Fall 2018 Newsletter

Dear FLAAEM members,

Welcome to the fall 2018 edition of the Florida Chapter Division of the American Academy of Emergency Medicine (FLAAEM) newsletter. We at FLAAEM are working hard to represent our members’ interests. Let us know of 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 flaaembod@list.aaem.org with any questions or concerns.

Sincerely,

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


President’s Message

Letter to Our Colleagues Affected by Hurricane Michael

Those of you in the panhandle and northwest Florida are still dealing with the aftermath of Hurricane Michael, which made landfall over Mexico Beach on October 10, 2018. Conditions are so bad that many roads are still impassable, hundreds of thousands are still without electricity and many are left without homes, as the storm wiped out entire blocks. You have described the destruction of your towns, and you survivors are now experiencing violence, looting, and gas shortages. But there have also been amazing acts of kindness and rescue efforts.

First responders, hospital staff and emergency physicians have been tirelessly helping the communities affected and some have seen their hospitals, fire stations and police stations irreparably damaged. Nevertheless, you work on in unimaginable conditions and under great stress to the system and yourselves. Now that you have weathered the storm, you are not alone. FEMA has 1,500 staff deployed to distribute supplies and provide shelter. In addition, linemen from surrounding states are working around the clock to help restore power to the panhandle. Search and rescue crews continue to dig out victims of this brutal storm and finding the remains of those who didn’t survive.

Our prayers go out to those of you affected. Emergency care providers, who even now are working and caring for the communities affected by this disaster. You are the best of us in the worst of all circumstances. We are proud to call you our colleagues. Thank you for all that you do.

Sincerely,
Vicki Norton, MD FAAEM
President, Florida Chapter Division of AAEM

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Wellness and Resilience in Emergency Medicine: A 30-Year Career Perspective

Ramon J. Pabalan, MD FAAEM
Vice President, FLAAEM Board of Directors
Partner Cape Coral Emergency Physicians

It seems almost every recent physician news lead or paper I read has an article on the demise of physician wellbeing. Burnout and dissatisfaction are apparently rising to unprecedented levels. A finger in the wind to the percentage of “burned out” emergency physicians seems to hover roughly around 50% or greater, depending on which survey you read. EM as a specialty is not alone, as other specialties show burnout rates as high as 65%. Is the practice and business of medicine such that it’s a detriment to the health of physicians? Apparently this is the case.

At the deep dark end of the wellness issue, it is said that over 400 physicians a year commit suicide. And that’s just the known cases, not accounting for “accidental” deaths. It would take an average of three graduating medical classes per year just to make up for these losses. In my career I have known three physicians who violently took their own lives. Typically these were physicians in the prime of their careers, who had the most to contribute to society and their families.

 At the shallow end of this enigmatic quagmire are a significant number of physicians who feel burned out, physicians with a decreasing interest in their practice, and increasing apathy toward patients. The labyrinth of practice rules and onerous EMR systems are but two of the many cited causes contributing to burnout.

Somewhere in the middle are physicians who have had enough and have decided to leave the practice of emergency medicine. The recent article by EM physician Dr. Alex Mohseni “Why I Quit Emergency Medicine” (Emergency Medicine News, October 2018) poignantly highlights the multitude of stressors that EM physicians face. Those stressors are our every day reality, but how one deals with these challenges seems to be the crux of the wellness conundrum, whether “to suffer the slings and arrows of outrageous fortune or to take arms against a sea of troubles … (Shakespeare, Hamlet) to avoiding burnout or being consumed by it.

I say enigmatic, as it seems puzzling that some physicians seem to thrive under the same circumstances that causes others to succumb. The quagmire is the murky underpinnings within the soul of some physicians that portend adverse outcomes. Often the machinations of these inner forces are unknown to the physician themselves. I read a recent article on why apparently happy physicians commit suicide. Suicidal ideation was not suspected with their affable exterior.

