Official Publication of the Florida College of Emergency Physicians A Chapter of the American College of Emergency Physicians
OUR ADVOCACY AT WORK:
A LICENSE PLATE
HONORING
YOU
WHILE RAISING FUNDS FOR THE STATE EMS TRUST FUND WHAT’S INSIDE: The Dark Side of the ED Ultrasound Zoom: Airway Management with POCUS Left Lateral Canthotomy with Cantholysis for Foreign Body Removal Forging International Care Connections During the Delta Surge: A Reflection on Providing COVID-19 Medical Relief to India
EMpulse Winter 2022
Vol. 28, No. 4 | Winter 20221
“Out of suffering have emerged the stongest souls; the most massive characters are seared with scars” -KAHLIL GIBRAN
WE SUPPORT OUR HEALTHCARE HEROES
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TABLE OF CONTENTS FROM THE COLLEGE 6 FCEP President’s Message By Dr. Sanjay Pattani 7 A New Year with New Beginnings By Melissa Keahey 8 Government Affairs By Dr. Blake Buchanan 11 Membership & Professional Development By Dr. René Mack
12 COVID-19 in Children: Frequently Asked Questions by Emergency Providers By Dr. Shiva Kalidindi 14 EMS/Trauma By Dr. Desmond Fitzpatrick 16 EMRAF President’s Message By Dr. Elizabeth Calhoun, PGY-3 23 Medical Student Council By Cristina Sanchez, MS, MS-2
WINTER 2022
Volume 28, Issue 4 EMpulse Magazine is the official, quarterly publication of the Florida College of Emergency Physicians (FCEP). EDITOR-IN- Karen Estrine, DO, FACEP, FAAEM CHIEF karenestrine@hotmail.com MANAGING Samantha League, MA & DESIGN sleague@emlrc.org EDITOR
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FEATURES & COLUMNS 12 Daunting Diagnosis By Dr. Karen Estrine 13 EMpulse 2022 Calendar & Updates and Top 10 Most Viewed Articles on fcep.org By Samantha League 14 Too Much of a Good Thing: Excessive Ventilation By Dr. Jason Jones 24 Forging International Care Connections During the Delta Surge: A Reflection on Providing COVID-19 Medical Relief to India By Dr. Sanjay Pattani 26 Case Report: Left Lateral Canthotomy with Cantholysis for Foreign Body Removal By Dr. Roland Zamora Jr., Dr. Joseph Gomes & Iris Cruz 28 Ultrasound Zoom: Airway Management with Point-of-Care Ultrasound: A Breath of Fresh Air By Drs. Kristopher Hendershot & Leila Posaw 32 Ultrasound Guided Vascular Access Workshop: A DIY Guide for Homemade Phantoms By Marisa Carino Mason, Sadhana Anatha, Dr. Joshua Goldstein, Jessica Le, Ankit Shah & Dr. Daniel Hercz
36 Education Corner: Curious About What? An Introduction to Medical Education Scholarship By Drs. Carmen Martinez Martinez & Caroline Molins 38 Poison Control: Loperamide: The Poor Man's Methadone By Drs. Chiemela Ubani, Molly Stott & Dawn Sollee 40 Notes From the Field: Reducing Harm among Injection Drug Users during and after the Emergency Department Visit By Heather Henderson, Dr. Asa Oxner, Dr. Bernice McCoy & Dr. Jason Wilson 42 Case Report: A Case of the Blues By Dr. Jonathan Liu 43 The Dark Side of the ED By Dr. Doreen Parkhurst 44 In Memorium: Dr. Jay Edelberg By FCEP 50 Musings from a Retired Emergency Physician: Should We Vaccinate Our Patients in the ED? By Dr. Wayne Barry
EMpulse Spring 2022 EMpulse Spring 2022 will be print + digital. Members will receive a copy in their mailboxes and a Table of Contents email of online articles.
Deadlines: • Mar 9: “Intent to Submit” article or advertisement due » • Mar 23: All content due • May: Spring 2022 in mailboxes & articles uploaded online
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Pre-Order Your “Support Healthcare Heroes” Specialty License Plate
This is your license plate. Last Session, the Florida Legislature passed SB 676 (2021), authorizing FCEP & FEMF to create a license plate honoring healthcare workers. No other license plate in Florida is dedicated to the healthcare sector -- until now.
PRE-ORDER NOW Price: $35
When ordering through the EMLRC Competitors have higher processing fees
We must sell 3,000 before the plate is manufactured But we are confident we can reach this goal within a year!
Learn more at emlrc.org/licenseplate
TABLE OF CONTENTS CONTINUED
Florida College of Emergency Physicians Board of Directors:
UPDATES FROM FLORIDA’S EM RESIDENCY PROGRAMS 17 Kendall Regional Medical Center By Dr. Kelly Wright
Florida Atlantic University By Dr. Tony Bruno
18 North Florida Emergency Medicine By Dr. Manna Varghese
Orange Park Medical Center By Dr. Dillon Smith FSU at Sarasota Memorial By Dr. Thomas Cox
19 UF Gainesville By Dr. Megan Rivera
20 Jackson Memorial Hospital By EM Residency Program Staff AdventHealth East Orlando By Dr. Shannon Caliri
21 Oak Hill Hospital By Drs. Ryan Johnson & Mohammad Razzaq UF Jacksonville By Drs. Jeanne Rabalais & Chris Phillips St. Lucie Medical Center By Dr. Nicole Tobin
Brandon Regional Hospital By Dr. Calixto Romero, III
22 UCF/HCA Healthcare GME Consortium Emergency Medicine Residency Program of Greater Orlando By Dr. Amber Mirajkar Orlando Health By Drs. Gregory Black & Brody Hingst
USF at Tampa General Hospital By Dr. Kenneth Dumas
PRESIDENT Sanjay Pattani, MD, MHSA, FACEP PRESIDENT- Damian Caraballo, MD, FACEP ELECT VICE Aaron Wohl, MD, FACEP PRESIDENT SECRETARY- Jordan Celeste, MD, FACEP TREASURER IMMEDIATE Kristin McCabe-Kline, MD, FACEP, PAST- FAAEM, ACHE PRESIDENT INTERIM Melissa Keahey EXECUTIVE DIRECTOR MEMBERS Rajiv Bahl, MD, MBA, MS;
Blake Buchanan, MD, FACEP; Elizabeth Calhoun, MD (EMRAF Representative); Kyle Gerakopoulos, MD; Jesse Glueck, MD; Eliot Goldner, MD, FACEP; Shayne Gue, MD, FACEP; Erich Heine, DO; Saundra Jackson, MD, FACEP; Shiva Kalidindi, MD, MPH, MS(Ed.); Amy Kelley, MD, FACEP; Gary Lai, DO, FACOEP; Dakota Lane, MD, FACEP; Russell Radtke, MD; Todd Slesinger, MD, FACEP, FCCM, FCCP; Stephen Viel, MD, FACEP
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Florida Emergency Medicine Foundation Board of Directors: PRESIDENT Ernest Page, MD, FACEP VICE Roxanne Sams, MS, ARNP-BC, MA PRESIDENT SECRETARY- Maureen France TREASURER
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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
All advertisements in EMpulse are printed as received from advertisers. The Florida College of Emergency Physicians does not endorse any products or services unless otherwise stated. FCEP receives and distributes employment opportunities but does not review, recommend or endorse any individuals, groups or hospitals that respond to these advertisements. Opinions stated within articles are solely those of the writers and do not necessarily reflect those of the EMpulse staff, the Florida College of Emergency Physicians, our advertisers/sponsors, or any of the institutions our writers are affiliated with.
EMpulse Winter 2022
The Florida College of Emergency Physicians (FCEP) and Florida Emergency Medicine Foundation (FEMF) are nonprofit organizations dedicated to advancing emergency care through education and advocacy. Both are headquartered at the Emergency Medicine Learning & Resource Center (EMLRC) at 3717 S. Conway Rd., Orlando, FL 32812. 5
FROM THE COLLEGE
FCEP President’s Message By Sanjay Pattani, MD, FACEP, MHSA FCEP President 2021-2022
Dear Colleagues, I hope that each of you had a great Christmas and enjoyed the holiday season. Starting a new year usually marks a fresh beginning: the opportunity to do some familiar things again and maybe be better at them. In this spirit, I’d like to share my top New Year’s Resolutions for what we hope to accomplish in 2022, which are unlike those resolutions that about 45% of us make and 25% of us break before month’s end—come on, admit it… Resolution 1: Bridge the gap between what FCEP strives for organizational success and what is truly meaningful and adds value to FCEP members. FCEP membership is deep, diversified, and powerful. But is the membership empowered to make a difference and have a voice in today’s acute unscheduled care delivery model? How do we support each other, and how do we measure success? We can ask hard questions, but we need to be willing to answer them candidly and collaborate for our mutual understanding and benefit. Please consider Attending our next virtual Membership & Professional Development Committee meeting on February 8 to share your input. We did a lot of internal restructuring in 2021. With back-to-back years in our executive director leadership transition, the FCEP Board of Directors will continue to focus on staff retention and providing new growth opportunities for team members to thrive in 2022. Resolution 2: With a fresh perspective, identify operational areas for improvement while continuing fiscal responsibility. This strategy may require FCEP to relinquish traditional
6
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FCEP membership is deep, diversified, and powerful. But is the membership empowered enough to make the difference in today’s acute unscheduled care delivery model?
meetings and commitments and promote new member-specific agendas with educational venues. Our FCEP staff and BOD stand ready to disrupt the usual and embrace new avenues that promote best and safe practices. Please consider Attending our next virtual Education & Academic Affairs Committee or Board meeting on February 8 to provide feedback on educational initiatives and events. Now I’d like to shift gears and reflect on the reality of our current practice environment. We find ourselves facing the ongoing pressures of the COVID-19 pandemic, and it has presented unimaginable challenges for you and our entire workforce. Unfortunately, the Omicron variant continues to rapidly spread nationwide. Within Florida,
urgent care clinics and emergency departments have noted recordbreaking volumes and positivity rates, surpassing levels experienced during the summer’s Delta surge. While early studies indicate that the Omicron variant may cause less severe disease than Delta, we must prepare and remain vigilant, as the sheer number of infections could still overwhelm healthcare systems nationally. FCEP will rise to the occasion as we always have: continuing to promote the public health benefit when it comes to vaccination and boosters, organizing chaos in the midst of supply chain shortages for outpatient testing, and giving practical insight on the appropriate return to work policies in our respective clinical practices. To conclude, I challenge you to share any of your New Year’s Resolutions with your fellow FCEP member colleagues. Remember that the resolutions we make as a team we are most likely to achieve! As our challenges continue within this pandemic, we will continue to make meaningful advances and add value together in our emergency departments. I wish you and your families a very happy, healthy, and safe New Year. ■
FCEP Board & Committee Meetings February 8, 2022 9:00 am - 3:00 pm Virtual due to the Omicron surge Stay tuned via email and at fcep.org All members are invited to attend committee & Board meetings
EMpulse Winter 2022
FROM FCEP HEADQUARTERS
A New Year with New Beginnings By Melissa Keahey
Interim Executive Director
Towards the end of 2021, FCEP found itself in another leadership transition at our headquarters. As with any sudden change, challenges are to be expected; however, our staff is committed to making this transition as smooth as possible. Our chapter is in a good place moving into 2022 and, as ACEP’s 4th largest chapter, we are ready to reassess our mission, priorities, benefits of membership, education programs, and events to better meet the needs of our members and the emergency medicine community. It is an honor to have been chosen by the Executive Committee of our Board of Directors to step into the role of FCEP’s interim Executive Director. As an employee here for the last eight years, I have admired the work of our members and the impact you make on a daily basis in your communities and throughout our state. Since joining the FCEP team in 2014 as a program coordinator, I have been involved in planning every meeting, program, and event that we have hosted or sponsored. In my most recent position as Director of Development & Operations, I have developed our annual sponsorship program, cultivated critical partnerships, created new revenue streams, and managed the Florida Association of EMS Medical Directors (FAEMSMD). I could spend
FCEP/FEMF Staff FCEP & its foundation, the Florida Emergency Medicine Foundation (FEMF), are housed at the EMLRC and share the same staff.
Melissa Keahey Interim Executive Director & CEO mkeahey@emlrc.org
the rest of this article providing reasons as to why I am the right person for this position, but this is not about me — it is about our members. It is about you.
Top Five Priorities of the Interim Executive Director:
Engagement with our members is the top priority this year while we refocus on our mission after celebrating our 50th anniversary. We plan to direct some of our efforts to reshaping FCEP as a whole and enhancing our member services. Rather than outline my own plans and ideas, I desire to listen. I want to hear from our members regarding the concerns and challenges you face as an emergency physician, the value you receive from your FCEP membership, and what brings you back each year when it is time to renew. Our best opportunities for improvement come from direct member feedback: How are we doing? What do you need more of from your professional association?
2. Align FCEP as a leader in legislative advocacy on the state and national level.
There is something about turning 40 during this pandemic that changed me as a woman, mother, and professional in the nonprofit sector. Since March 2020, I have been reminded so frequently, and sometimes excessively, that time is fleeting and we need to make our moments count. FCEP and FEMF have and continue to provide me with a greater purpose – one which has guided me through challenging
1. Engage with members, community partners, and other medical societies.
3. Understand and maximize ACEP resources and services for the chapter and our members. 4. Assess all education programs and finalize our annual program calendar. 5. Solidify HQ personnel structure and create HR policies that promote and support longevity, growth, and organization efficiency. transitions in my own life. I am grateful for the chance to continue to serve in this elevated role. I look forward to hearing from and working with our members and partners in the year ahead, utilizing this wonderful opportunity to demonstrate my passion for this organization, our members, and emergency medicine while working with our talented team of staff. Happy New Year! ■
Kim Palm, MA Director of Finance & Operations actg@emlrc.org Samantha League Smith, MA Director of Communications sleague@emlrc.org Reana DePass Accounting & Education Assistant rdepass@emlrc.org
EMpulse Winter 2022
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COMMITTEE REPORT
Government Affairs By Blake Buchanan, MD, FACEP Committee Member
As we head into 2022, we have seen the practice of medicine and healthcare as a whole become a lightning rod in politics at both the state and federal level. While all political discussion has become extremely polarized, your advocacy team at FCEP has stayed above the fray and avoided getting involved or being used in any partisan fights. This is important because it allows us to remain a well-respected voice for emergency physicians on the many issues that affect our practice in the eyes of members from both parties. This year, we enter the 2022 legislative session with the same leadership team of Senate President Wilton Simpson, Speaker of the House Chris Sprowls, and of course Governor Ron Desantis in Tallahassee. Session starts earlier this year on January 11 since 2022 is an election year. Although a great deal of the oxygen in Tallahassee is being taken up by redistricting, we have kept our ears open for any issues affecting emergency medicine. See what our priority issues are below. This year, Emergency Medicine Days will once again be different as we comply with group size restrictions for
visits at the state capitol building. We are splitting EM Days 2022 into four parts: two separate trips to the state capitol to advocate for emergency physicians with small groups of FCEP leaders, plus two virtual legislative briefings on our priorities and experiences for all members to attend. We will be in Tallahassee over two consecutive weeks: the last week of January and first week of February, and the legislative briefings will take place in January, right before and after our first visit. Please register for these virtual legislative briefings. COVID-19 and pandemic-related policies have continued to be a hot topic in Tallahassee both in the legislative halls and in the media. One of our biggest focuses will be to ensure that there is an extension of the COVID-19 related malpractice protections, which are set to expire this spring. We will also work to meet with regulators on the problems we have seen with our state’s current implementation of the surprise medical billing law. Currently, insurers are not acting in good faith and coming to the table for arbitration. This was not the intent of the law passed in 2016, and
with the No Surprises Act passing at the federal level last year deferring to each state’s surprise medical billing law, it is very important that we come to a solution that provides both a fair arbitration process for emergency physicians and keeps patients out of the middle with no balance billing. As always, we will continue to be your voice in Tallahassee with our state officials. The only way we can do this is through our Political Action Committees, and I encourage everyone to give to the PAC so that we can continue to be your well-respected voice to our local leaders. I hope all of you had a happy holiday season and wish a great 2022 to each and every one of you. ■
Next Government Affairs Committee Meeting February 8, 2022 Virtual; time TBD Stay tuned via email and at fcep.org
Bills we're Monitoring: ON OUR RADAR TO SUPPORT: SB 7014: COVID-Related Claims Against Health Care Providers by Senate Judiciary: Extends the duration of COVID-19 liability protections through June 1, 2023. SB 1114 & HB 817: Emergency Medical Care & Treatment to Minors Without Parental Consent by Sen. Bradley & Rep. Massullo: Glitch bill to fix HB 241 (2021): Parents' Bill of Rights. Removes the requirement that emergency medical treatment provided to a minor without parental consent must be administered in a hospital or college health service, 8
thus allowing emergency care to be administered to a minor outside of an ED without the threat of criminal penalties. SB 1192 & HB 861: Medical Specialty Designations by Sen. (A) Rodriguez & Rep. Massullo: Prohibits the use of an ACGME specialty title to be used by anyone other than a physician. SB 1222 & HB 937: Nonemergent Patient Care by Sen. Bean & Rep. Altman: Defines term "community paramedicine."
