EMpulse Summer 2021 by Florida College of Emergency Physicians

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

Celebrating

50 Years of Florida ACEP

FOUNDING DATE:

OCTOBER 15, 1971

WHAT’S INSIDE: • False Positive HIV due to p24 Antigen and CD4 Lymphocytopenia • Ultrasound Zoom: On Cardiac Tamponade • Government Affairs: End of 2021 Legislative Report • Next Steps for the EM Resident Class of 2021

Plus: Symposium by the Sea 2021 Preview

EMpulse Summer 2021

Vol. 28, No. 2 | Summer 2021

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EMpulse Summer 2021

TABLE OF CONTENTS FROM THE COLLEGE

6 FCEP President’s Message By Dr. Kristin McCabe-Kline

17 Pediatric EM Committee By Dr. Todd Wylie

7 Membership & Professional Development Committee By Dr. Shayne Gue

19 EMRAF President’s Message By Dr. Elizabeth Calhoun

10 Government Affairs: End of 2021 Legislative Session Report By Dr. Blake Buchanan & Toni Large

Medical Student Council By Dan Schaefer

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

16 EMS/Trauma: Drowning Update By Drs. Desmond Fitzpatrick & Ben Abo

EDITOR-IN- Karen Estrine, DO, FACEP, FAAEM CHIEF karenestrine@hotmail.com

FEATURES & COLUMNS 18 Re-Launch of FCEP’s Leadership Academy By Dr. Stephen Viel 20 Next Steps for the EM Resident Class of 2021 By Residency Program Staff & Samantha League 30 Emergency Department Case: Covid-19 Related Guillain-Barre Syndrome By Dr. Katherine Wietcha 32 Ultrasound Zoom: The VExUS Score: Fluid Status, Reconsidered By Dr. Anna Culhane; edited by Dr. Leila Posaw 36 Case Report: False Positive HIV due to p24 Antigen and CD4 Lymphocytopenia By Dr. Jason Wilson, Heather Henderson & Kaitlyn

37 Daunting Diagnosis By Dr. Karen Estrine 38 Poison Control: The F(ab2)ulous Expanded Indication of Anavip By Anthony DeGelorm, Pharm.D & Chiemela Ubani, Pharm.D 40 Education Corner: New Beginnings: Building a Foundation between Educators and Learners By Drs. Carmen J. Martinez Martinez and Caroline M. Molins 42 Musings from a Retired Emergency Physician: The Dangers of Medical Misinformation By Dr. Wayne Barry

35 Envision Physician Services

Pontiac, IL 61764 jpapontiac.com

EMpulse Fall 2021 EMpulse Fall 2021 will be print + digital. Members will receive a copy in their mailboxes and a Table of Contents email of online articles.

Deadlines:

• Aug 19: “Intent to Submit” form due » • Aug 23: Ad Insertion Orders due • Aug 30: Articles and ads due • October: Fall 2021 in mailboxes

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39 EMPros 43 VITAS® Healthcare

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PUBLISHER 800 N. Court St.

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

Advertise in EMpulse Fall 2021

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MANAGING Samantha League, MA & DESIGN sleague@emlrc.org EDITOR

EMpulse Online:

ADVERTISER INDEX 2 DuvaSawko | abeo + Gottlieb

SUMMER 2021

Volume 28, Issue 2

ORDER NOW EMpulse Summer 2021

EMpulse Online Homepage fcep.org/empulse

All advertisements in EMpulse are printed as received from advertisers. The Florida College of Emergency Physicians does not endorse any products or services unless otherwise stated. FCEP receives and distributes employment opportunities but does not review, recommend or endorse any individuals, groups or hospitals that respond to these advertisements. Opinions stated within articles are solely those of the writers and do not necessarily reflect those of the EMpulse staff, the Florida College of Emergency Physicians and our advertisers/sponsors. 33

50 YEARS, 50 VOICES

a digital campaign honoring FCEP & emergency medicine Debuting at our 50th Anniversary Celebration: August 6, 2021 6:30 pm - 8:30 pm Naples Grande Beach Resort in Naples, FL a separate, ticketed event during Symposium by the Sea 2021

Then online at fcep.org/50years New videos will be announced on social media and through FCEP’s enews 44

EMpulse Summer 2021

TABLE OF CONTENTS CONTINUED

RESIDENCY PROGRAM UPDATES 23 AdventHealth East Orlando Dr. Tyler Mills Kendall Regional Medical Center By Dr. Kelly Wright

27 Florida Atlantic University Dr. Tony Bruno Jackson Memorial Hospital EM Residency Program Staff FSU at Sarasota Memorial Dr. Thomas Cox

24 Orlando Health Drs. Gregory Black & Brody Hingst Orange Park Medical Center Dr. Penny Côté North Florida Regional Dr. Jayden Miller

28 UCF at Greater Orlando Dr. Amber Mirajkar UCF/HCA Ocala Regional Drs. Jean Laubinger & Emily Clark 29 Oak Hill Hospital Dr. Mohammad Razzaq UF Health Jacksonville Dr. Chris Phillips North Florida Regional Dr. Jayden Miller

25 UF Health Gainesville Dr. Megan Rivera St. Lucie Medical Center Dr. Shelby Guile

Jackson Memorial Hospital EM Program Staff

26 Aventura Hospital Dr. Scarlet Benson Brandon Regional Hospital Dr. Rashmi Jadhav USF at Tampa General Hospital Dr. Kenneth Dumas

All articles originally published online at fcep.org in July 2021. Visit fcep.org/summer-2021 to read the digital versions and share with others.

» ON THE COVER: First FCEP President, Dr. William (Bill) T. Haeck (left), receives the Florida ACEP Charter on October 15, 1971.

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

FAAEM, ACHE

PRESIDENT- Sanjay Pattani, MD, MHSA, FACEP ELECT VICE Damian Caraballo, MD, FACEP PRESIDENT SECRETARY- Aaron Wohl, MD, FACEP TREASURER IMMEDIATE J. Adrian Tyndall, MD, MPH, FACEP PASTPRESIDENT EXECUTIVE Jonathan Dolan, MA DIRECTOR MEMBERS Rajiv Bahl, MD, MBA, MS; Daniel Brennan, MD, FACEP; Elizabeth

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

Florida Emergency Medicine Foundation Board of Directors:

Learn more about FCEP’s rich history in the next edition of EMpulse Magazine and online at fcep.org/50years

PRESIDENT Ernest Page, MD, FACEP VICE Roxanne Sams, MS, ARNP-BC, MA PRESIDENT SECRETARY- Maureen France TREASURER

ENJOY OUR FIRST INTERACTIVE MAGAZINE Access webpages, PDFs and other resources directly from this document: • Items with this symbol

are hyperlinked

• Underlined text is hyperlinked • Each advertisement is hyperlinked

EMpulse Summer 2021

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

The Florida College of Emergency Physicians (FCEP) and Florida Emergency Medicine Foundation (FEMF) are nonprofit organizations dedicated to advancing emergency care through education and advocacy. Both are headquartered at the Emergency Medicine Learning & Resource Center (EMLRC) at 3717 S. Conway Rd., Orlando, FL 32812. 5

FROM THE COLLEGE

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

As we celebrate FCEP’s 50th anniversary this year, let us take a moment to reflect and appreciate those who came before us, those who stand alongside us now, and those who will come after us. Our specialty was essentially born when dedicated physicians saw an opportunity to better serve patients. They fought from the back doors and the basements to improve the care provided in these hospital afterthought care areas. Defining the unique skill set of emergency medicine specialists, creating a board certification process, and many years of struggling to be acknowledged by physicians of other specialties, payers and health systems was required to pave the way for our specialty. Our specialty has flourished as emergency physicians have continued to discover areas of need and opportunities to better serve our patients, resulting in the development of multiple subspecialties and areas of expertise. Health systems have recognized the importance of our specialty in their markets, and emergency departments have become the front door of hospitals, with billboards on the interstate to advertise our services. This revolution

and emergence of our specialty as a well respected and essential voice in the house of medicine was not won without substantial individual and collective commitment and dedication. There are ongoing issues emergency physicians face, including systembased barriers to wellness, appropriate reimbursement by payers, and increasingly onerous regulatory requirements. Most recently, we have faced a pandemic head on, which has taken a tremendous toll on everyone and separated us from one another. Fluctuations in emergency department volumes due to the pandemic intersecting with the growth of emergency medicine residency programs across Florida accelerated issues that were arising in the workforce. The emergency physicians who will come after us deserve our dedication to this work. FCEP gives us the ability to come together across lines of employment to collaborate and seek solutions. Emergency medicine is a specialty that was born out of a need for change in order to improve care for our patients, and the evolution of emergency medicine has been fueled

EMpulse Summer 2021

by a need for change ever since. We will most successfully navigate times of significant change that make us uncomfortable if we do it with confidence in our value, transparency and respect for perspectives that may differ from our own. Over the last 50 years, FCEP has been a powerful way for emergency physicians in Florida to offer a cohesive and collective voice when addressing health systems, legislators, patients and other specialties/organizations. Many FCEP leaders and staff have helped improve the quality of care for all those who seek care in our emergency departments, and sought to protect the integrity of our specialty. Please keep an eye out for the upcoming “50 Years, 50 Voices” digital celebration of some of their stories. It is with incredible gratitude and respect that I close out my tenure as FCEP President. I am honored to have had the opportunity to serve you, our specialty and, most importantly, our patients. ■

READ ONLINE

COMMITTEE REPORT

Membership & PD Committee By Shayne Gue, MD, FAAEM Committee Co-Chair

Greetings and happy summer! I recently had the opportunity to travel to my hometown of Huntington, WV to spend time with my family after a long time apart. Hopefully, you have found some time to relax, recharge, and maybe even getaway for a bit after a long-fought pandemic battle. While the threat of COVID-19 has not been completely erased, it’s nice to see the return of some semblance of “normal.” And with that, we are very much looking forward to welcoming you back to our first in-person conference since the start of the pandemic. Symposium by the Sea 2021 will take place LIVE and in-person on August 5-8 at the Naples Grande Beach Resort in Naples, FL. The planning committee has been hard at work to ensure that you will receive the highest quality presentations as well as the full slate of social events you have come to know and love. This year is particularly special in that we are celebrating our 50th anniversary, and revealing our “50 Years 50 Voices” project to commemorate the 50 years of excellence in FCEP members’ service to emergency medicine and the state of Florida. Be sure to check out the SBS schedule for a full listing of presentations and events — won’t you join us?

SBS 2021 will also mark the re-launch of our new and improved Leadership Academy with Dr. Stephen Viel at the helm. FCEP’s Leadership Academy is a one-year program that fully immerses participants into the world of organized medicine. You will have the opportunity to get actively involved in FCEP committees, take part in a variety of local and national conferences and advocacy events, and network with leaders and mentors from across the state. FCEP is seeking individuals with a commitment to our specialty, an interest in getting more involved, and a desire to become the future leaders of our organization and of emergency medicine at large. Check out the brochure for more information and the application form. Applications are due at the end of August, and Dr. Viel will be at SBS 2021 to meet interested participants and provide more information. In addition, Dr. Dakota Lane continues to develop and lead our new Early Career Physicians section to promote mentorship, fellowship, and resources to our senior residents and new attendings as we navigate the world beyond training. Follow along for more information and planned events coming up this fall!

As always, we have to take a moment for reflection and wellness. For me, wellness is an investment I choose to make in myself every day. I do this by finding the time for family and friends, by focusing on maintaining a positive mental state, by owning my thoughts and emotions (even when they are not the best), and by taking advantage of opportunities to improve my skills and share fellowship with my colleagues around the state and beyond. I look forward to seeing you in Naples, where we can continue to look out for each other and promote mental, physical, and emotional wellness after a very draining year. We are excited for the opportunity to be back together again and hope you will consider joining, for all or part of our upcoming events. Don’t hesitate to reach out at any time if there’s anything we can do to assist you. We have some difficult battles ahead, but we at FCEP are committed to serving YOU, our members, and leading the fight as we continue to advance the specialty of emergency medicine. ■

OCT 24-27, 2021 EMpulse Summer 2021

August 5-7, 2021 | Naples Grande Beach Resort | Naples, FL REGISTER NOW

AGENDA AT A GLANCE Day 1 | AUG. 5

Day 2 | AUG. 6

Day 3 | AUG. 7

8:00 AM – 8:55 AM:

8:30 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 12:00 PM – 1:00 PM:

Lunch

1:00 PM – 2:00 PM:

EMS/Trauma Committee Meeting 1:00 PM – 3:00 PM:

Council of EM Residency Program Directors & Core Faculty Meeting 2:00 PM – 3:00 PM:

FCEP Pediatric EM Committee Meeting 3:00 PM – 5:30 PM:

FCEP Board of Directors Meeting 6:00 PM – 7:30 PM:

FCEP President’s & Corporate Partners’ Reception 8

Breakfast 9:00 am – 5:30 pm:

Exhibit Hall Open

9:00 am – 11:45 am:

Sponsored Education 10:00 am – 11:30 am:

FEMF Board of Directors Meeting 12:00 pm – 1:30 pm:

Breakfast & Announcements: Prize Winners 9:00 am – 12:00 pm:

Pediatric Track: Cardiovascular Emergencies 9:00 am – 10:25 am:

Rapid Fire Presentations 10:30 am – 11:30 am:

New Speakers Series

Emergency Medicine Town Hall Session (lunch first-come, firstserve)

11:30 am – 12:30 pm:

1:45 pm – 3:30 pm:

11:30 am – 12:30 pm:

3:30 pm – 5:30 pm:

12:30 pm – 2:00 pm:

Sponsored Education Wine, Beer & Cheese Reception 5:30 pm:

Deadline for Passports to Prizes and Exhibit Hall Game cards (winners announced following morning) 6:30 pm – 8:30 pm:

FCEP’s 50th Anniversary Reception (separate ticketed event)

Past Presidents’ Luncheon (invitation only) Women in Medicine Meeting Workforce Panel Session & Member Q&A (lunch first-come, first-serve) 2:15 pm – 4:15 pm:

Education & Innovation Track 2:15 pm – 5:15 pm:

Rapid Fire Presentations 8:00 pm – 11:00 pm:

Annual Family Casino Night, hosted by DuvaSawko & EMPros

Different this year: Due to pandemic travel restrictions on many residency programs, our four competitions typically held at Symposium by the Sea were either cancelled, rescheduled, or moved to a virtual format. EMpulse Summer 2021

Platinum Level Sponsors

50th Anniversary Celebration

honoring FCEP’s past, present & future

Friday, August 6, 2021 6:30 pm - 8:30 pm Naples Grande Beach Resort Naples, FL

WiFi Sponsor

Reveal of our “50 Years, 50 Voices” project begins at 7:30 pm

Gold Level Sponsors

Silver Level Sponsors WATCH THE PREVIEW

It’s not over yet: SAVE THE DATE 13TH ANNUAL

Emergency Medicine Research Competition TO BE HELD VIRTUALLY ON

August 30 – September 3, 2021

Stay tuned at fcep.org/sbs EMpulse Summer 2021

COMMITTEE REPORT

EMS/Trauma By Desmond Fitzpatrick, MD, FACEP

Committee Co-Chair The state of Florida has seen a disturbing rash of drownings unlike anything seen in recent history. There have been reports of this becoming a near-daily occurrence in places such as the central Florida region. The causes seem multi-factorial, including the rise of AirBNB type rentals vs. traditional hotels or more supervised community pools. Many visitors want to come to Florida to relax and let their guards down. Given the insanity of the last year or so, we understand this feeling; however, we must strive to make people aware of the dangers of unattended pools. Water safety and drowning awareness must continue to be crucial statewide issues. We must identify partnerships and critical stakeholders to ensure we do not continue to have these types of preventable deaths. Thank you to FCEP Executive Director Jonathan Dolan and Dr. Chrissy Van Dillen for spearheading the FCEP charge trying to tackle this issue. Due to the Eagles EMS conference, there was no regular FAEMSMD meeting, so look forward to more updates in the next issue. As a special edition, we have FCEP’s very own Dr. Ben Abo, who put together a piece on drowning for us:

RESOURCES • Drowning Literature Blog • Drowning Expert, Dr. Andrew Schmidt • Stop Drowning Now • Lifeguards Without Borders

Drowning Update By Benjamin Abo, DO, PMD, FAWM EMS Physician & Toxinologist FSU College of Medicine

Summertime has come, and the state of Florida is witnessing a disturbing amount of drownings unlike anything in recent history. There have been reports of drowning being a neardaily occurrence in places such as the central Florida region. The causes seem multi-factorial, including the rise of AirBNB type rentals vs. traditional hotels or more supervised community pools.

encountering a drowning patient. While a vast majority of drownings involve children at home or in friends’ pools, drowning is a pathologic process that can affect any age, sex or race. Despite tremendous advances in medical care, drowning statistics are still high. Why? Our general approach to treating drowning cardiac arrests as most cardiac arrests is likely doing a disservice to our patients.

