Jamie Schneider, MD
EM3, MCW Emergency Medicine Residency
WACEP Alternate Delegate to WMS and ACEP

As the end of residency nears I have noticed a subtle shift in my education. Until recently, I had been focused on how to treat patients; medical school taught me disease and diagnosis and the broad strokes, and the first years of residency honed my treatment of crashing patients and worried well.

It’s only in the last year that I’ve really started learning what it means to be a physician in the real world.  This includes billing workshops, applying for jobs, reviewing contracts, and engaging in philosophical discussions on management of our profession.

To this end, I had the awesome opportunity to join the WACEP delegation at the ACEP 2018 Annual Meeting last fall as an alternate delegate. Where the ACEP Scientific Assembly adds to our education and tools for treating patients, the Annual Meeting gives us a venue to shape the practice and profession of Emergency Medicine.

ACEP, as with seemingly every other organization in America, spent much of its time at the Annual Meeting on opioids. Just as interesting, however, was the vast amount of discussion about what Emergency Medicine is, and how we as a profession should manage and advance it. We heard keynotes on how to tackle the lack of trained EPs in rural areas, bylaws amendments on who should be a part of ACEP, and resolutions on topics from protecting physicians’ mental and physical health to ensuring fair and appropriate remuneration to appropriately training future EPs.

As a physician early in my career, these debates were valuable in shaping my understanding and views, and for our more experienced members gave a forum for sharing their wisdom. It can be argued that Emergency Medicine attracts one of the most diverse groups of practitioners, caring for the most diverse group of patients in the most diverse environments in all of medicine. There is clearly no “one best way” forward for our profession, but forums like the ACEP Annual Meeting are invaluable for allowing us to find common ground.

With that in mind, I am looking forward to the Wisconsin Medical Society’s Annual Meeting coming up on April 7. Representatives from each Wisconsin specialty society (including WACEP) and from all geographic districts of the state will gather in Madison to discuss topics relevant to the entire house of medicine of Wisconsin. Resolutions this year will include at least two that are sponsored by WACEP. If you don’t happen to be sleeping off a Saturday overnight shift, consider joining us for what is sure to be interesting and enlightening discussion.

ATTENTION MEDICAL STUDENTS! If you're considering Emergency Medicine for residency the April 13th Midwest Medical Student Emergency Medicine Symposium is for you!

We know the residency match process can be overwhelming. That's why Wisconsin-ACEP is teaming up with the MCW and UW Emergency Medicine Residency Programs to co-sponsor the event alongside Ohio and Michigan Chapters of ACEP, EMRA, and some of the top residency programs from around the country.

This event will show medical students the ropes on choosing the right residency, rocking your interview, and standing out from the competition! Don't miss out on this one-of-a-kind event with a dynamic agenda designed to maximize your participation.    

Midwest Med Student Symposium & Residency Fair

April 13, 2019
Hilton Garden Inn Toledo/Perrysburg, Ohio

Learn more and register online. Registering by phone? Call Monday-Friday, 1-888-642-2374 between 7am and 4pm CST.

A recent article in the USA Today quoted WACEP leader Bobby Redwood, MD, MPH, FACEP, and highlighted over a year of work being done by Wisconsin ACEP, the Wisconsin Hospital Association, and other organizations in regards to initiating Medication Assisted Treatment (Buprenorphine), in the Emergency Department.

Redwood points out a few of the efforts to date: 1) WACEP surveyed the EM workforce in Wisconsin on MAT; 2) WACEP developed an infographic on MAT & the ED; 3) WACEP and other organizations scheduled and promoted X-waiver training opportunities in Wisconsin; and 4) WHA developed a webinar to encourage MAT cooperation between primary care and emergency physicians.

WACEP's next steps are to work with key stakeholders to secure funding and develop regional streamlined care processes to make sure patients get the coordinated care they need.

"While WACEP will continue its efforts in 2019," says Redwood, "I am really hopeful that we will start to stem the tide of morbidity and mortality from opioid overdoses in Wisconsin. Thanks to all who contributed to this important work."

A monthly webinar series, Health Care Workforce Resilience, jointly sponsored by the Wisconsin Medical Society and the Wisconsin Hospital Association, is offered the second Tuesday of each month throughout 2019.

Each month will focus on a unique topic. Participants will receive one hour of continuing education credit, as well as practical and easy-to-implement tools for dealing with burnout in health care.

Resources and the recording of the January webinar, Prevalence & Severity of Burnout: Workforce Resilience as Care Quality, are available online.

