Spring 2018 Newsletter

Dear FLAAEM Members,

Welcome to the spring 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 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 Emergency Medicine Residency
FLAAEM Board of Directors, Communication Committee Co-Chair and Newsletter Editor


In this Issue


President’s Message

We just had another successful FLAAEM Scientific Assembly in Miami Beach and we are already looking forward to next year’s conference. For those of you who missed the FLAAEM Scientific Assembly, every year only gets bigger and better. We look forward to seeing you next year.

It was enlightening and beneficial to connect with so many of you in the state to gain perspective on the issues we face as a specialty. Many voiced concerns over increasing corporate interference in the practice of medicine. Many talked about ways to combat this and how we can better advocate for ourselves. The problem is most doctors don’t advocate for themselves. We are amazing patient advocates but terrible at standing up for ourselves…and this has to change.

If you work at a facility where you are seeing more than two patients an hour, you are understaffed. You are not a badass because you saw 50 patients in a 12-hour shift; you are being exploited. If you work at a facility where you are not able to see what is billed in your name, you are being underpaid. Why else would you not be able to see what you are directly earning through your hard work? If you work at a facility where you are written off the schedule or fired when you speak out about patient safety issues, you are being penalized for doing your job.

We are all dealing with these issues by putting our heads in the sand and ignoring what’s happening around us. We can fix the problem if we stick together. Let’s support one another, stand up for what’s right and stop working for companies that treat us this way.

There’s strength in numbers. You can make an impact by getting your colleagues involved. Talk about AAEM, get them to sign up, and come to events where we can all come up with ways to move forward. I am asking that everyone reading this get two of your colleagues to join the Florida Chapter Division of AAEM in the next month. I can’t wait to see what we can do to protect our specialty, our patients, and ourselves in the future.

Respectfully,

Vicki Norton, MD FAAEM
President, Florida Chapter Division of AAEM (FLAAEM)


The 7th Annual FLAAEM Scientific Assembly: Bigger and Better than Ever!

Michael T. Dalley, DO FAAEM
Program Director EM Residency MSMC Miami Beach
FLAAEM At-Large Board of Director
Editor of FLAAEM Newsletter

The 7th Annual Florida Chapter Division of AAEM (FLAAEM) Scientific Assembly took place in Miami Beach at the iconic Fontainebleau Hotel on February 10-11, 2018. This year’s conference was the best attended to date, with over 220 Emergency care providers present. As in previous years, participants received up to 12.75 hours of continuing medical education credit. Highlights from the conference include the keynote address on effective leadership in emergency medicine by Dr. Robert A. Barish, MD MBA FAAEM. Vice Chancellor for Health Affairs and Professor of Emergency Medicine at the University of Illinois at Chicago. The conference schedule included a robust list of guest speakers, representing almost every academic residency program in the state of Florida.  For the first time, three education tracks were offered for Sunday, including Point of Care ultrasound sessions in the morning and afternoon, the Medical Student Lecture Series, and the 1st Annual FLAAEM Scientific Assembly Sim Wars Competition.

This year’s meeting also continued the poster, abstract and oral presentation competition. Overall, there were 38 posters (original abstracts, case reports and interesting photo submissions) submitted from residency programs and medical schools from across the country. At the end of the Saturday lectures, there was an oral presentation component, which was moderated by Dr. Lisa Moreno-Walton, AAEM Secretary-Treasurer, and Dr. Mark Foppe, FLAAEM Past Presidents Representative. The winners are acknowledged below:

Original Research Abstracts

1st place (The Sal Silvestri Award): Ultrasound Guided Trigger Point Injections for Musculoskeletal Pain. Drs. Rob Farrow, Adam Memmon, Justin Burkholder, Jackie Lorenzo-Farrow, Michael Rosselli, Mark Newberry, David Farcy. Mount Sinai Hospital, Miami Beach, FL.

