Download Summer 2016 Issue

A Newsletter for the Members of the Utah Chapter
John Dayton, MD, FACEP
President & Newsletter Editor
Paige DeMille
Executive Secretary
Phone: 801.747.3500
Fax: 801.747.3501
From the President
John Dayton, MD, FACEP
Our goal for Utah ACEP is to be a valuable resource for both education and advocacy for Emergency Physicians
that practice in Utah. I’d like to highlight some of our recent efforts and future goals:
Advocacy in Utah

UtahAccess+: Last fall, Governor Herbert proposed UtahAccess+, a plan to expand Medicaid by increasing
the cost of physician licenses to at least $5,000. By surveying our members, we found that while most are in
favor of Medicaid expansion, 98.5% were not in favor of a new license tax to accomplish that goal. With that
in mind, our leaders talked with legislators and worked with other specialty groups at the annual Utah
Medical Association (UMA) House of Delegates to not only stop UtahAccess+ but also to propose other

solutions.
Doctors Day at the Legislature: This annual event is sponsored by the UMA, takes place at the State
Capitol building, and is attended by Utah ACEP leaders. This year, we spoke with our State Legislators
about proposed legislation involving Utah’s Controlled Substance Database, marijuana, and a Nurse

Practitioner request to increasing their scope of practice.
Legislative Committee: As both a national ACEP Councilor and Chair of the UMA Legislative Committee,
Dr. Jim Antinori is our advocacy leader. Dr. Antinori, who works at the VA and Jordan Valley West (Pioneer
Valley), reviews all proposed state legislation that could impact patients and physicians, and discusses the
potential impact with the Legislative Committee to determine what position the UMA should take on the
legislation.
National Advocacy

Leadership and Advocacy Conference: This annual ACEP conference takes place in Washington DC and
combines education on political issues affecting emergency medicine with lobbying appointments with our
state’s Senators and Representatives and their staff. This year, we were represented by Board members
Dr. H. Todd Yeates, who works at St. Marks and Lone Peak Hospital, and Dr. Eric Schenfeld, who works

at IHC facilities.
ACEP Council: Our state has four Councilors who attend this annual event that meets a few days before
the annual Scientific Assembly. Last October, our Councilors were involved in discussing how ACEP would
address national issues like expert witness testimony, medication shortages, and psychiatric care. ACEP
policy changes were also discussed including EMRA representation, reimbursement for ultrasound
studies performed by physicians, and patient satisfaction scores.
Education Resources

2015 Utah Emergency Medicine Physicians’ Summit: Our first annual conference featured Dr. Stephen
Anderson, form ACEP’s Board of Directors, Dr. Haney Mallemat, #FOAMed Contributor, and Senator Brian
Shiozawa, MD. Almost ninety physicians enjoyed lectures, ultrasound training, LLSA review and
networking. This event was provided for free thanks to an ACEP Section grant contest that our Board won.
It was also inspired and led by our Immediate Past President, Dr. Geoff Crockett, who works at both Park

City and Heber Valley Medical Centers.
Resident Conference: You can watch Resident Conference and receive free CME! To watch the
University of Utah’s Emergency Medicine Residency conferences, follow the instructions Dr. Susan Stroud
provided in the 2015 Newsletter (2nd article) to set up accounts with Schoology and Evernote and access
this resource.
Upcoming Events

2016 Utah Summit: This year’s event will feature our national ACEP President, Dr. Jay Kaplan, lectures,
ultrasound training and an LLSA review. It will take place on Friday, September 23rd at the Raddisson
Downtown Hotel in Salt Lake City. To register, go to this Eventbrite page or contact Paige De Mille at
Paige DeMille or call 801.747.3500 x228.

