The annual Midwest Medical Student Forum, hosted by the Michigan College of Emergency Physicians, is taking place virtually on Thursday and Friday, January 28-29.  Register today by calling 517-327-5700. This year's Forum will include:

• Small-group advising
• Residency panel
• Residency fair
• Virtual SIMS course (space is limited)

Brad Burmeister, MD, FACEP
WACEP President

Welcome to 2021!

We are off to a great start! This is my first message as the new President, so "hello" to those of you I do not know. Just a bit about me... I work for an independent group in Green Bay which staffs Bellin Hospital.

Before we get to some updates, I want to thank our now Immediate Past President Ryan Thompson, MD, FACEP for all the important work he has done. I’m particularly thankful for his leadership along with our legislative committee and the lobbying team (HWZ) for their hard work on the WI CARES act, efforts on Surprise/Balance Billing at the state level, and ongoing work on Medicaid Reimbursement. I think we are in a great spot moving forward and have some excellent ground work accomplished.

On that note, the legislative team at ACEP has been very busy ensuring the voice of the Emergency Physicians are heard across the country. As a result, we have many favorable outcomes with the “2020 Year End Package” which Congress passed. In particular we have reasonable legislation on Surprise/Balanced Billing as well as better outcomes with Medicare cuts that what had been pending.

WACEP has been working on our own Surprise/Balanced Billing battles at the state level, ongoing efforts for Medicaid reimbursement increases, extending liability protections due to COVID-19, among many other things!

If you haven’t already checked out our virtual Spring Symposium please do so. It will be held Thursday, April 8th, so coming up quickly! We have some great speakers including Dr. David Talan with some insights into infectious disease and Emergency medicine, education on Buprenorphine (Suboxone) and Dexmedetomidine (Precedex), an ATLS update, and an update from Dr. Ryan Westergaard (“The Dr. Fauci of Wisconsin”).  Learn more and register!

If you have any questions or issues you want us to look at, please do not hesitate to contact me.

Please follow us on Facebook! @WiACEP

Stay safe!
Brad Burmeister, MD, FACEP

The DC-ACEP Chapter is hosting an EM MAT Waiver Training Course on Monday, February 1, 2021 and has extended an invitation to all ACEP members to participate for free. Anyone looking to get their waiver early this year is encouraged to register. 

The course is hosted by the DC ACEP Chapter and provided by national ACEP, in partnership with Providers Clinical Support System and the American Academy of Addiction Psychiatry. The 8-hour training is open to Physicians (MD/DO), Residents, Medical Students, NPs (including those in training) and PAs (including those in training). Medical Students and those currently in training can apply for the waiver once they complete their training.

• No expiration for Waiver Training Completion Certificate.
• No pre-work/course requirements.
• CME provided and in order to fulfill requirement for CME you will have to complete the post-course evaluation from national ACEP and from PCSS for evaluation of the Waiver Training Completion Certificate.
• This training course is not graded but completion or all evaluation questions is required.
• The only requirement to be eligible for completion is that you stay connected and logged in to the zoom platform through your email account for 8-hour duration of this course.
• The webinar will not be recorded but the slide deck will be shared with everyone after the webinar has been completed.

Learn more and register here (ACEP login is required). 

AJ Wilson and Greg Hubbard
Hubbard Wilson Zelenkova LLC

Election Recap

Election Day has come and gone but likely won’t be one we forget anytime soon.  When it was all said and done, now President-elect, Joe Biden defeated Donald Trump in Wisconsin by just over 20,000 votes.   The close result was anything but new for the Badger State at the top of the ballot.  Two years ago, Tony Evers defeated Scott Walker by 29,000 votes; in 2004, John Kerry defeated George W. Bush by only 11,000 votes; and in 2000, Al Gore defeated George W. Bush by only 5,700 votes.   As I type, a potential recount is still pending but unlikely to change results significantly.  

Notwithstanding the close presidential contest, legislative races were less competitive in Wisconsin. Despite very favorable pre-election polling, Democrats defeated only two incumbent Republicans in the State Assembly where Deb Andraca (D-MKE) and Sara Rodriguez (D-Brookfield) defeated Republicans Jim Ott and Rob Hutton respectively.   

The State Senate went the opposite way altogether as Republicans picked up two seats held by Democrats. In the 12th SD that encompasses much of Northwestern WI, Rob Stafsholt (R) defeated Patty Schachtner (D) handily in the seat that Schachtner won in a special election just under two years ago.  In the Green Bay area, Eric Wimberger (R) beat Jonathan Hansen (D) to snatch the open seat from Democrats that had long been held by retiring Dave Hansen.   

