The Pulse- Summer 2019 by ACOEP

SUMMER 2019

HELPING VULNERABLE POPULATIONS HELPING PATIENTS WITH AUTISM AND THEIR FAMILIES NAVIGATE EMERGENCY VISITS PG 15

CREATING A GERIATRIC FRIENDLY EMERGENCY DEPARTMENT PG 21

PSYCHOLOGICAL BARRIERS TO CARE FOR THE HOMELESS PATIENT PG 33

E THE DATE V A S GREETINGS FROM

JW Marri ott

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The Pulse VOLUME XLI No. 3

TABLE OF CONTENTS EDITORIAL STAFF Timothy Cheslock, DO, FACOEP, Editor Wayne Jones, DO, FACOEP-D, Assistant Editor Tanner Gronowski, DO, Associate Editor Justin Grill, DO, FACOEP John C. Prestosh, DO, FACOEP-D Christine F. Giesa, DO, FACOEP-D Erin Sernoffsky, Director of Media Services Janice Wachtler, Executive Director Gabi Crowley, Senior Communications Manager EDITORIAL COMMITTEE Timothy Cheslock, DO, FACOEP, Chair Justin Grill, DO, FACOEP John C. Prestosh, DO, FACOEP-D Roseanna Roundtree. DO, FACOEP Kaitlin Bowers, DO Tanner Gronowski, DO Dominic Williams, DO Erin Sernoffsky, Director of Media Services

PRESIDENTIAL VIEWPOINTS Christine Giesa, DO, FACOEP-D

THE EDITOR'S DESK Tim Cheslock, DO, FACOEP

EXECUTIVE DIRECTOR’S DESK Janice Wachtler, BAE, CBA

THE ON-DECK CIRCLE Robert Suter, DO, MHA, FACOEP-D

FOEM FOCUS Janice Wachtler, BAE, CBA

CONFRONTING HUMAN TRAFFICKING Jenny Reyes, DO

HELPING PATIENTS WITH AUTISM AND THEIR FAMILIES NAVIGATE EMERGENCY VISITS Rena Sorensen, PhD and Laura Srivorakiat, PsyD

The Pulse is a copyrighted quarterly publication distributed at no cost by ACOEP to its Members, Colleges of Osteopathic Medicine, sponsors, exhibitors, and liaison associations recognized by the national offices of ACOEP.

SPECIAL NEEDS CHILDREN AND ED VISITS: WHAT MEDICAL STAFF SHOULD KNOW Karen Ursic, MA

The Pulse and ACOEP accept no responsibility for the statements made by authors, contributors, and/ or advertisers in this publication; nor do they accept responsibility for consequences or response to an advertisement. All articles and artwork remain the property of The Pulse and will not be returned.

CREATING A GERIATRIC-FRIENDLY EMERGENCY DEPARTMENT Elizabeth Baum, MD

COMMUNICATION: IT’S CRITICAL TO CARE Michelle L. Stransky and Megan A. Morris

HELPING THE UNINSURED Janice Wachtler, BAE, CBA

PSYCHOLOGICAL BARRIERS TO CARE FOR THE HOMELESS PATIENT Erin Sernoffsky, ACOEP Staff

ACOEP’S COMMITTEE FOR WOMEN IN EMERGENCY MEDICINE UPDATE Teagan L. Lukacs, DO, MPH, MBS

RSO UPDATE! Dominic Williams, DO, RSO President

ETHICS IN EMERGENCY MEDICINE: WHAT WOULD YOU DO? Bernard Heilicser, DO, MS, FACEP, FACOEP-D

Display and print advertisements are accepted by the publication through ACOEP, 142 East Ontario Street, Chicago, IL 60611, (312) 587-3709, or electronically at marketing@acoep.org. Please contact ACOEP for the specific rates, due dates, and print specifications. Deadlines for the submission of articles are as follows: January issue due date is November 15; April issue due date is February 15; July issue due date is May 15; October issue due date is August 15. Advertisement due dates can be found by downloading ACOEP's media kit at www.acoep.org/advertising. ACOEP and the Editorial Board of The Pulse reserve the right to decline advertising and articles for any issue. ©ACOEP 2019 – All rights reserved. Articles may not be reproduced without the expressed, written approval of ACOEP and the author. ACOEP is a registered trademark of the American College of Osteopathic Emergency Physicians.

PRESIDENTIAL VIEWPOINTS

Christine Giesa, DO, FACOEP

PRESIDENTIAL UPDATE

e’ve all heard it before: emergency departments are the front door to healthcare in America. Emergency departments are open to everyone— the uninsured, the undocumented, all socioeconomic groups. The emergency department is the catch-all for anyone seeking healthcare. We work with people at their most vulnerable, made all the more complicated when treating patients who already have barriers to quality care. This can include everything from language, to patients dealing with dementia, chronic health problems, mental illness, or homelessness. The list goes on and on. As we strive to help everyone who comes through our doors, we often become jaded, seeing these complications as a hassle that makes our jobs harder rather than an opportunity to show increased sensitivity and care to a person in need. This slide into weariness is natural and can seem inevitable. Swapping war stories at conferences or with a new class of students is helpful—it connects us and makes us feel as though we’re not alone and that we’ve earned our stripes. It can transform harrowing or stressful incidents into anecdotes which makes them less impactful. Unfortunately, this can also mean we don’t see the patient as a person and instead view them as an endless list of complaints, a story to be told later. We stop asking why a patient might be difficult and how we can

WE STOP ASKING WHY A PATIENT MIGHT BE DIFFICULT AND HOW WE CAN HELP, PORTRAYING THEM AS AN ADVERSARY THAT FORCES US TO SPEND INCREASED TIME CHARTING.” help, portraying them as an adversary that forces us to spend increased time charting. One way to combat this form of burnout is to find strength in community. This is just one reason I am so proud of our ACOEP family. We offer so many ways to be involved, to find support and guidance. Even seemingly unrelated avenues can help—you can join the EMS Committee and become involved in supporting legislation about Naloxone availability, for example. Affecting real, tangible change in this way not only helps patients, but gives us a sense of accomplishment when we otherwise feel at the mercy of the healthcare machine.

ACOEP’S COMMITTEE FOR WOMEN IN EMERGENCY MEDICINE Even though this is one of ACOEP’s newer initiatives, the Committee for Women in Emergency Medicine has quickly become a cornerstone in our community. Join us for social events, service projects, lecture series, and so much more.

This Committee clearly shines a light on the complex issues women in EM face and offers real-world strategies for ensuring success, supporting fellow women in EM, and celebrating excellence.

NEW PHYSICIANS IN PRACTICE As the old adage goes, ‘begin as you mean to go on,’ and for ACOEP’s New Physicians in Practice this includes joining a strong family of doctors going through the same difficult transition. Members of the NPIP begin their career by supporting each other, building confidence in critical skills, learning how to negotiate contracts, and navigating the difficult task of starting a career out strong. By starting out with strong skills and coping techniques, ACOEP’s NPIP are better prepared than ever to face the challenges of a career in EM.

SHARE YOUR EXPERIENCE You have seen it all, and you have wisdom to pass along. ACOEP gives you so many avenues to impart your hard-learned lessons, such as

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THE PULSE SUMMER 2019

THE EDITOR’S DESK

Tim Cheslock, DO, FACOEP

s emergency physicians we deal with challenging patient populations daily. We often encounter those that need help but have no place to go for care. Because of this, many patients wait to have their health problems addressed after things have progressed to the point of crisis. Some are sent to us and don’t want to be there, while others come in for non-medical assistance such as food, shelter from the elements, or a clean pair of clothes and the opportunity for fresh water to bathe. Homeless patients provide an ongoing challenge for management and safe disposition, which are complex problems for many reasons. EMTALA obligations must be met, but the real challenge comes in finding a safe disposition and assisting the patient in any countless number of ways. Some require medications they can’t afford, while some need transportation. Many just want a meal and somewhere to sleep. Hospital systems have taken many different approaches to helping the homeless. Some provide a sandwich pack prior to discharge. Often the intoxicated homeless patient will get to sleep it off in the ED if space permits. Others require assistance beyond the typical resources of the ED. Many need follow-up primary care, which is often difficult to obtain given the patients lack of resources and insurance. Some academic centers have resident clinics that provide some relief to this population, though compliance with appointments is

HOMELESS PATIENTS, A CHALLENGE AND A CRISIS often as big a challenge as finding them an appointment to begin with. Specialty evaluation is also an enormous challenge. Hospital social workers often have an idea of what can be scheduled, with whom, and which specialists are more apt to see patients who lack resources. Tragically, this is often not enough and many still slip through the cracks. Recent legislation often forces healthcare facilities to do more but does not supply the additional funds to accomplish the task. Such is the case with a California law mandating that hospitals provide increased services to the homeless population. The California legislation requires hospitals to provide meals and weather-appropriate clothing to homeless patients when needed and to offer them transportation to their next destination upon discharged if it’s within 30 miles or 30 minutes of the hospital. The law stops short of requiring hospitals to provide temporary housing, but it increases the demand on hospitals to do more. Recuperative care facilities can help lessen the impact on hospitals, but in many states these facilities are lacking or are woefully inadequate to meet the need. Many hospitals work with community non-profit groups to partner and strategize solutions to cope with the ongoing issue of homelessness. Legislation, such as California’s, increases the urgency to address the situation because of it’s unfunded mandate to provide specific resources to the homeless.

In addition to grass roots efforts at the community level, the federal government does offer different types of grant funding to help mitigate the ongoing homeless situation. Information on these grant programs, including the application process, can be found at HHS.gov. There is an entire section of the website dedicated to grants for vulnerable populations including the homeless. There are many examples of creative programs developed by community non-profits in conjunction with hospital support in different areas across the country. A few of the approaches that may already be functioning in your community include volunteer services of clinicians at free healthcare clinics, sample medications from the pharmaceutical industry, or mobile mass-care events to provide basic services such as dental cleanings, emergency dental procedures, immunizations, or other basic services. This crisis in healthcare is not going away. We all need to work creatively in our departments and in conjunction with our hospitals to help deal with this situation head on. If you have a great program in your community that you have access to through your department, please let us know. It would be great to highlight some of these programs in future issues of The Pulse to inspire others in their quest to deal with this ongoing challenge. –•–

SUMMER 2019 THE PULSE

EXECUTIVE DIRECTOR’S DESK

Janice Wachtler, BAE, CBA

PAYING IT FORWARD

or many years I walked to work, and speaking to people on your way was always your protection. If you spoke with a doorman or valet attendant, odds were they would watch for you on a regular basis. So, if you weren’t on your regular route, they’d watch out for you. Similarly, it gave me a network of people I would have never known. That led me to meeting a man named Bob, who just happened to be sitting on a milk crate at the corner near my parking garage. I said hello and gave him the loose change in my coat pocket. As the time passed, l learned his name was Bob and he was an ex-con just newly released from an eight-year stint for killing someone in a gang fight. He was living in a group home just a few blocks from where he decided to sit and ask for money. Each day we spoke, and he’d tell me about his day—who was nice to him, what corners were better spots, and about a hierarchy on the streets. He told me that he ‘was cleared to move’ and suddenly appeared outside of Burberry’s store on Ontario and Michigan. One day as he sat soaking

wet from a sudden downpour, I asked him if he wanted to join me at McDonald’s for dinner. I learned that he was only six months older than I was and had been married and had a son, who was now a lawyer on LaSalle Street, but his son wanted little or nothing to do with him because he still occasionally used drugs. As our friendship deepened, I learned he knew a whole lot of people. He’d met Mayor Daley on one of the Mayor’s famous walks from the office and he gave Bob a dollar he signed, which Bob kept in a special wallet hung around his neck. I also learned he was not getting any kind of social service care, but that he was eligible for Social Security. One Saturday, I came and met him at a Starbucks and we went online and got him registered for Social Security. Since he had to have an address, I paid for a post office box where he could get his check. The next issue was healthcare and, while I couldn’t figure out the twists and turns of the Affordable Care Act, a friend of mine was able to register him and he had a regular doctor at Northwestern Hospital. Over time, I bought him new boots for Christmas and gave him a down coat and flannel shirts from my

