Winter 2016-2017 Newsletter
Welcome to the Winter 2016-2017 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 firstname.lastname@example.org with any questions or concerns.
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
Dave Rosenthal, MD FAAEM
President, Florida Chapter Division of AAEM
BOHICA! Winter is coming to your ED.
While Floridians are welcoming the arrival of cooler weather, many of us are beginning to feel the return of a certain queasiness in our guts. With each cool breeze that enters our state comes that unsettling conditioned response that leaves us feeling anxious. Trucks loaded with cars belonging to snowbirds and airplanes packed with sun-seeking tourists are all on the way, and with them comes chaos in the Emergency Department.
The appropriate acronym often coined by residents comes to mind: BOHICA (bend over, here it comes again). As EPs, so many of us find ourselves dealing with the stress of winter department volumes that swell by 30% or more. From beginning to end, our winter shifts feature congested waiting rooms, hallways littered with gurneys, and a host of family members standing outside patient rooms piercing us with the stink eye. It's winter in the ED, it's usually not fun and it's making me anxious just writing about it.
I'd like to provide a cure for the anxiety that accompanies this season, but all I can offer are some reflections that most will find about as helpful as Tamiflu in a 5 day old infection. I've been doing this long enough to say that this winter, too, shall pass. While we're all in for some long shifts, we will do what we always do: leave them in the rear-view mirror as we're heading home. As EPs we're fortunate to have this gift that few other specialties enjoy.
It's comforting to know that we all face similar challenges. Staying connected with our colleagues through our professional organizations might not replace hours of therapy but I believe it helps. I hope to see you all in the spring in Miami Beach for the FLAAEM Sixth Annual Scientific Assembly where we can trade war stories of another winter past.
Free Annual Scientific Assembly
April 22-23, 2017
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:
- The venue for the Sixth Annual FLAAEM Scientific Assembly will be the Fontainebleau Hotel in Miami Beach, Florida. The meeting will be on April 22-23, 2017 with the Board Meeting held on the preceding day at the same location. Save the Date notices will be sent out with periodic updates.
- There is an At-Large Board position available for any qualified, interested emergency physicians. Nominations are requested from all FLAAEM members.
- A new 50% discount for the first year will be given to any independent democratic EM groups if the entire group joins.
- 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.
- Dr. Robert Farrow, Resident Representative, will act as liaison to the EM residencies in the state and encourage membership in FLAAEM. He will also contribute residency updates to the newsletter and provide updates to the board.
- FLAAEM will again co-sponsor the Sunny States Social at the upcoming national AAEM Scientific Assembly in Orlando, March 2017.
FLAAEM Scientific Assembly Case Presentation: Pediatric Occlusive Ischemic Stroke: 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
CC: Altered Mental Status
HPI: 9 year old female, with family history of epilepsy, who arrived via EMS. The patient had a headache earlier in the day followed by witnessed loss of consciousness without seizure activity. Her only verbalization was to complain of generalized pain during transport. The patient vomited in transit.
Physical Exam (pertinent findings):
Vital Signs: BP 126/71, Pulse 86, Temp 97.6F, Resp 14, WT 27.2 kg, SpO2 97%
General: Obtunded, in no acute distress
HEENT: PERRL, Disconjugate gaze, dried vomit around mouth and nose
Neurological: not following commands, localizes to pain
Initial orders included EKG, complete blood count, basic metabolic panel, hepatic function panel, blood cultures, urinalysis and urine cultures. The only noted abnormalities were elevated white blood cell count (15.8) and hypokalemia (3.1). Urine toxicology and MRI were ordered. The interpretation of the MRI was restricted diffusion consistent with acute non-hemorrhagic infarct. After consulting with neurology tPA was started. She was airlifted to another facility capable of endovascular intervention.
Absence of flow voids on the coronal T2 image suggestive of an acute occlusion in the left MCA (white arrow).
Lateral view of a left ICA injection demonstrated a carotid terminus occlusion.
View showing opacification of the posterior division of the left MCA with the Solitaire stent deployed. The distal tines can be seen deployed in the left M2 (white circle)
Recanalization of the major large vessels with delayed MCA opacification can be visualized on the lateral view of a left ICA injection
Few studies exist on treating pediatrics with ischemic strokes. None of them provide medical evidence on how to treat these patients. Do we use tPA? How about endovascular treatment? The 2008 American Heart Association Stroke Council states the use of intravenous (IV) tPA for thrombolysis for children with acute ischemic stroke is not recommended (Class III, Level of Evidence C).
This patient received IV tPA but continued to deteriorate. Her National Institutes of Health Stroke Scale (NIHSS) was 16 despite tPA. Endovascular intervention was successfully performed. The patients NIHSS was 6 and 2 at her 3 and 6 month follow up.
The Interventionists who performed this case had another pediatric case, 7 year old male, and published their finding together stating “In carefully selected pediatric patients modern endovascular techniques may be used to treat occlusive pediatric acute ischemic strokes”.
The Thrombolysis in Pediatric Stroke (TIPS) Study was published in 2015. Of all the study subjects all but one were excluded based on the criteria and that child received tPA. Due to the small number of subjects the authors concluded that a larger, more diverse study is required to define the appropriate inclusion criteria for pediatric tPA and endovascular intervention.
