Official Publication of the Florida College of Emergency Physicians A Chapter of the American College of Emergency Physicians
2019 LEGISLATIVE SESSION ENDS WHAT PASSED & FAILED? ALSO FEATURING: Regarding End of Life in the Emergency Department
Congratulations to the EM Residency Classes of 2019 Removal of an Entrapped Ring of Unknown Material
Clearing the Smoke: the Risks of Liquid Nicotine in E-Cigarettes
The Changing Landscape of Emergency Medicine Training in Florida
Updates on the Opioid Crisis: The MAT Bridge at Tampa General Hospital
PLUS: GET READY FOR SYMPOSIUM BY THE SEA 2019 Vol. 26, No. 2 | Summer 2019 EMpulse Summer 2019
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Summer 2019 | Volume 26, Issue 2
FCEP COMMITTEE REPORTS
4 FCEP President’s Message
13 Medical Economics
5 ACEP President's Message
14 Pediatric Committee
6 Gov’t Affairs: Session Ends
18 EMRAF President’s Message
J. Adrian Tyndall, MD, MPH, FACEP Vidor Friedman, MD, FACEP Damian Caraballo, MD, FACEP
9 Membership & PD
Danyelle Redden, MD, FACEP Pediatric Committee members Misty Coello, MD, PGY-2
30 Medical Student Committee
Shayne Gue, MD
Karen Estrine, DO, FACEP, FAAEM
Congratulations to Residency 18 Classes of 2019
Florida’s EM Residency Programs
20 Residency Program Updates
Florida’s EM Residency Programs
Changing Landscape of 28 The Emergency Medicine Training in Florida
Robert Levine, MD
31 Financing Our Future
Maureen France & Ernest Page, MD, FACEP
32 Regarding End of Life in the Emergency Department
Bridget Highet, MD & Andrea Sharpe, MS, MD
34 Musings from a Retired EM
J. Adrian Tyndall, MD, MPH, FACEP
Kristin McCabe-Kline, MD, FACEP, FAAEM, ACHE
Damian Caraballo, MD, FACEP
COLUMNS & FEATURES
FCEP Executive Committee
Sanjay Pattani, MD, MHSA, FACEP
Desmond Fitzpatrick, MD
3717 S. Conway Road Orlando, Florida 32812 t: 407-281-7396 • 800-766-6335 f: 407-281-4407 www.emlrc.org
10 Symposium by the Sea 2019
Florida College of Emergency Physicians
36 Opioid Crisis Update: MAT Bridge at Tampa General Hospital
Heather Henderson, MA, CAS, et. al
38 Poison Control: Clearing the Smoke
Kristen C. Lee, PharmD, BCPS & Madison Schwartz, PharmD
40 Ultrasound Zoom: Skin Deep:
POCUS of Soft Tissue Infections Kristina Jacomino, MD, PGY-3 & Leila Posaw, MD
44 Case Report: Removal of an
Entrapped Ring of Unknown Material
Hermann Pierre Piard, MD, PGY-2 & Eva M. Wojewoda, MD
Harsh Shah, MS4, et. al
50 Clinical Image in Emergency Medicine: Hampton’s Hump
Joel Stern, MD, FACEP, FAAEM
Beth Brunner, MBA, CAE
EMpulse Editorial Board Editor-in-Chief
Karen Estrine, DO, FACEP, FAAEM firstname.lastname@example.org
Managing & Design Editor Samantha League, MA email@example.com
Johnson Press of America, Inc. 800 N. Court St. Pontiac, IL 61764 t: 815-844-5161 | f: 815-842-1349 www.jpapontiac.com
Hashim Ejaz, MBBS, et. al
All advertisements in EMpulse are printed as received from advertisers. The Florida College of Emergency Physicians does not endorse any products or services, except those in its Preferred Vendor Partnership. FCEP receives and distributes employment opportunities but does not review, recommend or endorse any individuals, groups or hospitals that respond to these advertisements.
Physician: The ED and Hospice Revisited Wayne Barry, MD, FACEP
Fall 2019 Deadlines:
• Ad insertion orders due: July 26 • Ad design/payment due: Aug. 16 • Articles due: Aug. 16
EMpulse is always accepting articles, case reports and advertisements. Find our advertising kit and more at emlrc.org/empulse. EMpulse Summer 2019
Opinions stated within articles are solely those of the writers and do not necessarily reflect those of the EMpulse staff, the Florida College of Emergency Physicians and our advertisers/sponsors. 3
FCEP President’s Message By J. Adrian Tyndall, MD, MPH, FACEP FCEP President • Interim Dean of UF College of Medicine
Time moves quickly. Soon, I will be reflecting on the past year while handing over the gavel and presidency of the Florida College of Emergency Physicians to new leadership. This year has been a time for change and readjustment. New political leadership in the Governor’s seat and within the legislature presented a chance to grow relationships, understand the priorities of our elected and appointed officials, and prepare for opportunities to create synergies that will positively impact the patients whom we advocate for. We have encountered—with increasing concerns—new and more aggressive policies by insurers who claim the noble purpose of reducing costs of care. Surprise billing has turned from a national conversation to national action, with the American College of Emergency Physicians rightfully taking the lead in steering national legislation. In spite of the shifting sands of uncertainty in the healthcare space, I am proud to know that FCEP, its staff and its supporters remain as some of the most steadfast advocates for patients seeking unscheduled urgent and emergent care. FCEP remains one of the most recognized voices in support of the practice of emergency medicine. This is also an important time to say thank you to an amazing group of staff members and an executive director, who is a paragon of leadership for our organization. With my current day job as a professor and chair of an academic emergency department and interim dean of a College of Medicine, navigating the role of this presidency would have been impossible without the help and support of dedicated leadership and staff.
As the end of my term draws near, preparations are afoot for the annual gathering of emergency physicians, residents and medical students from across the state at Symposium by the Sea. This conference has become a staple of FCEP’s visibility and contributions to education, advocacy and influence. Over time, Symposium by the Sea has grown both in terms of attendance and registrants, but also in the range of innovative topics and programming. The medical student section has led the pace in growth, thanks in significant part to one of our former Board members, Robyn Hoelle, MD, FACEP. This year, Symposium will host the first ever gathering and conference tract for emergency medicine residency program directors in Florida. As the number of residency programs in the state has more than quadrupled over the last decade, so has the number of active residents in training. FCEP remains firmly committed to the education and development of the next generation of our workforce, and will continue the long-standing tradition of supporting programs, residents and students through this annual gathering and other high value experiences offered throughout the year. Emergency medicine has a lot to be proud of in the state of Florida. FCEP is a leader amongst chapters in the country due to our advocacy and offerings, and we continue to grow and advance our ability to support our physicians, our practice and our patients. Thank you for a great year, and see you all at Symposium by the Sea. ■
EMpulse Summer 2019
Join Us: FCEP Board of Directors & Committee Meetings August 1, 2019 Boca Raton Resort & Club Boca Raton, FL
All meetings take place in room Grand G unless otherwise stated Membership & Professional Development 8:00 am–9:00 am Education & Academic Affairs 9:00 am–10:00 am Medical Economics 10:00 am–11:00 am Government Affairs 11:00 am–12:00 pm Lunch 12:00 pm–1:00 pm EMS/Trauma 1:00 pm–2:00 pm Council of EM Residency Program Directors & Core Faculty 1:00 pm–3:00 pm Grand I Pediatric EM 2:00 pm–3:00 pm FCEP Board of Directors 3:00 pm–5:30 pm Venetian Room Reception for Chairman Paul Renner 5:30 pm–7:30 pm Venetian Room Incoming President’s Reception 6:30 pm–8:00 pm
ACEP President’s Message By Vidor Friedman MD, FACEP ACEP President • FCEP Past-President
I am now nine months into my 13-month term as ACEP president. What a ride it has been! It feels like I am living in D.C.: I have been there once or twice a month since October, advocating for our specialty regarding out-of-network billing (surprise bills). While this advocacy is not the only thing I am doing as president this year, it is the most important by far! At the beginning of June, the “STOP Surprise Medical Bills Act” (S. 1541) was released in the Senate by the Price Transparency Workgroup (led by Sen. Bill Cassidy, R-LA). Additionally, draft language for the “Lower Health Care Costs Act” (S. 1895) passed through the Senate Health, Education, Labor and Pension committee (HELP Committee), the committee of jurisdiction. In the House, we have the “Protecting People from Surprise Medical Bills Act” (HR 3502) from Congressmen Ruiz & Roe, with a number of co-signers already and draft language from the Energy and Commerce Committee (E&C Committee). Of course, the White House has also chimed in with their suggestions. ACEP is working with all the leading proponents to bring our voice and perspective to the debate. We have a totally different economic model than all other physician specialties: one that is defined by our obligations under EMTALA (the Emergency Medicine Treatment and Labor Act of 1986). Emergency physicians are the only physicians who provide diagnosis and treatment prior to determining payment, 100% of the time. Because of this unique arrangement, we also provide far more uncompensated care than any other physician specialty. In 2010,
We advocate for our patients every day at work, and now we must advocate for ourselves.
this pro bono care averaged $140,000 per year for each emergency physician, more than four times the next highest specialty. I am confident that today, the gap is even bigger. In 1986, the vast majority of people covered by commercial insurance had essentially first dollar health insurance coverage paid for by their employer. Over the past 10 years, this has changed considerably. The percentage of employed individuals with a high deductible plan has increased from 15% to 45%, and even those who do not have a high deductible plan have significant deductibles for emergency and out-of-network care. The unfunded public mandate of EMTALA requires that those who have commercial insurance essentially pay for those who cannot (uninsured & Medicaid patients). No one wants to pay for healthcare they have not directly received, and now that individuals are having to pay out-of-pocket for that care, they are understandably frustrated, upset and angry. So why is this so important to us in emergency medicine? Because this really is an effort by insurers to define all emergency billing, both in- and out-of-network. Huh? If you look at the language in the current HELP and E&C committee bills, the focus is on capping outof-network bills at the median in-network rate, which would have EMpulse Summer 2019
the effect of driving all contracts to the median in-network rate in short order. While that does not sound bad to policymakers, it would have a devastating impact on emergency medicine groups’ ability to contract at a reasonable rate. The effect of this legislation would be to rapidly shift all contracts to the median in-network rate or below, and the median would decrease every year thereafter. Fortunately, the Protecting People from Surprise Medical Bills Act (HR 3502) contains much more favorable language that mirrors the New York state legislation. ACEP is working hard to quickly garner as much support as possible for HR 3502 in the House and from other specialty societies within medicine. It is essential that there is strong support within the House for HR 3502, as we would like this bill to be adopted by the E&C committee. I urge you to contact your representative to support HR 3502, and ask your senator to support Sen. Cassidy’s amendments to the Lower Health Care Costs Act in the Senate. We advocate for our patients every day at work, and now we must advocate for ourselves. Please add your voice to ACEP’s in this fight. Protecting your future in emergency medicine—it’s what ACEP does for you every day! ■
URGE CONGRESS TO SUPPORT HR 3502 Take action now by scanning this QR code
Government Affairs: 2019 Session Ends By Damian Caraballo, MD, FACEP
Government Affairs Committee Chair • FCEP Secretary-Treasurer
2019 marked a wild session for the house of medicine. With a new House Speaker and Governor, the Florida Legislature came out aggressively seeking new healthcare legislation, much of which would have negatively impacted emergency physicians. Fortunately, FCEP was able to work with our allies to defeat the multitude of health bills that would have had a negative effect.
With the continued assault on physician autonomy, scope and right to well-being, it is essential that physicians band together to advocate for quality medical care.
Bills that passed:
• Telehealth: Florida finally passed
a telehealth bill which regulates telemedicine. Unfortunately, HB 23 is severely lacking in its coverage. As adopted, it does not include in-person services parity, allows out-of-state physicians to register to provide telehealth services without requiring a Florida license (through simple registration with Florida DOH), and gives tax incentives to insurance companies.
• E-Prescribing: this bill will
mandate e-prescribing for all physicians. HB 831 will require any physician with an electronic health record system to use E-prescribe by their license renewal date OR by July 1, 2021, whichever occurs first. Initially, the bill had no exclusions or workarounds. Fortunately, through our advocacy efforts, we were able to get exceptions based on hardships, technology limitations of physician practices, down-time exceptions, and exceptions which would facilitate price shopping for patients.
• Certificate of Need (CON): in a
contentious fight between the House and Senate, the Senate agreed to end the current CON, which limits the number of
hospitals in a geographic region. A last-minute amendment by the Senate placed limits on opening niche, boutique specialty hospitals if they do not provide a minimal amount of basic medical and surgical services in a given area. HB 21 will expand the amount of hospitals and specialty programs that compete in any given region. Free-standing EDs will still be required to be tied to a hospital.
• Other Bills: other bills passed
include expansion of the needle and syringe exchange programs to all of Florida (SB 366), expansion of Direct Care agreements to all physicians (HB 843), and a new requirement for human trafficking CME to replace previously required CME-programs for re-licensure in Florida (HB 851). (Editor’s note: Learn more about EMLRC’s human trafficking course on page 14.)
The 2019 Session might best be remembered for the formidable job the house of medicine did in defending its field. With Speaker Oliva eager to expand medicine’s scope of practice for nurse practitioners, optometrists, psychologists and even pharmacists, FCEP and its allies rallied to stave off bills that EMpulse Summer 2019
would have significantly lowered the quality and oversight of healthcare in Florida. FCEP fought hard to have physicians remain as the captains for medical decision-making, while assuring Florida patients continue to receive the highest level of care by board-certified and trained physicians. For the second year in a row, FCEP worked to defeat a bill that would have allowed pharmacists to practice medicine by diagnosing and treating streptococcal pharyngitis and influenza in pharmacies. FCEP collaborated with the FMA to ensure that NP’s and PA’s continue to work under the direction of physicians, within their scope of practice. FCEP also advocated to ensure Florida emergency physicians receive fair pay for their EMTALA-based work. Thanks in part to FCEP’s efforts, Florida’s No-Fault motor vehicle insurance (PIP) and physician medpay system remain in place, despite repeal attempts that would have disproportionately lowered reimbursement for emergency physicians and negatively impacted hospital-based, on-call services. Further, FCEP advocacy helped stave off an attempt by the Florida government to set draconian fee-schedules on physicians, which would have capped all physician reimbursement at 200% of Medicare. Next session we will undoubtedly see repeated efforts to expand scope of practice to those not properly trained to provide high levels of medical care. We also continue to see the influence of health insurance companies on the legislature, particularly on the House side: using the guise of “lowering costs,” insurers continue to lobby for lower physician reimbursement, decreased standards for medical care
August 1, 2019 | 11:00-12:00 pm Boca Raton Resort & Club Grand G Room
FCEP’S 2019 LEGISLATIVE SESSION REPORT Healthcare-Related Bills that Passed: Access to Care
and diminished coverage of illness. Expect to see a push for weaker, cheaper insurance plans that could conceivably not even cover emergency services as an essential benefit. Insurances will also continue to raise premiums and deductibles while shifting costs to patients, putting physician billing practices under further scrutiny. With the continued assault on physician autonomy, scope and right to well-being, it is essential that physicians band together to advocate for quality medical care. With session over, the summer offers an opportune time to meet with your local legislators and discuss issues that affect emergency departments across Florida. I urge you all to join the FCEP PAC, as well as other organized state PACs such as the FMA PAC, and attend organized medicine meetings so that we can continue to advocate for our fellow physicians and patients. Despite what seemed like insurmountable odds, FCEP and organized medicine was able to show its strength this session. The 2020 Florida session starts in January, and EM Days will happen the third week of January. Please join FCEP in our efforts to advocate for the advancement of emergency medicine in Florida. ■
• Medical Marijuana (SB 182) • Patient Access to Primary Care & Specialist Providers (HB 843) • Telehealth (HB 23 & 7067)
First Responders • • • •
E911 Systems (HB 441) Firefighters (SB 426) Tactical Medical Professional (HB 487) Workers’ Compensation for First Responders (HB 983)
Hospital & Office Policy
• Hospital Licensure (HB 21) • Office Surgery (SB 732) • Stroke Centers (SB 1460)
Insurance • • • •
Direct Health Care Agreements (HB 7) Health Insurance (HB 1113) Health Plans (SB 322) Insurer Guaranty Associations (HB 673)
Prescription Drugs & Prescribing • • • •
Controlled Substances (HB 7107) E-Prescribing (HB 831) Prescription Drug Importation (HB 19 & HB 7073) Prescription Drug Monitoring (HB 375 & HB 1253)
Public Safety & Welfare • • • • • • •
Alzheimer’s Disease (HB 449) Child Welfare (HB 7099) Human Trafficking (HB 851) Immunization Registry (HB 213) Nonemergency Medical Transportation Services (HB 411) Vaping (SB 7012) Wireless Communications While Driving (HB 107)
Substance Abuse & Mental Health
January 27-29, 2020
• • • • • • •
Alternative Treatment Options for Veterans (HB 501) Infectious Disease Elimination Programs (SB 366) Mental Health (SB 1418) Nonopioid Alternatives (HB 451) Public Records/Mental Health Treatment (SB 838) Substance Abuse Services (HB 369) Treatment-Based Drug Court Programs (HB 7025) Scan the QR code to read thorough summaries of each bill listed here in FCEP’s legislative report.