...JUST BY SAYING HELLO ONE DAY I GOT TO KNOW SOMEONE WHO HELD AND HOLDS A SPECIAL PLACE IN MY HEART – EVEN TODAY.”

dad’s closet. But the hardest thing was finding him housing. When his parole was up, the state gave him the boot, putting him on the street 24/7. He told me he’d met up with a friend, Lester, and they had found a two-bedroom apartment on the near west side. They were pooling their money to stay there. I was pleased that he had found a spot and could get off the street, but then I met Lester and wasn’t too happy that he was the man Bob hooked his star to. Lester was about Bob’s age, but mean and rugged. He bore scars from knife fights and gang tattoos on his hands. Frankly, he scared me. After that, Bob began to deteriorate. He was losing things; he’d lost the Daley autographed dollar, he told me of bouts of diarrhea and chills, and swore he wasn’t doing drugs. Then he disappeared. One Saturday I got a call from a shelter in the South Loop – they had found Bob, beaten up and on drugs near his usual spot, and my name was on his phone. The counselor said not to come to see him, but that he was calling for me and wanted me to know where he was. I said “OK” and waited. I spoke to the counselor several times and was told that they had gotten him housing up in Evanston and that he wouldn’t be back on the streets. Ha, I thought. They didn’t know Bob. Sure enough, six weeks later, he was back, on the corner of Ontario and Michigan, back to his friends and his birds and was sober. Now, he was seeing a doctor at Northwestern semi-

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THE PULSE SUMMER 2019

THE ON-DECK CIRCLE

Robert Suter, DO, MHA, FACOEP-D

THE BEST PART OF US

he recent birth of Master Archie is an appropriate time to reflect on the life of his Grandmother Diana who was truly passionate about improving the lot of vulnerable populations, which is the theme of this issue of The Pulse. Vulnerable populations, including the homeless, the poor, the abused, prisoners, and those with mental illness, are frequently the most challenging patients, and while some of us see more of them and some see less, these are our patients. Vulnerable populations constitute a significant percent of the over 140 million ED visits per year in the U.S. They are a heterogeneous subgroup of patients that stereotypically – and actually according to recent research – use the emergency department frequently. These frequent users have a high burden of complex social and medical needs that could be targeted for more rationale social and medical interventions. They deserve our respect as humans and we should strive for shared decision making in our interactions with them rather than disenfranchising them. As scientists, we know the importance of using accurate, group-specific data to inform risk estimates for shared decision aids for vulnerable populations. These patients need increased emergency departmentbased care coordination and transitional care management

NOTHING BRINGS ME MORE HAPPINESS THAN TRYING TO HELP THE MOST VULNERABLE PEOPLE IN SOCIETY. IT IS A GOAL AND AN ESSENTIAL PART OF MY LIFE - A KIND OF DESTINY. WHOEVER IS IN DISTRESS CAN CALL ON ME. I WILL COME RUNNING WHEREVER THEY ARE.” - PRINCESS DIANA

capabilities to create additional options that align with their needs. The impact of psychiatric patients and the tragedy of psychiatric boarding in our emergency departments is a category in and of itself. The double whammy of poor care for these patients combined with the adverse impact they have on the care of other patients has made this a high priority for advocacy. You should know that ACOEP is collaborating with other organizations to be at the forefront of advancing legislative and other solutions to this human tragedy. Check out S.1334/H.R. 2519 the Improving Access to Mental Health from Emergency Department Act and contact your representative and senators to Co-Sponsor! The keys to being comfortable in taking care of any category of patient are always knowledge and attitude

followed by experience and repetition. We know that the overwhelming majority of ACOEP members are true patient advocates who understand the necessity of the partnership between emergency physicians and the other portions of the safety net to ensure their patients get timely, quality care. The solution is to practice compassion and advocate for them, because our patients deserve as much. When we are empathetic and compassionate to vulnerable populations, like Princess Diana was, we make ourselves and the world a better place. Working together, collaboratively and with mutual respect, we can make a difference in the lives of these patients and connect with the best part of ourselves. Hope to see you in Austin in November! –•–

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“PRESIDENTIAL U PDATE” CONTIN U ED FROM PG 3

contributing to The Pulse, serving as a mentor for students and residents, running for a seat on the Board, or acting as a judge for the FOEM competitions. Our members are our most valuable recourse and your perspective can make a substantial difference in helping prevent someone else’s burnout.

NEVER STOP LEARNING As physicians we are scientists and as scientists we are, by definition, curious. With so many stressors and responsibilities it is tempting to put our knowledge on autopilot, and over time we forget how fascinating medicine and the human body are. Learning becomes about CME and license maintenance. ACOEP’s education is ever-expanding, bringing hands-on workshops, breakout lectures, deep dives, and quick reviews. I encourage our members to take advantage of everything we have to offer, not because you need to fulfill specialty credit requirements, but because

igniting our curiosity and passion for healing carries directly back to the patients who enter our emergency departments.

AFFECT CHANGE EMS. Practice management. Membership. Continuing Medical Education. Research. ACOEP and FOEM combine to offer a myriad of opportunities to make real change. Whether it’s finding new ways to advocate for emergency medicine or working on position statements for end of life care policy, committee members have an active hand in advancing the best in care. By becoming involved on a macrolevel, you can walk into work feeling empowered that you are a force in making healthcare better. By taking the time to get involved, you gain the opportunity to better connect with your patients and have a long lasting impact on their quality of care. –•–

“PAYING IT FORWARD” CONTIN U ED FROM PG 5

regularly and they made sure he had medicine, but he hated the trip to Evanston and wanted to be back in the city. I came back from vacation, and Bob looked awful. He had lost weight and told me he had cancer. “It’s back, Jannie,” he said, “I know this is it. Maybe two months, or three. I called my son, and I’m living in his basement. He don’t like that I come out here but these are my friends. My people. I don’t want to die in a hospital, I want to die here. I talked to the cops and they know – they watch out for me. But I’m dying on my terms.” That he did, he died sitting outside of the AT&T store in 2017. His friends, the bicycle cops, accompanied him to the ED at Northwestern and notified his son, whose name he had in his secret wallet. He lived and died on his terms. Now, the only one in front of the AT&T store is the robotic man who does his shtick for the tourists in the summer. But everyone in the neighboring area knew Bob and still inquire about him to the doorman at the Women’s Athletic Club across the

THE PULSE SUMMER 2019

street or in the stores along the Magnificent Mile. I remember him fondly as someone who was kind and only wanted people to say hi and drop a few coins in his McDonald’s cup. Someone who hid his milk crate seat in the bottom of the newspaper boxes that lined the curb and who always made me smile with his, “Jannie, I have to tell you about a joke I heard,” after a long day at work. Wherever Bob is, he’s still watching people – a hobby he enjoyed – and telling jokes. But I also know, that just by saying hello one day I got to know someone who held and holds a special place in my heart – even today. By paying it forward to someone who most might overlook, I was able to develop a friendship with Bob that taught me about life and to never take things for granted. In Bob’s honor, I hope that each of you reading this take a moment to pay it forward to someone, whether it’s paying for someone’s coffee, stopping to talk to a stranger, or in any other way. –•–

Denim De n im

Diamonds

SAVE THE DATE MONDAY, NOVEMBER 4, 2019

FOEM FOCUS By Janice Wachtler, BAE, CBA

CASE STUDY POSTER COMPETITION

NEW INNOVATIONS IN EMERGENCY MEDICINE COMPETITION

1ST PLACE

Orhay Mirzapolis from Midwestern University Emergency Medicine Residency in Downers Grove, IL for the case Fever Unmasked Brugada Syndrome in Pediatric Patient

Zachary Hampton from Doctors Hospital in Columbus, OH for Innovations in Airway Training: 3D Printed Pediatric Needle Cricothyrotomy Trainers

2ND PLACE

2ND PLACE THREE WAY TIE!

Kevin McLendon from Merit Health in Hattiesburg, MS for the case Got Milk? A Case Report of Lactating Ectopic Axillary Breast Tissue

3RD PLACE Kathryn Bartlett from Lehigh Valley in Bethlehem, PA for the case Creutzfeldt-Jacob Disease Presenting with Depression and Anxiety

CONGRATULATIONS TO THE WINNERS OF THE FOUNDATIONâ&#x20AC;&#x2122;S SPRING COMPETITIONS!

Angela Carrick from Norman Regional Hospital for Planning and Running a Residency Retreat Andrew Kalnow from Doctors Hospital in Columbus, OH for In Situ Simulation: A Model for Department-Wide Training and Improvement of Patient Care Kevin McLendon from Merit Health in Hattiesburg, MS for An E-learning Community: Bridging the Gap from Medical Student to Resident

SUMMER 2019 THE PULSE

CONFRONTING HUMAN TRAFFICKING By Jenny Reyes, DO Chief Resident, Aventura Emergency Medicine Residency Aventura Hospital & Medical Center

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87%

OF SEX TRAFFICKING SURVIVORS RECEIVED MEDICAL CARE AT SOME POINT DURING THEIR TRAFFICKING

uman trafficking generates an estimated $33.9 billion worldwide and is the 3rd largest source of income for organized crime.1,2 According to the 2017 US Department of State Trafficking in Persons Report, there were 100,409 victims identified across the globe in 2017, which has more than doubled since 2014.3 In the United States there were 8,524 confirmed cases of human trafficking in 2017, and the numbers are climbing every year.4 Despite these growing numbers, it is estimated that less than 1% of victims have been identified due to difficulty obtaining accurate surveillance data.5,6 Human trafficking can be further categorized into sex trafficking and labor trafficking. Sex trafficking is the recruitment, harboring, transportation, provision, or obtaining of a person for a commercial sex act, in which commercial sex is induced by force, fraud, or coercion, or in which the person induced to perform such an act is below 18 years of age. Labor trafficking is any means of obtaining a person for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery. The majority of human trafficking victims are women who are subjected to sex trafficking and domestic work.4 Risk factors for human trafficking include poverty, lack of education, undocumented immigrant status, marginalized populations such as LGBTQ, personal history of abuse, and an unstable family home. The states with the highest reported cases of human trafficking are California, followed by Texas and Florida.4

SUMMER 2019 THE PULSE

When I first started speaking publicly about my experience, I felt pressured to tell audiences that I was scared in order to satisfy their confusion about my compliance with the trafficker’s demands. But the truth is... I wasn’t scared. I felt stupid, duped, and disappointed, even sad and apprehensive; but I was not cowering in a corner as many images of sex trafficking convey.” HOLLY AUSTIN SMITH WALKING PREY: HOW AMERICA’S YOUTH ARE VULNERABLE TO SEX SLAVERY

THE PULSE SUMMER 2019

According to a study, 87% of sex trafficking survivors received medical care at some point during their trafficking.7 Of these, the most common healthcare setting was the emergency department. 8 Unfortunately only 10% of physicians recognize human trafficking victims and a mere 3% of emergency physicians receive training on human trafficking.5 Trafficking can also be confused with overlapping crimes like domestic violence, drug addiction, sexual assault, and prostitution.9 It is imperative that healthcare professionals receive training on the identification and treatment of victims of human trafficking, along with how to provide a trauma-informed approach to care.10

BARRIERS TO DISCLOSURE There are numerous barriers that prevent victims from disclosing their situation. Fear of arrest or deportation, fear of retaliation by the trafficker, distrust of authority figures, prior negative experiences with seeking for help, and re-traumatization when asked repeatedly to disclose the details of their abuse are just a few. Many victims are being tracked via GPS on their phone by the trafficker and simply don’t feel safe. Others truly believe that they are willingly complying with the abuse (referred to as trauma bonding) and don’t realize they are being trafficked, that safe alternatives exist, or that they have legal rights.6,12 Illegal immigrants in particular are at increased risk due to multiple risk factors.

