EMpulse Spring 2021

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

OUR VOICE IS ESSENTIAL

IN PLACES WHERE DECISIONS ARE MADE

 WHAT’S INSIDE: 

Future EP Workforce Considerations & Potential Next Steps Advocating Acute Monocular Painless Vision Loss in an for our Health Care Heroes Introducing the FL EM Resident Class of 2024 Elderly Man





Vol. 28, No. 1 | Spring 2021

2

EMpulse Spring 2021

TABLE OF CONTENTS COMMITTEE REPORTS

6 FCEP President’s Message

By Dr. Kristin McCabe-Kline

10 Government Affairs: Florida Legislative Session 2021

By Dr. Blake Buchanan

7 ACEP President’s Message: Future Emergency Physician Workforce Considerations & Potential Next Steps

By Dr. Mark Rosenberg

14 EMS/Trauma

By Dr. Desmond Fitzpatrick 26 EMRAF President’s Message

By Dr. Elizabeth Calhoun

8 Membership & Professional Development Committee

By Dr. Shayne Gue

Medical Student Council

By Dan Schaefer

9 Pediatric EM Committee

By Dr. John Misdary

SPRING 2021

Volume 28, Issue 1 EMpulse Magazine is the official, quarterly publication of the Florida College of Emergency Physicians (FCEP).

EDITOR-IN- Karen Estrine, DO, FACEP, FAAEM CHIEF karenestrine@hotmail.com MANAGING Samantha League, MA & DESIGN sleague@emlrc.org EDITOR

FEATURES & COLUMNS 9 Daunting Diagnosis

By Dr. Karen Estrine 12 Advocating for our Health Care Heroes

By Mary Mayhew 18 Two Florida Health Systems Receive SAMHSA Grants to Implement ED Alternatives to Opioids Program

By Dr. Phyllis Hendry, Natalie Spindle, Dr. Sophia Sheikh and Michelle Krichbaum,PharmD 20 Case Report: An unrecognized opportunity to diagnose Hepatitis C Virus (HCV) and decrease transmission in people who inject drugs (PWID)

By Heather Henderson, Dr. Jason Wilson and Kaitlyn Pereira 22 Introducing Florida’s Emergency Medicine Resident Class of 2024

By EM Residency Program Staff; edited by Samantha League 35 Leveraging AI to improve patient safety in the emergency department

By Dr. Dan Sullivan; sponsored by Nuance Communications 36 Disruptive Innovation in Emergency Medicine: 2020 Edition

By Dr. Mitchell Barneck

38 Case Report: Acute Monocular Painless Vision Loss in an Elderly Man

By Drs. Mani Hashemi, Harold Gomez Acevedo, Arvin Jandu and Moises Moreno 40 Ultrasound Zoom: The VExUS Score: Fluid Status, Reconsidered

By Ernesto H. Weisson, Dr. Joshua Goldstein, Duyen Vo, MS; edited by Dr. Leila Posaw 44 Poison Control: Death by Procainamide: Medication Errors and Toxicity

By Caroline Heider, PharmD 46 Education Corner: Expanding the Menu Beyond the Sandwich: Defining Effective Feedback

By Drs. Carmen J. Martinez and Caroline M. Molins 48 From Scribing Notes to Saving Lives: The transition from scribing in the Emergency Department to medical school and beyond

By Patrick Anderson, OMS-III 50 Musings from a Retired Emergency Physician: The Reds and the Blues of COVID Vaccine Hesitancy

By Dr. Wayne Barry

Follow Us: /fcep.org

@fcep

@fcep_emlrc

/emlrc.org

@emlrc

/company/emlrc EMpulse Spring 2021

Johnson Press of America, Inc.

PUBLISHER 800 N. Court St.

Pontiac, IL 61764 jpapontiac.com

EMpulse Summer 2021 Note: EMpulse Summer 2021 will be digital only. Members will receive an email when it is published online at fcep.org/empulse.

Deadlines: • May 28: “Intent to Submit” form due » • June 14: Articles and ads due • End of July: Summer 2021 in inboxes

Intent to Submit Form

EMpulse Online: Did you know? Every article published in EMpulse is also published online at fcep.org/empulse.

EMpulse Online Homepage fcep.org/empulse

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

“ Old ER docs never die;

they just go on advocating for good patient care wherever they can.

”

-Dr. William T. Haeck (1939-2008),

first FCEP President, in EMpulse Aug/Sep 2000

Please join us at our

50th Anniversary Celebration at Symposium by the Sea Friday, August 6, 2021 6:30-8:30 pm Naples Grande Beach Resort Dinner with program to follow

Stay tuned at fcep.org/sbs

4

Every healer has a stor y to tell...

EMpulse Spring 2021

TABLE OF CONTENTS CONTINUED RESIDENCY PROGRAM UPDATES 27 Florida Atlantic University

By Dr. Tony Bruno AdventHealth East Orlando Dr. Tyler Mills 28 North Florida Regional Dr. Jayden Miller UF Health Gainesville Dr. Megan Rivera 29 Jackson Memorial Hospital EM Program Staff Orlando Health Drs. Gregory Black & Brody Hinst 30 FSU at Sarasota Memorial Dr. Courtney Kirkland Oak Hill Hospital Dr. Ryan Johnson UF Health Jacksonville Drs. Chris Phillips and Richard Courtney 31 Brandon Regional Hospital Dr. Rashmi Jadhav St. Lucie Medical Center Dr. Shelby Guile

32 USF Morsani Dr. Mikhail Marchenko Kendall Regional Medical Center Drs. Tina Drake, Ibrahim Hasan & Sara Zagroba 33 UCF at Greater Orlando Dr. Amber Mirajkar Aventura Hospital Dr. Scarlet Benson 34 UCF/HCA Ocala Drs. Jean Laubinger, Emily Clark & Caroline Smith Orange Park Medical Center Dr. Cody Russell Mount Sinai Medical Center Dr. Stephanie Fernandez

All articles originally published online at fcep.org in April 2021.

Visit fcep.org/spring-2021 to read the digital versions and share with others.

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 EXECUTIVE Jonathan Dolan, MA DIRECTOR MEMBERS Rajiv Bahl, MD, MBA, MS; Daniel Brennan, MD, FACEP; Elizabeth

Calhoun, MD (EMRAF Representative); Jordan Celeste, MD, FACEP; Vidor Friedman, MD, FACEP* (ACEP Rep); Jesse Glueck, MD; Shayne Gue, MD; Erich Heine, DO; Saundra Jackson, MD, FACEP; William Jaquis, MD, MSHQS, FACEP (ACEP Rep); Shiva Kalidindi, MD, MPH, MS(Ed.); Amy Kelley, MD, FACEP; Gary Lai, DO, FACOEP; Dakota Lane, MD, FACEP; Russell Radtke, MD; Danyelle Redden, MD, MPH, FACEP; Todd Slesinger, MD, FACEP, FCCM, FCCP

ADVERTISER INDEX 2 Gottlieb 13 Envision Physician Services 29 EMPros

35 Nuance Communications 42 Duva Sawko 51 VITAS® Healthcare

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

MD, FACEP*; Jay Falk, MD, MCCM, FACEP*; 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

ON THE COVER: ACEP & FCEP members at a Leadership & Advocacy Conference in the early 2000’s. Remember our in-person advocacy events? Photo provided by Dr. Wayne Lee, FCEP Past-President 1983-85; graphic design by Joe Stern.

EMpulse Spring 2021

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

5

FROM THE COLLEGE

FCEP President’s Message

By Kristin McCabe-Kline, MD, FACEP, FAAEM, ACHE FCEP President 2019-2021

I recently watched a video on LinkedIn of Match Day for a medical school in Florida. There were masks all around with graduating students holding up signs showing the specialties and locations of their matches. There was one sweet moment when a graduating doctor, in a fit of excitement, grasped the neck of a spouse and leaned in for a kiss, all the while forgetting to remove the masks. I was thrilled to see top performing graduating physicians choosing emergency medicine and prioritizing our specialty, despite the precarious circumstances we found ourselves in during 2020: job insecurity, unfulfilled contractual promises and financial risk of inability to meet obligations of student loans, mortgages, etc. became a frightening reality for many emergency physicians.

The community of emergency physicians has long been an exceptional group of people. It is more certain than ever this match season that those who choose our specialty are doing so because they believe

“

Without question, emergency medicine will always be an essential voice in the house of medicine.

in the good we can do and see the need for our skills in service to our communities. Emergency physicians will bravely walk into an uncontrolled situation when no one else is willing to do so. We stand arm in arm, willing to try to do good knowing there will be times when, due to circumstances beyond our control, we will not be able to do all we would like to do.

However, bravery is not without cost.

I spoke to one of my dearest and most precious friends recently who told me, “I said the next dead baby would be my last one and I would hang up my hat. I just want you to know I might be done with this gig.” This amazingly talented doctor is skilled, experienced, empathetic and dedicated to a degree

few humans will achieve in a lifetime.

It is emergency physicians being vulnerable without shame, treating one another with the respect we show our patients and open appreciation of one another because we have walked a mile in the shoes of our colleagues, who will see us through to be brave for another day. Only if we lean in on each other will we be able to withstand the storms that are inevitable in emergency services.

I am excited for the rising physicians choosing our specialty and accepting an uncertain future where the four walls of the emergency department do not restrain us. Let us welcome them with open arms into our family of innovators, healers and doctors who are uniquely positioned to meet both imminent and long-term healthcare needs in our state, country and around the world. Without question, emergency medicine will always be an essential voice in the house of medicine. ■

OCT 24-27, 2021 6

EMpulse Spring 2021

FROM THE COLLEGE

ACEP President’s Message

By Mark S. Rosenberg, DO, MBA, FACEP ACEP President 2020-2021

Future Emergency Physician Workforce Considerations & Potential Next Steps ACEP recently unveiled the results of its multi-year, multi-organizational workforce study, which concluded that, for the first time in history, we are headed towards a likely oversupply of emergency physicians in the next decade.

The data shows the stark reality of the impending workforce needs and provides the foundation for our next steps to correct its course. It’s time to move past fear and frustration into action. There is not one perfect, holistic solution to address marketdriven industry instability and no quick fixes for the challenges we face.

You have our promise that ACEP will work tirelessly toward solutions and action plans to protect your role in the future of emergency medicine.

Nothing will stand in our way — not corporations or private equity, not insurance companies or non-physician practitioners. We stand united with you.

From ACEP’s perspective, there are several key considerations, including: 1. Stop the proliferation of emergency medicine residents and residency programs 2. Raise the bar to ensure consistency across emergency medicine residency training 3. Ensure business interests are not superseding the needs of educating the workforce 4. Support practicing physicians to encourage rewarding practice in all communities 5. Ensure appropriate use of NPs and PAs to protect the unique role of emergency physicians 6. Ensure every patient has access to a board-certified emergency physician 7. Broaden the umbrella to expand emergency physician scope of practice 8. Expand the reach of emergency medicine to ensure that no community is left behind

No matter where the future takes us, ACEP remains committed to fighting for and supporting the front line emergency physician — from academia, large or small groups, government, to any other model of care. Even now, ACEP and our chapters are advocating in states nationwide to ensure your job is not done by anyone less qualified than you by fighting NP/PA independent practice creep in state legislatures.

These considerations are a starting point to outline pressing issues and potential solutions proposed to date. Very importantly, your perspectives and approaches are critical to these ongoing deliberations.

Differing opinions are still needed and welcomed, as it is vital all consequences, whether intended and unintended, are considered in advance.

The Workforce Task Force’s next step is to gather ideas from the entire specialty and develop action plans to stabilize and strengthen emergency medicine.

Ask your chapter leaders to coordinate a town hall where you can propose and debate ideas related to this issue and potential solutions. If you are not able to convene this kind of intimate group, EMpulse Spring 2021

consider sending your individual thoughts to workforce@acep.org or join the EM Physician Workforce of the Future discussion forum on the ACEP EngagED platform (acep.org/ workforce).

ACEP remains dedicated to working together with our members and partners who share our commitment to identify data-driven solutions that promote both patient safety and emergency physician opportunities. ■

WHAT FCEP IS DOING: This is a critical moment for our specialty and we encourage you to make your voice heard.

• FCEP leaders are working to

convene a Virtual Meeting/ Listening Session for members’ concerns, questions or comments on this issue.

• Additionally, at Symposium by

the Sea 2021 in August, we will be hosting an EM Workforce Panel with national and statewide leaders. This session will provide updates and leave time available at the end for Q&A discussion.

In the meantime, please share your thoughts with FCEP leadership, your FCEP colleagues on the Doc Matters discussion board, and your national colleagues on the ACEP Workforce discussion board.

Residents can also join the EMRAF Facebook Group discussions.

7

COMMITTEE REPORT

Membership & Professional Development Committee

By Shayne Gue, MD, FAAEM Committee Co-Chair

FCEP leaders work tirelessly throughout the year with targeted advocacy efforts on behalf of emergency physicians and patients across our state. Thanks to our continued efforts, the landscape for the practice of emergency medicine in Florida is among the best in the entire country. However, we must continue to fight back efforts that threaten the safety of our patients: scope of practice expansion for non-physician providers, unfair reimbursements from insurance payors and PIP repeal, while supporting efforts that increase penalties for assault against healthcare providers and COVID liability protections for healthcare professionals.

As we begin to emerge from the global coronavirus pandemic, there are many new struggles we must face. ACEP just completed and released the results of a two-year task force that evaluated the employment market for EM physicians across the country. This data indicates we could have approximately 10,000 “surplus” physicians in the job market by 2030. As daunting as that figure may seem, thankfully, we have the time to correct our course for the future.

As a result, ACEP is working

8

collaboratively with various emergency medicine specialty organizations to tackle this problem head on. The best and brightest minds in our specialty across the country are working together to identify the problems, including the rapid expansion of residency programs (where Florida is leading the country), the continued infringement of non-physician practitioners, and the role of private equity in practice of medicine (and emergency medicine specifically). I trust that when we work together, we can find solutions to take back emergency medicine for the safety and well-being of our patients receiving the most advanced, high-quality care they deserve. If you are interested in getting engaged in the on-going conversations, visit the ACEP Workforce page or feel free to reach out to me directly at shaynegue@hotmail.com.

Although there are many challenges ahead, we must continue to support one another and remember to devote time to personal wellness.

Unsurprisingly, burnout remains on-the-rise as emergency physicians continue to fight on the front lines against COVID-19 while struggling with the aforementioned challenges.

EMpulse Spring 2021

Unfortunately, physician suicide rates continue to climb with as many as 300 physicians dying by suicide each year (learn more here). Recently, our specialty lost another great physician, advocate, and friend to suicide. Dr. Brian Fletcher was a beacon of light in our specialty and a member of our LGBTQ community, who tragically chose to end his own life. So many continue to suffer in silence—please lean on one another for support and help! ACEP offers a myriad of services to promote wellness and resiliency, and every ACEP member has access to three free counseling or wellness sessions (learn more here). Please take advantage of any and all resources available and reach out when you need help. We are in this together, and we will make it through together.

As challenging as the future may seem, I am confident that we will make it out on the other side stronger and better than ever. Emergency physicians are among the best and brightest; I am confident that when we work together, we can overcome these obstacles and create a brighter future for our specialty. ■

COMMITTEE REPORT

Pediatric EM Committee

By Dr. John Misdary, MD, FACEP Committee Co-Chair

Pediatric psychiatric holds have been the norm for years in the emergency department (ED) with a shortage of pediatric beds nationwide.

Unfortunately, the problem has only grown worse during the pandemic.

With schools closed, routines disrupted, and parents anxious over lost income or uncertain futures, children are shouldering burdens that many were unequipped to bear. With the number of hospitalized COVID-19 patients, bed space is even scarcer for these patients. Most states are seeing upwards of a 400% increase in pediatric psychiatric holds. Kids’ mental health-related visits have climbed steadily since the start of the pandemic, according to a recent CDC report. This has created a crisis of its own in pediatrics.

Studies and surveys in Asia, Australia, the U.S., Canada, China and Europe have shown overall worsening mental health in children and teens since the

“

Most states are seeing an upwards of a 400% increase in pediatric psychiatric holds.

pandemic began. In a World Health Organization survey of 130 countries published in October, more than 60% reported disruptions to mental health services for vulnerable people, including children and teens. There are no national studies on pediatric ED wait times for mental health treatment.

According to a recent review published in the journal Pediatrics, small studies show that up to 60% of U.S. children who need inpatient care are boarded in EDs, often with little or no mental health care during those waits.

Shortages of pediatric psychiatrists in some areas and hospital closures in others have worsened the problem and

contributed to rising ED mental health visits. The number of U.S. children’s mental health hospitals dropped from 50 to 38 between 2008 and 2018. The number of U.S. hospitals reporting that they offer any inpatient psychiatric services to adults or children dropped by almost 200 from 2008 to 2018, when the tally was 1,487, according to data from the American Hospital Association.

The ED boarding of pediatric psychiatric patients was a problem prior to COVID that has now become exponentially worse, and a return to the world we knew prior to the pandemic may never occur. The mental health crisis for children during the COVID pandemic has been worse than COVID itself in its effect on the pediatric population worldwide. More resources will need to be allocated soon, or this crisis will turn into a pandemic of its own. ■

Daunting Diagnosis: Q

By Karen Estrine, DO, FACEP, FAAEM

Free Pediatric Emergency Resources

Editor-in-Chief

A 22-year-old male presents to the ED with a status of post GSW to his right chest. The patient’s CXR and chest CT show what findings?

FOR EDs AND EMS AGENCIES

emlrc.org/flpedready

CONTINUE ON PAGE 47 ▶

EMpulse Spring 2021

9

COMMITTEE REPORT

Government Affairs:

Florida Legislative Session 2021

By Blake Buchanan, MD Committee Co-Chair

Photo provided by Dr. Wayne Lee, FCEP past-president 1983-85, from an ACEP Leadership & Advocacy Conference years ago.

Graphic design by Joe Stern

Greetings, and I hope this update finds you well. Emergency Medicine Days 2021 was held virtually this year on April 8-9, 2021, but this remix did not stop us from having a productive and successful Legislative Session.

Session ended on Friday, April 30, and Governor Ron DeSantis has a 15-day window to sign or veto the bills that were successfully passed through the State Legislature. Here is an update on where our priority issues stand:

1) PERSONAL INJURY PROTECTION (PIP) REPEAL - PASSED In the closing hours of Session, the House and Senate signed off on SB 54: Motor Vehicle Insurance, which will repeal Florida’s no-fault personal injury protection (PIP) system and replace it with bodily insurance (BI) coverage in January 2022 if signed into law by Gov. DeSantis.

