EMpulse Spring 2011

SPRING 2011

Emergency Ultrasound EM Days 2011 Bath Salt Craze

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

Executive CommitteeAmy R. Conley, MD, FACEP • PresidentVidor Friedman, MD, FACEP • President-ElectKelly Gray-Eurom, MD, FACEP • Vice PresidentMichael Lozano Jr., MD, FACEP • Secretary/ TreasurerMylissa Graber, 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 advertisements.

Published by:LynDee Press, Inc. dba Fidelity Press649 Triumph Court, Orlando, FL 32805Tel: (407) 297-8484www.fidelitypress.us

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 2

EMpulse • Spring 2011 1

Emergency UltrasoundUltrasound Fellowship: A Resident’s Perspective 15Rene Mack, MD

The Academic Life of Emergency Ultrasound 16Petra Duran-Gehring, MD, RDMS

Is Emergency Ultrasound Really Necessary? 18Alfredo Tirado-Gonzalez, MD

Recent Technological Advances in Bedside Ultrasound 20 Petra Duran-Gehring, MD, RDMSAdrian Elliot, MD

EM DaysMy Take on EM Days 26Jason W. Wilson, MD

EM Days Photo-op 28

Emergency Management and You 29Bryan Koon

DepartmentsPRESIDENT’Smessage 3 Amy R. Conley, MD, FACEP

GOVERNMENTALaffairs 7 Steve Kailes, MD, FACEP

CODINGtip 8Lynn Reedy, CPC, CEDC

MEDICALeconomics 9 Ashley Booth Norse, MD, FACEP

EMStrauma 12 Dagan Dalton, MD

PROFESSIONALdevelopment 13 Paul Mucciolo, MD, FACEP

ACADEMICaffairs 14 Joseph A. Tyndall, MD, MPH, FACEP

GeneralThe State of Florida EMS 10 Michael Lozano, MD, FACEP

POISONcontrol 24Bath Salts: The Latest Craze

RESIDENCYmatters 30

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HB 155 - The Gun Bill

HB 155, Gun Bill, either of these sound

familiar? In its original form, this bill

could have placed considerable

constraints on the information that we as

physicians can ask and receive when

assessing a patient. With the legislative

session now closed we are fortunately left

with a much more dilute form than the

original bill, though still a new law that

dictates how we practice medicine and

potentially impinges on the doctor- patient

relationship.

The Gun Bill, pushed by the NRA,

originated when two politicians (Brodeur

R-Sanford and Evers R-Baker) filed this

bill (along with punitive recommenda-

tions) after one of Evers constituents in

the panhandle district reported being

"grilled about guns in the home". This

brings to my mind bright hot lights in an

isolated exam room with a repeated

barrage of questions.

I really have to doubt this occurred in such

a manner but again we all have unique

interpretations, don't we? The original bill

would have subjected doctors to criminal

penalties if they asked a patient whether

they owned guns. The punishment recom-

mended in fact was up to 5 years in prison

and a $5,000.00 fine! Naturally the physi-

cians contested this proposal. This briefly

pitted the medical community against the

gun industry, could you even imagine this

occurring when you became an emer-

gency medicine physician?

We have enough concerns over flimsy

litigation without the fear of imprisonment

from conveying our true interest for our

patient’s safety. We are not alone on this

front as the pediatricians are compelled to

ask about firearms, poisons, and other

threats in the home that may endanger

children. We ask these same questions in

the emergency department as well; not as

an inquisition but to raise awareness and

to educate. Some families actually are not

cognizant of potential harmful agents in

their own homes.

As the legislative session progressed, the

germinal bill was tempered to asking

about gun ownership only if “in good faith

(believe) that this information is relevant

to the patients medical care or safety, or

the safety of others.” This evolution was

an interesting exercise in Tallahassee

considering that we health care providers

have inquired about gun ownership based

on these concerns all along. Hmmmm….

A compromise was reached and the

outcome of the gun bill allows the physi-

cians to ask about gun possession and to

record the information in the patient chart

as long as it relates to patient safety and

health and as long as the doctor does not

discriminate against gun owners. As a

repercussion of violating this bill, the

physician will be reported to the Depart-

ment of Health if the questions are

construed as discrimination against a

patient because they own a gun.

Passing this legislation even in its some-

what neutered form to placate the NRA

places a potential legal obstruction in the

path of patient safety and undue pressure

on the patient - doctor relationship.

PRESIDENT’Smessage


Amy R. Conley, MD, FACEPPresident

technology

Conference OverviewSymposium by the Sea 2011 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 4-7, 2011 . Naples Grande Beach Resort . 475 Seagate Drive . Naples, Florida 34103Reservations (888) 422-6177 . www.naplesgranderesort.com . Mention Symposium by the Sea Guest Room Reservations Cut-O� Date: July 21, 2011 . Reserve your room early!

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Members!!

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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 2011 Symposium by the Sea Conference at The Naples Grande Resort in Naples, FL, Saturday August 6, 2011. 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 2011 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/sbs2011.htm or contact Jerry Cutchens at [email protected] Exhibit/Sponsorship Prospectus is avail-able directly at www.emlrc.org/pdfs/sbs2011prospectus.pdf.

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

www.orleansonline.com

REGISTER TODAY @ WWW.FCEP.ORG

Symposium by the Sea 2011The Annual Meeting of the Florida College of Emergency Physicians

August 4-7, 2011 . Naples Grande Beach Resort . Naples, FL

determine what in their opinion are the top three challenges to pre-hospital care of pediatric and neonatal patients. Secondly, the EMSC Advisory committee will work with Division of Medical Quality Assur-ance (MQA) to develop a method of capturing this information during the physician and nurse recertification process.

Airway management is a sine qua non skill for paramedics, yet it remains contro-versial to this day. Part of this has to do with the significant diversity in terms of training and quality assurance that we eluded to in past series installments. There is a general sense by the FAEMSMD that airway management skills in Florida are of a higher caliber than in other states. To be able to better quantify this opinion, the association selected three key perfor-mance indicators related to airway management: a) percentage of time that there is recognition of proper placement of an endotracheal tube as documented by end-tidal capnography, b) percentage of patients in which endotracheal intubation is attempted and is not successfully completed, and c) percentage of patients in which active airway assistance is utilized other than endotracheal tube.

One of the first steps will be to define an intubation attempt. Is it when you put the blade in the mouth? What if you have to adjust position to get a better view? Is that an attempt? What if you chose to place a “rescue airway” like a combi-tube or LMA first? There is some recent data that indicates that endotracheal intubation may be deleterious for cardiac arrest patients.5,6 In that case, should one segregate cardiac arrest cases from the calculation of the overall intubation rate? Is an endotracheal intubation rate relevant in the era of multiple supraglottic airway devices? These are the sorts of questions that the EMRC will have to take on as they exam-ine the airway management data in EMSTARS.

In the next issue we will look at the rest of the objectives in Goal Six. They address the destination of EMS patients as well as quality assurance and injury prevention efforts though the lifeguard association. We will also have a separate article exploring the proposed reorganization of the Department of Health and its implica-tions on the EMS community.

1 Meretoja A. Effectiveness of primary and comprehensive stroke centers:

PERFECT stroke: a nationwide observa-tional study from Finland. Stroke 01-JUN-2010; 41(6): 1102-7.

2 Wentworth D., Atkinson R. Implementa-tion of an acute stroke program decreases hospitalization costs and length of stay. Stroke 27. 1040-1043.1996.

3 Newgard CD, Schmicker RH, Hedges JR, et. al. Emergency medical services intervals and survival in trauma: assess-ment of the "golden hour" in a North American prospective cohort. Ann Emerg Med - 01-MAR-2010; 55(3): 235-246.e4.

4 Carr BG. A meta-analysis of prehospi-tal care times for trauma. Prehosp Emerg Care - 01-APR-2006; 10(2): 198-206.

5 Studnek JR. The association between prehospital endotracheal intubation attempts and survival to hospital discharge among out-of-hospital cardiac arrest patients. Acad Emerg Med - 01-SEP-2010; 17(9): 918-25.

6 Wang HE. Interruptions in cardiopul-monary resuscitation from paramedic endotracheal intubation. Ann Emerg Med - 01-NOV-2009; 54(5): 645-652.e1.

In the most recent installment of this series, we started to look at Strategic Goal Six: Improve performance of key EMS processes through benchmarking and partnerships. The first three objectives of the overall goal focused on EMS dispatch, response time definition, as well as off-load and diversion time definitions. We now get into the meat and potatoes of what an EMS system does on a day to day basis.

Objective 6.4 gets at the core mission of an EMS system by identifying key perfor-mance indicators of pre-hospital treatment in the areas of cardiac care (including STEMI and cardiac arrest), stroke, trauma, pediatric and neonatal manage-ment, and airway management. As we shall see, there is a surprising amount of evidenced-based data providing justifica-tion for the various objectives.

The lead group responsible for this series of objectives is the EMSAC Medical Care Committee, with support from the Quality Managers group, and the FL Association of EMS Medical Directors (FAEMSMD). Movement in all these objectives is limited by the availability of accurate data that can be generalized state-wide.

The four key performance indicators for pre-hospital cardiac care that were chosen by the FAEMSMD are a) rate of pre-hospital return of spontaneous circula-tion (ROSC) reported in an Utstein format, b) percentage of times that a 12-lead EKG was performed on a patient

with suspected cardiac related symptoms, c) percentage of EMS agencies that obtain a 12-lead EKG by protocol on suspected cardiac patients, and d) percentage of times that aspirin was given or intention-ally held due to medical considerations (e.g. allergy) in patients with cardiac related symptoms.

Although you may think that these would be fairly easy metrics to measure, not all EMS systems in Florida are on electronic medical records. So, the expertise of the Emergency Medical Review Committee (EMRC) which has access to the EMSTARS database is essential to overcome the data barrier. There is a proposal to link EMSTARS with ACHA’s hospital outcomes database. Should this become a reality, we could potentially have the answers to some key pre-hospital efficacy questions.

On June 17, 2004, Florida created the nation’s first statewide emergency stroke system when the governor signed the Florida Stroke Act. It provides for identifi-cation of stroke centers and establishment of an AHCA administered website to list certified stroke centers. The law also calls for each agency medical director to have protocols in place to assess, treat, and transport stroke patients to the most appropriate hospital. Although there is data to support preferential transport of stroke patients to stroke centers, no such requirement was put in place by the initial stroke law.1,2

The key performance measure related to stroke care in the Strategic Plan is the percentage of time a Stroke Alert was initiated based upon primary or secondary impression by a paramedic or EMT. As with cardiac care, this data is extremely difficult to collect, and the EMRC is needed to determine how this metric is being met state-wide. As we go to press, the 2011 legislative session has not started, but a bill has been filed to amend the Florida Stroke Act.

Thanks to the work of Dr. R Adams Cowley in the 1960’s, the medical community has worked with the concept of the “golden hour” of trauma care. Although it is somewhat intuitive that a short EMS on-scene time would be beneficial to trauma patients based on the “golden hour” concept, data reported in 2010 would argue otherwise.3 Addition-ally little evidence exists to actually quan-tify this time interval. A 2006 meta analy-sis of studies from 20 states determined that this interval ranges from 13.4 to 14.6 minutes.4 Objective 6.4.3 seeks to identify the average on-scene time for Florida trauma alert patients.

Objective 6.4.4 seeks to identify and address the top three challenges to pediat-ric and neonatal pre-hospital care in the state. There is a two pronged approach in place to achieve this objective. First, there will be a survey of EMS for Children (EMS-C), Florida Neonatal Pediatric Transport Network Association (FNPTNA), and other stakeholders to

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

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Position is both clinical and administrative.