Therefore, Republicans will continue to hold strong majorities in both houses of the State Legislature.   The composition of the assembly will be 61-38 when they return in January.   The State Senate will be 20-12 with one seat vacant as Scott Fitzgerald’s seat will be open as he won the WI’s 5th Congressional District.  That heavily republican seat will most likely give Republicans a 21-12 majority early in session once the seat is filled.

Governor’s Proposal for additional COVID-19 response Legislation

The Governor proposed legislation in mid-November to address a number of pandemic related issues.   The Legislature has not said whether it will come in before the end of the year to consider any of the proposals.  The Governor’s draft, among several other provisions, includes the following:

• Require that insurers cover all telehealth services that would be covered were the services provided in- person.
• Prohibit insurers from requiring prior authorization or imposing quantity limitations below a 90 days supply through the end of 2021.
• Allow pharmacists to extend most Rx refills by 30 days through the end of 2021, where it is safe to do so.
• Ensure that health plans provide coverage for testing, diagnosis, treatment, prescriptions, and vaccines related to COVID-19.
• Prohibit cost-sharing and prior authorization for testing, diagnosis, treatment, prescriptions, and vaccines related to COVID-19.
• Establish that insurers will reimburse providers for out-of-network care (including telehealth) resulting from COVID-19 related disruptions at 250% of Medicare rates.
• Allow critical workers, including healthcare workers, to claim worker’s compensation benefits related to COVID-19, presuming that they received the illness from their occupation.

We are engaging with the Legislature to improve the Surprise Billing provision should this or any other bill move forward to include a definition of “usual and customary rate” as well as favorable dispute resolution.

We are also asking the Legislature to include a liability immunity provision for health care providers similar to what we were able to get included in the COVID response bill this Spring.

Board of Nursing Rulemaking Activity

The BON has taken action on three issues related to APNP scope of practice in the last two months.  The first is a rule proposal that would allow the BON to waive APNP Collaboration Requirements contained in WI Nursing Code 8.10(2) and (7) during a state declared emergency.  This rule change is in progress - Clearinghouse Rule 20-069.  The comment period closed on Dec. 10 with a hearing where a joint letter was submitted from WACEP, the WI Society of Anesthesiologists, and WI Psychiatric Association in opposition.

The second is a proposed scope statement that would give the BON the ability to draft a new rule that would permanently amend current law collaboration requirements for APNP contained in WI Nursing Code - N8.  The third is a proposed scope statement that would give BON the go ahead to draft permanent rule changes related to APNP prescribing limitations also contained in N8.   Undoubtedly, this would be to expand those privileges, but details are not yet available.  We have expressed front-end concerns and will continue to monitor and engage if these proposals move forward.

Surprise Billing Work Group

WACEP is working with the Wisconsin Radiological Society, the Wisconsin Society of Anesthesiologists, and the Wisconsin Society of Pathologists on comprehensive surprise billing legislation as well as the aforementioned proposal for pandemic response.  At this moment, negotiations are taking place again on a federal bill.   The direction Congress goes on this issue will dictate our response or pro-action on the state level. 

Emergency Psych Task Force Work with State Sheriffs and Wisconsin Counties Association 

HWZ, WCA, and Sheriffs’ lobbyists met recently with the Governor’s policy director to discuss options for including proposals of mutual agreement in the Governor’s executive budget.   Among those proposals was a more substantive suggestion for regional crisis stabilization centers as well as proposed codification of the SMART medical clearance form.

Looking Forward

Over the month, the legislature will fill out committee assignments and will then come back to start the new session in January.  It is unlikely that another pandemic response bill will be taken up before inauguration day, however we continue to do outreach on the aforementioned priorities just in case they do come into session.

WACEP President's Message, December 2020
Ryan Thompson, MD, FACEP

As I write this message, I just scheduled my appointment to get my first COVID-19 vaccine. It feels fitting for this to be the way 2020 finally goes out – a year that has been absolutely dominated by the coronavirus pandemic. State guidelines have designated frontline healthcare workers as 1A priority for vaccination, front of the line for protection. This is far from the end of COVID-19, as viral precautions, limited opening of businesses, and mask orders are likely to continue until a large portion of the general population can be vaccinated (hopefully mid 2021). However, it does perhaps feel like the end of the beginning, as Churchill might say.

This year has been a stressful one for emergency physicians all over the state. We were thrust into a pandemic with extremely limited PPE supplies, and little to go on for treatment options other than what could be glommed together from earlier hot spots like China, Italy, and New York. We saw our volumes plummet as patients feared contamination in the hospital, only to be inevitably replaced by scores of patients suffering from the virus months later, and nowhere to admit them. Some of us caught the disease ourselves. Many of us have been called liars by patients when we tell them they contracted COVID-19, even while being placed on BiPAP machines, due to rampant misinformation. Some of us had the misfortune of seeing beloved family members, friends, and colleagues succumb to the plague.

