EMpulse

FLORIDA COLLEGE OF
EMERGENCY PHYSICIANS

SPRING 2013

Emergency Medicine Days

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Practice Management: Documentation Billing and Lawsuits

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 EMpulse
Volume 18, Number 2

Florida College of Emergency Physicians Departments

3717 South Conway Road 2 | President’smessage | Kelly Gray-Eurom, MD, MMM, FACEP
Orlando, Florida 32812-7606
t: (407) 281-7396 • (800) 766-6335 4 | Governmentaffairs | Steve Kailes, MD, FACEP
f: (407) 281-4407
fcep.org 5 | ACADEMICaffairs | Preeti Jois, MD, FACEP

6 | EMStrauma | Christine VanDillen, MD, FACEP

Executive Committee
7 | MEMBERSHIP&Professionaldevelopment | Rene Mack, MD
Kelly Gray-Eurom, MD, MMM, FACEP • President
Michael Lozano Jr., MD, FACEP • President-Elect 8 | POISONcontrol | Rachel O’Geen, Pharm.D. and Dawn R. Sollee,
Ashley Booth Norse, MD, FACEP • Vice President Pharm.D, DABAT
Steven Kailes, MD, FACEP• Secretary/Treasurer
10 | MEDICALeconomics | Ashley Booth Norse, MD
Vidor Friedman, MD, FACEP • Immediate Past President
Beth Brunner, MBA, CAE • Executive Director 34 | Residencymatters

Editorial Board
Features
Karen Estrine, DO • Editor-in-Chief 13 | FCEP and FENA Collaborate to Influence Practice of
editor@fcep.org Procedural Sedation—An Update | Sharon Reuter, RN
Shannon Costello • Managing Editor/Graphic Designer 14 | End Game In The Emergency Department: The Tip Of The
scostello@fcep.org
Spear | Kristin McCabe-Kline, FACEP, FAAEM, ACHE

16 | Residency Match | Karen Estrine, DO

19 | Strangulation Injuries in Domestic Violence | Danielle

Christiano MD

21 | Anatomy of a Lawsuit | Cheryl Reynolds, MD, FACEP, CPHRM

22 | A Small Complaint, but Making a Big | Difference Graham

Ingalsbe, MD

23 | Tell Me A Story: Why Proper Documentation of Differential

Diagnoses Can Bolster Medical Necessity and Justify an
Emergency Physician’s Hard Work | John Stimler, DO, CPC,
All advertisements appearing in the Florida CHC, FACEP
EMpulse are printed as received from the
advertisers. Florida College of Emergency 27 | Emergency Medicine Days in Tallahassee | Aaron Wohl, MD
Physicians does not endorse any products or
services, except those in its Preferred Vendor 30 | Florida Emergency Nurses Joined FCEP for Emergency
Partnership. The college receives and distributes
employment opportunities but does not review,
Medicine Days | Penny Blake, RN, CCRN, CEN and Terri
recommend or endorse any individuals, groups or Repasky MSN, RN, CEN, EMPT
hospitals that respond to these advertisements.
32 | Southeast Regional Emergency Medicine Medical Student
Symposium | Nicole Hodgson MD Candidate, Class of 2014
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.
 PRESIDENT'Smessage

Passing the Editorial Torch

Kelly Gray-Eurom, MD, MMM, FACEP

President

I
t is with sadness and gratitude that we say goodbye to our most recent
Editor-in-Chief of the EMpulse, Dr. Leila Posaw; but it is with sincere
thanks and confidence that we welcome her successor, Dr. Karen Estrine.

Dr. Posaw has served as the Editor-in-Chief of the EMpulse for the past
four years. During that time she worked to provide quality content on pertinent
issues facing Emergency Medicine. Her goal was to create a medical journal
Leila PoSaw, MD, MPH, FACEP
packed with articles touching on the diverse cases presented in the emergency
department. Over the years she far exceeded her goals and continued to produce
a quality magazine; she will be missed.
2
Throughout her career, Leila has worked in Thailand and various hospitals
in South Florida. After several years in EM practice, she decided to pursue
a new career tract. She completed a fellowship in emergency ultrasound at
fcep.org

Mount Sinai School of Medicine in New York and has recently re-located to
Quad Cities, Iowa where she has taken the position of Emergency Ultrasound
Director at Genesis Health Systems.

Leila has been a wonderful asset to our team and we are grateful for the effort
and time she has put into editing and shaping our magazine. We wish her well
Karen Estrine, DO
as she settles into her new career path.

The editorial torch has been officially passed to Dr. Karen Estrine, who has
served as our assistant editor for the past year. As you will see in this edition,
she is already hard at work.

Our new Editor-in-Chief obtained her medical degree from Michigan State
University College of Osteopathic Medicine in Michigan. She completed a
dual accredited MD/DO internship at Providence Hospital in Michigan and
completed an emergency medicine residency at Sinai-Grace Hospital/Detroit Both our outgoing and incoming Editor-
Medical Center - Wayne State University. Dr. Estrine currently works as an in-Chiefs exemplify a strong work ethic
Assistant Professor of Clinical Medicine for the University of Miami Miller and a love for academic medicine. I know
School of Medicine and as an attending physician at the University of Miami they will continue to shine as they fol-
Hospital. She has spent many years writing and publishing research and hu- low their goals in the field of Emergency
manitarian medical pieces. We are extremely proud to promote her to our Medicine. FCEP applauds their efforts
Editor-in-Chief and look forward to adding her visions to the pages of the and successes and look forward to what
EMpulse. comes next from each of them.
 3

EMpulse
 GOVERNMENTaffairs
Steve Kailes, MD, FACEP
Committee Chair
What is in a name?
T
his year, legislatures across
this country are grap-
pling with how to proceed
in healthcare. The federal
Affordable Care Act (ACA) has many
provisions directing how federal funding
will flow to states, providing insurance
coverage for the uninsured. Opponents
to the ACA had pinned their hopes on
4 is supported by the federal government,
President Obama’s defeat in November’s
elections and the eventual repeal of the
ACA. Didn’t happen; now what?
fcep.org
Now, many ACA opponents are look-
ing for ways to work within the ACA
and still have more state control of
how millions of uninsured people ob-
tain coverage. They are opposed to
Medicaid expansion, fearing states will
lose control over their healthcare, ceding
decision-making power to the feds, and/
or the states will ultimately be saddled
with the expense. There are reasonable
concerns of how this will be financed in
both the short and long term. However,
many are puzzled at the idea of our state
opting out of the ACA and Medicaid
expansion. This path leaves billions of
dollars in the US Treasury rather than
our own state’s coffers. Congress has
authorized 100% Federal financing of
this initiative for the first three years and
then 90% going forward.
Interestingly, leaders in Florida and
several other states are now pursuing a
“private market option.” Basically, they
will take the Federal money for cover-
age of the uninsured. However, rather
than adding these people to Medicaid
rosters, states would use the money for
the uninsured to purchase private health
insurance. This could be a win-win.
The uninsured get insurance, funding
and Medicaid rosters are not expanded.
This last point is key since it is politically
difficult to reduce entitlement programs.
Nobody knows if this will win fed-
eral approval. But, whether you call
it Medicaid or something else, isn’t
it still government funded health-
care? Shakespeare had it right...”That
which we call a rose by any other name
would smell as sweet.” The details have
been hard to come by on these plans.
Presumably, by not officially expand-
ing Medicaid, if federal funding ever
dries up, it will be politically easier to
scale back than cutting Medicaid ros-
ters. Many would also argue that private
market involvement is better than fur-
ther government expansion.
Realistically, healthcare is already
paid for by the government or sub-
sidized by taxpayers and those with
private insurance. For emergency care,
reimbursement is typically from com-
mercial payers (~30%), Medicare (~25%),
Medicaid (~25%) and self-payers (~20%).
Each preceding category subsidizes
those that follow. The private market
option described above will help de-
crease the self-payer percentage, but
will likely also decrease those covered
by commercial insurance. This leads us
closer to universal healthcare funded by
the government, with close to 75% of our
patients being covered by varied govern-
ment-funded health insurance.
Cost savings in healthcare can come
from eliminating inefficiencies, coor-
dinating care, and reducing defensive
practices based on our current mal-
practice tort system. Costs can also be
controlled by forcing cuts on expenses.
But what to cut? They will cut a little
here and there. The easiest place to
cut...doctors’ pay. There is a significant
apathy from members of the “House of
Medicine,” impeding efforts by those
willing to carry the load for us all.
Physicians notoriously are not engaged
in large enough numbers or with enough
financial support from our peers to truly
move the needle in Tallahassee or in
Washington, D.C. We primarily play
defense with proposed laws, regulations
and rules. The well-known Dr. Greg
Henry, when speaking to emergency
physicians about the coming changes
in healthcare over this next decade, said
something like, “If you are making only
20% less than you do right now, you
should consider yourself a winner!”
This does not sit well with me. Yet,
unless we get more support from our
peers, I fear he is correct. I prefer action
and will continue to fight the good fight.
Please lend your support.
 ACADEMICaffairs

Committee Update

T
his has been a very active year, with dedicated planning underway for Symposium
by the Sea 2013, the unveiling of plans for new EM residency programs, continued
growth in our existing residencies with new updates and guidelines from the recent
CORD meeting, and ongoing celebrations as new residents match and our senior
residents prepare to start their careers. Preeti Jois, MD, FACEP
Committee Chair
Symposium by the Sea
Our annual meeting will be held August 1-4, 2013 at the Hilton Clearwater. The week-
end’s activities will begin on Friday with LLSA and Ultrasound workshops as well as the 2nd
Annual SimWars competition. The resident Case Presentation Competition (CPC) will be
held Saturday morning. We are excited to welcome Dr. Robert Levine from the University
of Miami Hospital, Miller School of Medicine, as our new CPC chair. We thank Dr. Fred
Epstein for all the work he has done in the past to make CPC a success. Dr. Levine and the
chairs of Symposium by the Sea (Dr. Mack and Dr. Jois) are looking for judges for CPC- {note:
judges cannot be affiliated with any Florida EM residency programs; if you are interested in
judging (or know of someone who is) please contact us}.
Didactic courses will be offered at Symposium by the Sea (SBS) on Sunday morning. An ex-
citing series is planned, including a grand rounds on high risk medicolegal cases in chest pain,
as well as dedicated lecture/hands-on for difficult airway management.
Florida Emergency Medicine Network
A big thanks goes out to Dr. Linda Papa for spearheading the Florida Emergency Medicine
Network (FLEMNET)- a statewide research consortium, additionally inclusive of all EM
residency programs in this state. The steering committee for FLEMNET will be comprised
of one member from six key sites. Stay tuned as this develops into a prime source of emergency
medicine research initiative in Florida.
Board Review Course
At the last FCEP Committee meeting, several members expressed an interest in having
a FCEP Board Review Course. A subcommittee evaluated the feasibility of such an idea.
Florida has a large pool of incredible faculty and such courses, written and oral, would be an
outstanding value for our residents and physicians. However, it appears that the American
Academy of Emergency Medicine (AAEM) already has an established written board review
course in Florida, with this year’s course set for August 21-23. AAEM uses several outstand-
ing faculty from FL, and the board review dates fall very close to FCEP's SBS (Aug 1-4). For
now, the Academic Affairs Committee has tabled this proposal for a new written board review
course, and instead plans to further our involvement with AAEM in their endeavors. Future
initiatives may involve an oral board review course.
EM Resident Career Day
Florida Hospital-Orlando will be hosting the event this year, in the Fall. Dates are being
finalized.
New EM Residency Programs
2015 will be an exciting year for our state with the start of two new EM residency programs-
Osceola Regional Medical Center and Lakeland Regional Medical Center. I know that we
will all be eager to help these new programs earn their successes and to welcome new col-
leagues to our FCEP family.
 EMS/trauma

Committee
Update
Southwestern, has recently made a presentation available on his
website in regard to the DEA imposing serious consequences
on EMS medical directors whose agencies may not be meeting
Christine VanDillen MD, FACEP the requirements for drug handling. Then, it was announced
Committee Chair
that the trauma Stabilization position paper is under final re-
view. The idea behind this position paper is to provide EMS