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EMpulse Summer 2019
Membership & Professional Development By Shayne Gue, MD MPD Committee Co-Chair
Summer is my favorite time of year: longer days, beach and pool time, and most importantly, Symposium by the Sea! SBS is our largest CME and member appreciation event, and it continues to grow year by year. SBS 2019 is back at the beautiful Boca Raton Resort & Club in Boca Raton, FL. Events will take place August 1-4, 2019, and we are thrilled to be hosting you! Symposium by the Sea is Florida’s premier emergency medicine event, offering a robust slate of educational and social programs for all. As always, SBS is designed with YOU in mind. It is tailored for the clinician at all levels of training—attending physicians, residents, medical students, APPs, nurses and more—so there’s always something for everyone. Be sure to bring your family too, as we will have plenty of events for them as well. Some favorite events are returning again, as well as an expansion of resident competitions to include CPC, SimWARS, Research Poster Abstract Presentations and the new SonoRace (ultrasound competition). We’re also bringing back the highly lauded Pediatric and Critical Care learning tracks, as well as LLSA, Rapid Fire sessions and the New Speaker’s Forum. Some other personal favorites are the Town Hall discussions, the annual Past Presidents’ Volleyball Tournament and
Casino Night. Whether this is your first SBS or you are returning, you are guaranteed to have an experience like no other learning, collaborating and rejuvenating with your colleagues and friends. Register online now at www. emlrc.org/sbs. The Membership & Professional Development Committee is thrilled to announce further increases in our total membership numbers, heavily fueled by the continued growth in graduate medical education in our state. We currently have 18 residency programs in Florida, 10 of which have been instituted in the last 3-4 years. Our membership has surpassed 2,100 total members, awarding us an extra councillor (and vote) for the ACEP Council Meeting at the Scientific Assembly in Denver this fall. While membership naturally comes to the forefront, professional development is also an integral part of our committee’s objectives. Our goal is to turn more attention to this important subject, and we welcome your help! What does professional development mean to you? What would you like to see us offer? And how can FCEP and ACEP further support you? Wellness is another significant topic that cannot be overstated. Burnout in emergency medicine continues to be
an obstruction, and physician suicide is increasing in dramatic fashion. EM clinicians have been defending the front line and providing the safety net since the inception of our specialty. Our knowledge and skills allow us the privilege to save lives on a daily basis, but this responsibility can take a toll. Finding effective means of burnout mitigation and promoting wellness in and out of the work place can benefit us all. What do you do to promote wellness? We’d love to hear about it and share your advice with others. Please send in pictures of you celebrating wellness that we can share during Symposium by the Sea, and be on the lookout for more wellness tips and tricks in the future. As always, we welcome your input and want to know how we can best serve you. Becoming an active participant is the best way to enact change and we welcome everyone at our committee meetings either in-person or via phone. We look forward to seeing everyone at Boca in August! ■
August 1, 2019 | 8:00-9:00 am Boca Raton Resort & Club Grand G Room
October 27-30, 2019 Colorado Convention Center Denver, CO Register at acep.org/acep19 EMpulse Summer 2019
AUGUST 2 | 12:30 PM–4:30 PM COMPETING PROGRAMS: »» Kendall Regional DEFENDING CHAMPS
»» Aventura »» FAU
»» Oak Hill Hospital »» Port St. Lucie »» UF Jacksonville »» USF
FCEP’s Annual Meeting &
August 1 Boca Raton R Boca Ra
Research Poster Abstract Competition
Free for FCEP residents & med students •
AUGUST 2 | 6:00 PM–8:00 PM Posters are available for viewing August 2-3. Official presentations take place during the Wine, Beer & Cheese Reception.
»» FCEP Board & Committee Meetings
»» FEMF Board Meeting »» SimWARS Competition
»» Florida CORD Meeting
»» Research Poster Abstract Competition
»» Reception for Rep. Paul Renner
»» EMRAF Networking Reception
»» Incoming Presidents’ Reception
»» Wine, Beer & Cheese Reception
»» No CME this day
»» 9 hours of CME & 7 hours of CEUs available
AUGUST 3 | 11:00 AM–1:30 PM COMPETING PROGRAMS: »» Jackson Memorial DEFENDING CHAMPS
»» Mount Sinai
»» UCF HCA at Osceola »» UCF HCA of North FL »» UCF at Ocala
AUGUST 4 | 9:00 AM–11:15 AM
COMPETING PROGRAMS: »» AdventHealth Orlando »» Kendall Regional »» Oak Hill Hospital »» Orlando Health 10
»» UCF HCA of North FL »» UCF at Ocala »» UF Gainesville »» UF Jacksonville EMpulse Summer 2019
Online Registration C
Symposium by the Sea Chair:
Dr. Rene Mack
SimWARS Committee: Dr. Ademola Adewale CO-CHAIR
& Educational Conference
1-4, 2019 Resort & Club aton, FL *
»» Case Presentation Competition
»» SonoRace Competition (new!)
»» EMRAF Meeting
»» New Speakers’ Forum (new!)
»» Med Student Meeting »» Casino Night: Cheeseburger & Margarita Paradise
Dr. Alexandra Mannix
Dr. Shiva Kalidindi
Dr. Carmen Martínez
Dr. Melissa Parsons
Dr. Caroline Molins
Dr. Javier Rosario
• $100 for ACEP/FCEP members (online )
Dr. Ryan McKenna CO-CHAIR
»» Awards Ceremony
Dr. Alfredo Tirado CO-CHAIR
Dr. Javier Rosario CO-CHAIR
Dr. Giuliano De Portu
Dr. Diana Mora
Dr. Petra DuranGehring
Dr. Mark Newberry
Dr. Douglas Haus
Dr. Andrew Shannon
Case Presentation Committee:
Research Poster Abstract Committee:
Jennifer Jackson CHAIR
Jason Wilson CHAIR
Dr. Leila Posaw
»» 2 hours of CME & CEUs available
»» Annual Volleyball Game
Scan to read our SBS brochure
»» Past Presidents’ Luncheon »» 4 hours of CME & CEUs
Closes July 28, 2019
ACCME & AMA: The Emergency Medicine Learning and Resource Center (EMLRC) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. EMLRC designates this live activity for a maximum of 15.0 AMA Category 1 PRA Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. FPA: The Emergency Medicine Learning and Resource Center (EMLRC) is approved as a provider of continuing medical education by the Board of Florida Physician Assistants; Provider #50715. EMpulse Summer 2019
A maximum of 15.0 AMA Category 1 PRA Credits™ will be provided by EMLRC. AAPA accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by the ACCME or a recognized state medical society. Physician assistants may receive a maximum of 15.0 hours of Category 1 credit for completing this program. FBON: The Emergency Medicine Learning and Resource Center (EMLRC) is approved as a provider of nursing education by the Florida Board of Nursing, Provider #2731. Up to 13.0 nursing contact hours will be provided by EMLRC. 11
By Desmond Fitzpatrick, MD EMS/Trauma Committee Member
Heat, trauma and envenomation, oh my! The summer season is upon us, and with it comes a slew of patients that are spending more time outdoors and in cars. As you prepare yourself and your ED for the sultry summer months, keep a few important points in mind: Old or Young – Heat’s No Fun! Pediatric and geriatric patients are much more susceptible to critical heat-related illness and it is on all of us to ensure their safety. As the CDC points out, “When temperatures outside range from 80 to 100 degrees, the temperature inside a car parked in direct sunlight can quickly climb to between 130 to 172.” That is not only incredible, but incredibly dangerous. It’s not just cars that pose a risk— elderly at home or in care facilities with inadequate air conditioning also suffer from heat-related illnesses. Keep First Responders Hydrated! Our prehospital providers respond to patients in all types of weather, but during these periods of very high temperatures, it is even more important to stress their hydration and ability to take relief from the heat. Between their gear and high humidity environments, sweat no longer provides evaporative cooling, leading to quick rises in core temperatures. Crew safety is paramount so we don’t create more patients while responding in the extremes of heat. Remember your XABCs! As far as trauma goes, most are familiar with the “Stop the Bleed” campaign. It is also important to stress that the ABCs of trauma have become the XABCs. “X” is for exsanguination, which should receive the highest priority in our trauma responses.
Dr. Abo’s Do’s & Dont’s of Snake Bites It is that time of year where we are more active outside, and so are crawling critters. Not to mention, storm season has time and time again proven to result in more envenomations before and after storms. Do not rely on hearsay, wives’ tales or even little blurbs that get you by for board certification! DO: • Stay calm & calm patient • Immobilize above the heart at 60 degrees if possible; otherwise, at level of heart • Mark fang or scratches and leading edge of skin changes and tenderness every 10 min • Call venom specialist or poison control • Provide analgesia (it hurts!) • Leave the snake alone and alive! DO NOT: • Kill or bring the snake for ID • Taze, shock or use electricity • Tourniquet • Suck or extract • Excise • Ice • Wait for symptoms or assume dry bite • Prophylactically give NSAIDs or antibiotics
MAY EMS/TRAUMA COMMITTEE MEETING QUICK HITS: • Encourage statewide response
to opioids, including appropriate use of Narcan and ED-initiated Buprenorphine. Form connections with local treatment programs, as well as social work and psychiatric assistance
• Support the use of Dispatcher-
initiated Bystander CPR following No-No Go line of questions
• Drs. Antevy and Scheppke have expanded their resuscitation academies to include multiple areas across the state
• Encourage using or establishing
registry standards, such as Florida Stroke Registry or CARES
August 1, 2019 | 1:00-2:00 pm Boca Raton Resort & Club Grand G Room
Stay Up-to-Date! The EMLRC is finishing up its MCI, LCI, Oh My!: A Review of Prehospital Hemorrhage Control series with some great speakers and interesting topics. Dr. Abo lectured on “Mass Casualty Overview” and “Wilderness Considerations for MCIs.” Dr. Christopher Hunter of Orange County lectured on the medical response to the Pulse Nightclub shooting in “#OrlandoUnited.” If you missed these free webinars, rest assured they’ll be available via EMLRC Online soon. ■ emlrc.org/education/mci
EMpulse Summer 2019
Medical Economics By Danyelle Redden, MD, FACEP Medical Economics Committee Chair
Emergency medicine groups throughout Florida continue to report a variety of tactics by insurers to avoid fair physician reimbursement. FCEP remains engaged with the Florida Office of Insurance Regulation regarding ongoing payment violations by Humana. Since Florida’s balance billing legislation went into effect, Humana has been underpaying out-of-network claims. At our meeting in January, OIR staff stated they would investigate. Thus far, OIR has taken no action. We anticipate another meeting this summer. FCEP and EDPMA held a series of conversations with Blue Cross Blue Shield of Florida over the last several months regarding their practice of using a “non-emergent” diagnosis list to deny level 4 and 5 claims. BCBS maintained that this practice is not a violation of the prudent layperson standard and that they intend to continue the practice. Another trend recently noted by Florida EM groups is the refusal of some Medicaid Managed Care plans to contract. As insurer denials become more fre-
quent and complex, it is essential for the EM community to monitor trends that violate the prudent layperson standard and ultimately threaten the emergency care safety net. If you are experiencing unreasonable denials/ rejections, or notice reimbursement trends of interest, please communicate this information with FCEP.
at 200% of Medicare rates. Although many of these bills did not pass, we expect to see similar legislation in the future.
TESTING THE DISPUTE RESOLUTION PROCESS
Out-of-network billing is a hot issue at the federal level this session, with several pieces of legislation proposed to address it. Hundreds of emergency physicians represented ACEP in May at the annual Leadership & Advocacy Conference in Washington, D.C., and met with legislators to advocate for reasonable legislation that preserves fair payment. ACEP has released a formal statement on surprise billing and bundled payments, which can be found on the ACEP website.
One of the legislators proposing federal legislation is Florida Senator Rick Scott, who held a roundtable in Tampa in May to discuss a variety of healthcare reform issues, including out-of-network billing. Dr. Damian Caraballo represented FCEP at the event. ■
We anticipate that at least two cases may be submitted to the state dispute resolution process in the near future. These will be the first such cases to be submitted since Florida’s balance billing legislation took effect in 2017. Historically, dispute resolution favored the payer.
Broad healthcare reform was clearly a priority in the 2019 legislative session. Numerous bills were considered that could have significant economic impact on emergency physicians, including bills related to telehealth, certificate of need, personal injury protection (PIP) insurance, and scope of practice for APPs and pharmacists. One piece of legislation (HB 1317/ SB 1790), which did not pass, would have capped hospital-based services
August 1, 2019 | 10:00-11:00 am Boca Raton Resort & Club Grand G Room
Daunting Diagnosis: Q By Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief
A 30-year-old male was sent to the ER from the health department for a left temporal facial lesion that he has had for two months after traveling to Central America. He reports that he was bitten by an insect. He denies past medical history. What does this image show, and how is it treated? CONTINUE ON PAGE 22 » EMpulse Summer 2019
Perils & Pitfalls of Pediatric EM: Avoiding the Trap of the Tar-Baby
By members* of the Pediatric Committee
In pediatric emergency medicine today, we constantly find ourselves under pressure from all directions: patients, their parents, the nursing staff, our medical directors and sometimes ourselves. Patients-perhour, patient satisfactions surveys, turnaround times and 72-hour returns to the ED are metrics we are judged by that affect our bottom dollar and how we practice in the ED. Along with all of these external pressures, there is one pressure that we create and force on our own selves: dealing with results of tests that we order. Our habit of ordering tests indiscriminately is particularly troubling for the generally healthy pediatric patients in the ED. There are many reasons we order tests for patients, ranging from justifiable reasons such as medical necessity and evidence-based protocols, to ‘soft’ reasons such as primary physician expectations and parental demands—and because of our own fear of litigation. However, what do we do when a result is abnormal, especially when that finding is unexpected? Given that there is a nearly 10% error rate in laboratory data, we need to think about what an ‘abnormal’ result truly means. Further, what kind of predicament do we get ourselves into when we order additional tests to investigate
the initial abnormal result, and in the process, gather larger amounts of data? This predicament has been nicely documented in medical literature. In “Uncle Remus and the Cascade Effect in Clinical Medicine,” Brer Rabbit becomes naively involved in a seemingly innocent encounter that rapidly evolves into inescapable entanglement and entrapment. Each step in this process of irreversible commitment is triggered by a straightforward, explainable and understandable prior event. The cumulative result of these simple actions, however, is an inexorably accelerating cascade that is costly and dangerous, but seemingly unavoidable. This cascade effect described by Joel Chandler Harris in the 1880s has a parallel in medical practice today when an innocent initial action leads to a series of prolonged and expensive investigations and interventions, frequently of no benefit to either patient or physician, and commonly a source of frustration for both.
There are ‘Tar-babies’ at every corner in clinical medicine. Unfortunately, so many clinicians are too eager to kick them, sometimes in the name of ‘completeness,’ other times assuming it is a benign act, not realizing the trap they are getting into. In the ED, we order seemingly simple tests in our determination to not ‘miss’ anything, no matter how unlikely it may be. Thus, we sometimes create our own triggering event that inevitably progresses into an unstoppable force. In doing so, we make the patient, ourselves, and the healthcare system helpless victims of a frustrating, runaway situation that often leads to an endless cascade of costlier interventions that are simultaneously unnecessary and unavoidable. ■
August 1, 2019 | 2:00-3:00 pm Boca Raton Resort & Club Grand G Room
*FCEP’s Pediatric Committee, pictured above right, presented the PEM Workshop: Neonatal Emergencies at the EMerald Coast Conference on June 2, 2019. Front row: Drs. Vanessa Perez, Cristina Zeretzke-Bien and Tricia Swan Back row: Drs. Shiva Kalidindi, Nicholas Erbrich, Todd Wylie and Joseph Grantham
HUMAN TRAFFICKING & EMERGENCY MEDICINE Meets new HB 851 requirement Approved for AMA PRA Category 1 Credits™ 14
EMpulse Summer 2019
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Congratulations to the
EM RESIDENCY CLASSES OF 2019 WHERE THEY’RE GOING NEXT:
Editor’s Note: Information published as received from EM residency programs. Most lists obtained by June 2019.
