Empulse Summer 2018 by Florida College of Emergency Physicians

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

High Dose Insulin Therapy

THE NEW LAW & How It Affects Your Practice

Focused Assessment Sonography for HIV/TB Testing

Symposium by the Sea Conference Schedule Inside! VOL. 25, NO. 2 |SUMMER 2018

Is Your ED Practice Leaving Money On The Table? Customized results | Only 3 data-points needed | Instantly identify lost revenue

DuvaSawko has developed an industry-first Revenue Calculator. This revolutionary tool was developed to immediately identify valuable missing revenue from your practice.

WWW.REVCALCULATOR.COM Founded & Operated by ED Physicians | Dedicated Account Managers | Up to 30% More Revenue EMPULSE SUMMER 2018

SUMMER 2018 | VOLUME 25, ISSUE 2

TABLE OF CONTENTS FCEP CHAPTER UPDATES 4| 5| 6| 8|

President’s Message, by Joel Stern, MD, FACEP, FAAEM Government Affairs, by Damian Caraballo, MD, FACEP EMS/Trauma Committee, by Christine Van Dillen, MD, FACEP Membership & Professional Development Committee, by René Mack, MD, RDMS 10 | ACEP Board, by Vidor Friedman, MD, FACEP 20 | EMRAF Committee, by Jesse Glueck, MD 30 | Medical Student Committee, by Alicia Bishop

SPECIAL SECTIONS 12 | The Ultrasound Zoom: FASH, by Michael Traum, MD and Leila PoSaw, MD 21 | Residency Reports, by Florida’s Emergency Medicine Residency Programs 28 | Poison Control: High Dose Insulin Therapy, by Madison Schwartz, Pharm.D. & Emiy Winograd, Pharm.D. 34 | Musings From a Retired Emergency Physician: The Affordable Care Act: Where Are We Now?, by Wayne Barry, MD, FACEP

FEATURES 9 | Symposium by the Sea 2018 Conference Schedule 11 | ACEP Leadership & Advocacy Conference Recap, by Jordan Celeste, MD, FACEP 16 | Safe Opioid Prescribing for Acute Pain, by Jay Falk, MD, FACEP, MCCM 18 | HB 21 at a Glance, by Aaron Wohl, MD, FACEP & Toni Large 19 | Communication Across the Continuum of Care: EDie, by Kristin McCabe-Kline, MD, FACEP, FAAEM, ACHE 33 | It’s an Election Year & FCEP Needs Your Support, by Damian Caraballo, MD, FACEP

CALL FOR CONTENT: FCEP is always accepting article submissions for EMpulse. We are currently looking for articles that are relevant to the following topics: • The history of emergency medicine in Florida • The intersection of LGBTQ+ and emergency medicine • The rise of suicides and sucidal attempts • Resident case reports and publications

Upcoming Editorial Deadlines: • Fall 2018: August 27, 2018 • Winter 2018-19: November 5, 2018

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

EMpulse Editorial Board Editor-in-Chief Karen Estrine, DO, FACEP, FAAEM karenestrine@hotmail.com Managing & Design Editor Samantha League, MA sleague@emlrc.org

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

All advertisements in EMpulse are printed as received from advertisers. Florida College of Emergency Physicians does not endorse any products or services, except those in its Preferred Vendor Partnership. FCEP receives and distributes employment opportunities but does not review, recommend or endorse any individuals, groups or hospitals that respond to these advertisements. Opinions stated within articles are solely those of the writers and do not necessarily reflect those of the EMpulse staff, the Florida College of Emergency Physicians and our advertisers/sponsors. 3

CHAPTER UPDATES

President’s Message: Looking Back By Joel Stern, MD, FACEP, FAAEM FCEP President

The time has come to write my final President’s Message. As I look back on my presidency, my mind drifts back even farther: how I ended up in Florida, things that have changed in our emergency medicine community since then, and changes still ongoing today. I moved to Florida in 1998 – about four years post-residency, and still a relatively young physician in my thirties. I am now, 20 years later, one of the older practitioners at most locations where I am on staff. It’s hard to believe that I am now one of “those guys.” The difference is that when I first started working here, most of the older EM docs were not EM-Boarded. Those that were had usually grandfathered-in under the old practice track and had not experienced an EM residency. Nowadays, it is much less common to find non-EM Boarded physicians working. Some of this is probably related to the proliferation of EM residencies. When I was graduating from medical school in 1991, there were two programs in Florida: Jacksonville and Orlando Regional. Mount Sinai became the third program when I moved here in 1998. By my last count, there are now 14 programs in Florida, mostly in or around the larger cities and medical schools. I always felt like part of the reason we did not get as much respect as other specialties was the relatively low number of academic training programs producing EM-trained doctors. That doesn’t seem to be the case anymore. I’m hearing less of the phrase, “I used to do emergency medicine.” This is something that consultants would say right before they would try to tell me why my recommendation for admission or consultation on a particular patient was unnecessary. As if they all knew what was going on in emergency medicine because of the moonlighting they did during their fellowship training? Well, it’s not the same anymore. Other things have changed in our specialty over the years, like ultrasound, for example. I had zero ultrasound training as a resident. We just didn’t do it back then. Now it seems like ultrasound is being used for almost everything. It certainly has helped a great deal with vascular access. Many hospitals now have designated nurses who can use ultrasound for vascular access, including peripheral lines, midlines and piccs. That brings up another big change I have noticed over the years: services that hospitals provide to emergency departments has really increased. More and more, I’m seeing real-time radiology reads 24/7 and things like tele stroke services. Some of this technology was probably prohibitively expensive in the past. But I would also like to believe that some of it is due to the increased focus on emergency 4

medicine due to increasing percentages of hospital admissions coming through our departments. Managing transfers also seems to be less problematic than in years past. I recall having to spend hours making phone calls and praying to find an accepting facility for a critically ill patient. Now it seems that transfers happen more expeditiously in general, although psych placement is still an issue. So what does this all mean for us as emergency physicians? I think that our jobs are becoming easier and more enjoyable. At least it seems that way to me. I feel that I am better able to focus on my patients and the actual delivery of patient care, without as many extraneous issues to deal with. I haven’t even mentioned scribes and compensation. Through all of these changes, I am proud to say that I have been a member of ACEP every year since I started my career as an intern. ACEP is consistently on the forefront of identifying and addressing issues that improve our practices. The money spent on membership has been paid back to me many times over in job satisfaction. Having the privilege to serve as your chapter president has been one of the most humbling and gratifying experiences of my professional life. Getting to meet so many dedicated and truly outstanding doctors who are so committed to our specialty is truly inspiring. I would also be remiss if I did not mention how much I appreciate all of the terrific work being done daily by our staff in Orlando. Everyone in the office is a superstar, and our chapter would not be as successful and respected as we are without them. In conclusion, I would like to thank everyone involved with FCEP, past and present, for allowing me to have this tremendous opportunity. I am looking forward to Symposium by the Sea in August and hope to see everyone there. ■

Dr. Joel Stern during his residency years.

EMPULSE SUMMER 2018

CHAPTER UPDATES

Government Affairs Committee By Damian Caraballo, MD, FACEP Government Affairs Committee Chair | FCEP Board Memberw

I had the privilege of listening to an inspiring speech by Surgeon General Dr. Jerome Adams at the ACEP Leadership and Advocacy Conference in May. In it, he reiterated that ED doctors are problem solvers, and any solutions to today’s healthcare issues are going to have to come from doctors. He rightly said that doctors have stood by on the sidelines too long while other outside forces have stripped our influence and negated our ability to practice medicine. He said the only way for us to take back medicine is to get involved with policy-making and advocacy; otherwise, someone else is going to make our policy, and we’re not going to like it. In that spirit, FCEP is working to get its members involved in meetings with their local legislators this summer. When I first started with advocacy, everyone said the most important aspect to help shape policy was to have a good relationship with your local representatives and senators. However, I found it difficult to arrange meetings due to their busy schedules. In effort to improve our members’ ability to forge local relationships with their legislators, we are splitting into regions to coordinate meetings and donation hand-offs to our local leaders (see map to the right). Each region will be led by an FCEP member experienced in emergency medicine advocacy. The goal is to help FCEP members meet with their legislators and shape policy. You’d be surprised how little many local leaders know about the challenges facing the ED, such as predatory insurance practices, malpractice, the opioid epidemic, drug shortages, etc. It’s our responsibility to educate and make them aware of these issues, and then advise them on ways to improve healthcare. Meeting with your legislator in the summer and forming a relationship will help us during session when bills pop up that could potentially benefit or hurt medicine. Once they understand our perspective and challenges, they will be more willing to listen to us about how to vote on healthcare-related bills. I’d be remiss if I didn’t mention a big part of this equation involves money and having the funds to facilitate meetings with legislators. We need everyone involved in FCEP to help us amplify our influence by donating to FCEP’s Political Committees (PCs). Together, we can answer the call of our Surgeon General Adams and put doctors back as the leaders in solving today’s healthcare challenges. ■

Get Involved in Local Politics FCEP is designating local leaders in each region to lead advocacy efforts this summer. To get involved in your region, email Dr. Damian Caraballo at dcaraballo44@gmail.com.

Regions Panhandle/Tallahassee Northeast FL/Jacksonville North FL/Alachua West Central/Tampa Bay Central Florida/Orlando Space/Treasure Coast Palm Beach/Broward Southwest/Sarasota Miami-Dade/Monroe

Donate to FCEP Political Committees

Send the text “FCEPPC” to “41444” or

Donate online at: emlrc.org/fcep-pac-donations or

Mail a check to FCEP at 3717 S. Conway Road, Orlando, FL 32812

EMPULSE SUMMER 2018

CHAPTER UPDATES

EMS/Trauma Committee By Christine Van Dillen, MD, FACEP EMS/Trauma Committee Co-Chair

School’s Out for Summer! As the temperature increases for summer, so does the opportunity for heat-related illness and trauma. Make sure prehospital personnel are aware of the signs and symptoms of heat-related illnesses, as well as the importance of prevention. Those at increased risk for heat-related illness include patients at the extremes of age, patients with comorbidities and those performing athletic activities outdoors (military and sports). The elderly perspire less, acclimatize slower, have decreased mobility, tend to feel thirst less and are on medications such as diuretics and beta blockers, which blunt their natural ability to dispel heat. When compared to adults, infants and small children have higher metabolic heat production; when dehydrated, their core temperature increases faster and their vascular system does not dissipate heat as efficiently.

Patients present along a spectrum of fatigue, nausea, abdominal cramps, muscle cramps, hypotension, syncope, tachycardia and even altered mental status. Treatment includes movement of patients into a cool environment, evaporative cooling and hydration, both orally and intravenously. Increases in outdoor activities lead to increases in trauma. With increases in tourism, we see visitors who are not accustomed to the area. We will start seeing patients who cross busy streets on foot in an unsafe manner and unfamiliar drivers making quick decisions on the road. Prevention is of utmost importance: ensuring that everyone is using crosswalks, wearing a seatbelt, using the recommended car seat, wearing helmets on bicycles and motorcycles, and obeying traffic laws.

FAEMSMD Meeting in Review House Bill 1165: Trauma Services

The Department of Health initiated a requirement by October 1, 2018 to establish an 11-member Florida Trauma System Advisory Council. They have changed the number of traumaservice areas from 19 to 18, and in addition, no service area can have more than a total of five Level I, Level II, Level II/ pediatric, and stand-alone pediatric trauma centers. They have also limited the total number of trauma centers in the state to 35 for 5 years.