T
he EMS/Trauma Committee met on February 20, medical directors with a resource to refer to when changing
2013. After introductions and the approval of min- current practice of immobilizing all trauma patients to selec-
utes, the meeting quickly started with an FSED tively choosing those who truly require stabilization.
update from our Florida State EMS medical direc-
Also, as previously discussed, a protocol clearinghouse folder
tor. Dr. Nelson first discussed an upcoming survey to provide
has been set up by Ms. Costello in a Dropbox. We are hoping
Florida EMS medical directors with an opportunity to collect
to see that EMS medical directors will start sending in their
data on protocols/practices across the state with the goal of in-
protocols to share in this Dropbox folder soon.
creasing survival rates statewide. He notified the committee
Dr. Van Dillen reported that the CAE Caesar simulator
that the review of disaster protocols has been completed with
6 has been delivered to Gainesville for use in training; several
minor format revisions but no major content changes. Soon,
agencies have already had training with Caesar, and more are
these protocols will be made available statewide.
scheduled. Dr. Van Dillen noted that due to the complexity
The drug shortage was again discussed as it continues to affect of the mannequin, an IT person is needed for best utilization.
fcep.org

many EMS agencies. We have been able to gain attention at a

national level with the Congress requesting that the GAO get
involved. We were reminded that, on the state level, a rule is in
place to allow a medical director to write a letter to authorize a
substitution medication to be used instead of a medication that
may be unavailable. Further discussion took place regarding a
statewide initiative to collect information on this topic, while
EMLRC is actively conducting a survey that addresses the ef-
fects of the drug shortage on EMS agencies.
The issue of free-standing emergency departments (FSED)
was discussed. Just prior to our committee meeting, FHA-
FCEP conducted a meeting to focus is on patient care and
created a report which we discussed. The committee was glad
to hear that Drs. Fraunfelter, Husty, and Scheppke are heading
up a task force to collect existing protocols regarding transport
to FSEDs. Dr. Gray-Eurom emphasized that the focus should
always be on patient care, and suggested that there be a re-
quirement of being a member of either organization in order to
actively participate in the committee.
Dr. Dalton reported on discussions from the last FAESMD
meeting. First, he announced that Dr. Ray Fowler, from UT
Regarding new trauma center designations, Dr. Nelson has
met with the ACOS. They have released several recommenda-
tions, but most do not affect EMS agencies. Recommendations
are available for download on their website. Dr. Nelson feels
that the EMS Program is likely to adopt whatever EMS-related
recommendations are made. A current hold has been placed on
new trauma center applications until later notice.
In new business, Ms. Beth Brunner reported that UCF creat-
ed a beta test for a medication error study that will be piloted to
a few key EMS medical directors; it will then eventually be sent
to all Florida medical directors. Hopefully this will provide us
with more information to help educate pre-hospital providers
and prevent future errors.
Get excited for ClinCon 2013! This year’s theme is tacti-
cal medical/active shooter, with new interactive labs and
many national speakers. EMLRC has recently appointed Dr.
Christopher Hunter as medical director to ensure maintenance
of high accreditation standards. EMS fellowships across the
United States have been approved for accreditation through
ACGME, University of Florida in Gainesville and Orlando
Health are amongst the first 20 to receive this honor.

Start at the Beginning
T
here are some really excit-
ing developments taking
place in the Membership and
Professional Development
Committee. Over the past few months,
FCEP has renewed its dedication to
those in the developing and early stages
of their careers in Emergency Medicine.
We have developed an extensive medical
student outreach program and continue
to encourage resident growth through
advocacy and leadership.
With the invaluable help of many,
especially Dr. Robyn Hoelle of UF-
Gainesville, we have been able to
develop and initiate several programs
aimed at enriching the learning of
medical students, especially those inter-
ested in EM. In support of our efforts,
FCEP members have been meeting with
Emergency Medicine Interest Groups
(EMIGs) at various medical schools
throughout the state. From all reports,
the visits have been a great success! We
can all remember “that” time during
medical school when either you knew
exactly what specialty you wanted to
enter or you were still searching for the
perfect fit, but either way, you searched
for more information. The opportunity
to interact with a practicing physician
not only helps to solidify your interest,
but gives much needed insight into an
uncertain world.
In addition to the EMIG visits, we
have developed a Medical Student sub-
committee. There was a need for the
Florida-based medical students inter-
ested in EM to have a common meeting
MEMBERSHIP&PROFESSIONALdevelopment
arena where they can interact with each
other as well as have increased access to
practicing physicians who can provide
guidance and support. From the onset,
the idea was greeted with much enthu-
siasm and the medical student response
continues to be exuberant!
In case the aforementioned was not ex-
citing enough, there is more! Through
very generous donations from groups
and individuals around the state, we have
approximately 45 sponsored ACEP/
FCEP/EMRA memberships for Florida
medical students! We are so grateful and
truly appreciate those who realize the
potential and value of engaging and en-
couraging our medical students.
We are also very inspired by the re-
sponse we have received from our
resident members. FCEP Board mem-
bers continue to demonstrate their
commitment to advocacy and resident
enrichment by visiting the residency
programs throughout Florida. The op-
portunity to reach out to the residents
and share the many, sometimes un-
recognized, benefits of ACEP/FCEP/
EMRA membership is a privilege that
is always welcomed. Residency visits
also give the residents a chance to ask
questions regarding various areas of EM
leadership available to them (there are
many!) as well as having a live example
of an EM physician actively engaging in
advocacy outreach.
I had the pleasure of attending the
very successful EM Days in Tallahassee
a few weeks ago, and it was enjoyable
Rene Mack, MD
Committee Chair
to interact with residents from all over
the state. Some were veterans, already
aware of the role advocacy plays in their
profession, but the majority were first
time attendees, eager yet a bit uncertain
of what would be taking place while
in Tallahassee. The residents quickly
realized that the experience, like our
profession, is a team approach and they
7
had the full support of all involved dur-
ing their time at the Capitol. On the last
day of our visit, I was able to talk with a
EMpulse
few of the first time attendees. I was in-
spired by one of the residents who shared
a very touching story. She admitted that
she did not believe her presence would
make a difference but that she was at-
tending EM Days mainly because it
was recommended by the residency at-
tendings. By the end of EM Days, she
was intrigued and excited about the
many ways advocacy is intertwined in
her career, and she is looking forward
to attending the ACEP Leadership and
Advocacy Conference in May.
Again, many thanks to those who
have devoted their time and resources to
making the past few months a huge suc-
cess! I look forward to hearing from you
regarding any suggestions or concerns
for the future of the committee.
 POISONcontrol

High-Dose
Insulin for
Cardiovascular
C
ardiovascular medications are some of the most commonly prescribed medi-

Drug
Overdose
Rachel O’Geen, Pharm.D.
Clinical Toxicology Fellow
Dawn R. Sollee, Pharm.D, DABAT
Assistant Director
Florida/USVI Poison Information
Center-Jacksonville
8 acids under normal circumstances. Fortunately, the heart has a high degree of flexibil-
fcep.org
cations in the United States. In 2010, a total of six beta blockers and four
calcium channel blockers were among the top 200 generic drugs as counted by
total prescriptions.1 With such a high prevalence of being in homes, it is no
surprise that cardiovascular drugs are also one of the most common encountered drug over-
dose groups reported to the American Association of Poison Control Centers (AAPCC).
In the same year, the AAPCC reported cardiovascular drugs to rank eighth on a list of
those most frequently involved in exposure and third when looking at the greatest rate of
exposure increase. In contrast, the group is ranked second among those associated with the
largest number of fatalities.2 Although it is not known the specific cause of this disparity,
likely explanations include the overall severity of cardiovascular drug overdose along with
inefficient treatments in management. The use of high-dose insulin therapy has become a
standard when considering the management of beta blocker and calcium channel blocker
overdose.3
The high energy requirement of myocardial cells is maintained by beta-oxidation of fatty
ity and is also able to utilize glucose, lactate, and ketone bodies as a substrate for energy
metabolism. Although free fatty acids are able to produce more energy than glucose, this
comes at a high cost due to the large amount of oxygen that is also required in their me-

