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FALL/WINTER 2014
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2014
Since 1990
fcep.com
EMpulse
Volume 21, Number 4
Florida College of Emergency Physicians
3717 South Conway Road
Orlando, Florida 32812-7606
t: (407) 281-7396 • (800) 766-6335
f: (407) 281-4407
fcep.org
Executive Committee
Ashley Booth-Norse, MD, FACEP • President
Steven Kailes, MD, FACEP • President-Elect
Jay Falk, MD, FACEP • Vice President
Joel Stern, MD, FACEP, FAAEM • Secretary/Treasurer
Michael Lozano, Jr., MD, FACEP • Immediate Past President
Beth Brunner, MBA, CAE • Executive Director
Departments
4 | PRESIDENT’Smessage | Ashley Booth-Norse, MD, FACEP
5 | MEDICALeconomics | Daniel Brennan, MD, FACEP
7 | GOVERNMENTaffairs | Joel Stern, MD, FACEP
12 | EMS/TRAUMAupdate | Christine Van Dillen, MD, FACEP
14 | POISONcontrol | Kristin Bohnenberger, PharmD
15 | MEMBERSHIP & PROFESSIONALdevelopment | René Mack, MD
20 | MEDICAL STUDENTupdate | Tushar Gupta, MSIV
22 | EMRAF Case Presentation | Bryant Lambe, MD
26 | RESIDENCYmatters Editorial Board
Karen Estrine, DO, FACEP, FAAEM • Editor-in-Chief
[email protected]
Features
Gina Fickett • Managing Editor/Graphic Designer
[email protected]
10 | Medical Malpractice Caps Overturned by Supreme Court | Michael R. Lowe, Esquire
9 | DAUNTINGdiagnosis | Karen Estrine, DO, FACEP, FAAEM
11 | Emergency Medicine Wins Ruling for PIP | Rutledge M. Bradford, Esquire
13 | CODING TIP | Lynn Reedy, CPC, CEDC
17 | ITLS Florida Chapter Report | Melissa McNally, MMSc, PA-C,
EMT-P
18 |
Better ER Management Requires Partnership Between Physicians and Clinical Care Coordinators | Roxanne Sams, MS, ARNP-BC, MA; Lisa M. Bragg, RN, BSN, MBA
19 |
Nursing Specialty Certifications Benefit | Katrin Breault BSN, RN, CEN; Darleen Williams MSN, CNS, CEN, CCNS, CNS-BC, EMT-P
21 |
Representative Pigman Addresses EM Residents on Advocacy; Touts Simulation Training | Kevin Fritz
All advertisements appearing in the Florida EMpulse are printed as received from the advertisers. Florida College of
Emergency Physicians does not endorse any products or services, except those in its Preferred Vendor Partnership. The
college receives and distributes employment opportunities but does not review, recommend or endorse any individuals,
groups or hospitals that respond to these advertisements.
NOTE: Opinions stated within the articles contained herein are solely those of the writers and do not necessarily reflect
those of the EMpulse staff or the Florida College of Emergency Physicians.
4
PRESIDENT’Smessage
Ashley Booth-Norse, MD, FACEP
FCEP PRESIDENT
Ebola - the Latest in
Potential Public Health Crises
I took over as FCEP president
in August during the 2014
Symposium by the Sea held in
Boca Raton from Dr. Mike Lozano.
I have to say that I have big shoes to fill. I want to personally
thank Dr. Lozano for his service as FCEP president. He did an
amazing job and will be hard to follow as president. I also
want to thank the off-going board of directors’ members- Drs.
Kelly Gray-Eurom, Gary Gillette and Nate Lisenbee (EMRAF
rep). They all did a wonderful job and will be missed. Special
thanks go to Dr. Gray who leaves the BOD after serving as
FCEP president in 2012-13 and immediate past President in
2013-14. No one does this job alone and I am blessed to have
a wonderful and very talented board of directors. I would like
to thank my executive committee for all the work they have
done already this year- Drs. Steve Kailes, Jay Falk and Joel
Stern- they are a great team!
As I start my term as FCEP president, FCEP and FEMF are in the
process of literally building a new home for both organizations.
The new building is scheduled to be completed in October
(which as we all know means more likely November). This will
mark a new chapter in FCEP history. We have grown so much
in the last decade that we are desperately in need of the
new space. The new building will allow us to provide more
educational opportunities, host more events and provide
more services to our members. However the new building
comes at a cost- we must pay for the new space and as we
get closer to our targeted move-in date this task becomes
more daunting. The FCEP/FEMP Capital Campaign continues.
In the eloquent words of our former president: “please give
generously yourself and if you happen to know someone
who has been blessed with more of life’s tangible riches,
please refer them to us.”
In my first quarter as FCEP president, our profession of
emergency medicine has been under attack in the media.
Once again we are being targeted in our role as the safety
net for the healthcare system in this country. Articles in the
Tampa Bay Times to the New York Times have stated that,
“Even in in-network hospitals, insurance may not cover ER
physicians.” These articles attack our ability to balance bill
even when insurance companies ignore the “usual and
customary standard” in regards to reimbursement. A ban on
balance billing will create huge benefits for health insurance
companies while endangering the health care safety net.
We have responded with a letter to the editor of the Tampa
Bay Times that was published in September 27, 2014. We
will continue to educate legislators as well as the public.
Emergency Medicine is essential to every community and
must have adequate resources. We must ensure that health
plans provide fair payment for emergency services or patient
care/access will suffer.
In addition, we as emergency physicians are also facing the
public health crisis of Ebola. Like SARS, MERS, Hantavirus, and
the anthrax crisis after 911, newly identified serious population
health threats continue to occur. The world is a much smaller
place than it used to be and as the Ebola epidemic in West
Africa continues, concern for spread to the US becomes real--this became evident when the first case was diagnosed in
Texas in September. As emergency physicians, we are skilled
in responding to disasters and treating every kind of medical
condition as part of our daily routines. We are also critical
to the American health care response to infectious diseases.
Clearly this disease deserves our attention and emphasis
from health care providers across the country.
The CDC, the Emergency Care Coordination Center and
the Assistant Secretary for Preparedness and Response
have provided materials that are excellent resources for
emergency physicians and other staff in the ED. Ebola is a
serious communicable disease. Heightened vigilance for case
presentations and strict adherence by health care personnel
to CDC advice, public education and a pre-planned medical
response is necessary.
These resources are available on ACEP’s website at www.acep.
org/ebola. They include screening criteria and case definition.
The CDC recommends two initial steps in screening for Ebola
Virus Disease:
1. The symptoms are likely to be fever, headache, joint and
muscle aches, weakness, fatigue, diarrhea, vomiting,
stomach pain and lack of appetite, and in some cases
bleeding.
2. Travel to West Africa or other countries where EVD
transmission has been reported by the World Health
Organization within 21 days of symptom onset.
If both of these criteria are met the patient should be moved
to a private room, and standard contact and droplet isolation
precautions followed during further assessment.
We see dozens of patients each week, and particularly at this
time of year, many will have a common cold or influenza.
All health care professionals in the emergency department
should know the protocols and what to ask so we can do
everything possible to ensure that this Ebola case in Dallas
remains isolated.
2014
MEDICALeconomics
fcep.com
5
Daniel Brennan, MD, FACEP
MEDICAL ECONOMICS COMMITTEE CHAIR
CMS Physician Quality
Reporting System (PQRS) Update
As Ashley Booth-Norse has assumed FCEP President’s
duties, I am pleased to Chair the Medical Economics
Committee. My goal is to use this column to update
members on the issues that impact the economic life
of your groups. Often, these issues will overlap with
Governmental Affairs, including PPACA, Medicaid
reform (HMOs, possible expansion), PIP, ACOs, and
payment reform. Hopefully the information will be of
use to all FCEP members, whether focused clinically or
in administrative roles, overseeing payor contracting,
coding and billing, and compliance.
Recently, CMS announced updates to their Physician
Quality Reporting System (PQRS). This program began
as an incentive program, initially providing a bonus for
merely reporting metrics (regardless of success achieved
with the measures). Highlights of the 2014 changes:
• Reporting can be done by individual EPs, or by group
practices.
• Reporting options include Medicare Part B claims,
Qualified PQRS registry, EHR (Certified EHRs, directly
or via data submission vendors), qualified clinical
data registries or CMS Certified survey vendors.
• Measures reported vary year to year and by specialty.
For EM, commonly reported measures include:
o #28: ASA at arrival in AMI
o #54: 12 lead ECG for nontraumatic chest pain
o #55: ECG for syncope
o #56: VS in Community Acquired Pneumonia (CAP)
o #59: Empiric antibiotics in CAP
o #254: Ultrasound determination of pregnancy location in pregnant patients with
abdominal pain
o #255: RhoGam for Rh- pregnant women at risk for fetal blood exposure
o Note: #29 (B-blocker in AMI), #57 (O2 saturation in CAP), and #58 (Mental status in CAP) have been retired.
• Payment incentives up to +0.5% of the total estimated
Medicare Part B Professional Fee Schedule (PFS) for
individual EPs satisfactorily submitting PQRS quality
data.
• EPs who do not satisfactorily report data on quality
measures for 2014 will be subject to a 2% payment
•
•
•
•
•
•
•
“adjustment” (penalty) to their Medicare PFS for
services provided in 2016.
An additional -2% Value-Based Modifier (VBM)
payment penalty may be added.
Group practices can participate in the group practice
reporting option (GPRO).
Registration needed to be completed by Oct 3rd,
2014.
In 2016, groups with 10 or more EPs submitting claims
to Medicare under a single tax ID will be subject to
the value modifier, based upon 2014 performance.
If the GPRO is not chosen, at least 50% of the EPs
must report individually, and CMS will calculate
the group quality score to make the VBM and PQRS
adjustments.
