Official Publication of the Florida College of Emergency Physicians A Chapter of the American College of Emergency Physicians
Complications of Flakka: More Than Just Agitated Delrium
Flumanezil: Antidote or Antidonâ€™t?
Cognitive Errors & Risks Associated with Provider Hand-Offs
Living in Hurricane-Torn Territory
University of South Floridaâ€™s emergency medicine residents pose at Symposium by the Sea 2018. More photos inside! VOL. 25, NO. 3 | FALL 2018
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EMPULSE FALL 2018 Email CV to: Maureen.France@emprosonline.com
FALL 2018 | VOLUME 25, ISSUE 3
TABLE OF CONTENTS FCEP CHAPTER UPDATES 4 6 7 8 9
President’s Message J. Adrian Tyndall, MD, MPH, FACEP ACEP Board Vidor Friedman, MD, FACEP Government Affairs Damian Caraballo, MD, FACEP Medical Economics Daniel Brennan, MD, FACEP Leadership Academy Laura Hummel, MD
10 11 16 33
EMS/Trauma Desmond Fitzpatrick, MD Membership & Professional Development René Mack, MD, RDMS EMRAF Jesse Glueck, MD & Misty Coello, MD Medical Student Committee Kimberly Herard
20 30 34
Residency Program Updates Florida’s EM Residency Programs Daunting Diagnosis Karen Estrine, DO, FACEP, FAAEM Ultrasound Zoom: RUSH VTI Benjamin Chan, BS & Leila Posaw, MD, MPH
Resident Case Reports (New!): Cognitive Errors & Risks Associated with Provider Handoffs Kenneth Frye, DO, Ademola Adewale, MD, & Clara Mora Montero, MD
Poison Control: Flumazenil: Antidote or Antidon’t? Madison Schwartz, Pharm.D. & Emily Jaynes Winograd, Pharm.D. Musings from a Retired EM Physician: About Medicare for All? Wayne Barry, MD, FACEP
Symposium by the Sea Recap Samantha League, MA In Memoriam: Bethany Ballinger Jose Rubero, MD, FACEP, FAAEM
Living in Hurricane-Torn Territory Christina Krager, BSN, RN, CCRN, EMT-P, NREMT-B & Terri M. Repasky, MSN, RN, CNS, CEN, EMT-P
Complications of Flakka Tim Montrief, MD, MPH, Jeff Scott, DO & Mehruba Anwar Parris, MD
FCEP Executive Committee President J. Adrian Tyndall, MD, MPH, FACEP President-Elect Kristin McCabe-Kline, MD, FACEP, FAAEM, ACHE Vice President Sanjay Pattani, MD, MHSA, FACEP
Immediate Past-President Joel Stern, MD, FACEP, FAAEM Executive Director Beth Brunner, MBA, CAE
EMpulse Editorial Board Editor-in-Chief Karen Estrine, DO, FACEP, FAAEM firstname.lastname@example.org Managing & Design Editor Samantha League, MA email@example.com EMpulse is always accepting articles, case reports and advertisements. Winter 2018-19 Deadline: November 5, 2018
3717 S. Conway Road Orlando, Florida 32812 t: 407-281-7396 • 800-766-6335 f: 407-281-4407 www.emlrc.org/fcep
Secretary-Treasurer Damian Caraballo, MD, FACEP
QUARTERLY COLUMNS 17
Florida College of Emergency Physicians
Intubation Rodeo: Key to Saving Patient Lives Mary Anne Kolar, DO, FACOEP, FACEP
In Memoriam: John Emory Campbell ITLS Staff
Continuing Promise 2018 Misty Coello, MD, Bridget Pelaez, BSN, RN, EMT-P, Robert Levine, MD, Ruben D. Almaguer, MA Ed, EMT-P Clincon RFP & Recap Niala Ramoutar
Published by: Johnson Press of America, Inc. 800 N. Court St. Pontiac, IL 61764 t: 815-844-5161 | f: 815-842-1349 www.jpapontiac.com All advertisements in EMpulse are printed as received from advertisers. Florida College of Emergency Physicians does not endorse any products or services, except those in its Preferred Vendor Partnership. FCEP receives and distributes employment opportunities but does not review, recommend or endorse any individuals, groups or hospitals that respond to these advertisements. Opinions stated within articles are solely those of the writers and do not necessarily reflect those of the EMpulse staff, the Florida College of Emergency Physicians and our advertisers/sponsors. 3
President’s Message By J. Adrian Tyndall, MD, MPH, FACEP FCEP President
It is an honor to have been elected as the 47th president of the Florida College of Emergency Physicians. For me, this is a culmination of 12 years of active membership since my move from New York to the University of Florida in 2006. As I begin this year of service to the college, I am perpetually aware of the great number of physicians and citizens in Florida who have worked tirelessly to improve the conditions for emergency medicine practice and have advocated tirelessly for access to care for all citizens. The Florida College of Emergency Physicians was chartered in 1972 by ACEP, and the brilliance of the success of the college has so far rested on the shoulders of numerous board members, past presidents, dedicated staff and a single executive director. I am in awe of their dedication and I hope that I will be able to carry on the tradition of excellent service that my predecessors have consistently demonstrated. We have a vibrant and powerful organization with substantial influence and unimpeachable credibility amongst other state chapters and ACEP. During my 12 years of involvement in FCEP, I have seen our membership grow, and I have noticed the increasing impact on the state and national level from our educational offerings to political advocacy and influence on national policy. This year, in celebrating the 50th anniversary of the American College of Emergency Physicians, it is only too fitting that one of our own members, Dr. Vidor Friedman, will be celebrated as the next national president. At our annual conference, Symposium by the Sea, we had a record attendance of members who were undeterred by the advancing red tide and other algal blooms to meet in fellowship, compete, network, strategize and simply talk about and plan for the future of emergency care in the state and nationally. We also had a record attendance of medical students who traveled to Sanibel harbor to learn from a record number of residency program directors from around the state on graduate medical education opportunities. We had a robust research poster session for students, residents, fellows and even faculty, showing off their most recent research 4
Pictured: Dr. Tyndall welcomes guests at Symposium by the Sea’s Incoming President’s Reception, sponsored by Collective Medical.
activity and findings. We learned about contemporary clinical practice from Florida emergency physicians who are expert in their fields. We witnessed residents at all levels distilling complex clinical clues with eloquence and wit to arrive at final diagnoses, or going head-to-head as rival teams working on complex SimWARS scenarios. We learned from teams of our members who ventured to Puerto Rico and the US Virgin Islands in the aftermath of the devastation wrought by the hurricanes in 2017. In my first remarks as president addressing the College at the Board of Directors meeting, I emphasized the importance of thinking of ourselves as the best possible advocates for our patients, and with this in mind, we will be unwavering in our advocacy for the patients we treat and for the system within which they receive that treatment. I am proud of this College!
EMPULSE FALL 2018
Today, there is no better time to get involved in organized medicine. As a matter of fact, the need is unquestioned. To not get involved is nearly equivalent to the concept of not voting when it truly counts. American medicine is undergoing significant change. The challenges are substantial and the consequences are dire if we, as physicians, do not step forward to contribute actively to the discourse that will continue to impact our lives and the lives of our patients. It is time that you find an active way of contributing. Attend Symposium by the Sea! Get involved in a committee! Encourage the membership of your peers! Donate to our state political committees! Donate to the Florida Emergency Medicine Foundation (FEMF)! We need the presence, activity and strength of our members to seize the momentum that has been handed to us, and continue on the trajectory that has been set through the tireless efforts of all those who preceded us. We must be just as powerful as the other advocacy groups and professional organizations whose memberships are at times formidably organized to counteract our efforts to enact policy and make changes that are vital to our practice and for patient access. I cannot be any prouder to serve this organization and to represent its missions and values at both the state and national levels. As I take on the mantle of leadership, I ask that you join me in moving our organization forward as we work tirelessly to deliver on the one constant that serves as the core of our mission: to protect the patients we serve.
BOARD OF DIRECTORS
Patrick Agdamag, MD, FACEP
Daniel Brennan, MD, FACEP
November 28, 2018 9:00 am – 4:00 pm EMLRC in Orlando, FL
Damian Caraballo, MD, FACEP Secretary-Treasurer Jordan Celeste, MD, FACEP Misty Coello, MD EMRAF President Vidor Friedman, MD, FACEP ACEP President Erich Heine, DO Shiva Kalidindi, MD, MPH, MS(Ed.) Gary Lai, DO, FACOEP Kristin McCabe-Kline, MD, FACEP, FAAEM, ACHE President-Elect Sanjay Pattani, MD, MHSA, FACEP Vice President Russell Radtke, MD Danyelle Redden, MD, MPH, FACEP Todd Slesinger, MD, FACEP, FCCM, FCCP Kristine Staff, MD, FACEP Joel Stern, MD, FACEP, FAAEM Immediate Past-President
February 7, 2019 9:00 am – 4:00 pm EMLRC in Orlando, FL May 22, 2019 9:00 am – 4:00pm EMLRC in Orlando, FL BOARD MEETINGS: November 29, 2018 9:00 am – 1:00 pm EMLRC in Orlando, FL March 11-13, 2019 Hotel Duval, Tallahassee, FL Hosted during EM Days May 23, 2019 9:00 am – 1:00 pm EMLRC in Orlando, FL August 1, 2019 Boca Raton, FL Hosted during Symposium All meetings are open to FCEP members
J. Adrian Tyndall, MD, MPH, FACEP President
Find the full list of committees at emlrc.org/fcep-board-of-directors
Jill Ward, MD, FACEP
Find the full calendar of events at emlrc.org/fcep-calendar
Aaron Wohl, MD, FACEP
With gratitude, Joseph Adrian Tyndall, MD, MPH, FACEP Professor and Chairman, Department of Emergency Medicine, Interim Dean, College of Medicine, The University of Florida
Board of Directors at Symposium by the Sea 2018. Turn to page 11 for more photos or visit emlrc.pixieset.com. EMPULSE FALL 2018
ACEP Board By Vidor Friedman, MD, FACEP ACEP President | Past FCEP President | FCEP Board Member
This is my first chance to update many of you since the June ACEP Board of Directors meeting. As I shared at Symposium by the Sea, this was the most emotionally difficult Board meeting I have personally experienced, and I am sure that I was not alone in this. We accomplished a great deal under exceedingly difficult circumstances. Let me start by saying a few things about Dr. John Rodgers, who resigned his position as President-Elect of the College just before the June Board meeting started, and the Board’s actions in response to this. Last year, after examining his credentials, weighing his service to the College and the specialty, and hearing his vision for the future, the Council — ACEP’s representative body — elected an outstanding emergency physician and advocate to be their future president. Unfortunately, some ACEP members and many non-ACEP members publicly criticized and shamed Dr. Rogers for his lack of board certification in emergency medicine, even though Dr. Rogers has practiced emergency medicine exclusively for over 20 years and successfully represented ACEP on local, state and national levels for many years without the issue of his board status or training causing a problem. Given the negativity of the comments and the persistent, strident and aggressive nature of the threats to the College and the specialty he loves, Dr. Rogers, after deep reflection, decided to resign his position as President-Elect and, with it, his position on the Board. Your Board of Directors initially refused the resignation and worked to develop alternatives, but Dr. Rogers felt that the unity of the College was the most important priority. Reluctantly, the Board accepted his resignation. The consensus of the Board was that considering there was quite a lot of work to be done leading up to the annual
meeting, and to ensure smooth functioning of the college, the best course of action was to elect a replacement for the President-Elect, as provided for in the by-laws. Section 4.2 — President-Elect In the event of a vacancy in the office of the president-elect, the Board of Directors, speaker, and vice speaker may fill the vacancy by majority vote for the remainder of the unexpired term from among the members of the Board. If the vacancy in the office of president-elect is filled in such a manner, at the next annual Council meeting, the Council shall, by majority vote of the credentialed councillors, either ratify the elected replacement, or failing such ratification, the Council shall elect a new replacement from among the members of the Board. The Council shall, in the normal course of Council elections, elect a new president-elect to succeed the just-ratified or just-elected president-elect only when the latter is succeeding to the office of president at the same annual meeting. (ACEP bylaws, revised Oct. 2017) A special election was then held by the Board and Council Officers, and a number of candidates stepped forward. After several ballots, it was my honor to be elected as President-Elect of ACEP. I have pretty much been on-the-go ever since! Despite this unexpected circumstance, we managed to get through the bulk of our usual work at the June Board meeting. We approved about 19 policies, including a Clinical Policy Guideline on Suspected ACS. We received reports on Membership issues, the Governance task force, the lawsuit against Anthem BC/BS in G.A., the “Greatest of 3” lawsuit resolution, drug shortages, and legislation related to the opioid crisis. We also discussed the evolution of CEDR (ACEP’s Clinical Emergency Data Registry), approved the budget for the upcoming year, and had a little social media training to top it all off! ■
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EMPULSE FALL 2018
Government Affairs Committee By Damian Caraballo, MD, FACEP Government Affairs Committee Chair | FCEP Board Member
Florida witnessed a wild primary election in August. The biggest news of the night was the upset victories of Congressman Rob DeSantis (R) and Mayor Andrew Gillum (D). Both were considered political outsiders and, at one point, big underdogs in their respective elections. Gillum (D) energized urban voters in Florida’s largest metropolitan areas, which led to a surprising victory over pre-election favorite Gwen Graham. The former Tallahassee mayor was able to tap into the left-wing of the Democratic Party, securing an endorsement from Senator Bernie Sanders and capitalizing on recent anti-Trump sentiment. Meanwhile, Congressman DeSantis (R) road the pro-Trump wave to the Republican nomination. President Trump’s endorsement proved to be a huge asset in the Deland Congressman’s victory over acting Agricultural Commissioner and Tallahassee lifelong insider Adam Putnam. November is shaking out to be one of the most interesting and groundbreaking elections for Florida governorship in recent history, as it will feature a showdown of two of the most partisan candidates of both parties. It also will ensure that once again, Florida will have a governor who is an outsider to the Tallahassee political machine. Meanwhile, virtually all of FCEP’s supported legislators won their respective districts for state representative/senator. In the Congressional Primaries, FCEP ally State Rep. Mike Miller (R) won an impressive victory in his primary to set
How to Donate to FCEP’s Political Committees Text “FCEPPC” to “41444” Donate online at: emlrc.org/fcep-pac-donations Mail a check to FCEP at 3717 S. Conway Road, Orlando, FL 32812
up a tight race in November for Orlando’s district 7 race vs. Congresswoman Stephanie Murphy (D). Dr. Julio Gonzalez (R) was not as fortunate and lost a tough primary to State Senator Greg Steube (R) in Sarasota/Charlotte County District 17. November’s mid-term elections will be crucial in deciding the near-term future of medicine. FCEP will need your help reaching out to our state legislators running for office in attempts to advocate for emergency physicians. We will be sending out information to our members for meetings in October. If you are interested in meeting with some of the future leaders of the Florida Legislature, please contact Sanjay Pattani (email@example.com) or me (firstname.lastname@example.org). And if you haven’t done so, please contribute to FCEP PCs to ensure our voices are heard in the Florida Legislature. ■
