EMpulse January-February 2010 Issue

empulse-Jan-Feb-10:Layout 1 12/23/2009 3:48 PM Page 2

International MedicineThe Antarctic Explorer: Bud Ferguson 15

EM: An Ideal Specialty for the Military 16LTC Lisa DeWitt, DO

Academic IEM and Me 17Elizabeth DeVos, MD, MPH

Revolutionizing the Development of Academic IEM in India 18Sagar Galwankar, MD, MPH & Kelly P. O’Keefe, MD, FACEP

What’s the Allure of IEM? 19Erin C. Connor, DO & Scott Stirling, MD

The Challenges of Maritime Medicine 20Arthur L. Diskin, MD, FACEP

Locum Adventures 21Marlene Buckler, MD

Missionary EM: No Labs, No X‐Rays, No Problem! 23Arlen Stauffer, MD, MBA, FACEP

DepartmentsPRESIDENT’Smessage 2Mylissa Graber, MD, FACEP

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

GOVERNMENTALaffairs 6Steve Kailes, MD, FACEP

ACADEMICaffairs 8Joseph A. Tyndall, MD, MPH FACEP

EMS/trauma 10Michael Lozano, MD, FACEP

MEDICALeconomics 12Ashley Booth, MD, FACEP

PROFESSIONALdevelopment 14Paul Mucciolo, MD, FACEP

EMdays 24Vidor Friedman, MD, FACEP

HEALTHreform: Lessons from the Massachusettes Experience 25Peter B. Smulowitz, MD, MPH

RURALem: A Perspective on Rural EM in Florida 28Cary Pigman, MD, FACEP

CONSCIOUSsedation / DOCTORS’lounge 29Ernest Page II, MD, FACEP

ERchronicles: Breaking the News 30Arlen Stauffer, MD, MBA, FACEP

POISONcontrol 32Calvin Tucker, PharmD. & Joe Spillane, Pharm.D., DABAT

New ACCME CME Rules 33John Todaro, BA, REMT-P, RN, TNS, NCEE

RESIDENCYmatters 34

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

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

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

Michael Citro • Managing [email protected]

Cover Design by Michael Citro / Leila PoSaw

All advertisements appearing in the FloridaEMpulse are printed as received from theadvertisers. Florida College of EmergencyPhysicians does not endorse any products orservices, except those in its Preferred VendorPartnership. The college receives and distrib‐utes employment opportunities but does notreview, recommend or endorse any individu‐als, groups or hospitals that respond to theseadvertisements.

Published by:Franklin Communications, LLC5301 Northwest 37th AvenueMiami, Florida 33142‐3207Tel: (305) 633‐9779 • Fax: (305) 633‐2848www.frankgraph.com

NOTE: Opinions stated within the articles con‐tained herein are solely those of the writersand do not necessarily reflect those of theEMpulse staff or the Florida College ofEmergency Physicians.

EMpulseVolume 15, Number 1

EMpulse • Jan-Feb 2010 1


Happy New Year everyone! It’s amazing

to think we are already in 2010. It seems

like only yesterday everyone was con-

cerned about Y2K and what would happen

with the turn of the century. Yet, that is

now already 10 years ago. Time just con-

tinues to march on by.

Well, FCEP is working hard for you, get-

ting ready for this year’s legislative ses-

sion. Many bills have been filed pertain-

ing to healthcare, and we are analyzing

those to make sure they are in the best

interest of emergency physicians and their

patients.

This year several bills have been filed

about texting and driving. With the num-

ber filed, it is very likely that a bill will be

passed this year, making it illegal in

Florida to text while driving. Studies have

shown that people are 15 times as likely to

get in an accident if texting, which makes

sense since it is impossible to do so and

look at the road. FCEP has chosen to sup-

port such legislation, and I’m sure the

telecommunications industry will be hard

at work coming up with even better alter-

native methods to communicate while

driving. Multi-taskers, like me, need not

worry.

One issue that we may be facing this year,

although no actual bill has been filed as of

yet, is that of making it illegal for physi-

cians to balance bill patients. Currently in

Florida, there is a ban on balanced billing

for HMO patients, but the insurance indus-

try is looking to expand this. Basically,

without putting in safeguards that require

them to pay us fairly, we will lose all

recourse with obtaining proper payment

for services rendered. This would be a

huge problem and basically give the insur-

ance industry the ability to underpay doc-

tors and hospitals whatever they want, with

no recourse from the medical industry.

This is something we will work hard to

fight if it does surface, as an overhaul of

the insurance system would need to occur

before any type of law should be enacted,

if at all.

As for the amicus brief we had filed con-

cerning our cap on non-economic dam-

ages, the judge found that the caps did not

apply because the case occurred prior to

the caps even though the case wasn’t filed

until after the caps, so it turned out not to

be the challenge case. There was one other

case in which the caps were upheld in a

Florida court, so that is good news for us.

It’s been six years and the caps are holding

strong. We’ll continue to watch and be

ready.

EM Days is coming up, so please join us

this year. We really need more participa-

tion from our doctors. Don’t worry; we

will walk you through the process so there

is no need to be shy if you’ve never come

before. If you have any questions about

ways to get involved or what to do, please

feel free to contact me at any time. As

always FCEP is here for you! See you in

Tallahassee!

2 EMpulse • Jan-Feb 2010

PRESIDENT’Smessage

Happy New Year!

Mylissa Graber, MD, FACEP

FCEP President Mylissa Graber and Vice-President Vidor Friedman recently greetedGubernatorial candidate Alex Sink (center) recently at the FCEP office in Orlando.



The EMpulse staff wishes each and every

one of you a very Happy New Year!

We could think of no better way to ring in

2010 than with an issue celebrating

International Emergency Medicine. And

what a party it is!

Elizabeth Devos questions the very idea of

IEM. What is it? Is it about EPs going

abroad and helping the poor and the sick or

is it about us helping to establish EM in far

off countries so that they can then take care

of their own emergency patients? Is it a

personal quest on a deep, spiritual level or

an intellectual process on an academic

level?

The section of International Emergency

Medicine with over 1000 members is the

largest and most active section of ACEP. It

notes that “as the trend towards globaliza-

tion continues so does the need to support,

promote and develop the specialty of emer-

gency medicine” and that “together, we can

serve as a resource to other countries in

their development of emergency medicine

and promote international interchange,

understanding and cooperation among

physicians practicing emergency medi-

cine.”

However, the EMpulse has taken the liber-

ty to expand on this idea. As health knows

no borders, we have taken IEM out of the

box. We have brought together Florida

EPs who have broken all boundaries, who

have taken EM out onto the high seas or

the snowy ice caps of the South Pole to

take better care of sick people. Keeping in

mind that any sickness is an emergency for

the patient and his/her family, we are doc-

tors first. Healing the sick is an honor and

a privilege, in the US and abroad.

Arlen Stauffer tells of his passion for mis-

sionary medicine in the remote jungles of

South America while Sagar Galwankar and

Kelly O’Keefe describe their efforts to

establish EM in India and “positively affect

the emergency medical care of a billion

people.” Erin Conner and Scott Sterling

talk glowingly of their resident experiences

with EM development in India.

On the more wild side, Lisa Dewitt, the

first residency program director at Mount

Sinai, writes how she gave it all up to fol-

low her true calling in the military. She has

abandoned civilian EM and “gone rogue”

in more than 19 countries. Arthur Diskin,

former FCEP president, is “yo-ho-ho-ing”

at Royal Caribbean Cruises as their Global

Chief Medical Officer. I wonder if a bottle

of rum and an eye patch is part of his

mandatory cruise ship uniform.

On the more practical side, not being resi-

dency trained in the U.S., Marlene Buckler

is forced to work global locum tenens. She

has done so in New Zealand, Canada, and

is off to England soon. Her tenacity to suc-

ceed in the face of adversity is admirable.

We continue to honor Bud Ferguson,

recently deceased, for his work in the

Antarctic. Annette, his wife, was kind

enough to share his photograph and mem-

ories at the South Pole. He continues to be

our hero.

Wayne Barry has done a considerable

amount of work in Haiti. He has shared his

experiences with us in prior EMpulseissues. More of his thoughts and adven-

tures can be found on the online forum

(www.fcep.org).

This issue reflects the accomplishments of

our friends, our peers, our colleagues. With

such a lineup, I hope you feel the same way

I do: very proud of the singular achieve-

ments of Florida EPs. Our work in IEM,

whether this is spiritual or intellectual or

both, is not limited to our ED or our town

or state. It has far reaching effects and con-

sequences in remote corners of the globe.

I am inspired by the efforts of those who

try to make a difference. It is in keeping

with the spirit of this season: joy to the

world and peace on earth!

EDITOR’Semergencies

Leila PoSaw, MD, MPH, FACEP


Joy to the World



Ideas on healthcare reform are buzzing

everywhere. We can easily feel doubtful

that any of this will improve our practice.

One thing is certain: we need to be part of

the solution or accept whatever decisions

are forced upon us. Your involvement now

is more important than ever. Yes, I mean

YOU.

For those of us who have been actively

involved, we are doing our best to keep up

with the never ending moving target that is

“healthcare reform.” At the same time, we

are following scores of bills being filed in

Tallahassee which will guide our efforts for

the 2010 legislative session and focus our

energies for EM Days, March 8-10.

What can you do? There are many ways to

get involved, including the most important

of them all - just show up! Join us for our

committee meetings on February 17 in

Orlando. Participation in Tallahassee at

EM Days is especially needed as we meet

with every legislator to educate them about

our concerns and issues. Some of you will

read this, get nervous and think, “I can’t do

that. I won’t know what to say or do.”

Fear not, for you won’t be alone. You can

join other members, follow or lead the way.

What is important is our strength in num-

bers. Yes, we really need you.

There are issues that have grabbed our

attention and efforts. Of great concern is a

probable attempt for a state ban on bal-

anced billing of patients. If the anticipated

efforts to extend this ban to all patients

passes (the ban already exists for HMO

patients), our negotiating power with insur-

ers will be cut right out from under us and

we should expect a significant decline in

our reimbursements. FCEP opposes initia-

tives which limit a practitioner’s ability to

receive fair payment and which will erode

the availability of emergency care and

services.

Another issue is the 2003 caps on non-eco-

nomic damages. A recent case, McCall

versus the U.S., deals with the unfortunate

death of a young woman shortly after child

birth. The plaintiffs argued the 2003 caps

were unconstitutional. Importantly, “The

court concludes that section 766.118(2)

[FL statutes], which limits and aggregates

noneconomic damages in medical mal-

practice actions, does not violate equal pro-

tection under the United States

Constitution.” This is likely not the end of

the challenges to the caps. We need to

remain vigilant. We have submitted an

amicus brief for one trial challenging the

caps and will continue work to support any

efforts that will improve our medical liabil-

ity concerns.

Furthermore, insurance coverage does

not equal access when it comes to patient

care. We are working towards expanding

the number of EM residents in Florida. We

are also working on ways to increase

patient access to primary care physicians,

mental health providers, and other special-

ists, including on-call specialists.

We have challenged efforts that will limit

or hamper our practice, including a recent

Board of Nursing rules hearing that could

significantly affect performing procedural

sedation.

Finally, we are supportive of efforts to

improve patient safety. We support legisla-

tion that promotes patient safety, including

booster seats for young children, as well as

efforts to prohibit cellphone texting while

driving.

So, please, get involved. There is much at

risk. We need your time AND we need

your financial support. Encourage your

fellow EM physicians to join FCEP, and

please contribute to our CCEs: Emergency

Physicians of Florida (for individuals) and

People for Access to Emergency Care (for

groups). Your dollars are extremely impor-

tant in our efforts to be recognized and

heard. You can donate online at FCEP.org

under the government -advocacy tab at the

top of the page.

Be a part of the solution and I’ll see you in

Tallahassee.


GOVERNMENTALaffairs

Steve Kailes, MD, FACEP

If this passes, our negoti‐ating power with insurerswill be cut right out fromunder us.

Change is Coming


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Once again, we find ourselves at the begin-

ning of a brand new year and the start of a

cycle of activities for the Academic Affairs

Committee. We begin with the academic

program during EM Days in the early

spring and end with the Symposium by the

Sea in the late summer.

This year, however, FCEP’s investment in

long term strategic planning has led to

important considerations beyond the annu-

al cyclical planning of prior years. This

long term vision for the Florida College

has enormous potential and is vitally

important to sustaining FCEP’s mission. In

the case of the Academic Affairs

Committee, one word could be used to

summarize this long term strategic view –

collaboration.

A product of this strategic thought is the

Florida Consortium for Academic

Emergency Medicine (FCAEM). Still a

proposal in draft form, this statewide col-

laboration would be an effort to bring

together the best and most productive aca-

demic minds in EM and research from

across the state - from institutions, depart-

ments and institutes that value the

advancement of EM as a specialty. I view

this network as having the future potential

to support the development and promotion

of EPs interested in academic EM; to

organize and grow external resources that

will aide in the education of EM residents

across the state; and to create a state wide

research network for the purposes of shar-

ing information and data in support of the

College’s mission. This network could

serve as a conduit for extramural funding

that could support research activity in a

broad range of areas that could include

health services research, patient safety, dis-

aster preparedness and many other areas of

importance to EM.

Why such a consortium? This is an oppor-

tunity for collaboration (again that word)

amongst so many individuals in our state

currently isolated in informational silos in

their own institutions and efforts. This

opportunity to gain leverage for funding

through FCAEM can positively impact our

own departments, as well as faculty and

other individuals interested in academic

career advancement. Such a truly participa-

tory network will have the potential to cre-

ate and to recruit future leaders in academ-

ic EM from the state of Florida. Clearly

there is much detail to be worked through.