Globally, and most likely significantly underestimated, there are over 372,000 drowning fatalities per year. In the U.S., an average of 4,000 people drown per year, with an unfortunate average of 10 fatalities per day, and Florida already has the highest unintentional drowning death rate among children ages 0-9 years compared with other states.

Some commonly still taught misconceptions regarding drowning that we encounter in both the hospital and pre-hospital environments must change. It doesn’t matter if it’s warm or cold water, saltwater or freshwater, a young or old individual — the time of submersion and reversal of that process, with a focus on the respiratory part of resuscitation, are what make a big difference. General resuscitation C-A-B is not appropriate prioritization, and in small print, AHA guidelines even acknowledge that it is still A-B-C with drownings. There is also no appropriate use of terms like “dry drowning” or “secondary drowning” or “near-drowning.”

While Floridians are used to enjoying water-related activities year-round, there is a large flux of people moving down or visiting this time of year with summer vacations. Many visitors want to come to Florida to relax and let their guards down. Given the insanity of the last year or so, we understand this feeling; however, we must strive to make people aware of the dangers of unattended pools. Water safety and drowning awareness must continue to be crucial statewide issues. We must identify partnerships and critical stakeholders to ensure we do not continue to have these types of preventable deaths. We must also ensure we, as providers, are up-to-date on best practices when EMpulse Summer 2021

Hopefully, this shallow dive into the topic stimulates some thoughts. We urge you to reach out to Dr. Benjamin Abo or our true local water emergencies expert, Dr. Andrew Schmidt, so that you don’t drown in a sea of misinformation. ■

READ ONLINE

COMMITTEE REPORT

Pediatric EM Committee By Dr. Todd Wylie, MD Committee Co-Chair

EDUCATION It was a return to in-person learning at the 2021 Emerald Coast Conference in Destin, FL. The 4-day conference (June 7-10) was hosted by the ACEP Alabama and South East State Chapters. Members of the FCEP’s Pediatric Emergency Medicine Committee provided a threehour immersive, simulation-based workshop at the conference focused on pediatric trauma and non-accidental trauma. Thank you to Drs. Amit Patel, Vanessa Perez, Tricia Swan, Cristina Zeretzke, John Misdary, Carmen Martinez and Shiva Kalidindi for volunteering your time and expertise to make the workshop a success. Also, coming soon to a conference near you: members of our Pediatric Emergency Medicine Committee will present the sixth annual Pediatric Track at Symposium by the Sea. This 3-hour workshop will use didactic lectures, small group sessions, and interactive high-fidelity simulation scenarios to bring participants the latest in management of pediatric cardiovascular emergencies (NRP and PALS 2020 guidelines updates, COVID-19 related cardiac complications, approach to neonates with congenital heart lesions in the ED/PED, and more). We’d like to extend a sincere “Thank You!” to Dr. Shiva Kalidindi for organizing the programs at both conferences.

COVID-19, VACCINATIONS, AND KIDS Over 4 million children have tested positive for COVID-19 in the United States since the start of the pandemic (as of June 17, 2021).1 Children represented 24.6% (15,763) of new COVID-19 cases for the week 6/10/21 to 6/17/21, and account for 14.2% of all U.S. cases since the start of the pandemic.1 Though children tend to have a mild COVID-19 disease course overall, severe disease and complications do

occur. A systematic review of children with confirmed COVID-19 infection found 2% of cases were identified as severe and 0.6% were identified as critical.2 Further, there have been over 4,000 cases of MIS-C in the United States as of June 2, 2021.3 The hospitalization rate for children has been 0.80.9% so far in 2021 and the mortality rate has been 0.01% for the same time period.1 Vaccination against COVID-19 has proven to be an incredibly effective measure to prevent infection and symptomatic disease in adults. The FDA reported in May 2021 that the Pfizer-BioNTech COVID-19 vaccine was found to be “100% effective in preventing COVID-19” for children ages 12-15 years in an analysis of available effectiveness data.4 An emergency use authorization (EUA) for the Pfizer-BioNTech vaccine was expanded to include children 12-15 years of age on May 10, 2021 (note: an EUA was filed for the Moderna COVID-19 vaccine on June 10, 2021). As of June 23, 2021, over 8.2 million children 12-17 years of age in the United States have received at least one dose of the Pfizer-BioNTech COVID-19 vaccine, and over 5.8 million have received both.5 The initial safety data described by the FDA primarily noted adverse reactions to the Pfizer-BioNTech vaccine that included pain at the injection site, headache, muscle pain, fever, chills and fatigue. Anaphylaxis was also reported, though the majority of cases were described in people with a history of allergic reactions.6 Recently, reports of myocarditis or pericarditis in people receiving an mRNA vaccine, including the Pfizer-BioNTech vaccine, have emerged. As of June 2021, the CDC has confirmed 393 cases of myocarditis or pericarditis in people that have received mRNA COVID-19 vaccines, and are investigating the possible associaEMpulse Summer 2021

tion with mRNA vaccines. Most reported cases have been in males that are 16-30 years of age. Even if a causal link is found between mRNA vaccines and myocarditis or pericarditis, when compared to the potential morbidity and mortality associated with COVID-19, the benefits of vaccination far exceed the potential risks. Leading health care experts and organizations recommend and encourage COVID-19 vaccination for all eligible individuals 12 years of age and older.7 ■

READ ONLINE

REFERENCES: 1. American Academy of Pediatrics. Children and COVID-19: State-Level Data Report. Accessed 6/22/2021. 2. Liguoro I, Pilotto C, Bonanni M, Ferrari ME, Pusiol A, Nocerino A, Vidal E, Cogo P. SARS-COV-2 infection in children and newborns: a systematic review. Eur J Pediatr. 2020 Jul;179(7):1029-1046. doi: 10.1007/ s00431-020-03684-7. 3. CDC. Health Department-Reported Cases of Multisystem Inflammatory Syndrome in Children (MIS-C) in the United States. Accessed 6/22/21 4. FDA. Coronavirus (COVID-19) Update: FDA Authorizes Pfizer-BioNTech COVID-19 Vaccine for Emergency Use in Adolescents in Another Important Action in Fight Against Pandemic. May 10, 2021. Accessed 6/23/21. 5. CDC. COVID-19 Vaccinations in the United States. Accessed 6/23/21. 6. Allergic Reactions Including Anaphylaxis After Receipt of the First Dose of Pfizer-BioNTech COVID-19 Vaccine—U.S., Dec. 14–23, 2020. CDC COVID-19 Response Team; FDA. MMWR Morb Mortal Wkly Rep. 2020. 7. American Academy of Pediatrics. Statement Following CDC ACIP Meeting from Nation’s Leading Doctors, Nurses and Public Health Leaders on Benefits of Vaccination. Accessed 6/24/21 11

FROM THE COLLEGE

Government Affairs: End of 2021 Legislative Session Report By Blake Buchanan, MD, FACEP Committee Chair

Though summer finds us in the early days of hurricane season, it finds us in the doldrums of political activity in Tallahassee. After a Legislative Session that was less focused on healthcare than previous years, but still heavily focused on pandemicrelated measures, along with a quick gambling-focused special legislative session that followed, Tallahassee has emptied out until the fall. Since this is a non-election year, committee weeks for the State Legislature will begin with the return of college football. We will continue to push for changes in the application of the surprise medical billing laws that are currently on the books, to make insurers come to the table and work with us on an even footing. We should also anticipate another round of attempts by special interests at broadening scope-ofpractice laws for other healthcare providers. FCEP will continue to work with the FMA and stand firmly against independent practice for mid-level providers. While this time of year is not filled with activity, and many of us have our eyes towards getting back out, traveling and visiting others, I encourage everyone to remember the key element that allows us to meet with key players in Tallahassee: donations from FCEP’s

Political Action Committee (PAC). This committee, funded by your donations, opens doors for us that would otherwise be closed. We have a great advocacy team representing emergency physicians on the ground that is happy to give time to represent you, but we need your help to make the biggest impact. Please donate to FCEP’s PAC, and let us be there to give you a voice.

End of 2021 Legislative Session Report

I hope to see many of you at Symposium by the Sea this August in Naples. 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. Thank you all for your hard work caring for patients each and everyday across this state. Even though the spotlight is no longer on us, the work each one of you do day in and day out is of no less importance. As Mel Herbert of EMRAP always likes to remind us, “Remember, what you do, matters.” If you have any concerns about issues that you think can or should be addressed, or if you would like to learn more ways to be involved in advocacy, please email me at BlakeBuchanan87@gmail.com anytime.

With SB 54 vetoed by the Governor, no changes will be made to Florida’s no-fault auto insurance market this year. However, we anticipate this issue to surface again next session. FCEP did negotiate in good faith with the bill sponsors, and was able to secure the following items in the legislation (now vetoed):

DONATE TO OUR PAC NOW: Text “FCEPPC” to “41444” 12

Donate online at: fcep.org/support EMpulse Summer 2021

By Toni Large FCEP Lobbyist

VETOED: SB 54: Mandatory BI/PIP Repeal*

• Physician set-aside retained for emergency physician care (5K) • Mandatory offer of med-pay with written opt out if coverage isn’t selected, otherwise presumed to have a $10k med-pay benefit

SIGNED INTO LAW: SB 716: Consent for Pelvic Exams* FCEP worked hand-in-hand with other specialties affected by the 2020 passage of the written consent for pelvic exam legislation. As a result, FCEP was able to secure the necessary changes in SB 716 to mitigate the unintended negative consequences to emergency care. FCEP started by clarifying that the

* = 2021 Priority Issue

exemption for emergency care extends to both the exam to determine an emergency medical condition in the ER AND the care needed post exam. The legislation also: • Amends, narrows, and simplifies the definition of “pelvic examination” to exclude a visual assessment, imaging or non-diagnostic medical or surgical procedure. • Narrows only to require written consent for anesthetized or unconscious patients outside the ER and to require verbal consent from any conscious patient • Adds three new exceptions, thereby allowing an examination without consent, related to emergency medical conditions outside the ER, a child protective investigation, and certain criminal offenses against a child; and • Provides that a single written consent for a pelvic examination may authorize multiple health care practitioners or students to perform a pelvic examination on a pregnant woman having contractions.

SB 72: COVID Liability Protections* FCEP made liability protections for emergency physicians working during the pandemic a priority and applauded the Florida Legislature passage of SB 72 as the first bill of the Session. Below are highlights that will protect emergency physicians: • Plaintiff must prove gross negligence or intentional misconduct • Protection when the emergency physician substantially complied with authoritative or applicable government-issued health standards or guidance • Protection for delaying or canceling a medical procedure due to government-issued health standards or guidance. • 1-year statute of limitation

HB 431: Physician Assistants* FCEP is happy to report that HB 431 no longer grants independent practice to PAs as originally filed, but instead increases the number of

PAs a physician can supervise (1:10, previously 1:4). We were also successful in killing the ARNPs push to expand their independent practice outside the practice of primary care.

readily accessible to the patient. If the patient needs more than a 24-hour supply of a drug, the prescriber must provide the patient with a prescription for use after the initial 24-hour period.

The bill allows a PA to do the following:

SB 262 extends patient eligibility to include a patient discharged from a hospital (inpatient). The bill also authorizes a hospital pharmacy to dispense the greater of a 48-hour supply of a medicinal drug or a supply of a medicinal drug that is sufficient to last a patient until the end of next business day. The bill also authorizes a hospital pharmacy to dispense up to a 72-hour supply of a medicinal drug if the patient is located in an area in which a state of emergency is declared. The bill corrects current statutory language to reflect that it is the hospital pharmacy that dispenses the medicinal drug, rather than the prescriber.

• Prescribe psychiatric mental health controlled substances to minors under certain circumstances; • Procure certain medical equipment and devices; • Supervise medical assistants; and • Sign and certify documents that currently require a physician’s signatures including, but not limited to, Baker Act commitments, do-notresuscitate orders, school physicals, and death certificates. The bill specifies that a PA may not sign for medical marijuana certifications under s. 381.986, F.S., or workers’ compensation medical examinations required to determine maximum medical improvement under s. 440.02, F.S., and an impairment rating under s. 440.15, F.S. The bill also authorizes physician assistants to directly bill for and receive payments from public and private insurance companies for the services they deliver.

SB 676: Specialty License Plates* SB 676 passed the Florida Legislature with numerous specialty license plates, and our “Support Health Care Heroes” license plate was one of them! Once they are available for pre-order, we encourage the entire health care community to purchase one and show your support. Funds generated from the sales will be deposited in the EMS Trust Fund. Stay tuned for more information from FCEP.

SB 262: Dispensing Medicinal Drugs Currently, an authorized prescriber may dispense up to a 24-hour supply of a medicinal drug to an emergency department patient of a hospital that holds an appropriate institutional pharmacy permit, provided that the treating physician determines that the medicinal drug is needed and that community pharmacy services are not EMpulse Summer 2021

HB 157: First Aid Training in Public Schools HB 157 requires school districts to provide basic training in first aid, including one hour of cardiopulmonary resuscitation (CPR) instruction, for public school students in grades 9-11. Basic CPR instruction for students is currently encouraged, but not required by state law. The bill provides that the CPR training must be based on a nationally recognized program that uses the most current evidencebased emergency cardiovascular care guidelines. The instruction must allow students to practice the psychomotor skills associated with performing CPR. If a school district has the necessary equipment, students must also be provided instruction in the use of an automated external defibrillator. The bill also encourages school districts to provide basic first aid training, including CPR instruction, to students in grades 6-8.

HB 1157: Freestanding Emergency Departments Continuing on the House Speaker’s health care transparency initiates from previous sessions, the Legislature passed HB 1157. Quoting directly from testimony provided by the bill sponsor: Continue on next page ▶ 13

◀ Continued from page 13 “Consumers sometimes mistake FEDs for urgent care centers because these facilities can often look and feel like urgent care centers. As a result, they may be surprised to receive a bill that is significantly higher than expected. Unlike an urgent care center, which provides non-emergent care and only charges a physician fee, a FED provides emergent care and charges a physician fee and a facility fee. The average cost for primary care at an urgent care center is $193, compared to over $2,000 in an emergency room.” This bill: • Defines the term “hospital-based off-campus emergency department” (HBOCED) and amends current law to draw a stronger distinction between HBOCEDs and urgent care centers (UCC). • The bill restricts an HBOCED from holding itself out as a UCC and requires that a HBOCED clearly identify itself as an emergency department (ED) and post signage in conspicuous areas that specified that the HBOCED is an ED and not a UCC. • The bill also includes similar identity transparency requirements for all HBOCED advertising. The bill requires AHCA to publish the following information on its website, which must be updated at least annually: • A description of the differences between a HBOCED and an urgent care center; • At least two examples illustrating the cost differences between nonemergent care provided in a hospital emergency department setting and an urgent care center; • An interactive tool for consumers to locate local urgent care centers; and • Steps to take in the event of a true emergency. The bill also requires a health insurer to post on its website at least two examples illustrating the impact on insured and insurer paid amounts of inappropriate utilization of nonemergent services and care in a hospital ED setting, compared to a 14

UCC and an interactive tool to locate in-network and out-of-network UCCs.

HB 805: Volunteer Ambulance Services The bill provides a legislative finding that it is in the public interest to foster the development of emergency medical services that address religious sensitivities and recognizes the value of augmenting existing county and municipal emergency medical services with those provided by volunteer service organizations. The Florida EMS Medical Directors were successful in placing into statute several safeguards in the implementation of HB 805: • Exempts ONLY certain not-forprofit faith-based volunteer first responder agencies who have been operating in this state for at least 10 years, and which provide advanced or basic life support services solely through at least 50 unpaid licensed emergency medical technician or paramedic volunteers, from COPCN requirements. • To be exempt from the COPCN requirements, the volunteer ambulance service MUST also provide services free of charge, not receive government funding (excluding specialty license plate proceeds), provide a disclaimer on all written materials that the volunteer ambulance service is not associated with the state’s 911 system, and meet other requirements as outlined in the bill. • The COPCN exemption created in the bill may also ONLY be granted to no more than four counties. • The bill requires an applicant to take all reasonable efforts to enter into a memorandum of understanding with the EMS licensee within whose jurisdiction the applicant will provide services in order to facilitate communications and coordinate emergency services for situations beyond the scope of the applicant’s capacity, and for situations of advanced life support that are deemed priority 1 or priority 2 emergencies. The bill also makes it clear that an EMpulse Summer 2021

EMS or fire rescue services provider operated by a county, municipality, or special district is responsible for the care and transport of an unresponsive patient if a volunteer ambulance service arrives at the scene of an emergency simultaneously with such a provider and a person authorized to consent to the medical treatment of the unresponsive patient is not present.

