EMpulse (Spring 2016)

Volume 23, Issue 1 Spring 2016

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

The Highs and Lows

An indepth look at Florida’s growing heroin epidemic

The rise of 'flakka' in the Sunshine State I nside : H ighlights

Miami injection drug use case study reveals morbid results

and

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Chapter Updates President’s Message | 4

Medical Economics Committee | 5 Editor’s Briefing | 6 ACEP Update | 7 Government Affairs Committee| 8 EMS/Trauma Committee | 9 Membership & Professional Development Committee |10

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

FAEMSMD Update | 11 EM Medical Student Committee | 12 EMRAF Committee | 13

FCEP Executive Committee Steven Kailes, MD, FACEP • President

Florida Emergency Medicine Foundation Update | 14

Jay L. Falk, MD, FCCM, FACEP • President-Elect Joel Stern, MD, FACEP • Vice President

Leadership Academy Update | 16 FITLS Update | 18 Residency Matters | 20

Joseph Adrian Tyndall, MD, MPH, FACEP • Secretary/Treasurer Ashley Booth-Norse, MD, FACEP • Immediate Past President Beth Brunner, MBA, CAE • Executive Director

Features

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

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

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

Daunting Diagnosis | 12 Coding Tip | 18 Poison Control | 19 Florida Emergency Medicine Residency Match 2016 | 24 EM Days and the Balance Billing Blues | 25 Snapshots of EM Days 2016 | 26 Florida’s New Drug Epidemic: Heroin | 28 Got Flakka? | 32 Musings of a Recently Retired Emergency Physican | 34

A Cost Analysis of Hospitalizations for Infections Related to Injection Drug Use at a County Safety Net Hosptial In Miami| 36 Published by: Johnson Press of America, Inc. 800 North Court Street Pontiac, IL 61764 Phone: 815-844-5161 Fax: 815-842-1349 www.jpapontiac.com

Outsmarting Some Smartphones | 41 The Florida Needle Exchange Program: Infectious Disease Elimination Act (IDEA) | 42 FCEP Call for 2016 Board Candidates | Back Cover Spring 2016 | Volume 23, Issue 1

EMpulse | 3

President’s Message Your reimbursement may be cut 20-50% due to proposed new legislation coming out of the Florida legislature! The originally filed legislation would have done this to you in banning balance billing for out of network care (HB221 and SB1442). However, as of this writing, it looks like that isn’t true anymore. Due to the hard work of many, we anticipate something will pass preventing balance billing but also preserving our ability to pursue fair reimbursement. As always, there is much for us to still do.

Steven Kailes, MD, FACEP FCEP President

In other areas, we have been advocating to expand community services for our mental health patients. We have also been asked to weigh in on the idea of broadening access to Naloxone for first responders and lay persons. We are supportive of this idea as we view this as a patient safety issue. However, we have concerns about the implementation of this concept and any liability issues we could face when dealing with any unintended consequences.

We continue working on a new strategic plan for the College. I hope this will help identify areas of strengths and weaknesses so we can make the College stronger and deliver an even greater value to you. In addition, we are taking a fresh look at our educational programming. Through a variety of venues, from webinars and podcasts to in-person lectures and simulation training, we strive to provide meaningful and useful training and CME, at a great value and sometimes even at no cost to our members. We are re-engaging the EM residents in Florida and building a more useful and worthwhile resident section within FCEP. We are reaching out directly to the new residency programs in south Florida and even cultivating relationships with the medical student EM interest groups around the state.

Importantly, the College is preparing for our second Written Board Review Course. The course was great last summer. I should know, since I was one of the inaugural students! Although it is a new course for us, it is not new. It has blossomed from a course previously offered by the Pennsylvania ACEP chapter. I expect this course to become one of the premier board review courses available and would highly encourage you to consider taking it when the time is right for you. Oh, and I did pass the recertification examination. I am certain the course helped me.

Our mission is to promote high quality emergency medical care, to empower emergency physicians, and to protect the patients we serve. In our new building, in partnership with the Florida Emergency Medical Foundation and the Emergency Medicine Learning and Resource Center, we will be able to deliver great content and serve the College’s mission for years to come. We continue our efforts to raise money for our Center Campaign and I urge you to take a moment to go online at www.emlrc.org/capital-campaign and make a pledge to support us.

Finally, we actively seek member engagement and new members to join us. While we have different communities and many different passions, we share a common profession. The College will be stronger and better able to serve your needs with your involvement. It is easy; just show up! Please try to join us for one of our quarterly meetings and definitely make plans to join us in August in Naples, FL, for our annual Symposium by the Sea. This is a great way to relax, have fun, see old friends, make new friends, enjoy some quality education and CMEs, and make connections that could open a new door for you in the future. As you can see from my opening statements, we work on important things for you and the patients you serve. There is great value in this for you personally, and we know you can add value to us.

4 | EMpulse

SPRING 2016 | VOLUME 23, ISSUE 1

Medical Economics Committee Balance Billing Compromise The process of creating legislation has been compared to watching sausages being made, but that may be too flattering. Since the balance billing ban proposal was made in the 2015 legislative session, it has been the No. 1 priority of FCEP to avoid damaging the fragile safety net we provide for FL patients. In last year’s session we successfully avoided bad legislative “fixes” and strove to be a credible and trusted source for policy-makers. Much work was done gathering data, educating legislators, and preparing for this year’s session. EM days in January at the start of session was a good opportunity to reinforce these messages and meet with key legislators, Florida’s Insurance consumer advocate, and other key stakeholders.

Our emphasis in between sessions and for this year’s session was to advocate for a solution for Daniel Brennan, MD, FACEP patients caught in the middle of payors and providers in out of network balance bills. Coined Medical Economics Committee “surprise bills” by the insurance lobby and the media, the legislative atmosphere was primed Chair to enact a “consumer-friendly” balance billing ban, so FCEP’s priority was to ensure any ban would not harm the EM safety net our patients rely upon. Our priority for the legislation was to ensure adequate payment for our services (“Fair payment”) and to ensure adequate dispute resolution processes.

Prior to session, FCEP leadership met with FMA specialty leadership and drafted our ideal legislation. This entailed 4 main provisions: (1) Fair payment – charge based OON payment (2) defining usual and customary via an objective, independent non profit database (FairHealth.org) (3) improved alternative dispute resolution processes (ADR) and (4) moving the burden of collection of patient responsibility to the insurers, rather than the EM providers. Resistance from the insurance lobby made achievement of all the elements politically unattainable. In fact, the initially proposed legislation this session was worse than the proposals last year, in that the payment provisions were Medicare based, insurer controlled, and additionally applied to the HMO as well as PPO arena. So our work was cut out for us as the session unfolded.

FCEP Leadership and our lobbyist continued to work with the bill sponsors, and within the medical community via FMA. FMA thankfully was very solicitous and attentive to EM’s input. And despite the fact that FCEP was respected and trusted as a credible and patient oriented voice, it became clear to me that the influence and access FMA has far overshadowed FCEP’s.

I do believe FCEP was able to effectively leverage our voice with FMA’s in achieving significant movement to a reasonable compromise. The compromise legislation evolved to accomplish the top 2 items on our agenda – fair payment provisions that are charge-based and an improved ADR process. We still hope to get FairHealth incorporated into regulations that we expect will need to be drafted to flesh out the specifics of the ADR process called for in the compromise legislation. The last item re: shifting of patient responsibilities to the insurers was never likely, especially as the legislation became wider than just EM based.

The compromise legislation (HB 221 and SB 1442) progressed though all 3 committees in each chamber, and the House passed HB 221. SB 1442 was threatened by last minute attempts to carve out anesthesia and radiology, which initially was included, then reversed shortly thereafter to allow the bills to more closely match. Eventually the Senate passed their amended version of the HB, including among a few other differences, provisions to preclude retroactive denials, to include hospitals, and to include autism/disabled care. None of the differences between the HB and SB affect EM materially, but the amended bill goes back to the House for reconciliation in the session’s last week.

By the time this is published I suppose anything could have happened, but it appears that compromise balance billing legislation is more likely than not to occur. Through the coordinated efforts of FCEP and FMA (and our Tallahassee lobbyists) I believe the compromise legislation does protect patients while preserving EM’s ability to obtain adequate payment for our services. While there are concerns insurers may conveniently decide to interpret the “usual and customary charges in the community for similar services” as something else (i.e., usual “payments”), it was important to incorporate charge based methodology into the legislation. This gives EM groups the best chance to negotiate for fair payment for in network PPO agreements, or failing that, obtain fair OON charge based payment. And while hopefully unnecessary, an effective dispute resolution process to fall back on in the end.

Update: The legislation was passed during the ninth hour of legislative session on March 11. This is a significant bill for FCEP and all of emergency medicine.

SPRING 2016 | VOLUME 23, ISSUE 1

EMpulse | 5

Editor’s Briefing

Impaired Physicians — It could be you Drugs are everywhere; we prescribe them every day. Not only is street-drug use on the rise, but so is abuse of prescribed medications. As medical professionals, we often see individuals roll into our emergency departments intoxicated on alcohol, illicit street drugs, or home medications. Often, we may judge these individuals that may shape the care we give them.

But, do not be too quick to judge...

Have you ever thought this could be you one day? Have you ever had your significant other need emergent surgery and become addicted to post-operative opiates? Have you ever had a sibling, friend, child or parent addicted to a substance? It can happen to your loved ones, your colleagues, and even you--so perhaps, do not be so quick to judge others.

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

In addition to patients or loved ones having substance abuse issues, so can medical professionals. Substance abuse affects everyone. Every day, impaired physicians--- on alcohol, prescription, or illicit medications--- treat patients. There is help if this affects you.

The Federation of State Physician Health Programs Inc. (FSPHP) evolved from initiaves taken by the American Medical Association and individual state physician health programs. It focuses on rehabilitation and monitoring of physicians with psychoactive substance use disorders as well as mental and physical illness.

As far back as 1958, the Federation of State Medical Boards of the United States identified drug addiction and alcoholism among doctors as a disciplinary problem. It called for the development of a model program of probation and rehabilitation that could be adopted by individual state boards.

Today, nearly every state has developed programs to service physicians in need.

The Professional Resource Network (PRN) provides evaluation and treatment to impaired practitioner on behalf of the State of Florida. The Professionals Resource Network, Inc. (PRN) is a nationally recognized, legislatively enacted private nonprofit 501(c)3 organization, that is widely cited as one of the premier programs for impaired health care professionals in the United States. The state of Florida seeks to "protect the health, safety and welfare of the public, while at the same time, supporting the integrity of the healthcare professionals."

For some individuals, PRN in Florida is mandatory. For others, it is voluntary and often suggested by an employer or the licensing board as a way to avoid licensing action. If the PRN evaluation determines that a physician is impaired, the physician will be required to sign a monitoring/advocacy contract with the Professional Resource Network. Most contracts are for five years. Participation is confidential, but your employer must be informed that you are enrolled in the program.

While participating and complying with the terms of your PRN agreement, the Department of Health and Licensing boards will not take action against you unless you violate the terms of your PRN in which the PRN can refer your case to the Department of Health for Disciplinary action.

The DOH and the DBPR contract with PRN to provide mandated services of the Florida Statutes in Chapters 455 and 456, as well as each individual's practice act. PRN is often an alternative to the DOH/DBPR disciplinary process. This allows PRN to maintain an individual's confidentiality and limits the negative impact on his/her life.

If you are in need or know a colleague in need, please contact The Professional Resource Network online or at 800-888-8776.

This may not only save your career, but your life.

6 | EMpulse

SPRING 2016 | VOLUME 23, ISSUE 1

ACEP Update As your representative on the ACEP Board of Directors, I wanted to give you a quick update on what your board has been up to. We meet at least 5 times a year and at the recent Board meeting in January we approved the creation of two new sections: the Event Medicine and Pain Management sections.

Our Chapter, FCEP, was awarded a State Public Policy grant to bring in a public relations firm to assist in a campaign for media exposure on the issue of balance billing. It was very effective with numerous FCEP leaders having their op-eds published in newspapers, FCEP President Dr. Kailes was interviewed by a radio station and mutliple of our physicians were interviewed for newspaper articles also. The ACEP Georgia Chapter was awarded a State Public Policy grant to fight a ban on balanced billing, in addition to five other Chapter grant awards.

ACEP policy topics that were reviewed and approved included: • • • • • • • •

Mobile Integrated Healthcare Out of Hospital Medical Direction Pedestrian Injury Prevention Appropriate Inter-hospital Patient Transfer Emergent Use of Telemedicine Patient Medical Records in the ED Advanced Life Support Courses Resident Duty Hours

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

Clinical policies were approved regarding: Verification of Endotracheal Tube Placement and Approach to Febrile Children under Two Years of Age. Reviewed and approved the ACEP Legislative and Regulatory Agenda for this year. Which includes; Federal Tort Reform, Protecting Emergency Physician Reimbursement, Medicaid and Medicare reform as highlights!

Received an update from the CDC regarding Opioid Guidelines, and the STEADI Fall Prevention program. Tweaked and updated the ACEP Strategic Plan. Deliberated over the development of a National Emergency Department Information exchange system, and considered legal options regarding the “Greatest-of-Three” rules recently promulgated by CMS! Oh, and of course reviewed the colleges financial position, and the progress on the new college headquarters building.

To say that our 2-day Board meetings are jam packed is truly an understatement! I think our preparatory reading was about 650 pages for this meeting, a bit light in my experience. While much of the business of the Board, & college, is the behind the scenes stuff that is not very exciting; it is very necessary for the functioning of our organization. You can see that in addition to the day-to-day business of the college the Board works hard to anticipate the future needs of our members.

Government Affairs Committee Subcommittee Update: Political Committees FCEP has two Political Committees, or PCs. These are also commonly referred to as PACs or Political Action Committees.

The purpose of these are to raise money for Political Action, which includes donations to political campaigns of candidates running for office our state.

You may be familiar with ACEP’s organization, known as NEMPAC. Many of you may be donating annually to NEMPAC, as this is included on your national annual dues form. Our PCs are separate from NEMPAC. NEMPAC uses it’s donations at the federal level only. We do not receive any funding from them for our state level candidates. That is the reason that we have our own separate state PCs. It is important to donate at the state as well as the federal level. We have requested that our state PC dues be included on the annual dues statement from ACEP. At this time a decision on that is still pending. In the meantime we will proceed with our own separate dues statement for the state PCs. Annual dues have been set at $100 for FCEP members and $50 for EM resident and students.

