Spring 2019 Newsletter

Dear FLAAEM members,

Welcome to the Spring 2019 edition of the Florida Chapter Division of AAEM 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 EM Residency
Board of Directors FLAAEM
Communication Committee Co-Chair
Newsletter Editor


In this Issue


President’s Message

Time to Take a Stand

We are at a crossroads in the state of Florida and in six other states. Whether you are a resident, student or attending physician, sit up and take notice, because the time of blissful ignorance is over. For years, physicians in this state have fought against harmful legislation that can impact our patients and our careers. Sometimes we win and sometimes we lose. We can’t afford to lose on this issue.

House Bill 821 and Senate Bill 972 would allow for independent practice by APRN’s without direct physician supervision. If you think this is not a threat to emergency physicians and our patients, let me clarify a few things. While APPs are an essential and important part of our emergency care team, they only have a fraction of the training physicians receive and APPs are not standardized in the training they do receive. They should not be practicing independent of physicians. This is a safety issue. AAEM has released a position statement regarding APPs and I encourage you all to read it: AAEM Position Statement on Advance Practice Providers. And the message to AAEM membership: AAEM Takes a Stand on the Use of APPs in the ED.

Our patients deserve to be seen by a board certified emergency physician if they so request it. If these bills pass, I see emergency departments staffed exclusively by ARNPs. Why? Because it is less expensive to employ an APP than a physician. Already across this state, there are emergency departments that staff more APPs than physicians. How many of you supervise multiple APPs simultaneously during a single shift? I know many who supervise 3:1 and doctors’ hours are cut in favor of hiring more APPs. This is probably standard practice if you work for a contract management group. Patient care is secondary to the company’s profits and physicians are expensive to employ. If we want to preserve employment opportunities for the residents and students who strive for a career in emergency medicine, we have to oppose this legislation.

Already in the country APRNs can practice independently in numerous states (click here to view map).

Even if this legislation is not passed this time, it will keep coming up. Lobbying from NP groups is strong and a lot of legislators are not physician friendly. However, there is something all of you can do:

Click the link to find your state representative and senator and call, email or visit them: https://www.myfloridahouse.gov/Sections/Representatives/myrepresentative.aspx

You, as a constituent, have a voice and it’s time to make it heard. We at FLAAEM will continue to fight for you and make you aware of the issues facing emergency medicine physicians. Please do your part and get involved. Encourage your colleagues to join FLAAEM and get involved. It’s the least you can do but I guarantee you it will make a huge difference.

This is my outgoing message as your Florida Chapter Division President, as by the time of the next newsletter, a new president of FLAAEM will have been elected. It has been a pleasure to serve you and I will continue to work with FLAAEM and AAEM in order to make a difference. We are only as strong as our members and I am proud to be a part of this organization. Thank you so much.

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

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The 8th Annual FLAAEM Scientific Assembly: It Is Sure to Impress

The 8th Annual Florida Chapter Division of AAEM Scientific Assembly (FLAAEM19) will take place in Miami Beach at the iconic Fontainebleau Hotel on Mother’s Day Weekend May 10-11, 2019.

Accreditation Statement:  This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American Academy of Emergency Medicine (AAEM) and the Florida Chapter Division of the American Academy of Emergency Medicine (FLAAEM).  The American Academy of Emergency Medicine is accredited by the ACCME to provide continuing medical education for physicians.

Credit Designation Statement:  The American Academy of Emergency Medicine designates this live activity for a maximum of 10.75 AMA PRA Category 1 Credit(s) ™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity. 

What can you expect when you attend:

Friday, May 10:

  • Pre-Conference Ultrasound Course led by Mark Newberry, DO FAAEM
    • POCUS hands-on course for beginners
    • POCUS hands-on course for advanced users
  • 2nd Annual FLAAEM SimWars competition led by Dave Edwards, DO
    • Winning Residency will have the right to hold the Kevin G. Rodgers, MD MAAEM FAAEM award “The Rodgers Cup” for the year.
    • Current Defending Champion is the Aventura Hospital Emergency Medicine Residency Program

Saturday, May 11:

  • A keynote address from Salem Razaie, MD (Greater San Antonio Emergency Physicians GSEP), creator and founder of the robust and popular R.E.B.E.L EM, an online FOAMed resource.
  • The conference lecture schedule organized by Joseph Shiber, MD FAAEM includes a robust guest speaker list with representatives from almost every academic residency program in the state of Florida.
  • Dedicated Medical Student Lecture Track led by Laurie Boge, DO FAAEM.
    • Topics include applying for “audition” rotations, residency application advice, the match process, and life as an intern.
  • 5th Annual FLAAEM scholarly activity competition, coordinated by Mike Dalley, DO FAAEM and moderated by Lisa Moreno, MD MS MSCR FAAEM and Mark Foppe, DO FAAEM FACOEP.
    • Enjoy submissions for original research abstracts, interesting case reports and interesting clinical photos from residents and medical students from across the nation. Overall there were 38 posters (original abstracts, case reports and interesting photo submissions) submitted from residency programs and medical schools from across the nation.
    • The 3rd Annual Sal Silvestri Research Award will be presented to the winner of the oral presentation for best scholarly activity submission of the assembly.
    • 1st Annual A Toast to Wonder WomEM – a Women in EM Session & Socia., organized and hosted by Laurie Boge, DO FAAEM and Vicki Norton, MD FAAEM.
      • Anticipate great dialogue with generations of women healthcare providers about life as a female provider in emergency medicine.

We can’t wait to see you all in Miami next month!

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

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Farewell, Florida: Student Member Representative Outgoing Message

Joshua Novy, MS4, MBA
FLAAEM Board of Directors, Medical Student Member Representative

As I write this message, I find myself with mixed emotions. My direct involvement with the Florida Chapter Division of AAEM (FLAAEM) will soon come to its end, as I will be returning to my home of New York to begin my residency training in emergency medicine. I discovered FLAAEM in 2017 at the FLAAEM Scientific Assembly in Miami Beach, and immediately I knew I found a specialty, a home – a chrysalis in which I could be guided through uncharted waters as a medical student. When I joined the FLAAEM Board of Directors in 2018, I was welcomed with praise and enthusiasm, as were my ideas. Having struggled through administrative red tape for years as a medical student, I thought the opportunity to work with such wonderful people was too good to be true. My service on the board of directors paved the way for special projects and writing opportunities, as well as access to immense human capital and mentorship in our specialty in Florida.

In my term as Student Member Representative, I have made it a point to enhance the visibility of our organization and to spread this message, “FLAAEM cares about medical students.” This is exemplified especially by the involvement of Mount Sinai Medical Center of Miami Beach’s engagement with students through the annual Student Track at the annual FLAAEM Scientific Assembly. This year, with the aid of Theddy Blanc, the AAEM/RSA Southern Regional Representative, I organized a statewide committee of student leaders from each of Florida’s medical schools EM interest groups; a pilot committee, this yielded mixed results and responses, but I will remain available to our incoming Student Member Representative to continue smoothing over the growing pains of a new committee. I encourage you to reach out to your school’s EM interest group regarding this opportunity.

My hope, as you read this, is that you will consider stepping up and getting involved with FLAAEM. It will be a worthwhile investment of your time, and the relationships you will make in FLAAEM will guide you and carry you into your residency program and beyond.

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Board of Directors Meeting Update – March 2019

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

2019 Board Election Nominations have closed.

Voting via an online ballot will open mid-April and will close Saturday May 11, 2019, at 1:00pm ET. To cast your vote click here.

Next FLAAEM Board of Directors Meeting

  • Friday, May 10, 2019 at 6:00pm ET – in-person meeting in the Splash 9 meeting room* at Fontainebleau Hotel.
    *Meeting room subject to change

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A Case of Acute Meckel’s Diverticulitis in an Adult Patient

Authors: Waroot Nimjareansuk, DO; Nicholas Boyko, DO; Laurie Boge, DO; David Farcy, MD; Michael Dalley, DO
Mount Sinai Medical Center, Miami Beach, Florida

Chief Compliant:

Right lower quadrant abdominal pain

History of Present Illness:

A 55-year-old male with a past medical history of hypercholesterolemia and prostate cancer in remission presents to the emergency department complaining of right lower quadrant abdominal pain for 1 day. He states that his abdominal pain is gradual in onset, intermittent, non-radiating, and has gradually worsened. He denies any fever, chills, nausea, vomiting, diarrhea, hematochezia, or melena.

Physical Exam:

VITALS: BP 135/83mmHg, Pulse 93bpm, RR 16bpm, Temp 98.3F, SpO2 98% on room air

CONSTITUTIONAL: Well-appearing male, no acute distress

ABDOMEN: Soft, normal appearance and bowel sounds, right lower quadrant tenderness to palpation, no rebound, guarding, or rigidity

RESPIRATORY: Breath sounds clear to auscultation bilaterally

CARDIOVASCULAR: Regular rate and rhythm

Questions:

  1. What are the most common complications of Meckel’s diverticulum?
  2. What are the key clinical signs and symptoms of the pathology?
  3. Which imaging modality is diagnostic?

