Articles

Click here to view the PDF of the newsletter. All source links are included in the PDF version.

In This Issue:

• Where is the Public and the Health in Drug Policies?
• CalACEP an Ally for Independent Emergency Doctors
• A collision of epidemics: Coronavirus disrupts addiction
• treatment
• Lev Featured on Episode of Frontline Podcast
• Fenton Receives ACEP Meritorious Service Award

Where is the Public and the Health in Drug Policies?
Roneet Lev, MD
President, IEPC

The original article was published  as “Good public health policies comes at the cost of an individual’s convenience. I see it in the ER,” on December 4, 2020 by the San Diego Union-Tribune. Reprinted with permission.

The emergency department is often the place one sees the carnage at the other end of failed policies. We see that with COVID-19, traffic collisions, and drugs.

Public health means caring about the overall health of a population. The CDC definition of public health is “the science of protecting and improving the health of people and their communities.” Public health policies calculate and balance individual behavior and preference, economics, and the benefit for the community at large.

Sometimes good public health policies come at the cost of an individual’s convenience. A classic example of such a health policy is wearing masks to prevent the spread of COVID-19. Who likes wearing a mask? I don’t. It hurts my face. I have a near-permanent red scar on the bridge of my nose for wearing it hours at a time at work and outside.  The discomfort is worth it, because masks wore when in close contact with others prevents the spread of COVID-19.  Masks are annoying for the individual, but the sacrifice is a wise public health policy.

Another example of a successful public health measure is seat belts. My first car was an orange 1972 Volkswagen Beetle that came with a useless lap belt that was way too big for me.  I recall the debate by people who did not like the restrictions of seatbelts and claimed that mandatory seatbelts violated their freedom and constitutional rights. According to the National Highway Traffic Safety Administration, in 1990, only 50% of Americans wore seatbelts. Now seatbelts are a habit most people don’t even think about.  Today, 90% of people buckle up. This public health policy saved 15,000 lives in 2016 and would have saved 2,500 more if everyone complied.  

Today motorcyclists still complain that helmets cause headaches, tunnel vision, and “it’s nobody’s business if I want to feel the wind in my hair.”  In the emergency departments and trauma centers, motorcycles accidents had an association of brain death injuries resulting in organ donation. Helmet laws changed that.  In 2016, helmets saved 1,859 motorcyclists’ lives and 802 more lives could have been saved if all motorcyclists had worn helmets. I would argue that it has proven to be a worthwhile inconvenience.

American innovation, regulation, and focus on traffic safety continues to save lives. Traffic fatalities peaked in 1937 with 30.8 deaths per 100,000 population. The most recent data from 2018 is 11.17 deaths per 100,000.  This improvement of over 60% occurred despite a marked increase in total miles driven and number of cars on the road. Improved traffic safety was no accident. This remains a major focus on multiple levels. Individuals made sacrifices by wearing seatbelts and helmets. The automotive industry introduced advanced engineering such as airbags, electronic stability, backup cameras and blind spot detection. Government worked on improved roads and traffic laws.

I am jealous of the efforts for car safety. We desperately need the same multi-disciplinary approach for drugs and addiction. Sadly, wise public health decisions are getting pushed aside for economic benefit and the call for individual freedom. For example, electronic cigarettes hit the market without appropriate public health consideration. The industry used an untested health claim that vaping helps tobacco cessation to promote their products. However, epidemiologic studies show that for every one adult who quits cigarettes using e-cigarettes, 80 adolescents who never smoked will eventually become daily smokers through e-cigarette use. We may have forgotten that just before the COVID-19 pandemic we were dealing with a vaping epidemic that caused severe lung injury known as EVALI – E-Cig Associated Lung Injury. As an emergency and addiction physician I feel for those addicted to nicotine and would offer treatment. However, if we followed the science and cared about public health, vaping products would never have come to market in the United States.

Similarly, marijuana legalization, both medically and recreationally is driven by economics and individual freedoms, rather than public health consequences. Public health consideration would account for the total associated increase drug use, increase emergency visits, and the various medical complications. I do not wish to judge or shame people who choose to use marijuana, but I strongly believe that the public has the right to informed decisions. People who smoke cigarettes understand the risks of addiction, cancer, emphysema and heart disease. People who use marijuana are sold on the multiple benefits without education on drug interactions with prescription medications, high potency psychosis and suicide, testicular cancer, pulmonary or heart risk.  California declared marijuana an important business during a pulmonary pandemic. This public health decision continues to bring marijuana toxicity patients to the emergency department with diagnoses such as psychosis, agitation, EVALI, scromiting (cannabis hyperemesis syndrome), and fainting.

