FCEP EMpulse Summer 2020

WHEN WE DO NOT HAVE THE TOOLS, WE MAKE THEM

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

WHEN WE DO NOT HAVE THE DATA, WE GATHER IT

WHEN IGNORANCE ABOUNDS, WE DO OUR BEST TO INFORM

WHEN WE ARE AFRAID, WE STEP FORWARD BRAVELY RATHER THAN RETREATING IN COWARDICE

RISE UP

WE HAVE NO CHOICE BUT TO USE OUR FEAR TO FACE EVERYTHING Now is the moment to show that the correct location of the safety net is not at the bottom of a broken system, but wrapped around it as an important component of care. �Lung Ultrasound in the COVID-19 Pandemic

� COVID-19 and Multisystem Inflammatory Syndrome in Children (MIS-C)

Plus: Symposium by the Sea 2020 is now a virtual experience!

� Management of Hydroxychloroquine & Chloroquine Toxicity Vol. 27, No. 2 | Summer 2020

The current global crisis is not without its challenges, but together, with unity and solidarity, we will prevail, and we will rise together.

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TABLE OF CONTENTS COMMITTEE REPORTS

6 FCEP President’s Message

14 EMS/Trauma

8 ACEP President’s Message

18 Membership & Professional Development

By Dr. Kristin McCabe-Kline

By Dr. William Jaquis

10 COVID-19 and Multisystem Inflammatory Syndrome in Children (MIS-C)

By Dr. Todd Wylie

12 Government Affairs

By Dr. Blake Buchanan

By Dr. Christine Van Dillen

By Dr. Shayne Gue

22 EMRAF President’s Message

By Dr. Matthew Beattie Medical Student Council

By Dan Schaefer, MPH, MS-3

FEATURES & COLUMNS 18 Daunting Diagnosis

By Dr. Karen Estrine

20 Congratulations, Emergency Medicine Residency Program 2020 Graduates

Florida’s EM Residency Programs

34 Poison Control: Management of Hydroxychloroquine & Chloroquine Toxicity

By Joshua Newell, PharmD, PGY-2 & Anthony DeGelorm, Pharm.D.

36 Ultrasound Zoom: Lung Ultrasound in the COVID-19 Pandemic

By Dennis D’Urso, MD, PGY-3; edited by Leila Posaw, MD, MPH

40 Trends in Exposures to the Florida Poison Control Centers during the COVID-19 Pandemic

By Sonya Rashid, MD; Wendy Blair Stephan, PhD, MPH; Jeffrey Bernstein, MD; Mehruba Anwar Parris, MD

44 Kratom Part II: Updates for the ED Provider on a Substance Skyrocketing in Use

By Vir Singh, MD, MBS, PGY-3 & Nicholas Titelbaum, MD, PGY-2

46 Florida Emergency Nurses Travel Overseas to Learn about Emergency Care

By Terri Repasky, APRN, MSN, CNS, CEN, EMT-P; Christie Jandora, BSN, RN; Lauren Sanguinetti, BSN, RN, CEN

48 Case Report: Extensive Pneumomediastinum in a 20-Year-Old

By Dr. Nancy W. Weber

50 Musings: Leadership in Crisis

By Dr. Wayne Barry

SUMMER 2020

Volume 27, Issue 2 EMpulse Magazine is the official, quarterly publication of the Florida College of Emergency Physicians (FCEP).

EDITOR-IN- Karen Estrine, DO, FACEP, FAAEM CHIEF karenestrine@hotmail.com INTERIM MANAGING Melissa Keahey EDITOR mkeahey@emlrc.org DESIGNER Samantha League, MA PUBLISHER Johnson Press of America, Inc.

800 N. Court St. Pontiac, IL 61764 jpapontiac.com

NOW ONLINE: fcep.org/empulse

Advertise in or Write for EMpulse NEXT DEADLINES: Sept. 21: Ad insertion orders & payment due ‘Intent to Submit an Article’ form or email due for Fall articles

THE COVER:

All words and phrases were pulled from committee reports in this issue.

Sept. 28: Articles and print ad designs due Oct. 15-31: EMpulse Fall 2020 in mailboxes

CORRECTION:

In the Spring 2020 issue, the case report, "A Disappearing Act: The curious case of Lemierre's Syndrome," by resident authors Amar Mittapalli, MD, Andrew Napier, MD and Walter D’Alonzo, MD, was incorrectly attributed to the University of Miami Miller School of Medicine. They are affiliated with Kendall Regional Medical Center's Emergency Medicine Residency Program.

Newsletters: • Every Wednesday: EMNews Now delivered • Biweekly/Monthly: PEDReady PEARL delivered • Every quarter: Partner Broadcast delivered

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EMpulse Summer 2020

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All advertisements in EMpulse are printed as received from advertisers. The Florida College of Emergency Physicians does not endorse any products or services unless otherwise stated. FCEP receives and distributes employment opportunities but does not review, recommend or endorse any individuals, groups or hospitals that respond to these advertisements.

Opinions stated within articles are solely those of the writers and do not necessarily reflect those of the EMpulse staff, the Florida College of Emergency Physicians and our advertisers/sponsors.

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TABLE OF CONTENTS CONTINUED RESIDENCY PROGRAM UPDATES 24 NORTH FLORIDA:

UF Health Jacksonville

By Rick Courtney, DO, PGY-2 UF Health Gainesville Dr. Christopher Purcell, PGY-3 UCF/HCA North Florida Regional Dr. Jayden Miller, PGY-2 Orange Park Medical Center Cody Russell, MD, PGY-2 & Ron Koury, DO, FAAEM, FACEP

28 CENTRAL FLORIDA:

AdventHealth East Orlando

By Tyler Mills, MD, PGY-1 UCF/HCA of Greater Orlando Dr. Amber Mirajkar, PGY-3 UCF/HCA Ocala

By Dr. Caroline Smith, PGY-3; Emily Clark, MD, PGY-2 & Jean Laubinger, MD, PGY-2 Orlando Health

By Gregory Black, MD, PGY-2; Brody Hingst, MD, PGY-2 & John Atiyeh, MD, PGY-3

26 WEST FLORIDA:

Oak Hill Hospital Drs. Jonathan Yaghoubian & Corey Cole, PGY-2s USF Health Dr. Mikhail Marchenko, PGY-3 Brandon Regional Hospital Dr. Rashmi A. Jadhav, PGY-3 FSU at Sarasota Memorial Dr. Courtney Kirkland, PGY-2

30 SOUTH FLORIDA:

Kendall Regional Medical Center

By Ibrahim Hasan, MD, Kristina Drake, MD & Sara Zagroba, MD, PGY-3s St. Lucie Medical Center

By Shelby Guile, DO, PGY-2 Aventura Hospital Dr. Scarlet Benson Florida Atlantic University Dr. Elizabeth Calhoun, PGY-2 Jackson Memorial Hospital Program Staff Mount Sinai Medical Center Dr. Stephanie Fernandez, PGY-3

FLORIDA ASSOCIATION OF EMS MEDICAL DIRECTORS (FAEMSMD) NEW OFFICERS:

Florida College of Emergency Physicians Board of Directors: PRESIDENT Kristin McCabe-Kline, MD, FACEP,

FAAEM, ACHE

PRESIDENT- Sanjay Pattani, MD, MHSA, FACEP ELECT VICE Damian Caraballo, MD, FACEP PRESIDENT SECRETARY- Aaron Wohl, MD, FACEP TREASURER IMMEDIATE J. Adrian Tyndall, MD, MPH, FACEP PASTPRESIDENT MEMBERS Rajiv Bahl, MD, MBA, MS;

Matthew Beattie, MD (EMRAF Representative); Daniel Brennan, MD, FACEP; Jordan Celeste, MD, FACEP; Vidor Friedman, MD, FACEP*; Jesse Glueck, MD; Shayne Gue, MD; Erich Heine, DO; Saundra Jackson, MD, FACEP; William Jaquis, MD, MSHQS, FACEP (ACEP President); Shiva Kalidindi, MD, MPH, MS(Ed.); Gary Lai, DO, FACOEP; Russell Radtke, MD; Danyelle Redden, MD, MPH, FACEP; Todd Slesinger, MD, FACEP, FCCM, FCCP; Jill Ward, MD, FACEP

Florida Emergency Medicine Foundation Board of Directors: PRESIDENT Ernest Page, MD, FACEP

PRESIDENT Christine Van Dillen, MD, FACEP, FAEMS VICE PRESIDENT Benjamin Abo, DO, EMT-P, FAWM

VICE Roxanne Sams, MS, ARNP-BC, MA PRESIDENT SECRETARY- Maureen France TREASURER

SECRETARY-TREASURER Marshall Frank, DO, MPH, FACEP, FAEMS MEMBER AT LARGE Angus Jameson, MD, MPH, FACEP, FAEMS MEMBER AT LARGE Christian Zuver, MD, FACEP, FAEMS

MEMBERS Dick Batchelor; Arthur Diskin,

MD, FACEP*; Jay Falk, MD, MCCM, FACEP*; Cliff Findeiss, MD*; James V. Hillman, MD, FACEP*; Michael Lozano, Jr., MD, FACEP*; Cory Richter, BA, NREMT-P; David Seaberg, MD, FACEP* *FCEP Past-President

QUICK LINKS:

ACEP/FCEP EngagED (online community)

MyACEP Portal

Donate to FCEP’s PAC (not taxdeductible)

Donate to FEMF’s Capital Campaign (tax-deductible)

(update your address, etc.)

EMpulse Summer 2020

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

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COMMITTEE REPORTS

FCEP President’s Message

By Kristin McCabe-Kline, MD, FACEP, FAAEM, ACHE FCEP President ’19-20

“There is nothing more certain and unchanging than uncertainty and change.” -JFK Change is only sometimes wanted, but often needed. Change during times of crisis may be thrust upon us at an exceedingly rapid pace. Life during the COVID-19 pandemic has brought much change that is wanted, needed and, most certainly, thrust upon us.

Perception of the work that is done in emergency departments across Florida has changed. Since the emergence of emergency medicine as a specialty more than 50 years ago, emergency physicians, ED advanced practice clinicians, ED nurses and first responders have struggled with a lack of public appreciation and appropriate compensation by payers for the work we do to bridge the gaps of the United States broken health care system. COVID-19 has, at least temporarily, changed the game.

Without us spending a single dollar, many multimillion dollar corporations have funded pricey ad campaigns, national and international corporations have gifted everything from food to hotel rooms to PPE, and local businesses and citizens have given their time and treasure in support of our work.

Current public perception of our work and the appreciation for the selflessness of our teams has been a welcome change, and many felt that “a flip was switched.” My hope is that this needed change lasts indefinitely and there is constant praise for our work from the community. Even if tort reform is lacking, juries will opine!

Our working environments have 6

changed. Emergency physicians have had to fight for the right to wear Personal Protective Equipment.

Some of our beloved colleagues have been bullied, mistreated and even terminated for serving their patients and teams as an advocate. Some of our patients have passed away without family surrounding them at the bedside. Many patients with life and limb threatening disease states needing our help have had their voices silenced due to the feared risk of contracting COVID-19 should they seek care. We have been confronted with patients with diabetes in DKA who would have previously sought treatment for vomiting; patients at risk for heart disease in cardiac arrest who would have previously sought treatment for chest pain; patients at risk for stroke that are hemiplegic, who would have previously sought treatment for transient alteration of sensation or weakness. We share the burden of suffering when we see the good we could have done, but are unable to do it.

Although our patients in the Emergency Department have been rising in acuity level, the decreased volume of patients overall has changed emergency medicine workforce demands.

Many emergency physicians and other members of our care teams have been furloughed, or their employment has been terminated.

Some emergency medicine graduating residents have been unable to procure adequate clinical experience due to decreased volumes, and their graduation dates have been pushed back. Those EMpulse Summer 2020

transitioning between residency or fellowship or otherwise between jobs have found themselves unexpectedly left without employment. Many who previously asked for shift reduction in the name of work-life balance have begun asking for guaranteed hours.

Many heroes who have committed their lives in service to others have found themselves on the cruel end of COVID-19 musical chairs and are now struggling to meet the needs of themselves and their families.

A noninvasive approach to emergency medicine has arisen. The role of telehealth in the emergency medicine space has moved from conceptual to operational for many emergency physicians across the state and our country. The infrastructure has been stood up at an unprecedented pace, including the agile move by CMS with respect to reimbursement. The ability to connect with patients virtually, whether they are physically within the ED, on hospital property or discharged home, is changing the way we practice and will continue to do so.

However our wellness has been challenged. Members of our care teams have not been able to gather and debrief in a social setting after a particularly grueling or frightening experience to show support for one another. Many have also been quarantined or otherwise isolated from their families and members of their core support system. The religious gatherings, gyms, choirs, book clubs, community groups and planned travel we have relied upon to make ourselves whole have been

“

This, I know to be true: there is no single group of people better prepared than emergency physicians to deal with change.

When we do not have the tools, we make them.

When we do not have the data, we gather it. When ignorance abounds, we do our best to inform. When we do not understand, we humbly seek to learn.

When we are afraid, we step forward bravely rather than retreating in cowardice.

snatched away suddenly. There has been an increase in pressure to care for family members who previously had access to community and privately-arranged assistance services that have been suspended, or those at risk for contracting COVID-19 who were previously more independent but have become housebound. There are millions of children who would have otherwise been in school, at extracurricular activities, attending youth groups or gathering with peers for social events, that have been home, needing structure, interaction and attention, not to mention help with virtual academics and developmental exercises.

This, I know to be true: there is no single group of people better prepared than emergency physicians to deal with change. Our adaptability

to adjust under less than ideal circumstances, willingness to meet the needs of our patients and their families, ability to conform and work to transform regulatory requirements, propulsion of health system initiatives in a constructive way that will improve patient care, embrace the unfamiliar when next steps are not known, and utter devotion to our teams is second to none. When we do not have the tools, we make them. When we do not have the data, we gather it.

When ignorance abounds, we do our best to inform. When we do not understand, we humbly seek to learn.

When we are afraid, we step forward bravely rather than retreating in cowardice.

My hope for every one of us is that we see the beauty of the challenges we have faced and the EMpulse Summer 2020

battles that rage on; the beauty of the opportunity that lies in rebuilding something better than what previously existed; the beauty of being hurt or suffering in a way that reminds us of our vulnerability and value; the beauty of allowing our scars to define more appropriate boundaries for ourselves and those who come after us such that the hurting is not perpetuated; the beauty of processing the things we have experienced and translating them into a sense of gratitude and strength that will transcend the challenges we may experience in the future; and the beauty of knowing, individually and collectively, that there is peace which extends beyond the limitations we previously placed upon ourselves, that might now be ours. â– Image Credit: Adobe Stock 7

ps://time.com/5824465/ lthcare-workers-protest/ COMMITTEE REPORTS

ACEP President’s Message

By William Jaquis, MD, FACEP ACEP President ’19-20

When I began my presidency, I already felt that it was time for a reboot in emergency medicine.

With many of the incremental changes over time, such as reimbursement, consolidation in the health care markets as well as many others, growing numbers of residency programs, and the growing volume of acute unscheduled care outside the ED, a pause for collective thought was needed. As a result, I convened the Future of Emergency Medicine Task Force.

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“

As leaders, this is our lane. Each one of us personally needs to know, understand and hardwire our vision. I know we will look back and be comforted and content with the directions we took.

Flash forward a few brief months and we not only have a pandemic, but also the worldwide Black Lives Matter movement that has touched communities throughout the world.

And currently, in the U.S., most of our communities seem to have decided that COVID is over enough that even relatively minor concessions, such as a mask and social distancing, are too much of an imposition.

that frustration is also the pain that moves us to seek longer-term solutions.

With much of what has transpired related and leading to the world where we live, I think about the energy and intention that is necessary to solve these issues.

Societies often get caught up in the need for immediate gratification. The dopamine and adrenaline responses to this need inundate us through social media and nearly every type of media. Those connections draw us to those who fill that need, often aligning us against some seen or unseen villains, and moving us away from discussion and dialogue that we need to move forward. As emergency physicians, we clearly and deeply understand the quick sprint. For many of us, the pull to what we do is the ability to quickly assess and solve problems, facing frustration with the barriers to achieving them. Frankly,

The difficulty in living within that atmosphere for too long is clear. It renders us, at times, incapable of the conscious intention that forces us to look deeper into issues, which could lead to longer-term solutions.

In the past few weeks, I have been reminded multiple times of work that has been done over time within ACEP by our staff and volunteers, physicians and others, that have led or are leading to change. In June, a law related to surprise medical billing in Georgia passed that encompassed many of the components we feel are necessary to protect patients and provide fair compensation for the work that we do. The Georgia ACEP Chapter has been working with the Georgia Medical Association and other specialties for years. Within the College at the national level, EMpulse Summer 2020

the Reimbursement Committee has also worked for years on this issue.

When Dr. Gerardi was President, he convened a Joint Task Force with the EDPMA to draw more ongoing resources to SMB, of which I was the Board liaison. Those efforts have significantly altered the course in Georgia. I also think about the work of the Alternative Payment Model Task Force — their ongoing efforts led to an AUCM model that is currently being addressed with state and commercial insurers.