ON OUR RADAR TO OPPOSE: SB 986 & HB 437: Collaborative Practice of Certified Registered Nurse Anesthetists by Sen. Diaz & Rep. Rommel: Grants independent practice and removes medical staff protocols. SB 560 & HB 6039: Recovery for Wrongful Death by Sen. (A) Rodriguez & Rep. Hinson: Authorizes parents of adult children to recover damages for mental pain and suffering in medical negligence suits.
*Bills were still being filed when this went to print, and amendments can change them at any time during Session. Visit emlrc.org/emdays for an updated list. EMpulse Winter 2022
Due to pandemic restrictions at the state capitol, Emergency Medicine Days 2022 will be a scaled-down, hybrid event spanning multiple weeks. Visits with legislators will take place in Tallahassee with a select number of FCEP members while legislative briefings for all members will take place virtually.
Virtual Legislative Briefing #1: Priorities & Predictions
Week 1 of In-Person Legislative Visits
January 19, 2022 at 2:00-3:30 pm via Zoom
January 24-25, 2022 in Tallahassee, FL
Agenda: • FCEP's top priority issues for 2022 Session • Overview of healthcare leadership • How to talk to legislators: messaging that works • Issues affecting emergency medicine and EMS • Open floor discussion
Closed; space no longer available
Virtual Legislative Briefing #2: Debrief from Tallahassee
Week 2 of In-Person Legislative Visits
January 27 at 2:00-3:00 pm via Zoom
February 1-2, 2022 in Tallahassee, FL
Agenda: • Updates on any bills & news from the Capitol • Experiences from Week 1 attendees • Strategy moving forward
The moment we become stagnant and decide that this is how
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Closed; space no longer available
it’s going to be and we can’t adjust the changing paradigms, the
changing laws, the changing needs — then we’ll become dinosaurs. We’ll become extinct. - Dr. Josef Thundiyil
Stay up-to-date at fcep.org/emdays
EMpulse Winter 2022
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Thank You, PAC Donors The success of FCEP’s advocacy efforts is dependent upon our ability to fund those efforts. Thank you to the individuals who donated in September - November 2021: Benjamin Abo
Simi Greenberg
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I Charles Sand
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Tessa A Haspil-Corgan
Christy Clemmons McKenna
Joel Stern
Kevin Gregory Bennett
Brendon Henry
Joshua R Middleton
Claire Jane Marie Stringfellow
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James V Hillman
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EMpulse Winter 2022 2022 EMpulse Winter
COMMITTEE REPORT
Membership & PD Committee By René Mack, MD, FACEP Committee Co-Chair
Happy New Year! It is now January 2022. How are you doing? Surviving and thriving through a continued global pandemic was not an anticipated skill needed, yet we persevere. What are three positive changes in your personal and/or professional life since January 2021? It is important to recognize these types of accomplishments as we enter another challenging year and surge in cases. As we all continue our adjustment to surviving and thriving during a pandemic, the FCEP Medical Student Council (MSC), led by Dr. Robyn Hoelle, remains hard at work creating opportunities for our learners to gain further insight and experience in our beloved field of emergency medicine. As a creative alternative to our highly anticipated annual in-person Residency Fair, our MSC created a Virtual Residency Fair, with individual program showcases and informational sessions. The Virtual Fair is designed to provide similar connections while allowing programs to personalize the experience. If your program is hosting a session in 2022, please contact the FCEP office so we can add it to fcep.org. Especially due to pandemic accommodations in place, opportunities for mentorship and clinical experiences are highly desired by our students. If you are able and willing to host an elective or serve as a professional mentor for our young
Next Membership & Professional Development (MPD) Committee Meeting February 8, 2022 Virtual; time TBD Stay tuned via email and at fcep.org
learners, please contact mkeahey@ emlrc.org to get connected with our mentoring program. Pre-pandemic stressors associated with the transition from learner to full practitioner are only intensified and magnified as we all work to negotiate the future unknowns. Concerns regarding career longevity, reimbursement, maintenance of certification, along with numerous personal and financial transitions, are the concerns we encounter most often with our colleagues. Your MPD team of practicing EM doctors recognize, empathize, and appreciate the shift in priorities during these transitions. For our benefit, the Early Career Physicians (ECP) subcommittee, led by Dr. Dakota Lane, was created to provide those experiencing a transition at all levels, yet specifically for residents and physicians within 10 years post-residency, with resources most applicable to your circumstance. A previous workshop on contracts, financial well-being, and career longevity was well received by your colleagues, and we look forward to providing more opportunities to share our resources with you. The ECP seeks to create innovative ways to serve us by addressing the issues causing the most impact on our wellbeing and development. What are the topics you would most like to see addressed? Contact sleague@emlrc.org or send us a DM on our social media platforms so we can connect you with Dr. Lane. Are you ready to delve further into leadership roles within medicine, specifically your chosen field of emergency medicine? As a physician, leading teams is a skillset we practice regularly, yet may not produce the career results we seek. FCEP’s Leadership Academy is a year-long program designed to equip you with EMpulse Winter 2022
the organizational education, skills training, mentoring, and guided experiences you will need to succeed as a leader in emergency medicine. The Leadership Academy is designed to meet all participants at their current level of experience. Whether you are building leadership skills, seeking to develop connections to execute your passion project(s) or alter your career course, or you recognize the benefit of physician engagement in medicine and would like to find your niche, we welcome you. Under the guidance of Dr. Stephen Viel, the FCEP Leadership Academy welcomes its 8th class of physicians seeking more from their profession and yearning to share their untapped talents. Participants in this energetic class include: Drs. Yaritza Arriaga, Andrew Martin, Camilo Mohar, Zach Terwilliger, and Geoffrey Wade. For more information, please visit the FCEP Leadership Academy at fcep.org/la or contact the FCEP offices directly. For more information on how the Membership and Professional Development team can help us all succeed, please contact the FCEP office directly via email, phone, or social media platforms. See you virtually at FCEP’s EM Days and our other upcoming events. As always, take care of yourselves and each other. ■
LEADERSHIP ACADEMY fcep.org/la 11
COMMITTEE REPORT
COVID-19 in Children: Frequently Asked Questions by Emergency Providers By Shiva Kalidindi, MD, FACEP Committee Co-Chair
1. Are certain groups of children at higher risk of severe COVID-19? Children with underlying medical conditions, including genetic, neurologic, metabolic, or congenital heart disease, are at increased risk for severe illness than children without underlying medical conditions. In a recently published study by the COVID-NET surveillance network, severe COVID-19 rates were highest among infants, Hispanic children, and non-Hispanic Black children. For children aged <2 years, chronic lung disease, neurologic disorders, cardiovascular disease, prematurity, and airway abnormality were associated with severe COVID-19. Among children 2-17 years, feeding tube dependence, diabetes mellitus, and obesity were associated with severe COVID-19.
2. When should I suspect MIS-C? Patients with Multisystem Inflammatory Syndrome in Children (MIS-C) may present with a recent history of COVID-19 exposure or infection and have a persistent fever with more than one of these symptoms: stomach pain, red eyes, diarrhea, dizziness, skin rash, or vomiting. They may have elevated inflammatory
Next Pediatric Committee Meeting February 8, 2022 Virtual; time TBD Stay tuned via email and at fcep.org
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markers (e.g., CRP, ferritin), elevated cardiac markers (e.g., troponin; BNP), and multisystem involvement without alternate plausible diagnoses.
3. What tests should I order to evaluate for MIS-C? CBC, CMP, CRP, ESR, BNP, Troponin, EKG. Additional tests (if ill-appearing): PT/PTT, D-dimer, Ferritin, Lactic acid, urine and blood culture, VBG, Respiratory Panel with COVID, CXR.
4. What can we do about the new SARS-CoV-2 variants? At this time, there is insufficient data to predict the impact Omicron or new SARS-CoV-2 variants might have in the United States, especially among children. The Centers for Disease Control, the American College of Emergency Physicians, and the American Academy of Pediatrics continue to support COVID-19 vaccination as the best way to prevent severe morbidity and mortality from SARS-CoV-2.
Daunting Diagnosis: Q By Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief
A 71-year-old male presents to the ER for an enlarged left neck mass, dysphagia, and weight loss for an “unknown amount of time.” The patient has an extensive smoking history. He states he is homeless and has not been seen for his neck mass by a physician. Below is photograph and a CT scan of his neck. What is the patient’s diagnosis?
5. What about the risk of myocarditis due to the COVID vaccine? Studies show that the risk of myocarditis in adolescents and young adults is 6-34x higher post-SARSCoV-2 infection than post-mRNA vaccines. Moreover, cases of postvaccine myocarditis were noted to require shorter hospital stays (1-2 days) vs. myocarditis caused by SARS-CoV-2 infection, which has been more severe, requiring an average hospital stay of five days. CDC continues to monitor the situation and provide guidance for healthcare providers. ■ EMpulse Winter 2022
CONTINUE ON PAGE 37 ▶
2022 Calendar & Updates Dear Readers,
from April 15-Dec. 23, 2021
EMpulse Magazine is a benefit provided at no cost to members, but it is a significant expense to print on a quarterly basis. Additionally, EMpulse Online is showing great success, and we are in a position to grow its presence. In effort to channel our resources most appropriately, we are reducing our print issues to 2x year starting with Vol. 29. You will receive the next issue in May 2022 and the following in October 2022. We will also be accepting and publishing articles submitted by members on EMpulse Online on a rolling basis. This magazine is intended to showcase your work and expertise while contributing to the greater body of literature for emergency medicine, and it cannot exist without you! Help us grow by contributing, advertising, sharing articles with your colleagues, and providing feedback to sleague@emlrc.org.
Publishing Schedule VOL. 29 ISSUE 1
Intent to Submit Due: March 9, 2022
CONTAINING:
Articles & Ads Due: March 23, 2022
• Fellowship Guide for Emergency
• Match Day & Graduating Residents' lists
Medicine Physicians (new)
• Legislative Session 2022 Recap
• Symposium by the Sea 2022 Preview
Fall 2022 VOL. 29 ISSUE 2 Intent to Submit Due: August 31, 2022 Articles & Ads Due: September 14, 2022 In-Mailboxes: End of October 2022
1. Ultrasound Zoom: The Vexus Score: Fluid Status, Reconsidered by Drs. Ernesto Weisson, Joshua Goldstein, Duyen Vo & Leila Posaw - 4,485 views 2. False Positive HIV due to p24 Antigen and CD4 Lymphocytopenia by Dr. Jason Wilson, Heather Henderson & Kaitlyn Pereira - 1,916 views 3. Ultrasound Zoom: POCUS of the Gallbladder: Always in Style by Drs. John Combs & Leila Posaw 947 views 4. Next Steps for the EM Resident Class of 2021 by Florida's EM Residency Programs - 691 views
Spring 2022
In-Mailboxes: Early May 2022
Top 10 Most Viewed Articles on fcep.org
CONTAINING:
• Symposium by the Sea 2022 Recap • 2023 Calendar
• Workforce Update
• Monitor your email for special "calls for content" for this issue
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5. Poison Control: The F(ab2)ulous Expanded Indication of Anavip by Drs. Chiemela Ubani, Anthony DeGelorm & Dawn Sollee - 372 views 6. Even for Complex Patients, Hospice has Compassionate End of Life Solutions, sponsored content by VITAS - 356 views 7. Introducing Broward Health's First EM Residents by Program Staff - 313 views 8. Ultrasound Zoom: A New Mode to Diagnose Pneumo(Peritoneum) by Drs. Brittney Giuffre & Leila Posaw - 312 views 9. Disruptive Innovation in Emergency Medicine 2.0 by Dr. Mitchell Barneck - 236 views 10. Education Corner: Fun & Games: Using Gamification to Engage Multi-generational Learners by Drs. Carmen Martinez Martinez & Caroline Molins - 229 views
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COMMITTEE REPORT
COMMITTEE FEATURE
EMS/Trauma Too Much of a Good Thing: Excessive Ventilation By Desmond Fitzpatrick, MD, FACEP Committee Co-Chair
The EMS/Trauma Committee met on Nov. 9, led by Dr. Chrissy Van Dillen.
• FAEMSMD and EMLRC are
collaborating on an upcoming video education program for pre-hospital providers entitled, “Bytes that You Can View.” This EMS matching grant project will have 16 “byte-sized” EMS lectures covering various topics for CEUs.
• Former State EMS Medical
Director Dr. Ken Scheppke presented on COVID and the fact that it will likely not go away “for the foreseeable future.” The state has a twopronged strategy of long-term prevention with vaccinations and immediate effective treatment with monoclonal antibody treatments. He also mentioned that progress is being made on Florida Resuscitation Centers with a potential Central Florida Pilot project.
• The Region V Trauma Agency
update with Dr. McPherson went over the successful Virtual Tabletop exercise that took place on Aug. 13. Their next project is to push the use of whole blood for our trauma patients, including at our trauma centers and with their EMS partners.
Thank you all for what you do, and remember that what you do matters! ■
Next EMS/Trauma Committee Meeting February 8, 2022 Virtual; time TBD Stay tuned via email and at fcep.org 14
By Jason Jones, MD, FACEP, FAEMS Committee Member
Clinicians who manage respiratory failure in the emergency setting are likely familiar with the dangers of excessive tidal volumes. When we deliver oversized breaths, our patients are harmed through barotrauma, impaired venous return, reduced coronary perfusion pressure, and induced hypotension. A landmark NEJM study showed that by limiting breath size (tidal volume) to 6 to 8 mL per kg of predicted body weight, we can reliably minimize lung injury, shorten ventilator dependence, and substantially improve patient survival.1 For more than 20 years, this “lung protective” strategy has been the cornerstone therapy to prevent the deadly Acute Respiratory Distress Syndrome (ARDS). These benefits hold especially true when started early, and one 2017 study found that initiating a lung protective strategy in the emergency department reduced in-hospital mortality from 34% to 20%.2
rapidly. In one observational study, most patients were hyperventilated, with 1 in 5 receiving breaths at more than double the recommended rate.5
However, even when armed with this knowledge, emergency clinicians may unwittingly deliver unsafe ventilation. In one simulation of 130 emergency personnel (doctors, nurses, paramedics, and EMTs), 93% delivered BVM ventilations that exceeded a lungprotective strategy, with an average tidal volume (800 mL) that was 44% larger than the safety limit.3 Similar results were found in studies using an endotracheal tube rather than mask seal. Another group asked 50 emergency personnel to perform simulated ventilations on an adult mannequin using adult and pediatricsized BVMs. In 98% of cases, the adultsize BVM delivered breaths that were too large.4 The best overall strategy for achieving a safe tidal volume was to squeeze a pediatric bag – attached to an adult-sized mask – with only two fingers. This resulted in 55% idealsized breaths, 42% oversized, and 3% undersized. Moreover, studies show that clinicians frequently ventilate too
1. Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000 May 4;342(18):1301-8. PMID: 10793162.