Re-Forming the Emergency Medical Review Committee (EMRC)

The EMS Office is exploring ways to reconstitute the EMRC at the state level to promote the use of EMS data for research. Ideally, this would enhance partnerships with academic institutions, government organizations at the state and national level, as well as other entities such as the AHA, NAEMSP, CARES, etc. FAEMSMD would like to be involved with the aim and scope of this committee.

NAEMSP – Proposed Florida Chapter

Dr. Meurer and Dr. Antevy are working to initiate a Florida chapter of National Association of EMS Physicians (NAEMSP). The Board has already approved the Intent to Form a Chapter (February 27, 2018) and within six months (August 27, 2018) this chapter will need to complete the following: Select a meeting date and location; send notice of meeting and 6

request reply; prepare an agenda; provide a copy of bylaws for each attendee; nominate chapter officers; maintain a roster; and distribute NAEMSP member information to current nonmembers.

House Bill 21: Opioids

House Bill 21 was passed and signed into law, which has created changes to controlled substance prescribing. These changes consist of: • 3-day limit for all Schedule II controlled substances prescribed for “acute pain.” • An allowance for a 7-day supply if the prescriber writes “ACUTE PAIN EXCEPTION” on the prescription. • For non-acute pain, the prescriber must write “NONACUTE PAIN”   • For the treatment of pain related to a traumatic injury with an Injury Severity Score of 9 or greater, a prescriber who prescribes a Schedule II controlled substance must concurrently prescribe an emergency opioid antagonist, as defined in s. 381.887(1). • E-FORCSE will transition to PMP AWARxE, with mandatory check when writing Rx for opioid controlled substance.   • A 2-hour opioid prescribing course for all physicians is mandatory by January 31, 2019 and on renewal thereafter. FCEP, FMA and FOMA have been approved to provide this training. You can learn more about FCEP’s course on page 16 and HB 21 on page 17. ■

EMPULSE SUMMER 2018

PHYSICIAN AND LEADERSHIP OPPORTUNITIES NORTH FLORIDA

Fort Walton Beach Medical Center (Ft. Walton Beach) Bay Medical Center (Panama City) Bay Medical FSED (Panama City) Gulf Coast Regional Medical Center (Panama City) Sacred Heart Hospital (Pensacola)

CENTRAL FLORIDA

Oak Hill Hospital (Brooksville) Largo Medical Center (Clearwater) Englewood Community Hospital (Englewood) Osceola Regional Medical Center (Kissimmee) Ocala Regional Medical Center (Ocala) Poinciana Medical Center (Orlando) Oviedo Medical Center (Oviedo) Fawcett Memorial Hospital (Port Charlotte) Bayfront Punta Gorda (Punta Gorda) Lakewood Ranch FSED (Sarasota) Brandon Regional Medical Center (Tampa Bay) Citrus Park ER (Tampa Bay) Lutz FSED (Tampa Bay) Mease Countryside Hospital (Tampa Bay) Mease Dunedin Hospital (Tampa Bay) Medical Center of Trinity (Tampa Bay) Northside Hospital (Tampa Bay) Palm Harbor ER (Tampa Bay) Tampa Community Hospital (Tampa Bay)

SOUTH FLORIDA

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

LEADERSHIP OPPORTUNITIES

Fort Walton Beach Medical Center (Ft. Walton Beach) Citrus Memorial Hospital (Inverness) Assistant Medical Director Largo Medical Center (Clearwater) Northwest Medical Center (Margate) Indian River Medical Center (Vero Beach) Assistant Medical Director St. Petersburg Hospital (Tampa Bay)

PEDIATRIC EM OPPORTUNITIES

Broward Health Children’s Hospital (Ft. Lauderdale) Northwest Medical Center (Ft. Lauderdale) Plantation General Hospital (Ft. Lauderdale) Medical Director and Staff Sacred Heart Hospital (Pensacola) Mease Countryside Hospital (Tampa Bay) The Children’s Hospital at Palms West (West Palm Beach)

Coast-to-Coast full-time, part-time and per diem opportunities. Ask about our EmBassador Travel Team Opportunities.

Visit us at the Symposium by the Sea Booths #203 and #205

EMPULSE SUMMER 2018

CHAPTER UPDATES

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

It’s that time of year again! We are wrapping up the details on Symposium by the Sea (SBS) 2018: our largest CME and member appreciation event of the year. This year we will be hosting SBS on August 2-5, 2018 at the Sanibel Harbor Marriott Resort & Spa in Fort Myers, FL. As always, we have robust educational and social programs planned for us to learn and rejuvenate together. The great thing about SBS is that there is something for everyone: the general EM practitioner, residents, medical students, EMS, nurses, etc. Remember to bring the family – we have events for them as well, to send the summer off in style! Things not to miss include the very popular pediatric and critical care sessions, LLSA, CPC and SimWARS, short-yetinformative rapid fire lectures, and a disaster debriefing session – to name a few. I can’t leave out the passionate discussions at the Town Hall, the annual volleyball game, and of course, Casino Night! Will this be your first SBS? Or maybe it’s been a while since you attended your last conference? Either way, I look forward to seeing you there. If you have any questions about registering and booking your hotel, visit www.emlrc.org/symposium-by-the-sea or contact ebuckley@emlrc.org. For this year’s conference, we are adding an intentional

focus on wellness and need your help. We all practice many forms of wellness and would like to celebrate you! Please send in 1-2 digital pictures of you celebrating your wellness to showcase during our weekend events. Also, in the spirit of sharing our wellness with others, we have decided to host a clothing drive. We will be accepting donations of gently used professional clothing and accessories (male and female) to be distributed to clothing centers targeting those who are looking to make the next step in their career but need some assistance to look the part. We will be sending more information as the event approaches but if you have any questions, please contact the FCEP office for more information. In the last EMpulse, I brought up ACEP Wellness Week (March 11-17). Did you actively take part in events that week? I’ll admit that I didn’t participate in all of the challenges, but I did incorporate a few of them into my regular activities. One of the daily challenges focused on gratitude and reaching out to someone who has made a difference in your life. It could be a mentor, colleague, family member, etc., as long as you perceive that they have made an impact on your growth. Who would you recognize? Who would recognize you? Share your story with us at SBS or contribute to EMpulse as a guest columnist. Either way, I look forward to hearing your story. See you soon! ■

by the

2018

August 2-5, 2018 Sanibel Harbour Marriott Resort & Spa in Fort Myers, FL www.emlrc.org/symposium-by-the-sea

EMPULSE SUMMER 2018

Symposium by the Sea Conference Schedule Thursday

Friday

7:00 am

Meditation

7:30 am

Emergency Medicine Town Hall Session

Hurricane Maria Effects on the U.S. Virgin Islands, Puerto Rico & U.S.: Florida Hospital Physicians

Challenges of Treating DVT & PE in the Hospital & After Discharge

Difficult ED Conversations; Marie-Carmelle Elie, MD, FACEP

Optimizing ImumnoOncology Therapy

7:45 am 8:00 am 8:30 am

Sunday

Morning Yoga

7:15 am

8:15 am

Saturday

Oncologic Emergencies in the ED

Membership Committee Meeting

8:45 am 9:00 am 9:15 am 9:30 am 9:45 am

Education & Academic Affairs Committee Meeting

LLSA for Today 7:00 am to 12:00 pm

10:00 am 10:15 am 10:30 am

Medical Economics Committee Meeting

Neonatal Resuscitation Update + Simulation Managing a Sick Neonate Ask the Experts

10:45 am 11:00 am 11:15 am 11:30 am

Government Affairs Committee Meeting

11:45 am 12:00 pm 12:15 pm 12:30 pm

Lunch

Neonatal Emergencies: Simulation Rotations

1:00 pm 1:15 pm 1:30 pm 1:45 pm

EMS/Trauma Committee Meeting & Council of EM Residency Programs Meeting

2:30 pm

Pediatric EM Committee Meeting

Toxicology Case Unknowns; Richard Shih, MD

Cardiac Arrest Resuscitation w/ Point of Care Ultrasound; Leila Posaw, MD, MPH, FACEP

Syncope—Blues Clues to the Deadly Misses; Todd Haber, MD

2:45 pm Exhibit Hall Open

3:15 pm 3:30 pm 3:45 pm 4:00 pm 4:15 pm 4:30 pm 5:00 pm 5:15 pm 5:30 pm 6:00 pm 8:00 pm 11:00 pm

FCEP EMRAF Committee Meeting

Women In Medicine

3:00 pm

Awards Ceremony: SimWARS, CPC, Poster Abstracts

Life-Threatening Weakness; Jose Rubero, MD, FACEP, FAAEM

Cardiac Arrest Update; David Lebowitz, MD

SimWARS

Exhibit Hall Open

Practical Bedside Ultrasound; Jilian Davidson, MD Case Presentation Competition

Rescue for Hypoxic Respiratory Failure; Joseph Shiber, MD, FACEP

2:00 pm 2:15 pm

FEMF Board of Directors Meeting

Addressing the Unmet Need for Universal Antidotes to Factor XA Coagulants

12:45 pm

H2-Ow! Myth Busting Water Emergencies; Benjamin Abo, DO, EMT-P, FAWM

Board of Directors Meeting

Past President’s Luncheon

Poolside Yoga

Annual Volleyball Game

& Leadership Academy Presentations EMRAF Reception Wine, Beer & Cheese with Vendors EMPULSE SUMMER 2018

Casino Night: White Party presented by DuvaSawko

Adjourn

Medical Student Forum

CHAPTER UPDATES

ACEP Board By Vidor Friedman, MD, FACEP ACEP Vice President | Past FCEP President | FCEP Board Member

I am writing this from the annual ACEP Leadership and Advocacy Conference (LAC) in Washington D.C. — one of my favorite conferences of the year. Once again, I enjoyed great meetings with many great speakers, and a chance to learn from and catch up with many good friends. This year, the ACEP Board decided to cut travel schedules a bit, but added a one-day board meeting at LAC. We had a packed agenda as usual, dealing with an ethics complaint and receiving updates on several important information papers and policies. We had a robust discussion regarding a report from the Free Standing Emergency Medicine Task Force, and are looking forward to further information from them. We received and acted on several recommendations from the Leadership Diversity and Inclusion Task Force. We also received an update on the Emergency Sedation Policy, which should be published in time for ACEP 2018. So what else has ACEP been doing for you lately? Here are a few examples:

1. Finding Solutions to the Drug Shortage As you are all aware, we are again in critical drug shortage for many of our essential emergency medications — from saline to anti-emetics to sedatives and pain medications. NAEMSP (National Association of EMS Physicians) has been working with ACEP, ASPR ([HHS] Assistant Secretary for Preparedness and Response), and the FDA (Food & Drug Association) to draw attention to this issue and hopefully get some movement towards resolution. We are asking that IAFC (International Association of Fire Chiefs), AAA (American Automobile Association), NAEMSO (National Association of State EMS Organizations) and NAEMT (National Association of EMTs) consider signing a letter with us to help both ASPR and the FDA better understand our concern and spur them to action. The FDA commissioner is now suggesting the safeharbor protections given to the GPOs (Group Purchasing Organizations) — which some believe is the root cause of the

generic injectable drug shortages — needs to be re-examined. Past ACEP President Dr. Rick Blum submitted an op-ed that was accepted by the WSJ on the GPO issue. We have information that “60 Minutes” is working on a multi-episode piece for this issue. As you know, ACEP is the only medical organization (so far) to call for the repeal of the safe-harbor protection (2017 Resolution 34[17]).

