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Executive Privilege Why I Have to Do This (Meaning: PACEP) I have been reflecting on a question my daughter asked me about my involvement in the PA College – “Why do you have to do this?” It’s a question most of us have heard from our families when we go into the ED for a night shift or on a holiday. By now, my children are used to their father’s weird sleeping and eating hours. What they are not as used to, it seems, is losing their father to organized medicine. When I think of the question, “why do we do this?” I find the answer to be simple – “for our patients.” This applies to night shifts and organized medicine equally. As much as we are the 24/7 safety net providers for our patients, we can also be their advocates in a complex health Ankur A. Doshi, care system. We all know of patients whose health has been affected by external forces such as MD FACEP bad public policy, excessive medical regulation, and/or the predatory practices of health insurers. PACEP President Some days in the ED, it feels that we can’t fight against these things. However, together, we are not powerless against them. As a College, we can take the lead and push back for our patients. Our previous leaders, including Drs. Merle Carter and Maria Guyette, left us (PACEP) in an excellent position. Over the past couple of years, we’ve won many victories for our specialty and our patients. For example, in the 2016 opioid prescribing bill, the PA College effectively advocated for and added the first specialty-specific medical liability protection into Pennsylvania law. PACEP continues to fight insurers’ unfair payments. Across the state, PACEP members developed Warm Hand-off programs to save lives from the opioid epidemic, and have been praised by the Department of Health and Physician General. While much of this work continues, there is still a lot to accomplish. We must continue to fight the insurance companies to ensure fair payment for our services so that we can provide 24/7 care and fight for our ability to safely practice medicine without unfair regulations. Additionally, we must protect our patients so they, as prudent laypersons, can come to the ED when they feel it is an emergency, or when we are the only ones open. We agree that patients should not have to foot the bill for medical care after paying their YOU CAN HELP BY: insurance company for coverage. We must find administrative fixes to our problems that • Contributing to PEP-PAC at affect our patients such as overcrowding and boarding. or by mailing Finally, we must focus on the future of our specialty. We must mentor our residents, students, a check to PEP-PAC, 200 N. 3rd and young physicians so that they, like us, can have long and satisfying careers in the ED. St., Suite 1500, Harrisburg, PA Why do we do this? Because, in this health care climate, it is up to us to protect 17101-1590. Emergency Medicine. Our past leaders fought to make our specialty respected and • Joining a PACEP committee or desirable (keep an eye out for our PACEP History Project!) I, like you, am honored to be task force. View all of PACEP’s an Emergency Physician and take care of patients whenever they needed it, at their committees at https://www. most scared and vulnerable times. It is also my honor as your current PACEP President to help YOU protect and enhance the future of Emergency Medicine, but I need your • Joining the PA 911 Network to help! Every voice matters, every hour of your time matters – even if you only have an easily contact your legislators. hour to give. Your unique perspective and expertise make the Pennsylvania College of Emergency Physicians as strong and effective as it can be. Please join me in service to our specialty and our patients.

{ Job Opportunities }

Assistant Medical Director Pediatric Emergency Medicine Leadership Assistant Program Director Vice Chair, Research

What We’re Offering: • We’ll foster your passion for patient care and cultivate a collaborative environment rich with diversity • Salaries commensurate with qualifications • Sign-On Bonus • Relocation Assistance • Retirement options • Penn State University Tuition Discount • On-campus Fitness Center, day care, credit union and so much more! What We’re Seeking: • Experienced leaders with a passion to inspire a team • Ability to work collaboratively within diverse academic and clinical environments • Demonstrate a spark for innovation and research opportunities for Department • Completion of an accredited Emergency Medicine Residency Program • BE/BC by ABEM or ABOEM • Observation experience is a plus

What the Area Offers: We welcome you to a community that emulates the values Milton Hershey instilled in a town that holds his name. Located in a safe family-friendly setting, Hershey, PA, our local neighborhoods boast a reasonable cost of living whether you prefer a more suburban setting or thriving city rich in theater, arts, and culture. Known as the home of the Hershey chocolate bar, Hershey’s community is rich in history and offers an abundant range of outdoor activities, arts, and diverse experiences. We’re conveniently located within a short distance to major cities such as Philadelphia, Pittsburgh, NYC, Baltimore, and Washington DC.

FOR ADDITIONAL INFORMATION PLEASE CONTACT: Susan B. Promes, Professor and Chair, Department of Emergency Medicine c/o Heather Peffley, Physician Recruiter, Penn State Health Milton S. Hershey Medical Center 500 University Drive, MC A595, P O Box 855, Hershey PA 17033 Email: : or apply online at: The Penn State Health Milton S. Hershey Medical Center is committed to affirmative action, equal opportunity and the diversity of its workforce. Equal Opportunity Employer – Minorities/Women/Protected Veterans/Disabled.

Dear PACEP Members: I think I can finally say “Happy Spring,” and I trust that all of you are well. I’d like to start by saying “thank you” to all of you for what you do. A recent illness necessitated an emergency department visit this spring and I’m eternally grateful for the EMS and ED care I received. All in all, I felt safe. And that’s because I have the privilege of working with so many of Pennsylvania’s finest emergency physicians.

A MESSAGE FROM... Cicely Elliott Executive Director

That being said, the first quarter of 2018 was a busy one for PACEP! Elizabeth Werley, MD, FACEP hosted a bang-up PACEP18 Scientific Assembly in March in Harrisburg, about which you’ll see more in the following pages. Yes, Day 3 was cut short by an unexpected snow storm, but initial feedback says that the conference was a hit. I would be remiss if I did not also extend heartfelt thanks to the rest of the SA planning crew and PACEP staff as well. Coordinating Scientific Assembly is practically a year-long process and requires passion, dedication, and energy. Speaking of…we’re already gearing up for PACEP19 Scientific Assembly! Mark your calendars now and plan to join us next April 10-12, 2019 in Philadelphia! Watch your inbox for more details. While one contingent of PACEP leadership was planning our annual conference, another was continuing important legislative and public health conversations. The Governmental Affairs Committee is currently working with your colleagues in Psychiatry to address pending Assisted Outpatient Treatment (AOT) legislation, and PACEP leadership has been involved in PA Department of Health-hosted Regional Warm Hand-off Summits across the state to highlight existing ED programs and facilitate discussion on how to increase warm hand-off resources in all communities. We’re additionally monitoring and responding to legislation around involuntary 302s, and are still intimately involved in conversations and fact finding around out-of-network billing. Read more about these issues and more in Milliron & Goodman’s Legislative Update. Starting now and continuing over the next several months, PACEP’s delegation to the annual ACEP Council meeting will convene to strategize and develop its proposed resolutions for onsite deliberation in San Diego this fall. As always, never hesitate to reach out if you’d like to know more about anything “PACEP” that you’ve read or heard – or if you’d like to be more involved. We hold a spot for everyone. I look forward to meeting/speaking with/seeing you soon,





