EMpulse Fall 2022 by Florida College of Emergency Physicians

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

Leading FCEP Forward WHAT’S INSIDE: » Symposium by the Sea 2022 Recap » The Status of the Emergency Medicine Workforce in Florida » The Unintended Consequences of Vitamin D in COVID Prophylaxis » Hematologic Emergency: Delayed Hyper-hemolytic Transfusion Reaction in a Pediatric Sickle Cell Patient

EMpulse Fall 2022

Vol. 29, No. 2 | Fall 2022

2022-2023

BOARD OF DIRECTORS EXECUTIVE LEADERSHIP

Damian Caraballo, MD, FACEP PRESIDENT

Jordan Celeste, MD, FACEP PRESIDENT-ELECT

Todd Slesinger, MD, FACEP, FCCM, FCCP VICE PRESIDENT

Saundra Jackson, MD, FACEP SECRE TARY TRE A SURER

Sanjay Pattani, MD, MHSA, FACEP IMMEDIATE PA STPRESIDENT

BOARD MEMBERS

Rajiv Bahl, MD, MBA, MS

Tom Bentley, MD, FACEP

Blake Buchanan, MD, FACEP

Natalie Diers, MD, PGY-2 EMRAF PRESIDENT

Kyle Gerakopoulos, MD, MBA

Jesse Glueck, MD

D. Eliot Goldner, MD, FACEP

Shayne Gue, MD, FACEP

Shiva Kalidindi, MD, MPH, MS(Ed.)

Amy Kelley, MD, FACEP

Dakota Lane, MD

David C. Lebowitz, MD, FACEP

Kristin McCabeKline, MD, FACEP, FAAEM, FACHT ACEP REPRESENTATIVE

Diana MoraMontero, MD, FACEP

Josef Thundiyil, MD, MPH, FACEP

Christine Van Dillen, MD, FACEP

Stephen Viel, MD, MBA, FACEP

On the cover: Board members at Symposium by the Sea 2022. From left to right: Drs. Josef Thundiyil, Diana Mora-Montero, Eliot Goldner, Chrissy Van Dillen, Rajiv Bahl, Shiva Kalidindi, Jordan Celeste, Todd Slesinger, Damian Caraballo, Sanjay Pattani, Saundra Jackson, David Lebowitz, Blake Buchanan, Stephen Viel, Kyle Gerakopoulos. 2

EMpulse Fall 2022

TABLE OF CONTENTS FROM THE COLLEGE 6 FCEP President’s Message By Dr. Damian Caraballo 7 EMpulse Bids Farewell to Editorin-Chief, Dr. Karen Estrine By Samantha League, MA 8 Government Affairs By Dr. Blake Buchanan 10 EMS/Trauma By Dr. Desmond Fitzpatrick 11 Pediatric Committee: Pediatric Airway Management & Respiratory Emergencies By Dr. Vanessa Perez

12 Membership & Professional Development By Dr. Shayne Gue 20 Early Career Physicians: Burn Notice By Dr. Dakota Lane 24 EMRAF President’s Message By Dr. Natalie Diers, PGY-2 33 Medical Student Council By Rachel Shi, MS-II

Florida Atlantic University By Dr. Christian Schuetz

23 Lakeland Regional Health By Dr. Andrew Barbera 24 UF Gainesville By Dr. Megan Rivera

HCA Orange Park By Drs. Davis Wood, Hillary Baker & Shannon Overholt

25 Jackson Memorial Hospital By Dr. Kristopher Hendershot

USF at Tampa General Hospital By Dr. Kenneth Dumas UCF/HCA North Florida EM By Dr. Chris Sowers

MANAGING Samantha League, MA & DESIGN sleague@emlrc.org EDITOR

26 Broward Health By Dr. Jean-Dominique Foureau HCA Kendall Regional By Dr. Jack Finnegan

27 UCF/HCA Ocala EM By Drs. Emily Weeks & Mortatha Al-Bassam UF Jacksonville By Dr. Jeanne Rabalais

28 Oak Hill Hospital By Drs. Ryan Johnson & Mohammad Razzaq FSU at Sarasota Memorial By Dr. Hannah Cianci Orlando Health By Drs. Sean Hire & Reshma Sharma

23 EMPros

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EMpulse Online: Call for Content: EMpulse will begin publishing articles online on a rolling basis in 2023. A print issue will be published once a year with content selected by an Editorial Committee. Learn more on page 7.

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EMpulse Online Homepage fcep.org/empulse

ADVERTISER INDEX 18 Envision Physician Services

EMpulse Magazine is the official publication of the Florida College of Emergency Physicians (FCEP). EDITOR-IN- Karen Estrine, DO, FACEP, FAAEM CHIEF karenestrine@hotmail.com

UPDATES FROM FLORIDA’S EM RESIDENCY PROGRAMS 22 AdventHealth East Orlando By Dr. Shannon Caliri

FALL 2022

Volume 29, Issue 2

30 Envision Physician Services 41 VITAS® Healthcare

All advertisements in EMpulse are printed as received from advertisers. The Florida College of Emergency Physicians does not endorse any products or services unless otherwise stated. FCEP receives and distributes employment opportunities but does not review, recommend or endorse any individuals, groups or hospitals that respond to these advertisements. Opinions stated within articles are solely those of the writers and do not necessarily reflect those of the EMpulse staff, the Florida College of Emergency Physicians, our advertisers/sponsors, or any of the institutions our writers are affiliated with. EMpulse Fall 2022

/emlrc.org

@fcep

@emlrc

@fcep_emlrc /company/emlrc 33

March 27-29, 2023

Four Points by Sheraton Tallahassee Downtown Tallahassee, FL dates tentative; pending contract

We are excited to invite all members back to our annual state advocacy event!

“

The moment we become stagnant and decide that this is how

it’s going to be and we can’t adjust the changing paradigms, the

changing laws, the changing needs — then we’ll become dinosaurs. We’ll become extinct. - Dr. Josef Thundiyil

More info coming soon at fcep.org/emdays

Florida College of Emergency Physicians Board of Directors:

TABLE OF CONTENTS CONTINUED

PRESIDENT Damian Caraballo, MD, FACEP

FEATURES & COLUMNS 4 2022-2023 FCEP Board of Directors 8 Daunting Diagnosis By Dr. Karen Estrine 10 “The Perfect Patient” - Mindful Narcan Use in the Opioid Epidemic By Dr. Danielle DiCesare 13 Symposium by the Sea 2022 Annual Meeting Recap, Residency Competitions & Conference Photos By Samantha League, MA 32 The Status of the Emergency Medicine Workforce in Florida By Drs. David and Barbara Orban 34 Going to the Beach to Catch the Peaked T-Waves: Heat Stroke Causing Multiorgan Failure By Drs. Kristopher Hendershot, Jameson Tieman & Emily Brauer 36 The Unintended Consequences of Vitamin D in COVID Prophylaxis By Drs. Shilpi Ganguly & John Cienki 38 Preliminary Analysis of Downstream Treatment Engagement Post-ED Visit in Opioid Use Disorder Patients with and Without Additional Psychiatric Comorbidity By Dr. Heather Henderson, Ana Gutierrez, Dr. Bernice McCoy, Dr. Jason Wilson & Owen Hastings

40 Poison Control: The Use of Fomepizole as an Adjunct Therapy in Massive Acetaminophen Overdose By Drs. Reeves Simmons, Molly Stott and Dawn Sollee 42 Use of Dexmedetomidine as a sedative for intubated, mechanically ventilated patients By Drs. Jacob Milling & Casey Carr 43 The Way We Were By Dr. Doreen Parkhurst 44 Ultrasound Guided Transgluteal Sciatic Nerve Block for Refractory Sciatica in the Emergency Department By Drs. Edward Hu & Taryn Hoffman 46 Hematologic Emergency: Delayed Hyper-hemolytic Transfusion Reaction in a Pediatric Sickle Cell Patient By Drs. William Waite & Camilo Florez 48 A Tale of Two Shocks: A Cardiogenic Shock Interview with the Heart Failure Specialists By Shaheen Emami, Dr. Joshua Goldstein, Jennifer Paciletti, ARNP & Dr. Waqas Ghumman 50 Musings from a Retired Emergency Physician: A PostRoe ER By Dr. Wayne Barry

PRESIDENT- Jordan Celeste, MD, FACEP ELECT VICE Todd Slesinger, MD, FACEP PRESIDENT SECRETARY- Saundra Jackson, MD, FACEP TREASURER IMMEDIATE Sanjay Pattani, MD, MHSA, FACEP PASTPRESIDENT INTERIM Melissa Keahey EXECUTIVE DIRECTOR MEMBERS Rajiv Bahl, MD, MBA, MS; Tom

Bentley, MD, FACEP; Blake Buchanan, MD, FACEP; Natalie Diers, MD (EMRAF Representative); Kyle Gerakopoulos, MD; Jesse Glueck, MD; Eliot Goldner, MD, FACEP; Shayne Gue, MD, FACEP; Shiva Kalidindi, MD, MPH, MS(Ed.); Amy Kelley, MD, FACEP; Dakota Lane, MD, FACEP; David Lebowitz, MD, FACEP; Kristin McCabeKline, MD, FACEP, FAAEM, FACHT (ACEP Representative); Diana Mora-Montero, MD, FACEP; Josef Thundiyil, MD, MPH, FACEP; Christine Van Dillen, MD, FACEP; Stephen Viel, MD, MBA, FACEP

Florida Emergency Medicine Foundation Board of Directors: PRESIDENT Ernest Page, MD, FACEP VICE Roxanne Sams, MS, ARNP-BC, MA PRESIDENT SECRETARY- Maureen France TREASURER MEMBERS Dick Batchelor; Arthur Diskin,

MD, FACEP*; Jay Falk, MD, MCCM, FACEP*; Vidor Friedman, MD, FACEP*; James V. Hillman, MD, FACEP*; Michael Lozano, Jr., MD, FACEP*; Cory Richter, BA, NREMT-P; David Seaberg, MD, FACEP*

39 ED Pain Coach Educator Model Program and Patient Toolkit Guide for Integrative Pain Management By Drs. Phyllis Hendry, Sophia Sheikh & the PAMI team

*FCEP Past-President

“ EMpulse Fall 2022

The Florida College of Emergency Physicians (FCEP) and Florida Emergency Medicine Foundation (FEMF) are nonprofit organizations dedicated to advancing emergency care through education and advocacy. Both are headquartered at the Emergency Medicine Learning & Resource Center (EMLRC) at 3717 S. Conway Rd., Orlando, FL 32812. 5

FROM THE COLLEGE

FCEP President’s Message: What You Can Accomplish Through Our Organization By Damian Caraballo, MD, FACEP FCEP President 2022-2023 During my eleven years of being involved at the Florida College of Emergency Physicians, I have seen just how much we can accomplish by working together towards common goals. Unfortunately, because so much of the work occurs behind the scenes, it’s striking how little physicians know about what organized medical groups such as FCEP do on their behalf. Here in Florida, members of FCEP wrote language in the Florida Balance Billing Law (now part of the Florida Constitution), which established out-of-network reimbursement (read: what you and I get paid) at usual and customary charges. That little change might not mean much to most physicians, but it was a huge victory that took hundreds of hours of uncompensated work by FCEP physicians and staff to lobby on behalf of physicians in Tallahassee. It established that physicians and their groups have the right to fairly negotiate with insurers and gave us a recourse to hold them accountable when they under-reimburse physicians. Had original language in the Florida Balance Billing Bill passed in 2017, Florida emergency physicians would be looking at minimum 10% reimbursement cuts from insurers. Last year we saw the passage of the No Surprises Act (NSA), which further banned balance billing from physicians to patients. The bill’s original language, confirmed by a Congressional Budget Office (CBO) budget estimate, would have put a reimbursement ceiling on hospital-based physicians and cut our pay 20% over 10 years. Given that the average emergency physician salary is approximately $342,000, ACEP – working along with other organized medicine partners – saved every 6

emergency physician approximately $68,000/year. Yet a common refrain I hear from many physicians is, “what does FCEP do for me?” or “why should I pay to be in FCEP when they don’t speak for me?” This cynical attitude is often erroneously repeated on social media and in conversations I have with clinical physicians. Truth be told, the only thing keeping physicians from a complete corporate take-over where everyone is employed by either a giant corporation, hospital, or (worst yet) a health insurer, is organized medical groups such as FCEP. While it may seem that physicians have been on the ropes for a while and the end of physician-led healthcare in the U.S. is nearing, here are some of the victories FCEP (and ACEP nationally) has helped lead in the past five years:

•

Changed NSA language, which would have cut physicians reimbursement 20%

•

Gave Florida Independent Dispute Resolution (IDR) for out-of-network bills instead of the proposed health insurer benchmarks, which would have set a price ceiling for all reimbursement at insurerdetermined in-network levels

•

Successfully opposed full independent practice authority to nurse practitioners and physician assistants in the ED and hospital setting

•

Changed the “pelvic law” to get rid of written consent for pelvic exams

•

Allowed opioids to be written for “short-term pain” when initially the Legislature proposed banning all opioid prescriptions written in an ED setting EMpulse Fall 2022

•

Fixed a law which would have made it illegal to render medical care to a minor without parental consent

•

Protected Florida Auto-Insurance Physician Med-pay, which insures $5,000 payment for physician services in all insured motorists seen in the ED. The proposed bill would have cut trauma center physician reimbursement an estimated 6-8%

•

Changed a law that would have ended all paper prescriptions for physicians in Florida to allow exceptions

•

Expanded MAT opioid treatment and funding in Florida

•

Started a workforce study group that will help examine potential oversupply or maldistribution of emergency physicians in Florida and seek to standardize baseline EM residency training requirements.

In addition to fighting for physician autonomy and rights, FCEP has also managed to host yearly residency events such as SimWARS, the CPC competition, and Life After Residency, along with Symposium by the Sea, CLINCON, and other EMS and EM educational programs. FCEP is the most equipped organization for improving emergency care in Florida — it’s the best way for emergency physicians to get plugged into a “problem-solving network” to fix the problems ailing emergency care in our state. In addition, FCEP puts emergency physicians in the position to fight for fair pay and oppose billiondollar, conglomerate U.S. health insurers, which take in over $1 trillion in revenue per year.

FROM THE COLLEGE

“

Ask not what FCEP can do for you, but what you can do through FCEP.

Unfortunately, doctors have let corporate and commercial interests hijack the U.S. healthcare system. As a $5 trillion industry, U.S. healthcare is now the 5th largest economy in the world. The more money involved, the more you can expect outside forces to strip physicians of autonomy and power in a manner that will most economically benefit them at the expense of physicians and proper patient care. FCEP is the way in which we can oppose outside forces deterring the physician-patient relationship. If you have a problem which hinders your care in the ED, reach out to us — we will get you in contact with the person who can help address that problem, and help improve your experience as an emergency physician. Now more than ever, physicians need to band together to fight for physician and patient rights, autonomy, fair compensation, and against encroachment by greedy, non-medical entities looking to make money. To paraphrase JFK, ask not what FCEP can do for you, but what you can do through FCEP. ■

Joint FCEP-FEMF Board & Committee Meetings November 15, 2022 8:00 am - 3:00 pm Virtual and in-person at EMLRC

Scan to learn more

EMpulse Bids Farewell to Editorin-Chief, Dr. Karen Estrine by Samantha League, MA

Director of Communications; EMpulse Managing Editor/Designer

After 10 years of service to EMpulse Magazine, we are sad to announce that Dr. Karen Estrine is stepping down from her position as editor-in-chief after this issue. Dr. Estrine assumed the position of editor-in-chief in Spring 2013 after serving as assistant editor for one year. In addition to editing each issue and overseeing the production of EMpulse, she wrote a Daunting Diagnosis every quarter and other feature articles throughout the years. EMpulse Magazine has grown significantly under her leadership. During her tenure, the magazine:

• • • •

Underwent two redesigns Grew from a 24-32 page magazine to a 48-52 page magazine Broke into the digital sphere in 2020 at fcep.org/empulse, where each article is published online in addition to print Grew its Residency Updates section from seven programs to 22 programs (100% participation rate for Match Day and Graduating Residents features)

It has been a great pleasure working with and learning from Dr. Estrine during my time here at FCEP. Please join me in wishing her the best as she pursues other ventures and welcomes her second child this December.

to publish residency updates and committee reports on a regular basis while publishing columns and features more frequently on a rolling basis. To best achieve this vision, the Executive Committee has identified the need for an Editorial Committee. This new committee will assist with EMpulse Magazine and other FCEP publications, like our Weekly eNews. The goal is to ensure that FCEP’s voice is consistent across all channels and that our scientific work continues to represent our collective excellence in emergency medicine. The FCEP Editorial Committee will be expected to: • Review, edit and approve article submissions on a rolling basis • Pitch story ideas and solicit content from other members • Identify articles that should be included in the annual issue of EMpulse Magazine (anticipated inmailboxes date: Oct.-Dec. 2023) • Attend virtual meetings to discuss the strategic direction of FCEP’s publications If you are interested in joining this committee, please email sleague@emlrc.org. Thank you, again, to Dr. Karen Estrine for her outstanding service to FCEP through EMpulse Magazine. ■

What’s Next for EMpulse Magazine Due to rising printing costs and an increasing demand for online components of the magazine, after this issue, EMpulse will become an annual print publication. This will allow us to grow EMpulse Online, continuing EMpulse Fall 2022

COMMITTEE REPORT

Government Affairs By Blake Buchanan, MD, FACEP

Committee Co-Chair | FCEP Board Member

The primaries are now over and all eyes have turned to the general election on November 8. This year’s election in Florida is an influential one. After redistricting during the last session (and all of the drama that followed), every single state Representative and Senate seat is on the ballot this fall. We will see the governor, along with other state executive branch offices, in addition to one of our federal Senate seats on the ballot this year. At FCEP, your political committees have been working hard to support pro-medicine candidates across the ballots all over the state. This next session will start a new era of leadership in Tallahassee. The likely new Speaker of the House will be Paul Renner, and a likely new Senate President will be Kathleen Passidomo. This is contingent on the Republicans continuing to hold majorities in each house of the legislature, as polling currently suggests. But, nothing is

guaranteed until each vote is cast and Florida has been known for its electoral surprises before. As emergency physicians, the issues important to us and our patients transcend party lines, and no matter your political views or those of your representatives, I encourage each of you to advocate and contact your legislators regularly about the issues that are important to emergency medicine. We cannot expect to have an effect on the outcome by simply standing on the sidelines. The upcoming legislative session in the Spring will be later this year following the election. Committee weeks will begin in January and the actual legislative session will run through March and April. Be on the lookout for EM Days 2023 information so that you can join us in Tallahassee to advocate with your fellow emergency physicians this spring.