San Diego leads the county with one of the best trauma systems in the world. Saving a trauma patient can require a blood transfusion, but for the bleeding to stop, the hole needs to be plugged. Many lives have been saved not just through blood, but with advanced surgical techniques that plug the bleeding hole. Similarly, saving a patient with a substance use disorder needs addiction treatment, like the critical blood transfusion for the trauma patient. The bleeding hole for addiction needs to be plugged by decreasing the supply of drugs as well as treatment of overdoses, withdrawal and poisoning. But that is not enough. Benjamin Franklin said an ounce of prevention is worth a pound of cure. It is estimated that for every $1 spent on addiction prevention, there is $18 in savings. Addiction prevention is the seatbelts, helmets, and traffic laws for the trauma centers. Addiction prevention means preventing any addictive substance use while the brain is growing. Brain development continues until age 25 or 27. The chances of addiction for someone under this age is 4 – 7 times higher than for older people. Policies that promote increase marijuana and drug use along with the normalization of drugs, sacrifice our youth and therefore our future for the benefit of the individual. We need strong public health consideration when it comes to drug policy.

CalACEP an Ally for Independent Emergency Doctors
Michael Gertz, MD
Antelope Valley Hospital and
Los Robles Hospital Medical Center

The California Chapter of the American College of Emergency Physicians (CalACEP) is the largest state chapter in the country with over 3500 members. CalACEP’s mission is to support emergency physicians in providing the highest quality of care to all patients and to their communities. It supports Emergency Physicians primarily through legislative advocacy but additionally provides clinical tools such as The Safe Prescribing toolkits and Medication assisted Therapy (MAT) toolkits. CalACEP sponsors the Western Journal of Emergency Medicine and an annual Conference called AdvaneED which targets the education of Residents and Medical Students.

While last year was primarily consumed by the challenges of Covid19, the legislature continued to work and CalACEP remained active in both supporting and opposing multiple measures. The quarantine made lobbying particularly challenging in that our normal avenues for accessing legislators was impeded allowing politicians to fast-track a number of laws without much input from interest groups. There were, however, some successes as well.

AB 890 better known as the Nurse Practitioner Scope of Practice Law allows NPs to practice independently without physician supervision once they have a predetermined level of experience. It was intended to aid in the primary care shortage but the law could impact Emergency Physicians by not specifying that independent practice is limited to primary care. CalACEP opposed this as a patient safety issue and sought an exclusion for the Emergency department. Unfortunately the Governor signed this into law and we will need to work to clean up the law with an exclusion this year. We were successful in passing our sponsored bill AB1544 which expands paramedic scope of practice to allow certain 911 patients to be diverted to Licensed Psychiatric facilities and sobering centers. We were opposed to similar bills in the past because they did not provide sufficient oversight over the receiving facilities. This law requires licensing of facilities, support of EMTALA mandates and evidence based practices to determine protocols. We were also successful in protecting the $20 million state grant that pays for Substance abuse councilors to be placed in Emergency departments.

This years priorities will include a reintroduction of a CalACEP sponsored bill tabled by the legislature last year to require all acute care psychiatric facilities to accept patients with psychiatric emergencies transferred from emergency departments regardless of insurance status. We will also be focusing on legislation to address systematic downcoding by insurance companies. We will likely have to defend another attack on MICRA this coming year as well.

CalACEP is the primary advocacy group for Emergency Physicians in California. The Board of Directors and staff work tirelessly to make sure our practice environments remain financially viable, continue to be able to deliver high quality care and that emergency physicians are the recognized leaders of an emergency response system. Please consider lending your experience and expertise by serving on one of its committees or running for the Board of Directors. Independent practice physicians have so much to offer and gain from the experience.

A collision of epidemics: Coronavirus disrupts addiction treatment

By Rachel Baker
Original article was published June 16, 2020 via CalMatters.

Breanna Dixon doesn’t remember struggling to breathe when she overdosed, but her younger brother Joshua hasn’t forgotten the sound.

At first, it sounded like heavy snoring coming from the TV room in the Dixon family home in Fontana, where the siblings were sheltering in place with their parents.

It had been a month since the novel coronavirus forced California to a standstill, and Dixon, 28, was struggling. She had already overdosed twice before in the two years she had used opioids. Stuck at home with her family and a soon-to-be-ex-boyfriend, she found herself using more than ever.

While other people were hoarding water and toilet paper, Dixon stocked up on oxycodone pills that turned out to be tainted with fentanyl, a dangerous, potent opioid.

“The stress of not knowing what’s going to happen in the world, and then on top of that having to deal with the little things inside my home,” she said. “I needed to cope with a lot of things, because I felt like I couldn’t fix it … and I felt like I already hurt my family so much.”

That night in April, Joshua Dixon, 23, could tell something was off with his sister, who pivoted from jittery to groggy. So at 4 a.m., when he heard what he thought was loud snoring, he checked on her.

He found her sitting up, her head drooping forward onto her chest.

“I looked closer, and I was like, okay that’s not snoring — so I kind of snapped into panic mode … started shaking her on the shoulder, like, ‘Wake up!’” Joshua Dixon said. “She wasn’t waking up.”

He called an ambulance, and Breanna’s ex-boyfriend stayed on the phone with the 911 operator until the paramedics arrived with naloxone, a drug that can reverse overdoses.

