MAY-JUN 2010
Simulation Lab Training
Current State of EMS
ED Use in Florida
EMpulse
Volume 15, Number 3
Florida College of Emergency Physicians 3717 South Conway Road Orlando, Florida 32812-7606 (407) 281-7396 • (800) 766-6335 Fax: (407) 281-4407 www.FCEP.org
Emergency Medical Services
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
Current State of EMS in Florida Joe A. Nelson, DO, MS, FACEP
12
State of Florida EMS Michael Lozano, MD, FACEP
14
Interview with an EMT Darren Coleman, EMT-P
18
The EMLRC Mobile Simulation Lab Jennifer Jensen
24
EMS Organizations in Florida Beth Brunner, MBA, CAE
26
Departments Editorial Board Leila PoSaw, MD, MPH, FACEP • Editor-in-Chief editor@fcep.org
PRESIDENT’Smessage Mylissa Graber, MD, FACEP
2
Jerry Cutchens• Managing Editor jcutchens@fcep.org
EDITOR’Semergencies Leila L. PoSaw, MD, MPH, FACEP
4
GOVERNMENTALaffairs Steve Kailes, MD, FACEP
6
MEDICALeconomics Ashley Booth Norse, MD, FACEP
8
CODINGtip Lynn Reedy, CPC, CEDC
9
Cover Design by Jerry Cutchens / 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: LynDee Press, Inc. dba Fidelity Press 649 Triumph Court, Orlando, FL 32805 Tel: (407) 297-8484 www.fidelitypress.us
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.
PROFESSIONALdevelopment Paul Mucciolo, MD
10
Use of Emergency Rooms in Florida by Patients with Ambulatory Care Sensitive Conditions Robert G. Brooks, MD, MBA, MPH Askar Chukmaitov, MD, PhD Anqi Tang, BS
20
CLINICALcase CPC Chair: Frederick Epstein, MD, FACEP Discussant: Brittany Thomas, MD
28
POISONcontrol Alexander Garrard, Pharm D Adrienne Perotti, Pharm D
29
RESIDENCYmatters
30
ADVOCACYnow!
32
EMpulse • May-Jun 2010 1
PRESIDENT’Smessage
Healthcare Reform What Does it Mean?
Mylissa Graber, MD, FACEP Well, right now all of us are trying to
even cover expenses and thus it will in the
exploring this employee model with the
figure out what the healthcare reform
long run cost us more money as with
likely upcoming changes.
means and how it will impact us both
increased utilization of the ER by these
professionally and in our personal lives.
now “insured” patients, there will be more
There has been a lot of backlash to this
I came across a good web site that outlines
expense as these patients will likely cost
healthcare reform. The state of Florida
the big changes that are supposed to occur
us money since the reimbursement will
among many other states has passed
over the next 10 years. This web site does
likely not even cover the malpractice and
opt-out legislation that would go on the
a good job of simplifying some of the
administrative costs.
ballot for a Constitutional amendment that
bigger changes that will occur. http://www.healthleadersmedia.com/ content/LED-248377/HealthcareReform-Provisions-Kick-in-Over10-Years
would allow Floridians not to accept the Currently many groups stay afloat due to
new healthcare reform.
the better pay by PPO’s and private insurance plans and that if more people opt into
There is a lot of debate about whether or
a public insurance there will be less
not the states can pass such legislation and
private patients and more publicly funded
there is argument that the states can not
So what does that mean for emergency
patients eventually decreasing the ability
keep their citizens from participating in
medicine? Well no one really knows for
to make any money.
national healthcare reform if they so choose.
certain. There are two schools of thought: one that we will be better off and one that
The other concern is with the push for
we will be worse off.
“bundling.” Hospitals are being encour-
It should be interesting to see how this all
aged or even pushed into hiring physicians
plays out. The good news is that since the
rather than contracting with physicians.
healthcare reform takes place in stages
The better off philosophy is that since we
over several years there is a lot of
already provide so much unfunded care, that since more people will be insured, we
This is not the model for most emergency
opportunity for change and ironing out of
will have less self-pay patients and
departments and will take away the
details as the plan’s details continue to
actually be better off in the long run, and
autonomy that many emergency physi-
evolve.
that although it is likely that emergency
cians and groups currently have and we
visits will increase, at least the patients
will in turn lose our current practice
I guess we will have to wait and see what
will have insurance. The other school of
models.
happens, but continue to be active in this process to protect ourselves as well as our
thought is that more patients will have insurance that pays too little and won’t 2 EMpulse • May-Jun 2010
There is talk of certain hospital chains
patients.
RE G w IST w w. ER em O rlc NLI .o NE rg
Symposium by the Sea 2010 The Annual Meeting of the Florida College of Emergency Physicians July 29 - August 1, 2010 . The Boca Raton Resort & Club . Boca Raton, FL
Conference Overview
Symposium by the Sea 2010 is an educational opportunity designed for the busy emergency physician, resident, nurse, PA, and allied health professional who demands cutting edge information regarding their ever-changing practice environment. In addition to the educational sessions, the conference provides: Symposium General Educational Sessions* Preconferences available for ED Administrators, Medical Directors & Nurses; Satellite Educational Symposia; Florida Emergency Medicine Resident's Case Presentation Competition (CPC); Wine & Cheese Reception with Exhibitors; Ferguson, Lee, Slevinski (FLS) Volleyball Tournament; EMRAF Job Fair. *All except the preconferences are no charge to FCEP members!
Conference Date & Location
July 29 - August 1, 2010 . The Boca Raton Resort & Club . 501 East Camino Real . Boca Raton, Florida 33431 Reservations: (888) 491-BOCA (2622) . www.bocaresort.com Mention EMLRC Symposium by the Sea 2010 Guest Room Reservations Cut-Off Date: July 14, 2010 Reserve your room early!
Who Should Attend
Emergency Physicians, Physician Assistants, Nurses and other Health Care Professionals.
FCEP Membership Benefit
Registration for the Symposium by the Sea general conference is FREE to all FCEP members. Join the Florida College of Emergency Physicians prior to Symposium by the Sea and your registration will be refunded upon receipt of your application and payment of your first year's dues. For further information, contact the FCEP office at (407) 281-7396 or by email at info@fcep.org.
Exhibit and Sponsorship Opportunities
Visit www.emlrc.org/sbs2010.htm or contact Jerry Cutchens at (407) 281-7396 x15, jcutchens@emlrc.org. The Exhibitor and Sponsor Prospectus is available directly at www.emlrc.org/pdfs/sbs2010prospectus.pdf.
More Information
Visit www.emlrc.org or call (800) 766-6335 . EMLRC . 3717 South Conway Road . Orlando, FL 32812
Presented by Emergency Medicine Learning & Resource Center (www.emlrc.org) in conjunction with the Florida College of Emergency Physicians (www.fcep.org).
EDITOR’Semergencies
Rethinking an Old Disease
Leila L. PoSaw, MD, MPH, FACEP Raindrops hit the tin roof hard and fast, offering a loud, brief respite from the smoldering heat. For a short while the swirling red dust, which gets into every nook and cranny to leave me choking and gasping for air, is calm. I lay on my bed under my mosquito net waiting for sleep which may or may not come. There is a power cut, again, and my flashlight throws gray dancing shadows on the ceiling above, calling out to tiny insects who gather buzzing around my light, my head. I wonder what is going on in the world I have left behind; so far away, I have no news. I wonder if my water will be less brown tomorrow, so I can wash the grime out of my hair. I wonder if I will get cerebral malaria, like the child I saw seizing at the casualty, here in Ghana, Africa. On my way to Accra, I am optimistic: I am to improve emergency systems at the Mampong district hospital, an hour from the busy city of Kumasi. I am with the sidHARTe program, which focuses on often overlooked district hospitals, which fall between community-based primarycare clinics and the larger, hard-to-reach tertiary hospitals in major cities. District hospitals are limited in resources and technology but represent the main source of hospital care for most Ghanaians. Skilled healthcare providers are scarce and patients often wait many hours, even 4 EMpulse • May-Jun 2010
when they present with life-threatening conditions. In Ghana, besides the more traditional health issues like obstetric complications and acute manifestations of malaria, pneumonia and diarrhea, injuries from road traffic accidents constitute an increasingly large proportion of the national burden of disease. SidHARTe aims to offer realistic tools and guidelines to improve emergency care. Yes, we can. The reality comes as a shock. The casualty is sparse – metal beds in divided areas for men, women and children. Everybody gets an IV line: bags hang on rusty poles, next to anxious mothers holding their sick child. There are neat numbers over the beds. A closet holds all emergency supplies, noticeable for little brown bottles and more IV bags. There are no monitors, no EKGs. A clear glass cabinet announces itself as AIRWAY, and proudly holds a neonatal laryngoscope, the rest being usurped by the operating theatre. Many essential medicines are unavailable. Everybody gets a malaria smear. There is no triage and no pre-hospital care. There are four doctors in the hospital who rotate through, a flash, gone in the blink of an eye. The casualty is run by four and a half nurses, students, and some “pink ladies,” who hang around and help. There is an ambulance service to Kumasi – but the patient has to pay. If you are too poor
to buy the government health insurance, you have to pay for everything. Most patients are poor farmers and have no money. A young man with an open leg fracture has no money to go to the OR. A child with pneumonia dies from septic shock because the government cannot afford equipment and essential medicines. An old lady dies from CHF because her family can’t afford the ambulance. Poverty is the real disease and it is not new. Indeed, we may not even recognize it as a disease. The diagnosis is easy, the prognosis is grim. It is the number one killer in the world. For so many of us, living luxurious lives, it is invisible. We eat sushi, drive our luxury cars, and deny its existence, everyday: “The poor are lazy,” followed by the justification: “Otherwise, why are they poor?” You do not need to go to Africa. You do not need to see the tears of a mother whose child has just died from a snake bite because she could not afford the anti-venom. I challenge you to look into the neglected corners of your city, the streets you avoid at night. You will find poverty. It is ubiquitous. Next time in your ED, you see a woman with an oozing, necrotic breast because she could not afford to have yearly mammograms, rethink the diagnoses: one, breast cancer; two, poverty.