SB 388: Injured Police Canines Working with FCEP and the EMS Medical Directors, SB 388 was amended to address our number one concern: a veterinary clinic vs. an emergency department as the best place for injured canines to be treated. Thus SB 388 authorizes an emergency service transport vehicle permit holder to transport a police canine injured in the line of duty to a veterinary clinic or similar facility if no person requires medical attention or transport when the canine needs it. The bill authorizes EMTs and paramedics to provide emergency medical care to an injured police canine at the scene of an emergency or while the canine is being transported. The bill provides civil and criminal immunity for EMTs and paramedics providing emergency care to an injured police canine and exempts them from the application of the veterinary practice act for providing medical care to a police canine injured in the line of duty.

SB 272: Rare Disease Advisory Council SB 272 creates section 381.99, Florida Statutes, to establish the Rare Disease Advisory Council (Council) adjunct to the Department of Health (DOH). The Council is tasked with providing recommendations to improve the health outcomes of Floridians who have a rare disease, defined as a disease that affects fewer than 200,000 people in the United States. The bill establishes the membership of the Council, and requires that the Council first meet by October 1, 2021, and provide its recommendations to the Governor and the State Surgeon General by July 1 of Continue on page 14 ▶

“If you’re not there fighting the fight, then who is?” SAVE THE DATE:

Emergency Medicine Days January 2022 | Tallahassee, FL Legislative Session begins January 11, 2022

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

Johnnie Ford

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Robert B Fulton

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Jackson Thomas Gamer

Nicolette Natale

Hong Diem Jennifer Truong

Matthew A Beattie

Allyson Paige Hansen

David J Orban

Daryl Maurice Turner

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Brian Scott Hartfelder

Venugopal Palani

Chanteil D Ulatowski

Michael A Borunda

Brandy Milstead Hollingsworth

Charles Sand, I

Benjamin William Webster

Kathleen S Schrank

Christina Lucile Wilson

Donna Schutzman-Bober

Jason Wilson

Matthew A Schwartz

Charles Wyatt

Masra Muhammad Shameem

Joshua Young

Ana Victoria Camagay Laksmy Castillo Jordan Celeste Justin Chacko Ian Paul Ciesielski Nicholas R Dodaro Alex T Doerffler Emeka Albert

Saundra A Jackson Sarah Maire Jacobs Courtney L Johnson Jonathan Journey Steven B Kailes Shiva Kalidindi Gary Lai Jon E Lamos

Todd L Slesinger Daniel Snediker John Caleist Soud Kyle Thomas Strickland

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◀ Continued from page 15 each year beginning in 2022. The Council must:

• Consult with experts on rare

diseases and solicit public comment to assist in developing recommendations on improving the treatment of rare diseases in this state.

• Develop recommended strategies

for academic research institutions in this state to facilitate continued research on rare diseases.

• Develop recommended strategies for health care providers to be informed on how to more efficiently recognize and diagnose rare diseases in order to effectively treat patients.

• Provide written input and feedback

to the DOH, the Medicaid program, and other state agencies on specified matters.

HB 183: Office of Minority Health In Florida, minority populations experience higher rates of illness and death from health conditions such as heart disease, stroke, specific cancers, diabetes, HIV/AIDS, mental health, asthma, and obesity. The Office of Minority Health and Health Equity, housed within the Department of Health (DOH), is responsible for helping to improve health and healthcare outcomes for racial and ethnic minority communities by developing or advancing policies, programs, and practices that address health, social, economic, environmental, and other factors that impact health. Under current law, the Office must be headed by a Senior Health Equity Officer, who must administer the Closing the Gap grant program in a manner that maximizes the impact of the grants in achieving health equity. HB 183 requires the Office to develop and promote statewide implementation of policies, programs, and practices that increase health equity for racial and ethnic minority populations in Florida. The bill requires the Office to work with other state agencies, organizations, and providers to 16

improve the health of racial and ethnic minority populations through data analysis and the development of health policies and programs that will help eliminate health disparities. The bill requires one representative from each county health department to serve as a minority health liaison and requires minority health liaisons to assist the Office in the implementation of the bill. The bill also authorizes the Office to serve as a liaison to and assist the federal Offices of Minority Health and Regional Health Operations, as appropriate.

HB 1381: Maternal Health Outcomes HB 1381 allows the Closing the Gap (CTG) grant program to fund projects directed at decreasing racial and ethnic disparities in severe maternal morbidity and other maternal outcomes. The bill also adds maternal health programs to existing community-based programs the DOH is required to coordinate. The bill creates telehealth minority maternity care pilot programs in Duval and Orange Counties to expand the capacity for positive maternal health outcomes in racial and ethnic minority populations. The pilot programs are required to use telehealth or coordinate with prenatal home visiting programs to provide services and education to eligible pregnant women and provide training to participating health care practitioners and other perinatal professionals. The bill requires that legislative appropriated funds for the CTG grant program be used to fund the pilot programs. The bill also requires that the DOH’s Division of Community Health Promotion and Office of Minority Health and Health Equity work together to apply for available federal funds to assist in the implementation of the bill.

HB 701: Behavioral Health Care Services Building on FCEP’s focus of increasing access to mental health coverage, especially as we struggle to find patients access to care outside the ED, HB 701 requires the Department of Financial Services (DFS) to submit a report, by January 31, 2022, to EMpulse Summer 2021

the Legislature and the Governor regarding complaints received from insureds and subscribers about the adequacy of coverage and access to mental health services through their individual or group health insurance policies or health maintenance organization (HMO) contracts. Further, the bill requires insurers and HMOs to provide insureds and subscribers a direct notice regarding the federal and state coverage requirements for mental health services, as well as contact information for the Division of Consumer Services within the DFS. Insurers and HMOs are also required to make this information available on their website.

HB 673: DNA Evidence Collection HB 673 creates “Gail’s Law” to require FDLE, subject to an appropriation and no later than July 1, 2023, to create and maintain a statewide database tracking the location, processing status, and storage of each Sexual Assault Kits (SAK or rape kits) collected after the database is implemented. The database must be accessible by law enforcement, alleged victims, and alleged victims’ parents, guardians, or other representatives. The database must track the status of a SAK from its collection throughout the criminal justice process all the way through the kit’s destruction. The bill requires FDLE to adopt rules and specified entities to participate in the database in accordance with those rules. The bill also requires FDLE to ensure that every victim or victim’s representative is notified that the database exists and is provided with instructions on how to use it. Under the bill, a victim must be notified when the analysis of his or her SAK results in a DNA match, but such notification must not release any identifying information of the match. The bill authorizes FDLE to phase in participation according to region, volume of kits, and other criteria, but requires all entities in the chain of custody to fully participate in the statewide database no later than one year after it is created. The bill also requires FDLE to apply for any available grant funds to assist in implementing the database.

SB 1934: Health Care Practitioner Discipline After two pediatricians were arrested on child pornography, legislators were shocked that such an arrest did not result in an automatic suspension of their medical license. Thus, legislation was passed to make sure certain offenses trigger action by DOH.

• Amends s. 456.072, F.S., to add to

the list of offenses that are grounds for disciplinary action against the license of a health care practitioner regulated by the Department of Health (DOH), for: Being convicted, found guilty, pleading guilty, or pleading nolo contendere, regardless of adjudication, to any of the crimes listed in s. 456.074(5), F.S., as amended; or Attempting, soliciting, or conspiring to commit an act that would constitute a crime listed in s. 456.074(5), F.S., or similar crime in another jurisdiction.

• Amends s. 456.074(1), F.S., to add

homicide to list of offenses that require the DOH to issue an Emergency Suspension Order (ESO) and broadens the application to any health care practitioner, instead of those currently listed in statute, if he or she pleads guilty to, is convicted or found guilty of, or who enter pleads nolo contendere to, regardless of adjudication.

• Amends s. 456.074(2), F.S., to specify

offenses that require the DOH to issue an ESO against any health care practitioner who is arrested for such offenses. The bill requires the DOH to issue an ESO if a health care practitioner is arrested for committing or attempting, soliciting, or conspiring to commit any one of the listed criminal offenses involving a child, an individual with mental or physical disabilities, or the elderly, or a similar offense in another jurisdiction.

• Directs the Office of Program

Policy Analysis and Government Accountability (OPPAGA) to analyze state laws and rules relating to grounds for health care practitioner discipline and ESOs of licenses, specifically with respect to criminal offenses, and to report to Executive and Legislative Branch leadership by January 1, 2022.

SIGNED INTO LAW & GLITCH BILLS ARE NEEDED The following bills will be priorities for FCEP next session:

HB 241: Parents’ Bill of Rights HB 241 creates Chapter 1014, Florida Statutes, as the “Parents’ Bill of Rights.” The law enumerates parental rights with respect to his or her minor child for education, health care, and criminal justice procedures. The bill prohibits a governmental entity from infringing upon the fundamental right of a parent to direct the upbringing, education, health care, and mental health of his or her minor child. Though more the 75% of the bill relates to the education system, the bill further requires a parent’s permission before a health care practitioner may provide services, prescribe medicine to the child, or perform a medical procedure, unless otherwise provided by law. The bill provides a misdemeanor penalty for a health care practitioner or similar person who violates the health care provisions and subjects these persons to disciplinary actions. At the request of FCEP, the Senate bill contained an exemption for acute care (point of injury care) or care provided by a volunteer team physician, but the Senate sponsor took up the House bill, thus excluding the exemption. Current law does include an exemption from written consent for emergency care in hospital emergency departments or provided by EMS.

HB 833: Unlawful Use of DNA The bill creates the “Protecting DNA Privacy Act.” The bill creates new crimes prohibiting a person from willfully, and without express consent:

• Collecting or retaining another

person’s DNA sample with intent to analyze such sample, as a first degree misdemeanor.

• Disclosing another person’s DNA

analysis results to a third party, unless such results were previously voluntarily disclosed by the person whose DNA was analyzed, as a third degree felony.

• Selling or otherwise transferring

another person’s DNA sample or analysis results to a third party, as a second degree felony.

• Under the bill, “express consent”

means authorization from a person or his or her legal guardian or representative, evidenced by an affirmative act demonstrating an intentional decision, after receiving a clear and prominent disclosure regarding the specified purpose for the collection, use, retention, maintenance, or disclosure of the DNA sample or analysis thereof.

The bill clarifies current law by providing that “exclusive property” means a person’s right to exercise control over his or her DNA sample or analysis with regard to the collection, use, retention, maintenance, disclosure, or destruction of such sample or analysis. The bill defines the terms “DNA analysis” and “DNA sample” and authorizes a separate criminal penalty for each instance of unlawful collection or retention, submission or analysis, disclosure, or sale of a person’s DNA sample or analysis results. The bill applies only to the use, retention, maintenance and disclosure of a DNA sample collected from a person in Florida after the bill is effective and does not apply to a DNA sample, analysis, or analysis results when used for specified purposes such as criminal investigation, determining paternity, complying with a court order, conducting specified research, or other healthcare purposes. ■

More Online: Find bill analyses and other resources in the online version of this article.

• Submitting another person’s DNA

sample for analysis or conducting or procuring the conducting of such analysis, as a third degree felony.

EMpulse Summer 2021

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Now Accepting Applications for FCEP’s

LEADERSHIP ACADEMY By Stephen Viel, MD, MBA, FACEP FCEP Leadership Academy Chair

FCEP’s Leadership Academy is a year-long program designed to equip you with the organizational education, skills training, mentoring, and guided experiences you will need to succeed as a leader in emergency medicine. The COVID-19 pandemic has proven that emergency physicians are primed to lead, not only our teams and departments, but our communities, legislators, and other leaders. Our specialty needs you – and FCEP is ready to be the catalyst for your growth and success. The power of FCEP is harnessed through interpersonal connections. Throughout the college are individuals that are leaders in every aspect of our field. As a Leadership Academy participant, you will be connected with these individuals who can augment your current interests, or help foster a deeper connection to an area you are interested in exploring. The end result will be reciprocal relationships that foster personal and professional growth for everyone involved. This program will also immerse you in the workings of FCEP. You will have the opportunity to participate in board meetings, help organize and plan our various activities throughout the year, and get a taste for how FCEP functions at an organizational level. Your participation here will not only deepen your connection to the day-to-day functions of the college, but also help identify you as an asset that may be tapped for future leadership opportunities within the organization. Many of our current and past FCEP leaders are Academy graduates, including our 2019-21 President, Dr. Kristin McCabe-Kline, and President-Elect, Dr. Sanjay Pattani. 18

Most importantly, FCEP’s Leadership Academy is designed to meet you where you are. Some participants already have extensive leadership experience and in-depth knowledge of specialized areas of our field, but may not have the connections they need for the next step in their career. Others have a particular interest in a facet of the world of emergency medicine, but have not yet found the best way to become involved in this area. Others come to the program with minimal outside experience, but feel the draw to become more engaged. Fortunately, because of the flexible nature of our Leadership Academy, leaders of any variety— emerging or established—will benefit from this program. FCEP is looking for individuals who have demonstrated a commitment to emergency medicine today and who desire to be the leaders in our industry tomorrow. Applications for our next class of Leadership Academy participants will be accepted through August 30, 2021. The program will officially begin in October. ■

Learn more in our Leadership Academy brochure

LEARN MORE

APPLY ONLINE NOW

EMpulse Summer 2021

COMMITTEE REPORT

EMRAF President’s Message By Elizabeth Calhoun, MD, PGY-3 Committee Chair

The summer brings an exciting gust to residency programs across Florida. With the warm weather comes intern orientations, fresh simulations, ultrasound and procedure training, beach-day wellness activities, and a fresh enthusiasm for our specialty. Training through the pandemic has afforded us surprising opportunities: an opportunity to be a part of our hospital’s conversation amidst crisis, an opportunity to gain more individualized instruction during the low volume times, and an opportunity to stretch ourselves when the floods of patients came rushing back in. These are experiences we will carry with us into our careers. As residents, we have developed adaptability, innovation, and communication doing what we love about emergency

medicine: making real-time tough decisions for the health and safety of our community. After facing these challenges, we are all the better equipped to face the challenges the specialty is carrying. I first discovered the FCEP community as a medical student at EM Days in Tallahassee and again as they represented Florida at the national Leadership and Advocacy Conference. As we met with legislators to champion our physicians and our patients, again and again lawmakers would say, “Wow, I had no idea it was like that in our emergency departments.” Or they would relay a single memorable experience they had long ago in the ED, which has since influenced their decision-making. What we do for our

communities is amazing and special, and from the waiting room to the Capitol, our knowledge and skills are needed. EMRAF interest is building, but there is so much more residents can benefit from this year. From Symposium By the Sea to Life After Residency, FCEP committees and planning, anyone can get involved and connect with emergency physicians across this sunny state. If you have not yet signed up to receive updates, click Subscribe to Announcements at the bottom of fcep.org, or send me an email at ecalhounmd@gmail.com. ■

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COMMITTEE REPORT

Medical Student Council By Dan Schaefer, MPH, MS-3

Secretary-Editor, FSU College of Medicine

Hello from the MSC! We have been meeting with the EMIGs from all around the state and learning more about what they have planned for their students over the past few months. It has been incredible to see all the hard work and dedication that the EMIGs have put into making sure that students have all the same opportunities and more as we move on to the next phase of the COVID-19 pandemic. We have also excitedly

been getting ready for Symposium by the Sea this year. Last, but certainly not least, the current MSC has selected the next FCEP MSC officers! There were a lot of incredibly talented potential candidates, so it was no easy feat to select the incoming officers. Those individuals will have been notified of their status by the time that this article is published, and we are EMpulse Summer 2021

confident that they will have a lot planned for all the medical students and EMIGs over the next year. Rest assured, the FCEP MSC will be left in good hands. On behalf of all the current officers, it was a pleasure to serve. ■

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Next Steps for the EM Resident

CLASS OF 2021 Lists provided by Residency Program Staff Edited by Samantha League, MA

They spent their entire last year of residency in a pandemic, navigating the job searc hvirtually and in an uncertain workforce. Congratulations to the emergency medicine resident class of 2021.

