EMpulse Fall 2011

FALL 2011

Cave Diving Emergencies My Heart is in Florida Scorpion Stings

Florida College of Emergency Physicians3717 South Conway RoadOrlando, Florida 32812-7606(407) 281-7396 • (800) 766-6335Fax: (407) 281-4407www.FCEP.org

Executive CommitteeVidor Friedman, MD, FACEP • PresidentKelly Gray-Eurom, MD, FACEP • President-ElectMichael Lozano Jr., MD, FACEP • Vice-PresidentAshley Booth Norse, MD, FACEP • Secretary/ TreasurerAmy R. Conley, MD, FACEP • Immediate Past PresidentBeth Brunner, MBA, CAE • Executive Director

Editorial BoardLeila PoSaw, MD, MPH, FACEP • [email protected]

Jerry Cutchens• Managing [email protected]

Cover Design by Jerry Cutchens / Leila PoSaw

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 advertise-ments.

Published by:LMC Printing & PackagingOrlando, FloridaTel: (321) 439-7648www.lmcprinting.com

NOTE: Opinions stated within the articlescontained herein are solely those of the writers and do not necessarily reflect those of the EMpulse staff or the Florida College of Emergency Physicians.

Volume 16, Number 4

EMpulse • Fall 2011 1

Symposium by the SeaMy Heart is in Florida 14Interview with ACEP President Dr. David Seaberg

New Airway Devices 16David A. Caro, MD, FACEP

Cave Diving in the Florida Springs: 18The Bends and Other Hyperbaric EmergenciesMichael L. Falgiani, MD

Tips of the Trade - Auricular Foreign Body Removal 20 Tracy G. Sanson, MD, FACEP

The Man with a Red Eye 22 Case Presentation Competition

The Girl Whose Skin Might Burst Into Flames 24 Case Presentation Competition

DepartmentsPRESIDENT’Smessage 3 Vidor Friedman, MD, FACEP

GOVERNMENTALaffairs 7 Steve Kailes, MD, FACEP

MEDICALeconomics 9 Lynn Reedy, CPC, CEDC

EMStrauma 10 Dagan Dalton, MD

PROFESSIONALdevelopment 11 Paul Mucciolo, MD, FACEP

GeneralThe State of Florida EMS 12 Michael Lozano, MD, FACEP

POISONcontrol 26Treatment of Scorpion Stings in Florida

TRAUMAscorecard 29ENA National Scorecard on State Roadway Laws

RESIDENCYmatters 30

Professional PIP Representation

Rutledge M. Bradford, Esq. Board Certified Civil Trial Lawyer by The Florida Bar

AV Rated by Martindale-Hubbell

EXPERIENCED EMERGENCY ROOM PHYSICIAN REPRESENTATION AGAINST AUTO CARRIERS.

WE FOCUS ON PERSONAL INJURY PROTECTION (PIP) LITIGATION SO OUR EMERGENCY ROOM PHYSICIAN CLIENTS CAN FOCUS ON TREATING THEIR PATIENTS.

LET MY EXPERIENCE AS A FORMER INSURANCE COMPANY ATTORNEY WORK FOR YOU.

•NO FEES OR COSTS IF NO RECOVERY.

IF WE PREVAIL AGAINST THE AUTOMOBILE INSURANCE CARRIER IN PIP LITIGATION, PER FLORIDA STATUTES, THE AUTO CARRIER IS RESPONSIBLE FOR OUR FEES AND COSTS.

KNOWLEDGEABLE, EXPERIENCED, AND PROFESSIONAL PIP RESPRESENTATION.

•LET OUR STRONG PIP EXPERIENCE ASSIST YOUR TEAM.

Attorneys at Law 5210 South Orange Avenue

Orlando, Florida, 32809 407-926-8710

Let’s Get Started!

Welcome to another year at FCEP!

I am honored and humbled to be your president this year. I have lost count of the number of FCEP presidents and past-presidents that I have worked with over the years and I hope to be able to live up to the tremendous leadership that they continue to show our organization. We have a proud and strong tradition of advo-cating for EM and this year my goal is to continue to ‘move the ball down the court!’

In Orlando, we are blessed to have tremendous support staff headed by Beth Brunner, who is truly the glue that holds us all together!

Our partnership with the Emergency Medicine Resource and Learning Center has paid tremendous dividends and your leadership is working diligently to ensure that our future together is a bright one.

During this past year, FCEP’s advocacy efforts, in Tallahassee and around the state, have once again served to safeguard our patients and our profession. While our CCE’s (Emergency Physicians of Florida and People for Access to Emergency Care) continue to prosper and serve as role models for other chapters around the country.

Symposium by the Sea was the best ever this year: highlighted by exceptional talks from our own Dr. David Seaberg, President-Elect of ACEP. We were also

treated to an excellent educational program, an amazing Case Presentation Competition, a private concert by "The HOPPEN Bros of ORLEANS," and a Casino Fun night to boot!

In addition to the usual amazing opportu-nity to meet and network with our peers from around the state, we were honored to have five ACEP Board members and two ACEP BOD candidates attending our symposium. A tradition we hope to sustain long into the future!

Once again we were honored this year by a visit from the President of the Florida Medical Association (FMA), Dr. Miguel Machado, who informed us that his number one legislative priority was to get sovereign immunity for all providers of EMTALA related care! Who would have imagined the day when FMA and FCEP had the same priority legislative goals!

I hope that you and your family were there with us in Naples. If not you missed a great symposium and I hope you can join us next year in Amelia Island for what I am sure will be yet another wonderful Symposium by the Sea!

Getting back to moving that ‘ball’ down the court, what do I see for this year?

Well, we need you! Our membership is our greatest asset and we need you, our members, to continue showing up at meet-ings to give voice to your ideas and concerns. We need you to continue, and

indeed expand, your support of our politi-cal advocacy efforts with your time and your dollars; the more resources we have, the more effective we can be for YOU!

We have a great relationship with ACEP and that relationship is built on the strength of our member involvement. We currently have one Board member, Dr Andy Bern, who does a great job repre-senting us at the national level, and one alumnus on the ACEP BOD, Dr. David Seaberg President-Elect, who also calls us home.

We are well represented on ACEP and council committees, but we are always looking for the next generation of leaders for our college. Are you ready to get involved? Your leadership is here to assist you. Are you ready to join us?

We must continue to improve and sustain our working relationships with the FMA, the Florida Hospital Association, the various Specialty Societies and the Emer-gency Nurses Association. Coalition building is our natural strength and we reap tremendous benefits from allying ourselves with the other professionals that we work with every day.

All in all, you have one of the most active and effective ACEP state chapters in the nation! But, yes, there is much to do as always!

Let’s get started…….

PRESIDENT’Smessage


Vidor Friedman, MD, FACEPPresident

Titan Emergency Group, an equity based group owned and operated by our physician mem-bers, is currently seeking a Pediatric Emergency Medicine Physician for a full

partnership opportunity. The ideal candidate will be dual boarded in EmergencyMedicine and Pediatrics or boarded in Emergency Medicine with a Pediatric

EM Fellowship. Additionally, candidate would possess leadership qualities, havepenchant for educating/teaching and the ability to be efficient and productive.

Position is both clinical and administrative.

Competitive compensation and benefits to include productivity bonus, administrative stipend, health and disability insurance, generous 401K retirement plan, CME and

professional expense funding as well as malpractice and tail coverage.

Come live on the Florida coast! Described as one of the nation’s most dynamic andprogressive cities, Jacksonville’s miles of beaches and waterways are some of its most

alluring assets. Due to its convenient location, mild climate and reasonable cost ofliving coupled with a high quality of life, Jacksonville is one of the top 15 fastest

growing cities in the US.

For more information, contact Alisha Lane at (904) 332-4322 or [email protected].

PEDIATRIC EMERGENCY MEDICINEPARTNERSHIP OPPORTUNITY

Stable, equity based physician group seeks top quality Emergency MedicinePhysician for Capital Regional Medical Center in Tallahassee, Florida.

Physician must be BE/BC ABEM/AOBEM certified to work in this 65,000 annual volume ED. Equal partnership opportunities available, excellent compensation,

productivity bonuses, health and disability insurance, generous 401K,CMEs and professional expense reimbursement as well as malpractice

and tail coverage.

Minutes from the Gulf and nearby beaches, experience excellent weather, biking trails and plentiful outdoor activities! Best known as Florida’s capital

city, Tallahassee is a fusion of cosmopolitan flair and charming personality.Deep rooted in history and culture, it is where college town meets cultural

center, politics meets performing arts and history meets nature.


FLORIDA PARTNERSHIPOPPORTUNITY

Presents:

5th ANNUAL SYMPOSIUM ON ADVANCED EMERGENCY ELECTROCARDIOGRAPHY

NOVEMBER 4-7, 2011

ROYAL CARIBBEAN CRUISE TO BAHAMAS! THIS COURSE WILL HELP YOU SAVE LIVES!!! Upon completion of this advanced course on Advanced Emergency Electrocardiography, you will improve your ability to recognize subtle findings that will help you diagnose and treat patients more accurately. Lively interactive ECG workshops incorporating real cases will challenge and educate participants. Application is being made for ACEP Category I Credits. Sponsors: Florida Hospital and Florida Emergency Physicians. For more information and to request a brochure, please call 1-800-268-1318, website: www.floridaep.net. Book your cabin early to ensure space!

GOVERNMENTALaffairs

The Work Never Ends!

Steve Kailes, MD, FACEPCommittee Chair

For Governmental Affairs, the work never ends. The most pressing issue of the moment is the fact that the 2003 caps on non-economic damages are being challenged and soon the question of their constitutionality will be heard by the Florida Supreme Court. We need help to fund our advocacy efforts as our coffers desperately need to be replenished.

Please donate and get your peers to donate to our CCE’s, Emergency Physicians of Florida (for individuals) and People for Access to Emergency Care (for groups). You can donate using a credit card by simply going to the Government-Advocacy tab on our website, www.fcep.org.

The 2012 legislative session and election campaign are quickly approaching and will be unique in many ways. The session is earlier than usual, so committees will begin work for 2012 soon, probably by the time you are reading this article.

Significantly, redistricting will occur and is leading to uncertainty for many of the House and Senate seats. This is an opportunity to give our support to candidates who will, ideally, be receptive as our issues are presented.

On the liability reform front, recognize that the process has been more about chipping away at the rock rather than simply pushing it out of the way. In 2012, we plan to continue our push for sovereign immunity protections. As providers supporting the fragile safety net for all, we believe provid-ers of emergency care act as agents of the State in providing care to all who have no other access to care as well as for the many who have inadequate access to meet their health care needs. The FMA supports this, and we believe the current legislature and governor hear this idea with a sympathetic ear.

Concerning Medicaid reforms, we are wary of the changes requiring all patients to be in a managed care system. Conceptually, the idea works but practically we don’t believe there is proof the resources exist to transform the idea into reality. In addition, we are moving to statewide Medicaid managed care even though the five county Medicaid managed care pilot programs have yet to produce evidence that patients had access to their care needs.

Yes, they may indeed save money for the insurers and even for the state, but I fear this

is accomplished only by shifting those savings into new costs for the patients, providers and facilities. For 2012 and into the future, we will be continually monitoring and attempting to correct the problems we and our patients endure.

Something I am sure you are already aware of are the new requirements for prescriptions and dispensing of controlled substances (2011 HB7095/SB818). While dispensing these medications is not generally an EM issue, prescribing them most certainly is, and we may be facing unintended conse-quences of legislative attempts to rein in the so called “pill mills” which have plagued our state. We have begun working to negate any substantially burdensome requirements for EM providers.

As always, there is too much to cover in too little space. Suffice it to say, we need your help to help you. Please contact us with issues or concerns. Please meet with your legislators so they can have someone they can turn to for information and ideas as we struggle to make change that matters. Be involved to be a part of the solutions and, please, give your monetary support to fund our advocacy efforts.


EmergencyMedicineDAYS‘12

EM DAYS - TALLAHASSEE, FL23rd Annual EM Days - January 23-26, 2012

Hotel Duval by Marriott - Tallahassee, FL 32301

Emergency Medicine Days in Tallahassee is the premier advocacy event each year for the Florida College of Emergency Physicians. All members are invited each spring to our state capital to spend time face-to-face with their legislators, lobbying for legislation that will provide better access to quality care for our patients. At EM Days, FCEP members gather with their colleagues and lobby for a better emergency medicine climate in Florida. Audience: All Florida EM Resi-dents, FCEP Board Members and other key leaders around Florida.

2012 EM Days - January 23-26, 2012Hotel Duval by Marriott415 North Monroe StreetTallahassee, FL 32301850.224.6000 - 866.957.4001

REGISTER TODAY AT WWW.FCEP.ORG

Making theObservation Decision

Lynn Reedy, CPC, CEDCDirector of Coding ServicesCIPROMS South Medical Billing

If your group faces the decision of providing

Observation Services in your hospital, the

biggest questions are “how much more money”

and “how much more work.”

The following chart will help with that

decision. Because only one E/M Level can be

billed each day, your documentation for the ED

E/M Level will roll into the Initial Observation

documentation. For a patient staying in your

ED for several days while waiting transfer to

another facility, adding up the multiple days of

Observation Services should increase your

reimbursement.