ADVERTISEMENT
GOVERNMENTALaffairs
Winds of Change
Steve Kailes, MD, FACEP Regardless of your politics, Congress has
ever, our legislators are being educated
passed “Health Care Reform.” I’ve heard
about the challenges and demands faced
many opinions on the matter.
by
For the
our
on-call
specialists
and
mission and reduce staff.
us.
We continue to encourage efforts to
pragmatists among you, it is time to move
Also, we have been very focused to
expand the physician work force in
on, figure out what has changed, how to be
oppose efforts to gain support for a ban on
Florida, both through increased GME
prepared and how to successfully adapt to
balanced billing of patients.
slots and through educating legislators
the future. Still, for those who are disap-
about the challenges faced by us in this
pointed or upset at what did and did not
While there wasn’t a bill filed for this
state. We remind them of the difficulties
occur, I urge you to engage in the process.
issue, the insurance industry is pushing for
with the lack of sufficient on-call special-
such a ban and is using a variety of tactics
ist availability as well as the lack of access
Congress won’t likely tackle health care
to get it. Proposed legislation this year
to care faced by patients before or after the
on such a scale as has just occurred for
would have required any hospital based
ED visit.
another decade or more. However, there
physician group to agree to contract with
is much work that still needs to be done,
any insurer that has contracted with the
Furthermore, we support patient safety
and we cannot afford to wait for political
hospital. We are watching for potential
issues which notably include a ban on the
winds to force Congress to act.
attempts to slip this in as an amendment to
use of cell phones (or similar devices) for
another bill and are concerned of what this
texting while driving, the use of booster
may become next year.
seats for children under a certain age and
FCEP has been hard at work during this state legislative session to affect change
size, and the administration of vaccines to
where necessary and protect our patients
Other issues being watched include the
children to help prevent the spread of
and us from the efforts of others. The
legislature’s efforts to deal with budget
disease and illness.
most intriguing story so far has been the
deficits, especially the Medicaid budget
momentum and support seen in the Senate
which represents close to 25% of the total
Things remain in flux as of this writing,
regarding a bill to provide sovereign
budget. Both houses are looking for ways
but we will continue to work hard to
immunity for providers of emergent care
to make cuts and consolidate services. The
protect our specialty and our patients. We
that falls under the mandates of EMTALA
number of Medicaid enrollees is expand-
need your help, and I encourage you to get
and the Florida Access to Care laws.
ing and the “Medical Home” model has
involved.
received much attention. In addition, the
you to give an enormous amount
Realistically, this issue is unlikely to move
legislature has proposed a restructuring of
of time or other resources to make
out of a House committee this year. How-
the Department of Health to focus on its
a difference.
6 EMpulse • May-Jun 2010
It really doesn’t require
MEDICALeconomics
Health System Reform What it Means for EM
Ashley Booth Norse, MD, FACEP The President signed “The Patient Protection and Affordable Care Act (H.R. 3590)—health system reform legislationinto law on March 23, 2010. While there are many divergent opinions about the recently passed legislation, most EPs agree that some sort of reform was needed. However, the question still remains if this legislation will have a positive or negative impact on patient care and our practices. HR 3590 will affect EM physicians- immediately and over the next several years (currently, timeline extends through 2019). The Patient Protection and Affordable Care Act (from here on referred to as “the Law”) requires health plans to provide a minimum or essential set of health care benefits, including: emergency services, ambulatory patient services, hospitalization, maternity and newborn care, mental health and substance use disorders, prescription drugs, rehabilitation, laboratory services, preventive/wellness services and chronic disease management, as well as pediatric services. Essential health benefits must also provide coverage for ED services without prior authorization whether the EP is a participating provider or not. It also limits the patient co-payment amount for out-ofnetwork services to the same level as in-network services. In addition, the Law requires the Secretary of HHS to establish a three-year demonstration program that would reimburse private, psychiatric hospitals for 8 EMpulse • May-Jun 2010
EMTALA services provided to Medicaid enrollees ages 21 – 64. The Law also directs the Secretary of HHS to award at least four multi-year contracts or grants to support pilot projects that design, implement and evaluate innovative models of regionalized, comprehensive and accountable emergency care and trauma systems. The Law requires the Secretary of HHS to support federal programs administered by NIH, AHRQ, HRSA, CDC and other agencies to expand and accelerate research in emergency medical care systems and EM. In addition, the Secretary of HHS is required to support research to determine the estimated economic impact of, and savings that result from, the implementation of coordinated emergency care services. It also requires the Secretary of HHS to support federal programs involved in improving the emergency care system to coordinate and expand research in pediatric emergency medical care systems and pediatric EM. Lastly the Law reauthorizes the Emergency Medical Services for Children (EMSC) program for five years. On the flip side of the coin, provisions that were not meaningfully addressed are Tort reform, the cost of defensive medicine, elimination of the sustainable growth rate (SGR), and the end of life issues. In addition, the projected cost of “The Patient Protection and Affordable Care Act” leads many to question the long-term viability of the legislation. In regards to tort reform, the Law does
authorize the Secretary of HHS to “award demonstration grants to states for the development, implementation and evaluation of alternatives to current tort litigation for resolving disputes over injuries allegedly caused by health care providers or health care organizations.” The law also “encourages states to develop and test medical liability alternatives to improve patient safety, reduce medical errors, encourage the efficient resolution of disputes, increase the availability of prompt and fair resolution of disputes, and improve access to liability insurance while preserving individual's right to seek redress in court.” The SGR will reduce overall Medicare physician payments by 21% in 2010 under current law with that number growing to 40% over the next several years. SGR elimination is something that has simply been pushed back annually and this legislation fails to address SGR and physician reimbursement. This legislation has probably disappointed 50% of EPs, but the real challenges lie ahead. We must move forward. Health insurance coverage does not equal access to medical care. We predict that emergency visits will increase and this means that the critical problems facing EPs and our patients are not going away. Details of The Patient Protection and Affordable Care Act” (H.R. 3590) may be found at: http://www.acep.org/advocacy.aspx?id=21632
CODINGtip The new diagnoses code set, ICD-10, will be required on October 1, 2013. Now is the time to start your preparation. The American Academy of Professional Coders (www.aapc.com) has put together a time-line of activities that you need to complete in order to be ready on 10/1/2013. Go to their website, click on Resources and then on ICD-10. You can learn more about ICD-10, get training, or use their benchmarks tracker. You will find this to be an excellent, one-stop resource. Lynn Reedy, CPC, CEDC Director of Coding Services CIPROMS South Medical Billing
VOLUNTARY EMpulse SUBSCRIPTIONS Contribute $20 or more to help defray the publishing and mailing costs of EMpulse. Check payable to: FCEP, EMpulse VS 3717 South Conway Road Orlando, FL 32812
PROFESSIONALdevelopment
The Aging Emergency Physician
Paul Mucciolo, MD “I saw you eating pizza!” admonished the forty-five year-old man I was admitting for unstable angina. “Do as I say and not as I do,” I quipped. We chuckled, but this made me think. A mere eight years separate me from the “senior” emergency physician - according to my literature search, EPs over the age of fifty! “Senior” physicians now comprise approximately half of the physician workforce in the United States. Health Maintenance “Don’t stand when you can sit, don’t sit when you can lie down. Most professional athletes retire before their fortieth birthdays. EPs endure the rigors of their careers for many decades beyond that. Proper nourishment, a realistic exercise regimen, and special schedule consideration are important to meet the changing needs associated with aging. In a survey, seventy-four percent of senior EPs reported difficulty recovering from night shifts. In light of this, physician groups might consider hiring physicians who prefer working only nights, shortening the night shifts, or providing incentives for night shifts. Regardless, some deference to “senior” physicians is in order. Wealth Management “A penny saved is a penny earned.” Not in today’s economy! EPs considering retirement are facing tough choices. EM groups are generally small and somewhat loosely structured. Additionally, EPs are 10 EMpulse • May-Jun 2010
unlikely to be partners in income producing investments such as outpatient surgery centers. EPs don’t typically hold positions where they can sell their stake in a private practice upon retirement. The EP’s asset is the skill and knowledge acquired over decades of caring for thousands of patients. As such, structuring a secure retirement strategy can be fraught with difficulty. The current economic crisis is a compelling reason for EPs to closely examine their own situations with regards to wealth management and financial responsibilities as they mature in their practices. Patient Care “You’re getting soft in your old age!” a nurse recently told me when I quietly came out of the room of a patient on his fifth visit that month for cocaine-induced chest pain. “No,” I smiled, “I’m getting smart.” I remember getting irritated with a COPD patient who was coming in by ambulance on a daily basis during my first month of practice. He refused admission and walked out every day—and continued to smoke. Later that week, a senior physician in my group treated the same COPD patient then quietly sat down. The sense of frustration I experienced was absent in my colleague. I asked him how he tolerated futile interactions with such composure. He replied that “there are a lot more of them than there are of you.” Futile attempts at trying to change certain patient behaviors are exhausting. Senior
EPs are often masters of creativity, negotiation and disposition. Senior EPs also provide an essential stabilizing influence on physician groups. They are more likely to provide viable solutions to problems regarding the practice due to lengthy experience in a changing health care climate. This administrative experience from EPs with planning ability and longterm vision is invaluable. Teaching “Every day is a school day!” said one of my surgery attendings when he discovered that his patient had two gallbladders during the cholecystectomy. Nowhere is that saying truer than in EM. Senior EPs were manning the helms for years while younger physicians were climbing the first few rungs of their career ladders. Clinical decisions were based on the history and physical and “ABC” meant Airway, Breathing and Circulation, not Airway, Breathing and CAT scan! Their vast warehouse of information was the cerebral hemispheres of the physician, not a mainframe computer. It is imperative that their clinical experience be passed on. A survey from FCEP will be arriving soon—please take a few minutes to respond. Assist FCEP in suggesting practice modifications that promote career longevity and maintenance of clinical competence among one of our greatest assets—senior EPs!