PACEP News | SPRING 2018


PEP-PAC Call to Action We Cannot Sit By And Do Nothing! It’s time for a change in our thinking and behavior. It’s time for us to rise up as a group and resume control of our careers and our Emergency Departments. It’s time for us to actively involve and engage our partners in the absolute necessity of political action. Edmund Burke said, “All that is necessary for the triumph of evil is that good men do nothing. Do not allow evil to triumph. Do not sit by and do nothing. Stand up and be counted.” As insurance companies earn record profits, they attack the prudent layperson standard and attempt to refuse payment for patients using the emergency department. We cannot sit by and do nothing. Todd Fijewski, MD, FACEP PEP-PAC Chair

We are the good men and women of Emergency Medicine. Treating disease and injury and performing life-saving work is not enough for the physician of today. Current balance billing legislation could reduce your salary significantly. We must defend. Bad legislation will reduce access to care. It will harm patients. We must prevail.

As the opioid crisis ravages our state, PACEP took the lead. We worked with the legislature and the Department of Drug and Alcohol Prevention. We participated in developing the Warm-Handoff Clinical Pathway and the creation of the PDMP. However, as the pendulum swings too far, there is current legislation that could mandate inpatient drug treatment by a family member. PACEP is in opposition. Our emergency departments are not proper areas to hold patients awaiting rehabilitation beds. Our mission of service and healing is different. There are many additional advocacy issues that both the Governmental Affairs Committee and PACEP leadership face. This is our current problem. In 2017, only about 4% of our membership contributed to our Political Action Committee. I personally want to thank each of you for your passion and continued support. Your contributions have changed Emergency Medicine within the state for all of us. 4% is not enough. Please make your contribution today. Help ensure our future. Please make your donation today at or mail a check to PEP-PAC, 200 N. 3rd Street, Suite 1500, Harrisburg, PA 17101-1590.

Thank you to our 2017 PEP-PAC Contributors! Donna L. Balewick, MD Michele M. Belak, MD Michael J. Bohrn, MD Merle A. Carter, MD, FACEP Theodore A. Christopher, MD, FACEP Joseph Clark, DO, FACEP Robert R. Cooney, MD Michael A. Donegan, DO, FACEP Ankur A. Doshi, MD, FACEP Joseph G. English, MD Marcus Eubanks, MD Mark L. Fennema, DO, FACEP Charles J. Feronti, DO, FACEP Todd Fijewski, MD, FACEP Laurence J. Gavin, MD, FACEP Daniel C. Geary, MD Glenn Geeting, MD, FACEP Stuart E. Greene, MD, MBA Rod Groomes, MD, MD Maria K. Guyette, MD, FACEP Frank Guyette, MD, FACEP Steven D. Guyton, MD, FACEP Ronald V. Hall, MD


PACEP News | SPRING 2018

Fred P. Harchelroad Jr, MD, FACEP F. Richard Heath, MD, FACEP Marilyn J. Heine, MD, FACEP Gregory J. Hellier, DO Joseph W. Hensley, DO Elizabeth Howe, MD, FACEP Kaveh Ilkhanipour, MD, FACEP Jerry D. Jamison, MD, FACEP Jacob Kleinman, MD Erik I. Kochert, MD, FACEP Scott J. Korvek, MD, FACEP Anne-Marie Laberge, MD Bruce A. Macleod, MD, FACEP Anthony V. Mosca, DO Dhimitri Nikolla, MD Rika N. O’Malley, MD Vishnu M. Patel, MD Christine M. Patton, MD, FACEP Gary E. Penner, MD Gary F. Pollock, MD, FACEP Shawn M. Quinn, DO, FACEP Jon C. Rittenberger, MD, FACEP Alexander M. Rosenau, DO, FACEP

Albert T. Saloom, MD Jennifer L. Savino, DO, FACEP Mark Scheatzle, MD, FACEP Steven K. Schirk, MD, FACEP Nicholas Schulz, MD, FACEP Anna Schwartz, MD, FACEP Lewis C. Shaw, MD, FACEP John Skiendzielewski, MD, FACEP Samuel C. Slimmer Jr., MD, FACEP Daniel Snediker, MD, FACEP Amy J. Snover, MD, FACEP Phiraphan P. Soontharothai, MD, FACEP Matthew A. Stephens, MD, FACEP Richard P. Sullivan, MD Michael A. Turturro, MD, PACEP Stephen F. Uhlman, DO, FACEP Arvind Venkat, MD, FACEP Daniel R. Wehner, MD, MBA, FACEP Brian J. Wieczorek, MD, FACEP Adam M. Yates, MD, FACEP David Zimmerman, DO, FACEP



Virginia | Maryland | Washington, DC | West Virginia EMA, an established twenty-four hospital regional, physicianpartnership, physician-managed group seeks full and part-time BC

A Political Action Committee is created by a private group with common interests formed to raise money to make contributions to the campaigns of political candidates whom they support. • PEP-PAC is the Pennsylvania Emergency Physicians Political Action Committee, a separately chartered affiliate of PACEP. • PEP-PAC represents emergency physicians and is the only political action organization in Pennsylvania devoted solely to emergency medicine causes. • PEP-PAC funds are directed to legislators and candidates of both parties who support the issues and positions most important to emergency medicine.

or BP Emergency physicians to practice in Virginia, Maryland, Washington, D.C. and West Virginia. Since 1971, EMA has offered our physicians an unmatched quality-of-life with the secruity of our 100% contract stability. • Partnership opportunities • Quality-of-life centered practice • Administrative & clinical opportunities • Full benefits package for physicians and family Send CV: Se V: Emergency Medicine Associates, P.A., P.C. Phone: 1-800-942-3363 Email:

L iv e, Wor k & P lay W ith U s!

