Some might say that the emergency department acts as the safety net for the United States healthcare system. After all, there is no question that many patients use the emergency room as their source of primary care medicine. However, does this place emergency medicine as a facet of public health? Or do the services provided within the emergency department actually link these two specialties together?  The answer to this question lies in the practice and perception of individuals who work in either emergency medicine or public health and on those that use both systems and value their worth.

The list of public health related services that exist through emergency departments is immense.  Some services are required by law, such as EMTALA, which stands for the Emergency Medical Treatment and Active Labor Act. It mandates a medical screening exam to all comers to the emergency room that are legally eligible to receive care regardless of ability to pay or of medical complaint. The reporting and treating of communicable diseases such as chlamydia, gonorrhea, HIV, measles, or lyme disease, are also the role of the emergency physician. Emergency rooms are likely to be the first to identify outbreaks or epidemics of food borne illnesses by noting an increased number of GI complaints, and are key to helping prevent and control the spread of illness. Hospital and state policies may require screening for HIV or obtaining routine testing of syphilis and hepatitis B on any newly diagnosed pregnant females.

The emergency room physician is often the first to generate suspicion or question patients regarding child or elder abuse, or domestic violence. In addition to documentation and providing patient education, we are mandated to report all cases of concern. The emergency room is no stranger to patients with mental health issues, including homicidal and suicidal ideation. Part of our assessment includes inquiring about homicidal/suicidal ideations, plans of attack, screening for depression, and observing them in the ER until can be seen by a professional mental health care worker. The role of preventing disease and promoting safety is seen when assessing eligibility for pneumonia and influenza vaccines in older adults, and updating tetanus immunity among trauma patients. The promotion of safety amongst the pediatric population is seen with asking questions regarding seat belt usage, working smoke detectors at home house, use of bike helmets, immunization status, and lead exposure.

So unbeknownst to them, a patient is not only entering the emergency department to seek care, but they have now entered the world of public health. As they are being registered into the hospital system, getting their vital signs collected, and as we start to delve into their medical history, they are providing information regarding their own public health: use to tobacco, alcohol and illicit drug use, counseling (or lecturing) regarding cessation of such products, last time they obtained routine screening tests such as mammograms or colonoscopies, or if they have ever been tested for diabetes. Often times, we are the first to diagnose asymptomatic hypertension or new onset diabetes, educate about sexually transmitted diseases and pregnancy prevention, start them on prenatal vitamins, or inform them that their out of control high blood pressure or diabetes is starting to affect their kidneys.

In addition to providing the care for patients on an individual basis, emergency departments and staff are relied upon by local, national, and international communities to provide medical care at city wide events, be the leaders behind disaster preparedness and mass casualty efforts, and be the first to respond in national and international natural disasters. The local poison control centers are act as a liaison and information source between families and the emergency departments.

So, is there a line between public health and emergency medicine based practice?  Do EM practitioners focus primarily on the individual, providing treatment and education without thinking about the larger realm of public health?

How conscious is the thought process of providing public health based initiatives in the emergency department?  As residents we are being trained to focus on learning about disease processes, patient management, time management, all while trying to keep our heads above water.

Your time as a resident passes by quickly and you become more skilled in your management of individual patients and on a huge variety of medical issues.  However, you must keep in mind your role as an emergency medicine physician is not limited to the immediate care you are providing, but the long term care you can provide as you address public health aspects for an individual patient. You serve a more valuable role than you think….patients are seeking care in a time of need or because they are limited on who they can turn to. Take advantage of the opportunity….you never know how much of a difference you can make.

Authored by Claire Pearson, MD

Dr. Claire Pearson is a third year emergency resident at Detroit Receiving Hospital/Wayne State University.  She is the EMRA representative for the ACEP Committee – Emergency Medicine Practice Group. Her academic and research interests include public health and health policy, prehospital medicine, and anthropology.

Being covered 24/7 by news networks is the latest health scare…swine flu. The World Health Organization (WHO) has declared it a phase 4 pandemic alert (confirmed person-to-person spread of a new influenza virus able to cause “community-level” outbreaks”).  As I watch the news to try and understand what is going on, I’m given images of people in masks, especially in Mexico City, travel alerts for those planning traveling in and out of the United States, and a clean bill of health for President Obama after his recent travel to Mexico and overseas. But lost in all of this is actual information is relevant information of what the swine flu is, how it came to be, what to look for, and why are we freaking out about it.

The swine influenza virus is a virus found to be endemic amongst pigs. There are 2 of the 3 viruses that are responsible for swine flu can also affect humans. Those who work with poultry and pigs are at risk of infection if the animals carry the virus that can infect humans. However, the virus is usually not passed from human to human, unless a mutation has taken place. This is the theory behind the current outbreaks that have taken place. Epidemiologists believe that the initial spread may have occurred at a swine farm outside of Mexico City. Spread of the disease has occurred as people have traveled into Mexico City affecting locals and travelers, who then travel out of Mexico and to other countries.

