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Volume 24, Issue 2 SUMMER 2017

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

F undamental F inancial Q uestions for the E veryday EM P hysician

W hat to E xpect from CLINCON 2017 and S ymposium by the S ea 2017


D on ’ ts for S nake B ites




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Chapter Updates

President’s Message | 4 Medical Economics Committee | 6 Government Affairs Committee| 7 EMS/Trauma Committee | 8 Leadership Academy Update | 10 Membership & Professional Development Committee | 11

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

Medical Student Committee | 12 EMRAF Committee | 13 Florida Internatinal Trauma Life Support Update | 14 ACEP Board Update | 17 Residency Matters | 18

FCEP Executive Committee Jay L. Falk, MD, MCCM, FACEP • President Joel Stern, MD, FACEP • President-Elect Joseph Adrian Tyndall, MD, MPH, FACEP • Vice President Kristin McCabe-Kline, MD, FACEP • Secretary/Treasurer Steven Kailes, MD, FACEP • Immediate Past President Beth Brunner, MBA, CAE • Executive Director

Features Daunting Diagnosis | 9 Poison Control | 16

Editorial Board Karen Estrine, DO, FACEP, FAAEM • Editor-in-Chief Samantha Rosenthal • Managing Editor/Design Editor

All advertisements appearing in the Florida EMpulse are printed as received from the advertisers. Florida College of Emergency Physicians does not endorse any products or services, except those in its Preferred Vendor Partnership. The College receives and distributes employment opportunities but does not review, recommend or endorse any individuals, groups or hospitals that respond to these advertisements. NOTE: Opinions stated within the articles contained herein are solely those of the writers and do not necessarily reflect those of the EMpulse staff, the Florida College of Emergency Physicians and our advertisers/sponsors.

See You In Boca!| 23 An Emergency Physician’s Career: Financial Planning Part II: A Deeper Dive | 24 Snapshots from APP Skills Camp - Spring 2017| 26 CLINCON 2017: Florida’s Premier EMS Conference| 26 EM Case Reports | 27 Do’s and Don’ts of Snake Envenomations for ED Providers | 29 Musings of a Recently Retired Emergency Physican | 30

Published by: Johnson Press of America, Inc. 800 N. Court St. Pontiac, IL 61764 Phone: 815-844-5161 Fax: 815-842-1349


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President’s Message This is my last opportunity to write this column as your president. It is striking how quickly the year has gone by. I am pleased to report that FCEP continues to be a thriving organization, effectively serving our record membership of more than 1,800, our patients, and our communities. As I write this column, the legislative session is now over, (unless special session is called), and the budget is on the Governor’s desk. I believe we were very successful in our advocacy efforts this year. We managed to kill PIP repeal for another year. As Dr. Brennan describes in his update in this issue, PIP repeal could have resulted in substantial financial hits to emergency physicians. We were able to secure a $100,000 appropriation for the FEMF, awaiting the Governor’s signature. Our sincere thanks to Rep. Mike Miller for his help. This appropriation will help us provide continuing education to the EMS community and develop a repository of “best practice” EMS protocols that could be accessed by EMS Medical Directors throughout the state. These successes resulted from the hard work of many of you and your leaders on our FCEP committees and the Board of Directors. With your help we raised $100,000 toward our PC, which Jay Falk, MD, MCCM, FACEP we used strategically to foster relationships with our representatives throughout the year, which FCEP President enabled our success during EM Days in Tallahassee during the legislative session. Special thanks to FCEP lobbyist Toni Large for her herculean efforts and guidance, Drs. Dan Brennan, Ashley BoothNorse, Sanjay Pattani, Damian Caraballo, Steven Kailes, Joel Stern, David Orban, Kelly Gray-Eurom, Kristen McCabe-Kline, Chuck Duva, Jay Rao, Rene Mack and many others, all of whom gave generously of their time and money on your behalf. Our alliance with the FMA has gelled nicely, contributing to our successes, and we are proud of the participation of our Board members in the FMA, including Dr. Booth-Norse currently running for Vice Speaker of the FMA. We continue to join forces with EDPMA and PFC to strengthen our legislative and regulatory presence. FCEP has participated nationally by providing support and data to ACEP President Dr. Rebecca Parker regarding the balanced billing issues that we continue to work on locally (see Dr. Brennan’s article). We are also providing ACEP leadership on opioid education. With the guidance of Drs. Aaron Wahl and Joseph Thundiyil, we are preparing a two-hour webinar that will be offered to our membership and will be available on-line and offered to ACEP as well. FCEP leaders remain very active in national ACEP: Dr. Vidor Friedman is ACEP Board of Directors candidate for president–elect, Dr. Jordan Celeste is chair-elect of the EMF board of trustees and ACEP’s 50th anniversary task force, and Dr. Kelly Gray-Eurom is this year’s recipient of the Council Meritorious Award. Our educational programs run through the EMLRC continue to grow and excel. The first Emergency Medicine Payment Reform Summit, created by Dr. Cliff Findeiss, drew leaders from across the country to brainstorm about how to best position emergency medicine for the future in the rapidly evolving healthcare macro environment. The Advanced Practice Provider Skill Camp, chaired by our FEMF Board member Roxanne Sams, was so successful it had to be run twice and prospective registrants were still turned away. Life After Residency continues to provide preparation for the real world and networking opportunities to our graduating classes. The Leadership Academy provides mentorship for young emergency physicians under the direction of Dr. Patrick Agdamag. The Written Board Review Course grew under the leadership of Dr. Adrian Tyndall offering an excellent, in-state option for both first-time takers and those recertifying. CLINCON and Symposium by the Sea continue to thrive, and we are looking forward to the upcoming meetings in July and August. I am grateful to FCEP Past-president Dr. Steven Kailes for giving us our five-year strategic plan. I have done my best to keep us on track and thank Dr. William McConnell and Dr. Kristen McCabe for their hard work on this. We wish Dr. McConnell all the best on his well-deserved retirement and thank him for his many years of service to the College during which he provided sage wisdom and guidance to all of us. I look forward to the incoming president Dr. Joel Stern continuing to strive to help us reach the goals we have set. We face many challenges as a specialty and as a society. There has been enormous growth in the number of residency programs in Florida. We welcome the new programs and are actively reaching out to the new program directors and faculty to participate in the activities of the college and to join their residents as members. While being supportive, as a College we want to see the new programs sufficiently resourced to provide the quality we have enjoyed among our established programs. We rely on the RRC in emergency medicine to monitor this, so that we can be assured that graduates from the new programs will join our ranks as capable clinicians. There continues to be aggressive consolidation of hospital systems and acquisitions and consolidation by practice management groups. These forces have the potential to threaten the professional prerogatives of practicing emergency physicians in our state. Combined with a plethora of graduating residents and a limited number of potential practice opportunities, our individual values as professionals may become diminished. Now more than ever, it is imperative that all emergency physicians in the state support ACEP and FCEP so that we can continue to effectively advocate for ourselves and for our patients. If you are a member, please engage your co-workers in conversation about how we can support them if they support us. If you practice in Florida and are not a member, please make an investment in your future by joining us. Whatever the political climate, the emergency department will likely continue to be a critical component of our healthcare system. We need to be able to participate in shaping how that will look. This organization is critical in enabling us to do that. I thank our excellent staff who provide leadership and support with our advocacy, education, communication, and presence in the local, state and national healthcare arenas. Our Chapter – FCEP/FEMF – is the only Chapter that is accredited to provide physician, nursing, and EMT/paramedic continuing education credits or CE. Thank you for allowing me to serve as your president. I leave this office optimistic because of all of the capable, energetic and honorable colleagues I have had the pleasure to get to know well during my tenure. Let’s keep at it.

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Fort Walton Beach Medical Center (Ft. Walton Beach) Oviedo Medical Center (Oviedo) Bay Medical Center (Panama City) Bay Medical FSED (Panama City) Gulf Coast Regional Medical Center (Panama City)


Blake Medical Center (Bradenton) Oak Hill Hospital (Brooksville) Englewood Community Hospital (Englewood) Munroe Regional Medical Center (Ocala) Emergency Center at TimberRidge (Ocala) Poinciana Medical Center (Orlando) Brandon Regional Emergency Center (Plant City) Fawcett Memorial Hospital (Port Charlotte) Bayfront Punta Gorda (Punta Gorda) Lakewood Ranch FSED (Sarasota) Brandon Regional Hospital (Tampa Bay) Citrus Park ER (Tampa Bay) Largo Medical Center (Tampa Bay) Mease Dunedin Hospital (Tampa Bay) Medical Center of Trinity (Tampa Bay) Northside Hospital (Tampa Bay) Palm Harbor ER (Tampa Bay) Regional Medical Center at Bayonet Point (Tampa Bay) Tampa Community Hospital (Tampa Bay)


Broward Health, 4-hospital system (Ft. Lauderdale) Northwest Medical Center (Ft. Lauderdale) Plantation General Hospital (Ft. Lauderdale) University Medical Center (Ft. Lauderdale) Lawnwood Regional Medical Center (Ft. Pierce) Raulerson Hospital (Okeechobee) St. Lucie Medical Center (Port St. Lucie) Palms West Hospital (West Palm Beach) JFK North (West Palm Beach)


Northwest Medical Center (Ft. Lauderdale) Assistant Medical Director Aventura Hospital and Medical Center (Miami) Brandon Regional Hospital (Tampa Bay, FL) Assistant Medical Director Brandon Regional Hospital (Tampa Bay, FL) EM Residency Program Director Citrus Park ER (Tampa Bay, FL) Assistant Medical Director Medical Center of Trinity (Tampa Bay, FL) Assistant Medical Director Palm Harbor FSED (Tampa Bay) 727-437-3533 or 727-507-2526 Ask about our provider referral program!


Broward Health Children’s Hospital (Ft. Lauderdale, FL) Northwest Medical Center (Ft. Lauderdale) Plantation General Hospital (Ft. Lauderdale, FL) Gulf Coast Medical Center (Panama City, FL) Brandon Regional Hospital (Tampa Bay, FL) Mease Countryside Hospital (Tampa Bay, FL) The Children’s Hospital at Palms West (West Palm Beach, FL)

Coast-to-Coast full-time, part-time and per diem opportunities. Ask about our EmBassador Travel Team Opportunities! Contact us today!

