Fall 2017 Newsletter
Dear FLAAEM Members,
Welcome to the fall 2017 edition of the Florida Chapter Division of the American Academy of Emergency Medicine (FLAAEM) newsletter. The fall edition includes a new section: Florida EM Residency Spotlight. We at FLAAEM are working hard to represent our members’ interests. Let us know any issues you are experiencing practicing emergency medicine in the state of Florida so we can bring light to the situation. Email the board at firstname.lastname@example.org with any questions or concerns.
Michael Dalley, DO FAAEM, Program Director Mount Sinai Medical Center Miami Beach EM Residency,
Board of Directors FLAAEM, Communication Committee Co-Chair, Newsletter Editor
In this Issue
Dear FLAAEM Members,
It is with a heavy heart I write to inform you that AAEM President, Kevin Rodgers, MD FAAEM, was tragically and violently taken away from us today in Indianapolis, IN.
Throughout the course of his career, Dr. Rodgers demonstrated incredible leadership and dedication to AAEM, serving faithfully on the board of directors for 12 years as an at-large member, secretary-treasurer, vice president and most recently, as president. He has been an integral part of AAEM’s educational programs and was a tireless champion for the organization.
He touched thousands of emergency medicine residents throughout his career in his roles as an educator and program director.
Kevin was also a veteran of the U.S. Army, where he served with distinction for over 10 years before honorably separating at the rank of Major.
It is still too early for us to process this tragedy. Our thoughts are with his family and his colleagues at Indiana University during this most difficult time. May he rest in peace with eternal love.
David A. Farcy, MD FAAEM FACEP FCCM
FLAAEM was honored to have him speak at our Scientific Assemblies for the past two years. Dr. Rodgers was a great supporter of the Florida Chapter Division.
Vicki Norton, MD FAAEM
President, Florida Chapter Division of AAEM
The Cost of Indifference
I always encourage my colleagues to join AAEM. I am always the one trying to convince my fellow EM physicians of the value of supporting an organization that looks out for our best interest. My plea, however, is usually met with indifference.
We are in a new age of medicine. Gone are the days of private practice and doctors controlling the care they deliver. Today, we are all saddled with numerous government regulations dictating our care and patient satisfaction scores are tied to reimbursement. Most of us work for corporations that are interested in their bottom-line and could care less about physician wellness and job satisfaction. We are not in control.
If you are an emergency medicine physician NOT in a situation where you feel the influence of corporate forces, then you are in the sweet spot my friends. Unfortunately for you, it may not last.
Academic emergency medicine has long been immune to the effects of the corporate practice of medicine, that is, until now. I hope you are all aware of what happened to the EM residency and independent democratic EM group at Summa Health in Akron, Ohio, this January. The EM group, that held the contract for 40+ years while running a thriving residency program, was suddenly ousted in favor of a corporate management group. The emergency department was in total disarray in the aftermath. Locum tenems physicians with zero orientation, and in some cases, no EMR access, walked in to work after 4 days notice of the contract upheaval. The emergency residency is now gone, closed down by the ACGME once word got out that appropriate faculty were no longer training residents.
In our state we are dealing with a variation of this. Multiple residency programs have opened in the last few years in departments managed by corporate management groups (CMGs). Will these residents get the same training as university based programs? Will they be unconsciously indoctrinated to see CMGs as the good guys?
What’s so bad about working for a corporation? Not much, if you ask many EM doctors. However, I plead with you to question: How many of you know what is billed in your name? If you ask your employer to see the books, what will they say? They will probably show you a list of meaningless RVUs and call it a day. If you press the issue you will probably be off the schedule, if not outright fired. The reason they don’t want you to see the numbers is because you will be outraged by how much they skim off the top of your reimbursement, sometimes 40-50%. This is illegal, by the way. It is called fee splitting. It is federal law that the doctor’s fee should go directly to the provider, who can then take some to pay for management and billing company fees, etc. usually <20%. But the CMGs know if they are transparent about billing and collection, we providers would be appalled that they were making such a large profit off of our labors.
Making a profit is usually at the expense of patient safety. How many of you work at a facility that is understaffed, seeing 3-5 patients an hour? You may feel like a rock-star, and believe me I’ve been there, but it is not safe and you will miss something. What about at a facility that encourages you to admit insured and Medicare patients? There was already a federal lawsuit filed in 2011 about this issue. (US ex rel. Meyer & Cowling et. al v. HMA, Newsome, Emergency Medical Services Corp. and EmCare, 11-cv-01713 (D.S.C. 2011).) Or what if you feel the need to keep quiet about patient safety issues when it could threaten your job? If you speak up and it paints the CMG in a bad light to hospital administrations, you could be “interfering” with their contract at the hospital. Not only could you be fired, but also you could be slapped with a tortuous interference lawsuit (read your contract!). I personally know physicians in our state who have had this happen to them.