Position Chair, Emergency Medicine

Congratulations to recipients of the EMRA Chief Resident of the Year Award! This award is given in recognition of your commitment and dedication to our specialty. Amy Zeidan, MD | Hospital of University of Pennsylvania Brian Wexler, MD | Hospital of University of Pennsylvania Jennifer Love, MD | Hospital of University of Pennsylvania

Holy Redeemer Health System, a 242 bed community hospital with a DNV certified stroke center, state of the art cardiac cath lab and an active pediatric urgent care program is actively recruiting an outstanding clinician to serve as Chair of the Department Of Emergency Medicine. The Hospital, located in suburban Philadelphia, provides emergency care to 30k patients annually. The department is staffed with board certified Emergency Medicine Physicians complimented by Advanced Practice Professionals. There are 22 exam rooms, a dedicated radiology suite and an active hospitalist program. Ultrasound is available within the department and there is 24 hour backup for all major specialties including on-site obstetrics. The individual will be a well respected, board certified clinician (ABEM/ABOEM) who has demonstrated leadership abilities. The physician candidate will be expected to manage and implement strategies which assure the delivery of high quality, cost effective care in ways which enhance the patient experience. In addition to administrative duties, the Chair will provide clinical coverage. The Chair serves on the medical executive committee and participates in hospital and system wide initiatives. They will demonstrate a strong clinical background and will work collaboratively with other hospital leaders to further the mission of the Health System. Qualified candidates must be a PA MD or DO Licensed and Board certified in Emergency Medicine with a minimum of 6 years of clinical experience and 2 years of leadership. Interested parties should submit their CV and cover letter to Hank Unger, MD, FACEP and Chief Medical Officer ( EOE.

PACEP News | SPRING 2018


While we had some unfortunate competition with mother nature at PACEP18 Scientific Assembly, held March 19-21 in Harrisburg, the conference exceeded the typical location attendance and the PA College successfully implemented a few new ‘firsts’ in activities and CME. The Inaugural PACEP Ultrasound Guided Procedural Course, conceptualized by Robert Stony, DO, RDMS and a core group of dedicated faculty, launched at PACEP18 to rave reviews. Participants learned new techniques through a blend of small lecture, discussion and didactic, hands-on learning. Thanks to our generous equipment sponsors and live models!






6 Committee Meetings

Ultrasound Course Registrants 6


PACEP News | SPRING 2018

PACEP’s new Wellness Committee thoughtfully planned a variety of wellness activities and offered attendees fitness classes and a “Recharge Room”. Attendees were encouraged to share their tips for burnout at the Wellness booth. The Wellness Committee is already working on bringing more wellness activities to PACEP19 Scientific Assembly in Philadelphia. All PACEP Past Presidents were honored at the Annual Awards Dinner and participated in focused and filmed interviews, which will ultimately serve as a living archive. 2018 is ACEP’s 50th Anniversary year; to take advantage of our national organization’s commemoration and festivities, the PA College kicked off its own anniversary initiative by acknowledging and highlighting the innovation and dedication of some of its founding members and “statesmen”.

Enjoy these event highlights and make plans now to attend April 10-12, 2019 at the Crowne Plaza in King of Prussia!


30 Spivey

attendees (Record for Harrisburg)

and CPC Competition Submissions

17.5 CME



PEP-PAC Contributions

2018 PACEP Officers from left: President-Elect Arvind Venkat, MD, FACEP; President Ankur Doshi, MD, FACEP; Immediate Past President Maria K. Guyette, MD MPPM, FACEP; Vice President Shawn Quinn, DO, FACEP; and Secretary F. Richard Heath, MD, FACEP. Not pictured, Treasurer Ronald V. Hall, MD.

PEP-PAC Chair Todd Fijewski, MD, FACEP, making the annual request for PEP-PAC contributions at PACEP’s Annual Membership Meeting.

Former PACEP Executive Director (left) conducting an interview with PACEP 59-year member Samuel Slimmer, Jr., MD, FACEP.

PACEP Ultrasound Guided Procedural Course instructors from Jefferson. (L-R) Arthur Au, MD and Zachary Risler, MD.

From left: Ankur Doshi, MD, FACEP; Maria K. Guyette, MD, MPPM, FACEP; ACEP President-Elect John Rogers, MD, CPE, FACEP; and Merle Carter, MD, FACEP.

2018 PACEP President Ankur Doshi, MD, FACEP presents Outgoing PACEP President Maria K. Guyette, MD, MPPM, FACEP with a plaque of appreciation.

From left: PA Secretary of Health Rachel Levine, MD and Maria K. Guyette, MD, MPPM, FACEP. Dr. Levine served as our Keynote Speaker.

From left: Maria K. Guyette, MD, MPPM, FACEP and Arvind Venkat, MD, FACEP speak with Senator Randy Vulakovich. PACEP News | SPRING 2018


From left: PACEP Wellness Committee Chairs Jennifer Savino, DO, FACEP and Katherine Lund, DO at the Wellness Booth showcasing their swag!

Penn State Hershey residents and medical students prepare for the Spivey and CPC Competitions.

PACEP Past Presidents from left: Ralph Riviello, MD, FACEP ; C. James Holliman, MD, FACEP; Jesse Weigel, MD, FACEP; Todd Fijewski, MD, FACEP; Maria K. Guyette, MD, MPPM, FACEP; Michael Turturro, MD, FACEP; Arthur Hayes, MD, FACEP; Daniel Wehner, MD, FACEP; Steven Parrillo, DO, FACOEP, FACEP; Alexander M. Rosenau, DO, FACEP; Theodore Christopher, MD, FACEP; Douglas McGee, DO, FACEP; and Charles F. Barbera, MD, MBA, FACEP.

