EMpulse (Winter 2017-2018)

Volume 24, Issue 4 WINTER 2017-2018

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

Medical Group Responds to Hurricane Maria Victims in Puerto Rico

A Look Ahead to Emergency Medicine Days 2018

Free-Standing EDs: A Burden or Benefit?

PHOTOS FROM LIFE AFTER RESIDENCY 2017 INSIDE THIS ISSUE!

Chapter Updates President’s Message | 4 Government Affairs Committee| 5 EMS/Trauma Committee | 6 Medical Economics Committee | 8 ACEP Board Update | 9 Leadership Academy Update | 10

Florida College of Emergency Physicians 3717 S. Conway Road Orlando, Florida 32812 t: 407-281-7396 • 800-766-6335 f: 407-281-4407 www.emlrc.org/fcep

Medical Student Committee | 10 Membership & Professional Development Committee | 11 EMRAF Committee | 13

FCEP Executive Committee Joel Stern, MD, FACEP • President

Residency Matters | 18

Joseph Adrian Tyndall, MD, MPH, FACEP • President-Elect

Features

Kristin McCabe-Kline, MD, FACEP • Vice President Sanjay Pattani, MD, FACEP • Secretary-Treasurer Jay L. Falk, MD, MCCM, FACEP • Immediate Past-President Beth Brunner, MBA, CAE • Executive Director

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

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

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

Published by: Johnson Press of America, Inc. 800 N. Court St. Pontiac, IL 61764 Phone: 815-844-5161 Fax: 815-842-1349 www.jpapontiac.com Photo cover courtesy of William Kotler, MD, a resident (PGY-3) at Florida Hospital Emergency Medicine Residency

Daunting Diagnosis | 13

Strategies for better AR Management – Maximizing Collections (Sponsored by Martin Gottlieb & Associates) | 14

Winter Is Coming!: Dealing with Hypothermia in Florida | 15 Poison Control | 16 Hospice Reduces Emergency Room Visits (Sponsored by VITAS Healthcare) | 23 First Impressions: A Story of First Responders in Puerto Rico Following Hurricane Maria | 24 A Look Ahead: Emergency Medicine Days 2018 | 26 ACEP on the Front Line of Emergency Physician Payment | 27 The Freestanding Emergency Department: Economic Burden or Benefit?| 28 Recommendations for a Vulnerable Population (Sponsored by Envision Physician Services) | 29 Snapshots from Life After Residency 2017 | 30 Musings of a Recently Retired Emergency Physican | 32 2017 Sponsor & Donor Thank You! | 34 Back Cover: FCEP Recognizes 100 Percent Membership & EMLRC ACCME Accreditation Announcement

WINTER 2017-2018 | VOLUME 24, ISSUE 4

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President’s Message Greetings and Happy Holidays!

The last few months have been busy ones. In October, ACEP held its annual scientific assembly, now known as ACEP17, in Washington D.C. In conjunction with the annual meeting, the ACEP Council convened two days prior. The ACEP Council is a gathering of representatives from all of the ACEP State Chapters and Sections. We meet annually to discuss and debate resolutions proposed by ACEP members. This gives direction to the ACEP Board of Directors as to their focus on issues for the coming year. We had a pretty large group of FCEP members attending this year. This is mainly because as our Chapter continues to increase membership and grow in size, we have more council seats for our state. The number of State Chapter representatives is based on total Chapter membership. Many thanks to our membership Joel Stern, MD, FACEP, FAAEM committee and staff for their ongoing outreach to Florida EM physicians. We are also allowed FCEP President an unlimited number of alternate councillors. This is a great opportunity for anyone who is interested in attending the council session to participate. This year we had all three of our Leadership Academy physicians in attendance as alternates, and we gratefully appreciate their efforts.

This year FCEP sponsored or co-sponsored several resolutions with other Chapters. Sadly, two prominent FCEP members passed away prior to the meeting. Drs. Sal Silvestri from Orlando and Robert Wears from Jacksonville were both honored at the Council meeting with memorial resolutions from FCEP. Both physicians made great contributions to emergency medicine in our state and were affiliated with residency programs in their respective cities. Another pair of resolutions introduced by our Chapter addressed a council rules and bylaws change, which allowed former Board of Directors Chairs to sit with their council delegations. These were approved without any significant opposition. Another resolution co-sponsored

by Florida and several other Chapters honored those EM providers involved with the response to the hurricanes that ravaged the U.S. and Caribbean this past year.

Another function of the ACEP Council is to elect the officers for the coming year. These elections include the ACEP Board of Directors, Council Speaker and Vice Speaker, and ACEP President. FCEP member Dr. Vidor Friedman, who is a former FCEP president and current ACEP Board member, threw his hat in the ring to run for president-elect. There were several rounds of voting, and he made it to the final round. Ultimately, Dr. John Rogers from Georgia won the election and is now the ACEP president-elect. Dr. Rogers has been a good friend to our Chapter and has attended Symposium by the Sea for many years. We wish him well in his new endeavors as president-elect. FCEP plans on supporting Dr. Friedman next year should he choose to run again. Dr. Kathleen Clem is another current FCEP member who was running for an open Board of Directors position this year. Despite making it through the first few rounds of voting, she was not elected to the Board. We will continue to support her leadership efforts at the national level.

In conclusion, the ACEP Council meeting was another eventful gathering for our state chapter. We once again achieved 100 percent participation from FCEP in NEMPAC and EMF donations. I strongly encourage our members to attend this great event and plan on joining us next year in San Diego!

Approved for AMA PRA Category 1 CreditsTM

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WINTER 2017-2018 | VOLUME 24, ISSUE 4

Government Affairs Committee The upcoming 2018 legislative session will mark another busy session for health care bills that will directly affect emergency medicine.

Damian Caraballo, MD, FACEP Government Affairs Committee Co-Chair

Here an update on key Florida bills: • Opioid Legislation - HB 21/SB 458 - This will be a key bill followed by FCEP. We are part of a state-wide panel of health professionals working to solve the opioid crisis, which is now the leading cause of death in Americans under 50. The main proposed bill by Representative Boyd and companion bill by Senator Benquisto currently puts strict limits on providers who write for opioids, including: • Three-day prescription limit for acute pain (with option for seven days requiring further documentation) • Mandatory checking of the Florida E-Forcse Prescription database for anyone who writes an opioid prescription • Mandatory CME for all prescribers • Proposed, but yet to be designated, funding for Medication Assisted Therapy (e.g. suboxone, naltrexone, etc.)

While FCEP certainly is working hard to guide lawmakers in the proper handling of the opioid epidemic, we feel the current limits are too draconian on physicians and do not address the issue of overdoses due to street availability of fentanyl and other potent street agents. Our opioid task force head Dr. Aaron Wohl has experience writing bills on Florida opioid laws, and he will work with the FCEP committee to make sure the Florida law correctly addresses the epidemic without tying the hands of emergency physicians who have been shown in literature to appropriately prescribe opioids to treat acute pain conditions.

• Personal Injury Protection (PIP) Repeal – HB19/SB150 – Florida currently uses a No-Fault system for insurance reimbursement during a motor vehicle accident. Part of this system involves having a set aside for physicians who treat patients in MVCs. This has traditionally allowed PIP reimbursement for physicians to be fair and timely.

HB19/SB150 would change that to a Bodily Injury (BI) system. Switching to a BI system could potentially tie up reimbursement in courts, as it would lead to more litigious resolutions of MVA victims.

• The House version of the bill would shift all medical reimbursements to personal medical insurance. Given that approximately 20 percent of Floridians are uninsured, this would take away reimbursement for these MVA patients and leave them as self-pay patients. MVAs account for 2 percent of visits and up to 14 percent of reimbursement for Florida EM groups -- this could lead to a significant decrease in reimbursement for EMTALA-based Florida emergency physicians.

• The Senate version does contain an $2,500 EMTALA-based physician carve out, which would at least allow for fair and prompt payment for Florida physicians. It would be less than the current $5,000 carve out in our PIP law.

• It is the view of FCEP that this bill, while in the name of lowering auto insurance, would only shift costs toward the already unaffordable and over-burdened medical insurances of Floridians. Further, it will increase law suits and tie-up payments for patients involved in MVAs. Last year we defeated the bill; this year it appears to be back on the agenda and heavily pushed by the auto insurances and trial-bar association. FCEP will continue to fight for fair and prompt payment from auto insurers and oppose any BI system which does not set aside reimbursement for MVA victims seen by emergency physicians.

Among other bills being closely watched by FCEP: a bill proposing to end requirement of Maintenance of Certification for hospital privileges in Florida, a bill which would require minimum nursing ratios in hospital wards, a telemedicine bill, and a bill which would set framework for limited licensure by foreign-trained doctors.

Advocating for Florida physicians on proposed legislation is the heart and soul of FCEP. We hope that you can join us in our efforts January 16-18, 2018, in Tallahassee for Emergency Medicine Days, where we will meet with state legislature to stand up for physician and patient rights.

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EMS/Trauma Committee This last hurricane season was overwhelming to say the least. This was a trial of state of preparedness in our emergency departments, EMS agencies, hospitals and communities. A hurricane is unique, as we do have some time to prepare. We can prepare by adding staff to cover long shifts and make plans for our family, home and pets. Ideally, communities will have plans in place to ensure that we are prepared with: • Supplies (medical, food, water, etc.)

• Designated shelter sites • Agreements in place for mutual aid • Evacuation plans when necessitated • Lists of special needs citizens in their area • Dialysis • Patients with oxygen requirements • Patients whom require electricity for their medical equipment (CPAP, ventilators) • Regional skilled nursing homes

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

As with all disasters, life safety, incident stabilization and property stabilization are the three priorities with life safety being the first focus. There are many issues that occur during a hurricane that affect patient care. This is very important for all medical staff to remember when planning on working before, during and after these types of events. Priority No. 1 is safety. If rendering aid or transporting will put lives in danger, you must refrain from performing this task. One example is how different agencies have different wind levels at which operations cease. In many agencies, this occurs with sustained winds from 40-50 m.p.h. This does not account for the occasional gusts that still can easily cause an ambulance to take a fatal turn.

Another nuance is that each station has it’s own wind velocity meter and once they respond to a call they complete the transport not knowing what the ambient wind velocity is dynamically. In these scenarios, medical professionals and citizens must remember we are operating with these concerns in mind. Preemptive strategic planning for patients whom require daily medications and treatment plans is important. Educating our community on evacuation and preparation will improve our response as a whole.

Summary from November 15, 2017 EMS/Trauma committee meeting: H.R. 304: Protecting Patient Access to Emergency Medications Act of 2017 This bill passed in the House and Senate, and is now pending approval and signature by the president. As we have previously explained, this is an important bill to EMS daily operations with use of controlled substances in the field by our staff under regular medical direction and protocols.

NASEMSO Announces Comment Period for the Revision of the National EMS Scope of Practice Model Five key areas are priority topics: 1. Use of opioid antagonists at the Basic Life Support (BLS) level 2. Therapeutic hypothermia following cardiac arrest 3. Pharmacological pain management following an acute traumatic event 4. Hemorrhage control 5. Use of noninvasive ventilation at the EMT level The National EMS Scope of Practice Model is available at http://nasemso.org/Projects/EMSScopeOfPractice/.

National Collaborative for Bio-preparedness (NCBP) The states of Florida and Rhode Island have become part of the National Collaborative for Bio-preparedness (NCBP) with fully executed Data Use Agreements.

Intranasal Treatment for Cyanide Poisoning - HHS Partners to Develop First Intranasal Treatment for Cyanide Poisoning The first intranasal treatment for the life-threatening effects of cyanide poisoning will be developed under an agreement between the U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Preparedness and Response (ASPR) and Emergent BioSolutions in Gaithersburg, Maryland. The concern is that cyanide could be used as a chemical weapon against the United States. Under the 17-month, $12.7-million agreement, a stabilized intranasal form of Isoamyl Nitrite will be developed.

