Official Publication of the Florida College of Emergency Physicians A Chapter of the American College of Emergency Physicians
FRONT LINE THE
AGAINST SARS-COV-2
� A Steadfast Approach to the COVID-19 Pandemic
� Pandemic Philanthropy
Plus: Introducing the Class of 2023 on p. 20
� Burnt-out Doctors Performing Whole Patient Care... Really? Vol. 27, No. 1 | Spring 2020
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EMpulse Spring 2020
TABLE OF CONTENTS COMMITTEE REPORTS 8 FCEP President’s Message By Dr. Kristin McCabe-Kline
10 COVID-19 in Pediatric Patients By FCEP’s Pediatric Committee
16 Government Affairs Dr. Blake Buchanan
18 Membership & Professional Development Dr. Rene Mack
22 EMRAF President’s Message Dr. Matthew Beattie, PGY-3
Medical Student Council Alexa Peterson, OSM-III
SPRING 2020
Volume 27, Issue 1
17 Medical Economics
EMpulse Magazine is the official, quarterly publication of the Florida College of Emergency Physicians (FCEP).
FEATURES & COLUMNS
EDITOR-IN- Karen Estrine, DO, FACEP, FAAEM CHIEF karenestrine@hotmail.com
Dr. Daniel Brennan
4 Dear FCEP Members FCEP Staff
6 A Steadfast Approach to the COVID-19 Pandemic Dr. Amy Souers
9 How Collective Medical’s Realtime Platform is Responding to COVID-19 Sponsored by Collective Medical
12 Pandemic Philanthropy: Medical Students Mobilize on COVID-19 Community Donations
Alison Ohringer, Samantha Lux & Dr. Jennifer Jackson
14 Farewell, FCEP Family Beth Brunner
20 Introducing the Class of 2023 Florida’s Emergency Medicine Residency Programs
32 Poison Control: Wading through the Weeds: in Search of the Truth Behind Kratom Drs. Kristen Lee & Anthony DeGelorm
35 Burnt Out Doctors Performing Whole Patient Care... Really? Dr. Ademola Adewale
36 Case Report: A Disappearing Act: The curious case of Lemierre’s Syndrome Drs. Amar Mittapalli, Andrew Napier & Walter D’Alonzo
38 Bleeding from a Chronic Head Wound: Squamous Cell Carcinoma Case Presentation Dr. Nancy W. Weber
39 Advanced Care Planning 2020 Sponsored by Gottlieb
40 Ultrasound Zoom: A New Mode to Diagnose Pneumo(Peritoneum): Using POCUS to Identify Intraabdominal Free Air
Drs. Brittney Giuffre & Leila Posaw
MANAGING Samantha League, MA & DESIGN sleague@emlrc.org EDITOR
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ON THE COVER: Photos of FCEP members on the front lines of COVID-19. Images submitted by (from left-to-right):
Top row: Drs. Kristy Whyte; Russell Radtke; Sanjay Pattani; Damian Caraballo; Kathleen Clem; L. Anthony Cirillo
Middle row: Drs. Aldo Manresa & colleagues; Shayne Gue; Rajiv Bahl; Jay Falk; Steven Kailes & colleagues Bottom row: Drs. Christina Caro; Christopher Hunter; Benjamin Abo; Blake Buchanan; Aventura EM Residency Program EMpulse Spring 2020
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All advertisements in EMpulse are printed as received from advertisers. The Florida College of Emergency Physicians does not endorse any products or services unless otherwise stated. FCEP receives and distributes employment opportunities but does not review, recommend or endorse any individuals, groups or hospitals that respond to these advertisements. Opinions stated within articles are solely those of the writers and do not necessarily reflect those of the EMpulse staff, the Florida College of Emergency Physicians and our advertisers/sponsors. 3
A NOTE FROM STAFF
Dear FCEP Members, Remember when our biggest concern for 2020 was the Florida Session? Now, your most pressing concern is staying alive while keeping others alive. You are expected to fight against a novel coronavirus with inadequate supplies of PPE, lifesaving medical equipment, medications and healthy team members. While you were making plans to isolate yourselves from your families and support systems for an unknown period of time, the general public was resisting stay-at-home orders and questioning whether or not this pandemic was a “hoax.” Now, you are bracing yourselves for the surge of critical COVID-19 patients—which is expected to peak in Florida this month—with inadequate support from elected officials, hospital systems and employer groups (that may have already cut your salary), and communities at large that are suffering from non-essential business closures.
4
organization—the Florida Emergency Medicine Foundation, otherwise known as the EMLRC— which reaches all of Florida’s emergency care providers. We cancelled all spring events, but have not cancelled CLINCON (July 8-11), Symposium by the Sea (Aug. 6-9) or Life After Residency Retreat (Sept. 16-17). While we have multiple revenue sources from grants and online courses, our live events are essential for business operations. Please consider making a donation to our Center Campaign so we can endure this pandemic with a little more financial security.
Scan to Donate to EMLRC Now (tax-deductible)
While we will never fully understand your reality, we certainly share your frustrations and anxieties. We are devastated by the current state of events and grim prospects ahead. For us, working for “emergency room doctors” and knowing some of you personally is a privilege. You may not perceive yourselves as “heroes” on the front lines “of war,” but you do know how to save lives, and you are fighting against an “invisible enemy” that is threatening millions of people and the communities we have worked so hard to build. Remember this when you are feeling exhausted and overwhelmed.
If society can remember one lesson from this pandemic, it should be this: access to high quality emergency care is essential for humanity’s overall wellbeing, and any state or federal policy that seeks to undermine emergency services and personnel is detrimental to patient safety, the economy, and the quality of life Americans expect to have.
These next few months will be challenging. Please know that FCEP staff is here to support you. We are doing our best to provide timely, state-related updates through FCEP EngagED and have launched a Statewide PPE Drive to help coordinate donations. We are also hosting a weekly FCEP COVID-19 call every Thursday at 9:30-10:30 am, which gives our lobbyist and state partners (the Florida Hospital Association, etc.) a chance to provide brief updates while hearing your present concerns.
Julie Gardell Director of Finance
At the same time, we will continue to provide lifesaving education through our sister 501(c)3
Donna Vennero Executive Assistant
Sincerely, Niala Ramoutar Interim CEO/Director of Education
Melissa Keahey Director of Meetings & Events Samantha League Director of Communications Kim Palm Accounting Manager Kim Stamp Education Coordinator
EMpulse Spring 2020
TABLE OF CONTENTS CONTINUED RESIDENCY PROGRAM UPDATES 23 NORTH FLORIDA:
UF Health Jacksonville Dr. Ty Tantisook, PGY-2 UF Health Gainesville Dr. Christopher Purcell, PGY-2 UCF/HCA North Florida Regional Dr. Jayden Miller, PGY-1
28 WEST FLORIDA:
Oak Hill Hospital Drs. Jonathan Yaghoubian & Corey Cole, PGY-2s USF Health Dr. Mikhail Marchenko, PGY-2 Brandon Regional Hospital Dr. Rashmi A. Jadhav, PGY-2 FSU at Sarasota Memorial Dr. Courtney Kirkland, PGY-1
24 SOUTH FLORIDA:
Kendall Regional Medical Center Dr. Ramsey Ataya, PGY-3 St. Lucie Medical Center Dr. Abby Regan, PGY-2 Aventura Hospital Dr. Scarlet Benson Florida Atlantic University Dr. Elizabeth Calhoun, PGY-1 Jackson Memorial Hospital Program Staff Mount Sinai Medical Center Dr. Stephanie Fernandez, PGY-2
30 CENTRAL FLORIDA:
AdventHealth East Orlando Dr. Shannon Armistead, PGY-3 UCF/HCA of Greater Orlando Drs. Amber Mirajkar, PGY-2 & Andrew Hanna, PGY-3 UCF/HCA Ocala Dr. Caroline Smith, PGY-2 Orlando Health Drs. Anne Shaughnessy & Laura Cook, PGY-3s
Newsletters: • Every Wednesday: EMNews Now delivered • Every Thursday: PEDReady PEARL delivered • Every month: EMRAF Newsletter delivered • Every quarter: Partner Broadcast delivered
Florida College of Emergency Physicians Board of Directors: PRESIDENT Kristin McCabe-Kline, MD, FACEP,
FAAEM, ACHE
PRESIDENT- Sanjay Pattani, MD, MHSA, FACEP ELECT VICE Damian Caraballo, MD, FACEP PRESIDENT SECRETARY- Aaron Wohl, MD, FACEP TREASURER IMMEDIATE J. Adrian Tyndall, MD, MPH, FACEP PASTPRESIDENT MEMBERS Rajiv Bahl, MD, MBA, MS;
Matthew Beattie, MD (EMRAF Representative); Daniel Brennan, MD, FACEP; Jordan Celeste, MD, FACEP; Jesse Glueck, MD; Shayne Gue, MD; Erich Heine, DO; Saundra Jackson, MD, FACEP; William Jaquis, MD, MSHQS, FACEP (ACEP President); Shiva Kalidindi, MD, MPH, MS(Ed.); Gary Lai, DO, FACOEP; Russell Radtke, MD; Danyelle Redden, MD, MPH, FACEP; Todd Slesinger, MD, FACEP, FCCM, FCCP; Jill Ward, MD, FACEP
Florida Emergency Medicine Foundation Board of Directors: PRESIDENT Ernest Page, MD, FACEP VICE Roxanne Sams, MS, ARNP-BC, MA PRESIDENT
Quick Links
SECRETARY- Maureen France TREASURER MEMBERS Dick Batchelor; Arthur Diskin,
ACEP/FCEP EngagED (online community)
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Donate to FCEP’s PAC (not taxdeductible)
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EMpulse Winter 2020
MD, FACEP*; Jay Falk, MD, MCCM, FACEP*; Cliff Findeiss, MD*; James V. Hillman, MD, FACEP*; Michael Lozano, Jr., MD, FACEP*; Cory Richter, BA, NREMT-P; David Seaberg, MD, FACEP* *FCEP Past-President
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
FEATURE
A Steadfast Approach to the COVID-19 Pandemic By Amy Souers, MD
EMS Fellow at Orlando Health/Orange County EMS System
Adaptability and agility: two words that describe one aspect of emergency medicine, and two qualities that we, along with all physician specialties, must continue to exercise on a daily basis in this COVID-19 pandemic. Over a month ago, we were looking at an outbreak in China, Italy, South Korea, and Iran. Thirty days ago, the number of cases in the U.S., including those repatriated from the Diamond Princess cruise ship, was in the double digits. As of this writing, there are over 385,000 cases in the US.1,2 A state of emergency has been declared, and “shelter-inplace” and social distancing are the norm. Powerhouse companies such as Hanes, Ford, and General Motors have converted to manufacturing ventilators and masks. Our country is adapting. On the front lines, we are also adapting. Daily, our inboxes and online meetings are full of new testing procedures, new PPE requirements, new emergency department patient flow diagrams, and new respiratory isolation policies and procedures. Our innate adaptability and agility, in the field of emergency medicine, are key components of our endurance and success in fighting this virus. We cannot forget: we are adaptable and agile human beings. 6
We have learned a great deal about the virus already. Before SARS-CoV-2 was even known, we had all heard frequently of novel viruses morphing via antigen shift and drift. Mutations allowing viruses to move from animal hosts to humans is not a new or novel concept. We all knew, from microbiology classes many years ago, that given probability and time, once in a great while a virus will succeed in shifting its RNA in such a way that the virus is “optimized” for human survival. This is one of those times. The “ideal virus” would spread human-to-human readily, replicate quickly, and avoid making its host too sick before being exposed to many other human hosts (along with asymptomatic carriers that are difficult to identify). The ideal virus is not overly deadly, and it is easily transmissible. Strains of influenza such as H1N1 caused a pandemic in such a way. Similarly, the novel strain of coronavirus reached a pandemic phase just 2-3 months after the pathogen’s emergence. Healthcare EMpulse Spring 2020
professionals and researchers already have had great experience in dealing with viruses, including those that are easily transmissible as well as dangerous. The flu is a great example. But in these times, we have challenged our knowledge, pushed the boundaries on antiviral therapy, applied old knowledge to new situations, and have made great strides in determining how this virus is transmitted, how to treat it, and even the beginnings of a vaccine to mitigate its effects. We are grateful to the many researchers and clinicians who are sharing their knowledge and experience—from N95 reuse and sanitation, to drug combinations to combat the virus and safe intubation strategies. We as clinicians will remain adaptable. We will stay up hours after our tiresome shift to read more about the virus, gain new knowledge, and work with healthcare leadership to advocate for the best practices. The virus first emerged in humans as early as December 2019 in Wuhan,
“
The mounting pandemic scarcities and fears are all too real, but our agility and ability to change directions at a moment’s notice keeps us fighting as best we are able. China. It was a respiratory viral infection that, at first, perhaps did not seem terribly different from other upper and lower respiratory tract infections that are easily transmissible, especially in close quarters such as the seafood and live animal market where the virus first emerged. But healthcare workers noticed a pattern. This virus showed a unique, pneumonia-like airspace pattern on radiographic imaging, and on January 7, 2020, China identified the pathogen’s RNA as a novel coronavirus. SARS and MERS are of the same coronavirus family. As January progressed, we saw an epidemic striking: the Hubei Province and Mainland China were at the center of the attention, but cases among travelers had emerged across the globe.3 Notably the cruise ship docked in Japan, held for quarantine just as it was planning for disembarkation, went from one case to over 500 cases within just two weeks.2 Italy, South Korea, and Iran then began to fight their own internal outbreaks.3 The virus is undoubtedly spreading through U.S. communities, and a state of emergency has been declared in Florida as of March 1, 2020.4 We are gaining knowledge and adapting our practices to match this knowledge: epidemiology, risk factors, early presenting symptoms, transmission, and treatment. Initially, the practice was that a positive flu or viral panel essentially meant SARS-CoV-2 was highly unlikely to be present. However, data out of California suggest a 23% co-infection rate with other viruses. This type of data changes testing and risk stratification vastly. In terms of presenting symptoms, we’ve learned that less than half of patients have fever on initial presentation, that
gastrointestinal symptoms should not be disregarded, and that anosmia and dysgeusia may be symptoms in otherwise asymptomatic carriers5. We’ve narrowed down that the virus lives longer on plastic than cardboard, and are storing masks in paper bags instead, just in case this helps.6 ACE2 is the cell’s entry receptor for SARS-CoV-2. In addition to this receptor being located in both the respiratory and GI tracts, leading to a variety of symptoms, ACE2’s role in the renin-angiotensin system may add to the understanding of why there is increased morbidity and mortality among those with preexisting hypertension or other co-morbidities.7 Understanding SARS-CoV-2’s mechanism helps us understand the pathophysiology of the disease process and therefore the most likely therapies. As far as antiviral medications to combat the ARDS picture, we are searching as quickly as possible. HIV medications are being tried; oseltamivir has not been found to be beneficial. Antimalaria meds such as chloroquine may show promise.8 We are innovating and improvising. The mounting pandemic scarcities and fears are all too real, but our agility and ability to change directions at a moment’s notice keeps us fighting as best we are able. COVID-19 presents a significant health and economic threat to our global society. It will continue to evolve in unpredictable ways before the print publication of this article. Though we have seen many similar viruses make the jump from animal vectors to human-tohuman transmission, the community transmission threat of this virus is incredibly high. We, as a healthcare EMpulse Spring 2020
community, must continue to stay informed and continue to practice protection of ourselves. An agile and adaptable approach is also our realistic and pragmatic approach, as COVID-19 is neither the first nor the last emerging viral disease that we will fight as a global health threat. ■ Editor’s Note: The number of current cases was last updated April 6, 2020.