My take on all of this along with the influence of what has been shared by others is, physicians really do not want to end their lives, they only want to end their emotional pain and that pain scale runs from minor to unbearable. The severity of burnout is a continuum, and one may sit anywhere from aggravating irritation to total despair.

All of us in health care whether clinicians, academicians, or administrators need to clearly define wellness and expedite real answers to address the root cause of burnout. It may not be easy and solutions will be multifactorial. But it needs to be addressed now before we lose more clinicians to what I believe is a preventable and curable malady.

Some have asked me, “How I have lasted more than three decades in sundry emergency practices?” At times I’ve asked myself the same question as most of my contemporaries have hung up their stethoscopes. So if you gray haired, weathered colleagues of mine are still curious, here’s my spin. No evidence based prospective randomized trials to prove it, just my humble opinion based on experience and observation.

Those who have more than just survived a career in medicine have had a support system. Whether a spouse, siblings or other, content physicians have taken the time to maintain the connections with those who mean the most to them.

They have taken the time to check their emotional and spiritual pressure and pulse. They are not afraid to admit their inner reservoir is running on empty. They find a means other than drugs, alcohol, or other denigrating methods to restore their raison d’être, their passion to be a physician. They are not ashamed to ask for help when needed.

They have a life outside of medical school, residency, shift work or training for the Board and they sacredly guard that aspect of their lives. Whether sports, performing art, or simply communing in another space, they balance their life. Taking in the twenty thousand foot view makes a difference on how they see themselves and they put it in perspective.

And beneath it all they nurture an unshakeable spiritual belief.

This needs to be our new mantra. We cannot let burnout beat us into submission. We came into this profession with a conviction that we would make a difference with every patient touch. That very important patient is the first one we see every day when we arise.

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FLAAEM Scientific Assembly Interesting Case Spotlight: DISH Syndrome and Trauma to the Cervical Spine

Chandelle Raza, DO, PGY-1; Jackeline Lorenzo-Farrow, DO, PGY-4; Laurie Boge, DO; John Esin, MD
Mount Sinai Medical Center Emergency Medicine Residency, Miami Beach, FL

Diffuse idiopathic skeletal hyperostosis (DISH), also known as ankylosing hyperostosis and Forestier’s disease, is a systemic non-inflammatory disease characterized by ossification of spinal ligaments and entheses.

DISH is typically asymptomatic and usually found incidentally by radiographic imaging for a non-related reason. Of those who develop clinical manifestations, neurological symptoms are the most common. The neurological manifestations are commonly due to involvement of the cervical spine, which is affected in 75% of patients with DISH.

The spines of patients with DISH become increasingly rigid and osteoporotic, and fractures may occur after a relatively minor traumatic event such as a ground-level fall. Fractures in the cervical spine of patients with DISH are associated with high morbidity and mortality compared to fractures through the normal spine. These patients are more prone to developing myelopathy due to less potential space in the spinal canal in the event of fractures and cord edema.

The etiology of DISH is unclear. DISH is more common in men than women. The incidence varies by population and increases with age, rarely being diagnosed before the age of 40. Incidence also increases with weight in both sexes, with obesity and metabolic syndrome described as the oldest recorded risk factor for DISH.

The prevalence of DISH makes it important for increased awareness of this disease, especially when evaluating trauma patients.

Case Presentation:

HPI: 62-year-old male with BIBA in a C-Collar for neck pain which occurred PTA s/p MVC. Patient was an unrestrained driver going 30mph and was rear-ended by another car at the same speed. Upon impact, the patient experienced hyper-extension of the cervical spine. Airbags did not deploy and all the windows remained intact. The patient ambulated on scene. Patient denies head trauma, loss of consciousness, headache, vision loss, muscle weakness, paresthesia, decrease range of motion of any extremity, SOB, abdominal pain, chest pain, lacerations, or any alleviating / aggravating factors.