Failure to participate will result in 2% PQRS and
2% VBM “adjustments” (ie, penalties), an impact of
approximately $2500 per provider according to
ACEP.
Whether participating as an individual or as a group,
ACEP has developed a PQRS registry reporting
option, which is being provided to ACEP members
at a discount.
In addition to the PQRS and VBM adjustments discussed
above, there is also a Maintenance of Certification (MOC)
Program. Submitting PQRS data, along with activities
associated with maintenance of Board Certification, can
qualify EPs for an additional 0.5% bonus incentive. This
requires registration with a CMS certified MOC Program
entity, like ABEM. The 2014 deadline for registration
is February 2015, but the MOC activities need to be
completed in calendar year 2014.
SUMMARY:
Four Distinct PQRS Programs
1. Traditional PQRS Incentive
2. PQRS MOC Incentive
3. PQRS Penalties For Failure
to Report
4. Value-Based Modifier
(VBPM)* For Failure to
Report PQRS*
2014 Performance Year (PY):
+0.5% payment in 2015
+0.5% payment in 2015
-2.0% in 2016
-2.0% in 2016
Join The Nation’s Premier Emergency
Practice Management Group
HOT JOBS!
Capital Regional - Tallahassee
Aventura Hospital and Med Ctr (Aventura)
70K annual visits; Brand new EM residency program
coming July 2016!
Residency Program Director Opportunity
Call Ody Pierre-Louis at 727-507-3621
University Hospital (Fort Lauderdale)
35K annual visits
Call Lisa M. Chamerski at 727-507-250
Lehigh Regional (Fort Myers)
36K annual visits
Call Sabrina Mesic at 727-507-2509
• 65,000 annual patient visits
• 42-bed ED
• Phys cvg: 41 hrs main + 12 hrs express +
10-20 hrs peds + 60 hrs PA/NP cvg
• Independent contractor status
Call Shawn Stampfli at 850-428-5819
West FL Hospital - Pensacola
Lawnwood Regional (Fort Pierce)
60K annual visits, Level II Trauma
Call Lisa M. Chamerski at 727-507-2508
NEW! Memorial Emergency Care Center - Atlantic
(Jacksonville). Brand new full-service Emergency Center
affiliated with Memorial Hospital Jacksonville, opened
summer 2014! Estimated 10K visits in year one.
Call Frances Miller at 727-507-2507
Lake City Medical Center (Lake City)
25K annual visits EM Medical Director Opportunity
Call Frances Miller at 727-507-2507
Raulerson Hospital (Okeechobee)
27K annual visits Call Lisa M. Chamerski at 727-507-2508
• 54,000 annual patient visits
• 40-bed ED (including FastTrack)
• 5 psyc beds in locked unit
• 41-52 hrs phys + 60 hrs PA/NP coverage
• Employee status w/benefits
Call Shawn Stampfli at 850-428-5819
Bayonet Point - Tampa
Osceola Regional (Orlando)
84K annual visits
Affiliated Freestanding ED - NEW! Hunter’s Creek ER
Call Amelia Hemsath at 727-437-0823
Poinciana Hospital (Orlando)
35K annual visits
Call Amelia Hemsath at 727-437-0823
Gulf Coast Med Center (Panama City)
60K annual visits
Call Esther Aguilar at 727-507-3656
Fawcett Memorial Hospital (Port Charlotte)
25K annual visits
Call Frances Miller at 727-507-2507
Fishermen’s Hospital (Marathon, FL)
9K annual visits
Call Sabrina Mesic at 727-507-2509
• Level II Trauma Center, 36K visits/yr.
• 22-bed ED and 6-bed Fast Track
• 46 hrs phys + 24 hrs PA/NP coverage
• Employee status w/benefits
• Stellar subspecialty backup (Trauma
surgeons and Anesthesia in-house 24/7)
Call Frances Miller at 727-507-2507
Leesburg Regional Medical Center (Leesburg, FL)
45K annual visits
Medical Director and Staff Opportunities
Call 877-751-1157
Northside Hospital (Saint Petersburg)
31K annual visits
Associate Director and Staff
Call Esther Aguilar at 727-507-3656
Clearwater ER (Clearwater)
Freestanding ED, a dept. of Largo Medical Center
Call Esther Aguilar at 727-507-3656
Doctor’s Hospital (Sarasota)
23K annual visits
Call Sabrina Mesic at 727-507-2509
FL Hospital Heartland System (Sebring)
3 campuses ranging from 11 to 25K annual visits
Call Sabrina Mesic at 727-507-2507 or
Derek Sawyer at 727-533-8715
Gadsden Memorial Campus (Tallahassee)
Freestanding ED affiliated with Capital Regional
15K annual visits
Shawn Stampfli at 850-428-5819
Bayfront Health (Tampa Bay)
2 campus system; 26K and 30K annual visits
Call Lisa M. Chamerski at 727-507-2508
Brandon Regional (Tampa Bay)
106K annual visits
Second campus in Plant City
Estimated 15K visits in year one
Call Esther Aguilar at 727-507-3656
Medical Center of Trinity (Tampa Bay)
50K annual visits
Call Frances Miller at 727-507-2507
Oak Hill Hospital (Tampa Bay)
35K annual visits
Call Frances Miller at 727-507-2507
NEW! Tampa Community Hospital (Tampa Bay)
18K annual visits
Call Barbara Lay at 727-507-3608
West Palm Hospital (West Palm Beach)
28K annual visits
Call Lisa M. Chamerski at 727-507-2508
Westside Med Ctr (Plantation)
45K annual visits
Call Lisa M. Chamerski at 727-507-2508
The Villages Regional Hospital (The Villages, FL)
40K annual visits
Staff Opportunities
Call 877-751-1157
For more opportunities, visit
www.EmCare.com or contact us directly at [email protected]
2014
GOVERNMENTaffairs
fcep.com
7
Joel Stern, MD, FACEP
FCEP SECRETARY/TREASURER
GOVERNMENT AFFAIRS COMMITTEE CO-CHAIR
The GA Committee met on August 7 in Boca Raton at Symposium by the Sea. Topics discussed were recent FMA
actions, communication with Representative Pigman, access to care for Behavioral Health patients, planning for
EM Days 2015, and issues regarding EMTALA. We also had a meeting of our PAC Committee. Items discussed were
increasing member awareness of the PAC, strategies for facilitating donations, and listing which candidates FCEP
will be endorsing through PAC in the upcoming elections. We are looking for participation on our GA Committee
and PAC. Please contact the FCEP office if you would like to get involved. Currently we are delivering campaign
checks to the candidates we are supporting in the November elections. We also encourage all members to set up
meetings with your local representatives in the Florida Congress and Senate. Asking them if they would like to tour
your local ED is a great way to make them aware of our issues on a personal level. Also, please make plans to attend
EM Days in March. It is our annual advocacy event in Tallahassee, where we meet one on one with the legislators
to educate them about what is important to us as Emergency Physicians in Florida. Remember, if we do not have a
seat at the table, we may end up as someone’s lunch!
Candidates Endorsed Through PAC
State Senator General Election 2014
State Representative General Election 2014
District
Candidate
City
District
Candidate
City
6
Thrasher, John (REP) *Incumbant
St. Augustine, FL
1
Ingram, Clay (REP) *Incumbent
Pensacola, FL
10
Simmons, David (REP) *Incumbent
Altamonte Springs, FL
2
Hill, Mike (REP) *Incumbent
Pensacola, FL
12
Thompson, Geraldine F. (DEM)
*Incumbent
Orlando, FL
3
Broxson, Doug (REP) *Incumbent
Milton, FL
5
Drake, Brad (REP)
Marianna, FL
14
Soto, Darren (DEM) *Incumbent
Kissimmee, FL
6
Trumbull, Jay (REP)
Panama City, FL
20
Latvala, Jack (REP) *Incumbent
Clearwater, FL
8
Williams, Alan (DEM) *Incumbent
Tallahassee, FL
22
Brandes, Jeff (REP) *Incumbent
St. Petersburg, FL
10
Lake City, FL
24
Lee, Tom (REP) *Incumbent
Brandon, FL
Porter, Elizabeth Whiddon (REP)
*Incumbent
32
Negron, Joe (REP) *Incumbent
Palm City, FL
11
Adkins, Janet H. (REP) *Incumbent
Fernandina Beach,
FL
34
Bogdanoff, Ellyn (REP)
Delray Beach, FL
12
Ray, Lake (REP) *Incumbent
Jacksonville, FL
36
Braynon, II, Oscar (DEM) *Incumbent
Miami Gardens, FL
15
Fant, Jay (REP)
Jacksonville, FL
16
McBurney, Charles (REP) *Incumbent
Jacksonville, FL
17
Renuart, Ronald “Doc” (REP) *Incumbent
Ponte Vedra Beach,
FL
18
Cummings, Travis (REP) *Incumbent
Orange Park, FL
21
Perry, Warren “Keith” (REP) *Incumbent
Gainesville, FL
25
Costello, Fred (REP)
Daytona Beach, FL
8
Candidates Endorsed Through PAC (continued)
26
Taylor, Dwayne L. (DEM) *Incumbent
Daytona Beach, FL
77
Eagle, Dane (REP) *Incumbent
Cape Coral, FL
27
Santiago, David (REP) *Incumbent
Deltona, FL
82
Magar, MaryLynn (REP) *Incumbent
Hobe Sound, FL
28
Brodeur, Jason (REP) *Incumbent
Sanford, FL
86
Pafford, Mark (DEM) *Incumbent
West Palm Beach, FL
29
Plakon, Scott (REP)
Longwood, FL
89
Hager, Bill (REP) *Incumbent
Boca Raton, FL
39
Combee, Neil (REP) *Incumbent
Auburndale, FL
92
Burton, Colleen (REP)
Lakeland, FL
Clarke-Reed, Gwyndolen “Gwyn”
(DEM) *Incumbent
Pompano Beach, FL
40
41
Wood, John (REP) *Incumbent
Winter Haven, FL
93
Moraitis, George (REP) *Incumbent
Fort Lauderdale, FL
46
Antone, Bruce (DEM) *Incumbent
Orlando, FL
103
Diaz, Jr., Manny (REP) *Incumbent
Hialeah, FL
47
Miller, Mike (REP)
Orlando, FL
105
Trujillo, Carlos (REP) *Incumbent
Doral, FL
51
Crisafulli, Steve (REP) *Incumbent
Merritt Isalnd, FL
108
Miami Shores, FL
53
Tobia, John (REP) *Incumbent
Melbourne, FL
Campbell, Daphne (DEM) *Incumbent
54
Mayfield, Debbie (REP) *Incumbent
Vero Beach, FL
110
Oliva, Jose (REP) *Incumbent
Hialeah, FL
59
Spano, Ross (REP) *Incumbent
Riverview, FL
112
Rodriguez, Jose Javier (DEM) *Incumbent
Miami, FL
61
Narain, Edwin “Ed” (DEM)
Tampa, FL
114
Fresen, Erik (REP) *Incumbent
Miami, FL
66
Ahern, Larry (REP) *Incumbent
Seminole, FL
115
Bileca, Michael (REP) *Incumbent
Miami, FL
67
Latvala, Chris (REP)
Clearwater, FL
116
Diaz, Jose Felix (REP) *Incumbent
Miami, FL
68
Young, Bill (REP)
St. Petersburg, FL
118
Artiles, Frank (REP) *Incumbent
Miami, FL
69
Peters, Kathleen (REP) *Incumbent
St. Petersburg, FL
119
Nunez, Jeanette M. (REP) *Incumbent
Miami, FL
72
Pilon, Ray (REP) *Incumbent
Sarasota, FL
74
Gonzalez, Julio (REP)
Sarasota, FL
75
Roberson, Ken (REP) *Incumbent
Port Charlotte, FL
76
Rodrigues, Ray (REP) *Incumbent
Fort Myers, FL
26th Annual
Advocacy all the way
to the State Capital!
