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EMpulse March-April 2010 Issue
Citation preview
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:53 AM Page 2
Haiti Disaster ResponseCONVERsations: David A. Farcy 14
Be Prepared: The Problem is Logistics 16Jay Park, MD
Fragments of a Shattered World 18Paul DePonte, DO
Really Surreal or Surreally Real 20Thomas Schaar, MD
God Doesn’t Wear Ray-Bans 21Arthur E. Palamara, MD
How Do I Really Feel? 23Joe Scott, MD, FACEP
DepartmentsPRESIDENT’Smessage 2Mylissa Graber, MD, FACEP
EDITOR’Semergencies 4Leila L. PoSaw, MD, MPH, FACEP
GOVERNMENTALaffairs 6Steve Kailes, MD, FACEP
EMS/trauma 8Michael Lozano, MD, FACEP
MEDICALeconomics 10Ashley Booth, MD, FACEP
PROFESSIONALdevelopment 12Kerry Neall, MD, FACEP, MPH
On Being Your Own Best Expert 24Kenneth Schultz, MD, MBA, FACP, FACEP
Notes on ACEP Sections 25Andrew Bern, MD, FACEP
FREESTANDINGemergency departments 28
CLINICALcase: The Young Lady With the Numb Leg 29Dan Grenier, DO
ERchronicles: On the Day of Judgment 30Arlen Stauffer, MD, MBA, FACEP
POISONcontrol 32Adrienne Perotti, Pharm.D.
DOCTORS’lounge 33
RESIDENCYmatters 34
ADVOCACYnow! 36
Florida College of Emergency Physicians
3717 South Conway Road
Orlando, Florida 32812-7606
(407) 281-7396 • (800) 766-6335
Fax: (407) 281-4407
www.FCEP.org
Executive Committee
Mylissa Graber, MD, FACEP • President
Amy Conley, MD, FACEP • President-Elect
Vidor Friedman, MD, FACEP • Vice President
Kelly Gray-Eurom, MD, FACEP • Secretary/
Treasurer
Ernest Page II, MD, FACEP • Immediate Past
President
Beth Brunner, MBA, CAE • Executive Director
Editorial Board
Leila PoSaw, MD, MPH, FACEP • Editor-in-Chief
Michael Citro • Managing Editor
Cover Design by Michael Citro / Leila PoSaw
All advertisements appearing in the Florida
EMpulse are printed as received from the
advertisers. Florida College of Emergency
Physicians does not endorse any products or
services, except those in its Preferred Vendor
Partnership. The college receives and distrib-
utes employment opportunities but does not
review, recommend or endorse any individu-
als, groups or hospitals that respond to these
advertisements.
Published by:
Franklin Communications, LLC
5301 Northwest 37th Avenue
Miami, Florida 33142-3207
Tel: (305) 633-9779 • Fax: (305) 633-2848
www.frankgraph.com
NOTE: Opinions stated within the articles con-
tained herein are solely those of the writers
and do not necessarily reflect those of the
EMpulse staff or the Florida College of
Emergency Physicians.
EMpulseVolume 15, Number 2
EMpulse • Mar-Apr 2010 1
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:53 AM Page 3
We can’t solve problems by using the same
kind of thinking we used when we created
them - Albert Einstein.
It is interesting that in all of these efforts to
reform healthcare no one wants to address
the issue of medical liability reform and
the real cost to healthcare of defensive
medicine. It is hard to quantify that cost. It
is not obvious, as every day we order tests
based on fear of litigation. What if this is
that one patient with the intracranial hem-
orrhage without loss of consciousness?
The family is demanding it, so I may as
well just get the test, rather than explain to
them again and again why it is unneces-
sary, which despite all my efforts will still
end up with a complaint to administration
and likely repeat visits.
We don’t usually write on our charts, “rea-
son for test - fear of litigation.” This is the
best kept secret and the most obvious real-
ity for those of us who make these deci-
sions every day. We practice defensively
because of our fears, which sadly are also
based in reality. The reality is stopping all
this unnecessary testing could save bil-
lions.
As most of government is controlled by the
legal profession, we physicians are at an
enormous disadvantage. Most legislators
are lawyers, so amazingly most healthcare
reform decisions are being made with very
little physician input. We are always stand-
ing on the sidelines trying to get a seat at
the table because of our smaller number of
participants and smaller monetary contri-
butions. We have no control over a system
that cannot survive without us and we are
best to determine what works and does not
work. Yet, individuals who directly bene-
fit monetarily from suing physicians, hos-
pitals, and health insurance companies are
the ones making all the decisions under the
guise of protecting people’s “access to
courts.”
I think this is our own fault. Physicians
notoriously do not support each other, do
not help their colleagues get elected to
office, do not contribute money, and do not
work well together. We continuously point
fingers at each other rather than working
together to address problems. This works
to the advantage of other groups, that bank
on the fact that physicians do not work well
together. This in turn keeps us from being
in charge of our own profession and from
driving healthcare, which is really what we
should be doing.
What we all need to realize is that getting
involved is not optional. It needs to be as
much a part of our practice as treating high
blood pressure. Why so? Because every
day there are groups and individuals chip-
ping away at what you are allowed to do,
what tests you can order, what and how
you will be paid and what skills you are
required to have to practice. The end result
will be a chaotic healthcare system with
very little physician involvement and con-
trol. The obvious next move will be to
make us all just highly educated govern-
ment employees who can be sued for any
little perceived mistake.
Or maybe we can change our way of think-
ing. We can participate, contribute money,
and help our friends get elected. We could
make sure our voices are not only heard but
that we help drive the change. You don’t
have the luxury anymore of just burying
your head and letting this be someone
else’s problem. Some of us get it and are
involved and contribute, but that small
group is only so strong and the burden is
becoming bigger and bigger. We need
everyone’s help. If we all carried a little of
the burden we could be so much more suc-
cessful than having a few carry us all.
You can be a part of the process and con-
trol your own future, or you can continue
to ignore it and let cards fall where they
may and just have to deal with the conse-
quences. That choice is up to you.
2 EMpulse • Mar-Apr 2010
PRESIDENT’Smessage
On Physician Control
Mylissa Graber, MD, FACEP
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In this issue we are honored to share the
experiences of those Florida physicians
who courageously went forward to help
those in great need: the people of Haiti.
The 7.0 earthquake in Haiti struck the cap-
ital city of Port-au-Prince where almost a
third of Haiti’s nine million people live. It
flattened the UN headquarters, killing
dozens of employees, brought down the
Presidential Palace and the National
Cathedral, and killed the archibishop and
several senior politicians. It wiped out
neighborhoods with shoddy, makeshift
houses, wrecked the port, hospitals, and
airport, and cut the power and phone serv-
ice. The country not only came to a com-
plete standstill, but was too paralyzed to
help itself.
An article I read sums it well: “Haitian his-
tory is a chronicle of suffering so Job-like
that it inevitably inspires arguments with
God, and about God. Slavery, revolt,
oppression, color caste, despoliation,
American occupation alternating with
American neglect, extreme poverty, politi-
cal violence, coups, gangs, hurricanes,
floods – and now an earthquake that
exploits all the weaknesses created by this
legacy to kill tens of thousands of people.”
(Packer G. Suffering, New Yorker. Jan 25,
2010)
The disaster response involved not only
militaries, government agencies, interna-
tional aid organizations, but also a large
civilian response in the form of faith based
organizations and individuals. And our
Florida physicians were everywhere!
Dr. Joe Scott was deployed with the
National Disaster Medical System and tells
us how he really feels. Dr. Paul Deponte
worked at the Adventist hospital in
Carrefour and Dr. Tom Schaar volunteered
at the Haiti Community Hospital at the
request of a missionary group.
Dr. Palamara tells of how a single day in
the life of a disaster can be life-changing
experience. Dr. David Farcy and Dr. Seth
Marquit jumped on a plane and joined a
group working in a tent outside the
Presidential Palace. Based on his experi-
ences in a makeshift hospital connected to
the UN, Dr. Jay Park advises us it is best to
be prepared.
I work with Dr. Jean Daniel Pierrot, an
emergency physician, who remembers the
time when he was growing up in Haiti.
Parents were stern, schools were strict, and
drugs had not infested the country. This
was before universities closed and corrup-
tion became rampant. Proud of his Haitian
heritage, Dr. Pierot believes that now is the
perfect time to rebuild the country despite
all odds. With help from the international
community, Haiti needs to take charge of
its future; a future that will preserve the
essence of Haitian culture while improving
the lives of the people.
It is believed that the best way to help is by
monetary contributions, rather than by
donating food and clothing. Now is the
time for us to reach deep into our hearts
and pockets. Dr. Laurent Dreyfus has
asked for donations to the L’Hôpital de la
Communauté Haïtienne, a hospital in the
Fréres Neighborhood of Petion-Ville. His
family helped found and run this hospital.
Details can be found in the Doctors’
Lounge.
Recently, I had a busy shift. I pronounced a
young man dead after extensive resuscita-
tion efforts, intubated a mentally ill man
who had overdosed, refilled grandma’s
prescriptions, talked a young lady through
an ongoing miscarriage, and took care of
Engelbert. He was due to sing in front of
3,000 people in a concert which would last
over four hours, and he needed help. I
hummed “The Last Waltz” for the rest of
the day.
You probably recognize this as your shift.
We all have our Engelberts. We make the
perilous decisions of life and death which
cut through the stress of the patients over-
flowing into the hallways. Just as we reach
our limits, there is that unexpected thank
you or Engelbert. That unanticipated twist
to our day, that makes it all worthwhile.
I, like many other physicians did not go to
Haiti, but I salute those who did. I also
salute those who stayed home and took
care of Engelbert.
EDITOR’Semergencies
Leila L. PoSaw, MD, MPH, FACEP
4 EMpulse • Mar-Apr 2010
Haiti and Engelbert Humperdinck
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The action in Tallahassee is heating up and
it is difficult to keep pace with the shifting
landscape of filed bills and the ongoing
process of changes. However, we are
using a team approach and have noted sev-
eral key areas to target during the 2010 leg-
islative session.
Perhaps the most concerning bill is an
effort to ban the practice of “balance”
billing patients for charges not paid by
their commercial insurance carriers to non-
participating medical providers. We see
this as potentially disastrous for EPs for
several reasons, including: 1) this will
undercut any negotiating power we have
with commercial carriers when attempting
to become a participating provider; 2) we
are powerless to preemptively steer these
patients away from our practices given cur-
rent laws; 3) we will have to struggle to
receive fair payment for our services from
commercial carriers; and 4) we can antici-
pate such a ban will lead to a further reduc-
tion of available specialists for ED on-call
services. The result will likely be inability
to support adequate EM staffing and serv-
ices, a potential exodus of providers from
the state, and decreased patient care quali-
ty.
Well, that is the bad news. The good news
is that we are actively engaging the legisla-
tors and the state’s Consumer Advocate
(who has been very supportive of this ban)
to point out the severe challenges it will
create and we see that many of them are
listening to our concerns. We are educat-
ing them how every EP already provides
on average (data from the AMA) approxi-
mately $138,000 of uncompensated care
annually (almost four times as much as any
other specialty). In addition, we are not
able to turn away patients based on their
insurance coverage, as can most other
practices in medicine. This proposed ban
amounts to an additional mandate for us to
provide unfunded/under-funded care and it
will erode the already weak foundation of
our state’s medical safety net.
We are pursing multiple avenues towards
medical liability / tort reform.
Representative Renuart and Senator
Thrasher have filed bills seeking sovereign
immunity protections for providers of
emergent care falling under EMTALA and
the Access to Care laws. The argument
being that we (and our on-call specialists)
are essentially acting as agents of the state
as we are compelled to provide care
regardless of injury, illness or ability to
pay. Though this unfunded mandate might
be a natural and welcome calling for doc-
tors to heal the sick, it also places an unfair
burden on us to provide care in inherently
higher risk situations. Interestingly, data
has shown that statewide our malpractice
premiums have decreased since 2003, but
are still higher than the rest of the country.
Healthcare reform efforts continue on the
state level. One idea is to create a “medical
home” for Medicaid patients to help coor-
dinate primary care needs and decrease
low-acuity usage of EDs for problems that
could be cared for in a primary care setting,
so long as the patients have access to that
care. Dr. Vidor Friedman recently spoke in
Tallahassee before a House select commit-
tee considering ways to reduce and control
Medicaid costs. He represented us well by
educating attendees on the unique role of
EPs in delivering care to the patients in
Florida.
