Summer 2017 Newsletter

Dear FLAAEM Members,

Welcome to the summer 2017 edition of the Florida AAEM newsletter. The newsletter is under new editorial leadership as Dr. Vicki Norton has started her term as president. As in the past, 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,

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

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

I am honored and excited to get to work as the newly elected president of the Florida Chapter Division of AAEM (FLAAEM). I am the first female president of FLAAEM and one of my goals as president is to have more women become actively involved in the future of emergency medicine. It is inspiring to see more and more women rise through the ranks to become ED directors and professors, but I would also like to see more women involved in our professional societies. It can start small, like someone forcing you to run for an associate board member position and practically filling out your application for you. (Thanks Dr. Mark Foppe!)

One of my aims for FLAAEM is advocating for our patients and our specialty. We are the safety net of medical care in this country. Without us, uninsured patients would fall through the cracks of our medical system. But there is a gap in insurance coverage for insured patients as well. High deductible plans sound familiar? What about balanced billing AKA surprise billing? Insurance companies have lobbied for lower reimbursement rates to providers and hospitals while at the same time cutting coverage to patients. Patients are left with large bills either to meet the deductible or to pay the balance that the insurance refuses to cover. While insurance companies continue to turn huge profits year after year, patients are receiving less coverage for higher costs. And doctors continue to receive lower reimbursement. It is unconscionable. Why is there a middleman in health care? Doctors provide care to patients and should be reimbursed directly and appropriately.

You are probably asking yourself, why does this matter to me? Most of us don’t know what is billed and collected in our names. Most of us work as independent contractors and are paid hourly regardless if the patients pay for care or not. But this affects you whether you realize it or not. Right now there are two main issues being debated on a state and federal level, which will directly affect our patients and our bottom line: waiving the prudent layperson standard and capping on out-of-network fees. Both will result in less reimbursement for the ED and likely in your paycheck. Pay cuts aside, if we don’t stand up and do something about these issues, EDs will close and patients will suffer.

Emergency physicians are tasked with providing a medical screening exam and stabilization to patients regardless of their ability to pay thanks to EMTALA. We cannot afford to keep an ED running without proper payment from private insurance. Medicaid pays 15 cents on the dollar, which will not keep the lights on in the ED; Medicare pays enough to break even without any profit to take home and feed your family; and so private insurance is necessary to subsidize the cost of running an ED. Private insurers are trying to put caps on out-of-network (OON) fees in order to drive down reimbursement further. I’m sure if the payment to the physicians for in-network services were adequate (80% Usual, Customary, and Reasonable UCR fee), no one would bill out-of-network. A cap on OON fees would further limit EPs ability to negotiate fairly with insurance companies and subsidize all of the “free” EMTALA-mandated care they provide.

The other issue that puts EDs at risk is waiving the prudent layperson standard. In Missouri in May of this year, Anthem Blue Cross stated that they would not reimburse for emergency care if the final diagnosis were on a list of “non-urgent” diagnoses. Among the diagnoses, which will not be reimbursed, is “chest pain with breathing,” which could be a pulmonary embolism until proven otherwise. The prudent layperson standard, as outlined by the Affordable Care Act, specifies that private insurance cannot refuse payment for emergency care. It defines an emergency as a condition that a prudent layperson, 'who possesses an average knowledge of health and medicine,' expects may result in placing the patient in serious jeopardy, serious impairment of bodily function, or serious dysfunction of any bodily organs. The new Better Care Reconciliation Act (formerly the American Health Care Act) has a provision in it that would allow states to waive the prudent layperson standard. This could mean patients sit at home with their MI because they are afraid that it might just be reflux and their insurance won’t pay for it.

There is one final matter that puts our specialty in jeopardy: due process. When you sign a contract with a contract management group (CMG), you are signing away your due process rights. Every doctor on the medical staff at a hospital has the right to due process before termination as granted by CMS. A third party contract should not be allowed to waive these rights. The situations I have seen unfold in the last year in Florida are physicians being fired from CMGs after they bring up patient safety issues. A CMG will do anything to preserve their contract with the hospital to run the emergency department. If you are seen as a threat to them by advocating for your patients and pointing out their weaknesses, such as understaffing to save money or upcoding charts, then you will be eliminated without notice. We cannot stand by and let our colleagues get fired over doing what is right for patients.

