Spring 2016 Newsletter
Welcome to the spring 2016 edition of the Florida Chapter Division of AAEM (FLAAEM) newsletter. This newsletter is intended to bring members periodic updates on the practice of emergency medicine in our state and to highlight the benefits of membership. 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.
Vicki Norton, MD FAAEM, Vice President FLAAEM, Editor
Michael Dalley, DO FAAEM, Board of Directors FLAAEM, Communication Committee Co-Chair
In this Issue
David Rosenthal, MD FAAEM
In the wake of FLAAEM’s 5th Annual Scientific Assembly I can’t help but think of the importance of the State Chapter Divisions in the overall AAEM landscape. Every spring as other states begin to thaw, FLAAEM members, along with a few visiting northerners gather on the shores of Miami Beach for a meeting that follows AAEM’s Scientific Assembly by a mere 6 or 7 weeks
Each year our chapter conference keeps gets bigger which begs the question: Why do FLAAEM members haul themselves down I-95 for yet another professional meeting? While there are plenty of CME opportunities out there, the FLAAEM Scientific Assembly brings together a regional group of like-minded EP’s in a setting that is as much social as it is academic. It has become a forum of discussion for the practice challenges that we all have in common. It’s a place where residents and students can mix with seasoned attendings and get a glimpse of what the real world practice of emergency medicine is really like here in Florida. While in Miami Beach, the bonds between Jacksonville and Naples are built over turkey wraps and cocktails as much as in the seats of conference rooms. It seems that regional meetings are every bit as valuable as the national ones.
Thanks to all of our members who participated in this year’s FLAAEM Scientific Assembly. The Board of FLAAEM hopes that it was a worthwhile investment of your time and we’ll see you back next year. We look forward to hearing your comments and suggestions for an even better event in 2017.
We are pleased to announce our former chapter division president, David Farcy, MD FAAEM, was elected President Elect of national AAEM at the 22nd Annual AAEM Scientific Assembly in Las Vegas this past February. In the past, Dr. Farcy has been a leading advocate for emergency physicians in our state and has recently been serving at the national level on the AAEM Board of Directors. We look forward to seeing Dr. Farcy lead AAEM into bigger and better things.
Free Registration to the
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 BOD meeting:
- Scientific assembly funding through sponsorship increased for this year’s SA.
- Poster competition participation also significantly increased.
- EM resident and student member recruitment with possible residency visits.
- Develop and create a support program for legislative issues germane to the successful practice of EM in Florida.
- Call for newsletter original article submissions and news links.
- Balanced billing act passed by Florida Legislature (see Government Affairs update in this issue).
- Discussion of legislative efforts and partnering with other like-minded organizations to lobby in Tallahassee, such as at EM Days
- Call for Board of Directors nominees and discussion of election timing for next year
Jill Ward, MD FAAEM
FLAAEM Board of Directors and Government Affairs Committee Chair
One of the most important issues for emergency physicians for this past Florida Legislative session, and one of the most controversial issues, was Balance Billing. For EM physicians, this reflects how we get paid for out-of-network health insurance. Though you may not be aware of its' impact, this Bill will affect your paycheck for the rest of your career. When a patient sees a provider who is out-of-network on their health insurance plan, the amount not paid by their insurer is billed to the patient as a "Balance Bill". This billing practice accounts for 20-30% of pay for ER visits. In Florida, Balance Billing is already illegal for HMO plans, but the legislation for HMO's was reasonable on the agreed payment amount from insurance companies. The new Bill that was passed this session pertains to PPO plans. Nationwide, insurance companies and patient advocates have been pushing for balance billing. It often revolved around a story of someone getting an outrageous bill at a Hospital that was in-network on their insurance plan but the physician was not. Almost all these stories were pertaining to surgeons or anesthesiologist, whose bills are much higher than the EM physician.
The original Bill presented was extraordinarily unfavorable to EM physicians, including a drastic decrease in agreed pay from the insurers, and only leaving a faulty system to argue for higher pay. The goal was to strike down or amend the Bill to provide a rate for EM care based on a fair, usual and customary rate and to improve the dispute resolution process when insurers underpay. After a lot of legislative argument, EM physicians, along with the FMA, were able to amend the Bill in favor of EM physicians.
The final bill requires Out-of-Network PPO insurance payments to mirror the HMO payment provisions for care in the ER, as well as creating a improved dispute resolution program which sets up a process for a settlement to be made by both parties. It also requires AHCA to develop rules for the dispute resolution program.