We are pursuing other issues. We will sup-
port legislation that attempts to improve
public safety, including a ban on texting
while driving and another mandating the
use of child booster seats. However, we
are wary of a bill intended to require physi-
cians to report patients with conditions that
may impair their ability to drive. We
believe this may not be the best approach
to the problem and will work to refine it.
We need your help in the coming months
and hope you will join our efforts to
improve our practice and care provided to
our patients.
6 EMpulse • Mar-Apr 2010
GOVERNMENTALaffairs
Steve Kailes, MD, FACEP
The good news is that we
are actively engaging the
legislators and the state’s
Consumer Advocate.
Tallahassee Action
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With a full range of support services for hospital- based physician groups, we take care of the everyday administrative worries so you can have more time for your patients and yourself.
Our services include:
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For those who have heard me speak on ED
flow, you know that I use the terms “first
and second seating.” Yes, this is my
favorite metaphor – the ED as a restaurant,
and the funny thing is that the first seating
occurs around lunch time. In my ED,
things are quite manageable first thing in
the morning, but mid-morning (first seat-
ing) you get an influx of ambulatory and
EMS patients. The second seating occurs
around six, the next big influx. Indeed, it
makes you wonder whether ambulance
crews are lured in by the cafeteria.
Depending on where you are in the state,
you get a motley crew from single or mul-
tiple EMS agencies. Some are private enti-
ties but most are fire department based.
Paramedics vary in their clinical acumen:
most are good and some are even quite
sharp. Some earnestly provide care and
have a genuine thirst for knowledge, while
others are quite burned out and cynical. For
many EPs, bedside interactions with EMS
constitute the full extent of their experi-
ences, and it is easy to come to the conclu-
sion that this is all there is to pre-hospital
care. The reality is that EMS in Florida is
very complex.
The Bureau of EMS at the Florida
Department of Health is tasked with the
management of the state’s EMS. It is statu-
torily required to biennially develop and
revise a comprehensive state plan for basic
and advanced life support services. The
plan needs to have at a minimum: (a) EMS
systems planning, including pre-hospital
and hospital phases of patient care, injury
control efforts, and the unification of such
services into a total delivery system to
include air, water, and land transport; (b)
requirements for the operation, coordina-
tion and ongoing development of EMS
services (including BLS or ALS vehicles,
equipment, and supplies; communications;
personnel; training; public education; the
trauma system; injury control; and other
medical care components); and (c) the def-
inition of areas of responsibility for regu-
lating and planning the ongoing and devel-
oping delivery service requirements.
The Emergency Medical Services
Advisory Council (EMSAC) advises the
Bureau of EMS. The 11 duties of EMSAC
are listed in chapter 401.245 of the Florida
Statutes, and include “providing a forum
for planning the continued development of
the state’s emergency medical services sys-
tem through the joint production of the
emergency medical services state plan.” At
their most recent meeting in Daytona
Beach, the EMSAC approved the Florida
EMS Strategic Plan 2010-2012. The plan,
which can be downloaded from
www.flems.com/Stratplan/stratplan.htm,
goes into effect in July.
Many of you have been exposed to or even
participated in strategic planning sessions
with your EM groups or hospital. These
sessions center on a SWOT analysis and
give the organizational leaders a chance to
review their mission, vision, and values.
For their strategic planning sessions, the
EMSAC and Bureau brought together rep-
resentatives and interested parties from the
24 constituency groups that comprise the
EMS community.
These groups represent a broad spectrum
of EMS, and include the Quality Managers
Association, EMS Dispatchers, Air
Medical Association, Association of
Trauma Agencies, Association of County
EMS, Air Medical Pilots, Association of
Trauma Coordinators, Association of EMS
Educators, Professional Firefighters, EMS
Medical Directors, Ambulance
Association, Neonatal Transport Nurses,
Rural EMS Association, US Lifesaving
Association, Air & Surface Transport
Nurses Association, Fire Chiefs,
Emergency Nurses, and EMS for Children
(EMSC). This list, although not compre-
hensive, gives you a sense of the players
that routinely sit at the table when EMS
issues are discussed.
The EMSAC’s mission is to facilitate, pro-
mote, and ensure the best pre-hospital care
to the residents and visitors of Florida.
Their vision is to become a unified EMS
system that provides evidence based pre-
hospital care and serves as the recognized
leader in EMS response nationwide.
In the next installment, we will review the
seven goals of the new strategic plan and
relate them to your ED practice.
8 EMpulse • Mar-Apr 2010
EMS/trauma
Michael Lozano, MD, FACEP
The State of Florida EMSPart 1 of a Series
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The United States uses the ICD-9 code set
to report diagnoses and inpatient proce-
dures. “ICD-9” stands for the World Health
Organization’s International Classification
of Diseases, Ninth Revision, Clinical
Modification (ICD-9-CM), implemented
in 1979, more than 20 years ago.
The Dept. of Health and Human Services
(HHS) announced the compulsory replace-
ment of the ICD-9 code set with ICD-10
from Oct. 1, 2013 for all encounters and
discharges. The regulation doesn’t allow
for use of ICD-10 codes prior to the 2013
start date. The Current Procedural
Terminology (CPT) and Healthcare
Common Procedure Coding System
(HCPCS) will continue to be the code sets
for ambulatory procedures.
ICD-10 will require significant clinical and
administrative systems changes. From an
administrative perspective, ICD-10 is very
specific and involves a greater number of
codes. Diagnosis codes increase from
14,000 to 68,000 in ICD-10-CM while the
procedure codes increase from 4,000 to
87,000 in ICD-10-PCS. For Diabetes
Mellitus alone, there are five categories in
ICD-10, E08-E13, with 203 codes. In addi-
tion, there are structural differences that
will make the conversion complex. While
the ICD-9-CM diagnosis codes are 3-5 dig-
its in length, the ICD-10-CM codes are 3-7
alpha numeric characters long. While the
expanded characters of the ICD-10-CM
codes specifically identify disease etiology,
anatomic site, and severity, the change will
require system upgrades and changes.
As EPs we will need to be more detailed
and specific in our chart documentation so
that the coder is able to select the appropri-
ate code. The non-specific diagnosis codes,
such as chest pain and hypertension, will
still be included in ICD-10 but it is predict-
ed that the majority of payers will not
accept these. For practices that currently
bill many non-specific codes, this will be a
big change. The concern is that there will
be a learning curve for providers after
implementation. Even with good docu-
mentation training prior to implementation
there could be as much as a 15-20%
decrease in coding/billing productivity.
Potential delays or denials of claims could
result in significant reimbursement issues.
Here are steps published by the AMA that
will help you prepare for the conversion:
1. Identify your current systems and work
processes, either electronic or manual, in
which you use ICD-9.
2. Talk to your current practice manage-
ment system vendor.
3. Talk to your clearinghouses or billing
service.
4. Talk to your payers about possible
changes to your contracts as a result of
implementing ICD-10.
5. Identify potential changes to existing
practice work flow and business processes.
6. Identify staff training needs.
7. Test with your trading partners, e.g.,
payers and clearinghouses.
8. Budget for implementation costs,
including system changes, resource materi-
als, consultants and training.
It is believed that ICD-9 codes are outdat-
ed and that the more specific ICD-10 codes
will provide better data for identifying
diagnosis trends, public health needs, epi-
demic outbreaks, and bioterrorism events.
Also, it is believed that the new codes will
provide potential benefits through fewer
rejected claims, improved benchmarking
data, improved quality and care manage-
ment, and improved public health report-
ing. Hope this helps a little with the
changes ahead. Please feel free to contact
me if you have any questions.
AMA web site: www.ama-
assn.org/ama1/pub/upload/.../icd9-icd10-conversion.pdf
WHO web site:
www.who.int/entity/classifications/help/icdfaq/en/index.html
Moderate Sedation and NCCI (National
Correct Coding Initiative)
Effective 10/1/2009, the following codes
are bundled with our ED E/M level codes,
99281-99285, as well as many other proce-
dures that may be provided in the
Emergency Department: 99148, 99149 and
99150.
These codes are for moderate sedation
services provided by a physician other than
the provider performing the procedure. In
NCCI the bundles for 99148-99150 have a
0 modifier, which means you cannot
unbundle the sedation under any circum-
stances or with any modifier (example, -
59). Bill only the ED E/M level.
Make sure your coding conforms to each
insurer’s policy by double-checking your
NCCI edits and your payer contracts. You
can purchase a book with the NCCI edits
for $600 or you can download the edits
from CMS for free. Go to:
http://www.cms.hhs.gov/NationalCorrectC
odInitEd/ Click on “NCCA
Edits–Physicians” in the left column. -
Lynn Reedy
10 EMpulse • Mar-Apr 2010
MEDICALeconomics
Ashley Booth Norse, MD, FACEP
Preparing for the Conversion
from ICD-9 to ICD-10
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:53 AM Page 12
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EM is one of the most challenging careers.
We are constantly being drained of our
energies - physically, emotionally and spir-
itually. We are challenged by our adrena-
line-driven jobs, shift work which inter-
rupts our sleep cycles and family lives, and
a frenetic and hectic work pace which
allows us no quiet reflective time. To be
able to provide top quality and efficient
care to our patients, we must take care of
ourselves. Sacrificing our health, relation-
ships, and spiritual connectedness are not
worth the price of our careers. If we are not
mindful of the pitfalls, our lives and
careers in EM will rapidly unravel. Thus,
a discussion on how we can purposefully
make positive changes is worthwhile.
Many of us have made recent New Year’s
resolutions. If not, it is not too late to do
so. Studies have shown that between 40 to
45% of American adults make one or more
resolutions each year. The top three New
Year’s resolutions are to lose weight, to
implement an exercise program, and to
stop smoking. Also popular are resolutions
dealing with better money management
and debt reduction.
Unfortunately, how many of these are
maintained as time goes on? It has been
shown that only 75% are maintained past
the first week, 71% past the first two
weeks, 64% past one month, and 46% for
more than six months.
While a lot of people who make New
Year’s resolutions do break them, research
shows that making resolutions is useful.
People who make resolutions are 10 times
more likely to attain their goals than people
who don't make resolutions. The following
seven steps are suggested for setting and
reaching personal goals:
1. Stay focused – Keep the broader goal in
mind. Don’t get bogged down in the details
and lose sight of your larger goals. Writing
down goals with specifics of what we want
to accomplish helps us to review them and
adjust our progress to be sure we reach
them.
2. Set realistic expectations – Small goals
are more valuable than brooding over
impossible expectations. Remember “it’s a
cinch by the inch, but it’s hard by the yard
and a trial by the mile!” Little steps lead to
big victories.
3. Expect challenges – We will all make
mistakes. Turn them into victories by
learning from them, adopting new strate-
gies and growing in wisdom. Mistakes are
the greatest stepping stones to achieving
our goals if we refuse to be defeated by
them.
4. Maintain a positive attitude – Check
negative thoughts. Envision the final
results. We have the ability to choose how
we think and feel about a situation.
Cultivate thankfulness, optimism, and trust
in a higher power.
5. Seek support and accept responsibility –
Spend time forming relationships with
people who have positive life skills. We
become what we surround ourselves with.
Social ties create mutual accountability,
and build responsibility and consistency in
our lives.
6. Practice new choices – Remodeling is a
process that takes place over time. Fast is
fragile, but slow is steady, stable and
comes with maturity over time. It is the
very slow steady process of repeatedly
making positive choices that builds mind,
body and spirit. Repetition and patience
are the keys to crafting a healthful lifestyle.
7. Connect – The best of intentions can
plunge without the quiet, reflective time
needed to connect with the power beyond
ourselves. Set aside time for prayer, self
reflection, and the reading of devotional
materials. This will connect us to positive
change.
Let’s make 2010 a year of change. At the
year’s end, we will be able to look back
with satisfaction at the positive changes we
have made, being more whole in the many
facets of our lives!