MEDICALeconomics


Evaluation and Mangement Codes (only one per day):

Presenting Problem:Documentation Requirements:

Time Required:

2011 Florida Medicare Reimbursement:

99284 High severity: N/A $119.76Requires urgent evaluation A detailed history HPI = 4+ elements

Emergency by the physician ROS = 2-9 systems

Dept PMFSHx = 1 history

Does not pose an immediate A detailed examination EX = 5-7 areas/systemssignificant threat to life or Medical decision making of Multiple mgmt optionsphysiologic function moderate complexity Moderate data

Moderate risk

99285 High severity: N/A $174.96

EmergencyPoses an immediate significant threat to life or

Dept physiologic function A comprehensive history HPI = 4+ elementsROS = 10+ systemsPMFSHx = 2 histories

A comprehensive examination EX = 8+ systems

Medical decision making of high Extensive mgmt optionscomplexity Extensive data

High risk

99218 Low severity N/A $65.51Initial A detailed or comprehensive HPI = 4+ elements

Observation history ROS = 2-9 systemsOver PMFSHx = 1 history

Midnight A detailed or comprehensive EX = 5-7 areas/systemsexamination EX + 5-7 areas/systemsMedical decision making that is Minimal mgmt optionsstraightforward of of low complexity Minimal data

Minimal risk99219 Moderate severity N/A $109.67Initial A comprehensive history HPI = 4+ elements

Observation ROS = 10+ systemsOver PMFSHx = 3 histories

Midnight A comprehensive examination EX = 8+ systems

Medical decision making of Multiple mgmt optionsmoderate complexity Moderate data

Moderate risk

99220 High severity N/A $145.82Initial A comprehensive history HPI = 4+ elements

Observation ROS = 10+ systemsOver PMFSHx = 3 histories

Midnight A comprehensive examination EX = 8+ systemsMedical decision making of high Extensive mgmt optionscomplexity Extensive data

High risk

99217 Discharge on other than the Report all services provided to a N/A $70.48Discharge initial date of OBS status

99224 Stable, recovering, or 15 minutes $28.53Subsequent improving Problem focused interval history HPI = 1-3 elementsObservation ROS = N/A

Day PMFSHx = N/A

Problem focused examination EX = 1 area/systemMedical decision making that is Minimal mgmt optionsstraightforward or of low complexity Minimal data

Minimal risk

99225 Responding inadequately 25 minutes $49.99Subsequent to therapy or has An expanded problem focused HPI = 1-3 elementsObservation developed a minor interval history ROS = 1 system

Day complication PMFSHx = N/AAn expanded problem focused exam EX = 2-4 areas/systemsMedical decision making of Multiple mgmt optionsmoderate complexity Moderate data

Moderate risk

99226 Unstable or has 35 minutes $74.92

Subsequent developed a significant A detailed interval history HPI = 4+ elementsObservation complication or a ROS = 2-9 systems

Day significant new problem PMFSHx = 1 history

A detailed examination EX = 5-7 areas/systems

Medical decision making of high Extensive mgmt optionscomplexity Extensive data

High risk

99234 Low severity N/A $135.35

Same Day A detailed or comprehensive HPI = 4+ elementsAdmit & Disc history ROS = 2-9 systemsObservation PMFSHx = 1 history

A detailed or comprehensive exam EX = 5-7 areas/systems

Medical decision making that is Minimal mgmt optionsstraightforward of of low complexity Minimal data

Minimal risk

99235 Moderate severity N/A $176.06

Same Day A comprehensive history HPI = 4+ elementsAdmit & Disc ROS = 10+ systemsObservation PMFSHx = 3 histories

A comprehensive examination EX = 8+ systems

Medical decision making of Multiple mgmt optionsmoderate complexity Moderate data

Moderate risk

99236 High severity N/A $218.88Same Day A comprehensive history HPI = 4+ elements

Admit & Disc ROS = 10+ systemsObservation PMFSHx = 3 histories

A comprehensive examination EX = 8+ systemsMedical decision making of high Extensive mgmt optionscomplexity Extensive data

High risk

Key Elements:3 of 3 key components:

3 of 3 key components:



patient on discharge from OBS status

Within the constraints imposed by the urgency of the patient's clinical condition and/or mental status

2 of these 3 key components:

3 key components:

3 key components:

3 key components:




VOLUNTARY EMpulseSUBSCRIPTIONS

Contribute $20 or more to help defray the publishing and mailing costs of EMpulse.

Check payable to:FCEP, EMpulse VS3717 South Conway RoadOrlando, FL 32812

Committee Meeting News

Dagan Dalton, MDCommittee Chair

The FCEP EMS/Trauma Committee met

at the Symposium by the Sea in Naples on

August 4, 2011. It was a nice setting for

what is always a great conference and the

FCEP Committee meetings were produc-

tive as well.

At the EMS/Trauma Committee meeting,

we approved the concept of Statewide

EMS Disaster Protocols and are now

awaiting the final draft from Dr. Joe

Nelson for review. Dr. Nelson is sending

the same to the state Public Health

Preparedness office for their review and

approval as well. Dr. Nelson is also

compiling a list of back-up or assistant

State EMS Medical Directors, who are to

be called into action if/when a

catastrophic event involves several

regions of the state, communications

throughout the state are disrupted or his

unexpected unavailability.

The State Trauma Alert Criteria are now

under final review by the state

committee/working group, with nothing

new to add at this time. Remember that

they can be accessed at any time on

myflorida.gov, search Florida Administra-

tive Code under sections F.A.C. 64J 2.004

and 64J 2.005.

There has been much discussion at both

EMS/Trauma Committee meetings and

FAEMSMD (Florida Association of EMS

Medical Directors) meetings recently

regarding the “pill mill”/controlled

substances legislation, and how that might

affect us – not only as EPs, but also as

EMS Medical Directors.

John Bixler, chief of the Bureau of EMS

for the Florida Department of Health,

addressed us at our recent FAEMSMD

meeting to assure us that it was not the

intent of the law to affect EMS operations.

He further stated that he would have the

State Attorney’s office review the law for

opinion, but that the process might take

1-2 months. In the meantime, he recom-

mended that we meet with our city/county

attorneys to make them aware of the law

and the pending review by the State’s

Attorney’s office, and to come to a

consensus on the best/safest way to

continue EMS operations.

Remember, approval has been granted for

a face-to-face meeting of the EMS Advi-

sory Council in September 27-28, 2011 at

the Fort Lauderdale Airport Hilton, and

the next FAEMSMD meeting will be at

that place and time. Also, funding has

been proposed for the same for July, 2012,

and we will keep you posted.

EMStrauma

10 EMpulse • Fall 2011

PROFESSIONALdevelopment

A Taste of Your Own Medicine

Paul Mucciolo, MD, FACEPCommittee Chair

After easing into my fourth decade, things have begun to change. My ankles are sore after I run and my back aches for days after cleaning out the garage. On my last visit to the ophthalmologist, he peered into my soul through a series of prisms and lenses and then leaned back to explain that I needed bifocals: “When you start to measure your age in decades, these things happen!”

I have deliberately avoided my primary care physician and I dreaded my annual physical exam. My Italian genes domi-nate my metabolism and tomato sauce, Pecorino Romano, and Pappardelle have become my personal fuel. I thought this visit was going to be “the talk” and was actually nervous when I saw my physician walk in. I thought the party was over.

However, my doctor cracked a joke, sat at eye level with me, listened, paused, and gave me practical guidance and encour-agement. I felt like a weight had been lifted off my shoulders. I learned a lot more on that visit than what I need to do to improve my health.

Be friendly. In EM, the first impression is really the lasting impression. One OB/GYN attending during medical school suggested that we introduce ourselves with a smile, ask the patient how she would like to be addressed, and then turn around to wash our hands. “Give her a

chance to size you up from a few different angles, because that’s how you’re going to be looking at her!”

Be prepared. Preparedness is an indica-tor of diligence. When a chronic atrial fibrillation patient asks, “What is my INR?” I like to have the exact number in my head for her. Saying that it’s within normal limits doesn’t inspire confidence. Giving the exact answer and then giving her a copy of the report does.

Be empathetic. When I see a patient on dialysis with heart failure, diabetes melli-tus and lupus, I think of how fortunate I am. Medical care consumes this person’s life. Imagine the indignities this individual endures going from doctor to doctor, being poked with needles, having lancets jabbed into the fingers three times a day before the shots of subcutaneous insulin in the abdomen…

Be patient. Some patients simply cannot formulate a chief complaint. My medicine attending on the first clinical rotation of my third year of medical school opened up Harrison’s (back in the days when we used books!) and pointed out the word “alexi-thymia”. His advice was to wait for the patient to deliver what he called “the punch line” before starting to ask questions. The chief complaint is in this story somewhere. He warned us that asking too many questions too soon could

lead the patient (and us) astray.

Be reasonable. I find it difficult to remember to take my daily aspirin. Many patients are burdened with the infamous “bag-o-meds” we dread reconciling. Then add on a TID antibiotic, a Q4H nebulizer and BID steroids. The literature may support this regimen, but practicality doesn’t. And how can a patient follow up with his primary care physician tomorrow when it’s Sunday of a holiday weekend?

Be prompt. If it took two hours to get a table at a restaurant, we wouldn’t go back. Wait times strongly influence patient satisfaction. Even if the patient knows you’re in a code, ask one of the techs or nurses to apologize on your behalf. The otitis externa case waiting next is certainly not life threatening, but it is very painful. And it is the only thing on that patient’s mind. If the patient knows that you value his time, he’ll value yours.

Be quiet. Everyone is pressed for time, but let the patient speak. A positive facial expression can encourage a patient to continue when he seems exasperated trying to tell you (the fourth person in twenty minutes to whom he’s had to tell his story) how he dislocated his shoulder. When the patient is nervous, a smile or nod of the head can ease her tension. After all, what the patient tells you will prove invaluable!


REFERENCES1. Cooper, R.M., J.A. Pacey, M.J. Bishop & S.A. McCluskey. (2005). Early clinical experience with a new videolaryngoscope (GlideScope) in 728 patients. Canadian Journal of Anaesthesia = Journal Canadien d'Anesthesie 52, 191-198.

2. Savoldelli, G.L., E. Schiffer, C. Abegg, V. Baeriswyl, F. Clergue & J.L. Waeber. (2008). Comparison of the Glidescope, the McGrath, the Airtraq and the Macintosh laryngoscopes in simulated difficult airways*. Anaesthesia 63, 1358-1364.

3. Ovassapian, A. (2001). The flexible bronchoscope. A tool for anesthesiologists. Clinics in Chest Medicine 22, 281-299.

4. Greenland, K.B., G. Liu, H. Tan, M. Edwards & M.G. Irwin. (2007). Comparison of the Levitan FPS Scope and the single-use bougie for simulated difficult intubation in anaesthetised patients. Anaesthesia 62, 509-515.

5. Turkstra, T.P., D.M. Pelz, A.A. Shaikh & R.A. Craen. (2007). Cervical spine motion: afluoroscopic comparison of Shikani Optical Stylet vs Macintosh laryngoscope. Canadian Journal of Anaesthesia = Journal Canadien d'Anesthesie 54, 441-447.

6. Byhahn, C., S. Nemetz, R. Breitkreutz, B. Zwissler, M. Kaufmann & D. Meininger. (2008). Brief report: tracheal intubation using the Bonfils intubation fibrescope or direct laryngoscopy for patients with a simulated difficult airway. Canadian Journal of Anaesthesia = Journal Canadien d'Anesthesie 55, 232-237.

7. van Zundert, A., R. Maassen, R. Lee, R. Willems, M. Timmerman, M. Siemonsma, M. Buise, et al. (2009). A Macintosh laryngoscope blade for videolaryngoscopy reduces stylet use in patients with normal airways. Anesthesia and Analgesia 109, 825-831.

8. Cavus, E., J. Kieckhaefer, V. Doerges, T. Moeller, C. Thee & K. Wagner. (2010). The

C-MAC videolaryngoscope: first experiences with a new device for videolaryngoscopy-guided intubation. Anesthesia and Analgesia 110, 473-477.

9. Arslan, Z.I., T. Yildiz, Z.N. Baykara, M. Solak & K. Toker. (2009). Tracheal intuba-tion in patients with rigid collar immobilisa-tion of the cervical spine: a comparison of Airtraq and LMA CTrach devices. Anaesthe-sia 64, 1332-1336.

10. Suzuki, A., Y. Toyama, N. Katsumi, T. Kunisawa, R. Sasaki, K. Hirota, J.J. Henderson, et al. (2008). The Pentax-AWS((R)) rigid indirect video laryngoscope: clinical assessment of performance in 320 cases. Anaesthesia 63, 641-647.

11. Maassen, R., R. Lee, B. Hermans, M. Marcus & A. van Zundert. (2009). A comparison of three videolaryngoscopes: the Macintosh laryngoscope blade reduces, but does not replace, routine stylet use for intubation in morbidly obese patients. Anesthesia and Analgesia 109, 1560-1565.

Emergency airway management has changed significantly over the recent past. Our technological advances have included the use of neuromuscular blockade, the conversion from blind nasal intubation to direct oral intubation, and more recently, the advent of a number of alternative airway devices designed to improve first-attempt visualization and ease of intuba-tion. In this article, we will review indirect visualization devices.

