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

Introducing... A separate site from LEARN MORE INSIDE �

Disruptive Innovation in Emergency Medicine

ALSO FEATURING: Every Vape You Take...

EMpulse Winter 2020

EM Days 2020 Prep: Priority Bills Vol. 26, No. 4 | Winter 2020


Quality Counts!

This Applies to Parachutes AND Your Billing Company! DuvaSawko was designed BY Emergency Medicine Physicians FOR Emergency Medicine Physicians!

Is Your Group Leaving Valuable Reimbursement Dollars On The Table? Find Out Today! Try Our Revolutionary New Revenue Calculator at WWW.REVCALCULATOR.COM! 2

EMpulse Winter 2020




FCEP President’s Message


EMS/Trauma Report


Government Affairs: Legislative Session Preview


Introducing the Women in Medicine Committee

10 12 14

Dr. Kristin McCabe-Kline Dr. Damian Caraballo

Medical Economics Report Dr. Danyelle Redden

Membership & Professional Development Report Dr. Shayne Gue

Dr. Desmond Fitzpatrick

Dr. Cristina Zeretzke-Bien

18 30

EMRAF President’s Message Dr. Matthew Beattie, PGY-3

Medical Student Council Report Alexa Peterson

Pediatric Education Report

Drs. John Misdary & Todd Wylie



Introducing FCEP Staff


Daunting Diagnosis


Event Recap: FIX19 Tidbits


As You Interview... Words of Advice from a Past-President

Dr. Karen Estrine

Dr. Cristina Zeretzke-Bien

Dr. Michael Lozano


Poison Control: Every Vape You Take... Drs. Kristen C. Lee & Anthony DeGelorm



Disruptive Innovation in Emergency Medicine

40 41 42 43

Dr. Mitchell Barneck, PGY-3

Ultrasound Zoom: Ultrasound Student Interest Group: A Model for Active Learning and Multi-Specialty Collaboration Andrew DiZenzo, Duyen Vo, Alessandra Della Porta & Dr. Leila Posaw

Even for Complex Patients, Hospice Has Compassionate End-of-Life Solutions Lillian Valeron

“Getting to Zero” with Collective Medical’s Care Collaboration Platform Collective Medical Staff

Musings: Hercules and the Three-Headed Dog, Cerberus Dr. Wayne Barry

2020 Sponsorship & Exhibitor Opportunities FCEP Staff



Kendall Regional Medical Center by Dr. Ramsey Ataya, PGY-3 St. Lucie Medical Center by Dr. Abby Regan, PGY-2 Aventura Hospital by Dr. Scarlet Benson Florida Atlantic University by Dr. Elizabeth Calhoun, PGY-1 Jackson Memorial Hospital by Program Staff Mount Sinai Medical Center by Dr. Stephanie Fernandez, PGY-2


Oak Hill Hospital by Drs. Jonathan Yaghoubian & Corey Cole, PGY-2s USF Health by Dr. Mikhail Marchenko, PGY-2 Brandon Regional Hospital by Dr. Rashmi A. Jadhav, PGY-2 FSU at Sarasota Memorial by Dr. Courtney Kirkland, PGY-1



EMpulse Magazine is the official, quarterly publication of the Florida College of Emergency Physicians (FCEP). EDITOR-IN- Karen Estrine, DO, FACEP, FAAEM CHIEF MANAGING Samantha League, MA & DESIGN EDITOR

Johnson Press of America, Inc.

PUBLISHER 800 N. Court St.

Pontiac, IL 61764


Upcoming Deadlines: • Jan. 24: Orders & payment for February banner advertisements due • Jan. 29: Designs for February banner ads due • Feb. 21: Orders & payment for March banner ads AND Spring 2020 print ads due • Feb. 26: Designs for March banner ads due • Mar. 2: ‘Intent to Submit’ article for Spring 2020 due



WINTER 2020 Volume 26, Issue 4


AdventHealth East Orlando by Dr. Shannon Armistead, PGY-3 UCF/HCA of Greater Orlando by Drs. Amber Mirajkar, PGY-2 & Andrew Hanna, PGY-3 UCF/HCA Ocala by Dr. Caroline Smith, PGY-2 Orlando Health by Drs. Anne Shaughnessy & Laura Cook, PGY-3s


Orange Park Medical Center by Dr. Chris Purcell, PGY-2 UF Health Jacksonville by Dr. Ty Tantisook, PGY-2 UF Health Gainesville by Dr. Christopher Purcell, PGY-2 UCF/HCA North Florida Regional by Dr. Jayden Miller, PGY-1 EMpulse Winter 2020

• Mar. 9: Articles AND designs for print ads due • Mar. 25: Last day to update your address for Spring 2020 delivery • April 6-20: EMpulse Spring 2020 in mailboxes See p. 17 for NEW Advertising Opportunities

All advertisements in EMpulse are printed as received from advertisers. The Florida College of Emergency Physicians does not endorse any products or services unless otherwise stated. FCEP receives and distributes employment opportunities but does not review, recommend or endorse any individuals, groups or hospitals that respond to these advertisements. Opinions stated within articles are solely those of the writers and do not necessarily reflect those of the EMpulse staff, the Florida College of Emergency Physicians and our advertisers/sponsors. 3

It’s finally here.

A separate site from, designed with FCEP members in mind.

NEW FEATURES: EMpulse Online Now you can read and share EMpulse Magazine articles online. Find all articles at Or jump to a section:

• Committee Reports: • Residency Updates: • Features:

Online advertising now available! Learn more on p. 17

-includes quarterly columns and sponsored articles

News Center Feel like you missed an email? Visit to find the latest newsletters and special announcements.

Florida EM Residency Programs Guide Interested in learning more about Florida’s 18 emergency medicine residency programs? Visit to find basic information, links to each program and quarterly updates from EMpulse.

Coming Soon: • Legislative Database (January 2020) • EMpulse Magazine Archive • & more! 4

TELL US WHAT YOU THINK: Email or fill out the Anonymous Feedback Form by scanning the QR code � EMpulse Winter 2020

Now in every issue!

FCEP/FEMF Calendar At a Glance

Dates subject to change. Find the master calendar at



14 17 20


HB 831: Electronic Prescribing becomes effective


» Learn more on p. 9

Florida 2020 Legislative Session Begins

EM Reimbursement & Innovation Summit Online Registration Closes


EM Days 2020 Online Registration Closes


Dr. Martin Luther King Jr. Day

27 -28


(FCEP office closed)

EM Reimbursement & Innovation Summit EMLRC Orlando, FL

Learn more on p. 11

27 -29

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



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

MARCH 2020

EM Days 2020


Hotel Duval Tallahassee, FL

Learn more on p. 8


Last Day of Florida 2020 Regular Session Match Day 2020

Newsletters: • Every Wednesday: EMNews Now delivered • Every month: EMRAF Newsletter delivered • Every quarter: Partner Broadcast delivered

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

Quick Links

MEMBERS Dick Batchelor; Arthur Diskin,

ACEP/FCEP EngagED (online community)

MyACEP Portal

Donate to FCEP’s PAC (not taxdeductible)

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

(update your address, etc.)






/company/emlrc EMpulse Winter 2020

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


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

As emergency physicians, fellows and residents, we are in constant motion. Early on in our training, we are taught to eat when we can, sleep when we can, use the facilities when we can, etc. We are instructed very early on that any downtime should be repurposed for task-oriented activities. During slower times in the emergency departments where we serve our patients, team members around us are taught to spend any time during a lull restocking, checking code carts, organizing supplies, cleaning out workstation drawers, etc. Beyond constant movement is the concept of multitasking. We rarely eat anywhere other than in front of a computer. We quickly move through EMR mouse clicks between bites while the phone is on speaker, playing easy listening music in the background, indicating we are on hold trying to transfer a patient. One of my beloved colleagues, Dr. Stephen “Blue” Coltharp, recently addressed the complicated nature of multitasking for emergency physicians during a journal club for my physician group based out of Daytona Beach. Incidentally, he has five children and his family likely does more in a day than most others accomplish in a month. Many of us adopt the mindset of movement and multitasking in such an internal way that our lives outside of work and many of our relationships become a “to do” list. We live in the margins of the activity around us and that which we create. If we aren’t traveling, dealing with the business of running a household, or accomplishing a goal in our personal lives, we struggle with idle time. I bought a t-shirt not long after my first daughter was born 6

that displays the following phrase: “Time Well Wasted.” Sitting with her and holding her while she slept was amazingly gratifying and time well spent, even though I could have laid her in her crib and walked away to do laundry. There are things that can happen that bring activity to a grinding halt. On November 19, many emergency departments around the country observed a moment of silence in memory of our colleague, Dr. Tamara O’Neal, who was killed in Chicago on that date last year. During the spring of 2019, one of my colleagues from another specialty committed suicide. During the third quarter of 2019, my former neighbor and colleague from another specialty suffered cardiac arrest and passed away at age 59. Two of our pillars of emergency medicine in the state of Florida passed away similarly in the not so distant past. What if we had moments of stillness, however short in duration, that existed within us and in the emergency departments where we serve our patients? What if there was a few second pause and a deep breath before entering the room of a new patient? What if the few seconds it would take to sit down in the room of a patient was customary, even if only to be perched on the edge of the bed because the patient’s child occupied the spinning stool perceived to be a toy? What if we took a few minutes when grabbing coffee or food to touch the arm of a colleague and truly ask, “How are you?” without expecting the answer to be “fine”? What is our worth when we are no longer in constant motion? Do we have value to our patients if we EMpulse Winter 2020

can’t diagnose them or cure them? Do we perceive that we have value to our colleagues, our emergency department teams, our communities and our families because of who we are or what we do? We are not widget makers—we are medicine men, priests, counselors, healers and humans willing to meet others where they are. We have technology and tools to help our fellow man, but in the end our stethoscopes are simply a conduit to have a conversation. When we allow the stillness in, there is an opportunity for connections to take place with those around us who truly matter. Winter in Florida’s emergency departments is similar to a natural disaster. Between snowbirds who are advanced in age with multiple comorbidities and without local healthcare providers, coupled with outbreaks of influenza and other viruses, our resilience is tested as individuals and teams and our systems are stressed beyond capacity. Please lean in and support your colleagues. In doing so, you will be supported. Embrace the opportunity to find moments of stillness. Those moments will restore the joy and meaning in your work and your relationships. “Peace. It does not mean to be in a place where there is no noise, trouble or hard work. It means to be in the midst of those things and still be calm in your heart.” -Unknown ■