Blood Glucose Monitor - FDA Approves First Blood Sugar Monitor Not Requiring Blood Sample Calibration The U.S. Food and Drug Administration (FDA) recently approved the FreeStyle Libre Flash Glucose Monitoring System -- the first continuous glucose monitoring system that can be used by adult patients to make diabetes treatment decisions without calibration using a blood sample from the fingertip. The system reduces the need for fingerstick testing by using a small sensor wire inserted below the skin’s surface that continuously measures and monitors glucose levels. Users can determine glucose levels by waving a dedicated mobile reader above the sensor wire to determine if glucose levels are too high or too low, along with how glucose levels are changing. This is an important innovation for ED and EMS personnel to be aware of in the treatment of diabetic patients.

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WINTER 2017-2018 | VOLUME 24, ISSUE 4

EMS Agenda 2050 Solicits Feedback on Straw Man Document In the Straw Man, the panel has proposed a vision for EMS in the United States that is people-centered with six guiding principles to help achieve that goal (http://emsagenda2050.org/).

EMS systems will be: • Integrated and seamless • Socially equitable • Inherently safe • Sustainable and efficient • Reliable and prepared • Adaptable and innovative New Report Addresses the Risks and Benefits of EMS Use of Lights and Sirens A whitepaper by Pennsylvania EMS Medical Director Dr. Douglas Kupas takes an evidence-based approach to examining the controversial issue of using lights and sirens in EMS response and transport. This report discusses the impact of emergency lights and sirens while driving on response and transport time, safety, public perception and patient outcome. “Lights and Siren Use by Emergency Medical Services (EMS): Above All Do No Harm” approaches the use of lights and sirens as a medical therapy, with a review of the evidence and recommendations for potential implementation by states, regional authorities and local EMS agencies. https://www.ems.gov/pdf/Lights_and_Sirens_Use_by_EMS_May_2017.pdf Low Dose Oxygen Not Useful in Acute Stroke The prophylactic use of low-dose oxygen does not reduce death or disability at three months among non-hypoxic patients with acute stroke, according to a study published in the September 26 issue of the Journal of the American Medical Association (JAMA).

National Model EMS Clinical Guidelines The NASEMSO Medical Directors Council led a team of physicians from collaborating organizations to produce Version 2 of the Model EMS Clinical Guidelines. Version 2 contains 15 additional guidelines as well as revisions to the original set. The new Guidelines document is now available at http://www.nasemso.org/documents/National-Model-EMS-Clinical-Guidelines-Version2Sept2017.pdf FirstNet Update Full Implementation Scheduled for March 2018 includes 24 states and territories that opted in to the First Responder Network Authority (FirstNet) network, the nation’s first high-speed broadband public safety network.

PPE Recommendations and Unknown Substance Precautions for First Responders Carfentanil is 10,000 times more potent than morphine, 5,000 times more potent than heroin, and 100 times more potent than fentanyl. Although the lethal dose is not specifically known, it is estimated that as little as 200 micrograms of carfentanil might be lethal.

Personal Protective Equipment (PPE) used today by first responders is adequate for overdose responses Standard gloves are all that is essential.

• Law enforcement officers conducting a pat-down should apply nitrile gloves over their leather gloves to reduce the risk of any agent binding to their leather gloves.

• If there is blood or other bodily fluids, use universal precautions — gloves, splash or face shield/standard mask.

• For active handling and processing fentanyl, which includes any time there has been aerosolization of the powder, such as a flash bang on raid, there is respiratory protection guidance from the National Institute for Occupational Safety and Health (NIOSH) as listed below. This is NOT for average response or overdose calls.

Respiratory Protection • RESPIRATORY PROTECTION APPLIES ONLY IF HANDLING AND PROCESSING HIGH RISK AGENT • While handling and processing fentanyl and its analogues, first responders should wear either a National Institute for Occupational Safety and Health-approved: • Half-mask filtering facepiece respirator rated P100, • Elastomeric half-mask air-purifying respirator with multi-purpose P100 cartridges, • Elastomeric full facepiece air-purifying respirator with multi-purpose P100 cartridges, OR • A powered air-purifying respirator (PAPR) with high-efficiency particulate air (HEPA) filters.

SB 474: Physician Orders for Life-sustaining Treatment Establishing the Physician Orders for Life-Sustaining Treatment (POLST) Program within the Department of Health — which would require the Agency for Health Care Administration to establish and maintain a database of compassionate and palliative care plans by a specified date — would authorize specified personnel to withhold or withdraw cardiopulmonary resuscitation if presented with a POLST form that contains an order not to resuscitate the patient, requiring the Department of Elderly Affairs, in consultation with the agency, to adopt by rule procedures for the implementation of POLST forms in hospice care, etc.

• Effective Date: 7/1/2018 • Last Action: 10/25/2017 Senate - Referred to Health Policy; Appropriations Subcommittee on Health and Human Services; Appropriations • Will be re-introduced during 2018 legislative session.

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Medical Economics Committee With Emergency Medicine Days 2018 approaching fast, the Medical Economics Committee has been hard at work making sure we are advocating for our FCEP members, along with staying up to date on the latest issues and bills concerning emergency medicine. Here are some updates from the Medical Economics Committee: OIR – Last January, FCEP met with the Office of Insurance Regulation regarding systematic underpayment of out of network claims by Humana. The prolonged investigation resulted in essentially no action, merely a restatement that Humana said they were paying correctly. FCEP responded with a follow-up letter disputing the OIR findings, but there has been no action or reply.

Affected provider groups will need to decide if dispute resolution using the re-vamped Maxiumus process is worth attempting, as opposed to other legal action.

Personal Injury Protection (PIP) legislation is expected back for 2018 session. Last year we were fairly successful advocating for EM protection, with an EM carve out via a “med Pay” setup should PIP be repealed and replaced with bodily injury of medical insurance coverage. The “savings” expected — $9/yr for the average insured for half the medical coverage based on the Florida CFO report commissioned in summer 2016 — will likely be dwarfed by increased legal costs with a litigation based system versus the no fault PIP system. Additionally, legal action will likely delay payments to patients and providers.

Daniel Brennan, MD, FACEP Medical Economics Committee Chair

AHCA – AHCA released a report in spring 2017 “Analyzing Potentially Preventable Health Care Events of Florida Medicaid Enrollees”, including 10 pages of data on “Potentially Preventable ED Visits (PPV)”.1 Toni Large arranged a conference call with Medicaid Director Beth Kidder and AHCA staff on November 3 to allow FCEP to discuss EP’s perspective on this issue. Despite the title, the report does focus on potentially preventable ED visits that may occur due to a lack of access to primary care, care coordination or poor chronic disease management. Despite the optimistic projections, with almost 77 percent of all ED MKD visits were felt to PPVs, the discussion we had focused on the fact that although many are “potentially” preventable, this does not mean they are inappropriate visits. FCEP emphasized the importance of the ED safety net as it appears unlikely the 1° care access, care coordination or chronic disease management will be significantly improved in the short-term future. Additionally, the increasing role of the ED as a diagnostic center of excellence was emphasized (RAND report provided to AHCA).2 CMS - On November 1, CMS released the 2018 Medicare Outpatient Prospective Payment System Final Rule.3 Some pertinent ED items of interest, CMS finalized future (2020) removal of the following quality measures: • OP-1: Median Time to Fibrinolysis • OP-4: Aspirin at Arrival • OP- 20: Door to Diagnostic Evaluation by a Qualified Medical Professional • OP-21: Median Time to Pain Management for Long Bone Fracture CMS is continuing door-to-discharge measures (OP-18b), but adding one (OP-18c) for Psychiatric/Mental Health Patients.

On November 2, CMS released final rules for the 2018 Medicare Physician Fee Schedule (MPFS) and the Quality Payment Program (QPP).4 The overall update to payments under the PFS are based on the finalized CY 2018 rates will be +0.41 percent, with the final 2018 PFS conversion factor is $35.99 — an increase to the 2017 PFS conversion factor of $35.89. Other key items include: • ED Visit Code Payment Rates: CMS sought comment from stakeholders on whether emergency department visits are undervalued due to increasing heterogeneity of the settings under which emergency department visits are furnished and increased acuity of the patient population. CMS will be reviewing emergency department visits (CPT codes 99281-99385) as potentially misvalued for future rulemaking.

• ED Visit Code Payment Rates: CMS stated that it believes emergency visit services may be potentially misvalued given the increased acuity of the patient population and the heterogeneity of the sites where emergency department visits are furnished. CMS stated that it will reviewing future RUC recommendations and consider these issues in future notice and comment rulemaking.

• E/M Code Documentation Guidelines: CMS had solicited public commentary on the E/M guidelines but postponed potential action to future rulemaking.

• Malpractice RVU Policies: A payment reduction due to malpractice cost data was expected but updates were adjusted to every three years, so 2018 MP RVU impact is now expected to be zero percent.

• MACRA/MIPS: Changes to MACRA/MIPS reporting thresholds and “continued flexibility” with less burdensome reporting requirements are touted by CMS. Specific ED impacts for 2018 will be important to monitor but are unclear at this time.

EDPMA and FCEP will be reviewing as more information becomes available.

Please plan to join FCEP in Tallahassee for Emergency Medicine Days January 16-18 2018.

References 1.

2.

3.

4.

https://ahca.myflorida.com/medicaid/Finance/data_analytics/BI/docs/Quarterly_SMMC_Report_Spring_2017.pdf https://www.rand.org/pubs/periodicals/health-quarterly/issues/v3/n2/03.html https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-01.html https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-02.html

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WINTER 2017-2018 | VOLUME 24, ISSUE 4

ACEP B oard U pdate More than 6,000 of your peers met in Washington, D.C. at ACEP2017. While not the largest annual meeting ever, it was certainly full of energy and enthusiasm! With more than 300 educational offerings, as well as unparalleled opportunities to network, it was an awesome meeting!

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

Our annual meeting is always preceded by the annual meeting of the ACEP Council, where the business of the College gets done. The Council is a representative body made up of ACEP members from every State Chapter and Section. The 2017 Council considered 62 resolutions over a wide range of topics: 39 were adopted, five were not adopted, five were withdrawn, 11 were referred to the Board of Directors, and two were referred to the Council Steering Committee.

The Council also elects the leaders of the College, and the Florida Chapter had two members nominated this year to run: Drs. Kathleen Clem for ACEP Board and Vidor Friedman for president-elect. I want to give a big shout out to the wonderful support and encouragement lent to Dr. Clem and myself by the Florida Chapter this year. While neither of us were elected this year, it is unusual for candidates to be elected on their first try. I am confident that we will both be strong candidates next year!

Dr. Paul Kivela, who is from California, was installed as president of the College. Dr. Rebecca Parker, after a strong year as your president, moved on to the past-president position. This year the Council elected Dr. John Rodgers, who is from Georgia, as president-elect. Drs. Stephen Anderson and Jon Mark Hirshon were re-elected to the Board. Drs. Allison Haddock from Texas and Aisha Liferidge from the D.C. chapter were elected as new Board members. Dr. Gary Katz, who is from Ohio, was elected vice speaker of the Council The ACEP Board of Directors also met prior to the Council meeting, here are some of the highlights: The College is in an excellent financial position. Equity is at an all time high in spite of significant investment in CEDR (approximately $5 million) and the new headquarters building ($13 million) over the past four years.

The suit against CIIO/CMS regarding their “Greatest of 3” reimbursement ruling is ongoing. The court has granted part of our motion for summary judgement and has asked CMS to respond with more information regarding our allegations. Given the current situation in the Federal government, we anticipate a response by April 2018.

ACEP’s qualified clinical data registry, CEDR, is on track to have approximately 15 million patient visits in 2017, making it one of the largest QCDRs in the country. CEDR is allowing emergency medicine physicians to report quality data to CMS, satisfying the MIPS/MACRA value-based reimbursement programs.

We received an updated from Alternate Payment Model task force. Two models have been developed and are being validated.

The Board received the Diversity & Inclusion Task Force Interim Report also.