These devices specifically include videolaryngoscopes and intubating stylets. Multiple variations exist and are worth review. All depend on video input from internal cameras as well as lighting from an internal light source, and all are designed for oral intubation use. Multiple studies have demonstrated superior Cormack-Lehane views of the larynx compared to direct laryngoscopy with a standard laryngoscope.1,2 What has not been described is the performance of any of these devices in the setting of blood, vomit, or significant airway secretions,all of which have been shown toimpair bronchoscopic video system performance.3

The intubating stylets include the Bonfils stylet (Storz), the Levitan scope (Clarus), and the Shikani scope (Clarus). These

devices combine a light source and fiberoptic camera into the shaft of a semi-malleable stylet over which an endotra-cheal tube is placed. The stylet is shaped by the manufacturer to allow the practitio-ner to place the tip of the stylet around the tongue with minimal force and minimal mouth opening, bringing the glottis into almost immediate view either through an eyepiece or via a cable attachment to a videoscreen. Once the glottis is visual-ized, the endotracheal tube is guided under video guidance into the airway. The intubating stylets have had proven track records in the operating room and appear to be solid choices as primary or difficult airway devices.4-6

The videolaryngoscopes include the Glidescope, the C-Mac (Storz), the AirTraq (King), the LMA C-Trach, the McGrath (LMA), and the Airway Scope (Pentax). Most of these devices are shaped like a McIntosh laryngoscope, with some important distinctions. The Glidescope is prototypical of this class of devices and is one of the most established.1 Its handle has a tip that is angled at 60 degrees compared to the McIntosh blade, allowing for a video view that is angled around the curvature of the tongue, more “anteriorly” directed. It is attached to a small videoscreen by cable,

and the screen is attached to a stand that is wheeled for ease of transport. Impor-tantly, the Glidescope is designed to be used with a rigid stylet shipped with the device. The stylet bends an endotracheal tube in the correct angle to make the acute angle around the tongue into the airway. It is essential to use this stylet to ensure intubation success with this device. Other videolaryngoscope systems have been recently introduced to compete with the Glidescope.7-10

It is wise to gain specific training and simulation experience with any of these devices before using them in an emer-gency setting. Each device has specific design features that must be understood in order to properly use the device, as well as to be able to immediately correct foresee-able problems that might occur during their use. It is important to know that these devices have been shown to provide superior laryngeal views to direct laryn-goscopy, and that they have been shown in some studies to improve intubation success rates in difficult airway settings.1,11 In contrast, we do not have data on their use in the “wet” (blood, vomit, secretions) airway. However, expect that as these devices become more popular, they will be more frequently employed in US EDs.

ECGs paramedics really do know what they are talking about. In the diagnosis of STEMI, the ECG is one piece of technology that can easily be applied in the prehospital setting. The same does not apply to the prehospital diagnosis of stroke. Until there is an accurate and practical method to image patient’s brains either in their homes or in the back of an ambulance, history and physical exam remain the only tool in the paramedic’s toolkit for acute stroke diagnosis.

National guidelines have been promul-gated to promote the integration of EMS into stroke systems of care.13 Just as with angina where the classic presentation is that of a chest discomfort sometimes described as pressure that is provoked by exertion, but atypical presentations abound, the clinical diagnosis can be elusive to pin down. One can simply include those who have an acute onset of a focal neurological deficit, but that would not really capture the universe of stroke patients.

The Birmingham (AL) EMS system uses the following definition: An acute episode of focal neurological deficit can include any combination of the following signs and symptoms : unilateral paralysis, focal numbness, language disturbance (speaking and/or understanding), sudden, severe, unusual headache, visual distur-bance, monocular blindness, acute onset vertigo, acute onset double vision, slurred speech, new onset of poor balance.14 Exclusion criteria would include those with significant preceding or accompany-ing head or spine trauma; intentional or accidental overdose; seizure immediately and clearly preceding the onset of the focal neurologic deficit(s); and of course the great mimicker – hypoglycemia.

The analog to the “STEMI alert” is the “Stroke alert.” In the next installment, we will look at the evidenced-based systems paramedics use to identify acute stroke in the prehospital setting and how that can a role in the regionalization of stroke care in Florida. We will also continue our detailed

look at the EMS system in Florida and the literature evidence that supports prehospi-tal care.

REFERENCES 1. Cummins RO, Chamberlain DA, Abramson NS, et al. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein Style. A statement for health professionals from a task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council. Circulation 1991;84:960-75

2. Jacobs I, Nadkarni V, Bahr J, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries. A statement for healthcare professionals from a task force of the international liaison committee on resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation). Circulation. 2004; 110: 3385-3397.

3. Eisenberg MS, Cummins RO, Larsen MP. Numerators, denominators, and survival rates: reporting survival from out-of-hospital cardiac arrest. Am J Emerg Med 1991; 9:544-6.

4. Rea TD, Eisenberg MS, Sinibaldi G, White RD. Incidence of EMS-treated out-of-hospital cardiac arrest in the United States. Resuscitation 2004; 63:17-24.).

5. Antman EM, Anbe DT, Armstrong PW, et. al. ACC/AHA guidelines for the manage-ment of patients with ST-elevation myocar-dial infarction: a report of the ACC/AHA Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction). J Am Coll Cardiol. 2004; 44: E1–E211.

6. Curtis JP, Portnay EL, Wang Y, et. al. National Registry of Myocardial Infarction-4. The pre-hospital electrocardio-gram and time to reperfusion in patients with acute myocardial infarction, 2000–2002: findings from the National Registry of Myocardial Infarction-4. J Am Coll Cardiol. 2006; 47: 1544–1552.

7. Diercks DB, Kontos MC, Chen AY, et. al. Utilization and impact of pre-hospital electrocardiograms for patients with acute ST-segment elevation myocardial infarction: data from the NCDR (National Cardiovascu-lar Data Registry) ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry. J Am Coll Cardiol. 2009; 53: 161–166.

8. Daudelin DH, Sayah AJ, Kwong M, et. al. Improving Use of Prehospital 12-Lead ECG for Early Identification and Treatment of Acute Coronary Syndrome and ST-Elevation Myocardial Infarction. Circ Cardiovasc Qual Outcomes, May 1, 2010; 3(3): 316 - 323.

9. Levis JT. Ability of First-Year Paramedic Students to Identify ST-Segment Elevation Myocardial Injury on 12-Lead Electrocardio-gram: A Pilot Study. Prehosp Disaster Med - 01-NOV-2010; 25(6): 527-32.

10. Foster DB, Dufendach JH, Barkdoll CM. Prehospital recognition of AMI using independent nurse/paramedic 12-lead ECG evaluation: impact on in-hospital times to thrombolysis in a rural community hospital. Am J Emerg Med (1994) 12 : pp 25-31.

11. Real-time paramedic compared with blinded physician identification of ST-segment elevation myocardial infarction: results of an observational study. Feldman JA - Am J Emerg Med - 01-JUL-2005; 23(4): 443-8.

12. Clark EN. Automated Electrocardiogram Interpretation Programs Versus Cardiologists' Triage Decision Making Based on Teletrans-mitted Data in Patients With Suspected Acute Coronary Syndrome. Am J Cardiol - December 15, 2010; 106(12); 1696-1702.

13. Acker JE, Pancioli AM, Crocco TJ, et. al,. Implementation Strategies for Emergency Medical Services within Stroke Systems of Care. A Policy Statement from the American Heart Association/American Stroke Associa-tion Expert Panel on Emergency Medical Services Systems and the Stroke Council. Stroke, 2007; 38:3097-3115.

14. Adapted from “Stroke System Entry Criteria” Birmingham Regional Emergency Medical Services System (BREMSS).

The State of Florida EMSPart 7 of a Series

Michael Lozano, MD, FACEPCommittee Chair

Last issue we looked at the fourth objec-tive of Strategic Goal Six: Improve perfor-mance of key EMS processes through benchmarking and partnerships. This issue will focus in more detail on the quality assurance measures that are central to the medical care provided by EMS systems statewide. Objective 6.4 addresses airway management as well as cardiac, stroke, trauma, pediatric, and neonatal patients. The cardiac quality measures cover prehospital return of spontaneous circulation (ROSC) reported in out-of-hospital cardiac arrest (OOHCA) patients using the Utstein format, 12-lead EKG performance on patients with suspected cardiac related symptoms, and aspirin administration in suspected cardiac patients. Do you remember the Utstein Criteria for OOHCA research from journal club in residency? First reported in 19911, and revised in 20042, it provides a standard set of definitions to assist resuscitation researchers in comparing results among different systems of care. The critical importance of a standard definition set was illustrated in a 1991 study by Eisen-berg et. al.3 They found that by simply changing the denominator definitions, OOHCA survival rates on a given data set could vary from 16% to 49%. Unfortu-nately, few EMS systems publically report their OOHCA survival rates using the Utstein template. A 2005 review by the same Seattle research group found that only 35 communities nationwide reported their OOHCA results.4 Their all-cause

survival rate was 8%, while that due to ventricular fibrillation was 18%. Why don’t communities report their data? The answer is multi-factorial, involving a lack of a legislative national reporting mandate, inadequate resources applied to EMS quality assurance, HIPAA-invoked sequestering of data, and lack of political will to disseminate embarrassingly dismal results. Local emergency physicians can help by advocating for transparency with uniform and standardized data reporting as well as encouraging their hospitals to provide EMS with outcomes data on OOHCA cases.

ACC/AHA guidelines on prehospital chest pain evaluation and treatment recommend that prehospital ECGs be performed on all patients with suspected acute coronary syndrome (ACS) and that aspirin be given to those with suspected STEMI.5 Despite this, early studies have found prehospital ECGs are performed on 8% to 27% of patients with STEMI.6,7 However, feedback reports and other quality improvement efforts improved prehospital ECG performance for patients with acute coronary syndrome and ST-elevation myocardial infarction (STEMI) from 76% to 93%, and 77% to 99% respectively.8 Objective 6.4.1 will look at EMS systems in the state to measure their prehospital ECG usage rates. This is important to the overall health of the population as paramedic initiated ECGs are associated with shorter times to fibrinolysis and PCI in STEMI patients.

ECG interpretation is taught in most Florida paramedic training programs, and a recent study demonstrated that 12-lead EKG interpretation is a skill that even first year paramedic students can master and retain.9 Older studies have firmly shown that paramedics can produce a 12-lead ECG and accurately appreciate the presence of a STEMI.10,11 Even if the paramedics are not trained to read the ECG directly, the ECG analysis algorithms in the monitor/defibrillators have be shown to have similar sensitivity, specificity, and positive predictive value to cardiologists.12

Given the high accuracy rates of paramed-ics in recognizing STEMI on a prehospital ECG, the Florida Association of EMS Medical Directors has advocated the use of standard nomenclature in EMS commu-nications with hospitals regarding STEMI patients. Whereas in the past the term “cardiac alert” was used by many agencies, it was an ill defined term that encompassed STEMI patients, unstable chest pain patients, and those with abnor-mal heart rhythms. The term “cardiac alert” is being discouraged in favor or the term “STEMI alert” which means a patients with ECG changes consistent with STEMI or a patient with symptoms suggestive of an AMI in the presence of a LBBB. Emergency physicians can assist EMS systems by being cognizant of the “STEMI alert” term, and provide ECG feedback when possible to their EMD providers. With a little bit of interaction, you will discover that with respect to

EMStrauma





















ECGs paramedics really do know what they are talking about. In the diagnosis of STEMI, the ECG is one piece of technology that can easily be applied in the prehospital setting. The same does not apply to the prehospital diagnosis of stroke. Until there is an accurate and practical method to image patient’s brains either in their homes or in the back of an ambulance, history and physical exam remain the only tool in the paramedic’s toolkit for acute stroke diagnosis.

National guidelines have been promul-gated to promote the integration of EMS into stroke systems of care.13 Just as with angina where the classic presentation is that of a chest discomfort sometimes described as pressure that is provoked by exertion, but atypical presentations abound, the clinical diagnosis can be elusive to pin down. One can simply include those who have an acute onset of a focal neurological deficit, but that would not really capture the universe of stroke patients.

The Birmingham (AL) EMS system uses the following definition: An acute episode of focal neurological deficit can include any combination of the following signs and symptoms : unilateral paralysis, focal numbness, language disturbance (speaking and/or understanding), sudden, severe, unusual headache, visual distur-bance, monocular blindness, acute onset vertigo, acute onset double vision, slurred speech, new onset of poor balance.14 Exclusion criteria would include those with significant preceding or accompany-ing head or spine trauma; intentional or accidental overdose; seizure immediately and clearly preceding the onset of the focal neurologic deficit(s); and of course the great mimicker – hypoglycemia.

The analog to the “STEMI alert” is the “Stroke alert.” In the next installment, we will look at the evidenced-based systems paramedics use to identify acute stroke in the prehospital setting and how that can a role in the regionalization of stroke care in Florida. We will also continue our detailed

look at the EMS system in Florida and the literature evidence that supports prehospi-tal care.

REFERENCES 1. Cummins RO, Chamberlain DA, Abramson NS, et al. Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein Style. A statement for health professionals from a task force of the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, and the Australian Resuscitation Council. Circulation 1991;84:960-75

2. Jacobs I, Nadkarni V, Bahr J, et al. Cardiac arrest and cardiopulmonary resuscitation outcome reports: update and simplification of the Utstein templates for resuscitation registries. A statement for healthcare professionals from a task force of the international liaison committee on resuscitation (American Heart Association, European Resuscitation Council, Australian Resuscitation Council, New Zealand Resuscitation). Circulation. 2004; 110: 3385-3397.

3. Eisenberg MS, Cummins RO, Larsen MP. Numerators, denominators, and survival rates: reporting survival from out-of-hospital cardiac arrest. Am J Emerg Med 1991; 9:544-6.

4. Rea TD, Eisenberg MS, Sinibaldi G, White RD. Incidence of EMS-treated out-of-hospital cardiac arrest in the United States. Resuscitation 2004; 63:17-24.).

5. Antman EM, Anbe DT, Armstrong PW, et. al. ACC/AHA guidelines for the manage-ment of patients with ST-elevation myocar-dial infarction: a report of the ACC/AHA Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction). J Am Coll Cardiol. 2004; 44: E1–E211.

6. Curtis JP, Portnay EL, Wang Y, et. al. National Registry of Myocardial Infarction-4. The pre-hospital electrocardio-gram and time to reperfusion in patients with acute myocardial infarction, 2000–2002: findings from the National Registry of Myocardial Infarction-4. J Am Coll Cardiol. 2006; 47: 1544–1552.