Even though the visions are broad and free

ranging, the focus should be on opportuni-

ties to start modestly and build incremen-

tally for a sustainable future.

Meanwhile, the 21st Annual Emergency

Medicine Days is fast approaching. This,

largest of FCEP’s advocacy events, will be

held in Tallahassee during March 8-10,

2010. The Academic Affairs Committee

will be working with the Governmental

Affairs Committee and the Emergency

Medicine Residents’ Asociation of Florida

(EMRAF) to construct yet another inform-

ative and interactive session for FCEP

members. Central to the success of these

efforts is the participation and presence of

residents and students. Advocacy is and

will be an indispensable part of our contin-

ued development as a specialty and will

remain an important part of educating our

future leaders.

On behalf of this committee, I would like

to personally thank all FCEP staff and

EMRAF. Thank you for your efforts and

contributions throughout 2009. Also to all

the FCEP staff, FCEP and EMRAF mem-

bers, here’s wishing you all a happy and

healthy New Year!

ACADEMICaffairs

Joseph A. Tyndall, MD, MPH, FACEP

Strategic Collaboration




Another holiday season has come and

gone. For most of us, that meant working

in the ED while our colleagues were home.

Of course the symmetry of the holidays

means that for every day that you work you

get to enjoy a day at home or at least one

not in the hospital. Such is the nature of our

chosen profession. We share this dedica-

tion with our fellow medical personnel as

well as countless firemen, EMTs, para-

medics, and law enforcement officers.

Just in case no one does, let me be the one

to say, “Thank you for being there.”

Sometimes a simple thank you makes what

we do worthwhile.

With the holidays over, the next season of

significance for us at the Florida College

are the legislative sessions. By the time

you read this, the 2010 version of the

STEMI bill will likely have been filed.

In devising our upcoming legislative agen-

da, the Board of Directors discussed the

2009 iteration of the bill and decided that

the College would be supportive of the

main concept behind the bill – regionaliza-

tion of cardiac care. We are still in the

spring training phase of legislative session,

so it’s too soon to predict what will happen

to the bill in the final stretch. Needless to

say, your fellow FCEP members on the

EMS/Trauma and Governmental Affairs

Committees will work closely with our

lobbyist and allies in Tallahassee to craft

the best bill possible for our patients and

ourselves. If you are not an FCEP member,

maybe this is the time for you to sign up

and attend EM Days.

One of the questions that has come up dur-

ing our deliberations is one with a complex

answer. Why isn’t there a common

statewide EMS protocol? After all, several

states have statewide EMS protocols

including Massachusetts, New York,

Pennsylvania, Alabama, and Arizona.

There are several benefits to common state

protocols. Uniformity is one of them. In

areas where there are multiple EMS agen-

cies, statewide protocols provide a uniform

expectation for EMS care on the part of

hospitals.

The Institute of Medicine, in its recent

report on the state of EMS nationwide,

called for the development of evidence-

based model pre-hospital care protocols for

the treatment, triage, and transport of

patients. An evidence-based approach to

protocol development is preferable as one

would expect all patients to receive the

best quality EMS care possible.

Such an approach would be the natural

consequence of a collaborative effort by a

state board of EMS medical directors.

Statewide protocols can incorporate new

treatment principles more rapidly than a

piecemeal approach. Standardized proto-

cols permit better integration when disas-

ters affect our state, causing EMS

resources to be pooled.

However, the Florida model is one of

decentralized control. Although the Bureau

of EMS licenses pre-hospital agencies

(known as licensees), the final authority for

an agency to operate in a county lies with

the Board of County Commissioners

through the Certificate of Need process.

Similarly, the Bureau will certify, not

license, EMTs and paramedics (known as

certificate holders), but it is up to the indi-

vidual agency EMS medical director to

define the standard of care for a given cer-

tificate holder within a given licensee.

But isn’t a medic a medic?

To answer that, I would ask you to think of

your hospital. Is a nurse a nurse? Are there

differences from shift to shift, or even on

the same shift? How about different EDs?

Similar logic applies to medics and EMTs.

The standard of care that the medical direc-

tor sets in an agency is due in large part to

the resources applied toward HR, training

and quality assurance. A medical director

for two agencies in the same region can

have different protocols depending on

many factors including supervision, train-

ing, and budget constraints. Unless you

take into account the differences among

EMS agencies, a statewide protocol would

handcuff high performance systems, and

be an unfunded mandate for others.


EMS/trauma

Michael Lozano, MD, FACEP

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As the 2010 legislative session draws near

it has become evident that balance billing

will be on the legislative agenda. This will

be a pivotal issue for FCEP. Balance

billing is the practice of billing patients the

difference in the cost of services rendered

and the amount paid by the patient’s insur-

ance company. It typically occurs when

specialists, including EPs, are non-par (out

of the patient’s insurance network).

You may be asking, “Why is this a big

issue?” EPs are mandated by federal, as

well as Florida state law, to provide emer-

gency care regardless of the patient’s abili-

ty to pay or insurance status. As such,

according to the Centers for Medicare and

Medicaid Services, forty to fifty percent of

emergency care goes uncompensated and

EPs provide the most uncompensated care

of all physicians. In addition, most health

plans do not adequately reimburse for

emergency services and there is a constant

threat of significant future decreases.

According to a 2007 article in the Annals

of Emergency Medicine, payments for

emergency visits have declined consistent-

ly since 1996. If health care reform is

enacted and the SGR is not repelled, physi-

cians will see as much as a 21.5 percent

decrease in Medicare reimbursement.

Decreasing reimbursement for emergency

services and increasing amounts of uncom-

pensated care have contributed to the clo-

sure of hundreds of EDs across the country.

Lack of fair reimbursement threatens

access to emergency care and the medical

care safety net.

Federal law prohibits balance billing of

Medicare and Medicaid patients. In

January 2009, the California Supreme

Court banned balance billing entirely.

However, physicians have won some bat-

tles. Earlier this year, the AMA and other

organizations reached a $350-million set-

tlement with United Health Group in a

class action suit. Along similar lines a set-

tlement was reached in a class action suit

against Aetna which has resulted in Aetna

now processing non-par claims at 239% of

the Medicare level of reimbursement.

The prohibition of balance billing would

affect hospital based EM in additional

ways. Insurance companies, knowing that

EPs are mandated to provide care regard-

less of the rate of reimbursement, would

have no incentive to enter into in-par net-

work agreements with EPs at fair reim-

bursement rates or even to contract at all.

The only leverage EPs currently have is the

ability to balance bill patients the differ-

ence in what the insurer pays and the cost

of services rendered. If we lose this, it will

leave us with out any leverage to negotiate

fair reimbursement rates. The only option

would be to continue to bring long and

costly class action suits against insurance

companies in an effort to achieve fair and

equitable payment.

The argument from the consumer’s stand-

point is that they get “stuck with large

bills” but this is because some insurance

companies reimburse out of network

physicians at lower than fair rates. Patients

often have little or no time to determine if

the EPs are in-network providers due to the

nature of the emergency situation. In addi-

tion, a ban on balance billing in the state of

Florida will inhibit EPs’ ability to obtain

follow-up care for the patients they treat. If

insurance companies have no incentive to

negotiate fair reimbursement rate for spe-

cialists, secondary to a ban on balance

billing, there will be a further shortage of

on-call specialists. Without enough in-net-

work specialists, patients would have to go

out-of-network or incur long waits for in-

network physicians.

Florida received an F for access to care in

the National Report Card on the State ofEmergency Medicine released by ACEP. A

ban on balance billing will lead to further

access issues and create even more prob-

lems for patients in the state of Florida.


MEDICALeconomics

Ashley Booth Norse, MD, FACEP

The Balance Billing Debate


FCEP Welcomes its New Members

Mark Attlesey, MDKerry Bachista, MD

Ronald Berman, MDCatherine Carrubba, MD

Jerry Gibbs, MDCarlton Hamilton, MD

Rory Hession, MDAnn Kaminski, MDFarah Lalani, DO

Celeo Ramirez, MDJulie Shamas, MD

Christopher Shaw, MDCarlos Alberto Smith, MD

Peter Spence, DOMichelle Tom

Frederick Ward, MDAnish Zachariah, MD

Christina Zeretzke, MD

Recently Moved Into Florida

Guillermo CabreraAmy Cutright

Edward J Hartwig, DOSandeep Johar, DO

Sarah McIverVictor Randolph, MD

FCEP Honors Emergency PhysicianGroups with 100% Membership

All Children’s Emergency Center PhysiciansEmergency Medicine ProfessionalsEmergency Physician EnterprisesFlorida Emergency PhysiciansSouthwest Florida Emergency PhysiciansTampa Bay Emergency PhysiciansUniversity of FloridaUniversity of Florida, Jacksonville

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

We all know that membership numbers are important.The more FCEP generates in membership revenue, themore good we can do for our members through advocacyand other membership benefit programs. With that inmind, the Florida College of Emergency Physicians wouldlike to salute the above groups for achieving 100% mem‐bership.


“I’m too busy to attend meetings,” “I don’t

understand politics,” and “Someone else

will take care of it” are some of my excus-

es for not being active for the first 12 years

I was an FCEP member. After years of

working nights only, I recently resumed a

rotating schedule.

My attendance at the Board of

Commissioners meeting at Halifax Health

Medical Center where I practice provided

the impetus for me to get involved.

Clearly, the patients who rely upon our ED

for medical care need us to be their advo-

cates.

After contacting Executive Director Beth

Brunner via email, I was invited to attend a

day of FCEP committee meetings in

Orlando. As the newcomer with experi-

ence in neither politics nor organized med-

icine, I was somewhat hesitant. I was

greeted warmly and thoroughly enjoyed

the exchange of ideas. My interest in

issues relating to professional development

and physician well being was sparked dur-

ing a subsequent lunch meeting with Dr.

Wayne Barry.

As the newly appointed chairman, I have

been charged with formulating an action

plan for the upcoming year. I have decid-

ed to structure the plan on three “Rs:”

Recruitment, Retention and Relaxation.

Recruitment is paramount to the continued

success of FCEP. Organized medicine is

replete with acronyms and fragmentation.

Every specialty has its own board, college,

lobbying agency and agenda. Multiply this

by the number of medical specialties and

one can understand the fragmentation that

exists. There are a lot of cooks in the

proverbial kitchen!

EM, now more than ever, needs a unified

voice to present a clear message to

patients, the public and to legislators. A

hall of murmurs will not suffice. FCEP

strives to provide unification, but cannot

do so successfully without a full chorus. In

order to promote the goal of 100% mem-

bership of all Florida EPs, we currently

offer a 25% discount on first-year member-

ship. There hasn’t been a better time to

join and get involved!

Retention is key to the success of FCEP.

Many members have been working dili-

gently for decades while maintaining unin-

terrupted membership. This loyalty and

support should be acknowledged and

rewarded. With the unanimous approval of

the FCEP Board of Directors, these physi-

cians will receive recognition on an annual

basis in the EMpulse magazine.

Medical technology has been accelerating

at an increasing pace, the political climate

is changing, and patient needs are increas-

ing. Without retaining the support of cur-

rent FCEP members, the ability to meet

these changes will be compromised.

Please let FCEP know how we may serve

you better. If your experience is anything

akin to mine, it will be an eye-opening and

overwhelmingly positive experience.

Relaxation is a factor which cannot be

ignored. As a full-time EP, I realized the

importance of this very late in my career.

While reading an article about Father

Damien de Veuster, a Catholic priest in

Hawaii in the late eighteenth century

assigned to a leper colony, the description

of his role caught my attention: “Fr.

Damien had to build his own living quar-

ters, repair a chapel, celebrate daily Mass,

visit the bedridden, wash and bandage the

patients, dig graves, build coffins, and con-

struct houses. The raw wounds and repug-

nant odor of those afflicted often made it

challenging...” Does that sound analogous

to the many hats worn by EPs on a daily

basis?

It is important for new EPs to integrate the

practice of EM into their lives if only to

avoid work related stress. Designating

time for family, friends, and hobbies is

incredibly important. We often hear of

physician “burn out.” This is entirely

avoidable by promoting physician well-

ness. Dr. Kerry Neall has graciously agreed

to take charge of promoting wellness.

I would like to express my gratitude to Dr.

Wayne Barry for his encouragement.

Hopefully, I can maintain Dr. Barry’s

enthusiasm, creativity and diligence during

my tenure.


PROFESSIONALdevelopment

Paul Mucciolo, MD, FACEP

Recruitment, Retention & Relaxation


Bud Ferguson, MD, MPH, FACEP,

FACPM, a past FCEP president, was the

medical director for the National Science

Foundation (NSF) program in Antarctica.

Bud went in the summer to three different

stations. Pictured is Bud at the South Pole,

as represented by the barber pole. The

stakes are placed at the exact pole site,

which changes yearly with ice movement.

It is 40 degrees below and the gear is sup-

plied and must be worn anytime outside of

the shelter because of sudden blinding

weather changes. He had a great adventure

meeting many of the daring folks who

eagerly competed to go there.