Join FCEP at the state capital, meet legislators,
and lobby for better access to quality care!
March 9 - 11, 2015
Hotel Duval by Marriott
Tallahassee, Florida
Registration is FREE for FCEP members.
Stay tuned to fcep.org for updates!
2014
DAUNTINGdiagnosis
fcep.com
Karen Estrine, DO, FACEP, FAAEM
EDITOR IN CHIEF
DAUNTING DIAGNOSIS
Question:
What does this picture show, and how
could this have been prevented?
(Answer on page 25)
SAVE THE DATE
9
10
EMPULSEeditorial
Michael R. Lowe
Board Certified Health Law Lawyer
Medical Malpractice Caps Overturned by Supreme Court
- How Does This Impact You?
Florida Supreme Court Overturns
Caps on Wrongful Death Medical Malpractice Awards.
In March, the Florida Supreme Court declared the
statutory caps placed on non-economic damages in
medical malpractice cases unconstitutional in cases
involving wrongful death claims. The Court did so in
McCall v. United States of America which was a federal
tort case involving medical malpractice claims against
the federal government and Air Force medical personnel.
Significantly, the federal trial judge who heard the case
awarded Ms. McCall’s surviving family members $2
million in non-economic damages, but reduced the award
to $1 million based on Florida’s caps on non-economic
damages. On appeal, the U.S. Eleventh Circuit Court of
Appeals upheld the ruling finding that the caps did not
violate the U.S. Constitution, but stating that the Florida
Supreme Court should consider Florida constitutional
issues. Thus, the Court did so and overturned caps on
non-economic damages awards in wrongful death medical
malpractice cases.
The McCall decision may or may not be addressed in further
litigation and/or by the Florida Legislature. Regardless, it
is significant for physicians and health care providers and
professionals of all types because of its possible impact on
the medical malpractice and professional liability industry
in Florida. One only need recall the medical malpractice
insurance crisis which Florida experienced in the early to
mid-2000s which caused many physicians to go bare due
to skyrocketing premiums and a large number of insurance
carriers leaving Florida and no longer offering medical
malpractice or professional liability insurance policies.
The decision is also significant as the Florida Supreme
Court has not yet ruled on whether caps on non-economic
damages are unconstitutional in medical malpractice cases
that do not involve a wrongful death claim. There are still
several cases making their way through litigation and the
appellate process which could ultimately end up before the
Court and result in a ruling either way.
For physicians, hospitals, ambulatory surgical centers,
and all other types of licenses health care professionals,
facilities and providers, it is important to take note of the
McCall decision and how it could impact them. Health
care providers, facilities and professionals should review
their professional liability and medical malpractice policies
to determine if they have sufficient limits and coverage to
address large claims and potential excess verdicts which
might exceed their coverage limits as many current
policies were designed, purchased and implemented after
the statutory caps were put in place in 2003-2004 and
before the McCall decision. Health care providers and
professionals should also consider whether the McCall
decisions impacts them if they have any currently pending
medical malpractice professional liability cases involving
wrongful death claims and/or potential excess verdicts.
Furthermore, they should consider retaining personal
counsel in cases involving wrongful death allegations or
significantly large potential damages claims which could
result in excess verdicts. Another recommendation would
be for all licensed health care professionals, and in particular
doctors and physicians, to review their employment
contracts or independent contractor agreements with any
employer, facility or health care provider to ensure that
they have sufficient medical malpractice or professional
liability insurance coverage, including tail coverage,
addressed in their contracts if such coverage is provided
by their employer or the entity with which the contract
to provide professional medical or health care services.
Finally, all licensed health care professionals and health
care providers and businesses should review their liability
and asset protection planning to account for the changes
which may result from the McCall and the underlying
decision and any future decisions on caps on noneconomic damages.
Mr. Lowe and our law firm regularly represent physicians
and other licensed health care professionals in the defense
of medical malpractice cases, review of their medical
malpractice professional liability insurance policies and
coverages, and personal counsel matters as well as the
review of employment contracts. To contact us regarding
such matters please visit our website www.lowehealthlaw.
com or call our office 407-332-6353. Michael R. Lowe, Esq.
is a board-certified health law attorney and shareholder at
Michael R. Lowe, P.A., 800-571-5208.
2014
EMPULSEfeature
fcep.com
11
Rutledge M. Bradford
Board Certified Civil Trial Lawyer
Emergency Medicine Wins Ruling for PIP
Thanks to Bradford Cederberg PA, emergency medicine has won two very significant rulings from the Circuit Court in
Seminole County sitting in its appellate capacity. The appellate rulings are the first of their kind in the state of Florida. In
affirming the trial court, the appellate court held that you cannot apply a provider of emergency services and care’s bill
toward an elected deductible in a PIP matter. This is a monumental ruling in favor of Emergency Physicians whose bills
are routinely applied toward patients’ deductibles in the PIP setting, despite a mandatory $5000.00 reserve for providers
of emergency services and care for payment of these charges. Auto insurers have basically ignored Florida’s PIP laws
promulgated for the benefit of Emergency Providers and have routinely ignored the mandatory $5000.00 reserve and
applied ED physician invoices to PIP auto deductibles. Thousands of claims have been filed on behalf of ED physicians
against auto insurance companies for the past several years and after initially settling the matter and paying the claim,
carriers united and took a hard line stance on this issue against ED physicians, despite more than 20 rulings in a three
county area in favor of ED physicians on this issue.
Emergency Physicians must submit their bills within 30 days of a MVA (date insurer knew of the claim) to avoid having
the deductible applied to their bill. If the Emergency Physician bills after that initial 30 day period, then the ED physician
loses the protection of the statute and stands in line like all other providers. The PIP deductible in those instances can
be applied toward their bill. These appellate decisions are being circulated around the state to others fighting on behalf
of ED physicians in the PIP arena.
SAVE THE DATE
12
EMS/TRAUMAupdate
Christine Van Dillen, MD, FACEP
COMMITTEE CO-CHAIR
The Florida humidity is finally tapering
off as the year moves into the fall
and winter. For most emergency
medical services personnel, this is an
exciting time because they are able
to participate comfortably in outdoor training. As snowbirds
and tourists traveling south for the winter swell our population,
emergency personnel remain prepared to respond to all calls.
Ebola: Our Worst Fears
This fatal virus is caused by infection with a virus of the family
Filovirdae, genus Ebolavirus. The Ebola virus causes disease
in humans and nonhuman primates. The first outbreak was
identified in Zaire in central Africa in 1976, claiming the lives
of 280 people. From 1976 through 2014, there were several
Ebola outbreaks with death tolls ranging from 1-280 individuals.
The current outbreak is a healthcare crisis: with 4400 fatalities
already documented, a number expected to only continue to
grow.
The Ebola case recently identified in Dallas, Texas, brought into
sharp focus the need to identify and contain the virus in the
United States. Are we prepared? Fortunately, the CDC has
extensive information and recommendations on how to prevent
spread of this disease:
http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/
index.html
The symptoms of Ebola include: fever, muscle pain, weakness,
diarrhea, vomiting, abdominal pain and unexplained bleeding.
Unfortunately, this presentation mimics sepsis, influenza and
other common diseases found in Africa such as typhoid fever
and malaria, making clinical diagnosis difficult. It is important
to recognize patients with these symptoms and question them
about risk of residence or travel to the high-risk African regions
of Guinea, Liberia, Nigeria, Sierra Leone, or contact with
symptomatic individuals from these regions. If patients confirm
exposure, they should be isolated immediately. It is critically
important that proper personal protective equipment (PPE)
be used in caring for these patients. If an infected patient is
identified in the pre-hospital setting, a limited number of EMS
personnel should be exposed and hospitals should be notified
prior to arrival.
