EMpulse - May/June 2010

MAY-JUN 2010

Current State of EMSSimulation Lab Training ED Use in Florida

Florida College of Emergency Physicians3717 South Conway RoadOrlando, Florida 32812-7606(407) 281-7396 • (800) 766-6335Fax: (407) 281-4407www.FCEP.org

Executive CommitteeMylissa Graber, MD, FACEP • PresidentAmy Conley, MD, FACEP • President-ElectVidor Friedman, MD, FACEP • Vice PresidentKelly Gray-Eurom, MD, FACEP • Secretary/ TreasurerErnest Page II, MD, FACEP • Immediate Past PresidentBeth Brunner, MBA, CAE • Executive Director

Editorial BoardLeila PoSaw, MD, MPH, FACEP • [email protected]

Jerry Cutchens• Managing [email protected]

Cover Design by Jerry Cutchens / Leila PoSaw

All advertisements appearing in the Florida EMpulse are printed as received from the advertisers. Florida College of Emergency Physicians does not endorse any products or services, except those in its Preferred Vendor Partnership. The college receives and distributes employment opportunities but does not review, recommend or endorse any individuals, groups or hospitals that respond to these advertisements.

Published by:LynDee Press, Inc. dba Fidelity Press649 Triumph Court, Orlando, FL 32805Tel: (407) 297-8484www.fidelitypress.us

NOTE: Opinions stated within the articlescontained herein are solely those of the writers and do not necessarily reflect those of the EMpulse staff or the Florida College of Emergency Physicians.

EMpulseVolume 15, Number 3

EMpulse • May-Jun 2010 1

Emergency Medical ServicesCurrent State of EMS in Florida 12Joe A. Nelson, DO, MS, FACEP

State of Florida EMS 14Michael Lozano, MD, FACEP

Interview with an EMT 18Darren Coleman, EMT-P

The EMLRC Mobile Simulation Lab 24 Jennifer Jensen

EMS Organizations in Florida 26 Beth Brunner, MBA, CAE

DepartmentsPRESIDENT’Smessage 2 Mylissa Graber, MD, FACEP

EDITOR’Semergencies 4 Leila L. PoSaw, MD, MPH, FACEP

GOVERNMENTALaffairs 6 Steve Kailes, MD, FACEP

MEDICALeconomics 8 Ashley Booth Norse, MD, FACEP

CODINGtip 9Lynn Reedy, CPC, CEDC

PROFESSIONALdevelopment 10 Paul Mucciolo, MD

Use of Emergency Rooms in Florida by Patients 20with Ambulatory Care Sensitive ConditionsRobert G. Brooks, MD, MBA, MPHAskar Chukmaitov, MD, PhDAnqi Tang, BS

CLINICALcase 28CPC Chair: Frederick Epstein, MD, FACEPDiscussant: Brittany Thomas, MD

POISONcontrol 29Alexander Garrard, Pharm DAdrienne Perotti, Pharm D

RESIDENCYmatters 30

ADVOCACYnow! 32

Healthcare Reform -What Does it Mean?

Mylissa Graber, MD, FACEP

Well, right now all of us are trying to figure out what the healthcare reform means and how it will impact us both professionally and in our personal lives.I came across a good web site that outlines the big changes that are supposed to occur over the next 10 years. This web site does a good job of simplifying some of the bigger changes that will occur.

http://www.healthleadersmedia.com/content /LED-248377/Healthcare-Reform-Provisions-Kick-in-Over-10-Years

So what does that mean for emergency medicine? Well no one really knows for certain. There are two schools of thought: one that we will be better off and one that we will be worse off.

The better off philosophy is that since we already provide so much unfunded care, that since more people will be insured, we will have less self-pay patients and actually be better off in the long run, and that although it is likely that emergency visits will increase, at least the patients will have insurance. The other school of thought is that more patients will have insurance that pays too little and won’t

even cover expenses and thus it will in the long run cost us more money as with increased utilization of the ER by these now “insured” patients, there will be more expense as these patients will likely cost us money since the reimbursement will likely not even cover the malpractice and administrative costs.

Currently many groups stay afloat due to the better pay by PPO’s and private insur-ance plans and that if more people opt into a public insurance there will be less private patients and more publicly funded patients eventually decreasing the ability to make any money.

The other concern is with the push for “bundling.” Hospitals are being encour-aged or even pushed into hiring physicians rather than contracting with physicians.

This is not the model for most emergency departments and will take away the autonomy that many emergency physi-cians and groups currently have and we will in turn lose our current practice models.

There is talk of certain hospital chains

exploring this employee model with the likely upcoming changes.

There has been a lot of backlash to this healthcare reform. The state of Florida among many other states has passed opt-out legislation that would go on the ballot for a Constitutional amendment that would allow Floridians not to accept the new healthcare reform.

There is a lot of debate about whether or not the states can pass such legislation and there is argument that the states can not keep their citizens from participating in national healthcare reform if they so choose.

It should be interesting to see how this all plays out. The good news is that since the healthcare reform takes place in stages over several years there is a lot ofopportunity for change and ironing out of details as the plan’s details continue to evolve.

I guess we will have to wait and see what happens, but continue to be active in this process to protect ourselves as well as our patients.

PRESIDENT’Smessage

2 EMpulse • May-Jun 2010

REGISTER ONLINE

www.emrlc.org

Symposium by the Sea 2010The Annual Meeting of the Florida College of Emergency Physicians

July 29 - August 1, 2010 . The Boca Raton Resort & Club . Boca Raton, FL

Presented byEmergency Medicine Learning & Resource Center (www.emlrc.org) in

conjunction with the Florida College of Emergency Physicians (www.fcep.org).

Conference OverviewSymposium by the Sea 2010 is an educational opportunity designed for the busy emergency physician, resident, nurse, PA, and allied health professional who demands cutting edge information regarding their ever-changing practice environment. In addition to the educational sessions, the conference provides: Symposium General Educational Sessions*

Preconferences available for ED Administrators, Medical Directors & Nurses; Satellite Educational Symposia; Florida Emergency Medicine Resident's Case Presentation Competition (CPC); Wine & Cheese Reception with Exhibitors; Ferguson, Lee, Slevinski (FLS) Volleyball Tournament; EMRAF Job Fair.

*All except the preconferences are no charge to FCEP members!

Conference Date & LocationJuly 29 - August 1, 2010 . The Boca Raton Resort & Club . 501 East Camino Real . Boca Raton, Florida 33431Reservations: (888) 491-BOCA (2622) . www.bocaresort.comMention EMLRC Symposium by the Sea 2010Guest Room Reservations Cut-Off Date: July 14, 2010 Reserve your room early!

Who Should AttendEmergency Physicians, Physician Assistants, Nurses and other Health Care Professionals.

FCEP Membership BenefitRegistration for the Symposium by the Sea general conference is FREE to all FCEP members. Join the Florida College of Emergency Physicians prior to Symposium by the Sea and your registration will be refunded upon receipt of your application and payment of your first year's dues. For further information, contact the FCEP office at (407) 281-7396 or by email at [email protected].

Exhibit and Sponsorship OpportunitiesVisit www.emlrc.org/sbs2010.htm or contact Jerry Cutchens at (407) 281-7396 x15, [email protected] Exhibitor and Sponsor Prospectus is available directly at www.emlrc.org/pdfs/sbs2010prospectus.pdf.

More InformationVisit www.emlrc.org or call (800) 766-6335 . EMLRC . 3717 South Conway Road . Orlando, FL 32812

Rethinking an Old Disease

Leila L. PoSaw, MD, MPH, FACEP

Raindrops hit the tin roof hard and fast, offering a loud, brief respite from the smoldering heat. For a short while the swirling red dust, which gets into every nook and cranny to leave me choking and gasping for air, is calm. I lay on my bed under my mosquito net waiting for sleep which may or may not come. There is a power cut, again, and my flashlight throws gray dancing shadows on the ceiling above, calling out to tiny insects who gather buzzing around my light, my head.

I wonder what is going on in the world I have left behind; so far away, I have no news. I wonder if my water will be less brown tomorrow, so I can wash the grime out of my hair. I wonder if I will get cerebral malaria, like the child I saw seizing at the casualty, here in Ghana, Africa.

On my way to Accra, I am optimistic: I am to improve emergency systems at the Mampong district hospital, an hour from the busy city of Kumasi. I am with the sidHARTe program, which focuses on often overlooked district hospitals, which fall between community-based primary-care clinics and the larger, hard-to-reach tertiary hospitals in major cities. District hospitals are limited in resources and technology but represent the main source of hospital care for most Ghanaians.

Skilled healthcare providers are scarce and patients often wait many hours, even

when they present with life-threatening conditions. In Ghana, besides the more traditional health issues like obstetric complications and acute manifestations of malaria, pneumonia and diarrhea, injuries from road traffic accidents constitute an increasingly large proportion of the national burden of disease. SidHARTe aims to offer realistic tools and guidelines to improve emergency care. Yes, we can.

The reality comes as a shock. The casualty is sparse – metal beds in divided areas for men, women and children. Everybody gets an IV line: bags hang on rusty poles, next to anxious mothers holding their sick child. There are neat numbers over the beds. A closet holds all emergency supplies, noticeable for little brown bottles and more IV bags.

There are no monitors, no EKGs. A clear glass cabinet announces itself as AIRWAY, and proudly holds a neonatal laryngoscope, the rest being usurped by the operating theatre. Many essential medicines are unavailable. Everybody gets a malaria smear.

There is no triage and no pre-hospital care. There are four doctors in the hospital who rotate through, a flash, gone in the blink of an eye. The casualty is run by four and a half nurses, students, and some “pink ladies,” who hang around and help. There is an ambulance service to Kumasi – but the patient has to pay. If you are too poor

to buy the government health insurance, you have to pay for everything. Most patients are poor farmers and have no money. A young man with an open leg fracture has no money to go to the OR. A child with pneumonia dies from septic shock because the government cannot afford equipment and essential medicines. An old lady dies from CHF because her family can’t afford the ambulance. Poverty is the real disease and it is not new. Indeed, we may not even recognize it as a disease. The diagnosis is easy, the prognosis is grim. It is the number one killer in the world. For so many of us, living luxurious lives, it is invisible. We eat sushi, drive our luxury cars, and deny its existence, everyday: “The poor are lazy,” followed by the justification: “Oth-erwise, why are they poor?”

