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EMpulse January-February 2010 Issue
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empulse-Jan-Feb-10:Layout 1 12/23/2009 3:48 PM Page 2
International MedicineThe Antarctic Explorer: Bud Ferguson 15
EM: An Ideal Specialty for the Military 16LTC Lisa DeWitt, DO
Academic IEM and Me 17Elizabeth DeVos, MD, MPH
Revolutionizing the Development of Academic IEM in India 18Sagar Galwankar, MD, MPH & Kelly P. O’Keefe, MD, FACEP
What’s the Allure of IEM? 19Erin C. Connor, DO & Scott Stirling, MD
The Challenges of Maritime Medicine 20Arthur L. Diskin, MD, FACEP
Locum Adventures 21Marlene Buckler, MD
Missionary EM: No Labs, No X‐Rays, No Problem! 23Arlen Stauffer, MD, MBA, FACEP
DepartmentsPRESIDENT’Smessage 2Mylissa Graber, MD, FACEP
EDITOR’Semergencies 4Leila PoSaw, MD, MPH, FACEP
GOVERNMENTALaffairs 6Steve Kailes, MD, FACEP
ACADEMICaffairs 8Joseph A. Tyndall, MD, MPH FACEP
EMS/trauma 10Michael Lozano, MD, FACEP
MEDICALeconomics 12Ashley Booth, MD, FACEP
PROFESSIONALdevelopment 14Paul Mucciolo, MD, FACEP
EMdays 24Vidor Friedman, MD, FACEP
HEALTHreform: Lessons from the Massachusettes Experience 25Peter B. Smulowitz, MD, MPH
RURALem: A Perspective on Rural EM in Florida 28Cary Pigman, MD, FACEP
CONSCIOUSsedation / DOCTORS’lounge 29Ernest Page II, MD, FACEP
ERchronicles: Breaking the News 30Arlen Stauffer, MD, MBA, FACEP
POISONcontrol 32Calvin Tucker, PharmD. & Joe Spillane, Pharm.D., DABAT
New ACCME CME Rules 33John Todaro, BA, REMT-P, RN, TNS, NCEE
RESIDENCYmatters 34
Florida College of Emergency Physicians3717 South Conway RoadOrlando, Florida 32812‐7606(407) 281‐7396 • (800) 766‐6335Fax: (407) 281‐4407www.FCEP.org
Executive CommitteeMylissa Graber, MD, FACEP • PresidentAmy Conley, MD, FACEP • President‐ElectVidor Friedman, MD, FACEP • Vice PresidentKelly Gray‐Eurom, MD, FACEP • Secretary/TreasurerErnest Page II, MD, FACEP • Immediate PastPresidentBeth Brunner, MBA, CAE • Executive Director
Editorial BoardLeila PoSaw, MD, MPH, FACEP • Editor‐in‐[email protected]
Michael Citro • Managing [email protected]
Cover Design by Michael Citro / Leila PoSaw
All advertisements appearing in the FloridaEMpulse are printed as received from theadvertisers. Florida College of EmergencyPhysicians does not endorse any products orservices, except those in its Preferred VendorPartnership. The college receives and distrib‐utes employment opportunities but does notreview, recommend or endorse any individu‐als, groups or hospitals that respond to theseadvertisements.
Published by:Franklin Communications, LLC5301 Northwest 37th AvenueMiami, Florida 33142‐3207Tel: (305) 633‐9779 • Fax: (305) 633‐2848www.frankgraph.com
NOTE: Opinions stated within the articles con‐tained herein are solely those of the writersand do not necessarily reflect those of theEMpulse staff or the Florida College ofEmergency Physicians.
EMpulseVolume 15, Number 1
EMpulse • Jan-Feb 2010 1
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:48 PM Page 3
Happy New Year everyone! It’s amazing
to think we are already in 2010. It seems
like only yesterday everyone was con-
cerned about Y2K and what would happen
with the turn of the century. Yet, that is
now already 10 years ago. Time just con-
tinues to march on by.
Well, FCEP is working hard for you, get-
ting ready for this year’s legislative ses-
sion. Many bills have been filed pertain-
ing to healthcare, and we are analyzing
those to make sure they are in the best
interest of emergency physicians and their
patients.
This year several bills have been filed
about texting and driving. With the num-
ber filed, it is very likely that a bill will be
passed this year, making it illegal in
Florida to text while driving. Studies have
shown that people are 15 times as likely to
get in an accident if texting, which makes
sense since it is impossible to do so and
look at the road. FCEP has chosen to sup-
port such legislation, and I’m sure the
telecommunications industry will be hard
at work coming up with even better alter-
native methods to communicate while
driving. Multi-taskers, like me, need not
worry.
One issue that we may be facing this year,
although no actual bill has been filed as of
yet, is that of making it illegal for physi-
cians to balance bill patients. Currently in
Florida, there is a ban on balanced billing
for HMO patients, but the insurance indus-
try is looking to expand this. Basically,
without putting in safeguards that require
them to pay us fairly, we will lose all
recourse with obtaining proper payment
for services rendered. This would be a
huge problem and basically give the insur-
ance industry the ability to underpay doc-
tors and hospitals whatever they want, with
no recourse from the medical industry.
This is something we will work hard to
fight if it does surface, as an overhaul of
the insurance system would need to occur
before any type of law should be enacted,
if at all.
As for the amicus brief we had filed con-
cerning our cap on non-economic dam-
ages, the judge found that the caps did not
apply because the case occurred prior to
the caps even though the case wasn’t filed
until after the caps, so it turned out not to
be the challenge case. There was one other
case in which the caps were upheld in a
Florida court, so that is good news for us.
It’s been six years and the caps are holding
strong. We’ll continue to watch and be
ready.
EM Days is coming up, so please join us
this year. We really need more participa-
tion from our doctors. Don’t worry; we
will walk you through the process so there
is no need to be shy if you’ve never come
before. If you have any questions about
ways to get involved or what to do, please
feel free to contact me at any time. As
always FCEP is here for you! See you in
Tallahassee!
2 EMpulse • Jan-Feb 2010
PRESIDENT’Smessage
Happy New Year!
Mylissa Graber, MD, FACEP
FCEP President Mylissa Graber and Vice-President Vidor Friedman recently greetedGubernatorial candidate Alex Sink (center) recently at the FCEP office in Orlando.
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:48 PM Page 4
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:48 PM Page 5
The EMpulse staff wishes each and every
one of you a very Happy New Year!
We could think of no better way to ring in
2010 than with an issue celebrating
International Emergency Medicine. And
what a party it is!
Elizabeth Devos questions the very idea of
IEM. What is it? Is it about EPs going
abroad and helping the poor and the sick or
is it about us helping to establish EM in far
off countries so that they can then take care
of their own emergency patients? Is it a
personal quest on a deep, spiritual level or
an intellectual process on an academic
level?
The section of International Emergency
Medicine with over 1000 members is the
largest and most active section of ACEP. It
notes that “as the trend towards globaliza-
tion continues so does the need to support,
promote and develop the specialty of emer-
gency medicine” and that “together, we can
serve as a resource to other countries in
their development of emergency medicine
and promote international interchange,
understanding and cooperation among
physicians practicing emergency medi-
cine.”
However, the EMpulse has taken the liber-
ty to expand on this idea. As health knows
no borders, we have taken IEM out of the
box. We have brought together Florida
EPs who have broken all boundaries, who
have taken EM out onto the high seas or
the snowy ice caps of the South Pole to
take better care of sick people. Keeping in
mind that any sickness is an emergency for
the patient and his/her family, we are doc-
tors first. Healing the sick is an honor and
a privilege, in the US and abroad.
Arlen Stauffer tells of his passion for mis-
sionary medicine in the remote jungles of
South America while Sagar Galwankar and
Kelly O’Keefe describe their efforts to
establish EM in India and “positively affect
the emergency medical care of a billion
people.” Erin Conner and Scott Sterling
talk glowingly of their resident experiences
with EM development in India.
On the more wild side, Lisa Dewitt, the
first residency program director at Mount
Sinai, writes how she gave it all up to fol-
low her true calling in the military. She has
abandoned civilian EM and “gone rogue”
in more than 19 countries. Arthur Diskin,
former FCEP president, is “yo-ho-ho-ing”
at Royal Caribbean Cruises as their Global
Chief Medical Officer. I wonder if a bottle
of rum and an eye patch is part of his
mandatory cruise ship uniform.
On the more practical side, not being resi-
dency trained in the U.S., Marlene Buckler
is forced to work global locum tenens. She
has done so in New Zealand, Canada, and
is off to England soon. Her tenacity to suc-
ceed in the face of adversity is admirable.
We continue to honor Bud Ferguson,
recently deceased, for his work in the
Antarctic. Annette, his wife, was kind
enough to share his photograph and mem-
ories at the South Pole. He continues to be
our hero.
Wayne Barry has done a considerable
amount of work in Haiti. He has shared his
experiences with us in prior EMpulseissues. More of his thoughts and adven-
tures can be found on the online forum
(www.fcep.org).
This issue reflects the accomplishments of
our friends, our peers, our colleagues. With
such a lineup, I hope you feel the same way
I do: very proud of the singular achieve-
ments of Florida EPs. Our work in IEM,
whether this is spiritual or intellectual or
both, is not limited to our ED or our town
or state. It has far reaching effects and con-
sequences in remote corners of the globe.
I am inspired by the efforts of those who
try to make a difference. It is in keeping
with the spirit of this season: joy to the
world and peace on earth!
EDITOR’Semergencies
Leila PoSaw, MD, MPH, FACEP
4 EMpulse • Jan-Feb 2010
Joy to the World
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:48 PM Page 6
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:48 PM Page 7
Ideas on healthcare reform are buzzing
everywhere. We can easily feel doubtful
that any of this will improve our practice.
One thing is certain: we need to be part of
the solution or accept whatever decisions
are forced upon us. Your involvement now
is more important than ever. Yes, I mean
YOU.
For those of us who have been actively
involved, we are doing our best to keep up
with the never ending moving target that is
“healthcare reform.” At the same time, we
are following scores of bills being filed in
Tallahassee which will guide our efforts for
the 2010 legislative session and focus our
energies for EM Days, March 8-10.
What can you do? There are many ways to
get involved, including the most important
of them all - just show up! Join us for our
committee meetings on February 17 in
Orlando. Participation in Tallahassee at
EM Days is especially needed as we meet
with every legislator to educate them about
our concerns and issues. Some of you will
read this, get nervous and think, “I can’t do
that. I won’t know what to say or do.”
Fear not, for you won’t be alone. You can
join other members, follow or lead the way.
What is important is our strength in num-
bers. Yes, we really need you.
There are issues that have grabbed our
attention and efforts. Of great concern is a
probable attempt for a state ban on bal-
anced billing of patients. If the anticipated
efforts to extend this ban to all patients
passes (the ban already exists for HMO
patients), our negotiating power with insur-
ers will be cut right out from under us and
we should expect a significant decline in
our reimbursements. FCEP opposes initia-
tives which limit a practitioner’s ability to
receive fair payment and which will erode
the availability of emergency care and
services.
Another issue is the 2003 caps on non-eco-
nomic damages. A recent case, McCall
versus the U.S., deals with the unfortunate
death of a young woman shortly after child
birth. The plaintiffs argued the 2003 caps
were unconstitutional. Importantly, “The
court concludes that section 766.118(2)
[FL statutes], which limits and aggregates
noneconomic damages in medical mal-
practice actions, does not violate equal pro-
tection under the United States
Constitution.” This is likely not the end of
the challenges to the caps. We need to
remain vigilant. We have submitted an
amicus brief for one trial challenging the
caps and will continue work to support any
efforts that will improve our medical liabil-
ity concerns.
Furthermore, insurance coverage does
not equal access when it comes to patient
care. We are working towards expanding
the number of EM residents in Florida. We
are also working on ways to increase
patient access to primary care physicians,
mental health providers, and other special-
ists, including on-call specialists.
We have challenged efforts that will limit
or hamper our practice, including a recent
Board of Nursing rules hearing that could
significantly affect performing procedural
sedation.
Finally, we are supportive of efforts to
improve patient safety. We support legisla-
tion that promotes patient safety, including
booster seats for young children, as well as
efforts to prohibit cellphone texting while
driving.
So, please, get involved. There is much at
risk. We need your time AND we need
your financial support. Encourage your
fellow EM physicians to join FCEP, and
please contribute to our CCEs: Emergency
Physicians of Florida (for individuals) and
People for Access to Emergency Care (for
groups). Your dollars are extremely impor-
tant in our efforts to be recognized and
heard. You can donate online at FCEP.org
under the government -advocacy tab at the
top of the page.
Be a part of the solution and I’ll see you in
Tallahassee.
6 EMpulse • Jan-Feb 2010
GOVERNMENTALaffairs
Steve Kailes, MD, FACEP
If this passes, our negoti‐ating power with insurerswill be cut right out fromunder us.
Change is Coming
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:48 PM Page 8
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Once again, we find ourselves at the begin-
ning of a brand new year and the start of a
cycle of activities for the Academic Affairs
Committee. We begin with the academic
program during EM Days in the early
spring and end with the Symposium by the
Sea in the late summer.
This year, however, FCEP’s investment in
long term strategic planning has led to
important considerations beyond the annu-
al cyclical planning of prior years. This
long term vision for the Florida College
has enormous potential and is vitally
important to sustaining FCEP’s mission. In
the case of the Academic Affairs
Committee, one word could be used to
summarize this long term strategic view –
collaboration.