Thank You Donors Nadia Abrahamsen Miguel Acevedo-Segui Timothy Bruce Allison Zaza Atanelov Mark Attlesey Isaac Azar Ian Backstrom David Ball Benjamin Barton Sheila Bawany Brian Baxter Adam Benzing Matthew Berrios Daniel Brennan Karen Calkins Rachel Carter Carlos Castellon Jordan Celeste
Daycha Cheanvechai Lawrence Chen Dane Clarke Julio De Pena Batista Camila Del Rio Oscar del Rio Charlotte Derr Alex Doerffler Michael Dolister Michelle Fox-Slesinger Tisha Gallanter Gary Gillette Steven Goodfriend Jonathan Grecco Shayne Gue Omar Hammad Manning Hanline Brian Scott Hartfelder
John Haughey Rory Hession Laura Hummel Saundra Jackson Jonathan Jones Steven Kailes Joseph King Seth Labinger Jon Lamos Richard Lartey Ian Leber Maylin Lopez-Cortes Michael Lozano Arthur Maduabia Christopher Martin Kristin McCabe-Kline Michael McCann Anna McClain EMPULSE FALL 2018
Ryan McKenna Daniel McMicken James David Melton Scott Meyer Pamela Miller Sylvie Moriniaux Kenneth Mueller Hayley Musial David Nicker William Osborn Marc Steven Plotkin Robert Andrew Raybin Christopher Robben Alvin Ruangsomboon Adam Rubin Reginald Saint-Hilaire Andrew Schare Christopher Scott
Jason Sevald Michael Simpson Todd Slesinger Aisha Subhani Andrea Catherine Suen JosephTyndall Jon Van Heertum Courtney Verboncoeur Onier Villarreal Alejandro Travis Weber Anne Elaine Wenglarski Andrew Wilson Fredric Wurtzel Joshua Young John Zelahy *Only June-August 2018 donors listed. 7
Medical Economics Committee By Daniel Brennan, MD, FACEP Medical Economics Committee Member | Board Member
Florida “Blues” – Denials undermine prudent layperson standard The October 2017 BCBSFL policy of “editing” high level E&M code claims (99284 & 99285) with “low severity diagnosis codes” has clearly impacted Florida EM physicians and our patients. Optimism from initial communication between FCEP/EDPMA and BCBSFL at the time the policy was announced was diminished when deliverables promised by BCBSFL had not been forthcoming. A specific appeal process for these rejections was never developed; there is no physician review and no ability to submit clinical documentation for review. Essentially, unless the Dx code is changed or the E&M code reduced, FL Blue will not pay the claim. During a follow up conference call in February 2018, BCBSFL committed to provide a response to EDPMA/FCEP concerns that this violates the prudent layperson (PLP)1 standard as well as example rejections upheld after appeal. Despite follow-up email reminders, there has been radio silence since. So what has been the impact thus far? Roughly 4-5% of FL Blue 99284 & 99285 claims are being rejected. “Low” acuity diagnoses appear to be the prevalent rejections, including UTI, vomiting, flu, respiratory infection, pharyngitis, diarrhea, constipation, cellulitis, otitis and rash. Interestingly, many of these same diagnoses are often also paid (typical denial rate 40-60%). Many visits can be resubmitted with an alternate diagnosis and paid; albeit with additional 1. The Prudent Layperson Standard requires health insurance companies to cover visits based on the patient’s symptoms, not the final diagnosis. This means if a patient has chest pain but turns out to have a non-urgent medical condition, such as a hiatal hernia, the insurance company must still cover the visit. It also eliminates the requirements for prior authorization before seeking emergency care. ACEP.org
claims processing costs and payment delays. However, about 20% are denied even after appeal. Overall, rejected or reduced payments have created significant losses in the six-figure range or more for some groups. Some “low acuity” cases rejected by the BCBSFL “edit”: • 3-month-old female, 30-week premature birth, presents with vomiting. Evaluation with labs and ultrasound for suspected pyloric stenosis. Consult and admission for aggressive IVF for dehydration and ongoing symptom management. ED Dx: acute emesis – claim denied. • 70-year-old male with multiple comorbidities (HTN, DM, ESRD, AFib, CVA) presents with right foot infection, necessitating labs, X-rays, IV antibiotics and consult/ admission. Subsequently found to have osteomyelitis and required operative intervention. ED Dx: Cellulitis of RLE – claim denied. • 5-week-old male presented with vomiting. Concern for pyloric stenosis, evaluation included labs, ultrasound, consult for admission for observation. Diagnosed with pneumonia and hospitalized. ED Dx: vomiting – claim denied. Similar denial policies by BCBS and other insurers are popping up in other states. ACEP and EDPMA have been advocating for patients’ access to care via adherence to the prudent layperson standard, which this—and other payment policies—undermine. FL Blue continues to deny claims based upon diagnosis. They have not responded to FCEP inquiries about compliance with PLP, nor agreed to a true appeal process with physician review of medical documentation. Groups should be aware, monitor BCBSFL denials and resubmit where alternative diagnoses are appropriate. FCEP will continue to work with ACEP and EDPMA to attempt to overturn this and other payor programs that undermine PLP and patients’ access to quality emergency care. ■
PAYMENT REFORM SUMMIT COST-EFFECTIVE CARE IN A RISK-BASED WORLD February 7-8, 2019 EMLRC in Orlando, FL emlrc.org/paymentreform 8
EMPULSE FALL 2018
Pictured from left: ACEP Past-President Dr. Paul Kivela, Leadership Academy Director Dr. Patrick Agdamag, Leadership Academy graduates Drs. Ryan McKenna and Laura Hummel, and new Leadership Academy participant, Dr. Rajiv Bahl at Symposium by the Sea 2018.
FCEP Leadership Academy By Laura Hummel, MD Leadership Academy graduate The Leadership Academy had another successful year of integrating some of FCEP’s newest members into committees and board meetings, and well as an important week up in Tallahassee for EM Days. Congratulations to our 2018 Leadership Academy graduates: Drs. Kirk Szustkiewics, Ryan McKenna and myself. Throughout the year, each participant chooses a topic of interest to understand further and develops a project to contribute to FCEP. Dr. Szustkiewics wrote an extensive white paper for EM Days highlighting prospective changes to the current malpractice policies. He addressed tort reform and advised to reinstate caps for non-economic damages. Dr. McKenna is fellowship-trained in simulation and became integral to planning and running SimWARS. His year was highlighted by a successful SimWARS at Symposium by the Sea, and he will continue to serve as a member of this team. I helped review the FCEP opioid best practice document that was used during EM Days. All participants this year would like to thank Dr. Patrick Agdamag for his guidance as the Chair of the Leadership Academy. The participants also thank the FCEP Board of Directors, Beth Brunner, Donna Vennero, Melissa
Keahey and all of the staff at EMLRC for their support and guidance. We’d also like to welcome our newest Leadership Academy participant, Dr. Rajiv Bahl! Dr. Bahl just moved from Toledo, Ohio, where he completed his residency, an administrative fellowship and MBA. He already has tremendous public policy experience from his membership with the Ohio ACEP chapter, and he aims to build on this within the Leadership Academy. ■
Apply to the Leadership Academy Established in 2012, FCEP’s Leadership Academy provides the necessary orientation and skills development for those who aspire to become future leaders in emergency medicine. The program is one-year long and participants are accepted on a rolling-basis. Learn more & apply at emlrc.org/fcep-leadership-academy.
EMPULSE FALL 2018
EMS/Trauma Committee By Desmond Fitzpatrick, MD EMS/Trauma Committee Co-Chair
“Always look for the helpers.” These words, which the immortal Mr. Rogers received from his mother about tragedies, ring true all too often these days. He went on to say, “I am always comforted by realizing that there are still so many helpers — so many caring people in this world.” These helpers are the men and women behind the scenes, thrust into dangerous and traumatic situations, who endeavor to perform the most good possible. They are exposed to daily trauma that was once reserved for the theater of war. Despite this, they continue to work and bring help and hope during these times of tragedy. Bearing this in mind, it is important to offer them thanks and support. In our day-to-day interactions with our first responders, fire and EMS personnel, it is important remember how much they give of themselves. More and more information is being published regarding the stressors and conditions emergency personnel face and the long-term effects resulting from this daily barrage of trauma. Large-scale changes need to happen to ease their burden. We are beginning to see change with new laws mandating training and PTSD support; however, there are simple things that we as emergency physicians can do in our everyday interactions to make an even bigger difference. It starts by being supportive and professional in our interactions with these providers. Too often, I hear about Doctor So-and-So yelling or belittling a pre-hospital provider for something that may or may not be under their control. We cannot allow this unacceptable practice to continue and must stand up against it if we witness it. This is not to say that we should not give appropriate and constructive feedback if the situation warrants. We should, however, not aim to ridicule or intimidate. As part of the emergency team, we fully understand the stress of horrific situations and should be providing support and encouragement instead. Our goal should be to ensure that all members of our team—be it RN, MD/DO, EMT, medic, tech, police or anyone exposed to these tragedies—receive the support they deserve.
EMS/Trauma Committee Updates Let’s bid a fond farewell to Dr. Joe Nelson, State EMS Medical Director, who has announced his retirement. An ADHOC committee for selection of the new Florida Medical Director has been established. FloridaNet/FirstNet Update Florida has OPTED IN to FirstNet, 54 States and Territories have Opted IN, AT&T has begun offering services. REPLICA continues to expand Interstate Compact cross state licensure recognition of EMTs and Paramedics in certain circumstances. Florida has not yet ratified. Stroke Care after release of DAWN Trial You may be seeing changes at your hospital or EMS system as they try to incorporate and balance the expanded thrombectomy window for suspected large vessel occlusions. Venom 2 Lake County is home to the state’s second venom response unit. The Venom Two unit consists of six team members (three primary and three backup) who have been trained to respond to venomous snake bites by providing antivenom. Dr. Ben Abo is a Venom 2 medical director; contact him at email@example.com. Region V Trauma Agency RDSTF Region 5 will include the following counties: Orange, Osceola, Lake, Brevard, Seminole, Volusia, Indian River, St. Lucie and Martin. A Trauma Advisory Board was formed. Regular meetings are being held to develop working documents, budget, etc. Dr. Pappas of CFR is acting Agency Director. Medical Directors can obtain trauma transport protocols and info by emailing Dr. Sandra Schwemmer at Sscwhemmer@gmail.com. ■
Donate for a chance to win 1 of 3 prizes! Text “FEMFraffle” to 41444 OR Donate at emlrc.org/livelikesal
Dr. Sal Silvestri EMS Research Fund
Each ticket will be entered into a random drawing. Suggested cash contributions are: 1 ticket = $10 | 5 tickets = $40 | 10 tickets = $75
Hosted by FCEP/FEMF & EMRAF EMPULSE FALL 2018
RAFFLE CLOSES December 2, 2018
DRAWING ON December 3, 2018
Membership & Professional Development By Rene Mack, MD, RDMS Membership & Development Committee Co-Chair
In August, our committee had a meeting at the lovely Sanibel Harbor Resort & Spa in Fort Myers. Were you there? We saw several new faces and enjoyed lively discussions regarding the future of the Membership and Professional Development (MDP) committee. One of the biggest changes came in the form of Dr. Shayne Gue, our new MPD Co-Chair. Dr. Gue is a former resident of the Florida Hospital EM Program and was a previous EMRAF Chair. He has been involved in many aspects of FCEP over the years, and I am pleased to have him join the MPD team. So what took place at our most recent meeting? We were elated that we continue to be supported by a great number of our colleagues—our current membership numbers are at a high of just over 2,000 members! Realizing that our fellow colleagues trust us to be their voice in emergency medicine is an honor that FCEP takes very seriously. We know that there are other avenues to achieve representation within our specialty, so we will continue to strive to maintain your confidence at the highest level. Dr. Adrian Tyndall, our new FCEP President, has many ideas of how to continue our growth and presence within EM and our community as a whole. FCEP has a large demographic
of members who have been in practice for a number of years and may be considering retirement in the near future. Did you know that ACEP/FCEP offers a special pricing structure for our retired members? Please contact the FCEP or ACEP offices if you have any questions regarding the various options to help keep you involved in our great community during all phases of your career. Additionally, during the MPD committee meeting, we had a hearty discussion regarding the goals of our committee and turning our focus inward towards our members and overall well-being. We have identified a few areas in which we hope to increase the visibly of our members and our commitment to showcasing our achievements. We welcome any suggestions for incorporating these goals and hope to hear from you soon. Finally, this Symposium by the Sea drew in the highest attendance in the past decade! If you were not able to attend SBS 2018, you missed a great weekend but never fear— we’ll save a space for you at SBS 2019 on August 1-4, 2019 in Boca Raton, FL. Thank you for all you do. Your community appreciates you. ■
On August 2-5, 2018, FCEP welcomed 107 physicians, 105 residents, 69 medical students and six other allied health professionals at Symposium by the Sea in Fort Myers, FL. Find resident competition winners, photos and brief recaps over the next few pages. Photos by communications manager Samantha League unless otherwise stated.
1) ACEP President Dr. Vidor Friedman, FCEP President Dr. Adrian Tyndall and ACEP Past-President Dr. Paul Kivela pose at Symposium by the Sea. 2) Attendees took advantage of morning yoga before sessions began on Friday. 3) Florida Hospital residents Dr. Elizabeth Kim, PGY-2 and Dr. Misty Coello, PGY-1 compete in the SimWARS final round. EMPULSE FALL 2018
SIMWARS COMPETITION WINNER: Kendall Regional Medical Center Pavel Antonov, MD, PGY-3 Erik Copelim, MD, PGY-3 Vinicius Knabben, MD, PGY-3 Joseph Proza, MD, PGY-3 COMPETITORS: Florida Hospital Mount Sinai Medical College Kendall Regional Medical Center UCF Ocala Regional UCF/HCA of Greater Orlando UCF/HCA of North Florida CHAIRS: Ademola Adewale, MD SimWARS Chair Ryan McKenna, MD SimWARS Vice Chair
CASE PRESENTATION COMPETITION
BEST DISCUSSANT: Alexander Thai, MD, PGY-3 Jackson Memorial Hospital
COMPETITORS: Florida Atlantic University Jackson Memorial Hospital Orlando Health UF—Gainesville UF—Jacksonville University of South Florida
BEST PRESENTER: Nina Gutierrez, MD, PGY-2 Jackson Memorial Hospital
CHAIR: Jennifer Jackson, MD CPC Chairperson
WINNERS: BEST OVERALL: Jackson Memorial Hospital
JUDGES: Shiva Kalidindi, MD Steven Warrington, MD Larry Zaret, DO
Kendall Regional Medical Center competing
Dr. Jennifer Jackson presents the CPC trophy to Dr. Alexander Thai
PEDIATRIC SESSION One of our first sessions focused on best practices for neonatal and infant care. Attendees practiced techniques such as intubation and neonatal spinal taps on high-tech manikins after lecture.