- Annette Ferguson

McMurdo Station on Ross Island is by far

the largest facility in the Antarctic. While

the station has around 1,000 people, there

are considerably more than that who go

through. The largest population is during

the summer, September to February. In the

winter, the population plummets. The

majority of our problems last year were

routine, a number of flu and upper respira-

tory problems, and general cold-like symp-

toms. Medical evacuation flights go to

New Zealand, which is 8 to 10 hours away

by air. From late February to September,

there’s no transportation in or out. Housing

is dormitory style, with an assigned room-

mate, bathrooms down the hall, and little

privacy. Meals are served in a common

room but there are many outdoor diver-

sions, games and an extensive library and

gym. The common theme among the peo-

ple who come to McMurdo Station is that

they enjoy the community. They come

back for that community relationship and

identity, which is difficult to achieve any-

where else.

- As told by Bud Ferguson to Cynthia

Pergam, Newsadvance.com, August 22,

2008.

Editor’s Note: Emmett “Bud” Fergusonpassed away on Jan. 27, 2009. During hislifetime, he was instrumental in FCEP his-tory, through his leadership and tirelesswork.


INTERNATIONALem

The Antarctic Explorer



I had always thought about joining the mil-

itary, but I knew nothing about it. None of

my family or my close friends was in the

military. I was a busy ER doc working in

four South Florida EDs and a residency

program director. Then, Sept. 11, 2001 hit.

That was my opportunity to use my skills

and give back to my country.

Once commissioned in the Florida Army

National Guard, I was deployed within six

months. As a National Guard I was only

obligated to a 90-day “boots on ground”

deployment, however, after being in

Kuwait for a tour, I extended and was

attached to an infantry unit in Iraq.

We were in combat operations throughout

my one-year deployment. As an ER doc,

trauma resuscitations and emergency care

was easy, but I now had to become profi-

cient in primary care and resource limited

medicine. My duties included caring for

combat traumas and all the other illnesses

and injuries a soldier encounters. I was

involved in local clinic renovations, educa-

tional exchanges with Iraqi doctors, and

training Iraqi military medics. Medical

assistance for special patients and provid-

ing humanitarian aid for the local popula-

tion was also a big part of being a military

physician. I also had to learn to make evac-

uation decisions based on transport risks

and tactical capabilities.

It was a life-changing 18 months for me.

Somehow, I knew I was in the right place

at the right time doing the right thing and I

didn’t go back to civilian EM. The military

offered me the opportunity to take chal-

lenging and exciting courses: the Flight

Surgeon course, Airborne School, other

tactical shooting and driving courses, as

well as officer development courses, and

medical conferences.

Once I returned I was asked to join the 20th

Special Forces Group (Airborne). (I remain

with that unit today, in the Alabama Army

National Guard.) With this unit, I deployed

to the Horn of Africa. Although I wasn’t in

constant combat operations, EM again pre-

pared me for my missions. As an ER doc,

now with battlefield experience, I taught

“Tactical Combat Casualty Care” to our

partner nations’ military medical person-

nel. This cultural exchange was challeng-

ing and rewarding. By assisting the

Army’s Civil Affairs units, I was also able

to do multiple humanitarian missions in

which we treated thousands of patients in

remote areas of Africa. The tropical dis-

eases and untreated genetic conditions I

saw were vast. I had done medical mis-

sions previously as a civilian and this was

similar; except, the capability to work with

the host nation and embassies at a national

level combined diplomacy and humanitari-

an aid. We hoped that this would prevent

terrorist groups from taking advantage of

the poverty of African nations for recruit-

ment and training.

More recently, I’ve been involved in

Special Operations in the Global War on

Terrorism. Whether it is training another

nation’s medics in caring for combat

injuries, creating a medical plan in a

remote area, evaluating a host nation’s

medical facility, or just treating our

American heroes, EM is the perfect tool in

my toolbox.

The path I’ve chosen has taken me away

from a lot of things: my previous career,

academia, American EDs, family and all of

what we call a ‘civilized world.’ But, it has

given me so much more. I treat the most

honorable patient population in the world!

I go to medical missions in remote places.

I’ve traveled to 14 countries, all expenses

paid! I have jumped out of airplanes, scuba

dived in foreign waters, climbed moun-

tains, and have experienced a lot of our

world that most people never see.

Most importantly, I believe in the mission

and that is why I am still doing what I do.

INTERNATIONALem

LTC Lisa DeWitt, DO

20th Special Forces Group (Airborne)

EM: An Ideal Specialty

for the Military


What is International Emergency Medicine

(IEM)? It is a question I am asked fre-

quently and truthfully, the scope of work

varies significantly for many practicing

IEM physicians throughout the US. Some

focus on refugee medicine, others on disas-

ter relief or infectious diseases and public

health crises. I chose to develop EM in the

world through academic International

Emergency Medicine.

In my fellowship at George Washington

University, I worked mostly on expanding

and building the specialty of EM in proj-

ects on nearly every continent — injury

prevention programs in Ethiopian orphan-

ages to disaster drills in Peru; collaborat-

ing with Turkish EPs to improve the care

provided by general practitioners in rural

hospitals; and residency curriculum and

faculty development in China. As a fellow,

I obtained my MPH, wrote grants, hosted

faculty exchanges, and lectured and taught

bedside rounds on five continents.

In addition to honing packing skills and

finding the best economy seats for long

international flights, I have had the good

fortune to develop collegial relationships

with faculty, students and health officials

around the globe. Most recently, I returned

to Ethiopia to participate in the first facul-

ty exchange program to develop residency

and nurse specialty training in EM at the

Black Lion Specialty Hospital. This is

Ethiopia’s only tertiary public hospital,

affiliated with Addis Ababa University,

which opened its first ER just over one

year ago and is working to train dedicated

emergency staff.

Compounding the burden of infectious dis-

ease facing most of Africa, Ethiopia leads

the world in mortality due to road traffic

injuries — together these cause an enor-

mous public health burden. During fellow-

ship, we delivered annual CME lectures in

EM skills in conjunction with the

Ethiopian Medical Society’s annual meet-

ing, worked with medicine and surgery res-

idents on basics of managing acutely ill

and wounded patients, and developed a

conference to share EM/EMS lessons

learned from other African countries.

Along with the local and federal Ministry

of Health and the medical school faculty,

we planned options for the progress we see

today.

When I first visited Ethiopia in 2007,

emergency patients were examined and

treated along with outpatients in the pri-

mary care and surgery clinics. Triage

mostly consisted of an armed guard per-

haps pointing the general direction of the

clinic he felt might be appropriate. In

another hospital, lists of several medical or

surgical complaints were posted on the

doors to the clinics allowing patients to

attempt to choose which line they should

join. Essential medications and equipment

were and still remain in short supply, and

often patients’ families would purchase

these from private pharmacies or clinics

for treatment. A slow progress can now be

seen in the current triage process where

emergency nurses appropriately streamline

the critically ill and injured patients. Next

month, the first public ambulance system

will be inaugurated in Addis Ababa.

Teams of emergency nurses will work from

fire stations providing patient care and

transport through a centralized call center.

Currently I serve in the ACEP Section on

the IEM steering committee. As the

Educational Chair, I am responsible for

organizing the section’s educational ses-

sions at the Scientific Assembly. This year

international panelists shared their experi-

ences practicing “Emergency Medicine in

Conflict Zones,” on Pediatric IEM

throughout the world, on rationing in pan-

demics, and on human rights initiatives.

During these sessions’ medical students,

residents, fellows, and practicing physi-

cians from across the globe have the

opportunity to network and share ideas.

For me, IEM allows the privilege to devel-

op ongoing relationships to work towards

mutual education and improved emergency

care. In each program, my residents, stu-

dents and I have gained many times more

in return than we have provided and we

hope that we will continue to learn with our

friends each time we return.


INTERNATIONALem

Elizabeth DeVos MD, MPH

Assistant Professor

Dept. of Emergency Medicine, U. of Florida-Jacksonville

Academic IEM and Me


We have been working overtime for the

last five years to help establish EM as a

recognized specialty in India. The INDO-

US Emergency and Trauma partnership

was initiated in 2005 through the joint

efforts of the University of South Florida

(USF), SUNY Downstate Department of

Emergency Medicine, the Medical College

of Vadadora-SSG Hospital in Gujarat,

India, and the All India Institute of Medical

Sciences (AIIMS) in New Delhi, India.

This partnership also enjoys the support of

the World Association of Disaster and

Emergency Medicine.

The goals include: to have EM recognized

as a specialty in India; to develop EM res-

idencies; to develop programs which edu-

cate and train faculty members; and to fos-

ter research for the advancement of trauma

systems and emergency care in India.

Since 2005, the collaborative has organ-

ized five INDO-US Emergency Medicine

Academic Summits attended by over 6000

delegates. The associated pre- and post-

conferences and workshops held all over

India have trained over 4000 delegates

over the last two years. (www.indusem.com)

In 2006, the Academic Council for

Emergencies and Trauma (ACET) was

formed comprising of nominated coun-

cilors from recognized Indian medical col-

leges. ACET has taken the lead in drafting

curriculum, guidelines, and standards for

emergency care and trauma in India.

Today, over 75 medical colleges participate

in ACET. The Council publishes a quarter-

ly newsletter called TEAMS (Trauma andEmergency Academic Medicine Sentinel). The Emergency Medicine & Trauma

Education Center for Health (EM-TECH)

was founded in 2007. Its mission is to for-

malize and facilitate the process of provid-

ing life long education in emergency care

and trauma. It provides the necessary

knowledge, support, and technical expert-

ise to produce workshops, courses, and

academic meetings. EM-TECH is support-

ed by a large number of academicians from

both the US and India.

To promote and publicize research, the

Journal of Emergencies Trauma and Shock(JETS) was founded in 2008, with editors

from over 30 countries and 20 disciplines.

This peer-reviewed and indexed journal

has more than 20,000 readers, and is avail-

able in both print and online format

(www.onlinejets.org). It is a landmark pub-

lication, synergizing basic sciences, clini-

cal medicine, and public health globally.

In 2008, the INDO-US collaborative pub-

lished a landmark position paper on devel-

oping academic EM in India. This white

paper was published in the Journal of theAssociation of Physicians of India (JAPI),

which has served over one million

internists over the last 64 years. The con-

tents of this manuscript served as a frame-

work for the Medical Council of India to

recognize EM as a specialty in 2009. This

recognition has led to the creation of aca-

demic departments and the recruitment of

faculty using the framework as a guide.

The INDO-US Academic Research

Cooperative (INDUS-ARC) was created in

2009 to push the collaborative, multi-cen-

ter, clinical research agenda at academic

medical institutions across India. This

arrangement will make the research

process simpler, as the cooperative will

develop common approval and administra-

tive mechanisms to accomplish multi-cen-

ter research studies within a minimum

amount of time, resulting in maximum

patient participation related outcomes. The

INDO-US collaborative will continue to

foster leadership in educational exchange

and cooperative research via its annual

INDUS-EM Summit, ACET Assembly,

year round training events, and ongoing

research initiatives.

USF’s Dr. Sagar Galwankar spearheaded

the development of these programs. Drs.

Tracy Sanson and Kelly O’Keefe served as

chairs of the INDUS-EM conferences. All

three remain intimately involved, traveling

each year to India. Also at USF, faculty

(David Orban, Charlotte Derr, Cathy

Carrubba, Brad Peckler), residents (Preeti

Jois-Bilowich, Jason Johnson, Rahul

Salooja, Scott Stirling), and medical stu-

dents are actively involved. Anyone inter-

ested in supporting this movement, with

time or financial contributions, should con-

tact Dr. Tracy Sanson.

It is not everyday that we can say, “The

work I am doing will positively affect the

emergency medical care of a billion peo-

ple.”


INTERNATIONALem

Sagar Galwankar MD, MPH

& Kelly P. O’Keefe MD, FACEP

Revolutionizing the Development of

Academic EM in India


During residency, there comes a point

when your enthusiasm begins to wane and

a little cynicism creeps in. Running in cir-

cles in the ED, the big picture can become

cloudy and you wonder how you ended up

here in the first place. Sometimes, chang-

ing your perspective is all that is needed to

bring back your drive and focus and

remind you why you chose EM.

When Dr. Sanson sent out the e-mail

inviting EM residents to apply for a

grant to participate in the 5th Annual

INDO-US Emergency and Trauma

Program in Coimbatore, India, we

both jumped at the chance. Like

other residents interested in interna-

tional EM and facing the day-to-day

challenges of residency, we saw this

as a golden opportunity. Along with

eight other EM residents, we were

awarded the TeamHealth grant,

which proved to be one of the most excit-

ing and rewarding experiences of residen-

cy to date.

The mission of the INDO-US program is to

promote the advancement of academic EM

through an exchange between Indian and

American academic institutions. The part-

nership involves the USF Global Emerg-

ency Medical Sciences Program, SUNY

Downstate Department of Emergency

Medicine, Baroda Medical College-SSG

Hospital, the All India Institute of Medical

Sciences and TeamHealth. It was an excel-

lent opportunity for attending physicians,

residents, medical students, nurses and

other healthcare providers from India, the

U.S. and other counties to come together

for one common goal.

India is the second most populous nation in

the world, with over one billion citizens.

Its geographical area is three times smaller

than that of the U.S., yet this area contains

four times the population. It was amazing

to arrive in Coimbatore and witness the

buzz of excitement surrounding the confer-

ence. Trauma surgeons, orthopedic sur-

geons, and ED physicians from the U.S.,

India, and other countries attended.