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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

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GOVERNMENTALaffairs

Tallahassee News

Steve Kailes, MD, FACEPCommittee Chair

As of this writing, the Florida House of Representatives and Senate are still in session. Medicaid reform is among the major issues being addressed. Florida Medicaid expenditures are approximately $21 billion and are estimated to increase substantially in the years to come unless changes are made. By the time you read this, many of the reform’s details will be known.

Current concepts have the state divided into regions in which insurers will compete for managed care contracts. The regions will be comprised of networks of providers manag-ing a beneficiary’s care. The insurers will commit to five years of participation, with penalties for withdrawing early or for not meeting benchmarks and quality measures. It is said they will be able to do all of this and still save the state money. I have my doubts.

We have been trying to insist that insurers are held accountable for an adequate network of providers, while still allowing for emergency care based on the “prudent layperson” standards in current statute. Given the woeful Medicaid reimbursement rates in Florida, I doubt these networks will materialize or be, at the very least, “adequate.” These networks would form more readily if Medicaid reimbursement improved, but this seems unlikely as our lawmakers are struggling to close our

multi-billion dollar budget deficit. Instead, we are likely to see more cost shifting as our EDs and hospitals provide more uncompen-sated care. Current bills include penalties for the insurers if they don’t deliver as promised. Why would insurers even want to sign on except for the opportunity to profit. One bill says the insurers will split any of their profits above 5%. Yes, Medicaid pays us physi-cians poorly but insurers will make millions participating in the Medicaid program. I have no issue with a business making a profit. Speaking purely from a practical view, one must question the justification for insurers making millions of dollars from a state program that continues to fail many of the beneficiaries it is intended to support.

Furthermore, I am concerned about how providers and networks (whether PSNs, ACOs or others) will be held accountable for outcomes and quality measures. This might be reasonable if we could also hold benefi-ciaries accountable for participation and doing their part to help achieve these goals (i.e. smoking cessation, medication compli-ance, weight loss). That’s right, I said it. I’m tired of the pack-per day smoker who also enjoys “a couple of beers” each day complaining to me how they couldn’t afford to see the doctor or the dentist. What of the innumerable noncompliant patients? We are

being asked to support the system more, and likely with much more uncompensated care (though legislators won’t acknowledge this), AND we are going to be held accountable for outcomes. I just want the patients to have some skin in the game, too. Perhaps the best news I have heard is that the Republican majority seems to be truly committed to passing some meaningful tort reform. In addition, we have worked tirelessly to either stop or amend SB 432/HB 155 (the bills prohibiting inquiry regarding gun ownership or else face significant penal-ties) so that we can perform our jobs. If confused, think of questions you might ask a suicidal patient. On these bills, we have seen progress. Also, we have continued to argue for the benefits of a prescription drug monitoring program to help us to know which medications our patients have been prescribed.

In closing, I have two requests of you. First, keep informed and get involved with our efforts to make it easier for you to do your job and to care of your patients. Second, with the knowledge you’ve gained from the first, contact your local legislators, meet them for coffee or something, and discuss the issues we face every day. Most of them don’t possess a true understanding of what we do or the challenges we face. If informed, they might legislate differently.












































CODINGtip

Chest Pain / ICD-10

One of the most common diagnoses in

the ED is chest pain. When we start

using ICD-10 in October 2013, we will

have a simple crosswalk between the old

and new coding systems.

ICD-9 ICD-10

Chest pain 786.52 R07.1on breathing

Chest pain, 786.59 R07.89other

Chest pain, 786.50 R07.9unspecified

Pleurodynia 786.52 R07.81

Intercostal pain 786.52 R07.82

Precordial pain 786.51 R07.2

Lynn Reedy, CPC, CEDC

Director of Coding Services

CIPROMS South Medical Billing

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Health Care Reform -Where We Are Now?

Ashley Booth Norse, MD, FACEPCommittee Chair

It has been just over a year since the President signed “The Patient Protection and Affordable Care Act” into law on March 23, 2010. So where are we now? Several states have filed lawsuits over the constitutionality of the legislation. In fact, at the time this article was written, neither Governor Scott nor the Florida Legislature are instituting any of the provisions of the law until the Supreme court makes a ruling as to its constitutionality. However, this has not stopped hospitals from moving forward. It has also left physicians perplexed as to if and how they should respond to the antici-pated changes.

In the last year, we have seen a trend towards more physicians becoming hospital employ-ees, both in Florida and nationally. A March 30, 2011 New England Journal of Medicine article titled “Hospitals’ Race to Employ Physicians — The Logic Behind a Money Losing Proposition” reports that “U.S. hospitals have begun responding to the imple-mentation of health care reform by accelerating their hiring of physicians. More than half of practicing U.S. physicians are now employed by hospitals or integrated delivery systems, a trend fueled by the intended creation of accountable care organizations (ACOs) and the prospect of more risk-based payment approaches. Whether physicians, hospitals, or payers end up leading ACOs will depend on local market factors, competitive behaviors, and first-mover advantage, but employment decisions made by physicians today will have long-term repercussions for the practice and management of medicine.”

Which leads me to ask: Where do we stand with ACOs? The creation of ACOs is one of the first delivery-reform initiatives that will be implemented under the Affordable Care Act (ACA). As a result hospitals and physicians have been rushing to develop ACOs over the last year, even though the rules for establishing ACOs have not even been developed.

On March 31, 2011, the Department of Health and Human Services finally took a major step toward establishing ACOs by issuing a notice of proposed rule-making that will define how physicians, hospitals, and other key constitu-ents can adopt this new organizational form. The proposed rule follows months of obtaining informal and formal input from members of the health care system. The Centers for Medicare and Medicaid Services will carefully review comments received in response to the proposed rule before issuing a final rule later this year with an implementation date of Jan 1, 2012.

Donald Berwick in a recent statement said: “a common criticism of U.S. health care is the fragmented nature of its payment and delivery systems. Fragmentation leads to waste and duplication and unnecessarily high costs.” According to the Affordable Care Act the solution to this fragmentation is ACOs. The Government and CMS are moving forward with the implementation of ACOs despite concerns by many that ACOs will result in capitated care, encourage decreased spending on patient care, and will ultimately not save money. For further details on ACOs visit: http://www.ofr.gov/OFRUpload/OFRData/201

1-07880_PI.pdf. In addition to the establish-ment of ACOs, other provisions in the ACA scheduled to be implemented in 2011 are:

1) Requirements that insurers provide first dollar coverage for preventative services, and that small insurers spend 80% and large insurers spend 85% of premiums on medical services.2) 10% Medicare bonus payment for PCPs and general surgeons.3) Additional restriction on physician self-referral.4) Redistribution of unused GME training positions for the purpose of increasing primary care.5) Medicare cuts to long-term hospitals, nursing homes and inpatient rehabilitation hospitals.6) Medicare cuts to ambulances services, diagnostic labs and DME.7) Consumers will begin paying premiums for federal long-term care insurance.8) Requirements that employers disclose the value of employer provided benefits and health insurance on employee’s W-2.9) Annual fees imposed on manufacturers and importers of branded drugs.10) Increased penalty for non-qualified HSA withdrawals to 20%.

Looming on the horizon in 2012 is the establishment of hospital “value based purchasing” programs, the establishment of an MD compare website for Medicare beneficia-ries, and Medicare cuts to hospice and dialysis centers.

MEDICALeconomics























The State of Florida EMSPart 6 of a Series

Michael Lozano, MD, FACEPCommittee Chair











EMStrauma

10 EMpulse • Spring 2011












EMStrauma












with the help of hospital buy-in and grants. We are now up to 5 new ultrasound machines, one for each area of the ED, and we have made use of the older machines for line placement and practice in the simulation center. With 45 residents and 30 faculty members, I struggle daily with keeping the machines maintained, clean and stocked!

There are many other obstacles that I have yet to completely overcome. Image storage and quality review are currently in flux. We have moved from thermal print images and paper reports to saving images and reports electronically on the ultrasound machine. Unfortunately, I am responsible for off-loading all images

weekly and then performing the quality review myself.

We plan to move to a wireless upload and electronic image storage and QA system soon, which will help tremendously since our volume of scans has increased steadily. We hope that once this electronic storage is in place, it will allow us to begin billing for our work.

I began this program to help residents master a skill that I did not learn as a resident. But, I have found that it has really required a culture change in our ED. In a busy county ED, it is difficult to get residents to see the importance of a skill that will add one more task to their

already hectic shift. But, change has come gradually. I now see residents placing ultrasound guided deep brachial lines instead of immediately going to a central line.

I see pediatric patients getting an ultrasound at the bedside to determine if an abscess is present and can be success-fully drained. I see residents evaluate critically ill patients using ultrasound to determine the next step in the patient’s care.

The culture will definitely change. Although my struggles have left me exhausted at times, it has been worth it in the end.

I returned to UF-Jacksonville in 2006, having worked in private practice for 2 years after graduation. I wanted to show residents that bedside ultrasound is an important skill to learn and that it could improve their practice once they gradu-ated and went out into “the real world.”

I finished my residency and confidently went into private practice in California. My partners there had had extensive training in bedside ultrasound during residency and it had paid off: they were confident in the skill of emergency ultrasound and used it to make bedside diagnoses and to make clinical decisions. Although I had ultrasound training is residency, there was not a strong empha-sis placed on mastery of this skill.

Consequently, I was forced to keep patients in the ED overnight until an ultrasound could be performed by Radiology the next morning. I consid-ered emergency ultrasound a very valuable skill and strongly desired to teach residents this. So, I began our department’s ultrasound program.

Getting a dedicated ultrasound program off the ground has presented quite a few challenges. Education was my first. Although newer faculty had ultrasound experience in residency, what about the faculty who did not?

I started training myself: attending courses and spending a lot of time in the ultrasound department, scanning with

professional sonographers. Once I felt confident with my skills as an ultrasound educator, I passed it on to the rest of our faculty.

Many of our faculty had some ultrasound experience, but few felt confident with using it routinely to make clinical decisions. I developed a training program that was based on their previous experience. Those who needed or wanted more practice were given opportunities to scan live models and to use the simula-tors in the Simulation Center.

Although our entire faculty has gone through this training, some are still hesitant to base their care solely on their exam. Most, however, have increased their confidence and have incorporated ultrasound into their daily practice.

While training the faculty, I also devel-oped the resident curriculum. We traditionally had an intensive two day ultrasound class with didactics and scan sessions, but this once a year course was not enough to drive home how this skill could be used on a daily basis.

I began bedside teaching rounds using ultrasound to increase the residents’ understanding of how this skill could be used to drive patient care. At the bedside, I could assist with scanning techniques and probe positioning, improving their ability to visualize structures and make a diagnosis.

Ultrasound Rounds has been well received by both residents and faculty.

Besides creating a dedicated intern ultrasound rotation and senior resident elective, I also began an ultrasound blog. Being the only dedicated ultrasound faculty member, it is tough to be in the ED at all times to answer questions and scan with residents. My blog created a way for me to teach using the Internet, a platform that we all use daily.

I currently present interesting cases weekly with images and video at the start of the week, and a discussion and conclusion of the case with teaching points at the end of the week. Since its inception, I have had great feedback from the residents and have expanded it to include posts on obtaining better images, discussions on current ultrasound literature and lectures. This also serves as a hub for Internet ultrasound resources that the residents can tap into when I cannot be in the ED.

Although I enjoy the educational aspects of my job, there are definitely some challenges. Equipment has proven to be an ongoing issue. At the start of my journey, we had two old ultrasound machines that were used infrequently. We did not electronically save images, but printed them on a thermal printer (if there was any paper in it!).

