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Social Medicine in the Emergency Department: Not all conditions can be treated with medicines

social medicine emergency department homeless

On the day we met Jane, a woman in her 70’s with diabetes and mobility impairment, she was visiting an Emergency Department (ED) for the 50th time in the past year. Jane was experiencing homelessness and spent much of her day riding public transportation in her wheelchair. Bystanders, often concerned for her health after noticing she had an episode of incontinence, would call 911 after which Jane would be brought to the nearest ED.

On the day Jane came to our ED, our multidisciplinary ED-based Social Medicine team was asked to help in her care. She was very thin, her clothes were wet from rain, and her belongings were falling from the plastic bags draped on the back of her wheelchair.  Our team sat with Jane to understand what type of help that she wanted — she was hungry, she hadn’t had stable access to food for months, and her bottom was painful as she had developed wounds from spending hours sitting in soiled clothes. That day, our team provided her with a sandwich and hot coffee, brought her a set of clean, dry clothes, and built enough rapport with her to interest her in moving indoors to a nearby respite center. Over the ensuing months, Jane gained back her strength, she established care with a primary care physician and improved her diabetes control, her wounds healed, and she built a relationship with a case manager who helped her to move into long-term housing. And, as a secondary outcome, her use of acute care services dropped substantially – she had less than 5 ED visits and no hospitalizations in the following year.  Caring for Jane and watching what happened next was a lesson for all of us about the impact of addressing medical and social needs together.

What is an ED Social Medicine team?

We formed the ED Social Medicine team in 2017 to support ED clinicians and help better meet the complex medical, behavioral health, and social needs of ED patients. A brief description of our work was recently published in JAMA [1], which provides one potential roadmap to medical and social care integration in the ED. A few core components of this work include:

  1. Asking patients about their self-identified social needs – Meeting a patient’s psychosocial needs allows them to better engage with medical care.
  2. Supporting ED clinicians in the care of patients with complex behavioral health and social needs – The ED and acute care system cannot function optimally in a silo. The Social Medicine team is multi-disciplinary and includes hospital-based social workers, nurses, pharmacists, care coordinators, AND strong partnerships with ambulatory health care clinicians and community-based organizations essential to the safe discharge and successful care of ED patients with complex social needs.
  3. Considering how to best promote the individual patient’s health and independence while preserving access to acute care for all patients – Medical, social, and behavioral health resources in the community are often more robust than we might realize; clinicians and patients both win by better understanding the landscape of care and resources available in the community. Leveraging available community resources also allows the ED and inpatient hospital to be preserved for patients with the most emergent medical conditions.

Integrating the medical, behavioral, and social care for your patient

Treatment of medical conditions without consideration of underlying social needs will be less effective, more costly, and may lead to moral distress for both patients and providers. We all want to feel that we are treating the patient so that they will do as well as possible in their life outside the hospital — to address not just the immediate medical issue, but the things that are fundamental challenges in their lives.

For instance, when we are treating a patient in the ED with diabetes, homelessness, and social isolation, prescribing medication to treat hyperglycemia may be the most straightforward solution, but it is unlikely to be maximally effective without ensuring the patient can do the following:

  • Afford the medication
  • Get to the pharmacy
  • Read the label and administer the medication
  • Access affordable food
  • Obtain transportation to follow up medical appointments
  • Find a stable place to live
  • Connect with social support in their community

These can seem daunting, and it may not be possible to improve all of these issues during the ED visit, but there are effective interventions to try to help patients experiencing complex social needs. As related to the example above:

  • Arrange a conversation with a social worker to assess and address the patient’s social needs
  • Dispense discharge medications directly from the ED
  • Ask the pharmacist to consider how to make dosing easier such as a medi-set or special labeling for patients who speak a primary language other than English, or have visual impairment or low literacy
  • Facilitate the next check up in primary care or other medical care by making an appointment or providing a warm handoff
  • Provide printed information about social and community resources such as meal kitchens, food pantries, housing programs and community groups (such as support groups, faith communities and cultural organizations)

No matter what the problem, a first step is always to ask the patient what support they need in order to be successful.