DONATE TO OUR PAC: Text “FCEPPC” to “41444” or Scan to donate online

Remember to vote this season as we continue to advocate for pro-medicine candidates and educate those in power on the issues important to emergency physicians. If you are able, I encourage you to donate to the FCEP PAC so that we can continue being your unified voice throughout the state. We may give our time to advocate on your behalf, but it is your contribution that gets our foot in the door. ■

Daunting Diagnosis: Q By Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief

A 28-year-old male presents statuspost assault. He states he was struck in the face and jaw several times. He presents with blood in his mouth and with multiple loose teeth. Attached are images of his CT scan. What are his findings? CONTINUE ON PAGE 47 ▶ 8

EMpulse Fall 2022

Thank You, PAC Donors The success of FCEP’s advocacy efforts is dependent upon our ability to fund those efforts. Thank you to the individuals who donated in April - August 2022:

Wesley Baber

Sebastian Fresquet

Matthew Lightcap

Scott Russo

Ian Charles Backstrom

Anthony Furiato

Benice Louis

Reginald Saint-Hilaire

Maisha Balaparya

Christine Gage

Mike Lozano

Andrew Schare

Steven Barrett

Tisha Gallanter

Judith Lucas

Kathleen Schrank

Kayla Batista

Ashley Garcia

Christopher Martin

Donna Schutzman-Bober

Caroline Baughn

Edward Anthony GarciaOlmeda

David Martin

Matthew Schwartz

Talor Matthews

Star Seliquini

Kristin McCabe-Kline

Jeremy Selley

John McGann

Jason Sevald

Ryan McKenna

Andrei Simon

Daniel McMicken

Todd Slesinger

Tom Merrill

John Caleist Soud

Liana Marie Milis

Joel Stern

Craig R Mitchell

Sarah Temple

Trevor Dale Morrison

Beatrice Thomas

Alicia Nassar

Tony Kong Vang

David Nateman

Roger Vazquez Gomez

Ryan Nesselroade

Vanessa Velazquez-Ruiz

Tatiana Nunez

Stephen Viel

Ernest Page

Farid Visram

Venugopal Palani

David A Wein

Daniel Parks

Kyle Robert Weinstein

Vanessa Peluso

Tara Wendt

Kristopher Alexander Perez

Nathan Scott Whitley

Vanessa Perez

Nicholas Trent Wilkes

Oswald Perkins

Brett Williams

Max Probst

Nathaniel James Williams

Amit Rawal

Jason Wilson

Danny Redman

Stephanie K Wood

Austin C Reed

Anthony Woolf

John Ricks

Marguerite Wright

Matthew Rill

Fredric Wurtzel

Maria Juliana Rodriguez

Taylor Marie Zeglam

Ricardo A Rodriguez

John Zelahy

Robert Tyler Rollins

Vicky Qianru Zhang

Matthew Beattie Brittany Bemis Kevin Gregory Bennett Dale Scott Birenbaum Ryland Boehnke Bailey Tomiko Brown John Bruno Blake Buchanan Christian Bustamante Jessenia Cabrera Jordan Celeste Anthony Cesare Cerquozzi Gianluca Cerri Nancy Churosh Dane Clarke Stephanie Cohen Terry Cohen Eddid David Colon Cruz Anizza Levine Custodio Kathryn Dasburg Marissa Danielle DeLima Harsheel Desai Edward Descallar Caroline Kay Dixon Nicholas R Dodaro Alex Doerffler Michael Dolister Emeka Albert Egbebike Michelle Escobar-Medina Timothy Timothy Fleming Barbara Flores-Gonzalez

James Gillen Gary Gillette Eliot Goldner Steven Goodfriend Simi Greenberg Omar Hammad Kelvin Harold Brian Scott Hartfelder Douglas Martin Haus Hannah Desiree Hedriana Brendon Henry James Hillman Robyn M Hoelle Brandy Milstead Hollingsworth Laura Hummel Saundra Jackson Jack Jimenez Milan Jockovich Mark Johnson Jonathan Journey Steven Kailes Steven William Kamm Frederick Michael Keroff Nickolas Glen Kessler Felice Koscinski Christopher Kumetz Gary Lai Jon Lamos Dakota Lane Thomas Leonard

David Rose Adam Rubin 9

COMMITTEE REPORT

EMS/Trauma By Desmond Fitzpatrick, MD, FACEP Committee Co-Chair

COMMITTEE FEATURE

“The Perfect Patient” – Mindful Narcan Use in the Opioid Epidemic By Danielle DiCesare, MD, FACEP Committee Member

FAEMSMD Update: For this update, we will cover the September EMS Medical Director/ FAEMSMD meeting. President Dr. Abo introduced the Deputy Secretary of Health for Florida, Dr. Ken Scheppke, who presented the highly successful Addiction Stabilization and Management Center project that is ongoing in South Florida. Dr. Scheppke shared personal success stories that demonstrate the program’s success and offered assistance to other agencies interested in creating their own programs. This is a project that is supported by the state and the Governor, and has been largely successful. State Medical Director Dr. Angus Jameson then presented his update covering a variety of projects, including the continued work with the Florida Stroke Registry and development of Resuscitation Centers. There were major updates to the medical director dashboards on Biospatial1 and some discussion of the state-supported mass casualty triage program, ReadyOp.2 Dr. Phyllis Hendry presented the state EMS for Children update that included some of the EMS survey data.3 Dr. Peter Antevy discussed the FL NAEMSP group and that we are excited to welcome the NAEMSP national meeting in Tampa in 2023.

Opioid use disorder (OUD) continues to be on the rise. There was a 30% increase in deaths caused by overdoses from 2019-2020 nationwide, and a continued 15% rise from 2020-2021.1 Some have called this the “epidemic within the pandemic.” As synthetic opioids like fentanyl continue to replace pills and heroin, deaths are expected to increase.1 OUD has become a well-known prehospital and emergency medical chief complaint. With the rise in fentanyl and fentanyllaced products, many have anecdotally seen an increase in the amount of Narcan required to achieve opioid reversal. Whereas pre-pandemic, 0.4 – 2 mg seemed to be enough, patients are now needing 8 - 12 mg doses before observing any clinical effect. While synthetic opioids likely require these higher doses for reversal, we must also be mindful of our goal of Narcan administration. Our goal is to maintain the “perfect patient” – the one that is breathing but is not in withdrawal. Narcan administration is not benign. Although thought to be rare with

sparse literature, rapid infusion, especially at higher doses, induces a catecholamine surge that can have fatal side effects. These include non-cardiogenic pulmonary edema, arrhythmias, and even cardiac arrest.2,3,4 Narcan use can also precipitate withdrawal. Patients in withdrawal feel miserable, can become agitated, may require sedative medications, and are certainly less likely to seek our help in the future. Although Narcan without a doubt saves lives, the overuse of Narcan can also be detrimental to our patients. It’s a classic case of too much of a good thing. How would we titrate Narcan in a cancer patient who took too much of her pain medication? Would it be the same as an addict well known to our hospital system who was found unresponsive with a needle in his arm? It is very easy as a healthcare provider to become callous towards OUD patients. Please, in the spirit of primum non nocere, be mindful of our goals of care and titrate Narcan to the perfect patient. ■

The next meeting will take place in January 2023 at Fire Rescue East. ■

For more information: 1. biospatial.io 2. readyop.com/who-uses-readyop 3. emlrc.org/flpedready

Free education at emlrc.org/project/bytes Approved for AMA PRA Category 1 CreditsTM

EMpulse Fall 2022

COMMITTEE REPORT

Pediatric Committee: Pediatric Airway Management & Respiratory Emergencies By Vanessa Perez, MD, FAAP

PEM Physician at Nemours Children’s Health | Committee Member

The Pediatric Committee provided an immersive workshop on pediatric airways at Symposium by the Sea 2022. This workshop focused on pediatric airway management, upper airway emergencies, and the use of intranasal medications in children. Here are the main takeaway points: 1) Anatomical and physiological differences Infants have a prominent occiput, causing flexion of the airway, and the larynx is in a superior position, making visualization challenging. During laryngoscopy, for better visualization, look anteriorly and cephalad. Consider utilizing a straight blade to lift the large epiglottis. Utilize preoxygenation during rapid sequence intubation. Children have smaller lungs and tidal volumes compared with adults, putting them at higher risk for barotrauma and rapid desaturation. We need to prioritize oxygenation before and during endotracheal intubation since hypoxia potentiates the risk for bradycardia. 2) How to assess the pediatric airway Work of breathing is a quick observational indicator of the adequacy of oxygenation and ventilation. Assess respiratory rate and quality. Listen for abnormal airway sounds and note any abnormal positioning, retractions, nasal flaring, or head bobbing. These are signs of severe respiratory distress and impending respiratory failure. Evaluate for the possibility of a difficult airway, determine minimal therapy, and plan for escalation. Identify required personnel and prepare anticipated equipment. There are several clues in the medical history that will help us prepare to manage a child in

respiratory distress. The sudden onset of cough in a toddler always raises suspicion for foreign body aspiration. A history of prematurity, previous craniofacial surgery, daily snoring, and obesity may signify a difficult airway. It is reasonable to attempt noninvasive positive pressure ventilation or highflow nasal cannula in pediatric patients with respiratory distress. Utilize LEMON method (LookEvaluate-Mallampati-ObstructionNeck mobility) to assess and determine a difficult airway. Consider the use of bougie and video laryngoscopy in patients with an anticipated difficult airway. Early recognition of difficult intubation and transition to alternate airway techniques and expert assistance are likely to improve outcomes. 3) There are advantages to using cuffed endotracheal tubes:

•

Fit well into elliptical-shaped pediatric airway

•

Favored in patients with poor lung compliance or airway obstruction

• •

May help prevent aspiration Reduce the need for tube exchange in critically ill patients

4) Apneic oxygenation The incidence of desaturation during intubation has been reported to be 15% but can reach 48% in difficult airways. Apneic oxygenation has been shown to prevent and delay desaturation during rapid sequence intubation (RSI) in the pediatric population. By providing continuous high-flow oxygen via a nasal cannula to the patient after the onset of neuromuscular blockade, apneic oxygenation extends the duration of safe apneic time (the time EMpulse Fall 2022

following cessation of breathing until arterial desaturation occurs). 5) Acute upper airway obstruction The most common causes of acute pediatric upper airway obstruction include croup, retropharyngeal abscess, foreign body aspiration, and anaphylaxis. Stridor is a sign of obstruction at the level of the larynx. In case of acute distress, allow the patient to remain in a position of comfort and seek emergent help from anesthesia and ENT appropriately. 6) Use of intranasal medications in children Delivering medications to children in emergency settings can be challenging for several reasons: 1) children may have difficulty taking oral medications, and 2) obtaining intravenous access can be difficult. The intranasal route (quick and painless) is an excellent option in critical situations where emergent medications are needed. We can use it for anxiolysis, analgesia, seizures, and sedation. Learn the strengths and limits of intranasal fentanyl, midazolam, ketamine, and dexmedetomidine. Utilize a mucosal atomizer for intranasal administration. The pediatric airway can undoubtedly present its challenges. But with proper education, preparation and teamwork, we can set ourselves up for success. ■

SCAN FOR REFERENCES All references could not fit in print. Please scan the QR code to view this article’s references. 11

COMMITTEE REPORT

Membership & PD Committee By Shayne Gue, MD, FACEP, FAAEM

Committee Co-Chair | FCEP Board Member

Greetings from the MPD team at FCEP! We are absolutely thrilled with the turnout and outcome of Symposium by the Sea this year! The event went off without a hitch thanks to the amazing FCEP staff who brought it all together. This year saw the return of resident competitions and a move to the beautiful Hyatt Regency Coconut Point in Bonita Springs. Thank you to everyone who attended. For those who missed out, mark your calendars for next year for August 2-5, 2023 at the same venue. We hope to see you there! As we continue to emerge from the COVID-19 pandemic, the MPD committee is coming back bigger and better than ever before. With a record 22 EM residency programs in Florida and a growth in all types of membership, we are actively reaching out to every FCEP member to ensure we meet your needs and foster development at every stage of your career. Please let us know what FCEP can do for you!

EMRAF:

We are thrilled to be working with EMRAF and their new president, Dr. Natalie Diers. Our goal is to connect with all of our resident members to provide education, collaboration, sponsorship, and advocacy. With over 600 resident members, we are actively seeking out representatives and points of contact for every Florida EM program. If you or someone you know would like to get involved with EMRAF, please let us know — we would love to have you!

Early Career Physicians:

With our Early Career Physicians section, our goal is to provide targeted education and collaboration amongst our newer attending colleagues (focused on the first 5 years out of 12

residency). We have had successful virtual meetings throughout the pandemic, but are now looking forward to future opportunities for collaboration, both online and inperson. Continue to look for updates and announcements in the coming months for how to get involved.

collective strengths, experiences, and resources to build the best future for our specialty and the millions of patients we serve each year. I look forward to partnering with each of you to ensure this ideal. ■

Leadership Academy:

Last year saw the rebranding and re-emergence of our Leadership Academy. With Dr. Stephen Viel at the helm, it was arguably one of the most successful years in the history of the program. The program graduated four phenomenal young leaders who will contribute to the specialty of EM on a local, regional, and national level. We are excited to announce the upcoming slate of LA participants for the 20222023 cycle in the sidebar. Reach out if you have any questions or want to get involved!

Get Involved:

I joined FCEP as a resident member in 2016. Since then, I have served on multiple committees, led the educational planning for Symposium by the Sea, actively participated in ACEP Council, and continue to serve on the Board of Directors. I had no special qualifications and no expertise in any of these areas — simply a desire to learn and a willingness to lead. Now is the time to get involved — all you have to do is show up! Our committee and board meetings take place quarterly at our EMLRC headquarters in Orlando and can be accessed from anywhere online. I urge you to attend and can assure you that we will help you get involved. FCEP is always getting bigger and better. We are there to serve our members in every facet of their lives and work. Now, more than ever, it is important that we bring together our EMpulse Fall 2022

LEADERSHIP ACADEMY 2022-2023 Class

We are proud to introduce our newest and largest Leadership Academy class: 1. Veronica Bonales, MD 2. Ricki Brown-Forestiere, MD 3. Teri Finklea, MD, MBA 4. Daniel McDermott, DO 5. Joshua Middleton, MD 6. Brandy MilsteadHollingsworth, MD 7. Diana Mora, MD, FACEP, FPDAEMUS 8. Samuel Muniz, MD 9. James Ontell, DO 10. Jeremy Selley, DO, FACOEP 11. Ian Storch, MD 12. Chrissy Zeretzke-Bien, MD, FACEP, FAAP, FAAEM

Learn more about the Leadership Academy at

fcep.org/la

August 4-6, 2022 | Hyatt Regency Coconut Point | Bonita Springs, FL

ANNUAL MEETING RECAP On August 4, the Florida College of Emergency Physicians held its annual Board meeting at the Hyatt Regency Coconut Point. This meeting features the transition of the guard for FCEP leadership, along with the conferring of awards. FCEP Officers Installed:

• • • • •

President: Damian Caraballo, MD, FACEP President-Elect: Jordan Celeste, MD, FACEP Vice President: Todd Slesinger, MD, FACEP Secretary-Treasurer: Saundra Jackson, MD, FACEP Immediate Past-President: Sanjay Pattani, MD, FACEP

New FCEP Board Members Elected: • Rajiv Bahl, MD (incumbent) • Jesse Glueck, MD (incumbent) • Shayne Gue, MD (incumbent) • Tom Bentley • David Lebowitz • Diana Mora • Josef Thundiyil • Christine Van Dillen, MD, FACEP • Natalie Diers, MD, PGY-2 (elected during the EMRAF Meeting on August 6) • Kristin McCabe-Kline, MD, FACEP (elected to the ACEP Board of Directors at 2022 Council and appointed to FCEP’s Board as the ACEP Representative in October) Outgoing Board Members: • Erich Heine, DO • Gary Lai, DO • Russell Radtke, MD • Elizabeth Calhoun, MD • Aaron Wohl, MD, FACEP

FCEP also recognized the following award recipients: Champion of Change Award (formerly the Martin J. Gottlieb Advocacy Award) Recipient: Blake Buchanan, MD, FACEP

Thank You, Planning Committee Co-Chairs: Shayne Gue, MD, FACEP, FAAEM

The Champion of Change Award for Outstanding Advocacy in Emergency Medicine was created in honor of Marty Gottlieb and recognizes a leading FCEP advocate who has mae a significant contribution to the advancement of emergency medicine issues and advocacy in Florida over the past year.

Shiva Kalidindi, MD, FACEP

William T. Haeck Member of the Year Award Recipient: Stephen Viel, MD, FACEP

Michael Lozano, MD, FACEP

The Bill Haeck Member of the Year Award is named after our first president and recognizes an individual who has performed a significant level of service that spans years and has positively impacted the field of emergency medicine over that time, noted or unsung.

If you are interested in joining this committee, please reach out to a committee member or FCEP staff at dbennett@emlrc.org.

