The WACEP is pleased to announce that the nominations for the 2022 Distinguished Service Award is now open!

The Distinguished Service Award recognizes a WACEP member who has made extraordinary contributions to the advancement of the emergency medicine specialty, and who has demonstrated the ideals of the organization through their ongoing activities and accomplishments.

Nomination Deadline: March 1

Nominate Someone Today!

President's Message, February 2022
Brian Sharp, MD

For those of you who tuned in for the Super Bowl, how incredible was that halftime show?  While it has generated plenty of hilarious memes poking fun at people like myself who were able to relive their “glory days,” I sure enjoyed all the artists getting back together for this show.  Whether or not the show featuring the music of Dr. Dre, Snoop Doggy Dogg, and Mary J Blige among others was targeted to your generation or your music taste, it does provide me with a great excuse to remind everybody about the upcoming WACEP Spring Symposium—April 20^th and 21^st.  Appropriately themed, “Getting the Band Back Together,” this will be an opportunity for us to finally gather, to learn together, and to celebrate the amazing work being done across our state.  To highlight some of the various reasons to attend, what better way than to quote some of the Super Bowl performers.

You can teach an old dog new trick if that old dog listens.

-Snoop Dogg

The WACEP Spring Symposium is packed with rich educational opportunities.  This includes keynote speakers, Dr. Tom Aufderheide and Dr. Gail D’Onofrio as well as talks on topics ranging from ED critical care to ED dental trauma.  You won’t want to miss the high yield “Hot Topics” roundtable discussions or the “Unique Procedures Workshop.”  Lastly, the popular LLSA Article Review Workshop returns—use this to knock that off your to-do-list.

Never let me slip cuz if I slip then I’m slippin’

-Dr. Dre

The WACEP research forum is an incredible opportunity to see the cutting-edge research work being done in Emergency Medicine across our state.  There will be numerous oral and poster presentations to learn from and a chance to celebrate the great achievements of our statewide researchers.

My mind on my money and my money on my mind

-Snoop Dogg

After 2 years of limited opportunities for in person conferences—including many conferences canceled, many of you have may extra CME money to use.  Take this opportunity to do that in a packed, fun conference—one where you don’t even have to fly.

Sunny days wouldn’t be special…if it wasn’t for rain.

Joy wouldn’t feel so good…if it wasn’t for pain.

-50 cent

Let’s be honest, the last two years have been rough at times.  April will be a great time to finally come together, to celebrate the value of emergency medicine and to grow relationships with our colleagues from around the state.  It has been three years since we were able to last hold our WACEP Spring Symposium in person and we have all been through a lot personally and professionally.  Let’s make this one count!!

So don’t forget to make your plans now, to register for the conference, and hopefully I will see you all in April in Milwaukee. 

Best,

Brian

Please do not hesitate to reach out to me if WACEP can help you or if you would like to connect.  My email address is bsharp@medicine.wisc.edu.

Congratulations to WACEP's Resident Representative and Symposium Planning Committee Member, Dr. Matthew Stampfl, University of Wisconsin School of Medicine, on being the winner of the Essentials of Emergency Medicine 2022 blog post contest! Here is the winning post! 

Written by Matthew Stampfl

The Controversy | Topical TXA for Epistaxis
An 83-year-old male with history of dementia and atrial fibrillation on warfarin comes in with bleeding from the nose for the past 90 minutes. Direct pressure doesn’t seem to have helped, but his caregiver really wants to avoid packing if possible, since he became extremely agitated last time he received it. Your attending says to pull out the vial of TXA, but you ask: “Wait, wasn’t there a recent study that found TXA didn’t help?”

The Case for TXA
TXA is a fixture in algorithms for epistaxis, including a recent one promulgated by the New England Journal of Medicine. This is based on multiple smaller studies showing promising efficacy.

For instance, a 2018 RCT included 124 patients with epistaxis on antiplatelet agents and compared topical TXA (500 mg) on a pledget to topical lidocaine-epinephrine on a pledget followed by nasal packing. Patients were only eligible for inclusion if 20 minutes of direct pressure failed to resolved their symptoms. The primary outcome was cessation of bleeding within 10 minutes, which occurred 73% of the time in the TXA group vs 29% in the lidocaine-epinephrine/nasal packing group.

