EMPULSE 2014 Fall_Winter issue
Transcription
EMPULSE 2014 Fall_Winter issue
FLORIDA COLLEGE OF EMERGENCY PHYSICIANS EMpulse FALL/WINTER 2014 IN THIS ISSUE ABEM UPDATE THE EMERGENCY ROOM STATE-OF-FLUX EBOLA - THE LATEST IN POTENTIAL PUBLIC HEALTH CRISES NOW HIRING! Board Certified Emergency Physicians For Popular East Central Florida Area JOIN s f ’ r u S e h ! T p e U r s y Whe a w Al Atlantic Coast of Florida Full Benefit Package Become a Partner in 18 Months Competitive Pay Flexible Schedules Accommodated Contact Maureen France at 386.479.2151 or [email protected] EMPROSONLINE.COM 2014 Since 1990 fcep.com EMpulse Volume 21, Number 4 Florida College of Emergency Physicians 3717 South Conway Road Orlando, Florida 32812-7606 t: (407) 281-7396 • (800) 766-6335 f: (407) 281-4407 fcep.org Executive Committee Ashley Booth-Norse, MD, FACEP • President Steven Kailes, MD, FACEP • President-Elect Jay Falk, MD, FACEP • Vice President Joel Stern, MD, FACEP, FAAEM • Secretary/Treasurer Michael Lozano, Jr., MD, FACEP • Immediate Past President Beth Brunner, MBA, CAE • Executive Director Departments 4 | PRESIDENT’Smessage | Ashley Booth-Norse, MD, FACEP 5 | MEDICALeconomics | Daniel Brennan, MD, FACEP 7 | GOVERNMENTaffairs | Joel Stern, MD, FACEP 12 | EMS/TRAUMAupdate | Christine Van Dillen, MD, FACEP 14 | POISONcontrol | Kristin Bohnenberger, PharmD 15 | MEMBERSHIP & PROFESSIONALdevelopment | René Mack, MD 20 | MEDICAL STUDENTupdate | Tushar Gupta, MSIV 22 | EMRAF Case Presentation | Bryant Lambe, MD 26 | RESIDENCYmatters Editorial Board Karen Estrine, DO, FACEP, FAAEM • Editor-in-Chief [email protected] Features Gina Fickett • Managing Editor/Graphic Designer [email protected] 10 | Medical Malpractice Caps Overturned by Supreme Court | Michael R. Lowe, Esquire 9 | DAUNTINGdiagnosis | Karen Estrine, DO, FACEP, FAAEM 11 | Emergency Medicine Wins Ruling for PIP | Rutledge M. Bradford, Esquire 13 | CODING TIP | Lynn Reedy, CPC, CEDC 17 | ITLS Florida Chapter Report | Melissa McNally, MMSc, PA-C, EMT-P 18 | Better ER Management Requires Partnership Between Physicians and Clinical Care Coordinators | Roxanne Sams, MS, ARNP-BC, MA; Lisa M. Bragg, RN, BSN, MBA 19 | Nursing Specialty Certifications Benefit | Katrin Breault BSN, RN, CEN; Darleen Williams MSN, CNS, CEN, CCNS, CNS-BC, EMT-P 21 | Representative Pigman Addresses EM Residents on Advocacy; Touts Simulation Training | Kevin Fritz All advertisements appearing in the Florida EMpulse are printed as received from the advertisers. Florida College of Emergency Physicians does not endorse any products or services, except those in its Preferred Vendor Partnership. The college receives and distributes employment opportunities but does not review, recommend or endorse any individuals, groups or hospitals that respond to these advertisements. NOTE: Opinions stated within the articles contained herein are solely those of the writers and do not necessarily reflect those of the EMpulse staff or the Florida College of Emergency Physicians. 4 PRESIDENT’Smessage Ashley Booth-Norse, MD, FACEP FCEP PRESIDENT Ebola - the Latest in Potential Public Health Crises I took over as FCEP president in August during the 2014 Symposium by the Sea held in Boca Raton from Dr. Mike Lozano. I have to say that I have big shoes to fill. I want to personally thank Dr. Lozano for his service as FCEP president. He did an amazing job and will be hard to follow as president. I also want to thank the off-going board of directors’ members- Drs. Kelly Gray-Eurom, Gary Gillette and Nate Lisenbee (EMRAF rep). They all did a wonderful job and will be missed. Special thanks go to Dr. Gray who leaves the BOD after serving as FCEP president in 2012-13 and immediate past President in 2013-14. No one does this job alone and I am blessed to have a wonderful and very talented board of directors. I would like to thank my executive committee for all the work they have done already this year- Drs. Steve Kailes, Jay Falk and Joel Stern- they are a great team! As I start my term as FCEP president, FCEP and FEMF are in the process of literally building a new home for both organizations. The new building is scheduled to be completed in October (which as we all know means more likely November). This will mark a new chapter in FCEP history. We have grown so much in the last decade that we are desperately in need of the new space. The new building will allow us to provide more educational opportunities, host more events and provide more services to our members. However the new building comes at a cost- we must pay for the new space and as we get closer to our targeted move-in date this task becomes more daunting. The FCEP/FEMP Capital Campaign continues. In the eloquent words of our former president: “please give generously yourself and if you happen to know someone who has been blessed with more of life’s tangible riches, please refer them to us.” In my first quarter as FCEP president, our profession of emergency medicine has been under attack in the media. Once again we are being targeted in our role as the safety net for the healthcare system in this country. Articles in the Tampa Bay Times to the New York Times have stated that, “Even in in-network hospitals, insurance may not cover ER physicians.” These articles attack our ability to balance bill even when insurance companies ignore the “usual and customary standard” in regards to reimbursement. A ban on balance billing will create huge benefits for health insurance companies while endangering the health care safety net. We have responded with a letter to the editor of the Tampa Bay Times that was published in September 27, 2014. We will continue to educate legislators as well as the public. Emergency Medicine is essential to every community and must have adequate resources. We must ensure that health plans provide fair payment for emergency services or patient care/access will suffer. In addition, we as emergency physicians are also facing the public health crisis of Ebola. Like SARS, MERS, Hantavirus, and the anthrax crisis after 911, newly identified serious population health threats continue to occur. The world is a much smaller place than it used to be and as the Ebola epidemic in West Africa continues, concern for spread to the US becomes real--this became evident when the first case was diagnosed in Texas in September. As emergency physicians, we are skilled in responding to disasters and treating every kind of medical condition as part of our daily routines. We are also critical to the American health care response to infectious diseases. Clearly this disease deserves our attention and emphasis from health care providers across the country. The CDC, the Emergency Care Coordination Center and the Assistant Secretary for Preparedness and Response have provided materials that are excellent resources for emergency physicians and other staff in the ED. Ebola is a serious communicable disease. Heightened vigilance for case presentations and strict adherence by health care personnel to CDC advice, public education and a pre-planned medical response is necessary. These resources are available on ACEP’s website at www.acep. org/ebola. They include screening criteria and case definition. The CDC recommends two initial steps in screening for Ebola Virus Disease: 1. The symptoms are likely to be fever, headache, joint and muscle aches, weakness, fatigue, diarrhea, vomiting, stomach pain and lack of appetite, and in some cases bleeding. 2. Travel to West Africa or other countries where EVD transmission has been reported by the World Health Organization within 21 days of symptom onset. If both of these criteria are met the patient should be moved to a private room, and standard contact and droplet isolation precautions followed during further assessment. We see dozens of patients each week, and particularly at this time of year, many will have a common cold or influenza. All health care professionals in the emergency department should know the protocols and what to ask so we can do everything possible to ensure that this Ebola case in Dallas remains isolated. 2014 MEDICALeconomics fcep.com 5 Daniel Brennan, MD, FACEP MEDICAL ECONOMICS COMMITTEE CHAIR CMS Physician Quality Reporting System (PQRS) Update As Ashley Booth-Norse has assumed FCEP President’s duties, I am pleased to Chair the Medical Economics Committee. My goal is to use this column to update members on the issues that impact the economic life of your groups. Often, these issues will overlap with Governmental Affairs, including PPACA, Medicaid reform (HMOs, possible expansion), PIP, ACOs, and payment reform. Hopefully the information will be of use to all FCEP members, whether focused clinically or in administrative roles, overseeing payor contracting, coding and billing, and compliance. Recently, CMS announced updates to their Physician Quality Reporting System (PQRS). This program began as an incentive program, initially providing a bonus for merely reporting metrics (regardless of success achieved with the measures). Highlights of the 2014 changes: • Reporting can be done by individual EPs, or by group practices. • Reporting options include Medicare Part B claims, Qualified PQRS registry, EHR (Certified EHRs, directly or via data submission vendors), qualified clinical data registries or CMS Certified survey vendors. • Measures reported vary year to year and by specialty. For EM, commonly reported measures include: o #28: ASA at arrival in AMI o #54: 12 lead ECG for nontraumatic chest pain o #55: ECG for syncope o #56: VS in Community Acquired Pneumonia (CAP) o #59: Empiric antibiotics in CAP o #254: Ultrasound determination of pregnancy location in pregnant patients with abdominal pain o #255: RhoGam for Rh- pregnant women at risk for fetal blood exposure o Note: #29 (B-blocker in AMI), #57 (O2 saturation in CAP), and #58 (Mental status in CAP) have been retired. • Payment incentives up to +0.5% of the total estimated Medicare Part B Professional Fee Schedule (PFS) for individual EPs satisfactorily submitting PQRS quality data. • EPs who do not satisfactorily report data on quality measures for 2014 will be subject to a 2% payment • • • • • • • “adjustment” (penalty) to their Medicare PFS for services provided in 2016. An additional -2% Value-Based Modifier (VBM) payment penalty may be added. Group practices can participate in the group practice reporting option (GPRO). Registration needed to be completed by Oct 3rd, 2014. In 2016, groups with 10 or more EPs submitting claims to Medicare under a single tax ID will be subject to the value modifier, based upon 2014 performance. If the GPRO is not chosen, at least 50% of the EPs must report individually, and CMS will calculate the group quality score to make the VBM and PQRS