Throughout my career, I have worked in the cities of Cleveland, Chicago and Baltimore, watching the barriers to care in these communities lead to significantly impacted health outcomes. Like many of you, those experiences have been formative in my career.

With growing understanding of the social determinants of health, our EDs have moved farther into the care delivery system both in-front and in-back of the acute visit. In Baltimore, I experienced first-hand the shift in our delivery system as the payment model changed and the care reached people instead of populations. Building health care delivery systems that provide better outcomes requires an understanding of communities from a very granular level, but it is achievable if we work with ongoing purpose. My experience and interest in Baltimore are part of what inspired me to get another degree in Healthcare Quality from the Jefferson College of Population Health.

Despite some significant changes in mobility in our communities and businesses, COVID-19 quickly resurfaced when all mitigation measures were ignored. Despite some effort over time to reduce

Thank You, disparities and improve social determinants, recent events have demonstrated that we are nowhere near equity in our society. As I watched the nearly 9-minute video of George Floyd’s death, I was struck by how many things had to go completely wrong within the system to allow that to happen. The officer at the “tip of the spear” must be responsible, but if the latent issues that led to that outcome are not considered and rectified, those actions will continue. Health care has its own root cause analysis processes which, when done well, work to that end.

As a College, we are already pivoting to a new world. From our Strategic Plan to the work Dr. Rosenberg has done for next year with staff and committees, we are making change.

In addition, that FOEM Task Force has led to great minds in our College and beyond, preparing for a Summit that will create more conversation on our specialty. Part of this will be specific to the pandemic. All of those efforts are not to have certainty on what is needed, but to continue learning from each other.

As leaders, this is our “lane.” Each one of us personally needs to know, understand and hardwire our own vision. Collectively, we must drive the same way: we need to use our energy as sprinters and control our efforts to achieve great results in the marathon. We need to inspire and listen, open our minds and our communication, find time to regroup and then do it all over again. We may never see a year as challenging as 2020, but then again, I know we will look back and be comforted and content with the directions we took as a result. ■

EMERGENCY MEDICINE TEAM During this crisis, teamwork in the emergency department is more important than ever. All of you show up every day, risking your own health to make sure the ED is ready to help the most vulnerable.

We want to thank our housekeeping teams, our clerks and administrators, and our nurses, as well as the pre-hospital and first responder teams, who work alongside us.

Thank you for working to provide a safe space for our patients and for everyone.

Thank you for your efforts to collect patient information and connect with families in such difficult times.

Thank you for braving the unknown as you respond to each call and bring those in need of most help directly to our door.

Thank you for standing beside us on the frontlines, through the worst of the worst.

EMpulse Summer 2020

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COMMITTEE REPORTS

COVID-19 and Multisystem Inflammatory Syndrome in Children (MIS-C)

By Todd Wylie, MD

Pediatric Committee Co-Chair

Based on the reports available, a lag between the peak of COVID-19 cases in the respective communities and presentation of symptomatic patients suggests MIS-C may be related to a post-infectious complication of SARS-CoV-2 infection and not necessarily the acute infection.

(Note: There is a lot going on, which makes it difficult to keep up with emerging medical information. Below is a brief discussion of a relatively new pediatric syndrome associated with COVID-19. Readers are encouraged to review the referenced articles for a more thorough understanding of MIS-C.) Per the Centers for Disease Control (CDC), a small proportion of COVID-19 cases seem to have occurred in children relative to the overall disease burden, with approximately 5% of all cases in the United States occurring in people <18 years of age as of June 23, 2020.

Additionally, the overall clinical course seems milder in children, and the rate of complications appears to be low relative to adults. A large study of COVID-19 in children documented <6% of patients as developing severe or critical disease.1 Hypotheses for why children have milder illness include: 1) cell receptors for the SARS-CoV-2 virus may be less developed resulting in decreased virus binding; 2) crossimmunity from other viral infections; 3) developing immune systems may respond differently to COVID-19.

Though children seem to have been largely spared, some have severe complications from COVID-19. In April 2020, UK clinicians identified a cluster of pediatric patients presenting with what was described as “hyperinflammatory shock, showing features similar to atypical Kawasaki disease, Kawasaki disease shock syndrome, or toxic shock 10

syndrome.”2 Children described in the report were previously healthy and presented with fevers and a compendium of other symptoms including vomiting, diarrhea, abdominal pain, conjunctivitis, myalgia, odynophagia and rash.

Patients progressed to apparent distributive shock that was refractory to volume resuscitation and required inotropic support.

Though there was not a definite association with COVID-19, four of the patients had known exposure to COVID-19 prior to illness, and several ultimately did test positive for SARS-CoV-2. Subsequently, children with similar presentations have been reported from other parts of Europe and the United States.3, 4 The reports all describe a syndrome of multisystem involvement and inflammation, shock and COVID-19 association. The CDC has identified the described syndrome as Multisystem Inflammatory Syndrome in Children (MIS-C). Based on the reports available, a lag between the peak of COVID-19 cases in the respective communities and presentation of symptomatic patients suggests MIS-C may be related to a post-infectious complication of SARS-CoV-2 infection and not necessarily the acute infection.

A wide spectrum of presenting symptoms associated with MIS-C have been reported, with the most common being persistent fever (93-100%), GI symptoms (vomiting, diarrhea, abdominal pain; 45-83%), rash (42-57%), and conjunctivitis (36-45%).3, 4, 5 Other symptoms EMpulse Summer 2020

described include headache (26%), mucous membrane changes (2129%), swollen hands and feet (16%), and sore throat (10%).3, 4, 5 Respiratory symptoms were variable (respiratory distress, shortness of breath) and often ascribed to shock as opposed to a primary pulmonary etiology.

Clinical evidence of shock was present in a majority of patients (50-80%).3, 4, 5 Features suggesting Kawasaki disease were present in a proportion of patients, with 12% of patients meeting the American Heart Association diagnostic criteria for Kawasaki disease.5 However, differences between MIS-C and Kawasaki disease exist, with age being one of the distinguishing features: whereas Kawasaki disease is predominantly a disease of young children and infants, most cases of MIS-C have occurred in older children and adolescents.

Laboratory findings in MIS-C have been significant for elevation of inflammatory markers (e.g.

C-reactive protein, erythrocyte sedimentation rate, ferritin and procalcitonin) in the great majority of patients. Of note, the C-reactive protein has been significantly elevated with median values ranging from 229 – 250 mg/L in recent studies.3, 4, 5 Elevated cardiac markers, including troponin, B-type natriuretic peptide (BNP) and N-terminal pro-BNP, were also found in a majority of patients.3, 4, 5 Other laboratory abnormalities include: lymphocytopenia, thrombocytopenia, elevated liver enzymes and hypoalbuminemia. Echocardiography

has demonstrated left ventricular dysfunction in a significant proportion of MIS-C patients, though the actual frequency is unclear.

Dilated coronary arteries were found in a smaller, but significant proportion of patients (14.5-17%).3, 5 Based on the case reports and studies available, the CDC has provided a case definition for MIS-C which includes the following criteria:6

• Individual < 21 years with fever

(either subjective fever, or temperature > 38.0 ° C for > 24 hours), laboratory evidence of inflammation, and evidence of clinically severe illness requiring hospitalization with multisystem (> 2) organ involvement; AND

• No alternative plausible diagnosis; AND

• Positive for current or recent REFERENCES

1. Dong Y, Mo X, Hu Y, et al. Epidemiological Characteristics of 2143 Pediatric Patients With 2019 Coronavirus Disease in China. Pediatrics 2. Riphagen S, Gomez X, Gonzales-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory shock in children during COVID-19 pandemic. Lancet. 2020. Advance online publication, doi: 10.1016/S01406736(20)31094. Retrieved from: www. thelancet.com/journals/lancet/ article/PIIS0140-6736(20)31094-1/ fulltextexternal icon 3. Belhadjer Z, Méot M, Bajolle F, et al.

SARS-CoV-2 infection by RTPCR, serology or antigen test; or exposure to a suspected or confirmed COVID-19 case within the 4 weeks prior to the onset of symptoms Management of MIS-C patients depends on the severity of their presentation. Patients presenting with shock should be resuscitated per standard protocols, recognizing that many patients with shock in recent reports required inotropic support (47-80%) in addition to fluid resuscitation.3, 4, 5 Respiratory support, including endotracheal intubation and mechanical ventilation may be indicated. As MIS-C presents with signs and symptoms suggestive of possible septic shock, early initiation of broad

Acute heart failure in multisystem inflammatory syndrome in children (MIS-C) in the context of global SARS-CoV-2 pandemic [published online ahead of print, 2020 May 17].

Circulation. 2020;10.1161/CIRCULATIONAHA.120.048360. doi:10.1161/ CIRCULATIONAHA.120.048360 4. Kaushik S, Aydin SI, Derespina KR, Bansal PB, et al. Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with SARSCoV- 2 Infection: A Multi-institutional Study from New York City, The Journal of Pediatrics (2020), doi: https://doi. org/10.1016/j.jpeds.2020.06.045.

EMpulse Summer 2020

spectrum antibiotics is appropriate pending culture results and definitive diagnosis. Additionally, patients should be treated for Kawasaki disease if they meet criteria.

Considering the multisystem effects, organizing a multi-disciplinary team to co-manage the patient is critical.

MIS-C is a new entity and much remains to be determined regarding the pathophysiology, clinical findings, management and prognosis. Early recognition is critical as appropriate management with existing therapies does appear to result in good outcomes in many cases. The longterm prognosis of MIS-C is currently unknown. ■

5. Whittaker E, Bamford A, Kenny J, et al. Clinical Characteristics of 58 Children With a Pediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2 [published online ahead of print, 2020 Jun 8]. JAMA. 2020;e2010369. doi:10.1001/jama.2020.10369 6. Health Alert Network (HAN): Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with Coronavirus Disease 2019 (COVID-19). https://emergency.cdc. gov/han/2020/han00432.asp

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COMMITTEE REPORTS

EMS/Trauma

By Christine Van Dillen, MD, FACEP, FAEMS EMS/Trauma Committee Co-Chair

Our world has changed. We are limited by where we can go, who we can see, and the normal everyday tasks that allow us to feel healthy and whole are gone. Not only do we have to wear uncomfortable protective equipment at work, but also we have to wear masks at the gym, grocery store, and everywhere else. This pandemic has left us feeling on-guard since the beginning of this year. The virus started with claiming our freedom, then our economy, all while attacking our friends and family along the way. The spectrum of illness is so variable, ranging from asymptomatic to death, which allows for it to spread through the masses silently.

We have an expansive knowledge of emergency conditions from trauma, STEMI, stroke and sepsis, but we have to consider each case as a possible COVID presentation. We have no choice but to use our fear to face everything and rise up: FEAR. When you feel angry, use your energy to fight this disease and the pandemic.

Do not allow your anger to take away your compassion for your colleagues and patients.

Amidst this worldwide pandemic, another ugly aspect of our culture has again come to light: the presence of racism. As first responders and caretakers of our citizens, we must remember to be vigilant and stay anti-racist. We must be aware of any implicit bias (unconscious bias), which Uche Blackstock, MD defined in an ACEP 2019 column as “a person’s tendency to associate a group or category attribute, such as being black, with a negative evaluation.”

People across our society, including ourselves, hold such unconscious biases. We have seen firsthand how these biases affect the criminal justice system. Unfortunately, these are also present in the healthcare 12

system. They exist as feelings towards our patients, which have been present since the beginning of our professional lives. This can affect the way we treat patients. There is clear evidence that both in the emergency department and in the prehospital setting, potential disparities exist in the way we provide care to our patients.

For example, differences amongst transport destinations, as well as the frequency of pain medication administration when comparing different races, raise concerns that bias is altering care. We must recognize that these biases are present and actively fight them. This can occur by educating ourselves and our medical colleagues, from paramedics, EMTs, nurses and physicians.

Another action would be to create a workforce that is representative of the population it serves. This is a recommendation from the National Association of EMS educators based on an article from ACEPNow in June 2020. The expression Black Lives Matter is as pertinent to healthcare as it is in law enforcement. As healthcare providers, we already recognize that all lives matter, but until we include black lives equally as part of that commitment, we will continue to fall short in our duty.

FAEMSMD had its last meeting March 4, 2020 in Tampa, FL. At this meeting, members discussed ideas on how to enhance the services the organization provides and how to increase the value of membership.

Some of their ideas included CME lectures and education, real-time legislative updates, mentorship programs, a newsletter with announcements, education programs, webinars and industry updates. We also held elections on July 8, 2020 via EMpulse Summer 2020

webinar. Please see the new officers list on the Table of Contents page 6.

There were several presentations during FAEMSMD’s recent meeting.

The first was from Dr. Alicia Buck, who reviewed the “EPIC trial: Excellence in Prehospital Care.” We discussed their recommendations for traumatic brain injury treatment, including an algorithmic approach to decrease intubation in the field and strive to maintain normal vital signs to try and improve overall outcomes in this patient population. Dr. Alison Leung reviewed the article, “TXA: the future of stop the bleed.” Dr. Leung attributed the inconsistent adherence to the administration of TXA in the field with the inconclusive data available surrounding its use in the field. She did discuss that the data does seem to support the safety of administration in certain populations. Dr. Desmond Fitzpatrick led the discussion regarding ECPR and ECMO. Dr. Fitzpatrick, AdventHealth and Lake County EMS have initiated a program that will allow ECMO to be utilized on specific patients, which are identified by EMS, followed by ECMO initiation in the ICU in the Lake County region.

Dr. John Mcpherson and our Region V trauma agency continue striving to create gold standard trauma EMS protocols that will streamline our treatment of trauma patients.

We would also like to welcome our new EMS fellows: Monty Putman, MD with Orange County and Orlando Health; Alicia Nassar, MD with Tampa Fire Rescue and Pinellas County EMS; Austin Reed, MD; and Dr. Bethany Johnston with UF Health. ■

July 27-31, 2020 VIRTUAL EXPERIENCE

emlrc.org/project/clincon-2020

Thank You!

Thank you to all attendees, faculty and sponsors for participating in our first ever CLINCON Virtual Experience.

PLATINUM

GOLD

SILVER

EXHIBITORS

EMpulse Summer 2020

13

COMMITTEE REPORTS

Government Affairs

By Blake Buchanan, MD

Government Affairs Committee Co-Chair

Politically, we are in the calm between the storms right now in Florida. After a busy legislative season at the state level this spring, which saw a mixture of wins and losses, we turn our eyes towards the coming months with primaries in August and the general election in November. No matter the outcomes that lay ahead, elections always have consequences on healthcare and affect the system we must work within to care for our patients -pandemic or not.

At the state level, we can anticipate continued battles with insurers and further scope of practice arguments in the coming year, as well as possible changes to Medicaid given our current economic outlook. The next legislative session will also enter Florida into an era of new leadership, as Speaker Oliva, whose primary

focus has been to leave his print on Florida healthcare, is completing his final term this fall.

At the national level, surprise medical billing continues to be one of the few arguments whose sides do not fall within partisan lines. ACEP continues to battle against special interest groups attempting to slip ratesetting solutions to surprise medical billing into COVID-related legislative packages in an attempt to capitalize on the pandemic that we are all serving on the frontlines, fighting against. ACEP continues to represent us well in this battle and works to help emergency physicians in D.C. The waters are murky going forward, and we must be prepared for an array of potential legislative battles after the upcoming election. I thank you all for your involvement in FCEP and

ask that you please encourage your colleagues to join and become active members. I also encourage everyone to donate to the Florida College of Emergency Physicians Political Action Committee. FCEP PAC is the voice of emergency physicians to politicians who make the decisions that shape our practice, and without appropriate funding, that voice falls on deaf ears.

As always, FCEP will continue to monitor any potential bills shaping physician rights, scope of practice, balance billing, opioid treatment and any other potential bills that can affect the practice of emergency physicians. If you have any concerns or would like to learn more ways to be involved in advocacy, please feel free to email me anytime at BlakeBuchanan87@gmail.com. ■

SUPPORTING EACH OTHER IS MORE IMPORTANT NOW THAN EVER BEFORE. Florida 2021 Session is right around the corner.

Let’s not have a repeat of 2020.

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

14

Donate online at: fcep.org/donate

EMpulse Summer 2020

When the World Stops, You Keep Going Healthcare Heroes like you rise to the occasion every day to protect patients. Itâ&#x20AC;&#x2122;s our responsibility to protect you.

You Are a Healthcare Hero Across the country clinicians are answering the call every day to protect patients.

We need your help. Will you join us in the fight to contain the spread of COVID-19?

877.226.6059 EnvisionPhysicianServices.com

COMMITTEE REPORTS

Medical Economics

By Jordan Celeste, MD, FACEP

Medical Economics Committee Co-Chair

I want to start by stating the obvious: quarterly print media is not well-suited for current updates on the pandemic. So, I want to take a step back and look at the bigger picture. This article contains a lot of complex questions to encourage reflection and dialogue, and absolutely no answers. I want to look at the role that emergency medicine has played over the past months, briefly glance into our potential future, and recognize the fragility of our healthcare system. I know that I am not the only person who has been sitting on shift and thinking about these things; and I know that we have many terrific leaders across the state who are innovating and guiding their departments and groups through these difficult times. We want and need your input.

