Beyond Resurrection Medicine

Emergency physicians are stepping outside their typical domain to partner with public health, lobby for legislation, and exploit technology for early-warning signs of injury and disease.

"A number of our faculty go to public
schools to talk about drug abuse and
to community events to talk about
heart disease," says Leon Haley Jr.,
chief of service at Grady Hospital.

by Sherry Baker

A man suffering from a suspected heart attack gasps beneath an oxygen mask, his eyes full of pain and fear as paramedics push his gurney quickly down the hall. A frightened woman in the waiting area holds her elderly mother's hand as she waits for a doctor to tell her what she longs to hear -- that her mother's hip is merely bruised and there is no broken bone. A nurse takes a car crash victim's blood pressure, reassures her in a calm voice, and directs the woman to hold an ice pack to her swollen forehead -- all the time watching for a vacant exam room so the stunned young woman can be moved out of the crowded hall. It's a busy night in the Grady emergency room, and at other Atlanta hospitals too. In fact, more than half the emergency rooms have called the ambulance services on this sweltering summer evening to say they can't take any more patients. Rooms are full. Halls are backed up. So the patients come in rotation, diverted from one area ER to another, while doctors and nurses and patients cope with the reality of too many sick and injured and frightened people.

But what if this scene could have been rewritten? What if there had been a way - months before this frenetic night of pain and frustration and crisis - to reach into the future and change the series of events that brought person after person to this evening of drama?

That's not just wishful thinking.

It's the promise of a new model being developed by Emory's emergency medicine department that posits the future can be changed. Emergencies can be stopped before they happen. And when accidents and acute illness can't be prevented, emergency physicians can identify patterns and intervene in health problems before they become a major crisis.

In other words, it's time to move beyond accepting emergency medicine as just a synonym for resurrection medicine, according to department chair Arthur Kellermann, MD, MPH.

"The image of the ER as a place where, at the very last possible moment, a lot of resources are poured into trying to revive people who are near death is accurate to a point. But we're working to expand our scope to take a population perspective."

The result is a growing synergy between emergency medicine and public health, says Kellermann.

In addition to his role as chair of emergency medicine in the medical school, Kellermann directs Emory's Center for Injury Control, which is sponsored jointly by his department in the School of Medicine and the Rollins School of Public Health, a unique situation among all such programs in the nation. Kellermann says this partnership is logical because emergency medicine and public health are intrinsically linked.

To illustrate his point, Kellermann recalls a feverish man, dressed in shabby, filthy, and torn clothes, who hobbled into the ER last winter with a severely infected foot. Doctors quickly made a diagnosis of cellulitis and prescribed appropriate antibiotics. "But the man was homeless and had no way to keep his foot clean and dry and no way to fill the prescription. So what is accomplished by handing him a piece of paper for a prescription he can't fill?" Kellermann asks. "To ignore the issues that created this problem is incredibly shortsighted. Emergency medicine must take a broader view. We can't just hunker down in the ER and wait for the next ambulance."

How could this visit have been prevented?

Emergency medicine must take a broader view. We can't just hunker down in the ER and wait for the next ambulance.

Arthur Yancey says that skills used to plan
for emergency care during the Olympics in
Atlanta were easily transferable when he
assisted with EMS planning at election
sites in rural South Africa.

The best way to deal with a life-threatening emergency is to keep it from happening in the first place. That's why Kellermann says he repeatedly drills this question into residents: "How could this ER visit have been prevented?" And it's one he still asks himself every time he sees a patient in the ER.

"We're emphasizing what can we do to anticipate predictable events that may involve identifiable high-risk populations. If we can modify our practice and address those issues - whether it's to keep people from getting shot, restraining people in their cars with seat belts so they don't get smashed if they wreck, or doing a more efficient job of managing chest pain before they develop a massive heart attack - if we do these things, we can interrupt the chain of events before the next 911 call."

One way to break that chain is to use a 911 call today to prevent more serious 911 calls in the future. To that end, Emory's emergency medicine department faculty, who serve as medical directors for Grady Hospital's emergency medical services (EMS), are working to determine if paramedics can function as what Knox Todd, MD, MPH, calls "the eyes and ears for the public health community, including the emergency room."