You do not need to go to Africa. You do not need to see the tears of a mother whose child has just died from a snake bite because she could not afford the anti-venom. I challenge you to look into the neglected corners of your city, the streets you avoid at night. You will find poverty. It is ubiquitous.

Next time in your ED, you see a woman with an oozing, necrotic breast because she could not afford to have yearly mam-mograms, rethink the diagnoses: one, breast cancer; two, poverty.

EDITOR’Semergencies


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GOVERNMENTALaffairs

Winds of Change

Steve Kailes, MD, FACEP

Regardless of your politics, Congress has passed “Health Care Reform.” I’ve heard many opinions on the matter. For the pragmatists among you, it is time to move on, figure out what has changed, how to be prepared and how to successfully adapt to the future. Still, for those who are disap-pointed or upset at what did and did not occur, I urge you to engage in the process.

Congress won’t likely tackle health care on such a scale as has just occurred for another decade or more. However, there is much work that still needs to be done, and we cannot afford to wait for political winds to force Congress to act.

FCEP has been hard at work during this state legislative session to affect change where necessary and protect our patients and us from the efforts of others. The most intriguing story so far has been the momentum and support seen in the Senate regarding a bill to provide sovereign immunity for providers of emergent care that falls under the mandates of EMTALA and the Florida Access to Care laws.

Realistically, this issue is unlikely to move out of a House committee this year. How-

ever, our legislators are being educated about the challenges and demands faced by our on-call specialists and us.Also, we have been very focused to oppose efforts to gain support for a ban onbalanced billing of patients.

While there wasn’t a bill filed for this issue, the insurance industry is pushing for such a ban and is using a variety of tactics to get it. Proposed legislation this year would have required any hospital based physician group to agree to contract with any insurer that has contracted with the hospital. We are watching for potential attempts to slip this in as an amendment to another bill and are concerned of what this may become next year. Other issues being watched include the legislature’s efforts to deal with budget deficits, especially the Medicaid budget which represents close to 25% of the total budget. Both houses are looking for ways to make cuts and consolidate services. The number of Medicaid enrollees is expand-ing and the “Medical Home” model has received much attention. In addition, the legislature has proposed a restructuring of the Department of Health to focus on its

mission and reduce staff.

We continue to encourage efforts to expand the physician work force in Florida, both through increased GME slots and through educating legislators about the challenges faced by us in this state. We remind them of the difficulties with the lack of sufficient on-call special-ist availability as well as the lack of access to care faced by patients before or after the ED visit.

Furthermore, we support patient safety issues which notably include a ban on the use of cell phones (or similar devices) for texting while driving, the use of booster seats for children under a certain age and size, and the administration of vaccines to children to help prevent the spread of disease and illness.

Things remain in flux as of this writing, but we will continue to work hard to protect our specialty and our patients. We need your help, and I encourage you to get involved. It really doesn’t requireyou to give an enormous amountof time or other resources to makea difference.


Health System Reform -What it Means for EM

Ashley Booth Norse, MD, FACEP

The President signed “The Patient Protec-tion and Affordable Care Act (H.R. 3590)—health system reform legislation- into law on March 23, 2010. While there are many divergent opinions about the recently passed legislation, most EPs agree that some sort of reform was needed. However, the question still remains if this legislation will have a positive or negative impact on patient care and our practices. HR 3590 will affect EM physicians- immediately and over the next several years (currently, timeline extends through 2019). The Patient Protection and Affordable Care Act (from here on referred to as “the Law”) requires health plans to provide a minimum or essential set of health care benefits, including: emergency services, ambulatory patient services, hospitaliza-tion, maternity and newborn care, mental health and substance use disorders, prescription drugs, rehabilitation, labora-tory services, preventive/wellness services and chronic disease management, as well as pediatric services.

Essential health benefits must also provide coverage for ED services without prior authorization whether the EP is a partici-pating provider or not. It also limits the patient co-payment amount for out-of-network services to the same level as in-network services.

In addition, the Law requires the Secretary of HHS to establish a three-year demon-stration program that would reimburseprivate, psychiatric hospitals for

EMTALA services provided to Medicaid enrollees ages 21 – 64. The Law also directs the Secretary of HHS to award at least four multi-year contracts or grants tosupport pilot projects that design, imple-ment and evaluate innovative models of regionalized, comprehensive and account-able emergency care and trauma systems. The Law requires the Secretary of HHS to support federal programs administered by NIH, AHRQ, HRSA, CDC and other agencies to expand and accelerate research in emergency medical care systems and EM. In addition, the Secre-tary of HHS is required to support research to determine the estimated economic impact of, and savings that result from, the implementation of coordi-nated emergency care services.

It also requires the Secretary of HHS to support federal programs involved in improving the emergency care system to coordinate and expand research in pediat-ric emergency medical care systems and pediatric EM. Lastly the Law reauthorizes the Emergency Medical Services for Children (EMSC) program for five years.

On the flip side of the coin, provisions that were not meaningfully addressed are Tort reform, the cost of defensive medicine, elimination of the sustainable growth rate (SGR), and the end of life issues. In addition, the projected cost of “The Patient Protection and Affordable Care Act” leads many to question thelong-term viability of the legislation.In regards to tort reform, the Law does

authorize the Secretary of HHS to “award demonstration grants to states for the development, implementation and evalua-tion of alternatives to current tort litigation for resolving disputes over injuries alleg-edly caused by health care providers or health care organizations.”

The law also “encourages states to develop and test medical liability alterna-tives to improve patient safety, reduce medical errors, encourage the efficient resolution of disputes, increase the avail-ability of prompt and fair resolution of disputes, and improve access to liability insurance while preserving individual's right to seek redress in court.”

The SGR will reduce overall Medicare physician payments by 21% in 2010 under current law with that number growing to 40% over the next several years. SGR elimination is something that has simply been pushed back annually and this legislation fails to address SGR and physi-cian reimbursement.

This legislation has probably disappointed 50% of EPs, but the real challenges lie ahead. We must move forward. Health insurance coverage does not equal access to medical care. We predict that emer-gency visits will increase and this means that the critical problems facing EPs and our patients are not going away.

Details of The Patient Protectionand Affordable Care Act”(H.R. 3590) may be found at: http://www.acep.org/advocacy.aspx?id=21632

MEDICALeconomics


CODINGtipThe new diagnoses code set, ICD-10, will

be required on October 1, 2013. Now is

the time to start your preparation.

The American Academy of Professional

Coders (www.aapc.com) has put together

a time-line of activities that you need to

complete in order to be ready on

10/1/2013. Go to their website, click on

Resources and then on ICD-10. You can

learn more about ICD-10, get training, or

use their benchmarks tracker. You will

find this to be an excellent, one-stop

resource.

Lynn Reedy, CPC, CEDC

Director of Coding Services

CIPROMS South Medical Billing

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PROFESSIONALdevelopment

The Aging Emergency Physician

Paul Mucciolo, MD

“I saw you eating pizza!” admonished the forty-five year-old man I was admitting for unstable angina. “Do as I say and not as I do,” I quipped. We chuckled, but this made me think. A mere eight years separate me from the “senior” emergency physician - according to my literature search, EPs over the age of fifty! “Senior” physicians now comprise approximately half of the physician workforce in the United States. Health Maintenance“Don’t stand when you can sit, don’t sit when you can lie down. Most profes-sional athletes retire before their fortieth birthdays. EPs endure the rigors of their careers for many decades beyond that. Proper nourishment, a realistic exercise regimen, and special schedule consider-ation are important to meet the changing needs associated with aging. In a survey, seventy-four percent of senior EPs reported difficulty recovering from night shifts. In light of this, physician groups might consider hiring physicians who prefer working only nights, shortening the night shifts, or providing incentives for night shifts. Regardless, some deference to “senior” physicians is in order. Wealth Management“A penny saved is a penny earned.” Not in today’s economy! EPs considering retire-ment are facing tough choices. EM groups are generally small and somewhat loosely structured. Additionally, EPs are

unlikely to be partners in income produc-ing investments such as outpatient surgerycenters. EPs don’t typically hold positions where they can sell their stake in a private practice upon retirement. The EP’s asset is the skill and knowledge acquired over decades of caring for thousands of patients. As such, structuring a secure retirement strategy can be fraught with difficulty. The current economic crisis is a compelling reason for EPs to closely examine their own situations with regards to wealth management and financial responsibilities as they mature in their practices.

Patient Care“You’re getting soft in your old age!” a nurse recently told me when I quietly came out of the room of a patient on his fifth visit that month for cocaine-induced chest pain. “No,” I smiled, “I’m getting smart.” I remember getting irritated with a COPD patient who was coming in by ambulance on a daily basis during my first month of practice. He refused admission and walked out every day—and continued to smoke. Later that week, a senior physi-cian in my group treated the same COPD patient then quietly sat down. The sense of frustration I experienced was absent in my colleague. I asked him how he tolerated futile interactions with such composure. He replied that “there are a lot more of them than there are of you.” Futile attempts at trying to change certain patient behaviors are exhausting. Senior

EPs are often masters of creativity, nego-tiation and disposition. Senior EPs also provide an essential stabilizing influence on physician groups. They are more likely to provide viable solutions to problems regarding the practice due to lengthy experience in a changing health care climate. This administrative experience from EPs with planning ability and long-term vision is invaluable.

Teaching“Every day is a school day!” said one of my surgery attendings when he discovered that his patient had two gallbladders during the cholecystectomy. Nowhere is that saying truer than in EM. Senior EPs were manning the helms for years while younger physicians were climbingthe first few rungs of their career ladders. Clinical decisions were based on the history and physical and “ABC” meant Airway, Breathing and Circulation, not Airway, Breathing and CAT scan! Their vast warehouse of information was the cerebral hemispheres of the physician,not a mainframe computer. It is impera-tive that their clinical experience be passed on.

A survey from FCEP will be arriving soon—please take a few minutes to respond. Assist FCEP in suggesting practice modifications that promote career longevity and maintenance of clinical competence among one of our greatest assets—senior EPs!


Current Stateof EMS in Florida

Joe A. Nelson, DO, MS, FACEPState EMS Medical Director

Florida’s Emergency Medical Services community is constantly changing. This article will briefly delve into present EMS challenges as well as issues that will mold EMS in the not too distant future.

