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• W4386585839 abstract "Figure: climate change, ED operations, natural disastersHospitals in Boston faced multiple heat waves during the summer of 2019, with at least 11 days where temperatures soared into the 90s. The oppressive heat became so overwhelming, said Renee Salas, MD, MPH, an emergency physician at Massachusetts General Hospital, that power failed at Cambridge's Mount Auburn Hospital and patients had to be evacuated from its upper floors. “Even when power was restored, diagnostic equipment, including potentially things like CT and MRI scanners, had become so overheated that they had to wait hours for them to cool down before using them again,” said Dr. Salas, a national expert on climate change and health. “Although it is unclear why this exact power outage occurred, the National Climate Assessment clearly states that power outages are going to become more common and longer with climate change, given the increased demand on grids with intensification of extreme weather.” Earth's vital signs—increasing heat, declining air and water quality, changes in vector ecology, growing allergens, and severe weather-related injuries—are changing the practice of emergency medicine. Many of the ways in which climate change affects human health can lead to the kinds of conditions that bring people to the emergency department. Just a few examples: Smoke from wildfires like those that have plagued California in recent years contributes to a host of pulmonary illnesses such as asthma and chronic obstructive pulmonary disease. A new study found that wildfire pollution increased emergency visits by 30 percent among children and teens in San Diego with respiratory conditions compared with four percent for non-wildfire pollution. (Pediatrics. 2021 Mar 23;e2020027128.) Extreme heat can produce surges in heat-related illness such as heat stroke, as well as exacerbate chronic health conditions such as kidney disease, pulmonary disease, and cardiovascular disease. The number of counties in the northeastern and upper midwestern United States that are considered high-risk for Lyme disease increased by more than 300 percent between 1993 and 2012, according to the Centers for Disease Control and Prevention. (Emerg Infect Dis. 2015;21[8]:1455; https://bit.ly/3x1tzpH.) Vector-borne diseases like Lyme have strong environmental links, and climate conditions are a likely contributing factor when an ED sees patients presenting with symptoms of Lyme disease in an area where it was previously unknown. More than Hurricanes Of course, climate change effects such as longer and more powerful hurricane seasons can produce the kinds of storms and other natural disasters that lead to devastating injuries, population displacement, and other outcomes that can overwhelm emergency departments. The ripple effects of climate change can also make providing emergency care exponentially more difficult. Physicians across the United States faced a shortage of normal saline supplies in late 2017 and well into 2018 because Baxter, the primary manufacturer, saw its Puerto Rico headquarters devastated by Hurricane Maria in September 2017. “I found myself handing out bottles of Gatorade instead of giving IV fluids,” Dr. Salas said. She and a cadre of colleagues are sounding the alarm, calling for emergency medicine to take a leading role in responding to the growing health impact of climate change: by preparing current trainees and practicing physicians alike for the ways in which their practices will be affected; by building more climate-resilient emergency departments, hospitals, and health systems; and by partnering with public health entities to pioneer efforts that protect health and to conduct research to understand and address the health effects of climate change. “Emergency medicine, with its focus on urgent and emergency care, its role as a safety-net provider for vulnerable populations, and its expertise in disaster medicine, has the opportunity to pioneer innovative, nimble, and effective responses to these complex challenges,” wrote a group of emergency physicians led by Cecilia Sorensen, MD. (Ann Emerg Med. 2020;76[2]:168; https://bit.ly/3wZuS8D.) Dr. Sorensen, who practices at the University of Colorado School of Medicine, was the inaugural fellow at the university's Living Closer Foundation Fellowship in Climate and Health Science Policy, a first-of-its-kind post-graduate training program offered in partnership with the National Institute of Environmental Health Sciences, the Centers for Disease Control and Prevention, and the Medical Society Consortium of Climate and Health. But galvanizing emergency physicians behind a focus on climate change can be challenging, she admitted. “The nature, and the Achilles heel, of our specialty is that we deal with the things that are so acute that they end up in the ED, which means you have to focus on the thing that's flying straight at your head. It can be hard to step back and look at the long-term factors that are impacting us from such a faraway perspective.” Through a Climate Lens First and foremost, Dr. Salas said, emergency physicians should develop the habit of adding a climate lens to everything they do in the ED. It's a topic she addressed in a recent article on the climate crisis and clinical practice. (N Engl J Med. 2020;382[7]:589; https://bit.ly/3tpVbCP.) “We are on the front lines, seeing the impacts on the health care system from climate disruption today, particularly on the vulnerable populations who rely on us most. We need to ensure that our triage protocols and other systems take into account how climate change is impacting health in our own areas,” she said. Dr. Sorenson and colleagues, for example, proposed an evidence-based prehospital and ED heat alert pathway to improve early diagnosis and resource mobilization for patients with heat stroke, along with an evidence-based treatment pathway to facilitate efficient patient cooling. (West J Emerg Med. 2021;22[2]:186; https://bit.ly/2QxhLuE.) “We know that heat stroke is becoming more common with increasing heat events, and it is similar to an ischemic stroke or heart attack in the sense that it is incredibly time-sensitive,” Dr. Sorensen said. “If you don't get that person cooled within 30 minutes, you will have incredibly bad outcomes. Yet when you look at the literature on this, there is not a lot about best practices. We designed this protocol with treatment goals, key steps, and tasks at five minutes, 10 minutes, and 30 minutes in the form of a diagram you can post on the wall of your ED so that you're ready to roll.” Many other such protocols could be developed and put in place depending on your ED's location and vulnerabilities, Dr. Salas said. “We need to add this lens to our patient instructions, to our ability to identify who is at high risk in whatever climate exposure pathway we're thinking about.” A Climate-Resilient ED It's not just an emergency department's