Official Publication of the Florida College of Emergency Physicians A Chapter of the American College of Emergency Physicians
Beyond
the Pandemic THE NEXT CHAPTER IN FCEP’S 50-YEAR HISTORY
INSIDE: » Busting Myths about the Coronavirus Vaccines » Every Healer has a Story to Tell » The Law Isn’t Working (it’s Time to Protect the Caregiver)
Plus: Meet the Corporate Partners of Emergency Medicine
Vol. 27, No. 4 | Winter 2021
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EMpulse Winter 2021
TABLE OF CONTENTS COMMITTEE REPORTS
6 FCEP President’s Message By Dr. Kristin McCabe-Kline
12 Medical Economics Committee By Dr. Danyelle Redden
7 Executive Director’s Message: Every Healer has a Story to Tell By Jonathan Dolan
15 Government Affairs Committee By Dr. Blake Buchanan
8 ACEP President-Elect’s Message By Dr. Gillian Schmitz 9 Pediatric EM Committee By Dr. Todd Wylie 10 EMS/Trauma Committee By Drs. Desmond Fitzpatrick & Jason Jones
Volume 27, Issue 4
26 EMRAF President’s Message By Dr. Elizabeth Calhoun
EMpulse Magazine is the official, quarterly publication of the Florida College of Emergency Physicians (FCEP).
36 Medical Student Council By Dan Schaefer
12 Join Us at EM Reimbursement & Innovation Summit By Dr. Steven Kailes
40 Finding Joy in Work: A Story of Resilience and Wellness By Dr. Cristina Zeretzke-Bien
13 The Law Isn’t Working By FCEP
36 Until the Monitor Alarms: Pain, Death and COVID-19 By Drs. Jonathan Yaghoubian & Veronica Tucci
12 Corporate Partners of Emergency Medicine By Melissa Keahey & Samantha League 14 Is it an Emergency? Or is it Hospice? By Dr. Eric Shaban, VITAS®
EDITOR-IN- Karen Estrine, DO, FACEP, FAAEM CHIEF karenestrine@hotmail.com MANAGING Samantha League, MA & DESIGN sleague@emlrc.org EDITOR
FEATURES & COLUMNS
16 The Synergy of Revenue Cycle Management and Practice Management By Shanna Howe, Gottlieb
WINTER 2021
17 Membership & PD Committee By Dr. Rene Mack
38 Detecting the Undetectable: Putting a Lid on Carbon Monoxide By Drs. Chiemela Ubani and Anthony DeGelorm 39 Fun & Games: Using Gamification to Engagge Multi-generational Learners in Medical Education By Drs. Carmen Martinez & Caroline Molins
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EMpulse Spring 2021 Note: EMpulse Spring 2021 will be digital only. Members will receive an email when it is published online at fcep.org/empulse.
Deadlines: • March 15: “Intent to Submit” form due » • April 6: Articles and ads due • End of April: Spring 2021 in inboxes
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EMpulse Online:
20 Musings: Busting Myths About the New Coronavirus Vaccines By Dr. Wayne Barry ON THE COVER: Photos of FCEP members receiving their COVID-19 vaccines in December 2020, featuring Marjorie Dorsainvil, LPN giving Dr. Rajiv Bahl his first dose. Read more on page 20 »
Did you know? Every article published in EMpulse is also published online at fcep.org/empulse. Articles can be published at any time; April 6 is simply the last day to submit your article for inclusion in the print version.
EMpulse Online Homepage fcep.org/empulse
It’s FCEP’s 50th Anniversary Read about how we’re celebrating you and the specialty of emergency medicine on page 5. Nominate an individual for our 50 Years 50 Voices Campaign »
All advertisements in EMpulse are printed as received from advertisers. The Florida College of Emergency Physicians does not endorse any products or services unless otherwise stated. FCEP receives and distributes employment opportunities but does not review, recommend or endorse any individuals, groups or hospitals that respond to these advertisements. Opinions stated within articles are solely those of the writers and do not necessarily reflect those of the EMpulse staff, the Florida College of Emergency Physicians and our advertisers/sponsors.
fcep.org/50years
EMpulse Winter 2021
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EMpulse Winter 2021
TABLE OF CONTENTS CONTINUED RESIDENCY PROGRAM UPDATES 27 Florida Atlantic University By Dr. Tony Bruno
33 Mount Sinai Medical Center Dr. Stephanie Fernandez UF Health Jacksonville Dr. Ryan Courtney
28 St. Lucie Medical Center Dr. Shelby Guile
Oak Hill Hospital Dr. Ryan Johnson
Jackson Memorial Hospital EM Program Staff 29 Brandon Regional Hospital Dr. Rashmi Jadhav
34 Kendall Regional Medical Center Drs. Tina Drake, Ibrahim Hasan & Sara Zagroba
Aventura Hospital Dr. Scarlet Benson
USF Health Dr. Mikhail Marchenko
30 UF Health Gainesville Dr. Megan Rivera
35 UCF/HCA Ocala Drs. Jean Laubinger, Emily Clark & Caroline Smith
North Florida Regional Dr. Jayden Miller
Orlando Health Drs. Gregory Black & Brody Hinst
32 Orange Park Medical Center Dr. Cody Russell
FSU at Sarasota Memorial Dr. Courtney Kirkland
AdventHealth East Orlando Dr. Tyler Mills
Florida College of Emergency Physicians Board of Directors: PRESIDENT Kristin McCabe-Kline, MD, FACEP,
FAAEM, ACHE
PRESIDENT- Sanjay Pattani, MD, MHSA, FACEP ELECT VICE Damian Caraballo, MD, FACEP PRESIDENT SECRETARY- Aaron Wohl, MD, FACEP TREASURER IMMEDIATE J. Adrian Tyndall, MD, MPH, FACEP PASTPRESIDENT MEMBERS Rajiv Bahl, MD, MBA, MS; Daniel Brennan, MD, FACEP; Elizabeth
Calhoun, MD (EMRAF Representative); Jordan Celeste, MD, FACEP; Vidor Friedman, MD, FACEP* (ACEP Rep); Jesse Glueck, MD; Shayne Gue, MD; Erich Heine, DO; Saundra Jackson, MD, FACEP; William Jaquis, MD, MSHQS, FACEP (ACEP Rep); Shiva Kalidindi, MD, MPH, MS(Ed.); Amy Kelley, MD, FACEP; Gary Lai, DO, FACOEP; Dakota Lane, MD, FACEP; Russell Radtke, MD; Danyelle Redden, MD, MPH, FACEP; Todd Slesinger, MD, FACEP, FCCM, FCCP
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26 Collective Medical
4 Envision
31 EMPros
11 DuvaSawko
37 VITAS® Healthcare
14 Orlando Health
42 Air Methods
16 Gottlieb
Florida Emergency Medicine Foundation Board of Directors: PRESIDENT Ernest Page, MD, FACEP VICE Roxanne Sams, MS, ARNP-BC, MA PRESIDENT SECRETARY- Maureen France TREASURER MEMBERS Dick Batchelor; Arthur Diskin,
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EMpulse Winter 2021
MD, FACEP*; Jay Falk, MD, MCCM, FACEP*; Cliff Findeiss, MD*; James V. Hillman, MD, FACEP*; Michael Lozano, Jr., MD, FACEP*; Cory Richter, BA, NREMT-P; David Seaberg, MD, FACEP* *FCEP Past-President
The Florida College of Emergency Physicians (FCEP) and Florida Emergency Medicine Foundation (FEMF) are nonprofit organizations dedicated to advancing emergency care through education and advocacy. Both are headquartered at the Emergency Medicine Learning & Resource Center (EMLRC) at 3717 S. Conway Rd., Orlando, FL 32812. 5
FCEP REPORT
FCEP President’s Message By Kristin McCabe-Kline, MD, FACEP, FAAEM, ACHE FCEP President ’19-21
As I sit down to write this message, the first thing I am faced with is a blank page. Sometimes, the blank page is intimidating. Not now. Not today. At this point in time, I am eager to embrace a fresh start with a new outlook, born out of lessons learned and insight gained. 2020 has been an unprecedented year in emergency medicine for the entire world, across the country, and throughout Florida. There have been some major disappointments professionally and personally for many of our colleagues, who have not been treated well by their employers. There have been amazing stories of our resilience and selfless service to our patients as well as each other. There have been tragic stories of colleagues and team members who have become ill with COVID-19 themselves, and some of whom have passed away. The adversity we have faced has brought out the best and the worst of our systems and teams at a remarkably accelerated pace. Emergency physicians are ready for
“
We have risen to the occasion, but it is now time to stop surviving and start thriving.
a new chapter. Our paradigms have shifted; the manner and settings in which we practice have changed; the circumstances we work in have morphed into a new normal. We have risen to the occasion, but it is now time to stop surviving and start thriving. It is time to take the mindfulness we were forced to rapidly develop and channel it into being truly present in our relationships and actions, fostering authenticity and peace. It is time to re-engage and remain true to the leaders and teams that have stood by you and advocated for you, including the Florida College of Emergency Physicians. It is time to discard the negative mindsets, habits, and relationships that do not bring love, trust, and positivity to your personal and professional life. It is time to collectively realize our
worth as emergency physicians, and actualize our potential as healthcare leaders that can educate and influence policymakers, educators, colleagues, and patients. I am optimistic about our strength that has grown out of the adversity we have faced over the last year. We have an opportunity to use our experiences during 2020 to be refined into our best selves individually and speak with a stronger, more unified voice as a specialty. I am invigorated by the passion for emergency services, the robust experience, and the overall expertise that Jon Dolan is bringing to the Florida College of Emergency Physicians as our new Executive Director. I look forward to 2021 being the year that we emerge stronger than ever before with a deeper sense of purpose and greater understanding of who we are as people and emergency physicians. ■ “Yesterday is gone, tomorrow is yet to come. We have only today, let us begin.” - Mother Teresa
License renewal deadline extended to March 31, 2021
SAFE PRESCRIBING OF CONTROLLED SUBSTANCES By Drs. Aaron Wohl, Josef Thundiyil and Jay Falk Approved for AMA PRA Category 1 CreditsTM emlrc.org/project/opioid-prescribing
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EMpulse Winter 2021
FCEP REPORT
Executive Director’s Message By Jonathan Dolan, MA
CEO & Executive Director of the Florida College of Emergency Physicians
Healers Have a Story to Tell Having recently joined FCEP, this is my first submission to EMpulse. I hope it does justice to the thoughtful and inspiring sentiments from our FCEP President and ACEP President-elect, which appear before and after my message, respectively. They speak of a new chapter in our profession — one that we can shape as we re-engage with one another, using our experiences and newfound sense of purpose gained from the pandemic as a catalyst for transformation. I will focus my message on letting it be known that healers have a story to tell. It is one informed by the trials, tribulations and lessons gained from the 50 years of your specialty, and through the impactful and lifesaving care rendered during this global pandemic. My 15-year career as a long-term care trade association executive in two states culminated in 2020. The early impact of the pandemic in New Jersey was significant and tragic, and Missouri is feeling it now as well. I never thought my sector and states would be so impacted. Nor did I expect my military and government affairs experience would help me assist members and the state in mortuary services, PPE acquisition and distribution, and operational plans for emergency staffing by the National Guard. I never thought highest reimbursement gains and testing dollars would be achieved, only to leave us with enormous challenges such as the unstoppable spread of a deadly virus and sector impacts that will be felt for years to come. Yet, I found a sense of purpose and passion for healthcare and association service that was unmatched previously. As I learned about the specialty of emergency medicine, I realized every-
thing I was doing paled in comparison to what healers like you were doing, and are still up against, on the front lines. You see it all and work 24/7 to make sure patients get the care they need most, despite having tragically lost colleagues during this fight against COVID-19. It is inspiring. When the number of cases and transmissions subsided for a time and help arrived in my state, I knew it was time for me to join you and serve your awesome group of physician leaders. I have immersed myself in the assessment of the systems, operation, plans and programs which, when combined with our leadership, will deliver member and industry value in 2021 and beyond. One way this can be achieved is by telling your stories through our 50 Years 50 Voices campaign, which will consist of personal interviews with those who were there at the beginning of our specialty, those who have proved vital to our success since, and the newest leaders serving today. Through digital media and a culminating program during Symposium by the Sea 2021, we will learn from our history and tell our story — the real story of emergency medicine in Florida. In a world of digital media and information overload, sometimes the most useful and accurate information is buried under the noise of others who simply have the resources to tell a better story. Our mission is to ensure we balance the playing field and bring the most credible and meaningful information to all stakeholders. FCEP leadership and staff are here to be the focal point, strategic planners and coordinators to execute for you. From Tallahassee to Washington, from main street to Miami Beach, you have a story EMpulse Winter 2021
to tell, and you deserve more from the government, healthcare systems and insurers. From workforce and training issues to reimbursement and policy solutions, we are here to help elevate your specialty, assist you in telling your story, and provide solutions to stakeholders that best serve you and your patients. May the pandemic end, our experiences empower us, and may you find some peace through a 50th celebration year that reflects a better and brighter future for healers and patients. ■
ABOUT: Jonathan Dolan joined FCEP & EMLRC on November 1, 2020 as CEO and Executive Director. He has served as chief executive for two healthcare trade associations over the past 15 years, most recently as President & CEO of the Health Care Association of New Jersey and previously as Executive Director of the Missouri Health Care Association. Prior to this, he served nine years as a state legislator in Missouri, first as a State Representative and then as a State Senator. Dolan has an MA in Security Management from Webster University and a BA from the University of Missouri at Columbia. He is a former Army Major, having served as a Military Police and Public Affairs Officer in the Army National Guard, serving during Operation Enduring Freedom. He began his career as a Special Agent in the Office of Security at the Central Intelligence Agency. Mr. Dolan brings a wealth of knowledge and extensive skillset in healthcare association management, government affairs, reimbursement, managed care and emergency planning to the College and its foundation. 7
ACEP REPORT
ACEP President-Elect’s Message By Gillian R. Schmitz, MD, FACEP ACEP President-Elect ’20-21
Fear. Anxiety. Uncertainty. These are emotions that almost everyone felt early in the pandemic. These are sentiments we are very familiar with as emergency physicians. We don’t always know what comes next or what to do in every single situation, but we draw upon our training: we jump in, we look for answers, and we find solutions. Unpredictability defines us as a specialty. In the words of Dr. Martin Luther King, “the ultimate measure of a man is not where he stands in moments of comfort or convenience, but where he stands in times of challenge and controversy.” We are facing unprecedented challenges: a global pandemic, surprise billing legislation, scope of practice issues, homeschooling our children while simultaneously participating in Zoom meetings (praying you turned off your camera if you forgot to put on pants), and even murder hornets. Just when you thought it couldn’t possibly get any worse, somebody had to throw that into the mix. But in challenging times like these, I think back to how far we have come as a specialty. Fifty years ago, they told us emergency medicine would never exist. They told us we would never be recognized as a
“
We are no longer a room or even a department— we are experts in acute unscheduled care, and a source of inspiration and hope for our country.
specialty. And yet, somehow, we made the impossible possible. We made the invisible visible. We’ve beaten these odds before and this, too, shall pass. The pandemic has changed my perspective. When I think about COVID now, it is no longer fear or uncertainty that comes to mind. I think of three different words: hope, humanity, and purpose. I saw people gathering on their balconies in the evenings across the globe to clap for healthcare workers. They were clapping for us. I see my community members sewing masks for complete strangers and people buying groceries for their elderly neighbors. Even in a deeply divided country, we have found common ground that demonstrates the power of kindness, compassion, and humanity. I see a number of opportunities for emergency medicine. The pandemic has been a catalyst in driving transformation for our specialty.