In Florida, one could argue that the largest role emergency medicine has played is preparedness. Not only in Florida but across the country, there was a scramble for PPE and ventilators, surge plans were revised, and departments were reconfigured to accommodate an influx of patients – some came, but some only came for a short while. We were mostly spared the New York City experience, with Miami seeing the largest concentration of cases in the state. I do not intend to downplay the effect that the virus has had in our state – we all have seen its impact and have cared for very sick people – but perhaps the biggest effect that we have seen is the precipitous drop in emergency department volumes following a period of intense stress and preparation. What do we do when we have gone through great lengths to prepare for patients 16

“

What do we do when we have gone through great lengths to prepare for patients that do not come in? Is it time that we explore getting compensated for such preparedness? that do not come in? Is it time that we explore getting compensated for such preparedness?

Can we attribute the decline in emergency department volumes to successful public health initiatives... or are patients not coming for other reasons? It has been well described in the lay press that myocardial infarction and stroke cases are down during the pandemic – and it is doubtful that one of the most tense times in recent memory has led to less heart attacks. We all have personal anecdotes where patients have delayed or avoided care out of fear of exposure while in the healthcare setting. I have had a patient tell me that she was “pretty sure she had a stroke three days ago,” but was afraid to come to the hospital. As a result, hospital systems have gone on the offensive, promoting that they are ready to care for patients – but will that be enough?

And are patients finding alternative ways to get care?

Now more than ever, patients are encouraged to seek care via telehealth. So while we are starting to see volumes increase EMpulse Summer 2020

at the time of the writing of this article, will they return fully?

How do we adjust staffing in our departments? And what is the best role for emergency medicine moving forward? Is it worthwhile to get involved in telehealth initiatives, from both a patient care and revenue standpoint? We all have anecdotes about patients’ telehealth visits as well – I know that on multiple occasions it has been unclear to me how antibiotics can be prescribed for so many conditions without actual exams or tests. I believe that emergency physicians should be leaders in this space – when it comes to who needs acute care and what that care entails, we are the specialists.

There are so many looming unknowns that will affect the approach to answering many of the questions posed in this article.

Will Covid-related care continue to be compensated, and to what extent? Will EMTALA changes remain in place? And will we be able to continue to bill E/M codes for televisits? ACEP’s D.C. office, with help from chapters and leaders across the country, are hard at work advocating for favorable answers. As I mentioned at the start of this article, your voice and experiences are important, and I encourage you to contact FCEP and ACEP with your input.

I do not want the take-away from this article to be one of pessimism or disillusionment. But let’s face it: we have all known for a while that the U.S. healthcare system is a ramshackle structure. Patients have variable access to care, as well as disparities in that care

THANK YOU, PAC DONORS

“

The success of FCEP’s advocacy efforts is dependent upon our ability to fund those efforts. Generous donations to our political action committees (PACs) are always needed and greatly appreciated. Thank you to those who donated in March-June 2020:

Perhaps now is the moment to show that the correct location of the safety net is not at the bottom of a broken system, but wrapped around it as an important component of care.

Christopher Adams

Simi Greenberg

Ina Sandeli

Jhanell Camille Allen

Julie Grenuk

Satesh Saroop

Jonathan O Anderson

Ian Robert Griffith

Ryan David Andrade

Kelvin Harold

Donna SchutzmanBober

Alfonso Luis Ayala Gonzalez

Brian Scott Hartfelder

Kevin Gregory Bennett

Saundra A Jackson William Paul Jaquis

Shelly Birch

Jonathan Journey

Michael A Borunda

Steven B Kailes

Isabel Jeannette Brea

Shiva Kalidindi

Blake Buchanan and its outcomes. Providers have been hobbling together payments across a range of payors, with continual roadblocks being erected and the patients intermittently thrown into the middle as well. There has long been a sense that a strong gust could bring everything down...

The emergency department is frequently described, for better or for worse, as the safety net. As the latter, it indicates a landing spot for those that the system has been unable or unwilling to accommodate in any meaningful way: a refuge. As the former, it emphasizes the vital role that we play in providing care to anyone at any time, and especially during the most challenging of times.

Perhaps now is the moment to show that the correct location of the safety net is not at the bottom of a broken system, but wrapped around it as an important component of care. ■

Matthew A Schwartz Masra Muhammad Shameem Todd L Slesinger John Caleist Soud John E Stimler Karima A Thompson Jenna L Varner

Jordan Celeste

Frederick Michael Keroff

Steven Tyrone Vassil

Ethan Adair Chapin

Gary Lai

Steven C Watsky

Terry B Cohen

Jon E Lamos

David A Wein

Michael C Collins

Christopher T Martin

Ernesto Weisson

Marissa Danielle DeLima

Michael D McCann

Bruce S Whitman

Timothy McNamara

Bruce S Whitman

Alex T Doerffler

William David Nimmons

Anna Williams

Simon R Edginton

Jean E Obas

Christina Lucile Wilson

Clifford Findeiss

Venugopal Palani

Jason Wilson

Jason Findlay

Matthew Parrish

Marguerite Wright

Johnnie Ford

Matthew S Partrick

Frederick Yonteck

Robert B Fulton

William James Pruitt

Daneil Nathan Young

Zackary M Funk

Aaron James Puebla

Eric Carlton Young

Nikkitta C George

Victoria Rea-Wilson

Larry S Zaret

Jonathan Gomez

Lauren Kathleen Rosenfeld

Conley Diaz-Gomez

DONATE NOW: Text “FCEPPC” to “41444” or

EMpulse Summer 2020

Donate online at: fcep.org/donate 17

COMMITTEE REPORTS

Membership & Professional Development

By Shayne Gue, MD

MPD Committee Co-Chair

Is it really only July? Why has 2020 felt like the longest year of my life… and we’re only halfway through?

From an unprecedented viral pandemic that has changed the way we interact with our world, to the political spotlight on how we deliver medical care, to the emerging focus on the role of private equity in medicine -- this has been a year full of surprises, challenges, changes and hardships. And more than any other profession, we have had to find a way to perform our craft and provide our skills with fewer and fewer resources for a larger and larger population in need.

In emergency medicine, we have always been on the front lines of the healthcare system. Now, more than ever, we serve as the leaders and innovators who continue to provide the highest quality care for our patients in the face of a global catastrophe.

While you heroes continue to battle on the front lines of the COVID-19 pandemic, we at FCEP want to continue to provide you with the tools to ensure victory in this war. Last month, our team at EMLRC organized a successful PPE Drive for our front line workers, and we continue to be a voice to lobby for ensuring access to care for our patients and the financial resources to provide that care for our physicians.

We’ve also been tasked with finding creative ways to bring you the premier quality educational resources and sociability you’ve come to expect from us. With Florida quickly becoming the new epicenter for COVID-19, pursuing Symposium by the Sea in its current form would be irresponsible and potentially deadly. Our team is working tirelessly to ensure that we can still benefit from superior educational activities and opportunities for networking and socializing while respecting

Daunting Diagnosis: Q

By Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief

A 19-year-old autistic male presents to the ED with his parents for right upper back pain. The patient is a poor historian, and the parents are unable to give any definitive history. There is no recollection of trauma, no obvious musculoskeletal injury, and no cough. Vitals are remarkable for a

18

heart rate of 144 and respirations of 26. The patient is afebrile. The mother attributes his tachycardia to anxiety, stating the patient is often highly anxious. What does the radiograph show?

CONTINUE ON PAGE 21 �

EMpulse Summer 2020

the need for continued distancing and directing our resources to the front lines. Although we don’t have a final plan yet, we are eager to share a renovated and modernized Symposium by the (Virtual) Sea for 2020.

As always, remember to find time for your personal wellness. While ‘burnout’ is a common theme year in and year out, the added pressures of this disaster make it so much more important to remember to focus on our resiliency and mental hygiene.

We owe it to our patients, our families, and ultimately, ourselves, to be the best we can be. So find time to do the things you love, spend time with your family, update your routine, renew your body and spirit, and appropriate the resources you need to be the best physician you can be. And as always, let us know how we may help!

Keep fighting the good fight! ■

by the

2020

VIRTUAL EXPERIENCE RESCHEDULED TO:

August 25-28, 2020 Approved for AMA PRA Category 1 Creditsâ&#x201E;¢ NOTE: Committee & Board meetings will still be held on August 6, virtually via Zoom. Find the schedule on fcep.org and page 21.

Join us online for the SBS 2020 Virtual Experience. All CME sessions will be available to registered attendees for 2 FULL WEEKS at ONE LOW PRICE, and offered in a virtual format with a mixture of live, semi-live, and on-demand sessions.

Learn more at fcep.org/sbs

EMpulse Summer 2020

19

COMMITTEE REPORTS

EMRAF President’s Message

By Matthew Beattie, MD EMRAF President ’19-20

I just returned home from my last shift of residency. It seems like, not that long ago, I was walking into my first shift. I don’t remember the details, like how uncomfortable I felt or how little I knew, because during residency, we gain the experience and knowledge necessary to venture out and care for patients on our own. It is a cool process, and it works. By spending so much time at the hospital and on so many different rotations, we learn what we need to know to prepare for our career. My first shift is in a week, and I’m excited, but I’d be lying if I said I wasn’t a little nervous.

privilege and responsibility to care for our community in this time of need. I encourage you to stay safe and keep your family safe.

I want to congratulate all the graduates who are starting the next phase of their careers. What a time to start practicing emergency medicine. Who else can say that they graduated residency in the middle of a pandemic!

Over recent weeks, the virus has taken an exponential turn just in time for us to start our new jobs. What a

It has been an awesome three years! Thank you for allowing me to serve as president of the Florida chapter of EMRA. I encourage you to get involved and to find ways to make a difference in our specialty. ■

For the upcoming senior residents and incoming interns, take the time to grow together as a class. Work hard and learn from your attendings and patients. Residency is an awesome time where you are surrounded by a community in a similar stage of life. When you walk into your shift, think of one way you can encourage someone that day.

COMMITTEE REPORTS

Medical Student Council

By Dan Schaefer, MPH, MD Candidate – M3 Secretary-Editor, FSU College of Medicine

The FCEP Medical Student Council has officially transitioned to a new leadership team. Please welcome our new chair: Patrick Anderson (NSU), our new advocacy chair: Chloe Gould (FIU), and our new secretary-editor: Dan Schaefer (FSU). Our outgoing team did an absolutely fantastic job over this last year.

At this time, medical students are facing very unique challenges to their medical education. Can you remember your own third and fourth years in medical school? Can you

20

remember the interview trail and the residency match process? Since the SARS-COV-2 pandemic resulted in economic turmoil and social distancing in March, students have been pulled off clinical rotations, hospitals have closed to student rotators, anatomy labs have shuttered, and curriculum has switched to online platforms. EM organizations aligned with the other medical specialty organizations across the nation and deemed that all residency interviews will be conducted virtually!

EMpulse Summer 2020

In response, the Medical Student Committee has worked to keep students across the state informed and prepared for the virtual interview season ahead. We are holding live, faculty-led informational sessions that are open to all students, as well as recording them and posting them to be viewed at a later date. If you are interested in more information, please check us out on Facebook at FCEP Medical Student Group. ■

Board & Committee Meetings August 6, 2020 via Zoom

Recordings will be emailed to FCEP members afterwards.

SCHEDULE: 8:00 AM – 8:55 AM Membership and Professional Development Committee Meeting 9:00 AM – 9:55 AM Education and Academic Affairs Committee Meeting 10:00 AM – 10:55 AM Medical Economic Committee Meeting 11:00 AM – 11:55 AM Government Affairs Committee Meeting 1:00 PM – 2:00 PM EMS/Trauma Committee Meeting 1:00 PM – 3:00 PM Council of EM Residency Program Directors and Core Faculty Meeting 2:00 PM – 3:00 PM Pediatric EM Committee Meeting

Daunting Diagnosis: A

By Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief

� CONTINUED FROM PAGE 18

Chest CT prior to chest tube insertion:

The chest XR was initially read by the radiologist as a “hydrothorax.” To further evaluate the hydrothorax, a rapid chest CT was obtained while the patient was set up for a chest tube insertion under conscious sedation.

Upon insertion of a right-sided chest tube, over 1000cc of bright red blood was evacuated from the chest cavity. Heart rate improved to the 120’s, and the patient was admitted to the SICU under cardiothoracic surgery.

CXR after 32 F chest tube inserted:

Throughout the week, chest tube drainage was monitored by the SICU team. The chest tube was eventually removed, and the patient was discharged home with no further insight into why he accumulated a massive hemothorax.

One week later, the patient presented again to the ED with fever, tachycardia, and tachypnea.

CXR a week later:

The patient now presents with sepsis from an empyema. A sepsis protocol was initiated, and the patient was admitted to cardiothoracic surgery for urgent pleurodesis. The patient tolerated surgery well, although his disease pathogenesis still remains a mystery. ■

3:00 PM – 5:30 PM FCEP Board of Directors Meeting fcep.org/sbs

EMpulse Summer 2020

21

Congratulations to the

EM RESIDENCY CLASSES OF 2020

Lists provided by Florida’s emergency medicine residency programs in June

INAUGURAL CLASS

UCF/HCA at North Florida Regional Dr. Zaza Atanelov Encino Hospital Encino, CA

Dr. Alexandru Barabas

Lawnwood Regional Medical Center Ft. Pierce, FL

Dr. Collin Bufano

Jackson Memorial Hospital Kendall Regional Medical Center Dr. Ramsey Ataya

TeamHealth, Southwest General Cleveland, OH

Dr. Spencer Barela

Envision, Citrus Memorial Health Tampa, FL

Dr. Sarah Dichter

LIJ Valley Stream at Northwell Health NYC, NY

Dr. Nikkitta Georges

Ultrasound Fellowship, Envision, Kendall Regional Medical Center Miami, FL

Dr. Karla Guzman Melero Hialeah Hospital Hialeah, FL

Dr. Amanda Haan

Ambar Marin Lopez, MD

Sumit Arora, MD

TeamHealth, AdventHealth Kissimmee, FL

Emily Ball, MD

TeamHealth, AdventHealth Celebration, FL

John Combs, MD

Emergency Care Partners St. Tammany Parish Hospital Covington, LA

Attending, St. Mary’s Hospital San Bernardino, CA Surgical Critical Care Fellowship, Univ. of New Mexico Albuquerque, NM

Ashley Mays, MD

Attending, Jackson Health System Miami, FL

Shannon Armistead, MD

Matthew Dybas, MD Paul Eugene, MD

Emergency Resource Group, Baptist Hospital Jacksonville, FL

Medical Center Pittsburgh, PA

Christina Gutierrez, MD

TeamHealth, AdventHealth Celebration, FL

UCF/HCA of Greater Orlando James Chiang

Faculty, Kaiser Permanente Central Valley Modesto, CA

Envision, Westside Regional Medical Center Plantation, FL

Ultrasound Fellowship, George Washington Univ. Hospital Washington, D.C.

Attending, Brandon Regional Hospital Brandon, FL

Scottsdale Emergency Associates (SEA) Scottsdale, AZ

Attending, Roper Emergency Physicians Charleston, SC

HCA Regional Medical Center San Jose, CA

Critical Care Fellowship, Univ. of Pittsburgh Medical Center Pittsburgh, PA

Ultrasound Fellowship UCF/HCA Greater Orlando, Osceola Regional Medical Center Orlando, FL

Dr. Arvinder Jandu

Dr. Andrew Napier

Dr. Jasminia Nuesa

Pasco County Emergency Physicians

Dr. Daniela Valenzuela

Envision Administrative Fellowship, Kendall Regional Medical Center Miami, FL

Dr. Jessica Wire

Envision, Sentara Northern Virginia Medical Center Woodbridge, VA

Matthew Kwon, MD

Timothy Montrief, MD

Dumi Presuma, MD

Fellowship in Anesthesia Critical Care, Jackson Memorial Hospital Miami, FL

Michael Traum, MD

Attending, Vituity Healthcare

Kelsey Wolfe, MD

Attending, Vituity Healthcare

Dr. Benjamin Murphy LeConte Medical Center Sevierville, TN

Dr. Alex Waldman

Southwest General Medical Center Cleveland, OH

Aventura Ulrika Agnew, MD

Attending, Greater San Antonio Emergency Physicians San Antonio, TX

Kristina Jacomino, MD

Dr. Ryan Luevanos

Undecided

Bradly Parrish, DO

Attending, Vituity Healthcare

Anwar Ferdinand, MD Attending, Univ. of Pittsburgh

Dr. Christopher Libby

Tri-City Medical Center San Diego, CA

Mohammad Ramadan, DO

Attending, Vituity Healthcare

Undecided

Cedars Sinai, Clinical Informatics Fellowship Los Angeles, CA

Ultrasound Fellowship, Yale Univ.