JUDGES: Isabel Brea, MD Bobby Desai, MD Steve Nazario, MD Tami Vega, MD
EMPULSE FALL 2018
POSTER ABSTRACT COMPETITION STUDENT WINNER: Evaluation of Ultrasonography vs. Computed Tomography in Diagnosis of Acute Lower Abdominal and Pelvic Pain in Women in the Emergency Department: Samuel Harris, medical student17; Rumana Tokaria, MBBS8; Austen Christen, MD8; Jason Wilson, MD, MA, FAAEM8, 17 RESIDENT WINNER: Alternative Medical Treatment Site Disposition and Treatment of Patients From an Electronic Music Festival: Nicholas Antoon, MD, PGY35; Alexa Rodriguez, MD7; Alexandria Williams, MS-17; Christian Zuver, MD4; Christopher Hunter MD, PhD5 FELLOW: Implementation of a Geographical Clinical Concierge Program to Improve Emergency Department Throughput: Jesse Glueck, MD6; JG Ladde, MD6; M Jaffar, MD6; A Graham, BSN6; J Glover6; PG Giordano, MD6
Robert King presenting his poster abstract on the HEART score
ALL SUBMISSIONS: STUDENTS Analysis of Predictors of Post Intubation Hypotension in Trauma Patients: Michaela O’Driscoll, BA11; Michael Marchick, MD11; Lars Beattie, MD11 Bridging The Gap: Defining Best Practice For Sexual Assault Victims Presenting To Tampa General Hospital Emergency Department – A Gap Analysis: Abigail Parrigan BS17; Darbi L Cox, MD, PGY-317; Jason Wilson, MD, MA, FACEP, FAAEM8, 17 Does the HEART Score Apply to Patients with Non-traditional Risk Factors?: Robert King, BA11; Lance Lehman, BS11; Michael Marchick, MD11; Brandon Allen, MD11 ECG Patterns and Diagnostic Characteristics of Structural Heart Disease and Dysrhythmias in Young Adults 18-40 Years Old at Risk for Sudden Cardiac Death Presenting to the Emergency Department from 2011-2017: Kristina Ledbetter, BS8, 17; Sri Palakurty, BS8, 17; Jason Wilson, MD, MA, FAAEM8, 17 Implementation of PatientControlled Analgesia Protocol for Sickle-cell Patients Presenting with Acute Pain Crisis Creates Consistent Patient Expectations with No Negative Impacts on Operation Metrics and Patient Experience: Deandre White, BA, BS8, 17; Carlos Osorno, BA8, 17; Jason Wilson, MD, MA, FAAEM8, 17
an Urban Emergency Department in Tampa, FL: Heather Henderson, MA, CAS8, 17; Jack McGeachy, MD8, 17; Jason Wilson, MD, MA, FAAEM8, 17 Nine Month Review of Wound Care Services at a Student Run Syringe Exchange Program: Leah Colucci, BS, CNC, MS-215; Hardik Patel, BS, MS-215; Amy Vidalin, BSN, MS-215; Jasmine Tomita-Barber, BS, MS-215; Kelly Ann Conley, BS, MS-215; Vivien Chen, BS, MS-215; Hansel Tookes, MD, MPH15; Jennifer S. Jackson, MD, FACEP15 Review of Recommended Naloxone Dosing Strategies in Fentanyl and Synthetic Opioid Overdose: Victoria Sands17; Heather Henderson, MA, CAS8, 17; Jack McGeachy, MD8; Zachary Terwilliger, MD; Austen Christen, MD8; Angus Jameson, MD, MPH, FAEMS, FACEP8,; Jason Wilson, MD, MA, FAAEM8, 17
Stroke Thrombolytic Therapy: Aiming to Decrease the InHospital Delay Window to 20 Minutes by Using a Cellphone: Carlos Osorno, BS8, 17; Rachel Semmons, MD8, 17; W. Scott Burgin, MD8, 17 Systematic Review of Chemical and Physical Restraints for the Treatment of Acutely Agitated Patients in the Emergency Setting: Caitlyn Balsav, MR17; Rachel Semmons, MD8, 17
Transcutaneous Electrical Nerve Stimulation (TENS) for Back Pain in the ED: Daniel Initiation of a Medication 17 8 Assisted Treatment Pathway for Gabl ; Clay Ritchey, MD8,;17Jason Wilson, MD, MA, FAAEM Opioid Dependent Patients at
RESIDENTS A Simple Intervention for Improving Provider Recognition of Human Trafficking Victims: Emerson Franke, MD1; Nicole Rodriguez Perez, MD1; Erin Marra, MD1 Are Pain Scores Useful for the Assessment of Abdominal Pain in the ED?: Jasminia Nuesa, MD, PGY-22; Tony Zitek, MD2; Lauren Pellman, MD16; Jessica Uribe14; Arantxa Guillen14 Are We Repeating Diagnostic Studies in Emergency Department to Emergency Department Transfers and Why?: Zaza Atanelov, MD, PGY210; Gary Gillette, MD10, 12; Hong Liang, PhD10; Robyn Hoelle, MD10, 12 Costs of Redundant Diagnostic Testing Performed for Outside-Hospital Transfers to UF- Health: Travis Murphy, MD, PGY-311; Henry W. Young, MD11; Carolyn K. Holland, MD11 Human Trafficking Protocol in the Emergency Department: Jennifer Reyes, DO1; Ulrika Agnew, MD1; Erin Marra, MD1 Is Urinalysis Helpful in the Evaluation of Acute Scrotal Pain?: Kent Martin, MD2; Tony Zitek, MD2; Omar Ahmed, MD16; Chee Lim, BS9; Rianda Carodine14 Medical Students’ Learning Modality Preferences in the Emergency Medicine Clerkship: Michael J. Roberds, MD, PGY315; Jennifer S. Jackson, MD, FACEP15
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FACULTY (NOT JUDGED) Prehospital End Tidal Carbon Dioxide Is Associated With the Diagnosis Of Diabetic Ketoacidosis On Patients With Hyperglycemia: Christopher Hunter MD, PhD5; Monty Putman, MD5; Jermaine Foster, medical student3; Stacie Miller, MD4; George Ralls, MD4; Linda Papa, MD, MSc5 Does the Association of American Medical Colleges (AAMC) Standardized Video Interview (SVI) Score Predict Emergency Medicine Rank List Placement or Match List Results?: David Caro, MD13; Jay Khadpe, MD13; Melissa Parsons, MD13; Thomas Morrissey, MD, PhD13 AUTHOR AFFILIATIONS 1. Aventura Hospital & Medical Center 2. Kendall Regional Medical Center 3. Meharry Medical College 4. Orange County EMS System 5. Orlando Health 6. Orlando Regional Medical Center 7. Ross University 8. Tampa General Hospital 9. Touro University Nevada 10. North Florida Regional Medical Center 11. UF – Gainesville 12. University of Central Florida 13. UF – Jacksonville 14. University Medical Center of Southern Nevada, Las Vegas 15. University of Miami 16. University of Nevada, Las Vegas 17. University of South Florida
Find all poster abstracts at emlrc.org/sbs-abstracts 13
Casino Night: White Party HOSTED BY DUVA SAWKO All Casino Night photos courtesy of Greg Hunter. Find and download all Symposium by the Sea photos at emlrc.pixieset.com.
ANNUAL BOARD OF DIRECTORS MEETING 1) Dr. Joel Stern finished his term as FCEP President. To show our appreciation of service, FCEP gave him adorable gifts for his beloved dogs, including “I Love My Daddy” onesies. 2) New FCEP President Dr. Adrian Tyndall came prepared for his term with a much larger, newand-improved gavel for Board meetings.
EMPULSE FALL 2018
Thank You Sponsors PLATINUM
3-4) Drs. Jay Falk and Kendall Webb completed their Board of Directors terms and received commemorative plaques. 5) To recognize his service and dedication to the opioid crisis, Dr. Aaron Wohl received the Martin Gottlieb Advocacy Award for the second year in a row. â–
EMRAF Committee By Misty Coello, MD, PGY-1 EMRAF President
By Jesse Glueck, MD EMRAF Faculty Advisor This is truly an exciting time to be an emergency medicine resident in Florida, and I am thrilled to stay involved as the EMRAF faculty advisor. When I started as the Orlando Health EMRAF representative as an intern, Florida had five EM residencies. This year, applicants can to apply to 17 programs. While there has been concern among some about what kind of impact this explosive growth will have on the quality of resident education, one thing is certain: there is strength in numbers, and if we work together, we will be able to accomplish great things.
I would first like to thank Dr. Glueck for his amazing work during his tenure as president. He has made significant contributions for equal representation among the residency programs. In addition, I am exceedingly appreciative for the enduring support and guidance that Dr. Gue and Dr. Glueck have provided me. I have worked closely within FCEP over the past few years as the advocacy coordinator and the co-chair of the Medical Student Committee. I am looking forward to transitioning into this new role as EMRAF President.
It was a privilege to serve as your EMRAF President this past year. Stepping into the role of president is Dr. Misty Coello, who is an intern at Florida Hospital and has been involved with FCEP as the co-chair of FCEP’s Medical Student Council since her time at the Herbert Wertheim College of Medicine – FIU. I know that she has big goals for the coming year and I look forward to helping her achieve each one.
I am excited to welcome all of the new programs and interns to the world of emergency medicine in Florida, and am committed to making Florida a well-known and represented state in this industry.
As always, the role of EMRAF within FCEP is to provide a unified voice of EM residents in Florida. Our primary goal is to increase resident engagement and facilitate the development of an EM resident well-versed in patient advocacy on a statewide level. ■
As Dr. Glueck stated, Florida now hosts 17 EM residency programs—a significant increase from a few years ago. With that in mind, I would like to extend the influence and effect of EMRAF throughout the state to create a progressive and united learning environment. I welcome those interested in getting involved to contact me at firstname.lastname@example.org. ■
Thank You 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 2018 corporate partners for believing in our mission and helping us provide life-saving education for lifesavers.
Are you interested in becoming a corporate partner? Contact Melissa Keahey, Director of Meetings & Events, at email@example.com to learn about opportunities.
