACEP national assembly meetings. For those not familiar with FCEP's Leadership Academy, it combines elements of mentoring, organization, and guided experiences to carefully selected Academy participants, who want to grow in their interest area(s) of EM. The Academy brings all the ingredients needed to grow leaders in our field, while harnessing their targeted areas of interest.

Pat Agdamag, MD FACEP FCEP Board Member At Symposium by the Sea, the annual journey begins. The time commitment for the Academy fits nicely with the hectic

schedules we have in our busy lives and practices. Our gatherings center around three to four large conferences and our quarterly Board/Committee meetings. The cost of attendance for the Academy program itself is free, and group practice sponsorship is encouraged to help cover any costs for travel and attending conferences. The typical venues include FCEP Board and Committee meetings; state legislature meetings in Tallahassee; Symposium by the Sea; and ACEP's Leadership and Advocacy Conference in Washington D.C. One requirement for graduation from the Academy is completion of an administrative project. This can be working toward a medical directorship, research project, administrative or leadership position, and even introduction of new legislation during our annual EM Days conference in Tallahassee. This year at SBS, while we were in Naples, we wanted to take the time to recognize our newest graduates of the 2015-2016 Leadership Academy for their efforts and dedication toward a search for growth in leadership: Drs. Kristi Staff (Tampa - project EMRAF Liason), Cesar Carralero (Miami - project Sim ED for Osteopathic EM programs) and Gary Lai (Weston - EMS education and Partnership - FCEP Board). On behalf of FCEP, I would like to say congratulations! FCEP is very proud of who these physicians are and who they will become after their amazing progress and growth in over these past 12 months. Please welcome me in congratulating our newest official graduates of FCEP's Leadership Academy! At the same time - we begin a new phase of the academy with the next class coming forth to take on the new challenge. A newly and carefully selected class is ushered in with two outstanding US Fellows to form the new class: Drs. Saundra Jackson (Jacksonville) and Ray Merritt (Tampa) round out our new 2016 - 2017 Leadership Academy Class. As FCEP's current Chair of the Academy, I can personally attest to the quality of candidates selected. It is a highly competitive process statewide with limited availability. This will no doubt be a springboard for more growth in their leadership experiences already attained. Once again, please join me in Drs. Staff, Carralero and Lai for their well-deserved honor and distinction. The applications can be downloaded directly from the EMLRC website, or you may email direct inquiries to pagdamag@gmail.com.

Coding Tip Supporting Critical Care Services

More insurance carriers are doing pre-payment audits for the Critical Care codes. Are you confident that your charts have the proper documentation showing the medical necessity for providing Critical Care services? What would you highlight in your chart to support the necessity for this life-saving service? • Do you have high or low vital signs that are consistent with organ system failure? • Do you have critical lab values? • Are you using IV medications beyond that for the support of a Level 5 high-complexity management? You can help your coders, and any auditors, understand that you are dealing with a critical situation by putting those vitals, labs and medications in your Critical Care note. Many EMRs have headings for “Indication” and “Interventions.” And be sure to document your total accumulated time in minutes. Lynn Reedy, CPC, CEDC, Director of Coding Services, Tampa Bay Emergency Physicians

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FALL 2016 | VOLUME 23, ISSUE 3

EM p u l s e F e a t u r e ACEP/EMF Corporate Council 2016: Better

emergency medicine through

collaboration and research

Article by Jordan Celeste, MD; FCEP Board Member The ACEP/EMF Corporate Council took place this July 2016 in Dallas. This annual event brings together companies, government agencies, and emergency medicine leaders to discuss the college, its chapters, the foundation, as well as specific aspects of emergency medicine. This year, over fifty companies and government agencies were in attendance, and the topics ranged from the future of research to data systems to clinical tools and beyond. Discussions were not simply educational, but also aimed at identifying opportunities for collaboration that will ultimately impact patient care in emergency departments across the country. The two-day event consisted of formal presentations, roundtable discussions, private meetings, as well as ample opportunities for networking. FCEP was well represented by its Executive Director Beth Brunner, as well as by Dr. Vidor Friedman and myself who were there as part of our roles with the ACEP Board of Directors and the EMF Board of Trustees, respectively. Ms. Brunner was one of a select few chapter executives in attendance, as Florida’s reputation as a large and established chapter allows it to provide potentially unique opportunities for corporate participants. The roundtable discussions gave participants the opportunity to not only select topics that were pertinent to them, but also to share any challenges that they are facing in those arenas. Potential solutions were explored, and in many cases future directions for discussions were also identified. Emergency medicine leaders were able to provide insight into clinical care as well as into administrative aspects of practice. A highlight of the formal presentations was a talk by Dr. Arjun Venkatesh, who traced his course in emergency medicine research from medical student all the way to distinguished researcher and EMF/EMAF Health Policy Scholar. Dr. Venkatesh clearly demonstrated the impact that investment in emergency medicine research can have, but also showed the immediate and future need for support for junior investigators. As EMF continues to grow, the importance of having close working relationships with government agencies as well as like-minded companies will only increase. As the work continues following this year’s productive Corporate Council, planning has already begun for next year’s event. While the meeting continues to expand and evolve, one thing is for certain – keeping open lines of communication with potential partners and nurturing the relationships that grow from them is of the utmost importance to successfully fulfilling the mission of ACEP, its chapters and EMF.

D a u n t i n g D ia g n o s i s Answer:

petechiae.

This patient has TTP, represented by the new onset of oral

Thrombotic Thrombocytopenic Purpura (TTP) is characterized as a rare blood-coagulation disorder causing extensive microscopic thrombi to form in the small blood vessels throughout the body. Red blood cells passing the microscopic clots are subjected to shear stress, which damages their membranes, leading to RBC rupture within blood vessels. This in turn leads to anemia and schistocyte formation. Reduced blood flow, due to thrombosis and cellular injury, results in end organ damage.

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

• • •

Classically, the following five features (“pentad”) are indicative of TTP, yet in most cases, some of these are absent:

• Thrombocytopenia leading to purpura • Microangiopathic hemolytic anemia Neurologic symptoms such as hallucinations, behavior changes, delirium, headache, and CVA Renal Failure Fever

(Question on page 5)

Most cases of TTP arise from autoantibody-mediated inhibition of the enzyme ADAMTS13, a metalloprotease, responsible for cleaving large multimers of von Willebrand Factor (vWF) into smaller units. The increase in circulating multimers of vWF increases platelet adhesion to areas of endothelial injury, particularly at arteriole-capillary junctions. Treatment includes plasma exchange. Immunosuppressants, such as glucocorticoids, rituximab, cyclophosphamide, vincristine, or ciclosporin, may also be used if a relapse or recurrence follows plasma exchange. Hematology should be consulted on all cases. FALL 2016 | VOLUME 23, ISSUE 3

EMpulse | 13

Florida International Trauma Life Support Update Article by Jeffery D. Gilliard, NRP/CCEMTP/FPM, BS; FITLS Chapter Coordinator/Affiliate Faculty With the ITLS International Conference approaching, I thought it would be appropriate to give the highlight report from last year’s conference in Las Vegas. The 2016 conference will be held October 27-29 at the Wyndham San Antonio Riverwalk in San Antonio, Texas. The 2015 International Trauma Conference, held November 10-13 in Las Vegas, Nevada, was a success with one of the largest attendance counts in conference history. More than 300 trauma care and EMS professionals from 20 countries worldwide attended. The conference opened with true Vegas flair: Elvis welcomed participants and performed, while Las Vegas showgirls passed out decks of playing cards.

Board of Directors Elections

Three members of the Board of Directors were elected during the conference’s Business Session. Serving their first terms on the Board of Directors are Liz Cloughessy, AM, RN, MHN, FAEN, Chapter Coordinator for ITLS Australia & New Zealand, and Mary Hancock, MD, FACEP, Chapter Medical Director for ITLS Ohio. Returning to the Board is incumbent Jonathan Epstein, MEMS, NRP, Vice Chair of the Board and Chapter Coordinator for ITLS Massachusetts. Jeffery Gilliard, NREMT-P, CCEMTP, FPC, BS, of Florida, was re-elected as Speaker. Amy Boise, NRP, FP-C, of Arizona, was elected Vice Speaker.