Congratulations PACEP’s 2018 Award Winners Emergency Physician of the Year Award Michael Lynch, MD

Meritorious Service Award Donald Shaw, DO, FACEP

Meritorious Service Award Roderick Groomes, MD

Congratulations to this year’s Spivey and CPC Competition Winners


CPC Competition Winners

Spivey Competition Winners

FACULTY 1st Place


PLATFORM 1st Place


Ernie Leber, MD, FACEP Drexel University Flecanide Toxicity

Zach Matuzson, DO Lehigh Valley | Celiac Artery Dissection

Glenn Burket, MD | Lehigh Valley Health Network | Hi-tech, Low-cost Cricothyrotomy Simulation Model

2nd Place

2nd Place

Iryna Matkovska, DO | Einstein University Low-dose Propofol for the Treatment of Severe Refractory Migraine Headache in the Emergency Department

Katrina Kissman, MD Crozer-Chester Medical Center | Embolic Ischemic Stroke

Shirley Shao, MD University of Pittsburgh | TTP

2 Place

Blake Bashor, DO | St. Luke’s Hospital Male and Female Estimate of Ability to Drive Versus Objective Measure

PACEP News | SPRING 2018


Zacary Schwarzkopf, MD; Justin Johnson, MD | Drexel University Decision-Making in Pulseless Electrical Activity Resuscitation

2nd Place

LEGISLATIVE UPDATE Milliron & Goodman Government Relations BUDGET UPDATE

Democratic Governor Tom Wolf’s election-year budget plan will renew battles with the Republican-controlled Legislature over imposing a tax on Marcellus Shale natural gas and increasing the minimum wage. Wolf, who is seeking re-election to a second term this year, wants to spend about $33 billion in the 2018-19 fiscal year, about a $1 billion, or 3.1 percent increase. During his budget address, Wolf was in campaign mode and touted his successes over three-plus years. He highlighted increased funding for schools, pension reform, liquor reform, medical marijuana legalization, prison reform, and the opioid fight as accomplishments. His budget plan does not increase broad-based taxes on Pennsylvanians (i.e. sales or income taxes),but does include a new provider tax on ambulatory surgery centers (ASCs) to generate $25 million. (Lawmakers have until midnight on June 30 to pass the state budget.)

GOVERNOR DECLARES HEROIN AND OPIOID EPIDEMIC A STATEWIDE DISASTER EMERGENCY On January 10, 2018, Governor Wolf declared the heroin and opioid epidemic a statewide disaster emergency through a proclamation. The proclamation is the first of its kind for a public health emergency in Pennsylvania and will utilize a command center at the Pennsylvania Emergency Management Agency to track progress and enhance coordination of health and public safety agencies. The proclamation includes 13 key initiatives, including the opening of an Opioid Command Center located at the Pennsylvania Emergency Management Agency (PEMA), which will house the Unified Opioid Coordination Group that will meet weekly during the disaster declaration to monitor implementation and progress of the initiatives in the declaration. Some other initiatives include increasing access to medication-assisted treatment, allowing EMS to leave behind Naloxone at a user’s home, and expanding 8

the Department of Drug and Alcohol Program’s 24/7 emergency drug hotline. The other initiatives include: • Adding overdose and Neonatal Abstinence Syndrome as reportable conditions to increase data collection. • Allowing pharmacists to partner with other organizations to increase access to naloxone, an overdose-reversing drug. • Permitting immediate temporary rescheduling of all fentanyl derivatives to align with the federal DEA standards. • Expanding the advanced body scanner pilot program currently in place at Wernersville used on people reentering the facility. • Waiving the face-to-face physician requirement for Narcotic Treatment Program admissions. • Expanding access to Prescription Drug Monitoring Program. • Waiving annual licensing requirements for highperforming drug and alcohol treatment facilities. • Waiving the fee provided for in statue for birth certificates who request a good-cause waiver affected by OUD. • Waiving separate licensing requirements for hospitals and emergency departments to expand access to drug and alcohol treatment. Typically, in Pennsylvania, a declaration of this type is used in cases of extreme weather or natural disasters in order to free up regulatory burdens and funding. Last fall, President Trump declared the opioid problem a public health emergency. Since then, other states have made similar declarations. The declaration does not give the authority to create new laws or regulations.

ELECTION 2018 NEW HOUSE HEALTH COMMITTEE CHAIR House Health Committee Chairman Rep. Matt Baker (R-Tioga) announced his resignation from the House of Representatives effective, Monday, Feb. 19. The decision came after the 25-year House veteran accepted a presidential appointment as Regional Director of PACEP News | SPRING 2018


the Office of Intergovernmental and External Affairs, Office of the Secretary of the Department of Health and Human Services (HHS). He will be one of 10 HHS regional directors across the country whose region includes Pennsylvania, Delaware, Maryland, Virginia, West Virginia and the District of Columbia. His many new responsibilities will include ensuring HHS maintains close contact with federal, state, local and tribal partners and addresses the needs of communities and individuals served through the numerous HHS programs and policies. State Rep. Kathy Rapp (R-Warren) was appointed by Speaker of the House Mike Turzai to serve as the new chair of the House Health Committee.


Milliron Goodman continues to work with PACEP’s leadership on legislation affecting your profession, your colleagues, and your patients. Here is a look at some of the noteworthy bills this session. E-Prescribing (HB 353 – Rep. Tedd Nesbit, R-Mercer): This bill amends the Controlled Substance, Drug, Device and Cosmetic Act to require electronic prescriptions of a Schedule II, III and IV controlled substance. Working with various stakeholders, PACEP clarified exceptions in the bill. As amended, the electronic prescription requirement shall not apply if the prescription is issued: By a veterinarian; Under circumstances when an electronic prescription is not available due to a temporary technological or electrical failure; By a practitioner and dispensed by a pharmacy located outside of this commonwealth; By a practitioner who or health care facility that does not have internet access or an electronic health record system; or By a practitioner treating a patient in an emergency department or a health care facility under circumstances when the practitioner reasonably determines that electronically prescribing a controlled substance would be impractical for the patient to obtain the controlled substance prescribed by electronic prescription or would cause an untimely delay resulting in an adverse impact on the patient’s medical condition. The bill as amended unanimously passed the state House by a vote of 194-0. The bill is now in the Senate Health and Human Services Committee. PACEP supports this legislation as amended. Involuntary Commitment for Individuals with Substance Use Disorders (HB 713 – Rep. Matt Baker, R-Tioga): This bill amends the Mental Health Procedures Act to include individuals with substance use disorder which has caused an overdose within 30 days as an individual subject to involuntary commitment. This will subject individuals with substance use disorder to emergency examination and treatment to be undertaken at a 10 PACEP News | SPRING 2018