tabolism.4 For this reason, metabolic efficiency is generally better when utilizing glucose
as an energy source which does not exhaust oxygen to the same degree. This concept
becomes particularly important when the myocardium is under stressed conditions such as
in ischemia, hypoxia, or drug overdose. In these scenarios, a reduced uptake of free fatty
acids from systemic circulation into the myocardium is noted, as well as an increase in glu-
cose consumption.4,-6 High dose insulin not only exploits these details by encouraging an
impaired myocardium to utilize an alternative energy source but also appears to have other
benefits outside of these metabolic effects.
Many antidotes are considered in the management of beta blocker and calcium channel
blocker overdoses including atropine, calcium, glucagon, and vasopressors. Although many
of these agents may improve symptoms at least transiently, consistent efficacy is lacking,
particularly in severe toxicity.3 In animal models, insulin appears to have cardioprotective
effects in times of myocardial stress by encouraging the use of glucose for metabolism.
Additionally, there are likely some anti-inflammatory and anti-oxidizing effects, as well as
direct inotropic actions on the heart. These effects are not mediated by catecholamines and
is likely partially independent of glucose metabolism. A series of studies initially evaluat-
ing the effects of insulin in severe verapamil toxicity in dogs found that insulin promoted
carbohydrate metabolism correlating to improved function of the heart. When compared
to other therapies including vasopressors or glucagon, insulin caused the greatest improve-
ment in myocardial contractility as well as the ratio of myocardial oxygen delivery to work.
These effects appeared to correlate strongly to myocardial glucose uptake.6-10 A more re-
cent study evaluated the potential ideal dose for insulin and randomized propranolol-toxic
pigs to receive either control (n=4) or an insulin dose of 1
unit/kg/hour (n=4), 5 units/kg/hour (n=4), or 10 units/
kg/hour (n=4). Over the six hour observation period
two pigs survived in the control arm, 3 pigs survived
in both the 1 unit/kg/hour and 5 units/kg/hour groups,
while all pigs survived in the 10 units/kg/hour group. A
References
57% increase in cardiac output was noted between the
1 unit/kg/hour group and the 10 unit/kg/hour group,
which was statistically and clinically significant in favor
of the higher dosing regimen. Despite the large doses of
insulin used, there were no differences seen in glucose
utilization between the three study arms giving evidence
to the hypothesis that insulin efficacy is partially inde-
pendent of glucose metabolism.11 There are several case
reports available regarding the successful use of high
dose insulin in cardiovascular drug toxicity as well as a
case series reflecting the efficacy of an aggressive proto-
col utilizing dosing up to 10 units/kg/hour.12
High dose insulin therapy should be considered first
line therapy for calcium channel blocker overdose and can
be considered in beta blocker toxicity when patients are
not responding to glucagon therapy. Recommendations
include an intravenous bolus dose of 1 unit/kg of regu-
lar insulin followed by an infusion of 1 unit/kg/hour.
Typically, results are seen within about 30 minutes and
titration can be considered if there is not an adequate
response to the initial dose. Close glucose and potas-
sium monitoring is necessary and it is recommended
to maintain glucose levels over 150 mg/dL in order to
prevent hypoglycemia during therapy. Administration
of aggressive supplemental glucose will likely be re-
quired, especially if used for beta blocker overdose
(calcium channel blocker overdose is likely to cause hy-
perglycemia in severe toxicity). For more information on
management of calcium channel blocker or beta blocker
toxicity and the use of high dose insulin therapy, contact
your local poison center at 1-800-222-1222.
1. Drug Topics. 2010 Top 200 generic drugs by total
prescriptions. June 2011. Available at drugtopics.com.
2. Bronstein AC, Spyker DA, Cantilena LR Jr, et al.
2010 Annual Report of the American Association of
Poison Control Centers' National Poison Data System
(NPDS): 28th Annual Report. Clin Toxicol (Phila)
2011;49(10):910-41.
3. Engebretsen KM, Kaczmarek KM, Morgan J, et al.
High-dose insulin therapy in beta-blocker and calcium
channel-blocker poisoning. Clin Toxicol (Phila)
2011;49(4):277-83.
4. Hantson P, Beauloye C. Myocardial metabolism in toxin-
induced heart failure and therapeutic implications. Clin
Toxicol (Phila) 2012;50(3):166-71.
5. Reikerås O, Gunnes P, Sørlie D, Ekroth R, Mjøs OD.
Metabolic effects of low and high doses of insulin
during Bêta-receptor blockade in dogs. Clin Physiol
1985;5:469–478.
6. Kline JA, Raymond RM, Leonova ED, et al. Insulin
improves heart function and metabolism during non-
ischemic cardiogenic shock in awake canines. Cardiovasc
Res 1997;34: 289–298.
7. Kline JA, Leonova E, Raymond RM. Beneficial myocardial
metabolic effects of insulin during verapamil toxicity in the
anesthetized canine. Crit Care Med 1995;23:1251–1263.
8. Kline JA, Leonova E, Williams TC, et al. Myocardial
metabolism during graded intraportal verapamil infusion in
awake dogs. J Cardiovasc Pharmacol 1996;27:719–726.
9. Kline JA, Raymond RM, Schroeder JD, et al. The
diabetogenic effects of acute verapamil poisoning. Toxicol
Appl Pharmacol 1997;145:357–362.
10. Kline JA, Tomaszewski CA, Schroeder JD, et al. Insulin
is a superior antidote for cardiovascular toxicity induced
by verapamil in the anesthetized canine. J Pharmacol Exp
Ther 1993;267(2):744-50.
11. Cole JB, Engebretsen KM, Stellpflug SJ, et al. 10 u/kg/
hr of high dose insulin is superior to 1 u/kg/hr in a blinded,
randomized, controlled trial in poison-induced cardiogenic
shock [abstract]. Clin Toxicol (Phila) 2011;49: 515.
12. Holger JS, Stellpflug SJ, Cole JB, et al. High-dose insulin:
a consecutive case series in toxin-induced cardiogenic
shock. Clin Toxicol (Phila) 2011;49(7):653-8.
 Medicaleconomics
Ashley Booth Norse, MD
Committee Chair
T
he Affordable Care Act’s
(ACA) recent enactment has
triggered a series of new and
concerted efforts to address
some of the many challenges relating to
health care costs, and access and qual-
ity that the U.S. faces today. One of the
most important challenges involves the
number and mix of health providers that
will be needed to meet the demand re-
10 sulting from changing demographics,
changing health insurance availability,
and a new emphasis on wellness and
preventive care. Given the dramatic
fcep.org
changes in the way health care services
will be offered and for which they will
be paid, it may take years for the coun-
try to determine the appropriate mix of
providers.
As part of the enactment of the ACA,
the Obama Administration is now look-
ing at Graduate Medical Education
(GME) and the role GME plays in the
Medicare system as well as the cost of
GME to Medicare. In addition, the cur-
rent administration will have to focus on
the balance between the cost of GME
(and who will fund it!) versus imple-
menting new programs designed to
address the physician shortage and more
specifically, the primary care shortage.
The “Teaching Health Center Graduate
Medical Education program” was au-
thorized under the ACA and began to
operate in 2011. However, an increasing
number of medical school graduates are
now being denied entry into a residency
program. This is largely due to the cur-
rent cap on the number of residencies that
the federal government finances through
its Graduate Medical Education (GME)
PPACA, Graduate Medical
Education and Medical
Economics…
program. While medical school admis-
sion numbers have increased 1-1/2-2%
every year for the past several years, resi-
dency position numbers have remained
stable. What do I mean by the “current
cap”? Congress passed a law in 1997 that
imposes a hospital-specific limit on the
number of residents that Medicare will
pay to train. In general, the limit is based
on the number of residents that a hospi-
tal trained in 1996.
Medicare is the largest single program
providing support for graduate medical
education (GME). In federal fiscal year
2011, the Medicare program paid hos-
pitals that train residents approximately
$3.2 billion dollars in direct graduate
medical education (DGME) funds, out
of approximately $15 billion in DGME-
related costs. DGME payments cover
a portion of the direct costs of training
residents, such as residents’ stipends and
benefits, teaching physicians’ salaries,
other direct costs and related overhead
expenses. The amount of Medicare
DGME payments a teaching hospital
receives is related to the share of the
hospital’s inpatients who are Medicare
beneficiaries.
Every hospital that trains residents
in an approved residency program is
entitled to receive Medicare DGME
funding. The amount of DGME pay-
ments varies for each hospital. DGME
payments are based on historical costs
that were set in the 1980’s. They are not
related to the costs the hospital currently
incurs for training residents. Teaching
hospitals also receive an indirect medi-
cal education (IME) adjustment from
Medicare. These payments are designed
to pay teaching hospitals’ increased pa-
tient care costs associated with treating
more complex patients; not resident
training costs.
In recent years, there has been increas-
ing scrutiny of GME funding amid
unprecedented budgetary pressure on
both Congressional and administration
policy makers. MedPAC, the Simpson-
Bowles Commission, as well as many
other organizations have called for a
substantial reduction in indirect GME
funding. Some have suggested both
reducing the federal commitment and
consolidating the two programs.
On the flip side, there are bills in both
the US House of Representatives and
the US Senate that would increase the
number of federally funded residency
slots. The House bill, named “Training
tomorrow’s doctor’s today act,” is spon-
sored by Representatives Schock and
Schwartz. The Senate bill, named “The
resident physician shortage reduction
act of 2013,” is sponsored by Senators
Nelson, Schumer and Reid. Both bills
would increase residency slots by up to
15,000 over the next 5 years and create
relief under the current “caps.” Both bills
also focus on creating new primary care
residency positions, increasing GME
funding transparency and increasing
GME clinical outcomes reporting mea-
sures for trainees.
This has left both hospitals and
Residency program directors wonder-
ing how the ACA will effect GME and
how GME will be funded moving into
future. The focus of many states is now
on Accountable Care Organizations,
Medicaid Expansion and Health
Insurance Exchanges. The effect that
these sweeping changes to the current
healthcare system will have on hospitals
is yet to be seen. But, it leaves GME as
an additional cost driver that states must
take into consideration as they move
forward with the implementation of the
ACA.
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The Annual Meeting of Florida College of Emergency Physicians
August 1-4
held in collaboration with Florida Emergency Nurses Association 2013
AT THE Hilton Clearwater Beach
400 Mandalay Avenue
Clearwater, FL 33767

Conference Highlights
ќ Symposium General
Educational Sessions*
ќ Preconferences include LLSA,
Ultrasound, and Simulation
Competitions;
ќ Florida Emergency Medicine Resident’s
Case Presentation Competition (CPC);
ќ Residents Poster Abstract Competition;
ќ A Building Takes Shape
Reception with Exhibitors
ќ Wine & Cheese Reception
with Exhibitors;
ќ Past Presidents Volleyball Tournament;
ќ EMRAF Job Fair Event;
ќ 13 Continuing Education Credits;
ќ Breakout Workshops: EKG Findings;
Difficult Airway; and Pediatric Dyspnea;
ќ Medicolegal “High Risk”
Grand Rounds Session;
ќ Medical Student Forum;
ќ Casino Night
*All except the preconferences are no charge for FCEP Members!

Florida College of Emergency Physicians | 3717 South Conway Road, Orlando, FL 32812
Want More Information:
t: (407) visit fcep.org
281-7396 (800) 766-6335 or call| (800)
| f: (407) 281-4407 fcep.org766-6335
 EMpulseupdate

FCEP and FENA Collaborate to

Influence Practice of Procedural
Sedation—An Update

T
Sharon Reuter, RN he July 2012 Empulse article regarding the Board of Nursing’s proposed rule
64B9-8.005 “Unprofessional Conduct,” which prohibits a RN from admin-
istering certain sedative-hypnotics such as propofol for procedural sedation,
concluded by saying “this issue may finally be moving to resolution.” Earlier,
in April, 2012, FMA, FOMA, and FPMA filed a petition for a state administrative
determination that the proposed rule was invalid because the BON “lacked the statutory
authority to limit medications . . .as prescribed or authorized by a duly licensed practi-
tioner.” At the time of the article, an administrative hearing was scheduled for August
28-30 in Tallahassee.
On November 2, 2012 an administrative Judge issued the following decision: “It is
ORDERED that proposed rule 64B9-8.005 is an invalid exercise of legislatively del-
egated authority.”
However, on November 28, 2012, the Florida Board of Nursing and the Florida
Association of Nurse Anesthetists (FANA) filed appeals with the First District Court 13
of Appeals in Tallahassee. Florida Nurses Association (FNA) also filed an appeal on
November 30. The deadline for filing briefs is April 15, 2013.
To be continued...

EMpulse
Dauntingdiagnosis

Daunting
Diagnosis
Chief complaint:
Difficulty Swallowing

Can you figure out this patients diagnosis?

Turn to page 32 to find out!

Picture submitted by Karen Estrine, DO

 EMPULSEfeature

End Game In
The Emergency
Department:
The Tip Of

I
walk into the room and see an ill appearing 90 year-old man being moved
The Spear from the EMS gurney to the ED cart. He is alert but quite hard of hear-
ing. His attentive wife of many years stands vigilantly at his side, anxious and
quite helpful in relaying the details of his health history. Despite smoking for
many years and undergoing several treatments for melanoma, he has been remark-
ably healthy and has been cognitively sharp. Over the last two weeks he has become
increasingly confused and forgetful, he has lost his balance several times and fallen,
today he was too weak to get out of bed. When his CT brain is resulted, numerous
metastatic lesions are apparent. As I walk in the room and deliver the bad news, the
patient's wife looks at me tearfully and asks, "What do we do now?" At what point
in our medical school education, residency training, and clinical experience do we
learn how to respond?
At the University of Texas Health Science Center at San Antonio, I believe I
learned more than many other medical students. By virtue of the desire of our physi-
14
cian educators to expand the curriculum to include communication skills, practical
instruction addressing methodologies to convey compassion, and reorganization of
the basic science curriculum I was taught to focus on the patient as a person rather
Kristin McCabe-Kline, MD, FACEP, than an accumulation of organs. Residency at Advocate Christ Medical Center on
fcep.org