Medical Economics Committee Fortunately for emergency medicine providers, the 2017 Florida legislative session ended without repeal of Florida’s no-fault PIP auto insurance. Despite successful reform in 2012, legislation to alter PIP was proposed and passed in the House, to repeal PIP and replace it with Bodily Injury coverage. This would have replaced our current no fault system, including EM protection with a litigation-prone system with delayed and lower payments. Fortunately, the Senate sponsor was more aware of the need to protect EM and had pledged to include an EM Medical Payments provision. This had not been incorporated in the legislation through two committee stops, and the bill was eventually pulled (postponed and withdrawn from consideration) at the third stop, ending the threat for this year’s session. On other fronts, FCEP and various groups throughout the state keep pushing AHCA and OIR to investigate and take action on the systematic underpayments many out of network providers have seen from Humana. Despite meeting in January in Tallahassee with representatives of AHCA and OIR, and providing much requested documentation soon thereafter, no formal action has been taken, and details of the ongoing investigation are shielded by statute. Bottom line, as of May 8, many groups are still suffering economic damage due to what providers feel is clear-cut deviation from the existing prompt pay statutes, as well as last year’s balance billing legislation. Daniel Brennan, MD, FACEP Medical Economics Committee Chair

FCEP is also working with AHCA on the rules process surrounding the dispute resolution language included in last year’s legislation. As noted above, disputes are likely and some assistance in enforcing the payment provisions of the statues would be valuable, if for no other reason than to create a fair negotiation field as providers attempt to contract with payers. On the national scale, discussion of ACA and replacement proposals is likely and ACEP is pushing to maintain EM coverage as a required benefit. The Medicare expansion is a larger issue for expansion states than for non-expansion states like Florida, but in any legislation as large as a comprehensive healthcare bill many foreseen and unforeseen consequences are likely. As 2017 progresses, groups should assess their progress on MACRA-MIPS, the subject of a recent EMPulse article. Reporting at least one quality measure for 2017 will avoid a penalty for 2019. To be eligible for a 4 percent bonus (up to 22 percent for exceptional performance) groups will need to submit the required six or more measures for at least 90 consecutive days in 2017. CMS did release an ED Measure set of quality measures, but given a required 20 patients per measure, many groups will want to look at additional measures to be sure of capturing enough to report. CMS will score your six best performance measures, and one must be a high-priority measure. Details of the measures and their documentation requirements is available on the CMS website ( Additionally, groups should decide to report via registry, like ACEP’s Clinical Emergency Data Registry [CEDR], or via individual claims. Keep in mind, using individual claim data requires 20 cases per provider and is limited to Medicare recipients only, making several of the measures relating to pediatrics or OB unlikely to be reportable. Registry reporting allows the 20 case threshold to be met by the group and additionally allows cases from all payers to be reported, alleviating the claim frequency concerns. Although the impact won’t be felt until 2019, assure your group is on track to capture the 90-day reporting period in what remains of 2017.

Thanks to all who made contributions to the Political Committees in March & April 2017! Miguel A. Acevedo-Segui Javier Ayo Carlos H Castellon Jordan Celeste Michael C Collins Clifford Findeiss Joseph S Ghebrial Gary Allen Goodman Laura Goyack John Hammock Manning H Hanline

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Jeffrey Edward Ingeman Steven Kailes Thomas K Leonard Paul Daniel Lucey Pamela C Miller David J Orban Leena Owen Daniel L. Puebla Daniel Ricci Lauren P Shapiro


Government Affairs Committee Florida’s 2017 legislative session is over. As one representative put it: "It was bizarre from start to finish. It was a slow-moving session. It was mean; there was retribution. This was a rough one. This was a brutal session." State legislators filed about 1,900 bills in the 63-day session that ended on May 8. Only 12.6 percent, or 234 bills, were passed by both the House and Senate chambers, perhaps the second lowest total in an annual session in at least 17 years. As of May 11, Gov. Rick Scott has signed 20 bills. This year might be known more for infighting and what didn't get done than what did. PIP Reform (FAILED): Repeals Florida Motor Vehicle No-Fault Law & requirements for personal injury protection coverage; increases amount of security required for owners, operators, & dealers of motor vehicles; increases amount of deposit to obtain certificate of self-insurance & certificate of insurance; increases amount of net worth to obtain self-insurance; provides legislative intent; provides notice requirements to inform policyholders of changes in insurance coverage. Sanjay Pattani, MD, FACEP Government Affairs Committee Co-Chair

Florida Emergency Medicine Foundation (Pending Governer Approval) - Education Clearinghouse for Emergency Medical Services: Provides an appropriation for the Florida Emergency Medicine Foundation - Education Clearinghouse for Emergency Medical Services.

CERTIFICATE OF NEED (FAILED): Eliminates a state requirement that hospitals get approval from the Agency for Health Care Administration before they can build any facilities or add types of programs (HB 7/SB 676). TRAUMA CENTERS (FAILED): Sets new standards for the minimum number of trauma centers each region of the state needs based on population, giving Hillsborough County two and Pinellas and Pasco two between them (HB 1077/SB 746). MEDICAL MARIJUANA (FAILED): Implements constitutional amendment making medical marijuana available to more people to treat a broader range of illnesses and ailments (HB 1397). PRIMARY CARE (FAILED): Allows employers or patients to contract directly with a doctor for primary care (HB 161/SB 240). RECOVERY CARE CENTERS (FAILED): Allows surgical centers to keep patients for a full 24 hours and creates new recovery centers that can care for them 72 hours after surgery (HB 145). SUBSTANCE CONTROL/ABUSE (PASSED): HB 239 creates a central data base for opioid overdoses via the EMSTAR System. The legislation permits EMS to data share with law enforcement regional information to help target high drug areas of a community. The bill also requires any hospital with an emergency room to produce best practice policies to help in lowering the number of drug overdoses in the state. HB 557 shortens the timeframe in which a dispenser of a controlled substance — typically the pharmacy — must report dispensing from seven days to the end of the next business day. It also requires the dispenser to submit required reporting information via an electronic system approved by the Department of Health. In addition, the bill expands access to the PDMP database now to healthcare employees of the U.S. Veterans’ Administration to assist with their patient’s treatment. The bill was amended to exclude a requirement for any doctor with a DEA number to complete an additional two-hour CME course. Overall, this session may not be perceived as one of the most productive on the healthcare legislation front. However, per Tallahassee MO, we are sure to revisit many of these issues again next year. Let’s remember the relationships we established and will continue to build upon. Let’s remember the good times at our social events with Dr. Jay Rao providing the “emergency” back up guitar rock star performance! As I wrap up this article, we are once again starting the planning for next legislative session. Please remember that in 2018, EM Days will be in January. Plan, prepare and god bless you all and our patients.


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EMS/Trauma Committee The heat is on — with high temperatures and the Florida sun beating down on citizens and tourists alike. Along with the summer heat comes the beloved hurricane season, starting June 1. We highly recommend you use this as a reminder to prepare your own agency, department, hospital and home to have a disaster plan and supply list. Prior to last year with hurricane Hermine and Matthew, Florida had a false sense of security with no hurricane having made landfall in over a decade. Hopefully with the experience from last year, we all take preparation seriously and ensure the safety of our community, which includes understanding storm terminology and having a reliable source of information. According to the State of, “Tropical depressions are cyclones with winds of 38 m.p.h. Tropical storms vary in wind speeds from 39-73 m.p.h., while hurricanes have winds 74 m.p.h. and greater. The greatest threats are damaging winds, storm surge and flooding.” A beginner supply list includes: three days of nonperishable foods, three days of water, a flashlight with the necessary batteries, personal hygiene items, matches or a lighter, pet supplies, and a family evacuation plan if separated. Television, radio and cellphone apps are a good way to receive weather alerts.

Christine Van Dillen, MD, FACEP EMS/Trauma Committee Co-Chair


Senate Bill 746 - requires the Department of Health (DOH) to designate trauma centers, publish a state-wide trauma plan, establish and maintain a statewide trauma registry, solicit input from stakeholders and experts, and foster the provision of trauma care. In addition, it requires revision of guidelines for trauma center designation and includes public records exemption to include EMS. This bill was withdrawn from further consideration on April 27, 2017. House Bill 1077- Regarding allocation of Trauma centers: is a general bill by HHS Committee which specifically determines the need for a minimum number of Level I or II adult trauma centers in a service area with certain population levels. This authorizes DOH to allocate additional centers. The last action for this bill was a vote that occurred on April 24, 2017 in the HHS subcommittee and the outcome was favorable.

Stroke Care

CS/CS/CS/HB 785 - Regarding Stroke centers: Directs Agency for Health Care Administration (AHCA) to include hospitals meeting criteria for acute stroke ready centers on list of stroke centers, authorizes DOH to contract with a private entity to establish & maintain a stroke registry, (which is subject to appropriation and provides immunity from liability) Last action on this bill was that it was voted on favorably on May 1, 2017. CS/CS/SB 1406 is the senate bill companion. The last action for this bill was a favorable vote which occurred on April 20, 2017. Status update on HR 304: Protecting Patient Access to Emergency Medications Act of 2017” which focuses on how emergency medical service personnel obtain, store and administer on a regular basis. As discussed in our last update, the last action was on January 12, 2017, it was referred to the subcommittee on crime, terrorism, homeland security and investigations. Update on Senate Bill 228: Physician Orders for Life-sustaining Treatment: if approved these orders would be extremely helpful in following patient’s wishes during their care at the end of their life. It specifies many forms of treatment other than just do not resuscitate after a pulse has been lost. Last Action: March 7, 2017 Senate - Introduced -SJ 52; Current Location: In committee/ council and no House companion at this time.

State EMS Advisory Council Nominations

EMS Advisory Council has positions that are due to expire on June 30, 2017. DOH is accepting nominations for the following upcoming vacancies: paramedic, EMS educator and physician. Currently, the two nominations for the physician candidate from FAEMSMD will be Drs. Ken Scheppke and Tony Gandia. FAEMSMD protocol database update: Dr. Scheppke reported that he has tested the Beta version and it appears to be working well. FCEP staff is working with the web designer/developer to finalize the timeline and launch of this section of the website.


On March 30, 2017, FirstNet and AT&T entered a contract to build and manage the Nationwide Public Safety Broadband Network

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(NPSBN). The 25-year agreement includes success-based payments to AT&T of $6.5 billion over the five-year build plan. AT&T intends to spend approximately $40 billion over the life of the contract for the system and will utilize AT&T’s network assets, which are valued at more than $180 billion.


The state of Florida Pharmacy will be distributing a supply of Duodotes to all EMS sites. Each participating site may receive up to four cases containing 30 autoinjectors each. Medical directors are required to confirm the shipments. Contact to confirm authorization of the shipments.

The entire emergency medicine and emergency medical services community was severely affected by the sudden passing of Dr. Salvatore “Sal” Silvestri, who was our friend, mentor, colleague and an active member of our community. The Florida Emergency Medicine Foundation and Florida College of Emergency Physicians are honored to announce the establishment of the Dr. Sal Silvestri EMS Research Fund. Funds will be distributed through a formal research grant application process. A committee is being formed by FEMF and FCEP leaders that will be comprised of experts in EMS research, who will serve as the reviewers for grant recipient(s). Further details will be released in coming weeks. Contributions to the Dr. Sal Silvestri EMS Research Fund can be made to FEMF, a 501(c)3 tax deductible educational and charitable foundation. In honor of the late Dr. Silvestri, this year's CLINCON will be dedicated to him. This will include a memorial video. Any additional videos or photos can be sent to You may also record a video message to be included in the memorial video. Please send you photos, videos and/or messages by June, 25, 2017.

D au n t i n g D i ag n o s i s Question: A 33 year-old male presents with dyspnea for 10 days. He has a history of HIV and recent Kaposi Sarcoma. What is the diagnosis? Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief

Turn to page 10 for the answer! Thanks to all who made contributions to the Dr. Sal Silvestri EMS Research Fund!