The expansion of EM in India in the past

five years has been incredible. New trauma

centers and EDs have been built across the

country. Funding for EM training has

increased. Finally, and most importantly,

physicians themselves have become more

organized in their advocacy for the special-

ty. One of the highlights of the trip was our

visit to the PSG Emergency and Trauma

Center. The director was eager to show us

how he had taken different elements from

EDs he had seen in the U.S. and elsewhere

and had incorporated them into his depart-

ment. While some of the equipment may

not have been state-of-the-art, the triage

system and trauma protocols were as

streamlined as any U.S. center. It was fas-

cinating to hear the staff talk about their

advancements and their plans for the future

and to liken these conversations to

ones that must have taken place in

the early years of U.S. EM.

As residents, our role was to serve as

models of American EM residents.

We all had the chance to present a

core emergency medicine topic and

to assist in the suture and ultrasound

labs. There were research posters

and presentations on topics we con-

sider exotic here in the U.S. but are

mundane in India - including

snakebites, malaria, dengue fever and other

tropical diseases. This is not to say that the

trip was all work. Our evenings were full

of wonderful meals, social gatherings and

even a grand gala, replete with ‘Jai Ho’ and

a snake charmer!

We arrived back in the US with a renewed

energy, a new appreciation for EM and a

whole group of new friends. We were

excited to come back and share our experi-

ence with our colleagues in Florida. Thank

you to our Indian hosts, TeamHealth, Drs.

Sanson, O’Keefe, Galwanker and all the

other residents. It was an invaluable expe-

rience.


INTERNATIONALem

What’s the Allure of IEM?

Our recent trip to India

Erin C. Connor, DO

Mt. Sinai EM Program, Miami Beach,

Scott Stirling, MD

Univ. of South Florida, EM program, Tampa


Much has changed in the last five years: I

was caught up in the malpractice crisis; a

victim of nasty hospital and corporate pol-

itics; had fun consulting on risk manage-

ment and ED operations; parental deaths;

losing touch with old friends and making

new ones; and watching the subject of my

first FCEP presidential editorial on nurtur-

ing grow to be a little man of five – going

on 20.

I thought I had settled in for a career-end-

ing final tenure as Chief of Jackson

Memorial’s ED – organize, consolidate,

redesign the place, and start another resi-

dency program. A little teaching, a bag

lunch at a medical school lecture, a little

clinical work, deal with the union and its

“Little Red Book” (oh, sorry, it was purple)

and lots of those infamous hospital plan-

ning meetings. Life was good!! A little

well-deserved break from FCEP to allow

others to bask in the glory and I was set.

For more than 20 years, I had been a con-

sultant to the cruise industry. Most recent-

ly, I was Medical Director for Carnival

Cruise Lines, a subsidiary of Carnival

Corporation. I would spend half a day per

week at their offices dealing with diverse

issues such as medical credentialing, for-

mulary selection, staffing and crew med-

ical issues. I found the industry fascinating

and challenging, but I certainly would

never have considered it as a full-time job

– financially or intellectually.

I started to consult with the Royal

Caribbean Cruise Lines when I moved to

Jackson Memorial, as they had a long-

standing relationship with the hospital, uti-

lizing the department for 24-hour emer-

gency calls. Soon, the familiar dance

began – Royal Caribbean had decided to

establish a new position at a vice-president

level and wanted me to accept the position.

“...but I am happy here.” “We will make

you happier!” And so it transpired – Vice-

president and Global Chief Medical

Officer for Royal Caribbean Cruises, Ltd.

(RCL) – parent company of Royal

Caribbean, Celebrity and Azamara Cruise

Lines – 30+ ships; 40,000 crew and of

course, the amazing new megaship Oasis.

First, let me set the record straight. I am not

the “Love Boat doc.” I’ve entered ‘corpo-

rate America’ with a bang. Quarterly fore-

casts, budgets, slide presentations, insider

trading warnings, planning sessions and

worldwide presentations to non-physician

groups have become part of my everyday

existence. Jackson Memorial does not

have its stock price on its home page.

My responsibilities include Public Health.

Due to outbreaks of norovirus, the cruise

lines are under constant scrutiny. The

Vessel Sanitation Program (VSP) inspec-

tors from the CDC inspect ships docking at

U.S. ports – deducting points for violations

of established standards. A score less than

85 signifies failure and a quick trip to the

principal’s office for some poor captain.

Fortunately, our scores have hovered

around 97. Public Health includes food

safety (temperature, storage, service and

other issues); integrated pest management

(I now know the life-cycle of the cock-

roach); potable and recreational water

quality, and safety and outbreak prevention

and mitigation. One of my first duties was

to approve the “Fecal Accident” policy for

swimming pools – a long way from writing

stroke center policies (well, not really).

We have retired VSP inspectors who train,

inspect, audit and prepare ships’ pools for

inspection. The program works well. I

would rather swim in a ship’s pool or eat in

a ship’s restaurant than any land-based

operation.

I have expanded my infectious disease

knowledge base and management skills.

We are experts in legionella and gastroin-

testinal illnesses such as norovirus, as we

must do everything to protect our guests

and crew and avoid media sensationaliza-

tion. Since we have a crew from 100+

countries and have ships in 24 time zones,

we can see malaria, dengue, varicella,

rubella, tuberculosis, typhoid and other ill-

nesses – all fortunately rare, but forever

looming. H1N1 has presented some amaz-

ing challenges for the industry with vary-

ing responses in every port around the

world. Immunization programs for our

crew for seasonal and H1N1 is a major ini-

tiative and undertaking.

My major function is the supervision of the

medical facility operations aboard the

ships – the recruitment, credentialing (two

full-time nurses just for this), and retention

of the physicians and nurses. This has and

continues to require significant attention

and led to some significant house cleaning

activities. We have to select equipment,

formularies and supplies and develop pro-

grams to train in their operation and pre-

ventative maintenance. We have a 24/7

hot-line staffed by physicians and nurses

who work for me to assist the ship in the

(Continued on Page 22)


INTERNATIONALem

Yo-ho-ho! A Sailor’s Life for Me:

The Challenges of Maritime Medicine

Arthur L. Diskin, MD, FACEP

Vice-president, Global Chief Medical Officer,

Royal Caribbean Cruises, Ltd.


In the summer of 2007, after 15 years of

full-time EM practice, I decided to take a

year off. The relentless pressures of 12-

hour shifts were taking their toll. My long-

standing marriage had ended and the

thought of having time again for me began

to feel exquisitely therapeutic. Perhaps I

would just retire and concentrate on writ-

ing and developing my website. But like

most ER doctors, the challenges and satis-

faction of treating patients still held a cer-

tain appeal, and when a job opportunity in

New Zealand presented itself, I said an

enthusiastic yes to adventure.

I received a warm welcome in picturesque

Wanganui, which sits on a meandering

river on the southwestern coast of the

North Island of New Zealand. The city’s

population of almost 40,000 comprises of

European descendents and Maori, New

Zealand’s indigenous people.

Most international flights enter New

Zealand at its largest city, Auckland. With

a quarter of the country’s total population,

Auckland is indeed a modern and stimulat-

ing city. Foreign doctors arriving to work

in New Zealand are required to meet with

the NZ Medical Council before being

granted a final license; this gave me a day

to explore the “City of Sails.” I arrived in

September, spring in the southern hemi-

sphere, perfect for exploring Auckland.

It’s no surprise New Zealanders have been

ranked among the happiest people in the

world. The visitor is greeted to down-home

hospitality, friendly faces and some of the

most beautiful scenery on the planet. Add

in delicious food, some of the best hotel

accommodations anywhere, low crimes

rates and a high standard of living and it’s

easy to see why one visit, even a six-

month-long one, would never be enough.

New Zealand enjoys a modern healthcare

system with state-of-the-art medical prac-

tices. Free healthcare to citizens includes

Accident and Emergency (A&E, i.e. ER)

and in-hospital care, lab and x-ray, preg-

nancy and childbirth services, specialist

care and subsidized prescription medica-

tions. School children get free dental care.

Though all modern medical technologies

are available and are utilized, there seems

to be less reliance on CTs and more empha-

sis on the history and physical exam.

Remember those days? Specialists will-

ingly come to the ER to evaluate patients

and surgeons never ask “What did the CAT

scan show?” It is felt that a person should

not be exposed to the radiation of a CT

scan just because the specialist doesn’t

want to be inconvenienced.

Almost all patients have a general practi-

tioner. When discharging patients from the

ER one knows that follow-up care will be

provided. This spirit of community support

and concern for the welfare of others is

typical of New Zealand.

Locum doctors are not well paid in the land

down under but most are provided with

free use of a vehicle, accommodations and

transportation to and from the country.

Doctors are not sued, though one can be

reported by a patient to the health board. I

certainly do not regret my decision to

experience EM in the land the Maori call

“Aotearoa.’

My next locum adventure took me to the

ER at Queen Elizabeth Hospital (QEH), in

Charlottetown, the capital of Canada’s

smallest province, Prince Edward Island

(PEI). I had not worked in a Canadian hos-

pital since immigrating to the U.S. in 1993.

Some Americans are under the impression

that Canada’s universal health care system

leaves many of its citizens without timely

treatment. Though it is likely that

Canadians will wait longer than their

American counterparts for some elective

surgeries, such as hip replacements, emer-

gency care is not significantly different

than that in the States.

ERs treat all patients who show up. EMS

and triage systems ensure timely care for

all who need it. At the QEH, a teaching

facility and the major referral hospital for

PEI, specialists are not only willing to

evaluate patients in the ER, , they are actu-

ally pleasant about it. Follow-up care for

patients who may go home, but need to see

(Continued on Page 22)


INTERNATIONALem

Marlene Buckler, MD

Locum Adventures

The author (right), sailboat racing off PEI.


a specialist, is often accomplished by the

next day. How’s that for service? And

believe it or not, suicidal and psychotic

patients are admitted to the hospital and

not transferred. Psychiatrists taking turns

on call actually see patients in the ER.

Medical and surgical patients too sick to

go home are admitted to their GPs, to a

hospitalist or to appropriate specialists. I

never encounter any resistance when call-

ing to have a patient admitted. In fact I

would say that the QEH medical staff is

the happiest and most cooperative group I

have ever encountered.

My daughter’s plans to start Veterinary

Medicine at UPEI influenced my decision

to work in Charlottetown. It has turned

into a six-month locum, sailboat racing all

summer, excellent pay and working with a

great group of ER docs and medical staff.

I have been asked to return next summer

and plan to do so. What’s not to like?

The recent EM climate in the U.S. and

especially in Florida has become

unfriendly to non-boarded docs. More and

more doors are closing. Despite recent

workforce studies illuminating the reality

that the supply of RT/BC EM physicians

will not meet the demand for 20-30 years,

if ever, hospitals persist in turning away

highly competent EM doctors. In New

Zealand and in Canada there is an appre-

ciation for knowledge and experience.

Doctors are respected for their skills and

competence. Of course residency training

is valued, as it should be, but those who

began their careers when EM was a

younger specialty are seen as a valuable

resource to fill a need that won’t go away

any time soon.

My permanent home is in Florida and I

will likely return to practice there soon,

but for now I am off on another adventure,

this time to England for a few months’

work. Doing locums is fun and fulfilling.

logistics of medical disembarkations and

answer other questions. However, the doc-

tors are independent contractors and must

make their own decisions, as I often say to

them, “you are there and I am here, do

what you think is best.” This is where I

most see my clinical EM background kick

in – they have amazingly complicated

cases on board the ships. Everyone wants

to take a cruise before they die. Diagnose

someone in Iowa with cancer, the next call

is to the travel agent. People cruise with

medication lists you need to scroll through.

Once they reach a certain age, they will

wane philosophical and tell you if they die,

they die – let them finish their cruise.

I am also responsible for the medical care

of the 40,000 crew (25,000+ on ships at

any given time). We approve non-emer-

gency surgeries and arrange for care in

ports and/or if they need to be repatriated

home. We are developing networks around

the world and certifying facilities as Royal

Caribbean Centers of Excellence based on

quality, location and ease of access. I uti-

lize all my negotiating skills and tactics to

negotiate fees and identify billing abuses.

If you think the ambulance chasers are bad,

you should see the crew chasers who hang

out at ships to get them to sign up as

clients. I use my medico-legal skills,

which I thought I might be done with,

every day. I’m also responsible for crew

wellness programs; pre-employment phys-

ical programs; the Care Team, which

assists the crew and guests who have

adverse events or must be disembarked for

medical reasons; and, a group of financial

analysts who support the medical budgets

in the department and ships, and supervise

the processing of all crew claims and

develop forecasting models.

RCL has been very supportive of our criti-

cal projects and purchases. We have a new

semi-annual conference in Miami for our

doctors and nurses; we are in the middle of

purchasing and deploying digital x-ray

processors for our ships; we have new ven-

tilators capable of NIPPV; we are develop-

ing a tele-dermatology program with the

University of Miami; there are new defib-

rillators on board and our formulary has

been revised to include new drugs and

eliminate obsolete ones while accepting

the variations in practice of our multina-

tional physician and nursing staff.

The travel is interesting but tough with a

five-year-old at home. I have been to

Turku, Finland to inspect our new ship;

attended meetings at the European CDC in

Stockholm, visited the P&I Clubs in

London; spoken at an H1N1 conference in

Athens; inspected medical facilities in

Dubai, Dubrovnik and Santo Domingo;

and met with the CDC in Atlanta and with

the PAHO division of WHO in Barbados.

Mankind has gazed out upon the sea with a

desire to conquer it for millennia – what

would they think of floating discos, water

slides and designer boutiques floating

through Caribbean waters formerly filled

with pirates? I must say it is quite interest-

ing to meet the descendants of these char-

acters, no less colorful.