PROVIDING TRAUMA INFORMED CARE Understanding the trauma patients have experienced is fundamental to providing a victimcentered approach to care. Providers need to understand that by the time they encounter survivors they have already been threatened with violence

from traffickers, buyers, and/or employers. They have suffered the consequences of prior attempts at seeking help. They have been subjugated to repeated victimization on a daily basis and doing nothing may have been self-protective. As one victim shares, “It is important for anyone working with victims of commercial sexual exploitation to realize that this population is… very reluctant to reveal anything personal…to adults, especially in professional positions…Many victims have been in circumstances where adults have consistently let them down.”11 After understanding their trauma experience and barriers to disclosure, providers may provide the emotional safety needed to offer help. The first step of providing trauma informed care is attending to the basic needs of the patient. If they are cold or wet, offer a change of clothes and a warm blanket. If they’re hungry, offer them food. Reassure the potential survivor and build trust and rapport. It is of utmost importance that the provider be conscious of his/her language. For example, asking “what happened to you?” as opposed to “what’s wrong with you?” Do not act shocked or disgusted when the patient discloses information. These patients are the most sensitive to power dynamics. Sit at their level and do not force disclosure of their situation. Victims are known to “test” the healthcare setting by making several visits before deciding if it would be safe to ask for help. 6 In addition, be sensitive if patients do not want to file a police report as many have a warrant out for their arrest. Above all, avoid re-traumatization caused by recounting their abuse experiences.11

GENERAL INDICATORS OF HUMAN TRAFFICKING If you’re not looking for human trafficking, you’re going to miss it! Patients will often provide a scripted or inconsistent history. It is not uncommon for the paramedics to provide a concerning history and the patient deny it altogether. This behavior grants the patient control over the process. Patients are often fearful, avoid eye contact, or may come off as hostile. It is safer to get angry at the advocate than the abuser.11 They may not know their home address, nor the current date or time. Victims often do not have possession of their personal identification and are not in control of their own money.

DOCUMENTATION IN THE CHART According to the Assistant State Attorney of the Anti-Trafficking Unit, physicians should document the following in order be pro-active: • State who the patient is with, e.g. “Male who seems to be answering all the questions for patient, very defensive about leaving patient alone in the room with the doctor.” • Document if the patient appears intoxicated, fearful, or disheveled. • Include tattoos, bruising, and clothing in the documentation, as well as the scene on EMS arrival. • It is appropriate to document statements by the patient or others around her/him.12

INDICATORS OF SEX TRAFFICKING

INDICATORS OF LABOR TRAFFICKING

Victims of sex trafficking frequent the emergency department. They come in Baker Acted for overdose attempt, have a history of multiple STIs, or come in with vague abdominal pain and depression. They may be accompanied by an older, controlling individual who speaks for them, claiming to be their “boyfriend,” “cousin,” etc. They may have tattoos or branding that say “Daddy,” “Property of…,” etc. History of multiple abortions is not uncommon. Patients often have somatization symptoms such as recurring headaches or pelvic pain. Pay attention to signs of trauma that are inconsistent with the patient’s explanation. Unfortunately most victims of sex trafficking at some point suffer from drug abuse, depression, and suicidal ideations, which often cloud the clinical picture. Traffickers are known to recruit in drug addiction clinics.12

Patients will often appear malnourished or extremely dehydrated. Most will have poor dental hygiene, untreated skin infections, or serious injuries from exposure to harmful chemicals.13 Some patients will have ophthalmologic complaints due to lack of protective eye equipment. They may claim to work in “mom-and-pop” businesses, farms, factories, construction, or oil/ gas extraction. Victims may carry high debt, live in crowded sleeping quarters, and sleep only in shifts.11

RESPONDING TO VICTIMS OF HUMAN TRAFFICKING

income. Ask questions pertaining to their work environment. Examples include “What are your work hours? Can you come and go as you please? Do you owe money to your employer or anyone else? Do you feel safe? Where do you eat and sleep? Is anyone hurting you or threatening you? Did someone tell you what to say today?” Questions helpful when assessing for sex trafficking: • Do you feel safe at home? At school? With your boyfriend or spouse? With your peers?

Institutions are encouraged to implement a human trafficking protocol in the emergency department. The National Human Trafficking Resource Center has examples of algorithms that may be used, as well as specific resources for patients. The first step is to carefully separate the victim from the trafficker. A reasonable example is to ask the patient to provide a urine sample. Next, attend to the medical, psychological, and basic (clothing, food, etc.) needs of the patient. Sit at eye level and perform a safety check by asking “Is it safe for you to talk to me right now?” Next, determine if the patient is working or has a means of

• Is anyone hurting you, threatening you, or pressuring you to do anything you don’t want to do? Is anyone hurting or threatening your family, children, or friends?

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SCREENING TOOLS

PROTOCOL AT AVENTURA HOSPITAL At Aventura Hospital, we developed a human trafficking protocol with three screening tools. The first screening method is based on indicators or “red flags” of trafficking. The second screening method is a question at triage that asks “Were you (or anyone you work with) ever beaten, hit, yelled at, raped, threatened, or made to feel physical pain for working slowly or for trying to leave?” The third screening method is also referred to as the “urine cup method.” Posters with educational material about human trafficking are placed in the restrooms and if patients believe they may be a potential survivor of human trafficking, they are asked to place a blue sticker on the bottom of their urine cup.

TRIAGE QUESTION RED FLAGS

MOVE PATIENT TO PRIVATE ROOM CALL NATIONAL HUMAN TRAFFICKING HOTLINE Attend to medical, psychological, and basic needs Refer to Toolkit for specific Qs - Use AMP model for discussion Conduct assessment to evaluate the patient’s unique goals, needs (shelter, substance abuse, mental health), and ability/readiness to leave situation

PATIENT INTERESTED IN ADDITIONAL SERVICES Refer to Toolkit for specific resources Call appropriate local organizations & arrange pick up Ask the patient if they would like law enforcement involved**

THE A-M-P MODEL MEANS

PURPOSE

RECRUITS

FORCE

HARBORS

FRAUD

COMMERCIAL SEX ACTS

TRANSPORTS

COERCION

ACTION

PROVIDES

INITIATION OF HUMAN TRAFFICKING PROTOCOL

NATIONAL HUMAN // TRAFFICKING HOTLINE \\

CALL 1-888-373-7888 (TTY:711) TEXT 233733

URINE CUP

“Were you (or anyone you work with) ever beaten, hit, yelled at, raped, threatened or made to feel physical pain for working slowly or for trying to leave?”

PATIENT NOT READY TO LEAVE SITUATION Provide anticipatory guidance Offer human trafficking number: In shoe In discharge instructions Have the patient memorize 888-3737-888 Place f/u appointment in d/c instructions

LABOR OR SERVICES

FILL OUT CASE LOG

OBTAINS, OR SO ATTEMPTS

** Caution: Many victims may have been forced to commit crimes and have a warrant out for their arrest. Be sensitive to their preferences.

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Patient presents at clinic with one or more trafficking indicators

PLAN AHEAD: BUILDING PROT0COLS

• Is anyone forcing you to have sex with others or to perform sex acts for money, food, clothes, drugs, or a place to sleep? • Has anyone ever taken a photo of you that made you feel uncomfortable? Was it posted on a website for classified ads?

OFFER RESCUE Educate the patient on their rights and resources available to them. Offer assistance, but if the patient declines then respect their decision. Call the Human Trafficking Hotline at 888-3737-888 to report a possible case. Offer to place the

Primary health and safety needs are met

Mandated reporting warranted OR the patient wishes to report

Reporting not warranted AND the patient does not wish to report

Report to designated contacts and/or contact the NHTRC Hotline (1-888-3737-888)

Provide referrals and contact the NHTRC Hotline (1-888-3737-888)

human trafficking phone number in the patient’s shoe. It may also be provided in the follow up instructions disguised as the primary care physician office number to follow-up with. Alternatively, the patient may memorize the number. Tell the patient that, if their “no” turns into a “yes” at any time, they can always return to the ER. If the patient needs an excuse to come back, place a follow up appointment in their discharge instructions. The goal should not be “rescuing” or gaining disclosure from the patient. The goal is to create a safe, non-judgmental space to educate the patient on their rights, options, and offer assistance.

CONCLUSION Human trafficking is an egregious criminal act and human rights violation. A majority of survivors of human trafficking access medical services at some point during their captivity. Providers everywhere, in particular those in primary care, reproductive health, mental health, and pediatrics, must be cognizant of the indicators of human trafficking, barriers to disclosure, and how to provide trauma-informed care. Emergency medicine providers are in a unique position to be a fundamental part of the solution to this global epidemic. –•–

Resources 1. Patrick Belser, Forced Labor and Human Trafficking: Estimating the Profits 14 (Int􀂶l Labour Office, Working Paper No. 42, 2005), available at http://digitalcommons.ilr 2. Moynihan, B. A. (2006). The high cost of human trafficking. Journal of Forensic Nursing, 2(2), 100-101 3. United States Department of State, Trafficking in Persons Report, 2017. Available at https://www.state.gov/wp-content/uploads/2019/01/282798.pdf 4. Polaris. National Human Trafficking Hotline. Available at https://humantraffickinghotline.org/ 5. Girgis, Linda. How Are You Treating Human Trafficking Victims in Your Practice? May 9, 2018. Physicians Weekly. https://www.physiciansweekly.com/howare-you-treating-human-trafficking-victims-in-your-practice/ 6. Alpert EJ, Ahn R, Albright E, Purcell G, Burke TF, Macias-Konstantopoulos WL. Human Trafficking: Guidebook on Identification, Assessment, and Response in the Health Care Setting. MGH Human Trafficking Initiative, Division of Global Health and Human Rights, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA and Committee on Violence Intervention and Prevention, Massachusetts Medical Society, Waltham, MA. September 2014 7. Farella C. Hidden in plain sight: identifying and responding to human trafficking in your ED. ENA Connect. 2016;40(4):4-22 8. Lederer LJ, Wetzel CA. The Health Consequences of Sex Trafficking and Their Implications for Ientifying Victims in Healthcare Facilities. Annals of Health Law, Vol 23(1) 9. Clott L, Burke M. Project to end human trafficking: training for medical professionals. Forbes Hospital Professional Seminar November 2015 10. Dearholt S, Dang D. John Hopkins Nursing Evidence-Based Practice: Model and Guidelines. 2nd edition, Indianapolis: Sigma Theta Tau Publishing; 2012 11. Dabby, C. Trafficking: Trauma & Trauma-Informed Collaboration & Advocacy. January 2018. Asian Pacific Institute on Gender-Based Violence 12. Hernandez, M. (2018). Human Trafficking: Seeing the Unseen. [Powerpoint Slides] 13. NHTRC. Recognizing and Responding to Human Trafficking in a Healthcare Context. National Human Trafficking Resource Center