Currently, EMS is being driven by factors such as budget contraction, looming reimbursement loss at the Federal level and retirement of a significant portion of the experienced workforce. On the clinical side there exists legislated disease management in the form of trauma and stroke laws as well as proposed ST Eleva-tion Myocardial Infarction (STEMI) law. Airway management is moving toward routine use of supraglottic devices such as the LMA or COBRA tube and away from “gold standard” endotracheal tube place-ment in the field. Advances in equipment have resulted in 12 lead EKG, pulse oxim-etry and waveform capnography being standard in advanced life support ambu-lances throughout Florida. Numerous agencies also utilize mechanical cardio-pulmonary resuscitation devices and carbon monoxide detection technology.

Several evolving trends affecting EMS in the next five years are in play. The National EMS Scope of Practice Model promotes the standardization of EMS training and licensure at the national level. According to the National Association of State EMS Officials, “States following the National EMS Scope of Practice Model as closely as possible will increase the consistency of the nomenclature and competencies of EMS personnel nation-wide, facilitate reciprocity, improve

professional mobility and enhance the name recognition and public understand-ing of EMS”.

Florida will soon need to adopt or reject certification/licensure of the Emergency Medical Responder (formerly known as First Responder), Emergency Medical Technician (replaces the EMT-Basic level), Advanced Emergency Medical Technician (akin to the EMT-Intermediate found in many States) and Paramedic (currently EMT-P).

Many States are likewise moving to exclu-sive use of a national certification exam (National Registry Exam) for all four levels of provider. The Board of Directors for the National Registry of EMT’s has indicated that after December 31, 2012 Paramedic program graduates will become ineligible to take their certifica-tion exam if they did NOT graduate from a nationally accredited paramedic program.

Thus, Florida will have a decision to make regarding use of the National Registry exam and the requirement of National Accreditation for its Paramedic training programs. This program accreditation is done by The Commission on Accredita-tion of Allied Health Education Programs (CAAHEP) which is in turn the parent organization of the Committee on Accreditation of Educational Programs for the EMS Professions (CoAEMSP). CAAHEP is a non-profit, non-governmental agency, who reviews and accredits over 2000 educational programs

in nineteen (19) health scienceoccupations. The “System of Care” is a concept with roots in trauma care that is expanding to include other disease entities. In terms of clinical practice, the issue of prehospital cardiac arrest awaits new American Heart Association Guide-lines and is becoming organized at locations throughout the US and Florida into a “system of care” otherwise called a “Cardiac Arrest Network”.

These networks of care would involve emergency medical services (EMS), referring hospitals, and dedicated, experi-enced centers that treat cardiac-arrest survivors. They would be capable of performing PCI, mechanical interven-tions, and other specialized treatment such as post resuscitation cerebralhypothermia. Stroke care will continue to require operational and protocol changes as the science develops, especially in the interventional diagnostic/treatment area. In the realm of STEMI care, look for continued efforts to organize systems of care from the regional and state-wide perspective. On the horizon is a more organized approach to septic shock that could change the EMS management and transport of patients with this clinical syndrome.

In conclusion, EMS operations are becoming changed, for better or worse, through financial, workforce and clinical factors. Emergency physicians and especially those who interact with EMS on a daily basis should have situational awareness of these influences.

EMSstate


The State of Florida EMSPart 2 of a Series

Michael Lozano, MD, FACEP

For many EPs who are not routinely involved with EMS, it may seem like EMS is very disorganized in Florida. The reality is that although significant latitude is given to local rule, there is indeed an overarching structure and plan to EMS activities in the state. This is the second of an ongoing series which examines the newly adopted 2010-2012 Strategic Plan for the Florida EMS Advisory Council (EMSAC). The strategic plan covers all aspects of EMS systems, and by studying it one can gain an appreciation of the workings of the system and develop an understanding of its underlying mecha-nisms.

The EMSAC was created by the legisla-ture pursuant to chapter 401.245, F.S., and acts as the advisory body to the emergency medical services program administered by the Department of Health. At a strategic planning workshop help last fall, key stakeholders met with Bureau of EMS staff to review the Council’s mission, vision, and value statements, as well as to develop specific goals and tactics to help guide Florida’s EMS system over the next two years. The EMS System is defined as all licensed providers, EMS personnel, and EMS training centers.

In developing the strategic plan, the Coun-cil and its constituency groups adhered to a core value system. Rather than manage-ment though fiat, the Council achieves and maintains quality results, accountability, and outcomes through guidance, direc-tion, encouragement, and reinforcement.

Above all, they value putting the patient first – always! There is a dedication to ensure that services are available which benefit and protect the public, and that active collaboration is utilized to solve problems, make decisions and motivate providers to work together in providing evidence-based pre-hospital care and achieving common goals. There is a basic expectation that ethical behavior is exhib-ited in all decisions, actions, and stake-holder interactions. Policy and decision making are supported by the most rigor-ous of scientific methods available, and participants research, identify and adopt evidence-based science and best practices to reduce mortality and morbidity. Finally, there is a dedication to continual educa-tion of the public, the EMS system, and all EMS stakeholders.

The current plan has ten major goals, each of which have a variable number of tactics associated with it. Tactics have objectives, or concrete measures of success, and strategies, designed to achieve the objec-tives. Additionally, for the sake of accountability, each tactic has a desig-nated lead group, associated resources, and a recommended timeline forcompletion.

The ten goals are:

Goal 1: Improve EMS system through effective leadership and communication by the EMS Advisory Council.

Goal 2: “Improving EMS data collection

and participation through advocacy, outreach, and improved accessibility to EMS incident-level data.”

Goal 3: Improve customer satisfaction through injury prevention, public educa-tion and knowledge of the EMS system. (Customer may be defined by the EMS agency.)

Goal 4: Improve EMS work-force educa-tion, performance and satisfaction.

Goal 5: Ensure economic sustainability of the EMS system.

Goal 6: Improve performance of key EMS processes through benchmarking and partnerships.

Goal 7: Assure the EMS system is prepared to respond to all hazard events in coordination with state disaster plans.

Goal 8: Maintain an accident-free environment and promote a culture of safe and appropriate utilization of Florida air assets.

Goal 9: Increase access to care by improving patient safety, respondersafety, and the safety of the generalpublic.

Goal 10: Improve consistency, efficiency and education of public safety personnel with respect to incident related emergency medical dispatch (EMD) and radio communications.

EMStrauma


Goal 1 The first goal deals primarily with the manner in which the Council conducts its business. Bylaws were amended to better align the Council with the overall strategic plan. Lines of communication between the EMSAC and the constituency groups were formalized though committee structure and a strategic plan, which the groups include as a standing item on their respec-tive agendas.

Finally, attention was paid to the council members’ professional growth through mentorship, workshops, and a formalized succession plan. There is a statutory position on the Council for a physician. Candidates for the position often have had meaningful participation in the EMSAC committees, and are appointed by the Surgeon General. Participation in the EMSAC committees is open to all. Goal 2The EMS Advisory Council’s Data Com-mittee and the Bureau of EMS’ Data Unit are tasked with the second goal. Accurate data is the cornerstone of all good management decisions, and these two committees maintain statewide standards for EMS incident level data collection. All fifty states and four territories have signed MOUs (memoranda of understanding) with the National EMS Information System (NEMSIS) . NEMSIS is funded by NHTSA, HRSA, and the CDC to support each state’s efforts to collect, retain, and send data to the national database.

It is assisted by 13 non-governmental agencies, including ACEP. The NEMSIS project’s three primary implementation goals and objectives are: an electronic EMS documentation systems in every local EMS system, EMS information systems in every state and territory which can receive and use a portion of the local EMS data via the XML standard, and a national EMS database which can receive and use a portion of the state and territorial EMS data via the XML standard. Florida has been a party to NEMSIS since 2004. Participation in the EMSTARS program, and the transmission of electronic incident level data from EMS Providers to Florida Department of Health is voluntary, but currently 136 agencies provide incident level data to the state via the EMSTARS project.

Goal 3Customer service is nothing new to clinical providers. For the EMS commu-nity, customers are both internal and exter-nal. A reflection of this is seen in the third strategic goal. The first objective for the third goal deals with injury prevention efforts. Its objective is to provide injury prevention programs to the public. The metrics are to (a) increase by 5% the number of educational programs provided to the public through EMS and fire agencies, (b) reduce the number of injury related ED visits, and (c) reduce the number of motorcycle crashes. The lead for this objective is the Public Information Education and Relations (PIER)Committee.

The second objective is to increase the quality of the EMS system as a whole by increasing participation of the EMS Qual-ity Managers (lead group) in statewide EMS activities. The hope is that by expanding the culture of quality to the EMS system there will be an increase in overall system quality.

The third objective has more of a direct impact on ED physicians and hospitals. It seeks to have EMS agencies identify, educate, and partner with stakeholders on issues related to access to care. The lead is the EMSAC Access to Care Committee, with support from FHA, the EMS Medical Directors Association, FL ENA, the Office of Trauma, Office of Injury Preven-tion, and PIER. Their metrics include an increase in the number of EMS agencies represented on hospital committees, a reduction in ED overcrowding, and a reduction in unnecessary ED visits. The last two are large multifaceted problems to tackle. What the EMS community seeks is a seat at the table to share their perspective when the house of medicine addresses these vital issues.

In the next issue, we will continue with the rest of the strategic goals for the Council, and explore how they may impact you the practicing EP.

1 - Dawson DE, National Emergency Medical Services Information System (NEMSIS). Prehosp Emerg Care. 2006 Jul-Sep; 10(3):314-6.

2 - www.floridaemstars.com/index.htm

EMStrauma


Important health informationfor the first year of your baby’s life

Richard S. Slevinski, M.D., developed the concept and content of Baby 911 based on 30 years of caring for families in the Emergency Department. He was the EMS Medical Director for the State of Florida for many years, leading the way in Emergency, Trauma and Disaster care. He currently practices at Sacred Heart Hospital in Pensacola Florida, a Level 2 adult and PediatricTrauma Center.

Emergency Medicine Learning and Resource Center (EMLRC) is a nonprofit organization dedicated to promoting and advancing emergency medicine, disaster management, prehospital emergency care, and public health through annual medical education conferences and research activities. As a leader in medical simulation education and training, EMLRC continues to explore and define new methods and technological formats for classroom and distance learning. Learn more at www.emlrc.org.


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Important health inform

ation for the first year of your baby’s life

Peace of mind – that’s what you’ll experience with the invaluable health and emergency information you need to care for your new baby at your fingertips. You’ll know how to care for your precious infant even during the most stressful emergency or routine healthcare situations.