NEXT BOARD MEETING: January 28, 2020 5:30-7:00 pm Hotel Duval in Tallahassee, FL


Gov’t Affairs: Legislative Session Preview By Damian Caraballo, MD, FACEP

FCEP Vice President | Government Affairs Committee Co-Chair

2020 will be an early Legislative Session in Tallahassee. FCEP will be holding its annual advocacy meeting, Emergency Medicine (EM) Days, on January 27-29. This year looks like it will reignite many of the battles we have been fighting over the past several years. At the forefront will be scope of practice bills. There will be another push to expand nurse practitioner and physician assistant scope of practice to independent practice. Separately, there will once again be a bill that would allow pharmacists to test for and treat influenza and strep pharyngitis through a collaborative agreement with a co-signing physician. Besides the obvious fact that pharmacists aren’t trained clinicians, another concern is that the bill does not necessitate the collaborative physician have an existing relationship with the patient, so conceivably, any national pharmacy-employed doctor who doesn’t practice clinically could write up a protocol for any pharmacy in Florida. FCEP, along with organized medicine, has successfully fought off any expansion of scope bills for the past several years. We’ve successfully worked with our friends in the Senate to avoid encroachment of non-physicians expanding their scope to practice medicine unsupervised. We will once again need to band together to hold off another strong push from the House, which will be heavily lobbied by pharmacies, health insurers and nursing organizations. A lesser talked about but still important bill involves the replacement of Personal Injury Protection (PIP) Auto Insurance with Bodily Injury (BI) Insurance. Motor vehicle accidents make up 2-5%

of ED visits in Florida. PIP, while far from the perfect system, does provide physicians with prompt and reasonable payments, and currently has a $10,000 medical (both hospital and provider) set-aside for reimbursement. The BI proposal would shift those costs back to health insurers, who are working ceaselessly to lower reimbursement. Even worse, we know 40-50% of our patients are Medicaid/uninsured. If they are involved in an accident and fault is not clear, it could take years of court dates to determine fault, and most physician bills will be delayed (or reimbursed at lower rates) until fault is determined. Coupled with the shift to high-deductible plans, this will exacerbate the worsening collection liquidity crunch for Florida groups, as it will take even longer to recoup reimbursement from autoaccidents. BI could work if there is a mandatory med-payment set aside. FCEP is working hard to have a setaside for EMTALA providers who see the majority of uninsured, selffunded patients in Florida. Many other issues remain on FCEP’s radar for 2020. We are closely watching a bill that would define the use of “doctor” in a clinical setting. Sponsored by Dr. Massullo, a representative in the Spring Hill area, it is well supported by organized medicine, and its movement in the legislature might signify where the scope battle heads. We are also supporting mental health and substance abuse disorder bills, which will add funding for opioid/mental health treatment, as well as define peer specialists in Florida. FCEP is also supporting a bill that will allow Florida schools to stock and use naloxone for opioid overdoses. In addition, we support a public records protection bill that would protect the EMpulse Winter 2020

personal addresses of EM physicians, nurses, techs, EMT’s and other first responders from being displayed as public record. FCEP believes this will protect first responders and ED practitioners from potentially violent patients, who can easily obtain home addresses. Finally, although there is no specific bill, we are closely watching insurance companies and their practices. We have two EM Maximus dispute resolution cases in progress. They both involve the same insurer, which FCEP first identified two years ago for its predatory and potentially illegal practices. Through our collaboration, we have been able to track and closely monitor health insurers’ behavior towards EM groups as more states pass balance billing laws. We expect insurers will grow more brazen as the U.S. adopts a national law. If your group has been targeted with what you believe to be an unfair practice by a health insurer, FCEP would like to hear from you so that we can connect your group with the appropriate people in the state to get your matter resolved. This is a good reminder of what FCEP can do when we work and band together. Last year, we were able to stop a bill in its tracks that would have capped all reimbursement at 150% of Medicare. Remember, we need both your expertise and PAC donations to combat big insurance, the nursing lobby, lawyers, pharmacies, and whatever else poses an existential threat to emergency medicine. Please join us in fighting for emergency physicians. We hope to see you all January 27-29, 2020 at Hotel Duval in Tallahassee for EM Days. ■ EM DAYS 2020 PREVIEW � 7


January 27-29, 2020

Hotel Duval | Tallahassee, FL

Register Now:

The Schedule:

The Venue:

Monday, January 27: 12:00 PM–5:00 PM: Presentations Review talking points, current bills and issues, and practice ‘talking to legislators’ with colleagues from your region 5:30 PM–7:30 PM: Legislative Reception at the Governor’s Club

Tuesday, January 28: 8:00 AM–5:00 PM: Appointments at the Capitol Appointments are subject to legislator availability and can happen any time

Hotel Duval by Marriott 415 N Monroe St. Tallahassee, FL 32301

8:30 AM–9:30 AM: Breakfast Meeting

Need a place to stay?

9:30 AM–10:30 AM: EMRAF Meeting 10:30 AM–12:30 PM: Medical Student Meeting 5:30 PM–7:00 PM: FCEP Board of Directors Meeting 8:30 PM–11:00 PM: EMRAF Reception, sponsored by EMPros Location TBD

Wednesday, January 29: 8:30 AM–9:30 AM: Breakfast Before the Capitol: Legislative


9:30 AM–10:30 AM: Open Forum Discussion with FCEP Leaders *Schedule subject to change. Find the latest at 8

EMpulse Winter 2020

Our room block at Hotel Duval expired Dec. 30, and limited rooms were available at the time of print. If you still need a place to stay, we recommend the following hotels in close proximity: DoubleTree by Hilton– Tallahassee Aloft Tallahassee Downtown Four Points by Sheraton Tallahassee Downtown Hampton Inn & Suites Tallahassee Capitol-University Please note FCEP does not have room blocks at these locations; these are simply recommendations.

Priority Bills for EM Days 2020

Start familiarizing yourself with our top issues now. *This list is subject to change. Please visit for the most current version.

CS/HB 607: Health Care Practitioners

Filed by: Rep. Cary Pigman, MD (R-District 55) Capsule Summary: Would allow nurse practitioners and physician assistants to practice independently without a supervising physician. Position: AGAINST Bill History: • Nov. 12: Filed • Nov. 25: Referred to Health Quality Subcommittee • Dec. 10: Strike All Amendment by Rep. Pigman • Dec 11: CS by Health Quality Subcommittee (YEAS 14 vs. NAYS 1) • Dec. 18: Now in Health Care Appropriations Subcommittee

HB 771: Motor Vehicle Insurance

Filed by: Rep. Erin Grall (R-District 54) Companion Bill: SB 378: Motor Vehicle Insurance by Sen. Tom Lee (R-District 20) Capsule Summary: Would repeal Personal Injury Protection (PIP) Auto-insurance for Bodily Injury (BI). This would shift medical payments from auto insurers to health insurers, and remove the current mandatory medical set aside for physicians and hospitals. Position: AGAINST Bill History: • Nov. 25: Filed • Dec. 16: Referred to Insurance and Banking Subcommittee

HB 389: Testing and Treatment of Influenza & Streptococcus

HB 309: Prohibited Acts by Medical Providers

Capsule Summary: Would allow pharmacists to enter into partnership agreements with physicians to test & treat influenza & streptococcus at pharmacies.

Capsule Summary: Would allow the DOH to impose financial penalties upon anyone who uses the title “physician” and/or “medical doctor” without a valid license.

Position: AGAINST

Position: SUPPORT

Bill History:

Bill History:

Filed by: Rep. Tyler Sirois (R-District 51)

• Oct. 17: Filed • Nov. 13: Favorable by Health Quality Subcommittee (YEAS 11 vs. NAYS 3); now in Health Care Appropriations Subcommittee

Filed by: Rep. Ralph Massullo (R-District 34)

• Oct. 8: Filed • Nov. 13: Favorable by Health Quality Subcommittee (YEAS 12 vs. NAYS 2); now in Health Care Appropriations Subcommittee

Also Monitoring: • SB 878: Public Records/Emergency Room Health Care Practitioners (Sen. Harrell) • HB 331 & SB 120: Naloxone in Schools (Rep. Geller & Sen. Pizzo) • HB 939 & SB 706: Insurance Coverage Parity for Mental Health and Substance Use Disorders (Rep. Slosberg & Sen. Rouson) • SB 926: Health Care Practitioner Licensure (Sen. Harrell)

• HB 57 & SB 100: Dispensing Medicinal Drugs (Rep. Willhite & Sen. Harrell) • SB 298: Prior Authorization for Opioid Alternatives (Sen. Farmer) • HB 743 & SB 1080: Nonopioid Alternatives (Rep. Plakon & Sen. Perry) • HB 747 & SB 736: Coverage for Air Ambulance Services (Rep. Williamson & Sen. Diaz) EMpulse Winter 2020

Other Updates:

Congress Tables Surprise Billing for 2020 The federal year-end spending bill that was signed into law at the end of December did not address surprise billing. This is good news, because the most recent proposal by Reps. Pallone, Walden and Sen. Alexander would have significantly cut reimbursement for emergency physicians by setting an IDR threshold of $750 and removing the ability to bundle claims. With the average bill for emergency physicians being around $679, bundling claims would be the only way to reach the $750 threshold. Furthermore, if a physician used IDR and won, they would be prevented from using IDR again for the next 90 days—during which time the insurer could pay anything they wanted to, and the physician would have no way to fight back. The year-end spending bill extends funding for several healthcare programs through May 22, 2020, giving Congress a new deadline to make a decision on surprise billing.

Mandatory E-Prescribing Bill is Now Effective FL HB 831: Electronic Prescribing requires healthcare practitioners who maintain EHR systems to electronically transmit prescriptions for all medications, including controlled substances. While the bill becomes effective Jan. 1, 2020, the requirement for practitioners becomes effective by their license renewal date OR by July 1, 2021—whichever occurs first. E-prescribing presents challenges for physicians in the ED and other emergent/urgent care settings. Fortunately, the Florida Board of Pharmacy is working on exemptions that might apply to emergency physicians. Stay tuned for more information from our lobbyist. Learn more on the Florida Board of Medicine’s electronic prescribing requirements page, which includes an FAQ of relevant questions for practitioners, at: flboardofmedicine. gov/latest-news/electronic-prescribingrequirements ■ 9


Medical Economics By Danyelle Redden, MD, MPH, FACEP Medical Economics Committee Co-Chair

Review of balance billing law implementation The Florida House of Representatives Health Market Reform Subcommittee is in the process of reviewing implementation of HB 221, which went into effect in 2017. The legislation banned balance billing in Florida. Since its implementation, we have seen repeated violations of the minimum reimbursement standard laid out in the legislation, in some cases resulting in drastically reduced payments to emergency physicians. FCEP brought the issue to the Office of Insurance Regulation last year, but OIR has not taken action to enforce the minimum reimbursement rate set in the statute. We are hopeful that the legislature will take action on this very important issue.

Centene violation of prudent layperson standard In recent months, Centene has adopted a practice of using final di-

agnosis lists to down code emergency claims in several states including Florida. This policy violates federal and state prudent layperson standard laws, which prohibit the reduction of payment for emergency care based on final diagnosis. The laws also require the insurer to review the medical record before down coding a claim, which has not been Centene’s practice. ACEP and EDPMA are actively engaging with Centene regarding this practice. The issue has also been referred to the Florida Medicaid office.

EM Days

Reimbursement and Innovation Summit

Florida Healthcare Transparency Database

FCEP’s annual Reimbursement and Innovation Summit will take place February 27-28, 2020 at EMLRC/ FCEP headquarters in Orlando. This conference highlights evolving EM payment issues and features nationally recognized reimbursement experts. Please join us in attendance.

FCEP’s annual advocacy event, EM Days, will take place January 27-29, 2020 in Tallahassee. As usual, we are closely monitoring legislative developments. The legislature will likely revisit some bills of interest that did not pass last session, including those related to pharmacist and ARNP scope of practice and personal injury protection (PIP) insurance. We hope you can join us as we represent emergency physicians throughout the state. Please also consider donating to our PAC below.

The long-awaited Florida healthcare transparency database, Florida Health Price Finder, launched in November. At present, it does not appear to include any information regarding emergency care. ■

Thank You, PAC Donors The success of FCEP’s advocacy efforts is dependent upon our ability to fund those efforts. Generous donations to our political action committees (PACs) are always needed and greatly appreciated. Thank you to those who donated in September-November 2019: Patricia Bette Allen David Ball Adam Branoff Isabel Jeannette Brea Jordan Celeste Gregory Chapman Manuel Colon-Menedez Kali D’Onofrio Nicholas R Dodaro Alex Doerffler Michael Dolister Michelle Fox-Slesinger James Gillen Steven Goodfriend 10

Brian Scott Hartfelder James Hillman Reuben W Holland Saundra Jackson William Paul Jaquis Mark Johnson Steven B Kailes Shiva Kalidindi Gary Lai Jon Lamos John Patrick Christopher Martin Michael McCann William Meadows

Daniel Peterson Donna Schutzman-Bober Matthew A Schwartz John Caleist Soud Joel Stern Daniel Thimann Peter Douglas Webster David Wein Deborah Widmer Andrew Wilson Christina Lucile Wilson Jason Wilson Daneil Nathan Young

EMpulse Winter 2020

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

Donate online at:



EMLRC in Orlando, FL

Approved for AMA PRA Category 1 Credits™

This conference brings together national healthcare leaders who are in the business of emergency medicine, healthcare delivery and payment reform. Topics include emergency care practice models addressing payment risk, government regulations, coordination of patient care, outcomes, quality measures, cost control and more.