I continue to work 1-2 shifts per month at

Jackson Memorial (love that sovereign

immunity) and encourage anyone who

moves out of everyday EM clinical prac-

tice to stay clinically active. It is what you

trained for and validates everything else

you may do.

While I am working as hard as I ever have,

there is really no other job like this in the

world. I am honored and privileged to have

been selected for it. EM, as a specialty, a

lifestyle and an intellectual process has

prepared me for this position like no other

area in medicine could have. Our options

are many, varied and often offer challenges

far greater than we might expect.

Maritime Medicine (Continued from Page 20)

INTERNATIONALem


Locum Adventures (Continued from Page 21)


For the past several years, I have had the

privilege to work in parts of the world

where people usually get very little med-

ical care. There are very few things in this

life that are more rewarding.

My wife and I have led medical mission

teams to numerous Central and South

American countries since the mid 1990s.

Each time we go it changes the reality of

our roles and purpose in this world.

Experience in EM creates the perfect back-

ground for providing healthcare to the

poorest parts of our world; but, it’s sure not

like working in the U.S.

There is almost always something that can

be done to ease the suffering in rural, poor

areas: whether it’s giving Rocephin to a

man in Bolivia with pneumonia; re-

hydrating an 18-month-old Peruvian Shuar

Indian girl with a week of diarrhea; com-

forting a young Mayan man in Guatemala

who was burned when his family’s jungle

hut burned down; or pulling the transporta-

tion and the few dollars together that are

required to get a fractured femur fixed cor-

rectly in a hospital a few hours from the

jungles of Ecuador.

This type of travel is not for everyone.

There are long hours in planes, buses, and

sometimes in boats or on foot. The heat

and humidity in the jungle makes Florida

seem cool, water is only cool/cold, and

sleep often takes place in a mosquito net on

a dirt floor. We’ve met various types of

critters face-to-face that we’d never seen

before, and we’ve eaten Anaconda and

Capybara that actually tastes OK. (No,

Anaconda doesn’t taste like chicken.)

This type of medicine is not for everyone.

When working in these isolated areas, we

only have what we take along. An Accu-

Check is the lab, and we use stethoscopes,

tongue blades, and otoscopes. We carry

large duffles full of various (donated and

purchased) medications, and bring along a

few instruments for suturing, some IV sup-

plies, and Lidocaine and scalpels for

abscesses. There is no radiology and there

are no consultants; when we are there, we

are it!

However, when we see the look of aston-

ishment on a mother’s face when she can

gets medicine for her baby for free, realize

the trust placed in us by a father who has

carried his injured son all day through the

jungle to get to our clinic, or see the tears

drop from grateful parents’ faces (who

have lost children earlier from lack of med-

ical facilities), it makes the heat, insects,

and the bed situation seem rather trivial.

We usually travel and work under the aus-

pices of Missionary Ventures International

(www.mvi.org), a faith-based mission

organization with headquarters in Orlando,

and with missions in more than 80 coun-

tries around the world. The missionaries

serve as hosts for the mission teams,

arranging all of the in-country travel and

translators, and coordinating food and

other safety arrangements for team mem-

bers. (I refer to us as the “wimpy

Americans,” as the folks who live in the

areas we visit never have protected food

sources, malaria prophylaxis, hot water, or

soft beds.)

If you’re looking for something new to try

on your next “vacation,” searching for a

way to help those who are much less fortu-

nate, and feeling like it’s time to “give

back,” I encourage you to check out the

numerous mission and humanitarian

organizations that send out medical mis-

sion teams to the poorest areas of our

world. This changed my life. If you try it,

you will not be the same when you return.

Arlen Stauffer is an emergency physician inNew Smyrna Beach, a former FCEP Boardmember, and is now the Associate MedicalDirector for Halifax Health – Hospice.Visit www.CoronadoMissions.org fordetails and pictures of past medical mis-sions.


INTERNATIONALem

Missionary EM: No Labs,

No X-Rays, No Problem!

Arlen Stauffer, MD, MBA, FACEP


Hello everyone! I hope your holidays were

full of happiness and joy!

By the time you read this it will be 2010,

and your Governmental Affairs Committee

will be already hard at work with our elect-

ed representatives to further the interests of

our patients and profession.

One of the most important events of the

year is on the horizon, Emergency

Medicine Days, in Tallahassee. This is an

annual event, entering its 21st year, where

FCEP members spend several days in

Tallahassee, both learning about our leg-

islative agenda and collectively lobbying

our elected officials about issues important

to our profession. We hope to see your

there!

So what is Emergency Medicine Days?

Well, in addition to getting the most up-to-

date information about what is going on

legislatively in Florida, EM Days offers a

unique opportunity to network with your

peers, learn about the political process, get

some CME and overall have a pretty good

time doing all of this!

It is vital to our profession that our mem-

bers have a strong showing at EM Days,

never more so than in these times of

change. The healthcare drama that is play-

ing out in Washington will have significant

ripple effects in our state; it is imperative

that our voices are heard.

Who knows the realties of healthcare better

then us? This is the beginning of a conver-

sation, not a complete solution. The debate

is all about the high cost of healthcare, and

many point to the ED as an expensive, and

inefficient part of that ‘system.’

We know that emergencies happen in spite

of our best efforts. The real safety net of

our healthcare network is the emergency

system, and it is vital that this safety net be

not only protected but improved!

You can be sure that whatever changes are

made will impact our state significantly. In

these times of fiscal challenges, our state’s

elected officials will need all the assistance

they can get to implement the changes that

are being demanded by both our society

and the Federal Government.

By virtue of the position that emergency

medicine occupies in the healthcare net-

work, we see the challenges that patients

face both in the outpatient and inpatient

worlds and we can speak for them, as well

as ourselves.

You have your own experiences and pas-

sion for medicine and your patients. Your

stories matter, not just to you, but to your

patients and your elected officials. So

come to Tallahassee.

Help us explain to our elected representa-

tives how an earache is really an emer-

gency when it is your child screaming in

pain in the middle of the night.

Help us explain why it is important to a

working mother that a competent physician

be there to take care of her child after the

doctor’s office is closed and why that same

physician should be fairly compensated.

Help us remind our elected officials that

when their time of healthcare crisis comes,

they will want and demand that an excel-

lent emergency care team take care of

them.

If you do not show up, who will?


EMdays

See You at EM Days

Vidor Friedman, MD, FACEP

Your stories matter, notjust to you, but to yourpatients and your electedofficials.

Visit FCEP online!

www.FCEP.org


While Massachusetts’s landmark health-

care reform is still in its nascent stages, the

ramifications of expanding access to health

insurance are already apparent. “An Act

Providing Access to Affordable, Quality,

Accountable Health Care” (termed chapter

58 of the Acts of 2006) has expanded cov-

erage to over two thirds of the previously

uninsured in Massachusetts while energiz-

ing the national conversation on healthcare

reform. However, the reform falls short of

universal health care, it did not solve the

problem of the affordability of health

insurance or limited access to healthcare

and even with the recent renewal of the

federal Medicaid waiver, the expansion of

the state subsidized insurance placed a sig-

nificant strain on the state budget.

Massachusetts will need to tackle health-

care costs, raise enough revenue during an

economic downturn, and focus on access to

care in order to ensure the solvency of its

healthcare reform.

The exact framework of the Massachusetts

health reform has been previously well

described.1,2 This paper seeks to describe

the major consequences of healthcare

reform in Massachusetts. We will then

comment on the implications of chapter 58

to broader efforts at healthcare reform.

Impact on the number of uninsured

Since implementation on July 1, 2006,

over 439,000 individuals have been

enrolled in health insurance.3 The original

estimate of the uninsured was between

396,000 and 657,000 Massachusetts resi-

dents.1,4 In 2007 tax filings, just 5% of

about 3.2 million tax filers reported being

uninsured as of Dec. 31, 2007.

Of the newly insured, about 41% obtain

insurance via the publicly subsidized

Commonwealth Care program, which is

available to all individuals with incomes

less than 300% of the Federal Poverty level

who do not meet Medicaid (MassHealth in

Massachusetts) eligibility criteria.3 By fall

2007, the un-insurance rate for adults with

incomes below 300% of poverty fell from

24% to 13%. Among adults with income

less than 100% of poverty the un-insurance

rate dropped by more than two thirds to

10%.2,3

About 43% of the newly insured are in pri-

vate, commercial insurance plans. This

growth comes from both employer spon-

sored (36%) and individually purchased,

“non-group” insurance (7%).3 The

remaining 16% newly insured are a prod-

uct of expansions of Masshealth, which

essentially includes an expansion of cover-

age of children in families up to 30% of

poverty.

The number of newly insured highlights

the success of the Massachusetts law in

extending health insurance coverage to

previously uninsured populations. Though

much of the expansion is due to subsidized

programs, the individual mandate has

played a key role in persuading others to

purchase private insurance plans, the

increase in private, commercial insurance

is the first significant increase in

Massachusetts in decades.2,3

Affordability of Health Insurance

One of the stated goals of the health reform

law was to make health insurance premi-

ums more affordable, in particular for

young adults and individuals by merging

the small-group and non-group insurance

markets. The Commonwealth Connector

reports that it was able to successfully cut

in half the price a typical 37-year-old

would pay for health insurance in this pri-

vate market, while adding twice the bene-

fits.3 For all age groups, health insurance is

less expensive in 2008 in comparison to

equivalent plans in 2006, even accounting

for an average of 8% annual inflation.5

Nevertheless, the 18-25 age group remains

the largest sector of the uninsured in

Massachusetts (accounting for 35% of the

remaining uninsured), and 80% of the

remaining uninsured find cost to be a sig-

nificant impediment to purchasing insur-

ance.2 The connector itself recognizes that

while health insurance is less expensive

after the reform, it is still not affordable for

many. For this reason it has excluded from

the individual mandate any individual

earning between 300 and approximately

500% of poverty (about 35,000 individu-

als).3 Furthermore, while cost of the

Connector plan’s premiums are rising

slower than comparable plans, cost sharing

requirements were recently increased in an

effort to reduce the $400 million gap

between projected and actual costs for

2008.

(Continued on the Next Two Pages)


HEALTHreform

LESSONS FROM THE

MASSACHUSETTS EXPERIENCE

Peter B. Smulowitz, MD, MPH

Beth Israel Deaconess Medical Center

Boston, Massachusetts


(Continued from Page 25)

The cost to Massachusetts

The cost of healthcare reform has been significantly higher than

predicted. The original estimate for the Commonwealth Care pro-

gram for fiscal year 2008 was $472 million,6 though the actual cost

will be closer to $717 million. For 2009, the projected cost was

$725 million, and Gov. Patrick’s administration is now stating the

cost to be over $1 billion. Lawmakers implemented an increase in

the cigarette tax to make up part of the budgetary shortfall, and the

Commonwealth Connector will be increasing cost sharing require-

ments and could cap enrollment as costs continue to rise.

The higher than expected cost of the reform is partly attributed to

underestimating both the number of lower income residents and

the speed in which they would enroll in the subsidized programs.7

In this latter part the state was largely a victim of its own success

- successful outreach led to faster-than-expected enrollment in the

subsidized plans. The state also estimated it would collect about

$95 million from employer assessments in 2008. The real amount

collected is closer to$5 million.8 However, it is significant to note

that costs per enrollee actually came in under budget for FY 2008,

at $352 per member per month, or 2% below the budget of $359

per member per month.3

Though the cost of expanding access to care is significant, the

health reform’s chance of survival was significantly improved

with the $10.6 billion dollars over four years promised by the fed-

eral Medicaid waiver renewal.8 After months of negotiations, this

increase in $2.1 billion from the original waiver should allow

Massachusetts to keep all the gains made thus far in covering the

uninsured.

Employers and employer-based coverage

Mass. has a strong history of employer-based health insurance. In

2007, 72% of Massachusetts employers offered health insurance

to their employees, compared to 60% and a downward trend

nationwide. The rate was even higher for employers with more

than 50 employees, 99% of which offer coverage.9 However, few

employers offer health insurance to part time employees and most

require employees work at least half time.10

These restrictions on access to employer offered insurance histor-

ically left a large number of employed individuals without access

to health insurance. Many of these individuals and their depen-

dants sought care paid for by the state’s free care pool. Healthcare

reform has not solved this problem, and many employed individ-

uals still rely on the free care pool. Overall in 2007, employees

and dependents of employers with 50 or more employees received

publicly subsidized care for a total of $638 million in public funds.

Chapter 58 included two employer-directed provisions aimed at

optimizing the availability of employer sponsored insurance.

First, employers with more than ten full-time equivalent employ-

ees must make a “fair and reasonable” contribution toward their

workers’ health insurance or face an assessment of $295 per work-

er per year. Second, they must set up a Section 125 “cafeteria

plan” in which employees can pool their pretax dollars (including

form other sources of employment) to pay health insurance premi-

ums.1,2

The initial employer assessment of $295 was purposefully modest.