A product of this strategic thought is the
Florida Consortium for Academic
Emergency Medicine (FCAEM). Still a
proposal in draft form, this statewide col-
laboration would be an effort to bring
together the best and most productive aca-
demic minds in EM and research from
across the state - from institutions, depart-
ments and institutes that value the
advancement of EM as a specialty. I view
this network as having the future potential
to support the development and promotion
of EPs interested in academic EM; to
organize and grow external resources that
will aide in the education of EM residents
across the state; and to create a state wide
research network for the purposes of shar-
ing information and data in support of the
College’s mission. This network could
serve as a conduit for extramural funding
that could support research activity in a
broad range of areas that could include
health services research, patient safety, dis-
aster preparedness and many other areas of
importance to EM.
Why such a consortium? This is an oppor-
tunity for collaboration (again that word)
amongst so many individuals in our state
currently isolated in informational silos in
their own institutions and efforts. This
opportunity to gain leverage for funding
through FCAEM can positively impact our
own departments, as well as faculty and
other individuals interested in academic
career advancement. Such a truly participa-
tory network will have the potential to cre-
ate and to recruit future leaders in academ-
ic EM from the state of Florida. Clearly
there is much detail to be worked through.
Even though the visions are broad and free
ranging, the focus should be on opportuni-
ties to start modestly and build incremen-
tally for a sustainable future.
Meanwhile, the 21st Annual Emergency
Medicine Days is fast approaching. This,
largest of FCEP’s advocacy events, will be
held in Tallahassee during March 8-10,
2010. The Academic Affairs Committee
will be working with the Governmental
Affairs Committee and the Emergency
Medicine Residents’ Asociation of Florida
(EMRAF) to construct yet another inform-
ative and interactive session for FCEP
members. Central to the success of these
efforts is the participation and presence of
residents and students. Advocacy is and
will be an indispensable part of our contin-
ued development as a specialty and will
remain an important part of educating our
future leaders.
On behalf of this committee, I would like
to personally thank all FCEP staff and
EMRAF. Thank you for your efforts and
contributions throughout 2009. Also to all
the FCEP staff, FCEP and EMRAF mem-
bers, here’s wishing you all a happy and
healthy New Year!
ACADEMICaffairs
Joseph A. Tyndall, MD, MPH, FACEP
Strategic Collaboration
8 EMpulse • Jan-Feb 2010
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:48 PM Page 10
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:48 PM Page 11
Another holiday season has come and
gone. For most of us, that meant working
in the ED while our colleagues were home.
Of course the symmetry of the holidays
means that for every day that you work you
get to enjoy a day at home or at least one
not in the hospital. Such is the nature of our
chosen profession. We share this dedica-
tion with our fellow medical personnel as
well as countless firemen, EMTs, para-
medics, and law enforcement officers.
Just in case no one does, let me be the one
to say, “Thank you for being there.”
Sometimes a simple thank you makes what
we do worthwhile.
With the holidays over, the next season of
significance for us at the Florida College
are the legislative sessions. By the time
you read this, the 2010 version of the
STEMI bill will likely have been filed.
In devising our upcoming legislative agen-
da, the Board of Directors discussed the
2009 iteration of the bill and decided that
the College would be supportive of the
main concept behind the bill – regionaliza-
tion of cardiac care. We are still in the
spring training phase of legislative session,
so it’s too soon to predict what will happen
to the bill in the final stretch. Needless to
say, your fellow FCEP members on the
EMS/Trauma and Governmental Affairs
Committees will work closely with our
lobbyist and allies in Tallahassee to craft
the best bill possible for our patients and
ourselves. If you are not an FCEP member,
maybe this is the time for you to sign up
and attend EM Days.
One of the questions that has come up dur-
ing our deliberations is one with a complex
answer. Why isn’t there a common
statewide EMS protocol? After all, several
states have statewide EMS protocols
including Massachusetts, New York,
Pennsylvania, Alabama, and Arizona.
There are several benefits to common state
protocols. Uniformity is one of them. In
areas where there are multiple EMS agen-
cies, statewide protocols provide a uniform
expectation for EMS care on the part of
hospitals.
The Institute of Medicine, in its recent
report on the state of EMS nationwide,
called for the development of evidence-
based model pre-hospital care protocols for
the treatment, triage, and transport of
patients. An evidence-based approach to
protocol development is preferable as one
would expect all patients to receive the
best quality EMS care possible.
Such an approach would be the natural
consequence of a collaborative effort by a
state board of EMS medical directors.
Statewide protocols can incorporate new
treatment principles more rapidly than a
piecemeal approach. Standardized proto-
cols permit better integration when disas-
ters affect our state, causing EMS
resources to be pooled.
However, the Florida model is one of
decentralized control. Although the Bureau
of EMS licenses pre-hospital agencies
(known as licensees), the final authority for
an agency to operate in a county lies with
the Board of County Commissioners
through the Certificate of Need process.
Similarly, the Bureau will certify, not
license, EMTs and paramedics (known as
certificate holders), but it is up to the indi-
vidual agency EMS medical director to
define the standard of care for a given cer-
tificate holder within a given licensee.
But isn’t a medic a medic?
To answer that, I would ask you to think of
your hospital. Is a nurse a nurse? Are there
differences from shift to shift, or even on
the same shift? How about different EDs?
Similar logic applies to medics and EMTs.
The standard of care that the medical direc-
tor sets in an agency is due in large part to
the resources applied toward HR, training
and quality assurance. A medical director
for two agencies in the same region can
have different protocols depending on
many factors including supervision, train-
ing, and budget constraints. Unless you
take into account the differences among
EMS agencies, a statewide protocol would
handcuff high performance systems, and
be an unfunded mandate for others.
10 EMpulse • Jan-Feb 2010
EMS/trauma
Michael Lozano, MD, FACEP
Thank You for Being There
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:48 PM Page 12
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As the 2010 legislative session draws near
it has become evident that balance billing
will be on the legislative agenda. This will
be a pivotal issue for FCEP. Balance
billing is the practice of billing patients the
difference in the cost of services rendered
and the amount paid by the patient’s insur-
ance company. It typically occurs when
specialists, including EPs, are non-par (out
of the patient’s insurance network).
You may be asking, “Why is this a big
issue?” EPs are mandated by federal, as
well as Florida state law, to provide emer-
gency care regardless of the patient’s abili-
ty to pay or insurance status. As such,
according to the Centers for Medicare and
Medicaid Services, forty to fifty percent of
emergency care goes uncompensated and
EPs provide the most uncompensated care
of all physicians. In addition, most health
plans do not adequately reimburse for
emergency services and there is a constant
threat of significant future decreases.
According to a 2007 article in the Annals
of Emergency Medicine, payments for
emergency visits have declined consistent-
ly since 1996. If health care reform is
enacted and the SGR is not repelled, physi-
cians will see as much as a 21.5 percent
decrease in Medicare reimbursement.
Decreasing reimbursement for emergency
services and increasing amounts of uncom-
pensated care have contributed to the clo-
sure of hundreds of EDs across the country.
Lack of fair reimbursement threatens
access to emergency care and the medical
care safety net.
Federal law prohibits balance billing of
Medicare and Medicaid patients. In
January 2009, the California Supreme
Court banned balance billing entirely.
However, physicians have won some bat-
tles. Earlier this year, the AMA and other
organizations reached a $350-million set-
tlement with United Health Group in a
class action suit. Along similar lines a set-
tlement was reached in a class action suit
against Aetna which has resulted in Aetna
now processing non-par claims at 239% of
the Medicare level of reimbursement.
The prohibition of balance billing would
affect hospital based EM in additional
ways. Insurance companies, knowing that
EPs are mandated to provide care regard-
less of the rate of reimbursement, would
have no incentive to enter into in-par net-
work agreements with EPs at fair reim-
bursement rates or even to contract at all.
The only leverage EPs currently have is the
ability to balance bill patients the differ-
ence in what the insurer pays and the cost
of services rendered. If we lose this, it will
leave us with out any leverage to negotiate
fair reimbursement rates. The only option
would be to continue to bring long and
costly class action suits against insurance
companies in an effort to achieve fair and
equitable payment.
The argument from the consumer’s stand-
point is that they get “stuck with large
bills” but this is because some insurance
companies reimburse out of network
physicians at lower than fair rates. Patients
often have little or no time to determine if
the EPs are in-network providers due to the
nature of the emergency situation. In addi-
tion, a ban on balance billing in the state of
Florida will inhibit EPs’ ability to obtain
follow-up care for the patients they treat. If
insurance companies have no incentive to
negotiate fair reimbursement rate for spe-
cialists, secondary to a ban on balance
billing, there will be a further shortage of
on-call specialists. Without enough in-net-
work specialists, patients would have to go
out-of-network or incur long waits for in-
network physicians.
Florida received an F for access to care in
the National Report Card on the State ofEmergency Medicine released by ACEP. A
ban on balance billing will lead to further
access issues and create even more prob-
lems for patients in the state of Florida.
12 EMpulse • Jan-Feb 2010
MEDICALeconomics
Ashley Booth Norse, MD, FACEP
The Balance Billing Debate
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:48 PM Page 14
FCEP Welcomes its New Members
Mark Attlesey, MDKerry Bachista, MD
Ronald Berman, MDCatherine Carrubba, MD
Jerry Gibbs, MDCarlton Hamilton, MD
Rory Hession, MDAnn Kaminski, MDFarah Lalani, DO
Celeo Ramirez, MDJulie Shamas, MD
Christopher Shaw, MDCarlos Alberto Smith, MD
Peter Spence, DOMichelle Tom
Frederick Ward, MDAnish Zachariah, MD
Christina Zeretzke, MD
Recently Moved Into Florida
Guillermo CabreraAmy Cutright
Edward J Hartwig, DOSandeep Johar, DO
Sarah McIverVictor Randolph, MD
FCEP Honors Emergency PhysicianGroups with 100% Membership
All Children’s Emergency Center PhysiciansEmergency Medicine ProfessionalsEmergency Physician EnterprisesFlorida Emergency PhysiciansSouthwest Florida Emergency PhysiciansTampa Bay Emergency PhysiciansUniversity of FloridaUniversity 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, themore good we can do for our members through advocacyand other membership benefit programs. With that inmind, the Florida College of Emergency Physicians wouldlike to salute the above groups for achieving 100% mem‐bership.
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:48 PM Page 15
“I’m too busy to attend meetings,” “I don’t
understand politics,” and “Someone else
will take care of it” are some of my excus-
es for not being active for the first 12 years
I was an FCEP member. After years of
working nights only, I recently resumed a
rotating schedule.
My attendance at the Board of
Commissioners meeting at Halifax Health
Medical Center where I practice provided
the impetus for me to get involved.
Clearly, the patients who rely upon our ED
for medical care need us to be their advo-
cates.
After contacting Executive Director Beth
Brunner via email, I was invited to attend a
day of FCEP committee meetings in
Orlando. As the newcomer with experi-
ence in neither politics nor organized med-
icine, I was somewhat hesitant. I was
greeted warmly and thoroughly enjoyed
the exchange of ideas. My interest in
issues relating to professional development
and physician well being was sparked dur-
ing a subsequent lunch meeting with Dr.
Wayne Barry.
As the newly appointed chairman, I have
been charged with formulating an action
plan for the upcoming year. I have decid-
ed to structure the plan on three “Rs:”
Recruitment, Retention and Relaxation.
Recruitment is paramount to the continued
success of FCEP. Organized medicine is
replete with acronyms and fragmentation.
Every specialty has its own board, college,
lobbying agency and agenda. Multiply this
by the number of medical specialties and
one can understand the fragmentation that
exists. There are a lot of cooks in the
proverbial kitchen!
EM, now more than ever, needs a unified
voice to present a clear message to
patients, the public and to legislators. A
hall of murmurs will not suffice. FCEP
strives to provide unification, but cannot
do so successfully without a full chorus. In
order to promote the goal of 100% mem-
bership of all Florida EPs, we currently
offer a 25% discount on first-year member-
ship. There hasn’t been a better time to
join and get involved!
Retention is key to the success of FCEP.
Many members have been working dili-
gently for decades while maintaining unin-
terrupted membership. This loyalty and
support should be acknowledged and
rewarded. With the unanimous approval of
the FCEP Board of Directors, these physi-
cians will receive recognition on an annual
basis in the EMpulse magazine.
Medical technology has been accelerating
at an increasing pace, the political climate
is changing, and patient needs are increas-
ing. Without retaining the support of cur-
rent FCEP members, the ability to meet
these changes will be compromised.
Please let FCEP know how we may serve
you better. If your experience is anything
akin to mine, it will be an eye-opening and
overwhelmingly positive experience.
Relaxation is a factor which cannot be
ignored. As a full-time EP, I realized the
importance of this very late in my career.
While reading an article about Father
Damien de Veuster, a Catholic priest in
Hawaii in the late eighteenth century
assigned to a leper colony, the description
of his role caught my attention: “Fr.
Damien had to build his own living quar-
ters, repair a chapel, celebrate daily Mass,
visit the bedridden, wash and bandage the
patients, dig graves, build coffins, and con-
struct houses. The raw wounds and repug-
nant odor of those afflicted often made it
challenging...” Does that sound analogous
to the many hats worn by EPs on a daily
basis?
It is important for new EPs to integrate the
practice of EM into their lives if only to
avoid work related stress. Designating
time for family, friends, and hobbies is
incredibly important. We often hear of
physician “burn out.” This is entirely
avoidable by promoting physician well-
ness. Dr. Kerry Neall has graciously agreed
to take charge of promoting wellness.
I would like to express my gratitude to Dr.
Wayne Barry for his encouragement.
Hopefully, I can maintain Dr. Barry’s
enthusiasm, creativity and diligence during
my tenure.