Call to action for social medicine

  1. Partner up: We encourage you to understand the underlying social needs of your patients and work with partners, such as your ED social workers and community social services, to help meet those needs. The ED visit can be an opportunity to go beyond healthcare, and help our patients realize optimal health.
  2. Ask the patient: At the frontline, we recommend asking your patients about their primary concerns and social needs, and doing what you can to help.
  3. Form a team: If you want to go a step further, form a team and develop partnerships with staff in your ED (e.g., social workers) and outside your health setting (e.g., community based organizations) to understand a system problem (e.g., access to medications, food or emergency housing) more deeply. Talk to your patients to get their input and recommendations. Then, use quality improvement techniques to improve the care of that problem in service to your patients.
  4. Look upstream: If you want to work upstream of direct care, join or form a group to understand a problem at the community level and advocate for increased social services available to your organization and community.

More resources

If you want to learn more or get more involved in the Social Emergency Medicine space:

 

References

  1. Chase J, Bilinski J, Kanzaria HK. Caring for Emergency Department Patients With Complex Medical, Behavioral Health, and Social Needs. JAMA. 2020;324(24):2550-2551. doi:10.1001/jama.2020.17017

Photo by Ev on Unsplash

By |2026-06-16T16:16:49-07:00Jan 22, 2021|Beyond the Abstract, Emergency Medicine|
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SplintER Series: A Fateful FOOSH

A 66 year-old man presents with right anterior elbow pain, ecchymosis, and a “lump” in his right upper extremity after a ground level fall (Figure 1). What is your suspected diagnosis? What physical exam maneuver(s) can help you confirm your diagnosis? What is your initial workup in the ED? What imaging confirms the diagnosis? What is your management and disposition?

Figure 1: Case Courtesy of Dr. Peter M. Martin

 

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By |2022-01-14T10:09:39-08:00Jan 17, 2021|Expert Peer Reviewed (Clinical), Orthopedic, SplintER, Sports Medicine|
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Doxycycline vs Azithromycin: Think Twice About the 2020 CDC Guideline Update on Treatment of Gonorrhea and Chlamydia

cdc gonorrhea chlamydia doxycycline

When the new Centers for Disease Control and Prevention (CDC) recommendations1 regarding the treatment of uncomplicated gonorrhea (and indirectly chlamydia) debuted like a slice of antibiotic resistance doom, it felt like another “gift” had arrived from 2020. Intramuscular (IM) ceftriaxone dosing has increased from 250 mg to 500 mg (or 1 g for weight ≥150 kg). Empiric chlamydia coverage switched from a single dose of 1 g of azithromycin to doxycycline 100 mg PO BID for 7 days. Being deferential to CDC expertise, many providers accepted them uncritically. Compliance rates with a switch from a 1-time to a 7-day regimen are not addressed, especially worrisome for a condition that can be minimally or asymptomatic. 

Case

A young woman presents with new and concerning discharge after an unprotected encounter. Her pregnancy test is negative. After agreement for empiric treatment, the patient then refuses empiric treatment when told about the new guidelines (2 injections and 14 chances for esophagitis). Patient specifically asks for the old regime or will just leave against medical advice.

Why a higher dose of ceftriaxone for gonorrhea?

It is important to note that the evidence of ceftriaxone, cefixime, and azithromycin resistance for gonorrhea is substantial.2 Observational data from across the United States and world demonstrate worsening resistance patterns. Many of our pharmacy colleagues are working on obtaining 500 mg/2 mL ceftriaxone for injection vials, so it can be given in single injection (or two for morbidly obese patients). While this guideline may be existentially troubling, this change is practically feasible and should become standard of care.

Read more about the Trick of the Trade on administering IV instead of IM ceftriaxone for gonorrohea.

Why no mention of the single-dose azithromycin option for chlamydia?

The evidence basis for the change to doxycycline for treatment of chlamydia co-infection coverage is substantially weaker. It is also decidedly mute on the risks of partial or non-compliance with treatment. The question then becomes: How profound is the treatment effect and how does it balance against its risks?