Committee Members: Sara Baker, MD Erich Heine, DO Maureen France René Mack, MD, FACEP

Scan to read the Symposium by the Sea 2022 Conference Program:

Congratulations to our 2021-2022 Leadership Academy Graduates:

• • • •

Dr. Andrew Martin Dr. Camilo Mohar Dr. Zack Terwilliger Dr. Geoffrey Wade

Pictured here with Chair, Dr. Stephen Viel, and Immediate Past-President, Dr. Sanjay Pattani, at the August Board Meeting

EMpulse EMpulse Fall Fall 2022 2022

Emergency Medicine Research Competition 2022 BEST CASE REPORT Ultrasound-Guided Costoclavicular Brachial Plexus Block Mediates Painless Reduction of Distal Radius Fracture in the Emergency Department by M. Townsend Reeves, MD5; Katherine O’Neil, DO5; Todd Slesinger, MD, FACEP, FCCM, FCCP5

BEST MEDICAL STUDENT POSTER Evaluation of Arrhythmia Detection Rates Among Patients with Syncope or Palpitations Discharged from the Emergency Department with Ambulatory Cardiac Monitoring Device

Whiteman14; Emily Holbrook, MA14; Jason Wilson, MD, MA, FACEP10,14

Floridian Emergency Department Fees Vary Significantly Based on Type of Control and Patient Characteristics by Alyssa Cartwright3; Tony Zitek, MD7; Brittney Pardinas3

Paramedic-performed Prehospital TeleUltrasound: A Powerful Technology or an Impractical Endeavor? A Literature Review by Rachel Shi11; Colton Amaral11, Javier Rosario, MD11

by Claire Dalby14; Naveen Perisetla14; Courtland Samuels, MD10; Alexander Breslin, MD9; Autumn Bass, DO10; Christopher Popiolek14; Enola Okonkwo, MD10

Repeat Fall Risk in Geriatric Patients following Fall-Induced Traumatic Head Injury by Brandon Knopp2; Thomas

BEST RESIDENT POSTER

Social Determinants of Health and Opioid Use Disorder by Ayesha Anwer14;

A Prospective Study Evaluating Emergency Medicine Resident Competency and Satisfaction Following the Implementation of Rapid Radiology Training Sessions Over a 4-month Period by Gary Cook, DO6; Chris Reilly, MD6; Priscilla Cruz, MD6

BEST FELLOW POSTER A Modified Ultrasound Lung Score in Patients with Pulmonary Symptoms of COVID-19 in the Emergency Department by Connor Karr, MD9; William Waite, MD9; Agnieska Gaertig, MD9; Linda Papa, MD, MSc9; Jillian Davison, MD9; Stephen Leech, MD9; Michael Clemmons, MD9

ALL ENTRIES: Medical Student Category Analysis of injury patterns related to standing electric scooters at a Level-1 Trauma center Emergency Department in an urban area by Theo Sher14; Jay Shah14; Andrew Thomas, MD, FACEP14; Emily Holbrook, MA14; Jason Wilson, MD, MA, FACEP14

Comparison of acute versus previous gunshot wound patients’ views on firearms by Jack Jimenez14; Paul Webb14; Andre Elder14; Jason Wilson, MD, MA, FACEP14; Roberta Baer, PhD14 14

Factors differentiating False Positive and Acute Positive Equivocal Fourth Generation HIV serum test results at the Tampa General Hospital Emergency Department by Thomas Shen14; Zachary

Caussat2; Joshua J. Solano, MD2; Lisa M. Clayton, DO2; Patrick G. Hughes, DO2; Richard D. Shih, MD2; Scott M. Alter, MD2

Jason Wilson, MD, MA, FACEP14; Emily Holbrook, MA14

The Effect of Diabetes on the Risk of Intracranial Hemorrhage Following Head Injury in Geriatric Patients by

Sohini Lahiri2; Joshua J. Solano, MD2; Lisa M. Clayton, DO2; Patrick G. Hughes, DO2; Richard D. Shih, MD2; Scott M. Alter, MD2

Resident Category A Case of Peri-Ureteral Abscess Following Ureteroscopy with Laser Lithotripsy and Ureteral Stent Removal

by Erik Hammond, DO5; Vincent Grekoski DO5; Amit Boukai MD, MPH5; Glenn Goodwin DO5; Laurence Dubensky, MD5

An Evaluation of Reflex Urine Culture Criteria for Emergency Department Patients by Ilya Luschitsky, MD8;

McKenzie Benz8; Tony Zitek MD8; David A. Farcy, MD8

An Infographic Utilized As A JustIn-Time Tool For Paramedic EKG Interpretation by Robert Pell, MD12;

Ayanna Walker, MD ; Latha Ganti, MD, MS, MBA, FACEP12; Anines Quinones, MD12; Ariel Vera, MD12; Javier Rosario, MD12; Alexa Ragusa DO12 12

Analyzing Stroke Alert Activations and the Correlation with a True Stroke Diagnosis by Natalie Diers, MD12; Latha Ganti, MD, MS, MBA, FACEP12; Abigail Alorda, MD12; Taylor Cesarz MD12; Alex Ragusa, DO12 EMpulse Fall 2022

Delta NIHSS after Alteplase for Acute Ischemic Stroke by Abigail Alorda, MD12;

Alexa Ragusa, DO12; Taylor Cesarz, MD12; Natalie Diers, MD12; Latha Ganti, MD, MS, MBA, FACEP12

Easy to treat, Easy to miss: A case of periodic paralysis in the emergency department by Akash Patel, DO5; Laurence Dubensky, MD, FACEP5

Effectiveness of Case-Based Learning Curriculum on Emergency Medicine Resident Self-Efficacy Related to Management of Radio Medical Communications by Linh Nguyen, MD9;

Lindsay Wencel, MD9; Danielle DiCesare, MD9; Christine Van Dillen, MD9

Factors associated with higher emergency department ICH scores by

Taylor Cesarz, MD12; Alexa Ragusa, DO12; Natalie Diers, MD12; Abby Alorda, MD12; Latha Ganti, MD, MS, MBA, FACEP12

Penetrating aortic ulceration with pseudoaneurysm and intramural hematoma: Emergency department management and point-of-care ultrasound diagnosis by Alexander

Huttleston, MD13; Derrick Huang, MD13; Frank Fraunfelter, MD, FACEP13; Leoh Leon, II, MD13; Latha Ganti, MD, MS, MBA, FACEP13

Resident-led Wellness: Fostering the skills Emergency Medicine Residents need to thrive using a longitudinal mentorship model & an innovative Residency House system by Erica

Warkus, MD4; Kelly O’Keefe, MD, FACEP4; Kevin Gil, MD4; Casey Cheney, DO4; Phil Bonar, MD4; Steven Kamm, MD, FACEP4

Spontaneous Retroperitoneal Hematoma Arising from an Adrenal Gland Mass by Edward Hu, MD7; Shilpa Amin, MD7

Stage-based interventions to improve EM provider efficiency when caring for patients with complex social situations such as intimate partner violence by Erica Warkusm, MD4; Celina Ramsey4

The Diagnostic Conundrum of a Brain Abscess by Jessica Rose, DO1; Caroline

Molins, MSMed1

Who gets cryptogenic strokes? by Alexa

Ragusa, DO12; Taylor Cesarz, MD12; Abigail Alorda, MD12; Natalie Diers, MD12; Latha Ganti, MD12

X: Play for your life - An interactive learning exercise to teach empathy and foster productive, clinically-relevant discussions in difficult social situations by Erica Warkus, MD4; Celina Ramsey4

Fellow Category Catatonia after minor head trauma in an adolescent by Lindsay Maguire, MD9;

Bryce Bergeron, MD9; Jeffer Pinzon, MD9

INSTITUTIONAL AFFILIATIONS: 1. AdventHealth East Orlando 2. FAU Charles E. Schmidt College of Medicine 3. FIU Herbert Wertheim College of Medicine 4. FSU at Sarasota Memorial Hospital 5. HCA Aventura Hospital 6. HCA Brandon Hospital 7. HCA Orange Park Hospital 8. Mount Sinai Medical Center 9. Orlando Health 10. Tampa General Hospital 11. UCF College of Medicine 12. UCF/HCA GME Consortium Emergency Medicine Residency of Greater Orlando 13. UCF/HCA Ocala Hospital 14. USF

In FCEP’s annual Case Presentation Competition, EM residents from selected programs deliver discussions of the initial approach, differential diagnosis and final impression of an unknown ED case from one of the other programs. The program that submitted the case then completes the case conclusion with the actual patient outcome. Best Presenter & Best Discussant: Vladislav Mordach, DO AdventHealth East Orlando Best Overall Program: AdventHealth East Orlando All Participating Programs: Jackson Memorial Hospital/University of Miami USF/Tampa General Hospital AdventHealth East Orlando UCF/HCA Greater Orlando FSU at Sarasota Memorial Hospital

THANK YOU, PLANNING COMMITTEE & JUDGES:

Orlando Health UCF/HCA North Florida

EM Resident QuizBowl (new!) The inaugural EM Resident QuizBowl Competition began with a “trivia night” speed round in which all but four teams were eliminated. The final four teams then participated in a two-round, debate-style competition that led to one final round of debate between the two remaining teams. First Place: Orlando Health Second Place: HCA Florida Kendall Hospital All Participating Programs: FSU Sarasota Emergency Medicine Residency Program USF Emergency Medicine Orlando Health HCA Florida North Florida AdventHealth East Orlando UCF/HCA Greater Orlando HCA Florida Kendall Hospital

Competition Chair: Jason Wilson, MD, FACEP Judges: Carmen Martinez Martinez, MD Caroline Molins, MD

THANK YOU, PLANNING COMMITTEE & JUDGES: Competition Chair: Jennifer Jackson, MD, FACEP Judges:

THANK YOU, COMPETITION HOSTS: Competition Chairs: Erich Heine, DO Sara Baker, MD

Leila Posaw, MD, FACEP Eliot Goldner, MD Scan to read abstracts here: fcep.org/research-2022

Erich Heine, DO Stephen Viel, MD, FACEP Diana Mora, MD EMpulse Fall 2022

CONFERENCE PHOTOS August 4-6, 2022 | Hyatt Regency Coconut Point Thank you for attending!

Scan to view & download photos by Greg Hunter

EMpulse EMpulse Fall Fall 2022 2022

Thank You Faculty

Thank You Sponsors

Benjamin Abo, DO, EMT-P, FAWM

Platinum Level Sponsors

Jason Adler, MD, MMM, FAAEM Sara Baker, MD Andrea Brault, MD, MMM, FACEP Damian Caraballo, MD, FACEP Casey Carr, MD

WiFi Sponsor

Jordan Celeste, MD, FACEP Kamal Chavda, MD, MBBS, FAAP L. Anthony Cirillo, MD, FACEP Nicholas Cozzi, MD, MBA Andrzej Dmowski, MD

Gold Level Sponsors

Nicolas Erbrich, MD, FAAP Ed Gaines, JD, CCP Latha Ganti, MD, MS, MBA, FACEP, FAHA Erich Heine, DO Jennifer Jackson, MD, FACEP Steven Kailes, MD, MPH, FACEP, FAAEM Sara Kirby, MD, FACEP Andrew Little, DO, FACEP Carmen Martinez Martinez, MD, MSMEd, FACEP Thom Mayer, MD, FACEP, FAAP, FACHE

Silver Level Sponsors

David McKenzie, CAE Yiraima Medina-Blassini, MD, FACEP Lary Mellick, MS, MD, FAAP, FACEP John Misdary, MD, FACEP, FAAEM, FAAP Caroline Molins, MD Diana Mora, MD, FACEP, FPD-AEMUS Arino Neto, MD Vanessa Perez, MD, FAAP Randy Pilgrim, MD, FACEP Townsend Reeves, MD Gillian Schmitz, MD, FACEP Joseph Shiber, MD, FACEP, FCCM, FNCS Jamie Shoemaker, MD, FACEP Tricia Swan, MD, MEd, FACEP, FAAP Ali Syed, MD Chrissy Van Dillen, MD, FACEP, FAAEM Ariel Vera, MD, FACEP William Waite, DO, MS Jason Wilson, MD, FACEP, FAAEM Todd Wylie, MD Cristina Zeretzke-Bien, MD, FAAP, FAAEM, FACEP EMpulse Fall 2022

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EMpulse Fall 2022

COMMITTEE REPORT

Early Career Physicians: Burn Notice By Dakota Lane, MD, FACEP

Subcommittee Co-Chair | FCEP Board Member

You can’t pinpoint the exact moment when it happens: when the fire inside you that represents passion for what you do becomes something painful. The warmth and security of the EMR now smothers you with blinking checkboxes, while you’re doggedly followed by the week’s hottest performance metric. Before you know it, your Figs are on fire, and you don’t even recognize the charred person in the mirror. We hear the term “burnout” far too often, in lectures or workshops that tell us to be stronger and more resilient. I propose that the reality of the situation is not that we have burned out; it is that we have been burned. The arsonist is a broken healthcare system that fails our patients, arbitrary measurements of customer satisfaction, and a medical culture that views us as weak if we even consider taking a sick day. We’re expected to keep up with these rising demands, leaving us vulnerable to feelings of inadequacy when we fail to hit an impossible mark. We lose our comrades-in-arms for reasons we understand all too well, and meanwhile, we’re told to be tougher; to fix this problem that must be our responsibility. The bottom line is this: it’s not your fault. While this article discusses ways to cope with what we’re feeling, it isn’t about trying to “buck up” and “deal with it.” It’s about giving ourselves grace when we fall down—because none of us are fireproof.

“medical doctor” into our identity, and pin our success and failure at the job into who we are. One of the things that can rejuvenate us the most is remembering how important life is outside of the doc-box. Commiserate with a colleague outside of the hospital’s four walls, and all of a sudden you realize that you aren’t alone in your frustration. Talking to a therapist (which you can even do via app) lets you connect in a more objective way while taking care of your mental health. Some days we just don’t have the strength to reach out, and that’s okay. Just remember that you aren’t alone.

2) Diversify. If you have the bandwidth, explore developing a niche or a side gig. Perhaps you had been interested in a fellowship, but instead started working straight out of residency. It’s never too late to go back and try something new. Being able to vary your work activities might be just the type of change you need to rebalance. Maybe you want to invest in real estate on the side or open a restaurant. Maybe you want to start a new cryptocurrency. Do what brings

1) Connect. It starts with the patients. As we get weary, we lose the connection to our empathy. But we begin to suffer even more when we start drifting away from our friends, our family, our partners, and our children. The career becomes everything; we tie 20

EMpulse Fall 2022

you joy.

3) Change. You can choose your employer; you can choose to take time off; you can even choose to leave medicine entirely. Some are living lives of quiet desperation, convinced there is no way out. I came here to say: you have a choice. Stop being burned by your employer. You can choose to work at a place you’re valued. Undoubtedly, there are often circumstances where one is deeply invested in a house, a community, or a retirement plan, certain that you “can’t” leave; but especially for those of you in your early career, remember that you have many years ahead of you. Weigh the cost of transplanting your life against your daily well-being. There is always a way to make it work. Hospitals may continue to offer pizza as a salve for our tired souls, while we work with inadequate staffing and bureaucratic mandates for the foreseeable future. And we will persevere, however much or little we are given. But give your burns a chance to heal—step out of the burning room. ■

COMMITTEE REPORT

EMRAF President’s Message By Natalie Diers, MD, PGY-2

EMRAF President | FCEP Board Member

Welcome to a new academic year, and congratulations to all of our new residents that have joined the ranks in emergency medicine. I am honored and excited to be your next EMRAF president. I have big ideas for this upcoming year, but will need your assistance and enthusiasm to make them a success. First, I want to share a bit about why I wanted to be your EMRAF president. Residency is one of the most challenging, albeit rewarding, times we experience in our medical careers. We share the experience of completing an emergency medicine residency in the state of Florida; thus, we should have more opportunities to reflect and build that unique bond we share. Although COVID may have put a damper on events in the recent past, it is important to unify our programs moving forward. We represent one of the larger factions of EM residents in the country. As a cohesive group, we can advocate for the change we want to see in our specialty. Serving one year as your EMRAF president does not offer the luxury of time to be able to find solutions for problems we face in emergency medicine, which is why it is important for all of us, including our newest residents, to become involved and to hear their concerns so that we can carry on the legacy to promote change within our specialty. Emergency medicine is hurting — not only in Florida, but across the country. As a specialty we are reeling from the negative economic and mental health factors produced by the recent pandemic. Private equities have infiltrated our profession and turned our community’s safety net into a profit generating business at the expense of patients, physicians, and

our communities. Physicians are being replaced by cheaper, far less qualified extenders to increase the bottom line for these large corporations. As resident physicians, we have spent years studying and working tirelessly to become the best we can be, for ourselves and our patients. We must continue to work with FCEP and ACEP to bring public awareness to this issue and educate our legislators at the state and national level on the distinct and incomparable skills of a trained emergency physician. We also need to address ominous warnings regarding the future of our job market. Advocating for a physicianled emergency department is only a part of fixing the problem. With the establishment of new residencies by these large hospital corporations, there has been a surplus of new physicians without appropriate job opportunities. We must continue to hold these corporations accountable for ensuring quality education and training for all residents while discouraging the establishment of new programs for the sake of the cheap labor of residents. Many of our emergency departments are also feeling the lingering effect the pandemic has caused on our nursing staff and the challenges that rise as staffing shortages continue. Limited staff has caused longer wait times and the development of “waiting room medicine,” with higher liability for physicians trying to provide healthcare to these patients. Disadvantaged populations that rely on the emergency room now have even more limited access to proper evaluation and treatment. A cohesive team is essential to a functional emergency department and to delivering proper patient care. While it is important to advocate for quality nursing to return to our EDs, it is also imperative to stand behind EMpulse Fall 2022

our nurses and unify our voices to help improve working conditions and demand safe nursing ratios within our emergency departments. To all my fellow residents, it is now your time to have your voice heard. I want to know what changes you want us to advocate for on a state and national level. What opportunities do you want to see within our state chapter of ACEP? Please do not hesitate to reach out to me at NJDiers14@gmail.com. EMRAF will only be as strong and effective as our residents make it. Together, we can affect a positive change for ourselves, our patients, and future residents. ■

Life After Residency 2023 Planning is underway! Anticipated date: April or May 2023 Target audience: Second- and third-year residents; residency program directors, coordinators and faculty FCEP’s Life After Residency event provides EM residents the opportunity to meet employers, learn valuable life lessons, and spend time together outside of the hospital in a relaxed, educational environment. Learn more: fcep.org/lar

Updates from Florida’s

Emergency Medicine Residency Programs

AdventHealth East Orlando By Shannon Caliri, DO, PGY-2 Hello, everyone! Currently, everyone is getting used to their new roles in the emergency department. The interns are quickly learning their new responsibilities of patient care. With most of everything being new to them, it is a steep learning curve that we know you all will be able to overcome. The second years are getting used to their new responsibilities as seniors in the department and being there to help the interns and medical students. We are learning to step into more of the teacher role and take on an increased number of patients. The third years are now learning to manage more patients while also being able to take ownership of the emergency department, all while pushing to learn more from each patient before graduation comes. An event we had recently was Disaster Day. We and the ER residents from HCA Florida Osceola teamed up to have a day where learning about what to do in a mass casualty event was turned into various games. Our residents were all split up into teams and competed for trophies. The day included games of jeopardy, rapid triaging, simulation cases, and even an escape room! It was such a great time and really made learning about this topic a fun experience. Thank you to everyone who was involved in making it happen and hopefully we can do more events like this in the future. ■ 22

Florida Atlantic University By Christian Schuetz, MD, PGY-2 A big hello from FAU here in Southeast Florida! We’ve enjoyed plenty of wellness, learning and fun over the past few months. Outside of the hospital, we cheered on our very own Owls at the FAU vs. UCF football game, savored some beach days, and recently enjoyed a bowling event. These have been great events for our residents to relax, recoup, and rejuvenate from life as an ER resident. Our new interns have been transitioning well into the world of emergency medicine, treating high acuity patients, performing procedures, and learning as much as possible. Our senior residents are preparing for the demands of independent practice while meeting the demands of increased responsibility, focusing on improving efficiency, and managing the flow of the emergency department. A big shout out to our chief residents, Drs. Timothy Buckley and Tony Bruno,

