a) Advocate for a change with your national college. For us that is the American College of Emergency Physicians and the Society of Academic Emergency Medicine

 

b) familiarize yourself with what options your patients have and where they can turn to for resources. It may be possible to get training in medical abortion depending on where you live

c) states where abortion remains legal will see an Increasing volume of patients seeking termination of pregnancy. There may be scope to to set up innovative programs for medical termination in the emergency department

Dr. Seth Berkowitz and Economist Hunt Alcott join us to discuss nutrition, food insecurity, and their relevance to emergency medicine. What questions can we ask to identify food insecurity quickly? What resources can we offer patients? How might it affect our clinical decision making?  

Objectives:

1. Explore how nutrition affects the health of patients in the ED
2. Identify factors that contribute to patient’s nutritional status
3. Understand how to effectively and efficiently address nutrition with ED patients
   
   

Take-home points:

1. Food insecurity can play a critical role in the health outcomes of ED patients in the following ways:
2. 1. Food insecurity can lead to poor quality diet with health consequences
   2. Patients with food insecurity may have competing demands. If you are worrying about paying for meals, you might have to decide between food and important issues like housing or medications, all of which can affect your health.
   3. High levels of stress related to food can put a strain on a patient’s mental and physical health.
   1. Know your hospital and community’s ability to address food insecurity. If a patient screens positive on the Hunger Vital Sign, you can link them to community resources like food pantries, SNAP or WIC.
3. Consider screening your patients for food insecurity using the Hunger Vital Sign (see link in references). 
4. Low income neighborhoods have less access to lots of things, including grocery stores. Many stores in these neighborhoods limit options for healthy eating.
5. Nutrition education for your patients can make a difference. Recognize that nutrition education may be the limiting factor as to why your patients are not eating nutritious food, so taking a moment to talk about it can make a difference.
6. Be mindful of how food access may affect your treatment plan for your patient, particularly with food-sensitive conditions like diabetes. 

Additional Resources:

1. Food Deserts and the Causes of Nutritional Inequality, Alcott et al.  
2. Health effects of dietary risks in 195 countries, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017, The Lancet. 
3. The Hunger Vital Sign
4. Gattu RK, Paik G, Wang Y, Ray P, Lichenstein R, Black MM. The Hunger Vital Sign Identifies Household Food Insecurity among Children in Emergency Departments and Primary Care. Children (Basel). 2019;6(10):107. Published 2019 Oct 2. doi:10.3390/children6100107
5. SNAP-ED

Guests:

Dr. Seth Berkowitz is an assistant professor in the division of general medicine and clinical epidemiology of medicine at the University of North Carolina and has done extensive research on food insecurity and its relation to human health, particularly in low-income patients and patients suffering from type II diabetes.

Hunt Allcott is an Associate Professor of Economics at NYU whose research includes investigation on consumer behavior.  He recently co-authored a 2018 study entitled “Food Deserts and the Causes of Nutritional Inequality”. 

Contributors:

• Bobby Needleman
• Dennis Hsieh
• Shannon Moffett
• Tony Spadaro

Drs. Otis Warren and Shannon Smith-Bernardin join us to discuss how alcohol relates to social issues. What more can we do for patients that are brought in drunk? What solutions exist at both the individual ED and healthcare system level? 

Objectives: 

1. Understand the challenges in treating alcohol use disorder in the emergency department
2. Understand alcohol use in the context of social determinants of health
3. Learn about diversion/sobering centers and their potential impact on the treatment of alcohol use disorder and emergency departments

Take-home points: 

1. Alcohol use disorder is a chronic disease that should be treated as such. Many of the drivers of alcohol-related ED encounters, however, are driven by social factors. 
2. Sobering centers are an alternative to the emergency department or jail for people who are acutely intoxicated on alcohol.
3. Diversion is a triage system that is based on an agreement between law enforcement and EMS allowing for diversion of intoxicated patients to sobering centers if they meet certain criteria. 

Additional resources: 

Warren O, Smith-Bernardin S, Jamieson K, Zaller N, Liferidge A. Identification and Practice Patterns of Sobering Centers in the United States. J Health Care Poor Underserved. 2016;27(4):1843‐1857. doi:10.1353/hpu.2016.0166

Smith-Bernardin SM, Kennel M, Yeh C. EMS Can Safely Transport Intoxicated Patients to a Sobering Center as an Alternate Destination. Ann Emerg Med. 2019;74(1):112‐118. doi:10.1016/j.annemergmed.2019.02.004

Smith-Bernardin S, Carrico A, Max W, Chapman S. Utilization of a Sobering Center for Acute Alcohol Intoxication. Acad Emerg Med. 2017;24(9):1060‐1071. doi:10.1111/acem.13219

Guests:

Shannon Smith-Bernardin

Dr. Smith-Bernardin is a professor at UCSF and has a PhD in nursing and health policy. She has extensive experience with sobering centers and diversion programs and has studied their safety, effectiveness, and implementation.