treatment facility. The bill would expand that definition of “clear and present danger” to include the ingestion of drugs to the point of unconsciousness, or in need of medical treatment to “prevent imminent death or serious bodily harm.” From an emergency medicine standpoint, this legislation would likely have far-reaching implications that would hinder rather than augment shared goals of enhancing substance use disorder treatment and decreasing overdose deaths in the Commonwealth of Pennsylvania. PACEP submitted a letter expressing concerns to the state House. The bill is currently in the House Appropriations Committee. Similar legislation has been introduced in the state Senate (SB 391 – Sen. Jay Costa, D-Allegheny). SB 391 is currently in the Senate Judiciary Committee. PACEP shared its concerns regarding this legislation with lawmakers and offered the following proposed solutions: • Increase support for community based engagement and harm reduction resources. Rather than force individuals into an inpatient treatment system that is already overwhelmed with little chance of success, meet that individual where he/she is physically and psychologically so that a therapeutic relationship based upon trust and collaboration can be established. • Develop and expand support and educational resources for family members and loved ones of individuals with SUDs. Programs aimed at assisting family members can improve their own health, provide tools to help in their relationship with loved ones with SUDs, and actually play a role in facilitating voluntary and effective treatment engagement and retention. • Current confidentiality rules in PA related to sharing information regarding substance use disorders (Pa. Cons. Stat. Ann. tit. 71 § 1690.108) limit the ability for treatment providers to coordinate care. Federal guidelines are less restrictive and application of those standards may improve the ability of providers to care for individuals with substance use disorders while maintaining appropriate confidentiality. • Continue to expand access to inpatient as well as outpatient substance use disorder treatment, including medication assisted therapy (MAT). Optimize existing and developing warm handoff programs. • Waive current regulations that prevent rehabilitation facilities from accepting individuals who are already on methadone, buprenorphine or other legal substances. Bed Registry Act (HB 825 – Rep. Doyle Heffley, R-Carbon): While there are no simple solutions to combatting the heroin and opioid epidemic, PACEP has proposed several recommendations, including a comprehensive, real-time statewide tracking system of available drug and alcohol treatment facility beds to allow for enhanced and timely

placement of appropriate patients from the emergency department. This bill provides for a detoxification bed registry. PACEP worked with the sponsor to enhance the legislation. The bill unanimously passed the state House by a vote of 187-0. The bill is now in the Senate Health and Human Services Committee. Mental Health Treatment – Database for Availability of Services (SB 179 – Sen. Camera Bartolotta, R-Washington): This bill would require the Health Department to establish the online database that would help doctors more quickly find inpatient beds for psychiatric patients in crisis. Participation of hospitals would be voluntary. Those electing to participate would input information, at least once every eight hours, about the number and types of inpatient psychiatric beds they have available. Participation by hospitals with inpatient psychiatric units be mandatory, not voluntary, and a real-time database would be preferable to one updated every eight hours. However, the legislation advanced is a step forward. PACEP has long advocated for a way to find and utilize available psychiatric beds for patients requiring additional care, and commends the sponsors of the legislation, which seeks to mitigate a genuine and frustrating barrier to quality emergency care. The bill was unanimously voted out of the Senate Health and Human Services Committee and is now before the full Senate. It is currently in the Senate Appropriations Committee. Assault of a Health Care Practitioner (HB 646 – Rep. Judy Ward, R-Blair): This legislation will raise the penalty for an assault on a health care practitioner, while in the performance of duty where there is bodily injury, from a misdemeanor of the second degree to a felony of the second degree. PACEP supports this bill. HB 646 passed the House by a vote of 188-6 and is currently in the Senate Judiciary Committee. Similar legislation has been introduced in the state Senate (SB 445 – Senator Don White, R-Indiana). That bill is also in the Senate Judiciary Committee. EMS Reimbursement for Non-Transport Services (HB 1013 – Rep. Steve Barrar, R-Delaware): This legislation would require managed care plans to pay all reasonably necessary costs associated with the provision of emergency services when an emergency medical services agency is dispatched by a 911 call center to provide medically necessary emergency care, including advanced life support services, to an individual covered by such plans, even if the covered individual does not require transport or refuses to be transported. Patients routinely experience emergent scenarios, such as diabetic emergencies, asthma exacerbations, and opioid overdoses that require immediate, life-saving care. Some patients don’t require or refuse transport. If

the patient is not transported, the cost of providing the service is directly assumed by the ambulance company a burden which could be so significant that the company would need to close, and the public would inadvertently be put at risk. PACEP voiced its support for HB 1013. The bill unanimously passed the House by a vote of 190-0 and is currently in the Senate Banking and Insurance Committee. Rather than moving HB 1013, the Committee voted out SB 1003, sponsored by Chairman Don White (R-Indiana). While the intent of both bills is the same – to reimburse emergency medical services agencies for services provided even when transport to a hospital does not take place – the details are different. The major concern with SB 1003 is that it also changes current law with respect to payment for emergency services (not just those with non-transport) to now allow a managed care plan to make a determination as to whether the emergency services are medically necessary for payment. It also adds that payment is subject to any copayment, coinsurance or deductible as specified in the health insurance policy and consistent with the managed care plan’s medical policies. Under current law, gatekeeper managed care plans are required to provide coverage for emergency transport and related emergency services provided by a licensed emergency service and are required to pay all reasonably necessary costs associated with the emergency services provided during the period of the emergency. SB 1003 changes the law to stipulate “the managed care plan shall pay any reasonably necessary costs associated with medically necessary emergency services provided during the period of emergency, subject to any copayment, coinsurance or deductible as specified in the health insurance policy and consistent with the managed care plan’s medical policies.” SB 1003 is currently on the Senate Calendar. PACEP sent letter to lawmakers reinforcing its support for the language in the House bill (HB 1013). Balance Billing (SB 678 – Senators Judy Schwank, D-Berks, Don White, R-Indiana, and Jay Costa, D-Allegheny)/HB 1553 – Reps. Matt Baker, R-Tioga (RESIGNED) and Tina Pickett, R-Bradford): This legislation seeks to address surprise balance bills, also known as surprise out-of-network medical bills. Among the concerns, the legislation would rely on health insurance companies to set and pay “the out-ofnetwork amount due under the health insurance policy” without an impartial, transparent standard and require providers to ask for cost-sharing amounts rather than the information being automatically provided to the provider by the insurance company any time a bill is sent to the insurer. In addition, the bill provides for the use of arbitration as a dispute-resolution mechanism with a “loser pays” payment model that would mandate PACEP News | SPRING 2018 11