10

The PIP system assures prompt payment to emergency physicians who provided mandatory care for injured motorists, and especially uninsured motorists. As such, any change in coverage should preserve first dollar coverage for the care we provide.

FCEP worked to ensure that the 2.8 million Floridians without proof of health insurance will be required to purchase or opt-out of Medical Payments coverage, and that the $5,000 physician set-aside would be retained, which is key to assuring liens do not give hospitals priority access to Medical Payment funds.

We succeeded: The final bill mandates Med Pay at both $5,000 and $10,000, with an opt-out in writing. Without an opt-out in writing, the policy reverts to the $10K med pay. Med pay has a $5K 30-day, physician set-aside for emergency care and inpatient care.

2) COVID-19 LIABILITY PROTECTIONS FOR HEALTHCARE PROVIDERS SIGNED INTO LAW In the first part of the legislative session, much of the focus was on bills related to the thing our whole world has centered around the past year: the pandemic. Through a lot of hard work and meetings with legislators and their staff, we witnessed the successful passing of COVID-19 liability protections for healthcare workers.

While many states passed protections against malpractice lawsuits related to COVID-19 early on in the pandemic last year, Florida was one of the holdouts since the legislative session had come to an end and the Governor chose not to take executive action. Thankfully, this has been corrected with passage in both houses and a signature by Governor DeSantis in March.

The bill acknowledges that healthcare

EMpulse Spring 2021

facilities and professionals have a special duty to patients and residents in their care. The bill applies to claims under existing medical malpractice and long-term care laws related to:

• Contracting COVID-19 • Delay/omission in scheduling

surgery caused by the pandemic

• Injuries in emergency care caused by the pandemic

• Treating COVID-19 patients with new or experimental therapies

• Injuries from the exacerbation of pre-existing conditions by COVID-19

Details:

• Plaintiffs who file a COVID-19-

related lawsuit must prove that the healthcare provider’s conduct constituted gross negligence or intentional misconduct.

• Claims must be filed within one

year after the date of death, hospitalization, or first diagnosis of COVID-19. The bill establishes procedures to filter out claims that have insufficient factual support.

• Current law provides different

procedures for negligence claims against nursing homes and assisted living facilities than for other types of healthcare providers, such as doctors and hospitals.

• The bill would take effect upon

becoming a law and applies retroactively, except to defendants named in lawsuits filed before the effective date of the bill.

• The liability protections will

apply until one year after the termination or expiration of the state public health emergency relating to COVID-19, or any nationwide emergency declaration by the federal government; whichever is later.

Claim Requirements:

• Third Party Claims: will require

a physician’s affidavit to support a plaintiff’s claim, i.e. that the plaintiff contracted the coronavirus on the defendant’s premise. Further, the plaintiff must prove the defendant failed to make a good faith effort to comply with applicable government guidance

at the time of exposure. Finally, the plaintiff must prove by clear and convincing evidence that the defendant’s actions were at least grossly negligent.

• Patient Claims: will require the

plaintiff to prove the defendant’s actions were at least grossly negligent. Defendants have an affirmative defense that they followed government guidance.

The court must consider the effects of the COVID-19 pandemic on the standard of care.

3) SCOPE OF PRACTICE EXPANSION FOR ADVANCED PRACTICE PROVIDERS - PASSED FCEP continues to use every fact and resource to oppose unwarranted, unnecessary and unsafe scope of practice expansions. When SB 894: Physician Assistants started off granting PA’s autonomous practice, FCEP and the physician community went to work. Through negotiations and compromise, an amendment removed the autonomous practice language in favor of an “unlimited cap” on the number of PA’s a physician can supervise, before finally settling on the amendment that ultimately passed, which raises the maximum number of PA’s a physician can supervise from four to 10. FCEP fought hard within the physician community to cap this number at six instead of 10 – especially since physicians remain liable for all care provided by their PA’s – but unfortunately, the majority overruled.

Gov. DeSantis has not signed the bill into law yet, and we encourage him not to. Before any more scope of practice expansion bills pass, it is prudent for legislators to evaluate last year’s law based on the intent and promises made, as well as the impact to healthcare.

• What has the new NP law

accomplished? If the goal was to increase access to primary care, did that actually occur?

• If expansion of primary care into rural areas was the intent, are we seeing that outreach? Or are autonomous NPs expanding in wealthy areas, suggesting the push EMpulse Spring 2021

was for NP use in cosmetic clinics and/or independent practice?

• What consideration is being given to the hospital quality of care and physician workforce issues brought about by these changes and the global pandemic?

• What metrics have been or will be established for patient safety, quality and outcomes related to NP or PA expansion goals?

We look forward to hearing the answers to these questions in the next Session, where we anticipate scope of practice expansion bills to make another comeback. If you have any data to provide on this important issue, please contact FCEP now.

4) PELVIC CONSENT LAW PASSED Last year, a bill was passed requiring written consent in lieu of verbal consent for pelvic examinations.

Over the summer, FCEP worked with coalition partners to address some deep concerns with the implementation of this bill.

We asked for a clarification of terms: The language used in the 2020 bill did not align with prior statute and created confusion. The pelvic exam language should track back to s. 395.002(9), which defines emergency treatment and care.

We asked for a general consent form to help avoid delays in care: Getting verbal consent in the ED gave practitioners the opportunity to provide real-time reassurance and education through “casual” conversation. The written consent process puts a halt to the traditional physician/patient medical exam by forcing the practitioner to stop and bring in non-clinician staff with additional forms. A single, general consent specifying that a pelvic may or will be performed should be used as opposed to requiring a separate, unique process for the pelvic examination.

We succeeded, and the new bill:

• Amends, narrows, and simplifies the definition of “pelvic examination”;

Continue on page 12 ▶ 11

◀ Continued from page 11

• Amends current law requiring

written consent for all pelvic examinations performed by health care practitioners and trainees to require written consent for anesthetized or unconscious patients and to require verbal consent from any conscious patient, with exceptions;

• Modifies the current exception

allowing an examination to avert a serious risk of bodily impairment to simply refer to the statute on emergency services and care;

• Adds three new exceptions, thereby

allowing an examination without consent, related to emergency medical conditions, a child protective investigation, and certain criminal offenses against a child; and

• Provides that a single written

consent for a pelvic examination may authorize multiple health care practitioners or students to perform a pelvic examination on a pregnant woman having contractions.

on Wednesday. On Thursday, April 29, the bill authorizing seven new specialty license plates was passed and awaits Gov. DeSantis’s signature.

that by sharing your payment dispute experiences with FCEP and ACEP. This will be a 2022 legislative priority.

We encourage our physicians to utilize the IDR / MAXIMUS process and even take an “opt out” case to court in order to clarify the law.

The work doesn’t stop there, though: At least 3,000 pre-sale vouchers must be sold within 24 months after vouchers become available in order to manufacture the plate. We are confident, however, that we can reach this threshold.

HELP US REACH OUR GOALS

When I first started to get involved in advocacy, a mentor explained to me that in order to get anything accomplished with politicians, you must have two resources: time and money. We use the latter to secure in-person time and events with elected officials or their staff. Please consider donating to the FCEP PAC. Without your help, we cannot be there to represent you in those Tallahassee offices. We are happy to give our time to meet with the legislators, if you give us the chance to get our feet in the door. ■

6) TEEING UP FOR 2022 SESSION: MAXIMUS AND THE INDEPENDENT DISPUTE RESOLUTION (IDR) PROCESS FCEP sought bill sponsors for an IDR fix that would require insurers to participate in the IDR process (through MAXIMUS) this session. Unfortunately, we discovered that our simple fix is not so simple without an agency or court opinion supporting our case.

We continue to make the case to AHCA & OIR, and you can help us do

5) “SUPPORT HEALTHCARE HEROES” LICENSE PLATE Florida has 99 specialty license plates, but none of them honor healthcare workers. We figured there was no better time than during a pandemic to push for a specialty license plate of our own that says: “Support Healthcare Heroes.” All funds raised from this plate (est. $250K annually) will be allocated to the Florida DOH Emergency Medical Services Trust Fund, which provides financial support for EMS and is dwindling due to a steady decline in its current funding source — traffic violation tickets.

We succeeded: FCEP worked with Sen. Gayle Harrell to promote the legislative language that was included in a larger transportation bill. Many specialty license plates were introduced this Session, and as a result, most of them — including ours — were stripped from the SB 676: Specialty License Plates bill by the House on the last Monday of Session. Thankfully, our lobbyist, Toni Large, worked to get our Healthcare Heroes License Plate back into the bill 12

DONATE TO OUR PAC NOW: Text “FCEPPC” to “41444”

EMpulse Spring 2021

or

Donate online at: fcep.org/donate

Join the Envision Physician Services Team in Florida Featured Florida Leadership Opportunities Connect with us to learn how our physician-led and clinician-led company can empower you – no matter the stage of your career.

As scension Sacred Heart Pensacola

St. Lucie Medical Center - FSED

Pensacola

Port St. Lucie

Medical Director

Associate Medical Director

Citrus Memorial Hospital

Osceola Regional Medical Center

Inverness

Orlando

Medical Director

EM Assistant Residency Director

Lake Nona Medical Center Orlando

Medical Director

We thank you for all that you do in serving your communities during the global pandemic.

To view our Covid-19 resources, please visit EnvisionPhyisicianServices.com

Contact us at: Practice@EnvisionHealth.com 844.437.3233 EMpulse Spring 2021

13

COMMITTEE REPORT

EMS/Trauma

By Desmond Fitzpatrick, MD, FACEP Committee Co-Chair

As we reflect upon the one-year anniversary of Covid-19, let us remember how EMS and emergency personnel stood in the face of the unknown to care for patients. We appreciated the displays of gratitude shown early in the pandemic, but I believe the courage and strength of character to persevere this length of time needs to be recognized, as well.

Most people outside of our field will never understand the constant toil and pressure to serve that we in EMS and emergency medicine felt as the world shut down. We were faced with reminders of our work, even during our downtime. Our staff and crews are remarkable, and need to be reminded and treated as such. The “safety net” system is not just a net, but more of a support beam for our society. We need to ensure that we continue to work as one. We must treat each other with respect and kindness so that all of us who make up this “safety beam” of society can continue to be the

strong support the country needs and expects us to be. The next time you are stressed and ready to yell at that crew, medic, doc, nurse, tech, etc. — remember, we are all in this together.

Support each other.

FAEMSMD UPDATES:

Led by the amazing Dr. Chrissy Van Dillen and with updates from State Medical Director Dr. Ken Scheppke, a variety of topics were covered at the latest FAEMSMD and EMS/ Trauma committee meetings. FCEP reminders included online education to meet state requirements, such as the mandatory opioid prescribing training, along with upcoming event announcements such as Symposium by the Sea on August 5-8, 2021.

Highlights from the FAEMSMD Meeting The state has contracted with Quality Improvement Organizations (QIO)

Introducing

faemsmd.org & the Mobilize FAEMSMD Online Community for members only 14

EMpulse Spring 2021

to establish community coalitions to focus on key health issues impacting rural and vulnerable populations. The Florida Hospital Association (FHA) is hosting virtual regional kickoff meetings; see more at AlliantQuality. org.

A shared resource (Google Drive) has been established, and FASEMSMD continues to have immensely valuable weekly meetings followed by Eagles group updates.

Finally, FAEMSMD is excited to announce its new website: faesmsmd. org. Check us out, and if you are an EM resident or EMS fellow, please consider joining FAEMSMD for free through our new Resident/Fellow membership category!

Stay safe, and remember that what you do matters! ■

STAY TUNED FOR NEW FALL 2021 DATES Dear Valued Competition Team Members and Clinical Conference Attendees, Considering all circumstances surrounding the COVID-19 pandemic and the feedback we received, the EMLRC is forced to postpone CLINCON and the Bill Shearer International ALS/BLS Competition, originally scheduled for July 14-16, 2021 at the Caribe Royale in Orlando, FL, to a later date in Fall 2021.

This was not an easy decision for the EMLRC and competition planning committee to make — after all, the Bill Shearer International ALS/BLS Competition has been held in the month of July for decades! But there were numerous and extensive challenges beyond our control that impacted this decision, including:

• The ability of competition teams to receive travel approval and reimbursement to cover hotel and other travel expense

• Three competitions within a 6-week time frame, with our competition falling in the middle • Lack of sponsor support due to COVID-19 consequences that prohibits the EMLRC from providing the hospitality, fun, and top-notch learning experience you all expect and will remember for years to come • The massive financial and emotional impact of this pandemic, which many agencies and personnel are still feeling as we enter the summer conference season

We want to host an amazing event for you and put the pandemic behind us once and for all. But with your health, safety and wellbeing as our top priority, we will continue to make tough decisions that will ultimately protect our participants, industry colleagues and frontline healthcare providers.

Our team is working on rescheduling CLINCON and the Bill Shearer International ALS/BLS Competition right now. Our goal is to provide the same high-quality education, exhibit hall, and social events you have experienced in the past – but with new enhancements and improvements!

Thank you for your continued understanding and support. Stay tuned to social media, email and emlrc.org for updates. ■ EMpulse Spring 2021

15

Advocating for our

Health care heroes

By Mary Mayhew President & CEO of the Florida Hospital Association (FHA)

As of April 5, more than 9.6 million Floridians had received one of the three vaccines authorized for use to protect against COVID-19. In just three months, the state rolled out an unprecedented vaccination effort first to protect health care workers and longterm care residents, and then quickly expanding to include those 65 and older, medically vulnerable individuals, teachers and other school employees, and first responders. Today, every individual age 16 and older is eligible to get vaccinated. These data points matter because they tell the story of concerted, coordinated efforts to get Florida back to school, back to work, and back to family and friends after a devastating year.

The virus, of course, is still with us. It may always be. But, with more advanced treatments and vaccines, more hopeful times are ahead. For all of us who work in health care, our task is to process every experience and lesson learned over the last year and begin to advocate for the changes and investments we need to make Florida the 16

envy of the nation when it comes to best-in-class health care delivery.

This advocacy is essential so that health care – institutions and the workforce – are a priority when it comes to local, state, and federal funding decisions and policymaking through laws and regulations.

At the time of this writing, the Florida Legislature was still in session. When it adjourns April 30, it will do so having crafted a state budget for 2021-2022 under some of the state’s most challenging economic circumstances.

Medicaid enrollment was up 20% in March over the same time last year – a reflection of the pandemic’s impact on employment and the economy overall.

More than 850,000 Floridians became eligible for the program over the course of the pandemic. At the same time, tax revenue was down – again a result of the pandemic’s impact on employment, people’s pocketbooks, and the hospitality and tourism industry.

Throughout the legislative session, our EMpulse Spring 2021

hospitals have consistently stated that now is not the time to cut health care funding and that our health care heroes deserve investment, not cutbacks.

When most of us stayed home and put distance between ourselves and others, hospitals opened their doors even wider, and their physicians, nurses, and so many others stood bravely in front of a new, never-before-seen virus that came with no instructions or manual on how to treat it, minimize its spread, or protect against it. These heroes deserve our gratitude and respect, and they deserve a budget that reflects a strong commitment to health care.

The legislature and the governor committed early in the session to prioritizing COVID-19 liability protection for health care workers. With strong advocacy from many organizations, including the Florida Hospital Association, Safety Net Hospital Alliance, Florida Health Care Association, Florida Medical Association, and Florida College of Emergency Physicians, lawmakers quickly passed, and the governor signed into law, Senate Bill

Thank You, PAC Donors The success of FCEP’s advocacy efforts is dependent upon our ability to fund those efforts. Thank you to the 82 individuals who donated in December 2020 - March 2021: Nadia Ashlee Adside

Henry Hauser

Matthew Apicella

Pedrito Hernandez Perez

Mark G Attlesey Alfonso Luis Ayala Gonzalez Wesley L Baber Ian C. Backstrom

72, to ensure that health care workers are not unfairly subjected to frivolous lawsuits related to COVID-19. This bill was essential not only to acknowledge that the health care system responded to COVID-19 in real-time with ever-changing information and guidance, but also to allow us to focus on the future, applying the lessons learned from the pandemic, and what is needed to shore up infrastructure, equipment, staff, processes, and supply chains for what comes next.

The perspective, experience, knowledge, and voices of every single person who works in health care are absolutely vital for having meaningful and productive conversations about what the health care system needs and for creating policy that supports a strong system that can deliver what Floridians expect and deserve. These conversations need to happen year-round, not only during the handful of months when the Florida legislature meets.

When we work together, we achieve progress and create an even stronger health care system. For all Floridians. ■

James V Hillman Brandy Milstead Hollingsworth Saundra A Jackson Divya James

Mary Elizabeth Schmieder Donna SchutzmanBober Matthew A Schwartz Christopher J Scott Masra Muhammad Shameem

Vincent L Battistini Olivieri

Chang-Woo Jang

Abdul-Aziz Adewale Shittou

Matthew A Beattie

Jonathan E Jones

Daniel Snediker

Evan Bishop-Rimmer

Jonathan Journey

John Caleist Soud

Michael A Borunda

Steven B Kailes

John E Stimler

Jerry Thomas Brooks

Gary Lai

Kendall Alexander Talley

Willie Charles Bruce

Jon E Lamos

Daniel A Thimann

John Bruno

Dakota R Lane

Beatrice C Thomas

Jordan Celeste

Thomas K Leonard

Kristine Thompson

Ethan Adair Chapin

Christopher T Martin

Daryl Maurice Turner

Ian Paul Ciesielski

Michael D McCann

Marko Velickovic

Winston Crowell

Joy McLaughlin

Peter Douglas Webster

Priscilla M Cruz-Menoyo

Daniel McMicken

Ernesto Weisson

Nicholas R Dodaro

Craig R Mitchell

Bruce S Whitman

Alex T Doerffler

Jan Moore

Christina Lucile Wilson

Steven C Eccher

Ryan Nesselroade

Jason Wilson

Simon R Edginton

William David Nimmons

Stephanie K Wood

Emeka Albert

Rhonda C Oeters

Mark Yassa

Beth Harper Ellis

Venugopal Palani

Frederick Todd Yonteck

Avichai Fagan

Rachel Nicole Rendon

Larry S Zaret

Stephen Scott Feilinger Jennifer Fredericks Robert B Fulton Shilpi Ganguly James P Gillen Jesse Glueck Kelvin Harold Brian Scott Hartfelder

EMpulse Spring 2021

DONATE NOW: Text “FCEPPC” to “41444” or Donate online at: fcep.org/donate

17

FEATURE

Two Florida Health Systems Receive SAMHSA Grants to Implement ED Alternatives to Opioids Program

By Natalie Spindle, MS, CHES®

Health Educator, UF College of Medicine – Jacksonville

FAAP, FACEP

FACEP

Assistant Professor, UF College of Medicine – Jacksonville

The number of U.S. deaths and overdoses from opioids continues as a top public health concern, even after the opioid epidemic was declared a public health emergency in 2017.