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HELPING PATIENTS WITH AUTISM AND THEIR FAMILIES NAVIGATE EMERGENCY VISITS By Rena Sorensen, PhD and Laura Srivorakiat, PsyD

hris’s family traveled more than an hour, with Chris kicking and screaming in the back seat, to make their fourth trip to an emergency department (ED) in as many months. A school provider in their town had told them that by going to this ED, the family might get the help they needed. They felt it was a long shot based on prior experiences but held out some hope. Chris is diagnosed with an autism spectrum disorder (ASD). One of his restricted interests is a love of ambulances, which helped him to calm quickly upon arriving at the ED. In the past he always de-escalated by the time the family arrived in the ED, so they were sent home without resources, irrespective of the seriousness of the behavioral episode they described. It initially seemed this fourth visit would be the same. The family was directed to a quiet room, and Chris promptly began bouncing happily on a sensory ball watching ambulances drive by. To the family’s surprise, the attending physician listened intently to their concerns for Chris and even asked the family what could be done to help Chris be more comfortable as they talked. The family felt heard. Although Chris was not admitted for inpatient care, the family left with outpatient appointments that connected them to needed services and Chris ultimately obtained the help he’d needed for many months.

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AUTISM SPECTRUM DISORDER INCIDENCE AND ED UTILIZATION The likelihood of seeing individuals with autism in the ED continues to climb. In 2018, the CDC estimated that 1 in 59 children have been identified with ASD, a 15% increase in prevalence since 2016. Incidence of autism has been on the rise over the years and, while causes remain largely unknown, genetic predisposition, environmental triggers, and increased sensitivity of diagnostic measurement are thought to be factors. Autism occurs across all racial, ethnic, and socioeconomic groups, is 4x more common in boys,

APPROXIMATELY 44% OF INDIVIDUALS WITH AUTISM HAVE AVERAGE TO ABOVE AVERAGE INTELLIGENCE.â&#x20AC;?

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and commonly co-occurs with other developmental, psychiatric, genetic, neurologic, and chromosomal differences. Approximately 44% of individuals with autism have average to above average intelligence. Research has demonstrated that individuals with ASD have increased rates of health care utilization and frequently report unmet healthcare needs. Additionally, families often express frustration over the unmet need for comprehensive services, including access and navigation of medical care due to behavioral challenges or lack of knowledgeable providers and, as a result, may avoid routine healthcare visits. ED utilization data demonstrates both adolescents and adults are more likely to access care in the ED than nonASD population. This is even more likely for those who live in rural areas. Additionally, research suggests that patients with ASD have suboptimal experiences in the ED. A survey of adults with ASD and no intellectual disability regarding ED experiences

found that most were somewhat dissatisfied with the care they received in the ED. Another study of caregivers indicated that a quarter of people with ASD experience restrictive measures during ED visits including physical or medical restraint. In our experience, it is not uncommon that children in behavioral crisis have underlying medical conditions that are identifiable and treatable with appropriate medical care. Behavioral escalation may be overestimated as a primary reason people with ASD come to the ED. A chart review conducted in 2014 indicated that only 10% of patients with ASD presented to the ED for a primary complaint of behavioral concerns. Studies have also shown that children with ASD were 9x more likely to receive care in the ED due to psychiatric crisis than those without ASD. It is important to recognize that externalizing behaviors, such as aggression or self-injury, that prompt these visits are sometimes found to be associated with physical

or medical conditions that were causing discomfort. Additionally, many individuals with autism who utilize the ED for a medical crisis may also be more prone to exhibiting disruptive behavior due to discomfort, as well as other challenges that can contribute to distress such as challenges with communication, hypersensitivity to stimulation, increased transitions inherent in the ED environment, and long wait times. When evaluating an individual who has demonstrated sudden onset of severe aggression or selfinjury, it is important to consider underlying medical conditions that may be causing pain or discomfort. Caregivers express frustration when providers assume behavioral outbursts are primarily a psychiatric or behavior disorder without first considering possible medical etiology. Additionally, if an individual presents with severe self-injury, they may also need to be evaluated for self-inflicted injuries, even when this was not their primary presenting concern. It is helpful for providers to inquire about the individual’s pain tolerance, how they typically show pain, and if the family feels that there may be an underlying medical concern. The most common medical concern resulting in ED visits for individuals with ASD after seizures and neurological symptoms are gastrointestinal issues. Research has demonstrated that individuals with ASD have more issues with constipation, diarrhea, and reflux than the typical population, and that these conditions often exacerbate behavioral outbursts. Each person with ASD is different, so no care-algorithm adequately describes how to care effectively for all people with ASD. Rather, each individual must be approached based on his or her unique presentation and needs. There are many similarities and

some important differences between patients with ASD and neurotypical patients Similarities include experiencing a high stress level while in the ED and having typical medical complaints. Due to the core features of ASD, patients on the spectrum may uniquely struggle to communicate their care needs or have extraordinary difficulty tolerating medical procedures. Their behavioral presentation may be atypical, however, this may be the person’s baseline, could signal illness, be part of a behavioral disorder, or be the person’s way of communicating stress.

? PROVIDERS CAN LEARN ABOUT THE PERSON WITH ASD’S NEEDS THROUGH ASKING FOUR CRUCIAL QUESTIONS: What are the person with ASD’s baseline behavior and functioning? How does the person with ASD communicate and understand the communication of others? What triggers stress or anxiety for the person with ASD? What helps the person with ASD cope with stress or anxiety?

BASELINE An essential component for a successful encounter is developing an understanding of the patient’s baseline or typical functioning and behaviors. There can be a tendency to ascribe behaviors to ASD when the behaviors may be related to pain. For example, a patient with ASD may engage in daily stereotypic body-rocking that is not related to pain. However, another patient with ASD who just started rocking her body may be doing so because she is experiencing back pain that has nothing to do with her ASD diagnosis. Developing an understanding of baseline behavior and functioning can help the provider determine how concerning the current presentation is, as well as provide an aim for symptom improvement. James, for instance, presented to the ED following surgery for bowel perforation. His parents expressed concern that he was not acting normally. When the provider saw him, he was laying on the bed in no acute distress. Initial plans were to discharge home, however, when parents were able to explain that James rarely lays on his back and is never still, additional workup was ordered and a large abscess was discovered in his abdomen. He was presumably laying still because it was too painful to move, however, he was nonverbal and he did not cry.

COMMUNICATION Communication challenges in ASD vary. Some people on the spectrum experience subtle communication deficits, such as challenges interpreting social cues. They may benefit from being asked closed, rather than open-ended questions and from visual supports to supplement verbal information given by the provider such

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as handouts or pain scales. As with all patients, walk them through procedures prior to initiation to ensure understanding and have the patient re-tell medical instructions to check comprehension. A quarter of individuals on the autism spectrum do not develop functional verbal communication. For individuals who have significant communication challenges, it is necessary to engage caregivers to understand the person’s needs and obtain information about the presenting concern. Providers should identify the patient’s primary communication method and their language comprehension. Patients with ASD who are nonverbal or have low verbal skills may use picture cards, electronic sound generating devices, sign language, or letter boards for communication. When asking about language comprehension, consider asking how much the individual understands and if they are able to demonstrate knowledge of body parts or respond to questions about where pain or discomfort is experienced? If so, how do they communicate what they know? Irrespective of the patient with ASD’s communication skills, it is important to always assume competence and understanding. Avoid saying things that you would not want the patient to hear or things that you would expect to cause anxiety. A patient with ASD who is not able to communicate verbally may still

understand and respond to what is said by others in the room. It is important to speak directly to the person with ASD unless the caregiver indicates that doing so would cause distress. Communication skills can be mixed in a person with autism. Malachi presented to the ED, accompanied by his mother, with agitation. Malachi is a nonverbal adolescent with significant self-stimulatory behavior at baseline. As the provider and caregiver discussed potential causes, Malachi was intrusive to the discussion. His mother brought out the letter board he uses to communicate and asked him what he needed. Malachi said, “This medication makes me drool and people think I’m stupid.” Many people

in several ways. Some individuals are very sensitive to sensory input and may become over aroused and overstimulated easily. These individuals may have a negative response to touch, sounds, or smells that increases anxiety and distress. On the contrary, others seek certain types of sensory input and may do so obsessively or to self-soothe. For example, one individual may seek deep pressure and, if the need is not adequately met, they may push until caregivers restrain them. In other sensory seeking situations, an individual may be fascinated with screaming and elope from their room to seek the source of a crying child down the hall. Most individuals with ASD have mixed sensory responses, meaning they may seek some types of input while being averse to other types. This makes management more challenging. Negative effects of overwhelming or anxiety provoking situations can result in increased sensitivity to sensory input and slow language processing and problemsolving in the general population. Imagine the impact for an individual with ASD who already has sensory sensitivities and communication challenges. Overstimulation coupled with challenges with communication and unknown expectations of a new environment can easily increase the risk of behavioral outbursts. Individuals with ASD are prone to challenges with transitions, adjusting to new environments, and understanding complex processes and concepts of time. The ED environment includes all these factors, increasing the potential for stress or anxiety during the visit. Sensory differences also

SENSORY PROCESSING INVOLVES HOW THE BRAIN PERCEIVES AND RESPONDS TO EXTERNAL AND INTERNAL STIMULI AND CAN MANIFEST IN SEVERAL WAYS.”

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might consider Malachi incapable of comprehending conversations, but he was aware of what was being said and made a valuable contribution to the medical encounter when given the opportunity.

SENSORY AND TRIGGERS Individuals with ASD process sensory information differently than their neurotypical counterparts, a difference that has been added as a key domain in the most recent revision of diagnostic criteria. Sensory processing involves how the brain perceives and responds to external and internal stimuli and can manifest

impact how individuals with ASD respond to pain. It is common for parents to report a very high pain threshold in their children with ASD; however, once that threshold is reached, the reaction can be extreme and include severe tantrums, aggression, and self-injury. Challenges with communication often make it difficult for individuals with ASD to reliably communicate pain. For these reasons, we often advocate for proactive pain management in conditions known to be uncomfortable. Waiting for the individual with ASD to indicate pain may result in an unsafe situation and more challenging pain management.