12 EMpulse • Mar-Apr 2010
PROFESSIONALdevelopment
Kerry Neall, MD, FACEP, MPH
Empowering our Lives with Resolutions
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:53 AM Page 14
FCEP Welcomes its New Members
James Calabro, MD
Francis Castano, MD
Andre Creese, MD FACEP
Steve Hilwa, MD
Marcia Hoffheimer
Daniel Kemple
Andrew Morris
Michael Mozzetti, MD
John Slish, MD
Larry Zaret, DO, FACEP
Recently Moved Into Florida
Mary Allen, MD
Teresa Berridge, MD, FACEP
Mark Caraker, MD
Karlene Chin, MD, FACEP
Stephen Dannewitz, MD, FACEP
Marc Deshaies, MD, FACEP
Adriano Goffi
Michael Heck
Sitha Mangipudy
Chris McAdams
Aaron Mickelson
Betty Peirsol, MD
Jessica Silversmith, MD
Pablo Smester, MD
Courtney Smiley
FCEP Honors Emergency PhysicianGroups with 100% Membership
All Children’s Emergency Center PhysiciansEmergency Medicine ProfessionalsEmergency Physician Enterprises
Florida Emergency PhysiciansSouthwest Florida Emergency Physicians
Tampa Bay Emergency PhysiciansUniversity of Florida
University of Florida, Jacksonville
Earn recognition for YOUR group by encouraging 100%participation in FCEP!
We all know that membership numbers are important.
The more FCEP generates in membership revenue, the
more good we can do for our members through advocacy
and other membership benefit programs. With that in
mind, the Florida College of Emergency Physicians would
like to salute the above groups for achieving 100% mem-
bership.
BRIEFLY...
FCEP Member Benefits Updates
Disability Insurance Partnership
The Florida College of Emergency Physicians is proud to announce
a new benefit program for our association members. We have
developed a program to offer disability insurance for our associa-
tion members at greatly reduced rates. Through an extensive
review process and due diligence, the board is proud to partner with
Professional Disability Insurance Specialists, LLC. Professional
Disability Insurance Specialists has a wealth of experience in the
disability insurance market and working with emergency physi-
cians. Their knowledge, experience and expertise will be a great
benefit to you.
Professional Disability Insurance Specialists can create a personal
and customized disability insurance plan that will meet your needs.
Physicians affiliated with our association will have options avail-
able for portable, individual, own- occupation policies at reduced
rates. PDIS has developed a program specifically tailored for
FCEP members with an A+ rated insurance carrier.
According to David B. Jablon, President of Professional Disability
Insurance Specialists, the mission and goal that PDIS sets out to
accomplish is to provide the most comprehensive and quality cov-
erage available to you as an association member. Mr. Jablon states
disability insurance is the most overlooked and underrated insur-
ance- until it is needed.
The Florida College of Emergency Physicians, as an association, is
constantly striving to provide meaningful and discounted benefit
programs for our members. We believe disability insurance is an
extremely important benefit for our members. We are excited about
our partnership with PDIS and offering the best benefits for our
members.
If you have any questions about this new program please contact
PDIS at phone number 561.499.7737 or electronic mail
Wealth Management Services
TEG Partners, a division of Detwiler Fenton & Co. (formerly The
Eaton Group of UBS Financial Services), has renewed its commit-
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EMpulse • Mar-Apr 2010 13
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:53 AM Page 15
EMpulse: Tell us a little about yourself?
David A. Farcy: I am Dr. David Farcy. I
trained at the Maimonides Medical Center
and did a fellowship in critical care at the
University of Maryland Shock-Trauma
Center. Prior, I was a paramedic for four
years with the US Air Force. I am very
interested in pre-hospital and disaster med-
icine. When the earthquake hit Haiti, I was
supposed to go with the DMAT team, but
this was held up. I waited and waited and
got frustrated. I decided to jump in a plane
and see what I could do.
EMPulse: How does this compare with the
other disasters you have been involved
with?
DF: I worked at Hurricane Andrew that hit
South Florida in 1995, the earthquake in
Mexico City in 1996, Hurricane Mitch in
2002, and September 11, 2001. The major
difference between those disasters and this
one in Haiti is the magnitude of the dam-
age. The former involved only a section of
a town or a country. For example,
Hurricane Andrew involved only
Homestead; Miami Beach and downtown
suffered some broken windows and loss of
light for six days. We arrived in Haiti and
there was no sense of normality. There is
complete mass destruction in the entire
country. And that is pretty shocking.
EMpulse: Do you feel that the disaster was
managed well in Haiti?
DF: The overall response was very chaot-
ic. Each country sent its own team, and
though they saved lives, teams did not have
a unified task or goal and lacked communi-
cation with each other. There was little
communication between the military
teams, the UN, the government and the
massive civilian response.
EMpulse: Do you think that communica-
tion is a major problem in Haiti and simi-
lar disasters?
DF: In September 11, we all lost commu-
nication after the first tower collapsed.
There were no cell phones and this led to
more injuries. If we had better communica-
tion we could have been better warned and
more people could have been saved.
During Katrina, the civilian response was
more powerful than FEMA. In Haiti too,
there is a massive civilian response of mis-
sionary and other groups. The French mili-
tary arrived in 14 hours, the US military in
8 days, and the civilian response acted
sooner than both. So how do we all com-
municate? I don’t have an answer to this.
One of the first things I would have done is
to map the city with the location of treat-
ment centers and MASH units. With the
help of cell phones and GPS, we can coor-
dinate medical treatment.
EMpulse: What was the role of the govern-
ment of Haiti?
DF: The president of Haiti and the heads of
State survived. They have a formal com-
mand structure. It focuses mainly on safe-
ty.
EMpulse: Is there a larger role for inter-
national organizations?
DF: I am originally from France and I have
traveled a lot. We live in one globe with
CONVERsations
On the Haiti DisasterA conversation with David A. Farcy, MD
14 EMpulse • Mar-Apr 2010
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:53 AM Page 16
(Continued from previous page)
easy access. In disaster medicine, there is
no single country and all countries have an
obligation. There should be an umbrella
organization like the UN which is capable
of coordinating efforts. The UN did do this
to some degree.
EMpulse: What prepared you for this
experience?
DF: I am a Buddhist. I belong to a cadre of
physicians who are chameleons. We are
able to do multiple things in the most
stressful of environments with minimum
resources. Overall, I don’t think I was pre-
pared. Though my military training kicked
in and I went into survival mode, this was
more than anything I could have imagined.
Pictures are flat and have no emotions.
When you see a two year old orphan crying
in front of his crumbled house there is no
picture that can describe what you feel.
EMpulse: What is the best way for people
to volunteer in Haiti?
DF: The humanitarian effort will be need-
ed for years. Project Medishare (pro-
jectmedishare.org) at the University of
Miami has short schedules; Project Hope
(projecthope.org) needs a three-week com-
mitment while Doctors without Borders
(doctorswithoutborders.org) and Doctors
of the World (dowusa.org) need a three-
month commitment.
EMpulse • Mar-Apr 2010 15
CONVERsations
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:53 AM Page 17
16 EMpulse • Mar-Apr 2010
Logistics is the word I heard often in Haiti.
The logistics of managing supplies,
resources, volunteers and transportation
was probably the reason that so many
earthquake victims unnecessarily died and
are still currently suffering. One would
believe, after having volunteered in Haiti,
that this was the first earthquake disaster
ever experienced by the world. There are
many specific problems unique to Haiti
that contributed to the difficulties of deal-
ing with the aftermath of the 7.0 earth-
quake. However, the lack of disaster and
logistical preparedness is by far the largest
contributor.
I volunteered at a makeshift hospital with
connections to the UN where we had only
one functioning blood pressure cuff for
over 150 inpatients. Trying to do my best
with inadequate supplies, I was assailed
with many logistical questions. Why did
our hospital at the UN base located next to
the airport lack basic supplies? Why was
there a shortage of disaster specific sup-
plies such as bone saws for our orthopedic
surgeons? Didn’t we learn from other
earthquakes to include supplies for emer-
gency amputations? Why was transporta-
tion of supplies and patients between med-
ical facilities and the airport such a prob-
lem, when I slept in a tent on a parking lot
full of unused UN trucks and buses?
I was frustrated that our hospital and so
many other hospitals in the area were lack-
ing essential supplies and support. We
should have been prepared. We should
already have the knowledge from other
disasters of what logistical support is need-
ed to deal with the after effects of this or
any other earthquake.
This is not a critique of the UN or the many
well-intentioned volunteer organizations in
Haiti, by any means. However, this is a
good reminder for us to review our disaster
planning and for us to reassess our readi-
ness. In this information age, the resources
needed for adequate disaster planning are
readily available. We just have to be pre-
pared to use them.
Most of our hospitals and medical prac-
tices have a disaster manual with protocols
to follow when a disaster strikes. The hos-
pitals and the city departments of New
Orleans also had disaster manuals and
plans in place. They thought that they
were prepared with adequate food and sup-
plies. In the aftermath, it became evident
that they had been ill prepared which
resulted in countless logistical problems.
Now let me ask you, when was the last
time you looked at your disaster manual?
When was the last time you exercised a
practice drill? Are you prepared for a dis-
aster that overwhelms your hospital and
public health system?
The Israeli military came to Haiti and set
up a fully functional hospital with x-rays,
operating rooms, a NICU, and everything
else that is needed for a proper medical
facility within half a day. Granted that they
were a military unit, but they succeeded
because they were equipped and practiced.
The officer in charge told me that they
were not as efficient and properly equipped
during their other deployments to the
tsunami hit areas and other earthquakes.
After those experiences, they learned to
fine tune their operation and to find ways
around common logistical problems.
Others could follow their example.
Let’s not complain about the problem of
logistics after a major disaster comes bar-
reling down Florida. How about if we
review that dusty disaster manual and get
prepared now?
HAITIdisaster
Jay Park, MD
Be Prepared: The Problem
is the Logistics
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:53 AM Page 18
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empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:53 AM Page 19
Just to go home is an all day wait for any
available flight. I leave Port-au-Prince on a
single-engine propeller plane, five-and-a-
half hours scrunched in the back with three
others. I reflect on my last seven days at
the Adventist Hospital in Carrefour,
approximately a mile from the epicenter of
the earthquake that crushed Haiti.
On that first ten mile ride from the Port-au-
Prince airport to the hospital, I witnessed
destruction: crushed buildings; cars leveled
to the ground; large piles of cement and
debris; tents and makeshift homes all over
the street. At an intersection, on the traffic
island, someone had built a shelter. I
remember thinking that some crazy vehicle
could actually run over one of those pre-
carious makeshift tents. Large fires blazed,
which smelled of burning rubber. The
atmosphere was like a sauna with a
stopped-up toilet, very hot and very humid.
Large crowds thronged the street, along
with lots of police and military vehicles
from the United Nations, United States and
France. It took what seemed like all day to
travel those ten miles.
We were taken to the back of the hospital.
I noticed goats and chickens roaming
freely, a fire of burning garbage, and lots of
human excrement lying around. We were
given a hallway on the second floor: we
would sleep here on the cement floor, with-
out beds, functioning toilets, or running
water.
I arrived at 4:30 p.m. and was informed
that I was already scheduled to work the
night shift. Feel free to rest and meet for
sign-out rounds at 5 p.m. The “emergency
department” was a series of three open
rooms. All patients lay on the floor, most
on blankets or on cardboard. The medical
record was an 8x4 inch index card with
hastily scribbled notes, half in French. In
the ED, there were all sorts of patients:
emergency patients, post-op patients, ICU
patients, pre/post partum patients, and
pediatric patients. Patients remained here
until they could be transferred to one of
three sections, all with tents, which ran
along the outside of the hospital. The first
section treated post-op patients, the second
section treated medical conditions, and in
the third section were somewhat well
patients who had nowhere to go and did not
want to leave the hospital grounds. French
physicians and nurses worked the day
shifts and emergency physicians worked
the night shifts. At any given time, the
tents housed about 300 patients. Imagine
the tents as part mobile ICU and part
refugee camp: I treated patients with car-
diac arrests and patients with toothaches.
My schedule was one morning transition,
followed by three night shifts starting at 5
p.m. and going until 7:30 a.m. All the
patients were on the floor and I was con-
stantly bending to examine patients. On my
second day there, my right hand became
red and swollen, and I had to take antibi-
otics. The sharps container was a card-
board box in the corner of the room. There
was no blood work and x-rays were avail-
able during daylight hours. Blood transfu-
sions were a very complicated process.
There was no running water, but plenty of
hand sanitizer, peroxide, and isopropyl
alcohol.
At 1 a.m., I was called to a tent with eight
paralyzed patients, one of whom was unre-
sponsive with no pulse. The temperature
and smell were unbelievable. I performed
CPR, and we were able to get a pulse back.
When I wiped the patient’s forearm to
place an IV, the alcohol pad turned black
from dirt, and after wiping for the second
time, we ran out of alcohol pads. We had
no anti-arrhythmic medications and no
ventilator, and the patient expired.