New Haven, CT

Desiree Delgado, MD

Dr. Donavan Ginest

Elizabeth Kim, MD

Ultrasound Fellowship, Emery Univ.

Atlanta, GA

Dr. Colin Hagen

22

AdventHealth East Orlando

Berkeley Emergency Medical Group Berkeley, CA

Alexandra Craen

Nicholas Fusco

Andrew Hanna

Undecided

Frederick Chu, MD

Fellowship, Walter Reed Hospital Washington, D.C.

Emerson Franke, MD

Fellowship, Children’s Hospital of New Jersey Newark, NJ

Jaskirat Gill, MD

Shock Trauma Fellowship, Univ. of Maryland Baltimore, MD

Mitali Mehta, MD

Coliseum Medical Center Macon, GA

Matthew Mungo, DO Northside Hospital Gwinnet, GA

Pediatric Emergency Medicine Fellowship, UF Jacksonville Jacksonville, FL

Katherine Peterson, MD

Faculty, Univ. of Kentucky Lexington, KY

Staten Island Univ. Hospital New York City, NY

Jessica Houck Joshua Tsau

EMS Fellowship, UT San Antonio San Antonio, TX

Karl Yousef, MD

Attending, Vituity Healthcare

EMpulse Summer 2020

Sheila Bawany Undecided Orlando, FL

Sparrow Main Hospital Lansing, MI

Jennifer Reyes, DO

Ricardo Rodriguez, MD Homestead Hospital Homestead, FL

Nicole Rodriguez Perez, MD Plantation General Hospital Plantation, FL

USF Health Matthew Beattie, MD South Florida Baptist Plant City, FL

Maram Bishawi, DO

TeamHealth Special Operations Tampa, FL

Dr. Dominic DiDomenico Health Front Emergency Physicians Santa Fe, NM

Dr. Kyle Friez AdventHealth Orlando, FL

Dr. Josiah Hill

Olympic Medical Center Port Angeles, WA

Dr. Alicia Nassar

EMS Fellowship, USF Health Morsani Tampa, FL

Dr. William Pearce

INAUGURAL CLASS

Florida Atlantic University Dr. Sean Argo

Morton Plant North Bay Hospital New Port Richey, FL

Dr. Diego Riveros

Dr. Jeffrey Klein

Envision Physician Services Ocala, FL

Morton Plant North Bay Hospital New Port Richey, FL Bethesda Hospital East Boynton Beach, FL

St. Lucie Medical Center

Dr. Megan Tyler

Dr. Christine Gonzalez

UF Jacksonville Steven Chadwick, DO Undecided

Cory Clugston, MD Undecided

Jessica Dalton, MD Undecided

Roseline Desvaristes, MD Undecided

Blake Duke, MD Undecided

Corey Dye, MD Undecided

Michael Gast, MD Undecided

Rebecca Lacayo, MD Undecided

Sean McAlister, MD, MPH Undecided

Tanner Miles, MD Undecided

Kimberly Papa, MD Undecided

Michael Schneider, MD Undecided

Brett Schubert, MD Undecided

Theodore Strom, MD Undecided

Verma Nandini, MD Undecided

AnMed Health Anderson, SC

Lawnwood Regional Fort Pierce, FL

Dr. Alexandra Chitty

St. Lucie Medical Center Port Saint Lucie, FL

Dr. Oliver Morris Oak Hill Hospital Brooksville, FL

Dr. Joe Gibney

Health Central and Horizon West, Orlando Health Orlando, FL

Dr. Natasha Brown

Dr. Nicholas McCauley

Johnathan Kennedy, MD

Envision Physician Services Milwaukee, WI

Dr. Vir Singh

Academic & Community EM Practice in the Rio Grande Valley Brownsville, TX

UF Gainesville Lindsay Beamon-Scott, MD

UF EM Global Health Fellowship Gainesville, FL

Michael Chami, MD

Tampa Veterans’ Hospital Tampa, FL

UAB Medical West Birmingham, AL

Stacey Lemmon, MD Undetermined

Ian Little, MD

South Lake Hospital / Freestanding EDs Orlando Health Orlando, FL

Ginny Owens, DO

Randall Park Orlando Health Orlando, FL

Katie Pearson, MD

Rebecca Brynne McAlpine, MD

Caitlin Premuroso, MD

Thuyen Nguyen, MD

Orange County EMS Fellowship Orlando Health / Orange County EMS Orlando, FL

Bronxcare Health/Bronx Lebanon The Bronx, NY

UF EMS Fellowship Gainesville, FL

Austin Reed, MD

Dr. Blake Guillory

Danielle Roberts, MD Norwalk Hospital Norwalk, CT

Laura Scieszka, MD

Bristol Regional Medical Center Bristol, TN

Ultrasound Fellowship, Orlando Health Orlando, FL

Monty Putman, MD

Anne Shaughnessy, MD

Simulation and Education Fellowship, Orlando Health Orlando, FL

Margaret Stutsman, MD

Georgia Emergency Physician Specialists Memorial Hospital Savannah, GA

Tierra Smith, MD

Dr. Chandelle Raza

UF Ultrasound Fellowship Gainesville, FL

Dr. Elizabeth Rubin

UF Internal Medicine Residency Gainesville, FL

Medical Simulation EM Fellow at Northshore Univ. Health Evanston, IL

FDNY EMS Fellowship New York, NY

UF EMS Fellowship Gainesville, FL

Bethany Johnston, MD

Dr. Zachary Gimbel

Westside Regional Medical Center Plantation, FL

Kirsten Kepple, MD

VA San Diego Medical Center La Jolla, CA

Westside Regional Medical Center Plantation, FL

Northwell/Sports Medicine Fellowship New Hyde Park, NY

South Lake Hospital / Freestanding EDs Orlando Health Orlando, FL

North Shore Medical Center Miami Miami, FL

Baylor College of Medicine Houston, TX

Dr. Waroot Nimjareansuk

Dr. P. Phillips Hospital Orlando Health Orlando, FL

Joshua Koplon, MD

Disaster Medicine Fellowship at Beth Israel Deaconess Boston, MA

Physicians Regional Medical Center Naples, FL

Brian Guetschow, MD

George Gulenay, MD

Dr. Mauricio Baca

Physicians Regional Medical Center Naples, FL

Laura Cook, MD

Dr. Jason Lippert

Envision Physician Services Nashville, TN

Weedley Funeus, MD

Mount Sinai Medical Center

Mitch Barneck, MD

Sports Medicine Fellowship, UF Gainesville, FL

Traveling Physician USACS

Cleveland Clinic Indian River Hospital Gifford, FL

Lakeland Regional Medical Center Lakeland, FL

Dr. Michael Ferras

Lee Memorial Health System Fort Myers, FL

Dr. Matthew Wallace

Innocent Akujuobi, MD

Dr. Lee Barker

EMS Fellowship VCU Richmond, VA

Dr. Daniel Parks

Orlando Health

Ultrasound Fellowship, Orlando Health Orlando, FL

Undecided

Dr. Benjamin Mazer

Dr. Kevin Summers

Team Health Tampa, FL

Dr. Samyr Elbadri

Envision Physician Services Ocala, FL

Dr. Jacob Stritch

TeamHealth Special Operation Tampa, FL

UCF/HCA at Ocala Health

Dr. Damien Carracedo

Emergency Resources Group Jacksonville, FL Sports Medicine Fellowship West Virginia Univ.

Morgantown, WV

INAUGURAL CLASS

Garrett Snipes, MD Dacia Ticas, MD

Univ. of Arizona Fellowship Tucson, AZ

EMpulse Summer 2020

Inaugural Class: 2021 • Brandon Regional • Oak Hill Hospital

Inaugural Class: 2022

• FSU at Sarasota Memorial • Orange Park Medical Center 23

NORTH FLORIDA EM RESIDENCY PROGRAM UPDATES

UF Gainesville

By Christopher Purcell, MD, PGY-3

Orange Park Medical Center

By Cody Russell, MD, PGY-2 & Ron Koury, DO, FAAEM, FACEP

We recently conducted a quality project using Six Sigma techniques that our residents learned as part of their program to improve their ED. The goal was to decrease the time patients wait in ER rooms after their physician had discharged them, due to patients waiting on their discharge paperwork. The project was based on an idea to have resident physicians discharge select patients, particularly patients that residents were already going back into the room to discuss results, prescriptions, return precautions, and follow up plans. The logic was: why not just have patients sign their discharge papers when we are in the room discussing all the items of their discharge packet?

The results of this project showed that, by using this new discharge process in only 22.6% of all ED patients, an additional 177 patients could be accommodated into ED rooms rather than being treated from the waiting room. It also could generate an estimated $442,500 in additional revenue for the hospital if continued throughout the year.

This project won first place at Orange Park Medical Centers Research Day and was presented by Cody Russell, MD, PGY-1 and led by Steven Warrington, MD. ■

After a hard-worked past few months through the COVID-19 pandemic, the UF Emergency Medicine residency program is taking time to focus on this year’s achievements and looking forward to a new year.

Summer brings an end to our senior residents’ time with us. In June, our PGY-3’s presented their hard work in research and quality improvement.

Two of those quality improvement projects include the development of a multidisciplinary DVT discharge pathway, as well as the creation of a standardized process for medically clearing Baker Act patients, and they have already started making a difference in our department The symbolic hand-off of chief responsibilities took place at the annual chief resident dinner. A huge thank you to Assistant Residency Program Director, Dr. Nicholas Maldonado, for hosting the dinner. If you have not had a T-bone steak cooked on his Big Green Egg grill… you are missing out.

Life

AFTER

RESIDENCY Retreat 2020

THRIVING BEYOND MEDICINE

Thank you so much Drs. Austin Reed, Tierra Smith and Garrett Snipes for their work as chief residents this past year! We would also like to welcome Drs. Christopher Purcell, Lauren Fisher and Shannon Williams as they prepare to lead us through this next year.

A new academic year means new interns and medical students who are eager to learn. We are excited to introduce a “teaching shift” into our PGY-3 schedules. This allows for dedicated on-shift teaching time to help enhance the medical student experience and gives the new interns another senior resident in the department to learn from. We cannot wait to get these shifts started!

Each July brings a “resident wellness day” where everyone is given the day off to participate in a group activity.

Last year we had such a blast floating down Ginnie Springs that we are returning this year for even more fun.■

Feedback Requested: in-person event OR

virtual experience?

Send your thoughts to mkeahey@emlrc.org

FCEP staff and the Life After Residency planning committee are still weighing all options with the safety of our residents, faculty and sponsors in mind.

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EMpulse Summer 2020

NORTH FLORIDA EM RESIDENCY PROGRAMS

UCF/HCA North Florida Regional

By Jayden Miller, MD, PGY-2

UF Jacksonville

By Dr. Rick Courtney, DO, PGY-2

Congratulations to our graduating third-years! We are grateful for the leadership you’ve exhibited over the years, and we look forward to celebrating all of your accomplishments moving forward. Good luck to all in your future endeavors. As we say goodbye to our seniors, we are thrilled to welcome the Class of 2023 to our family! It’s a unique and exciting time to be starting residency in the midst of the COVID-19 pandemic, and we know you are going to come in and meet the challenge head on.

We’d also like to take a moment to celebrate several members of our team who have been recognized within our hospital for their outstanding contributions. Dr. David Caro received the UF Meritorious Service Award for his great accomplishments this year as our program director and as the hospital’s Disaster Medical Officer, where he led our charge against COVID-19. Dr. Tom Morrissey won the College of Medicine Excellence in Student Education Award. This honor is awarded to the faculty member deemed the most outstanding teacher as selected by the medical students. Additionally, our very own Dr. Michael Gast, PGY3 won the Ann Harwood-Nuss Resident Advocate Award for his contributions in improving the educational and work environment of his fellow residents. Congratulations, everyone!

A lot has been happening at North Florida! We celebrated the graduation of our inaugural class in May. The gentlemen of the Class of 2020 have all graduated and moved off to their next chapters!

Several of our seniors headed out west: Dr. Zaza Atenalov is now an attending in Los Angeles, CA. Dr. Christopher Libby has also moved to Los Angeles for his Informatics Fellowship at Cedars Sinai. Dr. Ryan Luevanos is now an attending in San Diego, CA, and Dr. Colin Bufano is now practicing in Berkeley, CA. Dr. Donovan Ginest has not yet finalized his plans. Dr. Benjamin Murphy accepted an attending position in Knoxville, TN, and Dr. Alex Waldman will be practicing in Cleveland, OH. Finally, Dr. Alex Barabas will be an attending in Fort Pierce, FL. We are also extremely excited to announce that Dr. Shelby Martin, PGY-3 has accepted an early offer for a Critical Care Fellowship at Washington University in St. Louis.

Our residents stood in solidarity with protesters around the country during our “White Coats for Black Lives” gathering (socially-distanced, of course) on June 10th. We knelt for 8 minutes and 46 seconds to

remember the loss of George Floyd, and contemplated inequalities in our country.

COVID-19 is beginning to rebound in Florida, and we are seeing our share of patients suffering from the novel illness. Thankfully, our residents are never without PPE or support, and we have been able to care for our patients with safety in mind.

In light of COVID-19, many changes have been announced regarding audition rotations and interview season. We have sought interaction with the Medical School Class of 2021 by enhancing our social media and online presence. Dr. Ashley Barash, PGY-3 has taken over the reins of our Instagram, sharing “A Day in the Life” in the cardiovascular ICU and spotlighting rock stars from our program. We’ve also had our PD, Dr. Robyn Hoelle, give an informational session for EM applicants on our IGTV, not to mention loads of interaction and education happening on our Twitter. To learn more about North Florida EM and to interact with faculty and residents, follow us @northfloridaem on Instagram and Twitter, or visit the website at northfloridaem.com! ■

EMpulse Residency Updates Homepage

Access the latest EMpulse articles from all of Florida’s emergency medicine residency programs online. fcep.org/empulse/residency-updates EMpulse Summer 2020

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WEST FLORIDA EM RESIDENCY PROGRAM UPDATES

Brandon Regional Hospital

By Rashmi Jadhav, MD, PGY-3

USF Health

By Mikhail Marchenko, MD, PGY-3 Greeting from Tampa and the USF Emergency Medicine Residency!

The last few months have been quite busy and exciting for our residency program. Our new interns have started their orientation month and are awesome. We are excited to see how much they will grow as emergency medicine physicians over the next few years!

We congratulate our graduates and are happy to have two of them working alongside our residents: Dr. Alicia Nassar is now our EMS fellow and Dr. Megan Tyler for staying at Tampa General Hospital as an attending. For all the 2020 graduates, represent us well in Florida and beyond; we are proud of you and miss you already!

Despite having to adjust our education in the setting of COVID-19, our seniors and residents have been exceptional at running grand rounds online from home. Many awesome presentations and great learning has happened in the last several months. We are glad to be making steps into integrating safe group and simulations this summer.

We are proud of our seniors Dr. Nicole Abdo and Dr. Lauren Shapiro for representing emergency medicine and getting involved in leadership roles at USF by serving on the Resident Advisory Committee.

We look forward to what this summer brings. In the words of our EMRAF President, Dr. Matthew Beattie: “Stay up to date and learn every day, but place your health and happiness first.” ■

What a time to be in emergency medicine!

Our program, like many others, has been adjusting daily with the evolving pandemic. I am proud to say that our residents have shown great leadership, a strong work ethic, and a true sense of responsibility as we all face this global health crisis. Everyone is working harder than ever to keep up with the healthcare demand, and we realized that we are fortunate to be training during this time and gaining a unique educational experience, which we will carry with us throughout our careers. Through these trying times, all of our attending physicians have been incredible in providing support both clinically and on the educational front. Our PD and APDs have been working vigorously to ensure our education and clinical training remains unaffected, and we are incredibly thankful for their efforts.

Over the last few months, we have had several scholarly achievements by our residents. Drs. Kushwaha, Bacci, Au, Mcclure and Hsu published various case reports to the Cureus Journal. We also had several residents — including Dr. Jadhav, Rivera,

Additionally, our program is proud to announce our very first Chief Residents for the 2020-2021 academic year. Drs. Melissa Bacci, Rachel Oliver and myself are very excited to take on our new roles and help to grow and improve our amazing program even further. Additionally, we have several new faculty members joining our cohort who will bring immense value and experience to the ED and its residents.

Lastly, we are incredibly excited to have our incoming interns begin the new academic year. Our program is finally complete with a full cohort of PGY-1, PGY-2 and PGY-3 residents.

Although we have transitioned all academics and our boot camp to a virtual platform, we have several innovative ideas to make this experience meaningful to our interns. We look forward to a strong start to the new academic year! ■

HUMAN TRAFFICKING & EMERGENCY MEDICINE Meets new HB 851 requirement Approved for AMA PRA Category 1 Credits™

emlrconline.org 26

Al-Marzoog, Glickman, Shepherd and Kushwaha—present their research at the Brandon Regional Hospital Research Day in May. They have put in a significant amount of work and effort into their scholarly activities, and the program continues to proudly support them.