What would have taken decades to accomplish with telemedicine, we have been able to do in weeks. CMS and others are recognizing that we are not a location, we are a specialty. We are no longer a room or even a department—we are experts in acute unscheduled care, and a source of inspiration and hope for our country. I don’t have a crystal ball and I can’t tell you exactly how or when this is going to end, but I can tell you this: emergency physicians will be the driving force that navigates us out of this storm. The skills, credibility, and resilience we have developed as a specialty will serve us well in the legislative battles ahead. We have learned to adapt and overcome. We have transformed our image as healers and heroes. I am incredibly humbled and proud to be an emergency physician. The last nine months have truly been emergency medicine’s finest hour. It is a constant reminder that what we do has purpose. What we do is important and impactful. What we do not only saves lives; it transforms our entire healthcare system. I ask you to stand with me to fight for our patients and our specialty. Thank you for your commitment, your leadership, and your service to our College. ■
Daunting Diagnosis: Q By Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief
A 64 year-old male, who is a heavy smoker, presents to the ED with acute mouth pain. He states that he has been under tremendous stress and has not been caring for himself lately. The patient complains that his gums are tender and have been bleeding. His dental exam is below. What does this patient have?
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COMMITTEE REPORT
Pediatric EM Committee By Dr. Todd Wylie, MD, FACEP Committee Co-Chair
The COVID-19 pandemic has affected the population in all aspects of life, including healthcare utilization. Despite the morbidity associated with the ongoing pandemic, many reports have described a reduction in emergency department (ED) utilization. This reduction is perhaps most notable in the pediatric population. Anecdotally, multiple physicians and medical directors in Florida have reported declines in pediatric patient visits to EDs. The decline appears to be true for general EDs and pediatric EDs, with some pediatric EDs experiencing decreases in patient volume greater than 50% compared to the same period last year. This trend was particularly notable early in the pandemic, following the statewide stay-at-home order and during the mid and late summer, when the number of COVID-19 cases increased dramatically. As 2020 cames to a close, many EDs were still experiencing significantly reduced pediatric volumes in comparison to previous years. The decline in pediatric visits is not unique to Florida and has been documented in several studies. A single center study from Cincinnati, OH comparing pediatric ED visits from March 16 - April 30, 2020 to the same period in 2018-2019 found a significant reduction in daily volume.1 At a large tertiary children’s hospital, Chaiyachati et al. identified a significant decrease in the mean number of daily visits in 2020 compared to 2017-2019, as well as an increased proportion of high acuity patients (ESI 1, 2, 3). Though common chief complaints were similar to previous years, a significant increase in trauma was identified.2 International studies also document similar declines. A large Canadian study
evaluating ED visits for children 0-16 years of age in 18 hospitals, including a tertiary care children’s hospital, found an overall decline of 66.7% in visits during the peak of the COVID-19 pandemic relative to the same time period in 2019. The decline was most notable in general EDs (70%), but it was also significant at the children’s hospital (57%). The proportion of admissions during the study period increased, though the total number of admissions relative to the previous year decreased.3 In Germany, a single center study evaluating pediatric emergency healthcare utilization during March and April 2020 noted a 63.8% decline in visits compared to the same period in 2019. Similar to the Canadian study, the proportion of admissions increased in the German study,4 but all studies noted declines during peak pandemic times and in association with local public health measures to mitigate spread of COVID-19. Why have pediatric emergency visits declined so significantly? The answer is likely multifactorial. Physical distancing, school closures and other measures aimed at reducing the spread of COVID-19 may have reduced the spread of other communicable illnesses. Parent/caretaker reluctance to visit EDs for lower acuity conditions may have also contributed. Finally, healthcare utilization may have shifted to alternative resources, particularly for lower acuity concerns, such as telemedicine. Considering the ongoing decrease in pediatric visits to EDs, how can pediatric ED resources be efficiently utilized during the COVID-19 pandemic? Fraymovich et al. addressed that question recently in “A Blueprint for Pediatric Emergency Resource Reallocation During the COVID-19 Pandemic”
EMpulse Winter 2021
(Pediatric Emergency Care).5 Some of their findings and recommendations, in brief, consisted of: 1. Physical space: Reallocate a portion of the pediatric ED’s physical space for adult patient use. The remaining pediatric ED area can be reconfigured for pediatric patients while maintaining a designated area for pediatric resuscitations and an infant/newborn warmer. 2. Clinical services: Increase the maximum age of patients seen in the pediatric ED and by PEM providers (keep directing adult patients that are intoxicated, incarcerated, critically ill, or in respiratory failure to the adult ED). Additionally, pediatric admissions can be transferred to a local children’s hospital to preserve inpatient beds. 3. Staff reallocation: Decrease physician provider staffing to meet the projected need, and reassign pediatric ED nurses to other parts of the ED to meet demand. The COVID-19 pandemic is far from over. EDs, staff and practitioners have demonstrated tremendous resilience and innovation in response to the pandemic. Despite declines in pediatric patient visits, pediatric ED resources are still a vital resource. Reimagining and reconfiguring pediatric ED resources may help with the COVID-19 impact on adult patients. ■
REFERENCES All references could not fit in print. Please visit fcep.org/ to read this article online with its reference list.
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COMMITTEE REPORT
EMS/Trauma By Desmond Fitzpatrick, MD, FACEP Committee Co-Chair
The EMS/Trauma committee meeting in November focused on COVID vaccinations and NAEMSPs joint position statement on ketamine use, including the phenomenon known as excited delirium. An overview of excited delirium, written by one of our FAEMSMD medical directors who has spent a considerable time developing expertise on this topic, is included in this update.
COVID VACCINATIONS
At the FAEMSMD meeting, State EMS Medical Director Dr. Ken Scheppke discussed the vaccine’s high efficacy rates as being a significant victory in the fight against COVID-19. He wants to ensure that paramedics administering vaccines have a basic education in vaccine delivery, and created a great vaccination overview that was emailed out to members of the EMS community. An estimated 60-70% population immunity is needed to stop the spread of COVID-19. Stay safe out there, and remember that what you do matters!
Ketamine for Excited Delirium By Jason Jones, MD, FACEP Paramedics and EMTs face the possibility of violence and injury on every response to the uncontrolled prehospital setting. One systematic review found that most EMS personnel have suffered violence while on duty, and it estimated that verbal abuse or physical violence occurs during 1-8% of ambulance responses.1 The threat of injury to EMS crews is especially high when caring for patients with a controversial and often violent condition known as excited delirium syndrome (ExDS). ACEP has recognized ExDS as a clinical syndrome since 2009.3 Although ExDS 10
has no universally-accepted definition, a 2017 systematic review identified its most common features as “hyper-aggressive behavior with superhuman strength, a combative attitude toward the police, hyperactivity, bizarre behaviors, unusual pain tolerance and hyperthermia.”2 Though ExDS is a rare condition (2 per 10,000 EMS responses), it carries an exceptional risk of “sudden and unanticipated” death, with mortality estimated between 8-16%.
anism to gain rapid control of violently agitated patients, followed by physical restraints and rapid EMS transport to an emergency department. Ketamine has an excellent safety profile, though published rates of intubation after administration for ExDS vary from 0% to more than 50%. Consequently, personnel should focus intently on ventilatory status and recognize that dissociated patients will, by nature, be minimally responsive with a diminished GCS.
Chillingly, that systematic review also found that no ExDS management approach was free of patient deaths. These included conducted energy weapons, irritant sprays, physical restraints, and common medications for agitation control. The authors concluded that “excited delirium syndrome is a real clinical entity [which] still kills people.”
In 2020, leading EMS organizations, including the National Association of EMS Physicians (NAEMSP), published a position statement supporting the use of ketamine as “an effective method of protecting the violent or combative patient from self-injury” and detailed its use.7 ■
Guidelines generally focus on rapidly resolving agitation, reducing the physical struggle, addressing metabolic acidosis and unchecked catecholamine surge, supporting ventilation, and avoiding hyperthermia.4 Any ideal approach must minimize physical struggle and avoid poor respiratory mechanics, such as prone positioning, as both are felt to contribute substantially to mortality. Ketamine is uniquely suited to achieve rapid control, as it can dissociate patients after a single IM dose. While benzodiazepines and antipsychotics are the traditional therapy for agitated patients,5 these may be impractical when patients are dangerous, violent or suffering from ExDS. In one study, ketamine resolved agitation more quickly than midazolam, lorazepam, haloperidol, or their combination.6 Ketamine is unlikely to resolve the underlying process causing agitation. Rather, it should be viewed as a mechEMpulse Winter 2021
REFERENCES 1. Pourshaikhian M, et al. A Systematic Literature Review: Workplace Violence Against Emergency Medical Services Personnel. Arch Trauma Res. 2016 Jan 23;5(1). 2. Gonin P, et al. Excited Delirium: A Systematic Review. Acad Emerg Med. 2018 May;25(5):552-565. 3. DeBard ML, et al. ACEP Excited Delirium Task Force. White Paper Report on Excited Delirium Syndrome. 2009. 4. Vilke GM, et al. Excited Delirium Syndrome (ExDS): defining based on a review of the literature. J Emerg Med. 2012 Nov;43(5):897-905. 5. Linder LM, et al. Ketamine for the Acute Management of Excited Delirium and Agitation in the Prehospital Setting. Pharmacotherapy. 2018 Jan;38(1):139-151 6. Riddell J, et al. Ketamine as a firstline treatment for severely agitated emergency department patients. Am J Emerg Med. 2017 Jul;35(7):1000-1004. 7. Kupas D, et al. Clinical Care and Restraint of Agitated or Combative Patients by Emergency Medical Services Practitioners. National Association of EMS Physicians (NAEMSP). 2020 Oct. Available at: naemsp.org/NAEMSP/media/ NAEMSP-Documents/ClinicalCare-and-Restraint-of-Agitated-orCombative-Patients.pdf
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COMMITTEE REPORT
Medical Economics By Danyelle Redden, MD, FACEP Committee Co-Chair
State-level issues
FCEP continues to advocate for a solution to regulatory loopholes related to the 2016 balance billing legislation. After successful action by emergency physician groups to collect payment via the state independent dispute resolution process (administered by MAXIMUS), insurers are now choosing to opt out of the process, which exists to settle disputes regarding fair out-of-network reimbursement. You can read more about this in the next article. In the 2021 legislative session, we anticipate legislation addressing personal injury protection (PIP) coverage, which is currently required by the state and helps cover medical bills after auto accidents. PIP (also called “no-fault” insurance) provides critical reimbursement for auto-related trauma care, including payment to emergency physicians. If PIP is repealed, emergency physicians could see a significant reduction in trauma-related reimbursement.
Federal issues
The 2020 Year-end Congressional package addresses Medicare cuts and surprise billing. Emergency physicians initially faced a 6% cut in Medicare reimbursement but, thanks to aggressive advocacy efforts by ACEP, a 2% or less decrease is anticipated (depending on code mix). The federal surprise billing legislation applies to ERISA plans (employer self-funded) and will not apply to state-regulated plans in Florida due to pre-existing state-level balance billing legislation. Key features include a requirement for deductibles for out-of-network emergency care to be the same as for in-network, a requirement for insurers to respond within 30 days of an OON claim with payment or denial, and an independent dispute resolution process that has no minimum dollar threshold and prohibits the consideration of usual and customary charges, billed charges, or Medicare amounts.
FCEP’s Insurance Summit
FCEP’s first-ever Insurance Summit was held virtually on December 9, 2020. Other specialty groups and medical societies were invited to give presentations detailing the obstacles to proper reimbursement by insurers that they are experiencing. This prompted passionate discussion amongst physicians from multiple specialties, including EM, rheumatology and orthopedic surgery. We look forward to working closely with our colleagues throughout the house of medicine to continue to fight bad-faith insurer tactics. ■
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Join Us at EMRIS By Steven Kailes, MD FCEP Past-President
FCEP will be hosting its fifth Emergency Medicine Reimbursement & Innovation Summit on February 25-26, 2021. This year’s virtual meeting will again deliver AMA Category I CreditsTM along with relevant and meaningful discussions on issues affecting all emergency medicine practices. Speakers and subject matter experts from around the country will integrate complex topics, providing information every practice can use to navigate the minefields affecting our care of patients and our revenue streams. The program has been streamlined for two halfdays of online learning. Topics will include a fresh look at the latest coding and billing changes, opportunities to improve provider revenues, and updates on the most current federal balance billing legislation proposals. Attendees will learn how to expand current practices to better meet the needs of patients through care coordination, a success story of telehealth integration, and a review of the community paramedicine and ET3 voluntary payment model. As our patients and payers increasingly demand “quality” and the delivery of care at the right place at the right time for the individual, we’ll hear how practices can successfully negotiate shared savings in alternative care settings. Finally, there will be opportunities to interact and ask questions so you can get the most out of this unique and informative conference. I hope you will attend and bring your colleagues. The concentration of experts and critical content presented will surely help you and your practice. Register now at fcep.org/em-summit.
EMpulse Winter 2021
EM
DAYS
The Law isn’t Working
Florida has protected the patient. Now, it’s time to protect the caregiver. By the Florida College of Emergency Physicians FCEP believes it is extremely important to prevent “surprise bills” from being sent to patients who have been treated in an emergency department. These surprise bills are a result of “balance billing,” or the practice of when a practitioner sends a patient a bill for the remaining balance of the care provided that the health insurer did not pay. In the 2016 Legislative Session, FCEP, in good faith, agreed to legislation that would ban physicians from balance billing an insured patient treated in the emergency department in return for appropriate reimbursement, as defined by statute, from the insurer. The bill “requires insurers to provide coverage for emergency services without a prior authorization determination and regardless of whether the provider is a participating provider.”1 After all, balance billing results from the unwillingness of insurers to adequately pay healthcare providers. Unfortunately, the law is not working as intended. 1) Providers are not being compensated fairly: The patient no longer receives a surprise bill; instead, the healthcare provider is routinely being surprised by health insurers, who are underpaying for the care provided. This care, in many cases, has saved the patient’s life. Several physician groups have taken payment disputes falling under the
surprise billing ban to the Statewide Provider and Health Plan Claim Dispute Resolution Program, referred to hereafter as MAXIMUS, which is housed at AHCA. MAXIMUS has recently ruled in favor of these physician groups. These physician wins utilizing the dispute resolution program has prompted health insurers to “opt out” of the process. They claim a loophole is available because of past case law. Now, physicians have no easy way to challenge underpayments because of the insurer’s claimed ability to simply “opt out” of this venue. The only player winning under the current scenario is the insurer. They are able to pocket premium dollars without passing them on to the physicians providing care. This has never been truer than now, as emergency care providers struggle with the challenges of the COVID-19 pandemic. As frontline providers nationwide risk their lives daily to care for COVID-19 patients, many emergency medicine group practices have been forced to decrease their workforce, coverage and/or benefits. A recent workforce study released by the American College of Emergency Physicians paints a grim picture. Since the pandemic began:
• 21% have had to lay off physicians • 31% have furloughed physicians EMpulse Winter 2021
• 56% have cut pay for the same work
• 83% have experienced a decrease in productivity
• 83% have cut hours of ED coverage • 47% have deferred or cut benefits In 2015, each emergency physician provided an average of $138,000 in uncompensated care. Between being consistently undercompensated by health insurers and the unique challenges of this year, collectively, emergency physicians are expected to miss out on millions of dollars. 2) The cost of insurance and care keeps rising for patients anyway: While the patient has been taken out of the middle of billing disputes, they are now experiencing another problem: insured Floridians are paying their rising premiums and deductibles, but insurers are not honoring their obligations to compensate care providers appropriately. Physicians set charges based on the cost of recruiting and retaining qualified providers, providing for uncompensated and undercompensated care, standby costs for surge capacity, medical malpractice insurance costs, among other factors. National and state databases, such as FAIR Health, show Continue on page 14 ▶ 13
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or practice.”1
aggregate and median charges per zip code for billions of provider charges. Meanwhile, insurers arbitrarily decide how to reimburse out-of-network care, and amounts vary widely.
