Public health and emergency medicine—are these really two separate entities?
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.