EMpulse Winter 2019

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

CARING FOR CHILDREN: New Recommendations on Emergency Care for Children Bronchiolitis in Infants and Children Meet FCEP’s Pediatric Committee

ALSO FEATURING: The Case for MAT Induction in the ED The Pulmonary Embolism Response Team: Coming to an ED Near You Is There an Emergency Physician Shortage in Florida?

VOL. 25, NO. 4 | WINTER 2019

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WINTER 2019 | VOLUME 25, ISSUE 4

TABLE OF CONTENTS Florida College of Emergency Physicians

FCEP COMMITTEE REPORTS

4 5 6 7 8

FCEP President’s Message J. Adrian Tyndall, MD, MPH, FACEP Government Affairs Damian Caraballo, MD, FACEP ACEP President's Message Vidor Friedman, MD, FACEP EMS/Trauma Benjamin Abo, DO, EMT-P, FAWM & Christine Van Dillen, MD, FACEP Medical Economics Danyelle Redden, MD, MPH, FACEP

9

Membership & Professional Development René Mack, MD, RDMS, FACEP

11

Pediatric Committee John Misdary, MD, FACEP & Todd Wylie, MD

FCEP Executive Committee

18

EMRAF Misty Coello, MD Medical Student Committee Kimberly Herard

President-Elect Kristin McCabe-Kline, MD, FACEP, FAAEM, ACHE

25

QUARTERLY COLUMNS

6 19 28

Daunting Diagnosis Karen Estrine, DO, FACEP, FAAEM Residency Program Updates Florida’s EM Residency Programs Ultrasound Zoom: Twinkling Renal Stones Grant Barker & Leila Posaw, MD, MPH

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

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38

Poison Control: Brodifacoum Poisoning: A New Risk in the Use of Synthetic Cannabinoids Kristen C. Lee, PharmD, BCPS & Madison Schwartz, Pharm.D. Musings from a Retired EM Physician: A Funny Thing Happened at the Social Security Office Wayne Barry, MD, FACEP

President J. Adrian Tyndall, MD, MPH, FACEP

Vice President Sanjay Pattani, MD, MHSA, FACEP Secretary-Treasurer Damian Caraballo, MD, FACEP Immediate Past-President Joel Stern, MD, FACEP, FAAEM Executive Director Beth Brunner, MBA, CAE

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

Upcoming Deadlines Spring 2019 Ad Deadline: March 1, 2019

FEATURES

11

New Recommendations on Emergency Care for Children Madeline Joseph, MD, FACEP, FAAP

12

ED Evaluation & Management of Bronchiolitis in Infants & Children Michael Tandlich

14 17

26

32

An Update on the Opioid Crisis: The Case for MAT Induction Aaron Wohl, MD, FACEP Working Together to Reduce Patient Harm, Avoid Readmissions & Improve Quality Kim Streit

36

Spring 2019 Article Deadline: March 4, 2019

The Lack of Evidence of an Emergency Physician Workforce Shortage in Florida David Orban, MD, FACEP & Barbara Langland Orban, PhD The Pulmonary Embolism Response Team: Coming to an ED Near You Tim Montrief, MD, MPH, Justin Rafael De la Fuente, MS-2, Jeff Scott, DO, FACEP, EDIC Member Spotlights: Meet Your E-Board René Mack, MD, RDMS, FACEP & Shayne Gue, MD

EMPULSE WINTER 2019

Published by: Johnson Press of America, Inc. 800 N. Court St. Pontiac, IL 61764 t: 815-844-5161 | f: 815-842-1349 www.jpapontiac.com All advertisements in EMpulse are printed as received from advertisers. Florida College of Emergency Physicians does not endorse any products or services, except those in its Preferred Vendor Partnership. FCEP receives and distributes employment opportunities but does not review, recommend or endorse any individuals, groups or hospitals that respond to these advertisements.

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

3

COMMITTEE REPORTS

FCEP President’s Message

By J. Adrian Tyndall, MD, MPH, FACEP FCEP President | Interim Dean of UF College of Medicine

CREATING FORWARD MOMENTUM Once again, the legislative season is upon us and the halls of Tallahassee are in the throes of determining the direction the state of Florida will take in serving its citizens. By the time you read this article, the Governor has worked through his transition teams and appointed his cabinet and leadership. The House and Senate leadership will have coalesced. This is a time when the Florida College of Emergency Physicians becomes active again in an area in which we have distinguished ourselves: advocacy for our practices and patients that we serve throughout the state.

In order to prepare for this season of advocacy, we need to refocus on the foundations of our organization and review our strategic goals. Several years ago, FCEP Past-President Dr. Steve Kailes initiated a strategic planning process during his presidency. This critically important planning activity has become central to creating forward momentum for the college. The 201618 strategic goals centered around FCEP’s role as a leader in emergency medicine legislative and regulatory advocacy in the state of Florida, and focused on the importance of relationship building with our legislators, proactive planning and funding of our advocacy efforts and engagement with our members across the state to tirelessly support access to care for all citizens in the

4

state of Florida. Closely aligned with these strategic goals is our continual expansion as a high impact presence in education and training for emergency medicine professionals across the state.

In the coming weeks, FCEP leadership will be focused on re-energizing our goals for 2019-21. It is my intent that the top goals and objectives be posted on our website and disseminated to our membership. In the meantime, we aim to ensure that our leadership interacts as much as possible with our members—and especially with our residency programs across the state—to join forces with our sister organizations and discuss the goals of FCEP as well as our converging legislative priorities.

In my last column, I emphasized the importance of thinking of ourselves as the best possible advocate for our patients, and how important our unwavering commitment to advocacy was for the patients we treat and for the system within which they receive that treatment.

We need the presence, activity and strength of our members to continue the trajectory that has been set through the tireless efforts of all those who preceded us.

The time is now to get involved in organized medicine.

Forward momentum is my vision. ■

EMPULSE WINTER 2019

COMMITTEE REPORTS

Government Affairs Government Affairs

By Damian Caraballo, MD, FACEP Government Affairs Committee Chair | FCEP Secretary-Treasurer

November marked the U.S. midterm elections. In one of the wildest midterms in recent memory, Republican Ron DeSantis edged out Democrat Andrew Gillum for Florida governor, while Republican Rick Scott narrowly beat out Senator Bill Nelson. Overall, the U.S. House flipped to Democrat majority (224 to 197), while Republicans added 3 seats to take a 5-seat lead in the Senate (51 to 46 as of this writing).

The election of Governor DeSantis means he will work closely with the newly appointed Speaker of the House, Jose Oliva (R) from Miami Lakes. Speaker Oliva was one of the first Representatives to support DeSantis during primaries, so expect them to work closely together during the 2019 legislative session. Speaker Oliva has said that healthcare is his number one issue. Per past statements, he is a big advocate in expanding scope of practice in medicine, reducing medical costs, ending certificate-of-need for hospitals and expanding healthcare free-market competition by expanding telemedicine and surgical-center access.

As emergency physicians, we can expect another scope of practice battle in a repeat of last year's pharmacy bill, which would enable pharmacists to diagnose and treat flu/strep. Groups such as the FMA will also likely face a standoff over the expanding independent scope-of-practice for nurse practitioners. Governor DeSantis and Speaker Oliva will present some opportunities for the expansion of telemedicine billing. His willingness to encourage market-competition could potentially lead to independent, Texas-style, non-hospital-associated, free standing emergency departments here in Florida. It also will provide big growth opportunities for groups who are innovative in cost-saving solutions, as well as providing out-of-hospital care. Also ex-

pect some traction on increased inter-hospital data sharing, perhaps in an EDie-type system, which could revolutionize the way we currently share medical information. As always, FCEP will use the change in leadership to further combat unfair and predatory insurance practices.

From the Senate side, Bradenton Senator Bill Galvano (R) will take over as Senate President. Expect him to push for further opioid laws and funding to combat our state opioid crisis. We can also expect a third round of proposed Personal Injury Protection repeal, which, without an emergency med-pay carve-out, could pose significant reduction in revenue for emergency physicians who see both major and minor MVA-trauma patients, as well as limit access to EMTALA-related specialists. The more moderate Senate tends to be more sympathetic towards hospital systems, so we should expect a battle for hospital funding between the House and Senate.

As usual, FCEP will closely monitor all bills and tirelessly continue advocating for fair payment, physician rights, better access to care, opioid treatment, and any other EM issues that arise. If you would like your voice heard in Florida, please plan on attending FCEP’s EM Days on March 11-13, 2019 at Hotel Duval in Tallahassee. This is our chance to congregate and meet with state legislators and leaders to advocate for better emergency care in Florida. I’ll also throw an obligatory mention of the importance of donating to the FCEP PCs: through our funds, we were able to donate and form relationships with Speaker Oliva and President Galvano during their re-election bids, as well as support many victorious committee chairs who will be instrumental in shaping the current state of emergency medicine practice in Florida. ■

The Premier Advocacy Event for FCEP Members March 11-13, 2019 Hotel Duval in Tallahassee, FL Registration Now Open

emlrc.org/emergency-medicine-days EMPULSE WINTER 2019

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COMMITTEE REPORTS

ACEP President’s Message

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

As I sit down to write this, it is a little over a month since ACEP18. It has been a bit of a whirlwind…

Let me start back in San Diego. I was elected by the Board in June to fill the President-elect position (via a special election), but that needed to be ratified by the Council in San Diego. On the first day of the Council meeting, Speaker Dr. McManus asked if there was any objection to ratifying my election by unanimous consent. There was dead silence… you could have heard a pin drop in that room! While I was pretty confident that I would be ratified by the council, when it actually happened, I felt both relief and an incredibly heavy weight descend from my shoulders.

ACEP ELECTIONS: ACEP PRESIDENT Dr. Vidor Friedman PRESIDENT-ELECT Dr. William Jaquis VICE PRESIDENT Dr. Gillian Schmitz SECRETARY/TREASURER Dr. Mark Rosenberg CHAIR OF THE BOARD Dr. Stephen Anderson RE-ELECTED TO THE BOARD Drs. Christopher Kang & Mark Rosenberg ELECTED TO INITIAL TERMS Drs. Anthony Cirillo & JT Finnell

For me, taking on this position is about giving back to the profession that has given me so much. It is an incredible responsibility that does weigh heavily on whomever steps into this role.

My group (Florida Emergency Physicians of TeamHealth) has once again granted me the protected time to take on this full-time role. I really could not do this without them behind me—most presidents spend about half the year on the road!

I want to give a big shout out to my friends and colleagues in the Florida Chapter who have been so supportive of me for many years. You are the best!

And of course, I am ever-thankful for my wife Allyson, who has been patient and gracious as I follow my dreams.

I returned from San Diego with 28 action items, aside from the 34 resolutions passed by the Council. I have been working to delegate these issues to our many talented members and committees.

The most significant issue that has come up is an effort by a group of six bipartisan senators to address balance billing on a federal level. Led by Senator Cassidy (R-Louisiana), this group has been working since the summer on exploring possible legislation to address “surprise bills.” ACEP has

Daunting Diagnosis: Q

By Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief 6

A 20-year-old male presents to the ER two days statuspost gunshot wound to right forearm. He was treated at an outside facility and now returns with a swollen, indurated right forearm with inability to fully open his right hand. How was this patient treated inappropriately, and what must be ruled out?

ANSWER ON PAGE 16 ► EMPULSE WINTER 2019

met with them several times regarding this initiative. In October, I flew to D.C. to meet with them and discuss how emergency medicine is different from the rest of the house of medicine, and how this needs to be taken into account regarding this issue. While we would all like the patient taken out of the middle, the under-insured and uninsured that we take care of, when no one else will, must be part of the overall equation.

As providers of emergency care, we are legally mandated to provide treatment prior to any attempt to ascertain insurance status, or even ability to pay. This is unique within the U.S. healthcare system. We have argued strongly for a minimum benefit standard to be paired with a ban on balanced billing, pointing out that patients contract with health insurance providers to negotiate on their behalf, in good faith, with physicians. We want to preserve incentives for payers to negotiate with providers— otherwise, it is quite likely there will be no emergency providers “in-network.”

We also feel strongly that any co-pays or deductibles should be collected by the insurer, who mandates them; not by the provider of emergency care who has no binding contract with the individual being treated.

It will be another interesting year as we continue to battle for the respect that all emergency physicians deserve. ■

COMMITTEE REPORTS:

EMS/TRAUMA Hurricane Response

By Benjamin Abo, DO, EMT-P, FAWM

Member of Miami-Dade Fire Rescue Florida Task Force 1 Urban Search & Rescue and DMAT FL-5

Capt. Myles Kaplan of Miami-Dade Fire Rescue Florida Task Force 1 assesses damage during Hurricane Michael deployment to Panama City.

In emergency services, we are paid for what we are prepared to do and not so much for what we do. This year’s storm season proved to be just like the others: different than the one before.

nary care for our work dogs. For many, Hurricane Florence was a very long and hard, though rewarding, deployment— that was almost immediately followed

by Hurricane Michael.

As Hurricane Florence gained strength, preparations response was initiated.

North and South Carolina opened their doors to federal assets, including both state and federal Urban Search and Rescue (USAR) teams. Miami-Dade Florida Task Force 1, South Florida Task Force 2 and Pennsylvania Task Force 1 were deployed as large Type 1 teams in South Carolina. These teams offered aid in a variety of ways, including envenomation care, wilderness medicine and emergency veteri-

Hurricane Michael quickly grew to a Category 4 before it slammed into the Florida Panhandle. While Hurricane Florence required flood and swift-water rescues and evacuations, Hurricane Michael proved to be a much different mission, with active rescues, body recoveries from collapsed structures and treating injuries from handling the aftermath. Those deployed to the area would agree that the pictures and videos do not give justice to the sheer destruction right in our own backyard.

Despite austere conditions and infrastructure being all but annihilated (including two majorly-damaged hospitals), teams of firefighters, paramedics, law enforcement, physicians and more contributed to the disaster response system. There is still a lot of work to be done, but just like every other storm, once one mission is complete we have to quickly be at the ready for the next.

I truly believe the heroes of these storms are not just those running towards the disaster, but also those that keep home institutions running while others are gone. We all have a way to help, whether on an outfitted team or not, and I thank every medical provider for their part. ■

FAEMSMD Updates

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

The October FAEMSMD meeting was cancelled due to Hurricane Michael response and recovery efforts. The next meeting will take place in conjunction with the EMS Advisory Council and Constituent Group Meetings on January 23, 2019 from 9:00 am – 1:00 pm at Fire Rescue East.

specialty of EMS and has an extensive background in EMS management. He currently serves as the EMS Medical Director for six fire-rescue agencies in Palm Beach County, including his role as Chief Medical Officer for Palm Beach County Fire-Rescue. Read more about him at emlrc.org/scheppke.