As you view Baby 911, you will learn how to:• Administer rescue breathing and CPR• Relieve congestion with nasal suctioning• Accurately take your baby’s temperature• Handle dehydration related to vomiting and diarrhea• Care for your newborn’s umbilical cord• Tips for soothing a fussy baby• Introduce the family pet to baby• Identify and address postpartum depression• Plus much more

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Baby 911 provides peace of mind...

That’s what you’ll experience with the invaluable health and emergencyinformation you need to care for your new baby at your fingertips. You’llknow how to care for your precious infant even during the most stressfulemergency or routine healthcare situations. Baby 911 is a DVD educationalguide that gives you comprehensive, helpful advice and gentle reminders onhow to care for your bundle of joy, from the moment you are released from thehospital until your baby’s first birthday.

Developed and provided by the Emergency Medicine Learning & Resource Center - www.emlrc.org.

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The Emergency Physicianand EMT Training

The forefront of emergency medicine’s interface with the community is being practiced by EMT and paramedics in the ever evolving world of emergency medi-cal services (EMS) in Florida. A majority of these individuals are educated at over 150 EMS training programs in the state. A unique opportunity exists for physicians who have a strong interest in the field of EMS to participate in the education of these fine men and women who in turn provide care to the sick and injured in our society. The role of an EMS training program medical director in the present EMS environment is instrumental tothe education of emergency servicespersonnel.

In the state of Florida, there are currently over 50 program medical directors provid-ing input to programs of various sizes at colleges, universities, technical centers, and private institutions. General provi-sions under Florida Administrative Code rule 64-J exist that require that a training program has a medical director who will be responsible for the instruction of the DOT approved training program for EMTs and paramedics.

The medical director must have substan-tial knowledge of the qualifications, training, protocols, and quality assurance programs of the training facility. It is also expected, as teaching is part of being a training facility director, that the physician maintains certification as an ACLS instructor and a prehospital trauma life support instructor through PHTLS or ITLS. The program medical director will also be a patient advocate by ensuring that students are receiving the highest quality

education during their training. Represen-tation as a liaison between EMS training centers, regional EMS providers and hospital systems is another crucial role program medical directors assume to ensure quality.

The biggest impact physicians can make on training facility students is through direct education. It is recommended that program medical directors teach or evalu-ate student performance for four hours per month. The opportunity to teach skills is a positive benefit to being a training program medical director. Students are eager to learn and surprisingly willing to listen to everything you have to say about topics in EMS. Whether it is a war story from the battles of residency training or the latest techniques in airway manage-ment, the students enjoy the direct contact with their medical director. The interac-tion allows the students to ask questions, directly shadow the physician, and partici-pate in patient care with immediate feedback.

Due to the current economic situation, training programs are seeing many students who are pursuing a second career as an EMT or paramedic. This is a challenging time for EMS, yet it also one with new opportunities. Students with varying backgrounds and experiences are being introduced to the “magic of 3 am.” They are learning airway techniques with new devices, using patient simulators in

lab sessions to provide a more realistic patient experience, and learning skills to succeed in hostile environments and disas-ters. Program medical directors have been

instrumental in facilitating these neces-sary changes to keep up with the dynamic field of EMS.

There is also an initiative to adopt national educational standards for EMS education as part of an overall agenda for thefuture. Although not adopted inFlorida, the proposal would change the teaching curriculum at many of the training facilities in order to accommodate four levels of training and certification to include emergency medical responder, EMT-Basic, EMT Advanced or Intermedi-ate, and Paramedic. If adopted,program medical directors wouldbe instrumental to ensure qualityeducation and compliance with thisnew initiative.

Through program medical directors, students are afforded direct attention in the classroom and clinical setting. This experience is also beneficial for themedical director as this is anopportunity to make lasting impressions on individuals who will be performingin difficult and stressful environmentsprior to arrival to the emergencydepartment.

The educational process and the roleof program medical directors are two pivotal components to the continued success of EMS programs and theultimate treatment of the sick and injured. It is truly rewarding for program medical directors to be a part of the transformation of a student into a lifesaving EMTor paramedic after program completionas witnessed on a daily basisthroughout Florida.

EMStraining

David M. Bowden, DO, FACEPProgram DirectorManatee Technical Institute


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Interview with an EMT

Darren Coleman, EMT-Pinterviewed byMichael Lozano, MD, FACEP

I interviewed a Florida paramedic who traveled to Haiti a week after the earth-quake. He was part of a not-for-profit medical mission. This was his first experi-ence in a disaster zone. A word of caution, some of the descriptions are somber and sobering. How did you come to be in Haiti?On the day of the earth-quake, I was home, and had just got up from a nap to check my email. There was something about an earthquake in Haiti and I realized that something significant had happened. I have a lot of friends and colleagues who are Haitian.

People from my hospital go to Haiti annu-ally. I had always wanted to volunteer at Dr Guerrier’s clinic there, but had never made the trip. Now, I was compelled to go there partly because my minor is in African-American Studies and there is such a parallel with slavery. People of color in both countries come from the same roots.

Had you ever gone to Haiti before this?No, I had never been to Haiti. “We have to go right now,” is what I was feeling. I got on the phone and make a bunch of calls. I scrambled to find my passport and called

the Haitian doctors that I knew. Finally, we were able to get there with the help of the Pinson Foundation and Project Medis-hare.

Who was on your team, and how did you get to Haiti?Two ER nurses, Dr Guerrier, a nurse from his office, another medic, a New York pharmacist and I formed a team. We took a flight to Miami and connected with Medishare. We just got on the plane. They didn’t check passports, but did make sure we were on the approved list. We signed waivers. On the way back we came back on a military C-17, strapped in like human cargo.

What sort of preparations were you told to make?We were told to pack for thirty days. Yeah, thirty days - just in case there was unrest and we had to backpack into the Domini-can Republic. The big thing was to make sure we had enough water. I packed scrubs, power bars, a stethoscope, head lamp, underwear, you know – the bare minimum. When it was done, it weighed almost as much as me. Did you take any reference books?I didn’t take any books. I did take my cell phone which was handy. At one point, a medic at the front gate and I texted back and forth to sort patients before they got to the triage area in the back. Another time, there was a little girl in a knee immobilizer who had a closed fracture. We didn’t have any way to print x-rays from the portable machine. I was able to take a picture of the fracture with my phone and show the

surgeon in the OR.

Where did you provide care?At first, we worked at a field hospital at the Port au Prince airport with the Univer-sity of Miami. We were the second shift coming in. There were also medical people from other countries, each with their own area. Through the foundation, we stayed at the Haitian Baptist Mission. We had food and sleeping quarters. With the mission we were able to go out into the community. The mission has a clinic, an SUV and translators, so we were able to go into the neighborhoods and take care of people.

What was it like once you got on the ground in Haiti? We went into the city and saw patients who had not been seen by anyone right where they lived. It was just our crew from St. Pete, we had no security, and we never ran into any trouble. Half the day was scene response and house calls. We would walk up and down the street and call out. We would write down whatever

EMSinterview


we did on a piece of paper and this was their chart. The other half of the day would be at the airport and we would work there until nine or ten at night. After the first couple of days, we spent most of our time at the hospital. We were able to translate some of the skills and techniques from the ED into simple things like setting up a triage with a sign in sheet. We had wrist bands, and simple charts. Ropes were run across the tent to hang IVs. This was simple and smart medicine. You were there to help and do your best.

What was it like in the field hospital?We had pediatric and adult tents. There was an OR in back of the adult tent with a recovery room. There was a fast track area and a main treatment area. EMTs who had done helicopter rescue for six days were now doing repeat vitals. Folks from the Church of Scientology took care of the logistics and transportation. Locals worked at the field hospital in exchange for food and water. I was doing a lot of IVs, wound care and some physical therapy. I changed burn dressings on kids. We circulated and helped out.

Was it mostly trauma care?It was mostly trauma at first. There were three people who were trapped in their home, who came out weighing ninety pounds and needed IV fluids. As time went on, people found out about the hospi-tal at the airport by word of mouth. We would get patients by private vehicle or charities/ non-governmental organizations

would bring them in. If patients were too complex, we could evacuate them to the Hospital Ship USS Comfort. That was the highest level of care.

How many and what types of patients would you see?Once we got our triage organized, you would see big crowds coming and going. I saw a hundred patients a day. The most common complaint was, “A brick fell on me.” We even had a man with a gun shot to the head. There wasn’t anything that we could do. All we had was a portable x-ray. There was no CT scan or labs, just an accucheck. We put him to the side and let him pass on. There were others like that. We only had oxygen in the OR. There were no nebulizers. We had some people who came in with shortness of breath who we couldn’t help. They got comfort measures only. We usually didn’t work codes. There was just one lady we worked, but we didn’t get her back. We saw a lot of fractures. There were a lot of burns and crush injuries. We found that you only need low doses of medicines in most cases. One or two milligrams of morphine goes a long way, even with an open tib-fib. Overall, the patients were so appreciative. It was amazing how quiet it was in the hospital. You barely heard someone crying out.

Were there any security issues?No, not really. You could walk down the street with a case of water. As long as you kept it to yourself, no one would bother with you. If you tried to give it away there would be a scramble to get what was being given away.

How about the families of the injured?They were right there all the time. I did not clean up anyone’s stool or vomit. The families took care of it. Even when I was doing wound care, they would put on gloves and join right in. They did all of the custodial care, even for patients without families. The male volunteers were amaz-ing: they had lost everything, and all they wanted to do was help others.

At night in the tents, there were ministers who would lead the people in songs and prayers. You would hear singing coming out of the tents. It was amazing. You

would see people who were half out of it, and they would join in the singing. Ampu-tees were lifting up their stumps and singing along. It was very moving.

Was there anything else especially memorable?Going through Port au Prince, you would see bodies being pulled out of buildings. I saw one body burning by the side of the road. People would wait until the bulldoz-ers were able to get out their loved ones and then claim the bodies. As you went through the city, I saw femur and jaw bones. People had burned bodies on the sidewalk and left the bones behind among the debris. In the middle of this you saw regular people going about their business – trying to scratch out a living.

There is one man’s story that I have to tell. He was the first patient I took care of. He was buried in the rubble with his family, who were all dead. He was unconscious and paralyzed from the waist down. They threw all his family in a pit, and they threw him in there too. He was laying there paralyzed next to his dead family for three days. He came to, and more bodies were thrown on top of him. They couldn’t hear him screaming until they came to cover them up. It was then that they found him and got him out. He was catatonic from the experience. That’s the kind of stuff we experienced.