Dr. David Seaberg Dr. Jeff Lubin Beth Brunner Dr. Mark Chandler On behalf of Well Assembled Meetings, LLC: • Dr. Andy Godwin • Dr. Scott Silvers • Dr. David Carr • Dr. Andy Jagoda

Dr. Michael Lozano Dr. Charles Sand Dr. Jay Falk Dr. Jennifer Jackson Dr. Michael Sayre Roxanna Sams Dr. Richard Shih Dr. Wayne Lee Dr. Robert Swor Dr. Karloff Dupoux


Dr. Richard Slevinski Emergency Medicine Professionals, P.A. Dr. Steven Kailes Dr. Rory Hession Dade County Assoc. of Fire Fighter Charity Dr. Kathleen Schrank Dr. Amit Rawal Dr. Sean Isaak

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Leadership Academy Update The annual Symposium by the Sea (SBS) conference in August signifies many things for the Florida College of Emergency Physicians. As we usher in new officers and Board members, we also see a lot of new faces, great ideas and work to facilitate projects that begin during our annual conference. This year's Symposium by the Sea annual gathering will be held at Boca Raton Resort & Club from August 3-6. This year will be special for the Leadership Academy, as it marks the first time the Academy will showcase its graduates in a dedicated presentation on Sunday, August 6, 2017 at 11:15 a.m. For those of you not familiar with the Leadership Academy, it exists to promote participants to pursue the highest-quality emergency medical care, educate and empower emergency physicians to better protect the patients they serve across our great state. The Academy brings all the ingredients needed to grow leaders in our field, while harnessing their targeted areas of interest. Pat Agdamag, MD, FACEP

FCEP Board Member; Chair of FCEP’s Leadership Academy

The Leadership Academy typically selects two to four candidates each year across the entire state of Florida. It combines elements of mentoring along with providing high level of educational and leadership experiences — all from some of our most influential EM leaders across the state Florida and ACEP nationally.

Some of the venues candidates will be taking part in include: FCEP's Board of Director meetings, ACEP Council Meeting as alternates at the annual Scientific Assembly, and attending Tallahassee state legislature meetings for EM Days. The time commitment for the Academy fits nicely with the hectic schedules we have in our lives and work schedules. Our gatherings are centered around the conferences and our quarterly Board and Committee meetings. The cost of attendance for the Academy program itself is free. Group practice sponsorship is encouraged to help cover any costs for travel and attending conferences. The link to our online brochure and application can be found at One prerequisite for graduation is completion of an administrative project. This can be working toward a medical directorship, research project, administrative or leadership position; and even introduction of new legislation during EM Days in Tallahassee. Our current class, is represented by two outstanding Ultrasound fellows who bring much experience: Drs. Saundra Jackson (Jacksonville) and Ray Merritt (Tampa). Both attended EM Days and soaked in the unique experiences we face for our specialty in Florida. Please join us at Symposium by the Sea to congratulate our colleagues Drs. Jackson and Merritt at their graduation at Boca Resort in August. We are all excited to have witnessed their amazing growth and progress. We look forward to the next up-and-coming leaders who will take their place. With an open call for new candidates to apply, could that be you? Welcome, to the new Leadership Academy.

Daunting Diagnosis Answer: This patient was diagnosed with a tension hydrothorax. The trachea is severely deviated to the right. A pigtail catheter was immediately inserted into his left chest which started to alleviate the tracheal deviation. Later, it was found that residual Kaposi sarcoma was blocking the thoracic duct, causing what was actually a large tension chylothorax. Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief

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(Question on page 9) SUMMER 2017 | VOLUME 24, ISSUE 2

Membership & Professional Development Committee Are You Being Efficient?

When was the last time you visited the FCEP or ACEP website? Probably too long? I know, we all get busy and things like visiting websites get pushed to the bottom of the list. From a time management standpoint though, a visit to these two websites can actually help you manage your time and professional standing more efficiently. The FCEP website is full of information on the various programs and benefits that FCEP is able to directly provide for it’s members. Did you know that you can renew (or get initial) certification for ACLS, PALS, ITLS, Emergency Airway Management and several other emergency certification courses through FCEP? The courses take place at our FCEP offices in Orlando throughout the year; they fill up quickly, so reserve your space in advance. Rene Mack, MD Membership & Professional Development Committee Chair

Have you heard of “Gray Death”, “Flakka” or “Scooby Snax”? No, these are not strange candies — they are some of the illegal, usually synthetic, drugs that are flooding the streets and in turn present to the EDs in your area. These drugs and other street drug-related topics are discussed in the Street Drugs Webinar Series via the FCEP website. Each webinar provides CME and, more importantly, information that can help you save your patient’s life.

Maybe you are looking for a central location to host your own conference, group meeting or other event? The FCEP building has several meeting spaces that are available for you to host events or meetings. You can view the space options online and then contact the office for more information on how to reserve your space. On a larger scale, the ACEP website is also full of useful information. Below are a few areas on the ACEP website that I use on a regular basis. Hopefully, you will find them useful as well. Did you know that as an ACEP member you can get a summary of the LLSA articles? The summaries are from the “Critical Decisions in Emergency Medicine” and provide a comprehensive one-page summary with the “Key Points” of the article. The time savings have allowed me to keep up to date yet still manage my time more efficiently. Remember the last time you had to apply for privileges and the joy of finding all the supporting document? Yes, that was sarcasm. Keeping track of all the information can be a time consuming and frustrating if you don’t have it all in one place. This is where the ACEP website comes in; the ACEP Portfolio Tracker allows you to save digital copies of all the needed information — from medical school transcripts to residency graduation certificates to licensing information and more. Next time you need the information, it is just a few clicks away. Obtaining quality CME packages, especially for trauma, stroke or cardiology can also be difficult. I usually get the ACEP CME packages that include the annual required hours of the aforementioned topics. The CME site has a multitude of topics available, over 875 hours, to keep you informed about any areas of interest that are related to medicine and your well being. You can sign in to complete the various topics knowing that they are the required AMA PRA Category 1 CreditsTM. When you have completed the course, your credits get automatically logged into the ACEP CME Tracker. This section is another time saver, especially when you are required to provide documentation of your CME status. In addition, when you attend an ACEP/ FCEP, conference such as SBS, EM Days or ACEP Scientific Assembly, your CME is automatically sent to your profile. No more uploading or scanning the information into your computer because it’s already there! I hope this helps to give you some ideas of how you can make your ACEP/FCEP membership work harder for you. I would love to hear about the ways you utilize your membership. Are there any topics you would like to learn more about? Contact me with any questions or comments — better yet, I’ll see you in Boca at SBS 2017!


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Medical Student Committee This year marked the first Medical Student Legislative Session during EM Days led by Misty Coello, the Medical Student Committee Advocacy Coordinator. Misty and the Medical Student Council introduced students to the realm of health advocacy with a medical student-led primer. The event featured talks by FIU medical students Lindsay Ballard, Misty Coello, Amara Fazal and myself. Lindsay and Amara’s talk entitled “Human Trafficking and the ED” addressed Florida legislative efforts combating human trafficking and gave medical students instruction to recognize potential victims in the ED.

Hannah Gordon Secretary-Editor of the FCEP Medical Student Committee

Misty’s talk entitled “The Right of the People to Not Be Harmed Shall Not Be Infringed” discussed gun policy in Florida in the context of gun safety promotion, gun accident victims in the ED and efforts to fight veteran suicide.

My talk entitled “Emergency Medicine in an Era of Medicaid Block Grants” addressed the future of Florida Medicaid funding under possible Affordable Care Act repeal and how that may impact our ED patients. The session ended with a discussion with EMRAF about hot topics in health policy. To further help students prepare for their legislative sessions, Misty Coello coordinated workshops with local lobbyists for medical students in South Florida to learn how to effectively advocate before arriving in Tallahassee. She also prepared elevator speeches with the help of the Florida Health Alliance for students to give to legislators. Together, we arranged funding for students to travel to Tallahassee to attend their legislative sessions. Special thanks to Dr. Robyn Hoelle, Scott Darius, Natalie Castellanos, and all the EMRLC staff for assisting in the organization of the event. The Medical Student Committee will be accepting applications this June to lead the Medical Student Legislative Session next year. Please contact me at, or join the FCEP medical student Facebook page if you are interested in applying.

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EMRAF Committee Summer is finally here and Symposium by the Sea is just around the corner, marking the end of another year in Florida EM. Although I’m saddened my time as EMRAF President is coming to a close, I’m thrilled with all the accomplishments we’ve made over the past year thanks to this talented group of hard-working individuals! EMRAF has seen resident involvement like never before, expanding our group of representatives and the number of programs represented. We have resident leaders actively involved and engaged in FCEP committees and programs. We have actively participated in Symposium by the Sea and Emergency Medicine Days — in everything from planning to production. We have shared educational pearls and helped to incentivize resident involvement in FCEP/EMRAF and more. We have engaged and recruited medical student applicants to further the future of our specialty. And there’s so much more yet to do! Our next big project is a first of its kind, and we are looking for EVERYONE’S help and support. The entire Florida EM community lost a dear friend, mentor and leader earlier this year. The outpouring of love and support was nothing short of amazing. In the time following Dr. Silvestri’s untimely passing, almost $75,000 was collected for a program to place AEDs in Orange County Schools and FCEP/FEMF established the Dr. Sal Silvestri EMS Research Fund, which will award grants to further EMS education and services around the state. Shayne Gue, MD EMRAF President, Florida Hospital EM Resident

EMRAF will be sponsoring a Casino Night event this fall with 100 percent of proceeds benefitting the EMS Research Fund established in Dr. Silvestri’s name. We are seeking sponsors, participants, and donors to help make this a fun night of fellowship and remembrance while supporting a wonderful cause. If you have any interest in participating or supporting, please reach out to me. Any and ALL help will be greatly appreciated! As always, the role of EMRAF, within FCEP, is to empower residents to learn about all aspects of emergency medicine and to provide a unified voice of emergency medicine residents in the State of Florida. Our primary goal is to increase resident engagement and facilitate the development of a more well-rounded EM resident. This year, we are seeking to expand our membership by actively recruiting more resident representatives from around the state. Program representatives are tasked with serving as a liaison between the EMRAF Committee and their respective residency programs. As with all FCEP Committees, we meet quarterly, in conjunction with the FCEP Board of Directors at the EMLRC in Orlando and during Symposium by the Sea. It has been an honor serving as EMRAF President this year, and I look forward to remaining an active participant in the years to come. Our next meeting will take place in conjunction with Symposium by the Sea (August 3-6 in Boca Raton) and will serve as elections for the upcoming year. We highly encourage all residents to attend and become active participants. As always, if you have any questions, please reach out —


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Florida International Trauma Life Support Update Article by Roy Alson, MD, PhD, FACEP, FAAEM and Sabina Braithwaite, MD, MPH, FACEP

Role of TXA in Management of Traumatic Hemorrhage in the Field The guidelines and references contained in this document are current as of the date of publication and in no way replace physician medical oversight. Original Publication Date: July 2014. Updated October 2016.


Hemorrhagic shock remains a serious problem for the multiple trauma patient. It is the leading cause of preventable trauma deaths after loss of airway. Rapid and effective control of exsanguinating hemorrhage has been demonstrated to markedly improve survival and outcome, especially in the combat environment. Increased use of tourniquets has reduced death from hemorrhagic shock in the most recent wars fought by U.S. and NATO forces. The tactical and military environment is associated with a higher percentage of penetrating trauma and external hemorrhage than is seen with the civilian sector, in which blunt trauma predominates. This leads to the situation of ongoing hemorrhage that is difficult to control. Prompt recognition of this with transport to the appropriate facility (Trauma Center) and limiting fluid resuscitation to the level of restoring perfusion (hypotensive resuscitation) have been shown to result in improved survival for the trauma patient.