The Board endorsed the American College of Medical Toxicology (ACMT) and the American Academy of Clinical Toxicology (AACT) Position Statement: Preventing Occupational Fentanyl and Fentanyl Analog Exposure to Emergency Responders Approved clinical policies on; Health Care System Surge Capacity Recognition, Preparedness, and Response, Hospital Disaster Physician Privileging, Sub-Dissociative Dosing of Ketamine, Writing Admission and Transition Orders, Definition of a Boarded Patient, Medical Transport Advertising, Marketing, and Brokering, Pediatric Medication Safety in the Emergency Department, Unsolicited Medical Personnel Volunteering at Disaster Scenes, Distracted and Impaired Driving, The Clinical Practice of Emergency Medical Services Medicine, The Role of the Physician Medical Director in Emergency Medical Services Leadership, Mechanical Ventilation, CEDR Quality Measures Policy Statement, Guiding Principles for Interactions with External Entities; to name a few!

The Board also elected its officers for 2017-2018: Drs. Deborah Perina was elected as chair, Vidor Friedman was elected as vice president, and Stephen Anderson was elected as secretary-treasurer.

As always I would be happy to hear your feedback, or answer any questions you might have.

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Leadership Academy Update Article by Dr. Kirk Szustkiewicz, current FCEP Leadership Academy fellow The fellows of the Leadership Academy are pleased to report that our experience so far has been fantastic! We’ve already had several unique and exciting opportunities within FCEP. The exposure has been extremely enriching to our careers and has helped us to grow our professional passions.

The three of us, Laura Hummel, Ryan McKenna and myself, all had the privilege to serve as alternative councillors for Florida at ACEP 2017 in Washington D.C. We garnered invaluable insight into key issues that are affecting emergency physicians today and those that may in the future. We all agree that having the opportunity to shape the policies of our profession and collaborate with so many leaders in our specialty was immensely rewarding and reaffirmed our desire to be the future voices for emergency medicine.

Next up, the three of us will be joining the charge to Tallahassee for Emergency Medicine Days. We look forward to advocating for our profession at the state level. The big issue on the table this year is balanced billing, which threatens the entire reimbursement structure of our specialty.

Lastly, the three of us would like to thank Dr. Pat Agdamag for his mentorship and dedication to the advancement of leadership and advocacy in emergency medicine. The process of identifying future leaders and giving them the opportunity to develop as individuals is key to the future success of any organization, and we again thank Pat for this important contribution.

(L-R) Drs. Kirk Szustkiewicz, Patrick Agdamag, Laura Hummel & Ryan McKenna attend ACEP 17 in Washington D.C.

Medical Student Committee Article by Alicia Bishop, FCEP Medical Student Committee Secretary-Editor What will you stand up for and how will you make a difference? Emergency physicians will gather to answer this question in January 2018 at Emergency Medicine Days (EM Days), which is FCEP’s annual conference with a focus on advocacy.

This is also the question medical students interested in pursuing emergency medicine can begin to ask themselves, as they see firsthand how doctors can work with policymakers to tackle issues influential in their unique environment of practice. Taking place in Tallahassee, EM Days provides an avenue for medical students to be exposed to policy changes at the state level.

Students can expect to see a few key topics addressed this year. Trends in insurer repayment practices, especially balance billing for out-of-network providers, will be at the forefront of issues discussed. Attendees will hear more about past, recent and proposed legislation that could affect provider reimbursement, as well as the consequences of these policies on patient outcome, well-being and treatment options.

Physicians will also be advocating for innovative solutions and resources to address the opioid and prescription drug overuse crisis, which was declared a public health emergency by the president in October. There is perhaps no other specialty that sees firsthand the impact of the opioid epidemic more regularly. Guidelines and policy surrounding this issue may substantially change how future physicians prescribe and practice, making this an exciting time for students to become involved.

Legislation affecting end-of-life care, malpractice coverage and many other issues will also be explored. Many current health policy issues will directly impact students’ practice once they enter residency and continue to practice in the future — one reason that learning about the issues and finding a way to advocate for the causes most important to you is such a critical piece of a full medical education.

Coordinators know that preparing for and approaching an event like this as a medical student might be intimidating, which is why they have created the Medical Student Track for conference-goers.

“This track is created by students for students, allowing attendees to learn about what other students across Florida would like to advocate for, get first-hand training for patient advocacy, and join outstanding physicians in their tour to the capitol to advocate for emergency medicine,” Misty Coello, the co-chair of the FCEP Medical Student Committee, said.

FCEP Medical Student Advocacy Coordinator Mark Kastner says it’s a chance for medical student attendees to present on the issues most important to them.

“Students will be able to get more engaged than ever before by presenting to other medical students on policy issues,” Kastner said. “By getting more medical students familiar with and involved in the policy side of medicine, we can better prepare them for residency and for their future careers.”

EM Days is a powerful chance for medical students to learn what matters most to physicians who are already practicing, to begin identifying the causes they are most passionate about, and to begin finding their voice in fighting for those causes.

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WINTER 2017-2018 | VOLUME 24, ISSUE 4

Membership & Professional Development Committee Happy New Year! Wow, it’s 2018 already. The new year brings the promise of a fresh start and the growth of a solid foundation from years past. This time of year always brings with it a level of excitement that the rest of the year builds on, including exciting adventures on the road of emergency medicine.

By the time you receive this, we will be getting ready to take part in our annual Emergency Medicine Days in Tallahassee. That’s right, FCEP is back on the road. This time we will be traveling to Tallahassee to talk with our legislators during the current legislative session. The importance of attending became most evident to me when I realized that despite their best intentions, many of our legislators are unaware of the “real life” impacts that many of the health care bills they will be passing will have on Floridians.

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

Through personal visits and events during our time in Tallahassee, we are able to give our legislators a personalized view into health care and its complexities. Will you be joining us in Tallahassee? EM Days will be January 16-18, 2018. There is still time to register and attend. Just visit our website (www.emlrc.org) and check under the “Events”menu.

Another part of the FCEP outreach road trip is our goal of visiting all the residency programs in Florida. Since we are expanding the number of programs in Florida, we want to make sure that our members are aware of the various ways ACEP and FCEP can assist with enhancing the way we practice medicine. Rest assured, our visits are not only for residency programs. We would also be happy to visit your practice to meet with all who are interested in hearing more about the benefits of membership in ACEP and FCEP. We want to make sure that all EM providers know that ACEP and FCEP are available to help keep you informed and able to provide the best patient care.

Have we already been to your program or practice location? If not, please reach out to us at the FCEP office to schedule a visit.

Even though it’s the new year, I would like to take some time to reflect on a big event from 2017 — ACEP Scientific Assembly.

Did you attend ACEP Scientific Assembly this year? What were your favorite parts? The lectures and networking opportunities are always favorites, but have you ever been to the Council meetings?

The Council meetings take place over two days in conjunction with Assembly but deal with some of the biggest issues in EM. At the Council meetings, various resolutions and bylaw amendments that will affect the way our organizations are run are discussed and voted upon. In the last issue, I introduced our current Leadership Academy participants: Drs. Szustkiewicz, Hummel and McKenna. As a part of Leadership Academy, they were able to immerse themselves into the the inner workings of our democratic organization by taking part in the ACEP Council sessions as alternate councillors. As alternate councillors, they were able to assist in shaping the future of our organization, a large responsibility.

Attending and participating in Council meetings is an experience that reminds us that we are not only responsible for the way emergency medicine is practiced in our local hospitals and clinics, but also how emergency medicine is practiced throughout the country. We thank all our Councillors for their dedication and representing us as we look toward the future.

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EMpulse | 11

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EMRAF Committee The EMRAF Committee continues to represent and advocate on behalf of all EM residents in the State of Florida. As the number of programs in the state continues to grow, staying informed and involved in advocacy initiatives becomes more and more important. While as residents we may feel insulated from the direct impact of legislation regarding health care policy and medical economics, it is imperative that as emergency medicine physicians we stay involved in helping formulate these policies, which will directly impact our ability to practice medicine the way we believe is appropriate.

With that said, I am excited to tell you about one of the projects we at EMRAF are working on.

At the EMRAF Committee meeting in November, Travis Murphy (PGY-II, UF Gainesville) informed Jesse Glueck, MD us of a project he has been working on for the past year and has begun its initial data collection EMRAF President, Orlando phase. The project, entitled “Reducing Redundant Testing for Incoming Transfers”, aims to Health EM Resident (PGY-3) quantify and reduce the costs resulting from the unnecessary duplication of diagnostic tests for patients transferred between emergency departments with the final goal of promoting the creation of a universally accessible medical record here in the State of Florida. A system that would allow for the integration of electronic health records will have much larger implications than just reducing costs, and it will eliminate the headache many of us face when we receive transferred patients who arrive with incomplete records. ORMC has joined in assisting with Travis’ project, and we hope to present our initial data to state legislators during EM Days in January. The more programs that get involved in this project, the stronger our ability to promote the creation of a universal EHR will be. To get involved, please email Travis Murphy at twmurphy@ufl.edu.

By the time you are reading this article, Emergency Medicine Days, FCEP’s premier annual legislative advocacy session, will be right around the corner. EM Days provides residents with an amazing opportunity to learn about proposed legislation that will directly impact the practice of emergency medicine in Florida, spend face-to-face time with state legislators and network with the leaders of Florida emergency medicine. It has already proven to be an invaluable experience for me, and it is my utmost hope that each program will have representation at this year’s meeting in Tallahassee.

EMRAF currently only has representatives from seven of the 14 Florida residency programs: Orlando Health, Florida Hospital, UF-Gainesville, UF-Jacksonville, Aventura Medical Center, North Florida Regional Medical Center and Osceola Medical Center.

Our goal is to have two representatives from each of the fourteen programs. The main responsibilities of any representative is to attend or call in to the quarterly committee meetings, attend EM Days in Tallahassee and, most importantly, keep the residents at your program informed about the issues that are facing emergency physicians in Florida.

No matter which program you are individually a part of, the only way we can guide our training and future practice environment is by directly being involved in the processes that shape them. To get involved and represent your program on the EMRAF Committee, or if you have any questions about how to get involved, feel free to email me at JesseGlueckMD@gmail.com.

D a u nting D i a gn o s i s Question: A patient presents to the ER status-post alleged assault of his ear via human bite. Pictured are the avulsed ear and the missing ear tissue.

With any tissue amputation, how should the specimen be preserved for replantation?

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

Turn to page 27 for the answer!

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Strategies for better AR Management – Maximizing Collections Article by Shanna Howe, VP of Operations

In this everchanging healthcare industry, Emergency Medicine providers are constantly looking for ways to maximize collections and resolve Accounts Receivable sooner. Meanwhile, payors do not make this easy; so, working the “exceptions” has become more important than ever.

First, study your claim filings and file electronically wherever the opportunity exists. It is important to understand each individual payor’s claim filing requirements and file correctly the first time. In addition to filing electronically, work with the payors to setup EFT/ACH payments as well as ERA/835 remits, as this will help to expedite receipt of the funds and remittance advice.

Even when following best practices, there are always claims that don’t pay or pay incorrectly the “exceptions”. For those exceptions, analyze your AR in detail, and by pay specific attention to responsibility. Handling patient responsible payments requires its own plan. Here, we’ll focus on Insurance Responsible AR. • Start by reviewing unadjudicated claims by AR Aging by Payor Class – This allows you to focus on any potential issues early on based on each individual Payor Class.

• Next, take look at denials by Payor Class – Focus on the top denials by Payor Class, and drill down to each individual payor as needed, and focus on the denials that have opportunity for resolution with the payor.

• Technology makes the job easier, so use your resources wisely, and check claim status online via payor’s websites or send & receive 276/277 EDI Claim Status transactions.

Make phone calls only when necessary, as payor wait times and procedures may allow you to accomplish little for the amount of time spent.

