April 2017

SAN FRANCISCO MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M E D I CA L S O C I E T Y

EMERGENCY

MEDICINE IN SAN FRANCISCO DIVERSION THE CHRONIC CRISIS

OPIOID EPIDEMIC AND THE ED DISASTER RESPONSE TODAY AND TOMORROW

EMERGENCY PSYCHIATRY FROM INSIDE THE AMBULANCE

VOL.90 NO.3 April 2017

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IN THIS ISSUE

SAN FRANCISCO MEDICINE April 2017 Volume 90, Number 3

Emergency Medicine FEATURE ARTICLES

MONTHLY COLUMNS

10 Confronting the Emerging Crisis: The Status of Emergency

Medical Services in San Francisco

John Brown, MD

4

Membership Matters

7

President’s Message Man-Kit Leung, MD, and Peter Bretan, MD

12 A Pound of Prevention: Creating the Health Care Disaster

Response of Tomorrow

Naveena Bobba, MD, MPH 14 The View From Inside The Box: Understanding the Role of

EMS Providers

Joshua Smith, EMT-P 15 Supply, Demand, and Crisis: Emergency Department

Diversion of Ambulances in San Francisco

Christopher Colwell, MD

9

Editorial Gordon Fung, MD, PhD, and Steve Heilig, MPH

26 Medical Community News 30 Upcoming Events 30 Welcome New Members

18 The More Things Change, the More They Stay the Same

Marc A. Snyder, MD, FACEP

30 Classified Ads

20 Cardiopulmonary Resuscitation (CPR): An Update

Collin P. Quock, MD, FACC, FAHA

28 From the AMA: ACA Repeal and Replace

Bill Dies—What’s Next for Health Care?

19 Doing More With Less: Advances in Emergency Medicine

Corey Long, MD

22 Pain Without Gain: On The Opioid Epidemic

Hallam Gugelmann, MD, MPH

23 UCSF Benioff Children’s Hospital Emergency

Department at Mission Bay

Steven Bin, MD

OF INTEREST

SAN FRANCISCO

ADDICTION SUMMIT 5th Annual David E. Smith, MD Symposium

24 Emergency Psychiatry: Programs That Reduce Psychiatric

Patient Boarding and Improve Care

Scott Zeller, MD, and Jamie Cerny

Friday, June 9, 2017 8:30am - 5:30pm UCSF Laurel Heights Auditorium 3333 California Street, San Francisco Join us for an action-oriented forum with leading multidisciplinary faculty covering: • • • •

Editorial and Advertising Offices: San Francisco Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133 Phone: (415) 561-0850 Web: www.sfms.org

Opiates • Advances in addiction medicine Pain management and primary care Alcohol abuse • San Francisco problems and Tobacco responses, and more!

For more information, visit www.sfms.org or contact Steve Heilig at heilig@sfms.org Event co-sponsored by SFMS, SFDPH, CAFP, UCSF CME provided by CAFP

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members

Health Reform: Website will Help Patients, Physicians Take Action A recently-launched website launched makes it easier for patients and physicians to understand where the American Medical Association (AMA) stands on the health-system reform debate happening in Washington and gives them tools to take part in the effort to protect health care coverage for millions of Americans.

The site, Patientsbeforepolitics.org, colorfully delineates the nine objectives that will guide the AMA in its discussions regarding ongoing efforts to improve the nation’s health system. The Patientsbeforepolitics.org website makes it easy for patients and physicians to write their elected Congressional representatives and urge them to protect Americans’ access to quality care. In the weeks and months to come, the site will be updated to offer more ways to take action on this critical issue. The site will also offer interactive features such as a way for users to design their own health care proposal and gain an appreciation for the complexity of this area of policymaking.

In Landmark Victory, Court Strikes Down NRABacked Gag Rule on Doctors Discussing Guns

A federal appeals court struck down an NRA-backed Florida law that restricted doctors from talking to their patients about the risks of guns. The decision by the full panel of the United States Court of Appeals for the 11th Circuit in Atlanta is a victory for the Brady Center to Prevent Gun Violence and Ropes & Gray, who brought the lawsuit on behalf of doctors who believed the law violated their First Amendment rights. To read more, visit http://bit.ly/2n1fk2D.

Victory: Anthem-Cigna Merger Blocked by Court

In a significant win for organized medicine and the nation’s patients, federal judge Amy Berman Jackson blocked the proposed Anthem-Cigna merger. The judge found that the merger would have substantially lessened competition for the sale of health insurance to national employers resulting in higher prices and diminished prospects for innovation. The decision affirms the position urged by AMA and the 17-state medical association antitrust coalition members, particularly our partners in CA, CO, CT, GA, FL, IN, ME, MO, NY, OH, and VA. The AMA/coalition position was adopted in the plaintiffs’ complaint, and the judge rejected the insurers’ arguments that lowered physician reimbursement would benefit consumers and justify the merger. To read more, visit http://bit.ly/2mKBjbU.

Modernization of the AMA Code of Ethics

In 1847, the American Medical Association (AMA) created the world’s first national code of ethics for physicians. On June 13, 2016, the first comprehensive update of the AMA Code of Medi4

cal Ethics in more than fifty years was adopted at the annual meeting of the AMA. By so doing, physician delegates attending the meeting, who represent every state and nearly every specialty, publicly professed to uphold the values that are the underpinning of the ethical practice of medicine in service to patients and the public. Visit http://bit.ly/2n1idk5 for the newest edition of the AMA Code of Medical Ethics. Visit http://bit.ly/2ntKe1u to read more.

CMS Awards Approximately $100 Million to Help Small Practices Succeed in the Quality Payment Program

The Centers for Medicare & Medicaid Services (CMS) awarded approximately 20 million dollars to eleven organizations for the first year of a five-year program to provide on-the-ground training and education about the Quality Payment Program for clinicians in individual or small group practices of 15 clinicians or fewer. CMS intends to invest up to an additional 80 million dollars over the remaining four years. These local, experienced, community-based organizations will provide hands-on training to help thousands of small practices, especially those that practice in historically under-resourced areas including rural areas, health professional shortage areas, and medically underserved areas. The training and education resources will be available immediately, nationwide, and will be provided at no cost to eligible clinicians and practices. To read more, visit http://bit.ly/2nGeh51.

Communicable Disease (CD) Quarterly Report

The San Francisco Department of Public Health’s Communicable Disease Control Unit has published its 2016 Quarter 3 Communicable Disease Quarterly Report. The purpose of this brief report is to keep members of the San Francisco medical and public health community informed regarding communicable disease trends and issues in San Francisco. Read the full report at http:// bit.ly/2nGclcO.

CDPH Publishes New Zika Resources for Physicians

The California Department of Public Health (CDPH) has published new and revised Zika virus resources for physicians on its website. The evolving Zika virus outbreak and science have presented challenges for providers who are asked to educate, counsel, screen, monitor and manage patients with Zika virus exposure. These materials can be accessed through the CDPH Zika webpage at http://bit.ly/2mPSiem.

MACRA: What Should I Do Now to Prepare? A Checklist for Physician Practices

Wondering where to start? There are some critical first steps

SAN FRANCISCO MEDICINE APRIL 2017 WWW.SFMS.ORG

that physicians should take to prepare for MACRA implementation. The most important step is to get educated about MACRA. Download this CMA checklist for actions to consider now: http://bit.ly/2mKtuTr.

Opioid Safety in California: Having Difficult Conversations with Patients and with Colleagues

A recent California Health Care Foundation Update: Opioid Safety in California offers three tools in a challenging area—having difficult conversations about opioid safety with patients and with colleagues. Clinicians may struggle with how to say no— with compassion—to patients who are suffering and believe that opioids will help their pain. Dr. Roneet Lev and the California American College of Emergency Physicians (ACEP) developed a script (view the PDF at http:// bit.ly/2mKHwVo) to help emergency physicians discuss opioid safety with their patients. The San Diego Prescription Drug Abuse Task Force developed a script (viewable at http://bit.ly/2nbMVHK) for pharmacists to consider when calling providers to verify a potentially unsafe prescription. Partnership HealthPlan created a toolkit (view PDF at http://bit.ly/2nGf326) to help clinicians with the hard work of tapering patients on high opioid doses to safer regimens, which includes scripts and motivational interviewing techniques.

What To Do About Negative Patient Reviews Online

Physicians may find themselves the subject of comments and reviews posted on health care-related consumer review websites. While studies have shown that most online reviews of physicians are positive, these websites can be a concern for physicians because inappropriate negative comments can damage physicians’ reputations and affect their practice. The CMA recently hosted a webinar that provided an overview on how to monitor your digital presence, take control of information about you and your practice online, and develop and implement a social media policy. CMA members may download “How to Manage Your Professional Reputation Online” for free at http://bit. ly/2noX0Bu ($99 for non-members). CMA On-Call document #0401, “Online Consumer Review and Rating Sites,” which can be accessed at http://bit. ly/2mPX2Ro, also discusses how physicians can manage and respond to comments about themselves and their practices on consumer review websites.

CMA Releases 2017 Annotated Model Medical Staff Bylaws

The CMA has released its 2017 Model Medical Staff Bylaws. These bylaws are the definitive guide for medical staffs, providing details on professional and legal structures to support effective medical staff operations and self-governance. The model bylaws are fully annotated to provide background information on critical provisions, including explanations of relevant state and federal laws, hospital accreditation standards, and other explanatory information. The 2017 Model Medical Staff Bylaws are available free to any medical staff with an active membership in CMA’s Organized Medical Staff Section (OMSS). If your medical staff is not already an OMSS member, you can join by completing and submitting the OMSS membership application at www.cmanet.org/omss. The model bylaws are also available to non-OMSS members for a fee. For more information, visit CMA’s online resource library at http://bit.ly/2np42q0.

Healthy Parks Healthy People Program

The physical and mental health benefits of recreational experiences in nature are well established. The major park agencies in San Francisco have collaborated to offer free, guided “Healthy Nature Walks” to help health and social service providers “prescribe” activities that promote physical activity, relaxation, and social connection. These free and fun walking programs welcome any participant on the same 1st through 4th Saturdays every month, (mostly from 10 AM to noon) in San Francisco’s beautiful natural parks. More information at www.hphpbayarea.org/sanfrancisco.

WWW.SFMS.ORG

April 2017 Volume 90, Number 3 Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Production Editor Amanda Denz, MA Copy Editor Amy LeBlanc, MA EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Michel Accad, MD Erica Goode, MD, MPH Stephen Askin, MD Shieva Khayam-Bashi, MD Toni Brayer, MD Arthur Lyons, MD Chunbo Cai, MD John Maa, MD Linda Hawes Clever, MD David Pating, MD

SFMS OFFICERS President Man-Kit Leung, MD President-Elect John Maa, MD Secretary Brian Grady, MD Treasurer Kimberly L. Newell, MD Immediate Past President Richard A. Podolin, MD SFMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Erin Henke Director of Administration Posi Lyon Membership Coordinator Ariel Young BOARD OF DIRECTORS Term: Jan 2017-Dec 2019 David T. Duong, MD Robert A. Harvey, MD Dawn D. Ogawa, MD Ray Oshtory, MD Justin P. Quock, MD Dennis Song, MD Joseph W. Woo, MD

Term: Jan 2016-Dec 2018 Charles E. Binkley, MD Benjamin L. Franc, MD Nida Degesys, MD Raymond Liu, MD David R. Pating, MD Monique D. Schaulis, MD Winnie Tong, MD

Term: Jan 2015-Dec 2017 Steven H. Fugaro, MD Todd A. May, MD Stephanie Oltmann, MD William T. Prey, MD Michael C. Schrader, MD Albert Y. Yu, MD (To be determined)

CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD

APRIL 2017 SAN FRANCISCO MEDICINE

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PRESIDENT’S MESSAGE Man-Kit Leung, MD, and Peter Bretan, MD

Announcing the San Francisco Marin Medical Society It is with great excitement that we announce the pending merger of the Marin Medical Society (MMS) and the San Francisco Medical Society (SFMS).

The newly formed San Francisco Marin Medical Society (SFMMS) will consist of over two thousand physicians, residents, and medical students, including close to thirteen hundred active members. The combined organization will significantly strengthen its ability to serve its membership.

Why Merge?

The departure of longtime MMS executive director Cynthia Melody last December created a need for MMS to partner with another medical society to sustain its services to its members. As one of the oldest—if not the oldest—medical societies in California, SFMS has been a stalwart of organized medicine for close to 150 years. Besides geographic proximity, the two medical societies share similar values, missions, politics and even patients. In fact, many SFMS physicians live in Marin and vice versa. By representing a greater number of doctors from a larger region, the combined society will have stronger advocacy power as well as a wider sphere of influence. Indeed, SFMMS will be one of the most populous component medical societies within the California Medical Association (CMA).