EMSstate
Current State of EMS in Florida Joe A. Nelson, DO, MS, FACEP State EMS Medical Director
Florida’s Emergency Medical Services community is constantly changing. This article will briefly delve into present EMS challenges as well as issues that will mold EMS in the not too distant future. Currently, EMS is being driven by factors such as budget contraction, looming reimbursement loss at the Federal level and retirement of a significant portion of the experienced workforce. On the clinical side there exists legislated disease management in the form of trauma and stroke laws as well as proposed ST Elevation Myocardial Infarction (STEMI) law. Airway management is moving toward routine use of supraglottic devices such as the LMA or COBRA tube and away from “gold standard” endotracheal tube placement in the field. Advances in equipment have resulted in 12 lead EKG, pulse oximetry and waveform capnography being standard in advanced life support ambulances throughout Florida. Numerous agencies also utilize mechanical cardiopulmonary resuscitation devices and carbon monoxide detection technology. Several evolving trends affecting EMS in the next five years are in play. The National EMS Scope of Practice Model promotes the standardization of EMS training and licensure at the national level. According to the National Association of State EMS Officials, “States following the National EMS Scope of Practice Model as closely as possible will increase the consistency of the nomenclature and competencies of EMS personnel nationwide, facilitate reciprocity, improve 12 EMpulse • May-Jun 2010
professional mobility and enhance the name recognition and public understanding of EMS”. Florida will soon need to adopt or reject certification/licensure of the Emergency Medical Responder (formerly known as First Responder), Emergency Medical Technician (replaces the EMT-Basic level), Advanced Emergency Medical Technician (akin to the EMT-Intermediate found in many States) and Paramedic (currently EMT-P). Many States are likewise moving to exclusive use of a national certification exam (National Registry Exam) for all four levels of provider. The Board of Directors for the National Registry of EMT’s has indicated that after December 31, 2012 Paramedic program graduates will become ineligible to take their certification exam if they did NOT graduate from a nationally accredited paramedic program. Thus, Florida will have a decision to make regarding use of the National Registry exam and the requirement of National Accreditation for its Paramedic training programs. This program accreditation is done by The Commission on Accreditation of Allied Health Education Programs (CAAHEP) which is in turn the parent organization of the Committee on Accreditation of Educational Programs for the EMS Professions (CoAEMSP). CAAHEP is a non-profit, nongovernmental agency, who reviews and accredits over 2000 educational programs
in nineteen (19) health science occupations. The “System of Care” is a concept with roots in trauma care that is expanding to include other disease entities. In terms of clinical practice, the issue of prehospital cardiac arrest awaits new American Heart Association Guidelines and is becoming organized at locations throughout the US and Florida into a “system of care” otherwise called a “Cardiac Arrest Network”. These networks of care would involve emergency medical services (EMS), referring hospitals, and dedicated, experienced centers that treat cardiac-arrest survivors. They would be capable of performing PCI, mechanical interventions, and other specialized treatment such as post resuscitation cerebral hypothermia. Stroke care will continue to require operational and protocol changes as the science develops, especially in the interventional diagnostic/treatment area. In the realm of STEMI care, look for continued efforts to organize systems of care from the regional and state-wide perspective. On the horizon is a more organized approach to septic shock that could change the EMS management and transport of patients with this clinical syndrome. In conclusion, EMS operations are becoming changed, for better or worse, through financial, workforce and clinical factors. Emergency physicians and especially those who interact with EMS on a daily basis should have situational awareness of these influences.
EMStrauma
The State of Florida EMS Part 2 of a Series
Michael Lozano, MD, FACEP For many EPs who are not routinely involved with EMS, it may seem like EMS is very disorganized in Florida. The reality is that although significant latitude is given to local rule, there is indeed an overarching structure and plan to EMS activities in the state. This is the second of an ongoing series which examines the newly adopted 2010-2012 Strategic Plan for the Florida EMS Advisory Council (EMSAC). The strategic plan covers all aspects of EMS systems, and by studying it one can gain an appreciation of the workings of the system and develop an understanding of its underlying mechanisms. The EMSAC was created by the legislature pursuant to chapter 401.245, F.S., and acts as the advisory body to the emergency medical services program administered by the Department of Health. At a strategic planning workshop help last fall, key stakeholders met with Bureau of EMS staff to review the Council’s mission, vision, and value statements, as well as to develop specific goals and tactics to help guide Florida’s EMS system over the next two years. The EMS System is defined as all licensed providers, EMS personnel, and EMS training centers. In developing the strategic plan, the Council and its constituency groups adhered to a core value system. Rather than management though fiat, the Council achieves and maintains quality results, accountability, and outcomes through guidance, direction, encouragement, and reinforcement. 14 EMpulse • May-Jun 2010
Above all, they value putting the patient first – always! There is a dedication to ensure that services are available which benefit and protect the public, and that active collaboration is utilized to solve problems, make decisions and motivate providers to work together in providing evidence-based pre-hospital care and achieving common goals. There is a basic expectation that ethical behavior is exhibited in all decisions, actions, and stakeholder interactions. Policy and decision making are supported by the most rigorous of scientific methods available, and participants research, identify and adopt evidence-based science and best practices to reduce mortality and morbidity. Finally, there is a dedication to continual education of the public, the EMS system, and all EMS stakeholders. The current plan has ten major goals, each of which have a variable number of tactics associated with it. Tactics have objectives, or concrete measures of success, and strategies, designed to achieve the objectives. Additionally, for the sake of accountability, each tactic has a designated lead group, associated resources, and a recommended timeline for completion. The ten goals are: Goal 1: Improve EMS system through effective leadership and communication by the EMS Advisory Council. Goal 2: “Improving EMS data collection
and participation through advocacy, outreach, and improved accessibility to EMS incident-level data.” Goal 3: Improve customer satisfaction through injury prevention, public education and knowledge of the EMS system. (Customer may be defined by the EMS agency.) Goal 4: Improve EMS work-force education, performance and satisfaction. Goal 5: Ensure economic sustainability of the EMS system. Goal 6: Improve performance of key EMS processes through benchmarking and partnerships. Goal 7: Assure the EMS system is prepared to respond to all hazard events in coordination with state disaster plans. Goal 8: Maintain an accident-free environment and promote a culture of safe and appropriate utilization of Florida air assets. Goal 9: Increase access to care by improving patient safety, responder safety, and the safety of the general public. Goal 10: Improve consistency, efficiency and education of public safety personnel with respect to incident related emergency medical dispatch (EMD) and radio communications.
EMStrauma Goal 1 The first goal deals primarily with the manner in which the Council conducts its business. Bylaws were amended to better align the Council with the overall strategic plan. Lines of communication between the EMSAC and the constituency groups were formalized though committee structure and a strategic plan, which the groups include as a standing item on their respective agendas. Finally, attention was paid to the council members’ professional growth through mentorship, workshops, and a formalized succession plan. There is a statutory position on the Council for a physician. Candidates for the position often have had meaningful participation in the EMSAC committees, and are appointed by the Surgeon General. Participation in the EMSAC committees is open to all. Goal 2 The EMS Advisory Council’s Data Committee and the Bureau of EMS’ Data Unit are tasked with the second goal. Accurate data is the cornerstone of all good management decisions, and these two committees maintain statewide standards for EMS incident level data collection. All fifty states and four territories have signed MOUs (memoranda of understanding) with the National EMS Information System (NEMSIS) . NEMSIS is funded by NHTSA, HRSA, and the CDC to support each state’s efforts to collect, retain, and send data to the national database.
It is assisted by 13 non-governmental agencies, including ACEP. The NEMSIS project’s three primary implementation goals and objectives are: an electronic EMS documentation systems in every local EMS system, EMS information systems in every state and territory which can receive and use a portion of the local EMS data via the XML standard, and a national EMS database which can receive and use a portion of the state and territorial EMS data via the XML standard. Florida has been a party to NEMSIS since 2004. Participation in the EMSTARS program, and the transmission of electronic incident level data from EMS Providers to Florida Department of Health is voluntary, but currently 136 agencies provide incident level data to the state via the EMSTARS project. Goal 3 Customer service is nothing new to clinical providers. For the EMS community, customers are both internal and external. A reflection of this is seen in the third strategic goal. The first objective for the third goal deals with injury prevention efforts. Its objective is to provide injury prevention programs to the public. The metrics are to (a) increase by 5% the number of educational programs provided to the public through EMS and fire agencies, (b) reduce the number of injury related ED visits, and (c) reduce the number of motorcycle crashes. The lead for this objective is the Public Information Education and Relations (PIER) Committee.
