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EMpulse Volume 15, Number 2

Florida College of Emergency Physicians 3717 South Conway Road Orlando, Florida 32812-7606 (407) 281-7396 • (800) 766-6335 Fax: (407) 281-4407

Executive Committee Mylissa Graber, MD, FACEP • President Amy Conley, MD, FACEP • President-Elect Vidor Friedman, MD, FACEP • Vice President Kelly Gray-Eurom, MD, FACEP • Secretary/ Treasurer Ernest Page II, MD, FACEP • Immediate Past President Beth Brunner, MBA, CAE • Executive Director

Editorial Board Leila PoSaw, MD, MPH, FACEP • Editor-in-Chief Michael Citro • Managing Editor

Cover Design by Michael Citro / Leila PoSaw

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.

Published by: Franklin Communications, LLC 5301 Northwest 37th Avenue Miami, Florida 33142-3207 Tel: (305) 633-9779 • Fax: (305) 633-2848

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.

Haiti Disaster Response CONVERsations: David A. Farcy


Be Prepared: The Problem is Logistics Jay Park, MD


Fragments of a Shattered World Paul DePonte, DO


Really Surreal or Surreally Real Thomas Schaar, MD


God Doesn’t Wear Ray-Bans Arthur E. Palamara, MD


How Do I Really Feel? Joe Scott, MD, FACEP


Departments PRESIDENT’Smessage Mylissa Graber, MD, FACEP


EDITOR’Semergencies Leila L. PoSaw, MD, MPH, FACEP


GOVERNMENTALaffairs Steve Kailes, MD, FACEP


EMS/trauma Michael Lozano, MD, FACEP


MEDICALeconomics Ashley Booth, MD, FACEP


PROFESSIONALdevelopment Kerry Neall, MD, FACEP, MPH


On Being Your Own Best Expert Kenneth Schultz, MD, MBA, FACP, FACEP


Notes on ACEP Sections Andrew Bern, MD, FACEP


FREESTANDINGemergency departments


CLINICALcase: The Young Lady With the Numb Leg Dan Grenier, DO


ERchronicles: On the Day of Judgment Arlen Stauffer, MD, MBA, FACEP


POISONcontrol Adrienne Perotti, Pharm.D.







36 EMpulse • Mar-Apr 2010 1

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On Physician Control

Mylissa Graber, MD, FACEP

We can’t solve problems by using the same kind of thinking we used when we created them - Albert Einstein. It is interesting that in all of these efforts to reform healthcare no one wants to address the issue of medical liability reform and the real cost to healthcare of defensive medicine. It is hard to quantify that cost. It is not obvious, as every day we order tests based on fear of litigation. What if this is that one patient with the intracranial hemorrhage without loss of consciousness? The family is demanding it, so I may as well just get the test, rather than explain to them again and again why it is unnecessary, which despite all my efforts will still end up with a complaint to administration and likely repeat visits.

are lawyers, so amazingly most healthcare reform decisions are being made with very little physician input. We are always standing on the sidelines trying to get a seat at the table because of our smaller number of participants and smaller monetary contributions. We have no control over a system that cannot survive without us and we are best to determine what works and does not work. Yet, individuals who directly benefit monetarily from suing physicians, hospitals, and health insurance companies are the ones making all the decisions under the guise of protecting people’s “access to courts.”

We don’t usually write on our charts, “reason for test - fear of litigation.” This is the best kept secret and the most obvious reality for those of us who make these decisions every day. We practice defensively because of our fears, which sadly are also based in reality. The reality is stopping all this unnecessary testing could save billions.

I think this is our own fault. Physicians notoriously do not support each other, do not help their colleagues get elected to office, do not contribute money, and do not work well together. We continuously point fingers at each other rather than working together to address problems. This works to the advantage of other groups, that bank on the fact that physicians do not work well together. This in turn keeps us from being in charge of our own profession and from driving healthcare, which is really what we should be doing.

As most of government is controlled by the legal profession, we physicians are at an enormous disadvantage. Most legislators

What we all need to realize is that getting involved is not optional. It needs to be as much a part of our practice as treating high

2 EMpulse • Mar-Apr 2010

blood pressure. Why so? Because every day there are groups and individuals chipping away at what you are allowed to do, what tests you can order, what and how you will be paid and what skills you are required to have to practice. The end result will be a chaotic healthcare system with very little physician involvement and control. The obvious next move will be to make us all just highly educated government employees who can be sued for any little perceived mistake. Or maybe we can change our way of thinking. We can participate, contribute money, and help our friends get elected. We could make sure our voices are not only heard but that we help drive the change. You don’t have the luxury anymore of just burying your head and letting this be someone else’s problem. Some of us get it and are involved and contribute, but that small group is only so strong and the burden is becoming bigger and bigger. We need everyone’s help. If we all carried a little of the burden we could be so much more successful than having a few carry us all. You can be a part of the process and control your own future, or you can continue to ignore it and let cards fall where they may and just have to deal with the consequences. That choice is up to you.

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Haiti and Engelbert Humperdinck

Leila L. PoSaw, MD, MPH, FACEP

In this issue we are honored to share the experiences of those Florida physicians who courageously went forward to help those in great need: the people of Haiti. The 7.0 earthquake in Haiti struck the capital city of Port-au-Prince where almost a third of Haiti’s nine million people live. It flattened the UN headquarters, killing dozens of employees, brought down the Presidential Palace and the National Cathedral, and killed the archibishop and several senior politicians. It wiped out neighborhoods with shoddy, makeshift houses, wrecked the port, hospitals, and airport, and cut the power and phone service. The country not only came to a complete standstill, but was too paralyzed to help itself. An article I read sums it well: “Haitian history is a chronicle of suffering so Job-like that it inevitably inspires arguments with God, and about God. Slavery, revolt, oppression, color caste, despoliation, American occupation alternating with American neglect, extreme poverty, political violence, coups, gangs, hurricanes, floods – and now an earthquake that exploits all the weaknesses created by this legacy to kill tens of thousands of people.” (Packer G. Suffering, New Yorker. Jan 25, 2010) The disaster response involved not only militaries, government agencies, international aid organizations, but also a large 4 EMpulse • Mar-Apr 2010

civilian response in the form of faith based organizations and individuals. And our Florida physicians were everywhere! Dr. Joe Scott was deployed with the National Disaster Medical System and tells us how he really feels. Dr. Paul Deponte worked at the Adventist hospital in Carrefour and Dr. Tom Schaar volunteered at the Haiti Community Hospital at the request of a missionary group. Dr. Palamara tells of how a single day in the life of a disaster can be life-changing experience. Dr. David Farcy and Dr. Seth Marquit jumped on a plane and joined a group working in a tent outside the Presidential Palace. Based on his experiences in a makeshift hospital connected to the UN, Dr. Jay Park advises us it is best to be prepared. I work with Dr. Jean Daniel Pierrot, an emergency physician, who remembers the time when he was growing up in Haiti. Parents were stern, schools were strict, and drugs had not infested the country. This was before universities closed and corruption became rampant. Proud of his Haitian heritage, Dr. Pierot believes that now is the perfect time to rebuild the country despite all odds. With help from the international community, Haiti needs to take charge of its future; a future that will preserve the essence of Haitian culture while improving the lives of the people. It is believed that the best way to help is by

monetary contributions, rather than by donating food and clothing. Now is the time for us to reach deep into our hearts and pockets. Dr. Laurent Dreyfus has asked for donations to the L’Hôpital de la Communauté Haïtienne, a hospital in the Fréres Neighborhood of Petion-Ville. His family helped found and run this hospital. Details can be found in the Doctors’ Lounge. Recently, I had a busy shift. I pronounced a young man dead after extensive resuscitation efforts, intubated a mentally ill man who had overdosed, refilled grandma’s prescriptions, talked a young lady through an ongoing miscarriage, and took care of Engelbert. He was due to sing in front of 3,000 people in a concert which would last over four hours, and he needed help. I hummed “The Last Waltz” for the rest of the day. You probably recognize this as your shift. We all have our Engelberts. We make the perilous decisions of life and death which cut through the stress of the patients overflowing into the hallways. Just as we reach our limits, there is that unexpected thank you or Engelbert. That unanticipated twist to our day, that makes it all worthwhile. I, like many other physicians did not go to Haiti, but I salute those who did. I also salute those who stayed home and took care of Engelbert.

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Tallahassee Action

Steve Kailes, MD, FACEP

The action in Tallahassee is heating up and it is difficult to keep pace with the shifting landscape of filed bills and the ongoing process of changes. However, we are using a team approach and have noted several key areas to target during the 2010 legislative session. Perhaps the most concerning bill is an effort to ban the practice of “balance” billing patients for charges not paid by their commercial insurance carriers to nonparticipating medical providers. We see this as potentially disastrous for EPs for several reasons, including: 1) this will undercut any negotiating power we have with commercial carriers when attempting to become a participating provider; 2) we are powerless to preemptively steer these patients away from our practices given current laws; 3) we will have to struggle to receive fair payment for our services from commercial carriers; and 4) we can anticipate such a ban will lead to a further reduction of available specialists for ED on-call services. The result will likely be inability to support adequate EM staffing and services, a potential exodus of providers from the state, and decreased patient care quality. Well, that is the bad news. The good news is that we are actively engaging the legislators and the state’s Consumer Advocate (who has been very supportive of this ban) to point out the severe challenges it will create and we see that many of them are 6 EMpulse • Mar-Apr 2010

The good news is that we are actively engaging the legislators and the state’s Consumer Advocate. listening to our concerns. We are educating them how every EP already provides on average (data from the AMA) approximately $138,000 of uncompensated care annually (almost four times as much as any other specialty). In addition, we are not able to turn away patients based on their insurance coverage, as can most other practices in medicine. This proposed ban amounts to an additional mandate for us to provide unfunded/under-funded care and it will erode the already weak foundation of our state’s medical safety net. We are pursing multiple avenues towards medical liability / tort reform. Representative Renuart and Senator Thrasher have filed bills seeking sovereign immunity protections for providers of emergent care falling under EMTALA and the Access to Care laws. The argument being that we (and our on-call specialists) are essentially acting as agents of the state as we are compelled to provide care regardless of injury, illness or ability to pay. Though this unfunded mandate might be a natural and welcome calling for doctors to heal the sick, it also places an unfair

burden on us to provide care in inherently higher risk situations. Interestingly, data has shown that statewide our malpractice premiums have decreased since 2003, but are still higher than the rest of the country. Healthcare reform efforts continue on the state level. One idea is to create a “medical home” for Medicaid patients to help coordinate primary care needs and decrease low-acuity usage of EDs for problems that could be cared for in a primary care setting, so long as the patients have access to that care. Dr. Vidor Friedman recently spoke in Tallahassee before a House select committee considering ways to reduce and control Medicaid costs. He represented us well by educating attendees on the unique role of EPs in delivering care to the patients in Florida. We are pursuing other issues. We will support legislation that attempts to improve public safety, including a ban on texting while driving and another mandating the use of child booster seats. However, we are wary of a bill intended to require physicians to report patients with conditions that may impair their ability to drive. We believe this may not be the best approach to the problem and will work to refine it. We need your help in the coming months and hope you will join our efforts to improve our practice and care provided to our patients.

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Excellence in Emergency Medical Care

10th annual symposium on emergency medicine, standards of care 2010FEATURING advances for the clinician AND BEST EVIDENCE IN EMERGENCY MEDICINE (beem)

Enjoy Orlando This Spring! April 7-10, 2010 Rosen Shingle Creek Hotel Orlando, FL Sponsors: Florida Hospital and Florida Emergency Physicians This four-day intense course will provide you with a unique opportunity to learn State of the Art Diagnostic and Clinical Information from faculty representing major academic medical centers located throughout the U.S. Faculty has been personally chosen for their ability to practice the “Art of Medicine� and who specialize in patient care and use of clinical evidence.