Is there anything in general that you would like to share with ER physicians?The Haitian people are very receptive and thankful. One person can make adifference.

Darren Coleman is a hospital based paramedic based in St. Petersburg, Florida.

EMSinterview


Use of Emergency Rooms in Florida by Patientswith Ambulatory Care Sensitive Conditions

IntroductionHospital emergency departments (ED) in Florida continue to be severely challenged by an influx of patients, with continued upward growth in visits in recent years. Although most ED visits are for appropriate services, studies have shown that there exist an important minority of patients who use EDs for what are called Ambulatory Care Sensitive Conditions (ACSCs)- sometimes with multiple visits per year. ACSCs are, by definition, visits potentially preventable through use of primary care, and are believed to be one of the reasons for ED crowding and excess costs. Examples of the well-defined ACSCs include: asthma, bronchitis, urinary tract infection, gastroenteritis, and diseases of the skin.

In order to develop effective strategies for deterrence of ED crowding and misuse, policy-makers, payers, and physicians need a clearer understanding of the type of patients who visit the ED frequently for ACSCs. Moreover, decision makers need a better understanding of other important factors that may contrib-ute to avoidable utilization of ED services. It is for these reasons that we recently conducted a study of ED use in Florida using the statewide database for the years 2005 and 2006. The purpose of this article (which is based on the 2005 data) is to summarize some of the key findings as they relate to the patterns of use or misuse of EDs by patients with ACSCs in Florida. In our present study, we argue that the potential misuse of ED services can occur by three groups – (1) those with visits for ACSCs, (2) those with frequent ED visits, and (3) those with frequent ED visits for ACSCs. In this article, we describe data for all three groups, but concentrate most on the third group because these patients are particularly likely to be without a regular source of primary care (e.g., a medical home).

Study Methods For this study we used a cross-sectional design with an all-encounter, all-payer, multi-hospital, dataset to study ED use for ACSCs (Group 1), frequent visits (Group 2), and frequent visits for ACSCs- where group 1 and 2 overlap (Group 3). We studied patient demographic characteristics, patient case-mix, insurance status, day and time of ED use, and geographic varia-tion, for the calendar year 2005 in the state of Florida. We obtained the entire set of emergency department discharges (n= 5,748,375) for 2005 from the Florida Agency for Health Care Administration (AHCA). The data set contained key patient information on demographic characteristics, types of service, principal and up to four secondary diagnoses [as classified by the International Classification of Diseases (ICD-9-CM)], principal payer type, hour of arrival, weekday, facility, local health county regions, total charges, and other information. For purposes of this study, we excluded patients with missing (masked) social security numbers, those with out-of-state addresses, and those with missing gender or other key demographic information. The final sample used represented 4,914,933 visits made by patients who were discharged from EDs. We were interested in three outcome measures. First, we used an expanded list of ACSCs based on previous work of Weisman, Solberg, and Carminal (group 1). The list represents conditions that should, under most circumstances, be amendable to preven-tion and treatment by well-functioning primary care providers in a community, and can be useful to evaluate global primary care performance in a geographical area. Second, based on a review of the ED literature, frequent ED users were identified as patients who had four or more visits in a single year and accounted for a

ORIGINALresearch


Robert G. Brooks, MD, MBA, MPH 1

Askar Chukmaitov, MD, PhD 2

Anqi Tang, BS 3

1 Associate Vice President for Health Care Leadership, University of South Florida Health, Professor of Medicine/Infectious Diseases, USF College of Medicine, Professor of Health Policy & Management, USF College of Public Health

2 Assistant Professor, Department of Family Medicine, Division of Health Affairs, Florida State University College of Medicine3 Research Assistant, Division of Health Affairs, Florida State University College of Medicine

Table 1 Condition Present

Number (#) Percent (%)

All ACSCs 865,065 17.60

ACSCs by Categories (Group 1)

Immunization and preventable infectious diseases 30 <.001

Congenital syphilis 4 <.001

Tuberculosis 37 <.001

Diabetes mellitus 21,353 0.43

Disorders of hydro-electrolyte metabolism 14,206 0.29

Iron-deficiency anemia 504 0.01

Convulsions 5,814 0.12

Diseases of upper respiratory tract 207,283 4.22

Hypertensive heart disease 44,105 0.9

Heart failure 6,547 0.13

Pneumonia 34,588 0.7

Bronchitis /Chronic obstructive pulmonary disease

(COPD) 135,207 2.75

Asthma 68,503 1.39

Bleeding or perforating ulcer 110 <.001

Appendicitis with complication 76 <.001

Disease of the skin and subcutaneous tissue 154,244 3.14

Gastroenteritis 65,944 1.34

Urinary tract infections 98,825 2.01

Pelvic inflammatory disease 7,682 0.16

disproportionately high percentage of all ED visits (group 2). Third, we then combined the two above study groups by cross-tabulating ED visits for ACSCs, and those made frequently (four or more times in a year) by patients (group 3).

A number of patient characteristics were available and were assessed for each of these three groups. These included: patient age, race/ethnicity, gender, insurance types, geographical regions, and day and time of ED arrival. Patient co-morbidities were used, through a modification of the Charlson index, to adjust for the number of conditions using ICD-9-CM codes.

ResultsTable 1 provides descriptive statistics for ED visits for ACSCs, frequent visits, and frequent visits for ACSCs. Overall, 17.6% ED visits were for ACSCs (Group 1), and 21.61% were made by patients who were frequent visitors (Group 2). There were 203,354 (4.14%) patients who made four or more visits for ACSCs (Group 3). The majority of visits for ACSCs visits to ED were for upper respiratory track conditions, diseases of skin, bronchitis/COPD, urinary tract infections, asthma, and gastroen-teritis.

Table 2 describes some of the key patient demographic character-istics, their insurance status, case-mix, and day and time of ED use in all studied groups. The percentage of children (0 - 17 years of age) making ACSC visits and frequent ED visits for ACSCs was the highest in comparison with the other age groups popula-tion. Frequent ED visits were more often made by patients from 18 – 49 years of age, female gender was slightly more common, and the percentage of visits made by non-whites was higher than for white patients in all categories. The percentages of visits made during weekdays were comparable to those made during weekends in all studied categories. A slightly higher percentage of visits were made at night rather than at day time in all three categories. Severity of illness was the highest for patients who visited EDs frequently for ACSCs. Medicaid, Medicaid HMO, and self-pay patients contributed the largest number of visits and percentages in all studied groups. In fact, by logistic regression analysis, Medicaid HMO and Medicaid fee-for-service patient had more than three times higher odds of being in the set of patients seen frequently for ACSCs (group 3) compared to commercially insured patients. Some regional variations also were found. For example patients in the Pensacola region were more likely, and in the Ft. Lauderdale region were less likely, to visit EDs frequently for ACSCs in comparison with the Tallahas-see region (data not shown here).

Conclusions and ImplicationsED crowding is rising, putting pressure on physicians, hospitals, and patients alike to find solutions to this problem. This study demonstrated that around 17% of all visits to emergency depart-

ments were for conditions (ACSCs) that might be prevented through better access to medical care in the community. Addition-ally, we discovered that approximately 22% of all visits to the ED in Florida were made by patients seen four or moretimes annually. Finally, approximately four percent of visits were made for ACSCs by patients who were seen frequently in the ED. This latter group is particularly likely to not have a medical home for their routine care. We found that patients age, race, gender, time of ED visit, insurance status, and geographic location may be associated with this type of overuse of EDs in Florida. These findings lend themselves to a number of possible policy implications. One of the more obvious implications is the need for more community-based care for patients. The patient-centered medical home model has been one of the more impres-sive and recently discussed options for improving patient access to regular care and for avoidance of unneeded ED visits. For example, several states (including North Carolina, Oklahoma, Alabama, and Pennsylvania) have already instituted bold programs with financial incentives to primary care practitioners, to improve Medicaid patients’ access to primary care. A few

ORIGINALresearch


examples of a medical home model do exist in Florida (eg. Children’s Medical Services run through the Department of Health), and experience from this program, and from other states that have already implemented patient-centered medical home models suggest that significant cost savings can be realized through these community-based models. Well-run community health centers and local county health departments are also part of the health care safety net that routinely provide primary care to

Medicaid and self-pay patients in the community. These programs, which have current infrastructure in most counties of the state, could also be expanded and modeled as true medical homes, where institutions and individuals are rewarded for better coordinated care that prevents ED use and hospitalizations. Until the problem of access to care in the community is broadly addressed, the ED overuse by patients for ACSCs is likely to continue, and crowding of EDs will be a reality.

ORIGINALresearch

Table 2 *

All ED Visits

(n = 4,914,933)

ACSCs (Group 1)

(n = 865,065)

Frequent ED Visits (>=4 visits) (Group 2)

(n = 1,047,900)

Frequent ED Visits for ACSCs (Group 3)

(n = 203,354)

# (%) # % # % # %

Age1 (0-17) 1,032,840 (21.01%) 285,521 33.00 182,604 17.43 65,618 32.27

Age2 (18-49) 2,615,191 (53.21%) 377,665 43.66 683,886 65.26 107,788 53.01

Age3 (50-64) 626,931 (12.76%) 94,631 10.94 111,090 10.60 18,914 9.30

Age4 (65-74) 270,764 (5.51%) 44,987 5.20 29,646 2.82 6,011 3.0

Age 5 (75-84) 249,789 (5.08%) 39,403 4.55 27,008 2.58 4,618 2.27

Age6 (85 & Up) 119,418 (2.43%) 16,942 1.96 13,666 1.30 1,954 0.96

Female 2,721,463 (55.37%) 488,333 56.45 631,624 60.28 119,640 58.83

Male 2,193,470 (44.63%) 370,816 42.87 416,276 39.72 85,263 41.93

African American 1,113,710 (22.66%) 217,655 25.16 271,844 25.94 57,161 28.11

White 2,983,465 (60.70%) 480,735 55.57 643,200 61.38 114,057 56.09

Hispanic 687,501 (13.99%) 139,173 16.09 118,513 11.31 30,631 15.06

Other Race 130,257 (2.65%) 21,586 7.44 14,343 1.37 3,054 1.50

Weekend 1,518,626 (30.90%) 277,073 32.03 315,865 30.14 62,993 30.98

Weekday 3,396,307 (69.10%) 582,076 67.30 732,035 69.86 141,910 69.78

Day Time 4,140,750 (84.25%) 716,065 82.78 871,002 83.12 170,937 84.06

Night Time 774,183 (15.75%) 143,084 16.54 176,898 16.88 33,966 16.70

Charlson Case-Mix Index

0.12 0.14 0.14 0.15

Commercial PPO 913,238 (18.58%) 124,374 14.38 106,864 10.20 17,369 8.54

Medicare 665,530 (13.54%) 108,428 12.53 132,150 12.61 21,944 10.79

Medicare HMO 111,442 (2.27%) 17,370 2.01 14,438 1.38 2,253 1.11

Medicaid 638,115 (12.98%) 147,942 17.10 217,343 20.74 48,812 24.00

Medicaid HMO 482,554 (9.82%) 125,864 14.55 150,133 14.33 39,105 19.23

HMO 597,539 (12.16%) 91,978 10.63 64,529 6.16 11,633 5.72

Self-Pay 1,096,095 (22.30%) 191,511 22.14 275,307 26.27 50,378 24.77

Other Payer 410,420 (8.35%) 51,682 5.97 87,136 8.32 13,409 6.59

* Numbers may not add up to exactly 100% because of missing data and rounding.