Dr. Jennifer Wiler

“Disruptions in the ED: Innovations to Improve Healthcare”

Ed Gaines, JD, CCP

“Consumer Protection and the IDR Process”

Dr. Ethan Booker “EM Leadership in Telehealth”

Dr. Jason Adler

“CMS Proposed Changes and Potential Impacts”

Accreditation Statements: ACCME: This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Emergency Medicine Learning and Resource Center and the Florida College of Emergency Physicians. The Emergency Medicine Learning and Resource Center is accredited by the ACCME to provide continuing medical education for physicians.

AMA: The Emergency Medicine Learning and Resource Center designates this live activity for a maximum of 13.50 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Learn More in the Brochure

FBON: The Emergency Medicine Learning and Resource Center is approved as a provider of nursing education by the Florida Board of Nursing, Provider #2731. Up to 13.0 nursing contact hours will be provided by the EMLRC.

Register Now

EMpulse Winter 2020 11


Membership & Professional Development By Shayne Gue, MD

MPD Committee Co-Chair

Another year ends and we’re happy to report on another successful Scientific Assembly at ACEP19 in Denver, CO. Dr. René Mack and I once again served as councillors representing the great state of Florida during the ACEP Council Meeting, which preceded the conference. A number of resolutions were adopted expanding the breadth of emergency medicine, including those geared at promoting and protecting our specialty, while continuing to be the leaders at the forefront of the ongoing fight to provide the highest quality care for our patients. The Scientific Assembly is a tremendous gathering of some of the biggest and brightest minds in medicine! If you haven’t given it a try, we hope you’ll join us at ACEP20 in Dallas, TX. As the new year begins, FCEP hits the ground running. Emergency Medicine Days is the premier advocacy event of the year, and it’s coming up soon! Each year, a contingent of FCEP members travels to Tallahassee to meet with

and educate our elected officials on issues important to our patients and our specialty. This is a unique opportunity to converse with our leaders and advocate for the future of emergency medicine. In past years, we have counted many successes in the areas of balance billing, prudent layperson, PIP reform and opioid-related issues. We hope you’ll join us for EM Days on January 27-29 in Tallahassee so we can continue protecting our specialty and providing the highest quality emergency care for our fellow Floridians. While membership naturally comes to the forefront, professional development is also an integral part of our committee’s objectives. Our goal is to turn more attention to this important subject, and we welcome your input! What does professional development mean to you? What would you like to see us offer? And how can FCEP and ACEP further support you? Wellness is another significant topic

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

A 53-year-old male presents to the ED with several months of weight loss and cough. He states that he has become progressively dyspenic in the last week. He is a poor historian. He is noted to be febrile upon arrival to the ED. What does his radiograph show, and what is the treatment? CONTINUE ON PAGE 20 �


EMpulse Winter 2020

that cannot be overstated. Burnout in emergency medicine continues to be an obstruction, and physician suicide is increasing in dramatic fashion. Emergency medicine clinicians have been defending the front line and providing the safety net since the inception of our specialty. Our knowledge and skills allow us the privilege to save lives on a daily basis, but this responsibility can take a toll. Finding effective means of burnout mitigation and promoting wellness in and out of the workplace can benefit us all. What do you do to promote wellness? We’d love to hear about it and share your advice with others. As always, we welcome your input and want to know how we can best serve you! Becoming an active participant is the best way to enact change, and we welcome any and all to attend our committee meetings either in person at the EMLRC in Orlando or via phone. We look forward to seeing everyone at EM Days in Tallahassee! ■

EMpulse Winter 2020



Pediatric Committee By John Misdary, MD, FACEP

Pediatric Committee Co-Chair

One of the Pediatric Committee’s main goals for this upcoming year is to serve as a greater educational presence throughout the state, educating first responders, nurses, residents and physicians in all matters regarding pediatric emergency medicine. In early November, an APLS course was successfully conducted with our own Dr. Shiva Kalidindi as the course director and many members of the pediatric committee as the instructors. We extend a big thank you to Nemours Children’s Hospital for being the host. It was well attended! With the success of this event, we hope to conduct future courses throughout the state in order to conveniently ensure that all are getting the appropriate, up-todate pediatric emergency education that is needed. Stay tuned for APLS course dates and locations in the next update. Dr. Phyllis Hendry is continuing her efforts with Florida PEDReady.

By Todd Wylie, MD Pediatric Committee Co-Chair

If you have not already done so, please sign up for the PE2ARL weekly newsletter, which provides invaluable up-to-date information on pediatric emergency care for EMS agencies and hospitalists alike, along with a calendar of pediatric events throughout the state. Sign up now at: For more information on the PedReady program, visit or contact Dr. Hendry at or 904-244-8617. A congratulations is in order for our own FCEP and Pediatric Committee member, Dr. Tricia Swan, for becoming the new chairperson of the ACEP National Pediatric Committee. She has worked tirelessly in the committee and has been a vital member with putting together the educational endeavors over the last several years. Her expertise with simulation, education and academics will be put to excellent use in this position. It is well deserved.

EMLRC’s ABCs of Pediatric EMS workshop will take place this spring in Tampa, FL. Committee and FCEP Board member Dr. Russell Radtke will once again be the course director. We’d like to thank St. Joseph’s Children’s Hospital and the new CEO, Ms. Sarah Naumowich, for hosting the event for a second time. The last event was well attended by first responders throughout the state. This year‘s event includes up-to-date didactic lectures and excellent highfidelity simulations. We appreciate all who put their time and effort into making this event a success. Please reference future committee updates for upcoming pediatric educational sessions and courses in Florida. We will continue to work towards FCEP’s committee goals of making pediatric emergency education a priority and more accessible for all providers throughout the state. ■

July 8-11, 2020 • DoubleTree by Hilton—Universal • Orlando, FL Registration opens soon at 14

EMpulse Winter 2020


EMS/Trauma By Desmond Fitzpatrick, MD, FACEP EMS/Trauma Committee Co-Chair

Cold and flu season is upon us, and I want to bring to attention to appropriate BSI and PPE. “BSI scene safety” is not just a magical phrase we say to pass an EMS scenario; these are highly important actions for both our patients and ourselves. All too often I witness providers donning mask and gloves for interactions with possibly infectious patients, who then use those same gloves to grab their pens, doors, stethoscopes, etc., creating a whole new group of fomites (objects likely to transfer infection to others). When we don’t pay attention to what we do next with potentially contaminated equipment, it puts everyone at risk. To demonstrate this process, spray an object (like a pen or stethoscope) with fluorescent dye and see how far it spreads. UV light will reveal the cross contamination of your equipment and give your team a great visual to help them remember proper BSI and PPE usage. Remind your team how simple actions—such as uncovered coughs or sneezes, touching their faces, not fully cleaning our equipment, or not allowing appropriate time to dry—can truly affect our care, especially of those at highest risk (young, elderly or immunosuppressed). For a fun visualization of this, watch the Scrubs Clip on Youtube entitled, “How diseases spread.”

Updates from the EMS Advisory Constituent Meetings in October

A through paramedic programs. Hepatitis A outbreak sample protocols, training, checklists and MOUs have been developed by the state to assist local county health departments in implementing this recommendation. A question for further consideration is, should a paramedic’s scope of practice be expanded to include administring vaccinations during other pandemics and mass events, such as disaster sheltering? Additionally, Florida Department of Health has issued a public health emergency declaration urging first responders and those who work with homeless individuals or IV drug users outside of healthcare settings to get vaccinated because they are now considered at-risk populations for contracting Hep A.

Resuscitation and CQI: The Medical Care Committee announced that they have surpassed all target state benchmarks for their committee. They will now be focusing on post-resuscitation care initiatives and continuous quality improvement (CQI). A committee will develop post-resuscitation care initiatives that focus on moving from ROSC to CPC 1 2 rates. Additionally, in 2019, five Re-

Florida won a $750,000 multi-year grant—the Florida F.A.I.R. (FEASIBLE, ACTIONABLE, IMPACTFUL, RELEVANT)—to develop meaningful EMS quality measures. A goal is to use these measures for state inspections to help improve local performance.

Additional Items: Dr. John McPherson provided an update on the Region V Trauma Agency Plan. They are currently focusing on developing consistent EMS protocols throughout the region on pediatric care, TXA, spinal immobilization and elderly patients with head trauma using anticoagulants. Hurricane Dorian relief efforts revealed some gaps in efficiency that need to be addressed. A database that tracks volunteers and types of donations was discussed at the FAEMSMD meeting. Finally, the new Stroke-Triage Assessment Form, which was presented at the July EMSAC meeting, was approved at the October 24 meeting. ■



Hepatitis A Outbreak and First Responders: Earlier this year, state Surgeon General Scott Rivkees encouraged EMS providers to vaccinate individuals at high-risk of contracting Hepatitis

suscitation Academies were hosted across the state. This free program focuses on ‘training the trainer’ with a goal of improving resuscitation outcomes. Five more academies are planned for this fiscal year.

Free webinar series at EMpulse Winter 2020



New Committee: Women in Medicine By Dr. Cristina Zeretzke-Bien

Women in Medicine Committee Chair

Gender equality efforts over the past 50 years have resulted in a more diversified workforce. Today, one-third of physicians in the U.S. are women, and that number will only grow with over 50% of incoming medical students identifying as female. There should be little surprise, then, that research on gender issues within medicine is growing as well—and that research is shedding light on many areas in need of improvement, such as unequal salaries for male and female physicians of equal skill level; implicit gender bias that affects decision-making in patient care; higher rates of burnout, depression and suicide for female physicians; lack of

mentorship for women in medicine; and much more. The question then becomes: what can FCEP do about this? At the November Board meeting, Dr. Kristin McCabe-Kline approved a new, ad hoc committee, Women in Medicine, to investigate this very question. The committee will dedicate this first year to exploring gender issues within emergency medicine to determine:

port female members and gender equality efforts in general; and

• suggested methods of achieving these goals

Interested in joining this committee and shaping its future? Contact us now!

• how those issues are affecting FCEP members;

• what FCEP can do to better sup-


Scan to access the

FCEP Committee Interest Form

or visit:

“From EBM to HBM”


by Dr. Ken Milne

FIX19 Tidbits By Dr. Cristina Zeretzke-Bien On Sept. 16-18, 2019, a group of women from UF Gainesville visited New York City and attended the FemInEM Idea Exchange (FIX) 2019 conference. Here are some tidbits from a few of our favorite lectures: The full article could not fit in print. Read more online at Pictured: Drs. C. Zeretzke-Bien, C. Holland, B. McAlpine, L. Scieszka, T. Davis & C. Srihari at FIX19. 16



by Dr. Anwar Osborne

“I am an Angry but Effective Women” by Dr. Michelle Lall

Anger is a force that injects energy, intensity and urgency into battles that must be intense if they are to be won, but women’s anger is consistently silenced. Main Point: We need to be allies to one another, on shift, in the boardroom, etc. This includes men and women.

ANGRY MEN: vs. WOMEN: empowered, passionate, competent, influential, understanding

EMpulse Winter 2020

ugly, crazy, hysterical, aggressive, overly emotional, irrational, shrill

Main Point: Women are less noticed in the field of medicine, and their exclusion affects the quality of research and patient care. SEE FOR YOURSELF:

▶▶ Who gets most of the grant money? ▶▶ Who rises to the top academic positions? ▶▶ Who is the first author on a research paper? ▶▶ Who is more likely to be introduced with their professional title at grand rounds?