 The next monthly webinar, Enhancing Resilience: The Science and Practice of Gratitude, will occur on February 12 and will demonstrate a simple, enjoyable and effective tool for improving well-being by cultivating gratitude. Learn more and register.

Eric Jensen, Jensen Government Relations, LLC

After what feels like a never-ending election cycle, the 2019-20 Session of the Wisconsin Legislature is finally under way.  Dominating early news following the election:

Governor Tony Evers’ victory in November changes the partisan political dynamic in Madison for the first time in nearly a decade.  While Republicans maintained wide majorities in both the Assembly and Senate, they do not have sufficiently large majorities to override gubernatorial vetoes on their own, meaning as a general rule legislation will need bipartisan support to ensure passage.

The “Lame Duck” (post-election) Legislative Session in December set a contentious early tone to the 2019-20 Session.  However, as Inauguration Day approached, and in speeches given on Inauguration Day, Senate Majority Leader Scott Fitzgerald, Assembly Speaker Robin Vos and Governor Evers all spoke to a desire for cooperation, bipartisanship and civility.

The coming Budget Debate.  Prior to his inauguration, Governor Evers announced a variety of items he intends to include in his 2019-21 Budget Proposal (generally announced in Mid-February).  Of particular interest, the Governor made clear he intends to include a Medicaid Expansion proposal based on the original Affordable Care Act’s MA Expansion program.  While Republicans have historically and openly opposed MA Expansion, Senator Fitzgerald has signaled that the Senate will remain open-minded heading into the Budget process.

Typically, the Governor introduces the Budget in mid-February in a speech to a Joint Legislative Session.  Once introduced, the Budget Bill moves on to the Joint Finance Committee (currently made up of 8 Assembly Representatives – 6 GOP and 2 DEM, and 8 Senators – 6 GOP and 2 DEM).  JFC’s work on the Budget includes informational hearings, a period of research and analysis by the non-partisan Legislative Fiscal Bureau, a period of hearings during which the Budget is debated and voted on piece-by-piece, and finally passage of a recommended Budget Bill that moves on to the full Legislature.  While the Wisconsin Constitution requires the Budget to be signed by July 1, if that does not happen the State government does not shut down, rather all agencies continue operating at the prior Budget’s funding and programming levels.

This year, it is widely anticipated that rather than working from Governor Evers’ Budget proposal, the GOP-led Legislature will write their own version starting from scratch.  But because the Wisconsin Governor has the power of the line-item veto when it comes to the Biennial Budget, the final product will be one of negotiation – but we may be waiting well into the Fall of 2019 before a final Budget deal is reached.

The ACEP Nominating Committee is accepting individual and component body recommendations for Board of Directors, Council speaker, and Council vice speaker candidates. 

A true measure of a leader is knowing when it is time to accept the challenge of leadership. One must carefully consider their education, life experiences, and potential to determine when they are ready to lead. If you know you are ready to lead, don't wait for a phone call to determine your interest in seeking nomination! Take the initiative to contact your component body president or section chair to express your interest in nomination, and ask that a letter of support be submitted on your behalf.

To qualify for a Board position or Council office, a candidate must:
be highly motivated to serve ACEP and be committed for three years for a Board position;

• be an ACEP member in good standing with no delinquent dues;
  
• be an ACEP member for at least five years;
  
• show evidence of ACEP involvement in both national and chapter activities (such as current or past chapter officer, current or past national committee leadership, current or past service   as a councillor or alternate councillor, or current or past section leadership);
  
• show chapter and/or section support for candidacy. 

Criteria for nomination to Council office include:

• nominees must be active members of the Council (presently or recently); 
• nominees must be active nationally (presently or recently); and 
• there will be no exclusions because of past service.

Nominations must be received by March 1, 2019 and may be emailed to John G. McManus, Jr.. MD, MBA, FACEP and copied to Sonja Montgomery.

Elections for the Board of Directors will occur on Saturday, October 26, 2019, during the Council meeting in Denver, CO. Please contact Sonja Montgomery at 800-798-1822, ext. 3202 with questions about the nomination process. 

Lisa Maurer, MD
WACEP President's Message, December 2018

In keeping with essentially every organization providing a year-end countdown list, I would love to finish my last president’s message with a "Top-5 Chief Complaints" list and describe what WACEP is doing as an organization to improve each one of them for our physician members. Think of me as Casey Kasem reading off the chief complaints as they populate into your tracking board.