The second objective is to increase the quality of the EMS system as a whole by increasing participation of the EMS Quality Managers (lead group) in statewide EMS activities. The hope is that by expanding the culture of quality to the EMS system there will be an increase in overall system quality. The third objective has more of a direct impact on ED physicians and hospitals. It seeks to have EMS agencies identify, educate, and partner with stakeholders on issues related to access to care. The lead is the EMSAC Access to Care Committee, with support from FHA, the EMS Medical Directors Association, FL ENA, the Office of Trauma, Office of Injury Prevention, and PIER. Their metrics include an increase in the number of EMS agencies represented on hospital committees, a reduction in ED overcrowding, and a reduction in unnecessary ED visits. The last two are large multifaceted problems to tackle. What the EMS community seeks is a seat at the table to share their perspective when the house of medicine addresses these vital issues. In the next issue, we will continue with the rest of the strategic goals for the Council, and explore how they may impact you the practicing EP. 1 - Dawson DE, National Emergency Medical Services Information System (NEMSIS). Prehosp Emerg Care. 2006 Jul-Sep; 10(3):314-6. 2 - www.floridaemstars.com/index.htm
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EMpulse • May-Jun 2010 15
EMStraining
The Emergency Physician and EMT Training David M. Bowden, DO, FACEP Program Director Manatee Technical Institute
The forefront of emergency medicine’s interface with the community is being practiced by EMT and paramedics in the ever evolving world of emergency medical services (EMS) in Florida. A majority of these individuals are educated at over 150 EMS training programs in the state. A unique opportunity exists for physicians who have a strong interest in the field of EMS to participate in the education of these fine men and women who in turn provide care to the sick and injured in our society. The role of an EMS training program medical director in the present EMS environment is instrumental to the education of emergency services personnel. In the state of Florida, there are currently over 50 program medical directors providing input to programs of various sizes at colleges, universities, technical centers, and private institutions. General provisions under Florida Administrative Code rule 64-J exist that require that a training program has a medical director who will be responsible for the instruction of the DOT approved training program for EMTs and paramedics. The medical director must have substantial knowledge of the qualifications, training, protocols, and quality assurance programs of the training facility. It is also expected, as teaching is part of being a training facility director, that the physician maintains certification as an ACLS instructor and a prehospital trauma life support instructor through PHTLS or ITLS. The program medical director will also be a patient advocate by ensuring that students are receiving the highest quality 16 EMpulse • May-Jun 2010
education during their training. Representation as a liaison between EMS training centers, regional EMS providers and hospital systems is another crucial role program medical directors assume to ensure quality. The biggest impact physicians can make on training facility students is through direct education. It is recommended that program medical directors teach or evaluate student performance for four hours per month. The opportunity to teach skills is a positive benefit to being a training program medical director. Students are eager to learn and surprisingly willing to listen to everything you have to say about topics in EMS. Whether it is a war story from the battles of residency training or the latest techniques in airway management, the students enjoy the direct contact with their medical director. The interaction allows the students to ask questions, directly shadow the physician, and participate in patient care with immediate feedback. Due to the current economic situation, training programs are seeing many students who are pursuing a second career as an EMT or paramedic. This is a challenging time for EMS, yet it also one with new opportunities. Students with varying backgrounds and experiences are being introduced to the “magic of 3 am.” They are learning airway techniques with new devices, using patient simulators in lab sessions to provide a more realistic patient experience, and learning skills to succeed in hostile environments and disasters. Program medical directors have been
instrumental in facilitating these necessary changes to keep up with the dynamic field of EMS. There is also an initiative to adopt national educational standards for EMS education as part of an overall agenda for the future. Although not adopted in Florida, the proposal would change the teaching curriculum at many of the training facilities in order to accommodate four levels of training and certification to include emergency medical responder, EMT-Basic, EMT Advanced or Intermediate, and Paramedic. If adopted, program medical directors would be instrumental to ensure quality education and compliance with this new initiative. Through program medical directors, students are afforded direct attention in the classroom and clinical setting. This experience is also beneficial for the medical director as this is an opportunity to make lasting impressions on individuals who will be performing in difficult and stressful environments prior to arrival to the emergency department. The educational process and the role of program medical directors are two pivotal components to the continued success of EMS programs and the ultimate treatment of the sick and injured. It is truly rewarding for program medical directors to be a part of the transformation of a student into a lifesaving EMT or paramedic after program completion as witnessed on a daily basis throughout Florida.
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EMSinterview
Interview with an EMT
Darren Coleman, EMT-P interviewed by
Michael Lozano, MD, FACEP I interviewed a Florida paramedic who traveled to Haiti a week after the earthquake. He was part of a not-for-profit medical mission. This was his first experience in a disaster zone. A word of caution, some of the descriptions are somber and sobering. How did you come to be in Haiti? On the day of the earthquake, I was home, and had just got up from a nap to check my email. There was something about an earthquake in Haiti and I realized that something significant had happened. I have a lot of friends and colleagues who are Haitian. People from my hospital go to Haiti annually. I had always wanted to volunteer at Dr Guerrier’s clinic there, but had never made the trip. Now, I was compelled to go there partly because my minor is in African-American Studies and there is such a parallel with slavery. People of color in both countries come from the same roots. Had you ever gone to Haiti before this? No, I had never been to Haiti. “We have to go right now,” is what I was feeling. I got on the phone and make a bunch of calls. I scrambled to find my passport and called 18 EMpulse • May-Jun 2010
the Haitian doctors that I knew. Finally, we were able to get there with the help of the Pinson Foundation and Project Medishare. Who was on your team, and how did you get to Haiti? Two ER nurses, Dr Guerrier, a nurse from his office, another medic, a New York pharmacist and I formed a team. We took a flight to Miami and connected with Medishare. We just got on the plane. They didn’t check passports, but did make sure we were on the approved list. We signed waivers. On the way back we came back on a military C-17, strapped in like human cargo. What sort of preparations were you told to make? We were told to pack for thirty days. Yeah, thirty days - just in case there was unrest and we had to backpack into the Dominican Republic. The big thing was to make sure we had enough water. I packed scrubs, power bars, a stethoscope, head lamp, underwear, you know – the bare minimum. When it was done, it weighed almost as much as me. Did you take any reference books? I didn’t take any books. I did take my cell phone which was handy. At one point, a medic at the front gate and I texted back and forth to sort patients before they got to the triage area in the back. Another time, there was a little girl in a knee immobilizer who had a closed fracture. We didn’t have any way to print x-rays from the portable machine. I was able to take a picture of the fracture with my phone and show the
surgeon in the OR. Where did you provide care? At first, we worked at a field hospital at the Port au Prince airport with the University of Miami. We were the second shift coming in. There were also medical people from other countries, each with their own area. Through the foundation, we stayed at the Haitian Baptist Mission. We had food and sleeping quarters. With the mission we were able to go out into the community. The mission has a clinic, an SUV and translators, so we were able to go into the neighborhoods and take care of people. What was it like once you got on the ground in Haiti? We went into the city and saw patients who had not been seen by anyone right where they lived. It was just our crew from St. Pete, we had no security, and we never ran into any trouble. Half the day was scene response and house calls. We would walk up and down the street and call out. We would write down whatever
EMSinterview
we did on a piece of paper and this was their chart. The other half of the day would be at the airport and we would work there until nine or ten at night. After the first couple of days, we spent most of our time at the hospital. We were able to translate some of the skills and techniques from the ED into simple things like setting up a triage with a sign in sheet. We had wrist bands, and simple charts. Ropes were run across the tent to hang IVs. This was simple and smart medicine. You were there to help and do your best. What was it like in the field hospital? We had pediatric and adult tents. There was an OR in back of the adult tent with a recovery room. There was a fast track area and a main treatment area. EMTs who had done helicopter rescue for six days were now doing repeat vitals. Folks from the Church of Scientology took care of the logistics and transportation. Locals worked at the field hospital in exchange for food and water. I was doing a lot of IVs, wound care and some physical therapy. I changed burn dressings on kids. We circulated and helped out. Was it mostly trauma care? It was mostly trauma at first. There were three people who were trapped in their home, who came out weighing ninety pounds and needed IV fluids. As time went on, people found out about the hospital at the airport by word of mouth. We would get patients by private vehicle or charities/ non-governmental organizations
would bring them in. If patients were too complex, we could evacuate them to the Hospital Ship USS Comfort. That was the highest level of care.
would see people who were half out of it, and they would join in the singing. Amputees were lifting up their stumps and singing along. It was very moving.
How many and what types of patients would you see? Once we got our triage organized, you would see big crowds coming and going. I saw a hundred patients a day. The most common complaint was, “A brick fell on me.” We even had a man with a gun shot to the head. There wasn’t anything that we could do. All we had was a portable x-ray. There was no CT scan or labs, just an accucheck. We put him to the side and let him pass on. There were others like that. We only had oxygen in the OR. There were no nebulizers. We had some people who came in with shortness of breath who we couldn’t help. They got comfort measures only. We usually didn’t work codes. There was just one lady we worked, but we didn’t get her back.
Was there anything else especially memorable? Going through Port au Prince, you would see bodies being pulled out of buildings. I saw one body burning by the side of the road. People would wait until the bulldozers were able to get out their loved ones and then claim the bodies. As you went through the city, I saw femur and jaw bones. People had burned bodies on the sidewalk and left the bones behind among the debris. In the middle of this you saw regular people going about their business – trying to scratch out a living.
We saw a lot of fractures. There were a lot of burns and crush injuries. We found that you only need low doses of medicines in most cases. One or two milligrams of morphine goes a long way, even with an open tib-fib. Overall, the patients were so appreciative. It was amazing how quiet it was in the hospital. You barely heard someone crying out. Were there any security issues? No, not really. You could walk down the street with a case of water. As long as you kept it to yourself, no one would bother with you. If you tried to give it away there would be a scramble to get what was being given away. How about the families of the injured? They were right there all the time. I did not clean up anyone’s stool or vomit. The families took care of it. Even when I was doing wound care, they would put on gloves and join right in. They did all of the custodial care, even for patients without families. The male volunteers were amazing: they had lost everything, and all they wanted to do was help others.
