EMpulse Spring 2022 by Florida College of Emergency Physicians

EMpulse Spring 2022 1 Official Publication of the Florida College of Emergency Physicians A Chapter of the American College of Emergency Physicians Vol. 29, No. 1 | Spring 2022 Florida accepts 221 residentsEM View Match Lists from Florida's 21 programs » Plus: Where the EM Resident Class of 2022 is Going Next » »INSIDE:Managing Mild to Moderate COVID-19 in Children & Adolescents » Ultrasound Zoom: The {Painless} Fascia Iliaca »BlockHeart Attacks in the Younger Population: A Case of Spontaneous Coronary Artery »DissectionSocialEmergency Medicine: Getting Naloxone out of the ED and into the Community

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EMpulse Spring 2022 33 SPRING 2022 Volume 29, Issue 1 EDITOR-IN-CHIEFMANAGING&DESIGNEDITORPUBLISHER Karen Estrine, DO, FACEP, FAAEM Samanthakarenestrine@hotmail.comLeague, MA Johnsonsleague@emlrc.orgPressofAmerica, Inc. 800 N. Court St. Pontiac, IL 61764 jpapontiac.com EMpulse Fall 2022 EMpulse Fall 2022 will be print + digital. There will be no EMpulse Summer this year. Deadlines:EMpulse Online: Every article published in EMpulse is also published online at fcep.org/empulse. EMpulse Magazine is the official, quarterly publication of the Florida College of Emergency Physicians (FCEP). • Aug. 31: “Intent to Submit” article or advertisement due » • Sept. 14: All content due • October: Fall 2022 in mailboxes & articles uploaded online Intent to Submit Form EMpulse Online Homepage fcep.org/empulse TABLE OF CONTENTS FROM THE COLLEGE FEATURES & COLUMNS 6 FCEP President’s Message By Dr. Sanjay Pattani 7 Government Affairs Committee By Dr. Blake Buchanan 8 Membership & Professional Development By Dr. Shayne Gue 9 Medical Economics Committee By Dr. Danyelle Redden 10 Pediatric EM: Managing Mild to Moderate COVID-19 in Chldren and Adolescents By Dr. John Misdary 11 Call for Revisions and Updates to the PAMI Pain Management and Dosing Guide By the Pain Assessment and Management Initiative (PAMI) 14 Daunting Diagnosis By Dr. Karen Estrine 16 Introducing Florida's EM Resident Class of 2025 By EM Residency Program Staff & Samantha League 20 Next Steps for the EM Resident Class of 2022 By EM Residency Program Staff & Samantha League 26 Ultrasound Zoom: The {Painless} Fascia Iliaca Block By Drs. David Vega & Leila Posaw 36 Case Report: Heart Attacks in the Younger Population: A Case of Spontaneous Coronary Artery Dissection By Drs. Kelly Wright, Hernando Castillo, Jessica Quinones DeEchegaray & Valori Slane 38 Social Emergency Medicine: Naloxone out of the ED and into the Community By Kelley Benck, Dr. Joshua Goldstein, Dr. Naomi Newton & Dr. Emily Brauer 40 Patient Misconceptions about Buprenorphine Induction for Opioid Use Disorder in the Emergency Department By Dr. Heather Henderson, Emily Holbrook, Dr. Bernice McCoy, Dr. Jason Wilson & Breanne Casper 42 Poison Control: ofIdentificationOutbreak:SyntheticBrodifacoum-Contaminated2021CannabinoidOverviewofandManagementtheExposedPatient By Drs. Molly Stott, Chiemela Ubani, Alexandra Funk, Justin Arnold & Dawn Sollee 43 New Over-the-Counter Patient Education Brochures for Topical and Oral Analgesic Medications By the Pain Assessment and Management Initiative (PAMI) 44 Case Report: Thunderclap! By Drs. Graham Clifford & Priscilla Shen 46 The Golden Years: A View from the Bridge By Dr. Doreen Parkhurst 48 Education Corner: Mind the Gap: Appraisal of FOAM By Drs. Carmen Martinez Martinez & Caroline Molins 50 Musings from a Retired Emergency Physician: Isn't Medical Totalitarian?Misinformation By Dr. Wayne Barry 12 EMS/Trauma Committee By Dr. Desmond Fitzpatrick 14 Early Career Physicians By Dr. Dakota Lane 14 EMRAF President’s Message By Dr. Elizabeth Calhoun, PGY-3 15 Medical Student Council By Cristina Sanchez, MS, MS-2 Follow Us to See When Articles are Published Online: /fcep.org /emlrc.org @fcep@fcep_emlrc/company/emlrc @emlrc

Pre-Order Your “Support Healthcare Heroes” Specialty License Plate This is your license plate. Last Session, the Florida Legislature passed SB 676 (2021), authorizing FCEP & FEMF to create a license plate honoring healthcare workers. No other license plate in Florida is dedicated to the healthcare sector — until now. We must sell 3,000 before the plate is manufactured But we are confident we can reach this goal within a year! Learn more at emlrc.org/licenseplate Price: $35 When ordering through the EMLRC Competitors have higher processing fees PRE-ORDER NOW

Florida College of Emergency Physicians Board of Directors: 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

Florida Emergency Medicine Foundation Board of Directors: 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. FROM FLORIDA’S RESIDENCY 24 Orlando Health By Dr. Blaire Banfield Florida Atlantic University By Dr. Tony Bruno 25 HCA Brandon By Dr. Alec Bloom AdventHealth East Orlando By Dr. Shannon Caliri Mount Sinai Medical Center By Dr. Daniel Puebla 26 UF Jacksonville By Drs. Jeanne Rabalais & Chris Phillips HCA Oak Hill By Drs. Ryan Johnson & Mohammad Razzaq USF at Tampa General By Dr. Kenneth Dumas 27 UCF/HCA Ocala By Dr. Megan Rivera HCA Westside/Northwest By Dr. Matt Slane HCA North Florida Emergency Medicine By Dr. Katie Johnson 28 HCA St. Lucie Medical Center By Dr. Nicole Tobin HCA/Mercer Orange Park By Drs. Cody Russell & Ed Hu 29 UM/Jackson Memorial By Dr. Emily Brauer FSU at Sarasota Memorial By Dr. Thomas Cox UF Gainesville By Dr. Megan Rivera 30 UCF/HCA Healthcare GME Consortium Emergency Medicine Residency Program of Greater Orlando By Dr. Amber Mirajkar HCA Florida Kendall By Dr. Kelly Wright

Roxanne Sams, MS, ARNP-BC, MA Maureen France

Jordan Celeste, MD, FACEP

Sanjay Pattani, MD, MHSA, FACEP

SECRETARY-PRESIDENTPRESIDENTVICETREASURERMEMBERS Ernest Page, MD, FACEP

ADVERTISER INDEX 2 Envision 35 VITAS 46 EMPros All advertisements in EMpulse are printed as received from advertisers. The Florida College of Emergency Physicians does not endorse any products or services unless otherwise stated. FCEP receives and distributes employment opportunities but does not review, recommend or endorse any individuals, groups or hospitals that respond to these advertisements. Opinions stated within articles are solely those of the writers and do not necessarily reflect those of the EMpulse staff, the Florida College of Emergency Physicians, our advertisers/sponsors, or any of the institutions our writers are affiliated with. Advertise in EMpulse Fall 2022 PRINT + DIGITAL Each print advertisement purchase comes with complimentary digital banner ads Learn More

PROGRAMS TABLE OF CONTENTS CONTINUED

UPDATES

Kristin McCabe-Kline, MD, FACEP, FAAEM, ACHE Melissa Keahey Rajiv Bahl, MD, MBA, MS; Blake Buchanan, MD, FACEP; Elizabeth Calhoun, MD (EMRAF Representative); Kyle Gerakopoulos, MD; Jesse Glueck, MD; Eliot Goldner, MD, FACEP; Shayne Gue, MD, FACEP; Erich Heine, DO; Saundra Jackson, MD, FACEP; Shiva Kalidindi, MD, MPH, MS(Ed.); Amy Kelley, MD, FACEP; Gary Lai, DO, FACOEP; Dakota Lane, MD, FACEP; Russell Radtke, MD; Todd Slesinger, MD, FACEP, FCCM, FCCP; Stephen Viel, MD, FACEP

Damian Caraballo, MD, FACEP

SECRETARY-PRESIDENT-PRESIDENTELECTVICEPRESIDENTTREASURERIMMEDIATEPAST-PRESIDENTINTERIMEXECUTIVEDIRECTORMEMBERS

Aaron Wohl, MD, FACEP

EMpulse Spring 2022 5

Tuesday, May 10, 2022

Joint FCEP/FEMF Board of Directors Meeting 12:30 pm - 3:30 pm EMLRC in Orlando, FL All members are invited to attend committee & Board meetings Remember what drew you into the practice of emergency medicine and continue to embrace the specialty, our members, and our residents with the same vigor. “

By Sanjay Pattani, MD, FACEP, MHSA FCEP President 2021-2022 My fellow members and peers, spring is here! There are so many things I look forward to in the springtime — longer days, spring break with the kids, and outdoor activities in the warmer weather. For many of us, this spring also brought a noticeable downwards trend in ED volumes (a possible pandemic pause?). While this may provide you with a break from the non-stop daily grind in the trenches, some may also view this with concern regarding staffing and income stability. This trend is coupled with high hospital census and overcapacity, which exacerbate ED boarding and promote unsafe waiting room medicine. Yet this is where emergency physicians shine – innovating ways to deliver care to the patients that need us in their most vulnerable moments while maintaining high quality acute care medicine, despite space, staff and supply limitations. I have told each of you before that I firmly believe you are among the most intellectually nimble group I know, and your agility to create solutions in times of duress sets you apart from the rest of the medical staff. On another note, no doubt you all have already become aware of the 2022 EM Residency Match results. You may also be familiar with the joint statement from ACEP and seven other organizations on this match. Although there has been significant discussion regarding the match results, I’d like to emphasize that we should communicate what we know and lean away from what we fear. I urge you to maintain objectivity, focus and optimism. After we gather results from SOAP and have time to discuss the real issues with multiple stakeholders, like our residency program directors, ACEP will weigh in more, as will FCEP. The Florida College of Emergency Physicians is dedicated to providing Florida citizens with the highest quality emergency medicine in the world. We stand with our trainees, medical students and training programs to ensure Florida continues to have the highest standards and commitment to emergency care for its Remember,citizens. the ED is often the only place to which a patient or family can turn, and your actions have a major impact on patients and families. When seconds matter, you are there. Remember what drew you into the practice of emergency medicine and continue to embrace the specialty, our members, and our residents with the same vigor. You will always provide value to your emergency room and acute care patients. I hope you, your friends and your family are enjoying the spring in ways that bring value, refreshment and happiness to all. ■

Wednesday, May 4, 2022 EMRAF Committee Meeting 4:00 pm - 5:00 pm Rosen Plaza in Orlando, FL during Life After Residency 2022

Membership & Professional Development Committee 9:00 am - 9:55 am EMLRC in Orlando, FL Education & Academic Affairs Committee 10:00 am - 10:55 am EMLRC in Orlando, FL Medical Economics & Government Affairs Committee 11:00 am - 11:55 am EMLRC in Orlando, FL Lunch (provided) 12:00 pm - 12:30 pm EMLRC in Orlando, FL

EMpulse Spring 20226 FROM THE COLLEGE FCEP President’s Message

Read ACEP's joint statement on the 2022 Match by scanning now.

Next FCEP Board & Committee Meetings

Emergency Treatment of Minors Without Parental Consent (SIGNED INTO LAW) This bill fixes a glitch in a bill from last year’s session that unintentionally made it against the law for physicians to provide emergency medical care outside of the hospital to minors without consent of the parents, such as sporting events, pools, or the beach when helping a minor in need of emergent care. Telehealth Practice Standards (SIGNED INTO LAW) SB 312 allows physicians to prescribe schedule III, IV, and V drugs via telehealth. This bill codifies changes that were made during the COVID state of emergency that have shown to be beneficial enough to keep on after the state of emergency ends. However, “audio-only” telehealth visits do not qualify as telehealth under this bill.

COVID-19-related Claims Against Healthcare Providers (SIGNED INTO LAW) Protections that were passed last year were set to expire at the end of March, 2022, but SB 7014 extends the liability protections already in place until June 1, 2023. PIP Repeal (FAILED) After being vetoed last year by the Governor, PIP repeal was again brought up in both the House and Senate, but was defeated before receiving votes on the floor of either chamber.

Government Affairs Committee

This spring we have seen another busy and often contentious legislative session wrap up in March as the legislators in Tallahassee all turn their eyes towards campaigning for this fall’s election. Your team at FCEP has worked hard advocating for emergency physicians while also making sure to not be caught in the middle of any contentious battles. Most of the oxygen in the Capital this year was consumed by battles over redistricting, the budget and messaging bills. However, a few bills that have great importance on the daily lives and practice of emergency physicians were debated. Here are some of the big ones and how they affect us:

EMpulse Spring 2022 7

Step Therapy Protocols (SIGNED INTO LAW) HB 459 defines what “step therapy” is and outlines the requirements for insurers must provide a method for applying for protocol exemptions to physicians and patients. Pharmacies and Pharmacy Benefit Managers (PBMs) (SIGNED INTO LAW) HB 357 gives the Office of Insurance Regulation the power to fine PBMs that are not appropriately registering with the agency under current law and moves the audit provisions of the Florida Pharmacy Act to the Florida Insurance Code. It also gives pharmacies the ability to appeal findings made by insurers or PBMs through the existing independent dispute resolution process we currently use as physicians with Asinsurers.Imentioned before, we are gearing up for another election this fall and will again be advocating for emergency physicians throughout the state. We need your help getting our feet in the door. Please consider contributing to the FCEP PAC on page 31. Thank you all and take care. at fcep.org/sbs Point FL

COMMITTEE REPORT

Bonita Springs,

■ Register Now

By Blake Buchanan, MD, FACEP Committee Co-Chair | FCEP Board Member

August 4-7, 2022 Hyatt Regency Coconut

Deadline: August 31 Leadership Academy Chair Dr. Stephen Viel will be at Symposium by the Sea 2022 to answer questions from prospective applicants.

Withhiatus.all of this noted, I’m disheartened to see there are almost 2,000 ABEM certified (or eligible) physicians in Florida who are currently not members of FCEP/ACEP. I attribute this mainly to the cost-cutting measures of CMGs no longer supporting group membership, but it’s also the fault of the divisive rhetoric played out on social media daily. To top it all off, we can do a better job of spreading the word about what FCEP is doing for EM across our state and the entire country. If you or a colleague is not a member, please reach out to myself or René Mack today. We want to ensure you have your questions answered and your voices heard. FCEP has always been about doing what’s best for our specialty and our patients — although the challenges are daunting, we can weather this storm together. There is power in numbers, and we need your support, your voice, and your membership to win this war. ■

Annual Application

Membership & PD Committee

Apply for the Next Class of the LEADERSHIP ACADEMY

Learn more in our Leadership Academy brochure at fcep.org/la

EMpulse Spring 20228 EMpulse Winter 2022 As we emerge from yet another wave of the COVID-19 pandemic, despite our triumphs as emergency physicians, it seems that many of the most important challenges in the history of our specialty persist. From extreme staffing shortages, to the abundance of new emergency medicine residency programs, to the projected oversupply of emergency physicians in the next decade, we are at a crossroads for determining the future of our specialty. Coupled with these intrinsic factors are the external forces threatening patient care: the increase in private equity, inappropriate scope of practice expansion, and (to put it plainly) evil insurance corporations focused on a bottom line rather than the best interests of their patients. The road ahead is challenging, but it also presents opportunities to direct our future with the collective intelligence, persistence, and innovation of the strongest community in medicine: emergency physicians. In Florida, there is no organization better equipped to lead this charge than the Florida College of Emergency Physicians. From the outset of the pandemic, we led the way in: organizing drives to secure PPE for healthcare workers; supporting mask mandates in a state where politics was seemingly more important than science; educating the lay public on the importance of, and safety associated with, vaccinations; and continuing to fight for legislation that protects our patients and healthcare professionals. In a few short months, you are invited to see it played out firsthand as we come together in Bonita Springs for Symposium by the Sea 2022 on August 4-7 at the Hyatt Regency Coconut Point. Be a part of the collaboration, innovation, and opportunity that arises from this collection of some of the best and brightest emergency medicine has to offer! SBS is representative of the return to "normalcy" in a full slate of educational programs returning to live, in-person, events after our pandemic

COMMITTEE REPORT

By Shayne Gue, MD, FACEP Committee Co-Chair | FCEP Board Member

ACEP had great success in working with CMS to increase the value of ED E/M codes for 2021, more than offsetting the PFS cuts. We continue to advocate for increased value for the services provided by emergency physicians in 2022. ACEP also continues to advocate for stable Medicare reimbursement with more appropriate annual increases in the face of a recommendation by the Medicare Payment Advisory Commission that Medicare continue the physician fee payment freeze through 2026. ACEP recently signed onto a letter from the physician community at large asking Congress to create a long-term solution to provide stability to physician payments rather than recurring one-year fixes. There is hope this year that real progress could be made. A proposed draft of the 2023 physician fee schedule will be released midyear. (Adjusting for inflation, the Medicare physician fee schedule reduced physician pay by 20% over the last 20 years. Anticipated inflation in 2022 is likely to exacerbate the gap, according to the AMA.) Medicare reimbursement will be a key issue addressed at ACEP’s Legislative and Advocacy Leadership conference in Washington, D.C. on May 1-3, 2022. We hope to see you there, advocating for emergency physicians and our patients! No Surprises Act CMS has withdrawn its September 2021 interim final rule (IFR) provisions regarding its interpretation of the No Surprises Act (NSA) and will be reissuing guidance. The No Surprises Act took effect on January 1, 2022. Over the last year, there has been heated debate – and multiple legal challenges – over a flawed independent dispute resolution (IDR) process, which gives insurers an unfair advantage over physicians in arbitration. There was a significant development in a legal battle over the IDR process in March, when a judge found that the process as established by the Biden administration was inconsistent with the NSA and ordered that the policy be withdrawn and invalidated immediately on a nationwide basis. Five other cases are pending, including a lawsuit filed by ACEP. Insurer Downcoding and Denials Across the country, emergency physicians continue to see egregious payor activity including inappropriate downcoding and denials, in some cases based on final diagnosis (in violation of the Prudent Layperson Standard). Legal action against United Healthcare is ongoing. Cigna recently enacted a downcoding policy that has been contested by ACEP, but it does not appear to be in effect yet. Please notify FCEP of inappropriate payor behavior, as these reports are essential for monitoring trends and responding to such threats.

Florida Medicaid Payment Delays Sunshine State Health Plan was fined $9.1 million in response to payment delays for 121,227 healthcare claims for critically ill children with chronic conditions who were receiving care under the Sunshine State Medicaid program and Children’s Medical Services Health Plan. FCEP informed AHCA and OIR of the delays a few months Sunshineago.State maintains the problem stemmed from technical glitches after the company's merger on Oct. 1, 2021. ACHA has demanded that Sunshine State Health Plan provide more details about the problems leading up to the delays and will require the company to demonstrate within 30 days that future claims are being paid promptly through weekly updates. ■

Medical Economics Committee

COMMITTEE REPORT

Emergency physicians continue to face threats to reimbursement in various forms, but there have recently been a couple of significant wins on the state and federal level. As always, continued vigilance and advocacy is essential.

Personal Injury Protection Insurance A bill calling for the repeal of personal injury protection insurance (PIP) did not survive the 2022 Florida legislative session. PIP has been a hotly debated issue in the Florida legislature for decades. The bill would have removed the requirement for Florida drivers to carry $10,000 coverage for emergency medical conditions. This would likely have resulted in significant losses for emergency physician reimbursement. A similar bill was vetoed by the governor in 2021.

Medicare Reform Starting in April, the Medicare sequester that had been temporarily halted during the pandemic will phase back in, beginning as a 1% cut to all Medicare payments and increasing to 2% in July. The sequester is scheduled to last until 2030. An additional delayed sequester of up to 4% may be implemented in 2023. (Thanks to advocacy work by ACEP and other medical societies, the 9.75% cut to the Medicare physician fee schedule planned for 2022 was temporarily averted in December 2021. The “Protecting Medicare and American Farmers from Sequester Cuts Act” passed in December addressed three upcoming cuts to Medicare.)

