EMpulse (Winter 2016-2017)

Volume 23, Issue 4 WINTER 2016-2017

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

Resilience in the Emergency Department Means Wellness for Emergency Physicians

Financial Decision-Making for the Emergency Physician

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Chapter Updates President’s Message | 4 Medical Economics Committee | 5 Government Affairs Committee| 7 Florida College of Emergency Physicians 3717 S. Conway Road Orlando, Florida 32812 t: 407-281-7396 • 800-766-6335 f: 407-281-4407 www.emlrc.org/fcep

EMS/Trauma Committee | 8 Leadership Academy Update | 10 Membership & Professional Development Committee | 11 Medical Student Committee | 12

FCEP Executive Committee Jay L. Falk, MD, MCCM, FACEP • President

EMRAF Committee | 13

Joel Stern, MD, FACEP • President-Elect

FITLS Update | 14

Joseph Adrian Tyndall, MD, MPH, FACEP • Vice President Kristin McCabe-Kline, MD, FACEP • Secretary/Treasurer

Residency Matters | 18

Steven Kailes, MD, FACEP • Immediate Past President Beth Brunner, MBA, CAE • Executive Director

Features

Editorial Board Karen Estrine, DO, FACEP, FAAEM • Editor-in-Chief karenestrine@hotmail.com

Daunting Diagnosis | 9

Samantha Rosenthal • Managing Editor/Design Editor srosenthal@emlrc.org

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

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

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

Coding Tip | 12 Poison Control | 15 Memorable Moments from ACEP16| 22 Resilience in the Emergency Department | 24 An Emergency Physician’s Career: Financial Decisions| 26 Snapshots of Our 2016 Social Events | 32 EM Case Reports | 34 Hospice Reduces Emergency Room Visits (Reference Article Sponsored by VITAS Healthcare) | 36 ACEP Board Update| 37 Musings of a Recently Retired Emergency Physican | 38

WINTER 2016 - 2017 | VOLUME 23, ISSUE 4

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President’s Message I hope all of you enjoyed a happy and healthy holiday season, and that you had an opportunity to spend time with your families and friends. I am writing this column the day after Thanksgiving; Randye and I were fortunate enough to spend the holiday with our four adult children, their spouses and our four grandchildren. As is our family tradition, seated around the table, each person shared what he or she was thankful for. Our grandchildren were old enough this year to be “Thankful for mommy and daddy”, and the clear message from each of us was that we are grateful for our family.

It is through the bonds of our family and personal relationships that we derive the happiness, wellbeing and fulfillment that enables us to perform at our highest professional level.

One of my sons and his wife recently moved their family from the city to the suburbs. In choosing Jay Falk, MD, MCCM, FACEP a house and community, many considerations factored into their decision-making. Price, proximity to the city and the commute to work, quality of the schools, taxes, the “community vibe” and local FCEP President shopping opportunities were all carefully considered. Despite growing up with his father being an emergency physician, the availability of and proximity to emergency services and a quality hospital with a competently staffed emergency department never entered into my son’s calculus. One evening their then 18-month-old daughter, who had begun demonstrating some food allergies, had a full-blown anaphylactic attack. She was rushed to the nearest emergency department, about a 10 minute car ride, where the board-certified emergency physicians and the quality nursing staff literally saved her life.

Like so many Americans, my son and his wife took it for granted that if the need arose, quality emergency care would be there for them and their family. As luck would have it, in their case this turned out to be true. The caring EP, who my son now describes as a “rock star”, helped educate him and his wife as to when to use an EpiPen, when to call 911 and etc. My granddaughter, now almost 4 years old, has been to the same ED with severe reactions on three subsequent occasions but arriving in less critical condition due to the counseling of the EP. My son and daughter-in-law now consider proximity to excellent emergency care among the most important criteria in choosing where to live for now and in the future.

In our day-to-day work lives, fraught with the many frustrations of modern EM practice (EHR, time pressures, administrative scrutiny, documentation reimbursement issues, medico-legal climate, etc.), it is easy to loose sight of the heroic work we do and the profound impact we have on our patients’ lives. We need to remind ourselves of this frequently. This Thanksgiving, I was thankful for my wonderful family, but also thankful for the blessing and privilege of being an emergency physician with the opportunity each shift to help others in so many meaningful ways.

The presidential inauguration will be only weeks away when you read this. Irrespective of one’s political views, it should be clear to all that the house of medicine is in for a wild ride in the coming years. Without a doubt, the days of fee-for-service medicine are on life support. Value-based services will be rewarded and waste will be punished. Mergers and acquisitions among physician management groups, hospital systems, pharmaceutical companies and insurance companies all threaten the independence and professional prerogatives of emergency physicians. ACEP and FCEP are working tirelessly to educate the public and our political leaders about the needs of our patients and our members, while vigorously advocating for our positions both nationally and statewide. The scope and depth of our activities are far too involved to review in this column.

I urge you to read this issue of EMPulse to see the many ways in which your College is serving you. Please go to our website and the ACEP website to educate yourself regarding all aspects of our programs and services and to see how you can become more involved in this important work. I am optimistic that the creativity, energy and commitment of our many talented leaders, members and staff will enable us to emerge as trailblazers in helping to define and secure our own professional future.

For a New Year’s resolution, I encourage each of you to resolve to reach out to colleagues who may not be members and to ask them to join.

Non-member practicing emergency physicians are enjoying all of the benefits of the advocacy of the College, while they let members shoulder the substantial financial burden of this work. We need everyone to get off the bench and get in the game.

I wish you all a happy and healthy New Year.

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FCEP President Dr. Jay Falk's Thanksgiving family group shot.

Photo courtesy of Dr. Jay Falk

WINTER 2016 - 2017 | VOLUME 23, ISSUE 4

Medical Economics Committee MIPS – Merit Based Incentive Program

Performance Year 2017 – A Review for Emergency Medicine Physicians and Providers Summary as of October 15, 2016 - provided by Martin Gottlieb and Associates Medicare published their final rule for MIPS and APMS on October 14, 2016. A link to the final rule can be found here: https://qpp.cms.gov/docs/CMS-5517-FC.pdf In addition, CMS established a quality website which attempts to simplify information regarding MACRA, MIPS, and APMs. This website contains FAQs, webinar links, and CMS contact information for questions: https://qpp.cms.gov/education

What is MIPS?

Daniel Brennan, MD, FACEP Medical Economics Committee Chair

MIPS combines the existing Medicare Meaningful Use (MU), Physician Quality Reporting System (PQRS) and Value-Based Modifier (VBM) programs into one program (MIPS) as of 2017 performance year. Under MIPS, a physician or non-physician practitioner (NPP) will receive a composite performance score (CPS) based on three weighted performance categories: Quality, Advancing Care Information and Clinical Practice Improvement Activities (CPIA).

The CPS is a number between one to 100 and will be used to determine the physician or provider’s Medicare payments two years from the calendar service year. CMS will also report the provider’s CPS score publicly on the Physician Compare website.

Timeline

MIPS is scheduled to become effective with January 1, 2017 date of service and will begin affecting your payments in the 2019 payment year. All Emergency Department physicians and providers will be required to participate in either MIPS or an Advanced Payment Model (APM) in 2017 to avoid financial penalties.

Financial Impact

ED physicians and providers must meet the requirements for reporting the Quality and Clinical Practice Improvement Activities to avoid MIPS penalties. The minimum number of requirements is detailed in the table below along with associated bonuses available depending upon the practitioner’s level of reporting in 2017. For Performance Year 2017, CMS established a variety of compliance options called “Pick Your Pace.” Providers will eligible to receive various levels of bonuses depending on their “pace”.

MIPS – What do Emergency Medicine providers need to do?

1. Report Quality Measures - The Quality category works much like the current PQRS system with several modifications made. Under MIPS, providers will be required to report on six quality measures. Of these six measures, one measure must be an outcome measure. If an outcome measure is not available, at least one measure reported Continued on page 6 WINTER 2016 - 2017| VOLUME 23, ISSUE 4

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Continued from page 5

must be a high priority measure. Providers can meet their obligation to report Quality Measure through claims -based reporting, registry reporting, direct EHR submission or QCDR such as ACEP’s CEDR registry (QCDR).

CMS published 23 specialty-specific Measure Sets, including a set for emergency medicine. Emergency Medicine providers submitting through claims data or registry (excluding QCDR) will likely report on those measures included in the emergency medicine measure set.

For 2017, CMS has eliminated the requirement to report on a cross-cutting measure; therefore, the cross-cutting measure most ED providers reported in 2016, “Measure 317 Blood Pressure Follow Up”, will not be required. However, Measure 317 is included in the emergency medicine measures set and should providers wish to continue reporting this measure it will count towards their required 6 measures.

The table below lists the measures in the emergency medicine specialty set as outlined in the final rule. Be prepared to document and report six of these, including one high priority measure:

2. Complete Clinical Practice Improvement Activities (CPIA) - This category requires physicians and NPPs to perform clinical practice improvement activities. The list of CPIAs can be found at this link: https://qpp.cms.gov/measures/ia.

Clinicians seeking the highest bonuses in 2019 will need to submit at least one and up to four CPIAs. Of note, participation in ACEP’s E-QUAL program, as well as ACEP’s CEDR QCDR, counts towards CPIA fulfillment.

In addition, Maintenance of Certification activities (MOC) also count as CPIAs.

3. Advancing Care Information – This category is the new “Meaningful Use” and most emergency department providers will not be subject to meeting these requirements. Providers that are “hospital-based” will be excluded from this requirement. “Hospital-based” is defined as practitioners delivering 75 percent or more of their Medicare claims in a hospital-based setting.

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WINTER 2016 - 2017 | VOLUME 23, ISSUE 4

Government Affairs Committee It has been a roller coaster ride over the past few months. Thank you everyone for investing both your time and PC money to support our advocacy campaign. FCEP reinforced many of our current friendships with our legislators, but we also successfully established many new relationships with incoming “freshmen”. But now that election season is over, the committee chair selections have been made and many legislative agendas will start to emerge.

Emergency Medicine Days 2017 is approaching fast (March 13-15), and the FCEP Board preparation has already begun. The Governmental Affairs Committee, along with Medical Economics Committee, explored many topics that may come up this legislative season, and we established five legislative priorities that the Board approved and will serve as our discussion points during EM Days 2017: Sanjay Pattani, MD, FACEP Government Affairs Committee Co-Chair

1.

Balance Billing/Transparency Act a. Keep abreast of ACEP federal lawsuit b. Continue to monitor all payer claims database (APCD) selection process c. Monitor local payer reimbursements, and how may affect negotiations/rates d. Monitor network selection vs. narrowing

2.

Mental Health/ Substance Abuse a. Boarding /overcrowding in ED b. Local practices to model on outpatient follow up c. Opioid overdose/antagonist administration/dispense

3.

Worker’s Compensation a. New provisions that may increase claims, increase legal fees/costs, decrease ability to pay provider b. Downstream effect on ED specialty call coverage and access to care

4.

Impact on High Deductible plans on EM a. Continue to gather data on financial impact, payer specific information b. Link to balance billing and ACEP legal

5.

EM Clearinghouse a. Provide centralized EMS educational site b. Promote standardized protocols, training with SIM man, etc.