Fee: $625.00 Early bird fee $575.00 before Feb 21, 2010 To register or to request a brochure, please contact: (407) 875-0555 Rosen Shingle Creek Hotel Excellent room rate: $125.00 per room, per night! Reserve before March 4, 2010 (407) 996-9840


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The State of Florida EMS Part 1 of a Series

Michael Lozano, MD, FACEP

For those who have heard me speak on ED flow, you know that I use the terms “first and second seating.” Yes, this is my favorite metaphor – the ED as a restaurant, and the funny thing is that the first seating occurs around lunch time. In my ED, things are quite manageable first thing in the morning, but mid-morning (first seating) you get an influx of ambulatory and EMS patients. The second seating occurs around six, the next big influx. Indeed, it makes you wonder whether ambulance crews are lured in by the cafeteria. Depending on where you are in the state, you get a motley crew from single or multiple EMS agencies. Some are private entities but most are fire department based. Paramedics vary in their clinical acumen: most are good and some are even quite sharp. Some earnestly provide care and have a genuine thirst for knowledge, while others are quite burned out and cynical. For many EPs, bedside interactions with EMS constitute the full extent of their experiences, and it is easy to come to the conclusion that this is all there is to pre-hospital care. The reality is that EMS in Florida is very complex. The Bureau of EMS at the Florida Department of Health is tasked with the management of the state’s EMS. It is statutorily required to biennially develop and revise a comprehensive state plan for basic and advanced life support services. The plan needs to have at a minimum: (a) EMS 8 EMpulse • Mar-Apr 2010

systems planning, including pre-hospital and hospital phases of patient care, injury control efforts, and the unification of such services into a total delivery system to include air, water, and land transport; (b) requirements for the operation, coordination and ongoing development of EMS services (including BLS or ALS vehicles, equipment, and supplies; communications; personnel; training; public education; the trauma system; injury control; and other medical care components); and (c) the definition of areas of responsibility for regulating and planning the ongoing and developing delivery service requirements. The Emergency Medical Services Advisory Council (EMSAC) advises the Bureau of EMS. The 11 duties of EMSAC are listed in chapter 401.245 of the Florida Statutes, and include “providing a forum for planning the continued development of the state’s emergency medical services system through the joint production of the emergency medical services state plan.” At their most recent meeting in Daytona Beach, the EMSAC approved the Florida EMS Strategic Plan 2010-2012. The plan, which can be downloaded from, goes into effect in July. Many of you have been exposed to or even participated in strategic planning sessions with your EM groups or hospital. These sessions center on a SWOT analysis and give the organizational leaders a chance to

review their mission, vision, and values. For their strategic planning sessions, the EMSAC and Bureau brought together representatives and interested parties from the 24 constituency groups that comprise the EMS community. These groups represent a broad spectrum of EMS, and include the Quality Managers Association, EMS Dispatchers, Air Medical Association, Association of Trauma Agencies, Association of County EMS, Air Medical Pilots, Association of Trauma Coordinators, Association of EMS Educators, Professional Firefighters, EMS Medical Directors, Ambulance Association, Neonatal Transport Nurses, Rural EMS Association, US Lifesaving Association, Air & Surface Transport Nurses Association, Fire Chiefs, Emergency Nurses, and EMS for Children (EMSC). This list, although not comprehensive, gives you a sense of the players that routinely sit at the table when EMS issues are discussed. The EMSAC’s mission is to facilitate, promote, and ensure the best pre-hospital care to the residents and visitors of Florida. Their vision is to become a unified EMS system that provides evidence based prehospital care and serves as the recognized leader in EMS response nationwide. In the next installment, we will review the seven goals of the new strategic plan and relate them to your ED practice.

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Preparing for the Conversion from ICD-9 to ICD-10

Ashley Booth Norse, MD, FACEP The United States uses the ICD-9 code set to report diagnoses and inpatient procedures. “ICD-9” stands for the World Health Organization’s International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), implemented in 1979, more than 20 years ago. The Dept. of Health and Human Services (HHS) announced the compulsory replacement of the ICD-9 code set with ICD-10 from Oct. 1, 2013 for all encounters and discharges. The regulation doesn’t allow for use of ICD-10 codes prior to the 2013 start date. The Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) will continue to be the code sets for ambulatory procedures. ICD-10 will require significant clinical and administrative systems changes. From an administrative perspective, ICD-10 is very specific and involves a greater number of codes. Diagnosis codes increase from 14,000 to 68,000 in ICD-10-CM while the procedure codes increase from 4,000 to 87,000 in ICD-10-PCS. For Diabetes Mellitus alone, there are five categories in ICD-10, E08-E13, with 203 codes. In addition, there are structural differences that will make the conversion complex. While the ICD-9-CM diagnosis codes are 3-5 digits in length, the ICD-10-CM codes are 3-7 alpha numeric characters long. While the expanded characters of the ICD-10-CM codes specifically identify disease etiology, anatomic site, and severity, the change will require system upgrades and changes. As EPs we will need to be more detailed and specific in our chart documentation so 10 EMpulse • Mar-Apr 2010

that the coder is able to select the appropriate code. The non-specific diagnosis codes, such as chest pain and hypertension, will still be included in ICD-10 but it is predicted that the majority of payers will not accept these. For practices that currently bill many non-specific codes, this will be a big change. The concern is that there will be a learning curve for providers after implementation. Even with good documentation training prior to implementation there could be as much as a 15-20% decrease in coding/billing productivity. Potential delays or denials of claims could result in significant reimbursement issues. Here are steps published by the AMA that will help you prepare for the conversion: 1. Identify your current systems and work processes, either electronic or manual, in which you use ICD-9. 2. Talk to your current practice management system vendor. 3. Talk to your clearinghouses or billing service. 4. Talk to your payers about possible changes to your contracts as a result of implementing ICD-10. 5. Identify potential changes to existing practice work flow and business processes. 6. Identify staff training needs. 7. Test with your trading partners, e.g., payers and clearinghouses. 8. Budget for implementation costs, including system changes, resource materials, consultants and training. It is believed that ICD-9 codes are outdated and that the more specific ICD-10 codes will provide better data for identifying diagnosis trends, public health needs, epi-

demic outbreaks, and bioterrorism events. Also, it is believed that the new codes will provide potential benefits through fewer rejected claims, improved benchmarking data, improved quality and care management, and improved public health reporting. Hope this helps a little with the changes ahead. Please feel free to contact me if you have any questions. AMA web site: WHO web site:

Moderate Sedation and NCCI (National Correct Coding Initiative) Effective 10/1/2009, the following codes are bundled with our ED E/M level codes, 99281-99285, as well as many other procedures that may be provided in the Emergency Department: 99148, 99149 and 99150. These codes are for moderate sedation services provided by a physician other than the provider performing the procedure. In NCCI the bundles for 99148-99150 have a 0 modifier, which means you cannot unbundle the sedation under any circumstances or with any modifier (example, 59). Bill only the ED E/M level. Make sure your coding conforms to each insurer’s policy by double-checking your NCCI edits and your payer contracts. You can purchase a book with the NCCI edits for $600 or you can download the edits from CMS for free. Go to: odInitEd/ Click on “NCCA Edits–Physicians” in the left column. Lynn Reedy

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Empowering our Lives with Resolutions

Kerry Neall, MD, FACEP, MPH

EM is one of the most challenging careers. We are constantly being drained of our energies - physically, emotionally and spiritually. We are challenged by our adrenaline-driven jobs, shift work which interrupts our sleep cycles and family lives, and a frenetic and hectic work pace which allows us no quiet reflective time. To be able to provide top quality and efficient care to our patients, we must take care of ourselves. Sacrificing our health, relationships, and spiritual connectedness are not worth the price of our careers. If we are not mindful of the pitfalls, our lives and careers in EM will rapidly unravel. Thus, a discussion on how we can purposefully make positive changes is worthwhile. Many of us have made recent New Year’s resolutions. If not, it is not too late to do so. Studies have shown that between 40 to 45% of American adults make one or more resolutions each year. The top three New Year’s resolutions are to lose weight, to implement an exercise program, and to stop smoking. Also popular are resolutions dealing with better money management and debt reduction. Unfortunately, how many of these are maintained as time goes on? It has been shown that only 75% are maintained past the first week, 71% past the first two 12 EMpulse • Mar-Apr 2010

weeks, 64% past one month, and 46% for more than six months. While a lot of people who make New Year’s resolutions do break them, research shows that making resolutions is useful. People who make resolutions are 10 times more likely to attain their goals than people who don't make resolutions. The following seven steps are suggested for setting and reaching personal goals: 1. Stay focused – Keep the broader goal in mind. Don’t get bogged down in the details and lose sight of your larger goals. Writing down goals with specifics of what we want to accomplish helps us to review them and adjust our progress to be sure we reach them. 2. Set realistic expectations – Small goals are more valuable than brooding over impossible expectations. Remember “it’s a cinch by the inch, but it’s hard by the yard and a trial by the mile!” Little steps lead to big victories. 3. Expect challenges – We will all make mistakes. Turn them into victories by learning from them, adopting new strategies and growing in wisdom. Mistakes are the greatest stepping stones to achieving our goals if we refuse to be defeated by them. 4. Maintain a positive attitude – Check

negative thoughts. Envision the final results. We have the ability to choose how we think and feel about a situation. Cultivate thankfulness, optimism, and trust in a higher power. 5. Seek support and accept responsibility – Spend time forming relationships with people who have positive life skills. We become what we surround ourselves with. Social ties create mutual accountability, and build responsibility and consistency in our lives. 6. Practice new choices – Remodeling is a process that takes place over time. Fast is fragile, but slow is steady, stable and comes with maturity over time. It is the very slow steady process of repeatedly making positive choices that builds mind, body and spirit. Repetition and patience are the keys to crafting a healthful lifestyle. 7. Connect – The best of intentions can plunge without the quiet, reflective time needed to connect with the power beyond ourselves. Set aside time for prayer, self reflection, and the reading of devotional materials. This will connect us to positive change. Let’s make 2010 a year of change. At the year’s end, we will be able to look back with satisfaction at the positive changes we have made, being more whole in the many facets of our lives!

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BRIEFLY... FCEP Member Benefits Updates Disability Insurance Partnership The Florida College of Emergency Physicians is proud to announce a new benefit program for our association members. We have developed a program to offer disability insurance for our association members at greatly reduced rates. Through an extensive review process and due diligence, the board is proud to partner with Professional Disability Insurance Specialists, LLC. Professional Disability Insurance Specialists has a wealth of experience in the disability insurance market and working with emergency physicians. Their knowledge, experience and expertise will be a great benefit to you. Professional Disability Insurance Specialists can create a personal and customized disability insurance plan that will meet your needs. Physicians affiliated with our association will have options available for portable, individual, own- occupation policies at reduced rates. PDIS has developed a program specifically tailored for FCEP members with an A+ rated insurance carrier. According to David B. Jablon, President of Professional Disability Insurance Specialists, the mission and goal that PDIS sets out to accomplish is to provide the most comprehensive and quality coverage available to you as an association member. Mr. Jablon states disability insurance is the most overlooked and underrated insurance- until it is needed. The Florida College of Emergency Physicians, as an association, is constantly striving to provide meaningful and discounted benefit programs for our members. We believe disability insurance is an extremely important benefit for our members. We are excited about our partnership with PDIS and offering the best benefits for our members. If you have any questions about this new program please contact PDIS at phone number 561.499.7737 or electronic mail

Wealth Management Services TEG Partners, a division of Detwiler Fenton & Co. (formerly The Eaton Group of UBS Financial Services), has renewed its commitment to FCEP members as our Preferred Partner for wealth management services. The group offers discounted rates to FCEP Members and their families for investment management and planning and retirement planning for physician groups. TEG Partners also offers FCEP members discounted rates for long-term care insurance. Contact Mitch Goldfeld at 877-721-7035 to schedule a no-obligation consultation.