2. Collecting Information on Disaster Prepardness in Emergency Departments ACEP released a press release about a lack of preparation for disasters in emergency departments. Here is a snippet: Most Emergency Physicians Report Hospitals Lack Critical Medicines; Not “Fully Prepared” for Disasters, Mass Casualty Incidents WASHINGTON — Nine in 10 emergency physicians responding to a new poll say that in the past month, they have experienced shortages or absences of critical medicines in their emergency departments. In addition, nearly all (93 percent of 247 doctors) say their emergency departments are not “fully prepared” for patient surge capacity in the event of a natural, man-made disaster or mass-casualty incident, with 49 percent saying they are “somewhat” prepared, according to the poll conducted by the American College of Emergency Physicians (ACEP).

3. Raising Awareness About Anthem Retroactively Denying Emergency Department Payments ACEP recently released two new videos regarding Anthems policy retroactively denying payment for emergency department visits. Please share these with your social media connections (available at www.faircoverage.org). I hope to see you all in San Diego for ACEP2018, which will also be ACEP’s 50th Anniversary celebration! ■

ACEP Scientific Assembly 2018 October 1-4, 2018 San Diego, CA

www.acep.org/acep18 10

EMPULSE SUMMER 2018

EVENT RECAP

ACEP’s Leadership & Advocacy Conference By Jordan Celeste, MD, FACEP Medical Economics Committee Member | Board Member

In May, over 500 emergency physicians, with ample representation from Florida, traveled to Washington, D.C. to meet with legislators and staff on Capitol Hill and to participate in educational sessions. Pre-conference sessions included chapter leadership and a health policy primer directed at residents, young physicians and firsttime attendees of the meeting. The conference also allowed multiple groups to meet, including the ACEP and EMRA Board of Directors, the EMF Board of Trustees, ACEP’s Federal Government Affairs and State Legislative/ Regulatory Committee, ACEP’s Alternate Payment Model Task Force and the Free-Standing ED Section. The first full day of programming included a Leadership Summit, which was followed by break-out sessions on payment reform and MIPs, challenging perceptions of emergency care, defending the prudent layperson standard and using social media in our advocacy efforts. Dr. Robert Kadlec, the U.S. Assistant Secretary for Preparedness and Response, hosted a Town Hall and Amy Walter, National Editor of The Cook Report, provided political analysis of the upcoming mid-term elections. Participants heard from Sen. Bill Cassidy (R-LA) and Rep. Kyrsten Sinema (D-AZ) about health policy issues in Congress, and, of course, about the challenging political environment in D.C. Preparatory sessions were held prior to heading to Capitol Hill, which included advocacy training and issue briefings led by ACEP Washington D.C. staff and consultants. Key issues this year included drug shortages, the opioid epidemic and disaster preparedness. These were carefully chosen by college leadership due to the tense environment of an election year in D.C., and because they are currently being (or soon will be) considered in this session of Congress.

comprehensive package of opioid legislation later this year (“CARA 2.0”), so the goal of the Hill visits was to emphasize to legislators the importance of including these two bills in that final package. Congress is working to reauthorize the Pandemic and Allhazards Preparedness Act (PAPHA), which is up for renewal after 10 years. This important legislation impacts important issues relevant to the profession and we expect Congress to vote on PAPHA this summer. These “white hat” issues led to generally well-received and robust discussion on Hill visits, and attendees were able to truly delve into the important role that emergency medicine plays in the lives of the legislators’ constituents. For further discussion of these issues, as well as bill numbers, head to www.erdocsonthehill.com. The final day of the conference was designed as a Solutions Forum, which was started with a keynote address by United States Surgeon General VADM Jerome M. Adams. You may have seen his remarks in the press, as he urges emergency medicine to take a leading role in the opioid epidemic, calling emergency physicians the “MacGyvers of medicine.” Further panel discussions continued to delve into the topic of opioids, and there was robust discussion about End of Life care as well. If you are interested in attending next year’s conference, save the dates of May 5-8, 2019. If you are interested in working on issues closer to home, consider attending FCEP’s Emergency Medicine Days in Tallahassee, which will be taking place March 11-13, 2019. ■

If you are currently in clinical practice in an emergency department, you know about the drug shortages that we continue to face every day. The Leadership and Advocacy Conference provided a prime opportunity for those on the front lines to discuss the true impact this is having on emergency care with legislators and their staff. Legislators were specifically asked to sign on to a Congressional letter to FDA Commissioner Gottlieb to convene the agency’s Drug Shortage Task Force with other federal departments and relevant stakeholders. ACEP developed and introduced two bills this year designed to provide grants to emergency departments and hospitals in order to expand two innovative approaches to both preventing and treating opioid use disorders: non-opioid, evidence-based pain protocols and medication-assisted therapy, or MAT. Congress is planning to pass a large,

LAC 2018 photos, courtesy of Andrew Bern, MD, FACEP

EMPULSE SUMMER 2018

THE ULTRASOUND ZOOM

FASH

Focused Assessment with Sonography for HIV/TB As a first-year resident, the story of the Focused Assessment with Sonography for HIV/TB, or the FASH exam, is nothing short of inspiring, and I would like to share this with you. While working at a rural district hospital in South Africa, Dr. Tom Heller came up with a simple yet powerful idea: the transformation of the traditional FAST exam into the novel FASH exam. Dr. Heller was inspired by his very sick HIV/TB patients who suffered due to the lack of availability of sophisticated imaging modalities. For these sick patients, early diagnosis is crucial for appropriate treatment. Dr. Heller took the simple, readily available, ultrasound machine and developed a protocol that has been adopted by clinicians around the world.

By Michael Traum, MD, PGY-1

Edited by Leila PoSaw, MD, Ultrasound Director

Department of Emergency Medicine | Jackson Memorial Hospital

The FASH exam was developed in 2010 to rapidly diagnose extrapulmonary and disseminated TB in patients infected with HIV. It is a focused, integrated, goal directed, bedside examination. The protocol asks simple binary questions (yes/no). It is clinically relevant to the immediate treatment of the patient and easily performed by healthcare staff with minimal training. The FASH exam is recommended in HIV prevalent settings (rates >5%), in patients with known or suspected HIV and in whom you highly suspect extrapulmonary, smear negative TB. These patients usually appear sick and may present with chest pain, dyspnea, hypotension, abdominal pain or fever. The main objective of the FASH exam is to detect pleural and pericardial effusions, enlarged abdominal lymph nodes, and focal spleen and liver lesions - all suggestive of disseminated extrapulmonary TB. The following six questions (yes/no) are asked: 1. 2. 3. 4.

Is there a pericardial effusion? Is there a pleural effusion? Is there free fluid in the abdomen? Are there periportal/para-aortic lymph nodes? 5. Are there focal liver lesions? 6. Are there focal spleen lesions?

Map created by Jessica Bendy, July 2014. Source: UNAIDS Progress reports submitted by countries, UCSF, NIH, and Science and Education Publishing.

EMPULSE SUMMER 2018

Positive FASH Findings

Seven views are obtained with the curvilinear or phased array probe. 1. The Subxiphoid view evaluates for the presence of pericardial effusion. 2. The Para-aortic view assesses for the presence of enlarged abdominal lymph nodes. These appear as hypoechoic, round structures which may appear to grow or shrink when fanning through the image. Enlarged lymph nodes >1.5 cm are highly suggestive of disseminated abdominal TB. 3. The RUQ view assesses for the presence of pleural effusion and for free fluid. Pleural effusions are typically anechoic or hypoechoic; however, effusions from TB may be fibrinous with a heterogeneous sonographic appearance. Similarly, patients with TB may have hypoechoic ascites or may exhibit fibrinous strands. 4. The Focused Liver view evaluates for focal, hypoechoic liver lesions. 5. The LUQ view assesses for pleural effusions in the left lung. Unilateral pleural effusions are more common in TB. This view also assesses for free fluid in the spleno-renal space. 6. The Focused Spleen view evaluates the spleen to look for the focal, hypoechoic lesions which are often due to disseminated TB. These abscesses have a characteristic appearance and should prompt confirmatory studies. 7. The final view of the FASH exam is the Suprapubic view to evaluate for ascites. While not specific, this view is crucial for completeness.

Graphic courtesy of Heller T, Wallrauch C, Lessells RJ, Goblirsch S, et al.1 Continue on page 14 ►

FASH.To.Go

• Cut along the border of the table below. (Get as close to the edge as possible!) • Fold in the middle. • Stick in your wallet. Reference on-the-go. Courtesy of authors Leila PoSaw, MD and Michael Traum, MD, PGY-1

FASH: Focused Assessment with Sonography of HIV/TB

SubX: Is there a pericardial effusion?

Para-aorta:

RUQ: Is there Are there free fluid? Is enlarged lymph there a pleural effusion? nodes?

Focused Liver: LUQ: Is there Are there focal lesions?

free fluid? Is there a pleural effusion?

OOPS...

Not happy with your scissors? This table is also available online at www.emlrc.org/fash

Focused Spleen: Are there focal lesions?

Suprapubic: Is there free fluid?

Curvilinear/ phased array probe. Seven views.

EMPULSE SUMMER 2018

The FASH exam was not designed to replace detailed comprehensive imaging. It is meant as a technique to quickly assess critically ill patients, especially in resource-poor environments. Ultrasound is user-dependent, most valuable when the pretest probability is high, and is a rule-in test rather than a rule-out. Keep in mind that effusions can be due to multiple causes, including other opportunistic infections in patients with HIV. Also, liver and spleen findings can be caused by amebic or other infections especially in endemic, tropical regions. I practice at Jackson Memorial Hospital, which is a county hospital in Miami, Florida. We care for a large number of underserved and foreign-born patients. According to the CDC, the rate of TB in foreign-born persons is nearly nine times higher than that of those born in the U.S., and the Miami metropolitan area has the highest rates of new HIV diagnoses in the country. While we do not have higher than 5% HIV prevalence rates, I will be on the alert for positive FASH findings in my immunosuppressed, sick patients. I have a sneaky suspicion that having this protocol in my toolbox will prove useful someday! ■

Save the Dates Symposium by the Sea August 2-5, 2018 Sanibel Harbour Marriott Resort & Spa in Ft. Myers, FL www.emlrc.org/symposium-by-the-sea Life After Residency September 20-21, 2018 aLoft Hotel in Orlando, FL www.emlrc.org/life-after-residency Emergency Medicine Days March 11-13, 2019 Hotel Duval in Tallahassee, FL www.emlrc.org/emergency-medicine-days CLINCON 2019 July 16-20, 2019 Double Tree by Hilton-Universal Studios in Orlando, FL www.emlrc.org/clincon

Online Education CURRENT & UPCOMING COURSES

References: 1. Heller T, Wallrauch C, Lessells RJ, Goblirsch S, et al. Short Course for Focused Assessment with Sonography for Human Immunodeficiency Virus/ Tuberculosis: Preliminary Results in a Rural Setting in South Africa with High Prevalence of Human Immunodeficiency Virus and Tuberculosis. The American Journal of Tropical Medicine and Hygiene. 2010;82(3): 512–515. 2. Bélard S, Tamarozzi F, Bustinduy AL, et al. Point-of Care Ultrasound Assessment of Tropical Infectious Diseases—A Review of Applications and Perspectives. The American Journal of Tropical Medicine and Hygiene. 2016;94(1):8-21.

Safe Opioid Prescribing

EMS Wellness

FL Environmental Emergencies

Street Drugs

Unfamiliar Pediatrics

The Plug It Project: PAM

Human Trafficking

Access at: emlrc.org/online-education

FASH.To.Go Suprapubic

Focused Spleen

LUQ

Focused Liver

RUQ

Para-aorta

SubX

FASH: Focused Assessment with Sonography of HIV/TB Curvilinear/ phased array probe. Seven views.