#5.  “Spider monkeys have moved into my living room.” Yes, you guessed it, there are no spider monkeys. Not to make light of the frequent psychiatric crises that we stabilize.  Frustrating part,? It takes us so long to connect these patients in crisis to the definitive and specialized care they need and deserve. WACEP has worked all year long with the Wisconsin Psychiatric Association to work towards a streamlined process of medical stabilization. A white paper reflecting best practices for our state will be released soon, and this task force between our two organizations will keep chipping away at the small problems that build up an amount to major delays. In the meantime, check out the SMART protocol, which included in this group’s conclusions for best practices.

#4.  “I took my blood pressure at Walgreens and it was high.”  Ahhhhhh, asymptomatic hypertension. Are you taking your medications? No. Why don't you have medications? I don't have a doctor. Why don't you have a doctor? I have Medicaid can't find anyone to take my insurance. Yes in the state of Wisconsin, our Medicaid program covers a notably large population without even doing the official “expansion” of the ACA. However, the financial burden then rests on the physicians backs with record low reimbursement rates, drowning any practice that sees a significant amount of Medicaid enrollees. When primary care doctors can limit these patients in their panel, they come for emergency departments further exacerbating the unfunded mandate of EMTALA.  WACEP has worked with legislative and regulatory state leaders to make sure they understand the logistics of our situation, and keep this as a high priority in mind as we move toward the next state budget. We have come farther than ever before in making our case heard, and are confident that we will be moving forward with progress. Please help us to continue to support friends of emergency medicine in Wisconsin through supporting our political action committee.

#3.  Wait - stop seeing patients.  This chief complaint is from your hospital president, who wants you to field a patient complaint.  Good thing WACEP has continued to develop our annual Spring Symposium, scheduled for April 3-4 at the Harley-Davidson Museum in Milwaukee. This year we are featuring a new leadership development content, targeting all of you emergency department leaders who manage staff, colleagues, patients, (hospital administrators, police officers….) everyday.  Come check this out as well as information on ED-initiated Medication-Assisted Treatment for substance abuse disorders, alternatives to opioids hands-on work sessions, presentations by the immediate-past president of ACEP, ultrasound workshop for emergency physicians, and definitely check out the reception the evening of April 3rd.  Invite your physician and non-physician colleagues to join us!

#2.  “N/V/D.”  Stomach flu going around? Guess again. This “flu” also comes with goosebumps, severe diffuse pain, and a patient who really just wants you to help them transition into medication-assisted treatment for opioid abuse rather than prescribe 12 more Oxycodone to get them by till their next ER visit two days from now. Patients who are started on buprenorphine from the emergency department for their active withdrawal from opioids have a much better chance of staying clean in the long run. But how can emergency physicians play this important role when we do not have clear outpatient ongoing treatment resources for our patients, and need to partake in additional training to have the necessary DEA waiver. The good news is WACEP will be working to gather and disseminate information around the state for what the medication assisted treatment resources are in your community. What's more, look for our partnership and promotion of the Wisconsin Society of Addiction Medicine's series of X-waiver training courses traveling around the state in the next year.

#1. Woohoo! Rough shift.  This chief complaint is from you.  Come to think of it, they've all been rough recently. And it's hard to schlep to each of my six shifts in a row when I'm not sleeping in between my 12s, I haven't seen fresh produce for weeks, and let's just say exercise is not how I get my release on my days off.  It's hard to prioritize our own mental health when we see patients in crisis every day, and the crutches to deal with this stress can lead to the slippery slope of substance abuse among our colleagues. WACEP has declared it a priority to decrease the stigma of substance abuse disorders and mental illness and work together to find ways to increase access to treatment for both.  More to come on this important project in 2019. 

A huge THANK YOU to the WACEP Board members and staff for all of your work to make progress on these and many other important programs that our chapter works on.  Happy Holidays!

Bobby Redwood, MD, MPH, FACEP

The WACEP opioid task force has been very active in 2018, working with key stakeholders across Wisconsin to explore and develop opportunities to stem the tide of opioid-related morbidity and mortality in our state. One key initiative has been the development of the WACEP Alternatives to Opioids (ALTO) Pathways. The WACEP ALTO Pathways provide a roadmap for emergency physicians to treat a variety of acute pain syndromes using a multi-modal, receptor-based approach to analgesia. Using the ALTO approach, opioids are reserved as a rescue therapy with a goal of exposing fewer ED patients to this dangerous and addictive class of medications.

