EMpulse Fall/ Winter 2023

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

Leaving a Living Legacy » DR. CLIFF FINDEISS FCEP President, 1975-76

WHAT’S INSIDE:

»Leaving A Living Legacy: Remembering A Founding Member and EM Pioneer » 2023 Conferences and Events: Year in Review » Tianeptine: Gas Station Heroin » Case Report: Massive Subcutaneous Emphysema a Barrier to FAST Exam » Return of Spontaneous Circulation: Optimizing Cardiac Arrest with Point of Care Ultrasound

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Vol. 29, No. 1 • Fall/Winter 2023 EMpulse Fall/Winter 2023

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Lifestyle › Flexible Scheduling

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EMpulse Fall 2023

8 Immediate Past President’s Message

By Dr. Damian Caraballo 10 Government Affairs

By Dr. Blake Buchanan, Dr. Ricki A. Brown, Dr. Russell Radtke 12 EMRAF President’s Message

By Dr. Nicole Vuong

6 2023-2024 FCEP Board of Directors 9 A Message to Our Donors From FCEP & FEMF Presidents 16 The Rise of Xylazine

By Dr. Yuchen Duan

18 PAMI Patient Education and Activity Book for Patients Experiencing Pain

By Phyllis Hendry 20 2023 Conferences and Events: A Year in Review

By FCEP Staff 24 Annual Meeting Recap: Symposium by the Sea 2023

By FCEP Staff 32 Cover Story – Leaving A Living Legacy: Remembering A Founding Member and EM Pioneer

By Melissa Keahey 34 Return of Spontaneous Circulation: Optimizing Cardiac Arrest with Point of Care Ultrasound

By Dr. Alyssa King and Dr. Leila L. PoSaw

14 Pediatric EM Committee Report: The Crashing Child

By Dr. Vanessa Perez and Dr. Cristina Zeretzke-Bien

37 Level Up: Technology in Medical Education

By Dr. Carmen J. Martínez and Dr. Caroline M. Molins 38 Tianeptine: Gas Station Heroin

By Drs. Hayley T. Gartner; Reeves E. Simmons; Dawn R. Sollee 40 Flecainide Induced Atrial Flutter Causing Monomorphic Wide Complex Tachycardia

By Dr. Graham Clifford 42 Massive Subcutaneous Emphysema a Barrier to FAST Exam

By Shaheen Emami and Dr. Joshua Goldstein 44 An Accidental Holiday: The Beginning of a Passion to Care for those in Honduras

By Dr. Jeremy Selley 48 FROM CARE TO CRISIS: The Emergent Need to Address Violence Against Healthcare Workers

By Dr. Michelle F. Wallen

17 Advent Health 19 Logix Health

FALL/WINTER 2023 Volume 30, Issue 1

EMpulse Magazine is the official publication of the Florida College of Emergency Physicians EDITOR-IN- Latha Ganti, DO, FACEP, FAAEM CHIEF Lganti@hotmail.com

MANAGING Melissa Keahey EDITOR: mkeahey@emlrc.org ASSISTANT Tatiana Martin MANAGING EDITOR:

DESIGN Erin Gatz, Greg Hunter EDITORS: Speedway Custom Photo Lab PUBLISHER: Johnson Press of America, Inc.

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

EMpulse Online In addition to the content in this magazine, there is even more online!

Online content includes: • Fall 2023 Residency Program Updates • Medical Student Council Report • Case Reports • Feature Articles Call for Content: EMpulse is now publishing articles and updates online on a rolling basis. A print issues will be published once a year with content selected by the Editorial Committee.

Intent to Submit Form

50 2023-2024 Annual Calendar EMpulse Online Homepage fcep.org/empulse

ADVERTISER INDEX Inside Cover EMPros

1971

13 Membership and Professional Development Committee Report

By Dr. Rene Mack

FEATURES & COLUMNS 4 From the Editor’s Desk

By Dr. Latha Ganti

DA COLLEG RI

Medical Economics Committee Report

By Dr. Eliot Goldner

FL O

7 FCEP President’s Message

By Dr. Jordan Celeste

FICIEIP

NS

FROM THE COLLEGE

F EMERG E EO

Y PHYSICI A NC

TABLE OF CONTENTS

30 Envision 46 Envision 51 TeamHealth

On the cover: On the cover: Dr. Cliff Findeiss, FCEP President 1975-1976.

Read the cover story on page 32.

EMpulse Fall/Winter 2023

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From the Editor’s Desk

By Latha Ganti, MD, MS, MBA, FACEP

As the newly appointed Editor-in-Chief of EMPulse Magazine, I am deeply honored and humbled to take the helm of this prestigious publication. EMPulse has long stood as a beacon of excellence in emergency medicine in Florida, providing insightful, cutting-edge information to our members.

My appointment to this role is not just a personal milestone but also a testament to the trust and confidence placed in me by the FCEP board. In this role, I am committed to upholding the magazine’s legacy while steering it towards new horizons. I am excited to work with my newly appointed editorial committee: Drs. Rajiv Bahl, Shayne Gue, Carmen Martinez, Caroline Molins, and Diana Mora—all rockstars!

Over the next two years, my primary goal is to enhance the magazine’s impact and reach within the medical community. A significant part of this endeavor will be to achieve PubMed indexing for EMPulse. PubMed, is a free search engine accessing primarily the MEDLINE database of references and abstracts on life sciences and biomedical topics. Getting EMPulse indexed on PubMed will not only increase our visibility but also affirm the quality and credibility of our content. It also will enhance the “credit” that our members receive for their writing contributions.

To achieve this, we will focus on several key areas: 1. Enhancing Scientific Rigor and Quality: PubMed indexing requires adherence to specific scientific and editorial standards. We will ensure that all articles published in EMPulse meet these high standards. This will involve rigorous peer-review processes, ensuring accuracy, relevance, and originality in our content.

We will also encourage submissions that contribute significantly to the field of emergency medicine, including original research, comprehensive reviews, and case studies that offer new insights or perspectives.

2. Expanding our Editorial Board and Peer Reviewer Network: To maintain a high standard of review and editorial oversight, we will expand our editorial board to include more experts from diverse sub-specialties within emergency medicine. This expansion will bring in fresh perspectives and expertise, enhancing the overall quality of our content. Additionally, we will develop a robust network of peer reviewers who are leaders in their respective fields, ensuring that our review process is both thorough and fair.

3. Engaging with the Community: Building a strong community around EMPulse is vital. We will engage with our readers and contributors through various channels, including social media, webinars, and conferences.

Feedback from our community will be invaluable in shaping the magazine’s direction and ensuring that we remain aligned with the needs and interests of FCEP. 4. Promoting Ethical Standards: Upholding the highest ethical standards in publishing is non-negotiable.

We will continue to ensure transparency in our editorial processes, strict adherence to ethical guidelines in research and publication, and a zero-tolerance policy towards plagiarism and other forms of misconduct.

I am excited to embark on this journey with my dedicated editorial committee the support of the FCEP Board.

Together, we will work tirelessly to make EMPulse a leading voice in our field, contributing significantly to the advancement of emergency care in Florida and beyond.

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EMpulse Fall/Winter 2023

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.

Florida College of Emergency Physicians Board of Directors: PRESIDENT Jordan Celeste, MD, FACEP PRESIDENT- Todd Slesinger, MD, FACEP, FCCM, ELECT FCCP VICE Saundra Jackson, MD, FACEP PRESIDENT SECRETARY- Blake Buchanan, MD TREASURER

FEMF/EMLRC

IS ACCREDITED BY THE ACCREDITATION COUNCIL FOR CONTINUING MEDICAL EDUCATION (ACCME) TO PROVIDE CONTINUING MEDICAL EDUCATION (CME) HOURS FOR PHYSICIANS. We have worked with and accredited several events offered by ITLS, TCEP, NAEMSP, FADAA, and MARSI. FEMF/EMLRC also is accredited by the Florida Department of Health, Bureau of EMS; the Commission on Accreditation of Pre-Hospital Continuing Education (CAPCE); and the Florida Board of Nursing.

IMMEDIATE Damian Caraballo, MD, FACEP PASTPRESIDENT EXECUTIVE Melissa Keahey DIRECTOR MEMBERS Rajiv Bahl, MD, MBA, MS; Tom

Bentley, MD, FACEP; Ricki A. Brown, MD; Latha Ganti, MD, FACEP; Kyle Gerakopoulos, MD, MBA; Jesse Glueck, MD; Eliot Goldner, MD, FACEP; Shayne Gue, MD; David Lebowitz, MD, FACEP; Kristin McCabe-Kline, MD, FACEP, ACHE, FAAEM; Diana Mora-Montero, MD, FACEP; Jeremy K. Selley, DO, FACEP; Zach Terwilliger, MD; Josef Thundiyil, MD, MPH, FACEP; Chrissy Van Dillen, MD, FACEP; Stephen Viel, MD, FACEP, MBA; Nicole Vuong, MD; Cristina Zeretzke, MD, FACEP

FEMF/EMLRC conducts a limited number of joint sponsorships to provide continuing medical education credits to outside organizations for their CME activities.

Joint sponsorship will be considered under the following basic conditions: • CME activity is consistent with EMLRC’s CME mission.

• Organization is not an ACCME-defined commercial interest.

• Organization agrees to follow EMLRC’s terms, including its processes and policies, participation of EMLRC staff or physicians in the planning meetings, and payment of a fee based on the complexity of the activity.

• Upon fulfillment of these basic conditions, EMLRC’s Application for Joint Sponsorship will be forwarded for completion. Applications are then forwarded to EMLRC’s Medical Director and/or Education & Academic Affairs Committee for final approval.

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

Vidor Friedman, MD, FACEP*; James V. Hillman, MD, FACEP*; Michael Lozano, Jr., MD, FACEP*; David Seaberg, MD, FACEP* *FCEP Past-President

For more information on EMLRC’s Joint Sponsorship process for CME activities, please contact: Diane Bennett, CMP Director of Education & Events dbennett@emlrc.org, 407-281-7396 ext. 222

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.

EMpulse Fall/Winter 2023

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2023-2024

FCEP BOARD OF DIRECTORS EXECUTIVE LEADERSHIP

Jordan Celeste, MD, FACEP PRESIDENT

Todd Slesinger, MD, FACEP, FCCM, FCCP PRESIDENT-ELECT

Saundra Jackson, MD, FACEP VICE PRESIDENT

Blake Buchanan, MD SECRETARY TREASURER

Damian Caraballo, MD, FACEP IMMEDIATE PASTPRESIDENT

BOARD MEMBERS

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Rajiv Bahl, MD, MBA, MS

Tom Bentley, MD, FACEP

Ricki A. Brown, MD

Latha Ganti, MD, FACEP APPOINTED, NON-VOTING

Kyle Gerakopoulos, MD, MBA

Jesse Glueck, MD

Eliot Goldner, MD, FACEP

Shayne Gue, MD, FACEP

David C. Lebowitz, MD, FACEP

Kristin McCabe-Kline, MD, FACEP, FAAEM, FACHT ACEP REPRESENTATIVE

Diana MoraMontero, MD, FACEP

Jeremy K. Selley, DO, FACOEP

Zach Terwilliger, MD

Josef Thundiyil, MD, MPH, FACEP

Christine Van Dillen, MD, FACEP

Stephen Viel, MD, MBA, FACEP

Nicole Vuong, MD EMRAF PRESIDENT

Cristina Zeretzke, MD, FACEP

EMpulse Fall/Winter 2023

FROM THE COLLEGE

FCEP President’s Message: Opportunities in Times of Change Through Our Organization

By Jordan Celeste, MD, FACEP FCEP President

We all deal with pressure on shift – and I’m not even talking about providing high-quality, evidence-based, lifesaving acute care. I’m talking about throughput initiatives, patient satisfaction efforts, evolving documentation requirements, and so on. The image of the “healthcare hero” is long gone, and we face increased scrutiny, and yes, even violence at times.

And simultaneously, there are threats to our reimbursement – which serves as another slap in the face.

It’s easy to get down in the current environment that we find ourselves in.

Heck, I’m a bit disturbed by how easy it was for me to write that first paragraph!

In order to productively move forward, I truly believe that we must confront these issues head on with a positive attitude. We usually hear such things categorized as pressures, or perhaps as challenges, and often times even as outright threats – both existential as well as very real. I prefer to look at these as opportunities. We find ourselves in trying times, but FCEP can rise to the occasion and identify opportunities to advocate, educate, and advance the specialty of emergency medicine.

In order to accomplish anything in life, I have found that I must make lists. So here are some specific opportunities for FCEP that I have identified for my presidential year. In reality, many (if not all) of these will likely require multiple years of work.

Securing finances Like many organizations, FCEP has faced financial challenges over the past few years. Thankfully, we have exited the pandemic, but we have entered a new era. There is now an even greater emphasis on online education, and a decreased desire for in-person events and training.

As a result, we have unfortunately never quite grown into our

EMLRC building in Orlando. Fortunately, though, by FCEP and FEMF committing themselves to establishing a home for emergency medicine in Florida – and with extremely generous support from donors – we are now able to tap into our equity to right-size our physical footprint, alleviate some of the aforementioned financial strain, and to re-focus on our respective missions.

Stabilizing staff In order to accomplish our mission, it is critical that we have the appropriate staff in place. I am very happy to announce that a large piece of stabilization has already been accomplished, as Melissa Keahey has officially signed on as our Executive Director! She will build our staff to enable the execution of college programs and business as we enter a new era for FCEP. Fostering a functional – and fun! – leadership experience It is truly an understatement to say that FCEP would not be what it is today without the countless hours contributed by our amazing volunteer leaders. Our board members, committee chairs, leadership academy participants, and other actively involved members admirably demonstrate what it means to be servant leaders. By having clear expectations and communications, we want to ensure that everybody is getting as much from their experience as they are giving the college. By fostering a satisfying leader experience, we also hope to encourage ongoing participation and develop a leadership pipeline.

Enhancing voice and visibility Over the summer, I had identified enhancing FCEP’s voice and visibility as a priority for my presidential year, and it was heavily echoed by others on our recent EMpulse Fall/Winter 2023

board orientation meeting. FCEP already does amazing advocacy work, and while we certainly can (and will) do more – we need to make sure that people are aware of our current efforts and impact. We also need to make sure that our voice is directed not only to legislators, but also more widely – to other organizations, hospitals, regulators, and even the general public. With a dedicated focus on external communications, we can extend the reach of FCEP’s expertise and influence.

Meaningful membership We must also turn our communication efforts inward. Usually when we talk about membership, the focus is on increasing our numbers. And while this is important (and certainly augments our advocacy messaging), we also need to ensure that our current members are engaged and aware of all of the amazing work that FCEP does for them. We also need to understand member needs so that we can drive the college in the right direction. Obviously, we will still continue to work to grow our membership, and we believe that a dedicated focus on internal communications will aid in those efforts as well.