Terms of Merger

Since the end of last year, the Executive Committees of MMS and SFMS have been working diligently to develop equitable terms for the merger. As of March 9, 2017, both the MMS and SFMS Boards of Directors have approved the proposed by-laws changes required for the merger. Key terms of the merger are as follows:

Geographic Representation

Board of Directors: The initial SFMMS Board will consist of all currently elected directors from both MMS and SFMS until their terms expire. Thereafter, two Board seats will be reserved for members from Marin and two Board seats will be reserved for members from San Francisco. The remaining seats will be open to any SFMMS members without geographic restriction.

Executive Committee: The initial SFMMS Executive Committee will be comprised of the current SFMS Executive Committee members along with the current MMS officers until their elected terms expire. Thereafter, the Executive Committee must include at least one member each from Marin and from San Francisco.

WWW.SFMS.ORG

Nominations Committee: The Nominations Committee must include at least one member each from Marin and from San Francisco.

SFMMS Magazine Editorial Board: Current editors of Marin Medicine and of San Francisco Medicine are invited to join the editorial board of the new journal San Francisco Marin Medicine.

CMA House of Delegates: Once the CMA ratifies the merger, a ballot will be held to elect a new set of delegates who will represent the merged organization.

Formation of the Marin Committee: This ad hoc com-

mittee will consist of current MMS Board of Directors and be charged with communicating issues of importance for Marin physician members to the SFMMS Executive Committee during the transition period. The charge of the Marin Committee will be re-evaluated in two to three years.

Location of Board meetings: To facilitate attendance by

members from Marin and San Francisco, at least one Board meeting per year will be held in an easily accessible venue each in Marin and in San Francisco.

The Board of Directors from both MMS and SFMS unanimously support the merger of the two medical societies according to the above terms. Pending ratification of the by-law changes by the general membership of each organization along with formal CMA approval, the merger will create a unified medical society that is stronger, more efficient, and more influential than its individual components. We are truly excited by this opportunity and hope that other members are as well. Please do not hesitate to contact us with any questions regarding this momentous development.

Man-Kit Leung, MD is the current President of SFMS and can be reached at mleung@sfms.org.

Peter Bretan, MD is the current President of MMS and can be reached at bretan.surgery@usa.net.

APRIL 2017 SAN FRANCISCO MEDICINE

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EDITORIAL Gordon Fung, MD, PhD, and Steve Heilig, MPH

From the Frontlines Emergency departments and physicians are the front lines of our medical system. It takes a certain special kind of person to be drawn to emergency medicine, as some flee that heady setting after first exposure in training. But we all, in medicine and beyond, owe a debt of gratitude to those who choose to serve in the oft-intense setting that an urban hospital emergency department can be.

The specialty itself was not fully recognized until 1979, after a decade of advocacy for established residencies, specialty societies, and training programs (the AMA long held emergency care should remain a part of Family Practice training). Now it has long been very clear that Emergency Medicine fully warrants its own full status. Any other specialist might ask themselves, how confident would you be being tossed into practicing in a busy ED at this point?

In San Francisco, the specialty has also been one of the more active in advocating new approaches to improved care.

The San Francisco Emergency Physicians Association (SFEPA), a volunteer group, has decades of contributions to the field, including development of new services such as the "sobering center" that diverts some patients to a more appropriate level of care that does not contribute to hospital gridlock.

But there is much more to be done, both internally at hospitals and in the field.

Thirty years ago this month, one of us (Steve Heilig), writing in the UCSF campus newspaper the Synapse about looming cuts to public programs like Medicaid, noted "At SFGH, crowded conditions and a chronic shortage of nurses led last year to the diversion of a substantial number of emergency patients to private hospitals, angering administrators and physicians who felt they were receiving a disproportionate share of uninsured or underinsured patients. "Dr. Richard Fine, head of the Department of General Medicine at SFGH, believes the cuts will only worsen that problem. 'Diversion has decreased with the hiring of more nurses, but not yet to an acceptable level. If these cuts go through, there will be more diversions, and longer waiting times and less services for those patients who do get in to see us,' he predicts."

As others note herein, plus ça change, plus c'est la même chose (and RIP, the recently departed Dr. Fine). But most recently, prompted by longtime frustration, confusion, and the "new normal" of high diversion rates—not to mention the SFEPA—the Hospital Council of San Francisco last year commissioned a report on the state of our city's emergency services system. The report diagnoses growing issues of high demand, insufficient supply, and inefficient allocation in a growing city, for starters, and prescribes a new behavioral health task force to address the mental health and substance abuse issues bedeviling the system citywide. That well-conWWW.SFMS.ORG

stituted group has already begun meeting at this point. The underlying and sometimes conflicting financial interests and incentives among hospitals and other primary players were not addressed, but the report is a good starting point.

Emergency Departments do not exist in any kind of vacuum, of course, and problems there impact the entire hospital, and vice-versa. Crowding in hospitals and an inability to efficiently move patients "upstairs" to where they are best served results in what is now all-too-commonly seen as "boarding"— patients waiting for many hours if not days in sub-optimal places. This is bad for both care quality and costs. No one facility is immune or wholly to blame. But the status quo is a big part of the big problem, which seems to be threatening to get worse rather than better.

Our authors herein approach many issues from differing perspectives but with a shared goal of improving emergency—and yes, disaster—responses in our fair city. You can read here about at least three new emergency departments coming online; about new clinical developments of note; and especially, about the history of the ongoing "chronic crisis" in emergency services impacting us all and threatening to continually worsen as our city grows—if some innovations, perhaps some of them painful, are not found and implemented.

The alternative, aka the status quo, promises to be painful for far too many of us, professionally at a minimum and, if we are especially unlucky, personally. For none of us knows when we might find ourselves prone in an ambulance, and/or then in an emergency department, wholly dependent upon the expertise and availability of emergency medical professionals.

Let's help them fix this crisis at last—doing so is in everybody's interest.

APRIL 2017 SAN FRANCISCO MEDICINE

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Emergency Medicine

CONFRONTING THE EMERGING CRISIS The Status of Emergency Medical Services in San Francisco John Brown, MD Everyone knows the story of US Airways Flight 1549, which made a forced water landing in the Hudson River near New York City following a bird strike disabling the plane’s engines on January 15, 2009. Dur-

ing the National Transportation Safety Board hearing into the circumstances of the fast, accurate decision-making that saved 155 lives, I was struck by the acknowledgement of the pilot, Captain Chesley “Sully” Sullenberger, that it was a team effort that saved the passengers that day and not his isolated actions.

Over fourteen hundred First Responders rescued the passengers and crew in twenty-four minutes, resulting in the one hundred percent save rate that day, and eventually new safety practices addressing this very unusual safety hazard. The parallel for me with Emergency Medical Services (EMS) in San Francisco (SF) is my daily experience that the success of the hard work, dedication, and exemplary performance of our individual paramedics, Emergency Medical Technicians (EMTs), dispatchers, and supervisors is dependent on the actions of the entire medical community in San Francisco.

This successful aviation and rescue event in New York was due in part to the capacity that existed in the response systems that day—the ability of the air traffic controllers, the ferryboat crews and passengers, the water rescue personnel, the EMTs and Paramedics, the mass sheltering personnel, the receiving hospital facilities, the emergency management personnel—to provide needed care quickly, accurately, effectively, and compassionately. Such has been the case for emergency medical services in San Francisco up to the present time. We can see this when we extend the emergency care system to meet the needs of multicasualty incidents, such as our own aircraft crash at San Francisco International Airport in 2013, infectious disease surges in demand from flu-like illnesses, or day-to-day increases in the demand for care from weather events or mass gatherings.

We are well positioned to take advantage of a new era of technological advances, from computer-aided dispatch and predictive software to position ambulances near future calls, to electronic medical records and EKG capture and transmission, and innovative use of data programs to identify high users of medical services and match appropriate resources for their care with their needs. However, the demand for 911 services continues to rise, without commensurate resources and more efficient resource utilization, as it does for emergency department care statewide, as recently found in the Hospital Council Report “Protecting San Francisco Emergency Services: Diagnosing and Addressing the Challenges of San Francisco’s EDs.” Our current EMS System is being hobbled by periods of overutilization of resources for non-emergencies, intermittent ambulance shortfalls, utilization of 911 resources for inter-facility transports instead 10

of inter-facility ambulance services, high rates of ambulance diversion sending patients away from hospitals, and mismatches between patient need and EMS ability to deliver the appropriate care. If we were to have our own version of Flight 1549 today, our systems would be challenged to respond as well as our colleagues were in New York City.

What is the best way forward? In order for EMS to succeed, we need the entire spectrum of care to be robust. Starting with educating and supporting health prevention programs for the public on the appropriate use of emergency services, and developing alternatives to emergency care available to patients in a timely fashion in a way they can access—these can diminish the dependence on 911 to be the health care system of all resort rather than last resort.

Increasing the capacity of emergency departments to cope with this increased demand becomes the duty of the hospitals in which they are located, which means not only efficient care at the “front door” but throughout the hospital system. This in turn means capable facilities for patients to be discharged including skilled nursing facilities and group homes, assistance for living at home, alternate care and detoxification facilities for those with substance abuse issues, and supportive mental health care systems.

How can San Francisco physicians help with this issue, which I characterize as an emerging crisis? I offer some suggestions by area of impact; some simple and some more complex:

Decrease the inappropriate activation of 911 services: All providers can spend a small amount of time with

every patient educating them on the appropriate use of emergency medical services. For those nearing the end of their lives, encouraging them to express their wishes and fill out a POLST (Physician Orders for Life Sustaining Treatment) form can make an important difference.

Support community-based efforts to provide timely and appropriate interventions: Establish an Automatic

External Defibrillator program in your office, and elsewhere in the community, to improve the chance of survival from cardiac arrest. Support CPR training in schools (San Francisco Fire Department is doing this now with the SF Unified School District).

Support the efforts of Neighborhood Emergency Response Teams in your area to provide better disaster response, and join a disaster medical volunteer registry program, e.g. www.healthcarevolunteers.ca.gov, to be an effective responder in such an event.

Investigate, utilize, and support innovative ways to deliver emergency care: Community paramedics can be

SAN FRANCISCO MEDICINE APRIL 2017 WWW.SFMS.ORG

an important adjunct to the standard 911 paramedic response and can work hand in hand with community nursing, mental health, substance abuse, and case management/social work to help maintain individuals in their residences and decrease their utilization of emergency care when other means may fit their needs. We graduated the first class of community paramedics from the San Francisco Fire Department and they can use your support and advocacy on the local and state levels.

Improve hospital resilience and ability to absorb medical surges by decreasing/eliminating ambulance diversion: San Francisco hospitals vary widely in their

utilization of ambulance diversion, from one percent of the month to sixty-two percent. Review your hospital’s surge capability and assist with efforts to improve processes including throughput and efficient discharge.

Support community-based efforts to improve resources for patients with mental health, substance abuse, lack of financial capability, or lack of medical access due to immigration or cultural issues:

There is a spectrum of possible actions, from redistributing the cost burden of predictable needs for care (such as providing more robust alcohol treatment facilities financed by resources from the alcohol industry, similar to tobacco initiatives in the past) to requirements for participation in health care systems/ building permits to allot space and resources for provision of medical surge care.

Monitor our progress as the EMS Agency tackles these “front-end” issues in the spectrum of emergency care, and provide feedback to us on how our proposed and implemented solutions are affecting you and your patients.The San Francisco EMS Agency will

shortly be moving to a new home in the Department of Public Health (DPH) and adding resources in Quality Improvement, Data Management, System Administration and Training to better manage our EMS resource and provide regular feedback on our progress to the Health Commission, City government and the residents of San Francisco. I look forward to the challenges ahead, and appreciate the support of the Medical Society in recognizing the need and mobilizing the physician community to move us forward. We will post a new website link shortly on the SF DPH website www.sfdph.org so you can follow our progress and give us feedback on these important issues. Let’s make that team effort that helped so many emergency care patients that day on the Hudson River work for our patients here in San Francisco.

John Brown, MD, is an Emergency Medicine and Emergency Medical Services Medicine physician who is the Medical Director of the San Francisco EMS Agency and Attending Physician at Zuckerberg San Francisco General Hospital. He is also a Medical Officer for Disaster Medical Assistance Team California-6 based in the Bay Area, and has been writing for the SFMS journal since starting practice in San Francisco in 1996.

April 18, 2017 SFMS/CMA LOBBY DAY Sheraton Grand Sacramento

• LEARN about legislative issues affecting medicine • FOSTER relationships with state legislators • GAIN hands on experience in the practical aspects of physician advocacy

www.sfms.org/events/lobby-day.aspx

WWW.SFMS.ORG

APRIL 2017 SAN FRANCISCO MEDICINE

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Emergency Medicine

A POUND OF PREVENTION Creating the Health Care Disaster Response of Tomorrow Naveena Bobba, MD, MPH Traditionally, the health care system has prepared for disasters by focusing on the hospital response to mass casualty events, with the assumption that most victims would end up at the hospital doorstep.