ITLS Annual Awards

Five individuals were honored at the conference with ITLS’ annual awards. Roy Alson, PhD, MD, FACEP, Co-Editor and Editorial Board member, was presented with the Jackie Campbell Award. This special award is ITLS’ highest honor and recognizes individuals for their enduring service as “the wind beneath our wings.” Dr. Alson’s tremendous work on the 8th edition Provider manual and instructor materials was gratefully acknowledged. Qirong Du, MD, Chapter Medical Director for ITLS Shanghai Xin Hua Hospital in China, was presented with the ITLS Ambassador Award for his work in promoting ITLS programs and demonstrating a clear belief in the ITLS mission. Dr. Du was instrumental in presenting the ITLS Asian Regional Conference in Shanghai in April 2015. Dr. Du was not present to accept his award but it was accepted on his behalf by his colleague, Lujia Tang, MD. Michael Rushing, RN, BSN, NRP, CFRN, CEN, CPEN, CCRN-CMC, of Florida, was honored with the Pat S. Gandy, RN, ITLS Coordinator of the Year Award. The award recognizes Mr. Rushing’s outstanding leadership in promoting ITLS and prehospital trauma training under the Florida chapter. Linda Sims, RN, of Australia, was presented with the ITLS Instructor for the Year Award, named in honor of Dr. Ray Flower for excellence in teaching and innovation in ITLS programs. Wm. Bruce Patterson, BaBES, EMT-P, was presented with the ITLS Harvey Grant Memorial Award for outstanding leadership in ITLS Access, recognizing his dedication and efforts on the third edition of the ITLS Access manual, released at the conference.

ITLS Competition

Seven teams competed in the annual ITLS Trauma Competition at the conference, using the ITLS assessment to triage and treat trauma patients in three creative and challenging simulated scenarios. For the first time, the Competition was presented during the two-day conference rather than as a pre-conference event, allowing conference participants to watch the scenarios and earn continuing education credit. Teams represented Nevada, Niagara EMS, North East Ambulance Service UK, Toronto EMS, West Virginia, and two teams from Slovenia. The team from Niagara EMS was again declared the winner of the 2015 Competition. Team members were captain Brock Browett, ACP, Emma Santon, PCP, Megan Daza, PCP, and Jonathan Dyck, ACP. The team from Toronto EMS took second place. The team from North East Ambulance Service in the United Kingdom, first-time competitors, took third place. Once again, the 2016 conference will be held October 27-29 at the Wyndham San Antonio Riverwalk in San Antonio, Texas. ITLS of Florida has trained enough folks to have eight delegates eligible for the 2016 conference. Many have volunteered to go including myself, I hope to see you there!

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FALL 2016 | VOLUME 23, ISSUE 3

Poison Control To Fizz of Not to Fizz Patrick Leffers, Pharm.D. Clinical Toxicology/Emergency Medicine Fellow Little has changed in the management of acetaminophen toxicity in the past decade. Currently, available treatment options include one oral (PO) and one intravenous (IV) N-acetylcysteine (NAC) formulation.1 Acetylcysteine solution 20% for oral treatment is given as a loading dose (140 mg/kg) followed by 17 maintenance doses (70 mg/kg) every four hours. Acetylcysteine intravenous solution (Acetadote®) is dosed in three phases lasting a minimum of 21 hours.1 The loading dose, 150 mg/kg, is infused over one hour, followed by a 12.5 mg/kg/hr infusion for the next four hours, and finally a 6.25 mg/kg/ hr infusion for the next 16 hours. The adverse reactions involving both products are minimal but should be considered before choosing a route of administration. The IV formulation is well tolerated but infusion-related anaphylactoid reactions can rarely occur including itching (4.3%), hives and flushing (6.1%), and respiratory symptoms (1.9%).1 The PO solution is a foul smelling liquid that can cause nausea and vomiting. The PO route should be avoided if the patient is an aspiration risk due to concerns for aspirating the NAC solution. The reported rates of vomiting have ranged from as low as 13.1% to upwards of 40%.2,3 In January, the Federal Drug Administration (FDA) approved a new oral product named Cetylev™ (acetylcysteine effervescent tablets).4 The effervescent tablets are available in 500 mg tablets and 2500 mg tablets, and in an attempt to improve tolerability they are a lemon mint flavor. The indications and monitoring parameters do not change from those recommended for the PO solution.4 The dosing is similar to the solution, however rounding to the nearest whole tablet is required and the manufacturer provides a simple dosing chart in the package insert. Rates of vomiting caused by the product in clinical use are not yet known, and studies comparing the rates of vomiting with the other oral product are not yet available. Some potential issues with the new formulation bear mentioning. First, the product must be diluted in a large volume of water and consumed every four hours. For patients less than 60 kg, it is recommended that the dose be prepared in 150 mL of water. For patients 60 kg and up, the manufacturer recommends diluting the prescribed number of effervescent tablets in 300 mL of water. It is anticipated that this amount of volume may be difficult for some to tolerate. Second, the tablets are made effervescent in part by the addition of sodium bicarbonate. Each 500 mg tablet contains 88 mg of sodium, and each 2500 mg tablet contains 438 mg of sodium. A 100 kg patient would be required to take three of the 2500 mg tablets every four hours for a total of 7884 mg of sodium in one 24 hour period. It is currently unknown how this amount of sodium will effect a patient’s serum sodium, but certain disease states will likely not be able to tolerate this combination of extra fluid and sodium. Clinical experience with Cetylev™ is limited at this time. Efficacy studies were not required by the FDA for approval of the new formulation. Rather, the FDA only required pharmacokinetic studies demonstrating that a statistically comparable amount of acetylcysteine was delivered to healthy volunteers. Efficacy is not expected to be any different than that of the oral solution or the intravenous product. The rate of vomiting with clinical use of Cetylev™ during acetaminophen toxicity is unknown at this time. If a patient vomits within one hour of receiving either oral product, several options exist. Antiemetics can be given, the products can be diluted to improve taste, or the patient can be switched to the IV formulation. Emergency medicine physicians should contact their pharmacy about product price and availability if considering the use of Cetylev™. Your local poison center is available toll-free, at 1-800-222-122, if you have any questions regarding acetaminophen toxicity or any other potentially toxic exposure.

References:

1. Acetadote (acetylcysteine, injection) [package insert]. Cumberland Pharmaceuticals; Nashville (TN): December 2008. 2. BebartaVS, Kao L, Froberg B et al. A multicenter comparison of the safety of oral versus intravenous acetylcysteine for treatment of acetaminophen overdose. Clin Toxicol 2010; 48(5): 424–430. 3. Wright RO, Anderson AC, Lesko SL et al. Effect of metoclopramide dose on preventing emesis after oral administration of N-acetylcysteine for acetaminophen overdose. J Toxicol Clin Toxicol 1999;37(1):35-42. 4. Cetylev (acetylcysteine tablet, effervescent) [package insert]. Arbor Pharmaceuticals; Atlanta (GA): January 2016.

FALL 2016 | VOLUME 23, ISSUE 3

EMpulse | 15

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. Time is flying by! Our new interns rocked their first month of residency and still continue to work hard and challenge themselves in the emergency department. The second year residents have stepped up to the plate, handling the increased amount of responsibility and clinical autonomy with ease. The third years have quickly become fierce leaders in the department, serving as positive role models for our residents and running the show in the ED. It looks like this residency year is certainly off to a great start! In addition, we are very proud of the team of residents that represented our program at the Annual Symposium by the Sea in Naples, Florida. The team placed first in the Annual Sim Wars Residency Simulation Competition! This is the second year in a row that FHEM has taken home the big trophy! Our all-star team included Dr. Alex Drake, Dr. Shayne Gue, Dr. Chasi Skinner and Dr. Julian Trivino. However, it doesn’t stop there! Dr. Chasi Skinner also won Best Case Presenter. Additionally, Dr. Chasi Skinner and Dr. Julian Trivino, together, won Overall Best Case Presentation. Florida Hospital Day Zayas, MD PGY II

Outstanding job and huge congrats to this crew on their well-deserved win. Way to represent FHEM residency! We hope everyone continues to have a successful year!

July marked a big change for the UF EM residency. This July, we welcomed our first class of 14 interns, the largest we’ve ever had, commemorating the expansion of our residency program. As is tradition in Gainesville, the interns spent the month of July working less shifts and spending more time finding their way around the ED, in simulation labs learning how to do simple procedures (like using the ultrasound), getting certified in all types of life support, and learning their way around Gainesville. Now that they’re all a few months into residency, they’re getting more comfortable and definitely stepping up to the task of taking care of our high acuity patients. First step: orientation month; second step: core 2 fellowship; third step: senioritis. Heads up interns—it goes by way too fast… The month of July marked another huge milestone for UF—the change in our program leadership. Congratulations to Dr. Beattie, our new program director, and Dr. De Portu and Dr. Maldonado, our new APDs. While I’d like to take some time to extend some resident appreciation to the new leadership and let them know we think they’ll do a great job, I’d also like to take a moment to say a heartfelt thank you to Dr. Desai for everything he did for the residents and the UF EM residency program. Thank you for teaching us, giving us plenty of advice, writing our notes when we were swamped, and always having our backs. You will definitely be missed.

