EMpulse Fall 2019 by Florida College of Emergency Physicians

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

ITâ&#x20AC;&#x2122;S TIME TO

SPEAK UP

EMERGENCY PHYSICIANS NEED TO ACT NOW OR FACE 30-40% CUTS Congress is poised to make a move on balance billing this year. The method they choose will have enormous ramifications, affecting your practice for years to come. Learn more on p. 6

ALSO FEATURING: The 2020 CMS Physician Fee Schedule Proposed Rule

POCUS of the Gallbladder: Always In-Style EMpulse Fall 2019

Symposium by the Sea 2019 Conference Recap Vol. 26, No. 3 | Fall 2019

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EMpulse Fall 2019

Fall 2019 | Volume 26, Issue 3

COMMITTEE REPORTS

FCEP President’s Message

Gov’t Affairs: It's Time to Speak Up

Kristin McCabe-Kline, MD, FACEP, FAAEM, ACHE

Damian Caraballo, MD, FACEP

8 10

ACEP President's Message

Vidor Friedman, MD, FACEP

Medical Economics: The 2020 CMS Physician Fee Schedule Proposed Rule

EMS/Trauma

Pediatric EM

Membership & PD

EMRAF President’s Message

Christine Van Dillen, MD, FACEP Todd Wylie, MD Rene Mack, MD, RDMS, FACEP Matthew Beattie, MD, PGY-3

Medical Student Committee Alexa Peterson

Jordan Celeste, MD, FACEP

MIPS Tips: New Rules for 2019

13 16 24

CLINCON 2019

Daunting Diagnosis

SPONSORED CONTENT

2019 has resulted in several changes for the Meritbased Incentive Payment Systems (MIPS). Groups of 16 or more providers can no longer submit their MIPS quality data via claims. In addition, the Centers for Medicare & Medicaid Services (CMS) is offering a new option for facility-based groups to use their hospital’s Hospital Value-Based Purchasing (HVBP) facility score as the group’s quality and cost score for MIPS. Groups need to understand the nuances involved in these changes before deciding how to proceed in MIPS 2019. Bonus amounts for 2018, announced July 2019, showed a maximum bonus of 1.68% for 2018 MIPS providers/groups. However, with the 2019 change to claims reporting and the lure of using a facility score, many suspect that there will be fewer exceptional performers in 2019. Therefore, a greater opportunity may be created for those that perform and report exceptionally well in 2019 and aim for exceptional performer status. Groups should understand in CMS’s new mandate that only small groups or individual providers that are members of small groups may submit via claims. Groups should take caution when determining if your group is a “small group.” It is best to not rely on your

own count of providers but rather look up the number of affiliated providers via CMS lookup site. It is important to note that you may have had a few providers added or deleted in 2018/2019. You will need to account for each of those. Groups/providers should understand the difference between a QR and QCDR and the registry options available. 2019 is a strategic performance year for many groups due to the perceived potential of higher bonus percentages, along with the change to claims reporting and the new facility-based scoring option. In addition, 2020 will see more MIPS changes. CMS has stated that they understand the need for the 2020 bonus potential to improve beyond the virtual plateau bonuses reached in the last two years. Our team at Gottlieb continues to monitor regulatory changes that impact our clients. Be on the lookout for further communications or feel free to contact us directly for a quick update. We will be attending ACEP19 in October. If you have questions about MIPS or about improving your revenue results, stop by and visit us at Booth 1625!

www.gottlieb.com 4932 Sunbeam Road, Jacksonville, FL 32257 800.833.9986 EMpulse Fall 2019

COMMITTEE REPORTS

EMS/Trauma & FAEMSMD Update By Christine Van Dillen, MD, FACEP EMS/Trauma Committee Member

School is back in session and so is football! Exciting news to fans, but a significant strain on local EMS and law enforcement. When a mass gathering of this magnitude occurs, there is potential for one of these events to escalate into a catastrophic event causing multiple casualties. Public safety officials can use these mass gathering events as an opportunity to trial collaborations between EMS, law enforcement officials, fire and public works. Solid communication plans with each agency are of utmost importance. These plans should include redundancy as well as mutual aid agreements. Most of these events have alternative medical treatment sites in place to attempt to unload some of the burden off the system. In addition, it is important to consider evacuation plans for crowds of this size in the unfortunate event of an attack of any kind. Planning has traditionally been based on patient populations evaluated and treated at prior similar events. Unfortunately, there are challenges with emergency response planning due to variables such as venues, types of events, weather, etc. Consequently, there is a lack of standardization amongst all events and little evidence on how to efficiently manage resources at mass gathering events.

NEXT MEETING:

November 11, 2019 9:00-10:00 am EMLRC in Orlando, FL

CALL FOR UPDATES:

Hurricane Dorian hit the Bahamas as a Category 5 on Sept. 1, 2019, leaving 50 dead and hundreds still missing. Did you respond to relief efforts? Let us know at sleague@emlrc.org. 12

Florida Association of EMS Medical Directors (FAEMSMD) Update EMS State Medical Director Dr. Kenneth Scheppke reviewed the results of the FAEMSMD member survey:

• Annual Dataset: 52 respondents • # of Ground Agencies: 149 • # of Air Agencies: 15 • # of Personnel: 24.5K • Population Served: 16.5M, which represents 77% of Florida’s population • Conclusion: We collectively set the standard of care for EMS in Florida

State Strategic Plan Medical Care Subcommittee Updates Cardiac Arrest Update: • Dispatcher CPR survey will be sent out • Listen to calls and monitor 911 to compression is recommended • 2019 Cares Update • 43 active EMS agencies • 167 (60.6%) partnering hospitals • 375 agency/hospital links • 267 first responders • 2019 YTD CARES cases analyzed: 1,961 • Since inception: 4,081 cases • Florida coverage of 7.5 million people • The inception of resuscitation

centers is a statewide initiative STEMI Update: • Adopting Mission Lifeline Metrics • STEMI will be added to Biospatial • Measurement patient arrival to EKG is recommended • EKG is rate limiting step; training recommended • Pit Crew Method: Assign arrival to 12 lead duty each shift Stroke Update: • Florida Stroke Registry: Stroke equivalent of CARES Registry • Stroke centers are required to submit data • In a recent review of South Florida, data was presented noting that bypassing primary stroke centers increased rates of IV tPA treatment, decreased time from 911 to IV tPA, increased rates of endovascular therapy (EVT) and decreased time from 911 to EVT by 112 minutes. • Dispatcher Stroke Recognition: EMD (Need QA) • Stroke Alert Checklist was recently updated ■

NEXT FAEMSMD MEETING: October 23, 2019 9:00-2:00 pm Golf World Resort St. Augustine, FL

PODCAST: STAYING HEALTHY IN THE SUMMER HEAT By Gary Goodman, MD, FACEP

Attending Physician at Central Florida Regional Hospital & Heathrow ER | Assistant Professor of Emergency Medicine at UCF COM Summer may be ending, but high temperatures exist yearlong in Florida. Brush up on heat-related fundamentals with Dr. Goodman on HCA's "Helmet of Health" podcast at bit.ly/drGpodcast. EMpulse Fall 2019

CLINCON 2019

Florida's Premier EMS/Fire Conference & Bill Shearer ALS/BLS Competition JULY 17-19, 2019 AT THE DOUBLETREE BY HILTON-UNIVERSAL IN ORLANDO, FL

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REQUEST FOR PRESENTATIONS APPLICATIONS DUE OCTOBER 31, 2019 EMpulse Fall 2019

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COMMITTEE REPORTS

Pediatric EM By Todd Wylie, MD

Pediatric EM Committee Co-Chair

Education Another great Symposium by the Sea has come and gone. Members of FCEP’s Pediatric EM committee were present and hosted the annual Pediatric Track: a 3-hour workshop of didactic lectures, small group sessions and interactive, high-fidelity simulation scenarios. This year’s Pediatric Track focused on pediatric trauma and included lectures from Drs. Tricia Swan (Pediatric Trauma Tidbits) and Cristina Zeretzke (NonAccidental Trauma). Other committee members, including Drs. Shiva Kalidindi, Vanessa Perez, Corrine Bria, John Misdary and Todd Wylie, administered the small group sessions and high-fidelity simulation stations. We had an excellent turnout and attendees were enthusiastic and engaged. Many thanks to Dr. Shiva Kalidindi for leading the effort and to Melissa Keahey and the rest of the EMLRC staff for making everything come together so well.

The committee’s next order of business involves developing an ongoing Advanced Pediatric Life Support (APLS) course. The inaugural class is scheduled for November 5-6 at Nemours Children’s Hospital in Orlando, FL. Emergency medicine residents will be attending the first course, but subsequent courses are targeted to include paramedics and other healthcare providers in addition to resident physicians. The goal is to develop a series of APLS courses scheduled throughout the year and provided in different regions of the state. All interested in participating—either as attendees or instructors—are encouraged to contact the FCEP Pediatric Emergency Medicine committee at peds@fcep.org.

Florida News News from the Florida Legislature: House Bill 7099 (CS/HB 7099: Child Welfare) was passed by the Florida Senate and approved by

the Governor earlier this summer. The bill makes a number of changes to Florida child welfare laws and provides new requirements regarding the Department of Children and Families (DCF) response when a report is received from a health care facility or an emergency department physician. First, if a child is being evaluated for suspected abuse in a medical facility within the state of Florida, the central abuse hotline “shall accept the report or call for investigation” even if the instance of suspected abuse occurred outside the state of Florida. Second, DCF “shall initiate an investigation when it receives a report” specifically from an emergency department physician. Hopefully the new requirements will streamline the reporting process for emergency medicine physicians and provide more effective patient care. ■

EMERGENCY MEDICINE

REIMBURSEMENT & INNOVATION SUMMIT 2020

February 27-28, 2020 in Orlando, FL Approved for AMA PRA Category 1 Credits™

EMpulse Fall 2019

Stay tuned at: emlrc.org/emsummit

COMMITTEE REPORTS

Membership & Professional Development By René Mack, MD, RDMS, FACEP MPD Committee Co-Chair

Writing for this issue reminds me of the transitions that are taking place this time of the year: summer has ended, Symposium by the Sea (SBS) has passed, and learning/working environments have changed for some. This typically results in much appreciated growth, but the process can include difficult milestones along the way. How can we help each other make these transitions more comfortable and better recognize when we or fellow physicians need additional support? In terms of exciting events, I’ll start with a brief update on SBS 2019. Short story: great success! The feedback received during the weekend as well as the conversations since have all reiterated the high degree of enjoyment experienced from the various educational, networking and social events. If you were not able to attend, please check out the pictures on the next few pages or at emlrc. pixieset.com to get a glimpse of our annual conference. Don’t miss out on SBS 2020, August 6-9 in Clearwater Beach. As you know, Florida has 18 ACGMEaccredited emergency medicine residency programs, several of which are within the first five years of accreditation. Considering the steady rotation of medical students, interns and graduating residents, this can be

a time of uncertainty and discomfort for everyone involved in residency programs, and especially the incoming interns. Here are some tips I have learned over the years that I hope will be helpful. New residents and medical students: give yourself time and space to become accustomed to the varying schedules and working environments. Making time for appropriate sleep and eating is incredibly important. There will be many (seemingly uncontrollable) events and activities vying for your attention. Developing a system of keeping yourself organized and on task will make this transition much more manageable. This is likely your first experience with this type of rotating schedule. Ask for advice from your colleagues and program leaders—they are there to help you. One of your best resources will also be emra.org, which has information specifically for you and is divided into categories for easy searching. Recent graduates are now “attendings,” and this change in position and responsibility is exciting, as well as daunting and stressful. Although you have graduated from your residency programs, your program leaders are still a large part of your support system and will gladly help you with the various transitions. For this stage

in your career, the ACEP Young Physicians Section (YPS) is the best place for you. Here you will find a group of early career EM physicians who know exactly what you are going through along with a treasure trove of helpful information. Pro tip: the YPS section is included in your 'first year out of residency' ACEP membership. Luckily in Florida, we have arranged a special graduated membership rate, so now is the best time to renew your ACEP/FCEP membership! And don't forget to subscribe to online discussions with national members via ACEP engagED. Do you have recent graduates working in your group? Mentoring young doctors is a rite of passage that we all should undertake with great care. This mentoring process usually leads to an important symbiotic relationship when fostered. The young doctor has been practicing the most current evidence-based medicine and is happy to share the knowledge. As the more experienced doctor, you can lend your well-curated expertise of working in the “real world,” which can be quite different than the academic learning environment. What are some of your tips for successful transitions? I hope to see you at our next committee meeting. Until then, continue to care for yourself and each other. ■

HUMAN TRAFFICKING & EMERGENCY MEDICINE Meets new HB 851 requirement Approved for AMA PRA Category 1 Credits™ EMpulse Fall 2019

emlrconline.org 15

201 9

by the August 1-4, 2019 Boca Raton Resort & Club Boca Raton, FL By Samantha League, MA

Managing/Design Editor | Communications Manager

August 1, 2019: THE BOARD MEETING Photos by Greg Hunter

Scan for more photos or visit emlrc.pixieset.com

11) Dr. Kristin McCabe-Kline was installed as FCEP President.