adjustments. Failure to participate will result in 2% PQRS and 2% VBM “adjustments” (ie, penalties), an impact of approximately $2500 per provider according to ACEP. Whether participating as an individual or as a group, ACEP has developed a PQRS registry reporting option, which is being provided to ACEP members at a discount. In addition to the PQRS and VBM adjustments discussed above, there is also a Maintenance of Certification (MOC) Program. Submitting PQRS data, along with activities associated with maintenance of Board Certification, can qualify EPs for an additional 0.5% bonus incentive. This requires registration with a CMS certified MOC Program entity, like ABEM. The 2014 deadline for registration is February 2015, but the MOC activities need to be completed in calendar year 2014. SUMMARY: Four Distinct PQRS Programs 1. Traditional PQRS Incentive 2. PQRS MOC Incentive 3. PQRS Penalties For Failure to Report 4. Value-Based Modifier (VBPM)* For Failure to Report PQRS* 2014 Performance Year (PY): +0.5% payment in 2015 +0.5% payment in 2015 -2.0% in 2016 -2.0% in 2016 Join The Nation’s Premier Emergency Practice Management Group HOT JOBS! Capital Regional - Tallahassee Aventura Hospital and Med Ctr (Aventura) 70K annual visits; Brand new EM residency program coming July 2016! Residency Program Director Opportunity Call Ody Pierre-Louis at 727-507-3621 University Hospital (Fort Lauderdale) 35K annual visits Call Lisa M. Chamerski at 727-507-250 Lehigh Regional (Fort Myers) 36K annual visits Call Sabrina Mesic at 727-507-2509 • 65,000 annual patient visits • 42-bed ED • Phys cvg: 41 hrs main + 12 hrs express + 10-20 hrs peds + 60 hrs PA/NP cvg • Independent contractor status Call Shawn Stampfli at 850-428-5819 West FL Hospital - Pensacola Lawnwood Regional (Fort Pierce) 60K annual visits, Level II Trauma Call Lisa M. Chamerski at 727-507-2508 NEW! Memorial Emergency Care Center - Atlantic (Jacksonville). Brand new full-service Emergency Center affiliated with Memorial Hospital Jacksonville, opened summer 2014! Estimated 10K visits in year one. Call Frances Miller at 727-507-2507 Lake City Medical Center (Lake City) 25K annual visits EM Medical Director Opportunity Call Frances Miller at 727-507-2507 Raulerson Hospital (Okeechobee) 27K annual visits Call Lisa M. Chamerski at 727-507-2508 • 54,000 annual patient visits • 40-bed ED (including FastTrack) • 5 psyc beds in locked unit • 41-52 hrs phys + 60 hrs PA/NP coverage • Employee status w/benefits Call Shawn Stampfli at 850-428-5819 Bayonet Point - Tampa Osceola Regional (Orlando) 84K annual visits Affiliated Freestanding ED - NEW! Hunter’s Creek ER Call Amelia Hemsath at 727-437-0823 Poinciana Hospital (Orlando) 35K annual visits Call Amelia Hemsath at 727-437-0823 Gulf Coast Med Center (Panama City) 60K annual visits Call Esther Aguilar at 727-507-3656 Fawcett Memorial Hospital (Port Charlotte) 25K annual visits Call Frances Miller at 727-507-2507 Fishermen’s Hospital (Marathon, FL) 9K annual visits Call Sabrina Mesic at 727-507-2509 • Level II Trauma Center, 36K visits/yr. • 22-bed ED and 6-bed Fast Track • 46 hrs phys + 24 hrs PA/NP coverage • Employee status w/benefits • Stellar subspecialty backup (Trauma surgeons and Anesthesia in-house 24/7) Call Frances Miller at 727-507-2507 Leesburg Regional Medical Center (Leesburg, FL) 45K annual visits Medical Director and Staff Opportunities Call 877-751-1157 Northside Hospital (Saint Petersburg) 31K annual visits Associate Director and Staff Call Esther Aguilar at 727-507-3656 Clearwater ER (Clearwater) Freestanding ED, a dept. of Largo Medical Center Call Esther Aguilar at 727-507-3656 Doctor’s Hospital (Sarasota) 23K annual visits Call Sabrina Mesic at 727-507-2509 FL Hospital Heartland System (Sebring) 3 campuses ranging from 11 to 25K annual visits Call Sabrina Mesic at 727-507-2507 or Derek Sawyer at 727-533-8715 Gadsden Memorial Campus (Tallahassee) Freestanding ED affiliated with Capital Regional 15K annual visits Shawn Stampfli at 850-428-5819 Bayfront Health (Tampa Bay) 2 campus system; 26K and 30K annual visits Call Lisa M. Chamerski at 727-507-2508 Brandon Regional (Tampa Bay) 106K annual visits Second campus in Plant City Estimated 15K visits in year one Call Esther Aguilar at 727-507-3656 Medical Center of Trinity (Tampa Bay) 50K annual visits Call Frances Miller at 727-507-2507 Oak Hill Hospital (Tampa Bay) 35K annual visits Call Frances Miller at 727-507-2507 NEW! Tampa Community Hospital (Tampa Bay) 18K annual visits Call Barbara Lay at 727-507-3608 West Palm Hospital (West Palm Beach) 28K annual visits Call Lisa M. Chamerski at 727-507-2508 Westside Med Ctr (Plantation) 45K annual visits Call Lisa M. Chamerski at 727-507-2508 The Villages Regional Hospital (The Villages, FL) 40K annual visits Staff Opportunities Call 877-751-1157 For more opportunities, visit www.EmCare.com or contact us directly at [email protected] 2014 GOVERNMENTaffairs fcep.com 7 Joel Stern, MD, FACEP FCEP SECRETARY/TREASURER GOVERNMENT AFFAIRS COMMITTEE CO-CHAIR The GA Committee met on August 7 in Boca Raton at Symposium by the Sea. Topics discussed were recent FMA actions, communication with Representative Pigman, access to care for Behavioral Health patients, planning for EM Days 2015, and issues regarding EMTALA. We also had a meeting of our PAC Committee. Items discussed were increasing member awareness of the PAC, strategies for facilitating donations, and listing which candidates FCEP will be endorsing through PAC in the upcoming elections. We are looking for participation on our GA Committee and PAC. Please contact the FCEP office if you would like to get involved. Currently we are delivering campaign checks to the candidates we are supporting in the November elections. We also encourage all members to set up meetings with your local representatives in the Florida Congress and Senate. Asking them if they would like to tour your local ED is a great way to make them aware of our issues on a personal level. Also, please make plans to attend EM Days in March. It is our annual advocacy event in Tallahassee, where we meet one on one with the legislators to educate them about what is important to us as Emergency Physicians in Florida. Remember, if we do not have a seat at the table, we may end up as someone’s lunch! Candidates Endorsed Through PAC State Senator General Election 2014 State Representative General Election 2014 District Candidate City District Candidate City 6 Thrasher, John (REP) *Incumbant St. Augustine, FL 1 Ingram, Clay (REP) *Incumbent Pensacola, FL 10 Simmons, David (REP) *Incumbent Altamonte Springs, FL 2 Hill, Mike (REP) *Incumbent Pensacola, FL 12 Thompson, Geraldine F. (DEM) *Incumbent Orlando, FL 3 Broxson, Doug (REP) *Incumbent Milton, FL 5 Drake, Brad (REP) Marianna, FL 14 Soto, Darren (DEM) *Incumbent Kissimmee, FL 6 Trumbull, Jay (REP) Panama City, FL 20 Latvala, Jack (REP) *Incumbent Clearwater, FL 8 Williams, Alan (DEM) *Incumbent Tallahassee, FL 22 Brandes, Jeff (REP) *Incumbent St. Petersburg, FL 10 Lake City, FL 24 Lee, Tom (REP) *Incumbent Brandon, FL Porter, Elizabeth Whiddon (REP) *Incumbent 32 Negron, Joe (REP) *Incumbent Palm City, FL 11 Adkins, Janet H. (REP) *Incumbent Fernandina Beach, FL 34 Bogdanoff, Ellyn (REP) Delray Beach, FL 12 Ray, Lake (REP) *Incumbent Jacksonville, FL 36 Braynon, II, Oscar (DEM) *Incumbent Miami Gardens, FL 15 Fant, Jay (REP) Jacksonville, FL 16 McBurney, Charles (REP) *Incumbent Jacksonville, FL 17 Renuart, Ronald “Doc” (REP) *Incumbent Ponte Vedra Beach, FL 18 Cummings, Travis (REP) *Incumbent Orange Park, FL 21 Perry, Warren “Keith” (REP) *Incumbent Gainesville, FL 25 Costello, Fred (REP) Daytona Beach, FL 8 Candidates Endorsed Through PAC (continued) 26 Taylor, Dwayne L. (DEM) *Incumbent Daytona Beach, FL 77 Eagle, Dane (REP) *Incumbent Cape Coral, FL 27 Santiago, David (REP) *Incumbent Deltona, FL 82 Magar, MaryLynn (REP) *Incumbent Hobe Sound, FL 28 Brodeur, Jason (REP) *Incumbent Sanford, FL 86 Pafford, Mark (DEM) *Incumbent West Palm Beach, FL 29 Plakon, Scott (REP) Longwood, FL 89 Hager, Bill (REP) *Incumbent Boca Raton, FL 39 Combee, Neil (REP) *Incumbent Auburndale, FL 92 Burton, Colleen (REP) Lakeland, FL Clarke-Reed, Gwyndolen “Gwyn” (DEM) *Incumbent Pompano Beach, FL 40 41 Wood, John (REP) *Incumbent Winter Haven, FL 93 Moraitis, George (REP) *Incumbent Fort Lauderdale, FL 46 Antone, Bruce (DEM) *Incumbent Orlando, FL 103 Diaz, Jr., Manny (REP) *Incumbent Hialeah, FL 47 Miller, Mike (REP) Orlando, FL 105 Trujillo, Carlos (REP) *Incumbent Doral, FL 51 Crisafulli, Steve (REP) *Incumbent Merritt Isalnd, FL 108 Miami Shores, FL 53 Tobia, John (REP) *Incumbent Melbourne, FL Campbell, Daphne (DEM) *Incumbent 54 Mayfield, Debbie (REP) *Incumbent Vero Beach, FL 110 Oliva, Jose (REP) *Incumbent Hialeah, FL 59 Spano, Ross (REP) *Incumbent Riverview, FL 112 Rodriguez, Jose Javier (DEM) *Incumbent Miami, FL 61 Narain, Edwin “Ed” (DEM) Tampa, FL 114 Fresen, Erik (REP) *Incumbent Miami, FL 66 Ahern, Larry (REP) *Incumbent Seminole, FL 115 Bileca, Michael (REP) *Incumbent Miami, FL 67 Latvala, Chris (REP) Clearwater, FL 116 Diaz, Jose Felix (REP) *Incumbent Miami, FL 68 Young, Bill (REP) St. Petersburg, FL 118 Artiles, Frank (REP) *Incumbent Miami, FL 69 Peters, Kathleen (REP) *Incumbent St. Petersburg, FL 119 Nunez, Jeanette M. (REP) *Incumbent Miami, FL 72 Pilon, Ray (REP) *Incumbent Sarasota, FL 74 Gonzalez, Julio (REP) Sarasota, FL 75 Roberson, Ken (REP) *Incumbent Port Charlotte, FL 76 Rodrigues, Ray (REP) *Incumbent Fort Myers, FL 26th Annual Advocacy all the way to the State Capital! Join FCEP at the state capital, meet legislators, and lobby for better access to quality care! March 9 - 11, 2015 Hotel Duval by Marriott Tallahassee, Florida Registration is FREE for FCEP members. Stay tuned to fcep.org for updates! 