EMpulse Winter 2022
In the spirit of primum non nocere, we must protect those in our care from unsafe ventilation strategies. When placing a patient on the ventilator, clinicians must take responsibility to ensure lung protective settings. For patients receiving BVM ventilation, a variety of solutions have emerged, including metronomes for accurate rate, substituting a smaller BVM for safer tidal volumes, and selecting BVM devices with pressure-limiting manometers. Like so many dangers in medicine, the most vital safeguard is awareness and a commitment to prevention. ■
REFERENCES
2. Fuller BM, et al. Lung-Protective Ventilation Initiated in the Emergency Department (LOV-ED): A QuasiExperimental, Before-After Trial. Ann Emerg Med. 2017 Sep; 70(3): 406-418. PMID: 28259481. 3. Dafilou B, et al. It’s In The Bag: Tidal Volumes in Adult and Pediatric Bag Valve Masks. West J Emerg Med. 2020 May; 21(3): 722-726. PMID: 32421525 4. Kroll M, et al. Can Altering Grip Technique and Bag Size Optimize Volume Delivered with Bag-ValveMask by Emergency Medical Service Providers? Prehosp Emerg Care. 2019 Mar-Apr; 23(2): 210-214. PMID: 30130437. 5. McInnes AD, et al. The first quantitative report of ventilation rate during in-hospital resuscitation of older children and adolescents. Resuscitation. 2011 Aug; 82(8): 1025-9. PMID: 21497007.
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COMMITTEE REPORT
EMRAF President’s Message By Elizabeth Calhoun, MD, PGY-3 Committee Chair
As EMRAF moves into 2022, we are continuing to reach out to the unceasingly growing cohort of Florida residents. We have three short years to bring everything that FCEP offers, from educational programming to conferences and advocacy. We have improved our coordination with the FCEP Medical Student Council, and Life After Residency will be renewed after a COVID hiatus, now taking place in the spring. Please talk to your program directors and residency teams regarding Life After Residency. We want this event to truly fit our Florida residents’ needs. We are reaching out to programs directly to see what programming we can offer to be most helpful. EM Days will look different this year, with two sets of meeting dates to promote the needs of our patients to our legislators. The task
of understanding how active bills will affect our patient care is not as daunting as it seems! The first step is understanding how emergency medicine patient care functions, and you are already the experts in that. FCEP is hosting two quick legislative briefings, virtual and open to any member. Please take an hour out of your year to update yourself on emergency medicine’s priority issues in Florida. The first will take place January 19 at 2:00 pm and the second on January 27 at 2:00 pm. Find more information at fcep.org/emdays.
let me know and visit fcep.org/la for more information.
Our residency programs are vibrant and bustling through this season, working hard to interview the best candidates for their teams. FCEP welcomed Geoffrey Wade, PGY-3 from FSU Sarasota into FCEP’s Leadership Academy. If this is something that interests you or your colleagues, please
Next EMRAF Committee Meeting
Coming soon at emlrc.org 16
EMpulse Winter 2022
Are you receiving FCEP updates? Are you connected to our state ACEP chapter’s ongoings? It takes only a moment to visit fcep.org/emnews-now and simply click the orange Subscribe to Announcements button in the bottom right to receive periodic emails with latest EM news and events. ■
February 8, 2022 Virtual; time TBD Stay tuned via email and at fcep.org
Updates from Florida’s
Emergency Medicine Residency Programs
Kendall Regional Medical Center By Kelly Wright, MD, PGY-3
Emergency Medicine Chief Resident Hi from Kendall Regional Medical Center EM Residency! We hope everyone had an amazing holiday season with their friends and family. Our residents and faculty had the chance to celebrate the holidays at Program Director Dr. Slane’s annual party in December. We had so much fun and can’t wait to repeat it again next year! It has been an exciting first half to this academic year. While we unfortunately couldn’t have our annual friendly SimWars Competition with Aventura’s EM Residency due to COVID restrictions, we have continued to have several socially distant simulation activities at the Broward College Simulation Lab. We are also excitedly planning for our next Wilderness Day in a couple of months with Drs. Brea and Leiva. Congratulations to Drs. Mark Rivera and Ricardo Rodriguez Perez, who will be joining us at Kendall next year as the newest ultrasound fellows! We are also proud to announce that several of our senior residents have accepted fellowship positions in various parts of the country, including Dr. Glen Malaret Hernandez, who is going to Jacobi Medical Center in New York City for ultrasound and Dr. Caitlin Blackwell, who is going to Greenville Hospital in South Carolina for ultrasound. We will also be keeping two of our own on board: Drs. Kelly Wright and Collin Smith will be staying as the administrative fellows! ■
Florida Atlantic University By Tony Bruno, DO, PGY-2 Greetings from Southeast Florida, where we are enjoying the best weather of the year. There have been lots of exciting happenings down here at FAU over the winter months. Despite working hard and ramping up studying for the In-Training Exam, we have continued to enjoy our monthly wellness days after our simulation lab training. Our recent events included attending an FAU football game and a beach day that did not disappoint. Our annual holiday party was a huge success and included a white elephant gift exchange as well as a cookie making competition. Big thank you to our faculty and everyone who made our party happen this year. We thoroughly enjoyed our recent simulation lab skills session with the FAU Emergency Medicine Interest Group. We hosted 15 first- and second-year medical students who are interested in emergency medicine, all of whom participated in learning multiple skills like central lines, chest tubes, and airway management encompassing direct intubations and difficult airway management with glidescope and fiberoptic scope intubations. We are anxiously awaiting the next skills session. EMpulse Winter 2022
Big congratulations to the recently married Dr. Danny Gersowsky, and to Dr. Andrew Arteaga on his recent engagement. We’ve also had several new publications over the past few months, including: • Hughes PG, Alter SM, Greaves SW, Mazer BA, Solano JJ, Shih RD, Clayton LM, Trinh NQ, Lottenberg L, Hughes MJ. Acute and Delayed Intracranial Hemorrhage in Head-injured Patients on Warfarin versus Direct Oral Anticoagulant Therapy. Journal of Emergencies, Trauma, and Shock. 2021;14(3):123-7. PMID: 34759629. • Solano JJ, Clayton LM, Parks DJ, Polley SE, Hughes PG, Hennekens CH, Shih RD, Alter SM. Prehospital Ketamine Administration for Excited Delirium with Illicit Substance CoIngestion and Subsequent Intubation in the Emergency Department. Prehospital and Disaster Medicine. 2021;36(6):697-701. PMID: 34551849. • Khan M, Alter SM, Clayton LM, Hughes PG, Shih RD, Solano JJ. Age adjusted D-dimer cutoffs for pulmonary embolism in a geriatric population utilizing a D-dimer unit assay. [published online ahead of print, 2021 Oct 22]. American Journal of Emergency Medicine. 2021;51:103107. PMID: 34735966. ■ 17
UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS
Orange Park Medical Center By Dillon Smith, DO, PGY-1
North Florida EM By Jayden Miller, MD, PGY-3 Happy New Year from Gainesville! We finished out 2021 strong and are looking forward to 2022. Our PGY-3 class visited Boston for ACEP’s Scientific Assembly, where we learned from the many didactic courses offered. A favorite was “Little People, Big Lawsuits” about pediatric bouncebacks and malpractice. The Class of 2022 enjoyed exploring Boston – we were able to take a few tours and eat some delicious food! It was a fun and memorable week, although it was rather chilly for our Floridian sensibilities. In November, we had a special session during our monthly simulation experience where the cases were based on cases from our own department. This was a novel way to learn about challenges of management in the safe space of simulation. Simulation Director Dr. Evan Stern organized a case where the most challenging aspect was not airway or access, but ethics! We had guest lecturers Dr. Stefanie Lord, the Medical Director of Community Hospice, and representatives from North Florida Regional Medical Center’s risk management team to examine the more delicate aspects of decisionmaker roles and DNR orders, topics which come up frequently in the ED. Our intern class has become accustomed to residency and we are so happy to have them as the newest members of our North Florida EM family. Katie Johnson, DO, PGY-1 now runs our social media and has put in great work displaying our didactics, wellness, and residents on “Meet a Resident Monday.” You can see her work on Instagram @northfloridaEM. ■ 18
Greetings from Orange Park EM residency! We’ve been busy as ever with lots of exciting news and updates heading into the new calendar year. On the academic front, our EM residency research program continues to experience exponential growth with the addition of our newest faculty member, Dr. Martin Wegman. Our very own Dr. Kendall Talley, PGY-2, recently won 3rd place at the Clay County Medical Research Competition. Drs. Taylor Bosley, Cody Russell, and Ahmad Mohammadieh, PGY-3s, will also be presenting several projects at the upcoming International Meeting on Simulation in Healthcare in Los Angeles. We’ve also bolstered our clinical curriculum with the addition of a PGY-1 PICU rotation at nearby Wolfson Children’s Hospital. Likewise, our ultrasound program continues to grow by leaps and bounds under the direction of Dr. Michael Euwema and ultrasoundtrained faculty Drs. Taryn Hoffman and Matthew Carr. Our PGY-2s and PGY-3s recently underwent training in
resuscitative TEE and we look forward to implementing it in the department very soon. Many of our residents are preparing to take their talents and influence overseas with upcoming global medicine trips. Dr. Janae Fry, PGY-3 will be heading to Kenya; Dr. Hillary Baker, PGY-2 will be going to Nepal in connection with Stanford University; and Dr. Haley Williams, PGY-2 will be spending time in Trinidad. We’re also planning for our inaugural Winter Resident Sim Wars and are in the process of designing our brand new Simulation Center. Lastly, we’re busy planning graduation for our inaugural class of residents! We will be sad to see them go, but are celebrating with them as they accept exciting positions in academic and community positions throughout the country. Special shout out to Dr. Uju Eziolisa, PGY-3, who recently matched into an ultrasound fellowship at Baylor. Follow along @OrangeParkEM for more exciting news and updates! ■
FSU at Sarasota Memorial Thomas Cox, MD, PGY-3 Greetings from Sarasota! Since our last update, we have made it through the Delta variant surge and the holidays. In addition, our hospital system opened an eight story oncology tower on our main campus and a new hospital in Venice, FL. Somewhere along the line, we even found time to clean and restore a local trail system and host our annual holiday party. As our first group of PGY-3s prepare for life after residency, we would like EMpulse Winter 2022
to congratulate Dr. Darrel Ray, who has been accepted to the University of South Florida for an ultrasound fellowship. He has served as our ultrasound resident chair and has been instrumental in both starting our TEE resuscitation program and educating residents and students. Lastly, we would like to thank all the nurses, techs, ancillary staff, residents, and attendings from across the state for making it through another busy holiday season. ■
UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS
UF Gainesville By Megan Rivera, MD, PGY-2
We hope that everyone had a great holiday season! Holidays this year were extra special, as the department had the opportunity to come together once again for the return of our annual Holiday Party. This season has also given us pause to reflect on another difficult year, and we are so thankful to our UF family for their continued support. Perhaps what we have been most grateful for is the ability to travel again. Faculty and PGY-3s trekked to Boston for ACEP. While there, we were proud to watch our own Dr. Cristina Zeretzke-Bien as she was voted into the chair-elect position for the ACEP PEM section. PGY-2s are anxiously
awaiting their turn and look forward to SAEM in New Orleans this coming spring. We’d like to extend a hearty congratulations to Dr. Joseph Pompa, a recent 2021 UF EM graduate and current Global Health Fellow, who was awarded the 2021 SAEM Global Emergency Medicine Academy Scholarship for the ARMED (Advanced Research Methodology Evaluation and Design in Medical Education) MedED Course. We additionally would like to congratulate our seniors who recently matched into fellowship: Drs. Mysore and Borobia into Critical Care at University of Florida, Dr. Clifford into EMS at University of Florida, and
Dr. Kuai into Toxicology at Emory University. Meanwhile, our other seniors have been busy navigating job offers at various hospitals around the country. We’ve had a prosperous interview season with another record set of applications. We are always so impressed by the excellence and vigor of our next generation of doctors. We cannot wait to see who will join us in Gainesville! As we ring in 2022, we’re looking forward to another exciting calendar year. UF EM wishes everyone a year of health, wellness, and continued success. ■
Learn more & read EMpulse articles submitted by each one at fcep.org's "Guide to Florida's EM Residency Programs."
21 EM FLORIDA HAS ACCREDITED
RESIDENCY PROGRAMS
SCAN NOW Coming soon: Fellowship Guide EMpulse Winter 2022
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UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS
AdventHealth East Orlando By Shannon Caliri, DO, PGY-1
Jackson Memorial Hospital By EM Residency Program Staff Greetings from Miami! We can’t believe it’s already 2022. It seems like just yesterday we were hosting our orientation month and the annual Intern Welcome BBQ at Dr. Arthur Diskin’s house. Now, we are at the tail end of our second virtual recruitment season. Overall, it has been a success. Our faculty and residents, along with our applicants, have embraced the challenge and have done a great job. We have had an exceptional group of applicants and are looking forward to our Class of 2025. Our residents and faculty have also pushed forward with our social EM program. While it has been challenging during COVID, our residents have continued their commitment to incorporating a patient’s social context into their care to address their needs better. Our residents have focused on four core issues: community outreach, access to care, social justice, and curriculum integration. For more, you can check out our website at miamiemresidency.org in the Social EM Section. As we look back on 2021, we want to take a moment and express our thanks and gratitude. We are thankful for our talented, dedicated, and hard-working faculty, residents, and staff. We are grateful and proud to be at Jackson Health System and the University of Miami, providing care to all those in need. We are excited to continue the mission of our program and institution and are looking forward to 2022! ■
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The weather has started to cool down a bit here. Coming from Chicago myself, you would think I would be better at dealing with this, yet I am sitting here bundled up in blankets. Luckily, most of us were able to spend quality time with friends and family this holiday season. Recently, our residents took a practice ITE exam. This helps us see where we stand and what areas we need to continue working on. We also have exciting news! All of our senior residents have accepted positions for after they graduate: • Joey Ray will be completing a fellowship in Medical Education at Loma Linda • Yuchen Duan will be completing an EMS fellowship at Orlando Regional Medical Center • Saleh Hasan accepted a position at Bayfront Health in St. Petersburg, FL
• Bryce Hoer accepted a position at Team Health in Las Vegas, NV • Tyler Mills accepted a position at USACS in Tampa, FL • Ricardo Hernandez accepted a position at Team Health in Kissimmee, FL Lastly, I’d like to thank Shayne Gue, MD for everything he has done for our program. We were sad to say our goodbyes to him as he accepted a position elsewhere. Dr. Gue was our Exam Content Lead and has always made learning an enjoyable experience. He truly cares for the residents and rotating medical students, always wanting to help them grow as learners and physicians. With Dr. Gue being a former graduate of our program, it was a bittersweet goodbye on his last day. We wish you good luck and know you will continue to excel in all of your future endeavors. ■
USF at Tampa General Hospital By Kenneth Dumas, MD, PGY-2 Greetings from the EM family here at USF/TGH. We have some exciting updates to share. We have come to the conclusion of yet another exciting fellowship match. We want to congratulate Dr. Jared Senvisky for matching into a critical care fellowship here at USF and Dr. Tiffany Pleasent for matching into an EMS fellowship at UT Southwestern. Additionally, we are proud to say that Dr. Pleasent was also named the GME cultural champion at USF, showing how our EM residents strive to not only take active efforts to improve the life of our patients, but our co-workers and community overall. EMpulse Winter 2022
Speaking of creating a positive culture: ED volumes remained high as we entered into the holiday season, which is a tough time for residents away from their families. Our residency family came together to celebrate “friendsgiving,” where residents had the morning away from the ED to be able to spend quality time with each other, get active with outdoor games, and show off some culinary know-how. As always, follow along with us at our blog for the most up-to-date news and events: usfemergencymedicine.org/ blog ■
UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS
Oak Hill Hospital By Ryan Johnson, MD & Mohammad Razzaq, DO, PGY-2
WEST FLORIDA
Hello from Brooksville! A lot has been going on at Oak Hill Hospital since our last update. The most exciting news we’d like to share is that our new ED opened January 1! We have eagerly been awaiting this day over the last two years and were excited to move into our new home.
had an amazing time. It was a great networking, educational, and relaxing break from the past 20 months! Several have already secured jobs or fellowships. We look forward to hearing more about their successes, and can’t believe we only have six more months together.
It finally seems as though things are starting to return to normal, or at least a new normal. We are seeing a return of our cold-averse patients. More and more campers pour into town every day, and condos in the area are busier than they have been in recent memory.