Another RCT in 2019 took 135 patients and split them between three arms: atomized TXA (500 mg) with compression, nasal packing with Merocel, and compression alone. Primary outcome was cessation of bleeding within 15 minutes. This occurred 91.1% of the time in the TXA arm vs 93.3% in the Merocel packing arm and 71.1% in the compression alone group. On analysis, both TXA and Merocel were significantly better than placebo, though they were not different from each other.

The Argument Against
However, the largest RCT (NoPAC, 2021) on TXA in epistaxis comes to a different conclusion. It was a double-blinded multicenter RCT which enrolled 496 patients with epistaxis that failed to resolve with 10 minutes of direct pressure followed by topical vasoconstrictor application and then another 10 minutes of direct pressure. Patient were randomized between TXA or saline delivered via cotton wool dental rolls (the UK’s equivalent to pledgets). The protocol called for 200 mg TXA soaked into the dental roll which was held in place in the nare via nasal clip for ten minutes. If this did not control the bleeding, the treatment would be repeated once. Primary outcome in this trial was need for anterior nasal packing, which was placed at the discretion of the treating clinician. There was no significant difference in rates of packing between the groups, with 43.7% of the TXA undergoing packing vs. 41.3% of the placebo group.

My Take and Recommendations
So where does this leave us? We want to be evidence-based, and the largest study on the topic calls into question whether TXA in epistaxis improves outcomes. On the other hand, we know our 83-year-old won’t tolerate packing well, and we would like to spare him (and us) that experience if possible.

Digging into the NoPAC trial reveals a few differences that might contribute to its divergent findings. For one, TXA was given as a 200 mg dose x 2 rather than the single 500 mg used elsewhere. Moreover, all patients enrolled in NoPAC had to first fail a topical vasoconstrictor, which potentially selects a somewhat different patient population. Finally, NoPAC was conducted in the UK, which may limit generalizability to the US given practice variation (e.g. UK patients who undergo nasal packing are admitted for an average of three days). 

A 2021 systematic review of topical TXA in epistaxis included 1,299 patients across 8 studies (including NoPAC). Unfortunately, NoPAC was excluded from the analysis of bleeding cessation because its outcome was avoiding packing, but the remaining trials showed that TXA had 3.5 times greater odds of bleeding control at first reassessment.

Thus, the evidence isn’t clear. But as with all treatments we provide to our patients, we have to weigh the risks and benefits. On the benefit side of the ledger, it is unclear if TXA will help this patient to avoid packing. Conversely, topical TXA has minimal adverse effects, is quite inexpensive and won’t take long to trial. Given the negligible downsides of TXA and the known harms of packing this patient, let’s give TXA a try!

The Assembly amended and approved a bill Thursday that would allow advanced practice nurses to practice independently, while also taking up two bills passed on party lines that would bar automatic Medicaid renewals and stop some from turning down work to stay in the program. 

Under an amendment to the nursing bill, advanced practice nurses who have completed 3,840 clinical hours of practice while working with a physician or a dentist would be allowed to work independently. 

They could only provide pain management services while working in a collaborative relationship with a doctor, except if providing the services in a hospital or clinic associated with a hospital. 

“Ultimately, this bill, when passed, will lower healthcare costs as well as increase access,” bill co-author Rep. Rachael Cabral-Guevara, R-Appleton, said on the floor before passage of the plan. 

Cabral-Guevara said “not only the nurses, but the physicians” worked “to come to a bill that is passable.” 

But Mark Grapentine, Wisconsin Medical Society chief policy and advocacy officer, said that the coalition of physician groups that were working on the bill did not reach a deal with lawmakers. They’ll ask Gov. Tony Evers to veto the plan. 

“While the amendment that passed today took some smaller steps in the direction physicians felt were necessary to protect our state’s patients, it left other concerns unaddressed,” he said. “So what the Assembly passed fails to include what we felt were bare minimum guardrails.”