2014 DAUNTINGdiagnosis fcep.com Karen Estrine, DO, FACEP, FAAEM EDITOR IN CHIEF DAUNTING DIAGNOSIS Question: What does this picture show, and how could this have been prevented? (Answer on page 25) SAVE THE DATE 9 10 EMPULSEeditorial Michael R. Lowe Board Certified Health Law Lawyer Medical Malpractice Caps Overturned by Supreme Court - How Does This Impact You? Florida Supreme Court Overturns Caps on Wrongful Death Medical Malpractice Awards. In March, the Florida Supreme Court declared the statutory caps placed on non-economic damages in medical malpractice cases unconstitutional in cases involving wrongful death claims. The Court did so in McCall v. United States of America which was a federal tort case involving medical malpractice claims against the federal government and Air Force medical personnel. Significantly, the federal trial judge who heard the case awarded Ms. McCall’s surviving family members $2 million in non-economic damages, but reduced the award to $1 million based on Florida’s caps on non-economic damages. On appeal, the U.S. Eleventh Circuit Court of Appeals upheld the ruling finding that the caps did not violate the U.S. Constitution, but stating that the Florida Supreme Court should consider Florida constitutional issues. Thus, the Court did so and overturned caps on non-economic damages awards in wrongful death medical malpractice cases. The McCall decision may or may not be addressed in further litigation and/or by the Florida Legislature. Regardless, it is significant for physicians and health care providers and professionals of all types because of its possible impact on the medical malpractice and professional liability industry in Florida. One only need recall the medical malpractice insurance crisis which Florida experienced in the early to mid-2000s which caused many physicians to go bare due to skyrocketing premiums and a large number of insurance carriers leaving Florida and no longer offering medical malpractice or professional liability insurance policies. The decision is also significant as the Florida Supreme Court has not yet ruled on whether caps on non-economic damages are unconstitutional in medical malpractice cases that do not involve a wrongful death claim. There are still several cases making their way through litigation and the appellate process which could ultimately end up before the Court and result in a ruling either way. For physicians, hospitals, ambulatory surgical centers, and all other types of licenses health care professionals, facilities and providers, it is important to take note of the McCall decision and how it could impact them. Health care providers, facilities and professionals should review their professional liability and medical malpractice policies to determine if they have sufficient limits and coverage to address large claims and potential excess verdicts which might exceed their coverage limits as many current policies were designed, purchased and implemented after the statutory caps were put in place in 2003-2004 and before the McCall decision. Health care providers and professionals should also consider whether the McCall decisions impacts them if they have any currently pending medical malpractice professional liability cases involving wrongful death claims and/or potential excess verdicts. Furthermore, they should consider retaining personal counsel in cases involving wrongful death allegations or significantly large potential damages claims which could result in excess verdicts. Another recommendation would be for all licensed health care professionals, and in particular doctors and physicians, to review their employment contracts or independent contractor agreements with any employer, facility or health care provider to ensure that they have sufficient medical malpractice or professional liability insurance coverage, including tail coverage, addressed in their contracts if such coverage is provided by their employer or the entity with which the contract to provide professional medical or health care services. Finally, all licensed health care professionals and health care providers and businesses should review their liability and asset protection planning to account for the changes which may result from the McCall and the underlying decision and any future decisions on caps on noneconomic damages. Mr. Lowe and our law firm regularly represent physicians and other licensed health care professionals in the defense of medical malpractice cases, review of their medical malpractice professional liability insurance policies and coverages, and personal counsel matters as well as the review of employment contracts. To contact us regarding such matters please visit our website www.lowehealthlaw. com or call our office 407-332-6353. Michael R. Lowe, Esq. is a board-certified health law attorney and shareholder at Michael R. Lowe, P.A., 800-571-5208. 2014 EMPULSEfeature fcep.com 11 Rutledge M. Bradford Board Certified Civil Trial Lawyer Emergency Medicine Wins Ruling for PIP Thanks to Bradford Cederberg PA, emergency medicine has won two very significant rulings from the Circuit Court in Seminole County sitting in its appellate capacity. The appellate rulings are the first of their kind in the state of Florida. In affirming the trial court, the appellate court held that you cannot apply a provider of emergency services and care’s bill toward an elected deductible in a PIP matter. This is a monumental ruling in favor of Emergency Physicians whose bills are routinely applied toward patients’ deductibles in the PIP setting, despite a mandatory $5000.00 reserve for providers of emergency services and care for payment of these charges. Auto insurers have basically ignored Florida’s PIP laws promulgated for the benefit of Emergency Providers and have routinely ignored the mandatory $5000.00 reserve and applied ED physician invoices to PIP auto deductibles. Thousands of claims have been filed on behalf of ED physicians against auto insurance companies for the past several years and after initially settling the matter and paying the claim, carriers united and took a hard line stance on this issue against ED physicians, despite more than 20 rulings in a three county area in favor of ED physicians on this issue. Emergency Physicians must submit their bills within 30 days of a MVA (date insurer knew of the claim) to avoid having the deductible applied to their bill. If the Emergency Physician bills after that initial 30 day period, then the ED physician loses the protection of the statute and stands in line like all other providers. The PIP deductible in those instances can be applied toward their bill. These appellate decisions are being circulated around the state to others fighting on behalf of ED physicians in the PIP arena. SAVE THE DATE 12 EMS/TRAUMAupdate Christine Van Dillen, MD, FACEP COMMITTEE CO-CHAIR The Florida humidity is finally tapering off as the year moves into the fall and winter. For most emergency medical services personnel, this is an exciting time because they are able to participate comfortably in outdoor training. As snowbirds and tourists traveling south for the winter swell our population, emergency personnel remain prepared to respond to all calls. Ebola: Our Worst Fears This fatal virus is caused by infection with a virus of the family Filovirdae, genus Ebolavirus. The Ebola virus causes disease in humans and nonhuman primates. The first outbreak was identified in Zaire in central Africa in 1976, claiming the lives of 280 people. From 1976 through 2014, there were several Ebola outbreaks with death tolls ranging from 1-280 individuals. The current outbreak is a healthcare crisis: with 4400 fatalities already documented, a number expected to only continue to grow. The Ebola case recently identified in Dallas, Texas, brought into sharp focus the need to identify and contain the virus in the United States. Are we prepared? Fortunately, the CDC has extensive information and recommendations on how to prevent spread of this disease: http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/ index.html The symptoms of Ebola include: fever, muscle pain, weakness, diarrhea, vomiting, abdominal pain and unexplained bleeding. Unfortunately, this presentation mimics sepsis, influenza and other common diseases found in Africa such as typhoid fever and malaria, making clinical diagnosis difficult. It is important to recognize patients with these symptoms and question them about risk of residence or travel to the high-risk African regions of Guinea, Liberia, Nigeria, Sierra Leone, or contact with symptomatic individuals from these regions. If patients confirm exposure, they should be isolated immediately. It is critically important that proper personal protective equipment (PPE) be used in caring for these patients. If an infected patient is identified in the pre-hospital setting, a limited number of EMS personnel should be exposed and hospitals should be notified prior to arrival. The likelihood of contracting Ebola is extremely low unless there is direct, unprotected contact with bodily fluids of a sick individual (i.e., urine, saliva, feces, vomit, sweat, and semen). Human transmission is also possible through direct handling of bats or nonhuman primates from areas with Ebola outbreaks. Therefore, proper PPE and infection control techniques must be followed if there is concern that a patient is ill with Ebola or may have been exposed to the virus. If your community is at elevated risk for Ebola, questions about travel to high-risk areas need to be coordinated at the dispatch level. This strategy will help identify patients at risk and prepare EMS crews to enter high-risk homes with appropriate precautions. Florida Association of EMS Medical Directors (FAEMSMD) Report Our July 16th meeting started with an exciting election of new officers. They are as follows: • • • • President: Dave Meurer, MD Vice President: John Milanick MD Secretary-Treasurer: Chris Hunter MD Members at Large: Brooke Shepard MD and Christine Van Dillen MD Florida State Medical Director Report (provided by Dr. Joe Nelson): • At the State level, it was determined that the State EMRC was not meeting statutory requirements and so this group has been deactivated at this time. Some of their functions will be reallocated. • Both Adult and Pediatric Trauma Scorecard Methodology in rule development • Mandatory EMSTARS participation by EMS agencies remains in rule development • Dr. Nelson emphasized the importance of medical director involvement in local healthcare coalitions throughout the state • Spine board practices: FAEMSMD previously issued a position statement which coincides with the national trend towards selective spinal immobilization in the appropriate trauma patients. This practice across the state requires well written medical care protocols, along with diligent training and QA for success. • An EMS stroke destination best practices discussion took place. Should a primary stroke center be bypassed to take a patient to a comprehensive center? If so, is there an improvement in outcome? How far would this rule stretch? Due to the variety of regions across the state ranging from urban areas with multiple stroke centers within minutes of reach to rural areas where the closest stroke center requires transport for 1-2 hours, there is a great deal of controversy surrounding this issue. There was a suggestion that data from around the state may be helpful in this discussion. EMSC Update Dr. Lou Romig gave an update on EMSC activities, including a committee on hospital readiness that will help hospitals increase readiness to care for pediatric patients, and a focus on disaster readiness as it relates to children. Dr. Laurie Romig discussed the idea of creating a short survey to clarify the qualifications for pediatric medical direction. (CONTINUED ON PAGE 24) 2014 CODING TIP CRITICAL CARE SERVICES WITH PROCEDURES When you provide separately billable services with critical care, would you like to get paid for them? When documenting the critical care minutes, include this statement, “___ minutes spent engaged in work directly related to patient care and/or available for direct patient care, exclusive of procedure time.” Then document the appropriate procedure note. Procedures commonly provided with critical care are: • CPR – 92950 – work RVU 4.00 • Cricothyroidotomy – 31605 – work RVU 3.57 • CVP insertion – 36556 – work RVU 2.50 • Endotracheal intubation – 31500 – work RVU 2.33 • Pericardiocentesis – 33010 – work RVU 2.24 • Thoracostomy – 32551 – work RVU 3.29 • Tracheostomy – 31603 – work RVU 4.14 LYNN REEDY, CPC, CEDC, DIRECTOR OF CODING SERVICES, CIPROMS SOUTH MEDICAL BILLING “I can tell you without a moments hesitation the Icare is the only tonometer we will ever use. The Icare is easy to use, simpler to learn and operate than anything we have used before. There is no finesse or learning curve. We have used it on kids as well and they find it tickles and laugh during the experience! I have no problem endorsing this product at all, I believe in it.