FCEP is at its core a member organization.

With a strong foundation of secure finances and optimized staff, FCEP can focus on developing effective leaders, serving as a respected voice in the medical community, and creating an experience that satisfies current members and also attracts new ones. Even in the face of great challenges within the American healthcare system, we have the opportunity to move forward with a positive attitude to promote high quality emergency medical care, to empower emergency physicians, and to protect the patients we serve. ■ 7

FROM THE COLLEGE

Immediate Past President’s Message

By Damian Caraballo, MD, FACEP FCEP Board Member

2023 was another eventful year for FCEP and emergency physicians. In FCEP news, there were two big events which defined the year. Our Interim Executive Director Melissa Keahey was hired as our Executive Director on September 11th. Melissa has done an outstanding job righting the course for FCEP post-COVID, and the Board has the utmost confidence in Melissa leading FCEP through difficult times and back towards prosperity. The second big event was the sale of the EMLRC building in Orlando, which has been the home of FCEP and FEMF since 2015. We are “right-sizing” to a more central location in Orlando, and with the proceeds of the sale, we will eliminate our mortgage obligation and free up funds for the college to advance its goals on education and advocacy.

In EM business news, EM groups continue to be hit hard by the No Surprises Act (NSA). We saw two major groups—Envision and APP—file for bankruptcy in 2023. This speaks to the financial difficulties we are seeing in groups due to federal and state legislation. One thing FCEP will aim to do in 2024 is fix the independent dispute resolution (IDR) in Florida. Currently, health plans have been able to opt out of billing disputes through Florida Maximus, which acts as an arbitrator. FCEP will be working with the state legislators to eliminate this loophole and fix the arbitration process in Florida, which is actually more physicianfriendly than the current federal IDR. We are also facing threatened cuts to Medicare for the second time in two years. Centers for Medicare & Medicaid Services (CMS) is looking to impose 3.36% cuts in 2023, after imposing 2% cuts in 2022. Combine that with medical practice inflation rates of 8.3% in the past 2 years, and physicians are facing a 13.36% cut in real-rate reimbursements in just two years, on the heels of a pandemic.

Our specialty, along with other physicians need to come together and start advocating for ourselves in a clear, united front. Recent 8

delegate meetings at the AMA and FMA suggest group leaders are starting to get the message that further predatory cuts on physician reimbursement by health insurers will no longer be tolerated. The Texas Medical Association successfully sued the federal Health and Human Services (HHS) in federal court and won (four times), despite multiple government appeals.

The Federal Court ruled payers cannot use the qualifying payment amount (QPA) --essentially the insurer in-network rate— as the main determinant for arbitration reimbursement calculations. This is an example of how physician organizations benefit all US physicians in healthcare.

We as physicians can mobilize and unite to fix US healthcare.

In addition to working through organizations such as FCEP and ACEP, physicians need to accept they are woefully underfunding their Political Action Committees (PACS). In our current political system, money is the lifeblood and PAC money ensures access and exposure to the most important politicians. In the last cycle, the AMA (the largest general physician PAC) was outspent by the American Optometric Association (AOA). There are 6.5 times more physicians in the U.S. than optometrists, and the average physician makes approximately twice as much as the average optometrist. Yet the AOA is wise enough to realize their contributions are strategically important for their survival.

Every physician who practices in Florida should to know the value of contributing to both their state PAC as well as national PACs such as NEMPAC. We as physicians can mobilize and unite to fix US healthcare. In the end, we are the ones who provide care and take care EMpulse Fall/Winter 2023

of patients. We cannot turn our heads to the political and economic realities of practicing medicine in the US. For-profit entities are taking advantage of ignorance and indifference. It will take time, money, and cooperation— but it’s time for us to wake up and get in the game before it’s too late. FCEP has many opportunities to get you in contact with people who can help mold and shape policy to improve US and Florida healthcare. Ask FCEP how you can get involved to help fix US healthcare—it is only by working together that we can begin to heal the multiple ailments in healthcare in our nation. ■

Donate to Physicians for Emergency Care PAC (Individuals):

Donate to Emergency Care for Florida PAC (Groups):

A MESSAGE TO OUR DONORS:

The Future of the Emergency Medicine Learning and Resource Center Your generous contributions to the Emergency Medicine Learning and Resource Center (EMLRC) over the years

have helped us provide cutting edge training programs, hands-on education utilizing state-of-the-art simulation and technology, and didactic instruction to emergency medicine professionals. Your gifts have provided lifesaving education to life savers, and we are immensely grateful for your past support.

In this post-pandemic environment, we have recognized a continued demand for more online digital learning and less desire for the type of in-person education and training that our now under-utilized 8,000 square foot building was intended to provide. The management and expenses of such a building have been a recognized challenge for several years and had become a distraction from our vision and hindrance on our mission. After several months of conversation and deep reflection on both historical legacy and organizational values, our leadership reached a unanimous decision to sell the current home of the EMLRC and find a “right-size” location.

We accepted an offer and have closed on our current building on Conway Road, and the amazing growth in value will allow us to obtain a new home better suited to our current and future needs while redeploying additional returns from capital campaign contributions into ongoing and future projects and programs. This is an exciting time for the EMLRC, and although the building will be smaller, our mission will be bigger!

We remain committed to building ownership and assure you that your past gifts will continue to be honored and prominently recognized in our future home. We are currently in the process of finalizing the purchase of our future location and will provide an additional update when the move is complete. In the meantime, please do not hesitate to reach out with any questions.

Jordan Celeste, MD, FACEP FCEP President 9

Ernest Page, II, MD, FACEP FEMF President

EMpulse Fall/Winter 2023

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COMMITTEE REPORT

Government Affairs Committee Report

By Blake Buchanan, MD Committee Co-Chair FCEP Board Member

By Ricki A. Brown, MD Committee Co-Chair FCEP Board Membe

By Russell Radtke, MD Committee Co-Chair

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The 2023 legislative session in Tallahassee was once again a very busy, rapid-fire 60day period. FCEP members championed and successfully passed several patientcentered bills this year. House Bill 1550/ Senate Bill 1550 passed unanimously.

This is a groundbreaking bill that places regulations on Pharmacy Benefit Managers (PBMs) ability to pharmacy steer. It abolishes repetitive stepwise therapy, and requires patient notification for medication formulary changes that previously allowed these companies to change patient’s medications without notice or explanation. We also successfully maintained physician-led care with the passage of bill HB1067/SB1058.

The FCEP team was able to protect EM physicians compensation for treating patients requiring treatment following car accidents by defeating bill HB0429/SB0586, which again attempted to repeal Florida’s Personal Injury Protection(PIP) statutes.

Additionally, House Bill 0583/Senate Bill 0230; which requires transparency among care team participants with clearly labeled badges for hospital employees stating their profession, and required introductions to patients on first encounters. This bill also required transparency in advertising, with only physicians being able to refer to themselves as “doctor” in the clinical setting. Unfortunately, this bill was vetoed by the Governor over a technical issue, but we feel confident it will return again in the upcoming session. Despite the bill not passing, AdventHealth has already started implementing this in their hospital systems.

There is nothing preventing other hospital systems from doing something similar.

and national legislators to provide expert counsel on complex medical legislation.

We had great representation in the nation’s capital this spring at ACEP’s Leadership and Advocacy Conference. We met with the offices of many Congressional representatives around the state and held a personal meeting with Senator Rick Scott in his office.

FCEP leaders often travel to Tallahassee and Washington DC to meet with state

The bill promoting autonomous practice

by Advanced Practice Registered Nurses

Later this summer, the FCEP delegation at the Florida Medical Association General Assembly successfully pushed through proposals written by FCEP Immediate Past President Damian Caraballo. The Florida Medical Association now takes the position supporting our initiatives to fix the loopholes in Florida’ independent dispute resolution process. It will also support legislation that requires Florida insurance ID cards to contain information that clearly states if the insurance plan is state or federally regulated, so that patients and physicians can navigate the appropriate system when taking issue with insurer malfeasance (see more below).

Although FCEP had some great successes this past year, the next session will soon be upon us: the House held its first round of committee meetings in September, and the Senate holds its first set of meetings in October, with the 2024 Legislative Session slated to start January 9th. FCEP already has our sights set on our coming legislative priorities for this coming year. Here are some of the areas we are planning to focus on: Scope of Practice Expansion:

EMpulse Fall/Winter 2023

was defeated last legislative session.

That bill would have removed the requirement for APRNs practicing in primary care, thus allowing them to practice in any specialty. Similar bills allowing for continued scope creep are always on the horizon, and require our diligence to inform our legislators regarding the problems inherent in these scope expansion plans.

Health Insurance ID Cards: This bill was up for discussion last year, and we anticipate seeing additional movement this coming session. The bill requires a QR code on the back of every health insurance ID card, which could be scanned by the patient if they end up in the emergency department because they couldn’t get to the specialist they needed. It takes them to the Division of Consumer Services website where they can file a written complaint. This bill would also require there to be a “FL” or “FED” notated on all insurance cards to help identify the regulation of each plan and who to go to for help if the consumer is at an impasse with their insurer for their contractual obligations.

This would finally help collect the data on complaints to make it easier to see how insurers are behaving badly.

Transparency in Titles: As we mentioned above, although vetoed, we expect this legislation to return this session in some form. We will push to ensure non-physicians are prohibited from making misleading, deceptive, or fraudulent representations regarding the licensee’s profession or

specialty designation. All healthcare practitioners should be required to wear a nametag with the practitioner’s name and profession when seeing patients, unless the practitioner is providing services in his or her own office. In such a case, in lieu of a nametag, the practitioner should be required to prominently display a copy of his or her license in a conspicuous area of the practice. Senate President Passidomo is continuing to work on getting this bill passed this upcoming year, and FCEP maintains this as a major priority moving forward.

Personal Injury Protection: The annual battle over PIP repeal continues, after another attempt was defeated last session. Although the bill did not pass, the bill did contain some of the language we were hoping to see regarding minimum medical coverage for drivers. We will need to continue our push to convince legislators that if someone is going to drive a car, they should have medical coverage at least up to $10,000.

Ban Co-pay Accumulator Programs: Copay Accumulators are a new form of surprise billing that patients are largely unaware of. They are a feature or program within an insurance plan whereby a manufacturer’s payments do not count toward the patient’s deductible and out-of-pocket maximum.

This is related to the PBM issue, since payments previously made on a patient’s behalf by a manufacturer or foundation was being pocketed by PBMs as profit, stating that only the patient could pay

a copayment or deductible. This bill requires any payments made by, or on behalf of a patient, to be counted towards their deductible or other cost-sharing obligations. Several states have already passed similar legislation, and it did not increase the healthcare premium in those states - a common PBM argument.

In some states. It actually lowered the premium because a healthy patient visits the emergency department less.

Statewide Provider and Health Plan Claim Dispute Resolution: The plan we intend to push for will allow PIP payment disputes to also be heard

by Maximus which is needed after the one-way attorney fees were voided last Session. Require health plans to participate in Maximus if a claim is filed, or non-participation results in a default against the plan. Sets time-frame for a judgment to be paid once AHCA adopts a ruling by Maximus as a final order (35 days). It places the Health Insurance ID card bill from the 2023 Session into this legislation. This would require a state regulated plan to be indicated on the back left hand corner “FL” and also the QR code to access the CFO”s Consumer Complaint Website.

our foot in the door with legislators. It’s important for the FCEP team to be there so that we can represent emergency physicians. If we don’t have a seat at the table, we are on the menu. We need everyone to be a contributing member to the Political Action Committee, as it is an investment in the future of Emergency Medicine as a specialty. ■

Donate to Physicians for Emergency Care PAC (Individuals):

Donate to Emergency Care for Florida PAC (Groups):

How do we make this happen?

As the legislative session is slated to begin shortly, it is crucial that we are prepared to make key contributions that help ensure our ongoing access to the legislators we need to educate on these issues. It’s an unfortunate part of our political system, but political contributions are the best way to get

EMpulse Fall/Winter 2023

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COMMITTEE REPORT

EMRAF President Message

By Nicole Vuong, MD FCEP Board Member

Hard to believe another academic year has come and gone again. Welcome to the new year and a particularly warm welcome to all our new classes of residents as you begin your careers in the exciting specialty of Emergency Medicine. I am honored to have the opportunity to serve as your next Emergency Medicine Residents’ Association of Florida (EMRAF) President as we pave the way for future generations of emergency medicine physicians together.

EMRAF now represents 22 residency programs across the state and while programs and the number of residents has expanded, involvement and collaboration has waned.

Due to size of our state and the shear distance between programs, it has been difficult to connect and network in a capacity that isn’t regionally limited. With that said, one of my main goals this year is to bridge

this gap, with the intention of establishing improved relationships and more cohesiveness amongst residents in the state.

Over the past year, we have increased our social media presence via our Instagram account, @emra_florida (follow us!) and we expanded our Executive Board to include two new positions, Vice President of Recruitment and Vice President of Programming. With your help, we hope to continue growing and enhancing exposure. I will be reaching out to the representatives of each individual program as the liaison for better distribution of information and improved communication.

I often find that people want to get involved, but don’t know where to start, or want to effect change, but don’t know the appropriate channels to do so. To that, I encourage you,

my fellow residents, to utilize your membership in this association as your springboard.

Through continued alliance with FCEP and ACEP, we have the ability to positively impact the trajectory of our specialty. It’s no secret that emergency medicine has been suffering since the COVID-19 pandemic, the ramifications of which are still being felt in emergency departments across the country. However, we can correct the course through involvement and advocacy on a united front.

I invite you all to think about what changes you would like to see on a state level and at a national level. There’s no better time than now to get involved and let your voices be heard. Please reach out to me at nicolenvuong@gmail.com with any thoughts, concerns, ideas, or if you would like to get involved. ■

COMMITTEE REPORT

Medical Economics Committee Update

By Eliot Goldner, MD, FACEP FCEP Board Member

Physician Fee Schedule Updates This has been a year of change as emergency physicians adjust to the new medical decision making documentation guidelines that determine an encounter E/M code. To recap a previous win, CMS rejected the AMA RUC recommendation to reduce the RVUs assigned to ED E/M level 4 patient encounters in 2023, siding with ACEP’s argument that ED E/M codes should retain a value that reflects their higher typical intensity than office and outpatient visits. The proposed 2024 CMS physician fee schedule currently contains a 3.4% reduction in the 12

RVU conversion factor, with an additional 2% reduction expected for allowed charges for Emergency Medicine. The final schedule is expected in early November.

