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2025 EDITION | Volume 32, Issue 1

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

FRONTLINES OF PROGRESS

STRONGER VOICES.

STRONGER CARE.

COME FOR THE JOB

207

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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, our advertisers/sponsors, or any of the institutions our writers are affiliated with.

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

F EMERG E EO

2025 EDITION Volume 32, Issue 1 EMpulse Magazine is the official publication of the Florida College of Emergency Physicians EDITOR-IN-CHIEF: Jill Ward, MD, DABT, FACEP, FAAEM, MS jillangelaward@gmail.com MANAGING Dani Knipstein EDITOR: DKnipstein@emlrc.org

Florida College of Emergency Physicians Board of Directors: PRESIDENT - ELECT

VICE PRESIDENT

SAUNDRA A.JACKSON, MD, FACEP

BLAKE BUCHANAN, MD, FACEP

SHAYNE GUE, MD, FACEP, FAAEM

SECRETARY TREASURER

IMMEDIATE PAST - PRESIDENT

EXECUTIVE DIRECTOR & CEO

TODD L. SLESINGER, MD, FACEP, FCCM, FCCP

MELISSA KEAHEY

PRESIDENT

ELIOT GOLDNER, MD, FACEP

DESIGN Jennifer Finley, Greg Hunter EDITORS: Speedway Custom Photo Lab PUBLISHER: Johnson Press of America, Inc. 800 N. Court St. Pontiac, IL 61764 jpapontiac.com

View Residency Updates Online

MEMBERS

Rajiv Bahl, MD, MBA, MS, FACEP; Tom Bentley, MD, FACEP; Ricki A. Brown, MD; Stuart J. Bumgarner, MD; Latha Ganti, MD, FACEP; Kyle Gerakopoulos, MD, MBA; Anton Gomez, DO, FACE; Steven B. Kailes, MD, FACEP Non-Voting; Joseph King, MD; Sara Kirby, MD; Kristin McCabe-Kline, MD, FACEP, FAAEM, FACHT, ACEP BOD Non-Voting; Brandy Milstead, MD; Vincent Roddy, MD, MBA, FACEP; Jeremy K. Selley, DO, FACOEP; Zach Terwilliger, MD; Josef Thundiyil MD, MPH, FACEP; Christine Van Dillen, MD, FACEP; Cristina Zeretzke, MD, FACEP; Kylie Caouette, DO, EMRAF President; Melissa Keahey, Executive Director & CEO; Toni Large, Large Strategies Lobbyist

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Florida Emergency Medicine Foundation Board of Directors: PRESIDENT

VICE PRESIDENT

DAVID C.SEABERG, MD, FACEP

ROXANNE SAMS, MS, ARNP-BC, MA

SECRETARY - TREASURER

IMMEDIATE – PAST PRESIDENT ERNEST PAGE, MD, FACEP (PP)

JORDAN CELESTE, MD, FACEP

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MEMBERS

Jay L. Falk (PP), MD, MCCM, FACEP; Vidor Friedman, MD, FACEP; Jaime Greene, BA, MS, EMT; James V. Hillman, MD, FACEP; Michael Lozano, Jr, MD, FACEP; Thom Mayer, MD, FACEP, FAAP, FACHE; David C. Seaberg, MD, FACEP; Bryan Spangler, DHSc

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.

EMpulse 2025

QUICK QUIZ Keep an eye out for Quick Quiz questions sprinkled throughout the magazine! Answers are printed upside down in each question box—but don’t stop there. Turn to page 53 for full explanations and to see how much you really know!

TABLE OF CONTENTS FRONTLINES

FCEP President Message Saundra A. Jackson, MD, FACEP - From the College.................................................................................................7 Editor-in-Chief Update Jill Ward, MD, DABT, FACEP, FAAEM, MS - From the College...................................................................................6 FCEP Board of Directors FCEP Staff..................................................................................................................... 8

ADVERTISER’S INDEX EMPros............... 2-3 LogixHealth......... 23

RESUS ROOM

Kratom Rising: Patterns, Poisoning, and Withdrawal .Herbert Wan, PharmD; Reeves Simmons, PharmD, DABAT; Dawn R. Sollee, PharmD, DABAT, FAACT - Feature........... 9-10 Building a Stronger System: Florida EMS Advances in Resuscitation and Innovation Danielle DiCesare, MD - Committee Report........................................................................................................... 11 Nuances in ED Care for Necrotizing Soft Tissue Infections: A Case Series and Review Abram Reynolds; Lindsey Balta, MD; Cheyenne Quailey, MD; Azalea Samsam, DO; Ryan Littell, PA-C; Jonathan Littell, MD; Steven Nazario, MD; Maria Tassone, DO; Mary McLean, MD - Feature................................................................ 12-13

USACS................. 25 TeamHealth.....28-29 IWC..................... 39 Alfest................... 46

THE PEDIATRIC PULSE

Pediatric Pearls Small Patients, Big Challenges: Navigating Neonatal Emergencies, Yiraima Medina-Blasini, MD, FACEP; Amit Patel, MD, FAAP, FACEP - Committee Report..................................... 14-16 Enhancing Pediatric Readiness: Florida’s Prehospital Pediatric Readiness Recognition Program Gains Rapid Adoption Across the State and National Attention Phyllis L. Hendry, MD, FAAP, FACEP; Katelyn Dabhi, MS, CHES® - Feature.......................................................... 17-18

ERG..................... 49 HCA..................... 55

THE PHYSICIAN’S TOOLKIT

Sustaining Physician-Led Emergency Care: The Case for Democratic Groups Justin McNamee, DO, FACEP, FACOEP - Sponsored Feature........................................................................................................................................19 Medications on the Radar: What’s New, What’s Changed, and What’s Worth a Second Look Jill Ward, MD, DABT, FACEP, FAAEM, MS - Feature.............................................................................................................................................. 20-21 Thinking Outside the ED Box Michael Granovsky, MD, FACEP, CPC - Sponsored Feature..........................................................................................................................................24 Florida Resucitation Centers of Excellence FCEP Staff............................................................................................................................................ 25

SYSTEMS & SAFETY

The Cost of Caring: When the Hands That Heal Are Met with Harm Michelle F. Wallen, DO, MS, FACOEP - Feature...................................................................................................................................................... 26-27 Creating Psychological Safety in Medical Education: Building a Culture of Learning in the Emergency Department Carmen J. Martínez Martínez, MD, MSMEd, FACEP; Caroline M. Molins, MD, MSMEd, FACEP - Feature.........................................................................30 Embrace the Chaos: A Resident’s First Week Deepak Sukumar D.O., RRT - Feature........................................................................................................................................................................31 Symposium by the Sea Recap FCEP Staff............................................................................................................................................................ 32-37 Meet The Staff FCEP Staff.......................................................................................................................................................................................38

POLICY PULSE

Reimbursement Realities and Regulatory Shifts Eliot Goldner, MD, FACEP - Committee Report..........................................................................................................................................................40 Emergency Medicine Advocacy: Standing Tall in Tallahassee and Beyond Jeremy K. Selley, DO, FACOEP; Brandy Milstead, MD - Committee Report.....................................................................................................................41

