Emergency Medicine Legislative Day 2015

Legislative day 1

IUEM Residents attended the annual Emergency Medicine Legislative Day at the Indiana Statehouse, organized by Emily Fitz (PGY3 EM Chief Resident and INACEP Resident Representative) and Lindsay Weaver (Emergency Medicine Associate Professor). Throughout the day, several legislators from both the house and senate stopped by to discuss issues in healthcare with the residents.

Dr. Tim Brown (Chair of Ways and Means), Dr. Jennifer Walthall (Deputy State Health Commissioner), and Dr. Heidi Dunniway (President of the ISMA) also participated by sharing their thoughts and individual experiences in advocating for patients through healthcare policy. It was enlightening to hear the extent of their dedication and passion for advocacy, and the ways in which a physician can become a leader in their field.

During her reflections on advocacy and resident impact on health policy, Dr. Jen Walthall aptly described, “residents are adorable but ruthless” in creating positive change in the legislative arena, and if “you are not at the table, then you are on the table.”

At this time, the Indiana legislation is considering the following bills:

  • Naloxone prescriptions for lay people (abusers, family and friends)
  • Needle Exchange Programs
  • Funding for more Residency spots in Indiana
  • Programs to enroll prisoners in Medicaid Prior to Release so they can get mental health medications
  • Increase in Medicaid coverage for psychiatric medications and inpatient detoxification

Dr. Lindsay Weaver reflected on the following recent legislation. “A bill that would increase malpractice caps was defeated earlier this year.  However, it is expected that the malpractice law will continue to be under attack over the next several years.  Thankfully, being at the statehouse and showing interest year after year will give us a voice in this debate.”

Several presentation were prepared and given by IUEM residents:

Emily Fitz, EM PGY3, Chief Resident:  “Legislative Day Overview”

  • 6th year of the program
  • Put together and run by IUEM residents
  • Sponsored by INACEP and IUEM
  • Our collaborations have brought about real change. Examples include the – Lifeline Law and Narcan for first responders

Sarah Hemming-Meyer, EM PGY2:  “Mental Health”

  • Mental health affects everyone- 1/4 adults, 1/10 children, 26% homeless and >50% inmates
  • Access to Care is directly related to Funding-HIP 2.0 expansion of Medicaid will have provide services to some people, but more funding is needed
  • We support the currently bills that are at this house & senate–Bill 1448 & Bill 1269
  • B1448–widening Medicaid coverage for approved FDA drugs with aid with substance withdrawal and inpatient detoxification
  • B1269–Department of Corrections become POA and assist inmates with Medicaid application not only while in prison and when released to ensure proper medications and support for inmates with mental illness.
  • National shortage of providers- increase funding for loan reimbursement, psych residency spots to increase # of psychiatry providers.

Kyle Yoder, EM/Pediatrics PGY5, Chief Resident:  “Prudent Lay Person” 

  • “Emergencies” are defined by the patient, not the doctor‬
  • A layperson cannot be expected to be able to differentiate a serious medical condition masquerading as a common medical condition
  • As emergency medicine doctors, we sometimes practice outside of the scope of our “medical specialty” because we are the only medical access for a portion of the population and because we took an oath to do what’s best for our patients

Rob Cantor, EM PGY3:  “Opiate Abuse and the Heroin Epidemic”

  • Opioid abuse is becoming an epidemic issue affecting our city, state and country.  Americans comprise <5% of the world’s population yet we consume ~80% of the world’s opioid supply.  120 people die in the U.S. every day from an opioid drug overdose.
  • Opioid abuse does not discriminate.  It affects all socioeconomic classes and ages, and being unemployed/homeless are not good predictors of abuse.
  • Recent increased restrictions on opioid prescribing has had several unintended consequences.  This includes a worsening heroin epidemic as well as HIV outbreaks in select communities as a result of increased intravenous drug abuse.
  • Senate Bill 406 (SB406), if passed, would allow physicians to prescribe Naloxone OTC without examining the patient for whom the drug is intended.  It would also allow for family/friends/first responders to administer this medication to individuals experiencing an expected opioid-related overdose.  We support passage of this bill which, when used in conjunction with current 911 Good Samaritan laws, can help save lives.
  • We have several goals looking towards the future.  We request continued support for state-side databases such as INSPECT.  We need additional funding for addictions counselors and facilities across the state.  We need improved resources and treatment options for individuals with mental health.  Our vision is to better identify patients who have a high risk of opioid abuse/addiction/overdose so that they can be treated appropriately either in chronic pain programs, with addiction specialists, or in various opioid clinics around the state.