Tranexamic acid (TXA) is an antifibrinolytic that has been used for many years to assist with the management of spontaneous hemorrhaging in the hemophilia patient. The use of this agent for management of hemorrhage in combat wounds has been reported in several papers. One of the most significant findings in the CRASH-2 study is that the use of TXA is associated with a 1.5 absolute risk reduction for death from hemorrhage. Other studies show that TXA is most effective if given within 3 hours of the injury and may be detrimental if given after that time.


The side effects of the agent are minimal and the contraindications are few. It is administered as a simple IV infusion, does not require refrigeration or extensive laboratory studies to allow administration (as is seen with blood products) and is inexpensive. (NOTE: Use for traumatic hemorrhage is an off label use per FDA in the United States.)


Based on local protocols and clearance, TXA should be considered in those patients who show signs of hemorrhagic shock, including tachycardia (>110 BPM) and hypotension (SBP<100) and are less than three hours from injury. Do not give TXA through the same line as blood products.


Medical oversight should review current literature and develop pre-hospital EMS protocols in regard to appropriate use of TXA. Implementation of this protocol should be monitored and supervised through a quality assurance program.


ITLS believes that there is sufficient evidence to support the use of TXA in the management of traumatic hemorrhage in the adult patient, pursuant to system medical control approval. Following initial resuscitation including control of external bleeding and stabilization of airway, consideration should be given to administration of TXA during early stages of transport.


While there is no current dispute on the merits of TXA in patients with severe extracranial hemorrhage as stated above, a 2015 systematic review was undertaken of two relevant completed randomized trials looking at the effectiveness and safety of TXA in polytrauma with traumatic brain injury. In a meta-analysis there is a statistically significant reduction in intracranial hemorrhage. However because the confidence intervals are wide, the quality of this evidence is low. Therefore, the effectiveness and safety of TXA in traumatic brain injury are uncertain although randomized trials are underway to investigate the problem. The authors recommend that patients with isolated traumatic brain injury should not receive TXA outside the context of a randomized trial. REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9.

Morrison JJ, et al. Military application of tranexamic acid in trauma emergency resuscitation (MATTERs) study. Arch Surg, 2012 Feb; 147(2): 113—9. Shakur H et al, Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant hemorrhage (CRASH-2): a randomized, placebo-controlled trial. Lancet, 2010 Jul 3; 376(9734): 23–32. Kobayashi L, Costantini TW, Coimbra R. Hypovolemic shock resuscitation. The Surgical clinics of North America. 2012;92(6):1403-23. Rappold JF, Pusateri AE. Tranexamic acid in remote damage control resuscitation. Transfusion. 2013;53 Suppl 1:96S-9S. Collaborators C-. Effect of tranexamic acid in traumatic brain injury: a nested randomised, placebo controlled trial (CRASH-2 Intracranial Bleeding Study). British Med Journal. 2011;343:d3795. Ker K, Edwards P, Perel P, Shakur H, Roberts I. Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis. British Med Journal. 2012;344:e3054. Lockey DJ, Weaver AE, Davies GE. Practical translation of hemorrhage control techniques to the civilian trauma scene. Transfusion. 2013;53 Suppl 1:17S-22S. Cap AP, Baer DG, Orman JA, Aden J, Ryan K, Blackbourne LH. Tranexamic Acid for Trauma Patients: A Critical Review of the Literature. Journal of Trauma-Injury Infection & Critical Care. 2011;71(1 Supplemental):S9-S14. Mahmood A, Roberts I, Shakur H, Harris T, Belli A. Does tranexamic acid improve outcomes in traumatic brain injury? British Med Journal. 2016:354:i4814.

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CURRENT THINKING Role of TXA In Management of Traumatic Hemorrhage In The Field International Trauma Life Support

The guidelines and references contained in this document are current as of the date of publication and in no way replace physician medical oversight. Original Publication Date: July 2014. Updated October 2016.


This is the official current thinking of International Trauma Life Support (ITLS) with regard to the role of TXA in management of traumatic hemorrhage in the pre-hospital setting.


It is the position of International Trauma Life Support that: 1. There is sufficient evidence to support the use of TXA in the management of traumatic hemorrhage in adult trauma patients. 2. ITLS supports the use of TXA in the acute management of traumatic hemorrhagic shock within the framework of established system medical oversight and protocols. 3. Use of TXA is recommended in conjunction with initial resuscitation and control of external bleeding. Early TXA administration should be considered following airway stabilization, control of external bleeding, and initial volume resuscitation. 4. The use of TXA should be considered during the early stages of resuscitation and transport. Current research demonstrates TXA is most effective if given within 3 hours of the injury and may be detrimental if given after that time. 5. With reference to Updates-October 2016, ITLS recommends that patients with isolated traumatic brain injury should not receive TXA outside the context of a randomized trial.

Physician Led, Patient Focused.


TH-FEP Practice Made Perfect brand ad


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Poison Control A Therapy of LAST Resort: Intravenous Lipid Emulsion for Enteral Overdoses Kristen E. Heiner, Pharm.D. PGY2 Emergency Medicine Pharmacy Resident UF Health Jacksonville In 1998 Weinberg and colleagues first reported that an infusion of soy-bean oil emulsion prevented or improved the efficacy of resuscitation in severe bupivacaine overdoses in rats.1 Since then, the use of intravenous lipid emulsion (ILE) for toxicity has been studied in several animal models in addition to the reports of clinical efficacy seen in humans. What started out as an antidote for local anesthetic systemic toxicity (LAST) is now being used in patients with other forms of toxicity refractory to standard resuscitative measures.2,3 Several mechanisms make ILE a viable option for both LAST and other enteral overdoses. The first proposed mechanism is “lipid sink”. When ILE is infused, the toxin is bound to the lipid in the plasma which then pulls the toxin down the concentration gradient into the plasma and away from the target tissues. For this mechanism to be effective, the toxin needs to be lipid soluble. In cardiac toxicity, lipids have been observed to have a direct cardiotonic effect. While the exact mechanism of this is unknown, it could be related to the utilization of lipids as the heart’s preferred energy substrate. Other proposed mechanisms for ILE’s effectiveness involve membrane channel effects and intracellular metabolic signaling.2 The American College of Medical Toxicology (ACMT) provides three dosing regimens of ILE, none of which have been validated. The first is the American Heart Association recommendation: 1.5 mL/kg bolus followed by a 0.25 mL/kg/min infusion for 30 to 60 minutes (max dose: 10 mL/kg). recommendations suggest a second bolus (1.5 mL/kg) and an increased infusion rate of 0.5 mL/kg/min if there is persistent cardiovascular collapse over the first 30 minutes (max dose: 10 -12 mL/kg). The final recommended dosing regimen involves a 1.5 mL/kg bolus, followed by 0.25 mL/kg/min for 3-5 minutes, and then an infusion of 0.025 mL/kg/min.4 In LAST the absorption is quick and the toxicity is short-lived which lends itself to the first two dosing regimens which utilize high doses for short periods of time. This is in contrast to the prolonged absorption of enteral overdoses with an extended period of toxicity. With this toxicity comes a need for continued support which is provided by the third dosing regimen.5 Two case reports have demonstrated utilizing low dose ILE over a longer duration. In a tricyclic overdose, Agarwala and colleagues reported an infusion rate of 100 mL/hour, which was approximately 0.02 mL/kg/min for 24 hours.6 With an even lower rate of 0.008 mL/kg/hr for 12 hours, Bologa et al successfully treated a diltiazem overdose.7 In both case reports, patients survived to discharge. The goal of low dose ILE over a longer duration is to maintain lipemic plasma without causing fat overload and adverse effects. Some of the adverse effects associated with ILE include: lipemia, hyperamylasia, acute respiratory distress syndrome, and ventilation/perfusion mismatch.5 These were seen in patients with enteral overdoses that were often treated with volumes greater than the FDA recommended adult maximum dose (12.5 mL/kg over 24 hours).5,8 The FDA dosing limits were established for nutritional support; however, when treating toxicity, ACMT states that there is no known maximum dose, but suggests 10 mL/kg.4 The treatment of LAST with ILE is better defined than that of enteral overdoses. Current ACMT guidance recommends considering ILE when there is instability from a highly lipid soluble drug.4 There is little evidence to support a dosing strategy or maximum dose when a longer duration of ILE is required. At this time, it is reasonable to utilize lower doses for a longer duration to help support patients through toxicities that are more prolonged than LAST.4,5 Your local poison center is available at 1-800-222-1222 for any questions regarding ILE therapy or any other toxicity treatment. REFERENCES: 1. 2. 3. 4. 5. 6. 7. 8.

Weinberg GL, VadeBoncouer T, Ramaraju GA, Garcia-Amaro MF, Cwik MJ. Pretreatment or resuscitation with a lipid infusion shifts the dose-response to bupivacaine-induced asystole in rats. Anesthesiology. 1998;88:1071-5. Weinberg G. Lipid emulsion infusion resuscitation for local anesthetic and other drug overdose. Anesthesiology. 2012;117:180–7. Gosselin S, Hoegberg LC, Hoffman RS, et al. Evidence-based recommendations on the use of intravenous lipid emulsion therapy in poisoning. Clin Toxicol. 2016;54:899-923. ACMT position statement: guidelines for the use of intravenous lipid emulsion. J Med Toxicol. 2016; 13:124-5. Fettiplace MR, Akpa BS, Rubinstein I, Weinberg G. Confusion about infusion: rational volume limits for intravenous lipid emulsion during treatment of oral overdoses. Ann Emerg Med. 2015;66:185-8. Agarwala R, Ahmed SZ, Wiegand TJ. Prolonged use of intravenous lipid emulsion in a severe tricyclic antidepressant overdose. J Med Toxicol. 2014;10:210-4. Bologa C, Lionte C, Coman A, Sorodoc L. Lipid emulsion therapy in cardiodepressive syndrome after diltiazem overdose-case report. Am J Emerg Med. 2013;31:1154.e3–4. Intralipid® 20 %: A 20% I.V. Fat Emulsion In Excel® Container. 2004.

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ACE P B o a r d U p d a t e In March, while FCEP was at EM days in Tallahassee, ACEP held its Leadership and Advocacy Conference 2017. It was another great meeting of the advocacy brain trust of emergency medicine! With more than 600 attendees, it was also the largest we have ever had. Unfortunately, the weather put a damper on things, limiting hill visits. The Florida delegation, as shorthanded as we were, carried on and were able to visit most of our congressional offices.

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

I had a follow-up meeting with Sen. Nelson’s Health Counsel, which went very well. We had substantive discussion regarding Balanced Billing (Surprise Coverage Gaps) and EMTALA-related Tort Reform (S527). I had dinner with Rep. Darren Soto (FL), a long-time friend of FEP of TeamHealth. He is very interested in our help and advice as he continues to grow in Congress. I predict a bright future for him! I was also able to attend a dinner with Rep. Phillip Roe (TN) along with a number of TeamHealth physicians. He is very influential and engaged with Veterans Affairs; we are planning to follow up with him as well in the near future.