Jackson Memorial Hospital
AdventHealth East Orlando Tallahassee, FL
Dr. Kenneth Frye
AdventHealth Hospital Celebration, FL
Johnson City Medical Center Johnson City, TN
Dr. Foluso Akinradewo
Brandon Regional Hospital Brandon, FL
Dr. Brian McMaster AdventHealth Hospital Winter Park, FL
Dr. Ahmed Amer New York City, NY
Dr. Navid Arandi Sacramento, CA
Dr. Isaac Azar
Jackson Neuro CC Fellow
Texas Health Harris Methodist Hospital Stephenville, TX
Dr. Courtenay Glisson
Dr. Juvenal Havyarimana
Dr. Lavern Keitt
Attending Physician Miami, FL
Capital Regional Medical Center Tallahassee, FL Dr. Zachary Hester
UFCOM-Jacksonville Jacksonville, FL
Dr. Robert Jiang
Mid-Ohio Emergency Services
Dr. Michael Cecilia
South Georgia Emergency Physicians
Dr. Landon Lichtman
Duke Hyperbaric Fellow
Dr. Michael DiCenso
Dr. Laura Scheidt
Dr. Davis Lester Valdosta, GA
AdventHealth Orlando, FL
Dr. Keegan Michel
Dr. Natalia Diaz
Dr. Adam Sienkiewicz
Plantation, FL Dr. Bradly Koschel
South Georgia Emergency Physicians
Dr. Christopher Sweat
Dr. Megan Miller
Regions Hosp Tox Fellow
Orange Park Medical Center
Dr. Alexander Thai
Dr. Matthew Mui
San Antonio, TX
Dr. Meagan Lorenzo
Dr. Thomas Yang
Orange Park, FL
U.S. Air Force
Orange Park Medical Center
Dr. Aldo Manresa
Dr. Ariana Wilkinson
Dr. Jerry Tavornwattana
Yale Simulation Fellowship
Baptist Health & Mount Sinai
Dr. Matthew Yasavolian
Dr. Adam Memon
Ft. Lauderdale, FL
Dr. Peter Sayers
New Haven, CT
Dr. James Gabriel
US Acute Care Solutions, Mountains Division
South Georgia Emergency Physicians
New Orleans, LA
Dr. David Rose
Westside Regional Medical Ctr
Dr. Eric Edgerton
Santa Clarita, CA
Dr. Michael Roberds
Dr. Ana Castaneda Guarderas Dr. Salem Elkhayat
Dr. Adam Brunson
Westside Regional Medical Ctr
Adventist HealthCare Shady Grove Medical Center
Dr. Jeffrey Lombardo
Jackson Health Miami, FL
Fort Worth, TX
Dr. Daniel Hercz
Dr. Katie Laun
International Medicine Fellowship, SUNY Downstate Medical Center
Dr. Joseph Diaz
Dr. Marisa Gilbert
Dr. Elijah Kennedy
Dr. Emily Cooper
Dr. Andrew Gibson
Dr. Natalia Alvarez Dr. Jonathan Balakumar
Capital Regional Medical Ctr
Dr. Francis Behan
Emergency Medicine Consultants, LTD
UCLA EMS Fellow
Dr. Casey Arnold
BMC EMS Fellow
Orange Park, FL
AdventHealth Orlando, FL
Dr. Henry Zeng
Dr. Joseph Valentin
Stanford Palliative Fellow
EMpulse Summer 2019
St. Lucie Medical Center
Dr. Thomas Adams
Lawnwood Medical Center
Dr. Adam Barnathan
Dr. Jessica Chambers
Fort Pierce, FL
UCF/HCA at Osceola Regional Dr. Adam Benzing
EMS Fellowship, UT San Antonio San Antonio, TX
Dr. Rolando Cabrera
Palm Beach Gardens Medical Ctr
St. Petersburg, FL
NCH Healthcare Systems
Tampa Bay Area, FL
Dr. Patrick Davison
Envision Ambassador Team
Fort Pierce, FL
Dr. Leoh Leon
Dr. Jibran Khan
Dr. Byron Markel St. Petersburg, FL
Dr. Darrell Ritchey Lakeland, FL
Dr. Daniel Ryczek
Lawnwood Medical Center
Dr. Porsha RoacheRobinson
Lawnwood Medical Center Fort Pierce, FL
St. Petersburg, FL
Dr. Kristin Schumann Jacksonville, FL
Palm Beach Gardens, FL
Dr. Nicholas Kramer Denver, CO
Ultrasound Fellowship, Osceola Regional Medical Center Orlando, FL Dr. Abhishek Roka
Global Health & Ultrasound Fellowship, UT San Antonio
Dr. Eric Shamas
EMS Fellowship, UT San Antonio
Dr. Andrew Smith
Dr. Nicholas Antoon
Dr. Amanda Webb
Dr. Zain Tariq
South Seminole Hospital Orlando Health
Dr. Zachary Terwilliger
Dr. Theodore Clarfield
St. Petersburg, FL
Daytona Beach, FL
Kendall Regional Medical Center
Dr. P. Phillips Hosp & Orlando Health Medical Pavilion Orlando, FL
Dr. Lisa Cook
Ultrasound Fellowship, Orlando Health
Dr. Amninder Singh San Antonio, TX
Research Fellowship, Osceola Regional Medical Center
Dr. Brittney Beel
Dr. Alicia Evans
CHI Franciscan System
Dr. Nathan Hadley
Dr. Pavel Antonov Dr. Eric Copeli Tacoma, WA
Dr. Stefan Jensen
Baylor, Scott & White
Druid City Hospital Tuscaloosa, AL
Dr. Brandon Herb
Dr. Alicia Buck EMS Fellowship Gainesville, FL
Dr. Christopher DeFreitas Capital Regional Medical Ctr
Wake Emergency Physicians
Arizona Emergency Medicine
Dr. Dallas Joiner
UNC Pediatric EM Fellowship
WellStar Hospital System
Dr. Vinicius Knabben Tucson, AZ
Dr. Nicholas Koneri
GSEP Emergency Medicine
CCM Fellowship, Jackson Memorial Hospital
Dr. Jovana Obradovic
San Antonio, TX
Broward Health Medical Center
Baptist Health System
Dr. Tyler “TJ” Randall
Dr. Robert Maldonado San Antonio, TX
Dr. Kent Martin
GSEP Emergency Medicine San Antonio, TX
Dr. Ana Pineda
KRMC Administrative Fellowship Miami, FL
Dr. Joseph Proza
Envision EMBassador Travel Program
Fort Lauderdale, FL
Baptist Medical Center San Antonio, TX
Dr. Steven Ritchey Araya
Ultrasound Fellowship, Orlando Health
Dr. Nicole Hardy Raleigh, NC
Dr. Kevin Hord Atlanta, GA
Dr. Spencer Johnson
Georgia Emergency Associates Savannah, GA
Dr. Travis Murphy
UF Critical Care Fellowship Gainesville FL
Dr. Ryan Roberts
North FL Regional Medical Ctr
South Lake Hospital & Four Corners, Orlando Health
Dr. Jake Sanstead
Dr. Amy Souers
Dr. Cat Uthe
Dr. Kailee Smith Orlando, FL
Dr. Daniel Sirovich
Orange County EMS Fellowship
Dr. Moshe Yatzkan
Dr. Daniel Young
Dr. Joe Violaris
KRMC Attending Physician Miami, FL
Naples Community Hospital Naples, FL
DON’T FORGET! Renew your FCEP/ACEP membership
Dr. Josh Altman
UF Sports Medicine Fellowship
TeamHealth Travel Team
FL EM residents from 110 graduated residency programs & 11 EM staying in Florida 62 are
Dr. Nicholas Cramer
In June 2019:
San Antonio, TX
Tampa Bay Area, FL
By the Numbers
Naples Community Hospital
EMpulse Summer 2019
Florida’s Newest Programs Expect their inaugural classes to graduate in: 2020 • Florida Atlantic University • UCF/HCA at North Florida Regional • UCF at Ocala Regional
2021 • HCA West at Brandon Regional • HCA West at Oak Hill
2022 • FSU at Sarasota Memorial • Orange Park Medical Center 17
EMRAF President’s Message
Introducing Florida’s newest program:
By Misty Coello, MD, PGY2 EMRAF President FCEP Board Member In the midst of summer, and as we welcome the new incoming residency year, I am excited for all the changes and expansion that we will see at Symposium by the Sea. Those who know me also know my goals and vision for EMRAF and all of Florida EM residencies is to become a great educational forefront. We have expanded Symposium by the Sea by creating a new competition for residencies called SonoRace, which will be an ultrasound competition taking place on the last day of the conference: Sunday, August 4 at 9:00 am. Everyone is welcome to come and watch the event. We are also happy to announce some new changes and expansion to EMRAF. In this new year, EMRAF will be expanding to include a new committee by regions. The purpose is to expand and empower residents in those fields, including government affairs, education, pediatrics and EMS. If interested, please email me at firstname.lastname@example.org for more information. Applications and details will be given at the SBS EMRAF meeting. Thank you everyone for an amazing year. I look forward to seeing each of you at Symposium by the Sea. ■
August 3, 2019 | 1:30-2:30 pm Boca Raton Resort & Club Grand A Room
Orange Park Medical Center INAUGURAL CLASS OF 2022
Dr. Michael Bischof
Dr. Trevor Lofgran
Dr. Taylor Bosley
Dr. Patrick McKeny
Edward Via College–Auburn Univ. of Pikeville
Dr. James Broome
Edward Via College–Auburn
Dr. Obianuju Eziolisa
Edward Via College–Auburn
Dr. Ahmad Mohammadieh Wayne State Univ.
Dr. Cody Russell
East Tennessee State Univ.
Edward Via College–Auburn
St. George’s Univ.
Edward Via College–Auburn
Dr. Janae Fry Dr. Lauren Karsh
Dr. Lisa Vaccaro
Dr. Derek VanderVelde
UF Health: Gainesville By Michael Chami, MD, PGY-3
We’ve been excited to welcome our new intern class into the UF family. They are a diverse, fun and eager group that is ready to begin their journey as emergency physicians. After lots of careful preparation and interdisciplinary coordination, we’ve officially rolled out our new, high-sensitivity troponin assays in our emergency department. We hope this will allow for better diagnostic accuracy in diagnosis of acute MI and ultimately help our patients. The Cardiac Arrest Research Team has continued its mission in all aspects of resuscitation with several basic science, clinical and popuEMpulse Summer 2019
lations health studies. Abstracts regarding the extent of legal liability faced by bystander responders and factors leading to missed cardiac arrests have been submitted to ACEP. Another study exploring bystander misgivings about performing CPR was presented at SAEM and the manuscript is under consideration for publication. Grant funding from SAEM will fund a pilot study of perfluorocarbons to treat hypoxic brain injury in a swine model of cardiac arrest beginning in July. We are proud of the graduating class of 2019 and wish them the best in their future endeavors. ■
UCF/HCA at Ocala Health By Caroline Smith, MD, PGY-1 & Vir Singh, MD, PGY-2
Our third year has officially started and we welcome our class of 2022 to the team. We would also like to congratulate Drs. Samyr Elbadri and Nick McCauley on their election as class of 2020 chief residents. They will work alongside Dr. Joe Gibney as he continues his role as scheduling chief for the coming academic year. Dr. Gibney will have the unique experience of managing residency scheduling for the third year in a row. The residency program is excited to continue growing and evolving with their leadership. We are pleased to have Dr. Latha Ganti accept a position as interim research director for our program in Ocala. Dr. Ganti is a professor of emergency medicine and neurology, as well as the research director at UCF/HCA Osceola. We are extremely appreciative of her mentorship as she adds this interim role in Ocala on top of her faculty position in Osceola. Residents at UCF/HCA Ocala continue to work hard clinically and academically. Our residents have been working
on quality improvement projects, book chapters and case reports under Dr. Ganti’s guidance. Drs. Samyr Elbadri, Joe Gibney and Caroline Smith participated in FCEP’s EM Days in Tallahassee to lobby Florida lawmakers on legislation that affects our practice as emergency physicians. The Class of 2020 attended SAEM’s annual conference in Las Vegas, NV. Program coordinator Keith Molinary attended CORD in Seattle, WA, along with Drs. Joe Gibney and Vir Singh. Since ORMC was designated as a comprehensive stroke center this year, our team of residents, faculty, community physicians, nurses and staff have worked hard to improve outcomes for stroke patients in our area. In addition to seeing higher volumes of stroke patients, we are excited to increase our exposure to pediatric patients. Our pediatric emergency medicine and PICU rotations will now be at Nemours Children’s Hospital in Orlando. We are thrilled to work with and learn from the specialists at Nemours and continue improving our pediatric clinical skills. ■
UF Health: Jacksonville By Tyler Tantisook, MD, PGY-2
UFCOM-Jax is excited to welcome our new interns to the family. We have a talented incoming group from across the country with a variety of life experiences that are sure to make our team stronger, smarter and more fun.
Congratulations to Drs. Lexie Mannix, Melissa Parsons and Elizabeth Devos for awards they received at AWAEM/ SAEM in Las Vegas. We are fortunate to have their leadership and innovation in our program.
We are thrilled to have a distinguished faculty member back on shift in the department after a hard fought battle requiring ECMO in the ICU. His resiliency is motivation and inspiration for everyone at UF Jax.
Much appreciation and best of luck to our stellar seniors as they head off to all their well-earned positions in the “real world.” We’ve learned a lot from you all, made some lifelong friends, and are excited to see you develop as attendings. ■ EMpulse Summer 2019
UCF/HCA at North Florida Regional
By Ryan Luevanos, MD, PGY-3
Wish you were here enjoying our amazing weather in sunny Gainesville as I write this letter outside! By the time you are reading this, our newest third class of residents have just arrived and are adjusting to residency life. We have brought onboard an impressive group of hard-working interns with a huge range of achievements and backgrounds, and we cannot wait to see how they will serve this community! We could not have been more excited with how well our trip to SAEM Las Vegas went. I would like to extend an enthusiastic congratulations to our very own residents, Drs. Alex Waldman and Donovan Ginest, for their Top 100 presentation at the meeting. Fittingly, our attendings and residents decided the best way to celebrate was to ride a helicopter through the Grand Canyon and take in the amazing sights! I would also like to extend an eager congratulations to Dr. Zaza Atanelov for being one of the top resident presenters at this year’s Alachua County Medical Society Research Poster Symposium. I’m unbelievably proud of my fellow PGY-3s and honored to have witnessed our amazing PGY-2s develop over the past year. I can’t wait to see what is in store now that we finally have three full classes of bright and motivated residents serving our community alongside our extremely dedicated faculty. Feel free to stop by and visit! We look forward to meeting and reconnecting with you all at Symposium by the Sea, as well as ACEP 2019 in Denver! ■
HCA West at Brandon Regional By Michael Rains, MD, MPH, PGY-2 As our program’s first year comes to a close and another begins, it is evident that the future is bright. These past few months have taken us as far south as Bolivia and as northwest as Seattle. At home and abroad, our residents and faculty work to better the health of our patients and the systems upon which they rely. Our all-intern team (Drs. Rachel Oliver, Caroline Trippel, Michael Simpson and myself) placed fourth out of 14 in EMRA’s Quiz Show at CORD, and the team representing them placed second in the Chaos in the ED simulation contest. Dr. Michael Simpson, PGY-2, is serving as the Vice Chair of EMRA’s Toxicology committee. Working with core faculty members Drs. Anthony Furiato and Kirk Szustkiewicz, Dr. Roli Kushwaha, PGY-2 implemented a successful opiate use reduction program and was awarded first place for her presentation at the HCA-West Florida resident research competition, which had 80 presentations representing nine hospital systems. Through our collaboration with USF, I
provided medical care and mentored medical students in Bolivia while assessing the efficacy of care within the Bolivian healthcare system for a research project in collaboration with Dr. Furiato. We were awarded second place at the HCA-West Florida resident research competition for our project. Drs. Rashmi Jadhav, PGY-2 and Caroline Trippel, PGY-2 also presented impressive case reports at the HCA-West Florida resident research competition. Simulation is an area of growth in our program. As we grew to 30 residents this year, we gained five additional core faculty members. Dr. Kelly Grabbe is leading our simulation and disaster medicine programs. The residents have also been quite active in this regard. Dr. Melissa Bacci, PGY-2 created several incredible paper mache mannequins for practicing perimortem c-sections (pictured below). The residents masterfully completed two simulation cases designed by co-residents and faculty that covered massive transfusion in the context of medical and trauma resuscitation.