By Danyelle Redden, MD, FACEP Committee Co-Chair

EMpulse Spring 2022 9

EMpulse Spring 202210 COVID-19 cases among children spiked dramatically during the delta and omicron variant surges. Since the pandemic began, children represent 18.9% of cumulative cases and make up 22.2% of the U.S. population. This fortunately has not equated to hospitalizations. Among reporting states, children ranged from 1.5%-4.6% of their cumulative hospitalizations and 0.1%-1.5% of all child COVID-19 cases resulted in hospitalizations. In all states reporting, 0.01% of pediatric cases resulted in death. MISC (Multisystem Inflammatory Syndrome in Children) has been a concern, with the total number of patients meeting criteria having totaled 6851 with 59 deaths, which equates to 0.05% of all pediatric COVID-19 cases. MISC has remained a high concern in which vaccine effectiveness data has remained uncharacterized according to Pfizer’s data, and there is no data that shows treatment of COVID-19 or any type of Withprevention.therecent omicron surge, many of the previous treatments were deemed ineffective, and there are now only a few treatments available with limited supplies due the federal government’s control over the utilization of resources moving forward in the pandemic. Many states like Minnesota have made the decision based on the resources and availability that only 5% was allotted for pediatric treatment. Vaccination continues to be an effective tool in protecting all from ThereCOVID-19.arerecommendations for the outpatient management of mild to moderate COVID-19 in children and adolescents that will help navigate management challenges. The therapies have been authorized for individuals at highest risk for severe COVID-19 and disease progression, including those who may not be eligible for COVID-19 vaccination, have an underlying medical condition, or are receiving therapies that are known to result in a poor antibody response to vaccination. Current evidence remains limited regarding which underlying medical conditions are definitively associated with an increased COVID-19 risk in Therechildren.continues to be a paucity of pediatric-specific data regarding the safety, efficacy and pharmacokinetics of monoclonal antibodies and oral antiviral medications across all pediatric age groups, and no such data has been produced moving into year two of the pandemic. The NIH COVID-19 Treatment Guideline

Pediatric EM: Managing Mild to Moderate COVID-19 in Children and Adolescents

By John Misdary, MD, FACEP Committee Co-Chair Panel’s current outpatient treatment recommendations for mild to moderate COVID-19 in outpatients are Sotrovimab, Remdesivir, Paxlovid and Molnupiravir. The criteria for Sotrovimab for COVID-19 treatment has been the same as it has been for the previously approved monoclonal antibody treatments. They include: non-hospitalized patient ≥12 years of age and weighing ≥40 kg, laboratoryconfirmed SARS-CoV-2 infection, mild to moderate COVID-19 and within 10 days of symptom onset, and high risk for progressing to severe COVID-19 and/or hospitalization. With the limited supply and safety data, the children must meet one of the high risk criteria in order to qualify for therapy. The high-risk criteria in the FDA EUA for monoclonal antibody include: BMI ≥ 85th percentile for age and gender based on CDC growth charts, immunosuppressive disease, receipt of immunosuppressive therapies, neurodevelopmental disorders, medical-related technological dependence that is not related to COVID-19, sickle cell disease, congenital or acquired heart disease, chronic lung disease, asthma or other chronic respiratory disease that requires daily medication for control, diabetes, chronic kidney disease, pregnancy, and chronic liver disease.

COMMITTEE REPORT

emlrc.org/flpedready Free Pediatric Emergency Resources for EDs & EMS agencies Plus State EMS for Children Meeting Minutes and Resources Stay informed on pediatric readiness

Current NIH guidelines recommend the use of molnupiravir in eligible patients only when monoclonal antibody, Paxlovid, or remdesivir cannot be used. There will be varying access to monoclonal antibodies and antivirals geographically, requiring additional triage for patients at highest risk for COVID-19. State and local health departments will allocate therapies to healthcare facilities prioritizing the treatment of COVID-19 in patients at highest risk for COVID-19 complications and hospitalizations. This means supplies may be scarce for pediatric treatment and must only be given to those who truly meet the criteria put forth by the FDA. Other than supportive care, therapeutic interventions for children and adolescents with mild to moderate COVID-19 will be limited. Parents/ caretakers will be concerned and scared when their child is diagnosed with COVID-19 and will want some therapeutic intervention. Many people have heard of these treatments for COVID-19 and may ask about the option. With the limited safety and efficacy data supporting their use in children and adolescents under 18, a serious discussion about the risks, benefits, and shared decision-making with the parents/caretakers may be the best path forward. ■

EMpulse Spring 2022 11

The Guide contains six distinct panels of information, including oral, nasal, parenteral and topical medications for acute and chronic pain and procedural sedation, as well as patient safety, discharge planning and nonpharmacologic management Pleaseinformation.contact the PAMI team at pami@ jax.ufl.edu to share your input and be part of this year’s revisions. The Guide will also undergo revision by the PAMI multidisciplinary stakeholder team based on review of current medical literature and practice guidelines. Once finalized, it will be available online as a free access resource with an option to print or download.

The Pain Assessment and Management Initiative (PAMI) at the University of Florida College of Medicine –Jacksonville is preparing to make updates to the 2020 Pain Management and Dosing Guide. The Guide is a comprehensive tool for managing adult and pediatric pain in the emergency department and other health care

To contact PAMI, email us at pami@jax.ufl.edu or call (904) 244-4986.

The early use of intravenous remdesivir and new oral antiviral medications molnupiravir and Paxlovid have been evaluated in controlled clinical trials among non-hospitalized, high-risk individuals with mild to moderate COVID-19 and have been found to improve COVID-19 outcomes including disease progression, hospitalization, and death. Current NIH recommendations favor the use of Paxlovid followed by sotrovimab and remdesivir for mild to moderate COVID-19 in outpatients. Molnupiravir should only be considered in those over 18 if the three options are not available or clinically cannot be used. The EUA authorizes the use of remdesivir IV in children weighing at least 3.5 kg and with laboratoryconfirmed COVID-19, who are within 7 days of symptom onset, at high risk for progression to severe COVID-19, and not hospitalized for COVID-19. However this requires daily infusions on three consultative days, which can be difficult to coordinate in the outpatient setting. The FDA issued an EUA for the use of oral antiviral therapy for the treatment of mild to moderate COVID-19 at the end of December on the basis of results of a Phase 2/3 randomized, double-blind, placebo-controlled trial in high-risk individuals ≥18 years of age. There is no pharmacokinectic or pharmacodynamic data on anyone under the age of 18. Furthermore, there is no safety or efficacy date on this population as well. The EUA authorizes the use of Paxlovid in: children ≥12 years of age and weighing ≥40 kg, with laboratory-confirmed CVOID-19, are within 5 days of symptom onset, and who are at high risk for progression to severe COVID-19 and not hospitalized for COVID-19. Paxlovid should not be used in individuals with severe hepatic or renal impairment, and there is a potential for severe drug-drug interactions if given concurrently with other medications that rely on or induce CYP3A enzymes for metabolism and clearance, which include antiarrhythmics, oral drugs.antineoplastics,immunosuppressants,anticoagulants,anticonvulsants,andneuropsychiatricTheEUAauthorizestheuseof molnupiravir in: individuals ≥18 years of age with laboratory-confirmed SARS-CoV-2, who are within 5 days of symptom onset and at high risk for progression to severe COVID-19, and for whom other, FDA-authorized COVID-19 treatment options are not readily accessible, available, or clinically appropriate. Children were not eligible to participate in the study because of concerns about effects on bone and cartilage growth. No dosage adjustments are needed in patients with renal or hepatic impairment of any degree. Molnupiravir is not recommended for use in pregnancy given the potential of fetal harm.

Thesettings.PAMI team welcomes your clinical review and feedback to assist us in revising the current version to ensure we are providing the latest evidence based information in a concise resource. We are requesting your suggestions for information to add, remove or rearrange content.

1. FDA Takes Actions to Expand Use of Treatment for Outpatients with Mild-to-Moderate COVID-19. Jan. 21, 2022. Access at moderate-covid-19treatment-outpatients-mild-fda-takes-actions-expand-use-events/press-announcements/fda.gov/news-

Stay connected with us on Facebook and LinkedIn for our latest updates. ■

REFERENCES

Call for Revisions and Updates to the PAMI DosingManagementPainandGuide

August 5, 2022 at Symposium by the Sea Stay tuned via email and at fcep.org Director. A major congratulations to both! They have set high expectations for the future of EMS in the state of FAEMSMDFlorida. is celebrating its 40th anniversary. More to come regarding events and celebrations from EMLRC and FAEMSMD. The recording has wrapped up on the EMS educational matching grant, Bytes You can View. Dr. Abo, Dr. Frank, and the team at EMLRC will finish editing these 15-min video modules and make these available for EMS crews across the state. Many thanks to all involved! Florida EMSC is asking that everyone completes the pediatric readiness surveys. This survey is important for ongoing funding of state EMSC partnership grant programs. To begin, visit emscsurveys.org, select Florida as your state, identify your county from the drop-down menu, then select your agency name. The questionnaire should only take 10-15 minutes to complete. ■ Two thumbs down:

ANNIVERSARY

EMNote.orgEmergencyVentilationbyReubenStrayer

By Desmond Fitzpatrick, MD, FACEP Committee Co-Chair

Another helpful reminder comes from Reuben Strayer: "ventilation is the most important skill in airway management. It is more important than laryngoscopy… If you are outstanding at laryngoscopy but average at ventilation, you're in a bad position." He follows with, "this leads to bad patient outcomes and a sad doctor. If you are average at laryngoscopy but outstanding at ventilation, things are good… Regardless of what's happening with laryngoscopy, when you can ventilate, you can take as long as you need, pressure's off; happy day."

EMS/Trauma Committee Update Significant leadership changes on the state level have occurred in the past couple of months. Former state EMS Medical Director, Dr. Kenneth Scheppke, has been named Florida's new Deputy Secretary of Health. In his place, Dr. Angus Jameson has taken over as the new state EMS Medical Next CommitteeEMS/TraumaMeeting

Join now at faemsmd.orgOUR 40TH

EMS/Trauma Committee

EMpulse Spring 202212 COMMITTEE REPORT

"Sometimes less is more," a quote attributed to Shakespeare, serves as a reminder that all too often, we get fixated with technology and advancement. Instead, it would do our patients and us well to remember that we may have the best outcomes if we focus on delivering simple care well. This BLS before ALS concept frequently gets overlooked. Regarding cardiac arrest outcomes, high-quality CPR and early defibrillation — both BLS skills — greatly outweigh drugs, intubations, or other advanced procedures.

The ability to masterfully BVM the most challenging patient is often relegated to the least experienced person on the scene or in the room. This frequently is the opposite of what the patient needs. If we cannot achieve airway and breathing, we should not move on to other therapies. I urge all levels of providers out there to think about their comfort level with ventilating a difficult patient and learn about ways to improve this skill. Consider practicing, developing a failed ventilation troubleshooting algorithm, and learning about new methods like the two-person "thumbs down technique." Remember, when you can bag a patient, you have time!

CELEBRATING

It’s 4:00 am in the ED. The end of your shift is in sight, and the empty room in the back corner is inviting you to take a nap. You might have even forgotten for a moment that the shift is single coverage, since the ED has gotten so quiet — I mean, chill. And then it happens: the patient who comes in with everything wrong, needing resources you don’t have. Appropriately caring for this patient requires medications that aren’t in your Pyxis, specialists that aren’t on call, and, oh, by the way, needing that procedure you’ve never done. You know the one I mean: the procedure you’ve secretly hoped for and dreaded, the one you had the lucky misfortune to avoid in residency. It’s the horrifying moment when you look around for an attending and realize, it’s YOU! So, you look for a smarter attending: an “attendier” attending. Every physician in their early career has had this moment. If you haven’t yet, you will. Although you can’t entirely prepare for them, you can have a plan—and that, somehow, makes it just a little bit easier.

1. Reach for your resources. Some physicians in their early career feel a mild sense of embarrassment when they use reference materials while on shift, especially when you’ve been out for a few years. Don’t feel embarrassed about this. Anyone with perfect recall of the full breadth of medical knowledge is either fictional or already being studied in Area 51. Our scope is enormous, and we chose a field that requires a lifetime of learning. It doesn’t make you a bad doctor if you need to look up how to place a chest tube because you haven’t done one in two years, or if you can’t remember all of the pediatric ACLS doses. If you feel self-conscious, you can say out loud, “I just want to double check to make sure I got this right.” Practicing emergency medicine is an open book test. Take the win. 2. Call a consult. Yes, even at 4:00 am. When I use the term “consult” here, I don’t just mean specialists. Think about your former attendings, mentors, colleagues, or EM friend groups. Someone is bound to be up at any time of night. Consider your former residency classmates, who know exactly what you’re going through. At odd hours, talk to a fellow EM doc in another time zone, a nocturnist, or a medical social media group (while keeping HIPAA in mind). Talking through a clinical scenario can help give you new ideas, or catharsis after a tough case. Healthcare functions as a team system because we benefit from the input of multiple minds. Don’t forget about the knowledge of your RTs, veteran ER nurses, or other in-house staff who might have a solution to that major problem in your resuscitation, devastating equipment failure, or whatever weird circumstance arises. Recognize your limitations. On the topic of actual specialist consultations— don’t be afraid to call a consult, even in the middle of the night. If you’re in a sticky situation that overlaps with the territory of another specialty, get them involved. The worst thing they can say is “sorry, I can’t help,” and the best thing they can say is something that will save your patient’s life.

3. Trust your gut. You trained for this. Trust the years of residency training that were designed to prepare you for this moment. In those moments of paralyzing indecision, go back to the basics if you need to: the ABCs. You know how to improvise. Follow your instincts. Despite the multiple flaws in the world of medicine pictured in House of God, they did get one piece of advice right: “the first procedure is to take your own pulse.” Slow down and assess the situation. Focus on doing what you can. In those terrifying moments that come, you won’t be able to save every patient. Some days we fight the god of death and lose. Even though it might feel like you’re alone, you aren’t. You’ve got resources. You’ve got colleagues. Most importantly, you’ve got a residencytrained emergency medicine physician: YOU. ■

EMpulse Spring 2022 13

Early Career Physicians

By Dakota Lane, MD, FACEP Subcommittee Co-Chair | FCEP Board Member

COMMITTEE REPORT

MeetingsCommittee

news

click

by uniting together. FCEP offers a way for residents to become involved right from the beginning of their training. With most programming free for residents, please take a look at what events will best suit you or your residents this upcoming year. With Life After Residency now scheduled in the spring, the continuation of the well-loved Symposium by the Sea on August 4-7, 2022, legislative involvement in Tallahassee each January or March, contributions to our growing EMpulse Magazine, over 11 committees and available positions within EMRAF – there are convenient ways for each resident to be minimally or heavily involved. Are you receiving FCEP updates? Are you connected to our state ACEP chapter’s ongoings? It takes only a moment to sign up by fcep.org/emnews-nowvisitingandsimply the orange to in the bottom periodic emails with EM and events. President’s

right to receive

Message

■ COMMITTEE REPORT EMRAF

EMpulse Spring 202214

CONTINUE

Daunting

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By Elizabeth Calhoun, MD, PGY-3 Committee Chair EMRAF May 4, 2022 4:00 pm - 5:00 pm Rosen Plaza in Orlando, FL during Life After Residency August 4-7, 2022 Hyatt Regency Coconut Point in Bonita Springs, FL during Symposium by the Sea Stay tuned via email and at fcep.org

A 38-year-old male psychiatric patient presented to the emergency department after self-inflicting a wound to his abdominal cavity. The patient has a history of repetitive self-harming behaviors. Fig. 1 is a photograph of the patient’s abdominal wound. Fig. 2 is a CT scan of the abdomen and pelvis. What is the patient’s diagnosis? By Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief Diagnosis: Q ON PAGE 47 ▶ Fig. 2: CT enhancementdemonstratingofaforeign body in the subcutaneous tissue. Fig. 1: Self-inflicted abdominal wound.

Congratulations to our newly matched emergency medicine residents and to the programs who have worked so hard this year to recruit virtually! We know that it has not been easy. With overall application of medical students into emergency medicine down by 17% in the last year, more than any other speciality according to AAMC data, it is as important as ever that we support our speciality. Advocating for emergency medicine and promoting its quality and importance is part of our role and one of the best ways to remain our patients’ advocates. How can we do this during this rocky wave for EM residents, with growing numbers of Florida programs, workforce limitations, pandemic conditions for trainees and new graduates, and decreased interest in the Thespeciality?answerisclear:

students have witnessed the specialty’s exponential growth in recent years and understand that with it comes adjustments and factors that may take time to normalize, as evidenced by this year's match results,” said Veronica Abello, OMSIII. “However, we are excited about the opportunities that come with new programs and hopeful about the future of emergency medicine.” Despite these issues, watching Match Day and seeing our upperclassmen matching with EM programs was extremely motivating, and we continue to be excited by what the future of EM holds.

May 4-5, 2022 Rosen Plaza in Orlando, FL Learn More at fcep.org/lar FCEP’s Life After Residency event provides emergency medicine residents the opportunity to meet employers, learn valuable life lessons, and spend time together outside of the hospital in a relaxed, educational environment.

Medical Student Council

COMMITTEE REPORT

EMpulse Spring 2022 15

THRIVING BEYOND MEDICINE

Expectant first-, second-, and thirdyear students are also very excited to attend Symposium by the Sea this year in Bonita Springs, FL from August 4-7. We cannot wait to connect with EM physicians, residents, nurses, physician assistants and fellow students in person at this year’s Symposium.

By Cristina Sanchez, MS, MS-2 MD Candidate, Florida State University FCEP Medical Student Council Secretary-Editor

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The Medical Student Council is excited to share our ongoing collaboration with Emergency Medicine Interest Groups (EMIGs) in the state of Florida on brainstorming creative ways to bring emergency medicine topics to medical schools in the state. Many EMIGs are working on exciting events at their schools such as intubation clinics in simulation labs, ultrasound workshops with local EM residency programs, and match panels of M4’s sharing their experience on this year’s cycle. We are eager to see what these students are able to put together in the coming months. A newsworthy topic in emergency medicine has been the Match Day outcomes. We are aware there were 219 unfilled spots nationally and are unsure as to what this may mean for us. “As a student, I was surprised to see 219 unfilled emergency medicine spots for the 2022 match,” said Delaney Rahl, MS-1. “I am not sure if this is a result of the COVID-19 pandemic or what may have been the cause, but I look forward to seeing how the field of emergency medicine continues to progress and how this number may change in the “Medicalfuture.”

Harrison Goldenberg, MD Indiana Univ. School of Medicine

Texas A&M Health Science Center College of Medicine

Eric Bertroche, MD Univ. of Iowa Roy J. and Lucille A Carver College of Medicine

Mount Sinai Medical Center

Jessica Arango, MD St. George’s Univ. School of Medicine

Holly Hall, MD Univ. of South Florida Health Morsani College of Medicine

Scott Walker, MD UCF College of Medicine

Match Day Lists provided by EM Residency Program Staff

Michael Lowe, DO Rocky Vista Univ. College of Osteopathic Medicine

Lucas Eeftink, DO New York Institute of Technology College of Osteopathic Medicine

Orlando Health UF Jacksonville Jared Clements, MD Univ. of Tennessee Health Science Center College of Medicine

Nicolette Natale, DO Nova Southeastern Univ. College of Osteopathic Medicine

INAUGURAL CLASS

EMpulse Spring 202216

Bethany Cooke, MD Indiana Univ. School of Medicine

Christopher Serle, MD Eastern Virginia Medical School

Cheuk Kwok, MD UCF College of Medicine

Kendall Stevens, MD Michigan State Univ. College of Human Medicine

Justin Underwood, MD St. George's School of Medicine

Justin Sharp, DO West Virginia School of Osteo Medicine

Edward Lopez, MD Univ. of Texas at San Antonio

Moshe Bengio, DO Nova Southeastern Univ. College of Osteo Medicine

Carter Jardon, MD Univ. of South Carolina School of Medicine

Gregory Oliva, DO New York Institute of Technology College of Medicine

Joshua Frost, MD Texas Tech Univ. Health Sciences Center School of Medicine

Ariane Kubena, MD

Jason Graf, MD Indiana Univ. School of Medicine

Victor Perez, MD Louisiana State Univ. School of Medicine in New Orleans Nicolai Samuels, MD Morehouse School of Medicine

Nicholas Wilde, MD Univ. of South Dakota, Sanford School of Medicine

Madeline Boulet, MD St. George's Univ. School of Medicine

Gina Jozwiak, MD FSU College of MedicinePensacola Campus Hanna Kulbeth, MD Univ. of Arkansas for Medical Sciences College of Medicine

Gloria Orozco, MD Texas Tech Univ. Health Sciences Center School of Medicine

Ethan Start, MD Univ. of South Carolina School of Medicine – Columbia Morgan Sweere, MD Univ. of Arkansas for Medical Sciences College of Medicine

Scott Davis, MD Washington State Univ. Elson S. Floyd College of Medicine

Shivani Doshi, MD Loyola Univ. Chicago School of Medicine

Lawrence Brundidge, MD Univ. of Virginia School of Medicine

Hana Kayaleh, MD SUNY Upstate Medical Univ.