2nd place: Association Between Race/Ethnicity and Wait Time in Adult Patients Presenting to an Emergency Department with Emergent vs Urgent Presentations: a Secondary Analysis. Drs. Kunal Parmar, M Aboabdo, C. Madhwani, G. Castro, J. Zevallos et al.  FIU Herbert Wertheim College of Medicine, Miami, FL.

Interesting Case Report

1st Place: A Case of Left Ventricular Regional Wall Motion Abnormality in the Setting of Acute Loperamide Overdose. Tim Montrief and Mehruba Anwar, MD.  University of Miami/JMH Miami, FL.

2nd Place:  Breaking the Seal. Spontaneous Intraperitoneal Bladder Rupture after a Fall on a Pool Deck. Drs. Jackie Lorenzo Farrow, Gregory Alfred and Mike Dalley, DO. Mount Sinai Hospital, Miami Beach, FL.

Interesting Photo Submission

1st Place: A Crunchy Chest wall. Esophageal Food Bolus Impaction. Drs. Maurico Baca and Jeff Mesuk, MD.  Mount Sinai Hospital, Miami Beach, FL..

2nd Place: Acute Appendicitis Presenting as Intussusception on POCUS. Drs. Haley Watsky and Michael Dalley, DO. Mount Sinai Hospital, Miami Beach, FL.

Winners of the Sim Wars Competition

First place: The Kevin Rodgers Award (AKA the Rogers Cup) Aventura Hospital Emergency Medicine Residency Program.  Team of Drs. Tom Yang, Matt Yasavolian, Fred Chu and Salem Elkhayat.

Second Place: Mount Sinai Medical Center.  Team of Drs. Burr Fong, Robert Farrow, Meagan Lorenzo and Waroot “Shay” Nimjareansuk.

The first annual South Florida Women’s Physician Luncheon was held Sunday afternoon. The luncheon was organized and hosted by Drs. Laurie Boge and Vicki Norton. Those who attended found the dialogue and platform uplifting and inspiring. The meeting united generations of women healthcare providers and encouraged conversation about gender bias, disparities in healthcare and life as a female healthcare provider in emergency medicine.

Finally, we were privileged to host AAEM President-Elect, Dr. David Farcy as well as AAEM board members, Dr. Lisa Moreno-Walton, Secretary-Treasurer, and Dr. Bobby Kapur, At-Large Board of Director. Dr. Farcy followed the keynote address and spoke about the current state of emergency medicine, as well as how AAEM supports and advocates for emergency physicians.

A special thank you goes out to FLAAEM Scientific Assembly Planning Committee Chair, Dr. Joseph Shiber, FLAAEM President, Dr. Vicki Norton, the entire FLAAEM Board of Directors, Drs. David Edwards and Dr. Mark Newberry, chairs of the Sim Wars Competition and the Medical Student Lecture Series, and the Point of Care Ultrasound Tracks on Sunday afternoon, without whom the conference would not be as outstanding and educational as it was. Thank you to all those who supported the conference this year, including the speakers, sponsors and exhibitors, attendees from near and far, and all the people behind the scenes who contributed in making our 7th Annual FLAAEM Scientific Assembly a huge success!


2018 FLAAEM Board of Directors Election Results

FLAAEM is proud to congratulate the winners of the 2018 Board of Directors Election.

At-Large Directors
Michael Dalley, DO FAAEM
Lawrence Isaacs, MD FAAEM
Rian Pillitteri, MD FAAEM
Alexandra Terskiy, MD FAAEM

Associate Member Representative
Wanda E. Cruz, DO

Resident Member Representative 
Rob A. Farrow, DO

Student Member Representative
Joshua E. Novy, MS 4


State of Florida EM Residency Spotlight

Mount Sinai Hospital, Miami Beach

Greetings from Mount Sinai, Miami Beach.  Here are a couple of highlights from this past winter:

Our department chairman, Dr. David Farcy, will be accepting his role as President of AAEM at the upcoming 24th Annual AAEM Scientific Assembly in San Diego on April 7-11, 2018.