We are also fortunate to have two ultrasound core faculty—Ultrasound Director Dr. Eric Kalivoda and Dr. Gabriel Cabrera—on staff, as well as an EMS physician, Dr. David Arbona. Clearly, our residency has a bright future ahead. The program has taken off with a running start and we excitedly welcome our new class of interns this month. It will be a wild ride, and we are honored to have an incoming class with great potential to whom we can hand our intern torch to as we move onto our second year. ■
AdventHealth East Orlando By Shannon Armistead, DO, PGY-3
Greetings again from AdventHealth East Orlando. We wished our seniors good luck as they spread their wings, moving on to their new adventures as attendings across Florida and as far away as Tennessee. We are excited and geared up for the new class—our interns are coming from snowy Michigan, Ohio, West Virginia, and as close as Puerto Rico and Florida. Just weeks after receiving our Match List from NRMP, we received our In-Training exam scores. Of course no matter how well we do, as type A 20
personalities, we strive to do better. The faculty we work closely with help us not only synthesize our scores, but also help us modify our study habits to prepare for the next step and the next test. They also frequently remind us how important it is to take care of yourself and let loose, so we appreciate how they “drag us” to Universal Studios once a year to show us what the hard work is all about! This year has been a rollercoaster of experiences and learning for everyone. We’ve been able to pracEMpulse Summer 2019
tice cutting-edge procedures and count ourselves lucky to have these opportunities. As with all things, we would like to take a moment and acknowledge all those who take the time and energy to teach and mentor us: the nurses and staff who work with us, and the trauma team at Lakeland Regional who so graciously open their TICU to us. Without all of you, we would not be growing into the well-trained emergency medicine physicians you know. ■
HCA West at Oak Hill By Jonathan Yaghoubian, DO, MS & Corey Cole, DO, PGY-2s There is exciting news in the hospital! A recent ED expansion has been approved for a much needed 10,000 square foot addition. Two floors are also being added to the North Tower, expanding the beds in the hospital to 350. Construction has already started for the North Tower expansion with the ED to start in the near future. An expanding hospital is fitting for an expanding residency. We welcome our new class to our program, as well as our new faculty members: Assistant Program Director Dr. Jason Grabert, Ultrasound Director Dr. Edgar Miranda, and EMS/Simulation Director Dr. Vesta Anilus. They are in addition to our new ED Director Dr. Jonathan Schwadron and program coordinator Lisa Stoessel. Over the course of the year, we have been working closely with Research Director Dr. Veronica Tucci and have several projects in the works. Dr. Anilus will have her hands full as our new simulation laboratory is built and being furnished. Our lab will simulate a full resuscitation bay and be equipped with a high-fidelity simulator manikin. We are working on setting up a program to run simulations incorporating the ER staff. As part of our residency, we have been actively integrating wellness activities. Our most recent adventure was going kayaking on the Weeki Wachi river and seeing the manatees. Since we don’t have any seniors, we have been stepping up to take on additional responsibilities. Dr. Shaun Mansour, PGY-2 is our Wellness Coordinator, and Drs. Corey Cole, PGY-2 and Christopher Megargel, PGY-2 became Vice Chief Residents. ■
FSU at Sarasota
By Matthew Beattie, MD, PGY-3
By Kelly O’Keefe, MD, FACEP Program Director
Summer has arrived, and the Florida heat is back as we break out the swimsuits and sunscreen.
Greetings from Sarasota! It is hard to believe that we are finally welcoming our inaugural residency class after what has been several years of hard work and careful planning. We are thrilled with our match and excited to truly get started with training the next generation of emergency physicians. Our interns are coming to us from a variety of backgrounds and we are confident that they will form a solid backbone for our new program.
USF EM had a great end to the residency year. Half of our PGY-2’s attended CORD Seattle back in April while the other half went to SAEM in Vegas. Drs. Maram Bishawi, PGY-3 and Ryan McKenna did an awesome job in Seattle presenting about an interesting case of dural venous sinus thrombosis at the case presentation. In Vegas, Dr. Dan Ryczek presented at the simulation academy about the utility of guided visualization in simulation vs. traditional simulation teaching methods. Finally, Drs. Mikhail Marchenko, PGY-2 and David Orban went up to D.C. in May for LAC 2019 to advocate for our specialty alongside hundreds of other EM docs. Our core faculty does a great job of supporting our interests as residents and assisting us with attendance to these events. The residency year has come to an end and it seems like time has flown by. For our seniors, this means they are released into the wild to practice on their own, and they get a well-deserved raise. We are thankful for their leadership and friendship over the last three years. It also means a new group of eager, excited residents has arrived. At USF EM, July is full of fun events as we get to know the new group and welcome them to the family. We are excited for the year to come. ■
We are also grateful for the support of the FSU College of Medicine and everyone at Sarasota Memorial Hospital, especially the leadership headed by CEO David Verinder. We cannot wait to share the fruits of our labor with our inagural class. In anticipation of our interns’ arrival, our core faculty has been very involved with faculty development, with various members attending CORD, SAEM, simulation training courses and the ACEP teaching fellowship. The core faculty will outnumber our interns, which guarantees them pretty good odds when it comes to teaching and mentorship! Look for us at Symposium by the Sea as we will be excited to introduce our awesome faculty and interns to the rest of Florida’s emergency medicine community. See you there! ■
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EMpulse Summer 2019
Daunting Diagnosis: A « CONTINUED FROM PAGE 13
By Laura Cook, MD & Anne Shaughnessy, MD, PGY-3s Hello from ORMC! Summer has just begun, but it’s already been a hot year for our program. Many of our residents presented abstracts and posters at a variety of conferences this spring, including SAEM in Las Vegas, SAEM Southeast, CORD in Seattle, AMSSM in Houston, and our own Quality Retreat at Orlando Health. We are lucky to have wonderful mentorship and want to acknowledge some of our faculty’s accomplishments. Dr. John O’Brien was honored with the Dr. Ruth McKeefery Volunteer Physician of the Year Award for his dedication to community medical service, particularly with Orlando’s Shepherds Hope clinic. We’d also like to extend a big congratulations to Dr. Briscoe for Teacher of the Year and to Dr. Davison for Lecturer of
the Year. We’ve been looking forward to welcoming our great group of 18 residents and are excited they have finally joined us! With the entrance of the new, we must sadly say farewell to many of our graduating seniors. While several of our third-year residents have joined our faculty, are staying in the area or are completing a fellowship, their graduation is bittersweet. Thank you for your hard work, leadership, dedication and friendship over the past three years. We wish you the best in your future endeavors, and know that you will always have a place here in our family. As always, once you’re in, there’s no getting out. We look forward to seeing everyone in Boca at Symposium! ■
Upon physical examination, a hyperkeratotic plaque is found on the face with small satellite lesions and erythema. Dermatology was consulted and a punch biopsy was obtained. Initial diagnosis by dermatology was “deep fungal infection,” for which he was initially treated with itraconzaole. The tissue pathology result later demonstrated a diagnosis of cutaneous leishmaniasis. Treatment medication was changed to sodium stibogluconate (Pentostam) after qualifying for the medication by the CDC. In cases of uncommon skin lesions, tissue biopsy for pathology is always recommended. ■
UCF/HCA of Greater Orlando at Osceola
By Andrew Hanna, MD, PGY-3 & Amber Mirajkar, MD, PGY-2 Although we are sad to lose the senior and inaugural class, our PGY-3s have bright futures ahead of them in both academics and the private sectors. Congratulations to all of our PGY-3s! March marked our annual program evaluation and retreat. This time, we decided to take advantage of natural Florida and spend some time outdoors camping. It was a relaxing trip and a great way to catch up with everyone. While we see each other in-passing on shift, this provided us with an opportunity to connect outside the emergency room. Speaking of emergency medicine outside of the ED—we had the opportunity to participate in an extrication 22
event with EMS students. Several of our residents went to a junkyard and learned about what an extrication involves and what the scene is like for first responders. It was quite a learning experience and we hope to make it a regular event. This spring was also our annual community outreach event. From bringing breakfast to EMS to going to the county jail, we got to connect with the community providers who share our vulnerable patient population. Seeing the resources available and how far spread out they are gives a whole new insight into the struggles of many patients who come to the ED. Physically visiting our community partners also enabled us to learn about referral services available when we discharge from the ED. In the EMpulse Summer 2019
future, we hope to work with the county community clinic and not-for-profit clinics like OBT Family Clinic. In the realm of research, our residents continue to thrive, and we were excited to have multiple residents and faculty speak at SAEM. Our PGY-3s and PGY-2s had six abstracts and three didactic presentations, with topics ranging from gender differences in subarachnoid hemorrhage and prehospital sepsis to double sequential defibrillation. We were happy to contribute to the conference this year and strongly represent Florida. ■
RESIDENCY Retreat 2019
THRIVING BEYOND MEDICINE
September 19-20, 2019 Sirata Beach Resort St. Pete Beach, FL Target audience: Third- & second-year residents
New location. New program. New game show. Still free! Thursday, September 19 »» 2:00-4:00 pm: Presentations & Workshops »» 4:00-5:00 pm: EMRA Game Show »» 5:00-6:30 pm: Welcome Reception »» 6:30-8:30 pm: Dinner sponsored by Envision »» 8:30-11:00 pm: After Party sponsored by TeamHealth
Friday, September 20 »» 8:00-2:00 pm: Presentations & Workshops EMpulse Summer 2019
Palm Beach Consortium at St. Lucie By Blaire Laughlin, DO, PGY-3
As the academic year wraps up, St. Lucie has named our new chief: Dr. Oliver Morris, PGY-2. Congratulations! He has been working on new ways to streamline our conference agenda and continues to push our residents to new limits. Once again, special thanks to Dr. Jessica Chambers, PGY-4 for all the hard work she did as chief resident. All of our graduates will be staying in Florida. Dr. Jerome Daniels, PGY-1 attended AAEM in Vegas and did a presentation for faculty and residents on literature updates from the conference. Many of our residents presented at FLAAEM,
including Drs. Jerome Daniels, PGY-1, Shelby Guile, PGY-1, Ashkahn Zomorrodi, PGY-1, Blaire Laughlin, PGY-3 and Michael Gulenay, PGY-3. We also have a recent publication in the Western Journal of Emergency Medicine, “Polymethylmethacrylate Pulmonary Embolism following Kyphoplasty,” by Drs. Oliver Morris, PGY-2, Karl Weller and Josephin Mathai. We recently wrapped up our SIM curriculum with a SIM war competition featuring an Organophosphate poisoning. Special thanks to the staff at FAU SIM lab for their help in directing us. ■
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EMpulse Summer 2019
Florida Atlantic University By Jeff Klein, MD, PYG-3 Hello from Boca Raton. I would like to welcome our incoming class of residents and congratulate Drs. Matthew Wallace and Damien Carracedo for becoming our program’s first chief residents. Drs. Carracedo and Wallace kicked off their new roles by attending SAEM’s annual Chief Resident Forum in Las Vegas, NV this year. In keeping with the consistent expansion of not just our emergency medicine residency but the FAU residency consortium as a whole, I am proud to announce that FAU’s first ever Residency Research Day was a resounding success. Representing our emergency department, Dr. Jeffrey Klein presented a case series entitled, “Carbon Monoxide Poisoning at a FL Hospital Following Hurricane Irma.” In addition, Dr. Benjamin Mazer presented a case report entitled, “Pacemaker-associated Phlegmasia Cerulea Dolens treated with Catheter-directed Thrombolysis.” This quarter’s curriculum was further enhanced by visiting grand rounds speakers, including Dr. Mary Hughes, emergency medicine program director at Michigan State University; Dr. Karen Perkins from Virginia Tech Carilion School of Medicine; and Dr. Sharon Mace from the Cleveland Clinic. However, it has not been all work and no play: our wellness retreats continue with activities such as paintball, a day at the local waterpark and a private wine tasting from a vineyard located in Tuscany, Italy. We are looking forward to seeing everyone at Symposium by the Sea! ■
Jackson Memorial Hospital By EM Residency Staff Greetings from Miami! It was delightful to attend this year’s CORD in March in Seattle. Though not the closest location to Miami (actually, one of the furthest points possible within the continental U.S.!), it was a great opportunity to hear about the latest and greatest in EM education and to catch up with our colleagues. Subsequently, we were thrilled to be present at this year’s Florida AAEM, where several of our residents had posters accepted for presentation, including Drs. Dan Hercz, Anward Ferdinand, Sumit Aurora, Kristina Jacomino, Marisa Gilbert and Karl Yousef. In fact, Drs. Arora and Fer-
In May, Jackson Memorial participated in our first ever Sonogames competition that took place at SAEM in Las Vegas. We are proud to report that our team, the SonoCanes—represented by Drs. Dan Hercz, John Combs and Ryan Lynch, under the skillful tutelage of Dr. Brooke Hensley—brought home the second place prize, consisting of a Butterfly ultrasound probe and a large trophy. Congrats to the team on such a great job.
class of interns and the bittersweet departure of our graduating seniors. It is amazing how quickly times goes by, as it seems like just yesterday we were welcoming our inaugural class, and already we are sending them off to the real world. Six of them have moved onto fellowship (toxicology, critical care, EMS, hyperbarics and palliative care), and of the remaining 10, six have decided that they just can’t leave the sun, beach and palm trees and have taken jobs in South Florida. We can’t say we’re disappointed to have them stay close by.
Finally, June brought two exciting events: the arrival of our brand new
Here’s to a warm, breezy and not too wet hurricane season. ■
dinand were selected amongst the finalists, so congratulations to them.
Mount Sinai Medical Center By Michael Cecilia, DO
This past spring was very busy here at Mount Sinai Medical Center. We were proud to take part in the 8th Annual FLAAEM Scientific Assembly, where our residents submitted 10 posters. We would like to congratulate the following winners:
• Sal Silvestri Award for Best Original Research Abstract: Drs. David Farcy, Laurie Boge, Nicole Warren, Blake Guillory, Stephanie Fernandez and Luigi Cubeddu. We are especially proud of Dr. Stephanie Fernandez, who gave the oral presentation.
• 1st Place Honors in the Sim War
Competition went to Mount Sinai Medical Center Team: Drs. Meagan Lorenzo, Natasha Brown and Stephanie Fernandez.
We would like to give a special mention to the following residents and
attendings who gave lectures or led practical sessions:
• Dr. Newbery: Point of Care
Ultrasound Track Beginner and Advanced Sessions • Dr. Dave Edwards, Dr. Liz Reubin and Mickey Fuentes led the South Florida residency and medical student competitions • Dr. David Farcy: Sepsis Update • Dr. Laurie Boge: Pediatric Fever • Dr. Dave Edwards: Emergency Medicine Hot Topics • 2nd Annual Toast to Women in Emergency Medicine, sponsored and organized by Drs. David Farcy, Laurie Boge and Liz Reubin We’d also like to issue a special, bittersweet ‘thank you and goodbye’ to our founding Program Coordinator Betty Ubiera, who has been with the program since the very beginning. EMpulse Summer 2019
Betty will be retiring this summer. She has been the behind-the-scenes secret to our success. It is with some sadness that we say goodbye to our senior residents as they take the next big step in their careers and join the long line of past residents becoming attendings. We would like to give a fond farewell and wish good luck to our graduating residents, as well as extend a warm welcome to our new interns. As an outgoing senior resident, it is with great excitement that I introduce Dr. Stephanie Fernandez, who will be authoring these quarterly submissions moving forward. It has been a pleasure and honor to share updates of our program, and Stephanie will do an excellent job. ■
Aventura Hospital & Medical Center By Scarlet Benson, MD Assistant Clinical Professor
Aventura would like to say congratulations to its first graduating class of 2019! We are so proud and wish them the best of luck as they enter fellowships and start their careers. We would also like to congratulate our new chief class, including Drs. Emerson Franke, Mitali Mehta and Jennifer Reyes. This spring has been busy with conferences, and our residents and core faculty continue to excel with their academic pursuits. Faculty member Dr. Erin Marra and newly graduated Dr. Thomas Yang participated in ACEP’s Leadership & Advocacy Conference in Washington, D.C. in May. Aventura was heavily represented at FLAAEM in Miami Beach, with resident Drs. Jennifer Reyes, Katie Peterson, Mitali Mehta, Jaskirat Gill, Matthew Mungo and Thomas Yang participating in poster presentations with the support of core faculty Drs. Erin Marra and Laurence Dubensky. Many of the residents had been invited to present
these posters at the national AAEM conference in Las Vegas in March as well. Dr. Marra also participated in a forum about being a physician mother with Dr. Jessica Cook at the “She for She” second annual Toast to Wonder WomeEM. Assistant clinical professor Dr. Scarlet Benson participated in the Adult EM Topics/Rapid Fire session, discussing “Evidence-based Biomarker Use in the ED.” Dr. Daniel Samet actually won the best resident case presentation at FLAAEM for his poster, “Point of Care Ultrasound Diagnosis of Loculated Cardiac Tamponade Due to Malignant Effusion,” in collaboration with co-resident Dr. Laura Gomez Pumarejo. The SINcredibles of Aventura had a strong showing at SAEM in Vegas, participating in this year’s sonogames, and Dr. Thomas Yang co-wrote an SAEM SimWars case titled, “Greed: Serotonin Syndrome with Cocaine Ingestion,” along with faculty from another institution.