Legislation limiting opioid prescribing has driven a shift from prescription to illicit use, with increases in synthetic opioid use. This troubling problem has been a key issue for the U.S. Department of Health and Human Services and its agencies like the Substance Abuse and Mental Health Services Administration (SAMHSA).

National and state data indicate an alarming increase in opioid and other substance abuse overdoses and deaths since the beginning of the COVID-19 pandemic. The pandemic is now being referred to as a national relapse trigger.

18

By Phyllis Hendry, MD,

By Sophia Sheikh, MD,

Professor & Associate Chair for Research, UF College of Medicine – Jacksonville

During the height of this pandemic, UF Health Jacksonville and Broward Health emergency departments were selected to receive $2.96 million in funding for the new SAMHSA Emergency Department Alternatives to Opioids Demonstration Program. The purpose of this funding is to develop and implement alternatives to opioids for pain management in emergency settings. Only 10 grants were awarded across the U.S. in the first grant cycle.

UF HEALTH JACKSONVILLE PAMI ED-ALT PROGRAM The Pain Assessment and Management Initiative (PAMI) at the University of Florida College of Medicine – Jacksonville is creating a new patient- and provider-focused pain EMpulse Spring 2021

By Michelle Krichbaum, PharmD

Pain Management Clinical Coordinator, Broward Health Medical Center

management model. The PAMI EDALT project team is a collaboration between emergency medicine, nursing, rehabilitative services, pharmacy and pain management specialities targeting pain conditions such as musculoskeletal and back pain, renal colic, and headaches in adolescents and adults.

The PAMI ED-ALT program includes the implementation of new, comprehensive EMR order panels offering all pharmacologic and nonpharmacologic pain management options in one place and new discharge planning educational materials. New order panels improve providers’ access to a menu of pain management options.

Additional key program components include development of a pain coaching

and educator model program, and implementation of nonpharmacologic toolkits and supply carts. Patient ED-ALT toolkit options include aromatherapy inhalers, virtual reality viewers to use with smartphones, hot and cold gel packs, acupressure devices for headache, deep breathing exercise instructions, pain scale cards, dosing guides, educational materials, and more.

PAMI ED-ALT is the newest addition to the PAMI program founded in 2014 by Phyllis Hendry, M.D., a professor and associate chair for research in the department of emergency medicine, and Sophia Sheikh, M.D., an assistant professor of emergency medicine, medical toxicologist and medical director of the Florida/USVI Poison Information Center – Jacksonville.

Dr. Sheikh is the principal investigator for the SAMHSA PAMI ED-ALT program. PAMI’s overall goal is advancing innovation and safety in pain education, patient care and research.

The project submission was a joint effort with PAMI and the UF Center for Data Solutions, led by Jennifer Fishe, M.D., an assistant professor of emergency medicine and CDS director, along with Jennifer Brailsford, Ph.D., an epidemiology analyst, and Rebecca Liao, data analyst. Co-investigator Kendall Webb, M.D., chief medical information officer, and her team assist with development and implementation of order panels and EMR changes. Ashley Norse, M.D., associate chair of emergency department operations, assists with implementation feedback, education and promotion of project adoption by staff and physicians.

BROWARD HEALTH EDALT PROGRAM

At Broward Health Medical Center (BHMC) and Broward Health North (BHN), the ED-ALT team is focused on patients presenting to the ED with migraine or low back pain, with additional concentration

on patients with low socioeconomic status and/or co-occurring mental health or substance use disorders, or patients living with HIV/AIDS. Evidence-based non-opioid treatment protocols and order-sets were created by the multidisciplinary team of Michelle Krichbaum, PharmD; Neil Miransky, DO; Martina Holder, PharmD, BCPS; Evan Boyar, MD, MSE, FAAEM and Julie Aristyld, MSW, MPA. Treatment options in the migraine order set include fluids, acetaminophen, oral and parenteral NSAIDs, abortifacients (sumatriptan or dihydroergotamine), and antiemetics with efficacy in migraine pain. Treatment resistant options include parenteral magnesium, valproic acid, dexamethasone and haloperidol. Non-opioid treatments in the low back pain order set include oral, parenteral and topical analgesics,

muscle relaxants, gabapentin for neuropathic pain, and trigger point injections.

The order sets include guidance for escalation of treatment on presentation, symptomology and progression. Additionally, both order sets have relevant laboratory and radiology orders, as well as optional referrals to neurology, psychiatry or pain management. The order sets also include standard referrals to the pharmacy team and social worker.

To date, the team has trained 145 providers on the new protocols and impacted 67 patients with the use of new panels. Using baseline data from 2019 and 2020, the team found that opioid prescribing for patients with low back pain or migraine treated with the new pain management protocols has been reduced. ■

PICTURED: Opening photo: University of Florida College of Medicine – Jacksonville Pain Assessment and Management Team Representatives Top right photo: Broward Health Medical Center ED-ALT team: Michelle Krichbaum, PharmD and Neil Miransky, DO Bottom right photo: Broward Health North EDALT team: Martina Holder, PharmD, BCPS and Evan Boyar, MD, MSE, FAAEM

EMpulse Spring 2021

19

CASE REPORT

An unrecognized opportunity to diagnose Hepatitis C Virus (HCV) and decrease transmission in people who inject drugs (PWID) Fig. 1. Right forearm puncture wound and surrounding erythema

ABSTRACT

By Heather Henderson, MA, CAS

By Jason Wilson, MD, FACEP, FAAEM

By Kaitlyn Pereira, BS

20

This is a case of a 47-year-old patient who injects drugs (PWID) that presented to the emergency department (ED) with a right arm cellulitis and was diagnosed with acute hepatitis C virus (HCV) seroconversion. The patient presented during a window phase with a negative HCV Ab but detectable HCV RNA PCR. Identification of patients with HCV in PWID decreases viral transmission and provides opportunities for linkage to care, leading to improved rates of sustained virologic response (SVR)1. The HCV screening algorithm2 may not capture all opportunities for diagnosis in high pretest probability PWID patients during ED encounters. In patients at high risk for acute seroconversion (testing prior to time to mount antibody response), an under-recognized window phase may lead to a false negative classification of HCV status. Thus, when testing high pretest probability patients for HCV, providers should consider ordering a HCV RNA even if the HCV Ab is nonreactive. Routine screening for HCV did not identify the infection because the EMpulse Spring 2021

patient had not yet seroconverted.

Studies have shown3,4,5 that ordering an HCV RNA PCR may uncover previously unidentified HCV infections in PWID. Earlier detection of HCV status in patients during acute seroconversion may lead to decreased transmission of HCV in needle sharing networks, as well as improved chances of linkage to care for treatment and increases chances of obtaining SVR by 26%.6

INTRODUCTION

Persons who inject drugs (PWID) represent most people with hepatitis C virus (HCV), as intravenous drug use (IVDU) has become the primary route of HCV transmission.1,7 Identification of patients with HCV decreases transmission throughout PWID needle sharing networks and provides opportunities for linkage to care and treatment that can lead to sustained virologic response (SVR) through the use of direct acting antivirals (DAA) which are 95% effective even among PWID.8 The HCV screening algorithm, which does in-

clude the emergency department (ED) as a potential place for HCV screening,2 may not capture all opportunities for diagnosis in high pretest probability PWID patients during ED encounters.

In addition, PWID are higher utilizers of the ED compared to non-PWID,9 presenting an opportunity for HCV testing that may alter the epidemiology of comorbid disease (HCV and injection and drug use) through early detection.

Early detection may lead to decreased needle sharing related HCV transmission and improve the rates of sustained virologic response (SVR) through linkage to care and DAA initiation.

NARRATIVE

A 47-year-old man with a history of intravenous drug use (IVDU) presented to the ED with a 1cm puncture wound surrounded by 3cm of erythema and induration on the right forearm (Figure 1). Initial vital signs in the ED were unremarkable and remained stable during the ED course. Following CDC guidelines,2 routine screening for HCV was completed during the ED encounter, and the HCV Ab was non-reactive.

A complete metabolic panel (CMP) was also obtained and demonstrated an AST of 393 U/L (5 – 34 U/L) and an ALT of 324 U/L (5 – 55 U/L). The patient was diagnosed with a right forearm cellulitis. As part of a laboratory panel to test for hepatitis A and hepatitis B, the HCV Ab immunoassay was repeated. All of these antibody immunoassays were non-reactive. However, given the high pretest probability for acute seroconversion of hepatitis C in the context of IVDU with transaminitis, an HCV RNA PCR was ordered to test for the presence of quantifiable virus.

The patient was admitted secondary to several other concomitant metabolic abnormalities, including acute kidney injury and hyponatremia, providing an opportunity to follow the HCV RNA PCR results during the hospital course.

Typically, an HCV RNA PCR is only obtained in the setting of a reactive HCV Ab.2 The HCV RNA PCR identified 111,677 copies of the virus. On a subsequent ED encounter two months later, the patient was found to then have a reactive HCV Ab and 10,502,710 copies of HCV detectable via RNA PCR. HBV Ab was also reactive on the subsequent

encounter and 31,946 copies of HBV were identified.

DISCUSSION

A patient with known IVDU presented to the ED during the acute seroconversion phase of a newly acquired HCV infection. Routine screening and a hepatitis panel failed to detect the HCV antibody, while a PCR test did quantify a detectable level of HCV RNA. The patient presented during a window phase in which HCV RNA was detectable, but the HCV Ab was still non-reactive.

The current CDC HCV algorithm is a screening algorithm.2 ED patients may present with higher pretest probability for disease. HCV RNA testing in PWID leads to earlier detection, status notification, linkage to care and subsequent SVR, as well as decreased HCV transmission in needle sharing networks. In a cohort of 32 people, one PWID with chronic HCV transmitted the virus to 30 additional users in the same social group within a span of six months,10 and chances of contracting HCV per needle sharing event are roughly 57%.

This case represents a patient with HCV that could have been missed due to presentation during the window of seroconversion, suggesting that providers should consider ordering an HCV RNA by PCR if the patient is being tested for HCV with high pretest probability for disease (e.g., PWID).

Test turnaround time (TAT) for the HCV viral load represents a current barrier of clinical implementation of this strategy as many facilities cannot return an HCV RNA result during the ED encounter. Thus, the result may become available during hospitalization, or short-term follow up should be arranged for further PCR testing (if the HCV Ab is non-reactive and the patient has high pretest probability for HCV, but HCV RNA is not ordered in the ED) or to receive test results (if HCV RNA PCR is ordered in the ED, but not available during clinical encounter). In the future, an ability to detect HCV RNA in a serum sample during an ED encounter (e.g., rapid point-of-care viral load testing) may facilitate wider adoption of an important strategy as HCV prevalence will continue to increase during the ongoing opioid epidemic in the United States. ■

EMpulse Spring 2021

REFERENCES 1. Shiffman ML, Gunn NT. Impact of hepatitis C virus therapy on metabolism and public health.

Liver Int. 2017. doi:10.1111/ liv.13282 2. Testing for HCV Infection: An update of guidance for clinicians and laboratorians. MMWR 2013; 62. Early Release.

3. Bargiacchi O, Audagnotto S, Garazzino S, De Rosa FG. Treatment of acute C hepatitis in intravenous drug users. J Hepatol. 2005. doi:10.1016/j. jhep.2005.03.010 4. Judd A, Hickman M, Jones S, et al. Incidence of hepatitis C virus and HIV among new injecting drug users in London: prospective cohort study.

Br MeD J. 2005; doi:10.7748/ phc.16.2.8.s10 5. Edlin, Brian R et al. Managing Hepatitis C in Users of Illicit Drugs. Curr Hepat Rep. 2007. doi:10.1007/s11901-007-0005-8 6. Calner, Paul et al. HCV screening, linkage to care, and treatment patterns at different sites across one academic medical center. PloS one. 2019. doi:10.1371/journal.pone.0218388 7. Harder, J., Walter, E., Riecken, B., Ihling, C., Bauer, T. 2004.

Hepatitis C virus infection in intravenous drug users.

Clin Microbiol Infect.

2004. doi:10.1111/j.14690691.2004.00934.x 8. Grebely, J., Dalgard, O., Conway, B., Cunningham, E., Bruggmann, P., Hajarizadeh, B. 2018. Sofosbuvir and velpatasvir for hepatitis C virus infection in people with recent injection drug use (SIMPLIFY): an open-label, single-arm, phase 4, multicentre trial.

Lancet Gastroenterol Hepatol.

2018. doi:10.1016/S24681253(17)30404-1 9. Fairbairn N, Milloy MJ, Zhang R, et al. Emergency department utilization among a cohort of HIV-positive injecting drug users in a Canadian setting. J Emerg Med. 2012. doi:10.1016/j. jemermed.2011.05.020 10. Henderson, H. 2018. “I am More Than my Addiction”: Perceptions of Stigma and Access to Care in Acute Opioid Crisis. (Master’s Thesis). University of South Florida, Tampa, Florida. Available from ProQuest Dissertations and Theses A&I database (UMI No. 10784265).

21

Introducing Flor ida’s

EMERGENCY MEDICINE RESIDENT

CLASS OF 2024 Match Day Lists provided by Residency Program Staff Edited by Samantha League, MA

Orlando Health

UF Gainesville Montana Cole, MD

Univ. of Virginia School of Medicine

Laksmy Castillo, MD

USF Morsani College of Medicine

Michael D’Angelo, MD Katherine Dong, MD

FSU College of Medicine - Ft. Pierce Campus

UCF College of Medicine

Louisiana State Univ. School of Medicine in Shreveport

Tufts Univ. School of Medicine

Lake Erie College of Osteopathic Medicine

Technion Israel Institute of Technology Ruth and Bruce Rappaport Faculty of Medicine

FIU Herbert Wertheim College of Medicine

Univ. of Illinois College of Medicine

Western Michigan Univ. School of Medicine

Midwestern Univ. Chicago College of Osteopathic Medicine

FSU College of Medicine Sarasota Campus

Univ. of California, San Francisco School of Medicine

Univ. of Alabama School of Medicine

Lake Erie College of Osteopathic Medicine

Univ. of Texas Southwestern Medical School

Univ. of Illinois College of Medicine - Peoria

Aventura Amit Boukai, MD

Elise Clark, DO

Vincent Grekoski, DO

Erik-Jon Hammond, DO

USF Morsani College of Medicine

Lauren Dawn, MD

Matthew Hanley, MD Paula Kreutzer, MD Kendra Maple, MD

Lenexa Morais, MD

Vincent Battistini Olivieri, MD

Nazmul Hasan, MD Juhi Varshney, MD

Francesca Rios, MD Makena Owen, MD

Kansas City Univ. College of Osteopathic Medicine

Univ. of Texas Medical Branch School of Medicine

California Northstate Univ.

College of Medicine

Temple Univ. Lewis Katz School of Medicine

FSU College of Medicine Sarasota Campus

Drexel Univ. College of Medicine

Daniel Klein, MD

Leon Nguyen, DO

Michelle Nguyen, MD

Chinedum Onyeka, MD

Midwestern Univ. Arizona College of Osteopathic Medicine

Augusta Univ. Medical College of Georgia

New York Institute of Technology College of Osteopathic Medicine

Wayne State Univ. School of Medicine

Katherine O’Neil, DO Akash Patel, DO

Aaron Panicker, MD Ridhi Patel, MD

NSU Dr. Kiran C. Patel College of Osteopathic Medicine

Univ. of Virginia School of Medicine

Medical Univ. of South Carolina College of Medicine

Kansas City Univ. College of Osteopathic Medicine

Matthew Reeves, MD

Christian Ryckeley, MD

Univ. of North Carolina at Chapel Hill School of Medicine

Steven Shapiro, DO

Ina Sandeli, DO

Justin Sauter, DO

Kansas City Univ. College of Osteopathic Medicine

Matthew White, MD

Touro College of Osteopathic Medicine - New York

Medical Univ. of South Carolina College of Medicine

Midwestern Univ. Arizona College of Osteopathic Medicine

FAU Charles E. Schmidt College of Medicine

Bret Winners, DO

22

Grace Brown, MD

UM/Jackson Memorial

Whitney Winslow, MD

Lilien Socorro, MD

Rachel Armstrong, MD

Northwestern Univ. Feinberg School of Medicine

Courtney Petersen, MD

Univ. of South Carolina School of Medicine

Erin Smith, MD

Boston Univ. School of Medicine

Kunal Nath Agarwal, MD Univ. of Virginia School of Medicine

Jameson Christopher Tieman, MD

Sean Hire, DO

Katelyn King, MD

Graham Kirchner, MD Madison Miracle, MD UF College of Medicine

Tyler Moriarty, MD

FSU College of Medicine

Nathan Nuzman, MD

Texas A&M College of Medicine

Jeffer Pinzon, MD

Morehouse School of Medicine

Anna Rogers, MD

Louisiana State Univ. SOM in Shreveport

Opal Sekler, MD

Tel Aviv Univ. Sackler School of Medicine

Deborah Shimshoni, MD UCF College of Medicine

Max Sunoo, MD

Univ. of Hawaii John A. Burns School of Medicine

Joseph Thompson, MD

Univ. of Texas at Austin Dell Medical School

Univ. of South Carolina School of Medicine

Louisiana State Univ. School of Medicine in Shreveport

Wayne State Univ. School of Medicine

Jenna Mailhes, MD Regina Martinez Lorenzo, MD

Univ. of Minnesota Medical School

EMpulse Spring 2021

Jourdan Vann, MD

Edgardo Velez, MD

Ponce Health Sciences Univ.