CMS has continued to delay the penalty phase of the Appropriate Use Criteria Program, which requires use of a Clinical Decision Support Mechanism when ordering advanced imaging. CMS has also proposed continuing in 2024 the current rules for split and shared services, delaying the previously proposed time-based determination for determining the billing

EMpulse Fall/Winter 2023

provider. These are matters we continue to follow closely and will provide further updates if any changes occur.

The No Surprises Act (NSA) and Independent Dispute Resolution Since implementation of the NSA in 2022, ACEP and the EDPMA have continued to work collaboratively to advocate on behalf of both emergency physicians and patients to keep patients out of the middle of billing disputes while ensuring fair payment mechanisms that hold health plans accountable for adequate reimbursement CONTINUED ON PAGE 13

COMMITTEE REPORT

Membership and Professional Development

By René Mack, MD, FACEP, RDMS FCEP MPD Co-Chair

Welcome back to EMpulse and the Membership and Professional Development (MPD) Committee. While the EMpulse distribution was suspended, we acutely realized it’s role in allowing us to communicate with you and are thankful for its return.

We recently returned from SBS23, held at Hyatt Regency Coconut Point in Bonita Springs. With the leadership of the SBS planning committee and our dedicated FCEP staff, we had another successful event filled with many CME offerings along with numerous opportunities to network with colleagues, new and well known. Planning for SBS24 is already underway and we are looking forward to reconnecting you. Stay tuned for the Call for Submissions and other ways to be involved in SBS24, which will take place July 25-28, 2024 at the Eden Rock Miami Beach. See you there!

Our FCEP Leadership Academy, under the guidance of Dr. Stephen Veil, continues to create opportunities for our members to engage more intimately with FCEP’s efforts in advocacy and strengthening the role of EM physicians in Florida. The 2023 cohort of 9 EM physicians completed their cycle utilizing the tools and information they learned during the Leadership Academy to help shape the future of Emergency Medicine. The 2024 Leadership Academy class has been announced and we are excited for another wonderful year. We welcome Dr. Terwilliger, who joins the

Leadership Academy team as Co-Chair, alongside Dr. Veil.

Did you attend ACEP23 in Philadelphia?

Florida shined during ACEP23 in many areas, including several awards. The ACEP 2023 National Emergency Medicine Junior Faculty Teaching Award, given to an outstanding educator, less than seven (7) years post-residency, who demonstrates superior clinical teaching is one such award.

Of the ten recipients this year, three are from Florida! Winners: Dr. Lauren Page Black; Dr. Daniel Eraso; and our own MPD Committee Co-Chair, Dr. Shayne Gue. Additionally, Dr. Tracy Sanson was ACEP’s 2022-23 Honorable Mention Outstanding Speaker of the Year Award. Congratulations to all!

Ongoing education is integral to the practice of medicine and Florida is home to 22 EM Residency Programs dedicated to the growth and success of our EM physicians in training. Our EMRAF subcommittee has also expanded and restructured to accommodate the growth of our learning programs. With recent elections at SBS23, EMRAF is well positioned to continue as a voice for the EM residents of Florida. The MPD committee continues our outreach to the residency programs, sharing the resources available through FCEP and ACEP, to ensure the resident’s successful completion of the training program and transition to an enriching post training career. Life After Residency, an annual FCEP program

The MPD committee continues to develop and curate resources for our Early Career Physicians, a timeframe of approximately the first 5 years post training, a delicate time of transition after completing residency training. Utilizing resources specific to Florida and ACEP’s international resources, we are able to assist our Early Career Physicians navigate the many decisions which seem to arise during these years (and beyond!). If you are currently in a career transition or have one upcoming, let us know how we can help you transition with greater ease.

We look forward to reconnecting with you at both our FCEP in-person and virtual events and meetings, as we continue shaping the future of EM in Florida, together. As always, take care of yourself and each other. ■

LEADERSHIP ACADEMY 2023-2024 Class

CONTINUED FROM PAGE 12 for out-of-network services. ACEP joined the American College of Radiology and American Society of Anesthesiologists to file an amicus brief in support of the Texas Medical Association (TMA) recent successful suit against the U.S. Department of Health and Human Services, challenging several aspects of governmental rulemaking during implementation of the NSA. Rulings in favor of the TMA will help to combat methods by which insurers artificially reduce the Qualified Payment Amounts for out-of-network care

specifically geared toward PGY-2 and PGY-3 residents, took place in April 2023, providing resources surrounding the transition from resident to attending including: contract negotiation, lifestyle management, and other aspects of career longevity.

and the 2023 increased financial barriers for Independent Dispute Resolution. ■

We are proud to introduce our newest and largest Leadership Academy class: 1. Stuart Bumgarner, MD

DETAILED TIMELINE Scan for detailed timeline of ACEP’s advocacy with regard to the No Surprises Act. EMpulse Fall/Winter 2023

2. Elizabeth Calhoun, MD 3. Lara Goldstein, MD, PhD, FCEM(SA), Cert. Critical Care(SA) 4. Harold Gomez Acevedo, MD 5. Chrissy Zeretzke-Bien, MD, FACEP, FAAP, FAAEM 13

COMMITTEE REPORT

Pediatric EM Committee: The Crashing Child

By Vanessa Perez MD, FACEP Committee Member

The Pediatric Committee provided an immersive workshop on pediatric emergencies at Symposium by the Sea 2023.

This workshop focused on the initial resuscitation of the crashing child, THE MISFIT diagnosis to ensure emergency physicians consider all the differential diagnoses, prearrest epinephrine, and the RUSH exam.

Here are the main takeaway points: 1. Immediate assessment and stabilization: respiratory failure is the most common cause of pediatric arrest, so provide high - flow oxygen and assist ventilation if necessary.

2. Identifying and treating the underlying causes can be challenging with younger children, so remember THE MISFITS and treat the underlying causes while addressing all the possibilities.

Trauma, non-accidental trauma Heart Disease Endocrine Disorders Metabolic Disorders Inborn Errors of Metabolism Seizures Formula miscalculations

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By Cristina Zeretzke, MD, FACEP Committee Member FCEP Board Member

Intestinal disasters Toxins Sepsis 1. When managing a crashing pediatric patient, you can place an intraosseous needle in the proximal tibia, distal tibia, or distal femur.

2. Always check the glucose and treat hypoglycemia with the Rule of 50 for glucose correction: A. 1 ml/kg of D50 = 50 B. 2 ml/kg of D25 = 50 C. 5 ml/kg of D10 = 50 D. This way, you can ensure all amounts add up to 50 when correcting abnormal glucose levels in kids.

3. Fluid resuscitation with isotonic fluids at 10-20 ml/kg with frequent assessments to rule out cardiac disease, congenital heart disease, myocarditis, and pericardial effusion.

4. RUSH protocol in children: consider this ultrasound protocol to assess he modynamic compromise: “the pump,”

EMpulse Fall/Winter 2023

“the tank,” and “the pipes.” The heart and IVC can tell you if you need to be prudent with fluids or if you need to start major fluid resuscitation, which is essential to differentiate in a patient with shock. Then, you can tailor the rest of your assessment based on your suspicion of different pathologies.

5. Epinephrine use has been associated with lower mortality compared to dopamine. Consider pediatric push dose epinephrine as a bridge to other interventions or safe transfer of a crashing child (temporizing measure).

1/10th of the code dose of epi (1:10,000 concentration). You can make it by drawing a patient’s code dose and then diluting it into 10ml of saline. Give 1ml (1mcg/kg) before intubation or every 2-3 minutes for hypotension while waiting for your drip.

6. Remember to do frequent clinical assessments of the patient’s response to interventions and adjust the manage ment plan accordingly. ■

Heart

IVC

Abdomen

Lungs

Dx

Hypovolemic

Hyperdynamic

Collapsed

Positive FAST (trauma, ruptured ectopic)

Normal

Hemorrhage Dehydration

Cardiogenic

Hypodynamic

Plethoric

Normal

Interstitial fluid (B-lines)

Heart failure

Obstructive

Pericardial effusion

Plethoric

Normal

Absent lung sliding (PTX)

Cardiac tamponade, tension PTX, PE

Normal or collapse

Normal

Possible interstitial fluid, pneumonia

Sepsis, neurogenic shock, anaphylaxis

Right ventricle strain Distributive

Hyperdynamic

Early recognition, timely intervention, and close monitoring are central to improving the outcomes of critically ill children. The crashing child can undoubtedly challenge emergency physicians, but we can set ourselves up for success with proper education, preparation, and teamwork.

References 1. Shokoohi H, Boniface KS, Pourmand A, Liu YT, Davison DL, Hawkins KD, Buhumaid RE, Salimian M, Yadav K. Bedside Ultrasound Reduces Diagnostic Uncertainty and Guides Resuscitation in Patients With Undifferentiated Hypotension. Crit Care Med. 2015 Dec;43(12):2562-9. doi: 10.1097/ CCM.0000000000001285. PMID: 26575653.

2. Zieleskiewicz L, Lopez A, Hraiech S, Baumstarck K, Pastene B, Di Bisceglie M, Coiffard B, Duclos G, Boussuges A, Bobbia X, Einav S, Papazian L, Leone M. Bedside POCUS during ward emergencies is associated with improved diagnosis and outcome: an observational, prospective, controlled study. Crit Care. 2021 Jan 22;25(1):34. doi: 10.1186/s13054-021-03466-z. PMID: 33482873; PMCID: PMC7825196.

3. Reiter PD, Roth J, Wathen B, LaVelle J, Ridall LA. Low-Dose Epinephrine Boluses for Acute Hypotension in the PICU. Pediatr Crit Care Med. 2018 Apr;19(4):281-286. doi: 10.1097/ PCC.0000000000001448. PMID: 29319635.Thongprayoon C, Qureshi F, Petnak T, et al. Impact of Acute Kidney Injury on Outcomes of Hospitalizations for Heat Stroke in the United States.

Diseases. 2020;8(3):28. Published 2020 Jul 15. doi:10.3390/diseases8030028 4. Ross CE, Hayes MM, Kleinman ME, Donnino MW, Sullivan AM. Peri-arrest bolus epinephrine practices amongst pediatric resuscitation experts. Resusc Plus. 2022 Jan 14;9:100200. doi: 10.1016/j.resplu.2021.100200. PMID: 35072126; PMCID: PMC8763627.

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COMMITTEE REPORT

EMS/Trauma Committee Report

The Rise of Xylazine

By Yuchen Duan, MD, FACEP

By Danielle DiCesare MD, FACEP Committee Co-Chair

It has been an exciting year in EMS! Led by our talented State Medical Director, Dr. Angus Jameson, educators have been working on advancing National Education Standards and the DOH continues to look for ways to better support educators and to further EMS in the state of Florida. A new sub-committee, Best Practices for EMS Training/Education, was formed at the state meeting in June and has developed a Position Statement addressing Florida Pass Rates on the NREMT exam. In addition to his focus on improving prehospital education in Florida, Dr. Jameson has also led town hall meetings to evaluate Trauma Alert Criteria in Florida in light of the newly released ACS Trauma Triage Guidelines.

The EMS Bytes That You Can View video series, a 4-part series of free continuing education for EMS and EM providers available from October 31,2022 through June 30, 2023 was a huge success. Thank you to all who participated! Finally, there has been a lot of work recently to develop Pit Crew approaches to STEMI, stroke, and trauma. These were approved at the last state meeting and should be coming out for EMS crews to use shortly. We hope to see you all at our future meetings - be sure to contact FCEP staff to be added to our email list and committee roster! ■

Remembering Eugene “Gene” Nagel Eugene “Gene” Nagel, MD (1924 – 2023) A true pioneer in EMS, Dr. Nagel played a critical role in creating Florida’s EMS System and what it is today.

All of North America and much of the world have EMS systems fashioned after the models Dr. Nagel and a few other pioneers developed. FCEP and FEMF are honored to display his helmet and the Eugene Nagel trophy in our lobby.

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Since 1999 it is estimated that over 1 million people in the United States have died from drug overdose, the vast majority of those attributed to opioids (CDC). In response, there has been a renewed focus on combating the drug crisis as a public health issue and continued initiatives put forth at a Federal, State, and Local level to curb drug-related deaths. As we move forward in analyzing the landscape of drug use in the United States, it is important to recognize new emerging threats, namely the rise of xylazine.

Xylazine is a non-opioid-based sedative originally FDA-approved in 1972 for use in Veterinary Medicine for sedation. It functions as a central alpha-2 receptor agonist to decrease neurotransmission of norepinephrine and dopamine. Though these actions produce a very effective sedation, they also produce unintended consequences of profound hypotension and bradycardia. For this reason, xylazine was rejected for use in humans by the FDA. One may have thought that this niche veterinary sedative would have fallen into obscurity, but use is on rise in the United States. It was discovered that when mixed with other drugs, particularly fentanyl, xylazine can greatly improve euphoric effects. In 2001, xylazine was first identified in the illicit drug supply in Puerto Rico and soon spread to the United States as early as 2006. Since then, there has seen a monumental rise in xylazine-related incidents with a 193% increase in xylazine identification in the Southern United States from 2020-2021 and a 2,000% increase in xylazine-related deaths from 2015-2020.

In 2020, xylazine represented 25.8% of all overdose deaths in Philadelphia and 19.3% in Maryland. As xylazine continues its meteoric rise, it is important to educate providers on the intricacies of its clinical presentation and management.

The clinical presentation of xylazine can vary based on the degree of exposure.

EMpulse Fall/Winter 2023

Common clinical signs are lethargy, altered mental status, notable ataxia (often referred to as a “zombie walk” in appearance), and significant skin ulcerations. In high doses, xylazine can present very similar to opioids with apnea, unresponsiveness, and pinpoint pupils, but with added effects of profound, refractory hypotension and bradycardia. To make matters more complicated, since xylazine is commonly mixed with opioids, patients can have a partial response to Narcan which only reinforces the impression of a pure opioid ingestion. As a result, these patients are at risk of receiving large amounts of Narcan without successful reversal leading to both mismanagement of treatment priorities and the side effects of excessive Narcan. These factors greatly contribute to higher mortality and the need for recognition as the influence of this drug expands.

The most important step in managing these patients is having a high clinical index of suspicion. In patients presenting with a classic opioid toxidrome but only partial or no response to Narcan, consider xylazine, especially in the presence of hemodynamic instability.

The respiratory depression, hypotension, and bradycardia and should be managed with active airway assistance, initial fluid resuscitation, and early consideration for vasopressors. As of now, no safe reversal agents have been identified for clinical use. These patients may require intubation and intensive care admission.

It seems that “drug overdose” as a term has been assumedly synonymous with opioids and with ever-increasing dosages of Narcan to combat opioids, we must remember that large doses of Narcan are not always the answer.