• Protect your bottom line by verifying that contracted payors are paying according to the reimbursement terms of your managed care contract – payors often times may neglect to load contract renewals/annual escalators in their system, or may load and process claims incorrectly.

Reviewing your overall Days in AR will help you to determine your practice’s overall AR performance in terms of how quickly you are paid. However, depending on your self-pay/ uninsured process, the Days in AR statistic can vary greatly from one practice or billing company to another. Get to know your average Days in AR and be alerted of changes – with the use of Business Intelligence tools available to us today, being alerted of changes or potential issues will allow you to focus on those last dollars.

EM p u l s e F e a t u r e Winter Is Coming!: Dealing

with

Hypothermia in Florida

Article by Drs. David Alex Kranc, PGY III and Benjamin N. Abo, DO, EMT-P, FAWM

We all live in Florida, but it can still get cold enough down here to cause significant hypothermia — and this can easily be without submersion in water even here in Florida.

The picture you see here shows a gentlemen's core body temperature on an early November night here in Florida.

He was an alcoholic found outdoors unresponsive with no submersion at any point.

Here is a quick reminder on how to deal with patients who are hypothermic. First, you need to remember that they do not necessarily come in with the chief complaint of hypothermia. Sometimes they are an “Altered Mental Status”, MVC with prolonged time on scene (a cold street, maybe), naked trauma patient or a bar fight. As always in emergency medicine, we need to keep our head on a swivel and consider the unlikely. Once you've recognized someone as hypothermic, where do we go from there? Several different strategies can be employed depending on the patient's core temperature: either passive external warming, active external warming and active internal warming.

Mild hypothermia: >32C Remove all wet/soiled clothing, insulate the patient with warm blankets and warm the room, if possible.

Moderate to Severe Hypothermia: 28-32C Remove all wet/soiled clothing. Provide patient with heating pads, warm blankets and warm fans/fluids, attempting to warm the patient's core before extremities Severe Hypothermia: <28C Remove all wet/soiled clothing. Continuous bladder irrigation with warm fluids if foley in place. If patient is intubated, provide warmed air. Place a nasogastric tube and irrigate with warmed fluids. In severe cases, one could consider placed bilateral chest-tubes and circulating warm fluids.

Remember, don't stop resuscitative efforts until the patient is re-warmed. Stay cool amigos, but not too cool!

We will be diving into this topic much further and others in our special Florida Environmental Emergencies webinar series, which is free, online and provides continuing education credits. We had a very successful inaugural webinar with the wonderful Dr. Andrew Schmidt on drowning and submersion injuries. Next up, we will discuss lightning emergencies here in the lightning capital of the continent!

Dr. Abo is Assistant Professor of Emergency Medicine & EMS at the University of Florida and austere/wilderness & disaster specialist.

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Poison Control Carbon Monoxide Toxicity in the Aftermath of Irma Article by Emily Jaynes Winograd, PharmD Clinical Toxicology/Emergency Medicine Fellow Florida/USVI Poison Information Center – Jacksonville Dawn Sollee, Pharm.D., DABAT, FAACT Assistant Director Florida/USVI Poison Information Center – Jacksonville

In the aftermath of major hurricanes like September’s Hurricane Irma, the Florida Poison Information Center Network (FPICN) anticipates an uptick in calls regarding certain types of exposures. Snake bites increase as clean-up efforts begin. Persistent power outages result in calls regarding food safety, water sanitation and appropriate generator use. Carbon monoxide toxicity is a major concern after severe storms as generator and gas grill use increases, often resulting in clinically significant adverse effects secondary to carbon monoxide exposure.

Carbon monoxide is generated via the incomplete combustion of carbon-containing compounds (e.g. gasoline, propane, kerosene). A common post-hurricane source of carbon monoxide is the use of generators in poorly ventilated areas or too close to open windows of the home. Carbon monoxide is a colorless, odorless and tasteless gas. Symptoms of exposure range from minor effects like nausea, vomiting, headache and dizziness, to major events like seizures, dysrhythmias and death. Additionally, carbon monoxide exposure can cause permanent neurologic sequelae including amnesia, dementia, parkinsonism, psychosis and peripheral neuropathy.1

Figure 1. Carbon monoxide exposures reported to FPICN2

The FPICN received more than 200 reports of carbon monoxide exposures in the month around Hurricane Irma (September 6 – October 5). The majority of calls were inhalational exposures related to generator use. FPICN calls related to carbon monoxide exposure peaked on September 12 (Figure 1). The ages of those affected ranged from 6 months – 82 years.2 Diagnosis of carbon monoxide toxicity is most often based on carboxyhemoglobin (COHb) levels obtained via arterial or venous blood cooximetry testing. Normal COHb levels range from 0 – 5 percent, though smokers may have a baseline COHb level between 6 – 10 percent.3 Additionally, neonates may have falsely elevated COHb levels (up to 8 percent) due to fetal hemoglobin interference with the spectrophotometric cooximetry reading.4 Of note, most standard pulse oximeters will give a falsely normal oxygen saturation reading as these devices cannot distinguish between oxyhemoglobin and carboxyhemoglobin.

The treatment for carbon monoxide toxicity is administration of 100 percent oxygen via non-rebreather mask or endotracheal tube.1 The use of hyperbaric oxygen is controversial, but is indicated in patients with COHb levels >25 percent (>15 – 20 percent in pregnant women); patients who had a syncopal event, seizure, or altered mental status secondary to carbon monoxide exposure; patients with ischemic changes on ECG; or patients who were exposed to carbon monoxide for more than 24 hours.

On room air, the half-life of COHb is four to five hours. This decreases to one to two hours with administration of 100 percent normobaric oxygen, and decreases further to 20 minutes with hyperbaric oxygen treatment.1 Clinicians must take these halflives into consideration when evaluating an initial COHb level in the emergency department. For example, a patient’s initial arterial blood gas may show a COHb level of 15 percent. However, if the patient was removed from the carbon monoxide exposure and given 100 percent oxygen for an hour prior to this level being drawn, the COHb level on scene was likely closer to 30 percent. The highest possible COHb level is the one that should be used to determine whether a patient requires hyperbaric oxygen (in the absence of other aforementioned symptoms).

Emergency physicians should maintain a high level of suspicion for carbon monoxide exposure in patients presenting with nausea, vomiting, headache, dizziness, or confusion in the aftermath of a major storm. Obtaining a thorough history (e.g. generator use) and a COHb level can guide management. FPICN toxicologists are available 24 hours a day at 1-800-222-1222 to assist emergency physicians in the treatment of all toxic exposures, including carbon monoxide poisoning.

References 1.

2.

3.

4.

Tomaszewski C. Carbon Monoxide. In: Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank LR. eds. Goldfrank’s Toxicologic Emergencies, 10e New York, NY: McGraw-Hill; 2015.

Florida Poison Information Center Network Query Builder Stewart RD, Baretta ED, Platte LR et al. Carboxyhemoglobin levels in American blood donors. JAMA. 1974 Aug 26;229(9):1187-95.

Vreman HJ, Ronquillo RB, Ariagno RL, Schwartz HC, Stevenson DK. Interference of fetal hemoglobin with the spectrophotometric measurement of carboxyhemoglobin. Clin Chem. 1988 May;34(5):975-7.

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PHYSICIAN AND LEADERSHIP OPPORTUNITIES NORTH FLORIDA

Fort Walton Beach Medical Center (Ft. Walton Beach) Oviedo Medical Center (Oviedo) Bay Medical Center (Panama City) Bay Medical FSED (Panama City) Gulf Coast Regional Medical Center (Panama City)

CENTRAL FLORIDA

Oak Hill Hospital (Brooksville) Englewood Community Hospital (Englewood) Munroe Regional Medical Center (Ocala) Emergency Center at TimberRidge (Ocala) Poinciana Medical Center (Orlando) Brandon Regional Emergency Center (Plant City) Fawcett Memorial Hospital (Port Charlotte) Bayfront Punta Gorda (Punta Gorda) Lakewood Ranch FSED (Sarasota) Brandon Regional Hospital (Tampa Bay) Citrus Park ER (Tampa Bay) Largo Medical Center (Tampa Bay) Lutz FSED (Tampa Bay) Mease Countryside Hospital (Tampa Bay) Mease Dunedin Hospital (Tampa Bay) Medical Center of Trinity (Tampa Bay) Northside Hospital (Tampa Bay) Palm Harbor ER (Tampa Bay) Regional Medical Center at Bayonet Point (Tampa Bay) Tampa Community Hospital (Tampa Bay)

SOUTH FLORIDA

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

PEDIATRIC EM

Broward Health Children’s Hospital (Ft. Lauderdale) Northwest Medical Center (Ft. Lauderdale) Plantation General Hospital (Ft. Lauderdale) Munroe Regional Medical Center (Ocala) Gulf Coast Medical Center (Panama City) Brandon Regional Hospital (Tampa Bay) Mease Countryside Hospital (Tampa Bay) The Children’s Hospital at Palms West (West Palm Beach)

LEADERSHIP

Fort Walton Beach Medical Center (Ft. Walton Beach) Osceola Regional Medical Center (Kissimmee) Brandon Regional Hospital (Tampa Bay, FL) Assistant Medical Director Oak Hill Hospital (Tampa Bay, FL) EM Residency Program Director Medical Center of Trinity (Tampa Bay, FL) Assistant Medical Director Regional Medical Center at Bayonet Point (Tampa Bay, FL) Tampa Community Hospital (Tampa Bay, FL)

Call or text: 727.253.5466 Ask about our provider referral program!

Coast-to-Coast full-time, part-time and per diem opportunities.

Ask about our EmBassador Travel Team Opportunities!

Contact us today!

R e s i d e n c y M a tt e r s Our emergency medicine residency programs say goodbye to a great year!

Wishing everyone a happy holiday season from beautiful Boca Raton, Florida!

Florida Atlantic University Jeff Klein, MD PGY-1

As I will be taking over these updates for our inaugural class, I can confidently state that we are all extremely pleased with how our first four months have gone in the emergency department. The breadth of knowledge we have gained, the plethora of procedures and the diversity of patients and pathology have exceeded all of our expectations. We are additionally pleased to announce that our simulation center has now been expanded to a 15,000-square-foot facility made possible by a recent $300,000 donation by the Quantum Foundation and the Palm Healthcare Foundation. Our Simulation Director Dr. Patrick Hughes has done an excellent job of taking advantage of this by conducting monthly simulated patient encounters with our high-fidelity mannequins. These experiences have been extremely beneficial in helping us safely develop the needed skills to manage acute emergencies, including status asthmaticus, status epilepticus, ruptured AAA and intracerebral hemorrhage.

Life hasn’t been all work here at the FAU Emergency Medicine Residency Program. Our monthly wellness activities are off to a great start and have included an afternoon on the beach, an evening at the bowling alley, an evening at a local arcade and an afternoon spent boating and fishing. Furthermore, although it’s the time of year where residency programs begin the process of selecting applicants for their next entering class, we are pleased to announce that our close-knit family is growing in more ways than one with fellow resident Matt Wallace and his wife Vanessa welcoming their daughter Ava into the world. Congratulations to the Wallace family!

Here’s to another successful and groundbreaking four months to ring in the new year at the Florida Atlantic University Emergency Medicine Residency!

Interview season has begun at ORMC, and we couldn’t be more excited to showcase the many wonderful aspects of our program to applicants from all around the country. Our residency class size increases to 17 next year, and we look forward to welcoming a larger group to the ORMC family than ever before!

Congratulations to all our seniors on a successful trip to ACEP 2017 in Washington, D.C. Also, a big thanks to Orlando EMS staff and first responders, volunteers, nurses, and our EMS fellows and residents on a job well done at providing great medical care at the Orlando Electric Daisy Carnival in November.

With a new year comes new research, and our program is actively pursuing new projects and opportunities that we hope to share in the coming months.

We wish each and every program a happy and safe holiday season, from our residency family to yours.