BEYOND THE SHIFT

From Bedside to Bank Account: Why Paycheck Literacy Matters for Emergency Physicians Nicholas P. Cozzi, MD, MBA, FACEP, FAEMS; Jamie Shoemaker Jr., MD, FACEP -Feature................................................................................................44 Standing Strong Together TeamHealth - Sponsored Feature.....................................................................................................................................45 Making a Meaningful Impact: The Heart of the EMPros Foundation Jesse Santos - Sponsored Feature..............................................................................................................................................................................47

ACADEMIC PULSE

Connecting the Pulse of Florida Emergency Medicine René Mack, MD, RDMS, FACEP - Committee Report..................................................................................................................................................48 Life After Residency Recap FCEP Staff....................................................................................................................................................................49 EMRAF Update: Empowering Florida’s Next Generation of Emergency Physicians Kylie Caouette, DO - From the College................................................................................................................................................................. 50-51 Shaping the Future of Emergency Medicine: FCEP Medical Student Council Manuel Tarango III, Adam Kipust, and Edwin Rosa - Committee Report................................................................................................................. 52-53 FCEP FEMF Annual Calendar FCEP Staff.................................................................................................................................................................54

EMpulse 2025

FROM THE COLLEGE

EDITOR-IN-CHIEF UPDATE JILL A. WARD, MD, DABT, FACEP, FAAEM, MS Editor-in-Chief, EMpulse

THE YEAR IN REVIEW This year reminded us that resilience is not just a word, it’s a skill we practice daily. We saw our profession take steps forward in advocacy. Efforts to address surprise billing, Medicaid expansion, and fair physician reimbursement have started to shift conversations at both the state and national level. Wellness and workforce sustainability also remained at the forefront, with new initiatives focused on reducing burnout and reimagining what an emergency medicine career can look like long-term.

LOOKING AHEAD What comes next for us as emergency physicians is just as pressing as what we’ve been through. The year ahead will bring: • New technology: Expanded point-of-care ultrasound applications, AI-powered decision support, and real-time patient monitoring tools. • Practice innovation: More departments will adopt flexible staffing models, APP-physician collaboration frameworks, and alternative payment arrangements. • Clinical evolution: Expect updates in stroke care, trauma resuscitation, and prehospital systems of care — areas where emergency medicine continues to lead. • Physician well-being: Wellness will move beyond buzzword with institutions focusing on safety, psychological support, and work-life integration as core operational goals.

THE MISSION OF EMPULSE Our role at EMpulse is to reflect, amplify, and connect. We are here to deliver not only cutting-edge clinical insights but also stories of resilience, innovation, and humanity from the ED. Each issue will bring you practical pearls a spotlight on emerging science, and a voice for the everyday challenges and victories that define our work.

FRONTLINES

As your editor, my hope is that EMpulse becomes more than a magazine — that it serves as a pulse check for our specialty. Together, we’ll celebrate what we’ve achieved, prepare for what’s ahead, and continue to honor the privilege of being an emergency physician. Here’s to another year of practicing at the sharp edge of medicine — where seconds matter, and impact is measured in lives changed. With gratitude and resolve,

Jill A. Ward, MD, DABT, FACEP, FAAEM, MS Editor-in-Chief, EMpulse

EMpulse 2025

FROM THE COLLEGE

PRESIDENT’S MESSAGE

REFLECTING ON PROGRESS AND PURPOSE SAUNDRA A. JACKSON, MD, FACEP, President Florida College of Emergency Physicians

Dear Colleagues and Friends,

Since we came together at Symposium by the Sea this past August, I’ve continued to reflect on the energy, collaboration, and sense of purpose that filled those few impactful days. It was a powerful reminder that when we gather, listen, and lead together, real progress is not just possible — it’s inevitable. In that same spirit of connection and momentum, I want to share a few updates on what we’ve been working on since the conference, and how your voices continue to guide our efforts across the state and beyond.

ADVOCACY IN ACTION: FIXING THE NO SURPRISES ACT One of our top advocacy priorities this year remains addressing the flawed implementation of the Independent Dispute Resolution (IDR) process under the No Surprises Act. While the intent of the legislation was to protect patients from unexpected medical bills, the current IDR system has created new challenges — undermining fairness for emergency physicians and the very patients we serve. FCEP has been actively engaging with national partners, policymakers, and regulatory agencies to push for meaningful reform. We’re advocating for a process that restores transparency, efficiency, and balance, ensuring that emergency medicine is treated with the respect it deserves. Your stories, your data, and your lived experiences remain powerful tools in this fight. As The current process is not we continue this advocacy work, we’ll be calling on you to share those stories — helping us working — for physicians or illustrate the real-world impact of these policies on Florida’s emergency departments and for patients — and we are communities. Together, we are building a strong, united front to ensure emergency medicine remains respected, protected, and heard. committed to fixing it.

“

STRENGTHENING OUR COMMUNITY: INCLUSION, ENGAGEMENT, AND GROWTH Equally important to our advocacy work is our ongoing commitment to making sure that FCEP reflects you — our diverse, passionate, and forward-thinking membership.

”

Over the past several months, we have: • Launched new initiatives to better engage early-career physicians, residents, and medical students. • Created new pathways for member input in organizational priorities and advocacy agendas.

Our goal is to ensure that every member feels seen, valued, and heard. We recognize that the strength of FCEP lies not in a single voice, but in the diversity of perspectives that together define our specialty. If you haven’t yet had a chance to get involved, I encourage you to do so — whether that means joining a committee, mentoring a colleague, or simply reaching out to share your ideas. Your voice makes a difference.

LOOKING AHEAD: BUILDING A SUSTAINABLE FUTURE FOR EM As we look toward the remainder of the year — and begin planning for 2026 and beyond — our focus remains on the issues that matter most: • Excellence in patient care • Support for our physicians

• Sustainable, fair practice environments • Strong leadership at every level of emergency medicine

We know there’s more work ahead. But we also know that when this community comes together — united by shared values and a common mission — there is no challenge we cannot meet.

A SHARED MISSION Thank you for being part of the FCEP family and for continuing to lead with compassion, dedication, and courage. We are stronger because of you — and together, we’ll continue to advance the practice of emergency medicine in Florida and beyond. Warm regards,

Saundra A. Jackson, MD, FACEP

President, Florida College of Emergency Physicians

EMpulse 2025

FRONTLINES

• Prioritized inclusion, transparency, and responsiveness across all levels of leadership — from board discussions to program design.

