This edition of the newsletter covers a broad range of interesting topics, including DC’s electric scooter phenomenon, prescription drug monitoring, perspectives on the personalized treatment of sickle cell disease, and, of course, ACEP19.

This summer, DC ACEP held a Sickle Cell CME Dinner on August 14th, which turned out to be one of our most well-received member benefit events to-date. It was inspiring to see fellow emergency medicine physicians from diverse groups in the area join us for an important discussion about how to improve the care we give to our patients that are living with sickle cell disease, with hospitals represented within DC and in the DMV region listed below:

George Washington University Hospital

Veterans Affairs Medical Center

Children’s National Medical Center

Virginia Hospital Center

Novant Health UVA Health System

Walter Reed National Military Medical

Shady Grove Medical Center

University of Maryland Medical Center

Washington Hospital Center

Georgetown University Hospital

Inova Fairfax Hospital

Fort Belvoir Community Hospital

Andrews Air Force Base Hospital

Washington Adventist Hospital

Baltimore Washington Medical Center

Harbor Hospital

We also recognize that in part, the success of this event was due to members like you who saw the importance of continuing your education on important topics like sickle cell disease which affects our patient population. Our goal as a chapter is to continue to hold member benefit events like this again in the near future.

With ACEP19 around the corner, please don’t forget to RSVP for the upcoming Chapter Meeting and the Mid-Atlantic Reception to be held in Denver. Event details can be found in the articles below. We look forward to connecting with you at the conference! If you are unable to attend, please consider sending comments or feedback to us via email.

Upcoming Chapter Events

Prescription Drug Monitoring Programs (PDMPs): History and Implications for Emergency Physicians and Patients

Leah E. Steckler, MD

Over the past few months, you may recall receiving several e-mails regarding your mandatory participation in Washington, DC’s PDMP. The PDMP is a system which monitors prescribing and dispensing of controlled substances. The history of this system and its utility, as well as potential for harm, has been contested since this program was first adopted. As emergency physicians, we are an important part of PDMPs because we are required to participate in and check the database before writing prescriptions.

According to the Pharmacy Times, the first PDMP was enacted by New York State in 1918. At that time, the system was used to monitor prescriptions for many substances now considered to be illegal, including cocaine and heroin. The system also included monitoring for codeine, morphine, and opium. The onus at that time was on pharmacists who were required to report copies of prescriptions to the health department. The next state to create a drug monitoring program was California in 1939 [1]. The first electronic PDMP was created in Oklahoma in 1990 [2].

Moving forward in history, the overwhelming majority of PDMPs were created beginning with the establishment of the 2002 Department of Justice Harold Rogers PDMP grant. In 2005, Congress and President George W. Bush enacted the National All Schedules Prescription Electronic Reporting Act (NASPER) which required the Secretary of Health and Human Services to award grants to states to establish or improve PDMPs. Today 50 states, the District of Columbia, as well as Guam and Puerto Rico have operational PDMPs [3].

One major concern with these government regulated monitoring programs is that there is an expectation that all physicians participate and utilize the system before writing prescriptions for any controlled substances. Currently, PDMP reform is under active discussion in both medical and political circles. ACEP’s official stance is that several exceptions to access of PDMPs should be adopted. These include:

(i) patients undergoing cancer, hospice or palliative care

(ii) terminally ill patients

(iii) patients receiving care in an inpatient or observation setting

(iv) care at the scene of an emergency or in an ambulance

(v) nonrefillable prescription less than 7 days

(vi) the PDMP is not operational secondary to a technological or electrical failure or natural disaster [4]

With every new piece of technology that we encounter, there tends to be additional regulatory burdens and privacy implications. Some have also suggested that patients currently undergoing treatment for opioid use disorders be excluded from this system to mitigate the stigma of this disease process. For physicians, the additional work required to log in and check a monitoring site while actively trying to manage an emergency department may place an undue burden on the physician. Further, information may be incomplete, there is often delayed reporting, and there is limited interoperability among states.

It is vital that we continue to be involved in the process of monitoring these systems and the regulations put forth by local, state, and federal governments regarding their use and requirements for physician reporting and utilization. It is our duty to ensure that neither physicians nor patients are put at risk based on PDMPs as we work together to combat the opioid crisis and improve monitoring systems.

For further reading, the following article is recommended: Haffajee, Rebecca L. Prescription Drug Monitoring Programs - Friend or Folly in Addressing the Opioid-Overdose Crisis? N Engl J Med.

References:

1. The Evolution of the PDMP [Available Online 22 Aug 2019].

2. Haffajee, Rebecca L. Prescription Drug Monitoring Programs - Friend or Folly in Addressing the Opioid-Overdose Crisis? N Engl J Med. [Available Online 22 Aug 2019].