As my tenure as WACEP President draws to a close, I want to heartily thank each and every one of you for your resilience, your dedication, and your commitment to you patients and your communities. Without you, thousands more Wisconsinites would not be with their loved ones this holiday season. What you all do matters, and that fact has never been more clear than it is now. May the light at the end of the tunnel provide you some warmth, and hope, as we enter this next phase of the pandemic.

God speed, and keep up the good work. It has been an honor to serve you.

One of the most common complaints that I hear from Emergency Physicians around Wisconsin is the difficulty in medically clearing patients for admission to outside psychiatric facilities. Sometimes EM docs are being asked to get serial labs for minute electrolyte abnormalities, or prolonged observation for non-toxic overdoses. This leads to delays in transfer, prolonged ED stays, agitated patients, and exasperated ED staff.

WACEP has been a part of a joint task force with Wisconsin Psychiatric Association (WPA) to help address issues germane to both our specialties. While emergency physicians struggle on one end of the transfer, every inpatient psychiatrist can share stories of a patient who decompensates shortly after arrival at their facility, so they are appropriately wary.

At the end of the day, we all want to do what is best for patients. It is imperative that we provide a thorough evaluation and appropriately diagnose and treat any comorbid medical issues in the ED prior to transfer, but what to do when you feel your due diligence has been done and you are getting pushback you feel is inappropriate?

Often the first screener for admission is a nurse or APP, and many of these requests for additional workup come from a lack of medical understanding and an abundance of caution. The psychiatrists have encouraged us to ask to speak directly to the psychiatrist on-call for a given facility if you feel that further workup is not warranted. In particular, Dr. Pope, Medical Director at Winnebago, endorses this approach.

WACEP and WPA hope that this will help to alleviate unnecessary delays, and still ensure safe hand-off of patients between EDs and psychiatric facilities.

Caitlin Rublee, MD, MPH

WACEP has followed in ACEP's lead and joined the Medical Society Consortium on Climate & Health, which represents more than 60% of physicians in the U.S.

The Wisconsin chapter (Wisconsin Health Professionals for Climate Action or WHPCA), has several working groups and activities planned for the coming year.  WACEP members can get involved here.

Check out our recent report that highlights the health and economic opportunities of transitioning to clean energy, which would result in $21 billion per year in avoided health damages and would prevent 1,910 early deaths, 650 emergency department visits for respiratory concerns, 34,400 asthma exacerbations, and 650 heart attacks.

Climate change certainly has several implications for emergency medicine. Heat-related illnesses, acute on chronic disease exacerbations, changing infectious disease burdens (water and vector-borne), and traumatic injuries, even an increase in cold-water drownings from thinner ice. While the current pandemic cannot be ignored, higher mortality rates from COVID-19 were found in U.S. counties with worse air pollution.

All people are at risk, but specific populations are at increased risk of poor health from climate-related events. Older adults, infants and children, those with other medical problems, outdoor workers, and those with unstable housing or lower incomes are just a few examples. In severe circumstances, shortages in supplies (sterile saline) related to hurricanes and other tropical storms affect health care service delivery even far away from the area of impact. The health sector is also responsible for almost 10% of U.S. greenhouse gas emissions, which continues to fuel further warming.

December has been a busy month for climate change and health. December 12 marked the 5th Anniversary since the Paris Agreement was signed by 196 parties. The U.S. is expected to re-join in 2021. The 2020 Lancet Countdown on Health and Climate Change U.S. Brief and Appendix were released with recommendations for a just and equitable path forward. The Wisconsin Governor’s Task Force on Climate Change released their report with next steps for action across nine sectors and three policy pathways.

As we celebrate the New Year, let’s look for opportunities within our healthcare systems and across our great state to support the health of our residents and each other.  

Do you know an EM-bound medical student ready to lead?  Encourage them to apply to the EMRA Medical Student Council to advocate for and offer programming to our medical student members.  Deadline is December 1. These are funded positions to attend the ACEP Scientific Assembly in 2021. 

EMRA Committee Leadership - From Admin/Ops to Social EM to Wilderness Medicine, EMRA's Committees have a place for student, resident and fellow members.  Applications for Chair Elect and Vice Chair positions are due December 1. These are funded positions to attend the ACEP Scientific Assembly in 2021.

The EMRA/ACEP Leadership Academy is the perfect place for current and emerging leaders.  This program teaches the soft-skills of leadership through MBA-like courses.  Applications are due December 31. 

Lisa Maurer, MD, FACEP
WACEP Past-President & Current Legislative Chair

“I love it here,” my patient at the Alternate Care Facility (ACF) said, and if I hadn’t been wearing a respirator, my jaw may have dropped.  Since my EM group staffs the ACF, I knew the quality of care would be excellent.  However, I didn’t expect the patients to feel so relaxed and comfortable in the middle of a state fair exposition center. 