To a certain extent this has been true, especially when the focus is on the immediate response. At the federal level, the events of 9/11 drove the disaster health response through the hospital preparedness program (HPP), which started in 2002, and centered on preparing hospitals for terrorist events. Mass attacks, such as those in Paris in 2015, or the Orlando shootings in 2016, emphasize how hospitals quickly become the center of the response, and how actions taken by staff in the field and at the hospital save lives. With time and experience, though, it has also become evident that in order to adequately respond to a disaster, and improve the time to recovery, all parts of the health care system need to be involved. The intense behavioral health response required for months after the San Bernardino shootings, the infrastructure failures during Hurricane Sandy, and, most recently, the evacuations due to the Oroville spillway failure, highlight that all parts of the healthcare system play a critical role in disaster response. This has led to HPP evolving its guidelines to become more holistic in its approach. Under this new version, released for 2017-2022, four capabilities have been developed to push healthcare systems to better engagement, integration and ultimately response.

Capability #1: Foundation For Health Care And Medical Readiness

The capabilities, objectives, and goals of HPP require the health care system to be much more integrated in preparing for disasters. The foundation of this integration is developing health care coalitions that have representation from a wide variety of partners and stakeholders. While the core members of these coalitions still include hospitals, public health, emergency management, and emergency medical services (EMS), HPP also emphasizes other healthcare entities that serve critical roles, from outpatient care centers, skilled nursing facilities, home health, and dialysis centers to labs, blood banks, and durable medical equipment providers. The health care coalition is meant to bring together “diverse and often competitive health care organizations with differing priorities and objectives to work together.”1 It requires the coalition to define major hazards and risks, and then to develop strategies to prevent, prepare and respond to them. Creating and fostering relationships is a key strategy to fulfilling this capability, and is the foundation upon which HPP activities are built. Expanding the definition of health care coalitions acknowledges that a wide variety of entities play a role in the health and well-being of the community on a day-to-day 12

basis, and those critical functions continue during a disaster.

The health care system is an extremely complex sector, with multiple interdependencies that often act in silos. It can be difficult to maneuver in the best of circumstances. What happens in the worst case scenarios? There are multiple examples of systems that did not work well in a disaster, but with some forethought could have. Improving our response requires practice, drilling, and diligence to achieve better outcomes. The more we do this, the more we can uncover weaknesses and develop strategies to fix them. Fortunately, the San Francisco health care system has a rich history of working together on these problems and is committed to finding ways to improve our approach to disaster preparedness and response.

Capability #2: Health Care And Medical Response Coordination

One of the more difficult tasks during a disaster is coordinating response efforts.

In order for disaster victims to “receive the care they need at the right time, at the right place, and with the right resources,” the health care community must be able to share information in a timely manner.1 The Ebola response illustrated how interdependent the healthcare system is, and how important communication between different partners within the system is critical to both patient care and to ensuring the health of those responding. Multiple entry points into the health care system, including outpatient clinics, developed ways to screen for Ebola symptoms but also developed response plans for patients that screened positive. This included protecting themselves as well as those around them, providing adequate care, and conveying this information to the appropriate officials. 911 and first responders developed protocols around Ebola to ensure that the EMS system would receive critical information in a timely basis, but also how this information would get to destination facilities. Developing a unified approach to sharing information improves our ability to respond effectively in a disaster setting.

To this end the second HPP capability focuses on developing a disaster response plan for the entire coalition. This requires integrating individual plans into a collective response that takes into account higher level strategies and goals that will lead to better patient outcomes. The focus of these plans is around information and resource sharing, and the coordination of individual institutional efforts into the city disaster structure so that all populations receive adequate care in a disaster.

SAN FRANCISCO MEDICINE APRIL 2017 WWW.SFMS.ORG

Capability #3: Continuity Of Health Care Service Delivery Hurricane Sandy illustrated how disasters can have devastating effects on multiple parts of the health care system.

Evacuation of New York’s Bellevue hospital was a high profile event. There were, however, multiple other issues that directly impacted the health of the region, including loss of the pharmaceutical supply chain, limited fuel supply, and patients that were displaced from their durable medical equipment. The 3rd capability focuses on continuing care delivery in the face of adverse circumstances, including extreme circumstances such as evacuation. In order to provide optimal care under disaster conditions, health care organizations must be able to identify critical functions, structures and supply chains that have to be maintained, and the resources that are needed to maintain them. This includes taking in to account the needs of different patient populations.

Maintaining health care delivery also requires that those who provide this service are “well-trained, well-educated, and well-equipped” to provide care under disaster conditions.1 In order to do this, health care staff need to understand their roles in a disaster, and train and exercise these roles on an ongoing basis. Again, Ebola identified the complexity of an emergency response, and how technical expertise in donning and doffing personal protective equipment required intense training and practice. It also highlighted the need to ensure that the workforce remained protected and healthy during a response. Health care coalitions with single person representatives cannot do this on their own; they require engagement from all parts of the system.

Capability #4: Medical Surge

The final capability, medical surge, aims at developing plans when demand outstrips supply for health care services beyond daily operations. The first three capabilities paves the path to meeting this final capability. Medical surge encompasses both an increase in capacity—including increased demand for inpatient beds, laboratory testing, and blood products—as well as an increase in capabilities such as specialized care services like pediatric, infectious disease, or burn care. In general, surge can apply to both increased resource needs and specialty care needs. Health care coalitions need to plan and prepare for different surge needs based on the disasters that are most likely to occur. In San Francisco, earthquakes are high on the list of a likely disasters that would require a medical surge, as are infectious diseases outbreaks such as a pandemic flu. Defining surge ahead of time will help the health care system determine when a medical surge will lead to an inability to provide adequate care for the population, and when additional resources from the state or federal government are required, or altered standards of care need to be instituted.

Disasters cause an enormous amount of stress on an already stressed system. To deliver adequate care in these settings we must rely on all sectors including private entities, public institutions, and the community to plan and prepare together to limit and manage the consequences of these events. Readiness means that when an emergency event occurs, whether WWW.SFMS.ORG

for a single person or for the entire community, we are ready and able to respond as a system. Readiness is earned because we have established clear roles and responsibilities, and have trained and drilled together. The amount of effort to achieve the preparedness capabilities outlined in HPP is significant and will take dedication from all members of the health care sector. However, we are confident that the health care sector will rise to the challenge. I have no doubt that together we can and will save lives.

Hospital Preparedness Goals For 2017-2022

Goal of Capability 1: The community’s health care organiza-

tions and other stakeholders—coordinated through a sustainable HCC—have strong relationships, identify hazards and risks, and prioritize and address gaps through planning, training, exercising, and managing resources.

Goal of Capability 2: Health care organizations, the HCC, their

jurisdiction(s), and the (ESF-8) lead agency plan and collaborate to share and analyze information, manage and share resources, and coordinate strategies to deliver medical care to all populations during emergencies and planned events.

Goal of Capability 3: Health care organizations, with sup-

port from the HCC and the U.S. Department of Health and Human Services Emergency Support Function #8 (ESF-8) lead agency, provide uninterrupted, optimal medical care to all populations in the face of damaged or disabled health care infrastructure. Health care workers are well-trained, well-educated, and well-equipped to care for patients during emergencies. Simultaneous response and recovery operations result in a return to normal or, ideally, improved operations.

Goal of Capability 4: Health care organizations—including

hospitals, EMS, and out-of-hospital providers—deliver timely and efficient care to their patients even when the demand for health care services exceeds available supply. The HCC, in collaboration with the ESF-8 lead agency, coordinates information and available resources for its members to maintain conventional surge response. When an emergency overwhelms the HCC’s collective resources, the HCC supports the health care delivery system’s transition to contingency and crisis surge response and promotes a timely return to conventional standards of care as soon as possible.

Naveena Bobba MD, MPH, is Director Public Health Emergency Preparedness & Response, Population Health Division, San Francisco Department of Public Health.

Reference 1. U.S. Department of Health and Human Services (2016). “2017-2022 Health Care Preparedness and Response Capabilities,” pp. 5, 10, 32. https://www.phe.gov/

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Emergency Medicine

THE VIEW FROM INSIDE THE BOX Understanding the Role of EMS Providers Joshua Smith, EMT-P When a person calls 911 for a medical emergency, what is it that we expect? When we see an ambulance driving

down the road, what do we understand about the levels of training or differences in capability? What role do they play in the emergency response system and the overlap of the overall healthcare service system? What are the responsibilities of Emergency Medical Service (EMS) providers, the working conditions, and experiences of those who we rely on in our moment of need? The following is a broad overview that will orient those that do not have direct experience with EMS to understand the varied roles of EMS providers, highlight some challenges of the current system designs, and to inform and provoke questions that ask: What is it that we want when we call 911?

A Young Profession With A Long History

The concept of early care and movement of patients has a varied, documented history from the horse and litter transport of the wounded by the Normans, to the treatment sites of the Knights Hospitallers, and early use of ambulance volantes by the armies of Napoleon Bonaparte.1,2 Transport using specialized carriages for cholera patients in London in 1832 marked another evolution in civilian transport of the sick and injured to definitive care.

In the United States, what began as a wounded soldier evacuation service in the Civil War further developed into hospital based ambulance services staffed by doctors beginning their training.

The 1966 report from the National Academy of Sciences, “Accidental Death and Disability: The Neglected Disease of Modern Society,� argued that there were inadequate standards and no organized system for the provision of medical care for traumatic injuries.3 Later the same year, the National Highway Safety Act established the Department of Transportation (DOT) and subsequently the National Highway Traffic Safety Administration (NHTSA). It was this transportation agency, not a health care regulatory body, which developed standards for Emergency Medical Technicians (EMTs) and later paramedics. How might EMS be different today if it was initially governed by the Department of Health, Education, and Welfare? Would funding, reimbursement, focus, development, and oversight be different? In 1973, the EMS Systems Act established funding for EMS systems across the country; however, in time, funding was later restructured under the Omnibus Reconciliation Act directing funding from state preventative health block grants.4 Still, the question persists, is EMS viewed more as a transportation service or as a health care practice?5 By nature of the job, there are high attrition rates due to injury, limited career paths, high rates of post-traumatic stress disorder (PTSD), and few opportunities to earn a sustainable wage.6 Did this also help create an industry with a business/transportation model that demands lower educational entry standards to feed the demand created by attrition and low 14

remuneration due to low reimbursement rates?

The above history is in no way intended to be comprehensive.

The purpose is to highlight the disjointed history and lack of a single vision from all regulatory agencies. Has this contributed to the lack of understanding of the roles of EMS?

How Does One Become An EMT Or A Paramedic (EMT-P)?

Ideally, paramedics work as EMTs for a year prior to entering paramedic schools, but that is not always the case. The quality of EMT instruction can vary widely from intensive three-week education mills to one semester community college curriculums. Some programs require pre-requisites including basic anatomy and physiology or the introductory level of Emergency Medical Responder (EMR); others do not. These disparate experiences vary not only between states but also at the local level. In California, all certification standards for EMTs require minimum hours of didactic instruction (136), clinical and field hours (24), as well as ten patient contacts. Furthermore, students must pass the National Registry Emergency Medical Technician (NREMT) written and skills testing process. There is an intermediate level of EMT that is not widely used in California. The paramedic curriculum requires a minimum standard of hours for didactic and skills lab (450), hospital and clinical training (160), field internship training (480) including at least forty Advanced Life Support (ALS) contacts, and also requires passing the NREMT written and psychomotor exams.7 Some programs exceed these hours but keep these minimum standards in mind as we reflect on the nature of the job and the clinical decisions required of providers in a challenging environment.

What Is It That EMS Providers Actually Do On An Ambulance?

The answer to this question varies widely depending on the nature of the service. Here I focus on the 911 providers in a busy urban setting, though there is common experience across the spectrum. Paramedic and EMT counterparts share most of the same circumstances and work side by side. Paramedics have an expanded scope of EMT practice and are the highest level of medical care outside of the hospital or clinic environment. In some systems, paramedics and EMT partners often sit in the ambulance for twelve hours or more a day waiting for a dispatch. In a busy system, units regularly run twelve to fourteen calls a day of varying acuity. Even if not a busy day, the time in vehicle is analogous to a twelve-hour road trip from San Francisco, California to Portland, Oregon three to five days a week. The physical wear and mental fatigue of that alone can be taxing. Ambulances are not built for comfort. The physical demands of the job include carrying many hundreds of pounds of

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Emergency Medicine

SUPPLY, DEMAND, AND CRISIS Emergency Department Diversion of Ambulances in San Francisco Christopher Colwell, MD No one can be certain what the future holds or what the medical landscape will look like over the next four years with the potential repeal of the Affordable Care Act. What we do know is that we currently have

a crisis in healthcare access in San Francisco, and I do not use the word crisis lightly. Emergency Department (ED) diversion of ambulances is one very real and clear reflection of our current situation. Emergency Department diversion was initially intended to apply only in very rare disaster situations where an ED may have lost electricity, flooded, or for some other reason is legitimately unable to care for patients. It makes sense to have a method of communicating this situation to the prehospital personnel so they don’t bring patients to a place that is temporarily unable to care for them. Unfortunately, in part because if you define a disaster as demand overwhelming the resources dedicated to meeting that demand, most EDs are on the verge of a disaster every day, and ED divert has become far too common.