"Only about 10% of 911 calls involve the need for transport, and another 30% don't even result in transportation," says Todd, who is vice chair of emergency medicine in the medical school and director of research. "Paramedics have an ideal opportunity when they're inside a person's home to spot risk factors and problems and to disseminate information. EMS clients, such as the parents of a child who has just had a near-miss head injury because he wasn't wearing a bicycle helmet, tend to have a heightened sense of receptivity."

Once a patient is in the emergency room, that visit can also be used to prevent future health crises via what Kellermann and Todd call "the teachable moment."

"When a patient comes in for abdominal pain or a headache and I see a pack of cigarettes in their pocket, I talk about smoking cessation. I might also talk to them about the importance of seat belts. That advice may do more good by preventing the next emergency than my treatment for what brought them into the ER that night," Kellermann says.

Todd points out that pilot work suggests the ER could play a pivotal role in screening for alcohol problems, which can result in repeated injuries from falls, fights, and car accidents. "The connection between drinking behavior and injury outcome may be obvious to us but less so to patients. We want more progress in on-the-spot intervention. A person who has had an injury related to drinking may be ready to listen to advice that an emergency physician or paramedic can provide," he says. "They come to us for help, and we come across with a lot of credibility."

"We're also working outside the ER setting to prevent and control medical problems," says Leon Haley, Jr., MD, chief of service at Grady Hospital. "A number of our faculty go to public schools to talk about drug abuse and to community events to talk about heart disease."

Emory emergency physician Sheryl Heron, for example, is one who has combined church activities with her ER work. At Antioch Baptist Church North, she helps coordinate an annual health fair and an annual blood drive. And each Sunday, health care workers who are church members participate in a health "ministry" at the church. For example, an elderly lady, feeling faint, knows whom to go to for help, and a man with diabetes feels comfortable asking a church health team member a question about his blood sugar.

"At the health fairs, we discuss hypertension, prostate cancer, diabetes, domestic violence, and violence in general," Heron says. "We perform comprehensive screenings, including vision and hearing assessments. The congregation trusts me as part of the ministry, and they turn out to participate. They believe me when I present data, and they listen and act on the information I provide."

Heron also worked with the church's largely African-American congregation to test a new CPR training curriculum using a 30-minute videotape and a cardboard mannequin. "The purpose of this project was to look at how we could disseminate training in a streamlined fashion," says Todd. The results, published in the Annals of Emergency Medicine last year, showed that 30 minutes of video self-instruction and mannequin practice produced results superior to those of traditional CPR classes, which take 4 hours and require an instructor.

"Here's an example of a cheap, effective, easy way to disseminate information that can save lives," says Todd. "And it reached a community that especially needs the information because there's a twofold disparity in the rates of CPR training between blacks and whites. The payoff, in terms of having people in the community who can perform CPR in time to save lives and prevent permanent injury, may be profound."

An advocate with authority

Emory physician Sheryl Heron (standing)
works with others in her church, including
nurse Marie Thompson, to disseminate
health information and conduct screen-
ings for church members.

More than other specialists, emergency physicians see the human toll of violence, injury, and illness up close every day, a fact that makes them particularly powerful witnesses in the political arena to lobby for legislation that impacts health.

"What we see and do gives us the moral authority to combine data and science with passion and personal experience and to help inform and motivate legislators and others who make policy decisions," says Kellermann, who regularly talks to Georgia legislators about laws related to health and injury.

Recently, he was visiting the State Capitol when he saw Sheryl Heron with four emergency medicine residents in tow, lobbying on behalf of the Georgia Commission on Family Violence.

"They wore white coats and stickers that read 'There's No Excuse for Family Violence,'" Kellermann recalls. "It's one thing for a lobbyist to do this kind of work. It's another for a doctor who took care of a battered woman last night to explain to a senator what she saw and what can be done on a legislative level to address this problem."

Monitoring and surveillance

Helmet-wearing Knox Todd, vice chair of
Emory's emergency medicine department
and bicycle enthusiast, practices what he
preaches in his emphasis on preventing
serious injury.

