empulse march-april 2010 issue

empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:53 AM

Haiti Disaster ResponseCONVERsations: David A. Farcy 14

Be Prepared: The Problem is Logistics 16Jay Park, MD

Fragments of a Shattered World 18Paul DePonte, DO

Really Surreal or Surreally Real 20Thomas Schaar, MD

God Doesn’t Wear Ray-Bans 21Arthur E. Palamara, MD

How Do I Really Feel? 23Joe Scott, MD, FACEP

DepartmentsPRESIDENT’Smessage 2Mylissa Graber, MD, FACEP

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

GOVERNMENTALaffairs 6Steve Kailes, MD, FACEP

EMS/trauma 8Michael Lozano, MD, FACEP

MEDICALeconomics 10Ashley Booth, MD, FACEP

PROFESSIONALdevelopment 12Kerry Neall, MD, FACEP, MPH

On Being Your Own Best Expert 24Kenneth Schultz, MD, MBA, FACP, FACEP

Notes on ACEP Sections 25Andrew Bern, MD, FACEP

FREESTANDINGemergency departments 28

CLINICALcase: The Young Lady With the Numb Leg 29Dan Grenier, DO

ERchronicles: On the Day of Judgment 30Arlen Stauffer, MD, MBA, FACEP

POISONcontrol 32Adrienne Perotti, Pharm.D.

DOCTORS’lounge 33

RESIDENCYmatters 34

ADVOCACYnow! 36

Florida College of Emergency Physicians

3717 South Conway Road

Orlando, Florida 32812-7606

(407) 281-7396 • (800) 766-6335

Fax: (407) 281-4407

www.FCEP.org

Executive Committee

Mylissa Graber, MD, FACEP • President

Amy Conley, MD, FACEP • President-Elect

Vidor Friedman, MD, FACEP • Vice President

Kelly Gray-Eurom, MD, FACEP • Secretary/

Treasurer

Ernest Page II, MD, FACEP • Immediate Past

President

Beth Brunner, MBA, CAE • Executive Director

Editorial Board

Leila PoSaw, MD, MPH, FACEP • Editor-in-Chief

[email protected]

Michael Citro • Managing Editor

[email protected]

Cover Design by Michael Citro / 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 distrib-

utes employment opportunities but does not

review, recommend or endorse any individu-

als, groups or hospitals that respond to these

advertisements.

Published by:

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Tel: (305) 633-9779 • Fax: (305) 633-2848

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NOTE: Opinions stated within the articles con-

tained 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 2

EMpulse • Mar-Apr 2010 1


We can’t solve problems by using the same

kind of thinking we used when we created

them - Albert Einstein.

It is interesting that in all of these efforts to

reform healthcare no one wants to address

the issue of medical liability reform and

the real cost to healthcare of defensive

medicine. It is hard to quantify that cost. It

is not obvious, as every day we order tests

based on fear of litigation. What if this is

that one patient with the intracranial hem-

orrhage without loss of consciousness?

The family is demanding it, so I may as

well just get the test, rather than explain to

them again and again why it is unneces-

sary, which despite all my efforts will still

end up with a complaint to administration

and likely repeat visits.

We don’t usually write on our charts, “rea-

son for test - fear of litigation.” This is the

best kept secret and the most obvious real-

ity for those of us who make these deci-

sions every day. We practice defensively

because of our fears, which sadly are also

based in reality. The reality is stopping all

this unnecessary testing could save bil-

lions.

As most of government is controlled by the

legal profession, we physicians are at an

enormous disadvantage. Most legislators

are lawyers, so amazingly most healthcare

reform decisions are being made with very

little physician input. We are always stand-

ing on the sidelines trying to get a seat at

the table because of our smaller number of

participants and smaller monetary contri-

butions. We have no control over a system

that cannot survive without us and we are

best to determine what works and does not

work. Yet, individuals who directly bene-

fit monetarily from suing physicians, hos-

pitals, and health insurance companies are

the ones making all the decisions under the

guise of protecting people’s “access to

courts.”

I think this is our own fault. Physicians

notoriously do not support each other, do

not help their colleagues get elected to

office, do not contribute money, and do not

work well together. We continuously point

fingers at each other rather than working

together to address problems. This works

to the advantage of other groups, that bank

on the fact that physicians do not work well

together. This in turn keeps us from being

in charge of our own profession and from

driving healthcare, which is really what we

should be doing.

What we all need to realize is that getting

involved is not optional. It needs to be as

much a part of our practice as treating high

blood pressure. Why so? Because every

day there are groups and individuals chip-

ping away at what you are allowed to do,

what tests you can order, what and how

you will be paid and what skills you are

required to have to practice. The end result

will be a chaotic healthcare system with

very little physician involvement and con-

trol. The obvious next move will be to

make us all just highly educated govern-

ment employees who can be sued for any

little perceived mistake.

Or maybe we can change our way of think-

ing. We can participate, contribute money,

and help our friends get elected. We could

make sure our voices are not only heard but

that we help drive the change. You don’t

have the luxury anymore of just burying

your head and letting this be someone

else’s problem. Some of us get it and are

involved and contribute, but that small

group is only so strong and the burden is

becoming bigger and bigger. We need

everyone’s help. If we all carried a little of

the burden we could be so much more suc-

cessful than having a few carry us all.

You can be a part of the process and con-

trol your own future, or you can continue

to ignore it and let cards fall where they

may and just have to deal with the conse-

quences. That choice is up to you.

2 EMpulse • Mar-Apr 2010

PRESIDENT’Smessage

On Physician Control

Mylissa Graber, MD, FACEP


In this issue we are honored to share the

experiences of those Florida physicians

who courageously went forward to help

those in great need: the people of Haiti.

The 7.0 earthquake in Haiti struck the cap-

ital city of Port-au-Prince where almost a

third of Haiti’s nine million people live. It

flattened the UN headquarters, killing

dozens of employees, brought down the

Presidential Palace and the National

Cathedral, and killed the archibishop and

several senior politicians. It wiped out

neighborhoods with shoddy, makeshift

houses, wrecked the port, hospitals, and

airport, and cut the power and phone serv-

ice. The country not only came to a com-

plete standstill, but was too paralyzed to

help itself.

An article I read sums it well: “Haitian his-

tory is a chronicle of suffering so Job-like

that it inevitably inspires arguments with

God, and about God. Slavery, revolt,

oppression, color caste, despoliation,

American occupation alternating with

American neglect, extreme poverty, politi-

cal violence, coups, gangs, hurricanes,

floods – and now an earthquake that

exploits all the weaknesses created by this

legacy to kill tens of thousands of people.”

(Packer G. Suffering, New Yorker. Jan 25,

2010)

The disaster response involved not only

militaries, government agencies, interna-

tional aid organizations, but also a large

civilian response in the form of faith based

organizations and individuals. And our

Florida physicians were everywhere!

Dr. Joe Scott was deployed with the

National Disaster Medical System and tells

us how he really feels. Dr. Paul Deponte

worked at the Adventist hospital in

Carrefour and Dr. Tom Schaar volunteered

at the Haiti Community Hospital at the

request of a missionary group.

Dr. Palamara tells of how a single day in

the life of a disaster can be life-changing

experience. Dr. David Farcy and Dr. Seth

Marquit jumped on a plane and joined a

group working in a tent outside the

Presidential Palace. Based on his experi-

ences in a makeshift hospital connected to

the UN, Dr. Jay Park advises us it is best to

be prepared.

I work with Dr. Jean Daniel Pierrot, an

emergency physician, who remembers the

time when he was growing up in Haiti.

Parents were stern, schools were strict, and

drugs had not infested the country. This

was before universities closed and corrup-

tion became rampant. Proud of his Haitian

heritage, Dr. Pierot believes that now is the

perfect time to rebuild the country despite

all odds. With help from the international

community, Haiti needs to take charge of

its future; a future that will preserve the

essence of Haitian culture while improving

the lives of the people.

It is believed that the best way to help is by

monetary contributions, rather than by

donating food and clothing. Now is the

time for us to reach deep into our hearts

and pockets. Dr. Laurent Dreyfus has

asked for donations to the L’Hôpital de la

Communauté Haïtienne, a hospital in the

Fréres Neighborhood of Petion-Ville. His

family helped found and run this hospital.

Details can be found in the Doctors’

Lounge.

Recently, I had a busy shift. I pronounced a

young man dead after extensive resuscita-

tion efforts, intubated a mentally ill man

who had overdosed, refilled grandma’s

prescriptions, talked a young lady through

an ongoing miscarriage, and took care of

Engelbert. He was due to sing in front of

3,000 people in a concert which would last

over four hours, and he needed help. I

hummed “The Last Waltz” for the rest of

the day.

You probably recognize this as your shift.

We all have our Engelberts. We make the

perilous decisions of life and death which

cut through the stress of the patients over-

flowing into the hallways. Just as we reach

our limits, there is that unexpected thank

you or Engelbert. That unanticipated twist

to our day, that makes it all worthwhile.

I, like many other physicians did not go to

Haiti, but I salute those who did. I also

salute those who stayed home and took

care of Engelbert.

EDITOR’Semergencies

Leila L. PoSaw, MD, MPH, FACEP


Haiti and Engelbert Humperdinck


The action in Tallahassee is heating up and

it is difficult to keep pace with the shifting

landscape of filed bills and the ongoing

process of changes. However, we are

using a team approach and have noted sev-

eral key areas to target during the 2010 leg-

islative session.

Perhaps the most concerning bill is an

effort to ban the practice of “balance”

billing patients for charges not paid by

their commercial insurance carriers to non-

participating medical providers. We see

this as potentially disastrous for EPs for

several reasons, including: 1) this will

undercut any negotiating power we have

with commercial carriers when attempting

to become a participating provider; 2) we

are powerless to preemptively steer these

patients away from our practices given cur-

rent laws; 3) we will have to struggle to

receive fair payment for our services from

commercial carriers; and 4) we can antici-

pate such a ban will lead to a further reduc-

tion of available specialists for ED on-call

services. The result will likely be inability

to support adequate EM staffing and serv-

ices, a potential exodus of providers from

the state, and decreased patient care quali-

ty.

Well, that is the bad news. The good news

is that we are actively engaging the legisla-

tors and the state’s Consumer Advocate

(who has been very supportive of this ban)

to point out the severe challenges it will

create and we see that many of them are

listening to our concerns. We are educat-

ing them how every EP already provides

on average (data from the AMA) approxi-

mately $138,000 of uncompensated care

annually (almost four times as much as any

other specialty). In addition, we are not

able to turn away patients based on their

insurance coverage, as can most other

practices in medicine. This proposed ban

amounts to an additional mandate for us to

provide unfunded/under-funded care and it

will erode the already weak foundation of

our state’s medical safety net.

We are pursing multiple avenues towards

medical liability / tort reform.

Representative Renuart and Senator

Thrasher have filed bills seeking sovereign

immunity protections for providers of

emergent care falling under EMTALA and

the Access to Care laws. The argument

being that we (and our on-call specialists)

are essentially acting as agents of the state

as we are compelled to provide care

regardless of injury, illness or ability to

pay. Though this unfunded mandate might

be a natural and welcome calling for doc-

tors to heal the sick, it also places an unfair

burden on us to provide care in inherently

higher risk situations. Interestingly, data

has shown that statewide our malpractice

premiums have decreased since 2003, but

are still higher than the rest of the country.

Healthcare reform efforts continue on the

state level. One idea is to create a “medical

home” for Medicaid patients to help coor-

dinate primary care needs and decrease

low-acuity usage of EDs for problems that

could be cared for in a primary care setting,

so long as the patients have access to that

care. Dr. Vidor Friedman recently spoke in

Tallahassee before a House select commit-

tee considering ways to reduce and control

Medicaid costs. He represented us well by

educating attendees on the unique role of

EPs in delivering care to the patients in

Florida.

