Spring 2017 Newsletter

Welcome to the Spring 2017 edition of the Florida AAEM 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 flaaembod@list.aaem.org with any questions or concerns.

Sincerely,
Vicki Norton, MD FAAEM, Vice President Florida Chapter Division of AAEM, Editor
Michael Dalley, DO FAAEM, Board of Directors FLAAEM, Communication Committee Co-Chair




 


In this Issue


President’s Message

Dave Rosenthal, MD FAAEM
President, Florida Chapter Division of AAEM

Remembering Dr. Sal Silvestri: One of the Good Ones.

Have you ever googled yourself? I’ve resisted this temptation because whenever I search another doctor’s name, the first result that appears is an embarrassingly low “Health Grades” or “Vitals” review score. It would seem that the internet has found an avenue for disgruntled hypo-dilaudid-emic ED patients to vent their rage.

Still, there are some exceptions. Upon hearing the sad news of his untimely death I googled Salvadore Silvestri’s name in search of his obituary and learned that even the Internet likes him. A 4.7 out of 5 rating on Vitals?  Not too shabby Sal. For those of you who didn’t have the privilege of knowing him, his search result just about summarizes it. Sal was one of the most likable individuals who most Florida Emergency Medicine physicians will say they had the honor of meeting. For decades, he was committed to training residents, caring for patients, and developing modern EMS. He did so with a soft-spoken and respectful demeanor. When I first met him as a resident, he preferred “Sal” to Dr. Silvestri. He remained approachable and likable throughout the time I knew him. It’s not just what he did, it’s how he did it.

It’s been said time and again that tomorrow is guaranteed to no one. Sal’s sudden passing is yet another reminder of this. But it’s also a reminder of the ability we have as doctors, teachers, and colleagues to touch the lives of so many others…regardless of what Google says about us.

You will be missed Sal.


A Tribute to Dr. Silvestri from His Former Residents

Rawan Kablawi, M.D., Orlando Regional Medical Center EM Class of 2012

I remember feeling extremely nervous when arriving at ORMC for my first interview for EM residency. Although I have no recollection of how the interview went, I do recall the program director pulling me to the side. He told me he was sorry he wasn’t one of my interviewers, but that he would like to meet with me now if I had the time. All my nervousness dissipated and I immediately felt welcome around this large, jovial, bald man with a mustache. Later that night at the interview dinner, I was amazed at how all the residents’ faces lit up when he walked in. He had a calm smile and gentle nature, yet a force that demanded your respect. This man’s name is Sal Silvestri and he is the reason why I moved to FL.

My experience is not unique. Sal was one of a kind and everyone that met him was touched by his genuine personality, calmness, dignity, compassion, humility and composure. He somehow had enough heart to make every single person feel like they were the most important person to him.

He was everyone’s teacher, mentor, friend and father figure — the ultimate patriarch, aptly named the Godfather. His strength laid in in his quiet nature. He was a man of a few words, but when he spoke, you listened. And when he was present, you benefited from knowing that everything would be all right. He had the innate ability to be your biggest advocate during both tough times and good times. He encouraged those around him to reach higher and strive to be the best.

Every year Sal hosted the orientation party — a chance for interns to meet the other residents, attendings and their families. At the end of each party, he would gather all the interns around, pour shots of Limoncello and toast: “Welcome to the ORMC family. Once you’re in the family, there’s no getting out”.

Throughout hospitals across the nation, there is an EM family mourning the loss of its Godfather. I, along with many others, feel blessed to have known him and to have become part of his family. Although we grieve, lingering in sadness would be a disservice to a man who brought so much joy to so many. So for me, I think I’ll pour a small glass of Limoncello and toast to my friend and mentor, Dr. Sal Silvestri, who lived a beautiful life and inspired others to do the same. His spirit lives on in all our hearts. RIP Sal.