PMHx: afib, HTN, DM2, pacemaker

PSHx:: pacemaker insertion

Medications: metformin, rivaroxiban

Social history: Works as a concierge; smokes 6 cigarettes daily and drinks alcohol socially. He denies drug use.

Vitals: HR 109 BPM; RR 18 br/min; BP: 205/115; temp: 37.1C orally; SpO2 98% RA

FOCUSED C-SPINE NEURO EXAM:

  • tenderness to palpation over the paraspinal musculature
  • 5/5 finger abduction, adduction,extension, flexion, wrist extension and flexion, biceps, triceps, and deltoid bilaterally
  • Negative Hoffman's bilaterally
  • Normal heel toe, heel walk, toe walk, as well as tandem walk
  • Full strength in the hipflexors and hip abductors and adductors, knee flexion and extension
  • Symmetric 1+ patellar and Achilles reflexes

IMAGING C-SPINE:

X-ray of the C-spine demonstrates a fracture through this inferior endplate of the C3 vertebral body extending through the ossified anterior longitudinal ligament and a fragmentation of thick anterior longitudinal ligament calcification at C6-7.

CT of the C-spine demonstrates disc disease with an acute fracture of the cervical spine involving the densely calcified anterior longitudinal ligament extending into the anterior inferior endplate of C3 with associated mild anterior C3-4 disc space widening, as well as a nondisplaced fracture of the inferior right facet of C4

 

Discussion and Conclusion:

As in this case, DISH is typically an incidental finding on radiographic examination, seen as an ossification of his anterior longitudinal ligament along his cervical spine. This patient was in a relatively low-speed motor vehicle accident and denies hitting his head. With the whiplash forces, the patient was able to sustain a fracture through his ossified anterior longitudinal ligament, with potential for severe complications.

Because DISH exposes injury sites to larger movements via the lever arms produced by the stiffness of the otherwise largely ankylosed spinal column, even minor fractures can become highly unstable and place the patient at high risk for a neurologic injury, particularly if the cervical segment is involved.

The recommended treatment for spinal injuries in DISH patients is surgical, mainly through long-segment posterior fusion. However, stable fractures without any associated neurologic deficits have often been successfully managed with immobilization alone.

Although this patient had a benign course, DISH syndrome and cervical spine fracture predisposes the patient to catastrophic consequences with risk of mortality. Sreedharan and Li (2005) reported two patients with DISH who sustained traumatic cervical cord injuries from falling from ground-height. Both patients were tetraplegic on presentation and both died of mechanical respiratory failure. As such, patients should be informed about possible neurological sequelae from relatively minor trauma. Additionally, the increase in incidence of patients with identified risk factors for DISH (obesity, diabetes mellitus, hypertension, hyperinsulinemia, and dyslipidemia, and particular environmental exposures and drugs) can be used to manage and prevent the progression and traumatic complications of this condition

References:

Bransford, RJ. Et al. (2012). Cervical spine trauma in diffuse idiopathic skeletal hyperostosis: injury characteristics and outcome with surgical treatment. Spine. 37(23), 1923-1932. doi: 10.1097/BRS.0b013e31825b17fc.

Nascimento, F. A., Gatto, L. A. M., Lages, R. O., Neto, H. M., Demartini, Z., & Koppe, G. L. (2014). Diffuse idiopathic skeletal hyperostosis: A review. Surgical Neurology International5(Suppl 3), S122–S125. http://doi.org/10.4103/2152-7806.130675

Nouri, A., & Fehlings, M. G. (2017). Diffuse idiopathic skeletal hyperostosis with cervical myelopathy. CMAJ: Canadian Medical Association Journal189(10), E410. http://doi.org/10.1503/cmaj.160487

Sreedharan, S., Li, YH., (2005). Diffuse Idiopathic Skeletal Hyperostosis with Cervical Spinal Cord Injury—A Report of 3 Cases and a Literature Review. Annals Academy of Medicine. Volume 34-3.