SUPPORT AND ACCOMMODATIONS TO ENHANCE COPING With knowledge of resources available in the ED and the patient’s triggers and communication style, providers can arrange for appropriate supports to help the patient cope and facilitate a successful encounter. The provision of appropriate supports for patients and families with ASD is associated with higher patient compliance with the encounter, increased safety, and improved system flow, as well

as increased satisfaction for both provider and patient. The best way to know what supports are needed is to ask the patient and caregiver how they have been successful in past medical encounters and what could make the present encounter run smoothly. Studies have described negative and sometimes traumatizing experiences in the ED for individuals with ASD when the triggers of an individual are not recognized and addressed while providing care. Managing the environment is one of the most effective ways providers can enhance patient coping by reducing triggers. The best way to understand individual triggers is to discuss sensory challenges with caregivers or with the individual as part of the initial encounter. When a person with ASD is entering the ED, helpful strategies include reducing wait times in the waiting room, dimming harsh overhead lights, expediting to a room location away from high traffic and excessive noise, clearing the room of unnecessary items, access to services such as Child Life and social work, TV/ movies, music, toys, rearranging the room to allow for movement, etc.

Behavioral escalation can be prevented if individuals with high risk of escalation are given priority in triage. Consolidate care to reduce disruptions and reduce transitions when possible. Prior to any procedure or transition, it is important to ask, “How do you think this will go?” and “How might we make it go better?” Walk caregivers or individuals through the procedure step-by-step and problem solve the best way to approach care prior to initiating it. Other helpful strategies include use of visual supports, for example, a schedule with icons that tells the patient what is coming next or adapted pain scales. This should always include breaks from care and activities to help increase motivation. Gathering and documenting information about communication style, triggers, coping strategies, and baseline for use with all staff and providers interacting with the patient and caregivers can significantly improve care. This information can be sought as soon as a diagnosis of autism is known. There are available tools to structure the gathering of this information, such as the Autism Care Questionnaire (Carter et al., 2017) or the Instrument to Prepare for Acute CONTIN U ED ON PG 39

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SPECIAL NEEDS CHILDREN AND ED VISITS: WHAT MEDICAL STAFF SHOULD KNOW By Karen Ursic, MA

am a mother of three children, two of whom are on the autism spectrum and one who has type one neurofibromatosis (NF1). Most of what I have learned about their conditions is through lived experience. I also work part-time in the medical field, not as a doctor or nurse, but my job often brings me in contact with patients and has shown me that a little common sense and empathy goes a long way, no matter what my training or education is. It is in this spirit that I hope you find this information helpful, and are prepared to treat special needs children and successfully work with their parents and caregivers. –•–

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Under no circumstances should you belittle the parent, unless it is a clear case of neglect. I am sure that you think this goes without saying, but it still absolutely needs to be said. You went into the medical profession by choice, yet we parents did not directly volunteer to live this condition. We need your empathy and patience, not questioning as to why we did or did not do something a certain way or within a particular time frame. People with autism, for instance, can have a high threshold for pain or are not adept at communicating any adverse issues, even as adults, which may result in delaying seeking care or not understanding the severity of an issue.

Alternatively, even if you are very familiar with and comfortable with a certain condition, keep an open mind and be willing to learn more. Listen to us parents. We don’t have the medical expertise that you do, but we have 24/7 lived experience. I know my children better than anyone else and even I learn new things about them every day. A saying that we have in the autism community is, “If you know one person with autism, that means you know one person with autism.” Patients, as people, definitely apply to this principle. While disabilities and conditions have certain common characteristics, every person who has them is an individual. Parents and caregivers are uniquely positioned to understand the nuances of each child and how their disabilities manifest.

Nonverbal communication is still communication. If you have a nonverbal patient, please do your best to respect that person by still interacting with them and asking them questions. They can still respond. If a parent, family member, or whoever accompanies the patient to the ED needs to help translate responses then so be it, but never assume that you cannot interact with the nonverbal person.

If you are unfamiliar with the child’s medical condition, do not be afraid to get information from the parent. My youngest child has a neurological condition that less than two million people worldwide (less than 3% of the human population) have: type one neurofibromatosis (NF1). In my experience dealing with the doctors at Akron General and Akron Children’s pediatrics, most of the doctors are well educated about NF. Still, many in this country are not. While there is no need for you to admit complete ignorance, even if that is the case, use that as a moment to channel what you do know and simultaneously learn from the parents and what they know.

Consider that some parents, or someone accompanying the patient to the ED, may have special needs themselves. You must exercise patience, especially if the parent is in shock. For example, autism and neurological issues are inherited in my family, and have always suspected I am on the spectrum and am ADHD myself. I am an intelligent, capable person who always excelled in school, but personal communication, particularly in an emergency, is unscripted for me and therefore makes it difficult for me to process what you are saying about my child or asking from me.

If you send medication or instructions home with the patient, keep in mind that special needs people may need more visual and auditory information than others. For instance, if you send literature or instructions home with the patient, it can still be laden with jargon that a person with no medical background may not completely understand. Therefore, be willing to write some information in such a way that is easier to read. Perhaps you could develop a closed YouTube channel for videos on how to deal with certain aspects of a patient’s treatment once the ED visit is over. Better yet, demonstrate anything that could be helpful.

Sensory issues are the biggest trigger for my children, as well as many children with special needs. An ED atmosphere can be loud and confusing, so try to make the waiting areas as soothing and quiet as possible. You should also avoid harsh lighting when possible. Things like certain smells, lights, and the tones of people’s voices can send my children with autism into a full meltdown. This is traumatizing and potentially dangerous for everyone involved. For these reasons, staff should have every right to ask people in the waiting area to tone down their noise or be respectful of others around them.

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CREATING A GERIATRIC-FRIENDLY EMERGENCY DEPARTMENT By Elizabeth Baum, MD

y now everyone is familiar with the â&#x20AC;&#x153;Silver Tsunamiâ&#x20AC;? that started in 2011 with 10,000 Baby Boomers turning 65 every day in the United States. At the same time, life expectancy for those over age 85 has increased. Currently nearly 1 in 2 older adults will have an ED visit annually. Quality assessment and management of these patients, whether they are admitted to the hospital or discharged, can play a large role in determining the trajectory for the future care, function, and health care costs for that patient. Unnecessary hospitalization for frail, older adults only accelerates functional decline. The rapid pace of the ED is not a friendly environment for a frail, older person, nor is it an easy assessment to perform for the ED provider. In contrast to young adults, who usually present with one specific problem, older adults often present with multiple vague complaints. The complexity of the assessment is magnified since they often have multiple comorbid

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medical problems such as congestive heart failure or dementia and can be on more than 10 medications. Compared to young adults, older adults are more likely to be hospitalized and use more staff time and resources. The ED diagnoses tend to be less accurate despite greater use of diagnostic tests and procedures. How can an ED provider perform a timely, effective assessment of older adults to identify any serious medical problems but avoid unnecessary hospitalization? In 2014, the American College of Emergency Physicians (ACEP) published guidelines for optimal care of an older adult in the ED. Ideally it takes a team to care for a complex frail older adult. The three major areas for improvement are: (1) ED staffing and provider education, (2) Clinical processes of care, which includes the development of interdisciplinary teams, geriatric champions and leaders, and implementation of geriatric screens and protocols, and (3) Modification of the environment.

IF YOUR ED DOES NOT HAVE NURSES DOING A HIGH-RISK SCREEN ON ADMISSION, a faster screen you could incorporate into your own assessments is the FRAIL scale1 . This has not been ED validated, but is a quick screen that a provider can use with a mnemonic to help remember.

F R A I L ED GERIATRIC STAFFING AND EDUCATION Educating the staff on the unique needs of older adults is the foundation to creating a geriatric-friendly ED. ED staffing should include a Geriatric ED Medical Director and Nurse Manager. They should be actively involved in identifying needs for staff education and implementing geriatric-specific provider education. Residency and continuing education should contain interdisciplinary content such as transitions of care and referral to community services, managing cognitive and behavioral disorders, and atypical presentation of disease. Up to one third of older adults with a significant acute medical problem may present to the ED with vague, nonspecific symptoms such as acute change in mental status, frequent falls, new weakness, or dizziness. These nonspecific symptoms may be their presenting symptoms

The patient is asked if he had Fatigue most days in the last month... and if he has difficulty climbing 10 stairs (Resistance)... or walking 1 block (Ambulation). If the patient has 5 chronic diseases such as diabetes or COPD, that would count as Illness. Finally, Loss of 5% of their weight in one year is the last question.

If the patient scores > 2 they are considered FRAIL which would put them at higher risk for rapid functional with an acute illness.

for sepsis with no fever or leukocytosis, an acute abdomen with no peritoneal signs, or acute coronary syndrome (ACS). As high as 40% of patients over age 85 with ACS present without chest pain. For other specific educational topics and details of staffing, refer to the ACEP guidelines that can be downloaded from the Geriatric-ED.com site. They recommend that besides specialized nursing (nurse coordinator and case manager), the ED have a social worker and ideally access to a pharmacist, physical therapy, occupational therapy, and a Geriatrician. In addition, The American Geriatric Society has a number of excellent educational resources2. Lastly, Geri-EM.com provides free online education for emergency providers.

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CLINICAL PROCESSES OF CARE If a quick initial assessment rules out life-threatening, unstable conditions, clinical problems that are more common for the older adults need to be assessed to determine if they may be contributing to their acute problems, possibly impacting their outcome. The ACEP Geriatric ED Guidelines suggested using the Identification of Seniors At-Risk Tool (ISAR) to identify all patients over the age of 65 who are high risk for functional decline. These patients are probably using their functional reserves just to get through their daily routines and could decompensate quickly with any additional medical problem. The ISAR has six

HIGH-RISK OLDER ADULTS NEED TO BE SCREENED FOR DELIRIUM AND DEMENTIA. AT LEAST 17% OF OLDER ADULTS IN THE ED HAVE DELIRIUM AND MORE THAN 50% OF THESE CASES ARE MISSED.” 25

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questions such as; before this injury or acute illness did you need someone to help you on a regular basis? More than one positive response is considered high-risk. Any patient who screens positive should receive additional screens for cognition, mobility, and polypharmacy. Patients admitted need timely referrals to case management and discharges from the ED require closer community follow-up with their PCP and community agency referrals, such as home health for a home safety assessment. Just as EDs have improved the efficiency and effectiveness for ACS and sepsis by implementing rapid screens and protocols, there is a unique set of screens and protocols that will improve timely effective care of those older adults identified as high risk. High-risk older adults need to be screened for delirium and dementia. At least 17% of older adults in the ED have delirium and more than 50% of these cases are missed. Approximately 1 out of 3 older ED patients with delirium will die within six months. Two quick screening tests for delirium that have been validated in the ED are the Delirium Triage Screen (DTS) and the Brief Confusion Assessment Method (bCAM). Both of these tests can be accessed at www.eddelirium.org. The DTS is most useful to rule out delirium and can be done in 10-20 seconds using some information that has already been gathered. It consists of establishing a Richmond AgitationSedation Scale (RASS), a very familiar ED tool, and if the patient scores anything other than a 0, which would be alert and normal, then a test of attention needs to be done. The DTS uses spelling “LUNCH” backwards as a test of attention. If the patient has more than one error on this test it is a positive screen for delirium and a bCAM needs done. The bCAM is the best test to rule in delirium and is 78% sensitive and 97% specific if administered by a nonphysician. This test has four features: 1. Altered mental status or fluctuating course 2. Inattention 3. Altered level of consciousness 4. Disorganized thinking The test of attention for this is to have the patient say the months of the year backwards and it is positive if > 1 error. Both 1 and 2 and either 3 or 4 need to be positive to confirm delirium. The cause of delirium is usually multifactorial, often related to any acute medical problems, such as sepsis, but in a frail older adult it may be complicated by less life-