A hot topic that came up in the Government Affairs meeting was a recent balance billing issue in Pinellas County. Humana has stated that they overpaid a group practice for out-of-network exchange reimbursement. They have threatened to deduct their overpayment from future payments if not reimbursed now. FCEP is monitoring this payer and will work with ACEP to look at federal ACA issues versus local balance billing legislation.

FCEP is also talking to the Office of Insurance Commissioner, State Attorney Pam Bondi, and other agencies. We will have an update by EM Days 2017, and will likely provide up-to-date information in our talking points.

Although the above points above were approved by FCEP Board to be our main organizational legislative priorities, we should all be familiar with many other talking points to discuss that affect our specialty. These may range from PIP, freestanding EDs, nurse practitioner scope of practice expansion and many others.

I encourage everyone to participate on subcommittees so that we can provide a robust yet concise EM Days 2017 informational handbook that will may help educate our friends in Tallahassee who we are, what we do and how we care for their constituents — our patients. Please email me if you need any additional information or would like to get more involved with EM Days 2017.

Legislative session is right around the corner. Let’s be prepared, speak well and spread our intellectual capital. Thank you for your interest and your contributions to our specialty.

WINTER 2016 - 2017 | VOLUME 23, ISSUE 4

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EMS/Trauma Committee Winter is coming, and it is the season with significant additional concerns for our EM and EMS providers. The first is something many of you, hopefully all of you, have made an attempt to protect yourself against: influenza. Patients with influenza present with symptoms that we all know and hate: fever, chills, myalgias, cough, congestion, runny nose, headaches and fatigue.

Unfortunately, influenza is very contagious and has been known to spread via large particle respiratory droplets made when people cough, sneeze or talk. These droplets contaminate others by going into their oral or nasal cavity and can travel through the air up to six feet.

Less often, indirect contact transmission can occur where a well person contracts the illness via contact with an infected surface and then touches their own mouth, eyes or nose. Adults may be able to infect others beginning one day before symptoms develop and up to five to seven days after becoming sick. It is important for EM and EMS providers to be aware of concerning symptoms as well as don the appropriate level of personal protective equipment (PPE) prior to contact with these patients consider this with dispatch for these type of symptoms.

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

These droplet precautions include a mask for the patient, and a mask, gloves and gown for the provider. Disposal of all of these items after care, full hand hygiene and decontamination of the transport vehicle and equipment are also important. It is also necessary to avoid aerosol-generating procedures (intubation, nebulization of medications) if possible. In a pandemic situation, denial of transport or limitation of resources in the setting of stable, simple influenza symptoms are changes to consider at a dispatch level.

Just when you thought that influenza complicated the holiday season enough, there is another curveball coming your way: carbon monoxide poisoning. This unfortunately presents very similar to the flu with headache, dizziness, fatigue, nausea, vomiting, shortness of breath, chest pain, weakness and confusion. This occurs more frequently during the colder months, killing 400 Americans annually due to residents attempting to warm their home with heaters which are damaged or with items which are meant for use in an alternate fashion.

These are all things to consider when you have patients who present these symptoms and on scene it was noted that they are heating their home with charcoal, a gas oven, using of a portable gas stove indoors, using a generator indoors, or if there could be concern that the heating system may not have been serviced recently. Another clue is that small animals are deceased, or that the whole family has contracted similar symptoms with the most dramatic presentation in the infants, elderly and chronically ill.

Remember keep your differential broad!

FAEMSMD update (October 19, 2016)

Currently the membership is completing a compensation survey in order to get an idea of the range of pay for medical directors around the state. Stay tuned for a summary of these results. FAEMSMD has also continued to work on a searchable protocol database to provide a tool for medical directors to review best practices for medical care protocols.

Chapter 401

The state legislative committee is discussing a rewrite of Chapter 401 and a draft version is being circulated; this can be made available by request to EMLRC. This rewrite will likely include a definition of community paramedic and critical care paramedic, allow ground ambulance and vehicle equipment to be determined by the medical director, better define medical director education requirements, and potentially extend the Ryan White Act to protect rapid HIV testing of patients to help decide appropriate prophylaxis for EMS personnel exposed.

Trauma

State acceptance of the CDC adult criteria for the Trauma scorecard continues to be on hold. Regarding Statute 395.4015 and the proposal to initiate the regional trauma agencies by using department of Security Task Force (RDSTF) regions, Peter Pappas, MD, FACS continues to lead this pilot project, and it is progressing along nicely.

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

This legislation clarifies the current practice of physician EMS medical directors overseeing care provided by paramedics and other emergency medical service practitioners via “standing orders� is statutorily allowed and protected. H.R.4365 was passed in the House of Representatives and is now onto the Senate for further review and hopefully approval as well. We would like to thank all of those who have worked hard to lobby for our position on this issue, and we look forward to see further progress in the Senate.

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WINTER 2016 - 2017 | VOLUME 23, ISSUE 4

State EMS plan

In regards to the State EMS plan, FAEMSMD has currently designated working groups to create proposals that will allow EMS agencies around the state to accomplish these goals. Specifics on these goals were listed in our last EMpulse update.

Requirements for Physicians Reporting Supervisory Relationships

There was concern previously mentioned in the FAEMSMD meetings concerning the Florida State Statute 458.348 and the details required to be reported to the Florida Board of Medicine regarding the relationship between a medical director and the personnel he or she oversees. This has been clarified, and the requirement is that “the physician shall submit notice to the Board. The notice shall contain a statement that includes the following: I, (name and professional license number of physician), of (address of physician) have hereby entered in into a formal supervisory relationship, standing orders, or an established protocol with (number of persons) emergency medical technicians, (number of persons) paramedics, or (number of persons) advanced registered nurse practitioners. (b) notice shall be filed within 30 days of entering into relationships, orders, or protocol.� This is the only information required to be reported to the Florida Board of Medicine.

FCEP EMS-Trauma Committee General Clinical Discussion

Law enforcement use of naloxone remains a hot topic due to the high number of deaths that continue to occur secondary to narcotic overdose across our state and nation. Our discussion included the importance of appropriate training and involvement of an EMS medical director with any law enforcement agency that uses naloxone in the field. It is important to ensure that personnel administering this medication have continued training and quality assurance. Citizens receiving this medication are patients with a medical condition who need further care and evaluation.

Finally, the holidays are a time of year when our EM and EMS providers must work and be away from their family at a time of joy and celebration. We would like to thank you for your continued dedication throughout the year, but especially when you give up these precious moments and dedicate your life helping others.

D au ntin g D i ag n o s i s Question: A 21-year-old female presents to the ED from a foreign country.

She states that for two months, she has been having progressive headaches, left eye swelling and new-onset blindness. Exam of left eye shows significant proptosis and left eye swelling.

CT brain and MRI brain are shown. What is most likely the diagnosis for this patient?

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

Turn to page 10 for the answer!

Thanks to all who made contributions to the Political Committees in September, October & November 2016!

Jacqueline Barnes Jeffrey Barnes Benjamin Berteau Laurie Boge Daniel Brennan Jerry Thomas Brooks Carlos Castellon Jordan Celeste Erin Connor Steven Eccher Michael Estep Robert Alan Farrow Alex FinIinson

Jennifer Fredericks Rajesh Gutta Manning Hanline Reuben Holland Steven Kailes Clinton Keilman Ahmad Ksaibati Douglas Lee John Patrick Lewis Merci Madar Raymond McLane Pamela Miller Dion Samerson

WINTER 2016 - 2017 | VOLUME 23, ISSUE 4

Steven Schmidt Mary Elizabeth Schmieder Joel Stern Daniel Thimann Thang Tran Jon Van Heertum Janessy Vasquez Juan Felipe Villegas Therese Marie Whitt Anthony Woolf Gary David Wright Albin Xavier

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Leadership Academy Update Article by Saundra Jackson, MD, RDMS, FACEP; FCEP Leadership Academy Fellow, 2016-2017 Our experience in this year’s Leadership Academy is off to a great start. Dr. Ray Merritt and myself are both older than the traditional fellows, and, as such, we have broader perspectives and interests that have spawned out of our collective practice.

We had the unique opportunity to immerse ourselves in the behind-the-scenes world of emergency medicine and, specifically, in the issues that affect us as physicians in the Florida Chapter of ACEP by serving as councillors at the most recent Scientific Assembly in Las Vegas.

The exposure to the leadership of FCEP has been tremendous in providing us the privilege of being mentored by our Florida leaders and the ability to see first-hand product of their efforts in protecting our interests as emergency physicians practicing in this state — and this is just the beginning.

We are looking forward to the upcoming Emergency Medicine Days 2017 in Tallahassee and the novel experience of a face-to-face meeting with our legislators to advocate and lobby on behalf of our specialty, and, most importantly, on behalf of the patients that we have the honor of serving 24 hours a day, 365 days a year.

Thank you very much for the development of the Leadership Academy, the leadership’s genuine interest in our presence, and a special thank you to Dr. Pat Agdamag for his commitment to our individual and collective experience.

D a u ntin g D i a g n o s i s Answer: This patient is suffering from idiopathic intracranial hypertension, also known as benign intracranial hypertension or pseudotumor cerebri.

On Brain CT and MRI: the radiologist read the patient to have left intra-orbital mass effect with enlargement of extraoccular muscles.

Pseudotumor cerebri is characterized by increased intracranial pressure in the Karen Estrine, DO, FACEP, FAAEM absence of a tumor or other diseases.

The main symptoms are stroke-like Editor-in-Chief headache, nausea and vomiting, as well as pulsatile tinnitus, double vision and other visual symptoms. If untreated, it may lead to swelling of the optic disc, which can progress to vision loss (as seen in this patient).

The condition is most common in women aged 20–40.

Diagnosis includes physical exam, lumbar puncture for elevated opening pressure, and neurologic imaging.

Treatment includes medical and surgical.

Medications include acetazolamide (reduces CSF production), analgesics to control pain, and steroids (controversial). Surgeries include venous sinus stenting, optic nerve sheath decompression with fenestration and shunting, and CSF shunt.

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WINTER 2016 - 2017 | VOLUME 23, ISSUE 4

(Question on page 9)

Membership & Professional Development Committee The start of the FCEP working year began at Symposium by the Sea 2016 in August. Since then, we have been off to a great start in preparation for a productive and innovative year. The committee meetings on November 16, 2016 were well attended and informative. Were you there? If not, you missed several spirited conversations regarding the future of EM and our role in the process.

Rene Mack, MD Membership & Professional Development Committee Chair

Active participation in FCEP is an integral part of making our organization strong and relevant to the membership. One of the ways we have sought to bridge the gap is the continued growth and development of the Leadership Academy. Currently in it’s fifth year, the Leadership Academy has two participants this cycle — Drs. Sandra Jackson and Dr. Ray Merritt. Both are well-versed in the clinical aspect of emergency medicine and are looking to become leaders in EM through the multitude of experiences that will be available to then via the Leadership Academy. They have already been involved in several facets of our local organization and ACEP. They both attended ACEP16 in Las Vegas and were able to participate as ACEP Alternate Councillors, a unique experience which gives great insight into how ACEP functions. We look forward to their continued growth within EM and encourage you to consider the Leadership Academy as well. If you have any questions, please contact the FCEP office, or visit the website (www.EMLRC.org).