The 7th Annual FLAAEM Scientific Assembly was well supported by Mount Sinai’s Emergency Medicine Residency Program.  Our Ultrasound Director, Dr. Newberry, led a successful ultrasound workshop at FLAAEM that was attended by local emergency medicine physicians, residents and allied healthcare professionals.

Mt. Sinai’s Sim Wars team (Drs. Fong, R. Farrow, Lorenzo and Nimjareansuk) scored a strong 2nd place finish behind the Aventura Emergency Medicine Program team in the first annual FLAAEM Sim Wars Competition. Congratulations to all the programs that participated. A special thank you to our Assistant Program Director, Dr. Edwards, and Simulation Director, Mickey Fuentes, for leading and organizing this event.

Mt. Sinai’s Dr. Watsky (PGY-4) and Dr. Boge led the first annual Women in EM Luncheon at the Fontainebleau Hotel. The event was well attended and a hallmark of the FLAAEM Scientific Assembly weekend. Over 70 women attended including pediatric emergency medicine and emergency medicine residents and students.

Dr. Garrett (PGY-3) and Dr. Boge will be leading the first South Florida Wilderness Medicine conference on March 2-4, 2018. This will be the only AWLS course offered in a tropical zone of the US. Multiple Mt. Sinai core faculty and residents will be contributing to the courses and activities.

We recently had an acceptance of an original research abstract for presentation at SAEM national conference and the 1st place Sal Silvestri Award for original research at this year’s FLAAEM Scientific Assembly, Ultrasound Guided Trigger Point Injection for Musculoskeletal Pain in the ED (Drs R. Farrow, Memon, Burkholder, & J. Farrow).

We applaud acceptance of original research for abstract presentation at the 24th Annual AAEM Scientific Assembly in San Diego on April 7-11, 2018.

  • Was FOPA a Faux Paus? (Drs. Burkholder, Koschel, Boge)
  • Case report for abstract presentation at AAEM national conference in San Diego. La Vinchucas (Drs. Burkholder, Menendez)

Drs. R. Farrow & Memon will be presenting case reports at the American Medical Society of Sports Medicine national conference in Orlando.

Congratulations to the rest of our graduating class of 2018: Drs. Haley Watsky, Burr Fong, Jackie Farrow, Joe Sherer and David Kinas as they prepare to move forward with their careers in emergency medicine.

Robert Farrow, DO
Resident Representative, FLAAEM Board of Directors
EM Resident PGY 3

University of Miami/Jackson Memorial Hospital

We are very pleased to be able to provide updates on some of our residents’ recent academic achievements. At this year’s 7th Annual FLAAEM Scientific Assembly, Dr Henry Zeng presented a poster on Lomotil toxicity, Dr  Chris Sweat presented a case of unintentional acyclovir overdose, and Dr Timothy Montrief presented a photo poster on traumatic vision loss as well as a case report on loperamide toxicity, the latter of which won an award for best case presentation. Congratulations to Drs. Emily Ball and Anwar Ferdinand for their involvement in a project titled Opt-Out Emergency Department Screening of HIV and HCV in a Large Urban Academic, which was chosen for an oral presentation at the upcoming 24th Annual AAEM Scientific Assembly in San Diego. It will also be published in the Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health. Dr Laura Scheidt collaborated on a project entitled Longitudinal, Simulation-Based Disaster Response Curriculum Culminating in an Inter-Professional Large-Scale Response Exercise for MD/MPH Students that was just recently presented by our very own Dr Motola, guru of SIM, at the International Meeting on Simulation in Healthcare in Los Angeles. And finally, we commend Dr. Ariana Weber for serving as an instructor for the EMS Point of Care ultrasound course for Monroe and Miami-Dade County Air Rescue flight medics and nurses.

Having recently finished a grueling but exciting recruitment season, we look forward to match day to find out which talented individuals will be joining us to finally form the full complement of our residency program. It's really amazing how quickly three years can fly by. Finally, we are looking forward to hosting the quarterly South Florida Emergency Medicine Consortium on March 28, 2018, at which time we will be welcoming Dr Hilarie Cranmer, Director of Global Disaster Response at Massachusetts General Hospital.

