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Health-related social needs (HRSNs), such as food or housing insecurity, are important drivers of disparities in outcomes during public health emergencies. We describe the development of a telehealth follow-up program in Boston, Massachusetts, for patients discharged from the emergency department after coronavirus disease 2019 (COVID-19) testing to identify patients with worsening clinical symptoms, to screen for unmet HRSNs, and to deliver self-isolation counseling and risk-reduction strategies for socially vulnerable people. We prioritized telephone calls to patients with public health insurance and patients without primary care physicians. In the first 43 days of operation, March 30–May 12, 2020, our intervention reached 509 patients, with 209 (41.1%) patients reporting an HRSN, most commonly related to food, housing, or utilities. Thirty-one (6.1%) patients required assessment by a clinician for clinical worsening. This public health intervention may be useful for other institutions developing programs to address the social and health needs of patients discharged with suspected COVID-19.

Background and aim Early diagnosis and treatment of intracerebral hemorrhage (ICH) is thought to be critical for improving outcomes. We examined whether racial or ethnic disparities exist in acute care processes in the first hours after ICH. Methods We performed a retrospective review of a prospectively collected cohort of consecutive patients with spontaneous primary ICH presenting to a single urban tertiary care center. Acute care processes studied included time to computerized tomography (CT) scan, time from CT to inpatient bed request, and time from bed request to hospital admission. Clinical outcomes included mortality, Glasgow Outcome Scale, and modified Rankin Scale. Results Four hundred fifty-nine patients presented with ICH between 2006 and 2018 and met inclusion criteria (55% male; 75% non-Hispanic White [NHW]; mean age of 73). In minutes, median time to CT was 43 (interquartile range [IQR] 28, 83), time to bed request was 62 (IQR 33, 114), and time to admission was 142 (IQR 95, 232). In a multivariable analysis controlling for demographic factors, clinical factors, and disease severity, race/ethnicity had no effect on acute care processes. English language, however, was independently associated with slower times to CT (β = 30.7 min, 95% CI 9.9 to 51.4, p = 0.004) and to bed request (β = 32.8 min, 95% CI 5.5 to 60.0, p = 0.02). Race/ethnicity and English language were not independently associated with worse outcome. Conclusions We found no evidence of racial/ethnic disparities in acute care processes or outcomes in ICH. English as first language, however, was associated with slower care processes.

Background Gender and racial disparities in academic medicine have recently garnered much attention. Implicit Association Tests (IATs) offer a validated means of evaluating unconscious associations and preferences. This study examines the perceived role of implicit bias in faculty development in academic emergency medicine (EM). Methods EM faculty at a large urban academic medical center were invited to independently participate in a self-reflection assessment in preparation for a faculty retreat session discussing diversity, equity, and inclusion. Participants completed two IATs designed to examine gender associations (gender IAT) and race preferences (race IAT) followed by a short anonymous survey where IAT scores were recorded. The survey also captured demographic information and perceptions about the impact of gender and racial biases in faculty development. Results Forty faculty members (66%) completed the survey; 70% were male and 80% white. The majority (59%) reported gender IAT results indicating automatic male-sciences and female-liberal arts associations. Nearly half (45%) reported race IAT results indicating an automatic preference for white people. More than 70% of males reported that faculty recruitment, development, and promotion decisions were 'never' or 'seldom' affected by gender bias, while more than 80% reported racial bias 'never' or 'seldom' affects these decisions. Female faculty more frequently perceived adverse effects of unconscious gender and race biases. Conclusion Our group of academic physicians reported IAT results showing different levels of implicit bias compared to the general population. Female faculty may be both more aware of and more susceptible to the adverse effects of unconscious biases. Further study is needed to determine both the extent to which unconscious biases affect the academic workplace, as well as ways in which such unintentional forms of discrimination can be eliminated. Unconscious biases are not unique to EM. Intentional efforts to increase self-awareness of these 'blind spots' may help mitigate their impact and foster a more diverse and inclusive healthcare environment.

The authors appreciate the comments of Dr. Corbin and his colleagues, as well as those of our colleagues suggesting our findings are "premature conclusions." A primary concern of our colleagues pertains to the limited number of confounders adjusted in our analyses. Indeed, while we were able to adjust for two of the variables noted (substance use and mental health diagnoses), we did not have the data available in this study to analyze potential effects of infection, neurovascular or metabolic complications, or trauma.