EMPULSE SUMMER 2018

There’s an Emergency in Your ED How many of your patients should be transitioned to hospice? VITAS® Healthcare effectively transitions appropriate patients from the ED, before inpatient admission or aggressive treatment is necessary. Our interdisciplinary team expertly manages symptoms, engages patients holistically and keeps functionally declining patients out of your hospital, making ED resources available and freeing up beds for those who can benefit. When you see a patient repeatedly, and their functional status is declining, it may be time for hospice. Call VITAS. We’ll work with the ED to evaluate the patient and have the hospice conversation, while effectively moving the end-of-life patient to the appropriate level of care.

The right care in the right place at the right time. It’s the right thing to do.

SINCE 1980

VITAS.com/referral • 800.93.VITAS

SAFE OPIOID PRESCRIBING

for Acute Pain By Jay L. Falk, MD, FACEP, MCCM FCEP Immediate Past-President

FCEP and the EMLRC are excited to provide an online program that will fulfill the new state licensing requirements for physician and mid-level providers for mandatory two hours of opioid education. The course was developed by Education Committee CoChair Dr. Josef Thundiyil, Board of Directors member Dr. Aaron Wohl and myself. Dr. Thundiyil is a board-certified toxicologist with a strong interest in the opioid crisis. He has served on the Orange County task force examining the issues. Dr. Wohl has served as a strong vocal advocate for emergency physicians with state legislators in Tallahassee and Lee County regarding the formulation of HB 27, while helping to educate our representatives regarding the realities emergency physicians face in dealing with all aspects of the epidemic. Dr. Wohl has been a leader in his own healthcare system, developing protocols to reduce the use of opioids in the ED and managing the addicted patient. We hope this program will enable our members, as well as our non-member colleagues, to conveniently fulfill the new law’s educational requirements while enriching their understanding of this vexing and important epidemic. I know that in preparing this program, I have become far more educated about and sensitive to many key issues relating to opioids. These insights have already changed the way I practice for the better, and I am confident this course will help you improve your practice as well.

The course covers all aspects of the use and abuse of opioids relevant to emergency physicians, including: • The current scope of the epidemic • The historical perspective of factors leading to the current crisis • How to safely manage pain in the acute setting and reduce opioid use • Treatment options, strategies and standards to minimize harm and death resulting from opioid prescribing for acute pain • Understanding HB 21, the new law that requires prescribers to comply with various rules relating to narcotic use in the acute setting, and the exceptions for patients undergoing chronic pain management with its own attendant set of rules • HB 21 requirements for naloxone prescribing and availability • Non-narcotic alternatives for treatment of acute pain in the emergency setting • Introduction to addiction treatment, including MAT (medical assisted therapy) • Newer societal approaches to addiction, including decriminalization, drug courts, needle exchange programs, supervised injection sites, student and teacher education programs at all levels: primary through college and beyond. ■

COURSE FACULTY

Jay Falk, MD, FACEP, MCCM

Josef Thundiyil, MD, MPH, FACMT, FACEP

Aaron Wohl, MD, FACEP

FCEP Past-President Academic Chairman, Orlando Regional Medical Center Emergency Medicine Professor of Emergency Medicine UCF, College of Medicine

FCEP Education Committee Co-Chair Associate Residency Director, Orlando Regional Medical Center Associate Professor of Emergency Medicine, UCF, College of Medicine

FCEP Board of Directors Member Lee Health, Department of Emergency Medicine

EMPULSE SUMMER 2018

Do I Need This Course? Starting July 1, 2018, all DEA-licensed professionals must complete two hours of opioid education. Access our course, along with other continuing education courses, at www.emlrconline.org

NOW HIRING! Board Certified Emergency Physicians For Popular East Central Florida

Where the Surf’s Always Up!

LIVE

Course Title:

by the beach!

Safe Opioid Prescribing for Acute Pain

Deadline to Take Course:

WORK at Daytona

January 31, 2019 and at each subsequent biennial license renewal

International Speedway!

Duration: 2 hours

PLAY with colleagues

Format: Online

that become friends

Cost: FCEP and FHA members: $25 Non-members: $75

› Flexible Schedules Accomodated › Daytona Beach Area of Florida

Staffing 5 Hospitals & Daytona International Speedway

› Full Benefit Package › Become a Partner in 18 Months

› Competitive Pay

Come Join Us & Our Desirable Lifestyle! emprosonline.com

Email CV to: Maureen.France@emprosonline.com

HB 21 AT A GLANCE Physician Requirements EFFECTIVE JULY 1, 2018 P R ESC R IB I NG S C HE DULE I I D R U GS F OR D I F F E R E NT TYPE S OF PAIN D EFIN ITION

D E FI NI TI ON

D E FI NI TI O N

“Acute pain” means the normal, predicted, physiological and time-limited response to an adverse chemical, thermal or mechanical stimulus associated with surgery, trauma or acute illness.

“Acute pain” does not include pain related to cancer, a terminal condition, palliative care or a traumatic injury with an Injury Severity Score of 9 or greater.1

“Chronic nonmalignant pain” means pain unrelated to cancer which persists beyond the usual course of disease or the injury that is the cause of the pain, or more than 90 days after surgery.

T R EAT ME NT

TR E ATME NT

TR E ATME N T

Schedule II controlled substance treatment of acute pain may not exceed a 3-day supply. However, a 7-day supply may be prescribed if: • The prescriber believes that more than a 3-day supply is medically necessary to treat the patient’s pain as an acute medical condition; • The prescriber indicates “ACUTE PAIN EXCEPTION” on the prescription; and • The prescriber adequately documents in the patient’s records the acute medical condition and lack of alternative treatment options that justify deviation from the 3-day supply limit.

For Schedule II treatment of pain related to a traumatic injury with an Injury Severity Score of 9 or greater, physicians must concurrently prescribe an emergency opioid antagonist, as defined in s. 381.887(1).

A prescribing practitioner must see a patient being treated with controlled substances for chronic nonmalignant pain at least once every three months and maintain detailed medical records related to such treatment.

For dispensing physicians: Schedule II & III dispensing is limited to a 14-day supply and can not be dispensed more than 14 days post-surgery.

For the treatment of pain other than acute pain, a prescriber must indicate “FOR NONACUTE PAIN” on a prescription for an opioid drug listed as a Schedule II controlled substance.

PDM P R E Q UI RE M E NTS A prescriber must consult the PDMP to review a patient’s controlled substance dispensing history prior to prescribing any controlled substance for patients age 16 and older. Only 4 years of data will be maintained in the PDMP. This requirement does not apply when prescribing or dispensing a non-opioid controlled substance listed in Schedule V, but does apply to all other drugs Schedule II-V. A “non-opioid controlled substance” is one that does not contain any amount of a substance listed as an opioid in s.893.03 or 21 U.S.C. 812.

Exemptions from checking the PDMP: • DOH determines the system to be nonoperational; • Cannot be accessed by the prescriber or dispenser because of a temporary technological or electrical failure; • A prescriber or dispenser who does not consult the system shall document the reason he or she did not consult the system in the patient’s medical record and shall not prescribe or dispense greater than a 3-day supply of a controlled substance to the patient.

E -PR E SCR IB ING All prescriptions can be written, oral or e-prescribed (once FDA requirements are met). Now per Florida law, opioids can be e-prescribed mirroring the federal rule.2

R E SOU RCES 1. How to calculate an Injury Severity Score: www.mdcalc.com/injury-severityscore-iss 2. To start e-prescribing, visit: www. deadiversion.usdoj.gov/ecomm/e_rx/ faq/practitioners.htm 3. HB 21 Q&A: www.flhealthsource.gov/ FloridaTakeControl/faqs

This information has been summarized from a longer document prepared by Dr. Aaron Wohl, MD, FACEP and Toni Large, FCEP Lobbyist, for printing purposes. Find the full document online at emlrc.org/opioid-course ■ 18

EMPULSE SUMMER 2018

COMMUNICATION ACROSS THE CONTINUUM OF CARE:

Emergency Department information exchange (EDie) By Kristin McCabe-Kline, MD, FACEP, FAAEM, ACHE FCEP Vice President Imagine this: A minimally responsive, elderly Jane Doe arrives at your Emergency Department by ambulance. Within minutes of her being registered, you are notified electronically about her chronic conditions, recent hospitalization at a neighboring facility, as well as her advanced directives.

BY THE NUMBERS Who is Using EDie:

1500

Sounds like it’s too good to be true, right? Wrong. This is the reality for about 1500 providers in the 15 states who are currently using the Emergency Department information exchange (EDie). Endorsed by ACEP as a clinical best practice, EDie is a collaborative care management tool that helps coordinate the needs of complex patients by pulling data from a community of providers in real-time. Right now, EM physicians are dependent upon information that patients choose or have the ability to provide. EDie helps fill in the blanks by providing the most relevant information about a patient’s history in a clear and concise notification that can be read in about 60 seconds.

providers in

100%

states

retention rate

The Cost of EDie:

FREE

for FHA-member hospitals until July 2019

$15,000 average annual cost

Is your hospital an FHA member? Find out at emlrc.org/edie

HOW IT WORKS

How does it work? When a patient registers in a participating Emergency Department, EDie queries both a shared database populated by participating facilities and payors as well as the Prescription Drug Monitoring Program. The search reveals critical information including hospital utilization, care plans, current primary care and specialty providers, security alerts, etc. If a patient’s query meets criteria for a trigger, which is determined by the participating facility, an EDie alert is pushed to the attending physician through the electronic health record as part of the existing workflow. The benefits for Emergency Departments alone is enormous: EDie can help reduce readmissions, unnecessary testing, workplace violence, and duplicate prescriptions for controlled substances. For example, integrating EDie with the prescription monitoring program in Washington state led to a 25% decrease in opiate prescribing for Medicaid patients.

Patient registers in ER

EDie receives ADT message, identifies patient & queries databases, such as PDMP

Does this patient meet any criteria that warrants a notification, such as filling an opioid prescription recently?

criteria met

Hospital securely receives EDie alert with detailed recent prescription history

criteria not met

EDie does not include prescription history in notification if one is issued

What are the next steps? In partnership with Collective Medical Technologies, FCEP and the Florida Hospital Association (FHA) are leading the initiative to implement EDie in Florida hospitals. The relevance of the EDie shared database is dependent upon participation: the more institutions that contribute to the database, the more powerful and useful the tool becomes. FCEP has already submitted a letter to the Florida Department of Health requesting authorization of EDie and E-FORCSE integration.