Before we know it, we’ll be knee deep in orientation for our new residents, soon followed by the (re)opening of ERAS, and then interviews…. Lather, rinse, repeat!

Mark Supino, MD
Assoc Program Director

St Lucie Medical Center

It’s 2018 and we at St. Lucie Medical Center are off to the start of an outstanding new year!

This year marks our first year of participating in the ACGME match. After an exciting rotation and interview season, our match list is finalized and we are thrilled to welcome this July’s incoming class. Best of luck to all who are participating in the match this year!

As a residency program, we have enjoyed some recent wellness activities. In December of 2017, we participated in the Ropes Course at Florida Atlantic University – a well renowned outdoor course that emphasizes confidence building and teamwork. We also ran our yearly 5k run at Classics by the Sea in Jupiter, Florida. Once again, Dr. Matese, our beloved program director, took home the gold.

We are also proud to say that we have participated in several beach clean-up activities, Habitat for Humanity, and many of us will be volunteering at the Treasure Coast Marathon.

We at St. Lucie Medical Center wish you all a wonderful and productive year. We look forward to seeing you all at the next conference!


Member Benefits

Free Annual Scientific Assembly

http://www.flaaem.org/events/scientific-assembly

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 9, 2018

The following topics were discussed at the recent FLAAEM Board of Directors meeting:

2018 Board Election Nominations

At Large Director: Drs. Michael Dalley, Lawrence Isaacs, Kevin King, Thomas Matese, Rian Pillitteri and Alexandra Terskiy

Associate Member Representative: Dr. Wanda Cruz

Resident Member Representative: Dr. Rob Farrow

Student Member Representative: Mr. Joshua Novy

The online ballot is being created for the election to open later this January. Messages have been sent to candidates to accept their nomination and forward any missing information needed for the online ballot.

Government Affairs Committee Update

Dr. Cruz reported that FOMA and Williams and Jensen have helped prepare a Due Process Bill for Florida physicians that potentially may be added as an amendment to another bill in the Florida Legislature. Dr. Cruz requested that board members contact Representative Harrison’s office to endorse this Due Process for Florida Physicians Bill.

2018 Board Meetings

  • Friday, February 9, 2018 at 6:00pm ET – in-person meeting in Splash 9 meeting room at Fontainebleau Hotel.
  • Monday, April 9, 2018, 4:30pm PT – in person meeting in Pacific 16 meeting room at AAEM SA18 in San Diego.
  • Tuesday, July 10, 2018, 3:00pm ET – conference call.
  • Tuesday, October 9, 2018, 3:00pm ET – conference call.

2018 FLAAEM Scientific Interesting Case Competition: “Breaking the Seal” 2nd Place Winner

Jackie Lorenzo-Farrow, DO
Gregory Alfred, MD
Michael T Dalley, DO FAAEM

Case Presentation: 51 y/o female BIB husband for forehead abrasion after a slip and fall.  Pt has been drinking alcohol earlier today and 5 hours PTA she ran around the pool, slipped and fell onto her forehead. She immediately urinated on herself after the fall followed by two episodes of emesis, non-bloody, non-bilious. Pt states she was able to urinate PTA. 5 hours later, her husband is concerned that the patient is not sobering up after she fell onto her forehead.