We are pursuing other issues. We will sup-

port legislation that attempts to improve

public safety, including a ban on texting

while driving and another mandating the

use of child booster seats. However, we

are wary of a bill intended to require physi-

cians to report patients with conditions that

may impair their ability to drive. We

believe this may not be the best approach

to the problem and will work to refine it.

We need your help in the coming months

and hope you will join our efforts to

improve our practice and care provided to

our patients.


GOVERNMENTALaffairs

Steve Kailes, MD, FACEP

The good news is that we

are actively engaging the

legislators and the state’s

Consumer Advocate.

Tallahassee Action


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For those who have heard me speak on ED

flow, you know that I use the terms “first

and second seating.” Yes, this is my

favorite metaphor – the ED as a restaurant,

and the funny thing is that the first seating

occurs around lunch time. In my ED,

things are quite manageable first thing in

the morning, but mid-morning (first seat-

ing) you get an influx of ambulatory and

EMS patients. The second seating occurs

around six, the next big influx. Indeed, it

makes you wonder whether ambulance

crews are lured in by the cafeteria.

Depending on where you are in the state,

you get a motley crew from single or mul-

tiple EMS agencies. Some are private enti-

ties but most are fire department based.

Paramedics vary in their clinical acumen:

most are good and some are even quite

sharp. Some earnestly provide care and

have a genuine thirst for knowledge, while

others are quite burned out and cynical. For

many EPs, bedside interactions with EMS

constitute the full extent of their experi-

ences, and it is easy to come to the conclu-

sion that this is all there is to pre-hospital

care. The reality is that EMS in Florida is

very complex.

The Bureau of EMS at the Florida

Department of Health is tasked with the

management of the state’s EMS. It is statu-

torily required to biennially develop and

revise a comprehensive state plan for basic

and advanced life support services. The

plan needs to have at a minimum: (a) EMS

systems planning, including pre-hospital

and hospital phases of patient care, injury

control efforts, and the unification of such

services into a total delivery system to

include air, water, and land transport; (b)

requirements for the operation, coordina-

tion and ongoing development of EMS

services (including BLS or ALS vehicles,

equipment, and supplies; communications;

personnel; training; public education; the

trauma system; injury control; and other

medical care components); and (c) the def-

inition of areas of responsibility for regu-

lating and planning the ongoing and devel-

oping delivery service requirements.

The Emergency Medical Services

Advisory Council (EMSAC) advises the

Bureau of EMS. The 11 duties of EMSAC

are listed in chapter 401.245 of the Florida

Statutes, and include “providing a forum

for planning the continued development of

the state’s emergency medical services sys-

tem through the joint production of the

emergency medical services state plan.” At

their most recent meeting in Daytona

Beach, the EMSAC approved the Florida

EMS Strategic Plan 2010-2012. The plan,

which can be downloaded from

www.flems.com/Stratplan/stratplan.htm,

goes into effect in July.

Many of you have been exposed to or even

participated in strategic planning sessions

with your EM groups or hospital. These

sessions center on a SWOT analysis and

give the organizational leaders a chance to

review their mission, vision, and values.

For their strategic planning sessions, the

EMSAC and Bureau brought together rep-

resentatives and interested parties from the

24 constituency groups that comprise the

EMS community.

These groups represent a broad spectrum

of EMS, and include the Quality Managers

Association, EMS Dispatchers, Air

Medical Association, Association of

Trauma Agencies, Association of County

EMS, Air Medical Pilots, Association of

Trauma Coordinators, Association of EMS

Educators, Professional Firefighters, EMS

Medical Directors, Ambulance

Association, Neonatal Transport Nurses,

Rural EMS Association, US Lifesaving

Association, Air & Surface Transport

Nurses Association, Fire Chiefs,

Emergency Nurses, and EMS for Children

(EMSC). This list, although not compre-

hensive, gives you a sense of the players

that routinely sit at the table when EMS

issues are discussed.

The EMSAC’s mission is to facilitate, pro-

mote, and ensure the best pre-hospital care

to the residents and visitors of Florida.

Their vision is to become a unified EMS

system that provides evidence based pre-

hospital care and serves as the recognized

leader in EMS response nationwide.

In the next installment, we will review the

seven goals of the new strategic plan and

relate them to your ED practice.


EMS/trauma

Michael Lozano, MD, FACEP

The State of Florida EMSPart 1 of a Series


The United States uses the ICD-9 code set

to report diagnoses and inpatient proce-

dures. “ICD-9” stands for the World Health

Organization’s International Classification

of Diseases, Ninth Revision, Clinical

Modification (ICD-9-CM), implemented

in 1979, more than 20 years ago.

The Dept. of Health and Human Services

(HHS) announced the compulsory replace-

ment of the ICD-9 code set with ICD-10

from Oct. 1, 2013 for all encounters and

discharges. The regulation doesn’t allow

for use of ICD-10 codes prior to the 2013

start date. The Current Procedural

Terminology (CPT) and Healthcare

Common Procedure Coding System

(HCPCS) will continue to be the code sets

for ambulatory procedures.

ICD-10 will require significant clinical and

administrative systems changes. From an

administrative perspective, ICD-10 is very

specific and involves a greater number of

codes. Diagnosis codes increase from

14,000 to 68,000 in ICD-10-CM while the

procedure codes increase from 4,000 to

87,000 in ICD-10-PCS. For Diabetes

Mellitus alone, there are five categories in

ICD-10, E08-E13, with 203 codes. In addi-

tion, there are structural differences that

will make the conversion complex. While

the ICD-9-CM diagnosis codes are 3-5 dig-

its in length, the ICD-10-CM codes are 3-7

alpha numeric characters long. While the

expanded characters of the ICD-10-CM

codes specifically identify disease etiology,

anatomic site, and severity, the change will

require system upgrades and changes.

As EPs we will need to be more detailed

and specific in our chart documentation so

that the coder is able to select the appropri-

ate code. The non-specific diagnosis codes,

such as chest pain and hypertension, will

still be included in ICD-10 but it is predict-

ed that the majority of payers will not

accept these. For practices that currently

bill many non-specific codes, this will be a

big change. The concern is that there will

be a learning curve for providers after

implementation. Even with good docu-

mentation training prior to implementation

there could be as much as a 15-20%

decrease in coding/billing productivity.

Potential delays or denials of claims could

result in significant reimbursement issues.

Here are steps published by the AMA that

will help you prepare for the conversion:

1. Identify your current systems and work

processes, either electronic or manual, in

which you use ICD-9.

2. Talk to your current practice manage-

ment system vendor.

3. Talk to your clearinghouses or billing

service.

4. Talk to your payers about possible

changes to your contracts as a result of

implementing ICD-10.

5. Identify potential changes to existing

practice work flow and business processes.

6. Identify staff training needs.

7. Test with your trading partners, e.g.,

payers and clearinghouses.

8. Budget for implementation costs,

including system changes, resource materi-

als, consultants and training.

It is believed that ICD-9 codes are outdat-

ed and that the more specific ICD-10 codes

will provide better data for identifying

diagnosis trends, public health needs, epi-

demic outbreaks, and bioterrorism events.

Also, it is believed that the new codes will

provide potential benefits through fewer

rejected claims, improved benchmarking

data, improved quality and care manage-

ment, and improved public health report-

ing. Hope this helps a little with the

changes ahead. Please feel free to contact

me if you have any questions.

AMA web site: www.ama-

assn.org/ama1/pub/upload/.../icd9-icd10-conversion.pdf

WHO web site:

www.who.int/entity/classifications/help/icdfaq/en/index.html

Moderate Sedation and NCCI (National

Correct Coding Initiative)

Effective 10/1/2009, the following codes

are bundled with our ED E/M level codes,

99281-99285, as well as many other proce-

dures that may be provided in the

Emergency Department: 99148, 99149 and

99150.

These codes are for moderate sedation

services provided by a physician other than

the provider performing the procedure. In

NCCI the bundles for 99148-99150 have a

0 modifier, which means you cannot

unbundle the sedation under any circum-

stances or with any modifier (example, -

59). Bill only the ED E/M level.

Make sure your coding conforms to each

insurer’s policy by double-checking your

NCCI edits and your payer contracts. You

can purchase a book with the NCCI edits

for $600 or you can download the edits

from CMS for free. Go to:

http://www.cms.hhs.gov/NationalCorrectC

odInitEd/ Click on “NCCA

Edits–Physicians” in the left column. -

Lynn Reedy


MEDICALeconomics

Ashley Booth Norse, MD, FACEP

Preparing for the Conversion

from ICD-9 to ICD-10


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EM is one of the most challenging careers.

We are constantly being drained of our

energies - physically, emotionally and spir-

itually. We are challenged by our adrena-

line-driven jobs, shift work which inter-

rupts our sleep cycles and family lives, and

a frenetic and hectic work pace which

allows us no quiet reflective time. To be

able to provide top quality and efficient

care to our patients, we must take care of

ourselves. Sacrificing our health, relation-

ships, and spiritual connectedness are not

worth the price of our careers. If we are not

mindful of the pitfalls, our lives and

careers in EM will rapidly unravel. Thus,

a discussion on how we can purposefully

make positive changes is worthwhile.

Many of us have made recent New Year’s

resolutions. If not, it is not too late to do

so. Studies have shown that between 40 to

45% of American adults make one or more

resolutions each year. The top three New

Year’s resolutions are to lose weight, to

implement an exercise program, and to

stop smoking. Also popular are resolutions

dealing with better money management

and debt reduction.

Unfortunately, how many of these are

maintained as time goes on? It has been

shown that only 75% are maintained past

the first week, 71% past the first two

weeks, 64% past one month, and 46% for

more than six months.

While a lot of people who make New

Year’s resolutions do break them, research

shows that making resolutions is useful.

People who make resolutions are 10 times

more likely to attain their goals than people

who don't make resolutions. The following

seven steps are suggested for setting and

reaching personal goals:

1. Stay focused – Keep the broader goal in

mind. Don’t get bogged down in the details

and lose sight of your larger goals. Writing

down goals with specifics of what we want

to accomplish helps us to review them and

adjust our progress to be sure we reach

them.

2. Set realistic expectations – Small goals

are more valuable than brooding over

impossible expectations. Remember “it’s a

cinch by the inch, but it’s hard by the yard

and a trial by the mile!” Little steps lead to

big victories.

3. Expect challenges – We will all make

mistakes. Turn them into victories by

learning from them, adopting new strate-

gies and growing in wisdom. Mistakes are

the greatest stepping stones to achieving

our goals if we refuse to be defeated by

them.

4. Maintain a positive attitude – Check

negative thoughts. Envision the final

results. We have the ability to choose how

we think and feel about a situation.

Cultivate thankfulness, optimism, and trust

in a higher power.

5. Seek support and accept responsibility –

Spend time forming relationships with

people who have positive life skills. We

become what we surround ourselves with.

Social ties create mutual accountability,

and build responsibility and consistency in

our lives.

6. Practice new choices – Remodeling is a

process that takes place over time. Fast is

fragile, but slow is steady, stable and

comes with maturity over time. It is the

very slow steady process of repeatedly

making positive choices that builds mind,

body and spirit. Repetition and patience

are the keys to crafting a healthful lifestyle.

7. Connect – The best of intentions can

plunge without the quiet, reflective time

needed to connect with the power beyond

ourselves. Set aside time for prayer, self

reflection, and the reading of devotional

materials. This will connect us to positive

change.

Let’s make 2010 a year of change. At the

year’s end, we will be able to look back

with satisfaction at the positive changes we

have made, being more whole in the many

facets of our lives!