18 EMpulse • Mar-Apr 2010
HAITIdisaster
Fragments of a Shattered World
Paul DePonte, DO
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:53 AM Page 20
An x-ray under her head marked her death;
she had a C-6 cervical spine fracture. The
nurse who was with me thanked me for
being kind. I could not recall the last time
someone said thank you.
Other cultural differences: it was not
uncommon to have patients arrive with
their wounds wrapped in banana leaves,
not bandages. One patient arrived with an
ankle fracture that was splinted with a cut
out plastic milk jug. I ordered a chest x-ray
on a patient who I suspected had TB. I
wrote CXR on a piece of paper, however,
he returned without an x-ray as the tech-
nologist did not know what CXR meant. I
learnt via an interpreter that I should have
written Pulmonary and not CXR.
A case I am most proud of was a 12-year-
old girl who was hit by a motorcycle and
presented with a rigid, surgical abdomen.
Unbelievably, a quick-thinking radiologist
with a portable ultrasound machine did a
FAST exam and found free fluid. The U.S.
military transferred the patient to the
U.S.S. Comfort, a huge white ship with a
big red cross on both sides, docked in Port-
au-Prince harbor. No parents and no paper-
work.
There was no morgue. When a patient
expired, the body was simply given to the
family. My saddest experience was with a
2-month-old who died of sepsis. It was
very difficult to break the news to the par-
ents in a crowded, hot hallway in the mid-
dle of the night. The father was requested
to come back in the morning to get the
body. At the first light of day, Mr. Jim
Bunch (the CEO of Parkridge hospital) and
I escorted him to the small room where the
baby had been all night. The father first
carried the child to the chapel at the hospi-
tal and then walked down a 100-foot drive-
way into a crowd of people.
Mr. Bunch and I looked at each other, teary
eyed. It was a moment we will never for-
get: Mr. Bunch, a 6-foot-7-inch man, and
I, at 6-foot-4 inches, standing there crying
and experiencing sadness like I never have
in 15 years of practicing medicine, in a
place I never thought about until this trip.
EMpulse • Mar-Apr 2010 19
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:53 AM Page 21
We arrived at the Haitian CommunityHospital (HCH) six days following thedevastating January earthquake. Our groupwaited outside the front entrance, essential-ly a wrought iron gate with thirty otherpeople vying to enter, while our teamleader disappeared inside. We were in themidst of a sea of Haitians inhabiting asmall tent city surrounding the facility. Ayoung woman rushed by the gate holding apremature newborn. Its deceased twin wascarried away in the opposite direction. Aman in scrubs, we later knew as Dr. Tony,emerged from the facility and asked us tocome inside. It was a very surreal firstimpression soon followed by a period ofhelplessness and disorientation.
Our team was divided into three. Our anes-thesiologist went to the OR; our generalsurgeon went to post-op; and the rest of us,two emergency physicians, one physicianassistant, and two emergency nursesmanned the triage area. This consisted ofthe lobby and adjacent courtyard crowdedwith primarily orthopedic patients. Theywere marked with tape on their foreheads.Most had TBS, “to be seen,” written onthem. After an exam, debridement, dress-ing, and splint application, this tape was
replaced with another: “X-ray” patientswaited in line for the only machine in thefacility and “OR1” patients needed emer-gency surgery for infected wounds, openfractures and large soft tissue injuries.The rest were “OR2s,” with closed frac-tures requiring surgical repair after theOR1s were done. These patients weremoved back to the tent city.
We soon became veterans of the system.Later, we were joined by teams fromKorea, Hungary and Australia. Theyassumed we were in charge and wereappreciative of being assimilated into thebizarre routine. By dusk, the insanity thathad been triage was reasonably organizedand many of the teams left for the night.We stayed until noon the next day andreturned ten hours later to do a reverse 20-hour shift.
That night will be remembered for a septicnewborn resuscitation with 14 hours ofhand ventilation and by the aftershock weexperienced early the next morning.Despite no structural damage, the quakecaused a spontaneous, near-total patientevacuation of the hospital, and mostpatients crowded into the tent city. Patientswere reluctant to come inside unless it wastheir turn for the OR. Initially we thought“this can’t be good,” but over the next sixhours logistics were adapted, the hospitalwas cleaned, and things actually ran moresmoothly. We left exhausted that evening,many of us having slept only two to threehours between shifts in the heat of the day.
On our last day, we had a chance to talk toour interpreters and hear some of their sto-ries. Prior to our arrival they had acted asphysician extenders. Many had been
shown how to give injections, treat woundsand assist in the OR. These were not med-ical people: one sold ceramic tile, oneowned a bar, another a travel agency, butmany were students. They were well edu-cated, but this work was foreign. Manyexpressed interest in pursuing some type ofmedical career because of their experi-ences with us.
As a team, we were fortunate. We werehumbled by the Haitian people. Many hadlost friends, family, homes and businesses,but did not complain and worked tirelesslyto help the injured. The Haiti we experi-enced was appreciative and caring. We feltneither threatened nor witnessed riotingnor selfishness. It was a life-changingexperience for each of us and we weregrateful to serve.
Our trip was sponsored by Summit Churchin Estero, Florida, at the request of Missionof Hope, Haiti. On our last day, MOH dis-tributed 391,000 meals without incident,through a network they had developed overthe last ten years. Check them out atmohhaiti.com. They are the real deal!
20 EMpulse • Mar-Apr 2010
HAITIdisaster
Thomas Schaar, MD
Really Surreal or Surreally Real
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:53 AM Page 22
In the grand scheme of things, I recognize
that what I did was negligible. Still, this
experience paints a portrait of our frail
humanity and our incomplete ability to
deal with it.
On Thursday, Jan. 21, 2010, I had the priv-
ilege of traveling to Haiti on a medical
evacuation mission. Authorities had insist-
ed that this be supervised by a physician
and, by sheer chance, I was the appointed
one. After 40 years of being a doctor, I
admit to becoming desensitized to patholo-
gy. But this mission left in me an emotion-
al void that might never be filled. Perhaps
this is the conflict between our divinity and
our humanity.
Our mission was to transport five Haitians
to the United States, thereby reuniting a
divided family and allow the injured mem-
bers to receive medical care. This simple
task was made complex because it
occurred nine days after a major earth-
quake that jarred the soul of an already
impoverished nation. We stowed aboard a
plane chartered by Jackson Memorial
Hospital and Children’s Hospital.
Airplanes are allowed to land in Port-au-
Prince for only two hours since there is
simply insufficient room at the crippled
airport. Flights have one hour to deplane
and one hour to re-load. After that, they
are “wheels up” and if you are not on
board, good luck. It will be difficult find-
ing a hotel that accepts credit cards.
We left Opa Locka filled with uncertainty,
as none of us knew what to expect. With
us was Paul Farmer, MD, the infectious
disease specialist, who has started a hospi-
tal in Haiti against amazing odds and now
battles drug-resistant tuberculosis world-
wide. I have read his book. He smiled
when I pointed out that he must be on the
Harvard faculty since he was the only per-
son on the airplane wearing a white shirt
and a blue blazer.
The airplane made a soft landing. We were
warned to prepare for the acrid odor of
putrefaction when the cabin door opened.
Teams were organized to help unload the
airplane. My companion and I were told to
find our charges and return as quickly as
possible. If we did not return within two
hours, we would be left behind.
The cabin door opened with a faint hint of
smoke, neither oppressive nor fetid. The
100,000 dead bodies had already been
buried in mass graves or burned. Thrusting
through several cordons of uniformed
Haitian border policemen, we asked guards
to remember our faces to facilitate re-entry.
They understood little as they spoke only
Creole.
The airport itself, destitute by third world
standards prior to the earthquake, now
resembled a shattered cavern, with cracks
in the wall and piles of rubble and water
puddles littering the floor. The dimly lit
terminal challenged us to find a function-
ing exit. We left the sanctity of the termi-
nal through breaks in a security fence. The
inner perimeter was protected by rifle bear-
ing American GIs who prevented the
milling mass of underfed Haitians from
storming the terminal to seek escape.
Some have criticized the American govern-
ment for taking over the country.
However, without order, little could have
been accomplished and aid could not have
been dispensed. It provided generators to
light the airfield and organization to the
multitude of well-meaning countries offer-
ing aid. Dropping supplies from helicop-
ters would have resulted in starving people
killing each other for food. Organizing
food distribution lines and relief efforts is
necessary to avoid wanton killings by the
desperate.
We rapidly walked through a pitch-black
parking lot and a warehouse lit only by
automobile headlights. Columns of dust
billowed each time an army HumVee dart-
ed past. Using a satellite cellular phone, we
found our charges in a dark corner, wait-
ing, uncomplaining, with the patience of
Job for their saviors.
Transfer of medical information was mini-
mal. Wounds were re-dressed and IVs
restarted. Contrary to expectations, the
children silently accepted every pain and
indignity without protest. Obviously, they
could not have been prepared for this
calamity or its aftermath. My partner tells
a story of how he had transported a 5-year-
old to Miami. The child suffered a gaping,
infected head injury and crushed right arm
(since amputated). The receiving Jackson
(Continued on Next Page)
EMpulse • Mar-Apr 2010 21
HAITIdisaster
God Doesn’t Wear Ray-Bans
Arthur E. Palamara, MD
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:53 AM Page 23
God Doesn’t Wear Ray-Bans
(Continued from previous page)
resident surgeon (appropriately) asked
what the CT scan revealed. That young
doctor was oblivious of the depravity of
conditions in Haiti.
Gathering up our charges, we made our
way back through the smoky, dusty pot-
holed parking lot to a gap in
the perimeter fence. Haitians
without food, water, jobs,
homes, beds, or hope clutched
at us begging to be taken. Our
party was greeted by several
rifle bearing agents to whom
we explained our mission.
One Federal Agent had lived
in Miami and understood its
complex cultural composition.
They let us pass wishing us a
“God bless you for what your
doing.” This was repeated
many times more but I still
only partially comprehend its
profundity.
We arrived back at the plane, joined by 150
other émigrés desperately trying to exit the
ravaged country. We were told to wait at
the back of the line until we could be
accommodated. The three children, scared
and tired, uttered not a word.
A few minutes past the two-hour deadline,
our Sky King 737 was “wheels-up.” Kathy
and Seth, the two airline employees who
made this evacuation possible, were over-
joyed by the success of “our” mission.
Without them, it would not have been pos-
sible.
Approaching 11 p.m., we landed at Miami
International Airport, as straggly a group of
passengers that has ever deplaned. Here
we faced our last hurdle, American immi-
gration.
The mother and her two children traveling
with us did not valid American visas. The
mother was returning to see her severely
injured son and husband who had been
taken to Jackson a week earlier. The 5-
year-old had undergone a craniotomy for a
depressed, infected skull fracture and
amputation of his arm. The mother was
not aware of the loss of her son’s arm and
we worried about her reaction.
Mark, the organizer of the rescue mission,
pleaded our case to the immigration offi-
cer, a Haitian-American woman, who
asked: “Do they have passports?” The
answer was: “Probably, under the pile of
rubble that was once their home.” Two
TSA supervisors were called and shown
our only documentation, an email from
Senator George Lemieux authorizing
admittance. I was holding the young girl
and her IV bag and I showed the ravages of
our trip.
Wearing scrubs, with my white hair, and
with all the surgical officialdom I could
muster, I spoke up: “We have two injured
children: one with an epidural hematoma
and the other with a fractured radius and
dehydration. We sure wish you could help
us. We are taking them to Jackson
Memorial Hospital.” After a moment’s
pause, the senior officer
offered: “Do you need a
wheel chair?” I should have
said yes. But I, a 66-year-old,
proudly carried that 40-pound
child a quarter mile without
stopping.
Later, we marched onto the
pediatric floor at Jackson
Memorial Hospital and found
the boy and his father. The 3-
year-old girl, who had snug-
gled into my arms for
warmth, yelled “Pappi!” and
jumped from my arms into
his. The face of the boy with the amputat-
ed arm lit up like the national Christmas
tree at the White House.
We had done our job. I arrived home,
exhausted. A half hour later, famished, I sat
down to a bowl of fettuccine and a glass of
wine. I could not help thinking how lucky
I was that I had a home to go to and food to
eat. Those people who had clutched my
sleeve at the airport had no such reprieve.
Stiff and tired, I arose at 7 a.m. to do an
operation on an 89-year-old. Kind of puts
things in perspective.