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RESIDENCY UPDATES UCF/HCA at Osceola By Leoh N. León II, MD & Abhishek Roka, MD, PGY-2s Hello again from the UCF/HCA EM Residency Program of Greater Orlando. Our interns are officially working and doing an outstanding job! The PGY-3 residents are doing their PICU rotation at Memorial Health University Hospital in Savannah, GA, and we would like to extend our appreciation for the opportunity to work with them. Drs. Cabrera, Hanna, Tsau and Web had the opportunity to compete at Symposium by the Sea 2018. Although we did not win this year, they had an amazing time and really enjoyed the experience. We also had two faculty members give excellent talks, with Dr. Rubero presenting on “Life Threatening Weakness” and Dr. Lebowitz on “Advanced Treatment in Cardiac Arrest.” Furthermore, the entire senior class was extremely excited to attend ACEP18 in San Diego, CA! We had nine abstracts accepted, which were presented by fellow residents and faculty: • Adherence to standardized sepsis order set associated with lower 30-day hospital re-admission rate, by Dub, Lebowitz, Kramer, Leon, Rosario, Amico, Vera, Banerjee, Ganti • Addressing the overuse of neuro-imaging for patients with a primary headache and a normal neurologic exam, by Rosario, Lebowitz, Leon, Hanna, Fusco, Dub, Ganti • Routine ED laboratory studies as predictors of ED stroke severity, by Roka, Landeta, Webb, Macintosh, Banerjee, Ganti • Impact of ED blood pressure on stroke severity, by Roka, Landeta, Webb, Patel, Banerjee, Ganti • Prognostic indicators of being discharged home after acute ischemic stroke, by Webb, Roka, Landeta, Patel, Banerjee, Ganti • Delta Lactate (Three-Hour Lactate Minus Initial Lactate) Predicts In-Hospital Death in Sepsis Patients, by Kramer, Leon, Rosario, Dub, Lebowitz, Vera, Amico, Banerjee, Ganti • Predictive value of the Los Angeles Motor Scale for Large Vessel Occlusion Strokes, by Banerjee, Ganti, Rosario, Wallen, Dub, Lebowitz, Vera • Acute ischemic stroke and hospital discharge outcomes after tPA, by Ganti, Banerjee, Wallen, Lebowitz, Rosario, Dub • Every second counts: Time to epinephrine and return of spontaneous circulation after pediatric cardiac arrest, by Banerjee, Vera, Ganti, Singh, Pepe, Dub, Tsau, Wallen Lastly, we would like to thank everyone in the EM community for their outpouring support, sympathy, well wishes and love following the loss of Dr. Bethany Ballinger. She is very much missed. Our faculty and residents continue to work hard to make her proud. ■
Bethany Ballinger, MBBS, AFRCSEd, FFAEM, FACEP By José Rubero, MD, FACEP, FAAEM On August 13, 2018, Dr. Bethany Ballinger lost her long battle with cancer. Dr. Ballinger was the Founder and Program Director of the UCF/HCA Consortium Emergency Medicine Residency Program that began at Osceola in 2016 and Faculty/Associate Professor of Emergency Medicine at the University of Central Florida College of Medicine. She obtained her medical degree from the University College of London School of Medicine and did an EM residency at the Royal College of Surgeons of Edinburgh as well as here in Florida, at Orlando Health. Dr. Ballinger was my dearest friend and I do not believe I have ever known a physician with such passion, love and dedication to her residents’ (“children”) education. Her concern for their well-being, formation and her never-ending mentorship was always evident. As a physician and colleague, she was understanding and compassionate, and the love she had for her family was out of this world. Dr. Ballinger leaves behind her husband Steve and son Murdock. A memorial service was held on September 20, 2018. ■
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Florida Hospital East Orlando By Shannon Armistead, DO, PGY-2
Greetings from Florida Hospital East Orlando as we are now four months into the academic year. All of our residents are doing an outstanding job as they transition into new roles, whether it is a senior helping an intern learn the ropes or our second years “feeling the pressure” as they juggle managing one side of the Emergency Department and their documentation with only the attending. It has been incredible to see the number of medical students rotating with us already this year from varied Allopathic and Osteopathic schools across the country. We can tell that compiling a match list this year will be a challenge. The second-year class is currently embarking on the solo trauma rotation and they are coming back with exceptional learning experiences and pearls to teach all the residents of our program. The intern class had the pleasure of traveling to Miami as a group in July to do some team-building
and learn from one of our Ultrasound Fellowship graduates, Dr. Mark Newberry. Always with our eyes on the prize, Florida Hospital East Orlando Residency has been working on Board Prep from day one. Each week we do practice oral boards in effort to make the process so common that “it is just another day” for our graduates when they test. Also, academic faculty applied feedback after our Inservice Training Exam and our Annual Program Review, which resulted in some modifications to our Rosh Review and our use of Emergency Medicine Foundations to simulate the variability of patient presentation in the ED. Finally, we are so proud of our intern, Dr. Misty Coello, for becoming the newest EMRAF President and the youngest EMRA President in the history of the organization. ■
University of South Florida By Matthew Beattie, MD, PGY-2
As fall arrives, we are in full swing here at Tampa General. The new interns are acclimated and running around the ED, throwing in lines and tubes. We have a great group and it seems like each year our residency grows stronger. We are a family here at USF EM, and our new chiefs are taking the lead in fostering that atmosphere. We had a wonderful turnout at Symposium by the Sea. It’s always great to connect with the rest of you and hear what’s happening across the state. Our very own Zain Tariq and Byron Markel competed in the Case Presentation Competition, and thank you to our 18
simulation director, Ryan McKenna, for helping organize SimWARS. Congratulations to Misty Coello on her election as the new president of EMRAF. We look forward to a new year of advocacy for our profession, as there are constant changes in the healthcare landscape. The year is off to a great start as we continue to do what we love! We get to save lives every day, and we get to make a difference in our patients’ times of deepest need. Cherish time with your friends and family. Stay healthy. Take care of yourself so that you are ready to go when you walk into your next shift. ■ EMPULSE FALL 2018
Orlando Health By Laura Cook, MD, & Anne Shaughnessy, MD, PGY-1s Orlando Health EM is off to a fantastic start! We were excited to welcome our interns into “la familia” and are proud of their hard work as they acclimate to residency. In August, we enjoyed connecting with other EM programs around the state at Symposium by the Sea. We’re proud of our residents who represented our program at the conference. Co-chief resident, Dr. Nick Antoon, brought home the “Outstanding Resident Poster” award. Graduated resident and current pediatric fellow, Dr, Jesse Glueck, was honored with “Best Fellow Poster” and Leadership Award for EMRA President of Florida. Dr. Steven Ritchey, PGY-3 and Dr. Margaret Stutsman, PGY-2 gave engaging CPC presentations. We are already looking forward to Symposium 2019. This year, our program is working to promote wellness amongst our residents and physicians by developing a formal Wellness Committee, led by Dr. Tory Weatherford, former resident and pediatric fellowship graduate. Many of our residents are getting involved to tackle burn out and promote resilience. Our first monthly wellness event at Orlando Science Center had a great turn out. We are encouraging healthy habits, physical activity, mentoring and “great save” shout outs. Our educational committee has also undertaken a new conference curriculum using “Foundations of Emergency Medicine,” giving our lectures a more residentdriven and clinical scenario approach. We look forward to the fall, working hard, and having fun both inside and out of the ED. We are excited to start interview season! ■
UF Health: Jacksonville
UF Health: Gainesville By Travis Murphy, MD, PGY-2
By Corey Dye, MD, PGY-1
The 2018-19 academic year has been off to a racing start as we prepare the interns and rising residents for new roles and responsibilities. We also welcome our President, Dr. Adrian Tyndall, into his new position. Symposium by the Sea was an exciting chance to meet with representatives from programs all over the state and find new ways to collaborate on future projects. I can’t forget to thank the EMRAF Board for awarding me this year’s EMRAF Scholarship for the work towards quantifying the costs of redundant testing. Dr. Zaza Atenelov from the North Florida program has proven to be a dynamic and motivated partner in addressing this task from both major hospital sites in our town. Future work into bridging disparate hospital systems is still needed, but the presence of EDie and similar programs in our state is a step in the right direction. We look forward to future collaborations. Congratulations to Dr. Ideen Zeinali for her acceptance into the SAEM ARMED Research course! She has been a role model for excellence as a resident and we look forward to working with her. Our team of Resuscitationists are hard at work unifying post-arrest care practices across the hospital. ■
UFH Jacksonville wishes everyone well as an eventful summer winds down to a close. We have several announcements to cover. First, we’d like to welcome and thank our new oncoming faculty and those that expanded roles from the north to the main clinical campus: Dr. William Dishong, Dr. Daniel Eraso and Dr. John Kiel. Secondly, congratulations to Chief Resident Chris Behan who excelled as both a presenter and discussant in CPC at Symposium by the Sea. Additional commendations to second-year residents Becky Lacayo and Nandini Verma, who continue to advocate for female leadership in medicine through their participation in SheMD. New fellows Lauren Black (Research) and Chris Kumetz (Ultrasound) have officially begun the inaugural year of our two new fellowship programs. Dr. Faheem Guirgis continues with sepsis research and an RCT involving lipid interventions. Lastly, we would like to congratulate our new intern class of 2018 that started clinical shifts in July. The first few months of residency training can be particularly challenging, but our interns have done a fantastic job staying positive and pushing forward to become better physicians. ■
Lee Health Emergency Physicians Fort Myers, Florida
Lee Physician Group Emergency Physicians is seeking BC/BE Emergency Physicians to join our thriving emergency medicine practice in Fort Myers, FL. We staff two hospitals and a new ED is opening late 2018: • Lee Memorial Hospital – Level II Trauma Center with 55K annual visits • Health Park Medical Center – Accredited Chest Pain center with 45K annual visits We are employed physicians operating as a group with full benefits, hourly + RVU-based compensation model, full specialty back-up services, 9-10 hour shifts and advanced providers staffing fast track area. We offer a very competitive reimbursement and unbeatable location. We are a friendly, established group looking for motivated, personable doctors to join our long-standing and well-respected team. Located in SW Florida with outdoor opportunities abounding, waterfront living, boating lifestyle and year-round sunshine! Richard Macchiaroli, MD - Medical Director firstname.lastname@example.org
Carrie Dunn, MD - Clinical Director email@example.com EMPULSE FALL 2018
Suzanne Felt, MD - Recruiting firstname.lastname@example.org
North Florida Regional
By Zaza Atanelov, MD, & Collin Bufano, MD, PGY-2s
By Lee Barker, DO & Vir Singh, MD, PGY-2s
July 1 came and went with excitement for the new intern class at North Florida Regional Medical Center. The 2nd years – now seniors – welcomed their new roles as mentors and teachers with anticipation of the growth and challenges that lie ahead. We had a full department of residents rotating through in July before many of us went to our off-service rotations, where we continue to exceed expectations. August began with Symposium by the Sea, where we had the opportunity to participate in lectures, meet the people and residents involved in Florida’s fast growing emergency medicine residency programs, and cheer on our fellow residents at SimWARS. Our very own Assistant Program Director, Dr. Tamara Vega, was selected to judge the Case Presentation Competition (CPC). Our Program Director, Dr. Robyn Hoelle, and Clerkship Director, Dr. Thomas Bentley, organized and ran the Medical Student Forum with the help of one of our residents, Dr. Donovan Ginest. In addition, we were chosen to present our poster for “Are we Repeating Diagnostic Testing in ED to ED Transfers and Why?” — an exciting project first initiated at the neighboring University of Florida by Travis Murphy, with the goal of creating a unified EMR in Florida. It has been great working and collaborating with other Florida residency programs. Despite the challenges of being a new program, we have shown that we can and will be an emergency medicine residency where leaders are made. ■
Greetings from all at the UCF-Ocala Emergency Medicine Residency Program! We are well into the first few months of the program’s second year and are thrilled with the residency’s growth. We are proud of our new residents and are excited to watch them grow into fantastic emergency physicians. New faculty members have arrived, including Marion County EMS Director, Dr. Frank Fraunfelter, and our new ultrasound Director, Dr. Drew Jones. Dr. Fraunfelter recognizes that traditional EM residency training provides only a minimal glimpse into the EMS experience, so he worked with residents to develop an annual full day of EMS/fire training simulation and discuss its success in the literature. Exciting! Dr. Jones, fresh from a Stanford ultrasound fellowship, is busy putting the final adjustments on our ultrasound curriculum. Core faculty Dr. Joshua Walker is continuing Ocala’s push for 21st century didactics by implementing monthly discussions of EM:RAP into the curriculum. As our program continues to grow from within, Ocala Health continues to make strides towards further expansion. Ocala Regional Medical Center is currently undergoing construction of its new ED of more than 40 beds. It gets even better with ORMC’s recent announcement of plans for a new, free-standing ED that will bring emergency healthcare closer to Ocala’s southeast residents. This will be Ocala Health’s second free-standing ED since the Summerfield FSED opened in October 2016. We are excited for the diverse training experiences we are afforded at Ocala EM. Our program continues to get more involved in local and national activities. The entire second-year class attended Symposium by the Sea and participated in SimWARS. The program also plans to send the entire second class to SAEM 2019 next spring. There is no slowing down here at Ocala Health as we look forward to another exciting year! ■
Daunting Diagnosis: QUESTION An intentional self-hanging presents to the ER awake and alert, but with ligature marks around his neck. What pathology must be ruled out in such cases? By Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief 20
ANSWER ON PAGE 36 ► EMPULSE FALL 2018
Aventura Hospital & Medical Center By Scarlet Benson, MD, Assistant Clinical Professor In July, we were excited to welcome our new intern class, which led to a full complement of years PGY1-3 EM residents. Medical student clerkship director, Dr. Annalee Baker, hosted a 4th of July welcome party at her home in Fort Lauderdale, complete with barbecue ribs and pool games.
presented his poster on “An Educational Intervention to Improve Healthcare Provider Recognition of Human Trafficking Victims.”
Our faculty also continue to excel with their own projects. Dr. Laurence Dubensky recently co-authored an article in the journal of Neuroradiology We also elected our first group of senior entitled “Endovascular aspiration of chief residents. Congratulations to Drs. a symptomatic free-floating common Matt Yasavolian, Isaac Azar and Thomas carotid artery thrombus.” Dr. Huy Tran Yang! Dr. Yang has already added gave a presentation at AHMC’s trauma several new accomplishments to his CV grand rounds in August titled “Point-ofin 2018, including becoming the chair care ultrasound in the trauma bay.” Dr. for the EMRA Education Committee, Annalee Baker published an article in co-editing the EMRA fellowship book, EMDocs, “Rectus sheath hematoma,” hosting a quiz show and taking 1st place with the assistance of chief resident Dr. with his team in the ED Skills Challenge Thomas Yang. Doctors John Childress at CORD in April. and Huy Tran will also achieve FACEP status this year. AHMC had a great turnout at Symposium by the Sea in August. Dr. As fall approaches, we look forward Jennifer Reyes presented her poster to interview season and assisting on“Human Trafficking in the Emergency our senior residents in applying for Department,” and Dr. Emerson Franke fellowships and jobs! ■
FAU at Bethesda Health By Jeff Klein, MD, PYG-2
Hello from Boca Raton, FL. I hope everyone enjoyed themselves at Symposium by the Sea. For our residents, it was not only enjoyable to experience what Fort Myers has to offer, but it also provided an opportunity to showcase their hard work that has gone into their presentations. These presentations included “A Case of Postpartum Preeclampsia with PRES,” by Dr. Matt Wallace and “A Case of Granulomatosis with Polyangitis,” by Dr. Ben Mazer. Great job to you both! Along these same lines, I would like to congratulate to Dr. Ben Mazer for his new article in the Western Journal of Emergency Medicine titled “Pacemakerassociated Phlegmasia Cerulea
Dolens Treated with Catheter-directed Thrombolysis.” Speaking of conferences, our entire faculty and staff would like to offer a warm welcome to our grand rounds speakers. They include Dr. Linda Papa from UCF lecturing on “Changing the Paradigm of Concussion Management in the Emergency Department in Children and Adults,” and Dr. Matthew Wong from Beth Israel Deaconess Medical Center lecturing on several topics, including: “Neonatal Resuscitation for the ED Doc,” “Pediatric Trauma for the Pit Doc,” and “Stress and Productivity in EM.” We very much look forward to these speakers. ■ EMPULSE FALL 2018
PBCGME/St. Lucie Medical Center By Blaire Laughlin, DO, PGY-3 Congratulations to our four recent graduates. PBCGME put together a wonderful graduation ceremony where we celebrated their achievements and said our goodbyes. Although it was bittersweet to see them go, we are confident they will be successful in their careers. The start of another academic year has medical student season in full swing. Our emergency department has been humming with excitement since we welcomed our first class of six first-years. We continue to make our transition from a four-year residency to a three-year residency. We are pleased to welcome Dr. Drew Brooks, Dr. Shelby Guile, Dr. Michael Dressler, and—from our 2018 intern class—Dr. Jerome Daniels, Dr. Ashkahn Zamorrodi and Dr. Abby Reagan, a transfer from our FM program. We look forward to working alongside each of you. A huge congratulations to our new chief Dr. Jessica Chambers, whom we know will continue to lead our program with great distinction. In other exciting news, we have partnered with FAU for quarterly SIM labs. Our first one on July 18 was a huge success. We reviewed emergency medicine’s most beloved topics – ACLS, PALS and ATLS – as well as our bread and butter procedures: intubations, central lines and lumbar punctures. We anticipate that our core faculty will use these sessions in creative ways to augment our didactic and clinical experiences. We continue to look forward to the South Florida Consortium and the year to come. ■
Kendall Regional Medical Center By EM Chief Residents & Staff
Jackson Memorial Hospital By EM Residency Staff We took great pleasure in welcoming our 15 interns this past June. They joined the Jackson family from all over the country, bringing a breadth of diversity, experiences and insight. It is amazing how quickly time passes, as we now have our full complement and will soon be preparing to graduate our first class. This summer, we held three dedicated ultrasound days for each of our classes. The interns got hands-on experience on basic EM applications including cardiac, soft tissue, gallbladder and OB ultrasounds. The PGY-2s had an advanced ultrasound day that included ocular, DVT and RUSH protocols. The PGY-3s had an exciting musculoskeletal workshop including hip, shoulder and wrist ultrasounds. In August, many of our faculty and residents attended Symposium by the Sea in Fort Myers. Dr. Michael Roberds, PGY-3 presented an abstract with Dr. Jennifer Jackson on medical student learning. Drs. Supino and Posaw gave a lecture on ultrasound in cardiac arrest, and Dr. Nina Gutierrez, PGY-2 and Dr. Alex Thai, PGY-3 represented us in the annual Case Presentation Competition. Dr. Gutierrez won best presenter and Dr. Thai won best discussant, which resulted in Jackson Memorial Hospital winning best overall case. Congratulations! Many exciting events are also on the horizon. We held our first ever fullresidency retreat in September, which was a great opportunity for team building and brainstorming. In October, our senior class attended ACEP18 in San Diego. Finally, recruitment season will begin before we know it, and applicants can finally meet all three of our classes. ■
We are excited to congratulate our recent Symposium by the Sea SimWARS winning team of PGY-3 residents: Drs. Pavel Antonov, Erik Copeli, Vinicius Knabben and Joe Proza. Well done, guys! We would also like to thank the other teams that competed, which helped make it such a fun and challenging competition for everyone.
from his previous program to help us raise the bar at Kendall.