Finding funding for new equipment has been a hurdle that we have overcome






















Committee Proceedings

Dagan Dalton, MDCommittee Chair

At our most recent FCEP meetings in February 2011, the EMS/Trauma Com-mittee discussed at length the proposed rule change regarding board certification for EMS Medical Directors. The current language in the Florida Administrative Code [F.A.C. 64J-1.004(3)(c)] reads: “A medical director shall be board certified and active in a broad-based clinical medi-cal specialty”. This is under the section of F.A.C. titled “Medical Direction/ Qualifi-cations”. There are currently no such requirements in Florida Statute. Under a current proposal, the requirement for board certification will be deleted from this rule. This committee voted to recom-mend to the FCEP Board that FCEP lobby to keep the rule as it presently stands, maintaining the requirement for board certification in a broad-based clinical medical specialty.

Further debate in regards to changing the rule to ‘board certified in emergency medicine’ ensued, and the process of rule change and statute change was further discussed. The committee voted to support the current language in F.A.C. I am certain we will engage in this issue again in the future.

We also discussed F.A.C. 64J-2.004, the

State of Florida’s Trauma Scorecard Methodology. The CDC recently published and publicized their “Field Triage Decision Scheme: The National Trauma Triage Protocol”. This was also published in MMWR 1/23/09, as “Guide-lines for Field Triage of Injured Patients”.

The CDC Trauma Triage Protocol and the Florida Trauma Scorecard (or Trauma Alert Criteria) have been studied and compared by this committee, as well as by the Florida Trauma Triage Workgroup (several members of the FCEP EMS/Trauma Committee are also mem-bers of this Workgroup). Though not officially concluded at this time, the general consensus is that the Florida Trauma Alert Criteria are stricter and serve our communities and patients far better than would a changeover to the CDC guidelines.

However, following this review there are some recommendations to our current guidelines that we might consider. For example, Trauma Alert patients on Coumadin might qualify for a ‘blue’ criterion. (Currently, a Trauma Alert requires at least 1 red or 2 blue criteria to be called a Trauma Alert).

Dr. Joe Nelson, state EMS Medical Direc-

tor updated us on the progress of Florida’s statewide Disaster Protocol, as well as the 3 new state Cardiovascular Care Subgroups: STEMI, Cardiac Arrest, and Stroke. He then proposed a statewide program of Take Heart America, which began as a community or area-wide initia-tive to increase survival of cardiac arrest patients. This has proven to be successful in proportion to the active involvement of community partners - such as, hospitals, EMS, public health, private practitioners, schools, businesses, etc. This has already been done statewide in Minnesota and Alaska, and regionally in Ohio and Texas, with many more states sure to follow. Dr. Nelson encouraged us to learn more about Take Heart America on-line and be ready for the state-wide/community-wide efforts soon to come.

The last item was regarding the possible changes within the FDOH (Florida Dept. of Health) which oversees the Bureau of EMS and the Office of Trauma. This is still being debated at the state level at this time, but major reorganization is probable and we all need to stay current and involved.

Your attendance and membership in this and the Governmental Affairs Committee are much needed.

EMStrauma














































PROFESSIONALdevelopment

Home Sweet Medical Home

Paul Mucciolo, MD, FACEPCommittee Chair

Atul Gawande’s article The Hot Spotters in the January 2011 edition of The New Yorker is an eye opener on the pervasive-ness of the problem of medical non-adherence in EDs. Dr. Gawande’s descriptions of cases in Camden, New Jersey, reminds me of several patients in my ED where I’ve practiced for fifteen years. I specifically recall one patient who we nicknamed “the million dollar man.”

He was almost six hundred pounds and came to the hospital on a monthly basis for difficulty breathing. He would be discharged home after about two weeks of intensive treatment, including intubation and diuresis, weighing a svelte four hundred fifty pounds. Although ambula-tory at discharge, he never left his house once a specially equipped non-emergency transport vehicle dropped him home. According to the social worker who evalu-ated the patient, family members would bring him cases of soda, sweets, and pre-packaged foods, but not the patient’s prescriptions. And so, about two weeks later, the episode would repeat itself. When he died in 1994, his hospital bills exceeded a million dollars annually from 1989 onwards.

“Why don’t patients just go to their own doctors?” one of our nurses asked me when a middle aged man presented with the chief complaint of “medication refill”. In the middle of a busy shift during an event weekend when the local population

had expanded tremendously, her frustra-tion was palpable. “He’s here all the time!” A review of the electronic medical record revealed that the nurse was, indeed, correct—this patient was a “frequent flier” for clonidine refills. The pharmacy faxed a copy of the “frequent flier” patient’s prescription from his PCP: “Take one tablet every four hours for blood pressure greater than 160/90. Take two tablets every four hours for blood pressure greater than 180/110.” On further talking to the patient, it turned out that he took his blood pressure four times a day, dutifully recorded the readings in a log, and took the clonidine appropriately.

We had concluded wrongly that this patient frequented the ED for clonidine refills due to non-adherence. His PCP gave him ninety-day follow-up appoint-ments and thirty clonidine pills monthly. However, he was using over one hundred clonidine pills a month to control his blood pressure. I called the PCP who was shocked. He had no idea that the patient was using the PRN medication so often. Thankfully, the patient had sufficient insight to make sure that he never ran out. The ED was not a substitute for his PCP, but a safety net.

What Doctors Wish Their Patients Knew in the March 2011 edition of Consumer Reports talks about reducing fragmenta-tion in medical care by changing the PCP’s role from that of gatekeeper to one

of a patient advocate. Nutritionists, case mangers, and nurses participate in this idealistic system, but success requires an essential element—patient cooperation. If the patient does not buy in to the treatments, medication regimens, diet plans and follow-up schedules, this patient centered team approach will not work.

There is a significant difference between effectiveness and efficacy, and this gap is often the result of communication lapses between physicians and patients. As physicians, we have to be realistic about the ability of patients to follow the instruc-tions on a prescription. Patient education must be conducted in simple language that the patient and family can understand. It is important to listen carefully to what the patient is trying to tell us. Often, a bit of detective work is required.

On the other hand, we all have patients who simply don’t acknowledge the seriousness of their conditions and who continue to engage in self-injurious behaviors such as smoking. Gawande’s provides a fine example of the asthmatic with frequent ED visits due to exacerba-tions triggered by smoking crack cocaine.

I am not suggesting the ED become a substitute for the “medical home.” How-ever, if we make an effort to explore the “why” behind the “what” of a patient’s complaint, we might successfully improve the long-term outcomes of chronic medi-















































Symposium 2011Call for Abstracts

Joseph A. Tyndall, MD, MPH, FACEPCommittee Chair

3nd Annual Symposium Research Poster Presentation

Deadline for submission: July 6, 2011

Symposium by the Sea will host a 3rd annual emergency medicine research poster presentation. This year’s poster session as in prior years, will be open to emergency medicine residents, faculty and any practicing physician in the State of Florida. Research presentations first authored by residents will be judged by an independent emergency medicine faculty member for best overall research poster presentation based upon concept, original hypothesis, study quality and overall impact. In order for a poster to be judged as part of this competition, the individual who appears as the first author of each abstract must be an emergency medicine resident. In addition, although not manda-tory, the resident should be available to present at Symposium.

Topics can include the broad range of issues involving emergency medicine practice, education research, innovations in education and clinical as well as basic science research. Original hypothesis driven research, although not a prerequi-

site for submission, will be favored significantly in the judging. Abstracts presented at prior scientific assemblies (SAEM, ACEP) and other regional meet-ings can also be submitted for inclusion. Abstracts presented at prior Symposium Research Poster Presentations will not be accepted.

Abstract submissions must be in electronic format (Microsoft Word) and must include the following subsections; title, study objectives, methods, results and conclusions. The abstract should be written in complete sentences using gram-matically correct English and all abbrevia-tions should be spelled out on first usage. For the purposes of publication in EMpulse only, illustrations are discour-aged but small tables are acceptable. Figures and photos must be black and white with at least 300 dpi. Illustrations can be included in the Poster for display at Symposium. Abstracts are limited to 3000 characters and will be published as received in FCEP’s EMpulse without further copy editing. Authors should not be identified in any way on the page containing the abstract. A cover sheet stating the title of the

abstract, author(s), affiliations, IRB approval or exemption if applicable, mailing address (include the primary author’s phone/fax numbers and e-mail address) and information regarding previ-ous presentations or publication should be included with each abstract.

There will be an e-mail notification of receipt and a subsequent notification and confirmation of inclusion in the poster presentation at Symposium by the Sea and publication in EMpulse. Posters created for the research presentations should not exceed the poster board surface area of 5’10”wide x 4’10”tall.

Please send abstracts and cover sheets via e-mail to [email protected] and [email protected] with the subject heading “Symposium abstract submis-sion.” All abstracts must be received via E-mail by July 6th 5:00pm to be included in the Symposium.

ACADEMICaffairs













































Ultrasound Fellowship:A Resident’s Perspective

Rene Mack, MD PGY-3, Orlando Health - 2010-2011 EMRAF Chair

It’s 7:30am and I am 30 minutes into my 12 hour shift as the senior resident at ORMC. We have just received report from EMS that they will be bringing in a 60 year old male with sudden onset bilateral lower extremity anesthesia and paralysis. Later in the shift, a patient presents with increasing abdominal pain a few hours after a head-on collision. One of the last patients of the shift is an elderly female sent from a local nursing home for evaluation of fever and respira-tory distress. All these patients have at least one thing in common: their medical care in the ED was enhanced and expedited with the use of emergency ultrasound. The first gentleman’s symptoms of bilateral lower extremity anesthesia and paralysis were evaluated with ultrasound which showed an intimal flap and dilated abdominal aorta. Further testing confirmed his diagnosis of an aortic dissection. The patient was diagnosed and definitive treatment was established within 1 hour of arrival in the ED. A FAST exam on the patient in the motor vehicle crash revealed free fluid in the right upper quadrant. Additional radiol-ogy studies disclosed a liver laceration

and a surgical consult was placed within a short period of time after the patient’s arrival in the ED. As with many septic patients who we treat on a fairly constant basis, the elderly female from the nursing home was diagnosed with a lobar pneumonia and progressed to develop hypotension in the ED. The utilization of ultrasound facilitated a swift and visually accurate placement of a central line which enabled us to aggressively treat and resuscitate this patient.

Over the past few years of residency, the training I have received has significantly increased my interest in the utilization and applicability of Emergency Ultra-sound. The ability to diagnose and in some cases treat potentially fatal illnesses quickly and under direct visual guidance increases patient safety in addition to increasing my confidence in the success of the procedure. An added bonus to bedside ultrasound is increased patient contact and the ease of teaching and explaining certain findings using real-time images. Today, emergency ultrasound is one of the most relevant clinical adjuncts which is readily available to us. Yes, developing

comfort with the machine, learning the physics and the many various applica-tions does require some dedication, but I do believe that the rewards to both the patient and to us well justify the effort. Based on the aforementioned scenarios and many more, my decision to further my training by entering into an ultrasound fellowship at ORMC was an easy one. Personally, I am very excited to further my knowledge and increase my skills in ultrasound with intense training over the coming year and to continue my educa-tion over the years to come Although I believe that formalized training provides the best learning environment, I know that most EPs will not be doing an ultrasound fellowship. For those who are interested in improving their skills with specific exams/procedures, there are options available. One such option is to visit the ACEP website, where the Ultrasound Section has developed and maintains a great web resource. I hope to work with you in the future and enhanc-ing our practice of medicine with the use of ultrasound.

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The Academic Life ofEmergency Ultrasound

Petra Duran-Gehring, MD, RDMSUniversity of Florida, Jacksonville
















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EMERGENCYultrasound









































EMERGENCYultrasound

Is Emergency UltrasoundReally Necessary?