Citywide divert is currently over fifteen percent, with some hospitals significantly higher than that, including mine.

One of the biggest challenges to fixing the current ED diversion situation is the fact that there isn’t a single or even a predominant cause, making solutions more difficult to come by.

Poor or non-existent access to psychiatric care, lack of adequate resources to address substance abuse issues, ED boarding of admitted patients, patients in hospital beds that don’t require inpatient hospital management but don’t have adequate alternatives, and insufficient access to primary care are just some of the reasons ED overcrowding occurs. Ambulance diversion is one of the ways ED overcrowding expresses itself, and causes harm.

Another challenge to addressing the issue of ED diversion is that there are not really any bad actors here. Although we could all do better in some areas and ED processes can certainly be improved, no hospital or ED wants to be on diversion, and most if not all are making considerable efforts to avoid being on divert. In nearly every situation, a hospital goes on ED diversion because they honestly believe it is the safest thing for the patients for them to do so. They may be wrong in that belief, but it is generally well intended. One reason they may be wrong is that when a hospital goes on ED diversion, they are making an assumption that another hospital is better equipped to manage those ambulance patients than they are, and that assumption is often based on inadequate data and may therefore be incorrect.

Diversion is bad for our community and for patients for a number of reasons. Patients in need of emergency care may have to travel longer distances and wait longer to receive that care. Others may not be able to get care at the hospital of their choice or coverage, potentially causing delays or errors in their care and likely causing inconvenience, aggravation, and added WWW.SFMS.ORG

cost. The added cost can be for the patient as well as for the health care system they are part of, and added costs at this level will eventually become increased premiums for those paying for health insurance. Another significant problem with ED diversion is that it takes longer for an ambulance to get back into service (called turn-around time), which results in potential delays in ambulance response times that can affect patients needing an emergent ambulance.

Although the term might imply otherwise, ED diversion is not an ED problem. It is a hospital—and really a community— problem that results in the ED not having room to safely manage additional ambulance patients. A lack of adequate available resources backs the hospitals up, which backs the EDs up, who in turn pass the problem on to the ambulances in the form of ED diversion.

While many EDs are backed up with boarded patients waiting for a hospital bed, a lack of adequate resources at the community level results in more people having to rely on the ED for their needs, even though the ED may not have been designed or resourced to provide those needs. This is often referred to as inappropriate use of the ED, or even ED abuse, but those terms may not be the right way to describe it. Most of those who present to the ED have a very real problem and don’t have adequate alternatives to addressing that problem. Places like jails or many clinics trying to meet the needs of the underserved don’t have the resources to attend to the medical needs of populations they are caring for, and the ED is often the easiest, and sometimes the only, option available to them. As the only place mandated to be open to all 24/7/365, the ED has become the place many send their patients to, even if the issue they are facing is not something an ED might traditionally be expected to manage.

One all too common example of this is when law enforcement is asked to intervene on an unruly person who may be suffering from substance abuse or psychiatric disease or both. Even without any medical issues, they are often brought to the ED because they simply don’t have anywhere else to take them. The EDs then don’t have any place to send them, and are therefore put in the position of simply providing a safe environment for them to metabolize their substances to the point where they can care for themselves or reach a steady state for their psychiatric issue. I would argue this is not the role we should be asking the ED to fill.

There are many other similar examples of the ED being put in the position of filling a community gap that it was not intended to fill. This all creates a funnel effect where many get into the ED because it is the easiest immediate solution, but it is difficult to get patients out. The predictable result is ED overcrowding.

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Supply, Demand, and Crisis Continued from page 15 . . .

View from Inside the Box Continued from page 14 . . .

The only solution to this funnel effect is to decrease the input, which for some has been expressed as ED diversion, or increase the flow out of the ED, which will require additional resources either in terms of added hospital beds or community programs.

Because ED divert is a system problem rather than an ED problem, looking to the ED, or even in many cases the hospital, to fix the problem will not yield sustainable solutions. ED diversion is in many ways a result of excess demand for inadequate community resources that end up in the ED because there are no adequate alternatives.

The solutions will not be easy. Because ED diversion is really a passing along of the hospital problem to the prehospital community, doing away with ED diversion may be the right place to start. Simply eliminating ED diversion does nothing to address the real issue, however. Emergency Departments are simply being asked to fill too many gaps for a population that isn’t getting their needs met. Diversion is doing little more than pushing this problem out to the prehospital environment.

We need viable options other than EDs for the large number of psychiatric patients in our city. We need places other than EDs for people to safely metabolize substances that can be accessed by those that need them. We need adequate access to primary care. Until our community is ready to take these issues on and no longer depend on EDs to fill too many holes, this problem will continue. If we are able to successfully eliminate divert but don’t address the underlying problem, it will simply find other ways to express itself. San Francisco needs to decide if we want to face and address this very real problem, or continue to look the other way.

equipment and patients each day, repeated exposure to assaults on personnel, infectious disease, and motor vehicle accidents. Consider that each “rest stop” equivalent on this trip is an emergency that is often the patient’s worst day. Think of intubating patients on the floor, in a pool of blood, surrounded by roaches, or verifying an endotracheal tube placement in an ambulance going seventy miles per hour down a heavily trafficked street with the sirens blaring.

Many of our patients are no less sick because they are outside of a hospital. Paramedics and EMTs are expected to perform their roles without the support found in the hospital setting: registration, triage, nurse, physician of each specialty, medical assistant, sanitary services, and housekeeping. In addition, they are regularly called to serve as mental health specialist, police officer, grief support counselor, mediator, ombudsman, hospice, and social worker. These roles are each practiced with limited training in an uncontrolled environment. EMS providers are expected to respond to high emotion calls in this raw environment with no hospital-level support: unsuccessful pediatric resuscitations, shootings with volatile crowds, suicides with family members on scene, and high-profile mass casualty incidents. Meanwhile, the true daily work of an EMS provider is to act as the “safety net” for system challenges: incomplete discharge planning, inadequate insurance, inadequate mental health services, substance abuse, and lack of primary care access for chronic diseases. Considering the educational requirements previously covered, and the responsibilities asked, is it reasonable to accept that the means to become an accomplished, safe practitioner is only through experience? How, then, can we reconcile this given the high attrition rates of the profession?

In view of what we ask of our EMS providers, perhaps we should prepare them to think ahead to what other roles they can play when working in the field is no longer an option. After several years in the field, many paramedics find themselves looking for other options. The path they have chosen essentially has a short, linear trajectory without many branches. The fire service has given one possibility with the emergence of fire-based EMS; however, that is a different culture and is not compatible, or is not an option for some.

Many consider nursing, physician assistant, physical therapist, or physician only to find that they must start from the beginning from an educational standpoint late in a career. Perhaps by augmenting the educational requirements from the beginning, an EMS professional would find themselves better prepared to transition to other roles in the health care system. If we considered linking each EMS certification from junior colleges (EMT), to universities (EMT-P), on to graduate education (EMT-PA? EMT-MD? EMT-PhD?), EMS providers would be better prepared to both serve the public and have opportunities for a sustainable career in advanced practice. Should we consider demanding higher educational standards despite the resistance from the various interests? Who do you want responding when you call 911?

Joshua G. Smith EMT-P is currently a paramedic training captain for the San Francisco Fire Department. He has been with the SFFD for the last ten years including eight years as a street paramedic working on an ambulance. He worked five years prior for a private ambulance service iand is adjunct faculty for City College. The opinions expressed in this article are solely those of the author and do not necessarily represent the opinions of his past or present employers. A list of reference is available online at www.sfms.org.

Christopher B. Colwell, MD, is Chief of Emergency Medicine at Zuckerberg San Francisco General Hospital and Trauma Center and Professor and Vice Chair, Department of Emergency Medicine UCSF School of Medicine.

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Emergency Medicine

THE MORE THINGS CHANGE The More They Stay the Same Marc A. Snyder, MD, FACEP In September 1995, San Francisco Medicine published an issue focused on the 911 system and emergency medicine. At the time, I was the Medical Director of the Emergency Department (ED) at St. Luke’s Hospital and president of the San Francisco Emergency Physicians Association (SFEPA), and wrote a guest editorial for the issue. It’s interesting to go back almost twenty-two years and take a look at what’s changed and what remains the same.

A lot has changed. I’m retired from clinical practice now, but still participate on the hospital’s ethics committee and attend meetings of the SFEPA. St. Luke’s went from being a stand-alone hospital affiliated with the Episcopal Diocese to a Sutter Health hospital and then to a campus of California Pacific Medical Center under Sutter Health. A new hospital and emergency department will soon open on Cesar Chavez and Valencia Streets, as will the California Pacific Medical Center (CPMC) “mother ship” at Van Ness and Geary Streets. San Francisco General became the Zuckerberg San Francisco General Hospital (ZSFGH) with a new building. The University of California, San Francisco (UCSF) opened its Mission Bay campus and emergency department, and long ago closed the emergency department at Mt. Zion.

Health care financing has changed with Obamacare, which a third of the nation believes is different from the Affordable Care Act, and which could disappear before this issue is printed.

San Francisco developed a Healthy Families program and has attempted to further the concept of the “medical home.”

The Paramedic Division of the Department of Public Health was transferred to the Fire Department in 1997. The Emergency Medical Services (EMS) Agency moved from the Department of Public Health to the Mayor’s Office of Emergency Services, and in a few months, will move back to the Department of Public Health.

My 1995 editorial mentioned that the Fire Department responded to about two thousand medical calls each month. In 2016, that number was close to 6,900 transports per month.

Hospital ambulance diversion has become an enormous problem. Last year, ZSFGH diverted non-trauma ambulances an average of thirty-seven percent of the time each month (range, thirty to forty-five percent). When the General goes on diversion, the other hospitals in the City are deluged with ambulances, triggering a cascade of diversions, at UCSF, at the Pacific Campus of CPMC, at St. Luke’s especially. This leads the EMS system to suspend diversion, which it did twenty-eight percent of the time in 2016. ZSFGH was able to override the suspension seventy percent of the time, basically staying on diversion (except trauma) while other emergency departments struggled to handle the ambulance patients.

We are in a terrible crisis in our emergency departments.

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At ZSFGH, half of their sixty new ED beds contain patients who have been admitted to the hospital but remain boarded in the ED because no hospital beds are available. Across the city, hospital emergency departments board psychiatric patients, often beyond the seventy-two hours of their “5150” holds, because there are no beds available in the system. Ambulance diversion means that patients are sent to hospitals where they may not have been previously; their doctors and their records are often hard to obtain. While ambulance response times are meeting targets, first responder times have yet to meet their goals.

Emergency medicine has evolved as a specialty, well recognized, with a residency program now established at UCSF and ZSFGH. We have participated in protocols that streamline cardiac and stroke management. We have improved trauma care and management of poisons. Electronic medical records have given us access to critical data, but have burdened us with thousands of clicks per shift and the creation of documents that are more suited to a billing system than patient management at times.

We are beginning to incorporate principles of palliative care in the ED and starting to refer patients who need hospice or palliative care earlier rather than later. The Emergency Physicians Association successfully lobbied for the creation of Dore Street and the Sobering Center as alternatives to EDs for selected patients with psychiatric problems and inebriation. Ambulance field triage to the Sobering Center was suspended by State regulators last fall, but there is hope that it will be re-instated soon.

We also lobbied for a physician to lead the Emergency Medical Services Agency, and have worked closely with Dr. John Brown on issues of response times and quality improvement.

But we remained troubled and frustrated by system problems that have evaded solution, including homelessness and its medical consequences, alcohol and drug abuse, and a health system that still focuses more on expensive band-aids than on health promotion and prevention. In emergency medicine, like health care in general, we need to integrate public health with medical care delivery, and figure out ways to achieve desired results in a cost-effective manner.

Marc A. Snyder, MD, FACEP, completed a Family Practice Residency at SFGH/UCSF in 1977, and practiced emergency medicine at St. Luke’s Hospital from 1982-2013. He was Director of the Emergency Department there from 1989-2008, and a member of the hospital’s board of directors from 1997-2006. He also served on the Board of Directors of the California Chapter of the American College of Emergency Physicians from 2006-2010.