There is one man’s story that I have to tell. He was the first patient I took care of. He was buried in the rubble with his family, who were all dead. He was unconscious and paralyzed from the waist down. They threw all his family in a pit, and they threw him in there too. He was laying there paralyzed next to his dead family for three days. He came to, and more bodies were thrown on top of him. They couldn’t hear him screaming until they came to cover them up. It was then that they found him and got him out. He was catatonic from the experience. That’s the kind of stuff we experienced. Is there anything in general that you would like to share with ER physicians? The Haitian people are very receptive and thankful. One person can make a difference. Darren Coleman is a hospital based paramedic based in St. Petersburg, Florida.
At night in the tents, there were ministers who would lead the people in songs and prayers. You would hear singing coming out of the tents. It was amazing. You EMpulse • May-Jun 2010 19
ORIGINALresearch
Use of Emergency Rooms in Florida by Patients with Ambulatory Care Sensitive Conditions Robert G. Brooks, MD, MBA, MPH 1 Askar Chukmaitov, MD, PhD 2 Anqi Tang, BS 3 1 2 3
Associate Vice President for Health Care Leadership, University of South Florida Health, Professor of Medicine/ Infectious Diseases, USF College of Medicine, Professor of Health Policy & Management, USF College of Public Health Assistant Professor, Department of Family Medicine, Division of Health Affairs, Florida State University College of Medicine Research Assistant, Division of Health Affairs, Florida State University College of Medicine
Introduction Hospital emergency departments (ED) in Florida continue to be severely challenged by an influx of patients, with continued upward growth in visits in recent years. Although most ED visits are for appropriate services, studies have shown that there exist an important minority of patients who use EDs for what are called Ambulatory Care Sensitive Conditions (ACSCs)- sometimes with multiple visits per year. ACSCs are, by definition, visits potentially preventable through use of primary care, and are believed to be one of the reasons for ED crowding and excess costs. Examples of the well-defined ACSCs include: asthma, bronchitis, urinary tract infection, gastroenteritis, and diseases of the skin. In order to develop effective strategies for deterrence of ED crowding and misuse, policy-makers, payers, and physicians need a clearer understanding of the type of patients who visit the ED frequently for ACSCs. Moreover, decision makers need a better understanding of other important factors that may contribute to avoidable utilization of ED services. It is for these reasons that we recently conducted a study of ED use in Florida using the statewide database for the years 2005 and 2006. The purpose of this article (which is based on the 2005 data) is to summarize some of the key findings as they relate to the patterns of use or misuse of EDs by patients with ACSCs in Florida. In our present study, we argue that the potential misuse of ED services can occur by three groups – (1) those with visits for ACSCs, (2) those with frequent ED visits, and (3) those with frequent ED visits for ACSCs. In this article, we describe data for all three groups, but concentrate most on the third group because these patients are particularly likely to be without a regular source of primary care (e.g., a medical home). 20 EMpulse • May-Jun 2010
Study Methods For this study we used a cross-sectional design with an all-encounter, all-payer, multi-hospital, dataset to study ED use for ACSCs (Group 1), frequent visits (Group 2), and frequent visits for ACSCs- where group 1 and 2 overlap (Group 3). We studied patient demographic characteristics, patient case-mix, insurance status, day and time of ED use, and geographic variation, for the calendar year 2005 in the state of Florida. We obtained the entire set of emergency department discharges (n= 5,748,375) for 2005 from the Florida Agency for Health Care Administration (AHCA). The data set contained key patient information on demographic characteristics, types of service, principal and up to four secondary diagnoses [as classified by the International Classification of Diseases (ICD-9-CM)], principal payer type, hour of arrival, weekday, facility, local health county regions, total charges, and other information. For purposes of this study, we excluded patients with missing (masked) social security numbers, those with out-of-state addresses, and those with missing gender or other key demographic information. The final sample used represented 4,914,933 visits made by patients who were discharged from EDs. We were interested in three outcome measures. First, we used an expanded list of ACSCs based on previous work of Weisman, Solberg, and Carminal (group 1). The list represents conditions that should, under most circumstances, be amendable to prevention and treatment by well-functioning primary care providers in a community, and can be useful to evaluate global primary care performance in a geographical area. Second, based on a review of the ED literature, frequent ED users were identified as patients who had four or more visits in a single year and accounted for a
ORIGINALresearch disproportionately high percentage of all ED visits (group 2). Third, we then combined the two above study groups by crosstabulating ED visits for ACSCs, and those made frequently (four or more times in a year) by patients (group 3). A number of patient characteristics were available and were assessed for each of these three groups. These included: patient age, race/ethnicity, gender, insurance types, geographical regions, and day and time of ED arrival. Patient co-morbidities were used, through a modification of the Charlson index, to adjust for the number of conditions using ICD-9-CM codes.
ments were for conditions (ACSCs) that might be prevented through better access to medical care in the community. Additionally, we discovered that approximately 22% of all visits to the ED in Florida were made by patients seen four or more times annually. Finally, approximately four percent of visits were made for ACSCs by patients who were seen frequently in the ED. This latter group is particularly likely to not have a medical home for their routine care. We found that patients age, race, gender, time of ED visit, insurance status, and geographic location may be associated with this type of overuse of EDs in Florida.
Results Table 1 provides descriptive statistics for ED visits for ACSCs, frequent visits, and frequent visits for ACSCs. Overall, 17.6% ED visits were for ACSCs (Group 1), and 21.61% were made by patients who were frequent visitors (Group 2). There were 203,354 (4.14%) patients who made four or more visits for ACSCs (Group 3). The majority of visits for ACSCs visits to ED were for upper respiratory track conditions, diseases of skin, bronchitis/COPD, urinary tract infections, asthma, and gastroenteritis.
These findings lend themselves to a number of possible policy implications. One of the more obvious implications is the need for more community-based care for patients. The patientcentered medical home model has been one of the more impressive and recently discussed options for improving patient access to regular care and for avoidance of unneeded ED visits. For example, several states (including North Carolina, Oklahoma, Alabama, and Pennsylvania) have already instituted bold programs with financial incentives to primary care practitioners, to improve Medicaid patients’ access to primary care. A few
Table 2 describes some of the key patient demographic characteristics, their insurance status, case-mix, and day and time of ED use in all studied groups. The percentage of children (0 - 17 years of age) making ACSC visits and frequent ED visits for ACSCs was the highest in comparison with the other age groups population. Frequent ED visits were more often made by patients from 18 – 49 years of age, female gender was slightly more common, and the percentage of visits made by non-whites was higher than for white patients in all categories. The percentages of visits made during weekdays were comparable to those made during weekends in all studied categories. A slightly higher percentage of visits were made at night rather than at day time in all three categories. Severity of illness was the highest for patients who visited EDs frequently for ACSCs. Medicaid, Medicaid HMO, and self-pay patients contributed the largest number of visits and percentages in all studied groups. In fact, by logistic regression analysis, Medicaid HMO and Medicaid fee-for-service patient had more than three times higher odds of being in the set of patients seen frequently for ACSCs (group 3) compared to commercially insured patients. Some regional variations also were found. For example patients in the Pensacola region were more likely, and in the Ft. Lauderdale region were less likely, to visit EDs frequently for ACSCs in comparison with the Tallahassee region (data not shown here). Conclusions and Implications ED crowding is rising, putting pressure on physicians, hospitals, and patients alike to find solutions to this problem. This study demonstrated that around 17% of all visits to emergency depart-
Table 1
Condition Present Number (#)
Percent (%)
865,065
17.60
Immunization and preventable infectious diseases
30
<.001
Congenital syphilis
4
<.001
Tuberculosis
37
<.001
Diabetes mellitus
21,353
0.43
Disorders of hydro-electrolyte metabolism
14,206
0.29
504
0.01
5,814
0.12
Diseases of upper respiratory tract
207,283
4.22
Hypertensive heart disease
44,105
0.9
Heart failure
6,547
0.13
Pneumonia
34,588
0.7
Bronchitis /Chronic obstructive pulmonary disease (COPD)
135,207
2.75
Asthma
All ACSCs ACSCs by Categories (Group 1)
Iron-deficiency anemia Convulsions
68,503
1.39
Bleeding or perforating ulcer
110
<.001
Appendicitis with complication
76
<.001
Disease of the skin and subcutaneous tissue
154,244
3.14
Gastroenteritis
65,944
1.34
Urinary tract infections
98,825
2.01
Pelvic inflammatory disease
7,682
0.16
EMpulse • May-Jun 2010 21
ORIGINALresearch
Table 2 *
All ED Visits
ACSCs (Group 1)
(n = 4,914,933)
(n = 865,065)
# (%)
Frequent ED Visits (>=4 visits) (Group 2)
#
%
(n = 1,047,900)
Frequent ED Visits for ACSCs (Group 3) (n = 203,354)
#
%
#
%
Age1 (0-17)
1,032,840
(21.01%)
285,521
33.00
182,604
17.43
65,618
32.27
Age2 (18-49)
2,615,191
(53.21%)
377,665
43.66
683,886
65.26
107,788
53.01
Age3 (50-64)
626,931
(12.76%)
94,631
10.94
111,090
10.60
18,914
9.30
Age4 (65-74)
270,764
(5.51%)
44,987
5.20
29,646
2.82
6,011
3.0
Age 5 (75-84)
249,789
(5.08%)
39,403
4.55
27,008
2.58
4,618
2.27
Age6 (85 & Up)
119,418
(2.43%)
16,942
1.96
13,666
1.30
1,954
0.96
Female
2,721,463 (55.37%)
488,333
56.45
631,624
60.28
119,640
58.83
Male
2,193,470 (44.63%)
370,816
42.87
416,276
39.72
85,263
41.93
African American
1,113,710 (22.66%)
217,655
25.16
271,844
25.94
57,161
28.11
White
2,983,465 (60.70%)
480,735
55.57
643,200
61.38
114,057
56.09
687,501 (13.99%)
139,173
16.09
118,513
11.31
30,631
15.06
130,257
(2.65%)
21,586
7.44
14,343
1.37
3,054
1.50
Weekend
1,518,626 (30.90%)
277,073
32.03
315,865
30.14
62,993
30.98
Weekday
3,396,307 (69.10%)
582,076
67.30
732,035
69.86
141,910
69.78
Hispanic Other Race
Day Time
4,140,750
(84.25%)
716,065
82.78
871,002
83.12
170,937
84.06
Night Time
774,183
(15.75%)
143,084
16.54
176,898
16.88
33,966
16.70
Charlson Case-Mix Index
0.12
Commercial PPO
913,238
(18.58%)
124,374
14.38
106,864
10.20
17,369
8.54
Medicare
665,530
(13.54%)
108,428
12.53
132,150
12.61
21,944
10.79
Medicare HMO
111,442
(2.27%)
17,370
2.01
14,438
1.38
2,253
1.11
Medicaid
638,115
(12.98%)
147,942
17.10
217,343
20.74
48,812
24.00
Medicaid HMO
482,554
(9.82%)
125,864
14.55
150,133
14.33
39,105
19.23
HMO
597,539
(12.16%)
91,978
10.63
64,529
6.16
11,633
5.72
1,096,095
(22.30%)
191,511
22.14
275,307
26.27
50,378
24.77
410,420
(8.35%)
5.97
87,136
8.32
13,409
6.59
Self-Pay Other Payer
0.14
51,682
0.14
0.15
* Numbers may not add up to exactly 100% because of missing data and rounding. examples of a medical home model do exist in Florida (eg. Childrenâ&#x20AC;&#x2122;s Medical Services run through the Department of Health), and experience from this program, and from other states that have already implemented patient-centered medical home models suggest that significant cost savings can be realized through these community-based models. Well-run community health centers and local county health departments are also part of the health care safety net that routinely provide primary care to 22 EMpulse â&#x20AC;˘ May-Jun 2010
Medicaid and self-pay patients in the community. These programs, which have current infrastructure in most counties of the state, could also be expanded and modeled as true medical homes, where institutions and individuals are rewarded for better coordinated care that prevents ED use and hospitalizations. Until the problem of access to care in the community is broadly addressed, the ED overuse by patients for ACSCs is likely to continue, and crowding of EDs will be a reality.
