Seven years ago I thought of Public Health in terms of making sure the right paperwork and notifications occurred for reportable diseases. I would never have thought in terms of Emergency Public Health. An epidemic of eleven fatal teenage car crashes in eighteen months changed my perception as well as my approach to emergency medicine and public health.
The first crash occurred on a beautiful spring day with seven teenagers in a four passenger car, joyriding, lose control. A 16 year old girl due to take her driving exam that day was the most seriously injured. Transported to the trauma center, she dies. The other 6 teenagers, none seriously injured, are transported to the where I was working in. One of those senseless tragedies witnessed in the ER.
Six weeks later another crash, at noon a car runs a stop sign into the path of a tractor trailer truck. The passenger is thrown from the vehicle and dies at the scene. The driver of the car is transported to the trauma center, fortunately not seriously injured, he survives. Several hours later, the local police bring the parents to the ER. I try to help in making the notification of death. The victim is the same age as my son, the family known to me. I still get nauseous thinking about it.
The crashes continued and the community responded first trying to make sense and then to make change. Factors contributing to the crashes are identified: seat belts were not used by any of the victims, speeding and other moving violations are common, many of the drivers were very inexperienced and new driver education was identified as an issue. The response eventually grows into a non-profit corporation and New Hampshire's first Safe Communities program. The community effort leads to an attempt to change the seat belt law from age 12 to age 18, graduated licensing, reforms in driver education and increased penalties for moving violations. Working with others, legislation is introduced aimed at all these factors. In the state without a seat belt law and with the license motto, "Live Free or Die" not a small task. But the legislation and other efforts succeed. The epidemic of crashes lessens with data showing a 20 percent decrease in area injuries with a dramatic decrease in deaths after the legislative changes occur. Fewer parents, victims and loved ones for emergency physicians and EMS to face.
That was my introduction to public health, the response to a community health crisis with emergency medicine and EMS right in the middle. Emergency medicine and EMS are right in the intersection between acute care and the community, between failed prevention and health, between stories and data. Public health opportunities abound: substance abuse, violence, access, mental health, disaster, asthma, motor vehicle crashes. You can name your own list depending upon your practice.
At the American Public Health Association annual assembly a program was listed as an overview of the EMS and Public Health Roundtable. The program was presented by then National Association of EMS Physicians(NAEMSP) President Dr. Jon Krohmer and Jeff Michael EdD of the National Highway Traffic Safety Administration EMS Division. Participants were invited to attend the roundtable meeting in Boston 2 days later. The Roundtable was a gathering "of experts in public health and emergency medicine to identify opportunities ...through collaboration between local EMS and Public Health Professionals." (1) Led by NAEMSP and APHA and supported by the Health Resources Systems Agency and the National Highway Traffic Safety Administration. I attended and I was invited back to the next two meetings of the Roundtable.
It became increasingly clear during the next two meetings that although there were barriers and differences, these two disciplines are complementary and not mutually exclusive. Use of population based data and interventions could benefit EMS through problem identification and resource allocation. Delivery of Public Health services could be facilitated could be facilitated by EMS through mobility and outreach. Injury prevention, surveillance, access and ambulance diversion were among areas of mutual interest. Ironically, when the Roundtable ended in July 2001, disaster preparedness, bioterrorism, weapons of mass destruction were all areas for future development. (2)
September 11th and the subsequent Anthrax terror galvanized national attention on the need for emergency preparedness and response. EMS, Public Health and Public Safety all intersect at the time of crisis.
When the last meeting of the Roundtable concluded, Dr. Mohammed Akhter, Executive Director of the APHA challenged participants to bring the concept back to our home states and communities. Noting the numerous examples that I had seen in New Hampshire on a local and statewide basis, I thought that this was a tremendous opportunity to build systematic collaboration between EMS and Public Health. Based upon the past injury prevention and motor vehicle safety issues in NH, Public Safety was invited as a key component. Many examples of successful Public Health, EMS and Safety collaboration existed in New Hampshire as in all states: child passenger safety programs, the successful teen driving effort, use of highway safety data to promote seat belt use in older passengers, drowning prevention programs and the Safe Communities programs grew ad hoc out of local community needs and interest.
Since November the NH EMS Public Health and Safety Initiative has been meeting with over 20 individuals and organizations participating. Collecting and promoting examples, identifying resources and opportunities as well as promoting a dialogue between the disciplines are key contributions to this point. Establishing and maintaining systematic communication is the next goal.
Emergency physicians occupy a key role in identifying issues in their practice and in helping to bring together diverse groups for constructive action. Overcoming barriers between these disciplines is a key challenge that lends itself to emergency medicine. We are used to sitting at the intersection of and conflict of many interests. The mandate of preparedness in bringing many of the same diverse groups together on the local level provides an opportunity to create value to the community.
Major Disaster Declarations listed by the Federal Emergency Management Agency for 2002 include sever storms, floods, fire, earthquake, tornadoes, typhoons and winter storms. These are all natural disasters that local communities have and will continue to face. (3)EMS, Fire, Public Safety and Public Health acting at a community level will make the difference.
A lot of the fear since September 11th is reminiscent of the fear of the cold war years. In preparation for the possibility of nuclear exchange fallout shelters were not created but declared and prepared out of existing public buildings. Fallout shelters served a daily function that was enhanced to serve in an emergency. EMS, public health and public safety collaboration can serve as a daily function that is ready for disaster and emergencies. Bringing these forces together for preparedness is a tremendous opportunity for collateral gain.
A recent article in the American Medical Association AmedNews(June 24, 2002) (4) points out the waning interest by physicians in terrorism and weapons of mass destruction. In some ways it makes sense that people focus on things that impact their daily practice and lives.
Someone recently reminded me that all public health like politics is local. It is what impacts the community that makes the difference. An epidemic of car crashes is no less a disaster for a community than a flood. The same people that can make the difference are at the scene and on the front line. Let us take this opportunity as a building block for future progress. One profession or one group cannot make significant and sustained progress alone.
When you sit at the table and plan for disaster why not take a broader view and make
disaster part of community health and safety? Create lines of communication that can build
opportunities in everyday practice. Why stop at terrorism?
1. EMS and Public Health First Bulletin Summer 2000 NHTSA
http://www.nhtsa.dot.gov/people/injury/ems/emspublic/introduction.html
2. EMS and Public Health 3rd Bulletin correspondence NHTSA
3. Federal Emergency Management Agency http://www.fema.gov
4. AmedNews June 24, 2002 "Doctor interest in bioterrorism is wearing off"
Suggested References:
1. Bernstein and Bernstein: Case Studies in Emergency Medicine and the Health of the
Public 1996 Jones and Bartlett Publishers
2. Landesman, Linda Young 2001 "Public Health Management of Disasters" American Public Health Association
Published in Emergency Physician Monthly September 2002