Residency interviews are in full swing! We’ve been fortunate enough to meet some truly stellar applicants. We would like to give a special shoutout to residents Drs. Denise Nelson and Kim Wolfe for organizing amazing pre-interview dinners. It is not easy to adapt the old traditions to our virtual reality, but they have made something special for both residents and applicants. ■
Our seniors and several core faculty attended ACEP in Boston last month, and from what they’ve shared with us
UF Jacksonville By Jeanne Rabalais, MD, PGY-1 & Chris Phillips, MD, PGY-2
Fall was busy, yet exciting for our department here at Jax! Just as our new interns have started to settle in, we have turned our attention to recruitment and interview season for the Class of 2022. We have welcomed outstanding 4th year medical students to our department for their externship rotations. Additionally, we have continued with our Jax EM Sneak Peek events and have begun interviewing for Match 2022. We cannot wait to meet the next group of interns! In October, our PGY-3 class attended the ACEP Scientific Assembly in Boston. While education and networking were a top priority, they managed to have a ton of fun as well. While the third-years were off having a good time, our second-year residents stepped into new leadership roles within the department. We have no
doubt that they will be ready to run the department in the next academic year. Finally, we have several successes to celebrate. Congratulations to Dr. Andrew Warren for matching into an EMS fellowship at Medical College of Georgia and to Dr. John Hurley for matching into a combined Addiction Medicine and Toxicology fellowship at Virginia Commonwealth University! We would also like to congratulate one of our APDs, Dr. Melissa Parsons, for being named one of EMRA’s 25 Under 45 honorees for her work on gender equity, physician wellness, and physician infertility. We here at Jax hope everyone had a safe and happy holiday season. Until next time! ■
EMpulse Winter 2022
St. Lucie Medical Center By Nicole Tobin, DO, PGY-3 We hope everyone enjoyed the holiday season! While not the year we expected, 2021 brought many challenges that only helped us all grow stronger in both our medical knowledge and practice. It has been great and encouraging to see our interns become more confident in their abilities to see and treat patients in such a short period of time. Halfway into this year also means that our seniors are actively searching for jobs. Some have already signed their contracts for July 2022 while others patiently awaited the results of fellowship match. We cannot wait to see where everyone will end up! Weekly didactics have gone back to inperson and it is nice to be able to see all of our co-residents at least once a week, especially with so many being on out rotations. Guest lectures continue to bring us knowledge outside of our department and are very welcome. We are also using this time to prep for the ITE, which is coming up much sooner than some of us would like. We celebrated our annual Residency Holiday Party and white elephant gift exchange during the holiday season. With all the restrictions last year due to COVID, this is a tradition that only the current seniors have been able to experience, so we were very excited to be able to share this experience with our fellow residents. Stay tuned to find out who is lucky enough to get THE gift in the gift exchange and who wins the title for ugliest Christmas sweater! We are very excited to see what 2022 brings for us. ■
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UPDATES FROM FLORIDA’S EMERGENCY MEDICINE RESIDENCY PROGRAMS
UCF/HCA Healthcare GME Consortium Emergency Medicine Residency Program of Greater Orlando By Amber Mirajkar, MD Research Fellow
It is hard to believe the academic year is already halfway over. Despite the short time frame, we have managed to accomplish a great deal. Our ultrasound team’s hard work has been rewarded. In September, the Society of Clinical Ultrasound Fellowships’ (SCUF) 2021 Conference was in Nashville, TN. Both of our fellows, Drs. Michelle Hernandez and Thomas Lawyer, were selected to present at the conference’s Fellow Lightning Talk. Additionally, Ultrasound Fellowship Director Dr. Judy Lin won the Shazam! Award as recognition for her contributions to SCUF. At ACEP, we were honored by the acceptance of nine abstracts by current and former residents. One such abstract, “Impact of Emergency Department blood pressure on stroke severity,” was presented by Dr. Parth Patel, PGY-3. Our Ultrasound Director, Dr. Javier Rosario, won an award from the Emergency Ultrasound Section for his contributions as Section Secretary, managing subcommittees
and the newsletter. Dr. Judy Lin won an award for developing resources for fellows and POCUS education, as well as being selected for the ACEP Advanced Examination Review Course. Finally, our residency was selected to participate in MedWars. Thanks to Drs. Jesse Wu, PGY-3, Mark Rivera, PGY-3, and Martin Morales, PGY-2 for representing us. Many of our residents are working on research projects that have been selected for publication. Drs. Emily Drone and Cherian Plamoottil published “Testicular Compartment Syndrome: An unexpected diagnosis in a case of testicular pain,” in Urology Case Reports. Drs. Jeremy Mayfield, Ms. Sumedha Bandi, Latha Ganti, and Jose Rubero published “Anaphylaxis After Moderna COVID-19 Vaccine” in Therapeutic Advances in Vaccines and Immunotherapy. We are pleased to welcome a new faculty member: Dr. Shayne Gue. Originally from West Virginia, he completed medical school at the
Joan C. Edwards School of Medicine at Marshall University, followed by residency at AdventHealth East Orlando, where he was chief resident and served as faculty. Very active in FCEP and a member of the board of directors, Dr. Gue is the chair of the Symposium by the Sea planning committee and an active participant in EM Days. His educational interests include developing novel approaches to graduate medical education in the form of team-based learning curriculum and gamification. We are very excited to have him join the team, and the residents cannot wait to see what he has in store for our curriculum. In addition to academics and research, we also value wellness. This year we continued the annual tradition of having wilderness medicine didactics at a state park. It was a great experience for the residents to kayak down Shingle Creek afterward and explore parts of Orlando many did not know existed. As the COVID-19 Delta surge ebbs, we hope to explore more. ■
Orlando Health By Blaire Banfield, MD, PGY-2 It’s the most wonderful time of the year… flu season! Just kidding. Winter is off to a great start here at ORMC. We recently completed renovations at our behavioral health unit to allow for a more comfortable, safe, and secure environment for both our patients and staff. We are also well underway with construction on adding our third CT scanner in the department, which is scheduled to be up and running in early 2022. Dr. Keegan Mullins, informatics fellow and recent ORMC EM residency graduate, has done amazing work 22
spearheading our COVID-19 vaccination program. We are now able to provide vaccines to patients in the ED, and they can even choose between Pfizer or Moderna. Interview season is in full swing! While we are sad we can’t show our applicants around our beloved city in person, we are blown away every interview day with what dynamic, intelligent, and hardworking soon-to-be doctors we have the pleasure to meet with. We work our hardest at every pre-interview dinner and interview to let our La Familia atmosphere shine. EMpulse Winter 2022
Last, but certainly not least, huge congratulations to our PGY-3s who have already matched into fellowships! Drs. Conner Karr and Will Waite matched into ultrasound; Dr. Lindsay Maguire matched into research; Dr. Pooja Sarim matched into PEM; Dr. Tadashi Updegrove matched into critical care; Dr. Jessica Wanthal matched into EMS; and Dr. Hudi Wenger matched into sim/ education. This year’s class has led our department with strength, intelligence, and grace, and we know they will keep doing so in their fellowship endeavors. ■
COMMITTEE REPORT
Medical Student Council By Cristina Sanchez, MS, MS-2
MD Candidate, Florida State University FCEP Medical Student Council Secretary-Editor
This year, the ACEP21 Scientific Assembly was a hybrid conference, where attendees could choose between attending the conference live in Boston or attending virtually. This hybrid model made it possible for many students to attend the conference who may have otherwise been unable to due to school obligations or travel restrictions. The following excerpts were written by some of the virtual attendees, detailing their opinions on the conference as students. “As a newly minted second-year medical student, I was itching to learn more about clinical medicine, specifically relating to the practice of emergency medicine. ACEP21 delivered on these hopes and provided so much more. From seeing the best and latest practices of burn management or traumatic eye injuries, to finding out how to develop a career niche in emergency medicine, I found that my eyes were opened wide and my brain turned into a sponge. I was surprised to find out that the sessions I found most impactful were the ones that were more complex and nuanced. I found that sessions like “Ethical Dilemmas and Tough Decisions in the ED’’ really forced me to think and gave me a much deeper understanding of what life is like in the ED. Similarly, I found that “Unlearning Implicit Bias” and “Emotional Intelligence and Mindful Listening” helped me understand how to be a more compassionate physician. It is one thing to know differentials and best practices, and another thing entirely to be empathetic. I hope to be both, and I am happy to say that ACEP21 delivered in providing me the tools necessary to be the best possible clinician. I am so grateful I had the opportunity to join this conference, and I can’t wait to return next year.” -Katlyn Sullivan, MS-2 at FSU College of Medicine
“My favorite part of ACEP21 was the review of literature sessions and review of treatment sessions. Specifically, the session covering all of the pediatric emergency literature for the year was very helpful because the presenter narrowed what was significant and what could be ignored. Some of the articles covered I had remembered seeing the titles for but never had the time to go through them myself. Also, the session about STEMI and NSTEMI presentations was interesting because it covered more nuance and exposed me to developing terminology more than my cardiovascular block during MS1. Overall, I felt that ACEP21 helped me reconnect to the world of emergency medicine and sparked my excitement for the upcoming clinical years.” -Hunter Paterson, MS-2 at FSU College of Medicine “The road to medicine is long and can easily be forgotten in day-to-day life as a medical student. ACEP helped me re-spark my love and excitement for the medical field and for emergency medicine. This was the first conference I have attended in which I knew the names of many speakers. To hear about the latest advances in emergency medicine from some of my favorite podcasters and authors was a captivating experience. Furthermore, this was the first conference I have attended in which I could correlate many of the lecture topics to material covered in my medical school coursework. While the online platform provided challenges, ACEP was very receptive to feedback from virtual attendees and made changes during the week to enhance the at-home experience. I believe this reflected very positively on their desire to provide an optimal learning experience for attendees at home and I would not hesitate to attend this conference EMpulse Winter 2022
again in the future, online or in person.” -Analise Dilorio, MS-2 at FSU College of Medicine “My favorite part of the ACEP21 conference was that, although I was attending virtually, I nevertheless felt part of the larger ACEP community. The dialogue which occurred during the live sessions via chat facilitated a connection to the presenters and others at the conference. I enjoyed learning more about prehospital, emergency, and disaster medicine, as well as learning from the residents in the EMRA 20 in 6 Resident Lecture Competition. Some of the most rewarding sessions for me were those involving diversity, such as “Dx: Medical Racism - What’s the Treatment?” and the EMRA Diversity and Inclusion Committee Programming, as well as wellness, such as “Dead Tired: The Impact of Fatigue on Patient Safety & Physician Wellness” and “Tools for Combating Burnout: Using Mindfulness to Your Advantage Workshop.” Thanks to the interactive and engaging sessions, I did not leave the conference with Zoom fatigue as I have in many other virtual events, but rather was eager to watch the sessions I had missed! Each session I attended was interesting and unique. As a student, it was extremely beneficial to attend the sessions virtually, as it allowed me to plan which I would attend based on my class schedule. I am thrilled to see what next year’s ACEP conference has in store.” -Cristina Sanchez, MS-2 at FSU College of Medicine Overall, the consensus among students seems to be gratitude for having the opportunity to attend the conference and many seem excited to see what ACEP22 will bring! ■
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FEATURE
Forging International Care Connections During the Delta Surge: A Reflection on Providing COVID-19 Medical Relief to India Sanjay Pattani, MD, FACEP, MHSA FCEP President and Associate Chief Medical Officer at AdventHealth Orlando
Just as Florida came off its second COVID-19 surge this past spring and mass vaccination efforts were in full swing, the Delta variant began ravaging India. The headlines of death and despair dominated the news, and the impact on one of the most populous countries in the world was devastating. At its peak in early May, India experienced one of the largest COVID-19 surges the world had seen, with more than 400,000 new infections and 4,000 deaths reported each day. These were more than headlines to me. They hit close to my home and heart. My parents are first-generation immigrants from India, and I continue to have deep roots in the country. Many of my relatives are still there, including two of my cousins who are primary care physicians. I also have numerous physician colleagues I have met and stayed connected with over the years who live and work in India. As this new stage of the pandemic progressed, I kept hearing more and more first-hand accounts from my family and friends about the tragedies they were seeing and experiencing each day. My wife’s best friend’s grandmother died without family being able to conduct the usual and customary Hindu ceremony and cremation. Listening to all of their fear and suffering broke my heart and propelled me to find a way to do something to help.
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was experiencing some of the same issues we had in the U.S. during our first two COVID-19 surges but with a significantly different and hugely underfunded healthcare infrastructure. The country has almost no emergency medical services (EMS) system — just getting patients to the hospital is a huge barrier to accessing care. Compounding the challenge, severe staff and supply shortages plagued India’s hospitals before the Delta variant hit. As the virus surged, the healthcare system rapidly became overrun. Two of the greatest challenges that emerged were capacity and lack of oxygen. Quite literally, millions of sick people were starving for air. I am a physician, trained in emergency medicine, serving as associate chief medical officer for AdventHealth Orlando, a quaternary hospital in the U.S. As an American doctor, I have access to the very best medical resources and the ability to provide the highest level of patient care. In medical training, we are taught to be proactive, to do no harm and to never give up. I also have an innate humanitarian desire to help others. That is what drew me to a career in medicine in the first place. As the Delta variant was consuming my family’s homeland, I knew I had skills, knowledge, financial resources and the desire to help, but how could I from such a distance? It was an overwhelming and paralyzing feeling.
The Challenge
Developing a Plan to Provide Relief
From a medical standpoint, India
Despite the initial despair, I knew EMpulse Winter 2022
I wasn’t alone in my quest to do something to help. When the warning signals began ringing in India early last spring, my AdventHealth colleagues in Central Florida began discussing how we could apply the basic principles we knew as physicians to deliver some sort of relief in a compassionate way. However, with each idea we generated, we encountered obstacles, including travel restrictions, supply chain issues, limited manpower and government regulations. Finding the right contacts and resources would be essential to launching a successful disaster relief effort. At AdventHealth, I am blessed to work for a faith-based organization whose breadth and depth extends into various programs such as AdventHealth Global Missions. They already had relationships with a number of hospitals in India and helped us to establish direct communication with these healthcare providers to learn how we could best support their most urgent needs. One of the most heartbreaking things we learned during these initial outreach and conversations was that at some hospitals, despite the tremendous influx of COVID-19 patients, some ventilators were sitting unused simply because of a lack of available oxygen. With input from our colleagues on the frontlines in India, we decided to focus our combined relief efforts on two critical areas of need: 1) supplies and equipment, including personal protective equipment (PPE) and
can we sustain our cooperative efforts and become more proactive and prepared to respond?
Supplies and palettes donated to India. Photo courtesy of AdventHealth Marketing Department
ventilators, and 2) addressing the oxygen shortage. Working through AdventHealth Global Missions, we were able to secure and ship five pallets of surgical masks, respiratory circuits and ventilators to Southern India in June. They were also able to connect us with the Adventist Development and Relief Agency (ADRA), a humanitarian organization based in Maryland and operated by the Seventh-day Adventist Church.
touched us all in different ways, its effects were felt across the globe, demonstrating just how connected we truly are. The immediate, crushing crisis may have waned, but no doubt our world will continue to experience viral surges and other health challenges. In the years to come, how
As physicians, we are called to communicate and collaborate for the greater good, for the health of people across our planet. It is the oath we take when we put on the white coat and the core of our basic humanity. We can’t afford to stand on the sidelines and watch medical crises occur even if they are an ocean away. We must harness the power and innovation of the virtual world to bridge our geographic divides so that we can connect, organize and work together on plans and processes to address our most pressing needs and better prepare for those yet to come. We must forge new international forums to discuss best practices and develop new ideas. And most importantly, we must continue to share our strengths — our medical expertise, financial resources, leadership skills and intellectual capital — to help each other and find new solutions to our greatest healthcare challenges. Embracing our strength and the common good, our medical communities will continue to advocate for humanity. ■
Working with ADRA, we set a goal to help them raise enough funds to provide eight hospitals in India with medical oxygen-generating plants. These plants not only met the immediate need, but also ensured the hospitals could meet their longterm oxygen needs as well. The first oxygen-generating plant was quickly established at a hospital in the western Indian city of Surat over the summer, and three more plants are currently in progress.
Maintaining Global Health Connections to Extend Compassionate Care While the COVID-19 pandemic has
Oxygen installation. Photo courtesy of AdventHealth Marketing Department EMpulse Winter 2022
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CASE REPORT
Left Lateral Canthotomy with Cantholysis for Foreign Body Removal in the Emergency Department By Rolando Zamora Jr., MD, PGY-1
Department of EM, Memorial Hospital West
Introduction Lateral canthotomy and cantholysis is a vision-saving procedure most commonly used to relieve orbital compartment syndrome caused by retrobulbar hemorrhage, usually secondary to facial trauma. Bleeding in the enclosed bony orbit causes increased intraorbital pressure and resultant ischemia of the retina and optic nerve, leading to rapid and irreversible blindness.1,2,3 Despite its importance, lateral canthotomy and cantholysis is not often performed in the emergency department due to the rarity of the specific pathology requiring the procedure. The reported incidence of retrobulbar hematoma after blunt facial trauma is less than 1%, limiting a physician’s opportunity to perform the procedure.3 The use and utility of lateral canthotomy and cantholysis in the emergency department for conditions other than orbital compartment syndrome are underreported. A case is presented involving the use of lateral canthotomy and cantholysis for orbital foreign body removal.