As emergency medicine physicians, our ability to offer the best care to our patients in alignment with their wishes is often dependent on our access to information. This is a time when coming together across the state with a collective voice to promote participation at the institutions where we provide services is crucial. FCEP endorses systems that provide emergency medicine physicians with the tools we need to do our best work as well as leveraging the technology available to improve patient care and stewardship of resources. ■

EMPULSE SUMMER 2018

CHAPTER UPDATES

EMRAF Committee By Jesse Glueck, MD, PGY-3 EMRAF President | Orlando Health Emergency Medicine Resident

As the summer draws to a close, so too does the end of my residency in emergency medicine, as well as those of hundreds of other residents across the country. While I am excited to start what I hope will be a long career as an emergency medicine physician, no longer relying on a supervising attending, it seems the chances of being able to truly practice independently are slim. What keeps me up at night is not the preoccupation that in a few short months I will be the one solely responsible for the outcomes of my patients, but rather that as the time passes by, it seems that, as a specialty, we are giving more and more control to for-profit companies who are looking to profit on the backs of overworked physicians, and vulnerable patients in an already fragile system. Over the past decade, there has been an acquisition and merger spree with large, billion dollar corporations taking over the administration of emergency medical care. Some of these organizations now seem to hope to do the same with medical education. While at the beginning this was seen as a necessity in the face of ever-increasing and costly-to-keepup-with regulations, I fear that as physicians, we have given control of our futures — and more importantly our patients’ care — over to accountants and money managers looking to make a buck. No longer are we expected to use our close to a decade of medical training to care for patients, but rather adhere to counterproductive protocols and ensure we meet the metrics created by people who may have never worked in an emergency department. Physicians across the country are already being faced with pay cuts, as well as attempts to

be replaced by physician assistants and nurse practitioners, while for-profit hospital systems try to dilute the workforce in what is an obvious attempt to drive down the market value of an emergency medicine physician. All of this is in the hope of rising stock prices and increasing dividends. While this is all frustrating for many, it is our own faults that this happened. Many of the EM guard have been so focused on the day-to-day functioning of departments, advancements of careers and the stressors we all face outside of the hospital that they have lost sight of the big picture: that we are the safety net for the most vulnerable. Even more saddening and illustrative of this point is that many in the first and second generations of emergency physicians have decided to sell to large corporations in order to secure a financial windfall prior to retirement instead of passing on their groups to the next generation. I fear that if we do not take control back from those looking to profit on the backs of a system already on the verge of breaking, we will completely lose the ability to provide the kind of care that we all hoped to provide at the beginning of our careers. But there is a way to regain control of the future of emergency medicine: by being involved in the processes that shapes it. This means getting involved as a resident in advocacy through EMRAF, staying involved through FCEP, becoming leaders in our health care organizations and running for legislative office. To get involved and represent your program on the EMRAF Committee, or if you have questions about how to get involved, please email me at JesseGlueckMD@gmail.com. ■

Daunting Diagnosis: QUESTION A 90 year-old male presents to the ER with respiratory distress. In the field, EMS chose to intubate the patient nasally. Per the EMS report, the End-Tidal CO2 monitor after nasotracheal intubation showed good color change, and EMS confirmed tube placement to be correct. To the right is this patient’s XR. What is the pathology, and why was it missed by EMS? By Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief

ANSWER ON PAGE 32 ► EMPULSE SUMMER 2018

RESIDENCY REPORTS

FEATURED RESIDENCY:

UCF-OCALA REGIONAL MEDICAL CENTER By Vir Singh, MD, PGY-1 & Lee Barker, DO, PGY-1 The first year of the UCF-Ocala Emergency Medicine Residency has been one of growth, education and commitment to the communities of Marion and surrounding counties. Three years into being a GME established hospital, Ocala Health has embraced the Emergency Department’s goals of providing the latest in evidence-based care and a culture that fosters the growth and wellness of its residents. Founding Program Director Dr. Bobby Desai, who is the former Program Director of UF, Gainesville, brings a philosophy geared towards training residents that can thrive in any highvolume, high-acuity position across the country. Residents were excited to join a hospital system with a high-volume Trauma II center, a high-volume community hospital, and a busy, free-standing Emergency Department– all three of which are undergoing expansions as Marion county’s population of more than 350,000 continues to expand. Most recently, Ocala Health began the creation of a simulation center, dedicating an entire building solely to

GME use. Meanwhile, West Marion Community Hospital has undergone ED renovation and expansion; Ocala Regional Medical Center has broken ground on more-than-doubling its ED capacity; and plans have been made to increase the number of ED beds at Summerfield Free Standing ED. Residents are joining the Ocala Health GME’s transition from community-to-academic center by engaging in research and joining hospital committees to better understand administration and represent the department of emergency medicine on a hospital system-wide level. We are also excited to welcome new faculty members: Marion County EMS Director, Dr. Frank Fraunfelter, and Stanford EM Ultrasound fellowship graduate, Dr. Drew Jones. We will also welcome a new class of residents that hail from medical schools across the nation, ranging from Oregon to New York. The future is bright at Ocala Health and its residents are thrilled to continue building their program and establishing their culture. ■

EMPULSE SUMMER SUMMER 2018 2018 EMPULSE

NORTH FLORIDA physicians and people. We are blessed to have faculty such as Dr. Evan Stern, who was voted Educator of the Year for his dedication to the residency, development of our simulation program and commitment to teaching. The residents have illuminated the dedication of the faculty by quickly becoming the leaders and exemplary residents when on service rotations.

UF Health: Gainesville By Travis Murphy, MD, PGY-2 As the final year of UF Gainesville’s eight-resident program ends, we are looking ahead to a full complement of 42 residents across our various sites. We wish our graduating class well as they take on their roles in fellowship and practice! Drs. Agran, Hord and Roberts will be our rising chiefs who have ideas for exciting new simulation, teaching and staffing opportunities. The annual PGY-2 trip to SAEM was a success. Posters and projects were presented by Dr. Kranc, Mr. Emmett Martin (our research liaison) and Dr. Zeinali. Sessions were moderated by our own Drs. Beattie, Becker, Holland and Maldonado. We enjoyed seeing practice laps for the Indy 500 and touring the Colts’ stadium in addition to a few nights on the town as a second-year class. Steady progress continues with the ECPR program, which is designed to optimize the care of critically ill patients in hospitals. We anticipate sharing good news as it rolls out over the next few months in conjunction with a dedicated team of “Resuscitationists.” We were also able to put a dollar amount on redundant testing, and are taking steps towards reducing this through collaboration with inpatient colleagues and partner hospitals. This is going to be a very exciting summer in Gainesville, and we can’t wait to share it with you! ■

We very much intend to continue this strong dedication toward education, research and humanism, and pass the torch on to the incoming intern class of 2021. We are excited to greet the new residents coming from all over the U.S. and introduce them to the North Florida EM way right from the start. We are confident they will flourish and shine like their predecessors had done before them. ■

UF Health: Jacksonville By Corey Dye, MD, PGY-1 We at UF Health College of Medicine – Jacksonville would like to congratulate our graduating seniors as they move into the next chapter of their careers in emergency medicine. We have several seniors pursuing fellowship training this year: Ultrasound: Dr. Jason Arthur at the University of Arkansas and Dr. Christopher Kumetz at UFHCOM- Jacksonville Research: Dr. Lauren Black at UFHCOM- Jacksonville Pediatrics: Dr. Caitlin Borokowski at Loma Linda

North Florida Regional By Zaza Atanelov, MD, & Collin Bufano, MD, PGY-I Greetings from the North Florida Emergency Medicine Residency program. It’s hard to believe that we are done with our first year as a program. Both faculty and residents agree that this year far exceeded anyone’s expectations! As the year has gone by, we have become more than just a residency program aimed at pumping out residents. We have become a family unit, working together with the same goal, to make our residency one that breeds leaders in the community, academic and policy worlds of emergency medicine. This is exemplified by residents such as Christopher Libby, who was voted by our nursing staff to win the Resident Clinical Humanism Award for his compassion, integrity and devotion to his patients. Our attendings have time and time again shown their dedication to the residents and to the success of the residency, doing everything to make us well-rounded EM 22

Despite the challenges and difficulties of a new residency, we managed to publish several research projects and have begun many more. Notably, we are the first ones in the North Florida HCA division to be IRB accepted for a prospective research project.

Meanwhile, several others will be joining independent practices throughout Florida and Georgia: Dr. Justin Beyer, Dr. Hannah Fox, Dr. Tushar Gupta, Dr. Stephanie Hernandez, Dr. Heather Holstein, Dr. Dan McDermott, Dr. Shehzad Muhamed, Dr. David Navo and Dr. James Ontell. Dr. Ryan Shannon will be joining a private, group-practice based out of Nevada. We will also have the privilege of keeping graduating senior Dr. Warren Sher as an attending at the UFH – North campus. To all of our seniors: best wishes in your future endeavors, and thank you for the countless hours you have devoted to both patient care and becoming outstanding emergency physicians at our facility. In other news, the program remains very involved in outside organizations. Dr. Tom Morrissey contributed to a presentation at the Cord Academic Assembly in April regarding application SLOEs and the new standardized video interview process. In May, Dr. Jason Arthur, Dr. Christopher Kumetz, and Dr. Kim Papa participated in the ultrasound competition at SAEM. Dr. Melissa Parsons is scheduled to speak at FIX (FEMinEM Idea Exchange) this coming fall. ■

EMPULSE SUMMER 2018

CENTRAL FLORIDA

Orlando Health

Florida Hospital By Katie Laun, DO, PGY-2

By Laura Cook, MD, & Anne Shaughnessy, MD, PGY-1

Time continues to fly by. It is hard to believe the academic year is over and we are welcoming our new interns. Everyone here at FH East Orlando worked extremely hard to finish up the year strong while celebrating special events, including SAEM, the class of 2018’s graduation and Wellness Day for current and incoming residents.

Hello from beautiful Orlando! Orlando Health is happy to say “welcome to the family” to an amazing class of interns. We look forward to our new colleagues starting their residency with a fun-filled orientation month. We also congratulate our new chiefs and quality officers, who will continue to lead Orlando Health Emergency Medicine to success.

I, along with fellow second-year resident, Dr. Kenneth Frye, was elected chief resident for the upcoming 2018-19 year. We are working closely with the outgoing chiefs and doing our best to learn from them and carry on the legacy they will be leaving behind.

Spring was filled with many exciting events. The annual Orlando Health Quality Retreat featured many posters from our program. Co-authors Drs. Hunter, Miller, Ralls, Rodriguez, Papa and Shaughnessy were honored to present their award-winning poster at the Rapid Fire Presentation.

In April, I was fortunate to attend the annual CORD meeting that was held in San Antonio, Texas. It was a wonderful experience where I was able to attend classes with a wide variety of topics covered, in addition to connecting with other residents. I am excited to see what the next year brings, and I look forward to working with my current residents and future interns! ■

This past year, residents and faculty represented the program in various medical trips to underserved countries. Orlando City’s Corporate 5k also took place this spring, and a team of residents, nurses, faculty and staff represented Orlando Health with energy and a fast-paced run.

University of South Florida

In June, we had the bittersweet celebration of honoring the class of 2018. Seniors, thank you for your guidance and mentorship. We wish you the best of luck in your upcoming jobs and fellowships. We strive to continue the example you have set as physicians, friends and mentors. You have truly shown us what it means to live like Sal. We look forward to seeing you at Symposium by the Sea! ■

By Clay Ritchey, MD, MSHCA, MSEd, PGY-2 It is time to bring out the sun, heat and rain in Florida! Summer also bring about transitions within the residency program. We have an amazing class of new interns on the way with a wide array of accomplishments. We look forward to watching them grow over the next year and continue to accomplish amazing things. Our rising second years have earned their stripes: they are happily moving up and coming back into the ED after many educational months away. Our rising third years are beginning to see the light at the end of the tunnel and are welcoming their new roles as leaders and educators among the residents. Congratulations to all of the new chiefs for this upcoming year. Thank you for taking on leadership positions and continuing the rich history of USF EM, while fostering new ideas for growth. Lastly, congratulations to all of the graduates of 2018. In short, your leadership, knowledge and guidance will be missed. But know that the leadership and the wisdom you have passed down to the classes below you will continue to have an impact on the many residents who will make USF EM their home. We wish you all much success and fun out in the real world! ■

UCF/HCA at Osceola By Leoh N. León II, MD & Abhishek Roka, MD, PGY-2 Hello from UCF/HCA Emergency Medicine Residency Program of Greater Orlando. Our class of 2021 is here, and we are proud to say that we are now 21! Prior to the end of the academic year, we had a wellness day at Volcano Bay with the residents and faculty, and we had a blast! We would also like to extend a very special congratulations to Dr. Ganti, who was awarded the Distinguished Educator of the Year Award by the Clerkship Directors in Emergency Medicine, as well as to Drs. Cabrera, Amico and Ganti, who were awarded the Best Resident/Fellow Abstract in Pediatric Emergency Medicine Award at SAEM. Finally, we are looking forward to ACEP 2018 in San Diego, California. We are working hard to hopefully present more abstracts and papers with the Emergency Medicine family. To all of the new interns throughout the country, congratulations and enjoy the next few years! ■

EMPULSE SUMMER 2018

SOUTH FLORIDA

Mount Sinai Medical Center

St. Lucie Medical Center

By Michael Cecilia, DO, PGY-2

By Thomas Adams, DO, PGY-4

Greetings from the Mount Sinai Medical Center Emergency Medicine Residency Program. With another beautiful Miami Beach winter and spring behind us, we are eagerly looking forward to summer. July is always a bitter sweet time, as we welcome our newest interns and bid farewell to a great class of senior residents who are ready to make their mark on the world of emergency medicine.