A State in Crisis

The opioid epidemic in Wisconsin is unprecedented in scale and scope. 20,590 Wisconsinites suffered from opioid use disorder in 2016 (triple the rate observed in 2005). 1,074 Wisconsinites died from an opioid overdose in 2016 (double the rate observed in 2005). Wisconsin led the nation in in ED opioid overdose visits between 2016-2017 with an increase of 109%. Nationwide, 42,249 Americans died of an opioid overdose in 2016 and the death rate from all opioids (including heroin) now exceeds the death rate from motor vehicle accidents. One of every 550 patients started on opioid therapy died of opioid-related causes a median of 2.6 years after the first opioid administration.

Your Last Blue Patient?

Do you work nights or weekends? If so, you have probably treated a patient presenting with an opioid overdose in the last month…or week…or day. I am writing this newsletter after my third night shift at a community emergency department and I have treated a patient with a life-threatening opioid overdose each of the past three shifts. All three survived, but one young woman suffered an anoxic brain injury and will spend the rest of her life in a long-term care facility. We cannot save all of our patients, but we can certainly take steps to prevent the next opioid overdose or at least ensure that Wisconsin emergency physicians are not exacerbating the epidemic.

A Plan to Save Lives and Curb an Epidemic

The ED is actually a minor source of opioid prescriptions (4% of all opioid prescriptions originate from the ED); however, initial exposure to opioids is common in the ED setting since patients routinely present in acute pain. In an effort to do our part, proactive emergency physicians have developed a four-fold strategy to address the opioid epidemic from the ED: (1) Reduce the amount of opioids used in the ED, (2) Reduce the amount of opioids prescribed from the ED, (3) Offer patients harm reduction interventions from the ED if appropriate (i.e. naloxone prescriptions), (4) Treat addicted/withdrawing patients and refer them to treatment.

A Duty to the Individual Patient

The WACEP ALTO pathways address the need to reduce opioid use and prescriptions in the ED, while respecting the need to provide analgesia to patients in acute pain. ALTO interventions are not one-size-fits-all and should always be administered with the individual patient’s risk profile in mind (age, allergies, weight, etc.)

Balancing Evidence-based Practice with the Urgency of this Historical Moment

ALTO interventions are based on the evidence that is available, but have not been as rigorously investigated to the extent that we, as emergency physicians, are accustomed to in our usual practice. At WACEP, we recognize the importance of this moment in history and have made a conscious decision to prioritize opioid harm reduction over the potential harm of using alternative therapies that (in some cases) have only a low level of evidence to support their efficacy. That being said, most of the ALTO interventions will be recognizable to seasoned physicians as common off-label practice (migraine cocktail, etc). WACEP members can expect multiple iterations of these pathways, updated as the evidence evolves.

Becoming an ALTO Physician Champion

Want to get involved? WACEP is here to help! As an individual physician, you can download the protocols, post them prominently in your physician-workspace, and start using the pathways (as long as there is not conflict with your established hospital protocols). Or better yet, why not change the culture of your entire ED and join the Midwest ALTO Project? The Midwest ALTO project will provide your hospital with a comprehensive ALTO toolkit that includes sample protocols, order sets, public realtions materials, and data abstraction tools to ensure that your ED’s ALTO care transformation has a successful launch. It is led by emergency physicians, nurses, and pharmacists, and coordinated through the Wisconsin Hospital Association. To join, have your quality department contact Shruthi Murali.

Suzanne Martens, MD, FACEP, FAEMS, EMT
President, NAEMSP-WI Chapter
Immediate Past WI State EMS/Trauma Medical Director

There have been many questions generated over the discussion that Wisconsin EMS is headed towards universal statewide protocols.  This is a 180 degree turn in the historical decentralized, or “home rule” philosophy for Wisconsin.  However, I ask you to join me in anticipating a positive change. 

The resource document for the developing protocols, or perhaps more correctly termed patient care guidelines, is an excellent evidence-based project supported by the National Association of State EMS Officials (NASEMSO).  If you have never visited their website, please do… the site is home for other EMS projects including the Compass Project, the Fatigue in EMS project, and Naloxone Evidence-Based Guidelines.

Excerpts from the NASEMSO/Projects page:

The National Model EMS Clinical Guidelines Project was first initiated by NASEMSO in 2012 and has produced two versions of model clinical guidelines for EMS – the first in 2014 and the most recent version in late 2017. 