96% Men




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EMRAF President’s Message By Matthew Beattie, MD, PGY-3 EMRAF President ’19-20

I hope everyone had a wonderful Thanksgiving and Christmas. If you’re like me, this is your favorite time of the year. Not only do we get to celebrate the holidays, but we finally get a little taste of “cold” weather. Not quite as cold as Denver was for ACEP19, but at least we got a break from the Florida heat. As we roll into the second half of the year, continue to put forth your best effort and work hard. Our job is pretty cool, and I thank you for what you do. I want to encourage you to try and make it to EM Days on January 27-29 in Tallahassee. I went last year and it is an enlightening experience. As a resident or medical

student, you are paired up with practicing physicians who are well informed of the issues at hand, and it allows you to see advocacy in action. Every year, there is a list of hot issues which are addressed. A few issues to be addressed this year include scope of practice for APP’s/pharmacists, reimbursement and treatment of opioid addiction. You can read more about these issues on pages 7-9. Finally, I want to encourage you to get involved with EMRAF and FCEP. With 18 residency programs, we are looking for more interested members to share their ideas. Getting involved is a great way

to network with future employers, make new friends, make changes in your area of interest, and develop leadership skills. I welcome your input anytime. Please email me at if you have any ideas or questions. ■

NEXT EMRAF MEETING: January 28, 2020 9:30-10:30 am Hotel Duval in Tallahassee, FL

EMRAF RECEPTION: January 28, 2020 8:30-10:30 pm TBD in Tallahassee, FL



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EMpulse Winter 2020


Kendall Regional Medical Center By Dr. Ramsey Ataya, PGY-3

Emergency Medicine Academic Chief

It has been a mix of emotions at Kendall Regional Medical Center as we mourn the recent passing of Dr. Daniel (Danny) Sirovich. A recent graduate and leader of the program, Dr. Sirovich truly seized every opportunity to enjoy life and share it, from making even the sickest of patients smile and chuckle, to checking in on his fellow colleagues’ wellbeing. Our thoughts and prayers go out to his family, friends and all who knew him. As we continue to host monthly wellness activities, interdisciplinary conferences, and weekly simulation and ultrasound activities, we would like to thank all who were able to attend the first Medical Student Simulation Day earlier in September, where students took the lead in medical and trauma resuscitation. We would like to congratulate our residents on their strong showing at the National ACEP SIMWars Competition in Denver, as well as the vari-

IN LOVING MEMORY: Dr. Daniel (Danny) Sirovich, pictured here with his mother, passed away on August 14, 2019.

ous resident presentations accepted there. Our team earned 2nd Place against eight other programs across the nation. Special thanks to Drs. Antoinette Golden, Ramsey Ataya, Spencer Barela, Jasmin Nuesa and Arvin Jandu who worked tirelessly to prepare for this event. Our Global Health Track had their inaugural trip in September. They visited the Universidad de Panama to teach a week-long course in Emergency Ultrasound to our fellow Pan-

amanian residents. In the first week of December, a team of three EM residents and two faculty traveled to Costa Rica, where they provided medical care to Nicaraguan refugees who had abandoned their homes due to severe political unrest. We look forward to expanding our residents’ opportunities and collaborating more closely with our neighboring EM programs. ■

St. Lucie Medical Center By Abby Regan, DO, MSc, PGY-2

The temperatures are finally starting to cool this academic year, and at St. Lucie Medical Center, we are as busy as ever. Our current second-years are completing their trauma and PICU rotations, and the first-years are working through anesthesia, pediatric EM and ICU. We are fortunate to have such welcoming and accommodating sister facilities to help us broaden our knowledge base. This is the time of year when preparation for the yearly In-Service Exam really intensifies. We have all been working hard with Rosh Review and the weekly reading reviews provided by our first-years. Each week, our conferences have been filled with

engaging lectures to prepare us not only for the exam, but also for our future practices. We recently had the pleasure of having Dr. Gary Curcio, Trauma Medical Director at Lawnwood Regional Medical Center, provide us a lecture on rib fracture management. We have four graduating seniors this December, who represent the last class of our previously four-year program. Dr. Michael Gulenay will be going to Columbus Piedmont Regional in Georgia. Dr. Austin Hudson is traveling to Northern Virginia Medical Center. Dr. Blaire Laughlin will be at University Hospital in Augusta, GA, and Dr. Jeremy McCreary EMpulse Winter 2020

is heading to University of Tennessee Medical Center in Knoxville. We are sad to see them go, but also proud to see them flourish. This winter, we are saying goodbye to our Emergency Department Director and core faculty member, Dr. V. Andres Sasson. He encourages us to practice empathetic medicine with as much grace and style as we practice analytical medicine. He has provided St. Lucie Medical Center with many years of service, and his presence will be sorely missed. We wish you the best of luck with your new endeavors, Dr. Sasson! ■



Aventura Hospital By Dr. Scarlet Benson

Assistant Clinical Professor

Florida Atlantic University By Dr. Elizabeth Calhoun, PGY-1

Greetings from sunny Boca Raton, where the recent low temperature of 63 degrees is an exciting cold front! The year is moving quickly, but we have enjoyed another full season. The program is starting a new portion of our didactic curriculum titled “Meet the Specialist,” where we invite various specialists with important involvement in ED emergencies. For example, Dr. Joshua Cohen, a local second-generation Ophthalmologist with additional Harvard training in public policy, visited for a greatly interactive Q&A session to discuss eye emergencies from the specialist’s point of view. Later we welcomed Dr. Todd Parnes, otorhinolaryngologist, to shed light on highly practical questions such as, “which middle-of-the-night ENT consult is something that can usually wait until the morning?” or, “peritonsillar abscesses: when can we drain ourselves, and what are some related tips?” In November, we were joined by the well-recognized Diana Nordlund, DO, JD. She presented “Risky Business: The Medical Record and Your Career,” which was full of reminders and advice regarding the medicallegal world. We would also like to congratulate our residents, Drs. Spencer Greaves, PGY-1 and Damien Carrasco, PGY3 chief resident, who were each married this season. Damien and his new wife enjoyed a honeymoon in Denver, attending ACEP with the other seniors and core faculty. Talk about dedication to emergency medicine! ■


Aventura had a great turnout at ACEP19 in Denver, CO, with a large number of our senior residents and several core faculty attending. We are well into interview season with a record number of applicants and a busy interview schedule. Thank you to program coordinator Angie Taylor, our core faculty, as well as our chiefs and resident volunteers for their hard work with interviews, tours and social outings! Residents and staff continue to impress with their academic endeavors, and two seniors were already accepted into competitive fellowships. Dr. Fred Chu will start a Wilderness Medicine fellowship at George Washington University this fall, and Dr. Jas Gill matched into the Surgical Critical Care fellowship at University of Maryland/Shock Trauma. Congratulations to both—we are so proud of you two! Dr. Gill submitted an article for the

EMRA Critical Care Deep Dive series, “Implementation of the Cardiac Arrest Sonographic Assessment (CASA) protocol for patients with cardiac arrest is associated with shorter CPR pulse checks,” in addition to reviewing an article for the BMJ online, “Aberrant internal carotid artery in the middle ear: the duplication variant.” Intern Dr. Nicolas Ulloa published an article, “Refeeding Syndrome and Non-Alcoholic Wernicke’s Encephalopathy in a Middle-aged Male Initially Presenting with Gallstone Pancreatitis: A Clinical Challenge,” with the online newsletter Cureus. Core faculty and clerkship director, Dr. Annalee Baker, published an article with with former Aventura residents entitled, “Status Epilepticus: Overlooked and Undertreated.” With the new year upon us, we have some projects in the works and look forward to sharing more resident and faculty achievements at the upcoming FOMA conference in Weston. ■

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


This patient’s chest radiograph demonstrates a right upper lobe opacity with gas and an air fluid level, consistent with a pulmonary abscess. The patient was found to be septic in the ED. A sepsis protocol was initiated, and the patient was admitted. The patient required a thoracostomy tube. He was found to be HIV positive with a low CD4 count. After a protracted hospital course, the patient was eventually discharged with outpatient infectious disease management. ■

EMpulse Winter 2020


New Residency Sections on

Mount Sinai Medical Center By Stephanie Fernandez, MD, PGY-2

Season’s Greetings from Mount Sinai! We are halfway through the academic year and have had the pleasure of meeting several excellent candidates for next year’s cohort of residents. Interview season is in full swing, as well as our weekly “Toast Tuesday” dinners for interviewees. Our residents had a strong presence at ACEP19. Dr. Zachary Gimbel spoke about the approach to failed surgical airways in the Drop the Mic competition, and Dr. Elizabeth Rubin presented a fantastic overview of narcan-induced ARDS in the 20 in 6 competition. Sinai also had a team participate in the EMRA MedWar, comprised of Drs. Stephanie Fernandez, Hannah Gordon and Jiodany Perez. On the local stage, Dr. Jenna Varner and Dr. Laurie Boge were keynote

speakers at the AMWA regional Conference at NSU. Dr. Nicholas Boyko and Dr. Fenil Patel also led several educational opportunities for NSU medical students, including a splinting workshop and advanced airway course. Both residents and attendings also volunteered at the local soup kitchen at Camillus House and served dinner to nearly 800 people! Lastly, a word of congratulations to our seniors who have accepted positions for fellowship next year. Dr. Natasha Brown will be attending a Disaster Medicine fellowship at Harvard-affiliated Beth Israel Deaconess, and Dr. Elizabeth Rubin will begin a Simulation fellowship at University of Chicago. Mount Sinai is proud to report that we will also welcome our first Ultrasound fellows next summer, led by our own Ultrasound Director, Dr. Mark Newberry! ■

Jackson Memorial Hospital

In October, our entire senior class and many of our faculty attended ACEP19 in Denver. The conference was great; the weather a little less so, but it served as a reminder of why we live in Miami. We are happy to announce that one of our PGY-3

Access the latest EMpulse articles from all residency programs by visiting this homepage. Programs are grouped by region. Don’t forget to share yours online! SCAN OR VISIT: residency-updates

Florida’s EM Residency Programs

By EM Residency Program Staff Greetings from Miami! We have had a great fall thus far. We held our annual full-residency retreat at Crandon Park in September. The day was focused on wellness, team building and brainstorming for program improvements. It also included plenty of free time for fun sports such as beach volleyball, football and an amazing barbecue prepared by none other than our program director, Dr. Freeman.

EMpulse Residency Updates Homepage

residents, Dr. Tim Montrief, competed in the EMRA 20 in 6 Resident Lecture Competition at ACEP’s Scientific Assembly and was selected as the winner of the competition. His presentation on harm reduction in the ED entitled “Breaking Bad” was excellent. If you have not checked out this great event yet, make sure you attend next year. It’s hard to believe it’s recruitment season already. We have held a few interview days and are excited to meet many more applicants in the coming weeks! We hope everyone had a safe and happy holiday season and anticipate seeing many of you at CORD in the spring. ■ EMpulse Winter 2020

Browse through all of Florida’s programs easily with this new resource. Each one of Florida’s accredited EM residency programs has its own page containing basic program information, a feed of EMpulse articles, and a link to learn more.

SCAN OR VISIT: Information is pulled from program websites and will be checked every quarter. Program directors & coordinators: please email if you need to update information before the next issue. 21


USF Health By Mikhail Marchenko, MD, PGY-2

Oak Hill Hospital By Jonathan Yaghoubian, DO, MS, & Corey Cole DO, PGY-2s So many things have happened in the first half of the academic year. Our simulation center is up and running. We have been running weekly simulations with the help of our simulation coordinator, Dr. Vesta Anilus. She has been creating very life-like scenarios for us to run, and it has been a very educational experience for both first- and second-years. We have welcomed a sixth secondyear resident, Dr. James Newton. We are very excited to have him, and he has been fitting in quite well. With a growing residency, we have accepted more core faculty. We are happy to introduce Dr. Jason Grabert, our new assistant program director. He has been an immense help to our program and we look forward to what he contributes. Construction continues throughout the hospital. The additional floor to our North Tower is almost complete. It is scheduled to have a NICU, multiple private rooms and 24-hour pharmacy coverage. In addition, they are renovating the medical office building as well as the cafeteria. The ED expansion is slated to break ground sometime this winter. Although it will be during peak season, it will end up providing much needed additional space. ■


We’ve got a lot of exciting news from Tampa! First of all, congratulations to Dr. Enola Okonkwo on her role as the new Assistant Program Director for our residency. Dr. Okonkwo completed her residency in emergency medicine at Carolinas Medical Center in Charlotte, NC. She loves emergency medicine, research, spending time with her family, party planning, travel and fitness. We are grateful for her leadership. Our simulation department also has many new developments. Under the guidance of Dr. Ryan McKenna, we have started a new rotation in simulation and after a few short months, it has become a hit. We are also excited about the new fellowship in simulation, which is set to start in July 2020 and is now accepting applications. Furthermore, as part of the growing simulation program at USF, we are thrilled that the USF Health Simulation Center will be hosting the ACEP Sim Training Course on May 4-6, 2020.