7. Diercks DB, Kontos MC, Chen AY, et. al. Utilization and impact of pre-hospital electrocardiograms for patients with acute ST-segment elevation myocardial infarction: data from the NCDR (National Cardiovascu-lar Data Registry) ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry. J Am Coll Cardiol. 2009; 53: 161–166.

8. Daudelin DH, Sayah AJ, Kwong M, et. al. Improving Use of Prehospital 12-Lead ECG for Early Identification and Treatment of Acute Coronary Syndrome and ST-Elevation Myocardial Infarction. Circ Cardiovasc Qual Outcomes, May 1, 2010; 3(3): 316 - 323.

9. Levis JT. Ability of First-Year Paramedic Students to Identify ST-Segment Elevation Myocardial Injury on 12-Lead Electrocardio-gram: A Pilot Study. Prehosp Disaster Med - 01-NOV-2010; 25(6): 527-32.

10. Foster DB, Dufendach JH, Barkdoll CM. Prehospital recognition of AMI using independent nurse/paramedic 12-lead ECG evaluation: impact on in-hospital times to thrombolysis in a rural community hospital. Am J Emerg Med (1994) 12 : pp 25-31.

11. Real-time paramedic compared with blinded physician identification of ST-segment elevation myocardial infarction: results of an observational study. Feldman JA - Am J Emerg Med - 01-JUL-2005; 23(4): 443-8.

12. Clark EN. Automated Electrocardiogram Interpretation Programs Versus Cardiologists' Triage Decision Making Based on Teletrans-mitted Data in Patients With Suspected Acute Coronary Syndrome. Am J Cardiol - December 15, 2010; 106(12); 1696-1702.

13. Acker JE, Pancioli AM, Crocco TJ, et. al,. Implementation Strategies for Emergency Medical Services within Stroke Systems of Care. A Policy Statement from the American Heart Association/American Stroke Associa-tion Expert Panel on Emergency Medical Services Systems and the Stroke Council. Stroke, 2007; 38:3097-3115.

14. Adapted from “Stroke System Entry Criteria” Birmingham Regional Emergency Medical Services System (BREMSS).

EMStrauma


Last issue we looked at the fourth objec-tive of Strategic Goal Six: Improve perfor-mance of key EMS processes through benchmarking and partnerships. This issue will focus in more detail on the quality assurance measures that are central to the medical care provided by EMS systems statewide. Objective 6.4 addresses airway management as well as cardiac, stroke, trauma, pediatric, and neonatal patients. The cardiac quality measures cover prehospital return of spontaneous circulation (ROSC) reported in out-of-hospital cardiac arrest (OOHCA) patients using the Utstein format, 12-lead EKG performance on patients with suspected cardiac related symptoms, and aspirin administration in suspected cardiac patients. Do you remember the Utstein Criteria for OOHCA research from journal club in residency? First reported in 19911, and revised in 20042, it provides a standard set of definitions to assist resuscitation researchers in comparing results among different systems of care. The critical importance of a standard definition set was illustrated in a 1991 study by Eisen-berg et. al.3 They found that by simply changing the denominator definitions, OOHCA survival rates on a given data set could vary from 16% to 49%. Unfortu-nately, few EMS systems publically report their OOHCA survival rates using the Utstein template. A 2005 review by the same Seattle research group found that only 35 communities nationwide reported their OOHCA results.4 Their all-cause

survival rate was 8%, while that due to ventricular fibrillation was 18%. Why don’t communities report their data? The answer is multi-factorial, involving a lack of a legislative national reporting mandate, inadequate resources applied to EMS quality assurance, HIPAA-invoked sequestering of data, and lack of political will to disseminate embarrassingly dismal results. Local emergency physicians can help by advocating for transparency with uniform and standardized data reporting as well as encouraging their hospitals to provide EMS with outcomes data on OOHCA cases.

ACC/AHA guidelines on prehospital chest pain evaluation and treatment recommend that prehospital ECGs be performed on all patients with suspected acute coronary syndrome (ACS) and that aspirin be given to those with suspected STEMI.5 Despite this, early studies have found prehospital ECGs are performed on 8% to 27% of patients with STEMI.6,7 However, feedback reports and other quality improvement efforts improved prehospital ECG performance for patients with acute coronary syndrome and ST-elevation myocardial infarction (STEMI) from 76% to 93%, and 77% to 99% respectively.8 Objective 6.4.1 will look at EMS systems in the state to measure their prehospital ECG usage rates. This is important to the overall health of the population as paramedic initiated ECGs are associated with shorter times to fibrinolysis and PCI in STEMI patients.

ECG interpretation is taught in most Florida paramedic training programs, and a recent study demonstrated that 12-lead EKG interpretation is a skill that even first year paramedic students can master and retain.9 Older studies have firmly shown that paramedics can produce a 12-lead ECG and accurately appreciate the presence of a STEMI.10,11 Even if the paramedics are not trained to read the ECG directly, the ECG analysis algorithms in the monitor/defibrillators have be shown to have similar sensitivity, specificity, and positive predictive value to cardiologists.12

Given the high accuracy rates of paramed-ics in recognizing STEMI on a prehospital ECG, the Florida Association of EMS Medical Directors has advocated the use of standard nomenclature in EMS commu-nications with hospitals regarding STEMI patients. Whereas in the past the term “cardiac alert” was used by many agencies, it was an ill defined term that encompassed STEMI patients, unstable chest pain patients, and those with abnor-mal heart rhythms. The term “cardiac alert” is being discouraged in favor or the term “STEMI alert” which means a patients with ECG changes consistent with STEMI or a patient with symptoms suggestive of an AMI in the presence of a LBBB. Emergency physicians can assist EMS systems by being cognizant of the “STEMI alert” term, and provide ECG feedback when possible to their EMD providers. With a little bit of interaction, you will discover that with respect to





















primary care providers, I feel EM could serve as a bridge or conduit to better integrated care. We have access to over 124 million visits each year, and with the average 1–1.5 visitors for each patient, we have access to over half the population each year. We need to use this leverage to enhance our value.

We already use our Observation Units to reduce potentially unnecessary admis-sions and avoidable readmissions. Should we not consider a system to check and give immunizations; could we not consis-tently screen for HIV and alcohol abuse; could we not provide counseling on exercise, weight loss, alcohol and smok-ing cessation; could we not provide better chronic disease management for conges-tive heart failure, diabetes, COPD to prevent unnecessary hospitalizations?

Just think of how powerful EM could be as a leader and key contributor in the integrated healthcare delivery system. The primary care medical home is far from providing these services to the popu-lation right now, but we in EM could begin immediately through our access to patients.

How do you plan to address these issues as President?We need to start preparing for the coming changes in Medicine. The next three years may very well affect the next 30 years of practice. We need to get our message out to our members and start advocating for EM's role in the value equation.

We also need to start working with hospi-tals and payers to redesign our ED for the new era of emergency health care teams to provide better disease management, prevention and wellness counseling that will be required in the future.

We need to use our resources and advo-cacy power in EM, through ACEP and the newly formed Emergency Medicine Advocacy Fund, to position EM as a solution to enhance quality and reduce cost.

What is your favorite personal medical niche?I now focus on Medical Administration and Medical Education because of my current role and the expertise and value I feel I can provide in such areas.

What do you do in your spare time?I spend as much time with my wife and kids as possible. My two teenage boys are very active in High School sports, so I spend much of my free time watching their games. I also like to go to movies, theater and dancing with my wife, Carol. I will eventually get back into golf - which I have had to put on the back-burner due to my schedule. That was one nice aspect of Florida - I loved to play golf there.

Do you have any words of wisdom for our members?One must always work to improve your lot in life. That is true for your practice in medicine. You need to remain active in FCEP and organized medicine to improve your career, specialty and the care for your patients. Do not leave it for others. You must participate! The best way to predict the future is to create it!

Are you ever coming back to Florida?We really hope to some day. We loved living in Florida. We sold our beach condo in Jacksonville when we moved to Tennessee but we hope to return to the First Coast eventually!

My Heart is in FloridaInterview with ACEP President Dr. David Seaberg

David Seaberg, MD, CPE, FACEPACEP President / Past FCEP President

How long have you been involved with FCEP?This year was my 17th Symposium-by-the-Sea. I moved to Florida in 1995, first starting at the University of Florida/Shands Jacksonville as Residency Director and then moved to Gainesville, when we became a Department of EM. I was chair of the Gainesville campus until we moved in 2007. I have been with the University of Tennessee since then. I continue to serve on the Board of the Emergency Medicine Learning and Resource Center.

Over the years, how has EM in Florida changed?EM has become one of the premier specialties in Florida. FCEP is a very active Chapter and the efforts of its mem-bers have led to many legislative and advocacy successes. The tort reform achieved in 2003 was a major accomplish-ment for EM and FCEP's continued efforts on behalf of the sovereign immunity bill has garnered support from the FMA.

Additionally, when I arrived, there were only two EM training programs in the state. We trained too few residents for the

state's needs. I am very happy to see the growth of residency training programs throughout the state, with seven very strong programs. This is great for EM and for the citizens of Florida.

Why did you leave Florida?We loved living in Florida and I loved working with the EPs around the state. I had an opportunity to become the first Dean of the Chattanooga campus of the University of Tennessee College of Medi-cine. This was a natural growth of my career path and I was very excited to take on the challenge of developing an academic medical center campus. The Chattanooga campus has over 540 faculty, 170 residents in 9 specialties and 6 fellow-ships, and has over 220 medical students rotate through the campus. I was very happy to start another EM Residency program on the Chattanooga campus, the only EM program in the University system.

How is your current EM practice differ-ent from what yours was in Florida?My position is mainly administrative. My main responsibility is to ensure that the academic medical center receives

adequate resources for its four part mission of clinical care, teaching, research and community service. I also helped develop a new faculty practice plan that currently encompasses the primary care specialties. I still love EM and do a couple of ED shifts every month and give at least one Grand Rounds lecture each month for the EM Residency program.

What do you see are the major issues for EM nationally in the next year?EM will need to focus on value over the next several years. The government is looking at value-based purchasing and demand quality and lower cost. It will accomplish this through the formation of an integrated healthcare delivery system and a bundled or capitated payment system.

EM already provides significant value in terms of the care we provide the public and serve as the healthcare safety net, however we are often viewed as expensive and unnecessary. We need to enhance our value-added services to fit into the integrated delivery system. With the patient-centered medical home being a great idea in theory only due to the lack of

SYMPOSIUMbytheSea




















primary care providers, I feel EM could serve as a bridge or conduit to better integrated care. We have access to over 124 million visits each year, and with the average 1–1.5 visitors for each patient, we have access to over half the population each year. We need to use this leverage to enhance our value.

We already use our Observation Units to reduce potentially unnecessary admis-sions and avoidable readmissions. Should we not consider a system to check and give immunizations; could we not consis-tently screen for HIV and alcohol abuse; could we not provide counseling on exercise, weight loss, alcohol and smok-ing cessation; could we not provide better chronic disease management for conges-tive heart failure, diabetes, COPD to prevent unnecessary hospitalizations?

Just think of how powerful EM could be as a leader and key contributor in the integrated healthcare delivery system. The primary care medical home is far from providing these services to the popu-lation right now, but we in EM could begin immediately through our access to patients.

How do you plan to address these issues as President?We need to start preparing for the coming changes in Medicine. The next three years may very well affect the next 30 years of practice. We need to get our message out to our members and start advocating for EM's role in the value equation.

We also need to start working with hospi-tals and payers to redesign our ED for the new era of emergency health care teams to provide better disease management, prevention and wellness counseling that will be required in the future.

We need to use our resources and advo-cacy power in EM, through ACEP and the newly formed Emergency Medicine Advocacy Fund, to position EM as a solution to enhance quality and reduce cost.

What is your favorite personal medical niche?I now focus on Medical Administration and Medical Education because of my current role and the expertise and value I feel I can provide in such areas.

What do you do in your spare time?I spend as much time with my wife and kids as possible. My two teenage boys are very active in High School sports, so I spend much of my free time watching their games. I also like to go to movies, theater and dancing with my wife, Carol. I will eventually get back into golf - which I have had to put on the back-burner due to my schedule. That was one nice aspect of Florida - I loved to play golf there.

Do you have any words of wisdom for our members?One must always work to improve your lot in life. That is true for your practice in medicine. You need to remain active in FCEP and organized medicine to improve your career, specialty and the care for your patients. Do not leave it for others. You must participate! The best way to predict the future is to create it!

Are you ever coming back to Florida?We really hope to some day. We loved living in Florida. We sold our beach condo in Jacksonville when we moved to Tennessee but we hope to return to the First Coast eventually!

SYMPOSIUMbytheSea


How long have you been involved with FCEP?This year was my 17th Symposium-by-the-Sea. I moved to Florida in 1995, first starting at the University of Florida/Shands Jacksonville as Residency Director and then moved to Gainesville, when we became a Department of EM. I was chair of the Gainesville campus until we moved in 2007. I have been with the University of Tennessee since then. I continue to serve on the Board of the Emergency Medicine Learning and Resource Center.

Over the years, how has EM in Florida changed?EM has become one of the premier specialties in Florida. FCEP is a very active Chapter and the efforts of its mem-bers have led to many legislative and advocacy successes. The tort reform achieved in 2003 was a major accomplish-ment for EM and FCEP's continued efforts on behalf of the sovereign immunity bill has garnered support from the FMA.

Additionally, when I arrived, there were only two EM training programs in the state. We trained too few residents for the

state's needs. I am very happy to see the growth of residency training programs throughout the state, with seven very strong programs. This is great for EM and for the citizens of Florida.

Why did you leave Florida?We loved living in Florida and I loved working with the EPs around the state. I had an opportunity to become the first Dean of the Chattanooga campus of the University of Tennessee College of Medi-cine. This was a natural growth of my career path and I was very excited to take on the challenge of developing an academic medical center campus. The Chattanooga campus has over 540 faculty, 170 residents in 9 specialties and 6 fellow-ships, and has over 220 medical students rotate through the campus. I was very happy to start another EM Residency program on the Chattanooga campus, the only EM program in the University system.