22) The Board gave outgoing president

Dr. Adrian Tyndall a warm farewell by creating "Flat Adrian" faces they can take with them anywhere.

33) Dr. Damian Caraballo received the

Martin Gottlieb Advocacy Award.

44) Dr. Vidor Friedman received the

William Haeck Member of the Year Award.

55) Dr. Rajiv Bahl graduated from FCEPâ&#x20AC;&#x2122;s Leadership Academy.

66) FCEP hosted a reception for Rep. Paul Renner immediately after the Board meeting.

77) FCEP Past-Presidents at Dr.

6 16

7 EMpulse Fall 2019

McCabe's Incoming President's Reception, hosted by Dr. Charles Duva.

August 2-4, 2019: FLORIDA EM RESIDENCY COMPETITIONS 8th Annual

1ST PLACE: Florida Atlantic University (pictured) 2ND PLACE: Kendall Regional Medical Center

12th Annual

BEST OVERALL: Jackson Memorial Hospital BEST PRESENTER: Dr. Chandelle Raza Mount Sinai Medical Center BEST DISCUSSANT: Dr. Dennis Durso Jackson Memorial Hospital 1st Ever!

1ST PLACE & BEST COSTUME:

North Florida Regional

2ND PLACE & BEST TEAM NAME:

Kendall Regional Medical Center (the "Three Blind Mice") EMpulse Fall 2019

3RD PLACE:

Orlando Health 17

Cost-benefit analysis of dispensing antibiotics at emergency department discharge to uninsured patients:

RESEARCH POSTER ABSTRACT COMPETITION WINNERS:

Best Fellow Abstract:

Eye See What You Did There: a sickle cell patient with acute eye swelling: Ara Jamasbi, MD,19 Thomas Ruffin Jr., MD19

Best Resident Abstract:

End Tidal Carbon Dioxide Measured Prospectively at Ed Triage Performs Better Than Standard Triage Vital Signs in Predicting In-Hospital Mortality and ICU Admission:

Kirsten Kepple, MD,20 Cole Feffer, MD,20 Stacie Miller, MD,20 Christopher Hunter, MD, FACEP,20 Linda Papa, MD,19,20 Jay Ladde, MD19,20

Best Case Report:

Successful Management of Severe Adolescent Bupropion Overdose with Intravenous Lipid Emulsion Therapy: Carly

Muller, BS,9,25 Kasha Bornstein, MSc, Pharm, EMT-P,9,25 Timothy Montrief, MD, MPH,9,25 Mehruba Anwar Parris, MD9,25

Best Med Student Abstract: Aeromedical Rapid Sequence Intubation Using the King Vision Video™ Laryngoscope:

Linh Nguyen, BS, MS,7 Kirsten Kepple, MD,20 Karen Thurmond, RN,19,20 Greg Maples, EMT-P,19,20 Linda Papa, MD,19,20 Christopher Hunter, MD, PhD20

FELLOW ENTRIES:

Emergency Medicine Bound Student Preferences during Residency Ranking: Alexandra Mannix, MD,24 Nandini Verma, MD,24 Tom Morrissey, MD, PhD,24 David Caro, MD24

Uncommon Emergent Complications of a Common Pediatric Diagnosis: Thomas Ruffin Jr., MD,19 Carolyn Lyon, MD19

Photo by Kasha Bornstein 18

RESIDENT ENTRIES:

Adequacy of Healthcare by Insurance Type in Traumatic Brain Injury Patients: Juan

Santiago, MS,5 Drew Smith, MS,5 Dr. Noël C. Barengo,5 Grettel Castro,5 Pura Rodriguez de la Vega5

Adverse Childhood Experiences and Asthma Exacerbation Severity: Is there a relationship?:

Courtney Hibbs, MD,23 Avni Bhatt, PhD,23 Cristina ZeretzkeBien, MD23

Analyzing Patients Admitted from the Emergency Department Requiring Transfer to the Intensive Care Unit Within 24 Hours: Josh Koplon, MD,20 Justin Kittredge, MD, MSc,20 Dallas Joiner, MD,20 Josef Thundiyil, MD, MPH,19,20 Jay Ladde, MD,19,20 Linda Papa, MD19,20 Christopher Hunter, MD, PhD,20 George Ralls, MD20

Association Between Red Blood Cell Transfusion and Mortality in Patients with Trauma by Age: Brian

Guetschow MD, MSc, PGY-3,20 Susan Miller, MD,20 Linda Papa, MD19,20

The Association of Chest Pain Historical Factors with Adverse Cardiac Events:

Jessica Wire, MD, Tony Zitek, MD,11,16,26 Elizabeth Chen, MD,13,26 Armando Gonzalez-Ibarra28 11

Comparison of Resident Productivity from 2007 to 2018 Within an Emergency Medicine Residency Training Program: Mitchell Barneck,

MD,20 Alicia Evans, MD,20 Daniel Brennan, MD,20 Josef Thundiyil, MD20

Correlation of End Tidal Carbon Dioxide with Transcutaneous Carbon Dioxide in ED Patients:

Mitchell Barneck, MD,20 Linda Papa, MD,19,20 Ashley Cozart,22 Kain Lentine,22 Jay Ladde, MD,19,20 Linh Nguyen,7 Jeremy Mayfield,22 Josef Thundiyil, MD19,20

Ahmad Mohammadieh, MD,18 Travis Neighbor, DO,18 Naganna Channaveeraiah, MD,32 Steven Goodfriend, MD,18 Steve Warrington, MD, M.Ed.18

Differences in Serum Biomarkers in Youth After Concussion: Laura Cook,

MD,19 Linda Papa, MD,19,20 Jose Ramirez, MD,19 Alec Garfunkel, BS,19 Joseph Thundiyil, MD,19,20 Jay Ladde, MD,19,20 Manoj Mittal, MD,19 Mark Zonfrillo, MD19

Does a Change in End-tidal Carbon Dioxide Level Predict High Altitude Mountain Sickness?: Margaret Stutsman, MD,20 Jay Ladde, MD,19,20 Josef Thundiyil, MD,19,20 Ian Little, MD,20 Linda Papa, MD19,20

Does a Curricular Innovation Designed to Highlight “Great Saves” Improve Resident Wellness?: Bryce Bergeron,

MD,20 Josef Thundiyil, MD,20 Jay Ladde, MD,20 Olivia Munizza, MD,20 Innocent Akujuobi, MD,20 Tory Weatherford, MD20

Does an Educational Interactive Airway Lab Change Residents Choice of Airway and Comfort Level?: Keegan Mullins, MD, PGY-220

Educational Impact of Interactive Snake Envenomation Session on Learning and Retention in Emergency Medicine Residents: Kirsten Kepple, MD, MS,20 Erich Heine, DO,20 Alex Williams, MD,20 Josef Thundiyil, MD, MPH19,20

Effect of Prescription Drug Monitoring Program Databases on Opiate Prescribing at a Large County Safety-Net Hospital Emergency Department: Kasha

Bornstein, MSc,9,25 Mark Supino, MD,25 Patricia De Melo Panakos, MD,25 Christopher Freeman, MD9,25

The Effects of Controlled Substance Prescribing Legislation on Emergency Department Prescribing Practices: Joshua Briscoe,

MD,20 Anna Menis, MS, CPHIMS,20 Linda Papa, MD,19,20 Tom Maroney, MBA, PhD,20 Danielle DiCesare, MD,20 Margaret Stutsman, MD20

EMpulse Fall 2019

Emergency Department Patient Satisfaction and Experience Scores from a Questionnaire distributed by Press Ganey Versus Onsite at Discharge – A Comparison of Two Sampling Methods:

Tucker Maute, DO,20 Jesus Roa, MD,20 Johnathan Kennedy, MD,20 Linda Papa, MD19,20

End Tidal Carbon Dioxide (Etco2) Predicts Early Mortality After Trauma and is Associated with Injury Severity Along a Spectrum of Ages: Gustavo R. Rey, MD,20

Jessica Walsh O’Sullivan, MS,22 James Lee, MS,22 Will Fraser, MS,22 Linda Papa, MD,19,20 Jay Ladde, MD19,20

Exhaled End Tidal Carbon Dioxide Measured NonInvasively by Capnography at Triage is Associated with qSOFA Scores in Patients Presenting to a Tertiary Care Emergency Department: George Gulenay, MD,20 Linda Papa, MD,19,20 Jay Ladde, MD19,20

The Expected D-dimer Values During Each Trimester of Pregnancy: Andrew Napier, MD,11 Colin Hagen, MD,11 Tony Zitek, MD11

The Impact of Quality Initiatives on Resident Productivity and Satisfaction in the Emergency Department: Katie Pearson, MD,20 Tyler Randall, MD,20 Brandon Herb, MD,20 J Thundiyil, MD,20 D Brennan, MD20 J Ladde, MD20 C Hunter, MD, PhD20

Rapidly Expanding Hematoma After Facelift – A Terrible Complication of a Seemingly Benign Procedure: A Case Presentation and Literature Review: Amy Souers, MD,20 Christopher Hunter, MD, PhD20

Renal Infarction-An Elusive Diagnosis: Zachary Gimbel, MD14

Safety and Efficacy of Prehospital Diltiazem for Atrial Fibrillation with Rapid Ventricular Response:

Caitlin Premuroso, MD,20 Alexa Rodriguez, MD,20 Stacie Miller, MD,20 George Ralls, MD,20 Linda Papa, MD, MSc,19,20 Christopher Hunter, MD, PhD20

Squamous Cells of Unknown Significance: John Atiyeh,

MD,2 Kurt Weber, MD,20 Philip Giordano, MD,20 Valerie Danesh, PhD,20 John Cheesebrew, MD,20 Brian Johnson, MD20

Systematic Review of Randomized Controlled Trials Evaluating Patient Controlled Analgesia for the Management of Acute Pain in the Emergency Department: Mark

Availability of Emergency Contraception Options in the Emergency Department: A National Survey: Colleen

Interim Evaluation of CARA 2016 on Medication Assisted Treatment for Opioid Use Disorder: Jordan Zeldin,23

Case study of an acute HCV infection in PWID:

Introducing Point-ofCare Ultrasound to Medical Students with a Gastrointestinal Workshop:

Changing a culture: Preventing acute heart failure readmissions: Jonathan

Medical Student Ultrasound Interest Group: The Musculoskeletal Workshop:

The Cost of Firearm Related Injuries on Florida: J.

Medical Student Ultrasound Interest Group: The Pulmonary

Mitchell Barneck, MD,20 Linda Papa, MD,19,20 Ashley Cozart,22 Kain Lentine,22 Jay Ladde, MD,19,20 Linh Nguyen,7 Jeremy Mayfield,22 Josef Thundiyil, MD19,20

Descriptive Analysis of Scooter Related Injuries Since Initiation of a Shared Scooter Program: Sri Harsha Palakurty,

Medical Student Ultrasound Interest Group: Year in Review: Leah Colucci, BS,

STUDENT ENTRIES:

Differences in Prevalence of HIV and HCV Stratified by Emergency Department Utilization: Eliza Nguyen,30

Bender, MD,20 Ivan Samcam, MD,20 Linda Papa, MD19,20

Trends in Individualized Interactive Instruction Utilization and Correlation to In-training Examination: Erich Heine, DO,20 Anne Shaughnessy, MD,20 David Bailey, MD,20 Michael Clemmons, MD,20 Greg Black, MD,20 Josef Thundiyil, MD,19,20 Jay Ladde, MD19,20

The Utility of Transcutaneous Carbon Dioxide and Oxygen Measurements to Predict Severity of Illness in the ED:

A Low Risk Chest Pain Pathway utilizing Coronary CT Angiogram in a Type 4 Observation Emergency Department Observation Unit: Paul Francois,12 Louis Leon,30 Jason Wilson21,31

An Evaluation of Disparities Affecting Time from Emergency Department Door to Electrocardiogram in Patients with Chest Pain:

C. Wyatt, MS,6 L.A. Boge, DO,14 D.R. Sherman, DNP,6 M. Cecilia, DO,14 L.X. Cubeddu MD, PhD,17 E. Escolar, MD,14 R.C. Goldszer, MD, MBA,14 D.A. Farcy, MD14

An Overview of Emergency Medical Protocol and Challenges Faced by Emergency Medical Services in the Republic of Artsakh:

Dickran Nalbandian, MS,5 Molly Hulbert,5 Kent Garber, MD, MPH,10,27 Shant Shekherdimian, MD, MPH27

Analysis of Downstream Treatment and Outcome Patterns from an ED Based HCV Screening Program: Heather Henderson,21,31 Oluwatobi Ozoya,31 Brandi Travis,21,31 Jason Wilson21,31