2025 - 2026

FCEP BOARD OF DIRECTORS DIRECTORS

OFFICERS SAUNDRA A. JACKSON, MD, FACEP PRESIDENT

RAJIV BAHL, MD, MBA, MS, FACEP

TOM BENTLEY, MD, FACEP

RICKI A. BROWN, MD

STUART J. BUMGARNER, MD

LATHA GANTI, MD, FACEP

KYLE GERAKOPOULOS, MD, MBA

ANTON GOMEZ, DO, FACEP

STEVEN B. KAILES, MD, FACEP

JOSEPH KING, MD

Appointed, Non-Voting

BLAKE BUCHANAN, MD, FACEP PRESIDENT-ELECT

SHAYNE GUE, MD, FACEP, FAAEM VICE- PRESIDENT

ELIOT GOLDNER, MD, FACEP

ACEP BOD Non-Voting

SARA KIRBY, MD

ACEP BOD Non-Voting

SECRETARY-TREASURER

TODD L. SLESINGER, MD, FACEP, FCCM, FCCP IMMEDIATE PAST PRESIDENT

THANK YOU TO OUR OUTGOING BOARD MEMBERS! Jordan Celeste, MD, FACEP: 2015-2025 (2 Terms + Executive Committee) Jesse Glueck, MD: 2019-2025 David Lebowitz, MD, FACEP: 2022-2025 Diana Mora-Montero, MD, FACEP: 2022-2025 Michael Thompson, MD: 2024-2025 (EMRAF President)

KRISTIN MCCABE-KLINE, BRANDY MILSTEAD, MD MD, FACEP, FAAEM, FACHT,

VINCENT RODDY, MD, MBA, FACEP

JEREMY K. SELLEY, DO, FACOEP

ZACH TERWILLIGER, MD

JOSEF THUNDIYIL, MD, MPH, FACEP

CHRISTINE VAN DILLEN, MD, FACEP

CRISTINA ZERETZKE, MD, FACEP

KYLIE CAOUETTE, DO EMRAF President

MELISSA KEAHEY, Executive Director & CEO

TONI LARGE, Large Strategies Lobbyist

EMpulse 2025

FEATURE

KRATOM RISING: PATTERNS, POISONING, AND WITHDRAWAL Dawn R. Sollee, PharmD, DABAT, FAACT, Director Florida/USVI Poison Information Center - Jacksonville

Herbert Wan, PharmD Clinical Toxicology/Emergency Medicine Fellow Reeves Simmons, PharmD, DABAT, Assistant Director

Kratom (Mitragyna speciosa) is a plant that is a part of the Rubiaceae family (coffee family). This plant can be found natively in Southeast Asian countries such as Thailand and Indonesia and has been used historically for the treatment of ailments/diseases, as an energy booster, and in ritualistic ceremonies.1,3 Kratom contains approximately three dozen different indole alkaloids, but the most abundant and significant alkaloids are mitragynine and 7-hydroxymitragynine (7-OH). Although the exact mechanism of mitragynine and 7-OH is not well understood, numerous in vitro and rodent studies suggest that they act as a partial agonist at mu-opioid receptors while acting as an antagonist at kappa- and delta-opioid receptors. Interestingly, some studies have theorized that mitragynine and 7-OH display selectivity for G-protein signaling while having no recruitment of Betaarrestin at mu-opioid receptors. Beta-arrestin is implicated in the development of symptoms related to opioid use, such as respiratory depression and constipation. This may indicate that mitragynine and 7-OH use may be associated with a reduced risk for respiratory depression despite mu-opioid receptor agonism. Furthermore, these products may also interact with alpha-2 adrenergic, serotonergic, dopaminergic, and adenosine receptors, but the physiological significance is unclear.4,15

TRENDS AND USAGE In recent years, kratom has experienced a sharp increase in popularity for many proposed reasons, including:

1) It is perceived as a natural alternative to conventional pharmaceutical therapy, whether for treating opioid dependence or seeking alternative treatments for various illnesses/diseases. 2) Due to its legal/unregulated status, it is much easier to access and often available for purchase via online stores, in local smoke shops, and at some gas stations. 3) Some use it recreationally due to its stimulant and opioid-like effects.

Several products that are being advertised as kratom are believed to be more potent than the historical plant formulations, as manufacturers are extracting and concentrating 7-OH and mitragynine in efforts to offer a more “enhanced product”. In fact, some of these products ONLY contain 7-OH.2 As mentioned before, 7-OH has a higher binding affinity to mu-opioid receptors, thus providing a stronger effect. It is believed that due to the extraction and concentration of these two active ingredients, the higher binding affinity can potentially cause users to experience more serious adverse effects compared to natural kratom products. Additionally, the lack of regulation and quality assurance testing may result in kratom products being contaminated. In the past, Salmonella and heavy metals have been found as contaminants in kratom and kratom-containing products.17,18 The possibility of contaminants may result in unforeseen adverse effects outside of the ones that may be precipitated from the product itself.

CLINICAL MANIFESTATIONS, TOXICITY, AND MANAGEMENT Typically, at low doses (1-5 g) of kratom, users will experience a stimulating effect. But when doses exceed 5g, it can produce opioid-like effects (i.e., euphoria, sedation, analgesia, and respiratory depression). Outside of the opioid-like effects, acute exposures and overdoses have been associated with agitation, hallucinations, seizures, liver dysfunction, and even death.11 The lethal mechanism for these products is still not well understood. Many reports have shown pulmonary edema in post-mortem analyses and cases of fatalities often involve other substances being co-ingested.10 With “enhanced products,” the risk for adverse effects is much higher as these products will have much higher proportions of mitragynine and 7-OH, which can lead to more intense agonism and subsequent effects on the user.2 Management of acute exposures and overdoses is primarily symptomatic and supportive care. Naloxone has been reportedly utilized for the reversal of respiratory depression, but evidence of benefit and optimal dosing is limited, and further studies need to be conducted to determine any benefit.11

WITHDRAWAL EFFECTS AND MANAGEMENT

Kratom can be found in various formulations such as powders, capsules, resin extracts, tablets, and teas, just to name a few.2 However, with a spike in utilization, recent concerns have been raised regarding the safety and abuse potential of kratom-related products,6 especially in those with a previous history of substance use disorder.7

The risk for addiction is also a very real concern, and chronic users of kratom and kratom-related products have presented to healthcare facilities for management of withdrawal.5 A recent study surveyed 357 kratom users, and the most common adverse effect participants experienced across all groups was withdrawal.19 Withdrawal symptoms and treatment of

EMpulse 2025

RESUS ROOM

BACKGROUND

kratom-related products mirror opioid withdrawal and treatment. There is limited evidence and literature regarding optimal treatment and management of kratom-related product withdrawal, but buprenorphine-naloxone has been successfully utilized in several case reports, but the optimal dosing is unknown.6

Quick Quiz Question 1: Push-Dose Pressors CASE: A 58-year-old septic patient’s blood pressure drops to 78/40 mmHg during central line placement. You need a quick temporizing agent. Which push-dose pressor provides the most physiologic balance of alpha and beta activity with fewer dysrhythmias?