Jonathan Browne, MD Oregon Health and Science Univ. School of Medicine

HCA Westside

Brittany Jonap, MD FSU College of Medicine

Mitchell Garey, DO Arizona College of Osteo Medicine

Melissa Damaske, DO Lake Erie College of MedicineOsteopathic

Zachary Wetsel, DO William Carey Univ. College of Osteopathic Medicine

Max Trojano, MD Pennsylvania State Univ. College of Medicine

Michael Yanoschik, MD Wayne State Univ. School of Medicine

Rafael Peralta, MD Creighton Univ. School of Medicine

Michael Hinton, DO Nova Southeastern Univ. College Of Osteo Medicine

Thamana Ghani, MD McGovern Medical School at the Univ. of Texas Health Science Center at Houston Otis Green, MD Morehouse School of Medicine

Kristina Hart, MD Wayne State School of Medicine

Edited by Samantha League, MA

Patrick Frost, DO Nova Southeastern Univ. College of Osteopathic Medicine

Shawn Reed, MD Univ. of Utah School of Medicine

Amanda Getz, MD FSU College of Medicine Regional Medical School

Carla Forns, DO Nova Southeastern Univ. College of Osteopathic Medicine

Baileu Peacock, MD FSU College of Medicine

HCA Aventura

Kayla Daniels, MD Texas A&M Health Science Center College of Medicine

CLASS OF 2025 EM RESIDENT Introducing Florida’s

Jacob Wright, MD UCF College of Medicine

Jeremiah Ojha, DO Nova Southeastern Univ. College of Osteopathic Medicine

Harman Kaur, DO Nova Southeastern Univ. College Of Osteo Medicine

Jeffrey Marsh, MD St. George’s Univ. School of Medicine

Nicholas Torgesen, MD FSU College of Medicine

Stephanie Shiffert, MD UCF College of Medicine

Samanthalee Obiorah, MD Brown Univ. Warren Alpert Medical School

Grant Wandling, MD Pennsylvania State Univ. College of Medicine

Joy McLaughlin, MD FAU College of Medicine

Kendra Walbring, DO Lincoln Memorial Univ. DeBusk College of Osteo Medicine

Joseph McShannic, MD Northeast Ohio Medical Univ.

Evelina Arzanova, DO Nova Southeastern Univ. College of Osteopathic Medicine

Jillian Montague, DO Nova Southeastern Univ. College of Osteopathic Medicine

Nicolas Du Fayet De La Tour, DO Liberty Univ. College of Osteopathic Medicine

Rosemary Trewin, MD New York Medical College School of Medicine

Emily Alimia, MD American Univ. Caribbean School of Medicine

Akhil Patel, MD St. George’s Univ. School of Medicine

Christine Ibrahim, MD

Rebecca Heffner, DO Philadelphia College of Osteopathic Medicine

Sarah Liu, MD CUNY School of Medicine

Evan McElroy, DO Nova Southeastern Univ. College of Osteopathic Medicine

Amanda Moorefield, DO Kansas City Univ. College of Osteopathic Medicine

SUNY Downstate Medical Center College of Medicine

Christopher Vance, DO New York Institute of Technology College of Osteopathic Medicine

Rodger Brown, MD Meharry Medical College

Nicholas Chajec, DO New Mexico State Burrell College of Osteopathic Medicine

Mary Lee, MD Tufts Univ. School of Medicine

John Mroz, MD Michigan State Univ. College of Human Medicine

Marcus Nash, MD USF Morsani College of Medicine

Kayla Brubaker, MD Ross Univ.

Cameron Volpe, MD American Univ. Caribbean School of Medicine

Elizabeth Smith, MD Univ. of Louisville School of Medicine

Claudia Tusa, DO Nova Southeastern Univ. College of Osteopathic Medicine

Benjamin Monge, MD Univ. of New Mexico School of Medicine

Tiffany Christian, MD Univ. of South Carolina School of Medicine - Columbia Keenan Dunkley, MD Univ. of South Carolina School of Medicine - Columbia Alyssa King, DO Campbell Univ. Jerry M. Wallace School of Osteopathic Medicine

DeBusk College of Osteopathic Medicine

Vlad Didorchuk, MD

Ariel Fuentes, MD Ohio State Univ. College of Medicine

Mark D. Farchione, MD Univ. of Colorado School of Medicine

Gabriel Jane, MD USF Morsani College of Medicine

Sindhuja Tatagari, DO Liberty Univ. College of Osteopathic Medicine

HCA/USFBrandon

Joanne Bethencourt, DO Campbell Univ. Jerry M. Wallace School of Osteopathic Medicine

Jessica Porterfield, MD Univ. of Arkansas for Medical Sciences College of Medicine

Jessica Tonias, DO Kansas City Univ. College of Osteopathic Medicine

Brittany Munkres, DO New York Institute of Technology College of Osteopathic Medicine

Luis Cabrera, DO New York Institute of Technology College of Osteopathic Medicine

Taylor Dufour, MD Ross Univ. School of Medicine

Alexander Schwartz, MD Medical College of Wisconsin

Lexi Kobishop, DO Lincoln Memorial Univ.

Andrea Arrieta, MD St. George’s Univ. School of Medicine

Robert Ledbetter, MD Wake Forest Univ. School of Medicine

Andrew Hood, MD UF College of Medicine

Tatiana Barriga, MD Loyola Univ. Chicago Stritch School of Medicine

Jonathan Aguilar, MD Florida State Univ. College of Medicine

HCA Kendall Manuel Arzube, MD

Kiran Akbani, DO William Carey Univ. College of Osteopathic Medicine

Debra Linfield, MD Case Western Reserve Univ. School of Medicine Colleen McFarland, MD FSU College of Medicine

Katerina A. Toro Torres, MD Ponce Health Sciences Univ. School of Medicine

Benjamin Duppstadt, DO Lake Erie College of MedicineOsteopathic

Jeannie Kuang-Nguyen, MD Univ. of Arkansas for Medical Sciences College of Medicine

Harmanjit Khokhar, DO Touro College of Osteopathic Medicine - New York

HCA/USFUM/JacksonHealthOakHill

AdventHealthEastOrlando

Nikolas Foresteire, DO Lake Erie College of MedicineOsteopathic

Shawn Covello, MD New York Medical College

Morehouse School of Medicine

Katelyn Schultz, DO Lake Erie College of MedicineOsteopathic

Kimberly Bercy, DO Nova Southeastern Univ. College of Medicine

Nathan Holmes, DO Michigan State University College of Osteopathic Medicine

Connor Brittain, DO Campbell Univ. School of Osteopathic Medicine

Bradley Gershkowitz, MD Medical College of Wisconsin

Andre Girgis, MD Michigan State Univ. College of Human Medicine

Mario Hernandez,EspinosaMD Univ. of Alabama School of Medicine

Jeremy M. Wright, DO Pacific Northwest Univ. of Health Sciences College of MedicineOsteopathic

Gainesville

Jacob R. Eggett, DO Rocky Vista Univ. College of Osteopathic Medicine

Christien Pena, MD American Univ. of the Caribbean School of Medicine

HCA St. Lucie David Gregory, DO Kansas City Univ. College of Osteopathic Medicine

Christian Pilot, MD Cooper Medical School of Rowan Univ.

Austin French, DO Arizona College of MedicineOsteopathic

Regan Schwartz, Jr., MD Univ. of Virginia School of Medicine

Krishen Gosine, DO DeBusk College of MedicineOsteopathic

Courtney Albury, DO Alabama College of MedicineOsteopathic

FloridaUniversityAtlantic

Sandra Cabrera, MD Univ. of Cincinnati College of Medicine

Andres Vega, DO New York Institute of Technology College of Osteopathic Medicine

Hang Nguyen, DO Lake Erie College of MedicineOsteopathic Eric Nordhues, DO Des Moines Univ. College of Osteopathic Medicine

Adrienne Clermont, MD Weill Cornell Medicine

Yaseen Saleh, MD Univ. of Illinois College of Medicine

Brittany Castellanos, MD Wake Forest School of Medicine

EMpulse Spring 2022 17

Ethan Lambert, MD St. George’s Univ. School of Medicine

Wade Chen, MD UF College of Medicine

Kesley Peterson, DO Lincoln Memorial Univ. – DeBusk College of Osteopathic Medicine

Loyola Univ. Chicago Stritch School of Medicine

Eitan Joshua, MD Nova Southeastern Univ. College of Medicine

Ashley Dawson, MD Univ. of Kentucky College of Medicine

Carly Whittaker, DO Nova Southeastern Univ. College of Osteopathic Medicine

Maureen Mohan, MD UCF COM

Mark Yassa, DO Edward Via College of Osteopathic Medicine – Carolinas

Zoe Kinkead, MD USF Morsani College of Medicine

Hannah Sodergren, DO Pacific Northwest Univ. College of Osteopathic Medicine

Lucas Winter, MD Univ. of New Mexico School of Medicine

Chelsea Savona, DO Nova Southeastern Univ. College of Osteopathic Medicine

Ryan Long, MD Univ. of Louisville School of Medicine

Sean Casey, DO Lake Erie College of MedicineOsteopathic

Lauren Brown, DO, MPH Nova Southeastern Univ. College of Osteopathic Medicine

Darielys Mejias Morales, MD Ponce Health Sciences Univ.

Nicholas Murphy, DO Kansas City Univ. College of Osteopathic Medicine

Broward

Andrew Faus, MD Univ. of Miami Miller School of Medicine

Andrew Bobbett, MD Ross Univ.

Ella Modeen, MD St. George’s Univ. School of Medicine

Connor Fraser, MD St. Louis Univ. School of Medicine

Maryam Ossi, MD St. George's Univ. School of Medicine

Daniel Wind, MD USF Morsani College of Medicine

FSU at USFMemorialSarasotaMorsani

HCA/ Mercer Univ. Orange Park

Eva Gorney, DO Lake Erie College of MedicineOsteopathic

Kenneth-Walter “Kenny” Sorensen, DO Lake Erie College of MedicineOsteopathic

Anna Martin, DO Lake Erie College of MedicineOsteopathic

Kent "KC" Grimes, MD Texas Tech Univ. Health Sciences Center School of Medicine

Jennifer Truong, DO Nova Southeastern Univ. Dr. Kiran C. Patel College of Osteopathic Medicine

Michael Simoes, MD FAU College of Medicine

Jessie Cable, DO Kansas City Univ. College of Osteopathic Medicine

Jessica Marie Adams, DO Edward Via College of Osteopathic Medicine-Auburn Justin Clay, MD Medical College of Georgia at Augusta Univ.

Sebastian Fresquet, DO Campbell Univ. Jerry M. Wallace School of Osteopathic Medicine

Brian Darzi, MD American Univ. of Antigua College of Medicine

January Moore, DO Nova Southeastern Univ. College of Osteopathic Medicine

Courtney Lynn Smith, MD Medical College of Wisconsin

David Langley, DO Rocky Vista Univ. College of Osteopathic Medicine

Jaemin Song, MD Oakland Univ. William Beaumont School of Medicine

Gretchen Nonawzki, DO Univ. of New England College of Osteopathic Medicine

Abdullah Nejati, MD FIU Herbert Wertheim College of Medicine

RiveraRoldan, DO Pacific Northwest Univ. College of Osteopathic Medicine

Alexander Hoerig, DO Ohio Univ. Heritage Osteopathic

Krystal Tinney, MD St. George's Univ. Zsa Zsa Whyce, DO Philadelphia College of Osteopathic Medicine

Patrick Anderson, DO Nova Southeastern Univ. College of Osteopathic Medicine

UCF/HCA North Florida EM

Avichai Fagan, DO Nova Southeastern Univ. College of Osteopathic Medicine

UCF/HCAHealthOcala

Adrianne Alisse Buckles, DO Univ. of Pikeville - Kentucky College of Osteopathic Medicine

Aaron Grossberg, DO Lake Erie College of MedicineOsteopathic

Daniel Dagenhart, DO William Carey Univ. College of Osteopathic Medicine

Sara Greenwald, DO Touro Univ. Nevada College of Osteopathic Medicine

Ninoshka “Nina”

Drake Dixon, MD Univ. of Virginia School of Medicine

Nicole Vuong, MD American Univ. of the Caribbean School of Medicine

Alexander Maqueira, DO Alabama College of MedicineOsteopathic

Amir Khiabani, DO Alabama College of MedicineOsteopathic

Devon Khiabani, DO Alabama College of MedicineOsteopathic

Rebecca Jo Thomas, DO Rocky Vista Univ. College of Osteopathic Medicine

Jonathan Martin, MD Texas Tech Univ. Health Sciences Center School of Medicine

Jordan Memmott, DO Pacific NW Univ. of Health Sciences College of MedicineOsteopathic

Morgan Uebelacker, MD Univ. of Kentucky College of Medicine

HealthcareMemorial

John DiFebo, MD McGovern Medical School at Univ. of Texas Health Science Center

Matthew Gonzalez, DO Alabama College of MedicineOsteopathic

Courtney Mason, DO Michigan State Univ. College of Osteopathic Medicine

Danielle Slowey, DO Lake Erie College of MedicineOsteopathic

Nadine Ajami, MD Univ. of Medicine and Health Sciences, St. Kitts

Nicholas Prewitt, MD Oakland Univ. William Beaumont School of Medicine

Jalyn Joseph, MD St. George’s Univ. School of Medicine

David Melton, MD Eastern Virginia Medical School

Ryan Kelly, MD St. George’s Univ. School of Medicine

Michael Dang, DO Campbell Univ. School of Osteopathic Medicine

Kirk Kerkorian School of Medicine at the Univ. of Nevada, Las Vegas Maverick Lasker, DO Kansas City College of Osteopathic Medicine

Nabeel Markatia, MD FIU Herbert Wertheim College of Medicine

UCF/HCA of Greater Orlando

Claire Stringfellow, MD St. George's Univ. School of Medicine

Christopher Fama, MD Temple Univ.- Lewis Katz School of Medicine

Larissa Tavares, MD St. George’s Univ. School of Medicine

EMpulse Spring 202218

Andrew Rice, MD Univ. of Cincinnati College of Medicine

Brooke Burkins, DO Edward Via College of Osteopathic Medicine - Carolinas Michael Cho, MD UCF College of Medicine

Tony Kong Vang, MD Univ. of Minnesota Medical School

Christopher Wallace, MD Texas Tech Univ. Health Sciences Center School of Medicine

Kag Iglinski-Benjamin, MD

Ambika Shivarajpur, DO New York Institute of Technology College of Osteopathic Medicine

EMpulse Spring 2022 19 21 programsresidencymedicineemergencyaccreditedACGMEDistribution of incoming residents by region: 57 NORTH 93 SOUTH OrangeJacksonvilleOcalaParkGainesville 31 CENTRAL KissimmeeOrlando PembrokeBoyntonAventuraBeachFt.LauderdaleMiamiMiamiBeachPinesPlantationPortSt.Lucie 40 WEST BrooksvilleBrandonSarasotaTampa 221 incoming residents BY THE NUMBERS 87 DO’s 134 MD’s COMING148FROM: from another state 50 Floridafrom 23 Caribbeanfrom

Thomas Cox, MD Ultrasound Fellowship, UF Gainesville, FL Courtney Kirkland, DO Global PhysicianSMHCSNetwork/ Sarasota, FL Joshua Lehman, MD Global PhysicianSMHCSNetwork/ Sarasota, FL Darrell Ray, DO Advanced Emergency Ultrasound Fellowship, USF Tampa, FL Kevin Raymond, DO Southeast Georgia Health System Brunswick, GA Mary Roberts, DO Global PhysicianSMHCSNetwork/ Sarasota, FL Alexander Sterling, DO Global PhysicianSMHCSNetwork/ Sarasota, FL Geoffrey Wade, MD Global PhysicianSMHCSNetwork/ Sarasota, FL Melanie Worley, DO Sports Medicine Fellowship, West Virginia Univ. Morgantown, WV FSU at MemorialSarasota

INAUGURAL CLASS HCA/ Mercer Univ. Orange Park Michael Bischof, DO Gadsden Regional Medical Center Gadsden, AL Taylor Bosley, DO FirstHealth Moore Regional Hospital Pinehurst, NC James Michael Broome, DO HCA Memorial JacksonvilleHospital Jacksonville, FL Obianuju Eziolisa, DO Ultrasound Fellowship, Baylor College of Medicine Houston, TX Janae Fry, DO HCA Orange Park Medical Center Orange Park, FL Lauren Karsh, MD Lutheran Medical Center Wheat Ridge, CO Trevor Lofgran, DO HCA West Florida Hospital Pensacola, FL Patrick McKeny, DO Memorial Satilla Health Waycross, GA Ahmad Mohammadieh, MD St. Rita’s Medical Center Lima, OH Cody Russell, MD Mission Health Hospital Asheville, NC Lisa Vaccaro, DO AdventHealth Carrolwood Tampa, FL Derek VanderVelde, DO Mission Health Hospital Asheville, NC INAUGURAL CLASS

Warren Linnerooth, MD McLeod Health Florence, SC JenifferIkponmwosa,Okungbowa-MD GSEP San Antonio, TX Oswald Perkins, MD Anesthesia Critical Care Fellowship, Jackson Memorial Hospital Miami, FL Phillip Plevek, MD Holy Cross Fort Lauderdale, FL Miguel Ribe, MD Jackson South Miami, FL Max Rippe, MD Simulation Fellowship, MedStar Washington Hospital Washington, D.C. Cameron Shoraka, MD Attending Texas Melissa Velasquez, MD Jackson North Miami, FL Joseph Zakaria, MD Undecided

EMpulse Spring 202220

CLASS OF 2022

KendallMedicalRegionalCenter

UM/JacksonMemorial

Lists provided by Residency Program Staff Edited by Samantha League, MA Note: Lists were collected two months earlier than normal this year. Find the up-to-date information each program's residency update at fcep.org/empulse.