“ Attilla Kiss, MD Assistant Director of Emergency Department, St John Medical Center fcep.com 13 Do you have an event you would like to advertise? Contact Gina Fickett at [email protected] Don’t Don’t miss miss out out on on an an audience audience of of 1,500+ 1,500+ Get extensive exposure to Florida’s emergency physicians, residents, nurses, PAs and allied health professionals, Florida’s lawmakers, and through the FCEP website. Richard Homan [email protected] Toll Free: (800)428-1714 Cell: (813)505-3495 www.icare-usa.com 14 POISONcontrol Kristin Bohnenberger, PharmD Clinical Toxicology/ EM Fellow (2nd year) University of Florida Health Jacksonville, Jacksonville, Florida The nonmedical use of prescribed controlled substances has reached epidemic proportions in the United States, attracting national attention. In fact, illicit substance abuse cost the United States $11 billion in healthcare related costs in 2012.1 According to the results of the most recent National Survey on Drug Abuse and Health, 8.37% of Florida residents aged 12 years or older reported using illicit substances in the past month (compared to a national average of 9.4%).2,3 While the issue of substance abuse itself may come to you as no surprise, what you may find interesting are the novel ways abusers are utilizing pharmacokinetic principles to potentiate their highs. One such drug-drug interaction being used for this purpose is that of omeprazole and methadone. Omeprazole inhibits the proton pump in gastric parietal cells, blocking the secretion of gastric acid and thus increasing the pH of the stomach. In an alkaline environment, such as that created by omeprazole, methadone exists predominantly in the nonionized form. It is in this form that methadone is absorbed from the gastrointestinal tract and crosses the epithelium to exert its effects. Taking omeprazole prior to a dose of methadone, therefore, can theoretically increase the serum concentration of methadone. De Castro et al. evaluated the effect of pretreatment with omeprazole on serum methadone concentrations and respiratory depression in an They Want to Put What Behind the Counter?! animal model. A total of 40 rats were randomized to receive either intravenous omeprazole or saline 2 hours prior to receiving a dose of oral methadone. A correlation between serum methadone concentration and intragastric pH at 120 minutes following methadone administration was found to be statistically significant.4 The serum methadone concentration was noted to increase linearly with intragastric pH. A statistically significant decrease in the respiratory rate was observed in the omeprazole group at all time points beginning 30 minutes after methadone administration compared to placebo. Congruent with this finding, a decrease in arterial pH and pO2 and an increase in pCO2 was found to be statistically significant in the omeprazole pretreated group at 120 minutes.4 Secondary to this interaction, crafty street chemists have attempted to profit from the sale of commercially available omeprazole. Multiple news reports detailing the theft of omeprazole from pharmacies and other retail establishments surfaced as early as 2007. Increased media attention has led to discussion of placing overthe-counter omeprazole behind the pharmacy counter to prevent thefts. Not only are older drugs being misused to potentiate the highs of pharmaceutical agents, but substances newer to the United States, such as kratom, have also been utilized. Derived from plants of Mitragyna speciosa, kratom is a substance that has been used for centuries in southeastern Asia for its stimulant and opioid-like effects. Kong et al. found that alkaloids extracted from M. speciosa were strong inhibitors of CYP3A4 and CYP2D6 and moderate inhibitors of CYP1A2.5 Kratom therefore has the potential to potentiate the highs of fentanyl, methadone, benzodiazepines, zolpidem, zaleplon, trazodone, hydrocodone, oxycodone, dextromethorphan, and cyclobenzaprine. Lest we forget about food-drug interactions that also utilize enzymatic interactions to potentiate highs, online drug forums are rich with accounts of eating mangos prior to smoking marijuana or drinking grapefruit juice prior to taking tramadol. Both mangos and grapefruit juice inhibit CYP450 isoenzymes. Mangos inhibit the metabolism of the benzodiazepines and chlorzoxazone via inhibition of CYP1A1, CYP1A2, CYP3A1, CYP2C6, and CYP2E1.6 Grapefruit inhibits CYP3A4 and CYP1A2, thus having the potential to prolong the high of marijuana, fentanyl, alfentanyl, methadone, benzodiazepines, zolpidem, zaleplon, tramadol and trazodone. 6 Unfortunately, the time when prescribing a medication as seemingly harmless as a proton pump inhibitor without fear of its misuse and contribution to the prescription drug abuse epidemic may be no more. The utilization of crafty chemistry to potentiate the euphoric and/or psychotropic effects of prescription medications is something emergency physicians should consider. If you have any questions regarding medication toxicities, please contact your local poison center toll-free at 1-800-2221222. (CONTINUED ON PAGE 24) 2014 MEMBERSHIP & PROFESSIONALdevelopment fcep.com 15 René Mack, MD COMMITTEE CO-CHAIR Are You Certified? There have been several changes to the American Board of Emergency Medicine (ABEM) Maintenance of Certification (MOC) over the past years with the last major changes published in 2011. Although it has been three years, there are still many of us who are still unsure of the new requirements and how they affect our license and our ability to practice emergency medicine. To assist with understanding and simplifying the new requirements, ACEP and FCEP have created and implemented many timesaving and easily accessible programs. The ABEM MOC consists of essentially four sections: Part 1: Professional Standing – We must continuously maintain medical licensure in compliance with the ABEM Policy on Medical Licensure and individual state requirements. ACEP and FCEP provide easily accessible information on general and Florida-specific requirements for medical licensure and CME requirements. ACEP offers a myriad of CME AMA PRA Category 1 Credits™ online and via multiple live conferences. ACEP also offers a CME tracker so you’ll always know your status. FCEP offers a FREE annual CME conference where, on average, you can obtain 12 AMA PRA Category 1 credits™! Part 2: Lifelong Learning Self Assessment (LLSA) – ACEP membership grants you access to the very useful LLSA Resource Center which gives you access to EM: Prep, LLSA summaries and much more! At the FCEP Symposium by the Sea (SBS), the FREE annual CME conference, you have the opportunity to take one or several years of LLSA tests while concurrently earning AMA PRA Category 1 Credits™. Part 3: Assessment of Cognitive Expertise – This section covers the ConCert exam on which a passing score is required. For most of us this exam evokes strong emotions from hours spent studying and maybe even worrying about whether your studying will result in a passing score. Let ACEP and FCEP take some of the stress out of this part of your re-certification! ACEP offers PEER VIII, the comprehensive, well vetted study resource that is offered on multiple platforms including: print, iPhone, iPad and online. FCEP, earlier this year, offered a live multiday review course which provided upto-date information on the pertinent emergency medicine topics covered on the ConCert exam. Part 4: Assessment of Practice Performance (APP) – This applies to those who are clinically active; if you are not clinically active you do not need to participate in Part 4. The APP serves to evaluate your level of involvement on a national, regional, or local level regarding improving patient care practice improvement (PI) and patient centered communication/professionalism (CP) improvement plan that meets the ABEM’s APP requirements. ACEP offers many articles and lectures focused on completing this required step of the re-certification process. FCEP can also provide guidance on several areas of patient-centered improvement topics. FCEP also produces several workshops that can be used to help you develop your own improvement plans. The MOC requirements are divided in two five year increments (re- certification occurs on a ten year cycle). They are distinguished by years 1-5 and years 6-10. In each five year time period you must: • Pass four ABEM LLSA tests, one of which must be the patient safety LLSA • Complete (and attest to completion of ) an annual average of 25 AMA PRA Category 1 Credits™ or equivalent. Eight of those credits must be selfassessment, only required in years 1-5. • Complete and attest to completion of an Assessment of Practice Performance (APP) Patient Care Practice Improvement (PI) activity • Complete and attest to completion of an APP patient-centered Communication/Professionalism (CP) activity. **Also, in years 6-10, you must pass the ABEM continuous certification (ConCert) examination. Hopefully, this primer will provide some clarity on your requirements for continued licensure and remind you of the many resources available to you as a member of ACEP and FCEP. https://www.abem.org/public/abemmaintenance-of-certification-(moc)/ moc-overview http://www.abem.org/public/docs/ default-source/publication-documents/ moc-policies-and-procedures---2014. pdf?Status=Temp&sfvrsn=4 http://www.acep.org/ContinuingEducation-top-banner/Assessment-ofPractice-Performance/ FCEP_Life_After_Residency_Final.pdf 1 9/10/14 12:06 PM Service and Sol Top Rated Carrie C Competitive Prici M Y Comprehensive P CM Occurrence and C MY CY Service and Solutions CMY K P R O F E S S I O N A L L I A B I L I T Ycoverage A G E N C Yoptions / PLA BROKERAGE SERVICES Experienced Staf Top Rated Carriers Competitive Pricing Comprehensive Programs Occurrence and Claims-made coverage options Experienced Staff Active in Pennsylvania, New Jersey, New York, Florida; as well as Maryland, Delaware and West Virginia. Active in Pennsylv New Jersey, New 2213 Forest Hills DriveFlorida; as well a Delaware and W Suite 4 Harrisburg, PA 17112 (717) 526-8420 Phone (800) 375-3056 Toll Free (717) 526-8422 Faxwww.plagency.com Email us: [email protected] 800-375- www.plagen Proud member of: 2014 ITLSreport ITLS Florida Chapter Report fcep.com 17 Melissa McNally, MMSc, PA-C, EMT-P Affiliate Faculty/Regional 6 Coordinator, ITLS Florida President, Central Florida Emergency Education Consultants This past quarter, ITLS Florida had the unique opportunity to bring back the ITLS Access Course to the State of Florida. The ITLS Access Course teaches critical skills that are essential for EMS crews and first responders who are caring for individuals who were involved in a motor vehicle collision. This 8 hour course trains responders to use simple hand tools instead of hydraulics in order to reach, stabilize, and extricate trapped victims, while also giving special focus to the care of the patient. It is a great opportunity for both large and small departments, as well as rural training agencies and initial training programs to receive training in vehicle and patient extrication, especially during a time when funding is tight and the ability to purchase expensive hydraulic tools may not be feasible. The first course was a Provider-Instructor Hybrid. It was open to a small focus group of seasoned ITLS Instructors. lutions ROFESSIONAL LIABILI TY AGENCY/ The course was offered byPCentral Florida Emergency Education Consultants, a Central Florida Bureau of EMS ConPLA BROKERAGE SERVICES tinuing Education Company located in Davenport, Florida. We had the pleasure of having Vern Smith, EMT-P, lead this course. Vern Smith, a contributing author to the ITLS Access Course Textbook hails from Pittsburgh, Pennsylers vania and through a desire to promote ITLS Access, traveled to Florida to provide the hybrid course for this group. It is my hope that the ITLS Access Course’s popularity will continue to grow and will lay the foundation for addi of Florida. ,QVXUDQFH6ROXWLRQV ing tional trauma training in the State 2213 Forest Hills Drive IRUWKH+HDOWKFDUH&RPPXQLW\ Suite 4 Programs Harrisburg, PA 17112 (717) 526-8420 Phone Claims-made (800) 375-3056 Toll Free s (717) 526-8422 Faxwww.plagency.com ff Email us: vania, [email protected] w York, ,QVXUDQFH6ROXWLRQV as Maryland, IRUWKH+HDOWKFDUH&RPPXQLW\ West Virginia. -3056 ncy.com Proud member of: 800-375-3056 www.plagency.com 18 EMPULSEfeature Roxanne Sams, MSN, ARNP-BC, MA , Director Navigant Consulting FEMF VICE PRESIDENT Lisa M. Bragg, RN, BSN, MBA, Director Navigant Consulting Better ER Management Requires Partnership Between Physicians and Clinical Care Coordinators Growing regulatory and economic pressures, along with a dramatic increase in utilization, are putting hospital emergency departments in the middle of a difficult balancing act: the need to appropriately allocate costly resources, while providing timely medical care to meet patients’ needs. The many challenges in today’s everchanging healthcare environment mean these concerns are only expected to worsen over the next decade. A RAND Corporation study points out that the rate of emergency department utilization has grown twice as fast as the U.S. population, with demand outpacing supply. A key driver for this trend is the lack of access to primary care providers. The aging baby boomer population, along with the expansion of Medicaid services and the rollout of the Affordable Health Care Act are only expected to add to the problem. What can hospital emergency departments do to ensure that the right patients receive the right service, at the right time, and in the right setting? The solution is a strong, collegial partnership between emergency department physicians and the newly evolving role of the ED care coordination team. Coordination of care, with a focus on developing a safe and effective discharge care management plan, has long been part of the acute care hospital setting, but now it is also a vital step for successful emergency department management, especially in a cost- and resource-conscious healthcare climate. There are numerous reasons why it is advantageous for emergency department physicians and care coordinators to work together in a dynamic, proactive process that manages costs while improving patient outcomes. Several national studies show that for each dollar invested in case management, there was an equal or greater reduction in healthcare costs. But patients also benefitted significantly from a integrated delivery model that addressed both their medical and social issues. As members of the ED care coordination team, a registered nurse care coordinator and social work care coordinator are uniquely qualified to intervene quickly to explore and expedite discharge planning decisions that take into consideration the patient’s clinical, financial, social and psychological needs. This is especially important for target vulnerable populations, such as the frail elderly, the homeless, the indigent, and people with complex psychosocial problems, including alcohol or drug abuse and mental health issues. Many of these patients also have chronic medical conditions that are poorly managed due to the episodic care they receive. Care coordinators are in the best position to evaluate available community resources and to link atrisk patients with services, which may range from housing, home health care and elder care to ongoing primary medical care, as an alternative to the emergency department. The goal is to meet patients’ needs, while reducing frequent and costly non-urgent return visits to the emergency department. Accomplishing this goal will also go a long way toward addressing concerns about ED overcrowding, extended wait times and patient dissatisfaction. At the same time, effective care coordination in the ED can potentially reduce hospital readmissions. The Center for Medicare and Medicaid Services Readmission Reduction Program now penalizes hospitals up to 3 percent for readmissions that occur within 30 days of discharge from the same or another hospital. In order to be most effective, case coordinators should be readily available in the emergency department at least 16 hours a day, seven days a week. High-volume emergency departments should consider 24-hour coverage. In addition, the case coordinator must be in a convenient location within the ED in order to have frequent interaction with the physician – and to have solid input into all discharge planning decisions, whether the patient is admitted to the hospital or to a network of community services. The escalating demands being placed on hospital emergency departments can best be met by placing greater emphasis on discharge planning and coordination of care. A positive collaboration between emergency department physicians and care coordinators is a step in the right direction. 2014 FENAupdate fcep.com 19 Katrin Breault BSN, RN, CEN Darleen Williams MSN, CNS, CEN, CCNS, CNS-BC, EMT-P NURSING SPECIALTY CERTIFICATIONS BENEFIT RN SPECIALTY CERTIFICATION MEETS NURSING LICENSURE RENEWAL REQUIREMENTS IN FLORIDA The Florida Emergency Nurses Association (FENA) encourages Emergency Nurses to obtain specialty certification in Emergency Nursing. Achieving certification in a nursing specialty demonstrates commitment to patients, one’s profession and professional growth. Regardless of one’s nursing specialty - emergency, orthopedics, critical care, hospice, medical surgical, operating room or many of the other RN specialties - nursing certification may now count for continuing education requirements for licensure renewal in the State of Florida. Why allow nurses to renew their nursing license using RN specialty certifications? Nursing is a dynamic profession faced with a rapidly changing healthcare environment. The advancements in medical knowledge, technology and regulatory requirements are staggering. Certified nurses meet these professional challenges head-on every day with their continued commitment to meeting certification requirements. According to the ABNS, “Certification is the formal recognition of the specialized knowledge, skills, and As of July 1, 2014, Florida Senate Bill 1036 became experience demonstrated by the achievement of law. The Florida Board of Nursing now recognizes standards identified by a nursing specialty to promote that Registered Nurses, Licensed Practical Nurses, optimal health outcomes.” Specialty certifications Clinical Nurse Specialists and Nurse Practioners can provide for advancement opportunities in nursing who have achieved a nursing specialty certification and in some cases may be required for employment. may use this certification in lieu of the 24 continuing education hours and topic requirements to renew The Board of Certification for Emergency Nurses their Florida nursing license. offers four certifications in the field of emergency nursing: Certified Emergency Nurse (CEN), Certified Nursing specialty certifications must be accredited Flight Registered Nurse (CFRN), Certified Pediatric by either the National Commission for Certifying Emergency Nurse (CPEN), and Certified Transport Agencies (NCCA) or the American Board of Nursing Registered Nurse (CTRN). For more information Specialty Certification (ABNSC). Nurses holding a related to Emergency Nursing certifications please certification need only to show proof to the Florida see the Board of Certification for Emergency Nurses Board of Nursing at time of their license renewal and (BCEN®) website at www.BCENcertifications.org. pay the required fee. The BCEN is also working with nurses across the country advocating for State Boards of Nursing and “Nurses must still meet CE requirements of your employers to recognize specialty nursing certification certifying body. You are responsible for reporting as a way to satisfy ongoing continuing education current certifications during each renewal cycle to requirements. FENA offers scholarships to members CE Broker to meet eligibility for the exemption. To to use towards certifications. report your certification please create an account in CE Broker or login to your existing account at CEBroker.com.” CE Broker. 