During my recent first shift working at the ACF, I saw patients who were happy to come from overwhelmed hospitals to receive expert care, provided by warmly attentive staff, in a surprisingly relaxing environment.  If open inpatient beds are disappearing and ED holds are growing at your shop, I hope the details of my experience working at the ACF help you to convey the benefits of transfer to the ACF to your next patient with COVID. 

After being propped up by the U.S. Army Corps of Engineers in the Spring, the ACF was activated on October 16th to serve as an overflow facility for Wisconsin.  Check out this 15-second time lapse video showing the process of turning an Expo Center into a facility with the capacity to care for hundreds of patients. “Cubicle” type rooms are surprisingly quiet and have hospital beds.  It’s not uncommon to see a patient’s room featuring a blanket or keepsake from home.  Catered food is available three times daily, and on game day, the patients might be found in the common area by the big screen.  There are pods of bathrooms and showers for those who feel up to it.  Patients told me that they were getting more rest there than they were ever able to get in the hospital or even at home. 

From a medical standpoint, almost 300 of the cubicles have in-line oxygen with capabilities for nasal cannula, high flow, or opti-flow up to 50L at 50% FiO2.  They can receive IV fluids and medications, including remdesivir.  As of the time of this article’s publication, there were 18 patients at the ACF with 6:1 nursing ratio and two providers.  The onsite pharmacist is top notch, and many of the nurses and RTs are “travelers” who are more than comfortable caring for patients with COVID given their vast experience.  In the case where a patient needs respiratory support or other medical care than surpasses what’s readily available, the onsite EMS unit transfers them to a nearby hospital at the discretion of the onsite emergency physician.

In response to feedback from around the state, the intake form has once again been revised and simplified.  If you have a patient in your ED that meets the eligibility criteria as per the Reference Guide, fill out pages 4-5 of the guide and email to the address listed.  The information will be reviewed by the CMO or designee, who is another fellow emergency physician.  They review patients for transfer daily from 9a-5p, and patients may now arrive until 6:30p, updated from a previous 5p arrival deadline. 

Everyone involved wishes we didn’t need an ACF.  However, if you’re like me, I’m so grateful to have it as an option, especially now that I know it has proven to be a good experience for patients.  I would expect nothing less than the EM physicians of Wisconsin to lead the effort in managing patient flow around our state as we continue to fight this pandemic. 

Editor’s Note: this article was written for informational purposes only and does not constitute any endorsement of care. The author, the author’s independent group practice/employer, and Wisconsin ACEP do not benefit in any manner from the transfer of patients or their care at the Alternate Care Facility in Milwaukee, WI.  

WACEP President Message, November 2020
Ryan Thompson, MD, FACEP

Remember back in March when it seemed you couldn’t go through a shift without your department receiving pizza, cupcakes, or some other treat from well-wishers? Emergency physicians, nurses, and other staff were being hailed as heroes despite our mostly empty departments.

These days, that sort of praise and support feels a distant memory. As we enter this new phase of the pandemic where Emergency Departments are being asked to treat more and more COVID patients in addition to the myriad of health conditions brought on by delayed treatments, limited access to specialists, and prolonged social isolation, it seems we have fallen out of the public eye.  

To be honest, I was never comfortable with all the hero talk. Emergency Physicians were working in the trenches before this pandemic began and we’ll keep on trucking right through it and beyond. We don’t do it for the plaudits. We do it because we have the skill, we have the drive, and most of all, because we care about our patients, and we care about our communities.

So, while we may not be front and center in the minds of our communities anymore, we will keep giving back. To that end, I wanted to share a few of my favorite charities in case you were looking for even more ways to give back to your community.

Child’s Play: This charity gives games and toys to hospitalized children to make their stay in the hospital less daunting. You can either given monetarily or order directly off of the Amazon Wish lists curated by Child Life Specialists at your Children’s Hospital of Choice. http://childsplaycharity.org/

Wisconsin Youth Symphony Orchestra: Supporting musically-inclined children and teens from across the state, this group provides opportunities to perform and high-quality lessons (even remotely during COVID) to diverse and low-resource aspiring young musicians. https://wysomusic.org/

Alzheimer’s & Dementia Alliance of Wisconsin: Every emergency physicians recognizes the stress and difficulty that dementia can put on a family. This group offers support, education, and advocacy for patients and their families. https://www.alzwisc.org/

By no means are these the only worthwhile charities in our communities – I encourage you to find something near and dear to your heart. This year has been hard on all of us, and I can’t think of a better way to continue to support the communities we serve. So thank you all for the dedicated work you have put in over the course of this year, and thank you for continuing to give to support those who need it most during these difficult times.