PROFESSIONALdevelopment

Kerry Neall, MD, FACEP, MPH

Empowering our Lives with Resolutions


FCEP Welcomes its New Members

James Calabro, MD

Francis Castano, MD

Andre Creese, MD FACEP

Steve Hilwa, MD

Marcia Hoffheimer

Daniel Kemple

Andrew Morris

Michael Mozzetti, MD

John Slish, MD

Larry Zaret, DO, FACEP

Recently Moved Into Florida

Mary Allen, MD

Teresa Berridge, MD, FACEP

Mark Caraker, MD

Karlene Chin, MD, FACEP

Stephen Dannewitz, MD, FACEP

Marc Deshaies, MD, FACEP

Adriano Goffi

Michael Heck

Sitha Mangipudy

Chris McAdams

Aaron Mickelson

Betty Peirsol, MD

Jessica Silversmith, MD

Pablo Smester, MD

Courtney Smiley

FCEP Honors Emergency PhysicianGroups with 100% Membership

All Children’s Emergency Center PhysiciansEmergency Medicine ProfessionalsEmergency Physician Enterprises

Florida Emergency PhysiciansSouthwest Florida Emergency Physicians

Tampa Bay Emergency PhysiciansUniversity of Florida

University of Florida, Jacksonville

Earn recognition for YOUR group by encouraging 100%participation in FCEP!

We all know that membership numbers are important.

The more FCEP generates in membership revenue, the

more good we can do for our members through advocacy

and other membership benefit programs. With that in

mind, the Florida College of Emergency Physicians would

like to salute the above groups for achieving 100% mem-

bership.

BRIEFLY...

FCEP Member Benefits Updates

Disability Insurance Partnership

The Florida College of Emergency Physicians is proud to announce

a new benefit program for our association members. We have

developed a program to offer disability insurance for our associa-

tion members at greatly reduced rates. Through an extensive

review process and due diligence, the board is proud to partner with

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cians. Their knowledge, experience and expertise will be a great

benefit to you.

Professional Disability Insurance Specialists can create a personal

and customized disability insurance plan that will meet your needs.

Physicians affiliated with our association will have options avail-

able for portable, individual, own- occupation policies at reduced

rates. PDIS has developed a program specifically tailored for

FCEP members with an A+ rated insurance carrier.

According to David B. Jablon, President of Professional Disability

Insurance Specialists, the mission and goal that PDIS sets out to

accomplish is to provide the most comprehensive and quality cov-

erage available to you as an association member. Mr. Jablon states

disability insurance is the most overlooked and underrated insur-

ance- until it is needed.

The Florida College of Emergency Physicians, as an association, is

constantly striving to provide meaningful and discounted benefit

programs for our members. We believe disability insurance is an

extremely important benefit for our members. We are excited about

our partnership with PDIS and offering the best benefits for our

members.

If you have any questions about this new program please contact

PDIS at phone number 561.499.7737 or electronic mail

[email protected].

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EMpulse: Tell us a little about yourself?

David A. Farcy: I am Dr. David Farcy. I

trained at the Maimonides Medical Center

and did a fellowship in critical care at the

University of Maryland Shock-Trauma

Center. Prior, I was a paramedic for four

years with the US Air Force. I am very

interested in pre-hospital and disaster med-

icine. When the earthquake hit Haiti, I was

supposed to go with the DMAT team, but

this was held up. I waited and waited and

got frustrated. I decided to jump in a plane

and see what I could do.

EMPulse: How does this compare with the

other disasters you have been involved

with?

DF: I worked at Hurricane Andrew that hit

South Florida in 1995, the earthquake in

Mexico City in 1996, Hurricane Mitch in

2002, and September 11, 2001. The major

difference between those disasters and this

one in Haiti is the magnitude of the dam-

age. The former involved only a section of

a town or a country. For example,

Hurricane Andrew involved only

Homestead; Miami Beach and downtown

suffered some broken windows and loss of

light for six days. We arrived in Haiti and

there was no sense of normality. There is

complete mass destruction in the entire

country. And that is pretty shocking.

EMpulse: Do you feel that the disaster was

managed well in Haiti?

DF: The overall response was very chaot-

ic. Each country sent its own team, and

though they saved lives, teams did not have

a unified task or goal and lacked communi-

cation with each other. There was little

communication between the military

teams, the UN, the government and the

massive civilian response.

EMpulse: Do you think that communica-

tion is a major problem in Haiti and simi-

lar disasters?

DF: In September 11, we all lost commu-

nication after the first tower collapsed.

There were no cell phones and this led to

more injuries. If we had better communica-

tion we could have been better warned and

more people could have been saved.

During Katrina, the civilian response was

more powerful than FEMA. In Haiti too,

there is a massive civilian response of mis-

sionary and other groups. The French mili-

tary arrived in 14 hours, the US military in

8 days, and the civilian response acted

sooner than both. So how do we all com-

municate? I don’t have an answer to this.

One of the first things I would have done is

to map the city with the location of treat-

ment centers and MASH units. With the

help of cell phones and GPS, we can coor-

dinate medical treatment.

EMpulse: What was the role of the govern-

ment of Haiti?

DF: The president of Haiti and the heads of

State survived. They have a formal com-

mand structure. It focuses mainly on safe-

ty.

EMpulse: Is there a larger role for inter-

national organizations?

DF: I am originally from France and I have

traveled a lot. We live in one globe with

CONVERsations

On the Haiti DisasterA conversation with David A. Farcy, MD



(Continued from previous page)

easy access. In disaster medicine, there is

no single country and all countries have an

obligation. There should be an umbrella

organization like the UN which is capable

of coordinating efforts. The UN did do this

to some degree.

EMpulse: What prepared you for this

experience?

DF: I am a Buddhist. I belong to a cadre of

physicians who are chameleons. We are

able to do multiple things in the most

stressful of environments with minimum

resources. Overall, I don’t think I was pre-

pared. Though my military training kicked

in and I went into survival mode, this was

more than anything I could have imagined.

Pictures are flat and have no emotions.

When you see a two year old orphan crying

in front of his crumbled house there is no

picture that can describe what you feel.

EMpulse: What is the best way for people

to volunteer in Haiti?

DF: The humanitarian effort will be need-

ed for years. Project Medishare (pro-

jectmedishare.org) at the University of

Miami has short schedules; Project Hope

(projecthope.org) needs a three-week com-

mitment while Doctors without Borders

(doctorswithoutborders.org) and Doctors

of the World (dowusa.org) need a three-

month commitment.


CONVERsations



Logistics is the word I heard often in Haiti.

The logistics of managing supplies,

resources, volunteers and transportation

was probably the reason that so many

earthquake victims unnecessarily died and

are still currently suffering. One would

believe, after having volunteered in Haiti,

that this was the first earthquake disaster

ever experienced by the world. There are

many specific problems unique to Haiti

that contributed to the difficulties of deal-

ing with the aftermath of the 7.0 earth-

quake. However, the lack of disaster and

logistical preparedness is by far the largest

contributor.

I volunteered at a makeshift hospital with

connections to the UN where we had only

one functioning blood pressure cuff for

over 150 inpatients. Trying to do my best

with inadequate supplies, I was assailed

with many logistical questions. Why did

our hospital at the UN base located next to

the airport lack basic supplies? Why was

there a shortage of disaster specific sup-

plies such as bone saws for our orthopedic

surgeons? Didn’t we learn from other

earthquakes to include supplies for emer-

gency amputations? Why was transporta-

tion of supplies and patients between med-

ical facilities and the airport such a prob-

lem, when I slept in a tent on a parking lot

full of unused UN trucks and buses?

I was frustrated that our hospital and so

many other hospitals in the area were lack-

ing essential supplies and support. We

should have been prepared. We should

already have the knowledge from other

disasters of what logistical support is need-

ed to deal with the after effects of this or

any other earthquake.

This is not a critique of the UN or the many

well-intentioned volunteer organizations in

Haiti, by any means. However, this is a

good reminder for us to review our disaster

planning and for us to reassess our readi-

ness. In this information age, the resources

needed for adequate disaster planning are

readily available. We just have to be pre-

pared to use them.

Most of our hospitals and medical prac-

tices have a disaster manual with protocols

to follow when a disaster strikes. The hos-

pitals and the city departments of New

Orleans also had disaster manuals and

plans in place. They thought that they

were prepared with adequate food and sup-

plies. In the aftermath, it became evident

that they had been ill prepared which

resulted in countless logistical problems.

Now let me ask you, when was the last

time you looked at your disaster manual?

When was the last time you exercised a

practice drill? Are you prepared for a dis-

aster that overwhelms your hospital and

public health system?

The Israeli military came to Haiti and set

up a fully functional hospital with x-rays,

operating rooms, a NICU, and everything

else that is needed for a proper medical

facility within half a day. Granted that they

were a military unit, but they succeeded

because they were equipped and practiced.

The officer in charge told me that they

were not as efficient and properly equipped

during their other deployments to the

tsunami hit areas and other earthquakes.

After those experiences, they learned to

fine tune their operation and to find ways

around common logistical problems.

Others could follow their example.

Let’s not complain about the problem of

logistics after a major disaster comes bar-

reling down Florida. How about if we

review that dusty disaster manual and get

prepared now?

HAITIdisaster

Jay Park, MD

Be Prepared: The Problem

is the Logistics


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Just to go home is an all day wait for any

available flight. I leave Port-au-Prince on a

single-engine propeller plane, five-and-a-

half hours scrunched in the back with three

others. I reflect on my last seven days at

the Adventist Hospital in Carrefour,

approximately a mile from the epicenter of

the earthquake that crushed Haiti.

On that first ten mile ride from the Port-au-

Prince airport to the hospital, I witnessed

destruction: crushed buildings; cars leveled

to the ground; large piles of cement and

debris; tents and makeshift homes all over

the street. At an intersection, on the traffic

island, someone had built a shelter. I

remember thinking that some crazy vehicle

could actually run over one of those pre-

carious makeshift tents. Large fires blazed,

which smelled of burning rubber. The

atmosphere was like a sauna with a

stopped-up toilet, very hot and very humid.

Large crowds thronged the street, along

with lots of police and military vehicles

from the United Nations, United States and

France. It took what seemed like all day to

travel those ten miles.

We were taken to the back of the hospital.

I noticed goats and chickens roaming

freely, a fire of burning garbage, and lots of

human excrement lying around. We were

given a hallway on the second floor: we

would sleep here on the cement floor, with-

out beds, functioning toilets, or running

water.

I arrived at 4:30 p.m. and was informed

that I was already scheduled to work the

night shift. Feel free to rest and meet for

sign-out rounds at 5 p.m. The “emergency

department” was a series of three open

rooms. All patients lay on the floor, most

on blankets or on cardboard. The medical

record was an 8x4 inch index card with

hastily scribbled notes, half in French. In

the ED, there were all sorts of patients:

emergency patients, post-op patients, ICU

patients, pre/post partum patients, and

pediatric patients. Patients remained here

until they could be transferred to one of

three sections, all with tents, which ran

along the outside of the hospital. The first

section treated post-op patients, the second

section treated medical conditions, and in

the third section were somewhat well

patients who had nowhere to go and did not

want to leave the hospital grounds. French

physicians and nurses worked the day

shifts and emergency physicians worked

the night shifts. At any given time, the

tents housed about 300 patients. Imagine

the tents as part mobile ICU and part

refugee camp: I treated patients with car-

diac arrests and patients with toothaches.

My schedule was one morning transition,

followed by three night shifts starting at 5

p.m. and going until 7:30 a.m. All the

patients were on the floor and I was con-

stantly bending to examine patients. On my

second day there, my right hand became

red and swollen, and I had to take antibi-

otics. The sharps container was a card-

board box in the corner of the room. There

was no blood work and x-rays were avail-

able during daylight hours. Blood transfu-

sions were a very complicated process.

There was no running water, but plenty of

hand sanitizer, peroxide, and isopropyl

alcohol.