EMpulse Fall 2022

as their outstanding hard work has not gone unnoticed. They have been working hard at creating our ED schedules, scheduling Grand Rounds speakers, and finding solutions to any issues that may arise. We were honored to host the current NFLPA Medical Director Dr. Thom Mayer as one of our most recent Grand Rounds speakers. We would like to give a big welcome to our new core faculty member, Dr. Mary Billington. We are excited for her to hit the ground running and share her toxicology expertise. Our FAU EM family continues to grow in various ways. We also want to congratulate Dr. Hughes, our APD, and his wife Lindsey on the birth of their baby girl! We wish all programs and applicants good luck this interview season. We have enjoyed getting to know all our visiting students. As we head into this season of ERAS, we are excited to meet our potential future colleagues. ■

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS NEW PROGRAM

Lakeland Regional Health By Andrew Barbera, MD Program Director

We are excited to announce the newly ACGME accredited Lakeland Regional Health (LRH) Emergency Medicine Residency Program! Our three-year residency program is located in Lakeland, FL, directly between Tampa and Orlando along I-4. At 864 beds, LRH is among the largest hospitals in Florida and boasts as the 2021 second busiest ED in the nation with an average volume of approximately 200,000 patient visits annually. Highlights of our program include: a diverse urban, rural, and international patient population in a large volume and high acuity ED; a dedicated pediatric ED; the only

trauma center in the tri-county area; incredibly high procedural numbers and ED-owned procedures; a cardiac center stroke center and in-house simulation center; a large network for post-graduate employment; dedicated resources for scholarly activity and research; resident wellness programs, and much more! Graduates of LRH’s Emergency Medicine Residency Program will be well-prepared for careers within community and academic emergency medicine or additional fellowship training. This will be accomplished through a focused and intense clinical and didactic curriculum, mentoring by ABEM/AOBEM board-

certified core faculty members that have a variety of backgrounds and expertise, and centered around excellent patient care and bedside learning. We have spent years working on the curriculum, resources, and framework of this program and have designed the curriculum for the modern emergency medicine resident. Our program has generous benefits, including family leave policies, and places resident wellness as a top priority. We can’t wait to welcome our inaugural class of residents in July 2023! ■

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Email CVs to: maureen.france@emprosonline.com EMpulse Fall 2022

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

UF Gainesville By Megan Rivera, MD, PGY-3 Hello from UF! As we enter the fall season, that means one thing in Gainesville: football! Our recent opening game against Utah held the largest crowd in UF history with 90,799 fans joining. Residents have been enjoying this electric start to the season by tailgating and volunteering with our EMS crews. Our Gator family grew by 14 this summer as we welcomed our new interns from 12 different medical schools. They recently finished their orientation month filled with wellness, PGY-1 tailored lectures and simulation, and taking their first dip into life as a physician. We are already so proud of the Class of 2025 and can’t wait to see what great things they accomplish! Dr. Michael Marchick was named Assistant Program Director this summer. Dr. Marchick has been at the heart of our residency for years, with relentless dedication to research, scholarship, and well-being. We are so excited for Dr. Marchick and look forward to his continued contributions to our residency. We’ve had several fun additions to our conference schedule this academic year. Dr. Casey Carr, UF’s Director of Emergency Critical Care Education, recently held “The Great Sepsis Debate,” a flipped classroom model for residents to debate the evidence behind sepsis management. Residents have additionally enjoyed an escape room, obstetric emergency simulation, and a journal club with a competitive twist.

Orange Park Medical Center By Davis Wood, DO, Hillary Baker, DO & Shannon Overholt, MD, PGY-3s Chief Residents

The EM residents in Orange Park have had a busy summer. Drs. Deaton, Wood and Bosley started off in May with a mass causality training for our program at the Clay County Fairgrounds. They enlisted help from Clay County Fire and Rescue and a team of volunteer moulaged patients. Back on campus, our interns are off to a great start. Our medical student rotation has been restructured and we have had two wonderful cohorts of auditioning students so far. Our Sim Center construction continues to be underway, however, this is not holding Sim Faculty Dr. Codrin Nemes back from conducting weekly simulation sessions with small groups of residents and faculty. The real time and immediate feedback has been tremendous and impactful. Our program is proud to represent ACEP locally and nationally. Dr. Ed Hu, PGY-2 presented his research poster at Symposium by the Sea. Our Ultrasound Fellowship Director, Dr. Taryn Hoffman, also attended this conference to lead and meet with the inaugural FCEP Ultrasound Committee. Associate Program Director, Dr. Ed

As summer ends, we’re gearing up for another virtual interview season. We can’t wait to meet all the incredible new applicants and our future colleagues in emergency medicine. ■ 24

EMpulse Fall 2022

Descallar, was selected as ACEP’s Chair of the Young Physicians’ section and made new connections in San Francisco at the annual convention. Dr. P.J Bissmeyer, PGY-2 is excited to join as a member of the ACEP Ethics Committee and discuss these emotionally difficult topics for residents and attendings alike. Dr. Janae Fry, former Chief Resident and current faculty, and Dr. Michael Euwema are working with ACEP as part of the Kenya Global Medical ambassador team. Both have extensive knowledge in global medicine from several previous mission trips. In October, Chief Resident Dr. Hillary Baker presented at ACEP’s Scientific Assembly in San Francisco. We are looking forward to marvelous things in the near future. Our residents are attending a wellness event and will challenge each other at an escape room in a few weeks. Associate Program Director, Dr. Shilpa Amin, was chosen to serve on the Duval County Medical Society New Membership Committee and is looking forward to attending the annual conference in October. Dr. Michael Wakely, PGY-2 is eager to present at CORD in the spring. ■

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

Jackson Memorial Hospital EM Residency Program Staff There have been many exciting things occurring at the Jackson Health System/University of Miami program. In May, a team consisting of recent graduate Dr. Andrea Alvarado, Dr. Kristopher Hendershot, PGY-3, Dr. Rachel Armstrong, PGY-2 and Dr. Makena Owen, PGY-2 won 1st place at the annual Sim Wars at the Florida American Academy of Emergency Medicine Scientific Assembly! They were led by our fellowship-trained Simulation Director, Dr. Kelly Medwid. This summer, we also hired numerous core faculty, including Ultrasound Director Dr. Matthew Pyle, who completed his ultrasound training at George Washington University in D.C.

and attending positions across the country and have experienced some early success. Two of our chiefs, Josh and Kris, have already matched into their top choice programs for Anesthesia Critical Care and Neurocritical Care Fellowship, respectively.

We are also proud to announce our chief residents for the academic year: Drs. Danielle Cohen, Joshua Goldstein, Kristopher Hendershot, Julia Martinez and Naomi Newton. We have been impressed with their leadership thus far and look forward to an exciting rest of the year. Our senior residents are currently interviewing for fellowship

We have really enjoyed welcoming visiting students back for the first time in a couple of years due to the COVID-19 pandemic. Their presence has everyone excited for what will certainly be an amazing interview season, and we look forward to meeting brilliant young minds from all over Florida and the country! ■

In August, we enjoyed our annual residency retreat at Crandon Park in Key Biscayne. It was a great day of bonding at the beach between all three classes and program leadership. The highlight of the day was a competition between the classes consisting of numerous emergency medicinethemed summer camp style games!

USF at Tampa General Hospital By Kenneth Dumas, MD, PGY-3 Greetings from the USF family here. It’s been an exciting time as the new interns have settled in, completing their boot camp and ultrasound training like pros. This year, we were able to bring back the resident retreat and welcomed everyone with some BBQ, kayaking, and lake house views, which was a huge hit and likely back on the annual calendar of events. When our residents weren’t resting up for the year ahead, they took to the streets to help provide essential medical care to some of our most needy patients in the community. This

is always a great way to give back to the community we all love down here. We’re also excited to share that through the awesome research of our residents, we’ve been able to implement extended cardiac monitoring for our low risk palpitation and syncope patients, and they’ve already helped diagnose arrhythmias that otherwise might have gone unnoticed. As always, we invite you to follow along with us at our blog: tampaemergencymedicine.org. ■ EMpulse Fall 2022

North Florida Emergency Medicine By Chris Sowers, MD, PGY-2 Hello from North Florida! As everyone settles into the new academic year, we are excited to welcome some familiar faces into new roles at our program. Dr. DJ Martin has joined as core faculty and will be assuming a larger role in resident education. He will be maintaining his positions as the Medical Director of the freestanding emergency departments and as one of our nocturnists. Stay busy, Dr. Martin! We also welcome Dr. Joshua Middleton as our Assistant Ultrasound Director. A graduate of North Florida EM residency and ultrasound fellowship, there was clearly no one better for the job. Our interns and second-years have both enjoyed attending recent conferences. The intern class traveled to Miami for the POCUS Conference in July. The second-years traveled to Bonita Springs for SBS 2022 the following month. Always great educational and bonding experiences. Our nerve block program is taking off at North Florida EM. Leading the charge is Dr. Diana Mora, our Ultrasound Director. Our on-call nerve block team is available to assist residents as we learn fascia iliaca, PENG, interscalene, supraclavicular, and popliteal sciatic nerve blocks. Ortho is loving it, and so are our patients! Finally, we enjoyed one of our wellness days last month with a getaway on the Gulf. We rented a few boats for a day of snorkeling and scalloping. Gotta love residency in Florida! ■

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

Broward Health By Jean-Dominique Foureau, MD, CPT, PGY-2 Greetings from the emergency family here at Broward Health. It has been a busy year over here in sunny South Florida. 2021 was the first year of our program, and we sure have hit the ground running. Everyone in the intern class excelled not only in the emergency department, but several months in the ICU, trauma, labor/ delivery, and even got a chance to ride along with our heroes in the fire department. Our year of rotations enabled us to become comfortable with critical procedures and the vast array of pathologies that we see in the emergency department. Although we’ve put in a lot of time learning and working, we still have found time to have a little bit of fun as a family as well. Several of our faculty members work on the medical staff of the South Florida professional athletic teams, so our program has been able to enjoy Panthers hockey games, Dolphins football games, and Marlins baseball games all in the same year. Even though we have had plenty of fun as an emergency family, we were not strangers to war either. We closed out our year with paintball and SIM wars! Our end-of-the-year wellness activity consisted of an extreme paintball war that left us with more laughs than bruises. Our residents also had a chance to showcase everything we’ve learned this year in the Simulation Wars held in Miami, FL. With all that said, there is no doubt that our new intern class will make this year bigger and better. Special welcome to the class of 2025. ■

HCA Florida Kendall Hospital By Jack Finnegan, DO, PGY-3 ‘¡Que bola!’ from Miami! Summer is coming to an end and we couldn’t be more proud of our new interns. For the first time since Covid, we are re-incorporating some of the best parts of our residency. Our program director, Dr. Valori Slane, is currently abroad leading an elite team of senior residents and core faculty as they provide education and care to underserved patients in rural Nicaragua. Back home in Miami, our interns are resuming their prehospital experience with the worldclass Miami-Dade Fire and Rescue team (MDFR), and some of our senior residents will be joining them for specialized electives in Air Transport and Water Rescue. In October, once again we meet on the playing field with our friends and rivals, Aventura EM, and we also welcome competition from our “little sib” program, Westside Regional EM.

That’s right – it is SIMWARs Season. On the grid-iron, our fiercest clinicians will go toe-to-toe for bragging rights, education, and most importantly, fun! The competition doesn’t stop there – at home, we are competing against Kendall IM in the ICUlympics to determine the true Crit-Care Gurus within the hospital. When we aren’t practicing for SIMWARs, catch us at one of our monthly journal clubs. One-by-one, we are dropping through Miami’s best craft-breweries. We are so grateful to our research fellowship-trained attendings Drs. Murtaza Akhter and Daniel Leiva as they help us hunt for the truth behind the statistics in EM literature (while we hunt for the tastiest brews in Miami). Interested students, follow us on Instragram @kendall_emresidency to keep an eye out for our upcoming Med-Student Social! ■

DON’T FORGET TO SHARE ONLINE Access the online version of each residency program update at fcep.org/empulse or on your residency program’s fcep.org landing page.

EMpulse Fall 2022

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

HCA Ocala Hospital Emily Weeks, MD & Mortatha Al-Bassam, MD, PGY-3s Following a wonderful graduation dinner and farewell celebration at the World Equestrian Center in June, summer in Ocala brought the next academic year and a new class of brilliant residents into the Ocala EM Family! After a great start kicking off their year with Intern Boot Camp, they have hit the department in full stride! This year, our entire rising third-year class attended SAEM in New Orleans, representing UCF-Ocala EM with several research presentations while appreciating the history and sites of the city. We were also excited to see everyone at ACEP in October! We celebrated the arrival of our new class with a river float trip through Rainbow Springs, with tubing, kayaking, and enjoying the springs on a hot Florida summer day. We have continued our culinary tour of North Florida during our monthly Journal Clubs, held at local restaurants, featuring foundational articles as

well as up and coming research for discussion. We are looking forward to our upcoming annual anatomy dissection lab at the University of Central Florida, where we will spend the day reviewing procedures including lateral canthotomy, thoracotomy, among others, followed by a lunch event and pool wellness day. In our spare time, we are bonding during after-conference lunch traditions, attending weekly trivia nights and exploring downtown, landscaping our new residents’ yards (planting palm trees is a group effort!), attending college football games (even if we are rooting for opposite teams), and starting our own residency Fantasy Football League! We are very excited to kick off the upcoming interview season, and wish everyone a happy and healthy fall. ■

EM Residency Program Visits

UF Jacksonville By Jeanne Rabalais, MD, PGY-2 First and foremost, we would like to honor the late Dr. Bradford McGuire, Jr. We lost Brad in a tragic accident on June 15. Brad was a recent graduate of our program. He was well loved by everyone he met and had a unique ability to bring the most positive perspective to even the most trying times in our ED. We want to thank our Florida EM family for their support during our time of grief. As one academic year closed and another began, we have many accomplishments to celebrate. Dr. Moji Hassan, PGY-3, was awarded the Dr. Louis Ling Resident Scholarship Award at CORD22. Dr. Jeanne Rabalais, PGY-2, was the winner of the Resident Haiku Competition at the Clinical Decision Making in Emergency Medicine conference. Dr. Grant Barker, recent graduate, received the UF College of Medicine Excellence in Student Education Award; Dr. Nneka Azih, recent graduate, was awarded the Leon L. Haley Jr. Leadership Award for Inclusive Excellence; and Dr. Kasi Hartman, recent graduate, was awarded the UF Department of EM Outstanding Resident Teacher Award. We would also like to recognize Drs. Rick Courtney, Lexi Sughroue, Ray Hakh, Alex Derr, and Eric Lakey, who were departmental award winners. Our faculty are also doing amazing things. Dr. Petra Duran-Gehring was awarded the ACEP National EM Faculty Teaching Award and Dr. Lexie Mannix was awarded the ACEP National EM Junior Faculty Teaching Award.

FCEP wants to meet you! Invite FCEP leaders to your program in 2023 to learn about what FCEP does for members. We want to meet all of you, in-person or virtually! Contact Interim Executive Director Melissa Keahey to schedule a visit at mkeahey@emlrc.org.

We look forward to an exciting fall here at Jax EM as our interns get settled in and we begin recruiting our next class. Until next time! ■ EMpulse Fall 2022

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

FSU at Sarasota Memorial WEST FLORIDA

Oak Hill Hospital By Ryan Johnson, MD & Mohammad Razzaq, DO, PGY-3s Greetings everyone! It seems like ages since we’ve last written an update. A lot has changed here at Oak Hill Hospital. We missed hearing everyone’s updates over summer, and are excited to share all of our progress. When we last spoke, our construction had finally started to progress. We are happy to report that it has continued (relatively) on schedule, and we now have the new front and mid-sections of our department open. While there are certainly some growing pains with new construction, we are happy to finally be moving into our shiny new department. It is with a heavy heart that our program bids farewell to one of its founding core faculty, Dr. Grabert. We wish him luck in his new role as the Department Director at one of our local sister facilities. Dr. Lugo, our current clerkship director, will be stepping into his former role. While she has big shoes to fill, we are sure she is up to the task. Our program would also like to welcome our new Simulation Director, Dr. Komurek. We recently expanded our simulation facilities and are already putting them to use under Dr. Komurek’s tutelage. Our department welcomed a slew of new learners this summer. In addition to the six new interns we previously announced in spring, we have also accepted two transferring residents from another program. Please help us give a warm welcome to Drs. Paez and Hogan. Our senior class was happy to see all of our peers at ACEP SA this month. ■

Hannah Cianci, DO, PGY-3 Our program is excited to announce that we have officially graduated our inaugural class! Three of our graduates went on to begin fellowships: two in ultrasound fellowships and one in a sports medicine fellowship. Five of our nine graduates remained at Sarasota Memorial Hospital, and we are so lucky to have them working as attendings now. They have been an amazing asset to our department and continue to teach our residents every day. Our intern class has been extremely active – one of our interns has already completed over 300 ultrasounds! Two of our attendings, Drs. Ashley Grant and David Krahm, are now certified in utilizing transesophageal echocardiography during resuscitation in our emergency department. We have a TEE probe in our department, and we have already started training our residents on TEE probe use. Ideally, this can be

used during CPR to limit pauses in compressions and evaluate cardiac movement continuously. Our residents are very excited about this rare opportunity! We have been fortunate to attend both FCEP and SEA so far this year. We had a member of each residency class participate in FCEP and SEA. Our entire team is gearing up for this upcoming year too. Our administrative chief, Dr. Emily Wheeler, PGY-3, matched in a critical care fellowship and plans to head to Pennsylvania in the spring. Our academic chief, Dr. Amy Lowther, PGY3, is currently in the middle of match season for pediatric-EM fellowship, as well. Cheers from our program to yours! We are eager to see what all the incredible emergency medicine residents accomplish this year. ■

Orlando Health By Drs. Sean Hire, DO, PGY-2 and Reshma Sharma, DO, PGY-3 Fall is here, and along with it, the excitement of hurric- I mean, interview season! Our fantastic class of 2025 is completing its first few rotations of intern year, and our seniors attended ACEP22 in San Francisco. Symposium by the Sea was another high note with our residents taking first place in the Quiz Bowl. Congratulations to all those who had the opportunity to be involved. It has been an excellent start to the training year both on and off-shift. We have held a multitude of successful SIM lab workshops with a notable example being our recent Airway Lab, where we practiced not only airway adjuncts and standard endotracheal intubations EMpulse Fall 2022

but also fiberoptic and surgical airways with the help of our amazing attendings. On shift, we have launched our EMS medical control station where our seniors had the chance to answer radio calls from first responders and be involved in prehospital medical care. Lastly, ORMC is slated to begin their renovations and expansions to the trauma bay. We are excited to see the improvements that are planned. We want to thank all of our rotators thus far and anyone that has shown interest in getting to know our program better. It is always an honor to get to meet such amazing future doctors and we wish everyone the best of luck! ■