Associations Between Episodes of Hypotension and/or Hypoglycemia in Older Diabetic Patients and 30-Day Return to Hospital:

Michael Simoes, MS,4 Gabriella Engstrom, PhD,4 Bernardo Reyes, MD,4 Joseph Ouslander, MD4

Cowdery,23 Diana Halloran,23 Muhammad Abdul Baker Chowdhury, MPH,23 MarieCarmelle Elie, MD23

Brandi Travis,21,31 Heather Henderson,21,31 Jason Wilson21,31

Littell,30 Jason Wilson,21,31 Thomas Bloom21

Johnson,17 L. Owen,17 C. Serna,17 N. Cook,17 D. Cohen17

BS,30 Vincent Van Berkum, BS,31 Jason Wilson, MD31

Sri Harsha Palakurty,30 Heather Henderson,31 Geetha Sanmagulingham,31 Oluwatobi Ozoya,31 Jason Wilson, MD31

Henry Young, MD,23 Mohammad Abdul Baker Chowdhury23

Sophia Raia, BS,25 Leah Colucci, BS,25 Leila Posaw, MD9

Grant Barker, BS,25 Leila Posaw, MD, MPH,9 Robert Irwin, MD25

Workshop: Yuval Peleg, BA,25 Erik Anderson, BA,25 Leila PoSaw, MD, MPH9

CNC,9,25 Grant Barker, MD,9,25 Leila Posaw, MD, MPH9,25

Palliative Care Practices among Emergency Providers: Nabeel Mirza,23 Matthew Shaw,23 Rebecca Murray,23 Charles Hwang, MD,23 Phyllis Hendry, MD,23 Marie-Carmelle Elie, MD23

Evaluation of the Prehospital STEMI Pathway at Tampa General Hospital: A Quality Improvement Project: Lauren

Qualitative Analysis of Use of Chest Ultrasound in Detecting Pulmonary Edema in Pediatric Submersion Patients: Linh Nguyen, BA,

Four-Factor Prothrombin Complex Concentrate in Factor Xa Inhibitor-related Intracranial Hemorrhage:

Spontaneous Atraumatic Bilateral Renal Hematomas:

Allen, BS,30 Jason Wilson, MD,21,31 Kristina Ledbetter, BS30

Patricia Sanchez,31 Nathan Goad,31 Melissa Levesque,31 David Rose,31 Jason Wilson,31 Karl Kasischke,31 Swetha Renati31

Gap Analysis of Policy and Guidelines on Management and Treatment of Sexual Assault Victims presenting to Tampa General Hospital Emergency Department: Alexa Wynn,31 Darbi Cox, MD,31 Jason Wilson, MD31

Iatrogenic Air Embolism via Power Injector during Contrast Enhanced Computed Tomography Angiography: Justin Rafael De la Fuente, MS3,9,25 Timothy Montrief, MD, MPH,9,25 Jeffrey Scott, DO9,25

MS,7 Ara Jamasbi, MD,19 Tory Weatherford, MD,20 Jillian Davison, MD,19,20 Steven Ritchey, MD,19,20 Beulah Castor, MD19,20

Jazlyn Merida,9,25 Matthew Kwon, MD,9,25 Tyler Ericson,9,25 Jennifer Jackson, MD9,25

Survey of Knowledge, Attitudes and Barriers to Point-of-Care Ultrasound Utilization during Cardiac Arrest in three South Florida Academic Centers: Mallika

Singh, BS,25 Brooke Hensley, MD,9 Jennifer Jackson, MD,8 Mark Newberry, DO,14 Cameron Riopelle MS, PhD,25 Vu Huy Tran, MD,1 Leila Posaw, MD, MPH9

Trauma activations at provisional level II trauma centers during their inaugural year: Corban Caldwell, MS,3 Steven Warrington, MD, M.Ed,18 Kevin Wombacher, PhD,18 Jeffrey Levine, MD,15 Ahmad Mohammadieh, MD,18 Erik Barquist, MD2

EMpulse Fall 2019

Transitions of Care in ED Concussion Patients: Creating a best practices approach to concussion management in partnership with an outpatient clinic: Jay Gopal,30 Megan Tyler,21 Kristina Ledbetter,21 Ian Graulitch,29 Byron Moran,29 Jason Wilson31 Author Affiliations: 1. Aventura Hospital 2. Central Florida Regional Hospital, Acute Care/Trauma Surgery 3. Edward Via College of Osteopathic Medicine 4. FAU Charles E. Schmidt COM 5. FIU Herbert Wertheim COM 6. FIU Nicole Wertheim College of Nursing & Health Sciences 7. FSU COM 8. Holy Cross Hospital 9. Jackson Memorial Hospital, Dept. of Emergency Medicine 10. Johns Hopkins Bloomberg School of Public Health, Dept. of International Health 11. Kendall Regional Medical Center 12. Meharry Medical College 13. Mike O'Callaghan Federal Medical Center at Nellis Air Force Base 14. Mount Sinai Medical Center, Dept. of Emergency Medicine 15. North Suburban Medical Center, Acute Care/Trauma Surgery 16. NSU Dr. Kiran C. Patel College of Allopathic Medicine 17. NSU Dr. Kiran C. Patel College of Osteopathic Medicine 18. Orange Park Medical Center, Emergency Medicine Residency Program 19. Orlando Health, Arnold Palmer Hospital for Children 20. Orlando Health, Orlando Regional Medical Center, Dept. of Emergency Medicine 21. Tampa General Hospital, Division of Emergency Medicine, Dept. of Internal Medicine 22. UCF COM 23. UF Gainesville COM, Dept. of Emergency Medicine 24. UF Jacksonville COM 25. UM Miller School of Medicine 26. Univ. Medical Center of Southern Nevada, Las Vegas 27. Univ. of California, Los Angeles, Dept. of General Surgery 28. Univ. of Nevada, Las Vegas School of Medicine 29. USF Concussion Center 30. USF Morsani COM 31. USF Morsani COM, Division of Emergency Medicine, Dept. of Internal Medicine 32. Veterans Affairs NebraskaWestern Iowa Health Care System-Omaha Scan or visit emlrc.org/abstracts19 to read all abstracts 19

CASINO NIGHT

Hosted by Duva-Sawko and EMPros | All Casino Night photos by Greg Hunter

EMpulse Fall 2019

Thank You Sponsors PLATINUM

by the

2020

SAVE THE DATE: August 6-9, 2020 Wyndham Grand Clearwater Beach Clearwater, FL

REQUEST FOR PRESENTATIONS Deadline: November 1, 2019 LEARN MORE:

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COMMITTEE REPORTS

EMRAF President’s Message By Matthew Beattie, MD, PGY-3 EMRAF President

I want to welcome everyone to a new academic year, and we are excited to welcome a brand new class of residents. I’m thrilled to take over this year as EMRAF president, and I want to thank Misty for the work that she did last year. I’m grateful that she is maintaining her involvement and I want to encourage you to join us. We have 18 residency programs in Florida. That gives us the potential to be one of the most influential state chapters of EMRA, but we need you to get involved. I want to encourage you to think about what most interests you in emergency medicine, and

I want you to incorporate that into leadership within our state chapter. In an effort to make it easier for you, we have developed regional sections since Florida is so spread out. Also, we have developed committees in areas such as EMS and pediatrics. However, the key element of developing an effective organization is the participation of its members. The following are some of the benefits you will experience by getting involved:

• Work face to face with the leading

• Obtain a leadership position and

work on projects that will advance your career and make you a more competitive job applicant

• Attend fun conferences and develop new friendships

If you have an idea that you would like to propose or if you desire to get involved, please email me at mbeattie221@gmail.com. You can expect more frequent communication on upcoming meetings, conferences and leadership opportunities. ■

voices in emergency medicine on the state and national level

Outgoing President’s Message By Misty Coello, MD, PGY-2

Immediate Past EMRAF President It’s hard to believe a year has gone by! First of all, I want to thank everyone for their incredible support and giving me the opportunity to serve as your EMRAF president. It has truly been an honor. As an incoming intern, I had big dreams and goals for our EMRAF committee. I am enthralled to pass over the leadership to a great colleague, Dr. Matthew Beattie, who I know will continue with the vision and expansion of EMRAF. Dr. Matthew Beattie is a senior resident at USF and has been an active member of EMRAF during my tenure. I look forward to help him achieve the growth and development that is coming over to EMRAF. This year, during our most recent meeting that took place at Symposium by the Sea, I was pleased to announce our expansion of

EMRAF. The executive board has been expanded and subdivided into geographical regions North, Central, West and South. Those interested in applying or learning more can refer to the "call for council members" announcement on page 27. These positions serve the purpose to unite our residencies by regions and do not replace the roles of the EMRAF representatives. As we grow in numbers of residencies and members, this type of expansion allows us to identify local needs and empower each one of you in the field of emergency medicine. Last but not least, a special thank you for all of those who made possible the creation, and those who participated in this year’s new resident competition, SonoRace. ■

EMpulse Fall 2019

EMRAF Advisor and FCEP Board member Dr. Jesse Glueck recognizes Dr. Misty Coello’s contributions as EMRAF President 2018-19 at Symposium by the Sea’s EMRAF committee meeting. 23

SOUTH FLORIDA EM RESIDENCY PROGRAM UPDATES

Aventura Hospital & Medical Center By Scarlet Benson, MD

Mount Sinai Medical Center By Dr. Stephanie Fernandez, PGY-2 The 2019-20 academic year is off to a great start at Mount Sinai Medical Center. We are delighted to see our new interns approaching the ED with enthusiasm and are proud of the progress they have made over the past few months. Senior residents have transitioned into their leadership roles seamlessly and continue to grow as lecturers and mentors.

Since the summer, our residents have participated in many scholarly activities. Drs. Zachary Gimbel and Chandelle Raza competed in Symposium by the Sea’s Case Presentation Case Competition (CPC), and Dr. Raza took home the title of Best Resident Presenter. Our residents also led educational workshops for medical students, such as the Advanced Airway course at NOVA and the Student Wilderness Medicine Day at Sinai. On the horizon, Drs. Elizabeth Rubin and Zachary Gimbel will compete in the 20 in 6 and Drop the Mic competitions at ACEP2020 in Denver, respectively. We also have a team competing in the EMRA MedWar at ACEP2020. The team includes Drs. Hannah Gordon, Jiodany Perez and myself. In September, Sinai had strong representation at the AAEM MEMC international Conference in Croatia, where Drs. Natasha Brown and Mauricio Baca competed in the Oral Abstract competition. Our core faculty, Drs. Laurie Boge, Mark Newberry and Paul Petersen presented academic lectures.

Assistant Clinical Professor This summer was busy with intern orientation. We had a large number of EM and non-EM faculty step up to teach and lead hands-on procedural sessions, including a suture workshop, dedicated intern simulation day and two full days of ultrasound training. The Aventura emergency department was also able to purchase four new, beautiful Sonosite machines dedicated solely to the ED residency program. Resident Dr. Jenny Reyes published an article on human trafficking for Pulse, the newsletter for ACOEP in July. We would also like to congratulate resident Drs. Fred Chu and Nicholas Ulloa for being elected as our emergency medicine AHMC House Council Representatives for the 2019-20 academic year. The EM residents represented us in the annual SimWARS competition at Symposium by the Sea on August 2. The team, coached by Simulation Director Dr. Jessica Cook, consisted of team leader Dr. Fred Chu, PGY-3 and Drs. Katharine Peterson, PGY3, Andrew Morris, PGY-2 and Eva Ryder, PGY-2. The team won their

Our senior residents enjoyed the Life After Residency Retreat at the end of September. In fact, they won first place in the inaugural EMRA Quiz Show: Florida Style! They are pictured above with our program director Dr. Todd Slesinger, who happened to be co-hosting the game as "Dr. Lord Snow." The knowledge gained will help them prepare for job and fellowship searching. Finally, Research Director Dr. Erin Marra presented on recognizing human trafficking in the ED at the Mediterranean Emergency Medicine Congress in Dubrovnik, Croatia in September. Dr Annalee Baker, CDEM, authored an EB Medicine article for publication in September, entitled “Nonconvulsive Status Epilepticus: Overlooked and Undertreated.” ■

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Florida PEDReady PE2ARL a weekly newsbrief dedicated to pediatric emergency education Subscribe, view past issues and learn more » Are you a pediatric champion? Contact pedready@jax.ufl.edu for resources & to get involved with Florida PEDReady.

We look forward to what the rest of the year brings! ■

case in the first round of the competition.

EMpulse Fall 2019

SOUTH FLORIDA EM RESIDENCY PROGRAMS

Kendall Regional Medical Center By Dr. Ramsey Ataya, PGY-3

It has been an exciting and busy start to the new academic year, from attending comprehensive ultrasound and trauma courses to engaging in a two-day airway management simulation course. The Kendall family continues to grow as well: we invite you to join us in celebrating the birth of Fayette Jackson, daughter of Dr. Tyson Jackson, PGY-1. We are happy to announce that Drs. Rovira and Stein will be joining us

as core faculty. We look forward to working with both of them as we expand our interactive academic curriculum. Different mediums of simulation and asynchronous learning are being included at each conference and morning report.