BRIEFLY
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more FCEP generates in membership
Jerry Cajina, DO
N. SANDERSO
revenue, the more good we can do for our
Federico G Capriles, MD
Steven M Scott, MD
members through advocacy and other
Manuel Carmona, MD
Capri N Simms, DO
membership benefit programs.
Karlene M Chin, MD, FACEP
Daniel J Wouters
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EMStechnology
The EMLRC Mobile Simulation Lab Jennifer Jensen
EMLRC Program Director
The patient has a high fever, fatigue, severe headaches, general malaise, vomiting, and diarrhea…sounds like any other call on any day of the week…however, since you have pulled up on scene at the airport and loaded the patient in the ambulance he is slowly becoming more and more delirious and is drifting in and out of consciousness. As your crew rushes the patient to the hospital you are hoping to stabilize him before arrival. Unfortunately today’s case is not like others. You have never seen raised red welts on a patient’s face like these before. Reports from airport personnel indicate that the patient flew here from the Middle East. At some point on the flight he became increasingly ill, started to say thing that made no sense, and his raised welts started becoming more pronounced. Is it possible that an adult patient did not have chicken pox as a child? OH NO! What if this is not chicken pox? What if this is something more serious? It is a good thing that all of the crew put on their PPE suspecting a possible communicable condition. What should be done now? There is still a 15 minute drive to the hospital...and the ED is especially crowded today due to a five car accident. What if this patient has smallpox? Has my crew been exposed? What about the other patients on the flight? How many more patients may we expect in the near future? 24 EMpulse • May-Jun 2010
The scenario above is one of many that can be simulated by the EMLRC’s Mobile Simulation Lab. The patient’s life rests in the hands of the crew in the back of a simulated ambulance environment. What treatments they provide (or neglect) will immediately impact the patient’s welfare. This type of education is cutting-edge, immersion education. It has become increasingly popular and necessary for EDs, community colleges, and the EMS community. The EMRLC is a top leader in emergency healthcare simulation. For several years now they have had a dedicated instructor using Human Patient Simulators to provide the most real life education experience possible. Scenarios are designed based on agency or organization needs. Not only is the experience simulated, but the environment is as well. The Mobile SimLab has both an ambulance bay setting and ED treatment cubicle. For the last few years, the EMLRC has worked closely with the State of Florida Department of Health providing education
around the state. Agencies have provided tremendous feedback about the education experience, indicating that this is some of the best and most compelling education they have ever received. Participants enjoyed “being able to use critical thinking skills and not just follow protocol”, that “visual connections help learning”, that “the manikin helps visualize”, that they encountered “scenarios that they had never before seen in any schools attended”, that the manikin “allows you to see and feel how the patient reacts to treatment” and that the education “gives the overall picture of the patient’s condition”, as well as being able to finally “see” the simulation scenario. When a crew arrives in the Mobile SimLab, Clinical Coordinator Eric Dotten asks if they had any past experience with simulation technology. Depending on their response he tailors the education to meet their needs. They are instructed to interact directly with the manikin from this point on. The manikin is capable of responding verbally to a patient interview.
EMStechnology situational awareness, decision making/ planning, crew self evaluation, and technology and automation skills are also evaluated. It is noted whether the team makes any critical errors or requires any remediation during the scenario. This helps test how thoroughly comfortable and effective they are in treating patients with certain conditions.
From here, the call can become increasingly complex. The instructor can make the patient improve or decline based on the care given. Vital signs can be adjusted on a moment’s notice to test the crews’ ability to follow and recognize decline in the patient’s condition. It is also possible to examine their ability to make calls to Poison Control and to follow through on a complete radio report to the ED en route. Any aspect of a call can be enhanced and focused on depending on the needs of the agency. Simulation education is something that has blossomed tremendously over the past decade. The emergency healthcare community in particular vastly benefits from simulation experience, as it allows them to repeatedly practice skills with no harm to a live patient. They can acquire a comfort level with intubation and airway skills, as well as other complex procedures. This experience is invaluable when it comes to increasing confidence with patient treatment. New up and coming techniques and procedures can be demonstrated by medical directors and used to test paramedic and EMT skills before they try them on the streets. The instructor evaluates each team’s performance and measures whether they meet objectives, such as in the case of a chemical or biological scenario; if they recognize the incubation period, possible modes of transmission, team safety components, and signs and symptoms that the patient presents with following exposure. Their communication, leadership,
In the last two years a number of agencies have received simulation education from the EMLRC’s Mobile SimLab through funding from the State of Florida Department of Health. However, numerous agencies still need to be reached. It is also important to note that with agency turnover, new personnel will need to receive this education, as well as extending continuing education with seasoned employees. It is evident that CBRNE (Chemical/Biological/Radiological/Nucle ar/Explosive) education is still very necessary as indicated by numerous press articles in the last two years. According to a recent report from the Commission on the Prevention of WMD Proliferation and Terrorism, led by former Sens. Bob Graham of Florida and Jim Talent of Missouri, the United States is on track to receive an attack via nuclear or biological weapons before the year 2013. http://www.cbsnews.com/stories/2008/12/ 01/national/main4641534.shtml A U.S. study commissioned by US Senate Foreign Relations Committee Chairman Richard Lugar shows that the chance of an attack with a weapon of mass destruction somewhere in the world in the next 10 years runs as high as 70 percent. http://www.cnn.com/2005/US/06/21/wmd .threat/index.html As alarming as these reports are, the EMLRC is highly dedicated to bringing education to EMS agencies, hospitals, community colleges, nursing programs,
and private organizations to help our communities be prepared for the worst if, or when, it happens. Even with the growing threat of terrorist attacks and biological and chemical attacks, the frontlines of our healthcare system are confronted by challenging patient care on a daily basis. Stroke, cardiac arrest, trauma, and neardrowning, as well as pediatric care challenge the skills and judgment of our EMS professionals every day. As well, pediatric care is an area of discomfort and unfamiliarity at times. Emergency healthcare providers can increase their level of comfort in dealing with sometimes rare pediatric emergencies by practicing on SimBaby®. Often times they have not seen a call involving a young child and develop a fear of even the possibility of such an encounter. This feeling is tremendously eased by participating in repeated scenarios involving the baby. With the growing emergence of simulation education, there is no doubt that the need for the Mobile Simulation Lab and others of its kind is great. In addition to simulating the environments, in situ education, where the manikin is introduced into an environment where crews assess “on scene” is also becoming popular. The EMLRC has the ability to provide this type of education as well, with a wireless manikin intended for portability. The EMLRC will continue to develop simulation, with a conference planned in 2011 on simulation technology and how to best utilize it. The EMLRC plans to lead the charge on simulation technology innovation. EMpulse • May-Jun 2010 25
EMSorganizations
EMS Organizations in Florida