 

Brian Head, M.D., ORMC Class of 2015

There are very few people in this life aside from your family, who will help completely shape the outcome of who you are, what you become, your career, where you live, who you marry, your lifelong friends, and even your general outlook on life. Dr. Sal Silvestri did this for me, and probably more people than I can even fathom. Sal took all of us in as baby residents, welcomed us into his family at ORMC, and helped us become the people (not just physicians) that we are today. Aside from his beautiful wife and children, nothing seemed to make him happier than welcoming a new group of residents into our ever growing family each year. Sal was never our boss, always our friend, our Godfather, taken from all of us way too soon.


Member Benefits


Free Annual Scientific Assembly

April 22-23, 2017
Fontainebleau, Miami Beach


http://www.flaaem.org/events/scientific-assembly
Register Today!
Online Registration Closes Tuesday, April 18, 2017, at 11:59pmET.
Onsite Registration Available!

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


Board of Directors Meeting Update – January 10, 2017

The following topics were discussed at the most recent BOD meeting:

  • Nomination period for FLAAEM Board and Executive Committee is now closed. Voting will be finalized at the Florida Scientific Assembly in April and the new board will be announced on the second day of the Assembly.

  • Momentum is gathering for the Sixth Annual FLAAEM Scientific Assembly this April at the Fontainebleau Hotel in Miami Beach. Registration for the meeting is open. There is no registration fee for FLAAEM members.

  • Dr. Rob Farrow is asking all EM residents to join FLAAEM as there are many benefits including a special track at the Florida Scientific Assembly.

  • FLAAEM members attended the Sunny States Social that FLAAEM co-sponsored with CAL/AAEM at the Pub Restaurant on Friday March 17th during the AAEM Scientific Assembly in Orlando, Florida.


FLAAEM Scientific Assembly Case Presentation: Not Such a Treasure Chest

Kushal Patel, DO, Mt Sinai Medical Center, Department of Emergency Medicine, Miami, FL
Dave Farcy, MD, Mt Sinai Medical Center, Department of Emergency Medicine, Miami, FL

CC: Shortness of breath

HPI: 80-year-old Hispanic female brought in by EMS with a chief complaint of shortness of breath since this morning that began at rest, is of moderate severity, worse with exertion and mildly alleviated at rest. Patient denies any chest pain, abdominal pain, cough or fever. Patient does admit to low back pain since last night that began after she moved furniture at home. Back pain did not improve with 1 hydrocodone tablet. Patient states that her pain was so severe that she “passed out” for an unknown duration.

Initial EMS report stated that patient may have overdosed on opiates and she was found unresponsive at home with pinpoint pupils. Patient was given 2mg of Narcan with significant improvement in her mental status; however, patient continued to complain of shortness of breath. She was placed on CPAP and transported to the emergency department. Patient states that she is short of breath at baseline, using 4 L O2 via NC all day and CPAP at night.

Past medical Hx: Hypertension, COPD, CKD, descending aortic aneurysm
Surgical Hx: Appendectomy
Social Hx: Does not smoke, no alcohol, no drug use

Physical Exam:
VS:  BP 122/90, Pulse 70, Temp 98.4 C, Resp 25, O2 Sat – 100% (CPAP)
Constitutional: Alert and oriented x 3, well developed, well nourished
HEENT: normocephalic, atraumatic, EOMI, neck with full and normal ROM
CV: regular rate and rhythm, pulses 1+ radial bilaterally, 2+ femoral bilaterally
Pulm: decreased breath sounds on the left, no crackles or wheezing, on BiPAP
Abdomen: soft, non-tender, non-distended in all quadrants
MSK: full, normal ROM all 4 extremities
Neurologic: alert and oriented x 3, no cranial nerve deficits, no sensory or motor deficits.

Labs:
Lactic Acid – 8.3
INR -1.4
Troponin - <0.04
EKG: NSR, rate 68, RBBB, Qtc 435, no t wave inversions, no st elevation

Imaging Results:


 

Q&A:

Questions

  1. What is your primary diagnosis based on the chest x-ray?
  2. What is the next most appropriate test to order?

Answers

  1. A loculated pleural effusion, with a history of an aortic aneurysm is concerning for a ruptured aortic aneurysm.
  2. Next most appropriate test would be a CT angiogram of the chest and abdomen, once the patient is more stable.