University of Florida, Gainesville Merisa Kaplan, MD, MPH

The residency at St Lucie Medical Center is keeping busy with their new class of interns but certainly enjoying their presence and eager minds. The class is composed of Dr. Austin Hudson, Dr. Michael Gulenay, Dr. Blaire Laughlin, and Dr. Jeremy McCreary. A collection of our residents traveled to Naples for FCEP's Symposium by the Sea. They also took part in the sim wars competition, and although they didn't walk away as winners, they thoroughly enjoyed the variety and acuity of the cases. We also plan on attending NSUCOM's Residency Fair this October and are looking forward to the ACOEP's scientific assembly in San Francisco this upcoming November! St. Lucie Medical Center Rege Turner, DO PGY-IV

First and foremost we would like to welcome the new members of the UF Jax family. The newest class of EM Residents have hit the ground running. Dr. Amanda Roycik joins our ranks as our newest Pediatric Emergency Medicine Fellow. Dr. Roycik trained in Pediatrics at UF Jacksonville. We would like to welcome Dr. Carolina Pereira, a graduate of the Orlando Regional Medical Center EM Residency, as our newest Attending. Dr. Pereira recently completed her fellowship in Emergency Medical Services at Long Island Jewish/Fire Department of New York City (FDNY) and will serve as the Disaster Medical Officer for UF Health Jacksonville. We would like to congratulate Reed and Stephanie Flora on the arrival of their youngest son, Wilder Edward Flora. The faculty of UF Jax earned a slew of congratulations over the summer. Dr. Ashley Norse was awarded the Florida College of Emergency Physicians’ Outstanding Member of the Year for 2016. Dr. Madeline Joseph has assumed the role of ACEP Liaison to the Emergency Medical Services for Children Innovation and Improvement Center (EIIC) Quality Improvement Advisory Board. Dr. Todd Wylie has stepped into the role of Medical Director of the Pediatric Emergency Department. Dr. Hendry has stepped into the role of Trauma One Flight Services Deputy Medical Director for Pediatric Transport and Care. Dr. Andrew Schmidt has been named Trauma One Flight Services Deputy Medical Director for Outreach, Education, and Training. Dr. Elizabeth Devos has been promoted to Associate Professor. We would like to recognize UF Health Jacksonville was named the first and only accredited Chest Pain Center with Primary PCI and Resuscitation in Florida by the Society of Cardiovascular Patient Care. Lastly, we would like to wish Dr. Joseph Sabato a warm farewell as he moves back to Massachusetts to be closer to family.

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FALL 2016 | VOLUME 23, ISSUE 3

University of Florida, Jacksonville Jason Arthur, MD/MPH PGY-2

“Welcome to Miami….” (Will Smith Big Willie Style Voice). Hello again, and this is a fall update of the Mount Sinai Medical Center EM Residency! A few notable happenings are certainly worth writing about. First, our residency had a strong showing in Naples, FL at the 2016 FCEP Symposium by the Sea. Dr. Harrison Borno, Dr. Robert Fernandez, and Dr. Ben Abo’s “Patient Education and Satisfaction study” was well received and sparked great conversation. We did well in FCEP’s annual simulation contest “Sim Wars” where we tied for 3rd place, our best performance yet! This year’s team was led by Dr. Chad Lee, Dr. Kushal Patel, Dr. Burr Fong and yours truly, Dr. Matt Brooks. In the resident Clinical Pathology Case Competition, Dr. Burr Fong took first place as best resident discussant and Dr. Nick Garrett received honorable mention as a Case presenter. Overall, a very successful trip, and we expect to have an even stronger turnout next year, especially with our new Sim Lab opening very soon!

Mount Sinai Matthew Brooks, DO PGY-II

Our new residents have been acclimating very well and are proving that they come up with a wide differential, thorough workup, and appropriate disposition, all the while providing great patient care in a very busy emergency department. They consist of Dr. Aldo Manresa, Dr. Natalia Diaz, Dr. Adam Memon, Dr. Bradley Koschel, Dr. Mike Dicenso, Dr. Mike Cecilia, and Dr. Megan Lorenzo.

Construction of the new emergency department has begun, with sounds of the old MRI building being torn down by an ambitious demolition crew vaguely penetrating the ever present roar of the current ED. We hope to see it open in early 2018. Finally, this update would not be complete without a mention of Zika. The media tends to create an unwarranted hype in most new healthcare trends, and the Zika buzzword has proven to not be an exception. For the first time in history, the CDC has issued a travel warning for Miami, more specifically for pregnant women to avoid the Wynwood neighborhood, and now parts of Miami Beach. We have been seeing, diagnosing, and testing for Zika in our emergency department as clinically warranted, and at the time of writing this, it seems that the virus has spread to Miami Beach. It remains to be seen how this will affect the tourism and economics of the Miami area, but not to worry; if you are a man or a women not trying to get pregnant, Zika has so far been nothing more than a rash with flu-like symptoms. Miami-Dade has been aerially spraying target areas to eradicate as many mosquitos and larvae as possible. So be sure to periodically check with the CDC website for current recommendations and don’t be afraid to come down to visit beautiful Miami – just consider packing some bug spray with your sunscreen!

Although it has been almost two months since the tragic Orlando massacre, it is impossible not to reflect on or to be reminded of what happened here every day. Driving by the OrlandoHealth sign at the corner of Lake Beauty, adjacent to the ambulance entrance of our ER, we remembered the piles of dying flowers, deflated balloons, photographs, and 49 white crosses which were erected, and remained for weeks, in memoriam of those who were killed. The nightclub itself is still gated off and covered in signs, flowers, and pictures—and for many of us, is on our route home. The latest copy of EMpulse was found sitting in our mailboxes weeks after the tragedy. Tasked with writing the next “Residency Matters” section by one of our graduating residents, and now Pediatric EM fellow, Tory Weatherford, one of the five senior residents on duty the evening of the tragedy; it was difficult to begin. How could we write about what happened? Neither of us were there. But, the title of the section was inspiring. Residency Matters. Five of our now graduated seniors, Dr. Amanda Stone, Dr. Tory Weatherford, Dr. Thomas Smith, Dr. Chris Ponder, and Dr. Amanda Tarkowski, supervised by attendings Dr. Kate Bondani, and Dr. Gary Parrish, helped save lives with the skills and experience that residency taught them. There was horror and grief, heroism, and teamwork. In the subsequent weeks, there were lines of news trucks that filled the streets outside the hospital. Politicians and reporters walked our halls and our ER. Metal detectors were installed, doors were blocked off, there was extra security and there still is. Golden retrievers came to comfort us and lick our faces while we worked, and there were the families of the victims that we had to face everyday as we came into work, as they sat in vigil for their loved ones in our front entrance waiting room. All the while, the heavy, steady inflow of patients never seemed to cease. The COPD exacerbations, stomachaches and GSW’s all kept rolling in, while outside the ER, Orlando chanted togetherness and prayed for peace. As always, we are extremely grateful to the Orlando Health community. We want to thank our attendings, fellow residents, nursing staff, secretaries, and first responders, for every thing they do. In times of great loss, there is also great strength. #OrlandoStrong.

Orlando Health Shari Seidman MD, MPH & Erich Heine DO

The new USF residency year is off to a wonderful start. As always, our summer in Tampa is a celebration of everyone’s advancement in position and a welcoming of the new intern class. It started off with a bang in July at the welcome “Pool and Pool Party” and continued with the “Bonding on Boards Bash in the Bay.” When August rolled around, we were having so much fun that we needed to remind ourselves of the strong work we accomplish around here. Luckily, our Sim-Wars team did just that, returning from Symposium by the Sea as co-champions. In the research arena, our residents, students and team members, proved that they were a force to be reckoned with, by taking a 1st and 2nd place prize down in Naples. We want to give an enormous congratulation to Dr. Sasha Klemawesch. She matched into Washington University St. Louis for a critical care fellowship; way to go! We’d like to extend a warm welcome to attending physicians Dr. Whitney Cesari and Dr. Jasmine Patterson who have recently joined our team. Also, we’d like to extend a re-welcome to USF EM graduate Dr. Juliana Lefebre who has begun her attending career with us as our EMS fellow. We are excited to have such wonderful new teachers to help guide us, as we shape our careers in EM. University of South Florida Jeffrey Hoida, MD PGY-II

Finally we are excited about our team mud run at the end of the month and to meet up with all of our FL residency friends in Vegas, at ACEP. Some of our best folks will be there teaching ultrasound; stop on bye if you need some pointers!