EMpulse Summer 2020

WEST FLORIDA EM RESIDENCY PROGRAMS

FSU at Sarasota Memorial

By Courtney Kirkland, DO, PGY-2

Greetings from Sarasota! We are extremely excited to welcome our second class to the FSU family. They had orientation during the last week of June and started in July with all of their certifications. We have also had the privilege of welcoming another new member to our FSU family: resident Dr. Kevin Raymond and his wife, Laurel Raymond, gave birth to their third child, Emma Grace, in May. We have continued to make a name for ourselves at Sarasota Memorial Healthcare System. Julio Arrieta and Dr. Darrell Ray, one of our residents, recently published a study on the

first 30 patients at our hospital with COVID-19. Another one of our residents, Dr. Tom Cox, will be partnering with our emergency department pharmacists for an innovative study on phenobarbital used in alcohol withdrawal.

Unfortunately, with social distancing measures in place, we have been unable to have many group activities in person, and many events have been canceled. Our residents and faculty have adjusted to the changes without much resistance, as would be expected in true emergency medicine fashion. We have been very lucky

with PPE at our hospital, including being provided with P100 respirators by our faculty for which we are incredibly grateful.

We are looking forward to growing as a program with our second class of residents. While we were hoping the COVID crisis would settle down, we are prepared for anything now that cases in Florida seem to be growing significantly. I think I speak for everyone in my class when I say that we have come so far from the beginning of our intern year. It has definitely been one to remember. ■

Oak Hill Hospital

By Jonathan Yaghoubian, DO, MS, & Corey Cole, DO, PGY-3s

After much anticipation, our residency is finally at full capacity. It has been amazing to see our program grow to a full complement of residents and core faculty. As with any change, there is an initial resistance; however, now the ED staff sees us as an integral part of the team.

Now that we have third-year residents, it is exciting to introduce our first Chief Residents, Drs. Corey Cole and Christopher Megargel. Our new vice chiefs, Drs. Arun Malhotra and Juan-Diego Rodriguez, have also been chosen from the junior class.

The residents have been adjusting well to having a full complement with the seniors taking on a supervisory role, managing the juniors and our

newest interns, and the interns adjusting to life in residency.

The ED seems to be recovering after a brief reprieve from the COVID-19 pandemic keeping most people home. We anticipate a busy snow bird season and will use the slower months to get the interns ready for the “in-season” volume. As things start back up, the construction on the new ED will be resuming soon.

Though having parts of the ED shut down will create some challenges, the expansion will bring much needed space.

Recently, some of our residents participated in the HCA Poster Presentation Competition and their

EMpulse Summer 2020

posters will be published in the HCA Scholarly Commons. Due to the pandemic, they were not able to present in person but look forward to having the opportunity another year. Many conferences as of late have been cancelled or changed to virtual only.

Hopefully in the near future, these events will resume, allowing our residents to participate at the national level and build their networking.

With under a year left until graduation, our seniors will be the first graduating class of the program.

Some are getting ready for fellowship interview season while others are being interviewed for attending positions at emergency departments across the nation. ■

27

CENTRAL FLORIDA EM RESIDENCY PROGRAM UPDATES

Orlando Health

By Gregory Black, MD, PGY-2, Brody Hingst, MD, PGY-2 & John Atiyeh, MD, PGY-3

Hello from Orlando! We hope that everyone is staying healthy and safe.

As we begin our summer, we all take a collective sigh of frustration for what has been an incredibly difficult year thus far. We are facing the worst global pandemic of our lifetimes and continue to be diligent and cautious as COVID-19 still remains prevalent in our community. Additionally, we witnessed yet another heinous act of police brutality against our Black community followed by immediate nationwide outrage and protests calling for change to our broken system.

Orlando Health has always strived to be a loving and unified family. In the essence of these ideals, the EM residency organized a “Healthcare Workers for Black Lives” protest in the lobby of the hospital where

we knelt in honor of George Floyd for 8 minutes and 46 seconds. We heard many wonderful speeches from our amazing colleagues about inequality in our country and how we can continue the fight for equality moving forward. We are so proud of our residents, Drs. Beaulah Castor, Innocent Akujuobi and Agi Gaetig, for organizing this and bringing us together with love and support. The conversation will continue moving forward at Orlando Health with focus groups and meeting spaces for how we can help fight inequality in our community. Please remember that we have a responsibility as leaders in our community to seek reform for the systemic racism that exists in every facet of our nation, including healthcare. And we have a responsibility to our patients to look internally and identify our own internal

biases and overcome them.

If you have not done so already, please find out who your local and national representatives are and message them about making change, and most importantly, VOTE. Primary elections are on August 18 and the Florida general election is November 3.

We want to close by saying thank you to all of our graduating thirdyear residents. Thank you so much for all of your teaching and wisdom.

You guys are all awesome and we are going to miss you so much! And finally, we are so excited to welcome our entire new intern class! July 1 couldn’t come soon enough. Don’t forget to keep living like Sal! ■

AdventHealth East Orlando

By Tyler Mills, MD, PGY-1 Hello again from all your EM friends at AdventHealth East Orlando. It has been an eventful academic year full of many exciting challenges and changes. We congratulate Drs. Molins, Gue and Tomecsek on their new positions, and we look forward to meeting our new assistant program director, whose move was delayed by the coronavirus— congratulations, Dr. Little! The 2019-2020 academic year will be a memorable one for EM programs everywhere, and our program is no exception. The interns showed continuous growth in their new roles and adapted well to the additional challenges of training during a pandemic.

On the research front, interns made significant contributions as well.

Dr. Duan has already completed his first project on palliative care 28

consults in the ED and is waiting to publish. Dr. Ray seeks to maximize engagement and capitalize on the popularity of our “jeopardy board review.” He is awaiting approval to begin his project on “gamification” of EM education. We are eager to apply his findings so we can incorporate more competitive elements into the weekly conference. Second-years Dr. Muniz and Dr. Lawyer have joined forces to create tutorial videos for newcomers to the ED. The instructional videos—which include topics like documentation and order sets— will help interns and rotators hit the ground running. Senior resident Dr. Mays wrote a review article on frostbite and hypothermia and was paid for her work.

It was another record year for applicants and interviews. We are excited EMpulse Summer 2020

for the new interns to start so we can get to know them, but we are sad that this time of year also means saying goodbye to our third year class. They survived three hurricane seasons and a global pandemic to get to this point. They graduated in style (via Zoom) with their legacy secure.

They were a strong class academically and clinically across the board, but they were also well-liked. They were a nursing favorite and built close friendships with their intern class.

We will miss seeing all their faces everyday, but find solace in the fact that most are staying nearby. Drs. Marin, Parrish and Kim will be staying in the Advent Family and accepted positions at nearby campuses. Dr. Ramadan, one of our chiefs, won’t be too far from home after he moves his young family to Jacksonville. ■

CENTRAL FLORIDA EM RESIDENCY PROGRAMS

UCF/HCA at Ocala Regional

By Caroline Smith, MD, PGY-3, Emily Clark, MD, PGY-2 & Jean Laubinger, MD, PGY-2 UCF Ocala would like to congratulate the Class of 2020, our inaugural residency class. In the past three years, the program has grown from seven to 21 residents and has seen hospital expansion with a new emergency department at Ocala Regional, two new free-standing emergency departments, and a new designation as a comprehensive stroke center. We’re very thankful for the enthusiasm, work and dedication of the inaugural class in shaping the program into a great place to learn and work. Ocala has two new faculty members from the class: Lee Barker, DO and Samyr Elbadri, MD. Dr. Elbadri is staying

on as core faculty and simulation director for the residency program.

Michael Ferras, MD is starting his EMS fellowship at VCU in Richmond, VA. Joe Gibney, MD is working in Washington, D.C.; Jason Lippert, MD is working Nashville, TN; Nick McCauley, MD is working in Milwaukee, WI; and Vir Singh, MD is working in Brownsville, TX, where he will also serve as associate faculty for UT Rio Grande Valley. We are proud of the new graduates and wish them all the best in their careers (and in passing the boards).

We’re excited to start the new ac-

ademic year and welcome our new residents and faculty. This year, Caroline Smith, MD, Nicholas Titelbaum, MD, and Aaron Umansky, MD will serve as chief residents. Nathan George, MD will hold most of the power in the residency program in his role as scheduling chief. This year’s leadership plans to emphasize scholarly activities and resident wellness. We continued our intern boot camp this year with simulation and procedure workshops led by the second- and third-year residents. We’re excited for the program to continue to grow along with our new class. ■

UCF/HCA of Greater Orlando

By Amber Mirajkar, MD, PGY-3 It is the end of another academic year and, and like so many other programs, we have seen our Emergency Department changed by the COVID-19 pandemic. As front line providers, the job proves especially arduous, but our residents have risen to the challenge. From systematic reviews of aerosolizing literature (which led to a publication), to the widespread use of respirators — Drs. Andrew Hanna and James Chiang have led the way for provider safety.

Despite COVID-19, our research interests remain strong. A case of a rare, ruptured hepatic artery aneurysm was published in conjunction with the trauma surgery department by Drs. Amber Mirajkar, Ayanna Walker, Amanda Webb, and Sanjiv Gray. Drs. Alexandra Craen and Gideon Logan published a case of subarachnoid hemorrhage in a COVID-19 positive patient. Our Associate Program Director, Dr. Tracy MacIntosh, researched disparities in opioid pain management for our pa-

tients with long bone fractures. Even our alumni carry the research spirit, with Drs. Amanda Webb, Nick Kramer and Leoh Leon II affirming that an increase in delta lactate corresponds with increased mortality in septic patients. And, we have many more publications in the works.

The end of the academic year is a bittersweet time. Our PGY-3s graduated on Thursday, June 11, and we already miss them dearly. We wish all of them all the best in the next stage of their lives. At graduation, we also recognized the amazing faculty that make our program wonderful with several awards. Dr. Nubaha Elahi received the Educational Excellence Award, and Dr. Ayanna Walker received the Clinical Excellence and Professionalism Award. Despite the loss of our PGY-3s, our family continues to grow with a fantastic new class of interns. Drs. Jeffrey Adams, Jonathan Littell, Jovans Lorquet, Martin Morales, Marvi Qureshi, Mihir EMpulse Summer 2020

Tak and Adam Oswald started on July 1 with intern boot camp, and we cannot wait to welcome them to UCF and Osceola.

Our residency is also involved in pre-hospital medicine. PGY-2s and PGY-3s now act as medical control on shift, providing guidance and medication orders for Osceola, Kissimmee and St. Cloud EMS services.

We are fortunate to work with Dr. Walker, one of the medical directors for Osceola County, and Dr. Banerjee, the medical director for Polk County. Furthermore, our SIM director, Dr. Nubaha Elahi, Dr. Walker and Dr. Keegan McNally, PGY-2 have started using virtual SIM to help teach our EMS crews. We are always working to build on our friendships with our paramedic colleagues.

We hope everyone stays safe in these uncertain times, and we are looking forward to a promising new academic year. ■ 29

SOUTH FLORIDA EM RESIDENCY PROGRAM UPDATES

Florida Atlantic University

By Dr. Elizabeth Calhoun, PGY-2

Greetings from Florida Atlantic University! This has been quite an interesting season. Our small, lively group has managed to turn even WebEx residency conferences into interactive didactic sessions. Our ED volumes sank transiently due to the pandemic, but are now leveling out to a high-acuity-normal.

We will greatly miss our program’s first graduation class, wishing the best for Drs. Damien Carracedo, Matt Wallace, Sean Argo, Daniel Parks, Jeff Klein and Ben Mazer. With most of our graduates continuing to practice in Florida, we are glad they are able to stay in the sunshine.

We are excited to welcome our new interns: Drs. Tony Bruno, Tim Buckley, Collin Hickey, Daniella Lamour, Chris Williams and Miheal Plantak. We wish everyone a safe summer as we return to our new normal. ■

Kendall Regional Medical Center

By Ibrahim Hasan, MD, Kristina Drake, MD & Sara Zagroba, MD, PGY-3s Emergency Medicine Residency Co-Chiefs Kendall’s EM residents would like to welcome our new intern class to the family! As of this summer, we now have all three years of residency classes on board. We have a great new class and are excited to get to know them better.

This has been an exciting year for Kendall Regional Emergency Medicine. Our residents recently participated in the ACEP national SIM Wars competition in Denver, CO, where we took second place. This was under the guidance and training of our Simulation Director and Associate Program Director, Dr. Antionette Golden. The team trained hard throughout the year, coming in early mornings before conferences and shifts to run practice cases.

More exciting news is that Kendall Regional Emergency Medicine will be welcoming its first round of fellows for our new ultrasound fellowship!

This fellowship will be under the guidance of Dr. Moises Moreno, our ultrasound director, as well as Drs. Emilio Volz and Nicole Aviles, who are ultrasound fellows. This tremendous milestone could not have been done without the hard work and dedication of our program leadership and staff. We are tempted to say that our program has one of the best ultrasound curriculums in the country!

Residents become experts in bedside ultrasound under the guidance of these great teachers and mentors, and now to add two fellows. ■

Mount Sinai Medical Center

By Stephanie Fernandez, MD, PGY-3 Greetings from Mount Sinai!

First we’d like to extend a warm welcome to our new intern class, Drs. Matthew Apicella, Alyssa Eily, Ilya Luschitsky, Brijesh Patel, Dominique Pinzon, Daniel Puebla and Christopher Wong—we are excited to see such promising talent!

Our residents continue to thrive in the “new normal” following COVID-19. Residents are engaging in weekly online didactics. Drs. Stephanie Fernandez and Fenil Patel presented posters in the virtual 30

AAEM conference. We also look forward to hosting our colleagues in South Florida residencies during our annual Ultrasound Workshop in July.

As the academic year concludes, we extend a bittersweet farewell not only to our PGY-3 class, but to our core faculty member, Dr. Laurie Boge. We are lucky to have worked with such an outstanding clinician and value her dedication, guidance and friendship.

Lastly, in light of recent sobering EMpulse Summer 2020

events, our program has taken the time to reflect and open a dialogue regarding disparities within the medical field as well as society as a whole. We aim to look inward to confront our inherent biases and strive to support justice and equality for our colleagues and our patients.

From Mount Sinai, we wish you all a safe and successful new academic year. ■

SOUH FLORIDA EM RESIDENCY PROGRAMS

Jackson Memorial Hospital

By EM Residency Program Staff

With that said, we did hold a very successful Zoom graduation where well over 100 family members, friends, and alumni joined us virtually to celebrate this milestone. We had a very touching tribute video, which included a multitude of warm messages and wishes for all our resi-

dents. We were also extremely proud to celebrate our resident award recipients. Among others, Dr. Anwar Ferdinand received our “Sunshine award,” which is given to the resident who always has a positive outlook, promotes other residents’ wellness and is a delight to have on shift.

Dr. Desiree Delgado was the proud recipient of our “Clinical Excellence award” for excellent clinical acumen and caring bedside manners. Lastly, our overall “Resident of the Year award” went to Dr. Timothy Montrief for demonstrating excellence through clinical performance, bedside teaching, mentorship, scholarly activities and exemplary behavior.

CLINCON 2020

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Our virtual days are not over. Not only did we take advantage of AliEM’s Bridge to EM modules for our Class of 2023, but most of their orientation was done remotely. Time will tell as to how this will affect our interns’ learning, but it seems to be working well. We also had the privilege of having Dr. David Talan as our Grand Round guest speaker on July 1.

As we congratulate our class of 2020 and wish them the best in their careers, we are invigorated to welcome our new recruits and look forward to another great academic year. The work goes on, but stay safe everyone! ■

In celebration of the CLINCON National Symposium, we want to thank the brave men and women who serve as EMS providers for their dedication for responding to medical emergencies and saving lives.

EMpulse Summer 2020

20-ED-05976

We are sad and concerned about Florida’s new daily Covid-19 records and the state possibly pausing its reopening. We are certainly seeing an increase of positive cases throughout our system. To think that we were so hopeful that things would settle down and allow us to have a semi-normal graduation. Alas...

6/25/20 11:46 AM

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SOUTH FLORIDA EM RESIDENCY PROGRAMS

Aventura Hospital

By Dr. Scarlet Benson

Assistant Clinical Professor

St. Lucie Medical Center

By Shelby Guile, DO, PGY-2 Here at St. Lucie Medical Center, we have been working hard to be flexible and resilient during this unprecedented time. Similar to many other programs, we have had to adjust our didactics on a weekly basis to continue facilitating the best learning opportunities and keep everyone safe and healthy. We have enjoyed lectures via video conferences amongst our program, and have participated in ACEP virtual grand rounds, University of Maryland and ALiEM connect. We have also adapted to lower patient volumes and shorter hours as have many other departments in the country.

This pandemic has come at an especially bad time for our graduating seniors who we will not be able to celebrate in the grand fashion that we usually provide to send them off to begin their careers as attendings.

We are very sad to see them go, but also proud and excited for their careers to really begin. Chief resident Dr. Oliver Morris will be heading to Oak Hill in Spring Hill, FL; Dr. Kevin Summers will be working at AnMed in Anderson, SC; Dr. Chrissy Gonzalez will be working at Lawnwood Regional in Fort Pierce, FL; and we are thrilled to be adding Dr. Alexandra Chitty to our faculty here at St Lucie.