So what does this indifference cost us? Our training, our wellness, our money, our job satisfaction and ultimately, it will threaten our patients’ lives.
Still content to work with your heads down and keep the status quo? Who will stand with me and try to take back control? Talk to your colleagues, support AAEM, go to advocacy events, and don’t be indifferent anymore.
Save the Date: the 7th Annual FLAAEM Scientific Assembly February 10-11, 2018, at the Fontainebleau Hotel Miami Beach
Michael T. Dalley, DO FAAEM
Program Director EM Residency MSMC Miami Beach
FLAAEM at Large Board of Director
Editor of FLAAEM Newsletter
With each passing year, our hallmark event for members, the FLAAEM Scientific Assembly continues to grow and improve. This year, the scientific assembly planning committee can not be more excited about what the assembly has to offer:
New this Year:
- TED Talks in Emergency Medicine: Exciting High Yield rapid fire format which extracts the “need to know” information of a lecture topic and condenses the presentation to 25 minutes
- Expert Panel Discussions: Interactive discussion between attendees and expert panelists allowing for an academic debate on best practices as they relate to the management of difficult emergency cases
- Pro/Con Debates: Experts from across Florida will debate controversial topics in emergency medicine and support their practice approach based on the most current and relevant scientific evidence.
- Challenging EM Cases- Stump the Expert: Selected panelists will field challenging EM cases and with the help of an interactive audience and moderate come to a final diagnosis and management consensus
- Breakout Sunday Sessions: Small group sessions planned for Sunday morning and afternoon include
- Basic Ultrasound Workshop for the Community EM Doctor
- Advanced Ultrasound Workshop
- 1st annual Sim Wars for participating EM residencies in Florida
- Medical Student EM Interest Lecture Series
- First Annual South Florida Women Physician Luncheon
As always, the conference will offer over 16 hours of CME opportunity for the physicians in attendance, along with our annual Saturday Evening Social and Happy Hour after the conference on Saturday night.
I hope to see all of you at the 7th Annual FLAAEM Scientific Assembly at the Fontainebleau in Miami Beach on Saturday and Sunday, February 10-11, 2018.
Kendall Regional Medical Center
As we progress into the oncoming interview season the emergency medicine residency program at Kendall continues to grow. We now have our second class settled in and they are joined by a host of new faculty to help make the training experience even better.
We want to welcome our new faculty. Dr. Valori Slane, who is global health fellowship trained, a previous medical director and now one of our APDs. Dr. Matt Slane joins us as core faculty and brings with him a wealth of experience in tactical and mountain medicine. Dr. Astrid Sarvis started with us as core faculty in September and bring with her a wealth of experience in pediatrics and pediatric emergency medicine to round out the resident training in pediatrics. Dr. Tony Zitek will also be joining us as research director in the next few months to help us grow our research mission. His experience as associate research director will help us really ramp things up for the resident research experience. Dr. Jesus Seda, also joins us to round out the core faculty experience and has remained focused on enhancing resident and student education since he was chief resident.
What we are also really excited about is the South Florida Educational Consortium. This collaborative venture involving all of the emergency medicine residency programs in Southern Florida will allow us to help grow the educational experience for all the programs involved.
Now it is time to get back to the interview season and we are really looking forward to the opportunity to recruit our next class!
Kevin King, MD
Mount Sinai Hospital, Miami Beach
The transition to ACGME accreditation is going smoothly. The first seven residents of the revamped program are off to a strong start and making the residency proud. Below are some of our recent highlights:
Drs. Nick Garrett (PGY-3) and Laurie Boge are proud to announce that they will host the first annual of the South Florida Wilderness Medicine Conference on March 2-4, 2018. This will be the only Advanced Wilderness Life Support course in the subtropical zone of the US! More information about the conference and registration can be found on the website.
Our Ultrasound Director, Dr. Mark Newberry, hosted a hospital wide ultrasound workshop in basic and advanced applications of point of care ultrasound. The weekend conference was well attended by EM residents as well as other specialty house staff. A special thanks goes to the Florida Hospitals US fellowship director, Dr. Alfredo Tirado, and staff who were invited speakers.
Mt. Sinai was represented strongly by Drs. David Kinas (PGY-4) & Justin Burkholder (PGY-3) in the Clinical Pathology case competition at this year’s FCEP Symposium by the Sea.
As well all know hurricane Irma was a big challenge to all of south Florida and close to home for many of us. Our residents, attendings, and nursing staff successfully managed hospital coverage for over 65 hours during hurricane Irma. Miami Beach was evacuated, however Mt. Sinai remained open and continued to provide medical care to its close knit local community. We were thankful for the support and opportunity to give back to our community in a time of need.