The Florida Department of Health has appointed Kenneth A. Scheppke, MD as Florida’s new State EMS Medical Director. Dr. Scheppke is board-certified in emergency medicine and the sub-

The National Association of EMS Physicians (NAEMSP) is an organization many Florida EMS physicians respect and actively participate in. Thanks to Dr. David Meurer of UF Gainesville, EMPULSE WINTER 2019

NAEMSP approved a Florida Chapter in October. The goal of this group is to collaborate with FAEMSMD and obtain recognition for our activities at the state level; not to compete with or replace the FAEMSMD. Another goal is to liaison between the national group and Florida EMS medical directors.

There are plans to meet at the State EMS Constituency meetings in January.

Learn more at naemsp.org/membership/chapters/florida or by contacting Dr. Meurer at meurer@ufl.edu. ■ 7

COMMITTEE REPORTS

Medical Economics

By Danyelle Redden, MD, MPH, FACEP Medical Economics Committee Chair | FCEP Board Member

Florida Blue Denials The battle continues over claim denials by Florida Blue based on diagnosis codes. Throughout the last year, BCBSFL has been denying high level E&M code claims because they were associated with diagnosis codes that Blue has deemed “low severity,” a practice deemed by FCEP to be a violation of the prudent layperson standard. BCBSFL advises physician practices that the denied claims may be submitted for appeal or resubmitted with a lower level E&M code. Some groups report that denied claims have been paid after re-submission with an appropriate alternate diagnosis code.

Insurer Denial Trends Similar payment disputes are prevalent across the country. ACEP, in coordination with Medical Association of Georgia, has taken legal action against Anthem Blue Cross Blue Shield of Georgia. The lawsuit, filed in federal court, asserts that their policies violate the prudent layperson standard, which requires insurers to cover emergency visits based on symptoms rather than diagnosis codes. Anthem is also being

sued for violation of the 1964 Civil Rights Act, as its emergency denial policies disproportionately affect patients in protected classes. Other insurer policies under fire include denials for emergency care at out-of-network facilities and Medicaid policies which violate prudent layperson. Another denial tactic has emerged in Michigan, in which emergency visits are denied if a patient reports their symptoms have been present for more than 71 hours.

A study published in JAMA Network Open on October 19 investigated the use of diagnosis codes to determine coverage for emergency visits. The cross-sectional analysis of ED visits from the National Hospital Ambulatory Medical Care Survey ED subsample identified visits with Anthem’s non-emergent diagnosis codes. The authors concluded that, if Anthem’s policy were applied to all adult commercially-insured ED visits, it would result in coverage denials for nearly 1 in 6 visits. Further, those visits that would ultimately be denied presented with the same primary symptoms as 9 out of 10 adult commercially-insured visits.

Thus, up to 90% of patients presented to the ED had symptoms that could lead to non-emergent ED diagnoses.1

PAYMENT REFORM SUMMIT COST-EFFECTIVE CARE IN A RISK-BASED WORLD

February 7-8, 2019 EMLRC in Orlando, FL

REGISTER NOW: emlrc.org/paymentreform 8

EMPULSE WINTER 2019

Florida Healthcare Transparency Database In other medical economics news, Florida’s effort to develop a healthcare transparency database has stalled.

Governor Scott signed legislation in 2016 mandating the development of a database that would allow consumers to research the cost of care, procedures and drugs. The Agency for Health Care Administration announced early this year that the database would be complete in June. However, Florida Blue Cross Blue Shield and others have refused to provide the required data, citing privacy and trade secret concerns. At present, the database—which cost $3.5 million—does not have a launch date. ■

References 1. Chou, Shih-Chuan, et al. “Analysis

of a Commercial Insurance Policy to Deny Coverage for Emergency Department Visits With Nonemergent Diagnoses.” JAMA Network Open.

1(6)2018.

Open to all healthcare leaders, including: ED leaders Medical directors EM group business leaders Hospital executives EMS leaders Practice management companies Nursing leadership Academic leaders Revenue cycle management companies

COMMITTEE REPORTS

Membership & Professional Development

By René Mack, MD, RDMS Membership & Development Committee Co-Chair

I had the privilege to serve as an FCEP Councillor at ACEP18, our 50th anniversary, in San Diego. What an amazing experience! I have always known that our College is mighty, but to take an active part in the process leads me to another level of understanding. My experience serving on the Council allowed me to realize a few thing about us: the backbone of ACEP. I was introduced, on a large scale, to the breadth and depth of our knowledge on health-related issues in varying forms.

The other very apparent theme at the Council meetings is that emergency medicine is a passionate specialty, with members who are highly motivated to protect the patients, ACEP, and our specialty.

There were several issues where appropriate (and heated) discussions led to understanding the issues on a deeper level and exposing the real impact of our vote. I, along with other FCEP Councillors, stood up for the members in Florida and brought to light the impact of how a particular vote would affect FCEP and, more importantly, the healthcare of the people in Florida.

I was impressed that after airing the various points, many who were in opposition began to understand the impact on a deeper level, and this allowed for dialogue and eventual resolution.

This leads me to consider the FCEP membership impact at EM Days—our largest annual advocacy event.

Every year, a group of FCEP members travel to Tallahassee to have discussions with the Florida legislature about the agenda as it relates to healthcare. Our goal is to explain the more detailed and nuanced reper-

cussions of their votes’ effects on our specialty and the healthcare of Floridians. Over the years we have made some major impacts, particularly in the areas of balanced billing, opioid policies and prudent layperson—to name a few prominent issues. What we have come to realize is that when we advocate for ourselves and our patients, we can effect change and greater understanding. I hope to see you at the upcoming EM Days in Tallahassee on March 11-13, 2019 so that we can continue having discussions that lead to better healthcare for Floridians and maintain our vision of emergency medicine.

In the last issue of the EMpulse, I alluded to some new features from the MPD Committee, and I am happy to unveil our special section, "Meet Your E-Board," that we hope you will find useful and informative (find it on page 36). Our hope is that interviews with our executive board will get you more familiar with our leaders and create dialogue within our community. This series will also be a kick-off to our online segment, “Member Spotlight,” where we will highlight various members who are doing great work in EM and caring for the people of Florida through various methods. Do you have someone you would like to nominate for the “Member Spotlight” series? We would love to hear from you so that we can continue to get to know each other!

Please join us for our next committee meetings at the FCEP office (or via call-in) on February 13, 2019. ■

ON THE AGENDA Day 1: The Current Legislative & Regulatory Climate: Updates, Opportunities and Challenges • Ten Years of the Affordable Care Act: Where Are We Now and Where Are We Going?

• Successful Data Reporting Leading to Success with MACRA and MIPS • The Acute Unscheduled Care Model: Lessons Learned from ACEP’s First APM • CMS: Potential Changes That Could Affect EM • Poor Payer Behavior: Strategies from the States • Emergency Medicine’s Role in Payment Initiatives

Day 2: Tailoring Clinical Environment to Success and Future Threats • The Free-Standing Emergency Departments: Successfully Extending the Reach of the System, but with Challenges • Telemedicine: Utilizing Emergency Medicine Expertise Outside of the ED • Observation Medicine and Care Coordination: Expanding the Role of Emergency Medicine After the Acute Visit • Emergency Medicine Innovation: How to Successfully Partner with your Hospital • ED Systems Working with Hospitals – Running the Whole Show

Find the full schedule and more details at emlrc.org/paymentreform EMPULSE WINTER 2019

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COMMITTEE REPORTS

Pediatric Committee (new!)

By John Misdary, MD, FACEP Pediatric Committee Co-Chair

By Todd Wylie, MD Pediatric Committee Co-Chair

This is the introductory update from the Pediatric Committee, which was initially started by Dr. Dennis Hernandez as a task force about 10 years ago. After much hard work and with little help, he transformed the group into a committee and, in 2014, turned the committee over to Dr. John Misdary. In 2017, Dr. Todd Wylie became co-chair. Though we are both EM/PEM trained, we embrace the dichotomy of emergency medicine with Dr. Wylie, being an academician as both fellowship director and medical director of the division of pediatric emergency medicine at the UF–Jacksonville Health Sciences Center, and Dr. Misdary, being a private practice physician who practices both general and pediatric emergency medicine in community and tertiary care centers in Tampa Bay.

completed a webinar lecture series for prehospital personnel and have hosted a pediatric track at Symposium by the Sea for the last three years. The strength of our educational endeavors has been in simulation; Dr. Shiva Kalindindi from Nemours Childrens Hospital and Drs. Chrissy Zeretzke and Tricia Swan from UF– Gainesville have been invaluable with their staff delivering the highest quality of high-fidelity medical simulation.

Since 2013, the committee has grown exponentially with pediatric EM physicians from all over the state. Our main goal has been to increase pediatric education throughout Florida in all aspects of medical care. We have successfully

As we look forward to 2019, we will be conducting another pediatric track at Symposium by the Sea with a concentration in pediatric trauma. I would like to thank all members of the committee that have made this a success.

Most of all, I would like to thank the staff at EMLRC who have worked tirelessly to obtain the committee grants and funding in order to put on the educational events. As a committee, will we continue moving forward with the goal of educating first responders, nurses, APPs and physicians on pediatric emergency care. ■

ARE YOU PEDIATRIC READY?

Partnering with Florida EDs and EMS Agencies in the Care of Ill and Injured Children

COMING SOON:

PEDReady Pearls & News Delivered to Your Inbox Learn more at emlrc.org/flpedready 10

EMPULSE WINTER 2019

New Recommendations on Emergency Care for Children On November 1, 2018, ACEP, the American Academy of Pediatrics (AAP) and the Emergency Nursing Association (ENA) announced the publication of updated joint guidelines, “Pediatric Readiness in the Emergency Department.” This marks an important landmark that highlights ACEP’s continuous dedication to improving the emergency care of children.1 The majority of children (83%) present to general emergency departments (EDs) versus specialized pediatric EDs.2 With 69% of EDs providing care for fewer than 15 pediatric patients per day, it is crucial that all EDs have appropriate resources and capable staff to provide safe and effective emergency care for children.

In the 2006 report, “Emergency Care for Children: Growing Pains,” the National Academy of Medicine (formerly the Institute of Medicine) used the word “uneven” to describe the current status of pediatric emergency care in the U.S.3 This is due to the fact that resources within emergency and trauma health care systems vary locally, regionally and nationally.

Launched in 2013, the National Pediatric Readiness Project is an ongoing quality improvement initiative among the federal EMSC program, AAP, ACEP and ENA to ensure pediatric readiness of EDs.4 In phase 1, hospital ED leaders in the U.S. were asked to complete a comprehensive assessment of their readiness to care for children. The assessment was based on the 2009 joint Policy Statement.5-6 The response rate was 83%, representing more than 4,000 EDs.2 The data reveals that while much progress has been made to improve pediatric readiness across communities, there remains a significant opportunity for further progress nationwide and in Florida.4 The recommendations in the 2018 “Pediatric Readiness in the Emergency Department” policy statement1 include current information on equipment, medications, supplies and personnel that are considered critical for man-

By Madeline Joseph, MD, FACEP, FAAP

Florida’s Pediatric Readiness

78

82

state average state median hospital score hospital score n=126

69

nat'l median of hospitals n=4,146

Breakdown of Scores, by Volume Annual Pediatric Volume

# Hospitals

Avg. Score

Median Score

(<1800 patients)

Low

30

70.6

66.8

(1800-4999 patients)

Medium

36

71.7

74.4

(5000-9999 patients)

Medium High

25

80.5

84.4

High

35

89.5

94.1

(>=10,000 patients)

Scores from 2013 survey

aging pediatric emergencies in EDs. There are also recommendations for the administration and coordination of pediatric care in the ED; pediatric emergency care quality improvement (QI), performance improvement (PI) and patient safety activities; policies, procedures and protocols for pediatric care; and key ED support services. It is believed that all EDs in the U.S. can meet or exceed these recommendations, and that some hospitals, such as those with pediatric critical care capabilities or children’s hospitals with greater resources, will develop even more comprehensive recommendations and share their expertise.

An important first step in ensuring readiness is the identification of a pediatric emergency care coordinator (PECC). PECC includes a physician and nurse coordinator for pediatric emergency care who are identified by the ED’s medical and nurse directors. The 2018 recommendations include the qualifications and responsibilities of PECC to assist in pediatric preparedness, along with competencies for physicians, APPs, nurses and other health care providers.

In addition, the 2018 recommendations highlight the need for the ED’s QI and/or PI plan to include pediatric-speEMPULSE WINTER 2019

cific indicators, some of which were identified in the recommendations for system-based or disease-specific measures. Examples include measuring weight in kilogram, identifying agebased abnormal pediatric vital signs and administration of systemic steroids for pediatric asthma. Resources are available to assist ED staff with implementing QI and/or PI activities.

The relatively low frequency of exposure of hospital-based, emergency care professionals to critically ill and injured children and children with special health care needs is a barrier to the maintenance of skills and clinical competencies. These updated recommendations are intended to serve as a resource for clinical and administrative leadership as EDs strive to improve their readiness for children of all ages.

Thank you all for what you do every day and for your commitment to improving emergency care for children. ■

ACEP ACTIVITY Assess the Pediatric Readiness of Your ED

References 1. Remick K, Gausche-Hill M, Joseph MM, et al; AAP Committee on Pediatric Emergency Medicine and Section on Surgery, ACEP Pediatric Emergency Medicine Committee, ENA Pediatric Committee. Pediatric Readiness in the Emergency Department. Pediatrics.

2018;142(5): e20182459 2. Gausche-Hill M, Ely M, Schmuhl P, et al. A national assessment of pediatric readiness of emergency departments. JAMA Pediatr.

2015;169(6):527–534.

3. Institute of Medicine, Committee of the Future of Emergency Care in the US Health System.

Emergency Care for Children: Growing Pains.

Washington, DC: National Academies Press; 2006.

4. National Pediatric Readiness Project. 2014.

Available at: http://ow.ly/Xw2g30mEHxM. Accessed November 1, 2018.

5. AAP, Committee on Pediatric Emergency Medicine; ACEP, Pediatric Committee; ENA, Pediatric Committee. Joint policy statement–guidelines for care of children in the emergency department. Pediatrics.