threatening things such as dehydration, polypharmacy, fecal impaction, or urinary retention. Many of these patients may have an undiagnosed dementia, which makes them more vulnerable to delirium with any acute illness. One of the most accurate dementia screening tools validated in the ED is the Short Blessed Test. Another very quick screening test for dementia is the Mini-cog3. This involves giving the patient three words to remember, then distracting them and having them draw a clock. Give them a time to record that requires the hands of the clock to be in two different quadrants with a time such as 2:35 or 4:55. People with early dementia have difficulty abstracting to determine where that second hand goes. Any test done for dementia in a patient with active delirium will need to be repeated at a later date when the patient is back to baseline. The Family Questionnaire4 is another useful tool. An informant familiar with the patient is asked six questions to help determine if they may have had an undiagnosed dementia prior to their current illness. More than 50% of people with dementia have not been formally diagnosed or informed of their diagnosis. Those older adults who screen positive on the ISAR should be asked if they have had a fall in the last year and screened for safe mobility. A Timed Get Up and Go (TUG) can gather a lot of information and be done in < 1 minute for those able to participate5. The patient should be observed getting up from a chair, walking ten feet, and returning to sit down. This is an ideal test to quickly assess strength, stability, and gait. Those patients who take longer than 15 seconds are at

an increased fall risk. Ideally this is done with their usual gait aid. Things that often get missed on an ED fall evaluation are orthostatic BP and an assessment of vision. Just having the patient read something in regular print can be a quick screen. Older adults develop visual deficits so gradually that they often don’t complain about it. Older adults are more vulnerable to polypharmacy and adverse drug reactions due to multiple comorbidities and reduced physiologic reserves. 40% of patients > age 65 take five to nine medications daily. There is a 50-60% chance of a drug-to-drug interaction when taking this many medications. Medication reconciliation can be difficult and time-consuming in an older adult and could be streamlined with a pharmacist as part of the ED team. Any new symptom needs to be considered as a possible drug reaction. Many drug side effects are not well-known or recognized, such as a patient who presents with falls due to bradycardia from their cholinesterase inhibitor donepezil. Another example is a patient with diabetes type 2 with neuropathy and renal insufficiency who presents to the ED with increased confusion because of failure of their PCP to adjust duloxetine and gabapentin for renal function. The Beers Criteria, which is a comprehensive review of high-risk medications in older adults, was just updated in 20196.

EMERGENCY DEPARTMENT ENVIRONMENT Details outlining ED environment change can be found in the ACEP Geriatric ED Guidelines. Many of these recommendations will benefit

patients of all ages. Things that address comfort most include extra thick/soft gurney mattresses, warming blankets, and exam chairs/ recliners that can facilitate and provide safer transfers. Use separate enclosed rooms when possible to help noise reduction. Having soft music available can decrease noise and have a calming effect. Have at least two seats per room for family. Have wheel-chair accessible toilets with raised toilet seats, bedside commodes, and walkers available. For improved vision, enhance lighting using natural light where possible. Light-colored walls with matte sheen and light flooring with a low-glare finish are recommended. Signs with large print and large face clocks in each room are valuable additions. The most helpful sensory addition is investing in pocket talkers for patients with poor hearing. These can work even for some of those people who have refused to wear their own hearing aids. One very sturdy brand is Williams Sound PKT D1 EH Pocketalker Ultra Duo Pack Amplifier with Single Mini Earbud and Folding Headphone. This can be ordered at Amazon.com.

CONCLUSION Implementing some of these geriatric principles into ED processes should help address the complexity of the acute care of the older adult. The ultimate goal is to improve the quality and satisfaction with care for the patient, family, and providers. Incorporating team-based care and system-level changes takes time, but there are simple things that providers can implement immediately and become the geriatric champions.–•–

Geriatric Emergency Department Guidelines, Annals of Emergency Medicine. 2014;63;5:e7-e25.

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4515112

Melady Don MD, Perry Adam MD. Ten Best Practices for the Older Patient in the Emergency Department. 2019:314-326.

3. https://consultgeri.org/try-this/general-assessment/issue-3.1

Perry Adam MD, Macias Jonny Macias MD, Melady Don MD. An Approach to the Older Patient in the Emergency Department. 2019:300-311.

2. https://www.americangeriatrics.org 4. https://consultgeri.org/try-this/dementia/issue-d13 5. https://www.cdc.gov/steadi/pdf/TUG 6. https://nicheprogram.org/sites/niche/files/2019-02/Panel--2019-Journal of the American Geriatrics Society.pdf)

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Communication: Itâ&#x20AC;&#x2122;s Critical to Care This article was originally published in the March 2019 edition of THE ASHA Leader.

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Adults with communication disabilities struggle to access quality health care — significantly more than typical peers. How can we get them needed health information and services?

BY MICHELLE L. STRANSKY AND MEGAN A. MORRIS

Judith*, age 62, has cerebral palsy, uses a speech-generating device, and brings her personal care assistant (PCA) to all of her doctors’ appointments. She’s grateful that she and her primary care physician have a close relationship, and that he takes the time to learn how best to communicate with her. For example, he always schedules appointments to allow for extra time—care that led him to detect her breast cancer early. Unfortunately, Judith’s experience with her oncologist has not been as positive. The oncologist always speaks first (and primarily) to Judith’s PCA. If she does speak with Judith, she uses “baby talk.” Judith repeatedly asks the oncologist to use her normal voice and speak directly to her, but she never grants this request. Frustrated, Judith questions whether she receives the same quality of care that she would have if she did not have a disability.

las, the research suggests that the quality of care Judith receives is not just lower because of her disability—it’s compromised by the type of disability she has: a communication disability. In fact, in a new peer-reviewed research study we published in the December 2018 issue of the Journal of General Internal Medicine with Kristin M. Jensen, we find that adults with speech, language and voice (SLV) disabilities face greater challenges accessing health care than their peers without SLV disabilities (bit.ly/hc-access). These challenges include increased trouble finding medical care providers, seldom receiving quality emergency and routine health care, and delaying or foregoing medical care due to the cost and availability of services. In statistical analyses, we found that these disparities persisted even after accounting for non- SLV disabilities and chronic health conditions. This finding is especially important because people with SLV disabilities have more chronic conditions, such as arthritis, cardiovascular disease and

SUMMER 2019 THE PULSE

FAST READ: Though there’s been increasing recognition of health care disparities among adults with physical disabilities, this awareness has not extended to patients with communication disabilities. In fact, a new study finds that these patients have a harder time finding quality care than any other group—for a complicated set of reasons. TAGS > HEALTH CARE DISPARITIES, COMMUNICATION DISORDERS

emphysema, than their peers without communication disabilities. What accounts for this decreased access among people with SLV disabilities? And what can providers in communications sciences and disorders and other fields do to help counter this disparity? Let’s take a closer look.

THE DISABILITY DISPARITY A growing body of literature indicates that adults with disabilities face poorer health and medical care outcomes compared to their peers without disabilities (see sources). The literature defines these comparatively poor outcomes as disparities: differences in health and medical care outcomes and experiences based on some characteristic of a group of people that places the group at a social, economic or other type of disadvantage. In response, we aim for health equity—the principle of reducing such disparities and giving all people the opportunity to attain the best possible health and medical care. Historically, disparities work has focused on race and ethnicity, while disability was assessed as an outcome to be avoided. For example, we have evidence that adults who

identify as non-white are less likely to receive speech-language treatment following stroke than their white counterparts (see sources). And although racial/ethnic disparity is a critical problem that needs to be addressed, patients with disabilities are themselves a vulnerable population and are at risk for poor health and medical care outcomes. A person’s disability might be related to poor health (for example, a patient may suffer a stroke as a result of uncontrolled hypertension), but increasing evidence indicates that environmental, economic and social factors contribute to poor health and, thus, health disparities for people with disabilities (see sources). For example, adults with physical disabilities have fewer opportunities to exercise due to factors such as inaccessible fitness equipment at local gyms or inadequate neighborhood sidewalks. As a consequence, adults with physical disabilities have higher rates of obesity and obesity-related chronic conditions (such as hypertension and diabetes) compared with people without physical disabilities. Medical care disparities are disparities in access to and receipt of high-quality medical care services. As with health disparities, we see medical care disparities across adults with disabilities. For example, multiple studies have demonstrated that

IN ADDITION TO OUR FINDING THAT ADULTS WITH SLV DISABILITIES HAVE POOR ACCESS TO HEALTH CARE IN GENERAL, OUR ANALYSIS REVEALED THAT THESE PATIENTS ARE MORE MEDICALLY COMPLEX.

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women with physical disabilities have lower rates of preventative cancer screenings than their peers without disabilities (see sources). This difference is due to such factors as inaccessible medical equipment—including examination tables and mammography machines— and medical providers’ inaccurate perceptions of women with disabilities.

OVERLOOKED: COMMUNICATION DISABILITIES Even as recognition of health and medical care disparities among adults with physical disabilities grows, adults with SLV disabilities are often left behind. Very few studies have focused on adults with such disabilities, resulting in little evidence about the quality of health and medical care services they receive. Section 4302 of the Patient Protection and Affordable Care Act of 2010 requires that all federal surveys include disability questions, but the final questions determined by the Department of Health and Human Services query physical, cognitive, visual, self-care and independent living limitations, as well as being deaf or hard of hearing. No question focuses on adults with SLV disabilities, despite research showing that as many as 10 percent of the adult U.S. population has one of these disabilities. But a change to the National Health Interview Survey (NHIS) has finally positioned researchers to examine the health and medical care outcomes of adults with SLV disabilities. In 2012, the survey included a supplement on SLV disabilities, which asked respondents whether they had one or more of these disabilities in the past year. We used these data to conduct our Journal of General Internal Medicine analysis. In addition to our finding that adults with SLV disabilities have poor access to health care in

• Have more chronic conditions • Often struggle to find healthcare providers

ADULTS WITH SPEECH, LANGUAGE AND VOICE (SLV) DISABILITIES: general, our analysis revealed that these patients are more medically complex than those without SLV disabilities. Specifically, adults with SLV disabilities have poorer self-rated health and more chronic conditions, including hypertension, cardiovascular disease, stroke, emphysema, asthma, cancer, diabetes and arthritis. The findings of this study—one of the first population-based studies on adults with SLV disabilities—align

• Often delay or forego care due to cost/availability • Experience more medical errors • Are unlikely to have providers use visual supports

their health is lower than their peers without SLV disabilities. In line with such findings is a 2015 study led by one of the authors of this article (Megan Morris, bit.ly/patientaphasia) involving video- recorded primary and specialty care outpatient visits of patients with aphasia. Findings revealed that physicians rarely used supportive communication strategies that speech-language pathologists commonly train communication partners to use. Across 25 recorded visits, no physician wrote down key words while speaking, only one used a visual aid, and physicians inconsistently used meaningful gestures, despite all of the patients reporting benefits of these strategies. Providers used a wide variety of communication strategies, with some using different strategies during the same encounter. Interestingly, physicians and patients reported using similar strategies to communicate during the encounter. Another Morrisled study based on interviews with adults who use augmentative and alternative communication (bit.ly/ AAC-comm) identified time constraints, inappropriate assumptions about people’s cognitive

RESEARCHERS FOUND THAT PEOPLE WITH SLV DISABILITIES WERE THREE TIMES MORE LIKELY TO EXPERIENCE A PREVENTABLE MEDICAL ERROR. closely with previous research at the hospital and individual levels. In a 2008 study at several hospitals in Canada—led by Gillian Bartlett and published in the Canadian Medical Association Journal (bit.ly/SLV-error)— researchers found that people with SLV disabilities were three times more likely to experience a preventable medical error as inpatients than adults without SLV disabilities. At the individual level, qualitative focus groups and interviews have repeatedly found that adults with SLV disabilities describe difficulty accessing medical care and challenges interacting with their medical care team (see sources). As a result of these challenges, many adults report the quality of

• Seldom receive quality emergency/routine care

or hearing abilities, and difficulties communicating with physicians as barriers to receiving high-quality care.