Orlando Health Shari Seidman, MD & Erich Heine, DO PGY-3

Wow, it really feels like with every update another academic year is flying by! The Mount Sinai Medical Center Emergency Medicine Residency Program has been flourishing and continues to grow both academically and socially. The interview season is upon us, which means recruiting the very best, brightest and most enjoyable medical students from across the nation to add to one of the oldest and most recognized EM programs in Florida.

Academically, we have a number of unique studies currently in the works. In addition to various quality improvement projects, we have two ultrasound-guided procedural studies that when finished will complement our newly added and incredibly well-received ultrasound curriculum.

Mt. Sinai Medical Center Matthew Brooks, DO PGY-3

With the season ramping up, volume is going to increase exponentially in the next few months. This will really put the interns and new seniors to the test as they simultaneously learn to appropriately manage the undifferentiated sick patient as well as work in a fast-paced, high-volume emergency department — a skill that is taught so well at our facility.

As the temperature goes down, the tourists will come, which means more patients, more stories, more learning and, of course, more fun! I look forward to updating you all soon with more positive details on the success story that is Mount Sinai Miami EM!

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The American College of Emergency Physicians’ Scientific Assembly in Washington D.C. gave a welcomed excuse for UF Jacksonville faculty and seniors to explore our nation’s capital, celebrate our accomplishments and exchange experiences with our colleagues across the globe. We would like to thank our second-year residents for stepping into the role of senior residents and running the department during ACEP.

University of Florida, Jacksonville Jason Arthur, MD, MPH PGY-3

The entire senior EM class attended ACEP. While our residents enjoyed the educational opportunities, their Disney themed Halloween costumes may have been the highlight of the week. They were also delighted to see one of our interns sacrifice their vacation to spend the week along side them. The senior class would like to thank the faculty and graduates for their hospitality during an unforgettable week.

Drs. Kelly Gray-Eurom, Ashley Booth-Norse, and L. Kendall Webb served as FCEP Councillors, as did Jacksonville EM and Mayo Sim Fellowship graduate Dr. Ryan McKenna. Dr. Elizabeth Devos served as Section on International EM councilor, Section on International EM Steering Committee Member, and served as Deputy Chair of the IFEM Specialty Implementation Committee. Additionally Dr. Devos’ reflection “A Solitary Fantasy”, encouraging female leaders in the development of international emergency medicine, was selected for publication in Perspectives-Women in Emergency Medicine edited by Lauren A. Walter. Dr. Steven A. Godwin, who is the chairman of emergency medicine and a simulation education trailblazer, lead a simulation lab. UF North Assistant Medical Director Dr. Melissa Parsons, who is alsoan all-around rock star attending participated in SimWars.

UF Jacksonville would like to thank all the alumni for attending the annual cocktail hour and dinner. This event provided an opportunity for faculty, residents and graduates to deepen our bond, reconnect and reflect. Graduates are encouraged to contact Dr. Dave Caro at david.caro@jax.ufl.edu to update their contact information so they can be included on future alumni events.

Interview season is in full swing as UF Jacksonville searches for the next great class of emergency medicine residents and pediatric emergency medicine fellows. Additionally, UF Jacksonville continues to consider applicants for our first emergency ultrasound fellowship slated to start in July 2018. Applicants interested in training in a fast-paced, resuscitation-centered program should contact Fellowship Director Dr. Andrew Shannon at Andrew.Shannon@Jax.UFL.edu.

Interview season is officially underway, and we are excited to see the enthusiasm for our specialty with many impressive soon-to-be doctors coming through. We received about 900 applications for the 14 spots in the incoming class. There have been many talented applicants, and we are looking forward to meeting many more.

Despite an otherwise underwhelming Gator football season, our residency tailgating events have proven a big hit, and the extra time to socialize outside the hospital makes for a great way to spend a weekend in town — even though some of our undergrad allegiances are elsewhere in the SEC. On the quality front, our department-wide Quality Improvement Process Curriculum has begun!

We have been having twice-monthly meetings bringing faculty, residents, nursing and other specialties together to help streamline our processes for everything from urine collection times to Ophthalmology consultation to discharge planning to reducing redundant diagnostics on patients transferred from outlying hospitals.

University of Florida, Gainesville Travis Murphy, MD PGY-2

On the inpatient side, UF Health has just opened its newest tower with an upwards of 120 new ICU beds and 24 new operating rooms. This tower, dedicated to heart, vascular and neuromedicine specialties, will provide a fantastic new space for our patients and opportunities for better ED throughput. The third floor terrace bridge overlooking the newly completed Garden of Hope is also a nice way to enjoy a pre-shift coffee.

Altogether, the 2017-2018 academic year has been off to a busy start, and we are excited about our progress. Time to study, — that in-training exam is coming soon!

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The last few months have been busy for everyone at Florida Hospital East Orlando Residency with some life-changing experiences. First off, we all weathered Hurricane Irma in October, and, thanks to the hardwork of my fellow residents and awesome EM attendings, we kept Florida Hospital East Orlando going strong. We had a record number of patients both during and after the storm, but managed the flow very well.

Florida Hospital Katie Laun, DO PGY-2

Florida Hospital East Orlando has also embarked on relief aid trips to Puerto Rico, as well as to the Virgin Islands. I want to give a huge commendation to my fellow residents Drs. William Kotler and Julian Trivino, who along with attendings Drs. Alfredo Tirado, Katia Lugo and Jorge Lopez, spent more than 10 days in Puerto Rico providing much needed health care and supplies to the island devastated by Hurricane Maria. In addition, other teams of Florida Hospital physicians continue to travel to the islands to provide much needed aid. I couldn’t be more proud of my residency.

Back home in Orlando, the interns and second years continue to grow and learn, as the third years move into leadership roles and attend the yearly ACEP conference at the end of October.

We are looking forward to the coming months as we begin our first set of interviews soon Interview season is underway, and we are looking forward to soon having a full complement of residents. The team is excited to be a part of and guide the continued development of the program. The faculty and a select group of residents attended the ACEP 2017 Scientific Assembly, where Dr. Slesinger represented the Florida Chapter as a councilor and a member of the Board of Directors. Drs. Dubensky and Slesinger attended the ACEP E-QUAL sepsis steering meeting.

Dr. Baker continues to be prolific with her academic accomplishments. She co-authored with PGY-1 Dr. Jennifer Reyes an article thorough EMDocs on the ED evaluation and treatment of patients with thiamine deficiency. Dr. Yang continues to diversify his involvement with MDCalc and is now authoring board review style questions. Simulation Director Dr. Jessica Cook, and Dr. Pennardt are planning another multi-institution, high-fidelity, standardized patient assisted, simulated mass casualty incident at Broward Health Simulation Center. This year will focus on an active shoot event. On December 6, AHMC will host our second year of the South Florida EM Grand Rounds, with visiting speaker Dr. Dara Kass with five other local EM residencies.

Aventura Hospital Emergency Medicine Residency Staff

Our faculty are dedicated to furthering their academic and scholarly achievements. Dr. Dubensky authored a poster presentation titled “Ovarian Hyperstimulation Syndrome as a Complication of Molar Pregnancy”, in association with our radiology department. Drs. Tran and Patel, our US faculty, have taught two courses for our ED nurses on US guided peripheral access and blood draws, which have been very successful.

Finally, we would like to extend a warm welcome to Dr. Gaurav Patel as core faculty and co-director of our ultrasound program. Dr. Patel completed his emergency ultrasound fellowship at Northwell Health. We are looking forward to him taking POCUS to a new level!

Greetings from Miami. It has been a busy few months here in Miami. Like all the Florida programs, we felt the effect of Hurricane Irma. Luckily, we survived relatively unscathed. For many of our residents, not only was it was their first disaster activation, but it their first hurricane experience. It was great to see how the residency came together to help each other and take great care of patients. While we were very proud of how our residency came together, we are also happy to be near the end of hurricane season here in Florida.

We are looking forward to start interviews for our third residency class. We are excited to have applicants come in from all over the country to see our residency. It is a great chance to show Jackson Memorial Hospital Emergency Medicine off all the things that make our residency great: our hospitals, our patients, Miami and, most Residency Staff important, our faculty and residents. It will be our third class, and we are excited to have our full contingent of residents soon.

Happy holidays and interview season from the Jackson Health System/University of Miami Miller School of Medicine Emergency Medicine Residency Program.

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As we progress into the oncoming interview season, the emergency medicine residency program at Kendall continues to grow. It has been a great summer and now we are into the new interview season. We also have opened a new simulation center at Kendall to help enhance resident education and multidisciplinary training.

Along with the new class, who are settling in great, we want to welcome our new faculty. Dr. Valori Slane is one of our new APDs and also brings with her a wealth of experience in global health and from her time as a medical director. Dr. Matt Slane also joins us a core faculty to help enhance education in tactical and mountain medicine. Since mid-September, Dr. Astrid Sarvis has been working as core faculty at Kendall. She is pediatric residency and pediatric emergency medicine fellowship trained, and will help us grow and round out the resident training in pediatrics. We have Kendall Regional Medical Center Kendall Regional Medical Center a new research director who will be working with us a month from now. He has experience as an Emergency Medicine Residency Staff associate research director in the past, and some of his studies have been discussed on prominent emergency medicine educational sites. Finally, Dr. Jesus Seda has started with us as core faculty this month. He brings with him all the clinical skills and educational experience he has developed through residency training during his time as chief resident and beyond.

We are also really excited about the South Florida Educational Consortium and helping move this initiative forward. With all of the new emergency medicine residency programs approved in South Florida during the last few years, there is a fantastic opportunity to develop collaborative ventures.

Autumn is finally here after a busy hurricane season. We at St. Lucie Medical Center are looking forward to the beautiful upcoming Florida winter! The 2017-2018 residency year is in full swing, and we have been going through some exciting changes.

Our emergency medicine residency program has received initial ACGME accreditation starting this year. We have transitioned from a four-year program to a three-year program. We have revamped our lecture schedule, and we have added an outstanding weekly EKG conference.

St. Lucie Medical Center Thomas Adams, DO

We are happy to say that our new class of residents — Drs. Alexandra Chitty, Christine Gonzalez, Oliver Morris and Kevin Summers — are all doing an outstanding job, and we are very proud of their performance. Keep up the good work!

Currently, our residents are working on research in snake venom, emergency medicine learning modules for medical students, urinary tract infections and cost-saving measures in the emergency department. We are also preparing to take the ABEM in-training exam for the first time as a residency this coming year.

We have interviewed many outstanding candidates for our new incoming class of residents, and we are excited for the match to come. We wish you all happy holidays, and best wishes for 2018!

Greetings, once again, from UCF/HCA Emergency Medicine Residency Program of Greater Orlando. It’s hard to believe that 2017 is coming to an end, but we have so much to share with all of you as the last few months have been filled willed with exciting awards, events and news!

We would like to start by congratulating Dr. Ballinger for receiving the AMA Inspirational Physician Award. Dr. Lebowitz has received the UCFCOM Early Educator Award, and Dr. Rosario received the UCFCOM Innovative Teaching Award. Furthermore, we went to ACEP17 in Washington, D.C., and it was absolutely amazing! Dr. Rosario is now officially a Fellow of the American College of Emergency Physicians. We had four residents — Drs. Kramer, Leon, Roka and Singh — present their research abstracts. Drs. Amico, Banerjee, Ganti, Okuda and Rosario presented as well, and Drs. Okuda and Rosario assisted in SIM Wars.

UCF HCA of Greater Orlando Abhishek Roka, MD and Leoh N. Leon II, MD PGY-2

The second year class recently completed their APLS training at Nemours Hospital, along side the residents from UCF Ocala and UF Gainesville. It was great to meet our fellow UCF EM residents from the other programs! Also, we are excited to say that interview season has begun, and we are extremely excited to be a part of the interview process for our third class. It has been wonderful so far to meet all of the candidates. We wish you all the best of luck!

Last but not least, congratulations to Dr. Cabrera on the welcoming of his new baby. We are extremely excited to say that we are going to have a baby Benzing! Congratulations to Dr. and Mrs. Benzing on the new future addition to their/our family.