Now, with our first class of third-year residents in place, we are able to start some really great educational initiatives. We have started EMS, Ultrasound and Simulation tracks for interested thirdyears that will help them better learn the skills to transition into fellowship As of this summer, we now have all three or independent practice. We were also years of residency classes on board able to kick off our first annual teaching and would like to give a warm welcome fellowship for all of our third-year to our new intern class: Drs. Richard residents. We want to make sure they Boccio, Joseph Clemons, Kristina are all well-prepared for independent Drake, Jennifer Eells, Kelly Glazer, practice and learn how to take more Anton Gomez, Ibrahim Hasan, Matthew ownership over the department, EMS Mattioli, Anthony Peters, Nicholas triage and fast track care. Rosende, Boris Ryabtsev and Sara Zagroba. We have a great class and As our chiefs have said, “This is our are excited to get to know them better. last year, but it is the first complete ED We wish them the best of luck and look resident team for our program and is a forward to working and training with huge step forward. We are excited to be them through residency. present for this stage in the program’s development and can’t wait to see We also want to welcome our new where our co-residents will take the Ultrasound Director, Dr. Moises Moreno. program in the future.” The program He started with us this summer and leadership definitely agrees! ■ brings his skill as ultrasound director
Mount Sinai Medical Center By Michael Cecilia, DO, PGY-3
Greetings from the Mount Sinai Medical Center Emergency Medicine Residency Program. As summer comes to a close, it is with great pride that we reflect on all the recent events within our program. This August, we participated in Symposium by the Sea’s SimWARS competition. Our team—consisting of Drs. Adam Memon, Aldo Manresa, Elizabeth Rubin and Nick Boyko—did extremely well placing as finalists.
August at NOVA Southeastern University. This meeting brings together all six of South Florida’s EM programs for a joint conference. The guest speaker list was loaded with dynamic lecturers, including AAEM President Dr. David Farcy, ACEP Past-President Dr. Paul Kivela, Dr. Jason Morris from St. Lucie Medical Center, and our keynote speaker, Dr. Paul Pepe, a pioneer and innovator in pre-hospital emergency medicine care.
MSMC also had the pleasure of hosting the South Florida Emergency Medicine Consortium quarterly meeting this past
From our residency to yours, we wish each of you continued success as fall winds down and winter approaches. ■
EMPULSE FALL 2018
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Living in Paradise
Hurricane- Torn Territory By Christina M. Krager, BSN, RN, CCRN, EMT-P, NREMT-B Edited by Terri M. Repasky, MSN, RN, CNS, CEN, EMT-P Photos by Mark Repasky, PE
It was preparation like any other hurricane where I live and work as a RN in the Florida Keys. We’ve had many hurricane scares before. In the past I had prepared and evacuated, only to have the pleasure of going home and putting all my treasures away. But, this time was very different. Hurricane Irma was coming, and it was huge. We worked together to evacuate the hospitals and make sure our patients were safe, and I evacuated to Orlando in the early hours of Friday, October 8, 2017. The drive normally takes six hours; this time it took eight. It was bumperto-bumper on a hot, sunny Florida day. Once I arrived in Orlando, my first priority was to fill the car with gas. You learn this by living in an area where hurricanes are a seasonal occurrence. Saturday morning I helped family members prepare for their dreaded hurricane events. Then the wait began. By late Saturday night, the rain and
winds started to fall in the Florida Keys. It wasn’t until Sunday’s early morning hours that the reality hit home. I had lost contact with my close friend who decided to stay and endure the storm. The weather channel and local channels had very little updates on the Florida Keys due to the “extent of the storm.” It was known by 0100 Sunday morning that the peak of the storm was over the Florida Keys and its speed had slowed to a grueling 11 mph; not good when the winds were now up to over 130 mph. Every hour I would look at my watch and hope the speed of the storm had increased, only to find the winds increasing and the storm speed slowing. As I waited, the storm strengthened and Keys information became less available. By late Sunday morning, it was obvious that the Middle Keys—where I lived—and southern Keys had suffered massive damage. For a week I was unable to rest my mind, plagued by thought of the EMPULSE FALL 2018
unknown. Would I have a home to return to? Did the hospitals survive? It was October 16—nearly a week after the storm had passed—when Monroe County officials finally gave permission for Keys residents to return home. The damage was so significant that the National Guard, Red Cross, Sheriff and many hazmat teams were working day and night to prepare the Keys for safe re-entry. There was bumper-tobumper traffic going home to Marathon. Everyone was anxious to see if their home was still there. By late afternoon I had finally arrived at my home in Marathon. I saw road debris, boats moved from lifts, trees uprooted and homes moved by flood waters across US1. When I reached my condo, I was not prepared for the amount of damage
18 inches of flood water and the loss of a roof can do to a concrete building. No electricity, no air conditioning, no fresh running water to drink, no food. Everyone was at a loss. The week became a mode of survival. Ice coolers for bottled water, food provided from the National Guard at the high school, and security were all over town. We were on a sunset lock down and no one was allowed anywhere except by proof of ID to your own home. After sunset, the streets were so dark that only flash lights and lights from police cars at the end of the block could be seen. Closing and locking my condo in the dark was one of the scariest moments of the day. My once-secure home in paradise was no more.
What About the Hospitals? The “hospitals” have slowly reopened. Initially we worked in mash units, then in pods (below), and now in more “permanent” temporary modulars. Rebuilding may take three years to complete, but dedicated local physicians, nurses and other staff are glad that they can still provide the community with emergency and in-patient care, despite the challenging environment in our Florida paradise.
Days, weeks and months have gone by. I have moved four times, from hotel to hotel, into a studio, and I am now living in a 21 ½ foot camping trailer. Housing has been one of the most difficult things to find in the Florida Keys. The storm occurred at what is considered tourist season and many homeowners continued to use their homes for vacation rentals as opposed to opening them to locals who are still without housing. I resided for a while in a studio apartment and in spite of offering to pay more, I was informed by the owner, “No, it is rented for season and you will have to go.” Locals are charged $2000$2500/month for a 1-bed/1-bath shack. As an experienced critical care and emergency nurse, it has always been possible to work an extra shift or two when I need more cash, but I soon discovered that this was not going to work in the current situation—there was just no affordable housing available. The only way for me to endure what I was hoping to be short-term was to provide for my own housing; thus the camping trailer, which is currently my home. Today, almost a year later, I continue to live in the camper outside my condo in the street. Under housing definitions, this meets the homeless criteria. My electricity comes and goes and there is no date in sight as to when I might be able to move back into what was once my home in paradise. I will be forever grateful for the grant provided to me by fellow emergency nurses through the Florida Emergency Nurses Association. ■ EMPULSE FALL 2018
COMPLICATIONS OF FLAKKA: More Than Just Agitated Delirium Mehruba Anwar Parris, MD, FAAEM
Tim Montrief, MD, MPH, PGY-2
The Case A 28-year-old Afro-Caribbean American female with no significant known past medical history presented to a community ED after a low-speed motor vehicle accident in which she was the restrained driver with airbag deployment and no loss of consciousness. Two hours prior, she attended a party in which she endorsed using marijuana, alcohol and Flakka. The patient’s risk factors for stroke included a family history of strokes, including her mother, who suffered a stroke at age 35. The initial physical exam was unremarkable with stable vital signs, Glasgow Coma Score of 15 and no neurologic deficits. Initial CT brain without contrast was unremarkable. While in the ED, she had left-sided weakness, which was not reported by the patient or family, and a stroke alert was called seven hours after last known well time. On examination, mild dysarthria, slight left-sided facial droop and both left upper and lower extremity weakness were noted. Other cranial nerves including facial sensation were intact. Additionally, she had mild left-sided sensory loss in her extremities. NIH Stroke Scale/Score (NIHSS) was 6. Tele neurology was immediately consulted, and an MRI/MRA revealed diffusion restriction within a small portion of the right MCA subcortical territory and right M1 cutoff without collateral circulation on MR angiography. However, no tissue plasminogen activator (tPA) was given as she was outside the therapeutic window. She was transferred to a quaternary care center and taken directly for angiography. At this time, her NIHSS was 3. Angiography found a right carotid web, as well as a right M1 occlusion (Fig. 1). Given the patient’s young age, small lesion on diffusion-weighted imaging compared to right MCA territory with absent collateral flow, a thrombectomy was performed. The 26
two-hour post thrombectomy NIHSS was 0, and the patient was started on daily aspirin and rosuvastatin therapy. Her comprehensive workup did not indicate hypercoagulability or vasculitis. Transthoracic echocardiogram was performed and showed no evidence of right to left shunt by agitated saline challenge. Because of the acute CVA, infarct size and successful thrombectomy, no further intervention was performed during this admission. The patient was discharged on daily aspirin
Jeff Scott, DO
α-PVP is a synthetic cathinone. It stimulates the release of dopamine while inhibiting the reuptake of epinephrine, norepinephrine and serotonin in the central nervous system. Cathinones are highly hydrophobic molecules and easily cross cell membranes, as well as the blood brain barrier, thereby allowing them to saturate the monoamine transporters in the synaptic cleft between neurons.2,3 It is well known that α-PVP intoxication causes an excessive influx of sympathetic activation, lead-
Fig. 1. Angiography revealing a carotid web. Fig. 2. The clot after thrombolectomy.
and rosuvastatin therapy with close outpatient follow-up.
What do we know about flakka? “Flakka” or α-Pyrrolidinopentiophenone (α-PVP), is one of the more recent synthetic drugs that have become popular in the US, particularly in South Florida. It is chemically similar to MDPV and colloquially known as Bath Salts, which was recently implicated in a string of highly-publicized episodes of intoxication and agitation throughout the US.1 EMPULSE EMPULSE FALL FALL 2018 2018
ing to agitated delirium, which presents as an acute alteration in mental status including strange behavior, anxiety, violent outbursts, confusion, myoclonus and seizures.4-6 Likewise, as in our case, α-PVP ingestion has been implicated as a causative factor in impaired
driving and subsequent trauma.7-9 While the effects of many of the synthetic drugs of abuse—including α-PVP—closely resemble those of amphetamine, methamphetamine and MDMA, they are not reliably detected on routine urine immunoassays. This is due to the fact that antibody binding affinity (and thus cross-reactivity between substances) is based not only the concentration of the drugs in the specimen, but also the structural similarity. These synthetic drugs of abuse are typically developed through the modification of existing drug classes, losing the classic chemical structure tested by the immunoassay.10 However, commercial laboratories such as NMS and Quest Diagnostics have developed urine, blood and serum assays that can confirm the presence of α-PVP and other emerging synthetic drugs of abuse. These assays employ liquid chromatography (LC), mass spectrometry (MS), or a combination thereof.11
Could flakka have played a role in this patient developing a stroke? Although the most likely reason for this patient’s stroke was due to the carotid web, the patient’s initial presentation lends itself to a wide differential diagnosis and brings up an intriguing question: could flakka have played a role in this patient developing a stroke? A lesser known effect of cathinones and synthetic cathinones such as α-PVP is cerebrovascular and cardiovascular ischemic changes. There have been case reports in animals and humans describing sudden cardiac death in young patients after α-PVP ingestion, with post-mortem findings of advanced atherosclerotic disease, pulmonary edema and cerebral infarctions.12,13 A 44-year-old man with a history of substance abuse injected α-PVP, stripped off all his clothes, jumped over a barbed-wire fence and smashed a window, during which time he suffered a cardiac arrest and was successfully resuscitated, but later found to have evidence of raised intracranial pres-
sure, and died. Autopsy revealed cerebral infarctions with edema and tonsillar herniation, as well as evidence of α-PVP in blood samples.13 Likewise, a 41-year-old woman with no past medical history developed an ST-elevation MI after α-PVP use, and found to have diffuse atherosclerotic disease with multiple areas of 90% occlusion on cardiac catheterization.12 Additionally, α-PVP ingestion can also present with limb ischemia, compartment syndrome, or acute renal failure requiring dialysis.13
Conclusion As synthetic cathinones, particularly α-PVP, become more widespread in Florida, more patients are presenting with sequelae of their abuse. While most providers already know the classic “agitated delirium” presentation of α-PVP, it is important for us to be aware of the other complications, including cerebrovascular and cardiovascular ischemia, as well as trauma, limb ischemia, compartment syndrome and acute renal failure requiring dialysis. ■
References 1. Disalvo, D. The backstory you really need to know about flakka and other synthetic drugs. Forbes Magazine. 2015. 2. German CL, Fleckenstein AE, Hanson GR. Bath salts and synthetic cathinones: an emerging designer drug phenomenon. Life Sci. 2014; 97(1):2-8. 3. Felice, L et al. Synthetic Cathinones: Chemical Phylogeny, Physiology, and Neuropharmacology. Life Sci. 2014 Feb 24; 97(1): 20-26. 4. Prosser, JM et al. Toxicology of Bath Salts: A Review of Synthetic Cathinones. J Med Toxicol. (2012) 8:33-42 5. Chai, C. “What you need to know about flakka, the latest drug causing erratic behaviour,” Global News. 2015. 6. Cavanaugh, A. Flakka—The Drug Wreaking Havoc in South Florida. ADLS. 2015. 7. Knoy JL, Peterson BL, Couper FJ. Suspected impaired driving case involving α-pyrrolidinovalerophenone, methylone and ethylone. Journal of analytical toxicology. 2014; 38(8):615-7. 8. Rojek S, Kula K, Maciow-Glab M, Klys M. 2016. New psychoactive substance α-PVP in a traffic accident case. Forensic Toxicol. 34:403–410 9. Wright TH, Harris C. Twenty-One Cases Involving Alpha-Pyrrolidinovalerophenone (α-PVP). Journal of analytical toxicology. 2016; 40(5):396-402. Darragh J. What are the difficulties in detecting bath salts, their effects and how do we test for them? Forensic Magazine. December 2014. 10. Katselou M, Papoutsis I, Nikolaou P, Spiliopoulou C, Athanaselis S. α-PVP (“flakka”): a new synthetic cathinone invades the drug arena Forensic Toxicol. 2015; 34(1):41-50. 11. Cherry SV, Rodriguez YF. Synthetic Stimulant Reaching Epidemic Proportions: Flakka-induced ST-elevation Myocardial Infarction with Intracardiac Thrombi. J Cardiothorac Vasc Anesth. 2017; 31(1):e13-e14. 12. Sellors K, Jones A, Chan B. Death due to intravenous use of α-pyrrolidinopentiophenone. Med J Aust. 2014; 201(10):601-3. 13. Zawilska JB, Wojcieszak J. α-Pyrrolidinophenones: a new wave of designer cathinones, Forensic Toxicol. 2017; 35(2):201-216.