The guidelines for tPA in pediatrics is still being developed but our patient survived without deficits and is now getting ready to start her teen years.
Hu, Y. C., Chugh, C., Jeevan, D., Gillick, J. L., Marks, S., & Stiefel, M. F. (2013). Modern endovascular treatments of occlusive pediatric acute ischemic strokes: Case series and review of the literature. Childs Nerv Syst Child's Nervous System, 30(5), 937-943.
Roach ES, Golomb MR, Adams R, Biller J, Daniels S, Deveber G, Ferriero D, Jones BV, Kirkham FJ, Scott RM, Smith ER, American Heart Association Stroke C, Council on Cardiovascular Disease in the Y (2008) Management of stroke in infants and children: a scientific statement from a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. Stroke 39(9):2644–2691. doi:10.1161/ STROKEAHA.108.189696
Rivkin, M. J., Deveber, G., Ichord, R. N., Kirton, A., Chan, A. K., Hovinga, C. A., . . . Amlie-Lefond, C. (2015). Thrombolysis in Pediatric Stroke Study. Stroke, 46(3), 880-885.
Jackson Memorial Emergency Medicine Successfully Launches First Mini-Research Fellowship Program for Students
Jackson Memorial Emergency Medicine successfully launches first Mini-Research Fellowship program for students
The Jackson Memorial Hospital (JMH) Mini-Research Fellowship in Emergency Medicine is a 5-month (June-October) program offered by the JMH Department of Emergency Medicine. The program was designed and developed by Dr. Amado Alejandro Baez the academic affairs and residency director of Emergency Medicine, "this mini-fellowship allows undergraduate and medical students who are interested in emergency medicine the unique opportunity to either spearhead a new project, or work on established research questions in the field of emergency medicine" reports Baez. The program uses a hybrid learning format, where at the beginning, students complete self-learning structured internet-based modules followed by a pre-test that teaches the basic tenets of research, statistics, and study design and ethics. This online course brings students up to speed on clinical research techniques, and provides invaluable information that is not often taught in the standard medical school curriculum. Once students completed the six course modules, the program fostered innovative research questions by creating a conduit for students participating in the program to network with established emergency medicine physicians academicians from Jackson Memorial Hospital. Under the guidance of these mentors, students are able to learn what it takes to formulate a clinical question, design appropriate research methods, and analyze and communicate the results in the form of a structured abstract, poster, or manuscript. In addition to providing real-world insight into what it takes to conduct clinical research in emergency medicine, the program also required students to attend a lecture series on compliance in research put on by the Human Subjects Research Office. This lecture series taught students how to submit an Institutional Review Board (IRB) proposal, what it takes to be a site for a randomized clinical trial, and the history and contemporary laws involved in drug development and research regulation. At the end of the program each student submitted a summary of their work, and where they submitted each project. Most students submitted to the American Academy of Emergency Medicine (AAEM) Resident/Student Research Competition, as well as other academic journals/conferences. The program started with eight students, guidance and mentoring of the participants allowed to successfully produce multiple abstracts, indexed publications, presentations and Institutional Review Board protocol submissions.
Report from Alex Bode, the Mini Fellowship lead graduate: "As a second year medical student who hopes to enter the field of emergency medicine, the mini-research fellowship provided the vital resources I needed to get involved in EM research projects. I learned how to submit IRB proposals, design an abstract, and conduct meaningful research; all valuable skills that were not in my standard medical school curriculum. In addition to the research, the program allowed me to discover great mentors and colleagues on campus who have been instrumental in helping me pursue research I am passionate about. Overall, the program provided just enough structure without being limiting, to teach me how to conduct collaborative research, while also being a productive independent researcher; and of course, to further investigate the field of emergency medicine."
Correlates of length of stay and boarding in Florida emergency departments for patients with psychiatric diagnoses
Smith JL, et al., Psychiatric Services, November 15
Wait for medical marijuana could be lengthy
Kinsey, T., AP/News13 Florida, November 14
8 states receive federal grants for Vivitrol for offenders
AP/News13 Florida, November 14
What Trump Might Really Do with Health Care
Alonso-Zaldivar, R., AP/News13 Florida, November 12
DC Week: Obamacare Days Appear Numbered
Firth, S. MedPage Today, November 12
ERs Respond to the Opioid Crisis
HealthLeaders Media Staff, MedPage Today, November 6
Spontaneous Circulation: Rebellions of the Heart: The End of Amiodarone
Bruen, C., EM News, November 1
Careerealism: The Emergency Medicine Staffing Death Spiral
Fowler, C., EM News, November 1
EMNs Salary Survey: Nearly 10 Percent of Eligible EPs Shun Certification
Hoffman, L., EM News, November 1
Type 2 diabetes becoming a childhood epidemic
Sanchez, J., Miami Herald, November 1
Ebola Vax Candidate
MedPage Today, October 30
Using Double Sequential Defibrillation to Help Cardiac Arrest Patients
Neubert, D., JEMS, May 1