The likelihood of contracting Ebola is extremely low unless
there is direct, unprotected contact with bodily fluids of a sick
individual (i.e., urine, saliva, feces, vomit, sweat, and semen).
Human transmission is also possible through direct handling of
bats or nonhuman primates from areas with Ebola outbreaks.
Therefore, proper PPE and infection control techniques must
be followed if there is concern that a patient is ill with Ebola or
may have been exposed to the virus.
If your community is at elevated risk for Ebola, questions about
travel to high-risk areas need to be coordinated at the dispatch
level. This strategy will help identify patients at risk and
prepare EMS crews to enter high-risk homes with appropriate
precautions.
Florida Association of EMS Medical Directors (FAEMSMD)
Report
Our July 16th meeting started with an exciting election of new
officers. They are as follows:
•
•
•
•
President: Dave Meurer, MD
Vice President: John Milanick MD
Secretary-Treasurer: Chris Hunter MD
Members at Large: Brooke Shepard MD and Christine Van
Dillen MD
Florida State Medical Director Report (provided by Dr. Joe
Nelson):
• At the State level, it was determined that the State EMRC
was not meeting statutory requirements and so this group
has been deactivated at this time. Some of their functions
will be reallocated.
• Both Adult and Pediatric Trauma Scorecard Methodology
in rule development
• Mandatory EMSTARS participation by EMS agencies
remains in rule development
• Dr. Nelson emphasized the importance of medical director
involvement in local healthcare coalitions throughout the
state
• Spine board practices: FAEMSMD previously issued a
position statement which coincides with the national trend
towards selective spinal immobilization in the appropriate
trauma patients. This practice across the state requires well
written medical care protocols, along with diligent training
and QA for success.
• An EMS stroke destination best practices discussion took
place. Should a primary stroke center be bypassed to take
a patient to a comprehensive center? If so, is there an
improvement in outcome? How far would this rule stretch?
Due to the variety of regions across the state ranging from
urban areas with multiple stroke centers within minutes of
reach to rural areas where the closest stroke center requires
transport for 1-2 hours, there is a great deal of controversy
surrounding this issue. There was a suggestion that data
from around the state may be helpful in this discussion.
EMSC Update
Dr. Lou Romig gave an update on EMSC activities, including a
committee on hospital readiness that will help hospitals increase
readiness to care for pediatric patients, and a focus on disaster
readiness as it relates to children. Dr. Laurie Romig discussed
the idea of creating a short survey to clarify the qualifications for
pediatric medical direction. (CONTINUED ON PAGE 24)
2014
CODING TIP
CRITICAL CARE SERVICES WITH PROCEDURES
When you provide separately billable services with
critical care, would you like to get paid for them? When
documenting the critical care minutes, include this
statement, “___ minutes spent engaged in work directly
related to patient care and/or available for direct patient
care, exclusive of procedure time.” Then document the
appropriate procedure note.
Procedures commonly provided with critical care are:
•
CPR – 92950 – work RVU 4.00
•
Cricothyroidotomy – 31605 – work RVU 3.57
•
CVP insertion – 36556 – work RVU 2.50
•
Endotracheal intubation – 31500 – work RVU 2.33
•
Pericardiocentesis – 33010 – work RVU 2.24
•
Thoracostomy – 32551 – work RVU 3.29
•
Tracheostomy – 31603 – work RVU 4.14
LYNN REEDY, CPC, CEDC, DIRECTOR OF CODING SERVICES,
CIPROMS SOUTH MEDICAL BILLING
“I can tell you without a moments hesitation the Icare is
the only tonometer we will ever use. The Icare is easy to
use, simpler to learn and operate than anything we have
used before. There is no finesse or learning curve.
We have used it on kids as well and they find it tickles
and laugh during the experience!
I have no problem endorsing this product at all,
I believe in it.“
Attilla Kiss, MD
Assistant Director of Emergency Department, St John Medical Center
fcep.com
13
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Contact Gina Fickett at
[email protected]
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PAs and allied health professionals, Florida’s
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Richard Homan
[email protected]
Toll Free: (800)428-1714 Cell: (813)505-3495
www.icare-usa.com
14
POISONcontrol
Kristin Bohnenberger, PharmD
Clinical Toxicology/ EM Fellow (2nd year)
University of Florida Health Jacksonville,
Jacksonville, Florida
The nonmedical use of prescribed
controlled substances has reached
epidemic proportions in the United
States, attracting national attention.
In fact, illicit substance abuse cost the
United States $11 billion in healthcare
related costs in 2012.1 According to
the results of the most recent National
Survey on Drug Abuse and Health,
8.37% of Florida residents aged 12 years
or older reported using illicit substances
in the past month (compared to a
national average of 9.4%).2,3 While the
issue of substance abuse itself may
come to you as no surprise, what you
may find interesting are the novel ways
abusers are utilizing pharmacokinetic
principles to potentiate their highs.
One such drug-drug interaction
being used for this purpose is that
of omeprazole and methadone.
Omeprazole inhibits the proton pump
in gastric parietal cells, blocking the
secretion of gastric acid and thus
increasing the pH of the stomach. In
an alkaline environment, such as that
created by omeprazole, methadone
exists predominantly in the nonionized
form. It is in this form that methadone
is absorbed from the gastrointestinal
tract and crosses the epithelium to
exert its effects. Taking omeprazole
prior to a dose of methadone, therefore,
can theoretically increase the serum
concentration of methadone.
De Castro et al. evaluated the effect
of pretreatment with omeprazole on
serum methadone concentrations
and respiratory depression in an
They Want to Put What Behind
the Counter?!
animal model. A total of 40 rats
were randomized to receive either
intravenous omeprazole or saline 2
hours prior to receiving a dose of oral
methadone. A correlation between
serum methadone concentration and
intragastric pH at 120 minutes following
methadone administration was found
to be statistically significant.4 The serum
methadone concentration was noted
to increase linearly with intragastric
pH. A statistically significant decrease
in the respiratory rate was observed in
the omeprazole group at all time points
beginning 30 minutes after methadone
administration compared to placebo.
Congruent with this finding, a decrease
in arterial pH and pO2 and an increase
in pCO2 was found to be statistically
significant in the omeprazole pretreated
group at 120 minutes.4
Secondary to this interaction, crafty
street chemists have attempted to
profit from the sale of commercially
available omeprazole.
Multiple
news reports detailing the theft of
omeprazole from pharmacies and other
retail establishments surfaced as early
as 2007. Increased media attention
has led to discussion of placing overthe-counter omeprazole behind the
pharmacy counter to prevent thefts.
Not only are older drugs being
misused to potentiate the highs of
pharmaceutical agents, but substances
newer to the United States, such
as kratom, have also been utilized.
Derived from plants of Mitragyna
speciosa, kratom is a substance that has
been used for centuries in southeastern
Asia for its stimulant and opioid-like
effects. Kong et al. found that alkaloids
extracted from M. speciosa were strong
inhibitors of CYP3A4 and CYP2D6
and moderate inhibitors of CYP1A2.5
Kratom therefore has the potential
to potentiate the highs of fentanyl,
methadone, benzodiazepines, zolpidem,
zaleplon, trazodone, hydrocodone,
oxycodone, dextromethorphan, and
cyclobenzaprine.
Lest we forget about food-drug
interactions that also utilize enzymatic
interactions to potentiate highs, online
drug forums are rich with accounts
of eating mangos prior to smoking
marijuana or drinking grapefruit juice
prior to taking tramadol. Both mangos
and grapefruit juice inhibit CYP450
isoenzymes.
Mangos inhibit the
metabolism of the benzodiazepines
and chlorzoxazone via inhibition of
CYP1A1, CYP1A2, CYP3A1, CYP2C6, and
CYP2E1.6 Grapefruit inhibits CYP3A4
and CYP1A2, thus having the potential
to prolong the high of marijuana,
fentanyl,
alfentanyl,
methadone,
benzodiazepines, zolpidem, zaleplon,
tramadol and trazodone. 6
Unfortunately,
the
time
when
prescribing a medication as seemingly
harmless as a proton pump inhibitor
without fear of its misuse and
contribution to the prescription drug
abuse epidemic may be no more.
The utilization of crafty chemistry
to potentiate the euphoric and/or
psychotropic effects of prescription
medications is something emergency
physicians should consider. If you have
any questions regarding medication
toxicities, please contact your local
poison center toll-free at 1-800-2221222.
(CONTINUED ON PAGE 24)
2014
MEMBERSHIP & PROFESSIONALdevelopment
fcep.com
15
René Mack, MD
COMMITTEE CO-CHAIR
Are You Certified?
There have been several changes to the
American Board of Emergency Medicine
(ABEM) Maintenance of Certification
(MOC) over the past years with the
last major changes published in 2011.
Although it has been three years, there
are still many of us who are still unsure
of the new requirements and how they
affect our license and our ability to
practice emergency medicine. To assist
with understanding and simplifying
the new requirements, ACEP and
FCEP have created and implemented
many timesaving and easily accessible
programs.
The ABEM MOC consists of essentially
four sections:
Part 1: Professional Standing – We must
continuously maintain medical licensure
in compliance with the ABEM Policy
on Medical Licensure and individual
state requirements. ACEP and FCEP
provide easily accessible information
on general and Florida-specific
requirements for medical licensure and
CME requirements. ACEP offers a myriad
of CME AMA PRA Category 1 Credits™
online and via multiple live conferences.