Denies: LOC, neck pain, headache, vision loss, chest wall pain, SOB, n/v, abd pain, paresthesia, muscle weakness, urinary/fecal retention, hematuria

PMHx:: denied

PSHx: denied

Social: Daily drinker; denies smoking or illicit drug use; LMP 2 weeks ago

Vitals: BP: 129/82; HR 93; Temp 97.5F, RR 17, Sat 99% RA, BMI 31

FAST EXAM: negative upon arrival

PE: neuro, abd WNLLABS: BC, BMP, Coag, beta, tox NEG except: ETOH 281

Suprapubic view of FAST exam upon arrival:

Reassessment  2 hours after arrival:

CT Brain plain is negative for acute intracranial hemorrhage or mass. Labs are unremarkable except for elevated ETOH level as expected. Pt was hydrated and watched in ED for clinical sobriety. Upon reassessment, Pt remains intoxicated but able to express herself more clearly. She is now complaining of LLQ pain. Pain is not reproducible on re-exam and abdomen remains soft, non-peritoneal. Pt is mid-cycle and suspecting ovarian cyst versus UTI. Vaginal exam reveals no laceration, adnexal tenderness or blood at urethral meatus. UA  and US

Official US of the Pelvis:

US pelvis: Shows vascular mobile echogenic debris inside urinary bladder. No evidence of acute uterine or adnexal pathology. No free fluid in the pelvis.

US finding are concerning for traumatic bladder rupture. Pt states she is unable to give a urine sample. Foley was inserted and 20 cc gross blood was drained. CT abdomen/pelvis with IV contrast was ordered to evaluate for any genitourinary injury.

CT Abdomen/Pelvis with IV contrast:

CT abdomen/Pelvis with IV contrast: Showed a partially distended thick walled urinary bladder with a 4mm defect at the dome of the bladder with small amount of abdominopelvic ascites indicating intraperitoneal bladder rupture.

Hospital course:

Urology was consulted and they performed a CT Cystogram which confirmed extravasation of contrast between the bowel loops and sparing the extraperitoneal space.

CT Cystogram:

Intraoperative Images

Discussion

Urinary bladder rupture, a rare condition found in 1.6% of blunt abdominal traumas, is most frequently caused from blunt abdominal trauma in a motor vehicle collision secondary to seatbelt injuries. Other causes include direct blunt or penetrating trauma to the lower abdomen, iatrogenic causes from surgical or endoscopic procedures, or spontaneous ruptures from vaginal deliveries, radiation or malignancy (Simon et al). 90% of traumatic bladder injuries are associated with pelvic fractures, particularly pubic rami fractures. These patients normally present to the Emergency Department with lower pelvic pain and hematuria. This makes the remaining 10% of bladder ruptures, which are not associated with pelvic fractures, a more challenging diagnosis due to a lower energy mechanism of injury and lack of physical exam findings (Ramchandani et al. 2009).

There are five categories of bladder injuries: wall contusion, intramural, intraperitoneal, extraperitoneal and combined intra and extraperitoneal injury. The most common type of bladder rupture is extraperitoneal encompassing 60% of injuries and also associated with concurrent traumatic pelvic fractures and high-energy injuries (radioem). In contrast, intraperitoneal ruptures are most commonly caused by iatrogenic or spontaneous ruptures since the bladder wall is the weakest at the dome of the bladder. Other reported causes of intraperitoneal rupture are from a direct blow to the lower abdomen with a full bladder. AUA recommends plain film or CT cystography as the imaging modality of choice for a suspected bladder rupture both of which have 95% sensitivity and 100% specificity (Ramchandani). AUA guidelines recommends that uncomplicated extraperitoneal ruptures be treated with a Foley catheter, and in contrast intraperitoneal bladder ruptures must be treated surgically (Simon).

Conclusion

This case report demonstrates a unique presentation of intraperitoneal bladder rupture in an intoxicated middle-aged female that presented to the Emergency Department for an abrasion of her forehead after a slip and fall from standing. It is important that an ED physician maintain a high index of suspicion for a bladder rupture even when there is a low-energy mechanism and a initial negative FAST exam. 

Refrences

Ramchandani, P., Buckler, P. Imaging of Genitourinary Trauma. Department of radiology, University of Pennsylvania Medical Center. AJR:192, June 2009.

ACR-SAR Practice Parameter for the Performance of Adult Cystography and Urethrography. 2015.

Radeopedia Urinary Bladder Rupture

Heller, M. MD., Federle, M. MD. Bladder Trauma. STATdx


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