Latest News 

  • December 14, 2018 2:49 PM | Sally Winkelman (Administrator)

    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.

  • December 14, 2018 2:18 PM | Sally Winkelman (Administrator)

    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:

    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!

  • December 14, 2018 1:24 PM | Sally Winkelman (Administrator)

    "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!

  • December 05, 2018 1:01 PM | Sally Winkelman (Administrator)

    After weeks of speculation and media coverage, the Republican-controlled Legislature passed a number of bills in a “lame duck” Extraordinary Session.  All bills were passed on party-line votes, and while Governor Walker has signaled his willingness to sign the legislation, he has provided no details.

    Evident by the media reporting on the Extraordinary Session, these proposals were by and large forgone conclusions; they were destined to pass regardless of outside support or opposition.  While the Senate Republican caucus, in particular, was divided on key items in the various bills, ultimately they were able to make amendments sufficient to secure votes for final passage of the legislation.  (Though unrelated to healthcare, the controversial proposal to change Wisconsin’s presidential primary election date was not taken up.)

    Of particular interest to WACEP and other health organizations is Senate Bill 886, which makes a variety of changes to how the Department of Health Services (DHS) can make or recommend changes to the Medicaid program.  In advance of yesterday’s votes, and to no avail, a group of 20+ healthcare organizations and systems (led by the Wisconsin Medical Society and Wisconsin Hospital Association) wrote a joint letter to the Legislature expressing concerns about the breadth of SB 886, the lack of time for a full analysis of the legislation and the potential for unintended consequences.

    Among other things, the original SB 886 solidified in statute items contained in the most recent Medicaid Waiver approved by the Federal Government related to Wisconsin’s Medicaid/BadgerCare coverage for childless adults, including new work and premium requirements for eligibility.  Among those items, the Waiver contained a new $8 copay for non-emergency visits to Emergency Rooms – quoting SB 886’s official Analysis:

    DHS must charge recipients an $8 copayment for nonemergency use of the emergency department and must comply with other requirements imposed by the federal DHHS in its waiver approval effective October 31, 2018. The requirements in the bill must end no sooner than December 31, 2023, and the bill prohibits withdrawal of the requirements and DHS from requesting withdrawal, suspension, or termination of the childless adults demonstration project requirements before that date unless the legislation has been enacted specifically allowing for withdrawal, suspension, or termination.

    In addition, the original SB 886 limits DHS’s ability to make other changes to Medicaid programs including changes to provider reimbursement – again, quoting SB 886’s official Analysis:

    This bill prohibits DHS from submitting an amendment to the state's Medical Assistance plan or implementing a change to the reimbursement rate for or making a supplemental payment to a provider under the Medical Assistance program without first submitting the proposed state plan amendment, rate change, or payment to JCF. If the state plan amendment, rate change, or payment has an expected fiscal effect of less than $1,000,000 from all revenue sources over a 12-month period following the implementation date of the amendment…

    Ultimately, to secure agreement on SB 886, the Senate adopted (and the Assembly concurred) an amendment raising the original $1,000,000 fiscal effect to $7,500,000.  In other words, DHS may still make changes that cost less than $7,500,000 for the immediately following 12-month period without Legislative approval.

  • November 21, 2018 8:06 AM | Sally Winkelman (Administrator)

    Nicole Forbord, PA-C is the winner of the FitWell contest, WACEP's most recent wellness initiative. Nicole, a PA with Emergency Medicine Specialists, SC who contracts for Ascension, posted her activity and fitness images on WACEP's social media accounts during the summer. She was selected as the winner in a random drawing from among contestants, and has been awarded a WACEP branded fleece and $200 towards a gym/club membership of her choice. Congratulations Nicole!

  • November 07, 2018 12:13 PM | Sally Winkelman (Administrator)

    Eric Jensen, Jensen Government Relations, LLC

    Searching for a word to summarize last night’s Wisconsin state elections this morning (including early this morning as I obsessively watched the final results trickling in!), all I could come up with was:  Wow.