The guideline states, as evidence for the doxycycline switch:

“A recent investigation comparing children who received twice-yearly azithromycin with children who received placebo found that the gut’s resistome, a reservoir of antimicrobial resistance genes in the body, had increased determinants of macrolide and nonmacrolide resistance, including beta-lactam antibiotics, among children receiving azithromycin (10).3 A higher proportion of macrolide resistance in nasopharyngeal Streptococcus pneumoniae was demonstrated in communities receiving mass administration of oral azithromycin (11).4 Azithromycin resistance has been demonstrated in another STI, Mycoplasma genitalium, and sexually transmissible enteric pathogens (e.g., Shigella and Campylobacter) (12–14)5-7. In addition, evidence supports increasing concern for the efficacy of azithromycin to treat chlamydial infections, especially rectal infections (15,16)8,9.”

Citations 10 and 11 speak in generalities of resistance patterns, with citation 11 being a secondary analysis of a mass azithromycin treatment trial of young children in Niger. Citations 12-14 discuss rates of coinfection treatment failure – an important consideration, but only secondarily relevant. That leaves 2 citations (15 and 16)– one a meta-analysis and one a small poster that isn’t even available online related to known anorectal chlamydia.

That really leaves the meta-analysis8 to answer our question: how best do we protect the reproductive health of our patients in the setting of diagnostic uncertainty?

The meta-analysis

The meta-analysis is somewhat messy with substantial heterogeneity in many relevant subgroups.8 A single study comprises the majority of the evidence that shows doxycycline superiority in non-gonococcal urethritis.10 It was from 2011 and revealed that while doxycycline may be better for chlamydia treatment, azithromycin was better for coinfection treatment (such as shigella or mycoplasma). And to top the whole thing, the doxycycline superiority line reads:

“We found a pooled efficacy difference in favor of doxycycline of 1.5%… to 2.6%.”

In men with symptomatic urethritis, the superiority of doxycycline increases to 7% (an NNT of 14). If you ignore the heterogeneity and pool everyone, we arrive with an overall NNT for doxycycline over azithromycin of 38 (fixed effects model size was a 2.6% advantage). If the above study10 was removed, the pooled difference would have been non-significant with an NNT of at least 50.

Having thought perhaps they just didn’t include all the evidence, a secondary literature review was undertaken. A few small case studies11 and older observational studies12,13 were found, which showed a potential treatment failure rate of azithromycin of up to 8%, but comparable rates with doxycycline.12 That’s it. There is also genuine concern that use of azithromycin may induce resistance not only for itself but other antibiotic classes3,4 but this concern is based on fecal biome sampling from toddlers and requires a couple of steps to be relevant to our question. Doxycycline, an essential medication in its own right, for treatment of tick-borne disease, ascending genital tract infections, COPD exacerbation and MRSA, also requires our stewardship.

Medication compliance questions

Given patient non-compliance with filling and completing ED prescriptions approach rates of 20%,14,15 the recommendation for a 7-day course of doxycycline for chlamydia over single-dose azithromycin is fraught with peril. Additionally, consider that the patient may be relatively asymptomatic, placing them even more at risk for medication non-compliance for the 7-day course of doxycycline. Contrast this with the risks of pelvic inflammatory disease and infertility if untreated.

Conclusion

Given the sparse, heterogenous literature, we should have strong reservations about recommending doxycycline for patients for whom chlamydia has not been excluded. New gonorrhea treatment recommendations should be followed and efforts made to stock appropriate concentrations of ceftriaxone. A single-dose of azithromycin may be a reasonable alternative for your patient for non-gonococcal disease, after considering and discussing the risks and benefits. Pregnant patients require close follow up but should also continue to receive azithromycin.

If you are prescribing doxycycline, remember:

  • Each pill should be taken with 6-8 oz of liquid, water preferred. 
  • If taken with food, it decreases the risk of dyspepsia.
  • One should sit upright for 30 minutes following each pill, especially those with history of GERD.
  • If substantially sunexposed, sunscreen or full skin coverage should be recommended to prevent photosensitive reactions (which can be mild to quite severe).