Case Presentation A 51-year-old male presented to the emergency department for evaluation of a left-eye foreign body. One hour prior to arrival, the patient was trimming a palm tree when a palm frond fell and knocked off his 26
By Joseph J. Gomes, DO
Department of EM, Memorial Hospital West
safety goggles. The patient felt a thorn enter his left eye. He complained of discomfort in the eye but denied any vision changes. On exam, visual acuity was 20/100 in the right eye and 20/400 in the left eye. The pupils were equal, round, and reactive to light and accommodation. Extraocular movement and confrontational visual field testing were limited in the left eye secondary to pain. The left conjunctiva was injected with chemosis (Fig. 1). On Wood’s lamp examination, there was no Seidel sign and no fluorescein uptake. Tonometry measurement was deferred due to the presence of a foreign body. A linear foreign body was embedded into the inferior conjunctival fornix directed from the inferomedial orbit to the temporal orbit (Fig. 2).
Decision Making
An attempt was made to remove the foreign body using forceps. The attempt was aborted when it was discovered that the foreign body penetrated deeper than initially believed and the risk of foreign body fracture or splintering was identified. Ophthalmology was consulted and arrived at the bedside to further manage the patient. The inferomedial portion was freed from the inferior conjunctiva (Fig. 3). At this point, concern arose over potential globe rupture and a CT of the orbits was obtained (Fig. 4). The CT revealed no globe penetration and the decision was made to perform a lateral canthotomy EMpulse Winter 2022
By Iris C. Cruz, APRN
Department of EM, Memorial Hospital West
and cantholysis to facilitate the foreign body removal. Lateral canthotomy and cantholysis is a rarely-performed, vision-saving procedure.4 The primary indications for performing the procedure are suspicion of orbital compartment syndrome with at least one of the following: decreased visual acuity, intraocular pressure > 40 mm Hg, and proptosis. Secondary indications include: afferent pupillary defect; cherry red macula; ophthalmoplegia; nerve head pallor; and eye pain.5 The patient in this case lacked any of the primary indications listed, though it is important to note that intraocular pressure was not measured. On initial exam, the foreign body appeared to be much shorter than its true length. This highlights the importance to consider a more complex injury when managing any ocular or orbital trauma. Early screening for globe rupture or penetration is essential as the presence of this complication will change the course of treatment. In this case, the absence of globe penetration allowed for the use of lateral canthotomy and cantholysis to facilitate the foreign body removal. As the use of lateral canthotomy and cantholysis for foreign body removal in the emergency department is underreported, more research is needed to study the benefits and risks of performing the procedure without a primary indication. This case is one
Fig. 1. Injected conjunctiva with chemosis
example of the utility of the procedure for a non-indicated condition.
Conclusion Patients who present to the emergency department for evaluation of orbital foreign bodies should be screened for globe rupture or penetration. Those with complex lateral conjunctival foreign body embedment without globe injury should be considered candidates for lateral canthotomy and cantholysis. ■ Fig. 2. Foreign body embedded into the inferior conjunctival fornix
Free Pediatric Emergency Resources for EDs & EMS agencies emlrc.org/flpedready NEW
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REFERENCES 1. Rixen J, Randall Verdick BA, Allen RC, Carter KD. Lateral canthotomy, inferior cantholysis. The University of Iowa Department of Ophthalmology and Visual Sciences EyeRounds Website. 2013 Mar 12 [accessed 2021 Aug 23]. webeye. ophth.uiowa.edu/eyeforum/ tutorials/lateral-canthotomycantholysis.htm
Fig. 3. Release of the inferomedial portion of the foreign body
2. Desai NM, Shah Su. Lateral Orbital Canthotomy. [Updated 2021 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: ncbi.nlm. nih.gov/books/NBK557476/ 3. Fattahi T, Brewer K, Retana A, Ogledzki M. Incidence of retrobulbar hemorrhage in the emergency department. Journal of oral and maxillofacial surgery: official journal of the American Association of Oral and Maxillofacial Surgeons. 2014;72(12):2500–2502. 4. Rowh AD, Uf berg JW, Chan TC, Vilke GM, Harrigan RA. Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome. The Journal of emergency medicine. 2015;48(3):325–330.
Fig. 4. 2 cm linear low-density foreign body without globe involvement
5. McInnes G, Howes DW. Lateral canthotomy and cantholysis: a simple, vision-saving procedure. CJEM. 2002;4(01):49–52.
EMpulse Winter 2022
by Dr. Lou Romig
Request some for your EMS agency at PEDReady@jax.ufl.edu
Scan to visit FL PEDReady 27
ULTRASOUND ZOOM
Airway Management with Point-of-CareUltrasound: A Breath of Fresh Air By Kristopher A. Hendershot, MD, PGY-2 University of Miami / Jackson Health System
EMS just alerted you that a cardiac arrest is en route. You now have three minutes to gather all your airway equipment. You call respiratory therapy, get your oxygen and suction set up, and grab your tube, blade, lube, and syringe. Just in case, you grab your GlideScope and bougie. Did you grab your ultrasound? Sure, you probably grabbed it to assess cardiac activity, but what about the airway? The patient is brought in with an endotracheal tube already in place. You go to listen for breath sounds but with all of the chaos around, the airway is difficult to assess with your stethoscope alone. Quite frankly, you cannot hear anything, and the EtCO2 will take a couple of minutes to get set up. Now consider another scenario. A young woman just had a first date at a Red Lobster and in trying to impress her date, ate some lobster even though she knows she is allergic. She comes into your critical care area with a large amount of angioedema, with stridor, hypotensive, and covered in hives. You order the anaphylaxis medications and while the nurse is grabbing the medications, you quickly grab an eleven blade, a boogie, and a 6.0 endotracheal tube because you have a sick feeling in your stomach telling you where this is headed. You start palpating the neck for landmarks and quite frankly, this is a disaster—she is female, has a short neck, is obese, and with all the swelling, you really have no idea what you are feeling. In both situations, what do you do? After reading this article, I hope you will grab your linear probe.
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Edited by Leila Posaw, MD, MPH
Emergency Ultrasound Faculty, Jackson Memorial Hospital
ENDOTRACHEAL INTUBATION POCUS can be utilized to determine correct tube position either by direct visualization of the tube in the trachea or esophagus or indirectly by assessing ventilation, either by detecting pleural sliding or diaphragmatic excursion. Esophageal intubations might occur as often as 15.3% of the time during emergency airway access.1 Traditionally, auscultation is the preferred method of excluding esophageal intubation but it takes time, increases the risk of aspiration, and is relatively unreliable.2 EtCO2 is the gold standard for confirming tube placement; however, this too can be unreliable, particularly in cardiac arrest when it is only 60% to 65% sensitive for identifying endotracheal intubations.3 One of the first studies to look at point-of-care ultrasound (POCUS) confirmation of tracheal intubation found that it was accurate 98.2% of the time with a kappa value of 0.93, which aligns highly with capnography confirmation.4 A large meta-analysis of seventeen studies and 1,595 patients showed that POCUS was 98.7% sensitive and 97.1% specific.1 A more recent meta-analysis with 30 studies and 2,534 patients showed that POCUS was 98.2% sensitive and 95.7% specific.5 A study conducted in the emergency department at a Level I trauma center showed that the dynamic POCUS approach took an average of 18.25 seconds to identify esophageal intubations compared to the 177.5 seconds that it took in the EMpulse Winter 2022
EtCO2 group.2
Tube Confirmation Method STEP 1: Place the linear probe in a transverse plane superior to the suprasternal notch to visualize the trachea (Fig. 1). The esophagus may appear as a thick five-layered structure usually on the left of the trachea. Note the thyroid lobes and isthmus. STEP 2: In a tracheal intubation you will see one air-mucosal interface with a comet-tail artifact and posterior shadowing. However, if the intubation is esophageal, you will see two air-mucosal interfaces (“double tract sign”) with the comettail artifact and posterior shadowing. This double tract sign has a sensitivity of 98% and specificity of 95% for esophageal intubation.2 STEP 3: Next, use the same probe to check the lungs bilaterally for lung sliding. Absence of lung sliding on the left indicates a right main stem intubation, and the tube will need to be pulled back (Fig. 2). HOT TIP: You can confirm the depth of the tube by placing saline or air into the tube balloon cuff. Now when scanning in the longitudinal plane, the tube may easily be visualized. Location of the balloon at the sternal notch correlates to the correct tube depth.
CRICOTHYROTOMY The standard method for identification of the cricothyroid membrane (CTM)
Fig 1: Trachea, transverse plane, at level of sternal notch.
Fig 2: Bar-code sign on M-mode confirming absence of lung sliding.
Fig. 3: Bisected trachea, transverse plane, at the level of the sternal notch.
neck extended.
Longitudinal String of Pearls Method
Fig. 4: Trachea, longitudinal plane tracheal rings/string of pearls.
Fig. 5: Trachea, longitudinal plane - cricoid, thyroid and cricothyroid membrane.
is the landmark palpation technique. This involves palpating the midline skin between the cricoid cartilage and the thyroid cartilage; however, this is only accurate 62% of the time.6 Identifying the CTM is often even more difficult in patients with obesity, short neck, subcutaneous emphysema, prior neck surgeries or radiation, or in female patients.6
anesthesiologists using the landmark technique were successful 37% of the time compared to 83% of the time with ultrasound.6
Research has shown POCUS to be very useful. In cadavers with difficult or impossible landmark palpitation, POCUS resulted in a 5.6 times improvement in securing the surgical airway.6 On one female patient with a BMI of 45.3 with a two-minute limit,
There are two techniques to locate the CTM: the string of pearls method in the longitudinal plane and the Thyroid-Air-Cricoid-Air (TACA) method in the transverse plane. In both techniques, the patient should be placed in the supine position with the
Thus, experts have strongly recommended using POCUS to identify and mark the CTM prior to performing a needle or standard cricothyrotomy.
STEP 1: Place the linear probe in the transverse plane at the level of the sternal notch (Fig. 1). STEP 2: Next, move the probe towards the left and bisect the trachea with the right edge of the image (Fig. 3). STEP 3: Rotate the probe into the longitudinal plane and visualize the ‘string of pearls’ appearance of tracheal rings, which will appear as dark, anechoic structures anterior to a white, hyperechoic line (Fig. 4). STEP 4: Slide the probe towards the patient’s head to find the cricoid cartilage and the thyroid cartilage. The CTM lies between the thyroid cartilage and the cricoid cartilage (Fig. 5). Mark this point on the skin. Perform a standard cricothyrotomy procedure. Continue on next page ▶
Cricothyrotomy To-Go: Stick in your wallet. Reference on-the-go. Courtesy of authors Leila Posaw, MD, MPH and Kris Hendershot, MD
String of Pearls Method
Find the trachea at the sternal notch
Bisect the trachea with the right image edge
Rotate the probe to find the string of pearls
Slide towards the head to visualize the cricothyroid membrane between the cricoid & thyroid
Linear probe, longitudinal plane. Start at the sternal notch & slide in the caudal direction
EMpulse Winter 2022
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REFERENCES:
◀ Continued from previous page
1. Gottlieb M, Holladay D, Peksa GD. Ultrasonography for the Confirmation of Endotracheal Tube Intubation: A Systematic Review and Meta-Analysis. Ann Emerg Med. 2018 Dec;72(6):627-636. doi: 10.1016/j. annemergmed.2018.06.024. Epub 2018 Aug 14. PMID: 30119943.
Transverse TACA Method STEP 1: Place the linear probe in the transverse plane at the level of the sternal notch to visualize the trachea (Fig. 1). Slide cranially to locate the V shaped thyroid cartilage (T), which is visualized as a triangular pointy structure, like Mount Fuji (Fig. 6).
Fig. 6: Thyroid cartilage, transverse plane.
STEP 2: Continue sliding caudally toward the patient’s toes to reveal air (A) as a hyperechoic white line with posterior reverberation artifacts (A-lines). This crater is the CTM (Fig. 7).
3. Gottlieb M, Holladay D, Burns KM, Nakitende D, Bailitz J. Ultrasound for airway management: An evidence-based review for the emergency clinician. Am J Emerg Med. 2020 May;38(5):1007-1013. doi: 10.1016/j.ajem.2019.12.019. Epub 2019 Dec 11. PMID: 31843325.
STEP 3: Slide towards the patient’s toes until the cricoid cartilage (C) appears as a hypoechoic round archshaped structure, like Ayers rock (Fig. 8). STEP 4: Slide back cranially to confirm air (A), which is the CTM is located between the thyroid and cricoid cartilage. Mark the CTM on the skin. Perform a standard cricothyrotomy procedure (Fig. 7).
Fig. 7: Cricothryoid membrane, transverse plane.
T-A-C-A Method
Find the thyroid cartilage
Fig. 8: Cricoid cartilage, transverse plane.
Find the air (cricothyroid membrane)
Find the cricoid cartilage
Linear probe, transverse plane. Start at the thyroid cartilage
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4. Chou HC, et. al. Tracheal rapid ultrasound exam (T.R.U.E.) for confirming endotracheal tube placement during emergency intubation. Resuscitation. 2011 Oct;82(10):1279-84. doi: 10.1016/j. resuscitation.2011.05.016. Epub 2011 Jun 1. PMID: 21684668. 5. Sahu AK, Bhoi S, Aggarwal P, Mathew R, Nayer J, T AV, Mishra PR, Sinha TP. Endotracheal Tube Placement Confirmation by Ultrasonography: A Systematic Review and Meta-Analysis of more than 2500 Patients. J Emerg Med. 2020 Aug;59(2):254-264. doi: 10.1016/j.jemermed.2020.04.040. Epub 2020 Jun 14. PMID: 32553512.
SUMMARY It is my hope that I have convinced you to grab your linear probe before you grab your stethoscope or phone to call for an expedited portable chest x-ray. With practice, POCUS can be a powerful tool in your airway crash cart. Relax, and take a deep breath with POCUS. ■
2. Mishra PR, Bhoi S, Sinha TP. Integration of Point-of-care Ultrasound during Rapid Sequence Intubation in Trauma Resuscitation. J Emerg Trauma Shock. 2018 AprJun;11(2):92-97. doi: 10.4103/JETS. JETS_56_17. PMID: 29937637; PMCID: PMC5994849.
EMpulse Winter 2022
6. Alerhand S. Ultrasound for identifying the cricothyroid membrane prior to the anticipated difficult airway. Am J Emerg Med. 2018 Nov;36(11):2078-2084. doi: 10.1016/j.ajem.2018.07.027. Epub 2018 Jul 12. PMID: 30025948.
Confirm the air (cricothyroid membrane)
FCEP/FEMF Annual Program Calendar Dates subject to change. Find the most up-to-date information at fcep.org and emlrc.org.