Kendall Regional Medical Center UF Gainesville

USF Morsani Nicole Abdo, MD

Simulation Fellowship, USF Tampa, FL

Thomas Daniel Bloom, MD

Attending, U.S. Air Force Emergency Center at Lackland AFB San Antonio, TX

Morgan DuFresne, MD

Attending, Emergency Resources Group (Jacksonville, FL) Attending, Halifax Health (Daytona Beach, FL)

Johnathon Elkes, MD EMS Fellowship, USF Tampa, FL

Martin Gaccione, MD

Attending, Naples Community Hospital Naples, FL

Kelsey Marie Hundley, MD Attending, Hernando County Emergency Physicians Brooksville, FL

Adam Henry Koby, MD

Attending, Hernando County Emergency Physicians and Excelis Medical Associates Brooksville, FL

Mikhail M. Marchenko, MD Attending, Halifax Health Daytona Beach, FL

Brian R. Samuels, MD Attending, AdventHealth Kissimmee Kissimmee, FL

Lauren P. Shapiro, MD

AdventHealth Heart of Florida Davenport, FL 20

Kathryn Dasburg, MD

Sports Medicine Fellowship, Duke University Durham, NC

Terri Davis, MD Univ. of Florida Gainesville, FL

William DeMayo, MD AdventHealth Ocala Ocala, FL

Martin Dun, MD Marshfield Clinic Eau Claire, WI Pursing time off

Lauren Fisher, MD EMS Fellowship, UF Gainesville, FL

Aaron Frankel, MD Pursing time off

Taryn Morris, MD

Negotiating offers in Texas

April Pinto, MD Univ. of Florida Gainesville, FL

Joseph Pinto, MD

Global Health Fellowship, UF Gainesville Gainesville, FL

Christopher Purcell, MD

Administration Fellowship, USF Tampa, FL

Priscilla Shen, MD Univ. of Florida Gainesville, FL

Chanteil Ulatowski, MD EMS Fellowship, UF Gainesville, FL

Shannon Williams, MD

Nathan Boin, MD

Attending, West Virginia Univ. WV

Jonathan Brandon, MD

Attending, Univ. of Oklahoma Medical Center Oklahoma City, OK

Mitchell Evan Brown, MD

Attending, Seven Star Hospital Associates Hemet, CA

Attending, Capital Regional Hospital Tallahassee, FL

Samuel Thomas Cochran, MD

Toxicology Fellowship, Oregon Health Univ. Portland, OR

Dennis Stephen D’Urso, MD

Dr. Joseph Clemons

Dr. Kristina Drake

Wilderness Medicine Fellowship, MCOG, Augusta Univ. Augusta, GA

Dr. Jennifer Eells

Attending, Coral Gables Hospital Coral Gables, FL

Dr. Kelly Glazer

Caitlyn Emigh, MD

Baptist Hospital Pensacola, FL

Dr. Richard Boccio

UM/Jackson Memorial

Attending, Rockledge Medical Center Rockledge, FL

Dr. Anton Gomez

Administrative Fellowship, Kendall Regional Kendall, FL

Dr. Ibrahim Hasan

Attending, Southwest General Hospital Cleveland, OH

Dr. Matthew Mattioli

Attending, Coral Gables Hospital Coral Gables, FL

Dr. Anthony Peters

Attending, Jackson West Medical Center Doral, FL Attending, St. Peter’s Health Albany, NY

Christopher Gaines, MD Attending, James Haley VA Tampa, FL

Brittney Alexis Giuffre, MD Attending, Saint Barnabas Medical Center Livingston, NJ

Joseph Paul Greene, MD

Attending, South Miami CritiCare Miami, FL

Ludwig KoenekeHernandez, MD

Attending, Jackson West Medical Center Doral, FL

Ryan Daniel Lynch, MD

Attending, Holy Cross Hospital Ft. Lauderdale, FL

Athena Areti Mikros, MD Attending, U.S. Navy NC

Yijia “Jimmy” Mu, MD

Attending, Plantation General Hospital Plantation, FL

Attending, Ozarks Healthcare West Plains, MO

Emergency Ultrasound Fellowship, Kendall Regional Kendall, FL

Attending, Veterans Health Care System of the Ozarks Fort Smith, AR

Dr. Nicholas Rosende

Dr. Boris Ryabtsev

Attending, Ascension Sacred Heart Hospital Pensacola, FL

Dr. Sara Zagroba

Sports Medicine Fellowship, Univ. of Arizona - Tucson Tucson, AZ

EMpulse Summer 2021

Michael Osinski, MD

Shahnaz “Sonya” Rashid, MD Toxicology Fellowship, Cook County Cook County, IL

Daniel Felipe Rivera, MD

Toxicology Fellowship at Univ. of Texas Southwestern Dallas, TX

Florida Atlantic University Alexander Busko, MD, MPH

USF at Oak Hill Hospital

Orlando Health John Atiyeh, MD

Attending, Florida Regional Emergency Associates at Bayfront Health Port Charlotte / Punta Gorda, FL

David Bailey, MD

Attending, Queen’s Medical Center Honolulu, HI

Mark Bender, MD

Pain Management Fellowship, UF Gainesville, FL

Corey Cole, DO

Attending, Down East Community Hospital Machias, ME

Shaun Mansour, MD

Administrative Fellowship, Oregon Health & Science University Hospital Portland, OR

Christopher Megargel, DO Attending, Ocala Regional Medical Center Ocala, FL

West Florida Hospital Pensacola, FL

Zuheir Mirza, MD

Lee Memorial Healthcare System Ft. Myers, FL

Jonathan Yaghoubian, DO

Attending, Providence St. Mary Medical Center Los Angeles, CA

Danielle DiCesare, MD

Javier Ayo, MD Attending Destin, FL

Ryan Brandt, MD

Fellowship, UF Jacksonville Jacksonville, FL

Michael Carpenter, MD

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

Aventura

Ultrasound Fellowship, Orlando Health Orlando, FL

Attending, Ochsner St. Mary Morgan City, LA

Attending, EMPros, AdventHealth Northeast Florida

Attending, St Joseph’s Hospital Syracuse, NY

Andrew Grozenski, MD

Attending, Lee Health Fort Myers, FL

Attending, Wesley Hospital Wichita, KS

Adam Greeley, MD

Clinical Informatics Fellowship, Orlando Health Orlando, FL

Attending, Kettering Hospital Dayton, OH

Shaunn Hussey, MD

Attending, Lee Health Fort Myers, FL

Critical Care Fellowship, AdventHealth Orlando Orlando, FL

Yoldez Meroueh, MD

Agy Gaertig, MD

Justin Kittredge, MD Tucker Maute, DO

Keegan Mullins, MD

Olivia Munizza, MD

Christian Myburgh, MD St. Joseph’s Hospital Tampa, FL

Gustavo Rey, MD

Attending, Lee Health Fort Myers, FL

Mark Schattschneider, MD

Academic Practice, UF Health Gainesville, FL

Hieu Duong, MD

Kristina Eastman, MD Tuan Ha, MD

Andrew Morris, MD

Manuel Obando, MD

Laura Pumarejo Gomez, MD

Shivani Deopujari, MD Attending Orlando, FL

Christine Gage, DO

Fellowship, UF Jacksonville Jacksonville, FL Fellowship Nashville, TN Attending Nashville, TN

Military Service Naples Italy Attending South Florida

Ultrasound Fellowship, Kaiser San Diego San Diego, CA

Eamon Olwell, MD

Attending, Plantation Hospital Plantation, FL

Fellowship, Carolina’s Medical Center Charlotte, NC

Ioana Rider, MD Eva Ryder, MD

Attending Daytona Beach, FL

Attending, St Joseph’s Hospital Syracus, NY

Andrew Sellinger, MD

UPMC Monongahela Valley Hospital Pittsburgh, PA

Attending, Thibodaux Regional Medical Center Thibodaux, LA

Tyler Tantisook, MD

Wilson N. Jones Hospital Sherman, TX

Attending, AdventHealth Ocala Ocala, FL

Academic Practice, UF Gainesville Gainesville, FL

Alex Williams, MD

Daniel Samet, MD

Sean Zhao, MD

159 outgoing residents

63 96

Leaving the state

Staying in Florida

matched into fellowships Continue on next page ▶

Jessica Ryder, MD

Orlando Health, South Lake Freestanding ED Clermont, FL

Geraldine Uy, MD

NUMBERS

Anabelle Tavares, MD

UF Jacksonville

Attending, Salt Lakes Medical Center Klamath Falls, OR

Ultrasound Fellowship, Orlando Health Orlando, FL

Danielle Klein, MD

Alex Peterson, DO

Beulah Castor, MD

Michael Clemmons, MD

Mohsin Khan, DO

Ascension Sacred Heart Hospital Pensacola, FL

AdventHealth Ocala Ocala, FL

Attending, Lewis Gale Medical Center Sake, VA

Critical Care Fellowship, UF Gainesville, FL

Zachariah Hatoum, MD

Attending, NCH Healthcare System Naples, FL

James Newton, DO

Jordan Bjerke, MD

Attending, Orlando Health Freestanding EDs Orlando, FL

Critical Care Fellowship, Univ. of Alabama Birmingham Birmingham, AL

BY THE

Attending Tallahassee, FL

Attending Chattanooga, TN

EMpulse Summer 2021

Jesse Zadell

St. Lucie Medical Center Dr. Drew Brooks

Good Samaritan Hospital West Palm, FL

Dr. Mike Drechsler

UCF at North Florida Regional

Dr. Jerome Daniel

Ashley Barash, DO

Mohawk Valley Health Utica, NY Cleveland Clinic Martin Health Port St. Lucie, FL

Dr. Shelby Guile

Lawnwood Regional Medical Center Fort Pierce, FL

Dr. Abby Regan

Merit Health River Region Vicksburg, MS

Dr. Ash Zomorrodi

Cleveland Clinic Martin Health Port St. Lucie, FL

UCF at Ocala Regional Nathan George, MD

Emmanouil Kiriakopoulos, DO Attending, Alteon Health at Bon Secours Hospital Norfolk, CA

Shelby Martin, MD

Critical Care Anesthesia Fellowship, Washington Univ. St. Louis, MO

Joshua Middleton, MD

Ultrasound Fellowship, North Florida Regional Medical Center Gainesville, FL

Mollie Powell, DO

Ultrasound Fellowship, North Florida Regional Medical Center Gainesville, FL

Robert Skinner, MD

Attending, Ocala Regional Medical Center Ocala, FL

EMS Fellowship, Univ. of Cincinnati Cincinnati, OH

Attending, AdventHealth Ocala, FL

Attending, Sunrise Mountain View Hospital Las Vegas, NV

Aaron Umansky, MD Caroline Smith, MD

Attending, Christus Trinity Mother Frances Tyler, TX

Stephanie Iken, MD

Attending, Ocala Regional Medical Center Ocala, FL

Nicholas Titelbaum, MD

Fellowship, Emory University Atlanta, GA

Raza Kazmi, MD

Joseph Tran, MD

Jessica Yap Holman, DO Attending, Team Health at AdventHealth Florida

UCF of Greater Orlando Maria Chamorro, DO

Attending, AdventHealth Ocala, FL

Research Fellow, Osceola Regional Kissimmee, FL

Attending, Ocala Regional Medical Center Ocala, FL

Pediatric EM Fellowship at Orlando Health Orlando, FL

Kimberly Johnson, MD

The following EM residency programs will graduate their first class in: 2022 • FSU at Sarasota Memorial • Orange Park Medical Center

2024 • Memorial Healthcare West • Broward Health 22

Attending, Emergency Physicians of the Rockies Denver, CO

Emily Drone, MD

Michelle Hernandez, MD Ultrasound Fellow, Osceola Regional Kissimmee, FL

Keegan McNally, MD

USF at Brandon Regional Ali Al-Marzoog, MD

Attending, Mon Health Medical Center Morgantown, WV

Melissa Bacci, MD

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

AdventHealth East Orlando Thomas Lawyer, MD

Ultrasound Fellowship, Osceola Regional Hospital Orlando, FL

Misty Coello, MD

Ricki Brown-Forestiere, MD

EMS Fellowship, OhioHealth Doctors Hospital Columbus, OH

Andrew Glickman, DO

Ultrasound Fellowship, AdventHealth Orlando, FL

Attending, Brandon Regional Hospital Brandon, FL

Jon Risovas, MD

Attending, Brandon Regional Hospital Brandon, FL

Elizabeth Janevski, MD

Attending, Kaiser Permanente Los Angeles, CA

Ultrasound Fellowship, AdventHealth Orlando, FL

Natalya Grigoryan, MD Patrick Hsu, DO

Attending, Brandon Regional Hospital Brandon, FL

Rashmi Jadhav, MD

Simulation Fellowship, Georgetown Univ. Washington, D.C.

Roli Kushwaha, MD

Attending, Hackensack Riverview Medical Center Hackensack, NJ

EMspecialists Dayton, OH

Yasmani Cartaya, MD

Samuel Muniz, MD

EMPros at AdventHealth Daytona, FL

Mount Sinai Medical Center Nicholas Boyko, DO

Meredith Marlow, DO

Attending, Floyd Medical Center Rome, GA

Bryce McClure, DO

Ultrasound Fellowship, Mount Sinai Medical Center Miami Beach, FL

Attending, Decatur Morgan Hospital Decatur, AL Ultrasound Fellowship, UF Jacksonville, FL

Stephanie Fernandez, MD

Fenil Patel, MD

Ryan Ngo, MD

Ultrasound Fellowship, Jacobi Medical Center Bronx, NY

Rachel Oliver, MD

Attending, Northwest Medical Center Margate, FL

Attending, Baylor University Medical Center Houston, TX Attending, Memorial Hospital Jacksonville, FL

Alex Prestley, MD

Rahul Paul, MD

Kevin Sigler, MD

Attending, St. Francis Hospital Roslyn, NY

Attending, Mount Sinai Medical Center Miami Beach, FL

Amber Mirajkar, MD

Ultrasound Fellowship, Univ. of Massachusetts Boston, MA

Attending, Mount Sinai Medical Center Miami Beach, FL

Mary Cate Slome, MD

Ultrasound Fellowship, Univ. of Pennsylvania Philadelphia, PA

Attending, Northwest Medical Center Margate, FL

Sherwin Thomas, MD

ACCESS THE ONLINE VERSION OF THIS ARTICLE HERE

Brown University, Simulation Fellow Providence, RI Research Fellow, Osceola Regional Kissimmee, FL

Medical Student Clerkship Director & Clinical Faculty at UHS Wilson Hospital, part of SUNY Upstate Binghamton, NY AdventHealth Ocala Ocala, FL

Keyon Shakroneh, DO

Caroline Shepherd, DO

EMpulse Summer 2021

Jenna Varner, DO

Ethan Zimmerman, DO

Updates from Florida’s

Emergency Medicine Residency Programs

CENTRAL FLORIDA

AdventHealth East Orlando By Tyler Mills, DO, PGY-3 Hello again from all of your EM friends in East Orlando. It’s hard to believe that another academic year has come to a close, but here we are again, sending another six newly-minted emergency physicians out into the world. However, the AdventEM family continues to grow as we welcome another group of eager young learners into the department. The new interns are busy with their onboarding process, but have already started getting to know them at social events. We would like to formally extend our biggest congratulations and welcome to all our incoming interns! We would like to congratulate Dr. Rutledge on her new position as Simulation Director. Since assuming her new role, she has already organized two simulation days. This month, residents enjoyed a newer simulation format called Rapid Cycle Deliberate Practice as they worked through challenging pediatric resuscitations together on simulation day. The newer format — perhaps best described as “pause, debrief and try again” — emphasizes repetition and “microdebriefing” to promote learning and retention. Finally, we have some exciting announcements. First we are proud to announce that the new site for our trauma rotation will be at Jackson Memorial South in Miami, FL. Lastly, residents have continued their work recording for the AdventEM podcast. Give us a listen! ■

SOUTH FLORIDA

Kendall Regional Medical Center By Kelly Wright, MD, PGY-3 Emergency Chief Resident