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Emergency Medicine

DOING MORE WITH LESS Advances in Emergency Medicine Corey Long, MD Emergency Department visits across the nation are on the rise, and this is particularly acute in the Bay Area. A healthy economy and booming technology sector have

brought more jobs and people to our forty-seven square mile peninsula. Meanwhile, the Affordable Care Act has provided millions with health insurance, allowing them to stop deferring necessary care. Coupled with an overburdened primary care network, this has all led to steady growth in Emergency Medical Service calls and Emergency Department volume over the past several years.

The physical capacity to provide such care takes years to build out, and even with the new Zuckerberg San Francisco General Hospital and upcoming California Pacific Medical Center campuses, creeping wait times and increased ambulance diversion due to overcrowding seem to be the new norm. We are challenged, in effect, to do more with less—to provide care to a greater number of patients while utilizing fewer resources, and to do so at the highest level of quality and customer service.

The production line revolutionized manufacturing, the smartphone has put a supercomputer in our pockets, and selfdriving cars will one day ferry us to work. Emergency Medicine has had its own advances since emerging as one of medicine’s newest specialties in the 1970s. Initially known as a small group of “cowboys,” residencies soon blossomed and we have matured into a large profession of board-certified experts providing consistent and excellent acute care. The past decade has brought multiple technological advances, as computed tomography (CT) scans have become commonplace, Electronic Medical Records (EMRs) have replaced disorganized paper records, and Emergency Physicians have become proficient in bedside ultrasound to immediately guide treatment and diagnoses. The next revolution in efficiency in emergency care, however, has been process-oriented.

Working “smarter” means reducing waste and redundancy while streamlining necessary processes, and has inspired a number of programs used in Emergency Departments (EDs) across the country. While recognizing that no two departments are alike and solutions vary, the following represent concepts currently in use around the Bay Area.

Scribes: EMRs have replaced paper records and orders in most departments, but at a significant cost to the time of the physician, and indeed the physician-patient relationship, as it is tempting to chart as we gather our history. Enter scribes, who faithfully chart histories, document exams, and act as personal assistants in running down lost radiology reports, returning calls to nurses during procedures, or even providing that warm blanket to a patient.

Scribes are often highly motivated college students aspiring to a career in medicine who far exceed their expense through enhanced physician efficiency and happiness.

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Telemedicine: There are many situations in medicine in which

a helpful consultant is not able to be physically available, either because of scarcity, off hours, or demand. Such scenarios benefit from a remote connection to the specialist, via a simple webcam module. Large gains have been seen in use of neurology in evaluating acute strokes, dermatology to evaluate rashes, and psychiatry in evaluating depressed or psychotic patients, though the irony of patients talking to someone though a television isn’t lost on anyone.

Team Care: One of the easiest ways to cut down on redundancy is to have the relevant parties present with the patient all at once.

Once a patient is triaged, often a nurse performs an assessment, followed by a physician asking many of the same questions. Performing these functions in parallel saves the staff time, cuts down on the length of the evaluation, allows everyone to be on the same page, and keeps the patient from having to repeat themselves.

This process is excellent for discharge as well.

Provider in Triage: Following some of the same precepts as

Team Care, having a provider see the patient the moment they are triaged dramatically cuts down on the time to provider evaluation and can jump-start diagnostic testing and treatment, even when there is no bed available in the ED. Additionally, this can actually save the patient from being placed in a bed at all if the condition is one which can be quickly addressed and discharge furnished from triage.

The future will undoubtedly see additional advances in the way we care for patients in Emergency Medicine, some of which we have a hint of today. For instance, there are companies currently using Google Glass to assist in information gathering, data review, and telemedicine. Big data analytics is poised to change the way we provide care by using large pools of data to drive staffing, patient-specific testing, and guide decision instruments toward optimized care. Finally, genomics will play a role in deciphering individual predisposition to disease and allow treatment tailored to one’s unique DNA. Far from the tricorder promised to us by Star Trek, many of the notable recent advances in Emergency Medicine are processdriven, allowing us to leverage increased efficiency in order to meet the ever-growing demand for our services. As the Bay Area continues to grow and our volumes surge, we must adapt in order to provide the level of care our patients need and deserve.

Corey Long, MD, is an Emergency Physician at Saint Francis Memorial Hospital and Assistant Director of the Emergency Department there.

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Emergency Medicine

CARDIOPULMONARY RESUSCITATION An Update Collin P. Quock, MD, FACC, FAHA Carrie Fisher’s recent collapse on a commercial airliner again calls attention to bystander cardiopulmonary resuscitation (CPR). The tragic events that

followed brought tears to many eyes and only dramatized the need for health professionals to sharpen their first-aid skills.

You need not be a cardiologist or a paramedic, but as a health care provider, do you know what to do if you witness a collapse on your flight, on the street, or in your office—do you know what to do?

Here is the simple two-step first-aid approach for adults and bigger teens: shout for someone to call for help (911) then immediately begin mid-sternal compressions, hard and fast— one hundred twenty per minute and two inches deep! That’s all there is to it! Irreversible brain damage begins four minutes after effective circulation stops.

Checking the carotids, opening the airway and rescue breathing have been reserved for the training of those who want certificates and certain healthcare professionals, including hospital personnel. But these steps have been eliminated from the teaching of the general public. This technique is called HOCPR or COCPR—“Hands Only” or “Compression Only” CPR. It had previously been assumed that artificial respiration was necessary to maintain enough oxygenation of the blood to keep vital organs perfused during these critical four minutes.

But careful studies by Ewy and others have shown that the amount of oxygenated blood at the moment of collapse is perfectly adequate during these precious seconds.1 What is needed is to drive that blood to its vital destinations.

The American Heart Association (AHA) is leading the way for public education with its “HOCPR” Campaign. As of this writing, thirty-five states, including California plus Washington, DC, have incorporated mandatory teaching of HOCPR into their public school curricula. The emphasis is on the teaching—not testing or certification. It has been shown that, once taught, the skills re-emerge even after years of latency.

It can be taught in ten minutes, although addition on use of an automatic external defibrillator (AED) by some facilities will increase the time. The elimination of immediate attention to carotids, airway and artificial respirations has made the technique much more attractive to the general public and much easier to teach.

The San Francisco Medical Society, indeed, most of organized medicine, is on a mission to improve the health care of its constituencies. HOCPR is clearly a positive asset that should be generally promoted. There is a lesson in the development of public school education of HOCPR for those healthcare providers who understand the importance of advocacy. Here is a brief sketch of what happened.

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Three years ago, two of us asked the AHA Washington, DC Advocacy Office whether it was possible to obtain federal legislation or an administrative order to mandate the teaching of HOCPR in all public school systems receiving federal aid. Our consultants felt education was a states’ right issue. They said CPR training needed to be done state by state.

Thus we spoke to our California CPR advocates. We learned that a bill had in fact been introduced, but ran into resistance from some who had other curricular priorities and did not want to deal with an unfunded mandate. We were told we would have to obtain mandates to teach CPR in each school district, one by one.

We turned back to San Francisco and recruited Gwen Chan into our Chinese Community Cardiac Council (CCCC), an AHA component. Gwen Chan is a retired former superintendent of the San Francisco Unified School District. She was instantly attracted to helping us work through the steps we would need with the Board of Education to achieve our objective. Thanks to the hard work of Brittni Chicuata, then an AHA advocacy director, we were able to connect the dots by visiting various commissioners and the current superintendent, and arranging our testimony at a series of committee meetings. These included curriculum design and finance. Along the way, Gwen Chan invited Dr. Emily Murase, the Board’s president-elect to meet with our CCCC representatives. She came and quickly pledged her support as well. Money was still a problem. Then Brittni made contact with Chief Joanne Hayes-White of the San Francisco Fire Department (SFFD). The chief volunteered her training unit to train the physical education instructors. That solved the funding obstacle. A few days before the start of the fall semester in 2015, there was a meeting of the middle school Physical Education teachers in the district. We were there alongside Chief Hayes-White; Dr. Clement Yeh, the San Francisco Fire Department Medical Director; Section Chief Melany Brandon, the training director; and a half dozen fire fighters. There was great enthusiasm as we gave our presentations and then coached each instructor on a manikin. The following week the teaching of HOCPR in the San Francisco Unified School District began.

San Francisco was the first school district in the state to achieve this mandate.

Meanwhile, back on the legislative front, Assemblyman Freddie Rodriguez (D-Pomona), a certified emergency medical responder, had introduced a modified bill to do the same in the rest of California. The bill stalled in committee, but an advocacy campaign spurred by the AHA Western States Affiliate paid off.

The bill was signed by Governor Jerry Brown on September 24, 2016, and will go into effect with the 2018-2019 academic year in all public high schools with health education programs. Each

SAN FRANCISCO MEDICINE APRIL 2017 WWW.SFMS.ORG

district will find its own funding, and they will be asking local first responders to volunteer in training the trainers.

Nationally, the AHA has designated the first week of June as “National CPR Week.” Our local Bay Area CPR Task Force has tried to train the general public on that weekend over the past two years. We have decided to choose Friday, June 2, and Saturday, June 3 as “Bay Area CPR Weekend” for 2017. Our area stretches from Southern Marin through San Francisco to our Silicon Valley Division in San Jose and includes Contra Costa and Alameda Counties.

The chair is Joe Farrell, M App Sc, DPT, FAPTA, FAAOMPT (Contra Costa), himself a CPR save. The members are Nicolas Mottola, MD (Marin); Carol Chin, MPH, and Estrella Manio, RN (both of South San Francisco); Camie Sanchez (AHA Staff; Silicon Valley); Lisa Bellini (AHA Staff, Western States Affiliate); and Collin Quock, MD (San Francisco).

In 2015 we trained thirty-eight hundred individuals at fifty sites, and in 2016 we trained 5113 people in forty-two sites.

These were passers-by at public parking lots, lobbies and parks who were nabbed by volunteers for a ten-minute practical on our manikins. At some of our sites, blood pressure checks or distribution of heart-wise literature was added. Whenever an AED was available, a lesson on its use was made available.

AEDs are now widely available on airliners, at airports and public arenas all over the world. Its proper use is prompted by computer diagnosis of the rhythm and taped verbal commands to the rescuer.

That automatic shock has saved countless lives. Teaching of the AED is a welcome addition to the training program but is currently only in transition.

Our Bay Area goal for 2017 is to teach another seven thousand people. The AHA impact goal for the year 2020 is to have reached sixty-two percent of the national population.

As for you, dear friends and colleagues, we invite you to sharpen your first-aid skills at one of our sites on June 2nd or 3rd, or to sign up for one of our more extensive certification programs.

Information on these courses is usually available through your local hospital or AHA division. But if you are a healthcare provider already trained in HOCPR, please volunteer to help teach for an hour or two at a local site. For more information, please call Antoinette Sobalvarro at our Greater Bay Area AHA office at (510) 903-4046 or e-mail her at antoinette.sobalvarro@heart. org. Come! Be prepared to help save a life! See you in June!

Collin P. Quock, MD, FACC, FAHA, is a former SFMS board member. He is a Clinical Professor of Medicine Emeritus, UCSF and Past Chief of Staff, Chinese Hospital. A long-time volunteer with the American Heart Association, he has served at every level of that organization in various capacities. He is on the AHA Bay Area HOCPR Task Force.

Author's Note: I want to thank Antoinette Sobalvarro, Terry Mock, Kula Koenig and Donna Lew, AHA Western Affiliate Staff, for their help with this article.

Reference 1. Ewy, G.A. “Chest Compression Only Cardiopulmonary Resuscitation for Primary Cardiac Arrest.” Circulation, Vol. 134, No. 10, pp. 695-697, September 6, 2016.

SAN FRANCISCO

ADDICTION SUMMIT 5th Annual David E. Smith, MD Symposium

Friday, June 9, 2017 | 8:30am - 5:30pm

UCSF Laurel Heights Auditorium, 3333 California Street, San Francisco Join us for an action-oriented forum with leading multidisciplinary faculty covering: • • • •

Opiates Pain management Alcohol abuse Tobacco

• Advances in addiction medicine and primary care • San Francisco problems and responses, and more!