It had initially been vetoed Gov. Romney and was a significant

source of contention in passing Chapter 58. While the employer

assessments are not so robust as to create a financial burden for

small businesses, the moral hazard concern is that businesses may

either choose not to offer insurance and instead pay the assess-

ment, or may choose to alter the status of full-time employees to

part-time or change the eligibility criteria for health insurance in

order to encourage their employees to sign up for the

Commonwealth Care program. To date there is no discrete evi-

dence that this “crowd-out” of employer coverage occurs.2,3

Access to Care

The Massachusetts healthcare reform is a perfect example that

access to health insurance is not equivalent to access to health

care, though both are fundamental parts of a functional health care

system. The expansion of health insurance has had the intended

effect of reducing the impact of cost as a barrier to individuals

seeking necessary healthcare services and prescription drugs. In

the recent Urban Institute survey, fewer individuals in all income

groups reported that they did not get needed care in the past year

because of cost. For all adults, this number decreased from 17% in

2006 to 11.2% in 2007, and for adults with incomes under 300%

of poverty, the number fell from 27.3% to 16.9%.2

However, access to care goes beyond the cost of care. Overall, the

share of primary care doctors who accept new patient has dropped

to barely half, and the average wait by a new patient for an

appointment with an internist rose to 52 days in 2007 form 33 days

in 2006.11 Furthermore, the percentage of all adults and low

income adults that report not getting needed care in the past year

because of trouble getting an appointment is actually increasing.2

This could be one reason why emergency department utilization

amongst state-subsidized patients with the lowest incomes is 27%

higher than the state average.12

There is widespread recognition in Mass. that access to care is as

crucial as access to health insurance, though solutions are not

imminent. Gov. Patrick recently signed legislation that includes

provisions meant to bolster the state’s dwindling supply of


HEALTHreform


primary care physicians. These provisions include expansion of

training programs, loan forgiveness, and affordable housing pro-

grams for physicians who commit to working in primary care and

underserved communities in Mass., expansion of the role of nurse

practitioners and PAs in meeting primary care needs, and a focus

on alternative care models like “Medical Homes.”13

Lessons Learned

Future state or federal endeavors to expand health insurance must

heed the successes and failures of Massachusetts’ health reform.

Perhaps the most significant lesson learned is that broad health-

care reform is possible despite political obstacles. The passage of

such significant legislation required cooperation and compromise

between a Republican governor and a largely Democratic legisla-

ture. It required communication between government and business

groups, consumer advocates, hospitals, insurance companies, and

the people of Massachusetts. Bipartisan legislation and wide-

spread popular support will be crucial for the success of any

broader expansion of health insurance coverage.

Like any political compromise, there were certain sacrifices that

were made to pass Chapter 58. First, the employer assessment was

meager, which kept the business community content and may be

contributing to the lack of employer crowd-out, but which left lit-

tle authority to induce a significant number of employers to

increase the availability of employer sponsored insurance.

Furthermore, lawmakers kept with the tradition of using private

insurance companies to act as the payer.

One of the most important lessons taken from the Massachusetts

experience is that without significant financial assistance from the

federal government, states will not be able to achieve health insur-

ance expansion on their own. Massachusetts is a relatively

wealthy state with pervasive employer coverage and relatively

few uninsured. The recent failure of healthcare reform to progress

in states like California with a significantly higher number of

uninsured is a testament to the important role the federal govern-

ment will need to play in financing healthcare reform.

Along the same lines, the individual cost of health insurance plans

and the decision to exempt individuals up to 500% of poverty

from the individual mandate suggest that health insurance is cur-

rently not affordable for all Americans. Cost control will be a nec-

essary component to federal health care reform, though it is less

clear if cost control is a necessary precursor to such reform. As in

Massachusetts, the expansion of health insurance may ignite the

cost control conversation. However, many of the components of

cost control are more complex and even more politically challeng-

ing than expanding health insurance. Massachusetts has yet to

enact any meaningful cost control measures, and the failure to do

so is certain to threaten the reform’s viability.

The Massachusetts reform also serves to remind us that individual

mandates can be effective if a significant enough penalty is in

place for non-compliers. The main question is not whether indi-

vidual mandates can work, but whether they should be used at all

given the current cost of healthcare. Having an individual mandate

is supposed to bring down the cost of premiums for all by

enrolling younger, healthy individuals who would not otherwise

purchase insurance. In Massachusetts this demographic group still

accounts for the majority of the remaining uninsured.

Consequently, small group premiums in the private market have

not decreased as much as expected.

Finally, Massachusetts serves as a stark reminder that access to

health insurance is not equivalent to access to care. There are

many imprecations in the healthcare delivery system in the U.S.,

and many states are plagued with a short supply of primary care

physicians. These issues will need to be addressed to improve the

long term health of populations and decrease the long range cost

of the healthcare system.

References

1. McDonough JE, Rosman B, Phelps F, et al. The third wave of Massachusetts

health care access reform. Health Affairs 2006;25:w420-31.

2. Long K. On the road to universal coverage: impacts of reform in Massachusetts

at one year. Health Affairs 2008;27(4):w270-284.

3. Kingsdale J. Executive director’s message. Aug 25, 2008. http://www.mahealth-

connector.org/portal/site/connector

4. The New Big Dig. The Wall Street Journal Online. May 21, 2008.

http://online.wsj.com/article_print/SB121132884197208937.html

5. Turnbull N. “Individual Market Reforms: Data for a Few More Powerpoint

slides.” http://commonhealth.wbur.org/nancy-turnbull?2008/09/individual-market-

reforms-data-for-a-few-more-powerpoint-slides-by-nancy-turnbull/.

6. Healthcare reform: Overview. Mar 2008. http://www.mahealthconnector.org/por-

tal/site/connector/minueitem.d7b34e88a23468a2dbef6f47d7468a0c?fiShown=default

7. Lazar K. Mass. Gets $10.6 billion for healthcare insurance. The Boston Globe.

Oct 1, 2008.

http://www.boston.com/news/local/articles/2008/10/01/mass_gets_106b_for_healt

hcare_insurance/.

8. Dembner A. Subsidized care plan’s cost to double: enrollment is outstripping

state’s estimate. The Boston Globe. Feb 3, 2008.

9. Employers who had fifty or more employees using Masshealth, Commonwealth

Care, or the Uncompensated Care Pool in State FY07. Massachusetts Division of

Health Care Financing and Policy, May 2008.

10. Massachusetts employer health insurance survey. Massachusetts Division of

Health Care Financing and Policy, 2008.

11. Sack K. In Massachusetts, universal coverage strains care. The New York

Times. April 5, 2008.

12. Lazar K. Costly ER still draws many now insured. The Boston Globe. Oct. 6,

2008.

13. An act to promote cost containment, transparency and efficiency in the deliv-

ery of quality health care. Massachusetts State Senate Bill 2526. 185th General

Court, 2008. http:/www.Mass.gov/legis/bills/senate/185/st02/st02526.htm



A little over 15 years ago, I moved from

Washington, D.C. to Florida, where for

nearly all of that time I have lived in rural

small towns. In my service as the medical

director of small EDs I have noted that the

differences between urban and rural EDs

are minor.

I left behind most of the negatives of urban

living: traffic congestion, crowding, home-

lessness, and penetrating trauma. I also left

behind the concept of “Centers of

Excellence.” While I always found it hard

to know where marketing ended and real

healthcare began, I did buy into the notion

that those hospitals that did a lot of some-

thing were probably the best at it. As a

young physician recently out of the mili-

tary, I believed that evidence based medi-

cine and hospital specialization seemed

proper.

When I arrived in small town Florida I was

initially frightened by the absence of

homeless centers, local in-patient psychi-

atric care and other social safety nets. I

was shocked at the disenfranchisement and

alienation of the rural poor. I wondered at

the decreased prevalence of AIDS. But I

also noted that the majority of medical and

non-traumatic surgical cases were similar

to those in the city.

The greatest ongoing challenge I face is

recruiting ED docs: if you consider the

nationwide shortage of ED docs and the

many competing city opportunities then

this is not surprising.

Once recruited, the challenge becomes

retention. We all know how easy life is at

the hospital when your physician staff is

stable. Most of our doctors commute three

hours a day or more.

Meetings with mandatory attendance have

no place. You must rely on e-mails and fre-

quent, informal, face-to-face discussions to

discover problems, hear suggestions, and

establish policy. Whether dealing with

chart documentation or hospital politics, it

is more important as a medical director to

encourage rather than threaten ED docs.

The second greatest hassle is transferring

patients out. It is probably universally true

that receiving doctors are arrogant, curt,

and are too busy to be bothered. This all

seems more acute when you are calling

from the country. Most specialists have no

idea that broad areas of Florida don’t have

specialized care and seem to suggest that

all community docs must be idiots. Many

seem to hold me personally responsible for

this. Or maybe I am being too sensitive.

Those challenges are minor in the face of

the cordiality and collegiality I experience

in small hospitals. I remember those

debates and battles about the relevance of

EM in the 1980s. In the small rural hospi-

tals we won them all. Hospital administra-

tion often considers the ED medical direc-

tor to be principle in innovation and

improvement. An EP is able to achieve a

level of participation, activism, and author-

ity in the small community that could not

be achieved elsewhere.

Hospitals are a vital part of the business

and economics of a small town communi-

ty. They are typically among the largest

employers, offering highly skilled and

well-paid jobs. Recently I have noticed a

decentralization of healthcare, as more

complex care with the help of consultative

services like tele-radiology and tele-neu-

rology is provided locally. Few things are

more satisfying than to admit an ill, elder-

ly patient close to her family and home.

This decentralization is in part a response

to the times the referral centers have been

unavailable. This is also a reasonable

attempt by the small hospital to keep rev-

enue local: all of those well-paid hospital

employees eat at local restaurants, shop at

local stores, and use local services. Small

communities require this re-investment.

I find this all exciting. We are the docs

who pride ourselves on being able to do it

all. The small community hospital and its

ED are of the same mind.


RURALem

A Perspective on Rural EM in Florida

Cary Pigman, MD, FACEP

It is probably universallytrue that receiving doc‐tors are arrogant, curt,and are too busy to bebothered. This all seemsmore acute when you arecalling from the country.


Is the work you do in your ED so stressfulthat it spills into your home life? How doyou manage?

ED work can be very stressful. The ways I

like to relax are by working out and play-

ing sports. If it is too late for these activi-

ties, watching sports, spending time with

my family and a cold beer always serve as

a good backup!

- Barry Hahn, South Florida.

I rarely get stressed in the ED. I have

learned to not let things get me stressed out

while I am working. I try to keep a positive

attitude no matter how difficult or stressful

a shift might seem. If a stressful situation

arises, I work through it and then move on.

I don't let it ruin my entire shift.

- Donny Perez, Davie.

Have a question for Soundings? Pleasesend it to us at [email protected].


DOCTORS’loungeSoundings

I recently testified before the Florida Board

of Nursing (BON) concerning the delivery

of Propofol for procedural sedation by reg-

istered nurses (RN).

The Florida Association of Nurse

Anesthetists (FANA) and the Florida

Society of Anesthesiologists (FSA) have

submitted language to the BON that would

trigger disciplinary action under the

‘unprofessional conduct rule’ if an RN

were to administer Propofol to a patient

that is not mechanically ventilated. The

proposed language would include all med-

ications in which the manufacture’s pack-

age insert states that only individuals

trained in general anesthesia should admin-

ister the medication. This would limit the

use of sedative agents in the ED and many

office practices around the state.

The Joint Administrative Procedures

Committee of the Florida Legislature has

voiced several concerns about the language

and its wide spread impact. They noted,

“This proposed rule affects not only nurs-

es, but other professions and entities not

regulated by the board, such as physicians,

hospitals, and surgery centers.” They also

noted, “Florida Statute authorizes regis-

tered nurses to administer medications and

treatments as prescribed by a duly licensed

practitioner authorized by the laws of this

state to prescribe such medications and

treatments.”

In 2005, ACEP and the Emergency Nurses

Association (ENA) developed a joint poli-

cy statement that supports the delivery of

medications used for procedural sedation

and analgesia by credentialed RNs work-

ing under the direct supervision of an EP.

These agents include, but are not limited

to, Etomidate, Propofol, Ketamine,

Fentanyl, and Midazolam.

In 2007, Dr. Brian Keaton, former ACEP

president, noted that “the right for nurses to

administer sedation under the direct super-

vision of a physician is supported by the

Joint Commission in standards PC 12.20

and PC 13.20.”

During my testimony, I emphasized that

there is significant evidence that supports

the safe and efficient administration of

sedatives by supervised RNs, the unique-

ness of the ED, and the special training that

EPs have in conscious sedation and airway

management. The board was encouraged

to focus on the proper monitoring of

patients rather than on medication adminis-

tration as this would go far to improve

patient safety.

By the end of the testimony, the board indi-

cated interest in making the ED an excep-

tion, given the fact that we need to perform

time-sensitive procedures to diagnose and

treat conditions as well as alleviate pain.

The board has requested that we submit a

proposal which allows the ED to adminis-

ter these medications and not restrict their

use.

FCEP has included all the above-men-

tioned medications in the ACEP-ENA joint

policy statement. We will monitor this sit-

uation closely to ensure that we are able to

appropriately care for our patients in a safe

and timely manner.

CONSCIOUSsedation

Procedural Sedation Update

Ernest Page II, MD, FACEP


“Judy, do you smoke?”

It was a question that emergency physician

Tammy Cortez had asked thousands of

times in the ER. When a patient com-

plained of a cough that had been persistent

for weeks, she always asked this question.

She already knew the answer, as the smell

from Judy’s hair was telltale.

“Well,” Judy said sheepishly, “I’m down to

only a half pack a day now.”

“Since this cough has been going on for so

long,” Cortez responded, “I think we

should get a chest X-ray.”

Cortez knew, of course, that there were

many possible causes for this cough, and

she would take this logical first step now to

begin the investigation.

“Your lungs sound pretty clear right now,

so let’s see what the pictures look like.”

“OK, Dr. Cortez.”

“The X-ray Tech will come get you in a

few minutes.”