COMMITTEE REPORT

Medical Student Council By Rachel Shi, MS-II

MD Candidate, UCF College of Medicine FCEP Medical Student Council Secretary-Editor

The FCEP Medical Student Council has transitioned into new leadership as we welcome Cristina Sanchez (FSU) as our new chair, Kailey Jacobson (NSU) as our new advocacy chair, and Rachel Shi (UCF) as our new secretaryeditor. The FCEP MSC holds quarterly meetings with representatives of EMIGs in Florida to share ideas and helps plan upcoming events including EM Days, FCEP’s advocacy event that allows students to learn more about advocacy and government relations. More information on these events will be provided as the dates approach. This year, the annual FCEP Symposium by the Sea took place at the Hyatt Regency Coconut Point Resort in Bonita Springs, FL from August 4-7. The event brought together a diverse, multidisciplinary crowd of emergency medicine physicians, health professionals, and future physicians from all around the state of Florida to discuss topics in emergency medicine. From talks on Gender Bias in EM to skills stations on intubation and pediatric airway approaches, and a lively EM Resident Quiz Bowl competition, the conference was a huge success. Medical students are appreciative of the opportunities to connect with physicians in the field, and below are some of the opinions from several student attendees on aspects of the conference. “I have attended Symposium by the Sea since my MS1 year and have

FCEP Medical Student Council Executive Board 2022-2023

greatly enjoyed the event each time. However, attending for the first time after beginning clinical rotations as an MS3 felt like a whole new experience. I felt that I was able to truly understand and appreciate more of the lectures and apply them to my own clinical encounters. The most impactful talk for me was about addressing gender bias in the clinical setting. Despite identifying as a female and being on the receiving end of others’ biases throughout my life, it wasn’t until I reflected on this talk that my eyes were opened to the fact that I have previously acted on gender biases of my own in the clinical setting. I am thankful that this presentation reminded me that no one is free of bias and that it challenged me to mind my own.” -Alyssa Cartwright, MS-III Florida International University Herbert Wertheim College of Medicine “I attended Symposium by the Sea for the first time as a poster presenter and was struck by the outstanding quality of other research posters that were displayed. The poster “Play for Your Life” by Dr. Erica Warkus especially stood out to me because it featured an interactive game that raised awareness of intimate partner violence, such as the struggles experienced by survivors, and ways to support survivors. I admired the creativity and depth of the project and am glad to have learned more about an important topic that is often unnoticed or inefficiently

addressed. The talks were also very informative and inspiring. I look forward to attending next year and continuing to grow as a learner!” -Rachel Shi, MS-II at UCF College of Medicine “As a medical student, Symposium by the Sea was a unique experience, and it was incredibly rewarding to learn more about the world of emergency medicine. I was fortunate enough to have been able to attend the Women in Medicine Meeting and learn from various mentors about challenges they have faced as women in the field, as well as how they overcame those challenges. I also learned an enormous amount through listening to the “Gender Bias in EM’’ lecture, detailing issues I was not aware of within the discipline of emergency medicine, which greatly affect the care of the patients in the specialty. Finally, the Medical Student Forum was an incredible opportunity for me as a student. Meeting the program directors of EM programs in Florida and having the opportunity to speak to them as well as ask questions was an invaluable experience. I look forward to seeing what Symposium by the Sea has in store next year!” -Cristina Sanchez, MS-III at Florida State University College of Medicine Overall, students greatly enjoyed the experience, along with the ACEP22 Scientific Assembly in San Francisco from October 1-4. ■

CHAIR: Cristina Sanchez, MS-III Florida State University

ADVOCACY CHAIR: Kailey Jacobson, OMS-II Nova Southeastern University

SECRETARY-EDITOR: Rachel Shi, MS-II University of Central Florida

IMMEDIATE PAST CHAIR: Veronica Abello, OMS-IV Nova Southeastern University

EMpulse Fall 2022

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EMpulse Fall 2022

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Envision Emergency Medicine allows me to live the fast-paced lifestyle I enjoy. Constant alertness and the ability to act instinctively are essential, both on the job and the track. Alana Snyder, DO Medical Director for Medical City Fort Worth; Medical Director for Crowley Fire Department Medical Director for Pantego Fire Department; Chief of Emergency Medicine at Medical City Arlington

EMpulse Fall 2022

FEATURE

The Status of the Emergency Medicine Workforce in Florida Barbara Langland Orban, PhD

David J. Orban, MD, FACEP

Retired Chief of Emergency Medicine University of South Florida

The status of current and future emergency physician workforce needs in the United States continues to be a subject of heated debate. The American College of Emergency Physicians and others have projected an oversupply of emergency physicians in the next decade.1 In addition to the increased use of advanced practice professionals in U.S. emergency departments (EDs), a major component of the projected oversupply is attributed to recent increases in the number of emergency medicine residency training programs.2 However, an oversupply of emergency physicians in the next decade may not necessarily equate to an oversupply in all regions of the country.3 Since 2008, the number of programs in large cities has grown disproportionately when compared with the flat or declining growth of programs based in rural regions of the country.4 According to 2020 American Medical Association data, 98% of emergency medicine residents were in urban areas4 — specifically, 6,850 in urban areas, 114 in large rural areas, and 23 in small rural areas.5 According to ACGME data, over a seven-year period, the number of emergency medicine residency programs in the U.S. grew from 160 (2013) to 247 (2020).4 These new, 3-year training programs were disproportionately added to states with an already high number of programs: Florida (6 to 21), Michigan (11 to 25), New York (21 to 31), Ohio (9 to 18), Pennsylvania (12 to 21), California (14 to 22). Several, mostly rural, states had no emergency medicine residency programs in 2020: Alaska, Hawaii, Idaho, Montana, North 32

Professor Emeritus, University of South Florida

Dakota, South Dakota, and Wyoming. This is contributing to an emergency physician “desert” in these states and a wide variation in the supply of emergency physicians, particularly in rural areas, despite the growing number of programs.3 Observed changes in emergency physician densities and regional variation in supply could mean that urban markets will experience a higher degree of emergency physician saturation while rural markets suffer from an ongoing unmet demand for emergency physicians. Trends in the emergency medicine resident physician population and where these residents are training will likely impact future trends in where the clinically active emergency physician will practice. Florida has long been a “bellwether” state for trends in healthcare due to its aging population, its changing diversity, and its fast-growing urban areas. To provide a better overall understanding of the dynamic changes in the Florida emergency physician landscape, we report below on the status of the current emergency physician workforce in Florida.

2021 Florida Physician Workforce Annual Report The 2021 Physician Workforce Annual Report3 is based on responses to the Florida Physician Workforce Survey. The survey is part of the licensure renewal process for physicians and is administered by the Florida Department of Health’s Division of Medical Quality Assurance. Physicians must renew their license every other EMpulse Fall 2022

year. Newly licensed physicians are not included in the analysis because the survey is only administered upon licensure renewal. Florida Physician Workforce Practice Characteristics Over the last 10 years, the number of practicing physicians in all specialties increased 24%, from 44,804 to 55,809. However, the growth in practicing emergency physicians was 40%, with 2,344 in 2012-13 and 3,279 in 2020-21. During this same time, the population of Florida increased 13.5%, from 19.3 million to 21.9 million. Emergency medicine is the sixth largest specialty group in Florida following internal medicine (15,339), family medicine (7,951), pediatrics (4,441), surgery (4,132), and anesthesiology (3,348). The number of emergency physicians in Florida continues to grow, with the most recent one-year increase being 3%. It will continue to grow as additional residency programs have been approved and as newly credentialed emergency physicians renew their license after passing their boards. Emergency medicine has the largest percentage of physicians under age 40 (25.2%). It also had the lowest percentage of physicians age 60-69 (15.7%) and 70 and over (5.8%). Despite their comparatively younger age range, the number of emergency physicians who plan to retire in the next five years was 300 (9.2%), which is the same percentage as the overall physician retirement rate in Florida. Nearly 18% of emergency physicians surveyed reported they had relocated

to Florida within the last five years. Of these, just over half stated it was for employment opportunities or employment after finishing their residency. Additionally, emergency medicine had the highest percentage of physicians planning to relocate out of Florida within the next five years: 11.6%, compared with 4.7% (2,464) of all Florida physicians who answered the question in the 2020-21 survey cohort.

Physician Workforce Advisory Council The Physician Workforce Advisory Council was established in section 381.4018, Florida Statutes, and is charged with advising the State Surgeon General and the Florida Department of Health about the current and future physician workforce needs in the state.3 The Council is comprised of medical and academic stakeholders and serves as a coordinating and strategic planning body to assess the state’s physician workforce needs. The Council also monitors the status of Graduate Medical Education (GME) programs in Florida, which are an important component of Florida’s physician workforce. In 2013, the Florida Legislature created the Statewide Medicaid Residency Program and appropriated $80 million to the program in the form of recurring state and matching federal funds. In 2015, the Legislature also created the GME Startup Bonus Program to provide resources for educating and training physicians in specialties that are in a statewide supply-and-demand deficit — a list that included emergency medicine — and appropriated $100 million to the program. In 2020, the Legislature appropriated a total of $287.6 million to these programs. Emergency medicine was removed from the list of “shortage” specialties last year, but the growth of emergency residencies programs continues with the ACGME approval of two new programs within the past year. The Physician Workforce Advisory Council issued the following relevant recommendations in the 2021 annual report:3 1. Going forward, the Council recommends collaborating with the

Council of Florida Medical School Deans to develop and maintain a comprehensive database of current GME residency positions in Florida including emergency medicine. Their goal will be to measure the current and projected areas of need. In 2021, the GME Working Group determined that in 2020–2021, there were 7,608 residency and fellowship slots in the state, which is 1,761 more slots than in 2016–2017. A disproportionate growth in the number of emergency medicine resident slots was noted, which led to the specialty’s removal from the ”shortage specialty” list. 2. The Council will more carefully evaluate new models that forecast physician and subspecialty needs in Florida. The anticipated 2022 Florida Statewide and Regional Physician Workforce Analysis provided by the Safety Net Hospital Alliance of Florida will be reviewed. 3. The Council will review and revise its strategic plan, including emergency physician workforce issues. The list of accomplished objectives for the growth of emergency medicine residency programs was completed; objectives in process will be updated, and the need for new objectives will be evaluated. 4. The Council will determine how to best review the impact and quality of the new and existing GME programs, including emergency medicine. New metrics are being developed to assess the impact and quality of all GME programs. 5. The Council has recommended that the Legislature direct the Agency for Health Care Administration to seek resident physician specialty board pass-rate by program. These data will allow for comparisons between programs and foster the exchange of best practices with the goal of having the best GME residency programs in the U.S.

practice and geographic location for Florida emergency physicians. The Florida College of Emergency Physicians has started a Workforce Task Force to closely follow this issue as well. The continuing refinement, evaluation and reporting of this information will assist in the state’s efforts to meet current and future workforce needs. A summary of key information for policy consideration includes:

•

During the last 10-year period, the total number of practicing physicians increased over 24%. The number of practicing emergency physicians increased 40%. During this same time, the population of Florida increased only 15%.

•

Physicians are generally concentrated in populous counties and within large, urban population centers. Physicians working in rural areas are more likely to be primary care providers. Survey results indicated that 98% of emergency physicians work in urban counties while 2% work in Florida’s 30 rural counties.

•

Emergency physician gender and ethnic diversity of Florida’s emergency physician workforce has increased. The percentage of female physicians has increased from 24.4% in 2013 to 28.9% in 2021, and the percentage of Hispanic, Asian, Black and Native American physicians has increased by 6.2% over the same period.

•

Each year physicians report if they are planning to retire or move out of the state. Even though emergency medicine is the youngest specialty among Florida physicians, the percentage of emergency physicians who reported plans to retire within the next five years increased to 9.2% in 2020–21. Emergency medicine was third among specialties with the highest percentages of those planning to move to another state (11.6%). ■

Conclusion It will be important to review and assess current and future emergency physician workforce needs in Florida. Physician workforce assessment and planning by the Florida Agency for Healthcare Planning will result in new information for policymakers on clinical EMpulse Fall 2022

SCAN FOR REFERENCES All references could not fit in print. Please scan the QR code to view this article’s references. 33

FEATURE

Going to the Beach to Catch the Peaked T-Waves: Heat Stroke Causing Multiorgan Failure Kristopher Hendershot, MD, PGY-3

Jackson Memorial Hospital

Introduction An undifferentiated, unresponsive patient provides a unique challenge in the emergency department. We present a case of a patient with heat stroke after polysubstance use, who was found to have rhabdomyolysis, severe hyperkalemia, and multiple organ failure.

Case A 59-year-old male was brought by EMS after he was found unresponsive at the beach. EMS states that he had not moved for seven hours and that bottles of alcohol and two small bags of drugs were found at the scene. For EMS, the patient’s glucose was 36. They gave him one ampule of dextrose 50% and naloxone, which did not improve his mental status. When the patient arrived at the ED, his core temperature was 39.2 degrees celsius with systolic blood pressures in the 90s, and a GCS of 7 (eyes open, incomprehensible sounds, no motor response). On the monitor, the patient had bouts of irregular tachycardia and bradycardia with erratic PVCs and couplets. The EKG demonstrated bradycardia with peaked T-waves (Figure 1). Upon conducting a physical exam, the patient had diffuse erythema and ~10% body surface area was covered by bullae on his legs, back, buttocks, and groin (Figure 2). The patient’s initial labs were significant for: potassium 7.2; creatine 4.04; high sensitivity troponin 293; arterial blood gas pH 7.22, PCO2 46.9, HCO3 18.7; WBC 16.9; positive for MDMA, 34

Jameson Tieman, MD, PGY-2 Jackson Memorial Hospital

Emily Brauer, MD, FACEP Assistant Program Director, Jackson Memorial Hospital

benzodiazepines, and marijuana; total creatine kinase 10,980; ammonia 206; total bilirubin 3.8; AST 23,440; ALT 6370; and Lactic Acid 5.2. CT brain did not demonstrate any acute findings. Given the patient’s severely decreased mental status, he was intubated using etomidate and rocuronium. Based upon the initial EKG and arrhythmias noted on the monitor, the patient was empirically given four liter boluses of normal saline, six grams of calcium gluconate, four ampules of sodium bicarbonate, and 10 units of intravenous insulin with one ampule of dextrose 50% repeated three times. After receiving this regimen, the patient was in normal sinus rhythm with a repeat potassium of 5.4. After fluid resuscitation, he had only 400 mL of urine output and remained hypotensive, requiring a norepinephrine drip. A dialysis catheter was placed in the ER to facilitate emergent initiation of renal replacement therapy upon ICU admission. Eleven days after initial presentation, treatment was determined futile and care was withdrawn.

Fig. 1: Initial EKG taken at time of arrival, concerning for severe hyperkalemia.

Fig. 2: Patient’s bullae covering ~10% of his body.

Discussion

hyperkalemia, circulatory failure, acute liver failure, acute renal failure, and metabolic encephalopathy.

This is a case of an unresponsive patient suffering from heat stroke associated with polysubstance intoxication. Given that the outdoor temperature was 90 degrees Fahrenheit, the patient’s use of MDMA may have contributed to his hyperthermia. Secondarily, the patient developed rhabdomyolysis,

Heat stroke is a severe heat-related illness resulting in an acute increase in core body temperature and a decreased mental status. Early recognition and treatment of heat stroke is often challenging given how similar the presentation is to sepsis, drug overdose, and stroke. One study found that of 3,372 hospitalizations

EMpulse Fall 2022

for heatstroke, 12% of the patient developed shock and these patients had a 7.1-times higher mortality rate.1 The same group published another study where the mortality rate of patients with heatstroke was 5%, 20% required intubation, 2% required renal replacement therapy, and rhabdomyolysis was the most common complication of heat stroke.2 The most common systems of end-organ failure were renal, followed by neurological, respiratory, metabolic, hematologic, circulatory, and liver.2 Both rhabdomyolysis and acute kidney injury occurred in roughly a third of heat stroke patients and were associated with increased morbidity and mortality in these patients.3,4 The patient in our case presented with many of the complications of heat stroke that are typically encountered during a hospital course and not upon arrival. The aggressive use of intravenous fluids in our case played two roles: it helped to cool the patient, while simultaneously treating his acute kidney failure and rhabdomyolysis. Another important aspect of this case was the patient’s severe hyperkalemia, which was suspected from the erratic arrhythmias on the patient’s monitor and EKG. These arrhythmias allowed us to rapidly and aggressively treat this patient’s hyperkalemia and prevent the patient from going into cardiac arrest. Despite being a common presentation to the emergency department, there is not one standardized treatment for hyperkalemia, although it typically

involves stabilizing the cardiac membrane, shifting potassium back into the cells, and removing potassium from the body. Both calcium gluconate and calcium chloride have a rapid onset of action, a duration of action of about 30-50 minutes, and can be frequently re-administered to stabilize the cardiac membrane, if EKG changes persist.5 The administration of regular intravenous insulin acts to shift potassium into the cells, has a peak effect within 30 minutes, and has a duration of action of two to four hours.5 Second-line potassium shifting medications include sodium bicarbonate, which has only been effective in the setting of metabolic acidosis, and 20mg of nebulized albuterol, which has a peak effect within 30 minutes and a duration of action between two and six hours.5 In patients with functioning kidneys, furosemide can be particularly effective at removing excess potassium in fluid overloaded patients, with an onset of action of 30 to 60 minutes. Aggressive use of intravenous fluids in patients who are volume depleted can help dilute the potassium concentration.5 In cases of severe hyperkalemia or new renal failure, early insertion of a dialysis catheter in the emergency department facilitates earlier initiation of continuous renal replacement therapy or hemodialysis. The three most important teaching points from this case are: 1) Heat stroke should be high on your differential even in non-exertional cases, as

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rapid identification and cooling are important for reducing morbidity and mortality; 2) Early identification and aggressive treatment of hyperkalemia based upon monitor or EKG changes before a potassium level is resulted can prevent cardiac arrest; and 3) Be aware of the complications of heat stroke and identify and treat them on initial presentation. ■

References 1. Bathini T, Thongprayoon C, Petnak T, et al. Circulatory Failure among Hospitalizations for Heatstroke in the United States. Medicines (Basel). 2020;7(6):32. Published 2020 Jun 14. doi:10.3390/medicines7060032 2. Kaewput W, Thongprayoon C, Petnak T, et al. Inpatient burden and mortality of heatstroke in the United States. Int J Clin Pract. 2021;75(4):e13837. doi:10.1111/ijcp.13837 3. Thongprayoon C, Petnak T, Kanduri SR, et al. Impact of rhabdomyolysis on outcomes of hospitalizations for heat stroke in the United States. Hosp Pract (1995). 2020;48(5):276-281. doi:10 .1080/21548331.2020.1792214 4. Thongprayoon C, Qureshi F, Petnak T, et al. Impact of Acute Kidney Injury on Outcomes of Hospitalizations for Heat Stroke in the United States. Diseases. 2020;8(3):28. Published 2020 Jul 15. doi:10.3390/diseases8030028 5. Lasure Ben, Shaver Erica. Hyperkalemia. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. emrap.org/corependium/ chapter/recEcOnShorJunqD5/ Hyperkalemia#h.3siw3n2u4xbv. Updated July 6, 2021. Accessed September 22, 2022.