At 1 a.m., I was called to a tent with eight

paralyzed patients, one of whom was unre-

sponsive with no pulse. The temperature

and smell were unbelievable. I performed

CPR, and we were able to get a pulse back.

When I wiped the patient’s forearm to

place an IV, the alcohol pad turned black

from dirt, and after wiping for the second

time, we ran out of alcohol pads. We had

no anti-arrhythmic medications and no

ventilator, and the patient expired.


HAITIdisaster

Fragments of a Shattered World

Paul DePonte, DO


An x-ray under her head marked her death;

she had a C-6 cervical spine fracture. The

nurse who was with me thanked me for

being kind. I could not recall the last time

someone said thank you.

Other cultural differences: it was not

uncommon to have patients arrive with

their wounds wrapped in banana leaves,

not bandages. One patient arrived with an

ankle fracture that was splinted with a cut

out plastic milk jug. I ordered a chest x-ray

on a patient who I suspected had TB. I

wrote CXR on a piece of paper, however,

he returned without an x-ray as the tech-

nologist did not know what CXR meant. I

learnt via an interpreter that I should have

written Pulmonary and not CXR.

A case I am most proud of was a 12-year-

old girl who was hit by a motorcycle and

presented with a rigid, surgical abdomen.

Unbelievably, a quick-thinking radiologist

with a portable ultrasound machine did a

FAST exam and found free fluid. The U.S.

military transferred the patient to the

U.S.S. Comfort, a huge white ship with a

big red cross on both sides, docked in Port-

au-Prince harbor. No parents and no paper-

work.

There was no morgue. When a patient

expired, the body was simply given to the

family. My saddest experience was with a

2-month-old who died of sepsis. It was

very difficult to break the news to the par-

ents in a crowded, hot hallway in the mid-

dle of the night. The father was requested

to come back in the morning to get the

body. At the first light of day, Mr. Jim

Bunch (the CEO of Parkridge hospital) and

I escorted him to the small room where the

baby had been all night. The father first

carried the child to the chapel at the hospi-

tal and then walked down a 100-foot drive-

way into a crowd of people.

Mr. Bunch and I looked at each other, teary

eyed. It was a moment we will never for-

get: Mr. Bunch, a 6-foot-7-inch man, and

I, at 6-foot-4 inches, standing there crying

and experiencing sadness like I never have

in 15 years of practicing medicine, in a

place I never thought about until this trip.



We arrived at the Haitian CommunityHospital (HCH) six days following thedevastating January earthquake. Our groupwaited outside the front entrance, essential-ly a wrought iron gate with thirty otherpeople vying to enter, while our teamleader disappeared inside. We were in themidst of a sea of Haitians inhabiting asmall tent city surrounding the facility. Ayoung woman rushed by the gate holding apremature newborn. Its deceased twin wascarried away in the opposite direction. Aman in scrubs, we later knew as Dr. Tony,emerged from the facility and asked us tocome inside. It was a very surreal firstimpression soon followed by a period ofhelplessness and disorientation.

Our team was divided into three. Our anes-thesiologist went to the OR; our generalsurgeon went to post-op; and the rest of us,two emergency physicians, one physicianassistant, and two emergency nursesmanned the triage area. This consisted ofthe lobby and adjacent courtyard crowdedwith primarily orthopedic patients. Theywere marked with tape on their foreheads.Most had TBS, “to be seen,” written onthem. After an exam, debridement, dress-ing, and splint application, this tape was

replaced with another: “X-ray” patientswaited in line for the only machine in thefacility and “OR1” patients needed emer-gency surgery for infected wounds, openfractures and large soft tissue injuries.The rest were “OR2s,” with closed frac-tures requiring surgical repair after theOR1s were done. These patients weremoved back to the tent city.

We soon became veterans of the system.Later, we were joined by teams fromKorea, Hungary and Australia. Theyassumed we were in charge and wereappreciative of being assimilated into thebizarre routine. By dusk, the insanity thathad been triage was reasonably organizedand many of the teams left for the night.We stayed until noon the next day andreturned ten hours later to do a reverse 20-hour shift.

That night will be remembered for a septicnewborn resuscitation with 14 hours ofhand ventilation and by the aftershock weexperienced early the next morning.Despite no structural damage, the quakecaused a spontaneous, near-total patientevacuation of the hospital, and mostpatients crowded into the tent city. Patientswere reluctant to come inside unless it wastheir turn for the OR. Initially we thought“this can’t be good,” but over the next sixhours logistics were adapted, the hospitalwas cleaned, and things actually ran moresmoothly. We left exhausted that evening,many of us having slept only two to threehours between shifts in the heat of the day.

On our last day, we had a chance to talk toour interpreters and hear some of their sto-ries. Prior to our arrival they had acted asphysician extenders. Many had been

shown how to give injections, treat woundsand assist in the OR. These were not med-ical people: one sold ceramic tile, oneowned a bar, another a travel agency, butmany were students. They were well edu-cated, but this work was foreign. Manyexpressed interest in pursuing some type ofmedical career because of their experi-ences with us.

As a team, we were fortunate. We werehumbled by the Haitian people. Many hadlost friends, family, homes and businesses,but did not complain and worked tirelesslyto help the injured. The Haiti we experi-enced was appreciative and caring. We feltneither threatened nor witnessed riotingnor selfishness. It was a life-changingexperience for each of us and we weregrateful to serve.

Our trip was sponsored by Summit Churchin Estero, Florida, at the request of Missionof Hope, Haiti. On our last day, MOH dis-tributed 391,000 meals without incident,through a network they had developed overthe last ten years. Check them out atmohhaiti.com. They are the real deal!


HAITIdisaster

Thomas Schaar, MD

Really Surreal or Surreally Real


In the grand scheme of things, I recognize

that what I did was negligible. Still, this

experience paints a portrait of our frail

humanity and our incomplete ability to

deal with it.

On Thursday, Jan. 21, 2010, I had the priv-

ilege of traveling to Haiti on a medical

evacuation mission. Authorities had insist-

ed that this be supervised by a physician

and, by sheer chance, I was the appointed

one. After 40 years of being a doctor, I

admit to becoming desensitized to patholo-

gy. But this mission left in me an emotion-

al void that might never be filled. Perhaps

this is the conflict between our divinity and

our humanity.

Our mission was to transport five Haitians

to the United States, thereby reuniting a

divided family and allow the injured mem-

bers to receive medical care. This simple

task was made complex because it

occurred nine days after a major earth-

quake that jarred the soul of an already

impoverished nation. We stowed aboard a

plane chartered by Jackson Memorial

Hospital and Children’s Hospital.

Airplanes are allowed to land in Port-au-

Prince for only two hours since there is

simply insufficient room at the crippled

airport. Flights have one hour to deplane

and one hour to re-load. After that, they

are “wheels up” and if you are not on

board, good luck. It will be difficult find-

ing a hotel that accepts credit cards.

We left Opa Locka filled with uncertainty,

as none of us knew what to expect. With

us was Paul Farmer, MD, the infectious

disease specialist, who has started a hospi-

tal in Haiti against amazing odds and now

battles drug-resistant tuberculosis world-

wide. I have read his book. He smiled

when I pointed out that he must be on the

Harvard faculty since he was the only per-

son on the airplane wearing a white shirt

and a blue blazer.

The airplane made a soft landing. We were

warned to prepare for the acrid odor of

putrefaction when the cabin door opened.

Teams were organized to help unload the

airplane. My companion and I were told to

find our charges and return as quickly as

possible. If we did not return within two

hours, we would be left behind.

The cabin door opened with a faint hint of

smoke, neither oppressive nor fetid. The

100,000 dead bodies had already been

buried in mass graves or burned. Thrusting

through several cordons of uniformed

Haitian border policemen, we asked guards

to remember our faces to facilitate re-entry.

They understood little as they spoke only

Creole.

The airport itself, destitute by third world

standards prior to the earthquake, now

resembled a shattered cavern, with cracks

in the wall and piles of rubble and water

puddles littering the floor. The dimly lit

terminal challenged us to find a function-

ing exit. We left the sanctity of the termi-

nal through breaks in a security fence. The

inner perimeter was protected by rifle bear-

ing American GIs who prevented the

milling mass of underfed Haitians from

storming the terminal to seek escape.

Some have criticized the American govern-

ment for taking over the country.

However, without order, little could have

been accomplished and aid could not have

been dispensed. It provided generators to

light the airfield and organization to the

multitude of well-meaning countries offer-

ing aid. Dropping supplies from helicop-

ters would have resulted in starving people

killing each other for food. Organizing

food distribution lines and relief efforts is

necessary to avoid wanton killings by the

desperate.

We rapidly walked through a pitch-black

parking lot and a warehouse lit only by

automobile headlights. Columns of dust

billowed each time an army HumVee dart-

ed past. Using a satellite cellular phone, we

found our charges in a dark corner, wait-

ing, uncomplaining, with the patience of

Job for their saviors.

Transfer of medical information was mini-

mal. Wounds were re-dressed and IVs

restarted. Contrary to expectations, the

children silently accepted every pain and

indignity without protest. Obviously, they

could not have been prepared for this

calamity or its aftermath. My partner tells

a story of how he had transported a 5-year-

old to Miami. The child suffered a gaping,

infected head injury and crushed right arm

(since amputated). The receiving Jackson

(Continued on Next Page)


HAITIdisaster

God Doesn’t Wear Ray-Bans

Arthur E. Palamara, MD


God Doesn’t Wear Ray-Bans

(Continued from previous page)

resident surgeon (appropriately) asked

what the CT scan revealed. That young

doctor was oblivious of the depravity of

conditions in Haiti.

Gathering up our charges, we made our

way back through the smoky, dusty pot-

holed parking lot to a gap in

the perimeter fence. Haitians

without food, water, jobs,

homes, beds, or hope clutched

at us begging to be taken. Our

party was greeted by several

rifle bearing agents to whom

we explained our mission.

One Federal Agent had lived

in Miami and understood its

complex cultural composition.

They let us pass wishing us a

“God bless you for what your

doing.” This was repeated

many times more but I still

only partially comprehend its

profundity.

We arrived back at the plane, joined by 150

other émigrés desperately trying to exit the

ravaged country. We were told to wait at

the back of the line until we could be

accommodated. The three children, scared

and tired, uttered not a word.

A few minutes past the two-hour deadline,

our Sky King 737 was “wheels-up.” Kathy

and Seth, the two airline employees who

made this evacuation possible, were over-

joyed by the success of “our” mission.

Without them, it would not have been pos-

sible.

Approaching 11 p.m., we landed at Miami

International Airport, as straggly a group of

passengers that has ever deplaned. Here

we faced our last hurdle, American immi-

gration.

The mother and her two children traveling

with us did not valid American visas. The

mother was returning to see her severely

injured son and husband who had been

taken to Jackson a week earlier. The 5-

year-old had undergone a craniotomy for a

depressed, infected skull fracture and

amputation of his arm. The mother was

not aware of the loss of her son’s arm and

we worried about her reaction.

Mark, the organizer of the rescue mission,

pleaded our case to the immigration offi-

cer, a Haitian-American woman, who

asked: “Do they have passports?” The

answer was: “Probably, under the pile of

rubble that was once their home.” Two

TSA supervisors were called and shown

our only documentation, an email from

Senator George Lemieux authorizing

admittance. I was holding the young girl

and her IV bag and I showed the ravages of

our trip.

Wearing scrubs, with my white hair, and

with all the surgical officialdom I could

muster, I spoke up: “We have two injured

children: one with an epidural hematoma

and the other with a fractured radius and

dehydration. We sure wish you could help

us. We are taking them to Jackson

Memorial Hospital.” After a moment’s

pause, the senior officer

offered: “Do you need a

wheel chair?” I should have

said yes. But I, a 66-year-old,

proudly carried that 40-pound

child a quarter mile without

stopping.