A couple of weeks later, I attended Congressman Dr. Raul Ruiz’s annual strategic planning meeting in Palm Springs. This year, Congressmen Frank Palone (NJ), Ed Perlmutter (CO) and Salud Carbajal (CA) also attended the meeting. We had a number of excellent discussions regarding the direction of healthcare reform and the vital importance of emergency care within the healthcare continuum. Since then I have made visits to the Texas, Pennsylvania and Washington Chapters, as well as attending the April ACEP Board of Directors meeting in Dallas. At the Board of Directors meeting, we had spirited discussions around Fair Coverage (Balanced Billing), the ACEP strategic plan, the evolution of the CEDR registry, a number of Ethics Policies, MOC concerns, several policies related to Pain Control in the ED, Opiates, Ultrasound and Geriatric accreditation issues, and Wellness in EM to name a few. We approved this years ACEP and Council award winners, including FCEP’s-own Dr. Kelly Gray-Eurom, who was awarded, and welldeserved it, the Council Meritorious Service Award. Finally, we approved this year’s slate of candidates for the College and Council leadership, which included yours truly:

PRESIDENT-ELECT CANDIDATES Vidor Friedman, MD, FACEP Hans House, MD, FACEP William Jaquis, MD, FACEP John Rogers, MD, FACEP


John McManus, MD, FACEP (GS) – unopposed


Sabina Braithwaite, MD, FACEP (MO) Andrea Green, MD, FACEP (TX) Gary Katz, MD, FACEP (OH)

BOARD OF DIRECTORS CANDIDATES (FOUR POSITIONS TO BE FILLED) Stephen Anderson, MD, FACEP (incumbent – WA) Kathleen Clem, MD, FACEP (AAWEP Section and FCEP) J.T. Finnell, MD, FACEP (IN) Alison Haddock, MD, FACEP (TX) Jon Mark Hirshon, MD, FACEP (incumbent – MD) Aisha Liferidge, MD, FACEP (DC) Virgil Smaltz, MD, FACEP (NY)

Carrie de Moor, MD, FACEP (Freestanding Emergency Centers), has announced her intention to seek nomination from the Council floor for the Board of Directors. The elections will take place in Washington, D.C. in October at the Council meeting proceeding ACEP2017. Please shoot me an email and I can answer any questions you may have, or be of assistance in any way. SUMMER 2017 | VOLUME 24, ISSUE 2

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R e s i d e n c y M at t e r s See what our emergency medicine residency programs have been up to. Greetings from Florida Hospital! Another year has come and gone, and the excitement is high as we prepare to welcome our new interns and send off our amazing seniors! We are thrilled with the talented group of new interns starting in July and excited for the futures of our graduating seniors (even though we are sad to lose them).,

Florida Hospital Shayne Gue, MD PGY-2

While one of our chief residents, Dr. Kevin Goldman, is heading back home to practice near family in California, our other chief, Dr. Jessica Aun, has opted to stay local with FEP of TeamHealth in Orlando. Dr. Chasi Skinner will be moving north to join our friends in Tallahassee with TeamHealth at Capital Regional Medical Center. Dr. Alex Drake is making the big move back to family in Salt Lake City, working for MountainStar Healthcare. Drs. Jerome Clayton and Sulaiman Matto will be joining Dr. Aun in staying local as physicians for FEP of TeamHealth in Orlando.

We continue to strive for further education and better efficiency in the ED as evidenced by our small group’s ability to tackle a volume of more than 120,000 patient visits at Florida Hospital East Orlando in 2016. With only 18 residents, that’s a HUGE accomplishment! Many positive changes are coming to our educational programs/conferences and our clinical teaching within the ED, due to the hard work and investment of our residents and faculty members. In April, we convened at the Rosen Centre Hotel for our Annual Program Evaluation, where we were able to celebrate our many successes as a program and continue to strive for more. Our residents have been vocal about implementing new programs/procedures to improve our clinical education and our faculty has been receptive to each. We are looking forward to another excellent year ahead! Looking forward to meeting you all at Symposium by the Sea! It’s been an exciting time at UF for the residents this spring. Each spring, residents and EMS faculty gather for the annual EMS Day to gain insight into what our pre-hospital colleagues experience on a daily basis. This year, residents went to a local fire station to learn more about pre-hospital care. Additionally, we had an opportunity to practice certain key skills in less-than ideal circumstances, such as intubating beneath a picnic table. Residents also had the chance to apply different types of tourniquets and practice advising EMS personnel over the phone as medical control. We also just had our Senior Research Day. Each year, the third year residents have an opportunity to present to the department their scholarly projects. This year we had the opportunity to learn more about topics such as utilization of the age-adjusted d-dimer for PEs (Dr. Zeglam); ultrasound use for occipital nerve blocks in migraines (Dr. Lane); utilization of qSOFA in the ED (Dr. Rasheed); compassion fatigue in ED providers (Dr. Graham); predictors of PE in COPD’ers (Dr. Bell); HEARTSCORE predictor of MACE in patients discharged from the ED (Dr. Zeinali); hemoptysis management (Dr. Estrada), and sepsis recidivism and its contributors (Dr. Kaplan). As spring turns into summer, we’re preparing for graduation and getting ready to say goodbye to the senior residents and hello to the incoming interns. We’ve come full circle once again.

University of Florida, Gainesville Merisa Kaplan, MD, MPH PGY-3

It’s tough to believe that another academic year is coming to an end, and the month of new interns is fast approaching. We seem to be reaching the downslope of the busy season bell curve and rare lulls in the seemingly ever-swinging entrance door are coming more frequently. I was lucky enough to be one of the first rotators on our new official ultrasound rotation, and I can officially say it was an incredibly educational and very worthwhile month. Our well-used M-Turbo US machine, flaunting all of its battle scars from years of scans, has been replaced by two brand new Sonosite X- Porte machines that will propel the newly added US rotation to the highest caliber of cutting-edge ED ultrasound education.

Mt. Sinai Medical Center Matthew Brooks, DO PGY-2

The Mount Sinai Medical Center EM Residency hosted the FLAAEM annual conference at the Fontainebleau Hotel in April, which was a huge success. Three of our interns presented cases, and awards for best research and cases were given to Drs. Farrow, Boswell and Lorenzo. We also hosted a student track on Sunday which was very well-attended by first to fourth year medical students from various South Florida medical schools.

Since this is being written during one of the aforementioned lulls in my shift, I will have to end the update at this point. Stay tuned for an update that will introduce our new seven interns for the class of 2020!

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University of Florida, Jacksonville Jason Arthur, MD, MPH PGY-2

Recent months have been full of awards, activity and growth at UF Jacksonville. Outgoing chief resident Dr. Lexie Mannix was inducted into the University of Florida Gold Humanism Honor Society in recognition for her leadership and compassion as an emergency medicine physician. Dr. Mannix was also honored with the Academy for Women in Academic Emergency Medicine (AWAEM) SAEM Travel Scholarship. Dr. Matthew Lowery has completed his Registered Diagnostic Medical Sonographer (RDMS) certification. Drs. Phyllis Hendry and Robert Wears were awarded full Professorships in the Department of Emergency Medicine. Dr. Kelly Gray-Eurom has been awarded the ACEP Council Meritorious Service Award for 2017 and has been selected to become a fellow in the Fellows Program for America’s Essential Hospitals. Lastly, the Society of Academic Emergency Medicine has awarded Chairman of Emergency Medicine Dr. Steven Godwin the Simulation Academy Distinguished Educator Award for his dedication to simulation education.

The Council on Emergency Medicine Residency Directors (CORD) Meeting was recently held in Fort Lauderdale, and UF Jacksonville came out in force to learn and share lessons learned on how to become the best training program possible. Drs. Lexie Mannix, Jay Khadpe and Tom Morrissey sat on panels ranging from social media outreach to evaluating students to managing difficulty situations. Incoming Chief Resident Shehzad Muhamed along with Dr. Melissa Parsons, who is a former UF Jacksonville chief resident and now assistant professor of emergency medicine (among many other titles) presented clinical pathologic cases at CORD. Drs. Phyllis Hendry, Sophia Sheikh and Colleen Kalynych presented two different programs on pain management in the ED as part of the Pain Assessment and Management Initiative (PAMI). UF Jacksonville is experiencing a tremendous amount of growth. Our North Campus has offered a wonderful community experience for our residents and expanded service to the people of Northeast Florida. In-patient rooms at UF North opened on May 19. Seven new faculty members have joined our team. Dr. Alyssa Rotolo joins us from South Florida. Dr. Lamont Smith and his wife, Dr. Christine Braud, both EM/critical care trained, are joining us from private practice. Dr. Amanda Crichlow, fellowship trained in simulation education, will add to our aggressive sim program. Dr. Jennifer Fishe is coming on board as faculty after completing a Pediatric EM Fellowship at Johns Hopkins. Dr. Ian Storck comes to us after completing his year as Chief Resident at Stanford. Dr. Geoffrey Odom comes from community practice in Texas and Louisiana.

It is summer in Florida! What a magnificent time of year! We have an amazing class of new interns on the way, and we are so proud of their achievements. Our current interns are happily moving on up and will soon be flooding back into the ED after their various months away. Our second years now have the promise land in their sights. Congrats go out to the new chiefs and all of the rising third years, who are taking on leadership positions to help foster the ideals of our program. In the last few months many of us have had a terrific time at EM Days (getting to see the political background of the state and our practice), CORD (getting to see how our leaders in EM education inspire us all) and SAEM (helping to show the EM nation what mid-Florida is all about). We’d like to give a special congrats to soon-to-be graduate Allison DeRespino. She will become the USF EM Ultrasound fellow next year. We are excited to get to keep her around for another year, knowing that she will do an awesome job furthering the educational impact of our strong ultrasound program. Lastly, congratulations to all of the grads! You have inspired us from day one and played a big role in the residents that we are and the future doctors that we will become. Thanks for showing us the way, and have fun with your grown-up jobs out there in the real world!

University of South Florida Jeffrey Hoida, MD PGY-2

Every Tuesday and Thursday morning, our senior residency coordinator Carrie Chapman arrives to the conference room, a few minutes before 7 a.m., to set up the laptop where we all sign in. Next to it, she places an 8” by 10” photograph of Dr. Silvestri — his warm smile filling the thin silver frame. Not a day goes by where we don’t think about him. His legacy has impacted much more than our small group of residents. The Orange County School AED program Gofundme Campaign established in his honor has raised nearly $75,000; the Florida College of Emergency Physicians has established the Dr. Sal Silvestri EMS Research Fund; and, most recently, the CORD 2017 Academic Assembly in Fort Lauderdale has established a resident’s travel fund in his memory.

Orlando Health Shari Seidman, MD & Erich Heine, DO PGY-2

Three of our graduating seniors, Drs. Ryan Queen, Alexa Rodriguez and Justin Mauldin, presented at the CORD meeting. Their presentations were “Introducing Resident Quality Officers, a unique niche in emergency medicine” and the “Role of teaching resident in academic emergency medicine program”, which are two unique features of our program. Our rising second years are excited to fill these roles, as Drs. Aytana Alvarez-Ambas and Drew Bienvenue will become our new Quality Officers, focusing in areas of sepsis, education and toxicology.

For the 2017-2018 academic year, Drs. Allyson Best, Erich Heine and Christopher Mills will lead our program as chief residents, and our program will be under the direction of Dr. Josef Thundiyil, along with associate program directors Drs. Jay Ladde and Christopher Hunter. Together, we are all excited to welcome our new intern class. They come from all parts of the country — Oregon, Texas, Kentucky, Tennessee, Arizona, Alabama, Washington D.C., South Carolina, Georgia, and our own backyard, here in Florida. Like Dr. Silvestri used to say: “Once you’re in the family, there’s no getting out.” Welcome to the family.