Image: ©OscarStock | Adobe Stock
REFERENCES
1. Coronavirus COVID-19 Global Cases by Johns Hopkins CSSE. Johns Hopkins University. Updated daily. gisanddata.maps.arcgis.com/ apps/opsdashboard/index.html#/ bda7594740fd40299423467b48e9ecf6. Accessed March 26, 2020 2. Field Briefing: Diamond Princess COVID-19 Cases. National Institute of Infectious Diseases, Japan. Published February 19, 2020. www.niid.go.jp/ niid/en/2019-ncov-e/9407-coviddp-fe-01.html. Accessed February 27, 2020 3. Coronavirus Disease 2019 (COVID-19). Centers for Disease Control and Prevention. Updated daily. www. cdc.gov/coronavirus/2019-ncov/ summary.html. Accessed March 2, 2020 4. Florida Department of Health, Office of the State Surgeon General. Declaration of Public Health Emergency Executive Order Number 2020-51. Released 1 March 2020 5. Salim Rezaie, “Surviving Sepsis Campaign Guidelines on the Management of Critically Ill Adults with COVID-19”, REBEL EM blog, March 22, 2020. Available at: rebelem. com/surviving-sepsis-campaignguidelines-on-the-management-ofcritically-ill-adults-with-covid-19 6. N van Doremalen, et al. (2020). Aerosol and surface stability of HCoV-19 (SARS-CoV-2) compared to SARS-CoV-1. NEJM. doi: 10.1056/ NEJMc2004973 7. Hoffmann, M., et al. SARS-CoV-2 Cell Entry Depends on ACE2 and TMPRSS2 and Is Blocked by a Clinically Proven Protease Inhibitor. Cell (2020). doi. org/10.1016/j.cell.2020.02.052 8. Gautret P, et al. (2020). Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. International Journal of Antimicrobial Agents. doi: 10.1016/j. ijantimicag.2020.105949
7
COMMITTEE REPORTS
FCEP President’s Message By Kristin McCabe-Kline, MD, FACEP, FAAEM, ACHE FCEP President ’19-20
The end of winter and beginning of spring is often a time of great celebration and rejoicing in emergency departments across the state of Florida. We exhale collectively after having survived the migration of the snowbirds, the peak of viral illness outbreaks, being short members of our care teams due to staff illnesses, and working out of any hallway, nook or cranny a stretcher or chair could be placed because the entire ED is full of boarders. Alas, our hyperdrive workflow continues as the novel coronavirus results in emergency physicians, yet again, being placed on the front lines of disaster management. Colleagues are sending patients to the ED from their offices; any free moment we have to attend a social gathering is overtaken by questions about the personal and collective risk to our communities; the public are presenting as worried well or critically ill, needing respiratory support and health systems; and government officials are asking us to help weather the outbreak, all while mitigating public hysteria. Once again, emergency physicians will be at the helm and do what we can with the resources we have to weather the storm. This winter, I have had personal time to reflect upon the reasons as to why I am passionate about my work. One of the primary reasons I am committed to the work of emergency medicine is because our patients desperately need us: often they are unable to advocate for themselves, and frequently, they tolerate extreme circumstances to obtain our help. However, the most important factor in my commitment to emergency medicine is emergency physicians. We all have reasons as to why we 8
People are unreasonable, illogical and self-centered.
chose careers in our specialty, and they are common to us all. We meet people in their times of fear, distress and need. We provide the best care possible without regard to race, gender, creed, socioeconomic status or severity of illness. We do so despite the real and potential dangers we face, the sleep we lose, and the terror we endure as we care for undiagnosed patients under less-than-ideal working conditions, absorbing the burden of suffering as we are surrounded by tragedy and the difficult task of advocating for patients in a disjointed health care system, where burned out physician colleagues may not always receive our calls with joy. Emergency physicians do amazing work even when lives and limbs are lost. We leave people and places better than we found them. I cannot think of a greater challenge or privilege. This work is hard, underpaid and underappreciated but, nevertheless, worth doing. We all know this to be true or we wouldn’t be doing it. I am grateful for you and your commitment to serving your communities, patients and care teams during this difficult time. ■
LOVE THEM ANYWAY.
If you do good, people may accuse you of selfish motives. DO GOOD ANYWAY.
If you are successful, you may win false friends and true enemies. SUCCEED ANYWAY.
The good you do today may be forgotten tomorrow. DO GOOD ANYWAY.
Honesty and transparency make you vulnerable.
BE HONEST AND TRANSPARENT ANYWAY.
What you spend years building may be destroyed overnight. BUILD ANYWAY.
People who really want help may attack you if you help them. HELP THEM ANYWAY.
Give the world the best you have and you may get hurt. GIVE THE WORLD YOUR BEST ANYWAY. -MOTHER TERESA
Weekly FCEP COVID-19 Calls Led by Dr. Michael Lozano Every Thursday at 9:30-10:30 am
� Scan to register once for all Zoom meetings
Or call: (929) 205-6099,,932-449-771#
EMpulse Spring 2020
How Collective Medical’s Real-time Platform is Responding to COVID-19 By Collective Medical Staff Collective Medical has developed a real-time event notification and care collaboration platform ideally positioned to enhance regions’ and states’ ability to identify, treat, trace and analyze infectious diseases, such as COVID-19. This functionality is free to all existing clients and those not yet participating in the Collective network for the remainder of 2020. The platform connects patient data via a nationwide network in use by approximately 1,000 hospitals, tens of thousands of providers—including primary care clinics, behavioral health clinics, FQHCs, skilled nursing facilities and other ambulatory providers—as well as every national health plan in the country. The network spans 50 states and covers many ports of entry into the United States. Collective’s unparalleled network and sophisticated, configurable product capabilities position us to uniquely offer value to public health agencies and related stakeholders in combating infectious disease outbreaks. The size
of our facility footprint allows public health officials to identify and locate individuals across the United States— whether these individuals are already known to be at-risk, or if they present with symptoms that independently indicate they are high-risk. Known risk factors can be integrated from a vast variety of source systems and pushed directly into provider workflow at the point of care. This information can then be used by highly trained medical professionals to identify those in need of isolation and further assessment. Public health departments in states and regions where Collective’s platform is currently implemented can benefit from COVID-19 functionality almost immediately. For those regions that have not yet adopted Collective, implementation is a fast and lightweight process. And their participation in the Collective network will support the larger care continuum’s ability to quickly and effectively manage outbreaks. For more information please visit www.collectivemedical.com or email Collective’s COVID-19 response team at covid19@collectivemedical.com.
EMpulse Spring 2020
9
COMMITTEE REPORT
COVID-19 and Pediatric Patients By FCEP’s Pediatric Committee Image: ©Aron M | Adobe Stock
The COVID-19 pandemic is rapidly evolving and the healthcare challenges are continuing to increase. Despite the widespread global incidence and increasing number of cases, the epidemiology and clinical presentation of COVID-19 in pediatric patients is not well understood. The majority of children seen for emergent medical problems in the U.S. are seen in general emergency departments, not pediatric-specific institutions, and this will likely continue with the current pandemic. The information below is based on current evidence, and is meant to assist in the evaluation and management of pediatric patients with suspected or confirmed COVID-19. However, new information is available on a daily basis, and the understanding of COVID-19, including the epidemiology, clinical presentation, testing recommendations and clinical management, is subject to change. Additionally, the information below does not pertain nor apply to neonates.
Epidemiology: • A large proportion of pediatric cases appear to be associated with household contact.1
• Incubation period averages 5-6 days, range of 2-14 days.1
• Pediatric patients appear to have
the lowest rate of infection for all age groups, though the apparently low incidence may be due to a significant proportion of asymptomatic and mild cases in children that are not recognized and tested.2,3
• Current reports suggest very low
rates of hospitalization and critical disease (including ICU admission) in pediatric patients.2,3 Of those patients considered to have critical disease, the majority were < 1 year of age.4
• The mortality rate in pediatric
patients appears to be very low.
Statewide PPE Drive
The Centers for Disease Control and Prevention (CDC) reported no pediatric deaths related to COVID-19 in the U.S. as of March 16, 2020.1 Two epidemiological studies from China, the first with 965 pediatric patients (subset of a larger study cohort) and the second with 2,143 pediatric patients (731 laboratory-confirmed cases, 1,412 suspected cases), reported only one death respectively in each cohort of patients.3,4
• There is very limited data on
pediatric patients with chronic disease states and comorbid conditions. These patients, particularly those with pulmonary/ respiratory diseases and those considered immunosuppressed, whether congenital or acquired (including patients on chronic steroids), must be considered high risk for developing severe or critical disease.
The EMLRC, FCEP and Florida Association of EMS Medical Directors (FAEMSMD) are launching a Statewide PPE Drive to connect medical-grade supplies from businesses with EMS/fire agencies and emergency departments in need.
HELP US SPREAD THE WORD Organizations: Join our PPE Network Learn more at fcep.org/ppe 10
EMpulse Spring 2020
Transmission: • Person-to-person spread via
respiratory droplets is thought to be the predominant means of transmission.
• It is presumed that transmission
can also occur via contaminated fomites. At least one study has demonstrated that SARS-CoV-2 may remain viable in aerosols for up to 3 hours, on cardboard for up to 24 hours, and on plastic and stainless steel for as long as 3 days.5
• It is unclear whether infection
can be spread via other body fluids (e.g. blood, stool). SARSCoV-2 RNA has been detected in stool specimens, and in pediatric patients it has been demonstrated to persist longer in stool than the nasopharynx.6 More information is available on the CDC website.10
Clinical Presentation: • A significant proportion of
pediatric patients appear to be asymptomatic. In two reports, the proportion of asymptomatic cases was 12.9% and 15.8% respectively in confirmed cases.4, 7
REFERENCES:
1. Zimmerman P, Curtis, N. Coronavirus Infections in Children Including COVID-19: An Overview of the Epidemiology, Clinical Features, Diagnosis, Treatment and Prevention Options in Children. The Pediatric Infectious Disease Journal: March 12, 2020. Volume Online First Issue doi: 10.1097/INF.0000000000002660. Retrieved from: journals.lww. com/pidj/Abstract/onlinefirst/ Coronavirus_Infections_in_ Children_Including.96251.aspx 2. Centers for Disease Control and Prevention (CDC). (2020, March 18) Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) – United States, February 12-March 16, 2020. MMWR. Morbidity and Mortality Weekly Report. Retrieved from: cdc.gov/mmwr/ volumes/69/wr/mm6912e2.htm 3. The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020[J]. China CDC Weekly, 2020, 2(8): 113-122. 4. Dong Y, Mo X, Hu Y, et al.
• The most common clinical char-
acteristics in symptomatic pediatric patients appear to be fever and cough.7, 8, 9
• Other clinical characteristics
include pharyngeal erythema, diarrhea, fatigue, rhinorrhea, nasal congestion, vomiting and fatigue.7,8
• Tachypnea and hypoxia have been identified in more severe cases.7, 8
Testing Recommendations: • Testing recommendations for
pediatric patients are similar to those for adults. They are rapidly evolving as the pandemic continues and should be obtained from the CDC11 and the Florida Department of Health.12
Management: • No specific therapeutic drugs for
COVID-19 are currently approved by the FDA.
• Initial management priorities
should include infection control measures and supportive treatment as indicated.
• Though several potential
therapeutic agents are being
Epidemiological characteristics of 2143 pediatric patients with 2019 coronavirus disease in China. Pediatrics. 2020; doi: 10.1542/ peds.2020-0702 5. van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med. 2020 Mar 17. doi: 10.1056/NEJMc2004973. [Epub ahead of print] 6. Xu Y, Xufang L, Bing Z. Characteristics of pediatric SARS-CoV-2 infection and potential evidence for persistent fecal viral shedding. Nature Medicine. https://doi.org/10.1038/s41591-0200817-4 7. Lu X, Zhang L, Du, H, et al. SARSCoV-2 Infection in Children. N Engl J Med. 2020 Mar 18. doi: 10.1056/ NEJMc2005073. [Epub ahead of print]. 8. Chen Z, Fu J, Shu Q, et al. Diagnosis and treatment recommendations for pediatric respiratory infection caused by the 2019 novel coronavirus. World J Pediatr (2020). https://doi. org/10.1007/s12519-020-00345-5 9. Liu W, Zhang Q, Chen J, et al. Detection of Covid-19 in Children
investigated, none are currently recommended by the CDC for treating pediatric patients with COVID-19. More information regarding investigational therapeutics is available at the CDC website,13 and information regarding specific clinical trials is available at clinicaltrials.gov.14
• Pediatric patients with asymp-
tomatic or mild disease, who are not high risk patients (e.g. immunosuppressed), and for which admission is not clinically indicated, may not require transfer to a pediatric center.
• The decision to admit a patient to the hospital or continue observation at home must be made on a case-by-case basis.
• As a significant proportion of
pediatric patients appear to have a mild disease course associated with COVID-19, it is likely that many will be candidates for outpatient management.
• Pediatric patients managed on an
outpatient basis must be provided clear information and instructions regarding potential progression of signs and symptoms, and return precautions. ■
in Early January 2020 in Wuhan, China. N Engl J Med. 2020 Mar 12. doi: 10.1056/NEJMc2003717. [Epub ahead of print] 10. CDC. Healthcare Professionals: Frequently Asked Questions and Answers. Retrieved from: www.cdc. gov/coronavirus/2019-ncov/hcp/ faq.html 11. CDC. Evaluating and Testing Persons for Coronavirus Disease 2019 (COVID-19). Retrieved from: www.cdc. gov/coronavirus/2019-nCoV/hcp/ clinical-criteria.html 12. Florida Department of Health. Health Care Providers. Updated daily. Retrieved from: floridahealthcovid19. gov/health-care-providers 13. CDC. Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19). Retrieved from: cdc.gov/ coronavirus/2019-ncov/hcp/clinicalguidance-management-patients.html 14. NIH. Adaptive Trials COVID-19. U.S. National Library of Medicine. Retrieved from: https://clinicaltrials. gov/ct2/results?cond=adaptive+trial+ COVID-19&draw=2&rank=1#rowId0
Pandemic Philanthropy Medical Students Mobilize on COVID-19 Community Donations By Alison Ohringer, MPH, MS
Founder, Miami Med COVID Help; MS1 Class President, UM Miller SOM
After the first case of coronavirus (COVID-19) appeared in the United States in mid-January, it felt as though the entire country held its breath, silently hoping the virus would not spread outside the confines of that hospital. As we wished and waited, the virus proliferated within communities, causing outbreaks, epidemics, and finally, a global pandemic. In the U.S., hotspot zones quickly emerged in coastal, international travel hubs with densely populated urban centers. Florida, and Miami in particular, naturally seemed like the next hotspot. Outbreaks at South Florida nursing homes—such as Atria Willow Wood, with its seven resident deaths and nearly 20 confirmed cases—and the Port Everglades cruise port fueled the South Florida outbreak. As COVID-19 cases increased nationwide, many medical schools transitioned to an online curriculum, and thousands of medical students across the country found they had a critical opportunity to mobilize and 12
By Samantha Y. Lux Founder, PPE2NYC; MS3 MD/PhD, NYU Grossman SOM
organize. Several projects at different medical schools emerged: some offering childcare, some collecting PPE, and some trying to help frontline providers directly. At the University of Miami Miller School of Medicine (UM), Miami Med COVID Help (MMCH) formed with the intent of helping frontline providers with home-related errands. However, it quickly became apparent that the students’ enthusiasm would be better aimed at supporting the local emergency departments’ supply needs for PPE via community donations. Medical students from New York University (NYU) had already formed PPE2NYC and could offer shared wisdom and experience. Through a NYU/UM collaboration, MMCH developed the infrastructure needed to expand its project arms, like sourcing and distributing PPE. A fourth-year medical student at NYU shared his computer program to scrape Yelp for all businesses in a zip code that might have PPE to donate: nail salons, tattoo parlors, veterinarEMpulse Spring 2020
By Jennifer S. Jackson, MD, FACEP Clerkship Director & Asst. Professor of Emergency Medicine, UM Miller SOM
ians, etc. With this resource, MMCH quickly mobilized and recruited student volunteers to contact these South Florida companies to solicit donations. These efforts expanded into project arms including PPE drives throughout the community (while socially distanced), 3-D printing of PPE, requesting sponsorship from larger corporations, and collaborating with existing community organizations serving unhoused populations. Medical students from UM, in turn, shared best practices and resources with medical students at other schools working on similar projects. Having learned of potential pitfalls from organizations like PPE2NYC, MMCH defined its organizational structure very early in the process, making expanding operations smoother and more efficient. The creation of a website with an attached Venmo account (@MiamiMed), a GoFundMe page, and an active social media presence on Twitter, Facebook and Instagram
were key to developing an early community presence in Miami. The pro-bono assistance of an attorney turned the efforts of MMCH into a 501(c)(3) non-profit organization, which allows for tax-deductible, donation receipts and lends an air of legitimacy to the volunteer efforts. Local newspapers and TV media have showcased the volunteer efforts and ways to donate PPE, reaching a larger, broader South Florida audience. The entire MMCH Board of Directors, project chairs and student volunteers—nearly 150 UM medical students in total—are still actively enrolled in the new distance-learning medical school curriculum. Regardless, in less than 2 weeks, over 10,000 PPE items and $2,000 in cash have been raised from individuals and businesses throughout South Florida (as of April 5, 2020). These donations are directly supporting emergency departments at hospitals, including Jackson Memorial Hospital
UM medical student and Miami Med COVID Help founder, Alison Ohringer, sorts through PPE donations before delivering. This image by: Alex Santiago at the Miami Herald Left image by: Dr. Jennifer Jackson
in Miami and Holy Cross Hospital in Ft. Lauderdale and their UM-affiliated emergency physicians, residents, physician assistants, nurse practitioners, pharmacists, nurses and paramedic techs. As new needs arise in our community as a result of this COVID-19 pandemic, the medical student-run Miami Med COVID Help organization will adapt to meet those evolving needs and continue to be immersed in local, pandemic philanthropy. ■
Miami Med COVID Help Website
miamimedcovidhelp.com
Miami Med COVID Help GoFundMe Page gofundme.com/f/ MiamiMedCOVIDhelp
PPE2NYC Website ppe2nyc.com
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A NOTE FROM OUR FORMER CEO
Farewell, FCEP Family Resignation Letter from Beth Brunner Read during the FCEP Board of Directors Meeting on January 28, 2020 For 33 years, I have watched and witnessed your dedication to emergency medicine and the patients you care for through your involvement with FCEP, FEMF and other organizations. It has been a wonderful journey to learn about and work with you on legislative/regulatory issues, education, EMS, governance, leadership, building construction, and so many other areas. However, it is time for me to tender my resignation so I might care for and spend time with my 92-year-old parents and reassess my next steps. There have been many milestones that we have celebrated in all the years, and some sad times with the passing of four dedicated past presidents. The “Wall of Fame” of past presidents in the EMLRC needs
to expand around to another wall to make room for upcoming leaders. There is such great talent in emergency medicine and the membership of FCEP. I watched as medical students and then residents joined the FCEP Board, and then become officers. And constantly learning that yet another FCEP leader had become a hospital CEO, CMO, or appointed/ elected leader within FMA, ACEP, FHA, Boards of Medicine, County Medical Societies or major health care organization was so wonderful. How far the specialty has grown! The success of FCEP and FEMF is only due to your engagement and outreach, encouraging and mentoring more members to become leaders.
byist who each has amazing talents and dedication. You also have a broad community of friends and supporters. That is what I have enjoyed most: the FCEP family. My daughters grew up with many of your families through their fun and mischievousness at Symposium by the Sea. Who knew their game of elevator tag would generate calls from hotel managers?