OBJECTIVE Race-based bias in health care occurs at organizational, structural, and clinical levels and impacts emergency medical care. Limited literature exists on the role of race on patient restraint in the emergency setting. This study sought to examine the role of race in physical restraint in an emergency department (ED) at a major academic medical center. METHODS Retrospective chart analysis was performed, querying all adult ED visits over a 2-year period (2016-2018) at Massachusetts General Hospital. The associations between race and restraint and selected covariates (sex, insurance, age, diagnosis, homelessness, violence) were analyzed. RESULTS Of the 195,092 unique ED visits by 120,469 individuals over the selected period, 2,658 (1.4%) involved application of a physical restraint by health care providers. There was a significant effect of race on restraint (p

The International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) is the system used by clinicians and medical coders to document diseases, symptoms, social circumstances, and external causes of illness and injury. ICD-10-CM codes for various forms of abuse and violence perpetrated against children and adults exist and facilitate the study of incidence, social context, and comorbid illness and injury. Extant abuse codes, however, fail to capture the profoundly exploitative nature of trafficking and adequately distinguish trafficking patients from other types of abuse patients. As a result, the first trafficking-specific codes have been approved for the 2019 ICD-10-CM update and are expected to strengthen data collection on incidence of and risk factors for trafficking, the burden of comorbid illness and injury, and resources needed to effectively care for trafficked persons.

Because of a soaring number of opioid-related deaths during the past decade, opioid use disorder has become a prominent issue in both the scientific literature and lay press. Although most of the focus within the emergency medicine community has been on opioid prescribing-specifically, on reducing the incidence of opioid prescribing and examining alternative pain treatment-interest is heightening in identifying and managing patients with opioid use disorder in an effective and evidence-based manner. In this clinical review article, we examine current strategies for identifying patients with opioid use disorder, the treatment of patients with acute opioid withdrawal syndrome, approaches to medication-assisted therapy, and the transition of patients with opioid use disorder from the emergency department to outpatient services.

A Man with Episodes of Confusion and Hypoglycemia A 36-year-old man presented with episodes of altered mental status that had increased in frequency over 6 years. The episodes typically occurred at...

Human trafficking, also known as modern-day slavery, is an egregious human rights violation associated with wide-ranging medical and mental health consequences. Because of the extensive health problems related to trafficking, health care providers play a critical role in identifying survivors and engaging them in ongoing care. Although guidelines for recognizing affected patients and a framework for developing response protocols in health care settings have been described, survivors' ongoing engagement in health care services is very challenging. High rates of disengagement, lost contact, premature termination, and attrition are common outcomes. For interventions to be effective in this marginalized population, challenges in engaging survivors in long-term therapeutic primary and mental health care must be better understood and overcome. This article uses the socioecological model of public health to identify barriers to engagement; offers evidence- and practice-based recommendations for overcoming these barriers; and proposes an interdisciplinary call to action for developing more flexible, adaptable models of care.

It is estimated that 21 million people are trafficked worldwide, including 11.4 million women and girls. Approximately 4.5 million are forced to do sexual labor. The exact prevalence of human trafficking is difficult to ascertain, however, given the limitations of data collection in an illegal industry. Obstetrician-gynecologists should not only be aware of the widespread nature of human trafficking, but also have the tools to assess patients for trafficking and respond to victim identifications. Patients may present with signs of physical abuse, depression, anxiety, posttraumatic stress disorder, substance use, sexually transmitted infections, pregnancy, and nonspecific somatic complaints. As with intimate partner violence, clinicians should be suspicious if the patient is accompanied by an individual who refuses to leave her side. Other potential red flags include patients with wounds in various stages of healing, patients appearing fearful or unable to answer specific questions, and patients who do not have any personal identification. Health care providers should speak with the patient privately, using professional interpreters when indicated. Although there are no validated screening questions for the health care setting, in this article, we provide sample questions such as, "Is anyone forcing you to do anything physically or sexually that you do not want to do?" The physical examination should be thorough with appropriate workup, sexually transmitted infection prophylaxis, and emergency contraception. Physicians and patients should be aware of their state's mandatory reporting requirements and careful documentation is essential. Finally, to ensure a comprehensive, interdisciplinary response to trafficked patients, practitioners should engage hospital-based and community-based services when appropriate.