How is your current EM practice differ-ent from what yours was in Florida?My position is mainly administrative. My main responsibility is to ensure that the academic medical center receives

adequate resources for its four part mission of clinical care, teaching, research and community service. I also helped develop a new faculty practice plan that currently encompasses the primary care specialties. I still love EM and do a couple of ED shifts every month and give at least one Grand Rounds lecture each month for the EM Residency program.

What do you see are the major issues for EM nationally in the next year?EM will need to focus on value over the next several years. The government is looking at value-based purchasing and demand quality and lower cost. It will accomplish this through the formation of an integrated healthcare delivery system and a bundled or capitated payment system.

EM already provides significant value in terms of the care we provide the public and serve as the healthcare safety net, however we are often viewed as expensive and unnecessary. We need to enhance our value-added services to fit into the integrated delivery system. With the patient-centered medical home being a great idea in theory only due to the lack of
































New Airway Devices

David A. Caro, MD, FACEPResidency Director, Emergency Medicine University of Florida College of Medicine - Jacksonville








SYMPOSIUMbytheSea














SYMPOSIUMbytheSea









The Annual Meeting of theFlorida College of Emergency Physicians

August 2-5, 2012Omni Amelia Island Plantation Resort | Amelia Island, FL | www.fcep.org

Computed axial tomography exam of the revealed hyperdense and enlarged cavern-ous sinuses bilaterally with findings of exophthalmos and prominence of the right superior ophthalmic vein. These findings were concerning for a potential carotid cavernous sinus fistula. Given these findings a CTA and CTV were recom-mended to further evaluate the pathology of the above findings.

CTA/CTV revealed a direct carotid cavernous sinus fistula due to a dissection of the left internal carotid artery. Given these findings consultations were obtained from neurosurgery and radiology who recommended the patient be transferred to a facility which has interventional neuro-radiology services. The patient was then transferred to an outside facility and underwent a successful endovascular repair with subsequent resolution of his symptoms.

Traumatic carotid cavernous sinus fistulae are a rare but potentially fatal complica-tion of maxillofacial trauma, with a reported overall incidence of less than 1% of all patients with cranial facial trauma. They can present as either direct or indirect fistulas. Direct fistulae, secondary to trauma, cause shearing of the internal carotid artery from its dural connections. These shearing mechanisms can result in either carotid artery dissection, pseudoan-eurysm or occasionally rupture of the internal carotid artery. The shunting of blood from the carotid artery into the cavernous sinus causes a high flow state in the cavernous sinus which rapidly increases pressure. This increase in pressure is manifested clinically as chemosis, proptosis, elevated intraocular pressures, decreased ocular movements and occasionally a pulsatile ocular bruit. Direct fistulas generally require emergent surgical repair either open or more commonly via an endovascular approach. Approximately 75% of direct CCSFs are a result of antecedent trauma (usually associated with a basilar skull fracture), the remaining 25% are acute ruptures of the carotid artery due to atherosclerosis or hypertension. Complications of direct CCSFs include massive life-threatening

epistaxis, subarachnoid hemorrhage, ischemic infarction of the brain, ocular ischemia and blindness in the affected eye.

Most CCSFs are not immediately life-threatening unless further complica-tions occur. The treatment of choice for acute direct high-flow CCSFs is balloon embolization of the culprit lesion. Sponta-neous closure in high-flow states is unlikely. In low-flow states, spontaneous closure via thrombosis of the cavernous sinus rarely necessitates the need for operative repair. Indications for repair would include evidence of severe propto-sis, ischemia to the globe, glaucoma, diplopia or intolerable symptoms.

REFERENCES1. Fabian TS, Woody JD, Ciraulo DL, et al. Posttraumatic carotid cavernous fistula: frequency analysis of signs, symptoms, and disability outcomes after angiographic embolization. J Trauma 1999;47:275–281

2. Corradino G, Gellad FE, Salcman M. Traumatic carotidcavernous fistula. South Med J 1988;81:660–663

3. Mullan S. Carotid cavernous fistulas and intracavernous aneurysms. In: Neurosurgery. Wilkens RH, Rengachary S (eds). New York, McGraw-Hill, 1985, pp 1483–1494

4. Albers SA, Latchaw RE, Chapter 136 – Interventional Neuroradiology of the Skull Base, Head and Neck. In: Cummings Otolaryngology: Head & Necksurgery 5th ed. Flint, PW et al. (eds). Missouri, Mosby, 2010, pp 1940-1943

5. Fattahi, T., Brandt, M., Jenkins, W., & Steinberg, B. (2003). Traumatic carotid-cavernous fistula: Pathophysiology and treatment. Journal of Craniofacial Surgery, 14, 240–246.

Mr. D is a 31 year old male who presented to the ED with a chief complaint of dizzi-ness and right eye redness for one day duration. Mr. D admitted to alcohol use the previous night that lead to an alterca-tion with an unknown assailant. He states he was struck in the face multiple times with a closed fist and had some minor pain and bleeding after the incident but went home that night without any concerns. When he woke up the next morning, he noticed that his right eye was swollen, reddened and aching, but denied any visual changes. He also denies any loss of consciousness but states he could not remember many of the events of the previ-ous night. His past medical history was significant for a prior inferior orbital floor fracture and a closed maxillary angle fracture that was non-operatively managed. Past surgical history was significant for a repair of a previous facial fracture but further details were not known. Family history was non-contributory.

On admission his vital signs were stable (BP 124/78, HR 80, RR 16, O2 Sat 100%), his physical exam was remarkable for abrasions to his upper lip and face, inferior ecchymosis of the right eye. His ocular exam was significant for bilateral exoph-thalmos, chemosis (most prominent on the right) and conjunctival erythema. He was unable to abduct his right eye past midline, and his visual acuity was 20/40 bilaterally. His pupils were equal, round, and reactive to light and accommodation, visual fields were intact, and his intraocu-

lar pressures were mildly elevated at 22mmHg in the left and 23 mmHg in the right. On slit lamp exam the anterior chamber was difficult to visualize given his conjunctival erythema and chemosis but no obvious cells, flare or hyphema were noted. On fundoscopic exam no papilledema or retinal hemorrhage was noted. Under fluorescein exam no focal areas of uptake were noted however there was diffuse punctate uptake. At this point a brief differential diagnoses included intracranial hemorrhage, orbital compart-ment syndrome, tumor, and carotid

cavernous sinus fistula or aneurysm. The decision was then made to obtain a CT of the head to evaluate for any intracranial pathology.





















SYMPOSIUMbytheSea

Cave Diving in theFlorida Springs:The Bends and OtherHyperbaric Emergencies

Michael L. Falgiani, MDAssistant ProfessorPhysician Director of QualityDepartment of Emergency MedicineUniversity of Florida – Gainesville, FL

There are many opportunities for scuba diving in the state of Florida. From the shipwrecks off the panhandle and south-ern coast to the reefs near the keys to spear fishing in the gulf, Florida is a haven for all types of diving. What most people do not know is that the north central Florida fresh water springs provide some of the most diverse cave diving in the world.

People travel from many different coun-tries to train in and experience these massive cave systems. This is why it is paramount for emergency physicians in Florida to understand diving injuries. The major injuries that can occur in divers include decompression sickness (DCS), arterial gas embolism, nitrogen narcosis and oxygen toxicity.

Decompression sickness is also referred to as Caisson’s disease or the bends. Often people with DCS have pain in the joints of the knees and hips and bending over helped to relieve some of their pain, hence the name “the bends”. DCS occurs when a diver ascends to rapidly causing tiny nitrogen bubbles come out of the blood-stream and obstruct blood flow.

Typically divers ascending from a dive ascend slow enough that the nitrogen

bubbles stay in the blood and travel to the lungs and are exhaled safely and the diver ascends. DCS is dependent on depth and duration of dive. The longer and deeper the dive, the more time that diver must spend ascending to allow the lungs to exhale all of the nitrogen that has accumu-lated in the body tissues during the dive. There are two types of DCS. Type I DCS involves the skin and joints and occurs within 1 to 12 hours after surfacing from a dive. Pain is usually felt in the shoulders or knees. Type I DCS is treated with recompression therapy in a hyperbaric chamber. Type II DCS is much more serious. Type II involves the central nervous system. Nitrogen bubbles form in the low pressure venous plexus and impede venous outflow from the spinal cord.

This allows more nitrogen bubbles to form in and around the spinal cord. The symp-toms seen in Type II DCS include an ascending paralysis, autonomic dysfunc-tion, ataxia, numbness, tingling and fatigue. Both a motor and sensory loss is usually present. Since multiple bubbles may form, this will not present in a typical dermatomal distribution or stroke pattern. Type II DCS is also treated in a hyperbaric

chamber. Table 6 of the US navy recom-pression tables is used and the treatment is approximately 4 hours and 45 minutes in the hyperbaric chamber. There are many factors that predispose a diver to getting the bends. Divers who have had a prior DCS event are more likely to have another. Divers in extreme conditions, such as cold water, and those pursuing more strenuous dives with higher exertion during the dives are more prone to DCS. Females are more likely than their male counterparts to develop DCS, although the exact reason for this is unknown. Other risk factors include increased age, obesity and dehydration.

Another injury that occurs upon ascent is air-gas embolism (AGE). AGE occurs when divers rapidly ascend without exhal-ing. The volume of air in a diver’s lungs expands as the diver rises to the surface resulting in a rupture of the lung paren-chyma and embolization of air into the arterial circulation. Risk factors for AGE include asthma, COPD and congenital pulmonary cysts.

Symptoms of AGE include chest pain, dyspnea, coughing, pink frothy sputum, syncope, seizure and stroke-like symp-

toms. The air that escapes into the arterial circulation can also travel to the coronary arteries causing chest pain that mimics acute coronary syndrome. In contrast to decompression sickness, AGE symptoms occur immediately upon surfacing, are not dependent upon depth or duration of the dive and neurologic findings are stroke-like and follow a vascular distribution. Treatment of DCS and AGE includes: ABC’s, oxygen via non-rebreather mask at 100%, hydration with IV fluids, pain control and ultimately recompression in a hyperbaric chamber. Avoid high altitude transfers (helicopter preferred over fixed wing) whenever possible.

Descent injuries include oxygen toxicity and nitrogen narcosis. As the partial pressure of oxygen increases during descent, the likelihood of cerebral oxygen

toxicity increases. Cerebral oxygen toxic-ity presents with nausea, paresthesias, dizziness and seizures. An oxygen toxic-ity seizure can be deadly if experienced underwater.

Symptoms of oxygen toxicity can occur suddenly without prodrome. Nitrogen narcosis occurs as more nitrogen is dissolved into the bloodstream and other tissues as the diver descends. Symptoms include loss of fine motor skills and higher order mental processes. Unlike oxygen toxicity, nitrogen narcosis is a gradual process and for most begins around 100 feet of depth. Nitrogen narcosis is a euphoric feeling and is similar to the effects of alcohol. Divers call this the “Martini Law” which states that every 33 feet you descend on air is equivalent to drinking one martini on an empty stom-ach. As with alcohol, nitrogen narcosis

affects every diver differently.

In summary, both decompression injury and air-gas embolism are life threatening conditions that may present to your emer-gency department. Decompression injury usually presents several minutes to hours after the dive and can affect the skin, joints, and central nervous system. Air-gas embolism occurs immediately upon surfacing and presents with symp-toms mimicking a heart attack or stroke.

The treatment of both entities is similar with airway, breathing and circulation being paramount. After initial resuscita-tion, oxygen and IV hydration, recompres-sion therapy is the treatment of choice. I hope this helps to shed some light on life threatening diving injuries and hope to see you around the springs of north central Florida.


































There are many opportunities for scuba diving in the state of Florida. From the shipwrecks off the panhandle and south-ern coast to the reefs near the keys to spear fishing in the gulf, Florida is a haven for all types of diving. What most people do not know is that the north central Florida fresh water springs provide some of the most diverse cave diving in the world.

People travel from many different coun-tries to train in and experience these massive cave systems. This is why it is paramount for emergency physicians in Florida to understand diving injuries. The major injuries that can occur in divers include decompression sickness (DCS), arterial gas embolism, nitrogen narcosis and oxygen toxicity.

Decompression sickness is also referred to as Caisson’s disease or the bends. Often people with DCS have pain in the joints of the knees and hips and bending over helped to relieve some of their pain, hence the name “the bends”. DCS occurs when a diver ascends to rapidly causing tiny nitrogen bubbles come out of the blood-stream and obstruct blood flow.

Typically divers ascending from a dive ascend slow enough that the nitrogen

bubbles stay in the blood and travel to the lungs and are exhaled safely and the diver ascends. DCS is dependent on depth and duration of dive. The longer and deeper the dive, the more time that diver must spend ascending to allow the lungs to exhale all of the nitrogen that has accumu-lated in the body tissues during the dive. There are two types of DCS. Type I DCS involves the skin and joints and occurs within 1 to 12 hours after surfacing from a dive. Pain is usually felt in the shoulders or knees. Type I DCS is treated with recompression therapy in a hyperbaric chamber. Type II DCS is much more serious. Type II involves the central nervous system. Nitrogen bubbles form in the low pressure venous plexus and impede venous outflow from the spinal cord.