The improvements in the bill are still debatable. While fair payment to the EM physician is emphasized, there is some question of how this bill will affect the private democratic group. Will private groups have the same negotiating power for reimbursement as a large contract management group (CMG)? The future impact of this bill still remains to be seen.
Colin Zuchowski, Jeffrey Reese, Garrett Barr, and Charles Maitland MD
Florida State University College of Medicine, Tallahassee, FL
Evaluation of the dizzy patient poses a major challenge for emergency physicians. When determining the etiology of the dizziness, the most effective way to rule out a serious disorder like a stroke, is to rule in a peripheral vestibular disorder.1 However, with the absence of proven clinical examination techniques that identify underlying peripheral vestibular involvement in a dizzy patient with multiple comorbidities, a simple tool is needed for a correct diagnosis. The Quix test is a simple, non-invasive, clinical maneuver that can detect this vestibular involvement in patients without the stereotypical complaint of vertigo.
The Quix text was originally invented in 1925 by Dr. Franciscus Quix, an otolaryngologist from the Netherlands.2 Throughout the years there have been iterations to the original test, but the premise behind the maneuver remains the same.3,4 The Quix test detects imbalances in the vestibulospinal tonic inputs to the extremities, which elicits torsional truncal deviation from the midline when visual and proprioceptive inputs are eliminated.5 We previously reported the Quix test’s effectiveness in determining the involved side in benign paroxysmal positional vertigo, by correctly identifying 84.5% of cases with a specificity of 93%.6 We found the Quix test to be a useful tool in the evaluation of the non-vertiginous dizziness patient, where peripheral involvement would traditionally not be considered.
Two-hundred patients were evaluated with chief complaints of dizziness, vertigo, or imbalance. Based on obtained history, 84 patients were classified as non-vertiginous and were included; the remaining were classified as vertiginous and were excluded. The Quix Test was performed (as shown in Figure 1), followed by the standard testing of videonystagmography (VNG) and dynamic platform posturography (DPP). The Quix Test is considered positive if there is a congruent horizontal axis deviation of both fingers from the original target by at least 2.5 cm. Peripheral vestibular abnormality was identified if VNG and/or DPP showed canal paresis, visually suppressed nystagmus, or failed balance in vestibular dependent conditions. These results were compared to the results of the Quix test.
A logistic regression was performed to ascertain the effect of a positive Quix test in predicting the likelihood of peripheral vestibular involvement in the patient’s dizziness. The Quix test proved a statistically significant predictor of peripheral vestibular involvement in non-vertiginous patients, (p < .0005).
The model explained 29% (Nagelkerke R2) of the variance and correctly classified 73.8% of cases. The specificity was 77.8% and sensitivity was 70.8%. Patients with a positive Quix test were 8.5 times more likely to have peripheral vestibular involvement.
The Quix test is a statistically significant maneuver that can be administered quickly and safely in less than 30 seconds to identify underlying peripheral vestibular involvement in patients without the suspected complaints of vertigo. Suspicion for peripheral vestibular involvement should be increased with the presence of any of the risk factors associated with vestibular deficiency. The Quix test is not meant to be used as a stand-alone test. If used complementary to the typical history, physical, and work-up for the dizzy patient, it can further raise the probability of a suspected diagnosis. The Quix test is particularly helpful when patients present with multiple co-morbidities, and it is difficult to determine a specific etiology. Along with helping lower the possibility of serious causes of dizziness including a stroke, uncovering peripheral involvement in a dizzy patient with multiple co-morbidities is necessary because peripheral vestibular causes have the potential to be corrected with physical therapy. This can help improve symptoms, especially in circumstances where visual and proprioceptive input is compromised. The statistical evidence suggests that usage of the Quix test as a complementary tool better equips the emergency physician to diagnose the dizzy patient.
- Kerber KA. Vertigo and Dizziness in the Emergency Department. Emergency Medicine clinics of North America. 2009;27(1):39 viii.doi/j.emc.2008.09.002.
- Quix FH (1925) The function of the vestibular organ and the clinical examination of the otolithic apparatus. J. Laryngology Otology 40(8):493-511.
- Drachman DA and Hart CW (1972) An approach to the dizzy patient. Neurology 22:4.
- Hart CW (1983) The quix test.Laryngoscope 93(9):1160-1.