FAAEM, ACHE
Partner and Executive Committee
Member
Emergency Medicine Professionals
Medical Director, Bert Fish Medical
Center Emergency Department
the south side of Chicago was an immersion in trauma and acute cardiac resusci-
tation for the most part. Nevertheless, the close mentorship with our attending
physicians, which is sometimes unusual in residency programs, was critical modeling
of meaningful and compassionate patient encounters for me. After leaving the womb
of residency, however, learning how to better approach end of life care has become
increasingly important to me.
The first time I realized the depth and breadth of my responsibility with regard to
palliative care was while treating a patient who arrived amidst the flurry of lights,
sirens, and sweating EMS crew members loudly calling out "hypotensive," "tachy-
cardic," and "just discharged" as an ill appearing patient was thrust into a resuscitation
room of my community ED. The patient was a demented elderly male whose body
had just endured the full extent of ICU treatment for 6 weeks with sepsis and CHF
complicated by hepato-renal failure. He moaned quietly and I thought to myself, "I
believe he has suffered enough." I felt a small tap on my shoulder, turning to find his
anxious wife looking into my eyes and she said, "What do we do now?" The words
came out of my mouth before I had a chance to edit or amend them. "I believe he has
suffered enough." She broke down crying and fell into my arms saying, "Thank you."
She went on to explain that she had known her husband was not going to recover
with the treatments he was being offered and she felt a terrible sense of guilt over not
"doing everything." I reassured her that "doing everything" is not always "doing the
End game in the emergency department: the tip of the spear physician, continued
right thing." Had I rampaged on toward
resuscitation as we are programmed to
do that day, I would never have known
what a disservice I would have done to
that patient and his family.
We are trained to resuscitate, not
trained to accept deteriorating conditions
or abnormal vital signs. In the ED where
our opportunity to develop doctor/pa-
tient relationships is a setting much like
speed dating, we have to face these emo-
tionally charged discussions. Despite the
awkwardness of the situation, it is our
responsibility and our duty to appropri-
ately counsel patients and families when
outcomes are likely to be dismal. Even
in the setting of severely ill patients who
may be walking the tightrope of death
with harsh oncologic treatment plans, I
have found there is often a paucity of dis-
cussion regarding end of life care. One
patient's oncologist told me at one point
that he cared so much about a patient he
had cared for over decades of time that
he had been reluctant to "give up" or en-
gage in the conversation with his patient
and her family. Frequently primary care
physicians may not have addressed these
issues with patients because their doctor/
patient relationship was so deep seated
that the physician had become a medical
friend, bonding with emotional attach-
ments similar to those of family, making
end of life planning a sensitive topic to
discuss as well.
There are times when offering pal-
liative care is disturbing to us. A 38
year-old male with end stage metastatic
lung cancer complicated by upper ex-
tremity DVT and neutropenic fever with
four small children at home challenged
my ability to face the discussion. His
body resembled a character off of the old
television show "Tales from the Crypt,"
and his hand reaching up and grabbing
my arm sent a chill to my core. Then his
quite soulful eyes looked into mine and
he said, "I'm tired." It was my duty to
speak to his family and convey to all of
them that he wasn't giving up on them at
all by choosing not to fight further, his
body had given up on him.
There are times when offering palliative
care is not convenient for us. We can eas-
ily intubate, place central lines, and start
pressors. Delving into a complex medi-
cal history, contacting family or medical
specialists and discussing a patient's case
at length to better understand the ulti-
mate plan of care can sometimes jam a
spoke in the front bicycle tire of a busy
ED causing worsened metrics and glares
from coworkers. During the process of
enacting a palliative plan of care nurs-
ing and support staff may interrupt on
multiple occasions disrupting our work
flow, oftentimes needing significant re-
assurance that the abnormal vital signs
without intervention is not a reflec-
tion of lack of care, but a commitment
to dignified care. There must be some
acknowledgement in the ED, however,
that the "easiest thing" is not always "the
right thing."
As we just past an election year with an
increasing focus on medical economics,
we must acknowledge that although the
cost of Emergency Medicine is only a
few cents of every health care dollar, we
are often the gate keepers or front line
physicians who channel patients into
clinical pathways where they may con-
sume the majority of health care funds.
We have a responsibility not only to the
patient and the families we are treating
at present, but to the patients who will
need healthcare funds in the future.
Palliative care will undoubtedly play
a vital role in sustainable medical care
for our country and Florida in years to
come.
The appropriate placement of patients
into palliative care pathways allows for
dignified, respectful, holistic care that
sits well with the souls of both provider
and recipient. After years of practicing
Emergency Medicine, I am increasing- 15
ly convinced that this is an area where
we are particularly needed to provide
education and reassurance to patients
EMpulse
and their loved ones. We must educate
ourselves, get comfortable with the idea
of refraining from resuscitative efforts
when appropriate, and acknowledge
that we have a fiscal responsibility with
regard to the waste that results from fu-
tile interventions. As usual, Emergency
Medicine physicians will likely be the
tip of the spear as our health care system
evolves.
Make no mistake, though we are re-
sponsible for presenting plan of care
options, only a patient or the patient’s
advocate should ultimately determine
code status and choice of treatment.
However, the next time each of us is
faced with “What do we do now?” I am
hopeful we will all carefully consider our
responses.
 Residencymatch

Residency Match

F
riday, March 15, 2013: The Ides. All across the United States, medical
students who will graduate this spring tore open envelopes or secretly
logged online to find out where they would be heading for their residen-
cies. Match Day’s drama and joy derive from the emotion of learning
one’s future. The National Resident Matching Program (NRMP), (or the Match), is
a United States-based private non-profit non-governmental organization created in
Karen Estrine, DO 1952 to help match medical school students with residency programs. The NRMP
Editor-in-Chief is sponsored by the American Board of Medical Specialties (ABMS), the American
EMpulse Magazine Medical Association (AMA), the Association of American Medical Colleges (AAMC),
the American Hospital Association (AHA), and the Council of Medical Specialty
Societies (CMSS). Congratulations to Florida's Residency Programs newest mem-
bers, and welcome!

University of Florida
School Orlando Health University of South Florida
Shands - Jacksonville
Matched Spots/
14/14 9/9 15/15
Spots Filled
Name of Resident/ James Brown, MD Constantino Diaz, MD Kevin Gysling, MD
School Louisiana State University Escuela Autonoma de Ciencias Creighton University School of Medicine
Medicas de Centro America
Mark Chandler, MD Adam Hilton, DO
16 University of Miami Jesse Dubey, DO Lake Erie College of Osteopathic Medicine
Nova Southeastern University
Matthew Dean, MD Glareh Imani, DO
College of Osteopathic Medicine
University of Central Florida Arizona College of Osteopathic Medicine
Robert Grammatico, MD
Ashley Ferrara, MD Bryant Lambe, MD
New York Medical College
fcep.org

University of Central Florida University of Central Florida

Philip Lin, MD
Florida State University
Zoe McGowan, MD
Royal College of Surgeons Ireland
Kyle Norman, MD
University of Hawaii
Christopher Ponder, MD
University of Texas
Susan Seago, MD
University of Texas
Thomas Smith, MD
Jefferson Medical College
Amanda Stone, MD
University of Central Florida
Christopher Tann, MD
University of South Florida Morsani
College of Osteopathic Medicine
Amanda Tarkowski, MD
University of Florida
Tory Weatherford. MD
University of Arkansas
Nesreen Kaufman, MD
St. George’s University
Juliana Lefebre, DO
Philadelphia College of
Osteopathic Medicine
Joseph Rosenberg, MD
University of Vermont
College of Medicine
Radim Soucek, MD
Ruprecht‐Karls‐Universitaet Heidelberg
Andrew Spencer, MD
University of Missouri‐Kansas
City School of Medicine
Richard Talbot, DO
Nova Southeastern University
College of Osteopathic Medicine
Donald Wilkins, MD
American University of the Caribbean
Yarelies Malave-Diaz, MD
USF Health Morsani College of Medicine
Joel Mendez, MD
University of Texas
Luke Metzker, DO
Touro University Nevada College
of Osteopathic Medicine
Jignesh Patel, MD
Mercer University School of Medicine
Caleb Powell, DO
Edward Via Virginia College
of Osteopathic Medicine
Claire Roycroft, MD
USF Health Morsani College of Medicine
Michael Shah, MD
University of Florida
David Sterka, MD
Eastern Virginia Medical School
Christina Wieczorek, MD
Emory University School of Medicine
Amanda Young, MD
University of Arkansas
Christopher Zernial, MD
University of Texas
 Residencymatch

University of Florida
School Port St. Lucie Mt. Sinai Florida Hospital
Shands - Gainsville
Matched Spots/
8/8 4/4 5/5 6/6
Spots Filled
Name of Resident/ Chris Bucciarelli, MD Joseph Sarbu, DO Justin Klein, DO Anshul Gandhi, MD
School University of Florida Philadelphia College of Lake Erie College of Boston University
Osteopathic Medicine Osteopathic Medicine School of Medicine
Torey Kikukawa, DO
Western University of Health Kristen Minton Chad Lee, DO Eric Heckert, MD
Sciences/College of Osteopathic Hanraham, DO Nova Southeastern Florida International
Medicine of the Pacific Arizona College of University College of University Herbert Wertheim
Osteopathic Medicine Osteopathic Medicine College of Medicine
Charles Hwang, MD
University of Florida Daniel Hohler, DO Anthony Cruz, DO Mary Jo Lightfoot, DO
Philadelphia College of Nova Southeastern Nova Southeastern
Kendall Moore, MD
Osteopathic Medicine University College of University College of
Geisel School of Medicine
Osteopathic Medicine Osteopathic Medicine
at Dartmouth Rege Turner, DO
Lake Erie College of Kushal Patel, DO Catherine Maldonado, MD
Diana Mora Montero, MD
Osteopathic Medicine Ohio University University of South Florida
University of Florida
Heritage College of College of Medicine
Artur Pawlowicz, MD Osteopathic Medicine
Clara Mora Montero, MD
University of Central Florida
Ben Boswell, DO University of South Florida
Adarsh Patel, MD Lake Erie College of College of Medicine
University of Florida Osteopathic Medicine
Steven Swearingen, DO
Pratik Patel, MD Lake Erie College of
Government Medical Osteopathic Medicine
College, Surat

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 August 1-4

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EMPULSEfeature

Strangulation Injuries
in Domestic Violence
Danielle Christiano MD
Roughly 11 pounds of pressure placed on bilateral carotid arter-
Assistant Professor of Medicine
ies for 10-15 seconds can induce alterations in consciousness,
University of Florida
Medical Director, Emergency Services and if not alleviated, results in ischemia within minutes.
Winter Haven Hospital Strangulation is ultimately a form of asphyxia, and may be
performed with a ligature (articles of clothing, telephone cord,

B
ed 11 is “Not Acting Right.” Brought in by her
sister, she is a very withdrawn 29 year-old, with a
young child in tow. She cannot exactly say what
happened, but says that her arm does not work. On
clarification, she says that she cannot write anymore because
her fingers do not work. The exam shows significant weak-
ness to the bicep, and she has poor fine motor control. Her gait
is slow and shuffling, similar to what one would expect from
a patient 50 years her senior. Her affect is flat and intermit-
tently tearful. The clincher comes when the sister reports that
the child said, “daddy choked mommy.” The patient remembers
etc) or manually, using the hands, forearms or standing or
kneeling on the victim’s throat. The signs and symptoms of
strangulation may be subtle--indeed. While there may be rope
or cord burns from a ligature, often there are minimal findings.
Fingernail scratches, either from victim or perpetrator, may be
seen as well as petechia, swelling, or vocal changes. Up to 50%
of victims report some voice changes, which again, may be quite
mild. Dysphagia and dyspnea may also be experienced. There
19
are also case reports of delayed carotid dissection, occurring
months to years after the initial insult, so remote strangulation
injury should be considered in a young (typically female) stroke
victim without the usual risk factors.2

EMpulse
nothing. The patient’s CT shows a vague hyper-density, and
the MRI definitely details a left sided basal ganglia CVA. When asking about strangulation, there are several things
Strangulation injury is often one of the last abusive acts com- to keep in mind. Do ask about specifics regarding the assault:
mitted by a violent domestic partner before murder.1 Florida How did it happen? Did the perpetrator use one hand or two?
became the 8th state to recognize strangulation within the con- A forearm? An object? Did the assailant say anything in par-
text of domestic violence in 2007. The statute (784.041) defines ticular? Was the victim thrown against a wall or the ground
“domestic violence by strangulation” as a person knowingly and in the process? How many times was the victim strangled,
intentionally, against the will of another, who
impedes the normal breathing or circulation
of the blood of a family of household member,
or of a person with whom he or she is in a
dating relationship, so as to create a risk of or
cause great bodily harm by applying pressure
on the throat or neck of the other person or
by blocking the nose or mouth of the other
person. This is a felony of the third degree.
There is much confusion among lay people
regarding choking, and the term is often used
interchangeably. However, choking should
only be used to refer to food or other objects
obstructing the airway, and is always acciden-
tal. Strangulation is an intentional action that
causes an immediate threat to life as well as the
potential for delayed morbidity and mortality. MRI imaging from the patient's admission, demonstrating late-acute
infarction about the left basal ganglia and insular cortex.
 Strangulation Injuries in Domestic Violence, continued

and was consciousness lost? Obviously,
questions regarding dyspnea or throat
pain should be asked, but also ask about
what the victim thought was going to
happen, note if the perpetration was
wearing rings that may have left pattern
injuries, or if the patient had ever suf-
fered strangulation before. As this is a
common marker for lethality, many vic-
tims will have already suffered physical,
emotional and economic abuse, and yet
may not regard themselves as victims.
Utilize the indispensable resources of
your local domestic violence shelter, po-
lice, and victim’s advocates as these cases
are time-consuming and often result in
multiple subpoenas!
Asking about domestic violence is es-
sential, and sometimes challenging.
Perpetrators often accompany their
20
victim to appointments or to the ED.
Making sure that the patient is alone
when you see him or her is essential
to disclosure. Still, some patients are
not going to disclose, and reassuring
them that they are in a safe place may
encourage future disclosure. Domestic
violence is a cycle, perpetrated through
generations, and breaking that cycle is
challenging and is rarely accomplished
with a single ED visit.
Another important consideration to
keep in mind is Florida’s mandatory
reporting laws. In Florida, there are
only three things that mandate report-
ing, and domestic violence is not one
of them. However, the third area (after
child abuse and elder abuse) is gray. It
states that “treatment of gunshot wounds
or life threatening injury” is reportable.
While many would argue that stran-
gulation is indeed life threatening,
reporting domestic violence without the
consent of the victim is potentially dan-
gerous, and can result in increased risk
for the victim.
The patient in bed 11 was admit-
ted to the hospital, and the police were
involved at her request. Her hypercoag-
ulable workup was negative, and she was
ultimately referred for outpatient thera-
py. Her assailant is currently in prison,
after finally pleading no-contest to the
charges against him.
References
1. Hennepin County Domestic Fatality
Review Team, 2004 report
2. Forensic Sci Int. 2005 May
10;149(2-3):143-50

5th Annual Symposium on

fcep.org

Critical Care in the

Excellence in Emergency Medical Care Emergency Department
June 7-9, 2013 | Orlando, Florida
THIS COURSE WILL HELP YOU SAVE LIVES!!!
The Faculty members are four of the leading Critical Care
educators you will ever meet.