SimWARS team is now preparing to compete at the national ACEP conference this October.

We would like to congratulate our residents on their strong showing at Symposium by the Sea. They earned 2nd place in both SimWARS and SonoRace against eight other programs! Special thanks to Drs. Antoinette Golden, Moises Moreno, Jesus Seda, Isabel Brea, Emilio Volz and Nicole Aviles, who worked tirelessly to prepare for this event. Our

We continue to expand our PGY-3 special tracks. Our international medicine track is gearing up to support communities in Panama and Costa Rica. The EMS track is coordinating MDFR Air Rescue ride-alongs and tactical medicine shifts with the Hallandale Police Department. Finally, our ultrasound team continues to train the department in US-guided nerve blocks as we seek to decrease opioid utilization for improved clinical outcomes in trauma patients. ■

surgeon Dr. Lawrence Lottenberg to discuss pelvic trauma in the ED. In harmony with our monthly wellness events, this past month, the program joined together at Game of Axes–Ax Throwing Bar. Thankfully no one sustained any injuries chucking axes into wooden boards, but if one had, he would arguably be in the right crowd.

Competition and the new SonoRace— right around the corner at the Boca Raton Resort & Club. The simulations carried a strong pediatric focus with contributing judges from Nemours Children’s Hospital in Orlando. We are very proud to share that FAU participated and won first place in the eighth annual SimWARS!

Finally, as a group we attended Symposium by the Sea, with its array of resident competitions—including SimWARS, Case Presentation

In closing, we would like to wish you all the best as you also settle into a new year! ■

Florida Atlantic University By Dr. Elizabeth Calhoun, PYG-1 As we are all settling into a new year, I would like to say hello from FAU’s Emergency Medicine Residency Program. This year marks the first year with a full cohort of residents. In addition to our recently welcomed interns, we are also congratulating Daniel Parks, PGY-3 and Michael Turchiaro, PGY-1 as new fathers. Our FAU EM family continues to grow! The 2019-20 academic year is off to an exciting start with Grand Rounds from well-known trauma

EMpulse Fall 2019

SOUTH FLORIDA EM RESIDENCY PROGRAMS

St. Lucie Medical Center By Abby Regan, DO, MSc

Our first-year residents are settling into the routine and we are glad to have them aboard. We have made some exciting changes to our conference curriculum this year, including a central resource where residents and faculty can view the agenda and reading topics for many months in advance. Chief resident Dr. Oliver Morris has been working diligently with core faculty to make this vision a reality, and we as a whole are grateful for their efforts. We are excited to welcome this year’s rotating medical students to our program. They are also enjoying the rollout of a new student curriculum. Students will be guided through the basics of ultrasound knobology with our US Director, Dr. David Hotwagner. EKG conferences are taught by Dr. Sarah Fowles and APD Dr. Josephin Mathai leads our mock oral boards cases. Program Director Dr. Thomas Matese introduces the wonders of “Ordered Thinking,” which teaches students how to carve order out of the chaos of the ED. Our program took part in our quarterly SIM lab experience in Boca Raton, where we were challenged with obstetrics and geriatric trauma cases. The obstetrics cases were particularly challenging, as one was complicated by eclampsia and the need for resuscitative hysterotomy and the other by a shoulder dystocia. SLMC was chosen in the lottery to compete in SimWARS at Symposium by the Sea 2019. Drs. Laughlin, PGY4, Gulenay, PGY-4, Chitty, PGY-3 and Dreschler, PGY-2 (pictured above) showcased their medical knowledge in front of their peers. We are proud of their performance and look forward to competing again. ■ 26

Jackson Memorial Hospital By EM Residency Staff It has been a sweltering but exciting summer in Miami. We welcomed our class of 2022 with a visit to the ballpark, a night at the Arsht Center and a delightful BBQ. We are fortunate to have another amazing group of interns who come from all over the country, bringing a breadth of diversity, experiences and insight. We are energized by their spirit and can’t wait to get them started on their careers as EM physicians. Faculty and residents from Jackson/ University of Miami and Holy Cross Hospital were excited to attend, participate and present at this year’s Symposium by the Sea in Boca Raton. Dr. Panakos presented on spontaneous coronary artery dissection. Drs. Medwid and Supino presented on rapid cycle debriefing in simulation, and Dr. Posaw was instrumental in organizing and leading the ultrasound competition. Additionally, we were thrilled by our residents’ successes! Drs. Kelsey

Wolfe and Dennis D’urso competed in the Case Presentation Competition at Symposium by the Sea. Dr. D’Urso was awarded best discussant and both were selected as best overall team. Congratulations to them for their great presentations, hard work and well deserved victory. A shout out also goes to Dr. Timothy Montrief, whose contribution helped win first place for a student poster. The study that the poster was based on was also published in the Journal of Pediatric Intensive Care in July. We held our faculty and residency retreat in September, which was a great opportunity for team building and brainstorming. Many exciting events are also on the horizon. Our senior class will all be heading to ACEP20 in Denver. And before we know it, recruitment season will be before us. We look forward to seeing everyone at ACEP! ■

Call for EMRAF Council Members EMRAF is planning to create an executive board, and we need regional representatives to better serve our 18 residency programs. This will help us better meet the needs of Florida EM residents. We have the opportunity to develop an influential state chapter. But first, we need some motivated members! If interested, please email Dr. Matthew Beattie at mbeattie221@gmail.com.

EMpulse Fall 2019

CENTRAL FLORIDA EM RESIDENCY PROGRAMS

AdventHealth East Orlando By Shannon Armistead, DO, PGY-3

Hello from AdventHealth East Orlando. Starting strong this academic year was our focus, with each class transitioning to new roles and preparing for medical students to rotate through the ED in hopes of a residency spot. To increase the academic nature of our community emergency department, the intern class traveled to Miami in July for a weekend of daytime education and nightly adventures for the second year. It is always a pleasure to have Dr. Mark Newberry teach a new round of residents at the Mount Sinai Medical Center POCUS Conference. One thing remarked on is how exciting it

is to see how many programs across the state have at least one person trained by our founding director, Dr. Alfredo Tirado. Our newly minted second-years are not only completing their solo trauma rotations but also doing Pediatric Intensive Care Unit rotations to increase their pediatric experience as we once again work to keep our care of all ages longitudinal across the curriculum. The senior class is back at it, teaching pearls in sign out and “dropping knowledge bombs” on the interns as they navigate not only their new emergency department home but also the EMR.

Already hungry to demolish our Inservice Training Exam this spring, we are working on Rosh Review and with HippoEM to encourage different learning styles as we acknowledge that we all retain the material differently. Ever interested in connecting with our peers, we were pleased to participate in Symposium by the Sea and Life after Residency as our seniors finalize their plans for the immediate future after graduation. Lastly, we as a residency we would like to thank and congratulate Dr. Misty Coello, PGY-2 on her service as EMRAF President. ■

HCA West at Brandon Regional By Melissa Bacci, MD, MS, PGY-2 Our program has doubled in size as we welcomed our second class of interns! We started the year with a two-week boot camp that covered everything from calling consults to STEMIs to procedures. We had a day dedicated to airway management as well as an ultrasound day, led by our ultrasound-trained faculty Dr. Eric Kalivoda and Dr. Gabriel Cabrera. With a dedicated procedure day led by myself and core faculty, Dr. Sergio Martinez, our interns were able to get their hands dirty and practice suturing, chest tube placement, central line placement and more. They’ve only been working with us for two months, but we are already pleased

with their performance. As our program grows, we have expanded our core faculty as well. Dr. Cabrera is one of our new faculty members, along with Dr. David Arbona, who is fellowship-trained in EMS and will be coordinating our EMS rotation. Dr. Sergio Martinez will also be a fantastic resource to our program. Dr. Kirk Szustkiewicz is fellowship-trained in administration. Dr. Aleem Bakhtiar, fellowship-trained in sports medicine, will be joining us in the next few months. Dr. Kelly Grabbe, who has a special interest in disaster medicine, will also be coordinating our simulation

EMpulse Fall 2019

program. We are all excited to work with our new manikins and incorporate more simulations into our curriculum. To round out this summer, two PGY-2 residents were chosen to be our academic liaisons: myself and Dr. Rachel Oliver. We will be working with the core faculty to improve our conference days by incorporating more flipped classroom lectures, small groups and guest lecturers. With all of the new additions to our program this year, we can’t wait to get started! ■

CENTRAL FLORIDA EM RESIDENCY PROGRAMS

FSU at Sarasota Memorial By Sarah Temple, MD, FACEP Assistant Program Director

Hello from Sarasota! We have hit the ground running here with our inaugural class. After an educational and fun July orientation month, they have scattered to various off-service rotations. We could not have asked for a better bunch of residents to start off our program, and they already have become a tight-knit group. The faculty are excited and relieved to actually have interns after years of preparation! It has been an exciting transition from a community ED with medical students and the occasional off-service resident to what feels like a fully academic emergency department. Between our nine interns and all our FSU and visiting students, we were suddenly walking around with true “teams” of learnings at varying levels, including our brand new emergency pharmacology residents. Dr. Ashley Grant, our Ultrasound Director, and I have just returned after participating in the first half of the ACEP teaching fellowship in Dallas. We are excited to bring some new ideas home and look forward to collaborating with our academic EM colleagues from across the country and even the world. We plan to send all of our core faculty to this impressive course over the next few years as part of our faculty development process. We are in the process of designing an innovative wellness curriculum and look forward to sharing these updates with you in the future. A few of our interns attended Life After Residency Retreat in September and we are excited to see some of you at ACEP 2020 in Denver. ■ 28

USF Health

HCA Oak Hill Hospital

By Mikhail Marchenko, MD, PGY-2

By Jonathan Yaghoubian, DO, MS & Corey Cole, DO, PGY-2s

Aequanimitas: a term meaning imperturbability or coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril.* This is a quality regarded by Sir William Osler as the premier quality of a good physician. It has been awesome to see our USF EM family grow in imperturbability over the past several months: interns conquering their first July in the ED and moving on to off-service rotations in ICUs, second-years stepping up into teaching and leadership roles, and seniors taking up mentoring and managing roles, all with clarity, coolness and calmness. We are grateful to our faculty for exemplifying these qualities. A big thank you to our faculty members— Dr. Wilson, Dr. McKenna and everyone else involved—for working so hard to make Symposium by the Sea a success. From the research presentation competition to SimWARS, these events would not have been possible without their leadership. Of course, congratulations to the winners during the competitions this year! We are also excited that one of our own seniors, Dr. Matthew Beattie, now represents us as the new EMRAF president. We are looking forward to strengthening the emergency medicine residents of Florida and advocating on their behalf. It is exciting to see what the next few months bring as we all develop aequanimitas, the imperative quality of a physician and even more so an emergency medicine physician. *Indirect quote from Sir William Osler’s 1889 valedictory address. ■ EMpulse Fall 2019

After the first couple months of the new academic year, everyone is getting settled in. The seniors are adjusting to their new responsibilities and have been helping the interns with the transition from medical student to resident. This coming year is full of new developments. Our new simulation manikin has arrived and will be installed soon. We are looking forward to our simulation center opening in the next month. We will be running simulations not only with residents but also nurses and other disciplines in the hospital. As part of our second-year curriculum, we have been fortunate to set up rotations at John’s Hopkins All Children’s Hospital. It has been an excellent pediatric experience. We are excited to continue our relationship with them. The ED expansion is scheduled to begin soon. It will be an adjustment working around the construction, but part of being an ED resident is being flexible. It will bring about a much needed and anticipated increase in beds and space for not only the staff but residents as well. Recently, we participated in FCEP’s Symposium by the Sea. A few of our seniors and interns also had a chance to compete in SimWARS and SonoRace. We are looking forward to another chance to participate. Our residency has been evolving since it started over a year ago, and we are excited to have the opportunity to shape it. We are eager to see what the future holds. ■

CENTRAL FLORIDA EM RESIDENCY PROGRAMS

UCF/HCA of Greater Orlando at Osceola Orlando Health

By Anne Shaughnessy, MD & Laura Cook, MD , PGY-3s Hello from Orlando! We’ve had an excellent beginning to our academic year. Our interns have been rocking it in and out of the department, seeing a lot of exciting cases in the ER, practicing procedures in Sim Lab, and honing their laser tag skills. We expect great things from the class of '22! It was a blast to see everyone at Symposium in Boca. Orlando Health took home 1st place in both the Resident and Fellow categories of the Research Poster Abstract competition. We had 19 posters accepted to this year’s conference. Congratulations to our ultrasound team who placed 3rd in SonoRace! We are so proud of our residents. In September, ORMC residents, attendings, nurses and staff volunteered their efforts in serving the community at the Electric Daisy Carnival. Every year, Orange County EMS organizes medical tents to manage and treat carnival participants who are affected by various toxicities, particularly that of stimulant overdose. It’s an opportunity for our residents to manage sick patients outside the emergency department and treat toxic overdoses. We are in the midst of planning our next recruitment season and looking forward to starting interviews this fall. We have a great crew here at ORMC and hope that all students consider us on their journeys to finding their residency family! ■