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EMpulse | 17

R e s i d e n c y M at t e r s Kendall Regional Medical Center is happy to announce the successful start of our inaugural residency class on July 1st, 2016. Our program is dedicated to providing an outstanding training environment while ensuring resident wellness and a strong and varied clinical experience. We are proud of our residents and for what our program has to offer. The Kendall Regional Medical Center Emergency Medicine Residency, through its strong partnership with Florida International University Herbert Wertheim College of Medicine, offers 12 residents each year a truly exceptional educational experience. The residency is structured in a PGY-1,2,3 format. Kendall offers residents and medical students the opportunity to work closely with our dedicated and talented emergency medicine faculty in an environment that sees more than 89,000 emergency department visits per year. We are also able to offer each resident an exceptional clinical experience that includes rotating in our pediatric emergency department Kendall Regional Medical Center throughout all 3 years of residency training. Regardless of the path chosen, our comprehensive didactic, business, ethics Kevin C. King, MD, MS, FACEP and leadership curriculums are geared to prepare all of our graduates for successful careers in private practice or academics. Program Director “The City Beautiful,” home to the most magical place in the world, the Orlando City Lions, The Orlando Magic, and now, home to a new ACGME approved EM residency program at Osceola Regional Medical Center! After years of planning, we are extremely excited to announce that our inaugural class of 7 residents has come together from all 4 corners of the United States. We will be training in one of the fastest growing and diverse counties in the country. Our facility was recently designated a Level II Trauma Center, which is an extremely exciting part of our curriculum! We also have access to the UCFCOM state of the art Sim-Lab. Since the outset, we have all felt very welcomed by the Osceola Regional Medical Center family. We are excited to be a part of a medical team that is equally enthusiastic for us to be here. As the inaugural class of residents, we have made it our mission to give our best to this program. We strive to create a solid foundation for the future Emergency Medicine physicians who will undergo training at our facility. Continuing with UCF’s mission, our program has implemented many tools for us to succeed, and continue to adopt innovative technology to improve our healthcare delivery and the well-being of our community. Specifically the program is using integrated learning by utilizing various open access medical education to further promote up-to-date and lifelong learning. There is a lot to learn in the art of Emergency Medicine, and we know that we are being mentored by an incredible team who are there to guide us throughout the journey. We look forward to the years to come!

UCF-Osceola Abhishek Roka, MD and Leoh N. Leon II, MD

Jackson Memorial Hospital’s EM program got off to a bounding start as we welcomed our inaugural class of 15 talented individuals this past June. Our action filled orientation month included summer theater at the Adrienne Arsht Center for the Performing Arts, a baseball game at Marlins Park, our department chair’s fantastic welcome event by the water, Sim sessions at the renown Gordon Center, ATLS, ACLS, BLS and PALS, in addition to jumping right into the action of the hectic Jackson ED. Since then, our residents have been keeping busy in the ED and off-service, as well as at our community hospital affiliate Holy Cross. Oh, and we can’t forget to mention journal club by the pool with a water and skyline view; turns out Miami life isn’t so bad after all.

Jackson Memorial Hospital Mark Supino, MD Associate Program Director

We are also excited to have partnered with our neighboring Florida EM residency programs to form the South Florida Consortium of Emergency Medicine, rotating residency sites on a quarterly basis to host grand rounds. We have thus far had the pleasure of welcoming Dr. James J. Augustine, MD and Dr. Lisa Moreno-Walton, and look forward to many more fascinating and educational collaborations.

Finally, we were impressed to have learned that two of our new residents had already won awards as medical students in the field of EM. Natalia Alvarez received SAEM’s Excellence in Emergency Medicine Award and Laura Scheidt received ACEP’s Medical Student Professionalism and Service Award. Congrats to both. Exciting times undoubtedly lie ahead for Jackson Memorial and for the entire field of EM in South Florida.

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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FALL 2016 | VOLUME 23, ISSUE 3

EM p u l s e F e a t u r e New UCF Osceola Program adds another EM residency program to Central Fla. Article by Bethany Ballinger MD, FACEP; Program Director of UCF/HCA GME Emergency Medicine Residency Program of Greater Orlando Exciting things are happening in Florida in the world of Emergency Medicine education. In just one short year, the number of EM Residency Programs has grown from seven to 12 programs. The landscape is changing! One of these programs is the University of Central Florida College of Medicine/ HCA GME Consortium Emergency Medicine Residency Program of Greater Orlando! Locally we are known as the UCF Osceola Program. Osceola, as we are based at Osceola Regional Medical Center, an HCA facility in Kissimmee, just south of Orlando. Bethany Ballinger, MD, FACEP Our new three-year program received initial accreditation in April 2016 for seven residents per year. Program Director

So what was it like to start a new residency program? It is the most interesting and fascinating thing you can do as an Emergency Medicine educator. And yes, it is also really hard. In the realm of climbing Mount Everest? Maybe not, but certainly you have moments where you are exhausted and are gasping for air! But as they say, nothing worth having is easy! We were extremely fortunate to have the great support and assistance of a wonderful medical school and a forward thinking hospital. The graduate medical education program is one of the first in the new UCF-HCA consortium that plans to bring 550-plus residency slots to Florida by 2020 to ease our state’s dramatic shortage of residents per capita (42nd of the 50 states). EM residencies are currently planned at HCA’s North Florida Regional Medical Center in Gainesville and Ocala Regional Medical Center. HCA has shown a strong commitment to education in Florida and the development of a greater vision for graduate medical education throughout the US. It was a fulfilling endeavor to create a team of core faculty from the ground up and find colleagues who are outstanding emergency physicians and whose passion is education. Each of our new faculty members has their own area of expertise, including informatics, simulation, research, ultrasound and healthcare policy. We were undaunted by the fact that we had missed Match Day 2016 in selecting our first residents. “Can we start a first class in July?” we asked. “Should we?” Our answer was a resounding yes. Of all the things I’ve learned in the last year, (and there are many), one of the most important is that there are very qualified students/ M.D. graduates who are still looking for an EM residency after Match Day. You would be amazed at the sheer number (hundreds) of excellent applicants we received. We could have easily filled two classes. We have an inaugural cohort of outstanding people with the exceptional qualities, accomplishments and skills to be great EM physicians. The experience the residents will receive at Osceola Regional Medical Center is exceptional. Our Emergency Department sees approximately 80,000 patients a year and has a dedicated Pediatric ED. Sheridan Healthcare manages the ED and has helped transform it from a community based ED to the academic teaching ED setting. We have the wish list of learning facilities. In addition to the Level II Trauma Center, ORMC has a Chest Pain Center with 24-hour PCI, a Stroke Center, Obstetrics Labor and Delivery, and a Behavioral Health Receiving Facility. We have the people and the passion to make the learning experience, a great one. Our culture is one of compassion and we aim to teach in a way where patient-centered care is the expectation and the reality. Our new residents started with us on July 1 and took a leap of faith by agreeing to be part of a brand new program. But that’s part of the pioneering spirit that characterizes the UCF College of Medicine and one it encourages in students and faculty. So our residents are a perfect match. For more information, please ucfemergencymedicineresidency.org.

see

our

website:

www.

FALL 2016 | VOLUME 23, ISSUE 3

EMpulse | 19

EM p u l s e F e a t u r e

New Emergency Medicine Residency at Florida Atlantic University College of Medicine in Boca Raton, Fla. Article by Richard D. Shih, MD, FACEP, FAAEM; Residency Program Director at FAU Emergency Medicine at Bethesda Health This newly accredited emergency medicine training program is located at Florida Atlantic University (FAU) Charles E. Schmidt College of Medicine and will recruit its first class of residents through the match with an initial start date of July 2017. Our university-based program will offer clinical rotations at three highly respected hospital systems: Bethesda Health, St. Mary’s Medical Center, & Delray Medical Center. These sites will offer excellent clinical opportunities in emergency medicine, pediatric emergency medicine, emergency medical services, medical toxicology, critical care and emergency ultrasound. In addition, the medical school has a state of the art simulation and conference center that will allow us to provide a comprehensive, evidence-based and well-balanced emergency medicine education. The residency leadership team includes Richard D. Shih, MD (rshih@health.fau.edu), Lisa Clayton, DO (claytonl@health.fau.edu) and Colleen Mayer (mayerc@health.fau.edu). Dr. Shih most recently served Richard Shih, MD, FACEP, FAAEM during the past 19 years as the Emergency Medicine Program Director at Morristown Medical Center in Residency Program Director New Jersey. He is board certified in emergency medicine and medical toxicology and will serve as the founding program director. Dr. Clayton is board certified in emergency medicine and fellowship trained in Emergency Medicine Services and will take on the role of Assistant Program Director. Ms. Mayer has 16 years of experience as an EM program coordinator working with Dr. Shih and will serve as the program coordinator and academic program manager. In addition, the program has recruited a number of experienced emergency medicine educators who have all had primary training in emergency medicine. All of these individuals have completed fellowship training that bring additional expertise and teaching skills to the residency. These areas include simulation, ultrasound, integrative and alternative medicine, medical toxicology and EMS. The focus of this new emergency medicine program will be on teaching exceptional clinical skills in emergency medicine in an evidence based manner. All clinical rotations have been selected for specific clinical experiences that benefit an emergency medicine resident’s training with the prioritization of education over service duties. As an example, the residents’ weekly didactic experience will be entirely protected from clinical responsibilities to ensure that residents will not be working before or after the teaching sessions. This will ensure that residents be able to attend and participate fully in all of these sessions. In addition to emphasizing clinical skills with the goal of producing superb emergency medicine physicians, the new program also plans to provide a top-notch academic experience to train the future leaders in our specialty. The newly formed FAU Emergency Medicine Research Network Group, comprised predominantly by the emergency medicine core faculty, has been meeting in conjunction with the medical school over the past year. The group has been collaborating on emergency medicine research projects with the resources and support of the medical school. The mission of this group is to advance research and knowledge in emergency medicine. Further, the group will support and provide many opportunities for residents to participate in academic and scholarly activities supported by many mentors and collaborators. We know that not all emergency medicine residents will become researchers. However, our goal is to provide an excellent research and scholarly activity experience during their residency training. Geographically, FAU’s Emergency Medicine Program is located on the coast of Southeast Florida in the heart of Palm Beach County: Boca Raton, Florida. This community and surrounding areas provide wonderful schools, shopping, beautiful beaches, restaurants, indoor and outdoor recreation, theaters, healthcare, entertainment and much more. Boca Raton also offers a diverse selection of communities and activities. For more information about this area visit this website, http://www.palmbeachfl.com/. For more information about our emergency medicine residency please visit this website, http://med.fau.edu/residencies/emergencymedicine/.