FCEP Welcomes its New Members James Calabro, MD Francis Castano, MD Andre Creese, MD FACEP Steve Hilwa, MD Marcia Hoffheimer Daniel Kemple Andrew Morris Michael Mozzetti, MD John Slish, MD Larry Zaret, DO, FACEP

Recently Moved Into Florida Mary Allen, MD Teresa Berridge, MD, FACEP Mark Caraker, MD Karlene Chin, MD, FACEP Stephen Dannewitz, MD, FACEP Marc Deshaies, MD, FACEP Adriano Goffi Michael Heck Sitha Mangipudy Chris McAdams Aaron Mickelson Betty Peirsol, MD Jessica Silversmith, MD Pablo Smester, MD Courtney Smiley

FCEP Honors Emergency Physician Groups with 100% Membership All Children’s Emergency Center Physicians Emergency Medicine Professionals Emergency Physician Enterprises Florida Emergency Physicians Southwest Florida Emergency Physicians Tampa Bay Emergency Physicians University of Florida University of Florida, Jacksonville Earn recognition for YOUR group by encouraging 100% participation in FCEP! We all know that membership numbers are important. The more FCEP generates in membership revenue, the more good we can do for our members through advocacy and other membership benefit programs. With that in mind, the Florida College of Emergency Physicians would like to salute the above groups for achieving 100% membership.

EMpulse • Mar-Apr 2010 13

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On the Haiti Disaster A conversation with David A. Farcy, MD

EMpulse: Tell us a little about yourself? David A. Farcy: I am Dr. David Farcy. I trained at the Maimonides Medical Center and did a fellowship in critical care at the University of Maryland Shock-Trauma Center. Prior, I was a paramedic for four years with the US Air Force. I am very interested in pre-hospital and disaster medicine. When the earthquake hit Haiti, I was supposed to go with the DMAT team, but this was held up. I waited and waited and got frustrated. I decided to jump in a plane and see what I could do. EMPulse: How does this compare with the other disasters you have been involved with? DF: I worked at Hurricane Andrew that hit South Florida in 1995, the earthquake in Mexico City in 1996, Hurricane Mitch in 2002, and September 11, 2001. The major difference between those disasters and this one in Haiti is the magnitude of the damage. The former involved only a section of a town or a country. For example, Hurricane Andrew involved only Homestead; Miami Beach and downtown suffered some broken windows and loss of light for six days. We arrived in Haiti and there was no sense of normality. There is complete mass destruction in the entire country. And that is pretty shocking. EMpulse: Do you feel that the disaster was managed well in Haiti? DF: The overall response was very chaotic. Each country sent its own team, and though they saved lives, teams did not have a unified task or goal and lacked communi14 EMpulse • Mar-Apr 2010

cation with each other. There was little communication between the military teams, the UN, the government and the massive civilian response. EMpulse: Do you think that communication is a major problem in Haiti and similar disasters? DF: In September 11, we all lost communication after the first tower collapsed. There were no cell phones and this led to more injuries. If we had better communication we could have been better warned and more people could have been saved. During Katrina, the civilian response was more powerful than FEMA. In Haiti too, there is a massive civilian response of missionary and other groups. The French military arrived in 14 hours, the US military in 8 days, and the civilian response acted sooner than both. So how do we all communicate? I don’t have an answer to this. One of the first things I would have done is to map the city with the location of treatment centers and MASH units. With the help of cell phones and GPS, we can coordinate medical treatment. EMpulse: What was the role of the government of Haiti? DF: The president of Haiti and the heads of State survived. They have a formal command structure. It focuses mainly on safety. EMpulse: Is there a larger role for international organizations? DF: I am originally from France and I have traveled a lot. We live in one globe with

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(Continued from previous page) easy access. In disaster medicine, there is no single country and all countries have an obligation. There should be an umbrella organization like the UN which is capable of coordinating efforts. The UN did do this to some degree. EMpulse: What prepared you for this experience? DF: I am a Buddhist. I belong to a cadre of physicians who are chameleons. We are able to do multiple things in the most stressful of environments with minimum resources. Overall, I don’t think I was prepared. Though my military training kicked in and I went into survival mode, this was more than anything I could have imagined. Pictures are flat and have no emotions. When you see a two year old orphan crying in front of his crumbled house there is no picture that can describe what you feel. EMpulse: What is the best way for people to volunteer in Haiti? DF: The humanitarian effort will be needed for years. Project Medishare ( at the University of Miami has short schedules; Project Hope ( needs a three-week commitment while Doctors without Borders ( and Doctors of the World ( need a threemonth commitment.

EMpulse • Mar-Apr 2010 15

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Be Prepared: The Problem is the Logistics

Jay Park, MD

Logistics is the word I heard often in Haiti. The logistics of managing supplies, resources, volunteers and transportation was probably the reason that so many earthquake victims unnecessarily died and are still currently suffering. One would believe, after having volunteered in Haiti, that this was the first earthquake disaster ever experienced by the world. There are many specific problems unique to Haiti that contributed to the difficulties of dealing with the aftermath of the 7.0 earthquake. However, the lack of disaster and logistical preparedness is by far the largest contributor. I volunteered at a makeshift hospital with connections to the UN where we had only one functioning blood pressure cuff for over 150 inpatients. Trying to do my best with inadequate supplies, I was assailed with many logistical questions. Why did our hospital at the UN base located next to the airport lack basic supplies? Why was there a shortage of disaster specific supplies such as bone saws for our orthopedic surgeons? Didn’t we learn from other earthquakes to include supplies for emergency amputations? Why was transportation of supplies and patients between medical facilities and the airport such a problem, when I slept in a tent on a parking lot full of unused UN trucks and buses? I was frustrated that our hospital and so many other hospitals in the area were lacking essential supplies and support. We should have been prepared. We should already have the knowledge from other disasters of what logistical support is need16 EMpulse • Mar-Apr 2010

ed to deal with the after effects of this or any other earthquake. This is not a critique of the UN or the many well-intentioned volunteer organizations in Haiti, by any means. However, this is a good reminder for us to review our disaster

planning and for us to reassess our readiness. In this information age, the resources needed for adequate disaster planning are readily available. We just have to be prepared to use them. Most of our hospitals and medical practices have a disaster manual with protocols to follow when a disaster strikes. The hospitals and the city departments of New Orleans also had disaster manuals and plans in place. They thought that they were prepared with adequate food and supplies. In the aftermath, it became evident that they had been ill prepared which resulted in countless logistical problems. Now let me ask you, when was the last time you looked at your disaster manual? When was the last time you exercised a practice drill? Are you prepared for a disaster that overwhelms your hospital and public health system?

The Israeli military came to Haiti and set up a fully functional hospital with x-rays, operating rooms, a NICU, and everything else that is needed for a proper medical facility within half a day. Granted that they were a military unit, but they succeeded because they were equipped and practiced. The officer in charge told me that they were not as efficient and properly equipped during their other deployments to the tsunami hit areas and other earthquakes. After those experiences, they learned to fine tune their operation and to find ways around common logistical problems. Others could follow their example. Let’s not complain about the problem of logistics after a major disaster comes barreling down Florida. How about if we review that dusty disaster manual and get prepared now?

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Fragments of a Shattered World

Paul DePonte, DO Just to go home is an all day wait for any available flight. I leave Port-au-Prince on a single-engine propeller plane, five-and-ahalf hours scrunched in the back with three others. I reflect on my last seven days at the Adventist Hospital in Carrefour, approximately a mile from the epicenter of the earthquake that crushed Haiti. On that first ten mile ride from the Port-auPrince airport to the hospital, I witnessed destruction: crushed buildings; cars leveled to the ground; large piles of cement and debris; tents and makeshift homes all over the street. At an intersection, on the traffic island, someone had built a shelter. I remember thinking that some crazy vehicle could actually run over one of those precarious makeshift tents. Large fires blazed, which smelled of burning rubber. The atmosphere was like a sauna with a stopped-up toilet, very hot and very humid. Large crowds thronged the street, along with lots of police and military vehicles from the United Nations, United States and France. It took what seemed like all day to travel those ten miles. We were taken to the back of the hospital. I noticed goats and chickens roaming freely, a fire of burning garbage, and lots of human excrement lying around. We were given a hallway on the second floor: we would sleep here on the cement floor, without beds, functioning toilets, or running water. I arrived at 4:30 p.m. and was informed that I was already scheduled to work the 18 EMpulse • Mar-Apr 2010

night shift. Feel free to rest and meet for sign-out rounds at 5 p.m. The “emergency department” was a series of three open rooms. All patients lay on the floor, most on blankets or on cardboard. The medical record was an 8x4 inch index card with hastily scribbled notes, half in French. In the ED, there were all sorts of patients: emergency patients, post-op patients, ICU

patients, pre/post partum patients, and pediatric patients. Patients remained here until they could be transferred to one of three sections, all with tents, which ran along the outside of the hospital. The first section treated post-op patients, the second section treated medical conditions, and in the third section were somewhat well patients who had nowhere to go and did not want to leave the hospital grounds. French physicians and nurses worked the day shifts and emergency physicians worked the night shifts. At any given time, the tents housed about 300 patients. Imagine the tents as part mobile ICU and part refugee camp: I treated patients with cardiac arrests and patients with toothaches.

My schedule was one morning transition, followed by three night shifts starting at 5 p.m. and going until 7:30 a.m. All the patients were on the floor and I was constantly bending to examine patients. On my second day there, my right hand became red and swollen, and I had to take antibiotics. The sharps container was a cardboard box in the corner of the room. There was no blood work and x-rays were available during daylight hours. Blood transfusions were a very complicated process. There was no running water, but plenty of hand sanitizer, peroxide, and isopropyl alcohol. At 1 a.m., I was called to a tent with eight paralyzed patients, one of whom was unresponsive with no pulse. The temperature and smell were unbelievable. I performed CPR, and we were able to get a pulse back. When I wiped the patient’s forearm to place an IV, the alcohol pad turned black from dirt, and after wiping for the second time, we ran out of alcohol pads. We had no anti-arrhythmic medications and no ventilator, and the patient expired.

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An x-ray under her head marked her death; she had a C-6 cervical spine fracture. The nurse who was with me thanked me for

A case I am most proud of was a 12-yearold girl who was hit by a motorcycle and presented with a rigid, surgical abdomen.

dle of the night. The father was requested to come back in the morning to get the body. At the first light of day, Mr. Jim

being kind. I could not recall the last time someone said thank you.

Unbelievably, a quick-thinking radiologist with a portable ultrasound machine did a FAST exam and found free fluid. The U.S. military transferred the patient to the U.S.S. Comfort, a huge white ship with a big red cross on both sides, docked in Portau-Prince harbor. No parents and no paperwork.

Bunch (the CEO of Parkridge hospital) and I escorted him to the small room where the baby had been all night. The father first carried the child to the chapel at the hospital and then walked down a 100-foot driveway into a crowd of people.

Other cultural differences: it was not uncommon to have patients arrive with their wounds wrapped in banana leaves, not bandages. One patient arrived with an ankle fracture that was splinted with a cut out plastic milk jug. I ordered a chest x-ray on a patient who I suspected had TB. I wrote CXR on a piece of paper, however, he returned without an x-ray as the tech-

nologist did not know what CXR meant. I learnt via an interpreter that I should have written Pulmonary and not CXR.

