HOMELESS PATIENT MEDICAL CONSIDERATIONS
Category: Emergency Medicine
Abstract : the homeless patient - Special Medical Considerations General Hygiene Homeless persons have limited access to facilities for maintaining hygiene, and regular bathing and daily dental care may be severely impaired. The emergency physician should closely inspect all of the skin, lower extremities, and perineum as part of the routine evaluation of all homeless patients. Lower Extremity D
the homeless patient - Special Medical Considerations
General Hygiene
Homeless persons have limited access to facilities for maintaining hygiene, and regular bathing and daily dental care may be severely impaired. The emergency physician should closely inspect all of the skin, lower extremities, and perineum as part of the routine evaluation of all homeless patients.
Lower Extremity Diseases
Homeless patients have a variety of lower extremity disorders. Such patients may spend a disproportionate amount of time with their legs in a dependent position while sleeping upright or ambulating for extended periods. The poverty associated with homelessness may prevent some patients from obtaining socks and shoes that are seasonally appropriate and well fitting. Ulcers and wounds from lack of foot protection, blisters from poorly fitting shoes, or bites from rodents or insects may occur.
Some homeless patients may not have an available change of footwear or a place to change and bathe. Socks and shoes may not be removed for days to weeks for reasons such as warmth, fear that footwear may be stolen, embarrassment, or coexisting mental illness. These factors, along with limitations on hygiene, predispose to fungal infections, which can be treated with topical or oral therapy. Also of concern in this population is the condition known as trench foot. Protracted exposure to moisture around the foot (usually from wet or sweaty socks) leads to absorption of water into the stratum corneum.
Over 1 to 2 days, such exposure causes inflammatory changes that result in foot pain and skin breakdown. Bacterial superinfection with Corynebacterium species and Pseudomonas species can ensue. In the absence of superinfection, analgesia, leg elevation, and drying are adequate to treat the earliest stages of trench foot. In colder climates, frostbite from formation of ice crystals in the tissues is a serious threat to limbs, ears, and nose. Careful in-hospital management is warranted, since the environmental risks persist as long as the patient remains homeless, and compliance with treatment may be difficult if not impossible.
Patients predisposed to peripheral vascular disease can have exacerbation of their illness due to inadequate nutrition, poor protein status, alcoholism and substance use, use of tobacco, and inability to elevate the legs while sleeping upright. The resulting edema can lead to chronic venous stasis ulcers. The ulcers can become infected with common skin flora or even maggots (fly larvae). For uninfected ulcers, the use of venous support garments, such as Unna boots, is a valuable management tool. Unna boots are impregnated with antibiotic ointment and require less frequent changes. Patients with infected ulcers require admission.
The erythema associated with cellulitis may be difficult to distinguish from deep venous thrombosis or venous stasis changes. When the diagnosis is unclear, an evaluation of venous flow should be undertaken. For lesions infected with maggots, chloroform is a traditional therapy for deinfestation. Chloroform may not be available due to safety issues of combustibility. Ethyl chloride is an alternative. Ironically, maggots survive by ingesting necrotic tissue, keeping ulcers clean and well debrided. Once deinfestation is completed, close follow-up is mandatory, since natural debridement via fly larvae is terminated. Maggot infestation is a grave sign of serious neglect and suggests the inability to manage a clinical plan outside a supervised setting.
All homeless patients need education to minimize the risk of trench foot and fungal infections. Patients should be told to change or remove all footwear when environmental conditions allow, examine the feet, and attempt to find a place to rest where their legs may be elevated. Injection drug users should be warned about the risk of skin infection from drug administration into the extremities. Community resources, which can provide clean, dry socks and well-fitting shoes, should be identified. Such preventive measures are especially important for diabetic patients and those who suffer from peripheral neuropathies.
Infections
Homeless patients develop common community-acquired respiratory infections, but tuberculosis is also a threat.5 The incidence of tuberculosis increases dramatically when people live under crowded conditions and when patients are immunosuppressed from diseases such as AIDS, malnutrition, or alcoholism. Multiple studies of various homeless populations confirm the high incidence and prevalence of tuberculosis in homeless patients. For homeless patients, compliance with a treatment regimen for an exposure to tuberculosis may be limited. Daily, directly observed therapy programs have been very successful by using incentives to organize therapy and decrease the risk of tuberculosis transmission.
Homeless patients in shelters or other group living arrangements are also at higher risk than are domiciled patients for communicable skin diseases, such as pediculosis (lice), scabies, and impetigo. De-infestation of lice and scabies is problematic for patients, since bathing facilities and the ability to wash and change clothing are limited. Patients may return to the environment where infestation originally occurred, and they are at high risk for reinfestation. A dermatologic disease known as bacillary angiomatosis-peliosis has been identified in homeless patients exposed to lice. The causative organism is Bartonella quintana, and the condition can be treated effectively with macrolide antibiotics. Bartonella quintana infections may also cause trench fever, endocarditis, and chronic bacteremia in the homeless.
The living conditions of the impoverished can place them at risk for other infections. Diarrheal illness from the ingestion of improperly preserved or discarded food has been poorly studied, but has been described by homeless patients and is particularly problematic when access to toilet facilities is limited. Fecal-oral transmission of illness is also increased.
Sexually transmitted diseases are prevalent in homeless individuals who engage in sexual activity voluntarily or by coercion to obtain food, shelter, cash, or other goods. Money for prophylactic condoms or other forms of contraception is limited, unavailable, or a low priority for survival. These problems, in addition to injection drug use, have lead to epidemic rates of HIV among the homeless. Discrimination and disability from HIV disease are also implicated as a cause of homelessness.
The management of HIV disease is complicated for both patients and medical practitioners even under ideal circumstances. Newer drug regimens, which include multiple medications, are expensive and depend on a reliable dosing schedule and follow-up. The use of reverse transcriptase and protease inhibitors may depend on the ability of patients to comply with therapy.
Hospital admission of homeless patients with diseases such as varicella or hepatitis may be necessary to avoid infections in shelters or other public areas in which the homeless may congregate.
Compliance
Prioritization of other life-sustaining activities, such as finding food or shelter, may interfere with compliance to medical regimens or follow-up despite the intention to do so. Money may be unavailable for prescriptions. Even hospital-dispensed medications may be traded for cash or other items perceived as more essential, depending on the patient's level of despair and how well the patient understands the consequences of forgoing treatment. Some items necessary for treatment, such as insulin syringes or other medications, are valuable for illicit use and are at risk of theft. Agents such as insulin may lose their efficacy and safety when stored improperly. It may be impossible to refrigerate medications. A regular dosing medication schedule is complicated and nearly impossible in a lifestyle devoid of daily routines.
Lack of medical insurance may limit patient access to primary care for follow-up. Negotiating eligibility for various types of state and federal medical coverage is usually complicated, but may be of tremendous benefit to patients with chronic illnesses, for which poverty potentially thwarts adequate management. Patients should be referred to social workers familiar with eligibility requirements and processing. Unfortunately, even eligible patients may require several visits to social-services agencies to establish medical coverage, and this process alone may be too complex and demeaning to complete.
Other barriers to care include lack of transportation or mental illness. The precarious existence of such patients must be considered with compassion, and they should be treated with a medical regimen that accommodates the limitations of their social situation. For example, patients dependent on soup kitchens should have appointments arranged that would not limit access to mealtimes. Shelter-based drop-in clinic systems may be more realistic than tightly scheduled appointments.
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