Andrew Adams, MD Providence Mission Hospital Laguna Beach Laguna Beach, CA Andrew Allen, MD St. Anthony Hospital St. Petersburg, FL Ma Lovely Batasin, DO Attending Physician CA Caitlin Blackwell, MD Ultrasound Fellowship, Greenville Memorial Greenville, SC Nicolas Ellis, MD Simulation and Education Fellowship, Indiana University Indianapolis, IN Sean Ellis, DO Critical Care Medicine Fellowship, Advocate Lutheran General Hospital Chicago, Il Mani Hashemi, MD HCA Florida Mercy Hospital Miami, FL Tyson Jackson, MD Sports Medicine Fellowship, Univ. of New Mexico Albuquerque, NM Glen Malaret Hernández, MD Ultrasound Fellowship, Jacobi Medical Center Bronx, NY Amar Mittapalli, MD HCA Florida Northwest Hospital Margate, FL Collin Smith, MD Administration & ED Operations Fellowship, HCA Florida Kendall Hospital Miami, FL Kelly Wright, MD Administration & ED Operations Fellowship, HCA Florida Kendall Hospital Miami, FL

most

Carlos Garcia Rodriguez, MD Critical Care Fellowship, UT San Antonio San Antonio, TX Sebastian Gil, MD SCP Health Florida Sarah Jabre, MD Attending Out of the country

Andrea Alvarado, MD Critical Care Fellowship, Univ. of Pittsburgh Pittsburgh, PA Robert Barry, MD Loma Linda Univ. Medical Center Loma Linda, CA Anna Culhane, MD Simulation Fellowship, Rush Univ. Chicago, IL

Next Steps for the EM Resident

Jonathan Hill, MD Attending, Trauma Center Jacksonville, FL Jordan Johnson, DO Undecided Jordan Markel, MD Undecided

USFAventuraatOakHillHospital

BrandonUSFCenteratRegional

Michael Turchiaro, DO Emergency Medical Consultants Fort Worth, TX

Nushin Nataneli, MD Undecided Christian Padgett, MD Undecided Cecilio Padron, MD Undecided Kishan Patel, DO Undecided Itnia Pramanik, DO Attending Ithica, NY

Thomas Peterson, DO St. Mary’s Medical Center West Palm Beach, FL Ali Syed, MD Rio Grande Regional Hospital McAllen, TX

Rebecca Mendelsohn, MD

Fayez Ajib, DO BusinessFellowship,AdministrativeVituity Los Angeles, CA Leeran Baraness, MD Univ. Hospital Plantation, FL Jared Culp, MD Cleveland Clinic Hospital Indian River Vero Beach, FL Amir Hashemi, MD Piedmont Hospital Statesville, NC

Bryce Bergeron, MD Lee Health Fort Myers, FL Greg Black, MD St. Joseph’s Hospital Tampa, FL Bobby Butera, MD Emergency Physicians of Central Florida Orlando, FL Talia Cola, MD Emergency Physicians of Central Florida Orlando, FL Nykole Griddine, MD Emergency Physicians of Central Florida Orlando, FL Bradley Hamlin, MD Broward Health Medical Center Fort Lauderdale, FL Brody Hingst, MD Lee Health Fort Myers, FL Courtney James, MD Mayo Clinic Jacksonville, FL Connor Karr, MD Ultrasound Fellowship, Orlando Health Orlando, FL Lindsay Maguire, MD Research Fellowship, Orlando Health Orlando, FL Sophia Meziani, MD Emergency Physicians of Central Florida Orlando, FL Evelyn Ramirez, MD Simulation & Education Fellowship, Orlando Health Orlando, FL Pooja Sarin, MD Pediatric Emergency Medicine Fellowship, Orlando Health Orlando, FL Alex Tymkowicz, MD Clinical Informatics Fellowship, Orlando Health Orlando, FL Tadashi Updegrove, MD Critical Care Medicine Fellowship, Mt. Sinai NYC, NY William Waite, DO Ultrasound Fellowship, Orlando Health Orlando, FL Jessica Wanthal, MD EMS Fellowship, Prisma Health Columbia, SC Hudi Wenger, MD Simulation and Fellowship,EducationUSF Tampa, FL Orlando Health USF Morsani

Elizabeth Calhoun, MD AdventHealth Palm Coast, FL Spencer Greaves, MD HSHS Sacred Heart & HSHS St. Joe’s Eau Claire, WI

Michael Buchko, MD Undecided Yuya Burkhart, MD TeamHealth Physician Group Traveling Catherine Cantrell, MD Attending Colorado Springs, CO Bryan Hyman, DO Bay Area Emergency Physicians, Morton Plant Hospital Clearwater, FL Tiffany Pleasent, MD EMS Fellowship, SouthwesternUT Dallas, TX Wesley Priddy, MD Hernando County PhysiciansEmergency Hernando County, FL Jared Senvisky, MD Critical Care Fellowship, USF Tampa, FL Larry Seymour, MD Bay Area Emergency Physicians, Morton Plant Hospital Clearwater, FL Michael Weaver, MD Bay Area Emergency Physicians, Morton Plant Hospital Clearwater, FL Travis Weber, MD Lee Physicians Group Ft. Myers, FL Hannah Gordon, MD Health Policy & Advocacy Fellowship, Baylor Univ. Houston, TX Hannah Kim, DO Inova Alexandria Hospital Alexandria, VA Chia-Yuan Lee, DO Sports Medicine Fellowship, Allegheny Health Network Pittsburgh, PA Grethel Miro, MD Baptist Health Hospital Doral, FL Jiodany Perez, MD Sports Medicine Fellowship, Duke Univ. SOM Durham, NC Stefani Sorensen, DO Salem Health Hospital Salem, OR Paige Swalley, DO Northwest Medical Center Margate, FL Mount Sinai Medical

NASA/UTMB’s Aerospace Medicine Fellowship Galveston, TX

Nicholas Bencomo, MD Ultrasound Fellowship, Osceola Regional Medical Center Kissimmee, FL Dhiaa Daoud, MD Cleveland Clinic Vero Beach, FL Arun Malhotra, MD AdventHealth Orlando, FL Kyle Meggison, DO HCA Florida Fawcett Memorial Hospital Port Charlotte, FL Joel Miller, DO HCA Florida South Bay Hospital Sun City Center, FL Juan Rondon, MD Administration Fellowship, Shands Hospital Gainesville, FL

EMpulse Spring 2022 21

Annie Au, DO Attending, Team Health Las Vegas, NV Dasha Dewberry, DO Undecided Justin Harris, DO Undecided

Zachary Stanton, DO Attending, Team Health Tallahassee, FL Brian Szczucki, DO Undecided

Richard Winters, MD St. Anthony’s Hospital Shawnee, OK

FloridaUniversityAtlantic

Benjamin Pirotte, MD Simulation & Medical Education Fellowship, UC Davis Davis, CA Kenneth Roberts, MD HCA North Cypress Houston, TX Trung Tran, MD, MBA HCA North Cypress Houston, TX Nicolas Ulloa, MD Advanced Resuscitation Fellowship, Stony Brook Univ. Stony Brook, NY

Dennis James, MD AdventHealth Kissimmee, FL Osiris Johnson, MD HCA West Houston, TX Nathaniel Pearl, DO Citizens Memorial Hospital Bolivar, MO

Kevin Rivera Rodriguez, MD Undecided Calixto Romero, MD Undecided

2024 •

Yuchen Duan, MD EMS Fellowship, Orlando Regional Medical Center Orlando, FL Saleh Hasan, MD Bayfront Health St. Petersburg, FL Ricardo Hernandez, MD TeamHealth Kissimmee, FL Bryce Hoer, MD TeamHealth Las Vegas, NV Tyler Mills, DO USACS Tampa, FL Joey Ray, MD Medical Education Fellowship, Loma Linda Univ. Loma Linda, CA UF Gainesville John Baker, MD Undecided Manuel Borobia, MD Critical Care Fellowship,MedicineUF Gainesville, FL Graham Clifford, DO EMS Fellowship, UF Gainesville, FL Chelsea Crose, MD University of Florida Gainesville, FL J. Andreu Edge, MD Graduating in Dec. 2022

William Thomas Daly, MD Thomas Memorial Hospital Charleston, WV Jyoti Das, MD HCA Florida North Florida Hospital Gainesville, FL Anthony DeRenzi, DO HCA Florida North Florida Hospital Gainesville, FL James R. Lee, MD EMPROS Advent Health Daytona Beach, FL Marcos Marugan-Wyatt, DO HCA Florida North Florida Hospital Gainesville, FL Jayden Miller, MD Floyd Medical Center Rome, GA Andrew Nicholas, DO Atrium Health Charlotte, NC UCF at Ocala Regional Zack Albaugh, MD St. Anthony’s Hospital St. Petersburg, FL Emily Clark, MD Ocala Regional Medical Center Ocala, FL Michael Hughes, MD AdventHealth Ocala, FL Jean Laubinger, MD Hutchinson Regional Medical Center Hutchinson, KS James Neumeister, MD Corpus Christi Medical Center Corpus Christi, TX

UCF of Greater

UCF/HCAOrlandoNorthFloridaEM

Jonathan Rebik, MD University of Texas Health San Antonio, TX Jacob Ruzicka, MD Saint Francis Hospital Tulsa, OK

J. Joe Fernandez, MD, JD, FCLM University of Florida Gainesville Shikerria Green, MD Undecided David Kuai, MD Toxicology Fellowship, Emory University Atlanta, GA Jonathan Liu, MD AdventHealth Ocala, FL Pooja Mysore, MD Critical Care Fellowship,MedicineUF Gainesville Nykia Porter, MD Undecided Andrew Smith, MD Sports Medicine Fellowship, UF Gainesville Nina Xue, MD Undecided

UF Jacksonville Chelsea Allen, DO Academic Practice, UF Jacksonville Jacksonville, FL Nneka Azih, MD Undecided Grant Barker, MD EMPros Volusia County, FL Richard Courtney, DO Emergency Resources Group Jacksonville, FL Thomas Frauenhofer, DO Baptist Medical Center Jacksonville, FL Francisco Gironza, MD Undecided Kasondra Hartman, MD Ascension St. Vincent Jacksonville, FL John Hurley, MD Fellowship, CommonwealthVirginiaUniv. Richmond, VA Semir Karic, MD Emergency Resources Group Jacksonville, FL Katriin Kivilo, DO Undecided Jessica Ramos, DO Tallahassee Memorial Hospital Tallahassee, FL Alberto Romero, MD Undecided Ronya Silmi, MD Emergency Resources Group Jacksonville, FL Andrew Warren, MD EMS Fellowship, Medical College of Georgia at Augusta Univ. Augusta, GA Parker Young, DO Emergency Resources Group Jacksonville, FL

The following EM residency programs will graduate their first class in: Memorial Healthcare West • Broward Health 2025 • HCA Westside St. MedicalLucieCenter John Choi, DO Undecided Chase Hemphill, DO St. Elizabeth Hospital Appleton, WI Morgan Jensen, DO Sunrise Hospital Las Vegas, NV David Nguyen, DO Hospice & Palliative Care Fellowship, Wake Forest Univ. Winston-Salem, NC Nicole Tobin, DO AdventHealth Orlando, FL Lam Tran, DO EM Ultrasound Fellowship, Mt. Sinai Medical Center Miami Beach, FL AdventHealthEastOrlando

EMpulse Spring 202222

Gideon Logan, MD HCA Florida Osceola Hospital/ Envision Healthcare Kissimmee, FL Jeremy Mayfield, MD Central Florida Parth Patel, MD University of California, Irvine Simulation Fellowship Irvine, CA Mark Rivera Morales, MD HCA Florida Kendall Hospital EmergencyFellowshipUltrasound Kendall, FL Fernando Rivera-Alvarez, MD Envision Healthcare - Envoy Travel team Roger Sliney, MD HCA Florida Citrus Hospital/ Envision Healthcare Inverness, FL Jesse Wu, MD HCA Houston Healthcare/ Envision Healthcare Houston, TX

EMpulse Spring 2022 23 178 28% 65% 54% 46%matchedresidentsoutgoingintofellowshipsjoiningtheworkforce pursued a fellowship in Florida pursued a fellowship in another state Which fellowships have FL EM residents been pursuing over the last four years? Florida EM Fellowship Guide coming soon on fcep.org Florida EM Residency Program Guide 51% staying in Florida 11% still undecided 39% moving out of state 36 21 12 11 10 BY THE NUMBERS

By Tony Bruno, DO, PGY-2

EMpulse Spring 202224

Updates from Florida’s Emergency Medicine Residency Programs

Lastpickleball.butnot least, we want to give our third-year residents who are preparing to become attendings a big thank you for all of your contributions to our program! We are looking forward to seeing how well you will all represent us moving forward. We also want to wish a warm farewell to our wellness director and one of our favorite attendings, Dr. William Benda, who will be retiring at the end of the academic year. Dr. Benda has been serving people in his hometown community and involved in emergency medicine for 40 years. Best of luck in retirement, Dr. Benda; we will miss you.

After a fun interview season, we are beyond excited to welcome our incoming class of 2025. They have all done amazing things in medical school and life, and we cannot wait to welcome them in person to La Familia. We are also happy for our own Dr. Nathan Nuzman, who welcomed a baby boy this month. We are excited to welcome this tiny human into La Familia as well. Dr. Brad Hamlin has been working on a new medical device for increasing efficacy and efficiency in irrigation of wounds in the ER. After many rounds of development and testing, he will be presenting his findings at SAEM in May. Additionally, Dr. Lindsay Wencel will be presenting her research in the field of EMS at the Special Operations Medicine Association’s scientific assembly in May. Dr. Wencel has been very involved with EMS after finding her passion for the subspecialty during the rotation at ORMC. We are lucky enough to have this rotation opportunity and have our faculty as medical directors. Our ER is also becoming a medical control base station, allowing residents (with the help of our attendings) the opportunity to answer radio calls from our EMS first responders. This is an exciting learning opportunity and great training for future responsibilities after graduation! Lastly, a big congratulations to our new chiefs: Drs. Megan Marcom, Parnia Salehi, and Hunter Clonts.

Florida Atlantic University

We survived winter in Southeast Florida and are looking forward to spring days and beach sunsets. First off, we want to extend a big congratulations to our recently matched incoming residents. We can’t wait for you to start! Another round of congratulations is in order for our next chief residents: Drs. Timothy Buckley and Tony Bruno. We have had some very exciting and enjoyable wellness events over the past few months. We most recently went to a Florida Panthers ice hockey game where the Panthers earned a big 6-3 win over the Philadelphia Flyers. A few other wellness events included ax throwing, a beach day, and an afternoon of learning and playing

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Spring Seminar. We have just matched our second class of residents and are excited to have them start in June. With the next academic year about to start, we look forward to having more fourth-year medical students rotate with us in the emergency departments at Broward Health North and Broward Health Medical Center.

Orlando Health By Blaire Banfield, MD, PGY-2 Spring has sprung with full force here at Orlando Regional Medical Center!

By Kevin Boehm, DO, M.Sc, FACOEP, FACEP, FAAEM Program Director Broward Health

It's been a great first year for the Broward Health Emergency Medicine Residency. Our residents have been active with their scholarly activity, having presented posters at the Mayo Clinic Annual Stroke and Cerebrovascular Disease Review as well as at the American College of Osteopathic Emergency Medicine

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EastAdventHealthOrlando

It goes without saying that the last two years have been filled with challenges. However, our residents, faculty and program administrators rose to the occasion of creating an engaging educational environment despite the challenges of Covid-19. Regarding our faculty, we’ve accrued additional fellowship-trained faculty members such as Drs. Colon, Gomez, and Trivedi (hyperbaric, ultrasound, and hyperbaric, respectively). With the addition of these individuals, we now boast a total of 13 specialty boarded and fellowship-trained faculty members. Moreover, since our last EMpulse update, we graduated our inaugural class and had the fortune of matching multiple residents to top tier fellowship programs over the past two years. Our residents earned positions at Georgetown, Dartmouth, and UNC Chapel Hill to name a few! Furthermore, our graduates have matched into a myriad of different fellowships such as critical care, ultrasound, simulation, and EMS. By Alec Bloom, DO, PGY-2 These stellar matches would not have been possible without an excellent academic experience to help our residents reach their goals. Despite a greater emphasis on virtual academics during this pandemic, our program persistently finds ways to further our educational endeavors. From enrolling our residents into online EKG and ultrasound courses to pushing our simulation experiences to new heights with our newly acquired sim equipment, our academics are stronger than ever. Nevertheless, we expect significant growth in the coming months to years. Our hospital is expanding by building new wings, a new GME building, and working to add new training programs in anesthesia and interventional cardiology. Ultimately, these new additions will continue to expand on Brandon’s academic excellence, and we cannot wait to update you on all the positive changes in our next EMpulse article! ■

Hello from Miami Beach and the Mount Sinai Emergency Medicine

Lastly, I’d like to congratulate our new chief residents, Drs. Vlad Mordach and Casey McGillicuddy! We know you both will do an amazing job next year.

By Daniel Puebla, MD, PGY-2

WeResidency!havecome to the close of another unique interview season and are thrilled to congratulate and welcome the new class of 2025. We are extremely excited to meet them and look forward to a wonderful year with these new physicians! While we are excited for our new incoming class, it is always bittersweet to say goodbye to our graduating seniors. We’d like to congratulate Dr. Jiodany Perez for matching into the sports medicine fellowship at Duke University and Dr. Michael Lee for matching into the sports medicine fellowship at Allegheny General in Pittsburgh, both matching into their top choices. We are very proud of you! We would also like to welcome our two new ultrasound fellows for the 2022 academic year: Dr. Melissa Smith from the University of Connecticut and Dr. Lam Tran from St. Lucie Medical Center. We look forward to having you both as part of the Mount Sinai Family! This month, we had a collaborative learning experience with the Aventura Emergency Medicine Residency, where we all participated in SIMWARS. It’s been two years since the start of the pandemic, and it was refreshing to engage in an in-person educational learning experience. We loved working with our fellow EM colleagues! It is hard to believe another year has flown by. From MSMC at sunny south beach, we wish you a safe and happy summer. ■

By Shannon Caliri, DO, PGY-1

Mount MedicalSinaiCenter

Hello again! First of all, I would like to congratulate all of the fourth-year medical students who have matched into emergency medicine. Take this time to refresh and relax before you have to hit the ground running once July 1 comes around. Do not be afraid to lean on your upperclassmen or mentor for support. It’s a steep learning curve again, but you will all do just fine. We are all very excited to meet our new interns and cannot wait to help pave the way for you. With it getting close to the end of the year, the interns are all getting much more comfortable in the department. We are getting used to seeing more patients, establishing a flow, and doing procedures. Our second-years are getting ready to take on their new responsibilities of third-years and help teach the incoming class. Our thirdyears are preparing to step out into the “real world” and practice on their own.

■ UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

EMpulse Spring 2022 25 HCA Brandon

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

By Ryan Johnson, MD & Mohammad Razzaq, DO, PGY-2 HCA Oak Hill Hello from Oak Hill! We’ve had another busy winter season and are excited for summer to arrive. We have lots of exciting updates to share. First and foremost, the rebuild of our ED is proceeding on schedule! Phase 1 is complete, and phase 2 is well underway. We’ve already moved into the new building, and the feedback we have received from patients and guests is overwhelmingly positive. Our entire residency recently attended a simulation day at CAMLS, which was an excellent experience for us all. Our new in-house simulation suite is approaching completion as well. All of our new simulation equipment has been delivered and will be installed in the coming weeks. We are proud to now have dedicated ultrasound machines for simulation, a TEE probe, a Simbionix ultrasound mentor, trauma, OBGYN and pediatric manikins, as well as procedure sims for residents to practice LPs, CVCs and intubations. We would like to congratulate Drs. Lugo and Johnson, who recently represented our program at the WACEM Case Presentation Competition. There were many interesting and unusual cases presented by our national and international colleagues. We look forward to next year's competition. Finally, we would like to welcome the newly matched class of 2025! All of us at Oak Hill are excited for their arrival in the summer. This also means that our current PGY–3 colleagues will be graduating soon. We are thrilled to announce that all six of our seniors will be staying in the state of Florida! Two of the seniors will go on to complete fellowships: Dr. Rondon will be going to the University of Florida to pursue an administration fellowship and Dr. Bencomo will be joining Osceola Regional as an ultrasound fellow. We’re so proud of our entire PGY-3 class; they will be missed dearly. Best of luck to them as they go on to become attendings. ■

Greetings from the EM family here at USF/TGH. First off, we were so excited following this year’s match. We cannot wait to be able to personally welcome all our new amazing interns into the EM family here. It was a tough year battling COVID, but we were so happy to be able to celebrate our residents' hard work following ITE with a trip to Busch Gardens. It was a great day to be out in the Florida sunshine and get an adrenaline rush outside of the ED. If you follow our program, you know we love ultrasound here, but recently our residents have stepped up their game and have been able to take part in TEE (trans-esophageal echocardiography) -guided resuscitations. This helps them make those key split-second decisions even when little to no information is available. USF/TGH is also proud to be a part of the ACTIV-6 trial, helping to determine the best outpatient therapies for those affected by COVID. As always, we invite you to keep up with us at our usfemergencymedicine.org/blogblog:

EMpulse Spring 202226

By Jeanne Rabalais, MD, PGY-1 & Chris Phillips, MD, PGY-2 UF Jacksonville

Just like the spring season, it is a time of transition here at UF Jax. We look forward to meeting our newest class of interns but are also saddened that our seniors will be leaving us. As our PGY-3s approach their final months of residency, we want to acknowledge all of their hard work and success. They have been such an asset to our program and will continue to thrive in the field of emergency medicine. We are also excited to welcome our new intern class to Jax EM: 16 new physicians from 13 different medical schools. The spring proved to be a busy and exciting time here at Jax. This season has provided several opportunities for our residents to give back to the community while learning about event medicine. Residents had the opportunity to work first aid at the Gate River Run and again at the Player’s Championship at Finally,Sawgrass.we want to celebrate the achievements of some of our residents. Congratulations to our new chief residents: Drs. Chris Phillips, Moji Hassan and Sam Baxley. Dr. Kasi Hartman was awarded the Outstanding Resident Educator of the Year by the UF Department of Emergency Medicine. We also want to congratulate Drs. Alexa Peterson and Jeanne Rabalais for their leadership positions on EMRA WeCommittees.lookforward to an exciting summer here at UF Jax and can’t wait to welcome the newest members to our family in July! ■

■ By Kenneth Dumas, MD, PGY-2 USF at GeneralTampaHospital

What a season it has been! It has been a crazy time at North Florida the past few months. We have welcomed new interns and babies, all while saying goodbye to our beloved PGY-3s.

HCA NorthwestWestside/Florida

By Katie Johnson, DO, PGY-1 UCF/HCA North Florida EM

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By Emily Weeks Graham, MD, PGY-2 at our annual EMS day. Thank you, Dr. Fraunfelter and Ocala Fire! However, not all days are this hectic. We regularly enjoy Ocala’s finest dining during our monthly journal clubs discussing the newest literature, medical and pharmacology advances, and monumental studies behind current standards of care. We have a lot to look forward to in the coming months, including the completion of our new SIM center and welcoming our newest class of residents! We will be so sad to see our seniors go, but we are so proud of all that they have accomplished and all that they will achieve in their next endeavors, and cannot wait to celebrate together at our end of year graduation event! ■ the last couple of years for their arrival. We are also excited to welcome Sara Zagroba, MD this summer upon completion of her sports medicine fellowship at the University of Arizona. She will be a valuable addition to our EM team and residency.