EMpulse Winter 2020

Finally, congratulations to Dr. Jason Wilson, Dr. Jack McGeachy and Heather Henderson, MA, who received a grant through the National Institutes of Health (NIH) Helping to End Addiction Long-term Initiative (HEAL), which is a national effort that provides $945 million in total funding to research projects that tackle opioid addiction and the overdose crisis. Tampa General Hospital has been chosen as one of the 30 emergency department sites to participate in a study being conducted by the National Drug Abuse Treatment Clinical Trials Network’s New England Consortium Node and investigators at Yale University. Their research will test an implementation strategy to guide the development of ED-initiated treatment of opioid use disorder with buprenorphine. Cheers to all well-deserved successes, and of course to all of our PGY-3’s signing contracts and getting ready to start their own journeys as attendings. ■


Brandon Regional Hospital By Rashmi A. Jadhav, MD, PGY-2

Our second year is well under way with several exciting updates to our program. The addition of Dr. Aleem Bakhtiar to our core faculty has already proven to be an asset to our teaching staff. He brings a new perspective to our education with his advanced fellowship training in sports medicine. Dr. Kelly Grabbe has supervised several simulation scenarios with the use of our brand new, state-of-the-art Apollo simulation manikin, building the confidence of our residents with running codes and performing procedures. Additionally, our didactic and simulation scenarios have been relocated to our brand new GME classroom, providing a great space for lectures,

studying and much more. We are well underway with our interview season and have come across very strong applicants. Several of our residents and many of our faculty had the pleasure of meeting some applicants at ACEP19 in Denver, CO. As they braved the cold and snow, our program was incredibly proud to have Dr. Roli Kushwaha present her case report on Perforated Viscous at ACEP. Moreover, our intern class has assimilated very well and has proven to be a strong group of residents. There have been several social gatherings, which have created a wonderful bond

between all of our residents. We had our first wellness activity of the year where we had one hour of relaxing yoga during our didactics, which was followed by a fun-filled afternoon at an escape room. We are very excited to see what the rest of the academic year holds for us and cannot wait to add another class of residents to our program, completing our program with three full classes of residents. We eagerly look forward to meeting many more applicants, working even harder as we train with amazing faculty, and grow closer with each other. ■

FSU at Sarasota Memorial Courtney Kirkland, DO, PGY-1 Greetings from Sarasota! As the inaugural class, it’s hard to believe we are almost halfway through our intern year. First and foremost, I would like to say how grateful we are to have received a donation of $800,000 from the Louis and Gloria Flanzer Philanthropic Trust for new simulation and ultrasound equipment. We’ve received such a warm welcome from our faculty and hospital administration, and we are so grateful to be part of such a wonderful healthcare system. We are also excited to be part of the expanding statewide network of residency programs sponsored by the Florida State University

College of Medicine.

Kelly O’Keefe.

Despite our short tenure thus far, we have really begun to make a name for ourselves at the Sarasota Memorial Healthcare System by participating in the new joint EM/IM and trauma conferences, presenting didactics, and attending the hospital Quality Improvement meetings. Additionally, our intern class has also been presenting at Journal Club and our Evidence Based Medicine conferences, both led by Dr. Sagar Galwankar. I was lucky enough to attend ACEP19 in Denver, representing our program at the EMRA Representative Council Meeting and the Residency Program Fair with our program director, Dr.

Our tight-knit group of nine residents regularly participate in various team-building activities together, including extracurricular bowling, our hospital ED kickball tournament, and participating in a local Habitat for Humanity build. Everything in the hospital and with our group could not be going more smoothly!

EMpulse Winter 2020

It’s hard to believe that interview season has started already, and we cannot wait to see who joins our residency family in just a few short months… ■



UCF/HCA of Greater Orlando By Amber Mirajkar, MD, PGY-2 and Andrew Hanna, MD, PGY-3

AdventHealth East Orlando By Shannon Armistead, DO, PGY-3 From all of us at AdventHealth East Orlando, we hope you enjoyed happy and healthy holidays. We soon will come to the end of our interview season and have been greatly impressed, not only by the medical students rotating with us but also by the medical students who have journeyed near and far to sit with us for a few hours. During the season, Dr. Steven Nazario was promoted to Program Director after spending 12 years as the Associate Program Director. We greatly appreciate Dr. Dale Birenbaum for starting the program and leading us, and now hope to continue our strong tradition. Our seniors enjoyed ACEP19 in Denver, though it was a little cold for our tastes. We braved the snow to attend lectures and demonstrations on the exhibit floor. We were also lucky enough to catch up with past graduates and interact with our attendings and colleagues on a new level. And while the seniors were away, the second-years were allowed to play and try their hands at being on third-year shifts. Our interns are finally experiencing the joy that is our trauma month in Lakeland. They, as a class, have done well in the first half of the year and will continue to learn all that is set before them. As we come ever closer to our in-training exam, we hope all the studying and the hours of dedication continue to serve us well. Finally, AdventHealth is excited to announce a Critical Care Fellowship based at our flagship Orlando campus. This two-year program is currently interviewing to seat six spots. We wish all the best to applicants and are excited for Match! ■ 24

It is hard to believe we are approaching the halfway point of the academic year, but time flies when you are having fun! PGY-3s are interviewing for jobs and fellowships alike and we wish them the best. The third-years went to Life After Residency Retreat in St. Pete, FL, and learned a plethora about the non-medical realities of being a practicing physician. They also recently returned from ACEP19 where they spent time learning, networking and having fun amidst a Colorado snowstorm. We had a strong showing there, including Dr. James Chiang, PGY-3, who presented a well-received abstract on double sequential defibrillation. Needless to say, the PGY-1s and PGY-2s are looking forward to ACEP next year. PGY-2s partook in Advanced Pediatric Life Support at Nemours Hospital. It was a 2-day training to prepare residents not only for the pediatric ED, but also the PICU. Between small groups, lectures and simulation, it was a valuable learning experience. One simulation that stands out was the umbilical line placement. It is a rare, but essential procedure to know, and we certainly appreciated the practice.

The Electronic Daisy Concert is a nationally renowned annual event that takes place in Orlando this time of year. Our residents and faculty were invited to staff the medical tent, and we had a blast. Between triaging and managing toxidrome syndromes, our residents got a very unique experience. For residencies, fall is also synonymous with interview season and we are no different. The residents are excitedly welcoming the applicants at their homes weekly where not only do we all get the chance to get to know the interviewees, but also get to bond as a residency. Ultrasound is taking off at Osceola Regional Medical Center. In addition to having our first ultrasound fellow start, we have convinced other residents how amazing ultrasound is. One of the IM residents was the first to take the ED Ultrasound elective, and both sides had a positive experience. Hopefully this is the start of a beautiful friendship. We wish everyone a happy and safe new year, and good luck to all those interviewing! ■



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UCF/HCA at Ocala Regional By Caroline Smith, MD, PGY-2

As we head into the new year, residents at UCF Ocala continue to be involved in the community. Several residents have given academic lectures for EMT and paramedic students and informational lectures to local senior citizens’ groups. Residents and faculty participated in a mass casualty simulation along with Marion County and the City of Ocala emergency rescue services. The simulation increased awareness of protocols and cooperation between pre-hospital emergency response teams, medical control and hospital providers.

We also had our annual “Fire Day” at the Florida State Fire College. Residents and willing faculty members completed (or attempted to complete) the same physical fitness training exercises that our fire rescue colleagues complete as part of their training. The day included obstacle courses in full fire gear, repelling down a six-story building and putting out a controlled fire—all under expert supervision, of course. Both the mass casualty simulation and Fire Day increased our understanding and appreciation for the role emergency rescue services play

in our community and within patient care. We would like to express our appreciation to Frank Fraunfelter, MD, UCF Ocala core faculty member and Medical Director of Marion County Emergency Medical Services, for coordinating both of these events for residents. Outside of our local community, members of our third-year class attended ACEP19 in Denver. The senior residents had a great experience exploring Denver, networking and expanding their knowledge of emergency medicine. ■

Orlando Health

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

By Anne Shaughnessy, MD & Laura Cook, MD, PGY-3s Greetings from Orlando! Orlando Regional Medical Center (ORMC) has had a productive and busy fall season. Following with tradition, we sent our 16 seniors to Denver for ACEP19 with several members of our faculty. We enjoyed the conferences, exhibits and labs ACEP had to offer, but we Floridians also had some fun in the snow this year. We are now looking forward to CORD and SAEM in the spring. Many of our residents and faculty are excited to present their research and lectures. We continue to keep our didactics interactive and interesting at ORMC. Recently our program organized an obstetrics emergency simulation morning in collaboration with OB faculty from Winnie Palmer Hospital. Residents spent the morning mastering techniques to approach breech deliveries and shoulder dystocia. Additionally, residents participated in EMpulse Winter 2020

simulation for resuscitative hysterectomy. We recently participated in being part of the medical team at Electric Daisy Carnival with Orange County EMS in their medical tents. We enjoyed representing Orlando Health in the community and seeing some interesting toxicology. This past winter season, we enjoyed some wonderful time as a residency family with our annual holiday party. We can’t believe how quickly the last year passed, and we are excited for what 2020 brings. We have met many great applicants this past fall and are looking forward to the Match, hoping to welcome 18 new residents to la familia! We look forward to spring and the second half of the academic year. Hope to see everyone at EM Days! ■ 25


Orange Park Medical Center

UF Health Jacksonville

By Jennifer Chapman, MD

By Dr. Ty Tantisook, PGY-2

Assistant Program Director

We could not be happier with our inaugural class! Despite getting a late start to the match process last year, we matched 12 top-notch residents who continue to impress our faculty and ED staff daily. We are eagerly looking forward to meeting our next fantastic 12 in July. On the research front, our faculty and residents are heavily involved in both grant-funded and nonfunded projects. Dr. Ahmad Mohammadieh presented two studies entitled “Cost Benefit Analysis of Dispensing Antibiotics at Emergency Department Discharge to Uninsured Patients” and “Trauma Activations at Provisional Level II Trauma Centers During their Inaugural Year” at Symposium by the Sea this past August. Our residents and simulation faculty are gearing up to present “Arterial Line Catheter Insertion Trainer: DIY for Cheap!” as well as “Stop the Cognitive Bias!” at the International Meeting on Simulation in Healthcare conference in San Diego, late January 2020. Our program director recently launched a large, grant-funded ED clinical study in collaboration with our dermatology residency program. This fall, our PGY-1 class and faculty took part in Six Sigma training as well as dedicated TEE training. Despite all the hard work, we were able to bring the faculty and residents together for multiple wellness and team-building events such as a group Crossfit workout, Top Golf tournament and a Zamboni-riding ice hockey game. What a blast! ■


It was great to see everyone at ACEP19 this year in snowy Denver. Big congrats to our SimWars team, who took first place! Drs. Corey Dye, Kim Papa, Steven Chadwick and Cory Clugston got the job done while rocking some sweet Minshew Mustaches (pictured above). They had some tough cases against some great competition. We will be excited to defend the title next year in Dallas! We are happy to announce that Dr. Ashley Norse was awarded Medical Director of the Year by the Academy for Women in Academic Emergency Medicine. Additionally, our Chief Quality Officer, Dr. Kelly Gray-Eurom, was elected as Vice Speaker of ACEP. We are very lucky to work

with and learn from such a talented group of senior residents and faculty—their awards are well deserved. Best of luck to everyone during interview season, including our fourthyear medical students and graduating PGY-3s. It is exciting to see our seniors get the jobs and fellowships they have been working so hard to obtain. It has been great meeting everyone on the interview trail here in Jacksonville. We have had a great bunch of interviewees thus far; hopefully we can offer some Florida warmth during the cold winter. Enjoy the rest of 4th year as it flies by… you’ll be starting intern year before you know it! ■

UF Health Gainesville By Christopher Purcell, MD, PGY-2 We love being able to send our thirdyears to ACEP19 every fall. This year, our PEM faculty stole the show: Dr. Tricia Swan was appointed Chairelect of the ACEP Pediatric Emergency Section, Dr. Carolyn Holland was appointed to the ACEP Educational Meeting Subcommittee, and Dr. Cristina Zeretzke was appointed the Section Editor for Pediatrics of the Western Journal of Emergency Medicine. Congratulations!

medicine. On-field passes to watch the Gators play is a nice bonus!