Grapentine said it was disappointing to hear comments on the Assembly floor that made it seem like doctors signed off on the bill as amended.  

Doctor groups pushed for an amendment requiring 4,000 hours of experience of professional nursing practice and an additional 4,000 hours of physician-supervised experience after obtaining an advanced practice registered nursing certification before the nurses could practice independently. 

They also asked that physician-specific terms like medical doctor and anesthesiologist only be used by those with physician-specific degrees. 

And they wanted to see nurses outside a hospital setting practice pain management under the supervision of, or in collaboration, with a doctor trained in pain medicine.

The amendment doesn’t include specific training for the doctor the nurse would work with, “which doesn’t provide the level of safety we think is necessary for this area of medicine,” Grapentine said.

Wisconsin Nurses Association CEO Gina Dennik-Champion said the bill would allow advanced practice nurses to practice at the full scope of their license. They’ll be asking Evers to support the bill, which she says provides “access to quality, safe, affordable” care. 

“Our state desperately needs these providers to be practicing in these places where there are no physicians,” she said. 

Dennik-Champion said the “guardrails are there” with what the bill requires nurses to do to be licensed as advanced practice nurses.

The amendment includes a “transition to practice” provision similar to other states that requires nurses to practice for two years with a doctor before working independently, she noted. 

Dennik-Champion said that title protections for physicians can be “addressed at another time” and including it “didn’t make sense at this time” since the bill focuses on advanced practice nurses. If physicians want the protections, they could look at including it in their own practice act, she said. 

Certified registered nurse anesthetists delivering pain management services in clinics have to complete a fellowship before they can provide the service, she added, in response to doctors' concerns about that provision in the amendment.

“We think we have a bill that is clean and should be supported and enacted,” Dennik-Champion said.

Besides acting on the bill, the chamber also took up a series of workforce plans that, among other things, would make changes to the state’s Medicaid program. 

One of the measures approved by lawmakers would bar the Department of Health Services from automatically renewing a Medicaid recipient’s eligibility. DHS would have to determine eligibility every six months, rather than annually. Any enrollee failing to report changes that affect their eligibility would be ineligible for benefits for six months from the date DHS discovers the change. 

Wisconsin’s Medicaid program is under a continuous enrollment policy to qualify for more federal dollars during the COVID-19 national public health emergency. Under the bill, DHS would have to “promptly” remove people deemed ineligible for Medicaid once the funding ends. Until then, it would have to report the number of ineligible enrollees still receiving benefits. 

A separate measure, from Rep. Calvin Callahan, R-Tomahawk, would bar some BadgerCare adults from turning down work or accepting a raise in order to maintain eligibility for the program. 

“We are not kicking people off healthcare,” he said. “This bill would only affect those who are able-bodied and actually refuse work in an attempt to maintain their eligibility status.”

Advocates for those with disabilities and lower-income people oppose the measures. William Parke-Sutherland, health policy analyst for Kids Forward, said Callahan’s measure doesn’t take into account whether jobs provide affordable health insurance, offer hours recipients can’t meet or offer work that is unsuitable for their circumstances. 

The Medicaid enrollment bill would pose hurdles for people to renew their coverage, requiring them to submit twice as much paperwork to keep it. The plan would also bar the state from using one of its best tools to ensure people have continuous health insurance coverage, Parke-Sutherland said.

“These changes would weaken the workforce by making our state sicker and would worsen stark racial inequities in who has access to care and coverage,” he said in a statement.

The Assembly passed the Republican-backed measures on party lines, advancing them to the Senate for further consideration.

The chamber also passed a measure along party lines that would bar the governor from declaring certain businesses essential or nonessential during a public health emergency. Any actions applied during such an emergency to businesses would have to be applied to all uniformly. 

They also signed off on legislation requiring additional reporting on public benefits and the work of the Wisconsin Department of Health Services’ Office of the Inspector General. 

Lawmakers signed off on a bill that would regulate and license genetic counselors, amending the plan so that it bars those in the profession from encouraging an expectant parent to obtain an elective abortion.