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Kendall Regional Medical Center is proud to be completing the first year of our inaugural residency class, and we are looking forward to the incorporation of the next incoming class. Thanks to all the hard work of the faculty and residents, our program continues to grow! Our residents have learned to incorporate ultrasound into their daily practice and spent a dedicated two weeks as interns building their skills. As senior residents, they will develop advanced techniques and fine-tune their abilities with the image acquisition and interpretation by helping to train the intern class. The simulation program, utilizing the Broward Health Simulation Center, continues to mature and evolve through the hard work of our simulation co-directors, with a focus on high-acuity, low-frequency cases. Thanks to the Kendall Regional Medical Center hard work of the faculty, simulation co-directors and GME leadership at Kendall, we will be completing our largeKendall Regional Medical Center scale mass casualty drill at the end of May. Residency programs from Aventura Hospital and Kendall Regional Emergency Medicine Residency Staff Medical Center, along with Broward EMS, are joining us at the Broward Health Simulation Center to make this a great experience. We are also excited to be progressing on our EMS, Quality and Patient safety and research initiatives. When we include the other educational programs in development with Kendall and all the other emergency medicine residency programs in Southern Florida, there really is a lot of opportunity. It gives me the greatest pleasure to announce that our EM program was successful in our application to achieve our goal of Initial Accreditation within the ACGME. We'd like to especially thank our hardworking ADME Ms. Crystal Raines and our program director Dr. Thomas Matese for this accomplishment. We are also pleased to announce our chief resident Dr. Kristen Hanrahan was recently published in the MDedge Emergency Medicine journal for her case of "Hypothyroidism-Induced Stercoral Sigmoid Colonic Perforation," co-authored by our program director, Dr. Thomas Matese. In other news, the EM residents were treated to our annual residents day out at Ballpark of the Palm Beaches, courtesy of our DIO Dr. Bradley Feuer.

St. Lucie Medical Center Rege Turner, DO

As the academic year is winding down, the senior residents are soaking up every last bit of knowledge from their attendings. Chief resident Dr. Kristen Hanrahan will be heading to Martin Health Systems based in Stuart, Fla. Dr. Daniel Hohler will be joining EMPros in Daytona Beach, Fla. Dr. Joseph Sarbu will be practicing at Redmond Regional Medical Center in Rome, Ga. Dr. Rege Turner will be joining Georgia Emergency Associates in Savannah, Ga. It is hard to believe that the first year of the residency is almost over. We are very excited about the 2017 Match – we have an awesome group for the coming academic year:

Aventura Hospital Todd L. Slesinger, MD, FACEP, FCCM, FCCP Program Director

Ulrika “Riki” Andersson, MD Frederick Chu, MD Emerson Franke, MD Jaskirat Gill, MD Metali Mehta, MD Matthew Mungo, DO Katherine Peterson, MD Jennifer Reyes, DO Nicole Rodriguez Perez, MD Ricardo Rodriguez, MD

Linkoping University University of Illinois Ross University SUNY Upstate Morehouse University Nova Southeastern University of Southern California University of North Texas San Juan Bautista SOM Michigan State University

Our faculty continue to be involved in academics. Dr. Childress has co-authored a research publication in the Clinical Journal of Sports Medicine titled “Analysis of Central and Peripheral Vision Reaction Times in Patients with Post-Concussion Visual Dysfunction”. Dr. Tran presented at the Yale Point of Care Conference - Ultrasound course in Clearwater, Fla. Dr. Slesinger co-published two book chapters in the second edition of Critical Care Emergency Medicine — Chapter 7: Noninvasive Ventilation and Chapter 17: Hypertensive Crisis. The residents also remain very productive. In December 2016, Dr. Yasavolian co-authored an article titled “Comparison of Intravenous at Three Single-Dose for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial”. This was published the Annals of Emergency Medicine, and it was a truly practice changing study. Our emergency room expansion is finished and opened May 1, 2017, bringing 14 new exam rooms, two isolation rooms, five behavioral health rooms and a new ultrasound room. The new facility allows us to provide better clinical care to our expanding patient census, and offer a new and expanded space for enhanced clinical education and bedside teaching. For more information, please contact Angela Taylor, residency program coordinator at

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Greetings once again from UCF/HCA Emergency Medicine Residency Program of Greater Orlando! It is hard to believe that we have finally completed our first year, and we are proud to announce and welcome our new interns Drs. Baway, Chiang, Craen, Fusco, Hanna, Pollak and Tsau to the OsRMC family. We are extremely excited about the many things that have occurred since our last update. Earlier this year, Dr. Rubero, as well and Drs. Singh and Roka, had the opportunity to participate in the Disney Star Wars Race Marathon by working in the medical tent, providing care to the participants of the April races. Furthermore, we have worked hard on our Qi projects, which included sepis bundle compliance, time to pain meds in long bone fractures, and urinary catheter placement in the ED – indication and order compliance and had the opportunity to share our interventions and results in posters at various conferences. UCF HCA of Greater Orlando Abhishek Roka, MD and Leoh N. Leon II, MD PGY-1

Lastly, we had our first annual program retreat in New Smyrna Beach, Fla, and what an amazing experience that was! We are truly blessed to have such amazing faculty, mentors and friends. It was great to spend some time together and reflect on our first year of residency, give our input, and just “hang out” and catch some sun on the beautiful Florida beach.

We are very excited and look forward to our second year of residency. To all those who have graduated, and those interns just starting — congratulations! This past March we were able to give our residents protected time to attend the AAEM conference in Orlando, FL. The combination of didactics, team-building, socializing and networking provided them with a flurry of activities to help shape their EM world outside of the hospital and offered much appreciated respite from chaotic ED life. A great time was had by all. In April, the academic leadership at JMH was in full force at CORD, right here in our own Fort Lauderdale backyard. One can’t help but leave CORD feeling invigorated and motivated to continue shaping the next generation of learners, educators, leaders and innovators. It really was great to see everyone. We would also like to announce that Dr. Alejandro Baez, our current program director, has been promoted to Chief of Emergency Medicine at Kings County Hospital in Brooklyn, NY. He has done a great job starting our residency, and we are sad to him leave. We wish him the best of luck on his new job. We are excited to have Dr. Christopher Freeman take over as program director and continue the development of our program.

Jackson Memorial Hospital

Jackson Memorial Hospital Emergency Medicine Residency Staff

As we prepare to welcome our second class of residents (how quickly a year has passed), we reflect on what an exciting and groundbreaking year it has been for emergency medicine at JMH as well as throughout all of South Florida. We went from zero ACGME emergency medicine programs in South Florida to more than five and counting. This provides us with many unique opportunities to collaborate and to innovate, and to keep propelling our specialty forward. We look forward to many more exciting endeavors in the upcoming year.

THANK YOU TO OUR 2017 CORPORATE PARTNERS! The success of the Florida Emergency Medicine Foundation (FEMF) and the Emergency Medicine Learning & Resource Center (EMLRC) is due in large part to our corporate partners that provide annual sponsorship support for our educational programs and events. Thank you to our 2017 corporate partners for believing in our mission and helping us to provide lifesaving education to life savers!


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

EM p u l s e F e a t u r e See You In Boca! Regardless of whether this going to be your first Symposium by the Sea (SBS) or you are a returning guest, you are sure to be pleased with the programming for SBS 2017! In addition to our crowd favorites, we have made several program changes that we hope will enhance our learning and networking experiences. We have several highly engaging tracks taking place which may make it difficult for you to choose your activities, but we’re looking forward to seeing you try! SBS 2017 will begin with our quarterly committee meetings and Board Meeting; these meetings are open to all FCEP members. We encourage you to attend these meetings to get a more indepth understanding about how we work hard to ensure that our focus is always on preserving and enhancing the future of emergency medicine in Florida. Rene Mack, MD Symposium by the Sea 2017Chair

Don’t miss our lively Town Hall session which will be hosted by several ACEP and FCEP leaders. The Town Hall is where we will discuss the current and future positions of ACEP/FCEP on the status of Emergency Medicine. All conference participants are strongly encouraged to attend so we can share ideas about how best to approach the most pressing topics we face in caring for our patients. The educational program includes our renowned LLSA programming. This year you will able able to complete the 2016, 2017 and the Patient Safety LLSA. You can review the articles as well as take the test during the course, so no need to worry about completing those steps when you get back home or during the rest of the weekend. Last year, we had our first pediatric track, which was well received and prompted us to continue the excellence into this year. The 2017 Pediatric Emergencies track incorporates lectures, procedure and simulation stations to help make your next pediatric encounter a more positive one. After the success of the pediatric track, we worked to create a Critical Care track for SBS 2017! These critical care sessions will serve to bring you the “bottom line” on the best methods of managing our sickest patients. Our highly rated Rapid Fire Lectures give you pertinent information delivered in an informative and engaging manner. These fastpaced discussions are sure to give you “just enough” and allows for development of further investigation into the topics. Another addition to our programming this year includes our New Speaker Series. This section will showcase four EM physicians who are rising stars on the lecture circuit. Come and support them as they fine tune their presentations skills. Maybe you’ll do it next year? There are also numerous residency-focused activities also taking place, such as SIM Wars, Case Presentation Competition (CPC), Research Poster Presentation and the Residency Networking Social. This year we will welcome the Aventura, Kendall and Osceola Regional EM Residency programs to SIM Wars and the CPC. Join us in supporting our residents as they showcase their skills! Also notable is our Women In Medicine meeting, which is open to all who are interested. Many great topics and ideas have been generated from past meetings, and this year won’t be different. Come ready to be engaged and learn about how you can implement change in various arenas. Although we strive to provide high-quality educational topics, we can’t forget about finding time to enjoy the weekend! On Friday evening, in the Exhibit Hall, our vendors host a Wine, Beer and Cheese Social that provides a great time to become acquainted with the vendor products and network with colleagues. Beach volleyball anyone? The Past-Presidents’ Annual Volleyball Tournament takes place on Saturday. Somehow it usually turns into a resident versus, ahem, non-resident competition that carries bragging rights, so come ready to play or cheer on the teams. Continuing the festivities, Duva-Sawko and EMPros hosts the annual Casino Night on Saturday evening, which is one of the highlights of SBS. There are activities taking place throughout the night that are sure to please any age group and all are welcome. With so many activities taking place, we hope you’ll still take the time to let us know how you are enjoying the programming. We look forward to learning and celebrating with you at SBS 2017. See you in Boca! ** Due to the rising costs of food, beverage and meeting space, you will notice that we have initiated a nominal registration fee. If you have any questions, please contact our FCEP office for more information.