- Maitland CG, Skidd P, Booker T, Holcomb K: Examination of vestibulospinal function identifies the canal affected in benign paroxysmal positional vertigo. North American Neuro-ophthalmology Society. Orlando, FL. March 2008.
- Coughlin K, Sherrod K, Miles, J, Fitzgerald R, Barr G, Salud, J, Adams S, Maitland CG: The Quix test predicts canal sidedness in BPPV. American Academy of Neurology. Boston, MA. May 2015.
Michael Dalley, DO FAAEM
FLAAEM Board of Directors and Communications Committee Co-Chair
The 5th Annual Florida Chapter Division of AAEM (FLAAEM) Scientific Assembly took place in Surfside at the Grand Beach Hotel on April 2-3, 2016. This milestone conference was the best attended to date, with an overall 30% increase in registrants. As in previous years participants received up to 12.75 hours of continuing medical education credit. Highlights from the conference include a robust guest speaker list with representatives from almost every academic residency program in the state of Florida, as well as Dr. Richard Shih and his popular 2015 LLSA review.
We continued our successful medical student track on Sunday afternoon, moderated by Dr. David Edwards and Dr. Mark Foppe. There was a strong student presence at the meeting and this track was well received.
This year’s meeting also continued the poster, abstract and oral presentation competition. Overall there were 29 posters (case reports and original abstracts) submitted from residency programs and medical schools from across the nation. New this year, there was an oral presentation component, which was moderated by Dr. Lisa Moreno-Walton and FLAAEM Board of Director representatives. The winners are acknowledged below:
1st Place: Pediatric Occlusive Ischemic Stroke to tPA or not to tPA?
Andrew S. Rudin, DO, OGME 1, Orange Regional Medical Center, Middletown, NY
Michael F. Stiefel, MD, Department of Neurology, New York Medical College, Valhalla, NY
Dulaya Santikul, DO, EM Program Director, Orange Regional Medical Center, Middletown, NY
2nd Place: Perineal Hydrostatic Blowout Injury from a Jet Ski
Chad Lee DO, Michael Dalley DO FAAEM and Luis Derosa Jr., RN BSN
Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, Florida
3rd Place: A Twist in the Case of Abdominal Pain
Juliana Lefebre DO and Tearikirangi Benioni MD FACEP
TEAM Health USF Emergency Medicine Residency
4th Place: Painful Leg Spasms
Talor Matthews, MD and Jason Wilson, MD
University of South Florida Morsani College of Medicine, Department of Emergency Medicine, Tampa, Florida
Two of the winners Juliana Lefebre and Andrew Rudin posing with Mike Dalley and Dave Rosenthal
Finally, we were privileged to host AAEM President, Dr. Kevin Rogers, and have him speak about the current state of emergency medicine, as well as how AAEM supports and advocates for emergency physicians.
A special thanks goes out to FLAAEM Scientific Assembly Planning Committee Chair, Dr. Joseph Shiber, and to FLAAEM Immediate Past President and current national AAEM President Elect, Dr. David Farcy, without whom the conference would not be as outstanding and educational as it is. Thank you to all those who supported the conference this year, including the speakers and attendees from near and far and all the people behind the scenes. We will continue to improve and grow in the years to come.
Association of fluid resuscitation initiation within 30 mins of severe sepsis...
Annals of Emergency medicine, April 15
Pediatric Skull Fractures: When to Admit
Med Page Today, April 11
Florida Gov. Rick Scott gets an earful at Starbucks
Yahoo News, April 6
Obama to shift Ebola funds to fight Zika; Florida leads nation in cases
Miami Herald, April 6
Toxicology Rounds: Dewshine
EM News, April 1
Surviving the Struggle: Nights in the ED
EM News, April 1
Spontaneous Circulation, Occlusion ECG Patterns Not to Miss
EM News, April 1
Florida reports three new Zika infections as CDC chief calls for more funding
Miami Herald, April 1
How lawmakers are changing mental health, substance abuse treatment in Florida
Tampa Bay Times, March 28
Researchers report progress in blood test for concussions
Tampa Bay Times, March 28
Florida bill on health care transparency headed to governor
Tampa Bay Times, March 11
Lawmakers had one vendor in mind when they wrote health transparency bill
Tampa Bay Times, March 3
Florida facing a 'nursing shortage tsunami'...
Tampa Bay Times, February 1
Broward Health CEO remembered as charismatic, tireless, passionate about patients
Miami Herald, January 24