For more information, visit www.sfms.org or contact Steve Heilig at heilig@sfms.org Event co-sponsored by: CME provided by CAFP

WWW.SFMS.ORG

APRIL 2017 SAN FRANCISCO MEDICINE

21

Emergency Medicine

PAIN WITHOUT GAIN On The Opioid Epidemic Hallam Gugelmann, MD, MPH The opioid epidemic continues, seemingly unabated, and the resulting strain on emergency medicine practitioners has never been greater. My first glimpse

of drug-seeking behavior was in medical school: a forty-ish man complaining of back pain after lifting a lawnmower into a pickup truck. The prescription drug monitoring program record revealed what has now become a familiar pattern: multiple prescribers, multiple pharmacies, and dozens of opioid and benzodiazepine prescriptions over the preceding six months. He was “doctor shopping,” a phenomenon I’d first heard of in William S. Burroughs’ Junky, where heroin addicts go from clinic to clinic to find a physician willing to prescribe morphine in exchange for cash. When confronted with his medication history the patient walked out of the room.

Since that encounter, my practice in emergency medicine has shown me hundreds of permutations of the same phenomenon. The volume of presentations associated with opioids is staggering. The Substance Abuse and Mental Health Services Administration reports that, of more than 1.2 million emergency room visits involving nonmedical use of pharmaceuticals in 2011, twenty-nine percent—more than 360,000—involved narcotic pain relievers.1 Given the coding criteria required by this study, these data likely significantly underestimate the true number of opioid-related emergency room visits. One study estimates that the 2007 health care costs associated with opioid abuse in California amounted to more than 4.2 billion dollars, with a total cost to the United States health care system of twenty-five billion dollars.2 The ground-level effect of this epidemic is harder to define, but is nonetheless a daily reality for the emergency room practitioner. We see acute overdoses, saved in the field by ambulance and fire crews who now rely more on naloxone than on any other rescue drug. We see neurological devastation after opioid overdose-induced anoxic brain injury. We see patients who, after months or years of gradually-increasing oral doses of opioids, shuffle from emergency room to emergency room for intravenous shots of hydromorphone to temporarily stave off pain and withdrawal. We see hyperalgesia, a paradoxical increase in pain with increasing doses of opioids in dependence.

We see patients whose inability to extract prescription opioids from legitimate medical prescribing has prompted them to turn to heroin, which is increasingly laced with fentanyl. We are constantly faced with a need to overcome anchoring bias and distinguish acute pathology from drug-seeking behavior. Above all, we attempt to balance compassionate care with a growing demand to avoid creating or perpetuating addiction.

The prescription opioid epidemic resulted from the confluence of miseducation, well-intended patient advocacy, and 22

shameless pharmaceutical marketing. Beginning in the 1980s, misleading scientific claims disseminated the belief that prescription opioids are rarely associated with addiction.3,4 In the late 1980s and early 1990s, cries of oligoanalgesia—readily adopted by drug company-funded “pain societies” including the American Academy of Pain Management and the American Pain Society—prompted the Joint Commission to create its 2000 standards for pain management.5,6 In the guise of patient interest, and facing a lack of regulation, pharmaceutical companies (most notably Purdue Pharma) used aggressive, unscrupulous maneuvering to massively increase opioid prescribing in the United States.7 Clinical decisions and actions in the emergency room are constantly under scrutiny. This definitely includes opioid prescribing practices, and not entirely without reason. A recent study concluded that long-term opioid use was more common in patients who received emergency care from high-intensity prescribers.8 Some groups provide their practitioners metrics on institutional ranking data on prescribing patterns, but these data don’t capture the complexities of caring for a prescription opioid addict in an emergency setting. These patient encounters are very often Pyrrhic victories: the patient’s anger, the time spent arguing, the other patients whose care is delayed all offset the feeling of doing the right thing, of not furthering the epidemic, and of doing no harm. Variability in both outpatient and emergency department opioid prescribing practices has created an extremely confusing situation for patients, and is probably creating more addicts. Patients whose primary care doctors prescribe opiates liberally have great difficulty grasping why an emergency practitioner wouldn’t do the same. Frequently, the encounter also undermines the relationship between emergency and outpatient providers: emergency practitioners who dispense opiates liberally may undermine the care plan of primary care providers.

Although the situation seems dire, there are three clear, evidence-based steps that emergency providers can take to help slow the opioid epidemic. First, emergency departments should adapt and adopt opioid prescribing guidelines. Originally developed and implemented statewide in Washington State, these documents provide a framework for caring for opioid-dependent and addicted patients.9 Second, emergency medicine practitioners should consider contacting the California Health Care Foundation to enroll in buprenorphine prescribing programs.

And third, every opioid-dependent or addicted patient seen in an emergency room should receive a prescription for naloxone, and brief information on how to administer it.

The United States—approximately five percent of the world’s population—consumes at least eight percent of the

SAN FRANCISCO MEDICINE APRIL 2017 WWW.SFMS.ORG

world’s prescription opioids.10 Every year, Britain, France, Germany, and Italy combined consume 3,237 grams of hydrocodone; the same figure for our country is 27.4 million grams.11 We in the emergency department have an obligation and a clear path to fight this epidemic, and its adverse effects on our patients demand that we do so.

Hallam Gugelmann, MD, MPH, is attending Physician at CPMC St Luke’s Hospital Emergency Department; Medical Toxicology Attending, University of California at San Francisco; and Assistant Medical Director, California Poison Control System, San Francisco Division. A full list of references is available online at www.sfms.org.

UCSF BENIOFF CHILDREN’S HOSPITAL EMERGENCY DEPARTMENT AT MISSION BAY Steven Bin, MD UCSF’s nineteen-bed Children’s Emergency Department (ED) treats the full range of illnesses and injuries that affect infants, children, and adolescents and was designed and built with children’s and families’ unique needs in mind. As the largest children’s ED in San Francisco and the Peninsula, we are staffed by doctors, nurses, and other specialists specially trained in children’s emergency medicine. We have access to more than 150 top-ranked pediatric experts and all the services of UCSF Benioff Children’s Hospital San Francisco. In addition to being a designated pediatric critical care receiving center by the City and County of San Francisco, our Emergency Department serves as a regional resource for referring physicians and other health care providers for consultation and treatment of children with complex, urgent medical needs.

Highlights

Join Operation Access for the Annual Gift of Health Breakfast on May 31 Operation Access services prevent colorectal cancer, medical emergencies, poor health outcomes, and economic distress for Bay Area families. They coordinated $19.7 million in donated care for over 1,200 clients in 2016. Tickets to the breakfast are complimentary, donations are accepted. Event proceeds benefit Operation Access.

Wednesday, May 31st, 2017 | 8:00am to 10:00 am The City Club of San Francisco 155 Sansome St., 11th Floor, San Francisco, CA Enjoy a fresh and hearty breakfast while you network with fellow health leaders and learn about the work of Operation Access. Anthony Iton, MD, JD, MPH, of The California Endowment will deliver the keynote address. Breakfast available starting at 8:00 am. Opportunities to network before and after the program. Visit www.operationaccess.org for details.

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• The February 2015 opening of our new children’s hospital—San Francisco’s only free-standing children’s hospital—in Mission Bay, which increased UCSF’s pediatric emergency volumes by more than sixty percent in its first year of operation.

• Child life specialists who help children be less fearful and better understand their treatment.

• Increased capacity (nineteen beds) that allows about ninety percent of patients to bypass the waiting room upon arrival and go directly to a patient care room. The average wait time between arriving at the ED and getting into a patient room is less than three minutes, ranking us in the top five percent of pediatric emergency departments in the country.

• A highly collaborative clinical environment staffed entirely by fellowship-trained pediatric emergency physicians and pediatric emergency nursing staff.

• The expansion of helicopter and rapid response transport services, including a heliport at the new hospital. With these expanded transport options, teams can mobilize even more quickly to take a child to tertiary care or conduct on-site rescues.

Address

UCSF Benioff Children’s Hospital San Francisco 1975 Fourth St., San Francisco, CA 94158 Phone: 415.353.1818 Physician Referrals: 877.822.4453 or 877 UC-CHILD Website: www.ucsfbenioffchildrens.org/emergency

Steven Bin, MD, is medical director and interim chief of Pediatric Emergency Medicine UCSF Benioff Children's Hospital, San Francisco

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Emergency Medicine

EMERGENCY PSYCHIATRY Programs That Reduce Psychiatric Patient Boarding and Improve Care Scott Zeller, MD, and Jamie Cerny The pervasive issue of boarding psychiatric patients in emergency departments (EDs) reveals a misaligned approach to the treatment of mental health emergencies in our country. The ED is tasked

with handling both medical and mental health problems, yet an ordinary ED lacks the adequate resources to promptly stabilize and treat psychiatric patients. As a result, the default treatment for patients experiencing a psychiatric emergency is to admit for inpatient care—opting for intensive hospitalization rather than engagement and community care. Without a sufficient number of psychiatric inpatient beds or psychiatrists to consult on every mental health patient, EDs nationwide face the problem of psychiatric boarding; patients who are otherwise medically stable must wait in the ED for psychiatric evaluation or disposition.

Boarding is no rare occurrence. A 2008 study by the American College of Emergency Physicians (ACEP) indicated that over ninety percent of EDs boarded psychiatric patients on a weekly basis—fifty-five percent on a daily basis—and the problem has only worsened in subsequent years.1 On average, psychiatric patients wait three times longer than other patients for a medical bed, and their average boarding time ranges from eight to thirty-four hours, translating to an average cost of $2,264 to the ED for each patient occurrence, just for the boarding segment of their visit.2,3 These waiting patients may be suffering from hallucinations, paranoia, confusion, or dysphoria and, during their time in the ED, are often untreated (or merely sedated) and isolated—many are kept under watch by a sitter, or restrained to gurneys in hallways or back exam rooms.

To appropriately and promptly treat these patients in a way that yields positive outcomes, for less than the current cost of boarding, the first step is to identify the earliest opportunity for intervention.

Typically, psychiatric boarding is excused as a consequence of insufficient inpatient psychiatric beds available for transfer from EDs, but this ignores the larger problem—namely that the default treatment for psychiatric emergencies is to ‘find an inpatient bed.’ In most other emergency medicine presentations—chest pain, for example—the ED physician would attempt stabilizing treatment and interventions prior to making an admission decision. Only ten percent of chest pain cases are admitted; if EDs simply resorted to finding an inpatient bed for such patients, we would be faced with the same boarding problem. Clearly the issue would not be availability of inpatient beds.

Psychiatric emergencies must be considered in the same way. If interventions begin at emergency care, only a small fraction of psychiatric emergency cases will need hospitalization, and beds are more likely to be available for those who do.3 24

So how do we shift the paradigm toward ‘care first, disposition decisions later’? Fortunately, there are solutions that have been proven effective and are currently utilized around the country, available for any hospital or care setting—from remote EDs with only a handful of mental health patients a week, to busy sites that see a dozen or more each day. Some options facilitate treatment quickly within the ED, while others involve specially-designed facilities that help prevent psychiatric patients from ever stepping foot in the ED. The key to de-escalating a psychiatric emergency is prompt patient evaluation by a psychiatrist and initiation of treatment as soon as possible. With this timely, appropriate intervention, the great majority of psychiatric emergencies can be stabilized in fewer than twenty-four hours.

For EDs with few psychiatric patient visits or limited resources, this intervention can be facilitated in a cost-effective manner with “on-demand telepsychiatry.” Telehealth technology allows ED staff to request a videoconference consult between the patient and a psychiatrist, often a specialist in emergency psychiatry, who may then recommend treatment and disposition options. Typically, a site will only pay for consults as needed, so if several days go by without any psychiatric patient visits, the site would not accrue any additional costs, as they would for an on-site or on-call psychiatrist. On-demand telepsychiatry has been proven to reduce psychiatric hospitalization rates and is associated with positive outcomes and high patient satisfaction scores.4 Currently, telepsychiatry is available in many states and will likely soon be an option in all.

One drawback to telepsychiatry, and telehealth in general, is that the technology is far more developed than the regulations governing its use. Doctors are currently required to be licensed in the state of the patient they are evaluating, limiting the pool of available telepsychiatrists, especially in states with smaller populations. In addition, contracting hospitals will still need each telepsychiatrist to be a fully-credentialed, duespaying member of their medical staff. As it can take as many as fifteen to twenty telepsychiatrists to cover each hospital 24/7, 365 days a year, this requirement can be very expensive and time-consuming for each site.

Further, while telepsychiatry in the ED is a major improvement over the status quo, it does not address adequately address the problem of treating psychiatric emergencies in the ED. Psychiatric patients are still held in the ED, surrounded by loud noises such as beeps and sirens, flashing lights, people rushing about frantically, and patients in severe pain—an environment that is not conducive to mental health healing. On top of that, even with a telepsychiatry consult, the logistics of an ED do not allow for treatment to be initiated, the patient to be observed

SAN FRANCISCO MEDICINE APRIL 2017 WWW.SFMS.ORG

over time, and then for a disposition decision to be made based on observed improvements. A solution to these issues is to create an alternative ED just for psychiatric care with trained staff and a calm, healing environment where mental health patients may receive ongoing treatment for up to twenty-four hours, emphasizing the importance of community care over institutionalization. These facilities have various names, but are most commonly known as a Psychiatric Emergency Service (PES) or a Crisis Stabilization Unit (CSU).