EMpulse Spring 2022 27

The new year in Ocala has kicked off to a very exciting start! We are thrilled to announce our faculty position changes, including the promotions of Program Director, Dr. Michael Falgiani, and Assistant Program Director, Dr. Samyr Elbadri, and our newest core faculty member addition, Dr. James Link Wilson. We are fortunate to have a strong core faculty team who are resident-centered and education focused, and cannot wait to continue to grow in the future! In the past several months, our residents got to show that they were stronger than the average resident by completing the firefighter physical fitness entry exam. Used to putting out fires in the department, residents got the chance to put out real fires, tear off car doors, and rappel down buildings

In February, some of our residents and faculty made their way to Big Sky and Yellowstone for the National CME Conference of Wilderness Medicine. They spent a week on the slopes and in the classrooms, sharpening their wilderness medicine skills. While it was an amazing trip, the crew did say they were happy to be back in the warm Florida sunshine.

Not long after this, one of our most favorite events of the year happened: Match Day! This is always an incredibly special time for us, as it signifies new life in the program, new friends, and most of all, new beginnings — not just for our program, but for the eight individuals who chose North Florida as home. During this crazy time, Dr. Mariah Cruz, PGY-1 also welcomed our tiniest North Floridian into the world: her baby girl, Aña-Sofía Grace Cruz. We are already in love, and can’t wait to watch her grow over the next few Lastly,years. while we have been celebrating our new members of the family, we have also been busy cherishing our last few months with our seniors. In April, we resumed our senior cruise. The PGY-3s spent a week in the sun, while the interns and PGY-2s stepped into new roles in the department. During this time we announced our new chief residents: Drs. Manna Varghese, SriHarsha Palakurti and Alex Basara. In the coming weeks, our new chiefs will officially begin their position while our PGY-3s will be packing their bags for the next adventure: attending life! ■

By Matt Slane, DO, FACEP, FAAEM Program Director After a successful interview and match season, we are excited to welcome our inaugural emergency medicine class to HCA East Florida Division Westside/ Northwest. It has been a long process to get to this point. Preparations have been made for the residents through UCF/HCA Ocala

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS HCA

CALL FOR SUBMISSIONS: 14th Annual EM Research & Clinical Case Poster Competition to be held at Symposium by the Sea 2022 EM residents, fellows and medical students invited to submit original research and cases for "Best Overall" awards Learn more at fcep.org/sbs

Happy spring from all of us here at St. Lucie! I’m sure we’re not the only ones to be happy to have the ITE out of the way for this year. It’s been nice not to have that ever-present day in February looming over our shoulders. In-person learning has continued, and we are all looking forward to our annual EKG competition near the end of the year. Everyone is also very excited to get back to SIM lab! While we haven’t had much opportunity for it recently, it is an invaluable learning tool, and the seniors are excited to share the experience with the interns. After yet another long and virtual interview season, we are very excited to welcome the class of 2025! We cannot believe that it is already time to welcome another new class of interns; it seems like only yesterday the class of 2024 was getting started. The current interns are very excited to pass down their knowledge. We hope that our new interns are as excited as we are to get started soon! With the end of the academic year approaching, our seniors are preparing to graduate and start practicing on their own. We wish them nothing but the best. It is also clear that our second-years are starting to take more command of the department as they prepare to lead it in just a couple short months. While not announced yet, we are anxiously waiting for our new chief to be named, so stay tuned!

Orange Park Medical Center As our academic year comes to a close, we’re excited to see our first class of residents transition to being attendings. Our current PGY-3 class has lined up solid jobs in seven states (Alabama, Colorado, Florida, Georgia, North Carolina, Ohio and Texas), including fellowships, core faculty positions, Level 1 trauma centers, and rural critical access sites. We’re also absolutely thrilled to welcome our full cohort of 12 incoming residents. Some other major updates include numerous upgrades to our ultrasound and simulation programs, including a multi-million dollar renovation of our new simulation/teaching center, two new Sonosite PX machines, an ultrasound trainer, and our now fully functioning ED EchocardiographyTransesophageal(TEE)program.

By Cody Russell, MD, PGY-3 and Ed Hu, MD, PGY-1

■ By Nicole Tobin, DO, PGY-3

Submission Deadline: July 11, 2022

EMpulse Spring 202228

Drs. Carr and Hoffman are leading the way, utilizing TEE for ED cardiac arrests and Fromresuscitations.aresearch perspective, we’ve enrolled in multiple additional research studies in the past few months and are looking forward to seeing what publications come from our new projects and ideas. Many of our residents and faculty recently traveled to the 2022 International Meeting on Simulation in Healthcare in Los Angeles, the 2022 Wilderness Medicine National Conference in Big Sky, and CORD in San Diego to learn tips and tricks that continue improving our Lastresidency.butnot least, we are also eagerly looking forward to our annual mass casualty training event as well as our inaugural resident olympics as major events to close the year out strong. ■ St. MedicalLucieCenter

EMpulse Spring 2022 29

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Thomas Cox, MD, PGY-3 FSU at MemorialSarasota

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

MemorialUM/Jackson

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By Emily Brauer, MD, FACEP Greetings from Miami! After another successful interview season, we are thrilled to welcome our stellar new intern class of 2025 to our Jackson family. Our new class will join us from all over the country, and we congratulate them on their success and medical school graduation. We can’t wait to meet you and have you join us in TheMiami!PGY-2 class recently attended AAEM in Baltimore and thoroughly enjoyed the live conference experience and time with their colleagues. Our residents continue their commitment and involvement to social EM, expanding our reach to our local community. Drs. Joshua Goldstein and Naomi Newton continue to tackle South Florida’s opioid epidemic and presented their social EM “Naloxone out of the ED and Into the Community” initiative at the Community Health Leadership Conference at University of Miami. You can read about their work in this edition of EMpulse on page 38. Accolades are also in order for Dr. Juhi Varshney on her Case Presentation Competition (CPC) at the CORD conference in San Diego. We would like to commend them for their tireless dedication, hard work and success. We are excited to welcome back prior graduates of Jackson and congratulate them on the completion of their fellowships. Our graduating class is bound for greatness, accepting positions all over the country. Several PGY-3s have accepted fellowships in SIM and critical care, and we are excited that several graduates have taken positions within the Jackson system. We are very much looking forward to a live graduation celebration as our seniors take their next steps in their careers. We are so proud of our class of 2022 and wish them luck on their future endeavors!

Greetings from Sarasota! Interview season is done, and we want to congratulate all the medical students that matched into emergency medicine. Additionally, we are excited to once again welcome the next class of interns to Sarasota. It is hard to believe that in a few short months we will graduate our first class of emergency medicine residents. Due to their three years of hard work, our program has found success in our department, hospital and community. We would like to recognize the third-years who will continue on to fellowship: Dr. Darryl Ray, USF Ultrasound Fellowship; Dr. Melanie Worley, University of West Virginia Sports Medicine Fellowship; and Dr. Thomas Cox, UF Jacksonville Ultrasound Fellowship. As always, we want to thank the administration, physicians, nurses, pharmacists and house staff that make the FSU/Sarasota Memorial Emergency Medicine Program a special place to learn and grow into emergency physicians.

UF Gainesville Greetings from UF Gainesville! We closed another virtual interview season and are thrilled to announce that we successfully matched 14 new PGY-1s! From Wisconsin to Virginia to our own backyard here at UF, we are excited to welcome another exceptional class. With the in-training exam in our rearview mirror, we’re full speed ahead as we close out the academic year. We’d like to give a special shout out to our PGY-1s who navigated through intern year with inquisitive minds and incredible resiliency. This spring, interns will be challenged with signing the never-ending wave of EKGs as they prepare for their PGY-2 senior roles. PGY-2s are eager to start leading the department and guide interns into their new roles as physicians. Lastly, the PGY-3s are busy navigating contracts and preparing for life after Drs.residency.Benjamin Arnold, Megan Rivera and Ziad Saqr were elected as chief residents for the upcoming academic year. We’d like to thank Drs. Manuel Borobia, Graham Clifford and Pooja Mysore for all the work they put into our program and wish them continued success as they transition into fellowship here at UF. The weather has been perfect for residents to enjoy various outdoor activities. Our PDs and residents recently volunteered at Habitat for Humanity, and residents have been spending extra time at the new UF baseball stadium. There is never a dull moment here at the Swamp, and we look forward to what the rest of the summer will bring! ■

By Megan Rivera, MD, PGY-2

By Amber Mirajkar, MD Research Fellow

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

While spring has always been a time of rebirth and hope, it feels especially so this year as the Omicron surge lessens and the mask mandates have been relaxed. Despite the ups and downs of this pandemic, our residents continue to work hard and accomplish much. Our ultrasound team continues to be an invaluable part of the ED. From creating nerve block kits and teaching residents different blocks to developing badge buddies with instructions and high-yield information, Drs. Michelle Hernandez and Thomas Lawyer are making ultrasound as second nature as a stethoscope. They also initiated inter-department education and taught the anesthesia department how to quickly assess a surgical patient with a FAST examination. They have set a high standard for ultrasound fellows, and we will be sorry to see them go at the end of this academic year. Nevertheless, we are delighted to announce that our new ultrasound fellows will be Dr. Nicholas Bencomo, MD from Oak Hill Emergency Medicine Residency in Brooksville, FL, where he is chief resident, and Dr. Kevin Sze, DO from Missouri, who has a Master’s in Biomedical Engineering. Our residents and fellows are constantly working on research and other projects. Their hard work has paid off with several publications. Dr. Thomas Lawyer developed a novel

HCA Florida Kendall

EMpulse Spring 202230

By Kelly Wright, MD, PGY-3 Emergency Medicine Chief Resident Hello again from Miami!

September 2022 Orlando, FL Stay tuned at emlrc.org/clincon Held in conjunction with State EMS Constituent Meetings

GreaterProgramEMConsortiumGMEResidencyofOrlando

HealthcareUCF/HCA

The last few months without COVID surges finally gave our residents more opportunities to hang out together outside of the department. This year, we got to have not one, but two post-ITE wellness events. One was a water sports day where our residents got to kayak and paddleboard with some friendly manatees before a group brunch. The other event gave us the chance to dress up for a nice group dinner in Miami Beach. With the summer coming up, we look forward to many more exciting events, including a Graduation Party for our senior residents and our annual Intern Welcome Party. We held our annual Wilderness Day at Oleta River State National Park this March and it was a complete success! Our residents were able to work through different patient scenarios to test their ability to handle lifethreatening injuries in the wilderness without having the usual resources available in an emergency department. Of course, we made it into a competition again between the classes, and our PGY-2 class won for a second year in a row! Can they repeat it again next year? We’ll see! Like always, summer is a bittersweet time for us! Just as we are welcoming our newest interns to the Kendall family, we have to say goodbye to our graduating senior residents. We want to congratulate the Class of 2022 as they embark on their next journey, some of which include fellowship positions in sports medicine, simulation and education, ultrasound, and administration. We wish them all the best and will miss them greatly! ■

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EMpulse Spring 2022 31 cricothyrotomy training, where he used his 3D printer to make an ultrasound-compatible model, then designed stations to teach the residents how to do an emergency cricothyrotomy with and without ultrasound. His work was published in the ACEP Emergency Ultrasound Section Newsletter. Research fellow Dr. Amber Mirajkar presented her work with “Assembly Line Education” at CORD Academic Assembly’s FirstUp! Speaking competition on March 27. Dr. Parth Patel, PGY-3 and Dr. Latha Ganti, Research Director, were invited to write a chapter in EMRAP’s Corependium. Drs. Michelle Hernandez and Ariel Vera published “Not Just a Sore Throat: A Case of a Retropharyngeal Abscess Causing Midline Shift of the Nasopharynx” in Cureus Journal of Medical Science

Emeka Albert Ian C.

Alex T Doerffler

. Last but not least, Drs. Robert Pell, PGY1, Jonathan Littell, PGY-2, Michelle Hernandez and Amber Mirajkar published “Cardiopulmonary Arrest from Metformin-Induced Lactic Acidosis” in Resuscitation Plus We are excited about SAEM in May and are delighted to have multiple members of our residency presenting. Chief Resident Dr. Gideon Logan, PGY-3 will be presenting his research on NSTEMI data. Drs. Abigail Alorda, PGY-1, Martin Morales Cruz, PGY-2, and Tracy Macintosh, Associate Dean of Diversity, Equity, and Inclusion at the UCF College of Medicine, are presenting “Race and Chemical/ Physical Restraints in the ED.” Drs. Gideon Logan, Martin Morales Cruz and Abigail Alorda also were accepted into the Ignite speaking competition. In the Innovations section, Drs. Judy Lin, Ultrasound Fellowship Director, Michelle Hernandez and Martin Morales Cruz will be presenting “A Multi-Modal Approach to Nerve Block Teaching.” Finally, Drs. Parth Patel, PGY-3, Jeff Adams, PGY-2, Jonathan Littell and Alexa Ragusa, PGY-1 will be participating in SAEM’s SimWars. We hope to see our Florida colleagues in New Orleans!

JerryDanvanillaMaishaBackstromBalaparyaQBarnesThomasBrooksBlakeBuchananJordanCelesteGianlucaCerriLAnthonyCirilloStephanieBCohen

Steven

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C Eccher Stephen Scott Feilinger Barbara N TimothyChristopherJenniferFlores-GonzalezFredericksBrentFGardnerNHannerBrianScottHartfelderRobynHoelleSaundraAJacksonChester"Chet"JelingerStevenBKailesJeremyFechterKirtz Felice I MaryKristinChristopherMatthewDakotaJonGaryKoscinskiLaiELamosRLaneKLightcapMichaelLozanoTMartinMcCabe-KlineRyanNesselroadeAdetoluOdufuyeRhondaCOetersCharlesSand,IElizabethSchmiederDonnaSchutzman-BoberMatthewASchwartzJohnCaleistSoudJoelBSternDarylMauriceTurnerStephenVielBrettWilliamsJasonWilsonMaryBrananEnnis DONATE TO OUR PAC NOW: Donate online at: fcep.org/support Text “FCEPPC” to “41444” ◀ Continued from previous page

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A 70-year-old female is brought in by EMS for left hip pain after a fall from standing. The patient’s left leg is foreshortened and externally rotated. The patient wails in distress with any attempt to manipulate the leg. Her wails increase in intensity echoing through the department, until the nurse finally pleads, “Doc, please do So,something!”whatare you going to do? Lower extremity fractures are not uncommon in the emergency department. Annually, more than 300,000 adults older than age 65 are hospitalized for hip fractures, which frequently result from ground-level falls.1 Managing lower extremity pain can be challenging, as non-steroidal anti-inflammatory drugs (NSAIDs) may increase bleeding risk and acetaminophen often under-treats the pain. Especially in elderly patients, we need to be cautious about using opioids for analgesia as these may cause respiratory depression, altered mental status or hypotension. In an era where providers are shifting away from opioids, regional nerve blocks like the Fascia Iliaca Block provide a great option for our patients with lower extremity pain. Why perform this nerve block? The Fascia Iliaca Block is a quick procedure, requires minimal training, and is executed with high success rates under ultrasound guidance. Emergency department-specific studies using ultrasound guidance have shown a 76% mean reduction in pain score in patients with hip fracture at 120 minutes.2 Studies involving a localized lower extremity nerve block were also associated with decreased rates of any in-hospital postoperative complications, decreased mortality, decreased altered mental status, and decreased pulmonary complications.3 What is the fascia iliaca compartment block? The fascia iliaca compartment is a potential space in the inguinal region bordered by the fascia iliaca anteriorly and the iliacus and psoas muscles posteriorly (see Fig. 1). Both the femoral nerve and lateral femoral cutaneous nerve lie within this compartment.4 A successful large volume injection of an appropriate anesthetic into this compartment will lead to anesthesia of the femoral (88%), obturator (variable), and the lateral femoral cutaneous nerves (90%).5 Who is this compartment block for? Though the elderly most often fall and fracture their hip and femur, the Fascia Iliaca Block can be successfully used in any age group.6 Any traumatic injury to the femur, hip, femoral neck or trochanter is a great indication for the Fascia Iliaca Block. Other indications include lacerations of the anterior, lateral, or medial thigh (see Fig. 2). How do I prepare? You will need: 1. Ultrasound machine with probe 2. A 5mL syringe/25-gauge needle with 5mL of 1-2% lidocaine A 20 mL syringe/21-gauge (nerve block/spinal) blunt-tipped needle with long-acting local anesthetic (20 mL of 0.2% Ropivacaine or 0.25% Bupivacaine). 18-gauge needle to draw up anesthetic Sterile ultrasound probe cover gloves Chlorhexidine prep An assistant Sterile extension tubing Access to airway supplies and by Leila Posaw, MD, MPH Emergency Ultrasound Faculty, MemorialJacksonHospital 1: compartment.fasciaofSchematictheiliaca Dove Press ResearchJournalJournal:ofPain

Edited

10.

Fig

The {Painless} Fascia Iliaca Block ULTRASOUND ZOOM University of Miami / Jackson Health System By David Vega, MD, PGY-2

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6. Sterile

Credit:

Fig 2: Block.FasciafromdistributionanestheticofanatomyofDistributionthetypicaltheIliaca NYSORA.comCredit:

Step 1: The linear transducer is the preferred probe to use. Use the “Nerve” or the “MSK” preset on the ultrasound machine. Visualization of the compartment requires a shallow

Credit: ALIEM.com Fig. 4: Infra-inguinal view of fascia Nerve.Artery,Muscle,SMfasciaarrowsfasciaarrowscompartment.iliacaWhitepointtotheiliaca.Redpointtothelata.=SartoriusFA=FemoralFN=Femoral

Step 4: Use your 5mL syringe/30gauge needle with 1% lidocaine to create a wheal adjacent to the short end of the probe. Then, utilize an inplane approach to insert the 22-gauge needle at a steep 60-degree angle.8 You should visualize the tip traversing through both fascia lata and fascia iliaca, and you should feel two “pops” (see Fig. 5).

Intralipid 20% Setting yourself up for success There are multiple ways to achieve similar sedation (e.g. supra-inguinal approach, 3-in-1 block, femoral nerve block), but we will focus on the Fascia Iliaca Block. The Fascia Iliaca Block is performed using the ‘loss of resistance’ technique, also known as the ‘2-pop’ Themethod.Fascia Iliaca Block can be performed solo, but the two-person technique allows for greater dexterity during the procedure: one hand to stabilize the sterile ultrasound probe and the other hand to direct the needle into the correct anatomical location (see Fig. 3). When using the two-person method, it is important to “prime” the sterile tubing by inserting NS to remove air bubbles and prevent an air Priorembolism.7togetting started, it is important to perform and document a thorough neurovascular exam. Always place your patients on a cardiac monitor and continuous pulse oximetry. Be sure to properly prep and drape using sterile technique. How do I perform the block?

Credit: NYSORA.com

depth setting. Step 2: We are accustomed to performing central lines in the femoral vein, thus the infrainguinal approach (inferior to the inguinal ligament) is the most familiar and easiest to perform. Hold the probe in transverse position, with the indicator pointing toward the patient’s right. With ultrasound, locate the femoral artery and vein, as if performing a central line. Use Fig. 3: The proceduralist holds the 22-gauge needle (on right) with one hand while holding the ultrasound in the other hand (not pictured). The assistant holds the 30mL syringe with long-acting local anesthetic (on left) attached to the sterile tubing.

EMpulse Spring 2022 33 Continue on next page ▶

Step 5: Once positioned just under the fascia iliaca, have your assistant inject Fig. 5: Position of needle for infrainguinal approach. The distribution of anechoic spread is in blue.

Credit: NYSORA.com

the NAVEL mnemonic (lateral-nerveartery-vein-medial) to your advantage. Slide the probe laterally to locate the femoral nerve, which will appear as a hyper-echoic, triangular structure wedged between the iliopsoas muscle (posteriorly) and the fascia iliaca (anteriorly) (see Fig. 4).

Step 3: Continue sliding the probe laterally to locate the sartorius muscle, which is separated from the iliopsoas muscle posteriorly by the hyperechoic linear fascia iliaca (see Fig. 4, white arrows). From this angle, it is easier to spot the fascia lata, which is the other hyperechoic linear plane seen more anteriorly (see Fig. 4, red arrows).

EMpulse Spring 202234 Fig. 6: The left image shows the needle trajectory for the Fascia Iliaca Block. The right image shows relevant anatomy. Credit: SJRHEM.ca a small volume of anesthetic solution. You should see the fascia lift up, off of the nerve. With more injection, you will visualize an expanding anechoic collection within the compartment. Have your assistant inject the remainder of your anesthetic (see Fig. 6). Contraindications: • Cellulitis over area of injection • Risk of compartment syndrome • Anti-coagulation • Allergy to local anesthetic Potential Complications: • Infection • Hematoma • Femoral nerve injury • Local anesthetic systemic toxicity LAST(LAST)isarare, but potentially lethal complication that occurs when local anesthetic is injected intravascularly, leading to sodium channel blockade ◀ Continued from previous page REFERENCES:

2. Haines L, Dickman E, Ayvazyan S, et al. Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency department. J Emerg Med. 2012 Oct; 43(4):692-7.