CASE REPORT

The Unintended Consequences of Vitamin D in COVID Prophylaxis Shilpi Ganguly, MS University of Miami Miller School of Medicine

INTRODUCTION In December 2019, a mass outbreak of SARS-CoV2 emerged. Since then, the disease has spread globally, with 613 million cases and over 6.53 million deaths (as of September 2022).1 SARSCoV-2 represents a major global health issue with a significant economic, financial, and personal burden. As the pandemic continues to take the lives of millions, many are turning to unapproved health products in an attempt to self-medicate, either due to a lack of access to adequate healthcare, desperation, or rampant misinformation that has been circulating via the internet and social media platforms.2 Among these health products, vitamin D has recently been making headlines as a possible tool in SARS-CoV-2 prevention.3 A recently published retrospective study attempted to examine the relationship between vitamin D levels and the likelihood of testing positive for COVID-19, and demonstrated a possible relationship between higher than normal vitamin D levels with a decreased risk of contracting the disease.3 Furthermore, it also demonstrated that more than 80% of the patients diagnosed with COVID-19 were vitamin D deficient.4 Previous studies have demonstrated that vitamin D supplementation may confer a decreased risk of contracting influenza.5 With respect to COVID-19, multiple considerations have been given for establishing a causal role in risk reduction. These include the outbreak being more severe in northern climates where serum vitamin D levels are lower, the proven causal relationship 36

John J Cienki, MD

University of Miami Miller School of Medicine/Jackson Memorial Hospital

between vitamin D deficiency and the development of acute respiratory distress syndrome, and that vitamin D has immunomodulatory effects within respiratory epithelia.5 It is postulated that the likely protective effects of vitamin D against COVID-19 are related to its ability to temper the proinflammatory cytokine response within the respiratory tract, thus decreasing the severity of illness caused by COVID-19.6 Primary human airway epithelial cells express relatively high mRNA levels of 1a-hydroxylase and lower levels of the inactivating 24-hydroxylase at baseline.7 Airway epithelial cells constitutively generate vitamin D and respond to pathogens by increasing the machinery needed to convert 25D, the inactive form of vitamin D to 1,25D, the active form.7 Viral infections may induce expression of 1a-hydroxylase and increase conversion of 25D to 1,25D, which may be of benefit to the host response against the virus.7 It is believed that the increase in local 1,25D in airways contributes to decreased tissue damage while maintaining viral clearance.7 Further examination of the role of vitamin D in airway antiviral responses has demonstrated that vitamin D induces IкBa in airway epithelium, which leads to reduced induction of NF-kB driven genes during active viral infection.8 The end result is decreased secretion of inflammatory chemokines.8 Finally, in addition to dampening expression of inflammatory chemokines, it has been shown that vitamin D increases the expression of CD14 and cathelicidin which functions in recognizing and eliminating viral pathogens, altering T-Cell activation.8 Together, this supports that vitamin EMpulse Fall 2022

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D potentiates innate immunity while controlling a potentially harmful inflammatory response in the respiratory tract. Further studies are needed to better define safe dosage, therapeutic range and risk versus benefit analysis of supplementation.9

CASE REPORT A 57-year-old male with a past medical history notable for hypertension and chronic kidney disease, benign prostatic hypertrophy, and gastroesophageal reflux disease, weighing 75kg, presented to the emergency department for significant worsening fatigue, weakness, and decreased appetite over the previous two weeks, with an unexplained 10lb weight loss over the previous two months. His home medication regimen included amlodipine 10mg daily, Flomax 0.4mg, and pantoprazole 20mg. The patient was afebrile on arrival with a blood pressure of 148/84 mmHg, heart rate of 79 BPM, and a respiratory rate of 18. Physical examination was unremarkable. However, laboratory analyses revealed an ionized calcium level of 2.08 mmol/L (reference range: 1.15 -1.30 mmol/L) and calcium level of 17.4 mg/dL (reference range: 8.6-10.3 mg/dL). When questioned further, the patient noted he had been taking anywhere from 20,000-30,000 IU daily of vitamin D for SARSCoV2 prophylaxis for a duration of greater than eight weeks, after being instructed to do so by a physician in Brazil. He reported his physician had not explicitly recommended a dosing regimen, and that he was simply informed that high doses of vitamin D would prevent him from contracting

COVID-19. Further lab studies revealed serum vitamin 1,25D level of 123 ng/ mL (reference range: 20-50 ng/ mL), parathyroid hormone level of 15, (reference range: 11-51 pg/mL), and phosphorus of 2.4 (reference range: 2.5 to 4.5 mg/dL). Nephrology was consulted due to concern for renal toxicity secondary to hypercalcemia in the setting of CKD. They recommended beginning 4 IU/kg of calcitonin every 12 hours, with repeat calcium levels every 12 hours, and aggressive intravenous fluid hydration at a rate of 250 cc/hr, adjusted as indicated to maintain appropriate fluid balances. Vitamin D supplementation was promptly terminated, and the patient was admitted to inpatient service for further management. Endocrinology was consulted and noted concern for possible underlying hyperparathyroidism (either primary or secondary due to the patient’s history of chronic kidney disease), that was subsequently worsened by vitamin D toxicity. The patient was ultimately treated empirically with continued aggressive hydration per nephrology’s recommendations, at 250 cc/hr for the first three days of admission, followed by 200 cc/hr for the remaining duration of his admission, and calcitonin 4 IU/kg every 12 hours, terminated at 72 hours to prevent tachyphylaxis. The patient’s calcium steadily improved over his admission, with final discharge 10 days later and a laboratory evaluation demonstrating a calcium level of 11.4 mg/dL (patient’s baseline) just prior to discharge. Of note, patient was ultimately lost to follow-up and unable to be evaluated for whether a component of underlying hyperparathyroidism may have exacerbated his presentation.

DISCUSSION The most common clinical sequela of vitamin D toxicity (VDT) includes vomiting, abdominal pain, confusion, polyuria, polydipsia, and dehydration.10 This symptomatic presentation is due to its downstream effect of severe hypercalcemia and hypercalciuria, precipitated by excessive intake. Although VDT is fairly uncommon in the general population, its health effects can be deleterious if not quickly identified and treated.10

Humans normally process vitamin D through synthesis in their skin following type B ultraviolet light exposure, and to a lesser extent from dietary sources. It remains stored in the body’s fat cells until needed. When required, stored vitamin D undergoes hydroxylation in the liver to 25-hydroxyvitamin D3 (25D), which is then transported and synthesized into its active form, 1,25-dihydroxyvitamin D3 (1,25D) by the mitochondrial enzyme 1a-hydroxylase, which conventionally occurs in the kidney, before playing a role in a variety of metabolic processes.9 With continued consumption of high doses of vitamin D, the negative feedback system which downregulates the hydroxylation of vitamin D is overwhelmed and unable to prevent the development of toxicity.11 It is believed that as vitamin D binding receptors become saturated, there begins a steady increase in the concentration of vitamin D metabolites.11 The increased concentration of these metabolites eventually exceeds vitamin-D binding protein (VDBP) binding capacity, causing a release of free 1,25(OH)2D, although it should be noted that the exact mechanism of vitamin D toxicity still remains unknown.11 The upper limit of safe consumption, defined as the highest level of daily intake that is likely to cause no adverse health effects over an extended duration in most of the general population for vitamin D3, ranges from 4,000-10,000 IU/d for both adolescents and adults.12 Persistent consumption of vitamin D beyond these levels over a period of several months can lead to chronic hypervitaminosis D and toxicity. Although less common, acute toxicity can also occur. Acute toxicity has been reported within the range of about 600,000-1,680,000 IU per day over a period of several days, with a median lethal dose of about 1,480,000 IU.13 Management of hypervitaminosis D is mainly supportive and focuses on treating the resulting hypercalcemia and providing symptomatic relief. Recommendations include discontinuing all vitamin D and calcium supplements immediately, EMpulse Fall 2022

and providing volume expansion using isotonic saline supplementation with a rate of 200-300 cc/hr, that is then adjusted to maintain urine output to 100-150 cc/hr. In cases of severe hypervitaminosis, as seen in this patient, calcitonin and bisphosphonates can be utilized, although calcitonin is the preferred mode of treatment. It is recommended patients are treated with 4 IU/kg every 6-12 hours. Depending on the severity of toxicity, levels may take days to weeks to normalize. During this time supportive treatments should be continued, and calcium levels should be monitored carefully.10 Although we report a case of a patient who developed severe hypercalcemia in the setting of acute vitamin D toxicity for the prophylaxis of SARSCoV-2, it remains unclear whether the administration of vitamin D provided any protective benefits with regard to respiratory health. The lack of appropriate guidelines for the off-label use of vitamin D as SARS-CoV-2 prophylaxis led to the development of VDT and severe hypercalcemia, which if had been left untreated, could have led to devastating consequences. The patient required a long 10-day admission before achieving normalization of his lab values, representing a great financial, nosocomial infection, and personal burden. With increased public awareness of the immune benefits and possible use of vitamin D as a respiratory protectant, the risk and incidence of vitamin D toxicity due to self-administration in doses significantly higher than recommended may become more common.

CONCLUSION This case clearly identifies the need for development of vitamin D related recommendations with respect to COVID-19 prophylaxis, especially given its widespread use and ease of availability. Both providers and patients need to be better educated regarding the risks and benefits of vitamin D supplementation in the prevention of COVID-19. With continued research, investigation, and guidelines targeting vitamin D supplementation in the prevention of COVID-19, future cases of VDT may be averted. ■ 37

FEATURE

Preliminary Analysis of Downstream Treatment Engagement Post-ED Visit in Opioid Use Disorder Patients With and Without Additional Psychiatric Comorbidity By Heather Henderson, PhD, CAS Dept. of Emergency Medicine, Division of Internal Medicine, Tampa General Hospital & Department of Anthropology, USF

Ana Gutierrez, BS

By Bernice McCoy, PhD, MPH Associate Director of Social Medicine Programs at Tampa General Hospital

By Jason Wilson, MD, FACEP, FAAEM Dept. of Emergency Medicine, Division of Internal Medicine, Tampa General Hospital

Owen Hastings, BS

Among patients who present to the ED with opioid use disorder (OUD), there is a high prevalence of comorbid mental illness – in some instances, as high as 64%.1 Further, research has shown that patients with comorbid OUD and other mental illness often experience worse treatment outcomes and have a higher risk for morbidity and mortality.1 In this patient population, it is vital to stabilize both OUD and concurrent mental illness. However, information on downstream treatment engagement and retention remain unclear. Various studies have reported that individuals with comorbid conditions were the least likely to engage in downstream treatment post-ED visit, while others report either equal or increased chance of treatment completion when compared to individuals without comorbid condition.2, 3 We sought to gain further insight on this phenomena by analyzing 438 patient charts from our BRIDGE program (Building Integrated Recovery for DruG users into Emergency medicine) and on-site interviews with participants at IDEA Tampa, our syringe services program (SSP). Rates of treatment retention were then analyzed among OUD patients with and without psychiatric comorbidities. Below, we present the findings from this analysis, identify barriers to treatment retention, and propose future directions to inform sustained downstream treatment engagement. BRIDGE patient chart review indicated that patients with OUD and another co-occurring psychiatric disorder had higher rates of addiction treatment follow up (68%) than their peers without another co-occurring disorder

EMpulse Fall 2022

(51%). This finding also mirrors data collected in the interviews conducted on-site with 25 SSP patients, of which 60% had co-occurring OUD and another mental health condition. SSP patients reported accepting some form of mental health treatment (counseling, medication, etc.) at least once in their lifetime (88%), and 72% were able to identify one or more positive outcomes related to mental health treatment, with the most common response being access to medication. Other positive outcomes included improved psychiatric symptoms, improved mood, improved mental state, improved sleep, and increased coping skills. Barriers were mainly structural for patients, including lack of financial resources, lack of insurance, and difficulty navigating treatment systems and services, which is largely consistent with existing literature.4 Further, all patients reported a relapsing event after losing access to mental health treatment. These findings suggest a higher level of engagement in mental health treatment among OUD patients than has been reported in previous literature. The ED visit plays a key role in stabilizing patients with OUD, and our findings indicate that there may be an additional opportunity to further improve downstream treatment engagement by utilizing medications for opioid use disorder (MOUD) and a direct referral to community treatment partners. We utilize these strategies in our BRIDGE Program, which offers buprenorphine induction and peer recovery specialists, who facilitate the warm hand-off to community OUD treatment facilities and/or community

ED Pain Coach Educator Model Program and Patient Toolkit Guide for Integrative Pain Management by Phyllis Hendry, MD, FAAP, FACEP, Sophia Sheikh, MD, FACEP and the PAMI Team harm reduction programs, like IDEA Tampa. Further, we are currently conducting a pilot where Master’s-level mental health counseling interns see patients alongside our peer recovery specialists in order to co-locate linkage and downstream support during the ED visit. While this preliminary analysis seems promising, more research is needed to determine the long-term impact of co-located care for OUD and other comorbid psychiatric conditions on treatment retention and longterm recovery for patients with cooccurring disorders. ■

REFERENCES: 1. Jones, C. M., & McCance-Katz, E. F. (2019). Co-occurring substance use and mental disorders among adults with opioid use disorder. Drug and alcohol dependence., 197, 78-82. https://doi.org/10.1016/j. drugalcdep.2018.12.030 2. Krawczyk, N., Feder, K. A., Saloner, B., Crum, R. M., Kealhofer, M., & Mojtabai, R. (2017). The association of psychiatric comorbidity with treatment completion among clients admitted to substance use treatment programs in a U.S. national sample. Drug and Alcohol Dependence, 175, 157-163. https://doi.org/10.1016/j. drugalcdep.2017.02.006 3. Friesen, E. L., & Kurdyak, P. (2020). The impact of psychiatric comorbidity on treatment discontinuation among individuals receiving medications for opioid use disorder. Drug and alcohol dependence., 216, 108244. https://doi. org/10.1016/j.drugalcdep.2020.108244 4. Barros, F. C., Matijasevich, A., Santos, I. S., Horta, B. L., Da Silva, B. G. C., Munhoz, T. N., . . . Rohde, L. A. (2018). Social inequalities in mental disorders and substance misuse in young adults. Social Psychiatry and Psychiatric Epidemiology, 53(7), 717-726. https:// doi.org/10.1007/s00127-018-1526-x

In 2021, the Pain Assessment and Management Initiative (PAMI) at the UF College of Medicine – Jacksonville, Department of Emergency Medicine launched a novel pain coach educator model to enhance patient education on nonopioid pain management options. The program has since expanded from the ED to inpatient and outpatient settings and can be completed in person or remotely via telephone or internet. This is the first known ED pain coach educator program in the US. A free, downloadable Pain Coach and Toolkit Guide is now available and provides comprehensive resources for institutions who want to develop a pain coach education program. Materials are appropriate for acute and chronic pain conditions, older children, adolescents, and adults. The guide contains: • the rationale for developing a pain coach education model • information on integrative pain management tools and resources such as aromatherapy, virtual reality, pain journaling, OTC oral and topical medications, acupressure, etc. • pain neuroscience analogies for patients • suggested data collection and evaluation tools • a list of helpful websites, literature, books, videos, and other resources. EMpulse Fall 2022

Download the Pain Coach and Toolkit Guide here

Patients are surveyed one month post pain coach visit for feedback and to determine if they are still using PAMI toolkits items. Patient and staff feedback, utilization and satisfaction have been overwhelmingly positive. Many patients now request to see the “pain coach” when they arrive in the ED or are admitted to the hospital. The Pain Coach and Toolkit Guide and PAMI resources can be adapted for use in your institution by including the phrase: “Used with permission from the UF College of Medicine – Jacksonville PAMI. Learn more at pami.emergency.med.jax. ufl.edu.” To contact PAMI, email pami@jax.ufl.edu or call us at (904) 244-4986. Stay connected with us on Facebook and LinkedIn for our latest updates. ■ 39

POISON CONTROL

The Use of Fomepizole as an Adjunct Therapy in Massive Acetaminophen Overdose By Reeves Simmons, Pharm.D.