David Weatherford, MD Univ. of South Carolina

USF at Oak Hill Hospital Ann Marie Fugarino, MD St. George’s Univ. School of Medicine

Chelsea Lynn Grant, MD

St. Lucie Medical Center Daniel Basselgia, DO Liberty Univ. College of Osteopathic Medicine

Jacob Berg, DO

A.T. Still Univ. - School of Osteopathic Medicine in Arizona

Richard Lardner, DO

New York Institute of Technology College of Osteopathic Medicine

Kara Mann, DO

FSU College of Medicine Pensacola Campus

Jeffery William Holloway, II, MD

Univ. of Missouri-Columbia School of Medicine

BY THE

NUMBERS

Asher Horowitz, MD

Univ. of Texas Southwestern Medical School

206

Toan Minh Tran, DO

Alabama College of Osteopathic Medicine

Kimberly Nicole Wolfe, DO Philadelphia College of Osteopathic Medicine

incoming residents

Edward Via College of Osteopathic Medicine - Auburn

Brian Overman, DO

UF Jacksonville

Stephen Rodriguez, MD

Blake Autry, DO

Edward Via College of Osteopathic Medicine - Auburn Univ. of Texas Southwestern Medical School

69 DO’s

Edward Via College of Osteopathic Medicine-Carolinas

Julia Buddendorff, MD UF College of Medicine

Kendall Regional Medical Center Laureana Andrade Vicenty, MD

Jeffrey Downen, MD

USF Morsani College of Medicine

Zackary Funk, MD

UF College of Medicine

Alexander Howard, MD

Brown Univ. Warren Alpert Medical School

Univ. of South Carolina School of Medicine Greenville

FSU College of Medicine

Morehouse School of Medicine

UF College of Medicine

Philadelphia College of Osteopathic Medicine

Conley Diaz-Gomez, MD Miguel Gil, MD

Erik Edward Grodus, MD

Universidad Central del Caribe School of Medicine

Olivia Igoe, DO

Alexander Kelly, MD

Meghan McCallister, MD FSU College of Medicine

Alexa Peterson, DO

Kansas City Univ. College of Osteopathic Medicine

NSU Dr. Kiran C Patel College of Osteopathic Medicine

Louisiana State Univ. School of Medicine

Univ. of Arkansas College of Medicine

Midwestern Univ. Arizona College of Osteopathic Medicine

Rocky Vista Univ. College of Osteopathic Medicine

Zucker School of Medicine

FSU College of Medicine

Univ. of Texas

Creighton Univ. School of Medicine

Andrea Popa, MD

Christine Evette Sayegh, DO Nathan Murray, MD

Thanh Van Mai Nguyen, MD Daryl Turner Jr., DO Liberty Univ. College of Osteopathic Medicine

Alan Wild, DO

Alabama College of Osteopathic Medicine

137 MD’s

Hunter Lively, DO

COMING FROM:

Jeanne Rabalais, MD Jessica Restad, DO

139

Bryan Salvato, MD

Alexa Sughroue, MD Eric Tizzard, MD

Louisiana State Univ. School of Medicine in New Orleans

Out of State

Malcolm Velasco, MD

Mercer Univ. School of Medicine

EMpulse Spring 2021

48

Florida

15

Caribbean Other Countries

Continue on next page ▶ 23

AdventHealth East Orlando Shannon Caliri, DO

Univ. of Pikeville - Kentucky College of Osteopathic Medicine

Eli Edward Johnson, DO

New Mexico State Univ. Burrell College of Osteopathic Medicine

UCF at Ocala Regional Thomas Alterman, MD

Univ. of Texas Medical Branch School of Medicine

Alexander Huttleston, MD

Tyler Littmann, DO

Univ. of Queensland School of Medicine

Stefania Markou, DO

Univ. of Texas Medical Branch School of Medicine

Lake Erie College of Osteopathic Medicine Lincoln Memorial Univ. - DeBusk College of Osteopathic Medicine

Jessica Lauren Rose, DO

NSU Dr. Kiran C. Patel College of Osteopathic Medicine

Melissa Sayegh, DO

New Mexico State Univ. Burrell College of Osteopathic Medicine

Morgan Killian, MD

Emily Macauley, MD

UCF College of Medicine

Brian Tan, MD

Mercer Univ. School of Medicine

Rohan Wanchu, MD

Oregon Health & Science Univ.

School of Medicine

Cynthia Wang, MD

USF Morsani College of Medicine

USF at Brandon Regional Stanley Budzinski, MD

Lincoln Memorial Univ. - DeBusk College of Osteopathic Medicine

Conner Daugherty, DO

Lake Erie College of Osteopathic Medicine

Brian Evans, MD

USF Morsani College of Medicine

Mathew Hagen, DO

Alabama College of Osteopathic Medicine

Henry Hauser, MD

USF Morsani College of Medicine

Austin Kennedy, MD

UCF College of Medicine

Charles Needham, DO

Lake Erie College of Osteopathic Medicine

Hien Nguyen, DO

Alabama College of Osteopathic Medicine

Richard Taft Peterson, DO

A.T. Still Univ. Kirksville College of Osteopathic Medicine

Mostafizur Rahman, MD

Michael Ament, DO

AT Still Univ. School of Osteopathic Medicine in Arizona

Emily Cloessner, MD

USF Morsani

Mariah Cruz, DO

Campbell Univ. Jerry M. Wallace School of Osteopathic Medicine

Cameron Grossaint, DO

Univ. of South Carolina – Greenville

Asahi Hossain, MD

Albert Einstein College of Medicine

Medical Univ. of South Carolina College of Medicine Edward Via College of Osteopathic Medicine—Virginia Burrell College of Osteopathic Medicine USF Morsani College of Medicine

Katie Johnson, DO

Univ. of Pikeville Kentucky College of Osteopathic Med.

Adriana Padilla, DO

Burrell College of Osteopathic Medicine

Christopher Sowers, MD

Virginia Commonwealth Univ.

School of Medicine

Andrew Arteaga, DO

Edward Via College of Osteopathic Medicine - Carolinas

Alexander Deri, MD

Texas Tech Univ. Health Sciences Center School of Medicine

Orange Park Medical Center Paul Bissmeyer, DO

Danny Gersowsky, DO

Kansas City Univ. College of Osteopathic Medicine

Salil Phadnis, MD

St. George’s Univ. School of Medicine

Philadelphia College of Osteopathic Medicine

USF Morsani College of Medicine

Bailey Pierce, MD

FAU Charles E. Schmidt College of Medicine

Christian Schuetz, MD

USF Morsani College of Medicine

David Gomez, MD

Jasmine Dennis, MD Nabi Ferra, MD

Luke Furtak, MD

USF Morsani College of Medicine

Samuel Harris, MD

USF Morsani College of Medicine

Daniel Mbom, MD

Medical College of Georgia

Amanda Priddy, MD

USF Morsani College of Medicine

Lorena Rodriguez-Perez, DO Nova Southeastern Univ. College of Osteopathic Medicine

Jennifer Shin, MD

Albert Einstein College of Medicine

Alexander VanFleet, MD FSU College of Medicine – Daytona Beach

Ashley Frost, MD Edward Hu, MD

Univ. of Illinois College of Medicine

Adrian Huffard, MD

FSU at Sarasota Memorial Jonathan Baird, DO

Indiana Univ. School of Medicine

Univ. of Pikeville - Kentucky College of Osteopathic Medicine

Alabama College of Osteopathic Medicine

West Virginia Univ. School of Medicine

Oakland Univ. William Beaumont School of Medicine

Rocky Vista Univ. College of Osteopathic Medicine

William Kantrales, DO

Mount Sinai Medical Center

Autumn Bass, DO

Kelsey Leonard, MD

Brandon Nielsen, DO

Seth Capehart, MD Danielle Glaze, DO

Roger “Casey” Kelly, DO

George Washington Univ. School of Medicine

FIU Herbert Wertheim College of Medicine

Rocky Vista Univ. College of Osteopathic Medicine

Alabama College of Osteopathic Medicine

West Virginia School of Osteopathic Medicine

Univ. of Virginia School of Medicine

Oakland Univ. William Beaumont School of Medicine

NSU Dr. Kiran C. Patel College of Osteopathic Medicine

Edward Via College of Osteopathic Medicine - Virginia

FIU Herbert Wertheim College of Medicine

Edward Via College of Osteopathic Medicine—Virginia

Campbell Univ. Jerry M. Wallace School of Osteopathic Medicine

Lincoln Memorial Univ. - DeBusk College of Medicine

Philadelphia College of Osteopathic Medicine

Edward Via College of Osteopathic Medicine—Carolinas

Lake Erie College of Osteopathic Medicine

Alabama College of Osteopathic Medicine

Renaissance School of Medicine

Rocky Vista Univ. College of Osteopathic Medicine

Liberty Univ. College of Osteopathic Medicine

NSU Dr. Kiran C. Patel College of Osteopathic Medicine

Luke Weber, MD

Univ. of Wisconsin School of Medicine and Public Health

St. George’s Univ. School of Medicine

Micaela Ramsey, DO Brett Riddle, DO

Thomas Tchir, MD

Barbara Van De Water, DO Salvatore Vassallo, DO

24

Florida Atlantic University

UCF at North Florida Regional

Alan Li, MD

Ramses Perez, MD Luis Puron, DO

Christopher Raciti, MD Alejandro Sanoja, MD Univ. of Arizona

Northeast Ohio Medical Univ.

Madelyn Nygren, MD

Elizabeth Piwowarski, DO Rachel Sealby, DO Dillon Smith, DO

Michael Wakely, MD

EMpulse Spring 2021

Michael Lai, DO

Amanda Locklear, DO Brian Merritt, DO

George Nackley, DO

Eduardo Pestana, MD

20

INAUGURAL CLASS

Memorial Healthcare System Kevin Abadi, MD

FAU Charles E. Schmidt College of Medicine

Francisca Aguilar, DO Rowan Univ. School of Osteopathic Medicine

Matthew Bidwell, MD

St. George’s Univ. School of Medicine

Eduardo Diaz, DO

NSU Dr. Kiran C. Patel College of Osteopathic Medicine

INAUGURAL CLASS

Ross Univ. School of Medicine

Broward Health

American Univ. of the Caribbean School of Medicine

American Univ. of Antigua College of Medicine

St. George’s Univ. School of Medicine

American Univ. of Antigua College of Medicine

Ben-Gurion Univ. of the Negev Faculty of Health Sciences

Univ. of Queensland School of Medicine

Rocky Vista Univ. College of Osteopathic Medicine

Sidney Kimmel Medical College at Thomas Jefferson Univ.

Sarah Eldin, MD

Steven Gayda, MD

Joris Hoogendoorn, MD Daniel Levi, MD

Jesse Shulman, DO

Rolando Zamora, MD

St. George’s Univ. School of Medicine

UCF of Greater Orlando

Ahmed Abd El Aziz, MD Olyn Andrade, MD Peter Ayoub, MD

Jason Beiriger, MD, MBA Jean-Dominique Foureau, MD

American Univ. of the Caribbean School of Medicine

Matthew Holme, MD

American Univ. of the Caribbean School of Medicine

Areeba Imam, MD

Abigail Alorda, MD

FIU Herbert Wertheim College of Medicine

Taylor Cesarz, MD

Loyola Univ. Chicago Stritch School of Medicine

Natalie Diers, MD

Warren Alpert Medical School of Brown Univ.

Robert Pell, MD

Creighton Univ. School of Medicine

Univ. of Toledo College of Medicine Univ. of Wisconsin School of Medicine and Public Health St. George’s Univ. School of Medicine UCF College of Medicine

Abdallah Jaber, MD Noah Lubin, MD

Thomas Mroz, MD

Lauren Murray, DO

Alexa Ragusa, DO

Lake Erie College of Osteopathic Medicine

Bridget Scheveck, MD

USF Morsani College of Medicine

FAU Charles E. Schmidt College of Medicine

Univ. of Wisconsin School of Medicine and Public Health

American Univ. of Antigua College of Medicine

NSU Dr. Kiran C. Patel College of Osteopathic Medicine

Mitchell Voter, MD

ACGMEaccredited emergency medicine residency programs

Joseph Pisa, MD Maria Saba, MD

EMpulse Spring 2021

Distribution of incoming residents by region:

49

NORTH

40

WEST

Jacksonville Ocala Orange Park Gainesville

Brandon Brooksville Sarasota Tampa

38

79

CENTRAL Orlando Kissimmee

SOUTH

Aventura Boynton Beach Ft. Lauderdale Miami Miami Beach Pembroke Pines Port St. Lucie

25

COMMITTEE REPORT

EMRAF President’s Message

By Elizabeth Calhoun, MD, PGY-2 Committee Chair

As we complete another academic year, I want to congratulate our Florida EM residency programs on their resident matches. Meet the 206 new emergency medicine residents in Florida here. Congratulations to all!

Now, maybe more than ever, incoming and outgoing residents are carrying concerns about Florida’s emergency medicine job market, affected by both the pandemic and the recent increase in residency programs within the state, even

sparking dialogue on the FCEP DocMatter Discussion board. To my fellow residents, know that ACEP and FCEP are aware of these concerns and working to address residents’ needs. FCEP is also constantly active in the legislature, represented by our lobbying team in Tallahassee through FCEP and on a national level, to protect provider compensation and quality of emergency care for our patients.

EMRAF has a new Facebook group for its members. Please click here

to join and help us make this an active forum for Florida’s many EM residents. Don’t forget to mark your calendars for FCEP’s annual meeting and conference, Symposium by the Sea, on August 5-8, 2021 in Naples, FL and stay tuned for announcements about the Life After Residency event for PGY-3s in the fall. These are a few of the many ways your resident involvement remains a vital component of our statewide EM community. ■

COMMITTEE REPORT

Medical Student Council

By Dan Schaefer, MPH, MS-3

Secretary-Editor, FSU College of Medicine

Hello from the FCEP Medical Student Council (MSC)! We have been collaborating with the many Emergency Medicine Interest Groups (EMIGs) in our wonderful state on how they are addressing their students’ emergency medicine needs and activities during the pandemic. The EMIGs have had skills workshops in COVID-friendly outlets, Zoom series with EM subspecialties, and residency panels for

26

the up and coming emergency physicians! Our quarterly meetings during the pandemic have been very helpful for the EMIGs to bounce ideas off of each other on how to best address social distancing precautions while simultaneously ensuring the safety of medical students. They have really gone above and beyond in helping their students.

EMpulse Spring 2021

The FCEP MSC will soon be transitioning to a new group of officers, so we would like to remind everyone to keep an eye out for applications for those positions in the upcoming weeks.

Although EM Days was virtual this year, we hope to be able to see all of you at Symposium by the Sea on August 5-8, 2021! ■

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

Florida Atlantic University

By Tony Bruno, DO, PGY-1 Winter has come and gone as we enter spring here in South Florida. While the cool temperatures were great, we look forward to longer beach days. Our FAU EM family has continued to grow. It’s hard to believe the match has already come and gone. We want to extend a big congratulations and welcome to all of our incoming residents.

We have several more additions to announce: congratulations to Dr. Spencer Greaves, PGY-2 and his wife, who had a baby boy, Charles Greaves, and to Dr. Thomas Peterson, PGY-2 and his wife, who also had a baby boy, Santiago Peterson. We’re excited to have them as part of our family.

During one of our beautiful spring days, we had our first inaugural Sim-

SOUTH FLORIDA ulation Olympics. We would like to give a big thank you to Dr. Hughes and everyone else who helped make this day a success. Events included various relay races with a variety of common procedures performed in the ED mixed with field day games.

We are very happy to announce a partnership with the medical students in the emergency medicine interest group at FAU. Within this group, we have

started a mentorship program and have also begun virtual as well as in-person learning and skills sessions.

We have continued our research with Dr. Spencer Greaves, PGY-2, who is planning to give an oral presentation at SAEM in May entitled, “Fluorescent Tracer in Personal Protective Equipment Training in the Era of Coronavirus Disease.” ■

AdventHealth East Orlando

By Tyler Mills, DO, PGY-2 CENTRAL FLORIDA Hello again from all your EM friends at AdventHealth! Visit our ED and you will notice that it’s still a consistent 71 degrees and fluorescent. However, the department and the people seem different: smiles are bigger because it’s summertime. Interns have hit their stride and have bonded as a class. All the residents and ED staff appear closer now than they were a few months ago—and it has nothing to do with new CDC guidelines. There is renewed optimism and energy from both the continued vaccine rollout and the arrival of summer. As we approach the end of a memorable academic year that was full of unique challenges, we are grateful for each other and our health.

We also have a lot to look forward to and celebrate. Since our last update, we celebrated two births: congratulations to Dr. Haus and Dr. Hoer on the newest additions to their families.

On the academic front, the year boasted academic achievements from residents in every class. Since our last update, multiple residents, including at least one from each class, presented at ACOEP’s Spring Seminar. We also announced the creation of the Advent EM Podcast and began researching and recording for initial episodes. We continue to be impressed by this group’s level of engagement in both academic production and extracurricular activity.

Despite limitations on away rotations, our record application cycle in 2020 was followed by another, seeing even more applicants and conducting more interviews for 2021. Thank you to all the EM applicants for their interest in our program—we enjoyed meeting each of you and learning about your unique journeys to emergency medicine.

Everyone is eager to meet the new intern class and welcome them to the EMpulse Spring 2021

family. To all of this year’s applicants and students: congratulations, and we wish you all the best in your future endeavors!

Sadly, this time of year means saying goodbye to our seniors. In addition to securing the most fellowships in recent memory, this class will be remembered as one that always supported one another. They were a close group that eagerly embraced the challenge of teaching interns and medical students early in their second year. Dr. Muniz accepted a position in Daytona. Drs. Janevski and Coello have both accepted positions in Ohio as an attending physician and for an EMS fellowship, respectively. Drs. Risovas, Lawyer and Cartaya will all remain in Central Florida for ultrasound fellowships next year. We are proud of our seniors and will miss them next year. Stay cool and stay safe. ■ 27

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

UF Gainesville

By Megan Rivera, MD, PGY-1 NORTH FLORIDA

UCF at North Florida Regional

By Jayden Miller, MD, PGY-1 We are just a few months into 2021, yet have so many exciting things to share.

First, we would like to congratulate one of our core faculty members and medical director, Dr. Gary Gillette, on concluding his year as Chief of Staff during one of the most difficult times in the history of our specialty. Dr. Gillette will continue to be very involved this year with his new role as past Chief and, as always, continue to be a true administrative exemplar and mentor for our residency. We also want to recognize and congratulate some familiar faces on their new titles: Drs. Diana Mora and Tom Bentley as Associate Program Directors, and Drs. James Lee, Marcos Marugan-Wyatt and Andrew Nicholas as Chief Residents.