This allows more nitrogen bubbles to form in and around the spinal cord. The symp-toms seen in Type II DCS include an ascending paralysis, autonomic dysfunc-tion, ataxia, numbness, tingling and fatigue. Both a motor and sensory loss is usually present. Since multiple bubbles may form, this will not present in a typical dermatomal distribution or stroke pattern. Type II DCS is also treated in a hyperbaric

chamber. Table 6 of the US navy recom-pression tables is used and the treatment is approximately 4 hours and 45 minutes in the hyperbaric chamber. There are many factors that predispose a diver to getting the bends. Divers who have had a prior DCS event are more likely to have another. Divers in extreme conditions, such as cold water, and those pursuing more strenuous dives with higher exertion during the dives are more prone to DCS. Females are more likely than their male counterparts to develop DCS, although the exact reason for this is unknown. Other risk factors include increased age, obesity and dehydration.

Another injury that occurs upon ascent is air-gas embolism (AGE). AGE occurs when divers rapidly ascend without exhal-ing. The volume of air in a diver’s lungs expands as the diver rises to the surface resulting in a rupture of the lung paren-chyma and embolization of air into the arterial circulation. Risk factors for AGE include asthma, COPD and congenital pulmonary cysts.

Symptoms of AGE include chest pain, dyspnea, coughing, pink frothy sputum, syncope, seizure and stroke-like symp-

toms. The air that escapes into the arterial circulation can also travel to the coronary arteries causing chest pain that mimics acute coronary syndrome. In contrast to decompression sickness, AGE symptoms occur immediately upon surfacing, are not dependent upon depth or duration of the dive and neurologic findings are stroke-like and follow a vascular distribution. Treatment of DCS and AGE includes: ABC’s, oxygen via non-rebreather mask at 100%, hydration with IV fluids, pain control and ultimately recompression in a hyperbaric chamber. Avoid high altitude transfers (helicopter preferred over fixed wing) whenever possible.

Descent injuries include oxygen toxicity and nitrogen narcosis. As the partial pressure of oxygen increases during descent, the likelihood of cerebral oxygen

toxicity increases. Cerebral oxygen toxic-ity presents with nausea, paresthesias, dizziness and seizures. An oxygen toxic-ity seizure can be deadly if experienced underwater.

Symptoms of oxygen toxicity can occur suddenly without prodrome. Nitrogen narcosis occurs as more nitrogen is dissolved into the bloodstream and other tissues as the diver descends. Symptoms include loss of fine motor skills and higher order mental processes. Unlike oxygen toxicity, nitrogen narcosis is a gradual process and for most begins around 100 feet of depth. Nitrogen narcosis is a euphoric feeling and is similar to the effects of alcohol. Divers call this the “Martini Law” which states that every 33 feet you descend on air is equivalent to drinking one martini on an empty stom-ach. As with alcohol, nitrogen narcosis

affects every diver differently.

In summary, both decompression injury and air-gas embolism are life threatening conditions that may present to your emer-gency department. Decompression injury usually presents several minutes to hours after the dive and can affect the skin, joints, and central nervous system. Air-gas embolism occurs immediately upon surfacing and presents with symp-toms mimicking a heart attack or stroke.

The treatment of both entities is similar with airway, breathing and circulation being paramount. After initial resuscita-tion, oxygen and IV hydration, recompres-sion therapy is the treatment of choice. I hope this helps to shed some light on life threatening diving injuries and hope to see you around the springs of north central Florida.

SYMPOSIUMbytheSea




































SYMPOSIUMbytheSea

Tips of the TradeAuricular ForeignBody Removal

Tracy G. Sanson, MD, FACEPAssociate Professor, Education Director Division of EM, University of South Florida

The most common foreign bodies in the ear are beads, plastic toys, pebbles, insects (especially cockroaches), popcorn kernels, earrings, paper, peas, cotton, pencil erasers, and seeds.

INSECTSKill the insect before attempting to remove it with Mineral oil, lidocaine (2%), or isopropyl alcohol. (Suggest baby oil, isopropyl alcohol, or cooking oil if patient is frantically calling the ED.)

Insecticidal activity of common reagents for insect foreign bodies of the ear Antonelli PJ, Ahmadi A, Prevatt A, Laryngoscope. 2001;111:15-20

Conclusion: Many agents commonly available in the EMS may be used to kill insect foreign bodies in the ear canal. Antiseptic agents and microscope oil were the most effective against the most common insect foreign body, the cockroach. Ticks were the most resistant to all agents tested.

Comment: What is the best agent to grab when you have a distraught patient severely agitated by the presence of a live insect in the ear? Mineral oil has been commonly recommended, but it tends to create a gooey mess, making foreign body removal more difficult. Isopropyl alcohol would be my drug of choice. Although it is only number 2 on the quick-kill list, it is probably more readily available than the number 1–ranked ethyl alcohol. Liquid anesthetics are a nice thought, but take at least 3 or 4 times longer to achieve the desired lethal effect on the bug.

Methods of Removal

● Irrigation: The simplest method of removal provided the tympanic membrane is not perforated. Use an irrigation syringe or standard syringe and angiocath or butterfly tubing cut short. Direct the stream along the wall of the ear canal and around the object, flushing it out.Do not irrigate: - Hygroscopic objects such as vegetables, beans, and other food matter - may swell. - Button Batteries: Avoid nasal and otic drops. These electrolyte-rich fluids enhance battery corrosion, leakage, generation of an external current, and local injury.

● Suction: If the object is light and moves easily, attempt to suction it out with a small catheter, a standard metal suction tip or specialized flexible tip.

● Alligator forceps are best for grasping soft objects like cotton or paper.

● Super Glue or cyanoacrylate. Place the glue material on the end of a cut cotton-tip applicator, avoiding the side of the ear. Contact with the object through the otoscope, and hold for ~ 15 seconds. Then remove.

Pediatr Emerg Care. 1989 Jun;5(2):135-6. A new technique for removing foreign bodies of the external auditory canal. Pride H, Schwab R.

Conclusion: “Cyanoacrylate adhesive (Super Glue) was used successfully to remove a soy bean in a 16-year-old male. The glue was placed on the blunt end of a

cotton swab, which was then introduced into the canal to make contact with the bean. Removal was easy, safe, and effec-tive.”

Emerg Med J. 2002 Jan;19(1):43-5. Comparative prospective study of foreign body removal fromexter-nal auditory canals of cadavers with right angle hook or cyanoacrylate glue. McLaughlin R, Ullah R, Heylings D.

Conclusion: “The authors feel that cyano-acrylate impregnated cotton buds are as effective at removing impacted foreign bodies as a right angle hook but the process takes longer. It is believed that patients could tolerate this longer time as the cyanoacrylate method is in theory less traumatic.”

METALLIC OBJECTSUsing a metal forceps, place a magnet on the end outside the ear. Touch the magne-tized forceps to the object and remove.

● Styrofoam: Instill the organic solvent acetone or ethyl chloride.

Ann Emerg Med. 1994 Mar;23(3):580-2. The use of acetone to dissolve a Styrofoam impaction of the ear. White SJ, Broner S.

Conclusion: Styrofoam can be particularly problematic because it can be compressed and become tightly impacted in an ear canal. Furthermore, Styrofoam is friable and tends to fragment with usual removal methods. Instillation of the organic solvent acetone into the ear canal was well-tolerated and caused rapid and near-complete dissolution of the Styrofoam impaction. This is the first reported case of

organic solvent dissolution of an otic foreign body.

BATTERIESRemove immediately to prevent corrosion or burns. A delay of only an hour or two or a missed diagnosis of a battery in a nose or ear may lead to a very severe outcome. On contact with most tissue, this type of alkaline battery is capable of producing a liquefactive necrosis extending into deep tissues. Do not crush battery during removal. Avoid nasal and otic drops. These electrolyte-rich fluids enhance battery corrosion, leakage, generation of an external current, and local injury After removal, the canal should be irrigated to

remove alkalai residue.

Objects which are difficult to remove and warrant referral are spherical objects, objects in contact with the TM and in the ear > 24 hours.

Otolaryngol Head Neck Surg. 2002 Jul;127(1):73-8. Pediatric external auditory canal foreign bodies: a review of 698 cases. Schulze SL, Kerschner J, Beste D.

Conclusion: “Attempts under direct visualization had lower success rates with removing spherical objects, objects touch-ing the tympanic membrane, and objects in the canal for more than 24 hours. Failed removal attempts resulted in higher complication rates. These cases should be

referred directly to otolaryngologists for otomicroscopic removal.”

www.bestbets.org Ear Foreign Body Removal B Fennessy October 2004. Search strategy: Medline 1966-09/04.

Conclusion: There is no evidence in the current literature for choosing any particu-lar method over another in the removal of foreign bodies from the ear, and many different techniques are applicable.

Clinical bottom line: No studies have been undertaken on comparing the different techniques to determine success. It is therefore advised that cases are treated individually.


































The most common foreign bodies in the ear are beads, plastic toys, pebbles, insects (especially cockroaches), popcorn kernels, earrings, paper, peas, cotton, pencil erasers, and seeds.

INSECTSKill the insect before attempting to remove it with Mineral oil, lidocaine (2%), or isopropyl alcohol. (Suggest baby oil, isopropyl alcohol, or cooking oil if patient is frantically calling the ED.)

Insecticidal activity of common reagents for insect foreign bodies of the ear Antonelli PJ, Ahmadi A, Prevatt A, Laryngoscope. 2001;111:15-20

Conclusion: Many agents commonly available in the EMS may be used to kill insect foreign bodies in the ear canal. Antiseptic agents and microscope oil were the most effective against the most common insect foreign body, the cockroach. Ticks were the most resistant to all agents tested.

Comment: What is the best agent to grab when you have a distraught patient severely agitated by the presence of a live insect in the ear? Mineral oil has been commonly recommended, but it tends to create a gooey mess, making foreign body removal more difficult. Isopropyl alcohol would be my drug of choice. Although it is only number 2 on the quick-kill list, it is probably more readily available than the number 1–ranked ethyl alcohol. Liquid anesthetics are a nice thought, but take at least 3 or 4 times longer to achieve the desired lethal effect on the bug.

Methods of Removal

● Irrigation: The simplest method of removal provided the tympanic membrane is not perforated. Use an irrigation syringe or standard syringe and angiocath or butterfly tubing cut short. Direct the stream along the wall of the ear canal and around the object, flushing it out.Do not irrigate: - Hygroscopic objects such as vegetables, beans, and other food matter - may swell. - Button Batteries: Avoid nasal and otic drops. These electrolyte-rich fluids enhance battery corrosion, leakage, generation of an external current, and local injury.

● Suction: If the object is light and moves easily, attempt to suction it out with a small catheter, a standard metal suction tip or specialized flexible tip.

● Alligator forceps are best for grasping soft objects like cotton or paper.

● Super Glue or cyanoacrylate. Place the glue material on the end of a cut cotton-tip applicator, avoiding the side of the ear. Contact with the object through the otoscope, and hold for ~ 15 seconds. Then remove.

Pediatr Emerg Care. 1989 Jun;5(2):135-6. A new technique for removing foreign bodies of the external auditory canal. Pride H, Schwab R.

Conclusion: “Cyanoacrylate adhesive (Super Glue) was used successfully to remove a soy bean in a 16-year-old male. The glue was placed on the blunt end of a

cotton swab, which was then introduced into the canal to make contact with the bean. Removal was easy, safe, and effec-tive.”

Emerg Med J. 2002 Jan;19(1):43-5. Comparative prospective study of foreign body removal fromexter-nal auditory canals of cadavers with right angle hook or cyanoacrylate glue. McLaughlin R, Ullah R, Heylings D.

Conclusion: “The authors feel that cyano-acrylate impregnated cotton buds are as effective at removing impacted foreign bodies as a right angle hook but the process takes longer. It is believed that patients could tolerate this longer time as the cyanoacrylate method is in theory less traumatic.”

METALLIC OBJECTSUsing a metal forceps, place a magnet on the end outside the ear. Touch the magne-tized forceps to the object and remove.

● Styrofoam: Instill the organic solvent acetone or ethyl chloride.

Ann Emerg Med. 1994 Mar;23(3):580-2. The use of acetone to dissolve a Styrofoam impaction of the ear. White SJ, Broner S.

Conclusion: Styrofoam can be particularly problematic because it can be compressed and become tightly impacted in an ear canal. Furthermore, Styrofoam is friable and tends to fragment with usual removal methods. Instillation of the organic solvent acetone into the ear canal was well-tolerated and caused rapid and near-complete dissolution of the Styrofoam impaction. This is the first reported case of

organic solvent dissolution of an otic foreign body.

BATTERIESRemove immediately to prevent corrosion or burns. A delay of only an hour or two or a missed diagnosis of a battery in a nose or ear may lead to a very severe outcome. On contact with most tissue, this type of alkaline battery is capable of producing a liquefactive necrosis extending into deep tissues. Do not crush battery during removal. Avoid nasal and otic drops. These electrolyte-rich fluids enhance battery corrosion, leakage, generation of an external current, and local injury After removal, the canal should be irrigated to

remove alkalai residue.

Objects which are difficult to remove and warrant referral are spherical objects, objects in contact with the TM and in the ear > 24 hours.

Otolaryngol Head Neck Surg. 2002 Jul;127(1):73-8. Pediatric external auditory canal foreign bodies: a review of 698 cases. Schulze SL, Kerschner J, Beste D.

Conclusion: “Attempts under direct visualization had lower success rates with removing spherical objects, objects touch-ing the tympanic membrane, and objects in the canal for more than 24 hours. Failed removal attempts resulted in higher complication rates. These cases should be

referred directly to otolaryngologists for otomicroscopic removal.”

www.bestbets.org Ear Foreign Body Removal B Fennessy October 2004. Search strategy: Medline 1966-09/04.

Conclusion: There is no evidence in the current literature for choosing any particu-lar method over another in the removal of foreign bodies from the ear, and many different techniques are applicable.

Clinical bottom line: No studies have been undertaken on comparing the different techniques to determine success. It is therefore advised that cases are treated individually.