There was no morgue. When a patient expired, the body was simply given to the family. My saddest experience was with a

Mr. Bunch and I looked at each other, teary eyed. It was a moment we will never forget: Mr. Bunch, a 6-foot-7-inch man, and I, at 6-foot-4 inches, standing there crying

2-month-old who died of sepsis. It was very difficult to break the news to the parents in a crowded, hot hallway in the mid-

and experiencing sadness like I never have in 15 years of practicing medicine, in a place I never thought about until this trip. EMpulse • Mar-Apr 2010 19

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Really Surreal or Surreally Real

Thomas Schaar, MD We arrived at the Haitian Community Hospital (HCH) six days following the devastating January earthquake. Our group waited outside the front entrance, essentially a wrought iron gate with thirty other people vying to enter, while our team leader disappeared inside. We were in the midst of a sea of Haitians inhabiting a small tent city surrounding the facility. A young woman rushed by the gate holding a premature newborn. Its deceased twin was carried away in the opposite direction. A man in scrubs, we later knew as Dr. Tony, emerged from the facility and asked us to come inside. It was a very surreal first impression soon followed by a period of helplessness and disorientation.

Our team was divided into three. Our anesthesiologist went to the OR; our general surgeon went to post-op; and the rest of us, two emergency physicians, one physician assistant, and two emergency nurses manned the triage area. This consisted of the lobby and adjacent courtyard crowded with primarily orthopedic patients. They were marked with tape on their foreheads. Most had TBS, “to be seen,” written on them. After an exam, debridement, dressing, and splint application, this tape was 20 EMpulse • Mar-Apr 2010

replaced with another: “X-ray” patients waited in line for the only machine in the facility and “OR1” patients needed emergency surgery for infected wounds, open fractures and large soft tissue injuries. The rest were “OR2s,” with closed fractures requiring surgical repair after the OR1s were done. These patients were moved back to the tent city.

shown how to give injections, treat wounds and assist in the OR. These were not medical people: one sold ceramic tile, one owned a bar, another a travel agency, but many were students. They were well educated, but this work was foreign. Many expressed interest in pursuing some type of medical career because of their experiences with us.

We soon became veterans of the system. Later, we were joined by teams from Korea, Hungary and Australia. They assumed we were in charge and were appreciative of being assimilated into the bizarre routine. By dusk, the insanity that had been triage was reasonably organized and many of the teams left for the night. We stayed until noon the next day and returned ten hours later to do a reverse 20hour shift.

As a team, we were fortunate. We were humbled by the Haitian people. Many had lost friends, family, homes and businesses, but did not complain and worked tirelessly to help the injured. The Haiti we experienced was appreciative and caring. We felt neither threatened nor witnessed rioting nor selfishness. It was a life-changing experience for each of us and we were grateful to serve.

That night will be remembered for a septic newborn resuscitation with 14 hours of hand ventilation and by the aftershock we experienced early the next morning. Despite no structural damage, the quake caused a spontaneous, near-total patient evacuation of the hospital, and most patients crowded into the tent city. Patients were reluctant to come inside unless it was their turn for the OR. Initially we thought “this can’t be good,” but over the next six hours logistics were adapted, the hospital was cleaned, and things actually ran more smoothly. We left exhausted that evening, many of us having slept only two to three hours between shifts in the heat of the day. On our last day, we had a chance to talk to our interpreters and hear some of their stories. Prior to our arrival they had acted as physician extenders. Many had been

Our trip was sponsored by Summit Church in Estero, Florida, at the request of Mission of Hope, Haiti. On our last day, MOH distributed 391,000 meals without incident, through a network they had developed over the last ten years. Check them out at They are the real deal!

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God Doesn’t Wear Ray-Bans

Arthur E. Palamara, MD

In the grand scheme of things, I recognize that what I did was negligible. Still, this experience paints a portrait of our frail humanity and our incomplete ability to deal with it. On Thursday, Jan. 21, 2010, I had the privilege of traveling to Haiti on a medical evacuation mission. Authorities had insisted that this be supervised by a physician and, by sheer chance, I was the appointed one. After 40 years of being a doctor, I admit to becoming desensitized to pathology. But this mission left in me an emotional void that might never be filled. Perhaps this is the conflict between our divinity and our humanity. Our mission was to transport five Haitians to the United States, thereby reuniting a divided family and allow the injured members to receive medical care. This simple task was made complex because it occurred nine days after a major earthquake that jarred the soul of an already impoverished nation. We stowed aboard a plane chartered by Jackson Memorial Hospital and Children’s Hospital. Airplanes are allowed to land in Port-auPrince for only two hours since there is simply insufficient room at the crippled airport. Flights have one hour to deplane and one hour to re-load. After that, they are “wheels up” and if you are not on board, good luck. It will be difficult finding a hotel that accepts credit cards. We left Opa Locka filled with uncertainty, as none of us knew what to expect. With

us was Paul Farmer, MD, the infectious disease specialist, who has started a hospital in Haiti against amazing odds and now battles drug-resistant tuberculosis worldwide. I have read his book. He smiled when I pointed out that he must be on the Harvard faculty since he was the only person on the airplane wearing a white shirt and a blue blazer. The airplane made a soft landing. We were warned to prepare for the acrid odor of putrefaction when the cabin door opened. Teams were organized to help unload the airplane. My companion and I were told to find our charges and return as quickly as possible. If we did not return within two hours, we would be left behind. The cabin door opened with a faint hint of smoke, neither oppressive nor fetid. The 100,000 dead bodies had already been buried in mass graves or burned. Thrusting through several cordons of uniformed Haitian border policemen, we asked guards to remember our faces to facilitate re-entry. They understood little as they spoke only Creole. The airport itself, destitute by third world standards prior to the earthquake, now resembled a shattered cavern, with cracks in the wall and piles of rubble and water puddles littering the floor. The dimly lit terminal challenged us to find a functioning exit. We left the sanctity of the terminal through breaks in a security fence. The inner perimeter was protected by rifle bearing American GIs who prevented the

milling mass of underfed Haitians from storming the terminal to seek escape. Some have criticized the American government for taking over the country. However, without order, little could have been accomplished and aid could not have been dispensed. It provided generators to light the airfield and organization to the multitude of well-meaning countries offering aid. Dropping supplies from helicopters would have resulted in starving people killing each other for food. Organizing food distribution lines and relief efforts is necessary to avoid wanton killings by the desperate. We rapidly walked through a pitch-black parking lot and a warehouse lit only by automobile headlights. Columns of dust billowed each time an army HumVee darted past. Using a satellite cellular phone, we found our charges in a dark corner, waiting, uncomplaining, with the patience of Job for their saviors. Transfer of medical information was minimal. Wounds were re-dressed and IVs restarted. Contrary to expectations, the children silently accepted every pain and indignity without protest. Obviously, they could not have been prepared for this calamity or its aftermath. My partner tells a story of how he had transported a 5-yearold to Miami. The child suffered a gaping, infected head injury and crushed right arm (since amputated). The receiving Jackson (Continued on Next Page) EMpulse • Mar-Apr 2010 21

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God Doesn’t Wear Ray-Bans (Continued from previous page)

resident surgeon (appropriately) asked what the CT scan revealed. That young doctor was oblivious of the depravity of conditions in Haiti. Gathering up our charges, we made our way back through the smoky, dusty potholed parking lot to a gap in the perimeter fence. Haitians without food, water, jobs, homes, beds, or hope clutched at us begging to be taken. Our party was greeted by several rifle bearing agents to whom we explained our mission. One Federal Agent had lived in Miami and understood its complex cultural composition. They let us pass wishing us a “God bless you for what your doing.” This was repeated many times more but I still only partially comprehend its profundity. We arrived back at the plane, joined by 150 other émigrés desperately trying to exit the ravaged country. We were told to wait at the back of the line until we could be accommodated. The three children, scared and tired, uttered not a word. A few minutes past the two-hour deadline, our Sky King 737 was “wheels-up.” Kathy and Seth, the two airline employees who made this evacuation possible, were overjoyed by the success of “our” mission. Without them, it would not have been possible. 22 EMpulse • Mar-Apr 2010

Approaching 11 p.m., we landed at Miami International Airport, as straggly a group of passengers that has ever deplaned. Here we faced our last hurdle, American immigration. The mother and her two children traveling with us did not valid American visas. The mother was returning to see her severely injured son and husband who had been taken to Jackson a week earlier. The 5-

year-old had undergone a craniotomy for a depressed, infected skull fracture and amputation of his arm. The mother was not aware of the loss of her son’s arm and we worried about her reaction. Mark, the organizer of the rescue mission, pleaded our case to the immigration officer, a Haitian-American woman, who asked: “Do they have passports?” The answer was: “Probably, under the pile of rubble that was once their home.” Two TSA supervisors were called and shown our only documentation, an email from Senator George Lemieux authorizing admittance. I was holding the young girl

and her IV bag and I showed the ravages of our trip. Wearing scrubs, with my white hair, and with all the surgical officialdom I could muster, I spoke up: “We have two injured children: one with an epidural hematoma and the other with a fractured radius and dehydration. We sure wish you could help us. We are taking them to Jackson Memorial Hospital.” After a moment’s pause, the senior officer offered: “Do you need a wheel chair?” I should have said yes. But I, a 66-year-old, proudly carried that 40-pound child a quarter mile without stopping. Later, we marched onto the pediatric floor at Jackson Memorial Hospital and found the boy and his father. The 3year-old girl, who had snuggled into my arms for warmth, yelled “Pappi!” and jumped from my arms into his. The face of the boy with the amputated arm lit up like the national Christmas tree at the White House. We had done our job. I arrived home, exhausted. A half hour later, famished, I sat down to a bowl of fettuccine and a glass of wine. I could not help thinking how lucky I was that I had a home to go to and food to eat. Those people who had clutched my sleeve at the airport had no such reprieve. Stiff and tired, I arose at 7 a.m. to do an operation on an 89-year-old. Kind of puts things in perspective.

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How Do I ReallyFeel? Joe Scott MD, FACEP

“So how was it?” I am asked daily since my return from Haiti. This is accompanied by hopeful expectations for an exciting story and gruesome details. It’s a question that I have trouble answering. How do I really feel? I feel great; it was rewarding. I deployed with the National Disaster Medical System (NDMS) to the Gheskio Field Hospital in Port-au-Prince. Our MASH-like facility was on the edge of Cité Soleil. We treated injuries and illness caused by the earthquake. Within two weeks we were a team and a family. I also feel great because I provided care to the needy, who appreciated my efforts. I practiced medicine without the constraints of paperwork and administrative headaches. On the other hand, the 18-hour days, the lack of flush toilets, sleeping outside in the heat, under mosquito netting, eating only military meals-ready-to-eat (MREs), the omnipresent hum of generators, and the choking smoke from trash fires were not so great. I feel frustrated. In a disaster, I expect to have the ability to transfer patients in extremis to a higher level of care outside the disaster zone. In Haiti, however, we were the highest level of care. As we had the only functioning pediatric ventilator, we became the pediatric ICU. We saved many kids and lost others. We had nowhere else to turn. It was exciting, of course. We were accom-

panied by armed members of the 82nd Airborne at all times. On the streets, the largest and fastest had the right of way. The sound of gunfire, the periodic aftershocks, and working in an ED 24/7 produced a continuous adrenalin surge that took its toll. It was heartbreaking, but not always. We saw 150 patients and performed five major surgeries daily. We celebrated births (cardboard boxes and space blankets make great bassinets). We played with kids who a few days earlier had been too weak with dehydration. Our care really made a difference. Heartbreak comes with remembering those who are the most sick, the ones we agonized over, and the ones we could not save. We could have been better organized. As in 9/11 and Katrina, medical professionals from throughout the world descended on Haiti. Many had no more than a backpack and protein bars, and no plans. There was minimal credentialing and lax accountability. Many required assistance as they succumbed to illness and fatigue. While some treatment may be better than no treatment, there are concerns regarding the quality provided in those early days. As a physician volunteer with NDMS, I was a federal employee. I heard complaints of the slow federal response. Why were the non-governmental organizations (NGOs) faster? However, I appreciate the organization that went into establishing supply lines, security, accountability, and credentialing. We were able to maximize our

efforts. This experience has been thought provoking. There are so many questions with so few answers. What is the responsibility of healthcare professionals in disasters such as this? Should the United Nations be the lead organization in coordinating volunteer efforts? What level of care should be provided? Should relief efforts be patient centered or focus on the population as a whole? How long should outside organizations provide assistance? How does one support the efforts of local physicians? What will happen to the patients when we leave? We as EPs are ideally suited to both respond to disasters and lead the discussion. The time to prepare is now. Florida is a national leader in disaster response. And yet, physicians are the rate limiting step. There are seven NDMS teams throughout the state that will gladly begin the credentialing process. In state, Florida has an equal number of State Medical Response Teams (SMRTs) dedicated to emergency care. Numerous NGOs also need physician volunteers. Get credentialed, update your immunizations, and complete all necessary training, so that when the next disaster strikes, you will be ready! So yes, this was rewarding, frustrating, exhausting, dirty and challenging. And, yes I would do this again in a heartbeat. Dr. Scott is Team Medical Director IMSuRT South - NDMS / HHS. EMpulse • Mar-Apr 2010 23