14 EMpulse • Jan-Feb 2010
PROFESSIONALdevelopment
Paul Mucciolo, MD, FACEP
Recruitment, Retention & Relaxation
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:48 PM Page 16
Bud Ferguson, MD, MPH, FACEP,
FACPM, a past FCEP president, was the
medical director for the National Science
Foundation (NSF) program in Antarctica.
Bud went in the summer to three different
stations. Pictured is Bud at the South Pole,
as represented by the barber pole. The
stakes are placed at the exact pole site,
which changes yearly with ice movement.
It is 40 degrees below and the gear is sup-
plied and must be worn anytime outside of
the shelter because of sudden blinding
weather changes. He had a great adventure
meeting many of the daring folks who
eagerly competed to go there.
- Annette Ferguson
McMurdo Station on Ross Island is by far
the largest facility in the Antarctic. While
the station has around 1,000 people, there
are considerably more than that who go
through. The largest population is during
the summer, September to February. In the
winter, the population plummets. The
majority of our problems last year were
routine, a number of flu and upper respira-
tory problems, and general cold-like symp-
toms. Medical evacuation flights go to
New Zealand, which is 8 to 10 hours away
by air. From late February to September,
there’s no transportation in or out. Housing
is dormitory style, with an assigned room-
mate, bathrooms down the hall, and little
privacy. Meals are served in a common
room but there are many outdoor diver-
sions, games and an extensive library and
gym. The common theme among the peo-
ple who come to McMurdo Station is that
they enjoy the community. They come
back for that community relationship and
identity, which is difficult to achieve any-
where else.
- As told by Bud Ferguson to Cynthia
Pergam, Newsadvance.com, August 22,
2008.
Editor’s Note: Emmett “Bud” Fergusonpassed away on Jan. 27, 2009. During hislifetime, he was instrumental in FCEP his-tory, through his leadership and tirelesswork.
EMpulse • Jan-Feb 2010 15
INTERNATIONALem
The Antarctic Explorer
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:49 PM Page 17
16 EMpulse • Jan-Feb 2010
I had always thought about joining the mil-
itary, but I knew nothing about it. None of
my family or my close friends was in the
military. I was a busy ER doc working in
four South Florida EDs and a residency
program director. Then, Sept. 11, 2001 hit.
That was my opportunity to use my skills
and give back to my country.
Once commissioned in the Florida Army
National Guard, I was deployed within six
months. As a National Guard I was only
obligated to a 90-day “boots on ground”
deployment, however, after being in
Kuwait for a tour, I extended and was
attached to an infantry unit in Iraq.
We were in combat operations throughout
my one-year deployment. As an ER doc,
trauma resuscitations and emergency care
was easy, but I now had to become profi-
cient in primary care and resource limited
medicine. My duties included caring for
combat traumas and all the other illnesses
and injuries a soldier encounters. I was
involved in local clinic renovations, educa-
tional exchanges with Iraqi doctors, and
training Iraqi military medics. Medical
assistance for special patients and provid-
ing humanitarian aid for the local popula-
tion was also a big part of being a military
physician. I also had to learn to make evac-
uation decisions based on transport risks
and tactical capabilities.
It was a life-changing 18 months for me.
Somehow, I knew I was in the right place
at the right time doing the right thing and I
didn’t go back to civilian EM. The military
offered me the opportunity to take chal-
lenging and exciting courses: the Flight
Surgeon course, Airborne School, other
tactical shooting and driving courses, as
well as officer development courses, and
medical conferences.
Once I returned I was asked to join the 20th
Special Forces Group (Airborne). (I remain
with that unit today, in the Alabama Army
National Guard.) With this unit, I deployed
to the Horn of Africa. Although I wasn’t in
constant combat operations, EM again pre-
pared me for my missions. As an ER doc,
now with battlefield experience, I taught
“Tactical Combat Casualty Care” to our
partner nations’ military medical person-
nel. This cultural exchange was challeng-
ing and rewarding. By assisting the
Army’s Civil Affairs units, I was also able
to do multiple humanitarian missions in
which we treated thousands of patients in
remote areas of Africa. The tropical dis-
eases and untreated genetic conditions I
saw were vast. I had done medical mis-
sions previously as a civilian and this was
similar; except, the capability to work with
the host nation and embassies at a national
level combined diplomacy and humanitari-
an aid. We hoped that this would prevent
terrorist groups from taking advantage of
the poverty of African nations for recruit-
ment and training.
More recently, I’ve been involved in
Special Operations in the Global War on
Terrorism. Whether it is training another
nation’s medics in caring for combat
injuries, creating a medical plan in a
remote area, evaluating a host nation’s
medical facility, or just treating our
American heroes, EM is the perfect tool in
my toolbox.
The path I’ve chosen has taken me away
from a lot of things: my previous career,
academia, American EDs, family and all of
what we call a ‘civilized world.’ But, it has
given me so much more. I treat the most
honorable patient population in the world!
I go to medical missions in remote places.
I’ve traveled to 14 countries, all expenses
paid! I have jumped out of airplanes, scuba
dived in foreign waters, climbed moun-
tains, and have experienced a lot of our
world that most people never see.
Most importantly, I believe in the mission
and that is why I am still doing what I do.
INTERNATIONALem
LTC Lisa DeWitt, DO
20th Special Forces Group (Airborne)
EM: An Ideal Specialty
for the Military
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:49 PM Page 18
What is International Emergency Medicine
(IEM)? It is a question I am asked fre-
quently and truthfully, the scope of work
varies significantly for many practicing
IEM physicians throughout the US. Some
focus on refugee medicine, others on disas-
ter relief or infectious diseases and public
health crises. I chose to develop EM in the
world through academic International
Emergency Medicine.
In my fellowship at George Washington
University, I worked mostly on expanding
and building the specialty of EM in proj-
ects on nearly every continent — injury
prevention programs in Ethiopian orphan-
ages to disaster drills in Peru; collaborat-
ing with Turkish EPs to improve the care
provided by general practitioners in rural
hospitals; and residency curriculum and
faculty development in China. As a fellow,
I obtained my MPH, wrote grants, hosted
faculty exchanges, and lectured and taught
bedside rounds on five continents.
In addition to honing packing skills and
finding the best economy seats for long
international flights, I have had the good
fortune to develop collegial relationships
with faculty, students and health officials
around the globe. Most recently, I returned
to Ethiopia to participate in the first facul-
ty exchange program to develop residency
and nurse specialty training in EM at the
Black Lion Specialty Hospital. This is
Ethiopia’s only tertiary public hospital,
affiliated with Addis Ababa University,
which opened its first ER just over one
year ago and is working to train dedicated
emergency staff.
Compounding the burden of infectious dis-
ease facing most of Africa, Ethiopia leads
the world in mortality due to road traffic
injuries — together these cause an enor-
mous public health burden. During fellow-
ship, we delivered annual CME lectures in
EM skills in conjunction with the
Ethiopian Medical Society’s annual meet-
ing, worked with medicine and surgery res-
idents on basics of managing acutely ill
and wounded patients, and developed a
conference to share EM/EMS lessons
learned from other African countries.
Along with the local and federal Ministry
of Health and the medical school faculty,
we planned options for the progress we see
today.
When I first visited Ethiopia in 2007,
emergency patients were examined and
treated along with outpatients in the pri-
mary care and surgery clinics. Triage
mostly consisted of an armed guard per-
haps pointing the general direction of the
clinic he felt might be appropriate. In
another hospital, lists of several medical or
surgical complaints were posted on the
doors to the clinics allowing patients to
attempt to choose which line they should
join. Essential medications and equipment
were and still remain in short supply, and
often patients’ families would purchase
these from private pharmacies or clinics
for treatment. A slow progress can now be
seen in the current triage process where
emergency nurses appropriately streamline
the critically ill and injured patients. Next
month, the first public ambulance system
will be inaugurated in Addis Ababa.
Teams of emergency nurses will work from
fire stations providing patient care and
transport through a centralized call center.
Currently I serve in the ACEP Section on
the IEM steering committee. As the
Educational Chair, I am responsible for
organizing the section’s educational ses-
sions at the Scientific Assembly. This year
international panelists shared their experi-
ences practicing “Emergency Medicine in
Conflict Zones,” on Pediatric IEM
throughout the world, on rationing in pan-
demics, and on human rights initiatives.
During these sessions’ medical students,
residents, fellows, and practicing physi-
cians from across the globe have the
opportunity to network and share ideas.
For me, IEM allows the privilege to devel-
op ongoing relationships to work towards
mutual education and improved emergency
care. In each program, my residents, stu-
dents and I have gained many times more
in return than we have provided and we
hope that we will continue to learn with our
friends each time we return.
EMpulse • Jan-Feb 2010 17
INTERNATIONALem
Elizabeth DeVos MD, MPH
Assistant Professor
Dept. of Emergency Medicine, U. of Florida-Jacksonville
Academic IEM and Me
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:49 PM Page 19
We have been working overtime for the
last five years to help establish EM as a
recognized specialty in India. The INDO-
US Emergency and Trauma partnership
was initiated in 2005 through the joint
efforts of the University of South Florida
(USF), SUNY Downstate Department of
Emergency Medicine, the Medical College
of Vadadora-SSG Hospital in Gujarat,
India, and the All India Institute of Medical
Sciences (AIIMS) in New Delhi, India.
This partnership also enjoys the support of
the World Association of Disaster and
Emergency Medicine.
The goals include: to have EM recognized
as a specialty in India; to develop EM res-
idencies; to develop programs which edu-
cate and train faculty members; and to fos-
ter research for the advancement of trauma
systems and emergency care in India.
Since 2005, the collaborative has organ-
ized five INDO-US Emergency Medicine
Academic Summits attended by over 6000
delegates. The associated pre- and post-
conferences and workshops held all over
India have trained over 4000 delegates
over the last two years. (www.indusem.com)
In 2006, the Academic Council for
Emergencies and Trauma (ACET) was
formed comprising of nominated coun-
cilors from recognized Indian medical col-
leges. ACET has taken the lead in drafting
curriculum, guidelines, and standards for
emergency care and trauma in India.
Today, over 75 medical colleges participate
in ACET. The Council publishes a quarter-
ly newsletter called TEAMS (Trauma andEmergency Academic Medicine Sentinel). The Emergency Medicine & Trauma
Education Center for Health (EM-TECH)
was founded in 2007. Its mission is to for-
malize and facilitate the process of provid-
ing life long education in emergency care
and trauma. It provides the necessary
knowledge, support, and technical expert-
ise to produce workshops, courses, and
academic meetings. EM-TECH is support-
ed by a large number of academicians from
both the US and India.
To promote and publicize research, the
Journal of Emergencies Trauma and Shock(JETS) was founded in 2008, with editors
from over 30 countries and 20 disciplines.
This peer-reviewed and indexed journal
has more than 20,000 readers, and is avail-
able in both print and online format
(www.onlinejets.org). It is a landmark pub-
lication, synergizing basic sciences, clini-
cal medicine, and public health globally.
In 2008, the INDO-US collaborative pub-
lished a landmark position paper on devel-
oping academic EM in India. This white
paper was published in the Journal of theAssociation of Physicians of India (JAPI),
which has served over one million
internists over the last 64 years. The con-
tents of this manuscript served as a frame-
work for the Medical Council of India to
recognize EM as a specialty in 2009. This
recognition has led to the creation of aca-
demic departments and the recruitment of
faculty using the framework as a guide.
The INDO-US Academic Research
Cooperative (INDUS-ARC) was created in
2009 to push the collaborative, multi-cen-
ter, clinical research agenda at academic
medical institutions across India. This
arrangement will make the research
process simpler, as the cooperative will
develop common approval and administra-
tive mechanisms to accomplish multi-cen-
ter research studies within a minimum
amount of time, resulting in maximum
patient participation related outcomes. The
INDO-US collaborative will continue to
foster leadership in educational exchange
and cooperative research via its annual
INDUS-EM Summit, ACET Assembly,
year round training events, and ongoing
research initiatives.
USF’s Dr. Sagar Galwankar spearheaded
the development of these programs. Drs.
Tracy Sanson and Kelly O’Keefe served as
chairs of the INDUS-EM conferences. All
three remain intimately involved, traveling
each year to India. Also at USF, faculty
(David Orban, Charlotte Derr, Cathy
Carrubba, Brad Peckler), residents (Preeti
Jois-Bilowich, Jason Johnson, Rahul
Salooja, Scott Stirling), and medical stu-
dents are actively involved. Anyone inter-
ested in supporting this movement, with
time or financial contributions, should con-
tact Dr. Tracy Sanson.
It is not everyday that we can say, “The
work I am doing will positively affect the
emergency medical care of a billion peo-
ple.”
18 EMpulse • Jan-Feb 2010
INTERNATIONALem
Sagar Galwankar MD, MPH
& Kelly P. O’Keefe MD, FACEP
Revolutionizing the Development of
Academic EM in India
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:49 PM Page 20
During residency, there comes a point
when your enthusiasm begins to wane and
a little cynicism creeps in. Running in cir-
cles in the ED, the big picture can become
cloudy and you wonder how you ended up
here in the first place. Sometimes, chang-
ing your perspective is all that is needed to
bring back your drive and focus and
remind you why you chose EM.
When Dr. Sanson sent out the e-mail
inviting EM residents to apply for a
grant to participate in the 5th Annual
INDO-US Emergency and Trauma
Program in Coimbatore, India, we
both jumped at the chance. Like
other residents interested in interna-
tional EM and facing the day-to-day
challenges of residency, we saw this
as a golden opportunity. Along with
eight other EM residents, we were
awarded the TeamHealth grant,
which proved to be one of the most excit-
ing and rewarding experiences of residen-
cy to date.