Looking ahead, Xylazine should be viewed as an emerging threat that we should prepare for it as we continue to address the drug crisis in the United States. ■

That was close.

23-CFDS-07048

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Find your neighborhood ER at MyClosestER.com.

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EMpulse Fall/Winter 2023

FCEP

FEATURE

COMMITTEE MEETINGS

?

February 27, 2024 8 am – 5 pm Virtual/Zoom

PAMI Patient Education and Activity Book for Patients Experiencing Pain

By Dr. Phyllis Hendry, MD, FAAP, FACEP, Sophia Sheikh, MD, FACEP and the PAMI Team The UF PAMI team is excited to announce the development of a PAMI Patient Education and Activity Book!

The activity book was created as a helpful resource for patients to manage their pain at home and in collaboration with their healthcare team and caregivers. The activity book helps patients better understand why they feel pain, what contributes to making pain better or worse, nonpharmacologic and nonopioid ways to manage pain, and empowers patients to take charge of their health and pain.

This resource is available as a free downloadable resource on the PAMI website.

Access the PAMI Patient Education and Activity Book by clicking here.

This workbook and PAMI resources can be adapted for use in your institution by including the phrase, “Used with permission from the UF College of Medicine – Jacksonville PAMI. Learn more at pami.emergency.med.jax.ufl.edu.”

To contact PAMI, email pami@jax.ufl.edu or call us at 904-244-4986. Stay connected with us on Facebook and LinkedIn for our latest updates. ■

Download the Pain Coach and Toolkit Guide here 18

EMpulse Fall/Winter 2023

Scan to learn more

WANT TO STAY ON TOP OF THE LATEST NEWS AND UPDATES? Visit our website for ongoing updates

And sign up for our bi-weekly enews letter

Identify Your Key Revenue Opportunities

119

Focus on your group’s documentation of Medical Decision Making to identify key revenue opportunities.

For more info on our expert coding and billing services, visit www.logixhealth.com or call us at 781.280.1736.

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EMpulse Fall/Winter 2023

FEATURE

2023 Conferences and Events: Year in Review

There are few things more valuable than a highly-engaged member base. The member investment of time, knowledge, and attention into an association strengthens its credibility with sponsors, community partners, and increases a member’s lifetime value.

If you are interested in maximizing your membership dues investment please consider joining us at our 2024 conferences and events. Our committee and Board of Directors meetings are open to all members and are an excellent way to connect with other FCEP members while learning more about FCEP’s activities, projects, and goals.

Refer to the annual calendar on page 50 for dates and locations. Updates will be shared on www.fcep.org and in FCEP’s bi-weekly Enews.

You may also reach out to FCEP Executive Director Melissa Keahey at any time to learn more about how you can get involved – 407.281.7396 ext 221 or mkeahey@emlrc.org. ■

On March 28-30th, FCEP leaders and members gathered in Tallahassee during Florida’s legislative session for meetings with legislators, continuing education presentations, and social events hosted during our annual legislative event. During the conference 25 attendees met with over 30 legislators to discuss our 2023 legislative priorities while advocating for patients and the practice of emergency medicine.

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EMpulse Fall/Winter 2023

FCEP’s annual Life After Residency took place on April 12 & 13 and provided PGY-2 & PGY-3 emergency medicine residents the opportunity to meet employers, learn valuable life lessons, and spend time together outside of the hospital in a relaxed, but educational environment. The event was wellreceived with over 60 EM residents in attendance.

EMpulse Fall/Winter 2023

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2023 Conferences and Events: Year in Review - cont.

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EMpulse Fall/Winter 2023

ACEP COUNCIL 2023 On October 6th & 7th FCEP members gathered in Philadelphia with EM colleagues from across the nation to be part of ACEP’s council. The ACEP Council consists of members representing ACEP’s 53 chartered chapters (50 states, Puerto Rico, the District of Columbia and Government Services), its sections of membership, the Association of Academic Chairs in Emergency Medicine (AACEM), the Council of Emergency Medicine Residency Directors (CORD), the Emergency Medicine Residents’ Association (EMRA) and the Society for Academic Emergency Medicine (SAEM). The Council ensures “grassroots” involvement in ACEP’s democratic decision-making process.

Thank you to our 2023 FCEP Councillors and Alternates!

Drs. Tom Bentley, Andrew Bern, Ricki Brown-Forestiere, Elizabeth Calhoun, Damian Caraballo, Jordan Celeste, Edward Descallar, Anton Gomez, Gabriel Gomez, Shayne Gue, Saundra Jackson, Steven Kailes, Michael Lozano, Ryan McKenna, Brandy MilsteadHollingsworth, Ashley Norse, Jeremy Selley, Todd Slesinger, Zachary Terwilliger, Stephen Viel, and Kendall Webb.

Alternates: Drs. Vidor Friedman, Kevin Klauer, Carmen Martinez, Caroline Molins, Sam Muniz, and David Seaberg Left: FCEP Councillors and Alternates gathered at SPIN Philadelphia for casual networking and activities.

Below: FCEP Councillors and Alternates pictured with Dr. Kelly Gray-Eurom, 2023 ACEP Council Speaker and FCEP member.

EMpulse Fall/Winter 2023

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August 3-6, 2023 | Hyatt Regency Coconut Point | Bonita Springs, FL

ANNUAL MEETING RECAP On August 3, the Florida College of Emergency Physicians held its annual Board meeting at the Hyatt Regency Coconut Point. In addition to committee reports and standard business agenda items, this meeting features the passing of the gavel and changing of the guard for FCEP leadership. It is also a time of recognition of special guests comprised of state and national leaders form the Florida Medical Association and the American College of Emergency Physicians, along with the presenting of awards.

New FCEP Board Members Elected, 23- 26 term:

William T. Haeck FCEP Member of the Year Award:

• Ricki Brown, MD • Jeremy Selley, MD • Zach Terwilliger, MD • Cristina Zeretzke-Bien, MD, FAAP,

SHAYNE GUE, MD, FACEP

23-24 FCEP Officers:

Champion of Change Award:

• President: Jordan Celeste, MD,

RICKI BROWN, MD

• President-Elect: Todd L. Slesinger,

The FCEP Champion of Change Award, formerly the Martin L. Gottlieb Award for Outstanding Advocacy in Emergency Medicine is given each year in recognition of a leading FCEP advocate and individual that has a significant contribution to the advancement of emergency medicine issues and advocacy in Florida.

FACEP

MD, FACEP, FCCM, FCCP

• Vice President: Saundra Jackson, MD, FACEP

• Secretary/Treasurer: Blake Buchanan, MD

• Immediate Past-President: Damian Caraballo, MD, FACEP

FAAEM, FACEP

Outgoing Board Members:

• Shiva Kalidindi, MD, MPH, MS(Ed.) • Amy Kelley MD, FACEP • Dakota Lane, MD

The Bill Haeck Member of the Year Award is named for our first President and one of FCEP’s founding leaders who worked tirelessly to create FCEP and the specialty of Emergency Medicine. It represents an individual who has performed service of significant importance to the FCEP, its members and our State. It represents a level of service that spans years and whose impact has positively impacted the field of emergency medicine over that time, noted or unsung.

Congratulations to our 2022-2023 Leadership Academy Graduates: • Ricki Brown, MD • Daniel McDermott, DO • Joshua Middleton, MD • Brandy Milstead, MD • Diana Mora, MD, FACEP, FPD-AEMUS • Samuel Muniz, MD • James Ontell, DO • Jeremy Selley, DO, FACOEP • Ian Storch, MD 24

EMpulse Fall/Winter 2023

2023 -2024 FCEP Officers (L to R): Immediate Past-President Damian Caraballo, MD, FACEP; President Jordan Celeste, MD, FACEP; President-Elect Todd L. Slesinger, MD, FACEP, FCCM, FCCP; Vice President Saundra Jackson, MD, FACEP; and Secretary/Treasurer: Blake Buchanan, MD

THANK YOU

Thank You Faculty Jason Adler, MD, FACEP Sara Baker, MD Andrea Brault, MD, MMM, FACEP Daniel Brennan, MD, FACEP

SPONSORS

Blake Buchanan, MD Stuart Bumgarner, MD

Platinum Level Sponsors

David Caro, MD, FACEP Jordan Celeste, MD, FACEP Raymond Chahoud, DO, FACEP Joon Choi, DO L. Anthony Cirillo, MD, FACEP Mohak Davé, MD, FACEP Nicolas Erbrich, MD, FAAP Ed Gaines, JD, CCP Latha Ganti, MD, MS, MBA, FACEP, FAHA Juan Gonzalez, DO Michael Granovsky, MD, CPC, FACEP Erich Heine, DO, FACEP

Gold Level Sponsors

Jennifer Jackson, MD, FACEP Saundra Jackson, MD, RDMS, FACEP Danya Khoujah, MBBS, MEHP, FACEP Sara Kirby, MD, FACEP, FAAP Toni Large Andy Little, DO, FACEP Carmen J. Martinez Martinez, MD, MSMEd, FACEP Thom Mayer, MD, FACEP Kristin McCabe-Kline, MD, FACEP Yiraima Medina-Blasini, MD, FACEP Sarah Melendez, MD

Silver Level Sponsors

Caroline Molins, MD, MSMEd, FACEP Moises Moreno, DO, FACEP Amit Patel, MD, FACEP Joseph Pepe, DO, FAAEM Randy Pilgrim, MD Richard Shih, MD, FACEP Jamie Shoemaker, MD, FACEP Tricia Swan, MD, MEd, FACEP, FAAP Christopher Tana, DO, FACEP, FAAEM Alexandria Tymkowicz, MD Victoria Vazquez, MD Ariel Vera, MD, FACEP Jason Wilson, MD 25

EMpulse EMpulse Fall/Winter Fall/Winter 2023 2023

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Emergency Medicine Research Competition 2023 BEST CLINICAL VIGNETTE Samuel Harris, USF - Esophageal Stent Migration Diagnosed With Point of Care US.

BEST MEDICAL STUDENT POSTER Urmila Venkataramani, USF - Findings from a Quality Improvement Project Aimed at Improving the Care of Patients Presenting to the ED following Sexual Assault.

BEST RESIDENT POSTER Dr. Andrew Rice, USF Characterization of Out-of-Hospital and Emergency Department Cardiac Arrests at Tampa General Hospital

BEST FELLOW/ ATTENDING POSTER Dr. Peter Duan, Orlando Health - The Association Between Race & EMS Patient Offload Times.

ALL ENTRIES: Residents

The Association Between Race and Emergency Medical Service Patient Offload Times Yuchen Duan, MD; Danielle Dicesare, MD; Desmond Fitzpatrick, MD; Ariane Kubena, MD; Christian Zuver, MD. Moderate Complex Pericardial Effusion Diagnosed on Cardiac Point of Care Ultrasound Austin French, DO; Thanh Nguyen, MD; Mark D. Rivera-Morales, MD; Nicole Aviles, MD, FACEP; Moises Moreno, DO, FACEP. A Case of Scorpionfish Envenomation Matthew Holme.

Successful Treatment of Massive Pulmonary Embolism in Pregnancy with Catheter-Directed Embolectomy Carter Jardon, MD; Sarah Cheyney, MD/ MPH; Rachel D. Truong, MD; Mai Vo, MD; Joel Garcia, MD; Neeraj N. Desai, MD; Hatem Hassanein, MD; Jacqueline Kropf, MD; Sandra Perez, MD. Utilization of Point of Care Ultrasound to Evaluate for Enterovesical Fistula Zoe Kinkead, MD; Alexander VanFleet, MD; Jeannez Daniel, B.S.; Charlotte Derr, MD. Age and Sex Differences in Blood Product Transfusions and Mortality in Trauma Patients at a Level I Trauma Center 26

Nathan Nuzman, MD; Linda Papa, MD, MSc; Lindsay Maguire, MD; Josef Thundiyil, MD, MPH; Jay Ladde, MD; Susan Miller, MD. Bedside Echocardiogram Used in the Diagnosis of Delayed Myocardial Infarction Presentation with Ventricular Wall Rupture Shannon Overholt; Jessica Adams; Taryn Hoffman, MD. Creating a High-Fidelity, Cost-effective Meat-Based Model for Ultrasound Guided Regional Anesthesia Teaching Mark Rivera-Morales, MD; Ricardo Rodriguez-Perez, MD; Hernando Castillo, MD; Nicole Aviles, MD, FACEP; Moises Moreno, DO, FACEP. Spontaneous Intraperitoneal Hemorrhage Secondary to a Subserosal Uterine Leiomyoma Ricardo Rodriguez Perez, M.D.; Alexis Avellino, M.D.; Jessica Quiñones DeEchegaray, M.D. Pericapsular Nerve Group (PENG) Block for Prosthetic Hip Reduction in the Emergency Department Taryn Hoffman; MD; Matthew Carr, MD; Janae Fry, DO. Rare Case of Non-surgical Pneumoperitoneum as a Complication of CPAP Lucas Winter, MD; Derrick Huang, MD; Latha Ganti, MD.

Medical Students

Adoption of Emergency Department Crowding Interventions Among US Hospitals Between 2007 and 2020 Leila Azari; Kea Turner; Young-Rock Hong; Amir Alishahi Tabriz.