Alfredo Tirado-Gonzalez, MDAssistant Medical DirectorEmergency Ultrasound DirectorFlorida Hospital - East Orlando

In February this year, Chris Moore published an article in the New England Journal of Medicine on Point-of-Care Ultrasonography.1 The article describes emergency ultrasonography (EUS) and its utility, but this concept is not new for EM. Focused ultrasound began to make its way into EDs in the late 1980s and 1990s as technology became more compact and affordable.

The first publication in EM literature was in 1988 and addressed the utility of echocardiography performed by EPs.2 This inspired the development of the first ultrasound curriculum in 1994. In 2001, “Bedside Ultrasonography” was recog-nized as an “integral procedure and skill” by the Core Content Task Force II which required all EM residencies to provide ultrasound training. Since then, bedside ultrasound has become a standard EP skill that is taught in EM residencies, tested on boards and endorsed by ACEP and other EM professional societies.

Even though ultrasound has become a core competency, widespread implemen-tation has been limited in the community setting. In 2006, a national randomized survey of community EDs showed that only 33% of community hospitals reported access to an ultrasound system and only 16% requested reimbursement.3

In another survey of ultrasound use by EPs in California (2007), only 34% of California EDs reported using bedside ultrasound and the majority of EDs did

not have ongoing quality assurance programs or billed for interpretations.4 This means that we could potentially spend a large amount of time training residents and once finished they may move to community hospital that might not have this technology available.

This makes me wonder: Is bedside ultrasound really necessary?

The reality that our community hospitals deal with every day is very different from the academic setting. I can speak from personal experience. After I finished my ultrasound fellowship I started work at a community hospital ED where no ultrasound was available. In my very first shift, when I took care of a septic, diabetic patient with end stage renal disease in atrial fibrillation and on Coumadin who had no IV access, I realized how important this technology really is. After a barely successful central line, I made it my number one priority to get this technology into our ED. The use of ultrasound for procedural guidance has been well documented to improve care. In 1999, the Agency for Healthcare Research and Quality (AHRQ), published a report “To Err Is Human”, and which the “use of real –time ultrasound guidance during central line insertion to prevent complications” is listed as 1 of the 12 most highly rated patient safety practices designed to decrease medical errors.5 Once again, we have a Federal Agency, in charge of

improving quality, safety, efficiency and effectiveness, stating that we should be using this technology to improve patient care.

Point-of-care ultrasound has also been well documented in other instances to improve patient care. For instance, the Focused Assessment with Sonography for Trauma (FAST) has been shown to improve time from examination to the operating room (OR).6 Cardiac ultrasound continues to play an important role in cardiac arrest, helping to assess potential reversible causes such as pericardial tamponade. Abdominal ultrasound can quickly help evaluate patients with undifferentiated abdominal pain to assess for life-threatening conditions such as aneurysm or ruptured aorta, improving time to diagnosis and disposition to the OR.

Ultrasound continues to expand its use to more advanced applications like ocular ultrasound for retinal detachment or lung ultrasound to assess for pneumothorax. This makes this technology not a luxury but a necessity.

If ultrasound is a necessity, how is it that it is not available to all community hospitals? As part of the 2006 survey cited above, ED directors were asked for potential barriers to ultrasound imple-mentation. Lack of training, resistance from radiology, and adequate ultrasonog-raphy coverage by Radiology were the most common reasons for not implement-

ing emergency physician-performed ultrasonography.3 Other potential barriers listed were liability concerns, lack of financial benefit and time consumption.

Currently, Florida has 204 hospitals, seven EM residency programs and two EUS fellowship programs, but we lack specific data on the penetration of ultrasonography into our community EDs.

FCEP recognizes the importance of emergency ultrasound (EUS) to the daily practice of EM and strongly supports ACEP in its drive to establish EUS as the standard of care in every ED. In a joint venture between FCEP and Florida Hospital Emergency Medicine Residency Program all ED Directors will receive a survey to assess the current state of EUS in Florida. With this information in hand,

we will be able to understand where we stand, define major obstacles in our community, and start to work on strate-gies to overcome barriers to improve patient care.

References

1. Moore C andJ. Copel. Point-of-Care Ultrasonography. N ENGL J MED, 2011: 364;8

2. Mayron R, Gaudio FE, Plummer D, R. A, Elsperger J. Echocardiography performed by emergency physicians: impact on diagnosis and therapy. Ann Emerg Med 1988;17(2):150-4.

3. Moore CL, Molina A, Lin H. Ultraso-nography in Community Emergency Departments in the United States: Access to Ultrasonography performed by

consultants and status of emergency physician performed ultrasonography. Ann Emerg Med. 2006; 47(2): 147

4. River G, Stein J, Kalika I et al. A survey of Ultrasound use by Emergency Physicians in California. Ann Emerg Med. 2007; 50(3): S66.

5. Making healthcare sager: a critical anaylysis of patients safety practices. Rockville, MD: Agency for Healthcare Research and Quality. (AHRQ publica-tion no. 01-E058)

6. Melniker L, ET. Al . Randomized Controlled Clinical Trial of Point-Of-Care, Limited Ultrasonography for Trauma in the Emergency Department: Te First Sonography Outcomes Assess-ment Program Trial. Ann Emerg Med. 2006; 48(3): 227.
























In February this year, Chris Moore published an article in the New England Journal of Medicine on Point-of-Care Ultrasonography.1 The article describes emergency ultrasonography (EUS) and its utility, but this concept is not new for EM. Focused ultrasound began to make its way into EDs in the late 1980s and 1990s as technology became more compact and affordable.

The first publication in EM literature was in 1988 and addressed the utility of echocardiography performed by EPs.2 This inspired the development of the first ultrasound curriculum in 1994. In 2001, “Bedside Ultrasonography” was recog-nized as an “integral procedure and skill” by the Core Content Task Force II which required all EM residencies to provide ultrasound training. Since then, bedside ultrasound has become a standard EP skill that is taught in EM residencies, tested on boards and endorsed by ACEP and other EM professional societies.

Even though ultrasound has become a core competency, widespread implemen-tation has been limited in the community setting. In 2006, a national randomized survey of community EDs showed that only 33% of community hospitals reported access to an ultrasound system and only 16% requested reimbursement.3

In another survey of ultrasound use by EPs in California (2007), only 34% of California EDs reported using bedside ultrasound and the majority of EDs did

not have ongoing quality assurance programs or billed for interpretations.4 This means that we could potentially spend a large amount of time training residents and once finished they may move to community hospital that might not have this technology available.

This makes me wonder: Is bedside ultrasound really necessary?

The reality that our community hospitals deal with every day is very different from the academic setting. I can speak from personal experience. After I finished my ultrasound fellowship I started work at a community hospital ED where no ultrasound was available. In my very first shift, when I took care of a septic, diabetic patient with end stage renal disease in atrial fibrillation and on Coumadin who had no IV access, I realized how important this technology really is. After a barely successful central line, I made it my number one priority to get this technology into our ED. The use of ultrasound for procedural guidance has been well documented to improve care. In 1999, the Agency for Healthcare Research and Quality (AHRQ), published a report “To Err Is Human”, and which the “use of real –time ultrasound guidance during central line insertion to prevent complications” is listed as 1 of the 12 most highly rated patient safety practices designed to decrease medical errors.5 Once again, we have a Federal Agency, in charge of

improving quality, safety, efficiency and effectiveness, stating that we should be using this technology to improve patient care.

Point-of-care ultrasound has also been well documented in other instances to improve patient care. For instance, the Focused Assessment with Sonography for Trauma (FAST) has been shown to improve time from examination to the operating room (OR).6 Cardiac ultrasound continues to play an important role in cardiac arrest, helping to assess potential reversible causes such as pericardial tamponade. Abdominal ultrasound can quickly help evaluate patients with undifferentiated abdominal pain to assess for life-threatening conditions such as aneurysm or ruptured aorta, improving time to diagnosis and disposition to the OR.

Ultrasound continues to expand its use to more advanced applications like ocular ultrasound for retinal detachment or lung ultrasound to assess for pneumothorax. This makes this technology not a luxury but a necessity.

If ultrasound is a necessity, how is it that it is not available to all community hospitals? As part of the 2006 survey cited above, ED directors were asked for potential barriers to ultrasound imple-mentation. Lack of training, resistance from radiology, and adequate ultrasonog-raphy coverage by Radiology were the most common reasons for not implement-

ing emergency physician-performed ultrasonography.3 Other potential barriers listed were liability concerns, lack of financial benefit and time consumption.

Currently, Florida has 204 hospitals, seven EM residency programs and two EUS fellowship programs, but we lack specific data on the penetration of ultrasonography into our community EDs.

FCEP recognizes the importance of emergency ultrasound (EUS) to the daily practice of EM and strongly supports ACEP in its drive to establish EUS as the standard of care in every ED. In a joint venture between FCEP and Florida Hospital Emergency Medicine Residency Program all ED Directors will receive a survey to assess the current state of EUS in Florida. With this information in hand,

we will be able to understand where we stand, define major obstacles in our community, and start to work on strate-gies to overcome barriers to improve patient care.

References

1. Moore C andJ. Copel. Point-of-Care Ultrasonography. N ENGL J MED, 2011: 364;8

2. Mayron R, Gaudio FE, Plummer D, R. A, Elsperger J. Echocardiography performed by emergency physicians: impact on diagnosis and therapy. Ann Emerg Med 1988;17(2):150-4.

3. Moore CL, Molina A, Lin H. Ultraso-nography in Community Emergency Departments in the United States: Access to Ultrasonography performed by

consultants and status of emergency physician performed ultrasonography. Ann Emerg Med. 2006; 47(2): 147

4. River G, Stein J, Kalika I et al. A survey of Ultrasound use by Emergency Physicians in California. Ann Emerg Med. 2007; 50(3): S66.

5. Making healthcare sager: a critical anaylysis of patients safety practices. Rockville, MD: Agency for Healthcare Research and Quality. (AHRQ publica-tion no. 01-E058)

6. Melniker L, ET. Al . Randomized Controlled Clinical Trial of Point-Of-Care, Limited Ultrasonography for Trauma in the Emergency Department: Te First Sonography Outcomes Assess-ment Program Trial. Ann Emerg Med. 2006; 48(3): 227.

EMERGENCYultrasound


























EMERGENCYultrasound

Recent TechnologicalAdvances in BedsideUltrasound

Petra Duran-Gehring, MD, RDMSAdrian Elliot, MDUniversity of Florida, Jacksonville

Ultrasound was first adopted for medical use by implementing sonar technology developed during World War I.1, 3 Its use in medicine was first published in the late 1940s. Although initial ultrasound images were M-mode tracings, by the early 1980s ultrasonography had advanced to illustrate real-time anatomic images and visualize continuous motion, which led to its incorporation into multiple medical specialties.

A decade later, with improvements in portability,2 ultrasound imaging took the leap from the ultrasound suite to the bedside. Advancements in technology, most importantly in portability and image quality, have led to its adoption in the ED, leading to timely diagnosis and increased procedural safety.

Over the past decade, the push for technological advances in bedside ultrasound has focused on increasing portability, image quality and ease of use. Beginning in the late 1990’s, companies such as Sonosite began making small portable ultrasound machines for use at the bedside. These machines are the size of a laptop computer and have a more streamlined user interface, making them more useful for a busy clinician.

Although the initial portable machines had poor image quality, the current machines boast image quality that rivals machines 10 times their size.4 Besides ultrasound transduction and imaging, portable ultrasound machines targeted to EDs boast a large range of features. These include wireless connec-

tivity for image storage and connection to PACS (allowing for QA), remote-controlled and voice-activated systems, and multiple platform options.