Beth Brunner, MBA, CAE Beth FCEPBrunner, CEO MBA, CAE Few people realize that modern emergency medical service has only been around for the past 70 years. Florida’s EMS community has grown rapidly into one of the strongest, most active in the nation. This is due to the unique relationships amongst the many EMS constituency groups in Florida. In July, November, and January, the State’s Department of Health/Bureau of EMS Advisory Council meets throughout the state. The various EMS constituency groups hold their membership meetings in conjunction with the Council meeting. Dr. Joe Nelson serves as the State’s EMS Medical Director, and also serves on the FCEP Board. Several other FCEP leaders actively participate with other EMS organizations, such as the Florida Association of EMS Medical Directors, Committee on Trauma, Florida Fire Chiefs/EMS Section. The following list of Florida’s EMS constituency groups serves to help us recognize the expansiveness of EMS in Florida and to identify some of the EMS leaders who may be working alongside of you in your community. Florida EMS Advisory Council Members EMS Administrator (Non-fire) Michael Patterson Putnam County EMS 410 South State Road 19 Palatka, FL 32177 Lay Elderly Doris Ballard-Ferguson Florida A&M University School of Nursing 1767 Hermitage Blvd., Apt. 4204 Tallahassee, FL 32308 Lay Person Regina E. Sofer 325 W. Gaines Street, Suite 1633 Tallahassee, FL 32399-1950 Emergency Nurse Amy Paratore 10520 Greencrest Drive Tampa, FL 33626 Paramedic (Non-fire) Karen Chamberlain 12601 SW115 Avenue Kendall, FL 33176
26 EMpulse • May-Jun 2010
Physician David A. Meurer, M.D. Department of Emergency Medicine PO Box 100186 Gainesville, FL 32610-0186
Air Ambulance Operator John Scott Tampa General Healthcare Post Office Box 1289 Tampa, FL 33626
Paramedic (Fire) Charles E. Moreland, Ed.D. 1782 Fiddlers Ridge Drive Fleming Island, FL 32003
EMS Educator Daniel Griffin 4621 NW 46 Court Gainesville, FL 32606
EMT (Non-fire) Tom Quillin, Chief Leon County Emergency Services 2290 Miccosukee Road Tallahassee, FL 32308 EMS Administrator (Fire) William R. Colburn, Fire Chief Reedy Creek Fire Department Post Office Box 10170 Lake Buena Vista, FL 32830-0170
Hospital Administrator Javier I. Escobar II, M.D. 420 Plantation Road Tallahassee, FL 32303
EMT (Fire) Greg Rubin Miami-Dade Fire Rescue 9300 NW 41st Street Miami, FL 33178
Physician Bradley Elias, M.D. 617 Treehouse Circle St. Augustine, FL 32095 Commercial Ambulance Operator Alan Skavroneck 4351 Pinnacle Street Charlotte Harbor, FL 33980
EMSorganizations State EMS Medical Director Joe Nelson, DO, MS, FACOEP, FACEP 934 North University Drive #228 Coral Springs, FL 33071 Department of Education Tracy Yacobelis Program Specialist/Health Sciences & Human Services 325 West Gaines Street, Room 701 Tallahassee, FL 32399 Department of Highway Safety & Motor Vehicles Walter Liddell Florida Highway Patrol 75 College Drive Havana, FL 32333 Department of Financial Services Barry Baker Florida State Fire College 11655 NW Gainesville Road Ocala, FL 34482 Department of Transportation Trenda McPherson DOT Traffic Safety Specialist 605 Suwannee Street, MS 17 Tallahassee, FL 32399-0450 Department of Management Services Todd Mechler EMS Communications Engineer/Coordinator Department of Management Services 4030 Esplanade Way, Suite 180 Tallahassee, FL 32399 Emergency Medical Services For Children Liasion Julie Bacon 1008 Hill Island Drive Oakland, FL 34787
Florida Emergency Medical Services Constituent Groups Association of Florida Trauma Agencies Barbara Uzenoff, RN, Manager Hillsborough County Trauma Agency 2410 N. Tampa Street Tampa, FL 33602-2199 Emergency Nurses Association Florida Chapter Keith M. McKernan, RN, LHRM, MA, CEN, President 940 SW 79th Terrace Gainesville, FL 32607-3397 Association of Florida Trauma Coordinators Celeste Kallenborn, President Tampa General Hospital 2 Columbia Drive, Rm. G417 Tampa, FL 33606
Florida Association of Ems Educators Captain Daniel J. Griffin Alachua County Department of Fire/Rescue Services Post Office Box 548 Gainesville, FL 32602-0548 Critical Incident Stress Management Natalie Duran Miami-Dade Fire Rescue 5680 SW 87 Avenue Miami, FL 33173 EMS Providers of Florida Daniel Azzariti Deputy Chief of Administration Marion County Fire Rescue 2631 SE 3rd Street Ocala, FL 34471 Florida Ambulance Association Jim Judge 2761 West Old Highway 441 Mount Dora, FL 32757 Florida Aeromedical Association Scott Wyant, RN, BSN, CEN, EMT-P 701 Sixth Street South St. Petersburg, FL 33701-4891 Florida Association of County EMS (FACEMS) Michael Patterson Putnam County EMS 410 South State Road 19 Palatka, FL 32177 Florida Basic Trauma Life Support Joe Nelson, DO, MS, FACEP 2872 65th Street, North Saint Petersburg, FL 33710-3255 Florida College of Emergency Physicians Beth Brunner, Executive Director 3717 South Conway Road Orlando, FL 32812 Florida Pilots Association Mark Womack ShandsCair at the University of Florida Department of Health Air Methods Corporation 25145 NW 140th Lane High Springs, FL 32643 Florida Association of EMS Medical Directors George Ralls, M.D. 6131 Linneal Beach Drive Apopka, FL 32703 Emergency Medical Dispatch Jim Lanier ECC Division Manager Manatee County (941) 749-3557 - Office (352) 209-4206 (cell)
Florida Association of Professional EMTs & Paramedics (FAPEP) Todd Soard, President 7220 NW 39TH Manor Coral Springs, FL 33065 Florida Chapter of The America College of Surgeons - Committee on Trauma Patricia Byers, MD, Chairperson P.O. Box 016960 (R310) Miami, FL 33131 Florida College of Emergency Physicians Government Affairs Committee Beth Brunner, MBA, CAE 3717 South Conway Road Orlando, FL 32812 Florida Neonatal & Pediatric Transport Network Association Louise Bowen, NNP-BC, CMTE-BC, CNA, MSN Transport Director All Children’s Hospital Transport Team 801 6th Street South St. Petersburg, FL 33701 Florida Council On Rural EMS (COREMS) Cliff Chapman, Asst. Chief Alachua County Fire / Rescue P.O. Box 548 Gainesville, FL 32602 Florida Professional Firefighters Gary Rainey, Chairman, Vice President 20271 NW 10 Street Pembroke Pines, FL 33029-3429 Florida Fire Chiefs Association - EMS William R. Colburn Fire Chief Reedy Creek Emergency Services P.O. Box 10170 Lake Buena Vista, FL 32830-0170 EMS Quality Managers Association Arthur Garcia Post Office Box 398 Fort Myers, FL 33902-0398 Florida Chapter of Air & Surface Transport Nurses Association Karen Chamberlain, RN 1535 S. Perimeter Road Ft. Lauderdale, FL 33309 Florida Association of Rural EMS Providers Michael Patterson Putnam County EMS 120 Orie Griffin Blvd. Palatka, FL 32177 United States Lifesaving Association Joe McManus Post Office Box 1259 Fellsmere, FL 32948-1259
EMpulse • May-Jun 2010 27
CLINICALcase
The Fertile Female with Abdominal Pain CPC Chair: Frederick Epstein, MD, FACEP Discussant: Brittany Thomas, MD Florida Hospital, Orlando
A 35 year-old G 6 P 4024 white female
revealed a leukocytosis with bandemia,
aneurysm. Risk factors include multipar-
presented to Florida Hospital complaining
and a hemoglobin/hematocrit of 5.4/16.3.
ity (as in this case), infection, atheroscle-
of sudden dizziness, nausea, and abdomi-
rosis, and portal hypertension. Symptoms
nal pain. Six days prior, she had under-
Four units of PRBCs were ordered. Tropo-
can include epigastric or LUQ pain,
gone a cesarean section, which was
nin, lactate, and coagulation levels were
nausea/vomiting, dyspnea, and hypovole-
complicated by postpartum endometritis.
normal. The CXR was unremarkable, and
mic
the EKG showed sinus tachycardia. With a
diagnoses are uterine rupture, uterine
She was treated with Gentamycin and
heightened suspicion for a surgical abdo-
artery bleed, and septic shock from
Cleocin before hospital discharge. The
men, the patient's OBGYN was contacted.
endometritis. With regard to an unrup-
rest of her past medical history and past
He recommended a CT of the Abdomen
tured
surgical history were unremarkable. She
and Pelvis, but the emergency physician
Abdomen/Pelvis is the best diagnostic test
took oxycodone-acetominophen for pain
recommended
in the ED.
and smoked a pack of cigarettes a day.
exploration.
immediate
surgical
shock.
Important
aneurysm,
a
differential
CT
of
the
A CXR may reveal a calcified ring to the On physical exam, she was tachycardic
While waiting for the CT scan, the patient
left of L1, but plain films are not the first
(124), tachypneic (24), and hypotensive
rapidly deteriorated and was rushed to the
line test. Digital subtraction angiography
(110/48). The temperature and oxygen
OR. Surgery revealed a ruptured splenic
is the gold standard for non-emergency
saturation were normal. She appeared
artery aneurysm. The bleeding was
physicians.
very anxious, diaphoretic, and in moderate
controlled by clipping the artery both
distress. She had pale conjunctiva and oral
proximally and distally. She recovered
If the aneurysm is asymptomatic and less
mucosa, left basilar crackles, and 3 plus
well and was discharged on postoperative
than 2 cm, it can be observed; however, if
pitting edema in the lower extremities.
day #2.
more than 2 cm, elective surgery is recom-
The abdomen was distended and diffusely tender with hypoactive bowel sounds. The
mended to prevent rupture. Surgery
Discussion
options include percutaneous emboliza-
rest of the exam was nonspecific.
tion or laparoscopic ligation or resection. A splenic artery aneurysm is the most
If the aneurysm is ruptured, then a
CMP revealed hypokalemia, hypocalce-
common visceral artery aneurysm and
laparotomy with ligation or clipping
mia,
third
would be appropriate.
and
hypoalbuminemia.