2009;124(4):1233–1243 6. AAP, Committee on Pediatric Emergency Medicine; ACEP, Pediatric Committee; ENA, Pediatric Committee. Joint policy statement–guidelines for care of children in the emergency department. Ann Emerg Med. 2009;54(4):543–552 11

Emergency Department Evaluation and Management of Bronchiolitis in Infants and Children

By Michael Tandlich MD Candidate, FSU College of Medicine, Class of 2020

Bronchiolitis is one of the leading causes of hospitalization in infants and young children that is often mistreated in the emergency department.

Bronchiolitis is clinically defined by wheezing or crackles in a child less than 2 years of age with history and physical exam findings characteristic of a lower respiratory tract infection (LRTI). A virus is thought to infect and cause damage to the bronchiolar epithelial lining, leading to an inflammatory response. The subsequent inflammatory debris and mucus directly blocks small airways and leads to atelectasis.

Respiratory syncytial virus is the leading cause of bronchiolitis in children less than age 1, as well as medically attended LRTIs in children less than age 5. Rhinovirus is another major cause. Most cases of bronchiolitis have a viral etiology. Additional viral causes may be parainfluenza virus, adenovirus, coronavirus and bocavirus.

A significant number of young children hospitalized for bronchiolitis test positive for two or more viruses.

Bronchiolitis typically occurs in the colder months. Risk factors for increased disease severity include prematurity, age younger than 12 weeks, immunodeficiency, low birth weight, chronic lung disease, anatomic airway defects and hemodynamically significant heart disease.

In an otherwise healthy child, bronchiolitis typically presents with a history of 1-3 days of upper respiratory symptoms followed by the onset of fever and respiratory distress worsened with crying, coughing and agitation.

Signs of a LRTI such as wheezing typically occur most prominently between 4-6 days after initial symptom onset. The disease is usually self-limited and resolves gradually between 1-2 weeks after initial symptom onset.

The diagnosis should be made clinically on the basis of history and physical exam findings. Routine labs and radiographic studies for diagnosis do not need to be ordered routinely unless clinical findings suggest other potential diagnoses.

A crucial step in evaluation of bronchiolitis is the assessment of disease severity. Mild severity is characterized by normal feeding, minimal respiratory distress and pulse oximetry above 95%. Moderate severity is characterized by signs of respiratory distress and mild hypoxemia corrected with oxygen. Severe bronchiolitis is characterized by inability to feed, signs of severe respiratory distress and hypoxemia that is not corrected with oxygen.

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The presence of crepitus on chest auscultation and hypoxemia are sensitive predictors of the need for hospitalization. Patients with severe bronchiolitis often require close observation and immediate treatment, largely supportive. Providing adequate hydration, oxygen with respiratory support as indicated, and monitoring progression of disease are most important. With severe respiratory distress, IV fluids and intensive care unit consultation may be necessary.

Bronchodilators have not been shown to improve oxygen saturation. Corticosteroids are not effective in the immediate treatment of bronchiolitis symptoms. Antibiotics are not indicated as they have no action against viruses, and secondary bacterial infection in bronchiolitis is uncommon. In the emergency setting, nebulized 3% saline has not been shown to reduce hospitalization.

Infants may often develop one or more minor complication. Infants with fever, tachypnea and decreased oral intake are at risk for dehydration. Serious complications may include apnea and respiratory failure and occur more commonly among infants with a history of prematurity or congenital abnormalities. Secondary bacterial infection is unlikely in the absence of fever, but intubation and ventilation may increase the risk of bacterial pneumonia. Palivizumab is a monoclonal antibody against RSV reserved for prophylactic treatment of children at a very high risk for complications, although its use is debated. â&#x2013;

References 1. AAP Subcommittee on, D., & Management of, B.

(2006). Diagnosis and management of bronchiolitis. Pediatrics, 118(4), 1774-1793. doi:10.1542/ peds.2006-2223 2. Bordley, W. C., Viswanathan, M., King, V. J., Sutton, S. F., Jackman, A. M., Sterling, L., & Lohr, K. N. (2004).

Diagnosis and testing in bronchiolitis: a systematic review. Arch Pediatr Adolesc Med, 158(2), 119-126. doi:10.1001/archpedi.158.2.119 3. Fitzgerald, D. A., & Kilham, H. A. (2004). Bronchiolitis: assessment and evidence-based management. Med J Aust, 180(8), 399-404.

4. Ralston, S. L., Lieberthal, A. S., Meissner, H. C., Alverson, B. K., Baley, J. E., Gadomski, A. M., AAP. (2014).

Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics, 134(5), e1474-1502. doi:10.1542/peds.2014-2742

EMPULSE WINTER 2019

Understanding Observation Services By: Paula Allen, Director of Documentation Education Gottlieb

Why should an Emergency Department group consider observation Services? There are several reasons, including providing an additional revenue source, improving hospital partner relationships, as well as reducing inpatient admission rates.

So, what do observation services include? The definition of observation services, per Current Procedural Terminology (CPT), is “to report evaluation and management services provided to patients designated/admitted as ‘observation status’ in a hospital” (for example, in an emergency department). Observation services are a designation and not a specific unit within a hospital. In other words, it is not necessary that the patient be located in an observation area designated by the hospital.

“Most clinicians and payers agree that observation services should be used to potentially forestall a lengthy inpatient admission." Given that premise, there are two basic circumstances when observation is appropriate: 1.

Lack of diagnostic certainty, where a more precise diagnosis could decide inpatient admission or discharge to home, 2.

Therapeutic intensity, where extensive therapy has a reasonable possibility of abating the patient's presenting condition, and thereby prevents inpatient admission. Patients who require continued evaluation and treatment beyond the usual ED length of stay for certain presentations of chest pain, asthma, abdominal pain, renal calculi, dehydration, syncope, allergic reactions, drug ingestion/overdose, or alcohol intoxication, to name a few, might require observation.”

(Source: https://www.acep.org/Clinical---Practice-Management/Observation---Physician-Coding-FAQ) Gottlieb recommends that the provider assess: Whether admission is a foregone conclusion. If it is uncertain that the patient will be admitted or discharged and that Given treatment and additional evaluation it is possible the patient may be able to be discharged, then the patient meets observation status criteria. Patients being held in the department (due to inpatient bed not being available), and for whom admission is a certainty, do not meet observation criteria.

Documentation Requirements: 1. Admission to Observation a. A statement that the provider is “placing” or “admitting” the patient into observation status. b. The time the patient is placed into observation status must be documented. Example: “Placed patient in observation status 20:15” 2. Observation treatment plan- dated/timed physician’s admitting orders, plan of care 3. Periodic reassessments – physician progress notes 4. Discharge final assessment c. A statement that patient is discharged from observation status, a brief review of the status at discharge d. Time the patient is “discharged” from observation status 5. If the patient’s stay in observation status extends into the next calendar day, the physician must document a discharge service exam. The discharge service/exam should include: e. Final examination of the patient f. Discussion of the hospital stay, instruction for follow-up care

EMPULSE WINTER 2019

www.gottlieb.com

AN UPDATE ON THE OPIOID CRISIS:

The Case for MAT Induction in the ED

By Aaron Wohl, MD, FACEP FCEP Board Member Emergency Physician, Lee Health Memorial

In 2017, opioid overdoses claimed 47,872 lives in America. This staggering number is an increase from 2016 and America’s average life expectancy fell for the second year in a row by 1.2 months as a result of opioid-related deaths, alcoholism and suicide.1 Florida’s opioid-related death rate has also increased dramatically by 109% from 2013-16.2 Opioid-related deaths continue to rise despite significant reductions in prescribing opioids because these policies have not yet adequately addressed the needs of those who have already developed opioid use disorder (OUD)—and those individuals are turning to illicit sources. Heroin use has increased an estimated 37% per year since 2010 and 4 in 5 new users start by misusing prescription opioids (often not prescribed to them).3 In Florida specifically, death rates from illicit opioids have sharply increased since 2013 and heroin is no longer the main culprit.

Synthetic fentanyl analogues are now prevalent in the heroin supply and are killing with alarming efficiency.2 The consequences of this epidemic are devastating to families, communities and the economy, costing the U.S. an estimated $95.3 billion in 2016.2 Yet treatment and recovery services have been scarce, underfunded and plagued by long waiting lists, and relationships between EDs and outpatient programs offering medication assisted treatment (MAT) have been virtually nonexistent.

As emergency physicians (EPs), we must expand the scope of our practice to meet the pressing needs for the epidemic of our times. ED clinicians are uniquely situated to assist in prevention and recovery efforts by offering MAT now. A study published earlier this year in Annals of Internal Medicine 14

found that treatment with buprenorphine or methadone after a nonfatal overdose was associated with a 4060% reduction in all-cause and opioid-related mortality. Yet, only 3 in 10 of these patients received medications for OUD.4 This is a travesty and ethically dubious. There is a limited number of things we can do as emergency physicians that decreases the risk of all-cause mortality by up to one-half in any disease. We would consider this a “breakthrough therapy” in any other pathologic process; we must embrace this therapy for addiction to opioids.

To be successful however, ED’s must engage and build relationships with their community resources, educate patients on harm reductions strategies and offer MAT induction from the ED.

FCEP’s Position EDs can attempt to mitigate opioid-related morbidity and mortality with five main strategies: 1 Through rational opioid prescribing

2

3

4

5

practices for both acute and chronic pain (reduce supply and prevent new misuse and addiction) Use of the state PDMP prior to prescribing opioids when concerned for OUD (mandatory per H.B. 21) Educate and counsel patients on realistic pain control expectations and the dangers of opioid use as well as alternative therapies to opioids (reduce demand) Engage revealed OUD patients in harm reduction strategies and provide naloxone for overdose reversal if they are not ready for treatment Screen suspected patients for OUD and encourage patients to start induction with MAT in the ED and then enter outpatient MAT programs (a process described as a "warm handoff" or "ED Bridge") EMPULSE WINTER 2019

About MAT MAT for addiction is the most effective method EPs can suggest for patients who desire a path to recovery. This approach can help alleviate withdrawal symptoms and drug cravings while patients turn their attention towards other aspects of recovery, such as avoiding triggers and reducing harmful behaviors. A stable safe source of medication helps stem the pursuit of illegal behaviors and acquisition harms motivated by the need to obtain opioids elsewhere.

MAT programs address addiction with a combination of drug and behavioral therapies. Drugs used in MAT include buprenorphine, methadone, naltrexone, or combination buprenorphine-naltrexone (Suboxone). This whole-patient approach has been shown to improve substance abuse-related disorders and psychosocial functioning. Surprisingly, evidence suggests that the counseling component adds little to the patient’s outcomes; what seems to matter most is getting them on the replacement MAT. The alternative to MAT isn’t a drug-free patient; rather, it is a continually relapsing patient, and relapse has a high association with death.

About Harm Reduction This is a philosophy and commitment to meeting patients where they are.

It realizes that addiction is a medical disease and not a moral failing. It is a practical set of strategies aimed at reducing the negative consequences associated with drug use. It emphasizes evidence and education over neglect. Telling people to “just say no” has been an abject failure. The majority of IV drug users are not ready to quit on the day they see us in the ED. If our time and counseling is geared

towards getting them to quit, we’ve set ourselves up for failure.

Harm reduction teaches them to keep themselves safe until they are ready for recovery. A commonly heard criticism is that this facilitates illegal behavior.

It does not. You have to do what is best for your patients. If we continue to neglect them, the death tolls will continue to rise. Does this enable people?

Yes, we are enabling people who use drugs to protect themselves and their communities from HIV, hepatitis C, endocarditis, and overdose. You are enabling them to take personal responsibility for their health and their futures.

About Warm Hand-Offs There is a small window of opportunity to act when an OUD patient in the ED expresses his or her willingness to enter a recovery program. In a perfect system, patients seeking treatment for opioid addiction will be identified in the ED, initiated on buprenorphine and referred to an MAT program—a process described as a “warm hand-off” or “ED Bridge.”

A successful warm hand-off procedure works best with the following: •Emergency physicians initiating the first dose of treatment using specific, shared protocols: When OUD patients ask for treatment, physicians should be empowered and understand how to provide it. Administering the first dose of treatment in the ED also buys time for the hospital to mobilize its network of treatment centers, peer specialists and transportation providers while physicians can monitor the patient’s response to buprenorphine.

“

The alternative to MAT isn’t a drug-free patient; rather, it is a continually relapsing patient, and relapse has a high association with death.

Administering buprenorphine in the hospital or ED setting requires no special training or waiver. To prescribe a patient for outpatient buprenorphine for addiction however, a provider must obtain their DEA X-Waiver. This requires an 8-hour online course, which takes about 5 actual hours to complete.

All EPs should obtain their X-Waiver as it’s simple to do, informative, and shows the community and hospitalist physicians that they too can, and should, take on the responsibility of treating addiction. We must be the leaders that challenge other providers to change their paradigm and begin evidence-based therapy with MAT for OUD patients.

•Outpatient treatment centers expanding intake hours: At this time, most intake hours are only weekday mornings. Patients in withdrawal cannot and should not be expected to wait to begin treatment when (a) they need immediate relief and (b) know they can find that relief in the form of an opioid in their medicine cabinet or on the streets. Ideally, treatment

centers should be open and accepting patients 24/7, but we are learning that this is prohibitively expensive for these facilities with scarce funding. In lieu of expanded intake hours, X-waivered EPs can write a prescription for 1-2 days until open intake hours are available.

•24/7 access to addiction peer specialists: Peer specialists are recovered addicts who provide essential support for OUD patients who are beginning their journey to recovery. Preferably, peer specialists will be hospital-based or “on-call” at a nearby facility. The idea of implementing an EMS model, where peer specialists and EMS personnel serve full shifts and are dispatched to follow up with the patient outside of the hospital, is the most robust system and is already being utilized at one or two sites in Florida.

Many sites have care managers serving as educators and coordinators for selected OUD patients until a peer specialist can be utilized. These care managers can educate on harm reduction strategies such as safe needle injection practices and use of Narcan, and coordinate referral with the outpatient MAT clinic.

•Easily accessible transportation to treatment centers: Expecting OUD patients to coordinate their own transportation to a treatment facility is extremely risky. The route should be direct and the patient should be accompanied by a peer specialist vs. law enforcement.

Some hospital systems have utilized Uber for transport with a peer or have designed transport systems utilizing hospital personnel.