    Neck and neck all night, at about 1:00 am came an announcement that nearly 50,000 absentee ballots from Milwaukee County were still being counted and would be reported shortly.  With the Governor and Attorney General races very close at that point, the announcement of those ballots yet to come from the traditional Democratic stronghold signaled that both races were likely over, and indeed they were.  Those ballots gave Tony Evers a nearly 30,000-vote lead over Governor Walker, and gave Josh Kaul a nearly 15,000-vote lead over Attorney General Schimel.  Despite possible recounts, barring any unanticipated irregularities most insiders agree those totals will be sufficient to sustain victories for both Evers and Kaul.  (Of note, Democrats also won all three other statewide races – US Senate, Secretary of State and State Treasurer.)

    While the statewide races were swept by Democrats, with results that were quite close to the closely watched Marquette Law School poll results leading into Election Day, the real “wow” factor came through in the races for State Senate and State Assembly. 

    Democrats entered Election Day optimistic that high turnout for the statewide races would help their causes in both the State Assembly and Senate.  In the end, it did not.  In fact, Assembly Republicans did not lose a single seat – including several seats they hold in what have long been viewed as traditionally strong Democratic areas – and will maintain a 64-35 majority.  Meanwhile, Senate Republicans, viewed by many as quite vulnerable after losing two GOP-held seats during Spring Special Elections, actually expanded their majority by holding all of their seats and winning back the 1st Senate District up in Door/Kewaunee Counties they had lost during the June Special Election.

    Drawing conclusions from all of this will be an interesting political and social science discussion for some time to come, but what the numbers showed is fairly simple:  the very high concentration of Democratic voters in Dane and Milwaukee Counties voting in large numbers is sufficient to win statewide races (borne out during this Spring’s Supreme Court race as well).  Meanwhile, there remain more areas of the state where Republican voters appear to outnumber Democratic voters by smaller percentages (compared to the Democratic advantages in Dane and Milwaukee Cos.) allowing Republicans to out-perform their statewide candidates by just enough to win the smaller Assembly and Senate districts and control the Legislature.

    The Governor, Attorney General, State Senators and State Representatives will be sworn in the first week of January, and action will commence soon after.  What the dynamic will be between the new Governor and the existing Legislative majorities will be interesting to see.  Also interesting, will be watching the dynamic between the two Republican majorities that did not see eye-to-eye on several major policy areas last session.

  • October 30, 2018 12:37 PM | Sally Winkelman (Administrator)
    Eight hours of training on medication-assisted treatment (MAT) is required to obtain a waiver from the Drug Enforcement Agency to prescribe buprenorphine, one of three medications approved by the FDA for the treatment of opioid use disorder. Providers Clinical Support System (PCSS) offers free waiver training for physicians to prescribe medication for the treatment of opioid use disorder. PCSS uses three formats in training on MAT:
    • Live eight-hour training
    • “Half and Half” format, which involves 3.75 hours of online training and 4.25 hours of face-to-face training.
    • Live training (provided in a webinar format) and an online portion that must be completed after participating in the full live training webinar
    Trainings are open to all practicing physicians. Residents may take the course and apply for their waiver when they receive their DEA license. For upcoming trainings consult the MAT Waiver Training Calendar. For more information on PCSS, click here. Please email Sam Shahid at ACEP for more information on MAT training.
  • October 24, 2018 12:08 PM | Sally Winkelman (Administrator)

    October 18, STAT

    When I walk through my hospital’s emergency department, I’m sometimes overwhelmed by the number of people languishing there as they wait for help with a mental health issue, like the woman clutching her chest as if she’s having a heart attack but is really suffering from a panic attack. It’s her third time here in a week.

    She is just one of the hundreds of patients who will be admitted this year to my emergency department in the Mat-Su Regional Medical Center in Palmer, Alaska, experiencing psychiatric emergencies.

    Many stay in the emergency department for hours; some even stay there for a few days. The practice, called psychiatric boarding, occurs when an individual with a mental health condition is kept in an emergency department because no appropriate mental health care is available. It’s rampant around the country.