A. Epinephrine 10–20 mcg B. Phenylephrine 100 mcg

C. Norepinephrine 5–10 mcg D. Dopamine 5–10 mg Answer: C

24/7, 365 days a year, at 1 (800) 222-1222 for recommendations and guidance on the treatment and management of patients presenting with kratom-related toxicities and withdrawal as well as other exposures. ■ REFERENCES (cont. from page 10)

LEGAL STATUS

Due to increased use and various risks associated with 7-OH, mitragynine, and kratom usage, they have become targets for regulation by the Food and Drug Administration (FDA) and local state governments. Back in 2023, Florida passed The Florida Kratom Consumer Protection Act that restricted the purchase of kratom and related products to those 21 years and older.12 A news release by the FDA on July 29, 2025, recommended pursuing scheduling actions against certain 7-OH products under the Controlled Substances Act.9 As such, as of August 13, 2025, the attorney general of Florida classified products that contain 7-OH as a Schedule I controlled substance in Florida.13 Even before this, kratom had been banned in Sarasota County since 2014. Other states where kratom and kratom-related products are banned include Alabama, Arkansas, Indiana, Rhode Island, Vermont, and Wisconsin.14

CONCLUSION

Despite the new restrictions and regulations, there are still many states that have not enacted any protection measures against kratom-related products. The public can still access these products across state lines or even from online stores. It is pertinent for emergency responders and healthcare providers to understand the prevalence and risks of these products if someone afflicted presents to their facility for care. The Florida Poison Information Center Network is available. 10

United States Drug Enforcement Administration. Kratom. Dea.gov. Published 2019. https://www.dea. gov/factsheets/kratom. Reissig CJ, Chiapperino D, Seitz A, Lee R, Radin R, McAninch J. 7-Hydroxymitragynine (7-OH): An Assessment of the Scientific Data and Toxicological Concerns Around an Emerging Opioid Threat. US Food and Drug Administration, Center for Drug Evaluation and Research; 2025. Accessed September 29, 2025. https://www.fda.gov/. Singh D, Narayanan S, Vicknasingam B. Traditional and non-traditional uses of Mitragynine (Kratom): A survey of the literature. Brain Research Bulletin. 2016;126:41-46. doi:https://doi.org/10.1016/j. brainresbull.2016.05.004. Todd DA, Kellogg JJ, Wallace ED, et al. Chemical composition and biological effects of kratom (Mitragyna speciosa): In vitro studies with implications for efficacy and drug interactions. Scientific Reports. 2020;10(1). doi:https://doi.org/10.1038/s41598-020-76119-w. Veltri C, Grundmann O. Current Perspectives on the Impact of Kratom Use. Substance Abuse and Rehabilitation. 2019;Volume 10:23-31. doi:https://doi.org/10.2147/sar.s164261. Kiyokawa M, Kwon AK, Cape MC, Streltzer JM. Kratom use disorder: case reports on successful treatment with home induction of buprenorphine-naloxone. Family Practice. 2023;40(4):596-598. doi:https://doi. org/10.1093/fampra/cmad081. Schimmel J, Amioka E, Rockhill K, et al. Prevalence and description of kratom ( Mitragyna speciosa) use in the United States: a cross‐sectional study. Addiction. 2020;116(1):176-181. doi:https://doi. org/10.1111/add.15082 Garcia-Romeu A, Cox DJ, Smith KE, Dunn KE, Griffiths RR. Kratom (Mitragyna speciosa): User demographics, use patterns, and implications for the opioid epidemic. Drug and Alcohol Dependence. 2020;208:107849. doi:https://doi.org/10.1016/j.drugalcdep.2020.107849. Office. McIntyre IM, Trochta A, Stolberg S, Campman SC. Mitragynine ‘Kratom’ related fatality: a case report with postmortem concentrations. J Anal Toxicol. 2015 Mar;39(2):152-5. doi: 10.1093/jat/bku137. Epub 2014 Dec 16. PMID: 25516573. Plants-Mitragyna. In: MerativeTM Micromedex® POISINDEX® (electronic version). Merative, Ann Arbor, Michigan, USA. Available at: https://www.micromedexsolutions.com/ (cited: September 29, 2025). Senate Bill 1734 (2025) - The Florida Senate. Flsenate.gov. Published 2025. Accessed October 2, 2025. https://www.flsenate.gov/Session/Bill/2025/1734/ByCategory. Attorney General James Uthmeier Files Emergency Rule; Immediately Removing Dangerous 7-OH from Store Shelves | My Florida Legal. Myfloridalegal.com. Published 2025. https://www.myfloridalegal.com/ newsrelease/attorney-general-james-uthmeier-files-emergency-rule-immediately-removing-dangerous-7 Kratom Regulation: Federal Status and State Approaches. Congress.gov. Published 2025. https://www. congress.gov/crs-product/LSB11082. Eastlack SC, Cornett EM, Kaye AD. Kratom-Pharmacology, Clinical Implications, and Outlook: A Comprehensive Review. Pain Ther. 2020;9(1):55-69. doi:10.1007/s40122-020-00151-x. U.S. Food and Drug Administration. Preventing the Next Wave of the Opioid Epidemic: What You Need to Know About 7-OH. Silver Spring, MD: FDA; 2025. Accessed October 2, 2025. https://www.fda.gov/drugs/ information-consumers-and-patients-drugs/hiding-plain-sight-7-oh-products. Human Foods Program. Outbreak of Salmonella Infections Linked to Products Contain Kratom. U.S. Food and Drug Administration. Published 2024. https://www.fda.gov/food/hfp-constituent-updates/fdainvestigates-multistate-outbreak-salmonella-infections-linked-products-reported-contain-kratom. Commissioner O of the. FDA In Brief: FDA releases test results identifying dangerous levels of heavy metals in certain kratom products. FDA. Published online December 20, 2019. https://www.fda.gov/news-events/ fda-brief/fda-brief-fda-releases-test-results-identifying-dangerous-levels-heavy-metals-certain-kratom. Smith KE, Panlilio LV, Feldman JD, et al. Ecological Momentary Assessment of Self-Reported Kratom Use, Effects, and Motivations Among US Adults. JAMA Network Open. 2024;7(1):e2353401. doi:https://doi. org/10.1001/jamanetworkopen.2023.53401.

EMpulse 2025

COMMITTEE REPORT

BUILDING A STRONGER SYSTEM:

FLORIDA EMS ADVANCES IN RESUSCITATION AND INNOVATION FLORIDA RESUSCITATION CENTER OF EXCELLENCE EXPANDS ACROSS THE STATE The Florida Association of EMS Medical Directors (FAEMSMD) convened on October 3, 2025, focusing on the continued advancement of cardiac arrest care across Florida through the Florida Resuscitation Center of Excellence (FRCE) program. This statewide initiative recognizes hospitals that demonstrate commitment to evidence-based resuscitation practices and emphasizes the vital role of hospital–EMS collaboration in improving patient outcomes. As of October, 16 hospitals have achieved FRCE designation, while 21 additional hospitals are actively working toward recognition — clear evidence of growing engagement and momentum throughout Florida’s healthcare system.

The FRCE program embodies the best of what Florida EMS can achieve — data-driven, team-centered care that directly translates to lives saved,” said one committee member.

FLORIDA CENTER FOR EMS LAUNCHES AT USF CAMLS

Dr. Desmond Fitzpatrick and Dr. Ben Abo were honored with the first-ever EMS Award at the Florida Stroke Registry Annual Meeting. Their recognition highlights their exceptional leadership in establishing the Central Florida Stroke Coalition, a regional collaboration aimed at strengthening stroke systems of care and improving time-totreatment metrics.

“

Their work reflects the power of coordinated leadership in saving lives and setting a new standard for prehospital stroke care,” said one attendee.

”

Congratulations to both on this well-deserved honor!

LOOKING AHEAD:

”

A major highlight of the meeting was the official opening of the Florida Center for EMS, housed at the USF Center for Advanced Medical Learning and Simulation (CAMLS) in downtown Tampa. Supported by the Florida Department of Public Health, this new statewide hub is designed to drive innovation, education, and data integration within the EMS community.