By Andrew Hanna, MD, PGY-3 & Amber Mirajkar, MD, PGY-2 It has been an exciting and busy start to the academic year. Our interns completed their bootcamp month, which included an ultrasound workshop in Miami, and now are getting into the swing of things in the ED. From cadaver lab to difficult airway workshops, we have been exploring new, interactive ways to learn. We were even able to practice thoracotomies and aortic clamping—an exciting experience for everyone, medical students and senior residents alike. A new year also means new fellows! We welcomed Dr. Leoh Leon, one of our own graduates, as the first ultrasound fellow. He has already been hard at work, teaching medical students and interns the ways of ultrasound as well as providing valuable management information in the ED. We also welcomed Dr. Amanda Webb, another one of our graduates, as the first research fellow. Under the guidance of our research director Dr. Latha Ganti, we look forward to Dr. Webb helping us take the plunge into

the waters of research. Both fellows will serve as attendings and educate us both in and outside of the ED. This year we partook in Symposium by the Sea and the CPC Competition. It was an interesting experience, and our residents had a chance to display their creative, theatrical side. We look forward to partaking again next year. It is always a pleasure to connect with our ever-growing EM community in Florida and encourage academic pursuits. The year is off to a good start and before we know it, we will be full throttle into recruitment season. I wish good luck to all programs and students as we head into another fun and exciting year. Remember to take the time and check in with your colleagues and remain an encouragement during this stressful time as new faces make their way into the ED! ■

Daunting Diagnosis: Q By Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief A 37-year-old female presents to the ER with right, upper back pain. She has a history of trauma two months prior where she was impailed in her right chest with a tire rod while driving. At the time of injury, she sustained a right comminuted clavicular fracture, which required ORIF by orthopedic surgery. She states she has tenderness at her surgical site, swelling of

EMpulse Fall 2019

her right upper back and subjective fevers at home. What does her chest CT show?

CONTINUE ON PAGE 40 »

NORTH FLORIDA EM RESIDENCY PROGRAMS

Orange Park Medical Center By Steven Warrington, MD, MEd, FACEP Residency Program Director

UCF/HCA at North Florida Regional By Mollie Powell, DO, PGY-2 The Florida sun is hot, but our residency may be hotter. It has been a groundbreaking few months around here. In May, our very own Dr. Alex Waldman presented his study, "Controlled Substance Prescription Rates Are Not Associated with Decreased Discharged Patient Satisfaction Scores," at the Society for Academic Emergency Medicine (SAEM) national conference in Las Vegas. The abstract was selected as top 100 of the 500+ presented at the conference! In July, our residency family was finally completed with three full classes as we welcomed our eager and impressive interns. In August, 10 of our residents attended Symposium by the Sea. Senior chief residents Dr. Alexandru Barabas and Dr. Alex Waldman represented North Florida in the annual Case Presentation Competition. Dr. Barabas presented the North Florida case of high-altitude pulmonary edema, and Dr. Waldman discussed a competitor’s case of hemorrhagic cholecystitis. North Florida also had a presence in the first SonoRace. Drs. Emmanouil Kiriakopoulos, Joshua Middleton and I competed in the inaugural ultrasound competition and won first place as well as best costume. All in all, North Florida continues to grow and thrive. To name but a few of our future plans, we anticipate competing in the SAEM SonoGames, starting an official ultrasound group, both locally and regionally, and sending a cohort to ACEP. Lastly, I could not mention all of this without recognizing and thanking our amazingly dedicated faculty. ■ 30

Orange Park Medical Center has welcomed its inaugural class into its 3-year program with 12 fantastic residents. Highlights of our young program include:

• Our program director is primary

investigator recipient for one grant for approximately $40,000.

• Residency leadership is co-in-

vestigator for a multi-site project with a second grant worth approximately $50,000.

• All residents are undergoing

introductory training on six sigma quality principles. We are currently collaborating on various research projects with four external institutions and projects that involve investigators from various other departments such as trauma, pediatrics and dermatology. In the upcoming months we look forward to planning resuscitative TEE training, finishing six sigma training for our interns, mapping out our next wellness retreats and continuing to grow. ■

UCF/HCA Ocala By Caroline Smith, MD, PGY-1 The academic year is off to a great start at UCF/HCA Ocala Emergency Medicine. Our newest residency class went through our inaugural intern boot camp. The intensive training week was directed by our new chief residents, Samyr Elbadri, MD and Nick McCauley, MD. The interns had procedure workshops, simulation cases, an ultrasound clinic and lectures on emergency medicine fundamentals. Additionally, the boot camp focused on getting the new residents acquainted with department staff, protocols, workflow and the EMR. We are excited to continue training our new class over the next three years. To celebrate their arrival in Central Florida, the residents had a teambuilding day at Rainbow River in July. The PGY-2 class attended Symposium by the Sea, where residents participated in the Case Presentation Competition and SonoRace. EMpulse Fall 2019

Our facilities are growing alongside our quorum of residents. Ocala Health’s new freestanding ED opened in September, which will increase medical access for the residents of Marion County. We’re looking forward to the completion of expansion projects and continuing to improve care for our patients. Our ultrasound director, Drew Jones, MD, is moving to Orlando and will be missed by the residents and staff at Ocala Regional. During his time as core faculty, Dr. Jones implemented an ultrasound curriculum and acquired a new ultrasound machine for the ED. We wish Dr. Jones all the best in Orlando and look forward to the future of our ultrasound program. We would also like to congratulate Vir Singh, MD on being named to EMRA’s award committee. ■

NORTH FLORIDA EM RESIDENCY PROGRAMS

UF Gainesville

Learn More About Treating Patients with Opioid Use Disorder

By Michael Chami, MD, PGY-3

FREE WEBINAR:

We are pleased to begin training providers in PRIM-ER: Primary Palliative Care for Emergency Medicine, and begin instituting this into our main emergency department. This is an NIH, NINR-funded project in association with UCSF and Emory University that will evaluate patient outcomes after training providers on the use of evidence-based skills to communicate difficult information, including advanced disease and end-of-life care to patients.

logic emergencies.

We are also excited to continue training in Emergency Neurologic Life Support (ENLS) to all residents and faculty again this year. ENLS consists of 14 protocols designed and written by neurointensivists and emergency medicine physicians that are designed to provide expert management in the first hours of neuro-

We are proud of our diverse class of interns, who are excelling and adapting well into their new roles. Our faculty remains dedicated to simulation, teaching and giving our residents the opportunity to learn and grow. We look forward to the coming educational year! ■

Our EMS department, led by Drs. Jason Jones and Torben Becker, have instituted a novel intubation protocol in coordination with Alachua County Fire Rescue, which includes EMS providers using I-Gel supraglottic airways and ketamine in the field. We hope that this new protocol allows for safer out-of-hospital airway management that leads to better outcomes for our patients.

Implementing Warm Hand-Offs Between EDs and Treatment Providers for Patients with OUD Approved for AMA Category 1 PRA credits™

Faculty: Chief Judge Frederick J. Lauten; Nancy McConnell, MSW, MCAP, CRPS-A; Mark Stavros, MD, FACEP; Aaron Wohl, MD, FACEP Provided by: FCEP, the Florida Alcohol & Drug Abuse Association (FADAA) and the Aetna Foundation About: Patients suffering from opioid use disorder (OUD) present unique and unprecedented challenges to emergency care providers. This webinar:

• discusses misconceptions about treatment and the disease itself

• introduces the concept of warm handoffs between EDs and treatment providers

• reviews legal issues surrounding opioid overdose cases

• reviews the important role of peer specialists in recovery

UF Jacksonville

Expires November 30, 2019

By Tyler Tantisook, MD, PGY-2

ACCESS NOW It was a pleasure for all of us at UF–Jax to meet our colleagues from across the state at Symposium. There were lots of great lectures, presentations and competitions throughout the weekend. Emergency medicine is definitely picking up steam in our state. Thanks to all of our staff, residents and students who contributed to the weekend. We are looking forward to seeing everyone in Denver at ACEP. Good luck to our SimWars team, who will be competing at ACEP. Our interns have really hit the ground running here at UF–Jax. We are lucky to have a fun and hard-working class who are already making our program better. It is exciting to see them continue to grow

and become leaders in our shop. We recently had a great time escaping the hospital while having a conference at Jax Beach with our surf medicine expert, Dr. Andrew Schmidt. Learning about all of the emergencies that can happen at the beach and ocean was eye-opening and fun. It was great to add these skills to our toolkit, especially living here in Florida. Good luck to all of the medical students we have hosted during the away rotation season. We have had lots of great, motivated students who will surely do great in the interview and match season. Enjoy the rest of your 4th year! ■ EMpulse Fall 2019

emlrc.org/opioids

FCEP is working closely with Florida’s Department of Children and Families (DCF), the Florida Hospital Association (FHA) and FADAA to provide a toolkit for creating ED Bridge/Warm-Handoff programs. Are you an opioid champion at your hospital? Do you have tools to share? Contact FCEP’s communications manager Samantha League at sleague@emlrc.org to learn more and get involved. 31

COMMITTEE REPORTS

Medical Student Council

By Alexa Peterson, OMS-III, Nova Southeastern University FCEP Medical Student Council Secretary-Editor

FCEP’s medical student council is off to a busy start this year. The first big event that drew aspiring emergency medicine physicians together was FCEP’s annual meeting and conference, Symposium by the Sea. It was a weekend for all to enjoy great conversation about the rapidly evolving future of emergency medicine. The medical student council was responsible for hosting the annual Medical Student Forum at SBS. Sixteen of Florida’s emergency medicine residency programs were represented at the panel, where medical students from around the state had the opportunity to inquire about upcoming application cycles directly from programs of their interest. As the field is becoming increasingly more competitive, students are all too aware of the stress that comes with the preparation and application for residency, and the forum served as an outlet to identify some of the unknown. Whether it was a program

discussing application logistics or hearing stories of interview faux pas, the overall message students took away from the forum was: the power of grit. In all aspects of life, whether you’re at the student or physician level, there will always be obstacles. Regardless of the challenge each of us are facing, whether it be completing an exhausting shift, overcoming a poor score or missing out on family and friends to tirelessly care for patients, the courage to continuously show up each day is vital and a testament to the passionate people in emergency medicine, and was a reinforced message at the Medical Student Forum. Throughout the weekend, students were showcasing their hard work at the Case Presentation Competition and Research Poster Abstract presentations, as well as engaging in SonoRace and SimWARS. These events relied on many volunteers, residents and students to be suc-

cessful. A congratulations is in order for Linh Nguyen from Florida State University, who won the Best Medical Student Abstract with her presentation on the “Aeromedical Rapid Sequence Intubation Using the King Vision Laryngoscope.” Leena Owen, OMS-IV and Jaqui Johnson, OMS-III from Nova Southeastern University also presented their research on the cost of gun violence in Florida’s emergency rooms. “(Participating in this competition) gave us a great chance to talk to more people and receive constructive comments from faculty and residents alike,” Johnson stated. “We look forward to incorporating some of the thoughts and suggestions in the future.” This serves as a small sample of the important topics students are tackling in the realm of emergency medicine, and Symposium by the Sea continues to serve as the perfect format to bring great minds together! ■

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EMpulse Fall 2019

SPONSORED CONTENT

Sepsis in the ED and Hospital:

Is Hospice an Often-Overlooked Solution? By Anjali Vyas MD, MBA

Associate Medical Director, VITAS® Healthcare Two recent medical studies underscore what many emergency room physicians and healthcare professionals already know about sepsis: It is a common, costly and largely unpreventable condition and a significant cause of in-hospital mortality and readmission. Separate studies in Chest® Journal (Gadre S et al; March 2019) and JAMA Open Network (Rhee C, et al; February 2019) conclude that patients who ultimately die of sepsis in the hospital typically exhibit underlying diseases and comorbidities that complicate treatment and contribute to death. With only 1 in 8 sepsis-associated deaths considered to be preventable, the findings reinforce VITAS® Healthcare’s pursuit of treatment and prevention strategies that offer sepsis-vulnerable patients targeted, appropriate care and timely referral to hospice.

Hospice: an option for seriously ill, sepsis-vulnerable patients The fact that 40% of sepsis-vulnerable patients are eligible for hospice care when they arrive at the hospital—but are never referred—is an opportunity to both reduce hospital mortality statistics and provide more targeted, patient-concordant care. Just as VITAS encourages doctors and patients to engage in early and ongoing goals-of-care conversations for any serious disease, our hospice experts also encourage hospitals, emergency physicians, specialists and other healthcare professionals to engage in “whole-person” evaluations of seriously ill, sepsis-vulnerable patients when they are admitted to the hospital or ED:

• Who is this patient and what are their goals for the care they receive?