Injection drug use is a major public health problem in the United States. Cocaine, heroin, and methamphetamine are the most commonly injected illicit drugs, whereas opioids are responsible for the majority of overdose fatalities. Although recent emergency department (ED) efforts have focused on expanding capacity for buprenorphine induction for opioid use disorder treatment, the injection of illicit drugs carries specific health risks that require acknowledgment and management, particularly for patients who decline substance use treatment. Harm reduction is a public health approach that aims to reduce the harms associated with a health risk behavior, short of eliminating the behavior itself. Harm-reduction strategies fundamental to emergency medicine include naloxone distribution for opioid overdose. This clinical Review Article examines the specific health complications of injection drug use and reviews the evidence base for 2 interventions effective in reducing morbidity and mortality related to drug injection, irrespective of the specific drug used, that are less well known and infrequently leveraged by emergency medicine clinicians: syringe service programs and supervised injection facilities. In accordance with the recommendations of health authorities such as the Centers for Disease Control and Prevention, emergency clinicians can promote the use of harm-reduction programs in the community to reduce viral transmission and other risks of injection drug use by providing patients with information about and referrals to these programs after injection drug use–related ED visits.

Human trafficking is an egregious human rights violation with profound negative physical and psychological consequences, including communicable diseases, substance use disorders, and mental illnesses. The health needs of this population are multiple, complex, and influenced by past and present experiences of abuse, neglect, and exploitation. Effective health care services for trafficked patients require clinicians to consider individual patients' needs, wishes, goals, priorities, risks, and vulnerabilities as well as public health implications and even resource allocation. Applying the bioethical principles of respect for autonomy, nonmaleficence, beneficence, and justice, this article considers the ethics of care model as a trauma-informed framework for providing health care to human trafficking victims and survivors.

Background Lead toxicity from retained bullet fragments is difficult to both predict and diagnose, but important to treat early, given the potential severity of disease. Blood lead levels > 25 μg/dL and 40 μg/dL are considered toxic in children and adults, respectively. Symptoms may range from nonspecific constitutional symptoms to seizures and coma. Chelation is the mainstay therapy for lead poisoning and levels to treat depend on patient age, blood lead levels, and the presence of symptoms. Case Report We present the case of a woman with symptoms of severe lead toxicity from 20-year-old retained bullet fragments. She had been seen by multiple providers for evaluation of each symptom, but a unifying diagnosis had not been found. After identifying this complication, she was treated appropriately and more serious complications were prevented. Why Should an Emergency Physician Be Aware of This? We present this case to increase awareness among emergency physicians of lead toxicity in patients with a seemingly unrelated constellation of symptoms and a history of a previous gunshot wound with retained bullet or bullet fragments.

Emergency department (ED) physicians must familiarize themselves with all mandatory reporting laws that apply to those whom they suspect of being the victims of human trafficking. Furthermore, ED physicians must be aware of when to require a forensic evaluation and when to enlist social services to help with the process of documentation, keeping in mind the medical, legal, and safety considerations of the patient. Subspecialty consultation should proceed in accordance with typical practice. Following the identification of a trafficked patient, a comprehensive interdisciplinary response should ensue: in addition to social workers, other hospital-based health professionals whose knowledge and skills may be needed include addiction service providers, child protection specialists, forensic and sexual assault nurse examiners, mental health providers, case managers, hospital legal counsel, and risk management specialists. Despite ED physician and related professional intervention, little is known regarding the outcomes of human trafficking. This review contains 1 figure, 3 tables and 13 references Key words: forensic evaluation, mandatory reporting laws, medical record documentation, neutral language, reported human trafficking, suspected human trafficking, trafficking in persons