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Intubation Rodeo Key to Saving Patient Lives By Mary Anne Kolar, DO, FACOEP, FACEP Medical Director at Nature Coast EMS On February 2, 2019, Nature Coast Emergency Medical Services will host the 5th Intubation Rodeo in Citrus County, FL. Thanks to a grant from the Florida Department of Health, the Rodeo, which is paramount to performing proper intubation in the field, will bring together a large contingent of healthcare professionals throughout the state for an entire day of intense training and competition. Only one person will emerge as the winner. It is a coveted prize. Why the intubation rodeo, one might ask? Because intubation is not only a skill, it is an art, and without continued practice, paramedics in the field suffer when faced with this life-saving challenge. Studies have shown that medical professionals in hospitals are quite comfortable with intubation procedures, primarily because they are in a controlled environment and have many opportunities to perform this necessary yet critical procedure.
Photo courtesy of Dr. Mary Anne Kolar stress-infused scenarios. This, in turn, would give them more experience and confidence in the procedure when reality rears its ugly head and requires quick and successful patient intubation. For the 2019 Rodeo, Nature Coast EMS hopes to have 75 competitors who want to improve their intubation skills in intense scenarios. In 2016, 54% of the participants were paramedics, 36% were paramedic students and 9% were other healthcare providers. We are looking for a blend of professionals in 2019, as well. The Rodeo will include scenario-based drills in high-risk patients. Participants will improve their skills in different scenarios presented by our healthcare educators. Over 50% of the intubation stations will use pediatric simulation. Some studies have shown that field paramedics have an intubation fail rate of 25% on adults; the fail rate for pediatrics is almost twice that rate.
Paramedics, on the other hand, are rarely in a controlled environment, and intubation may need to be performed on someone in a partly submerged vehicle, on a road during a thunderstorm, on a boat with 5 ft. seas... Just use your imagination and you’ll see why proper intubation in stressful, non-sterile environments must be performed with precision and confidence. Hence, the competition was born. The Nature Coast EMS Intubation Rodeo was the first of its kind. Thirty-eight dedicated professionals competed, with some coming from as far as Miami and the panhandle. The entire purpose of the rodeo was to give paramedics practice on intubation utilizing different,
Nature Coast Emergency Medical Services is committed to serving our Citrus County community with excellence and compassion. The Intubation Rodeo is just one event that helps us meet that goal, and brings us one step closer to our vision of becoming a national leader in patient-centered care. ■ For more information or to register for the Rodeo, contact Jane Bedford at email@example.com or 352-249-4700.
ITLS Founder & President Has Passed Away John Emory Campbell, MD, FACEP of Alabama passed away on August 29, 2018 after battling a long illness. He leaves behind a rich legacy of dedication and excellence in trauma care, and his work has has touched more than 750,000 providers worldwide. John Emory Campbell, MD, FACEP 1943—2018
Dr. Campbell founded the Basic Trauma Life Support (BTLS) program in Alabama in 1982. It was the first course and curriculum dedicated to prehospital trauma assessment and trauma care worldwide. Soon after, Dr. Campbell’s local coursEMPULSE FALL 2018
es grew into what is now International Trauma Life Support (ITLS): a global organization offering 15 types of trauma courses to more than 30,000 students in 40 countries annually. ITLS will continue advancing Dr. Campbell’s mission of improving trauma care worldwide by developing innovative curricula, programs and services that are evidenced-based, flexible and assessment focused for trauma care providers and the patients they serve. To learn more about ITLS and Dr. Campbell, visit www.itrauma.org. ■
Is It an Emergency? Or Is It Hospice? By Lillian Valeron, Director of Market Development, VITAS Healthcare
What are best practices for terminally ill patients who frequent your emergency department? What do patients, families, hospitals and payers want? What is your role? What is the role of hospice? The Hospital Readmissions Reduction Program was developed for a reason. Consider this: a third of Medicare patients readmit within 90 days while 1 in 5 Medicare patients readmits within 30 days. VITAS Healthcare, the nation’s leading hospice provider, can admit hospiceappropriate patients directly from the ED, even when they are symptomatic.
VITAS has streamlined the hospice referral process with a mobile application for iPhone, iPad and Android users. You can instantly refer patients with serious progressive illness to VITAS with a face sheet snapshot and a few clicks— available 24/7, including holidays. Download it for free at VITASapp.com.
When your hospital partners with VITAS, patients with end-of-life needs get the right care. Your hospital achieves key goals: • Reduced ED overcrowding, readmissions and observation periods • Improved ED throughput and bed cycling • Seamless transitions to post-acute care • Improved family-satisfaction metrics Hospitals are dinged for decreased “core measure” outcomes and reduced patient/family satisfaction scores, and seriously ill patients do not want to readmit. When surveyed, their preferences include pain/symptom control, improving their relationships with family rather than increasing their burden on family, not prolonging the dying process and maintaining a sense of control. Yet readmissions are often due to a failure in discharge planning or insufficient outpatient or community-based care, as well as severe progressive illness. Readmitted patients tend to not have follow-up plans, and not be able to state their diagnosis or explain their medications. Once realized, such issues are easily remedial. What signs tell you a patient might be hospice-eligible? • Frequent readmissions to the ED, hospital or ICU • Ongoing symptoms despite optimal treatment • Declining functional status • Declining renal function • Use of inotropes • Patient’s goals are for quality of life • Answering “no” to the question: Would you be surprised if this patient died in the next 6–12 months?
When referred to hospice as soon as they are eligible, patients receive medical and psychosocial care to control their symptoms and improve quality of life. Care is brought to them where they live by an interdisciplinary team. Continuous care is provided at home when medically necessary, keeping the patient out of the hospital.
About VITAS Healthcare: A pioneer and leader in the hospice movement since 1978, VITAS offers customized care, services and programs to meet the unique needs of each patient and family we care for. For information about VITAS Healthcare—a Medicareapproved hospice provider—visit VITAS.com or call 866.41.VITAS.
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THE ULTRASOUND ZOOM
RUSH VTI Rapid Ultrasound for Shock & Hypotension and Velocity-Time Integral I am a fourth-year medical student with a keen interest in emergency medicine. I understand how hypotensive patients in shock can be a formidable challenge. However, I also believe that point-of-care ultrasound can assist in overcoming this challenge in several ways. One such way is the Rapid Ultrasound for Shock and Hypotension (RUSH)1 exam, which is a comprehensive assessment protocol performed with ultrasound that provides valuable information on why the patient in front of us is in shock. However, while the RUSH exam informs us on the possible causes of hypotension, it does not direct management. Recently on my ultrasound elective, I read a very interesting article2, which proposes the addition of Velocity-Time
By Benjamin Chan, BS, MD/MPH Candidate, Miller School of Medicine, University of Miami
Edited by Leila Posaw, MD, MPH, Dept. of Emergency Medicine, Jackson Memorial Hospital
Integral (VTI) to the standard RUSH protocol. The goal of resuscitation in shock is to increase stroke volume. The VTI is a surrogate for stroke volume, and can not only be used to predict a patient’s response to fluids (“fluid responsiveness”), but it can also guide resuscitation with the administration of fluids or inotropes.
RUSH While there are several forms of the RUSH protocol, I find that the HIMAP version (Figs. 1-2) is easy to remember and perform. Technically, it is performed in the B-mode using a curvilinear or phased-array probe. CONTINUE ON PAGE 31 ►
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Fig. 1. HIMAP Version of RUSH Exam: Views & Questions VIEWS
QUESTIONS Is there a pericardial effusion? What is the global ventricular function? Is there RV strain? What is the baseline LVOT VTI?
IVC Morison’s Pouch
M A P
Fig. 2. Probe Positions for Rush Exam
in the right upper quadrant
Is the IVC collapsed or full? I
Is there a pleural effusion or hemoperitoneum?
Is there an aneurysm or dissection?
Is there a pneumothorax?
Courtesy of authors Model: Jimmy Mu, MD
Fig. 3. Obtaining LVOT Diameter, LVOT VTI and Vmax Measurement
Left Ventricular Outflow Tract (LVOT) diameter
Base of the open aortic valve annulus
Apical 3 of 5
Sample area in the left ventricle just proximal to aortic valve
Traditionally, stroke volume is calculated with this equation: [LVOT VTI x (LVOT diameter)2 x 0.785] Technically, it is performed with a phased-array probe in the B-mode and Doppler mode as depicted in Fig. 4. It is important to place the pulsed-wave marker directly in line with the LVOT blood flow and to place the pulsed-wave sampling gate in the correct location, otherwise your LVOT VTI measurement might not be accurate. Measuring LVOT diameter in emergent situations can be technically difficult and errors are magnified due to the
squaring of the diameter in the equation. An easier and more accurate alternative is to only measure the LVOT VTI (step 2) and omit the LVOT diameter (step 1), which remains constant in all calculations. Similarly, it would be even simpler to use the Vmax (step 3) rather than the LVOT VTI (step 2) because it obviates the difficulty of tracing around the VTI curve using the ultrasound machine cursor. A normal LVOT VTI is between 18 and 22 cm for heart rates between 55 and 95 beats per minute. CONTINUE ON PAGE 32 ►
• Cut along the border of the table below. (Get as close to the edge as possible!) • Fold in the middle. • Stick in your wallet. Reference on-the-go. Courtesy of authors Leila Posaw, MD, MPH and Benjamin Chan, BS
RUSH VTI: Rapid Ultrasound in Shock & Hypotension and VelocityTime Integral
H1: Is there a
pericardial effusion? What is the global ventricular function? Is there RV strain?
H2: What is the baseline LVOT VTI?
I: Is the IVC
collapsed or full?
M: Is there a
pleural effusion or hemoperitoneum?
Not happy with your scissors? This table is also available online at www.emlrc.org/rush-vti
A: Is there an aneurysm or dissection?
P: Is there a
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LVOT VTI is limited as a surrogate for stroke volume in conditions of dynamic LVOT obstruction and moderate to severe aortic regurgitation. If the VTI cannot be obtained on the LVOT because of these or other technical difficulties, then other potential sites for measuring VTI include the right ventricular outflow tract, the mitral valve and the descending aorta.
Fig. 4: Measurement of LVOT diameter & LVOT VTI2
Management Simply, stroke volume (SV) can be increased with fluids or with inotropes. Fluid responsiveness is defined by an increase in SV of greater than 15% after a fluid bolus. Contractile reserve is defined as an increase in SV of greater than 20% after administration of inotropes. The concept of measuring stroke volume pre- and post-intervention (fluid bolus, inotropes or other interventions) has been shown to be more important than static measurements. We know that fewer than half of hypotensive patients will increase their stroke volume as a response to fluids. Which patients are these? We can easily discern this by measuring the LVOT VTI (or the Vmax) prior to and after a fluid challenge (small fluid bolus or passive leg raising). An increase of more than 15% would indicate fluid responsiveness. A simplified VTI algorithm in the management of different types of shock is depicted in Fig. 5.
to every hypotensive patient, I look forward to managing my patients with ultrasound. Seeing with ultrasound will be my superpower. ■
References 1. Weingart, S. (2008). https://emcrit.org/rush-exam/orignal-rush-article/ Accessed: 8/31/2018. 2. Blanco, P., Aguiar, F. M. and Blaivas, M. (2015), Rapid Ultrasound in Shock (RUSH) Velocity-Time Integral. Journal of Ultrasound in Medicine, 34: 1691-1700.
All emergency departments manage critical hypotensive patients. Instead of the usual mantra of “let’s give 2L of fluid”
Fig. 5. VTI Algorithm in the Management of Different Types of Shock2 Shock?
Goal: LVOT VTI > 18 cm
LVOT VTI < 18 cm Fluid challenge: LVOT VTI >15%
LVOT VTI < 18 cm Fluid challenge: LVOT VTI >15% Contractile reserve: LVOT VTI > 20%
LVOT VTI <18 cm Fluid challenge: LVOT VTI >15%
Early: LVOT > 22 cm Late: LVOT <18 cm Fluid challenge: LVOT VTI >15% Contractile reserve: LVOT VTI > 20%
RUSH VTI.To.Go P
Morison’s Pouch, Right Upper Quadrant
Heart, Apical 4 Chamber (AP4C) LVOT VTI
Heart, Parasternal Long Axis (PSLAX) LVOT Diameter
RUSH VTI: Rapid Ultrasound in Shock & Hypotension and VelocityTime Integral HIMAP Protocol
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Medical Student Committee By Kimberly Herard, MD Candidate, FAU Class of 2020 Medical Student Committee Secretary-Editor
This year, Symposium by the Sea was held at the beautiful Sanibel Harbour Marriott Resort & Spa in Fort Myers, FL. Many discussions and forums were held that highlighted the growth of emergency medicine, the advocacy occurring within the specialty and even hinted at where we could assist in the future. Another very important piece of Symposium by the Sea was the chance to recognize all of the research presented by medical students and residents. The projects ranged from a variety of unique and important topics such as the HEART score, the risk of sudden cardiac death in young adults, naloxone dosing for opioid overdose and analgesia protocol for sickle-cell patients. Samuel Harris, a second-year medical student at USF, won the student research category for his project, Evaluation of ultrasonography vs. computed tomography in diagnosis of acute lower abdominal and pelvic pain in women in the emergency department. “(We) hoped to elucidate whether or not dual imaging is being overused to assess pelvic and abdominal pain for non-pregnant females in our ER,” Harris explained. “We hope that the answer to this project will benefit both patients and our hospital by saving time and money.” His advice to all students and residents who are interested in research is to “pick a project you are passionate about. Take a second and listen to your gut before you accept.” Opioid overdose, death and drug shortages are major public health problems facing many patients we serve daily. Daniel Gable’s research on Transcutaneous Electrical Nerve Stimulation (TENS) for back pain in the ED will contribute to solutions for these issues. “Opioid addiction and overdose is currently a huge public health issue, and I am interested in ways to augment treatment regimens so patients are not as reliant on them,” Gable said.