    Millions of Americans with mental health issues are not getting the care they need. It’s a crisis so profound that it is overwhelming emergency departments and the entire health care system. The causes? Too few outpatient resources and inpatient treatment options for mental health issues; separate systems for treating mental health and physical health; and a shortage of specialists able to respond to patients in the midst of mental health crises, to name just a few.

    I believe hospitals can curb this trend by doing a few key things, beginning with improved collaboration.

    The statistics are staggering: Nearly 1 in 5 U.S. adults — about 44 million — experiences mental illness in a given year, a number that is certain to increase. And it comes at a time when the demand for mental health professionals is outstripping the supply. For psychiatrists alone, a 2017 report published by the National Council for Behavioral Health estimates the shortage will be between 6,100 and 15,600 practitioners by 2025. That same report points out that lack of access to psychiatric services in hospital emergency departments is especially problematic. 

    Read full article.

  • October 17, 2018 3:33 PM | Sally Winkelman (Administrator)

    Eric Jensen, WACEP Lobbyist

    In less than three weeks, on Tuesday, November 6th, Wisconsinites will go to the polls to vote in races for the U.S. Senator, Governor, 17 of Wisconsin’s 33 State Senate districts, all 99 of Wisconsin’s State Assembly districts and a variety of local elections and referenda.  Between now and then, we’ll be inundated with radio and TV ads, campaign flyers (and maybe candidates) at our front doors, political “robocalls” and media reports about candidates, races, polls and predictions.  ‘Tis definitely the season!

    Political insiders watch political polls like hawks, hoping to glean from them predictions of election outcomes.  But in 2016 we learned a powerful lesson about political polling in modern times – not one national pollster predicted victory by President Trump, either in Wisconsin or nationally.  More and more, people of different demographics are moving from landlines to mobile phones increasing the difficulty of getting a representative population sample in a poll.  That simple fact, along with how questions are asked, who asks the questions and a variety of other factors increase the difficulty of getting statistically accurate poll results.

    For WACEP, our attention is primarily on the races for Governor, State Senate and State Assembly as the outcomes of those races can have a profound effect on health care policy making for the next two years and beyond.

    The Governor’s race is the one most discussed in the state’s media.  Governor Walker has served two four year terms, yet won election as Governor three times.  Tony Evers, his Democratic challenger, has served as Wisconsin’s State School Superintendent, himself winning multiple statewide elections.   As divided as Wisconsin’s voting population has become, and both candidates holding strong name recognition throughout the state, this race figures to be close to the end.

    In the State Senate, after Democrats won two previously Republican-held seats during Spring Special elections, Republicans hold a 18-15 majority heading into November.  Democrats are focusing on two key Republican seats (one in the Appleton area, one in the large rural district west of Madison) in an effort to win the majority.  But Republicans see opportunities of their own to win back one of the Special Election seats in the 1st Senate District in Door/Kewaunee County, as well as a far northern seat that includes Superior, Ashland and Rice Lake.

    In the State Assembly, Republicans hold a far larger 64-35 majority.  To win the majority, Democrats must hold all their current seats and win 15 more.  It’s a daunting challenge, and while anticipated high voter turnout in places like Democratic stronghold Dane County may have a big impact on the Governor’s race, it won’t affect Assembly races in central and northern Wisconsin.

    The outcomes of these 2018 elections will come down to voter turnout for both parties – throughout the state, not simply in party stronghold areas.  As you see polls being reported in the media, remember 2016.  Elections aren’t won by polls or pundits, they’re won by votes – so get out and cast yours on November 6th!

  • October 15, 2018 9:53 AM | Sally Winkelman (Administrator)

    WACEP President's Message, October 2018
    Lisa Mauer, MD

    Emergency physicians do not typically think of cannabis as pertinent to our typical clinical practice.  This is demonstrated by the fact that ACEP has not adopted any of 14 resolutions (both in favor of and in opposition to recreational marijuana) that have been proposed in the last 10 years.  On the other hand, our practice is, in some ways, is defined by the failures of the healthcare system, from chronic intractable conditions in need of a novel treatment to the unanticipated side effects of increasing exposure to a recreational substance.  We may get pulled into this debate on the national level.  