In May, graduating senior Dr. Ana Castaneda-Guarderas published a PubMed article titled, “Women’s Values and Preferences Regarding Osteoporosis Treatments: a Systematic Review,” in the Journal of Clinical Endocrinology and Metabolism. Many of our residents and faculty have also published PubMed articles through the popular StatPearls medical reference database, including core faculty Drs. Laurence Dubensky, Erin Marra, Scarlet Benson and Huy Tran, and resident doctors Andrew Morris, Eva Ryder, Laura Gomez Pumarejo and Ioana Ryder. The residents participated in a Spa Wellness Day organized by SIM Director Dr. Jessica Cook on May 29, with kombucha and healthy organic snacks as well as yoga, acupuncture and mini-massage. We rounded out the season and ended the academic year with our first senior class graduation at Margaritaville in mid-June. Congratulations again and best of luck to you all! ■
Kendall Regional Medical Center By Stefan Jensen, MD
Congratulations to our incoming intern class! We are excited to welcome them into our Kendall family and get to know them as they start their final leg of the long journey to becoming emergency physicians. As the class of 2019 says goodbye to the team that trained us to be confident, independent practitioners, please welcome our new Chief Residents that you will be hearing from now: Drs. Ramsey Ataya, Amanda Haan, Spencer Barela and Jasmin Nuesa. We continue to expand our PGY-3 research tracks. The EMS track has 26
expanded to include MDFR Air Rescue ride-alongs and tactical medicine with the Hallandale Police Department. Our Simulation track is coordinating monthly critical care scenarios for our interns. Finally, our ultrasound team continues to train the department in US-guided nerve blocks as we seek to decrease opioid utilization for improved clinical outcomes in trauma patients. Our first Wilderness Day at Amelia Earhart Park this past May was a huge success. It was capped off by an adventure race incorporating austere medicine scenarios. Special thanks to Dr. Julio DePeña and resident Drs. EMpulse Summer 2019
Pineda and Maldonado for helping set up the event. We are excited that two of our graduating residents, Drs. Moshe Yatzkan and Ana Pineda, will be staying with us next year! Dr. Pineda will also be our first Administrative Fellow. Thank you all for your help, mentorship and advice these past three years. It has been great to meet members of the other programs in the South Florida Consortium. We look forward to seeing how our program and all of our neighboring programs continue to expand caring, evidence-based medicine in South Florida. ■
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The Changing Landscape of Emergency Medicine Training in Florida By Robert Levine, MD Professor and Founding Chair of Emergency Medicine & Critical Care, Associate Dean for Graduate Medical Education, Herbert Wertheim College of Medicine, Florida International University
Over the past five years, there has been a profound change in emergency medicine (EM) residency training in Florida. A quick review of EMpulse Spring 2019 demonstrates a tremendous increase in training programs. In addition, there has been a move from traditional academic medical centers where a teaching hospital is closely attached to a medical school, to independent systems loosely affiliated with medical schools. New graduate medical education (GME) programs are being developed in for-profit (HCA) or private non-profit hospitals/systems. The article reports 17 programs; an 18th was approved January 7, 2019 at Orange Park. Eleven of these 18 programs began in or after 2016. The number and location of these programs has caused concern about excessive supply and quality of graduates. In EMpulse Winter 2019, using state-published data and other information, Drs. David and Barbara Orban questioned the need for so many new EM residency programs in Florida. Training too many EM specialists might serve individual hospital pipelines, but not the greater good of the community. Concern has also been raised regarding the quality of this larger group of students we are recruiting. This might not be reflected in the insignificant decline in EM’s match rate—99% to 98%—but might be reflected in the number of programs matching less competitive graduates. Hoelle et al. (2018) from the UCF-HCA North Florida Consortium raise additional questions centered on for-profit groups running training 28
programs at for-profit hospitals and dilution of the academic talent-pool. Fewer experienced educators combined with a potential decrement in the quality of graduates is concerning. These issues coupled with a softening of the American College of Graduate Medical Education’s (ACGME) Common Program Requirements for scholarly activity could have a disproportionately large negative impact on investigative science and advancement of patient care in emergency medicine. However, this issue is more complex than at first glance. To address the anticipated shortage of physicians, new schools have been established in Florida. Five of eight allopathic and two of three osteopathic schools were accredited in 2000 or later. Class sizes increased from 478 to 995 in allopathic schools and 248 to 550 in osteopathic schools. Unfortunately, established academic
centers lack the clinical capacity and financial resources to absorb these students. Given this bottleneck, Florida became a GME exporting state. With the creation of new programs, we can keep our students in-state and increase the number of students we import. While new programs may serve as pipelines for the individual system’s workforce needs, if they produce well-trained EM clinicians, are they not doing a greater good? What metric besides board passage rate will convince skeptics that these programs are producing well-trained EM physicians? Finally, just as some medical schools are research-intense while others are not, if for-profitbased residency graduates all pass their boards and deliver excellent patient care, perhaps we need to recognize the different missions that institutions address instead. ■
14 accredited since 2000 »11 accredited since 2016 »9 HCA programs
7 accredited since 2000
185 incoming emergency
»995 allopathic students »550 osteopathic students
medicine residents this year
EMpulse Summer 2019
1,545 incoming students this year
Floridaâ€™s Medical Schools & Emergency Medicine Residency Programs
RESIDENCY PROGRAM UCF/HCA at Ocala Regional ACGME Accredited: 2017
RESIDENCY PROGRAM UCF/HCA at North Florida Regional (Gainesville) ACGME Accredited: 2017
MEDICAL SCHOOL UF COM Gainesville (Allopathic) Founded: 1956
RESIDENCY PROGRAM UF COM Jacksonville First Accredited: 1975 ACGME Accredited: 1982
MEDICAL SCHOOL FSU COM (Allopathic) (Tallahassee) Founded: 2000
RESIDENCY PROGRAM UF Gainesville ACGME Accredited: 2005
RESIDENCY PROGRAM HCA Orange Park Medical Center ACGME Accredited: 2019 RESIDENCY PROGRAM Orlando Health ACGME Accredited: 1985
RESIDENCY PROGRAM HCA West at Oak Hill Hospital (Brooksville) ACGME Accredited: 2018 RESIDENCY PROGRAM USF Morsani (Tampa) ACGME Accredited: 2002
MEDICAL SCHOOL UCF COM (Allopathic) (Orlando) Founded: 2006
MEDICAL SCHOOL NSU Dr. Kiran C. Patel College of Osteopathic Medicine in Clearwater Opening: 2019
RESIDENCY PROGRAM HCA West at Brandon Regional Hospital ACGME Accredited: 2018
MEDICAL SCHOOL Lake Erie College of Osteopathic Medicine in Bradenton Founded: 2004
RESIDENCY PROGRAM FSU COM at Sarasota Memorial Hospital ACGME Accredited: 2018
MEDICAL SCHOOL NSU Dr. Kiran C. Patel College of Osteopathic Medicine in Fort Lauderdale Founded: 1979
MEDICAL SCHOOL NSU Dr. Kiran C. Patel College of Allopathic Medicine in Fort Lauderdale Founded: 2017
MEDICAL SCHOOL UM Leonard M. Miller School of Medicine (Allopathic) Founded: 1952 Data provided by: Robert Levine, MD Graphic designed by: Samantha League
RESIDENCY PROGRAM AdventHealth East Orlando ACGME Accredited: 2007
MEDICAL SCHOOL USF Morsani COM (Allopathic) (Tampa) Founded: 1971
RESIDENCY PROGRAM UCF/HCA of Greater Orlando at Osceola ACGME Accredited: 2016 RESIDENCY PROGRAM HCA Palm Beach Consortium (Port St. Lucie) First Accredited: 2008 ACGME Accredited: 2017 RESIDENCY PROGRAM FAU Charles E. Schmidt COM (Boynton Beach) ACGME Accredited: 2016 MEDICAL SCHOOL FIU Herbert Wertheim COM (Allopathic) (Miami) Founded: 2006
MEDICAL SCHOOL FAU Charles E. Schmidt COM (Allopathic) (Boca Raton) Founded: 2010
RESIDENCY PROGRAM Jackson Memorial Hospital (Miami) ACGME Accredited: 2016
RESIDENCY PROGRAM HCA Aventura Hospital & Medical Center ACGME Accredited: 2016
RESIDENCY PROGRAM HCA Kendall Regional Medical Center (Miami) ACGME Accredited: 2016
RESIDENCY PROGRAM Mount Sinai Medical Center (Miami Beach) ACGME Accredited: 1998
EMpulse Summer 2019
Medical Student Committee By Kimberly Herard, MD Candidate, FAU Class of 2020 Medical Student Committee Secretary-Editor
It is that time for fourth-years where their knowledge, passion and grit is put to the test on away rotations. SLOES are extremely important for us medical students pursuing emergency medicine, and they are one of the biggest focuses (and stressors!) that we face before interviews begin. Mount Sinai Medical Center’s residency program in Miami Beach, FL decided to step in and help serve as support to medical students by hosting their Emergency Medicine Mindset Bootcamp. This day consisted of four valuable hours of information to strengthen our clinical performance along with development of a wonderful guide for EM Clerkships. What sparked such a wonderful idea that could help so many of the rotating fourth-year students? Leena Owen, MS-4 at Nova Southeastern University’s College of Osteopathic Medicine served as an important spark for this event. “During my third year, I spoke with Dr. (Laurie) Boge about how I wish there was something to prepare me for that first sub-internship since I would not have the opportunity to complete a core EM rotation before then,” Leena said. “When she proposed the idea of EM Mindset Bootcamp, I was all for it, and I knew other students in the area would be too.” From there, she and Dr. Boge worked together with the help of Dr. Nikki Warren and Miami Beach EM resident Drs. Chandelle Raza, Mauricio Baca, Liz Rubin and Jenna Varner to put together an afternoon of high yield points for the EM-bound student. Some of the first tips presented focused on student wellness and understanding our roles as students in the emergency department: Be 30
Nice, Caring, Calm, Smart, and Walk Fast! Be nice to everyone you meet, and make sure to be caring to your patients—you have the most time to devote to caring for them, so take a little extra time during your shift to check up on patients. Dr. Boge also emphasized studying in chunks and suggested a variety of resources, including Tintinalli and different podcasts like EMRAP C3. And don’t forget the amazing EM Mindset Student Guide created by the organizers of EM Mindset.
Scan to download the EM Mindset Student Guide
Within the umbrella of being calm and caring, important lessons were taught: keep in contact with “your tribe,” be your own #1 fan, and understand your core values. Supporting and loving yourself, keeping and fostering relationships despite a very hectic life, and aligning your
goals and decisions with your core values are keys to success in medical school and beyond. Students also learned about ultrasound, including how to perform the FAST Exam in trauma cases—an important pro tip and skill to strengthen during clerkships. There was also the fun opportunity to practice patient presentations, which are incredibly important on EM rotations. The day ended with an extremely exciting and educational Jeopardy game. Thank you to the amazing team in Miami Beach for giving students the opportunity to soar. ■
August 3, 2019 | 1:30-3:30 pm Boca Raton Resort & Club Grand B Room
EM Mindset organizers, from left: Dr. Mauricio Baca, Dr. Liz Rubin, Dr. Jenna Varner, Dr. Nikki Warren, Dr. Chandelle Raza and Dr. Laurie Boge. EMpulse Summer 2019
Financing our Future By Ernest Page, MD, FACEP FEMF President FCEP Past-President
For many nonprofits, donor contributions are the primary source of revenue. The Florida Emergency Medicine Foundation (FEMF), dba the Emergency Medicine Learning & Resource Center (EMLRC), is fortunate to have various revenue sources— including conference and course registrations, joint sponsorship of accreditation, and vendor sponsorship and exhibits—that support day-to-day operations. However the largest source of revenue comes from our corporate sponsors. Without them, we could not exist. We ask you to show them your appreciation at every opportunity. Here are some ways we can do our part:
In 2013, we made the bold move of building a permanent home for FCEP and FEMF. We knew that this venture could not be financed entirely by FEMF operations; support would have to come from donations. As FCEP members, your ongoing support of this venture is vital for the sustainability of our organizations. When we opened the doors in 2015, our mortgage obligation totaled $1.58 million dollars. In four years, we’ve reduced the principal by $630K (42%). Pretty impressive!
• Board members can take the lead
Our ambitious, long-term goal is to pay off the loan within 5 years. The total amount needed to do this is $984K after factoring in principal and interest.
• Board members can invite con-
This is not insurmountable. Consider this:
in visiting all booths in our exhibit halls and engaging with vendor representatives. ference attendees to join them for sponsor presentations and product showcases where they can enjoy a meal.
• Residency program directors and chief residents can follow suit by ensuring residents attend all resident-specific events.
Most importantly, we can take the time to personally thank our partners for their continued support. At Symposium by the Sea, we are proud to have eight of our 10 corporate sponsors present: Collective Medical, Duva-Sawko, EMPros, Emergency Physicians of Central Florida, Envision Physician Services, Gottlieb, TeamHealth and VITAS Healthcare.
• The total amount of $984K divided by 1,370 regular members = $718 each
By Maureen France FEMF Board Member Physician Liaison, EMPros
We Need Your Help If every one of FCEP’s 1370 regular members makes a...
...we will meet our goal of owning EMLRC’s building debt-free by 2024. Will you join us in making a tax-deductible contribution to the Florida Emergency Medicine Foundation today?
TEXT TO GIVE Scan or text “EMLRC” to “41444”
• Annual mortgage cost of $117K
divided by 1,370 regular members = $85 each
To kick off our new campaign, the Findeiss Family Foundation made a pledge to match new contributions up to $50K. The Vidor and Allyson Friedman charitable fund immediately followed with a donation of $50K. Thanks to their generosity, we are now $100K closer to reaching our goal—and it’s a good thing too, because current funds will be depleted by September of this year.
EMpulse Summer 2019
DONATE ONLINE Scan or visit: emlrc.org/donate
Please join us in this ambitious endeavor. Every dollar amount counts. Your gift will help ensure that lifesaving educational programs continue to make an impact on families and their loved ones. ■ 31
Regarding End of Life in the Emergency Department Bridget Highet, MD Hospice & Palliative Medicine Fellow, Mayo Clinic
On most shifts, emergency physicians encounter patients nearing the end of life—some in their last months, others in their last hours or days.1 We bear witness to “spectacular deaths” captured so frequently in the media, with heroic attempts at resuscitation and unexpected, traumatic loss of life. Just as often, we encounter the “subtacular” — punctuated by the frailty, deterioration and debility that precedes death in our patients with dementia, cancer and chronic illness.2 As emergency physicians, we convene at the crossroads of this human experience, and we have the hallowed opportunity to make a difference in the trajectories of these patients we serve. In this article, we propose five tips that a busy emergency physician can use to improve the delivery of high quality care for patients at the end of life.
CALL IT DEATH
Medicine is rich with euphemisms. We use words like non-accidental trauma to veil the emotions that come with the tragedies we face. Hypoxic respiratory failure, septic shock, multiorgan dysfunction— these are no exceptions. At times, what we are seeing is a dying patient. Recognizing this process and being able to communicate it to families is the first step in empowering decision-makers to understand what is happening and engage in vital and necessary 32
Andrea Sharpe, MS, MD Senior Associate Consultant, Mayo Clinic
conversations at the end of life.
Emergency physicians are in a unique position to make hospice referrals in a timely fashion. While hospice is intended as a six month benefit, in 2016, over half of hospice patients were enrolled for less than 30 days.3 Asking the question, “would I be surprised if this patient died in six months?” allows emergency physicians to identify a group of patients that are hospice appropriate and have a high impending mortality.4 Palliative care involvement in patients early in their disease process has demonstrated measurable improvements in quality of life.5 If a patient’s goals are aligned with a comfort care approach, hospice can provide a robust extra layer of services upon discharge, particularly to elderly or chronically ill patients in whom more functional decline is anticipated.