There are many variations on these models, but in general, a PES is staffed with mental health professionals trained to work with psychiatric patients. Their specialized training allows for reduced incidence of coercive treatment, such as forcible medication or physical restraints, and efforts are redirected towards collaborative engagement, with a goal of a community disposition rather than hospitalization, when appropriate. Time is allotted for medications to take effect, intoxication to subside, withdrawal symptoms to abate, or external issues to resolve before reevaluation to determine the appropriate disposition.

Nurses, therapists, and even former patients known as ‘peer counselors’ (in roles similar to Alcoholics Anonymous ‘sponsors’) intermingle with the patients, conducting anything from organized group therapy to supportive chats. These techniques help patients improve enough to avoid hospitalization in greater than seventy percent of cases where they would have otherwise been hospitalized. Furthermore, because only patients who truly have no alternative are admitted, psychiatric hospital beds are far more likely to be available than in systems where the default treatment is hospitalization.4 PESs can be set up to accept transfers from a hospital ED or multiple area EDs, or they can receive patients directly from the community, thereby circumventing the ED altogether. Such designs can greatly reduce boarding times for the surrounding EDs. In a 2014 study, a regional PES reduced the psychiatric patient boarding time in local EDs by over eighty percent below the state average, essentially eliminating the concept of boarding in the region.4 Operating a psychiatric emergency program to be financially self-sufficient can be a major benefit to hospitals and EDs in cost avoidance alone, as the per-patient cost can be less than the cost of ED boarding. Insurers, HMOs, Medicaid and other government payers will find tremendous savings by avoiding expensive psychiatric hospitalizations in a majority of their patients. As a result of these new practices, Emergency Psychiatry is evolving into a desirable and rapidly-growing subspecialty that is attracting both psychiatric and emergency medicine physicians. Large medical groups and care systems are beginning to see the value of adding an Emergency Psychiatry Practice Line to their integrated care strategies. This movement places an emphasis on psychiatric care that is high-quality, integrative, and appropriate for the patient, which ultimately reduces ED boarding, cuts costs, and improves patient satisfaction.

known as a leading expert in emergency psychiatry across the nation and around the world.

Jamie Cerny is the Project Analyst for CEP America’s Acute Psychiatry practice line. She is a graduate of the University of California, Berkeley with a Bachelor’s degree in Public Health and currently supports process improvement initiatives in hospital operations, specific to emergency psychiatry.

References 1. American College of Emergency Physicians. “ACEP Psychiatric and Substance Abuse Survey.” ACEP, Irving, TX, 2008.

2. Weiss AP, Chang G. et al. “Patient- and practice-related determinants of emergency department length of stay for patients with psychiatric illness.” Ann Emerg Med. 2012 Aug;60(2):162-71.

3. Zeller, S., Calma, N., & Stone, A. “Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments.” Western Journal of Emergency Medicine, 15(1), 1–6.

4. Deslich S, Stec B, Tomblin S, Coustasse A. “Telepsychiatry in the 21st Century: Transforming Healthcare with Technology.” Perspectives in Health Information Management / AHIMA, American Health Information Management Association. 2013;10(Summer):1f.

Tracy Zweig Associates INC.

A

REGISTRY

&

PLACEMENT

FIRM

~ Physicians ~ Nurse Practitioners Physician Assistants

Voice: 800-919-9141 or 805-641-9141 FAX: 805-641-9143 tzweig@tracyzweig.com www.tracyzweig.com

Scott L. Zeller, MD, is the Vice President of CEP America’s Acute Psychiatry practice line. Dr. Zeller is the former Chief of Psychiatric Emergency Services of the Alameda Health System, based in Oakland, CA and one of the busiest psychiatric Emergency Departments in the U.S. He is the author of several textbooks and numerous peer-reviewed articles on emergency psychiatry. He is WWW.SFMS.ORG

APRIL 2017 SAN FRANCISCO MEDICINE

25

MEDICAL COMMUNITY NEWS SFVAMC

C. Diana Nicoll, MD

Throughout our Health Care System, we focus on integrating nutrition, health and wellbeing efforts across the continuum of care as our patients are at high risk for nutritionally related chronic diseases, with rates of overweight and obesity at seventy-eight percent, hypertension thirty-six percent, and diabetes twenty-five percent.

To support improvements in health and medical management, our registered dietitian/nutritionists work closely with the medical team and Veterans to develop personalized nutrition goals to support healthy eating and reduce their diet- and nutrition-related risk factors. We offer individual nutrition counseling and group nutrition programs at our main campus and all our community clinics.

We have developed several successful weight management programs, the interdisciplinary MOVE! Strength and Wellness, Women’s MOVE!, and Mindful Movement MOVE! Yoga.

To support our rural Veteran populations, we utilize both video-telenutrition and telephone visits along with secure messaging to support individualized patient centered care.

Assisting Veterans in the development of personal lifestyle skills to support their health goals is a priority within our nutrition programs. We have a nationally recognized Healthy Teaching Kitchens Cooking Matters program at the San Francisco campus, a sixweek hands on cooking program where Veterans learn new skills and gain confidence in cooking and shopping for healthy eating. Due to the success of this program, versions for this program are now offered at four of our community clinics.

Our focus for hospitalized Veterans is modeling healthy eating practices with a menu that emphasizes fresh and seasonal ingredients, with our regular diet also being heart healthy. Our food service department has collaborated with the Veterans Affairs National Prime Vendor and the local Bay Area Hospital Team to advocate for locally grown produce and serve sustainably raised meats farmed without the use of antibiotics to the greatest extent possible.

26

SMMC

Carl Bricca, DO

The Spine Center at Dignity Health St. Mary’s Medical Center recently combined the minimally invasive iFuse Implant System® procedure with the Mazor Robotics Renaissance® Guidance System in order to perform California’s first robot-assisted fusion of the sacroiliac (SI) joint, which commonly causes lower back pain. Combining these two methods may allow more accurate implant placement and enhanced patient safety.

Using the Mazor surgical robot, Dimitriy Kondrashov, MD, a surgeon with St. Mary’s Spine Center and associate program director of the San Francisco Orthopaedic Residency Program, is able to quickly and precisely place the titanium iFuse implants across the SI joint to maximize SI joint fixation and postsurgical stability.

The minimally invasive procedure takes approximately one hour and is done through a small incision, avoiding damage to surrounding soft tissue. This reduces the need for postoperative immobilization and speeds up recovery, whereas traditional SI joint fusion involves open surgery to access the joint, remove bone, and perform a bone graft, often requiring days-long hospitalization.

The iFuse Implant System is intended for sacroiliac fusion for conditions including sacroiliac joint dysfunction that is a direct result of sacroiliac joint disruption and degenerative sacroiliitis. This includes symptoms that begin during pregnancy and have persisted postpartum for more than six months.

St. Mary’s is proud to be the only hospital in California to exclusively offer this stateof-the-art technology for spine surgery. This latest innovation adds to an impressive list of spinal devices and procedures researched and developed by the surgeons at the St. Mary’s Spine Center, including the X-Stop interspinous process device, ProDisc lumbar total disc replacement, FzioMed non-adhesive spinal gel, FlexiCore total disc replacement, CerviCore cervical disc replacement, Prestige cervical disc replacement, and Kiva vertebral augmentation system.

SFMH

Robert Harvey, MD

Dignity Health Saint Francis Memorial Hospital now offers minimally invasive, rotator cuff-sparing total shoulder replacement.

This groundbreaking technique leaves the rotator cuff tendons completely intact, allowing patients improved post-surgical function, substantially less pain, and a quicker recovery.

Robert Purchase, MD, medical director of shoulder surgery at Saint Francis Orthopedic Institute, was the first to use this highly specialized technique in California. In traditional shoulder replacement, a surgeon cuts through the rotator cuff tendons to gain access to the shoulder. Using this method, Dr. Purchase reaches the shoulder joint through a small opening between the tendons. Post-surgery, patients are in a sling for only a few days and can start rehab right away. Patients can achieve an increased range of motion and even full mobility in as little as three to five weeks as opposed to three to six months.

Dr. Purchase always advocates that patients explore non-surgical options first, but if those fail and their pain continues, this minimally invasive option can help patients get back to living their lives pain-free faster than with other surgical methods.

Saint Francis adds this game-changing procedure to a lineup of advanced surgical techniques and treatment options, including minimally invasive, robotic-assisted partial knee replacement and same-day anterior approach hip replacement surgery. Saint Francis Orthopedic Institute provides a continuum of orthopedic care, from orthopedic evaluation and surgery to acute rehabilitation and outpatient physical therapy.

SAN FRANCISCO MEDICINE APRIL 2017 WWW.SFMS.ORG

CPMC

Edward Eisler, MD

Kaiser Permanente Maria Ansari, MD

California Pacific Medical Center, which accounts for over twenty percent of all Emergency Department (ED) visits in San Francisco and twenty-five percent of all ambulance runs, is currently undergoing major new construction projects that will enhance emergency services in San Francisco. These significant improvements will increase ED capacity from the current forty-nine treatment bays to sixty-seven, allow CPMC to accommodate up to twenty thousand additional ED visits annually, provide additional critical disaster management resources, and prioritize comfort for patients and families.

The Castro (Davies) Campus remodel, which is scheduled to open in the fall of 2017, will expand the current number of ED treatment bays from twelve to fifteen. This will also improve the patient experience by adding additional private rooms and an upgraded patient triage/waiting room with efficiently designed work spaces. The Mission Bernal Campus (new St Luke’s) facility, with an anticipated opening of fall 2018, will more than double the ED’s current footprint, creating a total of sixteen private treatment rooms.

The hospital will continue to provide care to the local community with a focus on its Family Health Center, integrated Women’s Health Services and Elder Care program featuring a dedicated ACE (Acute Care for the Elderly) unit. The Van Ness Campus, which is slated to open in the summer of 2019, will consolidate acute care services currently provided at the Pacific and California Campuses. With the closure of the California Campus, women’s and children’s services will relocate to the Van Ness Campus. The Van Ness ED will have thirty-six private treatment rooms. This expansion of total ED beds will include a separate, dedicated Pediatric ED with its own waiting room, triage, resuscitation room and staff.

Urgent Care services/afterhours care is planned for the area near the California Campus, with details to being finalized soon. The Pacific Heights Outpatient Campus will provide only outpatient services.

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Our Emergency Medicine (EM) physicians are beginning to approach how they communicate with their emergency room patients in new and innovative ways. Because EM physicians routinely care for patients during times of acute, life-threatening medical crises, there is little time left for in depth discussions and further investigations into causes of issues that lead to an emergency department (ED) visit.

Historically, many EM physicians have been reluctant to have complex discussions with patients and families during these times because of the perception that they do not have the skills or time to engage. However, the hospital trajectory of care is often determined in an ED. Few EM physicians have had formal training in “goals of care” discussions, in which patient values are explored and then matched to an appropriate medical plan. As a result, there is growing concern that some patients are receiving invasive medical care that is both burdensome and inconsistent with their goals and values, particularly at the end of life.

At Kaiser Permanente (KP), Monique Schaulis, a KP San Francisco emergency and palliative care physician, together with a national group of like-minded EM physicians from both the community and academics, created an innovative communication training program for EM physicians –“EM Talk”. It is based on Vital Talk, a well-accepted communication training program to help doctors and patients improve communication around serious illness.

“EM Talk” was piloted at KP San Francisco in 2016 with each of our EM Physicians participating in a four-hour serious illness communication skills training. The course involves trained actors and typical difficult ED cases like metastatic cancer, sepsis, dementia, and other chronic illnesses. The program was very well received and plans to expand it include a widespread Kaiser Permanente San Francisco physician training based on Vital Talk.

ZSFG

Malini Kishen Singh, MD, MPH

Zuckerberg San Francisco General Hospital (ZSFG) first opened its doors May 21. The construction costs of $887.4 million for ZSFG was approved when voters passed Proposition A in November 2008. A large impetus for the new building was to have a seismically safe structure given that it is the only regional Level 1 trauma hospital serving San Francisco and Northern San Mateo counties. The new building is nine stories, with the Emergency Department (ED) on ground level built on base isolators that can glide thirty inches in either direction in the event of an earthquake.

The building is built with energy saving green technologies and light wells to allow natural light into each floor. The new ED is three to four times the square footage of our former ED with an increase from twenty-seven exam spaces to fifty-nine state of the art private exam rooms, which includes six dedicated resuscitation rooms, one Residential Treatment Center room with a dedicated shower to evaluate sexual assault victims, three isolation rooms with their own antechambers, a dedicated Ear Nose and Throat (ENT)/Ophthalmology room with dedicated equipment to evaluate ENT and eye emergencies, and our first ever Pediatric Emergency Department that has eight rooms with its own dedicated waiting room. Each room is outfitted with two sets of gases and emergency power to accommodate two patients in each room, allowing us to have a surge capacity of 120 patients in the event of a major disaster. If there is a chemical disaster, we have eighteen separate decontamination showers.