Later, we marched onto the

pediatric floor at Jackson

Memorial Hospital and found

the boy and his father. The 3-

year-old girl, who had snug-

gled into my arms for

warmth, yelled “Pappi!” and

jumped from my arms into

his. The face of the boy with the amputat-

ed arm lit up like the national Christmas

tree at the White House.

We had done our job. I arrived home,

exhausted. A half hour later, famished, I sat

down to a bowl of fettuccine and a glass of

wine. I could not help thinking how lucky

I was that I had a home to go to and food to

eat. Those people who had clutched my

sleeve at the airport had no such reprieve.

Stiff and tired, I arose at 7 a.m. to do an

operation on an 89-year-old. Kind of puts

things in perspective.


HAITIdisaster


“So how was it?” I am asked daily since

my return from Haiti. This is accompanied

by hopeful expectations for an exciting

story and gruesome details. It’s a question

that I have trouble answering. How do I

really feel?

I feel great; it was rewarding. I deployed

with the National Disaster Medical System

(NDMS) to the Gheskio Field Hospital in

Port-au-Prince. Our MASH-like facility

was on the edge of Cité Soleil. We treated

injuries and illness caused by the earth-

quake. Within two weeks we were a team

and a family.

I also feel great because I provided care to

the needy, who appreciated my efforts. I

practiced medicine without the constraints

of paperwork and administrative

headaches. On the other hand, the 18-hour

days, the lack of flush toilets, sleeping out-

side in the heat, under mosquito netting,

eating only military meals-ready-to-eat

(MREs), the omnipresent hum of genera-

tors, and the choking smoke from trash

fires were not so great.

I feel frustrated. In a disaster, I expect to

have the ability to transfer patients in

extremis to a higher level of care outside

the disaster zone. In Haiti, however, we

were the highest level of care. As we had

the only functioning pediatric ventilator,

we became the pediatric ICU. We saved

many kids and lost others. We had nowhere

else to turn.

It was exciting, of course. We were accom-

panied by armed members of the 82nd

Airborne at all times. On the streets, the

largest and fastest had the right of way.

The sound of gunfire, the periodic after-

shocks, and working in an ED 24/7 pro-

duced a continuous adrenalin surge that

took its toll.

It was heartbreaking, but not always. We

saw 150 patients and performed five major

surgeries daily. We celebrated births (card-

board boxes and space blankets make great

bassinets). We played with kids who a few

days earlier had been too weak with dehy-

dration. Our care really made a difference.

Heartbreak comes with remembering those

who are the most sick, the ones we ago-

nized over, and the ones we could not save.

We could have been better organized. As

in 9/11 and Katrina, medical professionals

from throughout the world descended on

Haiti. Many had no more than a backpack

and protein bars, and no plans. There was

minimal credentialing and lax accountabil-

ity. Many required assistance as they suc-

cumbed to illness and fatigue. While some

treatment may be better than no treatment,

there are concerns regarding the quality

provided in those early days.

As a physician volunteer with NDMS, I

was a federal employee. I heard complaints

of the slow federal response. Why were the

non-governmental organizations (NGOs)

faster? However, I appreciate the organi-

zation that went into establishing supply

lines, security, accountability, and creden-

tialing. We were able to maximize our

efforts.

This experience has been thought provok-

ing. There are so many questions with so

few answers. What is the responsibility of

healthcare professionals in disasters such

as this? Should the United Nations be the

lead organization in coordinating volunteer

efforts? What level of care should be pro-

vided? Should relief efforts be patient cen-

tered or focus on the population as a

whole? How long should outside organiza-

tions provide assistance? How does one

support the efforts of local physicians?

What will happen to the patients when we

leave? We as EPs are ideally suited to both

respond to disasters and lead the discus-

sion.

The time to prepare is now. Florida is a

national leader in disaster response. And

yet, physicians are the rate limiting step.

There are seven NDMS teams throughout

the state that will gladly begin the creden-

tialing process. In state, Florida has an

equal number of State Medical Response

Teams (SMRTs) dedicated to emergency

care. Numerous NGOs also need physician

volunteers. Get credentialed, update your

immunizations, and complete all necessary

training, so that when the next disaster

strikes, you will be ready!

So yes, this was rewarding, frustrating,

exhausting, dirty and challenging. And, yes

I would do this again in a heartbeat.

Dr. Scott is Team Medical Director -

IMSuRT South - NDMS / HHS.


HAITIdisaster

Joe Scott MD, FACEP

How Do I ReallyFeel?


Preparing a physician witness to tell his or

her story in front of a jury at trial, or to

safely navigate a deposition conducted by

an experienced interrogator, is not easy.

Plaintiffs’ attorneys are skilled at capitaliz-

ing on a doctor’s anger, frustration, resent-

ment, and self-doubt. Combined, these fac-

tors can create a high degree of psycholog-

ical stress that often renders defendant doc-

tors poor witnesses.

Further compounding the situation is the

physician’s basic psychological makeup.

Physicians tend to be thinkers and doers,

but not talkers. This can handicap physi-

cians, making it difficult for them to suc-

cessfully testify at deposition and trial.

First and foremost, physician defendants

need to realize that being named in a law-

suit does not diminish their skills as a

physician. The key to surviving an experi-

ence in the health law arena is to under-

stand the objectives surrounding a lawsuit.

Lawsuits are not about right and wrong,

they are about winning and losing. This

article discusses how to present a success-

ful defense.

The Physician Defendant

Physician defendants and defense attor-

neys may not share the same beliefs on

what it takes to win a case. It is a defense

attorney’s job to provide a physician with a

thorough description of the litigation

process and the defense strategy. The

physician’s role is to serve as a medical

expert and a witness to the facts.

What the Jury Wants

In malpractice lawsuits, the jury decides

who is right by determining which side has

the preponderance of the evidence. Juries

often misinterpret a physician’s inability to

serve as a good witness as an admission of

failure to properly diagnose or treat a

patient. They assume that the demeanor of

a physician during trial is also their

demeanor when treating patients. Jurors

have also been patients, and they expect

professionalism, competence, credibility,

and caring from the physician defendants.

Physicians on trial must behave in a way

that makes them likable and credible to the

jury.

The Medical Record

Juries tend to believe written documenta-

tion more than oral testimony. While there

is no substitute for accurate and complete

documentation, your case will be based on

three sources of information:

1. The medical record itself.

2. Your recollection of events.

3. Customary methods of practice (e.g.,

the manner in which you routinely per-

form a neurological exam).

Although independent recollection and

customary practice require credibility, they

may be your best defense if documentation

on the medical record is inadequate.

Think Before You Speak

One of the most important things to do dur-

ing a deposition is to stay calm. Emotions

cloud judgment, and people tend to speak

without thinking when they’re upset or

nervous. Go into it with the mind-set that

you provided the best care possible under

the circumstances. Stay focused on that

fact and do not let the plaintiff's attorneys

convince you otherwise.

• Become comfortable with silence.

Think before you speak, and do not offer

information beyond that necessary to

answer the question that has been asked.

• Don’t answer any question too quick-

ly. Give your attorney time to object to

any questions that are inappropriate or

leading.

• Have an attorney rephrase a question if

you do not understand it.

• Ask to review documents referenced

by the plaintiff’s attorney before

answering questions about them.

Preparation and Practice

There are some common mistakes that

physician witnesses often make when testi-

fying including:

• Failure to comprehend the defense

strategy devised by an attorney.

• Inadequate knowledge of the facts.

• Failure to study the medical record in

detail.

Preparation and practice will help you to

avoid these mistakes. If you are named in a

malpractice suit, do the following:

• Be compliant, be available, and be

ready to devote time and effort to your

defense.

• Work closely with your attorney to

(Continued on )

MEDmal


On Being Your Own Best Expert

Kenneth Schultz, MD, MBA, FACP, FACEP

empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:53 AM Page 26

Congratulations to all sections on their

annual meetings during Scientific

Assembly in Boston. This past Scientific

Assembly was a huge success having the

most registrants of any Scientific

Assembly to date.

In this past year, the Sections Task Force,

chaired by Dr. Kelly Gray-Eurom and me,

as the board liaison, oversaw the awarding

of section grants and section awards in the

categories of increased membership,

newsletter excellence, service the college,

and service to sections. In the next few

weeks, we hope to receive the annual

reports of each section on the activities for

this past year. This report can be used in

developing the self -nominating forms for

service to college and service to section

awards. It is also an historical record of the

accomplishments of your section for the

year that would be helpful for new section

leaders and section members. This report

is important to send out through the section

e-list or to be printed in the first issue of

your section’s newsletter.

At this year’s Scientific Assembly a meet-

and-greet was held for section leaders.

Susan Morris, Bobby Heard, Kelly Gray-

Eurom, and I met with section leaders

between 8 a.m. and 9 a.m. for coffee and

doughnuts to share experiences and solu-

tions as to problems facing section leaders.

Council Meeting

Some section councilors took advantage of

the councilor training session and met with

the small chapter and section caucus on

Friday afternoon and Sunday morning. It

is a tradition for section and small chapter

councilors to assist each other with training

and support during the Council meeting.

Sections and small chapter councilors

often have the role of councilor for only

one year. Clearly, this is a disadvantage in

experience when compared to larger chap-

ters, where councilors can serve many con-

secutive terms and truly get to know the

system and the individuals.

Section councilors and alternate councilors

should plan on attending the councilor ori-

entation and these important caucus meet-

ings on Friday afternoon and Sunday

morning next year. It is yet another oppor-

tunity for section leaders to get together

and share common experiences.

Webinar: The Power of 100

This year, for the first time, a webinar was

produced to help educate section leaders.

The webinar can be accessed at the ACEP

website. Although directed to the section

leadership, any section member who in the

future wants to become leader or just wants

to know more about sections can go to the

site.

I encourage each of you to listen to the

webinar. Section members who have taken

advantage of this resource tell me that it

has been very helpful and is well worth the

40 or so minutes of their time to gain a

really good understanding of what you can

do with the section.

Growth in Section Membership

Your College, under the direction of the

Membership Committee and Membership

Division staff, has seen the successful

growth of membership to more than 27,500

members. There has also been a growth in

section membership. One of the reasons

for this has been the block payment for res-

idents by residency directors. Often, when

this block payment occurs, complementary

section selections for the resident are not

made. This creates an opportunity for each

section to be in contact with these new res-

ident members and invite them to partici-

pate in your section. Sections offer many

opportunities for residents in leadership

development, professional development,

and in publishing in the section newsletter.

Size matters, because sections can use 15%

of the membership dues generated in the

previous year to finance projects.

Membership growth equates to more funds

for projects. It is also important if you want

to influence College direction.

Section Grant Program

About this time, many sections will begin

to think about the section grant program.

Documents outlining the grant program

and how to apply for a grant will be posted

to the Section link on the ACEP web site

shortly.

Communications and action plans

Now is the time to develop action plans for

the section during this activity year. The

communications plan details how the sec-

tion will communicate with its member-

ship through three different communica-

tions tools. These tools include the section



ACEPsections

Andrew Bern, MD, FACEP

Notes on ACEP Sections


(Continued from Page 24)

become active participants in the claims

process.

• Listen to your legal team, and work to

understand your defense strategy.

• Understand your role as the defendant,

as well as the roles of your legal team,

the plaintiff, and the experts. Study the

plaintiff’s medical record and commit it

to memory. Understand common tactics

that may be used by the plaintiff’s attor-

ney. The plaintiff’s attorney will use

psychological warfare in an attempt to

negatively impact your performance.

Discuss these tactics, and get training in

how to best handle them.

• Have a discussion with your attorney

or your insurance company representa-

tive about hiring an experienced physi-

cian witness coach to help you prepare

your testimony.

• Practice your testimony - the regular

meetings with your attorney will not

sufficiently prepare you for testimony.