3. Pedersen S, Borgbjerg F, Schousboe B, et al. A comprehensive hip fracture program reduces complication rates and mortality. J Am Geriatr Soc. 2008;56(10):18311838.

4. Yang L, Li M, Chen C, Shen J, et al. Fascia iliaca compartment block versus no block for pain control after lower limb surgery: a meta-analysis. J Pain Res. 2017 Dec 14;10:2833-2841.

5. Capdevila X, Biboulet P, Bouregba M, et al. Comparison of the three-in-one and fascia iliaca compartment blocks in adults: clinical and radiographic analysis. Anesth Analg. 1998 May;86(5):1039-44.

6. Ultrasound-guided fascia iliaca nerve block. NYSORA. (2022, March 3). Retrieved March 24, 2022, from topics/regional-anesthesia-for-www.nysora.com/ specific-surgical-procedures/ lower-extremity-regional-anesthesiafor-specific-surgical-procedures/ block/ultrasound-guided-fascia-iliaca-

1. CDC. (2016, September 20). Hip fractures among older adults. Centers for Disease Control and Prevention. Retrieved March 24, 2022, from fractures.htmlwww.cdc.gov/falls/hip-

7. Fascia iliaca nerve block: A hip fracture best-practice. ALiEM. (2020, November 28). Retrieved March 24, 2022, from iliaca-nerve-block/.www.aliem.com/fascia8. Lewis, D. (2021, February 15). Fascia iliaca nerve block. Department of Emergency Medicine | Saint John. Retrieved March 24, 2022, sjrhem.ca/fascia-iliaca-nerve-block/from 9. Canders, C, et al. (2018, Mar 1). Ultrasound-guided Nerve Blocks in the Emergency Department. Emergency Medicine Reports. Retrieved Mar 26, 2022, from the-emergency-departmentultrasound-guided-nerve-blocks-in-reliasmedia.com/articles/142305-www. in both the cardiovascular and central nervous system.9 Symptoms range from oral tingling and tinnitus to seizures, respiratory depression, and cardiac arrest. Any patient with LAST should promptly be treated with a 1.5mL/kg bolus of Intralipid 20%, followed by a continuous infusion. Tips and Tricks: Large volumes of more dilute solution are better than smaller volumes of more concentrated solution (e.g., 40mL of 0.25% Bupivacaine is better than 20mL of 0.5% Bupivacaine). A shorter bevel for spinal needle insertion (e.g., 22-gauge blunt-tipped Whitacre or Sprotte needle) helps provide tactile feedback to feel the “pop” through the 2 fascial layers. If the local anesthetic is collecting in one location and not “layering out,” stop and reposition your needle before continuing to ensure adequate spread. ■ 2022 in Orlando, FL info coming soon at emlrc.org/appsc

SKILLS CAMP Advanced Practice Provider September 8-9,

35 If hospital readmissions and emergency department visits are increasing for your seriously ill patients, it may be time to refer them to hospice. As part of the continuum of care, hospice is most beneficial when it is provided for months, rather than weeks or days. With hospice, patients with advanced disease receive coordinated care wherever they call home. VITAS clinicians offer expert medical care, pain and symptom management, and emotional and spiritual support to your patients. Refer to VITAS 24/7/365 for hospice evaluations, admissions, and compassionate care for your seriously ill patients. VITAS® Healthcare hospice services: • Supplement the high level of care attending physicians and clinical staff bring to their patients. Our staff actively monitors and manages changes and declines in your patient’s condition • Facilitate seamless patient transitions and conduct medication reconciliation • Help to reduce avoidable rehospitalizations and ED visits and help to optimize HEDIS® and CAHPS® score Visit VITAS.com for hospice eligibility guidelines. Call 800.93.VITAS to refer patients quickly. Download our mobile app for fast, seamless, secure referrals from your mobile device. VITAS.comSince1980 When Advanced Illness Patients Keep Returning, It May Be Time for Hospice

EMpulse Spring 202236

Fig. 1: Initial EKG showing diffuse ST depression with ST elevations in aVR and V1. EM

DirectorProgram

By PGY-2Castillo,HernandoMD, By Slane,ValoriMD

By PGY-3Wright,KellyMD, By Echegaray,QuiñonesJessicaDe-MD

factorsdiabetes.asriskatheroscleroticconventionaldowhoyoungeroftencardiacresultSCADgivenunderestimateisHowever,postpartum.thislikelyanthatmanycasesinsuddendeath.Itpresentsinindividualstypicallynothavethefactors,suchhypertensionorSomeriskassociated with SCAD include fibromuscular dysplasia, pregnancy, arteriopathies, connective tissue disorders and systemic inflammatory disorders. Pregnancy-associated SCAD is most often seen during the third trimester and up to six weeks postpartum but can occur at any time during the pregnancy. It also tends to present with more aggressive and extensive dissections compared to nonpregnancy-associated SCAD. While the underlying mechanism of SCAD is poorly understood, it is thought to occur when there is an intimal tear and intramural hematoma formation or spontaneous bleeding of the vasa vasorum leading to narrowing of the coronary artery lumen that subsequently causes myocardial ischemia. In pregnant and postpartum patients, there is a belief that it is due to hormonal changes weakening

ED DirectorMedical

Case A 37-year-old female, G1P1 and one week postpartum via C-section, was brought to the emergency department by EMS after having a near-syncopal event at home. The patient reported she was feeding her newborn when she suddenly felt lightheaded and almost passed out. She also endorsed experiencing chest pain, lower back pain and dyspnea. Per the patient, her pregnancy was only notable for in-vitro fertilization during which she was on high-dose hormonal therapy, thrombocytopenia of unknown etiology, and C-section delivery due to thrombocytopenia. Patient denied other symptoms, including abdominal pain or abnormal vaginal bleeding. Initial vital signs in the ED showed the patient to be hypotensive (71/53), tachycardic (101 bpm), afebrile (36.3°C), and saturating well (100% on room air). On exam, the patient was noted to be toxic-appearing and in moderate distress. She was also diaphoretic with pale, ashy looking skin and had a delayed capillary refill time. Otherwise, the remaining physical exam was unremarkable. In addition to obtaining labs and starting IV fluids, an immediate electrocardiograph (EKG) was done, which showed diffuse ST depressions with ST elevations in aVR and V1 (see Fig. 1). Interventional Cardiology was immediately consulted, and the decision was made to emergently take the patient to the catheterization lab for left heart catheterization. Prior to catheterization, a CT Angio

Heart Attacks in the Younger Population: A Case of Spontaneous Coronary Artery Dissection CASE REPORT

Chest/Abdomen was obtained and negative for pulmonary embolism and aortic dissection. During left heart catheterization, the patient was found to have a coronary artery dissection of the distal left main and proximal left anterior descending arteries (see Fig. 2), consistent with the diagnosis of spontaneous coronary artery dissection. Diagnosis Spontaneous coronary artery dissection (SCAD) is a rare spontaneous separation of the coronary arterial wall that can cause acute myocardial infarction. It is estimated that SCAD represents 1-4% of all acute coronary syndrome (ACS) cases. SCAD accounts for nearly 35% of all ACS cases in women less than 50 years old and is the most common cause of myocardial infarctions in patients who are pregnant or

Fig. 2: Cath Lab Images showing a 90% eccentric segmental lesion of the proximal LAD.

Fig. 3: Successful re-vascularization post stent placement in the proximal LAD.

3. Hayes SN, Kim ESH, Saw J, Adlam D, Arslanian-Engoren C, Economy KE, Ganesh SK, Gulati R, Lindsay ME, Mieres JH, Naderi S, Shah S, Thaler DE, Tweet MS, Wood MJ; on behalf of the American Heart Association Council on Peripheral Vascular Disease; Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Functional Genomics and Translational Biology; and Stroke Council. Spontaneous coronary artery dissection: current state of the science: a scientific statement from the American Heart Association. CIR.0000000000000564.2018;137:e523–e557.Circulation.DOI:10.1161/

4. Arrivi A, Milici C, Bock C, et al. Idiopathic, serial coronary vessels dissection in a young woman with psychological stress: a case report and review of the literature. Case Reports in Vascular Medicine. 2012 ;2012:498465. DOI: 10.1155/2012/498465. PMID: 23133786; PMCID: PMC3485898.

1. Saw, J. (2021). Spontaneous Coronary Artery Dissection. J.C. Kaski; P.A. Pellikka (Eds.), UpToDate. Available from www. rank=1result&selectedTitle=1~11&display_type=default&source=search_dissection?search=SCAD&usage_spontaneous-coronary-artery-uptodate.com/contents/

2. Kreider, D.; Berberian, J. (2019). STEMI Equivalents: Can’t Miss Patterns, EM Resident. Available from www.emra.org/emresident/ article/stemi-equivalents/

REFERENCES

5. Krishnamurthy, M., Desai, R., & Patel, H. (2004). Spontaneous coronary artery dissection in the postpartum period: association with antiphospholipid antibody. Heart (British Cardiac Society), 90(9), doi.org/10.1136/hrt.2004.038869e53.

coronary artery. It is often diagnosed with coronary angiography where a dissection will be visible in the absence of

artery(PCI)coronarywithrevascularizationemergencymanagement,includingofThereatherosclerosis.areawiderangetreatmentoptions,conservativepercutaneousinterventionorcoronarybypassgrafting (CABG), fibrinolytic therapy, cardiologymanagedpatientsimprovessurvivaladmission,thatofanthrombosis.apposition,restenosis,likelihoodSCAD,ischemia.withiswhereasmyocardialwithisConservativetransplantation.support,hemodynamicmechanicalandcardiactreatmentpreferredinpatientsnosignsofischemia,PCIorCABGpreferredinpatientssignsofmyocardialIncasesofPCIhasahighofin-stentstentmal-andstentSCADhasoverallmortalityrateover50%.Inpatientssurvivetohospitaltherateoftodischargeto85%.Thesearetypicallybyoutpatientwithlongterm aspirin, beta-blockers, short-term clopidogrel, and a statin in patients with dyslipidemia. In this patient, two drug-eluting stents were placed (see Fig. 3) along with a right-sided catheter-based miniaturized ventricular assist device due to a reduced ejection fraction of 35-40% in the setting of a highrisk intervention. The patient was subsequently admitted to the ICU where she had an uncomplicated postcatheterization hospital course. She was weaned off the catheter-based miniaturized ventricular assist device after three days and had a repeat echocardiogram demonstrating an improved ejection fraction of 50%. The patient was later discharged from the hospital on dual antiplatelet therapy and has since followed up with the outpatient cardiology team without residual symptoms or complications. Given the rarity and poor prognosis of this condition, particularly in pregnant and postpartum patients, it is important that emergency physicians consider SCAD when evaluating young, low-risk patients that present to their emergency department with signs and symptoms that are concerning for ACS. ■

EMpulse Spring 2022 37 coronary arterial walls or due to the physiological hemodynamic changes seen in pregnancy, which place increased stress on the coronary arterial walls. The signs and symptoms seen in SCAD are essentially the same as those seen in an acute myocardial infarction due to atherosclerosis, with chest pain being the most common symptom. Less common symptoms include arm pain, neck pain, back pain, dyspnea, nausea and vomiting. The most common EKG findings are ischemic changes, such as ST elevations affecting the left anterior descending artery and occasionally affecting the left main

Objectives To address South Florida’s opioid epidemic, we aimed to design and implement a novel model for OUD screening and naloxone distribution within the setting of publicly available health fairs. In addition, our group aimed to educate community members on the proper recognition of a suspected opioid overdose and administration of intra-nasal naloxone (commonly known by its brand name, ThisNarcan).article highlights our novel model for distribution of naloxone in a community setting at the University of Miami’s medical student-run health fairs. These fairs take place directly in

Existing Interventions Within the South Florida region, naloxone distribution sites can be found at CVS, Walgreens, and through the isavefl.com website. The availability of adequate user training, as well as the cost of this life-saving medication, varies with each vendor. Some community clinics, such as the University of Miami’s IDEA Needle Exchange Clinic, provide both the medication and the proper training for free. However, patients must seek out these clinics to procure this lifesaving medication. Therefore, there is a growing need for more robust community-centered interventions, focusing on naloxone education and distribution to high-risk patients.

Social CommunitytheNaloxoneMedicine:EmergencyoutofEDandintothe

By Kelley N. Benck, BS By Newton,NaomiMDBy Goldstein,Joshua MD By Brauer,EmilyMD University of Miami Miller School of Medicine, Department of Community Service Hospital,MemorialJackson Department of Emergency Medicine Hospital,MemorialJackson Department of Emergency Medicine Hospital,MemorialJackson Department of Emergency Medicine

Whileliability.4the distribution of naloxone to first responders (police, emergency medical technicians, and paramedics) has become widespread, initiatives to distribute naloxone directly to members of at-risk communities has been confined to a far narrower subset of populations.5 In this article, we report on the first emergency department-partnered program in the state of Florida to distribute naloxone directly to the community.

Background Recent events, including the tragic rash of opioid overdose deaths in Broward County, FL, have highlighted the continued toll that the opioid epidemic has on communities and healthcare systems across the state of Florida. Opioid overdoses remain an epidemic in the United States, and they were responsible for nearly 50,000 deaths in 2019 alone.1 In that same year, fatal opioid overdoses in Florida increased by 6.5% compared to 2018.2 However, great strides have been made in the recognition and treatment of opioid use disorder (OUD) over the last decade, due to the tireless efforts of patient advocates. In particular, the increasing distribution and use of naloxone has been one of the most critical interventions in the ongoing opioid Naloxoneepidemic.3isasafe, effective opioid antagonist that targets the mu-opioid receptor, displacing exogenous opioid agonists and reversing the lifethreatening respiratory depression associated with opioid overdose.3 In 2015, the Florida Legislature recognized naloxone’s crucial role in combating the opioid epidemic.

FEATURE

EMpulse Spring 202238

The ensuing Emergency Treatment for Suspected Opioid Overdose Act (Florida Statutes 381.887) authorized healthcare providers and pharmacists to dispense naloxone to any patient or caregiver who requests it. This law also ensured that a dispensing provider is acting in good faith and exercising reasonable care is granted immunity from civil, criminal or professional

3. In the past year, how many times has someone in your home or someone you care for used any of the following: heroine, fentanyl, oxycodone (OxyContin, Percocet), hydrocodone (Vicodin), methadone? Each question had the following options and corresponding points: Never (0), Once or Twice (1), Monthly (2), Weekly/Daily/Almost Daily (3). Responses were recorded in the health fair’s EMR program. Patients who scored a 2 or higher were flagged. Once the flagged patients were in a private space for their HIV/HCV testing, they underwent a more comprehensive screening for OUD, based on the full DSM-5 criteria. Naloxone education was provided to all patients, regardless of their screening scores, to ensure that all patients were aware of the medication’s purpose. Naloxone was offered to patients who were deemed high-risk after screening, and to any patient who felt they or someone in their household was at risk. Pre-packaged kits, which contain two doses of intranasal naloxone along with pictorial and written instructions, were dispensed. Patients were trained on the indications for use and proper administration, using a “Dummy-Dose” Intranasal Naloxone trainer. Screening questionnaires and administration instructions were printed in English and Spanish. Responses to the OUD screening questions did not affect the patient’s ability to receive HIV/ HCV testing. Each distribution site was staffed by an emergency medicine physician. To date, over 200 patients [BK1] have been successfully screened for OUD, and 83 units of naloxone have been dispensed across four health fair sites. Conclusion The opioid epidemic continues to affect the state of Florida. OUD screening and education in the community is imperative for better prevention of lethal opioid overdoses. Our team continues to work to decrease the morbidity and mortality

All patients triaged to receive HIV/ HCV point-of-care testing at the health fairs were first screened for OUD and offered intra-nasal naloxone (Fig. 1). Patients were provided a sheet of paper with three initial screening questions:

Methods A partnership was established between the University of Miami IDEA Needle Exchange Clinic and the University of Miami Michael Wolfson Department of Community Service (DOCS) program. Patients were screened for OUD by a DOCS Health Fair Screening Volunteer using DSM-5 criteria.6 All patients who indicated that they, or a member of their household, were at risk for life-threatening opioid overdose were offered naloxone. Naloxone was dispensed by an IDEA Clinic provider, acting under the State of Florida Department of Health Statewide Standing Order For Naloxone (Section 381.887, Florida Statutes).4

3. Ashton, H. “Intranasal Naloxone in Suspected Opioid Overdose.” Emergency Medicine Journal, vol. 23, no. 3, 2006, pp. 221–223. org/10.1136/emj.2005.034322.doi.

4. “Emergency Treatment for Suspected Opioid Overdose.” Chapter 381 Section 887 - 2021 Florida Statutes, State of Florida 2021 Legislative Statutes , 1 Jan. 2021. m.flsenate.gov/Statutes/381.887.

5. Cherrier, N., Kearon, J., Tetreault, R., Garasia, S., Guindon, E., “Community Distribution of Naloxone: A Systematic Review of Economic s41669-021-00309-z11PharmacoEconomics,Evaluations.”ePublication,November,2021,doi.org/10.1007/

Implementation and Results

2. “2020 Overdose Prevention Investment Snapshot - Florida.” 2020 Overdose Prevention Investment Snapshot, Centers for Disease Control & Prevention; National Center for Injury Prevention & Control, 2020, Florida-State-Snapshot.pdf.budget/opioidoverdosepolicy/pdfs/cdc.gov/injury/

EMpulse Spring 2022 39 high-risk communities within public spaces, such as churches, schools and community centers. These fairs help providers raise a greater awareness of naloxone across a broader and more varied patient population. These fairs also allow providers to screen for OUD in the community and subsequently distribute naloxone to patients at risk for opioid overdoses.

1. “Drug Overdose Deaths.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 3 Mar. 2021. drugoverdose/deaths/index.html.cdc.gov/

2. In the past year, how many times have you used heroine, fentanyl, oxycodone (OxyContin, Percocet), hydrocodone (Vicodin), or methadone drugs?

1. In the past year, how many times have you used prescription drugs for non-medical reasons?

6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC, American Psychiatric Association, (2013), p 541. associated with OUD, by increasing access to lifesaving naloxone and enhancing communities’ awareness of OUD. We hope that this article will help stimulate the establishment of similar programs elsewhere in Florida. ■ Fig. 1: Schematic of progression of patients undergoing OUD screening and Naloxone education prior to HIV/ HCV testing.point-of-care

REFERENCES

Buprenorphine without naloxone (Subutex) can be used in induction of patients convinced of an allergy that is likely prior precipitated withdrawal. Of note, buprenorphine should also be used for pregnant women instead of buprenorphine-naloxone. If precipitated withdrawal does occur, paradoxically, more buprenorphinenaloxone can be given (up to 32 mg buprenorphine). Adjuvant symptomatic treatment can include ondansetron, ibuprofen, and clonidine as needed. Our pathway is available via the QR code. Patient Resolution: Explain to patients when to properly induce buprenorphine. Successful buprenorphine induction is dependent upon the absence of opioids in a patient’s system at time of induction. We avoid use of buprenorphine in patients that have taken methadone in the last 72 hours (long acting) or other opioids in the last 12 hours (oxycodone, heroin, hydromorphone, morphine). Commonly used urine drug screens are not helpful since fentanyl does not lead to a positive drug test. Patient self-report, combined with a validated scoring tool such as the Clinical Opioid Withdrawal Scale (COWS), is a more reliable and useful tool for measuring withdrawal severity. To avoid precipitating withdrawal, we do not induce patients with a COWS of <5. Explaining this induction process to patients can help them understand their historical reaction to buprenorphine and allay fears of having an allergic reaction to the medication. USF EM protocolsSectionEmergencySocialMedicine(pathwayandforMOUD)

By Heather Henderson, PhD, CAS Associate Director of Social GeneralProgramsMedicineatTampaHospital

By Jason Wilson, MD, FACEP, FAAEM

By Bernice McCoy, PhD, MPH By Holbrook,Emily MA By Casper,BreanneMA Dept. of HospitalTampaInternalMedicine,EmergencyDivisionofMedicine,General

It is common for patients to assume that they are allergic to buprenorphine, though a true allergy is rare. It is more likely that the patient received buprenorphine-naloxone (Suboxone) while they still had opioids in their system, which precipitated withdrawal. Precipitated withdrawal leaves patients physically uncomfortable and has been linked to increased rates of relapse, treatment dropout, and can act as a deterrent to future treatment.