We have two Siemens Edge 128 slice CT scanners, and X-ray rooms outfitted with direct capture digital radiology machines, both fixed and portable, that are located in the resuscitation area of Emergency Department. Additionally, there are many technologies we were prviously without, and we have an imrpoved layout. ZSFG has enabled all of us to continue to provide the same quality of compassionate care to our community, further enhanced with the use of state of the art equipment in a more seismically sound plant.

APRIL 2017 SAN FRANCISCO MEDICINE

27

FROM THE AMA ACA Repeal and Replace Bill Dies—What’s Next for Health Care?

On Friday, March 24, House Speaker Paul Ryan and President Donald Trump pulled the American Health Care Act (AHCA) from a floor vote. The move followed a

six-week sprint to repeal and replace the Affordable Care Act (ACA) after it failed to garner enough votes within the House Republican caucus. Conceding defeat, Speaker Ryan called it a “major setback” and said Congress and the Trump Administration are moving on to other issues, such as tax reform. Speaker Ryan said, “President Obama’s health care law will be around for the foreseeable future.”

CMA worked with Republican leadership to improve the AHCA, but the final bill—polling nationally with only 17 percent support— raised too many concerns. CMA’s top priority was to increase Medicaid physician reimbursement rates to ensure patients had access to a doctor. CMA ran a unified grassroots effort with partners at the American Medical Association (AMA), California Dental Association (CDA), hospital groups, physician associations, and patient groups to stop the loss of health insurance coverage, severe Medicaid cuts and the erosion of access to care under the AHCA. CMA also opposed the proposed cuts to the ACA public health fund and Planned Parenthood. CMA wants to thank our physician leaders who made calls and met with Congressional representatives to educate them about the successes of the ACA and its failings, and where significant improvement is needed.

What Happened?

The defeat of the AHCA comes on the heels of intense lobbying

by President Trump and the House Republican leadership to unite support within the differing factions of the Republican Caucus. As the President made more concessions to the conservative Freedom Caucus (formerly the Tea Party Caucus), it eroded support among more moderate Republicans. The Freedom Caucus wanted a total repeal of the ACA, and they argued that the AHCA’s proposed tax credits constituted another entitlement program. The more moderate Republicans were concerned about the Medicaid cuts and the loss of insurance coverage.

With two final amendments to repeal the ACA’s Essential Health Benefits package, Speaker Ryan scheduled a floor vote for Thursday, but it was cancelled when he realized the votes were short. President Trump stepped in and called for Congress to remain in Washington and vote on Friday, daring the Freedom Caucus and others to vote against a bill that repealed the ACA – a law they had voted to repeal dozens of times over the last seven years. The President said that if the bill failed, he would move on to other issues. On Friday afternoon, when it was clear the bill would badly fail, President Trump and Speaker Ryan agreed to pull it. While many political pundits are blaming the loss on the 36-member Freedom Caucus, the bill lost because of the negative impact on millions of Americans, which ultimately moved the moderates to oppose it.

Once the non-partisan Congressional Budget Office (CBO) estimated that 24 million more Americans would be uninsured, a block of moderate Republicans began to quietly withhold their support. While the vote was ultimately canceled, at least 20-24 moderate Republicans would have likely voted against the bill (including a few Californians), according to organized medicine’s vote count.

This was enough to sink the legislation without the Freedom Caucus. Congressman Darrell Issa (R-San Diego) said “the ACHA was 28

an imperfect approach,” and he believed “Congress could do better.”

What Happens Next?

After the bill was withdrawn, President Trump said he might be amenable to reopening negotiations with the Democrats “when the ACA explodes.” Many conservative economists don’t believe the ACA will implode in the near future; however, it is unclear whether the Trump Administration will reach out to Democrats or adopt regulations to hasten the demise of the ACA. Earlier this year, the Administration attempted to stop advertising for the ACA’s open enrollment.

They also announced they will give states more flexibility under Medicaid to institute work requirements, among other things. While they can do a few things to cut funding, it is difficult to dismantle the law without Congress. Democrats have expressed interest in making improvements to the ACA; including shoring-up the individual market with more reinsurance support that could reduce premiums and providing more assistance to families with high-deductibles that block them from accessing care.

While CMA supports many parts of the ACA, CMA agrees it needs immediate improvement. The ACA Medicaid changes expanded health care coverage to 3.7 million Californians, yet many have no access to a doctor. CMA’s goal is to increase Medi-Cal reimbursement rates so that patients can find a doctor when they need one. CMA will also keep fighting to enforce more patient choice of physicians within health plan networks. CMA supports stabilizing the individual market through increased access to reinsurance, which would spread the risk in the pool and make insurance more affordable. One of the reasons Covered California’s average 4 percent premium increases jumped to 13 percent in 2017 was the loss of reinsurance funding, which was cut by Republicans but inadequately funded by the ACA. Working with partners, CMA will continue to work with Congress and the Trump Administration to create a bipartisan environment to reform our health care system so that it works for physicians and patients (see attached infographic). And we will vigilantly protect those parts of our health care system that are working.

CMA’s Core Principles for Health Care Reform:

1. Improve access to physicians.

2. Ensure Californians do not lose coverage.

3. Protect state and federal Medicaid funding.

4. Continue tax policies and subsidies that help low-moderate income patients afford coverage.

5. Advocate for broad patient choice of physicians, plans and coverage through Health Savings Accounts (HAS), private contracting, private insurers, and government programs.

6. Maintain the important insurance reforms that protect physicians and their patients, such as coverage for pre-existing conditions, no lifetime/annual limits on benefits, essential health benefits, and coverage for children up to age 26 on parent’s policies.

7. Stabilize the individual insurance market by funding reinsurance for catastrophic cases and incenting healthy to purchase coverage.

8. Provide access to affordable prescription drugs.

9. Eliminate regulatory burdens in the Medicaid and Medicare programs.

10. Medical liability reform that does not undermine California’s MICRA law.

SAN FRANCISCO MEDICINE APRIL 2017 WWW.SFMS.ORG

Resilience - A New Take on Wellness

Free CME Program for San Francisco Physicians Can a successful physician really enjoy work-life balance?

Please join us May 11, 2017 as Carole A. Lambert, MPA, RN, Vice President, Practice Optimization at the Cooperative of American Physicians (CAP) presents Resilience - A New Take On Wellness.

This presentation will address the topics of why we worry about physician wellness and why we characterize our lives as unbalanced. Most advice tells us to search for work-life balance: that work is bad and life happens when we are not at work.

A more achievable goal and more enduring result is resilience...the capacity to live life to the fullest and face adversity, change and challenge with purpose and determination.

CAP is proud to join the San Francisco Medical Society in hosting this free, no-obligation CME* program.

We look forward to an evening of refreshments, hors d’oeuvres, and learning with you.

Join Us:

Thursday, May 11, 2017 The Learning Center Zuckerberg San Francisco General Hospital 1001 Potrero Avenue, Building 30, 2nd Floor San Francisco, CA 94110

Event Times:

5:30 p.m. — Networking and Refreshments 6:00 p.m. to 7:00 p.m. — Program

Cost:

Free for all physicians - please bring a colleague

Reserve Your Spot Today!

For Your Protection. For Your Success.

About CAP: The Cooperative of American Physicians, Inc. provides California’s finest physicians with superior medical professional liability protection at remarkably low rates as well as an incredible variety of resources to help them run a safe and successful medical practice.

http://sfms.pingg.com/newtakeonwellness Call or email Erin Henke: 415-561-0850 ext. 268 ehenke@sfms.org

Space is limited, so RSVP by May 4, 2017

About SFMS:

*This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Institute for Medical Quality/California Medical Association (IMQ/CMA) through the joint providership of the Cooperative of American Physicians, Inc. and the San Francisco Medical Society.

The San Francisco Medical Society unites dedicated physicians to champion quality health care and innovation for our patients and community and serves the professional needs of all San Francisco physicians.

The Cooperative of American Physicians, Inc. designates this live lecture for a maximum of (1) AMA PRA Category 1 Credit(s)™.

Physicians should claim only the credit commensurate with the extent of their participation in the activity.

UPCOMING EVENTS CMA Legislative Advocacy Day April 18, 2017 | Sheraton Grand, Sacramento The California Medical Association will host is 43rd annual Legislative Advocacy Day on April 18th. Join SFMS at the State Capitol to learn about legislative issues affecting medicine, foster relationships with state legislators, and gain hands on experience in the practical aspects of physician advocacy. SFMS members will have the opportunity to meet with legislators.

All meetings with legislators will be scheduled and coordinated

by SFMS. Visit http://www.sfms.org/events/lobby-day.aspx for more information or to register.

Physician Investment Discussion Group

April 25, 2017 - 6:00pm to 7:30pm | Mechanics Bank - 343 Sansome St. 15th Floor, San Francisco | Join us for a quarterly discussion group for SFMS member physicians and associates who are interested in learning more about investing. The informal group provides an opportunity to learn and grow as an investor—from basic to more advanced concepts. For more information or to RSVP, contact George Fouras, MD, at geofou@ sbcglobal.net or Roger Eng, MD, at rseng8@yahoo.com. Please

note: This discussion group does not offer investment or financial planning advice, nor do we promote any financial products or services. SFMS is not liable for any risks associated with investment/financial decisions made as a result of participating in the discussion group.

Western Health Care Leadership Academy May 5-7, 2017 | Marriott Marquis San Diego Marina | Save the date for the 20th Annual Western Health Care Leadership Academy. The 2017 Leadership Academy will continue its mission of providing the information and skills needed to succeed in today’s rapidly changing health care marketplace. Visit http:// bit.ly/2kXOkjG for more information.

CME Program: Resilience – A New Take on Physician Wellness

May 11, 2017 – 5:30pm to 7:00pm | The Learning Center at Zuckerberg San Francisco General Hospital | Presented by the Cooperative of American Physicians. Attend a physician mixer and educational program highlighting resilience, with its emphasis on developing the capacity to live life to the fullest and face adversity, change and challenge with purpose and determination, as a more realistic, achievable and enduring response to the demands of a physician’s life. Open to SFMS members and non-members—bring a colleague! Drinks and refreshments will be provided. To register, contact Erin Henke at ehenke@sfms.org or (415) 561-0850 x268.

San Francisco Addiction Summit: 5th Annual David E. Smith, MD Symposium

June 9, 2017 8:30am - 5:30pm | UCSF Laurel Heights Auditorium | Join us for an action-oriented forum with leading multidisciplinary faculty covering opiates, pain management, alcohol abuse, tobacco, advances in addiction medicine and 30

primary care, and more. Event co-sponsored by SFMS, SFDPH, CAFP, UCSF. CME provided by CAFP. For more information, contact Steve Heilig at heilig@sfms.org or (415) 561-0850 x270.

UPCOMING WEBINARS

Implementing Strategies to Enhance Advance Care Planning April 12, 2017 | 12:15pm - 1:15pm | Discussing care goals with patients is often challenging, especially during a serious illness or toward the end of life. This webinar will review the kinds of conversations that are necessary for effective advance care planning and when to have them. Register at https://www. cmanet.org/events/register/attendees.

Antibiotic Resistance: Global Threats and Novel Responses

April 20, 2017 | 10:00am | Learn more about global resistance, agricultural policy and a novel educational strategy during a webinar panel, moderated by SFMS’s Steve Heilig, and featuring David Wallinga, MD, author of an article in the March issue of SF Medicine. Visit http://bit.ly/2mwOgEg for more information.

Aligning Clinical Practice with Diabetes Prevention: Screen, Test and Refer

April 26, 2017 | 12:15pm - 1:15pm | Diabetes remains one of Californias fastest-growing and most costly diseases. An estimated 2.5 million California adults have been diagnosed with diabetes and 13 million—nearly half of the states adult population—have prediabetes, increasing their risk of developing diabetes over the next few years. Register at https://www.cmanet. org/events/register/attendees.

Welcome SFMS New Members!

David Omar Andino-nieves, MD | Internal Medicine Arash Babaki, MD | Internal Medicine Ashish Patel, MD | Internal Medicine HOUSE OFFICERS Scott Bauer, MD, MSc | Internal Medicine Jessica Bloome, MD, MPH | Internal Medicine Timothy Judson, MD, MPH | Internal Medicine Monika Roy, MD | Infectious Disease STUDENTS Theora Bordon Cimino Cameron Donald

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SAN FRANCISCO MEDICINE APRIL 2017 WWW.SFMS.ORG

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