A Cross-Sectional Assessment of Variations in Discounted Cash Prices for Critical Care Time at American Hospitals Joseph Bui; Tony Zitek, MD Eric Scheppke; Nicole Gonzalez; Jacob S. Alexander, MD; Christopher Wong, MD; Samanthalee Obiorah, MD; David A. Farcy, MD. Assisting ED Providers in Turnaround Time of Infectious Causative Agent Diagnosis with MeMed BV Ashkon Chamani; Marci O’Driscoll, MS; Daniel Wind, MD; Suzanne Silbert, PhD; Jason W. Wilson, MD, MA, FACEP Keeping Us All Up at Night Shaheen Emami; Krisopher Hendershot, MD. Pyomyositis in an Immunocompetent IV Drug User Shaheen Emami; Joshua Goldstein, MD. EMpulse Fall/Winter 2023

Evaluating the Presence of Nontraumatic, Primary Medical Diagnoses in Geriatric Patients Presenting as a Trauma Alert Following a Fall from Standing Mehdi Rizk; Andrew Thomas, MD; Amanda Priddy, MD; Morgan Uebelacker, MD; Enola Okonkwo, MD. Esophageal Stent Migration Diagnosed With Point-of-Care Ultrasound Samuel Harris, MD; A. Brad Hall, MD; Charlotte Derr, MD, RDMS, FACEP, FPD-AEMUS. TBI Biomarker Test Implementation with the Emergency Department Gabrielle Bailey; Emily Holbrook; Jason W. Wilson, MD, MA, FACEP. Return Visits to the Emergency Department in Patients Receiving CoLocated Treatment for Hepatitis C and Opioid Use Disorder Sarah Nestler, BS; Jack Schaefer, BS; Leah Burkinshaw, APRN; Emily Holbrook, MA; Heather Henderson, PhD; Jason Wilson, MD,MA,FACEP. Using Coronary Computed Tomographic Angiography as Part of Emergency Department Workup of Low to Moderate Risk Chest Pain January Moore, DO; Maryam Ossi, MD; Maria Saba, MD; Edmara Y. Nieves Cruz, MD FAAEM. Using Coronary Computed Tomographic Angiography as Part of Emergency Department Workup of Low to Moderate Risk Chest Pain Maryam Ossi, MD; January Moore, DO; Maria Saba, MD; Edmara Y. Nieves Cruz, MD FAAEM. Meningovascular Syphilis: A Case of a Young Man Presenting with Acute Ischemic Stroke and Pulmonary Emboli Alexa Ragusa, DO; Adrian Kapustka; Shayne Gue, MD. Findings from a Quality Improvement Project Aimed at Improving the Care of Patients Presenting to the ED following Sexual Assault Urmila Venkataramani; Julia Wang; Iman Awan; Amir Khiabani, MD; Naveen Perisetla; Enola Okonkwo, MD. Predictors of Major Arrhythmias in Patients Presenting to the Emergency Department with Low to Moderate Risk Palpitations or Syncope Celeste Wilson, Alexis Behne Sharma, Julia Wright, Naveen Perisetla, Courtland Samuels, Claire Dalby, Alexa Frederique, Autumn Bass, Ryan Long, Alex Hoerig, Enola Okonkwo.

SBS 2023 Competition Winners

EM RESEARCH POSTER COMPETITION: Best Clinical Vignette:

Samuel Harris

USF- Esophageal Stent Migration Diagnosed With Point of Care US.

Best Medical Student Poster:

Urmila Venkataramani

USF- Findings from a Quality Improvement Project Aimed at Improving the Care of Patients Presenting to the ED following Sexual Assault.

Best Resident Poster:

Dr. Andrew Rice

USF- Characterization of Out-of-Hospital and Emergency Department Cardiac Arrests at Tampa General Hospital

Best Fellow/ Attending Poster:

Dr. Peter Duan

Orlando Health- The Association Between Race & EMS Patient Offload Times.

CASE PRESENTATION COMPETITION (CPC):

EM RESIDENT DROP THE MIC:

EM RESIDENT QUIZ BOWL:

First Place:

First Place:

Best Presenter:

Dr. Abigail Alorda (UCF)

UCF/HCA Greater Orlando

Dr. Alexa Ragusa

(UCF/HCA- Greater Orlando/Osceola)Case: Typhoid Fever

Best Discussant:

Dr. Melissa Sayegh

“The Cure ALLmost Anything”

Second Place:

AdventHealth Orlando

Dr. Taylor Cesarz (UCF)

Third Place:

“The Art of Feedback”

(AdventHealth) - Case: Tick Paralysis

Third Place:

Overall Program:

Dr. Mitchell Voter (UCF)

AdventHealth

(second time in a row!)

Second Place:

HCA- Orange Park

“Big Medicine, Small Towns: Critical Access Emergency Medicine

EMERGENCY MEDICINE RESEARCH AND CLINICAL CASE POSTER COMPETITION Chair: Dr. Jason Wilson (University of South Florida)

EMERGENCY MEDICINE RESIDENT CASE PRESENTATION CONFERENCE (CPC) Chair: Dr. Jennifer Jackson (Sollis Health)

EMERGENCY MEDICINE RESIDENT QUIZ BOWL Chairs: Drs. Erich Heine & Sara Baker (Orlando Health)

DROP THE MIC COMPETITION Chair: Dr. Andy Little (AdventHealth)

EMpulse Fall/Winter 2023

27

CONFERENCE PHOTOS August 3-6, 2023 | Hyatt Regency Coconut Point Thank you for attending!

SCAN TO VIEW & DOWNLOAD PHOTOS

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SATURDAY’S KARAOKE PARTY Hosted by

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Our Emergency Medicine Clinicians Enjoy Work-Life Balance Why Do Emergency Medicine Clinicians Choose Envision?

Competitive compensation and comprehensive benefits

Flexible and equitable scheduling options

Career development and leadership opportunities

Diverse practice settings in attractive locations

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Florida Featured Emergency Medicine Opportunities STAFF ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

LEADERSHIP

Cleveland Clinic Indian River Hospital, Vero Beach HCA Florida Citrus Hospital, Inverness Ascension Sacred Heart Hospital, Pensacola HCA Florida Largo Hospital, Largo HCA Florida Central Tampa Emergency, Tampa HCA Florida Fawcett Hospital, Port Charlotte HCA Florida Sarasota Doctors Hospital, Sarasota HCA Florida Airport North Emergency, Orlando HCA Florida Lawnwood Hospital, Fort Pierce HCA Florida Cape Coral FSED, Cape Coral

■ ■

ACADEMIC ■ ■

HCA Florida Oak Hill Hospital, Brooksville HCA Florida Lawnwood Hospital, Fort Pierce

PEDIATRIC ■ ■

877.560.2125 Envision.Health/FCEP 30

HCA Florida Sarasota Doctors Hospital, Sarasota HCA Florida Northside Hospital, St. Petersburg

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HCA Florida Palms West Hospital, Loxahatchee HCA Florida Fort Walton-Destin Hospital, Ft. Walton Beach

Thanks for attending Symposium by the Sea! It was an honor to learn, network and grow with you in support of emergency medicine in Florida.

Congratulations!

Todd Slesinger, MD, FACEP, FCCM, FCCP President-Elect Florida College of Emergency Physicians

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EMpulse Fall/Winter 2023

FEATURE

Leaving A Living Legacy: Remembering A Founding Member and EM Pioneer

By Melissa Keahey

Executive Director & CEO

This past April we said goodbye to one of our founding members J. Clifford “Cliff” Findeiss, MD, FACEP. Knowing the influence and guidance that Dr. Findeiss offered to me through my career here at FCEP and FEMF, I understand that his impact is even more exponential among you all, his colleagues, fellow members, and friends.

Dr. Findeiss provided a lifetime of service to the Florida College of Emergency Physicians since joining in 1973. He served as the College’s sixth President in 1975-76, Chairman of the Florida Emergency Medicine Foundation Board from 2011-2015, and as a Foundation Board Member from 2007-2021. He was one of the first to recognize that care provided in emergency departments should be provided by full-time physicians who dedicate their skills to the practice of acute, unscheduled care, and recruited other physicians to support the specialty’s development in Florida and beyond.

He was a staunch advocate for emergency medicine and pre-hospital care, investing in educational and political activities that would advance the specialty and bring value to the Florida College of Emergency Physicians. His visionary leadership, pioneering spirit, and tireless dedication to advancing the College and specialty of emergency medicine over the last five decades have been invaluable.

In 2021 we were honored to create and present to Dr. Findeiss the Cliff Findeiss Emergency Medicine Legacy Award as a small tribute to his commitment to our organizations and emergency medicine. This year FCEP Councillors submitted a Memorial Resolution in his honor 32

which was adopted in October at ACEP’s Council meeting.

Over the years, Dr. Findeiss mentored and nurtured relationships with countless individuals within the field of emergency medicine and beyond. His personal values, professional accomplishments, and actions resonated with his community and the people around him, adding to the building blocks of his lasting legacy. He fostered a positive environment, inspired others to strive to be their best selves, and he led by example. As he paved the path that many of you walk on today, he not only contributed to his legacy, but also

EMpulse Fall/Winter 2023

created a shared legacy with a positive ripple effect that continues on through FCEP, FEMF, and the emergency medicine community.

And so, you all now have the privilege of living the legacy of Dr. Cliff Findeiss through innovation, visionary leadership and pioneering nature. I challenge us all to honor his wonderful legacy by finding opportunities to live with purpose and intention: 1. Take risks: Stepping out of your comfort zone forces you to trust your gut and unleash your potential. Adopt a growth mindset that pushes you to take on ambitious projects, advocate for your disruptive ideas, and take smart risks. Even if you fail along the way, perseverance and new lessons learned will all become a part of your legacy.

2. Pursue a life of learning: Knowledge is infinite, and prioritizing a life of new lessons equips you with tools to share your wisdom and experiences with others. In addition to fine-tuning professional skills and industry knowledge, commit to a personal life of learning, too.

3. Share your wisdom: You spread your legacy by sharing your values, know-how, and experiences with the world.

4. Build your brand: Curating your personal brand guides how others perceive you. Define how you’d like others to remember you and align your decisions and communications with this professional persona.

5. Dream big and plan accordingly: Reflect on your biggest career goals. Adjust and re-organize when necessary, keeping your sights on the finish line to make strategic and well-informed decisions. ■

Resolution: In Memory of Clifford Findeiss, MD Submitted by: Florida College of Emergency Physicians Adopted October 7, 2023 WHEREAS, J. Clifford “Cliff” Findeiss, MD obtained both a MS in Pharmacology and MD from Northwestern University Feinberg School of Medicine in 1968, completed a surgical internship at Jackson Memorial Hospital in Miami. and then proudly served as a Lieutenant in the US Navy Medical Corps; and WHEREAS, Dr. Findeiss, was an active member of the American College of Emergency Physicians since 1971, i s recognized as an early national leader in the new specialty of emergency medicine; and served on the American College of Emergency Physicians’ original exploratory Committee on Board Establishment, ultimately becoming Board Certified himself in 1983 and maintaining the certification until his death on April 1, 2023; and WHEREAS, Dr. Findeiss possessed the intelligence, confidence, and stamina to turn possibilities into reality, always seeking to put his philosophy of “doing well by doing right” into practice, combining his analytic and creative skills to change emergency medical care delivery; and WHEREAS, Dr. Findeiss co-founded Emergency Medical Services Associates (EMSA), which gradually established a new system of 24/7/365 physician on-site care in south Florida emergency departments, during which time Dr. Findeiss also served as the first Medical Director of Miami-Dade County Fire Rescue and the Hialeah Fire Department, initiating field care protocols for first responders; and WHEREAS, Dr. Findeiss is renowned as one of the first to recognize that care provided in emergency departments should be provided by full-time physicians who dedicate their skills to the practice of acute, unscheduled care; and WHEREAS, Dr. Findeiss actively recruited other physicians to support the specialty’s development nationally and in Florida traveling around the state, bringing emergency physicians together through the Florida Chapter of ACEP; and WHEREAS, Dr. Findeiss provided a lifetime of service to the Florida College of Emergency Physicians since joining in 1973, having served as the College’s sixth President in 1975-76, Chairman of the Florida Emergency Medicine Foundation Board from 2011-2015, and as a Foundation Board Member from 2007-2021; and WHEREAS, Dr. Findeiss’ entrepreneurial approach to the practice of emergency medicine expanded opportunities for emergency physicians to choose a professional practice model congruent to the needs of individual physicians and their families; and WHEREAS, Dr. Findeiss’ visionary leadership, pioneering spirit, and tireless dedication to advancing the specialty of emergency medicine over the last five decades have proven to be invaluable; WHEREAS; Dr. Findeiss was a role model and mentor leaving exponential and immeasurable impact among his colleagues and future leaders in emergency medicine; and WHEREAS; Dr. Findeiss was a dedicated and devoted husband, father, grandfather, colleague, mentor, and friend who inspired all of those who knew him; therefore, be it RESOLVED that the American College of Emergency Physicians remembers with honor and gratitude the contributions of a trailblazing pioneer, visionary leader, invaluable mentor, and outstanding emergency physician, J. Clifford “Cliff” Findeiss, MD and his selfless contributions to emergency medicine; and extends condolences and appreciation to his wife Jean, his four sisters Marcia, Joan, Pat, and Michele; as well as his four children and his granddaughter in whom his legacy lives on: Dr. Laura Findeiss, Craig Findeiss, Amanda (Findeiss) Rosillo, Allison Findeiss, granddaughter Elizabeth (Lily) Rosillo; family, friends, and colleagues for his remarkable service to the specialty of emergency medicine, patient care, and the communities he served. ■

EMpulse Fall/Winter 2023

33

ULTRASOUND ZOOM

Return of Spontaneous Circulation: Optimizing Cardiac Arrest with Point of Care Ultrasound

By Alyssa King, DO

Resident Physician, Florida Atlantic University

By Leila L. PoSaw, MD, MPH Clinical Associate Professor, Florida Atlantic University

Images and videos referenced in this article can be viewed/accessed using QR codes on pages 35 & 36.

Introduction Managing a cardiac arrest can be very challenging. Have you found yourself fumbling for a pulse in the inguinal region that has been too weak to palpate? Are you sure that the asystole displayed on the monitor is not a fine ventricular fibrillation in disguise? Are you certain that your patient’s pulseless electrical activity is not associated with cardiac contractions and flow? Are you stumbling through the Hs and Ts, wondering what to do next?

No stress. Point of care ultrasound can shine a light on our most confounding conundrums! We routinely use POCUS in our high adrenaline, anxiety provoking cardiac arrest resuscitations and find it most helpful for (a) checking a pulse, (b) diagnosing ventricular fibrillation, (c) managing pulseless electrical activity (PEA), and (d) identifying reversible causes.

Pulse Check Manual pulse checks have been shown to be suboptimal in accuracy and performance time. The use of POCUS on the carotid or femoral vessels with B-mode (pulsatility and lack of compression), color Doppler, and/or pulse wave Doppler (peak systolic velocity > 20 cm/s) can easily and rapidly determine return of spontaneous circulation (ROSC) as well as adequacy of chest compressions.

While POCUS pulse checks can be performed with the high frequency linear probe (beautiful clear images), the phased array probe has the advantage of versatility and this single probe can be used to investigate pulse checks, cardiac activity and reversible causes as well. Hot tip! You can save precious time by not 34

changing the probe. (Image 1, Video 1 Pulse check linear probe) (Image 2, Video 2 - Pulse check phased array probe).

High-quality chest compressions have been shown to be critical, and it is important to minimize pause durations to less than 10 seconds. For pulse checks, the extra moves of hopping on and off the groin, and the time to find that elusive pulse can add critical seconds to the pause duration and lead to unwanted delays. In our code room, the POCUS operator stands on the upper right side of the patient and places the probe continuously on the carotid artery (our preference). We have found this to minimize disruptions, and free up the groin to those who insist on manual palpation (yes, there are those!) of the femoral pulse.

Refractory Ventricular Fibrillation POCUS can most definitely differentiate asystole from fine ventricular fibrillation.