Clinical Toxicology/EM Fellow, Florida/USVI Poison Information Center - Jacksonville

Acetaminophen (APAP) is one of the most common over-the-counter medications used in the United States, but can produce severe liver injury if taken in excess.1 APAP is among the top reported exposures to poison centers annually, with the Florida Poison Information Center Network documenting more than 7000 exposures in 2021 alone.2 APAP is the cause of 46% of all cases of acute liver failure (ALF), making it the most common cause of ALF in the United States.3 In 2004, the 21-hour protocol utilizing intravenous N-acetylcysteine (NAC) was approved by the FDA for the management of acetaminophen toxicity, and is described as having near 100% efficacy if initiated within eight hours of an APAP overdose (OD).4 Recently there have been several case reports, case series, and retrospective reviews published that note treatment failure resulting in hepatic injury, particularly in massive ingestions, even when NAC was initiated within eight hours from the known ingestion time.5,7 There is currently no standard definition of a massive acetaminophen (APAP) ingestion; however, based on current literature, the most commonly listed include an ingestion of >30g, a serum APAP level ≥ 300mcg/mL at any time, or a multiplication product (serum APAP x ALT) of ≥ 10,000.5,6,7,8 All three situations have led to significant hepatotoxicity, even when n-acetylcysteine (NAC) was initiated within the optimal eight-hour window. In the setting of a massive acetaminophen overdose, it has been shown that traditional NAC dosing 40

By Molly Stott, Pharm.D. Clinical Toxicology/EM Fellow, Florida/USVI Poison Information Center - Jacksonville

may not always provide adequate glutathione peroxidase (GSH) to keep up with the increased production of N-acetyl-p-benzoquinone (NAPQI) to prevent hepatoxicity.6,7 The studies evaluating alternative dosing regimens have reached the general consensus that doubling the dose of the maintenance bag of NAC (from 6.25mg/kg/hr to 12.5mg/kg/hr) should provide adequate GSH to account for the increased NAPQI burden. In addition, the mathematical findings on which traditional NAC dosing is based upon provides rationale for doubling or even tripling the maintenance bag of NAC depending on the serum APAP level. However, in massive APAP overdose, the GSH stores are rapidly depleted and even doubling the dose of NAC may still not be able to restore them fast enough to detoxify NAPQI. APAP is converted to NAPQI via cytochrome 2E1 (CYP2E1) and it has been postulated that with inhibition of this enzyme, in addition to replenishing GSH stores, massive overdoses could be treated more effectively with less hepatotoxicity. Fomepizole, which is commonly used in the treatment of toxic alcohol ingestions, is an inhibitor of CYP2E1. Its CYP2E1 inhibiting properties has led to the recent evaluation of its potential role as an adjunctive treatment in the setting of a massive APAP overdose.10 Additionally, another proposed mechanism supporting fomepizole use in APAP toxicity, especially in late presenting patients, involves the inhibition of c-Jun-N-terminal kinase (JNK). By inhibiting JNK activation and EMpulse Fall 2022

Edited by Dawn Sollee, Pharm.D., DABAT, FAACT Director, Florida/USVI Poison Information Center- Jacksonville, UF Health Jacksonville

translocation into the mitochondria, oxidative stress and further hepatotoxicity is reduced.11,12 Reasonable, but not proven, indications for the use of fomepizole in massive APAP ingestions are massive overdose as previously defined, delayed patient presentation/identification, and evidence of hepatotoxicity despite adequate NAC therapy. Optimal dosing of fomepizole as an adjunctive therapy for massive APAP overdose has yet to be determined in the literature. However, given the known safety profile, it is reasonable to utilize the same dosing scheme for the treatment of toxic alcohol exposure (15mg/kg IV loading dose followed by 10mg/kg every 12 hours).13 It is not yet known what the endpoint of therapy of fomepizole is and must be determined on a case-by-case basis with the treating team. Florida’s Poison Control Centers are available at 1-800-222-1222 if you have any questions regarding acetaminophen toxicity or any other toxic exposure. Toxicologists are available 24 hours a day to assist if needed in the management of the poisoned patient. ■

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Refer Patients to Hospice Quickly via the VITAS App Snap-tap-send • Determine hospice eligibility quickly and confidently* • Refer patients securely via face sheet or mobile form** • Receive in-app referral confirmation • Register for continuing education webinars • Utilize in-app prognostication tools • Send patients hospice education materials *The app is designed for clinicians. While it cannot replace the professional clinical judgment of a healthcare professional, the app has several new and helpful features to guide clinicians in establishing hospice eligibility, making a difficult job easier. **Referrals are securely transmitted using industry-standard encryption protocols from end to end. Data is encrypted in private cache while at rest in the app and deleted after successful transmission. Contact your IT department to inquire about whitelisting the VITAS App for your organization.

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FEATURE

Use of Dexmedetomidine as a sedative for intubated, mechanically ventilated patients Casey Carr, MD

Jacob Milling, MD, PGY-3

University of Florida, Department of Emergency Medicine, Division of Critical Care Medicine

University of Florida, Emergency Medicine

Sedation for intubated mechanically ventilated patients is a complicated practice that must be tailored to the specific clinical situation. There are several options, some of which have been used for decades, as well as the continued emergence of more novel sedative agents, some of which hold analgesic properties as well. It has been well documented in the literature that benzodiazepines, in particular, carry an increased risk of prolonged over-sedation, which in turn leads to delirium and prolonged time to extubation. An additional shortcoming of benzodiazepines is that they hold no analgesic properties. Propofol, opiates, and ketamine are also tools we can utilize, but we may be underutilizing an additional agent that has both sedation and analgesic properties and a rather reassuring safety profile, under the use of an experienced provider. This is dexmedetomidine. What is dexmedetomidine and how does it work? Dexmedetomidine is an a2 agonist, which has properties of anxiolysis, sedation and analgesia. Postsynaptic activation of the a2 adrenoreceptors in the CNS inhibits sympathetic activity, primarily leading to decrease in heart rate and blood pressure (to a lesser degree). In addition, a2 agonism leads to inhibition of presynaptic release of norepinephrine, leading to termination of propagation of pain signals and provides sedation. Therefore, in combination, dexmedetomidine can lead to analgesia, sedation and anxiolysis – three components that are often desired in the treatment of intubated and mechanically ventilated patients. These components are also highly desired in the immediate post42

extubation period as well. However, safety can be an issue in achieving these goals adequately, as several sedatives cause respiratory depression. What are the benefits of dexmedetomidine? For our mechanically ventilated patients, dexmedetomidine can act as an adjunct to our known anesthetic/ analgesic agents, or potentially as a sole agent for sedation and pain control. In regards to an adjunct, dexmedetomidine has synergistic properties with opiates, which can aid in decreasing the amount of opiates, and therefore avoid the adverse effects associated with long-term opiate administration. There is a low incidence of delirium with dexmedetomidine, and delirium is a known barrier to extubation. Therefore, with lower incidence of delirium, this may provide decreased length to extubation and length of stay. As eluded to earlier, the dangers of respiratory depression often leads to discontinuation of sedative medication in the extubation period. Dexmedetomidine appears to have significantly fewer respiratory side effects in comparison, particularly when not used as a bolus dose. It has been shown with a high degree of safety that dexmedetomidine can be continued in the extubated, spontaneously breathing patient. How do I dose and administer dexmedetomidine in a intubated, mechanically ventilated patient? Dexmedetomidine is administered as an IV infusion, with an expected onset of approximately 15 minutes and a EMpulse Fall 2022

half-life of approximately 6 minutes. We recommend a high dose infusion without a bolus in this setting. Our practice is starting infusion at 1.0 mcg/ kg/hr concurrently with an opioid infusion (e.g fentanyl). After infusion has started, titrate infusion to the indicated RASS goal. What are other indications in which I can utilize dexmedetomidine in the emergency department? Dexmedetomidine can be used to promote sedation while maintaining airway reflexes. Awake fiberoptic intubation, reduction of fractures/ dislocations (e.g shoulder, hip), and lumbar punctures are reasonable procedures to consider the use of dexmedetomidine. Dexmedetomidine may become especially useful in those patients where there is significant concern for respiratory depression in which you want to avoid agents such as propofol. ■

REFERENCES: 1. Gertler R, Brown HC, Mitchell DH, Silvius EN. Dexmedetomidine: a novel sedative-analgesic agent. Proc (Bayl Univ Med Cent). 2001 Jan;14(1):13-21. doi: 10.1080/08998280.2001.11927725. PMID: 16369581; PMCID: PMC1291306. 2. Jewett, Jess; Phillips, William J.. Dexmedetomidine for procedural sedation in the emergency department. European Journal of Emergency Medicine: February 2010 Volume 17 - Issue 1 - p 60 3. Should dexmedetomidine replace benzodiazepines as the preferred sedative, as suggested by new guidelines from the society for critical care medicine? Can J Hosp Pharm. 2013 Nov;66(6):393-6. doi: 10.4212/ cjhp.v66i6.1307. PMID: 24357874; PMCID: PMC3867569.

FEATURE

The Way We Were Doreen C. Parkhurst, MD, FACEP Retired; former Board Member and Education Committee Co-Chair

I had the pleasure of watching the EM:RAP interview with Dr. Jim Roberts, a pioneer of emergency medicine who recently died. As he reminisced during the interview, it took me back.

I remember one time when I was treating a patient with a kidney stone, I ordered ketorolac. The nurse said, “Are you sure? He’s a patient of Dr. Kidneystone.”

I can remember when I was working a night shift and taking care of a young woman with a likely ectopic pregnancy, I had to call the Chief of Radiology to get permission to call in an ultrasound tech. The radiologist said it could wait until morning. I understand my nephew, an emergency physician, carries a pocket ultrasound device!

I soon found out what she meant. Dr. Kidneystone came in to see his patient, but not before he spent 10 minutes yelling at me in the middle of the department. He didn’t want any of “his” patients to ever receive that medication. I remember when the nurses had orders to call certain physicians whenever “their” patients came into the ED. They would be told orders to give us, mostly “don’ts.”

When I had a patient with a ruptured abdominal aortic aneurysm on a night shift, I confirmed the diagnosis with a cross table lateral abdomen x-ray. There was no other imaging option available. If I had an awake patient requiring intubation, I did a nasal intubation with the patient cooperating. It seems we didn’t use many medications for intubation back then. RSI came a bit later on. Before that, if I needed a little something for a patient’s agitation, I would have the nurse push 10 mg of morphine and then quickly place the tube. Dr. Roberts talked about the response of other medical departments at the beginning of the emergency medicine specialty era. I remember some of those turf battles. Anesthesiologists believed intubation and sedation belonged only to them and should not be undertaken by us. Surgeons believed they owned procedures – chest tubes, for example – and should not be entrusted to EPs. Dr. Roberts spoke of a time when emergency physicians weren’t allowed to administer antibiotics!

When I trained in EM at Henry Ford Hospital in Detroit, we had a schedule of when we would put in chest tubes and when surgery would insert them. We learned procedures that may no longer be needed today. For example, do you ever need to perform diagnostic peritoneal lavage (DPL)? How about diagnostic pericardiocentesis? Culdoscentesis? Does anyone remember writing admission orders for the admitting physician? Thankfully, ACEP ultimately issued a clear position statement about that. In fairness, I remember a story told to us by an orthopedist in the l970’s. He spoke of a doctor who moonlighted in the ED before the emergence of our specialty. This doctor was a delightful man who didn’t know very much about anything. He had never done residency. His income was based solely on moonlighting.

“In his leg,” Dr. Moonlight answered. “Which bone in the leg?” “The big one.” “Is it the big one below the knee or the big one above the knee?” “Above the knee.” “Okay.” “And it’s sticking out.” “I’ll be right in.” We’ve come a long way. As we began to win the turf battles, the other specialists treated us as their residents. Surgeons would call us in the night: “Can you place a chest tube on the 4th floor for me? Will you start a central line on one of my patients?” Internists would ask us to intubate their patients on the floor and move them to the ICU. There were no hospitalists then (they came later). We were expected to respond to all codes in the hospital. We would leave the ED, where we were the only doctor on duty, to resuscitate patients elsewhere. Over the years, I saw many changes. Trauma centers and trauma teams were developed. By then, there was cooperation rather than competition. We both did the procedures. We talked about the plan. We worked together to save the patients. We saw the development of stroke teams where the neurologists and EPs work together for timely intervention.

The doctor called the orthopedist one time to report a patient with a broken bone.

When I started out, we practiced based on anecdotal information: something that always seems to work must be the way to do it. As time passed, clinical trials emerged. Evidence-based medicine (EBM) became the goal: where is the evidence that what we’ve been doing is the right thing to do?

“Where is it?” the orthopedist asked.

CONTINUE ON PAGE 45 ▶

EMpulse Fall 2022

FEATURE

Ultrasound Guided Transgluteal Sciatic Nerve Block for Refractory Sciatica in the Emergency Department Edward Hu, MD, PGY-2

Taryn Hoffman, MD

HCA Florida Orange Park Hospital Emergency Medicine Residency Program

Case A 50-year-old male presents to the emergency department with low back pain. He describes a history of chronic low back pain that has been progressively worsening lately. Pain is a sharp, shooting pain that radiates down his right leg and worsens with movement and ambulation with some associated numbness in the same area. The patient had to be wheeled into his room due to the severity of the pain. He reports no issues with bowel or bladder function, numbness in the groin, fevers, or chills. Vital signs are normal, and the physical exam reveals a positive straight leg raise test. The patient receives multiple rounds of multimodal pain management without significant relief of his symptoms. He remains unable to ambulate largely due to the severity of his pain. You perform an ultrasound guided nerve block in an attempt to control his pain enough to be able to discharge the patient home.

HCA Florida Orange Park Hospital Emergency Medicine Residency Program

8. Lidocaine and 27 gauge needle for superficial skin wheal Procedure 1. Be aware of signs and symptoms of local anesthetic systemic toxicity (LAST) and have Intralipid therapy readily available. 2. Obtain consent. Perform preprocedure time out. 3. Position the patient in lateral decubitus position with the affected side exposed. Flex the affected leg so the knee and hip lie at 90°. 4. Palpate the greater trochanter and the ischial tuberosity. Place the curvilinear probe along the line connecting these two landmarks with the indicator pointed toward the greater trochanter.

5. Identify the structures on ultrasound including the greater trochanter and ischial tuberosity with the hyperechoic sciatic nerve bundle in between. The gluteus maximus muscle lies superficially, and the quadratus femoris muscle lies deep to the sciatic nerve (Fig 1). 6. Administer a small superficial skin wheal of lidocaine near the planned insertion site. 7. Prep the area with a chlorhexidine swab. Drape the area with sterile towels and open supplies into the sterile field. Don sterile gloves and place the sterile probe cover over the curvilinear probe. 8. Using an in-plane approach technique, advance the spinal needle toward the sciatic nerve. As the needle is advanced, adjust the

Description Supplies 1. Ultrasound machine with curvilinear transducer 2. Sterile probe cover with sterile gel 3. Chlorhexidine prep stick 4. Sterile gloves and drapes 5. 10-20 mL of bupivacaine 0.5% (5 mg/mL; maximum 2 mg/kg). 4-8 mg dexamethasone may be added to reduce rebound symptoms. 6. 20-22 gauge spinal needle (90 mm) 7. Extension tubing up to 90 cm 44

Fig 1. Ultrasound anatomy of sciatic nerve with structures as labeled EMpulse Fall 2022

probe until the needle and its tip are visualized. 9. Once the needle tip is adjacent to the sciatic nerve, aspirate to ensure no blood return. 10. Have a non-sterile assistant inject 1mL of bupivacaine to ensure adequate positioning of the needle tip via hydrodissection of the fascial plane from the sciatic nerve. 11. Inject 4-5 mL of bupivacaine, then readjust the needle to the far side of the sciatic nerve, aspirate and inject the remaining bupivacaine.

in refractory low back pain in the ED in 2019 and a subsequent case series demonstrating safety and efficacy was published in 2020.5 This block results in a motor and sensory block of the posterior thigh and below the knee except for the medial leg and foot. In the hands of a trained practitioner, this technique can be a useful tool to treat refractory low back pain due to sciatica and may help avoid unnecessary hospital admissions and possibly reduce long term disability as well. ■

Discussion

References:

Low back pain is one of the leading causes of disability worldwide, and there are approximately 2.7 million annual visits to the emergency department (ED) in the United States for this chief complaint.1 According to one retrospective study on these presentations, sciatica accounts for up to a third of these visits.2 Once more emergent etiologies of low back pain have been ruled out, either via history and physical exam, or by various diagnostic modalities, the focus turns toward treatment of the pain both in the ED and once discharged. Many studies have been conducted focusing on the efficacy of various pharmacologic therapies including non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, muscle relaxants, glucocorticoids, lidocaine patches, opiates, combination therapy, and more.3 NSAIDs are the first-line pharmacologic therapy as a 2020 Cochrane review did show some benefit in patients with acute low back pain.4 Opiates are commonly used in the acute setting in the ED, but there is limited data supporting their use, and their side effects and abuse potential limit their utility.

1. Friedman BW, Chilstrom M, Bijur PE, Gallagher EJ. Diagnostic testing and treatment of low back pain in United States emergency departments: a national perspective. Spine (Phila Pa 1976). 2010;35(24):E1406–11.

The ultrasound guided transgluteal sciatic nerve block as described here provides ED physicians with an additional treatment option in patients who present with low back pain related to sciatica. This technique has been used previously by anesthesia for pain management surrounding lower extremity orthopedic or podiatric surgeries, but it has only just recently been introduced to emergency medicine. It was first described for use

2. Nunn ML, Hayden JA, Magee K. Current management practices for patients presenting with low back pain to a large emergency department in Canada. BMC Musculoskelet Disord. 2017 Feb 23;18(1):92. doi: 10.1186/ s12891-017-1452-1. PMID: 28228138; PMCID: PMC5322663. 3. Gillespie, Lauren, et al. “Back to Basics: Treatment of Acute Low Back Pain in the ED.” Taming the SRU, 1 Sept. 2020. Access at: www. tamingthesru.com/blog/diagnostics/ back-pain. 4. van der Gaag WH, Roelofs PD, Enthoven WT, van Tulder MW, Koes BW. Non-steroidal antiinflammatory drugs for acute low back pain. Cochrane database Syst Rev. 2020;4(4):CD013581. doi:10.1002/14651858.CD013581 5. Goldsmith AJ, Liteplo A, Hayes BD, Duggan N, Huang C, Shokoohi H. Ultrasound-guided transgluteal sciatic nerve analgesia for refractory back pain in the ED. Am J Emerg Med. 2020 Sep;38(9):1792-1795. doi: 10.1016/j. ajem.2020.06.001. Epub 2020 Jun 6. PMID: 32738473. 6. Fang, J., Shi, Y., Du, F. et al. The effect of perineural dexamethasone on rebound pain after ropivacaine singleinjection nerve block: a randomized controlled trial. BMC Anesthesiol 21, 47 (2021). https://doi.org/10.1186/ s12871-021-01267-z 7. Atchabahian, Arthur, et al. “Ultrasound-Guided Sciatic Nerve Block.” NYSORA, 28 Apr. 2022. Access at: www.nysora.com/ topics/regional-anesthesia-forspecific-surgical-procedures/ lower-extremity-regional-anesthesiafor-specific-surgical-procedures/ foot-and-anckle/ultrasou nd-guidedsciatic-nerve-block-2/

EMpulse Fall 2022

◀ CONTINUED FROM PAGE 43 The development of 24-hour Cath labs emerged. Patients with STEMI and non-STEMI were treated based on continually growing evidence. Clocks were set for the goal of reperfusion. Hyperbaric chambers became available and developed a growing list of afflictions that could be treated. When I re-certified with ABEM this year (4th time), I had some studying to do. I haven’t worked in EM for years, so I was surprised to learn that oxygen is no longer routinely administered to patients with acute MI. This is based on evidence that it may be harmful. The questions on the board exam have not changed, but the answers sure have! This is all good. Emergency medicine now stands as a respected specialty with physicians who are eminently qualified to manage acute patients and to make a difference in their outcomes. I salute the pioneers like Dr. Jim Roberts and so many others who braved the rocky terrain. I revere emergency physicians today. Like a parent, I feel so proud of you! Thank you for making our profession so honorable. ■

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CASE REPORT

Hematologic Emergency: Delayed Hyperhemolytic Transfusion Reaction in a Pediatric Sickle Cell Patient By William Waite, DO, MS

Camilo Florez, MD

Orlando Regional Medical Center & Arnold Palmer Hospital for Children

Background Individuals with sickle cell disease (SCD) often receive blood transfusion for acute on chronic anemia due to vaso-occlusive crisis, splenic sequestration, acute chest syndrome and many other reasons. Alloimmunization is one of the many risks of blood transfusion in individuals with sickle cell disease that can lead to delayed hemolytic transfusion reaction (DHTR). Cases with hyperhemolysis are rare but lifethreatening. Patients may present up to three weeks post transfusion with symptoms of pain, worsening fatigue, fever, and hematuria. The mainstay of treatment includes intravenous immunoglobulin, glucocorticoids, and phenotypically matched PRBCS.