EMERGENCYultrasound













































The Man with a Red EyeCPC Chair: Fred Epstein, MD, FACEPCase Presenter: Christopher Mann, MD David Caro, MD, FACEP University of Florida, JacksonvilleCase Challenger: Jonathan DeGroat, MD University of Florida, Gainesville





SYMPOSIUMbytheSea












SYMPOSIUMbytheSea







SYMPOSIUMbytheSea

A 28-year-old female presented to the ORMC Emergency Department complaining of a painful, diffuse rash. It started three days prior, gradually expanded, and was intensely painful. The lesions were erythematous, circular, non-raised, and located on the abdomen, flank, and left leg. The patient stated, “It feels like my skin is going to burst into flames.”

Her past medical history revealed no chronic medical conditions. She had a similar rash two months ago while incar-cerated that was resistant to topical steroids and Benadryl - it resolved sponta-neously after one week. She had no surgi-cal history, took no medications, and had no allergies. Her family history was unremarkable. The patient smoked 1 pack/day, drank a moderate amount of alcohol, and used both cocaine and marijuana on a regular basis. She was a former pet groomer, and lived with her mother in Orlando. She was bisexual with multiple sexual partners and was released from jail one month prior to presentation. The patient denied recent travel, sick contacts, or new medications.

On physical exam, the patient was noted to be a white female appearing disheveled, non-toxic, and slightly uncomfortable. Her vital signs were within normal limits. She had mild edema to both hands and a small effusion of her left knee. A rash was present on her abdomen, flank, and left leg that was non-blanching, tender, and purpuric with necrotic centers ranging from 1-5 cm in diameter with clearing

near the edges. There were no vesicles or blisters, and no involvement of the palms, soles, or mucous membranes.

Initial work up showed an unremarkable CBC, CMP, coagulation panel, chest x-ray, and urinalysis. A urine drug panel was positive for THC and cocaine. Rapid HIV was non-reactive. Her ESR and CRP were elevated at 53 and 3.8, respectively. Her RPR returned at 1:256.

After admission, treponemal IgM and IgG were both positive. Skin biopsies confirmed the presence of spirochetes, and histopathology was consistent with

gummata/Lues Maligna. The patient was treated with IM Penicillin, and the lesions immediately improved. She was discharged with instructions to complete outpatient treatment. The patient returned three weeks later with recurrence of rash. Again her HIV was negative and RPR was positive, but titers had decreased from 1:256 to 1:128. This new rash was thought to be secondary to cocaine-induced vasculitis given the patient’s rich social history, and could easily be confused with her initial syphilitic rash.

Lues Maligna is also known as malignant or ulceronodular syphilis. It differs from other forms of secondary syphilis in its morphology and location. It can present as pustules, nodules, or ulcers with or without mucosal involvement. The hallmark skin findings are multiple, well demarcated round or oval lesions that may have a lamellar crusting to the edge. The diagnostic criteria include a strongly positive RPR titer, a severe Jarisch-Herxheimer reaction, characteristic gross and microscopic morphology, and rapid resolution of lesions with antibiotics. Despite the fact that the patient may have returned with cocaine-induced vasculitis, an initial diagnosis of syphilis should never be missed in the ED. Syphilis is a vital diagnosis to make in the ED because it is easily treatable, yet devastating if left undiscovered. This patient illustrated the importance of always including “the great masquerader” on the differential of an unknown rash in the ED and to always keep a high clinical suspicion of syphilis in mind.















The Girl Whose SkinMight Burst Into Flames

CPC Chair: Fred Epstein, MD, FACEPCase Presenter: Jillian Davison, MD; Sal Sylvestri, MD, FACEP Orlando Regional Medical CenterCase Challenger: Jill Ward, MD Florida Hospital - Orlando

technology

Conference OverviewSymposium by the Sea 2012 is an educational opportunity designed for the busy emergency physician, resident, nurse, PA, and allied health professional who demands cutting edge information regarding their ever-changing practice environment. In addition to the educational sessions, the conference provides: Symposium General Educational Sessions* Preconferences available for ED Administrators, Medical Directors & Nurses; Satellite Educational Symposia; Florida Emergency Medicine Resident's Case Presentation Competition (CPC); Wine & Cheese Reception with Exhibitors; Ferguson Memorial Volleyball Tournament; EMRAF Job Fair; A Night with Orleans - Saturday Evening Private Concert.

*All except the preconferences are no charge for FCEP Members and 50% o� for ACEP Members!

Conference Date & LocationAugust 2-5, 2012 . Omni Amelia Island Platation Resort . 6800 First Coast Highway, . Amelia Island, Florida 32034 Reservations (904) 261-6161 . Mention Symposium by the Sea Guest Room Reservations Cut-O� Date: July 2, 2012 . Reserve your room early!

Free forall FCEP

Members!!

50% offall ACEP

Members!!

Presented by Emergency Medicine Learning & Resource Center (www.emlrc.org)in conjunction with the Florida College of Emergency Physicians (www.fcep.org).

A Night with Orleans - Saturday Evening Private ConcertThe Florida College of Emergency Physicians is proud to present a private concert for you by the legendary band Orleans at the 2012 Symposium by the Sea Conference at The Naples Grande Resort in Naples, FL, Saturday August 4, 2012. Orleans will be performing such favorites as Dance with Me (1975), Still the One (1976) and Love Takes Time (1979) and many more!! Be sure not to miss this night to remember by signing up for the 2012 Symposium by the Sea Conference today!!

Who Should AttendEmergency Physicians, Physician Assistants, Nurses and other Health Care Professionals.

FCEP Membership Bene�tRegistration for the Symposium by the Sea general conference is FREE to all FCEP Members. Join the Florida College of Emergency Physicians prior to Symposium by the Sea and your registration will be refunded upon receipt of your application and payment of your �rst year's dues. For further information, contact the FCEP o�ce at (407) 281-7396 or by email at [email protected].

Exhibit/Sponsorship OpportunitiesVisit www.emlrc.org/sbs2012.htm or contact Jerry Cutchens at [email protected] Exhibit/Sponsorship Prospectus is avail-able directly at www.emlrc.org/pdfs/sbs2012prospectus.pdf.

More InformationVisit www.fcep.org or call (800) 766-6335 EMLRC . 3717 S. Conway Road . Orlando, FL

www.orleansonline.com

REGISTER @ WWW.FCEP.ORG

Symposium by the Sea 2012The Annual Meeting of the Florida College of Emergency Physicians

August 2-5, 2012 . Omni Amelia Island Resort . Amelia Island, FL






























POISONcontrol

Treatment ofScorpion Stings in Florida

Rachel O’Geen, Pharm.D.Clinical Toxicology FellowDawn R. Sollee, Pharm.D., DABATAssistant DirectorAdam Wood, Pharm.DClinical Toxicology FellowFlorida/USVI Poison Information Center – Jacksonville

Scorpion stings account for a large number of calls to poison control centers nationwide. In 2009, there were 17,154 scorpion exposures reported to the Ameri-can Association of Poison Control Centers. Of these, 1,625 were treated in a health care facility with 50 cases resulting in major outcomes.1 In that same year, the Florida Poison Information Center Network received reports of 585 scorpion stings with no major effects.2 To improve treatment of severe scorpion stings, the FDA approved Anascorp® on August 3, 2011. It is the first equine derived F(ab’)2 anti-venom specific for scorpion enven-omation in the United States.3

Most scorpions found in the US are of the Centruroides genus and produce primarily neurotoxic venom. The severity of enven-omation will vary depending on the species of the scorpion. The principle site of toxicity is the sodium channel where the venom causes continuous firing of axons. This leads to initial symptoms consisting of pain, tingling, and burning at the site of the sting which might lack signs of inflammation. When symptoms progress past the initial site, common manifestations include pain in areas distal to the site and subjective complaints of dysphagia. Severe cases may develop symptoms of cranial nerve and somatic motor dysfunction including rotatory eye movements, tongue fasciculations, and respiratory arrest. Patients may also develop uncontrollable muscle move-

ments that can be mistaken for anything from restlessness to seizures. While adults are more often stung by scorpions, children under 10 years of age are more likely to develop severe symptoms requir-ing treatment.4

When considering treatment for scorpion envenomation it is important to determine which species was responsible for the sting. Of the scorpions indigenous to the United States, only Centruroides exilicauda (also referred to as Centruroi-des sculpturatus, the Arizona bark scorpion) is able to deliver enough venom with its sting to produce potentially life-threatening effects in humans. This species is native to Arizona but is also found in parts of New Mexico, Nevada, and California. Although there have been reports of travelers unknowingly trans-porting scorpions in their personal belong-ings or people keeping one as a pet, they are not likely found outside the southwest-ern region of the US.4 There are three species of scorpions indigenous to Florida (C. gracilis, C. hentzi and C. guianensis); fortunately, none are expected to cause systemic effects.6

Most people with history of a scorpion sting will not manifest systemic symptoms and can be managed sufficiently at home.6 Prior to the availability of anti-venom, treatment of severe scorpion envenom-ation consisted of intensive supportive care including benzodiazepines for

muscular manifestations and intubation as needed for respiratory support. Boyer, et al evaluated the efficacy of Anascorp® in 15 Arizona children with systemic mani-festations of scorpion stings. All patients receiving antivenom experienced a complete resolution of symptoms within 4 hours of administration compared to only 14% of patients in the placebo group (p = 0.001). In addition, patients treated with anti-venom received an average cumula-tive midazolam dose of 0.07 mg/kg prior to discharge compared to 4.61 mg/kg in the placebo group (p = 0.01).7

Treatment of scorpion stings in Florida should involve symptomatic and support-ive care similar to that of other insect bites. Patients who have been exposed to a scorpion native to Florida will generally only develop pain at the site. Although hypersensitivity reactions to the venom may occur, symptoms are not generally expected to progress systemically. Patients may find cold compresses and analgesics helpful in the management of local symptoms. Use of anti-venom may be considered in patients in Florida presenting with systemic symptoms who have history of recent travel to the south-western US or who have come into contact with a pet scorpion from this area. Recommended dosing consists of 3 vials of Anascorp® given intravenously over 10 minutes. Each vial is reconstituted with 5 mL of normal saline and swirled, as to not denature the proteins. The contents of the

3 vials are then combined and further diluted with normal saline to create a total volume of 50 mL. Additional vials, if needed, may be given following a period of 30-60 minute observation. Common adverse effects include vomiting, fever, rash, pruritus, and headache. Hypersensi-tivity reactions including anaphylaxis are possible when using Anascorp®. Particu-lar caution is advised in patients who have a known allergy to horse proteins or those who have previously received equine derived anti-venom. Patients should be counseled on the risk of serum sickness, which may present as delayed flu-like symptoms (rash, fever, and arthralgias).8

Feel free to contact your local poison center toll-free at 1-800-222-1222 with questions regarding general management of patients with scorpion stings or the use of Anascorp® anti-venom.

REFERENCES1. Bronstein AC, et al. 2009 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 27th Annual Report. Clin Toxicol. 2010 Dec; 48(10): 979-1178.

2. Florida Poison Information Center Network Query (2009). Scorpions.

3. FDA approves the first specific treatment for scorpion stings. Food and Drug Admin-istration website. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm266611.htm. Accessed September 1, 2011.

4. Curry SC, et al. Envenomation by the scorpion Centruroides sculpturatus. J Toxicol Clin Toxicol. 1983-84; 21(4 & 5): 417-449.

5. Koehler PG and Oi FM. Stinging or Venomous Insects and Related Pests. University of Florida IFAS Extension website. Published October 1994. Revised March 2003. http://edis.ifas.ufl.edu/IG099. Accessed September 1, 2011.

6. Gibly R, et al. Continuous intravenous midazolam for Centruroides exilicauda scorpion envenomation. Ann Emerg Med. 1999 Nov; 34(5): 620-625.

7. Boyer LV, et al. Antivenom for critically ill children with neurotoxicity from scorpion stings. N Engl J Med. 2009 May; 360(20): 2090-2098.