20 MEDICAL STUDENTupdate Tushar Gupta, MSIV University of Florida College of Medicine FCEP MEDICAL STUDENT COMMITTEE SECRETARY Symposium by the Sea A Model for the Modern Medical Student The sun shone brightly over Boca Raton, FL earlier this year as students, residents, physicians, families and leading figures in Emergency Medicine flocked to the Boca Raton Resort and Club for the annual Symposium by the Sea from August 7-10, 2014. This conference, the premier event hosted by the Florida College of Emergency Physicians (FCEP), enabled current and future health care professionals to rub shoulders and delve into – apart from the inviting ocean - everything that is Emergency Medicine. Including but not limited to the sandy beaches and pristine fairways of the adjacent golf course, this meeting had something to offer for everyone! Health policy concerning the future of emergency medicine along with best practice guidelines and cutting-edge research highlighted the 3-day symposium. Apart from these topics, the conference showcased some of the brightest medical students and residents from the Sunshine State. Students representing the various medical schools around the state had the opportunity to share their research endeavors at the poster presentation sessions while also partaking in the Medical Student Forum. Coordinated by Dr. Robyn Hoelle and in conjunction with the FCEP Medical Student Committee (MSC), approximately 25 aspiring students had the invaluable experience of picking the brains of residency program leaders over lunch. Program directors, faculty, and residents representing their respective residency programs fielded questions regarding a career in EM. Among the allopathic and osteopathic programs, Florida Hospital, Mount Sinai, Orlando Regional Medical Center, UF Health Gainesville, and UF Health Jacksonville were represented. The candid and welcoming environment enabled students to gain a deeper understanding of the profession while networking with leaders in the field. student group dedicated to EM into reality. They have paved the way and provided a model of excellence for incoming President Adam Gray (MSIV UF) and SecretaryEditor Tushar Gupta (MSIV UF). Medical students then had the chance to learn from their future counterparts, as residents from training programs around the state competed in the annual Case Presentation Competition (CPC) and the everpopular SimWars competition. With respect to SimWars, the event served as a culmination of residency training and a measure of the milestones of a resident. The competition highlighted the attributes needed to make a great emergency physician as it emphasized communication and placed individuals in a high-stress environment where their clinical decision-making was placed under a microscope by the judges– similar to how an emergency physician may be viewed by peers and the rest of the hospital out in the workplace. Above all, the competition showcased the art of Emergency Medicine beyond the ABC’s, as teams had to work together and relay information among the patient, family, and medical team while preserving patient safety and quality. These events provided medical students with a great model for the successful emergency physician and fostered the desire to pursue a career in EM. For the modern medical student aspiring to become an emergency physician, the weekend provided a blueprint for success and gave a glimpse into the life of a physician, both in and out of the ER. Symposium by the Sea was a fun yet intellectually stimulating event that not only fostered interest in EM for students but also reinforced current residents’ and physicians’ passion for their profession. As they walked away from the beaches of Boca Raton, participants of the Symposium left with sand in their shoes and invaluable knowledge regarding New leadership within the FCEP MSC was introduced at the practice of Emergency medicine along with new the luncheon, which will be responsible for advocating friendships and fond memories. Not surprisingly, for medical students for the upcoming year. The MSC members of FCEP can be heard echoing the sentiments thanks outgoing President Brittany Beel (MSIII UF) and of their children walking hand in hand with their parents Secretary-Editor Kyle Dalton (MSIV UF) for their hard asking “When are we coming back!?” work this past year in transforming the vision for a 2014 EDITORIALfeature fcep.com 21 Kevin Fritz Communications Consultant for FCEP and FEMF Representative Pigman Addresses EM Residents on Advocacy; Touts Simulation Training Florida House Representative Cary Pigman, an emergency medicine physician in Avon Park, treated EM residents preparing for post-residency life to a special presentation October 1st at the Embassy Suites Orlando. Addressing the importance of advocacy in the field of emergency medicine at the annual “Life After Residency” workshop presented by the Florida College of Emergency Physicians, Pigman noted that at least one person in the room packed with residents would one day run for office. room care issues. “The business community wants to save money. Emergency physicians see how that can be done. The challenge is to keep the purity and the vision and not get sidetracked.” Pigman also touted the world-class training and education being offered via the Emergency Medicine Learning & Resource Center (EMLRC) and its use of simulation. The Florida College of Emergency Physicians and its sister organization, the Florida Emergency Medicine Foundation, are scheduled to move into a “And that someone needs all our help,” he said, noting new, modern EMLRC by year end, providing additional the time, energy and money it takes to run for office space for simulation education, training and meetings. that prompts a large pay cut in exchange for effecting positive change. “You see everything in medicine,” he To assist first responders, EMLRC makes significant use of human patient high-fidelity simulators. Pigman strongly said. “You see what’s bad and believes in the importance of what’s good.” simulation training to better The annual program, designed prepare for disasters. “Everyone to prepare residents for their expects us to react at a high skill career in emergency medicine, level to any catastrophic event,” was co-hosted by the Florida he said. “It’s at the core of what Hospital and Orlando Health we do.” residency programs. This spring, Pigman and Grimsley A former emergency room co-sponsored SB/HB 1036 on nursing supervisor and currently nursing education to allow, employed by Highlands Regional among other things, lifting the Medical Center in Sebring, cap for the amount of simulation the now State Senator Denise training allowed in clinical Grimsley groomed Pigman for a education from 25 to 50 percent. political career. When her term “There is a growing acceptance limit was reached, he ran and of simulation training for all House Representative Cary Pigman won her seat in the Florida House. medical emergency clinicians in Pigman said that emergency room professionals have hospitals,” said Pigman. the schedules necessary to run for office, like realtors A journalist, copywriter, and ghostwriter, Kevin Fritz has and attorneys. “I knew all along I was going to run,” he been writing professionally for 30 years. President of Fritz said. “We see the pitfalls in the system, such as being a Communications since 2007, Kevin is a marketing consultant for charity provider for the uninsured. We need to fight for FCEP and FEMF. He is the author of the fiction novel Crossover patient advocacy.” and publisher of The Hestia Report. He received his BS in Pigman noted that emergency room professionals can make a difference by presenting solutions to emergency Journalism from Ohio University and can be reached at kevin@ fritzcomm.com. 22 RESIDENT CASE PRESENTATION Bryant Lambe, MD PGY2 at University of Florida College of Medicine Jacksonville Splenic Rupture Case Presentation A 68 year old African American male presented to our county emergency department with the complaint of left sided flank pain that had begun earlier in the day. He was well appearing at arrival and triaged into the fast track portion of our department. The pain had started around 9AM without any inciting factor, no trauma, no coughing or other heavy movement. It wrapped around his left flank and down into his left inguinal region. It had been going on for almost 12 hours, coming in intermittent sharp, stabbing waves of 10/10 pain before receding spontaneously to almost gone. The pain did not seem to be incited by any specific movement, and when it came on no position of movement would relieve it, though he favored leaning over to his left while the pain was present. There was no associated dysuria or hematuria, and he had no prior history of kidney stone or renal issues. He denied any other associated symptoms, including no chest/back pain, no sob, no fevers, chills, nausea, or vomiting, and no neurologic deficits. His PMH was significant only for asthma and HTN, but he was taking no medications. He had never undergone surgery. His social history included six beers per day alcohol intake, as well as two packs of cigarettes. He denied other prescription medication or illicit drug use. Vitals on arrival included temperature 97.3, blood pressure 99/74, pulse 98, respirations 18, O2 sat of 100% on room air. On physical exam, he generally appeared uncomfortable, sitting up in bed leaned over to his left side. He was mildly tachycardic in the 90s but with regular rhythm, no abnormal sounds. Abdominal palpation revealed mild tenderness diffusely, worse in the left flank and inguinal regions. Despite the tenderness he had no guarding and no rebound. His rectal exam revealed guaiac negative brown stool. Initially concerned for renal colic, a non-contrast CT scan of the abdomen and pelvis was performed revealing free fluid in the peritoneal cavity appearing to be ascites, so further workup was started with spontaneous bacterial peritonitis now higher on the differential. CBC revealed an elevated WBC of 13, hgb/hct 8.7/25 (no known baseline), normal platelets. BMP revealed Na 132, K 5.0, Cl 96, HCO3 14, BUN 13, creatinine 2.3, glucose 253. LFTs were normal, INR 1.2, Lactate 6.9. At this point his abdomen became more tender with increased guarding, and with no suitable window for paracentesis found, a dose of Rocephin was given and surgery was consulted to evaluate. The surgeon’s impression at this time was likely SBP as well, did not feel surgical intervention was required, recommended admission to primary team for continued antibiotics and further management. While in the ED awaiting admission, the patient’s condition progressed with his mental status declining, blood pressure decreasing, and the abdomen becoming rigid. Surgery was re-consulted and an over read of the CT scan revealed likely splenic bleeding, though difficult to assess secondary to no contrast. He was taken immediately to the OR for emergency surgery for intra-abdominal bleeding. Discussion Atraumatic Splenic Rupture is a condition first described by English surgeon Atkinson in 1874. Since that time, only sporadic case reports have been presented on this very rare event. In 1958 a set of criterion was established for diagnosis of true spontaneous splenic rupture including that first there be no trauma or unusual effort, second no evidence of complimentary organ dysfunction that could prompt it, third no perisplenic adhesions or scarring present, and fourth that the spleen should be normal on gross and histologic exam after splenectomy. Known medical causes of atraumatic rupture are generally separated into five categories as described in Table 1 below. 