Joel Stern, MD, FACEP Government Affairs Committee Co-Chair

Physicians for Emergency Care (PEC), is intended for donations from individuals, Physicians or non-Physicians. Emergency Care for Florida (ECF), is intended for donations from organizations, such as group practices or other companies. Year to date donations for the PCs are for PEC, and for ECF.

Our goal is to raise at least $100,000 this year between both PCs. Your participation is necessary for us to be successful.

Please donate at whatever level is possible, and ask your group practice to participate as well. Donations can be made easily online, and options for one time and monthly or annually recurring are available. Donors and donor levels for 2016 are listed below. Remember that elections are coming in November, and we will need money to support the candidates who will promote our interests in Tallahassee.

ECF & PFEC PC Contribution Levels: Code Gold: $25,000+ Code Red: $20,000-$24,999 Code Black: $15,000-$19,999 Code Blue: $10,000-$14,999 Code Silver: $5,000-$9,999 Code Orange: $1,000-$4,999 Code Yellow: $500-$999 Code Pink: $250-$499 Code Green: $100-$249

Thank You for Your Continued Support!

Emergency Care for Florida Contributors through March 2016 EmCare

Physicians for Emergency Care Contributors through March 2016 Aaron Wohl Amit Rawal Ashley Norse Charles Chung Daniel Thimann Floriano Putigna Frederick Yonteck Jesse Caron Joel Stern Jordan Celeste Joseph Tyndall Joshua Young Michael Lozano Richard Temple Steven Kailes Miguel A. Acevedo-Segui

8 | EMpulse

Spring 2016 | Volume 23, Issue 1

EMS/Trauma Committee Controlled Substances Use in EMS When someone is in pain, or has sustained a severe traumatic injury or is having a medical emergency they dial 911. The public expects EMS to respond and provide immediate medical care. A large part of this service includes their ability to administer medications. This includes anything from delivering fentanyl to an adolescent with a femur fracture on the side of the I-4 to administering versed to an actively seizing patient. Controlled substances also assist our prehospital personnel in calming an acutely agitated patient and securing an airway with rapid sequence intubation when appropriately trained.

Currently EMS personnel across the nation administer these medications based on standing medical care protocols. Recently there has been concern from the Drug Enforcement Administration (DEA) that the Controlled Substances Act, written before the establishment of modern EMS and the concept of standing orders does not permit the administration of controlled substances without a patient specific physician’s order. This is a national issue.

Representative Hudson (R-NC) is sponsoring a bill HR 4365 “Protecting Patient Access to Emergency Medications Act of 2016� which will allow EMS providers to continue using standing Christine Van Dillen MD, FACEP EMS/Trauma Committee orders from their medical director to administer controlled medications to their emergency Co-Chair patients. As a group the emergency medicine community needs to ensure that these changes protect our abilities to provide these drugs in the prehospital setting without unnecessary delay, as currently is the practice with standing orders. Failure of the passage of this bill will mandate EMS to contact on-line medical control in every instance in order to treat pain with narcotics or to treat seizure patients with benzodiazepines.

FCEP members and EMS Medical Directors around the state need to reach out to Members of Congress in the House to urge them to co-sponsor this bill (future outreach in the Senate is planned when companion bill gets filed). An email template to support this effort and an email list of Legislative Aides for members of the House of Representatives can be made available on request to Melissa Keahey at the EMLRC office.

Trauma update

The Bureau of Emergency Medical Oversight will be holding a public hearing to discuss proposed rule changes related to the allocation of trauma centers for each trauma service area as published in the FAR on February 4, 2016. This meeting will be held in Tallahassee on March 10, 2016 at 9 a.m. at the Department of Health. There was also a notice sent out late in February of the development of rulemaking to review the rules and amend rule language related to Trauma triage as necessary to ensure that all rules conform to statutory requirements and delete unnecessary and obsolete language.

The department intends to update trauma rule definitions and prehospital requirements for trauma care and adult and pediatric trauma scoring methodologies. The Department is considering repealing sections 64J-2.003, 64J-2.004, and 64J2.005 and adopting the Guidelines for Field Triage of Injured Patients, Recommendation of the National Expert Panel on Field Triage, 2011, as the trauma scoring system. This will affect EMS agencies, trauma centers and emergency departments across the state requiring additional training as well as leading to changes in trauma patient destination.

OHCA Focus

Out of hospital cardiac arrest (OHCA) remains a focus of the EMS FCEP committee and FAEMSMD. For the next year EMLRC will be offering high performance CPR training with high fidelity manikins for EMS agencies. This training focuses on the quality of compressions: allowing recoil, ensuring the ideal rate, ideal depth and minimizing interruptions. The high fidelity manikins being used provide for immediate feedback to the providers to allow them to perfect their CPR performance. There is also a workgroup from FAEMSMD, which is meeting quarterly to review data and attempt to identify best practices in OHCA resuscitation. Our goal is to improve neurologic outcomes for victims of cardiac arrest.

SPRING 2016 | VOLUME 23, ISSUE 1

EMpulse | 9

Membership & Professional Development Committee Greetings from the Membership and Professional Development Committee! We had the opportunity to meet at EM Days and continue the fight for patient advocacy and our ability to practice medicine in a safe and patient-centered atmosphere. With the help of you, our membership, we were able to share the positives and negatives of the more pressing issues taking place during this legislative cycle. The power of a substantial membership is multifold and many times not truly recognized until a great need arises.

Rene Mack, MD Membship & Professional Development Comittee Chair

Unfortunately, medicine and emergency medicine specifically, is currently in a time of need as we experience potential and actual changes in our practice structure. I’m sure you will be (and have been) getting the majority of this information from the Government Affairs committee but without a robust and active membership we’re not able to advocate for our patients and ourselves in the most effective manner. On that note, the majority of eligible ACEP/FCEP members in Florida are members and are doing their part to help sustain our profession. Even with our current level of membership involvement, we will continue to reach out to those eligible non-members to ensure that we all have access to the many visible and intangible, benefits of membership.

The medical students in Florida are another area of membership that we are also devoted to seeing their growth and development within medicine in general and emergency medicine, if they decided on EM as their career plan. The medical student committee is very active and works hard to remain active with our organization. We are hoping to expand our medical student programming in the future so keep tuned for upcoming activities.

EM Residents are also in the spotlight. Several of the residency programs were represented at this year’s EM Days (as they usually are!) and were instrumental in helping FCEP discuss our positions with the legislators in Tallahassee. FCEP has already completed several residency program visits and more are being scheduled. Our goal is to make personal contact with the residents to give them more information on the many ways that ACEP/FCEP are supporting them through their medical career and to help facilitate their transition from resident to attending physician. On their part, our residents provide several educational opportunities for us as well including the Resident’s Case Presentation Competition (CPC) and SimWars which take place annually at Symposium by the Sea. Symposium by the Sea (SBS) will take place from August 4-7, 2016 at the Naples Grande Beach Resort in Naples, FL. We are looking forward to hosting another FREE CME event for our members! The annual SBS is a great, FREE, benefit included with your membership in ACEP/FCEP, along with many other benefits. The SBS is a great time to reconnect with colleagues, obtain FREE CME and strengthen your knowledge of various aspects of our profession.

Ultimately, regardless of your membership status, FCEP is working for you! We are constantly revising and updating our programming in an effort to provide you with the most up-to-date information. Join us at the next committee meetings, taking place at the FCEP office, in Orlando on April 20, 2016. If you’re not able to make it to the next event(s) make sure to visit the website fcep.org for more information and updates to all our events. You can also find us on Facebook, Twitter and Instagram!

FAEMSMD Update Elections for officers for the Florida Association of EMS Medical Directors will be held at the July meeting. A nominating committee will be appointed at the April meeting. Anyone interested in serving on the committee should contact Dr. Meurer, the current president or Melissa Keahey at the office to indicate his or her interest in serving.

Dr. Joe Nelson, the Florida State EMS Medical Director, gave a report on current items of interest to EMS medical directors on both the national and state level. Included in the discussion were the following topics: • REPLICA (the Recognition of Emergency Medical Services Personnel Licensure Interstate Compact Agreement) • When enacted by ten US states, EMS personnel initially licensed by NREMT, will have reciprocity across state lines for day-to-day operations.

David A. Meurer, MD President of the Florida • FloridaNet, an interoperable public safety broadband network to link public safety agencies Association of EMS Medical across the state, which will be HIPPA compliant.

Directors • Florida Bureau of Emergency Medical Operations Update. There is an ongoing rules review process for 64-J, the rules which regulate EMS in Florida. Current topics of interest by the Bureau include Community Paramedicine, Trauma Alert Criteria with consideration of adoption of the CDC Trauma Triage Guidelines, and the establishment of local Regional Trauma Agencies. There is also interest in Florida joining with the CARES (Cardiac Arrest Registry to Enhance Survival) Registry on a statewide basis as opposed to an agency by agency basis.

Stroke Care in Florida

Discussions have been held between the Florida Puerto Rico Stroke Registry, based at the University of Miami Miller School of Medicine, and the Florida Department of Health to share EMSTARS data. A committee, led by Dr. Charlie Sands, has developed an updated prototype Stroke Alert Check list for use by EMS agencies. This will be the first proposed update since the passage of the Florida Stroke Act in 2004 requiring EMS to use a Stroke Alert Check list. Dr Peter Antevy and Dr Paul Banerjee presented updates on current clinical aspects of stroke care.

An update on vehicle collision telemetry data transmission for use in dispatch of EMS resources to vehicle crashes was given

by Catherine Bishop form OnStar and Chief Corey Richter of Indian River County Fire Rescue.

A brief update on legislation with impact on EMS agencies pending before the Florida Legislature was given. DEA/ HR 4365 Protecting Patient Access to Emergency Medications Act of 2016. In reviewing the Controlled Substances Act, the current practice of EMS utilizing standing orders of a medical director to ALS providers to administer covered substances (benzos for seizures, narcotics for pain) does not meet the requirements of the law. Technically, a specific physician order is required for each specific patient before the drugs can be administered, even in an emergency condition. A bill has been proposed in the federal House of Representatives, HR 4365, addresses this and other issues involving the use of controlled substances

by EMS. This bill has unanimous support from the EMS community, and members of FAEMSMD and FCEP are requested to notify their legislators of support for this bill. NAEMSP has provided a tool kit to make this process easier for physicians. It can be found at http://naemsp.org/Pages/Advocacy.aspx.

After the FAEMSMD meeting, a workshop was held on prehospital cardiac arrest management. Dr. Charlie Sand and Dr. Peter Antevy presented updates on the 2015 AHA ACLS guidelines. A robust discussion was held afterwards regarding the importance of collecting standardized data to review outcomes, with the plan to utilize a standard form for Florida EMS agencies to use. Another workshop and discussion is planned for the July meetings at Clincon.

The next meeting for the FAEMSMD is scheduled for April 18, 2016 at the EMLRC office in Orlando. We look forward to seeing you there, but if you are not able, a conference call option will be available for those who cannot attend in person.

The phone number for the conference call is 866-453-5550, and the passcode is 486231#.

SPRING 2016 | VOLUME 23, ISSUE 1

EMpulse | 11

EM Medical Student Committee This edition of FCEP’s Medical Student Committee quarterly update features the University of Florida’s Emergency Medicine Student Association.

On December 3rd 2015, the University of Florida Emergency Medicine Student Association held the 5th annual ProcedurePalooza event at the UF College of Medicine. The purpose of this event is to allow students the opportunity to learn how to perform multiple commonly utilized procedures, as well as to network with current residents and attending physicians in different departments from both Gainesville Ben Banapoor EM Medical and Jacksonville. This year the event was coordinated by UF EMSA Co-Presidents Ben Banapoor and Ryan Student Committee Brown, Treasurer Brandon Burns, and faculty mentor Dr. Matthew Ryan. Over 200 people attended the Secretary Editor carnival themed event, including medical students, nursing students, professors, residents, fellows and attending physicians from the departments of Emergency Medicine (Gainesville), Emergency Medicine (Jacksonville), Anesthesia, Orthopedics, and Neurosurgery.

A free pair of trauma shears was provided to the first 100 students in attendance. Upon entry to the event each student was given a PaloozaPass which listed all of the stations. Students received a sticker on their pass after successfully completing a station, and students who finished all stations qualified for entry to win one of several prize drawings held at the conclusion of the event. Final prizes included a pocket otoscope, White Coat clipboards, and UF Medicine bags.

The event featured multiple stations including how to start an IV, suture, intubate, conduct ultrasound studies, place a central line, splint, cast, and perform an endoscopy, lumbar puncture, and trans-esophageal echocardiogram. For the majority of students in attendance, this was their first opportunity learn about both the significance and technique of performing these procedures.

The robust learning environment lasted for approximately 3 hours as residents and attending physicians taught students about the importance of a particular procedure and how to perform it. Students then performed the procedure under supervision and sometimes went on to teach other classmates.

One of the most popular stations was the “wheel of misfortune,” a station at which students spun a wheel with multiple x-ray findings on it and had to match the finding with the corresponding x-ray. Students that correctly matched the finding with the x-ray were given an extra entry to the raffle for the final prize drawings.

Refreshments included popcorn, corndogs, cotton candy, and pretzel dogs. Highlights of the event included a visit by Dr. Fantone, Senior Dean for Medical Education, and Dr. Tyndall, the Chairman of the Department of Emergency Medicine.

We would like to extend a special thank you to the UF Department of Emergency Medicine, faculty sponsor Dr. Matt Ryan, and Michael Di Lena for providing the simulation equipment and support in planning and managing this event!

D au n ti n g D i ag n o s i s Question: A 40-year-old male shows up to the ER in the middle of the night with abdominal pain. What does this KUB show?

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

12 | EMpulse

Turn to page 39 for the answer!

SPRING 2016 | VOLUME 23, ISSUE 1

EMRAF Committee Article by Merisa Kaplan, MD, MPH, FCEP Board of Directors Representative for EMRAF In January, residents throughout the state had the opportunity to attend EM Days, a conference in which FCEP members went to Tallahassee to advocate for the top legislative priority to emergency medicine physicians- balance billing. Those of us able to attend the conference were able to sit in on meetings between FCEP members and Florida legislators to discuss how the issue of balance billing would impact not only emergency medicine physicians but also patients and hospitals, based on states that have passed similar legislation.