Disordered depolarization of the ventricle may display as an irregular line on your monitor, which may then be easily misinterpreted as asystole. Your cardiac POCUS, however, may reveal high frequency ventricular contractions as a chaotic “flickering” of the ventricle, and your quick thinking immediate defibrillation may save the day! (Image 3, Video 3 - Ventricular fibrillation). Given that ventricular fibrillation (and subsequent defibrillation) has a higher survival rate than other rhythms, go ahead and congratulate yourself that you (and POCUS) single handedly improved survival rates in your emergency department.

POCUS can also be useful in the detection and management of refractory ventricular fibrillation, when ventricular EMpulse Fall/Winter 2023

fibrillation does not respond to three standard defibrillation attempts, In such cases, you might want to consider alternative strategies like dual sequential defibrillation, changing pad position (from anterior/lateral to anterior/posterior) or esmolol, an excellent sympatholytic that raises the fibrillation threshold.

PEA/Pseudo-PEA POCUS can easily distinguish PEA from pseudo-PEA. PEA is also known as PRES (Pulseless with a Rhythm with Echocardiographic Standstill) while pseudo-PEA is known as PREM (Pulseless with a Rhythm with Echocardiographic Motion). In both, the monitor will display organized electrical activity and no pulse will be manually palpable. However in PEA, POCUS reveals no cardiac contractions, while in pseudo-PEA, POCUS reveals organized cardiac contractions. (Image 4, Video 4 - PRES) (Video 5 - PREM) Typically, the MAP in pseudo-PEA lies between 25-50 mmHg, which is lower than the manual pulse threshold. Thus, several experts recommend managing pseudo-PEA/PREM (with presence of POCUS contractions) as profound shock: placing an arterial line and titrating a norepinephrine infusion to a MAP over 60 mmHG. Many would consider continuing chest compressions if pseudo-PEA/ PREM does not produce an associated POCUS pulse.

Reversible Causes POCUS can identify several reversible causes of cardiac arrest, including cardiac tamponade, pulmonary embolism, ruptured aortic aneurysm, massive hemothorax, tension pneumothorax. (Image 6, Video 6 - Cardiac tamponade) (Image 7, Video

7 - Pneumothorax)(Image 8, Video 8 - Abdominal aortic aneurysm)(Image 9, Video 9 - Massive hemothorax).

Image 11

Appropriate management of a reversible cause will often lead to ROSC. A pericardial effusion suspected to be causing a tamponade should prompt pericardial drainage.

Strong suspicion for pulmonary embolism should prompt thrombolytics, for pneumothorax should prompt needle thoracostomy, and for free intraperitoneal fluid should prompt surgical management.

Protocols Several unique POCUS protocols (CASA, CAUSE, FEEL, FEER, and others) have been developed to optimize rapid and targeted interventions. While it is less important to know every protocol, it is essential to practice and use one protocol that suits you and your team the best.

The Cardiac Arrest Sonographic Assessment (CASA) exam is a three-step protocol that can rapidly be performed with a phased array transducer to rapidly evaluate for pericardial effusion, right heart strain, and cardiac activity during the 10 second pauses. (Image 10) Regardless of which protocol is eventually used, the literature suggests several strategies to prevent pause delays, including, scanning by the most experienced operator who focuses solely on POCUS, performance of non-cardiac applications only during compressions, identification of optimal windows prior to the pause, analyzing saved images during compressions, and a countdown for compression resumption. (Image 11) Conclusion It is our hope that after reading this article you will be inspired to perform POCUS pulse checks on the carotid artery, rapidly identify ventricular fibrillation and defibrillate, identify pseudo-PEA and start vasopressor therapy, and expeditiously manage reversible causes. Let’s celebrate your saves! ■ Image 10

Alyssa King, DO Leila Posaw, MD MPH

EMpulse Fall/Winter 2023

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Image

Video

Ventricular Fibrillation Image 3 & Video 3

Video/Image credits: Florida Atlantic University Residency Program

PEA/PRES Image 4 & Video 4

Video/Image credits: Florida Atlantic University Residency Program

Pseudo-PEA/ PREM Video 5

Video/Image credits: Florida Atlantic University Residency Program

No Image

Cardiac Tamponade Image 6 & Video 6

Video/Image credits: Florida Atlantic University Residency Program

Pulse Checks Image 1 & 2 Video 1 & 2

Video/Image credits: Florida Atlantic University Residency Program

Aortic Aneurysm Image 8 & Video 8

Video/Image credits: Florida Atlantic University Residency Program

Pneumothorax Video 7

Video/Image credits: Florida Atlantic University Residency Program

No Image

Massive Hemothorax Image 9 & Video 9 CASA Protocol Image 10

ACEP Protocol Image 11

Video/Image credits: Florida Atlantic University Residency Program

view on pg. 37

view on pg. 37

No Video

Created by Alyssa King, MD

No Video

https://www.acep.org/ emultrasound/newsroom/ january-2022/use-ofultrasound-in-cardiacarrest2

Scan to view full size images & videos for this article

References Clattenburg EJ, Wroe PC, Gardner K, Schultz C, Gelber J, Singh A, Nagdev A. Implementation of the Cardiac Arrest Sonographic Assessment (CASA) protocol for patients with cardiac arrest is associated with shorter CPR pulse checks. Resuscitation. 2018 Oct;131:69-73. doi: 10.1016/j. resuscitation.2018.07.030. Epub 2018 Jul 30. PMID: 30071262.

Gottlieb M, Alerhand S. Managing Cardiac Arrest Using Ultrasound. Ann Emerg Med. 2023 May;81(5):532-542. doi: 10.1016/j. annemergmed.2022.09.016. Epub 2022 Nov 2. PMID: 36334956.

Long B, Alerhand S, Maliel K, Koyfman A. Echocardiography in cardiac arrest: An emergency medicine review. Am J Emerg Med. 2018 Mar;36(3):488-493. doi: 10.1016/j.ajem.2017.12.031. Epub 2017 Dec 16. PMID: 29269162.

Kang SY, Jo IJ, Lee G, Park JE, Kim T, Lee SU, Hwang SY, Shin TG, Kim K, Shim JS, Yoon H. Point-of-care ultrasound compression of the carotid artery for pulse determination in cardiopulmonary resuscitation. Resuscitation. 2022 Oct;179:206-213. doi: 10.1016/j.resuscitation.2022.06.025.

Epub 2022 Jul 2. PMID: 35792305.

Rabjohns J, Quan T, Boniface K, Pourmand A. Pseudo-pulseless electrical activity in the emergency department, an evidence based approach.

Am J Emerg Med. 2020 Feb;38(2):371-375. doi: 10.1016/j.ajem.2019.158503. Epub 2019 Oct 14. PMID: 31740090.

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EMpulse Fall/Winter 2023

EDUCATION CORNER

Level Up: Technology in Medical Education

By Carmen J. Martínez MD, MSMEd, FACEP

Using technology in education can be challenging for all educators, regardless of their age and generation. Medical education is not any different. Moving beyond the complexities of technology and harnessing the advantages of technology is essential.

When looking at how best to implement, educational learning theories can be useful in how to apply learning technology. One common learning theory that is often cited in medical education literature that supports the use of technology in learning is Kolb’s experiential learning cycle. Kolb’s

experiential learning cycle illustrates how learning is continuous and cyclical for our learners. It has 4 stages: active experimentation, concrete experience, reflective observation, and abstract conceptualization. Yang et al describes how these stages occur in patient care activities; concrete experience is gained during the history and physical exam; reflective observation is used to develop the initial assessment and differential diagnosis; abstract conceptualization helps the student hypotheses and arrive at a diagnosis; active experimentation occurs

By Caroline M. Molins MD, MSMEd, FACEP

as a management plan and in follow up visits. As you can see, in one patient care scenario, a learner can complete the cycle, which as Kolb mentions is needed for learning to be effective.

Before we delve into how technology in medical education and learning theory converge, let’s discuss what is meant by technology in medical education.

Technology in medical education can be divided into three large categories: M-learning (apps and “adds”), simulation

and social media. For the sake of brevity in this article, we will be focusing on the first.

M-learning represents learning via mobile devices such as smartphones or tablets.

Mobile devices allow for textbooks, drug reference books and medical calculators to be at our fingertips. Downloadable applications (apps) help users have the information organized and facilitate quick access. Apps can also help our learners work through clinical scenarios and think about diagnosis and even watch videos about procedures. In addition to the apps, there are also the “adds” or linked or

plugged-in devices to the mobile devices, such as stethoscopes, ultrasound probes, and EKG monitors which can be used by physicians and patients alike. In all, these different forms of m-learning support learning, can spark conversations between educators and learners through instant communication and facilitate clinical decisions for all physicians. (Bulluck) The ease with which to adopt m-learning to our daily clinical work, clinical education and learning is of particular importance because many educators and learners already have smartphones. This makes m-learning available to all those willing to try.

Now, let’s put educational learning theory and medical education technology together, with m-learning as our medium.

Kolb’s experiential learning cycle can also be illustrated in technology in medical education, so let’s put these together.

Concrete experience is used when students use case based apps to recreate patient scenarios; reflective observation is used to develop the initial assessment and differential diagnosis or even when using procedure based applications where the learner is watching a video and reflecting on how they would approach the scenario; abstract conceptualization is utilized when learners use apps help look up managements and treatments for cases or even used medical calculators to inform clinical decisions; active experimentation occurs when apps allow students to work through cases and chose management plans and feedback is given, simulating live cases and outcomes. As you can see, using applications to enhance clinical learning is possible with some intentionality.

After all this discussion about education theory and medical education, are you willing to try it? The truth is many of us are already using technology to teach and reach our students. For example, we use software like New Innovations CONTINUED ON PAGE 39

EMpulse Fall/Winter 2023

37

POISON CONTROL

Tianeptine: Gas station heroin

By Hayley T. Gartner PharmD

By Reeves E. Simmons PharmD

By Dawn R. Sollee PharmD, DABAT, FAACT

What is tianeptine and how does it work?

Tianeptine, also known as Zaza, Tia, Tianna, gas-station dope, gas-station heroin, TD red, and pegasus, was originally classified as a tricyclic antidepressant due to its structure.1 Since tianeptine does not inhibit monoamine reuptake, this description is inaccurate.1 One article suggests tianeptine has no effect on serotonin reuptake while another suggests it enhances serotonin reuptake.2,3 Therefore, the mechanism may more accurately be described as a glutamatergic modulator with anxiolytic properties, shown to be effective in managing somatic symptoms.2 Ligand binding studies have also confirmed that tianeptine is a µ-opioid receptor and δ-receptor agonist.4,5 It is not approved for use in the United States but it is used to treat major depressive disorder in Europe, Asia, and Latin America.6 It is commonly sold at convenience stores, gas stations, and on the internet across the United States.7 The abuse and misuse of tianeptine has led to making it a scheduled substance in certain states, including Georgia and Alabama.8 It is not currently a scheduled substance in Florida.8

The Florida Attorney General filed an emergency rule on September 21, 2023 to outlaw tianeptine and place it on the state’s Schedule 1 list of controlled substances.

Why do people tianeptine?

misuse

or

abuse

People suffering from opioid use disorder are increasingly turning to “legal highs” such as over-the-counter medications to

38

“Gas station dope:” The legal and personal battles over Tianeptine (alreporter.com) “get high,” or to mitigate the symptoms of opioid withdrawal.9 Tianeptine was previously sold as a dietary supplement but according to the FDA, it does not meet criteria for a dietary ingredient.7 In 2018, the FDA issued warning letters to two companies who sold products marketed as dietary supplements but were labeled as containing tianeptine.7 These products continue to be sold but may be marketed as nootropics or may not be labeled as tianeptine to circumvent these warnings by the FDA.7 The potential for abuse of tianeptine is likely due to its µ-opioid receptor agonist activity and misuse reportedly causes euphoria, similar to other opioid agonists.6 What are the clinical effects associated with tianeptine toxicity?

In overdose, there have been reports of neurologic (lethargy, agitation), cardiovascular (hypertension, tachycardia), and gastrointestinal symptoms (gastrointestinal distress) following exposure to tianeptine with some effects being similar to opioid toxicity.9,10 These include euphoria, constipation, nausea, vomiting, hypotension, EMpulse Fall/Winter 2023

and respiratory depression.10 Physical dependence and withdrawal have been reported in patients following chronic use.9,10 What are the treatment modalities for tianeptine toxicity?

Activated charcoal can be considered if a patient presents soon after an ingestion and is not manifesting signs and symptoms of toxicity.6 Naloxone, an opioid antagonist, has been used successfully in some patients exposed to tianeptine.

Naloxone can be given intravenously, intramuscularly, subcutaneously, intranasally or endotracheally. The usual dose is 0.4 to 2.0 mg IV. In patients with suspected opioid dependence incremental doses of 0.2 mg IV should be administered, titrated to reversal of respiratory depression and coma. Doses may be repeated every 2 to 3 minutes up to 10 mg. Very high doses are rarely needed, but may be necessary. A continuous infusion may also be required in patients that have persistent symptoms of CNS and respiratory depression. The starting rate is typically two-thirds of the dose effective for initial reversal that is administered each hour; titrate as needed.

Naloxone may precipitate withdrawal in a tianeptine-dependent patient. Symptoms of withdrawal have also been reported with the sudden cessation of tianeptine in chronic users. Symptoms have included anxiety, agitation, nausea, vomiting, diaphoresis, lacrimation and yawning.

Treat withdrawal with benzodiazepines as needed. Administer oxygen and assist ventilation for respiratory depression. Orotracheal intubation for airway protection should be performed early in cases of obtundation and/or respiratory depression that do not respond to naloxone.

Hemodialysis and hemoperfusion are not anticipated to be of value due to high protein binding (approximately 94%) of tianeptine.6 The Florida Poison Information Center Network is available at 1-800-222-1222 for any questions regarding tianeptine or any other potential toxin. ■

REFERENCES 1. Samuels BA, Nautiyal KM, Kruegel AC, et al. The Behavioral Effects of the Antidepressant Tianeptine Require the Mu-Opioid Receptor.

Neuropsychopharmacology.

2017;42(10):2052-2063. doi:10.1038/ npp.2017.60 2. Alamo C, García-Garcia P, LopezMuñoz F, Zaragozá C. Tianeptine, an atypical pharmacological approach to depression. Tianeptina, un abordaje farmacológico atípico de la depresión.

Rev Psiquiatr Salud Ment (Engl Ed).

2019;12(3):170-186. doi:10.1016/j. rpsm.2018.09.002 3. Stablon [package insert] Serdia Pharmaceuticals India Pvt Ltd; 2008.

4. Springer J, Cubała WJ. Tianeptine Abuse and Dependence in Psychiatric Patients: A Review of 18 Case Reports

in the Literature. J Psychoactive Drugs.

