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Clinical Experience General Hero

Michael Cooper

History

Michael Cooper is a 27-year-old male who presents to the Emergency Department for a “skin infection.” He has been using fentanyl for the last 2 years. He is new to town. He’s had problems like this before, and attributes the arm swelling (and pain) to injecting. His review of systems is otherwise negative. He had asthma as a child but no other active medical problems; his surgical history is significant for a broken left leg from a motorcycle accident approximately 2 ½ years ago. He takes no prescribed medications and has no allergies. He does smoke daily, no alcohol.

You are on your 1st day of your ED clerkship.

On exam, his vital signs are: BP 120/60 HR 102 RR 16 T 37C (98.6F) 97% RA.

He is poorly groomed and his clothes are old and badly torn. He avoids eye contact. His lungs are clear to auscultation, his heart is regular and without murmurs. The rest of his physical exam is remarkable only for marked swelling, erythema, and fluctuance of the left antecubital fossa. (See picture.) He describes this as a common site of heroin injection.

Based on the physical exam, your ED attending walks you through an ultrasound to confirm that this is an abscess (amenable to incision and drainage) as opposed to a vascular structure.

Case 4a

On ultrasound, you appreciate a hypoechoic fluid collection (asterisk in marked video below). Superficial to the fluid collection, there is some thickening of the subcutaneous tissue suggestion of an overlying cellulitis. Deep to the collection is muscle (evidenced by the rope-like strands of hyperechoic muscle tissue).

Under the supervision of your ED attending, you perform an incision and drainage of the antecubital abscess with return of a large amount of purulent material. You decide to discharge the patient with a 7-day course of Sulfamethoxazole/Trimethoprim. When the attending leaves the room, you have a few more questions for the patient.

Great Video of an I&D

Ask Yourself

  • What other questions would you have for Mr. Cooper?

As mentioned, Mr. Cooper has been using fentanyl for the past 2 years. He suffered a left tibia/fibula fracture 2 ½ years ago that required surgery. Post-operatively, he began to take escalating doses of oxycodone. When his doctor refused to refill his prescriptions, he began to use heroin to manage his cravings and withdrawal symptoms. He tries to be good about using clean needles, but sometimes he re-uses his needles (but never shares). He has been in rehabilitation twice in the past and was clean for 4 months prior to his latest relapse, which began 2 weeks ago. He is new to town and is interested in staying at a shelter.

He is no longer under his parents’ insurance and is currently unemployed. He is worried about being able to afford the prescribed antibiotics – you quickly arrange for Social Work to fill his prescription at the Apothecary (free). He is not interested in inpatient detox or suboxone or methadone at this time.  

Ask Yourself

  • Summarize Mr. Cooper's issues/needs (3 broad categories).
  • Come up with a plan to manage each of these issues/needs.

A Reasonable Plan to Manage His Social Issues/Needs


Housing Instability
  • Ensure that Mr. Cooper is discharged with a list of shelters as well as the Project Home Outreach Coordination Center Number: 215-232-1984
  • Talk to Mr. Cooper about where he spends his time in the community, encourage him to engage with Outreach workers in the community if he is not ready/willing to go to a shelter at time of discharge
  • Multiple outreach teams work throughout the entire city 24/7 to engaged individuals about housing and other resources
  • Consult SW and CHWs for additional support about connecting Mr. Cooper to housing
Health Insurance
  • Reminder that Medicaid eligibility in PA includes: Adults with income up to 138% of of the Federal Poverty Level (FPL) are eligible for Medicaid (Medicaid expansion population) – go to https://www.compass.state.pa.us to apply or to get more information
  • Children in households with incomes up to 319% of FPL are eligible for Medicaid or CHIP
  • You may access a “Federal Poverty Level Calculator” by clicking here
  • To qualify, though, patients will need documentation to prove their identity AND they need a place to receive mail (a shelter can work for this)
  • In the meantime, be sure to refer your patient to a Federally Qualified Health Center (FQHC) to get follow-up care; there are oftentimes social workers and case managers on-site at those centers

Opiate Use Disorder – Transitions of Care

  • Mr. Cooper may benefit from guidance about the disposal of used syringes and how to obtain clean syringes
  • A great resource for this is Prevention Point - Philadelphia
    • Brief summary: Syringe service programs (SSPs) provide a way for those people who inject drugs to safely dispose of used syringes and to obtain sterile syringes at no cost
      https://ppponline.org/about-us/frequently-asked-questions
    • PPP also provides a number of other essential services such as: Syringe services, free medical care, medication Assisted Treatment (MAT), HIV/HCV testing, case management, overdose prevention and reversal training, free meals, linkage to drug treatment, wound Care Clinic, and housing services
  • You may also provide him with various outpatient resources for substance use disorder
  • In general, you should consider looping in our Certified Recovery Specialists (CRS) and Social Work when possible to discuss inpatient and outpatient treatment - there are a variety of options/considerations in arranging transitions of care for individuals with OUD (e.g. medication-assisted treatment, opioid counselors, outpatient treatment centers, etc.), and a social worker will be aware of all of the opportunities (read more about OUD transitions of care).
  • In your discussions with patients suffering from OUD, you will need to employ a valuable skill known as “motivational interviewing” - engaging your patients in difficult conversations and changing behaviors will be some of the most challenging activities you will participate in as a provider
  • To add a human dimension to this discussion of OUD, I’d ask you to read about one of my favorite nurses with whom I worked in the ED at the Hospital of the University of Pennsylvania. Bill Kinkle’s struggles are documented in a great USA Today article (1/22/19) [link] as well as his podcast on Apple. Bill’s story is remarkable.
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