THE FIX: ADDRESSING DISPARITIES What can be done to help turn the tide and improve health care access for patients with SLV disabilities? Education of providers is key, and medical schools, health facility administration, and continuing education programs should promote efforts to improve the health care experiences of patients with SLV disabilities. Audiologists and SLPs can be prime ambassadors in this regard. They can do much to champion the needs of adults with SLV disabilities in their work settings and communities. Promoting communication is not just ethical. It is specified in regulations mandating hospitals and clinics (Section 1557 of the Patient Protection and Affordable Care Act; Nondiscrimination in Health Programs and Activities 2016) and state and local government services, as well as public accommodations and commercial facilities (U.S. Department CONTIN U ED ON PG 40

ACROSS 25 VIDEO-RECORDED VISITS, NO PHYSICIAN WROTE DOWN KEY WORDS WHILE SPEAKING, ONLY ONE USED A VISUAL AID, AND PHYSICIANS INCONSISTENTLY USED MEANINGFUL GESTURES.

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HELPING THE UNINSURED By Janice Wachtler, BAE, CBA

nyone who works in emergency medicine knows that many of the patients seen on an average day are uninsured. You also know you cannot turn them away, send them to the county or state-run hospital, and that, in all likelihood, the care you give today will not be reimbursed to your institution. You also know about a program called the Affordable Care Act (ACA) that allows anyone to be insured for healthcare. So, wouldn’t it be of use to all hospitals to employ someone to help all these people navigate the difficult waters of healthcare? Imagine if your institution had a segment of its personnel trained and stationed in the emergency department simply to work with uninsured patients and help them get on the government’s insurance coverage. What would that do to your bottomline? Would this cover needed equipment, salary, employee benefits, additional staffing, a few more resident positions, or even a new ultrasound machine? The list is endless. For the additional salaries of people trained in the nuances of the ACA filing requirements, your emergency room and hospital would receive fees for people who would normally not be insured.

This is not a panacea for all patients who aren’t registered anywhere or who have no interest in registering, but how many patients are just not able to get that help to file because of mental status, the inability to read and understand the complexity of the process, or simply aren’t aware of the program. Would it be worth it to have someone sitting down at the bedside or in a room outside of the ED just working with clientele after they are seen by the physician? Sure, they may never return to your facility for care, but they may appear in a neighboring hospital for care or see a physician regularly to take care of their recurring problems such as blood pressure or diabetes. The ACA may not be popular with the current administration, but it should be our right as citizens to have access to healthcare, and it should be your right as a physician or hospital to receive payment for your service. Think about it. –•–

WOULDN’T IT BE OF USE TO ALL HOSPITALS TO EMPLOY SOMEONE TO HELP ALL THESE PEOPLE NAVIGATE THE DIFFICULT WATERS OF HEALTHCARE?”

THE PULSE SUMMER 2019

MARK MITCHELL, DO, FACOEP-D, FACEP

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PSYCHOLOGICAL BARRIERS TO CARE FOR THE HOMELESS PATIENT By Erin Sernoffsky, ACOEP Staff

n August 2017, Hazel Williams became homeless. For seven months she lived in a shelter for veterans, and during this time she noticed a growth on her gum. Because she did not have health insurance, she did what many others in her circumstance do—she went to the emergency department. Hazel’s experience in the ED was largely positive and, with help from hospital staff, she was able to navigate the difficult waters of applying for insurance. “I didn’t have a bad experience,” she recollects. “I think it was because I didn’t verbally tell them I was homeless. I [used] the shelter address on the forms.” Hazel’s decision not to tell the healthcare professionals about being homeless did not have to do with her pride. She has a “don’task-don’t-tell policy” because she is a private person and as she puts it, “I think, because of my personality, it doesn’t allow me to be disrespected by anyone, even if they try.” Hazel has a very direct approach to discussing this period in her life, and it’s impossible not to admire the confidence in which she handled her healthcare during her time living in the shelter. Unfortunately, not all people in Hazel’s situation have the same experience or attitude. Homelessness and poor health are inextricably linked, perpetuating a cycle that can be impossible to break. According to the National Coalition for the Homeless (NCH),

POOR HEALTH IS BOTH A CAUSE AND A RESULT OF HOMELESSNESS.”

NATIONAL COALITION FOR THE HOMELESS

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“Poor health is both a cause and a result of homelessness. Many people are reduced to homelessness because of poor health, which can rapidly escalate into employment problems, financial difficulties, and housing issues.” Emergency physicians are very familiar with these issues faced by the homeless and the resulting financial implications. Although these issues no doubt affect physicians everywhere, they do not always fall into the bedside scope of practice. However, physicians’ attitude toward homeless patients can have a profound impact on the individual, empowering them to be an active part of their care team. A 2009 NCH article points to psychological roadblocks like “embarrassment, nervousness about filling out the forms and answering questions properly, and self-consciousness about appearance and hygiene when living on the streets.” By remembering the day-to-day challenges these patients face and the fears that keep them from coming in for care, physicians can treat the person—not the additional challenges treating a homeless patient can present. As Hazel directly points out, “Doctors and medical personnel should treat each patient with the respect they deserve. I don’t think they should mistreat them because of the perception they may have about the homeless.” Philippe Bourgois, PhD and Barry Zevin, MD Medical Director, explored some of these barriers in a Dean’s Seminar presented at the University of California, San Francisco. They report, “there are multiple physical, logistical, and psychological barriers to medical care for homeless people. Most homeless people are alienated from existing social structures.

Their scope of living is narrowed to mere survival and existence marked by multiple traumas and losses. Homeless people are frightened, distrustful, and extremely sensitive to any threat, real or perceived, to what remains of their integrity (humanity and dignity).” In Hazel’s case, she has developed skills to handle difficult situations head on, as well as access to institutions to help her through her career in the Marine Corp. “[The Marine Corp] was a great experience and some of the things I learned, I carry with me today,” she said. “Also, being a homeless veteran had some extra benefits that I wouldn’t have had, but, at the same time, there were additional hoops I had to jump through in order to get housing.” Understanding the perspective of the homeless patient is key to providing collaborative, patientcentric care. In an article published by the American Family Physician, Patricia Czapp, MD, advises physicians to be more aware of cultural proficiency. She writes, “low-income patients may be labeled noncompliant even when they do not deliberately disregard medical instructions. They may be ashamed to admit that a prescription was too costly to fill, that they take it every other day to make it last, or that they share it with another family member with the same

condition. They may arrive late to an appointment because they have to take three buses to get to their physician’s office. They may not have completed the screening test ordered because their employer is unforgiving of work absences or they could not arrange for a reliable person to watch their children. Practice team members should maintain a nonjudgmental attitude and carefully tease out the ‘why’ of nonadherence.” Hazel’s strong personality, access to VA help, and hospital social workers helping her to navigate insurance applications helped her to access

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care and move beyond her healthcare issues. However, not all homeless patients are Hazel, and the myriad of health problems homeless patients typically present with are complex. Knowing that fear of judgment and sometimes embarrassment keeps homeless patients from seeking care highlights the importance of physician attitude toward patients. Placing focus on the person, maintaining a nonjudgmental attitude, and respecting the challenges homeless patients face are all vital to maintaining patient-centered care. –•–

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ACOEP’S COMMITTEE FOR

WOMEN IN EMERGENCY MEDICINE UPDATE By Teagan L. Lukacs, DO, MPH, MBS

he ACOEP Women’s Committee is proud to report on a successful 2019 Spring Seminar! This year we enjoyed and learned from lectures by Doctors Jaime Hope, Sandy Simons, and Gita Pensa. They focused on reframing our mindset, the #MeToo movement, women’s bias against other women, strategies to overcome bias, physician litigation, and litigation stress. Their experiences and insights expanded our perspectives on tough situations we encounter every day, as well as situations we may only encounter once in our careers. Their viewpoints and advice were even more refreshing than the tropical Florida air. This year we choose to spread our reach outside the conference center and hosted a philanthropic event in collaboration with a local Girl Scouts troop and Path2Freedom. Over 40 people got together on Tuesday night and created 22 rag tie blankets. Women, men, Girl Scouts, and doctors came together to provide comfort and warmth, physically and emotionally, to those who have survived human trafficking in partnership with Path2Freedom. This organization creates hope and healing for child victims by providing safe environments and long-term programs for recovery from human trafficking. Human trafficking is a version of slavery and involves force, fraud, or coercion to obtain labor or sexual acts. The average age of trafficking victims is 9-14 years old worldwide. Many young female victims are lured from the Foster Care System, and survivors are at risk of being returned to this system if they are lucky enough to be rescued or escape. Path2Freedom recognized the need for comprehensive long-term care and developed family-style residential programs that are traumainformed, therapeutic, and focus on rebuilding

THE PULSE SUMMER 2019

by utilizing a biopsychosocial-spiritual approach. They utilize six pillars of restoration: nutrition and wellness, individualized treatment team intervention, trauma informed care, educational assessment, counseling and recreational therapies, and spiritual experience. The emergency department is one of the few places a human trafficking victim may intersect with the general population. As one of the few opportunities for a victim to receive help, it is of critical importance that we, as emergency physicians, be vigilant to screen, identify, and intervene on their behalf. There is no classic presentation of sexually-trafficked patients as there is often great complexity to each case. But physicians can better identify potential cases by increasing their awareness to the phenomenon, using qualified interpreters, isolating potential victims by providing privacy, using simple clear reassuring statements, and ensuring security. A multidisciplinary team can then be mobilized to help these patients who will require long-term support such as that Path2Freedom provides. We were excited and inspired by Path2Freedom’s cause and hoped to instill the passion to help others in the next generation. The girls involved with Girl Scouts have already shown their interest in community involvement and leadership. They are taking action to change the world and we hope to show them this is a life-long pursuit. The Women’s Committee is committed to leading by example and living out the lessons we learn from each other and our lecture tracks. In the spirit of lifelong philanthropy, we’d like to thank FOEM for their donation to our collaborative outreach event, their continued support of patient centered holistic emergency care, and their commitment to the osteopathic philosophy. –•–

WE WERE EXCITED AND INSPIRED BY PATH2FREEDOM’S CAUSE AND HOPED TO INSTILL THE PASSION TO HELP OTHERS IN THE NEXT GENERATION.” SUMMER 2019 THE PULSE

RSO UPDATE! By Dominic Williams, DO, RSO President

he RSO continues to promote student and resident education from our local clubs to our national conferences. We are excited to be attracting attendees from all walks of emergency medicine. Our Club of the Year competition is coming to a close and the winner will be announced at this year’s Scientific Assembly in Austin, TX. Prior to that, we will have a regional symposium in Oklahoma to teach students about the intricacies of a mass casualty incident and the skills to do “the most good in the least time.” In Austin, we will be offering exciting lectures to the students, as well as opportunities to mingle with residents and program directors to get the inside scoop on the application process. Emergency medicine continues to draw some of the most talented and accomplished aspiring doctors and we want to ensure our RSO members are the best candidates they can be. Residents can look forward to dedicated courses and research presentation opportunities. Find more information about our events at www.acoep-rso.org.