The mission of the INDO-US program is to
promote the advancement of academic EM
through an exchange between Indian and
American academic institutions. The part-
nership involves the USF Global Emerg-
ency Medical Sciences Program, SUNY
Downstate Department of Emergency
Medicine, Baroda Medical College-SSG
Hospital, the All India Institute of Medical
Sciences and TeamHealth. It was an excel-
lent opportunity for attending physicians,
residents, medical students, nurses and
other healthcare providers from India, the
U.S. and other counties to come together
for one common goal.
India is the second most populous nation in
the world, with over one billion citizens.
Its geographical area is three times smaller
than that of the U.S., yet this area contains
four times the population. It was amazing
to arrive in Coimbatore and witness the
buzz of excitement surrounding the confer-
ence. Trauma surgeons, orthopedic sur-
geons, and ED physicians from the U.S.,
India, and other countries attended.
The expansion of EM in India in the past
five years has been incredible. New trauma
centers and EDs have been built across the
country. Funding for EM training has
increased. Finally, and most importantly,
physicians themselves have become more
organized in their advocacy for the special-
ty. One of the highlights of the trip was our
visit to the PSG Emergency and Trauma
Center. The director was eager to show us
how he had taken different elements from
EDs he had seen in the U.S. and elsewhere
and had incorporated them into his depart-
ment. While some of the equipment may
not have been state-of-the-art, the triage
system and trauma protocols were as
streamlined as any U.S. center. It was fas-
cinating to hear the staff talk about their
advancements and their plans for the future
and to liken these conversations to
ones that must have taken place in
the early years of U.S. EM.
As residents, our role was to serve as
models of American EM residents.
We all had the chance to present a
core emergency medicine topic and
to assist in the suture and ultrasound
labs. There were research posters
and presentations on topics we con-
sider exotic here in the U.S. but are
mundane in India - including
snakebites, malaria, dengue fever and other
tropical diseases. This is not to say that the
trip was all work. Our evenings were full
of wonderful meals, social gatherings and
even a grand gala, replete with ‘Jai Ho’ and
a snake charmer!
We arrived back in the US with a renewed
energy, a new appreciation for EM and a
whole group of new friends. We were
excited to come back and share our experi-
ence with our colleagues in Florida. Thank
you to our Indian hosts, TeamHealth, Drs.
Sanson, O’Keefe, Galwanker and all the
other residents. It was an invaluable expe-
rience.
EMpulse • Jan-Feb 2010 19
INTERNATIONALem
What’s the Allure of IEM?
Our recent trip to India
Erin C. Connor, DO
Mt. Sinai EM Program, Miami Beach,
Scott Stirling, MD
Univ. of South Florida, EM program, Tampa
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:49 PM Page 21
Much has changed in the last five years: I
was caught up in the malpractice crisis; a
victim of nasty hospital and corporate pol-
itics; had fun consulting on risk manage-
ment and ED operations; parental deaths;
losing touch with old friends and making
new ones; and watching the subject of my
first FCEP presidential editorial on nurtur-
ing grow to be a little man of five – going
on 20.
I thought I had settled in for a career-end-
ing final tenure as Chief of Jackson
Memorial’s ED – organize, consolidate,
redesign the place, and start another resi-
dency program. A little teaching, a bag
lunch at a medical school lecture, a little
clinical work, deal with the union and its
“Little Red Book” (oh, sorry, it was purple)
and lots of those infamous hospital plan-
ning meetings. Life was good!! A little
well-deserved break from FCEP to allow
others to bask in the glory and I was set.
For more than 20 years, I had been a con-
sultant to the cruise industry. Most recent-
ly, I was Medical Director for Carnival
Cruise Lines, a subsidiary of Carnival
Corporation. I would spend half a day per
week at their offices dealing with diverse
issues such as medical credentialing, for-
mulary selection, staffing and crew med-
ical issues. I found the industry fascinating
and challenging, but I certainly would
never have considered it as a full-time job
– financially or intellectually.
I started to consult with the Royal
Caribbean Cruise Lines when I moved to
Jackson Memorial, as they had a long-
standing relationship with the hospital, uti-
lizing the department for 24-hour emer-
gency calls. Soon, the familiar dance
began – Royal Caribbean had decided to
establish a new position at a vice-president
level and wanted me to accept the position.
“...but I am happy here.” “We will make
you happier!” And so it transpired – Vice-
president and Global Chief Medical
Officer for Royal Caribbean Cruises, Ltd.
(RCL) – parent company of Royal
Caribbean, Celebrity and Azamara Cruise
Lines – 30+ ships; 40,000 crew and of
course, the amazing new megaship Oasis.
First, let me set the record straight. I am not
the “Love Boat doc.” I’ve entered ‘corpo-
rate America’ with a bang. Quarterly fore-
casts, budgets, slide presentations, insider
trading warnings, planning sessions and
worldwide presentations to non-physician
groups have become part of my everyday
existence. Jackson Memorial does not
have its stock price on its home page.
My responsibilities include Public Health.
Due to outbreaks of norovirus, the cruise
lines are under constant scrutiny. The
Vessel Sanitation Program (VSP) inspec-
tors from the CDC inspect ships docking at
U.S. ports – deducting points for violations
of established standards. A score less than
85 signifies failure and a quick trip to the
principal’s office for some poor captain.
Fortunately, our scores have hovered
around 97. Public Health includes food
safety (temperature, storage, service and
other issues); integrated pest management
(I now know the life-cycle of the cock-
roach); potable and recreational water
quality, and safety and outbreak prevention
and mitigation. One of my first duties was
to approve the “Fecal Accident” policy for
swimming pools – a long way from writing
stroke center policies (well, not really).
We have retired VSP inspectors who train,
inspect, audit and prepare ships’ pools for
inspection. The program works well. I
would rather swim in a ship’s pool or eat in
a ship’s restaurant than any land-based
operation.
I have expanded my infectious disease
knowledge base and management skills.
We are experts in legionella and gastroin-
testinal illnesses such as norovirus, as we
must do everything to protect our guests
and crew and avoid media sensationaliza-
tion. Since we have a crew from 100+
countries and have ships in 24 time zones,
we can see malaria, dengue, varicella,
rubella, tuberculosis, typhoid and other ill-
nesses – all fortunately rare, but forever
looming. H1N1 has presented some amaz-
ing challenges for the industry with vary-
ing responses in every port around the
world. Immunization programs for our
crew for seasonal and H1N1 is a major ini-
tiative and undertaking.
My major function is the supervision of the
medical facility operations aboard the
ships – the recruitment, credentialing (two
full-time nurses just for this), and retention
of the physicians and nurses. This has and
continues to require significant attention
and led to some significant house cleaning
activities. We have to select equipment,
formularies and supplies and develop pro-
grams to train in their operation and pre-
ventative maintenance. We have a 24/7
hot-line staffed by physicians and nurses
who work for me to assist the ship in the
(Continued on Page 22)
20 EMpulse • Jan-Feb 2010
INTERNATIONALem
Yo-ho-ho! A Sailor’s Life for Me:
The Challenges of Maritime Medicine
Arthur L. Diskin, MD, FACEP
Vice-president, Global Chief Medical Officer,
Royal Caribbean Cruises, Ltd.
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:49 PM Page 22
In the summer of 2007, after 15 years of
full-time EM practice, I decided to take a
year off. The relentless pressures of 12-
hour shifts were taking their toll. My long-
standing marriage had ended and the
thought of having time again for me began
to feel exquisitely therapeutic. Perhaps I
would just retire and concentrate on writ-
ing and developing my website. But like
most ER doctors, the challenges and satis-
faction of treating patients still held a cer-
tain appeal, and when a job opportunity in
New Zealand presented itself, I said an
enthusiastic yes to adventure.
I received a warm welcome in picturesque
Wanganui, which sits on a meandering
river on the southwestern coast of the
North Island of New Zealand. The city’s
population of almost 40,000 comprises of
European descendents and Maori, New
Zealand’s indigenous people.
Most international flights enter New
Zealand at its largest city, Auckland. With
a quarter of the country’s total population,
Auckland is indeed a modern and stimulat-
ing city. Foreign doctors arriving to work
in New Zealand are required to meet with
the NZ Medical Council before being
granted a final license; this gave me a day
to explore the “City of Sails.” I arrived in
September, spring in the southern hemi-
sphere, perfect for exploring Auckland.
It’s no surprise New Zealanders have been
ranked among the happiest people in the
world. The visitor is greeted to down-home
hospitality, friendly faces and some of the
most beautiful scenery on the planet. Add
in delicious food, some of the best hotel
accommodations anywhere, low crimes
rates and a high standard of living and it’s
easy to see why one visit, even a six-
month-long one, would never be enough.
New Zealand enjoys a modern healthcare
system with state-of-the-art medical prac-
tices. Free healthcare to citizens includes
Accident and Emergency (A&E, i.e. ER)
and in-hospital care, lab and x-ray, preg-
nancy and childbirth services, specialist
care and subsidized prescription medica-
tions. School children get free dental care.
Though all modern medical technologies
are available and are utilized, there seems
to be less reliance on CTs and more empha-
sis on the history and physical exam.
Remember those days? Specialists will-
ingly come to the ER to evaluate patients
and surgeons never ask “What did the CAT
scan show?” It is felt that a person should
not be exposed to the radiation of a CT
scan just because the specialist doesn’t
want to be inconvenienced.
Almost all patients have a general practi-
tioner. When discharging patients from the
ER one knows that follow-up care will be
provided. This spirit of community support
and concern for the welfare of others is
typical of New Zealand.
Locum doctors are not well paid in the land
down under but most are provided with
free use of a vehicle, accommodations and
transportation to and from the country.
Doctors are not sued, though one can be
reported by a patient to the health board. I
certainly do not regret my decision to
experience EM in the land the Maori call
“Aotearoa.’
My next locum adventure took me to the
ER at Queen Elizabeth Hospital (QEH), in
Charlottetown, the capital of Canada’s
smallest province, Prince Edward Island
(PEI). I had not worked in a Canadian hos-
pital since immigrating to the U.S. in 1993.
Some Americans are under the impression
that Canada’s universal health care system
leaves many of its citizens without timely
treatment. Though it is likely that
Canadians will wait longer than their
American counterparts for some elective
surgeries, such as hip replacements, emer-
gency care is not significantly different
than that in the States.
ERs treat all patients who show up. EMS
and triage systems ensure timely care for
all who need it. At the QEH, a teaching
facility and the major referral hospital for
PEI, specialists are not only willing to
evaluate patients in the ER, , they are actu-
ally pleasant about it. Follow-up care for
patients who may go home, but need to see
(Continued on Page 22)
EMpulse • Jan-Feb 2010 21
INTERNATIONALem
Marlene Buckler, MD
Locum Adventures
The author (right), sailboat racing off PEI.
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:49 PM Page 23
a specialist, is often accomplished by the
next day. How’s that for service? And
believe it or not, suicidal and psychotic
patients are admitted to the hospital and
not transferred. Psychiatrists taking turns
on call actually see patients in the ER.
Medical and surgical patients too sick to
go home are admitted to their GPs, to a
hospitalist or to appropriate specialists. I
never encounter any resistance when call-
ing to have a patient admitted. In fact I
would say that the QEH medical staff is
the happiest and most cooperative group I
have ever encountered.
My daughter’s plans to start Veterinary
Medicine at UPEI influenced my decision
to work in Charlottetown. It has turned
into a six-month locum, sailboat racing all
summer, excellent pay and working with a
great group of ER docs and medical staff.
I have been asked to return next summer
and plan to do so. What’s not to like?
The recent EM climate in the U.S. and
especially in Florida has become
unfriendly to non-boarded docs. More and
more doors are closing. Despite recent
workforce studies illuminating the reality
that the supply of RT/BC EM physicians
will not meet the demand for 20-30 years,
if ever, hospitals persist in turning away
highly competent EM doctors. In New
Zealand and in Canada there is an appre-
ciation for knowledge and experience.
Doctors are respected for their skills and
competence. Of course residency training
is valued, as it should be, but those who
began their careers when EM was a
younger specialty are seen as a valuable
resource to fill a need that won’t go away
any time soon.
My permanent home is in Florida and I
will likely return to practice there soon,
but for now I am off on another adventure,
this time to England for a few months’
work. Doing locums is fun and fulfilling.
logistics of medical disembarkations and
answer other questions. However, the doc-
tors are independent contractors and must
make their own decisions, as I often say to
them, “you are there and I am here, do
what you think is best.” This is where I
most see my clinical EM background kick
in – they have amazingly complicated
cases on board the ships. Everyone wants
to take a cruise before they die. Diagnose
someone in Iowa with cancer, the next call
is to the travel agent. People cruise with
medication lists you need to scroll through.
Once they reach a certain age, they will
wane philosophical and tell you if they die,
they die – let them finish their cruise.
I am also responsible for the medical care
of the 40,000 crew (25,000+ on ships at
any given time). We approve non-emer-
gency surgeries and arrange for care in
ports and/or if they need to be repatriated
home. We are developing networks around
the world and certifying facilities as Royal
Caribbean Centers of Excellence based on
quality, location and ease of access. I uti-
lize all my negotiating skills and tactics to
negotiate fees and identify billing abuses.
If you think the ambulance chasers are bad,
you should see the crew chasers who hang
out at ships to get them to sign up as
clients. I use my medico-legal skills,
which I thought I might be done with,
every day. I’m also responsible for crew
wellness programs; pre-employment phys-
ical programs; the Care Team, which
assists the crew and guests who have
adverse events or must be disembarked for
medical reasons; and, a group of financial
analysts who support the medical budgets
in the department and ships, and supervise
the processing of all crew claims and
develop forecasting models.