Sundeep, M., Hirano, Y., Iketani, S., & Konno, A. (2017). Surgical management of symptomatic ossified anterior longitudinal ligament: A case report. Surgical Neurology International8, 108. http://doi.org/10.4103/sni.sni_102_17

Yunoki, M., Suzuki, K., Uneda, A., Okubo, S., Hirashita, K., & Yoshino, K. (2016). The Importance of Recognizing Diffuse Idiopathic Skeletal Hyperostosis for Neurosurgeons: A Review. Neurologia Medico-Chirurgica56(8), 510–515. http://doi.org/10.2176/nmc.ra.2016-00.

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Florida EM Residency Spotlight

Robert Farrow, DO
Resident Member Representative, FLAAEM Board of Directors

Several exciting things are happening in the FLAAEM community. Over the course of the last several years multiple emergency medicine residencies have opened their doors to new classes of residents and have joined the ranks of other strong emergency medicine programs in the state.

AAEM president, Dr. David Farcy, is from our home state of Florida and is also the Department Chair at Mount Sinai.

The annual FLAAEM Scientific Assembly continues to grow and this year included a Sim Wars competition, Ultrasound course and research submissions from across the state. While we look for the Assembly to continue to grow. If you have any ideas for the 8th Annual FLAAEM Scientific Assembly (FLAAEM19) or questions about how to get involved please email the Resident Member Representative on the FLAAEM Board of Directors, Rob Farrow (PGY-4, Mt. Sinai) at ra.farrow2@gmail.com. We are looking forward to a great year for FLAAEM!

 

Mount Sinai Hospital, Miami Beach

Below is a summary of the recent happenings at Mount Sinai Miami Beach

We are almost midway through the year and at a period of transition at Mount Sinai as we prepare to send off our senior class at the end of December. Originally part of a 4 year program, the graduating seniors transitioned to 3.5 years of training as the residency at MSMC converted to a 3 year ACGME accredited residency. Congratulations to our senior class as they move forward in their future endeavors (Nick Garrett, Matt Brooks, Justin Burkholder, Nikki Warren, & Rob Farrow).

Despite the season of change it has also been a busy start of the year for our program. Below are some of the highlights:

The ACGME transition has been a success and is complete. This September we received notice of continued accreditation. A big thanks to the faculty and administration who made this transition possible.

Several of our residents, alumni & faculty have been notified of acceptance for publications:

  • Dr. Mauricio Baca (PGY-2) & Dr. Mark Newberry: “Amyloid Cardiomyopathy in the Emergency Department” Journal of Emergency Medicine
  • Dr. Brad Koschel (PGY-3), Dr. Justin Burkholder (PGY-4) & Dr. Laurie Boge: “Patients’ Perceptions on the Role of Physicians in Questioning and Educating on Firearm Safety: Post-FOPA Repeal Era” Southern Medical Journal
  • Dr. David Kinas (2018 graduate & current Ultrasound fellow at Mt. Sinai St. Luke’s, NY), Dr. Michael Dalley, Dr. Mark Newberry & Dr. David Farcy: “Point-of-Care Ultrasound Identifies Decompensated Heart Failure in a Young Male with Methamphetamine-Associated Cardiomyopathy Presenting in Severe Sepsis to the ED” Case Reports in Emergency Medicine

Our Sim Team for FCEP’s Symposium by the Sea scored a strong second place finish. Members of the team were: Dr. Adam Memon (PGY-3, Chief), Dr. Aldo Manresa (PGY-3), Dr. Liz Rubin (PGY-2), & Dr. Nick Boyko (PGY-1).