• Work with your attorney to develop a

witness preparation strategy that

includes role playing and videotaped

mock testimony. Watch the videotape,

critique yourself, and practice again.

Deposition and trial can be frightening.

You can manage this situation successfully

if you trust your clinical skills and knowl-

edge, stay focused, and work to understand

the process and the purpose behind the

plaintiff attorney's actions and tactics.

Dr. Kenneth Schultz is President of

Skyview Loss Prevention Services. He is a

nationally-known expert in witness prepa-

ration and medical legal strategy.


ACEPsections

MEDmal

(Continued from Previous Page)

newsletter, the section e-list, and the sec-

tion website. Each of these tools should

have an editor or project director. Ideas

and survey results from the section e-list

can be summarized in the section newslet-

ter or website. Resources of a particular

section might be carried in the section

newsletter so it is always there for the

members. Many sections use the annual

meeting as an opportunity to define the

topics that they will cover in the newsletter

over the course of this year. With an aver-

age of 10 stories per newsletter, a section

would be able to cover 40 different stories

over the course of the year.

Partnership

There are three main types of partnerships.

First, sections can partner with one another

when applying for section grants. There

have been many examples where two or

more sections have worked with one

another on grant projects. Second, sections

have partnered with chapters in providing

lectures as part of the chapter meeting and

have become associated with specific

meetings. Examples include the Disaster

Medicine Section that has a meeting of the

section at the Florida Chapter’s

International Disaster Management confer-

ence; the Emergency Medicine Informatics

Section also has partnered with the

Pennsylvania Chapter in their annual infor-

matics meeting. These partnerships are a

win-win for both the section and the chap-

ter. The last partnership is the develop-

ment of a course program that is so large

that the partnership is between the section

and college through the education commit-

tee that produces a dedicated program. The

Pediatric Advanced Educational Program

is an example of such a partnership.

The Team

We want your section to succeed. Happy

and engaged members who find value in

the community of others who share a simi-

lar interest within their practice of emer-

gency medicine determine success. We

look forward to each section reaching a

goal of four newsletters, participating in

the section grant program and in the ability

to finance section projects through the 15%

of dues allocation. We want to help each

section member reach their full potential,

including professional development, by

using sections as an alternative path to

leadership development. Finally, we would

like to see each section member become

politically engaged by attending the

Leadership and Advocacy Conference in

Washington, D.C. this spring, the annual

Council meeting next year in Las Vegas,

and participating in NEMPAC and EMF.

Visit FCEP Online!

www.fcep.org

www.twitter.com/fcep

Become a Fan of FCEP

on Facebook!


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FREESTANDINGemergency departments

Freestanding EDs: An Overview

Antonio Gandia, MD,FACEP

Charlene Walker,RN

The concept of a Freestanding Emergency

Department (FSED) has existed since the

mid 1960s. In Florida, the first FSED

called the Emergency Center at

TimberRidge opened in Marion County

(Ocala) in 2002. It is owned and operated

by Munroe Regional Medical Center.

Shortly thereafter in 2003, the second

FSED opened in Destin (Destin

Emergency Care Center) which is operated

by Fort Walton Beach Medical Center.

Thereafter, state legislators placed a mora-

torium on new FSEDs while they studied

the issue. In 2007, Governor Charlie Crist

overturned the ban and the Mount Sinai

Aventura Freestanding Emergency

Department, owned and operated by

Mount Sinai Medical Center, opened in

Miami-Dade. Since 2008, three additional

FSEDs have opened: the Bardmoor

Emergency Center (Morton Plant

Hospital), the Emergency Care Center at

North Port (Sarasota Memorial Hospital),

and the Emergency Care Center at St.

Lucie West (Martin Memorial Health

Systems).

With six FSEDs successfully operating in

Florida, FCEP formed a committee repre-

sented by the medical directors and admin-

istrators of each facility.

The first meeting was held in November

2009. We agreed to jointly monitor per-

formance improvement indicators and

compare quality outcomes, throughput

times, patient safety and patient satisfac-

tion. We also discussed relationships with

local EMS systems, transport protocols,

and community outreach. The committee

plans to meet quarterly to assess and

exchange data.

With success, many state committees and

organizations have welcomed the FSED as

an additional resource to improve access to

emergency medical care in our state.

Exceeding All Expectations

Antonio Gandia, MD, FACEP

Two years after opening its doors, Mount

Sinai Medical Center’s FSED in Aventura

has proven to be an asset to the communi-

ty it serves. Since January 28, 2008, it has

provided care to close to 25,000 patients.

The Mount Sinai FSED is the third of its

kind in Florida. It operates in Aventura,

Miami-Dade County, which is one of the

most densely populated areas in the state.

Since Mount Sinai Medical Center is one

of six statutory teaching hospitals in

Florida, the FSED serves as a unique edu-

cational venue for medical students, nurse

practitioners, physician assistants, para-

medics and residents. During their rota-

tions, students get to experience a wide

range of emergency conditions as well as

get a glimpse into the future of EM.

To provide safe and efficient care we are

staffed with the customary EPs, registered

nurses and emergency room technicians.

The 24/7 staffing plan also includes full-

time respiratory therapists, radiology tech-

nicians, CT technicians and medical tech-

nologists.

On-site paramedics for patient transport, as

well as an on-call roster of 14 different spe-

cialists, ensure that patients receive the

best medical care.

The department’s commitment to provid-

ing the finest medical care, matched by

efficient and friendly service, has resulted

in an overall 99 percent patient satisfac-

tion.

Combining all of these quality outcomes

has resulted in the community receiving an

efficient and personal ED experience.

Timber Ridge/Munroe County MC

Frank C. Biondolillo, DO, FACEP, FAAEM

Greetings from TimberRidge!

TRED is located on the southwest corridor

of SR 200 in Marion County, in the city of

Ocala, just 12 miles west from the main

hospital campus of Munroe Regional

Medical Center.

TRED has served as the model for FSEDs

in and around the state and was the first

FSED that opened its doors in April 2002.

To date, TRED is averaging over 27,000

patients seen annually, and has improved

access to emergency care, decreased wait

times to see a physician, significantly

decompressed the main campus

Emergency Department, due to its strategic

location, in a rapidly growing segment of

the county.

As another quality service of Munroe

Regional Medical Center, we look forward

to continued growth and expansion. In tan-

dem with Munroe’s mission to “meet the

changing healthcare needs of the commu-

nity of Marion County and beyond,” we

provide caring and compassionate care.

Save the Date!

Symposium by the Sea 2010

takes place July 29 - Aug. 1

in Boca Raton.

See www.fcep.org

for more details.



CLINICALcase

The Young Lady with a Numb Leg

CPC Chair: Frederick Epstein, MD, FACEP

Discussant: Dan Grenier, DO

Mt. Sinai Medical Center

A 28-year-old female presented to Mount

Sinai’s ED complaining of left leg numb-

ness for approximately one month. The

numbness had been constant, but now had

worsened so much so that it caused her gait

to become unsteady. She went to her PCP

three days prior to presentation when she

received a Vitamin B12 shot. She had not

improved.

She was noticed by her family to have been

acting “unlike herself” for the last few

days, which is why she came to the ED.

She had no other symptoms, denied

headache, fever, nausea, vomiting, neck

pain, chest pain or cough.

Her past medical history was significant

for anemia, which was related to gastric

bypass surgery she had four years prior.

Also, she had been treated for an episode

of syphilis in the past and recently had a

URI that was described as some mild con-

gestion. She took daily vitamins and a PPI,

had no allergies, and had a breast augmen-

tation and tummy tuck a year ago.

On physical exam, her vital signs were nor-

mal: she was afebrile. She appeared gener-

ally healthy. On HEENT exam, it was

noticed that she did have slight bilateral

ptosis. Her EOM were intact. Her neck was

supple and her heart, lung, and abdominal

exam were normal. A complete muscu-

loskeletal and neurologic exam was per-

formed. She had 5/5 strength and normal

sensation in all extremities, however, her

gait was ataxic as she seemed to feel

uneasy putting weight on the left leg.

Neurologically she showed no cranial

nerve deficits, had normal reflexes in her

extremities, but had difficulty with the fin-

ger to nose test and heel to shin test.

A CBC and CMP were only remarkable for

her known anemia. A CT scan (pictured on

left) showed an abnormality.

The CT was read as subcortical and deep

white matter lucency in the right posterior

parietal and temporal lobes. Neurology

was consulted and the diagnosis was deter-

mined. Also, a MRI was obtained (pictured

on right).

The MRI was read as multifocal white and

grey matter processes demonstrating mild

mass effect and edema. Differential diag-

noses included lymphoma, multicentric

glioma, multi-focal cerebritis, or an atypi-

cal demyelinating process.

The patient was diagnosed with acute

demyelinating encephalomyelitis (aka

acute disseminated encephalomyelitis).

She was admitted to the hospital and

received high dose steroids for one week

and had improvement of her symptoms.

ADEM is characterized by inflammation

of the brain and spinal cord caused by dam-

age to the myelin sheath. It can occur in

association with recent viral or bacterial

infections, as a complication of vaccina-

tions, or maybe idiopathic. The onset is

sudden with various symptoms including

delirium, seizure, ataxia, optic neuritis and

commonly monoparesis. ADEM is some-

times misdiagnosed as a first attack of mul-

tiple sclerosis, however ADEM will more

commonly have symptoms of encephalitis

such as fever or coma whereas MS does

not. The symptoms typically respond well

to steroids and patients generally return to

normal. In some cases, the symptoms will

not resolve with steroids and other thera-

pies such as plasmapheresis or IVIG have

shown benefit.


“Sinners, repent!”

The disheveled, bearded man in Room 12

called out to every passerby. His blue jeans

were torn, and his long hair had not been

cleaned or combed in several days.

“I am the Lord! You must repent now, or

you will burn in Hell!”

In the Ocean’s Hospital ER, Room 12 was

often reserved for those who appeared to

be mentally ill. Sometimes, it was for

patients who were depressed or anxious,

sometimes for those who had threatened or

attempted suicide. Today, it was for

Randall, a middle-aged man who was in

Room 12 after a police officer had com-

pleted involuntary commitment papers on

him.

As a nurse walked by Room 12’s doorway,

Randall looked up, wide-eyed, and he

flipped some greasy curls off his forehead.

“Ma’am, I say unto you. Come unto me, all

ye that labor and are heavy laden, and I

will give you rest.” Randall appeared con-

fident as he brushed the backside of his

hand across his unshaven chin. He

smirked, and winked at the nurse.

Dr. Tammy Cortez was speaking to the

officer that had driven Randall to the ER.

“So, it looked like he was going to jump?”

“Well, Doc. He said he would jump. He

leaned out over the edge of that roof, and

said something about being Jesus, and he

was going to sacrifice himself for the sins

of all of us.” The officer rolled his eyes,

and then continued, “My partner crept up

behind him and grabbed him before he

could jump.”

He continued, “I’m really not sure what his

name is. He had no ID on him. One time,

he called himself Randall, but then he just

kept referring to himself as ‘Jesus.’”

“OK. Thanks.” Cortez turned toward

Room 12. “We’ll see what we can do.”

“Hi, Randall. I’m Dr. Cortez.”

She kept a cautious distance from the

stretcher, and stayed near the doorway.

Even though there was a leather waist

restraint on Randall, ER personnel know

they can never trust a delusional or halluci-

nating patient.

“Tell me what happened today, Randall.”

She kept her voice low and soft.

Randall spoke with conviction. “My Father

sent me to try to save you!” Then, throwing

his head back and peering intently at the

ceiling, he continued. “Yes, Father. I hear

you! Yes, I’ll try my best! But they’re not

listening to me; they’re not listening to

me!”

Randall’s face scowled, and his lip started

to quiver as though he was about to cry.