3. Sacco, Lisa N., Duff, Johnathan H, Sarata,. Amanda L. Prescription Drug Monitoring Programs, Congressional Research Service. May 2018.

4. PDMP Legislation

Resident Corner

The Electric Scooter Phenomenon: Safety in the District

Vishal K. Goswami, MD

Since 2017, the District of Columbia has had a rampant rise in the number of electric scooters (E-scooters) roaming the city’s streets and sidewalks. Everyone from tourists to local commuters use these vehicles everyday. They’ve become an affordable and green alternative for getting around in the city while avoiding traffic. About 1 in 6 residents of the District used E-scooters within the past year, and about 6% of residents use them multiple times a week. And companies like Lime, Skip, Jump and Lyft have plans to further expand the number of scooters accessible to residents. With that arise issues of safety and care for accidents related to E-scooter injuries.

As this mode of transportations expands, emergency physicians around the country are noticing an increase in injuries related to E-scooters present to hospitals. A recent study revealed that most injuries related to scooters included head injuries (40.2%), fractures (31.7%), and soft-tissue injuries (27.7%). The study also found that only 4.4% of riders wore a helmet. ACEP launched a campaign in February sharing tips, and a 1-minute video, for riders regarding safety while riding E-scooters. The most important part of their message is to promote helmet use while riding scooters.

Most cities don’t require scooter riders to wear a helmet, and the same applies the District. In DC, bicycle riders under age 16 are mandated by the Bicycle Helmet Law to wear a helmet. The law expands to include vehicles like “scooters, skateboards, sleds, coasters, toy vehicles, or any similar devices.” However, E-scooters fall under the “Personal Mobility Device” rules, which assert that motor vehicles cannot be ridden by anyone under the age of 16. And most companies require that riders be at least 18 or older to ride. Companies like Bird and Skip will mail helmets to users who request them. But, there is no current policy that requires riders to wear helmets.

We faced similar questions about rider safety regarding bicycles. After several campaigns in the 1990’s, support for helmet use for bicycle riders became more widespread. Studies as recent as 2017 have shown that helmet use while riding a bicycle reduced odds of “head injury, serious head injury, facial injury, and fatal head injury.” However, most states similar to DC, have laws that only pertain to certain ages. Organizations like the CDC, SAEM, and ACEP continue to recommend that all ages wear helmets while riding bicycles, and have now extended that recommendation to include E-scooters.

In addition to wearing helmets, ACEP’s tips include starting slowly and avoiding speeding, as well as no riding while intoxicated. In DC, scooters, like bicycles, are prohibited on sidewalks within the central business district, which is outlined in this map. Riding on congested sidewalks places riders and pedestrians at risk for injury. And when riding on streets, it is encouraged for riders to use bicycle lanes when they are available. E-scooters are not allowed to run faster than 10 mph within the District. Other states and cities have placed this limit at 15 mph. And like throughout the country, it is illegal to ride an E-scooter while intoxicated. In the same study mentioned earlier, it was found that 4.8% of those injured also either had a blood alcohol level of greater than 0.05% or were deemed intoxicated by a physician.

The District has issued permits for almost 5,000 dockless bikes and scooters. Jump was recently permitted to add 300 more bikes; Lyft, Skip and Spin were permitted to add up to 120 more scooters each. Lime was permitted to add 75 more scooters. As the number of scooters and riders rise, more scooter-related injuries presenting to our ED’s is expected. We should continue to advocate for laws regulating helmet use for E-scooters to help prevent head injuries among our patients. In addition, we should continue to encourage riders to adhere to traffic laws, be weary of riding in busy areas, and never operate a scooter while intoxicated.

Medical Student Corner

Brandon Robinson

I had my first patient with Sickle Cell Disease on my Internal Medicine rotation. The senior resident had gotten a call for a consult from the Emergency Department and asked me to go interview the patient. On arriving, I found out that she was there for a sickle cell pain crisis. She described her symptoms in vague terms, emphatically stating that she was in pain and volunteered little other information. She couldn’t localize it to more than her arms and legs, designating it as deep and unrelenting no matter how she moved. She had no other medical conditions, had no surgical history, did not take any medications, and no regiment of Tylenol, Ibuprofen, or other over the counter medication made a dent in the pain. Eventually in the interview, I discovered the pain crisis had been triggered by the cocaine that she and her husband had done in celebration of their anniversary two days prior.

I went back to report to the team with confusion, not sure what the best treatment moving forward would be. In my inexperience, I did not have a way to quantify her pain level that would allow us to treat her with medication. Her lab results had come back with mild anemia, and radiographs ruled out avascular necrosis. A quick search of literature showed that transfusions were not indicated, her vital signs were normal, and there was no quantifiable tool to treat her pain. Additionally, very little evidence could support a standardized scale for sickle cell pain. Eventually, I had to rely on the wisdom of my attending physician to find the regimen of pain medication that would alleviate her pain. Unfortunately, she had seen multiple patients who presented after indulging in cocaine.