The main issue on the EMRAF agenda this year is to obtain support and buy-in from the program directors. Every few months, EMRAF members meet throughout the state as one of the FCEP committees to discuss current topics and issues relevant to emergency medicine residents. Additionally, members present have the opportunity to sit in on all other committee meetings to learn about hot topics in Florida emergency medicine. This not only provides residents with an invaluable experience to know and understand the issues but also to make contacts throughout the state as potential future colleagues.

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As all residents understand, we’re not always guaranteed to have a request for time off approved, making it somewhat difficult to attend the one day meeting every few months. Our goal this year is to get all program directors to understand the important of these meetings and to realize how participating contributes to knowledge and experience of the emergency medicine field outside the clinical setting.

Moreover, it is difficult to hold board meetings and advocate resident issues without board members (residents) actually present to participate. I’m happy to report that some of the Florida residencies have already had some success in speaking with program leadership.

Understanding the significance of attending these meetings, some residencies have already agreed to provide shift credit and/or conference credit, allowing residents the opportunity to take some time off to attend the meetings. With the end of the academic year approaching and only a few residency programs left to provide a final decision as to whether or not they will support their residents and facilitate their commitment to attend these meetings, I implore all people in leadership positions to recognize the value in having their residents be a part of the FCEP community early on and participate throughout their residency.

The next EMRAF board meeting will be held April 20th in Orlando. While all board members are strongly encouraged to attend, all residents are welcome to express opinions and views on current matters or issues yet to be addressed.

After this meeting, the next will be held during this year’s Symposium by the Sea in Naples, scheduled for August 4-7.

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Florida Emergency Medicine Foundation Update Many of our members ask: What is the EMLRC? What is its relationship to the Florida College of Emergency Physicians (FCEP) and what does it do?

The short answers: EMLRC is an alternate name for FEMF commonly used when referring to the headquarters’ building. FEMF is a not-for-profit affiliate of FCEP, which functions as a virtual service arm of FCEP. As the emergency management education affiliate, FEMF conducts continuing medical education (CME) activities for emergency physicians, other EM professionals and the lay public.

Clifford Findeiss, MD FEMF President

Since the founding of the Florida Chapter of the American College of Emergency Physicians in 1971, FCEP members and active leaders have led the way in providing high quality educational conferences for emergency medicine professionals. CME accreditation for FCEP conferences was first granted by the AMA approximately four decades ago. In 1990 FCEP founded the Florida Emergency Medicine Foundation (FEMF), d/b/a Emergency Medicine Learning and Resource Center (EMLRC). The mission of the EMLRC is to provide “Life Saving Education for Life Savers.” FEMF has continued the legacy of FCEP’s commitment to education for the past 25 years by continually developing and conducting conferences with clinically relevant educational topics. FEMF provides current continuing medical education for all levels of emergency medicine professionals ranging from American Board of Emergency Medicine (ABEM) certified emergency physicians to emergency medicine residents to emergency nurses, paramedics and other first responders.

FEMF with the collaborative efforts of FCEP members, academic institution faculties and EMS leaders, educates thousands of EM providers annually. Conference attendees learn state of the art diagnostic and treatment regimens as well as cutting edge skills to sharpen their diagnostic and therapeutic capabilities.

Through the years FEMF has expanded its scope of activities and priorities to address the current intellectual challenges of EM providers, along with the needs of our patients, to keep up with the times. FEMF has progressively expanded its education programs, its technology and its accreditation credentials.

Today FEMF is accredited to confer CME credits through the following pertinent agencies: 1. the Accreditation Council for Continuing Education (ACCME) to sponsor continuing medical education for physicians; 2. the Florida Board of Nursing; 3. the Florida Board of Health, Bureau of EMS; 4. and, the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS).

Maintenance of accreditation requirements of these entities requires continuous diligence and thorough documentation for each and every program.

FEMF’s CME accreditation status is an important strength that materially helps us to achieve our educational mission.

FEMF is a not-for-profit 501c3 corporation, governed by an independent board of directors. FEMF’s Board of Directors consists of eleven directors, including its officers. Four (4) Directors are appointed by FCEP; four (4) are appointed by FCEP’s Past-Presidents Council (whose members are all Past-Presidents of FCEP); and three (3) community representatives. The composition of the FEMF Board may be modified by joint approval of the FCEP Board and the Past Presidents Council. Beth Brunner serves as Executive Director and CEO of both FCEP and FEMF and supervises a hard working administrative staff of eight.

A joint FCEP/FEMF Education & Academic Affairs Committee is composed primarily of FCEP’s academic members, but also includes other EM professionals such as Registered Nurses, Advanced Practice Providers, and first responders. Our Education Committee members work closely with Niala Ramoutar, Director of Education, to create and manage pertinent content, faculty, finances and logistics. Course objectives and program content is determined by the academic advisory input from the Committee members. FEMF’s program success is measured by surveys of attendees to ascertain whether course objectives have been met.

On behalf of the FEMF Board of Directors, I would like to offer my sincere thanks to all of our volunteers who have provided their leadership and time as Education Committee Chair persons and members, including current and recent Committee Chairs, Dr. Adrian Tyndall, Dr. Tracy Sanson, Dr. Rob Levine, Dr. Sal Sylvestri, Dr. Joseph Thundyll, and Dr. Jay Ladde! Grateful thanks also to all of the individual conference chairs and faculty members for all of FEMF’s programs! You are the ones who plan curriculum content and ultimately deliver the individual learning experiences. With the benefit of your intellect and commitment, our attendee physicians, nurses and paramedics save more lives and our mission is accomplished.

Your contributions to medical excellence mean everything to many untold patient’s lives!

FEMF’s Written Board Review Course, hosted on behalf of FCEP, prepares emergency physicians for their re-certification exam. This conference is being offered again for its 2nd year. FEMF conducted the inaugural Florida Written Board Review Course (WBRC) in 2015 in Orlando. This year the four day Florida WBRC will be presented at the Rosen Plaza Hotel, August 22-25, 2016. Our 2015 collaborating faculty garnered rave reviews from course attendees by thoroughly covering all of the ABEM Certification exam's key topics. Our course faculty did a remarkable job under course directors, Adrian Tyndall, MD, UF-Gainesville and Robert Levine, MD, FIU. Our participating faculty represented an exceptional level of collaboration among our Florida academic centers. Kudos to all for a remarkable Board Certification Review Course! Visit our website at www.EMLRC.org for more information.

FEMF conducts other first class, major conferences. Symposium by the Sea (SBS) and ClinCon have been presented annually for decades. Symposium by the Sea (SBS), hosted on behalf of FCEP, focuses on critical topics benefitting FCEP members and, of course, their patients. Educational content

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includes clinical didactic education courses, health care policy forums, simulation and case presentation competitions, skills lab training, networking events and more. Vendor exhibitors offer access to cutting edge technology, job opportunities, and business management resources. SBS is not only offer a terrific academic update on state of the art emergency care, but also is a wonderful event for networking with piers and friends. I look forward to seeing you at SBS in Naples on August 4-7, 2016 to also celebrate FCEP’s 45th Anniversary. ClinCon addresses the largest cohort of EMS professionals with academic content for all levels of first responders, paramedics, EMS medical directors, and others involved with pre-hospital care. ClinCon includes one of the most respected Advanced Life Support (ALS) competitions in EMS circles. In addition, numerous educational lectures and skill labs are conducted each year with the focus on current hot topics. Vendor exhibitors offer access to cutting edge patient care technology from rescue vehicles to EMS equipment, patient care meds, job opportunities, management resources and every other need imaginable.

ClinCon is the perfect conference for networking with EMS friends and colleagues.

On another important note, the grand opening of the Emergency Medicine Learning Resource Center was celebrated in May, 2015. Our administrative staff is now housed in a well- equipped, efficient, safe environment. The two-story, 10,000 square foot building, was designed to function as an educational center for emergency medicine professionals and as the headquarters for FCEP, FEMF, the Florida Association of EMS Medical Directors, and International Trauma Life Support of Florida. Two multi-functional conference rooms, one large and one small, located on the ground floor comprise approximately 50% of the building space. The second floor houses the staff administrative employees, as well as meeting rooms, archives, storage, and technology equipment. New state-of-the-art technology will enable real time audio/visual digital communications equipment for live meetings and conferences.

Development of the EMLRC Center building was driven by the critical need to both replace the previous headquarters and to expand educational functionality. Analysis and concept planning was a result of more than a decade of work by both FEMF and FCEP leadership. The new building is a joint venture of FCEP and FEMF with equally shared financial and maintenance obligations. The new EMLRC Center is located on the same site as our previous headquarters at 3717 S. Conway Rd. in Orlando.

Many donors have made generous contributions to support our causes over the past fifteen years including members of FCEP, EM practice groups, EM business vendors, unrelated charitable foundations and other supporters. Altogether our generous donors have contributed over $1.5 million to date. Your contributions to the center campaign represent ownership in your future and our ability to continue to provide quality educational programs to the EM community.

On behalf of the Board of Directors of the Florida Emergency Medicine Foundation, I want to sincerely thank each of you for your dedicated commitment, active support and generous donations. Your support dramatically enables our organizations to achieve our goals. As advocates for high quality emergency medical care and cutting edge excellence in educational programs. We strive together to achieve the best patient care possible for the residents of the State of Florida through our emergency medicine professional colleagues.

THANK YOU TO OUR DONORS FOR YOUR CONTINUED SUPPORT!

Leadership Academy Update FCEP's New Triple Threat Article by Patrick Agdamag, MD FACEP, Chair of FCEP’s Leadership Academy FCEP's 2016 Leadership Academy is taking on a whole new face. Actually, three new faces to be exact: Kristi, Gary and Cesar.

And chances are some point in the near future you will be able to recognize all of their faces.

For those of you who may not be familiar with the Leadership Academy, let me take moment to give some brief history.

The initial idea for a leadership development program within the Florida College was primarily put forward by then past-president Dr. Vidor Friedman.

(L-R) FCEP Leadership Academy Chair Pat Agdamag, MD; Kristi Staff, MD; Cesar Carralero, DO; and Gary Lai, MD all served as ACEP Councilors and directly participated in the 2015 Council meeting in Boston.

It seems only fitting at the time Dr. Friedman was serving as a member of ACEP's Board of Directors, after completing a successful year as our chapter President. His vision for starting an academy for Florida took hold.

After having the next few years to develop and gauge feedback from its first few graduates, the Academy seemed primed and ready for new heights at the end of 2014.

In early 2015, I was asked to Chair the Leadership Academy, and was happy to accept the new challenge. Our goal as a Board was to have the Academy combine elements of mentoring, organization, and guided experiences to selected Academy participants who wanted to grow in their interest area of EM. My personal goal for the Academy was to reshape and energize the program into a highly coveted springboard of leadership.

One that could submerge an emergency physician deep into a pool of networking and leadership experiences spanning across the state of Florida and beyond.

The Application Process and Experience

Each year applications begin coming in early spring through the end of June. In early July, we have the difficult task of narrowing the applicant pool down to 5, or less for final selection. The applicant pool for the Academy is comprised of many talented and upcoming emergency physicians practicing in our state. Anyone can be nominated, and individuals may also self nominate. The final participants are announced at our annual Symposium by the Sea conference in August.

At Symposium the annual journey begins. The time commitment for the Academy fits nicely with the hectic schedules we have in our busy lives and practices. Our gatherings center around 3 - 4 large conferences and our quarterly Board/Committee meetings.

The cost of attendance for the Academy program itself is free, and group practice sponsorship is encouraged to help cover any costs for travel and attending conferences. The typical venues include FCEP Board and Committee meetings; state legislature meetings in Tallahassee, Symposium, and ACE's Leadership and Advocacy Conference in D.C. The applications can be downloaded directly from our FCEP homepage. You may email with direct inquiries to pagdamag@ gmail.com.

Goals of an Academy Graduate

Much of the new excitement in FCEP's committee meetings and conferences is generated around the Academy members

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themselves, their administrative projects, and the future its' graduates will bring to our practice in Florida. Three main goals that are achieved for graduates are networking, mentorship, and ultimately taking on an administrative project of their own.

Communication and Networking is paramount and is the key ingredient I like to foster. It helps participants get the most out of their experience in the Academy.

Mentorship - participants are paired up with Board members during conferences, committees, and social gatherings. This is key to the development with a leader in their shared field, or area of interest.

Administrative Project. - Understanding their own interests and goals they want to accomplish, each will take on a project of their choosing.

After which, we begin to assist each member in accomplishing their goal.

Lastly, I make sure they enjoy the experience. The Academy brings all the ingredients needed to grow leaders in our field and while harnessing their areas of interest.

The upcoming application process and selection for 2016 -2017 Academy class is now underway. FCEP is once again opening the call to applicants who are ready to take the next step as leaders.

On behalf of FCEP, I welcome all who have made the commitment to our patients and their practice of emergency medicine today, and those who desire to be physician leaders tomorrow.

Welcome to the new FCEP Leadership Academy.

Do you want to advertise in EMpulse?

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

Florida International Trauma Life Support Update Flexing Your Assessment Muscles

Article by Jeffery D. Gilliard, NRP/CCEMTP/FPM, BS, FITLS Chapter Coordinator/Affiliate Faculty One of the most basic skills that every medical professional should be familiar with is the patient assessment. In fact, the assessment is probably the single most important skill a medical professional can possess. Every caregiver in the field, right down to the first responder, will be familiar in one way or another with the concept of the patient assessment. Obviously, the first responder will not have the assessment skills of the EMT, and similarly, the EMT will not have the same tool bag as the paramedic. It is thought schooling and continuing education that different levels of training gather different abilities in assessment. As far as utility goes, and besides interventions, patient assessment skills are probably what sets about each of the training levels more than any other skill. It is important that the modern paramedic be well versed in assessment procedures because it not only helps treat the patient properly, it also controls the situation and prevents the provider from becoming biased in their treatment plan.

First and foremost, patient assessment leads to proper patient care. Initially recognizing signs and symptoms are the first step to treating the patient effectively. By carrying an extensive depth and breadth of symptoms and their underlying causes, the medic can avoid misdiagnosing an otherwise treatable condition. Even more importantly, it prevents misdiagnosis. Treating the wrong condition does no good for the patient, at best. At worst, it could prove fatal to give the wrong medicine to a patient suffering from a missed affliction.