2016 UMA House of Delegates: If you are interested in representing your colleagues and your practice
group, this is an annual UMA meeting involving leaders from each specialty. Our Board will be representing
you as well. This year’s event will take place on September 16th and 17th at the Homestead Resort in

Midway.
ACEP Council: We have four Councillors who will attend this year’s Council meeting at ACEP16 in Las
Vegas.
If you would like to be involved on the Utah ACEP Board, write an article for the Newsletter, or have questions or
concerns, please click here to e-mail me.
Washington DC ACEP Conference
H. Todd Yeates, MD, Utah ACEP Treasurer
Eric Schenfeld, MD, Utah ACEP Board Member
(From left to right, Dr. Todd Yeates, Dr. Eric Schenfeld, Dr. Alison Smith, and Dr. Sean Slack)
ACEP’s annual Leadership and Advocacy Conference was held in Washington, D.C. in May of this year. The
Utah Chapter of the American College of Emergency Medicine had four representatives attend to support and
advocate for our patients, fellow physicians and profession. During the upcoming legislative session, there are
several important bills being presented. Our UCEP delegation had an opportunity to meet with the offices of our
Utah Senators and Representatives. The conference attendees focused on four legislative priorities:

Mental Health Reform. Emergency mental health care is limited and there are significant barriers to
providing timely and appropriate care for patients struggling with mental health disease. There are current
bills in both the House and the Senate (House Bill 2646 and Senate Bill 1945) which address these issues.
Some of their issues include extending Assisted Outpatient Treatment grants, modifying HIPAA regulations
to allow better communication between healthcare providers and a patient’s caregivers, and promoting
telemedicine services. In addition, we advocated for increases in funding for research and services related

to those with mental health disorders and disabilities.
The Opioid Epidemic. Fortunately, most of the legislators on the hill are already aware of this issue and
many bills are being considered regarding the opioid epidemic. ACEP advocated to keep physicians
involved in the legislative process and to work with legislators to develop guidelines and best care practices
for use of opioids, as well as to increase access to naloxone and assistance for those who struggle with

opioid addiction.
Improving EMS Delivery of Care. The DEA recently became aware that current legislation prohibits
prehospital providers from administering schedule II-IV medications using standing orders from medical
control; in effect, this makes the practice of an EMT utilizing a benzodiazepine to break a seizure illegal.
The "Protecting Patient Access to Emergency Medications Act" (House Bill HR 4365) will allow prehospital
providers to continue acting on standing orders to provide both opioids and benzodiazepines per preestablished guidelines thereby saving lives, expediting appropriate care and decreasing pain in the pre-

hospital setting.
Medical Liability Reform for EMTALA Services. This legislation, the “Health Care Safety Net
Enhancement Act” (House Bill 836), seeks to expand liability protections for any medical providers who are
acting under the EMTALA mandate. This would include emergency physicians as well as all specialist
consultants. This will help ensure that emergency and on-call physicians remain available to treat patients in
their communities.
Each of these issues affects all emergency physicians in Utah on nearly every shift. By attending the Leadership
and Advocacy Conference, we were able to be a part of the conversation by advocating for our patients, our state,
and our profession. One positive and tangible byproduct of our meetings is that Congressman Chris Stewart (R) has
expressed interest in visiting an emergency department in Utah to develop a better understanding of our challenges
and current needs.
Advocacy for our profession is essential in ensuring that we, as physicians, are able to provide the best care
possible to our patients while maintaining a favorable practice environment. The Leadership and Advocacy
Conference is open to all ACEP members interested in making a difference in the future of our profession and we,
as Utah ACEP, encourage you to participate next March.
Residency Update
Susan K. Stroud, MD
Residency Director
Utah ACEP Board Member
Thank you to every Utah ACEP member for your continued generous support of our residents. Your support has
made it possible for all of our residents to be members of ACEP, UCEP, and EMRA, and learn the importance of
belonging to an organization dedicated to advocating nationally and locally for patients and emergency physicians.
With the addition of our residents as members of Utah ACEP, we were able to qualify for an additional Councilor
position (and an additional vote) in the ACEP National Council increasing our state’s representation in the national
organization.
The class of 2016 will graduate at the end of June, and are headed for exciting opportunities in a wide variety of
practice settings. Here is where this year's graduates are headed (L to R):