Imaging Results:
CXR: enlarged aortic arch with atherosclerotic calcifications. Opacity extending along the lateral portion of the left hemithorax that can represent a loculated pleural effusion, correlation with CTA of the chest is recommended. No right airspace consolidation or pleural effusion is noted.

CT angio chest/abdomen and pelvis:
There is marked aneurysmal dilation of the transverse thoracic aorta, which measures up to a maximum of 5.2 cm at the mid transverse arch the proximal transverse aorta measure up to 4.2 cm in diameter, just distal to the origin of the left subclavian artery. In addition there is massive aneurysmal dilation of the descending thoracic aorta, with probable underlying pseudoaneurysm formation and heterogeneous mixing of contrast, measuring up to maximum of 7.7 cm. just below this level there is a focal out-pouching of contrast which likely represents the site of aneurysm rupture into the left pleural space. There is an associated large hyperdense partially loculated left pleural fluid collection noted throughout the left hemithorax.

Associated mass effect upon the left mainstem bronchus, which demonstrates a slit like appearance, related to mass effect from the descending thoracic aortic aneurysm/pseudoaneurysm. 

Findings are consistent with ruptured/ leaking descending thoracic aortic aneurysm. Emergent surgical consultation is suggested as warranted.

Case Discussion:
Our patient’s ED course was complicated by a brief episode of hypotension that improved with a fluid bolus. Cardiothoracic surgery and vascular surgery were consulted for the patient. Given the size and the location of the aneurysm, cardiothoracic surgery was unable to intervene. Vascular surgery recommended a stent placement, which came with a high risk of developing cerebral, renal and limb ischemia. After a lengthy discussion with the patient and her family, the patient decided that she would not like to undergo any intervention that could result in stroke, paraplegia or renal failure. Patient decided to sign the do no intubate and do not resuscitate forms.  She was admitted to the intensive care unit, where her condition deteriorated over the next 8 hours and she ultimately passed away.

Aortic aneurysms are divided into ascending, arch and descending aneurysms. The prevalence of aortic aneurysms is approximately 3-4%, and only 6 cases per 100,000 are thoracic aortic aneurysms (TAA).  Of all TAAs only 10% involve the arch. Aortic aneurysm is defined as dilations of the blood vessel having at least 50% increase in diameter compared to expected normal diameter. On average, the mean rate of growth for TAAs is 0.1 cm/year. Most patients with thoracic aortic aneurysms are asymptomatic at the time of discovery. The most worrisome complication of TAA is a ruptured TAA, which presents as pain and hypotension. The location of the pain may indicate the area of aortic involvement. Ascending aneurysm can cause more anterior chest pain, while arch aneurysms cause pain radiating to the neck. Descending aneurysms typically cause pain that radiates to the back. Large aneurysms may cause SVC syndrome, hoarseness secondary to stretching of the laryngeal nerve, dysphagia from compression of the esophagus and dyspnea or stridor if the trachea is compressed. Ruptured TAA are treated by either open or endovascular approach, depending on the size and location of the aneurysm. The most common cause of morbidity and mortality post treatment is stroke. Additional complications include paresis and paraplegia in about 2.7% of the cases, myocardial infarctions, and pulmonary and renal dysfunctions.  If detected earlier thoracic aortic aneurysms can be monitored and treated if they grow faster than 1 cm/ year, or are noted be larger 5.5 cm. However a ruptured thoracic aortic aneurysm results in a mortality rate between 97% and 100%.

Pearls:
Keep a broad differential for patients presenting to the ED with shortness of breath.
Early consultation with vascular or thoracic surgery is imperative for definitive treatment.

References:

http://emedicine.medscape.com/article/424904-overview

http://circ.ahajournals.org/content/117/6/841.full

http://content.onlinejacc.org/article.aspx?articleid=1142683

http://www.uptodate.com/contents/management-and-outcome-of-thoracic-aortic-aneurysm

http://circ.ahajournals.org/content/111/6/816.full

http://circ.ahajournals.org/content/121/13/e266.full.pdf

http://www.jvascsurg.org/article/S0741-5214(95)70227-X/abstract?cc=y=


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