You have an excellent staff and lob-
-Beth Brunner, MBA, CAE
2020 and beyond will be full of more challenges and opportunities for FCEP and FEMF growth. I know you will continue to support each other; it is so important that we all have this through the ups and downs. Thank you for so many wonderful years. Keep the FCEP family growing! ■
Our Thoughts & Prayers are with ALL of the frontline heroes during this COVID-19 Pandemic!
An Open Letter to the Emergency Medicine Industry from DuvaSawko We are living and working in an unusual time. DuvaSawko has been taking stringent steps towards the strategic planning for the well-being of our workforce and our business continuity. We have taken several approaches in terms of protection and prevention, which include education, notification and strict social distancing requirements for our teams. Thankfully, due to our sophisticated automated processes and our remote coding workforce, the coding of charts and automated electronic claim submission continues without interruption. We have segregated specific business functions to operate in their intended capacity from home. We have detailed business continuity processes in place for emergencies such as this and will be implementing a staged approach to our business operations to address any additional changes that we may encounter. Although our team has the necessary processes in place, we have no control over what trading partners or payers will experience in response to our claim submissions. As a result, we do advise fiscal preparation if there is a slow-down in payer processing of claims and that you proactively anticipate potential fluctuations. As you continue to plan for these unexpected changes, our thoughts and prayers are with you and all your providers during this challenging time in healthcare. 14
EMpulse Spring 2020
Jill Reynolds President www.duvasawko.com
July 8-11, 2020 DoubleTree by Hilton-Universal in Orlando, FL Approved for AMA PRA Category 1 Credits™
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Register & find the most up-to-date information at: www.emlrc.org/clincon-2020 EMRLC/FCEP is closely monitoring the COVID-19 pandemic. The planning committee has decided to move forward with the conference as scheduled. We will communicate any changes as soon as possible. EMpulse Spring 2020
15
COMMITTEE REPORTS
Government Affairs By Blake Buchanan, MD
Government Affairs Committee Co-Chair
This year’s legislative session had a very heavy focus on healthcare, as this was a priority of Speaker of the House, Rep. Jose Oliva, who is in his final year of his position. Below are some of the key bills affecting the specialty of emergency medicine:
FAILED TO PASS: SB 378/HB 771: Motor Vehicle Insurance This would have replaced the PIP coverage mandate with optional medical payments coverage. It would have driven the cost of coverage up by 5.3% and shifted $470 million towards private health insurers.
SB 1830/HB 1103: Electronic Prescribing This would have effectively prohibited written prescriptions, except when electronic prescribing was unavailable due to a temporary electrical or technological failure. FCEP advocated against this bill as being too restrictive and our voices were heard immediately at Emergency Medicine Days, leading to the bill’s demise.
PASSED: The following bills (effective July 1) reached Governor DeSantis’s desk on the afternoon of March 11 and were quickly signed before 7:00 pm—a move that took everyone by surprise.
SB 1676/HB 607: Direct Care Workers Authorizes an APRN who meets certain eligibility criteria to register with the Board of Nursing to engage in autonomous practice related to primary care without a supervisory protocol or physician supervision. 16
The bill authorizes the Board of Nursing and the new Council of Advanced Practice Registered Nurse Autonomous Practice to develop a list of medical acts that an APRN engaging in autonomous practice may perform. To register to engage in autonomous practice, an APRN must hold an active Florida license and:
• Not been subject to any disci-
plinary action during the five years immediately preceding the application.
• Completed, in any U.S. juris-
diction, at least 3,000 clinical instructional or practice hours supervised by an actively licensed physician within the 5-year period immediately preceding.
or her designee shall serve as the chair of the council.
SB 1094/HB 389: Practice of Pharmacy Authorizes pharmacists who meet certain criteria to enter into a collaborative pharmacy practice agreement (CPPA) with a physician for the management of chronic and non-chronic health conditions. The pharmacist must complete additional continuing education courses addressing minor, non-chronic health conditions and collaborative pharmacy practice each biennial licensure renewal.
• Completed within the past five
Chronic health conditions: arthritis, asthma, COPD, type 2 diabetes, obesity, and any other chronic condition or co-morbidity identified by the collaborating physician.
• The board may provide additional
Non-chronic health conditions: flu, strep, lice, skin conditions such as ringworm and athlete’s foot, and minor, uncomplicated infections.
years: (3) graduate-level semester hours or the equivalent, in differential diagnosis and pharmacology, respectively. registration requirements by rule.
The Council of APRN Autonomous Practice is established within the Department of Health. The council must consist of the following nine members: • Two physician members of the Board of Medicine, appointed by its Chair; • Two physician members of the Board of Osteopathic Medicine, appointed by its Chair; • Four APRNs, registered under this chapter and with experience practicing advanced or specialized nursing, and • The State Surgeon General or his
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EMpulse Spring 2020
The bill requires the Board of Pharmacy to adopt rules in consultation with the Boards of Medicine and Osteopathic Medicine. Regardless, this has significantly stepped beyond a pharmacist’s scope of practice and will lead to patient harm due to their lack of clinical training. While Rep. Oliva had his eye on “disrupting healthcare” from the beginning, these bills ultimately passed because of significant lobbying and PR efforts by supportive parties. We must not let this happen again. ■
Donate online at: fcep.org/donate
COMMITTEE REPORTS
Medical Economics By Daniel Brennan, MD, FACEP
Medical Economics Committee Co-Chair
State and federal legislative sessions are always a perilous time for EM medical economics, and 2020 was no exception. FCEP had some high priority items at Emergency Medicine Days 0n January 27-29. As of press deadline, it appears emergency medicine received another reprieve from the ill-advised attempt to repeal personal injury protection (PIP) coverage (HB 771) that provides a setaside for emergency physician care. This proposal for the third straight year would have replaced a no-fault system for a tort driven system, with no clear mechanism for emergency medical payments likely at artificially low reimbursement rates. Estimates range, but a 5% overall revenue reduction could have been the result for most practices. This was FCEP’s #1 priority: avoid repeal, or secure equivalent EM payments if eliminated, and will likely be again next year. In terms of scope of practice, FCEP supported FMA’s argument against independent practice of ARNPs/ PAs, which was a priority of House Speaker Oliva. The measure (HB 607) passed in both houses and was signed by Governor DeSantis within three hours. More applicable to EM, expanded practice for pharmacists to diagnose and treat strep and flu (HB 389) steamrolled through the house, stalled, and then passed in the Senate, and was also immediately signed into law. In the era of COVID-19,
“
In the era of COVID-19, doesn’t it sound like a great idea to allow pharmacists to reassure that “flu-negative” patient?
doesn’t it sound like a great idea to allow pharmacists to reassure that “flu-negative” patient? On the federal level, interest in “fixing” surprise billing remains perilously popular, without much consideration as to how allowing insurers to unilaterally price set would devastate access to care. ACEP and EDPMA continue to advocate vigorously, but we all must pay attention as this could drastically reduce practice revenue (estimates of 30% have been quoted), while effects on compensation would be larger given fixed overhead costs. Please take action when our professional society representatives sound the alarm. FCEP’s EM Reimbursement and Innovation Summit on February 2728 again hosted a nationally expert faculty and covered an array of subjects, including federal balance billing legislation, independent dispute resolution, payor challenges, Medicare payment / MIPS / alternative payment models, proposed regulatory and documentation changes, telehealth and more. Forward-looking
group leaders would be well served by attending this excellent summit. And now for some more upbeat payment notes: 1. The efforts of the RUC (RVU Update Committee) allowed a re-evaluation and increase in EM RVUs: overall, a 1% or so increase to 2020 MCR reimbursement for EM. (Unfortunately, a much larger primary care re-evaluation for 2021 may trigger budget neutrality, and EM is posed to be one of the biggest losers as a specialty without the advantage of any office-based codes, to the tune of potentially a 7% reduction unless some reprieve is granted). 2. FCEP’s outreach with AHCA was rewarded when AHCA agreed that Medicaid Managed Advantage (MMA) plans should be paying EM providers Medicare rates for pediatric patient care as of Oct. 1, 2019. This should result in a significant boost to Medicaid revenues for most practices seeing substantial numbers of pediatric MMA patients. 3. Emergency medicine had a favorable dispute resolution ruling via MAXIMUS, which ordered a payor (Humana) to pay an EM providers’ charges in an out-of-network claim dispute. ■
ESSENTIAL
LEGAL MATTERS IN EMERGENCY MEDICINE A GUIDE FOR MEDICS
Free webinar series at emlrc.org/education/legal EMpulse Spring 2020
17
COMMITTEE REPORTS
Membership & Professional Development By Rene Mack, MD
MPD Committee Co-Chair
You are likely reading this in April 2020. Compared to your experiences up to the release of the January 2020 edition, there have been many significant changes over the past few weeks and with more likely to come. With the gravity of battling a viral pandemic, COVID-19, it is understandable that the annual tradition of Match Day would have mattered most to those in its immediate orbit.
even your family and friends, you opened the envelope that would shape your future. The rush of emotion, along with the shouts and cheers of celebration as you announce your Match location, is almost overwhelming. Match Day is the culmination of the many years of dedication and sacrifice you have made for your chosen profession and specialty. It is a Rite of Passage on the journey of medicine.
For those to whom Match Day 2020 played a role, congratulations! Congratulations especially to the Class of 2020 medical students (and residents) who matched into emergency medicine! We look forward to your contributions to our specialty and will share with you the tools needed to succeed and flourish within your new profession.
Unfortunately, the Class of 2020 did not have this experience. Due to the current pandemic of COVID-19, on Match Day 2020, our nation was in a state of social distancing to help curb the spread of the viral infection. Groups of no more than 10 persons and maintaining at least 6 feet of separation was the national guideline. Instead, the Class of 2020 opened an email/envelope with their Match results either individually or with a small group of family, friends and other classmates. Some schools were able to host smaller scale celebrations that adhered to the guidelines but overall, due to social distancing, the Class of 2020 was not
In years past, Match Day was filled with a sense of anxious excited tension, which was heightened by it taking place in a banquet room, auditorium or similar large space. Surrounded by your equally anxious and uncertain classmates, maybe
Daunting Diagnosis: Q By Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief
A 34 year-old female presents to the ED with worsening left upper extremity pain and weakness. She has a past medical history of neurofibromatosis 1. On exam, she has decreased use of her left deltoid,
18
biceps, triceps, and wrist flexion and extension. She endorses paresthesias. What do you see on her left shoulder radiograph? CONTINUE ON PAGE 43 ďż˝
EMpulse Spring 2020
able to partake in this tradition that we all hold so dear. The changes associated with Match Day are only a few of the innumerable parts of our lives and experiences that have changed drastically in a very short period of time. We will all be affected by the rapid social changes enacted. As a practicing emergency physician, I can anticipate a few of the decisions we will need to make throughout the COVID-19 pandemic. The toll of our actions and experiences as we work on the front lines to overcome this pandemic will be difficult to predict, but will likely be high. As we welcome the Class of 2020 into our ranks, let us also show them the importance of self-preservation. Let us share with and remind each other of the tools necessary to have a long and healthy career. Maybe on your next shift you can share these techniques with your partner, so that we can continue the fight, together. Take care of yourselves, and each other. â–
2020
by the
August 6-9, 2020 • Wyndham Grand Clearwater Beach, FL Approved for AMA PRA Category 1 Credits™
Join us for another year of: RESIDENT COMPETITIONS:
SOCIAL EVENTS:
MEETINGS & MORE:
SimWARS (Simulation Wars)
Wine, Beer & Cheese
EMRAF Networking Reception
Case Presentation Competition (CPC)
Reception with Exhibitors
Research Poster Abstract Competition SonoRace (Ultrasound)
Volleyball Game Casino Night
Medical Student Forum Past-Presidents’ Luncheon FCEP Board of Directors Meeting FEMF Board of Directors Meeting
Learn more at fcep.org/sbs EMRLC/FCEP is closely monitoring the COVID-19 pandemic. The planning committee has decided to move forward with the conference as scheduled. We will communicate any changes as soon as possible.
EMpulse Spring 2020
FCEP Committee Meetings Town Hall & CME Lectures
19
Mount Sinai Medical Center
Introducing the
CLASS OF
2023
Meet Florida’s newest emergency medicine residents:
Orlando Health Blaire Banfield
UF College of Medicine
Michael Boyd
Texas A&M Health Science Center COM
Stuart Bumgarner
East Virginia Medical School
Rami Bustami
David Chang
Miltiadis Kostas Kerdemelidis
Medical Univ. of South Carolina COM
Louisiana State Univ. SOM in Shrevport
Vladislav Mordach
Thomas Campbell
Univ. of Oklahoma COM at Oklahoma City
Chase Clemesha
Univ. of Southern California Keck SOM
New York Institute of Technology COM
Quoc Vinh Tran
Kansas City Univ. of Medicine and Biosciences COM
Florida International Univ.
Kevin Fan
Florida International Univ.
Lara Goldstein
Florida Atlantic Univ.
Glenn Goodwin
Florida International Univ.
Iman Isayli
Florida International Univ.
Peyton Lampley
George Washington Univ.
Univ. of Witwatersrand Touro COM New York Rocky Vista Univ.
Edward Via College Auburn
Bruno Moraes
Edward Via College Auburn
Rodney Owen
Kody Sacks-Moynihan Univ. of Hawaii
Matthew Sorenson Philadelphia COM
HCA West at Brandon Regional Johnathan Agil
American Univ. of the Caribbean SOM
Kathleen Alfonso
St. George’s Univ. SOM
Chicago Medical School
Jillian Stariha
Lake Erie COM
Katherine Wietecha
Lake Erie COM
Medical College of Georgia at Augusta Univ.
Megan Marcom
St. George’s Univ.
Texas A&M Health Science Center COM
Linh Nguyen
Univ. of Texas Medical Branch
Reshma Sharma Lake Erie COM
Laura Stamper
East Tennessee State Univ. James H. Quillen COM
Carissa Ford
Christopher Wong
UCF/HCA at Ocala Health FIU College of Medicine Edward Via College of Osteopathic Medicine
Shane Dluzneski
State Univ. of New York Downstate Medical Center COM
Derrick Huang
Oakland Univ. William Beaumont School of Medicine
Bryson Renouard
Univ. of Utah School of Medicine
Dipal Shah
Sidney Kimmel Medical College at Thomas Jefferson Univ.
Emily Weeks
UF College of Medicine
Orange Park Medical Center Hillary Baker
Tim Cookson
Liberty Univ. COM
Amanda Craven
St. George’s Univ.