If you are prescribing azithromycin, remember:

  • Azithromycin can cause clinically significant increases of QTc even with a single dose, but typically only to those with multiple risk factors.16 Consider ECG if patient on QTc prolonging medications and/or coexisting electrolyte derangements discovered.
  • The risk of treatment failure for chlamydia and other non-gonococcal coinfections is real. For men with symptomatic urethritis, that risk is substantially higher.
  • Have a shared decision discussion about doxycycline versus azithromycin.
  • While all patients should receive verbal and written follow-up instructions, close follow up should be emphasized, given that you are essentially contravening a CDC guideline.

Patient case resolution

You explain to your patient that the new guidelines should be followed for gonorrhea, and so she receives 500 mg of IM ceftriaxone. While the new guideline for doxycycline MAY be slightly more effective for the treatment of chlamydia, using shared decision making, she receives the old regimen (single-dose azithromycin). You verbally emphasize and document in the discharge instructions the importance they follow up with either their PCP, gynecologist, or the local sexually transmitted infection clinic for a recheck, if their symptoms don’t resolve within 7 days.

References

  1. St. Cyr S, Barbee L, Workowski KA, et al. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1911–1916. DOI: http://dx.doi.org/10.15585/mmwr.mm6950a6external icon
  2. https://www.cdc.gov/std/treatment-guidelines/toe/GCEvidenceTables2020.xlsx [Download file link]
  3. Doan T, Worden L, Hinterwirth A, et al. Macrolide and nonmacrolide resistance with mass azithromycin distribution. N Engl J Med 2020;383:1941–50. PMID 33176084
  4. Doan T, Arzika AM, Hinterwirth A, et al.; MORDOR Study Group. Macrolide resistance in MORDOR I—a cluster-randomized trial in Niger. N Engl J Med 2019;380:2271–3. PMID 31167060
  5. Bachmann LH, Kirkcaldy RD, Geisler WM, et al. Prevalence of Mycoplasma genitalium infection, antimicrobial resistance mutations and symptom resolution following treatment of urethritis. Clin Infect Dis 2020;ciaa293. Epub March 18, 2020. PMID 32185385
  6. Yousfi K, Gaudreau C, Pilon PA, et al. Genetic mechanisms behind the spread of reduced susceptibility to azithromycin in Shigella strains isolated from men who have sex with men in Québec, Canada. Antimicrob Agents Chemother 2019;63:e01679–18. PMID 30455248
  7. Gaudreau C, Pilon PA, Sylvestre JL, Boucher F, Bekal S. Multidrug-resistant Campylobacter coli in men who have sex with men, Quebec, Canada, 2015. Emerg Infect Dis 2016;22:1661–3. PMID 27533504
  8. Kong FY, Tabrizi SN, Law M, et al. Azithromycin versus doxycycline for the treatment of genital chlamydia infection: a meta-analysis of randomized controlled trials. Clin Infect Dis 2014;59:193–205. PMID 24729507
  9. Dombrowski JC, Wierzbicki MR, Newman L, et al. A randomized trial of azithromycin vs. doxycycline for the treatment of rectal chlamydia in men who have sex with men. Presented at the National STD Prevention Conference, Atlanta, GA: September 14–24, 2020.
  10. Schwebke JR, Rompalo A, Taylor S, et al. Re-evaluating the treatment of nongonococcal urethritis: emphasizing emerging pathogens randomized clinical trial. Clin Infect Dis. 2011 Jan 15;52(2):163-70. PMID 21288838
  11. Bhengraj AR, Vardhan H, Srivastava P, Salhan S, Mittal A. Decreased susceptibility to azithromycin and doxycycline in clinical isolates of Chlamydia trachomatis obtained from recurrently infected female patients in India. Chemotherapy. 2010;56(5):371-7. PMID 20938174
  12. Golden MR, Whittington WL, Handsfield HH, Hughes JP, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. New Engl J Med. 2005 Feb 17;352(7):676-85. PMID 15716561
  13. Fortenberry DJ, Brizendine EJ, Katz BP, et al. Subsequent Sexually Transmitted Infections Among Adolescent Women With Genital Infection Due to Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis. Sex Transm Dis. 1999 Jan 1;26(1):26-32. PMID 9918320
  14. Saunders CE. Patient compliance in filling prescriptions after discharge from the emergency department. Am J Emerg Med. 1987 Jul 1;5(4):283-6.
  15. Ho J, Taylor DM, Cabalag MS, Ugoni A, Yeoh M. Factors that impact on emergency department patient compliance with antibiotic regimens. Emerg Med J. 2010 Nov 1;27(11):815-20. PMID 20513734
  16. Hancox JC, Hasnain M, Vieweg WV, et al. Azithromycin, cardiovascular risks, QTc interval prolongation, torsade de pointes, and regulatory issues: a narrative review based on the study of case reports. Ther Adv Infect Dis. 2013 Oct;1(5):155-65. PMID 25165550