On that note, Dr. Justin Burkholder (PGY-3) accompanied EMS personnel into the Florida Keys post hurricane Irma relief effort as part of his EMS month. This provided our residency with a unique perspective of disaster medicine and the role EM physicians play during and the aftermath of catastrophe.
Our Department Chairman, Dr. David Farcy, had the honor of speaking at the Red Sea Emergency Medicine conference in Saudi Arabia. At the conference, Dr. Farcy was recognized for his outstanding contribution and effort to our specialty.
Robert Farrow, DO
University of Miami/Jackson Memorial Hospital
Greetings from Miami. It has been a busy few months here in Miami. Like all the Florida programs we felt the effect of Hurricane Irma. Luckily we survived relatively unscathed. For many of our residents it was their first disaster activation, as well as the first hurricane experience for many of them. It was great to see how the residency came together to help each other and help take great care of patients. While we were very proud of how our residency came together we are happy to be near the end of hurricane season here in Florida.
We are looking forward to start interviews for our third residency class. We are excited to have applicants come in from all over the country to see our residency. It is a great chance to show off all the things that make our residency great; our hospitals, our patients, Miami and most important our faculty and residents. It will be our third class and we are excited to have our full contingent of residents soon.
Happy Holidays and Happy interview season from the Jackson Health System/University of Miami Miller School of Medicine Emergency Medicine Residency Program.
Chris Freeman, MD
St. Lucie Medical Center
Autumn is finally here after a busy hurricane season. We at St. Lucie Medical Center are looking forward to the beautiful upcoming Florida winter! The 2017-2018 residency year is in full swing and we have been going through some exciting changes.
Our emergency medicine residency program has received initial ACGME accreditation starting this year. We have transitioned from a 4 year program to a 3 year program, we have revamped our lecture schedule, and we have added an outstanding weekly EKG conference.
We are happy to say that our new class of residents, Drs. Alexandra Chitty, Christine Gonzalez, Oliver Morris and Kevin Summers, are all doing an outstanding job and we are very proud of their performance. Keep up the good work!
Currently, our residents are working on research in snake venom, emergency medicine learning modules for medical students, urinary tract infections, and cost-saving measures in the emergency department.
Several of our residents attended the 2017 FLAAEM conference earlier this year in Miami and we are looking forward to the upcoming conference in February 2018. Can’t wait to see you all there!
Thomas Adams, DO
Free Annual Scientific Assembly
February 10-11, 2018
Dress A Med - 20% Discount on scrubs/uniforms
FLAAEM is pleased to announce our latest partner in our member discount program. Dress A Med provides quality scrubs and medical uniforms. FLAAEM members receive a 20% discount sitewide.
Advanced Medical Certification - 35% Discount on online ACLS & PALS
FLAAEM has aligned with Advanced Medical Certification (AMC), the premier online certification and recertification course provider for health care professionals offering 100% online courses for certification and recertification in ACLS, PALS, BLS and CPR.
American Seminar Institute - 15% Discount on custom travel CME
American Seminar Institute (ASI) offers portable and accredited continuing education courses. You can take your individual course at home or anywhere in the world. Complete your continuing education when it fits into your schedule. Multiple specialty areas and topics are available.
FLAAEM Advocacy and Legislation reform
Free Western Journal of Emergency Medicine (WestJEM) subscription
The following topics were discussed at the most recent FLAAEM Board of Directors meeting:
- The 7th Annual Scientific Assembly Planning Committee is assembled. Date and location confirmed for Saturday and Sunday, February 10-11, 2018, at the Fontainebleau Hotel, Miami Beach.
- 2018 AAEM membership renewal will be sent to members soon! FLAAEM membership/ renewal will be accessible through the same site.
- WestJEM subscription was renewed and will be offered free of charge to our FLAAEM members.
- The board of directors hopes to further develop FLAAEM advocacy within our state as with the challenge presented by the overwhelming number of contract management groups. Any member input is welcome. Options include co-sponsoring EM Days with FCEP or establishing another advocacy day unique to FLAAEM.
- Next FLAAEM Board of Directors meeting is scheduled for January 10, 2018.
“Don’t Skip Leg Day, Bro”: A Case of Unprecedented Exertional Rhabdomyolysis without Acute Kidney Injury
Aadil Vora, OMS-III – Nova Southeastern University College of Osteopathic Medicine, FL
Ayesha Hussein, MD – Director of Emergency Medicine, Palmetto General Hospital, FL
Introduction: A young male complaining of dark urine following strenuous exercise is characteristic to Exertional Rhabdomyolysis. Creatine Phosphokinase (CPK) values typically peak at 25,000 IU/L in 24 hours.1 However, we present the case of a typical Exertional Rhabdomyolysis patient who’s CPK rose to an atypical 545,000 IU/L 48 hours after he tried squatting at the gym.