OUR THANKS TO YOU, THE ACOEP MEMBER, THE OFFICE STAFF, AND TO THE BOARD OF DIRECTORS FOR YOUR CONTINUED HELP AND SUPPORT IN OUR ENDEAVORS. WE COULD NOT DO IT WITHOUT YOU, AND WE ARE BOTH PROUD AND HONORED TO LAY THE FOUNDATION FOR THE FUTURE OF THE COLLEGE.”

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As president of the RSO, it was my pleasure to attend the Leadership and Advocacy Conference, hosted by ACEP, this May in Washington DC. It is an experience that I would recommend to each of you. It’s a privilege to live in a nation with such smooth access to our elected officials and those I interacted with were very eager to listen to what we, as caregivers, had to say. As physicians we play a unique role in society—perhaps even more so as emergency medicine physicians. We witness life at its most raw. Many of us can recount thousands of tales of patients that we have cared for over our time in the department. This year’s advocacy focus was on mental health. This topic, although still taboo in some circles, impacts a vast number of individuals, many of whom seek refuge inside our doors. From the suicidal child to the broken widower, we do not turn the needy away. Yet so often we struggle to bring the best resources to our patients, as the needs outweigh the means. We watch our patients wallow and become more frustrated, often agitated, with their situation. Stuck in hallways, behind curtains, and watched perpetually, these patients vegetate, waiting for the miracle of an available bed. It was these stories we took to Capitol Hill. Our efforts were met with a listening ear and we trust that in the near future a bipartisan program to help fund mental health projects will be forthcoming. –•–

Western Journal of Emergency Medicine Call for Papers:  Social Emergency Medicine  Systematic Reviews

CALL FOR SECTION EDITORS  Behavioral Health  Pediatric Emergencies  Public Health  Cardiac Care  Trauma Care  Ultrasound  International Medicine  Clinical Practice  ED Administration Send your CV and letter of interest to editor@westjem.org Learn more at www.westjem.org

“H ELPING PATIENTS WITH AUTISM AN D TH EIR FAMILIES NAVIGATE EM ERGENCY VISITS” CONTIN U ED FROM PG 20

Care of the Individual with Autism Spectrum Disorder in the Emergency Department (Venkat et al., 2016). In addition, some organizations develop their own tools. If the information can be stored in the medical record, this will ease assessment for future visits. During the encounter, interactions can be enhanced by utilizing the information gathered to support the individual through the necessary evaluations and procedures. Adapted care strategies include explaining or modeling procedures before performing them, changing the way questions are asked, allowing extra time for the patient to process and respond to questions, offering comfort items, and allowing the patient to engage in safe coping behaviors such as movement breaks, pacing the room, or interacting with preferred items. It can also be helpful to give the patient information about what is coming next and to allow them to understand when they will be able to go home.

UTILIZING STRATEGIES IN THE ED SYSTEM While these strategies may appear straightforward, their application can be challenging given the varied presentation of patients on the autism spectrum and the chaotic nature of the ED setting. Studies have suggested formal training as a possible mechanism to improve staff confidence in working with people on the autism spectrum and to improve provider and patient experience. In some areas, ED staff have been able to obtain training through colleagues from local assessment and treatment clinics serving people with ASD. Because the stress and anxiety of medical encounters can trigger unsafe behavior in some patients with ASD, staff will also benefit from training about how to support behavioral de-escalation, personal safety, and safe physical management. There are numerous professional training models for non-violent physical

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management of unsafe behavior, such as Crisis Prevention Institute or Therapeutic Crisis Intervention that aim to keep both patients and staff safe. Protective Services professionals can also play a key role in supporting staff when an unsafe behavioral escalation occurs, however, a show of force approach is likely to escalate rather than de-escalate the situation. Protective Services professionals may also benefit from first responder training geared towards understanding individuals with ASD. For patients who use PRN medication, it is best practice for the medication to be administered at early signs of escalation rather than after serious behavior is observed. Additionally, it is not uncommon for individuals with autism, especially the pediatric population, to have paradoxical reactions to medications. It is helpful to work with pharmacists or psychiatrists who are knowledgeable about potential PRN medications for this population. Some ED’s have developed algorithms for PRN use with individuals with ASD and trained all of their providers to improve consistency. Caring for individuals with ASD in the complex ED environment is no easy task, however, given the increasing incidence of autism and the challenges of access to appropriate community resources, these encounters are likely to continue to soar. There is a growing trend for emergency departments to begin to address these challenges using quality improvement methodology and current research. Some institutions have utilized parent input to improve processes and systems. Emergency departments are encouraged to walk through their system from entry to discharge, looking at processes through the lens of a person with autism and their family to determine where to start improvement efforts. Staff and patient safety initiatives have also been drivers of this work. Environmental management, education

of healthcare providers to increase knowledge and comfort, as well as strategies for partnering with the family for both understanding and providing care are key components to most improvement efforts. Additionally, families report significant benefits when they are connected with appropriate follow-up care to prevent future emergency room visits. This may include referrals to primary care physicians knowledgeable in ASD, as well as behavioral and psychiatric treatment providers and other medical specialists. Individual providers who work well with this population can be hailed as heroes to an individual family, however, we are charged to improve care at a system level so that all patients with ASD, their families, and the staff will experience improved safety, interactions, and outcomes. –•–

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“COM M U NICATION:IT’S CRITICAL TO CARE” CONTIN U ED FROM PG 28

of Justice), to provide people with disabilities with auxiliary aids and services to ensure equitable access to communication. These regulations are supported by the Joint Commission, which designates people with communication disabilities as high risk for ineffective communication and calls for medical care systems and clinicians to provide additional supports to ensure effective communication with patients with communication disabilities (bit.ly/ JC-equity). SLPs and other providers can employ four strategies to promote use of such supports: Partner with leadership at your organizations to help create and implement institutional policies for effective communication. Ensure that policies are informed by evidence and implemented according to bestpractice guidelines. ASHA offers extensive information on evidence and implementation in its Evidence Maps (www.asha. org/evidence-maps). Incorporating these practices is not easy or simple, given the constraints of time and money. But consider the severe legal ramifications of not addressing the needs of adults with SLV disabilities. Educate staff and providers using informal and formal methods. Given the high rates of chronic conditions in patients with SLV disabilities, providers likely interact with a wide range of medical care providers and teams when treating them. Formally, audiologists and SLPs can provide

A CHANGE TO THE NATIONAL HEALTH INTERVIEW SURVEY (NHIS) HAS FINALLY POSITIONED RESEARCHERS TO EXAMINE THE HEALTH AND MEDICAL CARE OUTCOMES OF ADULTS WITH SPEECH, LANGUAGE AND VOICE DISABILITIES.

in-service trainings and help develop educational materials, including pamphlets and signs, for colleagues. Remember that most medical care providers receive little to no training on effectively communicating with patients with SLV disabilities. General education on patient-provider communication is available, but advanced training to address the needs of people with communication disabilities is rare. This specific training should become part of medical school curricula and continuing education. Informally, audiologists and SLPs can model effective communication strategies with these patients and alert their colleagues about suggested strategies, including presenting information in ways that the patient can understand and not interrupting the patient. List key communication strategies to use with patients in a prominent place, such as the patient’s medical chart. How to do this differs by institution and electronic medical record (EMR) systems, but many EMRs offer a demographic field in which to describe a patient’s disability and needed accommodations. Documenting SLV disabilities and strategies that work is key: Many adults with SLV disabilities visit multiple medical care providers, many of whom are unaware of the patients’ needs. Be aware of the medical complexity and difficulties that patients with SLV disabilities face accessing medical care services. These complexities can significantly affect patients’ ability to attend to treatment-related instructions and tasks. For example, if a patient has uncontrolled diabetes, kidney pain (or other such symptoms) could hamper their concentration during an audiology or speech-language treatment session. Providers need to individualize treatment and care-delivery styles to each patient’s specific needs.

The pages of this magazine contain countless stories of audiologists and SLPs partnering with physicians and organizations to share tools and best practices for work with adults with SLV disabilities (for example, Tiffany Turner’s 2018 article “Widening Her Circle,” on.asha.org/ wide-circle). Judith’s story, which began this article, underscores the value of using effective communication strategies with this population, as well as the need to partner with physicians and other health care providers to improve their medical care outcomes. Federal regulations and our ethical responsibilities as medical care providers require that we work together to improve patient care and outcomes across the medical care system. With support from administrators and other providers, audiologists and SLPs are well-poised to help improve health care access, quality and outcomes for patients living with all types of SLV disabilities. –•– Michelle L. Stransky, PhD, is a lecturer in the Department of Community Health at Tufts University and is an affiliated research faculty member at the Social Science Applied Research Center at the University of North Carolina– Wilmington. michelle.l.stransky@gmail.com Megan A. Morris, PhD, MPH, CCC-SLP, is a faculty member in the Department of Family Medicine in the School of Medicine at the University of Colorado megan.a.morris@ucdenver.edu *The patient’s name has been changed for identity protection.

FIND SOURCES FOR THIS ARTICLE AT LEADER.PUBS.ASHA.ORG.

SUMMER 2019 THE PULSE

Bernard Heilicser, DO, MS, FACEP, FACOEP-D

What Would You Do? Ethics in Emergency Medicine

In this issue of The Pulse we will review the ethical dilemma presented in April 2019 by Elise Zahn, DO. Dr. Zahn offers a question regarding patients in the emergency department whose alcohol level is checked and then wants to leave. Medicolegally, the level should be under the state’s legal limit, unless a responsible person is signing them out. Many patients are homeless or intoxicated, and brought in by EMS or the police. The ED wants the patient discharged ASAP. Dr. Zahn indicates her discomfort in discharging this patient home or to the streets when their alcohol level is above the legal limit. Dr. Zahn further relates a case when a patient was discharged alone to the street, only to return two hours later as a trauma victim.

WHAT WOULD YOU DO? We are all subjected to the pressure of “metrics” coercing us to move “customers” in our departments. I personally believe these two words to be profane. We can simply discharge the patient to the street, hoping Darwin is wrong, and await the instant replay of the patient returning later that night or soon thereafter. Do we look the other way as the patient leaves without our knowledge? Neither answer meets any ethical standard. We may also force the patient to stay, possibly restrained, until their alcohol level is appropriate for discharge. I would maintain we: 1. Not look the other way 2. Although time consuming, arrange safe follow-up for the patient when the discharge is appropriate 3. Restrain if needed for patient or staff safety Although, understandably, rather frustrating, we must never forget our calling to care for human beings. When we falter in that altruism, we are losing part of ourselves. Not only is this the right thing to do, the consequences of a negligent decision could be devastating. Don’t be the “dirtball’s dirtball”.1 We thank Dr. Zahn for her caring and professionalism in bringing this dilemma to us for discussion. –•– 1. Heilicser, B. Redefining “Dirtball”. Annals of Emergency Medicine, April 1995: 25: pp 559-560.

If you have any cases that you would like to present or be reviewed in The Pulse, please email them to us at esernoffsky@acoep.org. Thank you.

THE PULSE SUMMER 2019

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