RCL has been very supportive of our criti-
cal projects and purchases. We have a new
semi-annual conference in Miami for our
doctors and nurses; we are in the middle of
purchasing and deploying digital x-ray
processors for our ships; we have new ven-
tilators capable of NIPPV; we are develop-
ing a tele-dermatology program with the
University of Miami; there are new defib-
rillators on board and our formulary has
been revised to include new drugs and
eliminate obsolete ones while accepting
the variations in practice of our multina-
tional physician and nursing staff.
The travel is interesting but tough with a
five-year-old at home. I have been to
Turku, Finland to inspect our new ship;
attended meetings at the European CDC in
Stockholm, visited the P&I Clubs in
London; spoken at an H1N1 conference in
Athens; inspected medical facilities in
Dubai, Dubrovnik and Santo Domingo;
and met with the CDC in Atlanta and with
the PAHO division of WHO in Barbados.
Mankind has gazed out upon the sea with a
desire to conquer it for millennia – what
would they think of floating discos, water
slides and designer boutiques floating
through Caribbean waters formerly filled
with pirates? I must say it is quite interest-
ing to meet the descendants of these char-
acters, no less colorful.
I continue to work 1-2 shifts per month at
Jackson Memorial (love that sovereign
immunity) and encourage anyone who
moves out of everyday EM clinical prac-
tice to stay clinically active. It is what you
trained for and validates everything else
you may do.
While I am working as hard as I ever have,
there is really no other job like this in the
world. I am honored and privileged to have
been selected for it. EM, as a specialty, a
lifestyle and an intellectual process has
prepared me for this position like no other
area in medicine could have. Our options
are many, varied and often offer challenges
far greater than we might expect.
Maritime Medicine (Continued from Page 20)
INTERNATIONALem
22 EMpulse • Jan-Feb 2010
Locum Adventures (Continued from Page 21)
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:49 PM Page 24
For the past several years, I have had the
privilege to work in parts of the world
where people usually get very little med-
ical care. There are very few things in this
life that are more rewarding.
My wife and I have led medical mission
teams to numerous Central and South
American countries since the mid 1990s.
Each time we go it changes the reality of
our roles and purpose in this world.
Experience in EM creates the perfect back-
ground for providing healthcare to the
poorest parts of our world; but, it’s sure not
like working in the U.S.
There is almost always something that can
be done to ease the suffering in rural, poor
areas: whether it’s giving Rocephin to a
man in Bolivia with pneumonia; re-
hydrating an 18-month-old Peruvian Shuar
Indian girl with a week of diarrhea; com-
forting a young Mayan man in Guatemala
who was burned when his family’s jungle
hut burned down; or pulling the transporta-
tion and the few dollars together that are
required to get a fractured femur fixed cor-
rectly in a hospital a few hours from the
jungles of Ecuador.
This type of travel is not for everyone.
There are long hours in planes, buses, and
sometimes in boats or on foot. The heat
and humidity in the jungle makes Florida
seem cool, water is only cool/cold, and
sleep often takes place in a mosquito net on
a dirt floor. We’ve met various types of
critters face-to-face that we’d never seen
before, and we’ve eaten Anaconda and
Capybara that actually tastes OK. (No,
Anaconda doesn’t taste like chicken.)
This type of medicine is not for everyone.
When working in these isolated areas, we
only have what we take along. An Accu-
Check is the lab, and we use stethoscopes,
tongue blades, and otoscopes. We carry
large duffles full of various (donated and
purchased) medications, and bring along a
few instruments for suturing, some IV sup-
plies, and Lidocaine and scalpels for
abscesses. There is no radiology and there
are no consultants; when we are there, we
are it!
However, when we see the look of aston-
ishment on a mother’s face when she can
gets medicine for her baby for free, realize
the trust placed in us by a father who has
carried his injured son all day through the
jungle to get to our clinic, or see the tears
drop from grateful parents’ faces (who
have lost children earlier from lack of med-
ical facilities), it makes the heat, insects,
and the bed situation seem rather trivial.
We usually travel and work under the aus-
pices of Missionary Ventures International
(www.mvi.org), a faith-based mission
organization with headquarters in Orlando,
and with missions in more than 80 coun-
tries around the world. The missionaries
serve as hosts for the mission teams,
arranging all of the in-country travel and
translators, and coordinating food and
other safety arrangements for team mem-
bers. (I refer to us as the “wimpy
Americans,” as the folks who live in the
areas we visit never have protected food
sources, malaria prophylaxis, hot water, or
soft beds.)
If you’re looking for something new to try
on your next “vacation,” searching for a
way to help those who are much less fortu-
nate, and feeling like it’s time to “give
back,” I encourage you to check out the
numerous mission and humanitarian
organizations that send out medical mis-
sion teams to the poorest areas of our
world. This changed my life. If you try it,
you will not be the same when you return.
Arlen Stauffer is an emergency physician inNew Smyrna Beach, a former FCEP Boardmember, and is now the Associate MedicalDirector for Halifax Health – Hospice.Visit www.CoronadoMissions.org fordetails and pictures of past medical mis-sions.
EMpulse • Jan-Feb 2010 23
INTERNATIONALem
Missionary EM: No Labs,
No X-Rays, No Problem!
Arlen Stauffer, MD, MBA, FACEP
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:49 PM Page 25
Hello everyone! I hope your holidays were
full of happiness and joy!
By the time you read this it will be 2010,
and your Governmental Affairs Committee
will be already hard at work with our elect-
ed representatives to further the interests of
our patients and profession.
One of the most important events of the
year is on the horizon, Emergency
Medicine Days, in Tallahassee. This is an
annual event, entering its 21st year, where
FCEP members spend several days in
Tallahassee, both learning about our leg-
islative agenda and collectively lobbying
our elected officials about issues important
to our profession. We hope to see your
there!
So what is Emergency Medicine Days?
Well, in addition to getting the most up-to-
date information about what is going on
legislatively in Florida, EM Days offers a
unique opportunity to network with your
peers, learn about the political process, get
some CME and overall have a pretty good
time doing all of this!
It is vital to our profession that our mem-
bers have a strong showing at EM Days,
never more so than in these times of
change. The healthcare drama that is play-
ing out in Washington will have significant
ripple effects in our state; it is imperative
that our voices are heard.
Who knows the realties of healthcare better
then us? This is the beginning of a conver-
sation, not a complete solution. The debate
is all about the high cost of healthcare, and
many point to the ED as an expensive, and
inefficient part of that ‘system.’
We know that emergencies happen in spite
of our best efforts. The real safety net of
our healthcare network is the emergency
system, and it is vital that this safety net be
not only protected but improved!
You can be sure that whatever changes are
made will impact our state significantly. In
these times of fiscal challenges, our state’s
elected officials will need all the assistance
they can get to implement the changes that
are being demanded by both our society
and the Federal Government.
By virtue of the position that emergency
medicine occupies in the healthcare net-
work, we see the challenges that patients
face both in the outpatient and inpatient
worlds and we can speak for them, as well
as ourselves.
You have your own experiences and pas-
sion for medicine and your patients. Your
stories matter, not just to you, but to your
patients and your elected officials. So
come to Tallahassee.
Help us explain to our elected representa-
tives how an earache is really an emer-
gency when it is your child screaming in
pain in the middle of the night.
Help us explain why it is important to a
working mother that a competent physician
be there to take care of her child after the
doctor’s office is closed and why that same
physician should be fairly compensated.
Help us remind our elected officials that
when their time of healthcare crisis comes,
they will want and demand that an excel-
lent emergency care team take care of
them.
If you do not show up, who will?
24 EMpulse • Jan-Feb 2010
EMdays
See You at EM Days
Vidor Friedman, MD, FACEP
Your stories matter, notjust to you, but to yourpatients and your electedofficials.
Visit FCEP online!
www.FCEP.org
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:49 PM Page 26
While Massachusetts’s landmark health-
care reform is still in its nascent stages, the
ramifications of expanding access to health
insurance are already apparent. “An Act
Providing Access to Affordable, Quality,
Accountable Health Care” (termed chapter
58 of the Acts of 2006) has expanded cov-
erage to over two thirds of the previously
uninsured in Massachusetts while energiz-
ing the national conversation on healthcare
reform. However, the reform falls short of
universal health care, it did not solve the
problem of the affordability of health
insurance or limited access to healthcare
and even with the recent renewal of the
federal Medicaid waiver, the expansion of
the state subsidized insurance placed a sig-
nificant strain on the state budget.
Massachusetts will need to tackle health-
care costs, raise enough revenue during an
economic downturn, and focus on access to
care in order to ensure the solvency of its
healthcare reform.
The exact framework of the Massachusetts
health reform has been previously well
described.1,2 This paper seeks to describe
the major consequences of healthcare
reform in Massachusetts. We will then
comment on the implications of chapter 58
to broader efforts at healthcare reform.
Impact on the number of uninsured
Since implementation on July 1, 2006,
over 439,000 individuals have been
enrolled in health insurance.3 The original
estimate of the uninsured was between
396,000 and 657,000 Massachusetts resi-
dents.1,4 In 2007 tax filings, just 5% of
about 3.2 million tax filers reported being
uninsured as of Dec. 31, 2007.
Of the newly insured, about 41% obtain
insurance via the publicly subsidized
Commonwealth Care program, which is
available to all individuals with incomes
less than 300% of the Federal Poverty level
who do not meet Medicaid (MassHealth in
Massachusetts) eligibility criteria.3 By fall
2007, the un-insurance rate for adults with
incomes below 300% of poverty fell from
24% to 13%. Among adults with income
less than 100% of poverty the un-insurance
rate dropped by more than two thirds to
10%.2,3
About 43% of the newly insured are in pri-
vate, commercial insurance plans. This
growth comes from both employer spon-
sored (36%) and individually purchased,
“non-group” insurance (7%).3 The
remaining 16% newly insured are a prod-
uct of expansions of Masshealth, which
essentially includes an expansion of cover-
age of children in families up to 30% of
poverty.
The number of newly insured highlights
the success of the Massachusetts law in
extending health insurance coverage to
previously uninsured populations. Though
much of the expansion is due to subsidized
programs, the individual mandate has
played a key role in persuading others to
purchase private insurance plans, the
increase in private, commercial insurance
is the first significant increase in
Massachusetts in decades.2,3
Affordability of Health Insurance
One of the stated goals of the health reform
law was to make health insurance premi-
ums more affordable, in particular for
young adults and individuals by merging
the small-group and non-group insurance
markets. The Commonwealth Connector
reports that it was able to successfully cut
in half the price a typical 37-year-old
would pay for health insurance in this pri-
vate market, while adding twice the bene-
fits.3 For all age groups, health insurance is
less expensive in 2008 in comparison to
equivalent plans in 2006, even accounting
for an average of 8% annual inflation.5
Nevertheless, the 18-25 age group remains
the largest sector of the uninsured in
Massachusetts (accounting for 35% of the
remaining uninsured), and 80% of the
remaining uninsured find cost to be a sig-
nificant impediment to purchasing insur-
ance.2 The connector itself recognizes that
while health insurance is less expensive
after the reform, it is still not affordable for
many. For this reason it has excluded from
the individual mandate any individual
earning between 300 and approximately
500% of poverty (about 35,000 individu-
als).3 Furthermore, while cost of the
Connector plan’s premiums are rising
slower than comparable plans, cost sharing
requirements were recently increased in an
effort to reduce the $400 million gap
between projected and actual costs for
2008.
(Continued on the Next Two Pages)
EMpulse • Jan-Feb 2010 25
HEALTHreform
LESSONS FROM THE
MASSACHUSETTS EXPERIENCE
Peter B. Smulowitz, MD, MPH
Beth Israel Deaconess Medical Center
Boston, Massachusetts
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:49 PM Page 27
(Continued from Page 25)
The cost to Massachusetts
The cost of healthcare reform has been significantly higher than
predicted. The original estimate for the Commonwealth Care pro-
gram for fiscal year 2008 was $472 million,6 though the actual cost
will be closer to $717 million. For 2009, the projected cost was
$725 million, and Gov. Patrick’s administration is now stating the
cost to be over $1 billion. Lawmakers implemented an increase in
the cigarette tax to make up part of the budgetary shortfall, and the
Commonwealth Connector will be increasing cost sharing require-
ments and could cap enrollment as costs continue to rise.
The higher than expected cost of the reform is partly attributed to
underestimating both the number of lower income residents and
the speed in which they would enroll in the subsidized programs.7
In this latter part the state was largely a victim of its own success
- successful outreach led to faster-than-expected enrollment in the
subsidized plans. The state also estimated it would collect about
$95 million from employer assessments in 2008. The real amount
collected is closer to$5 million.8 However, it is significant to note
that costs per enrollee actually came in under budget for FY 2008,
at $352 per member per month, or 2% below the budget of $359
per member per month.3
Though the cost of expanding access to care is significant, the
health reform’s chance of survival was significantly improved
with the $10.6 billion dollars over four years promised by the fed-
eral Medicaid waiver renewal.8 After months of negotiations, this
increase in $2.1 billion from the original waiver should allow
Massachusetts to keep all the gains made thus far in covering the
uninsured.
Employers and employer-based coverage
Mass. has a strong history of employer-based health insurance. In
2007, 72% of Massachusetts employers offered health insurance
to their employees, compared to 60% and a downward trend
nationwide. The rate was even higher for employers with more
than 50 employees, 99% of which offer coverage.9 However, few
employers offer health insurance to part time employees and most
require employees work at least half time.10
These restrictions on access to employer offered insurance histor-
ically left a large number of employed individuals without access
to health insurance. Many of these individuals and their depen-
dants sought care paid for by the state’s free care pool. Healthcare
reform has not solved this problem, and many employed individ-
uals still rely on the free care pool. Overall in 2007, employees
and dependents of employers with 50 or more employees received
publicly subsidized care for a total of $638 million in public funds.