This was not my first patient to have had sickle cell disease, and certainly wouldn’t be the last. On further rotations, including Pediatrics, Psychiatry, OBGYN, and Emergency Medicine I encountered patients with SCD. Each patient had a unique story and different way their blood disorder was treated. One was an infant that presented with swelling in her hands and feet, and yet another in the Emergency Department that was there for his eight-pain crisis in the last 3 years and had his complete pain regimen from prior visits on his phone and new the attending by name. However, the common factor in their treatment plans was that it relied heavily on the experience of the attending physician who had encountered it more and experienced it in ways that textbooks can’t describe. I couldn’t rely on numbers and data alone to treat the patient, but more so on the years of practice and relationship with patients that more experienced physicians had developed and attempted to teach me.

Despite the years of classroom learning, and even time on the wards as a student, there is the indescribable gestalt that a physician develops in treating patients that can supersede academic knowledge. There is no easy way to learn it, and the longer a physician practices the more developed it becomes. I challenge the physicians who work with medical students to strive to teach the ways that they treat complicated conditions like SCD that rely more on the gut feeling and experience; your wisdom will help us to grow in our education in practice, and better treat these patients. Take the time to explain your reasoning, as some of my attending physicians did, and help to grow our clinical decision making in more nuanced and personal ways that academic study alone. The next time I encounter a patient with SCD, I will be able to draw on the conversations that I had with other physicians during medical school provide better care.

Doctors for America

2019 DFA NLC Registration

For more information or to register - click here.

Webinar - White Coat Investor

A webinar will be held by Dr. James Dahle on Tuesday, September 17th at 7pm CST.

This webinar is geard toward the life cycle of emergency physicians. For more information, click here. To register, click here.

Welcome New Members!

A special welcome to the new members of the District of Columbia Chapter. We are excited to have you. You may wonder if you should get involved with DC ACEP or EMRA or at the national level? We encourage you to please get involved!

If you are unsure about how to get involved, feel free to contact the chapter directly via email.

Alexander B. Kreisman, MD

Anahita Rahimi-Saber, MD

Ayal Zev Pierce, MD

Brandon Chaffay, MD

Brian Q. Gacioch, MD

Damani R. McIntosh-Clarke, BA

Fatmah Abdulazia Alsomali, MD

Jesus Trevino, MD

Joel Lange, MD

Jordan Selzer, MD

Joseph T. Brooks, MD

Kristin N. Raphel, MD

Malori Lankenau, MD

Margarita Popova, MD

Patrick McCarville, MD

Jean Mahoney Williams, MD, FACEP

Kerry Lind, MD

John D. Kelly, MD

Susan R. O'Mara, MD

Todd Mueller, MD

Adrienne M. Caiado, MD

Aera R. Shin, MD

Allison Carroll Becker, MD

Damali N. Nakitende, MD

Dana Lev-Ran, MD

Erik Michelle Kane, MD

Gifford Alexander Mezey, MD

Gina Piazza, DO, FACEP

Jessica Waters, MD

Joseph Daniel Pauly, MD

Kavita S. Jackson, MD

Kevin Semelrath, MD, FACEP

Ksenya K. Badashova, MD

Nadia Lehtihet, MD

Omoyemen Blue, MD

Thrang Thai, MD

Camilo E. Gutierrez, MD, FACEP

Grace Carolyn Kunas, EMT

Katherine Mariko Markin

Michael West

Anika Clark

Marcus Jermere Wooten

Allison Megan Rooney

Timothy Devita

Larissa Spagnol Silverman

Oswald George Reid, Jr.

Ashlam Akhtar

Veronica Andrews

Katherine P. Banks

Haroon Omar Ismail

Taylor Wahrenbrock

Zachary Winchester

FROM NATIONAL ACEP

Congress Needs to Hear from Emergency Physicians about Surprise Billing

The ACEP DC office hosted an ACEP members only Surprise Billing Advocacy townhall on August 5th. Laura Wooster, Associate Executive Director, ACEP Public Affairs, provided an update on Congressional activity and spoke about the importance of utilizing the August congressional recess while legislators are back home to advocate for emergency physicians and patients. ACEP offered tips to effectively engage your legislators and a toolkit with resources to facilitate effective outreach. A link to the archived townhall is available here. And, you can login here to access the ACEP members-only surprise billing advocacy toolkit. Related resources are available to view and share here. For updates on ACEP’s federal advocacy activities, join the ACEP 911 Grassroots Network here.