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On Being Your Own Best Expert

Kenneth Schultz, MD, MBA, FACP, FACEP

Preparing a physician witness to tell his or her story in front of a jury at trial, or to safely navigate a deposition conducted by an experienced interrogator, is not easy. Plaintiffs’ attorneys are skilled at capitalizing on a doctor’s anger, frustration, resentment, and self-doubt. Combined, these factors can create a high degree of psychological stress that often renders defendant doctors poor witnesses. Further compounding the situation is the physician’s basic psychological makeup. Physicians tend to be thinkers and doers, but not talkers. This can handicap physicians, making it difficult for them to successfully testify at deposition and trial. First and foremost, physician defendants need to realize that being named in a lawsuit does not diminish their skills as a physician. The key to surviving an experience in the health law arena is to understand the objectives surrounding a lawsuit. Lawsuits are not about right and wrong, they are about winning and losing. This article discusses how to present a successful defense. The Physician Defendant Physician defendants and defense attorneys may not share the same beliefs on what it takes to win a case. It is a defense attorney’s job to provide a physician with a thorough description of the litigation process and the defense strategy. The physician’s role is to serve as a medical expert and a witness to the facts. 24 EMpulse • Mar-Apr 2010

What the Jury Wants In malpractice lawsuits, the jury decides who is right by determining which side has the preponderance of the evidence. Juries often misinterpret a physician’s inability to serve as a good witness as an admission of failure to properly diagnose or treat a patient. They assume that the demeanor of a physician during trial is also their demeanor when treating patients. Jurors have also been patients, and they expect professionalism, competence, credibility, and caring from the physician defendants. Physicians on trial must behave in a way that makes them likable and credible to the jury. The Medical Record Juries tend to believe written documentation more than oral testimony. While there is no substitute for accurate and complete documentation, your case will be based on three sources of information: 1. The medical record itself. 2. Your recollection of events. 3. Customary methods of practice (e.g., the manner in which you routinely perform a neurological exam). Although independent recollection and customary practice require credibility, they may be your best defense if documentation on the medical record is inadequate. Think Before You Speak One of the most important things to do during a deposition is to stay calm. Emotions cloud judgment, and people tend to speak without thinking when they’re upset or

nervous. Go into it with the mind-set that you provided the best care possible under the circumstances. Stay focused on that fact and do not let the plaintiff's attorneys convince you otherwise. • Become comfortable with silence. Think before you speak, and do not offer information beyond that necessary to answer the question that has been asked. • Don’t answer any question too quickly. Give your attorney time to object to any questions that are inappropriate or leading. • Have an attorney rephrase a question if you do not understand it. • Ask to review documents referenced by the plaintiff’s attorney before answering questions about them. Preparation and Practice There are some common mistakes that physician witnesses often make when testifying including: • Failure to comprehend the defense strategy devised by an attorney. • Inadequate knowledge of the facts. • Failure to study the medical record in detail. Preparation and practice will help you to avoid these mistakes. If you are named in a malpractice suit, do the following: • Be compliant, be available, and be ready to devote time and effort to your defense. • Work closely with your attorney to (Continued on Page 26)

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Notes on ACEP Sections

Andrew Bern, MD, FACEP Congratulations to all sections on their annual meetings during Scientific Assembly in Boston. This past Scientific Assembly was a huge success having the most registrants of any Scientific Assembly to date. In this past year, the Sections Task Force, chaired by Dr. Kelly Gray-Eurom and me, as the board liaison, oversaw the awarding of section grants and section awards in the categories of increased membership, newsletter excellence, service the college, and service to sections. In the next few weeks, we hope to receive the annual reports of each section on the activities for this past year. This report can be used in developing the self -nominating forms for service to college and service to section awards. It is also an historical record of the accomplishments of your section for the year that would be helpful for new section leaders and section members. This report is important to send out through the section e-list or to be printed in the first issue of your section’s newsletter. At this year’s Scientific Assembly a meetand-greet was held for section leaders. Susan Morris, Bobby Heard, Kelly GrayEurom, and I met with section leaders between 8 a.m. and 9 a.m. for coffee and doughnuts to share experiences and solutions as to problems facing section leaders. Council Meeting Some section councilors took advantage of the councilor training session and met with the small chapter and section caucus on Friday afternoon and Sunday morning. It

is a tradition for section and small chapter councilors to assist each other with training and support during the Council meeting. Sections and small chapter councilors often have the role of councilor for only one year. Clearly, this is a disadvantage in experience when compared to larger chapters, where councilors can serve many consecutive terms and truly get to know the system and the individuals. Section councilors and alternate councilors should plan on attending the councilor orientation and these important caucus meetings on Friday afternoon and Sunday morning next year. It is yet another opportunity for section leaders to get together and share common experiences. Webinar: The Power of 100 This year, for the first time, a webinar was produced to help educate section leaders. The webinar can be accessed at the ACEP website. Although directed to the section leadership, any section member who in the future wants to become leader or just wants to know more about sections can go to the site. I encourage each of you to listen to the webinar. Section members who have taken advantage of this resource tell me that it has been very helpful and is well worth the 40 or so minutes of their time to gain a really good understanding of what you can do with the section. Growth in Section Membership Your College, under the direction of the Membership Committee and Membership

Division staff, has seen the successful growth of membership to more than 27,500 members. There has also been a growth in section membership. One of the reasons for this has been the block payment for residents by residency directors. Often, when this block payment occurs, complementary section selections for the resident are not made. This creates an opportunity for each section to be in contact with these new resident members and invite them to participate in your section. Sections offer many opportunities for residents in leadership development, professional development, and in publishing in the section newsletter. Size matters, because sections can use 15% of the membership dues generated in the previous year to finance projects. Membership growth equates to more funds for projects. It is also important if you want to influence College direction. Section Grant Program About this time, many sections will begin to think about the section grant program. Documents outlining the grant program and how to apply for a grant will be posted to the Section link on the ACEP web site shortly. Communications and action plans Now is the time to develop action plans for the section during this activity year. The communications plan details how the section will communicate with its membership through three different communications tools. These tools include the section (Continued on Next Page) EMpulse • Mar-Apr 2010 25

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(Continued from Previous Page)

newsletter, the section e-list, and the section website. Each of these tools should have an editor or project director. Ideas and survey results from the section e-list can be summarized in the section newsletter or website. Resources of a particular section might be carried in the section newsletter so it is always there for the members. Many sections use the annual meeting as an opportunity to define the topics that they will cover in the newsletter over the course of this year. With an average of 10 stories per newsletter, a section would be able to cover 40 different stories over the course of the year. Partnership There are three main types of partnerships. First, sections can partner with one another when applying for section grants. There

have been many examples where two or more sections have worked with one another on grant projects. Second, sections have partnered with chapters in providing lectures as part of the chapter meeting and have become associated with specific meetings. Examples include the Disaster Medicine Section that has a meeting of the section at the Florida Chapter’s International Disaster Management conference; the Emergency Medicine Informatics Section also has partnered with the Pennsylvania Chapter in their annual informatics meeting. These partnerships are a win-win for both the section and the chapter. The last partnership is the development of a course program that is so large that the partnership is between the section and college through the education committee that produces a dedicated program. The Pediatric Advanced Educational Program is an example of such a partnership.

The Team We want your section to succeed. Happy and engaged members who find value in the community of others who share a similar interest within their practice of emergency medicine determine success. We look forward to each section reaching a goal of four newsletters, participating in the section grant program and in the ability to finance section projects through the 15% of dues allocation. We want to help each section member reach their full potential, including professional development, by using sections as an alternative path to leadership development. Finally, we would like to see each section member become politically engaged by attending the Leadership and Advocacy Conference in Washington, D.C. this spring, the annual Council meeting next year in Las Vegas, and participating in NEMPAC and EMF.


(Continued from Page 24)

become active participants in the claims process. • Listen to your legal team, and work to understand your defense strategy. • Understand your role as the defendant, as well as the roles of your legal team, the plaintiff, and the experts. Study the plaintiff’s medical record and commit it to memory. Understand common tactics that may be used by the plaintiff’s attorney. The plaintiff’s attorney will use psychological warfare in an attempt to negatively impact your performance. Discuss these tactics, and get training in how to best handle them. • Have a discussion with your attorney or your insurance company representative about hiring an experienced physician witness coach to help you prepare 26 EMpulse • Mar-Apr 2010

your testimony. • Practice your testimony - the regular meetings with your attorney will not sufficiently prepare you for testimony. • Work with your attorney to develop a witness preparation strategy that includes role playing and videotaped mock testimony. Watch the videotape, critique yourself, and practice again. Deposition and trial can be frightening. You can manage this situation successfully if you trust your clinical skills and knowledge, stay focused, and work to understand the process and the purpose behind the plaintiff attorney's actions and tactics. Dr. Kenneth Schultz is President of Skyview Loss Prevention Services. He is a nationally-known expert in witness preparation and medical legal strategy.

Visit FCEP Online! Become a Fan of FCEP on Facebook!

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discha discharge orders, night shifts, on-call issues, overcrowding, wding, sstaffing taffin shortages, medical bill coding, patient admissions ssions orders, holiday shifts, triage, family conflicts, tests, diagnoses, lab tests, broken bones, car accidents, dog bites, gunshot wounds, prolonged stress, after-hours urgent care, mild traumatic brain injuries, acute headaches, pediatric sedation, inter-hospital patient transfers, community disaster preparedness, equipment approvals, budgetary decisions, continuing education, coordination of multiple providers and healthcare facilities, out-of-hospital medical control system, EMTALA compliance, patient transfer forms, tracking boards, patient records, workers comp forms

What are yyou missingg out on?? Wh Emergency E mergency C Consultants, onsultants, IInc. nc. u understands nd deerstands tthat hat your your p priorities riorities eextend xtend ffar ar beyond beyond h hospital ospital w walls. alls. B Because ecause of of this, this, we we provide p rovide you you with with a personalized p Schedul Scheduling ling Consultant w wh who ho w will ill customize customize your your practice practice schedule schedu ule to to suit suit yyour our llifestyle. ifestyle. E ECI CI h helps ellps yyou ou m maintain aintain a healt healthy thy work/life balance ssoo tthat hat yyou ou ccan an p provide rovide qu quality uality h healthcare ealthcare iin n tthe he E ED, D, aand nd sstill till h have ave en enough nough ttime ime ttoo sspend pend w with ith tthose hose w waiting aiting ffor or yyou ou aatt HOME.