Summer 2018 is finally here, and we at St. Lucie Medical Center are ready for some fun in the sun! We send our warmest St. Lucie bear hug to the incoming class of 2021: Drs. Drew Brooks, Jerome Daniel, Michael Drechsler, Shelby Guile, Abby Regan and Ashkahn Zomorrodi. We welcome you with open arms and are more than thrilled to bring you into our family. You all have what it takes to be outstanding EM physicians and we will work hard to help you achieve success along the way.

This past winter, our program was proud to support two exciting EM conferences: the 7th annual FLAAEM Scientific Assembly and the first South Florida Wilderness Medicine AWLS course. We look forward to hosting our 2nd annual introduction to Point of Care Ultrasound Conference in July. We would like to commend Drs. Justin Burkholder, Robert Farrow and Adam Memon for their outstanding research project testing the efficacy of trigger point injections in patients presenting to the emergency department with back pain. The abstract was accepted for presentation at the AAEM SA 2018 in San Diego this past April and at the SAEM annual meeting in Indianapolis this past May. We are also pleased to announce that our Sinai family is growing in more ways than one. Congratulations to core faculty member Dr. Michael Rosselli and resident Drs. Joseph Sherer and Nick Garrett on the newest additions to their families. From our residency to yours, we wish each and every program a successful start to the 2018-19 academic year. ■

We also wish our graduating class of 2018 a warm farewell. Dr. Alexa Yager is headed to Washington State; Dr. Thomas Caraballo will be working in the Chicago area; Brittany Nobilette is heading home to San Diego; and Hicham El Alami will return to the San Francisco Bay Area. We are exceedingly proud of your accomplishments and we wish you the best on your journey to the other side of the mountain. We cherished our time with all of you, as you helped brighten our lives and the lives of your patients. You will all be missed! This past year, we participated in several wellness events. All of PBCGME participated in the FAU ropes course, which was a thought-provoking, team-building event. We also ran the Classics by the Sea 5K and soaked in some rays by the pool for our annual Resident’s Day Out. This year, we look forward to adding simulation to our curriculum in partnership with the FAU Simulation Center. We at St. Lucie wish you a wonderful and safe summer, and we look forward to seeing you at the next conference. ■

Life After Residency September 20-21, 2018 Aloft Orlando Downtown Join EM residents & faculty from all over Florida at this two-day conference that features workshops & presentations on navigating life after residency.

emlrc.org/life-after-residency 24

EMPULSE SUMMER 2018

SOUTH FLORIDA

Aventura

FAU at Bethesda Health

By Laurence Dubensky, MD, Assistant Program Director & Director of Education

By Jeff Klein, MD, PYG-2

Investing in the faculty is an essential aspect of a healthy and thriving program. This year our parent company, HCA, organized a superb faculty development seminar at the NOVA Southeastern College of Allopathic Medicine, which hosted programs from the southeast Florida division of GME. There was a breadth of expert speakers who educated us on topics such as “The Differential of the Struggling Resident,” remediation, and faculty and resident wellness. With match day behind us, we have been eagerly looking forward to the end of June, when our new residents begin their orientation. This is a very exciting time for us. As a newly developed program, we will now have a full complement. Our orientation committee developed a stellar program this year, both at our home institution and in collaboration with other south Florida programs. We are proud to commend our residents’ continued commitment to scholarly activity. Dr. Ana CastanedaGuarderas has published two papers, titled “Humor During Clinical Practice: Analysis of Recorded Encounters,” published in the Journal of American Board of Family Medicine, and “Weight Changes After Thyroid Surgery for Patients with Benign Thyroid Nodules and Thyroid Cancer: Population Based Study and Systematic Review and Meta Analysis,” in Thyroid. Dr. Thomas Yang was appointed chairelect for the EMRA Education Committee, and also serves as the EMRA Liaison for ACEP’s Clinical Policy Committee. Dr. Cook, in conjunction with a team of simulation faculty, created and successfully executed our second annual high fidelity simulated mass casualty training event at the Broward College Simulation Center. This exercise was structured to simulate a real MCI, with a focus on an active shooter scenario. Fire rescue units from regional stations were deployed, S.W.A.T. units used live blank rounds to enhance the reality of the scene, and volunteers from the nursing school were the live, moulaged patients we encountered during the scenario. It was an incredible educational experience for the residents and teams working that day. Lastly, we would like to congratulate Dr. Scarlet Benson on her appointment as academic faculty. Dr. Benson joined AHMC over a year ago as clinical faculty, but her goal was always to be involved in clinical teaching and graduate medical education. Dr. Benson completed her Medical Degree at University of Washington and her training in emergency medicine at Beth Israel Deaconess in Boston. ■

Hello from Boca Raton, Florida. We are exceptionally pleased with and eager to welcome our second class of residents this July: Alexander Busko from the University of Miami, Zachariah Hatoum from George Washington University, Mohsin Khan from FAU’s internal medicine residency program, Danielle Klein from FAU, Zuheir Mirza from USF, and Anabelle Taveras from University of Illinois. We have no doubt that these residents will have a positive impact on our surrounding community and become an integral part of our close-knit family here at FAU. Our very first mass casualty simulation day was extremely well-executed, thanks to the hard work and countless hours invested by our core faculty and 30+ undergraduate students who volunteered their time as simulated patients. Our day of simulation began with a background on START (Simple Triage And Rapid Treatment) and the basics of EMS. This was followed by three different simulation scenarios, where a team of residents and nurses applied the knowledge learned in the first portion of the day to rapidly triage, treat and move a large number of victims to a casualty containment area. The event was held at FORTs Medical in Coconut Creek, FL, which specializes in producing rapidly deployable emergency medical facilities. Their products are routinely used by various governments, disaster relief agencies and other organizations, such as the U.N., to produce on-site, state-of-the-art disaster relief and medical care. We would like to express our gratitude to FORTs Medical, Dr. Patrick Hughes and the student volunteers for making such an invaluable experience happen. In closing, congratulations to all of the EM residency programs across the state as I’m sure your incoming class of residents is just as highly-anticipated as ours is. Additionally, good luck to everyone as we embark on a new and formative year of graduate medical education! ■

New Section: Case Reports We’re launching a new section in the next edition of EMpulse: Resident Case Reports. This will be a dedicated section for case reports and academic publications published by Florida’s emergency medicine residency programs. Case reports will be accepted on a rolling basis. Send in your final reports to managing editor, Samantha League, at sleague@emlrc.org.

EMPULSE SUMMER 2018

SOUTH FLORIDA

Jackson Memorial Hospital

Kendall Regional Medical Center

By Emergency Medicine Residency Staff

Greetings from Miami! After a wonderful and busy interview season, we were thrilled to find out who our 15 new residents would be on match day. We are excited to welcome an extremely talented and diverse group of residents who come from many different backgrounds and from all over the country. We have planned a fun-filled orientation month packed with social events, including a Marlins baseball game and barbecue at Crandon Park, along with many learning opportunities, such as an airway workshop, central venous line training, ATLS, ACLS, BLS and PALS. We are ecstatic to finally have the full complement of residents in our three-year EM program.

Things have really come together at Kendall Regional as we prepare to welcome our third class of residents! We are very excited to finally complete our resident family after years of intensive groundwork put in by all of our faculty.

As our current second years rise to their final year in residency, we are also elated to have our first-ever group of chief residents: Dr. Natalia Alvarez, Dr. Emily Cooper and Dr. Michael Roberds. They were selected by their peers and mentors and are ready to jump into this rewarding and exciting inaugural role. Finally, we want to congratulate some of our residents for their involvement and academic achievements. Dr. Emily Ball and Dr. Anwar Ferdinand presented their abstract “Opt-out Emergency Department Screening of HIV and HCV in a Large Urban Academic Center” at AAEM and received the runner-up award for the Western Journal of Emergency Medicine Population Health Abstract Competition. Dr. Henry Zeng also presented a very interesting case of cerebral toxoplasmosis at AAEM, and Dr. Ariana Weber will be attending Dr. Richard Levitan’s advanced airway course this summer. We look forward to a sunny summer, and soon it will be interview season all over again. Time flies when you’re having fun! ■

We are also happy to announce that Dr. Moises Moreno will be joining us as our new Ultrasound Director. Dr. Moreno brings with him previous experience as a residency ultrasound director that will help us move our ultrasound training to the next level. We are excited to work with him, as well as with our two brand new ED ultrasound machines. Our residency recently participated in the 2nd Annual Mass Casualty Incident Drill at Broward College. In attendance were the Florida Department of Health, Broward Police Department, Broward Fire Rescue, Broward College, and multiple residency programs from Kendall Regional and Aventura. This large-scale, interdisciplinary exercise combined a simulated bomb explosion, gunshots and high-quality moulage to produce an intense afternoon of simulation training. This event prepared us to coordinate and work effectively with our pre-hospital providers during mass casualty and disaster events. Special thanks go to Dr. Antoinette Golden, our Simulation Director, and the multitude of other faculty and personnel at Kendall, Aventura and Broward who worked tirelessly to make this massive event possible. We can’t thank them enough! The past two years have been an exciting time in our rapidly growing program. We hope to continue our focus on resident clinical and academic achievement with our new faculty, drawing from their diverse experiences to promote resident engagement and education while we continue our collaborations with prehospital organizations and other institutions. We look forward to what we can build in the future. ■

Stay in Touch! EMpulse is just one form of communication for FCEP members. Stay informed by signing up for email announcements and following us on social media.