Football season at the University of Florida always provides a unique EMS opportunity for our residents. We are able to gain exposure to mass gathering medical care and event

As interview season winds down, we eagerly await Match Day 2020. We can’t wait to welcome the newest 14 members to our UF Gator Family! ■

EMpulse Winter 2020

Look out for our new fellowships starting soon. We are excited to have Research, Administration, Toxicology and Pediatric Emergency Medicine fellowships in the works. This is in addition to our already established EMS, Critical Care, Ultrasound, Global Medicine, Sports Medicine and Simulation fellowships.


UCF/HCA North Florida Regional By Jayden Miller, MD, PGY-1 It was a busy fall at North Florida! The interns are settled in, and the third-years are looking to the future. In September, our program held the first Difficult Airway Course taught by faculty. Last year, several of our faculty became certified to instruct the Difficult Airway Course so we could host it at our program. There were lectures, skills labs and simulation to advance our airway management skills, and it was a very valuable learning experience. We also had an educational session on physician finance with an

advisor who works primarily with EM physicians. It was a fun and interactive session, answering a lot of questions almost no one addressed in medical school. The intern class also recently attended ATLS and APLS, ensuring their preparation for any emergent patient who may come in, no matter their age. The third-year class went to ACEP19 in Denver, where they enjoyed networking, education and the outdoors. Mollie Powell, DO, PGY-2 presented at CaseCon, sharing her poster, “Listen to your Heart, or at Least theirs.” A faculty member, Evan

Stern, MD, ran a cricothyrotomy simulation. Chief resident Christopher Libby, MD, PGY-3 represented North Florida at the 2019 AMA Interim Meeting in San Diego. He is on the governing council of the Resident and Fellow Section, and participated in debate about parental leave and other protections for residents. We are looking forward to the winter, which will include wellness activities and lots of excellent clinical and educational opportunities. ■

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As you interview... WORDS OF ADVICE FROM A PAST-PRESIDENT By Michael Lozano Jr., MD, MSHI, FACEP

FCEP Past-President | Senior Vice President, Southeast Operating Unit at Envision Healthcare | Associate Medical Director, The Physicians Quality Registry (The PQR)

As it goes with print publishing, you are reading this article several months from when I wrote it. For me it’s Halloween, and I’m on the way home from ACEP19. It’s also interview season for graduating residents and fellows, so I want to share some thoughts that tie these two concepts together. It was a great Council and Scientific Assembly for Florida EM docs. Dr. Bill Jaquis received the ACEP President’s gavel from Dr. Vidor Friedman. Dr. Kelly Gray-Eurom was elected to the Council Vice Speaker post, and the Jacksonville EM residents were the champions of SimWars. The Scientific Assembly boasted of hosting over 6,000 attendees from most states and multiple countries. I found it particularly invigorating to see the great variety of people in the sessions and walking the concourses. I believe that one of the hidden strengths of our specialty is our diversity—people, opinions, and approaches to solving problems. After all, isn’t that we do best as EM docs? We attempt to solve problems for people who couldn’t figure them out for themselves. Sometimes these problems even involve medicine. I don’t know for sure, but I have the suspicion that we as a specialty reflect the patients we serve more than other 28

specialties. This is relevant to our early-career physicians. Studies have demonstrated that diverse groups generally perform better on multiple dimensions of measurement. Additionally, patients feel more at ease, share a richer amount of history, and are more compliant with care plans when they share characteristics with their physicians. A word of advice for those interviewing: look for a job where you can feel comfortable with you colleagues—where you feel welcome. This applies to docs, NPs, and PAs.

I believe that one of the hidden strengths of our specialty is our diversity— people, opinions, and approaches to solving problems. After all, isn’t that we do best as EM docs? Emergency medicine is a team sport, so you need to feel like you can add to and grow with the team. Having a welcoming and inclusive group is important. Another equally important feature to look toward EMpulse Winter 2020

is the leader. Years ago, when I was a med student, I was told not to choose a program based on famous faculty members or chairs because people inevitably move on to other positions. That may be true, but while they are there, the leader will have a significant impact on your professional life. A good leader works with you to make you a better clinician. For many, the leader is the one who shields them from the slings and arrows of outrageous hospital administrators. The truly wise leaders will be able to coach you and advise you so that you don’t become a target. Good leaders pass on messages; great leaders inspire their teams to excellence. For new graduates, be comfortable with the leader you are signing on with. For our middle- and late-career physician leaders, be the best leader that you can be. Keep working on your leadership skills even if you have been at it for years. Another word of advice for our job seekers is to look for a work situation where you can branch out from the daily grind of shift work to explore additional areas of medicine. This

will go a long way to strengthen your resilience to stress. We work in a demanding specialty—physically, cognitively, and emotionally. Look for a group where there is opportunity for growth, especially over the longterm of your career. In the first six months or so, you will still be getting comfortable in your new attending skin. Once you get past that and the Boards, look for other quasi-medical and full on medical areas to spread your wings and make a difference. Stress and burnout are widespread in our specialty. Some estimates say that up to half of emergency physicians are exhibiting signs and symptoms of burnout. As I’ve heard from several leaders in the field, you can’t yoga your way out of burnout. Look for a work situation that is supportive of you, and that can provide the supportive services to help get you through the rough spots. This applies regardless of where you are in your career path. By the time you read this, the whole issue of balance billing will have been hashed out in Congress, or it would

have been put on the back burner. Regardless, it was the elephant in the room at ACEP Council this year, and you might have been following the drama on social media. Unfortunately, it became a divisive issue in our specialty this past year. I say unfortunately because physicians are being assailed on all sides. Getting paid fairly by insurance companies should be something that we all can agree on. Getting patients out of the line of fire between insurance and physician companies is something that we can all agree on. To paraphrase our own Vidor Friedman, “point the barbs outward and not at each other.” The House of Emergency Medicine needs to stand together or it will surely fall apart. In conclusion, we can all agree that our chosen specialty is challenging. It is also rewarding. We have the privilege to help people out on what they feel is their worst day. Most people don’t want to seek out our

services, and sometimes we don’t get the respect that we deserve for all we have been through and all we do. However, there are those little bright spots that make it all worthwhile. To our early career colleagues looking for their first job, I wish you well. Don’t focus solely on the financial aspects of a potential position. Look for the intangibles as well. Those are the aspects that will make your professional life more rewarding and fulfilling. For the rest of you, be well and try to focus on the reasons that got you into our specialty. It will help get you through the rough patches. ■

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Medical Student Council

By Alexa Peterson, OMS-III, Nova Southeastern University FCEP Medical Student Council Secretary-Editor

This fall has been busy and bustling for emergency medicine interest groups (EMIG) around Florida. FCEP’s Medical Student Council held its quarterly conference call, gathering eight EMIG student leaders from around Florida to reflect on fall activities. Students at Florida International University (FIU) were exploring disaster medicine and took initiative to engage students in conversation about pre- and post-disaster management. Additionally, Florida State University kick-started a new event, “Women in Emergency Medicine Night,” where local emergency physicians gathered with students over a shared a meal for a relaxing evening of conversation and connection. We also saw the trend of celebrating women in medicine at Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine (NSU-KPCOM) as they hosted the Region 4 AMWA conference with the theme, “My Body and I.” Speakers explored topics related to protecting female bodies and positively promoting and supporting other women. One of the coolest parts? The two keynote speakers were emergency physicians. Dr. Laurie Boge, Clerkship

and Wilderness Medicine Director at Mount Sinai South Beach and Dr. Jenna Varner, PGY-2 at Mount Sinai South Beach both gave inspirational keynote speeches. “I knew they would be a perfect start for our conference,” stated Courtney Hundzinksi, OMS-III at NSU-KPCOM and the AMWA Region 4 Director. “Dr. Boge has been breaking down gender barriers and fighting for equal treatment of women physicians in her field… hearing from two EM physicians that are in varying stages of training, and while dominating in their careers, was motivating and inspirational.” Continuing with the fall excitement, we had students from all over Florida representing medical students at ACEP19 in Denver, CO. Student leaders were able to take advantage of the student-focused day on Saturday as EMRA hosted an intern panel to continue inspiring M1-M4 students about the excitements to come. There were also several breakout sessions to learn from, ranging from M3 students navigating the match, or how as an M1 and M2 student you should be positioning yourself for success, all the way to M4’s learning how to present your best self for interview day. A student favorite is always the



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EMpulse Winter 2020

Residency Fair as there are program directors from all over the country connecting, networking and allowing students the opportunity to find the best fit program for themselves. NSU-KPCOM’s Emergency Medicine Club coordinated the attendance of 12 very fortunate second-year medical students to ACEP19. “This was an absolutely incredible experience that not only facilitated learning all about the multiple EM residency programs throughout the county, but also allowed us to attend multiple educational talks about a wide variety of specialties within the world of emergency medicine,” said Patrick Anderson, OMS-II, President of the Emergency Medicine Club. Overall, students have been hard at work immersing themselves into the field this fall, and whether it’s schoolsponsored events or a national conference, the vibrant personality and tight-knit community of emergency medicine shines through! ■

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Vape Every

Take... You

Kristen C. Lee, Pharm.D., BCPS Clinical Toxicology/EM Fellow at Florida/USVI Poison Information Center-Jacksonville

E-cigarette, or vaping, product use associated lung injury (EVALI) is one of the hottest topics in emergency medicine. The Centers for Disease Control (CDC) is describing it as an “outbreak” due to rapid growth in cases over the last year.1 As of November 13, 2019, there have been 2,172 cases of EVALI reported to CDC from 49 states and 42 confirmed deaths.1 With new cases being reported daily, it’s important that providers become familiar with the information available in order to better assess potential cases. Electronic cigarettes are portable devices that heat a liquid in order to aerosolize it for inhalation. These liquids most often contain nicotine, but may include a variety of other chemicals, including tetrahydrocannabinol (THC) or cannabidiol (CBD).2 The main ingredient is usually solubilized in a hydrophilic vehicle such as propylene glycol or vegetable glycerin. The belief among many users of these devices is that fewer ingredients makes vaping a safer alternative to cigarettes. Because 32

Anthony DeGelorm, Pharm.D.

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

vaping is still relatively new, there is limited information available regarding complications associated with chronic use. However, at least six different groups of potentially toxic compounds have been identified in e-cigarette fluids, including nicotine, carbonyls, volatile organic compounds (benzene, toluene), trace metal elements, bacterial endotoxins and fungal glucans. No specific cause has been identified, but a reported 86% of 867 EVALI patients utilized THC-containing products, which makes their use a cause for concern.1 A common additive in these THC products is vitamin E acetate, which was recently found to be a potential chemical of concern in EVALI cases. In fact, CDC laboratory testing of bronchoalveolar lavage fluid samples from 29 patients found vitamin E acetate in all of the samples.1 EVALI is considered a diagnosis of exclusion because no specific test exists to confirm its presence. A variety of symptoms are associated with EVALI. Respiratory symptoms are the most common, including cough, EMpulse Winter 2020

chest pain and shortness of breath.3,4 Gastrointestinal symptoms are also prevalent, including abdominal pain, nausea, vomiting and diarrhea. In addition, constitutional symptoms including fever, chills and weight loss are frequently reported. Laboratory abnormalities in these patients may include elevated white blood cell count, serum inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), and liver transaminases. Patients often have pulmonary infiltrates on chest x-ray and opacities on chest CT. Due to the nonspecific nature of these findings, healthcare providers should consider the possibility of other or multiple etiologies in their assessment. At this time there are no specific guidelines on the management of EVALI, but the Department of Health and Human Services and the CDC have put together interim guidance for the treatment of the condition.3 Corticosteroids may be considered, except in patients with suspected fungal infections, due to their effect on inhibition of the inflammatory

response. 82% of 140 cases reported nationally to CDC improved on corticosteroids. There is no single dose suggestion for the use of steroids, so consultation with a pulmonologist may be considered. Patients who present with symptoms consistent with community-acquired pneumonia should be treated in accordance with the current guidelines. Patients should also be provided with education regarding the risks associated with vaping, with discontinuation advised. If successfully treated, patients should receive a follow-up evaluation within 1-2 weeks post discharge with consideration for additional follow-up at 1-2 months after discharge. While there is no single known cause identified for EVALI, the one commonality among all cases is the reported use of e-cigarettes or vaping. In order to better charac-

terize and treat this illness, CDC is stressing the importance of reporting cases to state, local, territorial or tribal health departments.4 CDC is also accepting vaping-related products and devices, as well as laboratory specimens, for testing. Statistics and recommendations are updated and released on the CDC website regularly.1 With continued efforts from providers and health systems across the nation, the knowledge and treatment paradigms for this new threat continue to evolve and progress toward control of this outbreak. ■ FPICN toxicologists are available 24 hours a day, free of charge, at 1-800-222-1222 to answer any questions practitioners may have about EVALI or any other toxic exposure.