Another big benefit of effective patient assessment is that the provider gains added control over the situation. Although it is easy to see some of our patients as “just another call,” they are much more than that. Each of our patients is a person experiencing a very stressful event in their life. Something we do a dozen times a day might be something the patient experiences only once or twice. It is for this reason that the patient may be acutely aware of how the provider is acting. If the provider is confused or hesitant and not sure of his diagnosis, the patient will be put at unease. Alternatively, if the provider is competent and able to treat the ailment quickly and confidently, the patient will be put at ease and control can be easily maintained.

Finally, a less critical but still important aspect of patient assessment is the ability to avoid biased diagnosis and treatment.

Tunnel vision is an all too common problem when the provider is running multiple calls every shift. The incidents may all seem to blend together and cause the medic to become careless and diagnose the obvious symptom. Furthermore, the patient may continuously complain of one minor ailment when there is a much more serious underlying condition. This condition could be missed if the patient assessment skills are not up to par.

Throughout the modern medic’s career, there will be opportunities to continue education and to flex the assessment muscles.

By avoiding complacency and giving each patient the time and care they are due, the caregiver may give the highest standard of care possible. Assessment skills will also affect what interventions are put into play, which carries inherent benefits and risks.

The correct interventions could save a life or improve the patient immeasurably, while the wrong treatment could easily prove catastrophic. Avoiding the pitfalls of lazy assessment is half the battle, and the other half is education. In observing proper assessment procedure throughout their career. The medic will continue to provide the pinnacle of prehospital care.

Coding Tip Poisoning Documentation and Coding Lynn Reedy, CPC, CEDC, Director of Coding Services

The poisoning codes apply to drugs that are not used in accordance with the physician’s instructions. The primary code should reflect the drug taken. Physicians, you can help your coders tremendously by documenting the generic name for the drug. Any conditions resulting from the poisoning would be coded second. Coded last should be the External Cause code identifying the cause for the poisoning: accidental, self-inflicted, therapeutic use or undetermined.

An adverse drug reaction to medication properly administered is coded in the reverse. The symptoms of the adverse reaction would be primary. The medication responsible should be coded second and, again, the generic name will be extremely helpful.

Coded last will be the External Cause code for therapeutic use.

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Poison Control News Bites: A Quick Review of Novel Antivenom Therapy from 2015 Article by Jami Johnson, PharmD Clinical Toxicology & Emergency Medicine Fellow Florida/USVI Poison Information Center-Jacksonville

Anavip®

Anavip® [Crotalidae Immune F(ab’)2(Equine)] was approved by the FDA in May of 2015 for management of adult and pediatric patients with North American rattlesnake envenomation. The recommended dose is 10 vials repeated every hour until the following are met: arrest in progression of swelling, resolution of systemic symptoms, and normalization or trend toward normalization of coagulation parameters.1 Though the product has been approved by the FDA, it will not be available for purchase until 2018. In 2013, shortly after Instituto Bioclon submitted a New Drug Application to the FDA, BTG, the makers of Crofab® filed a complaint with the International Trade Commission stating that the importation and sale of crotaline antivenom by Instituto Bioclon and its United States affiliate Rare Disease Therapeutics infringed upon US Patent No. 8,048,414 regarding the manufacture of CroFab®.2 Shortly before the scheduled trial, Rare Disease Therapeutics filed a petition with the U.S. Patent and Trademark Office challenging the validity of the patent. The two entities settled shortly out of court. Though the exact settlement terms have not been disclosed, it has been released that Anavip® may be brought to market in the United States in October 2018.

In a prospective, blinded, multicenter, randomized clinical trial Anavip® was shown to reduce subacute coagulopathies compared to CroFab®.3 The authors also conclude that maintenance dosing is not required and patients should be monitored for 18 hours after initial control. Anavip® is a larger F(ab’)2 fragment antibody (as compared to CroFab® being a smaller Fab fragment), which may be responsible for the decreased incidence of symptom recurrence.

Analatro®

This is another F(ab’)2 product being studied by Instituto Bioclon with Rare Disease Therapeutics Inc. A Phase III randomized, double-blind clinical trial was completed in patients 10 years and older with latrodectism within 24 hours of envenomation by a Black Widow spider. Efficacy of Analatro® (pain control at 48 hours) was compared to control (a traditional pain management algorithm).4 Results of this study are pending, however the Phase II trial resulted in significantly faster pain relief than placebo.5 Latrodectism, a syndrome caused by massive release of neurotransmitters, can cause pain disproportionate to exam findings, muscle fasciculations, and localized diaphoresis that can be managed with opioids and benzodiazepines in conjunction with local wound care and tetanus prophylaxis.6 In severe envenomations and at-risk patient populations (pregnancy, extremes of age, or bites involving the trunk or face), patients can develop muscle fasciculations so severe that it can mimic an acute abdomen, acute chest or even induce early labor.

Antivenin (Micrurus Fulvius)®

Production of Antivenin (Micrurus Fulvius)®, originally manufactured by Wyeth, which has since been acquired by Pfizer, has been discontinued and all lots have expired, with the exception of Lot #4030024, for which the expiration date has been extended to April 30, 2016 by the FDA and is available for purchase from Pfizer.7 It is anticipated that this lot will once again be tested for expiration extension. Please contact your local Poison Center at 1-800-222-1222 regarding acquisition of the product to treat coral snake envenomation. In the face of this critical shortage, a study coordinated by the VIPER Institute of the University of Arizona and the Florida Health Sciences Center, Inc. (Tampa General Hospital) of an alternative F(ab’)2 antivenom is underway.8 Stay tuned!

Your Poison Center is available 24 hours a day at 1-800-222-1222 to assist you in the treatment of envenomations or any other toxic exposure.

References available upon request.

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

Florida Hospital Jessica Aun, DO PGY II

Spring has arrived!!! Nonetheless, we had a great time during this winter here at Florida Hospital East. As part of our residency, a yearly tradition is the annual trip to ICE at the Gaylord Palms Resort. As always, our residents enjoyed walking through the holiday-themed attraction kept at nine degrees while looking at two million pounds of hand-carved ice sculptures. Our residents have been working hard as they prepared for the In-training exam. If you think we have a lot of fun here in Orlando, you’re right!! It was nice to take a short break from studying. We celebrated being finished with the In-training exam at Dave and Buster’s where the competitive nature of our residents came out while playing air hockey, shooting hoops, and many video games.

We play hard and continue to work hard. The number of patients our emergency department sees continues to grow as we set record numbers several days ago. We can’t wait to find out who our new interns are going to be. Interviews have come to an end and we have had some great potential future residents. In the next EMpulse issue we’ll be proud to share the newest additions to our team. We hope you are enjoying the beginning of the year and we look forward to more updates in the summer.

As spring approaches and another academic comes closer and closer to an end. Our residents have been keeping busy with what feels like a larger flux of "season" patients, and they have been doing it well. It is exciting to know that as our seniors graduate and go on to new things, we have a solid selection of interns coming in. Along with that we have multiple big research projects underway. To add to that, a new exciting academic year will be starting in January. This year we are very happy that we matched within our top 13 choices! Welcome to Aldo Manresa, Michael Cecilia, Michael Descenso, Bradley Koschel and Meagan Lorenzo!

The residency at St Lucie Medical Center is pleased to announce Mount Sinai the much anticipated match results. The class of 2020 will be Benjamin Abo, DO EMT-P composed of Austin Hudson, Michael Gulenay, Blaire Laughlin, and Jeremy McCreary. We are excited to welcome these aspiring emergency medicine physicians into our St Lucie family. A handful of our residents participated in FOMA's annual research poster competition in February in Weston. We are also expecting a few residents to partake in the 2016 FLAAEM scientific assembly poster competition in April.

St. Lucie Medical Center Rege Turner, DO, OMS-III

Congratulations to all of the third year residents staying in Orlando for fellowship. Mandi Stone matched to EMS, Chris Ponder and Tom Smith matched to Ultrasound, Amanda Tarkowski matched into Medical Critical Care, Zoe McGowan and Tory Weatherford matched into Pediatric EM. We are very excited to be keeping such great residents in the Orlando Health family next year. Another big congratulations to all of the third years who already have contracts signed or job offers pending.

As interview season has wrapped up we are very much anticipating the reveal of the match list.

We had such a great group of medical student rotators as well as interviewees that this will be a great group of new interns.

As usual we had a great time during the holiday season. The department party did not disappoint, and the residency party was equally as fun. Every holiday season is good reminder of how great our program is. We always have a wonderful time celebrating with the attendings, alumnae and fellow residents.

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Orlando Health Tory Weatherford, MD

It’s been a busy time for the residents at UF. First, we had our 2nd annual resident retreat when all the residents and many attendings gathered to come up with the rank list for this year’s upcoming Match Day. Given the ACGME’s recent approval to expand the emergency medicine program from 8 to 14 residents annually, it took a little longer than usual to review all the highly qualified applicants. Come July, it’ll be a bittersweet time as we meet and welcome the newest members of the UF EM residency while saying goodbye to most of our beloved seniors.

University of Florida, Gainesville Merisa Kaplan, MD, MPH

Shortly after the retreat, residents went to hit the study books hard for the annual in-service exam. There was an audible sigh of relief amongst the residents as afterwards, they kicked back at the Swamp with each other and attendings to celebrate the end of another exam. It’s an annual tradition in Gainesville that all residents enjoy and appreciate—a day to look forward to rather than dread given the four hours of testing that precede it.

Coming up next is the annual SAEM conference in New Orleans. All second years and a few of the other residents will be going to New Orleans for a week of interesting lectures and fun times. Meanwhile, those left back in Gainesville will be holding down the fort, pulling longer shifts all week long to cover for those down in the Big Easy.

It’s March already?!? Time flies when you are working hard. I hope everyone has taken the time to stop and laugh at the presidential debates amidst studying for in-service exams. Have to start by giving a shout out to a very important, well-known and iconic figure here at UF Health Jax, Dr. Morrissey. He was appointed the chair of the awards committee for the Clerkship Directors in Emergency Medicine. This and many other achievements were accomplished without even taking off his boardshorts and flip flops.

We have three residents who will be presenting at SAEM national meeting – Chris Zernial, Adnan Javed and Christina Cannon. Our own Dr. Sherifali and Lexie Mannix will be presenting clinical University of Florida, Jacksonville pathophysiologic case presentations at CORD. Be sure to tune in, these two can always teach Nathan Bach, DO you something. It’s already the one year anniversary of our north ED opening and it shows no signs of slowing down. Kudos to all those who made this new campus such a great success.

Congratulations to our interns who have all done very well this year in addressing everyday challenges as they transition to their new leadership roles. Our seniors are starting to get a taste of what it will be like living the attending life. Our second years….well, you are still here for a while to come, so get back to work, haha.

It’s getting close to match day. I would like to go ahead and welcome our next batch of interns who will be here next year.

Enjoy your time off now because next year will be quite a ride!

Greetings from the University of South Florida! Several residents joined FCEP in Tallahassee for Emergency Medicine Days this January. They spent three days meeting with members from the state legislators to discuss balanced billing. It was a tremendous learning experience, as well as wonderful opportunity for networking.

A big congratulations to Drs. Radim Soucek and Michael Butterfield for their recent research presentations/publications. Dr. Soucek presented a poster entitled, “Management of Rapid Atrial Fibrillation and Associated Length of Stay in the Emergency Department,” at USF Research Day. He and his team identified significantly longer LOS-ED were for patients receiving metoprolol when compared to diltiazem. Also, that a combination therapy of metoprolol and diltiazem appeared disadvantageous. A letter to the editor, written by Dr. Butterfield, was published in University of South Florida Talor Matthews, MD the February 2016 edition of the Journal of Emergency Medicine. He describes the successful use of “peripheral internal jugular” placed under ultrasound guidance in the setting of a patient with access difficulty who does not require a central venous catheter. He also presented this in the form of a poster titled “Peripheral Internal Juglar Line Placement in Patients with Difficult Access,” along with a poster titled, “Fatalities Associated with alpha-pyrrolidinopentiophenone (Flakka) in Broward Country, Florida.”

Lastly, with interview season completed, our staff and directors are working hard to fine tune and submit our rank list. We are anxiously awaiting Match Day on March 18!

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R e s i d e n c y M a tt e r s Jackson Memorial Hospital/University of Miami Affiliated Emergency Medicine Residency: First ACGME-accredited EM Program in South Florida Article by Amado Alejandro Báez, M.D., MSc, MPH, FAAEM, FCCM, Program Director Jackson Memorial Hospital (JMH)/Jackson Health System’s Emergency Medicine Residency Program, in collaboration with its primary educational affiliate, the University of Miami Miller School of Medicine, has recently been accredited by the Accreditation Council for Graduate Medical Education (ACGME) to offer residency training beginning in July 2016. Under the leadership of its Founding Program Director, Amado Alejandro Báez, M.D., MSc, MPH, FAAEM, FCCM the JMH Emergency Medicine Residency Program will offer first class supervision and training to fifteen residents per academic year. “This is an important milestone for Jackson Health System. With this Residency we mark a new dawn for South Florida Emergency Medicine, one that could not have been achieved without decades of hard work and the collective efforts of our faculty and institutional leadership,” points out Dr. Baez.

This three-year comprehensive training experience will offer a “patient-centered” innovationfocused educational experience designed to develop compassionate and highly-trained future Emergency Medicine physician leaders. Training will take place at primarily at Jackson Memorial Hospital with added rotations at the University of Miami Hospital and Holy Cross Hospital. The learning experience is complemented by structured time at the JMH patient Safety Center, the South Florida Regional Poison Center, City of Miami Fire Department EMS and an integrated immersive simulation program.

The mission of our residency program is to educate future leaders and advance the science and practice of Emergency Medicine. Our residency is housed out of Jackson Memorial Hospital; a world-renowned tertiary medical center in Miami with superb rotations included at Holy Cross and the University of Miami Hospitals. The educational experience is unparalleled, including important volume and acuity sites, diverse pathology, dedicated residency-trained faculty, strong innovative didactic sessions with an integrated immersive simulation program developed and taught by the prestigious Gordon Center for Research in Medical Education.

The three-year program is designed to accept 15 residents per year, with an optional fourth “juniorfaculty/fellowship” year designed to strengthen leadership and develop skills in niche areas that include, Critical Care, Education, Research, Emergency Department Management and EMS/ Disaster Medicine. Our academic faculty has been carefully selected to foster a rich and fulfilling educational environment. The faculty has trained at many of the leading residency programs in the United States, and includes nationally recognized experts in disaster medicine, emergency medical services, critical care, toxicology, ultrasound and administration/ quality, as well as active leaders at national and international Emergency Medicine organizations.