8. Anascorp® [package insert]. Franklin, TN: Rare Disease Therapeutics; 2011.















Scorpion stings account for a large number of calls to poison control centers nationwide. In 2009, there were 17,154 scorpion exposures reported to the Ameri-can Association of Poison Control Centers. Of these, 1,625 were treated in a health care facility with 50 cases resulting in major outcomes.1 In that same year, the Florida Poison Information Center Network received reports of 585 scorpion stings with no major effects.2 To improve treatment of severe scorpion stings, the FDA approved Anascorp® on August 3, 2011. It is the first equine derived F(ab’)2 anti-venom specific for scorpion enven-omation in the United States.3

Most scorpions found in the US are of the Centruroides genus and produce primarily neurotoxic venom. The severity of enven-omation will vary depending on the species of the scorpion. The principle site of toxicity is the sodium channel where the venom causes continuous firing of axons. This leads to initial symptoms consisting of pain, tingling, and burning at the site of the sting which might lack signs of inflammation. When symptoms progress past the initial site, common manifestations include pain in areas distal to the site and subjective complaints of dysphagia. Severe cases may develop symptoms of cranial nerve and somatic motor dysfunction including rotatory eye movements, tongue fasciculations, and respiratory arrest. Patients may also develop uncontrollable muscle move-

ments that can be mistaken for anything from restlessness to seizures. While adults are more often stung by scorpions, children under 10 years of age are more likely to develop severe symptoms requir-ing treatment.4

When considering treatment for scorpion envenomation it is important to determine which species was responsible for the sting. Of the scorpions indigenous to the United States, only Centruroides exilicauda (also referred to as Centruroi-des sculpturatus, the Arizona bark scorpion) is able to deliver enough venom with its sting to produce potentially life-threatening effects in humans. This species is native to Arizona but is also found in parts of New Mexico, Nevada, and California. Although there have been reports of travelers unknowingly trans-porting scorpions in their personal belong-ings or people keeping one as a pet, they are not likely found outside the southwest-ern region of the US.4 There are three species of scorpions indigenous to Florida (C. gracilis, C. hentzi and C. guianensis); fortunately, none are expected to cause systemic effects.6

Most people with history of a scorpion sting will not manifest systemic symptoms and can be managed sufficiently at home.6 Prior to the availability of anti-venom, treatment of severe scorpion envenom-ation consisted of intensive supportive care including benzodiazepines for

muscular manifestations and intubation as needed for respiratory support. Boyer, et al evaluated the efficacy of Anascorp® in 15 Arizona children with systemic mani-festations of scorpion stings. All patients receiving antivenom experienced a complete resolution of symptoms within 4 hours of administration compared to only 14% of patients in the placebo group (p = 0.001). In addition, patients treated with anti-venom received an average cumula-tive midazolam dose of 0.07 mg/kg prior to discharge compared to 4.61 mg/kg in the placebo group (p = 0.01).7

Treatment of scorpion stings in Florida should involve symptomatic and support-ive care similar to that of other insect bites. Patients who have been exposed to a scorpion native to Florida will generally only develop pain at the site. Although hypersensitivity reactions to the venom may occur, symptoms are not generally expected to progress systemically. Patients may find cold compresses and analgesics helpful in the management of local symptoms. Use of anti-venom may be considered in patients in Florida presenting with systemic symptoms who have history of recent travel to the south-western US or who have come into contact with a pet scorpion from this area. Recommended dosing consists of 3 vials of Anascorp® given intravenously over 10 minutes. Each vial is reconstituted with 5 mL of normal saline and swirled, as to not denature the proteins. The contents of the

3 vials are then combined and further diluted with normal saline to create a total volume of 50 mL. Additional vials, if needed, may be given following a period of 30-60 minute observation. Common adverse effects include vomiting, fever, rash, pruritus, and headache. Hypersensi-tivity reactions including anaphylaxis are possible when using Anascorp®. Particu-lar caution is advised in patients who have a known allergy to horse proteins or those who have previously received equine derived anti-venom. Patients should be counseled on the risk of serum sickness, which may present as delayed flu-like symptoms (rash, fever, and arthralgias).8

Feel free to contact your local poison center toll-free at 1-800-222-1222 with questions regarding general management of patients with scorpion stings or the use of Anascorp® anti-venom.

REFERENCES1. Bronstein AC, et al. 2009 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 27th Annual Report. Clin Toxicol. 2010 Dec; 48(10): 979-1178.

2. Florida Poison Information Center Network Query (2009). Scorpions.

3. FDA approves the first specific treatment for scorpion stings. Food and Drug Admin-istration website. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm266611.htm. Accessed September 1, 2011.

4. Curry SC, et al. Envenomation by the scorpion Centruroides sculpturatus. J Toxicol Clin Toxicol. 1983-84; 21(4 & 5): 417-449.

5. Koehler PG and Oi FM. Stinging or Venomous Insects and Related Pests. University of Florida IFAS Extension website. Published October 1994. Revised March 2003. http://edis.ifas.ufl.edu/IG099. Accessed September 1, 2011.

6. Gibly R, et al. Continuous intravenous midazolam for Centruroides exilicauda scorpion envenomation. Ann Emerg Med. 1999 Nov; 34(5): 620-625.

7. Boyer LV, et al. Antivenom for critically ill children with neurotoxicity from scorpion stings. N Engl J Med. 2009 May; 360(20): 2090-2098.

8. Anascorp® [package insert]. Franklin, TN: Rare Disease Therapeutics; 2011.

POISONcontrol



ENA National Scorecard onState Roadway Laws

The Emergency Nurses Association (ENA) invites FCEP to join us in injury prevention efforts in our state.

According to the Centers for Disease Control and Prevention, a person is taken to an ED to be treated for a vehicle crash-related injury every 10 seconds. That translates into approximately 3.8 million emergency department visits a year from vehicle crashes alone. Every 12 minutes, someone in the United States dies from a vehicle crash. Study after study show that injury and death can be prevented when states pass and enforce laws that protect citizens from roadway related injury.

The ENA has created a tool and report to empower ENA members and others to engage in collaborative efforts that encourage lawmakers to pass research-based laws protecting people from roadway-related injuries.

The 2010 National Scorecard on State Roadway Laws: A Blueprint for Injury Prevention examines roadway safety laws in all 50 states and the District of Columbia and assigns scores on 14 legislation based criteria. Of the 14 possible criteria Florida scored 7. This report is current as of October 11, 2010.

The Scorecard ranks states based on 14 types of legislation that address: seat belt use; child passenger safety; graduated driver licensing for teens; all-rider motorcycle helmet requirements; ignition interlock devices to prevent drunk driving; entering, sending, reading, or retrieving data for all drivers using cell phones or other interactive wireless communication devices; and the authority to develop, maintain and evaluate a state trauma system.

The full report is available online at www.ena.org.

TRAUMAscorecard

Terri M. Repasky RN, MSN, CEN, CNS, EMTPClinical Nurse Specialist, Emergency / TraumaPresident Elect Florida ENA

RESIDENCYmatters

University of Florida, GainesvilleDavid Nguyen, DO

Greetings from Gainesville! With the start of a new academic year, we have had to say goodbye to our former senior residents. The class of 2011 has spread its Gator pride as far as Arizona! This excep-tional class has set high standards with their excellent patient care, hard work, and dedication. We wish them well in their future careers. We also welcome the class of 2014. During July, the new interns went through an ED orientation month. Not only did they have shifts in the ED, but also had daily EM lectures and hands-on procedure labs at our dedicated simulation lab. This orientation month eased our interns into the program, and they have quickly adjusted. To celebrate the completion of their first month, we had a city-wide scavenger hunt, an epic paintball battle, and a pool party!

On July 1, the new Pediatric Emergency Room at Shands Hospital for Children at the University of Florida opened, becom-ing north central Florida’s first ED specifi-cally geared toward kids. It is staffed by seven board-certified/ board-eligible Pediatric EPs and 22 Pediatric-trained EM registered nurses. We will be able to treat up to 24,000 patients a year.

At the Symposium by the Sea CPC, Residents Justin Bennett and Jonathan Degroat looked to defend our title of the Bud Ferguson award. We are proud to announce that we are back-to-back cham-pions! Justin Bennett placed 3rd for his case presentation of Ehrlichiosis and

Greetings from Florida Hospital! We hope everyone is having a great summer. The transition that occurs during this time of year always brings excitement. We proudly graduated our inaugural class in June. We wish them the best of luck in their new endeavors. Taking their place are six fresh faces from all over the country. Our intern class has hit the ground running and is quickly assimilating to their new roles. We congratulate our four residents who represented our program in the AAEM Sims Wars and placed third in the compe-tition. Our second year residents, Drs. Troy Mostaan and Jill Ward placed 2nd and 3rd place respectively in individual CPC case presentations at the Symposium by the Sea. FHEM Residency is proud to be part of the movement of FH becoming a large academic hospital. Until next time: we hope to see everyone at the ACEP Meeting.

Jonathan DeGroat won 1st place for best case discussion of carotid-cavernous fistula. Their combined score won the overall highest score! Also at the Sympo-sium, resident Brandon Allen took home second place for his fantastic poster presentation investigating return visits within 72 hours. Congratulations to all our residents for representing our program so well… and Go Gators!

Before striking out on their own, our seniors rocked the in-service exam, leading us to rank 12th among 154 EM programs!

Bidding them farewell, Dr. Ferdinand Richards graciously hosted a Hawaiian Luau complete with a steel drum band and fire-dancers.

We are thrilled to retain Dr. Jason Wilson as our Associate Research Director. We will continue research in septic shock and soft tissue infections. We are also eager to launch studies in the reversal of coagu-lopathy and the rapid bedside confirma-tion of NG-tube placement. Our new Chief Resident, Tamas Gaspar, along with Administrative Chief Sara Temple and Research Chief Veronica Tucci, will lead our program to new heights. Dr. Charlotte Derr has introduced innova-tive technology to securely beam bedside ultrasound scans to a server for quality assurance, research and more.

Florida HospitalVu Nguyen, MD

University of South Florida Nicholas N. Healy, DO


RESIDENCYmatters


Univ. of Florida, JacksonvilleTravis Smith, DO

Greetings from Shands!!!! Just like every-where around the state and across the nation, we are welcoming our new interns to the craziness we like to call the "The Shands."

We all remember the steep learning curve during our first months in the ED. Our seniors are doing a great job in the new transition. The next big step is our transi-tion to EPIC in the next few months.

In an effort to integrate online medical education into our didactics, we have introduced a new awesome online educa-tional resource for the residents. It was created by our resident selected faculty teacher of the year Dr. Alex Berk and by me. Check it out at jaxem.squarespace.com.

Look forward to seeing everyone at ACEP.

Mount Sinai Medical CenterRoberto Fernandez, Ashley Lisiewski, Aaron Mickelson, Kirsten Ritchie & Daniel Aronovich

Another exciting year has begun for our residency program at Mount Sinai. The installation of our new electronic records system (EPIC) is underway and has provided a novel challenge for the depart-ment. With new technology comes new faces, and the ED would like to formally welcome its new interns: Ashley Lisiewski, Kirsten Ritchie, Roberto Fernandez, Aaron Mickelson and Daniel Aronovich. We would also like to welcome our new attending, Dr. David Edwards, to the Sinai family. They are already proving to be quite an asset to our program!

Last month heralded the success of the First Annual FLAAEM Scientific Assem-bly, held at the Grand Beach Hotel in Miami Beach. Our own Dr. David Farcy holds the position as 2011 President to the FLAAEM Association, while Dr. Erin Connor (PGY-4) holds the title of Resident Representative. Two days of lecturers were followed by resident poster presentations.

Dr. Richard Giroux (PGY-2) presented an interesting poster on “Sudden Cardiac Arrest”, Dr. Michael DeVarona (PGY-2) presented a poster on “Spontaneous Tracheal Rupture” and Dr. Nicole Camp-field (PGY-2) delivered a case presenta-tion poster on paraphimosis. The posters will be showcased at subsequent confer-ences throughout the year.

Lastly, sincere congratulations go out to our program director, Dr. Beth Longe-necker, on her wedding last month!

Greetings from Orlando!

It’s been busy as we geared up for another interview season! Our first candidates have come and gone. Thanks to all of the residents who contributed to recruitment and preparations – the caliber of candi-dates is outstanding, and the support of the residents and faculty is sure to make this an amazing year!

Orlando Health is exploring an exciting ED expansion goal. While planning is still underway, initial recommendations include expanding the department to approximately 70 beds, with over 30 beds in the pediatric emergency department. We’re looking forward to final blueprints – it looks like we’ll have plenty of room to grow!

Orange County EMS is teaming up with Orlando Health to study the incremental benefit of 12-lead transmission on-scene for STEMI patients, specifically benefits of 12-lead transmission on the time-to-reperfusion in STEMI patients. It is an exciting study, and both EMS teams and our physicians are dedicated to the project. Congratulations to everyone involved in this partnership!

It seems like this year is racing by! Our intern class is performing far beyond expectations, and our upper classmen are providing excellent guidance as they continue to demonstrate their skills.

Mount Sinai Medical CenterNicole Campfield, DO

Orlando Regional Medical CenterRebecca Blue, MD

EAST COAST, FLORIDA

Outstanding opportunity for an Emergency Physician to

join this 41,000 volume state -of –the- art facility, located

less than one hour from Orlando. This family-oriented

community is on the intracoastal and just minutes from

the beaches. Double coverage as well as mid level

providers and excellent back-up. Excellent compensa-

tion and benefits package. Contact: Robin Lorber at

Team Health Southeast, 1-800-442-3672, ext. 2904. FAX

(954) 424-3270.

EMERGENCY MEDICINEOPPORTUNITY

JACKSONVILLE, FLORIDA

Come Live on Florida’s Coast! Described as one of the nation’s most dynamic and progressive cities,

Jacksonville’s miles of beaches and waterways are some of its most alluring assets. Home of the Jacksonville Jaguars, the city boasts a sports and entertainment

complex, a major symphony orchestra, diverse cultural and recreation opportunities along with abundant

natural resources. Due to its convenient location, mild climate and reasonable cost of living coupled with a high

quality of life, Jacksonville is one of the top 15 fastest growing cities in the US.

Titan Emergency Group, an equity based group owned and operated by our physician members, is currently seeking an Emergency Medicine Physician for a full

partnership opportunity in Jacksonville, Florida. Candi-date must be BE/BC ABEM/AOBEM certified to work in

our facilities. Memorial Hospital is a 353-bed tertiary care hospital

offering a breadth of services including the new state-of-the-art CyberKnife Cancer Center and innovative

Memorial Neuroscience Center. The ED is comprised of 33 beds with a 12 bed fast track and sees 72,000 patient

visitors annually. Orange Park Medical Center has a fully accredited 255-bed hospital that is currently seeking a Level II

Trauma designation and has recently added Open Heart Surgery to its comprehensive heart care services. The ED has 24 beds with a 12 bed fast track and is under renova-

tion to double its size.

At Titan, you have the ability to capitalize on perfor-mance based compensation!! We offer competitive

compensation that includes both an hourly rate as well as productivity bonuses. Further we have a very compre-

hensive benefits package that includes heath and disabil-ity insurance, generous 401K retirement plan, CME and professional expense funding as well as malpractice and

tail coverage.


Florida College ofEmergency PhysiciansFCEP|

3717 South Conway Road, Orlando, FL 32812

NONPROFITORGANIZATION

US POSTAGEPAID

PERMIT NO. 2361ORLANDO, FL

EMpulse Fall 2011

Documents

Transcript of EMpulse Fall 2011