The Assembly also advanced the biennial agreed-upon bill recommended by the Worker’s Compensation Advisory Council.

Wisconsin Health News
February 16, 2022

Gov. Tony Evers said Tuesday he’s investing around $27 million to support emergency medical services providers and $25 million in mental health initiatives for schools, the University of Wisconsin System and the Wisconsin National Guard.

There are nearly 800 emergency medical service providers in the state, with more than half either operated by volunteers or a combination of volunteers and paid staff, Evers said in his State of the State address. Finding new volunteers has been difficult, he said, noting that state aid to local governments fell over the past decade as costs increased.

“Some have even gone without ambulance services, left with no other option but to hope and rely upon neighboring providers,” Evers said. “No one should be calling for an ambulance and have to wonder whether help will come.”

Around $20 million in American Rescue Plan Act money will head to rural Wisconsin to increase staffing support, get first responders more training and help purchase ambulances, medical equipment and supplies.

Evers' administration will also fund a 16 percent Medicaid rate increase for private and municipal ambulance services for emergency medical transportation, around $7.4 million in state and federal funds.

“This announcement and investment will be a tremendous help for EMS in Wisconsin, especially our rural and smaller services,” Alan DeYoung, Wisconsin

EMS Association executive director, said in a statement.

Evers also said he’ll invest $15 million to support additional mental health services in schools. Schools will be able to use the money to provide mental healthcare, hire and support mental health navigators, provide training and offer family assistance programs.

He’ll give $5 million to the University of Wisconsin System to provide mental health services through telehealth and additional mental health staff. And he’ll put $5 million toward expanding access to mental health supports for Wisconsin National Guard members.

Evers will also establish a Blue Ribbon Commission on Veteran Opportunity to make recommendations for his next budget. That could include mental health and substance use treatment investments, he said.

And he’ll sign an executive order on Wednesday calling for a special session to take up his plan to spend part of the state’s anticipated $3.8 billion surplus by the end of the 2021-23 biennium, including providing $100 million in tax relief to family caregivers.

In response, Senate Majority Leader Devin LeMahieu, R-Oostburg, criticized Evers for his stay-at-home order at the beginning of the pandemic, saying the governor deemed “hundreds of Main Street employers ‘non-essential’” and “devastated our small business community.”

“Now, Tony Evers’ COVID response centers on handing out giant, cardboard checks using the federal tax dollars, which are borrowed against our kids and grandkids’ futures,” LeMahieu said. “He promised to ‘get the money out the door’ as quickly as possible. But, now nine months later, he still has nearly $1 billion left in his Madison bank account.”

LeMahieu called on the governor to sign into law a series of initiatives aimed at getting more people into the state’s workforce.

They include a measure that would prohibit automatic renewal for Medicaid and require eligibility to be determined every six months, rather than every year. A separate bill would bar some BadgerCare recipients from declining work for the sole reason of continuing eligibility for the program.

Wisconsin Health News
November 17, 2021

U.S. Reps. Ron Kind, D-La Crosse, and Glenn Grothman, R- Glenbeulah, recently joined 150 other lawmakers in urging the federal government to revise the interpretation of its surprise billing rule.

In a letter sent to Department of Health and Human Services Secretary Xavier Becerra, U.S. Department of Labor Secretary Martin Walsh and Department of the Treasury Secretary Janet Yellen, the lawmakers said the administration’s interpretation does not “reflect congressional intent” when the No Surprises Act passed Congress in December 2020. 

Specifically at issue is the administration’s use of the median in-network rate as the primary determining factor in payment disputes between providers and payers during the independent dispute resolution process established in the law.

"This approach is contrary to statute and could incentivize insurance companies to set artificially low payment rates, which would narrow provider networks and jeopardize patient access to care – the exact opposite of the goal of the law,” they said in the letter. “It could also have a broad impact on reimbursement for in-network services, which could exacerbate existing health disparities and patient access issues in rural and urban underserved communities.”