Answers:

Case Discussion:

A CT abdomen and pelvis with IV contrast was ordered with concern for acute appendicitis given the patient’s clinical presentation. Complete blood count showed a leukocytosis of 13.19 with no left shift. Chemistry, lipase, liver function tests, and lactic acid were within normal limits. CT revealed a blind-ending structure arising from a distal ileal loop with mural enhancement measuring up to 1.5 cm transversely, with extensive adjacent fat stranding and inflammatory changes correlating to an inflamed Meckel’s diverticulum without evidence of rupture or fluid collection; the retrocecal appendix was normal. Surgery was consulted and he was admitted for Meckel’s diverticulitis. He started on ciprofloxacin and flagyl. He was treated conservatively with antibiotics, bowel rest, and repeat abdominal examinations. He had improvement of his abdominal pain and was discharged 3 days later with surgery outpatient follow up.

The vitelline duct, also known as the omphalomesenteric duct, is an embryonic structure that connects the yolk sac (site of maternal-fetal nutrient exchange) to the midgut of the embryo. The duct normally obliterates around the 7th-8th week of gestation. Failure to obliterate most often results in Meckel’s diverticulum, a true diverticulum containing the mucosa, submucosa, and muscularis layers of the intestinal wall. This is in comparison to a pseudodiverticulum, also known as a false diverticulum, such as those seen in colonic diverticulosis, which lack inclusion of the muscularis layer.

Meckel’s diverticulum is characterized by the, “Rule of 2s.” Meckel’s diverticulum protrudes from the ileum approximately 2 feet proximal to the ileocecal valve and is 2cm wide. The prevalence is 2% (Anderson), it is twice as common in males than females (Ruscher), and most commonly presents between 2-8 years of age (Ruscher). Most cases are asymptomatic and diagnosed incidentally on radiographic imaging, during surgery, or autopsy. Symptoms are secondary to complications and are estimated to occur in one third of patients. The most common complications are obstruction, bleeding, and intussusception (Ruscher, Ghahremani).

Complications may present with periumbulical pain radiating to the right lower quadrant. A key component of the history in differentiating from appendicitis is the presence of rectal bleeding. Bleeding has been reported among a spectrum ranging from bright red to dark or tarry (Kusumoto). On examination, tenderness greater periumbilically than in the right lower quadrant may guide the clinician. It must be noted that clinical diagnosis is difficult, and as Dr. Charles W. Mayo stated, "Meckel's Diverticulum is frequently suspected, often looked for, and seldom found." Yet, the undifferentiated patient may be diagnosed with the technetium-99m pertechnetate scintiscan, referred to as a Meckel scan. Sensitivity and specificity are also improving with computerized tomography (Connolly).

Our case is of particular interest because the patient is far above the average age of presentation and was identified to have Meckel’s diverticulitis on imaging.

Pearls:

  • Meckel’s diverticulum and associated complications must be in your differential for a patient presenting with periumbilical/RLQ pain and rectal bleeding.
  • Some cases may be missed by CT; the Meckel’s scan, or technetium-99m pertechnetate scintiscan, is diagnostic.

References:

Connolly, Susan A., et al. “Meckel’s Diverticulitis: Diagnosis With Computed Tomography and Tc-99m Pertechnetate Scintigraphy.” Clinical Nuclear Medicine, vol. 29, no. 12, 2004, pp. 823–824., doi:10.1097/00003072-200412000-00017.

Ghahremani, GG. “Radiology of Meckel's Diverticulum.” Crit Rev Diagn Imaging, vol. 26, no. 1, 1986, reference.medscape.com/medline/abstract/3525002.

Kusumoto, Hiroki, et al. “Complications and Diagnosis of Meckel's Diverticulum in 776 Patients.” The American Journal of Surgery, vol. 164, no. 4, 1992, pp. 382–383., doi:10.1016/s0002-9610(05)80909-2.

Ruscher , KA, et al. “National Trends in the Surgical Management of Meckel's Diverticulum.” J Pediatr Surg, vol. 46, no. 5, 2011, reference.medscape.com/medline/abstract/21616248.

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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 and register!

Registration Now Open

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

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Recent News Headlines and Articles

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