clinical emergency medicine, critical medical anthropology
Author: Jason Wilson, MD, PhD, CPE, FACEP
Jason Wilson, MD, PhD, CPE, FACEP is an emergency physician, academic healthcare leader and medical anthropologist with an interest in developing patient-centered pathways that are medically efficacious but also consider the role of structural and cultural forces in determining health inequities and disparities.
Our (JW and RB) students have been interviewing people in the ED who have been shot recently or in the past over the last few years in order to understand lived experiences of those that survived firearm violence with an aim to generate potential interventions to impact this epidemic that is sometimes lost on the radar (burden & opportunities of gunshot wound survival).
Great job to our students for helping us get this manuscript over the finish line – it’s one I am really proud of! Thanks to grad student Emily Holbrook, MA for all of her efforts on this project and with the undergrad & medical students. https://lnkd.in/eW-cttbt
I enjoyed talking to Bloomberg about some of the heat related issues we have seen during this ongoing climate catastrophe and the highest temperatures ever recorded.
“At Tampa General Hospital, several heat-related cases have been particularly concerning, said emergency-medicine physician Jason Wilson. Some patients had temperatures as high as 107, while others had third-degree burns from lying in the hot sun, which can happen when heat stroke alters a victim’s mental state.
Doctors sometimes take extreme measures in these cases, including implanting tubes that move cold water into a patient’s body, said Wilson, chief of the University of South Florida’s emergency medicine division, which is affiliated with the hospital.”
“While Wilson hasn’t seen the number of patients rise above past years, he said doctors are concerned and keeping an eye on the situation.
It’s “like a shark bite summer,” he said. “You kind of have to wait and see where things fall out.”’
Megan Sarmento (PhD student) and Ana Gutierrez have an on-demand poster that discusses our collaborative, interdisciplinary approaches at the needle exchange.
Emily Holbrook (PhD candidate) will serve as chair (!) for a panel regarding reproductive health and work on resettled refugee women.
Heather Henderson, PhD and Jason Wilson, MD (PhD Candidate) will serve as co-chair on a panel with Bernice McCoy, PhD and Roberta Baer, PhD regarding our use of anthropology in clinical spaces to create structurally informed pathways.
Great work everyone!
For residents, medical students and grad students on this message – we always welcome your involvement in Social EM. Please just reach out!
Above, PGY-2 Resident Physicians Daniel Mbom (L) and Lorena Martinez (R) take a break after the CPC.
USF Emergency Medicine and USF Morsani College of Medicine Medical Students Well Represented at Symposium by the Sea Research Session 2022
Symposium by the Sea took place in Bonita Springs from August 4-6, 2022. USF was well represented at the conference. Faculty members Enola Okonkwo, MD, David Orban, MD, Jim Gillen, MD, and Jason Wilson, MD all attended. Residents Vincent Coster, MD, PGY-3, Courtland Samuels, MD, PGY-3, Alex Breslin, MD, PGY-3, Lorena Martinez, MD, PGY-2, and Daniel Mbom, MD, PGY-2 were all in attendance and most presented posters or participated in competitions. Medical students from the EM Summer Research Symposium (many sponsored by RISE and SELECT programs at USF) presented posters and included Claire Dalby, MS2, Jack Jimenez, MS2, Andre Elder, MS2, Ayesha Anwar, MS2, Thomas Shen, MS2, Theo Sher, MS2, and Jay Shah, MS2. Thanks so much to Emily Holbrook, MA for helping to run the summer session!Dr. Orban participated in numerous past-president functions while Dr. Wilson served as the Research Session Chair and Dr. Okonkwo made sure our residents were prepared for the Case Presentation Competition (CPC) while also helping student Claire Dalby, MS2 (along with Naveen Perisetla, MS2 and Christopher Popiolek, MS2) and a team of residents (Courland Samuels, MD; Alex Breslin, MD; Autumn Bass, DO) present their award winning poster evaluating arrhythmias after ED discharge using an ambulatory cardiac monitoring device.The arrhythmia project has taken teamwork and coordination to pull off a novel pathway that improves patient care. The poster deserved an award and the work will likely garner many future awards!
USF Medical Students at Symposium by the Sea. Claire Dalby, Ayesha Anwar, Jack Jimenez, Jay Shah, Theo Sher, Andre Elder. Not shown but also presenting was Thomas Shen.
Dr. Wilson served as the Research Chair. The conference featured a total of 6 case reports and 21 research posters. 1 fellow presented a case report and 5 were by residents. 1 Fellow presented a research poster. 12 residents presented research posters and 8 students presented posters as the first author/presenter. Of the 8 research posters by students, 5 were by USF students and 4 of those contained resident and attending authors or investigators.USF Medical Student Claire Dalby, MS2 won best medical student poster which was conducted under the mentorship of Dr. Enola Okonkwo with the help of resident leaders/investigators Dr. Courtland Samuel, Dr. Alex Breslin and Dr. Autumn Bass.Way to go Claire!!!