Hill Stoecklein – EMS fellowship at the University of Utah

Jamie McGinnity – Portland, Oregon

Chad Agy – Utah Emergency Physicians, Salt Lake City, UT

Mike Morgan – Global Health Fellowship at the University of Utah

Dave Wagner – Santa Cruz, CA

Cody Hood – Bozeman, MT

Angela Jarman – Global Health Fellowship at Brown University in Providence, RI

Zak Drapkin – Pediatric Emergency Medicine Fellowship at Primary Children’s Medical Center
We also welcome the class of 2019 who will be starting their residency in June. We have been very successful in
recruiting a stellar class from all over the country. Here is where our new residents are coming from:

Mark Carlberg– SUNY Upstate

Brennen Holt – University of Utah

Noah Jordahl – University of North Carolina

Chris Kelly – Stony Brook University

Anne Porter – Medical College of Wisconsin

Christine Nelson – University of Nevada

Lisa Rodziewicz – Emory University


Kara Sawyer – University of Washington
Lucy Unger – Vanderbilt University
Thanks for continuing to welcome our residents into our community and supporting them throughout their training.
Poisonous Mushrooms
Tim Fuller, MD
PGY-2 Resident
Springtime is here, and with it, the spring rains. Even though Utah is more arid than the rest of the US, there are still
plenty of mushrooms popping up in our own backyards and the many square miles of wilderness we have in the
state. So what better time to review these fascinating organisms and a few of the many varieties of poisonous
mushrooms that we could encounter in the ED.
Of all mushroom poisonings, perhaps the most feared is that of the death cap mushroom, or amanita phalloides,
which contains amatoxin. Amatoxin is a cyclopeptide that disrupts RNA polymerase II thus preventing transcription
of DNA. For this reason, the toxic effects of amatoxin are manifested most strikingly in rapidly dividing cells of the GI
epithelium, liver and kidneys.
Clinical manifestations of amatoxin can be divided into 3 phases:

In phase 1 the patient will experience severe gastroenteritis-like symptoms; this occurs approximately 5-6
hours after ingestion.

Phase II is considered the quiescent phase and begins approximately 12-36 hours after ingestion. During
this time the patient’s clinical symptoms resolve, but insidious hepatotoxicity begins.