Lastly, congratulations to our new chief resident, Dr. Mike Drechsler, who has already been hard at work as we prepare to transition back to normal program activities. ■

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Although the coronavirus pandemic drastically affected the practice of both clinical and academic medicine, Aventura residents and faculty continued to contribute in many ways. The CEME Scientific Research Competition was transmitted to booklet form, and ultrasound gurus Drs. Vu Tran and Guarav Patel supervised several of our residents who published the POC ultrasound cases below:

• “POC US Identification of Ten-

sion Hydrothorax” by Dr. Leeran Baraness • “POC US Diagnosis of Fournier’s Gangrene” by Dr. Dennis James • “POC US Evaluation of Pulmonary Embolism in Pregnancy with Cardiac Arrest” by Drs. Manuel Obando and Benjamin Pirotte Dr. Huy Tran also had a poster presentation accepted for AIUM (unfortunately canceled due to COVID) entitled, “Assessing barriers to supervision of trainees in use of POCUS due to cardiac arrest by emergency medicine physicians.” Dr. Erin Marra

collaborated with resident Drs. Jenny Reyes, Leeran Baraness and Hieu Duong in publishing their case, “Xanthogranulomatous Pyelonephritis: A case of the great mimicker,” in the CEME booklet as well.

Outgoing chief residents Drs. Emerson Franke and Jenny Reyes advocated for providers regarding issues such as hazard pay, the need for PPE, and medical liability coverage during the COVID era at the inaugural ACEP Virtual Hill Day on April 28. Intern Dr. Leeran Baraness published a StatPearl on Acute Headache in addition to her CEME poster publications above.

2020 has thus far been an unprecedented and difficult year, but our core faculty and residents have handled the stress with equanimity and poise. We celebrated our second graduating class on June 16 and congratulate them as they move on to the next chapter of their physician career! ■

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EMpulse Summer 2020

THANK YOU

for being your best when things are seemingly at their worst Clinicians are our most valuable resource. Thank you for your tireless efforts and dedication to safe, high-quality patient care.

Join us

teamhealth.com/join or call 866.750.6256

POISON CONTROL

Management of Hydroxychloroquine & Chloroquine Toxicity Joshua Newell, PharmD, PGY-2

Anthony DeGelorm, Pharm.D.

UF Jacksonville Emergency Medicine

What is hydroxychloroquine?

Hydroxychloroquine (HCQ) is a part of the 4-aminoquinolones family. The drug is structurally related to chloroquine (CQ), which has historically been utilized for malaria prophylaxis.

HCQ is similar to CQ in therapeutic, pharmacokinetic, and toxicologic properties. The side effect profiles of the two are slightly different, favoring CQ use for malarial prophylaxis and HCQ use as an anti-inflammatory.1-2 HCQ is used in the treatment of rheumatic diseases such as rheumatoid arthritis and lupus erythematosus.3 HCQ, like CQ, is a weak base and may exert its effect by concentrating in the acid vesicles of the parasite and by inhibiting polymerization of heme. It can also inhibit certain enzymes by its interaction with DNA. The mechanisms underlying the anti-inflammatory and immunomodulatory effects of HCQ for rheumatoid arthritis and systemic lupus erythematosus are unknown.4-5

Why was it recommended for use in COVID-19?

CQ and HCQ appear to have invitro inhibition of the SARS-CoV-2 (COVID-19) virus, which has led many to explore these agents as potential treatment options. These drugs are

34

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

hypothesized to block viral entry into the cell by inhibiting glycosylation of host receptors, proteolytic processing, and endosomal acidification.6 Subsequently, its use was propagated by the media and early studies demonstrating possible utility during the COVID-19 pandemic.

Toxicity of the drug?

CQ and HCQ both have narrow therapeutic windows. Symptoms may become evident as early as 30 minutes after ingestion and death has been reported in as early as 1-3 hours post ingestion. Patients may present with neurologic, cardiovascular, ophthalmic, and various other systemic manifestations such as: nausea, vomiting, diarrhea, abdominal pain, convulsions, visual and auditory disturbances, hypotension, hypoglycemia, respiratory depression, apnea, QTc prolongation, QRS prolongation, hypokalemia, and subsequent cardiac dysrhythmias.7-8 The mechanism of cardiovascular toxicity is related to sodium and potassium channel blockade leading to hypokalemia with cardiovascular collapse.

Case reports of toxicity Unfortunately, a tweet by a government official on March 21, 2020

EMpulse Summer 2020

claimed that the combination of HCQ and azithromycin â&#x20AC;&#x153;has a real chance to be one of the biggest game changers in the history of medicine.â&#x20AC;? This accelerated a worldwide demand on the medications, with pharmacies reporting shortages within 24 hours.

The U.S. Food and Drug Administration released a letter to the stakeholders regarding chloroquine phosphate after a case report of a husband and wife ingested an aquarium product containing chloroquine phosphate in order to prevent viral illness, which ultimately led to death.

Management of the toxidrome Aggressive supportive care, oxygen, cardiac and hemodynamic monitoring, large-bore IV access, and serial blood glucose concentrations should be performed. Gastric decontamination techniques, such as activated charcoal, are recommended for patients presenting early as activated charcoal adsorbs chloroquine well, binding 95% to 99% when administered within 5 minutes of ingestion.9 If hypotension is present, then fluid resuscitation, followed by vasopressors, should be considered with a focus on epinephrine per previous studies.10-11 High dose diazepam has been shown to demonstrate efficacy in CQ toxicity to augment the

treatment of dysrhythmias and hypotension while also treating convulsions.12-13 Previously studied doses included diazepam 2 mg/kg IV over 30 minutes followed by 1–2 mg/kg/day for 2–4 days). The postulated mechanism of action for diazepam during CQ overdose includes: (1) a central antagonistic effect, (2) an anticonvulsant effect, (3) an antidysrhythmic effect by an electrophysiologic action inverse to chloroquine, (4) a pharmacokinetic interaction between

REFERENCES

1. Luzzi GA, Peto TE. Adverse effects of antimalarials. An update. Drug Saf. 1993;8:295–311 2. Vinetz J, et al. Chemotherapy of malaria. In: Brunton L, et al., eds. Goodman & Gilman’s The Pharmacological Basis of Therapeutics.

12th ed. New York: McGraw-Hill Companies; 2011.

3. Jordan P, et al. Hydroxychloroquine overdose: toxicokinetics and management. J Toxicol. 1999;37:861– 864.

4. Product Information: PLAQUENIL(R) oral tablets, hydroxychloroquine sulfate oral tablets. Concordia Pharmaceuticals Incw (per DailyMed), Kansas City, MO, 2019 5. Titus EO: Recent developments in the understanding of the pharmacokinetics and mechanism

diazepam and chloroquine, and (5) a decrease in chloroquine-induced vasodilation.10,11,13,14 The utilization of sodium bicarbonate for correction of QRS prolongation is controversial as it may worsen hypokalemia. No clinical trials regarding sodium bicarbonate have been conducted evaluating safety and efficacy in CQ overdose; however it may be necessary to prevent dysrhythmias from occurring.

Correction of hypokalemia should be done so cautiously as hyperkalemia

of action of chloroquine.. Ther Drug Monit 1989; 11(4):369-79.

6. Awadhesh K, et al. Diabetes Metab Syndr. May-Jun 2020;14(3):241-246. doi: 10.1016/j.dsx.2020.03.011. Epub 2020 Mar 26 7. Guly U, Driscoll P. The management of quinine-induced blindness. Arch Emerg Med. 1992;9:317–322.

8. Jaeger A, et al. Clinical features and management of poisoning due to antimalarial drugs. Med Toxicol Adverse Drug Exp. 1987;2:242–273 9. Kivisto KT, Neuvonen PJ. Activated charcoal for chloroquine poisoning.

BMJ. 1993;307:1068.

10. Riou B, et al. Treatment of severe chloroquine poisoning. N Engl J Med. 1988;318:1–6.

EMpulse Summer 2020

FPICN toxicologists are available 24 hours a day, free of charge, at 1-800-222-1222 for consultation regarding monitoring, management and disposition.

can occur while toxicity resolves with subsequent redistribution of drug from the intracellular space. ■ Image Credit: Adobe Stock

11. Riou B, et al. Protective cardiovascular effects of diazepam in experimental acute c ­ hloroquine poisoning. Intensive Care Med. 1988;14:610–616 12. Clemessy JL, et al. Treatment of acute chloroquine poisoning: a 5-year experience. Crit Care Med. 1996;24:1189–1195.

13. Marquardt K, Albertson TE. Treatment of hydroxychloroquine overdose. Am J Emerg Med. 2001;19:420–424.

14. Reddy VG, Sinna S. Chloroquine poisoning: report of two cases. Acta Anaesthesiol Scand. 2000;44:1017– 1020.

35

ULTRASOUND ZOOM

Lung Ultrasound in the COVID-19 Pandemic

By Dennis D’Urso, MD, PGY-3 Jackson Memorial Hospital

Have you ever asked yourself how your ultrasound probe can be used to fight the COVID-19 pandemic? Well, read on.

In my experience, point-of-care lung ultrasound (POC-LUS) has been invaluable in the bedside assessment of patients with respiratory complaints, helping to differentiate among the most common diagnoses, including congestive heart failure, pneumonia, pneumothorax or COPD. Now, I can add COVID-19 to my list!

In the setting of a pandemic, rapid case identification and severity stratification are crucial. RT-PCR of a nasopharyngeal specimen is the current standard for diagnosis, with rapid testing turnaround time approaching 1 hour or less.

Meanwhile, patient disposition is determined — and often delayed — by a combination of clinical and radiographic assessment.

Noncontrast chest CT is highly sensitive (approximately 97%) for detecting the usual lung changes seen in COVID-19; however, it has several limitations preventing its widespread use, including availability, cost, radiation exposure, requirement for the patient to leave the evaluation area, and necessary cleaning between patients. Portable chest X-ray is often more rapidly available; however, it has poor sensitivity (approximately 65%), limiting its reliability as a screening or stratifying tool.

POC-LUS has proven to be an excellent imaging modality for COVID-19. First, the disease tends to follow a peripheral to central 36

progression, making it amenable to surface imaging even in its earliest stages. In fact, the sensitivity of POC-LUS for detecting COVID-19 pneumonia can approach or even exceed that of chest CT. Furthermore, POCUS has utility beyond lung imaging alone. A more extensive evaluation of dyspnea can be performed in the same bedside assessment by evaluating the heart and IVC in addition to the lungs. This “triple scan” can provide important information such as left ventricular function, presence of right ventricular strain, and volume status to further guide patient care.

Additionally, POCUS is portable, inexpensive, rapid, and therefore easily repeatable, making it an effective tool for monitoring the progression of disease and recovery without exposure to ionizing radiation. POC-LUS has been successfully utilized to

Edited by Leila Posaw, MD, MPH

Emergency Ultrasound Director, Jackson Memorial

determine responsiveness to alveolar recruitment maneuvers such as proning and mechanical ventilation, as well as to guide mechanical ventilation weaning and extubation.

TECHNIQUE

Probe: High-frequency linear or curvilinear probe Settings: Select the lung preset (or manually disable filters and tissue harmonics; lung ultrasound is based on artifacts!). Use adequate depth to visualize the pleura and peripheral parenchyma, less than 5 cm to evaluate the pleural line, and more than 15 cm to evaluate B-lines.

Position: Seated positioning is preferred. Lateral decubitus positioning may be required to access all lung fields (e.g. in patients lying supine or prone).

Technique: Orient the probe marker cephalad. Systematically scan the lungs in “lawn mower”

Fig. 1: Lung scanning in 12 zones (R1-6 and L1-6). The anterior axillary line and posterior axillary line divide the hemithorax into anterior, lateral, and posterior segments. An imaginary horizontal line further divides into upper and lower segments. Scan each zone in a systematic horizontal “lawnmower” fashion.

Repeat on the contralateral side.

Image Credit: Marini TJ, Castaneda B, Baran T, et al. Lung Ultrasound

EMpulse Summer 2020

Fig. 2: Ultrasonographic findings in COVID-19 correspond to clinical severity. A) A-lines represent well aerated normal lungs. B) Irregular pleural line and few scattered B-lines are seen in mild disease. C) Coalescent B-lines, small subpleural consolidation, and more diffuse involvement is characteristic of more severe disease. D) Consolidations with air bronchograms suggest severe disease in a critical patient. Small pleural effusions can occur.

Image Credit: Smith, et al. 4

pleural effusions are sometimes present, however large effusions are suggestive of alternative pathologies. Figure 3 demonstrates ultrasonographic images of these changes.

fashion in 12 zones (upper and lower portions of the anterior, lateral, and posterior segments of each lung) as demonstrated in Figure 1.

FINDINGS

The typical CT pattern of COVID-19 is a diffuse bilateral interstitial pneumonia, with “ground glass” infiltrates primarily affecting the bases. Investigators in China and Italy have demonstrated that these

infiltrates can be identified on ultrasound as B-lines; the density and scope of these B-lines were found to correspond with both CT findings and the clinical condition of the patients. Additional lung ultrasound findings are summarized in Figure 2 and include 1) a thickened pleural line, 2) multifocal B lines ranging from discrete to confluent, 3) small subpleural consolidations, and 4) large consolidations with air bronchograms. Small

While no imaging findings are specific for COVID-19, the constellation of these POCUS-LUS findings in the setting of a clinical picture with high pretest probability is strongly suggestive of COVID-19.

Next time you evaluate a patient presenting with dyspnea, make sure to bring your ultrasound for a quick visual assessment that may support a rapid diagnosis and disposition!

LIMITATIONS

For those without any prior CONTINUE ON PAGE 38 �

Pneumoperitoneum.To.Go. Stick in your wallet. Reference on-the-go. Courtesy of authors Leila Posaw, MD, MPH and Dennis D’Urso, MD

EMpulse Summer 2020

37

� CONTINUED FROM PAGE 37

ultrasonography experience, a short training session in knobology will be useful; otherwise, the technique of lung scanning is simple and the interpretation is fairly straightforward.

A recognized limitation of lung

ultrasonography is that it cannot detect lesions that are deep within the lung, as aerated lung blocks transmission of ultrasound waves.

Chest CT is required to detect pneumonia that does not extend to the pleural surface.

Finally, adequate safety measures are required to prevent disease

transmission. At minimum, the ultrasound probe and the machine in its entirety should be cleaned with an appropriate cleaning solution after each use. During this pandemic, additional measures such as covering the probe and machine in a protective barrier is recommended — especially during any aerosolizing procedures. ■

Figure 3. Ultrasonographic images of COVID-19 Pneumonia. A) A-lines in a well aerated normal lung. B) Pleural thickening. C) Multiple B-lines and a small subpleural consolidation. D) Consolidation with air bronchograms.

Image credit: Eric Abrams, MD and Nicholas Hoda, MD

REFERENCES

1. Nazerian P, Volpicelli G, Vanni S, et al. Accuracy of lung ultrasound for the diagnosis of consolidations when compared to chest computed tomography. Am J Emerg Med. 2015;33(5):620–625

5. Is Superior to Plain Radiography in the Diagnosis of Pneumoperitoneum.” British Journal of Surgery, vol. 89, no. 3, 2002, pp.

351–354., doi:10.1046/j.00071323.2001.02013.x.

2. Wu J, Wu X, Zeng W, et al. Chest CT findings in patients with coronavirus disease 2019 and its relationship with clinical features.

Invest Radiol. 2020

6. Grassi, Roberto, et al. “GastroDuodenal Perforations: Conventional Plain Film, US and CT Findings in 166 Consecutive Patients.” European Journal of Radiology, vol. 50, no.

1, 2004, pp. 30–36., doi:10.1016/j. ejrad.2003.11.012.

9. 1Asrani, Ashwin. “Sonographic Diagnosis of Pneumoperitoneum Using the ‘Enhancement of the Peritoneal Stripe Sign.’ A Prospective Study.”

Emergency Radiology, vol. 14, no. 1, 2007, pp. 29–39., doi:10.1007/s10140007-0583-3.

7. Hefny, Ashraf, and Fikri AbuZidan. “Sonographic diagnosis of intraperitoneal free air.” Journal of Emergencies, Trauma, and Shock, vol.

4, no. 4, 2011, p. 511.

10. Indiran, Venkatraman, et al. “Enhanced Peritoneal Stripe Sign.” Abdominal Radiology, vol. 43, no. 12, 2018, pp.

3518–3519., doi:10.1007/s00261-0181628-7.

3. Peng Q, Wang X, Zhang L. Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic. Intensive Care Med. 2020 4. Smith, et al. Point‐of‐care lung ultrasound in patients with COVID‐19 – a narrative review.

Anaesthesia. 2020

38

8. Karahan, Okkes Ibrahim, et al.

EMpulse Summer 2020

“New Method for the Detection of Intraperitoneal Free Air by Sonography: Scissors Maneuver.”

Journal of Clinical Ultrasound, vol. 32, no. 8, 2004, pp. 381–385., doi:10.1002/ jcu.20055.