best-offer binary decision making, require deposit of arbitration costs prior to resolution, and lacks a floor above which arbitration would kick in. Insurance companies have more personnel and resources to contest reasonable charges by physicians who have already provided emergent care to patients at times of crisis without knowledge or concern for insurance network status. PACEP has added its voice to discussions with lawmakers and key decision makers and is working with other hospital-based specialties. Pennsylvanians should be able to use the closest and most appropriate emergency department when they have an acute need. No patient at a time of medical crisis should have to worry about insurance network coverage. At the same time, insurance companies should be required to pay fair and reasonable reimbursement rates to emergency care providers, regardless of whether they are considered in- or out-of-network. SB 678 is currently in the Senate Banking and Insurance Committee and HB 1553 is on the House Tabled Calendar. Please stay alert for updates as Milliron Goodman and PACEP’s leadership continue discussions with lawmakers and stakeholders. We will need you to join the effort to urge legislators to vote NO on the current language in the balance billing legislation. Considers military education for EMT/ paramedic (HB 302 – Rep. Jesse Topper, R-Bedford): This bill establishes that any person who is professionally licensed/certified by the Department of Health (DOH) and who is called to active duty will be exempt from continuing educational requirements or in service training requirements, and will not forfeit his/her current license/registration. Currently, a military medic or paramedic who applies for a Department of Health license does not receive credit for military training. Many military veterans are forced to go through training they have already received. This “retraining” of veterans is costly and not needed. The bill unanimously passed the House (188-0) and is currently in the Senate Veterans Affairs & Emergency Preparedness Committee. PACEP sent a support letter to the state Senate.


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12 PACEP News | SPRING 2018 EOE

UPMC Pinnacle is an Equal Opportunity Employer.

MEMBER PERSPECTIVE Disaster Medical Assistance Team: A PACEP Member’s Perspective Scott Goldstein, DO, FACEP Chair, PACEP EMS Committee It is 5 p.m. on a Sunday. You are sitting down to eat dinner with your family. You are so excited to be home. You have been working evenings/night shifts and this is your first full day home with your family. You are vaguely aware of the world news as of late, but none of them concern you right now—or do they? As you sit down, you get a text message alert. Your agitation takes over and you check your phone. It’s a message from HHS/NDMS (Health and Human Services/National Disaster Medical Services) to check your email. Your stomach drops, you sweat a little. You know what the email will say. Your DMAT (Disaster Medical Assistance Team) has been put on alert to travel. But you just got to sit down with your family after four days of working! How will your significant other take this? How will your kids take this? Do they even understand (you are leaving to do work, but you go to work daily and don’t return for two weeks at a time)? Why do they need “YOU”? You had plans and shifts coming up. How will they get covered? Will your significant other accept this leave of absence of the children’s father and their spouse? All these questions, and more, can be yours if you join DMAT. It sounds all negative, but it’s not, otherwise people wouldn’t do it. I do it. I do it because I like to help people. I do it because I like Emergency Medicine, I think the best place to do the best for the sickest people…is in a disaster. Where they have no medications, they may be hurt or injured, they are scared, and you are there to do what you do best—Emergency Medicine. The federal team is under the umbrella Health and Human Services and National Disaster Medical Services. They host numerous teams and persons. They have DMAT, NDVS (veterinary), DMORT(mortuary), with over 6,000 involved persons. Each DMAT team is regionally/ geographically specific. They are a close knit group of similar-minded persons that have one goal in mind, and that is to help others. It is a group of pharmacists, respiratory therapists, nurses, paramedics, MEET’s, dentists, doctors (emergency medicine/surgery), PAs, NPs, and support staff that train together and work together. Everyone does work putting up tents, and setting up equipment. It’s a group mentality with one the main goal in mind. Training occurs every few months and deployments are when a lot of training can occur.

The deployments that I have been on have been for disasters (Hurricane Harvey) and standby’s National Security Events (State of the Union address, Papal visit, etc…). The State of the Union was a fantastic experience, where we were in a NDMS warehouse in Maryland. We trained for three days practicing donning/doffing equipment, reviewing medical equipment cache’s, practicing putting up and taking down tents, and medical procedures. We were ready to go if needed, and the SOTU occurred without any incident. We demobilized and went home. This time was well utilized with training and the DMAT team became closer, as we spent a lot of time together. We were able to learn the equipment in a centralized area with experts. The deployment for Hurricane Harvey was similar. There was a need. A large need for assistance. There were numerous DMAT teams from across the country preparing, training and waiting. Teams came in, trained for a day (or two) and were sent to the front lines in Texas or Louisiana. They were helping a lot of people who had some very complicated needs. Overall, the experience with DMAT has been positive. Those involved are stand-up people. They are motivated to help others and are all actively practicing clinicians. The trainings are well thought out and informative. The work that is done on a federal level is rarely ever seen or known, but the DMAT lets you get a glimpse into the world of the federal side of medical care. To join the DMAT team, just keep an eye for and set up an alert on and wait for a space to open up. Do not be afraid to think outside your geographic area, especially if you are a near a state border, look at both states. Stay safe and good luck! Member perspectives do not reflect that of the PA College as a whole.