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North Florida Emergency Medicine’s first residency class is making big strides in health advocacy, ultrasound, education, simulation, research, mentorship and more. Our very own Dr. Christopher Libby was elected to the Florida Medical Association Board of Governors and has rapidly become an integral leader. Furthermore, Drs. Collin Bufano and Zaza Atanelov have become active members of EMRA and FCEP. While several of the residents are making changes within organized medicine, the class of 2020 has become essential to the emergency department and hospital. With our Ultrasound Director Dr. Diana Mora and our cutting-edge ultrasound machines, the North Florida EM Residency Zaza Atanelov, MD & residents have utilized ultrasound in making diagnoses in musculoskeletal, respiratory, Collin Bufano, DO and even ophthalmologic complaints. The residents, along with the leadership, are making PGY-1 efforts to utilize POC ultrasound to decrease health care costs, radiation exposure and ED visit times. Further, our goal is to utilize ultrasound to implement regional anesthesia and decrease opiate use in the ED. Additionally, we are utilizing FOAMED, simulation, oral board cases and hands-on skills sessions in our weekly conferences for a more multifaceted and engaging didactics experience. Our Simulation Director Dr. Evan Stern plans to utilize the new simulation lab to reinforce more than just procedures, and medical and trauma codes, but to reinforce established interprofessional relations by running simulation with all types of health care providers.

We are not limited to implementing innovative ultrasound, education and simulation; rather, we want to make significant contributions that will shape the practice of emergency medicine by becoming avid researchers and teachers. Our residents are already involved with more than six research projects utilizing the enormous data privy to us as a UCF/HCAsponsored institution. Furthermore, we have already accepted and worked with a diverse group of learners,including PA, nursing and medical students. The residents have taken on mentorship and teaching roles, helping learners with differentials, case presentations and even proper procedure technique.

With our tireless Program Director Dr. Robyn Hoelle and Associate Program Director Dr. Tami Vega, we are always ready for novel approaches to enhancing our learning environment and to support us in becoming leaders in emergency medicine!

It’s hard to believe that the first half of the residency year is soon coming to a close. The weather is turning a bit cooler, the nights are getting a bit longer, interns are flying along, second years are taking an even bigger role as lead residents, and third years are starting to receive the positions that they have been working so hard for over the last three years. As the holidays approach, the USF EM program hosted our first Friendsgiving, where current faculty, residents and past alumni joined together in a potluck and a “spirited” game of softball. For the upcoming winter holiday season, we will once again have our USF EM Ugly Sweater contest. Be sure to check out our Facebook and Instagram accounts to see these beautiful creations.

At the beginning of this quarter, we made an appearance at ACEP in Washington, D.C. All who attended had an amazing time. It was great to catch up with old friends and to make new ones along the way.

University of South Florida

Back home at Tampa General, interview season is in full swing. These months are such a Darrell “Clay” Ritchey Jr, MD, MSHCA, MSEd wonderful time to meet the exceptional faces that will soon enter into the EM family. It is also a PGY-2 proud time as we have the opportunity to share with candidates our amazing program, faculty and residents. We could not have been happier with our rotating students this year, and we are very excited to see where all find a home for their future training.

We would like to give special congratulations to three of our senior residents who have accepted positions to continue their education through fellowship. Dr. Nita Avrith has accepted a position at Mount Sinai in New York for Global Health Fellowship; Dr. Mike Butterfield has accepted a position at UC San Diego for Ultrasound Fellowship; and Dr. Stephanie Tershakovec will be staying with us at the University of South Florida as our EMS Fellow.

We would like to welcome Missy Moore as our new program coordinator. She comes to us from our very own emergency department where she had been working with nursing leadership at Tampa General. We are extremely excited that she will be joining our USF EM family!

Lastly, we would like to thank Jean Dunn for all of the support, leadership and guidance that she has provided to those associated with USF EM. We are extremely grateful for all you have done to help make USF EM the program it is today. We wish you all the best on your new endeavors. Happy holidays to everyone from University of South Florida!

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Hospice Reduces Emergency Room Visits

By Lillian Valeron, 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 hospiceappropriate, 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.

EM p u l s e F e a t u r e First Impressions: A Story of First Responders in Puerto Rico Following Hurricane Maria Article by Julian Trivino DO, MS, Chief Resident at Florida Hospital Emergency Medicine Residency and William Kotler, MD, Resident (PGY-3) at Florida Hospital Emergency Medicine Residency The heat and humidity strike you, the air thins, your respirations increase, and you pause to catch your breath. Beads of sweat rapidly accumulate as they begin to make their way down your eyebrows, now the taste of salt on your lips. Your nose senses the stagnant air and illness that fills the rooms. In the background, the whoosh from ventilators pushes air into lifeless bodies — a white noise. Hallway beds surround you. Your spirit quickly overwhelmed by the hemorrhaging moral. On the floor, the word “Emergencias”. As you proceed, you are greeted by puzzled smiles, their light blue scrubs now tainted to a dark ocean blue by the sweat. Their shoulders are slumped, yet their bodies moving hastly as they make their way from patient to patient.

Thirty seconds was all that was needed in this Puerto Rico emergency department (ED) to sense the level of destruction Hurricane Maria had brought to the health care system and its people.

Thirty-six hours prior, we landed as a group of five emergency physicians from Florida Hospital via a United States Customs and Border Patrol Plane. We landed on an island where communication lines were obliterated. This made our arrival a complete mystery, and our agenda a skeleton of a plan. To make matters worse, due to unforeseen delays, we arrived to Puerto Rico at 1 a.m. The streets were dark and desolate as the whole island was under a 7 p.m. curfew.

Due to these limitations, we had no established hotel or method to (L-R) Drs. William Kotler, Alfredo Tirado and Julian Trivino performing a cardiac and transport our supplies. Not because we were ill prepared but because lung ultrasound on a patient with shortness of breath. there was no means of communication as greater than 95 percent of the island was without power. We shook hands with our pilots as the last of our supplies were offloaded in the parking lot. An airport employee offered to take us to a nearby Hyatt where we were met by locked front doors and security guards surrounding the perimeter as concerns for looting threatened the entire island. As we flashed our credentials, we were allowed to enter. Here we were met with open arms by some of the most wonderful staff. Their hearts immediately filled with joy when they read “Dr.” on our shirts. To their knowledge, we were the only physicians that had arrived from the U.S. to aid in their recovery. The remainder of the hotel was filled with military personnel, private security, FEMA employees and private contractors. At 3 a.m., we finally put our feet up.

Down at 3 a.m. and up by 7 a.m., our first day was spent evaluating the EM residency program at Hospital UPR in Carolina and making contact with the Department of Health and FEMA to make sure we went through the proper channels to practice legally on the island (this is still U.S. territory after all). We were given information on the island’s greatest needs, but the red tape was thick. After being issued the first emergency provisional licenses by the Puerto Rico Department of Health, we made the decision to head to a hospital on the brink of closing.

We travelled to the North West part of the island from San Juan, a trip that usually would take two hours now would take four hours due to debris and downed power lines. We arrived midday to Aguadilla and walked into the muggy ED where the temperature was approaching 100 degrees Fahrenheit inside. We met with the hospital’s Board of Directors whose plan was to organize a hospital shut down within the next two hours. We were hardly given the chance to introduce ourselves and explain our mission when a frantic call came from the ED. A patient had gone into cardiac arrest and the only physician in the ED was pre-occupied with the care of another critically ill patient — our instincts took over. One physician to the head of the bed, one starting chest compressions, and one giving orders. Nursing ratios were 15 patients to one nurse, yet all four nurses on duty came to the bedside to assist.

Doctor: “Can we get the patient on the monitor?”

Nurse: “The monitors are down.”

Doctor: “Can we get pads and a pulse ox on the patient?”

Nurse: “Yes, we have pads, but the pulse ox we have to find as it is being used on another patient.”

Following multiple shocks and heroic efforts, the patient was stabilized. The tearful family was soon updated that their loved one was still alive. Five strangers had just introduced themselves to the staff, no words needed — brought together by a shared knowledge and a passion to save our fellow man. As the sweat poured down our faces, we debriefed at the nurses’ station as we formally met our new colleagues. The staff was quick to hand out what little bottled water they had, followed by a cafecito — such is the way of life in Puerto Rico. That night we heard story after story about hardships the staff had endured since Hurricane Maria ravaged the island. One nurse had lost her home and all her belongings. Nurses were giving away their scrubs so they could continue to work her shifts. Once the waters began to calm, one of our colleagues drove to a nearby restaurant and bought dinner for the entire emergency department staff — after all, what better way to make friends than to break bread. Spirits were lifted, and

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smiles began to show themselves.

Two of us spent the night in the hospital seeing all the patients that came into the ED, relieving pressure from the doctors that had been so tirelessly working since the hurricane struck. One of our team members returned to San Juan to continue to cut through red tape. We inquired on the needs of the ED and hospital moving forward in order to stay open. Potable water, tetanus vaccines, normal saline, antibiotics, central lines, laceration repair kits and diesel were the overwhelming needs. We pleaded with the Board to keep the hospital open for another 24 hours as we worked to fulfill their needs via our connections with the Department of Health back in San Juan, as well as our Florida Hospital support system in Orlando. Following the revival of our cardiac arrest patient, morale changed and the nurses seemed excited to work again. The doctors did not seem tired. As the night grew dark, hope shined bright in the ED. We updated our team in San Juan via satellite phone to discuss needs and try to mobilize supplies. The next morning as the sun rose, diesel and potable water trucks started to arrive. We arranged for daily deliveries Drs. Alfredo Tirado, Katia Lugo, William Kotler & Julian Trivino at a school in Utuado that via our contacts in San Juan. The hospital did not close. Through served as a shelter. They triaged the needs of 81 people in need of medications here. these efforts and the incredible selfless teamwork of the entire hospital staff, thousandths of people located on the North West of the island received the care they deserved. We resuscitated those in DKA, stabilized COPD and CHF exacerbations, repaired complex lacerations, treated multiple MVC and burn victims, and on more than one occasion obtained return of spontaneous circulation on a pulseless soul. With portable ultrasounds loaned to us by SonoSite, we helped with diagnostic exams both in the ED and the decimated intensive care unit. We were emergency physicians — “jacks of all trades”, experts in whatever needed to be done. Five doctors from Florida Hospital had secured the world’s largest tourniquet around the northwest corner of the island and the hearts of their people. We may have been five in bodies, but we were an army made possible by those working overtime in our absence. We were representing all those who wanted to make the trip but could not. We were Florida Hospital, we were Team Health — we were an army of thousands camouflaged as five physicians from Florida.

After we helped stabilize the Aguadilla hospital, we made our way back to San Juan. Shortly after, we met with Dr. Antonia Novello, who much like us, found a way onto the Island while thousands were praying to leave. A legend in Puerto Rico, she was the first female and Hispanic to serve as Surgeon General to the U.S. She would become an integral part of our team moving forward. Once word spread of our success at keeping this crucial hospital open, we were asked to assess the medical needs of other hospitals throughout the Island. Our next task was to go deep within the mountains to places no outsider had travelled since the hurricane struck.

For the remainder of our trip, we would have to travel in both military and private helicopters to reach decimated towns deep within the island. We brought medical supplies, lifted morale, and provided water and food to those isolated by Mother Nature.

The antibiotics, insulin and supplies delivered would leave a mark farther than our eyes would ever see. Our journey took us to 28 different towns. We made sure to not only assess hospitals but also assisted living facilities, nursing homes and orphanages — we tended to any patient who required medical assistance. Call us the whitest black cloud. On two separate occasions, we arrived at a clinic as a trauma code rolled in. These clinics were not equipped to handle traumas, and personnel was not trained to manage such complex cases. On each occasion, we took over and worked to stabilize and establish definitive management for the patient.

We did all that we could to save lives and touch hearts.