Our PGY-2s just returned from their class retreat where they discussed QI projects, community service and transitioning to being a PGY-3. Several wellness activities were also scheduled, one of which was a 3-hour ropes course! Several of our senior residents, led by Program Director Dr. Robyn Hoelle and faculty members Drs. Dakota Lane and Mahesh Setty, will be publishing an upcoming chapter in the Healthy Aging and Longevity series in the volume “Redox Signaling and Biomarkers in Aging,” set for publication in January 2022. The chapter will discuss the clinical applications of redox biomarkers in the acute setting with a focus on the geriatric population. Contributors to the chapter include resident Drs. Anthony DeRenzi, James Lee, Jyoti Das and Mollie Powell.

Lastly, it wouldn’t be a NFEM update if we didn’t mention ultrasound! We are thrilled to announce that we officially have two ultrasound fellows, Drs. Joshua Middleton and Mollie Powell, set to start this July for our new ultrasound fellowship. ■ 28

NORTH FLORIDA Spring is finally upon us! This marks one year since the pandemic began, and what a year this has been. It’s hard to believe that we were all learning about this novel coronavirus just one year ago, and how all of our lives have been impacted in this short time.

We are full of excitement, however, as all residents had the opportunity to get their first vaccination dose before the holidays and received both vaccination doses shortly into the new year. Although not out of the COVID woods yet, we are finally beginning to get a taste of normalcy. We are back to in-person conferences, and although we are socially distancing, it is so nice to be back together again.

We’re shuffling the deck here at UF and have several congratulations to make!

First and foremost, we would like to give a bittersweet congratulations to Dr. Marie-Carmelle Elie, who will be assuming the role as Chair of Emergency Medicine at the University of Alabama at Birmingham. Dr. Elie has been one of the most gifted educators our department has seen and a favorite among residents for years. Dr. Elie will certainly be missed, and we wish her nothing but success in her new endeavor. Dr. Guiliano De Portu is taking his talents from Assistant Program Director to our new Ultrasound Fellowship Director. Dr. De Portu was the first ultrasound fellow here at UF years ago, and we cannot wait to see what new heights he will take our ultrasound curriculum and fellowship to. Dr. Caroline Srihari will be assuming her new position as Assistant Program Director.

Dr. Srihari is incredibly popular among all residents and we cannot think of someone more deserving. And finally, a huge congratulations to our new

EMpulse Spring 2021

chiefs: Drs. Borobia, Clifford and Mysore! Our outgoing chiefs, Drs. Fisher, Purcell and Williams did an incredible job navigating our residents through the pandemic and left quite the shoes to fill. We are confident that our new chiefs will step into this role with grace and look forward to their impact on our residency.

We recently had resident simulations in our UF simulation center, which is a fun experience for both residents and faculty. Our simulation lab offers all the bells and whistles to get our residents comfortable with whatever might be thrown at them. Whether it’s ultrasound-compatible mannequins, fiberoptic and difficult intubations, ventilator troubleshooting or virtual reality central lines, there is little that our simulation lab cannot offer. We want to give a shout-out to our simulation staff, who flawlessly execute our cases and always add a little bit of humor.

The simulation lab is not the only place we practice, however. We regularly have simulation codes in our pediatric resuscitation bays. These simulations are a great opportunity for residents and staff as it allows us to practice flow and communication during stressful and time-sensitive situations. Simulation here at UF makes us proud and prepares our residents to handle any situation that the emergency department may bring.

Our virtual interview season has ended, and we are happy to announce that all of our PGY-1 spots have been filled.

We are so excited to welcome another diverse intern class to the Swamp. We look forward to embracing them into our UF family and are anxiously awaiting their arrival this summer. ■

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

Jackson Memorial Hospital

By EM Residency Program Staff And here we are... a year later. Though it is fair to say we are Zoomed out and all too eager to resume in-person events, we were impressed that our Zooming capabilities did lead to an exciting and fruitful recruitment season. All the technological nightmares we thought would come our way, did not. We did not experience any major glitches or setbacks! Right before starting our last interview session, we virtually high-fived each other for such a seamless process, and looked forward to rank.

If COVID has taught us anything, however, it should be to never know what to expect. So of course, on the very last afternoon, of our very last day, with our very last group, those of us using AT&T in South Florida suffered a total and complete loss of both cell and internet connections. Our interviewees were left alone in their breakout rooms, pondering how long this new solitude would last. And last it did—for

SOUTH FLORIDA over two hours.

Luckily, our fearless program coordinator, who was fortunately unaffected by the blackout, was hosting the Zoom session, so at least that was intact; and the interviewees who were left hanging were all able to reschedule for the following week. Having learned our lesson, once we finally did interview them, no high-fives were given until we certified our rank list one month later.

And even then, it was a tepid high-five as we waited with bated breath until Match Day. Vaccines in arms and masks still on faces, we could not be more thrilled with our incoming intern class, a fantastic group who will be joining us in Miami from far and wide, as well as some who are returning to their home state or city. We welcome them with open arms, but still six feet apart, of course. ■

CENTRAL FLORIDA

Orlando Health

By Drs. Gregory Black and Brody Hingst, PGY-2s Greetings from Orlando Health! We hope everyone has continued to remain healthy and hopeful since last we spoke - we look forward to 2021 returning some semblance of normalcy to our lives.

In March, Orlando Health had its 4th annual Sal Silvestre Memorial Wiffle Ball game, where residents, attendings and faculty gathered in honor of the great Sal Silvestre. His loving and family-centered legacy continues ever on.

Let’s all remember to love each other and #livelikeSal. Many of our faculty and residents presented at the virtual CORD conference this year. A special congratulations to our speakers: Sara Baker, Erich Heine, Susan Miller, Anne Shaughnessy, and Tory Weatherford. You all made us proud!

Orlando Health has officially rolled out its new Epic-based EMR system, which was spearheaded by our faculty member Dr. Joshua Briscoe, the Medical Director of IT Innovation. Way to go!

We are thrilled to welcome all 18 of our new interns to the Orlando Health Family! Thank you to our interview committee who worked endlessly to make the interview season enjoyable and productive. Also, congratulations to our new chiefs and fearless leaders: Courtney James, Connor Karr, and William Waite!

Finally, we lament to say goodbye to all of our amazing seniors! We have been blessed to learn under you all the last few years, and we will miss you dearly.

Good luck to everyone in 2021. Keep wearing those masks and washing those hands so we can go to the beach in the summer! ■

EMpulse Spring 2021

29

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

Oak Hill Hospital WEST FLORIDA

FSU at Sarasota Memorial Courtney Kirkland, DO, PGY-2 Greetings from Sarasota! We are so excited to welcome our third intern class and cannot wait for them to join our family this July. With the addition of this group, we look forward to finally having a full complement of residents.

Our program has also undergone different types of growth as well. Dr. Josh Pavlik, PGY-1, and his wife, Mindy, welcomed Jackson Pavlik into the world on March 17, 2021. Dr. Hannah Cianci, PGY-1 was also able to marry her fiancé, internal medicine resident, Dr. Bobby Malik, on March 20, 2021. Congratulations to all!

Late last year, we were fortunate enough to receive Moderna’s COVID-19 vaccination. Since then, our residents have volunteered within the community to vaccinate our EMS workers during our EMS rotation. It has been great to give back to our community in this small way and help get our frontline workers protected.

Our inaugural class will be PGY-3 residents in the coming year, and they are gearing up to fully take on the role of senior. Our residency retreat will take place at the end of April, and our leadership positions, including chief resident, will be designated at that time. We will also get to enjoy a little time at the beach with our families and faculty during the retreat! Happy spring to all. ■

30

By Ryan Johnson, MD, PGY-1 Greetings from Oak Hill! We have had an incredibly busy winter season and have just finished our in-training exam for the year. We would like to extend a warm welcome to the newly matched Class of 2024! All of their hardwork has paid off, and we cannot wait to have them become part of the Oak Hill family. We look forward to working with each of them in July.

Our ED expansion is going well, and construction is ahead of schedule! We are all very excited to begin transitioning to our new facility in the coming year. The new building will include an increased amount of private patient rooms to care for our growing volumes and new resuscitation bays for our most critical patients. While this has created no shortage of headaches for traffic and parking in the short term, the benefit of having a new, larger space will be immeasurable for our continued growth.

WEST FLORIDA Our simulation program continues to mature, and we have now progressed to doing weekly simulations. We recently conducted a mass casualty event simulation in which the residents worked to risk stratify and treat multiple patients in an acute crisis. Oak Hill research day is fast approaching, and we have several residents who will be presenting posters this year. Some of the topics include orthopedic injuries in pregnancy and novel therapeutics for the acute management of COVID-19 patients.

The seniors are quickly approaching graduation! Dr. Shaun Mansour, PGY-3 is going on to complete an administration fellowship. The other PGY-3’s have signed contracts with hospitals around the country, with some moving to other states while others are staying close by. We will be sad to see them go, but we are all excited to see what the future holds for them!■

UF Jacksonville

By Chris Phillips and Richard Courtney, DO, PGY-3 As this challenging academic year comes to an end, we have a lot to be thankful for. We would like to start off by congratulating the medical students who matched at our program this year.

We look forward to meeting all 15 of you in July. Welcome to the Jax EM family!

While we get ready to welcome in our new interns, we would like to take a moment to recognize the achievements of our PGY-3 residents. Four residents matched into fellowships this year: Dr. Andrew Grozenski with a sports medicine fellowship at Vanderbilt; Dr. Christine Gage with an administration fellowship at UF Health Jacksonville; Dr. Jessica Ryder with a disaster medicine EMpulse Spring 2021

NORTH FLORIDA fellowship at Carolinas Medical Center; and Dr. Ryan Brandt with a medical education fellowship at UF Health Jacksonville. In addition, we would like to congratulate all the PGY-3s on finishing residency and obtaining job offers.

We wish everyone success in their careers and know the training you’ve received has prepared you to handle anything thrown your way. You are all rockstar emergency physicians!

Finally, we’d like to give a shoutout to our upcoming chief residents: Drs. Chelsea Allen, Richard Courtney and Semir Karic. They are all excellent role models and we look forward to their guidance next year.■

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

SOUTH FLORIDA

St. Lucie Medical Center

By Shelby Guile, DO, PGY-3

WEST FLORIDA

Brandon Regional Hospital

By Rashmi Jadhav, MD, PGY-2 Congratulations to the Class of 2024!

We are thrilled to welcome our new class of interns to our program. After a grueling match season, we are excited to begin this upcoming academic year strong and have many new and exciting things planned. Although COVID has not left us quite yet, we have all learned to work within its confines and make sure we continue to train hard and effectively.

We recently had another great Simulation Extravaganza at our HCA Simulation Center led by Simulation Director, Dr. Martin Kim. He has been a huge asset to our program and has enhanced our education through simulation. We had a very educational day working with all our new simulation equipment and performed various procedures, like lumbar punctures and transvenous pacing. In one short year, our simulation program has really taken off!

Additionally, our ultrasound attendings, Drs. Kalivoda and Cabrera, have been especially active in our scholarly work and have published numerous articles in various prestigious journals. They have worked with resident Dr. Rivera to publish an article on the use of POCUS for identification of intraabdominal abscess in a Crohn’s patient; resident Dr.

Al-Marzoog, who published in JACEP Open on the use of POCUS to identify pyomyositis; and Drs. McClure and Patel, who wrote a case report describing the use of POCUS to identify a liver abscess. Congratulations on all your hard work and continued research.

Lastly, while we welcome another class of residents, our program will graduate its first residency Class of 2021 this June. This particular class holds a special place at Brandon Regional Hospital as it is the inaugural class of this residency program. All our seniors have grown tremendously over the last three years and it is with a heavy heart that we will be leaving our hospital, our peers, and most importantly, our incredible staff of attendings who trained us. Words cannot describe how we feel about you! You have created a family here for us and no matter where we go, we know we will always have you behind us. We will miss you all tremendously, and words cannot express the gratitude we have for each of you. From the bottom of our hearts, thank you!

Welcome to the Class of 2024! You are about to join a very special family and you’re in for a fun ride. ■

EMpulse Spring 2021

Here at St. Lucie, we have been enjoying some of the changes that the spring has brought and are very excited to be nearing the end of the academic year. Many of the residents have been able to be a part of administering the COVID-19 vaccine to our fellow healthcare colleagues over the past few months. We are so happy to have been given the opportunity to help defeat the virus that has changed our education and all of our lives over the past year. Even with vaccinations in full force, we continue to wear our PPE and maintain virtual conferences.

After a long and unusual interview season, we are very excited to welcome the Class of 2024! Though the interviews were virtual and students did not have as much opportunity for rotations in the department, we are confident that our new interns will find their home here and fit right in.

Our current interns are very excited to pass down their knowledge and take on more responsibility.

It is also the time of year again to welcome our new chief resident, Dr. Lam Tran. Dr. Tran has been a natural leader since his first month here and we have no doubt that he will continue to display all of the characteristics that we want our program to embody.

We hope to begin in-person learning again soon, as well as attending our quarterly simulation labs. Despite the limitations of virtual learning this year, we have continued to grow closer, test our creativity, and become more resilient than ever. ■

31

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

WEST FLORIDA

USF Health

By Mikhail Marchenko, MD, PGY-2 Greetings from Tampa and the USF Emergency Medicine Residency Program!

We have finally come to the close of what was one of the most unique interview seasons so far. We are so excited to congratulate and welcome the new Class of 2024! It is always an exciting and uplifting time welcoming new residents into our family, and we cannot wait to meet them.

Our program is also proud to announce that this year, we were able to establish the USF Underrepresented in Medicine (URM) Travel Scholarship. This travel scholarship is available for any 4thyear student at a U.S. medical school who comes from an underrepresented background in medicine (racial, ethnic, socioeconomic status, sexual orientation, gender identification, etc.).

Our hope is to break down obstacles for those who wish to see what a truly special program we have here.

Finally, as we end one year of COVID, we are exceptionally proud of our residents & staff who have adapted to ever-changing situations, made personal sacrifices, and functioned as role models to the community by getting vaccinated. Thanks to their efforts, some of our residents were even lucky enough to be invited to the Super Bowl and witness history as Tampa Bay became Super Bowl Champions!

We invite you to follow along for even more exciting updates and information at our website/blog at www.usfemergencymedicine.org. ■

32

SOUTH FLORIDA

Kendall Regional Medical Center

By Tina Drake, MD, Ibrahim M. Hasan, MD & Sara Zagroba, MD, PGY-3s Co-Chiefs, Emergency Medicine Residency Hello again from Miami! We are thrilled to announce that we are expanding the Kendall family to include 12 fantastic new interns for the coming 2021-2022 academic year.

Match Day is always an exciting time, but we are especially thankful for the wonderful group of medical students who braved the virtual recruitment season to join us. We are also proud to welcome the next generation to our team, as two of our residents have become fathers this year! Chief resident Dr. Ibrahim Hasan and intern Dr. Danny Lopez have both welcomed beautiful and healthy babies into the world.

The strong, cooperative bond between our EM crew and the trauma team at Kendall continues to result in excellent training experiences and patient outcomes. We recently hosted helipad training for our residents and trauma staff, including hands-on practice in safely approaching and off-loading air rescue

EMpulse Spring 2021

trauma patients from the arriving helicopters. We also co-hosted, with Miami-Dade Fire Rescue, a Citizen’s Award presentation to a bystander who provided lifesaving prehospital care to one of our trauma patients, and who is now an advocate for our Stop The Bleed program.

We continue to prioritize high-fidelity simulation as an integral part of our curriculum. We hosted our annual Medical Student Simulation Day this spring and have our annual Mass Casualty Incident training day coming up soon! In addition, having all of our residents vaccinated against Covid-19 has allowed us some additional freedom in our resident wellness curriculum, which has included group activities like interdepartmental kickball and Topgolf day! We look forward to continuing these regular activities through the summertime, and to welcoming our new interns in June. ■

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

UCF/HCA of Greater Orlando

By Amber Mirajkar, MD, PGY-3 Despite the uncertainties and concerns over the COVID-19 pandemic, we are trying to keep things business as usual. Although interview season was far from traditional this year, it did not prove to be a barrier for an enormous number of qualified applicants. We thank everyone who applied to our program, and we are excited to be welcoming seven fantastic new interns.

While we are excited about our new incoming class, it is also bittersweet for our seniors leaving to pursue fellowships and jobs. Dr. Michelle Hernandez will be one of two Ultrasound Fellows at our program, and she will be joined

by Dr. Thomas Lawyer who is coming from AdventHealth East Orlando’s EM Residency. Drs. Maria Chamorro and Amber Mirajkar will stay on as Research Fellows. Dr. Keegan McNally is heading to Brown University as their new Simulation Fellow. Dr. Mary Cate Slome is joining the faculty at UHS Wilson Hospital, part of SUNY Upstate, as the medical student clerkship director and clinical faculty. Dr. Emily Drone matched into a Pediatric EM Fellowship at Orlando Health. Last but not least, Dr. Sherwin Thomas will be joining the ED staff at AdventHealth Ocala. We wish them all the best of luck!

A pandemic is no reason to hamper one’s inquisitive nature, and ours is running wild. From perichondritis to heroin-induced mycoplasma pneumoniae pneumonia causing respiratory failure, we have published on a wide range of subjects. Drs. Mark Rivera-Morales, Pell, Jose Rubero, and Latha Ganti published about acute myopericarditis in the post-COVID-19 recovery phase. Furthermore, alumni and faculty continue to publish, ranging from assembly line education to COVID-19. Congratulations to Drs. Andrew Hanna, James Chiang, David Lebowitz, and Latha Ganti on their published article, “Elastomeric respirators are safer and more sustainable alternatives to disposable N95 masks

CENTRAL FLORIDA during the coronavirus outbreak,” in the International Journal of Emergency Medicine. We have many more publications in the works!

We had a strong showing at virtual ACEP. Dr. Gideon Logan presented on opiate use disorder; Dr. Emily Drone discussed active shooter response in the ED; Dr. Keegan McNally reviewed his research in virtual training for EM residents; Drs. Maria Chamorro and Michelle Hernandez unveiled their outcomes after reversal of anticoagulation in intracerebral hemorrhage; and Dr. Amanda Webb examined EM physician COVID-19 readiness and practices.

SAEM is right around the corner, and we are eagerly preparing.

Although we might be biased, we believe we have the best teaching faculty in Florida. One physician, however, we wish to specially recognize is Dr. Jose Rubero. This year he received UCF COM’s 2020 Educational Leadership Award. We also wish him a hearty congratulations on being selected as Program Director of a new Emergency Medicine Residency in Pensacola, FL. Furthermore, a warm congratulations goes to our Associate Program Director, Dr. Tracy MacIntosh, who was selected as University of Central Florida College of Medicine’s Associate Dean of Diversity, Equity & Inclusion.