The law, effective Jan. 1, states that patients are held harmless and will not be responsible for medical bills higher than what they would pay an in-network provider. If providers or insurers believe an out-of-network medical bill or payment is unreasonable, either party may initiate the independent dispute resolution process

Congratulations to WACEP President, Dr. Brad Burmeister, for being inducted into ACEP's Young Physicians Leadership Society. This Annual Award program recognizes attending emergency physicians who have demonstrated exceptional leadership within the specialty. Dr. Burmeister was recognized during the Young Physicians Leadership Section Leadership Summit at ACEP21 in Boston. He will also be recognized in the YPS "What's Up" newsletter, on the YPS website and in ACEP Now magazine.

“Since joining the WACEP Board two years ago, Dr. Burmeister has been incredibly active, taking the reins of the Membership Committee and going above and beyond in recruiting new members to ACEP around the state, and improving our retention numbers with personal outreach… As the current president of our chapter, he continues to grow and diversify our board beyond the Madison/Milwaukee area and has been a great proponent of rural outreach, helping our rural colleagues get education focused on the care of the patients that they see in resource-limited settings.”

Congratulations Dr. Burmeister! We are proud to call you our own!

Members,

What is your mission?

Our mission at WACEP is to “support quality emergency medical care and to promote the interests of emergency physicians.”

We do this in many ways. At WACEP, I think that the foundation of our work is advocacy at the state level. We are the only physician-based organization representing emergency medicine in Madison and we have a strong and growing voice there. Outside of advocacy, we also strive to provide educational opportunities for our members and to connect each other as a social function.

What is your mission? What is your purpose in this career? Emergency medicine is challenging, but people come to you because they need some sort of help. I like to think that it is my job to try and make people’s lives just a little bit better. For some this means perhaps trying to change the trajectory of their life. Whether it is to perform a life-saving intervention or to give them some medical advice to alleviate their concern that’s my purpose. When things are tough in the department, I try to remind myself that I have a mission and make sure that everything I do aligns with this.

--

As far as current things WACEP, in Madison things have been a little less busy than they were earlier this year during the budget process. In terms of working with ACEP, we just returned from the Scientific Assembly in Boston where we had several representatives on the ACEP Council where the priorities of ACEP are developed for the coming years. Lastly, the American Medical Association is currently meeting (or has just concluded) and as Emergency physicians via ACEP we have a growing presence there. Though things seem quiet right now a lot of work is happening to set our foundation for the future. I’m really happy as I follow along with this work and things look great.

Anyway, have a great early winter!

Best,
Brad

Sally Winkelman, former Executive Director of the Wisconsin Chapter, ACEP, was nominated by the WACEP Board and selected as the 2021 recipient of the ACEP Honorary Membership Award. The award is annually presented to an individual who has rendered outstanding service to the College or to the specialty of emergency medicine. Sally's name will be inscribed on a master plaque at ACEP Headquarters. The recipient is considered a lifelong member of the College, is not required to pay any dues, and cannot vote or hold office but receives all other benefits and privileges of membership.

Sally, who received her Bachelor of Business Administration degree in management and marketing from the University of Wisconsin-Madison, spent most of her career working with non-profit professional membership organizations. Prior to retirement, she served for eight years as an account executive with Badger Bay, a Wisconsin-based association management company, where she was the executive director for the Wisconsin Chapter of the American College of Emergency Physicians and several other statewide medical specialty associations. She is grateful to have been part of a professional community of ACEP chapter executives who support each other and serve their state chapters with unwavering dedication and professionalism.

Congratulations Sally!

It’s starting to feel like fall!

In just over a week your representatives from Wisconsin will be meeting at representing your voice at the ACEP Council. A diverse group of Emergency physicians from around the country which essentially considers new proposed policies (called resolutions). This is where the agenda for our national organization comes from. It helps to determine what things are we going to care about over the coming years and where should we put our collective resources. This year there are over 70 resolutions that will be considered during this process. They can be found here: https://www.acep.org/what-we-believe/actions-on-council-resolutions/council/action-on-2021-resolutions/. Should you have interest in policy, or being a member of our board, our meetings are always open and we can always use your help. At the same time, your membership is important no matter how active you care to be as your voice makes us stronger!

Thanks!
Brad