Lake Erie COM
Chicago Medical School
Texas Tech Univ. Health Sciences Center Paul L. Foster SOM
Parnia Salehi
Gary Cook
Nataly Blanco
Midwestern Univ. Chicago College
Morehouse School of Medicine
Tyler Bogus
St. George’s Univ. SOM
FSU College of Medicine
Renet Roy
Alec Bloom
Alexis Avellino
Jack Finnegan
Daniel Puebla
Mohammad Chaudhry
Louisiana State Univ. SOM, New Orleans
Northeast Ohio Medical Univ.
Dominique Pinzon
Edward Via College Auburn
Arizona COM of Midwestern University
Fallon Kelley
Brijesh Patel
Mortatha Al-Bassam
Kendall Regional Medical Center
Mitchell Guedry
Ilya Luschitsky
USF Morsani
Umar Rashid
FIU Herbert Wertheim COM
Hunter Clonts
Alyssa Eily
Charles Latimore
Meharry Medical College
James Clayton Leal
UM Miller School of Medicine
Allison Clark
Univ. of Maryland
Western Univ. of Health Sciences COM of the Pacific
Casey Shea Mcgillicuddy
Nova Southeastern Univ.
Trinity College Dublin
NSU Dr. Kiran C. Patel COM
UCF College of Medicine
Michael Caire
Penelope Cote
Nawzad Jacksi
Dorian Delgado
Edward Via COM, Auburn
Alexander Domozick
Kansas City Univ. of Medicine & Biosciences COM
Stephen Ferguson
UCF College of Medicine
Ori Gat
NSU Dr. Kiran C Patel COM
Matthew Kiley
Univ. of Mississippi SOM
Rachel Pagarigan
American Univ. of the Caribbean SOM St. George’s Univ. SOM
Hernando Castillo USF Morsani
St. George’s Univ. SOM
Leo Ferretti
Nova Southeastern Univ.
St. George’s Univ. SOM
Victor Gonzalez Vazquez
Univ. of Texas Medical Branch
Ross University SOM
Daniel Lopez
Christy Joseph Jack Keehn
Raza Master
Shannon Overholt Daniel Scholz
Nicholas Toselli
FSU College of Medicine
St. George’s Univ. SOM
Kansas City Univ. of Medicine & Biosciences COM
Lindsay Wencel
Univ. of Texas Southwestern Medical Center
St. George’s Univ. SOM
Edward Via COM, Auburn
Alabama COM
Edward Via COM – Carolinas
St. George’s Univ.
UCF College of Medicine Texas Tech Univ. Health Sciences Center Paul L. Foster SOM
20
AdventHealth East Orlando
Matthew Apicella
Aventura
Sussana Oad
Raul Rodriguez
Christopher Reilly
EMpulse Spring 2020
Hillary Schmalzer
Kendall Talley
Marko Velickovic
St. Lucie Medical Center Brendan Mahoney
Univ. of Arkansas for Medical Sciences COM
John Martin
Philadelphia COM
Timothy McNamara SC-Edward Via COM
Jaron Nielson
Kansas City Univ. of Medicine and Biosciences COM
Kyle Nielsen
Edward Via COM, Auburn
Alec Underhill
William Carey Univ. COM
Oak Hill Hospital Kyle Altman
Philadelphia COM
Jacob Erfurth
Campbell Univ. Jerry M Wallace School of Medicine
Florida Atlantic University Tony Bruno
NSU College of Osteopathic Medicine
Timothy Buckley Collin Hickey
Edward Via COM - Carolinas
USF Health Morsani COM
Daniella Lamour
FSU COM - Sarasota
FIU Herbert Wertheim COM
Lake Erie COM
Ponce Health Sciences Univ. SOM
UCF College of Medicine
Lake Erie College of Osteopathic Medicine
UCF/HCA at North Florida Regional
Univ. of North Texas at Fort Worth-Texas COM
UCF College of Medicine
Univ. of Hawaii, John A. Burns SOM
UCF College of Medicine
Precious Anyaoha
West Virginia Univ. SOM
Arizona COM of Midwestern Univ. Edward Via COM, Carolinas Loma Linda Univ. SOM
Christopher Williams FSU College of Medicine
Meagan Powers
Louisiana State Univ. SOM
Lake Erie COM
UF Gainesville Benjamin Arnold
Saint Louis Univ. SOM
Piers Frieden
Univ. of Southern California Keck SOM
Jeffrey Katz
Alex Basara John Day
Hank Gureasko
Lake Erie COM
Tanner McGill
Univ. of South Alabama COM
Jacob Milling
Univ. at Buffalo Jacobs SOM & Biomedical Sciences
Nishil Patel
NSU Dr. Kiran C. Patel COM
Milly Pau
State Univ. of New York Upstate Medical Univ.
Ryan Richardson
Univ. of South Carolina SOM
Megan Rivera
FSU COM, Sarasota
Kalei Rollins
VCOM, Auburn
Ziad Saqr
Howard Univ. COM
Nikita Shokur
East Tennessee State Univ. James H. Quillen COM
Noopur Tripathi
Virginia Commonwealth Univ. SOM
Kevin Gil
Amy Lowther
Stephanie Murphy Joshua Pavlik Erica Warkus
Jonathan Littell Jovans Lorquet
Martin Morales Cruz Adam Oswald
Marvi Qureshi Mihir Tak
Emily Wheeler
UF Jacksonville Samantha Baxley
Jackson Memorial Hospital
Tulane Univ. School of Medicine
Torey Alling
Colleen Cowdery
Christina Caminita Boston Univ. SOM
Univ. of Southern California
UF College of Medicine
Thomas Lemaster
Univ. of Miami Miller School
Philadelphia COM
Johnny Nguyen
Univ. of Vermont
William Carey Univ. College of Osteopathic Medicine
Alain Artiles
Alexandra Derr
UCF College of Medicine
Harshal Athalye
Ashton Federico
Edward Via College of Osteopathic Medicine
Charles Brown
Jacob Feldsher
Loma Linda Univ.
Lake Erie COM
Sri Harsha Palakurty
Daniel Cohen
Univ. of Southern California Keck SOM
Manna Varghese
Danielle Cohen
Virginia Commonwealth Univ. SOM
Henry Gemino
Emory Univ. School of Medicine
Joshua Goldstein
Univ. of Colorado SOM
Kristopher Hendershot
Virginia Tech Carilion SOM
Florida International Univ.
Brian Knight
Univ. of South Florida
Univ. of California
Lincoln Memorial Univ.-DeBusk COM
Kenneth Domas
Johnathan Marin
George Washington Univ.
Univ. of Nevada, Reno SOM
Marco Gerges
West Virginia Univ.
Morehouse School of Medicine
Jillian Kiely
Emory Univ.
Univ. of Queensland SOM
Indiana Univ.
Mercer Univ. SOM, Savannah
Boston Univ.
USF Health Morsani COM Univ. of Missouri, Kansas City SOM
FAU Charles E. Schmidt COM
Nhi Luu
Hannah Cianci
Mihael Plantak
Univ. of Minnesota Medical School
Mohammad Razzaq
Jeffrey Adams
UCF College of Medicine
Denise Nelson
Ross Univ. School of Medicine
Casey Cheney
UCF/HCA of Greater Orlando
Liberty Univ. COM
Morehouse School of Medicine
Lake Erie COM
Phillip Bonar
Tulane Univ. SOM
Univ. of Texas Health at San Antonio, Long SOM
Ryan Johnson
USF Health Morsani COM
FSU at Sarasota Memorial
California NorthState Univ. Thomas Jefferson Univ.
USF Health
Univ. of Miami Miller School
Alexander Breslin Vincent Costers
Univ. of Central Florida
Rowan Univ.
Julia Martinez
Morehouse School of Medicine
Naomi Newton
Eastern Virginia Medical School
David Vega
Lance Lewis A.T. Still Univ.
Raymond Hakh
Mojibade Hassan Eric Lakey
Rosemary Mallonee Brendan McGowan Austin Meng
Amblessed Onyema Chritopher Phillips Joy Turner
Adam Morris Indiana Univ.
Rishi Rane
Florida International Univ.
Courtland Samuels Florida Atlantic Univ.
Bernhard Wolmarans Univ. of Florida
Lists will be added to their respective program’s update online. Find them at: fcep.org/empulse/residency-updates
EMpulse Spring 2020
21
COMMITTEE REPORTS
EMRAF President’s Message By Matthew Beattie, MD, PGY-3
EMRAF President ’19-20 | USF Health
Spring has arrived, and we are coming to the close of another academic year. For interns, this is an exciting time as they transition to performing most of their clinical duties in the ED. For second-years, they can now develop their own practice style and take over as leaders for the incoming class. For senior residents, it is time for us to venture out on our own and put many years of education and training to use.
the best physician you can be. Work hard and strive every day to provide the best care to your patients while making sure that you are happy and healthy in your personal life. In light of recent events, there is going to be pressure on us as healthcare professionals to provide answers amongst this new pandemic. Stay up to date and learn every day, but place your health and happiness first. ■
I encourage you to continue your journey to become
COMMITTEE REPORTS
Medical Student Council
By Alexa Peterson, OMS-III, Nova Southeastern University FCEP Medical Student Council Secretary-Editor
What does advocacy mean to you? Advocacy is formally and generically defined as “the public support for or recommendation of a particular cause or policy.” However, advocacy has a very real and raw meaning that varies from person to person. Specifically, there are many causes that emergency medicine physicians are passionate about, and they were able to share their voice at Emergency Medicine Days on January 27-29, 2020 in Tallahassee, FL. There were several medical students that joined the physician forces and took advantage of the free conference to learn about FCEP’s legislative priorities. Topics discussed ranged from current issues affecting physicians such as expansion of scope of practice, opioids, and physician
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e-prescribing. Once medical students, residents and physicians alike were briefed on current policies, we were able to meet with individual Representatives and Senators in order to share the meaningful examples of how these policies directly affect patients, physicians and the field of emergency medicine as a whole. As a participating medical student, the important connections and bridge in differing perspectives that were made between physicians and legislative leaders were established quickly and directly observed in the brief meetings. It is experiences like these that remind us medical students how important, as future emergency medicine physicians, it is to quickly build rapport during your brief interactions with a patient, or in this case, government officials.
EMpulse Spring 2020
In addition to the policy review, medical students were able to interact with residents from North Florida Regional HCA/UCF GME Consortium during a medical student forum led by Program Director, Dr. Robyn Hoelle. The eye-opening presentation covered a topic that a few of their residents are strong advocates for: human trafficking. We reviewed statistics, current protocols and trainings, and how we, as future physicians, have the power to intervene and save a life. So, moving forward this season, the FCEP Medical Student Council urges all medical students, and the greater emergency medicine community alike, to reflect and contemplate: what are your passions, and what does advocacy mean to you? ■
NORTH FLORIDA EM RESIDENCY PROGRAMS
UCF/HCA North Florida Regional By Jayden Miller, MD, PGY-1
UF Jacksonville By Dr. Ty Tantisook, PGY-2
Congratulations to our rising chiefs: Drs. Jess Ryder, Chrissy Gage and Ryan Brandt. We are all excited to see you in your new leadership roles. Our PGY-2s had a great time in Greenville, SC for Southeastern SAEM. The weekend trip to the mountains was refreshing, and USC-Greenville did an excellent job in hosting the event. Hats off to everyone who presented at the conference, and especially to Dr. Andrew Sellinger, PGY-2, who won first place for his CPC on Vaping Associated Pulmonary Injury (VAPI). It has been very exciting to see our Shands family grow, with multiple residents and staff bringing new children into the world. Welcome, little ones, and congratulations to the new parents. Good luck to everyone during this challenging time in medicine and society in general. The worldwide outpouring of innovation, philanthropy, sacrifice and kindness has been inspiring. Take extra care of yourselves, mentally and physically, during this time period: your patients and families are counting on you. We were all made for this. As FDR said, “Smooth seas don’t make skillful sailors.” UF Jax is pulling for everyone across the state. ■
UF Gainesville By Christopher Purcell, MD, PGY-2
We have had a busy winter here at North Florida. Let’s start with the most exciting news: our program coordinator, Kim Watkins, was honored at the CORDAA20 conference as the 2020 EMRA Residency Coordinator of the Year! Kim is unspeakably deserving of this: she has worked tirelessly to improve our program since its inception, and is such an integral part of our North Florida family. Aside from her premier work as our coordinator, she did all of it while dealing with the death of her father and her husband’s diagnosis and treatment for a rare cancer. I’d like to share a brief passage from the many enthusiastic words we shared in her nomination: Through five weeks of radiation, eight weeks of chemotherapy, almost a dozen hospital visits related to complications of the chemotherapy, and countless tears, Kim never went anywhere without her laptop. Not one resident missed registration of a conference. Not one poster went unprinted. Not one interview day went awry. The “snack fridge” still had Monsters to drink! Faculty meetings went on. We told her to take time off! Kim was singularly devoted to the residents... Our residency is better; our residents are better, because of her.
and residents attended EM Days at the Capitol in Tallahassee. They participated with other emergency physicians and residents around the state, advocating for upcoming policy that affects us. Ashley Barash, DO, PGY-2 gave a presentation about sex trafficking victims at the conference. She is uniquely suited to this, as prior to medical school, she spent time as a research assistant for the Domestic Violence Homicide Prevention Demonstration Initiative at Brigham and Women’s Hospital in Boston. The faculty and PGY-3 class attended a CME cruise at the end of February, adventuring around the Caribbean and enhancing their EM knowledge. Many of our faculty gave presentations to other practitioners aboard for CME credit. This opportunity also served as the faculty’s graduation gift to our first graduating class!
In other news, several of our faculty
Speaking of which, our senior class is looking to their rapidly approaching futures with excitement! One of our chief residents, Chris Libby, MD, will complete a fellowship in Medical Informatics at Cedars-Sinai in Los Angeles. Most of our other seniors have signed with community hospitals around the country, in California, Tennessee, Ohio, and right here in Florida. ■
Fellowships galore! Congratulations to many of our third-years who recently found out where their next year will take them:
allow our residents to practice procedures not done routinely, including cricothyrotomies, chest tubes, pericardiocentesis and more.
• Drs. Chami & Ticas: Sports Med • Drs. Reed & Johnston: EMS • Dr. Smith: Ultrasound • Dr. Beamon: Global Medicine Weekly conference is being taken to another level with our “rare procedure” conferences. Cadaver lab and simulation models this spring will EMpulse Spring 2020
After another successful and exhausting interview season, we can’t wait to meet our new intern class. Welcome, Class of 2023! To all of our Florida co-residents and faculty, please be safe as we take on this pandemic. ■ 23
SOUTH FLORIDA EM RESIDENCY PROGRAM UPDATES
Florida Atlantic University By Dr. Elizabeth Calhoun, PGY-1
Greetings from sunny South Florida in Boca Raton. As we grew into the second half of the academic year, our second- and third-year curriculum has begun incorporating longitudinal trauma shifts into our EM months. The first-year cohort will now begin their longitudinal EMS shifts, including ride-along shifts with the Boynton Beach Fire Rescue. As part of our monthly Wellness Curriculum, we spent an afternoon in February together as a program, assisting with beach clean-ups through Gumbo Limbo Nature Center in Boca Raton. We also welcomed Dr. Judd Hollander, now with Thomas Jefferson University, for Grand Rounds. He commented on the role of emergency physicians in the rapidly growing area of telemedicine, and he also lectured on his highly regarded research on high sensitivity troponins. Finally, Assistant Program Director and Simulation Director, Dr. Patrick Hughes, had planned in March our biannual FAU Disaster Day, in coordination with Forts Medical Portable Clinics in Coconut Creek. With 40+ volunteers and actors, we simulated mass casualty and disaster scenarios, including a simulated viral outbreak in the setting of ongoing development of the Covid-19 eruption. ■
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Aventura Hospital By Dr. Scarlet Benson
Assistant Clinical Professor After a busy interview season, we’re already preparing for the next academic year. We are excited to welcome students from the new Dr. Kiran C. Patel College of Allopathic Medicine, who will be joining osteopathic students from the existing program at Nova Southeastern University. In addition to these, and our allopathic students from Florida International University, we are actively recruiting visiting 4th-year students for audition rotations. We welcomed our first participant for the inaugural medical student ultrasound elective with us in March. Thank you, Elan Baskir from FIU, for participating! We are now accepting applications for the elective for the next academic year as well. As our senior residents focused their attention on the job search, intern Dr. Nicolas Ulloa was involved in multiple academic endeavors. He completed a StatPearls article
EMpulse Spring 2020
entitled “High altitude pulmonary hypertension,” presented a poster at FOMA entitled “Confirmation of atrial myxoma using bedside US in the ED,” and had planned on presenting a poster entitled “Acute calcific tendonitis: an uncommon cause of neck pain” at AAEM until it was cancelled due to COVID-19. Our faculty had a busy and involved winter as well. Simulation Director Dr. Jessica Cook received the FACEP designation and will be recognized at the Fellows ceremony in Dallas in October. Ultrasound Director Dr. Huy Tran presented a poster at AIUM entitled “Assessing barriers to supervision of trainees in use of POCUS during cardiac arrest by emergency medicine physicians. Do years of practice matter?” He and Assistant Ultrasound Director Dr. Gaurav Patel also provided hands-on teaching at the Yale POC ultrasound course in Fort Lauderdale in March. ■
SOUTH FLORIDA EM RESIDENCY PROGRAMS
Jackson Memorial Hospital By EM Residency Program Staff Greetings from Miami! What to say about the University of Miami/Jackson Health System residency in 2020 so far? We could easily discuss the preparations that went into organizing the South Florida Consortium— but, it had to be cancelled. We could talk about how excited our PGY-2s were to head out to Arizona for AAEM—but, that too was cancelled. Or the enthusiasm we all shared discussing the details of our second class’ graduation celebration—which is, as we write this, still very uncertain. Finally, many of us attended CORD in NY, but we are happy to report that we are all doing ok. Instead, let’s focus on the fact that we were fortunate to fully match our program and are very excited and proud of the class that will be joining us in June. Our candidates
come from all over the country: from California to Vermont, all the way south to our own city of Miami. Their onboarding promises to be unique, and we are ready for the challenge. We had a very successful EM Foundations Small Groups session via Zoom; our first of the kind. It worked so well that we are thinking of permanently adapting the concept to our regular conferences moving forward.