1. CDC. Outbreak of lung injury associated with e-cigarette use, or vaping. Atlanta, GA: US Department of Health and Human Services, CDC; 2019. 2. Christiani DC. Vaping-Induced Lung Injury. N Engl J Med. Sept 6. 2019. 3. Siegel DA, Jatlaoui TC, Koumans EH, et al. Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury — United States, October 2019. MMWR Morb Mortal Wkly Rep 2019;68:919–927. 4. Layden JE, Ghinai I, Pray I, et al. Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin - Preliminary Report. N Engl J Med. Sept 6. 2019.


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DISRUPTIVE INNOVATION IN EMERGENCY MEDICINE By Mitchell Barneck, MD, PGY-3 Orlando Regional Medical Center

Every year at ACEP, the exhibit hall features innovatED: an interactive, educational space that provides a sneak-peek of new innovations in emergency medicine. This year, four start-up companies participated in a “Shark Tank” style pitch competition at the exhibit. This article highlights their disruptive technologies. The author is not affiliated with any vendors in this article and has no conflicts of interest to report.


Soundly Simplifying Surgery Current hemostatic and vessel ligation devices utilize either mechanical ligation, high frequency electrical currents, or “harmonic” ligation that relies on friction heat by means of mechanically vibrating cutting bars. These solutions are functional, but can result in surrounding tissue damage. In addition, they are limited in speed, precision and range of application.


Novuson’s technology is the first vessel ligation device capable of rapid, precise ablation using ultrasound waves for coagulation and hemostatic control. It may be the first substantive innovation in over 20 years for targeted vessel sealing, dividing and hemostasis. Transducers embedded into UltraStat device transmit direct therapeutic ultrasound, focusing the waves between the opposing jaws. This results in the

EMpulse Winter 2020

controlled application of energy without passing electrical current through the patient. The unique therapeutic delivery method reduces surrounding tissue damage, eliminates tissue adhesion and does not create smoke. Novuson’s technology may enable clinicians to more rapidly and safely control bleeding. For more information, visit:


Engineered Skin Replacement

Every year, thousands of patients suffer from poor wound healing after tissue loss from trauma, burns or infection. Current grafts use a scaffold that healthy skin cells invade, allowing the process of skin barrier recreation to start. However, these products typically experience an unacceptably high rate of complication and failure. Fesarius Therapeutics is developing an engineered skin replacement product that uses patented micro-

sphere hydrogel technology. The gel scaffold uses microspheres embedded in a collagen hydrogel to maximize the number of differential density interfaces. These differential densities uniquely drive cell invasion, proliferation and eventual healing. These innovations have potential to benefit patients with wounds that typically fail grafting. For more information, visit:


Point-of-care Troponin Assay Chest pain is a very common chief complaint of patients in the ED. In 2016, there were approximately 8 million visits to emergency departments for chest pain in the U.S. In addition, 18.2 million Americans had coronary artery disease (CHD) in 2016, according to the 2019 American Heart Association Statistical Update for Heart Disease and Stroke. The diagnostic workup for chest pain is often complicated by lengthy lab turn-around times, especially in facilities without 24-hour on-site labs. Brava Diagnostics is developing a highly sensitive troponin point-of-care test for diagnosis of heart attack. The proprietary evanescent planar waveguide platform


Advance Extracorporeal Membrane Oxygenation Extracorporeal membrane oxygenation (ECMO) was initially developed in the 1970’s to treat premature infants with poor lung development. Since then, its use has expanded to include children and adults as a last resort oxygenation therapy. However, ECMO is complicated by its physical size, blood clotting, necessity for systemic anticoagulation and the systemic inflammatory response.

delivers a lab-quality troponin test in a point-of-care ED setting. The test is run on a whole blood sample with results in less than 15 minutes. In contrast with other point-of-care troponin tests, this meets the American College of Cardiology and European Society of Cardiology guidelines for sensitivity and precision. Rapid diagnosis will allow for faster cardiac ischemia rule-out for patients presenting with chest pain. Decreasing workup times can reduce excess admissions, reduce costs and improve patient satisfaction.

Elsius Biomedical is developing a compact, integrated ECMO device that leverages a proprietary biocompatible coating specifically developed for extra corporeal life support applications. The coating, which has been developed in conjunction with Ension Inc, utilizes a glycocalyx to mimic the way blood interacts with blood vessel walls. This reduces the inflammatory response and need for anticoagulation associated with the procedure. In addition, the oxygenator and blood pump are a combined, portable, compact unit. By reducing both complications and increasing portability, it is possible that Elsius’ ECMO machine could expand ECMO initiation to the ED.

For more information, visit:

For more information, visit: ■

EMpulse Winter 2020


Members of the Ultrasound and Trauma Surgery Interest Groups conducting an e-FAST exam during the “Fast FAST Competition.” Photo courtesy of Jonathan Amodio.


Ultrasound Student Interest Group:

A Model for Active Learning & Multi-Specialty Collaboration By Andrew DiZenzo, BA UM Miller School of Medicine

A Brief History of Ultrasound Education In recent years, the use of pointof-care ultrasound (POCUS) has exploded. Medical ultrasonography was developed as an imaging modality a half-century ago, originally to non-invasively search for tumors and other growths in the World War II era.1 Since then, not only have the capabilities of POCUS evolved with the advancements of image optimization techniques, transducers and Doppler, but its applications have also expanded dramatically across many medical specialties. Unfortunately, current clinical utilization of POCUS in healthcare settings is limited, mostly due to 36

By Duyen Vo, MS

UM Miller School of Medicine

By Alessandra Della Porta, BS UM Miller School of Medicine

the operator’s unfamiliarity with the instrument and the lack of formal education. Although POCUS training has been incorporated as a residency requirement by some specialties— such as emergency medicine, obstetrics and gynecology, and internal medicine, to name a few—its integration and standardization as a part of a medical school curriculum is highly variable. In a 2012 survey of MD-granting accredited medical schools in the U.S., 62.2% reported that ultrasound education was integrated into their curriculum in at least one of the four years, either as a tool to teach basic science and medicine concepts or to teach students how to obtain ultrasound scans.2 Historically, at the EMpulse Winter 2020

Edited by Leila Posaw, MD, MPH

Emergency Ultrasound Director, Jackson Memorial

University of Miami Miller School of Medicine (UMMSM), ultrasound education is offered as a third-year elective, and only recently within the past academic year has ultrasound been introduced to first-year students. As second-year medical students at UMMSM, our interest in POCUS in all its glory stems from its easy and rapid usability, portability, little-tono-risk of radiation, and low cost to the patients we serve.

USIG at UMMSM: The Beginnings Concurrent with the development of POCUS as a robust diagnostic and procedural tool in clinical practice, Ultrasound Student Interest Groups

(USIGs) have emerged as popular extracurricular entities. These not only augment the medical school curriculum, but also help students develop the skills necessary to become comfortable with ultrasonography. Furthermore, medical school administrations have also begun to pay heed to the student demand for integrating ultrasound into the formal curriculum. Of note this year, the University of California, Irvine became the first medical school to purchase handheld ultrasound machines for every student.3 Given the shortfall of ultrasound education in our medical school curriculum, our USIG was created three years ago at the Miller School of Medicine as a student organization with officer positions held by second-, third- and fourth-year medical students, and under the guidance of the Emergency Ultrasound Director at Jackson Memorial Hospital’s Emergency Department in Miami. Our mission has been to promote and expose students to the use of ultrasound, including acquiring and interpreting ultrasound scans, and to demonstrate its integration across many specialties with the intent of creating student leaders in ultrasound. Participation in USIG activities has been voluntary and open to first- through fourth-year students.

What is particularly unique about our USIG this year is that we have incorporated the gamification model of active learning into our organ system-focused workshops, and also we have expanded our collaboration with a wide array of other student interest groups.

Gamification The primary means by which our USIG engages and informs student members is through workshops that focus on the application of ultrasound to particular organ systems. In order to promote student involvement and active learning, our workshops are designed on the principles of “gamification.” Similar to published literature, we define gamification as “the process of game-thinking and game mechanics to engage users and solve problems.”4,5 Gamification is a new genre of teaching that has risen in popularity in the 21st century, and it is being utilized by a variety of professional specialities.6,7 Cell phone applications, group competitions and video games are being adapted from social hobbies outside of the classroom to serious learning mechanisms in the realm of higher education.6,7,8,9 Indeed, this mechanism of learning has been shown to be advantageous

in promoting motivated learning and improved task performance.6 A core component to learning ultrasound must be a direct “handson” experience due to the complex ultrasonographic stereoscopy involved with imaging internal anatomy. Learning through gamification has been supported by research in teaching similar stereoscopic procedural hospital interventions, such as chest tube placement and laparoscopic surgery.10,11 We find gamification to lend itself to learning POCUS by promoting persistence, creativity, risk taking and self-direction. We have created several games for our workshops. The “Mirror Image Challenge” in our Respiratory Workshop and the “Fast FAST Exam” in our Gastrointestinal Workshop have been very successful. In the “Mirror Image Challenge,” teams of students were instructed to reproduce a referenced ultrasound image using an ultrasound machine on a live model. Teams then saved and submitted their best-acquired image. All students voted on the best-acquired ultrasound image that matched the original (of course, students could not vote for their CONTINUE ON PAGE 39 �

Members of the Ultrasound and Trauma Surgery Interest Groups at the University of Miami Coral Gables Simulation Hospital for an ultrasound workshop. Photo courtesy of Jonathan Amodio. EMpulse Winter 2020


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Our success as an interest group is due not only to great mentorship, but also to the engagement of faculty and students from specialties beyond emergency medicine. We have reached our largest membership base, serving 177 students across all four classes—nearly 25% of our medical student body. own image). This task challenged students to learn how transducer and machine manipulations of angle, depth and gain could be optimized in the acquisition of images. Furthermore, the spirit of competition and the announcement of the winning team incentivized student effort and achievement through extrinsic motivation. In the “Fast FAST Exam,” pre-selected teams of students learned how to perform the FAST exam for 30-minutes on human models. Teams then played each other for the fastest time to obtain the standard views of the FAST exam. Anonymous, self-reported student feedback from our workshops has shown overwhelmingly positive support for learning ultrasound through games. More specifically, 87.5% (n=8) of students reported a rating of >4 out of 5 as their level of enjoyment of the “Fast FAST exam” and 100% (n=10) of students reported a rating of >4 out of 5 for the “Mirror Image Challenge.”