Otis Warren

Otis Warren is an Associate Professor of Emergency Medicine at Brown University. Dr. Warren has been a champion for sobering centers in and around Providence, RI. He and Dr. Smith-Bernadin authored "Identification and Practice Patterns of Sobering Centers in the United States" in the Journal of Health Care for the Poor and Underserved, helping launch the national debate on diversion of intoxicated patients away from emergency departments and to sobering centers.

Contributors:

• Charles Zhang
• Harrison Alter
• Livia Santiago-Rosado
• Austin Tam

Across the US, LatinX and Black people are dying from COVID-19 at twice the rate of their white counterparts. In this special episode of Announce, hosts Drs. Ayesha Khan & Quincy Moore explore some of the issues underlying these disparities and what EM providers need to be aware of to combat them.

Additional Resources:

As a doctor, how do I tell a black family of five, struck by the virus, to ‘social distance’ in a two-bedroom apartment? -- Garth Walker

COVID-19 Racial Disparities in U.S. Counties, The Foundation for AIDS Research.

Vahidy FS, Nicolas JC, Meeks JR, et al. Racial and Ethnic Disparities in SARS-CoV-2 Pandemic: Analysis of a COVID-19 Observational Registry for a Diverse U.S. Metropolitan Population. medRxiv. January 2020:2020.04.24.20073148. doi:10.1101/2020.04.24.20073148

Guests:

Dr. Garth Walker is an emergency physician in Chicago whose research focuses around health disparities and social determinants of health.

Dr. Italo Brown is an emergency physician at Stanford with an interest in health equity, and barbershop-based health initiatives.

Dr. Moises Gallegos is an emergency medicine physician at Stanford. He is a Faculty Fellow at the Hispanic Center of Excellence. 

Contributors:

• Quincy Moore

• Ayesha Khan

Drs. Sheryl Heron and Camara Phyllis Jones join us to discuss race and how it affects our practice in the ED.

Objectives: 

• Debunk misunderstandings about the biological basis of race
• Analyze the relationship between race, social determinants of health, and health outcomes
• Discuss interventions that work to improve racial health disparities
• Predict how race may play a role in current policy and public health problems

Take-home points: 

1. Race is a social, not biological, construction 
2. Ancestry is poor marker genetics, and race a poor indicator of ancestry
3. Racial health disparities are driven by racial disparities in social determinants of health
4. Residential segregation is a large driver of disparities in SDH
5. Working deliberately to treat racial groups similarly on individual and population levels is necessary to ameliorating racial health disparities

Additional resources: 

Allegories on Race and Racism. Camara Jones, TEDxEmory

https://www.youtube.com/watch?v=GNhcY6fTyBM

Cohan D, Racist Like Me — A Call to Self-Reflection and Action for White Physicians. N Engl J Med 2019; 380:805-807

Jones CP. Levels of Racism: A Theoretical Framework and a Gardener’s Tale. Am J Public Health 2000; 90:1212-1215 

Williams DR, American A, Wyatt R. Racial Bias in Health Care and Health Challenges and Opportunities. JAMA 2015;314(6):555–6

Washington, HA. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present.  Harlem Moon an imprint of DoubleDay Publishing 2007

Guests:

Sheryl L. Heron, MD, MPH, FACEP Sheryl Heron is a Professor and Vice Chair of Administrative Affairs in Emergency Medicine and an Assistant Dean of Medical Education and Student Affairs at Emory University. While her accomplishments are too numerous to list, her 20 year career in emergency medicine, academia and public health, has led to national recognition as an expert on diversity and inclusion in medicine. Dr. Heron has also lectured and published extensively on diversity and inclusion in medicine. Most recently, she served as co-editor of the textbook, Diversity and Inclusion in Patient Care.

Camara Phyllis Jones, M.D., M.P.H., Ph.D Jones is a former president of the American Public Health Association and Adjunct Professor at the Morehouse School of Medicine and Emory Rollins School of Public Health. She has also served as the Research Director on Social Determinants of Health and Equity in the Division of Adult and Community Health at the CDC. As a family physician and epidemiologist, Dr. Jones’s work focuses on the impacts of racism on the health and well-being of the nation. From TED talks to National Symposia, Dr. Jones’ allegorical pedagogy has elevated the national dialogue on race and health.

Contributors:

John Lewis

Dan Gingold

Sean Schnarr

Jenny Tsai

Our team took a breather for the holidays. Tune in February 1st for another episode!

In the U.S., a homeless person’s lifespan is 25 years less than average. In this episode, hosts Dr. Ayesha Khan & Dr. Quincy Moore explore how the EM providers can be pivotal in improving health outcomes for those that lack basic shelter with Dr. Kelly Doran and Stephen Brown.