Photo courtesy of Jackson Memorial Hospital

Goals of the JMH/ UM Residency Program: • Provide excellent emergency care, with a special mission to care for the injured, indigent, and vulnerable.

• Train physicians to be prepared, competent and excellent in assuming independent, responsible roles in the clinical practice of Emergency Medicine.

• Expose residents to the broad options in careers within Emergency Medicine, including clinical practice, research, teaching, administration, and advocacy, and to promote leadership in the field of Emergency Medicine across all areas of practice.

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Kendall Regional Medical Center gains new emergency medicine residency program Article by Kevin C. King, MD, MS, FACEP, Program Director Kendall Regional Medical Center is proud to announce the accreditation of an Emergency Medicine Residency program to begin on July 1, 2016. The Accreditation Council on Graduate Medical Education (ACGME) notified Kendall Regional Medical Center that Initial Accreditation has been granted for the Emergency Medicine Residency Program.

The program will begin July 1, 2016 and is approved for 36 resident positions. Kevin King, MD, MS, FACEP, will lead this new, dynamic and innovative program with a cadre of accomplished and experienced faculty. Kendall Regional Medical Center is Photo courtesy of Kendall Regional Medical Center well-equipped and resourced to provide high quality training to the residents with our Level II Trauma Center, Burn Center, and variety of medical, general surgical, critical care, orthopedic and other subspecialties.

“This is the second new allopathic (MD) emergency medicine training program ever in Southern Florida.” Kendall Regional Medical Center is proud to be recognized as having the top notch faculty, environment, resources and capability to train the next generation of compassionate, caring and capable emergency physicians,” said Dr. King.

In addition to emergency medicine, Kendall Regional Medical Center has residency training programs in anesthesiology, general surgery, internal medicine and podiatry.

About Kendall Regional Medical Center Kendall Regional Medical Center is a 417-bed, full-service regional teaching hospital providing 24-hour comprehensive medical, Level II Trauma, burn (adult & pediatric), surgical, behavioral health, pediatric and diagnostic services, along with a wide range of patient and community services. Kendall Regional Medical Center has been honored by being nationally recognized with many prestigious awards and accolades, including: Healthgrades Distinguished Hospital (Top 5%) for Clinical Excellence, Agency for Healthcare Administration Certification as a Comprehensive Stroke Center, Accredited Chest Pain Center with PCI, recognized by US News and World Report for receiving The American Stroke Association’s Get With The Guidelines – Stroke Gold Plus award, The Joint Commission as a “Top Performer” on key quality measures, and nine years as a Top 100 Hospital by Truven Health Analytics.

For further information, call (305) 222-2200, or visit www.kendallmed.com.

WE’D LIKE TO CONGRATULATE ALL CLASS OF 2019 EMERGENCY MEDICINE RESIDENTS IN THE STATE OF FLORIDA! CHECK OUT PAGE 24 FOR A LIST OF ALL 2016 MATCHED EM RESIDENTS! SPRING 2016 | VOLUME 23, ISSUE 1

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Florida Emergency Medicine Residency Match 2016 Orlando Health Nicholas Antoon, Wright State University Boonshoft School of Medicine Lisa Brown, University of Missouri-Columbia School of Medicine Theodore Clarfield, Sackler School of Medicine - New York State American Branch Nicholas Cramer, University of Central Florida College of Medicine Alicia Evans, Pennsylvania State University College of Medicine Amy Gutwein, Indiana University School of Medicine

Florida Hospital

University of South Florida

University of Florida - Gainesville

Casey Arnold, USF Health Morsani College of Medicine

Adam Barnathan, Rowan University School of Osteopathic Medicine

Jason Agran, University of Illinois College of Medicine

Kenneth Frye, Lake Erie College of Osteopathic Medicine

Jibran Khan, Philadelphia College of Osteopathic Medicine

Joshua Altman, University of Florida College of Medicine

Andrew Gibson, East Tennessee State University James H Quillen College of Medicine

Byron Markel, American University of the Caribbean School of Medicine

Brittany Beel, University of Florida College of Medicine

Darrell “Clay” Ritchey, University of Missouri-Kansas City School of Medicine

Chacey Bryan, University of Florida College of Medicine

Daniel Ryczek, University of Virginia School of Medicine

Alicia Buck, University of Arizona College of Medicine

Kristin Schumann, Nova Southeastern University College of Osteopathic Medicine

Christopher DeFreitas, W Alpert Medical School Brown University

Eric Shamas, USF Health Morsani College of Medicine

Nicole Hardy, Meharry Medical College

Elijah Kennedy, East Tennessee State University James H Quillen College of Medicine Katie Laun, Lake Erie College of Osteopathic Medicine Brian McMaster, William Carey University College of Osteopathic Medicine

Nathan Hadley, University of Alabama School of Medicine Brandon Herb, Albert Einstein College of Medicine of Yeshiva University Dallas Joiner, University of Florida College of Medicine

Andrew Smith, University of Alabama School of Medicine Zain Tariq, USF Health Morsani College of Medicine Zachary “Zach” Terwilliger, American University of the Caribbean School of Medicine

Jovana Obradovic, University of Central Florida College of Medicine

James Gabriel, Texas Tech University School of Medicine - Amarillo

Kevin Hord, Emory University School of Medicine Spencer Johnson, Pennsylvania State University College of Medicine

Robert Jiang, Ohio State University College of Medicine

Travis Murphy, USF Health Morsani College of Medicine

Davis Lester, University of Alabama School of Medicine

Landon Lichtman, Florida State University College of Medicine - Daytona Beach

Ryan Roberts, University of Florida College of Medicine

Catherine Uthe, UM Miller School of Medicine Joseph Violaris, Florida International University Wertheim College of Medicinew

Steven Ritchey Araya, University of Minnesota Medical School

Joseph Diaz, University of Florida College of Medicine

Eric Edgerton, Loma Linda University School of Medicine

Courtenay Glisson, University of Tennessee Health Science Center College of MedicineChattanooga

Juvenal Havyarimana, Texas A&M Health Science Center College of Medicine

Zachary Hester, University of Louisville School of Medicine

James Sanstead, USF Health Morsani College of Medicine

Tyler Randall, University of Texas Southwestern Medical Center Southwestern Medical School

University of Florida - Jacksonville Chris Behan, University of North Texas Health Science Center at Fort Worth/Texas College of Osteopathic Medicine

Kailee Smith, Charles E. Schmidt College of Medicine at Florida Atlantic University

Keegan Michel, Michigan State University College of Human Medicine - Grand Rapids

Megan Miller, Virginia Commonwealth University School of Medicine

Matthew Mui, University of Central Florida College of Medicine

Jerry Tavornwattana, Wayne State University School of Medicine Joseph Valentin, University of Minnesota Medical School

Daniel Young, Saint Louis University School of Medicine

St. Lucie Medical Center

Mt. Sinai Medical Center

Austin Hudson , Lake Erie College of Osteopathic Medicine - Bradenton

Michael Alexander Cecilia, Nova Southeastern University College of Osteopathic Medicine

Michael Gulenay, Philadelphia College of Osteopathic Medicine - Georgia Campus

Michael Thomas DiCenso, Kansas City University of Medicine and Biosciences

Blaire Laughlin, Lincoln Memorial UniversityDebusk College of Osteopathic Medicine

Bradley Ryan Koschel, Touro University Nevada College of Osteopathic Medicine

Jeremy McCreary, Lincoln Memorial University - Debusk College of Osteopathic Medicine

Jackson Memorial Hospital Natalia Alvarez, Boston University School of Medicine Jonathan Balakumar, University of California, Los Angeles David Geffen School of Medicine Adam Brunson, University of South Carolina School of Medicine

Kendall Regional Medical Center Pavel Antonov, American University of the Caribbean School of Medicine Eric Copeli, State University of New York Down State Medical Center College of Medicine

Emily Cooper, Texas Tech University School of Medicine

Stefan Jensen, University of Texas School of Medicine at San Antonio

Megan Angelik Lorenzo, Nova Southeastern University College of Osteopathic Medicine

Marisa Gilbert, Chicago Medical School at Rosalind Franklin University of Medicine & Science

Vinicius Knabben, Icahn School of Medicine at Mount Sinai

Aldo Omar Manresa, Touro College of Osteopathic Medicine – New York

Daniel Hercz, University of Sydney – Sydney Medical School

Nicholas Amruth Koneri, University of Texas School of Medicine at San Antonio

Lavern Keitt, Medical University of South Carolina College of Medicine Michael Roberds, University of Texas School of Medicine at San Antonio Martin Sayers, Ohio State University College of Medicine Laura Scheidt, UM Miller School of Medicine Adam Sienkiewicz, UM Miller School of Medicine Christopher Sweat, University of Texas Medical School of Medicine Alexander Thai, University of Louisville School of Medicine Ariana Wilkinson, Boston University School of Medicine Henry Zeng, Tulane University School of Medicine

Robert Anthony Maldonado, University of Texas School of Medicine at San Antonio Kent Grant Martin, University of Arizona College of Medicine Ana Iris Pineda, Universidad Iberoamericana (UNIBE) School of Medicine, Santo Domingo Joseph Franklin Proza, University of Texas School of Medicine at San Antonio Daniel Alves Sirovich, American University of the Caribbean School of Medicine Samantha Tarshis, University Of Colorado School of Medicine Moshe Yatzkan, Universidad Iberoamericana (UNIBE) School of Medicine, Santo Domingo

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

and the

B alance B illing B lues

On January 18-20 the Florida College of Emergency Physicians held its annual EM Days.

This year once again featured a familiar challenge to Emergency Physicians, as FCEP worked ceaselessly to improve the language on House Bill 221/Senate Bill 1442, both better known as the ban on balance billing. FCEP members and leaders met with key legislature and government officials on the topic of balance billing, including Insurance Consumer Sha’Ron James, Senate President Andy Gardiner, Senate Majority Leader Bill Galvano, House Majority Leader Dana Young, and Florida Surgeon General Dr. John Armstrong. We also met with FMA president Dr. Ralph Nobo and FHA President Bruce Reuben, and our very own Dan Brennan testified before the House Banking and Insurance Committee on the importance of fair reimbursement to support Florida Healthcare’s safety net. Our members advocated for a resolution to balance billing which would give Emergency Physicians equitable and fair payment, as well as protect their patients’ rights to emergency care and specialists.

Damian Caraballo, MD, FACEP

FCEP Board member The resolution to the balance billing quagmire will have a profound impact on the future of Emergency Medicine in Florida. Physicians in California have dealt with a complete ban on balance billing, without any fair payment system in place, the result of which was a 19% decrease in reimbursement to Emergency Physicians in California. Insurers such as Anthem have further piled on EP’s In California by auditing all Level 5 CPT codes and holding back payments per what they retroactively consider to be a Level 5 chart, further cutting reimbursement another 40% over Usual and Customary Billed Rates.

Illinois also passed a similar Balance Billing ban, which uses arbitration as a sort of “invisible hand” to get EP groups and Insurers to come to agreement on payment. Although this sounds like a better solution, ACEP feedback has been that the arbitration system has been cost-prohibitive, with it cost of arbitration being higher than the actual contested bills. Unfortunately, this Illinois solution is currently being advocated as the solution to Florida’s proposed ban on balance billing. The premise of the current Florida House bill is that the Insurer can set what they deem reasonable rates, and that the “threat of arbitration,” per Insurance Consumer James’ words, will work to keep Insurers honest. It’s no surprise that Insurance Companies have pushed this “solution” for the current version of HB 221, as the current language places all negotiating leverage in the Insurers’ hands.

As dire as the picture seems, there is hope for Emergency Physicians. In Connecticut, their State’s ACEP group was able to aid in the passage of a monumental bill which sets customary reimbursement at 80th percentile of the FAIR Health Database (FAIR Health is an objective non-profit who’s millions of data-points represent transparent, truly fair payment for emergency physicians, and has been heavily supported by ACEP groups across the nation as a solution to balance billing.) New York passed a similar bill version, and in Colorado, the state put the onus on insurers to seek arbitration in bills they find excessive, not the other way around as in Illinois.

Rest assured FCEP will continue to advocate for its physicians to seek fair an equitable payment. I’ll admit there were times at FCEP EMDays where I felt our words were falling on deaf ears; but during the House Business and Finance Committee, something magical happened (a line which has never been written about any House Committee). During questions, one of its members, Rep. David Santiago, countered the Committee Chairman, Rep. Wood (co-sponsor of HB-221), with a line verbatim out of the FCEP Handout. Something we had said had stuck! Not only that, Rep. Santiago’s statement opened a flurry of questions by other committee members which made the same arguments we had been making all week. Something indeed had broken through, and it offered hope that what we do can make a difference and does actually affect the Legislative process.

It will take all emergency physicians in Florida banding together to fight off the 900-pound gorilla that is the Health Insurance Lobby Complex. It will take our coordinated efforts, and to be frank, our financial resources to defeat the Insurance Companies’ efforts to manipulate physician reimbursement (in the past 15 years, Insurances rank 2nd in money spent on lobbying; physicians as a whole rank 13th, right behind real estate agents .) But what we have on our side is much stronger than anything Insurances will ever offer—our hands. At the end of the day, we are the good guys—we are the ones who treat the wheezing 2 year-olds at 2am or lay hands on the shoulders of the suffering elderly septic patients who present on Christmas Eve. Through some well-funded and well-led attack by Insurances, we have been made out to be the greedy bad guys in the “war” on balance billing. It’s time we took our profession back, and it starts by giving our time, effort, and financial support to propose legislation which reinforces, not frays, Florida’s delicate Emergency Medicine safety net.

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Snapshots of EMdays 2016 All photos taken by Samantha Rosenthal

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EM p u l s e F e a t u r e F lorida ’ s N ew D rug E pidemic : H eroin

Josef G. Thundiyil, MD, MPH FCEP/FEMF Education & Academic Affairs Co-Chair

I can still vividly recall the persuasive lecture that was delivered to a large audience of healthcare providers 15 years ago during my residency training. A so-called “thought leader” or “expert” on best practices powerfully described the pain and suffering that our patients were experiencing because of our under treatment of pain. In talking with other colleagues, I later realized that similar discussions were held at many other hospitals around the country. The culmination of these efforts to increase pain prescribing was a stunning Institute of Medicine (IOM) report which had revealed that physicians in the United States grossly under treated pain . The questions I was left with about the IOM report include: how could we be woefully under-treating pain when our country prescribes 80% of the worlds narcotics? How can over 110 million people in the U.S. be suffering with chronic pain? That would be 37% of the U.S. population including children, infants, and neonates. And, does this pain actually require narcotic treatment? And why were the large majority of authors, specialists in pain management and not addiction, emergency medicine, public health, toxicology, or psychiatry?