Emergency Medicine Days January 19 & 27, 2022 Virtual
FCEP’s premier advocacy event for members Registration open at fcep.org/emdays
July 2022 TBD in Orlando, FL
The oldest and most prestigious ALS/BLS competition in Florida Stay tuned at emlrc.org/competition
Advanced Practice Clinician Skills Camp Spring/Summer 2022 EMLRC in Orlando, FL
EMLRC’s workshop for APCs in emergent care settings Stay tuned at emlrc.org/apcsc
Symposium by the Sea August 4-7, 2022 Location TBD
FCEP’s annual meeting & conference for emergency medicine practitioners Stay tuned at fcep.org/sbs
Life After Residency
CLINCON
Where Florida EM PGY-2s network and learn how to thrive beyond medicine
Educating Florida's lifeline of emergency first responders
Stay tuned at fcep.org/lar
Stay tuned at emlrc.org/clincon
ABC’s of Pediatric EMS
EMT & Paramedic Refreshers
April or May 2022 Location TBD
May 2022 Nemours Children’s Hospital in Orlando, FL
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Bill Shearer International ALS/BLS Competition
September 2022 TBD in Orlando, FL
Fall 2022 EMLRC in Orlando, FL
EMLRC’s day-long workshop on pediatric skills for EMS personnel
Get the 30 hours of required CE to renew your EMT or paramedic license
Stay tuned at emlrc.org/abcofpeds
Stay tuned at emlrc.org/refreshers EMpulse EMpulse Winter Fall 2021 2022
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FEATURE
Ultrasound Guided Vascular Access Workshop: A DIY Guide for Homemade Phantoms By Marisa R. Carino Mason, BS
University of Miami, Miller School of Medicine
By Sadhana Anantha, BS
University of Miami, Miller School of Medicine
By Joshua Goldstein, MD
Jackson Memorial Hospital, Dept. of Emergency Medicine
By Jessica Le, BA
University of Miami, Miller School of Medicine
By Ankit Shah, BS
University of Miami, Miller School of Medicine
By Daniel Hercz, MD Jackson Memorial Hospital, Dept. of Emergency Medicine
Background Vascular cannulation is a fundamental clinical skill that is applied across diverse medical specialties. Insertion of central venous catheters (CVC) is a common procedure to establish definitive venous access for infusion of sclerosing or vasoactive medications. While these procedures are relatively straightforward, they do carry major risks particularly in patients with anatomically challenging or abnormal vascular anatomy.1 To help address these challenges, ultrasound guidance has become the standard of care for establishment of central venous access in the emergency department. Ultrasound (US) guidance for CVC placement has shown impressive benefits in the reduction of total complication rate, and number of attempts and improved overall success rate.2 Multiple observational and randomized controlled studies demonstrate improved procedural success rates with the use of ultrasound guidance for the insertion of all manner of vascular access devices.3,4,5,6
Current Practice To keep pace with the expansive use of US-guided procedures, medical education programs must evolve and create new opportunities for simulation-based, inexpensive, no-
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EMpulse Winter 2022
risk learning programs using lowfidelity models.7,8 Handmade and/ or commercial “phantoms,” tools designed to mimic the sonographic and physical properties of human tissue under ultrasound, have become popular training tools to teach vascular access techniques.9, 10 After receiving phantom training, operators reported significantly higher comfort using ultrasound compared to those who did not.6, 7 Low-cost handmade phantoms using chicken breast, tofu, and gelatin mixtures are utilized in settings where commercial models are not readily available or affordable11,12 and have been shown to be comparable to commercial phantoms.13 A recent systematic review of undergraduate medical education revealed that 21 out of 95 formal ultrasound curricula utilized phantoms, eight of which were handmade.14 This article details a workshop designed by the University of Miami’s Ultrasound and Anesthesia Interest Groups, facilitated by emergency medicine & anesthesia physician educators. The workshop utilized the advantages of affordable homemade gel phantoms to simulate US-guided procedures for undergraduate medical students in a safe, cost-effective manner. This article will provide the methods, resources, and workshop
Table 1. Materials for the phantom model construction and the procedure. structure for other student interest groups to reference as a guide to host similar sessions.
Model construction
Objectives The main objectives of this two-hour workshop were for students to be able to obtain appropriate views of access sites on human models, gain familiarity with central vessel catheterization kits, and successfully cannulate phantom models under US guidance. Students practiced using the Sonosite SII, Butterfly iQ+, and Philips Lumify ultrasound machines. Each station was led by 1-2 emergency medicine or anesthesia residents. The student-tomachine ratio was ~6:1, with “time-onprobe” estimated at roughly 15 minutes per student per station.
Materials
Tools
Knox Gelatin (120 g/L)
18oz Disposable Foam Cups
Psyllium Husk Powder (110g/L) Citric Acid (10g/L) 0.25” ID Latex Tubing 0.33” Diameter Nylon Rope
Procedure
Ultrasound Gel
10cc Syringe (empty)
Absorbent chucks
Water (colored if desired)
Central Venous Access Kit
Ultrasound Machine
Sharps Disposal Bin
Linear Transducer
Materials & Methods Two different central access phantoms were made: one to simulate femoral central line placement and another for subclavian central venous line placement. Materials required to create the gel phantom model are listed in Table 1. To create the femoral access phantom, we suspended two 6-inch lengths of 0.25-inch internal diameter latex tubing within an 18 oz. disposable foam cup using drinking straws. A commercially available 0.33inch diameter nylon rope was also suspended lateral to the vessels to constitute a simulated femoral nerve (Fig. 1). To create the subclavian venous model, a 3D-printed PLA plastic clavicle was placed above tubing representing the subclavian vein. The tubing was then embedded into a gelatin mixture to construct the simulated central access site. To create the gelatin mixture, we slowly mixed 120 g of Knox Gelatin (Treehouse Foods Inc, Oak Brook, Illinois, USA) powder into 500 mL of cool water using a power mixer or hand whisk (Fig. 2). Once fully dissolved, we added 500 mL of boiling water to the gelatin mixture while mixing continuously. Then, 110 g of commercially available psyllium husk powder and 10 g of citric acid
(Left) Fig. 1: The Femoral Access Model mold. Straws were removed once gel had solidified. (Above) Fig. 2: Gelatin phantom ingredients.
powder was slowly added to the mixture, and we continued to mix until well combined. We suspended the structures centrally inside a container to allow for a 1-inchthick gel layer around all sides of the vessel and coated the container with commercially available nonstick cooking spray to aid in removal. The mixture was set overnight in a refrigerator (1.7-3.3oC) for approximately 12 hours. Once the gel had set, we removed and discarded the molds. For the femoral access model, arterial blood flow and pulsatility were simulated by connecting a syringe partially filled with colored water EMpulse Winter 2022
to one end of the latex tubing. The syringe was periodically pushed to create pulsatile flow on color doppler. Students used central line kits to cannulate vessels. The total cost to produce one phantom is approximately $3.88, not including the vascular access kit and ultrasound machine.
Results Pre- and post-survey questionnaires were used to assess students’ experience with the workshop. Operators assessed improvement in student comfort with the following Continue on next page ▶ 33
◀ Continued from previous page tasks on a 1-5 Likert scale: “Setting up the US machine;” “Identifying a Vein and Artery;” and “Using US to insert a Central Line.” All tasks demonstrated statistically significant positive results (p < 0.05), indicating the students felt more comfort with the described tasks after the workshop. Fig. 3 demonstrates real time images from the workshop.
Discussion The adoption of simulation models into modern undergraduate medical education has been limited, and lack of financial support may be one of the prevailing barriers in doing so.14, 15
can be effectively utilized for undergraduate ultrasound medical education. While there is no consensus on criteria to assess ultrasound competency,15 early exposure to develop comfort with materials and technical skills may be beneficial. Medical students participating in this workshop reported a significant improvement in handling an ultrasound probe, satisfaction with understanding the benefit of bedside use of ultrasound, and readiness to use ultrasound in a clinical setting. Our workshop provides a foundation upon which medical students can build their clinical knowledge. ■
The phantoms used in this workshop demonstrate how low-cost models
Fig. 3: Model stations and live hands-on instruction.
REFERENCES 1. Silverman MA. Immune 1) Rippey JC, Blanco P, Carr PJ. An affordable and easily constructed model for training in ultrasound-guided vascular access. J Vasc Access. 2015 Sep-Oct;16(5):422-7. doi: 10.5301/ jva.5000384. Epub 2015 Sep 1. PMID: 26349885. 2. Saugel, B., Scheeren, T.W.L. & Teboul, JL. Ultrasoundguided central venous catheter placement: a structured review and recommendations for clinical practice. Crit Care 21, 225 (2017). doi. org/10.1186/s13054-017-1814-y 3. Egan G, Healy D, O’Neill H, et al. Ultrasound guidance for difficult peripheral venous access: systematic review and meta-analysis. Emerg Med J. 2013;30(7):521-526. doi. org/10.1136/emermed-2012-201652. 4. Smith CC, Huang GC, Newman LR, et al. Simulation training and its effect on long-term resident performance in central venous catheterization. Simul Healthc J Soc Simul Healthc. 2010;5(3):146-151. doi.org/10.1097/ SIH.0b013e3181dd9672. 5. Dodge KL, Lynch CA, Moore CL, Biroscak BJ, Evans LV. Use of ultrasound guidance improves central venous catheter insertion success rates among junior residents. J Ultrasound Med. 2012;31(10):15191526. doi. org/10.7863/ jum.2012.31.10.1519. 6. Andreatta P, Chen Y, Marsh M, Cho K. Simulation-based training improves applied clinical placement
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of ultrasound-guided PICCs. Support Care Cancer Off J Multinat Assoc Support Care Cancer. 2011;19(4):539543. doi.org/10.1007/s00520-0100849-2 7. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005;142(4):260-273. doi.org/10.7326/0003-4819-142-4200502150- 00008 8. O’Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, Masur H, McCormick RD, Mermel LA, Pearson ML, Raad II, Randolph A, Weinstein RA. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep. 2002 Aug 9;51(RR-10):129. PMID: 12233868. 9. Di Domenico S, Santori G, Porcile E, Licausi M, Centanaro M, Valente U. Inexpensive homemade models for ultrasound-guided vein cannulation training. J Clin Anesth. 2007 Nov;19(7):491-6. doi: 10.1016/j.jclinane.2007.05.002. PMID: 18063202. 10. Selame LA, Risler Z, Zakaria SJ, Hughes LP, Lewiss RE, Kehm K, Goodsell K, Kalwani R, Mirsch D, Kluger SB, Au A. A comparison of homemade vascular access ultrasound phantom models for peripheral intravenous catheter insertion. J Vasc Access.
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2021 Nov;22(6):891-897. doi: 10.1177/1129729820961941. Epub 2020 Oct 6. PMID: 33023394. 11. Cheruparambath V, Sampath S, Deshikar LN, Ismail HM, Bhuvana K. A low-cost reusable phantom for ultrasound-guided subclavian vein cannulation. Indian J Crit Care Med. 2012 Jul;16(3):163-5. doi: 10.4103/0972-5229.102097. PMID: 23188960; PMCID: PMC3506077. 12. Chao SL, Chen KC, Lin LW, Wang TL, Chong CF. Ultrasound phantoms made of gelatin covered with hydrocolloid skin dressing. J Emerg Med. 2013 Aug;45(2):240-3. doi: 10.1016/j.jemermed.2012.11.022. Epub 2013 Feb 8. PMID: 23399392. 13. Lahham S, Smith T, Baker J, Purdy A, Frumin E, Winners B, Wilson SP, Gari A, Fox JC. Procedural simulation: medical student preference and value of three task trainers for ultrasound guided regional anesthesia. World J Emerg Med. 2017;8(4):287-291. doi: 10.5847/ wjem.j.1920-8642.2017.04.007. PMID: 29123607; PMCID: PMC5675970. 14. Davis, J.J., Wessner, C.E., Potts, J., Au, A.K., Pohl, C.A. and Fields, J.M. (2018), Ultrasonography in Undergraduate Medical Education: A Systematic Review. J Ultrasound Med, 37: 26672679. doi.org/10.1002/jum.14628 15. Díaz-Gómez, J. L., Mayo, P. H., & Koenig, S. J. (2021). Point-of-Care Ultrasonography. New England Journal of Medicine, 385(17), 15931602.
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EDUCATION CORNER
Curious About What? An Introduction to Medical Education Scholarship By Carmen J. Martinez Martinez, MD, MSMEd, FACEP, FAAEM
When the word research is mentioned, most people think about beakers and spending long hours in a laboratory. In healthcare, research determines the safety and effectiveness of treatments, diagnostic studies, or devices. Medical education scholarship can broadly be defined as research that relates to the education of medical professionals, including research related to undergraduate, graduate, and continuing medical education.1 Scholarship is more than research, as it is conducted systematically, based on evidence, and findings are publicly distributed for peers to review and expand knowledge. In the course of this article, we will provide an introduction to medical education scholarship. To define the work done by academic professors and change the notion of “teaching vs. research,” Ernest Boyer described four functions of scholarships: discovery, integration, application, and teaching. As higher education institutions evolved, the scholarship of teaching failed to describe the assumptions of its research,2 thereby insisting that the processes of teaching and learning should be studied together. In addition, this type of research should be public, critically reviewed, and produced in a form that allows others to build on it. Considering all of this, Shulman introduced the term “Scholarship of Teaching and Learning” (SoTL).3 Medical education scholarship can be performed on a variety of topics, including curriculum development, teaching methods, assessment and evaluation, faculty development, and use 36
By Caroline M. Molins, MD, MSMEd, FACEP, FAAEM
of technology in education.1 Ultimately, the primary purpose is to improve patient care through the improvement of student learning outcomes. In addition, it aims to advance learners’ knowledge and skills by understanding how they learn and what affects their learning experience.4 Furthermore, it should support and improve educational innovations, increase effectiveness and efficiency, and promote professional responsibility and curiosity. You may ask, this sounds interesting to me; so where should I begin? All scholarships should follow Glassick’s six core principles of excellence, including clear goals, adequate preparation, appropriate methods, outstanding results, effective communication, and a reflective critique. Table 1 provides a brief description of each of these principles.5 Sullivan provides those interested in medical education scholarship with eight strategies to get started:6 1. Read. Make a habit of reading. The idea is to “pick one and stick with it.” For example, choose one medical education journal, one topic, and at least once a month. 2. Determine your focus. Think about leveraging your personal interest, future goals, or your skill set to your institutional needs. 3. Create a personal infrastructure. Budget time off your schedule to work on and accomplish your scholarly work — you may need to negotiate for protected time, but just a few hours a month makes a difference. Think strategically by EMpulse Winter 2022
starting small with a pilot and then growing the project into a larger study or multi-institutional project. Stay on task by developing a timeline that you hold yourself accountable for and allows you to show your work to your supervisors. 4. Develop a network of collaborators and mentors. You can look both within your institution and outside of it to develop alliances. Collaborators are often found when going to meetings and even by harnessing the power of technology through email, virtual communities, and social media. 5. Learn to critique scholarship and write. Now that you have been reading medical education journals, sign up to be a reviewer and learn to critique scholarship and write. If this is your first time, consider reviewing as part of a group review or team up with other faculty. You may also consider taking some professional development courses on medical education research. 6. Think prospectively, not retrospectively. Plan for the scholarship before starting the educational activity. Do not retrofit assessments or outcomes to a delivered educational activity or survey. 7. Write a review paper. If you have an educational question with no recent review papers, consider writing one. It will help others with the same educational question. 8. Pass it on. Lastly, now that you have mastered all of the above, be a mentor for a junior faculty and
Table 1. Glassick’s Core Principles of Scholarship Does it state the basic purpose of his or her work clearly? Does it define objectives that are realistic and achievable? Does it identify important questions in the field?
Clear Goals
Adequate Preparations
Does it show an understanding of existing scholarship in the field? Does it bring the necessary skills to his or her work? Does it bring together the resources necessary to move the project forward?
Appropriate Methods
Does it use methods appropriate to the goals? Does it apply effectively to the methods selected? Does it modify procedures in response to changing circumstances?
Significant Results
Does it achieve the goals? Does the work add consequentially to the field? Does the work open additional areas for further exploration?
Effective Presentation
Does it use a suitable style and effective organization to present his or her work? Does it use appropriate forums for communicating the work to its intended audiences? Does it present his or her message with clarity and integrity?