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EM p u l s e F e a t u r e An Emergency Physician’s Career: Financial Decisions - Part II: A Deeper Dive Article by Andrew Bern, MD, FACEP, DTM; Todd Lesk, ChRPS; and Marc Lowell, CLU, ChFC Our first article (EMpulse Winter 2016 - 2017 | VOLUME 23, ISSUE 4) concentrated on financial decisions that each emergency physician will make over a career. These decisions are executed during one or multiple time periods (1). In “Part II: A Deeper Dive”, we will explore some fundamental questions: How do I select where I get my advice? What credentials are relevant? What is the difference between knowing and doing? In medicine, there is an understanding of “know what you know” and when you need to rely on additional expertise from those who “know what you don’t know or who can do what you can’t do". Thus, it is common under the care of a patient that we rely on consultants to provide specialists with expertise that meet a patient's need. The same truth is present in financial, legal, and accounting areas, where we must make decisions that will impact our lives and those of our families. How do I select where I get my advice (for a qualified financial planner)? There are six elements to consider: credentials (see Table 1), independence, products, references, dynamic annual reviews, and education. Table 1: Abbreviations CLU: Chartered Life Underwriter CFC: Chartered Financial Consultant ChRPS: Chartered Retirement Plans Specialist ChFP: Chartered Financial Plan Specialist ChLC: Chartered Life Consultant CFP: Certified Financial Planner We have listed six credentials typically held by experts in the areas of financial planning and insurance. Independence, in financial services, recognizes that there are practitioners who can choose the products that are determined “best for you”. This determination occurs after a detailed analysis of your income versus expenses, student debt, identifying your financial goals and risk management issues, regardless of proprietary restrictions based on company policies. Practically speaking, they can recommend programs from multiple companies. Product recommendations can be very complicated. For example, if you were looking at mutual funds, there are more than 5,000 choices. An independent advisor can recommend “no-load funds", where the adviser does not get paid commission for that decision. Product selection is also complicated. The first question asked: Is there a minimum investment? Some products have a minimal threshold that is needed to make an investment. The second issue relates to the impact on your taxes and risk management: Is your investment part of an overall asset protection strategy? For example, if your advisor recommended an annuity, your money can grow tax-free and be protected against medical malpractice judgments against you. Alternatively, money invested in a money market will be subject to tax on growth. These funds will be at risk under current laws. As you consider your selected advisor, references from current clients, attorneys and accountants can assist you in making your decision. The chemistry that exists between you and your potential advisor can also be critical. A good chemistry can lead to trust, enhanced communication, and emotional support and comfort during good and bad times. A longterm relationship with your advisor will be essential to your financial health. The relationship is dependent on dynamic and fluid review process that begins with an in-depth analysis of your previous financial picture; where you are currently; and where do you want to be? This scrutiny should have the ability to make course corrections and, at least, an annual review. Is this plan meeting my objectives? Is my advisor easily available for questions? Will they be there if there are changes in my career? Education, in this context, is what you must know, as well as knowing the credentials of your potential financial advisor (2). It is also building your team that includes legal and accounting advice.


“Disability coverage is one of the most ignored insurance coverages out there,” observes Keith Kruk, a Texas-based regional vice president of Fidelity Brokerage Services. “But the greatest asset we have isn’t our home or our car,” he says. “It’s our ability to

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wake up each morning, go to work, and get a paycheck.” (from articles from referencing the importance of disability insurance, 3-7). “One in three women and one in four men will have a disability that keeps them out of work for 90 days or more at some point during their working lifetime.” (3) What is it that we must know? First, there are two types of disability insurance: a short-term policy that can cover up to three months (90 days) with a variable waiting period, and a long-term policy (long term disability or LTD). The short-term policy can reimburse up to 60 percent of your base pre-tax income, while the LTD can pay 40-60 percent of your base pre-tax income. "If the program is obtained with after-tax dollars, the benefits you receive income tax-free." (3) There is also a difference between employer-provided policies and individually purchased policies. Separately purchased plans could be taken with you if you changed employers or jobs. What do we do with this knowledge? In a study conducted by the Insurance Institute in 2015, “61% of Americans say that most people need disability insurance yet only 26% of people have it.”(8) The answer is that most of us do not take the time to understand one of the most important foundations to anyone that has earned income. The protection of that revenue can be achieved through disability programs that guard against the interruption of that financial stability. These programs often require a layered approach to both a short-term and long-term policies. For many, a layered approach that includes employer provider, as well as individual coverage that is portable, is ideal, and disability programs are critical in time blocks 1-4.


In this article, Part II, we have learned where do we get our financial advice, how to recognize the credentials of potential advisors, and the differences between knowing and doing. We also focused on disability insurance as a strategy in building our foundation for financial health and stability. In our next installment, we will focus on the other end of the career (time block 4-5): planning for retirement and long-term care requirements or options. REFERENCES (1)

A Physician’s Career - Financial Decisions Time Blocks: 1 = 0-30 Years of age 2 = 31-40 years of age 3 = 41-50 years of age 4 = 51-60 years of age 5 = 61 Years of age going forward

(2) By Marc L. Lowell: (3) (4) The Real Risk of Disability in the United States, Milliman Inc., on behalf of the LIFE Foundation, May 2007 (5) The Council for Disability Awareness, Long-Term Disability Claims Review, 2010 (6) CDC Disability Facts and Statistics: (7) Social Security Disability Facts: (8) 2015 Insurance Barometer Survey: Life Happens and LIMA

Approved for AMA PRA Category 1 CreditsTM

Snapshots from APP Skills Camp - Spring 2017 Photos by Samantha Rosenthal, FCEP/EMLRC Communications Manager

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

CLINCON 2017: Florida’s Premier EMS Conference Article by Benjamin N. Abo, DO EMT-P, University of Florida Department of Emergency Medicine Time flies like an arrow — fruit flies like bananas! CLINCON 2017 is already coming up, and boy are we excited! From cadaver labs to the ALS/BLS Skills competition to some seriously cutting-edge hot topics of the times, there is going to be a lot offered at this year’s conference. Keynote talks you ask? We've got keynotes including Lessons Learned from the Pulse Nightclub Shooting by Chiefs Wales and Smith, and an excellent autobiographical talk presented by Benjamin Vernon from San Diego Fire Department. He is going to talk about workplace violence and his battles with PTSD. Street drugs, trauma, trauma centers, capnography, pediatric pain management are just some other topics for this year’s educational sessions.We are seriously looking forward to some truly cutting edge and diverse continuing education.

Benjamin Abo, DO, EMT-P CLINCON 2017 Co-chair

As chair of this year's conference, I sure hope I am not too busy during the actual conference so that I can get around to so many awesome programs.

Do note: We are not only back at the Caribe Royale, but the layout of the days for the conference and pre-conferences are different from what has been done in the past. Be sure to get your days off, get registered and reserve your room for what I am really looking forward to as a terrific conference!

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EM C a s e R e p o r t s Case Report: Hypothyroidism with abdominal peritonitis

induced stercoral sigmoid colonic perforation

Article by Kristen Hanrahan, DO; Thomas Matese, Jr, DO; and Adam Kurtin, DO


There are many complications associated with hypothyroidism, including constipation. Most cases of constipation can be resolved with medication adjustment or over-the-counter treatments. Rarely does this side effect of hypothyroidism lead to an acute surgical abdomen. We present a case of a patient who had uncontrolled hypothyroidism with severe constipation which led to the rare case of stercoral sigmoid colonic perforation with associated peritonitis requiring emergent surgical intervention.


According to the CDC, non-traumatic abdominal pain accounts for approximately 11% of all visits to the emergency department with approximately 7 million visits per year1. The differential for non-traumatic abdominal pain is vast, but one critical diagnosis is acute colonic perforation. Most perforations are caused by diverticulitis, trauma, malignancy, ulcerative colitis as well as other etiologies2. However, a rare, yet life threatening cause of colonic perforation is stercoral colonic perforation2. There have been few documented cases in the literature. Although no matter the etiology the critical action for any colonic perforation is quick recognition, medical stabilization and surgical evaluation, this case report highlights the diagnosis and treatment of acute stercoral colonic perforation with peritonitis secondary to hypothyroidism.


An ill appearing, 49-year-old female with past medical history significant for hypothyroidism presented to our emergency department for evaluation of diffuse abdominal pain, nausea and nonbilious, nonbloody vomiting that started the day of presentation at approximately 17:00. Patient denies any pain or associated symptoms previously. Patient states her abdominal pain began as mild on the morning of presentation; however her symptoms acutely worsened at approximately 17:00. She does relay that she had a small, hard bowel movement one day prior to arrival. She denies any diarrhea, melena or hematochezia. Her surgical history is significant for cesarean section and she denied a history of small bowel obstruction. Of note, patient did state that she had not been taking her Levothyroxine 150mcg for approximately 1 month and was recently restarted approximately 2-3 days ago by her primary care physician. On physical exam in the emergency department her temperature was 97.4F, heart rate was 156 beats per minute, blood pressure was 134/84 and respiratory rate was 20 breaths per minute. Patient appeared ill and diaphoretic, writhing on the stretcher. Abdominal exam was significant for diminished bowel sounds, diffuse abdominal distension, rigidity and tenderness with light palpation. Laboratory data showed an elevated lactic acid of 7.7mmol/L. White blood cell count was noted to be 7,200 cells/mm3 (segment form, 69.5%), as well as the following abnormal blood chemistries: Creatinine 2.08 mg/dL, AST 176 U/L, ALT 138 U/L, TSH 225.3 mcInu/mL. Other laboratory results were within normal range. EKG showed sinus tachycardia with a heart rate of 154. QTc was within normal limits and there was no ST elevations or depressions. Abdominopelvic computed tomography (CT) revealed free air, free fluid and possibly stool within the abdomen and pelvis. Findings were concerning for a ruptured hollow viscus, possibly sigmoid colon

Continued on page 28 SUMMER 2017 | VOLUME 24, ISSUE 2

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Continued from page 27 perforation. Radiologist also noted hepatomegaly and significant hepatic steatosis. The surgeon was immediately notified and the patient was evaluated in emergency department. Working diagnosis was stercoral colonic perforation secondary to severe hypothyroidism. Patient was taken emergently to the operating room for repair. Intraoperatively, patient underwent exploratory laparotomy and was noted to have gross fecal contamination of the abdomen. Surgeon noted the small bowel to have fecal staining along its serosal surface and as well as throughout pelvis. There were also large, hard stool balls noted outside of the colon. The perforation was along the mesenteric surface of the sigmoid just above the rectosigmoid junction. The abdomen was copiously irrigated, perforated segment was resected and Hartmann colostomy was created. Patient was diagnosed with stercoral sigmoid perforation with peritonitis. She was transferred to ICU for antibiotic treatment and further medical care, including IV Levothyroxine. She was extubated on post-operative day two without any respiratory complications. Her acute renal failure improved with supportive care and did not require hemodialysis. Bowel function slowly returned without complication. Patient was restarted on her Levothyroxine and given strict instructions for continuation and close monitoring. Patient was admitted to the hospital for a total of 13 days and was discharged home with adequate close follow up.


There can be multiple contributing factors leading to bowel perforation; our case illustrated a case of severe hypothyroidism with constipation leading to colonic perforation. The difference between more common causes of bowel perforation and the above case study is the underlying endocrine pathology. The patient had severe constipation this increased intraluminal pressure, causing the bowel wall to become ischemic and subsequently perforate5. Other causes of similar perforation would be any disease that causes significant constipation or diseases that cause obstruction of transit. With fewer than 90 cases of general stercoral bowel perforation reported up to 2002, according to one source, it is hard to distinguish an age range6. However, it appears that mid-50s to mid-60s appears to be the most common age group effected by this rare complication6. Our patient was at the young end of this age group so identifying her by age alone would have been difficult. Hypothyroidism is a common disease affecting much of the population. The incidence of hypothyroidism in iodine-replete communities varies between 1-2% of the population and is more common in older women with approximately 10% of the population affected over the age of 65. “In the US population, the prevalence of biochemical hypothyroidism is 4.6%, but clinically evident hypothyroidism is present in only 0.3%.7” Common causes for hypothyroidism are listed in table 1 below. Common symptoms include fatigue, weight gain, constipation, cold and heat intolerance7. It is typically diagnosed with TSH, total and free T4 and T3 laboratory values8. Treatment includes starting a synthetic thyroid hormone, such as Synthroid. As in our patient, hypothyroidism can also lead to many different fatal conditions; other conditions include myxedema coma. Common symptoms include hypothermia, hypotension, bradycardia, respiratory depression and altered mental status8. Severe myxedema coma can lead to cardiovascular collapse and eventual death. EKG findings of severe hypothyroidism can include bradycardia, low voltage QRS and widespread T-wave inversions8. However, our patient was tachycardia without any acute findings to suggest myxedema coma. Treatment includes supportive care with ventilatory support and pressor support if necessary. Patients should be given 100mg Hydrocortisone IV to treat possible adrenal insufficiency and levothyroxine (T4) 4 micrograms/kg by slow IV infusion8. Caution should be taken if giving patient L-triiodothyronine (T3) due to risk of arrhythmias and myocardial infarction8. Treatment of the underlying cause of the bowel perforation is imperative to prevent recurrence. We were recommended to not start treatment prior to going to the OR as the patient was not in myxedema coma. In retrospect I believe the patient would have benefited from IV levothyroxine, with little downside to giving the medication.