Trafficking in persons, or human trafficking, is the obtaining of persons by force, fraud, coercion, or other improper means, with the intention of exploiting them for financial gain. According to the US Department of State, the more prominent global forms of human trafficking include forced labor, bonded labor (or debt bondage), forced commercial sexual exploitation (or sex trafficking), involuntary domestic servitude, forced child labor, child sex trafficking, child soldiering, and organ trafficking. In the United States, the forced exploitation of persons in the labor industry (i.e., labor trafficking) and in the commercial sex industry (i.e., sex trafficking) account for the majority of human trafficking cases recognized, reported, investigated, and prosecuted. Women and girls account for 55% (11.4 million) of the global trafficked population, whereas men and boys comprise the difference. Three quarters of trafficked persons are adults, whereas children younger than 18 years represent 26% (5.5 million) of victims. Risk factors that have been associated with increased risk of human trafficking include but are not limited to a childhood history of abuse and neglect; financial insecurity; housing instability associated with homelessness, running away, or being thrown out of the home; kinship placements with distant family members, foster care, and other residential placements; intellectual and learning disabilities; identification as lesbian, gay, bisexual, transgender, and questioning (LGBTQ); racial and ethnic minority status; status as an immigrant, migrant worker, and refugee; and involvement in gangs or illicit substance use. Due to the inherently abusive and violent nature of this crime, human trafficking has profound negative implications for the health and well-being of affected persons. This review contains 2 figures, 4 tables and 53 references Key words: commercial sexual exploitation, debt bondage, domestic servitude, forced labor, forced substance use, HIV, modern-day slavery, posttraumatic stress disorder, trafficking in persons

Introduction: Alcohol use disorders (AUD) place a significant burden on individuals and society. Theemergency department (ED) offers a unique opportunity to address AUD with brief screening tools andearly intervention. We undertook a systematic review of the effectiveness of ED brief interventions forpatients identified through screening who are at risk for AUD, and the effectiveness of these interventionsat reducing alcohol intake and preventing alcohol-related injuries. Methods: We conducted systematic electronic database searches to include randomized controlled trialsof AUD screening, brief intervention, referral, and treatment (SBIRT), from January 1966 to April 2016. Twoauthors graded and abstracted data from each included paper. Results: We found 35 articles that had direct relevance to the ED with enrolled patients ranging from12 to 70 years of age. Multiple alcohol screening tools were used to identify patients at risk for AUD.Brief intervention (BI) and brief motivational intervention (BMI) strategies were compared to a controlintervention or usual care. Thirteen studies enrolling a total of 5,261 participants reported significantdifferences between control and intervention groups in their main alcohol-outcome criteria of number ofdrink days and number of units per drink day. Sixteen studies showed a reduction of alcohol consumptionin both the control and intervention groups; of those, seven studies did not identify a significant interventioneffect for the main outcome criteria, but nine observed some significant differences between BI and controlconditions for specific subgroups (i.e., adolescents and adolescents with prior history of drinking anddriving; women 22 years old or younger; low or moderate drinkers); or secondary outcome criteria (e.g.reduction in driving while intoxicated). Conclusion: Moderate-quality evidence of targeted use of BI/BMI in the ED showed a small reduction inalcohol use in low or moderate drinkers, a reduction in the negative consequences of use (such as injury),and a decline in ED repeat visits for adults and children 12 years of age and older. BI delivered in the EDappears to have a short-term effect in reducing at-risk drinking.

Human trafficking, a form of modern slavery, is an egregious violation of human rights with profound personal and public health implications. It includes forced labor and sexual exploitation of both U.S. and non-U.S. citizens and has been reported in all 50 states. Victims of human trafficking are currently among the most abused and disenfranchised persons in society, and they face a wide range of negative health outcomes resulting from their subjugation and exploitation. Medicine has an important role to play in mitigating the devastating effects of human trafficking on individuals and society. Victims are cared for in emergency departments, primary care offices, urgent care centers, community health clinics, and reproductive health clinics. In addition, they are unknowingly being treated in hospital inpatient units. Injuries and illnesses requiring medical attention thus represent unique windows of opportunity for trafficked persons to receive assistance from trusted health care professionals. With education and training, health care providers can recognize signs and symptoms of trafficking, provide trauma-informed care to this vulnerable population, and respond to exploited persons who are interested and ready to receive assistance. Multidisciplinary response protocols, research, and policy advocacy can enhance the impact of antitrafficking health care efforts to interrupt the cycle of abuse and violence for these victims.

Background West Nile virus (WNV) has spread rapidly across the United States since 1999, causing epidemics of neurologic illnesses including meningitis, encephalitis, and acute flaccid paralysis. West Nile encephalitis can be fatal; recovery can be incomplete; and constitutional and neurological symptoms can persist for months to years. Objectives To raise awareness of an important epidemiologic cause of febrile illness with neurologic involvement in the United States. Case Report We report the case of a 46-year-old woman who presented with fever, altered mental status, and maculopapular rash, who was diagnosed with locally acquired WNV encephalitis. Conclusion Infection with WNV should be considered in patients presenting to emergency departments with fever and neurologic symptoms. Recommended evaluation includes serologic testing of cerebrospinal fluid and serum.