Chapter 58 included two employer-directed provisions aimed at
optimizing the availability of employer sponsored insurance.
First, employers with more than ten full-time equivalent employ-
ees must make a “fair and reasonable” contribution toward their
workers’ health insurance or face an assessment of $295 per work-
er per year. Second, they must set up a Section 125 “cafeteria
plan” in which employees can pool their pretax dollars (including
form other sources of employment) to pay health insurance premi-
ums.1,2
The initial employer assessment of $295 was purposefully modest.
It had initially been vetoed Gov. Romney and was a significant
source of contention in passing Chapter 58. While the employer
assessments are not so robust as to create a financial burden for
small businesses, the moral hazard concern is that businesses may
either choose not to offer insurance and instead pay the assess-
ment, or may choose to alter the status of full-time employees to
part-time or change the eligibility criteria for health insurance in
order to encourage their employees to sign up for the
Commonwealth Care program. To date there is no discrete evi-
dence that this “crowd-out” of employer coverage occurs.2,3
Access to Care
The Massachusetts healthcare reform is a perfect example that
access to health insurance is not equivalent to access to health
care, though both are fundamental parts of a functional health care
system. The expansion of health insurance has had the intended
effect of reducing the impact of cost as a barrier to individuals
seeking necessary healthcare services and prescription drugs. In
the recent Urban Institute survey, fewer individuals in all income
groups reported that they did not get needed care in the past year
because of cost. For all adults, this number decreased from 17% in
2006 to 11.2% in 2007, and for adults with incomes under 300%
of poverty, the number fell from 27.3% to 16.9%.2
However, access to care goes beyond the cost of care. Overall, the
share of primary care doctors who accept new patient has dropped
to barely half, and the average wait by a new patient for an
appointment with an internist rose to 52 days in 2007 form 33 days
in 2006.11 Furthermore, the percentage of all adults and low
income adults that report not getting needed care in the past year
because of trouble getting an appointment is actually increasing.2
This could be one reason why emergency department utilization
amongst state-subsidized patients with the lowest incomes is 27%
higher than the state average.12
There is widespread recognition in Mass. that access to care is as
crucial as access to health insurance, though solutions are not
imminent. Gov. Patrick recently signed legislation that includes
provisions meant to bolster the state’s dwindling supply of
26 EMpulse • Jan-Feb 2010
HEALTHreform
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:49 PM Page 28
primary care physicians. These provisions include expansion of
training programs, loan forgiveness, and affordable housing pro-
grams for physicians who commit to working in primary care and
underserved communities in Mass., expansion of the role of nurse
practitioners and PAs in meeting primary care needs, and a focus
on alternative care models like “Medical Homes.”13
Lessons Learned
Future state or federal endeavors to expand health insurance must
heed the successes and failures of Massachusetts’ health reform.
Perhaps the most significant lesson learned is that broad health-
care reform is possible despite political obstacles. The passage of
such significant legislation required cooperation and compromise
between a Republican governor and a largely Democratic legisla-
ture. It required communication between government and business
groups, consumer advocates, hospitals, insurance companies, and
the people of Massachusetts. Bipartisan legislation and wide-
spread popular support will be crucial for the success of any
broader expansion of health insurance coverage.
Like any political compromise, there were certain sacrifices that
were made to pass Chapter 58. First, the employer assessment was
meager, which kept the business community content and may be
contributing to the lack of employer crowd-out, but which left lit-
tle authority to induce a significant number of employers to
increase the availability of employer sponsored insurance.
Furthermore, lawmakers kept with the tradition of using private
insurance companies to act as the payer.
One of the most important lessons taken from the Massachusetts
experience is that without significant financial assistance from the
federal government, states will not be able to achieve health insur-
ance expansion on their own. Massachusetts is a relatively
wealthy state with pervasive employer coverage and relatively
few uninsured. The recent failure of healthcare reform to progress
in states like California with a significantly higher number of
uninsured is a testament to the important role the federal govern-
ment will need to play in financing healthcare reform.
Along the same lines, the individual cost of health insurance plans
and the decision to exempt individuals up to 500% of poverty
from the individual mandate suggest that health insurance is cur-
rently not affordable for all Americans. Cost control will be a nec-
essary component to federal health care reform, though it is less
clear if cost control is a necessary precursor to such reform. As in
Massachusetts, the expansion of health insurance may ignite the
cost control conversation. However, many of the components of
cost control are more complex and even more politically challeng-
ing than expanding health insurance. Massachusetts has yet to
enact any meaningful cost control measures, and the failure to do
so is certain to threaten the reform’s viability.
The Massachusetts reform also serves to remind us that individual
mandates can be effective if a significant enough penalty is in
place for non-compliers. The main question is not whether indi-
vidual mandates can work, but whether they should be used at all
given the current cost of healthcare. Having an individual mandate
is supposed to bring down the cost of premiums for all by
enrolling younger, healthy individuals who would not otherwise
purchase insurance. In Massachusetts this demographic group still
accounts for the majority of the remaining uninsured.
Consequently, small group premiums in the private market have
not decreased as much as expected.
Finally, Massachusetts serves as a stark reminder that access to
health insurance is not equivalent to access to care. There are
many imprecations in the healthcare delivery system in the U.S.,
and many states are plagued with a short supply of primary care
physicians. These issues will need to be addressed to improve the
long term health of populations and decrease the long range cost
of the healthcare system.
References
1. McDonough JE, Rosman B, Phelps F, et al. The third wave of Massachusetts
health care access reform. Health Affairs 2006;25:w420-31.
2. Long K. On the road to universal coverage: impacts of reform in Massachusetts
at one year. Health Affairs 2008;27(4):w270-284.
3. Kingsdale J. Executive director’s message. Aug 25, 2008. http://www.mahealth-
connector.org/portal/site/connector
4. The New Big Dig. The Wall Street Journal Online. May 21, 2008.
http://online.wsj.com/article_print/SB121132884197208937.html
5. Turnbull N. “Individual Market Reforms: Data for a Few More Powerpoint
slides.” http://commonhealth.wbur.org/nancy-turnbull?2008/09/individual-market-
reforms-data-for-a-few-more-powerpoint-slides-by-nancy-turnbull/.
6. Healthcare reform: Overview. Mar 2008. http://www.mahealthconnector.org/por-
tal/site/connector/minueitem.d7b34e88a23468a2dbef6f47d7468a0c?fiShown=default
7. Lazar K. Mass. Gets $10.6 billion for healthcare insurance. The Boston Globe.
Oct 1, 2008.
http://www.boston.com/news/local/articles/2008/10/01/mass_gets_106b_for_healt
hcare_insurance/.
8. Dembner A. Subsidized care plan’s cost to double: enrollment is outstripping
state’s estimate. The Boston Globe. Feb 3, 2008.
9. Employers who had fifty or more employees using Masshealth, Commonwealth
Care, or the Uncompensated Care Pool in State FY07. Massachusetts Division of
Health Care Financing and Policy, May 2008.
10. Massachusetts employer health insurance survey. Massachusetts Division of
Health Care Financing and Policy, 2008.
11. Sack K. In Massachusetts, universal coverage strains care. The New York
Times. April 5, 2008.
12. Lazar K. Costly ER still draws many now insured. The Boston Globe. Oct. 6,
2008.
13. An act to promote cost containment, transparency and efficiency in the deliv-
ery of quality health care. Massachusetts State Senate Bill 2526. 185th General
Court, 2008. http:/www.Mass.gov/legis/bills/senate/185/st02/st02526.htm
EMpulse • Jan-Feb 2010 27
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:49 PM Page 29
A little over 15 years ago, I moved from
Washington, D.C. to Florida, where for
nearly all of that time I have lived in rural
small towns. In my service as the medical
director of small EDs I have noted that the
differences between urban and rural EDs
are minor.
I left behind most of the negatives of urban
living: traffic congestion, crowding, home-
lessness, and penetrating trauma. I also left
behind the concept of “Centers of
Excellence.” While I always found it hard
to know where marketing ended and real
healthcare began, I did buy into the notion
that those hospitals that did a lot of some-
thing were probably the best at it. As a
young physician recently out of the mili-
tary, I believed that evidence based medi-
cine and hospital specialization seemed
proper.
When I arrived in small town Florida I was
initially frightened by the absence of
homeless centers, local in-patient psychi-
atric care and other social safety nets. I
was shocked at the disenfranchisement and
alienation of the rural poor. I wondered at
the decreased prevalence of AIDS. But I
also noted that the majority of medical and
non-traumatic surgical cases were similar
to those in the city.
The greatest ongoing challenge I face is
recruiting ED docs: if you consider the
nationwide shortage of ED docs and the
many competing city opportunities then
this is not surprising.
Once recruited, the challenge becomes
retention. We all know how easy life is at
the hospital when your physician staff is
stable. Most of our doctors commute three
hours a day or more.
Meetings with mandatory attendance have
no place. You must rely on e-mails and fre-
quent, informal, face-to-face discussions to
discover problems, hear suggestions, and
establish policy. Whether dealing with
chart documentation or hospital politics, it
is more important as a medical director to
encourage rather than threaten ED docs.
The second greatest hassle is transferring
patients out. It is probably universally true
that receiving doctors are arrogant, curt,
and are too busy to be bothered. This all
seems more acute when you are calling
from the country. Most specialists have no
idea that broad areas of Florida don’t have
specialized care and seem to suggest that
all community docs must be idiots. Many
seem to hold me personally responsible for
this. Or maybe I am being too sensitive.
Those challenges are minor in the face of
the cordiality and collegiality I experience
in small hospitals. I remember those
debates and battles about the relevance of
EM in the 1980s. In the small rural hospi-
tals we won them all. Hospital administra-
tion often considers the ED medical direc-
tor to be principle in innovation and
improvement. An EP is able to achieve a
level of participation, activism, and author-
ity in the small community that could not
be achieved elsewhere.
Hospitals are a vital part of the business
and economics of a small town communi-
ty. They are typically among the largest
employers, offering highly skilled and
well-paid jobs. Recently I have noticed a
decentralization of healthcare, as more
complex care with the help of consultative
services like tele-radiology and tele-neu-
rology is provided locally. Few things are
more satisfying than to admit an ill, elder-
ly patient close to her family and home.
This decentralization is in part a response
to the times the referral centers have been
unavailable. This is also a reasonable
attempt by the small hospital to keep rev-
enue local: all of those well-paid hospital
employees eat at local restaurants, shop at
local stores, and use local services. Small
communities require this re-investment.
I find this all exciting. We are the docs
who pride ourselves on being able to do it
all. The small community hospital and its
ED are of the same mind.
28 EMpulse • Jan-Feb 2010
RURALem
A Perspective on Rural EM in Florida
Cary Pigman, MD, FACEP
It is probably universallytrue that receiving doc‐tors are arrogant, curt,and are too busy to bebothered. This all seemsmore acute when you arecalling from the country.
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:49 PM Page 30
Is the work you do in your ED so stressfulthat it spills into your home life? How doyou manage?
ED work can be very stressful. The ways I
like to relax are by working out and play-
ing sports. If it is too late for these activi-
ties, watching sports, spending time with
my family and a cold beer always serve as
a good backup!
- Barry Hahn, South Florida.
I rarely get stressed in the ED. I have
learned to not let things get me stressed out
while I am working. I try to keep a positive
attitude no matter how difficult or stressful
a shift might seem. If a stressful situation
arises, I work through it and then move on.
I don't let it ruin my entire shift.
- Donny Perez, Davie.
Have a question for Soundings? Pleasesend it to us at [email protected].
EMpulse • Jan-Feb 2010 29
DOCTORS’loungeSoundings
I recently testified before the Florida Board
of Nursing (BON) concerning the delivery
of Propofol for procedural sedation by reg-
istered nurses (RN).
The Florida Association of Nurse
Anesthetists (FANA) and the Florida
Society of Anesthesiologists (FSA) have
submitted language to the BON that would
trigger disciplinary action under the
‘unprofessional conduct rule’ if an RN
were to administer Propofol to a patient
that is not mechanically ventilated. The
proposed language would include all med-
ications in which the manufacture’s pack-
age insert states that only individuals
trained in general anesthesia should admin-
ister the medication. This would limit the
use of sedative agents in the ED and many
office practices around the state.
The Joint Administrative Procedures
Committee of the Florida Legislature has
voiced several concerns about the language
and its wide spread impact. They noted,
“This proposed rule affects not only nurs-
es, but other professions and entities not
regulated by the board, such as physicians,
hospitals, and surgery centers.” They also
noted, “Florida Statute authorizes regis-
tered nurses to administer medications and
treatments as prescribed by a duly licensed
practitioner authorized by the laws of this
state to prescribe such medications and
treatments.”
In 2005, ACEP and the Emergency Nurses
Association (ENA) developed a joint poli-
cy statement that supports the delivery of
medications used for procedural sedation
and analgesia by credentialed RNs work-
ing under the direct supervision of an EP.
These agents include, but are not limited
to, Etomidate, Propofol, Ketamine,
Fentanyl, and Midazolam.
In 2007, Dr. Brian Keaton, former ACEP
president, noted that “the right for nurses to
administer sedation under the direct super-
vision of a physician is supported by the
Joint Commission in standards PC 12.20
and PC 13.20.”