Explaining the AUC Exemption

We've heard that some of your hospitals are already implementing the 2020 AUC requirements, so we drafted a sample letter you can personalize to help you explain the emergency exemption to your administrators. Download it on the AUC section of our EHR advocacy page.

Point-of-Care Tools - 3 New Smart Phrases

3 new Smart Phrases are available on the ACEP Website on Suicide Prevention, Tobacco Cessation and Why Antibiotics Were Not Prescribed for a Viral Infection. Smart Phrases are blocks of text that can be copied and pasted into a hospital's electronic health record (EHR) system to automatically create discharge papers for common ED presentations. We've created these smart phrases to help you seamlessly disseminate the most important information your patients will need to manage their conditions after leaving the ED. View all Smart Phrases.

Articles of Interest in Annals of Emergency Medicine - Summer 2019

Sam Shahid, MBBS, MPH

Practice Management Manager, ACEP

ACEP would like to provide you with very brief synopses of the latest articles and articles coming soon to Annals of Emergency Medicine. Some of these have not appeared in print. These synopses are not meant to be thorough analyses of the articles, simply brief introductions. Before incorporating into your practice, you should read the entire articles and interpret them for your specific patient population. View synopses here.

New Policy Statements and Information Papers

During their June 2019 meeting, the ACEP Board of Directors approved the following new policy statements and Information papers. For a full list of the College's current policy statements, consult the ACEP Policy Compendium.

New Policy Statements:

Advanced Practice Provider Point-of-Care Ultrasound Guidelines

Compensated Time for Faculty Academic Administration and Teaching Involvement

Medical Cannabis

Safe Discharge from the Emergency Department

Separation of Children from Caregivers

The Role of Emergency Physicians in the Completion of Death Certificates

New Information Papers:

Best Practices in Testing Adults and Adolescents for Chlamydia and Gonorrhea in the Emergency Department

Models for Addressing Transitions of Care for Patients with Opioid Use Disorder

Care Under Fire: EDs, Gun Violence and Threat Assessment

ACEP19 Pre-Conference

Saturday October 26th from 1:00 - 5:00 PM

Threat management is an evidence-based, multidisciplinary team approach to identifying people at risk of engaging in targeted violence - including mass shootings - and intervening before they attack. Cost: $250. Learn More Here!

Approved for AMA PRA Category 1 Credit^TM

ACEP EM Specific X-Waiver COURSE

ACEP19 Pre-Conference

Saturday October 26th from 8:00 AM - 5:30 PM

This course will provide the tools to turn lives around with best practice addiction treatments and satisfies 8 hours of training required by federal law to prescribe buprenorphine, the most effective treatment for opioid use disorder.

While most “X Waiver” training courses are developed for and led by psychiatrists and office-based addiction specialists, this recently approved version of the course was written by a team of EM docs, specifically for EM Docs. The MAT-EM course minimizes lecture in favor of case-based discussion and participants will emerge from the course not only credentialed to register for their DATA 2000 (X) waiver but prepared to manage all aspects of emergency care of OUD patients.

Approved for AMA PRA Category 1 Credit^TM

ACEP Members: $70 | Residents: $50 | Non-Members: $100. Register Here.

Funding for this initiative was made possible (in part) by grant no. 1H79TI081968 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

Registration Open for the EMBRS Course

Interested in research but not sure where to start? The Emergency Medicine Basic Research Skills (EMBRS) is a 9-day, 2-session program where participants learn how to identify clinical research opportunities and become familiar with clinical research and outcomes. Participants are also eligible to receive an EMF/EMBRS grant based on their research grant application. This course targets: Junior faculty with limited research experience; Physicians in academic and community centers who are interested in research basics; Physicians who have as part of their duties involvement in research, including mentoring young researchers; Fellows in non-research fellowships. Click here to learn more and to register. The next course will take place Dec. 2-7th, 2019 (session 1) and April 14-16, 2020 (session 2).

News from the American Board of Emergency Medicine

August 2010

ABEM Security Systems Enhancements

ABEM takes the protection of all our users’ data and information seriously. We will soon be undertaking system enhancements to help maintain the security of your data. The change most users will notice is the need to reset their password the first time they sign in.

See You at ACEP19!

ABEM will be attending ACEP19, and will have a booth in the exhibit hall. Visit booth # 2012 and have an ABEM director or staff member answer your questions. Hope to see you there!

ExNominations to the Board of Directors

Do you know someone who would be a great addition to the ABEM Board of Directors? Then nominate the ABEM-certified physician of your choice! The physician must be clinically active. Click here to view nominee requirements and required documentation. Nominations are due December 1, 2019, and the Board will elect two new members at its February 2020 meeting.

District of Columbia Chapter

c/o National ACEP

4950 West Royal Lane

Irving, Texas 75063-2524

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