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The EMLRCMobile Simulation Lab

Jennifer JensenEMLRC Program Director

The patient has a high fever, fatigue, severe headaches, general malaise, vomit-ing, and diarrhea…sounds like any other call on any day of the week…however, since you have pulled up on scene at the airport and loaded the patient in the ambu-lance he is slowly becoming more and more delirious and is drifting in and out of consciousness. As your crew rushes the patient to the hospital you are hoping to stabilize him before arrival. Unfortunately today’s case is not like others. You have never seen raised red welts on a patient’s face like these before. Reports from airport personnel indicate that the patient flew here from the Middle East. At some point on the flight he became increasingly ill, started to say thing that made no sense, and his raised welts started becoming more pronounced. Is it possible that an adult patient did not have chicken pox as a child? OH NO! What if this is not chicken pox? What if this is something more serious? It is a good thing that all of the crew put on their PPE suspecting a possible communicable condition. What should be done now? There is still a 15 minute drive to the hospital...and the ED is especially crowded today due to a five car accident. What if this patient has small-pox? Has my crew been exposed? What about the other patients on the flight? How many more patients may we expect in the near future?

The scenario above is one of many that can be simulated by the EMLRC’s Mobile Simulation Lab. The patient’s life rests in the hands of the crew in the back of a simulated ambulance environment. What treatments they provide (or neglect) will immediately impact the patient’s welfare. This type of education is cutting-edge, immersion education. It has become increasingly popular and necessary for EDs, community colleges, and the EMS community. The EMRLC is a top leader in emergency healthcare simulation. For several years now they have had a dedicated instructor using Human Patient Simulators to provide the most real life education experience possible. Scenarios are designed based on agency or organiza-tion needs. Not only is the experience simulated, but the environment is as well. The Mobile SimLab has both an ambu-lance bay setting and ED treatment cubicle.

For the last few years, the EMLRC has worked closely with the State of Florida Department of Health providing education

around the state. Agencies have provided tremendous feedback about the education experience, indicating that this is some of the best and most compelling education they have ever received. Participants enjoyed “being able to use critical think-ing skills and not just follow protocol”, that “visual connections help learning”, that “the manikin helps visualize”, that they encountered “scenarios that they had never before seen in any schools attended”, that the manikin “allows you to see and feel how the patient reacts to treatment” and that the education “gives the overall picture of the patient’s condi-tion”, as well as being able to finally “see” the simulation scenario. When a crew arrives in the Mobile SimLab, Clinical Coordinator Eric Dotten asks if they had any past experience with simulation technology. Depending on their response he tailors the education to meet their needs. They are instructed to interact directly with the manikin from this point on. The manikin is capable of responding verbally to a patient interview.

EMStechnology


From here, the call can become increas-ingly complex. The instructor can make the patient improve or decline based on the care given. Vital signs can be adjusted on a moment’s notice to test the crews’ ability to follow and recognize decline in the patient’s condition. It is also possible to examine their ability to make calls to Poison Control and to follow through on a complete radio report to the ED en route. Any aspect of a call can be enhanced and focused on depending on the needs of the agency. Simulation education is something that has blossomed tremendously over the past decade. The emergency healthcare community in particular vastly benefits from simulation experience, as it allows them to repeatedly practice skills with no harm to a live patient. They can acquire a comfort level with intubation and airway skills, as well as other complex proce-dures. This experience is invaluable when it comes to increasing confidence with patient treatment. New up and coming techniques and procedures can be demon-strated by medical directors and used to test paramedic and EMT skills before they try them on the streets. The instructor evaluates each team’s performance and measures whether they meet objectives, such as in the case of a chemical or biological scenario; if they recognize the incubation period, possible modes of transmission, team safety components, and signs and symptoms that the patient presents with following expo-sure. Their communication, leadership,

situational awareness, decision making/ planning, crew self evaluation, and technology and automation skills are also evaluated. It is noted whether the team makes any critical errors or requires any remediation during the scenario. This helps test how thoroughly comfortable and effective they are in treating patients with certain conditions. In the last two years a number of agencies have received simulation education from the EMLRC’s Mobile SimLab through funding from the State of Florida Depart-ment of Health. However, numerous agencies still need to be reached. It is also important to note that with agency turnover, new personnel will need to receive this education, as well as extend-ing continuing education with seasoned employees. It is evident that CBRNE (Chemical/Biological/Radiological/Nuclear/Explosive) education is still very neces-sary as indicated by numerous press articles in the last two years. According to a recent report from the Commission on the Prevention of WMD Proliferation and Terrorism, led by former Sens. Bob Graham of Florida and Jim Talent of Missouri, the United States is on track to receive an attack via nuclear or biological weapons before the year 2013. http://www.cbsnews.com/stories/2008/12/01/national/main4641534.shtml

A U.S. study commissioned by US Senate Foreign Relations Committee Chairman Richard Lugar shows that the chance of an attack with a weapon of mass destruction somewhere in the world in the next 10 years runs as high as 70 percent. http://www.cnn.com/2005/US/06/21/wmd.threat/index.html As alarming as these reports are, the EMLRC is highly dedicated to bringing education to EMS agencies, hospitals, community colleges, nursing programs,

and private organizations to help our communities be prepared for the worst if, or when, it happens. Even with the grow-ing threat of terrorist attacks and biologi-cal and chemical attacks, the frontlines of our healthcare system are confronted by challenging patient care on a daily basis. Stroke, cardiac arrest, trauma, and near-drowning, as well as pediatric care challenge the skills and judgment of our EMS professionals every day. As well, pediatric care is an area of discomfort and unfamiliarity at times. Emergency health-care providers can increase their level of comfort in dealing with sometimes rare pediatric emergencies by practicing on SimBaby®. Often times they have not seen a call involving a young child and develop a fear of even the possibility of such an encounter. This feeling is tremen-dously eased by participating in repeated scenarios involving the baby. With the growing emergence of simula-tion education, there is no doubt that the need for the Mobile Simulation Lab and others of its kind is great. In addition to simulating the environments, in situ education, where the manikin is introduced into an environment where crews assess “on scene” is also becoming popular. The EMLRC has the ability to provide this type of education as well, with a wireless manikin intended for portability. The EMLRC will continue to develop simulation, with a conference planned in 2011 on simulation technology and how to best utilize it. The EMLRC plans to lead the charge on simulation technology innovation.

EMStechnology



EMSorganizations

EMS Organizationsin Florida

Beth Brunner, MBA, CAEBeth Brunner, MBA, CAEFCEP CEO

Florida EMS Advisory Council Members

EMS Administrator (Non-fire)Michael PattersonPutnam County EMS410 South State Road 19Palatka, FL 32177

Lay ElderlyDoris Ballard-FergusonFlorida A&M UniversitySchool of Nursing1767 Hermitage Blvd., Apt. 4204Tallahassee, FL 32308

Lay PersonRegina E. Sofer325 W. Gaines Street, Suite 1633Tallahassee, FL 32399-1950

Emergency NurseAmy Paratore10520 Greencrest DriveTampa, FL 33626

Paramedic (Non-fire)Karen Chamberlain12601 SW115 AvenueKendall, FL 33176

PhysicianDavid A. Meurer, M.D.Department of Emergency MedicinePO Box 100186Gainesville, FL 32610-0186

Paramedic (Fire)Charles E. Moreland, Ed.D.1782 Fiddlers Ridge DriveFleming Island, FL 32003

EMT (Non-fire)Tom Quillin, ChiefLeon County Emergency Services2290 Miccosukee RoadTallahassee, FL 32308EMS Administrator (Fire)William R. Colburn, Fire ChiefReedy Creek Fire DepartmentPost Office Box 10170Lake Buena Vista, FL 32830-0170

EMT (Fire)Greg RubinMiami-Dade Fire Rescue9300 NW 41st StreetMiami, FL 33178

Air Ambulance OperatorJohn ScottTampa General HealthcarePost Office Box 1289Tampa, FL 33626

EMS EducatorDaniel Griffin4621 NW 46 CourtGainesville, FL 32606

Hospital AdministratorJavier I. Escobar II, M.D.420 Plantation RoadTallahassee, FL 32303

PhysicianBradley Elias, M.D.617 Treehouse CircleSt. Augustine, FL 32095

Commercial Ambulance OperatorAlan Skavroneck4351 Pinnacle StreetCharlotte Harbor, FL 33980

Few people realize that modern emergency medical service has only been around for the past 70 years. Florida’s EMS community has grown rapidly into one of the strongest, most active in the nation. This is due to the unique relationships amongst the many EMS constituency groups in Florida.

In July, November, and January, the State’s Department of Health/Bureau of EMS Advisory Council meets throughout the state. The various EMS constituency groups hold their membership meetings in conjunction with the Council meeting. Dr. Joe Nelson serves as the State’s EMS Medical Director, and also serves on the FCEP Board. Several other FCEP leaders actively participate with other EMS organizations, such as the Florida Association of EMS Medical Directors, Committee on Trauma, Florida Fire Chiefs/EMS Section.

The following list of Florida’s EMS constituency groups serves to help us recognize the expansiveness of EMS in Florida and to identify some of the EMS leaders who may be working alongside of you in your community.