PACEP News | SPRING 2018 13

Emergency Department Buprenorphine Treatment of Opioid Withdrawal Emergency Department (ED) buprenorphine treatment for patients in opioid withdrawal has gained more attention. Michael Lynch, MD Evidence suggests that treatment of acute opioid withdrawal with buprenorphine is superior to alpha-2 agonists, e.g. clonidine, in symptom reduction and ED recidivism.1,2 Additionally, ED-initiated buprenorphine therapy is associated with improved rates of addiction treatment engagement and completion.2,3 The Drug Addiction Treatment Act of 2000 (DATA 2000) provided for the expansion of medication assisted treatment (MAT) to include office based therapy with buprenorphine in addition to traditional narcotic treatment programs and methadone. What Are the Federal Regulations Regarding Administration of Buprenorphine in the ED? DATA 2000 outlines statutory provisions allowing physicians with a valid DEA license to complete training and apply for additional treatment privileges, the socalled “x-waiver”, to prescribe buprenorphine provided all regulatory requirements are met. Emergency physicians can complete an online 8-hour course to obtain an x-waiver. The educational modules and additional information can be accessed at https://www. Emergency physicians who have not completed additional training or obtained their x-waiver may still provide buprenorphine in certain circumstances outlined in the Code of Federal Regulations (CFR). Specifically, Title 21, Chapter II Part 1306 (§1306.07) section b of the CFR4, the “Three Day Rule”, states: “Nothing in this section shall prohibit a physician who is not specifically registered to conduct a narcotic treatment program from administering (but not prescribing) narcotic drugs to a person for the purpose of relieving acute withdrawal symptoms when necessary while arrangements are being made for referral for treatment. Not more than one day’s medication may be administered to the person or for the person’s use at one time. Such emergency treatment may be carried out for not more than three days and may not be renewed or extended.” Therefore, emergency providers may legally provide a single dose of buprenorphine to patients suffering acute opioid withdrawal. A single daily dose of buprenorphine 14 PACEP News | SPRING 2018

may be provided for no more than three consecutive days. A prescription for buprenorphine may not be written by a provider who has not received an x-waiver according to Federal regulations. How Do I Administer Buprenorphine in the ED? There is no single way to provide treatment and appropriate pathways may vary depending upon a provider’s clinical practice environment and accessibility of addiction treatment resources. However, some recommendations based upon experience and available evidence are: • Facilitated Addiction Follow Up Care: First, and most importantly, establish a process to facilitate rapid addiction treatment follow up in order to optimize patient care and treatment engagement while avoiding otherwise unnecessary daily ED visits. Ideally, buprenorphine therapy would be integrated into a warm handoff process. • Multidisciplinary and Administrative Coordination: Coordinate with nursing, pharmacy, social work, case management and hospital leadership to ensure a cohesive process and administrative support. • Avoid Precipitated Opioid Withdrawal: Do not administer buprenorphine to a patient who is not in active withdrawal as the agonist-antagonist properties of buprenorphine (not the presence of naloxone) may induce withdrawal. A Clinical Opioid Withdrawal Scale (COWS) score of at least 5 is recommended before considering buprenorphine administration. The preferred duration of abstinence will vary depending upon the pharmacokinetics of the specific opioid being used by the patient, but the objective presence of withdrawal (not related to naloxone reversal) is indicative of appropriate treatment timing. • Buprenorphine Dosing: Individual buprenorphine dosing requirements to alleviate acute withdrawal symptoms and craving vary. However, 8mg of buprenorphine, or its equivalent depending upon formulation, is a safe and effective initial dose for most patients in the ED. 3If the patient returns on subsequent days 2 and 3 while follow up is established, dosing may be titrated by 4-8mg/ day depending upon symptom relief. It is unlikely that more than 16mg of buprenorphine would be necessary within the scope of ED management of acute withdrawal and facilitated follow up. Once dosed, a brief observation period is appropriate to ensure that there is no precipitated withdrawal or

other adverse effects as well as to assess effectiveness. If the patient has received a dose of buprenorphine in the ED on 3 consecutive days, then he/she may not receive a dose on day 4 per the CFR.4 • Adjunctive Therapy: Some patients will have mild opioid withdrawal symptoms despite ED dosing with buprenorphine. Prescriptions of symptomatic therapy including clonidine, hydroxyzine, loperamide or diphenoxylate, ondansetron, and NSAIDs to be taken as needed remain appropriate adjunctive therapy upon discharge. • Naloxone: Patients presenting for addiction treatment remain at high risk for opioid use and overdose as well as association with others who are at risk. Naloxone distribution programs have been associated with community mortality reductions.5 Provision or prescription of take home naloxone is recommended by Substance Abuse and Mental Health Services Association (SAMHSA), Centers for Disease Control (CDC), and World Health Organization (WHO).6,7,8 Resources • Poison Control Centers in Philadelphia and Pittsburgh: 1(800)222-1222 • PA GET HELP NOW: 1-800-662-HELP (4357) • Single County Authorities: gethelpnow/CountyServices.aspx • • SAMHSA MATx Mobile App to Support MedicationAssisted Treatment of Opioid Use Disorder: https://

References 1. Berg ML, Idrees U, Ding R, Nesbit SA, Liang HK, McCarthy ML. Evaluation of the use of buprenorphine for opioid withdrawal in an emergency department. Drug Alcohol Depend. 2007 Jan 12; 86(2-3): 239-44. 2. Love JS, Perrone J, Nelson LS. Should buprenorphine be administered to patients with opioid withdrawal in the emergency department? Ann Emerg Med. 2017 Nov 3. 3. D’Onofrio G, O’Connor PG, Pantalon MV, Chawarski MC, Busch SH, Owens PH, Bernstein SL, Fiellin DA. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015 Apr 28; 313(16): 1636-44. 4. Administering or Dispensing Narcotic Drugs, 21 Code of Federal Regulations (CFR) 1306.07. 39 FR 37986, Oct. 25, 1974, as amended at 70 FR 36344, June 23, 2005. 5. Walley AY et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013 Jan 30; 346:f174. 6. World Health Organization. Community management of opioid overdose. Geneva, Switzerland: World Health Organization; 2014 7. Wheeler E, Jones TS, Gilbert MK, Davidson PJ; Centers for Disease Control and Prevention (CDC). Opioid Overdose Prevention Programs Providing Naloxone to Laypersons - United States, 2014. MMWR Morb Mortal Wkly Rep. 2015 Jun 19;64(23):631-5. 8. Member perspectives do not reflect that of the PA College as a whole.