Emergency physicians treat anyone and everyone. Emergency care is provided for about 10 million patients in Florida every year, and then reimbursement is sought for that care. Many of these emergency patients are uninsured, underinsured by government payers, or uncompensated altogether, which is not a sustainable business model.
Insurers are cutting their costs by paying providers less while raising deductibles on patients, increasing financial burdens on consumers and providers as insurance profits rise every year. When resources are withheld from these providers, the care they are able to provide patients suffers as well. And, as this pandemic has acutely reminded us, anyone could be one of those emergency patients, including you or a loved one. “The bill provides that willfully failing to comply with the balance billing provisions with such frequency as to constitute a general business practice is defined as an unfair method of competition and an unfair or deceptive act
patients and emergency physicians. Florida has protected the patient. Now, it’s time to protect the caregiver. ■
REFERENCES
1. Florida Senate Health Poli-
Emergency care is unique. It is healthcare’s safety net. Without safeguards from the Florida Legislature in place, there is no way for emergency physicians to recoup the cost of care when insurers do not pay correctly. Caregivers should be reimbursed appropriately for the services they provide. Closing the loophole being used by insurers to opt out of the payment dispute program enacted during the 2016 Session is a top priority for 2021 Session. The intent of the law was to protect
cy Committee. “CS/CS/CS/ HB 221 — Health Care Services Bill Summary.” 2016. Access at: www.flsenate.gov/Committees/billsummaries/2016/ html/1387#:~:text=The%20 bill%20prohibits%20an%20 out,services%20or%20covered%20nonemergency%20 services.&text=Insurers%20 or%20health%20care%20providers%20may%20not%20balance%20bill%20the%20insured
2. FCEP. “Surprise Billing.” Pre-
sentation. Health Insurance Summit, December 9, 2020.
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COMMITTEE REPORT
Government Affairs By Blake Buchanan, MD Committee Co-Chair
We saw a lot of new things in 2020, including an election that was performed in a different way. We should all thank our local election officials for pulling this massive undertaking off so successfully. In Florida, not much has changed in Tallahassee as we head into a new legislative session. Republicans hold the majority in both state legislative chambers and in the Governor’s office. By the time you are reading this, committee weeks in Tallahassee will be underway. However, this next session will start a new era of leadership in Tallahassee, with the new Speaker of the House, Chris Sprowls, and a likely new Senate President in Wilton Simpson. We will also likely see a major focus on budgetary changes given the drastic
changes to the Florida economy that have occurred due to the COVID-19 pandemic. In December, FCEP hosted a virtual Insurance Summit with multiple legislators participating. I would like to thank Toni Large and Dr. Steve Kailes for their hard work and representing us so well. They illustrated the problems we have all been seeing with insurers under the balance billing laws in Florida. We hope that this will jumpstart a movement to adjust the current law to make participating in arbitration mandatory, not voluntary. COVID-19 has led to a great deal of changes in Tallahassee, just as it has in
the rest of society. For EM Days 2021, we will be meeting with legislators virtually instead of in-person to advocate for issues important to our members. I encourage everyone to give to FCEP’s political action committees (PACs) so that we can continue being your representatives to our local leaders, during Session and otherwise. I also encourage all of you to join our discussions on DocMatter and let us know your thoughts on important issues related to Government Affairs. Thank you all for your time, and I wish a happy 2021 to everyone. Reach out any time if you have any questions or concerns. ■
PROTECTING ACCESS TO CARE
March 2021 | Virtual Meetings Learn more & register at fcep.org
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The Synergy of Revenue Cycle Management and Practice Management By Shanna Howe, Vice President of Emergency Medicine, Gottlieb
Every Emergency Medicine group practice must deal with many complex business issues, due to many fluid parts and ever-changing details. In addition to optimizing your practice from a Revenue Cycle Management perspective, we often find that there is opportunity for optimization in Practice Management. There is a synergy between Practice Management and Revenue Cycle Management and combining the two can provide a cost effective and more efficient solution for your practice. Consider having your Practice Management and Revenue Cycle Management handled by one company. If your Practice Management and Revenue Cycle Management are handled by separate companies, make sure that the two companies are collaborating for the success of your practice. Practice Management includes things such as, but not limited to: • Accounting • Provider Payroll • Incentive/Compensation Modeling • Full Financial reporting, including forecasting expenses and revenue • Professional Liability Insurance management • Income tax planning • Funding Application assistance (HHS Provider Relief Funds, Payroll Protection Program) Ongoing practice management assistance can make a big difference in achieving superior business performance of your practice! We understand that each group is unique – the structure of your practice, the volume, the communities you serve, your hospital partners, etc., and each group’s needs vary. When you partner with an expert in Revenue Cycle Management and Practice Management, like Gottlieb, we can help you navigate the uncertain, but hopefully bright, future of emergency medicine.
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We focus on optimizing revenue so physicians can focus on what’s important. We’ve Got This.
EMpulse Winter 2021
Gottlieb.com
COMMITTEE REPORT
Membership & Professional Development Committee By René Mack, MD, RDMS, FACEP Committee Co-Chair
Happy New Year, FCEP family! How are you doing? No, really—how are you doing?
Consider your questions, Be a great listener, and follow-up. Peer support is helpful, but guidance from a trained professional is also important. The ACEP Wellness and Assistance Program provides a reliable resource: ACEP members now have access to three, FREE, confidential counseling or wellness coaching sessions via Mines & Associates. Sessions are available 24/7, including holidays. For more details, visit acep.org, COVID-19 Physician Wellness.
This issue is being distributed in January 2021, approximately 10 months into the Covid-19 pandemic. We have developed strategies to care for our communities, and recent vaccine releases represent hope for a safe and healthy future. Unfortunately, several other areas have been highlighted in this pandemic’s saga: burnout, physician suicide, diversity and inclusion, PTSD and compassion fatigue, to name a few. More than 85% of EM attendings and residents report increased stress since March 2020, yet 45% of us do not feel comfortable seeking mental health treatment. The hesitancy to reach out for treatment is multifactorial, and FCEP and ACEP continue to fight on a local and national level to remove these barriers. In the interim, we cannot ignore the need. The ACEP Peer Support Project provides tools for us to help each other. Everyone copes differently, which means there isn’t a perfect formula for how to walk beside your friends and colleagues during hard times. These tips can help you grow from a concerned observer to an active peer supporter: Check on yourself first, Context matters, Learn to detect distress,
National Suicide Prevention Lifeline: 800-273-8255 The New Year also brings several additions to FCEP, including resources focused on a special group: our Early Career Physicians! The PGY3-PGY10 years (and beyond!) are filled with transitions and readjustments, which can be stressful and isolating, especially if you don’t know where to find useful resources. Our Early Career Physicians will receive guidance on contract negotiation, work/life balance, saving for retirement, and much more. We are grateful to Dr. Dakota Lane, who will lead this group. Join us for the first session on January 30, 2021 (details to follow in FCEP’s enews). All are welcome! As the practice of medicine evolves, especially during a pandemic, we value
our connections and converted to virtual meetings, including Virtual Residency Visits. With a virtual platform, we are even more accessible, allowing us to interact with our residency programs and members more easily than before. We can also facilitate joint meetings with ACEP BOD members for broader discussions on the current and future role of EM. There are many changes taking place in EM and medicine as a whole, and we want to offer our resources to keep us all informed. To schedule your FCEP/ACEP visit or meeting, please contact Ms. Donna Vennero, dvennero@emlrc.org. Reminder, many of us will need to renew our Florida Medical License by 01/31/2021. FCEP/EMLRC offers many of the required courses, including Opioid Prescribing and Human Trafficking. EMLRC courses, taught by our knowledgeable FCEP colleagues, report directly to CE Broker so that all your CME is centralized. Another welcome addition to the FCEP family is Mr. Jonathan Dolan, our new Executive Director. Under his leadership and with your direction, FCEP will continue serving our community and advancing the field of emergency medicine. Join us at the upcoming committee meetings on February 16, 2021, to help shape our next steps. As always, take care of yourself, and each other. ■
HUMAN TRAFFICKING & EMERGENCY MEDICINE emlrconline.org
Meets new HB 851 requirement Approved for AMA PRA Category 1 Credits™
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Corporate
Partners
in Emergency Medicine To kick off FCEP’s 50th anniversary year, we asked our most dedicated partners — FCEP/ EMLRC Annual Corporate Sponsors, who donate $10,000 or more each year — why they choose to invest in educating and supporting the emergency medicine industry. Read on to learn not only how these companies can support you and your practice, but why they love to do so. By Samantha League, Director of Communications & Melissa Keahey, Director of Development & Operations
Air Methods EM ADVOCATE Air medical transport is the lifeline that delivers patients to the healthcare facility they need most in emergency situations – particularly in rural America. Every year, Air Methods delivers lifesaving care to more than 70,000 people through its fleet of more than 450 aircraft and prehospital flight crews. “The pandemic has affected all of us at Air Methods on a very visceral and personal level,” says CEO JaeLynn Williams. “It has amplified our core values. Our flight crews – the nurses, paramedics, and pilots – are on the frontlines of this crisis every day. They are putting on full personal protective equipment (PPE) for every single flight. In some places, at the height of summer, the temperature hovered around 120 degrees Fahrenheit. And they did it, because it is the essence of who they are.” Air medical services help strengthen the rural safety net for more than 60 18
million Americans by extending the capabilities of rural hospitals. Now more than ever, it’s imperative that Americans have timely access to care, and that this care is adequately covered by the payer. As a preferred partner for hospitals, Air Methods helps ensure adequate coverage along with safe and timely transport between trauma and specialty centers. Cultivating strong relationships between EMS agencies and hospital systems is something Air Methods and the EMLRC both understand and value. “We support members of (FCEP) because the EMLRC supports the growth and development of EMS within the state,” says Williams. “The EMLRC strives to advocate for the customers we support in our air medical operations. They (also) work to improve overall relationships between prehospital providers and physicians within the medical facilities through (their) education and advocacy.” ■ EMpulse Winter 2021
CLINCON 2017
LEARN MORE: Company size: 5,000+ Located in: HQ in Greenwood Village, CO; provide access to air medical service in 49 states Function: Emergency air medical service Founded: 1980 CEO: JaeLynn Williams Did you know? With over 450 aircrafts, Air Methods has the largest commercial fleet of rotorcraft under one certificate in the U.S., and is basically considered an airline by the FAA. Website: airmethods.com
Gottlieb EM INNOVATOR
Gottlieb is a leader in end-to-end revenue cycle management and practice optimization solutions. Gottlieb has been helping emergency medicine providers navigate the complex landscape of medical billing for over 40 years: they focus on their clients’ revenue, so their clients can focus on caring for patients. FCEP and Gottlieb share a mission of protecting the rights of patients and the profession of emergency medicine. Gottlieb is active in industry trade associations at the state and national level, participating in out-of-network dispute resolution & arbitration processes and fighting bad payor behavior on behalf of their clients and the entire emergency medicine community. “We enjoy working alongside EMLRC/ FCEP,” says CEO Mike Drinkwater. “They offer us an extended community of emergency medicine partners and colleagues who also share our passion for emergency medicine, and they value our expertise in the area of revenue cycle management.” Gottlieb and FCEP’s partnership spans
Symposium by the Sea 2018 over 25 years. Their staff are regularly invited as faculty at EMLRC/FCEP conferences, and Gottlieb sponsors the annual Martin Gottlieb Award, which honors an FCEP member’s advocacy efforts in Florida and is given at Symposium’s annual Board Meeting. “We love attending all FCEP’s events, especially Symposium by the Sea. It is always fun to see familiar faces every year and to meet new friends,” says VP of Emergency Medicine, Shanna Howe. In the same way in which the pandemic has affected emergency medicine group practices, Gottlieb’s business has been impacted by the decrease in patient volume. But Gottlieb remains committed to helping their clients recover some of their COVID-related losses, and each client has a dedicated service representative who communicates with them on a regular basis. “It takes an army, and we believe that working together makes our emergency medicine community stronger,” says Drinkwater. ■
Shanna Howe speaking at EM Reimbursement & Innovation Summit 2018
LEARN MORE: Company size: 450 employees Located in: Jacksonville, FL Function: coding & billing/ revenue cycle management Founded: 1978 CEO: Mike Drinkwater Did you know? Gottlieb is a real person. Mel Gottlieb founded the company, and it was later taken over by his son, Martin Gottlieb. Gottlieb partners with FCEP each year to award one recipient with the Martin Gottlieb Advocacy Award, for their advocacy efforts on behalf of emergency medicine in our home state of Florida.
Life After Residency 2018 EMpulse Winter 2021
Website: gottlieb.com 19
DuvaSawko EM INNOVATOR
Symposium by Founded by emergency physicians over 23 years ago, DuvaSawko delivers high quality business solutions exclusively to EM physician groups. Their solutions, support and unmatched analytics are designed to help EM practices identify missing revenue, increase operational efficiencies and mitigate compliance risk. Their detailed and thorough approach has resulted in DuvaSawko collecting up to 30% more revenue for their clients.
Officer, Nettie McFarland, provides physician training on an as-needed basis to ensure that providers are coding at the highest level of reimbursement possible. The company offers a Coding Academy, where medical coders entering the field can prepare for the credentialing process through extensive and robust training. DuvaSawko also publishes complementary and informative white papers about critical current topics in the healthcare industry.
DuvaSawko takes pride in the unparalleled level of personalized and customized attention the provide to each client. Each client’s dedicated account management team is only a phone call away, at any time of the day.
“Our founders, being emergency medicine physicians themselves, have always supported growth and advancement within the industry, which is at the core of EMLRC/FCEP,” says Reynolds.
“As a DuvaSawko client, you’re never just ‘a number,’” says CEO Jill Reynolds. “We handle each client with the same level of care and acuity, whether your practice sees 1,000 patients a year or 10,000 patients.”
DuvaSawko is dedicated to increasing awareness within the specialty, and actively looks for opportunities to share improvements or enhancements they have encountered with others in the industry. This is why they love FCEP’s annual conference, Symposium by the Sea, and sponsor its biggest event, Casino Night, every year.