Cortez noted Randall’s escalating tension

and his rising voice.

Then, with a sudden conversion to a smile,

he offered a quick comment.

“Hey, Doc, that shirt looks really good on

you,” and he winked at Cortez.

His head snapped back quickly toward the

physician, and he pushed forward against

the leather.

“You’re not putting those evil drugs back

into me!” There was fire in his eyes.

“Don’t even try it!”

He reached out, but Cortez remained out of

reach.

“Randall, what did your name used to be?

Can you tell me that?”

“Randall Smith,” he retorted in a sing-

song, mocking tone. Then, with an

emboldened spirit, he added, “but I’ll

never go back to that sinful life! I’ve been

chosen by the Father to save the sinners of

this world! There! Do you hear that? He’s

telling me to even try to save you!”

Cortez backed out of Room 12. It wasn’t

safe to try to perform any meaningful

physical exam.

“Susie, check for any old records on a

Randall Smith.”

The ward secretary typed in the name.

“Here you go, Dr. Cortez. I’ll bet it’s this


ERchronicles

On the Day of Judgment

Arlen R. Stauffer, MD, MBA, FACEP


one with the psych admissions.”

“Ah. Of course. He’s been admitted with paranoid schizophrenia

at least twice before,” Cortez muttered softly.

“Phil.” Cortez turned to the charge nurse. “The guy in Room 12

has apparently stopped taking his psych meds again. He’s pretty

delusional, and we need to get him calmed down.”

Phil nodded. As Phil and two other men strolled into Room 12,

Randall squinted, now very suspicious that their intent was not

good. He growled, and a look of real fear covered his face.

“A good man out of the treasure of his heart bringeth forth good

things; and an evil man out of the evil treasure bringeth forth evil

things!”

Surrounding Randall now, the three men secured his limbs.

“This is for your own good, Randall.”

“Noooo!” Randall squirmed and twisted. He felt the needle in his

right thigh, and he howled loudly. “Noooo!”

“It’s OK, Randall,” Phil said calmly. “The Haldol’s in now; you’ll

feel better in a minute.”

Again, with his eyes torn wide open, his voice boomed at his

attackers.

“But, I say unto you, that every idle word that men shall speak,

they shall give account in the day of judgment.” He closed his

eyes and sighed, and his shoulders sank forward slightly. “In the

day of judgment, gentlemen, in the day of judgment...”

His voice tailed off, and he allowed his head to lie back against the

stretcher. Randall was calm now. He allowed a nurse to draw his

blood without uttering a whimper. There was a tear on his cheek.

He felt defeated.

Schizophrenia is one of the world’s serious public health prob-

lems, and it accounts for a fourth of psychiatry admissions in this

country. It is characterized by abnormal perceptions or expres-

sions of reality, and it is felt that genetics, neurobiology, early

environment, and psychological and social processes are contrib-

utory factors. Victims of schizophrenia often have co-morbid con-

ditions such as major depression or anxiety disorder, and there is

said to be a 40% lifetime occurrence of substance abuse.

Schizophrenia occurs equally in males and females, and studies

have found an overall lifetime prevalence of 0.55%. The cost to

society in terms of healthcare expenses, lost productivity, vio-

lence, and patients with schizophrenia in prison is staggering.

The author is a long-time emergency physician from New Smyrna

Beach, and a former FCEP Board member and EMpulse editor.

This is a revised version of one of the “Chronicles” that ran in

several Florida newspapers a few years ago. Contact: stauf-

[email protected]



Opiate abuse associated deaths have risen

in Florida in recent years, with heroin con-

tinuing to be the most lethal drug found in

deceased persons, according to a 2009

interim report by the Florida Medical

Examiners. In fact, the top four drugs

found in greater than 50% of drug-associ-

ated deaths were heroin, methadone, fen-

tanyl and oxycodone.1

Opiate toxicity can

cause CNS and respiratory depression that

can lead to coma, respiratory arrest and

death. However, the administration of

naloxone, an opiate antagonist, may limit

toxicity. Traditionally, naloxone is admin-

istered via the intramuscular (IM) or

intravascular (IV) routes, but this always

carries a risk of occupational exposure to

blood-borne pathogens, including human

immunodeficiency virus (HIV) and hepati-

tis B and C. According to the World Health

Organization, 40% of hepatitis B and C

infections and 2.5% of HIV infections

among healthcare workers are due to occu-

pational hazards.2 In an ED setting, admin-

istration of naloxone may be delayed due

to difficulties in gaining IV access or the

patient’s body habitus may cause a prob-

lem for IM administration. Needle-free

administration of naloxone has been pro-

posed.

Intranasal (IN) administration is a novel

way of administering drugs in the ED. It

does not require sterile technique and can

prevent needle-stick injuries. The nasal

mucosa is an ideal route for medications

since it has a very large surface area and a

large amount of blood flow. However,

there are limitations to IN administration.

Particle size, pH and volume all play a role

in absorption. The ideal volume should be

no more than 1 mL per dose; otherwise

excess volume will be lost or swallowed.

Until recently, there was not much human

data comparing routes of administration of

naloxone.

An article in 2008 looked at the pharmaco-

kinetics of IV, IM, and IN naloxone admin-

istration in healthy volunteers. IN nalox-

one only showed a 4% bioavailabilty.

However, this study had many limitations.

A very low concentration of naloxone was

utilized requiring 5 mL of solution to be

atomized into subjects’ nares to achieve a

dose of 2 mg. The subjects were also

healthy volunteers, not under the influence

of opioids. Even with the low bioavailabil-

ity reported, it is known that as little as

0.05-0.1 mg of naloxone can cause an opi-

ate antagonistic effect. The study was also

extremely small with only 8 subjects tested

at different occasions. The authors con-

cluded that further studies need to be con-

ducted.4

Several studies have shown efficacy in the

implementation of IN naloxone in a pre-

hospital setting.5-7 In 2005, a study was

conducted in Salt Lake City, Utah. Ninety-

five subjects were enrolled and received 2

mg of IN naloxone (1mg/mL in each nare),

if they were found unresponsive or if opi-

oid overdose was suspected. As IN nalox-

one was being given, intravenous (IV)

access was obtained, and 2 mg of IV nalox-

one was administered if needed. Of the 95

subjects, 83% responded to IN naloxone

alone and only 16% of these required

repeat IV doses.5

In March of 2004, the use of IN naloxone

as a first line agent in suspected overdose

was implemented by EMS in San

Fransisco, CA. A retrospective chart

review comparing the administration of IN

naloxone and IV naloxone was then per-

formed. The study showed no difference in

the response rates for IN and IV naloxone.

Although the time for response was slight-

ly longer for IN naloxone, there was no dif-

ference in time of contact to clinical

response. The study did note that more

subjects in the IN naloxone group needed a

repeat dose than in the IV naloxone group.6

Despite the lack of in-hospital studies, IN

naloxone can be considered as an alterna-

tive route in the event of an opioid over-

dose. The use of a mucosal atomizer device

(MAD©), when purchased, can easily

attach to the IV naloxone syringe of

2mg/2mL and administer 1 mL to each

nare. The Florida Poison Information

Center Network is available at 1-800-222-

1222 for questions.



POISONcontrol

Novel Naloxone Administration

Adrienne Perotti, Pharm.D.

Clinical Toxicology Fellow

Florida/USVI Poison Information Center-Jacksonville


Hi everyone:

L’Hôpital de la Communauté Haïtienne is a 50-bed hospital in the

Fréres Neighborhood of Petion-Ville, in the area where many of

my family live. My cousin, Edith Dreyfuss-Hudicourt, is one of

Haiti’s first woman doctors and a founding member of this non-

profit hospital created by the Haitian Health and Education

Foundation (Fondation Haitienne pour la Santé et l’Education,

FHASE) in 1985. The hospital has always had emergency servic-

es and opened Haiti’s first ICU last year. The hospital attempts to

be self-sustaining by charging patients minimal fees for services.

The hospital has been one of the few in the Port-au-Prince and

Petion-Ville with no structural damage and with teams of physi-

cians, nurses, and volunteers working night and day.

Thousands of wounded people have overtaxed the hospital’s

capacity to respond to the earthquake emergency. People have

come with multiple traumas: mainly with broken limbs and head

injuries from fallen cement. There are not enough beds, and peo-

ple lie on makeshift mats on the floor.

The disaster that has befallen Haiti is of enormous proportions.

We are raising funds to be able to offer free services. We have

received gifts of supplies and medicine, but these gifts cannot pos-

sibly cover all needs. Orthopedic supplies are in great demand.

The people who arrive at the hospital are in desperate situations.

Many have lost their homes and family members. Some people

are camping in the hospital yard because they do not know where

to go after receiving care. People of all ages are being dropped at

the hospital after being pulled from the rubble.

We hope you can contribute funds to help us to continue helping

people who are in desperate need of care. You can follow your

donation dollars by becoming a fan of the hospital on Facebook.

Haitian Health and Education Foundation is a non-profit organiza-

tion registered in the US. You can read more on the hospital at:

http://www.haitihosp.org/lHopital_de_la_Communaute_Haitienne/Home.html

My aunt Dr. Ginette Dreyfuss-Diederich has opened a bank

account in Miami:

Hopital de la Communauté Relief-G. Diederich

Account number 1000103902598

Suntrust Bank

11333 South Dixie Highway

Pinecrest FL 33156

Laurent Dreyfuss, DO

Department of Emergency Medicine, Cleveland Clinic Florida

Weston, FL


DOCTORS’lounge

Speak Out / Letters

(Continued From Previous Page)

Opiate abuse associated deaths have risen

in Florida in recent years, with heroin con-

tinuing to be the most lethal drug found in

deceased persons, according to a 2009

interim report by the Florida Medical

Examiners. In fact, the top four drugs

found in greater than 50% of drug-associ-

ated deaths were heroin, methadone, fen-

tanyl and oxycodone.1

Opiate toxicity can

cause CNS and respiratory depression that

can lead to coma, respiratory arrest and

death. However, the administration of xone

was administered if needed. Of the 95 sub-

jects, 83% responded to IN naloxone alone

and only 16% of these required repeat IV

doses.5

In March of 2004, the use of IN naloxone

as a first line agent in suspected overdose

was implemented by EMS in San

Fransisco, CA. A retrospective chart

review comparing the administration of IN

naloxone and IV naloxone was then per-

formed. The study showed no difference in

the response rates for IN and IV naloxone.

Although the time for response was slight-

ly longer for IN naloxone, there was no dif-

ference in time of contact to clinical

response. The study did note that more

subjects in the IN naloxone group needed a

repeat dose than in the IV naloxone group.6

Despite the lack of in-hospital studies, IN

naloxone can be considered as an alterna-

tive route in the event of an opioid over-

dose. The use of a mucosal atomizer device

(MAD©), when purchased, can easily

attach to the IV naloxone syringe of

2mg/2mL and administer 1 mL to each

nare. The Florida Poison Information

Center Network is available at 1-800-222-

1222 for questions.

References

1. Florida Medical Examiner’s Commission. Drugs

Identified in Deceased Persons by Florida Medical

Examiners: Interim Drug Report; Nov 2009:i-34.

2. Wilburn SQ, Eijkemans G. Preventing Needlestick

Injuries Among Healthcare Workers: A WHO-ICN

Collaboration. International Journal of Occupational

Environmental Health. 2004;10:451-56.

3. Kerr D, Dietze P, Kelly AM. Intranasal Naloxone

for the Treatment of Suspected Heroin Overdose.

Addiction. 2008;103:379-86.

4. Dowling J, Isbister GK, Kirkpatrick CMJ, Naidoo

D, Graudins A. Population Pharmacokinetics of

Intra-venous, Intramuscular, and Intranasal

Naloxone in Human Volunteers. The Drug

Monitor;2008:490-96.