Regardless of the reasons, change followed swiftly. It seemed like overnight, we went from using discretion in prescribing NSAIDs, codeine, and acetaminophen to hydromorphone and oxycodone. Moreover, we were evaluated from a customer service standpoint on our ability to make our patients happy. The Joint Commission endorsed making pain the 5th vital sign. Patients were given pain scale questionnaires (never validated for outpatient or ED use) to express their sentiment of pain and indirectly affect our prescribing patterns. I found myself routinely giving patients dozens of oxycodone at discharge and it became the expectation and the standard of care. I would later discover, disappointingly that the association between our oxycodone prescribing was strongly correlated with oxycodone related deaths, ED visits for drug abuse, hospitalizations and increases in neonatal abstinence syndrome (Table 1) .

It would take years for us to see the repercussions on a large scale and even longer to take action. Over the next decade, we would see the number of deaths from opiate use in our state skyrocket nearly 10 fold. For the first time in public health history, drug related deaths eclipsed motor vehicle crashes and became the number one cause of injury related death.

Florida became “ground-zero” for this epidemic peaking at approximately 7 deaths per day from prescription drug use (mostly accidental deaths).

And unknowingly we became accessories to violating our first Hippocratic oath- to do no harm.

Unfortunately, this unfettered pain medication prescribing set the stage for a new epidemicheroin. It is overly simplistic and inaccurate to Table 1: Correlation between amount of each drug prescribed in Florida annually from 2001-2010 and various health outcomes. attribute the shift toward heroin to be the result of the crack down on prescription drugs. In fact Center for Disease Control data reveals that the uptick in heroin began in the midst of the prescription drug epidemic but was heavily overshadowed by its over bearing relative. Unlike the heroin epidemic in the 1960’s where nearly all users found that their entrée into opiates was heroin, nearly 75% of current heroin users entered addiction via prescription opiates. More accurately, the prescription drug epidemic fueled the hunger for heroin. Set in a backdrop of increasing heroin production and distribution to our state at very low cost, we encountered the perfect storm.

Since 2002, heroin deaths have quadrupled . The numbers are rapidly rising with no discernible end in sight. Orange County Medical Examiner data reveals that we had 26 heroin deaths in 2012, 49 deaths in 2013, 90 deaths in 2014, and even higher numbers expected for 2015. The health effects don’t end with just with mortality. Heroin use is associated with multiple other comorbidities including HIV outbreaks, nearly half of all Hepatitis C cases, MRSA infections, endocarditis, neonatal abstinence syndrome, and addiction. Rates of heroin related ED visits, drug rehab, and hospitalizations has increased the burden on an already stressed healthcare system. The epidemic affects all demographics and income groups,

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but especially 18-25 year old males. And unlike illnesses that affect elderly populations, the impact of the loss of young lives has tremendous social implications. They represent large quantities of years of potential life lost. This equates to children raised without parents, a workforce that underperforms, and professionals that never see their full potential and contributions realized.

In Orange County, Mayor Teresa Jacobs and Sheriff Jerry Demmings have convened a task force to look into this problem and develop solutions. As a medical toxicologist and emergency physician, I have been invited to participate in this multidisciplinary task force along with other community experts and 3 other FCEP members: George Ralls, MD, Chris Hunter, MD, and Ademole Adwale, MD. As the co-chair of the healthcare subcommittee, I found the task to be overwhelming.

Fortunately, as ED physicians, this is when we thrive. In the face of chaos, resource shortages, and daunting odds, it is not in the mindset of our specialty to despair. But, we also know that we can’t solve this alone.

There are a few glimmers of hope. First, multiple counties throughout Florida, like Orange County, are recognizing the scope and reality of the heroin epidemic. They are assembling experts, collecting data, partnering with private sector resources, accessing funding, and pressing legislative action. An important legislative piece is the HB751 Florida’s Emergency Treatment and Recovery Act on Naloxone, which allows any healthcare practitioner to prescribe naloxone to a patient.

Interestingly, a drug that has been utilized and widely available in hospital settings for nearly half a century is finally available to the general public. And why not? When considering what it takes to combat mortality from heroin induced respiratory arrest, time is critical. According the Orange County Medical Examiner’ s data, nearly 2/3 of heroin related deaths occurred in the home. A place where family members, roommates, or friends may be available to make a difference - if they have the right tools. Additionally, as emergency physicians, we are now able to prescribe naloxone to third party members such as a patient’s family or roommate. Importantly, Florida legislation provides legal protection to prescribers who prescribe it and bystanders who use it. The Center for Disease Control estimates that, to date, over 10,000 lives have been saved by naloxone programs .

I have adjusted my practice accordingly and liken the prescribing of naloxone to prescribing an Epi-pen to a patient who has had a severe allergic reaction. I teach my ED residents that if we have the opportunity to prescribe a life-saving drug with a low side effect profile to someone with a high risk for a recurrent illness, then it’s a slam dunk- we should definitely do it. Studies have delineated that specific high-risk groups for death from heroin include: patients recently released from jail, recent discharge from detox programs, and recent overdose and release from an emergency department. In fact, for a heroin-using patient who presents to your ED, they have a 3 fold higher risk of death from heroin overdose within the ensuing 28 days . These are the people for whom we should be prescribing naloxone. In my experience, patients who fall into this group have been very receptive to this idea. It is no surprise, considering nearly 20% of them have witnessed an overdose and wished they could have intervened to help. An even larger number know of a friend who has overdosed or died from opiate abuse. And many heroin users strive to be functional contributing members of society but are afraid to discuss their habit for fear of stigma.

One challenge is getting the naloxone into the bodies of those who need it. Through the task force, our goal for Orange County is to start a pilot program to make naloxone free for one year from the county health clinics. This week I received a call from Congressman John Mica’s office to offer support in securing federal grants to support availability and distribution of naloxone. In Orange County, other actions are taking place to change the landscape of our fight to end heroin abuse.

Sheriff Jerry Demmings of Orange County Sheriff’s Department has committed to training and arming a select group of officers with intranasal naloxone for the occasion when they can be the first responders on scene to a respiratory arrest.

Police are aggressively pursing distribution networks. A new bill has been introduced to the Florida legislature which could allow patients to access naloxone from pharmacies without a prescription. Florida may follow what 37 other states have (Continued on page 30) SPRING 2016 | VOLUME 23, ISSUE 1

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(Continued from page 29)

done and allow a standing order for naloxone to give access to those who want to obtain the life-saving antidote without having to go through a physician. As the push continues to make naloxone a household product, we may hope to see a reduction in mortality. Spread the word and consider prescribing it not only to your heroin using patients but also to any patient who is taking chronic opiates especially methadone and oxycodone. Additionally, as emergency physicians, our knowledge and contribution to grass roots efforts to combat this epidemic is vital. Join your local communities heroin task force and be a force for change.

We need to continue to advocate judicious opiate prescribing. As a state, we have come a long way with cracking down on pill mills and rampant prescribing. But since we know that nearly 75% of heroin users got their start on opiates via prescription narcotics, we need to continue judicious prescribing of narcotics and often look for non-narcotic alternatives. Several years ago, two large hospital systems (Orlando Health and Florida Hospital) in our area collaborated to limit opiate prescribing from our Emergency Departments despite the intense pressure on Press-Ganey scores and customer satisfaction measures. We still reap the benefits from this collaborative endeavor. The Prescription Drug Monitoring Program (PDMP) continues to be a useful tool to help clinicians in difficult cases screen for suspected drug- seeking behavior, diversion, doctor shopping, and drug abuse. As ED physicians, we need to know that it is okay say no to prescribing narcotics while balancing compassion.

Finally, we need to re-emphasize our commitment as doctors to also be teachers. We must educate our patients on the dangers of narcotics and the risk of fatality. We must educate them about prescription drugs. We have to teach our pediatric patients, young adults, and their families about the addictive and abuse potential of opiates.

In Orange County, through the heroin task force, plans are being made to educate children in schools, students in universities, nursing schools, medical schools and residencies about the dangers of opiates. In our jails, pilot programs are being planned to educated heroin users, provide naloxone, and in select groups initiate treatment with naltrexone (a long acting narcotic antagonist) to help facilitate their transition back into society and employment. Proposals are underway to expand the number of rehabilitation beds available to those who are uninsured. In Orange County, analogous to most of Florida, we have approximately 20% the necessary detox beds available. We are developing a town hall forum to meet with the public and educate them on dangers, antidotal administration, recognizing the signs and symptoms of addiction, and treatment options. The withdrawal from heroin is not life threatening but the drug itself is. I have known, treated, and even worked alongside heroin users whom I never suspected of having a drug problem. I have seen them recover to point where they can be successful parents, raise families, and thrive as professionals who help others. We must continue to treat heroin addiction as a disease and treat its victims with respect and compassion and provide them with opportunities for hope and recovery. If we are to combat Florida’s latest epidemic, we must undo the damage that has been done and work together as a specialty to improve the lives of future generations.

References available upon request.

Drug and Alcohol Addiction Recovery Hotlines

Below is a list of resourceful hotlines you can refer patients and/or physicians to if you believe they might need additional assistance to whatever they’re doing to combat their addiction.

Alcoholics Anonymous (AA) English: 305-461-2425 Spanish: 305-642-2805 Narcotics Anonymous (NA) 305-365-9555 305-620-3875 Families Anonymous (FA) 800-736-9805

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Al-Anon & Al-Ateen 800-344-2666 Toxicology Testing Services, Inc. 305-593-1595 305-593-2260 Cocaine Anonymous World Service Office (CAWSO) 310-559-5833

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Crystal Meth Anonymous 24-Hour Helpline 855-METH-FREE/855-638-4373 Marijuana Anonymous World Services 800-766-6779 Substance Abuse and Mental Health Services Adminstration (SAMHSA) National Helpline 800-662-HELP (4357)

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

EM p u l s e F e a t u r e Got Flakka?

Article by: Dawn R. Sollee, Pharm.D., DABAT, FAACT, Assistant Director, Florida/USVI Poison Information Center – Jacksonville Jeffrey N. Bernstein, MD, FACEP, FACMT, FAACT, Medical Director, Florida Poison Information Center – Miami In February 2013, the Florida Poison Information Center Network (FPICN) received its first potential Flakka exposure. Since then, the Network has received a total of 226 potential Flakka exposures ranging from 15-64 years of age.[1] (See Figure 1 for distribution). We know that many physicians may choose to “go it alone” by not reporting their cases to the Florida Poison Control Center. Our numbers, therefore, probably only represent the tip of the iceberg. Flakka, otherwise known as gravel or alphapyrrolidinopentiophenone or alpha-pyrrolidinovalerophenone (alpha-PVP), erupted in the south Florida scene in 2013. We’ve all heard the media stories of bizarre behavior attributed to this new drug of abuse.[2] Reports have included tales of various individuals hallucinating and running naked through the streets.

Pharmacology and Clinical Effects

Figure 2.[3] Alpha-pyrrolidinopentiophenone structure, with amphetamine backbone highlighted in

The hallucinogenic amphetamines, methamphetamines, orange cathinones, like most of the more recent designer amphetamines, have been made by molecular substitutions around the basic amphetamine structure. (Figure 2) [3] By small changes to the chemical structure, novel drugs can be Figure 1. Distribution of alpha-PVP cases made to side skirt the legal classification of the drug and create unique highs.

Flakka, another cathinone derivative, produces effects similar to those seen with the “bath salts.” Because of the common amphetamine backbone, the sympathomimetic/stimulant toxidrome can be predicted.

Depending on location, substitutions around the amphetamine structure determine the hallucinogenic potency as well as the propensity for hyperthermia and cardiovascular complications. Because these chemicals are exported from China and purchased over the internet, there is no certainty as to what the user is truly being exposed to.

Testing of samples from exposed individuals has revealed a heterogeneous mixture of previously known and unknown drugs.

Alpha-PVP can be utilized through multiple routes: nasal insufflation, smoking, oral, rectal and IV.[4] Onset of action varies depending on the route,

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with inhalation and intravenous administration being the quickest. From animal studies, alpha-PVP has been shown to stimulate dopamine release, and inhibit dopamine and norepinephrine uptake. [4,5] This mechanism, similar to cocaine, ecstasy, and other sympathomimetics, has treatment implications. However, the administration of dopamine antagonists, such as haloperidol, has resulted in mixed effects. In animal studies, alpha-PVP demonstrates a similar abuse potential as other cathinones.[6] Of the 226 exposures reported to the FPICN, the most common clinical effects were agitation (in almost 50% of the patients), tachycardia (in over 30% of the patients), hypertension (in over 16% of the patients), increased creatine kinase, confusion, drowsiness, fever, and hallucinations.[1] Most concerning is the 5% incidence of seizures, coma and the 2% incidence of chest pain.[1]

Management

Initial management of a suspected Flakka exposure, in both the prehospital and hospital setting, would include stabilization, with a focus on airway and vital sign instability. South Florida EMS community has put into protocol the administration of ketamine for patients with agitated delirium. [7] Ketamine produces minimal respiratory depression or hypotension, and may suppress seizure activity. Therefore, the patients may be presenting with a mixed toxidrome due to the prehospital sedation. Supportive care for these patients would include intravenous fluid hydration, to ensure an adequate urine output, and electrolyte replacement. Of utmost importance is the aggressive management of hyperthermia. Prolonged elevated temperature appears to correlate with the development of multi-organ failure, DIC, rhabdomyolysis and acute respiratory distress syndrome. As in other causes of toxicologic agitation, benzodiazepines should be utilized to manage any tachycardia, hypertension, agitation, or seizures.

Propofol is another agent available in your treatment armamentarium. Dexmedetomidine, an alpha 2 adrenoreceptor agonist for sedation, has been used in cocaine toxicity and alcohol withdrawal. Either agent may be a viable option to assist in the treatment of the sympathetic overflow, and may be a better choice than ketamine for long-term sedation.[8] The diagnosis of Flakka toxicity is made on clinical grounds. Just like the other synthetic drugs created recently, Flakka is not detected in routine health care facility toxicology testing. In addition, there does not appear to be any cross-reactivity with existing amphetamine/methamphetamine on routine urine drug screens.