28 EMpulse â&#x20AC;˘ May-Jun 2010
CBC
most
common
intra-abdominal
POISONcontrol
The Role of the Florida Poison Information Center Network in H1N1 Surveillance Alexander Garrard, Pharm D Adrienne Perotti, Pharm D
Florida/USVI Poison Information Center
The Florida Poison Information Center Network was recently asked by the Florida Department of Health (FL-DOH) to assist with a hotline for the 2009 H1N1 flu vaccine. Below is a summary of an interview with Dr. Schauben, the Director of the Florida/USVI Poison Information Center - Jacksonville, who was instrumental in getting the hotline off the ground. The Poison Centers in Florida have expanded their role in the DOH by providing more than just triage and consultation in poisoning emergencies. After the terrorist attacks on September 11th, 2001, the role of poison centers in Florida took on a new face. The FL-DOH was looking into novel ways to gather public health information in a fast, “real time” manner and noticed that the poison centers could accomplish this. During hurricane season, the poison centers are able to track carbon monoxide exposures due to generator use immediately after the storms passed. They can also track food-borne and water contamination illnesses and use that information to shut down restaurants, investigate various food products, or recommend alternate water sources within a very short period of time. The FL-DOH has just realized that the poison center is able to gather information using the pediatric, accidental cough/cold exposures concordance with general illness in counties where their traditional data streams (i.e., OTC sales, county health department
reports, etc) non-existent.
are
very
weak
or
Since the Florida poison centers were already receiving funds to provide disaster and medical surge support for the State, and were already functioning on some level for surveillance, the FL-DOH posed the question, “Can you provide information to healthcare practitioners who are calling into the Florida Flu Hotline?” The FL-DOH preferred that healthcare professionals be able to speak with other healthcare professionals in the poison centers rather than provide such services themselves. The poison centers were unique in this role given the diverse selection of healthcare professionals who work at the poison centers, their infrastructure and their daily operational mandate which includes this type of practice. They initially requested a separate information line specific for healthcare professionals to be answered “Florida Flu Hotline” using a script approved by FL-DOH. H1N1 response staff (nonSpecialists in Poison Information) would answer questions which appeared on the FL-DOH script. Questions not on the script were triaged to the on-call toxicologist to answer. When the statewide flu hotline was dialed, the selection of the “health care professional” option automatically forwarded the call to the appropriate poison center within the State
using geographic routing. These calls were programmed to come in on different lines than used for normal poison center operations, so they were easily separated and sent to the H1N1 response staff preferentially. Subsequent to the implementation of the health care professional response effort, the FL-DOH has expanded their request to include the handling of lay public calls where vaccination has produced an adverse reaction. The DOH recognized that this was in direct concordance with the normal poison center operational charter within the State. This option when selected from the statewide Flu Hotline would automatically and geographically direct the call to the appropriate poison center, but this time the calls arrived on the normal poison center operational line and were handled directly by the Specialists in Poison Information. The Poison Center cooperative effort with the FL Flu Hotline allows us to act as both an informational resource and a patient care resource and surveillance system. The center’s involvement in the Florida Flu Hotline has proven its ability to mobilize and rapidly deploy large public health operations in a short period of time. This ability allows the poison centers to be used in a variety of different ways in the future whether it is for food-borne illnesses, drug/food recalls, environmental hazards or bioterrorism events.
EMpulse • May-Jun 2010 29
RESIDENCYmatters
Orlando Regional Medical Center Rebecca Blue, MD
Florida Hospital Brittany Thomas, MD
University of South Florida Jason W. Wilson, MD
Greetings from Orlando! The ED is undergoing many changes this spring. We can’t wait to welcome our new interns – it’s going to be a fantastic class. It's hard to believe that this academic year is nearly finished. While it's hard to watch our seniors prepare to leave ORMC, we are excited to see the new interns arrive. Thank you again for making this interview season one of our most successful matches ever!
Hope everyone has enjoyed their spring! As we approach the summer, we are excited about our six incoming interns who have recently graduated from USF, Tufts, Florida State, Ross, Virginia Commonwealth, and SUNY Downstate. We know that they will be a wonderful asset to our program.
Thanks to the efforts of FCEP, our Program Director and our Department Chair, the USF EM Residency Program was able to take 10 residents to Tallahassee for an education in organized medicine and a chance to advocate for EPs across the state.
Another welcome goes out to our newest faculty member, and one that we are all ecstatic to see return! Dr. Sara Baker, chief resident, class of 2009, returns to ORMC this summer. Since her graduation, Dr. Baker has pursued a Critical Care fellowship and she returns to direct our simulation program. We are lucky to have her – welcome back Dr. Baker!! Dr. Linda Papa, attending, has gotten her NIH study underway! She is studying treatment protocols and early indicators of long-term prognosis in traumatic brain injuries. We wish her luck! Finally, our chief residents for 2010-2011 are three amazing physicians and fantastic leaders. Congratulations to Drs. Chip Clay, Christopher Hunter, and Jeremy Williams! As always, it's a busy time in the ORMC Emergency Department - as the weather warms up, we are all looking forward to changes to come. From all of us in Orlando, take care and enjoy the spring!
30 EMpulse • May-Jun 2010
During the spring months, several of our faculty attended the 2010 CORD Academic Assembly for Emergency Residency Directors and learned key points about improving residency programs. With a new class and the new knowledge from this conference, our program is sure to reach new heights. Also our attending Dr. Katia Lugo has worked tirelessly with the University of Miami on two research grants for the SBIRT Study and the NIDA CTN Study. Each focuses on the follow up and treatment of patients with drug and alcohol abuse problems who are seen in different U.S. emergency departments. Both will be a great opportunity for Florida Hospital East and its residency. Finally, congratulations to our new and first-ever chiefs, Dr. Alexander Garcia and Dr. Javier Gonzalez. Their leadership in academics and administration will be greatly appreciated, especially now that we have three classes. Good luck to all in the upcoming year, and have a happy summer!
The Capitol was buzzing with activity during the spring session and many of the representatives were happy to meet with us during the officially recognized EM Days which took place 3/9 - 3/10. First, we received an excellent summary of the legislation important to EM. This was followed by a session on effective communication skills presented by a professional consulting group. Finally, we were scheduled to meet with reps in the House and Senate to make a personal case for important bills including the Sovereign Immunity Bill that, unfortunately, did not pass this year but did make it through at least one important committee before dying in another. While we did not meet all of our legislative goals during EM Days, we did make a difference and put a face to our profession. More importantly, FCEP helped to ensure another generation of engaged EPs by fueling a spark in myself and nine other young docs. EM will continue to be one of the most active and involved specialty in the House of Medicine!
RESIDENCYmatters
Univ. of Florida, Jacksonville Oscar D. Espetia, MD
Mount Sinai Medical Center Marshal A. Frank, DO
First of all, congrats to all programs across the state on the recent match! For all the graduating seniors: you will be missed. We have a new batch of motivated young residents that have some big shoes to fill in. Here is a little update for the rest of Florida on some the activities at UF/Shands Jacksonville.
Match day has come and gone! We are all excited to see the list of the new interns we will be welcoming to our family and we are reminded that we are about to complete yet another year of emergency medicine training.
Dr. Zeretzke was selected by the AAP Section on Emergency Medicine Executive Committee to receive a scholarship to attend the AAP Advocacy Institute in Schaumburg, IL March 10-12. Drs. Zeretzke, McIntosh and Wylie’s abstract, “Impact of an Immunization Registry on FWS in Children Aged 6-24 months who present to the Pediatric Emergency Department” has been selected for poster presentation at the SAEM Annual Meeting in Phoenix, AZ June 3-6. Dr. Ricke and Hendry’s abstract “Incidence and recognition of elevated triage blood pressure in the pediatric emergency department” has also been selected for poster presentation at the SAEM Annual meeting. We are looking forward to our new chief residents for next year. This was a very difficult decision because there were so many well qualified and interesting seniors. But in the end, our chief residents will be Drs. Michael McCann, Adrian Elliot, Andrew Vihlen, and Ashley Fox. Congratulations chiefs!
The Annual Meeting of the Florida College of Emergency Physicians July 29 - August 1, 2010 The Boca Raton Resort & Club Boca Raton, FL
REGISTER ONLINE www.emrlc.org
Speaking of welcoming new members to families, I must acknowledge two new additions. Mezeda Meze gave birth to a beautiful baby boy. Incidentally, much to her distaste, she went into labor while on an overnight shift in the ED at Jackson Memorial Hospital. She delivered in the OB ward and everyone is happy and healthy. Congratulations Mezeda! Selfishly, I have to announce that I too have a new addition to my family. I rescued a kitten from the streets of Miami Beach. His name is Mojo and he is 7 pounds (picture included). Mostly everything else is status quo here in Miami. This, in my opinion, is a good thing. Everybody is working very hard and doing a fantastic job. We are looking forward to a strong finish of a great year.
EMpulse • May-Jun 2010 31
ADVOCACYnow!
PAEC
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.
To find out more about contributing to PAEC, or to join our 2010 contributors, contact Beth Brunner at: bbrunner@fcep.org.
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.
2010 Platinum Members: Florida Emergency Physicians, Inc.
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.
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 FL Emergency Physicians, PA 2009 Other Members: Tampa Bay Emergency Physicians, PL.
EPF
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 legislative 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: fcep.org/flacpac.htm. Thank you to all who have donated since the 2009 Symposium by the Sea! 32 EMpulse • May-Jun 2010
Miguel 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 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 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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FCEP|
Florida College of Emergency Physicians
3717 South Conway Road, Orlando, FL 32812
NONPROFIT ORGANIZATION US POSTAGE PAID PERMIT NO. 2361 ORLANDO, FL