In Phase III (2-6 days post ingestion) the clinical manifestations of the patient’s hepatic and renal failure
become apparent, resulting in hypoglycemia, jaundice, hepatic coma, and eventually death.
Treatment for amatoxin poisoning is variable and not well established. In most cases a variety of potential antidotes
are utilized. Fluid and electrolyte repletion are paramount, both in phase I and beyond. Activated charcoal, which
absorbs amatoxin, should be administered every 2-4 hours or continuously via NG. N-acetylcysteine is thought to
be hepatoprotective and should be administered as well. Silybum marianum or milk thistle extract and high dose
penicillin G (1g/kg) are both thought to interfere with hepatocyte uptake of amatoxin and show improved outcomes
in animal studies. Hemodialysis may provide a benefit, but only if used immediately post-ingestion (prior to symptom
onset). Finally, liver transplant may be necessary, although there are no clear guidelines to suggest when or with
what criteria transplantation should occur. Therefore, transplant surgeons should be involved early on in the
patient’s course.
While amatoxin poisonings are the most feared mushroom poisonings, they are also very rare in the United States.
Perhaps the most likely mushroom intoxication we will encounter in Utah is that of the psilocybin containing
mushrooms, colloquially known as psychedelic mushrooms.
Psilocybin is a tryptamine similar to naturally occurring serotonin and melatonin. It is rapidly hydrolyzed to psilocin
which acts on our 5-HT receptors involved in myriad neuronal pathways including mood, appetite, sleep
regulation, sexuality, pain perception, and others. Its exact mechanism for causing visual hallucinations is not
completely understood.
Patients who have ingested psilocybin containing mushrooms may experience lightheadedness, weakness, anxiety,
and GI upset within 30-60 minutes. Within 4 hours the onset of visual illusions and hallucinations will have occurred
as well as sympathomimetic symptoms including tachycardia, mydriasis, tremor, and agitation. After 6-12 hours all
symptoms will have resolved.
Patients will typically present to the ED confused and anxious. Supportive care such as a darkened quiet room with
friends and family at bedside should be offered. Benzodiazepines can be administered for severe anxiety
and antipsychotics may be beneficial for frank hallucinations. Although deaths have been reported with psilocybin
use, they are exceptionally rare and were likely the result of co-ingestions with other street drugs.
Morel mushrooms are some of the most prized edible mushrooms in the United States. To the untrained eye the
false morel, or gyromitra esculenta, may be mistaken for its edible cousin. However, eating this “false morel” will
result in sickness and in some rare cases, even death. Gyromitra esculenta mushrooms contain
gyromitrin toxin, which after ingestion is hydrolyzed to multiple hydrazines (a component of rocket fuel). These
hydrazines interact with pyridoxal 5’-phosphate and inhibit GABA production. Patients will initially experience GI
upset, headaches, muscle weakness and cramps 5-10 hours post ingestion. At 12-48 hours, on rare occasions,
they may experience delirium, stupor, seizures, coma, and death. Most of the treatment centers on supportive care,
however activated charcoal should also be given. Benzodiazepines should be administered if the patient seizes and
pyridoxine should be administered in an attempt to overcome the PLP inhibition of gyromitrin toxin. Overall, most of
these patients will do well with minimal interventions.
Poisonous mushroom ingestions are not a common presenting complaint or diagnosis in the arid state of Utah.
However, with ever increasing immigrant populations who are used to foraging in their homelands, and with the
recent burgeoning interest in ethnobotany and home foraging in this country, it is likely that these presentations will
continue to increase. By knowing the signs, symptoms, and treatments of different mushroom poisonings, we can
be better prepared to prevent the significant mortality and morbidity associated with these ingestions.
Reference:

Nelson L, Goldfrank LR. Goldfrank's Toxicologic Emergencies. 10th ed. New York: McGraw-Hill Medical Pub. Division; 2015.