Judy nodded, and then leaned back against

the wall by her stretcher in Room 14. She

could hear a baby crying down the hall,

and she noticed someone else coughing

every minute or two. A siren that seemed

to be just a few feet away suddenly stopped

squealing. Now, it hit her for the first time:

there must be some reason for this cough...

An X-ray Tech appeared in her doorway,

smiled as he asked her name, and then

motioned for her to follow him. They

strolled quietly down the hall and into

another room, where Judy put on the thin,

cloth hospital gown.

“OK, take a deep breath and hold it,” the

Tech said after positioning Judy against the

flat surface. “Good. Now let’s get one

view from the side.”

Within a few minutes, Judy was back in

Room 14.

Cortez had just finished discharging a

patient from Room 10, and she noticed that

Judy was back in her room as she passed

by.

“I’ll check those X-rays in a minute, Judy.”

Judy produced half a smile. She really did-

n’t feel bad; it was just that lingering

cough. Surely this was just a little cold,

she hoped. She really hoped.

“Dr. Cortez, Dr. Angler is on the phone

about Room 8.” The secretary held up her

phone as Cortez rounded the corner by her

desk, then punched in the transfer.

“Hi, Bill. Tammy Cortez. Remember that

Morgan guy we talked about last

Tuesday?” For the next few minutes,

Cortez focused on arranging the appropri-

ate disposition for Mr. Morgan, and, when

she hung up the phone, she dictated a cou-

ple lines into his record.

Shifting gears quickly, she wheeled around

to face the radiology viewing monitor, and

tapped in her login and password. She

sighed as she wondered out loud why these

things have to log her off every minute that

she’s not using the system.

“What a pain.”

She pulled up the new images and double-

clicked on Judy’s chest X-ray line.

“Oh, no.”

A hollow feeling zipped across her chest;

her shoulders slumped. She pushed back

away from the pictures to scan the entire

image up and down.

There was no escaping this. The mass that

was visible in Judy’s right lung was ugly,

more than 3 cm across with irregular,

streaky edges that looked like “feelers”

reaching out. Is that mediastinum a bit

wide over there?

This was almost certainly a cancer. It was

times like this that Cortez wished the emo-

tional parts of this job were easier. Judy

was such a nice woman, a professional,

only 49 years old. Now, her life – whatev-

er was left of it – would never be the same.


ERchronicles

Breaking the News

Arlen R. Stauffer, MD, MBA, FACEP


And, of course, it was Cortez’ job to begin breaking the news.

Hoping to perhaps get a more optimistic twist, Cortez asked her

friend in Radiology for his opinion. “Jack, what do you think?”

she asked as he pulled up the images on his screen. Dr. Jack Miller

frowned and shook his head. Opinion delivered.

Cortez sat quietly for a moment, took a deep breath, and gathered

herself. She put the rest of the people in this ER out of her

thoughts. There were at least 10 charts representing patients in the

waiting room, and she knew that some of them had already been

here for a couple hours. They’ll have to wait.

She walked slowly to the

doorway of Room 14, took

another deep breath, and

walked in, looking Judy

directly in the eyes.

“Judy, your chest X-ray is

not normal,” she blurted

out as she sat down on the

chair beside Judy. She

paused for a moment to let

her patient react.

“What do you mean?”

There was just no good

way to say this. “There’s

an area in your right lung

that looks like a mass, a

tumor.” She paused again, not so much to await Judy’s reaction,

but rather because she just didn’t like these types of moments.

“You mean...cancer?”

“It could be, Judy. But we’re going to need to get several more

tests to be sure.”

Uncomfortable silence filled Room 14 for nearly a minute. The

look of terror on Judy’s face was, of course, what the doctor had

anticipated.

With her hand on Judy’s shoulder, Cortez continued. “Let me

make some calls to get things started right now. We’ll figure out

what we’ll need to do about this.” She tried to sound authoritative

and convincing.

Judy wiped one tear away, took a deep breath, and then looked up.

The determination on her face now was surprising and somewhat

encouraging. This was a strong woman.

“OK. Let’s get things started, Dr. Cortez.” Judy brushed aside

another tear, flinging it away as though she was angry at it. “What

do we do next?”

Cortez smiled, and leaned forward in her chair. Those other

patients in the ER would have to wait a bit longer.

Each year in the USA,

cancer of the lung is diag-

nosed in nearly 200,000

people, and more than

160,000 of them will die

from these cancers. The

most common presenting

symptoms are cough

(sometimes hemoptysis),

shortness of breath, and

weight loss, although up

to 25% of lung cancer

patients have no symp-

toms when their tumors

are discovered on routine

chest X-rays or CT scans.

Smoking is by far the main contributor to lung cancer, with near-

ly 90% of the lung cancer deaths worldwide being caused by cig-

arettes. Among male smokers, the lifetime risk of developing lung

cancer is 17%, and in females it is 11%, while it is less than 1.5%

in non-smokers. Cigarette smoke contains more than 60 known

carcinogens.

Patients who smoke should be made aware of these horrible stats.

The author is a long-time emergency physician from New SmyrnaBeach, and a former FCEP Board member and EMpulse editor.This is a revised version of one of the “Chronicles” that ran inseveral Florida newspapers a few years ago. Contact: [email protected]



In the U.S., cocaine abuse results in more

ED visits than any other illicit drug.1 In

2008, Florida medical examiners reported

1,791 Florida decedents where cocaine was

present, and in 36 percent of these cases,

the cocaine was considered causative.

Miami reported the most cocaine-related

deaths in Florida with 201, followed by

Orlando at 179 and Jacksonville with 165

deaths. Most of the Florida cocaine caused

decedents were male, and 35 to 50 years

old.2 Adding to the potential danger, toxic-

ity and complication of patient presenta-

tion is the presence of adulterants.

Although the effects of cocaine on the

human body have been well documented in

the literature, adulterants add an additional

component that must be considered when

assessing patients for cocaine toxicity.3,4

Cocaine is mixed or “cut” with adulterants

to increase the amount of product available

to sell and / or to augment the effects of

cocaine. The average purity of cocaine sold

at the street level is 40%, suggesting that

adulterants can represent more than half of

all cocaine sold.1 Innocuous compounds

such as mannitol and lactulose are added

because they match the appearance of

cocaine and to serve as bulking agents to

increase the available volume to be sold.

A variety of pharmacologically active

compounds have been used to adulterate

cocaine, but the agents consistently present

are lidocaine, benzocaine, caffeine, dilti-

azem, hydroxyzine, atropine, methyl-

phenidate, methylephedrine, phenacetin

and acetaminophen.5-7 Sometimes, phar-

macologically active adulterants are added

to cocaine to increase profits. For example,

stimulants and local anesthetics are added

as a cheap way to mimic and / or augment

the effects of cocaine. Other adulterants,

such as diltiazem, hydroxyzine and aceta-

minophen, are sometimes added as chemi-

cal signatures to track the distribution of

cocaine.1,5-7 This explains why a wide vari-

ety of adulterants can appear in a given

sample of cocaine. A more recent and

alarming development is the increasing use

of levamisole as an adulterant.

Since 2002, levamisole, a veterinary anti-

helminthic, has been detected with increas-

ing frequency in cocaine. By 2009, approx-

imately 70 percent of the cocaine that the

DEA analyzed contained levamisole.8

Theories on why it is being added to

cocaine include its availability as a cheap

bulking agent and for its purported ability

to increase dopamine and endogenous opi-

oids in the brain.9,10 It appears the cattle,

sheep, and pig deworming agent is being

added in Colombia and has been found in

samples of cocaine all over the world.

Levamisole had been used in humans in

the USA for a variety of dermatologic dis-

orders and rheumatoid arthritis.11 It was

FDA approved as combination therapy

with fluorouracil for the treatment of col-

orectal cancer in 1990.12 The medication

was thought to act as an “immunomodula-

tor” boosting lymphocyte activity, and as a

biochemical modulator, increasing the

pharmacological activity of other medica-

tions.13 Unfortunately, it also possesses

some toxicologic properties that prompted

its voluntary withdrawal from the market

for human use in 2000.

Its activity against pathogenic nematodes

is through a nicotinic cholinergic mecha-

nism — first causing contraction of the

worms’ musculature, followed by a flaccid

paralysis. Levamisole and nicotine are

structurally similar and both can cause

nausea / vomiting, abdominal pain,

increased salivation, tremor, CNS excita-

tion and convulsions.13 Levamisole can

cause pruritic rash, fixed drug eruptions,

lichenoid rash and necrotizing vasculitis.11

However, the most concerning toxic effect

of levamisole is its ability to destroy gran-

ulocytes.

Agranulocytosis was described when used

medically in humans and has resurfaced in

association with cocaine abusing patients

in 2009.10,14-16 The time of onset is variable,

but usually the adverse effect is reversible

upon discontinuation of the levamisole.16


POISONcontrol

Cocaine Adulterants: The Cut That Can Kill

Calvin Tucker, Pharm.D., Pharmacy Practice Resident

& Joe Spillane, Pharm.D., DABAT,

Emergency Medicine Pharmacist

Shands Jacksonville


Cocaine abusing patients in Alberta,

Canada presented to an emergency depart-

ment with fever, infections, total leuko-

cytes less than 3X 109 cells/L, and zero

neutrophils.10 All patients fully recovered

with antibiotics, supportive care and fil-

grastim (Neupogen), and their neutrophil

counts increased to greater than 1X

109cells/L in five to twenty days.10

Women seem to be uniquely predisposed to

levamisole induced agranulocytosis,

accounting for approximately 80% of the

agranulocytosis cases when used in cancer

patients and eight of the eleven patients

described in Canada.10,16 There is some

evidence that agranulocytosis can recur

rapidly, in some cases within hours, upon

rechallenge.14,16 This may be important

given the high rate of recidivism seen with

cocaine addiction.

Urine testing for levamisole is not current-

ly available in most EDs. However, lev-

amisole has been detected in Florida

cocaine decedents over the last several

years. The toxicity of adulterants should

be considered when treating cocaine abus-

ing patients and the toxicity of levamisole

should be considered when treating

cocaine abusing ED patients particularly

with fever and leukopenia. The Florida

Poison Information Center Network is

available 24 hours a day (1-800-222-1222)

if you have any questions with regards to

cocaine toxicity or levamisole adulteration.

References:

1. Goldstein et al. Cocaine: History, Social

Implications and Toxicity- A Review. Dis Mon

2009;55:6-38.

2. Florida Department of Law Enforcement. Drugs

Identified in Deceased Persons by Florida Medical

Examiners 2008 Report. 2008 Medical Examiners

Commission Drug Report.

3. DEA Briefs and Background, Drugs and Drug

Abuse, State Fact Sheets, Florida. www.justice.gov.

Accessed on 11/12/09.

4. Brunt et al. An analysis of cocaine powder in the

Netherlands: content and health hazards due to adul-

terants. Addiction, 104, 798–805.

5. Sellers, Kristi; Morehead, Rick. Identify and

Quantify Adulterants in Seized Cocaine. The Restek

Advantage: Turning Visions into Reality 2005 Vol. 2.

www.restek.com. Accessed on 11/12/09.

6. Behran, Alysha. Luck of the Draw: Common

Adulterants Found in Illicit Drugs. J Emerg Nurs

2008; 34:80-2.

7. Fucci N. "Unusual adulterants in cocaine seized on

Italian clandestine market." Forensic Sci Int. Oct 25,

2007;172(2-3):85-224.

8. Reuter, N. Natonwide public health alert concern-

ing life-threatening risk posed by cocaine laced with

veterinary anti-parasite drug. SAMHSA Press release

September 21, 2009.

9. Spector S, Munjal I., Schmidt DE. Effects of the

immunostimulant, levamisole on opiate withdrawal

and levels of endogenous opiate alkaloids and mon-

amine neurotransmitter in rat brain.

Neuropsychopharmacology 1998;19(5):417-427.

10. Zhu NY, LeGatt DF, Turner RA. Agranulocytosis

after consumption of cocaine adulterated with lev-

amisole. Ann Int Med 2009;150(4):287-289.

11. Scheinfeld N, Rosenberg JD, Weinberg JM.

Levamisole in dermatology: a review. Am J Clin

Dermatol 2004;5(2):97-104.

12. Moertel CG, Fleming TR, Macdonald JS, et al.

Levamisole and fluorouracil for adjuvant therapy of

resected colon carcinoma. New Eng J Med

1990;322:352-358.

13. Hsu W: Toxicity and drug interactions of lev-

amisole. Am J Vet Med Assoc 1980; 176:1166-1169.

14. van Holder R, van Hove W. Recureent agranulo-

cytosis after levamisole. Lancet 1977;1:100.

15. Williams GT, Johnson SA, Deippe PA, Huskisson

EC. Neutropenia during treatment of rheumatoid

arthritis with levamisole. Ann Rheum Dis

1978;37(4):366-369.

16. Symoens J, Veys E, Mielants M, Pinals R.

Adverse reactions to levamisole. Cancer Treat Report

1978;62:1721-30.


POISONcontrol (continued from Page 28)

The Emergency Medicine Learning & Resource Center is accred-

ited through the Accreditation Council for Continuing Medical

Education (ACCME) to provide physician continued medical edu-

cation (CME). The ACCME has established a new standard for

CME based on the following four specific concepts: CME will be

focused in terms of improving competence, and/or performance-

in-practice and/or patient outcomes; CME will be a contributor to

patient safety and practice improvement; CME content will be

anchored in evidence–based medicine; CME will be independent

of commercial interests.