Expanding ED MOUD programs increases retention in opioid use disorder (OUD) addiction services and decreases overdose deaths.1 ED MOUD programs improve the quality of care for patients presenting to the ED with OUD-related complications through the integration of warm hand-off linkages to downstream care (e.g. direct referral with preestablished access to a community substance use disorder treatment facility).2 Below, we dispel and counter frequent patient misconceptions about buprenorphine induction that we have encountered. These barriers to buprenorphine induction are based on over 1,500 unique patient encounters since September 2018 through our coordinated regional harm reduction continuum at the University of South Florida, which includes 700 patients enrolled in the Building Integrated Recovery for Drug Users into Emergency Medicine (BRIDGE) Program, a syringe services program at IDEA Tampa, and a low-barrier buprenorphine downstream treatment site (USF OBOT). We also offer important clinical clarifications on the buprenorphine induction process. Patient Misconception #1: “I’m allergic buprenorphine.”to

The Emergency Department (ED) can serve as an access point for patients to initiate medication for opioid use disorder (MOUD) with buprenorphine.

FEATURE

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Patient Misconceptions about Buprenorphine Induction for Opioid Use Disorder in the Emergency Department Dept. of Anthropology,&TampaofMedicine,EmergencyDivisionInternalMedicine,GeneralHospitalDepartmentofUSF

Patient Misconception #2: “I heard that you have to be in really bad withdrawal to take buprenorphine.”

Patient Misconception #3: “I have to be ready to stop using in order to start MOUD” Patients often believe that they must be ready to cease opioid use ‘cold turkey’ in order to begin MOUD. This misconception is commonly encountered in patients that present to the ED for a chief complaint not directly associated with OUD. However, opioid withdrawal is a high-risk period associated with elevated mortality after discharge, and it is beneficial to stabilize withdrawal symptoms that present during the ED encounter. Patient Resolution #3: Provide MOUD for patients with non-OUD related chief complaints. Initiating buprenorphine in the ED has been associated with increased rates of linkage to outpatient treatment.3 Patients presenting to the ED for nonOUD related concerns may begin to experience acute withdrawal during the encounter and could benefit from buprenorphine induction (which may also decrease AMA, LWOT scenarios). If COWS >= 4, consider a stabilizing dose of buprenorphine-naloxone in the ED (we often start at 8mg - 2mg but a lower 4mg - 2mg dose can be tried first if needed).

EMpulse Spring 2022 41

Patients often relay to us that they "heard" that they must be in severe withdrawal (COWS >8) to begin buprenorphine. However, buprenorphine induction can occur with even mild withdrawal symptoms (COWS 4-8). The earlier a patient can be induced in the withdrawal process, the easier it is to avoid more severe symptoms. Patient Resolution: Utilize COWS to inform the buprenorphine induction process. Waiting until a patient is experiencing moderate to severe withdrawal symptoms before buprenorphine induction can result in unnecessary discomfort. Patients with mild symptoms (e.g., sweating, runny nose, goosebumps, shaking, nausea), are appropriate for induction (COWS >= 4). A quick conversation with the patient about the induction process, as well as how utilizing COWS to inform the induction process will actually help avoid severe withdrawal, can increase patient comfort and resolve this misconception.

Patient Resolution #4: Explain how MOUD are considered best practice. MOUD (including buprenorphinenaloxone [Suboxone], extended release naltrexone [Vivitrol], and methadone) are considered best practice, evidence-based, front line treatments for OUD. Buprenorphine, in particular, as a partial agonist binds to opioid receptors of the brain to block withdrawal symptoms, but also has a ceiling effect which mitigates the euphoria felt with medications like methadone. The naloxone component also ensures the medication is taken as intended and is ineffectual if administered in ways other than indicated. A conversation with the patient that reframes MOUD is helpful. For example, many of us legally purchase coffee or an energy drink each day or take blood pressure medication or an allergy pill each morning. With these substances, we don’t risk infectious disease, stigma or arrest, but instead utilize those drugs in a safe way that provides happiness, better health and wellness. MOUD provides the same function for those that have opioid use disorder. Clinical Clarifications: DATA 2000 Waiver Historically, addiction treatment has been separated from the traditional medical and psychiatric fields and has been reliant on specialized doctors and facilities, such as those with opioid treatment programs

REFERENCES 1. D’Onofrio 2015 Herring AA, Vosooghi AA, Luftig J, et al. HighDose Buprenorphine Induction in the Emergency Department for Treatment of Opioid Use Disorder. JAMA Netw Open. 2021;4(7):e2117128. jamanetworkopen.2021.17128doi:10.1001/ 2. Adams, K.K., Machnicz, M. & Sobieraj, D.M. Initiating buprenorphine to treat opioid use disorder without prerequisite withdrawal: a systematic review. Addict Sci Clin Pract 16, 36 8doi.org/10.1186/s13722-021-00244-(2021).

3. Woodruff, A. E., M. Tomanovich, L. Beletsky, E. Salisbury-Afshar, S. Wakeman, and A. Ostrovsky. 2019. Dismantling Buprenorphine Policy Can Provide More Comprehensive Addiction Treatment. NAM Perspectives. Commentary, National Academy of Medicine, Washington, DC. doi. org/10.31478/201909a 4. Emergency Quality Network. "How to Apply for Buprenorphine Waiver Notification of Intent (NOI)." ACEP. Access at acep.org/globalassets/ sites/acep/media/equaltutotrial.pdfopioidw4_aplying-to-bup-noi-documents/webinar-documents/

5. Huhn, A. S., and K. E. Dunn. 2017. Why aren’t physicians prescribing more buprenorphine? Journal of Substance Abuse Treatment doi.org/10.1016/j.jsat.2017.04.00578:1–7.

6. Weintraub, E; Senevirante, Anane, J.; et al. Mobile Telemedicine for Buprenorphine Treatment in Rural Popuilations with Opioid Use. (OTP). Though approval of the Drug Addiction Treatment Act (DATA) in 2000 sought to change this paradigm and create an avenue for primary care physicians to be formally certified (x-waivered) to treat patients for OUD outside of OTP settings, barriers to treatment expansion remain.4 Only 23,000 physicians in the U.S. possess an x-waiver, leaving many areas of the country, particularly rural areas, without access to a single x-waivered buprenorphine prescriber. There is now a pathway for non-waivered physicians to prescribe buprenorphine in the ED by following a few simple steps and notifying the DEA of their intent to However,prescribe.5thepresence of the Continue on page 43 ▶

Patient Misconception #4: “I don’t want to just trade one drug for another.” Due to the social stigma surrounding MOUD, it is common to hear patients say things like, “if I wanted to keep taking drugs, I would just stay on heroin.” Abstinence-based treatment programs they have previously experienced frame MOUD as replacing one drug for another, rather than ‘doing the work’ to get clean.

Synthetic cannabinoids are a class of lab-derived cannabinoids that are full agonists of the Cannabinoid receptor 1 (CB1) and CB2 receptors throughout the body, but more specifically in the brain. Synthetic cannabinoids are commonly referred to as “K2”, “Spice” or “Cloud 9” and are a common drug of abuse.5 How to identify patients possibly exposed to brodifacoum Most commonly, patients exposed to brodifacoum will present to the emergency department with unexplained bleeding. Hematuria is the most common type of bleeding seen, but other common types of bleeding include epistaxis, vaginal, and gastrointestinal bleeding. Patients will also have unmeasurably high PT/ INR levels. In addition, most exposed patients have a history of drug use or reported using synthetic cannabinoids in the days to weeks prior to their presentation. Laboratory tests to detect brodifacoum are not readily available in the acute setting, so the diagnosis of brodifacoum exposure is clinical in nature and dependent on a high index of suspicion. Contact your local poison center if you are suspecting a patient exposed to brodifacoum. What is the approach to treatment? A baseline CBC and PT/INR should be immediately obtained in addition to consultation with your local poison control center.

–Tampa By Justin Arnold, DO, MPH, FACEP, FACMT What happened during the 2021 brodifacoum outbreak? In December 2021, patients started presenting to emergency departments across Hillsborough County with profound and persistent coagulopathies in which standard treatments were inadequate. It was later determined that these patients had been exposed to brodifacoumcontaminated synthetic cannabinoids.

EMpulse Spring 202242

To date, there have been a total of 55 cases resulting in six deaths. The Florida Poison Information Center Tampa collaborated with local and state health departments and hospitals to develop a course of action for the identification and management of these patients.

Edited by Dawn Sollee, Pharm.D., DABAT, FAACT

2021 Brodifacoum-Contaminated Synthetic Cannabinoid Outbreak: Overview of Identification and Management of the Exposed Patient Clinical Toxicology/EM Fellow, Florida/USVI Poison Information Center - Jacksonville By Chiemela Ubani, Pharm.D. Florida InformationPoisonCenter

What is brodifacoum? What are synthetic cannabinoids? Brodifacoum belongs to a class of agents that was developed to overcome warfarin resistance in rats. Brodifacoum is a vitamin K antagonist and works similarly to warfarin by inhibiting vitamin K 2,3-epoxide reductase.1 Inhibition of this enzyme inhibits the regeneration of vitamin K 2,3-epoxide to vitamin K. Vitamin K is an integral cofactor for factors VII, IX, X, II and proteins C and S.1,2,3 By preventing its activation, the coagulation cascade is impaired, thus resulting in coagulopathy. These rodenticides are referred to as “superwarfarins” or long-acting anticoagulant rodenticides (LAARs). Brodifacoum is the most potent agent in this class; it is over 100x more potent than warfarin and can last from 2-12 months.2,4

Clinical Toxicology/EM Fellow, Florida/USVI Poison Information Center - Jacksonville By Molly Pharm.D.Stott, Florida InformationPoisonCenter –Tampa By Alexandra Funk, PharmD, DABAT Director, Florida/USVI Poison UFCenter-InformationJacksonville,HealthJacksonville

POISON CONTROL

■ New MedicationsOralTopicalBrochuresPatientCounterOver-the-(OTC)EducationforandAnalgesic Navigating OTC pain medication products can be confusing for patients who are met with hundreds of products on pharmacy and store shelves. Many products which were previously available by prescription are now available OTC. The PAMI team has developed patient education brochures to provide an overview of popular topical and oral products, including dosing and precaution information. Emergency, trauma and pain physicians and pharmacists were consulted in product development. The brochures include: • Topical agents • Lidocaine • Diclofenac • Counterirritants (IcyHot, Biofreeze, Tiger Balm, etc.)

• Acetaminophen • Ibuprofen • Naproxen Visit pami.emergency.med.jax.ufl.edu to access the complete discharge planning toolkit and download the OTC brochures to use or adapt for your patient population. To contact PAMI, email pami@jax.ufl.edu or call us at (904) 244-4986. Stay connected with us on Facebook and LinkedIn for our latest updates.

■ By the Pain Assessment and Management Initiative (PAMI) at the UF College of Medicine – Jacksonville x-waiver certification contributes to OUD stigma and creates a sense that prescribing buprenorphine to treat OUD is somehow “riskier” than a provider prescribing opioids, including buprenorphine for pain.6,7 Legislation for removal of the x-waiver requirement is a resolution that should continue to be supported by ACEP. ACEP has worked with the DEA, SAMHSA, and HHS to “X the x-waiver” and helped implement the new intent to prescribe in-lieu of traditional x-waiver policy. Telemedicine via videoconference, with an x-waiver physician, is an identified evidencebased strategy to mitigate this treatment gap both in the ED and in downstream care. This strategy, along with ECHO models (a provider expert available for other physicians) has proven successful, particularly in remote areas far from OBOT MOUD programs and areas without adequate public transit infrastructure.7 BRIDGE incorporates a hybrid approach offering buprenorphine induction not only within the ED, but at officebased location within proximity to areas with high opioid use, as well as via telehealth at IDEA Tampa, a mobile syringe exchange program, reflecting the evolving role of the ED as a healthcare coordination hub in the 21st century.

5. Mills B, Yepes A, Nugent K. Synthetic Cannabinoids. Am J Med Sci. 2015 this other exposure.

4. Gunja N, Coggins A, Bidny S. Management of intentional superwarfarin poisoning with longterm vitamin K and brodifacoum levels. Clin Toxicol (Phila). 2011 Jun;49(5):385-90.

EMpulse Spring 2022 43 Initial treatment may include both IV and high-dose oral vitamin K, fresh frozen plasma (FFP), or if the patient is critically bleeding, 4-factor prothrombin complex concentrate (PCC). After initial treatment and stabilization, serial CBCs and PT/INR values are required at least every 12 hours monitoring. Initial treatment is not curative, and these patients will all require admission until normalization of their PT/INR and an appropriate outpatient dose of vitamin K is established. As mentioned previously, brodifacoum has a very long duration of action and exposed patients require treatment with high doses of oral vitamin K for an average of 6-9 months. What are the long-term effects? Due to the long duration of action of brodifacoum, exposed patients require continued treatment for an average of 6-9 months. They will require close outpatient monitoring and medication administration. One major barrier to the long-term treatment of these people is medication noncompliance, which may result in the redevelopment of coagulopathy and bleeding requiring representation to the hospital.

or any

2. H.A. Spiller. Brodifacoum,Editor(s): Philip Wexler,Encyclopedia of Toxicology (Third Edition),Academic Press,2014,Pages 543-545

• Oral medications

■ ◀ Continued from page 41

availableInformationprofessionalsbrodifacoumWhenJul;350(1):59-62.managingasuspectedexposure,healthcareattheFloridaPoisonCenterNetworkareat1-800-222-1222toanswer questions concerning to, or assist in the management of,

REFERENCES: 1. Brodifacoum. In: IBM Micromedex POISINDEX (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: Marchmicromedexsolutions.com/www.(cited:1,2022).

toxic

3. Kelkar AH, Smith NA, Martial A, Moole H, Tarantino MD, Roberts JC. An Outbreak of Synthetic CannabinoidAssociated Coagulopathy in Illinois. N Engl J Med. 2018 Sep 27;379(13):12161223.

A 36-year-old female presented to the emergency department for evaluation of a headache. The patient's only medical history included anxiety and an uncomplicated childbirth three months prior. Three hours prior to arrival, the patient was going about her daily activities when she developed a sudden onset, 10/10 headache. The headache was described as severe and radiated to the left side of her head. The patient reported associated photophobia, left sided neck pain, nausea and vomiting. She denied any trauma or history of similar headaches. On exam, the patient appeared in distress secondary to pain, while shielding her eyes from the light and actively dry heaving. Her vital signs were remarkable for a slightly elevated blood pressure of 140/67 and bradycardia to 37 beats per minute. Her neurologic examination was benign aside from photophobia, notably without any visual field deficits, cranial nerve deficits or motor Althoughabnormalities.thepatient met none of the institution’s “stroke alert” criteria, given the patient’s distress and concerning symptomatology, CT imaging was expedited. The chief differential diagnosis was intracranial hemorrhage. Introduction The thunderclap headache is a wellknown and feared presentation amongst emergency medicine clinicians. This headache is distinguished from others by both its rapidity of onset and severity in nature.

Diagnostic testing and treatment included a pituitary panel, serum cortisol, ACTH, estradiol, IGF1, prolactin, TSH, free T4 followed by administration of hydrocortisone 100 mg IV.

Case Report: Thunderclap! CASE REPORT

Management/Outcome

Conclusion The thunderclap headache remains one of the most feared complaints for any patient presenting to the ED, as it is commonly considered in association with intracranial aneurysms. PA is a clinical syndrome that ED providers should consider when patients presenting to the ED report a thunderclap headache. Despite its rare occurrence with communitybased studies finding a prevalence of 6.2 cases per 100,000 individuals and broad presenting symptomology ranging from a mild headache to sudden death, an emergency physician needs to be able to promptly recognize

By Clifford,GrahamDO By Shen,PriscillaMD

Upon CT interpretation and correlation with clinical presentation, it was recognized that the patient required emergent neurosurgical evaluation. The patient was promptly transported from the free-standing ED where she presented to the institution's nearby tertiary care site. There, she was rapidly evaluated by neurosurgery. Prior to transfer she was treated with normal saline, ondansetron, hydromorphone and magnesium, and the patient’s head of bed was placed at 30 Thedegrees.patient underwent an MRI of the sellar region that confirmed the prior CTA results: “findings are in keeping with the clinical diagnosis of pituitary apoplexy with hemorrhage within both sides of the pituitary gland.”

The patient was promptly admitted to the neurologic intensive care unit and remained clinically stable in the ICU for two days. Her headache improved with analgesic medications. The patient was deemed not a surgical candidate by neurosurgery, was evaluated by endocrinology inpatient, and was discharged home with a steroid taper and close outpatient follow up.

While there are many intracranial causes of a thunderclap headache, pituitary apoplexy (PA) is a rare and overlooked cause for this type of Pituitaryheadache.apoplexy is a potentially lethal clinical syndrome characterized by sudden hemorrhage into the pituitary gland. It is most commonly associated with pituitary adenomas. PA can also be seen when a normal pituitary gland becomes under-perfused, infarcts and bleeds (e.g. Sheehan syndrome).

Case Presentation

EMpulse Spring 202244

Pregnancy and anticoagulation use are important precipitants associated with PA. While a headache is the most common symptom, the clinical presentation of PA can vary from mild visual disturbances to severe disability, such as coma, or even sudden death. Below is a case report highlighting PA presenting with the well-known red flag feature for high-risk headaches: “thunderclap.” Imaging CTA imaging of the head and neck was obtained. The reading radiologist concluded there was an 8x7 mm hyperdensity in the pituitary gland seen on the non-contrast portion of the study. This lesion was thought to represent hemorrhage within a pituitary adenoma. Otherwise, there were no other gross abnormalities, signs of midline shift, or signs of herniation.

REFERENCES

4. Ishii M. Endocrine Emergencies With Neurologic Manifestations. Continuum (Minneap Minn). 2017;23(3, Neurology of Systemic Disease):778-801. CON.0000000000000467doi:10.1212/

5. Raappana A, Koivukangas J, Ebeling T, Pirila¨ T. Incidence of pituitary adenomas in Northern Finland in 1992-2007. J Clin Endocrinol Metab 2010;95(9):4268–4275. doi:10.1210/ jc.2010-0537.

2022 BILL SH EARER

these patients as this represents a surgical emergency. CT imaging is a limited modality in the diagnosis of PA. As with diagnosing subarachnoid hemorrhage, the ability to detect hemorrhage in the pituitary gland decreases with time as the blood density decreases. CT has been found to be diagnostic in only 21-28% of PA cases, while an intrasellar mass is visualized in 80% of PA cases. If CT imaging identifies an intrasellar mass

COMPETITIONALS/BLS Learn

Orlando, FL Figure 2

6. Rajasekaran S, Vanderpump M, Baldeweg S, et al. UK guidelines without hemorrhage in a case with clinical concern for PA, the patient requires an emergent MRI as it is the superior diagnostic modality. MRI has been found to confirm the diagnosis in 90% of patients. Once diagnosed, PA can be managed surgically or medically. Both neurosurgical and endocrine consultation are required to make this determination. Surgical management consists of resecting the hemorrhagic region with a goal of resolution of symptoms. A strictly medical approach is an option in cases with absent or mild stable neuro-ophthalmic signs. These patients can present with elevated blood pressure which should be treated like other types of intracranial hemorrhage with antihypertensives. In our patient’s case, it was noted that the hemorrhage shrunk on outpatient MRI approximately three weeks later. Since endocrine dysfunction is a common complication, patients with PA should be evaluated for the need for corticosteroid and other hormonal replacement based on symptomatology and lab findings prior to discharge. Specifically, these patients can develop marked hypotension with development of cortisol deficiency which should be treated with intravenous fluid, corticosteroid therapy and pressors to combat hypoperfusion.

7. Semple PL, Jane JA, Lopes MB, Laws ER. Pituitary apoplexy: correlation between magnetic resonance imaging and histopathological results. J 2008;108(5);909–915.Neurosurg JNS/2008/108/5/0909.doi:10.3171/

8. Singh TD, Valizadeh N, Meyer FB, et al. Management and outcomes of pituitary apoplexy. J Neurosurg doi:10.3171/2014.10.JNS141204.2015;122(6):1450–1457. ClinCon International more at ALS/BLSemlrc.org/competitionBILLSHEARERCOMPETITION 14-15, 2022

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3. Fernandez A, Karavitaki N, Wass JA. Prevalence of pituitary adenomas: a community-based, cross-sectional study in Banbury (Oxfordshire, UK). Clin Endocrinol (Oxf) 2010;72(3):377–382. doi:10.1111/j.13652265.2009.03667.x.

1. Briet C, Salenave S, Bonneville JF, et al. Pituitary apoplexy. Endocr Rev 2015;36(6):622–645. doi:10.1210/ er.2015-1042. [PubMed]

July

2. Diri H, Karaca Z, Tanriverdi F, et al. Sheehan’s syndrome: new insights into an old disease. Endocrine 2016;51(1):22–31. doi:10.1007/s12020015-0726-3.