Claire Dalby, MS2, discusses her award winning poster with EM Division Chief, Dr. David Orban
Claire Dalby, MS2, discusses her award winning poster with Research Session Judges
Evaluation of Arrhythmia Detection Rates Among Patients with Syncope or Palpitations Discharged from the Emergency Department with Ambulatory Cardiac Monitoring Device. Claire Dalby, MS2; Naveen Perisetla, MS2; Courtland Samuels, MD, PGY-3; Alexander Breslin, MD, PGY-3; Autumn Bass, DO, PGY-2; Christopher Popiolek, MS2; Enola Okonkwo, MD
PGY-3 USF EM Residents Courtland Samuels and Alex Breslin in front of the Arrhythmia poster
Dr. Courtland Samuels, PGY-3, accepts the best medical student research poster award on behalf of Claire Dalby, MS2 for the arrhythmia project he has worked very hard to coordinate, help design and keep running!
Dr. Daniel Mbom, PGY-2, CPC Chair Dr. Jennifer Jackson, and Dr. Lorena Martinez, PGY-2 at the CPC
Jay Shah next to the scooter poster
Theo Sher attempting not to become part of the scooter injury data set by sticking to an imaginary scooter
Analysis of injury patterns related to standing electric scooters at a Level-1 Trauma center Emergency Department in an urban area. Theo Sher MS2, Jay Shah, MS3; Andrew Thomas, MD; Emily Holbrook, MA, PhD Student; Jason Wilson, MD
Jack Jimenez, MS2 and Andre Elder, MS2, discuss their poster considering the lived experiences and viewpoints of participants with non-fatal gunshot wounds with session judges
Jack Jimenez, MS2 and Andre Elder, MS2, in front of their poster.
Comparison of acute versus previous gunshot wound patients’ views on firearms. Jack Jimenez, MS2; Paul Webb MS2; Andre Elder MS2; Jason Wilson, MD; Roberta Baer, PhD
Ayesha Anwar, MS2 discusses her poster considering social determinants of health and opioid use disorder with EM Division Chief, Dr. David Orban
Social Determinants of Health and Opioid Use Disorder. Ayesha Anwar, MS2, Emily Holborok, MA, PhD Student; Jason W. Wilson, MD
Thomas Shen, MS2 stands in front of his poster analyzing equivocal HIV results in the ED next to Dr. Jason Wilson
Factors differentiating False Positive and Acute Positive Equivocal Fourth Generation HIV serum test results at the Tampa General Hospital Emergency Department. Thomas Shen,MS2; Zachary Whiteman; Emily Holbrook, MA, PhD Student; Jason Wilson, MD
Dr. David Orban, PGY-93, accepted the Case Presentation Competition participation plaque on behalf of USF Emergency Medicine residents, Dr. Lorena Martinez, PGY-2 and Dr. Daniel Mbom, PGY-2
Dr. Courtland Samuels (L) and Dr. David Orban (R) stand with awards for best medical student poster (Claire Dalby, MS2) and participation in the CPC (Dr. Lorena Martinez and Dr. Daniel Mbom)
Below, Claire Dalby, MS2 and Dr. Enola Okonkwo stand next to Claire’s award winning poster on ED based ambulatory arrhythmia monitoring
Congrats to everyone for participating and showing off the great work and people at USF! See you next year at Symposium!
Overdoses linked to fentanyl are rising exponentially in Florida, according to the state department of health. Doctors say the epidemic is now disproportionately affecting people of color.
Florida has seen an “exponential rise” in overdoses linked to fentanyl, according to the state department of health, which issued a public health alert in July. In Florida, and around the nation, doctors say the epidemic is now disproportionately affecting people of color.
“I will go to work tonight in the emergency department, and I will see a patient who has an opioid overdose,” said Jason Wilson, associate medical director of the emergency department at Tampa General Hospital, and associate professor at USF Health.
“This is an expected type of patient presentation. Just like a heart attack or stroke or patient with sepsis, this is something that every emergency doctor working a clinical shift today is going to see in their shift.”
Fentanyl is a powerful painkiller that officials say is 100 times stronger than morphine.
More than 6,150 people died in Florida in 2020 from overdoses linked to fentanyl. State health officials say more died in 2021, according to preliminary data.
The opioid epidemic in America began in the late 1990s, with increased prescribing of painkillers, according to the Centers for Disease Control and Prevention. Then, a second wave emerged around 2010 with a surge in heroin overdoses.