Presuma for the next year, and Dr. Timothy Montrief will be spending the next two years at the University of Pittsburg doing his Critical Care fellowship. Last but certainly not least, Dr. Emily Ball will be heading to the University of New Mexico for her Surgical Critical Care fellowship. We are proud to share their success with you and want to publicly congratulate them all.
We have five senior residents going into fellowships. Dr. John Combs is heading to Yale for an Ultrasound fellowship. Dr. Kristina Jacomino is heading to George Washington University for an Ultrasound fellowship as well. The Anesthesia Critical Care fellowship at Jackson Memorial Hospital will be the home of Dr. Dumi
Now our focus is in line with the entire country and world. We continue our mission of training our residents while doing our best to keep them safe. And although we have uncertain times ahead of us, we keep a positive outlook and look forward to seeing everyone on the other side of this. Stay safe, everyone! ■
Kendall Regional Medical Center By Dr. Ramsey Ataya, PGY-3
Emergency Medicine Academic Chief It has been a busy start to the new year at Kendall Regional Medical. From the opening of the new garage for residents, medical students and staff to utilize (yay!), to another successful in-service training exam, everyone is excited to seize every moment leading up to the end of the academic year. We would like to congratulate our Global Health Track on their successful trip to Costa Rica, where three EM residents and two of our faculty provided medical care to Nicaraguan refugees who abandoned their homes due to severe political unrest. Advanced, portable ultrasound was utilized (see photo), allowing U.S.-based ultrasound faculty to provide real-time feedback and interpretation with residents. Special
thanks to Drs. Valori Slane, Matthew Slane, Emilio Volz, Moises Moreno, Nikkitta Georges, Kristina Drake and Sara Zagroba who worked tirelessly to prepare for this trip. We were looking forward to continuing the annual 200+ Mass Casualty Event simulation in April in conjunction with the Florida Department of Health, Broward Fire Rescue, Broward Police, Broward College, and Aventura across various specialties. In this simulation, residents must utilize Incident Command and triage principles to risk stratify patients and allocate limited resources in an otherwise overburdened system. As of print, whether or not this event will still happen is uncertain. The past year has been an exciting EMpulse Spring 2020
time in our rapidly growing program. We hope to continue our focus on resident clinical and academic achievement with our faculty, drawing from their diverse experiences to promote resident engagement and education while we continue collaborations with prehospital organizations and other institutions. ■ 25
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SOUTH FLORIDA EM RESIDENCY PROGRAMS
St. Lucie Medical Center By Abby Regan, DO, MSc, PGY-2
Mount Sinai Medical Center
We’ve enjoyed a bustling winter season at St. Lucie Medical Center. Our program is proud to announce Dr. Josephin Mathai as our new Medical Director in the emergency department. In addition to her tireless leadership within our residency program as Associate Program Director, she will now be spearheading our department in all of its future endeavors. In the past few months, our program has enjoyed our quarterly SIM lab conference, where we all had the opportunity to place several transvenous pacemakers and walk through a neonatal altered mental status case. It is invaluable to have these experiences in a SIM environment, and we as a group feel more comfortable with these high-stress cases each time we go. Many of our residents volunteered at the Marathon of the Treasure Coast in Stuart, FL in March. We are always excited and thankful to be a part of the events in our community. Additionally, several members planned on attending the annual CEME 2020 Resident Poster Competition until it was cancelled.
By Stephanie Fernandez, MD, PGY-2
Congratulations to the incoming class of 2023! We look forward to seeing you this summer.
We also just recently had the pleasure of hosting Dr. Christopher Kuppler, a local trauma surgeon practicing at Lawnwood Regional Medical Center, for a lecture on traumatic brain injury, emergency surgical airways, and resuscitative thoracotomy. Our residency is incredibly thankful to have shared in his extensive fund of knowledge and expertise in his field. And finally, the Match. We interviewed many distinguished and qualified candidates this year, and we are excited to meet our incoming Class of 2023! ■
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EMpulse Spring 2020
Due to conditions caused by COVID-19, MSMC has transitioned to online weekly conferences in lieu of in-person lectures. In the face of recent challenges, let’s take a moment to recognize the incredible work of ED staff, nurses and physicians across the nation! As this year comes to a close, we congratulate our talented PGY-3 class as they prepare to start their careers as attendings. Drs. Chandelle Raza and Zachary Gimbel will work at West Side Regional in Plantation, Dr. Natasha Brown will attend a Disaster Medicine fellowship at Beth Israel Deconess, Dr. Elizabeth Rubin will attend a Simulation fellowship at the University of Chicago, Dr. Shay Nimjareansuk will attend a Sports Medicine Fellowship at Northwell, and Drs. Mauricio Baca and Blake Guillory will work at Naples Florida Physicians Regional Medical Center. We look forward to seeing them showcase their knowledge and passion for emergency medicine during the Senior Lecture Series and wish them luck in their careers! Lastly, join us in celebrating this season’s highlights. Dr. Chandelle Raza and Ivan Rodriguez tied the knot in January, and we had two new additions to the MSMC family: Dr. Jenna Varner’s daughter, Kiera, and Dr. Liz Rubin’s son, Noam. From MSMC, we wish you a safe and happy summer. ■
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WEST FLORIDA EM RESIDENCY PROGRAM UPDATES
USF Health By Mikhail Marchenko, MD, PGY-2 Greetings from Tampa and the USF Emergency Medicine Residency. We’d like to extend a big welcome to our newly matched residents! We are excited to have you join us and be a part of what is going on in Tampa. We are looking forward to working with you side-by-side in the best specialty in medicine. We appreciate everyone’s effort at Emergency Medicine Days on January 27-29, as critical bills were up for discussion and it was vital for physicians to accurately represent the importance of physician-led care in providing medical care to our patients. With the first Florida cases of COVID-19 occurring in the Tampa area, we appreciate our infectious disease colleagues and all of the emergency personnel who tirelessly worked to provide the most upto-date information and best care practices while in the emergency room. Continue to stay safe fellow colleagues: you are awesome at taking care of the most vulnerable while at the same time risking your lives while doing it! Finally, we are excited for all of our seniors that have signed contracts and will be soon practicing as attendings. On behalf of your residency program, congratulations to all of the soon-to-be grads! ■
Brandon Regional Hospital By Rashmi Jadhav, MD, PGY-2
The last few months have been quite eventful for the Brandon Regional Hospital EM Residency Program. In February, our residents took the in-training examination. Afterwards, they were able to relax at Dave and Busters for a fun-filled night outside of the hospital with food, arcade and basketball games. Our wellness committee also hosted a hospital-wide talent show, which showcased many hidden talents of residents across all specialties. In March, we travelled to New York City to attend the CORD EM conference. There, Drs. Rachel Oliver, Cecilio Padron, Melissa Bacci and Caroline Shepherd represented BRH at the EMRA Quiz Show. We are elated to announce that they won 1st Place! Our faculty and residents are all very proud of the work they did to prepare. I also began my fellowship training in wellness at the CORD Academic Assembly, and look forward to incorporating what I learn into our program in the upcoming year. Furthermore, BRH is very excited to announce that we are expanding our Emergency Department faculty
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EMpulse Spring 2020
with several highly-qualified physicians who are very eager to teach and contribute to our education. Our new department Chief, Dr. Victor Sasson, has been an incredible asset to the growth of our department. Starting in July 2020, we are thrilled to have Dr. Robert Truckner join us and boost our Pediatric EM training. Dr. Martin Kim will enhance our simulation sessions as he has extensive specialized training in this field. Further, Dr. Amanda Webb will be joining our department to exclusively assist with EM research projects. Our growing staff and faculty continuously prove to be the most integral part of our program, and are truly the driving force behind training our residents. Finally, we are most excited to welcome our incoming intern class and complete our program with three full classes of residents. Our program has come a very long way in such a short time, and we are very proud of all our achievements. We anticipate the next academic year will be the best one yet and look forward to a great year ahead! ■
WEST FLORIDA EM RESIDENCY PROGRAMS
Oak Hill Hospital By Jonathan Yaghoubian, DO, MS, & Corey Cole DO, PGY-2s
The snow bird season is finally coming to an end and we enjoyed a brief reprieve. Every year the break gets shorter, and especially now with the widespread pandemic of COVID-19. We are preparing for the inevitable inundation of the worried well and truly ill, but as for now, we are seeing the “calm before the storm.” We are trying to keep morale up and spirits high, and the community is being an active participant in that aspect. Many local restaurants are delivering food to our department and cheering us on. We are very grateful for them. Our adaptability as residents has been a great asset to us as protocols are changing daily. With the suspected rush of patients and the annual increase in patient load, we are very fortunate to have our newest interns coming this July; our residency program will be up to full capacity with our third class
joining us! The ED expansion is actively in the works to accommodate the increasing volume and residents. As part of the continued growth of our hospital, the long-awaited Level II NICU has opened, and with it two new neonatologists have joined our hospital staff. This past season has been one of many new changes and faces. We were approved for an additional off-cycle resident, Dr. Fred Gardezy, as well as a new, fellowship-trained pediatric emergency physician, Dr. Lorraine Mendez. Our assistant program director, Dr. Jason Grabert, is also our new assistant director of the emergency department, as well as our new stroke champion. We survived our annual in-training exam after an intensive review course. It has become tradition for us to have a wellness event after our
exam. This year, just like last, we went as a group to the nearby bowling alley and enjoyed a few games as well as food and drinks. We had other wellness events planned; however they have been postponed due social distancing recommendations. As the second year is halfway over, some are considering jobs while others are working on applications to fellowship. It has been great to see the first-years growing; they are definitely ready to take on the role of a second-year. It will be interesting progressing to third-year and being able to help the intern class. It was not that long ago we remember being called a doctor for the first time, or the oddly gratifying feeling of signing our first prescription and placing orders. It is nice to see our program continue to grow and we look forward to being the first graduating class. ■
FSU at Sarasota Memorial Courtney Kirkland, DO, PGY-1 Hello from Sarasota! Our inaugural class is almost done with our intern year, and we can’t believe how quickly it has flown by. We have worked with so many different physicians and staff all over the hospital, especially on our off-service rotations, that Sarasota Memorial Hospital is really starting to feel like home. Expanding upon our last update, we have continued to collaborate with various specialties at our hospital for grand rounds. Our most recent joint conference was done in conjunction with the pediatric hospitalists from Johns Hopkins All Children’s Hospital. We have had similar conferences
with internal medicine, neurology, and trauma surgery. Additionally, we have been continuing our Journal Club monthly, and we are looking forward to the day when we have more residents to help present the articles! Two of our core faculty, Dr. Sarah Temple and Dr. Rose Goncalves, were able to attend CORD in New York City, along with our amazing program coordinator, Jean Dunn. I was lucky enough to attend CORD as well, representing our program at the EMRA Representative Council Meeting. Our tight-knit group of nine residents regularly participate in various EMpulse Spring 2020
wellness activities together, including our most recent gathering after the in-training exam for food, bocce ball, and even professional tennis lessons organized by our wellness director, Dr. Steve Kamm, at the Bird Key Yacht Club. The weather has been amazing this time of year, and the days we have off are spent enjoying the beautiful weather and beaches we have surrounding our city. It’s hard to believe that our next batch of residents will be here soon! We can’t wait to expand our family here at SMH. ■
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CENTRAL FLORIDA EM RESIDENCY PROGRAM UPDATES
Orlando Health By Drs. John Atiyeh, PGY-2, Gregory Black and Brody Hingst
AdventHealth East Orlando By Shannon Armistead, DO, PGY-3 Hello again from AdventHealth East Orlando! We cannot believe Match Day has already come and gone. We look forward to meeting our soonto-be interns and welcoming them to our East family. On a similar note, it is amazing to think we are already so close to the end of the academic year. Soon scores for the In-Training Exam will be released, signaling another benchmark closer to graduation for our seniors. Our seniors are completing their last round of trauma rotations as they rapidly prepare our interns for their quick transition to second-years. The fact that soon we will all be stepping into our new roles is somewhat daunting. Due to the COVID-19 pandemic and concerns to encourage social distancing and the health of our residency, we completed our Annual Program Evaluation as a video conference. We have also transitioned to weekly online conferences in effort to continue our educational pursuits while navigating through this uncharted and undersupplied territory. As always, we are so proud of our soon-to-be graduates, as well as our rising second-years and seniors, as we have watched them see patients and deal with workflow. Our current residents continue to actively seek opportunities to teach the next generation as they learn concomitantly from the attendings on all the current literature. We are excited for all we continue to learn and grateful for the learning opportunities. To our colleagues, please stay safe, be well and we are happy to stand with you, as we are all in this together. ■ 30
Orlando Health has been staying busy in 2020! Many of our residents and faculty attended Emergency Medicine Days in January to advocate for pressing issues in emergency medicine. In February, some senior residents and faculty headed north to Greenville, SC for the SAEM southeastern regional conference. Dr. Mitch Barneck won best resident presentation for his “Outcomes of Immediate vs. Early Antibiotics in Severe Sepsis and Septic Shock: A Meta-Analysis.” We are also incredibly proud of our residents and faculty who presented at CORD in March: congratulations to Drs. Jay Ladde, Susan Miller, Erich Heine, Anne Shaughnessy and Carrie Chapman. You all rock! Also in March, we celebrated the memory of Dr. Salvatore Silvestri with our 3rd annual Sal Silvestri Memorial Wiffle Ball Game. With residents, faculty, staff and alumni in attendance, we had the opportunity to honor the great Sal with some bonding time and a healthy dose of competition. The game reminds us every year to continue striving to “live like Sal.” We hope to always continue his legacy, which can be found in the close-knit family values of our program that extend far beyond the walls of our ED. The medical community continues to prepare and brace for COVID-19 seeping into our hospital systems, and Orlando Health is no exception. While implementing CDC and Health
STREET DRUGS in the
SUNSHINE STATE W E B I NA R S E R I E S
emlrc.org/education/streetdrugs EMpulse Spring 2020
Department guidelines and travel screenings, we have also diverted COVID patient rule outs to certain areas of our ER with negative pressure rooms and implemented strict PPE and work up protocols. A high risk triage area has also been set up in the ambulance bay in preparation for higher volumes of COVID patients. Our EHR rollout for EPIC continues to move forward, with current plans to go live at ORMC this upcoming academic year. Our downtown medical campus will also be expanding, with plans to break ground on the $250 million Orlando Health Jewett Orthopedic Hospital this spring. Upgrades continue in the ED, with some fresh renovations to the trauma bay having recently been completed. Our senior residents have begun passing their leadership roles to the next generation, most recently with the election of our new and fearless Chief Residents. Congratulations to Drs. Keegan Mullins, Olivia Munizza and Justin Kittredge! Finally, all of us at ORMC are so excited to welcome our 18 new residents to the family. We had a phenomenal group of applicants this interview season from all over the country! Amidst all the excitement of new family members, we also face the bittersweet reality of our current seniors moving on. You will be dearly missed; may you continually strive to #livelikeSal. ■
CENTRAL FLORIDA EM RESIDENCY PROGRAMS