The process for development and presentation of CME has three

integrated components

1. Needs and Gaps

a. Establishment of the current practice - examples:

i. 2007 Model of the Clinical Practice of Emergency

Medicine (ACEP, SAEM, UAEM, CORD, RRC-EM).

ii. AOA Basic Standards for Residency Training in

Emergency Medicine.

iii. AOA Basic Standards for Residency Training in EMS.

b. Best practices – examples:

i. ACEP Clinical Policies, Studies and White Papers.

ii. AOA Clinical Policies, Studies and White Papers.

iii. NAEMSP Clinical Policies, Studies and White Papers.

c. Resulting Gaps – areas in which gaps have been found that

require specific CME to fill those gaps. These are determined dur-

ing the education program planning process from multiple

sources.

2. Design and Format – CME programs are designed to (be):

a. Reflective of learner’s scope of practice - current and/or

potential.

b. Employ formats of education that enhance the potential to

achieve and sustain improvement results.

c. Relate to national priorities for universal and specialty

physician competencies.

d. Sensitizes learner to cultural issues relating to patient care.

3. Educational Outcomes – required for every educational activi-

ty:

a. Evaluate if identified gaps were closed.

b. Document specific results in terms of improved competence,

performance, and/or patient outcomes for every CME activity.

c. Process to make regular improvements to the CME pro-

gram based on outcome analysis and scope of practice.

For more information and how you could get involved in the

EMLRC’s CME planning please contact me at

[email protected] or (407) 281-7396, ext 17.

New ACCME CME StandardsJohn Todaro, BA, REMT-P, RN, TNS, NCEE, Director/COO of the Emergency Medicine Learning & Resource Center


Orlando HealthRebecca Blue, MD

Greetings from Orlando!

It’s been an incredibly productive year at

the research table, with fifteen abstracts

submitted to SAEM. In addition, attending

physician Dr. Papa is preparing for enroll-

ment of patients into her NIH funded proj-

ect. Her research is designed to evaluate

the presence of a serum biomarker corre-

lating with traumatic brain injury. We are

very excited about the initiation of this

research, and very proud of all of our

scholars - congratulations to everyone who

submitted!

It is nearly midway through our interview

season, and we have all been amazed by

the caliber of applicants this year. We can’t

wait to see how next year’s intern class

shapes up! Thanks to all of our residents

and attendings who have gone out of their

way to welcome our applicants!

Also new at ORMC, our AirCare program

will soon be assuming all 911 scene

requests for air transport and trauma serv-

ice in Orange County. I recently had the

opportunity to fly with the AirCare team,

and was more than impressed by their pro-

fessionalism and efficiency. Thank you to

all of our AirCare crews for their efforts!

We hope all of you had a wonderful holi-

day season!

Florida HospitalBrittany Thomas, MD

Seasons Greetings and a Happy New Year

to all! Towards the end of 2009, several

residents were able to get involved in

extracurricular activities.

Marshall Narquin is now a certificated

multi-engine private pilot, and Michele

Rorich placed third overall in the 4th

Annual Orlando Women’s Triathlon.

Javier Gonzalez became the alternate

board representative for EMRAF, and I had

the opportunity to walk the runway at the

Park Avenue Fashion Week in Winter Park

to benefit the American Heart Association.

Involvement in educational activities has

been plentiful as well. Many residents have

engaged in research and are eagerly await-

ing IRB approval. Also, the first-year class

participated in the 3rd Annual EKG

Symposium, and in January both classes

will attend Florida Emergency Physicians’

1st Annual Symposium on Risk

Management in Acute Care.

In other noteworthy news, Dr. Patricia

Nichols was recently named the assistant

medical director at Florida Hospital Cele-

bration. She will be greatly missed by the

residents and faculty at the East campus.

Finally, interview season has been an excit-

ing time, as it reminds us that we will soon

have three residency classes. We have had

applicants from all over the country, and

one medical student even traveled from

Ireland. We look forward to adding six new

interns to our cohesive group.

University of South FloridaJason W. Wilson, MD

As the holiday season got underway, our

recruitment season started as well. We

recently kicked off our interview season. I

had a great time having lunch with the first

batch of applicants and at the evening

social event. This also allowed all the cur-

rent residents to come together.

I really enjoyed helping out with recruit-

ment last year and now, on my second time

around, I realize it is because it gives me

the opportunity to reflect on just how great

our program is and how much it has grown

during my short time here.

Our program director, Kelly O’Keefe, MD,

FACEP, continues to make innovative

changes with new rotations and computer

tracking of evaluations and procedures,

replacing the burden of paperwork entirely.

I love the fact that my colleagues and I still

get excited talking about this program to

new people halfway into our training.

On the international front, Scott Stirling

received a scholarship to travel to India

along with several attendings to help lay

the groundwork for EM infrastructure

there.

Finally, one of our first year residents will

be returning from paternity leave shortly

after having his first child - a beautiful

baby girl that will probably grow up to

break the heart of my own six-month-old

son someday! Congratulations to Matt

Fucarino. This is a welcome addition to the

program.


RESIDENCYmatters

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



University of Florida, JacksonvilleOscar Espetia, MD

Greetings! We are almost halfway through

the academic year. As the year goes on we

continue to work hard and we are now in

the midst of our interview season. Here is

an update on some of the happenings at

UF/Shands Jacksonville.

Our program has been very busy this year.

Dr. DeVos was elected as the councilor for

the International Medicine Section of

ACEP. Drs. Lenhart and Gray’s project,

“ED Documentation Training in the Face

of ED Overcrowding,” won the ACEP res-

idency program Teaching Innovations con-

test. Dr. Sabato has been elected Secretary

of the ACEP Disaster section.

Drs. Lim, Dembitsky and Sabato’s

“Evaluating the Effectiveness of Didactic

Teaching and Simulator Training on the

Ability of EMS to Recognize the

Appropriate Patient for Therapeutic

Hypothermia and Implement a

Hypothermic Protocol” has been accepted

for poster competition at NAEMSP’s 2010

Annual Meeting in Phoenix, AZ. And, last

but not least, Drs.Laperouse, Forrest and

Lissoway won the ACEP National Sim

Wars competition, a repeat win for UF

JAX, go Gators!

As the year progresses, we will continue to

work hard and make strides in advancing

the practice of emergency medicine. We

look forward to seeing what the rest of the

year has planned, good luck from

Jacksonville and have a safe and happy

holiday season!

Mt. Sinai Medical CenterMarshall A. Frank, DO

We are about to pass the halfway point in

our academic year. Our interns continue to

progress, they are doing excellently in the

ED and we continue to hear fantastic

things about them from off-service rota-

tions. On the other end of the spectrum, a

lot of our seniors have already signed con-

tracts for the next year.

Congratulations are in order for several of

our residents and one of our attendings. In

November, Drs. Carlos Cao (attending),

John Yashou (PGY-IV), Philip Scumpia

(PGY-1) and Jerry Cajina (PGY-1) present-

ed a case of Purple Glove Syndrome at

Nova / Southeastern University’s research

poster competition. They placed first

amongst nineteen posters. Great job guys!

Additionally, we learned that our program

director, Dr. Beth Longenecker, placed first

in her CPC discussion at the ACOEP con-

ference in Boston. And Daniel Friedman

has been assisting with EM Days planning.

I have a correction to make on my previous

residency update. I neglected to mention

Dr. David Farcy as one of the three authors

of our ultrasound textbook. Dr. Farcy,

along with Drs. Dalley and Begleiter, has

written a tremendous emergency ultra-

sound book for our program which has

been a true asset to our learning emergency

ultrasound.

Happy New Year to all, and we hope you

had a very happy and healthy holiday sea-

son. I look forward to hearing from every-

one in 2010!

University of Florida, GainesvilleRita Fairclough, MD

Greetings from Gainesville!

As the mysterious voice in the film Field ofDreams said, “If you build it they will

come,” and come they did!! On November

1 we moved into our new state-of-the-art,

65-bed emergency department, and we are

seeing a record number of patients.

Although it has been hectic, I think we are

all happy.

We have several new faculty members and

would like to welcome Drs. Sandeep Johar,

John Slish, and Lars Beattie.

However, we also have to say goodbye to

Dr. Joel Moll, our medical director, who

will leave to join Emory University and

our previous program director, Dr. Richard

Stair, who will leave to join East Carolina

University. These two have been awesome

teachers and mentors and will be missed

terribly. We wish them the best of luck.

Our intern class has settled in. Our inter-

view process has begun and the applicant

pool is stellar. Thanks go out to Beth

Nealon, Josh Kaplan and Miles Bennett for

all their hard work. Our third years are on

the job trail and see the light at the end of

the tunnel! It seems that most of us will be

staying in the Southeast to practice.

We hope that all of you had a very happy,

healthy and safe holiday season. If anyone

is around the Gator nation in the coming

days and weeks, please stop by and visit

our new ED!


Emergency medicine is the leader in pro-

moting patient access and safety. In order

to achieve our goal of taking emergency

medicine to the next level of policy influ-

ence in Tallahassee, the Florida College of

Emergency Physicians has formed an

advocacy entity called “People for Access

to Emergency Care” (PAEC).

PAEC provides a means for our friends in

the business world, such as billing compa-

nies, physician groups and other organiza-

tions, to assist FCEP in supporting legisla-

tive leaders and policy makers, and it

ensures that emergency medicine has a

seat at the table with key leaders in the

Florida House and Senate.

PAEC allows FCEP and its partners in

emergency medicine to act with a unified

voice in Tallahassee. Its members are

groups and organizations dedicated to

promoting emergency medicine in Florida

and providing better access to quality

emergency care to our patients.

In order to be successful at securing emer-

gency medicine’s place at the table, we

need you to join People for Access to

Emergency Care and joining is easy.

There are three levels of membership:

• Platinum $15,000 per year

• Gold $10,000 per year

• Silver $5,000 per year

PAEC’s goal is to raise $200,000 for the

2008-09 legislative cycle. With these

funds we will be able to help elect candi-

dates who support your issues. This will

enable us and your organization to partic-

ipate in the decision-making process.

To find out more about contributing to

PAEC, contact Beth Brunner at:

[email protected].

Thank you!

2009 Platinum Members:

Emergency Physicians of Central Florida

Florida Emergency Physicians, Inc.

2009 Silver Members:

Comprehensive Medical Billing Solutions

Jacksonville Emergency Consultants, PA

Martin Gottlieb & Associates, LLC

Southwest Florida Emergency Physicians,

PA

2009 Other Members:

Tampa Bay Emergency Physicians, PL

Miguel Acevedo, MD, FACEPWayne Barry, MD, FACEPJeffrey Bettinger, MD, FACEPDale Birenbaum, MD, FACEPBradford Bowls, MD, FACEPJohn Braden, MDMitchell David Brantley, MDKa Hang Chan, MD, FACEPGregory Chapman, MDLeonardo Cisneros, DO, FACEPCasey Corbit, MDPaul Deponte, DOJack Derovanesian, MD, FACEPSteven Eccher, MD, FACEPDonald Franklin, MDVidor Friedman, MD, FACEPVicki Friend, DO, FACEPWayne Friestad, MD, FACEPMark Frisch, MD, FACEP

Brent Gardner, MD, FACEPGary Gillette, MD, FACEPDavid Goldman, DO, FACEPReuben Holland, MD, FACEPMilan Jockovich, MD, FACEPHugh Jones, MDRodney Kang, MD, FACEPWilliam Knibbs, MD, FACEPKarl Korri, MD, FACEPRonald Koury, DO, FACEPRonald Krome, MD, FACEP(E)Mark Kruger, MD, FACEPLinh Tung Le, MD, FACEPGretchen Lipke, MD, FACEPJorge Lopez‐Ferrer, MD, FACEPMichael Lozano, MD, FACEPKaivon Madani, MDMichael Maxwell, MD, FACEPWilliam McConnell, DO, FACEP

Terry Meadows, MD, FACEPGary Mendelow, MD, FACEPCraig Mitchell, MDSteven Nazario, MD, FACEPSteven Newman, MD, FACEPPatricia Singh Nicholls, MDBrian Nobie, MD, FACEPLisa O'Grady, MDWilliam Osborn III, DOErnest Page II, MD, FACEPKetan Pandya, MD, FACEPVanessa Peluso, MDPaul Petersen, MDW. Randall Poole, MD, FACEPJohn Prairie, MD, FACEPCheryl Reynolds, MDMaritza Rodriguez, MD, FACEPCharles Sand, MDMarc Santambrosio, DO, FACEP

David Sarkarati, MD, FACEPThomas Schaar, MD, FACEPKathleen Schrank, MD, FACEPRegan Schwartz, MD, FACEPEhsan, Shirazi, MDClaire Simpson, MDWeylin Sing, DO, FACEPSiva Sivanesan, MD, FACEPSouth Miami Criticare, Inc.Richard TempelJohn Tilelli, MDBryce Tiller, MD, FACEPGeorge Tracy, MDJohn Valentini, MDDavid Vukich, MD, FACEPH. Kenneth West, MDDebra Williams, MDSusan Wolcott, MDFredric Wurtzel, MD, FACEP

Emergency Physicians of Florida (EPF),

formerly known as the Florida College

Political Action Committee (FLACPAC),

is one of the primary advocacy tools that

enables individual physician members of

FCEP to make a difference at the legisla-

tive and regulatory level. In order for us to

have a positive influence on our legislators,

both at home and in Tallahassee, we need

your help. Please consider “giving a shift”

from personal funds. You can even donate

online at:

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

Thank you to all who have donated in

2009!

Emergency Physicians of Florida

ADVOCACYnow!


People for Access to Emergency Care




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EMpulse January-February 2010 Issue

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