/fcep.org

@fcep

EMNews Now eNews multibriefs.com/briefs/fcep

@fcep_emlrc

/company/emlrc

Stay in Touch Webpage emlrc.org/stayintouch

EMPULSE SUMMER 2018

POISON CONTROL

High Dose Insulin Therapy: The Ups and the Downs By Madison Schwartz, Pharm.D. & Emily Jaynes Winograd, Pharm.D. Clinical Toxicology/Emergency Medicine Fellows at Florida/USVI Poison Information Center - Jacksonville High dose insulin (HDI) therapy is a cornerstone in the management of beta blocker and calcium channel blocker toxicity. This therapeutic modality enhances myocardial glucose utilization and improves inotropy in the setting of beta blocker or calcium channel blocker overdose. However, initiating and maintaining HDI appropriately can be challenging. A variety of insulin and dextrose dosing protocols have been published for the treatment of hypotension caused by beta blocker and calcium channel blocker toxicity. Experimental models, case reports and current protocols all suggest that very large doses of insulin (as high as 1-10 units/ kg via bolus doses or hourly infusions) may be necessary to provide the inotropic support and hemodynamic improvement sought when managing these overdoses.1-4 When initiating HDI, the Florida Poison Information Center Network (FPICN) recommends administering 0.5-2 units/ kg (depending on the toxicologist) of regular insulin intravenously as a bolus dose, followed by a continuous infusion of regular insulin starting at a rate of 1-2 units/ kg/hour. The insulin infusion rate should be increased based on hemodynamic response (e.g. improvement in blood pressure, mean arterial pressure, tissue perfusion), although it may take up to 60 minutes for effects to manifest. It is important to note that current recommended insulin infusion rates for HDI are at least 10 times higher than the typical 0.1 mg/kg/hour insulin infusion rate utilized in the management of diabetic ketoacidosis (DKA). Multiple case reports and articles have published use of “HDI” with these lower DKA doses rather than recommended insulin doses needed to provide inotropic and hemodynamic support in patients with drug-induced cardiovascular toxicity.5,6

Aggressive dosing of dextrose is indicated when administering high dose insulin both to maximize myocardial glucose uptake as well as prevent hypoglycemia. Different dosing strategies for dextrose administration are based on the patient’s initial blood glucose concentration. Stellpflug and Kerns recommend an initial dextrose bolus of 0.5 g/kg if the patient’s serum glucose concentration (SGC) is <300 mg/dL, followed by a dextrose infusion of 0.5 g/kg/hour to maintain a SGC of 100–250 mg/dL.7 The FPICN recommends administration of 50 mL of 50% dextrose injection (25g of dextrose) in adults if the SGC is <250 mg/dL before initiation of insulin, followed by infusion of 10% dextrose injection at 0.5 g/kg/hour and adjusted to maintain an SGC of >150 mg/dL. Furthermore, we recommend progressing to 20% dextrose, if needed, to accommodate the large amounts of dextrose (and its associated fluid) required to maintain an adequate SGC in the setting of high dose insulin therapy.8 If the patient becomes hypoglycemic, general consensus among toxicologists favors increasing dextrose administration rather than decreasing the insulin dose. Appropriate initiation, continuation and monitoring of HDI is very labor-intensive. Continuous cardiac monitoring, point of care blood glucose checks every 15-30 minutes, and monitoring and replacement of potassium are all important modalities in the provision of safe and effective HDI. Insulin administration will cause potassium to shift intracellularly, resulting in an apparent decrease in serum potassium concentration. Serum potassium should be measured 15-30 minutes after insulin initiation, every 30-60 minutes until stabilized, and then every 2-4 hours thereafter. We recommend supplementing potassium if the level is <2.5 mEq/L to maintain a level between 2.8–3.2 mEq/L; do not attempt to normalize the level.

2019 Save the Date: March 11-13, 2019 at Hotel Duval in Tallahassee, FL | emlrc.org/emergency-medicine-days 28

EMPULSE SUMMER 2018

IMPLEMENTATION AT A GLANCE Page et al. conducted a retrospective chart review of 22 patients with beta blocker and/or calcium channel blocker toxicity who received high dose insulin therapy.9 Insulin dosing in these patients ranged from 50-125 units as a loading dose followed with maximum insulin infusion rates ranging between 38-1500 units/hour. Glucose infusion rates ranged from 4-75 g/hour. Notably, 16 (73%) of these patients did develop hypoglycemia (defined as a serum glucose less than 62 mg/dL), although no neurologic sequelae from hypoglycemia were reported. Prolonged duration of hypoglycemia following discontinuation of insulin in these patients was associated with higher doses of insulin provided during HDI, reflecting the necessity of continuing glucose monitoring and dextrose administration beyond cessation of insulin therapy (potentially for more than 24 hours after insulin discontinuation). The authors also reported hypokalemia (potassium < 3.5 mEq/L) in 18 (82%) of patients, although no cardiac arrhythmias associated with hypokalemia were reported. In fact, the authors concluded there was no association between the amount of insulin administered and incidence of adverse effects. HDI can be a safe and effective antidotal therapy for beta blocker and calcium channel blocker toxicity. Appropriate and aggressive dosing, titration, monitoring, and glucose and electrolyte replacement are key to successful implementation. ■

When initiating HDI: • Administer 0.5-2 units/kg of regular insulin intravenously as a bolus dose • Followed by continuous infusion of regular insulin, starting at 1-2 units/kg/hour • Increase insulin infusion rate based on hemodynamic response When initiating dextrose: If SGC is <300 mg/dL: • Initial dextrose bolus of 0.5 g/kg • Followed by dextrose infusion of 0.5 g/kg/hour If SGC is <250 mg/dL in adults: • Administer 25g of dextrose before insulin • Followed by infusion of 10% dextrose injection at 0.5g/kg/hour • Adjusted to maintain an SGC of >150 mg/dL • Progress to 20% dextrose if needed to maintain adequate SGC If the patient becomes hypoglycemic, increase dextrose administration rather than decrease the insulin dose. Continuating and monitoring: • Continuous cardiac monitoring • Blood glucose checks every 15-30 minutes Measure serum potassium: • After 15-30 minutes of insulin initiation • Every 30-60 minutes until stabilized • Every 2-4 hours thereafter • Supplement potassium if the level is <2.5 mEq/L to maintain a level between 2.8–3.2 mEq/L

Your local poison center is available to answer any questions concerning beta blocker or calcium channel blocker toxicity and the use of HDI by calling 1-800-222-1222.

References: 1. Engebretsen KM, Kaczmarek KM, Morgan J, Holger JS: High-dose insulin therapy in beta-blocker and calcium channel-blocker poisoning. Clin Toxicol. 2011;49:277–283 2. Cole JB, Stellpflug SJ, Ellsworth H, et al. A blinded, randomized, controlled trial of three doses of high dose insulin in poison-induced cardiogenic shock. Clin Toxicol. 2013; 51:201-7. 3. Bechtel LK, Haverstick DM, Holstege CP. Verapamil toxicity dysregulates the phosphatidylinositol 3-kinase pathway. Acad Emerg Med. 2008; 15:368-74. 4. Kerns W, Schroeder JD, Williams C, et al. Insulin improves survival in a canine model of acute beta-blocker toxicity. Ann Emerg Med. 1997; 29:748-57. 5. Kumar K, Biyyam M, Bajantri B, Nayudu S. Critical Management of Severe Hypotension Caused by Amlodipine Toxicity Managed With Hyperinsulinemia/Euglycemia Therapy Supplemented With Calcium

Gluconate, Intravenous Glucagon and Other Vasopressor Support: Review of Literature. Cardiol Res. 2018;9(1):46-49. 6. Beavers JR, Stollings JL, Rice TW. Hyponatremia induced by hyperinsulinemia–euglycemia therapy. Am J Health-Syst Pharm. 2017; 74:1062-6. 7. Stellpflug SJ, Kerns W II. Antidotes in depth. In: Hoffman RS, Howland M, Lewin NA et al., eds. Goldfrank’s toxicologic emergencies, 10th ed. New York: McGraw-Hill; 2015. 8. Amlodipine [monograph]. In: Micromedex Poisindex [online database]. Greenwood Village, CO: Truven Health Analytics (accessed 2018 Feb 22). 9. Page CB, Ryan NM, Isbister GK. The safety of high-dose insulin euglycaemia therapy in toxin-induced cardiac toxicity. Clinical Toxicology 2017(26):1-8.

EMPULSE SUMMER 2018

CHAPTER UPDATES

Medical Student Committee: ON TO THE NEXT By Alicia Bishop, FSU Class of 2020 FCEP Medical Student Committee Secretary-Editor As another academic year draws to a close, medical students across Florida prepare to enter the next phases of their professional education. In this quarterly update from the FCEP Medical Student Committee, newly-minted MD’s, seasoned interns and faculty share their best advice for brand-new interns and incoming fourth-year medical students.

THE YEAR IN PHOTOS: Above & left two photos: FIU’s annual Wilderness Medicine Retreat taught medical

students several skills, such as situation assessment and splinting a fracture. Students rotated through stations taught by physicians trained in wilderness medicine and participated in a final disaster scenario at the end of the day. By Tori Ehrhardt, EMIG co-president at FIU. Right two photos: On March 24, 2018, FSU’s Emergency Medicine Interest Group (EMIG) hosted a disaster preparedness event for medical and physician assistant students. Students were guided on how to properly treat patients during natural disaster and active shooter scenarios. Students also practiced other procedural skills such as IV line placement, placing tourniquets and chest decompression. By Conley Diaz-Gomez, FSU EMIG president & Alex VanFleet, FCEP MSC representative. 30

EMPULSE SUMMER 2018

What do you wish you knew before starting fourth year?

What do you wish students knew before starting their intern year?

Most everyone will tell you that the fourth year of medical school is the best year. This is for many reasons. Aside from the obvious (match, graduation, etc.), you will finally have some freedom to move, catch up on sleep and have a social life again. With that being said, I wish I had known a few things beforehand. First, front-load your required clerkships if at all possible. Don’t put off your last required clerkships until the second half of the year. After the new year, you will not want to be balancing assignments and the stress of being “ON” while you are going through the constant stress of finalizing your rank list. Similarly, it will be harder to put in the same level of mental and physical effort at the end of the year when all you want to do is enjoy the last few months of “freedom” before residency.

What about the match process? Trust the system. I don’t mean don’t stress about it, since that is just not possible. What I mean is that the algorithmic system they have established is honestly what it is intended to be. Don’t try to “play” the system. Rank the programs by where you want to be; not by where you think you will be or where you think you will match.

How should incoming fourth years approach EM residency applications? One of the biggest things you need to know about going into EM: the SLOE is by-and-large the single most important component of your residency application. Yes, programs will use STEP scores on their side of ERAS to see a more reasonable number of applications, but time and time again, I heard from program directors that the SLOE was created by EM PDs for EM PDs. With that said, you have to do externships. Be mindful of where you do them. If you want to train in a county ED setting, do an externship at a county ED program. If you are in a Florida medical school but aren’t sure if you want to stay in Florida for residency, go to another state and do at least one externship. Lastly, go to a conference and the residency fairs. “Walk the room,” smile, shake hands and make contacts. Show the programs that you are a normal and cool person they would want to work with or even hang out with. Drew Williams, MD

Florida State University College of Medicine Class of 2018 EM Intern at Wake Forest Baptist Medical Center My advice is mostly for students who want to stay local: do not feel afraid to do all your externships in Florida. I know the common advice is to do at least one rotation out of your state in order to be a more well-rounded applicant. However, I felt that doing only Florida programs showed my commitment to the state, and I was taken more into consideration for those Florida programs. Misty Coello, MD

Florida International University Herbert Wertheim College of Medicine Class of 2018 | Intern at Florida Hospital

ABOUT INTERN YEAR

ABOUT FOURTH YEAR

I think it is important to start intern year as a completely new phase in your life. This is not just a continuation of fourth year. Students need to completely shift their paradigm when coming to work as an intern. You are not competing with your colleagues and focusing on trying to get a high grade or be ranked competitively anymore. Everything in your residency educational experience is designed to mold you into a clinician. You will never again have the opportunity to focus so fully on learning and honing your own skills. Take advantage of the opportunities. This is where you become the physician you are going to be the rest of your professional life! Robyn Hoelle, MD, FACEP

Associate Professor | Residency Program Director | Chairman of Emergency Medicine at North Florida Emergency Medicine Residency Program

What would you tell incoming students about the transition to intern year? Residency is hard. For many people, it means moving to a new state and being away from your support system. Working hours can be very long and you have to balance conferences, research and clinical work. With that being said, residency is also an incredible time where you will grow as a person and clinician. You will form bonds and memories with patients and your colleagues that will never be forgotten. The best advice is to take care of your well-being by implementing time management and balancing skills. We spend our lives dreaming of getting to medical school, getting to the residency of our choice, and then somehow we simply forget to enjoy our dream. Learn how to manage your time and do what makes you happy often and regularly. You may not be able to exercise or do what you love every day, but be consistent. Similarly, don’t forget about your support system. Keep in touch with your loved ones and find new support from your peers in your residency. You may be wondering what to do to “prepare” for residency. I was told not to read anything and enjoy all my free time. I agree with that advice, but I’ll add the following: now is the time to work on balance. I highly encourage everyone to enjoy the time off, but it if reading a clinical case might interest you, go for it. During residency, be selective about what projects you choose to be involved in. There will be plenty of opportunities. If you know your interests, find a mentor in that area and build a relationship with them. If you don’t know, try to expose yourself to different areas and see what works for you. Get involved with projects/research that will excite you. Do not do it just for your resume. You will already be working too much. Lastly, remember that you are exactly where you need to be and that you belong. You will have many humbling moments reminding you how much you still need to learn, and that’s okay. That’s the reason we need to go through residency. You are never alone. Most importantly, enjoy the ride and don’t forget to take care of your well-being. ■ Rodolfo Loureiro, MD, PGY-1

Beth Israel Deaconess Medical Center | Florida State University College of Medicine Class of 2017

EMPULSE SUMMER 2018

Thank You Corporate Partners The success of the Florida Emergency Medicine Foundation (FEMF) and the Emergency Medicine Learning & Resource Center (EMLRC) is due in large part to our corporate partners that provide annual sponsorship support for our educational programs and events. Thank you to our 2018 corporate partners for believing in our mission and helping us provide life-saving education for lifesavers.