Objectives:

1.     Describe how housing and homelessness affect a person's health and health outcomes

2.     Describe why emergency physicians should be addressing housing and homelessness

3.     Define important terms relevant to housing and homelessness: transient, intermittent, and chronic

4.     Highlight strategies for eliciting key information from patients

5.     Discuss how best to process and address a patient’s housing status in the ED

Additional Resources:

Housing and Health: An Overview of Literature

https://www.healthaffairs.org/do/10.1377/hpb20180313.396577/full/ https://www.rwjf.org/en/library/research/2011/05/housing-and-health.html

Medical Respites

https://nhchc.org/clinical-practice/medical-respite-care/

How Can Emergency Departments Help End Homelessness? A Challenge to Social Emergency Medicine

https://www.clinicalkey.com/#!/content/journal/1-s2.0-S0196064419311266

Uptodate: Healthcare of Homeless Persons in the United States

https://www.uptodate.com/contents/health-care-of-homeless-persons-in-the-united-states?search=homelessness&source=search_result&selectedTitle=1~102&usage_type=default&display_rank=1

Take-home points: 

1. There are 3 definitions within the category of homelessness.  

• Transitionally homeless: 80% of homeless individuals in the U.S. Often times these are people who have fallen off the grid maybe due a financial catastrophe and they're mostly back into housing within 3 months.  
• Episodic homelessness: People that are in and out of housing, couch surfing, or intermittently employed.  Many of the people that age out of foster care belong to this group. There's less known about this population.  Often, they also have a subacute mental illness that make it difficult to get the care they need.  
• Chronic homelessness: 10% of the overall homeless population, tend to have high comorbidity with psychiatric illness and substance abuse.  They're usually older and they're continually homeless over one year or homeless 4 times in the past 3 years. These tend to be the ones that are most easily identifiable in the ED.  

2. With just 10% of homelessness being chronically homeless, we need to do a better job routinely asking people about their housing status.  Possible questions to identify homelessness in your history include:

• "Where have you been staying at these days?"  

•  Ask a follow-up question like "Is that an apartment?  Someone else's house? A shelter?"

3. When dispositioning your patient, consider the treatment plan and if the patient is in a place they can follow it. Even shelters do not provide 24hour sheltering. Consider medical respite or admission if needed.

4. Half of homelessness is in urban areas, 25% in suburban areas, and 18% in rural areas.  

5. Ideally when we think about homelessness, we're trying to address the tri-morbidity of homelessness, substance use, and psychiatric illness. 

6. Don't forget, help your patient get undressed and do a physical exam.  It can be dangerous to avoid doing this.  

7. This is a difficult population to work with and no one has all the answers including both of our experts, but it's important to recognize how challenging this is and support our especially young providers in trying to treat these patients even when you don't have a ton of resources.  Try to make a difference in policies locally and nationally or even within your hospital to both help the problem and help a little bit with your tolerance of day-to-day frustrations. Connect to partners in the community or the Public Health Department to find collaborators. Emergency physicians really are the experts in homelessness and we can make a big difference in people’s lives.

Contributors:

• Crystal Donelan

• Sonal Batra

• Dennis Hsieh

• David Cheever

• Alexander Ulintz

Guests:

Dr. Kelly Doran is an emergency physician and faculty in the NYU School of Medicine Departments of Emergency Medicine and Population Health who studies how healthcare systems can better address homelessness and other social determinants of health. Her research on homelessness has been published extensively and she was previously an advisor to the New York State Department of Health on an innovative program to use Medicaid funds to support housing.

Stephen Brown is a MSW LCSW who is faculty and Director of Preventative Emergency Medicine at the University of Illinois at Chicago.  After a career in business, he switched gears to work as a social worker in the ED and soon afterward, was promoted to build a program to provide care coordination for high-utilizers of the ED.  He is now the program director for Better Health Through Housing which transitions patients that are chronically homeless into permanent supportive housing. His work on this project has been featured in the Chicago Tribune.

Objectives:

-       To introduce the concept of social determinants of health

-       To outline the ways in which social determinants of health affect the practice of emergency medicine

-       To highlight key reasons why emergency providers should care about social determinants of health

-       Introduce ways in which emergency providers can effectively identify social issues that might be affecting their patients’ health

Take-home points:

-       Try to avoid compartmentalizing your patients’ health. Social issues affect their health and you should take the time to identify and address them in the emergency department.

-       Recognize when it is important to practice “slow medicine” and take the time to talk with your patients about how you can best help them.

-       To change the culture of your department, first try to find, or create, impactful data. Then seek out funding to support your work. Data and funding will help garner support.

-       Think about how you can make an impact on the population level. Be bold. Step outside your comfort zone and always do the right thing for the patient.