This chapter describes the nexus of urbanization, human trafficking, and public health and identifies promising innovations to address global human trafficking. First, we briefly describe why human trafficking is an urban health concern. Second, we provide a brief overview of the social determinants of human trafficking. Third, we highlight innovative anti-trafficking efforts, including public awareness campaigns, vocational training, community education, and victim identification and support initiatives. Finally, we summarize the implications of these anti-trafficking interventions on urbanization and global health.

Study objective Drug-related emergency department (ED) visits have steadily increased, with substance users relying heavily on the ED for medical care. The present study aims to identify clinical correlates of problematic drug use that would facilitate identification of ED patients in need of substance use treatment. Methods Using previously validated tests, 15,224 adult ED patients across 6 academic institutions were prescreened for drug use as part of a large randomized prospective trial. Data for 3,240 participants who reported drug use in the past 30 days were included. Self-reported variables related to demographics, substance use, and ED visit were examined to determine their correlative value for problematic drug use. Results Of the 3,240 patients, 2,084 (64.3%) met criteria for problematic drug use (Drug Abuse Screening Test score ≥3). Age greater than or equal to 30 years, tobacco smoking, daily or binge alcohol drinking, daily drug use, primary noncannabis drug use, resource-intense ED triage level, and perceived drug-relatedness of ED visit were highly correlated with problematic drug use. Among primary cannabis users, correlates of problematic drug use were age younger than 30 years, tobacco smoking, binge drinking, daily drug use, and perceived relatedness of the ED visit to drug use. Conclusion Clinical correlates of drug use problems may assist the identification of ED patients who would benefit from comprehensive screening, intervention, and referral to treatment. A clinical decision rule is proposed. The correlation between problematic drug use and resource-intense ED triage levels suggests that ED-based efforts to reduce the unmet need for substance use treatment may help decrease overall health care costs.

Sex trafficking, trafficking for the purpose of forced sexual exploitation, is a widespread form of human trafficking that occurs in all regions of the world, affects mostly women and girls, and has far-reaching health implications. Studies suggest that up to 50 % of sex trafficking victims in the USA seek medical attention while in their trafficking situation, yet it is unclear how the healthcare system responds to the needs of victims of sex trafficking. To understand the intersection of sex trafficking and public health, we performed in-depth qualitative interviews among 277 antitrafficking stakeholders across eight metropolitan areas in five countries to examine the local context of sex trafficking. We sought to gain a new perspective on this form of gender-based violence from those who have a unique vantage point and intimate knowledge of push-and-pull factors, victim health needs, current available resources and practices in the health system, and barriers to care. Through comparative analysis across these contexts, we found that multiple sociocultural and economic factors facilitate sex trafficking, including child sexual abuse, the objectification of women and girls, and lack of income. Although there are numerous physical and psychological health problems associated with sex trafficking, health services for victims are patchy and poorly coordinated, particularly in the realm of mental health. Various factors function as barriers to a greater health response, including low awareness of sex trafficking and attitudinal biases among health workers. A more comprehensive and coordinated health system response to sex trafficking may help alleviate its devastating effects on vulnerable women and girls. There are numerous opportunities for local health systems to engage in antitrafficking efforts while partnering across sectors with relevant stakeholders.

This study retrospectively analyzed 123 patients undergoing helicopter emergency medical services transport for ischemic stroke (ischemic cerebrovascular accident) to the Massachusetts General Hospital during 2000-2004. To assess for system improvements over time, data were analyzed between the 2 consecutive 30-month periods comprising the 5-year study. Patients transported during the latter 30 months were transported from lesser distances (P = .002), were more likely to be younger than 65 years (P = .005), and were more likely to have documented symptom onset time (P = .03) and National Institutes of Health Stroke Scale (odds ratio, 3.6; 95% confidence interval, 1.7-7.6; P = .001). Time end points analysis found no significant improvements in any intervals compared across the 2 study eras. Age older than 65 years was the only covariate associated with a more rapid arrival at the Massachusetts General Hospital (odds ratio, 2.4; 95% CI, 1.1-5.4; P = .03). This study of our stroke transport system identified both areas of good performance and also areas for focusing further improvement efforts.