Alpha-PVP is yet another synthetic drug of abuse affecting Florida. Your poison center is available to assist in the management of Flakka cases, or any other toxic exposure, toll-free at 1-800-222-1222.

References available upon request.

Musings Of a Recently Retired Emergency Physician Personal Experience with Impaired Physicians Programs

This year marks my 43rd year since graduating from medical school. I was surprisingly naive to drug addiction having encountered very few instances of any kind of addiction in either my family or circle of friends well into my young adulthood. I learned about the subject nominally in medical school. Suddenly, I was confronted with my first clinical experience with drug addiction, which was a personal one-- early in my training as an internal medicine resident at Baltimore City Hospitals (now known as Hopkins Bayview Medical Center). I was called to a hospital administrator’s office to view a prescription for Valium, which had been reportedly forged with my name by one of the hospital nurses whom I did not even know. Though this took place over 40 years ago I remember the well spring of emotions which overtook me at the time.

I had just acquired a medical license in Maryland so I could moonlight during my training. I felt as though my new medical license was tainted or called into legitimacy by a criminal act in which I took no part. I did not know whether I was the perpetrator or the victim. Then I thought Wayne Barry, MD, FACEP what's the harm in a little extra non-prescribed Valium floating around in Baltimore? Then I worried if the un-named nurse might have overdosed on medication which appeared to be prescribed by me. I also began to wonder about the nurse involved. I never met her. I had no idea about what personal struggles she was undergoing. I hoped that she would find some help. It sounded as though she would be dealt with harshly by the hospital and the authorities.

Later, I learned first hand about Impaired Physicians (& Impaired Nurse) Programs designed to salvage the careers of health

COMMONLY USED ILLEGAL DRUGS The below chart is a list of illegal drugs, their commercial and street names, and how they are administred. Knowing the names and side effects of these drugs can help an emergency physician if a patient were ever to be rushed into an emergency department from an overdose.

ILLEGAL SUBSTANCE

EXAMPLES OF COMMERCIAL & STREET NAMES

HOW ADMINISTERED

Marijuana

Blunt, dope, ganja, grass, herb, joint, bud, Mary Jane, pot, reefer, green, trees, smoke, skunk, weed

smoked, swallowed

Heroin

Diacetylmorphine: smack, horse, brown sugar, dope, H, junk, skag, skunk, white horse, China white; cheese (with OTC cold medicine and antihistamine)

injected, smoked, snorted

Opium

Laudanum, paregoric: big O, black stuff, block, gum, hop

swallowed, smoked

Cocaine

Cocaine hydrochloride: blow, bump, C, candy, Charlie, coke, crack, flake, rock, snow, toot

snorted, smoked, injected

Amphetamine

Biphetamine, Dexedrine: bennies, black beauties, crosses, hearts, LA turnaround, speed, truck drivers, uppers

swallowed, snorted, smoked, injected

Methamphetamine

Desoxyn: meth, ice, crank, chalk, crystal, fire, glass, go fast, speed

swallowed, snorted, smoked, injected

MDMA (Methylenedioxymethamphetamine)

Ecstasy, Adam, clarity, Eve, lovers’ speed, Molly, peace, uppers

swallowed, snorted, injected

Flunitrazepam

Rohypnol (date rape drug): forget-me pill, Mexican Valium, R2, roach, Roche, roofies, roofinol, rope, rophies

swallowed, snorted

PCP & Analogs

Phencyclidine: angel dust, boat, hog, love boat, peace pill

swallowed, smoked, injected

LSD

Lysergic acid diethylamide: acid, blotter, cubes, microdot, yellow sunshine, blue heaven

swallowed, absorbed through mouth tissues

MESCALINE

Buttons, cactus, mesc, peyote

swallowed, smoked

PSILOCYBIN

Magic mushrooms, purple passion, shrooms, little smoke

swallowed

Information in above chart from www.centeronaddiction.org/addiction/commonly-used-illegal-drugs.

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care professional caught up in the devastating web of drug abuse. Studies quote an 80% recovery rate among health care professionals enrolled in such programs. My experience with referrals to these programs both in Maryland and Florida runs a dismal 33%. Several years after my residency training ended, I found myself working for the Johns Hopkins School of Medicine Internal Medicine faculty as the Medical Director of the Baltimore City Jail and the Maryland Penitentiary. A handsome young surgeon “wannabe� and recent graduate from the University of Maryland School of Medicine Medical School, joined me for one year to help me shepherd a bunch of self-styled physician's assistants. Some of them recently returned from the Viet Nam War dripping with advanced medical skills they were eager to utilize. Jeff and I took care of the inmates and supervised the PA's very successfully until one day in April Fool's Day I was told by my superiors that Jeff would be spending the entire month of April in a residential treatment facility for drug and alcohol abuse. He had apparently been identified as an impaired physician while still a medical student. I was asked to cover for him with the other health care team members which I did, and he returned one month later in seeming perfect condition, ready to resume his duties.

I never discussed this issue with him because it was not my place, and I was so happy he was doing well.

Two other reporting experiences with Impaired Physicians did not have such favorable outcomes. Some years later while directing the ER at a University of Maryland School of Medicine teaching facility, I proctored the ER residency experience through the ER in that hospital. One of the most popular residents, a young man who was popular by virtue of his "life of the party reputation" signed up for all night shifts during his ER rotation, and then failed to show up for over half of the them. When I flunked him for the rotation, residents and faculty members together begged me to give him another chance which I did so that he could reach his dream OBGYN residency in York Hospital in PA scheduled for him begin the next year.

When several witnesses suggested that he failed to show up for ER shifts because he was drunk, I reported him to the Impaired Physicians Program in Maryland anonymously.

Astonishingly he was cleared of suspicion, and I was thanked for my concern. Six months later, while in the OR locker room at the York Hospital, the chief of OBGYN found him intoxicated in the middle of the day and terminated him from the program immediately. I later heard that Danny was collecting DUI's, tearing up and down Interstate 81 between PA and Maryland as he attempted to work in various ER's.

My latest experience with Impaired Physicians came recently in Florida. I should note that the Impaired Physicians Network in Florida was founded by FCEP's own icon of Emergency Medicine, the late Dr. William Haeck for whom the FCEP Emergency Physician of the Year Award is named. I recently came to work in the same set of Urgent Care Centers as an Emergency Medicine colleague I had known casually for many years. He was friendly and likable, and he made no excuses about openly telling us that he was a heavy off hour drinker and a successful internet sports gambler. He first worked night shifts in a local hospital ER for many years, and then he went to work in the Urgent Care centers. After about 6 years his behavior with respect to keeping his employment in good standing in the Urgent Care centers. Finally, some of the patients reported smelling alcohol on this doctor's breath during working hours. Those of us who worked with him and knew about his self-admitted heavy drinking became concerned now about his performance on the job. Out of my concern and genuine affection for John, I reported him to the Impaired Physicians Program of Florida. I was hopeful that he would receive the persuasive treatment and counseling that he would need to reset his career course to his benefit.

To my bitter disappointment, he harassed almost all members of the Urgent Care staff making threatening accusations until I felt compelled to break my anonymity. I told him it was I who reported him. I was dumbfounded to hear a vitriolic diatribe in which I learned that many years ago while doing a pediatric residency, John was caught abusing cocaine and he was turned into the Impaired Physician Program at that time. He then proceeded to assure me that the program members made his life a living hell with constant monitoring, meetings and therapy sessions. He called the Program members Nazis, and he assured me that I had finished off ruining his career forever. To this day I cannot understand why he never saw the Program as an opportunity for treatment, healing, and change for him for the better. I guess he never was able to accept that he had a problem, a fact that I must admit I still cannot wrap my head around.

Despite a personally poor batting average of .333, I still have faith in the process of professional health care worker drug and alcohol rehabilitation. While I still do not pretend to understand the deep emotional and physiologic, and yes, maybe even genetic chasms of addiction after 43 years of practicing medicine, I hope I have a respect for the power it holds over some highly intelligent and skilled health care professionals. My two unsuccessful cases were hijacked by a lack of anonymity and perhaps some sociopathy on the part of the investigation targets which resulted in their personal failures to self-rehabilitate. I choose to believe in the data stating that there is an 80% career salvage rate for health care profession addicts. I urge all of you to be supportive and proactive when you come across a colleague in trouble with drugs or alcohol.

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EMpulse | 35

EM C a s e R e p o r t s A Cost Analysis of Hospitalizations for Infections Related Use at a County Safety-Net Hospital in Miami

to Injection

Drug

Hansel Tookes(1)*, Chanelle Diaz(2)*, Hua Li(3), Rafi Khalid(4), Susanne Doblecki-Lewis(5) (1) Department of Internal Medicine, Jackson Memorial Hospital, Miami, Florida, United States of America, (2) Department of Medical Education, University of Miami Miller School of Medicine, Miami, Florida, United States of America, (3) Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, United States of America, (4) Department of Jackson Health System Research, Jackson Memorial Hospital, Miami, Florida, United States of America, (5) Department of Internal Medicine, Division of Infectious Diseases, University of Miami Miller School of Medicine, Miami, Florida, United States of America. *These authors contributed.

ABSTRACT Background Infections related to injection drug use are common. Harm reduction strategies such as syringe Hansel Tookes, MD exchange programs and skin care clinics aim to prevent these infections in injection drug users (IDUs). Syringe exchange programs are currently prohibited by law in Florida. The goal of this study was to estimate the mortality and cost of injection drug user elated bacterial infections over a 12-month period to the county safety-net hospital in Miami, Florida. Additionally, the prevalence of HIV and hepatitis C virus among this cohort of hospitalized IDUs was estimated.

METHODS AND FINDINGS IDUs discharged from Jackson Memorial Hospital were identified using the International Classification of Diseases, Ninth Revision, codes for illicit drug abuse and endocarditis, bacteremia or sepsis, osteomyelitis and skin and soft tissue infections (SSTIs).

349 IDUs were identified for chart abstraction and 92% were either uninsured or had publicly funded insurance. SSTIs, the most common infection, were reported in 64% of IDUs. HIV seroprevalence was 17%. Seventeen patients (4.9%) died during their hospitalization. The total cost for treatment for injection drug use-related infections to Jackson Memorial Hospital over the 12-month period was $11.4 million.

CONCLUSIONS Injection drug use-related bacterial infections represent a significant morbidity for IDUs in Miami-Dade County and a substantial financial cost to the county hospital. Strategies aimed at reducing risk of infections associated with injection drug use could decrease morbidity and the cost associated with these common, yet preventable infections.

Introduction Miami-Dade County ranks first in the United States in new HIV infections [1]. Estimates of HIV prevalence among injection drug users (IDUs) in Miami range from 14% to 23% [2,3]. In 2011 Florida House Bill 7075 was signed into law, giving the State legal authority to close “pill mills” or pain management clinics and enacting stricter medical and pharmacy regulations of prescription opiates starting in July 2012. Heroin-related deaths in Miami increased from 15 to an estimated 36 from 2011 to 2013, and primary treatment admissions for heroin also increased from 227 to 294 during that time [4].

IDUs without access to sterile injection equipment commonly experience skin and soft tissue infections (SSTIs) such as cellulitis and abscesses [5–8]. One study of IDUs in San Francisco found that nearly one-third had experienced SSTIs [7]. SSTIs are associated with inexperience [9], subcutaneous or intramuscular injection known as “skin popping” [7], “speed balling” or the injection of heroin plus cocaine [10,11], and black tar heroin [12,13]. Similarly, the drug of choice may increase the frequency of injection and thereby the risk of infection; for example, IDUs injecting cocaine may inject more than 20 times per day [14,15]. The use of dirty needles and failure to disinfect the skin before injection can also increase the risk of infections [9,10].

In addition to SSTIs, IDUs are frequently hospitalized for complications of bacteremia, which results from inadvertently introducing bacteria into the bloodstream, and can lead to sepsis, endocarditis, and hematogenous osteomyelitis [16,17]. Musculoskeletal infections, such as osteomyelitis, can result from hematogenous spread without a related SSTI [9]. Infective endocarditis is an increasingly common consequence of injection drug use that requires hospitalization for intravenous antibiotics, and in severe cases, cardiac surgery to replace the infected valves [18–20]. Infective endocarditis may be complicated by septic embolization to (Continued on page 38)

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SPRING 2016 | VOLJUME 23, ISSUE 1

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EMpulse | 37

(Continued from page 36) the lungs, central nervous system, spleen, and other organs [21,22]. These complications can lead to lengthy hospital stays and are associated with a significant mortality risk.

The high incidence of skin and soft tissue infections among IDUs has costly implications for cities with large IDU populations. Studies from urban public hospitals demonstrate that SSTIs are one of the most common reasons for seeking emergency department and inpatient treatment by IDUs, and can comprise a significant proportion of emergency department visits [5,23–25]. Takashi et al. estimated that there were 106,126 hospitalizations for injection drug use-related SSTIs in the US from 1998 to 2001 with an estimated annual nationwide total cost of $193.8 million [26]. The authors found that most IDUs hospitalized with SSTIs were uninsured or relied on Medicare or Medicaid [26]. IDUs with SSTIs tended to have longer and thereby more costly hospital stays compared with other hospitalized patients with an overall cost per hospitalization of $4,449 [26].

This study sought to determine the morbidity, mortality, and cost of hospitalizations for bacterial infections related to injection drug use at the Miami-Dade County safety-net hospital, Jackson Memorial Hospital, over a 12-month period. Additionally, the prevalence of HIV and hepatitis C virus among IDUs admitted to the hospital during the study period was estimated. The data presented will provide a comprehensive estimate of the financial impact of injection drug use-related hospitalizations at a single hospital in Miami-Dade County.

METHODS Study design We conducted a retrospective chart review of patients hospitalized for injection drug use related infections at the county safety-net hospital, in Miami, Florida during a 12-month period, from July 1, 2013 to June 30, 2014.

Ethics Statement The study was approved by the University of Miami Miller School of Medicine Institutional Review Board and the Jackson Health System Clinical Research Review Committee. Informed consent was not obtained from participants and a consent waiver was granted. The data were de-identified prior to analysis.