As the summer months draw to a close, I urge everyone to get involved. Get to know your local politicians. Introduce yourself and tell them what is important to you as an emergency physician. Come to advocacy events in Washington, D.C. and Tallahassee. Talk to your colleagues and let them know about the issues going on right now. We may be a minority among the behemoth of insurance lobbyists, hospitals and contract management companies, but we are the only ones who can advocate for our patients and ourselves.

https://www.flsenate.gov/Senators/Find or https://www.myfloridahouse.gov/Sections/Representatives/representatives.aspx


Florida Chapter Division Celebrates a Successful 6th Annual Scientific Assembly

Michael Dalley, DO FAAEM
FLAAEM Board of Directors

The 6th Annual Florida Chapter Division of AAEM (FLAAEM) Scientific Assembly took place in Miami Beach at the iconic Fontainebleau Hotel on April 22-23, 2017. This conference was the best attended to date, with over 160 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 a keynote address from Dr. Stephen Ludwig, MD, a founding father of pediatric emergency medicine. The conference schedule included a robust guest speaker list with representatives from almost every academic residency program in the state of Florida, as well as Drs. Lisa Clayton and Patrick Hughes filling in for Dr. Richard Shih and his popular 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 with over 50 students from various medical schools 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 44 posters (original abstracts, case reports, and interesting photo submissions) 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 directors representatives Drs. Vicki Norton and Mark Foppe. The winners are acknowledged below:

Original Research Abstracts

1st place: “Bedside Ultrasound Evaluation for Shoulder Dislocation and Reduction.” Ben Boswell, DO; Michael Rosselli, MD; Rob Farrow, DO; Luanna Santana, BA; David Farcy, MD. Mount Sinai Medical Center. Miami Beach, FL.

2nd place: “The Association Between ADHD Severity with Risk of Head Injury, Traumatic Brain Injury, and Concussion.” Semir Karic, MS 3; Michael DesRosiers, MS3. Florida International University College of Medicine. Miami, FL.

Interesting Case Report

1st Place: “A Case of Fulminant Myocarditis Treated with ECPR.” Robert Farrow, DO1; Jackie Lorenzo, DO1; Michael T. Dalley, DO1; Dr. Madawali2. Mount Sinai Medical Center. Miami Beach, FL1. Jack Nicklaus Children’s Hospital. Miami, FL2.

2nd Place: “‘Don’t Skip Leg Day, Bro.’ A Case of Unprecedented Exertional Rhabdomyolysis Without Acute Kidney Injury.” Aadil Vora, MS 3. Nova Southeastern University. Davie, FL.

Interesting Photo Submission

1st Place: “Retro-Orbital Hematoma from a Taser Gun.” Jennifer Bach, DO PGY 3. St. Mary Mercy Hospital. Livonia, MI.

2nd Place: “Intussusception Diagnosed with Bedside Ultrasound.” Robert Farrow, DO. Mount Sinai Medical Center. Miami Beach, FL .

Finally, we were privileged to host AAEM president, Dr. Kevin Rogers, as well as three members of the national board: president-elect Dr. Dave Farcy, secretary-treasurer Dr. Lisa Moreno-Walton, and at-large board member Dr. Bobby Kapur. Dr. Rogers 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 thanks goes out to FLAAEM Scientific Assembly Planning Committee chair, Dr. Joseph Shiber, and to FLAAEM 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, sponsors and exhibitors, attendees from near and far and all the people behind the scenes who contributed in making our state conference a huge success!


Member Benefits

Free Annual Scientific Assembly

7th Annual FLAAEM Scientific Assembly - Announced Soon!