The most recent push in ultrasound technology is the miniaturization of ultrasound machines to handheld devices. Companies such as GE, Siemens, Signostic and Mobisante have released handheld ultrasound imaging devices in the past few years. Some of these devices are the size of larger cellular phones, making them easy to carry around at all times.

Siemens was the first to release a “pocket ultrasound,” the Acuson P10. This unit starts up in 5 seconds and can be used for cardiac and abdominal applications. It weighs a hefty 1.6 pounds and stores both video clips and still images. Signostic has created a hand held ultrasound machine with a high-resolution LCD touch screen display and text and voice annotation. It is the lightest at 11.2 ounces. GE has also released a handheld ultrasound unit this past year called the Vscan. It is the size of a Smartphone, but is a self-contained unit. It boasts a 3.5 inch color display with an easy user interface and a 4 GB memory card. The entire unit weighs in at 14 ounces and has the ability to perform color flow Doppler. The MobiUS, produced by Mobisante has recently gained FDA approval as a handheld ultrasound device that actually utilizes a Smartphone-based platform.5 The device uses the Toshiba TG01 smart phone and the probe connects via a USB

connection. It can connect to Wifi or a cellular network allowing the user to send images wirelessly via the Internet.

The whole system weighs in at 13 ounces and although it is not out for purchase yet, the estimated price will be $5,000 for a single probe system.

Many news articles have questioned whether these devices will eventually replace the stethoscope6,7,8. The hope is that these devices will allow physicians to substitute physical exam findings based on auscultation (i.e. heart sounds) quickly and quantitatively with visualization of left ventricular function or valvular abnormalities.

The increased portability of these ultrasound machines will make them attractive for pre-hospital and disaster settings and even remote locations.

These machines also cost significantly less than their larger counterparts, making their purchase more palatable to EDs.Other current ultrasound advancements include educational technology.For practitioners continuing to learn how to use ultrasound technology, there is an abundance of websites and Smartphone-based applications dedicated to emer-gency ultrasound education.

While there are no dedicated Android-based or Blackberry-based ultrasound apps, there are currently six different EM-focused applications downloadable for the Apple iPhone (see Table 1).

The future of emergency ultrasound lies in increased adoption, widened applica-tions, and continued technological development. With advances in ultrasound processing and micro circuitry, both portability and image quality can be expected to continue to improve. It seems that the “stethoscope of the future” is closer than we think.

References

1. Moore, Christopher L., Joshua A. Copel. Point-of-Care Ultrasonography. N Engl J Med. 2011; 364: 740-757.

2. Cosby, Karen S., John L. Kendall. Practical Guide to Emergency Ultra-sound. Lippincott Williams &

Wilkins, Philadelphia, PA, 2006.

3. Dussik KT. On the possibility of using ultrasound waves as a diagnostic aid. Z Neurol Psychiat 1942; 174: 153-168

4. Yale University. "Bedside ultrasound becomes a reality." ScienceDaily 24 February 2011. Accessed 1 March 2011. Error! Hyperlink reference not valid.

5. Swanson, Sandra. “Ultrasound Gets More Portable”. Technology Review. Massachusetts Institute of Technology. 29 November 2010. Accessed 1 March 2011.

6. Baker, Pam. “Will GE’s handheld ultrasound become the next stethescope”.

TechNewsWorld. October 22, 2009. Accessed 1 March 2011. http://www.technewsworld.com/rsstory/68433.html

7. Feig, Christy. “Ultrasound may mean the end to the classic stethoscope”. CNN.com. August 27, 2003. Accessed 1 March 2011. http://articles.cnn.com/2003-08-27/health/ultra.stethoscope_1_handheld-ultrasound-primary-care-stethoscope?_s=PM:HEALTH

8. Millburg, Steve. “Handheld Ultra-sound: The New Stethoscope?” Radiolo-gyDaily. January 24, 2011. Accessed 1 March 2011. http://www.radiologydaily.com/?p=5813
























Ultrasound was first adopted for medical use by implementing sonar technology developed during World War I.1, 3 Its use in medicine was first published in the late 1940s. Although initial ultrasound images were M-mode tracings, by the early 1980s ultrasonography had advanced to illustrate real-time anatomic images and visualize continuous motion, which led to its incorporation into multiple medical specialties.

A decade later, with improvements in portability,2 ultrasound imaging took the leap from the ultrasound suite to the bedside. Advancements in technology, most importantly in portability and image quality, have led to its adoption in the ED, leading to timely diagnosis and increased procedural safety.

Over the past decade, the push for technological advances in bedside ultrasound has focused on increasing portability, image quality and ease of use. Beginning in the late 1990’s, companies such as Sonosite began making small portable ultrasound machines for use at the bedside. These machines are the size of a laptop computer and have a more streamlined user interface, making them more useful for a busy clinician.

Although the initial portable machines had poor image quality, the current machines boast image quality that rivals machines 10 times their size.4 Besides ultrasound transduction and imaging, portable ultrasound machines targeted to EDs boast a large range of features. These include wireless connec-

tivity for image storage and connection to PACS (allowing for QA), remote-controlled and voice-activated systems, and multiple platform options.

The most recent push in ultrasound technology is the miniaturization of ultrasound machines to handheld devices. Companies such as GE, Siemens, Signostic and Mobisante have released handheld ultrasound imaging devices in the past few years. Some of these devices are the size of larger cellular phones, making them easy to carry around at all times.

Siemens was the first to release a “pocket ultrasound,” the Acuson P10. This unit starts up in 5 seconds and can be used for cardiac and abdominal applications. It weighs a hefty 1.6 pounds and stores both video clips and still images. Signostic has created a hand held ultrasound machine with a high-resolution LCD touch screen display and text and voice annotation. It is the lightest at 11.2 ounces. GE has also released a handheld ultrasound unit this past year called the Vscan. It is the size of a Smartphone, but is a self-contained unit. It boasts a 3.5 inch color display with an easy user interface and a 4 GB memory card. The entire unit weighs in at 14 ounces and has the ability to perform color flow Doppler. The MobiUS, produced by Mobisante has recently gained FDA approval as a handheld ultrasound device that actually utilizes a Smartphone-based platform.5 The device uses the Toshiba TG01 smart phone and the probe connects via a USB

connection. It can connect to Wifi or a cellular network allowing the user to send images wirelessly via the Internet.

The whole system weighs in at 13 ounces and although it is not out for purchase yet, the estimated price will be $5,000 for a single probe system.

Many news articles have questioned whether these devices will eventually replace the stethoscope6,7,8. The hope is that these devices will allow physicians to substitute physical exam findings based on auscultation (i.e. heart sounds) quickly and quantitatively with visualization of left ventricular function or valvular abnormalities.

The increased portability of these ultrasound machines will make them attractive for pre-hospital and disaster settings and even remote locations.

These machines also cost significantly less than their larger counterparts, making their purchase more palatable to EDs.Other current ultrasound advancements include educational technology.For practitioners continuing to learn how to use ultrasound technology, there is an abundance of websites and Smartphone-based applications dedicated to emer-gency ultrasound education.

While there are no dedicated Android-based or Blackberry-based ultrasound apps, there are currently six different EM-focused applications downloadable for the Apple iPhone (see Table 1).

The future of emergency ultrasound lies in increased adoption, widened applica-tions, and continued technological development. With advances in ultrasound processing and micro circuitry, both portability and image quality can be expected to continue to improve. It seems that the “stethoscope of the future” is closer than we think.

References

1. Moore, Christopher L., Joshua A. Copel. Point-of-Care Ultrasonography. N Engl J Med. 2011; 364: 740-757.

2. Cosby, Karen S., John L. Kendall. Practical Guide to Emergency Ultra-sound. Lippincott Williams &

Wilkins, Philadelphia, PA, 2006.

3. Dussik KT. On the possibility of using ultrasound waves as a diagnostic aid. Z Neurol Psychiat 1942; 174: 153-168

4. Yale University. "Bedside ultrasound becomes a reality." ScienceDaily 24 February 2011. Accessed 1 March 2011. Error! Hyperlink reference not valid.

5. Swanson, Sandra. “Ultrasound Gets More Portable”. Technology Review. Massachusetts Institute of Technology. 29 November 2010. Accessed 1 March 2011.

6. Baker, Pam. “Will GE’s handheld ultrasound become the next stethescope”.

TechNewsWorld. October 22, 2009. Accessed 1 March 2011. http://www.technewsworld.com/rsstory/68433.html

7. Feig, Christy. “Ultrasound may mean the end to the classic stethoscope”. CNN.com. August 27, 2003. Accessed 1 March 2011. http://articles.cnn.com/2003-08-27/health/ultra.stethoscope_1_handheld-ultrasound-primary-care-stethoscope?_s=PM:HEALTH

8. Millburg, Steve. “Handheld Ultra-sound: The New Stethoscope?” Radiolo-gyDaily. January 24, 2011. Accessed 1 March 2011. http://www.radiologydaily.com/?p=5813

EMERGENCYultrasound


Table 1: iPhone Ultrasound Apps

Application Developer Price

Diagnostic Ultrasound Video Clips Vol #1-4

SHUJUNSHA $5.99-16.99

EMed ViewSono $59.99

Emergency Medicine Ultrasound

EMApps $4.99

Pocket Atlas of Emergency Ultrasound

Usatine Media $69.99

SonoAccess SonoSite Free

StatUS Dania Tagan Free

(Information adapted from Apple App Store, 3/1/2011)

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. Candidate 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.



POISONcontrol

Bath Salts:The Latest Craze

Alexander Garrard, Pharm.D. Adam Wood, Pharm.D.Clinical Toxicology FellowsDawn R. Sollee, Pharm.D., DABATAssistant DirectorFlorida/USVI Poison Information Center-Jacksonville

There has been increased mention lately of “Bath Salts” in the media. Reports coming from Europe discuss a new drug that adolescents and adults are abusing to get high. Despite sales being banned in Florida from February 2011, the Florida Poison Information Center Network (FPICN) has continued to receive calls concerning Bath Salts.1 In fact, by March 2011, the FPICN received 90 exposure calls for paranoia, hallucinations, and suicidal thoughts after abusing this new drug.2

Little is known regarding Bath Salts, but what follows is a summary of available information. As with any drug bought off the street, Bath Salts are never 100% pure product and may be adulterated with any number of different agents which can alter the clinical presentation.

Bath salts is the generic term used by vendors who sell these products. Retail names include “Ivory Wave”, “Dusted”, “White Lightning”, “Vanilla Sky”, “Hurri-cane Charlie” and more. These are the newest drugs of abuse out on the market and little is known of their exact mecha-nism of action and toxicity. Chemical analyses show that these products most often contain MDVP (3,

4 - m e t h y l e n d i o x y p y r o v a l e r o n e ) , mephedrone, or methylone. These chemi-cals are structurally similar to amphet-amine and should produce similar effects. Mephedrone has recently made an appear-

ance in the U.S. drug scene, although it has been used in Europe for a number of years. It goes by a number of different names on the street, including “meow meow”, “MCAT”, “drone”, “meph”, and “plant food.” Mephedrone is a synthetic derivative of cathinone, which is the pharmacologically active alkaloid found in khat (Catha edulis), a shrub native in Africa and the Middle East. There, the leaves of khat are chewed in a social environment to elicit a stimulant-like effect.3

These products are available in powder form or as crystals sold on the street. Prior to the ban, Bath Salts could generally be obtained from a local tobacco or smoke shop. On the street, mephedrone may be sold as MDMA or cocaine and may be adulterated with acetaminophen, cocaine, amphetamine, caffeine, and ketamine. These products are commonly insufflated, which allows for a rapid onset of action within minutes and a peak of less than 30 minutes with a rapid offset. There are case reports of rectal and intravenous adminis-tration given the high water solubility of the drugs. Intravenous use is discouraged among users as it has a higher addiction potential. When the products are ingested, onset of action is generally within 45 minutes to two hours and the psychoactive effects are noted to last up to 4 hours.4

Little is known regarding the pharmacol-ogy of Bath Salts, but due to their similar

chemical structure to beta-ketoamphetamines, they can be expected to act as CNS stimulants by increasing the release and inhibiting the reuptake of monoamine neurotransmitters such as norepinephrine and serotonin. As such, they can produce a sympathomimetic-like picture. As with many drugs of abuse, the presence or absence of ring substituents can alter its receptor affinity and effects. In the case of mephedrone, the presence of ring substituents confers MDMA-like activity. MDMA is considered an entacto-gen, which means it gives the user a sense of euphoria and inner peace.