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FREESTANDINGemergency departments

Freestanding EDs: An Overview

Exceeding All Expectations

Timber Ridge/Munroe County MC

Antonio Gandia, MD,FACEP Charlene Walker,RN

Antonio Gandia, MD, FACEP

Frank C. Biondolillo, DO, FACEP, FAAEM

The concept of a Freestanding Emergency Department (FSED) has existed since the mid 1960s. In Florida, the first FSED called the Emergency Center at TimberRidge opened in Marion County (Ocala) in 2002. It is owned and operated by Munroe Regional Medical Center. Shortly thereafter in 2003, the second FSED opened in Destin (Destin Emergency Care Center) which is operated by Fort Walton Beach Medical Center. Thereafter, state legislators placed a moratorium on new FSEDs while they studied the issue. In 2007, Governor Charlie Crist overturned the ban and the Mount Sinai Aventura Freestanding Emergency Department, owned and operated by Mount Sinai Medical Center, opened in Miami-Dade. Since 2008, three additional FSEDs have opened: the Bardmoor Emergency Center (Morton Plant Hospital), the Emergency Care Center at North Port (Sarasota Memorial Hospital), and the Emergency Care Center at St. Lucie West (Martin Memorial Health Systems).

Two years after opening its doors, Mount Sinai Medical Center’s FSED in Aventura has proven to be an asset to the community it serves. Since January 28, 2008, it has provided care to close to 25,000 patients.

Greetings from TimberRidge!

With six FSEDs successfully operating in Florida, FCEP formed a committee represented by the medical directors and administrators of each facility. The first meeting was held in November 2009. We agreed to jointly monitor performance improvement indicators and compare quality outcomes, throughput times, patient safety and patient satisfaction. We also discussed relationships with local EMS systems, transport protocols, and community outreach. The committee plans to meet quarterly to assess and exchange data. With success, many state committees and organizations have welcomed the FSED as an additional resource to improve access to emergency medical care in our state. 28 EMpulse • Mar-Apr 2010

The Mount Sinai FSED is the third of its kind in Florida. It operates in Aventura, Miami-Dade County, which is one of the most densely populated areas in the state.

TRED is located on the southwest corridor of SR 200 in Marion County, in the city of Ocala, just 12 miles west from the main hospital campus of Munroe Regional Medical Center. TRED has served as the model for FSEDs in and around the state and was the first FSED that opened its doors in April 2002.

Since Mount Sinai Medical Center is one of six statutory teaching hospitals in Florida, the FSED serves as a unique educational venue for medical students, nurse practitioners, physician assistants, paramedics and residents. During their rotations, students get to experience a wide range of emergency conditions as well as get a glimpse into the future of EM.

To date, TRED is averaging over 27,000 patients seen annually, and has improved access to emergency care, decreased wait times to see a physician, significantly decompressed the main campus Emergency Department, due to its strategic location, in a rapidly growing segment of the county.

To provide safe and efficient care we are staffed with the customary EPs, registered nurses and emergency room technicians. The 24/7 staffing plan also includes fulltime respiratory therapists, radiology technicians, CT technicians and medical technologists.

As another quality service of Munroe Regional Medical Center, we look forward to continued growth and expansion. In tandem with Munroe’s mission to “meet the changing healthcare needs of the community of Marion County and beyond,” we provide caring and compassionate care.

On-site paramedics for patient transport, as well as an on-call roster of 14 different specialists, ensure that patients receive the best medical care.

Save the Date!

The department’s commitment to providing the finest medical care, matched by efficient and friendly service, has resulted in an overall 99 percent patient satisfaction. Combining all of these quality outcomes has resulted in the community receiving an efficient and personal ED experience.

Symposium by the Sea 2010 takes place July 29 - Aug. 1 in Boca Raton. See for more details.

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The Young Lady with a Numb Leg CPC Chair: Frederick Epstein, MD, FACEP Discussant: Dan Grenier, DO Mt. Sinai Medical Center

A 28-year-old female presented to Mount Sinai’s ED complaining of left leg numbness for approximately one month. The numbness had been constant, but now had worsened so much so that it caused her gait to become unsteady. She went to her PCP three days prior to presentation when she received a Vitamin B12 shot. She had not improved. She was noticed by her family to have been acting “unlike herself” for the last few days, which is why she came to the ED. She had no other symptoms, denied headache, fever, nausea, vomiting, neck pain, chest pain or cough.

tation and tummy tuck a year ago. On physical exam, her vital signs were normal: she was afebrile. She appeared generally healthy. On HEENT exam, it was noticed that she did have slight bilateral ptosis. Her EOM were intact. Her neck was supple and her heart, lung, and abdominal exam were normal. A complete musculoskeletal and neurologic exam was performed. She had 5/5 strength and normal sensation in all extremities, however, her gait was ataxic as she seemed to feel uneasy putting weight on the left leg. Neurologically she showed no cranial nerve deficits, had normal reflexes in her extremities, but had difficulty with the finger to nose test and heel to shin test.

She was admitted to the hospital and received high dose steroids for one week and had improvement of her symptoms. ADEM is characterized by inflammation of the brain and spinal cord caused by damage to the myelin sheath. It can occur in association with recent viral or bacterial infections, as a complication of vaccinations, or maybe idiopathic. The onset is sudden with various symptoms including delirium, seizure, ataxia, optic neuritis and commonly monoparesis. ADEM is sometimes misdiagnosed as a first attack of multiple sclerosis, however ADEM will more

A CBC and CMP were only remarkable for her known anemia. A CT scan (pictured on left) showed an abnormality. The CT was read as subcortical and deep white matter lucency in the right posterior parietal and temporal lobes. Neurology was consulted and the diagnosis was determined. Also, a MRI was obtained (pictured on right).

Her past medical history was significant for anemia, which was related to gastric bypass surgery she had four years prior. Also, she had been treated for an episode of syphilis in the past and recently had a URI that was described as some mild congestion. She took daily vitamins and a PPI, had no allergies, and had a breast augmen-

The MRI was read as multifocal white and grey matter processes demonstrating mild mass effect and edema. Differential diagnoses included lymphoma, multicentric glioma, multi-focal cerebritis, or an atypical demyelinating process. The patient was diagnosed with acute demyelinating encephalomyelitis (aka acute disseminated encephalomyelitis).

commonly have symptoms of encephalitis such as fever or coma whereas MS does not. The symptoms typically respond well to steroids and patients generally return to normal. In some cases, the symptoms will not resolve with steroids and other therapies such as plasmapheresis or IVIG have shown benefit. EMpulse • Mar-Apr 2010 29

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On the Day of Judgment

Arlen R. Stauffer, MD, MBA, FACEP

“Sinners, repent!” The disheveled, bearded man in Room 12 called out to every passerby. His blue jeans were torn, and his long hair had not been cleaned or combed in several days. “I am the Lord! You must repent now, or you will burn in Hell!” In the Ocean’s Hospital ER, Room 12 was often reserved for those who appeared to be mentally ill. Sometimes, it was for patients who were depressed or anxious, sometimes for those who had threatened or attempted suicide. Today, it was for Randall, a middle-aged man who was in Room 12 after a police officer had completed involuntary commitment papers on him. As a nurse walked by Room 12’s doorway, Randall looked up, wide-eyed, and he flipped some greasy curls off his forehead. “Ma’am, I say unto you. Come unto me, all ye that labor and are heavy laden, and I will give you rest.” Randall appeared confident as he brushed the backside of his hand across his unshaven chin. He smirked, and winked at the nurse. Dr. Tammy Cortez was speaking to the officer that had driven Randall to the ER.

leaned out over the edge of that roof, and said something about being Jesus, and he was going to sacrifice himself for the sins of all of us.” The officer rolled his eyes, and then continued, “My partner crept up behind him and grabbed him before he could jump.” He continued, “I’m really not sure what his name is. He had no ID on him. One time, he called himself Randall, but then he just kept referring to himself as ‘Jesus.’” “OK. Thanks.” Cortez turned toward Room 12. “We’ll see what we can do.” “Hi, Randall. I’m Dr. Cortez.” She kept a cautious distance from the stretcher, and stayed near the doorway. Even though there was a leather waist restraint on Randall, ER personnel know they can never trust a delusional or hallucinating patient. “Tell me what happened today, Randall.” She kept her voice low and soft.

Cortez noted Randall’s escalating tension and his rising voice. Then, with a sudden conversion to a smile, he offered a quick comment. “Hey, Doc, that shirt looks really good on you,” and he winked at Cortez. His head snapped back quickly toward the physician, and he pushed forward against the leather. “You’re not putting those evil drugs back into me!” There was fire in his eyes. “Don’t even try it!” He reached out, but Cortez remained out of reach. “Randall, what did your name used to be? Can you tell me that?” “Randall Smith,” he retorted in a singsong, mocking tone. Then, with an emboldened spirit, he added, “but I’ll never go back to that sinful life! I’ve been chosen by the Father to save the sinners of this world! There! Do you hear that? He’s telling me to even try to save you!”

Randall spoke with conviction. “My Father sent me to try to save you!” Then, throwing his head back and peering intently at the ceiling, he continued. “Yes, Father. I hear you! Yes, I’ll try my best! But they’re not listening to me; they’re not listening to me!”

“Susie, check for any old records on a Randall Smith.”

Randall’s face scowled, and his lip started to quiver as though he was about to cry.

The ward secretary typed in the name. “Here you go, Dr. Cortez. I’ll bet it’s this

Cortez backed out of Room 12. It wasn’t safe to try to perform any meaningful physical exam.

“So, it looked like he was going to jump?” “Well, Doc. He said he would jump. He 30 EMpulse • Mar-Apr 2010

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one with the psych admissions.” “Ah. Of course. He’s been admitted with paranoid schizophrenia at least twice before,” Cortez muttered softly. “Phil.” Cortez turned to the charge nurse. “The guy in Room 12 has apparently stopped taking his psych meds again. He’s pretty delusional, and we need to get him calmed down.” Phil nodded. As Phil and two other men strolled into Room 12, Randall squinted, now very suspicious that their intent was not good. He growled, and a look of real fear covered his face. “A good man out of the treasure of his heart bringeth forth good things; and an evil man out of the evil treasure bringeth forth evil things!” Surrounding Randall now, the three men secured his limbs. “This is for your own good, Randall.” “Noooo!” Randall squirmed and twisted. He felt the needle in his right thigh, and he howled loudly. “Noooo!” “It’s OK, Randall,” Phil said calmly. “The Haldol’s in now; you’ll feel better in a minute.” Again, with his eyes torn wide open, his voice boomed at his attackers. “But, I say unto you, that every idle word that men shall speak, they shall give account in the day of judgment.” He closed his eyes and sighed, and his shoulders sank forward slightly. “In the day of judgment, gentlemen, in the day of judgment...” His voice tailed off, and he allowed his head to lie back against the stretcher. Randall was calm now. He allowed a nurse to draw his blood without uttering a whimper. There was a tear on his cheek. He felt defeated.

Schizophrenia occurs equally in males and females, and studies have found an overall lifetime prevalence of 0.55%. The cost to society in terms of healthcare expenses, lost productivity, violence, and patients with schizophrenia in prison is staggering. The author is a long-time emergency physician from New Smyrna Beach, and a former FCEP Board member and EMpulse editor. This is a revised version of one of the “Chronicles” that ran in several Florida newspapers a few years ago. Contact:

Schizophrenia is one of the world’s serious public health problems, and it accounts for a fourth of psychiatry admissions in this country. It is characterized by abnormal perceptions or expressions of reality, and it is felt that genetics, neurobiology, early environment, and psychological and social processes are contributory factors. Victims of schizophrenia often have co-morbid conditions such as major depression or anxiety disorder, and there is said to be a 40% lifetime occurrence of substance abuse.