The EMRAF meeting was well represented by residents from most of the residency programs in Florida, including the newest additions. The residents have set forth goals for improving not only their education but also their involvement in FCEP and EM as a whole. The medical student section is also very active and they are eager to learn more about EM and how they can become more involved. Do you have a medical school in your area? Please reach out to the medical students and become a mentor for their further enrichment and education.

Even though the FCEP year started a few months ago, the calendar year is coming to a close. Do you still have unused CME funds?

If so, check out the upcoming programming available from FCEP. The Emergency Medicine Payment Reform Summit (February 9-10, 2017) will be an informative conference, bringing together EM leaders from across the US to discuss and develop plans related to the future of healthcare delivery and payment. Are you involved in the operational management of your hospital or group? Are you concerned about what the future of EM holds for you and the way you practice medicine? If so, this conference will provide you with a wealth of information and give you the opportunity to brainstorm with leaders who are concerned about the same topics. You can also visit the ACEP Bookstore and website for more available resources and events to keep you up to date on the many developments and innovations taking place in EM. Our next committee meetings will take place on February 15, 2017. We hope that you’ll be able to join us for another round of invigorating discussions regarding our role in the future of EM. I hope to also see you at EM Days 2017 in Tallahassee (March 1317, 2017). This is a very important and eye-opening conference where we meet with the Florida legislators to discuss the state of healthcare and provide context to the bills and amendments that will be voted on during the legislative session that may affect healthcare.

WINTER 2016 - 2017 | VOLUME 23, ISSUE 4

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M e di c a l S t u d e nt C o m m itt e e The Fall Medical School Update The Medical Student Committee is pleased to spotlight the work of the following Florida Emergency Medicine Interest Groups:

FAU’s EMIG, led by president Jeffry Kats, invited Dr. Shih from the new FAU residency to talk about matching EM and a local EMS director to talk about paramedicine. They are also organizing new ridealong opportunities with local EMS and are beginning a community CPR program that other medical school students are welcome to join.

Hannah Gordon Secretary-Editor of the FCEP Medical Student Committee

FIU’s EMIG, led by presidents Hannah Gordon and Semir Karic, are arranging shadowing opportunities at Baptist, Mt. Sinai and University of Miami hospitals. They also organized a resident talk by the new Aventura EM program, a screening of Code Black and are organizing the South Florida Wilderness Medicine Conference. It is open to all Florida medical school students. Contact Hannah Gordon at hgord002@fiu.edu for more information.

FSU’s EMIG, led by president Sarah Allen, organized a procedure clinic with chest tubes, intubation, ultrasound and X-ray. They are also increasing shadowing opportunities for students.

NOVA’s EMIG, lead by presidents Daniel Novak and Hannah Kim, hosted a talk by the Mt. Sinai residency program, a EM case conference and another talk about the allopathic and osteopathic residency merger. They also hosted an ultrasound and intubation clinic, and they are working on a splinting clinic and EMS ride-alongs.

UCF’s EMIG, led by president Tanner Barfield, organized various volunteer first aid events this fall, including a field hospital — the first of its kind — for the Electric Daisy Carnival in Orlando. They are also doing ride-alongs with EMS and participating in EM research. They are currently planning a mock code event and are arranging shadowing opportunities at the new EM residency in Osceola.

UF’s EMIG, lead by president Lawrence Castillo, organized a procedure clinic for M1s and M2s with more than 150 participants.

C o din g T i p ICD-10 Medicare Grace Period Has Ended Last year, Medicare gave a grace period of one year immediately following the implementation of ICD-10 diagnoses codes for the highest level of specificity. They said you would not be denied on an audit solely for not hitting that highest code. So as long as you were in the right ballpark, you would not be dinged for missing the laterality or some other detail.

Well, all good things must come to an end, and this is no exception. Your final diagnoses must hit all the right items so your coding team can assign the most specific final code. Please keep these items in mind when documenting your final diagnoses: • • • • • •

Acute vs. chronic anything Laterality for everything Abdominal pain - exact location or diffuse Diabetes – Type 1 or 2; controlled, uncontrolled or poorly controlled Fractures – the specific part of the specific bone Pregnancy – 1st, 2nd or 3rd trimester

Lynn Reedy, CPC, CEDC, Director of Coding Services, Tampa Bay Emergency Physicians

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EMRAF Committee Article by Shayne Gue, MD; EMRAF President Having just completed our second meeting of the year, I continue to be inspired and encouraged by this amazing group of people. Our November meeting, which took place in conjunction with the FCEP Committee meetings, saw representatives from six of Florida’s EM residency programs, the most we’ve ever had!

Our primary objective was to outline our goals for the 2016-2017 year and commit resident involvement in the planning and participation of Emergency Medicine Days 2017 (March 13-15) and Symposium by the Sea 2017 (August 4-7). We have placed representatives on the planning committees for each of these ventures and are continuing to solicit involvement beyond our current resident representatives.

Additionally, the majority of our residents were able to sit in on several FCEP Committee meetings, which explored methods for increasing membership and engagement within FCEP and outlining a cohesive legislative platform for the upcoming EM Days 2017 in Tallahassee. Our representatives unanimously support the proposed FCEP platform and are committed to being a part of this incredible event.

As always, the role of EMRAF within FCEP is to empower residents to learn about all aspects of emergency medicine and to provide a unified voice of emergency medicine residents in the State of Florida. Our primary goal is to increase resident engagement and facilitate the development of a better-rounded EM resident.

This year we are seeking to expand our membership by actively recruiting more resident representatives from around the state. Program representatives are tasked with serving as a liaison between the EMRAF Committee and their respective residency programs. As with all FCEP Committees, we meet quarterly in conjunction with the FCEP Board of Directors at the EMLRC in Orlando and during Symposium by the Sea. We currently have 12 resident representatives from 6 Florida residency programs: Florida Hospital, Orlando Health, UF Gainesville, University of South Florida, Aventura Medical Center and Osceola Regional Medical Center. Our objective for the 2016-2017 year is to increase our membership to a minimum of 20 resident members and include all 11 Florida residency programs.

If you are interested in serving as an EMRAF liaison for your program, please contact me at shaynegue@hotmail.com.

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

Florida International Trauma Life Support Update Highlights of the 2016 International Trauma Conference Article by Jeffery D. Gilliard, NRP/CCEMTP/FPM, BS; FITLS Chapter Coordinator/Affiliate Faculty The 2016 International Trauma Conference held October 27-29 in San Antonio, Texas was a success with more than 260 trauma care and EMS professionals from 20 countries worldwide in attendance. With the support of the FCEP/FITLS committee, our delegates from Florida ITLS (FITLS) were FITLS Chapter Coordinator Jeff Gilliard, FITLS Member at Large David Mattman, FITLS Medical Director Pete Gianas, FITLS State Coordinator Mike Rushing and FITLS State Co-Coordinator Melissa McNally.

Board of Directors Elections

Three members of the Board of Directors (L-R) FITLS Chapter Coordinator Jeff Gilliard, FITLS Member at Large David Mattman, FITLS Medical Director Pete Gianas, were elected during the conference’s FITLS State Coordinator Mike Rushing and FITLS State Co-Coordinator Melissa McNally Business Session. Serving his first term on the Board of Directors is Miles Darby, EMT-P, Chapter Coordinator for ITLS Pennsylvania. Returning to the Board are Tony Connelly, EMT-P, BHSc, PCGEd., of Alberta, Canada and Gianluca Ghiselli, MD, of Italy.

ITLS Annual Awards

Four individuals were honored at the conference at the ITLS annual awards. Our very own Pete Gianas, MD of Florida was presented with the Jackie Campbell Award. This special award is ITLS’ highest honor and recognizes individuals for their enduring service as “the wind beneath our wings”. Dr. Gianas is a former ITLS Board member and longtime medical director of ITLS Florida.

Director of EMS and Disaster Preparedness at the American College of Emergency Physicians (ACEP) Rick Murray was presented with the ITLS Ambassador Award for his work in promoting ITLS programs and demonstrating a clear belief in the ITLS mission. Mr. Murray has been instrumental in facilitating a solid partnership between ITLS and ACEP. Chapter Medical Director for ITLS Mid-Atlantic Lisa Hrutkay, DO, FACEP was presented with the John Campbell, MD, FACEP, ITLS Medical Director of the Year Award. Dr. Hrutkay has served as the Medical Director for ITLS West Virginia, and now ITLS Mid-Atlantic, for many years.

Elected Board Members (L-R) Gianluca Ghiselli, MD; Tony Connelly; and Miles Darby.

Corey Pittman, EMT-P of North Carolina was honored posthumously with the Pat S. Gandy, RN, ITLS Coordinator of the Year Award.

The award recognizes Mr. Pittman’s outstanding leadership and service in promoting ITLS and pre-hospital trauma training under the North Carolina Chapter until the time of his unexpected death earlier in 2016. Roy Alson, PhD, MD, FACEP authored and read a memorial resolution in honor of Mr. Pittman and Terry DeRhodes, EMT-P, longtime North Carolina Chapter Coordinator who also passed away in 2016.

ITLS Competition

Four teams competed in the annual ITLS Trauma Competition at the conference, using the ITLS assessment to triage and treat trauma patients in three creative and challenging simulated scenarios.

FITLS Medical Director Dr. Pete Gianas accepts the Jackie Campbell Award.

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The teams represented were Niagara EMS, North East Ambulance Service UK, Slovenia, and West Virginia – Berkeley County Ambulance Authority. The team from Niagara EMS was again declared the winner of the 2016 Competition. Team members were Captain Tracy Groszeibl, ACP; Brock Browett, ACP; Connor McCulloch, ACP; and Len Kowalik, ACP. The 2017 conference will be held November 3-5, 2017 in Quebec City, Quebec, Canada.

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Poison Control Kratom: the all-natural opioid “alternative”?

Patrick Leffers, Pharm.D. Clinical Toxicology/Emergency Medicine Fellow Florida/USVI Poison Information Center - Jacksonville Kratom (Mitragyna speciosa) is a tropical tree, related to the coffee plant, used medicinally in Southeast Asia for a variety of illnesses. It is known by a variety of names around the world, including krathom, kakuam, ithang, thom, biak-biak, ketum and mambog.1 In eastern cultures, the leaves are chewed to release the active components within. Additionally, a dried powder can be prepared to make a tea or be packed into gelatin capsules for easy consumption.

Medical conditions treated with kratom have varied widely from diabetes, appetite control, abdominal cramps, chronic pain and alcohol/opioid withdrawal. Recently, recreational use and abuse of this herbal product has become increasingly more popular in the United States.1 Kratom is readily available in smoke shops, and it is commonly used as an alternative source to opioids or to ease symptoms from opioid withdrawal. Clinical studies supporting the efficacy of kratom are lacking, with an increasing number of adverse outcomes related to its use.