During my testimony, I emphasized that
there is significant evidence that supports
the safe and efficient administration of
sedatives by supervised RNs, the unique-
ness of the ED, and the special training that
EPs have in conscious sedation and airway
management. The board was encouraged
to focus on the proper monitoring of
patients rather than on medication adminis-
tration as this would go far to improve
patient safety.
By the end of the testimony, the board indi-
cated interest in making the ED an excep-
tion, given the fact that we need to perform
time-sensitive procedures to diagnose and
treat conditions as well as alleviate pain.
The board has requested that we submit a
proposal which allows the ED to adminis-
ter these medications and not restrict their
use.
FCEP has included all the above-men-
tioned medications in the ACEP-ENA joint
policy statement. We will monitor this sit-
uation closely to ensure that we are able to
appropriately care for our patients in a safe
and timely manner.
CONSCIOUSsedation
Procedural Sedation Update
Ernest Page II, MD, FACEP
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:49 PM Page 31
“Judy, do you smoke?”
It was a question that emergency physician
Tammy Cortez had asked thousands of
times in the ER. When a patient com-
plained of a cough that had been persistent
for weeks, she always asked this question.
She already knew the answer, as the smell
from Judy’s hair was telltale.
“Well,” Judy said sheepishly, “I’m down to
only a half pack a day now.”
“Since this cough has been going on for so
long,” Cortez responded, “I think we
should get a chest X-ray.”
Cortez knew, of course, that there were
many possible causes for this cough, and
she would take this logical first step now to
begin the investigation.
“Your lungs sound pretty clear right now,
so let’s see what the pictures look like.”
“OK, Dr. Cortez.”
“The X-ray Tech will come get you in a
few minutes.”
Judy nodded, and then leaned back against
the wall by her stretcher in Room 14. She
could hear a baby crying down the hall,
and she noticed someone else coughing
every minute or two. A siren that seemed
to be just a few feet away suddenly stopped
squealing. Now, it hit her for the first time:
there must be some reason for this cough...
An X-ray Tech appeared in her doorway,
smiled as he asked her name, and then
motioned for her to follow him. They
strolled quietly down the hall and into
another room, where Judy put on the thin,
cloth hospital gown.
“OK, take a deep breath and hold it,” the
Tech said after positioning Judy against the
flat surface. “Good. Now let’s get one
view from the side.”
Within a few minutes, Judy was back in
Room 14.
Cortez had just finished discharging a
patient from Room 10, and she noticed that
Judy was back in her room as she passed
by.
“I’ll check those X-rays in a minute, Judy.”
Judy produced half a smile. She really did-
n’t feel bad; it was just that lingering
cough. Surely this was just a little cold,
she hoped. She really hoped.
“Dr. Cortez, Dr. Angler is on the phone
about Room 8.” The secretary held up her
phone as Cortez rounded the corner by her
desk, then punched in the transfer.
“Hi, Bill. Tammy Cortez. Remember that
Morgan guy we talked about last
Tuesday?” For the next few minutes,
Cortez focused on arranging the appropri-
ate disposition for Mr. Morgan, and, when
she hung up the phone, she dictated a cou-
ple lines into his record.
Shifting gears quickly, she wheeled around
to face the radiology viewing monitor, and
tapped in her login and password. She
sighed as she wondered out loud why these
things have to log her off every minute that
she’s not using the system.
“What a pain.”
She pulled up the new images and double-
clicked on Judy’s chest X-ray line.
“Oh, no.”
A hollow feeling zipped across her chest;
her shoulders slumped. She pushed back
away from the pictures to scan the entire
image up and down.
There was no escaping this. The mass that
was visible in Judy’s right lung was ugly,
more than 3 cm across with irregular,
streaky edges that looked like “feelers”
reaching out. Is that mediastinum a bit
wide over there?
This was almost certainly a cancer. It was
times like this that Cortez wished the emo-
tional parts of this job were easier. Judy
was such a nice woman, a professional,
only 49 years old. Now, her life – whatev-
er was left of it – would never be the same.
30 EMpulse • Jan-Feb 2010
ERchronicles
Breaking the News
Arlen R. Stauffer, MD, MBA, FACEP
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:49 PM Page 32
And, of course, it was Cortez’ job to begin breaking the news.
Hoping to perhaps get a more optimistic twist, Cortez asked her
friend in Radiology for his opinion. “Jack, what do you think?”
she asked as he pulled up the images on his screen. Dr. Jack Miller
frowned and shook his head. Opinion delivered.
Cortez sat quietly for a moment, took a deep breath, and gathered
herself. She put the rest of the people in this ER out of her
thoughts. There were at least 10 charts representing patients in the
waiting room, and she knew that some of them had already been
here for a couple hours. They’ll have to wait.
She walked slowly to the
doorway of Room 14, took
another deep breath, and
walked in, looking Judy
directly in the eyes.
“Judy, your chest X-ray is
not normal,” she blurted
out as she sat down on the
chair beside Judy. She
paused for a moment to let
her patient react.
“What do you mean?”
There was just no good
way to say this. “There’s
an area in your right lung
that looks like a mass, a
tumor.” She paused again, not so much to await Judy’s reaction,
but rather because she just didn’t like these types of moments.
“You mean...cancer?”
“It could be, Judy. But we’re going to need to get several more
tests to be sure.”
Uncomfortable silence filled Room 14 for nearly a minute. The
look of terror on Judy’s face was, of course, what the doctor had
anticipated.
With her hand on Judy’s shoulder, Cortez continued. “Let me
make some calls to get things started right now. We’ll figure out
what we’ll need to do about this.” She tried to sound authoritative
and convincing.
Judy wiped one tear away, took a deep breath, and then looked up.
The determination on her face now was surprising and somewhat
encouraging. This was a strong woman.
“OK. Let’s get things started, Dr. Cortez.” Judy brushed aside
another tear, flinging it away as though she was angry at it. “What
do we do next?”
Cortez smiled, and leaned forward in her chair. Those other
patients in the ER would have to wait a bit longer.
Each year in the USA,
cancer of the lung is diag-
nosed in nearly 200,000
people, and more than
160,000 of them will die
from these cancers. The
most common presenting
symptoms are cough
(sometimes hemoptysis),
shortness of breath, and
weight loss, although up
to 25% of lung cancer
patients have no symp-
toms when their tumors
are discovered on routine
chest X-rays or CT scans.
Smoking is by far the main contributor to lung cancer, with near-
ly 90% of the lung cancer deaths worldwide being caused by cig-
arettes. Among male smokers, the lifetime risk of developing lung
cancer is 17%, and in females it is 11%, while it is less than 1.5%
in non-smokers. Cigarette smoke contains more than 60 known
carcinogens.
Patients who smoke should be made aware of these horrible stats.
The author is a long-time emergency physician from New SmyrnaBeach, and a former FCEP Board member and EMpulse editor.This is a revised version of one of the “Chronicles” that ran inseveral Florida newspapers a few years ago. Contact: [email protected]
EMpulse • Jan-Feb 2010 31
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:49 PM Page 33
In the U.S., cocaine abuse results in more
ED visits than any other illicit drug.1 In
2008, Florida medical examiners reported
1,791 Florida decedents where cocaine was
present, and in 36 percent of these cases,
the cocaine was considered causative.
Miami reported the most cocaine-related
deaths in Florida with 201, followed by
Orlando at 179 and Jacksonville with 165
deaths. Most of the Florida cocaine caused
decedents were male, and 35 to 50 years
old.2 Adding to the potential danger, toxic-
ity and complication of patient presenta-
tion is the presence of adulterants.
Although the effects of cocaine on the
human body have been well documented in
the literature, adulterants add an additional
component that must be considered when
assessing patients for cocaine toxicity.3,4
Cocaine is mixed or “cut” with adulterants
to increase the amount of product available
to sell and / or to augment the effects of
cocaine. The average purity of cocaine sold
at the street level is 40%, suggesting that
adulterants can represent more than half of
all cocaine sold.1 Innocuous compounds
such as mannitol and lactulose are added
because they match the appearance of
cocaine and to serve as bulking agents to
increase the available volume to be sold.
A variety of pharmacologically active
compounds have been used to adulterate
cocaine, but the agents consistently present
are lidocaine, benzocaine, caffeine, dilti-
azem, hydroxyzine, atropine, methyl-
phenidate, methylephedrine, phenacetin
and acetaminophen.5-7 Sometimes, phar-
macologically active adulterants are added
to cocaine to increase profits. For example,
stimulants and local anesthetics are added
as a cheap way to mimic and / or augment
the effects of cocaine. Other adulterants,
such as diltiazem, hydroxyzine and aceta-
minophen, are sometimes added as chemi-
cal signatures to track the distribution of
cocaine.1,5-7 This explains why a wide vari-
ety of adulterants can appear in a given
sample of cocaine. A more recent and
alarming development is the increasing use
of levamisole as an adulterant.
Since 2002, levamisole, a veterinary anti-
helminthic, has been detected with increas-
ing frequency in cocaine. By 2009, approx-
imately 70 percent of the cocaine that the
DEA analyzed contained levamisole.8
Theories on why it is being added to
cocaine include its availability as a cheap
bulking agent and for its purported ability
to increase dopamine and endogenous opi-
oids in the brain.9,10 It appears the cattle,
sheep, and pig deworming agent is being
added in Colombia and has been found in
samples of cocaine all over the world.
Levamisole had been used in humans in
the USA for a variety of dermatologic dis-
orders and rheumatoid arthritis.11 It was
FDA approved as combination therapy
with fluorouracil for the treatment of col-
orectal cancer in 1990.12 The medication
was thought to act as an “immunomodula-
tor” boosting lymphocyte activity, and as a
biochemical modulator, increasing the
pharmacological activity of other medica-
tions.13 Unfortunately, it also possesses
some toxicologic properties that prompted
its voluntary withdrawal from the market
for human use in 2000.
Its activity against pathogenic nematodes
is through a nicotinic cholinergic mecha-
nism — first causing contraction of the
worms’ musculature, followed by a flaccid
paralysis. Levamisole and nicotine are
structurally similar and both can cause
nausea / vomiting, abdominal pain,
increased salivation, tremor, CNS excita-
tion and convulsions.13 Levamisole can
cause pruritic rash, fixed drug eruptions,
lichenoid rash and necrotizing vasculitis.11
However, the most concerning toxic effect
of levamisole is its ability to destroy gran-
ulocytes.
Agranulocytosis was described when used
medically in humans and has resurfaced in
association with cocaine abusing patients
in 2009.10,14-16 The time of onset is variable,
but usually the adverse effect is reversible
upon discontinuation of the levamisole.16
32 EMpulse • Jan-Feb 2010
POISONcontrol
Cocaine Adulterants: The Cut That Can Kill
Calvin Tucker, Pharm.D., Pharmacy Practice Resident
& Joe Spillane, Pharm.D., DABAT,
Emergency Medicine Pharmacist
Shands Jacksonville
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:49 PM Page 34
Cocaine abusing patients in Alberta,
Canada presented to an emergency depart-
ment with fever, infections, total leuko-
cytes less than 3X 109 cells/L, and zero
neutrophils.10 All patients fully recovered
with antibiotics, supportive care and fil-
grastim (Neupogen), and their neutrophil
counts increased to greater than 1X
109cells/L in five to twenty days.10
Women seem to be uniquely predisposed to
levamisole induced agranulocytosis,
accounting for approximately 80% of the
agranulocytosis cases when used in cancer
patients and eight of the eleven patients
described in Canada.10,16 There is some
evidence that agranulocytosis can recur
rapidly, in some cases within hours, upon
rechallenge.14,16 This may be important
given the high rate of recidivism seen with
cocaine addiction.
Urine testing for levamisole is not current-
ly available in most EDs. However, lev-
amisole has been detected in Florida
cocaine decedents over the last several
years. The toxicity of adulterants should
be considered when treating cocaine abus-
ing patients and the toxicity of levamisole
should be considered when treating
cocaine abusing ED patients particularly
with fever and leukopenia. The Florida
Poison Information Center Network is
available 24 hours a day (1-800-222-1222)
if you have any questions with regards to
cocaine toxicity or levamisole adulteration.
References:
1. Goldstein et al. Cocaine: History, Social
Implications and Toxicity- A Review. Dis Mon
2009;55:6-38.
2. Florida Department of Law Enforcement. Drugs
Identified in Deceased Persons by Florida Medical
Examiners 2008 Report. 2008 Medical Examiners
Commission Drug Report.
3. DEA Briefs and Background, Drugs and Drug
Abuse, State Fact Sheets, Florida. www.justice.gov.
Accessed on 11/12/09.
4. Brunt et al. An analysis of cocaine powder in the
Netherlands: content and health hazards due to adul-
terants. Addiction, 104, 798–805.
5. Sellers, Kristi; Morehead, Rick. Identify and
Quantify Adulterants in Seized Cocaine. The Restek
Advantage: Turning Visions into Reality 2005 Vol. 2.
www.restek.com. Accessed on 11/12/09.
6. Behran, Alysha. Luck of the Draw: Common
Adulterants Found in Illicit Drugs. J Emerg Nurs
2008; 34:80-2.
7. Fucci N. "Unusual adulterants in cocaine seized on
Italian clandestine market." Forensic Sci Int. Oct 25,
2007;172(2-3):85-224.
8. Reuter, N. Natonwide public health alert concern-
ing life-threatening risk posed by cocaine laced with
veterinary anti-parasite drug. SAMHSA Press release
September 21, 2009.
9. Spector S, Munjal I., Schmidt DE. Effects of the
immunostimulant, levamisole on opiate withdrawal
and levels of endogenous opiate alkaloids and mon-
amine neurotransmitter in rat brain.