Several of our residents have focused on education by leading the following clinics:

  • Suture Clinic hosted by the FIU EM Club & led by Drs. Adam Memon, Aldo Manresa, Chandelle Raza and Nick Boyko
  • Intubation Clinic hosted by the NSU EM Club & led by Drs. Adam Memon, Aldo Manresa, & Chandelle Raza
  • Basics of Critical Care for Mt. Sinai Internal Medicine Residency. Led by Drs. Nikki Warren, Adam Memon, and Aldo Manresa.
  • Splinting Clinic hosted by NSU EM. Led by Drs. Natasha Brown and Chandelle Raza.

Finally we are looking forward to the following key note speakers and clinics to end the calendar year.

  • Reuben Strayer, MD FRCP FAAEM, Maimonides Medical Center, New York
  • Airway Skills Workshop by Rich Levitan, MD

Robert Farrow, DO
Chief Resident
Mount Sinai Medical Center, Miami Beach
Resident Member Representative on FLAAEM Board of Directors

 

University of Miami/Jackson Memorial Hospital

We took great pleasure in welcoming our 15 new interns this past June. They join the Jackson family from all over the country, bringing a breadth of diversity, experiences and insight. It is amazing how quickly time passes, as we now have our full complement and will soon be preparing to graduate our first class.

This summer we held three dedicated ultrasound days for each of our classes. The interns got hands-on experience on the basic EM applications including cardiac, soft tissue, gallbladder and OB ultrasounds. The PGY-2s had an advanced ultrasound day that included ocular, DVT and RUSH protocols. The PGY3s got to have an exciting musculoskeletal workshop including hip, shoulder and wrist ultrasounds.

This August many of our faculty and residents attended the Symposium by the Sea in Fort Myers/Sanibel. PGY-3 Michael Roberds presented an abstract with Dr. Jennifer Jackson on medical student learning, Drs. Supino and Posaw gave a lecture on ultrasound in cardiac arrest, and PGY2 Nina Gutierrez and PGY-3 Alex Thai represented us in the annual CPC competition for case presentation and discussant, respectively. Congratulations to Alex and Nina for winning best overall case and to Alex for best discussant and best overall presentation.

We also just held our first ever full-residency retreat in September, which was a great opportunity for team building and brainstorming.

Many exciting events are also on the horizon. Our PGY-2 class will all be headed to AAEM19 in Las Vegas. Finally, recruitment season will begin before we know it, and applicants can finally meet all three of our classes.

We look forward to seeing everyone at AAEM19 and FLAAEM19!

Chris Freeman, MD
Program Director
University of Miami/ Jackson Memorial Hospital

 

Kendall Regional Medical Center, Miami Florida

Kendall’s EM Residents would like to welcome our new intern class to the family! As of this summer we now have all three years of residency classes on board. We have a great new class and are excited to get to know them better. We wish them the best of luck and look forward to working and training with them through residency.

We are proud to report that we have achieved full EM accreditation by ACGME. This could not have been done without the hard work and dedication of our program director, Dr. Kevin King and the faculty. Now that we have completed this first step together as a program, we are excited to see the many opportunities for the program to continue to grow and develop.

This past July we welcomed our newest addition to the faculty, our Emergency Ultrasound Director, Dr. Moises Moreno. He joins us from Good Samaritan Hospital where he was Chief Resident and Ultrasound Fellow.

In August we celebrated our Symposium by the Sea SimWars winning team of residents, and we are excited to defend the win at FLAAEM19 next May in Miami!

Now with our first class of third year residents in place, we have rolled out some new educational initiatives. We know the importance of developing our own niches within the house of emergency medicine. With that in mind, we have started EMS, Ultrasound, and Simulation tracks for interested third years that will help them better learn the skills to transition into fellowship or independent practice. We were also able to kick off our first annual teaching fellowship for PGY-3s. This important course was designed to teach supervisory skills and leadership skills to our senior class.

As the first graduating class, we are excited to be present for this stage in the program’s development and can’t wait to see what the future brings for Kendall Regional’s Emergency Medicine Residency Program.