DuvaSawko’s coding and billing experts go beyond what they can do for the company’s benefit. Their nationally-renowned Coding & Compliance
“Symposium by the Sea is such a phenomenal opportunity for sharing knowledge and expanding networks,” says Reynolds. “I’d love to see more groups show up and take advantage of this amazing opportunity. It’s therapeutic to look back on times when we were able to gather with friends and colleagues without the threat of a pandemic looming over us.” ■
Symposium by the Sea 2018
Symposium by
LEARN MORE: Company size: 350+ Located in: Ormond Beach, FL Function: Billing, coding, and revenue cycle & practice management services for emergency medicine groups Founded: 1998 CEO: Jill Reynolds
Symposium by the Sea 2018 20
Website: duvasawko.com EMpulse Winter 2021
Emergency Medicine Professionals, PA (EMPros) EM INNOVATOR
y the Sea 2018
Symposium by the Sea 2018
In 1976, before the specialty of emergency medicine was formally recognized by the medical community, West Volusia Emergency Physicians—now known as Emergency Medical Professionals (EMPros)—was founded by five “community physicians” who “filled in for emergencies.” Things were different back then, with 24-hour shifts (and nap times), and one founder, Dr. Owen Hunt, once took care of a horse in the ER. As pioneers of emergency medicine in their own right, it should be no surprise that EMPros is dedicated to preserving and protecting the specialty of emergency medicine. “Emergency medicine is like a family—a small universe of people,” says Dr. Charles “Chuck” Duva. “Whether the individuals you work with are in the ED or the broader industry, we are all united.”
y the Sea 2019
LEARN MORE: Company size: 120 Located in: Daytona Beach, FL Function: EM physician group Founded: 1976 CEO: Charles “Chuck” Duva, MD Website: emprosonline.com
And EMPros works these organizational values of family and unity into everything they do. “The camaraderie that EMpros creates within our group is unique,” says EMpros employee and FCEP President, Dr. Kristin McCabe-Kline. “We do not just hire physicians; we hire their entire families, and they remain part of our purpose and focus along the way.” When the pandemic began, EMPros responded by reducing shift hours so they could keep everyone employed while other companies began firing physicians to reduce labor costs. Instead of a one-size-fits-all approach, each EMPros medical director was empowered to adjust staffing schedEMpulse Winter 2021
ules in accordance with daily patient volumes. Shorter shifts resulted in pay reductions, but no physician was let go, and all families retained access to their benefits. EMPros is also involved in numerous charities and philanthropic efforts, supporting those who stand up for the specialty of emergency medicine. They give annually to EMLRC/FCEP and local hospital foundations, and participate in targeted community efforts, such as connecting opioid use disorder patients with medication-assisted treatment in the ED. Every year, EMPros and DuvaSawko co-host FCEP’s most highly-attended event: Symposium by the Sea’s Casino Night. Casino Night’s annual themes and family-friendly atmosphere always result in great memories. “One of our favorite years was FCEP’s 45th anniversary in Naples with the 70’s theme,” says Maureen France. “Many leaders dressed up in costume—Drs. Seaberg and Kailes wore matching outfits and Goldfish platform boots—and Dr. Findeiss, Dr. Pattani and the entire Kailes family owned the dance floor in a costume contest dance off” (see below). ■
Symposium by the Sea 2017 21
VITAS® Healthcare EM INNOVATOR
Symposium by the Sea 2017 Founded in 1978 in South Florida, VITAS Healthcare is a pioneer and leader in the American hospice movement as Florida’s largest and first-licensed hospice provider. VITAS employs over 11,000 professionals who care for patients with advanced illness in a variety of settings, ranging from patients’ homes, inpatient hospice units, nursing homes, hospitals, and assisted living communities. In Florida, VITAS provides coverage in 80% of Florida counties and cared for a total of 35,094 patients in 2019. VITAS is dedicated to providing care that honors the patient’s goals and wishes to embrace quality of life near the end of life. They are an integral part of the continuum of care, with teams available 24/7 in person and by phone to help identify and transition hospice-eligible patients directly from the ED to the right care at the right time, and in the patient’s preferred setting. “All physicians and healthcare providers, especially those whose patients face the challenges of advanced illness or life-threatening trauma, can bene-
Life After Residency 2018 22
fit from a referral to comfort-focused hospice or palliative care,” says President & CEO Nick Westfall. Hospitals whose patients experience timely hospice care enjoy lower rates of in-hospital morality, length of stay, and readmissions, plus lower overall healthcare costs and higher satisfaction scores. Just as FCEP members are experts in emergency care, VITAS physicians and clinicians are experts in hospice and palliative care. They are eager to serve as sources of updated, evidence-based data and trusted advice for colleagues, providing guidance on goals-of-care conversations and advance care planning decisions, ensuring that the care received matches patients’ wishes and values. “By establishing relationships and partnerships with (emergency physicians), we can support them professionally, serve as a trusted resource, identify new challenges, and work together to deliver evidence-based, patient-centered solutions,” says Westfall. This is why VITAS has been supporting FCEP/EMRC since 2014. They participate in various conferences, such as Life After Residency and Symposium by the Sea, and regularly write educational articles for EMpulse Magazine. “The annual Symposium by the Sea is an opportunity for our team to listen, educate and promote the value and benefits of comfort-focused, end-oflife care,” says Sarah Goldberg, regional director of market development for Central Florida. “The atmosphere is
EMpulse Winter 2021
conducive to the free flow of ideas and discussions that get to the heart of shared healthcare challenges and unique-to-VITAS solutions for patients and emergency medicine physicians.” ■
LEARN MORE: Company size: 11,649 employees in 14 states and D.C. ; 19,000 average daily census Located in: Miami, FL Function: Hospice and palliative care Founded: 1978 CEO: Nick Westfall Did you know?: VITAS was established by Hugh Westbrook, a Methodist minister, and Esther T. Colliflower, a registered nurse. Their first patient was Emmy Philhour, who had decided to forego cancer treatments that were no longer effective. “If you will take care of me so that I will not have to go to the hospital,” she asked of Holbrook and Colliflower, “I will teach you what you need to know about caring for patients.” One month later, Emmy died according to her wishes at home. Website: vitas.com
Envision EM INNOVATOR
Envision Healthcare is a leading, national medical group of physicians and advanced practice providers who care for 32 million patients a year. With 10,000 emergency physicians on the frontlines – and thousands more in anesthesiology, radiology, surgical services and women’s and children’s health – Envision focuses on protecting and empowering their clinicians so they can focus on what matters most: caring for patients. “We firmly believe in supporting physicians so they can focus on caring for patients,” says CEO Jim Rechtin. “By providing physicians with a range of resources and administrative support, we help improve the patient-physician relationship and patient outcomes.” This type of support ranges from leadership coaching and clinical research, to quality reporting and mental health and well-being support. Envision has more than 45 years of experience with emergency medicine and continues to drive improvements in clinical quality and research, care coordination and the patient experience. They understand the critical
Life After Residency 2018 role emergency medicine plays within the healthcare system, and how their teams of talented and dedicated individuals can change the delivery of care through their collective expertise. “As emergency physicians, we are often the first to treat patients. We are there for them and their families during some of their most challenging moments. We also make a meaningful difference in patients’ lives,” says CEO. Envision has worked to improve patient handoffs with radiology teammates at the hospital, relationships with local EMS, and national emergency/disaster trainings for their clinicians, to name a few. They are now actively working to create a more diverse, equitable and
inclusive healthcare environment that reflects the communities they serve. As a medical group committed to empowering physicians and improving the delivery of care, Envision shares a common goal with EMLRC/FCEP and recognizes what we do to support the emergency medicine specialty in Florida through annual support. The Life After Residency Retreat at Sirata Beach in 2019 is a favorite, recent memory. “We value the opportunity to network and collaborate with emergency medicine colleagues throughout Florida,” says CEO. “As we navigate the ever-evolving healthcare system, it’s important that we continue to build camaraderie, collaborate and improve the health of our communities.” ■
LEARN MORE: Company size: 25,000 physicians and advanced practice providers Located in: Nashville, TN Function: National medical group Founded: 1972 CEO: Jim Rechtin
Symposium by the Sea 2019
Website: envision.com
Orlando Health EM ADVOCATE
Orlando Health is a 3,200-bed system in Central Florida that includes 15 hospitals and emergency departments, among various other specialized services. They are on the forefront of patient care in multiple areas, including therapies for end-stage breast cancer and identifying biomarkers to detect traumatic brain injury. Orlando Health’s mission is to improve the health and quality of life of the individuals and communities they serve, and has provided more than $760 million in total value to the local region. Being an EMLRC Corporate Partner gives them an opportunity to support, impact and connect with those who are on the front line – and CLINCON gives them an annual opportunity to engage with the local EMS community.
“As Central Florida’s only Level One Trauma Center, Orlando Health’s Orlando Regional Medical Center has a responsibility to our local communities, which includes being an engaged partner with the EMS teams in our area,” says Dr. Christopher Hunter, Chief Quality Officer. “Working together, not just as we transition patients into our ERs from their initial care, but before that – through planning, training and drills – ensures we (will) ultimately provide the very best care and outcomes to the patients we both serve.” Every year, Orlando Health sponsors scholarships for local EMS to attend CLINCON. Stay tuned for announcements regarding these scholarships. ■
CLINCON 2017
LEARN MORE: Company size: 22,000+ team members Located in: Orlando, FL Function: Hospital and health care system Founded: 1918 CEO: David Strong Website: orlandohealth.com
Emergency Physicians of Central Florida, LLP EM ADVOCATE Founded in 1998, Emergency Physicians of Central Florida, LLP (EPCF) is an independent, democratic emergency medicine group in the Orlando Metro area with over 250 providers. EPCF has been supporting FCEP since its inception over 20 years ago: some EPCF physicians are incredibly active in FCEP, like EPCF Managing Partner and FCEP Board Member, Dr. Daniel Brennan, and the company joined our Corporate Sponsor program at the EM Advocate level. EPCF understands the value of leadership and vision in emergency medicine, and actively invests in the professional development of their physicians. They provide opportunities to develop leadership skills, administrative skills, and 24
effective relationships with hospital administration and fellow colleagues. EPCF also excels at providing medical education. Their physicians are faculty members in GME programs through the Orlando Health consortium, educating emergency medicine residents and fellows pursuing EMS, administrative, ultrasound, simulation and PEM fellowships. EPCF’s investment in the professional development of their providers benefits FCEP and the public at large. In return, FCEP provides further opportunities for EPCF physicians to cultivate their skills, whether it’s educating their peers and mentors at conferences or advocating for emergency medicine EMpulse Winter 2021
providers and their patients in Tallahassee. ■
LEARN MORE: Company size: 250 providers Located in: Orlando Metro Function: Staffing Founded: 1998 Managing Partner: Daniel Brennan, MD Contact: EPCFopportunities@ EPCFonline.com
Thank You, 2020 Sponsors
Collective Medical EM SUPPORTER Collective Medical is the nation’s leading, real-time care collaboration platform. Their product is improving patient care outcomes and lowering costs as it simultaneously connects disparate systems, closing communication gaps in local communities. Collective Medical’s platform integrates alongside EHRs and health information exchanges, improving clinical decision making and empowering caregivers to impact care outcomes outside their walls. A nationwide network comprised of thousands of hospitals and health systems provide real-time data, which tells providers where their patient is located, why they are being seen, who else is treating them, and what risks exist, if any, that can be avoided. Having access to this kind of information has proven to streamline care transitions, improve coordination, and reduce unnecessary length of stay and admissions. It is also revealing areas of further need. ■
TeamHealth EM INNOVATOR At TeamHealth, our purpose is to perfect the practice of medicine, every day, in everything we do. We are proud to be the leading physician practice in the U.S., driven by our commitment to quality and safety and supported by our world-class operating team. Learn more at teamhealth.com. ■
Become a
2021 Corporate Sponsor Contact Melissa Keahey, Director of Development & Operations, for more information mkeahey@emlrc.org (407) 281-7396 ext. 221
EM Innovators “The pandemic highlighted the need for more behavioral health and substance use disorder resources in the ED and beyond,” says Andrew Reeve. “We made sure all of our existing clients and the market at large knew that the Collective Platform could help these patients and the clinicians that care for them with real-time notifications across all care settings.”
LEARN MORE: Company size: 200 employees Located in: Cottonwood Heights, UT Function: Real-time care collaboration platform Founded: 2005 CEO: Chris Klemp
EM Dignitary
Website: collectivemedical.com
AdventHealth
EM Advocates
EM ADVOCATE At AdventHealth, extending the healing ministry of Christ is our mission. Our focus is on whole-person health: healing and restoring the body, mind and spirit. More than 80,000 skilled and compassionate caregivers in physician practices, hospitals, outpatient clinics, skilled nursing facilities, home health agencies and hospice centers provide individualized, wholistic care. Our Christian mission, shared vision and common values underline our commitment to making communities healthier with a unified system: nearly 50 hospital campuses and hundreds of care sites in diverse markets throughout nine states. Learn more at adventhealth.com. ■
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COMMITTEE REPORT
EMRAF President’s Message By Elizabeth Calhoun, MD, PGY-2 Committee Chair
The Emergency Medicine Resident Association of Florida (EMRAF), the resident committee of FCEP, is continuing to work toward establishing representatives for each of Florida’s residency programs. We met in November to discuss upcoming FCEP and ACEP events and opportunities for continuing education and recruitment. Involvement in EMRAF is simple and available at any level of commitment, and there are always ongoings geared toward residents. The Life After Residency: Thriving Beyond Medicine program was a virtual success this year, covering
topics ranging from financial and personal wellness to contracts and job changes. Next September, FCEP is looking forward to returning to Sirata Beach Resort in St. Pete Beach for an in-person event. Dr. Robyn Hoelle with North Florida Regional Medical Center’s residency program, Dr. Todd Slesinger with Aventura’s residency program, and Dr. Rajiv Bahl are on the planning committee and are very interested in incorporating resident involvement in planning next year’s event. This is one of countless ways to get involved with FCEP and meet some of the great minds working within the college. Your perspective as a resident is more important than
you realize. If you are interested in joining this planning committee, please contact one of the chairs or communications director, Samantha League, at sleague@emlrc.org. Do you feel like you are out of the FCEP news loop? Feel free to reach out to me to find ways to stay connected. Are you already receiving FCEP’s latest news updates? If not, please visit fcep.org/emnews-now and click the orange “Subscribe to Announcements” button to receive periodic emails with the latest EM news and reminders about upcoming events. ■
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EMpulse Winter 2021
UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS
19 EM UPDATES FROM FLORIDA’S
LEARN MORE Browse through all of Florida’s ACGMEaccredited emergency medicine residency programs at fcep.org
RESIDENCY PROGRAMS
Florida Atlantic University By Tony Bruno, DO, PGY-1 SOUTH FLORIDA Our FAU EM family continues to expand: congratulations to EMRAF president, Dr. Elizabeth Calhoun, who has given birth to a beautiful baby girl! On the endless education front, we would also like to extend a big congratulations to Dr. Alex Busko, who will be representing our program next year as a fellow in critical care medicine at the University of Alabama, Birmingham. Interview season is in full swing, and while we miss having applicants here in person to experience all that our program has to offer, we have enjoyed getting to know them via the virtual interview trail. We would like to wish all the future emergency medicine residents good luck in the upcoming match. In the ED itself, volumes have been steadily increasing, with many shifts seeing pre-COVID volumes. Our residents appreciate the influx of unique learning opportunities each day. We have continued augmenting our inhouse experience with our monthly in-
person simulation lab sessions, albeit with precautionary measures. While we didn’t think it was possible, Dr. Hughes and FAU have made our SIM experience even better with the addition of a new “high fidelity” pediatric manikin. The simulator allows for intubation, IV’s, IO’s, and can provide real time resuscitation feedback via a tetherless portable monitor to enhance our in situ pediatric emergency medicine curriculum. While it’s been a cold winter in other parts of the country and even the state, we have been forced to spend our off-time surfing, sailing and sunset cruising down the Intracoastal Waterway here in South Florida. While we are still not socializing as a group, we did have a blast at our virtual game night and holiday party. Our faculty has continued their dedication to research by publishing several peer-reviewed articles. Expanding our knowledge base in emergency medicine are: EMpulse Winter 2021
• Alter SM, Mazer BA, Solano JJ,
Shih RD, Hughes MJ, Clayton LM, Greaves SW, Trinh NQ, Hughes PG. Antiplatelet Therapy is Associated with a High Rate of Intracranial Hemorrhage in Head Injury Patients, Trauma Surgery and Acute Care Open. 2020;5:e000520. doi: 10.1136/ tsaco-2020-000520
• Shih RD, Louis PM, Alter SM, Hughes PG, Solano JJ, Clayton LM. Syncope: A Very Atypical Presentation of COVID-19, European Journal of Medical and Health Sciences. 2020 Nov 13; 2(6): 1-3.