Additional resources:

A centralized website for all things Social EM, highlighting important literature, a library of social EM initiatives, and creating a network for the social EM community. 

www.SocialEMpact.com

ACEP Social Emergency Medicine Section. https://www.acep.org/how-we-serve/sections/social-emergency-medicine/

SAEM Social Emergency Medicine and Population Health Section. https://www.saem.org/resources/social-emergency-medicine-and-population-health/research

"Inventing Social Emergency Medicine," supplement to Annals of Emergency Medicine

www.annemergmed.com/issue/S0196-0644(19)X0013-X

Anderson ES, Lippert S, Newberry J, Bernstein E, Alter HJ, Wang NE. Addressing social determinants of health from the emergency department through social emergency medicine. Western Journal of Emergency Medicine. 2016 Jul;17(4):487.

Alter HJ. Social determinants of health: from bench to bedside. JAMA internal medicine. 2014 Apr 1;174(4):543-5.

IDHEAL Social Emergency Medicine Teaching Modules. http://www.idheal-ucla.org/page-12/

Episode transcript

Contributors:

• Ayesha Khan
• Quincy Moore

Objectives:

• Outline the scope of the opioid epidemic as it relates to Emergency Medicine

• Detail innovative treatment options for opioid use disorder and overdose

• Discuss strategies and barriers to implementing ED-based Medication for Opioid Use Disorder (MOUD)

• Provide possible future strategies and necessary policy changes

Take-home points: 

• Opioid use disorder is a disease that is often chronic and relapsing

• Prescribing buprenorphine is easy and it only takes one person to start doing it. See the show notes for resources to help. 

• It’s helpful to have a champion for OUD treatment in the ED. The medical director is well positioned for this. 

• Find a community champion who can help continue treatment outside of the ED

• Stigma affects both providers and patients. Learn your terms and try to be consistent with their use: opioid use disorder (OUD), Medication for Addiction Therapy (MAT), and Medication for Opioid Use Disorder (MOUD). 

• Treatment for OUD can be with naltrexone, methadone, and buprenorphine. Buprenorphine is a partial opioid agonist and the best-suited for ED treatment. 

• You can use the COWS score to assess your patients for opioid withdrawal.

   

Outside resources: 

Emergency Department Contribution to the Prescription Opioid Epidemic

https://www.ncbi.nlm.nih.gov/pubmed/29373155

What Role Has Emergency Medicine Played in theOpioid Epidemic: Partner in Crime or Canary in theCoal Mine?

https://www.annemergmed.com/article/S0196-0644(18)30046-5/pdf

ACEP opioid resources

https://www.acep.org/by-medical-focus/mental-health--substance-abuse/opioids/#sm.0001e74hrth2sdxcqs82pd3l195ch

Emergency department–initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial

https://www.ncbi.nlm.nih.gov/pubmed/25919527

Resources that support medication-based treatment in the ED

https://medicine.yale.edu/edbup/

https://www.bridgetotreatment.org/

Contributors:

• John Purakal
• Maureen Gang
• Caleb Scarth
• Nate Coggins

Guests:

Gail D’Onofrio, MD, MS, is the chair of emergency medicine at Yale Medicine. She is internationally known for her work in substance use disorders, women’s cardiovascular health, and mentoring physician scientists in developing independent research careers. For the past 25 years she has developed and tested interventions for alcohol, opioids and other substance use disorders, serving as the principal investigator (PI) on several large NIH, SAMSHA, and CDC studies. She is a founding Board member of Addiction Medicine, now recognized as a new specialty, subspecialty by the American Board of Medical Specialties.

Lewis Nelson, MD, is Professor and Chair of the Department of Emergency Medicine and Chief of the Division of Medical Toxicology at Rutgers New Jersey Medical School in Newark, NJ. He is a member of the Board of Directors of the American Board of Emergency Medicine and a Past-President of the American College of Medical Toxicology. He is actively involved with several governmental and professional organizations and is an editor of Goldfrank’s Toxicologic Emergencies. His areas of specific interest include consequences of opioids, pain management, and emerging drugs of abuse.

In our debut episode, hosts Drs. Ayesha Khan & Quincy Moore along with special guest host Dr. Vibha Gupta sit down with our guests, Dr. Mary Cheffers (LA County), Dr. Todd Schneberk (LA County) and Mrs. Mayra Joachin (Attorney, National Immigration Law Center) to discuss what emergency providers should know about their patients with immigration-related issues.

Objectives:

• Learn the effects of anti-immigrant legislation on seeking care and ED presentation

• Learn barriers immigrants and undocumented patients face in seeking care

• Learn what rights undocumented patients in the ED have

• Learn where you can connect your patients to legal aid and healthcare resources

• Know your options when ICE shows up to your ED