Hello from Miami! We are excited to kick off another academic year by welcoming our newest class of interns to the Kendall Family. We are excited to meet them at our annual Intern Welcome Party and help mold them into the best emergency physicians they can be. This past May, with the help of our EMS Director Dr. Brea and core faculty, we hosted our annual Wilderness Day at Oleta River State National Park. The residents were split into teams by class and each had to work through patient scenarios, testing the residents’ ability to handle life-threatening injuries without the usual resources available to us in the emergency department. The event was such a success, it was even covered by the local news — did you catch us on TV? We also participated in SAEM’s SonoGames, where our team placed EMpulse Summer 2021

1st in Florida and 8th nationally. It wouldn’t have been possible without the help of Ultrasound Fellowship Director Dr. Moreno, Ultrasound Fellowship Assistant Director Dr. Aviles, and Ultrasound Fellows Dr. Georges and Dr. Gomez for all the work they put into helping the residents learn and perfect our ultrasound skills. We would also like to congratulate Dr. Georges and Dr. Gomez, who have graduated as part of the first inaugural ultrasound fellowship class! Summer is always a bittersweet time for us. Just as we are welcoming our newest interns, we have to say goodbye to our graduating senior residents. We want to congratulate the Class of 2021 as they embark on their next journey, some of which include fellowship positions in sports medicine, wilderness medicine, toxicology, ultrasound and administration. We wish them all the best and will miss them greatly! ■ 23

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

CENTRAL FLORIDA

Orlando Health

By Drs. Gregory Black and Brody Hingst, PGY-3s Happy summer from Orlando Health! First and foremost, welcome to all of our new interns! We are so excited for you to join our family, and look forward to getting to know you better and learning alongside you. The new academic year is bittersweet, as it means we have to say goodbye to our senior residents. You will all be missed dearly, and we will be rooting you on as you continue to accomplish amazing things! Every June, Orlando Regional Medical Center (ORMC) remembers the tragedy of the Pulse Nightclub shooting, where 49 individuals lost their lives. We also remember the amazing response from our ER and trauma teams, who saw 36 patients in 36 minutes and saved all 40 individuals that made it to the trauma bay. In remembrance of this tragedy, an anonymous donor has given ORMC a $5 million dollar donation to expand and improve the trauma bay. This generous donation will be used to double the size of the current trauma bay. We are incredibly grateful and excited to implement this as soon as possible so we can better serve our community. In other news, our hospital has officially transitioned to an Epic-based EMR, which means there have been some growing pains in the ED. We would like to extend a huge thank you to Drs. Joshua Briscoe, Mitch Barneck and Keegan Mullins for helping us through these times. We cannot begin to imagine the hard work you have been doing behind the scenes, and we appreciate it! Speaking of summer, Symposium is coming up! We have missed our Florida colleagues this year, and look forward to seeing each of you in beautiful Naples. We are preparing our sunglasses, flip flops and academic presentations! ■ 24

NORTH FLORIDA

Orange Park Medical Center By Penny Côté, MD, PGY-2 As this unprecedented academic year comes to an end, we’re very excited with the new developments at Orange Park Medical Center. We have two new ultrasound fellowship-trained emergency physicians joining us in the next few months from Brooklyn, NY. Both are trained in resuscitative transesophageal echocardiogram (TEE) and will continue with formal TEE training in the fall! Speaking of ultrasound: we have over $100,000 in new equipment coming in, consisting of TEE probes, multiple new Butterfly IQ+’s, and a brand new Sonosite PX. We recently had a mass casualty incident exercise organized by Dr. Davis and Dr. Taylor Bosley, PGY-2 (former Army Special Forces medic and currently a doctor in the Florida Army National Guard Special Forces). This involved risk-stratifying the “injured” patients and managing multiple acute, life-threatening injuries at once. Not only did it give us a glimpse into the chaos of an MCI, but more importantly, it further reiterated how far along

we have come as a program and how strong, reliable and hardworking our team is. It was a complete success in many ways! This is an event our program will be hosting annually. Our residents have also continued to be very involved in the local community and overseas. Dr. Cody Russell has been helping out with the Jacksonville Sports Medicine Program pre-participation sports physicals, which helps kids get cleared to play sports for the year. Multiple PGY-2’s went on international medical electives where they had extremely limited resources: Dr. Janae Fry recently returned from Kenya, where she spent her elective month providing medical care at Chogoria Hospital. Dr. Uju Eziolisa recently returned from Guatemala, where she was on a medical mission through Caring Partners International. Most importantly, we are preparing to welcome our 12 new interns to our family and we couldn’t be more excited! ■

SHARE ONLINE Access the online version of each residency program update by clicking on the photo that accompanies that update. Follow FCEP’s social media channels to share in realtime! EMpulse Summer 2021

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

UF Gainesville By Megan Rivera, MD, PGY-2 NORTH FLORIDA As summer marks the end of the academic year, a new chapter begins. We are preparing for the arrival of our new interns and fellows while sending our seniors off with bittersweet goodbyes. The Class of 2021 rose to the challenges of the past year and demonstrated an unwavering ability to lead. We have no doubt they will continue to soar as attendings and look forward to their contributions to our specialty. There seems to never be a shortage of exciting news, and our faculty have been making waves this summer. FCEP’s immediate past-president and our Chair of Emergency Medicine, Dr. J. Adrian Tyndall, has been selected as the next Dean and Executive Vice President at the Morehouse School of Medicine in Atlanta, GA. Dr. Tyndall became faculty at UF in 2006 and assumed Chair of the Emergency Department in 2008. Since then, he has established outstanding interdepartmental relationships, vigorously advocated for emergency medicine, and oversaw the department with grace. We are so thankful to Dr. Tyndall for his innumerable contributions.

Dr. Mary Patterson, a professor of pediatric emergency medicine, will be assuming the role of interim chair. Beyond caring for our tiniest patients, Dr. Patterson is the Director of the Center for Experimental Learning and Simulation, as well as the Associate Dean of Experimental Learning in the College of Medicine. She has worked tirelessly in the simulation lab with residents, and we are so excited to see what great things Dr. Patterson will accomplish next. Special announcements for the Pediatric Emergency Department continue! Our beloved Dr. Jennifer Light was recently awarded the UF Lifetime Achievement Award. Dr. Light was involved in the creation of the Pediatric Emergency Department and has been faculty at UF for over 20 years. Under her guidance, the Pediatric Emergency Department has thrived and is constantly striving for that next level of excellence. With that being said, the department’s application for a Pediatric Emergency Medicine Fellowship has recently been approved by the UF GME Committee and is pending review by

the ACGME. Drs. Carolyn Holland and Tricia Swan have worked diligently to make this happen, and their passion for education has not gone unnoticed. We are so thrilled and look forward to meeting our UF PEM Fellows as early as next year. Perhaps most importantly, our department has been doubling up the wellness in our continued efforts to return to post-COVID normalcy. Our PGY-2s worked hard and played even harder as they rented a beach house for their virtual SAEM conference. We have initiated post-conference, micro-wellness events for residents and faculty, which has included brewery hopping, annihilating our PD’s in paintball, and lots of arcade games so far. Residents also recently enjoyed a day at Rainbow Springs filled with grilling, swimming, and kayaking. We have many more exciting things planned as our interns are onboarding. We’re halfway through the year, and things have been bright here at UF! We look forward to what the rest of the summer has in store for us. ■

St. Lucie Medical Center By Nicole Tobin, DO, PGY-2 SOUTH FLORIDA We at St. Lucie are very excited that summer has also brought us back to in-person learning! We have been able to participate in our Jeopardy competitions again and complete our annual EKG competition. We are optimistic that, with these new changes, we will be able to participate in the SIM lab again and gain those invaluable experiences for our clinical knowledge and procedural skill abilities.

The incoming interns have relocated down to Port St. Lucie to start orientation! We are excited to welcome them all to our department and share our knowledge with them. The transition from medical student to resident is not always an easy one, but it is something we are happy to help them navigate through. In-person learning has also given us the opportunity to enjoy our seniors’ EMpulse Summer 2021

last lectures and send them off in the style they deserve. We have been able to reflect on both good and entertaining times that have been shared in and outside of our department together. We have all learned so much from them and are grateful to have had the opportunity to work with them. They will be greatly missed, but we have no doubt they will continue to achieve great things in their own practice. Good luck! ■ 25

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

Brandon Regional Hospital By Dr. Calixto Romero III, MD, PGY-3 SOUTH FLORIDA

Aventura Hospital By Dr. Scarlet Benson

Assistant Clinical Professor Aventura congratulated its third graduating class on June 15 with a lovely graduation dinner planned by our residency program coordinator, Angie Taylor, and hosted at Piazza Italia in Fort Lauderdale. We are so proud of them and look forward to seeing their careers blossom as new attendings, critical care and ultrasound fellows! In addition, we said goodbye to Clerkship Director Dr. Annalee Baker, who will be starting a new position as the program director at NYU Bellevue in Manhattan, and our assistant CDEM Dr. Scarlet Benson, who will be taking a clinical position within the community. We welcomed the new intern class of 2024 for orientation in July with a busy schedule of academic lectures coordinated by our education director, Dr. Laurence Dubensky, as well as hands-on workshops, including simulation and ultrasound days planned by our Sim Mom, Dr. Jessica Cook, and our US gurus, Drs. Huy Tran and Guarav Patel. Our senior chief residents were announced for the 2021-2022 academic year. Best of luck to Drs. Fayez Ajib, Benjamin Pirotte and Nicolas Ulloa - we know you will bring enthusiasm and positive energy to the new positions! Although summer is usually a slower season for academic conferences and publications with the change in residency classes, Drs. Kody Moynihan-Sacks and Drew Winters presented a poster at AAEM in St Louis in June 2021 on elbow injuries, mentored by our sports medicine attending, Dr. John Childress. We are gearing up for another busy fall and hope to engage our new intern class in their new academic pursuits soon! ■ 26

Chief Resident

Our program is having a bittersweet moment: the end of an absolutely wonderful (and stressful) year. We have seen an intern class start growing into amazing doctors, but we also said goodbye to our first graduating class. The Brandon Regional Hospital Emergency Medicine Graduating Class of 2021 have all accepted positions for post-residency life. Five of our graduates secured fellowships in critical care medicine, emergency ultrasound, and simulation. Two of our graduates have joined the ranks of our amazing attending physicians here at Brandon Regional Hospital. The other eight physicians have accepted positions in ERs across the country, including Alabama, New Jersey, Texas, California, Virginia and Florida. We all wish them luck in their future endeavors and on their board exams. We have accrued many wonderful faculty in our program over the last few months. Most recently, we welcomed Dr. Rafael Colon-Hernandez, who is a board-certified emergency physi-

WEST FLORIDA cian and fellowship-trained in hyperbaric medicine. This just adds to the star-studded lineup of amazing faculty physicians that we already have. Our program is very excited to welcome our incoming interns, the Class of 2024. They are a fantastic group and will surely do very well with us at BRH! We also continue to have wonderful additions to our academic calendar. This year, we will be adding a “Critical Care Corner,” more simulations in our hospital’s own simulation room (and at the state-of-the-art simulation facility), and much more! We also continue to have tons of new research and quality improvement projects being started. Lastly, the chief residents this year, Drs. Cecilio Padron, Brian Szczucki and myself, are all very thankful for each of our resident colleagues, our wonderful faculty, our program director and associate program directors, and our lovely program coordinators. This program’s success is certainly due to the comradery that we all have with each other. ■

USF at Tampa General Hospital By Kenneth Dumas, PGY-2 Greetings from the TGH/USF family. It is that time again, although bittersweet, to say congratulations and goodbye to the class of 2021! During their short time here, they were not only excellent doctors, but also leaders and mentors. We could not be prouder of their accomplishments and cannot wait to see what they will accomplish in their sure to be bright careers. We are also excited to announce that we recently had the opportunity to complete a nationally recognized difficult airway course. This was made possible by a grant obtained by one of our fabulous seniors, Dr. Hundley, in EMpulse Summer 2021

WEST FLORIDA combination with the hard work of our medical director, Dr. Wein, and many others. In this course, our residents worked with visiting and home faculty to gain experience on a variety of airway modalities, including fiber optic, and worked through different, challenging simulated airway cases in our state-of-the-art sim center CAMLS. We look forward to another exciting academic year and cannot wait to start working alongside our new intern class. Follow along to see other exciting developments in our program. ■

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

Florida Atlantic University WEST FLORIDA

By Tony Bruno, DO, PGY-2 Summer is in full swing down here in South Florida. While we are looking forward to our new class of residents to begin their training, we are sad to say goodbye to our departing seniors. We want to wish a big congratulations to our graduating residents, all of whom have signed contracts or moved onto fellowships. We thank you for your great leadership and contributions. You will make us proud representing our program in your next endeavors. To celebrate this momentous event, we attended a wonderful evening at the Addison in Boca Raton. Adding to the memorable distinction was the fact that this was the first time our program

SOUTH FLORIDA had been together in its entirety since the beginning of the COVID-19 pandemic. What a night it was, complete with cocktails, a fantastic dinner and great company! While we have said goodbye to our graduating class, we did have the pleasure of welcoming Dr. Michael Turchiaro’s newest and youngest daughter, Julia (Class of 2050), into our family. We are also excited to have chosen two new chief residents. Congratulations to Drs. Spencer Greaves and Rebecca Mendelsohn on your new positions. ■

Jackson Memorial Hospital By EM Residency Program Staff Greetings from Miami! It has been an eventful few months, as life is getting back closer to normal in Miami and Jackson Memorial Hospital. We had a much too long delayed residency retreat at Oleta River State Park, which was a lot of fun. It was great to get together as a group and spend time with our residents live and in-person. It was also fun to see people without masks; we even realized we had not seen our first-year class without them (except on Zoom)! We are excited to have our class of 2024 join us. Initially, like all things in the last year, we spent time on Zoom working through the Bridge to EM curriculum. Although it was a great way to meet our intern class and to get them started in emergency medicine, we were eager to have them join us in Miami and meet them for the first time in person during a fun outdoors BBQ.

SOUTH FLORIDA It is an exciting time to get to know the class and start their training as emergency physicians. We also had the bittersweet departure of our graduating seniors. It is incredible how quickly time goes by. It feels like it was just yesterday we were welcoming this class, and now we are sending them off to the real world. We had our second Zoom graduation ceremony, which, from a technical perspective, went much better than our first attempt. We really have become Zoom experts in the last year. We also had an evening event with family and friends, which was a great sendoff for our class of 2021. We wish them the best of luck as they move forward with their EM careers. Here’s to a warm and breezy and not too wet hurricane season. ■ EMpulse Summer 2021

FSU at Sarasota Memorial Thomas Cox, MD, PGY-3 Hello from Sarasota! We are excited to welcome our new class of PGY-1s and complete our residency program. Since our last update, we have had another successful Research Day, which highlighted research from faculty, residents, EMS, medical students, pharmacists and nursing. In addition, we announced our collaboration with the University of Michigan in the Emergency Medicine Education and Research by Global Experts Network. All of this is possible due to our Director of Research, Dr. Sagar Galwankar, who was named this year’s recipient of the American Academy of Emergency Medicine (AAEM) Amin Kazzi International Emergency Medicine Leadership Award. Under the leadership of Dr. Ashley Grant, Ultrasound Director, we are moving forward in implementing transesophageal echography for cardiac resuscitation in the emergency department. As we continue to advance our own ultrasound training, we are also starting to help train our internal medicine and medical student colleagues. At our resident retreat, we enjoyed the sun and beautiful waters of the Gulf Coast. Residents, faculty and family came together to celebrate the success our program has enjoyed since its inception 2 years ago, all of which culminated with the announcement of leadership roles of our rising PGY-3s. Additionally, we would like to congratulate our new Chief Residents, Drs. Courtney Kirkland and Geoffrey Wade. We wish everyone around the state a happy, exciting and safe start to the new academic year. ■