5. Barton ED, Colwell CB, Wolfe T, Fosnocht D,

Gravitz C, et al. Efficacy of Intranasal Naloxone as a

Needleless Alternative for Treatment of Opioid

Overdose in the Prehospital Setting. J of EM.

2005;29:265-71.

6. Robertson TM, Hendey GW, Stroh G, Shalit M.

Intranasal Naloxone is a Viable Alternative to

Intravenous Naloxone for Prehospital Narcotic

Overdose. Prehospital Emerg Care. 2009;13:512-15.

7. Kerr D, Kelly Anne-Maree, Dietze P, Jolley D,

Barger B. Randomized Controlled Trial Comparing

the Effectiveness and Safety of Intranasal and

Intramuscular Naloxone for the Treatment of

Suspected Heroin Overdose. Addiction.

2009;104:2067-74.

POISONcontrol


Orlando HealthRebecca Blue, MD

Greetings from Orlando!

It’s been a busy winter, and with spring

approaching we are all looking forward to

the match! It has been such an impressive

interview season, and it seems like every

year it gets harder to put together our

match list because there are so many amaz-

ing applicants to choose from! Our pro-

gram’s strongest attributes are the resi-

dents, and we are very blessed to have so

many highly talented young men and

women to work with. This year, our resi-

dents have gone out of their way to support

recruitment, make the applicants feel wel-

come, and offer invaluable insight into the

match list. Thank you so much to every-

one who has made this a successful appli-

cant season!

Our residents are already looking forward

to SAEM, and the momentum of academic

productivity is fantastic. We have had

another highly successful year and many of

our scholarly projects have been accepted

by SAEM. Residents will be delivering

oral presentations, moderated poster pre-

sentations, and multiple poster presenta-

tions on innovative procedural techniques

and unique applications of new technology.

The collaboration between residents, fel-

lows, and faculty is wonderful - congratu-

lations to everyone who has been accepted!

We are all shivering and hoping for warmer

weather soon, but despite the cold our pro-

gram is better than ever. Spring is just

around the corner, and we can’t wait to see

what it brings!

Florida HospitalBrittany Thomas, MD

Firstly, I'd like to mention that we are pray-

ing for the families in Haiti and hope to

arrange a trip soon to serve those in need.

As spring arrives, our residents have been

involved with various local conferences. In

January, both classes attended the 1st

Annual Risk Management Symposium. Dr.

Amal Mattu discussed risky cardiac and

pulmonary conditions, and our very own

Dr. Alfredo Tirado taught us how to utilize

ultrasound in emergency situations. Also,

we were advised on EMTALA, deposition

pitfalls, and correct medical documenta-

tion by two lawyers.

In February, we dedicated our Thursday

lecture series to in-service preparation. We

set the bar high and hope to continuously

improve our scores. A few of us traveled to

Tallahassee for EM Days to discuss med-

ical concerns with our state legislators.

And in April we will participate in the 10th

Annual Symposium on Emergency

Medicine, Standards of Care featuring

Advances for the Clinician and Best

Evidence in Emergency Medicine. Not

only will we learn more about the “Art of

Medicine,” we will also practice our skills

at the advanced airway and ultrasound

hands-on workshops.

We congratulate Dr. Alexander Garcia,

who went to the AAEM Conference in Las

Vegas to present a case on amoebic menin-

gitis, and Dr. Michele Rorich, who ran

Disney’s “Princess Half Marathon.” We

certainly have a multi-talented group!

University of South FloridaJason W. Wilson, MD

We are all aware of the recent crisis in

Haiti, following the devastating earth-

quake. This moved a country with poor

infrastructure to one of virtually no infra-

structure in the heart of that nation.

The state of Florida has responded to the

desperation in multiple ways, including

that of providing medical care both within

our borders and in Haiti. Our geographical

proximity and the considerable Haitian

population in Florida make the situation

even more urgent.

Our program, through the leadership of Dr.

Catherine Carrubba, has been intimately

involved in the care of Haitian medical

refugees evacuated from Haiti and brought

to Florida. This has been an excellent

learning opportunity for us as residents.

We meet the large U.S. Air Force cargo

planes at the airport and perform a second-

ary triage role.

Next, we arrange transport to area hospitals

- both by ground ambulance and, when

necessary, by helicopter transport to loca-

tions further away, such as Gainesville.

Not only has this allowed us residents to

contribute in some small way, but it has

also allowed us to learn disaster triage and

the process of patient transfer to other

facilities (something we rarely do at our

large tertiary care center).

This is a miserable international disaster

but it has been impressive see how our

country has responded in such a merciful

way.


RESIDENCYmatters

http://www.fcep.org/emraf.htm



University of Florida, JacksonvilleOscar Espetia, MD

Greetings!

2010 is well on its way and we are more

than halfway through the academic year.

For the all seniors graduating this year

good luck on the job hunt! Here is a little

update for the rest of Florida on some of

the activities at UF/Shands Jacksonville.

We are only a few months into the year and

our program has been very busy. Dr.

Wears’ published “Situated vs regulatory

rationality” in the January issue of the

Annals of Emergency Medicine. Drs. Caro

and Topp have authored the chapter

“Cardiopulmonary Resuscitation during

Pregnancy” for the Handbook of Obstetric

and Gynecologic Emergencies, 4th edition,

edited by Dr. Benrubi. Dr. Joseph has writ-

ten a book chapter entitled “Diabetes

Mellitus, Juvenile” in Rosen and Barkin’s

5-Minute Emergency Medicine Consult

edited by Schaider, Hayden, Wolfe, R.

Barkin, A. Barkin, Shayne, and Rosen.

Drs. Devos and Akhlaghi have been

appointed to the Eurasia Congress of

Emergency Medicine’s Scientific Advisory

Committee as International Members and

will also be members of the planning com-

mittee. The conference will be held

November 2010 in Antalya, Turkey.

As the year continues to progress, we look

forward to the upcoming match and are

eager to see who will be joining our ranks

here at Jacksonville. We also wish every-

one good luck on the in-service exam com-

ing up soon!

Mt. Sinai Medical CenterMarshall A. Frank, DO

This year our program received over 200

applications for five spots.

Our program director, Dr. Beth

Longenecker, broke her foot in a jump-rop-

ing accident. She was seen, however,

attending a department meeting before she

had an x-ray. She is now not bearing

weight on her right foot, using a knee-

scooter, and still working as hard as ever.

We all wish her a speedy recovery.

For the first time, several of us plan to par-

ticipate in Southeastern MedWAR

(Medical Wilderness Adventure Race) in

Fort Gordon, GA in April. MedWAR com-

bines wilderness medicine with adventure

racing and is designed to teach and test

wilderness survival and medical skills.

After the recent devastating earthquake, we

have seen a huge outpouring of support for

Haiti. Dr. David Farcy and Dr. Seth

Marquit traveled to Port-au-Prince to staff

a medical clinic. Dr. Farcy found a man

trapped in the rubble for almost 10 days.

He attached IV tubing to a stick and thread-

ed it through a hole so that the man could

drink while they dug him out. Dr. Farcy

then climbed into the hole to pull him out,

but thereafter became so exhausted that he

needed IV fluids himself. Awesome!

Miami is a very active city right now: we

have the Orange Bowl, Miami Marathon,

Pro Bowl and the Super Bowl. Hopefully

fans will behave themselves so we can get

through the upcoming weekend unevent-

fully.

University of Florida, GainesvilleRita Fairclough, MD

Greetings from Gainesville! In the last

four months, we have adjusted to our new

ED relatively well. Our visits are project-

ed to increase to 80-85,000 this year, and

we hope to see an increase in the number of

residents per year too.

Our third year class has finished interview-

ing and we will be a Florida, Alabama and

Texas class! Graduation is set for June 19

and the light at the end of the tunnel is get-

ting brighter!

Our interns are doing a great job. Kudos go

out to Andrew, Ben, David, Dan, Henry,

Justin, Tim and Tom for their hard work.

The interview season has ended and we

have stellar applicants. Hopefully we will

add some XX power to the incoming intern

class. We would like to thank Dr Desai,

who organized the interview season this

year. His NFL style draft board was a hit,

and made organizing the rank list easy. Big

thanks also to the faculty members who

helped interview and the residents that par-

ticipated in the breakfasts, lunches and din-

ners.

Several of our third and second year resi-

dents expect additions to their families.

We congratulate Bill Jackman, Miles

Bennett, Kevin Tench and their wives.

We are actively interviewing several candi-

dates for faculty positions, including

Program Director, and hope to apprise you

of the results in the next newsletter. Good

luck to all in the up coming in-service

exam.


Emergency medicine is the leader in pro-

moting patient access and safety. In order

to achieve our goal of taking emergency

medicine to the next level of policy influ-

ence 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 partic-

ipate 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].

Thank you!

2010 Platinum Members:

Florida Emergency Physicians, Inc.

2009 Platinum Members:

Emergency Physicians of Central Florida

Florida Emergency Physicians, Inc.

2009 Silver Members:

Comprehensive Medical Billing Solutions

Jacksonville Emergency Consultants, PA

Martin Gottlieb & Associates, LLC

Southwest Florida Emergency Physicians,

PA

2009 Other Members:

Tampa Bay Emergency Physicians, PL

Miguel Acevedo, MD, FACEP

Wayne Barry, MD, FACEP

Dale Birenbaum, MD, FACEP

Bradford Bowls, MD, FACEP

John Braden, MD

Michell David Brantley, MD

Ka Hang Chan, MD, FACEP

Leonardo Cisneros, DO, FACEP

Casey Corbit, MD

Paul Deponte, DO

Vidor Friedman, MD, FACEP

Vicki Friend, DO, FACEP

Wayne Friestad, MD, FACEP

Mark Frisch, MD, FACEP

Brent Gardner, MD, FACEP

David Goldman, DO, FACEP

Hugh Jones,MD

Rodney Kang, MD, FACEP

William Knibbs, MD, FACEP

Karl Korri, MD, FACEP

Ronald Krome, MD, FACEP(E)

Mark Kruger, MD, FACEP

Linh Tung Le, MD, FACEP

Jorge Lopez-Ferrer, MD, FACEP

William McConnell, DO, FACEP

Gary Mendelow, MD, FACEP

Steven Nazario, MD, FACEP

Steven Newman, MD, FACEP

Patricia Singh Nichols, MD

Brian Nobie, MD, FACEP

Lisa O'Grady, MD

William Osborn, III, DO

Ernest Page II, MD, FACEP

Ketan Pandya, MD, FACEP

Vanessa Peluso, MD

Paul Petersen, MD

W. Randall Poole, MD, FACEP

John Prairie, MD, FACEP

Cheryl Reynolds, MD

Maritza Rodriguez, MD, FACEP

Marc Santambrosio, MD,

FACEP

David Sarkarati, MD, FACEP

Thomas Schaar, MD, FACEP

Regan Schwartz, MD, FACEP

Ehsan Shirazi, MD

Claire Simpson,MD

Weylin Sing, DO, FACEP

Sivapragasm Sivanesan, MD,

FACEP

South Miami Criticare, Inc.

John Tilelli, MD

Bryce Tiller, MD, FACEP

George Tracy, MD

John Valentini, MD

H. Kenneth West, MD

Susan Wolcott, MD

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 legislators,

both at home and in Tallahassee, we need

your help. Please consider “giving a shift”

from personal funds. You can even donate

online at:

http://www.fcep.org/flacpac.htm.

Thank you to all who have donated since

the 2009 Symposium by the Sea!

Emergency Physicians of Florida

ADVOCACYnow!


People for Access to Emergency Care


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

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empulse march-april 2010 issue

Documents

facep presidentamy conley

efforts toreform healthcare

michael lozano

committeemylissa graber

day of judgment

thomas schaar

shattered world

doreally surreal