According to the research, sepsis disproportionately affects patients who are elderly, have severe comorbidities and have impaired functional status. Some may receive optimal, guideline-compliant care yet still die due from sepsis or underlying comorbidities.

• How long has he/she been sick? • What other underlying diseases or comorbidities are

VITAS supports targeted care and care transitions that keep vulnerable patients out of the hospital and help hospitals improve their quality and mortality metrics by:

• How likely is this person to die within 12 months? • And most importantly, would hospice care be a bet-

• Heightening awareness of sepsis vulnerability • Identifying patients at risk of sepsis once they enter the hospital

• Improving management of the care plan consistent with the patient’s goals

The JAMA study found that 40% of patients who died of sepsis in the hospital were eligible for—but never referred to—hospice care upon admission. Eligibility factors included underlying cancer (20%), severe dementia (5%), severe stroke (4%) and severe chronic lung disease (4%).

present?

• Where is this patient in the disease trajectory? • Where was the patient before admission to the hospital?

ter alternative for this seriously ill patient?

Asking holistic questions in a timely and honest manner ensures that seriously compromised patients will not have to die of sepsis in the hospital and can instead take advantage of the benefits and quality-of-life focus of compassionate hospice care. VITAS experts offer free monthly webinars to educate healthcare professionals on the benefits of hospice, including discussions on sepsis, hospice eligibility guidelines and other topics. Find details at VITAS.com/ webinars.

For more information about hospice eligibility guidelines for sepsis, visit VITAS.com. For seamless, secure hospice referrals 24/7/365, download the VITAS mobile app at VITASapp.com. EMpulse Fall 2019

When Treating Kids, Learn from the Emergency Department By Phyllis Hendry, MD, FAAP, FACEP

Florida EMSC Medical Director | Trauma One Deputy Medical Director of Pediatric Transport & Care at UF Health, Jacksonville | Professor of Emergency Medicine & Pediatrics & Associate Chair for Research at UF COM–Jacksonville

To prevent communication gaps when treating kids, all specialties can benefit from lessons learned in the Emergency Department (ED), where conversations are rushed, stakes are high, teams are assembled ad hoc, and physicians seldom have relationships with the patient. These same conditions are becoming more prevalent in other specialties due to patient or family relocations, rapidly merging healthcare systems, and changes in employee healthcare plans or contracts. The days of having the same doctor for decades are fast disappearing. Communication gaps are particularly risky when treating kids, because the patient often cannot communicate, and the caregiver—whether a parent, other relative, or babysitter—must speak on the patient’s behalf. Poor 34

communication not only endangers patients, but increases physicians’ exposure to potential malpractice claims, according to a recent study of malpractice claims involving children.1 Based on 10 years of claims filed against physicians in 52 specialties and subspecialties, the study found that communication breakdowns between patients/families and providers contributed to 15 to 22 percent of claims (depending on age group). System issues often contribute to communication failures, such as when a child’s previous medical records cannot be found in an electronic health record (EHR) database because of a misspelled name or incorrect date of birth. When facing such frustrating, systemic obstacles to providing care, it is espeEMpulse Fall 2019

cially important for physicians to have meaningful conversations with patients and parents/caregivers. Consider that when dealing with pediatric cases, you have a minimum of two patients—the child, the parent or guardian, the actual current caregiver, sometimes grandparents offering advice, coaches, teachers, siblings, and possibly more. Here are four communication lessons learned from the ED regarding pediatric patients based on cases seen over 30 years of pediatric EM practice:

1. Be Sure Caregivers Understand Discharge Instructions A mother brought her 10-year-old son to the ED with abdominal pain. Following examination, testing,

and observation, the patient was discharged home after verbal and written instructions to return immediately if the pain or symptoms worsened or if he developed specific red-flag symptoms. Over the next 48 hours, the child did display those symptoms, but the mother called her pediatrician’s office for an appointment the next day, not realizing her son needed to be seen immediately. After the boy began vomiting blood, his mother called 911. The boy arrived at the ED via ambulance in cardiac arrest and died two days later as a result of a perforated appendix. Lesson: Both verbal and written discharge instructions are important, and they must be presented in layperson’s terms. Some EHR instructions are complex and lengthy, so on a printout of instructions, highlight only key features or phone numbers. Three key components include: Follow-up details, disease or diagnosis red flags, and patient/family understanding of the treatment plan (antibiotics, physical therapy, antipyretics, and/or subspecialty referral). When conveying red-flag symptoms that indicate the patient should return, specify whom to call, the level of urgency, and the location (such as ED or clinic). Ask when the caregiver can obtain prescriptions, and if available, consider giving a first dose of medication in the clinic or ED before discharge. Try to determine if the child has an existing relationship with a primary care physician (PCP) or subspecialist(s). Medicaid covers over 30 million children nationwide, including many high-risk children with special healthcare needs. It is important to make sure the caregiver knows the name of the child’s plan, designated PCP, and contact information. Use the teach-back method: Instead of asking patients and/or parents whether they understand, ask them to tell you what they understand they should do, and when. This ensures everyone is on the same page. For school-age children and older, engage them in the process and discussion.

“

Good communication is not a luxury: It is essential to the well-being of both patients and physicians, particularly when those patients are young and often cannot communicate for themselves.

2. Avoid Vaccination History Assumptions Case example: A mother brought her three-month-old infant to the ED with fever of 102°F and mild cold symptoms. At triage intake, the mother stated the infant had not yet received her vaccinations. The staff and physicians initially assumed she was against vaccinations. On further questioning and review of the EHR, it was determined the mother had tried several times to obtain vaccinations for her child without success due to PCP clinic appointment availability and staffing shortages. The infant looked well but had a complete septic workup and was admitted and treated for meningitis with a good outcome. In another scenario, an eight-month-old infant presented during peak bronchiolitis season with fever of 102.8°F. The parent gave a history of all shots being up to date. The patient was discharged with a diagnosis of upper respiratory infection and bronchiolitis but returned two days later with pneumonia and sepsis. On further inquiry, the parent was not the regular caregiver and the immunizations were not current. Lesson: When treating children under two years of age, always request a detailed history regarding immunizations, neonatal history, and risk factors such as prematurity or chronic medical conditions. Parents often incorrectly indicate immunizations are up to date when having their child seen in the ED. Always check immunization records by asking if the parent has the patient’s immunization card, reviewing the EHR, or checking your state’s immunization registry (if available). Children without current immunizations and fever may require additional evaluation, and are at greater risk for serious bacterial disease. This is EMpulse Fall 2019

especially true for those under six months of age. Just because a patient is missing immunizations does not mean the parent is anti-vaccines or neglectful. There are legitimate reasons patients fall temporarily behind. Avoid making assumptions regarding the parent or caregiver that might negatively impact your communication and thought process.

3. Know Your Patient Case example: Paramedics brought an African American teenager to the ED for pain. Their report to the triage nurse was that the young man probably had sickle-cell disease, had not attempted any pain relief on his own, and possibly could be a drug seeker. This same information was related to the ED physician, who initially approached the patient with frustration, but took the time to ask additional questions, including some ice-breaker questions such as: “Where do you go to school?” “What are you doing during your summer school break?” and “Tell me what you know about your disease and pain control.” The physician discovered the patient was an advanced honors student at a nearby prestigious university who had finished high school early to start college. He did not have sickle cell but another hematologic condition. He was visiting grandparents and could not reach them at work. His pain medications were in his out-of-town dorm room. He wasn’t sure what to do, and concerned neighbors recommended he call 911. His hematologist was consulted, and he was admitted for pain management and evaluation. Lesson: Always confirm key elements of the history. It is difficult to get a correct history in a brief encounter, especially with someone you are meeting for the first time. Ask patients and/or parents some nonmedical getting-to-know-you questions, and confirm which adult is there with the child, the child’s primary caregiver, and the child’s level of functioning. What grade are they in? Do they play sports or have a hobby? Has their activity level changed? This helps give a sense of the person, and helps interpret what they say about

CONTINUE ON PAGE 36 » 35

« CONTINUED FROM PAGE 35

their physical condition or what parents say about their child’s condition. Always speak directly to the child and allow the child to tell part of their story, especially when dealing with adolescents.

4. Ask the Right Questions Case example: A mother signed her child in at triage/registration saying that her child was running a fever at home. The child had no fever and was playful. In fact, the mother was concerned her child had been abused while staying with her ex-husband over the weekend. The child had made some concerning comments upon her return home on Monday. The mother did not wish to report this concern at check in, and said she was scared of the father. Lesson: Do read triage notes or medical assistant/staff notes, but begin your conversation with the open-ended question: “What are you most worried about today?” This may reveal the patient’s or caregiver’s true presenting concern—or it may simply

help them cut through all the topics they could potentially discuss and skip straight to the most pressing concern. Finally, rapport matters. No matter how strong your emotional intelligence, you can’t communicate well with everyone. A patient may be willing to confide in a female physician but not a male physician, or the other way around. A patient may understand one physician’s way of explaining things better than another’s. If you are not having a successful communication experience with a patient or caregiver, consider requesting that your patient see another healthcare provider if one is nearby and readily available, or include another staff member in the conversation. As the recent study on malpractice claims involving children shows, good communication is not a luxury. It is essential to the well-being of both patients and physicians—particularly when those patients are young and often cannot communicate for themselves. ■

References: 1. Ranum, Darrell. Study of Malpractice Claims Involving Children. The Doctors Company. March 2019. Access at: www.thedoctors.com/articles/ study-of-malpractice-claimsinvolving-children

Additional Resources: 2. Pediatrics Risk Varies With Age; More Parental Outreach Needed. Healthcare Risk Management. June 1, 2019. Access at: www.reliasmedia. com/articles/144479-pediatricsrisk-varies-with-age-more-parentaloutreach-needed 3. Study of Malpractice Claims Involving Children.The Doctors Company. April 9, 2019. Access at: http://youtu.be/ nQIJhFh4KG0

Dr. Hendry is Professor of Emergency Medicine and Pediatrics and Associate Chair for Research, Department of Emergency Medicine, University of Florida College of Medicine – Jacksonville. She also serves as Trauma One Deputy Medical Director of Pediatric Transport and Care, UF Health, Jacksonville, and Florida EMSC Medical Director.

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POISON CONTROL

The Hydroxocobalamin Shortage Alexis Hochstetler, Pharm.D., PGY-2 Clinical Toxicology, EM Resident

Cyanide and the toxicities associated with its exposure have a long and rather famous history. Dating back to World War I, Napoleon was noted to have used cyanide in chemical warfare. The Nazis in Germany also utilized cyanide in the gas chambers during the Holocaust. Another infamous event was the Jamestown suicides where 913 people died from drinking juice poisoned with cyanide.1 Despite the ever-increasing education and detection monitors available, cyanide toxicity—whether from house fires, industrial work or medicinal exposure—continues to be seen on occasion in the emergency department. With the introduction and production of the most common modality of treatment, hydroxocobalamin (CyanoKit), providers are able to quickly and easily treat confirmed and suspected cases of cyanide toxicity. However, a national shortage of hydroxocobalamin occurred in late 2018, when Meridian Medical Technologies experienced major delays in production coupled with an increasing demand for the product.2 This drug shortage, as many do, left us to evaluate what alternative options we as emergency medicine providers have to treat a patient who presents with cyanide toxicity. Initial management of this toxicity includes a primary survey to assess the patient’s airway, breathing and circulation, and to ventilate the patient with 100% oxygen. While the patient is being stabilized, if there is suspicion of cyanide toxicity, (including hemodynamic abnormalities, headache, paired with history of possible exposure), providers should begin thinking about specific treatment for cyanide. Suspicion can be further confirmed by laboratory findings of metabolic acidosis, elevated lactic acid and anion gap, elevated levels of venous oxygen on blood gas 38

analysis, and a cyanide level (if readily available at your institution). Cyanide levels greater than 2.5 ug/mL have led to respiratory depression and coma while levels greater than 3 ug/ mL are associated with mortality. With a confirmed or suspected case of cyanide toxicity, prompt antidotal therapy is imperative.1,3 While hydroxocobalamin has been the treatment of choice for cyanide toxicity since its approval in 2006 by the FDA, it was not the original antidote used.1 The previous method of treatment included amyl nitrite, sodium nitrite and sodium thiosulfate. Although these agents may seem outdated, a resurgence of their use may occur in the face of the hydroxocobalamin drug shortage. Amyl nitrite and sodium nitrite work against cyanide toxicity by oxidizing hemoglobin to methemoglobin. Methemoglobin preferentially binds to cyanide releasing cytochrome a3, a component of the cytochrome c oxidase complex, to restore aerobic respiration.1 Amyl nitrite is a highly volatile substance that is packaged in ampules to be broken and administered via inhalation. The utility of amyl nitrite has been questioned in the literature due to the low percentage of methemoglobin produced, however, it may be an appropriate temporizing option to utilize while sodium nitrite is being prepared.1,3 Sodium nitrite is available as 3% solution given intravenously as a 300 mg dose over 2-4 minutes (adult dose).3 Hypotension is a known side effect of nitrite administration and the rate of infusion should be slowed if it occurs. Methemoglobin levels should be measured 30 minutes post-dose with a target level between 20-30%.1,3 Finally, sodium nitrite administration should always be followed with a dose of sodium thiosulfate. Sodium thiosulfate donates a EMpulse Fall 2019