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EMpulse Summer 2020

39

FEATURE

TRENDS IN EXPOSURES

to the Florida Poison Control Centers during the COVID-19 PANDEMIC Sonya Rashid, MD Jackson Health System; Florida’s Poison Control Center–Miami Wendy Blair Stephan, PhD, MPH Jackson Health System; Florida’s Poison Control Center–Miami Jeffrey Bernstein, MD Jackson Health System; Florida’s Poison Control Center–Miami Mehruba Anwar Parris, MD Jackson Health System; Florida’s Poison Control Center–Miami

700

Number of Exposures

Fig. 1: Comparison of Call Volumes for Chloramine Gas, Bleach & Vitamin C

600 500

The novel coronavirus that causes COVID-19 has caused notable trends in exposure calls to Florida’s Poison Control Centers (FPCC). Call trends were reviewed from March 1-May 6, 2020 and compared to the same timeframe for the previous year using data from the National Poison Data System. The exposure trends were examined to see if there were notable differences in call trends that may be of potential public health significance and necessitate awareness.

Substantial increases in exposures were seen in reference to calls for bleach products (47%), chloramine gas (143%) and vitamin C (217%) (Fig. 1). Chloramine gas exposures were more frequent in younger adults in the 21-30 age range, while vitamin C and bleach exposures occurred predominantly in younger patients, most under the age of 10 (Figs. 2, 4, 6). The most common clinical effect reported by callers exposed to chloramine gas was cough/choke (45%).

There were multiple clinical effects reported by callers exposed to bleach, the top five reported being:

+47%

March 1-May 6, 2019 March 1-May 6, 2020

400 300 200

+143%

+217%

100 0

40

Chloramine

VItamin C

Sodium Hypochlorite

EMpulse Summer 2020

cough/choke, ocular irritation/pain, vomiting, throat irritation and other.

A large proportion of callers exposed to vitamin C experienced diarrhea and dizziness/vertigo (Figs. 3, 5, 7).

The majority of medical outcomes associated with the three substances were not followed due to minimal clinical effects expected. The sole major effect seen with ingestion of bleach was atrial fibrillation and flutter. Vitamin C had one moderate effect, which was atrial fibrillation and flutter. It is unclear if these were isolated findings or were directly related to toxic ingestions of bleach and vitamin C. Factors causing the increase in exposures most likely stem from fear surrounding adequate disinfection and prophylactic measures to protect against the novel coronavirus. News and social media may also be lending to the increase in contact with these substances. Examples of questions asked to the FPCC were concerning, ranging from “if boiling bleach will disinfect the air” to “which disinfectants are safe to inject.” Although, thankfully, most of the exposures to the FPCC had minimal clinical effects, these exposures have the potential of becoming a serious public health issue. There are many toxic effects associated with all three of these substances, some of which have been shown to be fatal. It is important for the public to be informed about the effects related to these substances. The substantial increase in exposures to vitamin C is concerning, especially in young children. As the COVID-19 pandemic continues, clinicians may benefit from awareness of some of these substances and their toxic effects.

Fig. 2: Age distribution for chloramine gas exposure calls

45% Cough/Choke

Number of Exposures

20

16% Dyspnea

11% Throat irrigation

15

8% Ocular irritation

10

5% Respiratory 3% Burns

5 0

Fig. 3: Clinical effects reported for chloramine gas exposure

0-10

11-20

21-30

31-40

41-50

51-60

61-70

71-80

Unknown

3% Vomiting 2% Bleeding

2% Blurred vision

What is chloramine gas and what are some of its effects?

Chloramine gases are produced when household bleach and ammonia containing products are mixed together. When chloramine gas is inhaled, it releases ammonia, hydrochloric acid and oxygen free radicals upon contact with mucous membranes. This subsequently causes irritation to the epithelial lining of the upper and lower airways. Low con-

3% Nausea

centrations of the gas produce mild symptoms, while higher amounts lead to corrosive symptoms such as pneumonitis and edema. The most common symptoms reported are coughing and shortness of breath, with resolution of symptoms within one to six hours. Severe symptoms reported are skin burns, ocular injury and multi-organ dysfunction.

2% Dizziness/Vertigo Although there are multiple news reports of severe accidental exposure and suicide using chloramine gas, there is a single case report resulting in fatality due to exposure to chloramine gas, most likely from asphyxiation.1-6

Fig. 5: Clinical effects reported for bleach exposure calls

Fig. 4: Age distribution for bleach exposure calls 300

Number of Exposures

250

28%

200

Cough/Choke

25%

Ocular irritation/pain

150

14%

100

Other

16%

17%

Throat irritation

Vomiting

50 0 0-10

11-20

21-30

31-40

41-50

51-60

61-70

71-80

81-90

91-100 Unknown

Bleach exposures are common in my ED and usually show minor effects. When should I be worried?

Bleach, or sodium hypochlorite, is a caustic that is commonly found in household cleaning products.

The concentration of bleach differs depending on the product. However, most household products such as CloroxÂŽ contain 5.25% sodium hypochlorite. Therapeutic uses for diluted sodium hypochlorite solu-

tions are to irrigate skin wounds and dissolve necrotic tissue such as Dakinâ&#x20AC;&#x2122;s Solution, which is 0.4-0.5% sodium hypochlorite. Diluted bleach solutions are also used in root canal irrigation. Toxicity arises from its caustic effects as an oxidizer when in contact with mucous membranes.

EMpulse Summer 2020

Most exposures of household bleach have mild effects. Ingestions of large quantities of household bleach or any ingestion of industrial strength bleach (20% hypochlorite) can cause ulceration and perforation of the esophagus, along with hypotension, hyponatremia and hyperchloremia.

Severe cases can result in dyspnea, 41

Fig. 6: Age Distribution for Vitamin C Exposure Cells

Number of Exposures

stridor, pulmonary edema, cyanosis and pneumonitis, especially in those with preexisting asthma and COPD. Ocular exposure can result in conjunctival and corneal injury.

Parenteral exposure has been shown to cause intravascular hemolysis and multiple end organ damage. A case report of IV exposure to sodium hypochlorite was reported when a patient received 150 mL of 1% sodium hypochlorite. The patient subsequently developed bradycardia, hypotension and tachypnea. The patient improved with symptomatic treatment.7-10

40 30 20 10 0

0-10

11-20

21-30

31-40

Vitamin C can be tolerated in large quantities. What are some toxic effects I should be aware of?

Vitamin C, or ascorbic acid, is a water-soluble vitamin. Most of the water-soluble vitamins do not cause significant toxic symptoms. The maximum safe dose of vitamin C to be prescribed is 1 gram. Multiple therapeutic and prophylactic uses have been studied for vitamin C. However, there has not been concrete evidence to support disease prevention.

A few studies have shown vitamin C deficiency may be related to increased risk of influenza infections, though this has not been proven.

There are current trials studying the effect of vitamin C on the COVID-19.

REFERENCES

1. Sullivan, John B., & Gary R. Krieger, editors. Clinical Environmental Health and Toxic Exposures. 2nd ed, Lippincott Williams & Wilkins, 2001.

2. Goldfrank, Lewis R., editor. Goldfrank’s Toxicologic Emergencies. 7th ed., McGraw-Hill Medical Pub. Division, 2002., p. 1457 3. Tanen, David A., et al. “Severe Lung Injury after Exposure to Chloramine Gas from Household Cleaners.” New England Journal of Medicine, vol.

341, no. 11, Sept. 1999, pp. 848–49.

DOI.org (Crossref), doi:10.1056/ NEJM199909093411115.

4. Mrvos, Rita, et al. “Home Exposures to Chlorine/Chloramine Gas: Review of 216 Cases.” Southern Medical Journal, vol. 86, no. 6, June 1993, pp. 654–57.

5. Hypochlorites and related agents.

Micromedex Solutions. Greenwood Village, CO: Truven Health Analytics.

Available at: https://www.micromedexsolutions.com/micromedex2.

Accessed 26 May 2020.

42

However, other studies have shown adverse effects from chronic and large ingestions of vitamin C. Chronic ingestions as well as administration of an acute IV dose have been linked to renal failure. Acute hemolysis has also been known to occur in children with G6PD. Studies have shown that vitamin C intake was associated with higher risk of kidney stones in men.

Reports have shown that high doses of vitamin C ingestion can interfere with laboratory values such as creatinine, sodium, lactate, ammonia, total cholesterol and triglycerides.11-14 ■

6. Cohle, Stephen D., et al. “Unexpected Death Due to Chloramine Toxicity in a Woman with a Brain Tumor.” Forensic Science International, vol. 124, no. 2–3, Dec. 2001, pp. 137–39. DOI.org (Crossref), doi:10.1016/S0379-0738(01)00592-8.

7. Chlorine Bleach. https://chlorine.americanchemistry.com/Chlorine/BleachFAQs. Accessed 26 May 2020.

8. Levine, Jeffrey M. “Dakin’s Solution: Past, Present, and Future.” Advances in Skin & Wound Care, vol. 26, no. 9, Sept.

2013, pp. 410–414. journals.lww.com, doi:10.1097/01.ASW.0000432051.59348. cd.

9. Racioppi, F., et al. “Household Bleaches Based on Sodium Hypochlorite: Review of Acute Toxicology and Poison Control Center Experience.” Food and Chemical Toxicology, vol. 32, no. 9, Jan. 1994, pp. 845–61. DOI.org (Crossref), doi:10.1016/0278-6915(94)90162-7.

10. Marroni, Massimo, and Francesco Menichetti. “Accidental Intravenous Infusion of Sodium Hypochlorite.” DICP, vol. 25, no. 9, Sept. 1991,

EMpulse Summer 2020

41-50

61-70

71-80

81-90 Unknown

Fig. 7: Clinical effects reported for Vitamin C exposures 44% Diarrhea

25% Dizziness/Vertigo 6% Couch/Choke

6% Atrial Fibrillation

6% Erythema/Flushed 6% Abdominal Pain 6% Nausea

pp. 1008–09. DOI.org (Crossref), doi:10.1177/106002809102500919.

11. Vitamin C Infusion for the Treatment of Severe 2019-NCoV Infected Pneumonia - Full Text View - ClinicalTrials.Gov. https://clinicaltrials.gov/ct2/show/ NCT04264533. Accessed 26 May 2020.

12. Vitamins – multiple. Micromedex Solutions. Greenwood Village, CO: Truven Health Analytics. Available at: https:// www.micromedexsolutions.com/micromedex2/librarian. Accessed 26 May 2020.

13. Pm, Ferraro, et al. “Total, Dietary, and Supplemental Vitamin C Intake and Risk of Incident Kidney Stones.” American Journal of Kidney Diseases : The Official Journal of the National Kidney Foundation, Mar. 2016, doi:10.1053/j. ajkd.2015.09.005.

14. Meng, Qing H., et al. “Interference of Ascorbic Acid with Chemical Analytes.” Annals of Clinical Biochemistry, vol. 42, no. 6, Nov. 2005, pp. 475–77. DOI.org (Crossref), doi:10.1258/000456305774538274.

Improving Patient Safety & Communication During EMS to ED Handoffs Course PROVIDES 1 HOUR OF FREE CONTINUING EDUCATION For hospitals, the “hand-off” has long been called “the Bermuda Triangle” of health care. Dangerous errors and oversights can occur in the gap when a patient is moved from one setting or team to another. Handoffs and transitions of care in general continue to rank as a top national patient safety area of focus. Effective communication during handoffs between Emergency Medical Services (EMS) and emergency departments (ED) is especially important and presents a unique set of challenges and opportunities.

The course covers:

EMS personnel are often the only providers with knowledge about what happened at the scene of an injury, at the transferring ED, or in the patient’s home.

Key EMS information can become changed or lost after multiple “tellings” of the patient story to dispatch and ED personnel.

The course website provides resources, course slides and references related to EMS to ED handoffs for both ground to ED and interfacility transport of adults and children.

Improving Patient Safety & Communication During EMS to ED Handoffs is a 1-credit hour course developed by the University of Florida College of Medicine – Jacksonville Department of Emergency Medicine and is presented by the Florida Self Insurance Program. The course is intended for emergency medicine and trauma physicians, nurses, paramedics, EMTs, advanced practice providers, risk managers, residents and students.

Funding is provided by a University of Florida Self Insurance Program W. Martin Smith Interdisciplinary Patient Safety Award.

• The importance of effective communication during the patient handoff

• The risks and consequences of ineffective handoffs • Barriers to successful and safe handoffs • Real-life before and after adult, pediatric, medical and trauma case scenarios

• Standardized handoff tools and strategies

Credits: Approved for one CE/CME/CEU/ contact hour credit. Certificates are generated electronically after taking a short quiz.

Cost: FREE Visit the ufsip.learnupon.com to learn more and register for the course or download materials. Course works best when using Google Chrome or Firefox browser.

For questions, email emresearch@jax.ufl.edu or call 904-244-4986.

EMpulse Summer 2020

43

FEATURE

KRATOM PART II:

Updates for the ED Provider on a Substance Skyrocketing in Use

By Nicholas Titelbaum, MD, PGY-2

By Vir Singh, MD, MBS, PGY-3

UCF/HCA Emergency Medicine Residency at Ocala

UCF/HCA Emergency Medicine Residency at Ocala

A patient presents to your ED with a chief complaint of non-stop vomiting over the last day. She says she was sore from working in the yard all day and tried a pain reliever her relative swears by. Is this liver failure from acetaminophen overdose? Cyclic vomiting syndrome from marijuana? The substance is revealed to be… kratom.

Kratom is an emerging substance that patients are turning to for relief from opioid addiction. It is 44

becoming apparent that emergency physicians need to learn more about this substance before it shows up in your ED, so we are continuing the kratom discussion from the last issue of EMpulse.

Kratom refers to derivatives of Mitragyna speciosa, a tree native to southeast Asia. Leaves of this tree can be chewed or prepared in several ways for ingestion: ground into an extract, dried and crushed into powder, or drank as tea.1 Its use traces back to EMpulse Summer 2020

the 1800s by indigenous peoples in Malaysia and Thailand as an opium substitute.2 Since the 1960s, biochemical studies have isolated more than 25 alkaloid compounds from Mitragyna leaves, the major component (66%) being mitragynine, with paynantheine (9%) and speciogynine (7%) also being significant components.2 Mitragynine has μ-, κ-, and δ-opioid receptor agonism.3 Therefore, kratom is considered to be within the class of opioid substances. Uniquely, kratom

has been documented to have cocaine-like stimulant effects at lower doses and opioid-like sedative effects at higher doses.4 An overdose toxidrome has been described with sweating, dizziness, nausea and vomiting. Kratominduced liver injury has been described in various cases. The substance is habit and tolerance forming, leading users to require increasing dosages as they develop addiction. Chronic overuse may lead to tremors, anorexia, urinary frequency, seizures, psychosis, and a withdrawal syndrome of aggression and insomnia.

In the setting of the 21st century opioid epidemic in the Western World, kratom has seen its use skyrocket. The substance has a cultlike following of users on internet forums and throughout the country who use kratom for pain relief, or have claimed to successfully quit an opioid addiction by substitution with kratom. Kratom can be purchased on the internet, with many suppliers easily found on an internet search for “buy kratom.” Kratom is served in tea shops and found in tobacco and supplement stores. In 2016, the DEA served notice of intent to place mitragynine on the Schedule I controlled substance list.5 Kratom vendors and advocates lobbied vigorously against the illegalization of kratom, and even filed suit,6 resulting in the DEA withdrawing its notice and categorizing the supplement as a “drug of concern.”

Patrick Leffers of the Florida Poison Information Center first discussed the emergence of kratom in EMpulse Magazine: Winter 2016.7 Since that time, kratom has continued to rapidly gain popularity among community groups searching for opioid alternatives and on the internet. In fact, an analysis of poison control center calls between 20112017 determined 65% of the 1,807 kratom-related phone calls occurred between 2016 and 2017.8 Kratom is now discussed in the opioid chapter of the 9th edition of Tintinalli’s

Emergency Medicine.4 The Department of Health and Human Services in 2017 requested the DEA reconsider its withdrawal of notice to place mitragynine and 7-hydroxymitragynine in the Schedule I DEA list. It is illegal in Alabama, Arkansas, Indiana, Tennessee, Vermont, Wisconsin and Washington D.C. – in addition to numerous municipalities with local laws regarding the substance.

In 2019, the FDA issued a warning statement regarding use of kratom due to safety concerns and informed the public of several major seizures of kratom materials from importers during a ban on imports. Drs. Fluyau and Revadigar of the psychiatry departments of Emory University and Columbia University, respectively, published a risk evaluation of kratom as a potential analgesic, stating its potential benefits are outweighed by its “severe and real health hazards” with “clinical, psychological and medical manifestations.”9 The first comprehensive review article attempting to analyze the evidence behind kratom-related liver injury was published this year. It concluded that there is still a paucity of data on the subject, but the evidence does support liver injury in a mixed cholestatic and hepatocellular picture.10 What is clear: kratom’s use has skyrocketed since 2016, and EM providers should familiarize themselves with the presentations of acute and chronic toxicity, as well as withdrawal syndromes. Patients may be counseled on what is known and unknown about this substance, as well as its tenuous legal status in many areas. Your area poison control center is available to guide management of any kratom-related clinical scenario at 1-800-222-1222. ■

Image: A stock image of a logo, ready for kratom businesses to use.