But the night wasn’t over: About an hour later, Joshua Dixon found his sister’s ex-boyfriend crumpled in the backyard. He had overdosed, too.

A “collision of epidemics”

It’s a crisis that mental health experts worry they’ll see more often as people turn to illicit drugs to cope with the stressors of the pandemic. This “collision of epidemics” could magnify the dangers of both, according to warnings reverberating from scientific journals.

While the number of Californians killed by the coronavirus is tallied daily on public dashboards, its effect on illicit methamphetamine and opioid use is harder to track. Whether more people statewide are relapsing or overdosing is unclear.

But several local health departments in California as well as emergency rooms participating in a statewide treatment effort are seeing signs that fewer people addicted to drugs are receiving treatment since the pandemic reached California. The Public Health Institute’s CA Bridge Program reported 35% fewer people with opioid addictions in emergency rooms, dosed nearly 48% fewer people with medication to treat withdrawal and recorded 24% fewer people attending follow-up appointments, comparing April to January.

Experts worry that more people will fall through the cracks as the pandemic continues. And without increased state funding, budget cuts could hamstring their capacity to help.

“Fewer people are seeking treatment for services during this time period, but an increase in relapses has been noted for those who are involved in treatment,” said Jeffrey Nagel, director of Orange County’s Behavioral Health Services, which monitors trends at treatment providers.

The nation has seen it before: During previous economic downturns, more people died from opioid overdoses, but fewer people entered treatment for heroin addictions.

“There’s likely much more use of substances that we’re not capturing right now, either in hospitals or emergency rooms or jails,” said Gary Tsai, interim director of Los Angeles County’s division of Substance Abuse Prevention and Control. “There is a lot of concern that pent-up cases will materialize once our communities reopen. I think that’s a very real risk.”

The toll of opioids has been increasing in California over the past two decades. More than 4,386 people died from drug overdoses during the first nine months of 2019, about half from opioids, according to the state’s preliminary count. 

It’s too soon to know whether more Californians are overdosing since the pandemic began.

Fresno has seen a surge in suspected overdose deaths, although the exact numbers are unavailable, said Rais Vohra, the county’s interim health officer. Many other coroner’s offices said there are too many bodies awaiting toxicological tests to identify any pattern. “I really think this is the tip of a bigger iceberg,” Vohra said.

“Feeling irrelevant” in the time of COVID

The “collision of epidemics” endangers people who use drugs on multiple fronts. They face increased risks from respiratory infections if smoking and vaping drugs has damaged their lungs or if opioids suppress their breathing.

But the virus’s social-distancing measures also tear the fabric of medical care and social support for people who use drugs, Nora Volkow, director of the National Institute on Drug Abuse wrote in a recent paper.

“Feeling irrelevant, feeling that no one cares for you, is probably one of the most devastating feelings a human being can have,” Volkow said in a recorded videoconference. It can “increase dramatically the risk of taking drugs, and, if you are trying to stop taking drugs, it increases that risk of relapse.”

Weeks before Breanna Dixon overdosed in Fontana, Crystal Acosta in Oakland said she was thinking of quitting drugs, and 60-year-old William Smith was relapsing in Los Angeles.

Acosta, 33, who first took heroin when she was 11, lived in a tent with her partner as the pandemic intensified. She fears what she’ll do if drugs become scarce, struggles to stay safe on the streets and worries about their son, who lives with his grandfather.

“When you do heroin, you get sick and it’s bad when you don’t have those drugs,” she said. “I’ve been thinking about getting clean, just to not have to deal with that.”

Acosta said she had been treated with methadone, which can help reduce cravings and symptoms of withdrawal. But it was expensive to travel to a clinic on the bus, so she stopped going.

Some 370 miles to the south, in Los Angeles, the pandemic kicked off a chain reaction that led Smith, a former cast member on the TV show Celebrity Rehab, to relapse.

Smith said he’d been in show business for years and worked for a drug cartel, but first tried heroin when he was incarcerated in Chino. He had been in recovery on and off for about 20 years when the coronavirus began creeping into California.

He was working as a caregiver, but the job was coming to an end, and with it, his housing.

With his future uncertain, he relied on Narcotics Anonymous meetings to keep sober. “Worst thing I can be is bored and by myself,” he said. “That’s when you jump up and go to a meeting, and you start listening to people’s woes and problems … It’s camaraderie, and friendship.”

But the pandemic forced his meetings online, and he ran out of cell phone data for Skype. His prescription for a medication that curbs opioid cravings and blunts the high tapped out. “For a couple days, you’re okay,” he said.

And then, he wasn’t. He started smoking heroin and methamphetamine again. “I felt terrible, I knew that’s not the way I wanted to be,” Smith said. “And I knew the way to get back.”

New cracks in the road to treatment

Dr. Reb Close, an emergency medicine physician at Community Hospital of the Monterey Peninsula, is trying to track the number of people like Dixon, Smith and Acosta whose drug use has changed with the pandemic.