Amal Mattu, MD, FACEP, FAAEM
Professor and Vice-Chair
Director, Emergency Cardiology
Fellowship
Department of Emergency Medicine
University of Maryland School of
Medicine, Baltimore, Maryland
Evie Marcolini, MD, FACEP, FAAEM
Assistant Professor
Emergency Medicine, Surgical Critical
Care, Neurocritical Care
Yale University School of Medicine
New Haven, Connecticut
Dr. Winters and Dr. Marcolini are the senior editors of the
bestselling textbook “Emergency Department Resuscitation of
the Critically Ill” and are routinely invited to teach at numerous
conferences pertaining to critical care in the Emergency
Department. Dr. Mattu is author or editor of a dozen books
pertaining to high-risk topics in emergency medicine and is a
frequent invited speaker at many major conferences nationally
and internationally. Dr. Mallemat is an emerging superstar in
critical care teaching and is an invited speaker at multiple
national and international conferences.

You will not want to miss a minute of this conference!

Upon completion of this course in Critical Care in the Emergency

Haney Mallemat, MD, FACEP, FAAEM
Assistant Professor of Emergency Medicine
University of Maryland School of Medicine
Attending Physician, Surgical Critical Care
Maryland Shock Trauma Center
Baltimore, Maryland
Michael Winters, MD, FACEP, FAAEM
Associate Professor of Emergency Medicine
and Medicine
Co-Director, Combined Emergency
Medicine/Internal Medicine/Critical Care
Program, University of Maryland School of
Medicine, Baltimore, Maryland
Department, participants will be able to provide more comprehensive care
to the critically ill patient. Critical care case scenarios will be presented and
discussed in order to challenge and educate participants. Earn ACEP
Category I Credits. Co-sponsored by Florida Hospital. Accreditation for CME
Category I credits, AMA PRA Category 1 credits and CEU accreditation by the
Nursing Board of Florida.
For more information: www.floridaep.com

Cheryl Reynolds, MD, FACEP, CPHRM
Chief Risk Officer
Florida Emergency Physicians period. Discovery can consist of unsworn
“You have been served.” Oh no,
what does it mean? What do I do
now?
Y
ears ago, a process server might
arrive at your house or the
hospital to serve you with the
complaint or Notice of Intent
(NOI). Today the NOI usually arrives in
the mail, either at your residence, the hos-
pital, or your office. The NOI is a legal
document notifying you, the defendant,
that a plaintiff (injured party) is insti-
tuting legal action against you for some
perceived wrong. Usually the wrong is
medical malpractice.
If you are served with this paperwork,
it is very important to immediately con-
tact your insurance company so they can
appoint an attorney to defend you. It is al-
ways good to remember that the attorney
represents you and your employer even
though the insurance company appoints
them.
In the state of Florida, there are strict
rules that govern medical malpractice
claims beginning with the NOI. These
rules were put in place to hopefully de-
crease the number of lawsuits, but in
reality, they have not had that effect.
There is a statute of limitations, which
means the time period the plaintiff has
to begin the lawsuit: usually 2 years from
the time they should have known about
the injury. There are exceptions to this,
however.
The NOI is also a notice giving the
plaintiff 90 days of discovery in which
to decide whether to go forward with
the lawsuit or not. The defendant has
the same amount of time for discovery to
deny the allegations or to try and settle
the case. This is referred to as the pre-suit
Anatomy of a Lawsuit
statements, answers to questions, produc-
ing documents and/or producing records.
After the pre-suit period is over, a lawsuit
may or may not be filed.
Once a lawsuit is filed, there are four el-
ements that must be met by the plaintiff
– duty, breach, causation and damages.
The plaintiff attorney must prove the
four elements to proceed with the suit.
The court has the ultimate decision as
to whether the four elements have been
proven. Before trial, the court is actually
the judge, who may decide on motions
placed before him/her. Either the plain-
tiff or defense can enter the motions.
Once trial has started, the court is actu-
ally the judge and jury. Ultimately, if the
judge does not dismiss the case, the jury
decides upon the four elements.
Duty – This means you had a duty to
treat the patient, or that a physician pa-
tient relationship existed. In emergency
medicine, if the patient enters the ED
asking for care, then a duty exists. Due to
EMTALA regulations, it is difficult for
ED physicians to say a duty did not exist.
Breach of Duty – This means that you
did not meet the acceptable standard of
care. Standard of care is defined as what
a reasonable physician would do under
similar circumstances. It does not mean
perfect care and a bad outcome does not
prove breach of duty. This is the part of
the lawsuit where the experts come into
play the most. It is actually a battle of the
experts where a lot of cases are won or
lost, and you can be your own best expert.
Causation –This means that your failure
to meet the acceptable standard of care
was a direct cause of the patient’s injury.
In the law, this becomes more likely than
not which translates to a 51% chance of
having caused the injury. It is a very low
EMPULSEfeature
hurdle as it is a civil case not a criminal
case.
Damages – This is what the patient
is entitled to due to your negligence. It
includes economic and non-economic.
Economic damages are loss of wages,
loss of potential earnings, cost of care,
medical bills and others. Non-economic
damages include pain and suffering,
mental anguish, loss of companionship
and anything else where a specific price
cannot be placed.
Expect a lawsuit or claim to last any-
where from 2-5 years once it is filed. The 21
legal process is not quick and can be quite
frustrating to ED physicians who live in
a fast-paced world and often want things
to just go away. If you are experiencing a
EMpulse
lawsuit at this time or you do in the fu-
ture, please try to stay patient and know
that to the lawyers, it is just business.
They do not care that you have feelings
or emotions related to the lawsuit. That
is one of the hardest things to grasp for
many physicians. We just think differ-
ently than attorneys.
Once a party to a lawsuit, your attorney
will advise you not to discuss the case
with anyone. That means the particulars
of the case, but I think it is very impor-
tant that you talk to someone about your
reactions and feelings about being sued.
Maybe your life partner, a colleague, a
friend, or whoever you trust to discuss
confidential matters. Please remember
that your insurance company often has
resources to help you through this. Please
keep communications with them open.
Risk Tip – Documentation is very im-
portant in a medical record. If using a
scribe, the chart is still yours and you are
responsible for everything that is docu-
mented and not documented. It is always
helpful to spend an extra minute and read
over the completed chart, especially if you
are depending on others for scribing.
 EMPULSEfeature

A Small Complaint, but

Making a Big Difference

Graham Ingalsbe, MD
University of Miami Miller School of Medicine

E
mergency Medicine is full of exciting moments. Traumas, MIs, air-
ways, chest tubes, lines, cardioversion – there is plenty to keep the I rounded out the history. After a fo-
adrenaline pumping. The acuity, pressure, and exhilarating care in cused physical exam I, too, believed that
the ER are a big part of what draws many of us to the specialty. And this was most likely a rotator cuff injury.
yet, it is by no means all TV-worthy medicine. There are plenty of not-so-sexy There did not appear to be much need to
moments that must be dealt with every day. further analyze with imaging, so I walked
On one of my Emergency Medicine externships, I was in the middle of a busy the patient through the options. The
evening shift in the low-acuity section of the department. The next patient was best tool at my disposal, as it so often can
brought back with a chief complaint of “shoulder pain.” I reviewed the patient’s be, was bringing in our social worker. I
22
record, scanned the vitals (all within normal limits), and headed to the exam tracked down social work, explained the
room. situation, and presented the case to my
attending.
Shoulder pain. Ok, no sweat. Get a quick history, do some basic physical ma-
fcep.org

neuvers, consider imaging, rule out anything critical. I began my interview, and After a short conversation and some
the story started off fairly uneventful. The patient was a horticulturalist work- phone calls, the patient received an ap-
ing at a local nursery for several years. It had become more difficult to perform pointment with a local orthopedic group
the more physically taxing duties at work. She could not recall a specific injury, who would establish a payment plan af-
but reported worsening pain over the last 6 months. No swelling, no fevers, ter an initial courtesy visit. The patient
review of systems entirely negative. The pain was at most a 5-6 out of 10, no was then discharged. Before leaving, she
different on this day than any day over the past month. stepped behind the desk and gave me
a hug. You might think I saved her life
When I asked what brought her in specifically today versus any other day, to
or relieved her of some unbearable pain.
my surprise, she began to tear up. I offered a tissue while she caught her breath.
Simply being there as someone to listen,
As the conversation continues, she reported that though she held her job for
to find a potential solution in an otherwise
years, she would not receive health benefits as a part-time employee. She had
frustrating system, made all the difference
frequent visits to her longtime primary care provider, even seen without charge,
to her. An unsolvable situation now had
but found a dead-end there. She was unable to afford an MRI before meeting
an endpoint.
with her orthopedics consult, and was sure she cannot pay for any intervention.
It was not anything heroic, or drastic;
She was not there for pain meds; her discomfort had been moderately well con-
no TV-worthy performance. It is not the
trolled with over-the-counter analgesics. She was not there for a diagnosis; she
moment the adrenaline-junkies in EM
was previously told that it was mostly likely a rotator cuff tear that will require
itch for. Yet it is the perfect example of
surgical repair. It is not a true solution she was after; she just had nowhere else
how easily we can make a difference with
to go and did not know what to else do.
even the most minor complaints. And,
And she was right to feel that way. She was stuck between making a wage and how the most important moments in the
qualifying for benefits. She was stuck between having access to an emergency department don not have to just be the ex-
room and not being sick enough for surgery. She was trying, however possible, citing ones.
to manage, but no solution came. And so now she sat in front of me, asking
what to do.