At least 25 alkaloids have been isolated from the leaves of kratom plants, however two alkaloids are specifically thought to contribute to the pharmacologic effects. Mitragynine and 7-hydroxymytragynine (7-HMG) are structurally similar to yohimbine but are full μ-opioid agonists with some activity at δ and κ opioid receptors.1 Mitragynine may be as much as 13 times more active at opioid receptors than morphine.3 In addition to opioid-like depressant effects, kratom alkaloids may also have stimulating properties and mood enhancing capabilities, potentially due to inhibition of serotonin receptors (5-HT2A) and stimulation of postsynaptic α2-adrenergic receptors. The strain of plant used is thought to effect the balance of depressant and stimulant effects.

Side effects of kratom use include miosis, blushing, anxiety and agitation.1 While reports of severe toxicity with kratom use are rare, seizures and addiction have been reported with both acute and chronic use.2 A review of available literature by the Natural Standard Research Collaboration found that there were no available studies to grade the efficacy of mitragynine for any clinical use. Additionally, the review concluded that mitragynine is possibly unsafe when used in all patients due to lack of evidence and likely unsafe in those with neurologic disorders.4 The Federal Drug Administration (FDA) does not include Mitragynine speciosa on the Generally Recognized as Safe (GRAS) list. The FDA does however include the plant in its Poisonous Plant Database.4 Recently, the Drug Enforcement Agency (DEA) announced its intention to temporarily place kratom and its active compounds into Schedule I of the Controlled Substances Act to avoid an imminent hazard to public safety.5 This action has been the center of much controversy and received enough public outcry to force the DEA to delay the temporary ban while more information is gathered. However, at least one county in Florida (Sarasota) has banned the sale or transport of kratom. Proponents of kratom use feel that it is a natural way to avoid opioid use or ease opioid withdrawal symptoms. Emergency physicians should be aware that toxicity from these products could present similarly to other opioids, including central nervous system and respiratory depression. The opioid agonist effects of kratom are expected to be reversed by naloxone, although clinical experience is limited. Due to the wide safety margin of naloxone, reported or suspected cases of kratom toxicity should be challenged with naloxone in addition to symptomatic and supportive care. If you have any questions regarding kratom or any other toxic substance feel, free to contact your local poison center 24 hours a day at 1-800-222-1222.

References: 1. Warner ML, Kaufman NC, Grundmann O. The pharmacology and toxicology of kratom: from traditional herb to drug of abuse. Int J Legal Med (2016); 130:127–138.

2. Prozialeck WC, Jivan JK, Andurkar SV. Pharmacology of kratom: an emerging botanical agent with stimulant, analgesic and opioid-like effects. J Am Osteopath Assoc (2012); 112:792–799.

3. Rosenbaum CD, Carreiro SP, Babu KM. Here today gone tomorrow…and back again? A review of herbal marijuana alternatives (K2, spice), synthetic cathinones (bath salts), kratom, Salvia divinorum, methoxetamine, and piperazines. J Med Toxicol (2012); 8:15–32.

4. Ulbricht C, Costa D, Dao J, Isaac R, LeBlanc Y, Rhoades J, and Windsor R. An Evidence-Based Systematic Review of Kratom (Mitragyna speciosa) by the Natural Standard Research Collaboration. J Dietary Supplements (2013); 10: 152-170.

5. Drug Enforcement Agency (DEA). Schedules of Controlled Substances: Temporary Placement of Mitragynine and 7-Hydroxymitragynine Into Schedule I. 21 CFR Part 1308. Docket No. DEA-442. Federal Register (2016); 81: 59929-59930.

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PHYSICIAN AND LEADERSHIP OPPORTUNITIES NORTH FLORIDA

Destin Emergency Room (Destin) Fort Walton Beach Medical Center (Fort Walton Beach) Lake City Medical Center (Lake City) Oviedo Medical Center (Oviedo) Bay Medical Center (Panama City) Gulf Coast Regional Medical Center (Panama City)

CENTRAL FLORIDA

Blake Medical Center (Bradenton) Oak Hill Hospital (Brooksville) Clearwater ER - Dept. of Largo Medical Center (Clearwater) Englewood Community Hospital (Englewood) Munroe Regional Medical Center (Ocala) Poinciana Medical Center (Orlando) Brandon Regional Emergency Center (Plant City) Fawcett Memorial Hospital (Port Charlotte) Bayfront Punta Gorda (Punta Gorda) Central Florida Regional Hospital (Sanford) Doctors Hospital of Sarasota (Sarasota) Brandon Regional Hospital (Tampa Bay) Citrus Park ER (Tampa Bay) Medical Center of Trinity (Tampa Bay) Palm Harbor ER (Tampa Bay) Regional Medical Center at Bayonet Point (Tampa Bay) St. Petersburg General Hospital (Tampa Bay) Tampa Community Hospital (Tampa Bay) Northside Hospital (St. Petersburg)

SOUTH FLORIDA

Broward Health, 4-hospital system (Ft. Lauderdale) Northwest Medical Center (Ft. Lauderdale) Westside Regional Medical Center (Ft. Lauderdale) Raulerson Hospital (Okeechobee) St. Lucie Medical Center (Port St. Lucie) Palms West Hospital (West Palm Beach) JFK North (West Palm Beach)

PEDIATRIC

Broward Health, 4-hospital system (Ft. Lauderdale) Mease Countryside Hospital (Tampa Bay) Brandon Regional Hospital (Tampa Bay)

ACADEMIC

St. Lucie Medical Center (Ft. Lauderdale) Seeking Core Faculty and Faculty Aventura Hospital and Medical Center (Aventura) Seeking Core Faculty with interest in toxicology Brandon Regional Hospital (Tampa Bay) Residency Program coming in 2018!

Oak Hill Hospital (Tampa Bay) Residency Program coming in 2018!

JOIN THE EMCARE TEAM TODAY! LEADERSHIP

Mercy Hospital (Miami) Medical Director 49k annual visits; 37-bed ED Brandon Regional Hospital (Tampa Bay) Associate Medical Director 130k annual visits; 76-bed ED Citrus Park ER (Tampa Bay) Associate Medical Director 10k annual visits Northside Hospital (Tampa Bay) Assistant Medical Director 38k annual visits; 12-bed ED Trinity Medical Center (Tampa Bay) Medical Director 55k annual visits; 39-bed ED Contact us at: SoutheastOpportunities@EmCare.com 727-437-3533 or 727-507-2526 Ask about our provider referral program!

R e s id e n c y M a tt e r s Catch up with our emergency medicine residency programs and see what they’ve been up to.

Happy holidays from Florida Hospital East! Time just keeps flying by as we are now halfway through this residency year. We are all continuing to build our knowledge and confidence with all the great challenging cases we come across each day at our hospital.

In addition, we are very happy to announce that one of our second year residents, Dr. Shayne Gue, was chosen as president of EMRAF. We could not be more proud of this great accomplishment and trust that he will be an outstanding leader for the organization.

Florida Hospital Day Zayas, MD PGY II

We recently had our first wellness day of the year where the attendings, residents and medical students all came together for a day of friendly competition at the bowling alley. It was a great opportunity to get everyone together for some fun outside the hospital setting. We already can’t wait to start planning for our next wellness day. In the meantime, we have already begun the new interview season and are excited to meet all the prospective new residents coming from various medical schools.

We are looking forward to this interview season and finding our crew for next year. We here at Florida Hospital East hope everyone has a great holiday season!

As mentioned in the last update, the 2016-2017 academic year started off with a bang with the newest and largest group of interns. Since then, we have some new updates.

The latest UF Health freestanding emergency department, the Kanapaha ED, had its grand opening, allowing for some patient decompression (and resident relief) in the main ED. Located in southwest Gainesville, many of the second- and third-year residents are taking full advantage with moonlighting opportunities in the two community style freestanding EDs affiliated with UF Health.

In addition to the newest ED, we've also established a new fellowship in international medicine, which will offer opportunities from working within healthcare systems to developing EMS protocols and disaster medicine. The first fellow will be chosen for the 2017-2018 academic year. Stay tuned in the next edition for the announcement of next year's fellows in not just international medicine but ultrasound and EMS as well.

And with all the latest news, we also took some time recently to revisit some of the past. During this year's ACEP conference in Las Vegas, the UF EM residency had a 10-year reunion for many previous residents and faculty members, featuring Dr. DePortu's fantastic photographs.

University of Florida, Gainesville Merisa Kaplan, MD, MPH

For the third-year residents present in Vegas, it provided a great opportunity to see how previous residents are doing out in the real world and to look forward to life after residency. It was invigorating to see what lies beyond the light at the end of the tunnel.

The residency is diving into the busy winter season at full force! Our first year residents are continuing to see more and more patients every shift. Our sim lab is up and running thanks to Sim Lab Coordinator Juan Mejia and Assistant Program Director Dr. David Edwards.

We are happy to report that our ultrasound director will be starting on staff full time in January 2017, which will add yet another dimension of EM exposure to the residency. In addition to his experience, we will be gaining a couple more brand new ultrasound machines.

Interviews are ramping up and we are getting an impressive amount of applicants, once again setting a record in shear numbers. We have no doubt that with the new AOA/ACGME merger, the quality of residents that will match for the 2017-2018 year will be second to none.

Lastly, all of the South Florida emergency residencies have joined forces to form an EM residency consortium.

This allows all of local EM residents to periodically learn from the numerous leaders and speakers in emergency medicine education under the same roof.

Mount Sinai Matthew Brooks, DO PGY II

Expect a lot more updates to come, and I hope all of our North Florida friends start unpacking their sweatpants and jackets in preparation for the bone chilling weather that is sure to come!

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The last three months at UF College of Medicine Jacksonville has been full of excitement.

Faculty and PGY-3 residents attended ACEP16 in Las Vegas. There, our Faculty were incredibly active in expanding educational offerings at ACEP. Drs. Andy Godwin, our chairman, and Dave Caro, our program firector, put on a simulation lab. Assistant Program Director Dr. Jay Khadpe chaired the Social Media Committee of CORD. Drs. Emily Fontane and Joe Shiber put on a procedure lab. Assistant Program Director Dr. Melissa Parsons and Chief Resident Dr. Lexie Mannix, as well as Drs. Godwin and Caro, facilitated stages of SimWars.

Hurricane Matthew presented an unexpected challenge here at Jacksonville. While many citizens evacuated to other areas, our faculty, staff and residents banded together to serve our community. Our Disaster Medicine Faculty and Emergency Operations Staff assigned physicians and nurses to pre- and post-storm teams.

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

Both teams bunked in the hospital until well after the storm to ensure uninterrupted, high-quality medical care to the people of Northeast Florida. Having been through this, the unanimous opinion of the residents were that it was an opportunity to serve, learn and strengthened the bond among our program.

We would like to welcome a new dean to the University of Florida College of Medicine – Jacksonville. Leon L. Haley Jr., MD, MHSA comes to Jacksonville from Emory University and is a board-certified emergency physician. Dr. Haley completed his undergraduate degree at Brown University, his medical degree at University of Pittsburgh and his masters in health services administration at the University of Michigan.

He completed his residency in emergency medicine at the Henry Ford Health System, where he also served as chief resident. At Emory, he served as chief medical officer for Emory Medical Care Foundation, executive associate dean for Clinical Affairs, chief of emergency medicine for Grady Health System, vice chair of emergency medicine at Emory University, and professor of Emergency Medicine.

Emory University and UF College of Medicine Jacksonville share a close relationship, and we are excited to welcome Dr. Haley and strengthen that relationship further.