Are you interested in becoming a 2019 Corporate Partner? Contact Melissa Keahey, Director of Meetings & Events, at mkeahey@emlrc.org to learn about upcoming opportunities.

Daunting Diagnosis: ANSWER The ET tube is clearly extending out of the patient’s oropharynx; nasotracheal intubation was not successfully achieved. In this case, EMS had a false positive End-Tidal CO2 reading. The XR shows the ET tube curved back on itself in the oropharynx, with the cuff inflated in the oral cavity. Expired air from the patient’s lungs, entering the oropharynx from the trachea, went through the ET tube’s distal opening, thus registering color changes consistent with a false positive reading. In addition to End-Tidal CO2 monitoring, direct visualization of the ET tube going through the cords is the gold standard for tube placement. All ET tubes after EMS transport require checking of placement with direct visualization and CXR, as ET tubes initially in proper position can also be dislodged in transport. In this case, the patient became hypoxic and required rapid oraltracheal intubation. A definitive airway was finally achieved. ■

◄ CONTINUED FROM PAGE 20 32

EMPULSE SUMMER 2018

IT’S AN ELECTION YEAR

& FCEP Needs Your Support By Damian Caraballo, MD, FACEP Government Affairs Committee Chair 2018 is a very important election year in Florida. What happens in this election will shape the future of Florida politics for several years. FCEP’s Political Committees (PC) need your support to continue fighting for emergency physician rights and combating detrimental legislation which impedes on the patient-physician relationship. Our ability to advocate the legislature for pro-emergency medicine legislation will heavily impact how we practice medicine in Florida for several years to come. If you’re sick of outside entities dictating how to practice medicine, now is the time to do something about it and have your voice heard. The truth is, due to the nature of modern U.S. politics, we need money to support a physician-friendly agenda. Did you know that health professionals currently rank 13th in terms of money given for lobbying? We rank behind Big Pharma, the Trial Bar, insurers, hospitals, and even realtors and educators. It is no coincidence that increased physician burn-out and loss of autonomy in recent years has coincided with increased health-lobbying efforts by outside groups. It is only through our advocacy efforts that we will be able to take our profession back. In Florida, emergency physicians are supported by two FCEP PCs: Physicians for Emergency Care (PEC) and Emergency Care for Florida (ECF). Together, they make up the largest and most-influential emergency physician lobby in the state. So, just what do they do for you, as an emergency physician? Here are some key victories we had last legislative session:

• FCEP led the charge to kill the Personal Injury Protection (PIP) Bill, which

would have overturned No-Fault PIP auto-insurance in favor of a Bodily Injury Provision. The House version of the bill would have removed a mandatory carveout for EMTALA-providers who see auto-accident victims. By ORMC data, this would have cost Emergency Physician groups as much as 2-5% in lost revenue (totaling millions of dollars in lost in reimbursements)! • The Opioid Overdose legislation initially had a hard-cap on all opioid prescriptions at 3 days. We were able to negotiate for more reasonable provisions and exclusions, which would have tied up ED resources. FCEP is also one of the leading state groups in the Florida Opioid Taskforce. • FCEP also led the charge for initiating an EDie system in Florida, which will be the first step to link EHR data and prescriptions in several unconnected hospital systems throughout Florida. • FCEP successfully advocated to kill a bill which would have allowed pharmacists to practice medicine by diagnosing and treating influenza and strep throat. • FCEP has been the leading advocate fighting insurance claw-back provisions and petitioning AHCA and the Legislature about predatory health insurance practices. Now is the time to re-empower Florida emergency physicians. PEC & ECFF will continue to fight against incursions by non-physician entities which encroach on patient care and fair compensation. We cannot stress how important an investment this is towards how we practice emergency medicine. Please give to the PC today and contribute to the fight for Florida emergency physicians! ■

WILL YOU MAKE A DONATION? For just $150, you will become an FCEP-PC member and take the first steps in laying the ground work for our practice in the next 5-10 years. Every dollar counts in the fight for pro-emergency physician legislation. EMPULSE SUMMER 2018

Thank You, Donors FCEP’s Political Committees can’t exist without support from our generous donors. Thank you to all who contributed in March-May 2018: Zakaria Abdulla Mark Attlesey David Ball Brian Baxter Jay Bhula Michael Borunda Damian Caraballo Carlos Castellon Jordan Celeste Michael Collins Julio De Pena Batista Nicholas Dodaro Alex Doerffler Pamela Mohr Falcigno Clifford Findeiss Michelle Fox-Slesinger Vidor Friedman Miriam Joy Gamble Joseph Ghebrial Eliot Goldner John Hammock Manning Hanline Caleb Harrell Brian Scott Hartfelder Christopher Hayden Rory Hession Matthew Hevey Jordon Johnson Steven Kailes Christopher Kumetz Christopher Martin Talor Matthews Dylan Maziur Michael McCann James David Melton Pamela Miller David Orban Amit Rawal David Ian Sack Brooke M Shepard Todd Slesinger Niles Sulkko Farid Visram Basil West Therese Marie Whitt Tony Zitek

HOW TO DONATE: Send the text “FCEPPC” to “41444” Visit emlrc.org/fcep-pac-donations Mail a check to FCEP

MUSINGS FROM A RETIRED EMERGENCY PHYSICIAN

The Affordable Care Act: Where Are We Now? And What is the Future of the American Health Care System? By Wayne Barry, MD, FACEP Retired Emergency Physician

It appears that ER visits have increased since the implementation of the Affordable Care Act; not decreased, as originally hoped. The reasons for this phenomenon are multifactorial and complex. The expansion of Medicaid in many states has been followed by an increase in ER utilization. Lack of medical home establishment may be one explanation. Data from 2014 shows that the top reasons for visits were chest pain, abdominal pain, shortness of breath and injuries. Only 4.3% visits were non-urgent medical symptoms. Patients with chronic medical conditions made up a significant proportion of ED visits. There is also a rising number of patients seeking ER treatment with mental health issues. Finally, the increasing aging population and the current opioid epidemic are also explanations for the continued rise in ER patient traffic. Meanwhile, Republican control of the entire legislative and executive branches of the U.S. government astonishingly failed to result in their collective desire to repeal and replace Obamacare. I find that very few people are unaware of our current president’s loathing for anything passed by the Obama Administration. So, what has Donald J. Trump done to dismantle his predecessor’s landmark health care reform law so far? 1. He limited support for open enrollment, resulting in a decrease of 5 million sign ups compared with the previous year. 2. He slashed advertising by 90%. 3. He killed cost-sharing subsidies. 4. He eliminated the individual mandate. The Congressional Budget Office estimates there will be 13 million more uninsured patients in nine years. 5. He made it possible for states to exert more control over Medicaid spending for health care. Some states are requesting permission to charge Medicaid recipients, test them for drug use, and lock them out of receiving benefits if they fail to keep up with payments or paperwork. 6. He has proposed allowing small businesses to buy health insurance together in order to permit their employees to have health insurance like employees of larger companies.

8. He is encouraging the sale of short-term health plans, which do not have to adhere to Obamacare rules and also tend to provide far less coverage. It looks to me that if these attacks on the ACA gain traction, we will have fewer insured Americans paying increased premiums for decreased coverage, and while that helps ferment the ACA into something “rotten in Denmark,” where is the president’s plan for American health care that is “excellent, cheaper and more available” than Obamacare? I heard of an interesting plan for health care, which sounds similar to what I have been futilely advocating for the past 20 years. Amazon, Microsoft and Google are planning to join forces in order to provide comprehensive health care to all of their employees and their family members as an employee benefit. Their plan will be designed to provide high quality, comprehensive health care at a low cost since the health care coverage will be part of company overhead. I presume they will employ incentivized health care workers who will perform optimally for competitive wages, and provide and procure the best quality medical devices and equipment, even if they have to develop some of this with their own resources. Further, the health plan will be administered by managers whose job will be to provide maximum return - which is high quality and caring health care to employees for minimum cost. Lean and “nice” instead of lean and “mean.” While this sounds like a monumental task, who better than the brightest at these three mega-companies to pull off this feat? If Amazon, Microsoft and Google can accomplish this project, why wouldn’t a consortia of other companies and groups try the same thing? Small businesses and Mom and Pop shops will find it advantageous to negotiate with larger groups to be included in this high quality, low cost health care model of “Corporate National Health Care.” The U.S. government would be left to do what it does best, which is to enforce regulations associated with health plan structures and make sure the have-nots of our society are covered in some way. In the end, maybe both political parties could take credit for the success of such a system. Who cares, as long as it works! ■

7. He would like to enable enuresis to offer plans across state lines with associations offering alternatives to Obamacare.

EMPULSE SUMMER 2018

Locations In: Altamonte Apopka Celebration East Orlando Kissimmee Lake Mary Orlando Waterman Winter Garden Winter Park Waterford Lakes

Emergency Medicine Pediatric Emergency Medicine

Join a team of dedicated clinicians in Central Florida Delivering emergency care services for nearly 50 years.

teamhealth.com/join or call 888.861.4093 or email

physicianjobs@teamhealth.com

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

3717 S. Conway Road, Orlando, FL 32812 www.emlrc.org/fcep | (800) 766-6335

WE’RE HOSTING A

50-50 Raffle EN T E R TO W I N ! TEXT “JACKPOT” TO 51555 The EMLRC is hosting a 50-50 Raffle! One lucky “jackpot” winner will receive 50% of the total proceeds collected. The remaining proceeds will support programs at EMLRC. Open to all: tell your friends and family! Raffle tickets may only be obtained via your mobile device. Just text “JACKPOT” to 51555 to enter. The suggested cash contribution in connection with the receipt of the ticket is $20. Increase your odds of winning with 20 tickets for $200! Raffle ends at midnight Sunday, August 5, 2018 following Symposium by the Sea. The drawing will take place on Wednesday, August 8, 2018 at the EMLRC. Ticket holder need not be present to win. Applicable taxes are the sole responsibility of the winner. For any prize amount that exceeds $600, the winner must fill out a W9 form. Follow us on social media for updates on jackpot balance growth!