The model guidelines project has been led by the NASEMSO Medical Directors Council in collaboration with eight national EMS physician organizations, including: American College of Emergency Physicians (ACEP), National Association of EMS Physicians (NAEMSP), American College of Osteopathic Emergency Physicians (ACOEP), American Academy of Emergency Medicine (AAEM), American Academy of Pediatrics, Committee on Pediatric Emergency Medicine (AAP-COPEM), American College of Surgeons, Committee on Trauma (ACS-COT) and Air Medical Physician Association (AMPA).  Co-Principal Investigators, Dr. Carol Cunningham and Dr. Richard Kamin, directed the 2017 project as well as the original 2014 endeavor.  Countless hours of review and edits were contributed by subject matter experts and EMS stakeholders who responded with comments and recommendations during two public comment periods.  Drs. Cunningham and Kamin presented this project at the NAEMSP Annual Conference in January 2018. 

Excerpts from the Guidelines -Introduction/Purpose & Notes:

NASEMSO recognizes the need for national EMS clinical guidelines to help state EMS systems ensure a more standardized approach to the current practice of patient care and, as experience dictates, adoption of future practices.  Model EMS clinical guidelines promote uniformity in prehospital care which, in turn, promotes more consistent practice as EMS providers move across healthcare systems.  They also provide a standard to EMS medical directors upon which to base practice. 

The focus of these guidelines is solely patient-centric.  As such, they are designed to provide a resource to clinical practice and to maximize patient care, safety, and outcomes regardless of the existing resources and capabilities within an EMS system.  They are a set of clinical guidelines that can be used as is or adapted for use on a state, regional or local level to enhance patient care and benchmark performance of EMS practice.

The long-term goal is to develop a full range of evidence-based pre-hospital care clinical guidelines. However, until there is a sufficient body of evidence to fully support this goal, there is a need for this interim expert, consensus-based step. 

The National Model EMS Clinical Guidelines can fill a significant gap in uniform clinical guidance for EMS patient care, while also providing input to the evidence-based guideline (EBG) development process.

Successful development into State EMS guidelines and protocols include these examples:

• Ohio (link)
  
• Connecticut (link)
  
• New Hampshire (link)
  
• Maine (link)
  
• Rhode Island (link)
  

It is anticipated that the Wisconsin version of these patient care guidelines will become available in part during 2019, with development, roll out, implementation and editing to phase in over subsequent years.  There will be consideration for Wisconsin scope of practice and medication formulary choices.  It is recognized that not all sections will apply to all agencies.  The EMS Physicians Advisory Committee and Dr. Colella, as the State EMS Medical Director, will have primary input.  

These meetings, as well as the State EMS Board sessions, are open to the public and have remote access links for anyone who wishes to keep up with the debate, decisions and developments. Meeting information and member contact information are listed online. 

Please join me in supporting this project!

"Emergency Medicine: Where the Rubber Meets the Road" is the theme for Wisconsin ACEP's 2019 Spring Symposium & Annual Emergency Medicine Research Forum, scheduled to take place April 3-4, 2019 at the Harley-Davidson Museum in Milwaukee. Online registration is open!

Approved for AMA PRA Category 1 Credits™, the WACEP 2019 conference will kick off at noon on Wednesday, April 3 with an open Q&A forum over lunch, immediately followed by a plenary session that will walk attendees through the process of initiating medications for opioid addiction treatment in the ED. Attendees will then have the option between an MAT/ALTO workshop, or a leadership forum specifically for ED directors and emerging EM leaders.  Wednesday's dinner presentation will feature ACEP President, Paul Kivela, MD, 

Thursday's program features a number of sessions back by popular demand, including: 2018 LLSA articles workshop that will help attendees prepare for the ABEM-required exam; Hot Topics in Emergency Medicine round-table discussions featuring a variety of timely topics; hands-on Ultrasound workshop;  and optimizing antibiotic stewardship. 

WACEP is proud to continue its partnership with the UW and MCW Emergency Medicine Programs by offering the annual Emergency Medicine Research Forum on Thursday morning during the conference. The Forum will feature both poster and oral presentations and showcase the great research being done across our state. In the lunchtime general session on Wednesday, Daniel Spaite, MD from the University of Arizona will present on new findings in traumatic brain injury management. 

Afternoon sessions on Thursday will include a session led by Edwin Leap, MD on doing more with less; updates in managing and treating agitation; sex trafficking and what to look for; optimizing antibiotic stewardship; and more. 

Learn more and sign up today!