Congratulations are in order for Drs. Mannix and Carolina Pereira. Dr. Mannix recently accepted a position as a Simulation Fellow at Rush University/Cook County for 2017-2018. Dr. Pereira, a recent graduate of the Orlando Regional Medical Center EM Residency and EMS Fellowship at Long Island Jewish/Fire Department of New York City (FDNY), recently passed her oral boards.

Lastly, we would like to recognize two of our second-year residents in their efforts to bring awareness to men’s health issues. Drs. Shehzad Muhamed and Tushar Gupta have participated in the Movember Foundation by growing what can only be described as epic mustaches.

To this end, our residents suggest that next November we have a friendly competition between residency programs in Florida to see which can grow the most impressive mustache as evidenced by the most money raised for a worthy cause.

The months are zooming by over here at USF. Is it the end of the second quarter already? It feels like we all just got back from Vegas and are not nearly ready to be prepping for the holidays and the snowbird migration that is flying in! That’s right, our patient volumes may be up but so are our spirits with all the excitement around Tampa lately.

At ACEP, our research team made a strong showing, with many posters and presentations to display all the intriguing projects our residents have been working on. Rumor has it that we are not stopping there and may have already submitted it for the next national and state conventions. You will have to attend if you want to find out more.

Our state champion SIMWars team also had a solid showing. They had a ferocious battle with the defending national champion UCLA team, which ended in a nail biter. We all had a terrific time in Vegas and hope to continue the tradition next year with all of you in DC! Back home at Tampa General, we have been celebrating the successes of our third-year residents, who have now been achieving the positions they have been working so hard for over their residency years.

University of South Florida Jeffrey Hoida, MD PGY II

We would like to give a special congratulation to Dr. Beth Mannion who has achieved an EMS fellowship here at TGH for the upcoming year.

Additionally, we at USF have been overjoyed to have implemented an HIV and Hep C program in which we have the opportunity to test and help most anyone who walks through our doors. We see this program as a great avenue to make a positive change in not only our hospital, but also the entire surrounding community.

Finally, we have all been enjoying the full height of interview season. These months are such a wonderful time to meet and get to know the many exceptional faces of the future of emergency medicine. It is a wonderful reminder of the optimism and hope that we all bring to this career and to the care of our patients. We could not have been happier with our rotating students this year and are very excited about the fantastic candidates we have met who are bound to shape our program’s future.

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Greetings from UCF/HCA Emergency Medicine Residency Program of Greater Orlando! It’s hard to believe five months have gone b, and it is with pleasure that we update you on our incredible and busy journey. As a team thus far, we have managed to rotate though all the different specialties assigned and feedback has been excellent from all the departments. Our emergency department is busier than ever and with the help and support of our faculty and staff, we have managed to log countless amounts of procedures and learn more than we ever thought possible in such a short period of time! In early November, Drs. Rubero and Roka had the opportunity to work at EDC Orlando helping treat patients alongside with other EMS personnel from all over Florida.

Our interview process has begun for the upcoming class of 2020. It has been amazing to meet all the potential candidates! Our program is evolving and becoming better and better every day; we look forward to many great things in the future years.

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

We would like to take this opportunity to send our congratulations and best wishes to Dr. Benzing and his beautiful fiancé in their upcoming wedding.

The inaugural class of the Aventura Hospital and Medical Center Emergency Medicine Residency is off to a prolific start. The residents are actively engaged in their clinical rotations and becoming involved with numerous academic endeavors. In October, the Aventura team put on a stellar performance at ACEP Sim Wars. The faculty were also active at ACEP this year, serving on multiple committees, including Academic Affairs, Bylaws, Quality and Patient Safety, Emergency Medicine Practice, and the Sepsis Steering committees.

The faculty are absorbed in multiple local and national academic projects. Dr. Laurence Dubensky presented a sepsis webinar for the EQUAL Network. Dr. Annalee Baker worked on an editorial project for the ALiEM-PRO series, and Drs. Erin Marra and Todd Slesinger collaborated and wrote “Osteoradionecrosis and Osteomyelitis as a LongTerm Complication of Cobalt Radiotherapy”, which was presented at the CHEST meeting in October.

Dr. Slesinger was also appointed to the editorial board of Urgent Matters, and resident doctor Ana CastanedaGuarderas has published three original papers in peer-reviewed journals this fall, including “Shared Decision Making in the Emergency Department Among Patients with Limited Health Literacy: Beyond Slower and Louder”, in the September issue of Academic Emergency Medicine.

Aventura Hospital Annalee Baker, MD Assistant Program Director

Construction continues on the Emergency Room Expansion Project, which will bring 14 new exam rooms, two isolation rooms, five behavioral health rooms and a new ultrasound room. The new facility will allow us to provide better clinical care to our expanding patient census, and offer a new and expanded space for enhanced clinical education and bedside teaching.

The 2016-2017 interview season is well underway. Aventura received applications from nearly 1,000 impressively qualified applicants from across the country, and we are excited to meet and interview as many as possible in order to pick the next class of residents who want a dynamic, top-quality training experience in sunny South Florida.

For more information, please contact Residency Program Coordinator Angela Taylor at angela.taylor2@ hcahealthcare.com.

Life has been good in sunny Boca Raton. Our new Emergency Medicine residency program is off to a great start with recruitment and interviews.

Florida Atlantic University Lisa Clayton, DO Assistant Director

We are very excited with the number of applications we have received are very impressed with the applicants that have shown an interest in our program.

We look forward to the match and welcoming our first class of residents in July 2017.

Greetings from the Jackson Health System/University of Miami Miller School of Medicine Emergency Medicine Residency Program.

It is an exciting time here in Miami. Our first class of residents has had a great start and is taking the emergency departments at Jackson Memorial and our community affiliate, Holy Cross Hospital, by storm. The residents have already begun to have a positive impact, not only on patient care, but through involvement in quality improvement projects, scholarly activity, committee memberships and helping shape the culture of emergency medicine at both institutions.

Recruitment season has begun. It is hard to believe that we are already interviewing for our second class of residents. It is a much different experience this year being able to show the applicants our residents and residency rather than just describing our residency vision.

Jackson Memorial Hospital Chris Freeman, MD Associate Program Director

We are looking forward to another great match and growing out another complement of residents here. We are also very excited to welcome CORD to Fort Lauderdale in April as the official social chairs. We hope to see you all there.

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

The residency program at St. Lucie Medical Center is happy to say they survived their first hurricane as a residency. The storm fortunately steered away from our city in the last few hours, but the disaster preparation was great practice.

A number of residents made the cross-country trek to the Scientific Assembly in San Francisco. St. Lucie fared well in the residency competitions. The team, composed of Drs. Kristen Hanrahan, Alexa Dix, Blaire Laughlin and Rege Turner, placed third in both the quiz competition and the airway shootout. A number of residents also participated at Nova Southeastern’s CEME scientific poster competition. We are happy to welcome back one of our graduating residents, Dr. Nathan Coverman, as a full-time attending starting December.

The residency is looking forward to the New Year and next year’s match!

Airway shootout team: (L-R) Drs. Alexa Dix, Rege Turner, Kristen Hanrahan and Blaire Laughin.

It is a wonderful time to be at ORMC! Interview season is underway, and we are so excited to share the pride we have in our program with all the wonderful applicants from across the country. Our program recently took a trip to ACEP16, leading a panel discussion on the emergency response to the Pulse nightclub shooting. Congratulations to our ACEP Clinical Excellence award winners: Christopher Ponder, Thomas Smith, Amanda Stone, Amanda Tarkowski and Tory Weatherford. Each of you are shining examples of what we strive for every day. Another congratulation to our PGY-I Tyler Randall for receiving the Medical Student Professionalism and Service Award.

We could not be more proud of our new intern class. We look forward as they continue to develop into future leaders.

As we move onward in the year, many exciting things await. Our Education Committee is busy planning a toxicology day to learn about each of Florida’s venomous snakes. Research is ongoing on ETCO2, sepsis and TBI. Our residency has submitted many abstracts for the SAEM and CORD conferences, and we look forward to a strong presence at each early next year. See you in the spring!

Orlando Health Shari Seidman MD, MPH & Erich Heine, DO

THANK YOU TO OUR 2016 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 2016 corporate partners for believing in our mission and helping us to provide life-saving education to life savers!

EM p u l s e F e a t u r e Memorable Moments From ACEP16 Article by Jordan Celeste, MD; FCEP Board member and EMF Chair-Elect This year’s ACEP annual meeting took place in Las Vegas. The total attendance exceeded 13,000, with almost 7,500 four-day registrations – the largest ever. In addition to renowned speakers and innovative didactics, there was, of course, plenty of fun as well. The opening party took over Omnia Nightclub at Caesars Palace, and the closing celebration closed the week out at Drai’s Beachclub at the Cromwell. In between, participants learned about all aspects of emergency medicine, laughed about the good times and looked forward to the challenges that lay ahead for our specialty.

The week kicked off before the educational conference began with the ACEP Council meeting, which saw robust discussion on multiple issues facing emergency medicine and the election of new Board members. Resolutions covered topics ranging from diversity in emergency medicine to freestanding emergency departments to mental health to the ongoing boarding epidemic.

And of course, there were discussions touching on the perennial favorites: single payer healthcare and medical marijuana. FCEP was represented on the Council floor.

(L-R) FCEP President Dr. Jay Falk, FCEP Exectuvie Director Beth Brunner and FCEP Immediate Past-President Steven Kailes at the ACEP awards ceremony. Ms. Brunner was awarded an Honorary ACEP Membership for her years of hard work and dedication to the College. Photo courtesy of Dr. Steven Kailes

Incumbent ACEP Board of Directors candidates Drs. Jim Augustine and Dr. Debra Perina both held onto their positions, while two new board members were added: Past President of the ACEP Government Services Chapter Dr. Gillian Schmitz and past ACEP Council Speaker Dr. Kevin Klauer. Transitions also occurred at the highest level of the board with Dr. Rebecca Parker assuming the role of ACEP President from Dr. Jay Kaplan and the election of ACEP’s newest President-Elect Dr. Paul Kivela. After many years of dedicated service Immediate Past President Dr. Michael Gerardi and Chair of the ACEP Board of Directors Dr. Robert O’Connor both ended their tenure.

New roles were determined at the end of the week by the ACEP Board as well with Dr. John Rogers stepping into the role of Chair, Dr. Bill Jaquis becoming Board Vice President, and Florida’s-own Dr. Vidor Friedman being selected as SecretaryTreasurer. Dr. Friedman also cycled off of the EMF Board of Trustees after many years of dedication and most recently serving as the Immediate Past Chair. Dr. Jordan Celeste, FCEP board member, was elected to the position of EMF Chair-Elect.

Marilyn J. Heine, MD, FACEP receiving the Colin C. Rorrie, Jr, PhD Award for Excellence in Health Policy. Photo courtesy of Dr. Andrew Bern

Throughout the week, ACEP’s member groups – 27 committees and 35 sections – met to advance the business of the College and their respective memberships. Multiple task forces that have been active throughout the year also had the chance to meet and discuss ongoing initiatives addressing pertinent topics, such as out-of-network billing, Medicaid issues and alternative payment models.