Images from Wikimedia Commons
Clinical News
Avoid Airway Catastrophes on the Extremes of Minute Ventilation
Emergency airways commonly involve challenges of tube placement and oxygenation before and during the
procedure. There are a handful of instances, however, when the issue is ventilation and, more specifically, extremes
of minute ventilation. Minute ventilation is the amount of air the patient moves in one minute; it is a product of the
ventilatory rate and tidal volume (minus dead-space ventilation).
Read more
When to Use Fluoroquinolones in Pediatric Patients
The best questions often stem from the inquisitive learner. As educators, we love—and are always humbled—by
those moments when we get to say, “I don’t know.” For some of these questions, some may already know the
answers. For others, some may never have thought to ask the question. For all, questions, comments, concerns,
and critiques are encouraged. Welcome to the Kids Korner.
Read more
Benzodiazepine Prescriptions, Overdose Deaths on the Rise in U.S.
Even as opiate abuse has become a growing problem in the U.S., overdose deaths involving sedatives and
antiseizure medications in the benzodiazepine category have also risen steeply, according to a recent study.
Prescriptions for benzodiazepines have more than tripled and fatal overdoses have more than quadrupled in the
past 20 years,researchers found.
Read more
Make A Difference: Write That Council Resolution!
Many College members introduce new ideas and current issues to ACEP through Council resolutions. This may
sound daunting to our newer members, but the good news is that only takes two ACEP members to submit a
resolution for Council consideration. In just a few months the ACEP Council will meet and consider numerous
resolutions.
ACEP’s Council, the major governing body for the College, considers resolutions annually in conjunction with
Scientific Assembly. During this annual meeting, the Council considers many resolutions, ranging from College
regulations to major policy initiatives thus directing fund allocation. This year there are 394 councillors representing
chapters, sections, AACEM, CORD, EMRA, and SAEM.
The Council meeting is your opportunity to make an impact and influence the agenda for the coming years. If you
have a hot topic that you believe the College should address, now is the time to start writing that resolution.
I’m ready to write my resolution
Resolutions consist of a descriptive Title, a Whereas section, and finally, the Resolved section. The Council only
considers the Resolved when it votes, and the Resolved is what the Board of Directors reviews to direct College
resources. The Whereas section is the background, and explains the logic of your Resolved. Whereas statements
should be short, focus on the facts, and include any available statistics. The Resolved statement should be direct
and include recommended action, such as a new policy or action by the College.
There are two types of resolutions: general resolutions and Bylaws resolutions. General resolutions require a
majority vote for adoption and Bylaws resolutions require a two-thirds vote. When writing Bylaws resolutions, list the
Article number and Section from the Bylaws you wish to amend. The resolution should show the current language
Bylaws language with additions identified in bold, green, underline text and red strikethrough for any deleted text.
Please refer to the ACEP Web site article, “Guidelines for Writing Resolutions,” for additional details about the
process and tips on writing a resolution.
I want to submit my resolution
Resolutions must be submitted by at least two members or by any component body represented in the Council. The
national ACEP Board of Directors or an ACEP committee can also submit a resolution. The Board of Directors
must review any resolution from an ACEP committee, and usually reviews all drafts at their June meeting. Bylaws
resolutions are reviewed by the Bylaws Committee to ensure there are no conflicts with the current Bylaws. Any
suggestions for modifications are referred back to the authors of the resolution for consideration. Resolutions may
be submitted by mail, fax, or email (preferred). Resolutions are due at least 90 days before the Council meeting.
This year the deadline is July 27, 2015.
Debating the resolution
Councillors receive the resolutions prior to the annual meeting along with background information and cost
information developed by ACEP staff. Resolutions are assigned to reference committees for discussion at the
Council meeting. You, as the author of your resolution, should attend the reference committee that discusses your
resolution. Reference committees allow for open debate and participants often have questions that are best
answered by the author. At the conclusion of the hearings, the reference committee summarizes the debate and
makes a recommendation to the Council.
The Council considers the recommendations from the reference committees on the second day of the Council
meeting. The reference committee presents each resolution providing a recommendation and summary of the
debate to the Council. The Council debates each resolution and offers amendments as appropriate. Any ACEP
member may attend the Council meeting, but only certified councillors are allowed to participate in the floor debate
and vote. Non-councillors may address the Council at the discretion of the Speaker. Such requests must be
submitted in writing to the Speaker before the debate. Include your name, organization affiliation, issue to address,
and the rationale for speaking to the Council. Alternatively, you may ask your component body to designate you as
an alternate councillor status and permission for Council floor access during debate.
The Council’s options are: Adopt the resolution as written; Adopt as Amended by the Council; Refer to the Board,
the Council Steering Committee, or the Bylaws Interpretation Committee; Not Adopt (defeat or reject) the
resolution.
Hints from Successful Resolution Authors

Present your resolution to your component body for sponsorship consideration prior to the submission
deadline.

Consider the practical applications of your resolution. A well-written resolution that speaks to an important
issue in a practical way passes through the Council much more easily.

Do a little homework before submitting your resolution. The ACEP website is a great place to start. Does
ACEP already have a policy on this topic? Has the Council considered this before? What happened?

Find and contact the other stakeholders for your topic. They have valuable insight and expertise. Those
stakeholders may co-sponsor your resolution.