Reflective Critique
Does it critically evaluate his or her own work? Does it bring an appropriate breadth of evidence to his or her critique? Does it use evaluation to improve the quality of future work?
encourage them to participate and become an advocate for a scholarship! There are many medical education scholarship opportunities. Some examples are curriculum and teaching issues/innovations, skills, and attitudes relevant to the structure of our profession, individual characteristics of learners, the evaluation of students and residents, professionalism, leadership, and advocacy. Another area worth mentioning is the use of social media in medical education and the impact of free, open access to medical education on the learners to improve patient care and outcomes. In conclusion, we have summarized the origin and some key concepts involved with medical education scholarship. We have also reviewed some tips for those who would like to start getting involved in it. So, fellow medical educators, let’s use our ideas to improve and elevate the teaching and learning of our medical students and residents. ■
Adapted from Glassick.5
REFERENCES:
Daunting Diagnosis: A By Karen Estrine, DO, FACEP, FAAEM Editor-in-Chief ◀ CONTINUED FROM PAGE 12 The patient’s neck CT shows an extensive large mass in the left neck with prominent lymphoid tissue seen at the base of the tongue and supraglottic airway suggestive of malignancy. ENT was consulted, who performed a flexible nasopharnygolaryngoscope exam at bedside that revealed bilateral base of tongue fullness with extension into the vallecula and
lingual epiglottis. A punch biopsy and FNA were preformed. The biopsy was positive for high-grade neuroendocrine carcinoma with small cell features. Oncology was consulted, who recommended a CT of the chest, abdomen, and pelvis for staging. Oncology recommended that the patient undergo chemotherapy and radiation treatment, which the patient refused. Palliative care was consulted, who offered hospice services and assistance from social work. The patient did not show up for his most recent oncology appointment. Due to the aggressive nature of his cancer, his prognosis is poor. ■ EMpulse Winter 2022
1. Collins, Jannette. “Medical Education Research: Challenges and Opportunities.” Radiology, vol. 240, no. 3, 2006, pp. 639–647., 2. Boyer EL. Scholarship reconsidered: Priorities of the professoriate. Princeton, NJ: The Carnegie Foundation for the Advancement of Teaching; 1990. 3. Shulman, Lee S. Fostering a Scholarship of Teaching and Learning. Institute of Higher Education, 2000. 4. Atluru A, Wadhwani A, Maurer K, et al. Research in medical education: a primer for medical students. April 2015. aamc. org/download/429856/data/ mededresearchprimer.pdf. 5. Glassick CE. Boyer’s expanded definitions of scholarship, the standards for assessing scholarship, and the elusiveness of the scholarship of teaching. Acad Med. 2000;75(9):877–880. 6. Sullivan, Gail M. “A Toolkit for Medical Education Scholarship.” Journal of Graduate Medical Education, vol. 10, no. 1, 2018, pp. 1–5.
37
POISON CONTROL
Loperamide: The Poor Man’s Methadone By Chiemela Ubani, Pharm.D.
By Molly Stott, Pharm.D.
Clinical Toxicology/EM Fellow, Florida/USVI Poison Information Center - Jacksonville
What is loperamide and how does it work? Loperamide is an antidiarrheal agent that is available over-the-counter (OTC). It was first introduced in 1977 as a Schedule V prescription due to concerns for potential misuse and abuse. By 1982, loperamide lost its legend drug status and was placed on OTC status, no longer requiring a prescription.1 This radical change was catalyzed by studies showing loperamide had a low risk of physical dependence and abuse.2,3 Loperamide exerts its antidiarrheal effects through µ-opioid agonism that results in inhibition of intestinal peristalsis, thereby increasing
Clinical Toxicology/EM Fellow, Florida/USVI Poison Information Center - Jacksonville
gastrointestinal transit time. At high doses, loperamide inhibits sodium, potassium and calcium channels.4 The recommended daily maximum dose is 16 mg for the indication of diarrhea treatment.4 In the setting of CYP inhibitors, like azole antifungals or p-glycoprotein inhibitors like atorvastatin, the plasma concentration can increase by 2- and 4-fold, respectively.5
Why is loperamide abused? According to the American Association of Poison Control Centers 2019 Annual Report, there were 1310 documented exposures to loperamide resulting in six deaths.6 Loperamide was previously thought to have a low potential for
Safe Prescribing of Controlled Substances An online course satisfying the 2-hour requirement for CME on controlled substance prescribing mandated by the state of Florida for license renewal Approved for AMA PRA Category 1 CreditsTM This course has also been approved by the Florida Board of Medicine; Florida Board of Dentistry; the Florida Board of Osteopathic Medicine; Florida Board of Optometry and Florida Board of Podiatry.
emlrc.org/project/opioid-prescribing 38
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Edited by Dawn Sollee, Pharm.D., DABAT, FAACT Director, Florida/USVI Poison Information Center- Jacksonville, UF Health Jacksonville
abuse due to its low bioavailability at just 0.3% and poor penetration through the blood brain barrier.7 However, recent literature shows that, at high doses, usually 200 mg or greater, loperamide is sufficient in relieving opioid withdrawal effects and producing euphoric effects.5,7,8 Loperamide is inexpensive, readily available and seemingly innocuous, which makes it the perfect substance of abuse or treatment for withdrawal symptoms. Surprisingly, the sale of loperamide is not regulated like other OTC substances that have the potential for misuse or abuse, such as pseudoephedrine. As the cost of opioids increases and access decreases, many people are turning to other
modalities to get high. The misuse of loperamide has been detailed in online forums since 2008.9 Given the infinite nature of the internet, it is reasonable to think anyone can access information on how to abuse loperamide.9,10
What are the clinical effects associated with loperamide toxicity? One obvious clinical effect of loperamide, even when taken at therapeutic doses, is constipation; however this can give rise to more serious effects such as paralytic ileus, toxic megacolon and bowel obstruction when used at very high doses.4 In addition to gastrointestinal effects, lifethreatening cardiac dysrhythmias, such as ventricular fibrillation, may result from loperamide toxicity. Loperamide has many structural similarities to methadone in that it has multiple phenyl rings. Due to this similarity, loperamide, like methadone, can cause prolongation of the QT interval leading to the production of ventricular dysrhythmias.11 The mechanism behind loperamide-induced conduction abnormalities is poorly understood, but it is postulated it is due to the blockade of the human ether-go-go (hERG) potassium channel.7, 11 Inappropriate
function of these channels affects ventricular repolarization and leads to a prolonged relative refractory period of the cardiac myocytes, resulting in a prolonged QT interval.11 Similar to opioids, loperamide toxicity can also cause central nervous system depression and respiratory depression, but these effects only occur when very high doses of loperamide are used because it does not readily cross the blood brain barrier.1,4
What are the treatment modalities for loperamide toxicity? The management of loperamide toxicity is largely supportive care. Since loperamide acts on the opioid receptor, naloxone can be used to reverse respiratory depression and continuous infusions may be needed to maintain adequate respirations due to its long duration of action. ACLS protocol should be followed with loperamide-associated ventricular dysrhythmias. Amiodarone or transvenous pacing are options for patients with recurrent dysrhythmias.12 After assessment of the patient’s airway, breathing and circulation, if the ingestion occurred recently, a dose of activated charcoal may be
administered if there is no aspiration risk. Electrolyte abnormalities in potassium, calcium and magnesium, should be corrected to further prevent QT prolongation. Although the efficacy of IV sodium bicarbonate is unknown for loperamide induced QRS widening,12 it is reasonable to bolus 1-2 mEq/kg if QRS widening is found on ECG. However, it should be noted that administration of sodium bicarbonate potentially causes hypokalemia and may worsen QT prolongation. In patients with persistent cardiovascular collapse not responding to standard treatment measures, extracorporeal membrane oxygenation, if accessible, or IV lipid emulsion may be considered. In addition, case reports have shown success with isoproterenol infusions used as an adjunct in treating loperamide-induced Torsades de Pointes where standard antiarrhythmic agents were ineffective.4,13 When managing a suspected loperamide toxicity, healthcare professionals at the Florida Poison Information Center Network are available at 1-800-222-1222 to answer questions concerning, or assist in the management of, this or any other toxic exposures. ■
REFERENCES: 1. Wu PE, Juurlink DN. Clinical Review: Loperamide Toxicity. Ann Emerg Med. 2017 Aug;70(2):245-252. 2. Jaffe JH, Kanzler M, Green J. Abuse potential of loperamide. Clin Pharmacol Ther. 1980;28:812-819. 3. Korey A, Zilm DH, Sellers EM. Dependence liability of two antidiarrheals, nufenoxole and loperamide. Clin Pharmacol Ther. 1980;27:659-664. 4. Loperamide. In: IBM Micromedex POISINDEX (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: www. micromedexsolutions.com/ (cited: November 23, 2021). 5. EMDOCS. emDOCs.net – Emergency Medicine EducationTOXCard: Loperamide Toxicity - emDOCs.net - Emergency Medicine Education. Accessed November 16, 2021.
6. Gummin DD, Mowry JB, Beuhler MC, Spyker DA, Brooks DE, Dibert KW, Rivers LJ, Pham NPT, Ryan ML. 2019 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 37th Annual Report. Clin Toxicol (Phila). 2020 Dec;58(12):1360-1541. 7. O’Connell CW, Schricker AA, Schneir AB, Metushi IG, Birgersdotter-Green U, Minns AB. High-dose loperamide abuse-associated ventricular arrhythmias. HeartRhythm Case Rep. 2016;2(3):232-236. 8. Daniulaityte R., Carlson R., Falck R., Cameron D., Perera S., Chen L., Sheth A. “I just wanted to tell you that loperamide WILL WORK”: a webbased study of extra-medical use of loperamide. Drug Alcohol Depend. 2013;130(1):241–244. 9. Lasoff DR, Schneir A. Ventricular Dysrhythmias from Loperamide Misuse. J Emerg Med. 2016 EMpulse Winter 2022
Mar;50(3):508-9. 10. One more word. One more word about getting high with loperamide (Immodium) | Bluelight.org. Accessed November 16, 2021. 11. Salama A, Levin Y, Jha P, Alweis R. Ventricular fibrillation due to overdose of loperamide, the “poor man’s methadone”. J Community Hosp Intern Med Perspect. 2017;7(4):222-226. Published 2017 Sep 19. 12. Eggleston W, Palmer R, Dubé P, Thornton S, Stolbach A, Calello DP & Marraffa JM. Loperamide toxicity: recommendations for patient monitoring and management. Clin Toxicol. 2020;58(5): 355-359. 13. Katz KD, Cannon RD, Cook MD, Amaducci A, Day R, Enyart J, Burket G, Porter L, Roach T, Janssen J, Williams KE. Loperamide-Induced Torsades de Pointes: A Case Series. J Emerg Med. 2017 Sep;53(3):339-344. 39
FEATURE
Notes From the Field: Reducing Harm Among Injection Drug Users During and After the Emergency Department Visit By Heather Henderson, MA, CAS Dept. of Emergency Medicine, Division of Internal Medicine, Tampa General Hospital & Department of Anthropology, USF
By Asa Oxner, MD Vice Chair, Dept. of Internal Medicine at USF Morsani College of Medicine
By Bernice McCoy, PhD, MPH Associate Director of Social Medicine Programs at Tampa General Hospital
By Jason Wilson, MD, FACEP, FAAEM Dept. of Emergency Medicine, Division of Internal Medicine, Tampa General Hospital
Harm reduction is a public health approach that aims to reduce the harms associated with a health risk behavior, short of eliminating the behavior itself.1 The COVID-19 pandemic has increased the urgency of maintaining and expanding healthcare and harm reduction services for persons who inject drugs (PWID). Rates of morbidity and mortality associated with drug use in Florida were already alarming pre-COVID. Now, we are experiencing one of the highest rates of overdose increase (50%), which is roughly twice the national increase (28.5%).2 A variety of factors have played a role in this increase, including high rates of synthetic opioids and anxiety brought on by the pandemic (see sidebar), which has caused many to cope by either beginning or increasing illicit drug use. The pandemic has also triggered a collapse of social support structures and critical access to essential healthcare services that normally help prevent or treat overdoses, blood-borne infections, skin infections, and chronic conditions. These factors have culminated in a substantial increase in emergency department (ED) visits for PWID. Further, PWID—much like the general population—avoided hospitals and restricted their social networks during the pandemic, further cutting themselves off from available resources and support. This places them at a higher vulnerability for poor health outcomes and high morbidity from advancement of disease. While there has been significant recent efforts to address expanded
40
EMpulse Winter 2022
ED-based treatment access for PWID by focusing on expanding capacity for buprenorphine induction for opioid use disorder treatment, we must also consider specific strategies needed in the management of health risks related to injection drug use for patients who decline substance use treatment.3 We require strategies that address common risks such as wound care and medication adherence, but also risks associated with structural vulnerability, safe injection practices and harm reduction education to reduce injection-related complications and prevent the spread of infectious disease. Examples of strategic implementation include integrating infectious disease screening into routine ED care, availability of medication for opioid use disorder, broad access to the overdose prevention drug naloxone, and community-based harm reduction strategies for PWID who decline substance use treatment during the ED encounter. A timeline of our implementation efforts around these strategies at Tampa General Hospital (TGH) are below: 2016 — Our team initiated an EDbased Hepatitis C virus (HCV) screening program at TGH. We have tested over 75,000 patients, identifying over 3,000 people with Hepatitis C antibody and, of those, over 1,000 individuals with active HCV infection. The proportion of patients born after 1980 with new Hepatitis C virus now represents 90% of all HCV diagnoses, almost exclusively from intravenous drug use (IVDU). Patients with active HCV and IVDU can transmit HCV, and ultimately develop liver failure and liver cancer.
2018 — The literature for ED-based treatment utilizing medications for opioid use disorder (MOUD) was overwhelmingly favorable, suggesting potential mortality reductions and retainment in care that was much higher than programs that did not utilize medication stabilization therapy in the ED.4 Understanding that the HCV epidemic is linked to the rise in opioid use, we initiated an ED MOUD program. To offer MOUD in the ED, we established a close relationship with community substance use treatment facilities and employed two full-time peers who ensure linkage to services after medical stabilization. To date, over 800 patients have been stabilized and our linkage rate is 74%, which is well above the national average and similar to the prospective study that led to implementation of our program. 2020 — We established a program for take-home naloxone that is free to all patients with opioid use disorder as part of a more robust harm reduction strategy. To date, we have distributed over 1200 boxes of no-cost naloxone, with 863 reported overdose reversals. 2021 — We greatly expanded our harm reduction efforts by becoming the second approved syringe services program (SSP) in the state of Florida. We operate a daily exchange program that also offers naloxone, HIV/HCV testing, wound management, and hospital avoidance. Since February 2021, we have enrolled over 550 participants; completed over 1,300 daily visits, resulting in over 100,000 syringes exchanged; resolved 18 serious wounds on-site, negating the necessity of an ED visit; and performed nearly 200 HIV/HCV tests, linking 68% of all positives to care. Our strategy over these last 5 years has been finding innovative ways to curb the opioid epidemic with novel ED treatment strategies, increased community engagement, and moving towards a continuum of care that encompasses flexible approaches to PWID care. The next steps in our implementation plan include rapid pre-exposure prophylaxis (PrEP) for HIV negative PWID, offering telehealth-based MOUD, low-barrier MOUD induction and HIV treatment at our mobile syringe exchange site,
and a formalized training practicum for residents in internal medicine, emergency medicine, and psychiatry to increase access to formal addiction medicine training. Please scan our QR code for a more comprehensive example of the resources we have built for patients, including structural support, harm reduction education, and additional linkage to communitybased care. ■
Download our Behavioral Health Booklet
REFERENCES 1. Harm Reduction International.
2021. hri.global/what-is-harmreduction Accessed 12/17/21
2. CDC/National Center for Health
Statistics. Drug Overdose Deaths in the U.S. Top 100,000 Annually. November 17, 2021. cdc.gov/ nchs/pressroom/nchs_press_ releases/2021/20211117.htm
3. Macias-Konstantopoulos W,
Heins A, Sachs CJ, Whiteman PJ, Wingkun NG, Riviello RJ. Between Emergency Department Visits: The Role of Harm Reduction Programs in Mitigating the Harms Associated With Injection Drug Use. Ann Emerg Med. 2021 May;77(5):479-492.
4. D’Onofrio G, O’Connor PG,
Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644. doi:10.1001/jama.2015.3474
5. CDC. "Provisional Drug Overdose
Death Counts." Vital Statistics Rapid Release. cdc.gov/nchs/ nvss/vsrr/drug-overdose-data. htm
6. "Drugs Identified in Deceased
Persons by Florida Medical Examiners: 2020 Annual Report." Florida Department of Law Enforcement. Nov. 2021.
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Synthetic Opioid Trends Among our Patient Population since February 2021: Three main trends appear in substance-use patterns for IDEA participants. First, and most dramatically, is the rise of fentanyl and its impact on overdose rates. Rates of self-reported fentanyl use among participants are high and steadily increased every quarter in 2021: 11.9% in Q1; 23.1% in Q2; and 37.2% in Q3. Fentanyl overdoses have also risen precipitously, overtaking self-reported heroin overdoses. In Q1, 72.1% of enrolled participants reported having an overdose from heroin use and 18.6% from fentanyl. In the most recent quarter, 54.5% of participants reported having overdosed from heroin use, but 68.2% reported having overdosed from fentanyl use. Second, participants report high rates of methamphetamine use for both non-injection and injection. 7.1% of participants report having overdosed on methamphetamines. Third, most participants at IDEA report prescription opioid use as a prelude to injection drug use: 69% of participants report entering substance use through prescription opioids, and of these, 71.3% started taking opioids to manage pain and/ or following a medical procedure.