Symptoms are very similar to that of the common influenza virus that we are familiar with…fever, fatigue, coughing, sneezing, lack of appetite, vomiting, diarrhea, generalized body aches. As with most viruses, it is spread through casual contact and well as respiratory droplets (coughing, sneezing). Usual hygeine practices (such as frequent hand washing with soap and water!) can greatly reduce the spread of any influenza virus. There have been no reported cases of transmission of the virus within pork products.

Treatment that is currently recommended include using Tamiflu (oseltamivir) or Relenza (zanamivir), as resistance has been seen with amantidine and rimantidine. This bears the question of who should be treated. Currently it is recommended that those with recent travel areas to Mexico or exposure to reported cases and influenza symptomatology should undergo nasal swab testing. If the nasal swab is positive for influenza A and have severe symptoms, including multiple comorbities, these patients should be admitted with respiratory droplet precautions, and started on olseltamivir. Those with less severe symptoms can be treated as an outpatient and provided with a respiratory mask. Those that test positive for Influenza B should be given supportive treatment for influenza. High index of suspicion is key….make sure you obtain a good history including start of symptoms and exposure risks.

Why is this flu so concerning? Reportedly, there have been deaths in otherwise young, healthy individuals that would otherwise not get so sick from an influenza virus. In addition, cases reported from 5 states in the United States, as well as Scotland, Spain, Canada, New Zealand, and Israel are creating concern for quick global spread.

Working in a busy emergency room, it is expected that we are going to have many patients concerned about the swine flu and seeking treatment for their symptoms. Patient education will be key, as many will flu-like symptoms, but will most likely not have the swine flu. The best thing you can do is educate yourself, educate your patients, and take into consideration symptomatology, risk factors and exposures, and patient comorbidities.

Here’s a global photo gallery courtesy of National Public Radio

For more information:
Centers for Disease Control
World Health Organization

Dr. Marjan Siadat is a second-year Emergency Medicine resident at Detroit Receiving Hospital, Wayne State University. She is the editor of the public health section for Receiving.

Feb-stache-uary

Folks….it’s February. For some, it signifies the recognition of historical figures in Black History. For others, it is counting down to Feb 15th when Valentine’s Day will be officially done for the year. For us, it marks the beginning of Feb-stache-uary.In its second year in existence, our fellow male residents band together for one month to grow facial hair like it’s going out of style. The cause: to show support in preparation for the Emergency Medicine Inservice Exam. Last year, the females joined in on the cause by wearing fake moustaches. Overall, comraderie was in the air…and if anything, some great photos were taken which will definitely be a part of the graduation roast.

Historically, moustaches were worn by men in the military…the higher in rank, the more prominent the moustache. In some cultures, the moustache is a sign of virility. Villanous characters are often portrayed with a moustache. Some notable moustache types include Dali, Fu Manchu, Handlebar, and the Walrus.

For a complete listing as well as monthly mustache interviews, please visit the American Mustache Institute

The moustache holds its own place in the public health spotlight. Since 1993, the “Got milk?” campaign has recruited famous political and social figures to wear milk moustaches to promote the benefits of milk consumption (osteoporosis, sleep, cavities, muscle rebuilding, strong hair, skin and nails).

Movember is a charity event in November to raise funds and awareness for issues in men’s health, specifically prostate cancer. Originating in Australia, men worldwide can register online as “Mo Bros” with a clean shaven face and work on growing their “Mo” all month while raising money in support for the cause. The Gala Partes festivities take place at the end of the month, wear Borat and Hulk Hogan look-alikes come out and celebrate. Check it out!

Last but not least, reflect on some of these famous moustaches (we need to get Dr. Tabbey on this list):

Groucho Marx, Charlie Chaplin, Adolf Hiler, Friedrich Nietzsche, Josef, Stalin, Albert Einstein, Mahatma Ghandi, Frank Zappa, George Harrison, Dennis DeYoung, Steve Perry, Freddie Mercury, John Oates, Otis Redding, Jim Croce, Howard Hughes, Tom Selleck, Mark Spitz, Hulk Hogan, Salvador Dali, Pat Morita, Mike Ditka.

Happy Feb-stache-uary!  Here is a little treat…can you identify the face behind each stache

Thanks for reading.

Your comments and thoughts are much appreciated!

Dr. Marjan Siadat is a second-year Emergency Medicine resident at Detroit Receiving Hospital, Wayne State University. She is the editor of the public health section for Receiving.

No Love in the Time of Cholera

I was raised on drinking tap water. To this day, I still don’t understand why my California relatives are willing to spend money to drink bottled water. Evidently, they are not alone…..grocery stores and filled with complete aisles of multiple brands of bottled water, and now flavored water. However, the current cholera epidemic plaguing Zimbabwe has never made me so appreciative of our easy access to (clean) tap OR bottled water.