KEY PROGRAM INITIATIVES INCLUDE: • • • •

EMS & Trauma Committee

NAEMSP National Meeting comes to Tampa Florida’s EMS community will soon take center stage nationally as the National Association of EMS Physicians (NAEMSP) Annual Meeting comes to Tampa in January 2026. This event will bring together national experts, researchers, and EMS leaders for high-level discussions on clinical innovation, systems improvement, and the evolving future of prehospital medicine. Stay tuned for coverage and updates as Florida proudly hosts this premier national event. Florida continues to set a national example in EMS innovation, education, and collaboration. From cardiac arrest systems of care to new data-driven training centers, the state’s EMS leadership remains focused on building an integrated, high-performing emergency response system for every community. “Together, we’re not just responding — we’re transforming care” ■

Evaluation and enhancement of Mobile Integrated Health (MIH) Programs Curriculum development for EMT and paramedic education Defining best practices for Telehealth in EMS EMS data analysis and applied research initiatives

The Center will serve as a bridge between education, operations, and innovation — ensuring that Florida’s EMS systems remain at the forefront of national standards.

CELEBRATING LEADERSHIP: EMS EXCELLENCE RECOGNIZED

Quick Quiz Question 2: Droperidol’s Comeback CASE: A 32-year-old female with intractable migraine and multiple failed antiemetics presents with agitation and photophobia. Her QTc is 430 ms. Which of the following statements about droperidol is correct? A. It’s contraindicated for all C. Standard EM doses (≤ 2.5 QTc > 400 ms

B. ECG monitoring is re

quired for all patients

In a proud moment for Florida’s EMS and trauma community,

EMpulse 2025

mg) have minimal QT risk

D. It’s slower onset than

Answer: C

“

Danielle DiCesare, MD

eumoniae. He

FEATURE

NUANCES IN ED CARE FOR NECROTIZING SOFT TISSUE INFECTIONS: *Abram Reynolds; *Lindsey Balta, MD; *Cheyenne Quailey, MD; *Azalea Samsam, DO; Ryan Littell, PA-C; Jonathan Littell, MD; Steven Nazario, MD; Maria Tassone, DO; Mary McLean, MD *Pictured

A CASE SERIES AND REVIEW

INTRODUCTION Necrotizing soft tissue infections represent one of the most time-critical diagnoses in emergency medicine, where hours or even minutes can mean the difference between life versus death, or limb salvage versus amputation. These rapidly progressive infections demand immediate recognition and aggressive management, as delayed diagnosis leads to devastating complications including septic shock, multiorgan failure, and death. Unlike routine cellulitis or other more benign musculoskeletal infections, necrotizing infections classically feature disproportionate pain, systemic toxicity, and rapid tissue destruction extending along fascial planes, as well as other telltale features that make it unique. Emergency physicians must maintain high clinical suspicion and act decisively, oftentimes before confirmatory testing can be completed. We present three clinical cases demonstrating diagnostic challenges and management nuances.

a prescription for topical analgesics, and a referral to physical therapy. Primary care evaluation a week later uncovered persistent symptoms with new erythema which the patient attributed to topical irritation. Three days later, he returned to his PCP with severe shoulder pain, diffuse swelling, warmth, and patchy skin discoloration, for which he was referred immediately to the ED. In the ED, his vitals were as follows: HR 144, BP 138/69, T 37.9 °C, RR 24, 98% on RA, with shock index of 1.04. He was found to have critical WBC 31,000/μL, ESR 130.0 mm/hr, CRP 267.2 mg/L, x-ray showing soft tissue edema and subtle subcutaneous gas (Figure 1A), and CT revealing more extensive and obvious subcutaneous emphysema (Figure 1B). The LRINEC score was 11 (high risk for necrotizing infection).

CASE 2: MIDDLE-AGED MALE WITH LEG INJURY, NECROTIZING INFECTION, AND COMPARTMENT SYNDROME

A middle-aged male with DM and obesity presented with malaise and confusion following a fall with leg laceration. Despite obvious copious purulent and dark brown drainage CASE 1 from the laceration, the patient denied any significant pain and was remarkably nonchalant, attempting to reach for the TV remote and describing his condition as not a big deal. Vitals: HR 126, BP 120/70, T 37.8 °C oral, RR 25, 96% on 2 LPM, with shock index of 1.05. Examination revealed lower extremity erythema and severe swelling, decreased sensation, and thready pulses. Abnormal laboratory studies Figures 1 A through C. 1A: Right shoulder x-ray showing soft tissue swelling and very subtle subcutaneous emphysema. included ESR 110 mm/hr, CRP 1B: Right shoulder CT, axial view, showing more obvious appearance of subcutaneous emphysema. 400 mg/L, lactate 3.60 mmol/L, 1C: Clinical appearance after OR debridement and wound vac placement by orthopedics. CK 7,090 U/L (rhabdomyolysis), He was immediately started on broad spectrum antibiotics including clindamycin, and was sent emergently to the creatinine 2.63 and rapidly OR for the first of several debridement procedures with orthopedic surgery (Figure 1C). Surgical cultures grew Streptococcus required vacuum-assisted closure, prolonged rehabilitation, and reconstruction procedures, but he survived. worsening (acute renal failure). The LRINEC score was 10 points (high risk for necrotizing infection). CASE 1: ELDERLY MALE WITH

INDOLENT PROGRESSION OF NECROTIZING SHOULDER INFECTION

An elderly male with diabetes mellitus (DM) presented with right shoulder pain, reduced range of motion, and tachycardia. Laboratory studies revealed WBC 14.3 K/μL and hyperglycemia, and right shoulder x-ray showed AC joint osteoarthritis. After this initial visit, he was able to be discharged home with a new diagnosis of adhesive capsulitis, 12

CASE 3: ELDERLY MALE WITH FOURNIER’S GANGRENE AND LA BELLE INDIFFERENCE

An elderly male with DM presented with two days of progressive severe groin pain. The patient did not want to come to the hospital, stating he that he was “fine” and appearing calm and unconcerned, and his family had made him come to the ED for evaluation. Vital signs: HR 125 bpm, BP 90/55 mmHg, T 39.2°C oral, RR 20, 98% on RA, with shock

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FEATURE

CASE 2

Figures 2 A-E. 2A: Clinical image with subcutaneous dark “dishwasher fluid” discoloration, severe edema and taught skin appearance concerning for high compartment pressures. 2B: X-ray appearance with subcutaneous emphysema seen to the soft tissue overlying the medial calf. 2C/D: CT appearance with more obvious appearance of the subcutaneous emphysema as well as severe soft tissue edema. 2E: Clinical appearance after extensive debridement by general surgery. The patient was started on broad-spectrum antibiotics including linezolid, admitted to ICU, and taken to the OR by general surgery for debridement and fasciotomy. Hospital course included hypotension requiring vasopressors, intubation, compartment syndrome, and worsening renal failure requiring continuous renal replacement therapy (CRRT). Cultures grew Group A Streptococcus and MRSA. Despite aggressive management, he developed multi-organ failure and, unfortunately, did not survive.

index of 1.4. Examination revealed extensive scrotal and perineal edema with skin discoloration (Figures 2A and 2B) and subcutaneous crepitus extending to the lower abdomen. Laboratory studies revealed leukocytosis with left shift (22,000/μL with 18% bands), elevated lactate (4.1 mmol/L), severe AKI, and hyperglycemic crisis with venous blood gas pH 7.07 and blood glucose >700 mg/dL. The LRINEC score was 11 (high risk for necrotizing infection). Despite immediate ED management, he persisted in septic shock. He was brought emergently to the OR by urology and general surgery, and debridement revealed extensive fascial necrosis involving dartos, Colles’, and Scarpa’s fascia with frank purulence (Figures 2C and 2D). Cultures grew Bacteroides fragilis and Enterococcus faecalis. His hospital course was marked by further decline in his mental status while in the ICU. He returned to the OR for multiple further debridement procedures, diverting colostomy, and skin grafting. Despite these surgical efforts and optimal medical therapy, the infection continued to spread, and unfortunately the patient did not survive.