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FALL 2016 | VOLUME 23, ISSUE 3

EM p u l s e F e a t u r e

New EM Residency in Aventura Adds Another Program to South Fla. Article by Todd L. Slesinger, MD, FACEP, FCCM, FCCP, FAAEM; Residency Program Director at Aventura

I am so proud to announce that the Review Committee for Emergency Medicine at the ACGME gave Initial Accreditation on April 21, 2016 for our 3-year Residency Program in Aventura, Florida for 10 residents a year! The team we put together here did an amazing job creating this program, and I must give the Faculty, GME team, Administrative team, and Executive team both at HCA and EmCare enormous credit for all the support they gave us. Also, I must single out our Program Coordinator, Angela Taylor, for all of her hard work (angela.taylor2@hcahealthcare.com). We already filled a PGY-1 class this July with 10 excellent physicians that we are proud to have as an inaugural class. Feel free to meet them on our new website www.AventuraEM.com. All of our residents Todd Slesinger, MD, FACEP made it out to Symposium by the Sea and we hope to FCCM, FCCP, FAAEM make it a tradition for all of our PGY-1 residents to Program Director attend this amazing conference by the Florida College of Emergency Physicians annually. It was awesome to meet medical students from Florida schools interested in EM, and we are already planning the medical student forum at ACEP in Las Vegas; hope to see you there. Please visit follow us on Twitter at @AventuraEM, on Instagram at AventuraEMED, on Facebook at AventuraEM as well as YouTube at AventuraEM. Aventura Hospital and Medical Center (AHMC) is a 407-bed, acute care community hospital providing the residents of Miami-Dade and Broward counties with award-winning inpatient and outpatient diagnostic, medical, surgical and cancer services. AHMC has been nationally recognized as a Joint Commission Certified Primary Stroke Center and an AHCA Comprehensive Stroke Center as well as being an Accredited Chest Pain Center with PCI by the Society of Cardiovascular Patient Care amongst other awards and accolades. The Florida Department of Health has designated Aventura Hospital and Medical Center as a Level II trauma center (one of only three trauma centers in Miami-Dade County). AHMC is a major referral center for complex neurosurgical, orthopedic and cardiac surgical cases, as well as endovascular neurosurgical and vascular cases. The Emergency Department at AHMC sees approximately 75,000 patients annually with a 30-35% admission rate. We serve a very diverse community with equally diverse pathology. As the primary site of training, AHMC will provide rotations in Emergency Ultrasound, Toxicology, Medical Intensive Care Unit, Anesthesia, Sports Medicine, Cardiac Care Unit, Surgical Intensive Care Unit, Cardiovascular Intensive Care Unit, Trauma Surgery, Research and Administration. We are affiliated with Florida International University - Herbert Wertheim College of Medicine. We will be collaborating with the other EM programs in Southeast Florida in many educational collaborations. We are implementing a very progressive curriculum including an awesome simulation curriculum that is based at the Broward College Health Science Simulation Center, one of the most state-of-the-art in the country. Watch our team (all PGY-1) compete in SimWars at ACEP! In terms of location, Aventura is located north of Miami and is centrally located between the cities of Miami and Fort Lauderdale on the Dade / Broward county line in Southeast Florida. Miami is one of the nationâ&#x20AC;&#x2122;s most well-rounded metropolitan destinations due to its arts scene, shopping, family attractions, and hotspot Miami Beach including South Beach. With a colorful arts scene, world-class shopping, watersports splendor, professional sports and a load of family attractions, Miami makes one of the nation's most well-rounded metropolitan destinations. Fort Lauderdale is famous for its beaches, arts, culture and events. From shopping on Las Olas Boulevard, to gondola rides on the canals, to a historic riverfront. Please feel free to reach out to us for more information and watch our program grow. We will continue to regularly update EMPulse, and look forward to being very active at FCEP.

FALL 2016 | VOLUME 23, ISSUE 3

EMpulse | 21

EM p u l s e F e a t u r e CLINCON 2016 Goes Above Care for EMS Professionals

and

Beyond Sharing Advances

Pre-hospital

Article by Andrew Thomas, MD; CLINCON 2016 Co-Chair Thank you to everyone who participated this year as another successful CLINCON has come to a close. This year's event was possible thanks to the dedication of the Emergency Medicine Learning and Resource Center, contributions of the speakers, involvement of its participants and the support of our sponsors. Under the warm sun of Central Florida, several hundred attendees gathered from all around the state and beyond to collaborate and learn about advances in the prehospital care of patients and communities. This year's speakers discussed a broad range of topics from pediatrics to geriatrics, rural trauma, concussions, airway management and new drugs of abuse, just to name a few. Informative lectures covered some of the basic tenets of prehospital care, appropriate for newer providers, as well as more advanced topics for the seasoned vets in the audience. Several guest lecturers addressed topics of mass casualty events and the evolving strategies in responding to active shooters which have become an unfortunate necessity in the wake of abhorrent attacks like the one on Orlando's Pulse Nightclub just weeks ago. One of this year's educational arms focused on mobile integrated health, providing both an overview of its current role in the medical system as well as a perspective of how it could potentially expand in the coming years. Keynote speaker Dr. Brent Myers also gave the opening talk of the mobile integrated health track which featured an array of professionals with experience in this emerging role for prehospital providers. This marked the twenty-eighth Bill Shearer International ALS/BLS Competition. Several challenging scenarios tested the participating teams' knowledge, communication, and technical skills over the course of the multi-day competition. Ultimately, Miramar Team A received top honors, followed by Pembroke Pines Fire Rescue in second place. Third place was awarded to Orlando Fire Department. Two physician-led skills labs allowed participants to gain hands-on experience in uncommon and often challenging procedures. An obstetric skills lab featured several high-fidelity mannequins with demonstrations about how to guide deliveries complicated by shoulder dystocia, a breech presentation, and a nuchal cord. A fourth station taught providers how to effectively manage the resuscitation of a struggling newborn. The following day's procedure station featured Syndaver models for hands-on airway teaching. The scenarios included management of the adult and pediatric endotracheal intubation, the placement of intraosseus access, and cricothyrotomy airway procedures. Social events allowed participants to kick back and relax a little. Tuesday evening featured a wine, beer and cheese kick off party with food and live music. Friday evening was all about the pool party with snacks, drinks, and prizes. Guests were also encouraged to explore the endless attractions nearby, including multiple Disney parks, Sea World, Universal Studios, Universal's Islands of Adventure, and International Drive. With so much to do and to learn while at CLINCON, providers departed with new information and tools to care for patients in the prehospital setting and a readiness to educate others. We hope you enjoyed this year's CLINCON and we are already looking forward to next year's event!

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FALL 2016 | VOLUME 23, ISSUE 3

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Snapshots

from

C L I N C ON 2 01 6

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FALL 2016 | VOLUME 23, ISSUE 3

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

EM p u l s e F e a t u r e SBS 2016

celebrates educational lectures

FCEP’s 45th

anniversary and

Delivers

top-notch

Article by Rene Mack, MD; Symposium by the Sea 2016 Chair Photos by Samantha Rosenthal, FCEP Communications Manager Well, another fantastic Symposium by the Sea (SBS) has come to a close. The events of SBS 2016 at the Naples Grande Beach Resort continue to receive great reviews. This year we had the highest registrants to date which was quite fitting as we are celebrating 45 years of FCEP! We started SBS 2016 with our committee meetings and the Board of Directors (BOD) meeting, which are open to all members. At the BOD meeting we were pleased to welcome several ACEP leaders including Dr. Rebecca Parker, ACEP President-Elect. At the forefront of the BOD meeting was the passing of the torch and the induction of the 2016-2017 FCEP President, Dr. Jay Falk.

Rene Mack, MD Membership & Professional Development Committee Chair

Friday greeted us with the our first Pediatric Emergency Medicine Track that was well received by those in attendance. The 4 hour workshop included various pediatric specific topics as well as a simulation station and several other hands on training stations. This part of the program should definitely be on your list to attend for next year!