Dr. Hughes has authored three additional publications on various topics involving simulation and pediatrics. In addition, Dr. Shih has participated in an ABEM advisory panel tasked with setting standards for medical toxicology, and has published several other studies of his own. Be sure to stay up to date with our program’ evolution by following us on Twitter: @FAUmedEM. ■
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UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS
Jackson Memorial Hospital SOUTH FLORIDA
St. Lucie Medical Center By Shelby Guile, DO, PGY-3 The winter season has brought back some of the regular ED volumes in South Florida. We all continue to adapt not only to the usual seasonal fluctuation, but to the extra factor of ED crowding amidst the COVID-19 pandemic this year as well. Here at St. Lucie, we are very excited to have two brand new ultrasound machines. These will help us further improve our current ultrasound curriculum with clearer images, the ability to print, power doppler mode, and auto-calculations for cardiac output and IVC volumes. That’s not the only new technology in the department: we are also fortunate enough to have received a C-MAC videolaryngoscope, which will assist all levels of training with airway management. The C-MAC allows residents to intubate via direct laryngoscopy while the attending can visualize simultaneously via video. Despite everything being virtual, we have still been able to keep up with some of our research opportunities. Three residents presented their cases at the virtual HCA NSU research day in November. Drs. Drechsler, Tran and Daniel presented on “Cocaine Induced Celiac Artery Dissection,” “Secondary Spontaneous Pneumothorax in setting of Idiopathic Pulmonary Fibrosis,” and “Pulmonary Embolism: A Mimicker of Asthma,” respectively.
By EM Residency Program Staff Greetings from Miami! It has been an interesting last few months. We have welcomed our class of 2023. They are another fantastic class who come from all over the country, bringing a breadth of diversity, experiences and insight. Their onboarding occurred during South Florida’s second peak of COVID-19. We hit our apex at the end of July, but managed it well as a community, hospital system and residency.
We are over halfway through our first virtual recruitment season and are excited to say things have been running quite smoothly. We have already met an amazing group of applicants and can’t wait to welcome our new class of 2024. We have held socials virtually along with other events, such as a Women in Emergency Medicine gathering to discuss the topic of “imposter syndrome.”
Faculty and residents from the University of Miami/Jackson Health System were excited to attend, participate and present at this year’s virtual Symposium by the Sea. We were amazed by our residents, Drs. Joshua Goldstein and Andrea Alvarado, who competed in the clinical pathology competition. Dr. Goldstein won the award for the best presenter, Dr. Alvarado won best discussant, and we were selected as the best overall team. Dr. Naomi Newton, PGY-1 won an award for her HIV research at the poster competition as well. Congratulations to them for their hard work and well-deserved victories.
One of the newest additions to our residency has been the development of our social emergency medicine curriculum. Led by Dr. Naomi Newton, the project aims to increase community outreach, enhance access to care, and tackle social justice topics. We are excited about how these new opportunities will improve our Miami-Dade community. However the most exciting news of 2020 by far was that we began vaccinations at Jackson Memorial Hospital on December 15. We are hopeful and looking forward to post-COVID life. Stay safe everyone, and thank you for all that you do. ■
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We hope to continue our in-person simulation labs soon, as well as poster competitions and conferences when conditions allow again. In the meantime, we will continue to keep everyone as safe and healthy as possible. ■ 28
SOUTH FLORIDA
Learn through free resources, subscribe to our newsbrief and more » emlrc.org/flpedready EMpulse Winter 2021
UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS
Brandon Regional Hospital By Rashmi Jadhav, MD, PGY-2 WEST FLORIDA It’s hard to believe we are already halfway into the new academic year. Our interns have grown immensely from July and have become an integral part of our department. We are so proud of their growth and contributions to our program. Over the last few months, we have had some exciting events and resident accomplishments. Our academic days have continued to improve as we get new innovative ideas from our residents and faculty. We recently had our Simulation Extravaganza Day at our amazing simulation center. This full-day event was spearheaded by Simulation Director Dr. Martin Kim and APD Dr. Prascilla Cruz, and involved multiple, high-yield critical case scenarios, procedural skills, Jeopardy-style board review and much more. Thank you to all of our amazing faculty who participated in this event! We have also
implemented Morning Report into our program (see photo above). We have had some great discussions led by our residents on various topics such as indications and steps for cordis placement, recognition and management of stable vs. unstable afiv rvr, and Bartholin cysts. These teaching rounds have been received positively by all ED staff, including nurses and techs. Additionally, Brandon Regional EM is incredibly proud of our PGY-3s, who have secured fellowship positions in some of the most competitive and prestigious programs in the nation. Dr. Melissa Bacci will be going on to complete a critical care medicine fellowship at University of Pittsburgh. Drs. Caroline Shepherd, Matthew Bryce McClure and Keyon Shokraneh will continue on to ultrasound fellowships
at the University of Pennsylvania, UF Jacksonville and University of Massachusetts, respectively. Finally, Dr. Rashmi Jadhav will go on to Georgetown University for her simulation and patient safety fellowship. Drs. Ricki Brown and Andrew Glickman have accepted positions at Brandon Regional Hospital’s ED. We are incredibly proud of everyone’s accomplishments and look forward to more announcements like this in the upcoming months! Lastly, our interview season has brought us some very competitive applicants. It has been a pleasure meeting so many qualified candidates for our new intern class. As we continue with virtual interviews, we look forward to meeting many more potential candidates and a successful Match in March. ■
Aventura Hospital By Dr. Scarlet Benson
Assistant Clinical Professor Our faculty has had a productive quarter, with APD Dr. Andy Pennardt publishing a chapter titled “Blast Injury” in Emergency Medical Services: Clinical Practice and Systems Oversight, and “Riot Medicine: Civil disturbance Applications of the National Tactical Emergency Medical Support Competency Domains” in Journal of Special Operations Medicine. Program Director, Dr. Todd Slesinger, was re-elected to the FCEP board. Clerkship Director, Dr. Annalee Baker, published an article in the ACEP Journal: “Does Academic Practice Protect Emergency Physicians Against Burnout?” Director of Sports
SOUTH FLORIDA Medicine, Dr. John Childress, published, “Recommended Musculoskeletal and Sports Medicine Curriculum for Emergency Medicine Residency Training” in Current Sports Medicine Reports. The residents have also continued to show up, with Dr. Ben Pirotte writing two cases for our simulation program, a massive GI bleed case for SimWars vs. the Kendall EM Residency, and a hyperkalemic cardiac arrest case for just our residents. Dr. Nicolas Ulloa presented a poster at the NSU-HCA virtual research day: “HTLV- 1 confirmed T-cell lymphoma presenting EMpulse Winter 2021
with cutaneous manifestations.” Dr. Trung Tran presented his abstract at ACEP 2020 virtual assembly titled: “A Survey of the Perception of Emergency Medicine Residents and Attending Physicians on the Effect of Sign-out on Safety and Efficiency.” We also had two residents match into fellowship: Dr. Laura Pumarejo Gomez into ultrasound at Kaiser in San Diego, and Dr. Manuel Obando into critical care at AdventHealth in Orlando. We’ve had a busy interview season so far and look forward to gearing up again this month! ■ 29
UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS
UF Gainesville By Megan Rivera, MD, PGY-1 NORTH FLORIDA Hello from “The Swamp!” Florida winter has officially hit us in Gainesville, and us cold-blooded Gators are trying our best to stay warm. Our department held an interdisciplinary Abuse Awareness Symposium hosted by our own Dr. Cristina Zeretzke-Bien. Topics ranged from red flags for abuse to the implications of children’s privacy on social media. We discussed the prevalence of human trafficking within our own community and statewide, as well as ways to identify at-risk individuals. Our faculty gave great insight into victim advocacy and equipped us with tools to intervene in these sensitive situations. These problems exist in our EDs across the state and taking the time to have these conversations will make a huge difference in outcomes. Our awareness and attention to this topic will save lives. We are grateful to be at the forefront of medical intervention, and we will continue to educate ourselves for those who need us the most. As chief complaints of fever, cough and shortness of breath ramp back up, we
have been focusing on our resilience and professionalism. While COVID seems to be never-ending, we remain hopeful for what is to come. Residents have diligently worn their PPE as a second skin and have become more comfortable treating these patients. Discussions have now shifted to bettering our communication, empathy and self-care. Burnout shows its face in many ways, and this pandemic has added an extra layer of complexity. Our team here at UF has shown overwhelming support for one another and continues to inspire through example. Despite rising cases of COVID, we have seen an abundance of volume and acuity within our ED. The interns have acclimated well and their growth is outstanding. From MICU to ultrasound to ophthalmology, the interns are soaking up knowledge while off-service and bringing their skills to the ED. They’ve become more comfortable with MAC and Miller blades, approximating difficult wound closures and teaching medical students. PGY-2s have found their bearings in ED critical
care shifts and are showing increased mastery in resuscitating some of our most critically ill patients. Residents from all classes have enjoyed the return of Gator football and the volunteer opportunities this brings for pre-hospital care experiences. Last but not least, our PGY-3s are finding jobs and securing fellowships, and we couldn’t be more proud of them. Of course we have to acknowledge that interview season is in full swing! Our residents have worked hard to expand our social media footprint and connect electronically with applicants across the nation. We’ve been reviewing a record number of applications this season and are blown away by the incredible individuals we’ve met thus far. Our future colleagues have already shown resilience and the ability to overcome unprecedented circumstances, and their excitement is contagious. Their positivity, enthusiasm for emergency medicine and dedication to excellence is such an important reminder for us all. We wish all applicants luck and success this interview season! ■
UCF/HCA North Florida Regional By Jayden Miller, MD, PGY-1 NORTH FLORIDA Last chapter of 2020 in the books here at North Florida! It’s been quite a year for everyone in medicine, and although it has been rough in some places, I think we’ve learned a lot. At NF, we’ve learned so much about our own resiliency, our compassion, and the support we have around us. Many of our seniors are making their post-residency plans. Dr. Robby Skinner will be pursuing an EMS fellowship at the University of Cincinnati. Dr. Josh Middleton will be the first Ultrasound 30
Fellow here at North Florida. Drs. Diana Mora and Dakota Lane have developed our outstanding ultrasound curriculum for medical students and residents, and we cannot wait to see what their fellowship program accomplishes! As with many other programs, we’ve been spending a lot of time on Zoom. We continue to invite medical students to our weekly conference, whether rotating with us or not. We know many students don’t get the exposure to EM academics as much as they’d like, and EMpulse Winter 2021
hope our didactics can help bridge that gap. The annual opening of North Florida’s Duck Pond lights was celebrated virtually this holiday season, but they were as delightful as ever. In this reflective season, I’d like to thank our faculty especially. Their tireless effort this year for our protection and education has been remarkable. We look forward to our COVID vaccines and a brighter year in 2021. Happy New Year! ■
Looking Forward TO a
Brighter Future
CHEERS TO 2021
being a better year for all of us in Emergency Medicine!
emprosonline.com EMpulse Winter 2021
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UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS
Orange Park Medical Center By Cody Russell, MD, PGY-2 NORTH FLORIDA Orange Park Emergency Medicine has pushed hard to finish the year strong after a challenging season filled with new hurdles every week. We’ve found that the most important thing to remember in overcoming challenges is that having strong teammates and colleagues to work with and lean on is the most valuable asset in medicine. As such, we’re lucky to have added some really strong attending staff over the past few months as Dr. Cobau and Dr. Mantha joined our ED team. We’d also like to congratulate our very own Dr. Jennifer Chapman for transitioning to her role as Program Director, as well as to Dr. Shilpa Amin, who will be serving as Associate Program Director. To help us learn the artwork of becoming an efficient ED, our program has added a unique shift for PGY-2 residents nicknamed the “pretending shift,”
where we focus on managing the flow of the entire emergency department rather than just our panel of patients. Our ED has also experimented with different tracks to help move the ever-changing influx of patients through our ED in a timely and safe manner, including having a “fast track”/low-acuity area primarily staffed by PAs/NPs while residents attend to high-acuity patients and focus more on critical patients, procedures and resuscitations. From an academic standpoint, our program was excited to have multiple projects spearheaded by Dr. Warrington accepted at the International Meeting on Simulation in Healthcare, giving multiple faculty members and residents the chance to present on an international stage. We have continued our virtual rotation for medical students struggling to get time in the
ED due to COVID, which has been a big success thus far. We are also finishing up our virtual interview season and are excited about what next year will bring as we add our third 12-resident class to our Orange Park family. We’d also like to give a big shout out to the dynamic and brilliant Dr. Koury, who won a “Best Presenter” award for his CPC competition recently with Dr. Fry. Lastly, outside of the ER, our residents have continued to pursue areas of interest such as working with the sports medicine team at the Florida Ironman and participating in training events with Jacksonville’s Search and Rescue Teams. All in all, 2020 brought us closer together as a team, and we’re excited for whatever 2021 brings our way at Orange Park Medical Center. ■
AdventHealth East Orlando By Tyler Mills, DO, PGY-2 CENTRAL FLORIDA Seasons greetings from all your EM friends at AdventHealth. We are so thankful for the good health of our program and ED staff thus far. We hope all of you enjoyed a safe and healthy holiday season. Our program was proud to partner with Give Kids the World this year to play a small part in their big Night of a Million Lights event. The holidays looked a lot different for everyone this year, which is why Dr. Caroline Molins organized something special for our wellness activity. Residents and faculty enjoyed a break from the busy East Orlando ED to help transform the 89-acre, storybook village into a
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winter wonderland. Residents added sunscreen and work gloves to their list of PPE and worked together to assemble decorations and hang some of the three million plus lights in this year’s display. With the village closed to children and their families out of caution, the immersive holiday event acted as a fundraiser for the organization. Back in the ED, this month’s simulation day placed extra emphasis on procedures in addition to the usual simulation/case scenarios. Residents got an opportunity to sharpen their procedural skills with Drs. Tomecsek, Little and Mohar, as well as practice some of the rarer procedures encountered in
EMpulse Winter 2021
the ED, including pericardiocentesis and a resident favorite: lateral canthotomy. Special thanks to Dr. Mohar (and Mohar children) for constructing such realistic models. Last but not least, congratulations to Dr. Duan for winning first place in ACOEP’s Clinical Pathological Case Competition. We also would like to congratulate next year’s ultrasound fellows, Dr. Risovas and Dr. Cartaya, on a successful match. Residents are thrilled with the arrival of two new ultrasound machines to the department and look forward to working with the fellows next year. ■
UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS
Mount Sinai Medical Center By Stephanie Fernandez, MD, PGY-3 Hello from Mount Sinai! The academic year is in full swing, and we are proud to say that, despite challenges posed by the pandemic, our team continues to adapt and thrive. Interview season is underway, and we have adopted an online interviewing platform for our candidates, including regular social Zoom “scavenger hunts” with the current residents. We are continually impressed by the promising talent of our interviewees! Our residents continue to engage academically, both on the local and national scale: Drs. Stephanie Fernandez and Grethel Miro led the Ultrasound Workshop for FIU medical students, and Dr. Hannah Gordon moderated a talk at ACEP regarding evidence-based strategies to overcome health disparities in the era of COVID. We have a number of wonderful announcements this season. One of our
SOUTH FLORIDA critical care attendings, Dr. Elgozy, made a complete recovery and was discharged from the ICU in good health after battling COVID-19. Furthermore, we are happy to welcome several new members to the Mount Sinai family: Drs. Rob Farrow, Adam Memon and Carlos Cao all announced the birth of their first children near the end of the year. We wish them lots of happiness (and some opportunities for sleep)! Lastly, a word of congratulations to our seniors who accepted positions for fellowship next year: Dr. Fenil Patel will be attending an Ultrasound Fellowship at Jacobi Hospital in New York, and Dr. Stephanie Fernandez will be part of Mount Sinai’s inaugural Ultrasound Fellowship class. We are excited to see what the rest of the academic year has in store. Wishing you all a safe and happy new year. ■
By Ryan Johnson, MD, PGY-1 The emergency medicine residents at Oak Hill Hospital would like to extend their warmest greetings to readers around the state. It seems crazy to think that it was around this time last year when we were just starting to hear about COVID-19. Who could have predicted the year we would have! We are very proud of the way our department and residency have risen up to the challenge. Our interns started their training during a global health crisis and have come a long way since July. We would like to express our gratitude to our attendings for their dedication to teaching and invaluable insight during the worst public health crisis in recent history. Their support has been so important during this unprecedented time.