Patients who abuse Bath Salts most commonly present to the ED with a sympathomimetic toxidrome. The major-ity of patients experience agitation (53.3%), tachycardia (40%), hypertension (20%) and seizures (20%). Patients may report suicidal ideation, and there is at least one death reported so far due to suicide secondary to Bath Salts.5, 6

In one case series by James et al, skin discoloration or cool/cold extremities were reported. By the same author, 45% of patients had symptoms that persisted for greater than 24 hours after ingestion and 30% of patients had symptoms that persisted greater than 48 hours after inges-tion. Suicide precautions need to be taken with patients who abuse this drug on a chronic basis even if they do not immedi-ately display suicidal ideation.5

Management of these patients is mainly confined to symptomatic and supportive care. Due to the most common route of administration being insufflation, gastro-intestinal decontamination is unlikely to confer any benefit. There is no antidote unfortunately, but most patients can be managed with benzodiazepines as needed for seizures and agitation. Hyperthermia may respond to aggressive cooling measures. As these products are rarely pure and are oftentimes combined with other agents that have serotonergic activ-ity, it is always important to keep in mind that there is a risk for serotonin syndrome in these patients. Those patients with a diagnosis of serotonin syndrome may be candidates for the antidote, cyprohepta-dine. Of the death reports associated with mephedrone, most patients were also using other substances such as alcohol, cannabis, cocaine, amphetamine and methadone.4, 5, 6

We hope to learn more about Bath Salts as more and more cases are reported to the poison control centers. If there are any questions regarding these exposures, clinical manifestations, and/or manage-ment, please contact your local poison control center at 1-800-222-1222.

References1. Allen, G. (2011, February 8). Florida Bans Cocaine-Like 'Bath Salts' Sold in Stores. Retrieved March 4, 2011, from NPR: http://www.npr.org/2011/02/08/133399834/florida-bans-cocaine--like-bath-salts-sold-in-stores

2. USVI/Florida Poison Informa-tion Center - Jacksonville. (2010). Bath Salts.

3. Camilleri A, J. M. (2010). Chemical analysis of four capsules

containing the controlled substance analogues 4-methylmethcathinone, 2-fluoromethamphetamine, alpha-phthalimidopropiophenone and N-ethylcathinone. Forensic Science International, 59-66.

4. Schifano F, A. A. (2010). Mephedrone (4-methylmethcathinone; 'meow meow'): chemical, pharmacologi-cal and clinical issues. Psychopharmacol-ogy.5. James D, A. R. (August 2010). Clinical characteristics of mephedrone toxicity reported to the UK National Poisons Information Service. Emergency Medicine Journal.

6. Wood DM, G. S. (June 2010). Clinical pattern of toxicity associated with the novel synthetic cathinone mephedrone. Emergency Medicine Journal.

There has been increased mention lately of “Bath Salts” in the media. Reports coming from Europe discuss a new drug that adolescents and adults are abusing to get high. Despite sales being banned in Florida from February 2011, the Florida Poison Information Center Network (FPICN) has continued to receive calls concerning Bath Salts.1 In fact, by March 2011, the FPICN received 90 exposure calls for paranoia, hallucinations, and suicidal thoughts after abusing this new drug.2

Little is known regarding Bath Salts, but what follows is a summary of available information. As with any drug bought off the street, Bath Salts are never 100% pure product and may be adulterated with any number of different agents which can alter the clinical presentation.

Bath salts is the generic term used by vendors who sell these products. Retail names include “Ivory Wave”, “Dusted”, “White Lightning”, “Vanilla Sky”, “Hurri-cane Charlie” and more. These are the newest drugs of abuse out on the market and little is known of their exact mecha-nism of action and toxicity. Chemical analyses show that these products most often contain MDVP (3,

4 - m e t h y l e n d i o x y p y r o v a l e r o n e ) , mephedrone, or methylone. These chemi-cals are structurally similar to amphet-amine and should produce similar effects. Mephedrone has recently made an appear-

ance in the U.S. drug scene, although it has been used in Europe for a number of years. It goes by a number of different names on the street, including “meow meow”, “MCAT”, “drone”, “meph”, and “plant food.” Mephedrone is a synthetic derivative of cathinone, which is the pharmacologically active alkaloid found in khat (Catha edulis), a shrub native in Africa and the Middle East. There, the leaves of khat are chewed in a social environment to elicit a stimulant-like effect.3

These products are available in powder form or as crystals sold on the street. Prior to the ban, Bath Salts could generally be obtained from a local tobacco or smoke shop. On the street, mephedrone may be sold as MDMA or cocaine and may be adulterated with acetaminophen, cocaine, amphetamine, caffeine, and ketamine. These products are commonly insufflated, which allows for a rapid onset of action within minutes and a peak of less than 30 minutes with a rapid offset. There are case reports of rectal and intravenous adminis-tration given the high water solubility of the drugs. Intravenous use is discouraged among users as it has a higher addiction potential. When the products are ingested, onset of action is generally within 45 minutes to two hours and the psychoactive effects are noted to last up to 4 hours.4

Little is known regarding the pharmacol-ogy of Bath Salts, but due to their similar

chemical structure to beta-ketoamphetamines, they can be expected to act as CNS stimulants by increasing the release and inhibiting the reuptake of monoamine neurotransmitters such as norepinephrine and serotonin. As such, they can produce a sympathomimetic-like picture. As with many drugs of abuse, the presence or absence of ring substituents can alter its receptor affinity and effects. In the case of mephedrone, the presence of ring substituents confers MDMA-like activity. MDMA is considered an entacto-gen, which means it gives the user a sense of euphoria and inner peace.

Patients who abuse Bath Salts most commonly present to the ED with a sympathomimetic toxidrome. The major-ity of patients experience agitation (53.3%), tachycardia (40%), hypertension (20%) and seizures (20%). Patients may report suicidal ideation, and there is at least one death reported so far due to suicide secondary to Bath Salts.5, 6

In one case series by James et al, skin discoloration or cool/cold extremities were reported. By the same author, 45% of patients had symptoms that persisted for greater than 24 hours after ingestion and 30% of patients had symptoms that persisted greater than 48 hours after inges-tion. Suicide precautions need to be taken with patients who abuse this drug on a chronic basis even if they do not immedi-ately display suicidal ideation.5

Management of these patients is mainly confined to symptomatic and supportive care. Due to the most common route of administration being insufflation, gastro-intestinal decontamination is unlikely to confer any benefit. There is no antidote unfortunately, but most patients can be managed with benzodiazepines as needed for seizures and agitation. Hyperthermia may respond to aggressive cooling measures. As these products are rarely pure and are oftentimes combined with other agents that have serotonergic activ-ity, it is always important to keep in mind that there is a risk for serotonin syndrome in these patients. Those patients with a diagnosis of serotonin syndrome may be candidates for the antidote, cyprohepta-dine. Of the death reports associated with mephedrone, most patients were also using other substances such as alcohol, cannabis, cocaine, amphetamine and methadone.4, 5, 6

We hope to learn more about Bath Salts as more and more cases are reported to the poison control centers. If there are any questions regarding these exposures, clinical manifestations, and/or manage-ment, please contact your local poison control center at 1-800-222-1222.

References1. Allen, G. (2011, February 8). Florida Bans Cocaine-Like 'Bath Salts' Sold in Stores. Retrieved March 4, 2011, from NPR: http://www.npr.org/2011/02/08/133399834/florida-bans-cocaine--like-bath-salts-sold-in-stores

2. USVI/Florida Poison Informa-tion Center - Jacksonville. (2010). Bath Salts.

3. Camilleri A, J. M. (2010). Chemical analysis of four capsules

containing the controlled substance analogues 4-methylmethcathinone, 2-fluoromethamphetamine, alpha-phthalimidopropiophenone and N-ethylcathinone. Forensic Science International, 59-66.

4. Schifano F, A. A. (2010). Mephedrone (4-methylmethcathinone; 'meow meow'): chemical, pharmacologi-cal and clinical issues. Psychopharmacol-ogy.5. James D, A. R. (August 2010). Clinical characteristics of mephedrone toxicity reported to the UK National Poisons Information Service. Emergency Medicine Journal.

6. Wood DM, G. S. (June 2010). Clinical pattern of toxicity associated with the novel synthetic cathinone mephedrone. Emergency Medicine Journal.

POISONcontrol



My Take on EM Days

Florida State Senator Chris Smith-D recently told a newspaper reporter that he couldn’t figure out why a doctor would need to ask a patient if they own guns at home.

If you’ve been following the current Florida Legislative Session, you probably realize that this statement is in reference to a bill working its way through the Legislature. The ‘Don’t Ask’ gun bill, (HB155/SB818) has received support from the National Rifle Association and has been lobbied against by the Florida Medical Association, American Academy of Pediatrics and our College. The original language in the bill would have actually made it a felony punishable by jail time or a multi-million dollar fine for you to ask about gun ownership. Fortu-nately - thanks to direct conversations with your legislators - it is now permis-sible to ask about firearms in emergency situations (but still not in the pediatrician’s office) and violation will constitute a civil, instead of criminal, penalty. When this article goes to press, the bill might be a law or it might die a slow death in a House Committee.

In any case, this is exactly why we go to Tallahassee every year! Sen. Smith needs to hear our stories to understand why his statement does not reflect the reality of clinical practice in a busy ED.

EM Days takes place each year during the Florida Legislative session which runs for 60 days - starting the second

Tuesday after the first Monday in March. I have been to Tallahassee, either with the Florida Medical Association or FCEP four times and each year it becomes ever more apparent why physicians must be involved not just in direct patient encounters but also in the policy and legislative aspects of health care.

Medicine is an increasing proportion of the conversation at all levels of govern-ment - both in fiscal terms and in issues of health care access. The State budget - which faces, as of this writing, a 3.5 billion dollar deficit - is taken up predominately by health care costs and education. In addition, we all know that insurance reform does not necessarily lead to improved access to physicians.

With a demographic shift towards an older population, a slow-to-recover economy, millions without adequate health care, and a finite supply of resources our elected leaders will have to increasingly talk about - and legislate - healthcare over the coming decades. It is not acceptable at this point for a physi-cian to claim they went into medicine just to treat patients or to focus only on clinical skills. The factors that bring a patient to the ED are only partially explained by physical pathology but more so explained by issues such as transporta-tion, cost, and availability (we are always open and see everyone who walks through the door!)

EM Days is a great way for you to have a

direct impact on legislating medical care and health policy. Dr. Steve Kailes did a great job summarizing the major issues relating to EM that are being discussed during session. Beth Brunner and the FCEP/EMLRC staff did a wonderful job of making appointments with legislators from all over Florida - allowing EPs direct access and the chance to bring clinical clarity to our legislators by sharing stories and experiences.

This year, Medicaid Reform is the most significant healthcare issue facing the Legislature. It looks like Florida will probably move to some type of managed care system - even though there is no compelling data that this will save money. Some states are actually trying to move out of similar models (e.g. Connecticut). At EM Days, we stressed that a managed care system must be accountable. In other words, it is impor-tant to know that the money we pay to managed care companies with our tax dollars would actually go to improving patient care - namely access to physi-cians.