REFERENCES [1] Bhuiya F, Pitts SR, McCaig LF. Emergency department visits for chest pain and abdominal pain: United States, 1999-2008. NCHS data brief, no 43. Hyattsville, MD: National Center for Health Statistics. 2010. [2] Nam JK, Kim BS, Kim KS, Moon DJ. Clinical analysis of stercoral perforation of the colon. Korean J Gastroenterol. 2010;55:46–51. [PubMed] [3] Cathleen Heffernan, H. Leon Pachter, Alec J. Megibow, and Michael Macari. Stercoral Colitis Leading to Fatal Peritonitis: CT Findings. American Journal of Roentgenology 2005 184:4, 1189-1193. [4] Huang WS, Wang CS, Hsieh CC, Lin PY, Chin CC, Wang JY. Management of patients with stercoral perforation of the sigmoid colon: report of five cases. World J Gastroenterol. 2006;12:500–503.[PubMed] [5] Heffernan C, Pachter HL, Megibow AJ, Macari M. Stercoral colitis leading to fatal peritonitis: CT findings. AJR Am J Roentgenol. 2005;184: 1189-93 [6] Huang WS, Wang CS, Hsieh CC, Lin PY, Chin CC, Wang JY. Management of patients with stercoral perforation of the sigmoid colon: Report of five cases. World J Gastroenterol. 2006;12:500–3. [7] Hollowell JG, Staehling NW, Flanders WD, et al. Serum TSH, T4, and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III). J Clin Endocrinol Metab 2002; 87: 489–499. [8]Tintinalli, J. E., Kelen, G. D., & Stapczynski, J. S. (2004). Emergency medicine: A comprehensive study guide. New York: McGraw-Hill, Medical Pub. Division. [9] Maurer CA Renzulli P, Mazzucchelli L, Egger B, Seiler CA, Buchler MW. Use of accurate diagnostic criteria my increase incidence of stercoral perforation of colon. Dis Colon Rectum. 2000. 43:991-8. [10] Kawku MP, Burman KD. Myxedema coma. J Intensive Care Med 2007; 22:224. [11] Skugor, Mario. Hypothyroidism and Hypertyhyroidism. Cleveland Clinic Center for Continuing Education. August 2004.

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To work to perfect our physicians’ ability to practice medicine, every day, in everything we do.

EM p u l s e F e a t u r e Do’s and Don’ts of snake envenomations for ED providers Article by David A. Kranc, MD (PGY2) and Benjamin N. Abo, DO EMT-P, University of Florida Department of Emergency Medicine The weather is getting warmer, pollen is in the air, the trees are becoming green again, and the snakes are back! It's that time of year again when snake bites are on the rise. Florida is home to a large number of venomous snakes, and there are several common misconceptions regarding the management of snake envenomations. Below we present some DO’s and DON'Ts of snake envenomations for ED providers: DON'Ts

David A. Kranc, MD University of Florida Department of Emergency Medicine Residency, PGY-2


Apply a tourniquet

Immobilize the bitten area, keep at-level of heart if possible

Apply alcohol

Demarcate leading edge of bite area every 15-30m & where pain/tenderness is

Attempt to aspirate venom

Remove ALL jewelry bilaterally

Apply ice

Call Poison Control

Give prophylactic antibiotics/NSAIDs

Ask the patient to describe the snake as best as possible

Benjamin Abo, DO, EMT-P

University of Florida Department of Emergency Medicine Residency, EMS Fellow


Swelling that is more than minimal or that is progressing, coagulopathy, any systemic signs. What are examples of systemic envenoming signs? Vomiting or retching multiple times, altered mental status, and seizing are all examples of systemic signs/symptoms. Florida is home to many different kinds of snakes, however one must also consider exotic snakes kept as pets. Your hospital may not have an adequate supply of antivenin even if it’s a domestic species. If this is the case, you may consider calling Venom One in Miami 786-331-4443 for help in procuring the proper antivenin. Good luck out there, and stay safe! SUMMER 2017 | VOLUME 23, ISSUE 2

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Musings Of a Recently Retired Emergency Physician The ACA Roller Coaster or The Tragic Comedy of U.S. Healthcare Reform Article by Wayne Barry, MD, FACEP

So the first 100 Days of the President Trump Administration seem like we are riding on a big fast roller coaster with many drops and turns, and it even goes backwards some times! Though I am trying to keep my roller coaster seat belt securely fastened, I did nearly lose my lunch when we took the "ACA Repeal and Replace" drop into oblivion. What a stomach turner!

Wayne Barry, MD, FACEP

Obamacare, or as I like to refer to it is "ObamneyCare" since much of the ACA was patterned directly after Health Care Reform designed by Mitt Romney when he was Governor of Massachusetts, is astonishingly still with us. Referring to ACA as ObamneyCare allows me to get my "digs" into the fact that much of ACA is the idea of a prominent Republican politician namely. President Obama was able to struggle the ACA through a reluctant Congress even with Democrat majorities at the time. And then, the House went to the Republicans followed quickly by the Senate as well. The new Republican Senate Majority Leader Mitch McConnell defiantly ordered his caucus not to work with Democrats on any legislation proposed by President Obama in order to ensure that he would be a one-term only President.

Consequently, the ACA which was a hugely complex and revolutionary piece of healthcare legislation with many correctable flaws, was never worked on for the betterment of the people of this country whom it was suppose to help. An oversimplification of opposition to ACA involves objections to the mandate that all Americans must be covered by health insurance made available by any number of sources additional coverage provided by Federally subsidized and in some cases state-administered healthcare exchanges. Worse than that, was the fact that the Federal Government would provide comprehensive subsidies to individual Americans up to and including expanding the requirement for qualifying for Medicaid. The popular parts of ACA include no exclusions for coverage because of prior medical or surgical conditions, and children could be covered on their parentsâ&#x20AC;&#x2122; policy until age 26. Of course, there were a number of controversial features to the ACA, but because of the now Republican Majority Congressional boycott of cooperating with President Obama or the Democrats in Congress to fix the flaws in ACA, none of this happened, so we the American people have been stuck with this imperfect Law of the Land since 2010. For almost eight years encompassing both terms of President Obama, Republican politicians have vowed with the last measure of their being to "Repeal and Replace" Obamacare. Oh, by the way, did anybody consider an alternative Republican plan to accomplish this? No... because there WAS NO PLAN! Seemed to me that they just hated Obama Care for the sake of hating it,and President Obama, who did show a regrettable standoffishness to the Hill Cronies who perpetually inhabit the territory inside the DC Beltway, paid for his aloofness by earning the eternal enmity of Republican Congressional leaders Meanwhile 24 million or so American gained healthcare coverage where they never had it previously. This did not resolve but did make a sizable dent in the 45 millions not previously covered. People complained about the healthcare exchanges. There were embarrassing roll out technical glitches which underscored the ACA opposition's contention that the whole thing was an abomination. To make matters worse, healthcare premiums in some states began to rise astronomically casting more mud on ACA. Millions of people were unhappy with high deductibles and rising premiums. However just as many or more American citizens loved their new found healthcare coverage, some even expounded on how it changed their lives and the lives of their family members for the better. By the way, emergency departments became busier than ever because insurance covered individuals seem to have a lower threshhold for visiting the ED when they think they have some coverage for the expense. Of course, much of the increased ED traffic was in the form of the expanded pool of Medicaid recipients with their poor payer profiles, but so what else is new with respect to poorly compensated ED physician services? So the roller coaster is climbing toward the highest peak ready to hurtle down the track pitching from side to side jolting every rider nearly senseless. Oh did I just describe this last Election Season? Now the Republicans own universal power in the US political arena by occupying majorities not only in both Houses of Congress, but they won the U.S. Presidency as well. All Republicans, including Trump supporters and more traditional Republican partisans, have been united in pledging to repeal and Replace Obamacare ASAP. Let the task begin!

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President Trump told during the Presidential campaign that he was the only one who understood healthcare even though it was complicated. He then promised the American people a wonderful health plan much better than ObamaCare which has proven to be a disastrous failure. His plan would cover more people with better quality healthcare, and cost much less than Obamacare, which he claimed is projected to bankrupt the country in less than 10 years. So President Donald Trump is elected President of the United States, and a very smart and fine fellow named Paul Ryan, now Speaker of the U.S. House of Representatives, reminds us all that he actually designed a Republican Health plan version during the previous election season. Nobody much paid attention to it then. Now he brings it out of its box, dusts it off and proudly presents it to his fellow Republicans in the House as the answer to Repeal and Replace ObamaCare. Donald Trump endorses it as the panacea of health plans just like the one he concocted to solve the healthcare problem as part of putting "America First Again”. The only problem with this development is that a sizable chunk of the Republican House caucus hates it because it relies on the Big Bad Government to grant tax credits to poor people so they can afford to voluntarily buy health insurance. Meanwhile, the non partisan Congressional Budget Office calculates that more than 24 million people will lose their health coverage, and the whole plan will end up costing MORE than ObamaCare during the next 10 years. The Repeal and Replace ObamaCare train heading relentlessly fast down the tracks is now derailed in a crash of smoke and mirrors that leaves most of us stunned by the broken promises of President Trump and the entire Republican Party. You would think this would be the perfect time to kiss and makeup with some Democrats and maybe try to fix the many flaws in ObamaCare, but no. Congress and the White House cannot do that for it would be political suicide. Instead, they will leave healthcare alone and let ObamaCare implode or explode under the weight of its own unwieldiness. And this is how they expect to treat the American people by letting the ACA crush us with its incompetence and poor operation? There may be some hope. Objective analyses of the ACA suggest that it will not bankrupt the country, but rather may end up saving a little toward ultimately balancing the budget. The state exchanges, with a few notable exceptions, are stabilizing. While more and more people sign up for healthcare coverage under ACA, more of them seem to like it. As usual the burden of preparing for the wave of continually newly insured patients visiting the EDs across the country remains a challenge for our specialty. It would be nice if some beneficent power could make insurance companies behave with some sense of social responsibility. My hope is that some day payers and providers can get on the same page to truly work on providing and delivering high-quality healthcare affordably, despite inane interference by our incompetent legislators and greedy insurance executives. I see the roller coaster is approaching the station. Should I keep my seat belt fastened and ride again? I, like the rest of America, may not have a choice.

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Florida College of FCEP | Emergency Physicians

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EMpulse (Summer 2017)  
EMpulse (Summer 2017)