Overall State & National Trends: 100,306 Americans died from a fatal overdose between April 2020 and April 2021, which equals 275 deaths per day.5 14,708 people in Florida died from a drug overdose in 2020.6 Of those deaths, 6,089 were directly caused by an opioid, a 42% increase from 2019.6 5,302 of those deaths were directly caused by fentanyl, and 95% had at least one other drug present in their system.6 41
CASE REPORT
A Case of the Blues By Jonathan Liu, MD, PGY-3 University of Florida
HPI: A 17-year-old female with PMH of juvenile dermatomyositis, duplicated IVC and oral contraceptive use, presented with a one-day history of left leg swelling, discoloration and pain. Earlier this month, she received intravenous immunoglobulin for her juvenile dermatomyositis. She denied any shortness of breath or history of thromboembolism.
Physical exam: T: 98.6, BP 137/87, Pulse: 129, Resp 18, 98% on RA No respiratory distress. Left thigh was visibly swollen and discolored. Patient had monophasic L Dorsalis Pedis signals with Doppler. Patient had 5/5 strength with flexion and extension of the left hip and knee, and 5/5 strength with plantar and dorsiflexion of the ankle.
Labs: D dimer 3.5 (Normal <0.5). Lupus anticoagulant, Anticardiolipin IgG, Beta 2 glycoprotein IgG, Protein C, Protein S, Antithrombin III activity, Factor V Leiden, Prothrombin Gene Mutation were all within normal limits. Pregnancy test was negative.
Imaging: Venous Duplex Bilateral Ultrasound revealed a very large clot burden in the left lower extremity with a possible completely thrombosed common iliac vein. There was incomplete compressibility from the left common femoral vein to the left popliteal vein. Right lower extremity was unremarkable.
Management: The patient was started on Eliquis 42
after rheumatology and hematology consults. The patient was offered hospital admission, but she and her mother elected to undergo a trial of outpatient management. She was advised to stop oral contraceptive use. She returned one day later with increased swelling and pain. She was admitted to the hospital and underwent mechanical thrombectomy three days later, which showed extensive DVT throughout her left IVC, left renal vein, left iliac vein and left common femoral vein. She tolerated the procedure well and was discharged on Eliquis. Her follow up ultrasound three months later showed resolution of her DVT.
Discussion: Phlegmasia cerulea dolens is a rare disorder in the spectrum of venous thromboembolism. Large clot burden in the venous system causes significant venous congestion and increased venous pressure leading to edema from increased extravasation of fluid into the subcutaneous tissue. Thrombotic events are a known complication of immunoglobulin treatment. Proposed mechanisms include increased blood viscosity, activation of procoagulant factors, and vasospasm. Risk factors for thrombosis include a large first-time dose, OCP use, advanced age, hypercoagulable states, coronary artery disease, and ITP. The presence of four or more risk factors appears to be significantly associated with thrombotic events. Juvenile dermatomyositis is a proinflammatory condition that increases risk of thrombotic events by creating a hypercoagulable state. The patient had additional multiple risk factors for a thrombotic event that included duplicated IVC, recent IVIG infusion, EMpulse Winter 2022
Fig. 1: Left Leg discoloration and swelling.
Fig. 2: Venous Duplex Ultrasound showing large clot burden in the left common femoral vein.
recent hospitalization, and OCP use. Proposed strategies to reduce the incidence of IVIG associated thrombotic events include reducing first administration dosing and slowing down infusion rates. ■
REFERENCES: 1. Daniel GW, Menis M, Sridhar G, Scott D, Wallace AE, Ovanesov MV, Golding B, Anderson SA, Epstein J, Martin D, Ball R, Izurieta HS. Immune globulins and thrombotic adverse events as recorded in a large administrative database in 2008 through 2010. Transfusion. 2012 Oct;52(10):2113-21. doi: 10.1111/j.1537-2995.2012.03589.x. Epub 2012 Mar 12. PMID: 22448967. 2. Lee YH, Song GG. Idiopathic inflammatory myopathy and the risk of venous thromboembolism: a meta-analysis. Rheumatol Int. 2017 Jul;37(7):1165-1173. doi: 10.1007/ s00296-017-3735-0. Epub 2017 May 10. PMID: 28493173. 3. Lidar M, Masarwa S, Rotman P, Carmi O, Rabinowicz N, Levy Y. Intravenous immunoglobulins for rheumatic disorders and thromboembolic events-a case series and review of the literature. Immunol Res. 2018 Dec;66(6):668-674. doi: 10.1007/ s12026-018-9047-y. PMID: 30565202.
FEATURE
The Dark Side of the ED Doreen C. Parkhurst, MD, FACEP Retired; former Board Member and Education Committee Co-Chair
I met her in the checkout line at the supermarket. “You fixed my son’s hand,” she said. “How is he doing?” “Good. You did a good job.” “Remind me of his injury.” Once I heard the history, I remembered him. I don’t always remember a face, but I nearly always remember a patient’s injury. So many patients over the years! I’m sure we all remember some better than others – usually the ones that left an indelible mark on our souls. Those that we couldn’t help, those that we wish we could do over, those that made our day – or ruined it. So many. There’s one patient I would have liked a do over on. I wish I knew then what I know now. The chief complaint on the chart was “baby crying.” When I walked into the room, the patient was sleeping soundly and peacefully. He looked healthy, well and cared for. I talked to the mother for quite some time. She was very young and this was her first child. I found nothing pathologic about the child, so I educated the mother about swaddling and the normalcy of crying and discharged him. Experienced emergency physicians reading this already know the outcome. When I returned two days later, the baby was in the critical care section of the ED, waiting to be transferred to a pediatric ICU for injuries sustained from battering. He had sustained bilateral subdural hematomas, severe brain injury and multiple fractures. I
heard it was the boyfriend, and those cynical among us might say, “It’s always the boyfriend.” I learned from this that the only two clues I had were young mother and baby crying. In the absence of a reason for crying, one had to dig deeper into living arrangements, effect of the crying on close contacts and the need to develop an index of suspicion for potential abuse. I carry that baby in my soul. There were many other victims of abuse over the years, of course. Another baby had been seen by the pediatrician a week earlier. He had a cold. He suffered a seizure. The diagnosis was febrile seizure. EMS called to say they were transporting him with another febrile seizure. When I saw the child, I noticed two things immediately: he had no fever, and the nystagmus was constant. The parents arrived from work when he was in CT. The child had been in the care of a nanny. I do not know who inflicted the bilateral subdural hematomas and severe brain injury to this child, but it strengthened my opinion in the need for nanny-cams. I am old enough to remember when ED’s didn’t have urgent care departments. I also remember when they started them, and some of my shifts were there. You get a kind of mindset when you’re working in urgent care: nothing should take very long. I picked up one chart for suture removal. The seven-year-old boy had a well healed wound on his leg without any signs of infection. On my way out of the room, I thought to ask, “How did that happen, by the way?” His mother EMpulse Winter 2022
told me a story about him jumping from a table to the floor, getting the leg caught on the way down. I accepted the explanation. As I turned to leave, the boy said, “That’s not how it happened; Mommy cut me.” I can still remember the glare the mother gave him. The older sisterperhaps, nine years old, started crying and told her brother, “You’re going to get Mommy arrested.” That was certainly not a fast-track suture removal. The Child Protective Services team was there for hours. I doubt I will ever forget the two-yearold with the fractured femur. The mother said he fell down the stairs. The drunken father was creating disruption in the waiting room with three other children. When I asked the child, “What happened to your leg?” he responded, “Daddy broke it.” The protective team removed all four children from their parents that night. The father was arrested. In Florida, we have been mandated to obtain CME in child and elder abuse as well as domestic partner violence. We learn that these situations cross class lines and occur in every income and economic group. Despite this knowledge, I still felt shocked talking with the female physician patient and examining her multiple injuries inflicted by her esteemed physician husband. She explained it was in their culture for wives to be treated this way. Sometimes, I can only shake my head. ■
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FEATURE
In Memorium: Jay Edelberg, MD, FACEP Resolution Adopted by the American College of Emergency Physicians at Council 2021 WHEREAS, the specialty of emergency medicine lost one of its pioneering members on October 13, 2021, when Dr. Jay Edelberg succumbed to cancer after a long fight in Jacksonville, FL, at the age of 74; and WHEREAS, Dr. Edelberg received his medical degree from the University of Connecticut in 1976 and was part of the second class to graduate from the University of Florida – Jacksonville’s emergency medicine residency program in 1978; and WHEREAS, Dr. Edelberg began his career as Director of the Emergency Room at Baptist Medical Center just two weeks after graduating from residency, when emergency medicine was not even considered a specialty; and WHEREAS, Dr. Edelberg recognized the value of organized medicine immediately, joining FCEP’s Board as a resident and traveling around the state, bringing emergency physicians together through the Florida Chapter of ACEP, particularly in rural areas, and installing them on FCEP committees; and WHEREAS, Dr. Edelberg became the first emergency medicine residency-trained president of FCEP in 1982-1983 and continued his service to the College and its foundation as Chair of the Government Affairs Committee, Co-Chair of the spring Clinical Conference Planning Committee, member of the Reimbursement Committee, a Councillor, and various other positions throughout the years; and WHEREAS, Dr. Edelberg and his wife, ACEP honorary member Caral Edelberg, CPC, CCS-P, helped organize emergency physicians to be advocates for fair reimbursement practices in the early days of our specialty, a battle that still continues on to this day; and WHEREAS, Dr. Edelberg committed his life to founding and nurturing the specialty of emergency medicine, the Florida Chapter of ACEP, and the strong, vast community of emergency physicians and personnel; therefore be it RESOLVED that the American College of Emergency Physicians remember with honor and gratitude this trailblazing pioneer, Dr. Jay Edelberg, and his selfless contributions to emergency medicine; and be it further RESOLVED that the American College of Emergency Physicians extends the same gratitude and condolences to his wife, Caral, his family members, colleagues, and friends who are deeply saddened by this loss. Dr. Jay Edelberg and his wife, Caral Edelberg, attended the Emergency Medicine Reimbursement & Innovation Summit at the EMLRC in February 2020, where Caral was a speaker. We are so glad he made this trip! 44
EMpulse Winter 2022
FCEP lost one of its pioneering presidents when Dr. Jay Edelberg passed away on October 13, 2021. Born in Middleton, CT, Dr. Edelberg was one of the first practicing emergency medicine specialists in Florida. He played an integral part in FCEP's formative years, recruiting physicians from all over the state to join our association, and remained involved for many years after his presidency ended in 1983. We were lucky to have interviewed Dr. Edelberg for the 50 Years, 50 Voices project in July 2021, capturing him and his wife, Caral Edelberg, on camera together as they spoke about what FCEP has meant to them over the last 50 years. Read the full transcript from his interview at fcep.org/50years or by scanning here now.
50 YEARS, 50 VOICES a digital project honoring FCEP & emergency medicine
FCEP’s 50th Anniversary Tribute to Emergency Medicine Featuring: Rajiv Bahl, MD, MBA, MS; Ashley BoothNorse, MD, FACEP; Daniel Brennan, MD, FACEP; Elizabeth Calhoun, MD; Damian Caraballo, MD, FACEP; Jordan Celeste, MD, FACEP; Bill Davison, MD, FACEP; Arthur Diskin, MD, FACEP; Jay Edelberg, MD, FACEP; Caral Edelberg, CPC, CCS-P; Jay Falk, MD, FACEP; Kelly GrayEurom, MD, MMM, FACEP; Erich Heine, DO; Phyllis Hendry, MD, FACEP; Saundra Jackson, MD, FACEP; Steven Kailes, MD, FACEP; Wayne Lee, MD, FACEP; Michael Lozano, MD, FACEP; Kristin McCabe-Kline, MD, FACEP; Ernest Page, MD, FACEP; David Orban, MD, FACEP; Russ Radtke, MD, FACEP; John Stimler, DO, FACEP; Josef Thundiyil, MD, MPH, FACEP; Chrissy Van Dillen, MD, FACEP, FAEMS; David Vukich, MD, FACEP; Frederic Wurtzel, MD, FACEP
50 Years of Emergency Medicine in Florida Timeline
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fcep.org/50years EMpulse Winter 2022
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MUSINGS FROM A RETIRED EMERGENCY PHYSICIAN
Should We Vaccinate Our Patients in the ED? By Wayne Barry, MD, FACEP Former FCEP Board Member
A new villain has arrived in the world sponsored by the COVID-19 pandemic. The Omicron variant appeared in South Africa and contains up to 30 different variations, which may give it the ability to spread more efficiently and threaten the effectiveness of protection from our current vaccines. Vaccine scientists and others are working furiously to figure out more about it, and may have to start reconfiguring vaccines to combat it. Meanwhile, COVID surges are occurring in this country in which 60 million vaccine-eligible Americans remain unvaccinated. Worse than this, most of the world continues to experience low vaccine penetration, which prolongs the pandemic and the development of more resistant forms of COVID-19. Please continue to urge friends, family and patients to become vaccinated, and even boosted, as vaccine protection has been found to wane after about 6 months. While practicing emergency medicine for 32 years, I heard talk from smart doctors and nurses suggesting that the ER was a good place to conduct vaccine clinics and start medical treatment for drug addiction based on the premise that many patients visit the ER on a regular basis because they are disenfranchised from the medical establishment. They are victims of social ills like unemployment, chaos, and transient lifestyles, which prevent them from accessing the conventional outpatient and primary care medical system in this country. I remember thinking at the time that emergency medicine was hard enough to practice for its own sake, and trying to provide primary care and preventive medicine services correctly in the ED would be a daunting Herculean task. A great deal of organization and resources would be necessary to pull this off. Extra consumable supplies, 46
personnel possibly dedicated to this task, geographic space in generally crowded ER’s, and extra medical records keeping power are just a few of the components necessary to conduct these "extra curricular activities” efficiently in the ED. Yet after reading several articles on these subjects, I found some thoughts expressed by Drs. Anita Sudbury and Gigi Kwik Gronvall in the publication Think Public Health. They point out that 25% of Americans lack primary care physician coverage and 33% of Americans live in pharmacy deserts. There are between 139 and 150 million ER visits annually, with 90% of the patients discharged after their ER visit, and 89 million more patients visiting urgent care centers. They point out that vaccines offered and administered in the ER provide a rapid way to get vaccinated, and that administering vaccines in the ER is not a new concept. Flu vaccines, rabies shots, and tetanus shots have been given in most ER’s for quite a while. The authors believe that offering vaccinations such as COVID would accelerate the pace and expand vaccine access to many medically underserved populations. This process would be welcoming to undocumented people in this country. The authors point out that ED’s will have to carefully develop plans and systems to track vaccine administration. Accepting unused doses from vaccine clinics will enable ER’s to try and minimize wastage of thawed, but unused vaccine doses. Furthermore, the CDC is urging ED’s and urgent care centers to offer vaccinations before discharge from their respective facilities. My wife and I have recently returned from a week of adventure and EMpulse Winter 2022
relaxation aboard the 3rd largest cruise ship in the world sailing to the Bahamas and Mexico. The cruise industry is bouncing back from a devastating shut down thanks to the pandemic. Thousands of ships’ officers and crews were stuck on ships, more or less in self-quarantine, feverishly developing safe operating practices strictly in line with CDC guidelines and recommendations while floating aimlessly around Caribbean islands and other world venues, unable to dock safely. As a result, we felt quite safe even though we cruised with two unvaccinated children. All adult cruisers are required to be vaccinated and show proof of vaccination. All passengers, including unvaccinated children, must show a negative COVID PCR test result two days prior to sailing. In the case of Royal Caribbean, they will accept the results of a Binex quick turn around antigen test performed in front of telehealth witnesses. Crews are tested twice weekly. Unvaccinated children are repeatedly tested by ship personnel. Every crew member wore a mask at all times, and their name badges included their headshots. Guests were required to wear masks in all indoor public areas. Some venues had separate areas set aside for unvaccinated guests, such as the dining room and theater. You could see abundantly smiling faces and genuine gratitude displayed by each crew member. A great time was had by all. In closing, I find it strangely ironic if not distressing that our state is so against vaccine and mask mandates when the result of such measures is to make everyone safer. Just look at the cruise industry: thousands of passengers on our ship joined us in having great and safe fun while being vaccinated and wearing masks. ■
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