John Stimler, DO, CPC, CHC, FACEP
"Tell a complete story” and “paint a
whole picture” are not phrases that imme-
diately come to mind when one considers
the day-to-day role of the emergency
physician; however, as emergency phy-
sician reimbursement rates continue to
drop and RAC audits rise, it has become
increasingly important for clinicians to
re-consider the stories they tell and the
pictures they paint when completing the
records that exist as proof of the patients
they treat in the ED. Why is documen-
tation of a patient record so important?
Ultimately, documentation determines
the amount of money that is paid for
the services that you work so tirelessly
to provide. Secondarily, it serves to keep
you out of trouble in the event that your
work is audited.
Of the three key components of pro-
vider documentation - History, Exam,
and Medical Decision Making (MDM)
- MDM is the most critical. Used by
coders and auditors to determine fi-
nal Evaluation and Management code
choice, it is imperative that providers
understand the importance of proper
documentation, and how insufficient
documentation can negatively impact
reimbursement and compromise future
audit defense. This article explains the
importance of justifying the ordering
of ancillary studies and performance of
procedures via proper documentation
that clearly reveals the thought pro-
cesses that drive a patient work-up, and
Tell Me A Story: Why Proper
Documentation of Differential Diagnoses
Can Bolster Medical Necessity and Justify
an Emergency Physician’s Hard Work
ultimately result in a course of treatment
and a diagnosis.
Documentation of medical necessity
related to ancillary studies and treat-
ment is the primary area of focus in
governmental and non-governmental
audits. Many coders and auditors have
limited clinical experience, so it is criti-
cal that provider documentation tells
the complete story – beginning, middle,
and end, of the entire patient encounter.
Recent changes in the standard of care
for treatment of patients who present to
the ED now call for more extensive (read
expensive) work-ups that may not seem
justifiable without proper documenta-
tion of the thought processes that lead
to a course of diagnosis and treatment.
Auditors tend to focus on the chief com-
plaint or presenting problem, the final
diagnosis, or the amount of time that the
patient spent in the ED when selecting
an E/M level even though these items
may not tell the full story.
Often, providers fail to make a clear
connection between the documented
history and physical exam and the tests
that they subsequently order as no expla-
nation or differential diagnosis is listed
on the record. Excellent documentation
includes the differential diagnoses that
were entertained by the clinician and thus
compelled the orders, making it difficult
for auditors to downplay the interven-
tions that were ordered by the clinician
in an effort to select a definitive diagno-
sis and course of treatment. For example,
a chart that reads "Gradual onset of
typical migraine headache, patient in no
acute distress" may not justify labs, a CT
scan, an MRI, or a lumbar puncture to
rule out particular diagnoses. Inclusion
EMPULSEfeature
of the following statement would help
to justify the necessity of a significant
workup: "While this headache is similar
in character to previous headaches, the
symptoms are much more severe with an
onset that was more abrupt. Therefore,
I feel it is prudent to order a CT and
perform a lumbar puncture to evaluate
for a life-threatening condition such as
subarachnoid hemorrhage.”
While complete documentation is al-
ways critical, there are certain types of
cases that, if not documented properly,
are routinely down-coded due solely to 23
the fact that the provider failed to paint a
picture of the case to the extent that the
significance of the encounter was down-
EMpulse
played by the reviewer. These include:
• Cases involving major orders
where medical necessity
was not documented
• High severity cases posing
an immediate threat to life or
physiologic function where
work-up and therapy were not
justified by the documentation
• Cases involving documentation of
“No acute distress” by the provider
• Cases involving admissions or
transfers that were not justified
in the documentation.
• Cases involving negative
or normal studies.
While poor documentation results in
revenue loss and creates potential medi-
cal legal problems for the provider, good
documentation paints a picture that
supports the ordering of ancillary stud-
ies and/or performance of procedures.
Documentation that supports a pro-
vider’s initial clinical impression and the
 Tell Me A Story, continued
clinical decision making process that follows is
the best protection against governmental au-
ditors who, without a provider’s documented
reasoning – may not understand the rationale
behind the orders. A thorough understand-
ing regarding the importance of excellent
documentation will help to ensure maximum
reimbursement for provider services, and posi-
tive payer audit outcomes. The moral of this
story is that you should tell yours! Paint a
whole picture that explains your treatment ra-
tional with the best defense you have – good
documentation!
24
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Dr. John Stimler is a founder and managing member of Bettinger,
Stimler & Associates, LLC (BSA Healthcare) and the BSA
Healthcare Advisory Group. A nationally-recognized expert in ED
billing and coding, provider documentation, compliance, and prac-
tice management, Dr. Stimler has provided emergency medicine
consulting services to emergency physicians and hospitals in a variety
of practice environments including academic practice plans, hospital-
employed models, and independent fee-for-service environments.
A graduate of the College of Osteopathic Medicine and Surgery in
Des Moines, Iowa, Dr. Stimler completed his residency in emergency
medicine at University Medical Center in Jacksonville, Florida. He is
a Certified Professional Coder (CPC) and is certified in Healthcare
Compliance (CHC).
Dr. Stimler is an attending clinical instructor at the Shands
Jacksonville emergency medicine residency program. He is past
president of the Florida College of Emergency Physicians (FCEP), a
former chairman of the FCEP Medical Economics Committee, and
a former member of the American College of Emergency Physicians
(ACEP) Governmental Affairs Committee. Dr. Stimler is currently
a member of the ACEP Reimbursement Committee.
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 Emergency Medicine Days 2013

W
hen Ms. Costello, the managing editor of the EMPulse, asked
me to write an article about my experience at EM Days, my first
thought was I'm too busy; I’m not the right person for that. So when
I emailed her to express my reluctance, I was really just trying to
weasel my way out of a writing project—especially since I do not consider writing
one of my strong points. Ms. Costello responded to my email by saying, “I asked
Aaron Wohl, MD you because you seemed passionate about your visit to Tallahassee.” But I would not
Chairman describe myself as passionate about politics, I thought. Instead my view of politics
Department of Emergency Medicine is quite pragmatic. Another author sums up my sentiment by suggesting: "It has
Lee Emergency Physicians become increasingly clear that if politics is in medicine, then doctors had better be
in politics.” EM Days is exactly the atmosphere where good, sound policies can be
advocated for and unwise legislation disputed through meaningful dialogue.
As I thought about it more, I realized that Ms. Costello misinterpreted the fact that
Emergency I was happy to be in Tallahassee as passion for the political process. I thoroughly
enjoyed my time at EM days and thought, if I believed it was a good investment of
Medicine my time, why not share that experience with others? I got to exchange ideas with,
and learn from many bright, motivated leaders in emergency medicine. I shared

Days in drinks and anecdotes with friends I had not seen in years and advanced our specialty
by meeting with my local lawmakers.

Tallahassee
27
I have to admit that I had not been to EM Days in five years. I was too busy enjoy-
ing the benefits of a well-paying EM job (thanks to ACEP’s advocacy over the years).
I was working too many shifts; traveling when possible on my days off; focusing on
my hobbies, my relationship, and the daily happenings of my group. I was involved at

EMpulse
work, but only with small administrative projects. Then I decided to take the direc-
tor’s role for my group, which consumed me over the last two years as I struggled to
keep up with massive amounts of information and weekly crisis management. When
my tenure as director ended, I
felt I could invest more time in
FCEP, and was very fortunate
to be appointed to the FCEP
board by Dr. Gray-Eurom.
Because of this new directorial
responsibility, I felt compelled
to read legislation and prepare
myself more thoroughly than I
had for previous EM Days. The
extra investment made my visit
to Tallahassee far more enrich-
ing. And it was a huge benefit
that the FCEP staff had done
such great work in preparing
materials for us to present to
our legislators. They provided
background talking points on
our specialty concerning fair
payment for emergency services,
Pictured from left to right: Terri Repasky MSN, RN, CEN, EMPT, Kelly Gray-Eurom, MD,
MMM, FACEP, Michael Lozano, MD, FACEP (FCEP), Penny Blake, RN, CCRN, CEN and
Sharon Rueter, RN
 Emergency Medicine Days 2013
28 Attorney General Pam Bondi
Florida access to care, EMTALA, and our top legislative pri-
fcep.org
orities for 2013. With this material, any practicing emergency
physician new to the legislative apparatus could quickly famil-
iarize themselves with some of the more intricate issues facing
emergency medicine today. And the reading was reasonable: I
was able to finish most of it in the days leading up to the confer-
ence, and the last bit I finished at the hotel, which is something
else worth mentioning. The Hotel Duval on Monroe Street is a
noticeable improvement over the hotels of EM Days past. It is
not only walking distance to the capitol, but the décor is mod-
ern and the staff was kind and completely accommodating. Plus
there is a Starbucks and Shula’s Steakhouse in the lobby and
a rooftop bar with beautiful views of downtown Tallahassee.
FCEP definitely did a great job researching and designating
this particular venue.
Events got underway on a Monday afternoon and coincided
with Florida Hospital Association’s “Hospital Days” at the
capitol. A group of us, including FCEP’s leadership academy
participants, were able to slip into a talk by former senate ma-
jority leader and heart and lung transplant surgeon, Dr. Bill
Frist. Doctor Frist addressed many challenges of healthcare
policy and gave a compelling argument toward state acceptance
of the Medicaid expansion under the Affordable Care Act.
Listening to Dr. Frist's command of the issues, coupled with
his extensive and admirable résumé, helped me realize that I
could be doing much more as a physician advocate. Following
photos and handshakes with Dr. Frist, we headed to the FHA’s
legislative reception where we met with many of our group’s
hospital administrators.
That first evening ended with a reception held by Dr. Cliff
Findeiss and CitadelMed. Here I was able to meet some of
the residents from different Florida programs, as well as state
Rep. Cary Pigman, an emergency physician from Avon Park,
FL, who is a wonderful resource when it comes to understand-
ing the legislative process. He answered my questions with
ease and a refreshing honesty, and it was this forthright, ear-
nest attitude that helped to recapture some of my lost faith in
the political process. Representative Pigman delivered what I
believed to be his best advice at a luncheon hosted by FCEP
on the following day, when he urged: Although meeting in
Tallahassee with your legislators is helpful, the real impact is
meeting with them locally in your district prior to the legis-
lative session; help them to understand emergency medicine’s
uniqueness as a specialty and its safety-net role in healthcare;
develop a relationship with them and make yourself available
as a physician advisor. If you feel so compelled and can’t give
of your time, donate financially to their campaign or an action
committee whose ideas you support.
Though you might think you have little to contribute to a
candidate’s understanding of the issues, I think you would be
surprised. I continually heard legislators say that there are so few
physicians who are willing to enter into a dialogue with candi-
dates in order to help advise their campaigns. And furthermore,
that those who actually do are highly regarded as advisors and
trusted volunteers. For this reason, it is so important that we do
not underestimate how much the public—elected officials and
candidates included—trust and look up to us for our intimate
understanding of real issues.
On the second day, Dr. Gray-Eurom, Dr. Steve Kailes, and
Dr. Joel Stern briefed us on the legislative priorities for FCEP
2013. We were informed on the language of the sponsored bills
and why FCEP officially opposed or supported them. The
questions and answers heard here promoted further informed
discussion with legislative representatives later. We met with
Florida Attorney General Pam Bondi and discussed some of
the obstacles in utilizing the FPDMP. There were speakers
from AHCA and state Surgeon General Dr. John Armstrong
spoke with us concerning state trauma standardization, drug
shortages, and future physician shortages.
I had numerous legislative appointments that morning
and felt apprehensive about going alone to speak with my
Emergency Medicine Days in Tallahassee, continued

legislators and also feeling like I was fi-

nally doing my small part to promote
emergency medicine.
If you ask my friends, they'd probably tell
you I dislike politics and it is quite possible
I would not argue the point. But I have
come to think it is too easy to be apathetic,
too convenient to say I cannot help any of
it, so why get involved or give financially?
The “media of politics” disheartens me but
I realize now—especially after the time I
spent at EM Days—the importance of be-
ing involved. As physicians we work hard,
policies that dictate our care often miss
the mark, shifts can be emotionally drain-
ing, and there’s still so much to take care
of at home. Yet we must realize at some
29
point that all the issues we struggle with
in emergency medicine are interrelated,
and that each of us needs to be familiar
with what’s happening in our specialty.