She has published multiple times in this area and has been a great proponent of these ideals both in the emergency department and in the community.

There are many bittersweet changes on the horizon as the academic year winds down. Although the COVID-19 pandemic has provided us with many unique challenges, our emergency medicine family at Osceola and in Florida has persevered. We hope everyone stays safe in these persistently uncertain times, and we are looking forward to a promising new academic year. ■

EMpulse Spring 2021

SOUTH FLORIDA

Aventura Hospital

By Dr. Scarlet Benson

Assistant Clinical Professor We would like to congratulate our assistant program director, Dr. Andre Pennardt, regarding his new appointment as the new CMO of FEMA. He will be staying on part-time as core faculty with Aventura, so we are lucky enough to not lose him completely! Dr. Annalee Baker will be stepping up into the new role as Assistant Program Director for the 2021-2022 season.

Drs. Huy Tran, Gaurav Patel, Erin Marra and Charles Latimore, PGY-1 have started at Midline Utilization in the ED survey study, so stay tuned for more updates regarding their progress. In February, Sim Director Dr. Jessica Cook piloted the first joint EM/trauma in-situ simulation conference at Aventura for staff, residents and nursing. This was part of a new trauma simulation conference she is developing with the assistance of Dr. Ben Pirotte, PGY-2.

Dr. Cook also participated in a 2-hour virtual “speed mentoring” session at the International Meeting on Simulation in Healthcare.

Several of our residents recently received recognition as “Vaccination Warriors” after they participated in the COVID vaccine administration fair at Aventura. Congratulations to Drs. Kody Sacks-Moynihan, Kevin Fan, Charles Latimore, Allison Clark, Daniel Samet and Glenn Goodwin, who together administered a record number of vaccines for the state!

Aventura also had a successful match this year, and looks forward to welcoming our new interns in June. ■

33

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

Orange Park Medical Center

By Cody Russell, MD, PGY-2 NORTH FLORIDA

NORTH FLORIDA

Ocala Regional Medical Center

By Jean Laubinger, MD, MPH, PGY-2, Emily Clark, MD, PGY-2 & Caroline Smith, MD, PGY-3 Spring has arrived in Ocala. Along with it came our highly anticipated EMS Day at the Florida State Fire College in Ocala. We spent the day in fellowship with our local firefighters, gaining perspective on the pre-hospital challenges our fire/EMS colleagues face. Many residents completed the firefighter entrance physical exam, learned the basics of putting out a fire and used spreaders and cutters to simulate patient extraction from vehicles. We all enjoyed getting outside and learning some new skills.

We are proud and overjoyed to see the progress we have made individually and as a residency over the last 12 months. It’s exciting to watch our seniors take charge of the department as they near graduation. It is equally as thrilling to see the knowledge and confidence our first-year residents have garnered as they become more comfortable taking care of acutely ill patients in the department.

We look forward to our newest cohort of residents joining our residency and cannot wait to meet them in person in the coming months. We’d like to extend our congratulations to our senior residents as they move on to the next phase of their careers. We wish Dr. Titelbaum the best of luck at Emory University and welcome the continued presence of our newest attendings, Drs. Johnson, George and Smith. ■

This is an exciting time for Orange Park EM residents! The ITE is behind us, and we are looking forward to meeting our new interns in July. With the arrival of our 12 new interns, our residency family will be complete. We are excited to have our full complement of 36 residents led by our first 12 trailblazers.

As we prepare to welcome this new class, it is important to reflect on the past two years and give thanks where it’s due. We would like to highlight Dr. Ahmad Mohammadieh, who is finishing his second year of residency and his third year as Chief Resident. He led our inaugural class and is a continual shining example of dedication, leadership and perseverance. Over the past two years, he worked tirelessly with the faculty to make our program successful. Dr. Mohammadieh set the bar high for his successors and co-residents. Drs. Cody Russell and Janae Fry will be stepping into his role as CoChief Residents in July. They will help

On the academic front, Orange Park Medical Center just completed construction on a new patient tower, and we are looking forward to construction of our new simulation center. We are currently prepping for an outdoor mass casualty exercise complete with special effects and a post-conference barbeque. Dr. Kendall Talley, PGY-1 and Cody Russell, PGY-2 recently presented “Globe Luxation: Traumatic or Not?” and “Emergency Department ‘Provider Discharge’ A Quality Project” to the Clay County Medical Society. Dr. Cody Russell, PGY-2 is also leading a team that will travel to local medical schools to teach ultrasound. Dr. Trevor Lofgran, PGY-2 recently conducted a wilderness medicine training experience for Bradford County EMS with the help of faculty members Drs. Terrell Swanson and Justin Deaton. ■

Mount Sinai Medical Center

By Stephanie Fernandez, MD, PGY-3 Hello from Mount Sinai! After a busy and unique interview season, we would first like to extend a warm welcome to the incoming Class of 2024. We look forward to seeing you all in a few short months! Congratulations are also in order for our new chiefs, Drs. Stefani Sorensen and Grethel Miro. There is no doubt that you will excel in your new roles.

Over the last few months, we continued our Residency Game Day competition, where teams competed in areas of simulation, ultrasound-guided procedures, ECG interpretation and trivia.

Blue team remains in the lead! Addi-

34

our program transition from 24 to 36 residents and do their best to fill the shoes of Dr. Mohammadieh.

EMpulse Spring 2021

SOUTH FLORIDA tionally, residents continued to engage on the local level by leading workshops at South Florida medical schools.

Most recently, Drs. Jiodany Perez and Stephanie Fernandez led an Ultrasound conference at NSU-COM, where they discussed cardiac ultrasound and FAST exams. We also enjoyed some fun in the sun during our Wellness Wednesday, where residents and attendings came together for a beach volleyball tournament and Cuban coffee on the beach.

It is hard to believe that another year has flown by! From MSMC, we wish you a safe and happy summer. ■

SPONSORED

Leveraging AI to improve patient safety in the emergency department Why are diagnoses missed?

By Dan Sullivan, MD, JD, FACEP President and CEO at The Sullivan Group Just three diagnostic errors account for nearly 75% of all serious harm to patients. Misdiagnosed cancers, vascular events, and infections accounted for this and $1.8 billion in malpractice payouts.

WHY ARE DIAGNOSES MISSED?

A 2020 study by Newman-Toker, et al. identified that 15 diseases account for about half of all serious misdiagnosisrelated harms.7 The research focused on the “Big Three” categories of vascular events, infections, and cancers and found that 10% of patients with a “Big Three” disease are misdiagnosed.

A likely explanation for this result is that practitioners encounter these conditions infrequently, are not familiar with the variable presentations, and are prone to cognitive errors in the diagnostic process.

These diseases require a consistent, thorough evaluation that focuses on the history and exam’s diagnostic features that should prompt the practitioner to include the condition in the differential diagnosis. The authors of this study concluded succinctly that their findings allow us to “target diagnostic improvement initiatives to diseases with the highest error and harm rates.”

Additional studies outline the failure to diagnose profile demonstrates omission of elements in history taking, physical exams, and medical decisionmaking.

REDUCING DIAGNOSTIC ERROR

Leveraging 30 years of data into the root causes of the failure to diagnose, Nuance partnered with The Sullivan Group to develop ED Guidance for Dragon Medical Advisor, an AI-based decision support tool. ED Guidance for Dragon Medical Advisor specifically targets the most common diagnosisrelated errors.

ED Guidance for Dragon Medical Advisor drives clinical alignment around elements in the history, physical exam, and medical decisionmaking that improve diagnostic certainty. Additionally, the algorithms help identify possible high-risk conditions and passively notifies the practitioner of a “Risk Identified.”

Importantly, ED Guidance for Dragon Medical Advisor also fits comfortably within the practitioner workflow.

This real-time clinical feedback helps physicians avoid medical errors before they become an adverse event or malpractice claim.

For the last 30 years, I have taught risk and safety to 4,000 medical directors and tens of thousands of emergency practitioners. While I enjoy lecturing, unfortunately, it does not lead to a sustained change in clinical practice that keeps patients and providers safe.

Utilizing AI allows us to bring these risk and safety elements to the bedside.

Since wrong or delayed diagnoses cause more wrong serious harm to patients than any other type of medical error,6 leveraging AI is the most EMpulse Spring 2021

promising way to reduce diagnostic error. ■

REFERENCES

1. Makary M, Daniel M. Medical error – the third leading cause of death in the US. BMJ. 2016;353:i2139.

2. Newman-Toker DE. Diagnostic value: the economics of highquality diagnosis and a valuebased perspective on diagnostic innovation. Modern Healthcare Annual Patient Safety & Quality Virtual Conference; June 17, 2015.

3. Nearly 1 in 6 Docs Say They Make Diagnostic aErrors Every Day. Medscape. Sep 10, 2019.

4. Emergency Department Benchmarking Alliance. 2018 Annual Report. Madison, WI: EDBA. Published November 2019.

5. Sklar DP, Crandall CS, Loeliger E, Edmunds K, Paul I, Helitzer DL. Unanticipated death after discharge home from the emergency department. Ann Emerg Med. 2007;49(6):735-745. doi:10.1016/j. annemergmed.2006.11.018.

6. Tehrani A, Lee H, Mathews S, et al. 25-year summary of US malpractice claims for diagnostic errors 1986-2010: An analysis from the National Practitioner Data Bank. BMJ Qual Saf. 2013;22(8):672-680. doi: 10.1136/ bmjqs-2012-001550.

7. Newman-Toker DE, Schaffer AC, Yu-Moe CW, et al. Serious misdiagnosis-related harms in malpractice claims: The “Big Three” – vascular events, infections, and cancers [published correction appears in Diagnosis (Berl). 2020 May 16].

Diagnosis (Berl). 2019;6(3):227240. doi:10.1515/dx-2019-0019.

35

FEATURE

Disruptive Innovation

E2 di0 0 ti2 on

in Emergency Medicine

By Mitchell Barneck, MD

Orlando Regional Medical Center

Every year at ACEP, the exhibit hall features IncubatED: a medical device innovation challenge. This is an interactive, educational space that provides a sneak-peek of new innovations in emergency medicine. This last year, four medical device startup companies participated virtually in a “Shark Tank” style pitch competition. This article highlights their disruptive technologies.

The author is not affiliated with any vendors in this article and has no conflicts of interest to report.

36

HYPERFINE RESEARCH:

Portable MR Imaging Technology It is not uncommon for patients to present to the emergency department (ED) with complaints of headache, dizziness, numbness, weakness or vertigo. However, despite 40+ years since its inception, there are still a number of barriers to using magnetic resonance imaging in the ED. Many departments lack an in-house MRI scanner secondary to cost and space requirements. For institutions that can afford one, it is often located far from ED patient care areas and is backlogged for hours on waiting scans. This results in long holding times, significant throughput issues, and decreased utilization. Clinicians are often forced to rely on lower accuracy, radiation-producing CT scanners as an alternative.

Hyperfine Research, Inc. is developing a new, portable, easy-to-use, and affordable MRI scanner that is small enough to be wheeled into individual patient rooms. While the fundamental principles of MRI technology and its components

EMpulse Spring 2021

still exist, they have leveraged the million-fold improvement in computing power since the first system was designed almost 40 years ago.

This results in the machine generating high-quality images while using only 2-6% of the typical MRI magnetic field. The device is also 10 times lighter and uses 35 times less energy to run. Hyperfine secured initial FDA clearance in 2020, and early this year secured Series D funding to scale up commercial rollout of the device. This new portable, functional MRI machine could be a game changer for improving patient care, throughput, and access to MR technology in the emergency department.

For more information, visit: hyperfine.io

COAGULO MEDICAL TECHNOLOGIES:

Precision Coagulopathy Testing Approximately 10 million people in the U.S. are on anticoagulation medications, which are a common cause of drug-related adverse events. Oral anticoagulants are common, and Direct Oral Anticoagulants (DOACs) account for more than 50% of oral anticoagulant prescriptions. Despite widespread use, there is currently no FDA-approved clinical test to assess for levels or efficacy of these drugs. Current coagulation testing like the INR is based on 50-year-old technology that provides only limited general coagulopathy information. This puts patients at unnecessary risk of adverse bleeding events, especially in the emergent and surgical settings.

Coagulo Medical Technologies, an MITborn startup, has developed the world’s first precision-medicine platform for comprehensive and targeted blood clotting management. Their device is capable of pinpointing abnormalities across the entire clotting cascade and delivering clinically-valuable information that no other technology provides.

This is accomplished using an entirely new set of patent-pending coagulation assays, microfluidic technology, and proprietary data analytics. Coagulo’s new point-of-care testing platform is the first of its kind to deliver accessible and personalized diagnosis and management of all coagulation-related diseases.

It requires only a few drops of whole blood, delivers results within 10 minutes, is fully automated and portable, and can perform up to 20 tests simultaneously.

In a 100-patient blinded clinical study performed at the Massachusetts General Hospital Emergency Department, Coagulo demonstrated 100% specificity and over 95% sensitivity for identifying patients’ DOACs. This could enable clinicians to more rapidly and safely control bleeding. In the ED, where minutes can mean the difference between life and death, a rapid, portable, easy to use coagulation assay for detecting DOACs could be, well, life-changing.

For more information, visit: coagulomed.com

EM DEVICE LABS: TM

Quickloop Abscess Treatment Device Abscess drainage is necessary in over 1.4 million ED patients in the U.S. every year. Despite its frequency, it is still the second most painful procedure commonly performed in the ED. Abscess evaluation is consistently the seventh most common chief complaint for presenting ED patients every year.

Loop placement is quickly becoming the industry standard, with several studies showing lower failure rates and improved patient satisfaction, cosmetic appearance, and overall cost of care. Despite this evidence, there is no dedicated loop device.

EM Device Labs have developed the QuickloopTM Abscess Treatment Device, a patented, single-use loop with introducer and securing mechanisms.

This device is composed of a curved

needle, cutting bevel, and tubing with irrigation fenestrations. It also has a locking mechanism that eliminates the need for knotting the tubing. The QuickloopTM is designed to simplify the “loop” technique, improve outcomes, reduce provider time, and decrease the cost of caring for patients with abscesses. In addition, it incorporates the ability to irrigate the abscess from the inside out with a standard luerlock syringe. Given the potential to improve patient care and ease of use, as well as reduce discomfort and complications, the EM Device Lab QuickloopTM may be a useful device to incorporate into your abscess drainage care.

LINEUS MEDICAL:

Safebreak® Vascular

Approximately 60-90% of patients entering the hospital will receive an intravenous catheter, resulting in 220 million peripheral IVs every year in the U.S. However, up to 46% of these IVs will fail prematurely. Failure can be from any number of reasons, including phlebitis, infiltration, occlusion, dislodgement and infection. On occasion, mechanical stress on the line can cause one of these failures. Staff will typically tape and place an adherent dressing to secure the lines in place.

To decrease mechanical failure rates of peripheral IVs, Lineus Medical has developed their Safebreak® Vascular Dislodgement Prevention Device. This patented, FDA clearance-pending device is composed of an IV connected with a pressure sensitive release mechanism that is designed to release if a certain amount of pressure is applied. Upon release and disconnection, both ends seal to prevent loss of blood or infusion liquid. In theory, the quick release mechanism will prevent mechanical dislodgement and failure. This could result in fewer venipunctures, reduce procedure delays, and increase the time nurses can spend on other patient care activities.

For more information, visit: lineusmed.com ■

For more information, visit: emdevicelab.com

EMpulse Spring 2021

37

CASE REPORT

Acute Monocular Painless Vision Loss in an Elderly Man

By Mani Hashemi, MD

Kendall Regional Medical Center

By Harold Gomez Acevedo, MD

Kendall Regional Medical Center

By Arvin Jandu, MD

Kendall Regional Medical Center

By Moises Moreno, DO

A 79-year-old male with a history of diabetes mellitus, atrial fibrillation, and hyperlipidemia presented to the Emergency Department (ED) with a chief complaint of painless left eye vision loss. His symptoms started the previous night, approximately 20 hours prior to arrival, and were described as a sudden onset of “cloudy and darkening” vision from his left eye, which rapidly progressed to complete vision loss within minutes. Vision from his right eye remained unchanged. He noted that he had a history of uncomplicated cataract surgery to his left eye four months prior, and his family noted that he had stopped taking Xarelto one month ago. The patient otherwise denied other symptoms.

During his initial presentation, his vital signs were within normal limits.

On physical examination, he was noted to have an afferent pupillary defect as well as significantly reduced visual acuity in the left eye (20/200). Intraocular pressures were 14 mmHg and 11 mmHg in the left and right eyes, respectively. Ocular point-of-care-ultrasound (POCUS) was performed using a 12 Megahertz (MHz) linear probe (Fig. 1).

DIAGNOSIS:

Central Retinal Artery Occlusion CRAO is classically diagnosed in patients presenting with painless vision loss via fundoscopy,

Kendall Regional Medical Center

REFERENCES

1. Systemic diseases in noninflammatory branch and central retinal artery occlusion--an overview of 416 patients. Schmidt D, Hetzel A, Geibel-Zehender A, Schulte-Mönting. 2007 Dec 14, Eur J Med Res, pp. 12(12):595-603.

PMID: 18024271.

2. The retrobulbar "spot sign" as a discriminator between vasculitic and thrombo-embolic affections of the retinal blood supply. Ertl M, Altmann M, Torka E, Helbig H, Bogdahn U, Gamulescu A, Schlachetzki F. ltraschall Med. 2012 Dec;33(7):E263-E267. doi: 10. : Ultraschall Med., 2012 Dec, Vols.

33(7):E263-E267. doi: 10.

3. Vascular risk factors for central retinal artery occlusion. Rudkin AK, Lee AW, Chen CS. London : Eye (Lond)., 2010 Apr, Vols.

24(4):678-81. doi: 10.1038/ eye.2009.142. Epub 2009 Jun 12.

PMID: 19521436.

38

Fig. 1: Ultrasonography of the left eye obtained with the linear probe in axial-transverse axis with the patient in the supine position, demonstrating a retrobulbar hyperechoic focus (retrobulbar spot sign) at the junction of the optic nerve and the globe, highly suggestive of emboli.

EMpulse Spring 2021

ADVERTISING demonstrating a pale retina with a “cherry red” spot, retinal edema, and narrowing of blood vessels. This constellation of signs signifies ischemia of the main arteries supplying blood to the retina. Visualization of the retinal vasculature via fundoscopy is frequently difficult and limited without a dilated eye examination.