As per ACEP custom, the last evening of the conference saw the President’s Awards Banquet, and this year was quite special for the Florida Chapter. FCEP Executive Director Beth Brunner was honored with an Honorary ACEP Membership, which is awarded to individuals who have rendered “outstanding service to the College or the specialty of emergency medicine”. Given Ms. Brunner’s many years of dedication and commitment to our Chapter, it was certainly well-deserved.

Outgoing ACEP President Jay Kaplan toasting the members. Photo courtesy of Dr. Andrew Bern

If you missed out on the action this year in Vegas, fear not. You can still access the course content and obtain CME via VirtualACEP. You can plan even ahead and book your trip for ACEP17, which will take place in Washington, D.C. next fall. ACEP, of course, is planning way ahead as preparations are already underway for the 50th anniversary celebration at ACEP18 in San Diego.

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

EM p u l s e F e a t u r e Resilience in the Emergency Department

Article by Kristin McCabe-Kline, MD, FACEP, FAAEM, ACHE; Chief of Staff, Florida Hospital Flagler, Palm Coast, Florida; EMS Medical Director, Flagler County/City of Palm Coast/City of Flagler Beach

Over the last few years, I have given several lectures to fellow physicians on work/life balance. The crux of my talk has been intended to persuade the audience to move away from the idea of work/life balance and toward work/life integration. Work/life balance implies opposing forces of work and “everything else”, where either work or “everything else” trumps. Integration implies a harmonious or even synergistic relationship between work and “everything else”.

For the residents and faculty who have sat through them, I’m certain they will tell you that my message was heartfelt but overly personal and emotional. After all, “everything else” is personal, and I tend to get painfully sentimental and sappy when I talk about my husband and kids. Fortunately, I have recently had the opportunity to join the ACEP Well Being Committee and learn about a rising discussion around physician wellness that resonates — resilience.

Resilience is commonly defined as the quality enabling one to recover from challenging situations with a return to baseline or even in an improved state. Certainly emergency physicians can see that this quality is a valuable and even necessary one in achieving a long-term career in our area of specialty which requires us to function under extreme pressures that would be intolerable to many physicians. The question for most of us is how to achieve a state of resilience rather than allowing ourselves to become depleted and burned out.

We spend days listening to all of the problems our patients have with access, finances and the limitations of our healthcare system in its current state. We spend much of our time staring at a computer rather than a patient, leave the hospital walking past a waiting room of patients feeling like what we give is never enough to meet the needs of the community, and head home to face families who expected us home over an hour ago looking disappointed, dejected and marginalized. How can we achieve resilience in the face of these realities? The answer lies in the psychology of resilience with several core themes.

Adaptability

Emergency physicians are known for our adaptability. We see patients in hallways and rapid assessment areas when our beds are full we continue to function at a high level in the midst of national disasters and terrorist attacks. We make do with what we have when we lack supplies or use tools in new ways when trying to perform procedures on patients with difficult anatomy. We go without sleep, food, water and/or toileting for long periods of time when necessary, and the list goes on.

Overall, most of us have achieved adaptability. Our attitude while adapting is key; true acceptance of constant change being the crux of achieving the adaptability that results in resilience rather than adapting while incurring depletion.

Engagement

We are shift workers who essentially clock in and out, but we don’t make widgets. Emergency physicians have schedules that are the least amenable to engagement, yet our engagement is crucial to improving our work environment. Participating in an emergency department work group, such as a Unit Practice Council, joining a medical staff committee or offering a lecture at a department or local EMS meeting, are ways to engage.

EMPros providers (L-R) Dr. Kristin McCabe-Kline, Barbara Thomason and Suzana Bogdanovska.

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The gift of engagement is how we are able to not only influence our work environment but also build relationships that become the foundation of a team approach to the patient which is gratifying both for the emergency medicine physician, patient and members of the team.

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Connectedness

We do emotional work. We have baggage. We listen to the wailing of parents who have lost children, the agonizing moans of the long suffering with horrific and painful disease state, the curses of the addicted, and the horrified silence of those who have tragically lost a loved one traumatically and unexpectedly. At some point we expect ourselves to become more adept at dealing with this emotional burden, but until late, we have tried to do this in isolation or maybe within the confines of a friendship with a physician with whom we felt comfortable being vulnerable; usually a friend from medical school, residency or early on in our careers. Can you envision a culture where you have that kind of connection with your current colleagues?

Through efforts such as those of Dr. K. Kay Moody, social media is changing the degree to which we are able to connect. Via the EM Docs Facebook page, emergency physicians can connect with others to share the good, the bad and the ugly of their experiences, often discovering that they have a vast legion of supporters whom they have never met but who have navigated the same uncertain landscape illuminated by fluorescent lights in another ZIP code.

Optimism

Optimism is perhaps the most elusive of factors necessary to achieve resilience. Meeting our basal physical needs of nutrition, activity and sleep must be addressed regularly given the nature of our challenging schedules or we can rapidly be converted from optimists to cynics. It is difficult to be optimistic when one is hungry, unfit and exhausted. Meeting our spiritual needs is also essential to gaining perspective and mindfulness, although this particular area of nurturing varies amongst emergency physicians.

Engagement will keep us from feeling helpless and victim to policies adopted by others, serving to improve a positive outlook.

Connectedness will allow us to develop relationships that support us in challenging times and allow us to encourage each other to be optimistic. Ultimately, however, operating from a place of optimism is a choice we as emergency physicians must make repeatedly and deliberately.

Over the last decade I have seen some of the most talented physicians I have known go part time, relinquish leadership opportunities and leave permanent positions for locums roles in the name of work/life balance. I realize that for some physicians at various times in their careers the time constraints of full-time work and leadership involvement are not possible. However if the decision to work less or be less involved results from burnout, I fear the coping strategy will have a substantial negative impact on our specialty and perpetuate the very forces that we find most frustrating and draining.

Let’s build resilience as emergency physicians together. Let’s peacefully accept that constant change is our reality and look forward with the anticipation that change can be invigorating and positive. Let’s engage in our emergency departments, with our medical staffs and invest in those with whom we work. Let’s truly connect with each other, be vulnerable to each other and encourage each other. Let’s develop a culture of optimism in our specialty and step into the next era of healthcare with certainty of our value, contribution and ability to thrive as emergency physicians.

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EM p u l s e F e a t u r e An Emergency Physician's Career: Financial Decisions Article by Andrew Bern, MD, FACEP; Todd Lesk; and Marc Lowell, CLU, ChFC Throughout their careers, every emergency physician focuses on the knowledge and skills necessary to provide care to their patients. An important question should be asked: How much time do you spend making the right financial decisions for yourself and your family?

In a study by Mass Mutual entitled “Taking Chances” (2014), their survey found that “Americans generally put more effort into planning their next vacation than their financial futures …” In this first article, we have examined a number of financial decisions that are made throughout an emergency physician’s career. It is in that context that we believe each emergency physician should exam predictable issues that occur during anticipated periods of time (see graph above).

Let’s look at these five blocks of time and the decisions associated with them.

A Physician’s Career - Financial Decisions Time Blocks:

1 = 0-30 Years of age 2 = 31-40 years of age 3 = 41-50 years of age 4 = 51-60 years of age 5 = 61 Years of age going forward

Funding for College

Financial Decision Time Block 1: • 529 College Savings Plans • State Sponsored Plans • Insurance Based Plans (self-completing) • Federal and Private Loans • Academic Performance must be Superior • Acceptance into Medical Schools • Grants and Scholarships Financial Decision Time Block 1-5: • Advisor Selections: CPA’s, Attorney’s, Financial Advisors, Insurance Specialists • Extremely Important - Major Impact Going Forward

Quantify Risk Management

Financial Decision Time Block 2-5: • Asset Protection Strategies • Legal Docs, Trusts, Investment Products Financial Decision Time Blocks 1-3: • Disability Insurance Policy • Life Insurance Policy - Term/Whole Life/IUL Financial Decision Time Blocks 2-3: • Malpractice Insurance

Savings and Retirement Planning

Financial Decision Time Blocks 2-4: • Qualified Savings Programs • Asset Protection Programs • Legal Docs, Insurance and Annuity Products • Estate Planning • Wills, Trust Docs, Personalized Strategies/Concepts Financial Decision Time Blocks 1-5: • Appropriate Investment Vehicle Planning *Based on Timeframe - Aggressive Gradually Converting to Conservative* Financial Decision Time Block 5: • Social Security - Most likely will be Modified

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Continued from page 26

Family Planning

Financial Decision Time Blocks 2-3: • Major Event Planning • Home Purchase, Weddings, Bar/Bat Mitzvahs • Divorce Proof Assets • Prenuptial Agreements Financial Decision Time Blocks 2-4: • Create/Review Wills, Trusts Financial Decision Time Blocks 2-5: • Review/Alter Investment Plans, Disability Insurance, Life Insurance

Medical Practice Management

Financial Decision Time Blocks 3-4: • Meet with CPA’s, Attorney’s, Financial Advisors, Insurance Specialists • Have Buy/Sell Agreements Created • Purchase Key Man Insurances Policies Financial Decision Time Blocks 4: • Exit Strategy Planning

Retirement Right Around the Corner

Financial Decision Time Blocks 4-5: • Tax Planning - Strategies to Reduce and/or Eliminate Taxes • Income, Capital Gains, Gift and Estate • Long Term Care Planning • Prepare to Take Care of Parents if Needed • Validate Kids on Right Track to be Successful Financial Decision Time Block 5: • Funding Grandkids College Accounts/Possible Gifting Strategies • Secure Legacy - Utilize Unique and Guaranteed Concepts • Exit Strategy Execution

Funding for College

There are a number of specifically established programs that have been created to facilitate the future funding of college expenses using the most cost and tax efficient manners. Some of these programs include, but are not limited to, 529 Plans, Coverdell Education Savings Accounts, PrePaid State College Plans, UGMA-funded accounts and insurance-based savings programs. Each of these plans has a place; however, the right one for any individual can best be determined through a fact-finding engagement with a professional adviser.

Quantify Risk Management

When instituting goal-based financial plans and preparing for the future, it is essential to avoid deviation due to the unexpected and some expected events. Whether you are hedging against life events or employment-related situations, various instruments and strategies are available to help mitigate unforeseen results that can become roadblocks to reaching your destination. By using various asset protection strategies,such as trusts and proper investment vehicles, you can dramatically reduce your chances of failing to achieve your desired goals. Having the correct legal documents in place is another strategic part of the plan. An individual’s most important asset is the ability to earn an income. Disability income insurance should factor into everyone’s game plan. As you know, unintended consequences do arise from time to time in the work place. One way to avoid losing all you’ve worked for is to have malpractice insurance. This coverage can insure you from the damage that comes from patients who sue doctors claiming they were harmed by the physician’s negligent treatment decisions or surgical procedures. Another risk management tool that you want in place is life insurance. How will your family make ends meet if you are not around? Many people do not like to think about life insurance, but if you have people who depend on you financially, it’s an important topic to consider. If something were to happen to you or your spouse, life insurance would pay for funeral costs, bills, taxes and outstanding debt that which your family would otherwise be liable for. It could also be enough to continue a family business, protect retirement plans and pay for education. Why saddle loved ones with emotional and financial burdens when you don’t have to? We all have obligations that we worry about, and owning a life insurance policy takes some of that burden off our shoulders. As you can see, embracing the proper risk management approach can preserve assets that took you years to accumulate.