UCF/HCA at Ocala Regional By Caroline Smith, MD, PGY-2 It has been a busy start to 2020 at UCF/HCA Ocala Emergency Medicine. We are excited to announce the addition of two core faculty members to the program: Dr. Samyr Elbadri will join as simulation director, and Dr. Elbadri, who is currently serving as chief resident here in Ocala, will stay on as faculty after graduation. Dr. Leoh Leon will join as ultrasound director from Osceola Regional Medical Center, where he completed his ultrasound fellowship training. We are looking forward to working with both Dr. Elbadri and Dr. Leon and learning from their expertise. Residents have been busy with
academic pursuits and focusing on research. Dr. Aaron Umansky, PGY-2, was selected as our resident research and QI coordinator. He has not been short on work since taking the position. Dr. Nick Titelbaum, PGY-2, was accepted to the EMRA Leadership Academy. This is the second consecutive year UCF Ocala will have a representative in the Leadership Academy as Dr. Vir Singh, PGY-3, completed his training in the academy. In fact, Dr. Singh was one of five residents selected for EMRA’s travel award and scholarship to attend the ACEP ED Directors Academy. He is looking forward to learning more about leadership in emergency medicine. Dr. Singh was also accepted for
oral presentation at this year’s AAEM Scientific Assembly, where he will be speaking on Kratom. Dr. Joe Gibney, PGY-3, and Dr. Nick McCauley, PGY-3, were selected as oral presenters at CORD 2020 in New York. They offer unique perspectives on residency leadership as members of the inaugural UCF Ocala class. For the past three years, Dr. Gibney has managed resident scheduling, and Dr. McCauley has served as our wellness tzar. We are thankful for their work and contributions to the residency and proud to have them recognized at a national conference for their efforts. ■
UCF/HCA of Greater Orlando By Amber Mirajkar, MD, PGY-2 It is a new year and spring has sprung! We are honored by the sheer number of medical students who applied to our program, and creating a rank list was no easy feat. We cannot wait to meet our residents in July. In other news, we have chosen our chiefs for next year! We would like to congratulate Drs. Michelle Hernandez and Keegan McNally. Both have already started their on-thejob training and are taking on chief responsibilities. They are dedicated and brilliant, so we are excited to have them at the helm. Further congratulations are in order for our graduating PGY-3s, who are also the second graduating class from our program. They all are moving on to wonderful opportunities. Dr. Andrew Hanna matched into Pediatric EM fellowship at UF Health Jacksonville, FL. Dr. Joshua Tsau matched into EMS fellowship at UT San Antonio, TX. Dr. Nick Fusco will
be continuing his training with us as one of our new Ultrasound fellows. Dr. James Chiang will be working for the Kaiser system in the San Francisco Bay Area as clinical faculty for a new residency program. Dr. Alexandra Craen is joining the USF/HCA Brandon Regional Hospital faculty in Brandon, FL. Dr. Jessica Houck will be clinical faculty at University of Kentucky’s Albert B. Chandler Hospital in Lexington, KY. Last but not least, we would like to congratulate our inaugural fellows on their new positions. Our ultrasound fellow, Dr. Leoh Leon II, has accepted the position of ultrasound director at UCF/HCA Ocala’s Emergency Medicine Residency. Dr. Amanda Webb, our research fellow, will be the research director and clinical faculty at USF/HCA West Florida GME Consortium at Brandon Regional Hospital in Brandon, FL. We wish all our graduates the very best and good luck as they start new chapters in EMpulse Spring 2020
their lives. In addition to carving out post-graduate paths for themselves, our residents continue to pursue research avenues,. PGY-2 Drs. Mary Cate Slome and Sherwin Thomas will be presenting at SAEM this year. Dr. Jessica Houck, PGY-3 presented her research on racial disparities in stroke at the International Stroke Conference in February. Ultrasound Fellow, Dr. Leoh Leon, lectured on ultrasound at the Yosemite Post Graduate Institute in beautiful Yosemite National Park. There, he instructed primary care physicians on how to use ultrasound in-clinic to spot emergencies or conditions that need further evaluation in the emergency department. Our residents continue to have a strong interest in research, and we cannot wait to see what the new year has in store. ■ 31
POISON CONTROL
Wading through the
Weeds in Search of the Truth Behind Kratom Kristen C. Lee, Pharm.D., BCPS Clinical Toxicology/EM Fellow at Florida/USVI Poison Information Center-Jacksonville
Kratom is a substance that has been gaining popularity in the U.S. over the last decade as an herbal supplement and a drug of abuse, as well as an alternative option for treatment of opioid-use disorders. It is touted by users to provide relief from pain, stress, and anxiety. Others seek its euphoric effects, as it possesses both stimulant and opioid-like activity.1 Currently, Kratom is not scheduled by the DEA, and is easily purchased at gas stations and herbal shops throughout the U.S. However, Kratom sales are banned in six states, including Alabama, Arkansas, Indiana, Wisconsin, Vermont, and Rhode Island.2 In Florida, individual counties, including Sarasota County, have imposed a ban on Kratom sales as well. Kratom is sold as an herbal supplement and is supplied in a variety of formulations including bulk powder, capsules, tinctures, and electronic cigarette liquid. Lack of regulation means these products may vary widely in content and potency, raising safety concerns for consumers. Kratom (Mitragyna speciosa) is a tree in the coffee (Rubicaea) family that is native to Southeast Asia where it has a history of traditional use as an analgesic as well as a stimulant used by laborers and farmers.3 The leaves 32
Anthony DeGelorm, Pharm.D.
Clinical Toxicology/EM Fellow at Florida/USVI Poison Information Center-Jacksonville
are often chewed while working or made into a tea and consumed. Kratom contains dozens of unique indole alkaloids, including the primary active constituent, mitragynine. Mitragynine, which makes up about two-thirds of the alkaloid content of the plant leaves, is a partial agonist at the µ-opioid receptor and is responsible for Kratom’s opioid-like effects.3 It has activity at post-synaptic α-2 receptors, which may contribute to Kratom’s antinociceptive effects. In addition, mitragynine has affinity for 5-HT2C and 5-HT7 serotonin receptors which may play a role in its stimulant-like effects. Despite agonist activity at the µ-opioid receptor, some evidence suggests that mitragynine and its metabolite, 7-hydroxymitragynine, induce limited recruitment of β-arrestin, which is believed to be responsible for many of the undesirable effects associated with opioid use, such as respiratory depression.3,4 It was theorized that this may be why respiratory depression is not seen to the same extent in Kratom as with classic opioids. However, a recent study by Kliewer et al. that may disprove this theory has demonstrated that morphine is capable of inducing respiratory depression in mice independent of β-arrestin.5
EMpulse Spring 2020
Despite some promising characteristics, Kratom use is associated with a number of adverse effects. One retrospective review of cases reported to the National Poison Data System showed that the most common symptoms reported were agitation, tachycardia, drowsiness, and confusion.6 Neurologic symptoms included seizures, hallucinations, and (rarely) coma. Kratom use has been linked to end-organ system dysfunction, with hepatic injury being the most common. Other case reports have attributed various renal, cardiac, and pulmonary complications to Kratom use. The National Institute of Health lists Kratom as an agent of concern on their LiverTox® database with regards to its potential for hepatic dysfunction.7 Chronic use and discontinuation is associated with a withdrawal syndrome similar to that of opioid withdrawal.3 Symptoms include nausea, vomiting, diarrhea, chills and sialorrhea with physical exam findings demonstrating restlessness, hypothermia, tremors, and diaphoresis. Tolerance to Kratom along with withdrawal on discontinuation may explain the development of habitual use. Treatment of Kratom intoxication is largely supportive, including early airway support if needed. While opi-
Thank You, PAC Donors
oid antagonists such as naloxone are effective in opioid overdoses, there are no controlled studies evaluating efficacy in Kratom cases. Limited anecdotal evidence from case reports suggests that the use of opioid antagonists may be beneficial.8 Seizure activity should be managed with intravenous benzodiazepines.9 Acute hepatitis may be managed similar to other cases of drug-induced hepatitis with N-acetylcysteine.3 Management may be tailored to treat other symptoms as appropriate. Overall, the prognosis for Kratom overdose remains favorable and the majority of cases appear to resolve with simple supportive care. There are deaths linked to Kratom use, but many of the fatalities are clouded by the presence of other substances of abuse, making it difficult to attribute them solely to Kratom. With its growing popularity and ease of availability, Kratom may become a more significant public health issue in the coming years. Due to the current opioid epidemic, the number of individuals seeking alternatives to conventional opioid therapy or treatment of their withdrawal may increase. The absence of regulation and increased popularity could lead to growth in the Kratom industry which causes additional concerns due to lack of quality control and potential for adulteration. Future studies may continue to elucidate the health effects of Kratom both with chronic use and in overdose. In the meantime, healthcare professionals should continue to familiarize themselves with the available literature to optimize patient care. ■ FPICN toxicologists are available 24 hours a day, free of charge, at 1-800-222-1222 to assist in the management of Kratom toxicity or to answer questions regarding other potential exposures.
REFERENCES
1. Cinosi E, Martinotti G, Simonato P, et al. Following “the Roots” of Kratom (Mitragyna speciosa): The Evolution of an Enhancer from a Traditional Use to Increase Work and Productivity in Southeast Asia to a Recreational Psychoactive Drug in Western Countries. Biomed Res Int. 2015;2015:968786. 2. Veltri C, Grundmann O. Current perspectives on the impact of Kratom use. Subst Abuse Rehabil. 2019;10:23-31.
3. Eastlack SC, Cornett EM, Kaye AD. Kratom-Pharmacology, Clinical Implications, and Outlook: A Comprehensive Review. Pain Ther. 2020 4. Bohn LM, Gainetdinov RR, Lin FT, Lefkowitz RJ and Caron MG (2000) mu-Opioid receptor desensitization by beta-arrestin-2 determines morphine tolerance but not dependence. Nature 408(6813): 720-723 5. Kliewer A, Gillis A, Hill R, et al. Morphine-induced respiratory depression is independent of β-arrestin2 signalling. Br J Pharmacol. 2020 6. Eggleston W, Stoppacher R, Suen K, Marraffa JM, Nelson LS. Kratom Use and Toxicities in the United States. Pharmacotherapy. 2019;39(7):775-777. 7. LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012. Kratom. [Updated 2018 Apr 10]. Available from: www.ncbi.nlm. nih.gov/books/NBK548231/ 8. Overbeek DL, Abraham J, Munzer BW. Kratom (Mitragynine) Ingestion Requiring Naloxone Reversal. Clin Pract Cases Emerg Med. 2019;3(1):24-26. 9. Nelsen JL, Lapoint J, Hodgman MJ, Aldous KM. Seizure and coma following Kratom (Mitragynina speciosa Korth) exposure. J Med Toxicol. 2010;6(4):424-6.
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The success of FCEP’s advocacy efforts is dependent upon our ability to fund those efforts. Generous donations to our political action committees (PACs) are always needed and greatly appreciated. Thank you to those who donated in December 2019-February 2020: Mark G Attlesey Fernando Barajas Michael A Borunda Jerry Thomas Brooks Blake Buchanan Jordan Celeste Ilya Michael Chern Alex T Doerffler Steven C Eccher Stephen Scott Feilinger Jay S Feldman Jennifer Fredericks Anthony Furiato Jesse Glueck Andrea Gorjaczew Brian Scott Hartfelder Jonathan Journey Steven B Kailes Gary Lai Jon E Lamos Michael Lozano Christopher T Martin Michael D McCann James McCormick Daniel McMicken Rhonda C Oeters Mary Elizabeth Schmieder Donna Schutzman-Bober Matthew A Schwartz Elizabeth Skeins John Caleist Soud Claire Jane Marie Stringfellow Jason Wilson Daneil Nathan Young
DONATE NOW: Text “FCEPPC” to “41444” or
Donate online at: fcep.org/donate 33
VITAS Brings Your High-Acuity Patients Home. Break the cycle of rehospitalizations for patients needing specialized end-of-life care.
VITAS® Healthcare brings specialized Intensive Comfort Care® to the bedside in shifts of care up to 24 hours, when medically necessary, to manage symptoms, address pain and resolve crises. Avoid hospital and ED readmissions, support caregivers and honor hospice patients’ wishes to remain at home. Download our referral app, visit VITAS.com or call 800.93.VITAS.
VITAS.com A VITAS medical director, working with the patient’s specialist, determines appropriate modalities based on the plan of care. 34
EMpulse Spring 2020
Burnt Out Doctors Performing Whole Patient Care... Really? By Ademola Adewale, MD, FACEP
Director of Research & Medical Simulation at AdventHealth East Orlando and Assistant Professor of Emergency Medicine at Florida State University College of Medicine
The concept of whole patient care or patient-centered care was initially part of holistic medicine, but now is mainstream medicine. Unfortunately, the promise of whole patient care is too often negated by the dysfunctional environment in which care is delivered. Physical well-being addresses lifestyle behaviors that cultivate good health and help avoid preventable diseases. Emotional well-being addresses factors that are affecting the patient’s state of mind, coping mechanisms and mental health conditions such as anxiety or depressive disorders. Spiritual well-being encompasses a universal human experience that addresses our purpose in life, and can involve a religious affiliation or a deep sense of being interconnected with nature or the environment. And social wellbeing addresses the interactions and relationships with friends, family and the community. But who is to deliver this care? Obviously, not healthcare executives or the institutions they serve. Physicians are tasked with delivering this care to the patients the healthcare organizations serve. The burning
question is this: “Can a disengaged, burnt-out physician provide whole patient care?”
grams to address physician resilience. This is a sure way to miss the mark.
This sounds like an oxymoron in itself. The irony here is that the philosophy is backwards in its approach. For a physician to provide whole patient or patient-centered care, the physician must be whole. In the era where almost 55% of physicians express some level of burnout, 17% or so exhibit colloquial depression, and a physician commits suicide every day, shouldn’t healthcare organizations be investing first in physician wholeness?
Most physicians are resilient by virtue of being a physician. It takes a resilient person to make it through cut-throat medical school, survive the grueling and sometimes almost torture-like residency, before transitioning to be a full-fledged physician. This requires superb intestinal fortitude, the ability to tighten sphincter muscles, and, in all, possess the unique quality of equanimity under duress. The idea that physicians are not resilient and need resiliency training is perceived as insulting by practicing physicians.
It seems obvious that investing in the concept of physician wholeness should have been the first phase of the foundation of the patient wholeness campaign. Can you imagine a physician that is not physically fit or healthy, emotionally drained and detached, spiritually wanting or lacking, and socially isolated or uninvolved trying to address the pillars of wholeness with a patient? The oddity and irony here are very obvious. Ironically, instead of focusing on physician wholeness and addressing burnout, we are engaging in proEMpulse Spring 2020
The whole patient or patient-centered care concept is a welcome addition to modern healthcare; it has been long overdue. Healthcare organizations serious about delivering whole patient care need to deliberately and simultaneously invest in physician wellness. At the end of the day, it is only a whole physician that can effectively buy-in and deliver whole patient care. ■ Image: ©Robert Kneschke | Adobe Stock
35
CASE REPORT
A DISAPPEARING ACT:
The curious case of Lemierre’s Syndrome By Amar Mittapalli, MD
UM Miller School of Medicine
Background The textbook definition of Lemierre’s syndrome is thrombophlebitis of the internal jugular vein. This serious condition usually follows an oropharyngeal infection with ensuing septic emboli. The syndrome usually manifests with Fusobacterium necrophorum as the causative organism. Diagnosis of this rare condition can be made by confirmation of thrombophlebitis of the internal jugular vein via imaging, positive culture of F. necrophorum, or demonstration of septic embolization secondary to thrombophlebitis.1
Case Presentation A 63-year-old-male with questionable retropharyngeal abscess, which extended into the mediastinum, had concerning features for Lemierre’s syndrome. Diagnosis of Lemierre’s syndrome was confirmed by duplex ultrasound of the neck. The condition was managed with prolonged usage of intravenous antibiotics.
Conclusion Having suspicion for Lemierre’s syndrome in any patient who presents with probable retropharyngeal abscess is important as early diagnosis and treatment can lead to a complete recovery of this rare condition.
By Andrew Napier, MD
UM Miller School of Medicine
ments. Due to the patient having a very muffled voice, and the need to secure his airway quickly, gathering a history from the patient was difficult. Much of the history was obtained from the patient’s family. As preparations were made in the Emergency Department for a difficult airway, his O2 saturation began to decline while on room air. He began to complain of inability to swallow secretions, as well as inability to breathe while laying flat. The patient was intubated in the ED for airway protection, using awake intubation with ketamine in a seated position with a GlideScope Video Laryngoscopy device. Intubation was complicated by trismus, edematous vocal cords with a narrowed glottic opening, and pus in the airway; however, it was performed successfully in a single attempt. Prior to arrival from the outside facility, the patient had been given Vancomycin, Zosyn, and Decadron. On physical examination, the patient was intubated and sedated.