patients who are vulnerable to the health effects of climate change; it's also the staff, the emergency department itself, and its hospital systems. Last year marked one of the worst wildfire seasons Colorado has ever seen, with three fires that became the largest recorded in the state's history. “Where I was at the hospital in Greeley, the building itself smelled like wildfires, you couldn't escape it,” Dr. Sorensen said. “And we had staffing shortages when half our staff couldn't get to the hospital because of the wildfires. Along with staffing plans and protocols for needs such as extra respiratory therapists, hospitals in wildfire zones need to address their indoor air quality so that it is safe for patients and staff. The children's hospital in Denver, for example, has installed a high-tech air filtration system.” Emergency departments can take the initiative to help their hospitals prepare to function in extreme weather conditions, said Jeremy Hess, MD, MPH, a professor of emergency medicine, environmental and occupational health sciences, and global health at the University of Washington, who serves as the director of the Center for Health and the Global Environment. “We can actively incorporate the lessons we've learned as a specialty and through our work with partners in disaster management, like don't put your generators in the basement. That sounds stupid now, but 15 years ago, that was a problem.” What was then dubbed a 1000-year flood paralyzed Texas Medical Center in Houston in June 2001, with generators and switches under as much as 33 feet of water, forcing the evacuation of hundreds of hospitalized patients. A massive hazard mitigation plan improved campus infrastructure to the point that Texas Medical Center had no more than six inches of water in the basement when Hurricane Harvey devastated the region in 2017. Dr. Hess said hospitals now have to be prepared for events that were once thought historically unlikely and for cascading events and impacts that are more likely from a combination of neglected infrastructure, infrastructure that was not developed for these hazards, and the fact that there are more extremes and near-extremes that overwhelm capacity. “Emergency departments are prioritized in maintaining hospital operations; we're often one of the last sites standing,” he said. “So we need to be ready to play a coordinating role, not just in the immediate disaster phase, but in the short-term aftermath where there are often widespread outages in terms of care provision and when much of the system is down.” Greening the ED Health care is a notorious contributor to climate change, contributing 10 percent of greenhouse gases in the United States and generating two million tons of waste each year. A study published last year found that the ED at one urban tertiary-care academic medical center generated 671.8 kilograms (nearly 1500 pounds) of total waste, most of it plastic, during a 24-hour collection period, or 1.99 kilograms (more than four pounds) of total waste per patient encounter. (West J Emerg Med. 2020;21[5]:1211; https://bit.ly/3e8ZKL9.) “It's important that we work to reduce our own emissions in order to mitigate the negative effects on our patients and ourselves,” said Hanna Linstadt, MD, the current climate science and health policy fellow at the University of Colorado, who with Dr. Sorensen and others published a paper on how to green an ED. (Ann Emerg Med. 2020;76[2]:155; https://bit.ly/3mVlWww.) They recommend creating a climate-smart ED by first determining if your hospital or health system has a sustainability team and getting the ED involved, and then also forming your own cross-functional ED green team. “You don't prioritize what you don't measure, and you don't prioritize what you don't task individuals to do,” Dr. Salas said. “Tasking someone in the ED with a specific role to look at sustainability and other aspects of resilience for our practice is fundamental. It needs to be integrated throughout everything we do.” Dr. Linstadt recommended first doing a waste audit for the ED, even focusing on just a week's worth of refuse, to get a sense of how much you're producing and how to mitigate that. “There are lots of low-hanging fruit items, like decreasing the size of the biohazard bins for red bag waste,” she said. “When you have a giant bin, everyone throws trash in there instead of being selective. Red bag waste is more expensive and resource-intensive to treat, so the more you throw in the red bag, the more greenhouse gas emissions you're producing. An education program about what's appropriate for red bag waste and what can go in the general trash can be very effective.” ED leaders can also work with purchasing officials to address supply chain issues and minimize excess equipment use, Dr. Linstadt suggested. “Make sure that the procedure kits contain only the items needed so that you're not constantly throwing excess away,” she said. “Work with suppliers to minimize packaging for purchases. Supply chain is a huge opportunity to reduce the ED's impact on the environment.” Individual emergency physicians can mitigate the health effects of climate change in their own daily practice, and Dr. Salas recommended three key steps that don't require you to be a departmental leader. “First, talk about it. Talk about climate change with your patients, and help them see the connection between climate-related exposures and their health,” she said. “Then, talk to leaders in your institution to help them see the connections and advocate for a climate lens to be applied to your practice.” Secondly, look for ways to implement a climate lens in your clinical practice, identifying vulnerabilities in the ED, which will vary based on where you practice. And, third, educate your trainees. It may be hard to add something else to an already overwhelmed medical education curriculum, but if you're talking about management of pulmonary conditions, consider adding a slide or two about how climate change is affecting air quality through higher pollen levels, wildfire smoke, and heat-related ground ozone. Dr. Linstadt said no other specialty has the unique perspective on climate and health that emergency medicine does. “Not only do we see all the negative impacts, like respiratory distress from wildfires, dehydration from GI illness due to waterborne disease, and traumatic injuries from floods and hurricanes, but we are also uniquely positioned because of who we serve,” she said. “Vulnerable populations contribute the least to climate change, but typically bear the brunt of its negative effects, and as the safety net we are the primary care providers for these communities. As everyone's physician, we have the responsibility to advocate for their health by advocating for the mitigation of climate change and the resilience of our communities.” Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work atwww.writergina.com." @default.
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