Neuropsychopharmacology 1998;19(5):417-427.
10. Zhu NY, LeGatt DF, Turner RA. Agranulocytosis
after consumption of cocaine adulterated with lev-
amisole. Ann Int Med 2009;150(4):287-289.
11. Scheinfeld N, Rosenberg JD, Weinberg JM.
Levamisole in dermatology: a review. Am J Clin
Dermatol 2004;5(2):97-104.
12. Moertel CG, Fleming TR, Macdonald JS, et al.
Levamisole and fluorouracil for adjuvant therapy of
resected colon carcinoma. New Eng J Med
1990;322:352-358.
13. Hsu W: Toxicity and drug interactions of lev-
amisole. Am J Vet Med Assoc 1980; 176:1166-1169.
14. van Holder R, van Hove W. Recureent agranulo-
cytosis after levamisole. Lancet 1977;1:100.
15. Williams GT, Johnson SA, Deippe PA, Huskisson
EC. Neutropenia during treatment of rheumatoid
arthritis with levamisole. Ann Rheum Dis
1978;37(4):366-369.
16. Symoens J, Veys E, Mielants M, Pinals R.
Adverse reactions to levamisole. Cancer Treat Report
1978;62:1721-30.
EMpulse • Jan-Feb 2010 33
POISONcontrol (continued from Page 28)
The Emergency Medicine Learning & Resource Center is accred-
ited through the Accreditation Council for Continuing Medical
Education (ACCME) to provide physician continued medical edu-
cation (CME). The ACCME has established a new standard for
CME based on the following four specific concepts: CME will be
focused in terms of improving competence, and/or performance-
in-practice and/or patient outcomes; CME will be a contributor to
patient safety and practice improvement; CME content will be
anchored in evidence–based medicine; CME will be independent
of commercial interests.
The process for development and presentation of CME has three
integrated components
1. Needs and Gaps
a. Establishment of the current practice - examples:
i. 2007 Model of the Clinical Practice of Emergency
Medicine (ACEP, SAEM, UAEM, CORD, RRC-EM).
ii. AOA Basic Standards for Residency Training in
Emergency Medicine.
iii. AOA Basic Standards for Residency Training in EMS.
b. Best practices – examples:
i. ACEP Clinical Policies, Studies and White Papers.
ii. AOA Clinical Policies, Studies and White Papers.
iii. NAEMSP Clinical Policies, Studies and White Papers.
c. Resulting Gaps – areas in which gaps have been found that
require specific CME to fill those gaps. These are determined dur-
ing the education program planning process from multiple
sources.
2. Design and Format – CME programs are designed to (be):
a. Reflective of learner’s scope of practice - current and/or
potential.
b. Employ formats of education that enhance the potential to
achieve and sustain improvement results.
c. Relate to national priorities for universal and specialty
physician competencies.
d. Sensitizes learner to cultural issues relating to patient care.
3. Educational Outcomes – required for every educational activi-
ty:
a. Evaluate if identified gaps were closed.
b. Document specific results in terms of improved competence,
performance, and/or patient outcomes for every CME activity.
c. Process to make regular improvements to the CME pro-
gram based on outcome analysis and scope of practice.
For more information and how you could get involved in the
EMLRC’s CME planning please contact me at
[email protected] or (407) 281-7396, ext 17.
New ACCME CME StandardsJohn Todaro, BA, REMT-P, RN, TNS, NCEE, Director/COO of the Emergency Medicine Learning & Resource Center
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:49 PM Page 35
Orlando HealthRebecca Blue, MD
Greetings from Orlando!
It’s been an incredibly productive year at
the research table, with fifteen abstracts
submitted to SAEM. In addition, attending
physician Dr. Papa is preparing for enroll-
ment of patients into her NIH funded proj-
ect. Her research is designed to evaluate
the presence of a serum biomarker corre-
lating with traumatic brain injury. We are
very excited about the initiation of this
research, and very proud of all of our
scholars - congratulations to everyone who
submitted!
It is nearly midway through our interview
season, and we have all been amazed by
the caliber of applicants this year. We can’t
wait to see how next year’s intern class
shapes up! Thanks to all of our residents
and attendings who have gone out of their
way to welcome our applicants!
Also new at ORMC, our AirCare program
will soon be assuming all 911 scene
requests for air transport and trauma serv-
ice in Orange County. I recently had the
opportunity to fly with the AirCare team,
and was more than impressed by their pro-
fessionalism and efficiency. Thank you to
all of our AirCare crews for their efforts!
We hope all of you had a wonderful holi-
day season!
Florida HospitalBrittany Thomas, MD
Seasons Greetings and a Happy New Year
to all! Towards the end of 2009, several
residents were able to get involved in
extracurricular activities.
Marshall Narquin is now a certificated
multi-engine private pilot, and Michele
Rorich placed third overall in the 4th
Annual Orlando Women’s Triathlon.
Javier Gonzalez became the alternate
board representative for EMRAF, and I had
the opportunity to walk the runway at the
Park Avenue Fashion Week in Winter Park
to benefit the American Heart Association.
Involvement in educational activities has
been plentiful as well. Many residents have
engaged in research and are eagerly await-
ing IRB approval. Also, the first-year class
participated in the 3rd Annual EKG
Symposium, and in January both classes
will attend Florida Emergency Physicians’
1st Annual Symposium on Risk
Management in Acute Care.
In other noteworthy news, Dr. Patricia
Nichols was recently named the assistant
medical director at Florida Hospital Cele-
bration. She will be greatly missed by the
residents and faculty at the East campus.
Finally, interview season has been an excit-
ing time, as it reminds us that we will soon
have three residency classes. We have had
applicants from all over the country, and
one medical student even traveled from
Ireland. We look forward to adding six new
interns to our cohesive group.
University of South FloridaJason W. Wilson, MD
As the holiday season got underway, our
recruitment season started as well. We
recently kicked off our interview season. I
had a great time having lunch with the first
batch of applicants and at the evening
social event. This also allowed all the cur-
rent residents to come together.
I really enjoyed helping out with recruit-
ment last year and now, on my second time
around, I realize it is because it gives me
the opportunity to reflect on just how great
our program is and how much it has grown
during my short time here.
Our program director, Kelly O’Keefe, MD,
FACEP, continues to make innovative
changes with new rotations and computer
tracking of evaluations and procedures,
replacing the burden of paperwork entirely.
I love the fact that my colleagues and I still
get excited talking about this program to
new people halfway into our training.
On the international front, Scott Stirling
received a scholarship to travel to India
along with several attendings to help lay
the groundwork for EM infrastructure
there.
Finally, one of our first year residents will
be returning from paternity leave shortly
after having his first child - a beautiful
baby girl that will probably grow up to
break the heart of my own six-month-old
son someday! Congratulations to Matt
Fucarino. This is a welcome addition to the
program.
34 EMpulse • Jan-Feb 2010
RESIDENCYmatters
http://www.fcep.org/emraf.htm
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EMpulse • Jan-Feb 2010 35
University of Florida, JacksonvilleOscar Espetia, MD
Greetings! We are almost halfway through
the academic year. As the year goes on we
continue to work hard and we are now in
the midst of our interview season. Here is
an update on some of the happenings at
UF/Shands Jacksonville.
Our program has been very busy this year.
Dr. DeVos was elected as the councilor for
the International Medicine Section of
ACEP. Drs. Lenhart and Gray’s project,
“ED Documentation Training in the Face
of ED Overcrowding,” won the ACEP res-
idency program Teaching Innovations con-
test. Dr. Sabato has been elected Secretary
of the ACEP Disaster section.
Drs. Lim, Dembitsky and Sabato’s
“Evaluating the Effectiveness of Didactic
Teaching and Simulator Training on the
Ability of EMS to Recognize the
Appropriate Patient for Therapeutic
Hypothermia and Implement a
Hypothermic Protocol” has been accepted
for poster competition at NAEMSP’s 2010
Annual Meeting in Phoenix, AZ. And, last
but not least, Drs.Laperouse, Forrest and
Lissoway won the ACEP National Sim
Wars competition, a repeat win for UF
JAX, go Gators!
As the year progresses, we will continue to
work hard and make strides in advancing
the practice of emergency medicine. We
look forward to seeing what the rest of the
year has planned, good luck from
Jacksonville and have a safe and happy
holiday season!
Mt. Sinai Medical CenterMarshall A. Frank, DO
We are about to pass the halfway point in
our academic year. Our interns continue to
progress, they are doing excellently in the
ED and we continue to hear fantastic
things about them from off-service rota-
tions. On the other end of the spectrum, a
lot of our seniors have already signed con-
tracts for the next year.
Congratulations are in order for several of
our residents and one of our attendings. In
November, Drs. Carlos Cao (attending),
John Yashou (PGY-IV), Philip Scumpia
(PGY-1) and Jerry Cajina (PGY-1) present-
ed a case of Purple Glove Syndrome at
Nova / Southeastern University’s research
poster competition. They placed first
amongst nineteen posters. Great job guys!
Additionally, we learned that our program
director, Dr. Beth Longenecker, placed first
in her CPC discussion at the ACOEP con-
ference in Boston. And Daniel Friedman
has been assisting with EM Days planning.
I have a correction to make on my previous
residency update. I neglected to mention
Dr. David Farcy as one of the three authors
of our ultrasound textbook. Dr. Farcy,
along with Drs. Dalley and Begleiter, has
written a tremendous emergency ultra-
sound book for our program which has
been a true asset to our learning emergency
ultrasound.
Happy New Year to all, and we hope you
had a very happy and healthy holiday sea-
son. I look forward to hearing from every-
one in 2010!
University of Florida, GainesvilleRita Fairclough, MD
Greetings from Gainesville!
As the mysterious voice in the film Field ofDreams said, “If you build it they will
come,” and come they did!! On November
1 we moved into our new state-of-the-art,
65-bed emergency department, and we are
seeing a record number of patients.
Although it has been hectic, I think we are
all happy.
We have several new faculty members and
would like to welcome Drs. Sandeep Johar,
John Slish, and Lars Beattie.
However, we also have to say goodbye to
Dr. Joel Moll, our medical director, who
will leave to join Emory University and
our previous program director, Dr. Richard
Stair, who will leave to join East Carolina
University. These two have been awesome
teachers and mentors and will be missed
terribly. We wish them the best of luck.
Our intern class has settled in. Our inter-
view process has begun and the applicant
pool is stellar. Thanks go out to Beth
Nealon, Josh Kaplan and Miles Bennett for
all their hard work. Our third years are on
the job trail and see the light at the end of
the tunnel! It seems that most of us will be
staying in the Southeast to practice.
We hope that all of you had a very happy,
healthy and safe holiday season. If anyone
is around the Gator nation in the coming
days and weeks, please stop by and visit
our new ED!
empulse-Jan-Feb-10:Layout 1 12/23/2009 3:49 PM Page 37
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
2008-09 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, contact Beth Brunner at:
Thank you!
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, FACEPWayne Barry, MD, FACEPJeffrey Bettinger, MD, FACEPDale Birenbaum, MD, FACEPBradford Bowls, MD, FACEPJohn Braden, MDMitchell David Brantley, MDKa Hang Chan, MD, FACEPGregory Chapman, MDLeonardo Cisneros, DO, FACEPCasey Corbit, MDPaul Deponte, DOJack Derovanesian, MD, FACEPSteven Eccher, MD, FACEPDonald Franklin, MDVidor Friedman, MD, FACEPVicki Friend, DO, FACEPWayne Friestad, MD, FACEPMark Frisch, MD, FACEP
Brent Gardner, MD, FACEPGary Gillette, MD, FACEPDavid Goldman, DO, FACEPReuben Holland, MD, FACEPMilan Jockovich, MD, FACEPHugh Jones, MDRodney Kang, MD, FACEPWilliam Knibbs, MD, FACEPKarl Korri, MD, FACEPRonald Koury, DO, FACEPRonald Krome, MD, FACEP(E)Mark Kruger, MD, FACEPLinh Tung Le, MD, FACEPGretchen Lipke, MD, FACEPJorge Lopez‐Ferrer, MD, FACEPMichael Lozano, MD, FACEPKaivon Madani, MDMichael Maxwell, MD, FACEPWilliam McConnell, DO, FACEP
Terry Meadows, MD, FACEPGary Mendelow, MD, FACEPCraig Mitchell, MDSteven Nazario, MD, FACEPSteven Newman, MD, FACEPPatricia Singh Nicholls, MDBrian Nobie, MD, FACEPLisa O'Grady, MDWilliam Osborn III, DOErnest Page II, MD, FACEPKetan Pandya, MD, FACEPVanessa Peluso, MDPaul Petersen, MDW. Randall Poole, MD, FACEPJohn Prairie, MD, FACEPCheryl Reynolds, MDMaritza Rodriguez, MD, FACEPCharles Sand, MDMarc Santambrosio, DO, FACEP
David Sarkarati, MD, FACEPThomas Schaar, MD, FACEPKathleen Schrank, MD, FACEPRegan Schwartz, MD, FACEPEhsan, Shirazi, MDClaire Simpson, MDWeylin Sing, DO, FACEPSiva Sivanesan, MD, FACEPSouth Miami Criticare, Inc.Richard TempelJohn Tilelli, MDBryce Tiller, MD, FACEPGeorge Tracy, MDJohn Valentini, MDDavid Vukich, MD, FACEPH. Kenneth West, MDDebra Williams, MDSusan Wolcott, MDFredric Wurtzel, MD, FACEP
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 in
2009!
Emergency Physicians of Florida
ADVOCACYnow!
36 EMpulse • Jan-Feb 2010
People for Access to Emergency Care
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