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

UCF/HCA of Greater Orlando By Amber Mirajkar, MD CENTRAL FLORIDA As the academic year winds down, it is bittersweet to say goodbye to our seniors while simultaneously preparing to welcome our newest interns. Dr. Michelle Hernandez will be one of two ultrasound fellows at our program, and she will be joined by Dr. Thomas Lawyer, who is coming from AdventHealth East Orlando’s EM Residency. Drs. Maria Chamorro and Amber Mirajkar will stay on as Research Fellows. Dr. Keegan McNally is heading to Brown University as their new Simulation Fellow. Dr. Mary Cate Slome is joining the faculty at UHS Wilson Hospital, part of SUNY Upstate, as the medical student clerkship director and clinical faculty. Dr. Emily Drone matched into a Pediatric EM Fellowship at Orlando Health. Last but not least, Dr. Sherwin Thomas will be joining the ED staff at AdventHealth Ocala. We wish them all the best of luck! Rising vaccination numbers and easing mask restrictions are beneficial for our didactics. Always innovating, our attendings now have one didactic day a month for simulation, socially distanced at UCF, as well as one didactic day per month in person for small group learning. We also make time for excursions, such as working

with Osceola County EMS and Fire Rescue in extraction simulations at a junkyard. There, the senior class observed how EMS operates in the field, from removing a car around an entrapped patient to intubating said entrapped patient. Then, our residents got to do it themselves. It was an amazing experience we owe to EMS Medical Director, Dr. Ayanna Walker, and Osceola County. As Florida continues to open back up, our residents have started volunteering again. Our residents staffed the medical tent at the EDM festival in June. Our faculty are very supportive of our community efforts, even allowing volunteering activities to count as clinical hours. Speaking of faculty, we are excited to announce the addition of Dr. Judy Lin, MD, FACEP as our Ultrasound Fellowship Director. She is coming from Maimonides Emergency Medicine in New York City, where she was Director of Fellowship Ultrasound Education. Dr. Lin completed her EM residency and ultrasound fellowship at Georgetown University Hospital. We are looking forward to her expertise. Furthermore, we would like to

congratulate Dr. Ariel Vera, who has become our new Associate Program Director, taking over from Dr. Tracy MacIntosh. Dr. MacIntosh was selected as UCF College of Medicine’s Associate Dean of Diversity, Equity, & Inclusion. Luckily, both will remain as core faculty in our program. Although SAEM was virtual again this year, we had a blast participating, specifically in Sonogames. Drs. Emily Drone, Michelle Hernandez, Mark Rivera, and Martin Morales represented us during the games. We look forward to participating next year, too! ACEP is right around the corner, and we are eagerly preparing, with multiple residents having submitted abstracts. Our residents continue to be prolific in scholarly activity with several abstracts submitted to ACEP. Many thanks to Dr. Latha Ganti for coordinating all our efforts. There are many bittersweet changes on the horizon as the academic year comes to an end. However, we see it as a promising new beginning instead. Congratulations to all the graduating seniors, and good luck to all the incoming interns! ■

Ocala Regional Medical Center By Jean Laubinger, MD, MPH and Emily Clark, MD NORTH FLORIDA Summer is here in Ocala! Our residents were treated to a much deserved, endof-year float trip down Rainbow River. We celebrated our graduating residents and spent time with one of our new interns. It was a wonderful day of relaxation on the water as we enjoyed the beautiful nature of Ocala, including river otters, plenty of fish, and, to many of our residents’ delight, no alligators. The graduation festivities continued with families and friends at the 28

Ocala Country Club. In addition to the presentation of diplomas, we reminisced on our shared experiences with our senior residents and wished them well as they head out into their careers. Our faculty were also celebrated: Dr. Titlebaum was honored for his commitment to teaching this past year. Dr. Ganti deservedly earned faculty member of the year. Congratulations to Dr. Ilya Alexandrovski for completion of his administrative fellowship. EMpulse Summer 2021

Now in our program’s fifth year, we look forward to making new memories with our incoming residents and watching our current residents grow as leaders in the department. Although this past year was fraught with the unknown, we are emerging from the pandemic with the unwavering support of our faculty and emergency department staff. We look forward to the year ahead! ■

UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS

Oak Hill Hospital By Mohammad Razzaq, DO, PGY-2 Hello from Oak Hill! We’ve had an incredibly busy spring and we’re excited for summer to arrive. First, we would like to announce the graduation of our inaugural class. Last month, residents and faculty enjoyed dinner together to celebrate the occasion. Congratulations to all: we’re so proud of you, and wish you nothing but the best in your careers going forward. We’re also happy to announce that we have chosen our new chief residents for the upcoming academic year. Congratulations to Dr. Rondon and Dr. Bencomo! We’re thrilled to see what ideas our new chiefs will bring to the program. Best of luck to both of you!

WEST WEST FLORIDA FLORIDA The Class of 2024 began their residency journey on July 1 with a field day! We have several team-building events scheduled to help welcome the new intern class to the Oak Hill family.

As this is the end of the academic year, we would like to take a moment to recognize several members of our team for their outstanding contributions. Dr. Andrew Sellinger earned the UF Society of Teaching Scholars’ Outstanding Resident Educator Award, based on medical student feedback of his teaching

By Jayden Miller, MD, PGY-2 Here at North Florida, we have been busy with summer transitions. Our two new APDs have taken the reins. Drs. Tom Bentley and Diana Mora have spent time renewing and improving our education curriculum, wellness and clinical experiences.

NORTH FLORIDA

Graduation was a bittersweet affair on June 5. We were so happy to have an in-person event now that all participants are vaccinated. It was a joy to celebrate the Class of 2021 with our residency family and their families. Dr. Mollie Powell won Resident of the Year, voted on by our nursing and ancillary staff. Dr. Powell always goes an extra mile in the department, representative of her commitment to the team effort that is emergency medicine. Drs. Evan Stern and DJ Martin also won faculty awards for their commitment to our education.

By Chris Phillips, MD, PGY-2

We also recently competed in the SAEM virtual SIM wars. We’re proud of our team for making it to the finals and finishing in 2nd place this year! Drs. Chelsea Allen, Semir Karic, Jessica Ramos and Rick Courtney did a fantastic job representing UF Jax.

UCF at North Florida Regional

Construction of our new ED continues to grow closer to completion. The new building is starting to take shape, and we’ve gotten a glimpse into what the future holds. We are scheduled to move into the new facility by winter. We’ve also made headway in the expansion of the GME building, which will include a new resident wellness area. A lot is happening at Oak Hill, so stay tuned for more updates! ■

UF Jacksonville We would like to congratulate our graduating seniors: we are grateful for the leadership you’ve exhibited over the years and wish you the best of luck in your new careers. While it’s bittersweet to say goodbye to our seniors, we are thrilled to welcome the Class of 2024 to our family! The new intern class has begun their ultrasound training and first shifts in the ED.

NORTH FLORIDA

performance this year in the ED. This honor is well-deserved and speaks to Andrew’s strength as an educator within our residency program. Dr. Alberto Romero was recognized by UF Jacksonville leadership as an “Unsung Covid Leader” to honor the positive impact he had during the pandemic. Dr. Romero went beyond his responsibilities by spending his free time visiting, playing guitar and singing for patients who were struggling with COVID-19. He remained at bedside with one patient to fulfill a promise made to the patient’s mother, who was unable to be with her son before his passing. And finally, the following attending physicians won the Exemplary Teacher Award this year: Dr. David Caro, Dr. Daniel Eraso, Dr. Mark McIntosh, Dr. Thomas Morrissey, Dr. Stephen Topp, Dr. Deborah Williams, and Dr. Todd Wylie. We are lucky to have so many wonderful educators at our program and are looking forward to this upcoming year! ■ EMpulse Summer 2021

We have been working hard, but also finding time for wellness! The graduating Class of 2021 enjoyed a retreat to the beach to relax and prepare for their transitions to fellowship and attending roles. We are excited to get our ultrasound fellowship up and running with our new fellows, Drs. Josh Middleton and Mollie Powell.

We are so happy to have our newest residents in town, as well. We hosted the Intern Welcome Party at First Magnitude Brewery and welcomed the new interns to the North Florida Family. Intern boot camp will be facilitated by the chiefs, Drs. MaruganWyatt, Lee and Nicholas, to ensure a smooth transition for them into residency. ■

CASE REPORT

Emergency Department Case: Covid-19 Related Guillain-Barre Syndrome Dr. Katherine Wietecha Department of Emergency Medicine, Kendall Regional Medical Center

ABSTRACT

INTRODUCTION

CASE NARRATIVE

SARS-CoV-2 (Covid-19) is commonly associated with respiratory compromise. However, a wide range of neurologic syndromes have been reported over the past year. Of these complications, Guillain-Barre Syndrome (GBS) has manifested in several Covid-19 patients following initial illness. This case report describes a 57-year-old male who presented with acute onset symmetric bilateral lower extremity weakness after a recent Covid-19 infection.

SARS-CoV-2 (Covid-19) is commonly associated with respiratory compromise. However a wide range of neurologic syndromes have been reported over the past year.1 Of these complications, Guillain-Barre Syndrome (GBS) has manifested in a number of Covid-19 patients following initial infection.2,3 GuillainBarre Syndrome is characterized as a demyelinating process leading to symmetric weakness of the extremities and areflexia elicited by a viral or bacterial infection.4 The peak of the patient’s symptoms usually occurs within four weeks of onset, however patients may present for evaluation early in their course. A high clinical suspicion should guide the diagnosis in the emergency department. A lumbar puncture can support the diagnosis if an albuminocytological dissociation is seen. Nevertheless, a normal CSF cannot exclude the diagnosis in patients presenting earlier than one week of onset of symptoms.5 This case presentation describes a postCovid infection patient with clinical symptoms concerning for GuillainBarre Syndrome.

A 59-year-old male patient presented to our emergency department reporting symmetric bilateral lower extremity weakness lasting for one day. His weakness had gradually worsened over the past 24 hours, causing difficulty with walking. He also had associated numbness and tingling in his bilateral hands and feet. He had no incontinence or saddle anesthesia. The patient was diagnosed with Covid-19 two weeks prior with a positive test result.

In the emergency department, his cerebrospinal fluid analysis showed an albuminocytologic dissociation consistent with GuillainBarre Syndrome. Intravenous immunoglobulin treatment was initiated, and the patient was admitted to the hospital. As the incidence of SARS-CoV-2 cases increases, emergency physicians must keep a high index of suspicion for patients with weakness or areflexia following a recent Covid-19 infection. The ability to recognize the disease process in the emergency department could lead to lifesaving supportive care and early treatment. 30

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EMpulse Summer 2021

Upon neurological examination, the patient was alert and oriented with no cranial nerve deficits. His muscle strength examination displayed bilateral lower limb weakness of grade four on the MRC scale. His upper extremity strength remained intact. The patient’s sensation was diminished distally to proximally in his bilateral upper and lower extremities. His plantar and patellar reflexes were absent. On gait examination, the patient was staggering and ataxic. He was unable to walk greater than three feet. Due to high suspicion for Guillain-Barre Syndrome, a lumbar puncture was performed following a computed tomography of his brain

and cervical spine with no acute abnormalities. His cerebrospinal fluid analysis showed an albuminocytologic dissociation consistent with GuillainBarre Syndrome. Intravenous immunoglobulin of 0.4g/kg/day was ordered. The patient was admitted to the step-down unit for continued management due to an initial forced vital capacity of >20mL/kg, no respiratory distress, and no difficulty breathing per the patient. The following day, the patient was transferred to the intensive care unit following difficulty taking deep breaths and declining forced vital capacity. The patient was placed on BiPAP with a low threshold to intubate. His paresis ascended to involve his upper extremities and facial muscles. Magnetic resonance imaging of his brain, cervical spine, thoracic spine, and lumbar spine demonstrated no pathological findings to correlate with his neurological symptoms.

DISCUSSION In this patient presentation, the initial symptoms were distinctive of GuillainBarre Syndrome. Every year, 0.4 to 4 per 100,000 people are diagnosed with Guillain-Barre Syndrome.6,7 According to a retrospective case series, only up to 25% of Guillain-Barre patients are diagnosed on their first visit to the emergency department.7,8 The low rate of initial diagnosis is alarming, as 10-30% of Guillain-Barre Syndrome patients will develop respiratory muscle weakness requiring ventilatory management.9 As the incidence of SARS-CoV-2 cases increases, it is imperative that emergency physicians keep a high index of suspicion for patients with neurologic symptoms following a recent Covid-19 infection. Likewise, atypical symptoms should be considered when evaluating the patient including facial or arm weakness, cranial nerve involvement, dysautonomia, and pain from nerve root inflammation.4,10-12 The ability to recognize the disease process in the emergency department could lead to lifesaving supportive care. Furthermore, the initiation of therapy, plasma exchange or Intravenous Immunoglobulin, causes an accelerated recovery time.13 ■

REFERENCES 1. Paterson RW, Brown RL, Benjamin L, et al. The emerging spectrum of COVID-19 neurology: clinical, radiological and laboratory findings. Brain. 2020;143(10):3104-3120. doi:10.1093/brain/awaa240 2. Scheidl E, Canseco DD, HadjiNaumov A, Bereznai B. GuillainBarré syndrome during SARS-CoV-2 pandemic: A case report and review of recent literature. J Peripher Nerv Syst. 2020;25(2):204-207. doi:10.1111/ jns.12382 3. Abu-Rumeileh S, Abdelhak A, Foschi M, Tumani H, Otto M. Guillain-Barré syndrome spectrum associated with COVID-19: an up-to-date systematic review of 73 cases. J Neurol. 2021;268(4):1133-1170. doi:10.1007/ s00415-020-10124-x 4. Sejvar JJ, Baughman AL, Wise M, Morgan OW. Population incidence of Guillain-Barré syndrome: a systematic review and meta-analysis. Neuroepidemiology. 2011;36(2):123133. doi:10.1159/000324710 5. Fokke C, van den Berg B, Drenthen J, Walgaard C, van Doorn PA, Jacobs BC. Diagnosis of Guillain-Barré syndrome and validation of Brighton criteria. Brain. 2014;137(Pt 1):33-43. doi:10.1093/brain/awt285 6. McGillicuddy DC, Walker O, Shapiro NI, Edlow JA. GuillainBarré syndrome in the emergency department. Ann Emerg Med. 2006;47(4):390-393. doi:10.1016/j. annemergmed.2005.05.008 7. Noto A, Marcolini E. Select topics in neurocritical care. Emerg Med

Clin North Am. 2014;32(4):927-938. doi:10.1016/j.emc.2014.07.015 8. Suarez GA, Fealey RD, Camilleri M, Low PA. Idiopathic autonomic neuropathy: clinical, neurophysiologic, and follow-up studies on 27 patients. Neurology. 1994;44(9):1675-1682. doi:10.1212/ wnl.44.9.1675 9. Alshekhlee A, Hussain Z, Sultan B, Katirji B. Guillain-Barré syndrome: incidence and mortality rates in US hospitals. Neurology. 2008;70(18):1608-1613. doi:10.1212/01. wnl.0000310983.38724.d4 10. Moulin DE, Hagen N, Feasby TE, Amireh R, Hahn A. Pain in GuillainBarré syndrome. Neurology. 1997;48(2):328-331. doi:10.1212/ wnl.48.2.328 11. Ruts L, Drenthen J, Jongen JL, et al. Pain in Guillain-Barre syndrome: a long-term follow-up study. Neurology. 2010;75(16):1439-1447. doi:10.1212/WNL.0b013e3181f88345 12. Flachenecker P. Autonomic dysfunction in Guillain-Barré syndrome and multiple sclerosis [published correction appears in J Neurol. 2008 Feb;255(2):309-10]. J Neurol. 2007;254 Suppl 2:II96-II101. doi:10.1007/s00415-007-2024-3 13. Hughes RA, Wijdicks EF, Barohn R, et al. Practice parameter: immunotherapy for Guillain-Barré syndrome: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2003;61(6):736-740. doi:10.1212/wnl.61.6.736

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July 2021

ULTRASOUND ZOOM

On Cardiac Tamponade By Anna Culhane, MD, PGY-3

University of Miami / Jackson Health System

INTRODUCTION As an emergency physician, when I think of diagnosing cardiac tamponade, my mind immediately goes to the traditionally taught Beck’s triad of muffled heart sounds, low blood pressure, and distended neck veins. However, I have learned through experience that muffled heart sounds are difficult to hear in a noisy emergency department, hypotension is not always present, and neck veins are mostly elusive. A major concern for all emergency physicians is that cardiac tamponade can quickly decompensate into cardiac arrest. While a crash cart situation may sound exciting for some, it is disruptive and unsettling for most healthcare staff and most importantly terrible for the patient. It is relatively easy to diagnose a pericardial effusion. However, it is extremely difficult to convince consultants that there is an impending tamponade, especially in the face of normal blood pressures. This challenge appears to increase exponentially at night. How can we convince our consultants to spring out of bed at 3:00 am for a procedure on a patient with stable vital signs? Here is where a systematic cardiac point-of-care ultrasound (POCUS) might just do the trick. We know POCUS is quick and efficient. A 2017 study on 73 patients compared the diagnosis of tamponade with POCUS to that with CT scans, and demonstrated that POCUS led to decreased pericardiocentesis times (11.3 vs. 70.2 hours, P=0.055) and a shorter length of hospital stay (5.1 vs. 32

Edited by Leila Posaw, MD, MPH

Emergency Ultrasound Faculty, Jackson Memorial Hospital

7.0 days, P=0.222).1 To diagnose tamponade with POCUS, there are six questions that need careful evaluation. When these six findings are all present on a patient, they should prompt a response even from the most obstinate consultant.