ACEP also offers a CME tracker so you’ll
always know your status. FCEP offers a
FREE annual CME conference where, on
average, you can obtain 12 AMA PRA
Category 1 credits™!
Part 2: Lifelong Learning Self Assessment
(LLSA) – ACEP membership grants you
access to the very useful LLSA Resource
Center which gives you access to EM:
Prep, LLSA summaries and much more!
At the FCEP Symposium by the Sea
(SBS), the FREE annual CME conference,
you have the opportunity to take one
or several years of LLSA tests while
concurrently earning AMA PRA Category
1 Credits™.
Part 3: Assessment of Cognitive
Expertise – This section covers the
ConCert exam on which a passing
score is required. For most of us this
exam evokes strong emotions from
hours spent studying and maybe even
worrying about whether your studying
will result in a passing score. Let ACEP
and FCEP take some of the stress out of
this part of your re-certification! ACEP
offers PEER VIII, the comprehensive,
well vetted study resource that is
offered on multiple platforms including:
print, iPhone, iPad and online. FCEP,
earlier this year, offered a live multiday review course which provided upto-date information on the pertinent
emergency medicine topics covered on
the ConCert exam.
Part 4: Assessment of Practice
Performance (APP) – This applies to
those who are clinically active; if you are
not clinically active you do not need to
participate in Part 4. The APP serves to
evaluate your level of involvement on a
national, regional, or local level regarding
improving patient care practice
improvement (PI) and patient centered
communication/professionalism (CP)
improvement plan that meets the
ABEM’s APP requirements. ACEP offers
many articles and lectures focused on
completing this required step of the
re-certification process. FCEP can also
provide guidance on several areas of
patient-centered improvement topics.
FCEP also produces several workshops
that can be used to help you develop
your own improvement plans.
The MOC requirements are divided
in two five year increments (re-
certification occurs on a ten year cycle).
They are distinguished by years 1-5 and
years 6-10.
In each five year time period you must:
• Pass four ABEM LLSA tests, one of
which must be the patient safety
LLSA
• Complete (and attest to completion
of ) an annual average of 25 AMA PRA
Category 1 Credits™ or equivalent.
Eight of those credits must be selfassessment, only required in years
1-5.
• Complete and attest to completion
of an Assessment of Practice
Performance (APP) Patient Care
Practice Improvement (PI) activity
• Complete and attest to completion
of an APP patient-centered
Communication/Professionalism
(CP) activity.
**Also, in years 6-10, you must pass
the ABEM continuous certification
(ConCert) examination.
Hopefully, this primer will provide
some clarity on your requirements for
continued licensure and remind you of
the many resources available to you as a
member of ACEP and FCEP.
https://www.abem.org/public/abemmaintenance-of-certification-(moc)/
moc-overview
http://www.abem.org/public/docs/
default-source/publication-documents/
moc-policies-and-procedures---2014.
pdf?Status=Temp&sfvrsn=4
http://www.acep.org/ContinuingEducation-top-banner/Assessment-ofPractice-Performance/
FCEP_Life_After_Residency_Final.pdf
1
9/10/14
12:06 PM
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2014
ITLSreport
ITLS Florida Chapter Report
fcep.com
17
Melissa McNally, MMSc, PA-C, EMT-P
Affiliate Faculty/Regional 6 Coordinator, ITLS Florida
President, Central Florida Emergency
Education Consultants
This past quarter, ITLS Florida had the unique opportunity to bring back the ITLS Access Course to the State of
Florida. The ITLS Access Course teaches critical skills that are essential for EMS crews and first responders who are
caring for individuals who were involved in a motor vehicle collision.
This 8 hour course trains responders to use simple hand tools instead of hydraulics in order to reach, stabilize, and
extricate trapped victims, while also giving special focus to the care of the patient. It is a great opportunity for
both large and small departments, as well as rural training agencies and initial training programs to receive training in vehicle and patient extrication, especially during a time when funding is tight and the ability to purchase
expensive hydraulic tools may not be feasible.
The first course was a Provider-Instructor Hybrid. It was open to a small focus group of seasoned ITLS Instructors.
lutions
ROFESSIONAL LIABILI TY AGENCY/
The course was offered byPCentral
Florida Emergency Education Consultants, a Central Florida Bureau of EMS ConPLA BROKERAGE SERVICES
tinuing Education Company located in Davenport, Florida. We had the pleasure of having Vern Smith, EMT-P, lead
this course. Vern Smith, a contributing author to the ITLS Access Course Textbook hails from Pittsburgh, Pennsylers vania and through a desire to promote ITLS Access, traveled to Florida to provide the hybrid course for this group.
It is my hope that the ITLS Access Course’s popularity will continue to grow and will lay the foundation for addi of Florida.
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EMPULSEfeature
Roxanne Sams, MSN, ARNP-BC, MA , Director Navigant Consulting
FEMF VICE PRESIDENT
Lisa M. Bragg, RN, BSN, MBA, Director Navigant Consulting
Better ER Management Requires Partnership
Between Physicians and Clinical Care Coordinators
Growing regulatory and economic
pressures, along with a dramatic
increase in utilization, are putting
hospital emergency departments in
the middle of a difficult balancing act:
the need to appropriately allocate
costly resources, while providing timely
medical care to meet patients’ needs.
The many challenges in today’s everchanging healthcare environment
mean these concerns are only expected
to worsen over the next decade.
A RAND Corporation study points out
that the rate of emergency department
utilization has grown twice as fast
as the U.S. population, with demand
outpacing supply. A key driver for this
trend is the lack of access to primary
care providers. The aging baby boomer
population, along with the expansion
of Medicaid services and the rollout of
the Affordable Health Care Act are only
expected to add to the problem.
What
can
hospital
emergency
departments do to ensure that the right
patients receive the right service, at the
right time, and in the right setting? The
solution is a strong, collegial partnership
between
emergency
department
physicians and the newly evolving role
of the ED care coordination team.
Coordination of care, with a focus
on developing a safe and effective
discharge care management plan, has
long been part of the acute care hospital
setting, but now it is also a vital step
for successful emergency department
management, especially in a cost- and
resource-conscious healthcare climate.
There are numerous reasons why
it is advantageous for emergency
department physicians and care
coordinators to work together in
a dynamic, proactive process that
manages costs while improving patient
outcomes. Several national studies
show that for each dollar invested in
case management, there was an equal
or greater reduction in healthcare costs.
But patients also benefitted significantly
from a integrated delivery model that
addressed both their medical and
social issues.
As members of the ED care coordination
team, a registered nurse care coordinator
and social work care coordinator are
uniquely qualified to intervene quickly
to explore and expedite discharge
planning decisions that take into
consideration the patient’s clinical,
financial, social and psychological
needs. This is especially important for
target vulnerable populations, such
as the frail elderly, the homeless, the
indigent, and people with complex
psychosocial
problems,
including
alcohol or drug abuse and mental
health issues. Many of these patients
also have chronic medical conditions
that are poorly managed due to the
episodic care they receive.
Care coordinators are in the best
position
to
evaluate
available
community resources and to link atrisk patients with services, which may
range from housing, home health care
and elder care to ongoing primary
medical care, as an alternative to the
emergency department. The goal is to
meet patients’ needs, while reducing
frequent and costly non-urgent return
visits to the emergency department.
Accomplishing this goal will also go a
long way toward addressing concerns
about ED overcrowding, extended wait
times and patient dissatisfaction. At the
same time, effective care coordination
in the ED can potentially reduce
hospital readmissions.
The Center
for Medicare and Medicaid Services
Readmission Reduction Program now
penalizes hospitals up to 3 percent for
readmissions that occur within 30 days
of discharge from the same or another
hospital.
In order to be most effective, case
coordinators should be readily available
in the emergency department at least
16 hours a day, seven days a week.
High-volume emergency departments
should consider 24-hour coverage. In
addition, the case coordinator must be
in a convenient location within the ED in
order to have frequent interaction with
the physician – and to have solid input
into all discharge planning decisions,
whether the patient is admitted to the
hospital or to a network of community
services.
The escalating demands being placed
on hospital emergency departments
can best be met by placing greater
emphasis on discharge planning
and coordination of care. A positive
collaboration between emergency
department physicians and care
coordinators is a step in the right
direction.
2014
FENAupdate
fcep.com
19
Katrin Breault BSN, RN, CEN
Darleen Williams MSN, CNS, CEN,
CCNS, CNS-BC, EMT-P
NURSING SPECIALTY CERTIFICATIONS BENEFIT
RN SPECIALTY CERTIFICATION MEETS NURSING LICENSURE RENEWAL
REQUIREMENTS IN FLORIDA
The Florida Emergency Nurses Association (FENA)
encourages Emergency Nurses to obtain specialty
certification in Emergency Nursing.
Achieving
certification in a nursing specialty demonstrates
commitment to patients, one’s profession and
professional growth. Regardless of one’s nursing
specialty - emergency, orthopedics, critical care,
hospice, medical surgical, operating room or many
of the other RN specialties - nursing certification may
now count for continuing education requirements for
licensure renewal in the State of Florida.
Why allow nurses to renew their nursing license
using RN specialty certifications? Nursing is a
dynamic profession faced with a rapidly changing
healthcare environment. The advancements in
medical knowledge, technology and regulatory
requirements are staggering. Certified nurses meet
these professional challenges head-on every day with
their continued commitment to meeting certification
requirements.