Fig. 1: Longitudinal view of right internal jugular vein with visible thrombus formation
Case History A 63-year-old Hispanic male presented to the Emergency Department as a transfer from an outside hospital who endorsed sore throat, cough, congestion, and difficulty swallowing for the past several days. He complained of severe throat pain that was aggravated by neck move36
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By Walter D’Alonzo, MD
UM Miller School of Medicine
On arrival and on examination, the patient’s temperature was 37.5C. On examination, there was considerable erythema and edema over the anterior neck, which extended to the upper right arm. Examination of the oropharynx revealed poor dentition without evidence of peritonsillar abscess; the uvula was midline, and no erythema was noted in the oropharynx. Initial laboratory analysis showed a WBC count of 2.8/mm3 with left shift and consisted of 86% neutrophils. The C-reactive protein (CRP) was abnormally elevated at 56mg/ dL. Serum electrolytes revealed hyponatremia (131mmol/L), hypertriglyceridemia (301mg/dL). Urinalysis was positive for hematuria without evidence of infection. Evaluation of BUN (37mg/dL) and Creatinine (1.64mg/dL) showed an acute kidney injury. Further laboratory analysis showed lactic acidosis and transaminitis. In order to further assess if surgical intervention would be re-
Fig. 2: Color flow sagittal view of right internal jugular vein exhibiting thrombus formation
quired for a deep neck abscess, CT of the neck and chest with contrast was performed. CT of the chest showed bilateral pleural effusions with underlying areas of consolidation. CT of the neck revealed a soft tissue density in the nasopharynx and oropharynx, as well as mild thickening of the prevertebral soft tissue without evidence of drainable fluid collection. At the time of CT scan of neck, no filling defect was visualized. The patient was transferred to the ICU for further management. While in the ICU, there was a lingering suspicion for Lemierre’s syndrome. An initial duplex of the neck was performed, which showed echogenic material within the right internal jugular (RIJ) vein; possibly representing partial, nonocclusive thrombus versus sluggish flow. The confirmation of a thrombus could not be confirmed due to absence of Doppler imaging. The next morning, an educational bedside ultrasound of the neck did, in fact, show a thrombus in the RIJ. However, later that day a second ultrasound of the neck was performed; the echogenic material seen on the prior study was no longer present, which indicated that the clot had either resolved or embolized. The following morning, another educational ultrasound with Doppler imaging did reveal a thrombus in a non-collapsible RIJ. A stat formal ultrasound with Doppler imaging of the neck was quickly performed, which showed a deep venous nonocclusive thrombus involving the RIJ as well as a superficial thrombophlebitis in the right cephalic vein. These ultrasound findings confirmed our diagnosis of Lemierre’s syndrome.2 A repeat CT of the chest was performed given concern for embolization from the RIJ. CT chest revealed improved pulmonary edema with decreased pleural effusions and did not show any evidence of embolization to the lungs, however it did show new right middle lobe opacity, suggesting pneumonia.
Treatment The blood cultures that were performed did not show any growth. After confirmation of Lemierre’s
syndrome, the patient was kept on intravenous Zosyn (3.375gm q12hrs) and Zyvox (600mg q12hrs). Anticoagulation therapy with Heparin (5000U q8hrs delivered subcutaneously) was also started on the patient. Throughout the course of stay in the ICU, the patient’s condition gradually improved with significant reduction in erythema and edema of the anterior neck. The patient underwent a bronchoscopy and was extubated without problem.
Discussion Prior to the advent of antibiotics, the incidence of Lemierre’s syndrome was at its highest. This incidence met a sharp decline once penicillin entered the scene. However after the 1970s, there has been a rise in the reported case of Lemierre’s syndrome. This may be attributed to the steady dwindling use of empiric antibiotics to treat oropharyngeal infections. With this said, the worldwide incidence of this rare disease is approximately 1/1,000,000. The syndrome typically targets previously healthy young adults and adolescents. Approximately 90% of patients who come down with Lemierre’s syndrome are between 10 and 35 years of age.3, 4 The diagnosis of Lemierre’s syndrome is mainly clinical and should be considered in patients with oropharyngeal infection who begin to develop respiratory symptoms, neck swelling, or evidence of toxicity about a week after oropharyngeal infection symptom onset.5 In patients with the clinical presentation of oropharyngeal infection with associated soft tissue neck swelling, a broad differential must be considered. Such differentials include retropharyngeal abscess, infectious mononucleosis, Ludwig’s angina, and peritonsillar abscess. Imaging modalities to help diagnose Lemierre’s syndrome typically include CT imaging of the neck and chest, as well as color doppler imaging in order to visualize thrombosis and potential pulmonary emboli as a sequelae of thrombosis.6 Antibiotic coverage should include oral anaerobes. Duration of treatment is variable, however patients should be treated with IV antibiotics EMpulse Spring 2020
for 2-3 weeks until clinical improvement is observed. This should be piggybacked with a 4-6 week period of oral antibiotics.7
Conclusion In any patient who presents with a deep space tissue infection of the neck following an oropharyngeal infection, clinical suspicion for Lemierre’s syndrome should be high. Lemierre’s syndrome is a potentially fatal condition that is characterized by septic thrombophlebitis of the internal jugular vein secondary to oropharyngeal infection with potential embolization to the lungs as well as other organs. Given the correct clinical setting, diagnosis can be made via CT, MRI, or ultrasound of the neck indicating internal jugular vein thrombophlebitis. ■
REFERENCES
1. Katrine M Johannesen, U. B. Lemierre’s syndrome: current perspectives on diagnosis and management. Infect. Drug Resist. 9, 221 (2016). 2. Nadir, N.-A., Stone, M. B. & Chao, J. Diagnosis of Lemierre’s Syndrome by Bedside Sonography. Academic Emergency Medicine vol. 17 E9–E10 (2010). 3. Allen, B. W. & Bentley, T. P. Lemierre Syndrome. in StatPearls [Internet] (StatPearls Publishing, 2019). 4. Sacco, C. et al. Lemierre Syndrome: Clinical Update and Protocol for a Systematic Review and Individual Patient Data Meta-analysis. Hamostaseologie 39, 76–86 (2019). 5. Kristensen, L. H. & Prag, J. Human Necrobacillosis, with Emphasis on Lemierre’s Syndrome. Clinical Infectious Diseases vol. 31 524–532 (2000). 6. Riordan, T. Lemierre’s syndrome: more than a historical curiosa. Postgraduate Medical Journal vol. 80 328–334 (2004). 7. Riordan, T. Human Infection with Fusobacterium necrophorum (Necrobacillosis), with a Focus on Lemierre’s Syndrome. Clinical Microbiology Reviews vol. 20 622–659 (2007). 8. Li, H.-Y., Grubb, M., Panda, M. & Jones, R. A Sore Throat—Potentially Life-Threatening? Journal of General Internal Medicine vol. 24 872–875 (2009). 9. Karkos, P. D. et al. Lemierre’s syndrome: A systematic review. The Laryngoscope vol. 119 1552–1559 (2009). 37
CASE REPORT
Bleeding from a Chronic Head Wound:
Squamous Cell Carcinoma Case Presentation By Nancy W. Weber, DO, FACOEP, FACEP, MBA
Vice Chair for Quality and Patient Experience, Texas Tech University Health Sciences Center at El Paso
A 70-year-old Caucasian male presented via EMS with the complaint of “bleeding from a chronic head wound after a fall the day before.” He presented to a mid-western community hospital with an emergency medicine (EM) residency associated with a large academic university. The patient had fallen the day before, and it was uncertain as to why the wound was bleeding today, or if it had been bleeding intermittently since his fall. The patient was a poor historian; he was unable to tell us how long he had had the wound, what the reason for the wound was, or what treatment had been offered or accepted. He just stated that, “they wanted to do surgery that would have taken a skin flap from my forehead and grafted it onto my scalp. They said I would lose my eyebrows, and I didn’t want that.” Throughout the visit he alternately said the wound and the consultation
had been “just a few months ago,” to “a few years ago,” to “a while ago.” No family was present to give more information. The patient was admitted, the area biopsied, and diagnosed as cutaneous squamous-cell carcinoma with invasion of the calvarium. Because of the locally advanced progression, he was not a candidate for surgery or radiation treatment. Cutaneous squamous-cell carcinoma is the second most common skin cancer1; only basal-cell carcinoma has a higher incidence. There are 5.4 million basal cell and squamous cell carcinomas diagnosed each year, of which approximately 80% are basal cell carcinoma. The incidence of squamous cell carcinoma in Caucasians is 0.1-0.15% per year, and peaks in the mid-60s. Risk factors include chronic sun exposure, male sex, Caucasian, advanced age, fair skin that is sensitive to ultraviolet radiation (blonde or redhead), blistering sunburns, a history of actinic keratosis (a premalignant condition), HIV, tobacco use, and immunosuppression, including those being treated for solid organ tumors. In 2012, an estimated 3900 to 8700 people in the U.S. died from cutaneous squamous cell carcinoma. Surgery is the first line of treatment for skin cancer. In more than 95% of patients, the cancer is cured with surgery. Concerns about the effect on appearance are one of the most important issues to patients, such as this one. In a small percentage of patients, the tumor reaches an
38
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incurable state because it becomes metastatic or has locally advanced progression and is no longer amenable to surgery or radiation therapy. For patients with locally advanced or metastatic cutaneous squamous-cell carcinoma, the immune checkpoint inhibitor cemiplimab can induce a response in approximately half the patients. Palliative systemic therapy was offered and declined by the patient. Additionally, our patient was found to have a new diagnosis of a blood dyscrasia. In summary, the patient presented with bleeding from a chronic head wound, was found to have both squamous-cell carcinoma and a new blood dyscrasia. While there is the potential for treatment of one of both of these cancers, the patient chose to forego potential curative and/or palliative treatment and was discharged home with hospice per his expressed wishes. ■
REFERENCES:
1. K.S. Nehal and C.K.Bichakjian.
“Update on Keratinocyte Carcinomas.” NEJM. Vol 379 No 4 p. 363.
2. "Key Statistics for Basal and
Squamous Cell Skin Cancers." The American Cancer Society. Jan. 8, 2020. Access at www. cancer.org/cancer/basal-andsquamous-cell-skin-cancer/ about/key-statistics.html
3. M.R. Migden et al. “PD-1
Blockade with Cemiplimab in Advanced Cutaneous Squamous-Cell Carcinoma.” NEJM Vol 379 No. 4 p. 341
Advance care planning (ACP) can be defined as making healthcare decisions about the care a patient would want to receive, if the patient becomes unable to speak for themselves. Documents that appoint an agent and/or record the wishes of the patient are referred to as advance directives and include a Health Care Proxy, Durable Power of Attorney for Healthcare, a Living Will, or a Medical Order for Life Sustaining Treatment (MOLST). For Emergency Department providers, CPT allows the ACP service to be billed in addition to the E/M code (99281-99285) and all the observation codes. ACP cannot, however, be reported with critical care services, 99291. ACP codes 99497 and +99498 are time-based, which means providers must specifically document the time they spend offering these services. To record ACP services correctly, providers must document the time the conversation started, when it stopped, and the total amount of time included. Any payer that accepts current CPT coding should accept ACP codes, unless stated otherwise in written policies or contractual agreements. According to the FL Medicare Locality 99 2020(B) rates, the work RVU for 99497 is valued at 1.5 and 99498 code is valued at 1.4 RVU’s. This approximates to $79 and $75 respectively.
Advance care planning is reported utilizing the following CPT codes: 99497 – This code covers the first 30 minutes of discussion/counseling, including the explanation and discussion of advance directives. However, completion of these forms is not required to bill for the service. In order to qualify, at least 16 minutes must be performed and documented. This conversation must be face-to-face with the patient, family members, and/or surrogates. • If the minimum time requirement is not met, CMS states that the provider may consider billing a different E/M code, assuming that the requirements for that code are met. • Cannot count time managing patient’s medical problems. The CPT manual states that “no active management of the problem(s) is undertaken during the time period reported.” In other words, time spent managing the patient’s medical problems cannot be counted as ACP time. 99498 – this code is used if the conversation lasts longer and may be billed for each additional 30 minutes of the ACP discussion, with no limit. Documentation Requirements for ACP: CPT does not specify exact language to be used to bill for ACP. It would be reasonable, however, to have some documentation validating who the discussion was with (patient, family members, and/or surrogates), why you are having this discussion, what was discussed, and what decision was made. www.gottlieb.com 4932 Sunbeam Road, Jacksonville, FL 32257 800.833.9986
EMpulse Spring 2020
39
ULTRASOUND ZOOM
A New Mode to Diagnose Pneumo(Peritoneum): Using POCUS to Identify Intra-abdominal Free Air By Brittney Giuffre, MD, PGY-2 Jackson Memorial Hospital
For me, training in a busy public hospital has not only been an incredible opportunity to see a broad range of pathology, but also to experience many of the challenges faced by busy emergency departments. One of our biggest challenges at Jackson Memorial Hospital is the high volume of critically-ill patients, which may result in them waiting several hours for evaluation and imaging. Almost reflexively, after determining a patient is “sick,” I find myself running to grab our ultrasound machine. The ability to get quick answers, with the bonus of low cost and no radiation risk to the patient, has spiked my interest to learn and use point-of-care ultrasound (POCUS), especially on our sickest patients with life-threatening diagnoses. For example, even before the portable x-ray machine rolls into the patient’s room, I can confidently determine whether a patient with shortness of breath has acute decompensated heart failure or a COPD exacerbation. However, I first had to learn to identify B-lines. Recently, I came across an intriguing blog post in which POCUS was used to diagnose intra-abdominal free air (IFA). Now that I’ve learned the technique and signs, I am undoubtedly going to apply this to my next patient with acute abdominal pain, and hopefully, I will diagnose pneumoperitoneum.
PNEUMOPERITONEUM
Pneumoperitoneum is an all-encompassing term for IFA inside the peritoneal cavity but outside the bowel 40
Edited by Leila Posaw, MD, MPH
Emergency Ultrasound Director, Jackson Memorial
lumen. Most often, patients will present with severe, sudden onset abdominal pain, associated with nausea and vomiting. The physical exam is variable, and ranges from mild to severe abdominal tenderness with distension, rebound and guarding. There is a long list of causes for IFA (Table 1), and often the history is enough to narrow the differential diagnosis. Up to 85-95% of the time, IFA is caused by a perforated viscus or a defect in the gastrointestinal tract. These patients require emergent surgery, and a missed diagnosis is associated with high mortality. Non-operative etiologies include increased abdominal pressure (severe coughing, CPR, COPD) and iatrogenic causes (post-laparoscopic or open abdominal surgery).1
IMAGING Plain film radiography
Radiography alone is not sensitive enough to rule out IFA, and published sensitivities range between 55-85%.2 As patients need to be positioned upright or on their side for at least 10 minutes, plain films may prove difficult in our critically ill patients. Of upright and supine views, the former is more sensitive. Classically, you would look for air under the diaphragm; however, this is only seen in 60-80% of cases.3 Some studies describe the ability of upright films to detect as little as 1 mL of free air,4 though this involves a great deal of technical precision and patience. If unable to obtain upright views, the supine left lateral decubitus view is the next best choice. Free air can be EMpulse Spring 2020
Table 1: Common causes of IFA requiring surgical intervention, based on location Esophageal perforation
Risk factors: recent instrumentation, esophageal cancer, history of forceful vomiting ROS: +chest pain, +dysphagia, +epigastric pain Other clues: subcutaneous emphysema
Small bowel
Acute mesenteric ischemia Risk factors: atrial fibrillation, CAD History: postprandial pain, weight loss Labs: elevated lactate Other causes Malignancy Meckel’s diverticulum
Perforated peptic ulcer
Gastric or duodenal ulcer Risk factors: NSAID use, H. pylori
Colorectal
Toxic megacolon Risk factors: C. difficile colitis, IBD Other causes Diverticulitis Appendicitis Malignancy Ischemic colitis Iatrogenic (post colonoscopy) Bowel obstruction seen between the liver edge and the abdominal wall.