FPICN toxicologists are available 24 hours a day, free of charge, at 1-800-222-1222 to answer any questions practitioners may have regarding cyanide toxicity or the choice of antidotal therapy.

sulfur group to enhance the catalyzation of cyanide to thiocyanate by the enzyme rhodanese. Thiocyanate is less toxic than cyanide and is renally eliminated. Sodium thiosulfate is available as a 25% solution to be given intravenously at a dose of 12.5 g.3 Sodium nitrite and sodium thiosulfate, despite being used to treat cyanide toxicity, were not officially approved for this indication by the FDA until Nithiodote was approved in 2011.4 Nithiodote contains one 300 mg/10 mL vial of sodium nitrite and one 12.5 g/50 mL vial of sodium thiosulfate, making the product convenient for its indicated use in acute cyanide toxicity. Ultimately, patients who receive an antidote for cyanide toxicity should be admitted for observation and signs of improvement.3 Though the manufacturers of hydroxocobalamin now report an adequate supply of the medication, hospital pharmacies that experience a limited supply of hydroxocobalamin should evaluate their inventory for the alternative antidotes in preparation for potential cyanide toxicities. ■

REFERENCES

1. Howland M. Nitrites (Amyl and Sodi-

um) and Sodium Thiosulfate. In: Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS. eds. Goldfrank’s Toxicologic Emergencies, 11e New York, NY: McGraw-Hill; accesspharmacy. mhmedical.com/content.aspx?bookid=2569&sectionid=210264055. Accessed June 21, 2019.

1. Meridian Medical Therapeutics (personal

communication). July 25, Aug. 8, Sept. 11, Nov. 8, Dec. 10, 2018; Feb. 12, April 17, May 29, 2019. www.ashp.org/drug-shortages/current-shortages/Drug-Shortage-Detail.aspx?id=446

1. Micromedex® Healthcare Series [In-

ternet database]. Greenwood Village, Colo: Thomson Reuters (Healthcare) Inc. Updated periodically.

1. National Library of Medicine (U.S.). (Oct. 2018). DailyMed. Nithiodote. Bethesda, MD: U.S. National Library of Medicine, National Institutes of Health, Health & Human Services.

THE ULTRASOUND ZOOM

POCUS of the Gallbladder: Always In-Style Edited by Leila Posaw, MD, MPH

By John Combs, MD, PGY-3

Jackson Memorial Hospital

In my short time practicing EM, I have seen some point-of-care ultrasound (POCUS) applications go “out of fashion.” However, similar to how Ferraris are always cool, some ultrasound scans have stood the test of time and are always “in.” For me, that classic scan is POCUS of the gallbladder. I remember a case from early in my residency training. A 42-year-old female with a past history of gastro-esophageal reflux disease (GERD) presented to the emergency department with 12 hours of dull burning epigastric pain. She had visited the ED two times for GERD in the last two months. Each time she had normal lab tests and she was treated with a GI cocktail. She got better and went home. On this visit, her vitals were normal and she told me the pain felt like her usual GERD pain. “I just need a GI cocktail, doc!” she said. I wasn’t convinced. I performed a POCUS of her gallbladder and found a large

Emergency Ultrasound Director, Jackson Memorial Hospital

gallstone with sonographic signs of cholecystitis! Within six hours, she was taken to the OR for a cholecystectomy.

der); a RUQ-coronal approach (the probe is placed on the flank), and an “X-7” (the probe is placed 7 cm to the right of the xiphoid process).

Acute abdominal pain accounts for 7-10% of ED visits. Pain located in the right upper quadrant (RUQ) or epigastric region should prompt the diligent emergency physician (EP) to perform a POCUS of the gallbladder.

The location of the gallbladder can vary from patient to patient. If the gallbladder is difficult to find, have the patient lie in a left lateral decubitus position, or ask the patient to take a deep breath and hold it as long as possible. Both of these maneuvers will help bring out the gallbladder from under your patient’s ribcage. Once found, look for signs of a normal gallbladder, as shown in Fig. 1.

When scanning the gallbladder, the diligent EP should look for gallstones, signs of cholecystitis and signs of biliary ductal dilation. If the POCUS does not show any of these, the EP should search for causes of abdominal pain other than biliary disease. While some may use a phased array transducer to scan the gallbladder, I prefer a curvilinear transducer. There are several techniques that one can use to find the gallbladder. The three most common approaches are: a subcostal approach (the probe is placed on the right side of the abdomen, looking up at the liver and gallblad-

Gallbladder.To.Go.

Fig. 1: A normal gallbladder with a thin wall and empty lumen.

CONTINUE ON PAGE 40 »

Find this table online at emlrc.org/ultrasoundzoom

Stick in your wallet. Reference on-the-go. Courtesy of authors Leila Posaw, MD, MPH and John Combs, MD, PGY-3

Gallbladder Point-of-Care Ultrasound POCUS of the Gallbladder.

Probe Position Sagittal

Probe Position Transverse

X-7

RUQ-Coronal

Probe:

EMpulse Fall 2019

Daunting Diagnosis: A

« CONTINUED FROM PAGE 29

Her chest CT shows the development of a large, multiloculated complex collection involving the right posterior chest wall and right lung apex, including a posterior subcutaneous component extending to the skin, highly concerning for an abscess. Orthopedic surgery was again consulted. The patient required multiple surgical debridements for a right subclavicular and supraclavicular abscess and chest wall abscess. She was placed on IV antibiotics and had a protracted hospital course.

« CONTINUED FROM PAGE 39 That’s one happy looking gallbladder! Not all gallbladders are as happy. Some have stones and some are infected. The presence of a gallstone in the gallbladder is easy to identify: a mobile hyperechoic mass with posterior anechoic shadowing. The gallstone lies in the gravity dependent portion of the gallbladder. If the gallstone is not mobile, it may be impacted, as shown in Fig. 2.

Fig. 2: A gallstone resides within the gallbladder lumen. Note the hyperechoic gallstone with posterior shadowing. Now here’s an unhappy gallbladder in Fig. 3.

pain when the gallbladder is compressed underneath the ultrasound transducer. This is the most sensitive sign of acute cholecystitis. Other signs of an unhappy gallbladder include gallbladder wall thickening and pericholecystic fluid, both of which we can see in Fig. 3. These signs indicate edema of the gallbladder and gallbladder fossa, secondary to inflammation often resulting from infection. Finally, the diligent EP must evaluate the diameter of the common bile duct (CBD). Sometimes gallstones can actually get lodged in the bile duct, and this will cause a dilation of the CBD. The CBD is one of the three vessels of the portal triad, the other two being the hepatic artery and the hepatic portal vein. The CBD can be identified in the portal triad as the only vessel that will lack flow on color Doppler imaging, as bile flows much more slowly than blood. The diameter of the CBD should be measured perpendicularly from inner-wall to inner-wall, and a measurement of greater than 7 mm should increase suspicion for possible choledocholithiasis, or even cholangitis. Even the best POCUS is less sensitive and specific for biliary disease than a cholescintigraphy, as my surgical colleagues often remind me when we pass in the hallways. Nevertheless, POCUS has a superior sensitivity, specificity and safety profile than the CT scan for evaluating biliary disease. “Ultrasound first” should be every diligent EP’s motto!

Fig. 3: A gallbladder with multiple gallstones, a thickened wall and pericholecystic fluid: signs suggestive of cholecystitis.

POCUS is a powerful tool to evaluate the normal gallbladder and to diagnose cholelithiasis, cholecystitis and

The most obvious sign would be the presence of sonographic Murphy’s sign:

CONTINUE ON PAGE 41 »

Gallbladder Point-of-Care Ultrasound Diagnosis:

Normal Gallbladder

Cholelithiasis

EMpulse Fall 2019

Cholecystitis

Cholangitis

Table 1: Summary of POCUS Evaluation of the Gallbladder: Clinical Signs, POCUS Figure and Findings Normal Gallbladder

Cholelithiasis

Acute Cholecystitis

Acute Cholangitis

Clinical Signs:

Normal vital signs

Asymptomatic

May be tender

May be febrile and tachycardic

Abnormal vital signs

RUQ or epigastric pain

Persistent RUQ pain

Very sick RUQ pain, fever, jaundice, AMS, shock

Nausea/vomiting

« CONTINUED FROM PAGE 40 choledocholithisasis/cholangitis. Table 1 summarizes the POCUS evaluation of the gallbladder: clinical signs, POCUS figure and findings. I make sure I perform POCUS on all my patients with RUQ or epigastric abdominal pain patients. And I have found that my surgical colleagues are thankful. ■

References:

POCUS Findings:

Wall thickness <0.3cm

Normal gallbladder

Sonographic Murphy’s sign

No pericholecystic fluid

Presence of hyperechoic stone within the GB lumen

Pericholecystic fluid

Normal or abnormal gallbladder

No sonographic Murphy’s sign CBD <0.7cm

Wall thickness >0.3cm

CBD >0.7cm

CBD<0.7cm

1. Hwang H, Marsh I, Doyle J. Does ultrasonography accurately diagnose acute cholecystitis? Improving diagnostic accuracy based on a review at a regional hospital. Can J Surg. 2014;57(3):162–168. 2. Hilsden R, Leeper R, Koichopolos J, et al. Pointof-care biliary ultrasound in the emergency department (BUSED): implications for surgical referral and emergency department wait times. Trauma Surg Acute Care Open. 2018;3(1):e000164. Published 2018 Jul 30.

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CASE REPORT

Help, I Canâ&#x20AC;&#x2122;t Move My Legs! By Harsh Shah, MS4 Dept. of Emergency Medicine, UF

Vu-Anh Nguyen Dept. of Emergency Medicine, UF

Muskan Shah University of Florida

Abstract

Patient Presentation

The approach to a patient complaining of weakness includes three key components: distinction of muscle weakness vs. motor impairment, localization of the site of the lesion, and determining the cause of the lesion.

A 27-year-old male with no significant past medical history is brought in via EMS to the Emergency Department for a month-long history of worsening bilateral lower extremity weakness. He woke up the previous night with an inability to move his lower extremities, followed by a fall after attempting to get out of bed. He eventually regained strength and was able to walk a short distance before falling again. There was no loss of consciousness nor head injury as a result of his falls. He denied recent illness, trauma, associated headache, numbness/paresthesia or facial weakness. ROS was notable for recent unintended weight loss and palpitations.

In an undifferentiated patient, weakness is separated based on site of the lesion and diagnostic category (Fig. 1). The differential for weakness is broad and includes genetic, inflammatory, infectious, neoplastic, toxic and metabolic causes.1 The history and physical examination can help guide and tailor this broad differential to identify the cause of weakness in a patient.