According to the ABNS, “Certification is the formal
recognition of the specialized knowledge, skills, and
As of July 1, 2014, Florida Senate Bill 1036 became experience demonstrated by the achievement of
law. The Florida Board of Nursing now recognizes standards identified by a nursing specialty to promote
that Registered Nurses, Licensed Practical Nurses, optimal health outcomes.” Specialty certifications
Clinical Nurse Specialists and Nurse Practioners can provide for advancement opportunities in nursing
who have achieved a nursing specialty certification and in some cases may be required for employment.
may use this certification in lieu of the 24 continuing
education hours and topic requirements to renew The Board of Certification for Emergency Nurses
their Florida nursing license.
offers four certifications in the field of emergency
nursing: Certified Emergency Nurse (CEN), Certified
Nursing specialty certifications must be accredited Flight Registered Nurse (CFRN), Certified Pediatric
by either the National Commission for Certifying Emergency Nurse (CPEN), and Certified Transport
Agencies (NCCA) or the American Board of Nursing Registered Nurse (CTRN). For more information
Specialty Certification (ABNSC). Nurses holding a related to Emergency Nursing certifications please
certification need only to show proof to the Florida see the Board of Certification for Emergency Nurses
Board of Nursing at time of their license renewal and (BCEN®) website at www.BCENcertifications.org.
pay the required fee.
The BCEN is also working with nurses across the
country advocating for State Boards of Nursing and
“Nurses must still meet CE requirements of your employers to recognize specialty nursing certification
certifying body. You are responsible for reporting as a way to satisfy ongoing continuing education
current certifications during each renewal cycle to requirements. FENA offers scholarships to members
CE Broker to meet eligibility for the exemption. To to use towards certifications.
report your certification please create an account in
CE Broker or login to your existing account at CEBroker.com.” CE Broker.
20
MEDICAL STUDENTupdate
Tushar Gupta, MSIV
University of Florida College of Medicine
FCEP MEDICAL STUDENT COMMITTEE SECRETARY
Symposium by the Sea A Model for the Modern Medical Student
The sun shone brightly over Boca Raton, FL earlier this
year as students, residents, physicians, families and
leading figures in Emergency Medicine flocked to the
Boca Raton Resort and Club for the annual Symposium
by the Sea from August 7-10, 2014. This conference,
the premier event hosted by the Florida College of
Emergency Physicians (FCEP), enabled current and
future health care professionals to rub shoulders and
delve into – apart from the inviting ocean - everything
that is Emergency Medicine. Including but not limited
to the sandy beaches and pristine fairways of the
adjacent golf course, this meeting had something
to offer for everyone! Health policy concerning the
future of emergency medicine along with best practice
guidelines and cutting-edge research highlighted the
3-day symposium.
Apart from these topics, the conference showcased some
of the brightest medical students and residents from
the Sunshine State. Students representing the various
medical schools around the state had the opportunity
to share their research endeavors at the poster
presentation sessions while also partaking in the Medical
Student Forum. Coordinated by Dr. Robyn Hoelle and in
conjunction with the FCEP Medical Student Committee
(MSC), approximately 25 aspiring students had the
invaluable experience of picking the brains of residency
program leaders over lunch. Program directors, faculty,
and residents representing their respective residency
programs fielded questions regarding a career in EM.
Among the allopathic and osteopathic programs, Florida
Hospital, Mount Sinai, Orlando Regional Medical Center,
UF Health Gainesville, and UF Health Jacksonville were
represented. The candid and welcoming environment
enabled students to gain a deeper understanding of the
profession while networking with leaders in the field.
student group dedicated to EM into reality. They have
paved the way and provided a model of excellence for
incoming President Adam Gray (MSIV UF) and SecretaryEditor Tushar Gupta (MSIV UF).
Medical students then had the chance to learn from
their future counterparts, as residents from training
programs around the state competed in the annual
Case Presentation Competition (CPC) and the everpopular SimWars competition. With respect to SimWars,
the event served as a culmination of residency training
and a measure of the milestones of a resident. The
competition highlighted the attributes needed to
make a great emergency physician as it emphasized
communication and placed individuals in a high-stress
environment where their clinical decision-making was
placed under a microscope by the judges– similar to how
an emergency physician may be viewed by peers and the
rest of the hospital out in the workplace. Above all, the
competition showcased the art of Emergency Medicine
beyond the ABC’s, as teams had to work together and
relay information among the patient, family, and medical
team while preserving patient safety and quality. These
events provided medical students with a great model
for the successful emergency physician and fostered the
desire to pursue a career in EM.
For the modern medical student aspiring to become
an emergency physician, the weekend provided a
blueprint for success and gave a glimpse into the life of
a physician, both in and out of the ER. Symposium by the
Sea was a fun yet intellectually stimulating event that
not only fostered interest in EM for students but also
reinforced current residents’ and physicians’ passion for
their profession. As they walked away from the beaches
of Boca Raton, participants of the Symposium left with
sand in their shoes and invaluable knowledge regarding
New leadership within the FCEP MSC was introduced at the practice of Emergency medicine along with new
the luncheon, which will be responsible for advocating friendships and fond memories. Not surprisingly,
for medical students for the upcoming year. The MSC members of FCEP can be heard echoing the sentiments
thanks outgoing President Brittany Beel (MSIII UF) and of their children walking hand in hand with their parents
Secretary-Editor Kyle Dalton (MSIV UF) for their hard asking “When are we coming back!?”
work this past year in transforming the vision for a
2014
EDITORIALfeature
fcep.com
21
Kevin Fritz
Communications Consultant
for FCEP and FEMF
Representative Pigman Addresses EM Residents
on Advocacy; Touts Simulation Training
Florida House Representative Cary Pigman, an
emergency medicine physician in Avon Park, treated
EM residents preparing for post-residency life to a
special presentation October 1st at the Embassy Suites
Orlando. Addressing the importance of advocacy in the
field of emergency medicine at the annual “Life After
Residency” workshop presented by the Florida College
of Emergency Physicians, Pigman noted that at least one
person in the room packed with residents would one
day run for office.
room care issues. “The business community wants to
save money. Emergency physicians see how that can be
done. The challenge is to keep the purity and the vision
and not get sidetracked.”
Pigman also touted the world-class training and
education being offered via the Emergency Medicine
Learning & Resource Center (EMLRC) and its use of
simulation. The Florida College of Emergency Physicians
and its sister organization, the Florida Emergency
Medicine Foundation, are scheduled to move into a
“And that someone needs all our help,” he said, noting new, modern EMLRC by year end, providing additional
the time, energy and money it takes to run for office space for simulation education, training and meetings.
that prompts a large pay cut in exchange for effecting
positive change. “You see everything in medicine,” he To assist first responders, EMLRC makes significant use of
human patient high-fidelity simulators. Pigman strongly
said. “You see what’s bad and
believes in the importance of
what’s good.”
simulation training to better
The annual program, designed
prepare for disasters. “Everyone
to prepare residents for their
expects us to react at a high skill
career in emergency medicine,
level to any catastrophic event,”
was co-hosted by the Florida
he said. “It’s at the core of what
Hospital and Orlando Health
we do.”
residency programs.
This spring, Pigman and Grimsley
A former emergency room
co-sponsored SB/HB 1036 on
nursing supervisor and currently
nursing education to allow,
employed by Highlands Regional
among other things, lifting the
Medical Center in Sebring,
cap for the amount of simulation
the now State Senator Denise
training allowed in clinical
Grimsley groomed Pigman for a
education from 25 to 50 percent.
political career. When her term
“There is a growing acceptance
limit was reached, he ran and
of simulation training for all
House Representative Cary Pigman
won her seat in the Florida House.
medical emergency clinicians in
Pigman said that emergency room professionals have hospitals,” said Pigman.
the schedules necessary to run for office, like realtors
A journalist, copywriter, and ghostwriter, Kevin Fritz has
and attorneys. “I knew all along I was going to run,” he
been writing professionally for 30 years. President of Fritz
said. “We see the pitfalls in the system, such as being a Communications since 2007, Kevin is a marketing consultant for
charity provider for the uninsured. We need to fight for FCEP and FEMF. He is the author of the fiction novel Crossover
patient advocacy.”
and publisher of The Hestia Report. He received his BS in
Pigman noted that emergency room professionals can
make a difference by presenting solutions to emergency
Journalism from Ohio University and can be reached at kevin@
fritzcomm.com.
22
RESIDENT CASE PRESENTATION
Bryant Lambe, MD
PGY2 at University of Florida
College of Medicine Jacksonville
Splenic Rupture Case Presentation
A 68 year old African American male presented to our county emergency department with the complaint of left sided flank pain
that had begun earlier in the day. He was well appearing at arrival and triaged into the fast track portion of our department.
The pain had started around 9AM without any inciting factor, no trauma, no coughing or other heavy movement. It wrapped
around his left flank and down into his left inguinal region. It had been going on for almost 12 hours, coming in intermittent
sharp, stabbing waves of 10/10 pain before receding spontaneously to almost gone. The pain did not seem to be incited by
any specific movement, and when it came on no position of movement would relieve it, though he favored leaning over to
his left while the pain was present. There was no associated dysuria or hematuria, and he had no prior history of kidney stone
or renal issues. He denied any other associated symptoms, including no chest/back pain, no sob, no fevers, chills, nausea, or
vomiting, and no neurologic deficits.
His PMH was significant only for asthma and HTN, but he was taking no medications. He had never undergone surgery.
His social history included six beers per day alcohol intake, as well as two packs of cigarettes. He denied other prescription
medication or illicit drug use.
Vitals on arrival included temperature 97.3, blood pressure 99/74, pulse 98, respirations 18, O2 sat of 100% on room air. On
physical exam, he generally appeared uncomfortable, sitting up in bed leaned over to his left side. He was mildly tachycardic
in the 90s but with regular rhythm, no abnormal sounds. Abdominal palpation revealed mild tenderness diffusely, worse in
the left flank and inguinal regions. Despite the tenderness he had no guarding and no rebound. His rectal exam revealed
guaiac negative brown stool.