Attend debate concerning your resolution in both reference committee and before the Council. If you cannot
attend, prepare another ACEP member to represent you.
I need more resources
Visit ACEP’s website. Review the “Guidelines for Writing Resolutions” prior to submitting your resolution. There is
also information about the Council Standing Rules, Council committees, and
Councillor/Alternate Councillor position descriptions. Of special note, there is a link to Actions on Council
Resolutions. This link contains information about resolutions adopted by the Council and Board of Directors in prior
years.
Well, get to it
Writing and submitting Council resolutions keeps our College healthy and vital. A Council resolution is a great way
for members to provide information to their colleagues and ACEP leadership. Please take advantage of this
opportunity and exercise your rights as part of our Emergency Medicine community. Dare to make a difference by
submitting a resolution to the ACEP Council!
ACEP’s 2016 “Leadership & Advocacy Conference” brings hundreds of
Emergency Physicians to Washington, DC and Capitol Hill
A record number of nearly 600 emergency physicians visited with federal legislators and staff on Capitol Hill on May
17 during the ACEP 2016 Leadership and Advocacy Conference in Washington, DC. Conference attendees
(including residents and many first-timers) from 47 states, the District of Columbia and Puerto Rico participated in
405 meetings in Capitol Hill offices with legislators and/or their health care staff.
The conference touched on several important topics such as ACEP’s Registry (CEDR), recently released
regulations shaping the new physician payment system, strategies to deal with out of network billing issues and the
importance of physician involvement in the political process. During ACEP’s “Lobby Day” on Capitol Hill, ACEP
members:

Asked legislators to re-engage legislative efforts to expand access to psychiatric services and provide
appropriate mental health resources for constituents and patients with mental illness.

Informed legislators and staff on emergency medicine principles for opioid prescribing.

Asked legislators to “co-sponsor” bipartisan legislation to protect the current practice of using written
“standing orders” by physician medical directors overseeing care provided in the field by paramedics and
other EMS practitioners.

Thanked the 100 plus sponsors of the “Health Care Safety Net Enhancement Act of 2015” (H.R.836/S.884),
legislation that provides medical liability relief for physicians providing care under the EMTALA mandate,

and asked other legislators for support.
Invited legislators and their staff to visit a local Emergency Department.
The Lobby Day issue papers are available on the ACEP Advocacy website with your ACEP login credentials.
ACEP President Dr. Jay Kaplan introduced LAC attendees to a brand-new advocacy platform powered by
Phone2Action. The tool has many uses including social integrations, telephone services, and email tools that
provide multiple ways to engage with lawmakers on critical public policy issues. Several state chapters have already
utilized Phone 2 Action for advocacy campaigns on the state level.
During LAC, participants used the platform to alert legislators that ACEP members were coming to Capitol Hill and
to provide materials in advance on the key issues that would be discussed in the meetings. In just a few minutes
time, simply by using their smartphones, LAC attendees sent more than 1,200 communications to legislators
instantly via email, Twitter, and Facebook.
Watch Dr. Kaplan cheer on LAC attendees as their messages were sent live to legislators from all over the
nation.
If you were unable to attend the LAC16 Conference this year, you can participate in ACEP’s “Virtual Lobby Day” by
visiting the ACEP Grassroots Advocacy Website and clicking “Take Action.”
Update on ACEP 911 Grassroots Network “Triple E” Campaign
Although the "Triple E Campaign" contest concluded last year, our work isn't over! Efforts to “Expand – Enhance
– Engage” participation in the 911 Legislative Grassroots
Network are ongoing.
Several chapters and organizations were recognized during ACEP15 for their outstanding efforts during the
campaign:

Arizona Chapter ACEP (AzCEP),

Emergency Medicine Residents' Association (EMRA),

Michigan College of Emergency Physicians (MCEP),


North Carolina College of Emergency Physicians (NCCEP), and
Texas College of Emergency Physicians (TCEP).
ACEP continues to seek new participants in the 911 Network and there are still congressional districts that do not
have ACEP member representation in the 911 Network. View current Chapter progress and encourage ACEP
members to sign-up with their login credentials on the ACEP Grassroots Advocacy Center here.
Utah Chapter ACEP, 310 E 4500 South #500,
Salt Lake City, UT 84107
Copyright © 2016 Utah Chapter ACEP. All rights reserved.
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