EMpulse • Mar-Apr 2010 31

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Novel Naloxone Administration

Adrienne Perotti, Pharm.D. Clinical Toxicology Fellow Florida/USVI Poison Information Center-Jacksonville

Opiate abuse associated deaths have risen in Florida in recent years, with heroin continuing to be the most lethal drug found in deceased persons, according to a 2009 interim report by the Florida Medical Examiners. In fact, the top four drugs found in greater than 50% of drug-associated deaths were heroin, methadone, fen1 tanyl and oxycodone. Opiate toxicity can cause CNS and respiratory depression that can lead to coma, respiratory arrest and death. However, the administration of naloxone, an opiate antagonist, may limit toxicity. Traditionally, naloxone is administered via the intramuscular (IM) or intravascular (IV) routes, but this always carries a risk of occupational exposure to blood-borne pathogens, including human immunodeficiency virus (HIV) and hepatitis B and C. According to the World Health Organization, 40% of hepatitis B and C infections and 2.5% of HIV infections among healthcare workers are due to occupational hazards.2 In an ED setting, administration of naloxone may be delayed due to difficulties in gaining IV access or the patient’s body habitus may cause a problem for IM administration. Needle-free administration of naloxone has been proposed. Intranasal (IN) administration is a novel way of administering drugs in the ED. It does not require sterile technique and can prevent needle-stick injuries. The nasal mucosa is an ideal route for medications 32 EMpulse • Mar-Apr 2010

since it has a very large surface area and a large amount of blood flow. However, there are limitations to IN administration. Particle size, pH and volume all play a role in absorption. The ideal volume should be no more than 1 mL per dose; otherwise excess volume will be lost or swallowed. Until recently, there was not much human data comparing routes of administration of naloxone. An article in 2008 looked at the pharmacokinetics of IV, IM, and IN naloxone administration in healthy volunteers. IN naloxone only showed a 4% bioavailabilty. However, this study had many limitations. A very low concentration of naloxone was utilized requiring 5 mL of solution to be atomized into subjects’ nares to achieve a dose of 2 mg. The subjects were also healthy volunteers, not under the influence of opioids. Even with the low bioavailability reported, it is known that as little as 0.05-0.1 mg of naloxone can cause an opiate antagonistic effect. The study was also extremely small with only 8 subjects tested at different occasions. The authors concluded that further studies need to be conducted.4 Several studies have shown efficacy in the implementation of IN naloxone in a prehospital setting.5-7 In 2005, a study was conducted in Salt Lake City, Utah. Ninetyfive subjects were enrolled and received 2 mg of IN naloxone (1mg/mL in each nare),

if they were found unresponsive or if opioid overdose was suspected. As IN naloxone was being given, intravenous (IV) access was obtained, and 2 mg of IV naloxone was administered if needed. Of the 95 subjects, 83% responded to IN naloxone alone and only 16% of these required repeat IV doses.5 In March of 2004, the use of IN naloxone as a first line agent in suspected overdose was implemented by EMS in San Fransisco, CA. A retrospective chart review comparing the administration of IN naloxone and IV naloxone was then performed. The study showed no difference in the response rates for IN and IV naloxone. Although the time for response was slightly longer for IN naloxone, there was no difference in time of contact to clinical response. The study did note that more subjects in the IN naloxone group needed a repeat dose than in the IV naloxone group.6 Despite the lack of in-hospital studies, IN naloxone can be considered as an alternative route in the event of an opioid overdose. The use of a mucosal atomizer device (MAD©), when purchased, can easily attach to the IV naloxone syringe of 2mg/2mL and administer 1 mL to each nare. The Florida Poison Information Center Network is available at 1-800-2221222 for questions. (Continued on Next Page)

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POISONcontrol (Continued From Previous Page)

Opiate abuse associated deaths have risen in Florida in recent years, with heroin continuing to be the most lethal drug found in deceased persons, according to a 2009 interim report by the Florida Medical Examiners. In fact, the top four drugs found in greater than 50% of drug-associated deaths were heroin, methadone, fen1

tanyl and oxycodone. Opiate toxicity can cause CNS and respiratory depression that can lead to coma, respiratory arrest and death. However, the administration of xone was administered if needed. Of the 95 subjects, 83% responded to IN naloxone alone and only 16% of these required repeat IV doses.5 In March of 2004, the use of IN naloxone as a first line agent in suspected overdose was implemented by EMS in San Fransisco, CA. A retrospective chart review comparing the administration of IN

naloxone and IV naloxone was then performed. The study showed no difference in the response rates for IN and IV naloxone. Although the time for response was slightly longer for IN naloxone, there was no difference in time of contact to clinical response. The study did note that more subjects in the IN naloxone group needed a repeat dose than in the IV naloxone group.6 Despite the lack of in-hospital studies, IN naloxone can be considered as an alternative route in the event of an opioid overdose. The use of a mucosal atomizer device (MAD©), when purchased, can easily attach to the IV naloxone syringe of 2mg/2mL and administer 1 mL to each nare. The Florida Poison Information Center Network is available at 1-800-2221222 for questions. References 1. Florida Medical Examiner’s Commission. Drugs

Identified in Deceased Persons by Florida Medical Examiners: Interim Drug Report; Nov 2009:i-34. 2. Wilburn SQ, Eijkemans G. Preventing Needlestick Injuries Among Healthcare Workers: A WHO-ICN Collaboration. International Journal of Occupational Environmental Health. 2004;10:451-56. 3. Kerr D, Dietze P, Kelly AM. Intranasal Naloxone for the Treatment of Suspected Heroin Overdose. Addiction. 2008;103:379-86. 4. Dowling J, Isbister GK, Kirkpatrick CMJ, Naidoo D, Graudins A. Population Pharmacokinetics of Intra-venous, Intramuscular, and Intranasal Naloxone in Human Volunteers. The Drug Monitor;2008:490-96. 5. Barton ED, Colwell CB, Wolfe T, Fosnocht D, Gravitz C, et al. Efficacy of Intranasal Naloxone as a Needleless Alternative for Treatment of Opioid Overdose in the Prehospital Setting. J of EM. 2005;29:265-71. 6. Robertson TM, Hendey GW, Stroh G, Shalit M. Intranasal Naloxone is a Viable Alternative to Intravenous Naloxone for Prehospital Narcotic Overdose. Prehospital Emerg Care. 2009;13:512-15. 7. Kerr D, Kelly Anne-Maree, Dietze P, Jolley D, Barger B. Randomized Controlled Trial Comparing the Effectiveness and Safety of Intranasal and Intramuscular Naloxone for the Treatment of Suspected Heroin Overdose. Addiction. 2009;104:2067-74.

DOCTORS’lounge Speak Out / Letters Hi everyone: L’Hôpital de la Communauté Haïtienne is a 50-bed hospital in the Fréres Neighborhood of Petion-Ville, in the area where many of my family live. My cousin, Edith Dreyfuss-Hudicourt, is one of Haiti’s first woman doctors and a founding member of this nonprofit hospital created by the Haitian Health and Education Foundation (Fondation Haitienne pour la Santé et l’Education, FHASE) in 1985. The hospital has always had emergency services and opened Haiti’s first ICU last year. The hospital attempts to be self-sustaining by charging patients minimal fees for services. The hospital has been one of the few in the Port-au-Prince and Petion-Ville with no structural damage and with teams of physicians, nurses, and volunteers working night and day. Thousands of wounded people have overtaxed the hospital’s capacity to respond to the earthquake emergency. People have come with multiple traumas: mainly with broken limbs and head injuries from fallen cement. There are not enough beds, and people lie on makeshift mats on the floor. The disaster that has befallen Haiti is of enormous proportions. We are raising funds to be able to offer free services. We have received gifts of supplies and medicine, but these gifts cannot possibly cover all needs. Orthopedic supplies are in great demand.

The people who arrive at the hospital are in desperate situations. Many have lost their homes and family members. Some people are camping in the hospital yard because they do not know where to go after receiving care. People of all ages are being dropped at the hospital after being pulled from the rubble. We hope you can contribute funds to help us to continue helping people who are in desperate need of care. You can follow your donation dollars by becoming a fan of the hospital on Facebook. Haitian Health and Education Foundation is a non-profit organization registered in the US. You can read more on the hospital at: My aunt Dr. Ginette Dreyfuss-Diederich has opened a bank account in Miami: Hopital de la Communauté Relief-G. Diederich Account number 1000103902598 Suntrust Bank 11333 South Dixie Highway Pinecrest FL 33156 Laurent Dreyfuss, DO Department of Emergency Medicine, Cleveland Clinic Florida Weston, FL EMpulse • Mar-Apr 2010 33

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University of South Florida

Orlando Health

Florida Hospital

Rebecca Blue, MD

Brittany Thomas, MD

Jason W. Wilson, MD

Greetings from Orlando!

Firstly, I'd like to mention that we are praying for the families in Haiti and hope to arrange a trip soon to serve those in need.

We are all aware of the recent crisis in Haiti, following the devastating earthquake. This moved a country with poor infrastructure to one of virtually no infrastructure in the heart of that nation.

It’s been a busy winter, and with spring approaching we are all looking forward to the match! It has been such an impressive interview season, and it seems like every year it gets harder to put together our match list because there are so many amazing applicants to choose from! Our program’s strongest attributes are the residents, and we are very blessed to have so many highly talented young men and women to work with. This year, our residents have gone out of their way to support recruitment, make the applicants feel welcome, and offer invaluable insight into the match list. Thank you so much to everyone who has made this a successful applicant season! Our residents are already looking forward to SAEM, and the momentum of academic productivity is fantastic. We have had another highly successful year and many of our scholarly projects have been accepted by SAEM. Residents will be delivering oral presentations, moderated poster presentations, and multiple poster presentations on innovative procedural techniques and unique applications of new technology. The collaboration between residents, fellows, and faculty is wonderful - congratulations to everyone who has been accepted! We are all shivering and hoping for warmer weather soon, but despite the cold our program is better than ever. Spring is just around the corner, and we can’t wait to see what it brings!

34 EMpulse • Mar-Apr 2010

As spring arrives, our residents have been involved with various local conferences. In January, both classes attended the 1st Annual Risk Management Symposium. Dr. Amal Mattu discussed risky cardiac and pulmonary conditions, and our very own Dr. Alfredo Tirado taught us how to utilize ultrasound in emergency situations. Also, we were advised on EMTALA, deposition pitfalls, and correct medical documentation by two lawyers. In February, we dedicated our Thursday lecture series to in-service preparation. We set the bar high and hope to continuously improve our scores. A few of us traveled to Tallahassee for EM Days to discuss medical concerns with our state legislators. And in April we will participate in the 10th Annual Symposium on Emergency Medicine, Standards of Care featuring Advances for the Clinician and Best Evidence in Emergency Medicine. Not only will we learn more about the “Art of Medicine,” we will also practice our skills at the advanced airway and ultrasound hands-on workshops. We congratulate Dr. Alexander Garcia, who went to the AAEM Conference in Las Vegas to present a case on amoebic meningitis, and Dr. Michele Rorich, who ran Disney’s “Princess Half Marathon.” We certainly have a multi-talented group!

The state of Florida has responded to the desperation in multiple ways, including that of providing medical care both within our borders and in Haiti. Our geographical proximity and the considerable Haitian population in Florida make the situation even more urgent. Our program, through the leadership of Dr. Catherine Carrubba, has been intimately involved in the care of Haitian medical refugees evacuated from Haiti and brought to Florida. This has been an excellent learning opportunity for us as residents. We meet the large U.S. Air Force cargo planes at the airport and perform a secondary triage role. Next, we arrange transport to area hospitals - both by ground ambulance and, when necessary, by helicopter transport to locations further away, such as Gainesville. Not only has this allowed us residents to contribute in some small way, but it has also allowed us to learn disaster triage and the process of patient transfer to other facilities (something we rarely do at our large tertiary care center). This is a miserable international disaster but it has been impressive see how our country has responded in such a merciful way.