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

Registration Opens January 2018

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 – July 11, 2017

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

  • The 7th Annual FLAAEM Scientific Assembly Planning Committee is assembled. Date and location of the first meeting is TBA.
  • Dr. Kevin King, MD, Program Director of the Kendall Regional Emergency Medicine Residency, was appointed to fill the open board position.
  • WestJEM subscription renewal was approved and will be offered free of charge to full voting FLAAEM members.
  • The board hopes to further develop FLAAEM advocacy within our state as with the challenge presented by the overwhelming number of contract management groups. Any member input is welcome. Options include co-sponsoring EM Days with FCEP or establishing another advocacy day unique to FLAAEM.
  • The next FLAAEM Board of Directors meeting is scheduled for Tuesday October 10, 2017, at 3:00 EST.

FLAAEM Scientific Interesting Clinical Pathology Photo Submission: Abdominal Pain in a 50-Year-Old Female?

Robert Farrow, DO
Emergency Medicine, PGY-2
Mount Sinai Medical Center

Richard Menendez, MD
Vice Chair, Department of Emergency
Mount Sinai Medical Center

A 50-year-old woman presented to the ED with a chief complaint of severe abdominal pain. Past medical history was significant for multiple abdominal surgeries, including multiple bariatric surgeries. Onset of abdominal pain occurred just prior to arrival and is described as severe, constant pain that is periumbilical. Associated symptoms included severe nausea, non-bloody emesis and lack of appetite. On examination patient was found to be in severe distress and writhing on the hospital bed. Initial vital signs were as follows: BP 134/85, HR 83, oral temperature 98.6, RR 17, and SpO2 97% RA. Patient was alert and oriented but diaphoretic and complaining of severe abdominal pain. Patient was found with her legs flexed to her chest when the physician walked into the room and stated that this was her position of comfort. Abdomen was tender to periumbilical palpation with associated guarding during examination. There were no significant abnormalities on BMP or CBC. She had no leukocytosis and LFTs and lipase were within normal limits. Lactic acid was 2.1. Bedside ultrasound was significant for the following finding:

What classic finding is displayed on this abdominal ultrasound image?

What does the area of hypoechogenicity reflect in regards to the organ seen in this image?

Answers to the stimuli questions are below…

  1. This image is showing the classic image of target sign that is associated with several abdominal pathologies but most traditionally intussusception. This sign is seen in a transverse view of the intussusception.
  2. The area of hypoechogenicity is suggestive of bowel wall edema surrounding a hyperechoic central region that represents intussusceptum and associated mesenteric fat.

The patient that presented had a very long surgical history, which included modified Roux-en-Y gastric banding, lysis of adhesions and small bowel resection. She had a history of intussusception in the past but given the presentation and history, the differential included multiple pathologies. The bedside US shows the classic target sign associated with intussusception. This finding reflects a transverse view of the involved bowel with the hypoechoic rim representing bowel wall edema and the hyperechoic bullseye representing the intussuscepted bowel and associated mesenteric fat. In this case, the bedside US demonstrated convincing findings suggestive of intussusception allowed ED providers to get surgery involved early in clinical care and to allow them to focus on pain management, which ended up being the primary goal of therapy while in the ED.

Take home points:

  • Primarily a pathology seen in children, but 10% of intussusceptions occur in adults.
  • In adults 90% have a demonstrable cause such as neoplasm (60%), inflammation/trauma/suture lines (30%) and only 10% are idiopathic. This is opposed to children were 90% have no pathologic lead point and are thought to be due to lymphoid hyperplasia after viral illness.
  • Views that are needed for diagnosis include: transverse (target or doughnut sign), longitudinal (sandwich sign: layering of hypoechoic bowel wall and hyperechoic mesentery), Oblique (pseudokidney sign: hypoechoic bowel wall mimicking the renal cortex and hyperechoic mesentery mimicking the renal fat). Doppler can also be used to look for blood flow in the bowel wall to assess for ischemia.

References:

del-Pozo G, Albillos JC, Tejedor D. Intussusception: US findings with pathologic correlation--the crescent-in-doughnut sign. Radiology. 1996;199 (3): 688-92.

Choi SH, Han JK, Kim SH et-al. Intussusception in adults: from stomach to rectum. AJR Am J Roentgenol. 2004;183 (3): 691-8.


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