Data Collection We queried the electronic discharge and billing records from July 1, 2013 to June 30, 2014 for injection drug use-related infections in all patients aged 18–65 years. We searched all diagnosis fields in the discharge record database. Discharges included both emergency department discharges and inpatient discharges. Injection drug user related infection was defined as any discharge over the 12-month period from the inpatient services or emergency department with diagnoses of opiate, cocaine, amphetamine or sedative dependence/abuse and diagnoses of endocarditis, bacteremia/sepsis, osteomyelitis, abscesses or cellulitis.

Specifically, the discharge records for all emergency department visits and inpatient hospitalizations were queried for drug abuse AND infection AND hospitalization between July 1, 2013 and June 30, 2014 AND age 18–65. Drug abuse included opiates OR cocaine OR amphetamines OR sedatives OR other. Infection included endocarditis OR bacteremia/sepsis OR osteomyelitis OR skin/soft tissue infection.

Results The majority of the IDUs hospitalized for injection drug use-related infections had SSTIs (64%) resulting from direct inoculation of soft tissues with unsterile injection equipment. Serious infections such as endocarditis and bacteremia/sepsis were reported in 13% and 38% of IDUs, respectively. Osteomyelitis was diagnosed in 10% of the cohort. These infections were not mutually exclusive and 131 of the 349 IDUs in the cohort had multiple infections. The seroprevalence of HIV in the IDUs was 17%. Hepatitis C was reported in 15% of patients. Thirty-seven percent of the cohort had opiate abuse diagnosed in discharge records. The majority of IDUs in the study had cocaine abuse diagnosed (59%). Amphetamines and sedatives were less common (3% and 2%, respectively). A substantial proportion of patients had unspecified or other drug abuse reported (27%). Seventy-seven percent of IDUs had only one substance of abuse in their discharge diagnoses.

Charges for Hospitalizations The median charge (IQR) for hospitalization for injection drug use-related infection was $39,896 ($14,158-$104,912). The majority of charges were billed to state-funded Medicaid programs ($18,375,845). Miami-Dade County taxpayer funded indigent care was charged $7,094,895 over the 12-month period. Medicare, a federally funded program, was charged $4,702,008. $5,464,512 was billed to private insurers. Accounting for an average cost to charge ratio for Jackson Memorial Hospital, the total cost to the hospital for services rendered for treating injection drug use-related infections from July 1, 2013 to June 30, 2014 was $11,403,923. Specific infections were associated with higher charges for hospitalization according to the 2-tailed Wilcox on Rank Sums test. The adjusted mean charge for IDUs with endocarditis was $180,314 versus $71,581 for those without endocarditis (p<0.0001). Likewise, bacteremia/ sepsis and osteomyelitis were associated with higher charges (p<0.0001 and p<0.0001, respectively). SSTIs were the only type of infection associated with decreased adjusted mean charges for hospitalization ($100,497

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vs $128,432 in IDUs without SSTIs, p<0.0001). When age, HIV status, insurance status and opiate versus non-opiate drug abuse were added to the multivariable model, there was no significant effect on the association between the different types of infection and charges.

DISCUSSION This study identified a cohort of 349 IDUs with preventable bacterial infections that resulted in admissions to the county safety net hospital in Miami during a 12-month period. These hospitalizations resulted in $11.4 million in healthcare expenses and 17 deaths. The vast majority of hospitalized IDUs (92%) were either uninsured or relied on publicly funded insurers such as county, state and federal programs. While it is customary for hospitals to bill in excess of expected payment for services rendered based on pre-negotiated reimbursement rates, Florida Medicaid was billed $18.4 million over the study period for injection drug use related infections. While the number of injection drug use-related overdoses and deaths are one measure of the health impact of drug abuse, this analysis demonstrates that these numbers reflect only a portion of the morbidity, mortality, and cost associated with this high risk behavior.

SSTIs were reported in a majority of the patients in our study. Patients who only had an SSTI had a decreased cost of hospitalization compared with those experiencing other infectious complications, suggesting that earlier diagnosis and treatment of abscesses and cellulitis could lead to cost savings. Studies from urban public hospitals demonstrate that SSTIs are one of the most common reasons for seeking emergency department and inpatient treatment by IDUs, and can burden the system by comprising a significant proportion of ED visits [5,23–25]. Complications of SSTIs such as osteomyelitis, necrotizing fasciitis, and sepsis often require surgical intervention with incision and drainage, debridement, antibiotics and prolonged hospitalization [32–36]. A study conducted at Seattle’s county hospital found that 40% of IDUs who sought ED care for an SSTI were admitted to the hospital.

Of those IDUs admitted, 25% required operating room incision and drainage [37]. Similarly, a population-based study found that SSTIs were the leading cause of all non-psychiatric hospital admissions at San Francisco General Hospital from 1999–2000, resulting in $9.9 million in inpatient charges [5]. In response, San Francisco established a skin care clinic and reported that early intervention to prevent SSTIs saved San Francisco General Hospital $8,765,200 in its first year of implementation [38].

Economic modeling of syringe exchange programs for prevention of HIV infection has generally found this strategy to be costeffective and frequently cost-saving [39–43]. Given the substantial cost of severe bacterial infections related to injection drug use, estimates that consider only the cost and health impact of HIV and hepatitis C infection likely underestimate the potential benefit of these programs. In the 2013 and 2014 Florida Legislative Sessions a bill was presented to establish a pilot syringe exchange program in Miami-Dade County. According to Florida Department of Health projections, the annual cost to operate the syringe exchange program would be $202,451 [44]. With median charges of $39,896 for each member of the cohort, the syringe exchange program would cost less than acute bacterial infections of only 6 IDUs (1.7% of the cohort). Other mitigation strategies, including multidisciplinary methadone treatment and skin care clinics, have demonstrated efficacy in reduction of hospitalization for skin and soft tissue infections at minimal comparative cost [38]. A syringe exchange program in Miami-Dade would also present an opportunity to impact the incidence of HIV in Miami- Dade County, which remains the highest nationwide [1]. In 2014, a bill analysis concluded that if 10% of the HIV infections recorded among IDUs in Miami-Dade County had been prevented, the State of Florida would have saved approximately $124 million [45]. Furthermore, this study only reports injection drug userelated hospitalizations at one hospital in Miami-Dade County and likely underestimates the countywide financial burden of these infections. Similar results are likely seen in other hospitals in Miami-Dade County serving the urban poor population. In other cities without syringe exchange programs and a large IDU population, a high economic burden of infections related to injection drug use would be expected at safety net hospitals.

Despite these limitations, this study adds to recent reports of substantial morbidity, mortality, and expense related to complications of the injection drug use and heroin epidemic in South Florida in the absence of any harm reduction programs [4]. This epidemic is highlighted by a 2012 study that compared the syringe disposal practices of IDUs in Miami to those in San Francisco, where four legal syringe exchange programs operate. The study revealed that Miami had eight times the number of used syringes improperly discarded in public, even though IDUs in San Francisco possessed and therefore disposed of significantly more syringes over a similar period of time [46]. While this study is not a formal cost-effectiveness analysis, costs associated with acute bacterial infections including cellulitis, osteomyelitis, sepsis, and endocarditis are substantial, and prevention of these infections would add to the cost-effectiveness of syringe exchange programs already demonstrated in other modeling studies focusing on HIV prevention. Cities such as Miami may benefit from harm reduction strategies like syringe exchange to reduce the number acute bacterial infections related to injection drug use as well as HIV and hepatitis C infections, and ultimately mitigate the health and economic burdens of these preventable infections.

AUTHOR CONTRIBUTIONS Conceived and designed the experiments: HT CD SD. Performed the experiments: HT CD SD RK. Analyzed the data: HT CD SD HL. Wrote the paper: HT CD SD. Refererences available upon request SPRING 2016 | VOLUME 23, ISSUE 1

EMpulse | 39

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EM p u l s e F e a t u r e Outsmarting Some Smartphones Article by Benjamin Abo, DO EMT-P

It's "winter." It's party season here in Miami. Another EMS "red bag" patient wheels by on the EMS stretcher. "Just another intox" someone mutters. Maybe it is... or maybe it isn't. You go to assess the patient, realizing she definitely does not look of age even to buy a lottery ticket. Of course, there is no legitimate identification on her and her friends are nowhere to be found. Assessing her, you quickly realize it's more than just an â&#x20AC;&#x153;intoxâ&#x20AC;? (and boy are you glad you don't pinhole your diagnosis early). So you treat what you need to treat, but how do you notify family or parents? How do you find out your SAMPLE? Some may say "look in her phone for ICE (In Case of Emergency)." OK, that would be great except that her iPhone is locked. I propose to you two ways that you can do what I call "Romancing Siri." First, try their finger prints! I usually try the right pointer, then right thumb, then switch to the other hand if need be. This hasn't failed me yet except for one scenario I'll get to. Once the phone is unlocked, open contacts and that person's name and phone number should be at the very top. Otherwise, I search for mom, dad, etc.

Now, just a few days ago a middle-aged cardiac arrest came in. Young guy found without any identification who was down 35 minutes with EMS and another 15 in your department. You call the code... review things with your juniors. Still no identification. We took his phone out of his pocket and his thumb was still able to unlock the phone, at least long enough to get his name. When walking across the ED out of habit I accidentally lock the phone. It will not unlock with his thumb print anymore. So what did I do? I held the home button down and simply said "Call Dad." Not only did the phone number pop up for us to write down, but I was able to reach his father, have him come to the ED, and do the other part of our job.

So, keep this in mind given the prevalence of iPhones even among young kids!

D a u n ti n g D i a g n o s i s The patient was found to have a rectal foreign body (deodorant stick) on KUB. Removal of such objects can be challenging based on shape, material, and orientation in rectum.

Ideally, Gastroenterology should be consulted for extraction, but if the foreign body is too far in the colon, surgical removal by explorative laparotomy may be necessary by General Surgery.

( Q u e s ti o n

on page

10)

SPRING 2016 | VOLUME 23, ISSUE 1

EMpulse | 41

EM p u l s e F e a t u r e The Florida Needle Exchange Program: Infectious Disease Elimination Act (IDEA) Article by Karen Estrine, DO, FACEP, FAAEM, Editor-in-Chief of EMpulse

The Miami-Dade Infectious Disease Elimination Act will authorize a five-year pilot syringe exchange program.

Chapter 893 of the Florida Statutes currently forbids the transfer of a syringe to a person known to inject illegal drugs.

H...B 491 and SB 408 would remove this prohibition from law to allow for a pilot syringe exchange programs in Miami-Dade County. This legislation is a non-partisan, public health issue.

Officially in Support: Florida Osteopathic Medical Association Florida Chapter, American College of Physicians Florida Academy of Family Physicians University of Miami Infectious Diseases in Florida: • As of 2011 there were 97,436 reported adults living with HIV disease in Florida (3rd in the nation). Nine percent of HIV cases in Florida are due to injection drug use • There are more than 300,000 Floridians infected with hepatitis C (HCV). Injection drug use was the most commonly reported risk factor for hepatitis C infection (33%) Syringe Exchange Programs (SEPs) save lives and taxpayer’s money: • Eight U.S. funded studies, including studies conducted by the Centers for Disease Control and Prevention and the Institute of Medicine, as well as numerous scientific studies that were not federally funded, have established that syringe exchange programs are an effective HIV prevention intervention • The estimated lifetime cost of treating an HIV positive person is between $385,200 and $618,900.

As HIV-positive Injection Drug Users are often uninsured or reliant on public sector programs (such as Medicaid, Medicare, and Ryan White) for their care, taxpayers bear the lion’s share of treatment costs associated with new infections related to injection drug use. The cost of a sterile

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syringe can be as little as 97 cents • SEP services include HIV/AIDS counseling and testing, HCV counseling and testing, condom distribution, referral to substance abuse treatment, alcohol swabs, and safe-injection education. One study found that SEP participants are five times more likely to enter a drug treatment program than non-participants Public Safety: • When Syringe Exchange Programs are not available, syringes are disposed of improperly, posing a significant public health threat -Research shows that SEPs protect law enforcement personnel from needle stick injuries. In San Diego, nearly 30 percent of police officers surveyed had been stuck by a needle at least once, with more than 27 percent of those injured experiencing two or more needle stick injuries - Keeping contaminated equipment off the streets and out of parks reduces the risk that children will experience an accidental needle stick • SEPs do not encourage the initiation of drug use nor do they increase the frequency of drug use among current users, according to an assessment by the Institute of Medicine • The presence of SEPs in communities does not expand drug-related networks or increase crime rates As of 2012, at least 35 states had some version of a legal syringe exchange program (SEP) where injection drug users safely dispose of used syringes for clean ones (the degree of legality/design of the program, whether it’s the entire state or in specific counties, etc vary by state).

On March 23, 2016, the above bill was passed into law after passing in both the Florida State House and the Florida State Senate. The Florida Needle Exchange Act will go into effect July 1, 2016.

Please visit “The Florida Needle Exchange” on Facebook for more information.

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Florida College of FCEP | Emergency Physicians

3717 South Conway Road, Orlando, FL 32812

FCEP CALL FOR 2016 BOARD CANDIDATES! The Florida College of Emergency Physicians (FCEP) has five (5) Board positions available for 2016. If you are interested in serving on the FCEP Board of Directors, please submit a letter of interest to the Board Nominating Committee no later than MAY 15, 2016 either by mail or email.

If you’re sending you letter of interest by mail, use the below attention and address:

If you’re sending your letter of interest through email, send to bbrunner@ fcep.org.

Candidates must meet the following criteria: • Member of Chapter for at least two years prior to nomination.

• Active involvement in Chapter as evidenced by committee membership or other activity.

Elected directors shall serve a term of three (3) years and shall be eligible to serve a maximum of two (2) consecutive terms. The vacant seats of the directors shall be elected by mail or electronic ballot by a majority vote of the members voting.

The Board of Directors shall meet at least four (4) times per year. Notice of all meetings of the Board of Directors shall be sent by mail to each member of the Board at his or her last recorded address at least 10 days in advance of such meetings. Alternatively, notice of all meetings can be transmitted electronically to the last known electronic mail address of the member.

Notice may be waived with the written consent of two-thirds of the Board members. Unless prohibited by law, Board meetings may be conducted by other means of communication including telecommunication. A majority of the Board shall constitute a quorum at any meeting of the Board.

Board members will take office at the Annual Board Meeting immediately following the election of officers on August 4, 2016.

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

Attention: Beth Brunner 3717 South Conway Road Orlando, FL 32817