PROVIDE COMFORT CARE Some patients in the emergency department are actively dying. If in line with a patient’s goals of care, emergency physicians can provide the same level of aggressive medical management in the form of comfort care as we do for other critically ill patients. Emergency providers should provide a quiet location for the dying patient, discontinue monitors and use a sign or placard to signal the death to staff. Hospital chaplains EMpulse Summer 2019
can be a tremendous resource, assisting families with their spiritual needs. Dyspnea and pain are common at the end of life and should be managed with low dose opiates (morphine 1-2 mg IV Q15 min or hydromorphone 0.2-0.4 mg IV Q15 min), titrated until patient is comfortable. Anxiety can be managed with benzodiazepines and secretions can be modified with anticholinergic agents like IV glycopyrrolate (.2mg Q6H) or 1% ophthalmic atropine orally (.5mg/ drop, 1-2 drops Q2-4H).6, 7 While a common concern is hastening death with the provision of medications, studies support that titrating opiates and sedatives to symptom relief at the end of life does not impact survival.8
TAKE A PAUSE
When deaths happen in the emergency department, they are distressing for patients, families, and staff. John Bartels, a nurse at the University of Virginia, took a step several years ago to revisit the humanity in the moments following death. He introduced “the pause”: a moment following death where a team leader acknowledges the efforts of the staff, honors the life of the patient and takes a moment of silence.9 “The Pause” has spread to many emergency departments and intensive care units, and promotes team resilience while mitigating feelings of failure and grief in clinical staff.10
Thank You PAC Donors
Thank you to those who donated to FCEP’s political action committees (PACs) in March 2019-May 2019:
CONSIDER FAMILY WITNESSED RESUSCITATION
As providers, we are aware of the grim survival statistics associated with cardiac arrest and CPR. In these moments, our responsibility transfers from the body in front of us to the family experiencing a traumatic loss. While controversial when first introduced, family presence at resuscitation is well supported with evidence demonstrating no difference in mortality or length of resuscitation, and lower rates of depression and anxiety in bereaved family members.11 When inviting family presence during a resuscitation, it is recommended to include only one or two members and to have dedicated staff—whether it be a chaplain, social worker, nurse or physician—to support family members. Developing a protocol in your hospital can allow for structure and staff education prior to initiating this in your emergency department.12 For the emergency physician, the shepherding of a good death is often as rewarding as a heroic save. These five simple tools can improve the quality of care at the end of life, and allow your emergency department to provide humanistic care to some of its neediest patients. ■
REFERENCES 1. Smith, A.K., et al., Half of older Americans seen in emergency department in last month of life; most admitted to hospital, and many die there. Health Aff (Millwood), 2012. 31(6): p. 1277-85. 2. Bailey, C., R. Murphy, and D. Porock, Trajectories of end-of-life care in the emergency department. Ann Emerg Med, 2011. 57(4): p. 362-9. 3. NHPCO. Facts and Figures: Hospice Care in America. 2017. Available from: https://www.nhpco.org/ sites/default/files/public/Statistics_Research/2017_Facts_Figures. pdf. 4. Highet, B.H., Y.H. Hsieh, and T.J. Smith, A Pilot Trial to Increase Hospice Enrollment in an Inner City, Academic Emergency Department. J Emerg Med, 2016. 51(2): p. 106-13. 5. Temel, J.S., et al., Early palliative care for patients with metastatic nonsmall-cell lung cancer. N Engl J Med, 2010. 363(8): p. 733-42. 6. Mierendorf, S.M. and V. Gidvani, Palliative care in the emergency department. Perm J, 2014. 18(2): p. 77-85. 7. Shreves, A. and T. Pour, Emergency management of dyspnea in dying patients. Emerg Med Pract, 2013. 15(5): p. 1-19; quiz 19-20. 8. Sykes, N. and A. Thorns, The use of opioids and sedatives at the end of life. Lancet Oncol, 2003. 4(5): p. 312-8. 9. Bartels, J. The Pause. Virginia Magazine Spring 2016. Available from: http://uvamagazine.org/articles/ the_pause. 10. Kapoor, S., et al., “Sacred Pause” in the ICU: Evaluation of a Ritual and Intervention to Lower Distress and Burnout. Am J Hosp Palliat Care, 2018. 35(10): p. 1337-1341. 11. Oczkowski, S.J., et al., The offering of family presence during resuscitation: a systematic review and meta-analysis. J Intensive Care, 2015. 3: p. 41. 12. Oczkowski, S.J., et al., Family presence during resuscitation: A Canadian Critical Care Society position paper. Can Respir J, 2015. 22(4): p. 201-5. EMpulse Summer 2019
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MUSINGS FROM A RETIRED PHYSICIAN
The ED and Hospice Revisited By Wayne Barry, MD, FACEP FCEP Member
As some of you remember, this retired ER doctor is now a fulltime hospice team physician at VITAS Healthcare (a proud sponsor of FCEP). Have you also noticed that hospice, palliative care, and emergency medicine have been involved in a notable courtship for the past several years? Over the last seven years I have worked in hospice care, I have seen the patient census in West Volusia County alone increase from about 80 patients to nearly 300. I can only imagine that the number of hospice patients presenting in the area’s hospital and freestanding EDs has increased as well. Yet, none of the hospitals I know and have worked for in Volusia County have a seamless ‘ER staff-to-hospice staff’ transfer of patient care in the ED. A current member of ACEP’s Board of Directors, Dr. Mark Rosenberg, is double board-certified in both EM and hospice and palliative care. Among several notable accomplishments, Dr. Rosenberg has created an ED palliative care program called Life Sustaining Management and Alternatives (LSMA) at St. Joseph’s Healthcare System in Paterson, NJ. Whenever a hospice patient or a hospice-appropriate patient is admitted to the ED, the hospital’s Hospice Team—consisting of physicians, nurses, chaplains and social workers—is mobilized and takes over the care of the patient in question. The Hospice Team conducts appropriate ER treatment and disposition in the ED, and patients who are not already signed up as hospice patients are given the opportunity to do so on the spot if they and or their families desire. This model was absent from the over 40 hospital ER’s I have worked in up to 2012. Some hospitals nowadays have 34
in-house hospice programs, but many still do not. I would like to offer some helpful hints for those of you who do not work in an ED with a seamless process of handling hospice patients. The criteria for admission to a hospice service are: 1. The patient must be afflicted with a terminal condition (advanced dementia, Parkinson’s disease, end stage COPD, heart disease, other advanced neurodegenerative diseases and neoplasm are prime examples) 2. The expected course of the patient will be 6 months or less, or the patient appears to be following an inexorably downhill course with their terminal disease process. If you are presented with the opportunity, you may want to discuss this concept with patients you encounter in the ED who are not already receiving hospice services. It would be helpful to both the hospice patient and ED staff to determine as early as possible if the patient is receiving hospice services. If so, you can call the hospice company any time of the day or night. VITAS, for example, has a telephone answering service staffed by nurses and their receptionists. It should be easy for them to connect you with an on-call clinical representative who, if appropriate, can come directly to the hospital to help you and the family make treatment decisions based on the patient’s condition and wishes. Our after-hour nurses are called “runners” because they literally spend their shifts “running” from patient house to patient house, and they are available to come to the ED if appropriate. Social workers and chaplains are also on-call and can make ER visits if requested. EMpulse Summer 2019
It is worth noting that some of your patients will be ambivalent about their end-of-life wishes. In other words, we take care of hospice patients who qualify for our services and enjoy the benefits of in-home weekly nurse visits, monthly physician visits, home health aide care, and as needed chaplain and social services—but they may not have yet embraced the idea that they do not want aggressive treatment for their illness. Since hospice is a patient-centered service, we work with these patients on an individual case-by-case basis in effort to care for them exactly the way they want to be cared for. If a hospice patient shows up in your ER, more often than not, they chose to go there for you to do everything you can for them. Hospice patients can “come and go” from hospice if they wish to be admitted to the hospital for hospicerelated medical problems. They can be discharged from hospice so that their Medicare or other insurance can “kick in” to cover the expenses of hospital treatment. You should try to confirm this with them or their families as carefully as you can, and proceed with your treatment accordingly. In conclusion, I hope each of you will participate in this courtship between emergency medicine and hospice & palliative care as it plays out in our ER’s across the state of Florida. If you have any questions about the above material, please do not hesitate to contact me. ■
ARE YOU RETIRING SOON? Stay connected to FCEP for just $330 per year* through ACEP’s retired membership rate. *State dues included
How Soon Can Hospice Begin for Eligible Patients? When do you need us? VITAS is available 24/7/365.
When you contact VITAS Healthcare, a hospice professional is always available to answer questions, evaluate a patient, discuss goals of care, relieve pain, manage symptoms, reassure an anxious caregiver or accept a referral.
Days, nights, weekends, holidays. Download our referral app, visit VITAS.com or call 888.VITAS.80 for always-available hospice care.
UPDATES ON THE OPIOID CRISIS:
The MAT Bridge at Tampa General Hospital By Heather Henderson, MA, CAS MAT Team at Tampa General Hospital
By Brandi Travis, MS MAT Team at Tampa General Hospital
Jason Wilson, MD, MA, FACEP, FAAEM MAT Team at Tampa General Hospital
Jack McGeachy, MD MAT Team at Tampa General Hospital
Andrew Smith, MD MAT Team at Tampa General Hospital
REFERENCES 1. D’Onofrio et al. Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence. JAMA. 2015;313(16):1636-1644. doi:10.1001/ jama.2015.3474 2. McLellan, et al. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA. 2000. Oct 4;284(13):1689-95 3. TGH received a legal consult on this requirement. Scan the QR code to read it:
TGH’s MAT Bridge program has a follow-up rate of 57%. The national average is 20%. The increasing mortality rate from opioid overdose is evidence that the opioid epidemic is still ongoing. In the past, emergency departments had little resources for patients with opioid use disorder (OUD). However, newer medications, increased awareness and public recognition of this public health crisis allow for a new approach to patients seeking care for OUD in the emergency department (ED). Patients with OUD are consistently at an increased risk of adverse health outcomes versus non-OUD patients. Patients with OUD may present to the ED with healthcare issues directly related to OUD, co-morbidities or acute illnesses and trauma1, or with other complaints within the context of concomitant addiction. For emergency medicine, this means extending care structures past the initial clinical encounter in order to achieve greater success with patient outcomes. The acute treatment of OUD has historically fallen outside the scope of practice for ED providers, but this new disease-state legitimacy (as a chronic relapsing disorder) has shifted attitudes, with providers stating that “the detection and initiation of treatment for chronic and relapsing medical conditions (e.g., hypertension, diabetes and asthma) is not an uncommon ED practice.”2 To this end, we have built a medically-assisted treatment (MAT) program at Tampa General Hospital (TGH) that complies with state laws (which do not require a DEA waiver to administer buprenorphine in the ED3), and also shows strong evidence that supports utilization of MAT treatment in an acute setting of patients with OUD. This pathway both follows and also redefines best practices. EMpulse Summer 2019
Through this program, TGH has been afforded a unique opportunity to forge an exciting community partnership with DACCO, the largest provider of MAT, rehabilitation, outpatient care and wrap-around services for patients suffering from substance use disorder in Hillsborough County. Patients referred to DACCO from the TGH ED in need of MAT services will, in most instances, be able to initiate treatment same-day, with no patient going more than 72 hours without initiation of treatment. What we believe sets this program apart from traditional referrals is the actual stabilization of the patient in the ED, coupled with extensive follow-up and wrap-around care to ensure treatment adherence. Truthfully, it would be easy enough to stabilize withdrawal with buprenorphine, but the critical piece that shows the most chance of success for this treatment structure involves the warm-handoff to care facilities upon discharge. With a current follow-up rate of 57% (compared to a national average of 20%), the success of this pathway relies heavily on a standard workflow, easy-to-understand patient resources, and strong communication between partnering facilities. The collaboration necessary to build this warm handoff included creating robust partnerships with community substance treatment providers; working closely with our central managing behavioral health entity; building partnerships with care facilities to treat co-occurring disease states (HIV/HCV); and internal collaboration with social work, case management, nursing, ED leadership, psychiatry, internal medicine, pain management, pediatrics, residents and attending physicians.
Learn More About Treating Patients with Opioid Use Disorder
Fig. 1: TGH’s MAT Pathway
Scan the QR code for detailed information
Implementing Warm Hand-Offs Between EDs and Treatment Providers for Patients with OUD
PATIENT PRESENTS TO ED Chief Complaint: withdrawal, substance abuse, anxiety, back pain, abdominal pain, etc. If patient has overdosed, assess if they are appropriate for the Marchman Act Pathway first
MAT Specialist uses COWS to score for withdrawal and gains verbal consent for social work to meet with patient for MAT treatment
MAT Specialist meets with provider and social worker to discuss COWS results. Provider & social worker meet with patient to gauge readiness to stop using substances MAT Pathway Enrollment: patient readiness and ≥5 COWS
Approved for AMA Category 1 PRA credits™
Faculty: Chief Judge Frederick J. Lauten; Nancy McConnell, MSW, MCAP, CRPS-A; Mark Stavros, MD, FACEP; Aaron Wohl, MD, FACEP Provided by: FCEP, the Florida Alcohol & Drug Abuse Association (FADAA) and the Aetna Foundation About: Patients suffering from opioid use disorder (OUD) present unique and unprecedented challenges to emergency care providers. This webinar:
• discusses misconceptions about treatment and the disease itself
• introduces the concept of warm Upon pathway enrollment, provider dispenses 8/2 Buprenorphine dose* to patient Assess after 20 minutes & repeat if necessary Consult on-call MAT provider if patient is still ≥5 after two doses * If patient is pregnant, substitute Subutex for Buprenorphine Once patient is medically stable, social worker will email MAT referral form to DACCO and arrange transportation
handoffs between EDs and treatment providers
• reviews legal issues surrounding opioid overdose cases
• reviews the important role of peer specialists in recovery
Expires November 30, 2019
ACCESS NOW emlrc.org/opioids
Through these collaborations, we were able to identify and build multiple pathways for a variety of patients in this population (polysubstance, acute overdose, alcohol intoxication, behavioral health, as well as acute withdrawal/ seeking treatment). Due to the potential complications that arise in this population, having multiple pathways for patients that arrive with varied needs has exponentially strengthened our ability to provide care for patients with substance use
disorders. We are excited to share what we have learned, including clinical workflow and advice for various aspects of the process, which can be found in Fig. 1. While there is no one-size-fits-all OUD MAT pathway, we believe that some of the lessons learned from our community and hospital efforts are scalable to emergency departments and emergency physicians throughout Florida. ■ EMpulse Summer 2019
FCEP is working closely with Florida’s Department of Children and Families (DCF), the Florida Hospital Association (FHA) and FADAA to provide a toolkit for creating ED Bridge/Warm-Handoff programs. Are you an opioid champion at your hospital? Do you have tools to share? Contact FCEP’s communications manager Samantha League at email@example.com to learn more and get involved. 37
CLEARING THE SMOKE: POISON CONTROL
THE RISKS OF LIQUID NICOTINE IN E-CIGARETTES Kristen C. Lee, PharmD, BCPS Clinical Toxicology, EM Fellow
E-cigarette products alone, including nicotine devices and nicotine liquid, accounted for over 2,400 reported exposures to poison centers in 2017. Few substances hold as much historic weight as tobacco. The tobacco plant, thought to have originated around
E-cigarettes by Madison Schwartz 38
Madison Schwartz, PharmD Clinical Toxicology, EM Fellow
6000 BC in the Americas, quickly took hold in Europe when introduced following the return of early expeditions to the New World.1 Since then, tobacco has undergone multiple transformations in the quest to take in its main alkaloid: nicotine. Whether in the form of chewing tobacco, cigars, snuff or cigarettes, the addictive properties of nicotine have ensured its longevity. Equally persistent is the contribution of cigarette smoking to a global disease burden in the form of cardiovascular and pulmonary diseases, cancers and more. With a greater focus on the adverse effects of smoking cigarettes, additional nicotine products have become widely available in the form of smoking cessation aids, including transdermal patches, gum and lozenges. Most recently, e-cigarettes have gained traction as an alternative source of nicotine.2 E-cigarettes, unlike FDA-approved nicotine inhalers approved for smoking cessation, do not rely on aerosolized nicotine, but rather a user-activated heating element to atomize a liquid nicotine product EMpulse Spring 2019
contained in a cartridge. The liquid nicotine typically includes a stabilizing compound, nicotine and flavoring. When heated, the nicotine liquid vaporizes and creates a visible plume, which is inhaled (and from which the term â€œvapingâ€? is derived). There is no long-term data to suggest that e-cigarettes are an effective reduction tool.3 Unfortunately, the risks extend beyond conventional use. In the most recent report from the National Poison Data System, e-cigarette products, along with other tobacco and nicotine products, were listed in the top 25 substances most frequently involved in pediatric (<= 5 years) exposures. E-cigarette products alone, including nicotine devices and nicotine liquid, accounted for over 2,400 reported exposures to poison centers in 2017.4 The flavorings included in many liquid nicotine products may provide an additional draw for young children, leading to inadvertent exposures and nicotine toxicity. Products available for consumer purchase are typically 30 mL bottles and range in nicotine content from 0-36 mg/mL, but may be as large as 1 liter at a 100 mg/mL
concentration. With systemic exposure, nicotine binds to nicotinic receptors throughout the body, including the brain, spinal cord, autonomic ganglia, adrenal medulla, neuromuscular junctions and chemoreceptors of the carotid and aortic bodies. Effectively, it mimics the effects of acetylcholine, with dose-dependent clinical effects. Low doses cause sympathetic agonism through stimulation of nicotine receptors centrally and in motor nerve fibers. Prolonged stimulation of receptors at higher levels of exposure may lead to receptor blockade with parasympathetic and neuromuscularblocking effects.2 A popular mnemonic for effects of acetylcholine on the nicotinic receptor uses the days of the week, MTWtHF—mydriasis, tachycardia, weakness, hypertension, fasciculations. Early symptoms of nicotine toxicity (i.e. within the first hour) are due to
F i x e d
the cholinergic excess, with vomiting being most commonly-reported effect. Hyperpnea, hypertension and tachycardia may also be present. As the clinical course progresses, bradycardia and hypotension predominate. Severe toxicity may lead to dysrhythmias, shock or seizure. Patients who present with suspected nicotine toxicity due to e-cigarette liquid exposure should be placed on continuous cardiac monitoring and have blood chemistry, creatinine kinase and a 12-lead EKG assessed. Due to the rapid metabolism of nicotine, patients with signs and symptoms of toxicity typically recover within 12 hours. Care is symptomatic and supportive, with a focus on airway management, atropine for bradycardia or significant muscarinic symptoms, intravenous fluid resuscitation with the addition of vasopressors as needed for hypotension, and benzodiazepines as needed for seizures or agitation.2 ■
FPICN toxicologists are available 24 hours a day at 1-800-222-1222 to assist emergency physicians in the treatment of all toxic exposures, including triage and management of button battery ingestions.