Our hearts were heavy as the time approached for us to return to Florida, although this time, they were filled with joy. We were grateful for the opportunity to partake in the revival of such a beautiful island and its resilient people. We made an impact because of our training, our devotion to our careers, and the countless number of hours we spent studying. Suddenly, all those missed weddings, dinners and birthdays no longer weighed so heavy on our souls. At times, our profession can seem so thankless, and it takes an experience like this to revive one’s spirits. An experience with no EMR, no door to disposition — just pure unadulterated medicine.

As I sat on the plane on our return flight, the words of one of our nonphysician team members resonated with me: “Seeing you care for the critically ill and not being able to help made me feel so impotent. When I have a child, I hope they become a doctor and experience the feeling you have had by touching the lives of so many.”

Dr. Julian Trivino reads a C-spine X-ray outside the Aguadilla hospital.

As I returned to the U.S., I thought about his words. I thought about how privileged I felt to be a physician. I thought about how what we do as physicians truly matters. More so, it made me realize how often I lose sight of this. What we do is incredible and we are blessed for the opportunity to serve others. For this, I am grateful. Now its time for you to take a look in the mirror and remind yourself that you too are spectacular and what you do is AMAZING.

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EM p u l s e F e a t u r e A Look Ahead: Emergency Medicine Days 2018 Article by Sanjay Pattani, MD, MHSA, FACEP, Emergency Medicine Days Co-Chair

Welcome everyone to another round of legislative session season! Can you believe it? Emergency Medicine Days 2018 is right around the corner. FCEP has already been engaged on many legislative issues that are very familiar to the College.

We have already begun meeting with local representatives, and educating other public officials on our patient-centered concerns with some of the bills proposed. Here’s what’s on the radar: Opioid epidemic: Opioids now kill more Americans under 50 than any other cause. The epidemic has been declared a public health emergency this year by Fla. Gov. Rick Scott. FCEP has formed a coalition, led by FCEP Board member Dr. Aaron Wohl, who has talked with bill sponsors, given interviews on NPR and worked ceaselessly to educate the public on opioid treatment. The FCEP taskforce has reinforced and educated on addiction fighting strategies, including short-term intensive treatment beds, long-term outpatient services, and back medically-assisted treatment options which have been shown in the literature to improve treatment success. This session, EM will face issues including limitations on number of narcotic prescriptions written, mandatory CME, mandatory checking of the prescription drug monitoring program (PDMP), and integrated EHR to identify and help abuse patients.

Fair Payment/Balance Billing: Spearheaded by Dr. Duva, we continue to advocate against “narrow networks” and unfair payment practices. Last year, the Florida Legislature banned balance billing with a PPO law, which essentially mirrored the Florida HMO law. Current discussion now shifts toward the mediation process known as MAXIMUS to determine the usual and customary reimbursement. We are starting to see some individual insurance companies acting as bad-faith players, instituting claw-backs and rejecting claims. FCEP appealed to OIR, which ruled in favor of the insurance company. We are now working through both MAXIMUS and the small-court system to ensure fair reimbursement to emergency physicians, as well as work out long-term plans with legislature to address fair payment to physicians.

PIP: Led by Drs. Damian Caraballo and Daniel Brennan. Recurrent effort to repeal current state’s no-fault auto insurance program. Current legislation replaces PIP with mandatory bodily injury (BI) liability coverage. The bill is nearly identical so far to legislation last year that passed the House. A Senate version, requiring medical payments for a set aside Medpay system for emergency hospital-based physicians, did not reach a vote in the full chamber.

Maintenance of Certification: Seen last year and resurfacing, there is contention among FCEP and ACEP regarding this bill. It potentially states that a hospital, HMO or state licensure cannot require MOC recertification for hospital admitting privileges, insurance reimbursement or state medical licenses. FCEP had a productive conversation with ABEM on MOC, and we will continue to hear about this issue moving forward both at state and national levels.

These are among the many issues we will continue to work on as we get closer to EM Days. Remember that session is early this year, and EM Days will be January 16-18, 2018. Our last round of committee meetings this week will focus on our organizational message and strategies to improve our communication. If you have a chance, please take the opportunity to mingle with your local representatives during the holiday season. Until January, I wish you and your family a happy holiday season, and a happy new year!

Approved for AMA PRA Category 1 CreditsTM

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EM p u l s e F e a t u r e ACEP on the Front Line of Emergency Physician Payment Article by Jordan Celeste, MD, FACEP, FCEP Board member ACEP APM Task Force Nationally, ACEP has spent multiple years preparing for changes in the emergency medicine payment landscape in the new era of health care that followed passage of the ACA, and subsequently MACRA following repeal of the flawed SGR formula that CMS used to update physician payments. Task forces were convened to keep the finger on the pulse of regulations that may affect the specialty, as well as to determine how emergency medicine may fit into new payment models moving forward.

Specifically, ACEP’s APM task force was formed to address how emergency physicians could participate in Alternate Payment Models, and thereby qualify for enhanced payment under MACRA – up to a 5 percent incentive if you qualify as an advanced APM. The task force quickly took three potential paths, generally described as encounter-based, disease-based and populationbased. After much work and engagement of specialized consultants, the task force was able to submit a proposal to PTAC (Physican-Focused Payment Model Technical Advisory Committee), which is the body that evaluates and makes recommendations to the Secretary of Health and Human Services on Physician-Focused Payment Models (PFPMs). This model is entitled Acute Unscheduled Care Model (AUCM): Enhancing Appropriate Admissions (A Physician-Focused Payment Model for Emergency Medicine). This model is designed to facilitate safe and appropriate discharges while creating Medicare savings. The model can be found online at https://aspe.hhs.gov/ptac-physician-focused-payment-model-technical-advisory-committee. The proposal was not included on the agenda for the December 2017 PTAC meeting, but in the meantime, the task force is working on a populationbased submission as well.

ACEP/EDPMA Joint Task Force Both ACEP and EDPMA continue to join forces, along with Physicians for Fair Coverage, in address pressing reimbursement issues facing emergency medicine. The task force is divided into three arms – out-of-network/balance billing, Medicaid issues and public relations. This collaborative effort allows for the pooling of resources, as well as the prevention of redundant efforts. Each workgroup has been active and plans to be so in the foreseeable future, with challenges to the Prudent Layperson Standard and fair payment continuing to come up in multiple states.

In addition to tracking issues as they come up in the states, another goal of the task force is to develop resources that the states can use in their legislative and regulatory battles. By being able to have a local and regional presence, the task force is hoping to maximize all available resources in the crucial fight to defend the foundation of emergency medicine.

ACEP’s RUC Team While small in number, ACEP’s RUC team continues to provide large representation for the specialty. ACEP has a member seat on the AMA/Specialty Society RVS (Relative Value Scale) Update Committee, or “the RUC”, that impartially evaluate codes that emergency physicians do not bill. The team also consists of advisers, who present the codes that emergency physicians do perform, as well as dedicated staff members who help navigate through the process. As this process is budget neutral, it often conjures up images of smoke-filled back rooms or folks fighting over “their piece of the pie”. The process is actually quite structured and relies on data obtained via survey instrument.

Having some insight into this process is timely and vital because in the coming months you may be receiving a survey regarding the emergency medicine Evaluation and Management (or E/M) codes. These are the 99281-99285 codes that comprise approximately 85 percent of emergency physician coding. These codes will be coming up for review at the April RUC meeting, and it is absolutely critical that your RUC advisers are armed with robust data for their presentation. The recent successes that emergency medicine has experienced at the RUC with our moderate sedation and endotracheal intubation codes was made possible with strong data, and we thank you for your continued contribution to the process.

D a u nting D i a gn o s i s Answer: In this case, a partially avulsed ear can be reattached through suturing or microvasulcar surgery, yet the above small piece of ear tissue may not graft well due to relative avasulcarity of the ear cartilage.

The proper method to preserve avulsed tissue is to obtain sterile gauze, dampen the gauze with cold water and wrap the tissue. After that, put the wrapped tissue into a plastic bag with cold ice water. Do not directly place the tissue on ice. Time is of the essence!

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

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EM p u l s e F e a t u r e The Freestanding Emergency Department: Economic Burden or Benefit?

The Freestanding Emergency Department (FSED) was first conceived in the 1970s in the interest of improving access to emergency care in geographically disadvantaged locations. By 1978 there were 55 FSEDs in the U.S., a number that has grown to 400 as of 2015.1 In Florida, the number of FSEDs has nearly doubled from 15 in 2014 to 28 as of 2016.2 Medicare began coverage for care given in FSEDs in 2004.3 Arguments supporting FSEDs include the ability to provide high-quality emergency care in underserved areas, decreased patient wait times and improvement in hospital emergency department (HED) crowding. There exists concern, however, Joshua Novy, MS MD/MBA student at University of that the increased access to emergency care services created by the growing number of FSEDs Miami Miller School of Medicine may promote increased use of these facilities for conditions that could be adequately treated in a primary care setting, driving an increase in health care costs. Relatedly, in 2017, an article in Inquiry reported an association between the growing number of FSEDs and an increase in Medicare expenditures. Given the proliferation of FSEDs in Florida in the past few years, it is worthwhile to examine the impact these facilities have on the cost burden of emergency care in the Sunshine State. Using ED visit data from FloridaHealthFinder.gov, the benefits and burdens of FSEDs in Florida can be evaluated, and I will elaborate on my approach to answering the FSED question for Florida. Facility data for 2014-2016 was retrieved via the Emergency Department Query Tool on FloridaHealthFinder.gov; data was surveyed for 213 HEDs and 28 FSEDs, and then stratified by patient disposition, which, in the absence of corresponding Emergency Severity Index (ESI) data, serves in this review as a surrogate for visit acuity. Dispositions reported as “…

Steven G. Ullmann, PhD transferred to a short-term general hospital for inpatient care”, “…transferred to a psychiatric Chair, Department of Health Sector Management & Policy, hospital”, “…transferred to a designated cancer center or Children’s Hospital”, “…transferred School of Business Administration, to a Critical Access Hospital”, and “Expired” were assigned to surrogacy for ESI levels 1 and 2.

University of Miami Dispositions reported as “Discharged to home or self-care” were assigned to surrogacy for ESI levels 3 through 5. Disposition data was further stratified into six Principal Payer groups (Commercial Health Insurance, Self pay, Medicare, Medicare Managed Care, Medicaid, and Medicaid Managed Care). Total charges to each principal payer group within either ESI surrogacy class were averaged for total visits in their respective surrogacy classes. The acuity surrogacy classification assumes that a patient triaged at ESI 1 or 2 will either be hospitalized or expire, and that patients triaged at ESI 3 – 5 are sufficiently stable that they will not require hospitalization, but still require emergency care. It is noteworthy to mention that visits to FSEDs (as a percentage of total ED visits) have increased from 3.3% in 2014 to 6.1% in 2016, and FSED billing for 2016 reflects a 248.6% increase from billing in 2014. In 2016, FSEDs in Florida billed roughly $2.19B, but this accounts for only 4.58% of ED billing in Florida in 2016. This information becomes particularly meaningful when stratified by ESI surrogacy. For the ESI 1 & 2 surrogacy class, charges for FSED visits averaged $10,740, while charges for HED visits averaged $9,629.67. For the ESI 3-5 surrogacy class, charges for FSED visits averaged $3,973, while charges for HED visits averaged $5,489. It becomes apparent that for severely ill and injured patients, FSEDs may strain the cost burden compared to HEDs; however, this accounts for only 1.13% of the FSED visits examined in this analysis. The ESI 3-5 surrogacy class represents nearly 99% of FSED visits and the cost burden of this group must be considered as well. For lower acuity conditions, then, FSEDs reduce the cost burden compared to HEDs. Notably, all payer groups reviewed in this analysis benefitted from a lower average cost for ESI 3-5 surrogacy visits seen in an FSED compared to an HED. Given the existing problem of HED overcrowding, FSEDs may remedy this by improving access to care for non-life and limb threatening illness and injury that is above the level of acuity for a primary care setting. Greater resolution on visit acuity in the data would be helpful to more precisely assess cost burden as a function of illness/injury severity, though we believe this pilot analysis indeed demonstrates the existence of a relationship between the two.