22 EMpulse • Mar-Apr 2010
HAITIdisaster
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:53 AM Page 24
“So how was it?” I am asked daily since
my return from Haiti. This is accompanied
by hopeful expectations for an exciting
story and gruesome details. It’s a question
that I have trouble answering. How do I
really feel?
I feel great; it was rewarding. I deployed
with the National Disaster Medical System
(NDMS) to the Gheskio Field Hospital in
Port-au-Prince. Our MASH-like facility
was on the edge of Cité Soleil. We treated
injuries and illness caused by the earth-
quake. Within two weeks we were a team
and a family.
I also feel great because I provided care to
the needy, who appreciated my efforts. I
practiced medicine without the constraints
of paperwork and administrative
headaches. On the other hand, the 18-hour
days, the lack of flush toilets, sleeping out-
side in the heat, under mosquito netting,
eating only military meals-ready-to-eat
(MREs), the omnipresent hum of genera-
tors, and the choking smoke from trash
fires were not so great.
I feel frustrated. In a disaster, I expect to
have the ability to transfer patients in
extremis to a higher level of care outside
the disaster zone. In Haiti, however, we
were the highest level of care. As we had
the only functioning pediatric ventilator,
we became the pediatric ICU. We saved
many kids and lost others. We had nowhere
else to turn.
It was exciting, of course. We were accom-
panied by armed members of the 82nd
Airborne at all times. On the streets, the
largest and fastest had the right of way.
The sound of gunfire, the periodic after-
shocks, and working in an ED 24/7 pro-
duced a continuous adrenalin surge that
took its toll.
It was heartbreaking, but not always. We
saw 150 patients and performed five major
surgeries daily. We celebrated births (card-
board boxes and space blankets make great
bassinets). We played with kids who a few
days earlier had been too weak with dehy-
dration. Our care really made a difference.
Heartbreak comes with remembering those
who are the most sick, the ones we ago-
nized over, and the ones we could not save.
We could have been better organized. As
in 9/11 and Katrina, medical professionals
from throughout the world descended on
Haiti. Many had no more than a backpack
and protein bars, and no plans. There was
minimal credentialing and lax accountabil-
ity. Many required assistance as they suc-
cumbed to illness and fatigue. While some
treatment may be better than no treatment,
there are concerns regarding the quality
provided in those early days.
As a physician volunteer with NDMS, I
was a federal employee. I heard complaints
of the slow federal response. Why were the
non-governmental organizations (NGOs)
faster? However, I appreciate the organi-
zation that went into establishing supply
lines, security, accountability, and creden-
tialing. We were able to maximize our
efforts.
This experience has been thought provok-
ing. There are so many questions with so
few answers. What is the responsibility of
healthcare professionals in disasters such
as this? Should the United Nations be the
lead organization in coordinating volunteer
efforts? What level of care should be pro-
vided? Should relief efforts be patient cen-
tered or focus on the population as a
whole? How long should outside organiza-
tions provide assistance? How does one
support the efforts of local physicians?
What will happen to the patients when we
leave? We as EPs are ideally suited to both
respond to disasters and lead the discus-
sion.
The time to prepare is now. Florida is a
national leader in disaster response. And
yet, physicians are the rate limiting step.
There are seven NDMS teams throughout
the state that will gladly begin the creden-
tialing process. In state, Florida has an
equal number of State Medical Response
Teams (SMRTs) dedicated to emergency
care. Numerous NGOs also need physician
volunteers. Get credentialed, update your
immunizations, and complete all necessary
training, so that when the next disaster
strikes, you will be ready!
So yes, this was rewarding, frustrating,
exhausting, dirty and challenging. And, yes
I would do this again in a heartbeat.
Dr. Scott is Team Medical Director -
IMSuRT South - NDMS / HHS.
EMpulse • Mar-Apr 2010 23
HAITIdisaster
Joe Scott MD, FACEP
How Do I ReallyFeel?
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:53 AM Page 25
Preparing a physician witness to tell his or
her story in front of a jury at trial, or to
safely navigate a deposition conducted by
an experienced interrogator, is not easy.
Plaintiffs’ attorneys are skilled at capitaliz-
ing on a doctor’s anger, frustration, resent-
ment, and self-doubt. Combined, these fac-
tors can create a high degree of psycholog-
ical stress that often renders defendant doc-
tors poor witnesses.
Further compounding the situation is the
physician’s basic psychological makeup.
Physicians tend to be thinkers and doers,
but not talkers. This can handicap physi-
cians, making it difficult for them to suc-
cessfully testify at deposition and trial.
First and foremost, physician defendants
need to realize that being named in a law-
suit does not diminish their skills as a
physician. The key to surviving an experi-
ence in the health law arena is to under-
stand the objectives surrounding a lawsuit.
Lawsuits are not about right and wrong,
they are about winning and losing. This
article discusses how to present a success-
ful defense.
The Physician Defendant
Physician defendants and defense attor-
neys may not share the same beliefs on
what it takes to win a case. It is a defense
attorney’s job to provide a physician with a
thorough description of the litigation
process and the defense strategy. The
physician’s role is to serve as a medical
expert and a witness to the facts.
What the Jury Wants
In malpractice lawsuits, the jury decides
who is right by determining which side has
the preponderance of the evidence. Juries
often misinterpret a physician’s inability to
serve as a good witness as an admission of
failure to properly diagnose or treat a
patient. They assume that the demeanor of
a physician during trial is also their
demeanor when treating patients. Jurors
have also been patients, and they expect
professionalism, competence, credibility,
and caring from the physician defendants.
Physicians on trial must behave in a way
that makes them likable and credible to the
jury.
The Medical Record
Juries tend to believe written documenta-
tion more than oral testimony. While there
is no substitute for accurate and complete
documentation, your case will be based on
three sources of information:
1. The medical record itself.
2. Your recollection of events.
3. Customary methods of practice (e.g.,
the manner in which you routinely per-
form a neurological exam).
Although independent recollection and
customary practice require credibility, they
may be your best defense if documentation
on the medical record is inadequate.
Think Before You Speak
One of the most important things to do dur-
ing a deposition is to stay calm. Emotions
cloud judgment, and people tend to speak
without thinking when they’re upset or
nervous. Go into it with the mind-set that
you provided the best care possible under
the circumstances. Stay focused on that
fact and do not let the plaintiff's attorneys
convince you otherwise.
• Become comfortable with silence.
Think before you speak, and do not offer
information beyond that necessary to
answer the question that has been asked.
• Don’t answer any question too quick-
ly. Give your attorney time to object to
any questions that are inappropriate or
leading.
• Have an attorney rephrase a question if
you do not understand it.
• Ask to review documents referenced
by the plaintiff’s attorney before
answering questions about them.
Preparation and Practice
There are some common mistakes that
physician witnesses often make when testi-
fying including:
• Failure to comprehend the defense
strategy devised by an attorney.
• Inadequate knowledge of the facts.
• Failure to study the medical record in
detail.
Preparation and practice will help you to
avoid these mistakes. If you are named in a
malpractice suit, do the following:
• Be compliant, be available, and be
ready to devote time and effort to your
defense.
• Work closely with your attorney to
(Continued on Page 26)
MEDmal
24 EMpulse • Mar-Apr 2010
On Being Your Own Best Expert
Kenneth Schultz, MD, MBA, FACP, FACEP
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:53 AM Page 26
Congratulations to all sections on their
annual meetings during Scientific
Assembly in Boston. This past Scientific
Assembly was a huge success having the
most registrants of any Scientific
Assembly to date.
In this past year, the Sections Task Force,
chaired by Dr. Kelly Gray-Eurom and me,
as the board liaison, oversaw the awarding
of section grants and section awards in the
categories of increased membership,
newsletter excellence, service the college,
and service to sections. In the next few
weeks, we hope to receive the annual
reports of each section on the activities for
this past year. This report can be used in
developing the self -nominating forms for
service to college and service to section
awards. It is also an historical record of the
accomplishments of your section for the
year that would be helpful for new section
leaders and section members. This report
is important to send out through the section
e-list or to be printed in the first issue of
your section’s newsletter.
At this year’s Scientific Assembly a meet-
and-greet was held for section leaders.
Susan Morris, Bobby Heard, Kelly Gray-
Eurom, and I met with section leaders
between 8 a.m. and 9 a.m. for coffee and
doughnuts to share experiences and solu-
tions as to problems facing section leaders.
Council Meeting
Some section councilors took advantage of
the councilor training session and met with
the small chapter and section caucus on
Friday afternoon and Sunday morning. It
is a tradition for section and small chapter
councilors to assist each other with training
and support during the Council meeting.
Sections and small chapter councilors
often have the role of councilor for only
one year. Clearly, this is a disadvantage in
experience when compared to larger chap-
ters, where councilors can serve many con-
secutive terms and truly get to know the
system and the individuals.
Section councilors and alternate councilors
should plan on attending the councilor ori-
entation and these important caucus meet-
ings on Friday afternoon and Sunday
morning next year. It is yet another oppor-
tunity for section leaders to get together
and share common experiences.
Webinar: The Power of 100
This year, for the first time, a webinar was
produced to help educate section leaders.
The webinar can be accessed at the ACEP
website. Although directed to the section
leadership, any section member who in the
future wants to become leader or just wants
to know more about sections can go to the
site.
I encourage each of you to listen to the
webinar. Section members who have taken
advantage of this resource tell me that it
has been very helpful and is well worth the
40 or so minutes of their time to gain a
really good understanding of what you can
do with the section.
Growth in Section Membership
Your College, under the direction of the
Membership Committee and Membership
Division staff, has seen the successful
growth of membership to more than 27,500
members. There has also been a growth in
section membership. One of the reasons
for this has been the block payment for res-
idents by residency directors. Often, when
this block payment occurs, complementary
section selections for the resident are not
made. This creates an opportunity for each
section to be in contact with these new res-
ident members and invite them to partici-
pate in your section. Sections offer many
opportunities for residents in leadership
development, professional development,
and in publishing in the section newsletter.
Size matters, because sections can use 15%
of the membership dues generated in the
previous year to finance projects.
Membership growth equates to more funds
for projects. It is also important if you want
to influence College direction.
Section Grant Program
About this time, many sections will begin
to think about the section grant program.
Documents outlining the grant program
and how to apply for a grant will be posted
to the Section link on the ACEP web site
shortly.
Communications and action plans
Now is the time to develop action plans for
the section during this activity year. The
communications plan details how the sec-
tion will communicate with its member-
ship through three different communica-
tions tools. These tools include the section
(Continued on Next Page)
EMpulse • Mar-Apr 2010 25
ACEPsections
Andrew Bern, MD, FACEP
Notes on ACEP Sections
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:53 AM Page 27
(Continued from Page 24)
become active participants in the claims
process.
• Listen to your legal team, and work to
understand your defense strategy.
• Understand your role as the defendant,
as well as the roles of your legal team,
the plaintiff, and the experts. Study the
plaintiff’s medical record and commit it
to memory. Understand common tactics
that may be used by the plaintiff’s attor-
ney. The plaintiff’s attorney will use
psychological warfare in an attempt to
negatively impact your performance.
Discuss these tactics, and get training in
how to best handle them.
• Have a discussion with your attorney
or your insurance company representa-
tive about hiring an experienced physi-
cian witness coach to help you prepare
your testimony.
• Practice your testimony - the regular
meetings with your attorney will not
sufficiently prepare you for testimony.
• Work with your attorney to develop a
witness preparation strategy that
includes role playing and videotaped
mock testimony. Watch the videotape,
critique yourself, and practice again.
Deposition and trial can be frightening.
You can manage this situation successfully
if you trust your clinical skills and knowl-
edge, stay focused, and work to understand
the process and the purpose behind the
plaintiff attorney's actions and tactics.
Dr. Kenneth Schultz is President of
Skyview Loss Prevention Services. He is a
nationally-known expert in witness prepa-
ration and medical legal strategy.
26 EMpulse • Mar-Apr 2010
ACEPsections
MEDmal
(Continued from Previous Page)
newsletter, the section e-list, and the sec-
tion website. Each of these tools should
have an editor or project director. Ideas
and survey results from the section e-list
can be summarized in the section newslet-
ter or website. Resources of a particular
section might be carried in the section
newsletter so it is always there for the
members. Many sections use the annual
meeting as an opportunity to define the
topics that they will cover in the newsletter
over the course of this year. With an aver-
age of 10 stories per newsletter, a section
would be able to cover 40 different stories
over the course of the year.
Partnership
There are three main types of partnerships.