At present, there are a greater than 15,000 people affected, with a reported 775 people that have died from cholera. As Zimbabweans are fleeing the country to seek clean water and medical treatment in neighboring countries, the disease has the potential to spread throughout Africa. Due to breaking down of the government and health care system, and lack of access to clean water, Zimbabwe has had multiple outbreaks of cholera throughout the decade, but none this large or devastating.

Caused by the bacteria Vibrio cholerae, disease is transmitted through contaminated food or water, even shellfish. The enterotoxin that is produced invades the mucosal epithelium of the small intestine, leading to profound diarrhea. The severe dehydration the develops is considered a medical emergency, and may lead to shock and death in a rapid fashion.

Treatment is simple: aggressive oral rehydration therapy with a prepackaged mixture of sugar and salts which is mixed with water.IV rehydration is also acceptable, yet oral rehydration methods are more readily available, inexpensive and works well (if accesssible). Antibiotics are also available, but the key is rehydration. An oral vaccine has been developed, however it is currently not recommended by the World Health Organization (WHO) or Centers for Disease Control (CDC) once an outbreak has started or to travelers. Also chemoprophylaxis is also discouraged since it may not prevent disease and may facilitate antimicrobial resistance.

Some killer facts (courtesy of CNN):

• A healthy adult can be killed in hours (unique among diarrheal illnesses)
• Very short incubation period (2 hours to 5 days)
• 75% do not exhibit any symptoms (that is, until the runs hit)
• A total of 236 896 cases were reported in 2006, which is an increase of 79% compared with the number of cases reported in 2005
• HIV and malnourished individuals are more severely affected and more likely to die—-considering the high prevalence of HIV and malnourishment in Africa, this is a devastating problem.
• If left untreated, one out of two people may die

For more info:
WHO: World Health Organization
CDC: Centers for Disease Control

Here is an audio clip worth listening to.

It’s hard to write this and not feel helpless….the solution is clear, but what can be done on our end to help? It’s not only the issue of access to clean water and oral rehydration solutions, but getting them to the people who need it most. Can the Gatorade company or the electrolyte/vitamin fortified water manufacturers help out? Surely their products contain most of what is needed, and they have the financial means to do so.

So the next time you see a bag of normal saline or stop by the water machine, be thankful for what we take for granted.

Thanks for reading.

Your comments and thoughts are much appreciated!

Dr. Marjan Siadat is a second-year Emergency Medicine resident at Detroit Receiving Hospital, Wayne State University. She is the editor of the public health section for Receiving.

Hello! Welcome to the Emergency Medicine and Public Health section of Receiving. The goal of this section is to put forward public health topics and generate thoughts and discussions about these topics.   All are welcome to contribute!  The more input from people, the more we learn.

Elections and the ED

It is nearly impossible to turn on the television or radio, or read a newspaper or the Internet without the presidential debate as a top issue—-actually, you’ll often hear it discussed during a shift.

Actually, I think it would be great for some of our attendings to get together and debate!

While topics such as the economy, taxes and foreign relations are big during the debates, there is one issue pertinent to the field of emergency medicine…ED overcrowding. With a 6X next to many patient names, our ED is a prime example of a growing problem around the country. Unfortunately, many EDs do not have the space to “board” patients, and consequently, patients are seen in the middle of hallways.  This leads to concerns to patient discomfort and safety hazards. ED overcrowding is a public health issue on so many levels: access to health care and affordable health care, increasing number of under- and uninsured, ambulance diversion, and in some institutions, long wait times in non-patient care areas.

The September 2008 edition of Annals of Emergency Medicine (vol 52, number 3, pg 265) attempts to address the differences in health plans between the presidential candidates. As ED overcrowding is an issue on the forefront, their plans are discussed and compared on areas such as health insurance and their financial plans for supporting the proposed plans. In 2005, the CDC reported 115 million visits that occurred to emergency departments nationwide, which is a 20% increase over the last 10 years. Yet, there was a 9% decrease in the number of open hospital EDs. In response to the growing concern, multiple studies have been conducted regarding ED overcrowding…the problem is addressing the issue and implementing solutions.

On a personal note, I think we’re fortunate to work in an ED such as DRH that, despite our large volume, we have the physical space for our patients—although there are plenty of times when we are crowded, our patients are not found in a hall being squeezed next to a wall or near our supply equipment. (This is unless I’m running the module and my patients are in chairs outside the module sharing their chief complaints—no joke)!

Thanks for reading.

Your comments and thoughts are much appreciated!

Dr. Marjan Siadat is a second-year Emergency Medicine resident at Detroit Receiving Hospital, Wayne State University. She is the editor of the public health section for Receiving.