NORTH FLORIDA members to our family here at UF Jacksonville. Dr. Sam Ghali joins our faculty with a fellowship in ultrasound and special interest in emergency critical care. Dr. John B. Marshall is our other new addition and is bringing his expertise in tactical medicine. We look forward to learning from these two fantastic physicians.
Interviews for the class of 2024 are well underway. It has been exciting to see so many eager faces and the enthusiasm of our applicants. The residents have had a great time meeting the candidates. We would like to thank everyone involved for their creativity and flexibility adapting to the challenges of 2020.
As always, we send our well wishes and gratitude to every member of the medical community continuing to fight this battle with COVID-19! ■
Finally, we would also like to welcome the newest member of our EM family, Griffin Powers, son of Dr. Meagan Powers. ■
By Richard Courtney, DO, PGY-3
We are thrilled to welcome two new
Oak Hill Hospital
Several of our residents recently attended a policy meeting with Hernando County Fire and Rescue EMS. There, they were able to learn more about the pre-hospital treatment of our patients and have their voices heard on several policy changes. We look forward to continuing our relationship with county EMS in the future.
UF Jacksonville As this interview season continues on, we would like to thank our faculty who are working around the clock to make the interview experience as smooth as possible for our applicants and staff. Not only have we developed a great page on our website (www.BoldCityEM. com) to learn about our program, we’ve also started a resident and alumni spotlight series on our Instagram (@ Jax_EM) where we get to brag about our brilliant and talented family.
WEST FLORIDA
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UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS
Kendall Regional Medical Center By Tina Drake, MD, Ibrahim M. Hasan, MD & Sara Zagroba, MD, PGY-3s Co-Chiefs, Emergency Medicine Residency Kendall Regional Medical Center’s EM Residency is thrilled to report that our friendly SimWars competition with Aventura’s EM Residency at the Broward College Simulation Lab this past October was a success for the fifth year in a row, thanks to the planning and dedication of our Simulation Director and Associate Program Director, Dr. Antoinette Golden. We keep our skills honed for next year’s competition through regular simulation activities interspersed during our dedicated weekly didactics. Our leadership team has been amazingly resourceful in coordinating socially-distant and virtual learning opportunities this year to keep our training engaging, fun and effective. Thank you to all the guest lectur-
SOUTH FLORIDA ers who have joined us so far.
and support!
The range of resources in the fight against Covid-19 continues to evolve, and we were able to protect our frontline workers last month by launching the first phase of vaccine administration to healthcare personnel. As always, we dedicate ourselves to using the latest evidence-based guidelines as we serve our community. We also continue to make wellness activities a priority for our team during this difficult time, from outdoor recreation to virtual game nights, to keep our residents feeling refreshed and connected. Our senior residents and interns have been partnered up into mentor-and-mentee pairs this year for even more guidance
Many of our senior residents have accepted fellowship positions in various regions of the country, including Dr. Joseph Clemons to Portland, Oregon for toxicology and Dr. Kristina Drake to Augusta, Georgia for wilderness medicine, but we are proud to announce that we will be keeping two of our own at Kendall Regional. Dr. Nicholas Rosende will be one of two Ultrasound Fellows for the 2021-22 academic year, and Dr. Anton Gomez will be staying as our Administration Fellow. We welcome the opportunity to keep these fantastic physicians in the Kendall family. Happy New Year to all! ■
USF Health By Mikhail Marchenko, MD, PGY-2 Greetings from Tampa and the USF emergency medicine residency! (usfemergencymedicine.org) We are excited for the new year and have many announcements. Simulation Director Dr. Ryan McKenna established a Simulation Fellowship, and we are pleased to announce our inaugural fellow, Dr. Nicole Abdo. Sim Fellows will train at the Center for Advanced Medical Learning and Simulation (CAMLS), an unparalleled state-of-theart simulation center in Downtown Tampa. Dr. John Elkes matched into our EMS Program and Dr. Judith Oriental-Pierre, from UConn, will join us as our Ultrasound Fellow. We are also proud to partner with USF to offer a multi-disciplinary Global
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WEST FLORIDA Health Fellowship next year. Dr. Jasmine Patterson, Director of our Pediatric Emergency Department, has joined our core faculty. Our newest major initiative will be the launch of the Syringe Services Program operated in partnership with the USF Tampa Bay Street Medicine program. That initiative will ramp up harm reduction efforts while also focusing on decreasing HIV and HCV transmission in our community. Like all programs, COVID has forced our department to adjust in many ways. We are proud of the efforts we have made at Tampa General Hospital (TGH) to protect our patients, residents and staff. In October, our hospital
EMpulse Winter 2021
launched the Global Emerging Disease Institute (GEDI) to further facilitate interdisciplinary COVID care. Our ED serves as the hub of pivoting patients with COVID-19 to the right care at the right time, whether that be a monoclonal Ab infusion, a research study investigating new treatments, or other supportive care options within or outside the ED. We were thrilled to be one of the five sites chosen to receive vaccines in the first wave! 2020 has been a year like no other, but we are excited and look forward to what 2021 brings. We are grateful to be part of the USF family and wish all of the EM community a happy and healthy New Year! ■
UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS
Orlando Health
By Drs. Gregory Black and Brody Hingst, PGY-2s CENTRAL FLORIDA We at Orlando Health hope this finds everyone safe, healthy and in good spirits. Just like you, we have been busy these past few months. Dr. Josef Thundiyil and the recruitment committee have had the pleasure of interviewing many phenomenal applicants who we hope to one day call members of the Orlando Health family! We are continually impressed by the academic and extracurricular excellence of these talented individuals, who will undoubtedly become amazing emergency physicians. Thank you to the tireless efforts of our residents and faculty who have been recruiting and interviewing this season—you are awesome. To all the MS4 students out there: you are all amazing, and keep up the great work! Huge shoutout to our own third-year residents, who have already matched into fellowships. We are immensely proud of each of you, and look forward
to following your success in the years to come:
• Mark Bender: Pain management • Beaulah Castor: Critical care • Michael Clemmons: Ultrasound • Danielle DiCesare: EMS • Agy Gaertig: Ultrasound • Keagan Mullins: Informatics Orlando Health began its first round of COVID-19 vaccinations to healthcare providers just in time for the holiday season. Orange County administrators, like the rest of the state, worked hard to manage the logistics of the large vaccine rollout. We would like to give a huge thank you to everyone involved, including our medical directors and hospital administration. Stay safe, stay healthy, and good riddance to 2020! ■
FSU at Sarasota Memorial Courtney Kirkland, DO, PGY-2 Hello from Sarasota! Our intern class is all settled in and they are making us proud. We would like to welcome a very special new member to our family, Kennedy Kay Murphy, who was born December 9, 2020 to resident Dr. Stephanie Murphy and her husband, Greg Murphy. We are so excited for this amazing family to become firsttime parents. One of our rotations in the PGY-2 year includes an administrative month, where we learn about the various facets of the emergency department not taught in medical school, such as billing, ED flow, and working with ED staff to come up with plans for unex-
WEST FLORIDA pected circumstances. It has been a great experience for our residents to view the ED through a different lens. Our wellness events have been somewhat different this year given the circumstances. We were lucky enough to give back to our community by participating in a beach clean-up on Lido Key, where our residents and faculty removed invasive species of plants. We also managed to create a socially-distanced “White Elephant” event for all of the residents to participate in the holidays. We are very grateful to live in a beautiful city with great weather and many outdoor activities that we can enjoy regularly. ■ EMpulse Winter 2021
NORTH FLORIDA
Ocala Regional Medical Center By Jean Laubinger, MD, MPH, PGY-2, Emily Clark, MD, PGY-2 & Caroline Smith, MD, PGY-3 Hello from all of us here at Ocala Regional Medical Center, where have lots to celebrate. We are excited for Nicholas Titelbaum, MD, PGY-3, who matched into a medical toxicology fellowship at his first choice, Emory University School of Medicine. Throughout residency, Dr. Titelbaum has enthusiastically provided us with regular toxicology lectures. We are always excited to consult with him when we have a snake envenomation or toxic ingestion case in the department. We are lucky to have excellent teachers amongst our faculty and residents. Ultrasound Director Dr. Leoh Leon put together ‘ultrasound jeopardy,’ testing the knowledge of residents in a fun, interactive game. Our residents had a great time competing against each other while reinforcing the excelling ultrasound training skills learned in the ED. Dr. Samyr Elbadri has also helped shape our growing residency program with his focus on teaching. After joining our faculty upon graduation from our program, he continues to promote academics as our simulation director. Through simulation, our residents work to develop better understanding of team dynamics and leadership in preparation for treating critical patients. While our holidays this year looked different than years past, we helped keep spirits high in the department with our miniature tree and festive decorations. We look forward to this new year bringing high vaccination rates, more in-person wellness activities and less N-95s. ■
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COMMITTEE REPORT
Medical Student Council By Dan Schaefer, MPH, MS-3 Secretary-Editor, FSU College of Medicine
We at the FCEP Medical Student Council (MSC) are excited for the new year and all that it has in store! EM Days 2021 will be virtual this year. That means that medical students will not be taking the trip up to Tallahassee this spring, but a virtual setting makes it even easier to participate in this event that will directly benefit the future of emergency medicine here in Florida. If participating in EM Days is something that you have considered in the past but have forgone due to time and distance, this year is the perfect year to attend! If you are interested in learning how the policy process works, consider yourself to be naïve on the issues, or feel intimidated by the thought of speaking to legislators, have no fear because FCEP and the MSC will help guide you through all of this and more, from the comfort of your own home. To brush up on the ongoing issues for EM in the state of Florida, bookmark the EM Days 2021 Legislative Database at www.fcep.org/emdays. If you would like to look at a particular house or senate bill’s language, sponsors and status, start at www. flsenate.gov. If board exams and constant Zoom meetings have decreased your legislative acumen over the past year, please contact the members of FCEP MSC on our favorite resources before the legislative session starts on March 2, 2021. ■
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Thank You, PAC Donors The success of FCEP’s advocacy efforts is dependent upon our ability to fund those efforts. Thank you to the 93 individuals who donated in September-November 2020: Nadia Ashlee Adside
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EMpulse Winter 2021
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Is It an Emergency? Or Is It Hospice? By Eric Shaban, MD VITAS® Healthcare
What are best practices for patients with advanced illness who frequent your emergency department? What do patients, families, hospitals, and payers want? What is your role? What is the role of hospice? The Hospital Readmissions Reduction Program was developed for a reason. Consider this: a third of Medicare patients readmit within 90 days; 1 in 5 Medicare patients readmits within 30 days. During the last month of life, about half of patients are in the ED, and almost 10% are there on their last day. At VITAS Healthcare, we can admit hospice-eligible patients directly from the ED, even when they are symptomatic.
Partner with VITAS to Achieve Key Goals When your hospital partners with VITAS, patients with end-of-life needs get the right care. Your hospital achieves key goals:
• Reduced ED overcrowding, readmissions, and observation periods
• Improved ED throughput and bed cycling • Seamless transitions to post-acute care • Improved family-satisfaction metrics Hospitals are penalized for suboptimal ED “core measure” outcomes, reduced patient/family satisfaction scores, and readmissions of seriously ill patients who may not want to be hospitalized. When surveyed, patients report their preferences to include:
• Optimal pain/symptom control • Strengthening their relationships with family • Decreasing their care-burden on family • Prolonging the dying process • Autonomy and maintaining a sense of control • Dying at home surrounded by loved ones Yet readmissions are often due to unmet discharge planning needs, post discharge care coordination, or insufficient outpatient or community-based follow-up particularly when coupled with severe progressive illness. Readmitted patients tend to be elderly with multiple comorbidities that contribute to
their decline. Often they have not adhered to followup plans, and may not be able to state their diagnosis or explain their medications. Many of these patients are hospice eligible, and identification can fit into a busy clinician’s assessment and facilitate optimal disposition decisions.
Signs That a Patient Might Be HospiceEligible
• Frequent visits to the ED for a progressive serious illness
• Recent hospitalization or ICU • Ongoing symptoms despite optimal treatment • Declining functional status • Development of Delirium • Declining renal function • Use of inotropes • Patient’s goals are for quality of life • Answering “No” to the question: Would you be surprised if this patient died in the next 6–12 months?
When referred to hospice as soon as they are eligible, patients receive medical and psychosocial care to control their symptoms and improve quality of life. Care is brought to them where they live by an interdisciplinary team. Continuous care is provided at home when medically necessary, keeping the patient out of the hospital.
Refer Hospice-Eligible Patients With Your Phone VITAS has streamlined the hospice referral process with a mobile application for iPhone, iPad and Android users. Instantly refer patients with serious progressive illness to VITAS with a face sheet snapshot and a few clicks. Download the mobile app at VITASapp.com for interactive hospice eligibility guidelines, VITAS locations, and seamless, secure 24/7 referrals. Eric Shaban, MD, is regional medical director for VITAS® Healthcare, the nation’s leading provider of end-of-life care. For more information, call 800.93. VITAS or visit VITAS.com.