CONTINUE ON PAGE 16 ►

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15

◄ CONTINUED FROM PAGE 15

Other identified needs include reducing the cost of medications associated with treatment, improving metric collections and data-sharing, and the ability to monitor OUD patients as outpatients to ensure they stay in treatment.

NOW HIRING

EMERGENCY PHYSICIANS IN DAYTONA BEACH AREA

It's important to note that implementing a successful warm hand-off system requires significant and coordinated work.

To get started, simple ED MAT induction and very close referral to outpatient MAT is still a laudable goal.

About Funding

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CAREER S T AY F O R T H E

Perhaps the most important long-term need is consistent funding to pay for operating costs associated with warm hand-offs and MAT programs. The Florida Department of Children and Families (DCF) has secured and distributed federal funding via grants for treatment providers and EDs to implement MAT programs and warm hand-offs. In the next issue, we'll highlight their efforts, financial costs of MAT and more. ■

LIFESTYLE

Are you an opioid champion? We want to know what you're doing to combat the opioid crisis. Contact us at sleague@emlrc.org to join our statewide coalition list.

References 1. U.S. Department of Health and Human Services (HHS), Office of the Surgeon General. Facing Addiction in America: The Surgeon General’s Spotlight on Opioids. Washington, DC: HHS, September 2018.

2. Kasat, Sandeep. "Florida Opioid Research: Summary of Key Findings." Westat. October 22, 2018. Access at www. guidewellinnovation.com/opioids-crisis 3. Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA. Psychiatry. 2014;71(7):821-826 4. Larochelle et al. Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality: A Cohort Study. Annals of Internal Medicine. June 19, 2018.

Access at annals.org/aim/article-abstract/2684924/ medication-opioid-use-disorder-after-nonfatal-opioidoverdose-association-mortality

› Flexible Schedules Accommodated

Daunting Diagnosis: A This patient's entrance and exit wounds were sutured upon his first ER visit. Primary closure of these wounds is contraindicated as these wounds are frequently contaminated by the unsterile bullet penetrating often, unclean skin. These wounds require thorough washout, tetanus immunization, antibiotics and occasionally observation.

This patient has returned with cellulitis of the right forearm with early compartment syndrome from muscle edema secondary to the high velocity of the bullet. Labs, repeat radiographs, additional antibiotics, and an orthopedic consult are now further warranted. ■

◄ CONTINUED FROM PAGE 6 16

› Competitive Pay & Benefits › Signing/Relocation Bonus › Staffing 5 Hospitals & Daytona International Speedway

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Email CV to: Maureen.France@emprosonline.com EMPULSE WINTER 2019

Working Together to Reduce Patient Harm, Avoid Readmissions and Improve Quality

By Kim Streit VP/Healthcare Research & Information at FHA Over the past 10 years, the Florida Hospital Association (FHA) has been working with hospitals across the state to improve care to patients.

Since 2012, hospitals working with FHA have focused on reducing patient harm and readmissions through the Centers for Medicare and Medicaid Services Partnership for Patients “Hospital Improvement Innovation Networks” (HIIN). FHA HIIN hospitals are working to reduce 11 different areas of patient harm, including hospital-acquired infections, falls, pressure ulcers, adverse drug events, venous thromboembolism and readmissions, in addition to improving patient safety culture and engaging patients and families in their care.

Hospitals participating in the FHA HIIN get access to free resources, educational programming and national subject matter experts. Though FHA’s partnership with the American Hospital Associations’ Health Research and Education Trust’s (who holds the contract with CMS), innovative strategies are being offered to help hospitals improve care. In total, almost 1,700 hospitals are working together in 34 states to improve patient care.

SCAN HERE

to access resources and see a list of participating hospitals.

hospital coaching. Participating hospitals saw significant changes in almost all areas of harm.

FHA is hosting regional UP Re-Boot meetings in January. For information on those meetings, contact HIIN@fha.org.

Patient and Family Centered Care Strategies A centerpiece of FHA's quality and safety work is improving patient- and family-centered care. By engaging patients and families in care, patient harm can be prevented. Almost 2/3 of hospitals are formalizing the involvement of patients and families by creating Patient and Family Advisory Councils (PFAC). These Councils provide insights and bring the patient perspective into the hospital efforts to make care safer.

TEAM STEPPS Training Another cross-cutting strategy is to improve patient safety culture. Team STEPPs is a system to improve communication and teamwork with a focus on optimizing the use of information, people and resources to achieve the best outcomes for the patient. FHA conducted four “Train the Trainer” programs, of which one focused on the ED and sepsis. In total, 276 people have been trained since May 2017 on Team STEPPs, and more training is planned for 2019.

Results This work is making a difference in Florida.

A big focus is on implementing cross-cutting strategies that impact multiple areas of harm at once. Three key approaches are being offered to Florida hospitals:

UP Campaign Recognizing that hospitals can’t work on numerous areas of harm at once, FHA and AHA developed the UP Campaign.

These are specific, cross-cutting strategies that drive improvement in multiple areas of harm.

The UP Campaign encompasses four key strategies: SOAP UP – Hardwire Hand Hygiene GET UP – Mobilize Patients WAKE UP – Prevent Over-sedation SCRIPT UP – Optimize Inpatient Medications FHA provided support for these strategies through regional trainings, monthly webinars, resources, tools and individual

HIIN builds off the Partnership for Patient's Hospital Engagement Network, which, from 2012-16, prevented 31,000 cases of harm and avoided almost $200 million in health care costs in Florida. Preliminary data shows that through September 2018, the FHA HIIN has improved in all but two areas of harm (SSI colon surgery and hospital onset sepsis mortality).

In July, FHA HIIN received the American Hospital Association’s (AHA) High Performance Award. The award, which was presented at AHA’s Leadership Summit in November 2018, recognizes the significant progress our 94 hospitals are making toward our goals of reducing harm by 20% and readmissions by 12% across 11 key areas of harm.

FCEP has been a key partner in this work, especially around reducing readmissions and sepsis awareness and prevention. We look forward to providing additional updates as this work continues to make care better and safer for all patients in Florida. ■

EMPULSE WINTER 2019

17

COMMITTEE REPORTS

EMRAF

By Misty Coello, MD, PGY-1 EMRAF President | FCEP Board Member

In determination to integrate and advocate for all the emergency medicine residency programs, we met to brainstorm on our goals for the 2018-19 year before our second FCEP committee meeting. We are planning new and exciting resources, with our main goal for them to be available for all residents. I have been speaking and reaching out to advocacy and policy advisors to coordinate potential talks to empower and teach residents on the importance of policy involvement and to guide those who would like to be involved.

EDUCATION/ACADEMIC AFFAIRS

LEADERSHIP ACADEMY

Chairs: Joseph Thundiyil, MD, MPH, FACMT, FACEP Jay Ladde, MD, FACEP Staff Liaison: Niala Ramoutar nramoutar@emlrc.org

Chair: Patrick Agdamag, MD, FACEP Staff Liaison: Samantha League sleague@emlrc.org

EMS/TRAUMA

Chairs: Daniel Brennan, MD, FACEP Jordan Celeste, MD, FACEP Danyelle Redden, MD, FACEP Staff Liaison: Beth Brunner bbrunner@emlrc.org

In addition, I have been talking with financial advisors who specialize in guiding residents in their transition to the market place. These talks will include topics such as managing student debts, financial inquiries or even how to pick a good disability insurance.

Chairs: Christine Van Dillen, MD, FACEP Desmond Fitzpatrick, MD Staff Liaison: Melissa Keahey mkeahey@emlrc.org

Our talks during the meeting were how to make these resources available to all the residents, as schedules within residencies vary and flexibility can be restrained. One solution proposed was to have video conferences at EMLRC headquarters so residents with video and internet capabilities can participate in real time. As mentioned above, we are still within the planning phases of this project.

However, I sought this opportunity not only to update our members, but to encourage those with additional ideas to reach out and contact me.

EMPULSE MAGAZINE

On a similar note, we encourage each residency program to have two representatives that serve as liaison between the EMRAF committee and their programs. Their main responsibilities are to attend or call in to the quarterly committee meetings, attend EM Days and Symposium by the Sea. Residents who would like to be involved in other ways are encouraged to join other committees within FCEP (see list on right).

As always, the role of EMRAF within FCEP is to advocate for and serve the residents. If there are any topics or aspects within residency or emergency medicine that you would like EMRAF to address or engage, or if you interested in getting more involved, please contact me at mistycoello@gmail.com. â&#x2013; 18

FCEP COMMITTEES

Editor-in-Chief/Chair Karen Estrine, DO, FACEP, FAAEM FCEP Liaison Jorden Celeste, MD EMRAF Liaison Misty Coello, MD, PGY-1 Medical Student Liaison Kimberly Herard Staff Liaison/Managing Editor Samantha League sleague@emlrc.org

EMRAF Chair: Misty Coello, MD, PGY-1 FCEP Liaison: Jesse Glueck, MD Staff Liaison: Niala Ramoutar nramoutar@emlrc.org

GOVERNMENT AFFAIRS Chairs: Sanjay Pattani, MD, MHSA, FACEP Damian Caraballo, MD, FACEP Staff Liaison: Beth Brunner bbrunner@emlrc.org

EMPULSE WINTER 2019

MEDICAL ECONOMICS

MEDICAL STUDENT INTEREST GROUP Chair: Nicolas Ramsay Secretary-Editor: Kimberly Herard Advocacy Coordinator: Peter Kim FCEP Liaison: Robyn Hoelle, MD, FACEP Staff Liaison: Nia Ramoutar nramoutar@emlrc.org

MEMBERSHIP & PROFESSIONAL DEVELOPMENT Chairs: Rene Mack, MD, RDMS, FACEP Shayne Gue, MD Staff Liaison: Beth Brunner bbrunner@emlrc.org

PEDIATRIC Co-Chairs: John Misdary, MD, FACEP Todd Wylie, MD Staff Liaison: Melissa Keahey (interim) mkeahey@emlrc.org

RESIDENCY UPDATES SOUTH FLORIDA

Aventura Hospital & Medical Center

By Scarlet Benson, MD, Assistant Clinical Professor

FAU at Bethesda Health

By Jeff Klein, MD, PYG-2 Hello from Boca Raton, FL. We’d like to extend a warm welcome to Taryn Santiago, our new Academic Support Specialist, and Joanne Daly, our new Residency Program Manager.

Additionally, some of our core faculty have participated in several notable events. Assistant Program Director Dr. Lisa Clayton recently spoke at an Emergency Medicine Residency Symposium at the University of Kentucky on “Securing Your Spot in an EM Residency” and “Red Flags on your EM Residency Application and How to Address Them.” Director of Simulation Dr. Patrick Hughes spoke at ACEP18 on “Iatrogenic Critical Care Procedure Complication Simulation Utilizing Error Management Training (EMT).”

EMT encourages active exploration by learners with explicit encouragement to make errors and then learn from those errors. Dr. Hughes also spoke on oncologic emergencies and simulation at EMCON in November for the 20th annual conference for Society for Emergency Medicine India (SEMI) hosted in Bengaluru, India.

In closing, our small but close-knit program continues to expand and not only influence EM locally, but on a much broader scale. FAU wishes everyone happy holidays and good luck with the beginning of interview season! ■

We had a record turnout at ACEP18.

The Aventura Avengers—composed of Drs. Salem Elkhayat, Katie Peterson and Matt Yasavolian—were one of only five teams to successfully complete the EMRA Medical Wilderness Adventure Race (MedWAR). The residents put their wilderness medical and survival skills to the test for the first time with coaching from Assistant Program Director Dr. Andy Pennardt. Congratulations!

Our first resident, Dr. Thomas Yang, was accepted into fellowship and will be starting as a medical simulation fellow at Yale University in July. Our faculty also continue to show a strong academic presence. Ultrasound Direc-

EMPULSE WINTER 2019

tor Dr. Huy Tran contributed a chapter on paracentesis for ACEP’s I-book, Practical Guide to Critical Ultrasound.

In October, Drs. Annalee Baker and Erin Marra represented Aventura core faculty at the FEMINEM conference in NYC. Finally, Dr. Laurence Dubensky collaborated with the AHMC radiology department on a presentation titled “Diffuse alveolar damage within a month of initiating amiodarone therapy” for the upcoming NOVA poster symposium.

We look forward to a busy interview season and finding next year’s class! ■ @aventuraeus

@aventuraemed

@aventuraem

19

SOUTH FLORIDA

Kendall Regional Medical Center

By EM Chief Residents & Staff

Jackson Memorial Hospital

By EM Residency Staff Greetings from Miami! We’ve had a great fall. We held our first full-residency retreat at Crandon Park in September.

The day was focused on wellness, team building and brainstorming for program improvements. It also included beach volleyball, football and an amazing barbecue prepared by none other than our program director, Dr. Freeman. It’s safe to say this will become a yearly tradition!

Our Women in Emergency Medicine group also held their first potluck dinner this fall. These quarterly meetings are a fun and light way to discuss topics particular to women practicing emergency medicine and to support each other through our journeys in this specialty.

We are also elated to welcome two new faculty members to our program, Dr. Suzy Bialeck and Dr. Brooke Hensley, who are both ultrasound-fellowship trained and have been recruited to lead our Ultrasound program along with Dr. Leila Posaw. Dr. Bialeck completed her ultrasound fellowship at George Washington in D.C., and Dr. Hensley did her ultrasound fellowship at Mass General in Boston. We are lucky to have three extremely talented leaders in the field of ultrasound under our roof!

In October, our entire senior class and many faculty attended ACEP18. Dr. Henry Zeng, PGY-3 was selected as ACEP’s Choosing Wisely Champion for promoting quality, evidence-based and low-value care in the area of palliative medicine and hospice care. Dr. Daniel Hercz, PGY-3 presented his research on a clinical decision rule for avoiding imaging in low-risk traumatic thoracolumbar injuries, which is currently submitted for publication.

It’s hard to believe its recruitment season already. Soon it will be match day and we will be preparing to graduate our inaugural class of senior residents. We promise to try and not cry. ■ 20

We are proud to announce that we have achieved full accreditation from the ACGME. This important landmark could only be achieved though the hard work and dedication of our residents, faculty, coordinator and program director Dr. Kevin King.

In the spirit of providing high-yield clinical experiences to our residents, we have begun dedicated fast track and critical care shifts. These focused experiences were positively received by resident staff and will help provide a well-rounded clinical experience to our trainees.