Typically her department’s record system alerts her to one overdose roughly every three days. (It’s not the total, more of a preliminary snapshot.) But in May, alerts surged to an overdose a day, she said.

“You’ve got the experimenters,” Close said, recalling a teen boy who overdosed on what was likely an opioid. His mother started CPR until the cops arrived with naloxone, which can reverse overdoses. The boy later told Close he’d tried the drug because he was bored sheltering at home.

By Close’s count, three of 22 people who overdosed in March said their drug use was related to the virus. In April, it was seven out of 16. She hasn’t crunched numbers for May yet.

“You’ve got your substance use fragility of recovery,” Close said. And, with the pandemic, she said, “You have the fear, the hopelessness, the desperation.”

Smith knew where to go when he relapsed. His friend helped him find a bed at Tarzana Treatment Centers.

“I really didn’t think they’d have Tarzana or any of these big treatment centers still open,” he said. “A lot of people would have died if they didn’t have Tarzana.”

The number of people seeking treatment at Tarzana increased from 2019 to 2020, and the centers have been racing to add beds to meet demand. 

But since the beginning of this year, the number of people seeking care has dropped monthly.

It’s difficult to separate the effects of the pandemic from seasonal trends, since people seeking treatment typically spikes in January and February, said Jim Sorg, Tarzana Treatment Centers’ director of care integration.

But patients’ fear of the virus could be a reason for the decline. Smith was “a little scared to get around other people, of course, and I didn’t know how they would manage to keep us safe. I had to see it for myself.”

What he saw were mask requirements, constant cleaning, multiple temperature checks per day, no outside meetings or visitors and as much social-distancing as possible. 

Smith said that the changes haven’t hurt his recovery — they may have even helped.

“The fight against COVID is like the fight against addiction, so one hand just clasping the other,” he said. “It’s watching out for your neighbor, so your mind is constantly on something that’s positive.”

Officials in some counties with historically high numbers of overdose deaths report declines in people seeking or being admitted to treatment this year. Included are Sacramento, Santa Clara, Orange, San Diego, Riverside and Alameda counties. San Bernardino also saw an initial drop, although the numbers began increasing in May.

Part of the reason could be that federal rules have changed during the pandemic to allow people to take home more methadone at a time, which means fewer visits tallied at clinics. One woman told CalMatters that it made getting her medication much easier.  

Some people may also not be accessing outpatient services due to closures or fewer referrals, including from courts and schools. Some residential programs are limiting admissions to maximize social distancing, and a shift to telehealth could have lost those who lack access to a phone or the internet.

“Generally speaking, lockdown equals lack of access to critical services,” said Nevada County’s Behavioral Health Director Phebe Bell. “What we’re seeing is that people continued to be fearful of in-person services, but needed help with their substance use.”

In some areas, people are seeking more treatment from addiction medications. San Francisco’s street medicine team reports writing two to three times more prescriptions than usual, while Los Angeles, Nevada County and a major Santa Clara County hospital also reported increased demand. Bell suspects that medication, which requires little in-person interaction, may feel like the safest option during a pandemic.

A worrying precedent during a recession

The picture of how the coronavirus will affect Californians addicted to drugs is still developing — but history can help bring it into focus.

One study led by Temple University economist Catherine Maclean reported that during economic downturns, treatment admissions for stimulants increased by almost 8% for every one percentage point increase in state unemployment. But for heroin, they dropped 6%.

Previous research showed an increase in opioid-related deaths and emergency department visits in economic slowdowns.

Combined, Maclean said the results suggest an increased unmet need for treatment — particularly for opioid addictions — during recessions.

The gap between need for treatment and access to it worries Aimee Moulin, an emergency medicine physician at the University of California Davis Medical Center.

The CA Bridge Program, where Moulin is a principle investigator, aims to close that gap. Patients at 50-plus hospitals who are addicted to opioids are immediately treated with buprenorphine, a medication to ease symptoms and cravings, and are connected with ongoing care. Over the past year, the program offered buprenorphine to 9,666 patients, and treated 6,207.

“Now we see people coming back — they couldn’t get their treatment appointment. There’s a lot of delays, a harder time getting medications,” Moulin said. “If it was a struggle before, it is so much more exacerbated by closing down or pulling back on a lot of those resources.”

Breanna Dixon is one of the people who could have benefited from the CA Bridge Program.

The night she overdosed, an ambulance took her to a hospital. But eight hours later, she was back at home, sweating and crying on her mother’s couch. “I was withdrawing … I could feel it, so I was just like, ‘I’m going to use again,’ ” she said.

The period after being discharged from the emergency room is a dangerous one. A recent study reported that in the year after an opioid overdose, people are 100 times more likely to overdose again and die. Their likelihood of dying by suicide also increases 18-fold.

She searched for treatment programs that would take MediCal. It took her days to find a hospital where she could detox. The whole time, she said, her mother Jeannette Dixon kept telling her, “‘Just keep looking, keep looking.’”