EMpulse Winter 2021
37
MUSINGS FROM A RETIRED PHYSICIAN
Busting Myths About the New Coronavirus Vaccines By Wayne Barry, MD, FACEP Former FCEP Board Member
Now that the U.S. Presidential Election is in the rear view mirror, we are left to deal with the stark realizations of how divided we are as a country. I am trying to set aside the fact that political differences in this country are legion in their magnitude. However, I cannot seem to get past the outrageous attacks on science and medicine, which rose to the spotlight during the throes of the recent and ongoing coronavirus pandemic. I have to admit, I feel rather naive to realize, for the first time during my many years on this planet, that there are a large number of people living in this country who repudiate the findings that constitute science and the practice of good, evidence-based medicine. These anti-vaxers are people who believe vaccinations cause autism and other harmful side effects, even though there is no credible evidence to suggest these contentions are true. The truth is, vac-
cinations have saved many millions of lives across the globe for decades, greatly eclipsing the lives saved by all other medical technological advances invented to date, no matter how sophisticated. Unfortunately, during the current pandemic, scientific principles proven to offer meaningful defense against an airborne viral pandemic such as COVID-19 have been politicized and perverted, to the point where large swathes of Americans do not believe in the efficacy of social distancing and wearing a face mask in significantly reducing the spread of the virus. We are now in the third spike of rising COVID-19 cases among Americans, likely due to gatherings of people at the recent Thanksgiving holiday, and unfortunately Christmas is right around the corner. Fortunately, the first coronavirus vaccine has just received emergency use authorization from the FDA, and roll out
of vaccine doses is underway even as I write this essay. I believe that coronavirus vaccine myth-busting is critically important. Polls suggest that somewhere between 30-50% of Americans are thinking about declining the vaccine, even if it is given for free. Public health experts maintain that vaccine administration of less than 70% of the population will fail to confer herd immunity for all. Since many U.S. public health officials are now under attack by political propagandists, and anti-scientific and anti-medical sentiment seems to be at an all-time high in this country, I figure that the rest of us frontline healthcare workers need to take on the job of dispelling as many of the prevailing anti-COVID-19 vaccine myths as we can. Below is a review of some of them. In most cases, the truth should be relatively obvious to most of you.
HELP US EDUCATE LOCAL POPULATIONS Racial and ethnic minority populations, who have been historically disenfranchised from and treated poorly in healthcare settings, are hesistant to receive the coronavirus vaccine. They are also dying from COVID-19 at higher rates than white Americans.
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We need your help educating and reaching these vulnerable populations in Florida’s communities. Stay tuned for more information on FCEP’s outreach campaign, launching in February, at fcep.org.
BOARD MEMBERS LEADING CAMPAIGN: • Dr. Rene Mack & Dr. Saundra Jackson (FCEP Board) • Dr. Ernest Page (FEMF Board) 2 38
EMpulse Winter 2021
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MYTH-BUSTING THE CORONAVIRUS VACCINE The coronavirus vaccines contain live viruses. ▶ Wrong, because both the Pfizer/ Bio N Tech and Moderna vaccines contain very small fragments of the coronavirus genomes, or a piece of artificial genetic material, which provokes an appropriate immune response. mRNA vaccines can alter your DNA. ▶ First of all, the mRNA never enters a cell, and the mRNA is designed to stimulate an immune response to the spike proteins on the outer coat of the coronavirus. You do not need two doses of the vaccine. ▶ Wrong, because there are no studies studying the efficacy of one dose of the above two mentioned vaccines. If you got the flu shot this year, you do not need a coronavirus vaccine. ▶ Wrong, because there is no known cross reactivity between the flu vaccines and the corona virus vaccines. You can ditch your mask after you get vaccinated. ▶ Wrong because while studies have shown that the vaccine can protect you from becoming sick with the virus, there are no studies to show whether the vaccine can still transmit the virus to others. Public health officials will know when to exclude the need
for mask wearing when a sufficient number of the population have been vaccinated.
Vaccines are used to microchip people. ▶ This is not only false, but impossible!
Once you receive the coronavirus vaccine, you are immune for life. ▶ Studies have not confirmed how long native or vaccine immunity lasts, and some experts suspect the immunity may be short-lived: 6 months or less.
Vaccines are not safe because they were developed quickly. ▶ The current front-running vaccines have been proven to be safe in the populations tested.
If you’ve already contracted COVID-19, you do not need to get vaccinated. ▶ No one is sure how long natural immunity lasts, so keep close to the new scientific information about this subject. Vaccines make you sick. ▶ Pain, redness swelling at the site of injection, low-grade fever for 1-2 days accompanied by malaise, and symptoms similar to post-flu vaccine administration are all that you should expect to encounter. Vaccines contain toxic ingredients. ▶ Gelatin and egg products, which some people are allergic to, are not contained in the two current front-running vaccines. Vaccines can cause autism. ▶ There is absolutely no evidence that vaccines cause autism. EMpulse Winter 2021
COVID-19 vaccines were developed using fetal tissue. ▶ This is completely false! Please do your part to tell your patients and everybody else you know how important it is to accept the vaccine as soon as it is available to them. We must promote the use of these COVID-19 vaccines. We must champion their cause, and in this way we can be a powerful force to help bring an end to this modern day scourge known as COVID-19. May next year be a lot better for all of us than this year. ■ Pictured: 1) Dr. Christine Van Dillen 2) Marjorie Dorsainvil, LPN & Dr. Rajiv Bahl 3) Dr. Ashley Booth-Norse 4) Dr. J. Adrian Tyndall (UF Health) 5) Dr. Jeffrey Gehring 6-7) Dr. Christina Caro and her parents all received the vaccine when UF Health Jacksonville extended eligibility to their employees’ family members age 65 and older. 39
FEATURE
Joy
Finding
in Work
A STORY OF RESILIENCE AND WELLNESS By Cristina ZeretzkeBien, MD, FACEP Pediatric Emergency Physician
After the pandemic began, a friend of mine who manages student learners said to me, “no one is happy right now.” Most of us in emergency medicine just experienced one of our toughest years. We have all been dealt many hardships by living “a new normal,” which is hardly normal, amid a pandemic. Many days were dark and difficult, to say the least. Our personal lives have been affected. Our work lives have been dramatically altered. We have experienced cancelled vacations, changes in pay, more or fewer shifts, quarantines for ourselves or our family members, wearing PPE at all times on shift, and all while still trying to reach our career goals. I will remind us all of a simple word: grace. Grace, by definition, refers to a smooth and pleasing way of moving, or a polite and thoughtful way of behaving. This year, we all need to offer ourselves grace. We have all struggled. And it hasn’t just affected us; we need to offer grace to our partners, friends, families and patients, too. When I see others acting out or being unkind, I think, “wow, they sure need more grace. They must really be struggling, 40
too.” Another component I have found necessary is gratitude. Gratitude is a way for us to put it all back together. I call it G and G: Grace and Gratitude. I often find that when I reflect on what I’m most grateful for, I feel more fulfilled with my family and my career. As this unprecedented year comes to a close, I find it helpful to review the 5 Rs: review, reflect, refine, results and remind. These 5 R’s were adopted by Elizabeth Benton, the author of Primal Potential, of which I am an avid podcast listener. » Review. Make sure you review your major accomplishments and celebrate the victories, no matter how small. Some days, these accomplishments may just be getting up, getting dressed, getting to work, and having a shower at the end of it all. Write them down. » Reflect. Reflect on how you are feeling. How did you show up? What did you love, and what did you not love? What do you want to change? How are you going to make those adjustEMpulse Winter 2021
ments in the year ahead? » Refine. Refine your answers. What can you shift? How can you make it possible? Where will you budget your commitments? 2020 has helped many of us identify and clarify our top priorities. » Results. What results do you want to create for yourself? When you sit here next year, what do you want to be possible? » Remind. Remind yourself regularly and create a list. Write it down and place it somewhere you can see it. But I ask that we add one more R: Resilience. What have you done to remain resilient this year? When I think of resilience I think of Tigger from Winnie the Pooh. Resilience is our ability to bounce back. What has helped you bounce back? How well did you do it? What has kept you “bouncing on” amidst the many tragedies and challenges that we have encountered this year?
receive inadequate training in selfcare. In the accreditation standards for U.S. and Canadian medical schools, while highlighting the importance of exposure to personal counseling as a resource, the liaison committee on medical education does not specifically identify self-care or other related areas.3 Similarly, review of the literature reveals that there is no published curriculum focused specifically on self-care or any of these specialty areas. This review was performed by the Accreditation Council for Graduate Medical Education (ACGME), which oversees the training of U.S. residents and fellows.5 ACGME has not included self-care or related areas in its outline of competencies for trainees and all specialties, with the exception of education on sleep management.5 So, if most of us don’t know enough about self-care, so what are we teaching our learners?
My reflection of resilience will include G and G. Gratitude and grace are key partners within resilience. We need to offer ourselves grace and gratitude to remain resilient and to prevent burnout. Burnout was a problem before Covid-19. But what is it exactly? Burnout is defined as “the progressive loss of idealism, energy and purpose experienced by people in the helping professions as a result of the conditions of their work.” It is further defined by three key characteristics: 1) physical and emotional exhaustion, 2) cynicism and 3) inefficiency.1 Physicians are at risk for burnout due to both work and personal characteristics. Work factors include overload, lack of control over one’s workplace environment, lack of resources, feeling poorly managed, or spending a bulk of time at work on tasks that are inconsistent with one’s career goals. Another factor is high levels of work-home interference. Who this year has not had high levels of work-home interference? The consequences of burnout,
compassion fatigue and moral distress are profound, and range from personal crisis to suboptimal patient care practices. Burnout is most often measured through the Maslach Burnout Inventory, which can be measured simply by using questions such as, “do you feel burned out from your work?”2 So how can we keep these dangers at bay? How can we combat burnout? For me, it is self-care and reflection. Personal self-care refers to strategies for individuals to take better care of themselves. It starts with the recognition that people have multiple personal dimensions to attend to in order to live a “good” life, including our life experiences, families, community and spirituality. A widely available instrument called the “wellness wheel” refers to six types of wellness: physical, intellectual, emotional, spiritual, social and occupational. It allows individuals to reflect on their current life balance and self-care.3 Yet current evidence indicates that medical students, residents and fellows EMpulse Winter 2021
I remember driving into an ER shift this year, just not wanting to go back to work. The last few shifts were rough with little down time in between, but there were the ambulances and police cars outside of the ambulance bay, waiting for my arrival. I sat in my car, took a deep breath, and had a real moment of reflection. I had to change my mindset. I remembered something that was very important: I had always wanted to be a doctor. It was my dream to take care of the sick and injured. I had to reflect again on some gratitude, because I was living the life I had always wanted. Yes, we have all sacrificed a lot to get here. We have all missed weddings, family vacations, and delayed other opportunities to study hard and achieve this dream. I had to remind myself that I am now a double-boarded physician. I can walk through those doors of the ambulance bay and sit in the attending chair, the throne I have always wanted. This was my dream, and I am now living it! I love being a pediatric emergency medicine physician. After I changed my mindset, I walked through those ambulance bay doors, ready to take on the challenges of the day. Another way I have really learned to build resilience is to find what sparks joy at work. Maybe that includes Continue on page 42 ▶ 41
◀ Continued from page 41 writing with a new pen, comfortable scrubs, or your favorite coffee cup. Today, amongst this pandemic, we all need to do “what sparks joy.” A colleague of mine who grows a garden brought in a beautiful sunflower to work. She placed it in a urinal with water and put it next to the attending computer. (I know this group will appreciate that the urinal was the vase.) It was beautiful, and many commented on it. I now call the sunflower my “Covid-19 flower,” because it sparks joy for me. For others, maybe it is not a flower, but whatever it is, you need to find it or do it. I began to do other things to spark joy at work. I had to reflect on what really made me happy. I went back to memories of my college days. I loved music and I loved to run. I really miss concerts this year. So how did I spark joy? I created my own Covid-19 playlists. I blare them in my car pre- and postshift. I have my fight songs on the way in, and my comfort songs on the way
out. I also run long and hard after the tough shifts. Whatever it is that you do that you love, do it again. Find your hobby that speaks to you and do it. Reading, writing, art, music, crafts or exercise—there is no wrong answer here. Do what sparks joy for you. As physicians in Covid times, we need to remember to take care of ourselves and give lots of grace, reflect on gratitude, and spark joy wherever we can. We need to appreciate the little things that help us navigate the big things we cannot control. It may take more time, energy, and reminders this year to get through the day, but most of us are still living our dreams. We expend time, energy and tears caring for everyone else. Give grace, spark joy, and in the moments that are quiet and less chaotic, remember to have gratitude. And always remember that hope is ahead of us. We have come down a long road in an exceptionally hard year, but there is finally some hope: the vaccines are finally here. And I hope that 2021 will only bring more hope, resilience and wellbeing for us all. ■
REFERENCES
1. Kearney MK. Weininger RB, Vachon ML, Harrison RL. Mount BM. Self-Care of physicians caring for patients at the end of life. “Being Connected… a key to survival”. JAMA 2009; 301(11): 1155-1164. E1. (Pubmed: 19293416) 2. Linzer M, Rosenberg M, McMurray JE, Glassroth J. Respecting the lifecycle: Rational workforce planning for a section of general internal medicine. Am J Med, 2002; 113(5): 443-448. (Pubmed 12401545) 3. Wallace JE. Lemaire JB, Ghali WA. Physician Wellness: a missing quality indicator. Lancet, 2009: 374(9702):1714-1721. (Pubmed: 19914516) 4. Functions and structure of a medical school: LCME accrediation standards. Liaison Committee on Medical Education. Accessed Dec 2020. http://www.lcme.org/standard.htm. Published May 2012. 5. Wald HS, Davis SW, Reis sp, Monroe AD, Borkan JM. Reflecting on reflections: enhancement of medical education curriculum with structured field notes and guided feedback. Acad Med 2009: 84(7): 830-837. Pubmed 19550172.
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EMpulse Winter 2021
FEATURE
Monitor Alarms Until the
PAIN, DEATH AND COVID-19
Jonathan Yaghoubian, DO, MS, PGY-3 HCA Healthcare / USF Morsani GME: Oak Hill Hospital
“Mom, when can we go see Grandpa?” The truth was that Mom did not know. How could she tell Johnny that his grandpa’s heart was not functioning well, his lungs were filling with fluid, that he did not recognize his own children, let alone his grandchildren? Johnny idolizes his grandfather. “Soon, Johnny, soon.” She knows it is a lie as soon as the words leave her lips. The novel coronavirus of 2019 (COVID-19) outbreak has made life difficult for many, but it has become more difficult for a small subset of the population that many do not regularly acknowledge, hospice and end of life (EOL) patients, because of the restrictions in place. COVID-19 has brought with it a myriad of logistical, medical and emotional hurdles to patients at the EOL. They are suffering and dying alone. Physicians have developed many ways to define and classify pain, and a patient’s and family’s experience with EOL certainly qualifies. It is often difficult for many physicians to address pain in the EOL because it can feel like we are giving up and surrendering our charge to the Grim Reaper, who many physicians and nurses consider the enemy. Logistically, the healthcare team cannot take care of EOL patients in the same manner as expected due to the difficulty in accessing personal protective equipment (PPE) and the
Veronica Tucci, MD, JD, FACEP, FAAEM HCA Healthcare / USF Morsani GME: Oak Hill Hospital
delay associated with donning and doffing the PPE appropriately. Families have been asked to limit their physical presence with EOL patients for fear of spreading COVID-19, and as such have been less involved. They cannot provide immediate emotional, spiritual or religious support for their loved ones. Video chats, FaceTime and virtual applications have been employed by healthcare teams to give families access to their loved ones, but these workarounds cannot replace a bedside vigil where family members surround the patient as they pass. With these limitations, it has made EOL care more difficult for patients. Johnny’s last interaction with his grandpa would be artificial and would not ease either party’s pain or give them closure.
to speak with their loved ones. When we are isolated and alone, particularly at the end of our lives, this can cause significant emotional distress and pain.