Collaborations Our success as an interest group is due not only to great mentorship, but also to the engagement of faculty and students from specialties beyond emergency medicine. We have reached our largest membership base, serving 177 students across all four classes—nearly 25% of our medical student body. We believe our growth can be best attributed to our expanded reach, offering students exposure to a range of ultrasound

applications. The following interdisciplinary workshops are offered:

• Echocardiogram Workshop in the

Echo Lab – Cardiology Interest Group • GI Workshop with FAST Exam – Trauma Surgery Interest Group • Ultrasound-Guided Amniocentesis – The Vagina Monologues & Ob-Gyn Interest Groups • “How to Nerve Block” – Student Interest Group in Anesthesiology • Ultrasound of Soft Tissue – IDEA Clinic, a wound care clinic associated with a needle exchange • Ultrasound in Clinical Simulation – Medical Simulation Interest Group • Ultrasound Table at the EM Symposium – Emergency Medicine Student Association Our USIG has strongly advocated for incorporating ultrasonography into the official medical school curriculum. One of our major accomplishments has been partnering with the head teaching assistants of the anatomy course to organize ultrasound labs that utilize ultrasonography to augment the first-year medical students’ anatomy curriculum. At the heart of these collaborations has been our persistence to make non-traditional connections, to contribute to ultrasound implementation into medical curriculum, and to foster a love for ultrasound in as many students as possible, exemplifying that ultrasound is for everyone. ■

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1. Goldberg BB, et al. Early History of Diagnostic Ultrasound: The Role of American Radiologists. American Journal of Roentgenology 1993;160:189-194. Available at: www. ajr.160.1.8416623 2. Bahner DP, et al. The State of Ultrasound Education in U.S. Medical Schools: Results of a National Survey. Academic Medicine 2014;89(12): 1681-1686. Available at: medicine. ultrasoundinusmedicalschools.pdf 3. Comstock J. UC Irvine Medical School gifts Butterfly handheld ultrasounds to its whole class of 2023. MobiHealthNews 2019. Available at: www.mobihealthnews. com/news/north-america/ucirvine-medical-school-gifts-butterfly-handheld-ultrasounds-itswhole-class 4. Zichermann G, Cunningham C. Introduction. Gamification by Design: Implementing Game Mechanics in Web and Mobile Apps. Sebastopol, CA: O’Reilly Media, Inc; 2011:xiv 5. McCoy, Lise; Lewis, Joy H.; Dalton, David W. Gamification and Multimedia for Medical Education: A Landscape Review. The Journal of the American Osteopathic Association. Jan. 2016; Vol. 116 (No. 1). 6. Michael Sailer, et al. How gamification motivates: An experimental study of the effects of specific game design elements on psychological need satisfaction. Computers in Human Behavior, Vol. 69 (2017) 7. Lombardi MM; Oblinger DG, ed. Authentic Learning for the 21st Century: An Overview. Louisville, CO: EDUCAUSE Learning Initiative; 2007. 8. Gorbanev, louri, et al. A systematic review of serious games in medical education: quality of evidence and pedagogical strategy. Medical Education Online. 2018. 9. Edwards EA, et al. Gamification for health promotion: systematic review of behaviour change techniques in smartphone apps. BMJ Open. 2016 Oct 4. 10. Haubruck, P., et al. Evaluation of App-Based Serious Gaming as a Training Method in Teaching Chest Tube Insertion to Medical Students: Randomized Controlled Trial. Journal of Medical Internet Research. 2018; 20(5), e195. doi:10.2196/ jmir.9956 11. Ju, R., et a. Comparison of Nintendo Wii and PlayStation2 for enhancing laparoscopic skills. JSLS: Journal of the Society of Laparoendoscopic Surgeons. 2012. 16(4), 612–618. doi:10 .4293/108680812X13462882737294


Even for Complex Patients, Hospice Has Compassionate End-of-Life Solutions By Lillian Valeron

Director of Market Development in Central Florida, VITAS® Healthcare The Medicare law that defines hospice care and coverage for hospice services mandates four basic levels of care by all hospice providers: routine home care, continuous care up to 24 hours (when medically necessary), inpatient hospice care and respite care for caregivers. Some hospice providers go above and beyond the basic federal requirements, inspired by a commitment to care for all patients as they near the end of life, regardless of the complexity of their illness or diagnosis. VITAS® Healthcare, the nation’s leading provider of end-of-life care, offers numerous hospice and palliative care solutions and protocols that many other hospice providers do not. These are offered to high-risk patients whose underlying diseases and hospice diagnoses make their need for symptom management and pain relief all that more profound… and sometimes more challenging.

Non-curative modalities manage symptoms, ease pain, reduce end-of-life anxiety None of these complex modalities are provided for curative purposes. Instead, they are offered solely to manage symptoms and address pain related to the underlying disease, previous treatments (e.g., lingering adverse effects of chemotherapy or radiation) or ongoing and often distressing symptoms. For example, VITAS might offer radiation treatments to ease bone pain in a cancer patient who is 40

no longer receiving active cancer treatment. Without impacting the course of a patient’s disease, high-flow oxygen therapy can ease anxiety in lung cancer patients who struggle to breathe near the end of life. These complex modalities can be provided at home, wherever the patient calls home: private residence, nursing home, assisted living facility, hospital or inpatient hospice unit. Among the palliative, comfortfocused modalities that some VITAS programs offer:

• Intravenous therapies (pain

management and PCA; inotrope therapy for advanced heart disease; hydration; antibiotics) • Paracentesis and thoracentesis • Chest tube/PleurX • High-flow oxygen therapy • Palliative blood transfusions • BiPAP, CPAP and Trilogy noninvasive ventilation • PEG-tube care and tube feedings • Compassionate ventilator withdrawal at home • Nephrostomy tube management • Wound care • Palliative total parenteral nutrition (TPN) • Palliative dialysis • Specialized durable medical equipment (DME) • PT, OT and speech therapy • Palliative oncologic therapies on an individual basis for pain relief and symptom management As with all hospice care, an interdisciplinary hospice team develops an individualized plan of care, working closely with high-risk, high-acuity patients, their families and caregivers to identify and honor EMpulse Winter 2020

Download our mobile app at for VITAS locations, hospice eligibility guidelines or seamless, secure 24/7 referrals from a smartphone or tablet. Photo from

end-of-life preferences, and to support quality of life at the end of life. End-of-life care can be challenging and difficult. When it’s time for hospice, VITAS is the expert in caring for high-acuity, complex patients. Call us for an evaluation at 888.VITAS.80 or refer your patients at for quality of life at the end of life. ■

This article is sponsored by

“Getting to Zero” with Collective Medical’s Care Collaboration Platform By Collective Medical Staff When the medical community discusses workplace violence, it often focuses on preventing harm or eradicating the issue entirely. But in the meantime, individuals who have already been victimized and remain at-risk on the frontlines of healthcare around the country need help. Modern Healthcare recently published an article by Dr. Marie Vrablik, MCR. Dr. Vrablik shared the results of her recent study with her team at the University of Washington on successful coping strategies for physicians, nurses, and other healthcare providers who have been the victims of workplace violence. Through her research, Dr. Vrablik discovered several actionable ways organizations can support their staff to mitigate the long-term effects of violence.

Types of security events captured by Collective Medical's platform. As soon as a patient with a history of violence checks in, alerts are sent to providers and security staff. Photo from

Many of the healthcare workers who participated in the study reported feeling like workplace violence is inevitable and unpreventable, and Dr. Vrablik’s work shows this outlook can cause deep and lasting effects— especially burnout. If burnout is left unaddressed, it decreases both physical and emotional health, leading to increases in errors and staff turnover.

patient histories and consistent documentation of behavior patterns, the healthcare community will further achieve the ultimate goal of “Getting to Zero.” The study concluded that a care collaboration tool would provide the consistent documentation needed, with data analytics, to accurately predict and ultimately prevent potentially violent encounters.

The healthcare community shouldn’t have to endure violence in healthcare settings. With better access to

Collective Medical’s collaboration platform allows providers to document incidents of violence— including physical, verbal, and sexual assault, theft, self-harm, and infectious diseases—then flags them for future encounters. When a patient with a history of violence returns to the hospital or presents at any point of care, Collective immediately pushes a notification to hospital and security staff, giving

For more information about how Collective Medical provides a proactive approach to workplace safety visit: workplace-safety

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them the opportunity to prevent another incident. Hospitals around the country are using Collective to protect hospital staff and other patients. For example, according to an article by Health IT Analytics, CHI St. Anthony in Pendleton, Oregon used the platform to increase its WPV reporting rates by 20 percent. This increase qualified St. Anthony for additional funding to establish an in-house security team, ultimately increasing workplace safety by reducing response times—or in many cases preventing incidents altogether. ■

This article is sponsored by



Hercules and the Three-Headed Dog, Cerberus By Wayne Barry, MD, FACEP FCEP Member

Healthcare in America reminds me of the three-headed dog named Cerberus who, in Greek and Roman mythology, guarded the gates to Hades. Hercules was said to have captured this monster as one of his 12 labors. Here is a description of the three menacing heads of Cerberus: 1) Healthcare in America is more expensive than anywhere else in the world today. The cost of American healthcare is also rising faster than anywhere else. 2) Healthcare availability in the U.S. is inequitably maldistributed to U.S. citizens. 3) The outcomes of expensive and inequitably maldistributed healthcare in America are no better, and in some cases, poorer in quality compared to many of our Western industrialized neighbors. So, will a Hercules emerge from the crowded field of U.S. Presidential wannabes? Medicare for All is being promoted by Bernie Sanders and Elizabeth Warren. Medicare already pays only about 90% of its costs to its recipients, and the other 10% is borne by private insurance companies and employers. Healthcare costs are rising at a level of 6-8% whereas inflation remains between 2-3%. If private insurance companies and employers stop subsidizing the shortages in our current Medicare system, then decreased payments to hospitals and doctors will result in the closure of many more rural and marginally-funded inner city hospitals, and there will be nearly 1,000,000 unhappy U.S. physicians making much less money than they do now. If the Medicare system 42

stands up to cover its underages, the cost will be another $3 trillion extra dollars added to the national debt. Both Bernie Sanders and Elizabeth Warren are unabashed tax raisers who believe the extra tax burden should be borne by the rich who can better afford to do so. Moderate Democratic candidates like Pete Buttigieg and Corey Booker believe in Medicare for Some. They would like to see those citizens who like their current private insurance obtained through their jobs or otherwise to be able to keep it, while others less fortunate can choose to join the Medicare program. Both candidates see their schemes as leading to the inevitable Medicare for All of single-payor, nationalized healthcare within the next 10 or so years. Then their plans will presumably be plagued with the same drawbacks as previously described for Medicare for All. Kamala Harris believes that Americans should all be covered by enlarged Medicare Advantage Plans, where copays exist but are relatively small, and ancillary services such as dental and eyeglasses are supplied. These plans will be administered in partnership between the U.S. government and large healthcare organizations like Humana and United Health Care. Unfortunately, the restrictive hospital and physician networks may not be satisfactory to many patients. This plan will fall short of the ideal that U.S. citizens will be able to see whichever physicians and specialists they choose. Biden’s plan is to reinforce the ACA by preserving and bolstering private coverage options while EMpulse Winter 2020

expanding Medicaid to ensure coverage of all those who’ve been “left over” or “left out.” Medicaid, in its present form, is “bottom of the barrel” health insurance with a limited number of providers and facilities willing to accept the unconscionably low reimbursements, and there will still be no check on the soaring costs of healthcare in this plan, which are unsustainable at their present rate of increase. The Republicans and President Trump have been surprisingly quiet about healthcare issues, even though most voters believe their healthcare is one of the top 1 or 2 concerns in the upcoming election season. Maybe that is because they have tried to repeal and replace ObamaCare unsuccessfully year after year since 2010. President Trump favors the current inequitable system where everyone can see their own doctor, provided you are not one of the 44 million U.S. citizens without coverage. He favors skinny plans, which are low-cost alternative health plans with high deductibles and no coverage for pre-existing conditions or maternity care, previously not allowed by ObamaCare. So, will a Hercules emerge to win the 2020 U.S. Presidential election and slay Cerberus guarding the gates to Hell? And if Cerberus were removed from the entrance and we could look inside Hades, we would probably see about 535 U.S. Congressmen running around like headless chickens, scratching in the dirt for the next vote in order to keep their jobs. There has to be a better way to solve our healthcare problem in this country! What do you think? ■

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