Emergency medicine doctors see the human toll of violence, injury, and illness close up every day, making them powerful witnesses in the political arena to lobby for legislation that impacts health.

Collaborative efforts using new technology are changing the face of traditional public health surveillance -- and the role emergency medicine plays in monitoring public health problems. For example, when 911 calls are placed, the system not only directs the right emergency resources to the scene but collects and collates call-in data to determine the frequency and geographic patterns of violence, traffic incidents, and disease outbreaks.

One of the emergency medicine department's most important collaborative efforts is the "Cops and Docs" program, funded by the National Institute for Justice. "This is an example of the local police, the Georgia Bureau of Investigation, and the emergency medicine community all working together to add a piece to the epidemiologic puzzle of the causes of violence," notes Knox Todd. "The program identifies gunshot injuries and helps police link bullets to specific crime guns, which can help them identify the shooter and make an arrest."

Through Cops and Docs, emergency physicians are linking medical reports of shootings with police reports and medical examiner records and then plugging them into a geographic information system to map areas prone to gun violence. Documenting where and on which days of the week shootings most often occur can help police target geographic hot spots rather than just running after the next 911 call. It allows them to target zones of activity rather than just reacting to events as they occur," says Kellermann.

Grady attending physician Arthur Yancey, MD, MPH, who serves as medical director of the Fulton County Health Department's EMS, says 911 data can be categorized by callers' symptoms. When analyzed from a population perspective, such data can alert the health department and area emergency departments to various epidemics, from flu to weather-related hyperthermia to the possibility of bioterrorism. "Such data collected during the Olympics allowed us to measure the effect of this mass gathering on EMS call volume, call type, and call time distribution," says Yancey.

Kellermann adds that working with such data can allow emergency physicians to partner with public health specialists to form an early-warning network. "It's one thing to train your doctors how to do a good job of treating heat stroke, but it's even better to take that experience and develop a community mobilization plan to inform the public and get the vulnerable elderly and young children into an environment where they will be safe."

Kate Heilpern, MD, director of medical education for emergency medicine, is working with the "EMERGEncy" ID (infectious disease) NET, funded by the CDC, to create a large, national surveillance network involving 11 academic emergency medicine departments. "We've collected data at Grady for four years, and we're continually adding new modules to the surveillance system," she notes. "We've already seen tangible results. For example, I think this work will actually change the recommendations about the public health management of possible rabies exposure, based on the information we've collected on animal bites and on treatment for rabies. This has important implications for the cost of health care in the ER."

A global impact

Art Kellerman works with local police and
the GBI in the Cops and Docs Program, in
which ER doctors help police target geo-
graphic hot spots to determine where
shootings most often occur.

As emergency medicine redefines and broadens its role in the 21st century, Kellermann believes it will have a global impact. "Because of the department's synergy with public health and our collaborative connections with the CDC, we are particularly well positioned to help build emergency medicine in developing nations," says Kellermann. "We want a more village-based model that is simple, effective, economically sustainable, and engineered from day 1 to incorporate prevention and a public health approach."

Yancey, who has traveled to South Africa several times to work with that country's emerging EMS, points out that lessons learned in the "global village" can also have direct benefits at home: "We're discovering that some of the work done in sparsely populated rural provinces in South Africa may also be applicable to rural Georgia."

The Emory Center for Injury Control is one of four programs in this country recognized as a collaborating center for injury control by the World Health Organization and the only one with special expertise in emergency services. "That gives our activities the WHO imprimatur and makes multinational collaborations much easier," says Kellermann, who recently traveled to India to address the World Injury Control Conference with colleagues from Europe, Oceania, Africa, and Asia. To illustrate this point, faculty member John Lloyd, MD, is leading a USAID initiative to assist the government of Uzbekistan in developing a regionalized emergency medical service that stresses prevention as well as emergency care.

The expanded vision of the role of emergency medicine in the community is what drives the department's teaching, research, community service, and international interests. "We're trying to re-engineer not only the hospital's approach to emergency care but the whole health care system's approach," Kellermann says. "We're determined to make it a model for the nation -- and the world."

Sherry Baker is an Atlanta freelance writer.


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