Now she is in transitional housing after completing residential treatment.

“I miss her very much, but I know that this is good for her. She needs it,” said Jeanette Dixon, who has been in recovery herself for a crystal meth addiction since 2012. “Because who gets a third time — you know what I mean? She’s blessed.”

The state’s budget and crises collide

As the pandemic continues, treatment services are at risk of losing government funding.

Last year’s budget included $20 million to fund behavioral health counselors for hospitals. But California Gov. Gavin Newsom’s May budget revision scrapped it. The Legislature has proposed restoring it, but negotiations are ongoing.

In April, county behavioral health directors and 17 other groups sent a letter to the state Legislature seeking a hearing and emergency funding. So far, neither has happened. 

Michelle Cabrera, executive director of the County Behavioral Health Directors Association,  predicts a billion-dollar shortfall for counties’ behavioral health programs by next summer, at the same time as the number of people who depend on them is projected to swell.

The Legislature has proposed chipping in $1 billion for counties but $600 million is contingent on receiving federal money. Cabrera estimated that only $230 million would trickle down to behavioral health programs.

“It’s not going to be enough to stave off some of the harder decisions we’re going to have to make,” Cabrera said. “We’re leaving humans in the lurch.”

“We’re people too. We’re not just addicts.”

In the meantime, in Oakland, Crystal Acosta is already falling through the cracks. In April, she talked about the pandemic as a reason to get clean. Two months later, she said she was smoking twice as much heroin as before. Living without shelter amplifies the problem.

“We’re people too. We’re not just addicts,” Acosta said in April. “All of us have no help, or places like a house. And we’d be doing a lot better if we did.”

Alameda County is trying to address homelessness and addiction with counselors at some of the hotels set up for people during the pandemic.

For Acosta, though, it hasn’t helped. She spent weeks in a hotel but now is back on the streets. Her partner received an offer of housing, Acosta said, but turned it down because there wasn’t space for her. Now, they crash at friends’ places or walk all night, smoking heroin.

“It helps me relax to the point where I’m OK to deal with all of it,” she said.

After her disappointment about being homeless again, she’s less interested in seeking treatment. “If they’re not even willing to help me,” she said, “what’s the point?”

Lev Featured on Episode of Frontline Podcast

Cassie Chinn,
IEPC Communications Director

Hosted by Dr. Ryan Stanton, the official podcast of the American College of Emergency Physcians welcomed IEPC President Dr. Roneet Lev to discuss her tenure with the Office of National Drug Control Policy (ONDCP).

Ryan Stanton: How did you go from emergency medicine to working with the White House?

Roneet Lev: Through activity really through ACEP. I’ve always been active in medicine. We wear our white coat in the hospital but wear our white hat outside the hospital to really advocate for our patients and profession. I got involved in our local community. After serving as president for CalACEP I decided to use my time advocating locally. One day I was asked to do a presentation about why doctors are giving so many drugs to people. I went there and explained that people demand it! “Doc, what are you going to do for my pain?” We were taught to treat pain.

I met this community that I never would have been exposed to (in the ER) with these parents whose children died from these drugs we were prescribing. So, when I was confronted by other doctors who accused me of not being compassionate because they were prescribing more drugs to their patients, I was seeing the other side. I was meeting with the medical examiner and meeting with parents realizing that there was a problem. I became very active in established programs in San Diego in safe prescribing. I helped communities establish coalitions both locally and across the country. I thought, “If I was in charge, I could fix the world or end this epidemic. Just give me a few years and I could get it done.” They say be careful what you wish for because you may get it.

On one occasion I invited the director of the ONDCP James Carroll to come down to SD to see my emergency room to see what we have to deal with. He called me later that evening and took me up on my offer (to end the epidemic) and hired me as the Chief Medical Officer of the ONDCP.

Fenton Receives ACEP Meritorious Service Award

Walter T. Edwards Meritorious Service Award
Given by CalACEP at AdvancED 2020 to Dr. Andrew Fenton.

The Chapter’s highest honor, this award is given to a Chapter leader who, like Dr. Edwards, has distinguished themselves among their peers in the Chapter as demonstrating the highest commitment to emergency medicine and the Chapter, and who has made contributions to the Chapter that have significantly shaped its mission, vision, objectives or priorities.

Dr. Fenton’s years of service to the Chapter including one year as one of the Chapter’s first advocacy fellows, eight years on the Board Directors, and one year as President. During his time on the Board and as President, he brought a heightened awareness to the issue of firearm injury

prevention, ushering in CalACEP’s Firearm Policy in 2016. This was before many were comfortable taking a position on firearms, but Dr. Fenton believed a science-based approach to firearm violence prevention was the right thing to do to save lives. He also championed other public health issues including drug overdose prevention and pediatric trauma care. Even after his presidency, Dr. Fenton has been an active champion of emergency medicine and CalACEP and his leadership has had a profound impact on the organization and the patients of California.

Click here to view the PDF of the newsletter.