DISCUSSION AND REVIEW

Our cases illustrate critical emergency department diagnostic and management challenges of necrotizing infections. Early recognition depends on identifying features distinguishing these from routine cellulitis: disproportionate pain, rapid progression, systemic toxicity, and pathognomonic findings such as “dishwasher fluid” discharge, la belle indifference, and crepitus on exam. The most reliable signs include severe pain out of proportion to findings, subcutaneous crepitus, and systemic toxicity.1,2 However, pain may be masked in patients with DM and severe neuropathy, and a paradoxical absence of pain despite local tissue destruction can also suggest acute nerve involvement in the infection.3 “Dishwater fluid” discharge appears as dark brown leakage from the wound, or subcutaneous collection of dark brown fluid, and this suggests toxin-mediated liquefactive necrosis of tissue which is a unique feature of necrotizing infections.4 Subcutaneous emphysema is pathognomonic for gas-producing organisms.5 La belle indifference (French for beautiful ignorance) is the “paradoxical absence of psychological distress despite a serious medical illness” and is another unique feature of severe necrotizing infections,6

as experienced by the patient in Case 2. The SI (HR/Systolic BP) is a measure that can be used in conjunction with basic vital signs. SI>0.9 is suspicious for septic shock in these cases, but other cutoffs have been used as well (including >1.0).7 SI is particularly useful in patients with obesity who are likely to have higher baseline resting metabolic rate, HR, and BP. Many patients in whom necrotizing infections are a concern also have obesity, making SI an important tool for early detection. The LRINEC score incorporates laboratory values to stratify risk of necrotizing infections.8 Recent studies show variable performance with sensitivities 79-91% and specificities 7585%.9,10 LRINEC supplements but never replaces clinical judgment and a low score with high clinical gestalt should not delay surgical consultation.11 Immediate broad-spectrum antibiotics should target grampositive, gram-negative, and anaerobic organisms. Clindamycin provides antitoxin effects against streptococcal and clostridial toxins, while vancomycin or linezolid covers MRSA.12,13 Recent evidence suggests linezolid may provide equivalent antitoxin effects with superior tissue penetration.14 Emergency surgical consultation must be obtained immediately upon suspicion, even before imaging completion. Complications of necrotizing infections include septic shock (40-60%), multi-organ failure, acute kidney injury and renal failure requiring dialysis, compartment syndrome, rhabdomyolysis with hyperkalemia, limb loss, and death.15,16 Case 2 demonstrated multiple complications including rhabdomyolysis, compartment syndrome, renal failure with CRRT requirement. Early recognition reduces mortality from as high as 35% to as low as 10%,17 but even with the best medical and surgical management, risk of death remains high, long-term complications are common, and prolonged recovery should be expected.

CONCLUSION

Necrotizing infections require immediate recognition featuring disproportionate pain, subcutaneous crepitus, la belle indifference, and “dishwater fluid” discharge. Emergency physicians must initiate broad-spectrum antibiotics with antitoxin coverage and obtain immediate surgical consultation. ■

EMpulse 2025

COMMITTEE REPORT

PEDIATRIC PEARLS

SMALL PATIENTS, BIG CHALLENGES: NAVIGATING NEONATAL EMERGENCIES Yiraima Medina-Blasini1, MD, FACEP – Committee Member Amit Patel2, MD, FAAP, FACEP – Committee Member 1. HCA Florida Kendall Hospital, Miami FL 2. Nemours Children’s Hospital, Orlando FL Pediatric Emergency Medicine Committee

INTRODUCTION: Neonates represent one of the most challenging populations in emergency medicine. Their presentations are often subtle, their physiology unique, and their margin for error razor thin. Early recognition of warning signs along with timely evaluation and intervention is critical to prevent rapid decompensation or permanent injury. At Symposium by the Sea 2025, the Pediatric EM Committee delivered an engaging Neonatal Emergencies Workshop, designed to prepare providers for these high-stakes cases. 1. ABCS OF NEONATAL RESUSCITATION

THE PEDIATRIC PULSE

Resuscitation remains the cornerstone of neonatal emergency care. The session highlighted the updated NRP guidelines. • • •

Warmth, drying, and stimulation are the initial steps; up to 90% of neonates needing resuscitation require only initial warming and stimulation — but preparation for the remaining 10% is essential. Positive Pressure Ventilation (PPV) is the key intervention for newborns with apnea, gasping, or bradycardia. Early and effective PPV will improve your chances at a successful resuscitation. If the neonate’s condition does not improve or the heart rate drops below 60 bpm after 30 seconds of PPV, begin chest compressions and consider intubation!

are often non-specific and subtle therefore a high index of suspicion and timely management are essential. The most recent AAP guideline for well-appearing febrile infants 8 to 60 days old highlights several important updates including changes in the indications for lumbar puncture (LP) and the importance of inflammatory markers — absolute neutrophil count (ANC), C-reactive protein (CRP), and procalcitonin— to identify infants at risk for invasive bacterial illness (IBI). Inflammatory markers should be used in combination, no isolation. If procalcitonin is not available, an elevated ANC, elevated CRP, and a temperature ≥38.5°C should be considered abnormal.

Age-based evaluation (Well appearing, T ≥ 38°C): Infants 8–21 days: Full sepsis evaluation (including LP), IV antibiotics and hospitalization remain recommended for all. Infants 22–28 days: LP is not required in every case; results of inflammatory markers and urinalysis help guide the decision. Hospital admission is still recommended, and monotherapy with ceftriaxone (Rocephin) may be given safely in infants ≥ 22 days old. Infants 29–60 days: If inflammatory markers and urinalysis are reassuring, lumbar puncture and hospitalization may be avoided. Outpatient management with close follow-up is acceptable in selected low-risk infants.

3. FROM COLIC TO ABDOMINAL CATASTROPHES Abdominal emergencies in the neonatal period are rare but carry high morbidity and mortality if missed. The session covered a wide spectrum of presentations, from benign reflux to life-threatening catastrophes. • Hypertrophic Pyloric Stenosis – classic non-bilious projectile vomiting with metabolic alkalosis. • Malrotation with Volvulus – bilious emesis is an emergency until proven otherwise; urgent surgical evaluation is required. • Necrotizing Enterocolitis (NEC) – common in preterm infants; management includes bowel rest, decompression, antibiotics, and supportive care. • Hirschsprung-associated enterocolitis – often presents with distension and sepsis physiology.

2. NEONATAL FEVER

Sepsis continues to be a leading cause of morbidity and mortality in the neonatal period. Clinical signs of infection 14

• Neonatal jaundice – differentiating unconjugated benign causes from conjugated pathology (e.g., biliary atresia) is essential.