EMSorganizations


State EMS Medical DirectorJoe Nelson, DO, MS, FACOEP, FACEP934 North University Drive #228Coral Springs, FL 33071

Department of EducationTracy YacobelisProgram Specialist/Health Sciences & Human Services325 West Gaines Street, Room 701Tallahassee, FL 32399Department of Highway Safety & Motor VehiclesWalter LiddellFlorida Highway Patrol75 College DriveHavana, FL 32333

Department of Financial ServicesBarry BakerFlorida State Fire College11655 NW Gainesville RoadOcala, FL 34482

Department of TransportationTrenda McPhersonDOT Traffic Safety Specialist605 Suwannee Street, MS 17Tallahassee, FL 32399-0450

Department of Management ServicesTodd MechlerEMS Communications Engineer/CoordinatorDepartment of Management Services4030 Esplanade Way, Suite 180Tallahassee, FL 32399

Emergency Medical Services ForChildren Liasion Julie Bacon1008 Hill Island DriveOakland, FL 34787

Florida Emergency Medical Services Constituent Groups

Association of Florida Trauma AgenciesBarbara Uzenoff, RN, ManagerHillsborough County Trauma Agency2410 N. Tampa StreetTampa, FL 33602-2199

Emergency Nurses Association Florida ChapterKeith M. McKernan, RN, LHRM, MA, CEN, President940 SW 79th TerraceGainesville, FL 32607-3397

Association of Florida Trauma CoordinatorsCeleste Kallenborn, PresidentTampa General Hospital2 Columbia Drive, Rm. G417Tampa, FL 33606

Florida Association of Ems EducatorsCaptain Daniel J. GriffinAlachua County Department of Fire/Rescue ServicesPost Office Box 548Gainesville, FL 32602-0548

Critical Incident Stress ManagementNatalie DuranMiami-Dade Fire Rescue5680 SW 87 AvenueMiami, FL 33173EMS Providers of FloridaDaniel AzzaritiDeputy Chief of AdministrationMarion County Fire Rescue2631 SE 3rd StreetOcala, FL 34471

Florida Ambulance AssociationJim Judge2761 West Old Highway 441Mount Dora, FL 32757

Florida Aeromedical AssociationScott Wyant, RN, BSN, CEN, EMT-P701 Sixth Street SouthSt. Petersburg, FL 33701-4891

Florida Association of County EMS (FACEMS)Michael PattersonPutnam County EMS410 South State Road 19Palatka, FL 32177

Florida Basic Trauma Life SupportJoe Nelson, DO, MS, FACEP2872 65th Street, NorthSaint Petersburg, FL 33710-3255

Florida College of Emergency PhysiciansBeth Brunner, Executive Director3717 South Conway RoadOrlando, FL 32812

Florida Pilots AssociationMark WomackShandsCair at the University of Florida Department of Health Air Methods Corporation25145 NW 140th LaneHigh Springs, FL 32643

Florida Association of EMS Medical DirectorsGeorge Ralls, M.D.6131 Linneal Beach DriveApopka, FL 32703

Emergency Medical DispatchJim LanierECC Division ManagerManatee County(941) 749-3557 - Office(352) 209-4206 (cell)

Florida Association of Professional EMTs & Paramedics (FAPEP)Todd Soard, President7220 NW 39TH ManorCoral Springs, FL 33065

Florida Chapter of The America Collegeof Surgeons - Committee on TraumaPatricia Byers, MD, ChairpersonP.O. Box 016960 (R310) Miami, FL 33131

Florida College of Emergency Physicians - Government Affairs CommitteeBeth Brunner, MBA, CAE3717 South Conway RoadOrlando, FL 32812

Florida Neonatal & Pediatric Transport Network Association Louise Bowen, NNP-BC, CMTE-BC, CNA, MSNTransport DirectorAll Children’s Hospital Transport Team801 6th Street SouthSt. Petersburg, FL 33701

Florida Council On Rural EMS (COREMS)Cliff Chapman, Asst. ChiefAlachua County Fire / RescueP.O. Box 548Gainesville, FL 32602

Florida Professional FirefightersGary Rainey, Chairman, Vice President20271 NW 10 StreetPembroke Pines, FL 33029-3429

Florida Fire Chiefs Association - EMSWilliam R. ColburnFire Chief Reedy Creek Emergency ServicesP.O. Box 10170Lake Buena Vista, FL 32830-0170 EMS Quality Managers AssociationArthur GarciaPost Office Box 398Fort Myers, FL 33902-0398

Florida Chapter of Air & Surface Transport Nurses AssociationKaren Chamberlain, RN1535 S. Perimeter RoadFt. Lauderdale, FL 33309

Florida Association of Rural EMS ProvidersMichael PattersonPutnam County EMS120 Orie Griffin Blvd.Palatka, FL 32177

United States Lifesaving AssociationJoe McManusPost Office Box 1259Fellsmere, FL 32948-1259

CLINICALcase

The Fertile Femalewith Abdominal Pain

CPC Chair: Frederick Epstein, MD, FACEPDiscussant: Brittany Thomas, MDFlorida Hospital, Orlando

A 35 year-old G 6 P 4024 white female

presented to Florida Hospital complaining

of sudden dizziness, nausea, and abdomi-

nal pain. Six days prior, she had under-

gone a cesarean section, which was

complicated by postpartum endometritis.

She was treated with Gentamycin and

Cleocin before hospital discharge. The

rest of her past medical history and past

surgical history were unremarkable. She

took oxycodone-acetominophen for pain

and smoked a pack of cigarettes a day.

On physical exam, she was tachycardic

(124), tachypneic (24), and hypotensive

(110/48). The temperature and oxygen

saturation were normal. She appeared

very anxious, diaphoretic, and in moderate

distress. She had pale conjunctiva and oral

mucosa, left basilar crackles, and 3 plus

pitting edema in the lower extremities.

The abdomen was distended and diffusely

tender with hypoactive bowel sounds. The

rest of the exam was nonspecific.

CMP revealed hypokalemia, hypocalce-

mia, and hypoalbuminemia. CBC

revealed a leukocytosis with bandemia,

and a hemoglobin/hematocrit of 5.4/16.3.

Four units of PRBCs were ordered. Tropo-

nin, lactate, and coagulation levels were

normal. The CXR was unremarkable, and

the EKG showed sinus tachycardia. With a

heightened suspicion for a surgical abdo-

men, the patient's OBGYN was contacted.

He recommended a CT of the Abdomen

and Pelvis, but the emergency physician

recommended immediate surgical

exploration.

While waiting for the CT scan, the patient

rapidly deteriorated and was rushed to the

OR. Surgery revealed a ruptured splenic

artery aneurysm. The bleeding was

controlled by clipping the artery both

proximally and distally. She recovered

well and was discharged on postoperative

day #2.

Discussion

A splenic artery aneurysm is the most

common visceral artery aneurysm and

third most common intra-abdominal

aneurysm. Risk factors include multipar-

ity (as in this case), infection, atheroscle-

rosis, and portal hypertension. Symptoms

can include epigastric or LUQ pain,

nausea/vomiting, dyspnea, and hypovole-

mic shock. Important differential

diagnoses are uterine rupture, uterine

artery bleed, and septic shock from

endometritis. With regard to an unrup-

tured aneurysm, a CT of the

Abdomen/Pelvis is the best diagnostic test

in the ED.

A CXR may reveal a calcified ring to the

left of L1, but plain films are not the first

line test. Digital subtraction angiography

is the gold standard for non-emergency

physicians.

If the aneurysm is asymptomatic and less

than 2 cm, it can be observed; however, if

more than 2 cm, elective surgery is recom-

mended to prevent rupture. Surgery

options include percutaneous emboliza-

tion or laparoscopic ligation or resection.

If the aneurysm is ruptured, then a

laparotomy with ligation or clipping

would be appropriate.


POISONcontrol


The Role of the FloridaPoison Information CenterNetwork in H1N1 Surveillance

Alexander Garrard, Pharm DAdrienne Perotti, Pharm DFlorida/USVI Poison Information Center

The Florida Poison Information Center Network was recently asked by the Florida Department of Health (FL-DOH) to assist with a hotline for the 2009 H1N1 flu vaccine. Below is a summary of an interview with Dr. Schauben, the Director of the Florida/USVI Poison Information Center - Jacksonville, who was instrumen-tal in getting the hotline off the ground.

The Poison Centers in Florida have expanded their role in the DOH by provid-ing more than just triage and consultation in poisoning emergencies. After the terrorist attacks on September 11th, 2001, the role of poison centers in Florida took on a new face. The FL-DOH was looking into novel ways to gather public health information in a fast, “real time” manner and noticed that the poison centers could accomplish this. During hurricane season, the poison centers are able to track carbon monoxide exposures due to generator use immediately after the storms passed.

They can also track food-borne and water contamination illnesses and use that infor-mation to shut down restaurants, investi-gate various food products, or recommend alternate water sources within a very short period of time. The FL-DOH has just realized that the poison center is able to gather information using the pediatric, accidental cough/cold exposures concor-dance with general illness in counties where their traditional data streams (i.e., OTC sales, county health department

reports, etc) are very weak or non-existent.

Since the Florida poison centers were already receiving funds to provide disaster and medical surge support for the State, and were already functioning on some level for surveillance, the FL-DOH posed the question, “Can you provide informa-tion to healthcare practitioners who are calling into the Florida Flu Hotline?”

The FL-DOH preferred that healthcare professionals be able to speak with other healthcare professionals in the poison centers rather than provide such services themselves. The poison centers were unique in this role given the diverse selec-tion of healthcare professionals who work at the poison centers, their infrastructure and their daily operational mandate which includes this type of practice.

They initially requested a separate infor-mation line specific for healthcare profes-sionals to be answered “Florida Flu Hotline” using a script approved by FL-DOH. H1N1 response staff (non-Specialists in Poison Information) would answer questions which appeared on the FL-DOH script. Questions not on the script were triaged to the on-call toxicolo-gist to answer. When the statewide flu hotline was dialed, the selection of the “health care professional” option automatically forwarded the call to the appropriate poison center within the State

using geographic routing.