Recently, simulation directors from Aventura (Dr. Cook) and Kendall (Dr. Golden) hosted our 3rd annual Sim Wars competition at the Broward College Simulation Lab. The day was a great success by all accounts and is an example of what we can achieve when we work collaboratively. The Halloween-themed event featured amazing costumes and showcased the fine work of our Simulation Track residents, Drs. Proza and Knabben.

In December, Emergency Ultrasound Track residents—led by Dr. Moreno and senior residents, Drs. Copelli and Martin—launched our inaugural APP Emergency Ultrasound Course, which aims to teach our advanced practice providers skills that can aid in the rapid diagnosis of our fast track patients and assist with procedural guidance.

Our residents enjoyed seeing many of you at the CEME Scientific Research Poster Competition at Nova Southeastern University on November 9. We also hosted an emergency medicine information session for NSU medical students on November 15. In addition, we are preparing for our first Oral Boards Course, which will be offered to our senior residents as they edge closer to the end of their training.

Last but not least, we are happy to announce that our very own Dr. Ana Pineda will be staying with our group as our first Administrative Fellow this coming July. ■

Port St. Lucie Medical Center

By Blaire Laughlin, DO, PGY-3 At St. Lucie, we have been working at strengthening our research department and starting many new projects.

We’d like to extend a special congratulations to resident Dr. Alexandra Chitty, PGY-2, whose case report is being published by the Western Journal of Emergency Medicine. We’d also like to congratulate our four senior residents on signing contracts for their new jobs.

They all anticipate working on their own.

EMPULSE WINTER 2019

After enjoying our second SIM lab, the residents teamed up to do a volunteer beach clean-up. Upcoming events include our yearly volunteering with treasure coast marathon and our team-building activity at the ropes course on FAU campus.

Finally, St. Lucie would like to specially thank Mount Sinai for hosting the last consortium, and we look forward to hosting in March 2019. ■

SOUTH FLORIDA

Mount Sinai Medical Center

By Michael Cecilia, DO, PGY-3 Now that winter has arrived, we at Mt. Sinai wish to congratulate our senior class (Drs. Nick Garrett, Matt Brooks, Justin Burkholder, Nikki Warren & Rob Farrow) as they move forward in their future endeavors. As members of the final four-year class recruited prior to the ACGME merger, they were given the opportunity to graduate in 3.5 years.

Despite all of the changes, we have had a productive fall. The ACGME transition has been finalized and we have been given continuation accreditation for the program. We wish to thank our faculty and administration who worked so hard to make this transition possible.

Several of our residents, alumni and faculty have been notified of acceptance for publications: • Dr. Mauricio Baca, PGY-2 & Dr. Mark Newberry: “Amyloid Cardiomyopathy in the Emergency Department,” Journal of Emergency Medicine • Dr. Brad Koschel, PGY-3, Dr. Justin Burkholder, PGY-4 & Dr. Laurie Boge: “Patients’ Perceptions on the Role of Physicians in Questioning and Educating on Firearm Safety: Post-FOPA Repeal Era,” Southern Medical Journal • Dr. David Kinas (2018 graduate & current ultrasound fellow at Mt. Sinai St. Luke’s, NY), Dr. Michael Dalley, Dr. Mark Newberry & Dr. David Farcy: “Point-of-Care Ultrasound Identifies Decompensated Heart Failure in a Young Male with Methamphetamine-Associated Cardiomyopathy Presenting in Severe Sepsis to the ED,” Case Reports in Emergency Medicine Several residents have focused on education by leading the following clinics: • Suture Clinic hosted by the FIU EM Club & led by Drs. Adam Memon, Aldo Manresa, Chandelle Raza (PGY-2s) and Nick Boyko • Intubation Clinic hosted by the NSU EM Club & led by Drs. Adam Memon, Aldo Manresa, & Chandelle Raza • Basics of Critical Care for Mt. Sinai Internal Medicine Residency, led by Drs. Nikki Warren, PGY-4, Adam Memon and Aldo Manresa • Splinting Clinic hosted by NSU EM, led by Drs. Natasha Brown, PGY-2 and Chandelle Raza Finally, we would like to thank Dr. Reuben Strayer at Maimonides Medical Center in New York for his fantastic talk and Dr. Rich Levitan for coming to Mt. Sinai and allowing us to take part in his incredible Advanced Airway Clinic. ■

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EMPULSE WINTER 2019

21

NORTH FLORIDA

UF Health: Gainesville

UCF-Ocala Regional

By Travis Murphy, MD, PGY-2

By Lee Barker, DO & Vir Singh, MD, PGY-2s

With the academic year in full swing, our senior class is starting to look towards careers and fellowships while the rest of our residents are starting to really own the resuscitation and trauma bays. ACEP18 was a fantastic experience— our senior class thoroughly enjoyed San Diego and the scope of the lectures, exhibits, and educational sessions.

UCF Ocala Health’s EM Residency has continued on its path of innovation, growth and harnessing the power of an expanding hospital system to provide excellent training to our residents. On October 10, all residents participated in our first annual EMS Day at the Florida State Fire College.

This teambuilding activity gave us a better appreciation of the training our EMS-firefighter colleagues endure.

With the in-service exam on the horizon, our journal club and conference curriculum has been nicely supplemented with online quizzes and readings curated by Dr. Maldonado, who spoke about his educational strategies for residency at ACEP and from which we can already see a benefit.

We are excited to pursue more collaborations with our North-Central Florida programs and build on our experience, looking for ways to improve both data-sharing between hospital systems and educational opportunities between residencies.

As interview candidates from all over make the trip to Gainesville, we look forward to growing our Gator family this spring. Good luck on the in-service, everyone! We look forward to seeing you again at EM Days after this tough midterm cycle. ■

Ocala EM continues to leverage its variety of practice environments to give residents longitudinal experience in the academic/trauma center, community and free-standing ED settings. We are happy to welcome a fourth setting to our repertoire: the level I pediatric trauma center of Memorial Hospital in Savannah, GA. There is no question that residents at Ocala EM will not be phased by entering new ED environments in their emergency medicine careers! ■

North Florida Regional

UF Health: Jacksonville

By Zaza Atanelov, MD, & Collin Bufano, MD, PGY-2s

By Corey Dye, MD, PGY-1

With the start to application season in the midst of renovations to the Emergency Department, there has been lots of excitement at North Florida Regional Medical Center. We have just added 8 new beds to our Emergency Department as well as a whole new nursing pod to go with it. Along with these changes, we have renovated our resuscitation rooms and plan on expanding our doc box to make room for the anticipated class of 2022.

22

Speaking of EMS: second-year residents have begun their EMS rotations with Marion County Fire Rescue. Working under Residency EMS Director and Marion County EMS Medical Director Dr. Frank Fraunfelter, residents are working with paramedics in the field, educating them in the firehouse and engaging in conversations regarding system-wide initiatives for better pre-hospital care.

Interview season has begun! Our organization is very excited about the talented candidates coming through in hopes of matching another amazing intern class. We wish you all the best of luck on the interview trail!

We have already met many rotators and are excited to meet more as they flood North Florida to get a taste of our innovative and exciting residency. So far, our interviewers have come from all over the U.S., making up a diverse group of applicants who are excited to join our North Florida family.

In other news, our new ultrasound fellowship is off to a strong start due to the leadership of Dr. Chris Kumetz, who has already expanded our standard ultrasound curriculum with procedural-based workshops, weekly ultrasound cases and more. Assistant Program Director Dr. Melissa Parsons delivered an amazing lecture at FeminEM in October regarding fertility challenges amongst female physicians—raising awareness about a critical wellness issue that is seldom spoken about.

Our interns have grown tremendously from the start in July and so have our PGY-2s, who have taken on more leadership roles as they guide the first-year class to success as rising emergency medicine physicians. ■

We'd also like to give another shout out to all of our interns who are making fantastic strides and showing a tremendous amount of growth as the year progresses. Thanks for all of your hard work, and continue pressing forward! ■

EMPULSE WINTER 2019

CENTRAL FLORIDA

Orlando Health

By Laura Cook, MD, & Anne Shaughnessy, MD, PGY-1s Seasons greetings from Orlando Health!

The interview season is in full swing, and we are excited to welcome many great applicants in hopes of adding 18 new faces to our emergency family. This year, our program is increasing our intern class number by one, based on increasing volume needs in our emergency department. Match Day will be here before we know it!

Our own Simulation fellow, Dr. Erich Heine, graduate and former chief, took home the EMRA CORD scholarship award, given for his strong interest in academics and education in emergency medicine. Dr. Heine and the simulation crew have provided excellent and fun opportunities for our residents, including challenging SIM cases, chest tubes lab, and our Halloween themed “Candies and Canthotomies,” in which we practiced a lateral canthotomy on monster masks.

Our senior class represented ORMC at ACEP18 in San Diego. Each year, the third year class is sponsored to go for a week of learning and fun. We have an excellent class of seniors this year running our emergency department. They are proof that our program trains great EM doctors. Thanks for your hard work, seniors!

Our wellness committee is working to prevent the post-holiday blues with a lecture series on resilience and burnout this spring. We also plan to organize a residency volunteer event and continue to have our monthly wellness events.

Many of our residents and faculty are looking forward to the Disney-sponsored runs this year.

We look forward to spring and welcoming the future class of 2022 this Match Day! ■

University of South Florida

By Matthew Beattie, MD, PGY-2 The weather is starting to cool down as we move into winter. We hope everyone had a wonderful Thanksgiving and Christmas with friends and family. This is the best time of year to sit back and reflect on the things in life you’re thankful for.

We’ve had a few exciting events here at USF in the recent months. Our flight program, Aeromed, hosted its annual “Aeroscare” Halloween event and some notable attendees included the cast from Toy Story, Belle and the Beast, Finding Nemo and Rosie the Riveter.

Our program is fortunate enough to have leadership who encourage regular wellness events attended by all of

our residents. Most recently, we had some friendly combat through tactical laser tag. The legendary USF alumnus, Lin Poff, organized his second annual USF Friendsgiving where the current residents and alumni battled it out in a game of softball. We ended the day with a potluck.

Interview season is among us, and our senior residents only have about half the year until they are turned loose. It’s amazing how time flies! Continue to make the most of your time in residency. Learn from your faculty and take something away from each shift that will make you a better physician. ■

Florida Hospital East Orlando

By Shannon Armistead, DO, PGY-2

Greetings from Florida Hospital East Orlando. We cannot believe it is winter already! As a residency, we are not only prepared for cold and flu season but also interview season. Our interviewees had the pleasure of attending our annual Halloween party journal club where Arrow, Bob Ross, Batman and the Riddler all enjoyed some lively discussion of Cardiac Computed Tomography Angiography. Halloween night was all treats as we collectively sat down with our first round of applicants to kick off our season.

Our intern class will soon be trying on the pager as they embark on the trauma rotation with our seniors. Also, our secEMPULSE WINTER 2019

ond years will begin rotating through an intensive Pediatric EM month.

We have been working on honing our ultrasound skills with tiny, friendly competitions during some Thursday conferences (mostly for the bragging rights). Studying for the In-training Exam is in full swing as well. The Rosh and Foundations reviews in conjunction with the simulations continue to increase our knowledge and proficiency.

There are exciting changes coming to our hospital in 2019. The program is primed for new opportunities to grow and continue educating the next generation. ■ 23

CENTRAL FLORIDA

UCF/HCA at Osceola

By Andrew Hanna, MD, PGY-2 & Amber Mirajkar, MD, PGY-1 Hello from Osceola! The beginning of this academic year was marked by welcoming our new class of interns and getting them acquainted with the hospital and emergency department. At this time, they are settled in and thriving!

This fall, our PGY-3 residents enjoyed the events and occasions of ACEP18 in San Diego. We had a number of faculty and resident presentations that were well received. We would like to congratulate Dr. Lebowitz and Dr. MacIntosh for becoming Fellows of ACEP. We would also like to congratulate our faculty on receiving the following awards:

• Dr. MacIntosh: UCF COM Community Service Award & UCF COM Community of Practice Preceptor Award

• Dr. Banerjee: UCF COM Early Career Investigator Award • Dr. Rosario: UCF COM Early Career Educator Award • Dr. Vera: UCF COM Innovative Teaching Award This fall has been marked by increased resident involvement with the UCF College of Medicine. We are fortunate to be close to the Lake Nona campus, which has given us the opportunity to be directly involved with medical student education. At this time, we are teaching the weekly ultrasound curriculum to the first-year medical students. We look forward to the opportunities to come!

The construction of our new triage center is nearly complete and we are excited to get to use our new and expanded facility. We have added a whole set of rooms to our “fasttrack” that will provide ample space to facilitate a comfortable patient experience.

We are also back in full swing of the interview process, getting acquainted with the applicants for the class of 2022.

As always, we are enthusiastic about continuing to grow as a family and serve our community together.

On behalf of all members of the UCF/Osceola EM Residency, we would like to wish you all happy holidays! This season we are thankful for the opportunity to serve the patients of Central Florida and forward the field of emergency medicine in our region. ■

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COMMITTEE REPORTS

Medical Student Committee

By Kimberly Herard, MD Candidate, FAU Class of 2020 Medical Student Committee Secretary-Editor

In 2013, Stop the Bleed Initiative was started as a response to the shooting at Sandy Hook Elementary School (2012) by the U.S. government, the American College of Surgeons and the Committee on Trauma. They formed the Hartford Consensus under the leadership of Dr. Lenworth M. Jacobs Jr., MD, MPH, FACS, which provided recommendations for increasing survivability from active shooters or mass casualty incidents (MCIs). This initiative also supports former President Obama’s policy for national preparedness, which places responsibility of preparedness for lifesaving measures on the government, private and nonprofit sectors, and individual citizens.

Thus far, the Stop the Bleed program has trained 15,000 instructors and more than 125,000 community members to assist the injured during an active shooter or MCI. Even high school students are being trained through Stop the Bleed!

And those numbers will continue to grow, thanks in part to Jordyn Cohen, MS-2 at FAU. Cohen already had a strong interest in public health and disaster response and was touched by the recent mass shooting that occurred at Marjory Stoneman Douglas High School in Parkland, Fla. It didn’t take

long before her and a faculty member decided to implement a Stop the Bleed program at FAU. “In the Stop the Bleed program, we teach basic bleeding control, including what constitutes massive bleeding and how to stop it using applied pressure and tourniquets,” Cohen explains. “The training is aimed at community members with no medical background.”