Case Description The patient is a 6-year-old female with a history of sickle cell anemia, Hgb SS, who presents to the emergency department with a complaint of hematuria and lower abdominal pain that started three days prior to her arrival. She has never had noticeable blood in her urine, and her father states that her symptoms are different from her usual sickle cell pain crisis. There were no reports of chest pain, shortness of breath, fever, headaches, vision changes, nausea or vomiting. Upon further questioning, the patient’s father revealed that they recently returned from Senegal, Africa, where they were vacationing for two months. While there, she had a vasocclusive crisis requiring blood

transfusion. The transfusion was three weeks prior to this visit.

decrease metabolic demand and then upgraded to the PICU.

Physical exam noted an anxious appearing 6-year-old female, sitting up in bed and in mild distress. Pertinent positive findings on exam were delayed capillary refill, bilateral conjunctival icterus and tenderness to mild palpation in the right lower quadrant of her abdomen. See Table 1 for initial vital signs.

The patient had a complicated hospital course. Blood transfusion was continued until the goal of greater than 8 was achieved. She was continued on IVIG and methylyprednisolone. She was extubated after three days. The patient later developed seizures and was found to have an acute CVA. After 11 days, she was discharged home in

The patient became increasingly more uncomfortable, and her abdominal pain worsened. Initial lab work done in the emergency department included whole blood, CBC with Differential, reticulocytes, CMP, haptoglobin level, LDH, UA, lactic acid level, Type and screen, and Peripheral blood smear. See Table 2 for pertinent findings on lab work. The patient was emergently transfused phenotypically matched PRBCs at 10 cc/kg in the emergency department. Hematology was consulted, and the patient was admitted to the ICU step down unit with a diagnosis of Delayed Hemolytic Transfusion Reaction, UTI and Sickle Cell Crisis. Malaria was ruled out on peripheral blood smear. On admission she was given methylprednisolone and IVIG to inhibit destruction of RBCs. The patient became hypoxic and increasingly tachycardic shortly after admission. Repeat hemoglobin was 2.8. The patient was intubated to help

Table 1: Initial Vital Signs BP

95/56

Temp

99.4

Heart Rate

155

Resp Rate

SpO2

99%

Table 2: Lab Results WBC

29.6 (3.8 – 10.4)

Hematocrit

9.3 (34 - 42)

Hemoglobin

3.2 (11.5 – 14.3)

LDH

2141 (140 – 271)

Haptoglobin

5.8 (36 – 195)

Total Bilirubin

2.6 (0.3 – 1.0)

Retic Ct Pct

14.08 (0.5 – 2.20)

Retic Ct Abs

163.3 (19 – 124)

Reticulocytes

1.16 (4.1 – 5.2)

Urinary Analysis

+ Blood, + Nitrites

stable condition with no neurological deficits.

Discussion This is a 6-year-old female with history of sickle cell disease who presented to the emergency room with abdominal pain and hematuria. This case highlights the importance of a quick and detailed history (including recent travel) to hone in on the diagnosis. The differential diagnosis narrowed to include delayed transfusion reaction once it became known that she had a recent travel history to Senegal where she received blood transfusion. In certain parts of the world outside of the U.S., the blood cross matching process may not be as stringent, and she likely did not receive phenotypically matched blood which may have triggered her hyperhemolytic transfusion reaction. Hemolytic transfusion reactions (HTRs) occur when there is immunologic incompatibility between a transfusion recipient and the red blood cells from the blood donor. HTRs can range in severity from asymptomatic to severe causing DIC and shock. HTRs can be acute, occurring during the transfusion or within 24 hours after the transfusion. Delayed hemolytic transfusion reaction (DHTR) typically occurs 1-2

weeks post transfusion but can be up to three weeks. Many cases of DHTRs are mild, but it can be severe when there is hemolysis. In this case, the patient had a DHTR as she presented three weeks after transfusion. Patients with DHTR typically have extravascular hemolysis, which is hemolysis that occurs in the spleen, liver, and bone marrow. Her history of sickle cell disease puts her at risk for intravascular hyper-hemolysis in which transfused red blood cells is accompanied by hemolysis of the patient’s own red blood cells. This phenomenon has been seen most often in patients with SCD who have received multiple transfusions. Lab workup in these patients will show elevated LDH and indirect bilirubin with decreased haptoglobin levels. The hemoglobin level may be lower than expected given the patient’s clinical picture. In this case, the hematologist had asked to repeat H&H as her clinical picture initially on presentation did not fit a HgB of 3.2. The mainstay of treatment in these patients is with glucocorticoids and intravenous immunoglobulin. If no improvement, patients may benefit from plasmapheresis. In this case, the patient was transfused immediately with

phenotypically matched PRBC, started on IVIG and methylprednisolone. She went into shock and was intubated to decrease metabolic demand and slow the hyper-hemolysis process. Her condition improved after intubation and she did not require plasmapheresis or addition of DMARDs to treatment regimen.

Conclusion Delayed hyper-hemolysis reaction is a rare complication of blood transfusion in sickle cell patients. This is a hematologic emergency requiring immediate resuscitation, including phenotypically matched PRBCs and intensive care unit admission. Making the diagnosis promptly is challenging as these patients can present up to three weeks post blood transfusion with wide ranging symptoms. This case highlights the importance of a detailed history to make prompt diagnosis and facilitate early treatment. ■

REFERENCES: 1. DeBaun M, Chou S. Transfusion in sickle cell disease: Management of complications including iron overload. UpToDate. Accessed September 1, 2022. 2. Tobian A. Hemolytic Transfusion Reactions. UpToDate. Accessed September 1, 2022.

Daunting Diagnosis: A By Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief ◀ CONTINUED FROM PAGE 8 This patient sustained bilateral mandibular fractures that are comminuted, displaced, and communicating with the oral cavity. The CT scan shows a vertical

fracture on the right side of the mandible symphysis with mild anterior displacement of the rightside fragment. The second fracture is visualized in the left mandible at the angle with mild inferior displacement of the right-side fragment. There is significant soft tissue swelling in the region of fracture. OMFS was consulted who placed an Erich Arch Bar over the maxillary and mandibular teeth, as shown in the

Panorex. The patient was taken to the OR by OMFS for an open reduction internal fixation of the right mandibular parasymphysis fracture, the left mandibular angle fracture, and extraction of teeth #1, #16, and #17. The patient was with left V3 hypoesthesia, as expected. He has been following a normal postoperative course. ■

FEATURE

A Tale of Two Shocks: A Cardiogenic Shock Interview With The Heart Failure Specialists Shaheen Emami, BS University of Miami Miller School of Medicine

Joshua Goldstein, MD University of Miami/ Jackson Memorial Hospital Department of Emergency Medicine

Jennifer Paciletti, ARNP HCA Florida JFK Hospital, Advanced Heart Failure & Transplant Cardiology

Waqas Ghumman, MD HCA Florida JFK Hospital, Advanced Heart Failure & Transplant Cardiology

Shock is defined as any condition that causes hemodynamic compromise resulting in systemic hypoperfusion, cellular dysfunction, and potentially end-organ failure and death.1 It is a medical emergency, and identifying and managing shock states is an essential skill and role of the emergency medicine physician. All patients in shock have an underlying etiology of their circulatory failure. Classically, shock can be subdivided into hypovolemic, obstructive, distributive, and cardiogenic etiologies. Cardiogenic shock is an etiology that maintains a devastatingly poor prognosis. With studies showing ranges of 25-50% mortality, it should be kept high on the differential for any emergency medicine physician.2 In cardiogenic shock, the heart is unable to pump blood to the organs with sufficient volume to meet their metabolic demands. Over the past decade, the National Cardiogenic Shock Initiative has been aiming to provide protocols for the management of cardiogenic shock, with promising results.3, 4 By contrast, septic shock is perhaps the most talked-about form of shock.5 This subtype of distributive shock involves intact cardiac function, but with dilated, leaky vasculature, which causes third spacing of fluid and decreased tissue perfusion. Despite nationwide hospital initiatives to improve sepsis recognition and management, there is mixed evidence regarding overall outcomes.6 An issue that stands amongst clinicians is differentiating cardiogenic shock from other forms

EMpulse Fall 2022

of shock. Many forms of shock can present similarly, with hypotension, tachycardia, and elevated lactic acid indicating end-organ hypoperfusion. This presents a clinical dilemma to the emergency physician, as some etiologies of shock rely on fluid resuscitation as a mainstay of treatment, while cardiogenic shock requires IV inotropes, vasopressors, and diuresis to return the patient to homeostasis.4 We interviewed two heart failure specialists for their perspectives on the recognition and management of cardiogenic shock. Dr. Waqas Ghumman, MD, an Advanced Heart Failure and Transplant Cardiologist, and Jennifer Paciletti, ARNP, an Advanced Heart Failure Nurse Practitioner, practice at HCA Florida JFK Hospital. Dr. Ghumman is also the program director for the Heart Failure and Transplant Cardiology fellowship at HCA Florida JFK Hospital/University of Miami Miller School of Medicine. How do you recognize a patient in cardiogenic shock? Paciletti: Definitely get an echo. We utilize the point-of-care ultrasound (POCUS) a lot in the ICU settings. Also, checking lactates, of course, with hemodynamics and blood pressure. We can use a Swan-Ganz Catheter if we have one in place, but that comes a bit later in the ICU. Ghumman: I’ll make it even more simple. First, to diagnose shock, patients must show organ dysfunction, such as they’re not mentating, peeing, or something similar. Then, the question is, what kind of shock is it? Is it septic/

distributive, cardiogenic, obstructive, etc.? Cardiogenic is a cold shock, so patients tend to have cool extremities because they’re vasoconstricted and their cardiac output (CO) is low. It can be confusing which form of shock it is, especially compared to septic shock. With the Surviving Sepsis Campaign, all shock is septic until proven otherwise, because their criteria are the same criteria for all types of shock. [Once you’ve diagnosed shock], you have to prove it’s the heart. An echo can prove it if you have low cardiac output. At first glance, many patients in shock may look similar. Cases of cardiogenic shock may initially be mistaken for septic or distributive shock. How do you differentiate the two? Ghumman: It’s because the Surviving Sepsis criteria for septic shock are very non-specific. If you’re tachycardic, tachypneic, hypotensive, or have elevated lactate, it’s assumed to be septic. There is significant overlap in the presentations of patients in shock. They should, in theory, be different. Septic shock is a warm shock: patients are vasodilated, [cardiac] output is high, and they should have warm extremities. Cardiogenic is a cold shock, meaning high vascular resistance and low [cardiac] output. Using warm versus cold is a pretty good delineator. POCUS is important as well. Some physicians use troponin [and BNP], but that can go up not just in heart attacks, but also in sepsis and other conditions. In isolation, you can’t use troponin or BNP as purely cardiac. Additionally, if you make the wrong diagnosis, it does matter. The Surviving Sepsis Campaign is big because sepsis kills, and doing the right thing for sepsis does improve survival. We actually did a study here.7 It turns out, when you treat septic patients who have a history of heart failure with a bolus of fluid,

the higher volumes of intravenous crystalloid increase the mortality in some populations, precipitating pulmonary edema and worsening cardiogenic shock. The excess fluid translates to more ICU time, more ventilator time, and more myocardial dysfunction. What recommendations do you have for emergency physicians who are working up a patient in undifferentiated shock? Ghumman: Determine if it’s shock from low systemic vascular resistance (warm shock) or low CO (cold shock). That’s a good differentiator. If you’re in doubt, get an echo or POCUS. On ultrasound, getting a four-chamber view to look at the left and right ventricles is great. If you see the ventricles are hyperdynamic and collapsing on themselves, that’s not cardiogenic. Check the IVC. Septic or hypovolemic will be collapsed, whereas in cardiogenic, it’s going to be dilated. You can use [diffuse] B-lines as well to suggest pulmonary edema. And the stories need to fit. Septic shock should have a fever and a source of infection. [Patients with] cardiogenic generally have known heart disease

REFERENCES 1. Kislitsina ON, et al. Shock Classification and Pathophysiological Principles of Therapeutics. Curr Cardiol Rev. 2019;15(2):102-113. doi: 10.2174/1573403X15666181212 125024. PMID: 30543176; PMCID: PMC6520577. 2. Jones TL, et al. Cardiogenic shock: evolving definitions and future directions in management. Open Heart. 2019 May 8;6(1):e000960. doi: 10.1136/openhrt-2018-000960. PMID: 31168376; PMCID: PMC6519403. 3. Basir MB, et al. National Cardiogenic Shock Initiative Investigators. Improved Outcomes Associated with the use of Shock Protocols: Updates from the National Cardiogenic Shock Initiative. Catheter Cardiovasc Interv. 2019 Jun 1;93(7):1173-1183. doi: 10.1002/ccd.28307. Epub 2019 Apr 25. PMID: 31025538. 4. Moghaddam N, et al. Cardiogenic shock teams and centres: a contemporary review of

EMpulse Fall 2022

or an ischemic event, so make sure you get an EKG. Consider an echo. If it doesn’t fit, you have to quit. There’s no harm in asking for advice. What approach do you take to stabilizing and managing a patient recognized to have cardiogenic shock? Ghumman: You do what your body does. If you have low cardiac output, your body raises vascular resistance. If they have profound hypotension, start a vasopressor [such as norepinephrine]. If mild, start an inotrope [such as dobutamine or milrinone]. Paciletti: It is important to assess if the shock is due to ischemia. Then, if they need revascularization, activate the cath lab. Do you have any last thoughts or points? Ghumman: Be a good clinician. If the story doesn’t add up, ask for help. If it adds up, you’re probably clear. And then follow up, because if you’re wrong you’re going to know. And it’s okay to be wrong; we’re not perfect. ■

multidisciplinary care for cardiogenic shock. ESC Heart Fail. 2021 Apr;8(2):988-998. doi: 10.1002/ ehf2.13180. Epub 2021 Jan 16. PMID: 33452763; PMCID: PMC8006679. 5. Gyawali B, et al. Sepsis: The evolution in definition, pathophysiology, and management. SAGE Open Med. 2019 Mar 21;7:2050312119835043. doi: 10.1177/2050312119835043. PMID: 30915218; PMCID: PMC6429642. 6. Bauer, M., et al. Mortality in sepsis and septic shock in Europe, North America and Australia between 2009 and 2019— results from a systematic review and meta-analysis. Crit Care 24, 239 (2020). https://doi. org/10.1186/s13054-020-02950-2 7. Al Abbasi B, et al. Implementation of the Surviving Sepsis Campaign in Patients With Heart Failure: Gender-Specific Outcomes. Cureus. 2020 Jul 11;12(7):e9140. doi: 10.7759/ cureus.9140. PMID: 32789078; PMCID: PMC7417181.

MUSINGS FROM A RETIRED EMERGENCY PHYSICIAN

A Post-Roe ER By Wayne Barry, MD, FACEP Former FCEP Board Member

Having retired from the practice of emergency medicine over 10 years ago now, I realize that I may be a poor spokesperson for the post-Roe ER. However, please bear with me as I could not pass up the opportunity for some gentle musings on the subject. Before I begin, I must confess to my readers that I am suffering a low level of perpetual survivor’s guilt due to the fact that I never had to contend with the overwhelming stress of the COVID pandemic while working in the ER. I cannot imagine the unbearable physical and emotional toll that experience has taken on so many of you ER physicians, nurses, and other ER staff. I hear it in the voices and see it in the faces of my EM colleagues, many of whom are suﬀering from PTSD as a result of their heroic work during the recent pandemic. Now comes the SCOTUS overturn of the historic and precedent-setting 50-year-old Roe v. Wade decision, which transformed the moral and ethical landscape of this country and recognized the rights of fully one-half of the human population to make decisions regarding their bodies and their lives as free, living, human rights-enjoying women who were no longer subservient to male decision makers and political policy engineers. You can just reverse all the statements located in the previous sentence and you have the predicament we are enduring postRoe. So by now, I am sure that most of you actively practicing ER docs have engaged with colleagues and leadership with any changes in practice (or better lack thereof), anticipating potential blow back from law enforcement, politicians or other community members. I 50

have to confess, I worked the last 12 years of my EM career in a hospital without OB services on-site, so there was liberal referral and transfer to outside OB practitioners, due to the lack of both in-house OB facilities and physician back up. In the U.S., 25% of women experience abortion during their reproductive years. Seven percent of U.S. women have participated in a self-managed abortion, which means they induced abortion via medical (such as mail-order mifepristone and/ or misoprostol) or other means, including herbs, blunt abdominal trauma, or intrauterine manipulation to induce abortion. Women seeking help in the ER must obtain nonjudgemental expert, acute emergency treatment, even in states where abortion is outlawed. President Biden has reminded the emergency medicine community that providing emergency life-and limbsaving medical care trumps all state laws speaking against such matters. EMTALA, the cursed statue that many times made our lives miserable in the ER by mandating unfunded emergency care and and created sometimes endless disputes about what constitutes a safe and proper patient transfer between health care facilities, is now saving our bottoms with respect to potential litigation in the post-Roe world. How ironic! So what does all of this mean for practicing ER docs, ARNP’s and PA’s? I do not exactly know. I suspect OB patient ER traffic will be increased, maybe significantly in states with adverse abortion rights laws in effect. Some of these states, like Texas, have passed anti-abortion bounty hunter laws enabling citizens to tattle on any human being having anything to do with enabling a woman in EMpulse Fall 2022

Texas to obtain an abortion. This Machiavellian law provides $10,000 to such individuals, incriminating healthcare workers, Uber drivers, dogooding family members and others. Please keep these people out of Texas ER’s, and if they or trouble-making litigation-minded people in any other state go after ER personnel or their patients, let us hope EMTALA shields us all! Good grief. In closing, I am still trying to wrap my head around the recent SCOTUS decision striking down a U.S. woman’s right to an abortion. I would be the first to acknowledge that anti-abortion rights advocates in this country have fought long and hard for their position. They were boisterous, energetic, and passionately committed. Roughly 60% of U.S. citizens are pro-choice, or at least in favor of a woman’s right to choose what happens to her own body or how to manage her own personal health. Unfortunately, far fewer Americans are willing to get up on soapboxes and trumpet the cause of pro-choice. Astonishingly to me, the highest court in the land appears to have caved into political partisanship, and nullified a precedent-setting insurance of basic human rights to half of the population of this country. Interestingly, this recent Supreme Court ruling seems to have aroused a huge amount of sentiment on the opposite side and may galvanize more political support against the apparent red wave, which has been predicted to occur in the upcoming midterm election, which typically favors the political party out of power. Hold on to your hats and buckle your seat belts for this one. Happy Autumn. ■

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