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4. HANDS-ON STATIONS

The workshop placed heavy emphasis on practical skills through six interactive stations: a) Congenital Heart Disease Simulation This scenario challenged participant to identify neonates with cyanosisunresponsive to oxygen, a red flag for ductal-dependent congenital heart disease. Learners practiced the early recognition of these lesions, understanding when to suspect them, and how to stabilize before transfer. • • • • •

Oxygen alone will not resolve cyanosis in ductal-dependent CHD. Avoid aggressive fluid resuscitation — ABCs and stabilization are the priority. Prostaglandin infusion can be lifesaving and should be initiated promptly. • PGE1 dose: 0.05 - 0.1 mcg/kg/min • PGE1 can be started at a low dose: 0.01 mcg/kg/min The risk of apnea increases with higher PGE1 doses; careful monitoring and titration are essential. Improvement in blood pressure or oxygenation indicates a positive response, and PGE1 should then be titrated to the lowest effective dose. •

• Remember to minimize attempts and ensure sufficient sample volume for analysis. c) Cardiac and LP POCUS Point-of-care ultrasound (POCUS) is increasingly valuable in neonatal care. Participants used ultrasound to evaluate cardiac function and practice ultrasound-guided lumbar puncture. This highlighted how technology can improve both diagnostic precision and procedural success. • • •

Cardiac POCUS helps identify effusion, contractility issues, or anomalies. Ultrasound guidance improves landmark identification and increases success rates for lumbar puncture. Real-time imaging builds procedural confidence and reduces complications.

d) Airway & Ventilation Airway emergencies in neonates are some of the most stressful encounters in the ED. This station provided hands-on practice with bag-mask ventilation, intubation, and airway adjuncts. Faculty emphasized that basic airway maneuvers done well often make the biggest difference. • • •

A well-sealed mask and effective BVM is often more important than immediate intubation. Deliver breaths at 40–60 per minute, watching for chest rise and HR improvement. Have a backup plan — supraglottic devices can be lifesaving.

e) Vascular Access • Obtaining access in neonates is notoriously challenging but critical in resuscitation. • UVC is the preferred emergency line in neonates — cut cord cleanly, identify vein carefully. • Complications include infection and malposition (may result in thrombosis or organ injury). • IO access provides rapid, reliable access when UVC is not possible.

Adverse effects may include apnea (may require intubation), hypotension requiring hemodynamic support, as well as fever, flushing, seizures, and edema.

b) Lumbar Puncture The lumbar puncture station emphasized safe technique in neonates, a challenging population due to small anatomy and higher risk of complications. • • • •

Proper positioning, identifying landmarks and an experienced holder are key to success. Position carefully: flex the spine while keeping the airway secure. Use a 22–25 gauge needle to reduce trauma. Early stylet removal increases success by allowing clearer visualization of the spinal fluid flash. EMpulse 2025

• Secure all lines meticulously to prevent accidental dislodgement. f) Neonatal Resuscitation Simulation This high-fidelity simulation tied everything together. Teams managed a full neonatal resuscitation scenario, applying NRP algorithms under time pressure. • • • •

If, after warmth, drying, and stimulation, the newborn continues to have inadequate respiratory effort, is apneic, or has a HR < 100 bpm, positive pressure ventilation (PPV) should be initiated without delay. T-piece resuscitators are preferred over self-inflating bags. If the heart rate remains below 60 bpm despite adequate ventilation for at least 30 secs, chest compressions should be initiated, endotracheal intubation performed, and intravenous epinephrine strongly considered. Oxygen administration should be started at 21-30% and adjusted to meet saturation targets; may be reasonable to increase concentration during chest compressions.

KEY THEMES

Systematic algorithms — reliance on NRP, sepsis guidelines, and surgical pathways rather than improvisation. Teamwork under pressure — assigning roles early (airway, compressions, medications, recorder) to optimize resuscitation. Remember to employ closed-loop communication during critical tasks. Technology at the bedside — POCUS as a diagnostic and procedural adjunct. Bridging ED–NICU care — stabilizing neonates in community EDs until transfer to higher-level centers. Debrief after each case to reinforce lessons and strengthen teamwork. The Neonatal Emergencies Workshop at SBS 2025 highlighted the Pediatric EM Committee’s dedication to advancing

pediatric emergency care. Through structured didactics, high-yield procedural training, and immersive simulation, attendees left better equipped to face the challenges of neonatal emergencies and improve outcomes for the most vulnerable patients in the ED. ■

REFERENCES

Weiner GM, Zaichkin J, et al. Textbook of Neonatal Resuscitation, 8th Edition. American Academy of Pediatrics; 2021. Wyckoff MH, Wyllie J, Aziz K, et al. Neonatal Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2020;142(16_suppl_1):S185-S221. Pantell RH, Roberts KB, Adams WG, et al. Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old. Pediatrics. 2021;148(2):e2021052228. Gomez B, Mintegi S, Bressan S, et al. Validation of the “Step-by-Step” Approach in the Management of Young Febrile Infants. Pediatrics. 2016;138(2):e20154381. Biondi EA, Lee B, Ralston SL, et al. Prevalence of Bacteremia and Bacterial Meningitis in Febrile Neonates and Infants in the Second Month of Life: A Systematic Review and Meta-analysis. JAMA Netw Open. 2019;2(3):e190874. Neu J, Walker WA. Necrotizing Enterocolitis. N Engl J Med. 2011;364:255–64. Blakelock RT, Beasley SW. The Clinical Significance of Malrotation of the Intestine. Pediatr Surg Int. 1998;13(2–3):153–157. Hernanz-Schulman M. Pyloric Stenosis: Role of Imaging. Pediatr Radiol. 2009;39 Suppl 2:S134–S139. Subramanian S, Henig O, Mazhani L, et al. Point-of-Care Ultrasound in Neonatal and Pediatric Emergency Care: Current Evidence and Future Directions. Pediatr Emerg Care. 2020;36(6):e340-e347. Sawyer T, White M, Zaveri P, Chang T. Simulation-Based Medical Education for Neonatal Resuscitation and Pediatric Emergency Medicine. Clin Perinatol. 2021;48(3):655–672.

PEDIATRIC EMERGENCY MEDICINE COMMITTEE:

GROWING, TEACHING, AND LEADING ACROSS FLORIDA The Pediatric Emergency Medicine (PEM) Committee is looking for new members! If you’re passionate about improving pediatric emergency care and education, we’d love to have you join us. Reach out to any PEM Committee member to learn how you can get involved. This year, the committee continues to collaborate closely with the Emergency Medicine Learning & Resource Center (EMLRC) on pediatric education and Pediatric Readiness initiatives for both emergency departments and EMS agencies across Florida. Together, we’re working to ensure every child who comes through a Florida ED receives care that’s timely, coordinated, and child-centered. Summer Success: Pediatric Education in Action This summer marked another highly successful EMS Symposium, held in conjunction with Symposium by the Sea, bringing together EMS providers from across the state for a robust educational experience and hands-on learning. Special thanks to Dr. Swan, Dr. Martinez, and Dr. Kirby for their outstanding lectures and leadership, as well as to the teams from Nemours Gainesville, Orlando, and Miami, who partnered with PEM Committee members to provide exceptional hands-on pediatric training sessions. Annual Pediatric Track: Educating the Next Generation Following the EMS Symposium, the PEM Committee hosted its annual Pediatric Track, a popular educational series designed specifically for residents and faculty. The sessions covered a wide range of high-yield pediatric topics, blending clinical pearls with interactive discussion and simulation. This year’s programming once again highlighted the PEM Committee’s dedication to ensuring that Florida’s emergency physicians and EMS providers are prepared, confident, and ready to care for children in every setting. If you’re interested in pediatric emergency medicine education, advocacy, or training, now is the perfect time to get involved. Join the PEM Committee and help us continue advancing the standard of pediatric emergency care across Florida. Contact the FCEP office or any PEM Committee member for more information on how to join. 16