In This Issue:

• Building a telehealth program in the Emergency Department during COVID-19
• COVID-19 Testing in the Coachella Valley
• Congress Must Pass MAT Act to Save Lives
• Add Fentanyl to your Toxicology Screen
• IEPC Members respond to Legislative Call to Action
• Podcast: ACEP Frontline
• Emergency Care at Risk

Building a telehealth program in the Emergency Department during COVID-19

Casey Grover, MD
Community Hospital of the Monterey Peninsula, Monterey, CA

In March 2020, as COVID-19 rapidly began arriving in the United States, our Emergency Department was working diligently to develop pathways, policies, and procedures to deal with COVID-19. Everyone in our ED was helping to brainstorm; some of our doctors were focusing on airway management, others were focusing on how to avoid exposure at work. However, two of our docs, Dr. Michelle Krueger-Kalinski and Dr. Sameer Bakhda, saw the opportunity to integrate telemedicine into our Emergency Department during COVID-19, and ran with it.

Telemedicine, which is defined as “the remote diagnosis and treatment of patients by means of telecommunications technology”, has an extremely broad set of applications and ways in which it can be used. In our ED, over the last few months, we have created several different ways in which we can use it.

Step 1
We started in the simplest fashion, using telemedicine as “electronic PPE” (aka ePPE) to reduce the exposure of ED staff to patients with COVID-19 and to slow our burn rate of PPE. This was relatively easy to set up. An iPad was placed next to a patient in her/his room, and the ED provider would connect to the patient from her/his smartphone. This would allow for a video chat that allowed the ED provider to see the patient virtually. We started with this for ED providers that were on shift in the ED for patients in the ED – and if there were any issues with the technology, we could easily just put on PPE and go see the patient in person or talk to the person by phone. We started by using the platform Doxy.me – which allowed free, secure, HIPAA compliant video chat.

Step 2
As we gained some experience seeing ED patients while on shift with confirmed or suspected COVID-19 patients via telemedicine, Drs. Krueger-Kalinski and Bakhda took us to the next level with telemedicine: having providers at home see patients in the ED via telemedicine. As we learned about the potential for long quarantines for providers exposed to COVID, we realized we needed to allow docs who couldn’t come in to the ED still help move patients in the ED. Using the same platform, we trialed doctors at home logging into our EHR (EPIC), and signing up for patients with confirmed or suspected COVID. The doctor at home would see the ED patient via telemedicine, ordering tests as needed, and providing the patient with her/his results and discharge instructions via telemedicine. This, obviously, only works with patients who are not seriously ill. Additionally, this has the potential for managing surges in the ED during COVID-19. If we get 15 check-ins in an hour, it would be easy to have a provider at home log in and function as a provider in triage – in a LEAN just-in-time fashion – to get orders started and patients seen via telemedicine.

Step 3
Our ED experienced the nationwide trend in late March and April of record low numbers of patients checking in to our ED. Patients were afraid to come to the ED, and we were seeing very sad cases of people getting really sick by delaying their presentation to medical care. Drs. Krueger-Kalinski and Bakhda took this on as well, developing an ED telehealth follow-up program for our ED. When patients came to the ED and needed subsequent care – such as a wound check for a cat bite to make sure oral antibiotics were working – we developed a pathway to see the patients in follow-up after their ED visit via telemedicine. We worked with our IT team, our Patient Access (registration), and our ED leadership to create this pathway.

Here’s the basic summary:

• ED provider identifies a patient who needs follow-up during an ED visit
• ED provider offers the patient options for follow-up, including ED telemedicine follow-up
• If the patient chooses ED telemedicine follow-up, the ED provider works with ED practice coordinator to set up a follow-up time for the patient
• Patient is registered by Patient Access on the day of the follow-up visit as a “ED TELEHEALTH” patient that shows up in a separate track board on EPIC
• ED provider, from home, logs in and signs up for the patients. She/he does a verbal consent with the patient, ensuring that the patient gives consent for treatment, consent for treatment via telehealth, and consent to bill insurance
• ED provider completes the telehealth follow-up visit, and writes note in EPIC

We’ve been very successful and innovative with these visits. We bought some pulse oximeters to give to patients, and have been seeing COVID+ patients after their ED visit to check their symptoms and pulse ox levels – making sure they are not deteriorating. We even were able to recheck a pediatric abdominal pain – having the parent palpate the abdomen and having the child jump up and down. When we surveyed our patients about their ED Telehealth follow-up visits – almost all of our visits were 5/5 stars – a huge win in getting patients the follow-up care that they need while providing care that patients like and feel has value