David Hillhouse, EM PGY3:  “Malpractice and Increasing Residency Positions”

  • 1/4 of our residents choose to stay in IN
  • Opening up more residency spots will also keep good physicians in IN
  • A big reason residents choose to stay is because the malpractice laws are favorable (medical review board especially)
  • Maintaining the malpractice environment will keep physicians from leaving and will encourage more new physicians to come to IN

The following residents attended Legislative Day to meet their legislators and support their colleagues: Kailyn Kahre-Sights, Alex Rhea, Kara Reynolds, Beth Beard, Kyra Reed, and Dan Elliot.  Thanks also to Dr. Frank Messina, (Staff Emergency Medicine MD at Eskenazi), who was in attendance and reflected, “I think that it is important that we be involved at the level decisions are made.”

Legislative Day 2

Thank you to Dr. Emily Fitz and Dr. Lindsay Weaver for organizing a successful Legislative Day, and also to everyone for your participation and for representing Emergency Medicine in Indiana!

Submitted by Kyra Reed, PGY-3 EM/Pediatrics

Advocacy Workshop: Death and Dying in the ED

“There is a dignity in dying that doctors should not dare to deny.” – Unknown

Palliative Care Workshop 1

How do you respond when a family member pleas, “do everything”, for a dying patient?  What do you do for a patient with profound dyspnea at the end of life?  Did you know that hospice bereavement services are available to families of deceased patients even if the patient was never in hospice?

In February 2015, the Advocacy Track hosted a Palliative Care Workshop led by Dr. Lindsay Weaver, Assistant Professor of Clinical Emergency Medicine and Palliative Care Medicine. There was a tremendous turn out for the workshop, and included representation from multiple hospitals and a wide variety of specialties/fields – RNs, faculty/resident EM MDs, NPs, SWs, CMs, CNAs, hospice representatives, and palliative care experts.

A few of the critical topics related to death and dying in the ED were covered, including:

  • Withdrawal and end of life of care in the ED
  • Code status discussions in the ED
  • Hospice resources/information
  • Discussing the results of the palliative care needs assessment
  • Aiding in the development of an action plan for end of life care in our EDs

Why is this discussion so important, and how does it relate to emergency medicine?  

As Dr. Weaver aptly stated in her powerpoint, “The Emergency Department is the safety net for the acutely and chronically seriously ill. As the population ages, ED visits for crisis events in the setting of serious, chronic illness are likely to increase. Initiating end of life conversations in the ED allow for a more patient centered, quality of life centered focus that may save the patient from unwanted procedures, avoidance of unnecessary admissions, integration into resources such as palliative care sooner, and decreased overall cost to patients and families that does not ultimately improve end of life care.

Palliative Care Workshop 3

Individual patient cases were discussed in small groups, each illuminating key points in caring for patients at the end of life. The overwhelming theme was communication. Taking the time to discuss options with patients and families with the other team members (RNs, CMs, SWs) can prove to be the major factor in providing optimal care. The consensus was that we should start these conversations in the ED, because what we do has a snowball effect for the patient’s management/testing/procedures in the hospital.

What limitations or barriers exist to limit our ability as providers to achieve this in the ED?

  • Common responses include TIME. Conversations about end of life take time, and this can be a limited commodity in the ED during a bustling shift. However, sharing with your colleagues in the department that you are going to have a conversation with a family is OK. Some thoughts were to have secretaries hold pages for 10 minutes during this time, and to make a call-back list when you are finished. We often do not like to ask for help, but in some situations, this can prove to be the difference between intubation, central lines, arterial lines, vasopressors, and a week or more on the ventilator, when perhaps all the patient or family really wants is the option to go home with hospice or focus primarily on pain control and do it well.
  • Another concern was provider/RN comfort and perceived time required in providing medications for comfort. There seems to be a educational gap regarding goals of comfort measures in the department, because it is not performed often.
  • Furthemore, lack of documentation and medico-legal concerns are another factor.

Solutions we discussed to improve Palliative Care in the ED:

  • Creating an order set for withdrawal of care/comfort measures in the ED
  • Identifying a quiet place in the ED to provide comfort care and/or arrange services, for example, the observation unit
  • A bereavement resource basket filled with information for families who have a loved one pass in the ED
  • Resource handout available in the ED for easy reference for providers
  • Educating staff/residents/RNs/ancillary staff on medications used for comfort measures
  • Carrying out discussions and plan of care in the presence of the entire team, if possible, including MDs, RNs, chaplain, SW/CM to ensure communication is consistent
  • Holding pages from secretaries and asking fellow ED colleagues for help while you have this important conversation uninterrupted

Some of the above solutions are actively being implemented in the Methodist ED, and other sites are also being considered.

A sincere thank you to everyone who participated in this important conversation, particularly to our guest speakers, our resident leaders Amber Fouts (EM PGY-2) and Anar Desai (EM PGY-3), and to our faculty leader/presenter, Dr. Lindsay Weaver.

Submitted by: Kyra Reed, PGY-3 EM/Pediatrics