EMpulse
Exposure to and recognition of trends
Surgeon General John Armstrong, MD in healthcare and the political process
are necessary so we can contribute intel-
representatives, but I soon realized there was little to be nervous about. In fact, ligently and effectively to the discourse.
speaking on my own with legislators felt more like meaningful discussion than So if the only people who change The
a lobbying effort. The legislators and their staff were welcoming, personable, Course are the ones who actually stay on
and eager to discuss healthcare-related bills with a physician. During a meet- It, I urge you to be a part of EM Days
ing with representative Ken Roberson, who is chairman of the Health Quality and this important conversation, to share
subcommittee, I expressed disappointment that I’d missed a meeting with my your experiences and be willing to work
local representative, Dane Eagle. Upon hearing this, Rep. Roberson escorted in an informed and inspired way toward
me down to where a house session was starting and asked Rep. Eagle to come change. By doing nothing we relinquish
out of session to meet with me briefly. It made quite an impression on me that every bit of insight and value that our pro-
Rep. Roberson and his assistant went out of their way to ensure that I met with fession bestows upon us, and we choose
my district’s representative. to lose our one and only voice to the pol-
icy-making machine. EM Days 2014 . . .
This year we were also fortunate to have two delegates from the American
Hope to see you there.
Academy of Emergency Medicine attend EM Days, Dr. Mark Foppe and Dr.
David Rosenthal. They actually received a round of hugs from their represen-
tatives and staffers after sharing a poignant story about emergency medicine’s
role as a safety net and the unfairness of disallowing balance billing. I came
away from that particular day feeling like my opinion actually mattered to my
 EMPULSEfeature
Penny Blake, RN, CCRN, CEN
Chair, Government Affairs
Florida Emergency Nurses Association
Terri Repasky MSN, RN, CEN, EMPT
President
Florida Emergency Nurses Association
E
mergency nurses and phy-
sicians have a long history
of collaboration and work-
ing together for the welfare
30 of patients. Perhaps more so than any
other specialty areas, we have learned
the importance of depending on each
other to achieve the best outcomes. In
fcep.org
the spirit of that philosophy, four Florida
Emergency Nurses Association (FENA)
members participated with FCEP mem-
bers during Emergency Medicine Days
March 11-14, 2013 in Tallahassee. At
the conclusion of those days, participants
met to exchange ideas related to emer-
gency department (ED) crowding, the
future role of the emergency physician in
our changing healthcare environment,
and the increasing problem of violence
in our emergency departments.
Penny Blake RN, CCRN, CEN,
FENA State Government Affairs Chair;
Sharon Reuter RN, Immediate Past
Chair; Terri Repasky, MSN, RN, CEN,
EMTP FENA State President; and
Lynda Tiefel RN, CEN, Tallahassee
Chapter Secretary/Treasurer, joined
FCEP members in informational ses-
sions, visiting legislators, and attending
the FCEP Board of Directors meeting
during this event. This year FENA and
Florida Emergency
Nurses Joined FCEP for
Emergency Medicine Days
FCEP identified several common areas
of focus for their public policy agendas:
• HB 3 and SB 66-- (Child Safety
Devices in Motor Vehicles) FENA
is working with the Florida
Booster Seat Coalition and other
groups to get this legislation
passed this year. FENA members
attended a Press Conference held
by the Booster Seat Coalition at
the capitol during EM days.
• HB 13 and SB 52 (Wireless
Communication While Driving)
Both groups are supporting texting
and driving legislation by lobbying
legislators and by providing
education on effects of texting and
driving. If requested both groups
are willing to provide testimony as
to effects we have seen in the ED.
• Professional Practice/Conscious
Sedation. Together we continue
to monitor the situation with
the Florida Board of Nursing
and prepare to intervene if any
legislation looks eminent.
• Work Place Violence. Workplace
violence has been identified as a
particularly serious problem for
healthcare providers in the ED.
Along with psychiatric units and
nursing homes; the ED is one of
the most dangerous work settings
in healthcare; this is a concern of
FENA and FCEP. care. Boarding is a problem that affects
After the welcome and introductions
on March 12, those attending EM Days
heard from several speakers on topics of
interest and concern to both FCEP and
FENA. Florida Attorney General, Pam
Bondi, opened by describing a person-
ally tragic experience from the previous
weekend; a friend’s daughter who died
as a result of an motor vehicle collision.
She thanked nurses and doctors from
Tallahassee Memorial Hospital for their
caring and compassion, as well as their
skill. She then updated those present
on the actions Florida is taking to shut
down “pill mills” and the success that the
strike force was having. She also iden-
tified synthetic drug sales as being “out
of control” and stated that this session
she had signed two emergency orders to
prevent sales of such drugs. FCEP and
FENA members verbalized their sup-
port of the state initiative while noting
that there has been an increase in the
number of patients seeking narcotics in
the ED. The physicians also discussed
the on-line tracking of narcotic pre-
scriptions and suggested to Ms. Bondi
that the system might be made more
user-friendly.
AHCA Field Director, Polly Weaver
spoke after Ms. Bondi and stimulated
discussion when asked about the use of
hall beds for boarding of patients in hos-
pitals. She noted that use of a space for
a boarded patient must be approved by
AHCA ahead of time, and that having
patients in hallways in both emergency
departments and on hospital floors was
“not considered safe for patient care.”
FCEP and FENA members suggested
that most ED’s in Florida are utilizing
hall beds in an attempt to avoid delays in
every ED and suggestions ranged from
legislation to deal with obtaining needed
space to reporting to AHCA when vio-
lations occurred.
Florida Surgeon General, John
Armstrong, spoke to issues of concern
to both ED physicians and nurses. He
stated that in order to have an integrated
trauma system in the state, we need to
track all patients, not just those taken
to trauma centers. He described how,
in the past, “We have not thought of
it as a trauma system, but as a group
of trauma centers.” Regarding mental
health, he added that he felt funding for
mental health across the state would be
maintained this year. Physicians spoke
of concern for the continued drug short-
ages throughout the state in hospitals
and the pre-hospital arena. Armstrong
acknowledged the problem and said that
it was being tracked by the Department
of Health; he stated the causes were
complex.
After the presentations attendees vis-
ited legislators. During legislative visits,
FENA members met with four repre-
sentatives and six senators to discuss
FENA's Public Policy Agenda and also
left information packets with other key
legislators. Education was provided
on two issues of importance to FENA
members:
1. Funding and support for mental
health care in Florida, especially
prevention and follow up care.
that Florida has the weakest child
passenger laws in the country.
FENA members also attended the
FCEP Board of Directors meet-
ing. During the Board meeting, Ms.
Repasky presented an update of FENA
activities and the FENA strategic plan.
Activities include educational endeav-
ors with EMLRC, advocacy promoting
safety and well-being of Florida citizens,
children and healthcare providers, and
strategies to increase awareness of and
decrease workplace violence. FENA
also monitors issues related to care of
behavioral/mental health patients in the
ED, professional practice, and provides
scholarships to members for trauma
and emergency related education and
certifications.
Board members and guests discussed
the role of the ED physician in the
future related to accountable care or- Penny Blake Testifying During
ganizations (ACO) and to changes in Emergency Medicine Days
Medicaid reimbursement and billing.
31
Some of the physicians and nurses were Safety, found that ED nurses are more
able to speak to the success of changes in likely to be attacked than police officers
their workplaces which incorporated the or prison guards. In 2012, the Florida
ED physician in the hospital structure
Hospital Association, in collabora-

Cuts to mental health funding tend
to shift financial responsibility to
the ED, community hospitals, law
enforcement agencies, correctional
facilities and homeless shelters.
The result is delayed care while
transfer to an appropriate mental
health facility is being arranged.
In the meantime, these mental
health patients occupy ED beds,
delaying treatment of incoming
patients.
2. HB 3 and SB 66 (Child Safety
Devices in Motor Vehicles/HB
013 and SB 52 (Use of Wireless
Communication Device while
Driving), supported both by
FENA and FCEP. Data was
provided which demonstrated
that booster seats save lives and,
according to the National Highway
Traffic Safety Administration,
the proper use of a safety seat can
reduce a child’s fatality risk by up
to 71%. They also pointed out
for patient care and follow through.
Of particular interest to the FENA at-
tendees were the discussions that took
place during the wrap-up session. A
topic which engendered a great deal of
discussion, was the issue of failure to
enforce and prosecute the law relating
to violence against healthcare work-
ers. FENA member Penny Blake spoke
at the Florida Senate Appropriations
Subcommittee on Criminal and Civil
Justice about work place violence
(WPV). While not directly related to a
proposed bill; she brought the subject to
the attention of the committee members
by telling personal stories of substantial
injuries sustained by ED colleagues in
their workplace. She reported how the
Emergency Nurses Association collected
data on violence in the ED over the past
5 years and that 70% of ED nurses who
responded to a national survey on WPV
had been battered or assaulted within
the past last year. NIOSH, the National
Institute of Occupational Health and
EMpulse
tion with the Florida ENA, and other
stakeholders, surveyed Florida hospitals
regarding WPV. Fifty-two hospitals re-
sponded to the survey, reporting almost
3500 incidences of workplace violence –
an average of 67 incidences per hospital.
Of those, more than 75% occurred in the
ED.
As many of these WPV events go
unreported, or ARE reported and go
unprosecuted, Ms. Blake challenged
the committee to recommend an in-
terim study to investigate why Florida’s,
Statute 784.07 is so often not enforced.
After learning of Ms. Blake’s testimony,
FCEP members requested more infor-
mation and offered their support to the
effort.
Safe Practice and Safe Care is impor-
tant to FENA and FCEP members;
FENA would like to thank FCEP for
the invitation to join them for EM Days
and looks forward to future collaborative
efforts.
 EMPULSEfeature
Southeast Regional
Emergency Medicine Medical
Student Symposium
Nicole Hodgson, MSIII
University of Miami Miller School of Medicine
"Remind me again. What two things do we need for success-
ful bag ventilation?"
"An open airway and a good seal," the group chanted in
unison.
"Perfect. Now go do it."
More than 50 medical students turned out on March 2, 2013
to attend the Second Annual Southeast Regional Emergency
32
Medicine Medical Student Symposium at the Gordon Center
for Research in Medical Education at the University of Miami's
Medical Campus. The Emergency Medicine Interest Groups
of the University of Miami and Florida International University
fcep.org
co-hosted the event, while the Emergency Medicine Residents’
Association (EMRA) sponsored it.
Attendees came from all over the region, with representatives
from the University of Miami, Florida International University,
Florida Atlantic University, Nova Southeastern University, and
Ross University, in order to listen to lectures by distinguished
Victoria Garrett, MD, Rob Levine, MD, FACEP,
Andrew Bern, MD, FACEP discuss Emergency
Medicine
emergency medicine speakers, participate in hands-on work-
shops, and network with other students considering the field.
The event began with the exciting announcement by Dr.
Robert Levine, Chief of the Division of Emergency Medicine
at the University of Miami Hospital (UMH) that UMH has
begun the process of creating an Emergency Medicine (EM)
Medical students enjoying the Southeast Regional
Emergency Medicine Symposium
residency program and plans to select an initial class of resi-
dents in as little as two to three years. If the process continues
as planned, students currently in medical school potentially
could be members of the initial resident class.
After a discussion of the residency creation process, Dr. Levine
yielded the stage to Dr. David Caro, the Program Director of
UF-Jacksonville's EM Residency, who conveyed some advice
for potential EM students. The crowd was on the edge of its
seat as Dr. Caro shared secrets about how to excel in each year
of medical school, including advice on how to stand out in
externships and how to immerse oneself properly in research
experiences. Matching in Emergency Medicine is becoming
more difficult with each passing year, so advice on how to take
full advantage of one’s years in medical school and stand out
among the emerging competition is extremely valuable.
Next, students participated in a lunch panel with Dr. Levine,
Dr. Caro and two other speakers, Dr. Victoria Garrett, who is
a former faculty member of Jackson's Emergency Department
and of Carolinas Medical Center, and Dr. Andrew Bern of the
American College of Emergency Physicians Board of Directors.
The interactive discussion ranged from which qualities a

David Caro, MD, FACEP demonstrates
airway procedures using bag ventilation and
laryngoscopy.
program director looks for in an Emergency Medicine applicant to how
the Affordable Care Act will impact the field of Emergency Medicine.
A highlight for many students came at the end of the day, when Drs.
Caro and Garrett led a hands-on airway workshop focusing on bag ven-
tilation and laryngoscopy. Upon completing the session, students were
comfortable with both the one-hand and two-handed techniques of bag
ventilation, could compare and contrast Miller and MacIntosh blades,
and had the opportunity to attempt laryngoscopy and intubation of a
mannequin.
As most medical students are not exposed in-depth to Emergency
Medicine prior to their fourth year, at which point career decisions of-
ten have already been made, opportunities like the Southeast Regional
Emergency Medicine Medical Student Symposium are crucial in helping
students explore the field and select their future careers. Through this
event, students were able to hear about the benefits (as well as challenges)
of Emergency Medicine first-hand from attendings, network with upper-
classmen who recently committed to the field, and obtain useful advice for
setting themselves up to be strong applicants in the increasingly competi-
tive field of Emergency Medicine

Prep
33

exam, for Daunting diagnosis, continued from page 13.

the Diagnosis:

The whole exam,

EMpulse
Patient presents with dysphagia. He says he

nothing but the exam

And has been having trouble swallowing food for a
couple of days. First test was a soft tissue neck
radiograph. It appeared that he had dentures
August 15-18, 2013
95% stuck in his esophagus. Upon further question-
Pass Rate! ing of the patient, he proclaims, “I did loose
Baltimore, MD
my dentures two days ago, is that where they
www. Pa ACEP.org/written went?!” Later that day, his dentures were re-
moved from his esophagus via endoscopy by
Join us for 3 ½ days packed with what you need to know to pass the GI, and he was discharged home.
exam. Thousands of physicians have used our course to prep for the
-Picture submitted by Karen Estrine, DO
emergency medicine board review exam, with great success:
– Developed and taught by practicing, ACEP member, board-

– Teaches what you need to know to pass the exam

Do you have a Daunting Diagnosis
– Brought to you by the specialists in emergency medicine board
review courses you would like to share?
– Superior Board Review question and answer book of more than Send it to editor@fcep.org.
1,300 questions – mirroring the format of the ABEM exam

For more information, please visit our website

or contact Nancy Miller at 717.909.2685 or
nmiller@pamedsoc.org.