By |2026-06-16T16:16:47-07:00Jan 13, 2021|Genitourinary, Infectious Disease|
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Free eBook Announcement: Emergency Medicine Resident Simulation Curriculum for Pediatrics (EM ReSCu Peds)

emergency medicine resident simulation curriculum for pediatrics EM ReSCu Peds

 

The Emergency Medicine Resident Simulation Curriculum for Pediatrics (EM ReSCu Peds) is here! This free ebook contains 16 EM resident-tested, peer reviewed cases covering essential pediatric content identified through a robust modified Delphi process [1] with experts across the United States. Each chapter contains robust supporting materials to help educators prepare, execute, and debrief cases with residents at every level to help supplement the clinical experience.

Download the EM ReSCu Peds eBook

We request some basic demographic about you and how you plan to use the educational cases in the download form to provide us with necessary insights whether there is a need for such a resource.

Download the free EM ReSCu Peds e-book

A National Collaborative Effort

Cases were created and iteratively peer reviewed by members of 10 organizations represented in a national collaborative of EM, PEM, and simulation experts. Participating organizations included:

  • American Academy of Emergency Medicine
  • American Academy of Pediatrics
  • American College of Emergency Physicians
  • Council of Emergency Medicine Residency Directors
  • Emergency Medicine Residents’ Association
  • International Network for Simulation-based Pediatric Innovation, Research, & Education
  • International Pediatric Simulation Society
  • Pediatric Trauma Society
  • Society for Academic Emergency Medicine
  • Society for Simulation in Healthcare

In total, EM and PEM physicians from 44 institutions participated in the development process of this educational resource aimed at preparing EM residents to care for critically ill children.

 

Reference

  1. Mitzman J, Bank I, Burns RA, et al. A Modified Delphi Study to Prioritize Content for a Simulation-based Pediatric Curriculum for Emergency Medicine Residency Training Programs. AEM Educ Train. 2019;4(4):369-378. Published 2019 Dec 12. doi:10.1002/aet2.10412
By |2021-01-09T11:52:36-08:00Jan 12, 2021|Pediatrics, Simulation|
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SAEM Clinical Image Series: What Lies Beneath?

abscess

A 35-year-old male with a history of diabetes and pericarditis, status post pericardiectomy 3 years ago, presented with a painful lesion on his anterior chest wall. One month prior, the patient reported a bump at his sternotomy scar base which extruded a piece of suture when squeezed and subsequently healed. Two days ago, the patient developed diffuse right-sided chest pain. During the past 24 hours, an enlarging, erythematous, painful, non-draining lesion developed at the base of his scar. He reports subjective fever. He denies shortness of breath, exertional chest pain, nausea, and vomiting.

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By |2021-01-10T20:36:12-08:00Jan 11, 2021|Academic, Infectious Disease, SAEM Clinical Images, Ultrasound|
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SAEM Clinical Image Series: Left Ear Mass

ear mass

A 25-year-old male who was previously healthy presents to the emergency department with a painful left posterior ear mass. The mass began as a “pimple” and has been increasing in size for the last 6 months. He has an associated headache, dizziness, and malaise. He denies fever, trauma, drainage, known insect bite, dysphagia, dyspnea, trismus, and hearing loss. He emigrated to the United States from Honduras 8 months ago. He was seen in the emergency department 4 months prior for a similar complaint, which was diagnosed as lymphadenopathy by point-of-care ultrasound.

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By |2026-06-16T16:16:45-07:00Jan 11, 2021|Academic, ENT, Infectious Disease, SAEM Clinical Images|
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