REFERENCES

1. Hassan Z, Muzaimi M, Navaratnam V, et al. From Kratom to mitragynine and its derivatives: physiological and behavioural effects related to use, abuse, and addiction. Neurosci Biobehav Rev. 2013;37(2):138‐151. doi:10.1016/j. neubiorev.2012.11.012 2. Jansen KL, Prast CJ. Ethnopharmacology of kratom and the Mitragyna alkaloids. J Ethnopharmacol. 1988;23(1):115‐119. doi:10.1016/0378-8741(88)90121-3 3. Warner ML, Kaufman NC, Grundmann O. The pharmacology and toxicology of kratom: from traditional herb to drug of abuse.

Int J Legal Med. 2016;130(1):127‐138. doi:10.1007/s00414-015-1279-y 4. Love JS, Perrone J. Opioids.

In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds.

Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e New York, NY: McGraw-Hill; http://accessmedicine.mhmedical. com/content.aspx?bookid=2353& sectionid=220744738. Accessed May 15, 2020.

5. Withdrawal of Notice of Intent to Temporarily Place Mitragynine and 7-Hydroxymitragynine Into Schedule I, 81 Fed. Reg. 7065270654 (October 13, 2016).

6. Silverman L. Kratom gets reprieve from DEA's Schedule I list. CNN. www.cnn.com/2016/10/17/ health/kratom-dea-schedule-icomments. Published October 17, 2016. Accessed May 16, 2020.

7. Leffers, P. Kratom: The All-Natural Opioid “Alternative”? EMPulse Magazine. 2017;23(4):15.

8. Sara Post, Henry A. Spiller, Thitphalak Chounthirath & Gary A. Smith. Kratom exposures reported to United States poison control centers: 2011–2017. Clinical Toxicology, 2019;57:10, 847-854, DOI: 10.1080/15563650.2019.1569236 9. Fluyau D, Revadigar N. Biochemical Benefits, Diagnosis, and Clinical Risks Evaluation of Kratom. Front Psychiatry. 2017;8:62. Published 2017 Apr 24. doi:10.3389/ fpsyt.2017.00062 10. Schimmel, J., Dart, R.C. Kratom (Mitragyna Speciosa) Liver Injury: A Comprehensive Review. Drugs 80, 263–283 (2020). https://doi. org/10.1007/s40265-019-01242-6

© Patria Ari / Adobe Stock EMpulse Summer 2020

45

FEATURE

Florida Emergency Nurses Travel Overseas to Learn about Emergency Care

By Terri Repasky,

APRN, MSN, CNS, CEN, EMT-P Before COVID-19 changed our world, five emergency nurses — three from Northwest Florida and two from Northcentral Florida — joined other emergency department RNs from around the country on a cultural exchange trip to the Netherlands and Stockholm, Sweden to learn about emergency care in those countries.

They visited three different hospitals and learned about pre-hospital emergency medical systems.

The trip was organized by the national Emergency Nurses’ Association (ENA). The nurses spent 10 days observing, learning, sharing and comparing their practices in the USA with nurses and medical staff in the two countries. ENA international member and current board member, Joop Breuer RN, CEN, CCRN, FAEN, is a staff nurse and educator at Leiden University Medical Centre in Leiden, Netherlands, and served as host.

Leiden University Medical Centre was founded in 1575 and the medical school in 1636. It is said that Albert Einstein studied there.

The emergency nurses were able to compare the health care systems with that of the U.S. One notable difference in EMS is the make-up and education level of the EMS teams. Ambulances are staffed by a critical care nurse and are driven by 46

By Christie Jandora, BSN, RN

a driver with basic training. Helicopters are staffed by physicians. They may respond to a scene and provide care, but not transport the patient.

Ambulances are well dispersed throughout the country and can respond to any location within about 20 minutes. EMS nurses treat the patients on scene and make a decision of whether or not to transport to a hospital. Nurses work with protocols and can contact the hospital ED for assistance if needed. Unlike the U.S, there is only one ambulance company for the entire country, so there is consistency in training, protocols and processes. First responders may respond to a motorcycle (see photo to right) as opposed to an ambulance.

U.S nurses were impressed with the large, enclosed ambulance bay at the hospital. They noted that many hospital EMS receiving areas in the U.S. are drive-through, open areas, while this one was more “garage like” and extremely clean (see photo above).

Emergency departments may be “open or closed,” and patients are transported or assigned to either depending on their condition. Even if it means bypassing multiple hospitals, a patient with a fracture is transported to the hospital specializing in orthopedics. Academic/Teaching hospitals often receive the more complex patients. Low-acuity patients or EMpulse Summer 2020

By Lauren Sanguinetti, BSN, RN, CEN

those needing minor surgery may be transferred out of the academic centers to other hospitals. There is no such thing as EMTALA. Triage nurses may refer to a nearby urgent care or to a primary provider if the patient’s condition does not warrant an emergency department visit. The most used ED triage system is the Manchester Triage System (MTS). The MTS is a 5-level, color-coded system similar to ESI used in the U.S. Another difference noted was the lack of routine security with medications. U.S. medical personnel are used to medications being behind locked doors or in locked distribution systems like a pyxis. They noted, in at least one hospital, that medications were not locked. Staff in that particular hospital reported that they did not have an opiate crisis there.

Staff also reported a very low rate of mental illness, especially patients requiring admission, but they are well prepared for it. Under the socialized medical model, access to care is readily available to the homeless population, and the homeless appear to be well managed and cared for. It was noted that this most likely contributes to the low volume of mentally ill in the EDs. Physician/nurse working relation-

ships are collaborative, professional and respectful. One physician pointed out that ED nurses are highly respected for their expertise and that teams work very well together, especially in crisis situations.

In the two countries visited, the medical equipment and continuing education classes available to emergency nurses were similar to what is in the U.S. In order to work in the ED or ICU, nurses must have training

beyond that of their initial education.

Both countries offer ENA’s Trauma Nursing Core Course (TNCC) and Emergency Nursing Pediatric Course (ENPC). In the Netherlands, EDs require at least one nurse per shift to have TNCC and ENPC. Many bedside nurses have masters and doctoral degrees.

Like the U.S, both countries are experincing a nursing shortage.

Nursing education is covered by the health system and education is staged. Nurses can continue to expand their skills and education after their initial training, and salaries are increased based on this.

Our Florida RNs were able to compare the U.S. system to the socialized systems of the countries visited and noted advantages and disadvantages. Every citizen has basic coverage which is advantageous, but there is an option for those who can afford it to purchase additional health care coverage. Those with additional

coverage may get priority treatment for non-emergency events or a newly diagnosed illness.

In addition to learning about the healthcare system, they were able to visit interesting sites in the countries and participate in scheduled events and excursions if they desired. They visited the Drottningholm Palace, home of the Swedish royal family and childhood home of Princess Madeleine, who currently resides in Miami.

The windmills, the aged rum, and the food were amazing. The Heineken brewery, original ICE bar, the town of Gouda with its delicious cheeses, the town of Delft (blue china), and the Van Gough Museum were among many memorable experiences.

Each year the ENA organizes similar trips, which have proven to be educational and entertaining while promoting international collegiality and growth among emergency professionals. Hopefully this activity will resume in the not too distant future. ■

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47

CASE REPORT

Extensive Pneumomediastinum in a 20-Year-Old

By Nancy W. Weber, DO, FACOEP, FACEP, MBA

Vice Chair for Quality and Patient Experience, Texas Tech University Health Sciences Center at El Paso

A 20-year-old female presented “emergently” from an Urgent Care complaining of nausea, vomiting, diarrhea and facial swelling with crepitus. She presented to a Midwestern Community Hospital with an EM residency associated with a large academic university, and with several tertiary referral centers in a 60-90 mile radius.

her esophagus, and to her throat.

She has a sensation of fullness, and it hurts to take a deep breath and to swallow, but not to talk or breathe.

She denies fever, chills, dizziness, dehydration or other systemic signs or symptoms beyond what was noted above. Her mom notes that her voice sounded like it did before she needed a tonsillectomy and adenoidectomy.

She had intractable nausea, vomiting and diarrhea since waking, and several hours later she felt and heard a “pop.” Shortly thereafter, her boyfriend noticed some right sided facial swelling. It is now on her bilateral face, and has spread to her neck and proximal/mid chest over the past few hours.

PHYSICAL EXAM

She complains of a burning raw feeling of pain from her stomach to

General: She appears moderately anxious and in mild distress, otherwise healthy, non-toxic, and well appearing.

Skin: Warm, dry, normal color, no rash, with palpable crepitus in the neck and anterior chest; can visualize fullness/swelling in the face but no skin irregularities on the face or torso.

Eyes: Pupils equally round, extraocular movements intact, clear conjunctiva, normal sclera.

HEENT: Normocephalic atraumatic, moist mucous membranes, bilateral moderate cheek fullness.

Neck: Mildly tender to palpation, supple without nuchal rigidity, mild fullness, full range of motion.

Pulmonary: Clear to auscultation without wheezes, rhonchi or rales, no accessory muscle use, no stridor, normal excursion.

Cardiovascular: Regular rate and rhythm with normal heart sounds and without murmurs.

Gastrointestinal: Soft, non-tender, non-distended, normal bowel sounds, no crepitus.

Lymphatics: No edema in lower extremities.

Musculoskeletal: Extremities are non-tender and have no gross deformity, redness or swelling.

Neurologic: Alert and oriented x 3, GCS 15, normal mentation and speech, stable gait (as seen ambulating to the bathroom).

Psychiatric: Normal except as noted previously, clear and linear thought process.

Differential diagnosis: Pneumomediastinum consistent with Mallory Weiss tear; rule out Boerhaeve’s, will empirically treat with antibiotics, get Xrays (XR), CT’s, IV fluid rehydration, control nausea, consult as needed.

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IMAGING RESULTS

Chest XR: Extensive SQ air bilaterally into neck and into the abdomen, as well as pneumomediastinum. No definite pneumothorax, heart normal.

Soft Tissue neck XR: Extensive subcutaneous (SQ) air extending into the chest/mediastinum and up into the scalp.

CT chest/abdomen/pelvis with contrast: Extensive SQ air bilaterally that anteriorly extends to overlie the pelvis just superior to the pubic symphysis. Abnormal air extends down the thorax within the mediastinum and probably into the pericardial space. It also extends down the abdomen within the retroperitoneum and along the fascial planes. Questionable very small amount of free intraperitoneal air. Abnormal air also extends within the thoracic spinal canal from T1 to T11. Etiology for the extensive abnormal air collections are not clear from the CT. No obvious hole in the trachea or esophagus was seen.

Emergency Department (ED) course: Radiologist called the ED regarding the above results, and recommended further discussion with both cardiothoracic surgery and neurosurgery given the concerns about air in the pericardium and air in the spinal canal. “This is the most extensive pneumomediastinum I’ve seen in nearly 40 years of radiology.”

Cardiothoracic surgery recommended gastrograffin study to look for communication between the esophagus to the mediastinum, and agreed with transfer to a tertiary care center, as “95% of what I do is cardiac bypass surgery, and no other major chest surgery.” He also had not seen this extensive of a pneumomediastinum before.

Neurosurgery reviewed the films, disagreed about air in the spinal canal, asked about connective tissue

Images provided by Dr. Nancy Weber.

disease history, recommended a head CT to rule out air in the brain, and also recommended transfer to the tertiary care center.

DISCUSSION

Pneumomediastinum is an uncommon entity.

Pneumomediastinum can occur after surgery, infection, forceful coughing, vomiting, sneezing or VALI (Vaping Associated Lung Injury) due to the increased intrathoracic pressure causing air to enter the mediastinum from the lungs or airways. It can also be caused by barotrauma (scuba diving), as a result of childbirth, or cocaine and other drug abuse.1-4 Pneumomediastinum can be asymptomatic or can cause mild to moderate chest pain, voice change, cough, or stridor, as seen in this patient. Pneumomediastinum alone does not require further testing or intervention, unless the patient is symptomatic. In that case, a search for other injuries (larynx, trachea, pharynx, esophagus) is warranted.

Traditionally pneumomediastinum is limited to the mediastinum, and is treated with observation and reassurance, as the body will

EMpulse Summer 2020

gradually reabsorb the air. What made this case unique was the extent of the subcutaneous air; circumferentially including both anterior and posterior planes from the pubic symphysis to the scalp; more extensively than any of the four specialists (emergency medicine, radiology, neurosurgery, and cardiothoracic surgery) had ever encountered prior.

Disposition: The patient was discharged home from the tertiary care institution the following afternoon after a period of observation; no intervention was needed. ■

REFERENCES:

1. https://medlineplus.gov/

ency/article/000084.htm

2. Tintinalli’s Emergency

Medicine a Comprehensive Study Guide 9e, chapter 261, Pulmonary Trauma

3. N Engl J Med 2018; 378:el 4. J. Layden, M.D. et al,

“Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin-Final Report,” N Engl J Med 2020; 382:903-916

49

MUSINGS FROM A RETIRED PHYSICIAN

Leadership in Crisis

By Wayne Barry, MD, FACEP FCEP Member

My wife and I (a retired ER nurse and ER physician, respectively), were to chair a Task Force at our church to guide a safe “reopening” of the use of the sanctuary. As luck would have it, our church owns a beautiful and rustic 18-acre parcel of land within a mile of the current church campus on which we are too poor to have built anything more than a nice multi-purpose pavilion. We have successfully parlayed this circumstance into providing a “drive-in church” for our 150-member congregation. Some are longing to get back to more traditional interaction during services in the sanctuary, but we have an aging congregation, which coincidentally includes the longest living heart transplant patient and the longest living liver transplant patient in Florida. I hope that we and our church-mates are blessed with enough wisdom to make correct and safe decisions.

The U.S. has surpassed the ominous milestone of over 100,000 Americans who have died of Covid-19. I have missed consoling words by the “Consoler in Chief.” President Reagan consoled us after the Challenger Space Shuttle blew up on January 28, 1986. President Bill Clinton consoled us after the Oklahoma City bombing on April 19, 1995. President George Bush both consoled us and stirred us to fight terrorism on September 11, 2001. President Barack Obama wept as he consoled us after the small children were gunned down in their elementary school in Connecticut on December 14, 2012.

We all need some soothing words and reassurance from our current chief executive right now.

Leadership involves three important actions. First, leaders must tell the truth. Second, they must take some 50

responsibility for what is happening to our country. And finally, they must keep all of us accurately informed....

denly stopped breathing. She was wearing a surgical mask; not the safer N-95 mask. Just 14 days later, she died of Covid-19!

I am astonished that in the U.S., in 2020, in the face of an admittedly cataclysmic socioeconomic catastrophe caused by coronavirus, we somehow cannot prevent dairy farmers from pouring fresh harvested milk down the drain and hog farmers from euthanizing their herds because they cannot get their production sold, all while cars in many urban areas are lined up for miles around food pantries with recently unemployed citizens who cannot buy food. Many of these people are victims of the poorly operating unemployment compensation systems in states like Florida.

I also do not understand why in 2020 the U.S. is so befuddled as to who has Covid-19 and who doesn’t.

While Congress throws trillions of dollars into the mix to try and help the economy stay solvent, I would have liked to have seen many more resources directed towards testing and tracing viral spread. I believe that there has been very poor information exchange to Americans about testing options. Many front line healthcare workers have complained that they have not been able to get Covid-19 tests for themselves, which adds to the stress on them for their personal health and the potential of spreading disease to their families. In an ideal world, all humans should be tested on a regular basis while we do not yet have a vaccine available for protection. In other countries such as South Korea and Germany, their populations have fared far better than we have in the U.S. with respect to Covid-19 disease.

Hindsight may be 20/20, but dismantling the Pandemic Task force 2 years ago was not a good move. Recently, Christi Grimm was fired from her position as Inspector General at the Department of Health and Human Services when she surveyed over 300 hospitals in 50 states and found that “their most significant challenges centered on testing and caring for patients with Covid-19 and keeping staff safe.” At the time of writing this article, about 300 healthcare workers have died from Covid-19. Nearly 60,000 healthcare workers have become infected. Some believe Covid-19 deaths among healthcare workers is under reported and that there may be as many as 600 total deaths. Many healthcare workers in EDs and ICUs are still complaining that they do not have sufficient PPE. It is only fair to add that we healthcare workers have to be conscientious with our use of what’s available. There is also the case of a nurse who rushed to the bedside of a patient who sudEMpulse Summer 2020

Our healthcare workers are our true heroes today. I thought it very fitting that they were honored during the recent Memorial Day holiday.

A special tribute goes out to those who gave the last full measure of their lives like the war heroes they in fact are. I only wish that our leaders in Washington and in our State Houses will remember the three elements of leadership, namely honesty, accountability and transparency. In doing so, their leadership will honor the work of these modern day, non-military and self-sacrificing workers who fight to save lives on the new front lines in our ED’s and hospitals. Godspeed! ■

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