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PACEP News | SPRING 2018 15

RESIDENT SPOTLIGHT Josh Mervin (Awarded as Editorial Fellow to the Annals of EM Board) I came to Philadelphia a little over two years ago to start my residency in Emergency Medicine at Albert Einstein Medical Center. I was interested in Einstein because I was looking for a residency that had a county-feeling, much like my medical school training at Kings County Hospital in Brooklyn. Moving from Brooklyn to Philadelphia I thought that despite the escalation in responsibility, the experience would be very similar to medical school. Life in Philadelphia was no culture shock. To be glib, it seemed to be just a bit more driving and heroes became hoagies. My experience in training also did not change drastically. I still worked in a busy trauma center with patients in an underserved community who had limited access to care outside of the emergency department. Overall, my life and career were not climactically changed by my move two hours south. I enjoyed the setting I was working in, and felt I was overall seeing the typical mix of patients and disease processes of a county-style emergency department. In my second year in residency, as the shock of intern year wore off, the idea of getting back into research did not sound like too far of a stretch. Since my days

as an Economics major in college, I have always been interested in natural experiments and fortuitous data sets. As the patterns of regular practice started to sink in and with the reinforcement of faculty, I started to understand the small differences in the diseases affecting our population that made it a little more unique. Just some of these differences include our high prevalence of ACE inhibitor induced angioedema and nonischemic cardiomyopathy, and daily encounters with phencyclidine intoxication. For residents looking to get into research, finding those coincidental niches provides a rich environment for investigation into a clinical problem which can particularly help many of your patients. It also provides an avenue for interesting research, which may not be feasible at other institutions. For those uninterested in research, taking a moment to reflect on your coincidental niches, no matter how small or specific, can be a source of pride. Although Emergency Medicine is a field that emphasizes being a jack of all trades, it is important to highlight those which we have all personally mastered.


PACEP NEW MEMBERS Michael Ambrose Monisha Bindra, DO Jennifer A. Brennan Graham Connor Clifford Andrew S. Greenspon Michal Hammond

16 PACEP News | SPRING 2018

Max Kravitz Tripti Kumar Alexander Kurtzman Andre Lee Nevin G McGinley, MD Andrew McWilliams, MD

Kathryn A. Schmidt Arsalan Shawl Ronya Silmi Christopher Valente, MD Brian S. Van Dam Jason M. Wentzek

A Resident’s Council Experience One thing you should know about me is that I love professional conventions. Expanding my knowledge, meeting passionate members of the field, learning about new research and best practices, discovering novel subspecialties… these stand out among Camilla Sulak, MD Emergency Medicine my favorite aspects of Resident, PGY II conferences. This year Allegheny General Hospital I expanded my list in Pittsburgh, PA an unexpected way: to include the American College of Emergency Physicians (ACEP) Council Meeting. Although the Council Meeting takes place immediately prior to ACEP’s annual Scientific Assembly, planning starts months in advance. For me, it began at the 2017 PACEP Scientific Assembly Residents’ Day. As a conference junkie, I stuck around after lectures to meet trailblazer physicians, PACEP Officers and board members. They suggested many ways to become more active in the field including committees, interest groups and Council. “What is Council?” I asked. While everyone raved about it, Council defied explanation. However, no one could hide their enthusiasm. Participating in Council, they assured me, would expose me to the policy and advocacy aspects of Emergency Medicine (EM) I wished to understand better. Fortunately, I was selected to join the Pennsylvania delegation! Then the real work began. Throughout the following months, Councillors met frequently to draft new resolutions and consider those proposed by other chapters. In October 2017 at the ACEP Council Meeting in Washington, DC, the conversation expanded. Councillors from across the country packed into three

Reference Committee hearing rooms. Held to schedule and kept to task by the committee executives, debate ensued on every resolution submitted: expanding 911 access across the United States, promoting Resident participation in Council, exploring the role of EM in Supervised IV Drug Programs, advocating fair pharmaceutical pricing, considering paid parental leave for all EM Physicians, establishing immigrant “safe zones,” to name a few of the 55 resolutions proposed. Participants’ sound reasoning, informed commentary, and civility struck me. As I was drawn to the discussion, our PACEP Councillors encouraged me to contribute. Although I grew up in an academic family, I had never experienced such sound, vigorous debate professionally. Council Speaker James Cusick, MD called 410 voting Councillors to order the next morning. After adopting many resolutions by the unanimous consent of the preceding day’s Hearings, Councillors debated the remaining controversial proposals. Often our PACEP Councillors offered their voting cards to Alternate Councillors like me, allowing our entire delegation to contribute to the discussion and cast our votes. We helped solidify the coming year’s agenda for advocacy efforts, recommended how to direct ACEP funds, and established goals for ACEP Committees and the Board. PACEP prioritized Resident involvement beyond that of any other state chapter. While participating in this process of parliamentary governance, I met physicians from all over the country, learned of controversies I never knew existed, and contemplated future directions I had not imagined. I thank President Guyette, the PACEP Officers, and PACEP Board Members for encouraging active involvement, promoting informed conversation, and nurturing future EM leaders. In so doing, they have inspired a tradition of service, mentoring, and advocacy guaranteed to last well beyond their tenure.

PACEP News | SPRING 2018 17

Emergency Medicine Opportunity – Rural Pennsylvania $25,000 Starting Bonus and Loan Repayment St. Luke’s Hospital - Miners Campus is recruiting for full-time Emergency Medicine physicians to be an integral part of our successful physician team. The hospital is a fully accredited, not-for-profit, 45-bed acute care hospital located in Coaldale, Pennsylvania in Schuylkill County. It boasts a state of the art 14-bed Emergency Department and is on pace to treat more than 18,000 patients per year and is the first certified Level IV Trauma Center in Pennsylvania. We possess our own full-time 24/7 EMS transport team who work alongside our very experienced and patient focused nursing team. Candidate must be ABEM board certified. The ED physicians are partial single coverage with 12 and 10 hour shifts (Physician & PA) and are supported by state of the art radiology. This employed position offer: •

$25,000 starting bonus and up to $100,000 in loan repayment

Location and retention bonuses

Competitive salary with incentive plan

Rich benefits package, including relocation, malpractice, health & dental insurance, CME allowance

St. Luke’s Miners Memorial Hospital is a member of the nationally recognized St. Luke’s University Health Network, a nonprofit network comprised of physicians and hospitals, providing care in eastern Pennsylvania and western NJ. The Network includes more than 200 locations and seven hospitals and employs more than 450 physicians and 200 advanced practitioners. The Miners Campus is just 12 miles west of The Pocono Mountains of Jim Thorpe, PA. The location is ideal for skiers, mountain biking, hunting and fishing yet is just 35 minutes north of the Lehigh Valley, 90 minutes of Philadelphia and 2 hours to Downtown Manhattan.

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PACEP 2018 Spring Newsletter1  
PACEP 2018 Spring Newsletter1