First, sections can partner with one another
when applying for section grants. There
have been many examples where two or
more sections have worked with one
another on grant projects. Second, sections
have partnered with chapters in providing
lectures as part of the chapter meeting and
have become associated with specific
meetings. Examples include the Disaster
Medicine Section that has a meeting of the
section at the Florida Chapter’s
International Disaster Management confer-
ence; the Emergency Medicine Informatics
Section also has partnered with the
Pennsylvania Chapter in their annual infor-
matics meeting. These partnerships are a
win-win for both the section and the chap-
ter. The last partnership is the develop-
ment of a course program that is so large
that the partnership is between the section
and college through the education commit-
tee that produces a dedicated program. The
Pediatric Advanced Educational Program
is an example of such a partnership.
The Team
We want your section to succeed. Happy
and engaged members who find value in
the community of others who share a simi-
lar interest within their practice of emer-
gency medicine determine success. We
look forward to each section reaching a
goal of four newsletters, participating in
the section grant program and in the ability
to finance section projects through the 15%
of dues allocation. We want to help each
section member reach their full potential,
including professional development, by
using sections as an alternative path to
leadership development. Finally, we would
like to see each section member become
politically engaged by attending the
Leadership and Advocacy Conference in
Washington, D.C. this spring, the annual
Council meeting next year in Las Vegas,
and participating in NEMPAC and EMF.
Visit FCEP Online!
www.fcep.org
www.twitter.com/fcep
Become a Fan of FCEP
on Facebook!
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:53 AM Page 28
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28 EMpulse • Mar-Apr 2010
FREESTANDINGemergency departments
Freestanding EDs: An Overview
Antonio Gandia, MD,FACEP
Charlene Walker,RN
The concept of a Freestanding Emergency
Department (FSED) has existed since the
mid 1960s. In Florida, the first FSED
called the Emergency Center at
TimberRidge opened in Marion County
(Ocala) in 2002. It is owned and operated
by Munroe Regional Medical Center.
Shortly thereafter in 2003, the second
FSED opened in Destin (Destin
Emergency Care Center) which is operated
by Fort Walton Beach Medical Center.
Thereafter, state legislators placed a mora-
torium on new FSEDs while they studied
the issue. In 2007, Governor Charlie Crist
overturned the ban and the Mount Sinai
Aventura Freestanding Emergency
Department, owned and operated by
Mount Sinai Medical Center, opened in
Miami-Dade. Since 2008, three additional
FSEDs have opened: the Bardmoor
Emergency Center (Morton Plant
Hospital), the Emergency Care Center at
North Port (Sarasota Memorial Hospital),
and the Emergency Care Center at St.
Lucie West (Martin Memorial Health
Systems).
With six FSEDs successfully operating in
Florida, FCEP formed a committee repre-
sented by the medical directors and admin-
istrators of each facility.
The first meeting was held in November
2009. We agreed to jointly monitor per-
formance improvement indicators and
compare quality outcomes, throughput
times, patient safety and patient satisfac-
tion. We also discussed relationships with
local EMS systems, transport protocols,
and community outreach. The committee
plans to meet quarterly to assess and
exchange data.
With success, many state committees and
organizations have welcomed the FSED as
an additional resource to improve access to
emergency medical care in our state.
Exceeding All Expectations
Antonio Gandia, MD, FACEP
Two years after opening its doors, Mount
Sinai Medical Center’s FSED in Aventura
has proven to be an asset to the communi-
ty it serves. Since January 28, 2008, it has
provided care to close to 25,000 patients.
The Mount Sinai FSED is the third of its
kind in Florida. It operates in Aventura,
Miami-Dade County, which is one of the
most densely populated areas in the state.
Since Mount Sinai Medical Center is one
of six statutory teaching hospitals in
Florida, the FSED serves as a unique edu-
cational venue for medical students, nurse
practitioners, physician assistants, para-
medics and residents. During their rota-
tions, students get to experience a wide
range of emergency conditions as well as
get a glimpse into the future of EM.
To provide safe and efficient care we are
staffed with the customary EPs, registered
nurses and emergency room technicians.
The 24/7 staffing plan also includes full-
time respiratory therapists, radiology tech-
nicians, CT technicians and medical tech-
nologists.
On-site paramedics for patient transport, as
well as an on-call roster of 14 different spe-
cialists, ensure that patients receive the
best medical care.
The department’s commitment to provid-
ing the finest medical care, matched by
efficient and friendly service, has resulted
in an overall 99 percent patient satisfac-
tion.
Combining all of these quality outcomes
has resulted in the community receiving an
efficient and personal ED experience.
Timber Ridge/Munroe County MC
Frank C. Biondolillo, DO, FACEP, FAAEM
Greetings from TimberRidge!
TRED is located on the southwest corridor
of SR 200 in Marion County, in the city of
Ocala, just 12 miles west from the main
hospital campus of Munroe Regional
Medical Center.
TRED has served as the model for FSEDs
in and around the state and was the first
FSED that opened its doors in April 2002.
To date, TRED is averaging over 27,000
patients seen annually, and has improved
access to emergency care, decreased wait
times to see a physician, significantly
decompressed the main campus
Emergency Department, due to its strategic
location, in a rapidly growing segment of
the county.
As another quality service of Munroe
Regional Medical Center, we look forward
to continued growth and expansion. In tan-
dem with Munroe’s mission to “meet the
changing healthcare needs of the commu-
nity of Marion County and beyond,” we
provide caring and compassionate care.
Save the Date!
Symposium by the Sea 2010
takes place July 29 - Aug. 1
in Boca Raton.
See www.fcep.org
for more details.
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:53 AM Page 30
EMpulse • Mar-Apr 2010 29
CLINICALcase
The Young Lady with a Numb Leg
CPC Chair: Frederick Epstein, MD, FACEP
Discussant: Dan Grenier, DO
Mt. Sinai Medical Center
A 28-year-old female presented to Mount
Sinai’s ED complaining of left leg numb-
ness for approximately one month. The
numbness had been constant, but now had
worsened so much so that it caused her gait
to become unsteady. She went to her PCP
three days prior to presentation when she
received a Vitamin B12 shot. She had not
improved.
She was noticed by her family to have been
acting “unlike herself” for the last few
days, which is why she came to the ED.
She had no other symptoms, denied
headache, fever, nausea, vomiting, neck
pain, chest pain or cough.
Her past medical history was significant
for anemia, which was related to gastric
bypass surgery she had four years prior.
Also, she had been treated for an episode
of syphilis in the past and recently had a
URI that was described as some mild con-
gestion. She took daily vitamins and a PPI,
had no allergies, and had a breast augmen-
tation and tummy tuck a year ago.
On physical exam, her vital signs were nor-
mal: she was afebrile. She appeared gener-
ally healthy. On HEENT exam, it was
noticed that she did have slight bilateral
ptosis. Her EOM were intact. Her neck was
supple and her heart, lung, and abdominal
exam were normal. A complete muscu-
loskeletal and neurologic exam was per-
formed. She had 5/5 strength and normal
sensation in all extremities, however, her
gait was ataxic as she seemed to feel
uneasy putting weight on the left leg.
Neurologically she showed no cranial
nerve deficits, had normal reflexes in her
extremities, but had difficulty with the fin-
ger to nose test and heel to shin test.
A CBC and CMP were only remarkable for
her known anemia. A CT scan (pictured on
left) showed an abnormality.
The CT was read as subcortical and deep
white matter lucency in the right posterior
parietal and temporal lobes. Neurology
was consulted and the diagnosis was deter-
mined. Also, a MRI was obtained (pictured
on right).
The MRI was read as multifocal white and
grey matter processes demonstrating mild
mass effect and edema. Differential diag-
noses included lymphoma, multicentric
glioma, multi-focal cerebritis, or an atypi-
cal demyelinating process.
The patient was diagnosed with acute
demyelinating encephalomyelitis (aka
acute disseminated encephalomyelitis).
She was admitted to the hospital and
received high dose steroids for one week
and had improvement of her symptoms.
ADEM is characterized by inflammation
of the brain and spinal cord caused by dam-
age to the myelin sheath. It can occur in
association with recent viral or bacterial
infections, as a complication of vaccina-
tions, or maybe idiopathic. The onset is
sudden with various symptoms including
delirium, seizure, ataxia, optic neuritis and
commonly monoparesis. ADEM is some-
times misdiagnosed as a first attack of mul-
tiple sclerosis, however ADEM will more
commonly have symptoms of encephalitis
such as fever or coma whereas MS does
not. The symptoms typically respond well
to steroids and patients generally return to
normal. In some cases, the symptoms will
not resolve with steroids and other thera-
pies such as plasmapheresis or IVIG have
shown benefit.
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:54 AM Page 31
“Sinners, repent!”
The disheveled, bearded man in Room 12
called out to every passerby. His blue jeans
were torn, and his long hair had not been
cleaned or combed in several days.
“I am the Lord! You must repent now, or
you will burn in Hell!”
In the Ocean’s Hospital ER, Room 12 was
often reserved for those who appeared to
be mentally ill. Sometimes, it was for
patients who were depressed or anxious,
sometimes for those who had threatened or
attempted suicide. Today, it was for
Randall, a middle-aged man who was in
Room 12 after a police officer had com-
pleted involuntary commitment papers on
him.
As a nurse walked by Room 12’s doorway,
Randall looked up, wide-eyed, and he
flipped some greasy curls off his forehead.
“Ma’am, I say unto you. Come unto me, all
ye that labor and are heavy laden, and I
will give you rest.” Randall appeared con-
fident as he brushed the backside of his
hand across his unshaven chin. He
smirked, and winked at the nurse.
Dr. Tammy Cortez was speaking to the
officer that had driven Randall to the ER.
“So, it looked like he was going to jump?”
“Well, Doc. He said he would jump. He
leaned out over the edge of that roof, and
said something about being Jesus, and he
was going to sacrifice himself for the sins
of all of us.” The officer rolled his eyes,
and then continued, “My partner crept up
behind him and grabbed him before he
could jump.”
He continued, “I’m really not sure what his
name is. He had no ID on him. One time,
he called himself Randall, but then he just
kept referring to himself as ‘Jesus.’”
“OK. Thanks.” Cortez turned toward
Room 12. “We’ll see what we can do.”
“Hi, Randall. I’m Dr. Cortez.”
She kept a cautious distance from the
stretcher, and stayed near the doorway.
Even though there was a leather waist
restraint on Randall, ER personnel know
they can never trust a delusional or halluci-
nating patient.
“Tell me what happened today, Randall.”
She kept her voice low and soft.
Randall spoke with conviction. “My Father
sent me to try to save you!” Then, throwing
his head back and peering intently at the
ceiling, he continued. “Yes, Father. I hear
you! Yes, I’ll try my best! But they’re not
listening to me; they’re not listening to
me!”
Randall’s face scowled, and his lip started
to quiver as though he was about to cry.
Cortez noted Randall’s escalating tension
and his rising voice.
Then, with a sudden conversion to a smile,
he offered a quick comment.
“Hey, Doc, that shirt looks really good on
you,” and he winked at Cortez.
His head snapped back quickly toward the
physician, and he pushed forward against
the leather.
“You’re not putting those evil drugs back
into me!” There was fire in his eyes.
“Don’t even try it!”
He reached out, but Cortez remained out of
reach.
“Randall, what did your name used to be?
Can you tell me that?”
“Randall Smith,” he retorted in a sing-
song, mocking tone. Then, with an
emboldened spirit, he added, “but I’ll
never go back to that sinful life! I’ve been
chosen by the Father to save the sinners of
this world! There! Do you hear that? He’s
telling me to even try to save you!”
Cortez backed out of Room 12. It wasn’t
safe to try to perform any meaningful
physical exam.
“Susie, check for any old records on a
Randall Smith.”
The ward secretary typed in the name.
“Here you go, Dr. Cortez. I’ll bet it’s this
30 EMpulse • Mar-Apr 2010
ERchronicles
On the Day of Judgment
Arlen R. Stauffer, MD, MBA, FACEP
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:54 AM Page 32
one with the psych admissions.”
“Ah. Of course. He’s been admitted with paranoid schizophrenia
at least twice before,” Cortez muttered softly.
“Phil.” Cortez turned to the charge nurse. “The guy in Room 12
has apparently stopped taking his psych meds again. He’s pretty
delusional, and we need to get him calmed down.”
Phil nodded. As Phil and two other men strolled into Room 12,
Randall squinted, now very suspicious that their intent was not
good. He growled, and a look of real fear covered his face.