2014 RESIDENT CASE PRESENTATIONcontinued fcep.com 23 Once a splenic laceration is diagnosed, it is graded I through V based on the extent, see table 2 below. Based on this grading, the stability of the patient, and the surgeon’s preference, intervention is decided. Conservatively the patient can be admitted for close observation, best for low grade lacerations in a stable healthy patient. The advantage of this approach is that it spares the patient an abdominal surgery and the unwanted sequelae, and also allows them the immune benefits of keeping their spleen. The disadvantage is that many splenic lacerations do progress and this may occur up to 14 days or even further past the initial laceration, and it is impractical to observe a patient for this long a time. A second option growing in popularity is to embolize the bleeding portion of the spleen; suitable candidates are stable patients and fluid responsive otherwise healthy patients. This option keeps the benefits of non-intervention, but is complicated by a very high re-occurrence rate secondary to the spleen’s complex blood supply. Finally, for unstable patients or those deemed otherwise unfit for nonoperative management, surgery is undertaken. A rarely performed older procedure called splenorrhaphy used mesh netting wrapped around the spleen to provide compression to prevent further bleeding and rupture. This technique was fraught with failure, high adverse event rates, and development of aneurysms, and for these reasons most surgeons today opt for splenectomy. Removal of the spleen is generally curative in terms of future bleeding/rupture, but comes with a 3% risk of sepsis secondary to decreased immune function. This risk is generally thought to be lower than the associated risks of splenorrhaphy, contributing to splenectomy being the preferred procedure. Follow up In the OR the patient was found to have complete splenic rupture with extensive bleeding into the peritoneum. He underwent splenectomy and emergent blood transfusion, and was transferred out to the SICU in stable condition. The course was later complicated by abdominal abscesses and repeat exploratory laparotomies, as well as difficulty weaning off ventilation requiring tracheostomy placement, however did progress through his hospital stay to discharge to a skilled nursing facility with coherent mental status. His spleen appeared normal on gross and histologic exam post operation, and lab studies revealed no concurrent liver disease, hepatitis, viral infection, hematologic disorder, or other contributing factors. Although many etiologies remain not ruled-out, the ongoing working diagnosis is spontaneous splenic rupture. Table 1 – List of causes of atraumatic splenic rupture Hematologic Including hemophelia, congenital afibrogenemia, factor VIII deficiency, protein S deficiency, ITP, hemolytic anemia, polycythemia vera, leukemia, lymphoma, myelofibrodid, and multiple myeloma Metabolic Including amyloidosis, Wilson’s disease, Gaucher’s disease, and Niemann-Pick Iatrogenic Including shockwave lithotripsy and operative intervention Infective Including bacterial, viral, protozoal, syphilis, hydatid, typhus, leptospirosis, Q fever, and candidiasis Others Including medications (heparin,warfarin, tPAs, GCSF, ticlopidine, dicumarol to name just a few), inherent splenic disease (cysts, peliosis, angiomatosis, vein thrombosis, cancer), and miscellaneous other causes such as vomiting, uremia, pancreatitis, endocarditis, pregnancy, lupus, PAN, Wegeners, Ehler-Danlos, pheochromocytoma, sarcoidosis, and the list goes on Table 2 – Splenic injury grading system (from the American Association for the Surgery of Trauma) Grade I Grade II Grade III Grade IV Grade V Small, subcapsular hematoma covering < 10% surface area, with capsular laceration < 1cm in depth Moderate subcapsular hematoma 10-50% surface area, intraparenchymal hematoma < 5cm in diameter, laceration 1-3cm in depth and not involving trabecular vessels Large subcapsular hematoma > 50% surface area or actively expanding, intraparenchymal hematoma >5cm or actively expanding, laceration >3cm in depth or involving trabecular vessels, or a ruptured subcapsular or parenchymal hematoma Laceration involving segmental or hilar vessels with devascularization of >25% of spleen Ruptured/shattered spleen, or a hilar vascular injury with complete devascularization 24 ARTICLEScontinued (EMS/TRAUMA UPDATE CONTINUED FROM PAGE 12) (POISON CONTROL CONTINUED FROM PAGE 14) Cardiac Arrest Survey Feedback Results from the Medical Director Cardiac Arrest Survey were presented. Due to the low participation, it was concluded the data was of limited use. FAEMSMD suggested the creation of a cardiac arrest workgroup to identify the state of out-of-hospital cardiac arrest (OHCA) resuscitation in Florida and identify best practices. This group has already identified four main questions regarding OHCA resuscitation protocols and is performing an evidence-based review which will be presented to FAEMSMD at a later date. The group also initiated discussions with the EMSTARS data group to identify current practices with cardiac arrest patients. References: 1. Trends & Statistics. [Internet] Bethesda (MD): National Institute on Drug Abuse. [updated Dec 2012; cited on 3 Sept 2014]. Available from: http://www.drugabuse.gov/ related-topics/trends-statistics. 2. Substance Abuse and Mental Health Services Administration, State Estimates of Substance Use from the 2010-2012 National Survey on Drug Use and Health. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. 3. Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48; HHS Publication No. (SMA) 144863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. 4. De Castro et al. The effect of changes in gastric pH induced by omeprazole on the absorption and respiratory depression of methadone. Biopharm Drug Dispos 1996;17:551-63. 5. Kong et al. Evaluation of the effects of Mitragyna speciosa alkaloid extract on cytochrome P450 enzymes using a high throughput assay. Molecules. 2011;16(9):7344-56. 6. Rodriguez-Fragoso et al. Potential risks resulting from fruit/vegetable-drug interactions: effects on drugmetabolizing enzymes and drug transporters. J Food Sci 2001;76(4):R112-24. State Medical Director’s Position At our last FCEP meeting, the EMS/Trauma Committee discussed the importance of having a state medical director. This committee would like to present our position on this topic to the State to ensure that the position becomes codified. There is already a joint position statement from ACEP, NAEMSP and NASEMSO which states, “The state EMS medical director provides specialized medical oversight in the development and administration of the EMS system and is an essential liaison with local EMS agencies, hospitals, state and national professional organizations, and state and federal partners. The state EMS medical director provides essential medical leadership, system oversight, coordination of guideline development for routine and disaster care, identification and implementation of best practices, system quality improvement, and research. The state EMS medical director is essential to the comprehensive EMS system at the local level by promoting integration of direct and indirect medical oversight for the entire emergency health care delivery system.” This topic was added to the agenda of the FAEMSMD meeting on October 23, 2014 in Orlando at the Orange County Medical Examiner’s Office. Emergency Medicine Learning and Resource Center (EMLRC) update EMLRC is in the process of building a new home which will allow more opportunities for emergency medicine and EMS education. The next EMS/Trauma FCEP meeting is scheduled for November 12th, 2014. 2014 DAUNTING DIAGNOSISanswer fcep.com 25 DAUNTING DIAGNOSIS Patient encounter: ANSWER This patient was status-post neurosurgery for a chordoma Question on page 9 resection within the clivus. The chordoma was resected leaving his clivus resected as well. Post-op, the normal procedure is to place a NG (nasogastric) tube. However, as this case shows, there is a serious danger in placing a NG tube once you no longer have the bony protection of the clivus. Therefore, neurosurgeons specifically use OG (orogastric) tubes in this type of case. Clearly unaware of this, the physician handling the case above, inserted a NG tube into the patient. It immediately resulted in complete paralysis for the patient. CT finding: This CT of the region was preformed immediately after the incident. The CT shows the NG tube entering the CNS at the level of the cervicomedullary junction, and was continuously pushed further inferiorly through the central canal of the spinal cord. Contraindications to NG tube use: The use of nasogastric insertion is contraindicated in patients who have skull base fractures, certain neurosurgical cases, severe ENT related emergencies such as facial fractures especially to the nose and obstructed esophagus, esophageal varices, and/or obstructed airway as well as clotting disorders. 