FRAMEWORK A phased array transducer should be used to obtain cardiac views and answer the six questions listed below. These views include the inferior vena cava (IVC), parasternal long axis (PSLAX), parasternal short axis (PSSAX), sub-xiphoid (SX), apical four chamber (AP4C), and IVC size and collapsibility. B-mode, M-mode, and pulse wave Doppler modes are useful. The questions that need to be answered to diagnose tamponade are: 1. Is there a pericardial effusion, and how big is this? 2. Is there right atrial collapse during filling? 3. Is there right ventricular collapse during filling? 4. Is the inferior vena cava plethoric? What is the collapsibility index? 5. Is the respiratory variation of the mitral and tricuspid valve inflow velocities exaggerated? 6. Is the direction of blood flow in the hepatic veins reversed? But first, what is cardiac tamponade? Cardiac tamponade is a syndrome that results from the compression of the heart by a pericardial effusion, which impedes normal cardiac function and results in hemodynamic compromise and obstructive shock. EMpulse Summer 2021

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A normal heart is surrounded by a small amount of physiologic effusion which serves several useful functions, for example lubrication. Several conditions, such as infection, trauma, inflammation, and cancer may lead to the accumulation of larger effusions. Consider the case of a 26-year-old woman with a history of end stage renal disease who presented to our emergency department with dyspnea. Upon arrival, she was considered “stable” with a heart rate of 88 and blood pressure of 111/92. However, our careful systematic POCUS examination revealed a large pericardial effusion and the looming threat of cardiac tamponade.

Step 1a: Is there a pericardial effusion?

A pericardial effusion appears as a dark, anechoic collection typically surrounding the heart. However, in the setting of dissection, trauma, or cardiac surgery, it may present as a small, localized effusion. Physiological pericardial effusions are usually less than 50 mL and are visualized during systole. If an effusion is appreciated during both systole and diastole, we can assume that it is most likely greater than 50 mL. Additionally, effusions can be categorized as simple or complicated with septations, strings, and floating debris. Even though a pericardial effusion can be visualized in any of the four standard views, the preferred views to visualize an effusion are the PSLAX (Video 1) and SX (Video 2). On our exam, we found a large, anechoic

collection, which dominated every view (Fig. 1a-1b). The heart was seen swinging back and forth in this fluid, aptly called the “swinging heart” sign.

Step 1b: How big is the effusion?

The largest pocket of fluid should be measured at end-diastole from leading edge to leading edge of the pericardial sac. A small effusion is less than 10 mm, a moderate effusion is 10-20 mm, and a large effusion is more than 20 mm. It is important to measure the effusion in multiple views to obtain an overall 3D impression. Our effusion was found to measure 40-50 mm, a large effusion (Fig. 1c, 1d). Although size estimation is useful, the rate of fluid accumulation is often more important. Small volume effusions that accumulate quickly can cause a tamponade just as easily as large volume chronic effusions. However, neither the presence nor the absolute size is definitive for the diagnosis of cardiac tamponade, and we must move to Step 2 to assess for tamponade physiology.

Step 2: Does the right atrium collapse?

The right atrium has thin walls and collapses easily. When filling with blood in atrial diastole (ventricular systole), the right atrium should expand. Right atrial collapse in atrial diastole (ventricular systole) is the earliest POCUS finding in tamponade making it sensitive. However, as it may also occur in the absence of tamponade it is not specific.2 On our exam, we see this best in our PSSAX view (Fig. 2, Video 3).

Step 3: Does the right ventricle collapse?

The right ventricle has thicker walls than the right atrium and collapses less easily. Normally, the atria contract, the valves open, and the ventricles expand and fill with blood. In tamponade, the ventricles collapse due to high pressures exerted by the pericardial effusion. As opposed to right atrial collapse, right ventricular collapse is highly specific (75-90%), but not very sensitive (48-60%) for tamponade.2 The absence of both right atrial and ventricular collapse during filling has a 90% negative predictive value for tamponade.2 Right ventricular collapse in diastole is best visualized in the PSLAX view (freeze and scroll). The timing of mitral valve opening can be used to determine ventricular diastole. In tamponade, when the mitral valve is open, the right ventricular free wall will be seen to collapse (move inwards) (Video 1).

Fig 1a: Parasternal long axis view, B-mode: Pericardial effusion

Fig 1b: Parasternal short axis view, B-mode: Pericardial effusion

You can also confirm right ventricular collapse using M-mode. In the PSLAX view, the M-mode marker is placed on the mitral valve leaflets to produce the typical E-A pattern. The mitral valve is open at the E-wave. A corresponding dip in the right ventricular free wall at this point suggests ventricular collapse rather than expansion (Fig. 3). On our AP4C view both right atrial and right ventricular collapse are seen. This alternating collapse is also known as the “bouncing trampoline” sign (Video 4).

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Step 4: Is the IVC plethoric?

In cardiac tamponade, right atrial filling is impaired and blood backs up into the IVC, making it plethoric (more than 2.1 cm). This is sensitive (95-97%) but not specific (40%) for cardiac tamponade. Tamponade is associated with minimal (< 50%) respiratory variation.2 However, if there is > 50% respiratory variation, tamponade is excluded with a 97% specificity.3 On POCUS, the IVC is obtained in the sagittal view, and measured 2-3 cm from where the IVC meets the right atrium, or 1cm from where the hepatic vein enters the IVC. In the same sagittal view, M-mode can be utilized to calculate a collapsibility index. Continue on next page ▶

Fig. 1c: Apical 4-chamber view, B-mode: Pericardial effusion

Fig. 1d: Subxiphoid view: Pericardial effusion

Fig. 2: Short axis view, B-mode: Pericardial effusion 33

◀ Continued from page 13 On our exam, our patient was found to have a plethoric IVC with minimal respiratory variation (Fig. 4). Fig. 3: Parasternal long axis view, M-mode: Right ventricular free wall collapse timed with the E-wave opening of the mitral valve

Fig. 4: Inferior vena cava, sagittal view, M-mode: Dilated with minimal respiratory variation

Fig. 5: Parasternal long axis view, pulse wave Doppler: Respiratory variation of mitral inflow velocity. Slow speed allows assessment of several respiratory cycles

Step 5: Is the pattern of in-flow velocity of the mitral valve normal?

The in-flow velocities of the mitral and tricuspid valves gradually increase and decrease during the respiratory cycle. Analogous to pulses paradoxus, this pattern is exaggerated in cardiac tamponade. This is best obtained with the pulse wave doppler mode in the AP4C view, in which the blood flow through the valves is roughly parallel to the sound waves. The pulse wave Doppler gate is placed at the tip of the valve leaflets. Several respiratory cycles are captured with a slow sweep speed, adjusted to 25 mm/s. Next, the peak of the highest E-wave and the peak of the lowest E-wave is measured. This can be performed on the mitral and tricuspid valves. A respiratory variation of more than 25% for the mitral valve and more than 40% for the tricuspid valve suggests cardiac tamponade.2 On our exam, our patient had a respiratory variation of the in-flow velocity of the mitral valve of greater than 50%, further suggesting the

with three waves: a small retrograde A wave, followed by anterograde S and D waves. The S wave should be much larger in magnitude than the D wave with both showing negative deflections, as blood flows away from the probe. In the setting of cardiac tamponade, the magnitude of the S wave will decrease as systolic phase venous flow decreases and eventually becomes positive, corresponding to a reversal of blood flow (Fig. 6).

CONCLUSION Cardiac tamponade is a serious and life-threatening condition that requires prompt attention and intervention, before the patient becomes unstable. Our six-step POCUS framework can assist with making the diagnosis and convincing our consultants that immediate action is needed. Our patient had the characteristic findings of cardiac tamponade on POCUS: large, circumferential pericardial effusion, right ventricular collapse on filling, right atrial collapse on filling, plethoric IVC with minimal respiratory variation, exaggerated respiratory cycle changes in mitral valve in-flow velocity. An effusion drainage procedure was performed. Disaster averted with another save by POCUS! Celebrate to the tune of this rap by The EMC. ■

presence of cardiac tamponade (Fig. 5).

Step 6. Is the direction of blood flow in the hepatic veins normal?

The impairment of right heart filling leads to a backup of blood and venous congestion. Severe venous congestion, as in cardiac tamponade, can be seen as a reversal of blood flow in the hepatic veins.

Fig. 6: Hepatic vein, pulse wave Doppler mode: the upper row depicts normal and the bottom row depicts reversed blood flow in the hepatic veins 34

Any of the three hepatic veins (right, middle and left) can be evaluated. First, hepatic veins are located in B-mode. Then, the pulsed wave Doppler gate is placed in the hepatic vein proximal to where it enters the IVC. The normal flow pattern in the hepatic veins closely resembles a CVP tracing EMpulse Summer 2021

REFERENCES: 1. Alpert EA, Amit U, Guranda L, Mahagna R, Grossman SA, Bentancur A. Emergency department point-ofcare ultrasonography improves time to pericardiocentesis for clinically significant effusions. Clin Exp Emerg Med. 2017;4(3):128-132. doi:10.15441/ ceem.16.169 2. Alerhand S, Carter JM. What echocardiographic findings suggest a pericardial effusion is causing tamponade? Am J Emerg Med. 2019;37(2):321-326. doi:10.1016/j. ajem.2018.11.004 3. Himelman, R. B., Kircher, B., Rockey, D. C., & Schiller, N. B. (1988). Inferior vena cava plethora with blunted respiratory response: a sensitive echocardiographic sign of cardiac tamponade. Journal of the American College of Cardiology, 12(6) 1470–1477. https://doi.org/10.1016/s07351097(88)80011-1. No Title.

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CASE REPORT

False Positive HIV due to p24 Antigen and CD4 Lymphocytopenia

Jason Wilson, MD, FACEP, FAAEM

Dept. of Emergency Medicine, Division of Internal Medicine, Tampa General Hospital

The likelihood of a false positive HIV test increases as the prevalence of HIV decreases and other potential explanations for the presence of p24 antigen become as prevalent as HIV. Often, patients with a false positive laboratory signature do not have other serum evidence of HIV infection. However, we will outline a case of a patient that underwent routine, ED-based HIV screening and had two false positive HIV tests on different dates (reactive screening test, negative confirmatory Ab test, no detectable virus on further nucleic acid testing), but also had a profound reduction of CD4 lymphocytes. There are several hypotheses to explain false positive screening results, including lupus, CAR T-cell therapy, rheumatoid arthritis, and other autoimmune diseases.1–3 Some have suggested a syndromic emergence of a “Idiopathic CD4 lymphocytopenia,” while others have suggested that it is common to have CD4+ lymphocytopenia with malaria, infections, stress, burns, malnutrition, over-exercising and pregnancy.4 A 45-year-old male with eosinophilic esophagitis (EOE) presented to the Emergency Department (ED) with left facial swelling, weakness and 36

Heather Henderson, MA Dept. of Emergency Medicine, Division of Internal Medicine, Tampa General Hospital & Department of Anthropology, USF

numbness that started one hour prior to arrival. The symptoms started on his left upper lip and spread to his nose and cheek. He denied any associated facial droop, dysarthria, dysphagia, tinnitus, auditory symptoms, blurred vision and headache. He reports no history of stroke or TIA. He denied any recent trauma, bug bites, fever or chills. He was also recovering from a prior gastrointestinal infection. His medications include oral budesonide for EOE. He has no pertinent family history and he denies tobacco, alcohol and illicit drug use. While in the ED, he developed pruritus and hives along his left lateral thigh and arm, which were resolved with solumedrol and Pepcid. He received no medications before the hives occurred. The patient had a NIH stroke scale score of 1. A computed tomography image of the brain without contrast demonstrated right frontal encephalomalacia. While in the ED, the patient underwent routine fourth generation HIV Ab/ p24 Ag on the Abbot Architect, following CDC guidelines. Follow-up confirmatory HIV-1 and HIV-2 antibody test was negative on the Bio-Rad Geenius. An order was then placed for an HIV viral load via RNA PCR on the EMpulse Summer 2021

Kaitlyn M. Pereira, BS

Dept. of Emergency Medicine, Division of Internal Medicine, Tampa General Hospital & Morsani College of Medicine, USF

Hologic Aptima. No virus was detected. Testing was repeated, and the same laboratory signature was observed (HIV-1/2 Ab/Ag reactive, confirmatory Ab negative, no viral load detected). The patient test results were ultimately classified as false positives. The patient had an initial white blood count of 3.23, but his complete blood count and complete metabolic panel were otherwise unremarkable. The HIV nucleic acid test (viral load) results were not available during the ED encounter. Given the reactive screening test results and potential HIV infection, a CD4+ count was obtained. The absolute CD4+ count was 230, making up 28% of the lymphocytic count. The patient was also admitted to the hospital for further neurological and medical evaluation. He underwent magnetic resonance imaging (MRI) of the brain without contrast that demonstrated chronic and septal malacia changes of the posterior right frontal lobe. The neurological symptoms resolved during the hospital course and the patient was discharged home. A reactive fourth generation HIV Ab/

p24 test might be obtained in the presence of a p24 antigen, presence of HIV-1 or HIV-2 antibodies or from a laboratory error. A p24 antigen may be expressed secondary to HIV or other potential autoimmune conditions. In this case, the patient tested positive twice for HIV, which fundamentally rules out the possibility of a lab error. Since the patient tested negative for both HIV-1 and HIV-2 antibodies, the only remaining reason for having a false positive result twice could be due to the presence of p24 antigen in his blood system. It is important to note that his CD4+ count was concurrently low along with having a p24 antigen, which has been reported at least once by the CDC in 1989.9 The patient reported by the CDC had a p24 antigen verified via western blot and a CD4+ count of 103. These cases pose important questions for future investigation: does the p24 antigen have any association with the CD4+ counts, or are these isolated events? Do these patients simply have idiopathic CD4 lymphocytopenia and another reason for having a p24 antigen not yet discovered? We hypothesize that if we tested everyone with idiopathic CD4 lymphocytopenia for the p24 antigen, we may see more positive test results as evidenced by the patient in this case. ■ Disclaimer: The FOCUS Program is a public health initiative that enables partners to develop and share best practices in routine blood-borne virus (HIV, HCV, HBV) screening, diagnosis, and linkage to care in accordance with screening guidelines promulgated by the U.S. Centers for Disease Control and Prevention (CDC), the U.S. Preventive Services Task Force (USPSTF), and state and local public health departments. FOCUS funding supports HIV, HCV, and HBV screening and linkage to the first medical appointment after diagnosis. FOCUS partners do not use FOCUS awards for activities beyond linkage to the first medical appointment. Funding: Gilead Pharmaceuticals Inc.

ACCESS THE ONLINE VERSION OF THIS ARTICLE HERE

Daunting Diagnosis: Q By Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief

A 66-year-old female presents to the ER with a chronic left face wound. Vitals are significant for a fever and tachycardia. She has a history of diabetes, homelessness, and medical non-compliance. She complains of persistent face wounds with erythema and purulence. She also complains of left eye pain and redness. She admits to frequent picking at her wounds. Attached are photos of her face and left eye. Additionally, a head CT was performed the same day. What is her diagnosis? CONTINUE ON PAGE 41 ▶

REFERENCES: 1. Esteva MH, Blasini AM, Ogly D, Rodriguez MA. False positive results for antibody to HIV in two men with systemic lupus erythematosus. Ann Rheum Dis Published Online First: 1992. doi:10.1136/ard.51.9.1071 2. Ariza-Heredia EJ, Granwehr BP, Viola GM, Bhatti M, Kelley JM, Kochenderfer J, et al. False- positive HIV nucleic acid amplification testing during CAR T-cell therapy. Diagn Microbiol Infect Dis Published Online First: 2017. doi:10.1016/j. diagmicrobio.2017.05.016 3. Li YC, Yang F, Ji XY, Fang ZJ, Liu J, Wang Y. False human immunodeficiency virus test results associated with rheumatoid factors in rheumatoid arthritis. Chinese Med Sci J Published Online First: 2014. doi:10.1016/S10019294(14)60036-5 4. US Preventive Services Task Force (USPSTF). Screening for HIV Infection: US Preventive Services Task Force Recommendation Statement. JAMA. 2019;321(23):23262336. doi:10.1001/jama.2019.6587

EMpulse Summer 2021

5. Centers for Disease Control and Prevention. False-Positive HIV Test Results. 2018; :1–2. 6. Ollé-Goig JE, Ramírez J, Cervera C, Miró JM. Profound reduction of CD4+ lymphocytes without HIV infection: Two cases from the horn of Africa. Afr Health Sci Published Online First: 2012. doi:10.4314/ahs. v12i3.13 7. Zonios D, Sheikh V, Sereti I. Idiopathic CD4 lymphocytopenia: a case of missing, wandering or ineffective T cells. Arthritis Res. Ther. 2012. doi:10.1186/ar4027 8. Brooks JP, Ghaffari G. Idiopathic CD4 lymphocytopenia. Allergy Asthma Proc Published Online First: 2016. doi:10.2500/aap.2016.37.3992 9. Unexplained CD4+ T-lymphocyte depletion in persons without evident HIV infection-- United States. MMWR Morb Mortal Wkly Rep Published Online First: 1992. doi:10.1017/S0195941700015332

POISON CONTROL

The F(ab2)ulous Expanded Indication of Anavip Chiemela Ubani, Pharm.D.