These calls were programmed to come in on different lines than used for normal poison center operations, so they were easily separated and sent to the H1N1 response staff preferentially. Subsequent to the implementation of the health care professional response effort, the FL-DOH has expanded their request to include the handling of lay public calls where vacci-nation has produced an adverse reaction. The DOH recognized that this was in direct concordance with the normal poison center operational charter within the State. This option when selected from the statewide Flu Hotline would automati-cally and geographically direct the call to the appropriate poison center, but this time the calls arrived on the normal poison center operational line and were handled directly by the Specialists in Poison Infor-mation. The Poison Center cooperative effort with the FL Flu Hotline allows us to act as both an informational resource and a patient care resource and surveillance system. The center’s involvement in the Florida Flu Hotline has proven its ability to mobi-lize and rapidly deploy large public health operations in a short period of time. This ability allows the poison centers to be used in a variety of different ways in the future whether it is for food-borne illnesses, drug/food recalls, environmental hazards or bioterrorism events.

RESIDENCYmatters

Orlando Regional Medical CenterRebecca Blue, MD

Greetings from Orlando!The ED is undergoing many changes this spring. We can’t wait to welcome our new interns – it’s going to be a fantastic class. It's hard to believe that this academic year is nearly finished. While it's hard to watch our seniors prepare to leave ORMC, we are excited to see the new interns arrive. Thank you again for making this interview season one of our most successful matches ever! Another welcome goes out to our newest faculty member, and one that we are all ecstatic to see return! Dr. Sara Baker, chief resident, class of 2009, returns to ORMC this summer. Since her gradua-tion, Dr. Baker has pursued a Critical Care fellowship and she returns to direct our simulation program. We are lucky to have her – welcome back Dr. Baker!! Dr. Linda Papa, attending, has gotten her NIH study underway! She is studying treatment protocols and early indicators of long-term prognosis in traumatic brain injuries. We wish her luck! Finally, our chief residents for 2010-2011 are three amazing physicians and fantastic leaders. Congratulations to Drs. Chip Clay, Christopher Hunter, and Jeremy Williams! As always, it's a busy time in the ORMC Emergency Department - as the weather warms up, we are all looking forward to changes to come. From all of us in Orlando, take care and enjoy the spring!

Hope everyone has enjoyed their spring! As we approach the summer, we are excited about our six incoming interns who have recently graduated from USF, Tufts, Florida State, Ross, Virginia Com-monwealth, and SUNY Downstate. We know that they will be a wonderful asset to our program.

During the spring months, several of our faculty attended the 2010 CORD Academic Assembly for Emergency Residency Directors and learned key points about improving residency programs. With a new class and the new knowledge from this conference, our program is sure to reach new heights.

Also our attending Dr. Katia Lugo has worked tirelessly with the University of Miami on two research grants for the SBIRT Study and the NIDA CTN Study.

Each focuses on the follow up and treatment of patients with drug and alcohol abuse problems who are seen in different U.S. emergency departments. Both will be a great opportunity for Florida Hospital East and its residency.

Finally, congratulations to our new and first-ever chiefs, Dr. Alexander Garcia and Dr. Javier Gonzalez. Their leadership in academics and administration will be greatly appreciated, especially now that we have three classes.

Good luck to all in the upcoming year, and have a happy summer!

Thanks to the efforts of FCEP, our Program Director and our Department Chair, the USF EM Residency Program was able to take 10 residents to Tallahas-see for an education in organized medi-cine and a chance to advocate for EPs across the state.

The Capitol was buzzing with activity during the spring session and many of the representatives were happy to meet with us during the officiallyrecognized EM Days which took place3/9 - 3/10.

First, we received an excellent summary of the legislation important to EM. This was followed by a session on effective communication skills presented by a professional consulting group.

Finally, we were scheduled to meet with reps in the House and Senate to make a personal case for important bills including the Sovereign Immunity Bill that, unfortu-nately, did not pass this year but did make it through at least one important commit-tee before dying in another.

While we did not meet all of our legisla-tive goals during EM Days, we did make a difference and put a face to our profession.

More importantly, FCEP helped to ensure another generation of engaged EPs by fueling a spark in myself and nine other young docs. EM will continue to be one of the most active and involved specialty in the House of Medicine!

Florida HospitalBrittany Thomas, MD

University of South Florida Jason W. Wilson, MD


RESIDENCYmatters


Univ. of Florida, JacksonvilleOscar D. Espetia, MD

First of all, congrats to all programs across the state on the recent match! For all the graduating seniors: you will be missed. We have a new batch of motivated young residents that have some big shoes to fill in. Here is a little update for the rest of Florida on some the activities at UF/Shands Jacksonville.

Dr. Zeretzke was selected by the AAP Section on Emergency Medicine Execu-tive Committee to receive a scholarship to attend the AAP Advocacy Institute in Schaumburg, IL March 10-12.

Drs. Zeretzke, McIntosh and Wylie’s abstract, “Impact of an Immunization Registry on FWS in Children Aged 6-24 months who present to the Pediatric Emer-gency Department” has been selected for poster presentation at the SAEM AnnualMeeting in Phoenix, AZ June 3-6.

Dr. Ricke and Hendry’s abstract “Inci-dence and recognition of elevated triage blood pressure in the pediatric emergency department” has also been selected for poster presentation at the SAEM Annual meeting.

We are looking forward to our new chief residents for next year. This was a very difficult decision because there were so many well qualified and interesting seniors. But in the end, our chief residents will be Drs. Michael McCann, Adrian Elliot, Andrew Vihlen, and Ashley Fox. Congratulations chiefs!

Match day has come and gone! We are all excited to see the list of the new interns we will be welcoming to our family and we are reminded that we are about to complete yet another year of emergency medicine training.

Speaking of welcoming new members to families, I must acknowledge two new additions. Mezeda Meze gave birth to a beautiful baby boy.

Incidentally, much to her distaste, she went into labor while on an overnight shift in the ED at Jackson Memorial Hospital. She delivered in the OB ward and every-one is happy and healthy. Congratulations Mezeda!

Selfishly, I have to announce that I too have a new addition to my family. I rescued a kitten from the streets of Miami Beach. His name is Mojo and he is 7 pounds (picture included). Mostly everything else is status quo here in Miami. This, in my opinion, is a good thing.

Everybody is working very hard and doing a fantastic job. We are looking forward to a strong finish of a great year.

Mount Sinai Medical CenterMarshal A. Frank, DO

The Annual Meeting of theFlorida College of

Emergency Physicians

July 29 - August 1, 2010The Boca Raton Resort & Club

Boca Raton, FL

REGISTER ONLINEwww.emrlc.org

ADVOCACYnow!

Emergency medicine is the leader in promoting patient access and safety. In order to achieve our goal of taking emer-gency medicine to the next level of policy influence in Tallahassee, the Florida College of Emergency Physicians has formed an advocacy entity called “People for Access to Emergency Care” (PAEC).

PAEC provides a means for our friends in the business world, such as billing compa-nies, physician groups and other organiza-tions, to assist FCEP in supporting legisla-tive leaders and policy makers, and it ensures that emergency medicine has a seat at the table with key leaders in the Florida House and Senate.

PAEC allows FCEP and its partners in emergency medicine to act with a unified voice in Tallahassee. Its members are

groups and organizations dedicated to promoting emergency medicine in Florida and providing better access to quality emergency care to our patients.

In order to be successful at securing emer-gency medicine’s place at the table, we need you to join People for Access to Emergency Care and joining is easy.

There are three levels of membership:• Platinum $15,000 per year• Gold $10,000 per year• Silver $5,000 per year

PAEC’s goal is to raise $200,000 for the 2010-11 legislative cycle. With these funds we will be able to help elect candi-dates who support your issues. This will enable us and your organization to partici-pate in the decision-making process.

To find out more about contributing to PAEC, or to join our 2010 contributors, contact Beth Brunner at: [email protected].

2010 Platinum Members:Florida Emergency Physicians, Inc.

2009 Platinum Members:Emergency Physicians of Central FloridaFlorida Emergency Physicians, Inc.

2009 Silver Members:Comprehensive Medical Billing SolutionsJacksonville Emergency Consultants, PAMartin Gottlieb & Associates, LLCSouthwest FL Emergency Physicians, PA

2009 Other Members: Tampa Bay Emergency Physicians, PL.

PAECPeople for Access to Emergency Care

Emergency Physicians of Florida (EPF), formerly known as the Florida College Political Action Committee (FLACPAC), is one of the primary advocacy tools that enables individual physician members of FCEP to make a difference at the legisla-tive and regulatory level. In order for us to have a positive influence on our legisla-tors, both at home and in Tallahassee, we need your help.

Please consider “giving a shift” from personal funds. You can even donate online at: fcep.org/flacpac.htm.

Thank you to all who have donated since the 2009 Symposium by the Sea!

Miguel Acevedo, MD, FACEPWayne Barry, MD, FACEPDale Birenbaum, MD, FACEPBradford Bowls, MD, FACEPJohn Braden, MDMichell David Brantley, MDKa Hang Chan, MD, FACEPLeonardo Cisneros, DO, FACEPCasey Corbit, MDPaul Deponte, DOVidor Friedman, MD, FACEPVicki Friend, DO, FACEPWayne Friestad, MD, FACEPMark Frisch, MD, FACEPBrent Gardner, MD, FACEPDavid Goldman, DO, FACEPHugh Jones,MDRodney Kang, MD, FACEPWilliam Knibbs, MD, FACEPKarl Korri, MD, FACEP

Ronald Krome, MD, FACEP(E)Mark Kruger, MD, FACEPLinh Tung Le, MD, FACEPJorge Lopez-Ferrer, MD, FACEPWilliam McConnell, DO, FACEPGary Mendelow, MD, FACEPSteven Nazario, MD, FACEPSteven Newman, MD, FACEPPatricia Singh Nichols, MDBrian Nobie, MD, FACEPLisa O'Grady, MDWilliam Osborn, III, DOErnest Page II, MD, FACEPKetan Pandya, MD, FACEPVanessa Peluso, MDPaul Petersen, MDW. Randall Poole, MD, FACEPJohn Prairie, MD, FACEP

EPFEmergency Physicians of Florida

Cheryl Reynolds, MDMaritza Rodriguez, MD, FACEPMarc Santambrosio, MD, FACEPDavid Sarkarati, MD, FACEPThomas Schaar, MD, FACEPRegan Schwartz, MD, FACEPEhsan Shirazi, MDClaire Simpson,MDWeylin Sing, DO, FACEPSivapragasm Sivanesan, MD, FACEPSouth Miami Criticare, Inc.John Tilelli, MDBryce Tiller, MD, FACEPGeorge Tracy, MDJohn Valentini, MDH. Kenneth West, MDSusan Wolcott, MD


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Florida College ofEmergency PhysiciansFCEP|

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EMpulse - May/June 2010

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