26 RESIDENCYmatters Here in Tampa, the emergency department at TGH is making strides with respect to efficiency, patient satisfaction, and educational experiences. Now that our interns have a bit more grit under their nails, the “X-rays of the wrong knee” and “add-on CBC’s” have been steadily down-trending (much to the relief of our nursing staff ). Although we are all making gains in patients per hour, you can only be as fast as your slowest test, which time and time again, has proven to be the black hole of the CT. The Board at Tampa General has recently approved the construction of a second ED Scanner. Set to unveil in the next month this newest addition to the department will increase “Door to Dispo” times exponentially. Our community of EM physicians is like any other with a definitive work hard, play hard mentality. This was proven by our annual team building/welcoming party for our new class where we embarked on a 4 mile kayaking adventure through the scenic canals flanking Tampa Bay. In true USF fashion, the day would not University of South Florida have been complete without the obligatory mid-afternoon thunderstorm. Although exciting to behold, the blackened sky provided us with a certain amount of “Get the Lead Out” motivation from which some of our Robert Grammatico, MD residents set record times at the preserve. A new development we are excited for is that Drs. Semmons and Zachariah have pioneered a deal between the emergency department and the Tampa Bay Lightening! Tampa General’s EM docs will be sitting “Ice Side” during Lightening home games and attend to any medical emergencies that should befall the players of either squad. Our physicians will be responsible for watching over the pregame warm ups and all three periods while our Rolling-Thunder battle it out in an effort to once again hoist The Cup. I wish you all well and am looking forward to meeting you at ACEP ‘14. See you in Chicago! Fall Greetings from Florida Hospital! We have enjoyed a great start to the academic year. We welcomed a fabulous intern class who has quickly made their mark as a smart, hard working and dedicated addition to the crew! Shortly after our interns arrived, Andy Colburn (PGY3), Doug Haus (PGY3), Alex Drake (PGY1) and I participated in the Symposium by the Sea festivities. The pressure was intense and the competition was fierce! We were very proud to take home 2nd place honors in Sim Wars amidst such an impressive cast. Doug Haus and I also participated in the case presentation competition. We were thrilled to combine efforts to take home “Best Overall Presentation” and 2nd place honors in each of our respective individual categories. Our peers were well poised with very creative presentations. Doug and I were honored to represent Florida Hospital amongst our Florida Hospital talented peers. MJ Lightfoot, DO Turning to more recent events, we would like to formally congratulate Anshul Gandhi (PGY2) as he has been chosen to be the EMRAF Representative on the FCEP Board of Directors. He will be a full voting member of the FCEP Board and will be working with the leaders of Emergency Medicine in Florida! What an opportunity to make an impact in our community on both a local and state level! Thank you Dr. Gandhi for accepting this challenge to represent all of your fellow Florida EM residents! This is a very exciting time of year for Orlando Health! We recently had a great time at Symposium by the Sea, participating in SimWars, CPC and highlighting ongoing research projects. We presented several posters of original research in different research fields. PGY 3, Dr. Carolina Pereira, was given the “Outstanding Resident Poster” award and PGY 3’s Drs. Ayanna Baker and Kate Bondani took home runner up in the same category. We are truly proud of the amount of research that comes out of our program. In the last four months alone we’ve published nine new articles and have continued our work on serum biomarkers for traumatic brain injury with presentations at both the annual meeting of the American Academy of Clinical Neuropsychology and the Annual National Neurotrauma Symposium. We are always incorporating interactive teaching and simulation sessions to improve our learning, and this year has been no different. At the start of the year, PGY 2’s and PGY 3’s participated in a session on advanced resuscitation techniques. Here we practiced thoracotomies, transvenous pacing and double Orlando Health sequential defibrillation and updated our knowledge of the latest resuscitation evidence. We followed this up Kate Bondani, MD with our yearly advanced airway lab where we trained with the various airway devices including fiberoptics, different video laryngoscopy systems, and both needle and surgical cricothyroidotomies on cow tracheas. We are excitedly anticipating the opening of our new ED expansion as well as the opening of the new patient tower which should be occurring later this fall or early spring. The renovation will expand and improve both our emergency department and inpatient capabilities. With all these new changes on the horizon, we can’t wait to see what opportunities await our residency program! 2014 RESIDENCYmatters The St. Lucie Medical Center EM residency has had a busy summer. In late June, we graduated our inaugural class and saw three graduates take full time positions after graduation. We were excited to see one of our graduates, Sarah Fowles, D.O., sign with St. Lucie Medical Center and begin the process of becoming core faculty. Morgan Garrett, D.O. signed a contract to work at Cartersville Medical Center in Cartersville, GA. Dr. Leif Sahlgren took a full time job at Osceola Regional Medical Center in Kissimmee, Florida. St. Lucie Medical Center EM residency also took first place in the SIM Wars Competition at Symposium by the Sea. One of our core faculty, Jason Morris, D.O. also gave a guest lecture at the Symposium on stratifying high and low-risk chest pain. The residency attended a private screening of “Code Black,” a documentary about an EM residency at LA County Hospital facing increased government regulations while also working in a busy urban ED with many patients from a low socioeconomic status. Our residents are also looking forward to attending the ACEOP Scientific Assembly in Las Vegas, Nevada from October 10th-15th. We are looking to improve upon last year’s second place in the Jeopardy competition. University of Florida, Jacksonville Christina Wieczorek, MD fcep.com 27 St. Lucie Medical Center Brant Hinchman, MD 2014 continues to be a busy year for the residents and faculty at UF Jax! UF Jax sent a large contingent down to Boca for Symposium by the Sea this summer. We turned out in big numbers to help welcome and congratulate our very own Associate Program Director Dr. Ashley Booth-Norse as the incoming FCEP President. We also had multiple other faculty participate in forums and present throughout the long weekend. Our Sim Wars team (Drs. Kate Justus, Melissa Mann, Karl Horn and Christina Wieczorek) seemed like the early frontrunner in the simulation competition, but slipped up and didn’t make it to the final round...which was Ebola -- how timely! Our CPC competitors, Drs. Bryant Lambe and Kate Justus, did a fantastic job during the CPC competition and I know will be back next year with even more interesting and difficult cases. Our third years, though already counting down their time to entering the real world, are all looking forward to their trip to Chicago for ACEP in a few weeks. We will miss them that week, but look forward to the opportunity for first and second years to hold down the fort in their absence. Stay posted for even more happenings at UF Jax this spring. Our new hospital campus is slated to open soon, and we look forward to keeping everyone updated on the progress. Things are cooling down here at the Swamp, but UF Health is only heating up! We welcomed our new interns into the fold, and have enjoyed seeing them grow and learn the ropes. Our residency retreat was a blast. Our crew traversed out to the ropes course at Lake Wauburg and enjoyed a day of team building on the high and low ropes course. Our team grew together and learned to lean on each other - literally! Dr. Diana Mora-Montero attended the Levitan Advanced Airway course on a scholarship in Yellowstone! She brought back several techniques on the mastery of the advanced and difficult airway. The seniors had the opportunity to attend the “Life After Residency” workshop in Orlando this month. Held at the Embassy Suites downtown, lectures on coding, job opportunities, academic career pursuits, and even finding a work-life balance were all held on September 30 - October 1. PGY-3’s are excited for ACEP coming up at the end of October in Chicago. Many faculty members University of Florida will be presenting, and graduates from the UF Health program from across the country will be in town to Jordan Rogers, MD reunite with old friends. A week of learning and catching up with friends old and new will be enjoyed by the whole department. As our interviews are starting, we are eager to have medical students from across the country rotating through our department. It is always exciting to see new faces and encourage up-and-coming EM residents in their career paths. In addition to cooler weather, fall also brings football season to Gainesville! Dr. Chrissy VanDillen and the EMS fellows Dr. Joel Rowe and Dr. Desmond Fitspatrick have worked hard at every home game at the medical tent to keep spectators safe. Looking forward to another fall here in Gainesville! It has been a good summer for us down in Miami Beach - between our solid new first year residents and a relatively calm and quiet storm season... at least so far. Here in Florida, a number of our residents took part in Symposium by the Sea in Boca Raton. Dr. Aaron Mickelson won first place for best CPC case presentation with a case of Spinal AV Fistula presenting as lower extremity paralysis, and Drs. Valletta, Betancourt, Petrakos and Klein all competed in their first Sim Wars competition. Meanwhile the same weekend, Dr. Benjamin Abo was co-instructing a two day Wilderness EMS Medical Director’s Course at the international Wilderness Medical Society Meeting being held in Jackson Hole, Wyoming. Mt. Sinai Medical Center Benjamin Abo, DO, EMT-P Crescent Center 6075 Poplar Avenue, Suite 401 Memphis, TN 38119 You Take Care of Us. So We’re Returning the Favor. Who We Are and What We Do We Offer Premium Benefits Keystone provides Emergency Department and Hospitalist Physician Staffing throughout the Southeastern and Northeastern Regions of the United States. Keystone partners with its physicians, nurse practitioners and physician assistants to provide innovative and quality services to its client hospitals. 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Interactive training modules discuss: • Stroke basics T F A DR • The role of EMS personnel in stroke assessment and care • Stroke care systems • Case studies Get started today! Visit www.ems4stroke.com to view and download educational materials. Reference: 1. Loyola study finds paramedics skilled in identifying strokes [press release]. Maywood, IL: Loyola Medicine; March 27, 2012. http://www.stritch.luc.edu/neurology/newswire/news/loyola-studyfinds-paramedics-skilled-identifying-strokes. Accessed November 13, 2013. In partnership with © 2014 Genentech USA, Inc. All rights reserved. ACI/101014/0017 29 College of FCEP | Florida Emergency Physicians 3717 South Conway Road, Orlando, FL 32812 NONPROFIT ORGANIZATION US POSTAGE PAID PERMIT NO. 2361 ORLANDO, FL