Figure 1 for the management of pituitary apoplexy. Clin Endocrinol (Oxf) 2011;74(1):9–20. 2265.2010.03913.x.doi:10.1111/j.1365-

ATEMPROSONLINE.COM THANK YOU

Let’s count my husband’s doctors: locally, he has an internist, general cardiologist, electrophysiologist, neurologist, otolaryngologistnephrologist,neuro-ophthalmologist,urologist,optometrist,andaudiologist.

The Golden Years: A View from the Bridge Retired; former Board Member and Education Committee Co-Chair Doreen C. Parkhurst, MD, FACEP

FEATURE

HAPPY DOCTOR’S DAY FROM YOUR FRIENDS

Now that I am living my golden years of retirement, I can speak with some authority. The bridge, of course, is that part of life between active career and ever-after. My husband and I are living the perfect retirement dream. We live in a 55+ community in Florida that has a clubhouse, café, fitness center, two swimming pools, several tennis courts and daily exercise classes (aerobics, Zumba, Tai Chi, Chair Yoga and water Weaerobics).wereat a Baby Boomers dinner dance at our club recently. I was sitting next to a new resident. “So what are you doing with your time here?” I asked. “Do you play tennis or swim or play cards?” “Well,” she said, “I do play Mah-jongg but mostly, I go to doctors. When I lived in Atlanta, I went to the doctor once a year for an annual checkup. Now, I go to doctors all the time.” I knew exactly what she meant.

Nationally, he is followed by a surgeon in Texas for his ascending aortic aneurysm; a cardiologist in Chicago for his AICD and multiple ablations; and another cardiologist in Chicago for his cardiac amyloidosis. When my husband says, “I couldn’t live without my wife,” he means it literally. I cannot count the number of prevented hospitalizations we have achieved through my daily diligence at monitoring his chronic heart failure, fluid status and arrhythmias. In the past few years, he has had a pontine stroke, rapid atrial rhythms with cardioversion and ultimately A

toHeartfeltallthe medical professionals on the front lines.

Here are a few things I have learned about elderly patients since my retirement. These caveats may be helpful for physicians in medical practice: While they may have slower reflexes and responses, they can often speak for themselves. When they appear before a doctor with a caregiver, the doctor often directs the questions to the caregiver. The patients find this insulting. They can answer the questions, but it may take a little longer for them to retrieve the information. It is also a good idea to make sure the caregiver is treating them well. This is frequently not the case. So many elderly people are on anticoagulants, and falls occur frequently.

The general rule is that they should have a head CT scan to rule out a bleed after a ground-level fall. Many of them end up with intracranial bleeds. A famous person example most recently was former President Jimmy Carter. So many elderly people live very far from their grown children. Although they talk once a week or routinely, they are often able to confabulate well enough to conceal their developing dementia. Screening is useful, and notifying family is essential. Eventually, there will come a time when they shouldn’t be driving or living alone. They still have sex, but their concerns have evolved into male erectile dysfunction and female dyspareunia from vaginal atrophy. Many members of both groups have incontinence. These complaints will not be offered unless they are asked. The adult diaper market in 2021 was over $16 billion. Most people are worried about running out of money. Many people should have Medicare home services who do not. Many could benefit from physical therapy, nurse visits to check on medications and home health aides. After an injury or illness, they should probably not be sent home without help. ADL’s should be assessed. Flexibility, balance and strength are frequently compromised. It is far better to prevent falls than to deal with them. Many people need canes or walkers. Elderly people may not be eating well. Supplementing their diets may be Finally,helpful. old age is not a disease. Please don’t write them off because of their age. Too often, they are not offered an intervention that younger patients would receive. Even if they are in the old-old group, if they are still very active, perhaps the intervention should be That’sconsidered.theview from the bridge where the final destination is in sight.

■

The CT scan shows enhancement of a foreign body in the subcutaneous Generaltissue. surgery was consulted, and the wound was probed. Rolled-up aluminum foil was retrieved from the abdominal wound with no fascial Perviolation.general surgery recommendations, the wound was packed with wet-todry dressings. The plan was for the wound to heal by secondary intention. As the patient was at high risk for selfinjurious behavior, general surgery did not feel the wound should be closed with staples or sutures. The patient was also administered a tetanus shot and prophylactic IV

ablations, Sick Sinus Syndrome with pacemaker, wide complex tachycardia with defibrillator (AICD), and recent confirmation of cardiac amyloidosis. That’s in addition to his prostate cancer and robotic prostatectomy. And of course, he has the usual hearing loss that comes with birthdays. His double vision is corrected with prescription eyeglasses. He looks terrific. When he’s on the golf course, you wouldn’t know he has anything wrong with him. That’s Florida for you: the fountain of youth.

Theantibiotics.patient was additionally placed under a Baker Act and was subsequently transferred to a psychiatric facility for further psychiatric evaluation.

By FACEP,Estrine,KarenDO,FAAEM Editor-in-Chief

Fig. 3: Aluminum foil foreign body.

There are at least two groups of elderly people: the young-old and the old-old. Arbitrarily, the young-old fall in the 64-75 age bracket and the other group above 75. However, soon we will be describing three groups of old people with the third group being the superelderly: over 90. There are at least five people I personally know of who are nearing 100 and quite active. There is a 98-year-old woman in my water aerobics class. She was also in my Tai Chi class until she passed out. That was the day I revealed to the class that I am a doctor. Until then, I was just one of the group. Physicians in Florida are certainly familiar with the elderly population. What may be surprising is the logarithmic growth of this population. According to Forbes, “in 2011, baby boomers started turning 65, and from now until 2030, that number will swell by 10,000 each day. That’s 70,000 per week and over 280,000 per month.”

A ◀ CONTINUED

Diagnosis:Daunting FROM PAGE 14

EMpulse Spring 2022 47

EMpulse Spring 202248

Mind the Gap: Appraisal of FOAM

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

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

Free Open Access Medical Education (FOAM) has exponentially grown over the last decade. Each year, more residents turn away from textbooks and move towards using FOAM as a source of education and information. As an innovative form of education, FOAM is disruptive, challenging traditional modes of knowledge translation and dissemination.1 Although some educators are skeptical of its formal use, FOAM is appealing to learners for several reasons. It has a low cost, is easily accessible, and quickly disseminates new evidence and techniques when compared to traditional formats. In addition, the information is delivered in a variety of formats, which makes it suitable to the different types of learning styles. As educators, how do we know if they are using high-quality resources? Are we teaching our learners how to navigate and appraise these resources? There is a gap in the education on how to critically appraise different forms of FOAM

Top 5 FOAM Websites (ranked by SMi as of 2021) Courtesy of aliem.com/social-media-index EMCRIT ALiEM REBELEM EMCASES

#5#4#2#1#3 LIFL

Givenresources.theskepticism of many educators, many have turned to developing quality markers that help assess the quality of a given FOAM, to critically appraise and help guide both educators and learners alike. This article will discuss existing tools to help our learners assess FOAM and some best practices to help teach how best to use FOAM. FOAM can describe many components, including medical education websites and individualized online educational resources. These include a variety of applications such as blogs, podcasts, social media components, opinion, commentary and archives. Some examples of FOAM within emergency medicine include, but are not limited to: Life in the Fast Lane; EMCrit, Academic Life in Emergency Medicine, CanadiEM, Dr Smith’s ECG Blog and EMS 12 Lead (Fig. Some1).studies have suggested that the individual gestalt of assessment of these resources was unreliable. As a result, several investigators have worked to develop structured, critical appraisal tools to identify higher quality resources. For our field of emergency medicine, available critical appraisal tools are the Social Media Index (SMi), Academic Life in Emergency Medicine Approved Instructional Resource (ALiEM Air score), the revised Medical Education Translational Resources: Impact and Quality (rMETRIQ score), and Colmers' Quality checklists (Table 1). From these, SMi, rMETRIQ and ALiEM AIR score are the most used. The SMi is the most used tool to judge the overall impact of FOAM. At the early stages in which SMi was used, many critiqued its parameters for online readership, followership and popularity, but these have diminished as more research has been applied.2 SMi is based on a mathematical model, which allows for transparency and objectivity. Drawbacks to SMi include that they can be artificially overestimated, and since there are likely many contributors to one website, the quality can differ from each page or post. It is important to remember that SMi rates the website in its entirety; not an individual blog or podcast.1 The latest ranking can be viewed online ataliem.com/socialThemedia-index.ALiEMAir score is a scoring instrument used by medical educators for rating online educational resources. It is composed of five domains: Best Evidence in Emergency Medicine (BEEM) Rater Scale, Content Accuracy, Educational Utility, Evidence-Based Medicine, and Referencing. When used by medical educators for rating online resources, this score is moderately to highly reliable.3 A major disadvantage to mention is that a minimum of nine assessors was required to achieve that Thereliability.rMETRIQ score is intended to be used by a variety of healthcare providers, from students to content experts, derived from the previous METRIQ score (METRIQ - 8 and METRIQ 5). It looks at 3 main components: content, credibility and peer review. It is designed for pointof-care use in the assessment of blog FOAMarticles.does not replace the current

EDUCATION CORNER

3. Chan, Teresa Man-Yee et al. “Examining Reliability and Validity of an Online Score (ALiEM AIR) for Rating Free Open Access Medical Education Resources.” Annals of emergency medicine vol. 68,6 (2016): 729-735. annemergmed.2016.02.018doi:10.1016/j.

EMpulse Spring 2022 49 Table 1: Quality Assurance Tools for FOAM1,2,5 approach to medical education, but it should be considered a strong adjunct. We know that many young medical professionals are using it on a regular basis and some may solely use these resources as their primary source of education. Furthermore, it is an enticing resource that promotes engagement, knowledge dissemination, networking and collaboration. But we cannot forget that it has its limitations.4 The unguided use of these resources by learners can pose a danger to their education and potentially patient care. Next time you are looking at a FOAM resource, “mind the gap” and consider applying these tools! ■ Appraisal Tool Intended Audience Intended Use Domains Assessed Tips Social Media Index (SMi) FOAM users FOAM Websites Relies FacebookTwittertrafficmodelmathematicalon(Alexarankscore,followers,likes); Initially used for most careforGenerallyFOAMimpactfulWebsites;utilizedEMandcriticalwebsites rMETRIQ FOAM Users – any level of toprovidershealthcare(traineeexpertlevel) FOAMIndividualizedResources Assess commentarypublicationquality,publisher,references,editorialconstruction;content;Concisecontentprocess;writingpost- derivation;Rigorous based on prior METRIQ/ MERSQI scorings Pending validation ALiEM AIR Score Expert evaluators FOAMIndividualizedResources BEEM Rater scale; EBM;educationalcontentAssessaccuracy;utility;referencing Impact on EM Clinical Practice Colmers' checklistsQuality FOAMResearchers;Educators;Curators;Producers,Editors;Users Specific to Blogs and Podcasts Content;Credibility;Design Simple; validationfriendly;user-pending REFERENCES:

5. Colmers, Isabelle et al. "The Quality Checklists for Health Professions Blogs and Podcasts." The Winnower 9:e144720.08769 (2015). doi:10.15200/ winn.144720.08769

6. Chin, A., Taher, A., Thomas, A., Bigham, B., Thoma, B., & Woods, R. (2020, June 17). Using quality appraisal techniques to find trustworthy content in the foam universe. CanadiEM. canadiem.org/ using-quality-appraisal-techniques-infoam/ 7. Carley, S. (2017, April 29). The social media index (SMI): CAN & should we measure #foamed? St.Emlyn's. stemlynsblog.org/the-social-media-www. index-smi-is-it-flawed/

2. Chan, Teresa M et al. “Thinking Critically About Appraising FOAM.” AEM education and training vol. 3,4 398-402. 23 May. 2019, doi:10.1002/aet2.10352

4. Nickson, Christopher. "Free OpenAccess Medical education (FOAM) and critical care." ICU Management & Practice vol. 17,4 (2017): 222-225

1. Ting, Daniel K et al. “Quality Appraisal and Assurance Techniques for Free Open Access Medical Education (FOAM) Resources: A Rapid Review.” Seminars in nephrology vol. 40,3 (2020): doi:10.1016/j.semnephrol.2020.04.011309-319.

For those of you who have been reading my columns since the early 2000’s, I have turned 74 and do not know how many of these essays I have left in me. For my birthday, I received a new knee and a new job. I slid away from the hospice company I had been contentedly working for a little over 10 years now and joined a somewhat newer and slimmer version in another hospice company. I also underwent my second total knee arthroplasty in the past two and a half years. The good news is that God only gave me two knees to completely wear out. Shout out to Dr. Mark Hollmann of Florida Orthopedics and his trusty sidekick Henry Samsoe, PA-C, for doing an excellent job on both knee replacements. My convalescence and rehab from the second surgery exceeded the first in speed and pain recovery. Going from one relatively stress-free medical job to another in the midst of total knee replacement rehabilitation has been a little more stressful than I bargained for, but I am finding my groove with the new hospice company and enjoying the new faces and colleagues. It seems there are plenty of hospice patients to go around! I want to take this opportunity to address the embarrassing situation in our state where we are the only state so far to declare that Covid vaccinations are not recommended for healthy children. This would seem to fly in the face of most of the valuable principles and knowledge we have gained from public health officials and scientists as a result of battling a viral pandemic that has killed over 6 million people on our planet. First of all, if I were a Florida parent, I would be terribly confused about whether to vaccinate my children (and I do have two teenage grandchildren whose parents are just that)! Of the 28 M or so U.S. children between the ages of 5-11, there have been approximately 2 million cases of Covid-19 as of last October. Some of these children have become very sick with about 8,300 cases requiring hospitalization, and about 100 children have died in this country from Covid as of last October. Serious Covid illness complications like multisystem inflammatory syndrome have occurred, and children with serious underlying medical conditions are more at-risk for severe illness from Covid. Covid now ranks as one of the top 10 causes of death in children 5-11 years old. The Covid vaccines have been proven safe for children 5-11 years old and older. Serious health events after Covid-19 vaccination in children are rare. Myocarditis has been reported in a few children 12-17 of age who received the vaccine. In these cases, the myocarditis was mild and resolved without aggressive treatment or residual effects. The incidence of myocarditis in vaccinated children was a little less than that in the general population of children of that age group. No cases of myocarditis appeared in Covid vaccinated children aged 5-11. Severe anaphylactic allergic reactions in children are very rare. Children DO NOT get Covid-19 from Covid-19 injections. There are no fertility problems, and finally, children who are vaccinated against Covid-19 prevent the spread of Covid to other family members and their friends at school. These facts and other pertinent Covid-19 information can be found on NowCDC.gov.let’s return to Florida, where Surgeon General Dr. Ladapo has declared that the Florida Department of Health, which he directs, does not recommend Covid-19 vaccines for healthy children. This recommendation is not in any way in concert with the information I discussed above, which comes directly from the CDC. Most of us are familiar with Dr. Ladapo’s credentials. He is a cardiologist who came from a medical school in Southern California and has no demonstrable expertise in public health. He refuses to divulge whether he has been vaccinated against Covid-19, which is a requirement for membership on the faculty of the UF School of Medicine to which he was automatically appointed by virtue of being appointed Surgeon General of the State of Florida. He refuses to follow the CDC recommendations on mask wearing, and infamously was thrown out of a state senator’s office with whom he was assigned to curry favor for his appointment because she insisted he wear a mask in deference to her battle with cancer. Dr. Ladapo was appointed to his position by the current Governor Ron DeSantis, and in this capacity, his job is to protect the health and safety of all of Florida’s residents. By denying scientific, evidence-based medicine related to Covid pandemic fighting, recommendations, and enforcement of mitigation procedures to protect as many Floridians from the virus as possible, the Governor and Dr. Ladapo seem to be pursuing a political agenda that appeals to Gov. DeSantis’ base for re-election rather than to protect the health and safety of Floridians.

About a dozen students appeared on the stage, all wearing masks. Perhaps their parents had discussed with them that wearing a mask during a viral pandemic was a good idea because scientific evidence shows that chances of spreading the virus to others were reduced. Gov. DeSantis rammed a state law through the Florida Legislature recently, stating that it was illegal

An example of the weaponization of this medical misinformation occurred recently when Gov. DeSantis humiliated a bunch of high school students and their parents at an awards assembly.

EMpulse Spring 202250

Totalitarian?

MUSINGS EMERGENCY PHYSICIAN

By Wayne Barry, MD, FACEP Former FCEP Board Member

FROM A RETIRED

Isn’t Medical Misinformation

EMpulse Spring 2022 51 50 YEARS, 50 VOICES a digital project honoring FCEP & emergency medicine fcep.org/50years

NOWWATCH

Speaking of weaponizing misinformation with regards to Putin’s war against Ukraine, I recently heard an interview with a woman who holds office in the Russian Duma. She claimed that President Putin is protecting Russia from the Nazified and corrupt Ukraine who are in fact the military aggressors in the current conflict. When the reporter reminded her that the current President of Ukraine, Volodymyr Zelenskyy, is Jewish, her reply was Nazis are not restricted to specific religions, ethnicity or nationalities. Finally when she was shown pictures of the results of Russian bombing of multiple civilian sites inside Ukraine, she did not believe the pictures were real or genuine, and she believed the Russians were on the defensive because this is what she is told by President Putin. My intention is not to disrespect the duly elected highest official in the state of Florida, but I did want to point out some of the similarities between the belief in anti-science misinformation and the propaganda associated with the world’s most fearsome and violent totalitarian state. You can be the judge as to whether I am off base with my concerns. ■

FCEP’s 50th Anniversary Tribute to Emergency Medicine

Featuring: Rajiv Bahl, MD, MBA, MS; Ashley BoothNorse, MD, FACEP; Daniel Brennan, MD, FACEP; Elizabeth Calhoun, MD; Damian Caraballo, MD, FACEP; Jordan Celeste, MD, FACEP; Bill Davison, MD, FACEP; Arthur Diskin, MD, FACEP; Jay Edelberg, MD, FACEP; Caral Edelberg, CPC, CCS-P; Jay Falk, MD, FACEP; Kelly GrayEurom, MD, MMM, FACEP; Erich Heine, DO; Phyllis Hendry, MD, FACEP; Saundra Jackson, MD, FACEP; Steven Kailes, MD, FACEP; Wayne Lee, MD, FACEP; Michael Lozano, MD, FACEP; Kristin McCabe-Kline, MD, FACEP; Ernest Page, MD, FACEP; David Orban, MD, FACEP; Russ Radtke, MD, FACEP; John Stimler, DO, FACEP; Josef Thundiyil, MD, MPH, FACEP; Chrissy Van Dillen, MD, FACEP, FAEMS; David Vukich, MD, FACEP; Frederic Wurtzel, MD, FACEP for anyone other than parents to tell their children to wear face masks. In any event, Gov. DeSantis ridiculed the masked students and ordered them to remove their masks because he thought it was not necessary, and he further accused them of participating in “Covid theater.” The video clip went viral. The Governor has shown similar viciousness in positions, resulting in new state legislation bashing the expansion of voting rights, exhibiting antagonism towards LGBTQ rights and teaching or training in diversity issues, and denying the acknowledgment of certain dark chapters in U.S. history.

EMpulse Spring 202252 32812FLOrlando,Road,ConwayS.3717766-6335(800)|www.fcep.org EM Advocate EM Champion 2022 Corporate Partners Become a 2022 Partner Thank You Our Annual Corporate Partners provide support for a variety of projects and initiatives at the Florida Emergency Medicine Foundation (FEMF) and Florida College of Emergency Physicians (FCEP). Benefits include: DIGITAL & ADVERTISINGPRINT ☑ VIPSERVICECUSTOMER ☑ FIRST TO KNOW OPPORTUNITIESOF ☑ CUSTOMIZABLEPACKAGES ☑ YEAR-ROUNDVISIBILITY ☑ so much more & Contact Melissa Keahey Interim Executive Director JOIN OUR CORPORATE PARTNER PROGRAM TODAY (407)mkeahey@emlrc.org281-7396ext. 231 EM Innovator N Org.on-ProfitPOSTAGEU.S.PAIDIllinoisPontiac,592NO.PERMIT

EMpulse Spring 2022

Articles inside

Musings from a Retired Emergency Physician: Isn't Medical Misinformation Totalitarian?

Education Corner: Mind the Gap: Appraisal of FOAM

Poison Control: 2021 Brodifacoum-Contaminated Synthetic Cannabinoid Outbreak: Overview of Identification and Management of the Exposed Patient

Patient Misconceptions about Buprenorphine Induction for Opioid Use Disorder in the Emergency Department

UCF/HCA Ocala

HCA St. Lucie Medical Center

VITAS

Social Emergency Medicine: Naloxone out of the ED and into the Community

HCA Brandon

UM/Jackson Memorial

Orlando Health

FCEP President’s Message

Medical Student Council

Next Steps for the EM Resident Class of 2022

Membership & Professional Development

EMS/Trauma Committee

Government Affairs Committee

Call for Revisions and Updates to the PAMI Pain Management and Dosing Guide

Medical Economics Committee