Furthermore, as demonstrated by a prior study, the visualization of the thrombi in patients with CRAO view fundoscopy is only accomplished in 11% of patients.1 The utilization of point-of-care ultrasound can aid in the differentiation of CRAO from other causes of acute painless vision loss.2 The central retinal artery, arising from the ophthalmic artery (first branch of the internal carotid artery), travels within the optic nerve upon entering the orbit and enters the eye. A retrobulbar spot sign was present in this case, demonstrating

the utility of POCUS in being able to rapidly identify the thrombus within the central retinal artery, leading to the visual diagnosis of CRAO without fundoscopy. In a study of 31 patients with CRAO, 59% were found to have a retrobulbar spot sign, supporting the utility of bedside ultrasonography for this diagnosis.3 Given the diagnostic inaccuracy of bedside fundoscopy, these studies indicate the POCUS could be a powerful tool to expedite the diagnosis of this entity.

Our patient had no other signs of retinal detachment, vitreous detachment, or vitreous hemorrhage noted. The diagnosis of CRAO was confirmed by dilated eye examination by the consulted ophthalmologist.

He was subsequently found to have high-grade bilateral carotid bifurcation plaque formation and stenosis. He eventually underwent bilateral carotid endarterectomy. ■

Reach over 2,200 FCEP member physicians, residents and medical students plus hundreds more through online readership

Summer 2021 DIGITAL ONLY

Intent to Submit Due: May 28, 2021

Content Due: June 14, 2021

In-Inboxes:

July 19, 2021 (before Symposium)

Fall 2021 PRINT & DIGITAL

Intent to Submit Due: Aug. 12, 2021

Content Due: Aug. 30, 2021

In-Mailboxes:

Oct. 1-15, 2021 (after Symposium)

Get the best of both worlds: Each print advertisement purchase comes with up to 4* complimentary digital banner ads Fig. 2: Application of Color Doppler to optic disc demonstrates absence of vascular perfusion.

EMpulse Spring 2021

*number varies by print ad size

fcep.org/empulse 39

ULTRASOUND ZOOM

The VExUS Score: Fluid Status, Reconsidered

By Ernesto H. Weisson, BS UM Miller School of Medicine

UM Miller School of Medicine

UM Miller School of Medicine

CLINICAL PROBLEM

Proper evaluation of fluid status is imperative to the management and outcome of patients in the emergency department (ED), especially in cases of septic shock, congestive heart failure or acute renal failure. Traditionally, point-of-care ultrasound (POCUS) has been used to assess the inferior vena cava (IVC) for an estimation of fluid status and responsiveness. However, relying exclusively on the IVC diameter and collapsibility has been shown to be insensitive for identifying fluid tolerance in critically ill patients.

Like central venous pressure, estimation of the IVC is not a reliable measure of preload in the left ventricle. The IVC might be dilated in various euvolemic conditions, including pulmonary hypertension and valvulopathies, and it might also be dilated as normal physiologic variance in trained athletes. Another drawback of estimating fluid status only from the IVC is that this ignores the amount of congestion in other vital organs such as the lungs, liver, kidneys and gastrointestinal tract.

THEORETICAL CONSTRUCT

The Venous Excess Ultrasonography Score (VExUS) is a 4-step protocol that not only evaluates the presence of congestion in the IVC, but also assesses the severity of congestion in three target organs: the liver, the gut and the kidneys. Emergency physicians can easily utilize this protocol to guide fluid management in their patients. For example, a positive VExUS score might suggest conservative fluid administration or lead to the administration of diuretics and vasopressors.

HOW TO PERFORM A VEXUS EXAM

In preparation, the patient should lie supine with the head of the bed lowered to 0º and legs bent to relax the

Edited by Leila Posaw, MD, MPH

Emergency Ultrasound Faculty, Jackson Memorial

abdominal wall. The operator should be positioned on the patient’s right side to facilitate simultaneous scanning and manipulation of the controls. A curvilinear probe will result in a higher resolution of the vessels, but a phased array probe may be used as well. You will need an ultrasound system with color Doppler and pulse wave Doppler capabilities to perform a successful exam.

Step 1 – IVC assessment (B-mode)

Where to look: Place the probe on the patient in the subxiphoid location in the sagittal plane. You should see the IVC entering the right atrium. The hepatic vein may be seen entering the IVC. What to look for: The diameter of the IVC is commonly measured approximately 3-4 cm from the junction of the IVC and the right atrium, or 1-2 cm caudal to the confluence of the hepatic vein and the IVC. If the diameter is < 2 cm, there is no congestion. If the VExUS score is 0, and you do not need to proceed further.

If the diameter is > 2 cm, congestion is present. Further examination is necessary to determine the severity of congestion and VExUS scores 1-3. This is described in the following steps.

Venous congestion can first be appreciated in the IVC: its size increases proportionally to CVP until it reaches its maximum dilation. Pressure is then transmitted in a retrograde fashion through the veins to the abdominal organs.

40

By Duyen Vo, BS

By Joshua Goldstein, MD

Step 2: Hepatic vein assessment (B-mode, color mode, pulsed wave Doppler mode)

Where to look: Any of the three hepatic veins (right, middle and left) can be evaluated. However, the middle and right hepatic veins are easier to obtain, as they are less likely to be obscured by bowel/stomach gas. First, find the hepatic veins in B-mode. Place your probe in the right upper quadrant, fanning anteriorly and posteriorly. The hepatic veins are thin walled and communicate with the IVC. In the transverse view, the confluence forms the “Playboy Bunny” sign (Fig. 1). Next, assess the vessels with color Doppler. The veins should be blue (flow away from the probe). Finally, place the pulsed wave Doppler gate in the hepatic vein proximal to where it enters the IVC.

EMpulse Spring 2021

What to look for: The normal flow pattern in the hepatic veins closely resembles a CVP tracing with three waves: a small retrograde A wave, followed by anterograde S and D waves.

In a healthy patient, the S wave should be much larger in magnitude than the D wave, with both showing negative deflections as blood flows away from the probe.

In the setting of worsening venous congestion, the magnitude of the S wave will decrease as systolic phase venous flow decreases and eventually becomes positive, corresponding to a reversal of blood flow. At this point, venous congestion is severe enough that flow will be away from the IVC, and forward flow will only occur as the ventricle relaxes and fills during diastole.

Limitations: Hepatic vein Doppler is strongly influenced by tricuspid regurgitation, and in these patients, this step may not be suitable.

Step 3: Portal vein assessment (B-mode, color mode, pulsed wave Doppler mode)

Where to look: First, find the hepatic portal veins in the B-mode. Place your probe in the right upper quadrant, mid axillary line, and fan anteriorly and posteriorly. The portal veins are best identified by the presence of thick and hyperechoic walls. Next, assess the vessels with color Doppler. The portal veins should be red (flowing towards the probe). Finally, place the pulsed wave Doppler gate in the hepatic portal vein.

What to look for: Between the GI tract and the liver, the portal system should have constant monophasic flow with minimal variation. As venous congestion increases and pressure from the hepatic veins is transmitted across the hepatocytes into the portal system, the flow becomes pulsatile. The Pulsatility Index quantifies the degree of pulsatility:

Fig. 1: The confluence of the middle and left hepatic veins enter the IVC to form the “Playboy Bunny” sign.

Pulsatility index =

Flowmax — Flowmin Flowmax

Flowmax is measured as the distance between the baseline and the peak of the wave and Flowmin is measured as the distance between the baseline and the trough of the wave.

A pulsatility index of less than 30% is normal; between 30 and 49% denotes mild portal vein abnormality; and greater than 50% indicates severe portal vein abnormality.

Step 4: Renal vein assessment (B-mode, color mode, pulsed wave Doppler mode)

Where to look: First, find the renal veins in the B-mode.

Place your probe in the right posterior axillary line. The target vessels are the interlobar or arcuate renal veins located in the renal cortex. Next, assess the vessels with color Doppler (Fig. 2). Finally, since the arteries and veins run antiparallel to each other, the arterial and venous flows can be assessed simultaneously with a single pulsed wave Doppler gate placed over the color signal. Arterial flow will show a positive tracing, while venous flow will show a negative tracing.

What to look for: Normal renal veins have uninterrupted monophasic flow. As venous congestion increases, the systolic component of the flow decreases. The waveform becomes biphasic, with discrete diastolic and systolic phases. Eventually, in severe congestion there is only diastolic flow, and systolic flow is absent.

Limitation: The difficulty in visualizing the renal vessels might preclude the successful performance of this step.

Continue on page 42 ▶

Fig. 2: Color Doppler is used to localize the renal arteries & veins so they can be assessed with the pulsed wave Doppler.

EMpulse Spring 2021

41

◀ Continued from page 41

SCORING AND VALIDATION

The VExUS score ranges from Grades 0-3. In Grade 0, a non-dilated IVC (< 2 cm) indicates that no congestion is present. In Grades 1-3, the IVC diameter is > 2 cm. In Grade 1, a dilated IVC and any combination of normal or mildly abnormal flow patterns (but no severe features) indicates mild congestion. In Grade 2, a dilated IVC and one severely abnormal flow pattern indicates moderate congestion.

In Grade 3, a dilated IVC and two or more severely abnormal flow patterns indicates severe congestion. Figure 3 depicts normal and severely abnormal pulsed wave Doppler tracings of the hepatic, hepatic portal and renal veins. Figure 4 summarizes the easy to remember VExUS scoring system.

Beaubien-Souligny, et. al1 recently validated the VExUS grading system in a study that analyzed the risk of acute kidney injury in post-operative cardiothoracic surgery patients. This

Fig. 3: The upper row depicts normal and the bottom row depicts severely abnormal pulsed wave Doppler tracings of the hepatic, hepatic portal, and renal veins. study used statistical analyses to determine the risk of acute kidney injury associated with normal, mild and severe VExUS grades. In this system, a higher VExUS grade correlated with a higher risk of acute kidney

injury. VExUS Grade 3 outperformed traditional CVP measurement in the prediction of acute kidney injury in this patient population. This study suggests that damage to the kidney could result from venous congestion caused by

YOU DESERVE TO KNOW HOW YOUR PRACTICE IS PERFORMING! Central Operations REsource, or CORE, is DuvaSawko’s newest offering exclusively for Emergency Medicine practices! CORE helps Emergency Medicine groups maximize the value of their data.

Identify Trends with Impactful Data

Immerse Yourself in our State-of-the-Art User Experience

Analyze Your Operations from Anywhere

Pinpoint Areas of Improvement & Revenue Loss

KEY FEATURES

› Conveniently Monitor Performance on your Mobile Device › Quickly Develop Custom Analyses › Monitor Key Performance Indicators (KPIs) › Custom-designed Dashboards & Scorecards › Dashboard Subscription Services

Find out more about DuvaSawko’s CORE solution for your Emergency Medicine Practice today.

298 S. Yonge St. | Ormond Beach, FL 32174

888-311-8760 | DuvaSawko.com/core

42

EMpulse Spring 2021

Make Valuable Business Decisions with Quality Data

Grades

IVC

Severely Abnormal Wave Pattern

0

< 2 cm

-

None

1

< 2 cm

Zero

Mild

2

< 2 cm

One

Moderate

3

> 2 cm

Two

Severe

overhydration instead of by hypo-perfusion.

LIMITATIONS AND CONCLUSION

The protocol has limitations. Even though it estimates volume status well, the score does not specifically identify the source of venous congestion. It has been recommended that the VExUS score should not be used exclusively, but rather as an adjunct. Emergency physicians still need to clinically assess the patient to determine and correct the underlying causes of venous congestion.

The VExUS score is a powerful tool (Fig. 5), and should be strongly considered for the assessment and management of fluid status in our patients. With its straightforward approach and ease of use, this score is one of the most promising new techniques for the non-invasive assessment of volume status in some of our sickest patients in the emergency department.

Venous Congestion

Fig. 4: The VExUS grading system.

While current supporting evidence is limited, this technique holds the potential to significantly improve patient outcomes. ■

Fig. 5: The VExUS Ultrasound Score Pocket Guide. Reprinted with permission by Dr. Vi Dinh at POCUS101.com.

REFERENCES:

1. Beaubien-Souligny, W., Rola, P., Haycock, K. et al. Quantifying systemic congestion with PointOf-Care ultrasound: development of the venous excess ultrasound grading system. Ultrasound J 12, 16 (2020). doi.org/10.1186/s13089-02000163-w 2. Haycock, K., Spiegel, R., Bedside

Ultrasound: A Primer for Clinical Integration, 2nd edition: (2019).

Chapter 6, Special Skills: Venous Congestion.

3. Weingart, S., &; Rola, P. (2016).

EMCrit Podcast 263 – The VENOUS side, Part 1 – VEXUS score with Phillipe Rola. Retrieved April 05, 2021, from poddtoppen.

EMpulse Spring 2021

se/podcast/314020330/ emcrit-podcast-critical-careand-resuscitation/emcritpodcast-263-the-venous-side-part1-vexus-score-with-phillipe-rola 4. Dinh, V. POCUS 101. pocus101.com/vexus-ultrasoundscore-fluid-overload-and-venouscongestion-assessment/

43

POISON CONTROL

Death by Procainamide: Medication Errors and Toxicity Caroline Heider, PharmD, PGY-2 Clinical Toxicology/EM Fellow at Florida/USVI Poison Information Center-Jacksonville

Procainamide is a class 1A antiarrhythmic used for ventricular arrhythmias. A case report by Croskerry and colleagues described an error of communication in transcription for a patient in the emergency department (ED) receiving procainamide for ventricular tachycardia. In this patient case, the intended dose was intravenous (IV) procainamide 100 mg in 10 mL dextrose 5% (D5W) or normal saline (NS). The procainamide formulation supplied in the ED was a vial containing 1000 mg in 10 mL. The nurse withdrew 10 mL of this formulation, for a total of 1000 mg. Prior to administration, the nurse confirmed with the physician that the “whole thing” was to be provided. The physician assumed the prescribed dose of 100 mg in 10 mL was being given, and agreed “yes.” Ultimately, this error led to administration of IV procainamide 1000 mg over three separate instances during the acute resuscitation. The patient subsequently became hemodynamically unstable, was intubated, and died several days later.

This is an example of a miscommunication transmitted verbally to expedite medication administration in the high-stress ED environment. Contributing factors noted were unfamiliarity with the drug, time pressures, and low quality transfer of information.1 This product was meant to undergo dilution prior to administration, and the patient ultimately received 10 times the intended procainamide dose.

44

The procainamide package insert recommends procainamide as a direct IV injection or IV infusion for lifethreatening ventricular arrhythmias.

Direct IV injections of procainamide should be administered at a rate of 100 mg every 5 minutes, up to maximum rate of 50 mg per minute, until the arrhythmia is suppressed or 500 mg has been provided, at which point further doses are to be held for 10 minutes to allow redistribution. IV infusions of procainamide should be administered at 20 mg per minute, for up to 25-30 minutes, to deliver a total of 500-600 mg.2-3 The maximum dose of procainamide for each of these loading dose techniques is 1000 mg. Additionally, the 2020 American Heart Association (AHA) algorithm for Adult Tachycardia with a Pulse recommends IV procainamide for stable wide-QRS complex tachycardia.

The AHA recommends procainamide at a rate of 20 to 50 mg per minute until arrhythmia is suppressed, hypotension ensues, QRS duration increases greater than 50%, or a maximum dose of 17 mg per kg is given.4 Furthermore, in the PROCAMIO trial, procainamide was dosed as 10 mg per kg, infused over 20 minutes, for wide-complex tachycardia.5 Although the package insert, AHA guidelines, and the PROCAMIO trial provide guidance for procainamide dosing, these sources do not address the preparation for administration.

Procainamide is available as 1000 mg per 10 mL vials (Figure 1) and 1000 mg per 10 mL prefilled syringes (Figure

EMpulse Spring 2021

2).2-3 Both formulations are to be diluted prior to being given in order to facilitate control of the dosage rate, which is 20-50 mg per minute. Dilution may be achieved by placing the 1000 mg per 10 mL concentration in 50 mL to 250 mL of D5W. Procainamide prefilled syringes carry specific marking on the package label stating: “FOR THE PREPARATION OF IV INFUSIONS ONLY.”3 These prefilled syringes are manufactured with a luer lock connector typically associated with direct IV administration. Another medication packaged similarly is epinephrine 1 mg in 10 mL (Figure 3). However, this formulation of epinephrine is intended for direct IV administration and the prefilled syringe of procainamide is not. This procainamide formulation could result

Fig. 1. Procainamide Vial (1000 mg per 10 mL)

in unintentional administration of an undiluted procainamide 1000 mg bolus, despite package labeling stating otherwise. The risk of this error has resulted in specific safety recommendations from the Institute for Safe Medication Practices (ISMP) regarding procainamide prefilled syringes. ISMP recommends stocking procainamide prefilled syringes only in the pharmacy for use to prepare infusions, and stocking procainamide vials in crash carts and emergency supply areas.6 Dosing errors may result in toxicity due to prolonged AV conduction or AV block. Symptoms of toxicity may occur following a single dose of 2000 mg. Other effects that may occur with severe toxicity are seizures, hypotension, QRS and/ or QTc prolongation, ventricular dysrhythmias and respiratory depression.7 Monitoring parameters should include vital signs, mental status, serial ECGs, serum potassium and magnesium, and renal function.

All patients should be placed on continuous cardiac monitoring and managed according to symptoms.

This includes treatment of unstable tachyarrhythmias with cardioversion, hypotension with fluid resuscitation and/or inotropic medications, and torsade de pointes with magnesium.

Your local poison center is available at 800-222-1222 for any questions regarding procainamide toxicity, or to provide assistance with any toxic exposure.

Additionally, sodium bicarbonate 1 to 2 mEq/kg should be provided intravenously for wide-QRS complex tachycardia as it may narrow the QRS complex by overcoming the procainamide-induced fast sodium channel blockade. Other treatments include benzodiazepines for seizures and pacemaker placement for increasing AV block.7 In order to avoid procainamide-related medication errors and subsequent toxicity, procainamide should be stored in accordance with ISMP recommendations. Procainamide vials should be stored in patient care areas, while procainamide prefilled syringes should be stored in the pharmacy for the preparation of IV infusions.

Medical personnel should remember that procainamide requires dilution and the initial loading dose should not exceed the package size. Patients with potential toxicity should be carefully monitored for cardiac adverse events and management will involve symptomatic and supportive care. ■

REFERENCES

1. Croskerry P, Shapiro M, Campbell S, LeBlanc C, Sinclair D, Wren P, Marcoux M. Profiles in patient safety: medication errors in the emergency department. Acad Emerg Med. 2004;11(3):289-99.