Are reading all the LLSA articles but perhaps you’re looking for a more efficient method of digesting all the information? Then the the LLSA course is what you need! The course this year was at full capacity, as usual and continues to be help in high regard by those who attend. Make sure to sign up early for the SBS 2017 LLSA course as this high yield educational course, run by experts in the field, fills up quickly! Not to be overshadowed, the Resident SimWars and CPC were a crowd favorite and did not disappoint. The residents and the coordinators of these events did an amazing job of keeping everyone entertained while providing high yield content that was useful to all levels of practice. We were also able to meet representatives from the 12 EM residency programs that we now have in Florida! Having these additional programs in our state will be sure to create new methods of training and collaborative learning which will help our speciality flourish within the state and beyond. The Research Poster presentation highlighted all the hard work that is taking place in our state. We had submissions from fellows, residents and medical students and the caliber of the research was impressive across all categories. We are thankful to all who participated and encourage you to continue research endeavors and showcasing your efforts. Dr. Falk and Dr. Parker were great hosts for our annual Town Hall session. The attendees had an open forum discussion about the current state of (Emergency) medicine and discussed the steps that ACEP and FCEP are already taking to help remedy the deficits along with future propositions. As always, we had a spirited discussion regarding many of the more pressing topics both local and national. If you are interested in learning more about the efforts already in place or have alternate ideas please contact the FCEP office so that we can discuss a plan of action! We also had numerous high-yield lectures provided by the many talented EM practitioners in our state! These lectures were well received and covered a variety of topics including “There’s an app for that,” “Quick! Stop the bleeding,” and many other highly relevant and interesting topics. We look forward to seeing these and other presenters at our future conferences. Although the educational aspects of the conference are our forte, this year is also a very special one for FCEP, it’s our 45th Anniversary! We celebrated with our annual Volleyball tournament where the attendees, family and friends all played alongside each other and let the competitive spirits fly! Let’s just say there are no allegiances in volleyball and there was a great time had by all. We also give special thanks to Duva-Sawko and EMPros for outdoing themselves and sponsoring a spectacular “70’s Casino Night”! Many thanks and appreciations to those who joined us in their best 70’s regalia and danced the night away. It’s great to know that we can learn so much from each other and support each other both at work and at play. On behalf of the SBS 2016 committee and the FCEP staff we thank you for the continued support and look forward to seeing you at SBS 2017, August 3-6 in Boca Raton!

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FALL 2016 | VOLUME 23, ISSUE 3

EM p u l s e F e a t u r e Florida Emergency Medicine Written Board Review Course 2016 Receives Rave Reviews from this year’s Attendees Article by J. Adrian Tyndall, MD, MPH, FACEP; Florida Emergency Medicine Written Board Review Course 2016 Chair Photos by Samantha Rosenthal, FCEP Communications Manager In its second year running, the Florida Emergency Medicine Written Board Review Course has once again, drawn from a national audience of Physicians, proving that despite stiff competition and asynchronous high tech offerings in the education sphere, a focused immersion in to the content of emergency medicine still has appeal to a wide swath of clinicians seeking a review, especially in preparation for board certification or recertification. The Florida Emergency Medicine Written Board Review Course was created to specifically provide an easy access to clinicians seeking this specific experience in easy to reach Orlando mitigating excess costs of travel. The course has also had wide appeal to resident physicians and advanced practitioners interested in downloading the core content of emergency medicine in 3.5 days.

J. Adrian Tyndall, MD, MPH, FACEP FCEP Vice President

For the last two years, the course content was created and lecture presentations were made by 25 faculty from 6 teaching institutions including four Universities in the State, each faculty member providing a review in content areas of their own expertise and showcasing the prodigious talent that currently exists amongst emergency medicine faculty in the State of Florida.

Although only two years in existence, the adoption of the latest in information technology platforms to communicate information and stimulus imaging, while maintaining an old market class room basics of a published written board review book and daily exams, prompted many attendees to make more than favorable comparisons to board review courses that have now been in place for decades. The advantage to Florida’s course, like any educational offering both lies in the talent and expertise of faculty. With Florida’s growing offerings in graduate medical education, talented faculty have been recruited to the State of Florida and existing faculty have come forward to offer their own specific talents and expertise. As a result the second iteration of the Florida Emergency Medicine Written Board Review Course, underwritten by the Florida Emergency Medicine Foundation and supported by the Florida College of Emergency Physicians and the Emergency Medicine Learning Resources Center has been a resounding success. The collaboration of faculty from around the State that has resulted will have an enormous impact on emergency medicine education in the State of Florida. Florida’s teaching programs also will have another avenue to launch talented faculty to national prominence and to add to sought after faculty scholarship on the national stage. Not surprisingly, surveyed registrants reported 100% pass rates. The third installment of the board review course in 2017 will aim to bring an even greater national audience to Orlando while declaring that there is a new and affordable course in Florida for Florida Clinicians presented by Florida Faculty.

FALL 2016 | VOLUME 23, ISSUE 3

EMpulse | 29

M e d ica l S t u d e n t C o m m i t t e e Meet Your New Florida EM Residencies! Article by Hannah Gordon; Secretary-Editor of the FCEP Medical Student Committee This year’s Medical Student Forum at Symposium by the Sea gave a warm welcome to six new three-year Florida residency programs. The programs reflect the changing landscape of emergency medicine with increased emphasis on technology and early exposure to fellowship training disciplines. These new programs are a welcome addition to the Florida Hospital, Orlando Regional, Port St. Lucie, UF Health Jacksonville, UF Health Gainesville and USF Tampa programs. Continue reading below to see what a truly exciting time it is to be a Florida medical student as opportunities to remain in state grow exponentially. A recording of the Medical Student Forum can be found on Florida College of Emergency Physicians’ Facebook page.

Hannah Gordon Secretary-Editor of the FCEP Medical Student Committee

Aventura Hospital (Aventura, FL) just welcomed its first class of 9 interns this July and is rapidly growing into a noteworthy community hospital program. It boasts a simulation center, level 2 trauma center, STEMI and stroke center, and fellowship-trained faculty in sports medicine, pediatric emergency medicine, ultrasound, critical care, and geriatrics. The emergency department is currently undergoing a $60 million expansion of its facilities. Its’ curriculum includes an emphasis on critical care. It has an academic affiliation with Florida International University (FIU) Herbert Wertheim College of Medicine. Director: Todd Slesinger, MD, FACEP, FCCP Website: http://www.aventuraem.com

Florida Atlantic University Charles E. Schmidt College of Medicine (Boca Raton, FL) is committed to building academic leaders in emergency medicine. Residents train in dedicated pediatric and adult EDs, pediatric and adult level 1 trauma centers, and a comprehensive stroke center through Bethesda Hospital East (58,000 patients per year), St. Mary’s Medical Center & Palm Beach County Children Hospitals (70,000 patients per year), and Delray Medical Center (42,800 patients per year). Core emergency medicine faculty have all trained in emergency medicine and additionally have fellowship training in medical toxicology, simulation, EMS, and integrative & alternative medicine. The EM program was approved in April and will begin interviewing applicants October 2016 for 6 positions to start in July 2017. Director: Richard D Shih, MD, FACEP, FAAEM Website: http://med.fau.edu/residencies/emergencymedicine/ Jackson Memorial Hospital (Miami, FL) is an urban academic EM residency located at one of the few county public hospitals left in the country. It has unparalleled patient diversity. The department sees over 90,000 patients per year from the United States, South America, and the Caribbean. It is home to the Ryder Level 1 Adult and Pediatric Trauma Center, a STEMI and stroke center, and the Gordon Center, a nationally recognized simulation center. Residents also have the opportunity to rotate through Holy Cross Hospital, a community hospital in Fort Lauderdale. The University of Miami Miller School of Medicine-affiliated program will accept 15 residents per year beginning July 2016. Director: Amado Alejandro Baez, MD Website: http://www.umjacksonem.net Kendall Regional Medical Center (Miami, FL) is a great option for those looking for EM training in the community hospital setting with an academic affiliation (FIU Herbert Wertheim College of Medicine). It boasts a simulation center, burn center, level 1 trauma center, STEMI and stroke center, in addition to its separate adult and pediatric emergency departments. Core emergency medicine faculty have additional fellowship training in pediatric emergency medicine, public health, ultrasound, simulation, sports medicine and EMS. The hospital sees over 90,000 patients per year and is accepting 12 residents a year. Director: Kevin King, MD Website: http://kendallmed.com/professionals/graduate-medical-education/emergency-medicine-residency-program/ Mount Sinai Medical Center (Miami Beach, FL) may be new to the allopathic scene, but it has been well-established as an osteopathic EM program for the past 17 years. It provides training in an academic community hospital setting with a patient population that only Miami Beach can offer. Residents have the opportunity to rotate through Miami Children’s Hospital and Ryder Level 1 Adult and Pediatric Trauma Center. Past residents have been historically active (and successful) in FLAAEM and FCEP Symposiums. The newly designed 3-year program will be accepting 7 students per year beginning July 2017. Director: Michael T. Dalley, DO, FAAEM Website: http://www.msmc.com/education/emergency-medicine/ University of Central Florida at Osceola Regional Medical Center (Osceola, FL) places a strong emphasis on technology use in the ED and has a curriculum devoted to producing lifetime learners. Core emergency medicine faculty have fellowship training in evidence-based medicine, informatics, ultrasound, and simulation. Osceola Regional Medical Center boasts a simulation center, level 2 trauma center, and a PICU. The program accepts 7 residents per year. Director: Bethany Ballinger, MD, FACEP Website: http://ucfemergencymedicineresidency.org