Savings and Retirement Planning

Unfortunately, most individuals do not understand the importance of planning for retirement. Regardless of your age, saving for your retirement years is not something to take lightly. The amount of money that you save for retirement will have a profound impact on how your life is lived. As you get older and approach retirement, it is unlikely you will be able to generate enough income to sustain the lifestyle you imagined you would have. There are many types of savings vehicles available to help you. Working with the correct financial advisor will have a dramatic impact on the success or failure of your retirement. Do you have the proper qualified savings programs in place? Have you incorporated lifetime income vehicles into your plan? Social security benefits are nice, but they will not cover most of your retirement living expenses. Most individuals only

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receive about 35 percent of their income from social security benefits. For higher income individuals, that percentage is much less. Since you do not want to rely on social security benefits to survive, you will need to start saving for retirement at an early age. Are you protected against longterm care costs eating away at your assets? Having the appropriate investment plans in place at the correct time is crucial to making retirement work. Do not make excuses for not saving for retirement. Work with a certified financial advisor and take charge of your retirement now, or you will be sorry later.

Family Planning

For decades, the classic financial planning playbook has been based on a set of common assumptions: A family unit is created between individuals who love and are committed to each other. Children may become a central focus of that family unit. These days, however, millions of families find themselves following different patterns that call for new strategies. Over the past few decades, the shift has been profound and with these changes have come new financial challenges. Many couples live paycheck-to-paycheck and do not take a long-term view of their finances. This is the beginning of future money problems that will strain the marriage and could be catastrophic should one spouse die or become incapacitated. disability insurance and life insurance are essential cornerstones to successful family planning. The type and amount of insurance you need are good starting points of an in-depth financial plan. If the family depends on two incomes to cover daily expenses, include insurance to cover medical costs and replacement of at least a portion of the lost income if you or your spouse can no longer work. Another essential aspect of financial planning that should not be overlooked is the creation and annual review of your wills and/or trusts. You should review your estate plan, including wills and trusts, on a periodic basis to insure that your legacy planning is consistent with your current needs, goals and wishes. Your documents and plans need to be reviewed with new events: marriage, separation or divorce, birth of additional children, significant changes in your health, and significant changes in your financial condition. These can be invaluable resources for your executor and loved ones when the time comes. When it comes to planning for and protecting your family’s financial future, consulting with a qualified licensed financial professional is an important first step. You will want someone who is knowledgeable about various insurances and financial products as well as the proper legal documents that can help you and your family meet your needs and goals. It is never too early to start planning a successful future for yourself, your family and your business. A comprehensive financial plan can benefit your family for generations. The plan will continue through the parent’s working lives, their retirement years and even after death to provide a stable framework for their children.

Medical Practice Management

As stated in previous discussions, there are many moving and evolving parts in a plan for the future. There are different models of emergency practice: an employee of a group or a hospital, an independent contractor, or part of a democratic group practice. As emergency physicians have moved into ownership positions in freestanding emergency departments or urgent care centers, one should consider buy-sell agreements, keyman insurance policies and exit strategies. All of these circumstances should be governed after consultation with your financial team, including your CPA, attorneys, financial advisers and insurance planners. If you own all or part of a business, you should be familiar with buysell agreements and make sure you have one in place. A buy-sell, or buyout agreement, will include a buyout provision and protect business owners when a co-owner wants to leave the company by choice or by death. If a co-owner wants out of the business, wants to retire, wants to sell his shares to someone else, goes through a divorce or passes away, the buy-sell agreements contractually cover how owners can sell their interest, who can buy an owner’s interest, how to find the funds needed for a buyout and what price will be paid. Think of a buy-sell as a sort of “premarital agreement” to protect everyone’s interests, setting the price and terms for a buyout. Every day that value is added to a business without a plan for future transition, it increases the owners’ financial risk. The cost of a buy-sell agreement is small compared to its benefits. In addition to buy-sell agreements, another important form of protection businesses should have in place is key man insurance. Many businesses have key people who are invaluable to the organization and who are difficult at best to replace. The death of a key individual would likely cause the company to suffer major losses and revenue and profits to drop dramatically. Key man insurance, life insurance on a key employee(s) and those who are irreplaceable, will help the company survive that person’s unexpected death. The key man insurance policy, which is paid for and owned by the company, generates proceeds which can be used by the company for expenses, the cost of finding a replacement and to pay off debts and/or severance to employees if the business was no longer able to sustain itself. Key man life insurance protects the security of the business. Thinking ahead to the day you will no longer run your business requires formulation of exit plans which will impact your retirement and the future of the business. Whether you will be liquidating the company, selling out to a specific buyer, be acquired or take the company public, are decisions that will have tremendous implications down the road. You must make sure you have an exit strategy in place to get the money back out of the business you worked so hard to create. The way you grow your business should be aligned with your exit strategy and when executed will ensure a successful transition or wind down of the company. Implementing buy-sell agreements, key man insurance policies and exit strategies should be well thought out and discussed thoroughly with your financial team.

Retirement Around the Corner

During the last two blocks of time, retirement is right around the corner. Have you planned properly for financial independence? Now that you have entered the time of life when you have a little more control of how you spend — or save — your money, take the time to review your plans and maybe spend some of your hard-earned cash to make sure you have the proper insurance, up-to-date estate documents and a low-cost, wellthought-out investment strategy, all coordinated by you and a trusted financial advisor. It is common during a career to move between hospitals, cities and groups. The instruments established in each of those work situations may not be portable. Close attention would need to be paid to your policies and your 401K. Financial independence can come earlier than you may think possible if you make the right decisions to protect your financial world. And if retirement sneaks up on you earlier than you’d planned, you won’t be caught unprepared. For many of us in the Baby Boomer Generation, we find ourselves caught between providing support for our surviving parents and our children.

Mitigating risk, planning your legacy (the Wiegenstein Society or the Emergency Medicine Foundation [EMF] donations) and making sure your overall financial plan is in good health will lead to a satisfying retirement. It is imperative that you discuss any tax planning strategies with your

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Continued from page 29 CPA and financial advisers. Having the proper plan in place will allow you reduce and/or eliminate taxes and maximize your retirement nest egg. We are all living longer and the average life expectancy has now exceeded 80 years old. A longer life span means a longer and costlier retirement. This also may mean health deterioration which will inevitably lead to additional unexpected expenses. Making sure you have protection (long-term care insurance) in place can create certainty and protection for you and your family as healthcare costs are the number one burden that families face in the latter part of life. Are your kids prepared to take care of you if needed? Will they be there for you if needed?

LTC insurance can help assure that the burden is not placed on your loved ones while simultaneously protecting your assets from erosion due to the certainty of increasing health care costs which would otherwise force you to adjust your retirement life style. Would not it be nice to help your grandkids ensure they have a successful future? Have you thought about possibly funding their college accounts? Did you talk to your financial advisor about various gifting strategies designed to reduce your overall tax bill? Utilizing some well-thought-out strategies will allow you to accomplish these feats, live the retirement you’ve always dreamed of and secure your legacy.

Are your investments generating you enough income to meet your retirement goals? Are you worried you may outlive your income? Are there ways to insure you won’t? Answers to these questions can and will be answered by the right financial adviser.

Stay tuned to the next article where we will dive down on specific strategies and financial solutions that may be available for consideration.

Snapshots

of

O ur 2016 Social Events

The past year has been one for the books with lots of successful conferences, workshops, webinars and skills labs. Symposium by the Sea 2016 had a record-breaking attendance, while CLINCON 2016 had some of our most talked-about educational session to date.

While we could continue to describe how great our 2016 events were this year — and how much we’d like to thank our attendees, sponsors, exhibitors, faculty and staff for making it that way — here is an assortment of photos highlighting some of the fun social events at our various conferences held throughout 2016!

Emergency Medicine Days 2016 The Legislative Reception and EMRAF Reception were a hit at EM Days 2016! A special thank you to EMPros for sponsoring the EMRAF Reception.

CLINCON 2016 The CLINCON 2016 Kick-Off Party (sponsored by AirMethods), EMS Awards and Party at the Pool (both sponsored by Star & Shield Insurance) were enjoyed by all!

APP Skills Camp 2016 Thank you EMPros for sponsoring the APP Skills Camp 2016’s Networking Reception!

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Symposium by the Sea 2016 Thank you to Emergency Physicians of Central Florida and Martin Gottlieb & Associates for sponsoring the Incoming President’s Reception!

A big thank you to Florida Emergency Physicians’ for sponsoring the EMRAF Networking Reception!

We'd like to thank Duva-Sawko and EMPros for sponsoring SBS's Casino Night. It was one of the most talked about events of the year!

EM Written Board Review Course 2016 All our WBRC 2016 attendees enjoyed the Networking Reception. Thank you to all our sponsors!

Life After Residency 2016 Life After Residency 2016’s Welcome Reception and Networking Reception were a hit! Thank you EmCare, Inc. for sponsoring the Networking Reception.

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EM C a s e R e p o rt s Case Study: A Green Discharge in Prepubertal Female Article by Hillel Z. Harris, MD A mother brought in her 7-year-oldfemale with a chief complaint of vaginal discharge. She noticed the discharge seeping through the child’s underwear the night before, as she was putting the child to bed.

She bathed the child in the morning, but the green discharge returned. She denied fever and said her daughter did not appear to have any discomfort while urinating. There was no reported abdominal pain or vomiting. No one at home had been ill and there were no immediate sick contacts from her school.

The patient had no significant past medical or past surgical history. She was not on any medications, and her last pediatric well-child visit was about a year ago.

Physical exam revealed a vigorous and healthy appearing child.

Hillel Z. Harris, MD Emergency Physician at JFK Medical Center in Atlantis, Fla.

Vital signs: BP 90/60, HR 100, T 98.0, RR 18, spO2 99%

Her sclera where anicteric, she had normal conjunctiva, and she had no pharyngeal erythema or exudate. She had no adenopathy. Capillary refill was less than two seconds. Her abdomen was soft with no tenderness, and she had no organomegaly.

Upon external inspection of the perineum, she had a copious green vulvovaginal discharge. There was no evidence of ecchymosis, abrasions or hematomas. She was engaging and interacted appropriately for a child of her age.

I explained to the mother that a purulent vaginal discharge was concerning for a sexual-transmitted infection. I asked her if that

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was her prevailing concern today as well. She, too, was concerned about the possibility of sexual abuse. I turned to the patient and asked her if anyone had touched her inappropriately, and she said no. I told the mother that child protective services will need to be involved, and they were called from the ED. A urine GC/chlamydia nucleic acid amplification test was sent, and a UA resulted positive for 3+ leukocytes and 25-50 WBCs. I started her on oral trimethoprim/sulfamethoxazole for the possible UTI. I deferred treatment for GC/Chlamydia pending results in 24 hours.

Eventually, both the police and department of children's services determined that the child was safe to return home.

Although our ED has a system to follow up on pending test results, I asked the lab to notify me directly since I was working the following day as well. The gonorrhea culture was positive.