Lessons Learned
Having worked through building these various telemedicine pathways for our ED, we’ve found a few major pitfalls. First, not everyone is “technologically gifted”. In Step 1, with patients and providers both on site in the ED, this allowed us to have other people around to help troubleshoot the technology, and the patient could be seen in person as a backup. If I was working and Dr. Smith was having issues with his Doxy.me account, I was happy to help him get it working. When choosing to expand to Step 2 and 3, it’s important that providers and patients both be comfortable using technology to avoid failed telemedicine visits. Second, for providers working from home – it’s important to ensure that patients feel that the encounter is professional. Seeing patients in your pajamas with your child bugging you the whole time is not going to work. Wear professional attire and find a background for your telemedicine encounter that looks clean and professional. Third, keep the telemedicine encounters simple. We initially tried to set up Bluetooth otoscopes and stethoscopes for a nurse to use to examine the patient – and send information to us electronically, only to find that it was a lot of technical work with little change in patient care. Finally, poor video and/or audio quality makes connecting with patients via telemedicine very difficult. Make sure that both the providers and patients have good access to a strong Wi-Fi signal. You can also try some different platforms for telehealth – our providers have used video chat platforms from Doxy.me and Doximity with good success.

COVID-19 Testing In the Coachella Valley

Ian Kramer, IEPC Physician, retired

As a volunteer physician in the Coachella Valley, I have participated in a COVID-19 testing program that has been funded by a local Palm Springs artist and spear-headed by our US Congressman, Dr. Raul Ruiz. Dr Ruiz and I are both emergency physicians and work with the Coachella Valley Volunteers in Medicine at our Free Clinic and Street Medicine program.

We tested three separate groups for COVID between late April and May 2020.  The initial group was farmworkers in Mecca and a small number of their family members.  We had 4 positives out of 125 tests for a rate of 3%. Our second group was our unsheltered homeless population in La Quinta Indio Thermal and Coachella. We tested 50 and had zero positives for a rate of 0%. Our final group was a combination of some farmworkers and mostly residents of Thermal. Out of 175 tests there were 14 positives for a rate of 8%. The farmworkers of Thermal had a much higher positive COVID rate than the unsheltered or farmworkers of Mecca.

It is noteworthy that the temperatures in the Coachella Valley have been in the low 100s and these people work or live outside during the day while the homeless are in tents but not sheltered.  The lower incidence of disease may be due to factors such as weather, some moderate social distancing, and our efforts to provide masks sanitizers and education to the community, especially the unsheltered.  The Thermal group with a high 8% positive rate included larger families living in confined home likely leading to a higher incidence of disease. We intend to continue testing and monitoring our Coachella residents and will provide a future update.

Congress Must Pass the MAT Act to Save Lives

Roneet Lev, MD President, IEPC

A similar article was recently published in The Hill

Emergency physicians along with the majority of the house of medicine support the Mainstreaming Addiction Treatment Act (MAT), which supports expansion and removing barriers for medications that treat opioid addiction. We need to be able to prescribe medications without bureaucratic restrictions that create barriers for both patients and physicians and that perpetuate the stigma of addiction.

Tragically, the COVID-19 pandemic has increased drug and alcohol use and exacerbated the crisis of addiction in our country. I have intubated more patients with a fentanyl overdose than from coronavirus. If there were a single public health policy that should be endorsed to save the lives of people who struggle with addiction, it would be this act. 

The MAT Act will alleviate a serious barrier to treatment of patients who have an opioid use disorder — the Drug Enforcement Administration’s “X waiver.” The waiver prevents physicians from prescribing medications for opioid use disorder (MOUD), such as buprenorphine, without completing an eight-hour course, or a 24-hour course for nurse practitioners and physician assistants. I have treated patients with opioid withdrawal who went to three or four different clinics or emergency departments to find someone who can prescribe MOUD. They were the lucky ones. Many parts of the country have absolutely nowhere to go for treatment. There is no precedence in the medical world for requiring eight or 24 hours of education before prescribing a single medication. Can you imagine creating such a barrier to prescribing insulin or a new treatment for COVID-19? 

There are countless physicians who do not find value in a mandated eight-hour course to prescribe a single drug. As someone who has taken the time to take the long course, I don’t blame them — medical providers are spending time keeping up with changing coronavirus treatment recommendations. Furthermore, adding “extra” and a “different” medical standard for treating addiction perpetuates stigma for people who suffer and furthers a false divide between medical health and addiction health. 

The historic reasons behind the DEA X waiver regulation stems back to the 1914 Harrison Anti Narcotic Act. This was a time when opium addiction was a problem and the act prohibited doctors and pharmacists from prescribing opioids to people who were addicted to them. In 1974, when soldiers were returning from Vietnam with heroin addiction, Congress acted by allowing DEA to approve a special circumstance to using methadone for maintenance and detoxification of people with opioid use disorder. This opened up opioid treatment programs who used methadone under special DEA licensing and regulation. In 2000, as science and medicine progressed in terms of treating addiction with medication, Congress voted again to keep up with the time by passing the Drug Addiction Treatment Act, known as DATA 2000. This allowed providers to prescribe MOUD if they took the eight- to 24-hour course. It is time for congress to show compassion once again to people with opioid addiction and eliminate the outdated barriers that prevent physicians from prescribing life saving medications.