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FALL 2016 | VOLUME 23, ISSUE 3

We’d like to welcome all new and already-established FCEP Board members, FEMF Board members, FCEP Councillors and FAEMSMD Executive Board members! 2016-2017 FCEP Board of Directors Patrick Agdamag, MD, FACEP Daniel Brennan, MD Damian Caraballo, MD Jordan Celeste, MD Dagan Dalton, MD, FACEP Jay L. Falk, MD, MCCM, FACEP - FCEP President Vidor Friedman, MD, FACEP - ACEP Board of Directors Shayne Gue, MD - EMRAF Representative Robyn Hoelle, MD, FACEP Steven Kailes, MD, FACEP - Past President Gary Lai, DO, FACOEP

René Mack, MD Kristin McCabe-Kline, MD, FACEP - FCEP Secretary-Treasurer Joe Nelson, DO, MS, FACOEP, FACEP Sanjay Pattani, MD, MHSA, FACEP Russell Radtke, MD Danyelle Redden, MD Joel Stern, MD, FACEP - FCEP President Elect Joseph Adrian Tyndall, MD, MPH, FACEP - Vice President Jill Ward, MD Kendall Webb, MD Aaron Wohl, MD, FACEP

2016-2017 FEMF Board of Directors Arthur Diskin, MD, FACEP Cliff Findeiss, MD - FEMF Past President Maureen France James V. Hillman, MD, FACEP Michael Lozano, Jr, MD, FACEP - FEMF President

Ernest Page, MD, FACEP - FEMF Secretary-Treasurer Cory Richter, BA, NREMT-P Roxanne Sams, MS, ARNP-BC, MA - FEMF Vice President David C. Seaberg, MD, FACEP Salvatore Silvestri, MD, FACEP

2016-2017 FCEP Councillors and Alternates Dr. Kristin McCabe-Kline Dr. Danyelle Redden Dr. Andrew Bern Dr. Todd Slesinger Dr. Kristi Cottral

Dr. Sanjay Pattani Dr. J. Adrian Tyndall Dr. Michael Lozano Dr. Kendall Webb Dr. Ernest Page Dr. Larry Hobbs Dr. Amy Conley Dr. Joel Stern Dr. Steven Kailes Dr. Jay Falk Dr. Jordan Celeste Dr. Kelly Gray-Eurom

ALTERNATES Dr. Clifford Findeiss Dr. Raymond Merritt Dr. Saundra Jackson Dr. Gary Lai Dr. Cesar Carralero

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

FALL 2016 | VOLUME 23, ISSUE 3

EMpulse | 31

EM p u l s e F e a t u r e Heat Stroke and Hot Cars Article by Gary Goodman, MD, FACEP “The thing about heat is, no matter how cold you are, no matter how much you need warmth, it always, eventually becomes too much.” (Victoria Aveyard, Glass Sword (Red Queen, #2)). The total number of US heatstroke deaths of children left in cars for the year, 2016 is 23. Florida ranks only second to the Texas with 72 deaths recorded from 1998-2015. When adjusted for per capita (population per 1 million), Florida is the fifth worst state in the nation.1 The ages of most affected children are at most under 3 years of age. This mind staggering research comes directly from the source of national research done by Mr. Jan Null, CCM of the Department of Meteorology and Climate Science at San Jose University. “This danger exists despite public education, efforts, and lobbying for laws against leaving children unattended in vehicles.”2

The human science: What is heatstroke?

Gary Goodman, MD, FACEP Attending Physician in the Department of Emergency Medicine at Central Florida Regional Hospital

Heatstroke is defined as a condition by which the body develops hyperthermia (fever), during which the body experiences a failure of the thermoregulatory system. We manage heat exposure by way of the brain, circulatory system, and skin – in a way similar to a cooling system of a car. Humans cool by ways of convection and evaporation of sweat.

Severe hyperthermia is defined as prolonged exposure to a body temperature of 104° F (40° C) or higher. During this syndrome, the body first develops thirst, dehydration, and perspires. As the temperature of the infant raises above 104° F, it can lead to the inability to perspire, confusion, mental agitation, and eventual coma. The body’s maximum temperature before protein starts to break down and organ failure ensues is approximately 106° F. Children and infants are more susceptible to heat illness due to their innate inability to regulate heat when compared to adults.3 The important point is that the danger to the occupant is a function of not only the temperature, but time of exposure. The human body can only tolerate superheated environments for approximately 6-8 minutes before it loses its ability to respond.

The car science: Imagine a green house

No air movement. No internal cooling. On days with temperatures as low as 70° F temperatures can reach 117° F in as little as 60 minutes with 80% of this being met with in the first 30 minutes!4 At 60 minutes, the internal vehicle temperature can raise to nearly 45° F above the outside. Opening the window or “cracking the windows” ~8 inches had minimal effect on temperature rise and maximum temperature attained.5 Translation – it’s a myth! “Cracking the windows” will not only have little to no effect, but it is a practice that can and will lead to death as well.

Graph by Noheatstroke.org 6

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On July 29, 2016, Central Florida Regional Hospital and Seminole Safe Kids proved that internal car temperatures could be documented as high as 175° F with an outside temperature of only 94° F in one hour. In an attempt to demonstrate this, I sat in the car outside with the windows closed that reached a maximum of 140° F. I was only able to tolerate it for four minutes. Imagine a defenseless child, vulnerable adult, or pet. What can you do? Life is a function of routines. We get up. We eat. We go to school or work. Parents if not home, have to arrange for day care. Transportation of the children to and from day care (or running an errand) is part of that routine. Add a simple stressor to that parent that day and that variance could lead to a change in that routine. It is at that time, the biggest threat of forgetting a child can occur. It is important to recognize that vulnerable adults – senior citizens or developmentally delayed persons are also at risk. This applies to animals left unattended as well. Cars manufacturers are developing mechanisms with in the car – i.e. weight sensors in the back seat that cause a dashboard indicator to suggest “did you bring your belongings” etc. Something as simple as putting your purse or shoe in the back seat could also trigger your memory to make sure you look back in to the car so this never happens again! Florida laws have been recently changed to allow for good Samaritans to gain access to cars so long as: 1. The person immediately calls 911, 2. Using force only necessary to gain access, and 3. You remain with the vehicle. With public education, lobbying efforts, needless loss of life can be prevented.

Gary Goodman, MD, FACEP, is an Attending Physician in the Department of Emergency Medicine at Central Florida Regional Hospital, a Diplomate of the American Board of Emergency Medicine, and an Assistant Professor of Clinical Medicine at the UCF College of Medicine. References: [1] Noheatstroke.org [2] Noheatstroke.org [3] suzuki-Haykawak et al, Thermoregulation during heat exposure of young children compared to their mothers. Eur J Appl Physiol. 1995;72:12-17 [4] Noheatstroke.org [5] King et al, Heat stress in motor vehicles, a problem in infancy. Pediatrics 1981; 68:579-582 [6] Noheatstroke.org

EMERGENCY MEDICINE OPPORTUNITIES FIND YOUR BALANCE Ministry Health Care is an integrated network of 15 hospitals and 46 clinics serving patients throughout Central, Northern and Eastern Wisconsin. Together, with more than 700 employed clinicians, we have dedicated ourselves to delivering high-quality, costeffective, person-centered care for the past 100 years. We are currently recruiting for two unique opportunities.