1. Tobacco Timeline. http://archive.
tobacco.org/History/Tobacco_History.html. Accessed February 16, 2019.
2. Soghoian, Sari. Nicotine. In: Hoffman
RS, Howland M, Lewin NA, Nelson LS, Goldfrank LR. eds. Goldfrank’s Toxicologic Emergencies, 10e New York, NY: McGraw-Hill; 2015. http://accesspharmacy.mhmedical.com/content. aspx?bookid=1163§ionid=65096168. Accessed February 16, 2019.
3. Drummond MB, Upson D. Electronic cigarettes. Potential harms and benefits. Ann Am Thorac Soc. 2014 Feb;11(2):236-42.
4. Gummin DD, Mowry JB, Spyker DA,
Brooks DE, Osterthaler KM, Banner W. 2017 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 35th Annual Report. Clin Toxicol (Phila). 2018 Dec;56(12):1213-1415.
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THE ULTRASOUND ZOOM
Skin Deep Point-of-Care Ultrasound of Soft Tissue Infections More often than not, skin infections have straightforward treatments from the emergency department (ED): maybe a cream, perhaps an antibiotic, close follow-up, done. However, even the simplest infections can quickly become deadly, which is why prompt recognition and fast diagnosis is critical. This is precisely when my point-of-care ultrasound (POCUS) exam has proved to be enormously helpful.
By Kristina Jacomino, Edited by Leila MD, PGY-3 Posaw, MD, MPH Jackson Memorial Emergency Ultrasound Director, Jackson Hospital Memorial Hospital
Fig. 1: Patient presented with “pain out of proportion.”
The POCUS exam requires the operator to recognize the normal pattern of skin layers: epidermis, dermis, hypodermis (subcutaneous tissue), tendons, muscles and bones. Deviations from the normal are then interpreted as specific pathology (Fig. 2). The POCUS exam asks the following questions: 1. Is the anatomy in the area of interest normal or altered? 2. Is there cobblestoning, which suggests a cellulitis? 3. Is there a discrete, contained, avascular fluid collection, which suggests an abscess? 4. Is there dirty shadowing, which suggests air? 5. Is there a hyperechoic structure, which suggests a foreign body?
One of my patients in the ED presented with the classic “pain out of proportion” exam: with only the mildest erythema and no palpable crepitus (Fig. 1). He had been discharged with an antibiotic for cellulitis two days earlier. My POCUS led me to the diagnosis of necrotizing fasciitis and within an hour, a central line had been placed and the patient was rushed to the operating room. Over 4 million patients present to the ED with skin and soft tissue infections (SSTIs), and about onethird of those may require a drainage at the bedside for proper treatment. SSTIs come in many flavors and can present differently depending on the stage of the disease. Furthermore, what’s on the surface may or may not reflect the severity of the infection that lies deeper. SSTIs can range from a superficial cellulitis to the deepest abscess, from ordinary staphylococcus to deadly clostridium infections. All SSTIs are prioritized and managed differently, making a quick and accurate diagnosis in the ED paramount. POCUS is critical in this process.
The technique for the POCUS exam is very straightforward. Details regarding the technique are listed in Fig 3.
Photos courtesy of authors Typically, patients with SSTIs present with pain, redness and swelling of the skin. They may have associated malaise or fever. On inspection, there may be a change in skin color (erythema, various shades of brown or black), induration or rash. On palpation, the area may feel warm and tender and there may be crepitus suggestive of EMpulse Summer 2019
The normal soft tissue exam varies with location. But in general, the first epidermis/dermis layer is thin and hyperechoic. The second hypodermis layer is less echogenic and contains mostly fatty tissue, vessels and nerves. Next, fascia can be recognized as hyperechoic stripes. Muscles are organized into ordered bundles in hyperechoic sheaths. Ligaments can be recognized as hyperechoic linear structures which attach to bones, notable by their anisotropy. Bones appear hyperechoic and reflect sound to produce dark shadows. (Fig. 1, Image 1a).
Fig. 2: Differential diagnosis of SSTIs with POCUS
Cellulitis has a characteristic “cobblestone” appearance. This is when the hypoechoic fluid from the infection seeps in between the hyperechoic fatty tissues to produce the classic cobblestone pattern. (Fig. 1, Image 1b). Pearl: Not all cobblestoning is infectious. Peripheral edema looks like cobblestone on POCUS.
Image 1a: Normal
Image 1b: Cellulitis
Image 1c: Abscess
Image 1d: Necrotizing Fasciitis
Image 1e: Foreign Body
Image 1f: Water Bath
Abscess: By definition, abscesses are discrete collections of pus, and this is what they look like on ultrasound (Fig. 2, Image 1c). Some may be homogeneously hypoechoic, while others may have areas of hyperechoic debris. Complex abscesses may have septations and appear loculated. On compression with the ultrasound probe, purulent material tends to swirl around and this is called the “swirl sign.” Note: Abscesses are avascular, and color Doppler should always be performed to confirm that an “abscess” is not a blood vessel or a lymph node.
Necrotizing Fasciitis: While not much literature exists for diagnosis necrotizing fasciitis by ultrasound, the general rule of thumb is to look for subcutaneous thickening, air and fascial fluid (STAFF)2. This means blurring of the subcutaneous layers, dirty gas shadowing (air) in the infected tissue and the presence of more than 4 mm of fluid overlying the deep fascial layers (Fig. 1, Image 1d).
Photos courtesy of authors
CONTINUE ON PAGE 42 »
Find this table online at emlrc.org/ultrasoundzoom
Stick in your wallet. Reference on-the-go. Courtesy of authors Leila Posaw, MD, MPH and Kristina Jacomino, MD, PGY-3
Skin Deep Point-of-Care Ultrasound POCUS of Skin and Soft Tissue Infections: What to Look For
Discrete collection of pus
Necrotizing Fasciitis: Soft tissue thickening
Fluid in fascia
EMpulse Summer 2019
Foreign Body: Hyperechoic Reverberation Shadowing Halo sign 41
« CONTINUED FROM PAGE 41
Fig. 3: POCUS Technique for Skin and Soft Tissue Infections
Foreign Bodies: While radiolucent foreign bodies (FBs) will be missed on radiography (X-rays), all FBs are hyperechoic on sonography. The appearance of FBs varies depending on their composition. Metal FBs have reverberation artifacts (multiple hyperechoic lines) deep to the actual structure; wood and plastic FBs have posterior shadowing; and glass can have both. (See Figure 1, Image 1e) Pearl: Edema around the FB is called a “halo sign” and is helpful to locate FBs.
1. Apply gel generously to the area of interest. (Especially if the area is painful!)
Three infection mimics can present as pitfalls: lymph nodes, superficial/deep venous thrombosis (DVT/SVT) and blood vessels.
3. Use a linear probe.
2. Consider using a water bath for SSTIs of the hands and feet: Fill a large basin with water. Place the affected area in the basin. Place the probe in the water as close to the skin as possible, without touching the skin. Since water is an excellent conductor of sound, you do not need to use gel (Fig. 2, Image 1f).
4. If there is blood or pus at the site, protect your ultrasound probe with an impervious cover.
• Lymph nodes may easily be mistaken for
abscesses as they are oval hypoechoic structures. However, they have an echogenic hilus with color flow.
5. Examine in two planes: sagittal and transverse. 6. Avoid anisotropy, by keeping the probe perpendicular to the skin or structure of interest. Anisotropy is an artifact: loss of echogenicity due to non-perpendicular angles.
• While a DVT/SVT may look like an abscess, they appear tubular when scanned in two planes. They also lack the swirl sign.
• Blood vessels in cross section may appear
7. Start in normal tissue and move to the affected area. For comparison, scan the similar location on the opposite side of the body.
round and be mistaken for an abscess. However, scanning in two planes and applying color Doppler is helpful.
8. Use the “mowing the lawn” technique. Scan the entire affected area with your ultrasound probe like a lawn mower not missing a single blade of grass. Failure to do this might result in missing FBs or air.
Jackson Memorial Hospital is the third largest public hospital in the U.S. We serve the homeless, those who have HIV/AIDS and those who abuse IV drugs. We also serve those who cannot afford treatment elsewhere and those who suffer from chronic, debilitating diseases, such as diabetes. As such, a large proportion of our patients are at high-risk for skin infections, and particularly dangerous ones. I am always on high alert for these and POCUS has become invaluable in my practice. I strongly believe in the power of POCUS to identify and manage SSTIs. ■
SUGGESTED READING 1. Gotlieb, M. et al. (2017). What is the Utility of Ultrasonography for the Identification of Skin and Soft Tissue Infections in the Emergency Department? Ann of Emer Med, 70(4), 580-582. doi:10.1016/j.annemergmed.2017.01.042. 2. Castleberg, Erik, et al. “Diagnosis of Necrotizing Faciitis with Bedside Ultrasound: the STAFF Exam.” Western Journal of Emergency Medicine, vol. 15, no. 1, Feb. 2014, pp. 111–113., doi:10.5811/ westjem.2013.8.18303.
Skin Deep Point-of-Care Ultrasound Techniques:
Linear probe Mow the Lawn Water Bath 42
EMpulse Summer 2019
5 RCM Things You Can Do Today to Help Your Practice By Mike Drinkwater, CEO Gottlieb, LLC. Healthcare costs have been steadily increasing, roughly 11% in 2017, according to a TransUnion Healthcare report. Because of this, Emergency Department physician reimbursement is under continued pressure. There are several factors, in addition to increased healthcare costs, that are adversely impacting Emergency Physician Departments. Physicians are progressively being challenged by payors relative to several high-level codes. Urgent Care is one of the fastest-growing specialties pulling low-acuity patients out of the ED. Although Medicare committed to a .5% increase annually after sun-setting the sustainable growth rate law; with the changes to RVUs, Emergency Physicians have not seen the full increase in 3 years while expenses continue to rise. Insurance companies are looking at every option to remove patients from the emergency department. Insurance companies are disputing and reducing payments to the patients that end up in the ED. Proper procedures must be instituted to ensure reimbursement for every patient treated. The very structure of the emergency department results in lost revenue for emergency physicians in areas where office space physicians are not challenged. The following five revenue cycle management tips will help you gain better insight into your practice efficiencies to help increase your bottom line: 1. Professional Fee Schedule Audit. When is the last time you reviewed your fee schedule and compared it to one of the fee schedule databases? Fee schedule databases are updated and changed and may not sync with your practice fee schedule. In our experience, many groups are billing less than some payors allow. Remember, Insurers always pay the lowest of your fee schedule or the allowable.
2. Patient Billing Audit. Have you audited to see if all your patients have been billed? Request your revenue cycle company to provide a report reconciling the charge-entry billing report to the hospital log sheet. Emergency Departments are notorious for straggler charts that many times never get billed/processed as claims. 3. Physician Documentation Checkup. Do you have new physicians in your practice or had any training updates recently? Have an outside audit to compare your physician documentation with the standards published by the 1995 CMS guidelines. 4. Managed Care Contract Audit. Have you reviewed your managed care contracts recently, added a new insurer or are up for renewal? Have an outside professional review each of your managed care contracts and develop a strategy to improve rates. 5. Accounts Receivable Management. Are your receivables being properly managed? Unfortunately, low AR days can mean that your RCM is doing an outstanding job; or, it could mean that they are writing off claims without adequately working. Does your collection agency find insurance on claims that were written off? If your collection agency is collecting more than 4% of the dollars written off, your billing company many not be performing to optimal standards. These five revenue cycle management tips can help physicians gain better insight into the contributing factors for revenue governance. Asking the right questions, understanding processes, and utilizing reports and metrics can lead to a stronger bottom line.
EMpulse Summer 2019
Removal of an Entrapped Ring of Unknown Material
Written informed consent was obtained from the patient for publication of this case report and accompanying images. The authors would like to thank Melony Pino and Stefan Heinze, PhD for assistance with material science.
Rings made of titanium, hardened steel, tungsten and other strong metals are increasing in popularity and ultimately not amenable to conventional removal techniques such as cutting. Here we present a case of a challenging ring removal in a patient who presented with a swollen digit secondary to a ring of unknown material. On physical exam, he had a shiny black metallic ring of unknown material on the 4th digit of his right hand. There was edema at the proximal interphalangeal joint with normal sensation and capillary refill. In the emergency room, numerous failed attempts occurred with the winding technique, as well as with bolt cutters and electric ring cutters, resulting in damage to equipment. Orthopedic surgery and the fire department were consulted and also failed at removal with their saws. Ultimately, controlled compression using locking pliers resulted in shattering of the ring. In a ring of unknown origin, if cutting with an electric saw fails, it would be Fig. 1: Ring prior to removal
reasonable to infer the ring is a strong metal and/or alloy and thus consider controlled compression using locking pliers. Amputation or surgical intervention for ring removal are the worst case scenarios. In order to avoid this, we utilized intermittent icing and elevation in between removal attempts in order to buy time and prevent critical ischemia.
Emergency physicians are routinely faced with the need for emergent removal of entrapped rings. Traditionally, jewelry rings have been composed of soft metals such as gold and silver, which are amenable to conventional removal techniques such as cutting.1,2 Rings made of titanium, hardened steel, tungsten and other strong metals are increasing in popularity because of their strength and resistance to scratches, thus providing difficult removal scenarios for ED physicians. Difficulty occurs because hard metals are three to ten times the strength of gold and silver and thus not susceptible to cutting with regular tools.1-3 Entrenched rings may cause a tourniquet syndrome, resulting in digit edema at risk for nerve damage, ischemia and gangrene.4-6
A 17-year-old, previously healthy, right-handed male presented to the Pediatric ED with a chief complaint of finger swelling and pain to the fourth digit of his right hand, secondary to a ring that he found on the street. Upon presentation, a shiny black metallic-like ring was located at the base of the 4th digit of the right hand 44
EMpulse Summer 2019
By Hermann Pierre Piard, MD, PGY-2
Dept. of Pediatrics, Holtz Childrenâ€™s Hospital, UM/ Jackson Memorial Hospital
By Eva M. Wojewoda, MD
Dept. of Pediatrics, Holtz Childrenâ€™s Hospital, UM/ Jackson Memorial Hospital
(Fig. 1). The digit was swollen distal to the ring with significant edema at the proximal interphalangeal (PIP) joint; however, the patient had normal sensation and capillary refill was brisk. The composition of the ring was not not known to the patient or the ED physicians, but it was obviously not gold- or silver-based. Pain control was achieved using a digital block with 2% lidocaine without epinephrine. Over the next five hours, a multidisciplinary team failed multiple attempts of ring removal. As per standard of care, removal of the ring was attempted using bolt cutters as well as an electric ring cutter, which failed and resulted in equipment damage. The digit was then lubricated for multiple attempts at the winding technique, which were unsuccessful. Orthopedic surgery and the fire department were unsuccessful at removal using an electric cast saw, bolt cutters and high RPM electric saw. Success was finally achieved by shattering the ring via controlled compression using locking pliers. There was no injury to the digit except for minimal superficial lacerations confirmed with normal post-removal radiographs. Throughout multiple attempts, there was concern that continued manipulation of the digit could cause increased swelling. Between each attempt the patientâ€™s hand was iced and elevated, and visual reduction of swelling was noted.