Anthony DeGelorm, Pharm.D.

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

Due to our warmer climate, the Florida Poison Information Center Network (FPICN) receives calls concerning snakebites year-round. Last year, 668 calls were reported to the FPICN regarding snakebites. Fortunately, most species of snakes in Florida are nonvenomous. However, the majority of the venomous bites are from the pit vipers (subfamily: Crotalinae). Snakes in Florida within this subfamily include the eastern diamondback rattlesnake, canebrake/timber rattlesnake and the pigmy rattlesnake (genera Crotalus and Sistrurus), as well as the cottonmouth and copperhead snake (genus Agkistrodon). If a patient were to get bitten by one of these snakes, or any other, it is recommended that they seek immediate medical evaluation. Once at a healthcare facility, patients should be assessed for any evidence of envenomation, including swelling, coagulopathy and signs of systemic toxicity. If symptoms of moderate to severe envenomation are present, treatment is supportive care and antivenom. The two antivenom products available in the United States for the management of pit viper envenomation are CroFab® and Anavip®. CroFab® is an ovine derived Fab fragment antivenom and has been approved by the Food and Drug Administration (FDA) for the management of North American crotalid envenomations (rattlesnakes, copperheads and cottonmouth/water moccasins). Anavip® is an equinederived F(ab’)2 fragment product and was originally FDA approved only for the treatment of North American rattlesnake envenomations. However, as of April 1, 2021, Anavip®’s approved 38

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

indication has expanded to include copperheads and cottonmouth/water moccasin envenomation.1 The original Anavip® Phase 3 clinical trial enrolled all pit viper envenomations and was developed to determine the difference between Anavip® and CroFab® in relation to the primary endpoint of late coagulopathies.2 Late coagulopathies have been a common complication observed with CroFab® administration and are even cited in the CroFab® package insert to occur in approximately 50% of patients.3 The Anavip® trial sought to prove that late onset coagulopathies would not be as common with the F(ab)2 product. In fact, the trial demonstrated that patients who received Anavip® had a significantly lower number of delayed coagulopathies than patients receiving CroFab® (p<0.05). During the original review and approval of Anavip®, the FDA made the decision to exclude copperhead patients since late coagulopathies are more commonly observed in rattlesnake envenomations. The FDA’s focus on rattlesnake data at that time also led to the exclusion of copperhead envenomation as an indication for Anavip®. The original Anavip® clinical trial still included copperhead data, which was recently reviewed in a posthoc analysis and discussed with the FDA.4 This post-hoc analysis looked at time to initial control, doses to achieve initial control, and unscheduled doses of antivenom after initial control. A non-inferiority analysis concluded that Anavip® was non-inferior to CroFab® for the treatment of copperhead envenomations.4 This data, combined EMpulse Summer 2021

with evidence of Anavip® neutralizing venom from cottonmouth and copperhead in mice and human case report information, supported the FDA’s decision to expand Anavip®’s indication.5,6 No matter which antivenom your facility chooses to carry since the approved indications are now the same, the FPICN is available at 1-800-222-1222, 24/7/365 to answer any questions regarding these envenomations and antivenoms. ■

READ ONLINE REFERENCES: 1. Anavip [package insert] Laboratorios Silanes S.A. de C.V. Toluca, Estado de Mexico, Mexico; 2021. 2. Bush SP, Ruha A-M, Seifert SA, et al. Comparison of F(Ab’)2 versus Fab antivenom for pit viper envenomation: A prospective, blinded, multicenter, randomized clinical trial. Clin Toxicol (Phila). 2015;53(1):37-45. 3. Crofab [Package insert] BTG International Inc. West Conshohocken, PA; 2018. 4. Gerardo CJ, Keyler DE, Rapp-Olsson AM, Schwarz J III, Dart RC. Post Hoc Analysis of the RCT Comparing F(ab’)2 to Fab Antivenom: Control of Venom-Induced Tissue Injury in Copperhead Snakebite Patients. Annals of Emergency Medicine 76(4) Supp:S29Dec;26(4):472-87. 5. Wilson B, Larsen J, Smelski G, Dudley S, Shirazi FM. Successful Use of Anavip for Treatment of an Agkistrodon Envenomation. Clinical Toxicology 58(11):188. 6. Sanchez EE, Galen JA, Perez JC, et al. The efficacy of two antivenoms against the venom of North American Snakes. Toxicon. 2003; 41:357-365.

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New Beginnings: Building a Foundation between Educators and Learners By Carmen J. Martinez, MD, MSMEd, FACEP, FAAEM

Summer for those in medical education is filled with big endings and new beginnings. At the end of June, we said goodbye to our graduates, and on July 1, we welcomed new learners and new educators. It is an excellent time for everyone involved to examine how we teach and give feedback, and look for ways to improve our skills as we strive to be outstanding medical educators. Before we begin our journey this academic year, let’s look at how we frame our teaching to be as successful as possible. First, we must create a safe and supportive learning environment, and next, we should orient our learners and ourselves. Setting the stage for a safe and supportive learning environment is vital at the beginning of a learning period, and cultivating it is essential to promote critical thinking in the clinical setting. Jaffe and colleagues conducted a multi-institutional qualitative study that examined faculty’s perspectives of teaching critical thinking. The article discusses five main themes related to establishing a safe environment: building trust, respect, empathy, laying ground rules, and a “safe to be wrong” clinical setting. One faculty member describes that a crucial first step was laying the “groundwork (and) setting the atmosphere” so “people feel relaxed and safe.” Table 1 discusses the common themes needed to create a safe and supportive learning environment and some examples on how to build on these themes.1 As we begin to cultivate a positive and engaging learning environment, as educators, we should also focus on the 40

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

ACCESS THE ONLINE VERSION OF THIS ARTICLE HERE

Table 1: Common themes needed to create a safe and supportive learning environment. Theme

Description

Examples

Building Trust

Show the learner that feedback is intended to be supportive and constructive, not shaming or belittling.

“Dr. Lee, I saw that you were having some difficulty with this procedure. I did, as well. So let’s go over the procedure and see how I can help you succeed on the first attempt next time.”

Respect

Modeling respect of all roles (nursing, tech, medical students, residents, subspecialists).

After a pediatric resuscitation, the attending has a debriefing session with those involved (nursing, techs, residents and medical students) to discuss successful moments and how to improve for the next time.

Empathy

Empathy in relationships (teacher-learner/ learner-learner).

“You bring up a great question, and I am not sure of the answer. Let’s look it up together.”

Ground Rules

Discussing expectations, curriculum, establishing roles in the clinical environment.

“Hi, I’m Dr. Smith and I will be your attending for the rest of your shift. I do not think we have worked together before. However, I usually give feedback at the end of our time together. Is that ok with you?”

Safe to be Wrong

Clarify the importance of learning and critical thinking process rather than on “right answer.”

“Dr. Gonzalez, this is a very challenging case. Can you tell me why you think this patient should get TPA for these symptoms?”

teaching and learning that will occur. In 2000, Heidenreich and colleagues described eleven key methods to lead educators to efficient and effective EMpulse Summer 2021

teaching. The first one is the role of orientation in setting the stage for the learners. The description and use of orientation can be ambiguous.

For example, it can be defined as introducing policies and procedures or the informative process to give information about the curriculum, introductions, and available resources to the learners.2 But, what about orienting the learner at the beginning of your shift? Before we continue, take a moment to reflect about your actions on your last encounter with a learner on their first time working with you in the clinical setting. Did you orient the learner? What did you do well? What would you have done differently? Regardless of the time you spend with the learner, orienting the learner is critical to maximizing the experiencespecific time. It should serve as a complement to the general orientation for the rotation. The experiencespecific orientation elements can be summarized with the mnemonic ORIENT:3 • Overview: how things run • Review learning objectives • Insight into how evaluation occurs • Ensure they will get feedback • Negotiate teaching responsibilities • Talk about something personal The overview includes reviewing with the learners how you work and the department’s dynamic and physical facilities. It is essential for the learner to be aware of the educator’s vision for their role in the team and set up expectations for the learning experience. Gather information about their previous experience in your clinical setting. Each educator has a different teaching style. Let the learner know what your system of teaching and supervision is. Be specific and review your objectives for the time that you will spend together. However, also take time to discuss with the learners their objectives. Evaluation and feedback are integral to the process of acquiring knowledge and improving clinical skills. The educator should communicate to the learner their role and participation in the process of their evaluation, and

make sure that time is available to give meaningful feedback. The learning process should be a shared responsibility between the educator and the learner. In the clinical setting, teaching time can be limited. Establish what to expect regarding how the teaching will happen, on-the-fly or at the end of the learning experience. In addition, the educator can ask the learner to look up information and discuss it during clinical time. The last element is connecting with the learner beyond medicine. As adult learners, previous experiences can bring a different view to a clinical case or situation while creating a positive, friendly, and safe learning environment. In conclusion, although the beginning of the academic year can be challenging for educators and learners of all levels, we are called to create a safe and supportive learning environment to embody a spirit of academic excellence. As educators, we thrive on being efficient and effective in our teaching methods in the clinical setting. Therefore, orienting our learners and ourselves to our clinical environments and new roles is an excellent way to set the tone for a new academic year and even a new shift. ■

REFERENCES: 1. Jaffe LE, Lindell D, Sullivan AM, Huang GC. Clear skies ahead: optimizing the learning environment for critical thinking from a qualitative analysis of interviews with expert teachers. Perspect Med Educ. 2019;8(5):289297. doi:10.1007/s40037-019-005365 2. Heidenreich C, Lye P, Simpson D, Lourich M, Objective A. The Search for Effective and Efficient Ambulatory Teaching Methods Through the Literature. Pediatrics. 2000;105(1):231. 3. Christner J, Santen S. Orienting Your Learner. Teaching Clinical Skills. https:// d396qusza40orc.cloudfront. net/clinicalskills/OrientingYour LearnerHandout_07202014.pdf. Published 2014.

EMpulse Summer 2021

Daunting Diagnosis: A By Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief ◀ CONTINUED FROM PAGE 37 This patient has been diagnosed with pyoderma gangrenosum, a rare inflammatory skin disease where painful pustules or nodules become ulcerated and progressively grow. The patient was diagnosed from a previous biopsy. The patient has had one year of left ear hearing loss, a four month history of left eye proptosis and double vision, and chronic pain. She has had an extensive workup to rule out autoimmune conditions and infectious etiologies (including negative bacterial, viral, fungal, mycobacterial tissue cultures; negative PCR tests for cutaneous TB; and a negative workup for malignancy). The patient has responded well to methotrexate in the past, but is often non-compliant with medical treatment. Wound cultures were positive for gram-positive cocci due to a secondary superinfection. The patient had a CT scan showing subcutaneous emphysema throughout the left frontotemporal scalp extending from the left ear to the left orbit. There was concern for possible orbital cellulitis and dacryocystitis. The patient was placed on vancomycin. Ophthalmology and dermatology, who have seen her in the past, were consulted. Social work was also consulted to help the patient maintain proper medical follow-up and to help her obtain methotrexate and other medications. ■

MUSINGS FROM A RETIRED EMERGENCY PHYSICIAN

How Dangerous is Medical Misinformation? By Wayne Barry, MD, FACEP Former FCEP Board Member

Disturbingly, I believe that the recent proliferation of medical misinformation is a scourge in our modern life in some ways paralleling the seriousness of the current COVID-19 pandemic. Over my relatively long life, I don’t believe I have ever witnessed the attempted perversion of truth by politicians and others, many of whom place their own personal agendas above the health and safety of their constituents, to the current degree that exists today. Luckily, I have immersed myself in the study and practice of medicine, and I am eternally grateful to have been trained and taught me to believe in facts based on scientific evidence. Studies now show that adherence to medical misinformation, combined with a lack of planning for resource allocation and poor decision making in this country, may have led to tens of thousands of excess American deaths due to COVID-19 over the past year and a half.

of the three products currently in use have been in development for nearly 10 years. President Biden’s ambitious goals of 1 million, then 2 millions shots in arms daily were realized, but his latest goal of 70% of Americans with shots in their arms by July 4 was not. Failure to achieve herd immunity as soon as possible will not only delay getting back to normal life, but may encourage the development of more and worse COVID mutant variants, which may not be covered by our current vaccines.

Now we have vaccines, which are highly eﬀective against COVID-19 and available to literally every individual citizen of the U.S. It is recommended that the 3.4 million COVID-19 survivors take the vaccine too, as a way to increase their chances of avoiding a future infection. Scientific evidence tells us that the establishment of herd immunity against this virus will wipe its ability to infect humans. The sooner this happens, the sooner we will be able to analyze the mistakes made in combating the virus, and the sooner we will be able to prepare for the next pandemic while getting back to normal life. So what is taking so long? Sure, the highly eﬀective and safe vaccines available in this country were developed very quickly, yet, as I explained in a previous message, two

There are other segments of the U.S. population who will never accept vaccination. I will call these people “vaccine resistant.” A non-exhaustive list of these groups include: traditional anti-vaxers, many registered Republicans (predominantly male), QAnon followers and Evangelical Christians. There are a surprising number of healthcare workers and first responders who are vaccine resistant for reasons upon which I will not spend time explaining here.

So how do we get to the magic plateau of 70% immunity U.S. populationwide? There is a significant segment of the population who have leaped into getting vaccinated against COVID-19 with great relish. There are some vaccine distribution problems in some urban and rural neighborhoods upon which I will not elaborate here, but remember that there appears to be enough COVID vaccine available in this country to vaccinate all of us.

The last category of potential vaccine targets I will call “vaccine hesitant.” These people are not completely against vaccination; they are “fencesitters,” just not sure whether they should take it. Some say they just can’t be bothered with it right now. Others say they want to wait a EMpulse Summer 2021

little longer to see if the vaccine is safe in other people. These people need to be persuaded to become vaccinated. Some of the people may be susceptible to bribes. The state of Ohio is conducting a $1M lottery open to vaccinated individuals. Other states are oﬀering free meals, beer, sports event tickets, and even free marijuana (which is not a medically advisable kind of bribe). I recently read that COVID vaccine administration may become the next historically unconventional treatment to be oﬀered in the ED, along with childhood immunizations and suboxone treatment for drug abuse. Whatever it takes to successfully vaccinate this last group of unvaccinated folks seems worth it and very desirable to me. I believe that vaccinating this group of people is our best hope at reaching the threshold of 70-85% vaccination rate to achieve herd immunity. There are perpetrators of medical misinformation, consumers of medical misinformation, and victims of medical misinformation. Those victims are the 600,000 Americans who have been infected with COVID-19 and died. As I have said before, it behooves us in the medical field to convince as many people as possible to become vaccinated for their own health and for the safety of the rest of us. Together we can conquer the COVID-19 pandemic in this country, and then turn our attention and American generosity towards helping our fellow human beings who reside in other countries around the world. ■

ACCESS THE ONLINE VERSION OF THIS ARTICLE HERE

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Articles inside

Musings from a Retired Emergency Physician: The Dangers of Medical Misinformation

Re-Launch of FCEP’s Leadership Academy By Dr. Stephen Viel

FCEP President’s Message

EMS/Trauma: Drowning Update

Education Corner: New Beginnings: Building a Foundation between Educators and Learners

Ultrasound Zoom: The VExUS Score: Fluid Status, Reconsidered

Pediatric EM Committee

EMRAF President’s Message

Case Report: False Positive HIV due to p24 Antigen and CD4 Lymphocytopenia