“We’re in essentially, the third wave of an ongoing opioid epidemic that you can trace back to over a decade now. That ongoing heroin epidemic has started to be replaced by a newer fentanyl epidemic,” Wilson said.
“Now, moving into the middle of 2022, you actually do have people who are purposely and intentionally seeking out fentanyl at this point, because it’s been replaced —the heroin has been replaced by the fentanyl for so long.”
He said that while gains were made in cutting back on pill-mills that churned out addictive painkillers, the root problem of dependence on opioids was never solved, and people continue to use illicit opioids to keep themselves from suffering the symptoms of withdrawal.
“A person who is dependent on heroin may know a dose that will keep them out of withdrawal that they can take throughout the day or throughout the week. But when you replace that with fentanyl, suddenly that same dose that kept you out of withdrawal now becomes a toxic deadly dose,” Wilson said.
“What we have seen in the emergency department and throughout the healthcare system in Florida, is people overdosing on fentanyl because they thought they were getting heroin or other opioid medication and it was being replaced by fentanyl, which is much stronger.”
Unlike a decade ago, when heroin overdoses were largely among white people, “this is beginning to hit the African American community, disproportionately higher,” Wilson said.
“So new cases, new overdoses, new uses of fentanyl, are beginning to really hit that population at a much higher disproportionate rate, then we’re seeing in other populations, as well as lower income and vulnerable populations.”
The same pattern has been seen nationwide, as drugs bought on the street become more dangerous.
Wilson said prescription medications like buprenorphine, the active ingredient in Suboxone, can help people stop using illicit opioids, and another potentially life-saving public health intervention would involve making fentanyl test strips legal and widely available.
“In a lot of states, fentanyl test strips have become a legal way to test drug supply by the user to ensure that fentanyl is not present and that so the person is not receiving a deadly amount of illicit drug,” Wilson said.
“This went to the state legislature in Florida this past session, but did not pass.”
July 2022—Thanks to more than two years’ experience with SARS-CoV-2, perhaps at no point in U.S. history has the general public been as aware of antigen and PCR testing, and the difference between them, as it is now. SARS-CoV-2 has also raised the profile of emergency departments as critical access points to get patients with infectious diseases diagnosed and in treatment. Yet much remains to be learned about exactly how screening using PCR testing for infectious diseases can improve public health and what role the ED should play in ordering that testing.
Clinical research on nontargeted screening for HIV and HCV in the ED suggests that real-time PCR testing, ordered earlier in the standard screening algorithm for certain patients, can help EDs quickly identify people with those diseases and link them to care.
From May 2016 to February 2022, the ED at Tampa General Hospital, where Jason Wilson, MD, MA, is director of the ED’s clinical decision unit, ran an HIV antigen/antibody test on 99,691 ED patients, of which 1,725 were reactive. That was followed by HIV-1/2 Ab confirmatory testing and, if the first antigen/antibody test was reactive, by an HIV RNA PCR viral load test. He and his team deviate from the currently recommended algorithm by ordering HIV RNA PCR on anyone who is reactive on the first screen, regardless of what the antibody test reveals. “The patient is in front of us, we can get blood if we need it, but also we know 13 percent of our [reactive] patients are equivocal, and of those, one-third are acute positives who have negative or undetectable antibody,” Dr. Wilson explained at a conference this spring on “Advancing HIV, STI, and Viral Hepatitis Testing.”
While the clinical encounter in the ED lasts on average four to six hours, the HIV RNA PCR test has a 72-hour turnaround time, which sometimes means lost opportunity for care. “We’ve really begun to recognize that there’s a difference between screening for HIV or hepatitis C and testing for HIV or hepatitis C,” said Dr. Wilson, associate professor of internal medicine at the University of South Florida Morsani College of Medicine.
In a recent interview and in his presentation at the conference, sponsored by the CDC, Association of Public Health Laboratories, American Sexual Health Association, and American Sexually Transmitted Diseases Association, Dr. Wilson related his hospital’s experience with having the ED play a more effective role in screening for HIV and HCV and getting infected patients into treatment. He and his colleagues have found that an alternative testing strategy, using real-time PCR testing and obtaining results in 91 minutes rather than 72 hours, could mean greater likelihood of success in meeting that goal.
The CDC in 2006 revised its algorithm for HIV screening to a public health model with a multistep approach. “That approach works just fine in the public health clinic or a public event where you’re seeing lots of people and trying to screen as many as possible for a disease state,” Dr. Wilson says. But there is a growing view that emergency departments should be doing public health HIV screening on their patients as well.