Dr. Jennifer Reyes, PGY-2 at Aventura Hospital focused her research on Human Trafficking Protocols in the Emergency Department. “Up to 88% of sex trafficking victims receive medical care, of which the most common treatment site is the emergency department,” Dr. Reyes explained. “Our ED has come across potential victims before but without the tools to guide intervention, these patients have slipped through our fingers. I felt a moral obligation to fill this void and was excited to see the results pan out.”
Dr. Jennifer Reyes, PGY-2 at Symposium by the Sea 2018
The vast expanse of topics available to further investigate is limitless, and the most exciting part is that these projects matter. It is these topics, ideas and results that will further improve our health care, positively impact and benefit the millions of patients served in the ED, and create any needed change or adjustments in serving patients and the community. If you’ve always been intrigued by research, go out and pursue it! ■
August 1-4, 2019 Boca Raton Resort & Club Boca Raton, FL EMPULSE FALL 2018
RESIDENT CASE REPORTS (NEW!)
Cognitive Errors and Risks Associated with Provider Handoffs By Kenneth Frye, DO, PGY-3; Ademola Adewale, MD; Clara Mora Montero, MD
Abstract Background: The ED is a challenging environment to practice medicine, primarily due to the pace and logistics of practicing emergency medicine. Of these challenges, cognitive errors and provider hand-offs most notably can lead to poor patient outcomes. By avoiding cognitive errors, including premature closure, anchoring and diagnosis momentum, patients can be treated appropriately, potentially reducing the chances of a poor outcome. Additionally, by completing thorough, yet efficient sign-outs as per ACEP’s “Safer Sign Out Protocol,” the chances of a poor outcome are further reduced. Below, a case of “migraine headache” is presented, highlighting cognitive errors and the risks associated with provider hand-offs in the ED.
Introduction Emergency medicine is considered a “cognitive” profession and therefore cognitive biases, as opposed to knowledge deficits, are the primary causes of errors. Dual-process theory is the dominant theory of human cognitive processes and involves two unique, interdependent but overlapping systems. The first system uses primarily intuitive, unconscious, mental shortcuts (otherwise known as heuristics) to work through complex problems efficiently. The second system uses primarily analytical, conscious thought, but is typically slow, deliberate, and requires effort1. Both systems are required and contribute to high quality patient care, but the speed and efficiency in which heuristics are performed contributes to the biases we see in emergency medicine.
um-of-care” issues associated with shift change3. Furthermore, up to 80% of serious medical errors involve miscommunication during handoffs4 and up to 24% of ED malpractice claims involve faulty handoffs3. We report a case of rapidly progressive, invasive, CNS infection in the setting of multiple ED visits for migraines—a case report highlighting cognitive errors.
Case Report A 23-year-old female presented to the ED with six episodes of left-sided headaches over the course of two and a half weeks. She reported photophobia, nausea and vomiting, and had improvement in her symptoms with the use of medications such as prochlorperazine, diphenhydramine and ketorolac. Despite multiple evaluations in the ED, a negative head CT, negative MRI and prescriptions similar to what was used in the ED, the patient kept returning with a headache. The patient denied any previous history of migraines prior to her first presentation. On this visit, the patient was seen about two hours prior to shift change and was reported to be alert, oriented and with a GCS of 15. The patient had received prochlorperazine, diphenhydramine and
The patient’s initial diagnosis was migraine headache and she was treated accordingly. When the patient was found to have altered mental status as opposed to being drowsy from medication administration, the differential diagnosis was expanded to include medication effect (less likely due to duration of symptoms) and acute intracranial processes such as bleeding, masses or infections. Based on this new development, an emergent CT scan of the head was ordered, which revealed a rapidly progressive sinusitis that eroded through the left orbital wall causing inflammation of the left orbital apex with radiographic evidence of meningitis concerning for a possible fungal infection (see Fig. 1). Once the diagnosis of rapidly progres-
Fig. 1: “Progressive invasive sphenoid sinusitis which invades into the left orbital apex. Crowding of the left orbital apex demonstrated for which compression of the left optic nerve cannot be excluded. Correlate clinically. Progressive bone invasion with associated osteomyelitis involving the left anterior clinoid process and roof of left orbit with suspicion of adjacent dural thickening effacing suprasellar cistern suggesting intracranial extension with associated meningitis. Correlation with MRI of the brain/orbits with and without contrast may be helpful. Progressive left proptosis and subtle left retrobulbar edema demonstrated. ENT consultation recommended.”
Some of these common cognitive biases include premature closure, anchoring and diagnosis momentum2. In addition to the cognitive biases associated with this case, the patient was also at risk for a poor outcome due to the nature of shift change and provider hand-offs. Communication errors have been found to be the cause of 70% of sentinel events and 84% of treatment delays; of these, 62% are “continu34
ketorolac. and was signed out as “a migraine, medicated, discharge pending improvement.” Patient was examined without the pre-handoff provider after sign-out and was noted to be drowsy— presumably due to the prochlorperazine and diphenhydramine—but after several hours of observation in the ED (3 hours after medication administration) and with frequent examinations (patient persistently drowsy, GCS 10), the patient never returned to baseline as per family at the bedside.
EMPULSE FALL 2018
sive sinusitis with CNS involvement (radiographically evident meningitis with a later confirmed epidural abscess) was made, the patient was started on intravenous Vancomycin 25mg/kg, Rocephin 2g, and Amphotericin B 5mg/ kg concurrently. After ED intervention, the patient was emergently transferred to a tertiary care facility for evaluation by ENT and Neurosurgery.
Fig. 2: Axial images, T2 weighted with Flair, “There has been near resolution of the mucosal disease within the paranasal sinuses with only minimal mucosal thickening remaining within the sphenoid sinuses and ethmoid air cells bilaterally. Significant improvement in the intracranial extent of disease. There has been resolution of the epidural abscess seen previously. Also significant improvement in degree of inflammatory leptomeningeal enhancement with mild residual enhancement remaining within the suprasellar cistern.”
On arrival to the Neuro ICU, the patient was evaluated by ENT and taken immediately to the operating room for left total ethmoidectomy and bilateral sphenoidotomy with removal of contents. Cultures were obtained at the time of surgery, which grew methicillin resistant staphylococcus aureus. Patient continued with IV antibiotics, physical therapy and occupational therapy, and was discharged to a rehab facility. A week after admission, the patient suffered a left basal ganglia stroke, which was thought to have been caused by infective arteritis. She initially struggled with expressive aphasia but rapidly improved after the initiation of steroids and aggressive rehabilitation. At the time of discharge from the rehab facility, the patient had near complete resolution of her mucosal disease (sinusitis), complete resolution of her epidural
abscess, and significant improvement in her leptomeningeal inflammatory enhancement on MRI imaging (see Fig. 2). Additionally, the patient had full return of speech and could perform all activities of daily living. Walking still required supervision, but difficulty was only noted on uneven surfaces.
Discussion By avoiding cognitive errors, including premature closure, anchoring and diagnosis momentum, the patient was admitted, treated aggressively and eventually discharged from the hospital after a short stay in rehabilitation with an expected full recovery. She did however likely experience hours of delay in diagnosis due to an inefficient, incomplete,
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handoff process. The ED is a challenging environment for providers as there is an inordinate amount of opportunities for errors to occur. The speed and efficiency physicians are pushed to work forces providers to use primarily heuristic systems of thought, which as mentioned previously, is prone to cognitive errors due to mental shortcuts including pattern recognition and practice experience5. Some of the common errors seen within the ED include the following2: Premature Closure – Uncritical acceptance of an initial diagnosis and failing to search for information to challenge the provisional diagnosis or to consider other diagnoses. Anchoring – Focusing on one particular symptom, sign or piece of information, or a particular diagnosis early in the diagnostic process, and failing to make any adjustments for other possibilities, either by discounting or ignoring them. Diagnosis Momentum (aka Bandwagon Effect) – Diagnostic labels may stick to a patient. If everyone else thinks it, it must be right! Additionally, another source of errors to navigate in the ED are provider handoffs. Handoffs are an inherent, unavoidable challenge presented to emergency medicine providers due to the shift style work used to staff EDs. ACEP recogniz-
es the dangers of provider hand-offs and has proposed the “Safer Sign Out Protocol” in order to create a standardized approach to provider hand-offs. ACEP (via the Quality Improvement & Patient Safety Section), in conjunction with the Joint Commission, expert consensus and clinician feedback, has developed the following protocol to formalize the sign out process for ED physicians, which focuses on areas that are high risk for errors4: Five Key Steps – 5 R’s 1. Record: Patient and essential data/ updates/pending items 2. Review: Sign out form and computer data 3. Round: Bedside, together 4. Relay to the Team: Inform the team 5. Receive Feedback: Clinical outcome
Why should an EM physician be aware of this? Cognitive biases affect our daily work and can contribute to poor outcomes for patients. In order to deliver high quality patient care and reduce the risk of negative outcomes, the follow learning points should be considered:
• Many of the cognitive biases can
be avoided by gathering sufficient information, developing a differential diagnosis (~3 most life threatening and ~3 most common), and identifying any “red flag” symptoms for
diagnoses that are “can’t miss,” ie: emergently life threatening: ectopic pregnancy, myocardial infarction and subarachnoid hemorrhage2. • Use ACEP’s recommended “Safer Sign Out Protocol” or create a standardized approach to patient handoffs/sign outs within the ED to avoid high risk medical errors. • Research has found that verbal communication with note-taking style handoffs had high rates of data loss, whereas a written form of communication with a verbal exchange (as recommended by ACEP) was associated with minimal data loss.4 ■
References 1. Justin Morgenstern, “Cognitive errors in medicine: The common errors”, First10EM blog, September 15, 2015. Available at: https://first10em.com/ cognitive-errors/. 2. Scott, I., “Errors in clinical reasoning: causes and remedial strategies,” BMJ, Vol. 339, p22-25. 3. Cheung DS, Kelly JJ, Beach C, et al. Improving Handoffs in the Emergency Department. Ann Emerg Med. 2010;55:171-180 4. Quality Improvement & Patient Safety. Safer Sign Out Protocol. ACEP 2016. Available at: www.acep.org 5. Bharat Kumar, Balavenkatesh Kanna & Suresh Kumar. The pitfalls of premature closure: clinical decision-making in a case of aortic dissection. BMJ Case Rep. 2011, Oct. 7. Available at: http:// casereports.bmj.com/content/2011/ bcr.08.2011.4594
Daunting Diagnosis: ANSWER In addition to ruling out general trauma pathology, with hanging injuries, trauma to the carotid vessels must be ruled out. A CTA of the head and neck is warranted in these cases. In this case, several hours after presentation, the patient neurologically decompensated and a stroke alert was called. The patient developed a right MCA stroke syndrome, failed mechanical thrombectomy, and was found to have dissected his bilateral carotid arteries. The patient subsequently developed right MCA cerebral edema, herniation syndrome, and underwent a decompressive right temporalparietal hemicraniotomy. The patient was subsequently diagnosed with brain death and expired. The images demonstrate the progression of the patient’s cerebral deterioration. ■
CTA demonstrating blood in right MCA territory
◄ CONTINUED FROM PAGE 20 36
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Brain edema status — post decompressive right temporalparietal hemicraniotomy
If It Wasn’t Documented, It Didn’t Happen By Tracy Olsten, Regional Practice Administrator
In today’s world, there is so much focus on clinical documentation integrity. Have you ever wondered why this is so important? Is it to make your life difficult? Is there a valid reason? Is this related to revenue? The answer is simple—yes!
There are 3 key components to clinical documentation and coding: history, exam and medical decision-making (MDM).
There are two types of examination that the Centers for Medicare Medicaid Services recognizes: the 1997 physical examination bullets or the 1995 body area/organ systems. For the purposes of documenting the physical exam, emergency physicians typically defaults to the 1995 examination: body areas and organ systems. To qualify for a given level of exam, elements are captured and assigned a level of Problem Focused, Expanded Problem Focused, Detailed or Comprehensive Examination, based on what is reported.
Medical Decision-Making (MDM)
So how do I, as a provider, keep all of this information straight? To help, let’s revert back to the basics.
History is provided to build an accurate picture of a patient’s problem(s) to identify the direction for the exam and treatment. History is comprised of 4 elements:
• Chief Complaint is in the patient’s own words,
and is a brief description of why they are seeking care • History of Present Illness is a detailed interview with the patient to describe the presenting problem or chief complaint • ROS is an inventory of body systems obtained through a series of questions where the provider must make specific statements about areas that are positive or negative • Past/Family/Social History (PFSH) • Past history identifies any illnesses, injuries, operations, medications, etc. • Family history identifies relevant medical events, hereditary diseases, health status or cause of death of family members • Social history identifies an age-appropriate review of past and current activities such as use of tobacco, alcohol, or drugs; occupation; level of education; marital status
Many insurance payers have stated that due to the implementation of the EMR, your medical decisionmaking must be one of the determining factors when choosing your level of care. Because of this, it is important for providers to capitalize on the service you provide.