Sincerely,

Stefan Jensen, MD; Nicholas Koneri, MD; and Pavel Antonov, MD
Co-Chiefs, Emergency Medicine Residency
Kendall Regional Medical Center

 

St. Lucie Medical Center

In St. Lucie we have been working at strengthening our research department, while many new projects have started, a special congratulations goes out to one of our residents Dr. Alexander Chitty PGY-2 whose case report is being published by Western Journal of Emergency Medicine (WestJEM).

After enjoying our second SIM lab, the residents teamed up to do a volunteer beach clean up. Upcoming events include our yearly volunteering with treasure coast marathon and our team building activity at the ropes course on FAU campus.

Congratulations to our four senior residents on signing contracts for their new jobs. They are all anticipating working on their own.

St. Lucie would like to specially thank Mount Sinai for hosting the last consortium and we are looking forward to hosting the consortium in March.

Blaire Laughlin, DO, PGY-3

 

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FLAAEM Medical Student Update

Joshua Elliott Novy, MBA MS
MS4, University of Miami Miller School of Medicine
FLAAEM Student Member Representative

Greetings from Miami! 

The emergency medicine residency interview season is underway and I hope everyone is reaping the rewards of their hard work over the past three years. Our colleagues in AAEM/RSA organized not one, not two, but three medical student symposia across the country and each was a huge success! Our very own University of Florida Jacksonville was represented at the Southeast symposium. Speaking of symposia, Florida International University is working on a big EM student event to take place, tentatively, after Thanksgiving – keep an ear to the ground as more detailed announcements will circulate later this fall! We would also like to recognize the University of Miami’s Emergency Medicine Student Association for their hard work in organizing a FLAAEM membership drive earlier this year. If you’re interested in hosting a membership drive, FLAAEM will work with you to organize one and we have lots of fun pieces of AAEM flair for you to give away to medical students.

Finally, I would like to announce that the FLAAEM Student Interest Group Coalition convened earlier this year and both Theddy Blanc, AAEM/RSA Medical Student Council Southeast Region Representative, and me are extremely excited to have this vehicle to connect with each medical school and interest group in Florida. If you are interested, please reach out to your medical school’s emergency medicine interest group to learn more how you can become involved! Our goal is to be accessible, transparent, and create as many opportunities as possible for you to get involved in emergency medicine. Likewise, I can always be reached at j.novyMBA@gmail.com and am available to answer any questions about getting involved in AAEM, FLAAEM or emergency medicine in general. 

Stay cool out there!

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Member Benefits

FOMA - Discounted Rate of $25 for Prescribing Controlled Substances Course

The Florida Osteopathic Medical Association (FOMA) is providing FLAAEM members a $25 rate (regularly $75) for their two (2) hour online “Prescribing Controlled Substances” course. Fulfills the opioid prescribing requirement for all Florida physicians. Log-in to your member account to retrieve the discount code.

Free Annual Scientific Assembly - 8th Annual Scientific Assembly: May 10-11, 2019

Learn  more!

Registration opens January 2019

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.
Visit the FLAAEM member center to retrieve the code.

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.
Visit the FLAAEM member center to retrieve the code.

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.
Visit the FLAAEM member center to retrieve the code.

FLAAEM Advocacy and Legislation reform

Free Western Journal of Emergency Medicine (WestJEM) subscription

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Board of Directors Meeting Update October 9, 2018

New Business

FLAAEM Scientific Assembly (FLAAEM19) Planning Committee:

  • Preliminary lecture schedule and pre-conference course schedule determined.
  • New this year: Chief Resident Workshop - open to all newly elected chief residents.

Overall membership has improved year over year. FLAAEM BOD will continue recruiting efforts to appeal for additional members with an increase in valued benefits for our members.

FLAAEM Winter Social - Thursday January 10, 2019, at 6:00pm. Orlando, Florida. Venue TBA

2019 Upcoming Board Meeting: Dates TBA

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Recent News Headlines and Articles

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