“A good man out of the treasure of his heart bringeth forth good
things; and an evil man out of the evil treasure bringeth forth evil
things!”
Surrounding Randall now, the three men secured his limbs.
“This is for your own good, Randall.”
“Noooo!” Randall squirmed and twisted. He felt the needle in his
right thigh, and he howled loudly. “Noooo!”
“It’s OK, Randall,” Phil said calmly. “The Haldol’s in now; you’ll
feel better in a minute.”
Again, with his eyes torn wide open, his voice boomed at his
attackers.
“But, I say unto you, that every idle word that men shall speak,
they shall give account in the day of judgment.” He closed his
eyes and sighed, and his shoulders sank forward slightly. “In the
day of judgment, gentlemen, in the day of judgment...”
His voice tailed off, and he allowed his head to lie back against the
stretcher. Randall was calm now. He allowed a nurse to draw his
blood without uttering a whimper. There was a tear on his cheek.
He felt defeated.
Schizophrenia is one of the world’s serious public health prob-
lems, and it accounts for a fourth of psychiatry admissions in this
country. It is characterized by abnormal perceptions or expres-
sions of reality, and it is felt that genetics, neurobiology, early
environment, and psychological and social processes are contrib-
utory factors. Victims of schizophrenia often have co-morbid con-
ditions such as major depression or anxiety disorder, and there is
said to be a 40% lifetime occurrence of substance abuse.
Schizophrenia occurs equally in males and females, and studies
have found an overall lifetime prevalence of 0.55%. The cost to
society in terms of healthcare expenses, lost productivity, vio-
lence, and patients with schizophrenia in prison is staggering.
The author is a long-time emergency physician from New Smyrna
Beach, and a former FCEP Board member and EMpulse editor.
This is a revised version of one of the “Chronicles” that ran in
several Florida newspapers a few years ago. Contact: stauf-
EMpulse • Mar-Apr 2010 31
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:54 AM Page 33
Opiate abuse associated deaths have risen
in Florida in recent years, with heroin con-
tinuing to be the most lethal drug found in
deceased persons, according to a 2009
interim report by the Florida Medical
Examiners. In fact, the top four drugs
found in greater than 50% of drug-associ-
ated deaths were heroin, methadone, fen-
tanyl and oxycodone.1
Opiate toxicity can
cause CNS and respiratory depression that
can lead to coma, respiratory arrest and
death. However, the administration of
naloxone, an opiate antagonist, may limit
toxicity. Traditionally, naloxone is admin-
istered via the intramuscular (IM) or
intravascular (IV) routes, but this always
carries a risk of occupational exposure to
blood-borne pathogens, including human
immunodeficiency virus (HIV) and hepati-
tis B and C. According to the World Health
Organization, 40% of hepatitis B and C
infections and 2.5% of HIV infections
among healthcare workers are due to occu-
pational hazards.2 In an ED setting, admin-
istration of naloxone may be delayed due
to difficulties in gaining IV access or the
patient’s body habitus may cause a prob-
lem for IM administration. Needle-free
administration of naloxone has been pro-
posed.
Intranasal (IN) administration is a novel
way of administering drugs in the ED. It
does not require sterile technique and can
prevent needle-stick injuries. The nasal
mucosa is an ideal route for medications
since it has a very large surface area and a
large amount of blood flow. However,
there are limitations to IN administration.
Particle size, pH and volume all play a role
in absorption. The ideal volume should be
no more than 1 mL per dose; otherwise
excess volume will be lost or swallowed.
Until recently, there was not much human
data comparing routes of administration of
naloxone.
An article in 2008 looked at the pharmaco-
kinetics of IV, IM, and IN naloxone admin-
istration in healthy volunteers. IN nalox-
one only showed a 4% bioavailabilty.
However, this study had many limitations.
A very low concentration of naloxone was
utilized requiring 5 mL of solution to be
atomized into subjects’ nares to achieve a
dose of 2 mg. The subjects were also
healthy volunteers, not under the influence
of opioids. Even with the low bioavailabil-
ity reported, it is known that as little as
0.05-0.1 mg of naloxone can cause an opi-
ate antagonistic effect. The study was also
extremely small with only 8 subjects tested
at different occasions. The authors con-
cluded that further studies need to be con-
ducted.4
Several studies have shown efficacy in the
implementation of IN naloxone in a pre-
hospital setting.5-7 In 2005, a study was
conducted in Salt Lake City, Utah. Ninety-
five subjects were enrolled and received 2
mg of IN naloxone (1mg/mL in each nare),
if they were found unresponsive or if opi-
oid overdose was suspected. As IN nalox-
one was being given, intravenous (IV)
access was obtained, and 2 mg of IV nalox-
one was administered if needed. Of the 95
subjects, 83% responded to IN naloxone
alone and only 16% of these required
repeat IV doses.5
In March of 2004, the use of IN naloxone
as a first line agent in suspected overdose
was implemented by EMS in San
Fransisco, CA. A retrospective chart
review comparing the administration of IN
naloxone and IV naloxone was then per-
formed. The study showed no difference in
the response rates for IN and IV naloxone.
Although the time for response was slight-
ly longer for IN naloxone, there was no dif-
ference in time of contact to clinical
response. The study did note that more
subjects in the IN naloxone group needed a
repeat dose than in the IV naloxone group.6
Despite the lack of in-hospital studies, IN
naloxone can be considered as an alterna-
tive route in the event of an opioid over-
dose. The use of a mucosal atomizer device
(MAD©), when purchased, can easily
attach to the IV naloxone syringe of
2mg/2mL and administer 1 mL to each
nare. The Florida Poison Information
Center Network is available at 1-800-222-
1222 for questions.
(Continued on Next Page)
32 EMpulse • Mar-Apr 2010
POISONcontrol
Novel Naloxone Administration
Adrienne Perotti, Pharm.D.
Clinical Toxicology Fellow
Florida/USVI Poison Information Center-Jacksonville
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:54 AM Page 34
Hi everyone:
L’Hôpital de la Communauté Haïtienne is a 50-bed hospital in the
Fréres Neighborhood of Petion-Ville, in the area where many of
my family live. My cousin, Edith Dreyfuss-Hudicourt, is one of
Haiti’s first woman doctors and a founding member of this non-
profit hospital created by the Haitian Health and Education
Foundation (Fondation Haitienne pour la Santé et l’Education,
FHASE) in 1985. The hospital has always had emergency servic-
es and opened Haiti’s first ICU last year. The hospital attempts to
be self-sustaining by charging patients minimal fees for services.
The hospital has been one of the few in the Port-au-Prince and
Petion-Ville with no structural damage and with teams of physi-
cians, nurses, and volunteers working night and day.
Thousands of wounded people have overtaxed the hospital’s
capacity to respond to the earthquake emergency. People have
come with multiple traumas: mainly with broken limbs and head
injuries from fallen cement. There are not enough beds, and peo-
ple lie on makeshift mats on the floor.
The disaster that has befallen Haiti is of enormous proportions.
We are raising funds to be able to offer free services. We have
received gifts of supplies and medicine, but these gifts cannot pos-
sibly cover all needs. Orthopedic supplies are in great demand.
The people who arrive at the hospital are in desperate situations.
Many have lost their homes and family members. Some people
are camping in the hospital yard because they do not know where
to go after receiving care. People of all ages are being dropped at
the hospital after being pulled from the rubble.
We hope you can contribute funds to help us to continue helping
people who are in desperate need of care. You can follow your
donation dollars by becoming a fan of the hospital on Facebook.
Haitian Health and Education Foundation is a non-profit organiza-
tion registered in the US. You can read more on the hospital at:
http://www.haitihosp.org/lHopital_de_la_Communaute_Haitienne/Home.html
My aunt Dr. Ginette Dreyfuss-Diederich has opened a bank
account in Miami:
Hopital de la Communauté Relief-G. Diederich
Account number 1000103902598
Suntrust Bank
11333 South Dixie Highway
Pinecrest FL 33156
Laurent Dreyfuss, DO
Department of Emergency Medicine, Cleveland Clinic Florida
Weston, FL
EMpulse • Mar-Apr 2010 33
DOCTORS’lounge
Speak Out / Letters
(Continued From Previous Page)
Opiate abuse associated deaths have risen
in Florida in recent years, with heroin con-
tinuing to be the most lethal drug found in
deceased persons, according to a 2009
interim report by the Florida Medical
Examiners. In fact, the top four drugs
found in greater than 50% of drug-associ-
ated deaths were heroin, methadone, fen-
tanyl and oxycodone.1
Opiate toxicity can
cause CNS and respiratory depression that
can lead to coma, respiratory arrest and
death. However, the administration of xone
was administered if needed. Of the 95 sub-
jects, 83% responded to IN naloxone alone
and only 16% of these required repeat IV
doses.5
In March of 2004, the use of IN naloxone
as a first line agent in suspected overdose
was implemented by EMS in San
Fransisco, CA. A retrospective chart
review comparing the administration of IN
naloxone and IV naloxone was then per-
formed. The study showed no difference in
the response rates for IN and IV naloxone.
Although the time for response was slight-
ly longer for IN naloxone, there was no dif-
ference in time of contact to clinical
response. The study did note that more
subjects in the IN naloxone group needed a
repeat dose than in the IV naloxone group.6
Despite the lack of in-hospital studies, IN
naloxone can be considered as an alterna-
tive route in the event of an opioid over-
dose. The use of a mucosal atomizer device
(MAD©), when purchased, can easily
attach to the IV naloxone syringe of
2mg/2mL and administer 1 mL to each
nare. The Florida Poison Information
Center Network is available at 1-800-222-
1222 for questions.
References
1. Florida Medical Examiner’s Commission. Drugs
Identified in Deceased Persons by Florida Medical
Examiners: Interim Drug Report; Nov 2009:i-34.
2. Wilburn SQ, Eijkemans G. Preventing Needlestick
Injuries Among Healthcare Workers: A WHO-ICN
Collaboration. International Journal of Occupational
Environmental Health. 2004;10:451-56.
3. Kerr D, Dietze P, Kelly AM. Intranasal Naloxone
for the Treatment of Suspected Heroin Overdose.
Addiction. 2008;103:379-86.
4. Dowling J, Isbister GK, Kirkpatrick CMJ, Naidoo
D, Graudins A. Population Pharmacokinetics of
Intra-venous, Intramuscular, and Intranasal
Naloxone in Human Volunteers. The Drug
Monitor;2008:490-96.
5. Barton ED, Colwell CB, Wolfe T, Fosnocht D,
Gravitz C, et al. Efficacy of Intranasal Naloxone as a
Needleless Alternative for Treatment of Opioid
Overdose in the Prehospital Setting. J of EM.
2005;29:265-71.
6. Robertson TM, Hendey GW, Stroh G, Shalit M.
Intranasal Naloxone is a Viable Alternative to
Intravenous Naloxone for Prehospital Narcotic
Overdose. Prehospital Emerg Care. 2009;13:512-15.
7. Kerr D, Kelly Anne-Maree, Dietze P, Jolley D,
Barger B. Randomized Controlled Trial Comparing
the Effectiveness and Safety of Intranasal and
Intramuscular Naloxone for the Treatment of
Suspected Heroin Overdose. Addiction.
2009;104:2067-74.
POISONcontrol
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:54 AM Page 35
Orlando HealthRebecca Blue, MD
Greetings from Orlando!
It’s been a busy winter, and with spring
approaching we are all looking forward to
the match! It has been such an impressive
interview season, and it seems like every
year it gets harder to put together our
match list because there are so many amaz-
ing applicants to choose from! Our pro-
gram’s strongest attributes are the resi-
dents, and we are very blessed to have so
many highly talented young men and
women to work with. This year, our resi-
dents have gone out of their way to support
recruitment, make the applicants feel wel-
come, and offer invaluable insight into the
match list. Thank you so much to every-
one who has made this a successful appli-
cant season!
Our residents are already looking forward
to SAEM, and the momentum of academic
productivity is fantastic. We have had
another highly successful year and many of
our scholarly projects have been accepted
by SAEM. Residents will be delivering
oral presentations, moderated poster pre-
sentations, and multiple poster presenta-
tions on innovative procedural techniques
and unique applications of new technology.
The collaboration between residents, fel-
lows, and faculty is wonderful - congratu-
lations to everyone who has been accepted!
We are all shivering and hoping for warmer
weather soon, but despite the cold our pro-
gram is better than ever. Spring is just
around the corner, and we can’t wait to see
what it brings!