References

1. Gutierrez C, Lindor RA, et al. State Regulation of Freestanding Emergency Departments Varies Widely, Affecting Location, Growth, And Services Provided. HealthAffairs 35, no. 10 (2016):1857-1866.

2. Emergency Department Query Tool, FloridaHealthFinder.gov 3. Patidar N, Weech-Maldonado R, et al. Freestanding Emergency Departments Are Associated With Higher Medicare Costs: A Longitudinal Panel Data Analysis. Inquiry 54: 1-8. 2017.

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Recommendations for a Vulnerable Population

Article by Michael Lozano Jr., MD, FACEP, Senior Vice President, Envision Physician Services

Ask anyone who has ever spent any significant time in an emergency department (ED), and they would be able to tell you about the impact that mental illness and substance abuse have on our healthcare system. I mention both because they are intertwined. Numbers vary, but it has been reported that about a third of alcohol and 40% of cigarettes are consumed by individuals diagnosed with mental illness. There is also research suggesting that a shared genetic vulnerability could account for these dual diagnoses. The ED visits rate for these patients has increased over the past ten years, so attention to the care of behavioral health patients is increasingly relevant to the practice of emergency medicine (EM). This article covers several areas to focus on as you improve the care delivered to these patients.

Few other terms in EM are so widely used yet so imprecisely defined as medical clearance.

The topic is hotly debated in both the EM and psychiatry literature. Medical minimalists argue for an H&P and a blood glucose, while those at the other end of the spectrum argue for full blood testing (especially alcohol) and urine drug screens. Imaging studies with head CT is frequently advocated – especially in HIV+, elderly, traumatized, or immunocompromised patients. Your department protocol is likely the product of several years of gradual evolution.

Ensure all relevant stakeholders are involved when you update it, and look for opportunities to minimize inter-provider variability. Whatever clearance protocol you agree upon, ensure that there is a reporting mechanism so that neither side of the transfer call can deviate and put up a roadblock to an appropriate transfer.

Restraints are an important area to focus on from a regulatory perspective. Whether you’re surveyed by Joint Commission or DNV, be sure that you have reviewed your restraint policy and adhere to it 100% of the time. The whole point of increased vigilance of restrained patients dates back to several tragic deaths of patients who strangled themselves in vain attempts in get out of chest restraints. Be sure that all of your doctors, nurses, and allied health personnel are aware of the documentation standards (including frequency) in your policy. Restraints should never be used as punishment, or to make up for insufficient supervision.

Along the lines of supervision is the concept of hand offs. All too often, “cleared” patients waiting on transfer or psych evaluation are considered “inactive” and shed physician assignment as the shifts go by. What you then have is a patient in the ED being taken care of by the nurses, but no de facto physician of record. Best practice is to have every single patient accounted for and assigned to an active physician all the time. You should also write a progress note no less than daily. Remember, you are responsible for everyone in the ED.

Snapshots from Life After Residency 2017 Photos by Samantha Rosenthal, FCEP Communications Manager

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Musings Of a Recently Retired Emergency Physician P otpourri

Article by Wayne Barry, MD, FACEP

I am finally recovering from my apoplexy over the health care debacle in Washington. I was cautiously optimistic that some Republicans, however ungraciously they have reacted to their defeat, would finally sit down with Democrats and try to fix the ever-growing defects in the ACA — for the betterment of the country and its citizens. Indeed, there was talk about maintaining Federal subsidies so that less-advantaged Americans could continue to purchase Obamacare insurance policies, but no-o-o-o-o-o. Still stinging from “personal” defeat over health care, President Trump seems hell bent on dismantling Obamacare piece by piece so that it will “implode on itself” — because it such a terrible piece of legislation. I guess he considers it fake news that about 60 percent of the U.S. population is actually in favor of one or more of the provisions of the ACA — especially covering pre-existing illnesses and dependent children until age 26 — and are (shudder) benefiting from being covered with health insurance which they never had before.

Wayne Barry, MD, FACEP

Trump wants to stop insurance funding for contraception as part of women’s health, and he stopped extra payments to insurance companies to offset upward pressure on ACA premiums.

Ironically, a lot of companies will continue to provide contraception to women desirous of this service, and the Feds are still stuck with subsidizing poorer Americans on Obamacare for their premium payments no matter how high they may rise due to unpredictable and unstable market forces. Am I missing something, or does this behavior on the part of our president and his sycophants mean-spirited toward women and poor people or what? On November 1, Open Enrollment for Obamacare recommenced. President Trump has emasculated the efforts made to help inform people about, and help them enroll in, it. These acts would not be so counterproductive if there were viable alternatives to the ACA, but there is NO REPUBLICAN PLAN for health care. I also cannot figure out why President Trump goes out of his way to disparage everything that President Obama and even some other past Republican presidents have done, getting many of his facts wrong in the process. This behavior embarrasses me and makes me wonder whether I should just accept it as due to his popularly held psychiatric diagnosis (malignant narcissism). I guess I should instead feel sorry for the man like I have been taught to do for patients with afflictions even if the diagnosis is an untreatable one.

On another note, the much-awaited Republican Tax Cut and/or Tax Reform bill was revealed recently. Distressing to me, just like the ill fated “Repeal and Replace Obamacare” fiasco, no members from the other side of the aisle were consulted in its creation. Now lots of people are quickly analyzing who the winners and losers are. It appears that poor people have lost again. Apparently, you have to be inside the middle class to realize some tax savings, more specifically with regard to medicine, medical expenses are no longer deductible which would seem to leave many people who have medical bills they are at least in part responsible for paying out in the cold. To be fair, it is doubtful that many of these people itemize their tax deductions in the first place. I find it astonishing that so many Republican lawmakers are again hell bent on getting some kind of legislation passed when they have failed to accomplish any significant legislation in the face of an enormous legislative advantage of controlling both Houses of Congress and the U.S. presidency. Anything for a win even though adding $1.5 trillion to the national debt over the next 10 years flies in the face of the bedrock principles of the Republican Party.

We will soon see how anxious some hypocritical Republicans are to win. Oh I forgot — aren’t we already “tired of winning so much” yet (please excuse the sarcasm)? Again, I feel that I am missing some of the big picture here. Lawmakers are desperate for a legislative win that they are willing to compromise their bedrock Republican political values, which are to shrink government and cap out of control spending. And the ultimate goal is to get re-elected. “Good grief” as Charlie Brown used to say. Are these characters trying to pass legislation to help the American people? Their collective popularity rating is less than 12 percent. Why should we even care about them?

So where does this leave us emergency physicians and our patients? How many of the recent newly insured will fall out of their health care coverage? How will that affect our rising ER censuses and decreasing access to medical care? How many more patients will become medical paupers because of staggering financial burdens incurred as a result of ER visits? I think most of us know the answers to these questions. I only wish the individuals in the U.S. Congress and the White House would think about these issues and do something heartfelt and productive about them for the sake of American citizens.

32 | EMpulse

WINTER 2017-2018 | VOLUME 24, ISSUE 4

Introducing

E M L RC O N L I N E !

FEATURED COURSES INCLUDE: • Street Drugs Series

This series is a collection of lectures that reviews emerging topics and trends within the realm of street drugs.

• Unfamiliar Pediatrics - A Closer Look

Reviews topic areas that are not commonly seen by the prehospital provider such as newborn resuscitation, cardiovascular and respiratory emergencies, and trauma and non-accidental trauma.

• Primary Amebic Meningoencephalitis (PAM) Online Course

Reviews the pre-hospital red-flags and clinical guidelines for the diagnosis of primary amebic meningoencephalitis (PAM).

Visit EMLRCOnline.org for more information!

Approved for AMA PRA Category 1 CreditsTM, along with nurisng and prehospital continuing education units/hours.

Thank You For Your Support In 2017!

Thanks to all who made contributions to the Capital Campaign in 2017!

Miguel Acevedo Advantage Insurance Group, LLC Partrick Agdamag Ashley Booth-Norse Jordan Celeste Chepenick Management Inc Arthur Diskin Emergency Medicine Professionals (EMPros) Findeiss Family Foundation Florida Association of EMS Medical Dirrectors Florida Emergency Physicians Vidor & Allyson Friedman Charitable Fund Antonio Gandia Gary Gillette Mylissa Graber James V. Hillman Hoelle, Robyn Todd Husty Steven Kailes Gary Lai Michael Lozano Kristen McCabe-Kline William McConnell David Meurer Nina Roman Brian Nobie Ernest Page Sanjay Pattani The Physicians Advocate, LLC Russell Radtke David Seaberg South Miami Criticare Joel Stern Adrian Tyndall Jill Ward Kendall Webb Aaron Wohl

Thanks to all who made contributions to the Political Committees in September to November 2017!

John Bellew David Bryant Carlos Castellon Michael Cecilia Jordan Celeste Alan Claunch Richard Courtney Steven Eccher Michelle Fox-Slesinger Jeffrey Francis Jennifer Fredericks Manning Hanline Nicolas Heft James Hillman Reuben Holland David Husband Shiva Kalidindi Ahmad Ksaibati Thomas Leonard Arthur Maduabia Christopher Martin Michael Maxwell Ryan McKenna James David Melton Pamela Miller Daniel Mukamal Daniel Peterson Russell Radtke Scott Riley Andres Rodriguez Steven Schmidt Sarah Spelsberg Michael Stary Andrew Thomson Wenzel Tirheimer Richard Walbert Gary David Wright Albin Xavier Frederick Yonteck

Thanks to all who made contributions to the Dr. Sal Silvestri EMS Research Fund in 2017!

Miriam Gamble Rory Hession Sean Isaak Jennifer Jackson Steven Kailes Gary Lai Wayne Lee Michael Lozano David Lubin Amit Rawal Roxanne Sams Charles Sand Michael Sayre Kathleen Schrank David Seaberg Richard Shih Richard Slevinski Linda Swisher Robert Swor Andy Godwin Scott Silvers David Carr Andy Jagoda

THANK YOU TO OUR 2017 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 2017 corporate partners for believing in our mission and helping us to provide life-saving education to life savers!

Approved for AMA PRA Category 1 CreditsTM

We would like to acknowledge the EM groups and hospital that have 100 percent membership in FCEP and ACEP. Thank you for your involvement in both FCEP and ACEP!

Niala Ramoutar Director of Education FCEP/FEMF

After a 15-month long process, which included preparation of an organizational self-study, several performance-in-practice reports, and an in-depth interview with FCEP and FEMF/EMLRC leadership, the Accreditation Council for Continuing Medical Education (ACCME) has renewed the Emergency Medicine Learning & Resource Centerâ&#x20AC;&#x2122;s application for accreditation. EMLRC will remain an ACCME accredited provider through November 2021. ACCME accreditation is a voluntary endeavor that assures the public and medical community that the accredited organization is a strategic partner in health care quality and safety initiatives, providing physicians with relevant, effective education that meets their learning and practice needs that are designed to be independent, free of commercial bias, and based on valid, scientific content.

FEMF/EMLRC continues to position itself as an organization that facilitates the continuity of care within the entire team of emergency medicine professionals through the provision of quality continuing medical education activities.

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

ACCME Accreditation Announcement

Florida College of FCEP | Emergency Physicians

All Childrenâ&#x20AC;&#x2122;s Emergency Center Physicians Athens-Clarke Emergency Specialist Brevard Physician Associates, PLLC Emergency Medical Professionals , PA Emergency Medical Associates of Tampa Bay, LLC Emergency Physicians of Central Florida LLP Florida Emergency Physicians Florida Regional Emergency Associates Southwest Florida Emergency Physicians Tampa Bay Emergency Physicians UF Department of Emergency Medicine Group University of Florida Jacksonville

3717 South Conway Road, Orlando, FL 32812

FCEP Recognizes 100 Percent Membership!