Subtle signs of IFA include the Falciform Ligament sign (when air collects in bilateral subphrenic spaces to reveal a linear density on the ventral surface of liver) and the Rigler sign (when air is visualized on both sides of the bowel wall).5
CT
CT is the imaging modality of choice as it has the highest sensitivity and specificity. It is excellent at detecting air in the retroperitoneal spaces, such as with perforated sigmoid diverticulitis. IV contrast is useful to detect fat stranding, bowel wall defects, or bowel wall thickening. In 90% of positive scans, air will be most pronounced at the site of the perforation.6 Unfortunately, CT is not always the wisest first choice in EDs due to considerations of vague presenting symptoms, risks of radiation, cost, and potential delays in overcrowded EDs.
Ultrasound
Comfort with the POCUS technique is an invaluable skill for emergency physicians for several reasons. A busy ED might have imaging delays with CT scanners occupied with trauma patients or no available patient transporters, and a bedside exam might save the day. Another advantage of POCUS is that it is a quick, low radiation option in patients who are “too unstable” to leave the department. It is also a more appropriate first choice in pregnant women and infants, in whom we
want to reduce risks of radiation. Ultrasound is more sensitive for free air than plain radiography. One study found ultrasound to have a 95% sensitivity in detecting pneumoperitoneum compared to 78% with plain films.7 Additionally, ultrasound has improved ability to detect “indirect” findings of bowel perforation, such as decreased peristalsis and free fluid between intestinal loops.8 That being said, it is important to remember that POCUS is operator-dependent, and an average user might forget the subtleties of how to perform the scan or might not be familiar with the ultrasound findings altogether. POCUS is a “rule-in” test and is extremely useful as a screening test to expedite next steps. Given the significant morbidity and mortality associated with this diagnosis, a negative POCUS exam should not be interpreted as an absence of pathology.
TECHNIQUE
This exam seeks to answer one simple question: Is there free air in the abdomen?
Probe selection
This depends on the patient’s body habitus. The higher frequency linear probe (10-12 MHz) is preferred in thin patients due to superior resolution. Unfortunately, this probe is limited by shorter depth penetration. Thus, in patients with more adipose tissue, the lower frequency curvilinear
probe (3-5 MHz) will allow greater depth visualization. While Nazerian et. al. found improved specificity using the linear probe compared to the curvilinear probe (95.5% vs 81.8%), there was no significant difference in sensitivity.2 An additional benefit is that the same probe can be used to perform several other scans simultaneously, such as the gallbladder, aorta or FAST. Several scanning techniques have been published. Hefney et.al. describe scanning the patient in the epigastrium and in the RUQ, in both supine and left lateral decubitus positions. Deep inspiration was shown to enhance image acquisition.9 Karahan et. al. also describe scanning the patient in the supine position, with the sagittal probe in the right paramedian epigastric area, and in the left lateral position with the transverse probe placed in the right mid axillary line, parallel to parallel to 8th and 10th intercostal spaces. Strong reverberations may shift with position change, and this is known as the shifting phenomenon.10
Scissor Maneuver
Karahan et. al. have described a novel and useful technique called the “scissor maneuver,” which can assist in identifying pneumoperitoneum. When pressure is applied to the caudal aspect of the probe, the reverberation artifacts disappear as the free air is pushed away. When pressure is released, the reverberation artifacts CONTINUE ON PAGE 42 �
Pneumoperitoneum.To.Go. Stick in your wallet. Reference on-the-go. Courtesy of authors Leila Posaw, MD, MPH and Brittney Giuffre, MD
Pneumoperitoneum Point-of-Care Ultrasound: Signs Normal
EPSS: Enhanced Peritoneal Stripe Sign
Reverberation artifacts: A-lines
Gas Bubbles in Ascites
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Pitfall � Look for peristalsis when using the scissor technique to differentiate between normal air in the lumen and free air. 41
� CONTINUED FROM PAGE 41
become apparent again.10 For a better visual idea of what the Scissor Maneuver looks like, scan to read this blog post from EM Docs:
2 Scan FAST exam
Nazerian et. al. describe a quick 2-location exam, which has been shown to be equally efficacious as scanning five abdominal locations (epigastrium, right hypochondrium, left hypochondrium, umbilical, and right hypochondrium with patient in left lateral decubitus position).2 The best two locations were found to be the epigastric region with the patient in supine position, and the right hypochondrium with the patient in lateral decubitus position for at least 2 minutes.2 The goal of the 2-minute wait is to bring the free air anterior and close to the probe.
Signs
Four of the most well described POCUS signs in patients with IFA are: (a) the enhanced peritoneal stripe sign, or EPSS, (b) the presence of
reverberation artifacts, (c) comet tails artifacts and (d) the presence of air bubbles in ascites. (a) EPSS: Normally, the peritoneal stripe will appear as a thin, echogenic line between the anterior abdominal wall and underlying organs or peritoneal fluid. With disruption by air, the interface between the gas and underlying soft tissue scatters sound waves to result in an “enhanced” peritoneal stripe.11,12 (Fig. 1)
(c) Comet tail artifacts: Comet tails are essentially several echogenic reverberations stacked together to resemble a streak similar in appearance to a comet’s tail. (d) Air bubbles in ascites: Often, free air is found with free fluid in the abdomen. Air bubbles can be seen clearly as hyperechoic, mobile “bubbles” floating in dark pockets of ascites. (Fig. 3)
1. Epigastric region with the patient in supine position (or with head of bed slightly elevated)
2. Right hypochondrium with the patient in lateral decubitus position for at least 2 minutes
Pneumoperitoneum Point-ofCare Ultrasound: Techniques Purpose: to detect free air in the abdomen
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Fig. 2: Reverberation Artifact
(b) Reverberation artifacts: Large amounts of free air can produce echogenic reflections known as reverberation artifacts. These appear similar to the “A-lines” seen by ultrasound in normal lungs. (Fig. 2)
2 SCAN FAST EXAM
Probe Selection: Linear > curvilinear
Fig. 1: EPSS. Yellow arrow indicates enhanced peritoneal stripe
Scissor Technique: Pressure on the caudal probe will dissipate the reverberation artifacts. Release pressure and the artifacts reappear. 2 Scan FAST Exam: � (1) RUQ/epigastrium in supine position, HOB 10-20 degrees (2) Left lateral decubitus EMpulse Spring 2020
Pitfalls
There are several pitfalls to remember. The most frequently encountered one is confusing air in the bowel (Fig. 4) with free air in the abdomen. The presence of peristalsis can help differentiate the two. Another way to differentiate both is by scanning in the right hypochondrium, where the solid liver will prevent bowel loops from causing confusion. While scanning in the right upper quadrant, take heed to not confuse normal reverberation artifacts in the lung with that caused by IFA. Normal lung artifacts will move with respiration and will be located above the peritoneal line.9 POCUS is commonly used in patients presenting with acute abdomi-
2 Scan FAST Exam
Fig. 3: Gas in Ascites
REFERENCES
1. Tanner, Tiffany Nicole, et al. “Pneumoperitoneum.” Surgical Clinics of North America, vol. 98, no. 5, 2018, pp. 915–932., doi:10.1016/j. suc. 2. Nazerian, P, et al. “Accuracy of Ultrasonography for the Diagnosis of Pneumoperitoneum.” Critical Ultrasound Journal, vol. 7, no. S1, 2015, doi:10.1186/2036-7902-7s1-a14. 3. Williams, N. M., and D. F. Watkin. “Spontaneous Pneumoperitoneum and Other Nonsurgical Causes of Intraperitoneal Free Gas.” Postgraduate Medical Journal, vol. 73, no. 863, Jan. 1997, pp. 531–537., doi:10.1136/pgmj.73.863.531.
Fig. 4: Pitfall
4. Braccini, G., et al. “Ultrasound versus Plain Film in the Detection of Pneumoperitoneum.” Abdominal Imaging, vol. 21, no. 5, 1996, pp. 404– 412., doi:10.1007/s002619900092.
nal pain, especially if renal stones, gallstones or AAA is suspected. However, it is not utilized enough to diagnose IFA. Expanding our POCUS skills to include this diagnosis may prove invaluable in saving patients’ lives. Familiarity with the simple technique, signs and pitfalls is a bold move towards this. ■
5. Hokama, Akira, et al. “The Falciform Ligament Sign of Pneumoperitoneum.” Journal of Emergencies, Trauma, and Shock, Medknow Publications, July 2011, www.ncbi.nlm.nih.gov/pmc/ articles/PMC3162727 6. Borofsky, Samuel, et al. “The Emergency Room Diagnosis of Gastrointestinal Tract Perforation: the Role of CT.” Emergency Radiology, vol. 22, no. 3, 2014, pp. 315–327., doi:10.1007/s10140-0141283-4. 7. Chen, S.-C., et al. “Ultrasonography
Is Superior to Plain Radiography in the Diagnosis of Pneumoperitoneum.” British Journal of Surgery, vol. 89, no. 3, 2002, pp. 351–354., doi:10.1046/j.00071323.2001.02013.x. 8. Grassi, Roberto, et al. “GastroDuodenal Perforations: Conventional Plain Film, US and CT Findings in 166 Consecutive Patients.” European Journal of Radiology, vol. 50, no. 1, 2004, pp. 30–36., doi:10.1016/j. ejrad.2003.11.012. 9. Hefny, Ashraf, and Fikri AbuZidan. “Sonographic diagnosis of intraperitoneal free air.” Journal of Emergencies, Trauma, and Shock, vol. 4, no. 4, 2011, p. 511. 10. Karahan, Okkes Ibrahim, et al. “New Method for the Detection of Intraperitoneal Free Air by Sonography: Scissors Maneuver.” Journal of Clinical Ultrasound, vol. 32, no. 8, 2004, pp. 381–385., doi:10.1002/jcu.20055. 11. 1Asrani, Ashwin. “Sonographic Diagnosis of Pneumoperitoneum Using the ‘Enhancement of the Peritoneal Stripe Sign.’ A Prospective Study.” Emergency Radiology, vol. 14, no. 1, 2007, pp. 29–39., doi:10.1007/s10140-0070583-3. 12. Indiran, Venkatraman, et al. “Enhanced Peritoneal Stripe Sign.” Abdominal Radiology, vol. 43, no. 12, 2018, pp. 3518–3519., doi:10.1007/ s00261-018-1628-7.
Daunting Diagnosis: A By Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief �CONTINUED FROM PAGE 18
This female was diagnosed with a malignant nerve sheath tumor encroaching the brachial plexus. The CT scan demonstrates a large, firm mass, approximately 16cm x 10cm over the upper left aspect of the chest, located immediately below the clavicle. The MRI is of the left brachial plexus. It shows an enhancing and centrally necrotic mass at the left upper
chest/ axilla. There is surrounding edema. The patient was seen by orthopedic surgery. After discussion at a sarcoma tumor board, she underwent surgical intervention with a forequarter amputation. It was recommended that the patient undergo adjuvant chemotherapy after surgery. The patient was amenable to the plan due to lack of arm function and the high risk of metastatic spread without having operative intervention. ■
MRI of left brachial plexus
CT Scan of thorax EMpulse Spring 2020
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FEATURE
What Physicians Bring to Hospital Leadership By Michael Zappa, MD, FACEP
FCEP Past-President | President of Highsmith-Rainey Specialty Hospital and Vice President & Associate Chief Medical Officer of Cape Fear Valley Health System
I am often asked today if I am a doctor or an administrator; my response is both—always! You might ask, can a physician really be both? The answer is yes, though not every physician. If you take the group of all physicians, the first cut is those that are interested, then it is narrowed by those that are prepared: either through formal education, life experience, or both. The final cut is those that have the demonstrated ability to lead by inspiring a diverse team and operationalizing a vision. Today this represents a rather narrow playing field. It is important to remember that doctors are different; many have dreamed of being a physician since childhood, and rank among the best and brightest, with often only the top 0.5% of high school students eventually being accepted into medical school. Physician executives are wired differently; they are decisive, based on an unwavering priority hierarchy: 1. Patients 2. Mission of the Organization 3. Personal Needs No one debates their clinical expertise, but they also bring operational efficiency and are natural 44
“
Healthcare for tomorrow definitely needs the creative disruption that can only come from sharing a new vision and reaching for it from a different perspective. caring stewards as a result of years of bedside experience that cannot be taught in a classroom or read about with the same impact. Many critical advances in medicine over the years have resulted from the innovation and visionary talents of physicians; healthcare for tomorrow definitely needs the creative disruption that can only come from sharing a new vision and reaching for it from a different perspective. Healthcare is a little out of step with many other industries that support the concept that technical expertise can position someone to be a stronger manager and leader: actors become Hollywood producers and directors, star athletes become coaches and managers, plumbers become general contractors, etc. According to Amanda Goodall of the London School of Business: “Leaders should first be experts in the core business of their organization.” See her article entitled, “If Your Boss Could Do EMpulse Spring 2020
Your Job, You’re More Likely to Be Happy At Work” for more insight. According to Modern Healthcare, only 5% of hospital CEOs nationwide are physicians, yet the routinely top-ranked healthcare systems are led by physicians. US News and World Report studied the 115 largest US hospital systems and found a 25% improvement in quality metrics in physician-led hospitals versus non-physician-led entities with no loss of financial performance. So, beyond the skills that got physicians into medical school, through residency, and made them successful practitioners, if you’re looking for physician leaders to join the C-suite, be sure they have the following additional characteristics:
• Optimistic • Motivated to Share Success • Resilient • Even-tempered • Clinically Respected When you find a physician with that skill set who is willing, prepared, and able—hold on, because that white coat might just be the superhero cape hospital leadership is looking for. ■ Originally published on Healthcare Business Today
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MUSINGS FROM A RETIRED PHYSICIAN
Coronavirus Woes By Wayne Barry, MD, FACEP FCEP Member
While waiting for the Super Tuesday Primary Election results to become evident, it became clear to me that some thoughts about the COVID-19 pandemic may be more appropriate at this time. Indeed, I have been personally touched by the threats and fears posed by this situation. My church buddies and I have already postponed a cruise around Hawaii, and I just turned 72 years old, which puts my case fatality ratio at 8%. The wise tact is for all of us to take this novel coronavirus seriously. The pandemic of 1918 killed 50 million people and changed human life on this planet as we know it. Hopefully we have the scientific knowledge, technology and collective resources to prevent similar worldwide carnage. Unfortunately, there are a set of obstacles presenting challenges to successfully and expediently taking control of this epidemic. First of all, we need to keep our signals straight. It is incumbent upon all of us to listen to the scientific and medical experts in the fields of virology, epidemiology and public health, and take their lead in heeding warnings and recommendations. Political leaders across the world are exhibiting different degrees of cooperation with scientific leaders. China’s leadership in first acknowledging that it was the epicenter of the coronavirus outbreak and then putting up face-saving and authoritarian propaganda to minimize the problem was very suspect. They then repudiated and
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nearly imprisoned a brave Chinese primary care physician who tried to alert his fellow medical school classmates about the new epidemic. He went from goat to hero after he lost his life due to infection from the virus while working tirelessly to save his patients from infection in Wuhan, China. The Chinese finally came around to isolation and containment procedures which, at first, seemed rather Draconian, but have now proved somewhat effective in mitigating the disease in their country. Meanwhile, in this country, we have experienced mixed messages from our political leaders who have frequently contradicted the advice of medical experts. At the time of writing, President Trump wisely appointed Vice President Pence to take over the reins of the political leadership during this health crisis, and he appears to be coordinating more effectively with the medical experts. We are also suffering from a lack of sufficient number of test kits due, in part, to a misfire by the CDC in mass producing kits which were initially faulty due to too many false positive results. With few exceptions, notably Iran and maybe North Korea, most countries are coordinating their identification, isolation and treatment protocols with medical experts. This lack of testing brings us to the “tip-off the spear” for fighting this epidemic in the U.S., namely within the Emergency Department. At the
EMpulse Spring 2020
beginning of this pandemic, many medical offices were screening newly sick patients by telephone and referring them directly to the ED if COVID-19 was suspected. Besides creating a viral incubation environment for the coronavirus in the ED, threatening the health and safety of personnel and patients, a lack of test kits will confound diagnoses, which may lead to excessive crowding in ED’s and hospital in-patient services. We already know we don’t have enough ICU beds or functional ventilators in this country. Hospitals and emergency departments are developing contingency plans to deal with the crush of potential coronavirus patients screening protocols, etc. Patients who feel that they may have been exposed to COVID-19 need to quarantine safely and seek medical attention if they become sick, especially if they fall into particular vulnerable categories of patients of older age and/or with serious underlying chronic medical conditions which include hypertension, cardiovascular disease, chronic lung disease, cancer, and other ailments. Personal interaction hygiene measures such as frequent hand washing, keeping hands away from your face and other people, avoiding people who seem sick, and avoiding large crowds which may contain sick people (social isolation techniques), are being promulgated throughout the country. To my former mates in the ER, good luck and Godspeed. ■
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