Florida HospitalBrittany Thomas, MD
Firstly, I'd like to mention that we are pray-
ing for the families in Haiti and hope to
arrange a trip soon to serve those in need.
As spring arrives, our residents have been
involved with various local conferences. In
January, both classes attended the 1st
Annual Risk Management Symposium. Dr.
Amal Mattu discussed risky cardiac and
pulmonary conditions, and our very own
Dr. Alfredo Tirado taught us how to utilize
ultrasound in emergency situations. Also,
we were advised on EMTALA, deposition
pitfalls, and correct medical documenta-
tion by two lawyers.
In February, we dedicated our Thursday
lecture series to in-service preparation. We
set the bar high and hope to continuously
improve our scores. A few of us traveled to
Tallahassee for EM Days to discuss med-
ical concerns with our state legislators.
And in April we will participate in the 10th
Annual Symposium on Emergency
Medicine, Standards of Care featuring
Advances for the Clinician and Best
Evidence in Emergency Medicine. Not
only will we learn more about the “Art of
Medicine,” we will also practice our skills
at the advanced airway and ultrasound
hands-on workshops.
We congratulate Dr. Alexander Garcia,
who went to the AAEM Conference in Las
Vegas to present a case on amoebic menin-
gitis, and Dr. Michele Rorich, who ran
Disney’s “Princess Half Marathon.” We
certainly have a multi-talented group!
University of South FloridaJason W. Wilson, MD
We are all aware of the recent crisis in
Haiti, following the devastating earth-
quake. This moved a country with poor
infrastructure to one of virtually no infra-
structure in the heart of that nation.
The state of Florida has responded to the
desperation in multiple ways, including
that of providing medical care both within
our borders and in Haiti. Our geographical
proximity and the considerable Haitian
population in Florida make the situation
even more urgent.
Our program, through the leadership of Dr.
Catherine Carrubba, has been intimately
involved in the care of Haitian medical
refugees evacuated from Haiti and brought
to Florida. This has been an excellent
learning opportunity for us as residents.
We meet the large U.S. Air Force cargo
planes at the airport and perform a second-
ary triage role.
Next, we arrange transport to area hospitals
- both by ground ambulance and, when
necessary, by helicopter transport to loca-
tions further away, such as Gainesville.
Not only has this allowed us residents to
contribute in some small way, but it has
also allowed us to learn disaster triage and
the process of patient transfer to other
facilities (something we rarely do at our
large tertiary care center).
This is a miserable international disaster
but it has been impressive see how our
country has responded in such a merciful
way.
34 EMpulse • Mar-Apr 2010
RESIDENCYmatters
http://www.fcep.org/emraf.htm
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:54 AM Page 36
EMpulse • Mar-Apr 2010 35
University of Florida, JacksonvilleOscar Espetia, MD
Greetings!
2010 is well on its way and we are more
than halfway through the academic year.
For the all seniors graduating this year
good luck on the job hunt! Here is a little
update for the rest of Florida on some of
the activities at UF/Shands Jacksonville.
We are only a few months into the year and
our program has been very busy. Dr.
Wears’ published “Situated vs regulatory
rationality” in the January issue of the
Annals of Emergency Medicine. Drs. Caro
and Topp have authored the chapter
“Cardiopulmonary Resuscitation during
Pregnancy” for the Handbook of Obstetric
and Gynecologic Emergencies, 4th edition,
edited by Dr. Benrubi. Dr. Joseph has writ-
ten a book chapter entitled “Diabetes
Mellitus, Juvenile” in Rosen and Barkin’s
5-Minute Emergency Medicine Consult
edited by Schaider, Hayden, Wolfe, R.
Barkin, A. Barkin, Shayne, and Rosen.
Drs. Devos and Akhlaghi have been
appointed to the Eurasia Congress of
Emergency Medicine’s Scientific Advisory
Committee as International Members and
will also be members of the planning com-
mittee. The conference will be held
November 2010 in Antalya, Turkey.
As the year continues to progress, we look
forward to the upcoming match and are
eager to see who will be joining our ranks
here at Jacksonville. We also wish every-
one good luck on the in-service exam com-
ing up soon!
Mt. Sinai Medical CenterMarshall A. Frank, DO
This year our program received over 200
applications for five spots.
Our program director, Dr. Beth
Longenecker, broke her foot in a jump-rop-
ing accident. She was seen, however,
attending a department meeting before she
had an x-ray. She is now not bearing
weight on her right foot, using a knee-
scooter, and still working as hard as ever.
We all wish her a speedy recovery.
For the first time, several of us plan to par-
ticipate in Southeastern MedWAR
(Medical Wilderness Adventure Race) in
Fort Gordon, GA in April. MedWAR com-
bines wilderness medicine with adventure
racing and is designed to teach and test
wilderness survival and medical skills.
After the recent devastating earthquake, we
have seen a huge outpouring of support for
Haiti. Dr. David Farcy and Dr. Seth
Marquit traveled to Port-au-Prince to staff
a medical clinic. Dr. Farcy found a man
trapped in the rubble for almost 10 days.
He attached IV tubing to a stick and thread-
ed it through a hole so that the man could
drink while they dug him out. Dr. Farcy
then climbed into the hole to pull him out,
but thereafter became so exhausted that he
needed IV fluids himself. Awesome!
Miami is a very active city right now: we
have the Orange Bowl, Miami Marathon,
Pro Bowl and the Super Bowl. Hopefully
fans will behave themselves so we can get
through the upcoming weekend unevent-
fully.
University of Florida, GainesvilleRita Fairclough, MD
Greetings from Gainesville! In the last
four months, we have adjusted to our new
ED relatively well. Our visits are project-
ed to increase to 80-85,000 this year, and
we hope to see an increase in the number of
residents per year too.
Our third year class has finished interview-
ing and we will be a Florida, Alabama and
Texas class! Graduation is set for June 19
and the light at the end of the tunnel is get-
ting brighter!
Our interns are doing a great job. Kudos go
out to Andrew, Ben, David, Dan, Henry,
Justin, Tim and Tom for their hard work.
The interview season has ended and we
have stellar applicants. Hopefully we will
add some XX power to the incoming intern
class. We would like to thank Dr Desai,
who organized the interview season this
year. His NFL style draft board was a hit,
and made organizing the rank list easy. Big
thanks also to the faculty members who
helped interview and the residents that par-
ticipated in the breakfasts, lunches and din-
ners.
Several of our third and second year resi-
dents expect additions to their families.
We congratulate Bill Jackman, Miles
Bennett, Kevin Tench and their wives.
We are actively interviewing several candi-
dates for faculty positions, including
Program Director, and hope to apprise you
of the results in the next newsletter. Good
luck to all in the up coming in-service
exam.
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:54 AM 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
2010-11 legislative cycle. With these
funds we will be able to help elect candi-
dates who support your issues. This will
enable us and your organization to partic-
ipate in the decision-making process.
To find out more about contributing to
PAEC, or to join our 2010 contributors,
contact Beth Brunner at:
Thank you!
2010 Platinum Members:
Florida Emergency Physicians, Inc.
2009 Platinum Members:
Emergency Physicians of Central Florida
Florida Emergency Physicians, Inc.
2009 Silver Members:
Comprehensive Medical Billing Solutions
Jacksonville Emergency Consultants, PA
Martin Gottlieb & Associates, LLC
Southwest Florida Emergency Physicians,
PA
2009 Other Members:
Tampa Bay Emergency Physicians, PL
Miguel Acevedo, MD, FACEP
Wayne Barry, MD, FACEP
Dale Birenbaum, MD, FACEP
Bradford Bowls, MD, FACEP
John Braden, MD
Michell David Brantley, MD
Ka Hang Chan, MD, FACEP
Leonardo Cisneros, DO, FACEP
Casey Corbit, MD
Paul Deponte, DO
Vidor Friedman, MD, FACEP
Vicki Friend, DO, FACEP
Wayne Friestad, MD, FACEP
Mark Frisch, MD, FACEP
Brent Gardner, MD, FACEP
David Goldman, DO, FACEP
Hugh Jones,MD
Rodney Kang, MD, FACEP
William Knibbs, MD, FACEP
Karl Korri, MD, FACEP
Ronald Krome, MD, FACEP(E)
Mark Kruger, MD, FACEP
Linh Tung Le, MD, FACEP
Jorge Lopez-Ferrer, MD, FACEP
William McConnell, DO, FACEP
Gary Mendelow, MD, FACEP
Steven Nazario, MD, FACEP
Steven Newman, MD, FACEP
Patricia Singh Nichols, MD
Brian Nobie, MD, FACEP
Lisa O'Grady, MD
William Osborn, III, DO
Ernest Page II, MD, FACEP
Ketan Pandya, MD, FACEP
Vanessa Peluso, MD
Paul Petersen, MD
W. Randall Poole, MD, FACEP
John Prairie, MD, FACEP
Cheryl Reynolds, MD
Maritza Rodriguez, MD, FACEP
Marc Santambrosio, MD,
FACEP
David Sarkarati, MD, FACEP
Thomas Schaar, MD, FACEP
Regan Schwartz, MD, FACEP
Ehsan Shirazi, MD
Claire Simpson,MD
Weylin Sing, DO, FACEP
Sivapragasm Sivanesan, MD,
FACEP
South Miami Criticare, Inc.
John Tilelli, MD
Bryce Tiller, MD, FACEP
George Tracy, MD
John Valentini, MD
H. Kenneth West, MD
Susan Wolcott, MD
Emergency Physicians of Florida (EPF),
formerly known as the Florida College
Political Action Committee (FLACPAC),
is one of the primary advocacy tools that
enables individual physician members of
FCEP to make a difference at the legisla-
tive and regulatory level. In order for us to
have a positive influence on our legislators,
both at home and in Tallahassee, we need
your help. Please consider “giving a shift”
from personal funds. You can even donate
online at:
http://www.fcep.org/flacpac.htm.
Thank you to all who have donated since
the 2009 Symposium by the Sea!
Emergency Physicians of Florida
ADVOCACYnow!
36 EMpulse • Mar-Apr 2010
People for Access to Emergency Care
empulse-Mar-Apr-10-USE THIS ONE-2:Layout 1 3/11/2010 11:54 AM Page 38
REGISTER ONLINE
www.emrlc.org
Symposium by the Sea 2010The Annual Meeting of the Florida College of Emergency Physicians
July 29 - August 1, 2010 . The Boca Raton Resort & Club . Boca Raton, FL
Presented byEmergency Medicine Learning & Resource Center (www.emlrc.org) in
conjunction with the Florida College of Emergency Physicians (www.fcep.org).
Conference OverviewSymposium by the Sea 2010 is an educational opportunity designed for the busy emergency physician, resident, nurse, PA, and allied health professional who demands cutting edge information regarding their ever-changing practice environment. In addition to the educational sessions, the conference provides: Symposium General Educational Sessions*
Preconferences available for ED Administrators, Medical Directors & Nurses; Satellite Educational Symposia; Florida Emergency Medicine Resident's Case Presentation Competition (CPC); Wine & Cheese Reception with Exhibitors; Ferguson, Lee, Slevinski (FLS) Volleyball Tournament; EMRAF Job Fair.
*All except the preconferences are no charge to FCEP members!
Conference Date & LocationJuly 29 - August 1, 2010 . The Boca Raton Resort & Club . 501 East Camino Real . Boca Raton, Florida 33431Reservations: (888) 491-BOCA (2622) . www.bocaresort.comMention EMLRC Symposium by the Sea 2010Guest Room Reservations Cut-Off Date: July 14, 2010 Reserve your room early!
Who Should AttendEmergency Physicians, Physician Assistants, Nurses and other Health Care Professionals.
FCEP Membership BenefitRegistration for the Symposium by the Sea general conference is FREE to all FCEP members. Join the Florida College of Emergency Physicians prior to Symposium by the Sea and your registration will be refunded upon receipt of your application and payment of your first year's dues. For further information, contact the FCEP office at (407) 281-7396 or by email at [email protected].
Exhibit and Sponsorship OpportunitiesVisit www.emlrc.org/sbs2010.htm or contact Jerry Cutchens at (407) 281-7396 x15, [email protected] Exhibitor and Sponsor Prospectus is available directly at www.emlrc.org/pdfs/sbs2010prospectus.pdf.
More InformationVisit www.emlrc.org or call (800) 766-6335 . EMLRC . 3717 South Conway Road . Orlando, FL 32812
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