I called the mother and asked her to bring in her child again for treatment. She was given Rocephin IM, and a single dose of oral azithromycin.

Once again child services were called and were included in the management of the patient and her family. The child was referred to her pediatrician for follow up and long-term management. Child protective services arranged for follow-up laboratory testing, including HIV. The younger sibling was also screened for possible sexual abuse and tested negative for GC/chlamydia.

A purulent vaginal discharge, particularly in children, prompted an investigation into sexual abuse. Although the GC was positive and chlamydia was negative, it is still recommended to treat for both. First-line treatment in children is similar to adults. Vertical transmission can occur, such as mother to daughter, but only in the neonatal period. Non-sexual routes of transmission are highly unlikely.

Virtually all cases in prepubertal population are due to sexual abuse via direct genital contact. Repeat testing for GC/chlamydia is recommended to assess for treatment failure or for repeated abuse. Testing with nucleic acid amplification has been shown to have similar sensitivity to cervical swab and culture.

Subsequently all members of the household underwent GC/chlamydia testing, as is recommended when a child tests positive.

To work to perfect our physicians’ ability to practice medicine, every day, in everything we do.

Hospice Reduces Emergency Room Visits

By Natalia Hernandez, Senior Director of Market Development, VITAS Healthcare What do you think of when you hear the word “hospice?” What if I told you most people are misinformed about the definition and benefits of hospice?

Contrary to common belief, hospice is not a "place" or facility where people go before they die, it’s actually a philosophy of care that focuses on enhancing patients’ comfort and overall quality of life during their last moments of life by treating physical symptoms and providing pain management, as well as addressing their emotional and spiritual needs, all while reducing trips to the ER. Hospice can unclog the EMS system by preventing hospital readmissions by delivering medical care and other services to terminally ill patients in their homes, whether that’s the patient’s residence, a nursing home or an assisted living community—the care is administered wherever the patient lives. This gives patients and families an alternative to calling 911 and helps prevent hospitalization by opting continuous care, a service that puts trained clinicians at our patient’s bedside up to 24 hours a day during a brief period of crisis.

People are generally referred to hospice by their physician after it has been determined that they have a terminal condition and a diagnosis of six months or less to live. If they meet this requirement, then they can elect hospice at any time and the entire care team will be prepared to manage symptoms with quality care as soon as services begin.

VITAS Healthcare, the nation’s leading provider of end-of-life care, can arrange an appointment to determine if you or a loved one are eligible for hospice services. Once deemed hospice-appropriate, a dedicated staff— also known as an interdisciplinary team—of skilled doctors, nurses, hospice aides, social workers, chaplains and bereavement specialists, and trained volunteers, will be available to ensure hospice patients are comfortable, free of pain and maintaining the highest quality of life possible.

Many patients who frequently call 911 are hospice-appropriate, such as patients with end stage chronic heart failure, end stage liver disease and end stage Dementia, as well as cancer and many other life limiting conditions. Hospice is covered by Medicare, Medicaid and most private insurance plans. Additionally, most hospice providers supply the medications and medical equipment patients need as part of their individualized plan of care.

A pioneer and leader in the hospice movement since 1978, VITAS offers quality, customized care and a broad array of services and programs to help patients and their loved ones at one of the most important moments of life: the end of life. For more information about VITAS Healthcare—a Medicare-approved hospice provider— visit www.VITAS.com or call (866) 41-VITAS.

ACEP B o a rd U p d a t e ACEP16 was the biggest ever, with almost 7,500 attendees. I also think it was one of the best annual meetings that I have ever attended. Kudos to the Education Committee, and our outstanding Staff, for putting together a great event for us all.

At our Board of Directors meeting, we addressed ACEP clinical policy statements on: care of the bariatric patient in the ED, ED nurse staffing, screening questions in triage, automatic crash notification and intelligent transportation systems, nicotine products, corporal punishment of children, role of the state EMS medical director, and ACEP press releases and official statements.

We approved, or updated, clinical policies regarding: acute carbon monoxide poisoning and care of the early pregnant patient in the ED. We received progress reports on several resolutions from 2015 regarding: 34(15) Enabling access epinephrine for Anaphylaxis, 18(15) “ER is for Vidor Friedman, MD, FACEP emergencies", 24(15) interstate medical licensure compact legislation. We also reviewed task FCEP Board Member, Secretaryforce recommendations regarding: trauma center certification, EMS stroke care designation, Treasurer of American College of Emergency Physicians the influence of defensive medicine, managing advanced practice providers and ensuring competency, risk aspects of choosing wisely, EHRs and social media, alternative payment models for emergency medicine, a new online journal for EM, collaboration on next generation of pediatric life support education, and the 50th Anniversary Task Force report.

We also discussed the progress of our lawsuit regarding “The Greatest of 3” rule promulgated by CMS last year; discovery has been very promising. Our lawyers continue to believe that our case has excellent merit, and, as I write this, ACEP is filing a motion for Summary Judgement on our behalf. It was a pretty busy couple of days, to say the least! The Council meeting that followed was also one of the most productive and collegial ones ever. This time the kudos go to the the Council Leadership, who did an excellent job. The Council debated 29 resolutions, with the final tally being 22 adopted, five referred to the Board and two were declined. Dr. Paul Kivela was elected President-Elect of the College, and Drs. Augustine, Klauer, Perina and Schmitz were elected to the Board.

Wrapping up the business of the week at the meeting of the Board of Directors after ACEP16 , where we elect the Board officers: Drs. John Rodgers was elected Chair, Bill Jaquis was elected Vice President, and yours truly was elected Secretary-Treasurer.

Now that we have collectively caught our breath again, we are diligently planning for our Board Retreat in December, where our topics will include: • • • • •

Role of the Board member duties, responsibilities and expectations CEDR Status Report & Overview of Potential Revenue Models Demonstrating Value to ED Groups Diversity and Inclusion ACEP’s Role in Accreditation of EDs

Since I wear a lot of hats, I wanted to take this opportunity to update you on a couple of other things that I am involved with on your behalf.

This year finishes up my six year stint on the Board of the Emergency Medicine Foundation, an organization that funds research with an emphasis on growing researchers in emergency medicine. This year EMF was able to fund over $1.8 million of research in EM, and this portfolio covers the breadth of emergency medicine from bench research to health policy research and everything in between. It is an incredible resource for emergency medicine, and, ultimately, improves both patient care and our lives as emergency physicians. I strongly encourage you to consider donating some of your charity dollars to this very worthwhile cause (https://www.emfoundation.org/) I also sit on the Board of Governors of the Emergency Medicine Action Fund (https://www.acep.org/EMActionFund/). This is an organization that we started at ACEP that focuses on regulatory lobbying and dealing with all of the agencies that implement the laws that the legislature passes, like the Center for Medicare and Medicaid Services (CMMS). We have been very involved with supporting ACEP’s [emergency medicine’s] response to the myriad rules being promulgated as the PPACA has rolled out.

We recently had a meeting in Washington, D.C. with our consultants to discuss the implications of the recent presidential and congressional elections. While things are certainly up in the air right now, we do know that things are going to change in the regulatory environment. We are doing our best to anticipate those changes and to developed strategies to place emergency medicine in the best possible light.

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Musings Of a Recently Retired Emergency Physician Handicapping Healthcare Article by Wayne Barry, MD, FACEP

I am exhausted by the recently decided U.S. presidential race. I, like many others, was shocked by the result. I do suspect, that among us like-minded emergency physicians, that there was a divide among our preferences for president, which reflected the nation’s electorate profile. I intend to use the Trump victory as another opportunity for personal growth in my never-ending quest to become a better person.

So what does a Trump Presidency mean for healthcare in the U.S.? He has stated that one of his first official acts in office would be to repeal Obamacare. It is hard for me to fathom how this could occur quickly since it has been the law of the land for more than six years now. This act would require Congressional approval, and we all know how that will never work.

Wayne Barry, MD, FACEP

We may see some paradigm shifts in the Senate filibuster rules. It may be begin to look like Trump favors some of the more popular aspects of ACA, namely coverage for pre-existing illness, and coverage for children until age 26.

I was formerly hoping that flaws in the ACA would be attended to more expeditiously, but that was wishful thinking in the face of a gridlocked Congress. Maybe Trump’s actions short of total repeal of ACA will result in more timely, if not, momentous improvement.

I wonder if he is going to take on the insurance companies which seem be having their way with undermining the concepts of medical coverage for all Americans. Maybe we will see the details of the long-awaited Ryan alternative to the ACA and will be incorporated into improving the ACA. I am trying to remain optimistic!

I am not so optimistic about women’s issues. Overturning Roe v. Wade looms if Trump appoints an arch-conservative justice to fill the late-Antonin Scalia’s seat, but then there is the not-well Ruth Bade Ginsburg who could easily leave the Supreme Court in the near future. Actually, there may be a lot more than repealing Roe v. Wade to worry about if the U.S. Supreme Court becomes overwhelmingly conservative. On the other hand, one must have faith in the process to select and confirm Supreme Court Justices and with the subsequent wisdom of that august body.

We have just to look at some of the decision-making by conservative members John Roberts and Anthony Kennedy to harbor some cautious optimism. Trump seems to join with the boisterous opponents of Planned Parenthood. There goes free stuff, like contraception; mammography; folic acid supplements during pregnancy; and screening for gestational diabetes, STDs, and cervical cancer.

Other important provisions of ACA, including benefits for prescription drugs, behavioral health and others, may suffer adverse fates if Trump keeps his pledge to return action on these issues to the individual states. God help us in Florida, Alabama, and Mississippi, just to name a few states who might undoubtedly will turn back the medical and social gains in these provisions.

On the other hand, will some public health issues currently decided on a state-by-state level, such as legalizing medical and recreational marijuana, gun control measures, and taxes on cigarettes and sugary drinks, be swept under the collective Federal rug by a Trump Administration? We’ll have to wait and see on those issues. Remember Donald Trump does not drink or smoke.

He might drink sugary drinks in New York if former Mayor Rudy Giuliani tells him to.

I would fully support Trump’s pledge to take on Big Pharma in enabling Medicare to negotiate drug prices and to reduce exorbitantly high prescription drug prices (i.e. EpiPens). I am not sure how this will sit with his old-line Republican constituency. I have to admit that I am very foggy on where the fortunes of emergency medicine land in this new political landscape.

I doubt Medicaid expansion as we now know it in the ACA will survive Trump/Republican action. Then instead of enjoying a 12 cents reimbursement on every dollar of Medicaid charges, we will be back to scrounging for the old “getting blood out of a turnip” approach to charity care. Hey, at least we are damn good at providing it! Lack of adequate reimbursement for emergency care retards progress in our Access to Care Advocacy. National Tort Reform may enjoy a more favorable prospect with elected Democrat power on the wane, except in Florida where John Morgan is planning to run for Governor.

So I’ve stopped feeling sorry for myself, put on my big boy pants and wondered what I can do to help omnipotent Republicans guide our country into paths of righteousness for the betterment of all Americans. I hope you will do the same!

38 | EMpulse

WINTER 2016 - 2017 | VOLUME 23, ISSUE 4

Florida College of FCEP | Emergency Physicians

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