Northern Wisconsin (Tomahawk/Rhinelander)

• Full time (12 twelve-hour shifts per month) • Control your own schedule; great work/life balance • Saint Mary’s is Trauma Level III; annual volume 20,000 • Sacred Heart is Trauma Level IV; annual volume 5,000 • Lower volumes allow for greater individualized care • Surgery, OB, Peds, Oncology, Ortho, Neuro, ENT and Psych on site • Ideal locale for an outdoor enthusiast

Central Wisconsin (Merrill/Weston)

• Full-time (13 twelve-hour shifts/month) • Great opportunity to treat a full range of trauma • Saint Clare’s is Trauma Level III; annual volume 14,000 • Good Samaritan is Trauma Level IV; annual volume 13,000 • Easy access to sub-specialty referrals; easy one call transfers • Charming rural setting with easy access (20 min) to urban amenities At Ministry, we want our clinicians to be happy and healthy, too. You’ll enjoy a rewarding medical practice and still have time for the other things you love to do. We offer our clinicians a competitive, comprehensive compensation and benefit package. You’ll enjoy the financial stability that comes with being part of the nation’s largest non-profit health system, Ascension Health. CONTACT: Holly Anderson | 715-342-6583

mmgrecruitment@ministryhealth.org

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EM C a s e R e p o r t s Another case of acidosis, or is it? Article by Hillel Z. Harris, MD A 29-year-old female presented to the emergency department with a chief complaint of vomiting. She gave a one day history of vomiting associated with epigastric pain. The epigastric pain was crampy and intermittent. She had no diarrhea nor constipation. She denied any shortness of breath, but complained of feeling very weak. She was accompanied by her mother. Her past medical history was significant only for non-alcoholic pancreatitis. She denied alcohol use, was a smoker, and she denied drug use. Physical exam was remarkable for a dehydrated and ill appearing female, breathing rapidly, with vital signs: Blood pressure 112/72, heart rate 108, respiratory rate 24, temperature 99.0Â°, pulse oximetry 99% on room air. Hillel Z. Harris, MD Emergency Physician at JFK Medical Center in Atlantis, Fla.

Her sclera were anicteric. She was tachypneic, and had a shallow respiratory rate with clear lungs. She was tachycardic with bounding pulses, and had no murmurs or rubs. Her abdomen was soft and nontender. She was neurologically intact, and was awake and alert.

The patientâ&#x20AC;&#x2122;s mother gave her one of her own prescription diazepam 5 mg tabs several hours prior to arrival. She felt that her daughter was becoming anxious at home. Specimens of blood and urine were sent, and 1 L bolus of normal saline and IV famotidine was ordered. Her labs were as follows: WBC 13.2, Hgb 15.1, Hct 44.8, Plat 380 Na 141, K 3.8, Cl 113, CO2 11, BUN 19, Cr 0.9, Gluc 96 AST 50, ALT 48, Alk Phos 95, Lipase 102 UA 3+ ketones, U hcg (-) EKG: Sinus tachycardia 105, normal QRS and QTc intervals After wondering why she was profoundly acidotic with a normal glucose, I added on an acetone level, an alcohol level, and a urine drug screen. I went back to talk to the patient and she gave me a further history of a recent ED visit; In fact, she had been in the emergency department 12 hours prior because she was complaining of a toothache. I examined her oral cavity and there was evidence of some decay and dental tenderness. She had been placed on oral antibiotics, was given a prescription for NSAIDs and hydrocodone, but said she had not taken the pain medicine as of yet because she was already taking an OTC medicine for her toothache. She said she had been taking BC Powder, which was a combination of salicylates and caffeine. The rest of her laboratory tests were resulted which included a serum acetone level that was "large." At that point, I ordered an ABG. Her alcohol level was negative and her urine drug screen was positive for benzodiazepines and marijuana. Her ABG resulted as follows: pH 7.44, pCO2 16, pO2 128, HCO3 11 This perplexed me-- was her pCO2 low simply because she was tachypeic? Although she could have become acidotic and dehydrated solely from profound vomiting, I would not have expected a large acetone with an anion gap. At this point, I added on levels of aspirin and acetaminophen and went back to speak with my patient again. When I asked her how much and how often she had been taking the pain reliever, she said she took one packet every four hours. When I looked at the package, I saw that BC powder had 845 mg of aspirin and 65 mg of caffeine in each packet. Sure enough, her aspirin level came back at 48. I explained to her and her mother that she was toxic from the aspirin components of the medicine. I started an IV bicarbonate drip in an effort to alkalinize the urine, and admitted her to the ICU. I consulted nephrology and toxicology, but there was no indication for dialysis at this point.

Continued on page 36

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FLORIDA

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Central Florida Regional Hospital (Sanford) Doctors Hospital of Sarasota (Sarasota) Brandon Regional Hospital (Tampa Bay) Citrus Park ER (Tampa Bay) Medical Center of Trinity (Tampa Bay) Northside Hospital (Tampa Bay) Palm Harbor ER (Tampa Bay) Opening September 2016! Regional Medical Center at Bayonet Point (Tampa Bay) Tampa Community Hospital (Tampa Bay) SOUTH FLORIDA Broward Health, 4-hospital system (Ft. Lauderdale) Northwest Medical Center (Ft. Lauderdale) Westside Regional Medical Center (Ft. Lauderdale) Mercy Hospital (Miami) Raulerson Hospital (Okeechobee)

St. Lucie Medical Center and Free Standing ED (Port St. Lucie) Palms West Hospital (West Palm Beach) JFK North (West Palm Beach) LEADERSHIP Mercy Hospital (Miami, FL) Brandon Regional Hospital (Tampa Bay, FL) Assistant Medical Director Citrus Park ER (Tampa Bay, FL) Assistant Medical Director Northside Hospital (Tampa Bay, FL) Assistant Medical Director Trinity Medical Center (Tampa Bay, FL) PEDIATRIC Broward Health, 4-hospital system (Ft. Lauderdale, FL) Mease Countryside Hospital (Tampa Bay, FL) Brandon Regional Hospital (Tampa Bay, FL) Pediatric Medical Director and Staff

Continued from page 34

Their hope was to see if she improved overnight on bicarbonate therapy. Her heart rate came down to 92, her blood pressure was 110/70, and she was transported to the ICU. The degree of compensation for her metabolic acidosis via her increased respiratory rate was greater than I would have expected; this was explained by her toxic aspirin ingestion. Aspirin overdose caused a primary respiratory alkalosis. As reflected in her subsequent blood gas in the ICU eight hours later, the pH increased, while the pCO2 stayed the same. This was due to the infusion of bicarbonate. ABG 8 hours later: pH of 7.58 PCO2 of 16 and a PO2 124, HCO3 15 The repeat aspirin level had dropped to 43, even though her alkalosis had worsened. Her tachypnea upon initial presentation was a direct effect of aspirinâ&#x20AC;&#x2122;s toxic effect upon the respiratory center. The anion gap metabolic acidosis occurred as a result of aspirin causing a buildup of organic acids. The net result is both a primary respiratory alkalosis and primary metabolic acidosis. Aspirin toxicities nowadays are relatively rare due to the availability of several other more popular pain relievers. They do still occur, however, and should be considered in the setting of unexplained acidosis.

Hillel Z. Harris, MD is an Emergency Physician at JFK medical center in Atlantis, Florida. He is an Associate Professor at the University of Miami Miller School of Medicine. He is also a Fellow of the American College of Emergency Physicians.

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Congratulations to all Symposium by the Sea 2016 Competition winners! 5TH ANNUAL SIMWARS COMPETITION WINNERS: Florida Hospital Emergency Medicine Residency Program AND University of South Florida Emergency Medicine Residency Program COMPETITION CHAIR: Ademola Adewale, MD, FAAEM COMPETITION JUDGES: Leslie Simon, DO – Mayo Clinic, Jacksonville Kristin McCabe-Kline, MD, FACEP - Florida Hospital Fish Memorial Shiva Kalidindi, MD, MPH, MS (Ed.), FAAP– Nemours Children’s Hospital

8TH ANNUAL SYMPOSIUM RESEARCH POSTER PRESENTATION OUTSTANDING MEDICAL STUDENT POSTER: Stephanie Winslow; Using Outpatient Medications and Comorbidities as Predictors of Peri-intubation Hypotension During ED Rapid Sequence Intubation; University of Florida, Gainesville OUTSTANDING RESIDENT POSTER: Larissa Mueller, MD; Preliminary Analysis of staff attitudes of an expanded HIV testing program in an urban Emergency Department; Morsani College of Medicine, University of South Florida, Tampa General Hospital COMPETITION CHAIR: J. Adrian Tyndall, MD, MPH, FACEP COMPETITION JUDGES: Marie-Carmelle Elie, MD – University of Florida College of Medicine Rebecca Parker, MD – ACEP President-Elect Todd Slesinger, MD, FACEP, FCCM, FCCP – Aventura Hospital & Medical Center FLORIDA RESIDENT CASE PRESENTATION COMPETITION BEST PRESENTER: Chasi Skinner, DO – Florida Hospital BEST DISCUSSANT: Burr Fong, DO – Mt. Sinai Medical Center BEST PROGRAM: Florida Hospital Emergency Medicine Residency Program COMPETITION CHAIR: Jennifer Jackson, MD COMPETITION JUDGES: David Seaberg, MD, FACEP, CPE – Dean, University of Tennessee College of Medicine Rebecca Parker, MD – ACEP President-Elect Todd Slesinger, MD, FACEP, FCCM, FCCP – Aventura Hospital & Medical Center

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Florida College of FCEP | Emergency Physicians

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