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FEATURE

ENHANCING PEDIATRIC READINESS: FLORIDA’S PREHOSPITAL PEDIATRIC READINESS RECOGNITION PROGRAM GAINS RAPID ADOPTION ACROSS THE STATE AND NATIONAL ATTENTION In January 2025, the Florida Emergency Medical Services for Children (EMSC) State Partnership Program launched the voluntary Florida Prehospital Pediatric Readiness Recognition Program (PRRP) – an initiative aimed at recognizing EMS agencies that demonstrate a strong commitment to enhancing pediatric emergency care, education, and preparedness. On average, 80% of EMS agencies see fewer than eight children per month. The infrequency of pediatric calls makes it challenging for prehospital professionals to develop and maintain pediatric care competencies. By participating in recognition programs, EMS agencies can demonstrate their commitment to pediatric readiness, which has been associated with a lower mortality risk for children seeking emergency care. The Florida Prehospital PRRP was developed in collaboration with the Florida EMSC Advisory Committee, Florida EMSC EMS Pediatric Readiness Workgroup, Florida Association of EMS Medical Directors (FAEMSMD), Florida Department of Health (FDOH) Bureau of Emergency Medical Oversight (BEMO) Regional Coordinators, Florida EMS Medical Director, and other state organizations. The Florida Prehospital PRRP is based on national consensus recommendations from the EMSC Innovation and Improvement Center (EIIC) National PRRPs Collaborative, the 2020 Joint Policy Statement: Pediatric Readiness in Emergency Medical Services Systems, and other established state recognition programs. The Florida Prehospital PRRP is composed of two tiers: Florida PEDReady Silver and Florida PEDReady Gold. Each tier has defined criteria that agencies must meet to achieve recognition.

Phyllis L. Hendry, MD, FAAP, FACEP Florida EMS for Children Program and Medical Director Katelyn Dabhi, MS, CHES® Florida EMSC Program Manager

Personnel representing Kissimmee Fire Department, St. Cloud Fire Rescue, and Florida EMSC at their verification visit.

FLORIDA PREHOSPITAL PRRP CRITERIA CATEGORIES The recognition process involves a comprehensive review of the agency’s application and a formal verification visit, held virtually or in person. Verified agencies receive vehicle decals, certificates of recognition, and challenge coins.

FLORIDA PREHOSPITAL PRRP VEHICLE DECALS In less than a year, the Florida Prehospital PRRP has made a significant impact on pediatric readiness efforts across the state, with a rapid adoption by EMS agencies. The pilot phase of the program ran from January 2025 to June 2025, with nine EMS agencies across Florida applying to the recognition program. Eight of those EMS agencies achieved recognition at the Florida PEDReady Gold tier, including North Port Fire Rescue, Walton County Fire Rescue, Martin County Fire Rescue, Sarasota County Fire Department, St. Cloud Fire Rescue, Kissimmee Fire Department, Escambia County Public Safety – EMS, and Charlotte County Fire and EMS. One agency is in the process of preparing for its verification visit to achieve Florida PEDReady Silver recognition. All agencies that completed the recognition process agreed that the program improved their agency’s pediatric readiness.

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FEATURE

REFERENCES (cont. from page 13)

Personnel representing Escambia County Public Safety – EMS and Florida EMSC at their verification visit.

The program was presented at state and national forums, such as the state EMS Advisory Council meetings, through state and national news outlets, and at the 2025 National Association of EMS Officials (NASEMSO) Annual Meeting. An article featuring the program and North Port Fire Rescue was published by EMS World in May 2025 on EMS for Children Day. This program not only benefits the children and families in Florida but also serves as a model for other states interested in developing recognition programs and improving prehospital pediatric emergency care. Following the pilot phase, the application and verification processes underwent revision. The Florida Prehospital PRRP is expected to relaunch in November 2025. Learn more about the Florida Prehospital PRRP. ■

Stevens DL, Bryant AE. Necrotizing soft-tissue infections. N Engl J Med. 2017;377(23):2253-2265. Biaduń W, et al. Skin and subcutaneous tissue infections. J Educ Health Sport. 2025;82:60279. Wong CH, et al. The LRINEC score for distinguishing necrotizing fasciitis. Crit Care Med. 2004;32(7):1535-1541. Saijo Y, et al. White blood cell and C-reactive protein discrepancy. Plast Reconstr Surg Glob Open. 2025;13(6):e6917. Mittal V, Awati JS. LRINEC scoring system for early diagnosis. Paripex Indian J Res. 2025;14(3):208. Gokarakonda SB, Kumar N. La Belle Indifference. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2024. Updated May 7, 2024. Berger T, et al. Shock index and early recognition of sepsis. West J Emerg Med. 2013;14(2):168-174. Wong CH, et al. The LRINEC score. Crit Care Med. 2004;32(7):1535-1541. Ramesh AA, et al. LRINEC score distribution. Cureus. 2024;16(11):e73755. Ram G, et al. LRINEC scoring efficacy. Int J Sci Res. 2024;13(12):928. Suraphee S, et al. Modified LRINEC classification. Appl Sci. 2024;14(20):9241. Sartelli M, et al. WSES/SIS-E consensus on skin infections. World J Emerg Surg. 2018;13:58. Stevens DL, et al. Practice guidelines for skin infections. Clin Infect Dis. 2014;59(2):e10-e52. Babiker A, et al. Linezolid versus clindamycin for toxin inhibition. Lancet Infect Dis. 2025;25(3):265-275. Hakkarainen TW, et al. Necrotizing soft tissue infections review. Curr Probl Surg. 2014;51(8):344-362. Peetermans M, et al. Necrotizing infections in the ICU. Clin Microbiol Infect. 2020;26(1):8-17. Sarani B, et al. Necrotizing fasciitis: current concepts. J Am Coll Surg. 2009;208(2):279-288.

Thank you for helping make Florida PEDReady! For more information about Florida EMSC, scan the QR code below or visit flemsc.emergency.med.jax.ufl.edu/.

Charlotte County Fire & EMS is highlighting its Florida PEDReady Gold recognition with its pediatric equipment and recognition vehicle decal.

Personnel representing Charlotte County Fire and EMS, Florida EMSC, and other leadership at Charlotte, at their verification visit

FUNDING STATEMENT:

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The Florida EMSC Program is partially supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of a State EMSC Partnership Program Award. The Florida EMSC State Partnership Program is housed at the University of Florida College of Medicine-Jacksonville. EMpulse 2025

Walton County Fire Rescue (WCFR) is highlighting its Florida PEDReady Gold recognition with personnel from WCFR and a child in a pediatric restraint device.