Initially concerned for renal colic, a non-contrast CT scan of the abdomen and pelvis was performed revealing free fluid in the
peritoneal cavity appearing to be ascites, so further workup was started with spontaneous bacterial peritonitis now higher on
the differential.
CBC revealed an elevated WBC of 13, hgb/hct 8.7/25 (no known baseline), normal platelets. BMP revealed Na 132, K 5.0, Cl 96,
HCO3 14, BUN 13, creatinine 2.3, glucose 253. LFTs were normal, INR 1.2, Lactate 6.9.
At this point his abdomen became more tender with increased guarding, and with no suitable window for paracentesis found,
a dose of Rocephin was given and surgery was consulted to evaluate. The surgeon’s impression at this time was likely SBP as
well, did not feel surgical intervention was required, recommended admission to primary team for continued antibiotics and
further management.
While in the ED awaiting admission, the patient’s condition progressed with his mental status declining, blood pressure
decreasing, and the abdomen becoming rigid. Surgery was re-consulted and an over read of the CT scan revealed likely
splenic bleeding, though difficult to assess secondary to no contrast.
He was taken immediately to the OR for emergency surgery for intra-abdominal bleeding.
Discussion
Atraumatic Splenic Rupture is a condition first described by English surgeon Atkinson in 1874. Since that time, only sporadic
case reports have been presented on this very rare event. In 1958 a set of criterion was established for diagnosis of true
spontaneous splenic rupture including that first there be no trauma or unusual effort, second no evidence of complimentary
organ dysfunction that could prompt it, third no perisplenic adhesions or scarring present, and fourth that the spleen should
be normal on gross and histologic exam after splenectomy. Known medical causes of atraumatic rupture are generally
separated into five categories as described in Table 1 below.
2014
RESIDENT CASE PRESENTATIONcontinued
fcep.com
23
Once a splenic laceration is diagnosed, it is graded I through V based on the extent, see table 2 below. Based on this grading,
the stability of the patient, and the surgeon’s preference, intervention is decided. Conservatively the patient can be admitted
for close observation, best for low grade lacerations in a stable healthy patient. The advantage of this approach is that it
spares the patient an abdominal surgery and the unwanted sequelae, and also allows them the immune benefits of keeping
their spleen. The disadvantage is that many splenic lacerations do progress and this may occur up to 14 days or even further
past the initial laceration, and it is impractical to observe a patient for this long a time. A second option growing in popularity
is to embolize the bleeding portion of the spleen; suitable candidates are stable patients and fluid responsive otherwise
healthy patients. This option keeps the benefits of non-intervention, but is complicated by a very high re-occurrence rate
secondary to the spleen’s complex blood supply. Finally, for unstable patients or those deemed otherwise unfit for nonoperative management, surgery is undertaken. A rarely performed older procedure called splenorrhaphy used mesh netting
wrapped around the spleen to provide compression to prevent further bleeding and rupture. This technique was fraught
with failure, high adverse event rates, and development of aneurysms, and for these reasons most surgeons today opt for
splenectomy. Removal of the spleen is generally curative in terms of future bleeding/rupture, but comes with a 3% risk
of sepsis secondary to decreased immune function. This risk is generally thought to be lower than the associated risks of
splenorrhaphy, contributing to splenectomy being the preferred procedure.
Follow up
In the OR the patient was found to have complete splenic rupture with extensive bleeding into the peritoneum. He underwent
splenectomy and emergent blood transfusion, and was transferred out to the SICU in stable condition. The course was
later complicated by abdominal abscesses and repeat exploratory laparotomies, as well as difficulty weaning off ventilation
requiring tracheostomy placement, however did progress through his hospital stay to discharge to a skilled nursing facility
with coherent mental status.
His spleen appeared normal on gross and histologic exam post operation, and lab studies revealed no concurrent liver disease,
hepatitis, viral infection, hematologic disorder, or other contributing factors. Although many etiologies remain not ruled-out,
the ongoing working diagnosis is spontaneous splenic rupture.
Table 1 – List of causes of atraumatic splenic rupture
Hematologic Including hemophelia, congenital afibrogenemia, factor VIII deficiency, protein S deficiency, ITP, hemolytic
anemia, polycythemia vera, leukemia, lymphoma, myelofibrodid, and multiple myeloma
Metabolic
Including amyloidosis, Wilson’s disease, Gaucher’s disease, and Niemann-Pick
Iatrogenic
Including shockwave lithotripsy and operative intervention
Infective
Including bacterial, viral, protozoal, syphilis, hydatid, typhus, leptospirosis, Q fever, and candidiasis
Others
Including medications (heparin,warfarin, tPAs, GCSF, ticlopidine, dicumarol to name just a few), inherent
splenic disease (cysts, peliosis, angiomatosis, vein thrombosis, cancer), and miscellaneous other causes
such as vomiting, uremia, pancreatitis, endocarditis, pregnancy, lupus, PAN, Wegeners, Ehler-Danlos, pheochromocytoma, sarcoidosis, and the list goes on
Table 2 – Splenic injury grading system (from the American Association for the Surgery of Trauma)
Grade I
Grade II
Grade III
Grade IV
Grade V
Small, subcapsular hematoma covering < 10% surface area, with capsular laceration < 1cm in depth
Moderate subcapsular hematoma 10-50% surface area, intraparenchymal hematoma < 5cm in diameter,
laceration 1-3cm in depth and not involving trabecular vessels
Large subcapsular hematoma > 50% surface area or actively expanding, intraparenchymal hematoma
>5cm or actively expanding, laceration >3cm in depth or involving trabecular vessels, or a ruptured subcapsular or parenchymal hematoma
Laceration involving segmental or hilar vessels with devascularization of >25% of spleen
Ruptured/shattered spleen, or a hilar vascular injury with complete devascularization
24
ARTICLEScontinued
(EMS/TRAUMA UPDATE CONTINUED FROM PAGE 12)
(POISON CONTROL CONTINUED FROM PAGE 14)
Cardiac Arrest Survey Feedback
Results from the Medical Director Cardiac Arrest Survey were
presented. Due to the low participation, it was concluded the
data was of limited use. FAEMSMD suggested the creation of a
cardiac arrest workgroup to identify the state of out-of-hospital
cardiac arrest (OHCA) resuscitation in Florida and identify best
practices. This group has already identified four main questions
regarding OHCA resuscitation protocols and is performing an
evidence-based review which will be presented to FAEMSMD
at a later date. The group also initiated discussions with the
EMSTARS data group to identify current practices with cardiac
arrest patients.
References:
1. Trends & Statistics. [Internet] Bethesda (MD): National
Institute on Drug Abuse. [updated Dec 2012; cited on 3
Sept 2014]. Available from: http://www.drugabuse.gov/
related-topics/trends-statistics.
2. Substance Abuse and Mental Health Services
Administration, State Estimates of Substance Use from
the 2010-2012 National Survey on Drug Use and Health.
Rockville, MD: Substance Abuse and Mental Health
Services Administration, 2014.
3. Substance Abuse and Mental Health Services
Administration, Results from the 2013 National Survey
on Drug Use and Health: Summary of National Findings,
NSDUH Series H-48; HHS Publication No. (SMA) 144863. Rockville, MD: Substance Abuse and Mental Health
Services Administration, 2014.
4. De Castro et al. The effect of changes in gastric pH
induced by omeprazole on the absorption and respiratory
depression of methadone. Biopharm Drug Dispos
1996;17:551-63.
5. Kong et al. Evaluation of the effects of Mitragyna speciosa
alkaloid extract on cytochrome P450 enzymes using a high
throughput assay. Molecules. 2011;16(9):7344-56.
6. Rodriguez-Fragoso et al. Potential risks resulting from
fruit/vegetable-drug interactions: effects on drugmetabolizing enzymes and drug transporters. J Food Sci
2001;76(4):R112-24.
State Medical Director’s Position
At our last FCEP meeting, the EMS/Trauma Committee
discussed the importance of having a state medical director.
This committee would like to present our position on this topic
to the State to ensure that the position becomes codified.
There is already a joint position statement from ACEP, NAEMSP
and NASEMSO which states, “The state EMS medical director
provides specialized medical oversight in the development and
administration of the EMS system and is an essential liaison with
local EMS agencies, hospitals, state and national professional
organizations, and state and federal partners. The state EMS
medical director provides essential medical leadership, system
oversight, coordination of guideline development for routine
and disaster care, identification and implementation of best
practices, system quality improvement, and research. The state
EMS medical director is essential to the comprehensive EMS
system at the local level by promoting integration of direct and
indirect medical oversight for the entire emergency health care
delivery system.”
This topic was added to the agenda of the FAEMSMD meeting
on October 23, 2014 in Orlando at the Orange County Medical
Examiner’s Office.
Emergency Medicine Learning and Resource Center (EMLRC)
update
EMLRC is in the process of building a new home which will allow
more opportunities for emergency medicine and EMS education.
The next EMS/Trauma FCEP meeting is scheduled for November
12th, 2014.
2014
DAUNTING DIAGNOSISanswer
fcep.com
25
DAUNTING DIAGNOSIS
Patient encounter:
ANSWER
This patient was status-post neurosurgery for a chordoma
Question on page 9
resection within the clivus. The chordoma was resected leaving his
clivus resected as well.
Post-op, the normal procedure is to place a NG (nasogastric) tube. However, as this case
shows, there is a serious danger in placing a NG tube once you no longer have the bony
protection of the clivus. Therefore, neurosurgeons specifically use OG (orogastric) tubes in this
type of case. Clearly unaware of this, the physician handling the case above, inserted a NG tube
into the patient. It immediately resulted in complete paralysis for the patient.
CT finding:
This CT of the region was preformed immediately after the incident. The CT shows
the NG tube entering the CNS at the level of the cervicomedullary junction, and was
continuously pushed further inferiorly through the central canal of the spinal cord.