The training at FAU was led by faculty members such as Dr. George Luck and Stop the Bleed Expert Trainer Robert Moreland. In just one session, more than 30 medical students and 10 surgical residents were trained on how to present the Stop the Bleed program to fellow community members. The program was so successful that FAU decided to integrate this training into the Foundations of Medicine course. Now, every first-year student matriculating through the Charles E. Schmidt College of Medicine at FAU will be trained for Stop the Bleed.

“We have many community classes planned for this year, including trainings for local high school students, preschool teachers, undergraduates at FAU and community members at local hospitals,” Cohen said. “Currently, most schools in our area have one

“I knew that I wanted to somehow get involved with disaster response and prevention in my community,” said Jordyn Cohen, MS-2 at FAU, pictured here with Dr. Lawrence Lottenburg, Dr. George Luck and Robert Moreland.

tourniquet in the nurse’s office, so we are also working on raising money to provide tourniquets in every classroom.”

With the increasing incident of mass shootings, these efforts across the nation are extremely beneficial.

By teaching and empowering the community, many lives can be saved. ■

by the

201 9

August 1-4, 2019 Boca Raton Resort & Club Boca Raton, FL EMPULSE WINTER 2019

25

The

LACK OF EVIDENCE of an

EMERGENCY PHYSICIAN

Workforce Shortage in Florida Barbara Langland Orban, PhD

David Orban, MD, FACEP In 2012, the Department of Health initiated a survey to assess the state’s current and future physician workforce needs and prepared a report on the physician workforce in Florida.

Every year since, a summary analysis of the Physician Workforce Survey is completed. Physicians are required to complete the survey every two years when they renew their medical license.

This report helps policymakers make informed decisions about Florida’s current and future physician workforce and access to care.

The 2017 Workforce Report includes the following key points:

• A total of 66,988 physicians re-

newed their medical license during 2016 and 2017 and responded to the workforce survey.

• Nearly two-thirds (61.9%) of physicians are age 50 years or older.

• Of the 14 specialty categories, all but one specialty (emergency medicine) has more than 25% of physicians age 60 and older.

• On-average, emergency physicians are significantly younger than Florida physicians at-large (45 vs. 55).

• Emergency physicians are notably concentrated in coastal areas and in areas containing medical schools and large population centers.

• Florida is below the national median of active primary care physicians of 9.1 per 10,000 population, having only 7.7 primary care physicians per 10,000 population (defined as general internal medicine, family medicine and pediatrics). (AAMC 2016 State Physician Workforce 26

Data Book)

• In 16 of Florida’s 67 counties, over 20% of primary care physicians plan to retire in the next five years.

New medical schools have opened in Florida, and existing schools have expanded since 2010 to meet increased demand. However, this has created more applicants for a limited amount of Florida residency slots. For each available slot, a residency program may have hundreds of applicants.

The shortage in primary care is especially compounded by Florida’s lack of primary care residency slots. In 2012, for example, New York offered about 1,500 residency slots in internal medicine. In Florida, there were just 482.

Similar disparities in training numbers were found in pediatrics, family practice, general surgery, psychiatry and obstetrics (physicians willing to perform deliveries), and the annual Florida Physician Workforce Report has projected major shortfalls citing these as “critical shortage specialties.”

The 2013 Florida legislative session resulted in the passage of SB 1520, which repealed the Community Hospital Education Act (s.381.0403, Florida Statutes) and established the Statewide Medicaid Residency Program. The state has offered incentives to create more residency positions, providing $80 million in recurring state and matching funds in 2013 to create a program that funds new residency slots.

In 2015, legislators provided $100 EMPULSE WINTER 2019

million to give participating community hospitals $150,000 for every residency position created in a “critical shortage specialty,” but restricted to hospitals that did not previously have residency programs. The Agency for Health Care Administration provides the funds to hospitals based on certain criteria and a formula for calculating each participating Medicaid hospital’s portion. The Physician Workforce Advisory Council has continued to provide guidance to both the Department of Health and the Agency for Health Care Administration, as requested, to assure compliance with the Statewide Medicaid Residency Program as enacted by SB 1520.

The original draft of SB 1520's during the 2013 legislative session followed a template of similar bills in 12 other states facing similar physician shortages and listed only the six “critical shortage specialties” (internal medicine, family medicine, pediatrics, psychiatry, OB/GYN, general surgery) as eligible for funding new residencies. As the Florida bill made its way through the various Senate committees, emergency medicine was oddly added to the list of “critical shortage specialties,” making Florida the only state to add EM to the new residency funding list.

HCA Healthcare and others have brought more residency positions to Florida and other parts of the country by turning community hospitals into teaching hospitals. In the next five years, HCA plans to expand its residency positions in Florida from 767 to 2,115. The hospital chain received state incentives through the Statewide

Medicaid Residency Program for these new residency positions. All of the newly-minted positions will become eligible for federal funding once the programs have been in place for five years.

A report in 2017 showed that Florida hospitals increased the number of residency slots in all specialties by 19% since 2013. In the same timeframe, the number of slots in emergency medicine increased by 198%. With the recent RRC-EM approval of three more new EM residencies in April 2018, the 5-year growth of ERAS matching EM slots in Florida will be nearly 260%.

How did the specialty of emergency medicine in Florida get to this place?

Was there, in fact, a “critical shortage” of emergency physicians in the state, or was this a myth of epic proportions?

To answer this question, we went back to the publicly-available data in the annual DOH Physician Workforce Surveys and the Agency for Health Care Administration (ACHA) Emergency Department Visit data.

Based on Florida licensing data, 2205 physicians listed themselves as board-certified in emergency medicine in 2013. By 2017, that number had increased to 2452 — a 4-year increase of 11%. Over the same period, total ED visits in Florida grew from 9,387,465 to 10,737,365 — a 14% gain. However, a significant part of that growth was due to a substantial increase of licensed free-standing EDs in Florida. A closer examination of traditional hospital ED visits over the same period showed a more modest gain of 9.7% (7,548,543 in 2013 to 8,283,346 in 2017). In fact, 2017 was the first year in ACHA ED Data history that the number of hospital ED visits actually dropped from the previous year (8,318,350 in 2016 down to 8,283,346 in 2017). The Florida population only increased 7% over the same period (19,580,000 in 2013 to 20,980,000 in 2017).

A simple calculation demonstrates that in 2017, all the ED visits in Florida could have been seen by the 2452 emergency physicians working alone at a rate of 2.28 patients per hour.

Five-year growth of emergency medicine residencies relative to number of emergency physicians and ED visits in Florida

2017

2013 2205

+11%

2452

7,548,543

+14%

10,737,365

6 EM residencies

+198%

EPs in FL ED visits

EPs in FL ED visits

14

EM residencies

A simple calculation demonstrates that in 2017, all the ED visits in Florida could have been seen by the 2452 emergency physicians working alone at a rate of 2.28 patients per hour. Of course, we know that workforce projections are much more complex than just dividing the patients by physicians by hours.

in Florida? The Florida Department of Health says there is no shortage.

The annual DOH Physician Workforce Survey does not include emergency medicine in its list of shortage specialties. Emergency medicine should never have been quietly slipped into the list of “critical shortage specialties” on SB 1520 back in 2013.

Physician extenders have become commonplace, typically seeing lower acuity patients. Meanwhile, ED patient volumes continue to rise each year.

Despite increases in the number of emergency physicians and increased use of physician extenders, ED lengths of stay continue to rise, and our EDs are becoming increasingly crowded in response to an aging population, higher acuity, increased regulation and more available advanced testing.

National workforce studies project that there will be a continued need for more emergency physicians, particularly in rural underserved areas—a trend that reflects the overall undersupply of physicians in the United States. Due to the numerous variables involved and the statistical complexities, a more sophisticated analysis is required to project Florida’s future emergency provider needs.

The fact of the matter is that when APP coverage is factored in, Florida has an adequate number of emergency providers. Many previous physician workforce studies have recognized that emergency physicians, for the most part, do not want to work in isolated rural hospitals or low-income areas where the pay is also low. However, this is not just a Florida problem—it is a national problem that leaders of our specialty must acknowledge, address and solve.

Conclusion Is there currently a shortage of board-certified emergency physicians in the United States? Yes, although it is decreasing steadily each year and not relevant to Florida. Is there currently a shortage of emergency physicians EMPULSE WINTER 2019

So why are we spending our precious Medicaid tax dollars in the precipitous expansion of emergency medicine residency training slots in Florida if there is not a crisis? The primary care physician shortage is compelling and is likely to increase exponentially over time as primary care provider numbers dwindle. The Affordable Care Act, which was signed into law in March 2010, has increased access to medical care by expanding medical insurance coverage, further exacerbating current primary care shortages. Floridians would benefit far more from increasing our primary care workforce rather than permitting state tax dollars to shift an inordinate number of residency training slots into emergency medicine. ■ 27

THE ULTRASOUND ZOOM

Twinkling renal stones Improving the Ultrasound Exam for Suspected Urolithiasis

I am a fourth-year medical student with an interest in emergency medicine and point-of-care ultrasound (POCUS).

While attempting to hone my humble practice and POCUS skills, I learned about an ultrasound technique called the twinkling artifact (TA), or the color comet tail, that has been prospectively validated as being highly sensitive and specific for the diagnosis of renal calculi. I believe this technique—when added to any emergency physician’s ultrasound toolbox—will prove very useful in the fast and efficacious diagnosis and management of kidney stones.

Renal colic is a commonly encountered condition in the ED. Renal POCUS is a useful tool for diagnosing urolithiasis in patients with a low-to-moderate risk of important alternative diagnoses.

POCUS may also be used to quickly assess the aorta and exclude an aortic aneurysm or dissection. Since the ACEP Choosing Wisely campaign, providers have been much more cautious of exposing patients with renal colic to unnecessary radiation from computed tomography (CT). However, CT is still recommended for patients at high risk of alternative diagnoses: those with fever, abnormal vitals, intractable pain, vomiting or abnormal renal function.1

Edited by Leila Posaw, MD, MPH, Dept. of Emergency Medicine, Jackson Memorial Hospital

Gray Scale (B-mode) Imaging With traditional B-mode ultrasound, only about 64% of stones are in the “field of view,” consisting of the area proximal to the ureteropelvic junction and distal to the ureterovesical junction, due difficulty in assessing the ureter.2 Of the visualized stones, ultrasound is only about 16% sensitive for those <7mm and 75% sensitive for those ≥7mm.3 Ultrasound has been criticized as overestimating the size Fig. 1: Use of the acoustic shadow width to determine kidney stone size with of stones. If the discerning clinician ultrasound.4 wishes to more accurately measure a stone, one in vitro study found that measuring the acoustic shadow width led to 78% of the measurements to be accurate to within 1 mm, similar to CT resolution.4

Hydronephrosis Hydronephrosis can be used to guide management due to the association between stone size and hydronephrosis. Patients with mild/no hydronephrosis are less likely to have calculi >5mm.5 Renal cysts may be mistaken for hydronephrosis but are typically single and peripheral. Mild hydronephrosis may be seen in pregnant patients and the overhydrated patient. An under-hydrated patient may also not have hydronephrosis on scanning, even in presence of obstruction and colic.

Fig. 2: Grading of hydronephrosis.6

The kidney’s echogenic central area can make identifying stones (especially small stones less than 5 mm) difficult. Recently, techniques have been described to increase the sensitivity of POCUS in stone detection and measurement, which adds significantly to its utility in directing management of renal colic. The TA is one such technique that provides EPs with a comparable level of sensitivity and specificity of stone detection as non-contrast CT, while preserving the safety and efficiency of POCUS. 28

By Grant Barker, BS, MD Candidate at University of Miami, Miller School of Medicine

EMPULSE WINTER 2019

Twinkling Artifact Color Doppler (CD) ultrasound is an old technology that may have a new role in the diagnosis of urolithiasis. This is due to a phenomenon known as TA, first described in 1996 by Rahmouni et al., which is displayed as rapidly alternating colors of the Doppler signal, possibly due to the reflective nature of the calculi. A large prospective study comparing CT to TA in patients presenting to the ED with acute flank pain reported a sensitivity and specificity of 97.2% and 99%, respectively.7 This is far better than traditional scanning in B-mode alone. However, it is best to regard the TA with CD as complementary to gray scale imaging. The few false negatives on CD were stones <5mm with no hydronephrosis, and passed spontaneously.

Renal POCUS is performed with a 3.55 MHz probe (curvilinear or phased array). The right kidney is best visualized in the coronal view. The probe is placed on the right side of the patient, in the lower intercostal space and mid axillary line, and the acoustic beam is directed posteriorly. The left kidney is best visualized with the probe on the left side of the patient, in the coronal plane, in the low intercostal space and the posterior axillary line, and with the beam directed posteriorly.

First, the renal pelvis and upper ureters are evaluated with B-mode. If an echogenic focus is detected, the presumed stone is interrogated with CD.

Fig. 3. Probe Positions for Renal POCUS Exam. Model: Jimmy Mu, MD Fig. 4A: Kidney stone in B mode.

Fig. 4B: Twinkling artifact from same kidney stone in color mode.

Second, the bladder and vesicoureteral junction are evaluated with B-mode (and echogenic foci with CD). If no echogenic focus/stone is detected, and there is a high clinical suspicion, an effort should be made to trace the ureter from the renal pelvis to the vesicoureteral junction.

With CD, the TA (Fig. 4) will be observed as a series of alternating color signals in a triangular shape under an echogenic focus. This technique is best performed with a low-frequency probe and high pulse repetition frequency (tip: reduce depth of view and increase velocity scale to over 60 cm/s). To avoid being fooled with flashy mimics caused by motion, the technique should be performed and hold true for over 5 seconds.8 CONTINUE ON PAGE 30 ►

Renal Stone Twinkle.To.Go • Cut along the border of the table below.

• Fold in the middle.

• Stick in your wallet. Reference on-the-go.

Find this table online at emlrc.org/ultrasoundzoom

Courtesy of authors Leila Posaw, MD, MPH and Grant Barker, BS

Focused Renal/Bladder Ultrasound with Twinkling Artifact

Right Renal, coronal plane (B-mode)

Right Renal, transverse plane (B-mode)

Bladder, transverse plane (B-mode)

EMPULSE WINTER 2019

Left Renal, coronal plane, aurolithiasis (B-mode)

Left Renal, coronal plane, twinkling artifact (color Doppler mode)

29

Thank You Donors

◄ CONTINUED FROM PAGE 29

Increasing EP confidence in POCUS for confirming the presence of renal calculi in patients with flank pain will lead to a decrease in the ordering of CT scans and spare our patients the consequences of radiation exposure. I am determined to use POCUS and the TA in my practice; this can only make me a more effective clinician. ■

References & Suggested Reading 1. Wang RC. Managing Urolithiasis. Ann Emerg Med.