2018;50(3):275-280. doi:10.1080/02791 072.2018.1438687 5. Dempsey SK, Poklis JL, Sweat K, Cumpston K, Wolf CE. Acute Toxicity From Intravenous Use of the Tricyclic Antidepressant Tianeptine. J Anal Toxicol. 2017;41(6):547-550. doi:10.1093/ jat/bkx034 6. Tianeptine. In: IBM Micromedex POISINDEX (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: www. micromedexsolutions.com/ (cited: September 14, 2023).

7. Michienzi AE, Borek HA. Emerging Agents of Substance Use/Misuse.

Emerg Med Clin North Am. 2022;40(2):265-281. doi:10.1016/j. emc.2022.01.001

8. Know the Dangers of Gas Station Heroin. Cleveland Clinic Healthessentials. Brain and Spine. https://health.clevelandclinic.org/gasstation-heroin-tianeptine/. Accessed 20 September 2023.

9. Marraffa JM, Stork CM, Hoffman RS, Su MK. Poison control center experience with tianeptine: an unregulated pharmaceutical product with potential for abuse. Clin Toxicol (Phila).

2018;56(11):1155-1158. doi:10.1080/15563 650.2018.1476694 10. Rushton W, Whitworth B, Brown J, Kurz M, Rivera J. Characteristics of tianeptine effects reported to a poison control center: a growing threat to public health. Clin Toxicol (Phila).

2021;59(2):152-157. doi:10.1080/155636 50.2020.1781151

CONTINUED FROM PAGE 37 and MedHub to deliver feedback in real-time. Some use a central cohesive repository (ie: learning management software) to keep articles, interesting cases, or images to use for case-based learning. So, as we think of technology and learning, let’s explore other options.

As you can see in our graphic, we have paired applications with a stage of Kolb’s experiential learning cycle. Concrete learning can be exemplified by the application FullCode where learners….; By using One MinuteUltrasound, students can watch videos on indications for bedside ultrasounds and reflect on when to best use them in clinical scenarios and how to improve their own techniques.

Applications like QuickEM that facilitate access to medicine are a form of abstract conceptualization whereby learning occurs by thinking through the theoretical and applying it to the case scenario. Last, the Resuscitation! Application allows for learners to play the role of physician and make decisions, perform procedures and then feedback is given to the learner.

So next time you are on a clinical shift with learners, and you have some downtime, or you want to engage your student in a conversation, think of m-learning. Ask the learner, to download and open an application that exemplifies experiential learning. Using these techniques, learning can be fun, engaging and use technology at the same time! ■

REFERENCES 1. Boysen-Osborn, M., Cooney, R., Gottlieb, M., Chan, T., Brown, A., King, A., Tobias, A., & Thoma, B. (2017). Academic primer series: Key papers about teaching with technology.

Western Journal of Emergency Medicine, 18(4), 729–736. https://doi.org/10.5811/ westjem.2017.2.33076 2. Bullock, A., & Webb, K. (2015). Technology in Postgraduate Medical Education: A dynamic influence on learning?: Table 1. Postgraduate Medical Journal, 91(1081), 646– 650. https://doi.org/10.1136/postgradmedj-2014-132809 3. Efficient MD. (2022, September 7). The best emergency medicine apps in 2022. Efficient MD. Retrieved September 22, 2022, from https://efficientmd.com/the-best-emergencymedicine-apps/ 4. Grainger, R., Liu, Q., & Geertshuis, S. (2020). Learning technologies: A medium for the transformation of medical education? Medical Education, 55(1), 23–29. https://doi. org/10.1111/medu.14261 5. Yang, Y.-M., Kim, C. H., Briones, M. A., Hilinski, J. A., & Greenwald, M. (2014). Instinctive clinical teaching: Erasing the mental boundary between clinical education and patient care to promote natural learning. Journal of Graduate Medical Education, 6(3), 415–418. https://doi.org/10.4300/jgme-d-13-00277.1 6. Yardley, S., Teunissen, P. W., & Dornan, T. (2012). Experiential learning: Amee guide no.

63. Medical Teacher, 34(2). https://doi.org/10.3109/0142159x.2012.650741

EMpulse Fall/Winter 2023

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CASE REPORT

Flecainide Induced Atrial Flutter Causing Monomorphic Wide Complex Tachycardia

By Graham Clifford, DO, EMS Fellow

A 65-year-old male with a past medical history of atrial flutter on metoprolol, flecainide and apixaban reports to the ED for evaluation of palpitations. He relates he has undergone transesophageal echocardiogram guided cardioversion in the past for similar symptoms. His vital signs are remarkable for tachycardia in the 190’s but otherwise normal blood pressure, respirations, work of breathing and mentation with cap refill <2 seconds in extremities. Patient reports uninterrupted anticoagulation. An ECG is performed.

ECG: This ECG shows monomorphic wide complex tachycardia (WCT) at a rate of 192 bpm, extreme axis deviation, QRS of 160 msec, positive concordance in precordial leads V1-2, negative concordance in precordial V3-6 and absence of capture or fusion beats.

Clinical course: Old electrocardiograms were reviewed and did not reveal any signs of Wolff Parkinson White syndrome (WPW).

This patient’s R-R interval was normal prompting attempts at vagal maneuvers as SVT with aberrancy was on our differential diagnosis, but we were unsuccessful.

Adenosine was administered twice (6, 12 mg) without success and no notable pauses were noted. The patient was

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consented for synchronized cardioversion which successfully terminated the arrhythmia with reversion to normal sinus rhythm. Cardiology was consulted early in the patient’s ED course and reported his WCT likely represented flecainide toxicity causing QRS prolongation and atrial flutter with 1:1 conduction. Cardiology formally interpreted his ECG as “atrial flutter with 1:1 conduction, ventricular rate 192 bpm, with a bundloid QRS morphology”. Cardiology recommended discharge home with instructions to stop flecainide and to increase his metoprolol dose with outpatient clinic follow-up.

Teaching points: Wide complex tachycardia ● When treating a patient with wide complex tachycardia it is important to assess circulation, airway and EMpulse Fall/Winter 2023

breathing in accordance with standard ACLS. If a patient who is experiencing WCT is deemed unstable, then they should undergo synchronized cardioversion. ● There is observational research to support the use of adenosine in the treatment of stable monomorphic regular WCT. [1] ● There are case reports and studies that describe stable WCT deteriorating to ventricular fibrillation after adenosine administration. [2] ● Adenosine should never be administered without cardiology consultation to a patient with polymorphic WCT or if an irregular RR interval is noted as the patient may have WPW syndrome which places them at risk for degeneration to VF if given AV nodal blocking agents.

● Vagal maneuvers and namely Adenosine can be diagnostic and therapeutic when given in the setting of stable monomorphic wide complex tachycardia. Specifically, there is a therapeutic benefit if the rhythm represents SVT with aberrancy as adenosine may terminate the arrhythmia. ● Secondly, if the patient is suffering from another type of supraventricular tachycardia and the QRS complex is wide due to other reasons aside from ventricular tachycardia you may be able to evaluate p wave morphology to better attain a diagnosis (junctional tachycardia, ectopic atrial tachycardia, atrial flutter). This could then alter your treatment modality to the best suited method. ● Lastly, if there is no response to the above-mentioned interventions one can hypothesize that the arrhythmia is generated from the ventricles and ventricular tachycardia is the rhythm at hand. One study showed the odds of ventricular tachycardia increased by 9 when there was no response to adenosine in the treatment of WCT with adenosine. [3]

Flecainide: ● Flecainide is a class IC antiarrhythmic which acts by blocking the sodium channels responsible for phase 0 depolarization of the cardiac action potential. ● Flecainide is typically used to treat atrial fibrillation. ● Flecainide can also cause ventricular and supraventricular arrhythmias. ● Flecainide is known to convert atrial fibrillation into 1:1 atrial flutter where ventricular rates will exceed 200 bpm. The described rate of arrhythmia after flecainide use is 3.5-5%. It is thought to be closely associated with hyperadrenergic states and typically patients taking flecainide also are prescribed an AV nodal blocker to avoid this complication. [4] ● The incidence of ventricular dysrhythmias after flecainide administration for conversion of atrial fibrillation have been shown to be less than 3%. [5] ● Flecainide has a small therapeutic window which predisposes the patient to treatment failure and severe adverse reactions when taking it. [6] ● Over dosage of flecainide causes excessive sodium channel blockade manifesting as prolonged PR, QRS, and QT intervals on ECG. ● Flecainide toxicity can cause cardiac arrest not responsive to typical ACLS treatment protocols and may ultimately be responsive to sodium bicarbonate, lipid emulsion therapy and ECMO. [7] Flecainide has an FDA black box warning recommending restricting its use to life threatening ventricular arrhythmias

REFERENCES 1. Innes JA. Review article: Adenosine use in the emergency department. Emerg Med Austraas. 2008 Jun;20(3):209-15. doi: 10.1111/j.1742-6723.2008.01100.x.

PMID: 18549383.

2. Parham WA, Mehdirad AA, Biermann KM, Fredman CS. Case report: adenosine induced ventricular fibrillation in a patient with stable ventricular tachycardia. J Interv Card Electrophysiol. 2001 Mar;5(1):71-4. doi: 10.1023/a:1009810025584. PMID: 11248777.

3.

Marill KA, Wolfram S, Desouza IS, Nishijima DK, Kay D, Setnik GS, Stair TO, Ellinor PT. Adenosine for

wide-complex tachycardia: efficacy and safety. Crit Care Med. 2009 Sep;37(9):2512-8. doi: 10.1097/ CCM.0b013e3181a93661. PMID: 19623049.

4. Falk RH. Proarrhythmia in patients treated for atrial fibrillation or flutter.

Ann Intern Med. 1992 Jul 15;117(2):14150. doi: 10.7326/0003-4819-117-2-141.

Erratum in: Ann Intern Med 1992 Sep 1;117(5):446. PMID: 1605429.

5. McNamara RL, Tamariz LJ, Segal JB, Bass EB. Management of atrial fibrillation: review of the evidence for the role of pharmacologic therapy, electrical cardioversion, and echocardiography. Ann Intern Med.

2003 Dec 16;139(12):1018-33. doi: 10.7326/0003-4819-139-12-20031216000012. PMID: 14678922.

6. Devin R, Garrett P, Anstey C. Managing cardiovascular collapse in severe flecainide overdose without recourse to extracorporeal therapy. Emerg Med Australas. 2007 Apr;19(2):155-9. doi: 10.1111/j.1742-6723.2006.00909.x. PMID: 17448102.

7. Khatiwada P, Clark L, Khunger A, Rijal BB, Ritter J. A Case Report of Flecainide Toxicity With Review of Literature.

Cureus. 2022 Feb 15;14(2):e22261. doi: 10.7759/cureus.22261. PMID: 35350525; PMCID: PMC8933271.

EMpulse Online Homepage fcep.org/empulse

EMpulse Online In addition to the content in this magazine, there is even more online!

Online content includes: • Fall 2023 Residency Program Updates • Medical Student Council Report • Case Reports • Feature Articles

Intent to Submit Form

Call for Content: EMpulse is now publishing articles and updates online on a rolling basis. A print issues will be published once a year with content selected by the Editorial Committee.

EMpulse Fall/Winter 2023

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CASE REPORT

Massive Subcutaneous Emphysema a Barrier to FAST Exam

By Shaheen Emami, BS

By Joshua Goldstein, MD

University of Miami Miller School of Medicine, Miami FL

Introduction:

Case:

The focused assessment with sonography for trauma (FAST) bedside examination has become an integral function in the evaluation and management of the trauma patient1. It is both sensitive and specific as a screening tool for clinicians to evaluate for free intraperitoneal fluid and pericardial fluid, which ultimately leads to more rapid intervention and a shortened time to the operating room 1-5. In hemodynamically unstable patients, a positive FAST exam often warrants immediate surgical intervention, bypassing the time-consuming computed tomography (CT) and improving mortality 6,7.

A 40-year-old male presented to a level 2 trauma center after a high-velocity motor vehicle collision. The patient arrived at the hospital unresponsive, tachycardic, hypotensive, and hypoxic. He was intubated and large-bore peripheral intravenous catheters were placed bilaterally for volume resuscitation. Physical exam showed absent breath sounds on the right side and diminished breath sounds on the left side. His abdomen was distended, tympanic, and rigid.

This exam, however, has its limitations. A clinician can be expected to accurately complete the exam in less than five minutes8, yet this amount of time is variable based on the experience of the user, as well as the body habitus and pathology of the patient. In the trauma setting, a rare but well-known pathology is a tracheobronchial injury. The majority of these injuries are associated with subcutaneous emphysema, pneumomediastinum, and pneumothorax9.

Subcutaneous emphysema is a wellestablished barrier to ultrasound that causes significant reflection of ultrasound waves, leading to poor tissue penetration and poor image resolution, often termed “dirty shadowing”10. There have been accounts of subcutaneous emphysema in the cervical region impacting ultrasound-guided central venous cannulation11,12, however, reports of subcutaneous emphysema extending into the abdominal wall and pelvis, therein impacting the quality of a FAST exam, remains minimal. In this case report, we describe one of the barriers to utilizing the FAST exam in a patient presenting after a high-velocity motor vehicle accident with right-sided tracheobronchial injury and massive subcutaneous emphysema.

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Jackson Memorial Hospital, Department of Emergency Medicine, Miami FL

Bedside FAST examination yielded poor resolution due to dirty shadowing in all four views, and no clear images were obtained (Figure 1). Parasternal long-axis and shortaxis views were attempted, which had similar results. With firm pressure, the splenorenal recess was briefly observed, but the spleen tip and subphrenic space were not attained. The patient began to decompensate with low oxygenation and diminishing tidal volumes therefore a rightsided tube thoracostomy was performed and significant continuous air leakage was noted. Subsequent chest x-ray showed a left pneumothorax, right-sided pulmonary contusions, and severe subcutaneous emphysema (Figure 2). Pelvis x-ray showed subcutaneous emphysema in the abdominal wall. Chest CT demonstrated bilateral pleural effusions, with extensive right-sided pulmonary contusions, atelectasis and trace residual pneumothorax (Figure 3, Figure 4).

His left chest also showed a pneumothorax.

There was pneumomediastinum with air tracking into the neck and multiple rib fractures, with extensive subcutaneous emphysema noted. Abdominal imaging revealed a right hepatic laceration, grade 2 splenic laceration, moderate free intraperitoneal air, and air tracking into the inguinal region (Figure 5). His head CT was negative for intracranial abnormalities, but EMpulse Fall/Winter 2023

yielded subcutaneous emphysema in the soft tissues of the face (Figure 6).