Contraindications to NG tube use:
The use of nasogastric insertion is contraindicated in patients who have skull base fractures,
certain neurosurgical cases, severe ENT related emergencies such as facial fractures especially
to the nose and obstructed esophagus, esophageal varices, and/or obstructed airway as well as
clotting disorders.
26
RESIDENCYmatters
Here in Tampa, the emergency department at TGH is making strides with respect to efficiency, patient
satisfaction, and educational experiences. Now that our interns have a bit more grit under their nails, the
“X-rays of the wrong knee” and “add-on CBC’s” have been steadily down-trending (much to the relief of our
nursing staff ).
Although we are all making gains in patients per hour, you can only be as fast as your slowest test,
which time and time again, has proven to be the black hole of the CT. The Board at Tampa General has recently
approved the construction of a second ED Scanner. Set to unveil in the next month this newest addition to
the department will increase “Door to Dispo” times exponentially.
Our community of EM physicians is like any other with a definitive work hard, play hard mentality. This
was proven by our annual team building/welcoming party for our new class where we embarked on a 4 mile
kayaking adventure through the scenic canals flanking Tampa Bay. In true USF fashion, the day would not
University of South Florida have been complete without the obligatory mid-afternoon thunderstorm. Although exciting to behold, the
blackened sky provided us with a certain amount of “Get the Lead Out” motivation from which some of our
Robert Grammatico, MD
residents set record times at the preserve.
A new development we are excited for is that Drs. Semmons and Zachariah have pioneered a deal between the emergency
department and the Tampa Bay Lightening! Tampa General’s EM docs will be sitting “Ice Side” during Lightening home games and attend
to any medical emergencies that should befall the players of either squad. Our physicians will be responsible for watching over the pregame warm ups and all three periods while our Rolling-Thunder battle it out in an effort to once again hoist The Cup.
I wish you all well and am looking forward to meeting you at ACEP ‘14. See you in Chicago!
Fall Greetings from Florida Hospital! We have enjoyed a great start to the academic year. We
welcomed a fabulous intern class who has quickly made their mark as a smart, hard working and dedicated
addition to the crew!
Shortly after our interns arrived, Andy Colburn (PGY3), Doug Haus (PGY3), Alex Drake (PGY1) and
I participated in the Symposium by the Sea festivities. The pressure was intense and the competition was
fierce! We were very proud to take home 2nd place honors in Sim Wars amidst such an impressive cast. Doug
Haus and I also participated in the case presentation competition. We were thrilled to combine efforts to take
home “Best Overall Presentation” and 2nd place honors in each of our respective individual categories. Our
peers were well poised with very creative
presentations. Doug and I were honored
to represent Florida Hospital amongst our
Florida Hospital
talented peers.
MJ
Lightfoot, DO
Turning to more recent events, we
would like to formally congratulate Anshul
Gandhi (PGY2) as he has been chosen to be the EMRAF Representative
on the FCEP Board of Directors. He will be a full voting member of the
FCEP Board and will be working with the leaders of Emergency Medicine
in Florida! What an opportunity to make an impact in our community
on both a local and state level! Thank you Dr. Gandhi for accepting this
challenge to represent all of your fellow Florida EM residents!
This is a very exciting time of year for Orlando Health! We recently had a great time at Symposium
by the Sea, participating in SimWars, CPC and highlighting ongoing research projects. We presented several
posters of original research in different research fields. PGY 3, Dr. Carolina Pereira, was given the “Outstanding
Resident Poster” award and PGY 3’s Drs. Ayanna Baker and Kate Bondani took home runner up in the same
category. We are truly proud of the amount of research that comes out of our program. In the last four months
alone we’ve published nine new articles and have continued our work on serum biomarkers for traumatic brain
injury with presentations at both the annual meeting of the American Academy of Clinical Neuropsychology
and the Annual National Neurotrauma Symposium.
We are always incorporating interactive teaching and simulation sessions to improve our learning,
and this year has been no different. At the start of the year, PGY 2’s and PGY 3’s participated in a session
on advanced resuscitation techniques. Here we practiced thoracotomies, transvenous pacing and double
Orlando Health
sequential defibrillation and updated our knowledge of the latest resuscitation evidence. We followed this up
Kate Bondani, MD
with our yearly advanced airway lab where we trained with the various airway devices including fiberoptics,
different video laryngoscopy systems, and both needle and surgical cricothyroidotomies on cow tracheas.
We are excitedly anticipating the opening of our new ED expansion as well as the opening of the new patient tower which
should be occurring later this fall or early spring. The renovation will expand and improve both our emergency department and inpatient
capabilities. With all these new changes on the horizon, we can’t wait to see what opportunities await our residency program!
2014
RESIDENCYmatters
The St. Lucie Medical Center EM residency has had a busy summer. In late June, we graduated our
inaugural class and saw three graduates take full time positions after graduation. We were excited to see one
of our graduates, Sarah Fowles, D.O., sign with St. Lucie Medical Center and begin the process of becoming
core faculty. Morgan Garrett, D.O. signed a contract to work at Cartersville Medical Center in Cartersville,
GA. Dr. Leif Sahlgren took a full time job at Osceola Regional Medical Center in Kissimmee, Florida. St. Lucie
Medical Center EM residency also took first place in the SIM Wars Competition at Symposium by the Sea.
One of our core faculty, Jason Morris, D.O. also gave a guest lecture at the Symposium on stratifying high
and low-risk chest pain. The residency attended a private screening of “Code Black,” a documentary about an
EM residency at LA County Hospital facing increased government regulations while also working in a busy
urban ED with many patients from a low socioeconomic status. Our residents are also looking forward to
attending the ACEOP Scientific Assembly in Las Vegas, Nevada from October 10th-15th. We are looking to
improve upon last year’s second place in the Jeopardy competition.
University of Florida,
Jacksonville
Christina Wieczorek, MD
fcep.com
27
St. Lucie Medical Center
Brant Hinchman, MD
2014 continues to be a busy year for the residents and faculty at UF Jax! UF Jax sent a large contingent
down to Boca for Symposium by the Sea this summer. We turned out in big numbers to help welcome and
congratulate our very own Associate Program Director Dr. Ashley Booth-Norse as the incoming FCEP President.
We also had multiple other faculty participate in forums and present throughout the long weekend. Our Sim
Wars team (Drs. Kate Justus, Melissa Mann, Karl Horn and Christina Wieczorek) seemed like the early frontrunner in the simulation competition, but slipped up and didn’t make it to the final round...which was Ebola
-- how timely! Our CPC competitors, Drs. Bryant Lambe and Kate Justus, did a fantastic job during the CPC
competition and I know will be back next year with even more interesting and difficult cases.
Our third years, though already counting down their time to entering the real world, are all looking forward
to their trip to Chicago for ACEP in a few weeks. We will miss them that week, but look forward to the
opportunity for first and second years to hold down the fort in their absence. Stay posted for even more
happenings at UF Jax this spring. Our new hospital campus is slated to open soon, and we look forward to
keeping everyone updated on the progress.
Things are cooling down here at the Swamp, but UF Health is only heating
up! We welcomed our new interns into the fold, and have enjoyed seeing them grow and learn the ropes.
Our residency retreat was a blast. Our crew traversed out to the ropes course at Lake Wauburg and enjoyed
a day of team building on the high and low ropes course. Our team grew together and learned to lean on
each other - literally!
Dr. Diana Mora-Montero attended the Levitan Advanced Airway course on a scholarship in
Yellowstone! She brought back several techniques on the mastery of the advanced and difficult airway.
The seniors had the opportunity to attend the “Life After Residency” workshop in Orlando this month. Held
at the Embassy Suites downtown, lectures on coding, job opportunities, academic career pursuits, and
even finding a work-life balance were all held on September 30 - October 1.
PGY-3’s are excited for ACEP coming up at the end of October in Chicago. Many faculty members
University of Florida
will be presenting, and graduates from the UF Health program from across the country will be in town to
Jordan Rogers, MD
reunite with old friends. A week of learning and catching up with friends old and new will be enjoyed by
the whole department.
As our interviews are starting, we are eager to have medical students from across the country rotating through our department. It
is always exciting to see new faces and encourage up-and-coming EM residents in their career paths. In addition to cooler weather, fall also
brings football season to Gainesville! Dr. Chrissy VanDillen and the EMS fellows Dr. Joel Rowe and Dr. Desmond Fitspatrick have worked
hard at every home game at the medical tent to keep spectators safe.
Looking forward to another fall here in Gainesville!
It has been a good summer for us down in Miami Beach - between our solid new first year residents and
a relatively calm and quiet storm season... at least so far. Here in Florida, a number of our residents took part in
Symposium by the Sea in Boca Raton. Dr. Aaron Mickelson won first place for best CPC case presentation with
a case of Spinal AV Fistula presenting as lower extremity paralysis, and Drs. Valletta, Betancourt, Petrakos and
Klein all competed in their first Sim Wars competition. Meanwhile the same weekend, Dr. Benjamin Abo was
co-instructing a two day Wilderness EMS Medical Director’s Course at the international Wilderness Medical
Society Meeting being held in Jackson Hole, Wyoming.
Mt. Sinai Medical Center
Benjamin Abo, DO, EMT-P
Crescent Center
6075 Poplar Avenue, Suite 401
Memphis, TN 38119
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2014
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Reference: 1. Loyola study finds paramedics skilled in identifying strokes [press release]. Maywood, IL:
Loyola Medicine; March 27, 2012. http://www.stritch.luc.edu/neurology/newswire/news/loyola-studyfinds-paramedics-skilled-identifying-strokes. Accessed November 13, 2013.
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Emergency Physicians
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