2016;67(4):449-54.

2. Cullen I, Cafferty F, Oon SF, et al. Evaluation of suspected renal colic with non-contrast CT in the emergency department: a single institution study J Endourol 2008;22:2441e5.

3. Fowler KA, Locken JA, Duchesne JH, et al. US for detecting renal calculi with nonenhanced CT as a reference standard. Radiology 2002;222:109e13 4. Dunmire B, Harper JD, Cunitz BW, et al. Use of the Acoustic Shadow Width to Determine Kidney Stone Size with Ultrasound. J Urol. 2016;195(1):171-7.

5. Goertz JK, Lotterman S. Can the degree of hydronephrosis on ultrasound predict kidney stone size?

Am J Emerg Med 2010;28:813e16.

6. Timberlake MD, Herndon CD. Mild to moderate postnatal hydronephrosis--grading systems and management. Nat Rev Urol. 2013;10(11):649-56.

7. Abdel-gawad M, Kadasne RD, Elsobky E, Ali-el-dein B, Monga M. A Prospective Comparative Study of Color Doppler Ultrasound with Twinkling and Noncontrast Computerized Tomography for the Evaluation of Acute Renal Colic. J Urol. 2016;196(3):757-62.

8. Ania Z. Kielar, MD, FRCPC, Wael Shabana, MD, PhD, Maryam Vakili, MD, Jonathan Rubin, MD, PhD Prospective Evaluation of Doppler Sonography to Detect the Twinkling Artifact Versus Unenhanced Computed Tomography for Identifying Urinary Tract Calculi J Ultrasound Med 2012; 31:1619–1625.

The success of our advocacy efforts is dependent upon generous donations to FCEP's political action committees (PCs). Thank you to those who donated in September-November 2018.

Matthew Abbott Patricia Bette Allen Mark Attlesey David Ball Jeffrey Barnes Willie Charles Bruce Corrine Mary Bullock Jordan Celeste Alan Claunch Terry Cohen Manuel Colon-Menedez Thomas Richard Cox Julio De Pena Batista Alex Doerffler Jacob Eastman Johnnie Ford Michelle Fox-Slesinger Jesse Glueck Andrea Gorjaczew Shayne Gue Brian Scott Hartfelder Rory Hession Alexandra Heyes Matthew E Hughes Jorge Infante Charles Ingram Naomi Jean-Baptiste

Mark Johnson Steven B Kailes Shiva Kalidindi David Kinas Gary Lai Dakota Lane Douglas Lee Thomas Leonard Michael McCann Anna McClain Brian McMaster Pamela Miller Daniel Peterson Daniel Puebla Sarah Spelsberg Joanna Carol Steele Jason Stringer Sarah Temple Daniel Thimann Thang Tran Glenn Tremml True Connor David A Wein Christina Lucile Wilson Jason Wilson Aaron Wohl Gary David Wright

How to Donate to FCEP’s PCs: Text “FCEPPC” to “41444” Donate online at: emlrc.org/fcep-pac-donations Mail a check to FCEP at 3717 S. Conway Road, Orlando, FL 32812

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The Pulmonary Embolism Response Team COMING TO AN ED NEAR YOU

Tim Montrief, MD, MPH, PGY-2

Introduction Pulmonary embolus (PE) represents a rapidly occurring and potentially fatal condition that remains challenging to diagnose and manage. A patient with a PE can present in any clinical setting, so physicians from the ED to hospital wards must be prepared to face this disease. Although clearer guidelines exist for the management of low-risk PE, the situation can quickly grow more complex in patients with massive and submassive PE.1,2 In addition to anticoagulants, a number of more complex interventions exist, including systemic fibrinolysis, catheter-directed therapies and surgical embolectomy.3 Each management option comes with its own risks and benefits that can be difficult to tailor to the patient, and if a physician decides to pursue one of these therapies, specialists must be consulted. A wide variety of specialties exist for higher-risk PE consultation— including hematology, vascular surgery and interventional radiology—and each one may offer a unique perspective on how to approach the case. Challenges in management have prompted medical centers across the country to develop a multi-disciplinary approach to the PE, known as the PE Response Team (PERT).

Basis of the PERT The PERT is based on other similarlystructured response teams that play important roles in the hospital setting.

Code ST-elevation myocardial infarction (STEMI) teams have been pivotal in reducing the mortality associated with MI, due in part to their ability to mobilize the resources required for rapid intervention.4,5 PERTs aim to do the same by ensuring that if the patient is a good candidate for surgical or catheter-based intervention, the necessary steps are taken to ensure that intervention occurs as quickly as possible.6 Additionally, PERTs utilize the multi-disciplinary aspect of trauma teams, 32

Justin Rafael De la Fuente, MS-2

which assemble emergency physicians, trauma surgeons, orthopedic surgeons and more in order to provide the best possible care for the patient.5 The PERT similarly brings together experts in different specialties to ensure that the patient receives the best possible intervention for their PE.

PERT Structure Massachusetts General Hospital (MGH) was the first institution to successfully implement a PERT, providing a framework for the team’s structure.

There, it is comprised of experts in interventional cardiology, vascular medicine, cardiothoracic surgery, echocardiography, emergency medicine, hematology, pulmonology, critical care medicine and radiology.6 Activation of the PERT at MGH is available to any clinician who may encounter submassive or massive PE. Upon doing so, an on-call physician on the team is dispatched to provide a quick patient evaluation. After review of patient data, the referring physician and the PERT specialists have an online meeting to discuss the case, allowing the team of up to 15 physicians to devise a consensus treatment strategy that includes insight from multiple specialties. Once a plan is developed, necessary resources are mobilized, which may include organizing an urgent angiography suite or contacting the cardiac surgery team. Ideally this evaluation and meeting occur within a span of 90 minutes post-PERT activation.6 The PERT concept has led to the development of similar teams in medical centers across the country.6 The core concept of the PERT remains the same: to provide rapid, multi-disciplinary insight into management of PE. Some hospitals have gone further and developed algorithms for PE management that include the PERT. For example, at the University of Texas MD Anderson Cancer Center, the PERT can EMPULSE WINTER 2019

Jeff Scott, DO, FACEP, EDIC

be activated for patients with potential intermediate- to high-risk PE. If anticoagulants are not contraindicated, therapy should include IV unfractionated heparin prior to the PERT meeting, and data collected should include BNP, troponin, 2D-echo, type and screen, EKG and venous Doppler ultrasound of the lower extremities. With that information and a PERT first responder assessment, the patient is categorized, and if they remain high- to high-intermediate-risk, the PERT has a virtual meeting to consider more advanced intervention, including mechanical thrombectomy, low dose catheterdirected thrombolysis (CDT), or placement of an IVC filter.7 In addition to providing multi-disciplinary emergency care in the hospital, PERTs may also include a system of outpatient specialist care after discharge. This allows for expedited specialist follow-up, which is beneficial if the patient is developing long-term complications associated with PE, such as chronic thrombotic pulmonary hypertension. If the physician who discovered such a condition was a pulmonologist at a PERT specialist follow-up visit as opposed to the patient’s primary care physician, action can be taken immediately without having to arrange other consultations. This additional care allows for further testing that may elucidate potential cause of the PE, such as occult malignancy. By evaluating for and potentially treating such conditions, the PERT follow-up model can help prevent future episodes of recurrent PE.8

Implementation Outcomes Since the development of the first PERT at MGH, data suggests that the multi-disciplinary approach has key benefits in PE care. At the University of Kentucky, PERT implementation significantly shortened length of stay, both overall and within the ICU.9 Additionally at MGH, there was a noted increase in

12

the use of CDT—a treatment methodology that has demonstrated advantages in alleviating the PE obstruction over heparin alone.3,10 Greater utilization of CDT initially carried a fear for increased bleeding complications, but MGH demonstrated no significant increase in these events.10 Similarly, the Cleveland Clinic PERT utilized systemic thrombolysis in 18% of their patients in the first two years of implementation and experienced zero bleeding complications.3,11 In the absence of clear guidelines for massive and submassive

PE, PERT has allowed for safer utilization of advanced treatments, which can maximize patient benefit while also ensuring that minimal risk is involved.

Further work is needed to assess how PERT can be optimized for cost-effectiveness and to minimize mortality, but early results are promising. By utilizing a multi-disciplinary approach to PE care, multiple expert opinions can be consulted in navigating the numerous treatment options for PE, ensuring that the patient’s care is tailored to the best

option for them with the least risk.12 If you are interested in learning more about PERTs, a good first step is to contact the PERT Consortium at pertconsortium.org. This organization represents a growing number of medical centers dedicated to improving PE care via PERT implementation, and member institutions have experience establishing programs with varying levels of resources in a variety of locations. ■

References 1. Tapson VF. Acute pulmonary embolism. N 2.

3.

4.

5.

Engl J Med. 2008;358(10):1037-52.

Root CW, Dudzinski DM, Zakhary B, Friedman OA, Sista AK, Horowitz JM. Multidisciplinary approach to the management of pulmonary embolism patients: the pulmonary embolism response team (PERT). J Multidiscip Healthc. 2018;11:187-195.

Rali PM, Criner GJ. Submassive Pulmonary Embolism. Am J Respir Crit Care Med. 2018;198(5):588-598.

Ge Z, Baber U, Claessen BE, et al. The prevalence, predictors and outcomes of guideline-directed medical therapy in patients with acute myocardial infarction undergoing PCI, an analysis from the PROMETHEUS registry. Catheter Cardiovasc Interv. 2018 Kabrhel C. Achieving Multidisciplinary Collaboration for the Creation of a Pulmonary Embolism Response Team: Creating a

6.

7.

8.

9.

“Team of Rivals”. Semin Intervent Radiol.

2017;34(1):16-24.

Dudzinski DM, Piazza G. Multidisciplinary Pulmonary Embolism Response Teams.

Circulation. 2016;133(1):98-103.

Pulmonary Embolism Response Team.

The University of Texas MD Anderson Cancer Center. Available at: https://www. mdanderson.org/content/dam/mdanderson/documents/for-physicians/algorithms/clinical-management/clin-management-pert-web-algorithm.pdf. Accessed Oct. 17, 2018.

Rosovsky R, Borges J, Kabrhel C, Rosenfield K. Pulmonary Embolism Response Team: Inpatient Structure, Outpatient Follow-up, and Is It the Current Standard of Care?. Clin Chest Med. 2018;39(3):621630.

Xenos ES, Davis G, Green A, et al. The Implementation of a Pulmonary Embolism EMPULSE WINTER 2019

Response Team in the Management of Pulmonary Embolism. Journal of Vascular Surgery. 2018;67(1):e13-e14.

10. Kabrhel C, Rosovsky R, Channick R, et al.

A Multidisciplinary Pulmonary Embolism Response Team: Initial 30-Month Experience With a Novel Approach to Delivery of Care to Patients With Submassive and Massive Pulmonary Embolism. Chest.

2016;150(2):384-93.

11. Mahar JH, Haddadin I, Sadana D, et al.

A pulmonary embolism response team (PERT) approach: initial experience from the Cleveland Clinic. J Thromb Thrombolysis. 2018;46(2):186-192.

12. Rosenfield K, Rosovsky R. Multidisciplinary Care for Pulmonary Embolism.

Advances in Motion. https://advances. massgeneral.org/cardiovascular/article. aspx?id=1007. Published Oct. 24, 2017.

Accessed Oct. 26, 2018.

33

POISON CONTROL

BRODIFACOUM POISONING:

A New Risk in the Use of Synthetic Cannabinoids

By Kristen C. Lee, PharmD, BCPS Clinical Toxicology/EM Fellow at Florida/USVI Poison Information Center—Jacksonville

By Madison Schwartz, PharmD Clinical Toxicology/EM Fellow at Florida/USVI Poison Information Center—Jacksonville

A 27-year-old female presents to the emergency department complaining of increased bruising over the past few weeks and dark stool for the last three days. She has no prior medical history and is not on any prescription or overthe-counter medications. Her vital signs are within normal limits. Her urine drug screen is positive for cocaine and THC. Initial coagulation studies reveal an INR of 8.5 and a PTT of 85.7 sec. Upon further questioning, the patient admits to “occasional” cocaine use, as well as “intermittent” use of synthetic cannabinoid products that may include K2 or Spice.

What is the connection between the patient’s use of synthetic cannabinoids and her current presentation?

Synthetic cannabinoids, including those sold under the names “K2” or “Spice,” are synthetically-derived compounds that agonize the cannabinoid receptor. In March 2018, the Illinois Poison Center alerted the Illinois Department of Public Health to a series of cases of patients presenting to emergency departments with unexplained bleeding, elevated INRs from 5 to >20 and recent use of synthetic cannabinoids. Blood samples in subsequent cases seen throughout the U.S. were found to be positive for brodifacoum.1 Brodifacoum is a long-acting anticoagulant rodenticide (LAAR) in the same pharmacologic class as warfarin, with a chemical structure differentiated by a longer polycyclic hydrocarbon side chain. Brodifacoum is considered a “superwarfarin” because, like warfarin, it blocks formation of the active form of vitamin K to inhibit production of clotting factors II, VII, IX and X. However, its high lipid solubility and ability to concentrate heavily in the liver confers activity 100 times that of warfarin, with a longer duration of action.2 The terminal elimination half-life of brodifacoum in human cases has ranged from 24 to 31 days.3, 4 In animal models, brodifacoum has demonstrated a half-life of up to 120 days.5 Patients who present with signs or symptoms of bleeding— including hematemesis, hemoptysis, bruising, epistaxis, unusually heavy menstrual bleeding, melena, hematuria, bleeding gums, or bleeding disproportionate to injury— should be questioned about use of synthetic cannabinoids including K2/Spice in the last three months. Laboratory diagnostics should include an INR ≥ 2 or an abnormal coagulation profile with no alternative clinical cause, or identification of an LAAR through high-performance liquid chro¬matography–tandem mass spectrometry of blood 34

samples.1 Life-threatening bleeds due to brodifacoum should be managed similarly to warfarin toxicity, with rapid reversal of anticoagulation using fresh frozen plasma (FFP), prothrombin complex (PCC) or recombinant factor VIIa.6 To sustain the INR reversal achieved by FFP or factor products, vitamin K 5-10 mg (up to 400 mg has been needed) should be administered intravenously.7 Slower infusions (i.e. 1 mg/min) may reduce the risk of anaphylactoid reactions. In patients with elevated INR in the absence of significant bleeding, intravenous vitamin K alone can be given at the above-mentioned dosages. Caution should be used in patients on an anticoagulant for medical reasons.