Medically speaking, if the patient is awake, alert and oriented, then what options are available? Traditionally, these patients were treated symptomatically and occasionally sedated with medication when their pain became overwhelming. This of course brings into question the types of dying that may require management, i.e. palliation.1 In the post-COVID age, whether or not clinicians should be more liberal with sedation or pain management is an open question. Since EOL patients have less access to the physical presence of their caretakers/loved ones, there is a dilemma, because while sedating them might relieve their physical suffering, the agents we use might close the window for them to be able
At the same time, emotional considerations cannot be ignored. The EOL patient will likely be more lonely, depressed, agitated or anxious, especially if the patient is unable to have physical visitors during the COVID-19 era. Virtual presence can be helpful, but is not a replacement for physical presence. In addition, the emotional well-being of friends and family of the EOL patient should be considered as well. During this era, it will be more difficult to know that their EOL patient cannot have the appropriate/necessary visitation during EOL care. Furthermore, doctor/family meetings cannot take place as usual. How does a clinician
EMpulse Winter 2021
Clinicians must balance these types of pain. If EOL patients do not wish to be sedated but are still uncomfortable, pain management options should be considered. Certain guidelines have been suggested by various institutions given the omnipresence of COVID-19. These multimodal options include physical manipulations, opioids and benzodiazepines,2,3 although more research is needed.4 Treating grandpa’s agonizing air hunger upon his final breaths should be considered with or without Johnny’s virtual or physical presence.
Continue on page 45 ▶ 43
POISON CONTROL
DETECTING THE UNDETECTABLE:
Putting a Lid on Carbon Monoxide Chiemela Ubani, Pharm.D.
Clinical Toxicology/EM Fellow at Florida/USVI Poison Information Center-Jacksonville
The cold months are upon us, and that means so are the risks of being exposed to an invisible danger known as carbon monoxide (CO). CO is an odorless, colorless, tasteless gas that is created during the incomplete combustion of any carbon-containing compound. These properties make it incredibly difficult to detect, leading to a large number of exposures and fatalities over the years. One study conducted in 2007 suggested that there were more than 230,000 visits to the ED related to CO exposure in that year alone.1 In addition, approximately 393 unintentional deaths due to carbon monoxide exposure were reported in the U.S. in 2015.2 More locally, 407 human exposures to CO were reported to the Florida Poison Information Center Network during this last fiscal year (July 2019-June 2020). There are numerous sources of CO with the most common being motor vehicles, fires, and the combustion of fuels for heating and cooking. In fact, more than one-third of the COrelated deaths occur during the winter months in the U.S. due to the burning of charcoal, wood, or natural gas for heat.3 Gasoline-powered generators are also a potential source of exposure when used during natural disasters such as blizzards and hurricanes. Many 44
Anthony DeGelorm, Pharm.D. Clinical Toxicology/EM Fellow at Florida/USVI Poison Information Center-Jacksonville
of these scenarios put people in close proximity to the source, increasing their risk for CO inhalation. Once inhaled, CO quickly enters the systemic circulation and interferes with the red blood cell’s ability to deliver oxygen by binding to hemoglobin. CO competitively blocks oxygen from binding, preventing it from being carried to tissues for cellular respiration. In addition, CO decreases the offloading of the oxygen bound to hemoglobin making it even harder to bring oxygen to where it is needed.3 Ultimately this interference with oxygen transport leads to hypoxia. However, CO toxicity is not just limited to hypoxia. CO also interferes with cellular respiration by binding to the mitochondrial cytochrome oxidase, an important enzyme used in the electron transport chain. CO activates guanylate cyclase,4 which relaxes vascular smooth muscles resulting in vasodilation and potentially syncopal episodes. The earliest symptoms associated with CO poisonings are often nonspecific and may be confused with other illnesses, such as influenza (especially in the winter).5 The central nervous system (CNS) and the heart are the most sensitive to the effects of CO. CNS manifestations can include EMpulse Winter 2021
headache, dizziness, syncope, ataxia and coma. Cardiovascular effects may include tachycardia, dysrhythmias and chest pain. Patients commonly present with headaches, dizziness and nausea. These headaches are usually described as dull, frontal and continuous.3 Classic but uncommon phenomena include cherry-red skin coloration and cutaneous bullae. Patients exposed to CO are at risk of developing neurocognitive sequelae, which can take days to manifest, and most cases are associated with a loss of consciousness acutely after toxicity.3 When assessing a patient with a possible exposure, the ABC’s (airway, breathing, circulation) are of utmost importance. The patient should be placed on a cardiac monitor and be administered 100% oxygen as soon as possible via a nonrebreather face mask (NRFM), high flow nasal canula (HFNC),6 or endotracheal tube to enhance the dissociation of CO from the blood and tissue. A blood gas, with co-oximetry, should be obtained to assess the carboxyhemoglobin (COHb) level. The half-life of carboxyhemoglobin is reduced from a mean of 5 hours when breathing room air, to ~1 hour when breathing 100% oxygen.7 The end-point of treatment is unclear, but oxygen should be given
UNTIL THE MONITOR ALARMS REFERENCES
1. Iqbal S, Law H-Z, Clower JH, Yip FY, Elixhauser A. Hospital burden of unintentional carbon monoxide poisoning in the United States, 2007. Am J Emerg Med. 2012;30(5):657-664.
FPICN toxicologists are available 24 hours a day, free of charge, at 1-800-222-1222 if you suspect CO exposure in a patient or to assist in the management of this or other potentially toxic exposures.
2. Quickstats: number of deaths resulting from unintentional carbon monoxide poisoning,* by month and year - national vital statistics system, united states, 2010-2015. MMWR Morb Mortal Wkly Rep. 2017;66(8):234. 3. Nelson, L. S., Goldfrank, L. R., Howland, M. A., & Lewin, N. (2019). Carbon Monoxide. In Goldfrank’s Toxicologic Emergencies (11e ed., pp. 1663–1675). McGraw-Hill Education.
until the resolution of symptoms, usually accompanied by a COHb level less than 5%.3 One consideration is that patients who are smokers may have a baseline carboxyhemoglobin level of 5-10%.
4. Jackson EB Jr, Mukhopadhyay S, Tulis DA. Pharmacologic modulators of soluble guanylate cyclase/cyclic guanosine monophosphate in the vascular system - from bench top to bedside. Curr Vasc Pharmacol. 2007;5(1):1-14.
Hyperbaric oxygen (HBO) is another treatment option for significant carbon monoxide exposures. The use of HBO for CO is controversial and the availability is limited. HBO works by causing COHb dissociation to occur at a rate greater than breathing 100% oxygen at sea level, accelerating the restoration of mitochondrial oxidative processes. It also increases the amount of dissolved oxygen in the blood by 10-fold and reduces the halflife of COHb to approximately 20 mins at 2.5 atmospheric pressure.8 Patients with syncope, coma, seizures, altered mental status, abnormal cerebellar function, pregnancy with a COHb greater than 15% and fetal distress have the highest potential to benefit from hyperbaric oxygen treatment.3
5. Dolan MC, Haltom TL, Barrows GH, Short CS, Ferriell KM. Carboxyhemoglobin levels in patients with flu-like symptoms. Ann Emerg Med. 1987;16(7):782-786. doi:10.1016/ s0196-0644(87)80575-9
Despite CO being difficult to detect due to its lack of odor, there are several ways to prevent and minimize exposure to CO. Find prevention strategies at: floridapoisoncontrol. org/poisoning-in-florida/carbonmonoxide. ■
6. Onder Yesiloglu, Muge Gulen, Salim Satar, Akkan Avci, Selen Acehan & Haldun Akoglu (2020) Treatment of carbon monoxide poisoning: highflow nasal cannula versus non-rebreather face mask, Clinical Toxicology, DOI: 10.1080/15563650.2020.1817477 7. Peterson JE, Stewart RD. Absorption and elimination of carbon monoxide by inactive young men. Arch Environ Health. 1970;21(2):165-171. doi:10 .1080/00039896.1970.10667215 8. Weaver LK, Howe S, Hopkins R, Chan KJ. Carboxyhemoglobin half-life in carbon monoxide-poisoned patients treated with 100% oxygen at atmospheric pressure. Chest. 2000;117(3):801-808. doi:10.1378/chest.117.3.801
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◀ Continued from page 43 keep friends and family apprised of the significant events of grandpa? How does one inform them of grandpa’s imminent demise? Ultimately, a viral pandemic has made life difficult, but EOL patients and those associated with them cannot be forgotten. Johnny won’t ever hear his grandfather’s stories again while they sit together on a park bench. Johnny won’t have his grandfather at his high school graduation or wedding. And now, Johnny won’t even be with his grandfather as he takes his final breath. Grandpa will likely die alone in his hospital bed, and even the nurses and doctors may not know of his passing until the monitor’s alarm. Stress is omnipresent, especially during these unprecedented times. It is imperative to remain cognizant of all the stressors and collaborate accordingly with EOL care patients, friends, family and staff. ■
REFERENCES 1. Turner J, Eliot hodgson L, Leckie T,
Eade L, Ford-dunn S. A Dual-Center Observational Review of Hospital-Based Palliative Care in Patients Dying With COVID-19. J Pain Symptom Manage. 2020;60(2):e75-e78.
2. Managing COVID-19 symptoms
(including at the end of life) in the community: summary of NICE guidelines. BMJ. 2020;369:m1461.
3. Sun H, Lee J, Meyer BJ, et al. Char-
acteristics and Palliative Care Needs of COVID-19 Patients Receiving Comfort-Directed Care. J Am Geriatr Soc. 2020;68(6):1162-1164.
4. Lovell N, Maddocks M, Etkind
SN, et al. Characteristics, Symptom Management, and Outcomes of 101 Patients With COVID-19 Referred for Hospital Palliative Care. J Pain Symptom Manage. 2020;60(1):e77-e81.
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EDUCATION CORNER
FUN & GAMES Using Gamification to Engage Multi-generational Learners in Medical Education By Caroline M. Molins, MD, MSMEd, FACEP, FAAEM
By Carmen J. Martinez, MD, MSMEd, FACEP, FAAEM
Many factors can influence the effectiveness of medical education. Learners respond to educational strategies differently, and there is a generational dimension as to how these strategies are delivered and received. A generation is defined by a set period in which, despite their geographical location, they share common experiences, defining world history events and similar social traits. Each generation has distinctive teaching and learning styles (see sidebar), and thoughtful consideration of each generation’s preferred learning style empowers educators, helping
them understand how to appeal and motivate their learners. As Millennials and Generation Z become the most dominant type of learners, medical education must adapt by incorporating active learning styles with immediate feedback. While games have been used to facilitate learning for decades, gamification is one of the hottest trends in medical education, likely due to the increasing number of Millennial learners.3 Gamification refers to applying game design elements to a non-gaming topic, using concepts
Daunting Diagnosis: A By Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief �CONTINUED FROM PAGE 8
This patient is suffering from acute necrotizing ulcerative gingivitis (ANUG). Dentistry was consulted, who performed a bedside debridement of the dead gum tissue. Metronidazole was prescribed for outpatient care. The patient was counseled on proper oral hygiene, including daily mouth rinses. A follow up dental appointment was made for the patient to monitor his progress. ■ 46
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like badges, levels, leaderboards, and limited time and resources to create a narrative. This style appeals to both Millennial and Generation Z learners, and is a natural teaching approach for Generation X educators. Gamification encourages a positive learning environment, creates motivation, improves engagement and retention, gives learners control over the material, and delivers effective immediate feedback. Gamification’s strengths and potential weaknesses can be attributed to the self-determination learning (SDL) theory. SDL is a theory of human motivation and personality that defines a person’s inherent growth tendencies and innate psychological needs of competence, autonomy, and relatedness. A learner’s competence is related to their ability to achieve a goal. Goals help create a positive and linear relationship with a specific process or outcome, motivating learners and providing essential feedback. Creating visual goals helps motivate and remind learners of their achievement and progress. Learner autonomy allows the learner to choose how they desire to learn. Participation in gamification meets that psycholog-
turn mandatory tasks and assignments into quests to help them gain stars, points, badges, or coins that will be cumulative during different stages. This strategy will increase motivation and give learners a sense of accomplishment. The use of team-building games will reinforce knowledge, foster collaboration, and improve interpersonal and communication skills. Some examples are adopting well-known television games such as Jeopardy and Family Feud, or puzzle-solving games such as “Escape Rooms,” where learners must cooperatively find clues and solve puzzles to accomplish a goal. The increased use of technology and the number of online learning platforms has also facilitated and increased the use of gamification in medical education (like Kahoot, Quizlet, and Airway Ex.).
ical need. Relatedness refers to how learners are interconnected to others and the content, and is closely linked with intrinsic and extrinsic motivation. Relatedness can help promote the use of teams and collaborative learning communities, as well as autonomy through user interfaces. Motivational challenges that engage peer-to-peer comparisons and social aspects can be used to incentivize the learners.
It is important to remember that even though gamification is an exciting way to deliver content and engage learners, it must be used strategically. Educators should limit the incorporation of gamification elements to prevent learners from getting distracted.5 Gamification makes learning fun and experiential for learners. But it will also improve motivation and engagement by adding a degree of competition when used in a collaborative, positive, and supportive learning environment. ■
REFERENCES
1. Johnson SA, Romanello ML. Generational diversity: teaching and learning approaches. Nurse Educ. 2005. doi:10.1097/00006223-20050900000009
Gamification also poses some challenges, such as overjustification and the inherent negative effects of competition. Overjustification is the net negative effect on engagement and motivation from an overreliance on external incentives, such as prizes. This can have a negative impact on a learner’s autonomy, which can create disengagement. Competition can have negative effects on learners as it also can affect competence, especially when their abilities are publicly displayed and there are social implications.4
2. Eckleberry-Hunt J, Lick D, Hunt R. Is Medical Education Ready for Generation Z? J Grad Med Educ. 2018. doi:10.4300/JGME-D-18-00466.1
Gamification can be incorporated into medical education in many ways, from educational content to interpersonal communication skills. Educators can
6. The Annie E. Casey Foundation. “What is Generation Alpha?” Nov. 4, 2020. aecf.org/blog/what-is-generationalpha/
3. Boysen PG, Daste L, Northern T. Multigenerational challenges and the future of graduate medical education. Ochsner J. 2016. 4. Rutledge C, Walsh CM, Swinger N, et al. Gamification in action: Theoretical and practical considerations for medical educators. Acad Med. 2018. doi:10.1097/ ACM.0000000000002183 5. Singhal S, Hough J, Cripps D. Twelve tips for incorporating gamification into medical education. MedEdPublish. 2019. doi:10.15694/mep.2019.000216.1
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THE GENERATIONS Baby Boomers
born from 1946-1964
Educationally like contact with faculty through lectures, detailed handouts based on the lectures, and note-taking to apply subject matter into real-life experiences. This generation thrives in caring learning environments with positive reinforcement.
Generation X
born from 1965-1981
This generation prefers to learn on their terms, usually quickly and efficiently and likely through distance-learning or preprogrammed courses that allow the learner to work at their own pace and on their own time.
Millennials (Generation Y) born from 1982-1996
They grew up with technology and want to integrate it into the learning environment. They are goal-oriented, multi-taskers by nature, collaborative and enjoy experiential learning activities. They seek to learn from their mistakes immediately; therefore, simulations and game-styled learning suit them best.1
Generation Z
born from 1997-2009
The newest generation of learners that have entered medical education. They like their learning experiences to be customizable to their personal needs, in which they pick and choose the best time, place, and resources for them to learn. They enjoy hands-on experience and on-the-job learning with on-demand educational resources and feedback. Active learning through flipped classrooms, problem-based learning, simulation, and gaming is hugely beneficial.2 Next generation:
Generation Alpha
born from 2010-2025
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