    But what about at the state level?  Marquette Law School poll done in August showed that 61 percent of Wisconsinites say marijuana should be fully legalized and regulated like alcohol while 36 percent oppose legalization.  Advisory referendum questions on marijuana will be included on ballots in 16 different counties and 2 cities next month.  With all of this local action, I was recently faced with the question of “What would you say to a reporter who asked what emergency physicians of Wisconsin think about marijuana?”  While our state chapter of ACEP does not form individual policy apart from our national organization, it is important that our chapter reflects our local environment.  I believe there are likely low-hanging fruit that would reflect commonalities among WI emergency physicians’ opinions on how we could best represent our patients in this public debate.  Read below for background information on what pertinent policy exists, and then email me with how you think emergency physicians in Wisconsin should publicly regard marijuana for recreational use, medical use, research, or other!  

    Recreational use: Nine states and the District of Columbia have legalized recreational use of marijuana for adults over the age of 21.  Twenty-two states and the District of Columbia have decriminalized small amounts of marijuana.  AMA has policy on recreational use or legalization of marijuana:

    • Initially established in 1997 and modified several times until it was reaffirmed last year, the AMA urges legislatures to delay initiating the legalization of cannabis for recreational use until further research is completed on its consequences.
    • Advocates for point of sale warnings and product labeling regarding potential dangers of cannabis-based product use during pregnancy and breastfeeding.
    • For states that have already legalized cannabis, they should take steps to regulate it.  If taxed, a substantial portion of the revenue should be used for public health purposes.
    • Public health based strategies, rather than incarceration, should be used to handle individuals possessing cannabis for personal use.
    • Supports continued educational programs on substance abuse to include marijuana

    It is notable that ACEP does not have policy on legalization of recreational marijuana.  This also includes a proposal last month in San Diego at ACEP18 Council to approve policy language mirroring the first AMA policy listed above.  Discussion on the ACEP council floor in opposition to policies regarding recreational marijuana often centers around the idea that recreational marijuana is not within the scope of emergency medicine, although emergency physicians may have opinions on recreational marijuana as individuals.

    Medical use: Thirty-one states have legalized marijuana for medicinal use.  In addition, 15 other states, including Wisconsin, only allow use of low THC, high cannabidiol products for limited medical conditions such as seizure disorders.

    Much of existing AMA policy about medical use of marijuana focuses on the basis of physician-patient relationship being free from interference by the government:

    • Cannabis products for medicinal use should be considered for approval by the FDA, not legalized through legislative, ballot, or referenda initiatives.  Any FDA-approved cannabidiol medications should be regulated as other prescription products are, rather than state laws that may apply to unapproved cannabis products.
    • Cannabis products not approved by the FDA will have warning labels indicating such
    • Supports protection against federal prosecution for physicians who discuss cannabis with patients or recommend cannabis in accordance with state laws

    The Wisconsin Medical Society (WMS) policy affirms the third point above, and also goes on to state that smoked marijuana should only be used for therapeutic reasons for which we have scientific data regarding safety and efficacy. 

    Again of note, ACEP has a noticeable lack of policy in this realm, and in fact did not adopt 3 proposed policies over the last few years, including proposal to protect the right of emergency physicians to prescribe medical marijuana and a proposal to officially take no position on the medical use of cannabis products. 

    Research: AMA again takes the lead in ample policy regarding research of cannabis use. They encourage public health agencies to improve data collection of effects of cannabis.  The AMA and WMS have the same following policy:

    • Urge that marijuana’s status as a schedule I controlled substance be reviewed with the goal of facilitating the conduct of research and potential development of medicines
    • Call for adequate studies of cannabinoids
    • Urge federal agencies to fund and facilitate the conduct of research
    Interestingly, although the ACEP Council voted to not approve a resolution in 2014 to specifically promote research of medical marijuana, they did just last month approve the very first ACEP resolution regarding cannabis, mirroring language of the first above AMA/WMS policy point.