2. Procainamide Hydrochloride Injection, USP [package insert].

Lake Forest, IL: Hospira Inc.; 2021.

3. Procainamide Hydrochloride Injection, USP [package insert].

South El Monte, CA: International Medication Systems, LTD.; 2016.

4. Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, O’Neil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM; Adult Basic and Advanced Life Support Writing Group. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020;142(16_ suppl_2):S366-S468.

5. Ortiz M, Martín A, Arribas F, Coll-Vinent B, Del Arco C, Peinado R, Almendral J; PROCAMIO Study Investigators.

Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. Eur Heart J. 2017 May 1;38(17):1329-1335.

6. Institute for Safe Medication Practices (ISMP) Action Agenda. (July-September 2017).

ISMP Quarterly Action Agenda.

Retrieved from https://www. ismp.org/acute-care/july-september-2017.

7. Procainamide. In: POISINDEX Managements [database on the Internet]. Greenwood Village (CO): IBM Corporation; 2021 [updated 2020 Sept 3, cited 2021 Mar 7].

Fig. 2. Procainamide Prefilled Syringe (1000 mg per 10 mL)

Fig. 3. Epinephrine Prefilled Syringe (1 mg per 10 mL)

EMpulse Spring 2021

45

EDUCATION CORNER

Expanding the Menu Beyond the Sandwich: Defining Effective Feedback

By Carmen J. Martinez, MD, MSMEd, FACEP, FAAEM

Feedback is a process to provide learners with information about their performance based on direct observations. Ende defines feedback as information describing students’ or officers’ performance in a given activity that is intended to guide their future performance in that same or a related activity.1 Feedback is considered a pillar of training. It encourages and enhances the learners’ knowledge, skills and professional performance.2 There are three components necessary for effective feedback: giving feedback, receiving feedback and soliciting feedback. All three components must be present for the learner to achieve improvement. The absence of feedback can be misinterpreted as approval or can result in the learner using selfassessment.2 In addition, medical students and residents have stated that feedback, when given effectively, is useful in helping them gauge their performance and making action plans for improvement.3 Medical educators need to be well versed in the different 46

By Caroline M. Molins, MD, MSMEd, FACEP, FAAEM

ways of providing feedback, and learners should also be receptive in its many forms. This article aims to define feedback and its components and review different techniques to give feedback in medical education settings.

An important first step in effective feedback is preparation. The educator must prepare the learner to receive feedback by establishing objectives, goals and expectations. The setting is also important: it should be private.

In addition, feedback should be timely and frequent. The learner should receive feedback as soon as possible to give them the opportunity to remediate behaviors. It should also be based on direct observations so the teacher can give specific and descriptive examples.

Lastly, another step of effective feedback is the delivery. It should clearly be labeled as feedback and should be a two-way conversation that is balanced with positive and negative comments about the behaviors that can be changed. The delivery of EMpulse Spring 2021

feedback should be modulated to the learner’s temperament, personality and generation. Furthermore, the educator must be selective of the behaviors they want to address.

Focusing on one or two issues will help the learner understand the situation and how to address it without feeling overwhelmed. All of these will promote self-assessment, self-reflection and self-directed lifelong learning.4 Feedback can either be formal or informal. Formal feedback is a planned activity, such as semi-annual evaluations. Informal feedback occurs in the moment of a particular educational opportunity, such as feedback after a procedure that is completed in the clinical setting.

Feedback can be discussed as being either formative or summative.

Formative feedback is usually provided in real time during or directly after a specific educational moment and is focused on specific behaviors and skills.

Summative feedback usually occurs

at the end of a course or rotation and provides an end assessment of the learner’s performance. Competencybased education hinges on these types of feedback.

Different techniques have been developed to provide structure and positive feedback. Below are some examples of commonly-used feedback techniques.

Feedback Sandwich: This technique is one of the most used techniques. It is a way to give negative feedback in between two sets of positive feedback.

The sandwich technique is one of the easiest methods to give feedback, making it ideal for novice educators, but it may be disadvantageous as it is a unidirectional technique and doesn’t ask the learner for self-reflection or their plan for success.5 Ask-Tell-Ask: This is an example of a bidirectional feedback technique—an alternative to the feedback sandwich.

It is an excellent way to begin the feedback conversation by asking the learner for a self-assessment. The teacher then tells by acknowledging the concerns the learner has identified, states their observations as an educator, provides feedback about one thing done well and an area of improvement, followed by focused teaching. Last, the educator asks the learner if they understood the teaching and feedback and discusses the learner’s plan for improvement.5 ART: Ask, Respond, Tell: This technique is also bidirectional. The educator first asks if the learner is ready to receive feedback and asks for a self-assessment. The teacher then responds by summarizing the learner’s responses and provides 1-2 educational moments. Lastly, the educator tells the learner their assessment with specific actions and language.6 Pendleton: This bidirectional technique creates a dialogue about feedback by first asking the learner for a self-assessment with particular attention to their positives and negatives. The teacher then provides additional comments and moves to areas of improvement and a plan for

improvement.5 One-Minute Preceptor: This is a teaching technique that incorporates feedback into its model. It is also known as the 5-step micro-skills model. It asks the learner to make a commitment to the diagnosis, then the teacher asks questions to gather supportive data, teaches a general rule, provides constructive feedback highlighting what was well done, and then corrective comments explaining what was done right or wrong.5 In summary, feedback should be a timely, two-way conversation designed to address specific behaviors and develop action plans.

Medical educators should familiarize themselves with available techniques to give effective feedback. Giving feedback will only become easier with practice and time. ■ Pictured: Feedback being provided to learners at EMLRC’s Advanced Practice Provider (APP) Skills Camp in 2018.

REFERENCES:

Daunting Diagnosis: A

By Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief �CONTINUED FROM PAGE 9 This patient suffered a GSW to the right chest that resulted in a right hemopneumothorax and a right 3rd rib fracture. The patient was also found to have a large pulmonary contusion (as seen on CXR and chest CT). This patient received a chest tube that was eventually removed, and the GSW was treated with frequent wet-to-dry dressing packings. The patient continued to have residual dyspnea due to the pulmonary contusion that took about two months to resolve. ■

1. Ende J. Feedback in Clinical Medical Education. JAMA. 1983;250(6):777-781.

2. Mandhane N, Ansari S, Shaikh T, Deolekar S. Positive feedback: a tool for quality education in field of medicine. Int J Res Med Sci. 2015;3(8):1868-1873. doi:10.18203/2320-6012. ijrms20150293 3. Ramani S, Krackov SK. Twelve tips for giving feedback effectively in the clinical environment. Med Teach. 2012;34(10):787-791. doi:10.31 09/0142159X.2012.684916 4. Kelly E, Richards JB. Medical education: Giving feedback to doctors in training. BMJ. 2019;366(July):1-5. doi:10.1136/bmj. l4523 5. Jug R, Jiang XS, Bean SM. Giving and receiving effective feedback a review article and how-to guide. Arch Pathol Lab Med. 2019;143(2):244-250. doi:10.5858/ arpa.2018-0058-RA 6. Cochran N, Davis D, Laponis R, Myers K, White MK. The ART of Providing Effective Feedback.

2014;(859).

EMpulse Spring 2021

47

FEATURE

From Scribing Notes to Saving Lives: The transition from scribing in the Emergency Department to medical school and beyond

By Patrick Anderson, OMS-III Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University

Receiving your acceptance letter to medical school is one of the most exciting and joyous moments in an aspiring physician’s life, but the path taken to receive the letter can be daunting to say the least. One of the biggest contributors to this evergrowing ball of stress and anxiety is finding extracurricular involvement and medical experience that you believe will make you a standout applicant. Is there one experience that is better than the rest? I’m sure this could be answered differently by every healthcare worker you encounter, but I personally know that scribing in the emergency department (ED) not only helped guide me toward a career in emergency medicine, but also gave me the type of exposure and experience needed to be a great medical student.

So what exactly is a scribe and what do they do? As a scribe, you are fortunate enough to accompany the resident, attending or other healthcare provider in every patient encounter as they obtain a history, perform a physical exam and discuss their assessment and plan with the patient. Scribes get to see everything from the sniffles all the way up to Level 1 trauma alerts. They are responsible for writing all the health 48

information collected in the electronic medical record (EMR) in an organized, fluent and detailed manner. This alone is a wonderful learning opportunity, but it gets better. After the initial patient encounter, scribes watch the resident or healthcare provider present the patient to the attending as they discuss the differential diagnosis and workup. If there are residents present, this is likely a teaching hospital, in which there will be educational points made within the discussion. Altogether, scribes get to see a patient encounter from start to finish, all while picking up key skills that they will use throughout medical school, residency and their careers in medicine.

Over my two years of scribing in the ED at UF Health Gainesville, I gained a tremendous amount of knowledge that I did not fully appreciate until medical school. During my first two years of medical school, I was able to answer countless exam questions solely using my prior scribe experience. Learning how to perform a patient exam and write a SOAP note came much easier to me because I had done it so many times before. Not to mention, I also had multiple questions on the USMLE Step 1 exam that I would not have known if EMpulse Spring 2021

not for scribing. Throughout my first year of rotations as a medical student, I noticed that presenting a patient, proposing differential diagnoses, and formulating an assessment and plan came more naturally. The knowledge and skills I had gained from watching thousands of patient encounters and resident presentations as a scribe gave me the confidence to see more patients and get more involved during clinical rotations. Even three years later, I still remembered what scribing had taught me; it’s the gift that keeps on giving.

I knew I couldn’t be the only prior scribe to notice how the job has impacted my medical school career, and I wasn’t wrong. One of my personal mentors, current 4th-year medical student and future EM resident physician at UF Health Jacksonville, Alexa Peterson, had this to say about her scribing experience: “Looking back, if I had to pick, being a scribe prior to medical school was the single most beneficial thing I did to prepare myself for this path. It was what propelled me into the field of emergency medicine.

First, it taught me time management and prioritization, both of which we know are critical for surviving medical school. I was in class and on campus

from 8:00 am to 4:00 pm every day followed by multiple shifts of 5:00 pm to 1:00 am for scribing throughout the week/weekend. This made for some extremely long days and extremely early turnarounds. However, for as extreme and hectic as it seemed some weeks, I wouldn’t have changed it for the world. This is because, more importantly, scribing provided me with the best mentors. I came out of that experience thinking, ‘I want to be one of those docs.’ The physicians I was working with offered guidance on why I should pursue medicine and the admission process, provided teaching points on difficult patients, and were always motivating. These aspects were extremely important because nobody in my family is a physician and I was lacking mentorship at home. Yes, emergency medicine is fast-paced shift-work, with endless variety that can make the specialty appealing on the surface, but for me, it was the people I met in that department that made me feel part of the team and made me feel welcomed in the specialty.”

Not only does the knowledge and experience gained from scribing help you throughout your pre-clinical and

clerkship years of medical school, but it will follow you all the way to residency. Annabeth Johnson, DO, PGY-1 at Morristown Medical Center told me: “The skills I acquired through my time as a scribe helped prepare me for many of the challenges I encountered not only in medical school, but also in my first year of residency. I gained exposure to medical terminology, learned how to properly document and became familiar with formulating a differential diagnosis.

Working alongside physicians trained me to think clinically and allowed me to see firsthand all the different hats physicians wear when it comes to patient care. These are skills that have served me well during my audition rotations and into residency as I work with patients from all walks of life.”

This shows just how impactful being a scribe can be. Four years after scribing, Dr. Johnson is still implementing some of the skills and knowledge acquired from scribing as she cares for her patients every day.

Emergency physicians who have worked directly with scribes know the level of exposure they receive while in the ED writing notes and the immense amount of medical knowledge they EMpulse Spring 2021

pick up along the way. They even notice slight differences in students on audition rotations who have had prior scribe experience. Residency Ultrasound Director and Assistant Program Director of the Emergency Medicine Residency at North Florida Regional Medical Center, Diana MoraMontera, MD, said in reference to her experience working with scribes and medical students with prior scribe experience: “I did my residency at a program with its own scribe program.

I worked side by side with hopeful undergrads who had a better idea of what medicine really is than I did as a third- or fourth-year medical student.

Later as a brand-new attending, I often discussed the differential diagnosis and work up of complicated case presentations with scribes, not only as a way of teaching but also as a sounding board. There is a drastic maturity level and clinical acumen that is obviously identifiable in medical students who have been scribes. I have noticed that many times during their presentations, medical students with scribe experience do not require as much coaxing to provide a plan and disposition. Don’t get me wrong—we also have fantastic students without prior scribing experience. However, it just seems to come more naturally for students who have scribed in the ED before. Intern year has a huge learning curve, and documentation is part of it.

Residents with ED scribing experience have the documentation hurdle out of the way and can easily focus on the other billion things to learn.”

It goes without saying that if you are a pre-medical student looking for that one experience in medicine to give you an edge, then grab a laptop and head to the local ED because scribing is calling your name. Regardless of the level of education, expertise or perspective, those that have been a scribe or who have worked with scribes all agree that scribing in the ED prior to medical school is an unrivaled medical experience. To this day, I keep in contact with the physicians I scribed for and will cherish my memories as a scribe as they continue to make a tremendous impact on my path towards a career in emergency medicine. ■

49

MUSINGS FROM A RETIRED EMERGENCY PHYSICIAN

The Reds and the Blues of COVID Vaccine Hesitancy

By Wayne Barry, MD, FACEP Former FCEP Board Member

In my last column, I focused on dispelling the myths around COVID-19 vaccination hesitancy. At that time, the vaccine rollout was just beginning.

The Trump Administration pledged to vaccinate at least 20 million people by the end of the year. This was an ambitious goal, and unfortunately it failed with only about 2 million people becoming vaccinated by that deadline.

Newly inaugurated President Joe Biden promised to deliver at least 1 million doses of vaccines in arms per day during the first 100 days of his term. Fortunately despite many bumps in a decidedly uneven road to fully vaccinating the country, President Biden has exceeded his goal, and as of writing, over 3 million Americans were vaccinated against COVID-19 in one day! Moreover, he estimates that every American will have access to the vaccine who wants it by May 1 of this year.

Yet I am still worried about vaccine hesitancy among the general population. I am convinced that the curse of COVID-19 will never stop plaguing us until herd immunity is established. Health experts are fuzzy about what density of vaccination will result in herd immunity. Best guesses are that 70-85% fully-vaccinated U.S. citizens and others living in this country will confer herd immunity to the whole nation. Some scientists admit that they are not exactly sure that this virus will actually disappear under these circumstances.

Now that I am actively engaging in vaccine myth-busting and emphasizing the three pillars of vaccine success (1.

Protect yourself, 2. Protect your loved ones, and 3. Do your part to ensure that herd immunity against Covid is achieved so that Covid vanishes), I have run into another obstacle. If 50

it reaches significant levels, vaccine hesitancy could thwart our collective desire to return to life as we knew it before COVID-19. My first area of concern involves a reportedly low vaccine acceptance rate among Black and and Latino people. Part of the reason may be backlash against what some consider blatant inequality in vaccine distribution, which seems to favor vaccine delivery to more upper socioeconomic neighborhoods in some states, including Florida. Even if this is true, I am not so worried because of the ever increasing availability of the vaccine and the resources to administer it to more and more people. However, there is documented distrust of the medical establishment among these populations in the U.S. with multi-cultural and factorial explanations, which are too complex for me to attempt to describe or even fully understand. These people need to be approached by credible, local healthcare personnel whom they know and trust, and then respectfully informed about the benefits and safety of receiving the vaccine.

Another group of vaccine-reluctant people are, surprisingly, healthcare workers themselves. Some of these overlap the populations and their reasons mentioned above. But no matter what population groups they belong to, COVID-vaccine hesitators need to be reached out to by their trusted colleagues to convince them to take the vaccine. Polls have shown that 49% of predominantly male Republican voters have declared their refusal to take the vaccine. I do not know whether this reluctance is based in their strong beliefs about civil liberties, or whether they are just making a political statement. In any event, I believe their reasoning is misguided, and threatens the lives and safety of so EMpulse Spring 2021

many others. If you know any of these people, please use your relationships to try and convince them to change their minds.

Finally, I would like to discuss the concept of vaccine passports. I strongly recommend you rewatch the film “Contagion” released in 2011 if you haven’t already. The screenwriter Scott Burns consulted with the World Health Organization (WHO) and was inspired by the SARS outbreak. I was amazed by the striking similarities to the presentday COVID pandemic depicted in this film.

One of the features of the film was the fact that all vaccine recipients received a tattoo, which certified their vaccination status. The filmmakers must have thought this was a really good idea, and I agree with them.

Identifying individuals as vaccinated would permit them to safely resume activities of normal life, such as travel, sporting events, concerts and theaters.

In addition, the desire to obtain a vaccine passport may serve as an incentive for some vaccine hesitators to reverse their hesitation toward vaccination in order to resume doing some of the things we all enjoyed during pre-pandemic times. More than 65% of the U.S. population is in favor of vaccine passports, yet some elected officials have chosen to exert their opposition to this concept.

I hope these elected officials will someday listen to the majority of their constituents.

Remember, stay safe and get vaccinated! ■

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 SINCE 1980

A VITAS medical director, working with the patient’s specialist, determines appropriate modalities based on the Continue on page 42plan ▶ of care.

EMpulse Spring 2021

51

ANNUAL CORPORATE PARTNER program.

3717 S. Conway Road, Orlando, FL 32812 www.emlrc.org/fcep | (800) 766-6335

There’s never been a better time to join our

Our Annual Corporate Partners provide support for a variety of projects and initiatives at the Emergency Medicine Learning & Resource Center (EMLRC) and Florida College of Emergency Physicians (FCEP).

Benefits include:

☑

YEAR-ROUND VISIBILITY

☑

DIGITAL & PRINT ADVERTISING

CUSTOMIZABLE PACKAGES

&

☑

so much more

VIP CUSTOMER SERVICE

Meet our 2021 Corporate Partners EM Innovators

EM Dignitary

EM Advocate

JOIN OUR CORPORATE PARTNER PROGRAM TODAY Contact Melissa Keahey Director of Development & Operations 52

mkeahey@emlrc.org (407) 281-7396 ext. 231 EMpulse Spring 2021

Non-Profit Org. U.S. POSTAGE PAID Pontiac, Illinois PERMIT NO. 592

☑

FIRST TO KNOW OF OPPORTUNITIES

☑