A left-sided tube thoracostomy was placed and the patient was sent to the operating room for exploration. Upon surgical exploration, a right middle lobe avulsion of the bronchus intermedius was found, which resulted in a lobectomy with primary repair of the injury. In addition, he received a primary repair of a partial thickness right hemidiaphragm lacerationa splenectomy and hepatorrhaphy.

Discussion: This patient presented with a tracheobronchial injury resulting in massive subcutaneous emphysema that extended into his abdominal wall and pelvis. The complexity of the case demonstrates that significant artifacts from severe subcutaneous emphysema may render the FAST exam inconclusive and unreliable.

Although the patients’ vital signs were stable enough after resuscitation to receive a CT scan, he did have hepatic and splenic lacerations that were unable to be assessed on the FAST exam due to severe subcutaneous emphysema in the abdominal and chest wall. If this patients’ FAST exam was clear and positive, the decision to go to the operating room may have been taken more rapidly. Fortunately, the patient remained stable enough for advanced imaging, and prompt intervention from there was able to be done.

Clinicians should maintain a strong suspicion of tracheobronchial injury if they encounter “dirty shadowing” artifacts on the FAST exam, especially in the context of fluctuating oxygen saturation and evidence of pulmonary injury both clinically and on x-ray.

Additionally, considering that quicker time to the operating room has been associated with improved mortality6, clinicians should be sure to not spend an excessive quantity

of time attempting to find adequate FAST views when encountering this artifact. In a patient with massive subcutaneous emphysema extending into the pelvis, these measures would likely be futile. The clinician may consider attempting application of firm pressure on the transducer to potentially displace the underlying subcutaneous emphysema. In our case, this only temporarily improved visualization, and we still were unable to get a complete picture of the left upper quadrant view. In cases where hemodynamic stability is fluctuating, it may be imperative to proceed with exploratory laparotomy and thoracotomy immediately, forgoing advanced imaging. ■

Figure 1: Left upper quadrant view of FAST

Figure 2: Portable chest x-ray demonstrating right-sided pulmonary contusions, left-sided pneumothorax, and severe subcutaneous emphysema. The subcutaneous emphysema can be seen within the pectoralis muscles as striations.

Figure 3: CT Chest (axial) showed bilateral pleural effusions, with extensive right-sided pulmonary contusions, atelectasis and trace residual pneumothorax. Left-sided pneumothorax was also present. There was pneumomediastinum with air tracking into the neck and multiple rib fractures, with extensive subcutaneous emphysema visible in the chest and upper extremity soft tissue.

Figure 4: CT Chest (Coronal) more clearly

Figure 5: CT Abdomen and Pelvis showed a right hepatic laceration and grade 2 splenic laceration. There was moderate free intraperitoneal air, and subcutaneous air tracking into the inguinal region.

Figure 6: CT Head without contrast was negative for intracranial abnormalities.

Demonstrates severe subcutaneous emphysema of the facial tissue.

exam. There were no visible structures due to subcutaneous emphysema obscuring the image.

exemplifies the extent of the subcutaneous emphysema, as well as the described lung pathology from figure 3.

REFERENCES 1. Bahner D, Blaivas M, Cohen HL, et al. AIUM practice guideline for the performance of the focused assessment with sonography for trauma (FAST) examination. J Ultrasound Med. 2008;27(2):313-318.

2. Von Kuenssberg Jehle D, Stiller G, Wagner D. Sensitivity in detecting free intraperitoneal fluid with the pelvic views of the FAST exam. Am J Emerg Med. 2003;21(6):476-478.

3. Lobo V, Hunter-Behrend M, Cullnan E, et al. Caudal Edge of the Liver in the Right Upper Quadrant (RUQ) View Is the Most Sensitive Area for Free Fluid on the FAST Exam. West J Emerg Med. 2017;18(2):270-280.

4. Melniker LA, Leibner E, McKenney MG, Lopez P, Briggs WM, Mancuso CA. Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency

department: the first sonography outcomes assessment program trial.

Ann Emerg Med. 2006;48(3):227-235.

5. Ollerton JE, Sugrue M, Balogh Z, D’Amours SK, Giles A, Wyllie P. Prospective study to evaluate the influence of FAST on trauma patient management. J Trauma.

2006;60(4):785-791.

6. Barbosa RR, Rowell SE, Fox EE, et al. Increasing time to operation is associated with decreased survival in patients with a positive FAST examination requiring emergent laparotomy. J Trauma Acute Care Surg.

2013;75(1 Suppl 1):S48-52.

7. Hoff WS, Holevar M, Nagy KK, et al.

Practice management guidelines for the evaluation of blunt abdominal trauma: the East practice management guidelines work group. J Trauma.

2002;53(3):602-615.

EMpulse Fall/Winter 2023

8. Boulanger BR, McLellan BA, Brenneman FD, et al. Emergent abdominal sonography as a screening test in a new diagnostic algorithm for blunt trauma. J Trauma. 1996;40(6):867874.

9. Altinok T, Can A. Management of tracheobronchial injuries. Eurasian J Med. 2014;46(3):209-215.

10. Buttar S, Cooper D, Jr., Olivieri P, et al.

Air and its Sonographic Appearance: Understanding the Artifacts. J Emerg Med. 2017;53(2):241-247.

11. Verniquet A, Kakel R. Subcutaneous emphysema: ultrasound barrier. Can J Anaesth. 2011;58(3):336-337.

12. Kubodera T, Adachi YU, Hatano T, Ejima T, Numaguchi A, Matsuda N. Subcutaneous emphysema and ultrasound sonography. J Intensive Care. 2013;1(1):8.

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FEATURE

An Accidental Medical Holiday: The Beginning of a Passion to Care for those in Honduras

By Jeremy Selley, DO, FACOEP

ED providers are so alike. We work very hard taking care of too many patients.

We often spend more time coordinating social non-emergent issues than patients’ physical issues. Our workload is HUGE, our support and self-care suffer.

I have learned to welcome the break from the chaos of the ED. I was introduced to international medicine in 2016 when my wife and a local nurse in North Carolina decided that I would join her mission team to Honduras. Being voluntold can end in disaster, but in this instance, it was quite the opposite. I could have never guessed that my introduction to the Carolina Honduras Health Foundation (CHHF) would become my new passion.

I had always wanted to do some medical mission work, but years went by before opportunity met great timing. I had seen our local church take religious trips across the globe and watched medical teams

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help in Haiti and Guatemala. Unfortunately, I always found just the right excuse not to sign up. There was never anyone going on a trip that I knew… it wasn’t the right time…

I’d be gone too long… the fee seemed too much. Isn’t it easy to find reasons to avoid something that is appealing but scary?

In July 2017, I finally took the leap and made my first trip to Honduras. I was nervous. It wasn’t my first time out of the country with a passport, but it was my first time on a medical mission to a third world country. I had no idea what to expect. I had served in the US Navy and had even went to Jordan, Kuwait, Dubai and Bahrain.

I could not pinpoint why Honduras made me nervous, but it did. I even wrote a goodbye note to my wife and kids and placed it in the gun safe before leaving!

Once I arrived, things appeared just simple. My journey became more about experiencing the beautiful culture of the

EMpulse Fall/Winter 2023

country and less about my fears.

I found everything to be scaled down and less affluent. The people were all very friendly and welcoming. In some of the more populated areas I found a shanty next to a brand-new Pizza Hut. Many simple block homes did not have stucco, but the windows had bars and razor wire on top of their fences.

The trip from the airport in San Pedro Sula to the clinic in Limón took a full day. Two half days of driving with a one-night sleepover in La Ceiba where I was first introduced to Honduran fruit. The fruit. I could talk about it for hours (and crave it every day)! The fruit is absolutely amazing. Pineapple from Honduras is on a different level. Coupled with fresh coconut juice, that pineapple can make one hell of a Piña Colada. The fruit and fajitas that we had at the hotel the first night are truly what foodie dreams are made of.

Once at the clinic in Limón, after settling into our rooms, we all gathered onto the porch.

Lined with weather beaten wood rocking chairs, overlooking the ocean through dozens of coconut palms trees, there was an aura of solitude. It was such a contrast from the chaos I had expected to find.

The CHHF staff greeted us and we were introduced to Bexa and Elda, the two local cooks that would make us our food over the next 5 days, helping to cement my love for Honduran food and coffee. Both only speak Spanish, but the language of good food transcends any language barrier. It also provides the needed energy to face the long, busy days of clinics I was about to experience.

During four days of clinics, our team of 13 provided primary care to over 400 patients at the main clinic and two clinics in remote locations. The need for medical care was great, but there was such a huge difference from patients I typically saw in the ED. The patients I saw, many walking miles for their visit, were happy to see me. Every single one was happy, gracious, and thankful.

When was the last time you were able to say that about a week of patient care?

Remote villages were an exciting part of the experience. Just getting there on an old yellow school bus on unpaved, rocky roads was interesting. The dust was overwhelming at times. At one point we were forced to push past a heard of cows to continue our drive. It’s certainly a reminder that we were not in the United States.

The children were so happy and playful.

They comprised about 50% of the patients seen during the week. One young boy really touched my heart. Darlin was a 4-year-old who could barely walk the day I met him.

He sustained a traumatic brain injury from an auto accident in 2017. He needed to see a neurosurgeon in San Pedro to have a skull plate placed to cover his brain from his previous craniotomy. He needed to have his extraocular muscles corrected to fix his strabismus and he needed physical and occupational rehab. His parents did not know where to begin. They also did not have the money to provide for this medical care. It was heartbreaking. CHHF helps to coordinate and pay for referral specialist care for patients similar to Darlin that come to our clinic. Watching a young girl receive a leg prosthesis and walk for the first time, post traumatic leg amputation, with tears of joy streaming down her face, erasing two years of depression, is another example.

The villages served by the mission team are almost two hours from a hospital that does not even provide linen sheets or medication. If a patient finds transportation, they don’t the financial resources to pay.

No one in Honduras goes to the ED for small issues like patients do in the USA. During my week, I saw a lot of kids with sniffles and coughs. There were adults with chronic HTN and DM. Unlike at the government clinics and hospitals in Honduras, all CHHF clinics provide medications for free. The teams pay for and bring what they will use with them, and then some. There is always an ongoing and revolving pharmacy supply of a full

EMpulse Fall/Winter 2023

formulary that CHHF coordinates.

After the clinic days we reverse and make the 2-day trek back to the airport, sometimes with a day to decompress before making the long journey home. Uniformly, on the plane ride home, everyone starts to plan their trip for the following year, hoping they can make their schedule work. Before your feet touch the ground, you miss everything about Honduras. Because at this point, you have fallen in love with the country, people, food and most importantly the mission!

If you are like my wife, after her first trip, you will sit on the plane ride home, tearful, as the emotions overwhelm you and as you recant what an amazing experience from both a clinical and humanistic side. A medical mission team experience is difficult to explain, but it will change your life forever.

My wife, my friends, and I are proof that you can fall in love with missions. As an added bonus, you have created new friends on your team, have new CHHF staff family members in Honduras, and have lasting memories, group chats and Facebook friends to last the rest of your life!

CHHF medical mission teams go 18 times a year. There is always room for you. Put the stress of working in the ED aside for one solid week. Serve under resourced villages full of people who are generous and grateful.

For more information, you can visit www. chhf.org or email us at contact@chhf.org.

Take the first step and inquire today. I promise it will renew your spirit and refresh your energy. ■

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EMpulse Fall/Winter 2023

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EMpulse Fall/Winter 2023

Emergency Medicine CLINICIAN EDITORIAL ARTICLE

FROM CARE TO CRISIS: The Emergent Need to Address Violence Against Healthcare Workers — by Michelle F. Wallen, DO, MS, Emergency Medicine Medical Director at Envision Physician Services As clinicians, our core mission is to heal, assist, and empathize with our patients. Unfortunately, amidst our dedication, we face a growing epidemic: violence against healthcare workers. Recent statistics are alarming, with approximately half of Emergency Department physicians reporting physical assault in the past year. The World Health Organization estimates that around 38% of healthcare workers worldwide experience physical violence during their careers. Even more shocking, last year’s Press Ganey report revealed that two nurses were assaulted every hour.

Violence against healthcare workers takes on many forms, including physical and verbal assault, online threats, sexual harassment, stalking, and bullying. The underlying causes are complex, often stemming from patient and family frustrations related to diagnoses, extended wait times, miscommunication, or dissatisfaction with care. Mental health challenges and substance abuse can also exacerbate the problem.

The consequences of violence against healthcare workers are significant. Beyond physical injuries, healthcare workers endure psychological trauma and are at risk of developing post-traumatic stress disorder, diminishing their overall well-being. This, in turn, increases burnout, which can disrupt the delivery of care to patients.

To combat this epidemic, we must prioritize heightened awareness and education. Healthcare workers should be well-informed about the risks and actively participate in training, drills, and de-escalation techniques. Ensuring a secure environment is paramount. This can include installing security cameras, posting signage indicating that harming a healthcare worker is a felony if appropriate, having security guards and metal detectors present, and flagging patients’ behavior in electronic medical records to denote prior patient threat levels.

Furthermore, we must establish firm legal consequences for individuals who commit acts of violence against healthcare workers. Emphasizing the importance of reporting these crimes should be a universal practice across all healthcare sectors, ensuring that healthcare workers can report incidents without fearing retaliation.

In its commitment to supporting clinicians, Envision Physician Services is constantly evaluating solutions to reduce the risk of violence against healthcare workers and create safer workplaces. The medical group’s Clinical Center of Excellence continues to share best practices to help assess current safety measures and opportunities to improve mitigation efforts and education.

Violence against healthcare workers is a pressing issue that jeopardizes the well-being of those dedicated to healing others. By fostering awareness and decisive action, we can combat this epidemic. Healthcare workers should not live in fear when fulfilling their duties, and their safety should be paramount. These types of physical and verbal assaults are unacceptable in other workforces, and the same should hold true in the healthcare field. Together, we must take a stand to protect healthcare workers, so that healing hands remain unharmed as they strive to save lives and provide compassionate care.

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727.268.8374 Envision.Health/FCEP

EMpulse Fall/Winter 2023

CALL FOR PRESENTATIONS: SBS 2024 The Florida College of Emergency Physicians (FCEP), in conjunction with the Florida Emergency Medicine Foundation (FEMF), is requesting presentations for its 53rd Annual Meeting: Symposium by the Sea 2024 on July 25-28, 2024 at the Eden Roc Miami Beach.

Symposium by the Sea participants include emergency physicians, residents, nurses, physician assistants and medical students.

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Florida College of Emergency Physicians & Florida Emergency Medicine Foundation

ANNUAL CALENDAR 2023 - 2024

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July 25-28, 2024

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