Just like with the federal Patient Protec-tion and Affordable Care Act (PPACA), if there is no incentive for primary care physicians to see patients, there will be no significant change and no decrease in healthcare costs - the patients will still come to the ED because they can’t go anywhere else. Thus, the changes will need to include increased reimbursements up to Medicare levels for primary care

physicians.

Many would argue that our reimburse-ments in the ED should also rise to that level in order to cover the increased patient load that will follow the expanded Medicaid roles that will result from PPACA if the access issue is not addressed more completely (as occurred in Massachusetts after a state reform law.)

Tort Reform is always a hot topic with physicians and the FCEP supported, Sovereign Immunity concept, which would limit non-economic damages, has gained a little traction this year - mostly through the Medicaid Reform Act.

Briefly, since EMTALA necessitates that we see all patients that walk through our door, regardless of ability to pay, this federal law is widely considered an “unfunded mandate.” Also, many specialists fear taking call in the ED since seeing an unknown, possibly unfunded, patient in the middle of the night is felt to be high risk for liability. Thus, Sovereign Immunity for the ED would add more fairness to the EMTALA mandate and help ease the crisis we face with a shortage of specialists willing to take call. This year, a Sovereign Immunity House Bill (HB615) was introduced (again) by Rep. Renuart (a surgeon from Ponte Verde) but will likely not move far as there is currently no Senate companion bill and the topic is not a priority for Rep. Cannon, the Speaker of the House.

However, there is language in the Medicaid Reform Act that may provide immunity for Medicaid patient encoun-ters. When I met with Sen. Jones, he expressed concern that this would create a tiered system of patients - those who have access to the courts and those who don’t - based on their funding.

One nice feature of Medicaid Reform is the creation of a Florida Statute that gives the Board of Medicine rulemaking ability to create an Expert Witness Certificate. Expert Witness Certification has been a major legislative issue for the FMA and

FCEP over the past few years in an attempt to combat a trend of hired-gun physician witnesses that travel the country testifying to “the standard of care” in a state, and often, a specialty that they don’t even practice.

FCEP supports the “texting-while-driving” bill and legislation to increase booster seat requirements for children.

The other significant medical issue this session is the prescription drug epidemic. EPs see the ramifications of this epidemic first hand as we treat more patients suffering adverse events (such IVDA related infections and “overdoses”) from narcotic medications. In the ED, we need every tool possible to combat this epidemic - including an online prescrip-tion drug monitoring program (PDMP) to look for evidence of abuse or diversion of narcotics. While the PDMP was actually introduced and passed into law through a bill sponsored by Sen. Fasano, the Governor and House (led by Rep. Cannon) have tried to block implementa-tion of this program and have now shifted the focus from monitoring to regulation through a number of new bills that interfere with the doctor-patient relation-ship.

The regulation bill most likely to pass at this writing would ban doctors from dispensing controlled substances in their offices. This law will be easily avoided by pain clinics that simply place a full pharmacy -with separate corporate entity- inside their clinic. The motivation of our Governor to unravel an admittedly limited but cost effective (private money for first three years pays for the database) weapon for physicians is unclear at this time. Many members of the House who once supported the measure have now reversed course, seemingly to stay on the good side of the Speaker.

I also took time to speak with the Drug Czar for Florida, former state senator David Aronberg, who was appointed by Attorney General Pam Bondi. The Attorney General’s office and Senate President Haridopolos are at odds with

the House and Governor’s office over their support for PDMP and other tools to combat the worsening epidemic.

It is easy to get involved and make a difference for your patients - you can call your representative or - even better – meet them at their local office in your district. They will be excited to hear the viewpoint of a voting physician. Call the legislators who sit on a committee before an important bill is heard - let their staff know how you feel about a piece of legislation. When talking with your elected officials, be courteous to their aides and realize that the aide may have a strong influence on the actual representa-tive.

Whether through phone calls and emails or direct trips to Tallahassee, your patients need you to get involved in the legislative process!

Links:

Current Medicine Related Bills in Florida Legislaturehttps://spreadsheets0.google.com/ccc?hl=en&key=tlaOaB_AYumUCETK1ekvvWg&hl=en#gid=0

The Florida House - use to find your Representative, Committee Rosters and the Status of Each Billhttp://www.myfloridahouse.com/default.aspx

The Florida Senate - use to find your Senatorhttp://flsenate.gov/

Jason W. Wilson, MDChief Resident, USF Health · College of Medicine

EMdays

Florida State Senator Chris Smith-D recently told a newspaper reporter that he couldn’t figure out why a doctor would need to ask a patient if they own guns at home.

If you’ve been following the current Florida Legislative Session, you probably realize that this statement is in reference to a bill working its way through the Legislature. The ‘Don’t Ask’ gun bill, (HB155/SB818) has received support from the National Rifle Association and has been lobbied against by the Florida Medical Association, American Academy of Pediatrics and our College. The original language in the bill would have actually made it a felony punishable by jail time or a multi-million dollar fine for you to ask about gun ownership. Fortu-nately - thanks to direct conversations with your legislators - it is now permis-sible to ask about firearms in emergency situations (but still not in the pediatrician’s office) and violation will constitute a civil, instead of criminal, penalty. When this article goes to press, the bill might be a law or it might die a slow death in a House Committee.

In any case, this is exactly why we go to Tallahassee every year! Sen. Smith needs to hear our stories to understand why his statement does not reflect the reality of clinical practice in a busy ED.

EM Days takes place each year during the Florida Legislative session which runs for 60 days - starting the second

Tuesday after the first Monday in March. I have been to Tallahassee, either with the Florida Medical Association or FCEP four times and each year it becomes ever more apparent why physicians must be involved not just in direct patient encounters but also in the policy and legislative aspects of health care.

Medicine is an increasing proportion of the conversation at all levels of govern-ment - both in fiscal terms and in issues of health care access. The State budget - which faces, as of this writing, a 3.5 billion dollar deficit - is taken up predominately by health care costs and education. In addition, we all know that insurance reform does not necessarily lead to improved access to physicians.

With a demographic shift towards an older population, a slow-to-recover economy, millions without adequate health care, and a finite supply of resources our elected leaders will have to increasingly talk about - and legislate - healthcare over the coming decades. It is not acceptable at this point for a physi-cian to claim they went into medicine just to treat patients or to focus only on clinical skills. The factors that bring a patient to the ED are only partially explained by physical pathology but more so explained by issues such as transporta-tion, cost, and availability (we are always open and see everyone who walks through the door!)

EM Days is a great way for you to have a

direct impact on legislating medical care and health policy. Dr. Steve Kailes did a great job summarizing the major issues relating to EM that are being discussed during session. Beth Brunner and the FCEP/EMLRC staff did a wonderful job of making appointments with legislators from all over Florida - allowing EPs direct access and the chance to bring clinical clarity to our legislators by sharing stories and experiences.

This year, Medicaid Reform is the most significant healthcare issue facing the Legislature. It looks like Florida will probably move to some type of managed care system - even though there is no compelling data that this will save money. Some states are actually trying to move out of similar models (e.g. Connecticut). At EM Days, we stressed that a managed care system must be accountable. In other words, it is impor-tant to know that the money we pay to managed care companies with our tax dollars would actually go to improving patient care - namely access to physi-cians.

Just like with the federal Patient Protec-tion and Affordable Care Act (PPACA), if there is no incentive for primary care physicians to see patients, there will be no significant change and no decrease in healthcare costs - the patients will still come to the ED because they can’t go anywhere else. Thus, the changes will need to include increased reimbursements up to Medicare levels for primary care

physicians.

Many would argue that our reimburse-ments in the ED should also rise to that level in order to cover the increased patient load that will follow the expanded Medicaid roles that will result from PPACA if the access issue is not addressed more completely (as occurred in Massachusetts after a state reform law.)

Tort Reform is always a hot topic with physicians and the FCEP supported, Sovereign Immunity concept, which would limit non-economic damages, has gained a little traction this year - mostly through the Medicaid Reform Act.

Briefly, since EMTALA necessitates that we see all patients that walk through our door, regardless of ability to pay, this federal law is widely considered an “unfunded mandate.” Also, many specialists fear taking call in the ED since seeing an unknown, possibly unfunded, patient in the middle of the night is felt to be high risk for liability. Thus, Sovereign Immunity for the ED would add more fairness to the EMTALA mandate and help ease the crisis we face with a shortage of specialists willing to take call. This year, a Sovereign Immunity House Bill (HB615) was introduced (again) by Rep. Renuart (a surgeon from Ponte Verde) but will likely not move far as there is currently no Senate companion bill and the topic is not a priority for Rep. Cannon, the Speaker of the House.

However, there is language in the Medicaid Reform Act that may provide immunity for Medicaid patient encoun-ters. When I met with Sen. Jones, he expressed concern that this would create a tiered system of patients - those who have access to the courts and those who don’t - based on their funding.

One nice feature of Medicaid Reform is the creation of a Florida Statute that gives the Board of Medicine rulemaking ability to create an Expert Witness Certificate. Expert Witness Certification has been a major legislative issue for the FMA and

FCEP over the past few years in an attempt to combat a trend of hired-gun physician witnesses that travel the country testifying to “the standard of care” in a state, and often, a specialty that they don’t even practice.

FCEP supports the “texting-while-driving” bill and legislation to increase booster seat requirements for children.

The other significant medical issue this session is the prescription drug epidemic. EPs see the ramifications of this epidemic first hand as we treat more patients suffering adverse events (such IVDA related infections and “overdoses”) from narcotic medications. In the ED, we need every tool possible to combat this epidemic - including an online prescrip-tion drug monitoring program (PDMP) to look for evidence of abuse or diversion of narcotics. While the PDMP was actually introduced and passed into law through a bill sponsored by Sen. Fasano, the Governor and House (led by Rep. Cannon) have tried to block implementa-tion of this program and have now shifted the focus from monitoring to regulation through a number of new bills that interfere with the doctor-patient relation-ship.

The regulation bill most likely to pass at this writing would ban doctors from dispensing controlled substances in their offices. This law will be easily avoided by pain clinics that simply place a full pharmacy -with separate corporate entity- inside their clinic. The motivation of our Governor to unravel an admittedly limited but cost effective (private money for first three years pays for the database) weapon for physicians is unclear at this time. Many members of the House who once supported the measure have now reversed course, seemingly to stay on the good side of the Speaker.

I also took time to speak with the Drug Czar for Florida, former state senator David Aronberg, who was appointed by Attorney General Pam Bondi. The Attorney General’s office and Senate President Haridopolos are at odds with

the House and Governor’s office over their support for PDMP and other tools to combat the worsening epidemic.

It is easy to get involved and make a difference for your patients - you can call your representative or - even better – meet them at their local office in your district. They will be excited to hear the viewpoint of a voting physician. Call the legislators who sit on a committee before an important bill is heard - let their staff know how you feel about a piece of legislation. When talking with your elected officials, be courteous to their aides and realize that the aide may have a strong influence on the actual representa-tive.

Whether through phone calls and emails or direct trips to Tallahassee, your patients need you to get involved in the legislative process!