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University of Florida, Jacksonville

Mt. Sinai Medical Center

University of Florida, Gainesville

Oscar Espetia, MD

Marshall A. Frank, DO

Rita Fairclough, MD


This year our program received over 200 applications for five spots.

Greetings from Gainesville! In the last four months, we have adjusted to our new ED relatively well. Our visits are projected to increase to 80-85,000 this year, and we hope to see an increase in the number of residents per year too.

2010 is well on its way and we are more than halfway through the academic year. For the all seniors graduating this year good luck on the job hunt! Here is a little update for the rest of Florida on some of the activities at UF/Shands Jacksonville. We are only a few months into the year and our program has been very busy. Dr. Wears’ published “Situated vs regulatory rationality” in the January issue of the Annals of Emergency Medicine. Drs. Caro and Topp have authored the chapter “Cardiopulmonary Resuscitation during Pregnancy” for the Handbook of Obstetric and Gynecologic Emergencies, 4th edition, edited by Dr. Benrubi. Dr. Joseph has written a book chapter entitled “Diabetes Mellitus, Juvenile” in Rosen and Barkin’s 5-Minute Emergency Medicine Consult edited by Schaider, Hayden, Wolfe, R. Barkin, A. Barkin, Shayne, and Rosen.

Our program director, Dr. Beth Longenecker, broke her foot in a jump-roping accident. She was seen, however, attending a department meeting before she had an x-ray. She is now not bearing weight on her right foot, using a kneescooter, and still working as hard as ever. We all wish her a speedy recovery. For the first time, several of us plan to participate in Southeastern MedWAR (Medical Wilderness Adventure Race) in Fort Gordon, GA in April. MedWAR combines wilderness medicine with adventure racing and is designed to teach and test wilderness survival and medical skills.

Drs. Devos and Akhlaghi have been appointed to the Eurasia Congress of Emergency Medicine’s Scientific Advisory Committee as International Members and will also be members of the planning committee. The conference will be held November 2010 in Antalya, Turkey.

After the recent devastating earthquake, we have seen a huge outpouring of support for Haiti. Dr. David Farcy and Dr. Seth Marquit traveled to Port-au-Prince to staff a medical clinic. Dr. Farcy found a man trapped in the rubble for almost 10 days. He attached IV tubing to a stick and threaded it through a hole so that the man could drink while they dug him out. Dr. Farcy then climbed into the hole to pull him out, but thereafter became so exhausted that he needed IV fluids himself. Awesome!

As the year continues to progress, we look forward to the upcoming match and are eager to see who will be joining our ranks here at Jacksonville. We also wish everyone good luck on the in-service exam coming up soon!

Miami is a very active city right now: we have the Orange Bowl, Miami Marathon, Pro Bowl and the Super Bowl. Hopefully fans will behave themselves so we can get through the upcoming weekend uneventfully.

Our third year class has finished interviewing and we will be a Florida, Alabama and Texas class! Graduation is set for June 19 and the light at the end of the tunnel is getting brighter! Our interns are doing a great job. Kudos go out to Andrew, Ben, David, Dan, Henry, Justin, Tim and Tom for their hard work. The interview season has ended and we have stellar applicants. Hopefully we will add some XX power to the incoming intern class. We would like to thank Dr Desai, who organized the interview season this year. His NFL style draft board was a hit, and made organizing the rank list easy. Big thanks also to the faculty members who helped interview and the residents that participated in the breakfasts, lunches and dinners. Several of our third and second year residents expect additions to their families. We congratulate Bill Jackman, Miles Bennett, Kevin Tench and their wives. We are actively interviewing several candidates for faculty positions, including Program Director, and hope to apprise you of the results in the next newsletter. Good luck to all in the up coming in-service exam.

EMpulse • Mar-Apr 2010 35

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People for Access to Emergency Care Emergency medicine is the leader in promoting patient access and safety. In order to achieve our goal of taking emergency medicine to the next level of policy influence in Tallahassee, the Florida College of Emergency Physicians has formed an advocacy entity called “People for Access to Emergency Care” (PAEC). PAEC provides a means for our friends in the business world, such as billing companies, physician groups and other organizations, to assist FCEP in supporting legislative leaders and policy makers, and it ensures that emergency medicine has a seat at the table with key leaders in the Florida House and Senate. PAEC allows FCEP and its partners in emergency medicine to act with a unified voice in Tallahassee. Its members are groups and organizations dedicated to

promoting emergency medicine in Florida and providing better access to quality emergency care to our patients.

contact Beth Brunner at: Thank you!

In order to be successful at securing emergency medicine’s place at the table, we need you to join People for Access to Emergency Care and joining is easy. There are three levels of membership: • Platinum $15,000 per year • Gold $10,000 per year • Silver $5,000 per year PAEC’s goal is to raise $200,000 for the 2010-11 legislative cycle. With these funds we will be able to help elect candidates who support your issues. This will enable us and your organization to participate in the decision-making process. To find out more about contributing to PAEC, or to join our 2010 contributors,

2010 Platinum Members: Florida Emergency Physicians, Inc. 2009 Platinum Members: Emergency Physicians of Central Florida Florida Emergency Physicians, Inc. 2009 Silver Members: Comprehensive Medical Billing Solutions Jacksonville Emergency Consultants, PA Martin Gottlieb & Associates, LLC Southwest Florida Emergency Physicians, PA 2009 Other Members: Tampa Bay Emergency Physicians, PL

Emergency Physicians of Florida Emergency Physicians of Florida (EPF), formerly known as the Florida College Political Action Committee (FLACPAC), is one of the primary advocacy tools that enables individual physician members of FCEP to make a difference at the legislaMiguel Acevedo, MD, FACEP Wayne Barry, MD, FACEP Dale Birenbaum, MD, FACEP Bradford Bowls, MD, FACEP John Braden, MD Michell David Brantley, MD Ka Hang Chan, MD, FACEP Leonardo Cisneros, DO, FACEP Casey Corbit, MD Paul Deponte, DO Vidor Friedman, MD, FACEP Vicki Friend, DO, FACEP Wayne Friestad, MD, FACEP Mark Frisch, MD, FACEP Brent Gardner, MD, FACEP

36 EMpulse • Mar-Apr 2010

tive and regulatory level. In order for us to have a positive influence on our legislators, both at home and in Tallahassee, we need your help. Please consider “giving a shift” from personal funds. You can even donate online at:

David Goldman, DO, FACEP Hugh Jones,MD Rodney Kang, MD, FACEP William Knibbs, MD, FACEP Karl Korri, MD, FACEP Ronald Krome, MD, FACEP(E) Mark Kruger, MD, FACEP Linh Tung Le, MD, FACEP Jorge Lopez-Ferrer, MD, FACEP William McConnell, DO, FACEP Gary Mendelow, MD, FACEP Steven Nazario, MD, FACEP Steven Newman, MD, FACEP Patricia Singh Nichols, MD Brian Nobie, MD, FACEP Thank you to all who have donated since the 2009 Symposium by the Sea!

Lisa O'Grady, MD William Osborn, III, DO Ernest Page II, MD, FACEP Ketan Pandya, MD, FACEP Vanessa Peluso, MD Paul Petersen, MD W. Randall Poole, MD, FACEP John Prairie, MD, FACEP Cheryl Reynolds, MD Maritza Rodriguez, MD, FACEP Marc Santambrosio, MD, FACEP David Sarkarati, MD, FACEP Thomas Schaar, MD, FACEP Regan Schwartz, MD, FACEP

Ehsan Shirazi, MD Claire Simpson,MD Weylin Sing, DO, FACEP Sivapragasm Sivanesan, MD, FACEP South Miami Criticare, Inc. John Tilelli, MD Bryce Tiller, MD, FACEP George Tracy, MD John Valentini, MD H. Kenneth West, MD Susan Wolcott, MD

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Conference C onferencce Overview Overview Symposium by Symposium by the Sea Sea 2010 is an educa educational tional opportunity op pportunity desig designed ned for for the busy emergency em emer mergency physician, physician, rresident, esident, nurs nurse, se, P PA, A, and allied health professional proffessiona essionall who demands cutting edge inf information for orma m tion regarding regarding their ever-changing practice environment. sessions,, the conference ev er-changing pr actice en vironment. In In addition n tto o the educational educational sessions conf o ference provides: provides: General SSymposium ymposium G eneral EEducational ducational SSessions essions* Preconferences Administrators, Medical Directors P reconferences aavailable vailable ffor or ED A dministrators, M edical Dir ectors & Nurses; Sa tellite EEducational ducational SSymposia; ymposia; Satellite FFlorida lorida Emer Emergency gency M Medicine edicine R Resident's esident's Case Case a P Presentation resentation C Competition ompetition ((CPC); CPC);; Wine & Cheese Reception Reception with Exhibit ors; Wine Exhibitors; Ferguso on Lee, on, Lee, Slevinsk Vo olleyball Tournament; Tour ournament; Ferguson, Slevinskii (FLS) Volleyball EMR MRA AF Job FFair. air. EMRAF *All ex except cept the pr preconferences econferences ar aree no char charge rge ge ttoo FFCEP CEP members! C

Conference C onffer fer e en ncce Da Date te & L Location ocation

July 29 - A August ugu ust 1, 2010 . The The Boca Boca Raton Raton R Resort e t & Club . 501 East esor st C Camino amin no R Real eal . Boca Bocaa R Raton, aton, Florida Florida 33431 R Reservations: eservationss: (888) 491-BOCA 491-BOC 491-BOCA (2622) ( 2 .w 2) M Mention ention EMLRC EMLLRC SSymposium ymposium ym b byy the he SSea ea 2010 Guest R Room oom R Reservations es vations C eser Cut-Off ut-Off Da Date: te e: July J 14, 14, 2010 Reserve Rese eserve yyour our room room eearly!

Who Should W Shou uld A Attend ttend Emergency Emer ergenc g yP Physicians, hysicians ans, Physician Physician A Assistants, ssistants, Nurs Nurses s and other Healt ses se Health ealth C Care are Professionals. Profeession nals.

FCEP Mem Membership mbership B Benefit enefit Registration ffor Registration or the SSymposium ymposium b byy the Sea Sea gene general ral cconference onfference is FREE tto o all FCEP m members. embers. Join the Florida Florida College C ollege of Em Emergency mergency P Physicians hysicians pr prior ior tto o SSymposium ymposium by by the Sea Sea and your your registration registratio on will be rrefunded efunded upon rreceipt eceipt of your you ur application application and payment payment of yyour our first year's year's dues dues.. FFor or fur further ther information, inffor ormaation, ccontact ontact the FCEP officee aatt (407)) 281-7396 or b offic byy email aatt inffo@f o@ffcep.or . g.

Exhibit an and nd Sponsorship O Opportunities pportun nities Visit w Visit ww.em or ccontact ontact Jer Jerry ry Cutchens Cutchens aatt (407) 281-7396 x15, jcut TThe he Exhibitor Exhibitor and Sponsor P Prospectus rospectus is aavailable vailablee dir directly ectly at at bs2010prospectus.pdff.

Moree Information Mor Informa o tion

Visit V isit w ww.em or call (800) 766-6335 . EMLRC EMLR RC . 3717 South South C Conway onway R Road oad . Orlando, Orlando, FL 32812

Presented Present ted by by Emergenccy Me Emergency Medicine dicinee Learning Learning & Resource Resourcce C Center eentter (w ( in cconjunction onjunction with the Florida Flor lorida rida C o ollege of Emergency Emergenccyy Physicians Physicia y ns (w College (

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EMpulse March-April 2010 Issue  

EMpulse March-April 2010 Issue