There are those who will claim that MOUD can be abused or diverted. They are correct. There are many drugs that are abused or diverted from Vicodin, Percocet to Xanax and Suboxone, to name a few. The DEA must continue their important work in preventing illegal activity, but they no longer need to add the X waiver barrier to enforce drug safety.  

An overwhelming majority of the house of medicine is behind the MAT Act, with few exceptions. There is an old saying “follow the money” – when looking at who is opposing the MAT Act. Over 20 organizations, including American Medical Association, the American College of Emergency Physicians, the Society of General Internal Medicine, The National Academy of Medicine Consensus Study Report and 22 state public health departments, have submitted letters of support for the MAT Act across the county. 

National experts state that MAT medications save lives, and yet the DEA X waiver remains a major roadblock in prescribing. We need congress to pass the MAT Act.

Add Fentanyl to your Toxicology Screen

Roneet Lev, MD President IEPC

This is a request for all emergency physicians and hospitalists to add fentanyl to your urine drug tests. Fentanyl overdoses are the opioid epidemic this year – more than prescriptions or heroin.  Please work with your labs to add a rapid fentanyl screen to your toxicology screen. The lab test is not as useful as a send out and frankly should now be part of your standard rapid drug test panel.

Why Add Fentanyl Urine Drug Screen?

• You can assist in a homicide investigation

            33-year-old female presented to the ED in cardiac arrest.  She was admitted to the ICU on life support.  Her differential diagnosis included of MI, PE, and even drug overdose. Her standard urine drug screen was positive for Cocaine, THC, but negative for opioids.  Later the local law enforcement overdose team revealed that the patient may have been a victim of homicide as there was a threat to kill her by slipping fentanyl into her drugs. A fentanyl test was added a few days after admission and was positive. However, she received fentanyl as part of her ICU medications. If only she had the fentanyl test done the first time….

• You can confirm your assumed diagnosis

            36-year-old man presented to the ED with altered mental status. He received 4 doses of naloxone in the field and 2 more in the ED. He was passed onto the next shift doctor with instructions of “MTF” – metabolize to freedom.  Urine tox screen was negative for opioids.  Fentanyl is a synthetic opioid that does not show up on regular opioid screens.  Fentanyl drug screen was negative too.  Alcohol level was 252.  He was just drunk and did not need naloxone, buprenorphine or opioid use disorder referral.

• You can save lives besides the one patient in front of you

            If you have a patient with COVID the county will do contact tracing to see who else is affected. If you have a patient with diarrhea that is traced to bad lettuce or onions, there will be contact tracing and alerts.  If you treatment a patient who overdosed on fentanyl, especially unintentionally, you should think about who else is getting poisoned or killed? Some counties in California are working with special law enforcement teams that do contact tracing for overdoses. They save lives. 

• You will learn and become a better doctor

            The mix of fentanyl and methamphetamine is a popular combination for agitated delirium. Patient may not have the classic pinpoint pupils and decreased respirations.  Patients may complain their feel “weird” after using methamphetamine. That may be because of the contamination of fentanyl without their knowledge. That knowledge will make them careful and even motivate them to seek treatment for their addiction. You will discover that 50% of cocaine and 25% of methamphetamine is contaminated with fentanyl. This data should lead you to prescribe naloxone for these patients.

IEPC Members Respond to Legislative Call to Action

Cassie Chinn, IEPC Communications Director

IEPC has requested members to join the call to action by an emergency physician on both state and federal legislation. It is important for all emergency physicians to be involved to protect your practice and your patients.

The American College of Emergency Physicians is urging members to contact their congressional representative to halt impending Medicare cuts. that could be a 6% cut to emergency physicians in 2021.

Learn more at ACEP Advocacy
Take action: Send a Letter

California ACEP and the California Medical Association is urging members to contact their congressional member to vote against AB 890. This bill will allow nurse practitioners to practice medicine without supervision. We love our NPs, but we also love our patients and loved ones and not willing to compromise on quality of medicine.

Learn more and take action: Send a Letter

Podcast: ACEP Frontline

COVID-19: A Physician Who Got COVID and Lived to Tell the Story
ACEP Frontline, hosted by Dr. Ryan Stanton, features in-depth conversations on the hottest topics in emergency medicine and critical care.
In this episode, Dr. Daniel Lewis discusses his experience actually having COVID-19.

Emergency Care at Risk

Physicians who are small business owners are at risk for extinction by big business consolidation.

Many emergency physicians are small business owners and not hospital or corporate employees. They live and work in the community and have a vested interest to promote the best emergency care for their family and friends. Hospital consolidations and large health insurance companies have threatened the small business practice for physicians who devote their lives to their patients and community.

Giving money to big corporations to distribute for emergency services means giving leverage and tipping the scale in favor of big business over small business emergency physicians. We at IEPC want to protect small business emergency doctors.

Independent Emergency Physicians Consortium, IEPC is a group of small business emergency department owners who collaborate for best practices for their patients and community. As small business owners we are more cost efficient by eliminating middle management, recruitment fees and large overhead expenses.

Read the full story here.