The CDC in 2007 funded a small group of 10 emergency departments to implement its algorithm in the ED setting. But as Dr. Wilson was trying to implement the 2006 guidelines in the ED at Tampa General Hospital, there were a few obstacles. “One was that we still had laws in Florida around written consent and pre- and post-test counseling that made it difficult to do this type of work in the ER.”
The main problem was Florida’s opt-in requirement for obtaining consent for HIV testing. When the ED uses a consent form requiring patients to opt in to HIV testing—rather than including HIV testing among the general medical consent tests unless patients opt out—it greatly affects the number of HIV screening tests performed, Dr. Wilson notes. “I would have had to go into the room with a consent form and say to the patient, ‘I would like to test you for HIV. Here are the risks. Here are the benefits. Can you sign this form?’”
“It’s not that we couldn’t do that. But it creates a stigma, potentially, and it’s time-consuming. It carves out HIV as different from testing your white blood cell count or testing your BUN and creatinine.”
In Florida, opt-in was the law until 2015 when the state passed a statute dropping the requirement for separate written consent. After that, “We were able to move to notifying patients of an opt-out test and that’s what we do with the signs that are in every patient room and in other areas that are publicly accessible in the emergency department.”
Moving to opt-out testing was a game changer, Dr. Wilson says. “It allowed us to test for HIV as a nontargeted screening practice. We could start putting that strategy into our routine workflow.”
“We went from doing zero HIV tests in the ER for screening to a handful—five or six a week—to now more than 1,100 HIV tests per month consistently since 2016.” The ED conducts hepatitis C screening during the ED encounter along with HIV screening.
The ED integrated clinical decision support into its screening processes through its Epic EHR. “The way we got to nontargeted high-volume screening is we took the CDC algorithm and built it into the computer. So as that information is gathered during the patient’s encounter and entered into Epic, once the patient meets the screening criteria and has not opted out, a test order will pop up for the provider and say, ‘Please order the test.’”
Over time, the decision support has become more nuanced and more detailed, Dr. Wilson says. “For example, for the patient who has a nonconfirmatory antibody test for HIV, the viral load test order will automatically pop up as well. For a patient we identify as having IV drug use, we will want to order a hepatitis C RNA test because we have a number of patients who may have just acquired HCV and have no HCV antibodies but they do have detectable, quantifiable RNA, so we move right to RNA testing for them.”
Within the first couple of weeks of broad high-volume HIV screening, however, ED clinicians encountered something surprising. “We had had a couple of patient scenarios where the HIV antigen/antibody test was reactive, but then in one of those patients early on there was no HIV virus in the RNA and in the other one there was. So we realized we’re dealing here with clinically equivocal results during the clinical encounter.”
“They can go two ways: Either the person is an acute seroconverter and it’s important we intervene right now, or the person doesn’t have HIV but has a potentially transient p24 reactivity.” Over the past three or four years, Dr. Wilson says, “we thought about that population of people with reactive HIV antigen/antibody tests. Doing 1,100 tests a month, we have 1.73 percent seropositivity and 13.4 percent of those are equivocal.” It is one in every eight patients with a reactive HIV Ag/Ab, he says. “These numbers add up pretty quickly.”
Equivocal results can present a clinical dilemma for emergency medicine providers who see a patient for generally only a few hours. “Some people get admitted but we’re not as worried about the people who are admitted because they’re going to be sticking around,” he says. For those not admitted, “we may have lost an opportunity if we don’t know the true HIV status of that patient during the encounter.” But the other 68 percent of patients—the majority—will be p24 antigen positive for some other reason. If I were to result those patients during the ED encounter, I would likely give them undue grief and worry and my colleagues may not be willing to do the testing.”
He described a recent patient with a reactive HIV antigen/antibody result but a history and lack of risk factors that suggested she was not seropositive. “I would tell her we’re at a coin toss as to whether you have HIV or not; we’ll run the PCR and I’ll get you the result in another two days. But we can easily lose that patient into the transition space as to whether or not she was acutely seroconverted. So it’s a big game changer to know what the specific true diagnosis clinically is for that patient.” For positive patients, Dr. Wilson says, “we have a very good linkage to treatment rate.” But “we worry about these equivocals because we’re not telling them much of anything” before the typical patient encounter is over.
For the past year, on an experimental basis “in the background,” Dr. Wilson’s ED started ordering a GeneXpert real-time RNA PCR test for HIV as soon as a reactive antigen/antibody test result is known. Then the research team measured concordance between the GeneXpert qualitative HIV assay (not FDA approved) and the standard-of-care Aptima HIV-1 Quant assay on the Panther; calculated and compared turnaround time on the GeneXpert to the standard of care; collected GeneXpert actual run time metrics; reviewed ED length of stay and laboratory TAT data for the standard-of-care test; and calculated differences between GeneXpert and the standard of care