Once INR reversal is achieved, vitamin K should be continued orally and can be treated on an outpatient basis with regular follow-up for laboratory assessment once coagulation abnormalities have stabilized. While dosing strategies are variable based on response, one approach is 25-50 mg PO vitamin K 3-4 times daily for 1-2 days, with regular INR monitoring for adjustment of dosing.7 Serial serum concentrations of brodifacoum may also be useful in guiding duration of therapy, but may require analysis by independent laboratories and take multiple days to result.8 Because of the long duration of action of brodifacoum, patients should be followed to the resolution of coagulopathy, which may require weeks to months of observation. Serial INR measurements may guide tapering of vitamin K.2 Cases of brodifacoum-tainted synthetic cannabinoids have

EMPULSE WINTER 2019

been reported in at least nine states and are being monitored by Centers for Disease Control and Prevention (CDC). Since the outbreak, at least 300 cases have been reported, including at least seven deaths. Given the multi-state outbreaks, a variety of public safety announcements have been created by CDC and poison centers around the country to spread awareness about the dangers of brodifacoum-tainted synthetic cannabinoids. Consider questioning patients with a history of drug abuse regarding use of synthetic cannabinoids, and drawing a coagulation panel in patients with signs or symptoms of synthetic cannabinoid toxicity. ■

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 management of coagulopathy suspected to be secondary to brodifacoumcontaminated synthetic cannabinoids.

References 1. Moritz E, et al. Notes from the Field: Outbreak of Severe

Illness Linked to the Vitamin K Antagonist Brodifacoum and Use of Synthetic Cannabinoids - Illinois, March-April 2018.

MMWR Morb Mortal Wkly Rep. 2018 Jun 1;67(21):607608.

2. Chen BC, Su M. Antithrombotics. In: Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank LR. eds. Goldfrank's Toxicologic Emergencies, 10e New York, NY: McGraw-Hill; 2015. http://accesspharmacy.mhmedical.com/content. aspx?bookid=1163&sectionid=65096168. Accessed October 09, 2018.

3. Hollinger BR & Pastoor TP: Case management and plasma half-life in a case of brodifacoum poisoning. Arch Intern Med 1993; 153:1925-1928.

4. Pavlu J, Harrington DJ, Voong K, et al: Superwarfarin poisoning. Lancet 2005; 365:628.

5. Lipton RA & Klass EM: Human ingestion of a

"superwarfarin" rodenticide resulting in a prolonged anticoagulant effect. JAMA 1984; 252:3004-3007.

6. Holbrook A, Schulman S, Witt DM et al.: Evidence-based management of anticoagulant therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141:e152S–e184S. 7. Howland MA. Antidotes in Depth: Vitamin K1. In: Nelson LS, Hoffman RS, Lewin NA, Goldfrank LR, Howland MA, Flomenbaum NE editors. Goldfrank’s Toxicologic Emergencies. 9th ed. New York: McGraw-Hill: 2011. p. 876879.

8. Bruno GR, Howland MA, McMeeking A, Hoffman RS: Longacting anticoagulant overdose: brodifacoum kinetics and optimal vitamin K dosing. Ann Emerg Med. 2000;36:262– 267.

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35

NEW SECTION:

MEMBER SPOTLIGHTS Get to know fellow FCEP members through Q&A's, beginning with FCEP's Executive Board.

By René Mack, MD, RDMS, FACEP & Shayne Gue, MD

MEET YOUR E-BOARD: Dr. Damian Caraballo SECRETARY-TREASURER Q What sparked your interest in joining

FCEP’s Board of Directors and how did you first become involved?

A I became involved with FCEP after be-

ing invited by our group's CEO to attend quarterly meetings. At first it was just to know what was going on in emergency medicine, but eventually I realized how important advocacy is to our daily struggles in the ED. The balance billing fight in Tallahassee really opened up my eyes to how advocacy impacts our careers. I found that by becoming involved, I could have a say in improving the many issues we face in emergency medicine. It was through my interactions with FCEP leadership and the state legislature that I really learned the truth of the saying, "if you're not at the table, you're on the menu."

Q How has being in emergency medicine

changed the way you think about leadership and how will you apply those skills while serving on the Board?

A Emergency physicians tend to be up-

front, problem-solvers, quick-thinkers, and process information quickly. We “don't suffer fools gladly,” and there's a lot of “fools” in government policies that need our feedback. The ability to quickly process information and come up with solutions makes us natural leaders in both medicine and advocacy.

Q What is your biggest goal to accom-

plish during your tenure on the Board?

A My overall goal is to make everyone's

job in emergency medicine better after I leave than when I started. EM is a very hard job; bad policies make it all the much worse (eg. see the homeless ED bill in California). It might involve small stuff (eg. not having to login to the PDMP to write for mor-

36

“

Because of the huge money behind American medicine ($4 trillion/yr), more and more outside forces are encroaching on the doctorpatient relationship. We need to start collectively pushing back, and it starts with focusing on individual patient care and standing up for physician rights.

phine for patients while IN the ED, as was recently proposed by AHCA and rectified by FCEP). Sometimes it's advocating for patients, such as the MAT warm-handoff programs we are trying to implement in Florida. But overall, my goal is to make sure Tallahassee and other regulatory bodies do not make our tough job harder by implementing poorly thought-out or special-interest-driven policies, which adversely affect EM. Also, I'd like to get doctors more involved in being part of the solution rather than just complaining at ED meetings or on social media forums.

Q Physician wellness is an important

priority within the EM community.

How do you make it a priority not only to yourself but within your program/ institution?

A I highly recommend everyone read Dr.

Siddhartha Mukherjee's article in the New York Times regarding physician burnout. Basically, resiliency results from having meaning, mastery and autonomy. Both meaning and autonomy have been categorically stripped from physicians. When you're forced to be just a button-pushing, RVU-creating, algorithm-bound employee who spends more time in meetings listening to customer service tips than improving patient care or spending time with patients—then you've hit a disconnect.

Doctors will re-discover wellness and resiliency when they get back to the EMPULSE WINTER 2019

heart of medicine, which is the doctor-patient relationship.

Because of the huge money behind American medicine ($4 trillion/yr), more and more outside forces are encroaching on the doctor-patient relationship. We need to start collectively pushing back, and it starts with focusing on individual patient care and standing up for physician rights. Hospitals, institutions and groups—while well-intentioned— are going at it wrong in terms of wellness. You can't "yoga" or "ice-cream party" your way into wellness. You have to re-direct the mindset of physicians to focus on what matters most to them.

Q Where can we find you on your days

off?

A During the day, I love to be outside: at

the beach, on the water, fishing, parks with my kids, bike-riding. At night, I'm a big foodie, so I love trying out new restaurants and going out to dinner with a group of friends. I also love travel and live music—you'll find me at big concerts whenever I can snag a pair of tickets.

Q What’s your favorite tip for an EM res-

ident or medical student interested in pursuing a leadership position within emergency medicine?

A Find a niche and work on it. Find a

problem that bugs you and start talking to people on a way to fix it. Or, cultivate something you're interested in and work on it outside of just the ED. It will actually help prevent burnout by helping you build resiliency. FCEP Leadership Academy is a good way to network and find your niché. ■

“

We lead because it is what we must do to effectively care for our patients. The nature of our specialty forces the timid to be firm, the silent to speak and the fearful to be brave.

MEET YOUR E-BOARD: Dr. Kristine McCabe-Kline PRESIDENT-ELECT Q What sparked your interest in joining

FCEP's Board of Directors and how did you first become involved?

A The first year of the Leadership Acad-

emy (2012) was the year I became actively involved in FCEP. The Leadership Academy introduced me to leaders, innovators and BOD members who have served as mentors. I am very grateful for the Leadership Academy founded by our current ACEP President and former FCEP President, Dr. Vidor Friedman.

Q How has being in emergency medicine

changed the way you think about leadership and how will you apply those skills while serving on the Board?

A All emergency medicine physicians

are leaders. We forge relationships and engage with consultants, hospitalists, primary care physicians, family members of patients, administrators, nurses, techs, cafeteria workers, housekeepers, security guards, EMS, police officers, safety pets, etc. We lead because it is what we must do to effectively care for our patients. The nature of our specialty forces the timid to be firm, the silent to speak and the fearful to be brave. The BOD takes that same skill set and uses it to advocate for our patients, our colleagues and our specialty.

Q What is your biggest goal to accom-

plish during your tenure on the Board?

A During my tenure on the BOD, my

greatest goals are to advocate for three things: our patients’ access to care, building and transforming systems that support longevity in an emergency medicine career, and fair reimbursement for services we provide 24/7/365. This will help ensure ongoing recruitment of the most capable physicians to the specialty of EM.

Q Physician wellness is an important

priority within the EM community. How do you make it a priority not only for yourself but within your institution?

A Physician wellness is not only about

eating well, exercising and sharing miserable experiences with each other. Emergency medicine wellness is about building systems and workflows that minimize frustrations and make interactions with hospitalists, consultants and others facile. I believe EM physicians have been blamed for the gaps in care at present and are criticized for doing the best we can in a dysfunctional system as though WE are the dysfunction.

In my current position as Regional Operations Coordinator for my physician group, I have dedicated my efforts to addressing the gaps in standardization and lack of coordination of care. I have also focused on development of relationships among physicians, which enhances our inherent satisfaction in the work we do as well as lends personal support to physicians who are experiencing hardships such as med EMPULSE WINTER 2019

mal lawsuits, addiction issues, familial discord and physical/mental illness.

Q Where can we find you on your days

off?

A When I have a day off, I go to mass

with my family.

Q What is your favorite tip for an EM

resident or medical student interested in emergency medicine?

A Shadow EM physicians in a variety of

practice environments: academic tertiary care facilities, community hospitals, rural outposts, free-standing EDs, and traveling doing locums work. You need to know what “a day in the life of” an EM physician is like to make good choices for yourself at every stage in your career. If you’re interested in pursuing a leadership position, seek out opportunities offering mentorship. They are incredibly valuable and establish relationships that will sustain you in leadership, which can be an isolating endeavor. ■ 37

MUSINGS FROM A RETIRED EMERGENCY PHYSICIAN

A Funny Thing Happened at the Social Security Office

By Wayne Barry, MD, FACEP Retired Emergency Physician

My wife, six years younger than I, is all signed up for Medicare Part B, which will begin January 1, 2019, in honor of her turning 65 later that month; (she and the late Dr. Martin Luther King, Jr. share a birthday). “Now it’s your turn,” she told me. Friends of mine told me they did this through the U.S. Mail.

Easy peasy, right? Not so for me.

I turned Medicare age over five years ago, but continued to work and take commercially-offered medical insurance through my job in order to cover my non-working wife. As open enrollment started recently at my work site, I very carefully waived all my health care benefits, stripping myself bare of coverage so that I could earn the worthiness of Medicare Part B Coverage. I copied the waiver verification and marched off to the nearby Social Security Office to dot all the “i’s” and cross all the “t’s” in person to ensure a successful sign up… right?

Wrong! I learned, to my temporary dismay, that I was going to be penalized upwards of $75.00 for each Medicare premium payment I would be making till the end of my days here on earth, because I had not shown verification that I was covered by other insurance since I turned 65 on March 25, 2013.

You would think the Medicare Bureaucracy would be delighted to know that I have not been dipping into their pot of money for over five and a half years now. Thank goodness I had these illogical facts and rules explained to me by a very nice and patient social security clerk, who dispatched me on my way to procure the necessary additional prior insurance coverage verification. Mission accomplished! My Medicare Part B card arrived in the mail yesterday.

In November, one of the most heavily-participated and contentious midterm elections took place. Sixty-five percent of the electorate admitted that their vote in this year’s election 38

was a reflection of their feelings about the current president. Forty percent of these people represent President Trump’s “base,” and we know what their feelings are. Another 25% of voters cannot stand his bullying foreign policy and trade wars, his malignant narcissistic personality rants, his extremely poor judgment with respect to cabinet officials and other Administration appointees, and his ruthless self-aggrandizement from blatant violations of the U.S. Constitution’s prohibition against emolliements, and his notorious money laundering for Russian oligarchs during the 80’s and 90’s.

So how does the remaining 35% of the electorate weigh in? Beats the heck out of me! I cannot wrap my head around the significance of the Trumpled Republican Party increasing their majority in the Senate while losing their majority in the House of Representatives. What this unusual circumstance may mean is the fodder of endless speculation and punditry: more Washington D.C. gridlock, increasing dissatisfaction with the U.S. model of representative democracy, and sorrow over the extreme polarization of political views and values of the American people. This is not a pretty picture!

The real question I, and I imagine many others both in and out of our profession, seek answers to is what do the recent election results mean for health care in the U.S.? There appears to be little appetite in the Republican-controlled Senate to revisit “Repeal and Replace Obamacare,” which three mighty branches of Republican-controlled government failed to accomplish recently. I suppose the Affordable Care Act will continue to decay in its unimproved and imperfect present format while President Trump continues to emasculate it further via Executive Orders.

EMPULSE WINTER 2019

Once again, Florida has become an electoral laughing stock with its lost and uncounted votes in Broward and Palm Beach Counties, calling into question the validity of the razor-thin margins of victory obtained by the new Governor and U.S. Senator-elect. Both of these candidates came out against the very popular mandated insurance coverage for pre-existing conditions, and both are against the expansion of Medicaid to cover the working poor and other disadvantaged Floridians.

Interestingly, as both DeSantis and Scott are raising their indignant hackles about voter fraud (which has never been conclusively proven to any large extent in Florida or the rest of the U.S., for that matter), Scott walked back his opposition to preexisting condition coverage by revealing this concept strikes a personal note in his own family. DeSantis may still think that if you can’t get insurance for pre-existing conditions, then just report to your favorite ER and your troubles will all go away. Please God, help us all!

Meanwhile, the further I get away from my last shift in the ER, the more I admire those of you who are still toiling in the “pits” of the safety net of our still-broken U.S. medical care delivery system, fighting for improved access to care, and better reimbursement to result in better and safer staffing of our ER’s. Remember to take care of yourselves, carefully balance your work and personal life dichotomy, and guard against burnout. And lastly, I hope to not burn up too many Medicare dollars, which hopefully will still be around when you and your family need them. ■

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