• What do you think is wrong with the patient
(definitive conditions and/or signs and symptoms)? • Describe what you did surrounding the diagnosis (order labs, prescribe medication, etc.) • Did you offer any counseling or education? Consult with other medical professionals? • Rationale behind the treatment you’re providing • Disposition of the patient Medical documentation provides medical necessity, good patient care and keeps your organization compliant with insurance payers, and compliance rules and regulations. Remember to document everything you do, because as they say in this industry, “If It Wasn’t Documented, It Didn’t Happen.” ■
EMPULSE FALL 2018
Flumazenil: Antidote or Antidon’t? By Madison Schwartz, Pharm.D. & Emily Jaynes Winograd, Pharm.D. Clinical Toxicology/Emergency Medicine Fellows at Florida/USVI Poison Information Center — Jacksonville
Flumazenil (Romazicon®) is a benzodiazepine reversal agent that acts via competitive inhibition of the benzodiazepine binding sites on GABAA receptors.1 FDA-approved indications for flumazenil in patients include:
In 2012, Kreshak et al. published a historical case series of flumazenil use reported to the California Poison Control System from 1999–2008. The study included adult patients with documented flumazenil administration and excluded patients with unknown medical outcomes. The authors identified 904 patients meeting study criteria, and found that 13 (1.4%) of patients had at least one documented seizure. Of those, nine patients experienced a seizure immediately after flumazenil was given, while the temporal relationship between flumazenil administration and seizure onset in the other four patients was unknown. Notably, approximately one third (293, 32.4%) of all patients were exposed to a pro-convulsant agent, eight of whom developed a seizure after receiving flumazenil. Patients who developed seizures had co-ingestions of diphenhydramine, amitriptyline, bupropion, tramadol, and propoxyphene, among others. The authors concluded that seizures are rare following flumazenil use. However, development of seizures was significantly associated with exposure to a pro-convulsant agent (OR 3.41, 95% CI 1.13–10.72).2
• Complete or partial reversal of the sedative effects of
benzodiazepines administered for general anesthesia, or diagnostic and therapeutic procedures • Management of benzodiazepine overdose • Reversal of conscious sedation induced with benzodiazepines in pediatric patients (ages 1–17 years) Flumazenil is contraindicated in patients with hypersensitivity to the agent or any benzodiazepine, patients who have been given a benzodiazepine to control status epilepticus, patients with elevated intracranial pressures or other potentially life-threatening conditions, and patients exhibiting signs of serious cyclic antidepressant overdose.1
Clinical Controversy Controversy exists among toxicologists regarding safe and appropriate flumazenil use in patients who are sedated secondary to an unknown toxic exposure. The major concern with flumazenil administration is the possibility of unmasking seizures or status epilepticus, and the drug carries a boxed warning to this effect. Patient populations at risk of seizures following flumazenil administration include: patients taking a benzodiazepine chronically as an antiepileptic or for the management of some other condition, and patients who ingested a benzodiazepine in conjunction with a pro-convulsive agent. Patients taking benzodiazepines to control epilepsy will no longer have GABAergic protection from seizures following flumazenil administration. Individuals on chronic benzodiazepine therapy for other conditions are at risk because flumazenil may precipitate acute withdrawal and lead to seizures. Finally, patients with co-ingestions of pro-convulsant agents (e.g. cyclic antidepressants, bupropion) are at risk for seizures since the benzodiazepine may be providing a protective, anti-convulsant effect. An additional consideration is how to appropriately manage flumazenil-induced seizures should they occur. Benzodiazepines are generally recommended as first-line therapy for acute seizures, but may be a less viable option in the presence of a benzodiazepine receptor antagonist like flumazenil. Theoretically, large doses of benzodiazepines may be able to overcome flumazenil’s competitive inhibition of GABAA receptors. Alternative anti-convulsant agents such as barbiturates or propofol can also be considered.
In 2015, Nguyen et al. conducted a single-center retrospective observational study of flumazenil use in the emergency department from 2007–2013. Adult patients (18–90 years old) with documented administration of flumazenil were included in the study. Twenty-three patients were identified for analysis, half of whom had iatrogenic benzodiazepine toxicity (n=12, 52%). Approximately one third (n=7, 30%) of patients had a co-ingestion with a pro-convulsant agent (i.e. cocaine, bupropion, diphenhydramine, methylenedioxymethamphetamine). One patient had a history of seizures. Following flumazenil administration, the authors found 14 (61.9%) patients had improvement in mental status, one (4.3%) patient required intubation and no patients experienced seizure. However, based on this small patient population and even smaller subset of patients with pro-convulsant co-ingestions, significant conclusions cannot be made regarding the safety of flumazenil in the setting of unknown toxic exposures.3
Dosing, Administration and Monitoring Treatment with flumazenil should be initiated with a small dose and repeated until the desired level of consciousness is achieved or the maximum cumulative dose is reached (Fig. 1). Patients should be placed on a continuous cardiac monitor with continuous pulse oximetry throughout therapy. Flumazenil is not a substitute for airway management. Following administration of flumazenil, monitor patients closely for 4–6 hours for signs of resedation and respiratory depression. If seizures occur, large doses of benzodiazepines may be required. Administration of an intravenous barbiturate can also be considered for seizure management.
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Fig. 1. Flumazenil dosing recommendations1 INDICATION
Reversal of conscious sedation or general anesthesia
Reversal of suspected benzodiazepine overdose
Initial Dose: 0.2 mg IV over 15 secs Repeat Doses: every 60 secs PRN Max Cumulative Dose: 1 mg
PEDIATRICS (>1 year)
Initial Dose: 0.01 mg/kg (max = 0.2 mg) IV over 15 secs Repeat Doses: every 60 secs PRN Max Cumulative Dose: 0.05 mg/kg or 1 mg (whichever is lower)
ADULTS & PEDIATRICS
First Dose: 0.2 mg IV over 30 secs Second Dose: 0.3 mg IV if no response after 30 secs Third Dose: 0.5 mg IV if no response after 60 secs Repeat Doses: 0.5 mg IV every 60 secs Max Cumulative Dose: 3 mg (up to 5 mg if partial response)
Conclusion When benzodiazepine toxicity is suspected, the decision to give flumazenil requires careful consideration of both the indications and contraindications for its use. Per current literature, it appears that the assessment of a possible pro-convulsant co-ingestion is of utmost importance. However, when used in carefully selected patients, flumazenil quickly and effectively reverses the effects of benzodiazepines. ■
Florida Poison Information Network toxicologists are available 24 hours a day at 1-800-222-1222 to assist emergency physicians in the treatment of all toxic exposures, including determination of appropriate flumazenil use for reversal of benzodiazepine toxicity.
References: 1. National Library of Medicine (US). (April 30, 2018). Label: Flumazenil Inj. In DailyMed. Retrieved from: https://dailymed.nlm.nih.gov/ dailymed/drugInfo.cfm?setid=cf39cdaf-8cb74dbb-8672-9cf8e91ac86c 2. Kreshak AA, Cantrell FL, Clark RH, Tomaszewski CA. A poison center’s ten-year experience with flumazenil administration to acutely poisoned adults. The Journal of Emergency Medicine 2012; 43(4):677-682. 3. Nguyen TT, Troendle M, Cumpston K, Rutherford Rose S, Wills BK. Lack of adverse effects from flumazenil administration: an ED observational study. American Journal of Emergency Medicine 2015;33:1677-1679.
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EMPULSE FALL 2018
Giving Back Through Continuing Promise 2018 By Misty Coello, MD, Bridget Pelaez, BSN, RN, EMT-P, Robert Levine, MD & Ruben D. Almaguer, MA Ed, EMT-P
Florida International University’s all-volunteer team, Florida Advanced Surgical Transport Team (FIU-FAST), was invited for the second year in a row to participate in Continuing Promise 2018, a humanitarian medical mission organized by the U.S. Navy and U.S. Southern Command. The 10-day mission took place in Puerto Barrios, a remote city with a population of 120,000 located on the east coast of Guatemala. FIU leadership worked with U.S. Southern Command to coordinate the mission. The team’s deputy commander – an experienced disaster trauma nurse, paramedic and emergency management professional – managed all logistics and operations for the team in addition to performing triage and providing direct patient care once onsite. The rest of our team consisted of three EM physicians, one family medicine (FM) physician, one pediatrician and an EM-bound, fourth-year medical student at FIU. All physicians had prior disaster and humanitarian aid experience. After a commercial flight to Guatemala City followed by a six-hour ground transport, we reached Puerto Barrios and the Naval medical team, comprised of internal and FM physicians, pediatricians, a dermatologist, mid-level providers, surgeons, dentists, optometrists, corpsmen, a nutritionist and a fully-staffed pharmacy. Further support was provided by Team Rubicon, a civilian-based disaster team consisting of physicians, medics, etc., many of whom retired from military service and still dedicate their lives to helping others. The U.S. Navy brought tons of medications and medical supplies, and established a MASH-type facility to perform pre-arranged minor and elective surgeries. FIU-FAST brought life-saving 40
equipment and medications—including an AED, ACLS and critical care supplies—to protect our teams and any patient in need of life-saving interventions. Fortunately, we saw few patients requiring these types of intervention. The main treatment facility was a large gymnasium situated in a fenced-in compound providing restricted ingress and egress. Patients were triaged outside and directed to the appropriate patient examination area inside. These areas were created using screens, tables and chairs. The rest of the gym was divided into sections dedicated to laboratory medicine, vaccinations and—new to this mission—behavioral health. The laboratory provided CBC’s, routine chemistries and a few other tests performed within a few hours. Radiology, optometry, women’s health and a pharmacy were in separate buildings. A significant amount of our services included patient education, ranging from teaching adult patients how to use crutches or a metered dosed spacer inhaler for the first time to having classes on nutrition and food safety. On average, we examined 830 patients per day, some of whom were indigenous, non-Spanish speaking people brought in from remote mountain regions. Though most patients had common problems such as arthritis, gastritis, diabetes and hypertension, we saw patients with parasites, pin-worms and leishmaniasis. Viral illnesses such as Zika, Chikungunya and Dengue are extremely common in this population. At the tent-based surgical suite, Naval surgeons performed approximately 32 surgeries per week. In all, we treated over 5,000 patients ranging from two-week old infants to 98-year-old seniors. Many patients had EMPULSE FALL 2018
not seen a physician in years; others had never been seen. We provided women’s health through our FM physician, which is a real need for the local population. Many women presented with advanced cervical cancer and had never had a pap smear. Some patients presented with complex medical problems. One such patient, with no history of alcohol intake or hepatitis, presented with acute-onset of tense ascites, a caput medusa with normal liver enzymes and a normal liver ultrasound. Patients with serious medical problems were referred to the Ministerio de Salud, a Guatemalan government ministry that arranged referrals to local community hospitals and treatment centers or to Guatemala City. FIU-FAST and U.S. Navy personnel also provided care at Infantil Hospital, the only pediatric/neonatology hospital in the city, and Hogar La Asuncion, a local orphanage. This year we distributed inexpensive glasses to many of our patients. Watching their smiles when they could read or sew for the first time in years made the trip worthwhile. FIU-FAST looks forward to collaborating with U.S. Southern Command in future missions. We’d like to thank the Guatemalan military for their presence and protection, and especially the Mayor of Puerto Barrios and his staff for their assistance and dedication. Last but not least, Continuing Promise 2018 would have not been possible without the support of Herbert Wertheim College of Medicine and the Kimberly Green Latin American and Caribbean Center. ■
To learn more, visit www.fast.fiu.edu
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EMPULSE FALL 2018
MUSINGS FROM A RETIRED EMERGENCY PHYSICIAN
About Medicare for All? By Wayne Barry, MD, FACEP Retired Emergency Physician
I recently stopped working one of my two full-time jobs. After six years, I am no longer seeing patients in the Urgent Care setting. I have to admit that I was somewhat sorry to do this. Urgent Care patients have a generally pleasant nature and a remarkable gratitude for receiving professional and caring medical attention in a stress-free and efficient setting. But I grew tired of getting up early in the morning, driving about 33 miles to either of the two venues in which I practiced, and then staying on-duty for 12 hours. So now I work full-time tending to my hospice patients by visiting them in their homes, preparing numerous reports on their decline, and guiding the efforts of a talented team of healthcare professionals consisting of RNs, LPNs, CNAs, Chaplains and social workers as we all endeavor to make end-of-life for our patients a comfortable, pleasant, dignified, loving, familial and spiritual experience. At the age of 70 and a half, I am encountering unfamiliar milestone consequences. I started collecting Social Security each month and have to manage minimum required distributions from my savings so I do not run out of money before I die. The latter is not so pressing as I continue to work, but someday I’ll lay down my stethoscope for good. My wife of 31 years will turn 65 next January, so I am preparing for us both going onto Medicare as I forsake our coverage currently provided by my Hospice employer. To my surprise, it looks as if our coverage will be better and about the same cost as the more expensive Medicare Supplement coverage (which pays for everything standard Medicare does not cover and without co-pays or prescribed physician panels). As I learn about all of this new Medicare stuff, I find Medicare Part D somewhat intimidating. Most Medicare Plans will cover Medicare-approved medications (generics and such) up to a maximum of about $3,750 per beneficiary per year. Medication costs exceeding this amount are borne by the Medicare recipient until a “ceiling” of $5,000 is reached, after which Medicare resumes covering medications as before. It appears that both my wife’s and my medications are not expensive enough at this time to reach the donut hole. Medicare and Social Security are the two most popular government programs ever created. I do not consider them entitlements because we beneficiaries have paid into them for all of our working lives. Since Medicare seems fairly attractive to me and my wife in comparison to standard
employer-provided insurance, why shouldn’t there be Medicare for all? The U.S. medical care system is currently broken. There is not time nor space to elaborate much on this statement. We are all aware that each American citizen pays more per capita than any other citizen of any other developed country in the world, but our healthcare outcomes are no better and—in some cases, such as infant mortality—worse! One report suggests a 7.5% income-based premium paid by employers, which would save most businesses over $9,000/year for the average employee. A 4% income-based tax paid by households would produce more revenue to fund Medicare. An average family of four earning $50,000/ year would save about $4500/year on health care costs. Tax breaks subsidizing health care would become obsolete and add to the pool of funds available for Medicare costs. The rich should be asked to pay a little more in taxes, which would be earmarked for Medicare support. While as much as a 50% tax bracket for earning greater than $2M/ year may sound daunting to some, in 2014, only 136,000 households earned $2M-$10M while 16,700 households earned more than $10M. Capital gains and dividends would be taxed the same as income. There are some other painless taxes on the rich, which could be used to add to this pool of Medicare funding, which I will not elaborate on here. Critics of “Medicare for All” believe that payments to physicians might be lowered, and perhaps individual physicians’ ability to purchase expensive and sophisticated technology would be limited (although I think hospitals are better positioned to bear the costs of expensive medical technology). This, in turn, might discourage new folks from pursuing a career in medicine because they could no longer dream of acquiring unlimited wealth by becoming a physician. However, I interviewed over 30 prospective candidates for admission to the UCF College of Medicine, and very few of these bright and shining youngsters would set their medical career aspirations aside because they couldn’t become exceptionally wealthy. I am looking forward to some of these brand new doctors taking care of me and my family in the years to come. ■
EMPULSE FALL 2018
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