Anecdotally, ring removal in the ED is a common scenario; however, removal of a ring of unknown material is an uncommon occurrence. In our case,
multiple providers failed to recognize the composition of the ring, resulting in delayed removal as well as prolonged pain and discomfort to the patient. Markings to signify the ring material are located on the inside of the ring and thus not helpful in these situations. Given the indestructibility of the ring, we concluded that the ring must be composed of tungsten, titanium or another strong metal alloy. An algorithm for ring removal has been recently been proposed by Kalkan et al.3 In general, the process can be divided into non-cutting and cutting techniques. Non-cutting methods such as winding, caterpillar, twin thread and glove techniques can be implemented when there are no signs of ischemia or if the patient wishes to preserve the jewelry.2-4 Manual and electric ring cutters can be used on soft metals such as gold or silver, but are inadequate for steel, tungsten or titanium. For these materials, successful removal via an electric saw, diamond-tip saw or dental drill has been documented. This equipment is not available in all EDs and requires training and specialized adaptation for ring removal.3,4,7,8 Continued attempts to cut the ring may result in damage to ED equipment, as it did in our case. Post-removal, we were able to identify the ring as tungsten. Tungsten is brittle at room temperature and will shatter under compressive force.9 Tungsten has been shown to be safe
Fig. 2: The ring after controlled compression
and effectively removed via controlled crushing with locking pliers.2,10-13 During ring compression, shattering is an explosive process and there is a high risk of projectictile shards and superficial lacerations (Fig. 2); therefore, we recommend that controlled compression should be performed in a closed area with all personnel wearing skin and eye protection.2,12 Comparison of the winding technique versus controlled crushing found that the crushing was significantly faster and technically easier for a novice operator to perform.2 If there is evidence of digit ischemia, it may be prudent to bypass winding and progress to controlled compression fracture. Stuck rings can cause nerve damage, ischemia and gangrene through decreased venous and lymphatic
drainage with subsequent edema distal to the ring. Prolonged capillary refill, cyanosis and inability to perform two-point discrimination indicate ischemia, and emergent removal is indicated.3,4 In our patient, pain control with 2% lidocaine without epinephrine was used because the vasoconstrictive effects of epinephrine may exacerbate ischemia.3 Amputation or surgical intervention for ring removal are the worst case scenarios.6 In order to avoid this, we utilized intermittent icing and elevation in between removal attempts in order to buy time and prevent critical ischemia.4
CONCLUSION • Ring removal in the ED is a com-
mon scenario; however, removal of a ring of unknown material is an uncommon occurrence. • In a ring of unknown origin, if cutting with an electric saw fails, then it would be reasonable to infer the ring is a strong metal and/ or alloy and thus the most timely next step is to attempt controlled compression using locking pliers. Continued attempts to cut the ring may result in damage to ED equipment. • Amputation or surgical intervention for ring removal are the worst case scenarios.6 In order to avoid this, we utilized intermittent icing and elevation in between removal attempts in order to buy time and prevent ischemia. ■
REFERENCES 1. Tabor D. CH 1: Introduction. The hardness of metals. Clarendon Press; 2007:2-5. 2. Gardiner, Carolyn L., MD; Handyside, Krista, MD; Mazzillo, Justin, MD; Hill, Mandy J., PhD; Reichman, Eric F., PhD, MD; Chathampally, Yashwant, MD; King, Brent R., MD. A comparison of two techniques for tungsten carbide ring removal. American Journal of Emergency Medicine. 2013;31(10):1516-1519. doi: 10.1016/j.ajem.2013.07.027. 3. Kalkan, Asim, MD; Kose, Ozkan, MD; Tas, Mahmut, MD; Meric, Gokhan, MD. Review of techniques for the removal of trapped rings on fingers with a proposed new algorithm. American Journal of Emergency Medicine. 2013;31(11):1605-1611. doi: 10.1016/j.ajem.2013.06.009. 4. Peckler B, Hsu CK. Tourniquet syndrome: A review of constricting band removal. Journal of Emergency Medicine. 2001;20(3):253-262. doi: 10.1016/S07364679(00)00314-0.
5. Valente J. Minor infant problems. In: Baren JM, ed. Pediatric emergency medicine. Saunders/Elsevier; 2008:335-339. 6. Brooks, Darrell, MD; Buntic, Rudolf F., MD; Kind, Gabe M., MD; Schott, Karin, MS; Buncke, Gregory M., MD; Buncke, Harry J., MD. Ring avulsion: Injury pattern, treatment, and outcome. Clinics in Plastic Surgery. 2007;34(2):187-195. doi: 10.1016/j. cps.2006.11.001. 7. Chambers AF, A. Removal of a titanium ring using a dental saw. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2012;65(5):e129. doi: 10.1016/j. bjps.2011.12.024. 8. Ricks R. Removal of a tungsten carbide wedding ring with a diamond tipped dental drill. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2010;63(9):e702. doi: 10.1016/j. bjps.2010.03.058. 9. Lassila DH, Gray GT. Ductile-brittle transition behavior of tungsten under EMpulse Summer 2019
shock loading. Le Journal de Physique IV. 1994;4(C8):354. doi: 1994853. 10. Moser A, Exadaktylos A, Radke A. Removal of a tungsten carbide ring from the finger of a pregnant patient: A case report involving 2 emergency departments and the internet. Case reports in emergency medicine. 2016. doi: 10.1155/2016/8164524. 11. 1Hajduk SV. Emergency removal of hard metal or ceramic finger rings. Annals of Emergency Medicine. 2001;37(6):736. doi: 10.1067/mem.2001.115843. 12. Allen, Keith A., MD; Rizzo, Marco, MD; Sadosty, Annie T., MD. A method for the removal of tungsten carbide rings. Journal of Emergency Medicine. 2012;43(1):93-96. doi: 10.1016/j.jemermed.2011.07.032. 13. McCarver, S., Jeffery, SLA. Technical tip: Removal of tungsten carbide rings. Journal of the Royal Army Medical Corps. 2013;159(1):64. https://jramc.bmj.com/ content/159/1/64.abstract 45
A Curriculum Adjunct Integrating Clinical Skills and Techniques for Preclinical Students WHAT IS PROCEDUREPALOOZA? By Harsh Shah, MS4 MD Candidate at UF
By Jesse Terrell, MS3
Department of Pediatrics at UF
By Erik Black, PhD, MPH Department of Pediatrics at UF
By Richard Petrik, MD
Department of Emergency Medicine at UF
By Matthew Ryan, MD, PHD Department of Emergency Medicine at UF
ProcedurePalooza is an annual, half-day event co-hosted by the UFCOM Emergency Medicine Interest Group and the UFCOM Department of Emergency Medicine that introduces pre-clinical medical students to fundamental skills used in emergency medicine. ProcedurePalooza hopes to bridge clinical and procedural gaps by introducing students to various procedures with key learning points, allowing them to practice procedural skills in an interactive and judgement-free manner. Common medical school curricula includes two years of basic-science education before exposure to clinical medicine. This model may not effectively provide the student with key contextual relevancies necessary to link the fundamentals of basic science with the technical procedures employed in clinical medicine. In an effort to bridge this gap, the UFCOM has begun incorporating ultrasound and other clinical skills seminars into their pre-clinical curriculum. Despite this effort, students in pre-clinical years are limited in their exposure to additional procedural skills. ProcedurePalooza was conceptualized as one method to address these gaps. During the event, we expose students to procedures including but not limited to: intravenous placement, suturing, splinting, basic airway management, electrocardiogram
of medical students reported an increased interest in emergency medicine after ProcedurePalooza interpretation and ultrasound (D-Fig. 1)1. The event promotes interaction with upperclassmen, residents and faculty. Ultimately, the event aims to improve medical student confidence and provide an introduction to procedural skills.
MATERIALS AND METHODS
Medical students can freely participate in as many stations as they wish over the course of five hours. Then participants complete a self-administered questionnaire (IRB approved) addressing previous exposure to the techniques and assessing their perceived comfort level performing the techniques in a retrospective, pre-post format (D-Fig. 2).1
PARTICIPANT RECRUITMENT Medical students are recruited to participate in the event through social media, classmates, faculty and word-of-mouth. Lunch is provided for participating students during the event.
Scan the QR code below to view the list of required equipment.1
1. All figures could not fit in print. â€œD-Figâ€? notes figures only accessible on the digital version. Scan this code to view everything online.
EMpulse Summer 2019
Students are provided with a retrospective, pre-post Likert-style questionnaire to assess self-perceived changes in self-efficacy related to the technical procedures practiced during the event. The survey also queries participants about the utility of each station, prior experience with procedures and whether the event increased their interest in emergency medicine (D-Fig. 2).
for Spontaneously Breathing Patients
The numerical conversion is detailed on D-Fig. 2. Data was analyzed using SPSS v. 25; descriptive and inferential statistics were employed.
Data collection resulted in a convenience sample of 184 first- and second-year medical students. We achieved a statistically significant (p-value <0.001) improvement in student comfort level for each activity following their completion of the related station. Of the 184 student participants, 165 attended the intravenous insertion station, making it the most utilized station at the event. Students noted an average increase in comfort
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Fig. 3: Prior Experience with Skills IV Insertion
Fig. 4: Comfort Level with Skills, Before & After 5
IV Insertion n=165
EMpulse Summer 2019
level of 90% after completing the station (from 1.97 to 3.75 on a 5-point scale). The greatest level of improvement was seen in students who participated in the airway simulation (n=152). Students noted a 92% increase in comfort level after completing this station (1.98 to 3.80 on a 5-point scale) (Fig. 4). Students were also asked to identify which station they viewed as most valuable. This was based on the station’s simulation accuracy, the improvement in comfort level, and the amount of exposure to said technique prior to the event. Out of the 177 students that participated in this question, 51% selected intravenous insertion, 25% suturing and 16% identified airway management as the most valuable stations of ProcedurePalooza (Fig. 5). Among questionnaire participants, approximately 46% of pre-clinical (MS1s and MS2s) students had exposure to ultrasound techniques, the highest among all stations. The technique with the least amount of prior exposure was electrocardiogram interpretation, which was found to be 12% among sampled medical students (Fig. 3). We concluded the questionnaire by gauging interest in the field of emergency medicine after interacting with emergency physicians and residents, and learning various procedural skills through participating in ProcedurePalooza. From the 183 students that answered the question, 79% noted an increased interest in emergency medicine (Fig. 6).
During clinical rotations, medical students often cite fear of embarrassment and lack of exposure as reasons for not actively participating in clinical procedures. ProcedurePalooza aims to increase exposure by providing foundational skills to pre-clinical medical students in an interactive, lowstress format. Students begin to learn common procedures and interact with upperclassmen, faculty and residents in non-judgmental environment. The overall experience has received a very positive reviews from student participants, faculty, resident and 48
Fig. 5: Most Valuable Station Airway 16% IV Insertion 51%
Sample Size: n=177
Suturing 25% EKG 6%
Ultrasound 2% Splinting 0.5%
Fig. 6: Has your interest in emergency medicine increased after ProcedurePalooza?
5% upper-class facilitators. A key benchmark of our study was assessing the comfort level of students before and after station exposure. With increased comfort and exposure, students can feel confident in their ability to perform vital procedures, during their clinical rotations and as a future clinician. The medical curriculum at many U.S. medical schools does not expose students to these procedures during the pre-clinical years. However, the University of Florida has revised its curriculum to incorporate ultrasound sessions during the first two years of medical school. The benefit of this change is clearly visible when assessing student’s comfort level in ultrasound techniques (Fig. 4).
We illustrated the ability to teach fundamental procedures—including intravenous insertion, electrocardiogram interpretation, splinting, EMpulse Summer 2019
suturing, ultrasound and airway placement—to pre-clinical medical students during an afternoon training intensive. In addition to increased confidence, we identified the value of administering a fundamental, hands-on event to medical students— an opportunity which is normally delayed in medical curriculums until the third year. We observed students leaving with new clinical skills, evidenced through direct observation by faculty participants and energized in their ability to perform tasks that once seemed daunting. Future directions aim to measure the comfort level of clinical medical students (MS3s and MS4s) that participated in ProcedurePalooza. Future projects could study the impact of procedural training sessions in medical student procedural participation during their clinical years. Ultimately, medical school curriculi should focus on incorporating more procedural sessions and skills labs for pre-clinical students to increase technical exposure. ■
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Hampton’s Hump First described by radiologist Aubrin Otis Hampton in 1940, Hampton’s Hump is a dome/vault or wedge-shaped opacity seen on plain chest radiographs and CT pulmonary angiography that arises from the base of the pleura.1 Hampton’s Hump can be seen along with Westermark sign (regional oligemia), Fleischner’s sign (central pulmonary artery dilation) and/or Palla’s sign (engorgement of the right pulmonary artery) in patients who present with pulmonary embolism or pulmonary infarction.2, 3 However, the sensitivity of Hampton’s Hump is actually quite low (22%), according to the PIOPED Study.4 Emboli in the pulmonary artery often dispense with the apex of wedge due to secondary blood supply from bronchial artery. This results in a round shape.5 In the cases of lung infarction, blood loss from bronchial artery in lung parenchyma gives an opaqueness to the Hampton Hump. Infarction settles in several months and an elongated narrow scar remains.5 In the cases where
Fig. 1: Chest Radiograph
Fig. 2: CTA of the Chest
infarction does not occur, Hampton’s Hump keeps it shape and disappears within a week.5 This results in a pattern similar to melting ice and hence, it takes the name “melting sign.”5 Fig. 1 demonstrates a Hampton’s Hump seen on a portable chest radiograph. Fig. 2 demonstrates the Hampton’s Hump (blue arrow) and the underlying pulmonary embolism (red arrow) that led to the pulmonary infarction in the subject patient.
Pulmonary infarction occurs in less than one-third of cases of pulmonary emboli, although it is responsible for 60% of cases of deadly pulmonary embolism.6,7 Smoking, increasing body height and decreased age are some of the risk factors for pulmonary infarction. Pulmonary infarction is more prevalent on the right side.7 Most patients report with pleuritic chest pain.6 Hemoptysis is observed in less than 20% of cases of patients diagnosed with infarction on radiological studies.7 Infarction is rare due to dual blood supply of the lungs from pulmonary and bronchial vessels.7 Drop in the blood pressure or volume in bronchial artery or an increase in the pulmonary venous pressure predispose the lung to infarction.7 Occlusion of distal arteries smaller than 3 mm in diameter is also more likely to result in infarction.7 Infarcted region is located in the periphery against the visceral pleural and the apex is uninvolved because of the dual blood supply from bronchial artery. This results in the rounded appearance of the wedge.6, 7 The free edge is curved outwards and clean, and it is directed toward the hilum of the lung.6 The involved area does not have air bronchogram and is more commonly situated in the lower lobe of the lung.7 Treatment revolves around providing cardiopulmonary support and anticoagulation. Patients with widespread emboli benefit from thrombolysis.7 ■
EMpulse Summer 2019
By Hashim Ejaz, MBBS Army Medical College Rawalpindi, Pakistan
Christopher Megargel, DO, PGY2 Oak Hill Hospital Residency
Alfredo Tirado, MD, FACEP Director, Oak Hill Hospital Residency
Veronica Tucci, MD, JD, FAAEM, FACEP Faculty, Oak Hill Hospital Residency
REFERENCES 1. Hampton AO, Castleman B. Correlation of postmortem chest teleroentgenograms with autopsy findings with special reference to pulmonary embolism and infarction. AJR Am J Roentgenol. 1940; 43:305–326. 2. Palla A, Donnamaria V, Petruzzelli S, Rossi G, Riccetti G, Giuntini C. Enlargement of the right descending pulmonary artery in pulmonary embolism. AJR Am J Roentgenol. 1983; 141:513–517. 3. Taylor BT, Pezzo SP, Rumbak M. Palla’s sign and Hampton’s hump in pulmonary embolism. Respiration. 2010; 80:568 4. Worsley DF, Alavi A, Aronchick JM, Chen JT, Greenspan RH, Ravin CE. Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study. Radiology. 1993 Oct;189(1):133-6 5. https://radiopaedia.org/articles/hampton-hump-2 6. Miniati M. Pulmonary Infarction: An Often Unrecognized Clinical Entity. Semin Thromb Hemost. 2016 Nov;42(8):865-869. Epub 2016 Oct 15. PubMed PMID: 27743556. 7. https://radiopaedia.org/articles/ pulmonary-infarction-1?lang=us.
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