Links:

Current Medicine Related Bills in Florida Legislaturehttps://spreadsheets0.google.com/ccc?hl=en&key=tlaOaB_AYumUCETK1ekvvWg&hl=en#gid=0

The Florida House - use to find your Representative, Committee Rosters and the Status of Each Billhttp://www.myfloridahouse.com/default.aspx

The Florida Senate - use to find your Senatorhttp://flsenate.gov/

EMdays


EmergencyMedicineDAYS‘11


EMdays

22nd Annual EM Days - March 16-18, 2011Hotel Duval by Marriott - Tallahassee, FL 32301


Emergency Managementand You

1. For the average emergency physician working in Florida, how does the DEM affect us most? First, there are no average emergency physicians. We in Emergency Management are consistently awed by the dedication that these men and women demonstrate every single day on the job, and are thankful for their partnership. Now, on to the question: Emergency physicians are part of the local response to health and medical needs during the response to an event or disaster. We encourage them to participate in preparedness planning with their medical institution and county emergency management agency. The Florida Division of Emergency Management coordinates the state’s response when the event gets too big for any one county to handle and when multiple counties are severely impacted. This helps to make sure that residents receive the most timely and efficient help possible. If an emergency physician is interested in participating in response efforts, we encourage them to register as part of Florida's Medical Reserve Corps (MRC) at www.servfl.com. Additional information on the roles and responsibilities of the State Division of Emergency Management can be accessed at FloridaDisaster.org or at your county emergency management agency’s website.

2. What is the best way for an emergency physician to get involved in disaster response in Florida?Emergency physicians can register to volunteer with their local MRC Unit. There are currently 33 MRC Units in 60 different counties throughout Florida. For those in counties without an MRC, they may wish to register with another county’s MRC, volunteer with the American Red Cross, or volunteer with another recognized not-for-profit organization.

3. Is it true that if a physician volunteers in a disaster, they are covered by sovereign immunity?Yes, if they are registered and activated with the Florida MRC Network Program, which is deployed through the State Emer-gency Operations Center, then they are covered by the volunteer protections under Chapter 110, Florida Statutes.

4. How would I know if there is a DMAT in my area, and how would I contact them?

DMATs are designed to be a rapid-response resource that can supplement local medical providers until the situation is stabilized or other federal or contracted assets can be mobilized. DMATs deploy to disaster sites with enough supplies and equipment to sustain operations for approximately 72 hours while providing medical care at a fixed or temporary medical care site. The personnel are activated for about two weeks. Anyone interested in this great program can look up more information at http://www.phe.gov/Preparedness/responders/ndms/teams/Pages/default.aspx and http://www.phe.gov/Preparedness/responders/ndms/teams/Pages/dmat.aspx There are six DMATs established in Florida (designated as FL-1 through FL-6). Here are the links for individual team informa-tion: FL-1 http://www.floridaonedmat.com/FL-2 http://www.fl2dmat.org/FL-3 http://www.fl3dmat.org/FL-4 http://fl4dmat.com/FL-5 http://www.fl5dmat.com/FL-6 http://florida6dmat.com/default.aspx

5. What advice would you give to physicians who just show up at the site of a disaster like a hurricane or tornado strike?I would strongly advise volunteers and emergency health care providers not to show up at a disaster site without previously coordinating with their local or state emergency management agency. This coordination helps to make sure that volunteers have the resources they need to make a difference and stay safe in the disaster area. It’s been our philosophy for years that when a disaster strikes, everyone, especially health care providers, are part of the team. We just have to be able to ensure that we know where everyone is and how we can best support them. After all, we are all working towards the same goal: to make sure that our state’s residents and visitors are cared for after an emergency. To volunteer for an emergency response, you can become part of the Florida Medical Reserve Corps Network. This Network provides essential training and credentialing to develop teams for volunteer safety and a coordinated response. It is always best to be part of a team that has received training, has verified credentials, and understands their response role.

EMdays

Bryan KoonDirector, Florida Division of Emergency Management

RESIDENCYmatters

University of Florida, GainesvilleDavid Nguyen, DO

Greetings from Gainesville!

Changes are in the works for the Shands ED! A new, dedicated, free standing pediatric ED is scheduled to have its grand opening in July 2011. Our pediatric EM attendings, Drs. Light, Lucas, Brown, and Falgiani, have been crucial in the planning and design. There will be 20+ beds (more than double our current capacity), a larger waiting room filled with toys, games, and portable DVD players/movies, and 24-hour pediatric EM trained staff.

A new chest pain evaluation center is coming soon. This unit will allow low risk patients with chest pain to be observed and monitored, while serial biomarkers, stress tests and/or cardiac CTA are performed. This will open up beds in the main ED. Finally, all ED staff has completed training in the new Electronic Medical Records. We will all switch to EPIC this summer. This change brings the hope of being able to easily access patient medical records, improve patient safety, and improve work/patient flow through the entire hospital.

In other news, attending Dr. Ellie recently welcomed happy and healthy twins to her family and Dr. Falgiani is expecting a new baby boy any day now! Congratulations and love to both! Many of our residents, attendings, and nurses were part of the NASA flight medical team for the final launch of the spaceship Discovery. It was truly an amazing experience!

Go Gators!

Greetings!

The last few months have been very busy with preparation for the in-service exami-nation and the AAEM meeting. Nonethe-less, we are happy with our success in these endeavors.

The AAEM annual meeting was held in Orlando this year and we were eager to take part in this distinguished assembly. Florida Hospital enjoyed a very strong representation at the conference.

Our residents and faculty took part in case presentations and M&M case discussions. Congratulations to Dr. Acevedo and Dr. Garcia, our Chief Resident, for winning third place in the Oral Research National Competition!

We welcome Drs. Katia Lugo and Caro-line Molins to our EM family as the newest members of our core faculty. We are making preparations to graduate our first class in June and we are extremely proud and excited that the residency continues to grow and strengthen.

Lastly, we hope everyone had a great match this year!

Last week, a group of 5 EM residents from USF journeyed up to Tallahassee for EM Days at the Capitol. EM Days is an excel-lent opportunity for residents to get started in advocacy. The event takes place over two days in March during the 60 day Florida Legislative Session.

This year, Dr. Stephen Kailes gave an overview of the important bills facing EM and the FCEP staff set up meetings with legislators from all over Florida. Groups of residents and attendings then met one-on-one with representatives and senators to discuss possible impacts of legislation - most effectively done by telling stories from the ED. This event demonstrates the accessibility of elected officials to engaged physicians and the ease of getting involved.

While at EM Days, we waited excitedly for the Match List to be announced. Finally, in between sessions with senators, an email popped up on my iPhone that USF was able to recruit 10 top notch students. I look forward to seeing them this June! This will be my last update after 3 years of writing for EMpulse! I will be staying on at the USF/TGH program as the Associate Research Director. It has been an awesome privilege to represent our program at FCEP. I encourage all residents to take advantage of the amazing experiences and education available to you through FCEP.

Nicholas Healy will be the new USF EMRAF representative and I know he will do an excellent job!

Florida HospitalVu Nguyen, MD

University of South Florida Jason W. Wilson, MD


RESIDENCYmatters


Univ. of Florida, JacksonvilleTravis Smith, DO

Hello from UFCOM-Jacksonville! Interview season is finally over and I am sure it could not have gone fast enough for some of us. Match day is approaching and we are all getting a bit anxious about our new interns who get to spend three years of an eternity with us.

This past February, just about our whole second year class, with the help of Drs. Caro, Godwin and Simon were able to attend the AAEM 17th Annual Scientific Assembly in Orlando. While we were there we got the opportunity to help with the simulation course -- Bringing Techniques and Equipment from the Battlefield to Military and Civilian Emer-gency Medicine.

Under the direction of Dr. Jonathan Journey we enacted a battlefield mass casualty scenario and demonstrated some key life saving procedures, such as crico-thyroidotomy, performing a chest tube, hemodynamic stabilization of severed limbs, and video laryngoscopy. This was a great experience for all.

Our annual Research Day is scheduled for later this month when we will see all of the great research projects that our seniors have been working on for the past few years.

Last month, a group of our attendings and residents traveled to Orlando for the AAEM 17th Annual Scientific Assembly. Amongst them were residents Erin Connor (PGY-3) and Janelle Suarez (PGY-2).

Erin Connor currently holds the title of Resident Representative to the Florida Cabinet of Emergency Medicine and she was appointed to a second term while at the conference. Janelle Suarez will be setting out to do medical mission work this month.

Erin Connor (PGY-3) and Janelle Suarez (PGY-2)

She departs March 18th with attending Dr. Paul Peterson for Esquipulas, Guatemala.We congratulate both these ladies on their exceptional leadership. Erin Connor (PGY-3) and Janelle Suarez (PGY-2)

Jeremy White (PGY-3) will also be travel-ing abroad this month to do medical mission work in Sierra Leone. Dr. White will be working in the Kamakwie Medical Clinic for two weeks. We wish them safe travels.

Additionally, congratulations to Dennis Heard (PGY-2) on the birth of his daugh-ter, Charlotte Rose. She was welcomed into the Sinai family on January 21, 2011.

Greetings from Orlando!

First of all I would like to say hello as this is my first residency update! I would also like to thank Rebecca Blue for sharing the experiences of our program in the EMpulse for the past three years and for the opportunity to take over from her. Our residents and faculty are gearing up for EM Days in Tallahassee next week. They are looking forward to learning more about the legislative process pertaining to EM in the state. It is hard to believe that interview season has come to an end. Thank you to all of the residents and faculty that have worked endlessly to make this interview season an exciting and fun experience. We had a wonderful selection of applicants this year and cannot wait for match day.

Our graduating senior residents will be greatly missed and will certainly be an asset wherever they go. They are pursu-ing a variety of careers upon graduation. Five of our residents will join fellowships in EMS, Ultrasound, Pediatrics and Aero-space Medicine. Eight of our residents will be entering clinical practice here in the state of Florida, and one of our residents will be joining a group in Atlanta, Georgia.

It is hard to believe that spring has already arrived. The faces in our residency will soon be changing as we say goodbye to old friends and welcome the new. To all of our graduating residents: Good luck and thank you for all your guidance and support!

Mount Sinai Medical CenterNicole Campfield, DO

Orlando HealthSarina Doyle, MD

technology

Conference OverviewSymposium by the Sea 2011 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 4-7, 2011 . Naples Grande Beach Resort . 475 Seagate Drive . Naples, Florida 34103Reservations (888) 422-6177 . www.naplesgranderesort.com . Mention Symposium by the Sea Guest Room Reservations Cut-O� Date: July 21, 2011 . 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 2011 Symposium by the Sea Conference at The Naples Grande Resort in Naples, FL, Saturday August 6, 2011. 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 2011 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/sbs2011.htm or contact Jerry Cutchens at [email protected] Exhibit/Sponsorship Prospectus is avail-able directly at www.emlrc.org/pdfs/sbs2011prospectus.pdf.

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

www.orleansonline.com

REGISTER TODAY @ WWW.FCEP.ORG

Symposium by the Sea 2011The Annual Meeting of the Florida College of Emergency Physicians

August 4-7, 2011 . Naples Grande Beach Resort . Naples, FL

Halifax Health in Daytona Beach, Florida, a popular tourist destination on the sunny east central Florida coast is actively recruiting EM BC/BE physicians.

halifaxhealth.org

Excellent Opportunity forEmergency Medicine Physicians

› 90,000 square foot state-of-the-art emergency department - opened June 2009

› Level II Trauma Center› Stable, democratic hospital employed group› Outstanding administrative support

› Competitive hourly compensation› Additional RVU and quality incentive plans› Excellent benefits package› 24/7 multi-physician coverage plus

physician extenders

For more information, please contact:

Peter Springer, MD, FACEPDirector, Halifax Health - Emergency [email protected]

Paul Mucciolo, MD, FACEPAssistant Director, Halifax Health - Emergency [email protected]

0311-1342

Florida College ofEmergency PhysiciansFCEP|

3717 South Conway Road, Orlando, FL 32812

NONPROFITORGANIZATION

US POSTAGEPAID

PERMIT NO. 2361ORLANDO, FL

EMpulse Spring 2011

Documents

Transcript of EMpulse Spring 2011