Approved for AMA PRA

Category 1 Credit(s)TM
scan here for
Harrisburg, PA 717.909.2685 more information
 Residents compete on realistic simulated
patients
Presented with an unknown acute emergency
clinical scenario
Use a high fidelity simulator to diagnose and
manage critically ill patients – including
performing major procedures
Judged on the basis of teamwork, communica-
tion and decision making

RESIDENCYmatters
34
opportunity to present at national meet- leadership, attendings and fellow residents
ings over the course of this academic year, that help make this opportunity possible.
and this trend will continue with SAEM With growing national emphasis placed on
fcep.org

University of Florida, Gainesville
Joel Rowe, MD, PGY-2
Our residency continues to hit its stride
as this academic year marches into Spring.
We are especially excited about our recent
Match Day results. We offer our congratu-
lations to all those who are graduating this
year from medical school on a job well done,
and are excitedly awaiting the arrival of our
next class of interns. We are greatly antici-
pating them joining our team here at UF/
Shands in Gainesville.
In addition to having a very successful
Match, our residency continues to excel
academically on the regional and national
stage; meanwhile, our residents are actively
seeking out ways to contribute on a world-
wide scale. Multiple residents have had the
2013. Current PGY-2, Dr. Joel Rowe will
be presenting a poster entitled, “Evaluation
of an Age-Adjusted D-dimer Threshold
in the Diagnosis of Acute Venous
Thromboembolism” at the upcoming meet-
ing in Atlanta.
On a different note, current PGY-3 and
Co-Chief Resident, Dr. Brandon Allen,
was elected to be the National Residency
Review Committee (RRC) as Resident
Representative. Dr. Allen is also a current
member of the EMRA Board of Directors.
At the recent Regional SAEM meeting, the
Gator Nation was alive as multiple residents
were able to make the trip to Jacksonville.
PGY-1’s: Dr. Hannah Eason, Byron Bassi
and Matthew Tice; PGY-2: Jonathon
Holloway; and PGY-3: Jason Jones were
able to attend and participate in the SIM
WARS. The conference was fantastic, and
everyone was thrilled about having the op-
portunity to attend. Along the same lines,
the current PGY-2 class is gearing up to
attend SAEM in Atlanta. This is an an-
nual tradition for PGY-2’s in our program,
and many thanks go out to our program
QA in EM, current PGY-2, Dr. Elizabeth
Flail, is starting up a resident quality com-
mittee website. The website will have a
monthly agenda of issues to be addressed
at our regularly scheduled conferences. Dr.
Flail is currently a part of an institutional
committee that focuses on QA.
The commitment of our residents to
providing health care to those in need
reaches far beyond the Shands campus in
Gainesville. We have had multiple resi-
dents participate on medical missions in the
last several months. PGY-1 Krystle Hunt
ventured to Port Au Prince, Haiti with
Project Medishare to volunteer at Hospital
Bernard Mevs in February. Dr. Holloway
also recently traveled to Lake Azuei, Haiti
with one of our attendings, Dr. Harvey
Rohlwing, to provide medical relief. PGY-
3 Jonathon DeGroat helped organize and
lead a trip to Nicaragua this past March.
All parties returned safely and had numer-
ous stories and pictures that documented
their journeys.
Until next time, so long from Gainesville
and…GO GATORS!!!!

University of South Florida
Stacy Marlow, MD, JD
This is a very exciting time of year for ev-
ery EM residency program, and USF is no
exception. We are excited to announce that
we filled all ten of our EM slots with fabu-
lous candidates from around the country.
Welcome Tino Diaz, MD, Jesse Dubey, DO,
Robert Grammatico, MD, Nesreen Kaufman,
MD, Juliana Lefebre, DO, Joey Rosenberg,
MD, Rad Soucek, MD, Andrew Spencer,
MD, Richard Talbot, DO, and Don Wilkins,
MD. Our newest residency class represents
a very diverse group of people, including
those who have completed other residencies,
those who have been working in other fields
for many years, and those who have gone the
more traditional route. We are excited for the
upcoming year.
On the same note, we will greatly miss our
PGY3 residents who will be leaving for their
new full-time careers. We have residents trav-
eling to all corners of the country, and staying
right here in Tampa. They will all do amazing
things.
At SE SAEM, three of our USF PGY3’s,
Lindsay Lyon, Daniel Gowhari, and Phillip
Coker, participated in SonoWars and took
home first place. We are very proud of our
ultrasound program at USF and would like to
thank Charlotte Derr, MD, associate program
director and US director for pushing us to ac-
complish great things with US.
In March, four PGY2’s attended EM Days
in Tallahassee to increase their knowledge of
current health policy issues and discuss these
issues with legislators and aids. It was a very
informative experience and will help pre-
pare us to further advocate for EM policy in
Washington DC at the ACEP Leadership and
Advocacy Conference in May.
RESIDENCYmatters
Ashley Doscher, MD
Hello from Shands Jacksonville! Can you
believe that it was match time already? The
University of Florida-Jacksonville is proud
that we filled every spot in every specialty
this year. Quite a feat and it could not have
been done without the tremendous amount
of time and effort that faculty and residents
alike spent on planning and interviewing
the largest number of applicants ever. A University of Florida, Jacksonville
huge thanks to everyone involved. competed all the way to the finals. Finally,
Now, just a few short notes on some recent Jacksonville again hosted the Southeastern
events. Dr. Christine Swenton traveled to SAEM conference, and Drs. Brandi
Gainesville to receive the Outstanding Gilchrist, Nataly Saldana, and Melissa
Teacher in Emergency Medicine award.
Mann finished strong in the SONOwars
Dr. Kristin McKee, myself, and emergency
competition.
critical care nurse- Marsha Walker- trav-
We are also pleased to welcome our in-
eled to the Society for Simulation in
Healthcare Conference SimWARS and coming intern class.
35
Doug Haus, DO
In mid-January, we had a great journal
club on airway management at Dr. Bethany
EMpulse
Ballinger’s home. It was well attended by
residents, students, core & clinical faculty
as well as some program alumni. In early
February, Assistant Program Director
Dr. Ademola Adewale and PGY 2, Zach
Wilson MD, presented their poster on
workplace violence at the annual AAEM
Scientific Assembly. Way to go! Florida Hospital
Moving forward into February, the final
together at Farris & Foster’s Chocolate
moments of sorting out the Match list went
Factory.
well. We had over 875 applicants for 6 posi-
tions. We matched 6 great applicants from On March 14th the largest Greater
Orlando Disaster Drill took place incor-
as far North as Boston University to as far
porating nearly every level of emergency
South as Nova Southeastern University &
response in the area including the par-
Florida International University. We are
ticipation of more than 10 hospitals and
thoroughly excited to start working with
over 800 volunteer patient actors. The
these great new team members.
Florida Hospital EM Residents took lead
Coinciding with the Match, we had a at Florida Hospital East Orlando and per-
great time of preparation for this year’s formed admirably. We are now looking
ABEM In-Service exam on February 27th. forward to sending our Intern class to the
The In-Service exam went well for us. 13th Annual FEP Symposium on Critical
The day following the exam, we had some Care to help prepare them for the PGY 2
needed resident recuperation and all went year. It will be exciting as all prepare for
out and learned how to make chocolate the transition to the next step come July!
 RESIDENCYmatters
Mt. Sinai Medical Center
Andrea Apple, DO, PGY3
The ER has been busy with recent events
in the Miami area such as the Miami Music
Festivals/Ultra Fest (bringing in 300,000 to
our area) in addition to the spring-breakers.
These events have definitely increased our
number in the ER, but our residents have
been working hard and keeping our patient
satisfaction scores high.
Many of our residents attended FAAEM
and AAEM. We are proud of Dr. Rachael
36 Blumberg who was chosen to participate in
the photo competition at AAEM.
It is that time of year again and we are
fortunate to have a very outstanding intern
fcep.org
class selected! We have had outstanding
students rotate. We congratulate them on
graduation and wish them well in their
residencies.
We also want to thank our chiefs, Drs.
Cameron McDow and Michael Devarona,
who have contributed so much this year
to make our residency academically and
clinically stronger. Their time and dedi-
cation are appreciated. Furthermore,
our next year’s chiefs, Drs. Andrea Apple
and Richard Giroux, were selected in late
March. We look forward to their service.
Dr. Harrison Borno has stepped up as the
social chair.
As the year begins to close, our 4th year
residents have taken their boards and we
wish them the best as they start their new
careers. Our graduating senior residents
have secured jobs from Florida to Texas.
We are grateful for their friendship, leader-
ship, and hard work and are proud of the
outstanding emergency medicine physicians
they have become. We wish them all the
best in their professional endeavors.
St. Lucie Medical Center
Sarah Duquette Fowles, DO, OGME III
With snow-bird season in full swing,
the St Lucie Medical Center Emergency
Department has been busier than ever, and
so have our residents! In addition to our
clinical schedules, we are looking forward
to participating in some exciting events
this spring. During the first week of April,
all of our third year residents will be join-
ing Dr. White in the Dominican Republic
for a medical mission that includes teach-
ing a First Responder curriculum to
nurses, physicians, police officers, teach-
ers and hotel managers. They will also
spend a day of work in a Veron, Dominican
Republic medical clinic.
While the third year residents are away,
the first and second year residents will
be kept busy preparing and executing a
skills lab at the ACOEP Spring Seminar
which is expected to have over 100 partici-
pants. On April 10 we all participated in
the annual Residents Day Out, which as
is tradition, the activities of the day will
be kept secret until the day of the event.
With April, also came the ground break-
ing on construction of our new Emergency
Department. In addition to the upcom-
ing activities, we are also very excited to
announce that we matched our top four
choices in the match for the graduating
class of 2017! We greatly anticipate wel-
coming them to our family in July.
Orlando Health
Sarina Doyle, MD
Spring has finally arrived, bringing with it
exciting new changes. Congratulations to
everyone who matched in emergency medi-
cine in the state of Florida. We are looking
forward to welcoming our new family mem-
bers into the program in July, and could not
be happier with our match list. We have new
residents joining us from all over the country,
and are lucky enough to have matched some
of our rotators who we are grateful to have as
part of our program.
Of course, the new match results also mean
that soon, we will be saying goodbye to our
third year class. Our third years are sad to
be leaving the place they have called home
for three years, but are looking forward to
starting as attending physicians across the
country. This year, we have two residents
taking fellowships here in Orlando in ultra-
sound and research. As for the other seniors,
they have taken jobs in Florida, Virginia,
Wisconsin, Texas and Indiana.
As a program, we are thrilled to watch
as our residents continue to provide excel-
lent care for patients throughout the United
States. Good luck to all residency program
seniors as you take the next step toward your
future!
The other news here at Orlando Health is
definitely the construction. What was just
recently a large hole in the ground is shap-
ing up to be an enormous extension of our
hospital, and every day we are getting closer
to the completion of this large renovation. So
far, in the ED, we have four new resuscita-
tion rooms which are just a glimpse in what
is to come. We look forward to the project's
completion and the benefits it will provide to
patient care.
EMpulse
37