Fig. 1: Site of Lesion

Diagnostic Category:

Upper Motor Neuron

Anterior Horn Cell

Peripheral Nerve

NM Junction

Muscle

Genetic

Leukodystrophies

Spinal muscular atrophy

Peroneal muscular atrophy

Myasthenia gravis

Muscular dystrophies

Inflammatory

Vasculitis

Amyotrophic lateral sclerosis

Guillain- Barre

Myasthenia gravis

Polymyositis

Infectious

Brain abscess

Poliomyelitis

Leprosy

Botulism

HIV

Neoplastic

Brain tumor

Paraneoplastic syndrome

Myeloma/ amyloid

EatonLambert syndrome

Malignancyassociated myositis

Toxic/Drug

Radiation

Lead

Organophosphate poisoning

Steroid

Metabolic/ Endocrine

Vitamin B12 deficiency

---

Diabetes

---

Hypothyroid Hypoglycemia

EMpulse Fall 2019

Meredith Thompson, MD Dept. of Emergency Medicine, UF

On physical exam he was afebrile, tachycardic to 111 and normotensive. Neurologic exam was notable for proximal > distal weakness in the lower extremities (2/5 at hips, 4/5 at ankles) and hyporeflexia (1+ patellar). HEENT, cardiac, pulmonary, spine and the rest of the neurologic exam was otherwise normal. Initial work-up included complete blood count, basic metabolic panel, creatine kinase, magnesium, urinalysis, electrocardiogram and chest x-ray. His BMP was notable for potassium of 2.6 mmol/L (reference: 3.3 - 5.1 mmol/L). The rest of his workup was unremarkable. Thyroid stimulating hormone, free T4, and T3 were added after initial labs and neurology was consulted for further workup. Thyroid studies were notable for: TSH <0.030 mIU/L (reference: 0.400 - 5.000 mIU/L), free T4 3.49 ng/dL (reference: 0.60 - 1.20 ng/dL), T3 280 ng/dL (reference: 87 - 178 ng/dL), free T3 8.0 pg/ ml (reference: 1.8 - 4.2 pg/ml). His potassium was repleted and he was admitted to general medicine for further evaluation/ observation. Endocrinology was consulted inpatient, and he was started on methimazole 10mg BID and propranolol 10mg TID for symptomatic management. By the next day, he had significant improvement in strength and the patient was discharged with endocrinology follow-up. Ten days after discharge, he presented to the ED with substernal

chest pain and muscle weakness. He was in sustained ventricular tachycardia, had increased work of breathing and was unable to move his distal extremities. He was given amiodarone and cardioverted twice. He converted to normal sinus rhythm on the second attempt. He had severe hypokalemia to 1.5 mmol/L (reference: 3.3 - 5.1 mmol/L), hypophosphatemia to <1 mg/dL (reference: 2.7 4.5 mg/dL), and hypomagnesemia to 1.7 mg/dL (reference: 1.5 - 2.8 mg/dL). He was given dexamethasone, electrolyte repletion was started, and he was admitted to the medical intensive care unit. In the ICU, his propranolol was increased and he was monitored for two days with stabilization of his electrolytes and improvement in his free T4 levels. The electrolyte imbalances were thought to be driven by the hyperthyroid state, and the cardiac arrythmia was driven secondary to the electrolyte imbalances. The patient has been followed up extensively by endocrinology on an outpatient basis and was continued on his beta-blockers and methimazole. He is currently undergoing titration of his antithyroid medications and, per the

medical record, denies any recent episodes of paralysis.

Discussion Thyrotoxic periodic paralysis (TPP) is a rare complication of hyperthyroidism characterized by hypokalemia and muscle paralysis secondary to an intracellular shift in potassium levels.2,3 The condition primarily affects proximal muscles more that distal muscles and involves lower extremities greater than upper extremities.4 Symptoms of TPP can commonly be misdiagnosed for other metabolic, neurologic and idiopathic pathologies. Despite a higher incidence of hyperthyroidism in females, TPP occurs predominantly in males, and while it does not have familial inheritance, key human leukocyte antigens in Asians have been associated with increased susceptibility in developing TPP.5,6 TPP is initially managed by careful potassium replacement therapy, nonselective beta-blockers, and addressing any underlying hyperthyroid complications. Antithyroid medications are added once the patient is stable to control the hyperthyroid symptoms.7,8,9 ■

References: 1. Miller, ML (2019). Approach to the patient with muscle weakness. In M. R. Curtis (Ed.), UpToDate. Retrieved Aug. 16, 2019, from www. uptodate.com/contents/approach-to-the-patient-with-muscle-weakness 2. Kung AW. Clinical review: Thyrotoxic periodic paralysis: a diagnostic challenge. J Clin Endocrinol Metab. 2006;91(7):24905. doi.org/10.1210/jc.2006-0356 3. Vijayakumar A, Ashwath G, Thimmappa D. Thyrotoxic periodic paralysis: clinical challenges. J Thyroid Res. 2014;2014:649502. http://dx.doi. org/10.1155/2014/649502 4. Meseeha M, Parsamehr B, Kissell K, Attia M. Thyrotoxic periodic paralysis: a case study and review of the literature. J Community Hosp Intern Med Perspect. 2017;7(2):103106. 5. Lam L, Nair RJ, Tingle L. Thyrotoxic periodic paraly-

sis. Proc (Bayl Univ Med Cent). 2006;19(2):126–129. doi:10.1080/08 998280.2006.11928143. 6. Tamai H, Tanaka K, Komaki G, et al. HLA and thyrotoxic periodic paralysis in Japanese patients. J Clin Endocrinol Metab. 1987;64(5):10758. 7. Sharma ZD, Gokhale VS, Chaudhari N, Kakrani AL. Thyrotoxicosis presenting first time as hypokalemic paralysis. Thyroid Research and Practice. 2013;10(3):114. Doi: 10.4103/0973-0354.116132 8. Meseeha M, Parsamehr B, Kissell K, Attia M. Thyrotoxic periodic paralysis: a case study and review of the literature. J Community Hosp Intern Med Perspect. 2017;7(2):103106. doi.org/10.1080/20009666.20 17.1316906 9. Neki NS. Hyperthyroid hypokalemic periodic paralysis. Pak J Med Sci. 2016;32(4):1051-2. Doi: 10.12669/pjms.324.11006

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EMpulse Fall 2019

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FEATURE

MEMORIES OF

Lisa Wayne Lee, MD, FACEP

FCEP Past-President 1985-87

They’re both probably gone now. They were the elderly parents of my 17-year-old patient. She was their love child. It was a time before Trauma Centers. Hospitals and physicians were not prepared to respond to the massive trauma she had endured.

patients involved. Their premise was that these were the “easy” patients, and we could probably handle them.

I was in a hospital where sunburns and man-o-war stings were the usual fare. It was a cushy job sitting around all day reading or napping—until the next patient from Buffalo walked in looking like a recently boiled lobster. These were the early days of emergency medicine, and my experience was limited. Rescue knew not to bring difficult patients to us. We were on the wrong side of the tracks. Actually, the wrong side of the intracoastal. Coming to us meant coming over the intracoastal bridge, and risking having to stop for a passing sailboat. We were not the hospital of “choice” for anyone that was really sick or injured.

We readied the small five-bed ER. Getting ready meant calling the nursing supervisor to come stand by in case we needed her. There were only the two of us: the nurse and myself. Maybe there was a tech in the hospital that would also pitch in. That was it. Nothing else was required to get ready. Nothing else was available. We had no special trauma kits, and there were no other physicians in the hospital to come running and provide their special expertise… anesthesiology, trauma, surgery.

But this night had dealt me a sobering hand. It would test me and leave me with a memory tattoo. A case and a blessing I will never forget. The exact time is fuzzy now, but because the man in the other car was drunk and stoned, it must have been after dinner hours. The call came in over the radio as a car wreck. It was so bad that the paramedics were going to bring us two of the six or seven 44

The other hospital was going to have its hands full. They did the right thing, but they were wrong about the “easy” part.

The ambulance pulled up with two patients: a loud, adult male and another patient that was quiet and smaller. Today, each would have arrived in a much larger rescue vehicle equipped with two paramedics in the back and enough gear and equipment to do heart surgery. Tonight, however, the primitive pickup and release EMS system that was serving our community was not the problem. It was the severe impact. He was obnoxious, foul and in a lot of pain. I chose to see him first. There was blood on the lower sheet and his EMpulse Fall 2019

leg looked crooked. Before I crossed the 10 feet to his stretcher, I had decided I did not like him. He was yelling, cursing and admonishing us to do our job. He believed that was to focus on him and his injuries and treat him with the priority that his professional and social status demanded. He was an attorney. A BC. A big cheese. His leg had snapped just above the ankle and there was bone protruding from the open wound. This was one of the nastiest-looking injuries I had seen since coming home from SEA. The wounds had been bigger there. The legs were not always attached. I did have some experience. Those young boy soldiers in Laos had been tougher. They were never drunk on arrival and they had been quieter. Many of them survived; just not with all their limbs. Maybe this was easy. There really wasn’t much for me to do besides install the mandatory intravenous fluid line, give him something for pain, do the perfunctory exam to rule out other injuries and hide my disgust for him. Little did I know that that was going to become more difficult after I saw the other patient. I told the supervisor to see if she could find an orthopedic surgeon to come in and take him off my hands. I put his words on the chart in quotation marks: “I’m stoned on marijuana and drunk,” not knowing that would later

impact his life in a significant way. The newspapers would lead with my testimony from his trial. His high profile attorneys would attack me on the witness stand, but the quotation marks would be too hard to erase. He would be found guilty of manslaughter.

This night was blessed initially. The surgeon called back quickly and maybe, sensing the fear in my voice, he said he would come to the hospital. I would start getting some more blood typed and cross-matched and get some x-rays. Number one was still yelling. I stuck close to number two.

One down. Let me see number two. She was blonde, pretty, and I would guess she was in her high school years. She was barely conscious. Her injuries were not as visible as his, but her blood pressure of 70 hinted that she could be in trouble. Her face was uninjured, but her belly was distended and her chest crackled when I touched it. She was pale. She was trying to die in front of me.

The big hospital on the other side of the intracoastal had received all three of the other girls. They were all dead now. Their car had been hit with tremendous force as it drove through the green-lighted intersection. Number one had not stopped.

Okay, I had dealt with this in my war years. Shock. I needed to get some blood in her, and get the on-call surgeon to come quickly. In those days, that was always a challenge. No one wanted to come out in the middle of the night and take care of a trauma patient. For the sake of a little more sleep, there was always a request for more blood tests, just to make sure I wasn’t overreacting. There was an assumption that I did not have much experience with these things, and the hospital rules were loose. As emergency medicine evolved over the next 20 years, that would change. We would gain control of the hammer, and if we said “come to the hospital now,” the debate ended.

While waiting for the x-ray tech to get warmed up, a call came into the ER. For the sake of anonymity, we’ll call him Dr. Z: a plastic surgeon, Chief of Staff at the really big hospital across town, and president of the county Medical Society. He was high up on the pecking order. He told me that his daughter had been involved in a car accident and wanted to know if she was in our ER. Her name was Lisa. She was a young ballerina. His princess. We didn’t know the name of number two, so I put him on hold and went to her bedside. “Is your name Lisa?” “Yes,” was one of the few words she had been able to get out. I told Dr. Z, and he was on his way.

In x-ray, Lisa kept trying to die. Two units of blood already and her pressure was still low. She was unresponsive. I was hoping the orthopedist was in the ER, dealing with number one. I was watching from behind the lead shield when Dr. Z rushed in. He looked at the girl on the x-ray table and said, “that’s not Lisa.” There had been two Lisas in the car. I suddenly felt nauseated. This was the hardest part of my job. Could I avoid the task of telling him what I knew? I didn’t. He was gone in a second. The OR team started to arrive, and the surgeon was in the hospital. We could take Lisa upstairs. Number one was being prepped for surgery on his leg. He had stopped yelling. Things were quieting down. It was after midnight. The nurse called to tell me that Lisa’s parents had arrived, and I should come update them. As I approached, I was struck by their age: older, and not the parents of a teenager that I expected. They were warm, gracious and kind as I told them about their daughter. I painted a cautious picture but allowed for hope. I couldn’t leave them, so we talked. Lisa was their second daughter, born later in their marriage.

CONTINUE ON PAGE 47 » EMpulse Fall 2019

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They had lost their first daughter to cancer. Surgery dragged on. I became the line of communication between the parents and the OR. Back and forth. Nothing good and nothing bad. Eventually, Lisa was taken to the recovery room still alive. The parents began the wait, and I went to bed. In those days when someone went into cardiac arrest in the hospital, the operator yelled out “Code Blue” over the hospital intercom. Everyone in the hospital could hear it. The operator would then call me and tell me which room. This time it was in the surgery ICU. It was Lisa. I ran. She was in full cardiopulmonary arrest. Her heart only had a little electrical activity and she was not breathing. Cardiac arrest from trauma is not good. Rarely is there anything that can be done to reverse course. I tried. More blood, more air, but Lisa would not survive the greatness of her malady; severe intra-abdominal and intra-thoracic trauma.

She was gone. Now, for the second time that evening, I felt nauseated. I needed to go to the surgical waiting room. I knew her parents would have heard the “Code Blue.” I knew that they probably knew what that meant but were not sure of the most common outcome. In those days, waiting rooms were not as structured and strategically placed as they are today. In this small hospital, it was a small room at the end of a very long hallway that lead directly from the door of the ICU. Everything was quiet. As I walked that hallway, I could see Lisa’s mother standing in the doorway of the waiting room. The walk seemed longer than the hallway. I could see her, and she could see me. We both waited as I walked. My approach to these conversations had always been to get it out clearly, so the answer to their question was immediate and not confusing. Within a few feet of Lisa’s mother and now her father, I said, “Lisa is gone.” I could not have said more. I could barely speak. Somehow, I had be-

come related to these folks. We had transcended our social or economic or ethnic boundaries and we were connected. It didn’t always happen like that. As I was struggling to put composure in place—composure that was required but didn’t make sense—Lisa’s mother reached out with her hand and touched my arm. She told me that she understood how hard my job was and was sorry for my pain. I was stunned. They had just lost the last love of their lives, the dream of seeing grandchildren one day, joyful holidays and so much more… and she still had room for me in her heart. I didn’t know it at the time, but I would experience this again a number of times in my career. It wasn’t guaranteed, but it would happen. Medicine has given me far more than I could have ever given it. I am truly blessed. ■

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EMpulse Fall 2019

EMpulse Fall 2019

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