Case Report: A 19 year old male with no past medical history presented to the ED complaining of red, foul smelling urine and lower extremity soreness after squatting 135 pounds two days prior. He was afebrile with a heart rate of 93 bpm, blood pressure of 130/80 mmHg and weight of 130 Lb. He denied medications, illicit substances (UDS confirmed), recent illness, remarkable family history and trauma. The patient was slim, with tenderness to palpation of bilateral quadriceps. CPK was 37,000 IU/L, ALT was 266 U/L and AST was 2371 U/L. BUN and Creatinine were normal. Dipstick UA showed proteinuria and hematuria. EKG showed normal sinus rhythm. The patient was diagnosed with Exertional Rhabdomyolysis; 0.9% NS was started at 250 mL/hr and he was admitted to telemetry. Repeat CPK level taken on admission had spiked to 545,000 IU/L. Inpatient, he received a Bicarbonate Drip and D5W 300mL/hr. He never developed Acute Kidney Injury (AKI). Further workup of hepatitis panel, thyroid studies, coagulation panel and autoantibody titers were negative. The patient was discharged 8 days later with a CPK of 1,396 IU/L.
Discussion: This case, reports the highest CPK level secondary to Exertional Rhabdomyolysis without AKI in the literature.2 Rhabdomyolysis is diagnosed when CPK surpasses 5 times the normal limit; this patient peaked at 500 times the normal limit. 7 Furthermore, it is astonishing that this patient’s unprecedented CPK did not cause common comorbidities of rhabdomyolysis such as arrhythmias, compartment syndrome or AKI, of which a 30-50% of patients develop.8
The incidence of Rhabdomyolysis is well documented, with trauma and infection as leading causes and exertion relatively rare.4 This patient’s markedly high CPK value suggests an underlying metabolic disorder, such as a McArdle’s, which has been reported to cause extremely elevated CPK in teenagers.5 However, patients tend to have multiple occurrences of rhabdomyolysis, and for this patient, it was his first time.6
One other case of Exertional Rhabdomyolysis with a peak CPK of 500,000 IU/L was reported, and it too was in a young male who attempted heavy weight-lifting.2 However, that patient developed Stage 3 Renal Failure after being administered morphine. Morphine is known to cause urinary retention due to impaired sensation of urinary urgency and increased tone of the urinary sphincter, which could have exacerbated his intrinsic AKI by creating a post-renal obstruction.3 Our patient did not receive morphine, and may have therefore not developed any renal injury. His only complaint was copious urine production. Our patient’s good outcome was likely due to his healthy kidneys, early recognition, aggressive hydration and the avoidance of opioid analgesics. This case also reminds us of the great prognosis of rhabdomyolysis, even when extreme, in young healthy patients.
- Rhabdomyolysis: an evaluation of 475 hospitalized patients. Melli G, Chaudhry V, Cornblath DR Medicine (Baltimore). 2005;84(6):377.
- Khan, Asif. "Lose 500,000 Creatine Phosphokinase With a 2-Hour Workout: A Case Report on Rhabdomyolysis in a Novice Athlete." World Journal Nephrology and Urology 5.3 (2016): 54-57. Web. 25 Jan. 2017. .
- Effects of Analgesic and Anesthetic Medications on Lower Urinary Tract Function Sammy E. Elsamra, MD; Pamela Ellsworth, MD, FAAP, FACS Urology Nursing. 2012;32(2):60-67.
- Chen CY, Lin YR, Zhao LL, Yang WC, Chang YJ, Wu HP. Clinical factors in predicting acute renal failure caused by rhabdomyolysis in the ED. American Journal of Emergency Medicine. 2013;31(7):1062-1066
- "Glycogen storage disease type V - Genetics Home Reference." U.S. National Library of Medicine. National Institutes of Health, n.d. Web. 25 Jan. 2017.
- Lofberg M, Jankala H, Paetau A, Harkonen M, Somer H. Metabolic causes of recurrent rhabdomyolysis. Acta Neurol Scand. 1998;98(4):268-275.
- Mougios, Vassilis. "Reference intervals for serum creatine kinase in athletes." British Journal of Sports Medicine. BMJ Group, Oct. 2007. Web. 29 Jan. 2017.
- Keltz, E., Khan, F. Y., & Mann, G. (2014). Rhabdomyolysis. The role of diagnostic and prognostic factors. Muscle, Ligaments and Tendon Journal, 3(4), 303–312. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3940504/#b106-303-312