Emergency Medicine as Social Emergency Medicine

A conversation about social emergency medicine would have sounded incredibly dry before I became a medical student and a mother living through a global pandemic.  Now, as I contemplate my own future, as well as the reality of Canadian families navigating complex challenges facing our health and livelihoods, the conversation feels deeply personal.  I often wonder how I will practice differently in the future because of what my mentors and teachers are learning today.  Social emergency medicine refers to Emergency Department (ED) care that holistically incorporates knowledge of patients’ social environments and contexts into ED management and disposition.^​1​  Emergency medicine is positioned on the front lines both literally and figuratively, in dealing with sick and undifferentiated patients, in witnessing first-hand the interactions between patients and their environments, and in rising to the forefront of academic advocacy and leadership, especially in times of trauma, disaster, and social crisis.^​2​  In this conversation of sustainable, longevity-focused healthcare practices, Emergency Medicine (EM) clinicians are being asked to lead the way. 

It’s safe to suggest that most EM physicians went into emergency medicine at least partly motivated by trauma, acuity, and procedures.  However, although less adrenaline-inducing, equally as important as traumatology is the EM clinician’s role in social emergency medicine, specifically in health promotion.  Even pre-pandemic, the opportunities to influence public perspectives, provide education, and reinforce preventative healthcare were tremendous.^​3​  Now, EM clinicians are increasingly viewed on the national and international stage as experts, leaders, and educators.^​4​   Sustainable healthcare starts with strong and effective public health, and ED clinicians play a vital role in reinforcing these messages.  Now, more than ever, our health system needs our EDs to be proactive rather than reactive. 

What is proactive EM?  One example is the huddle that you have with your team right before you receive a CTAS 1.  As the team lead, you rehearse the plan with the team out loud.  You pre-emptively discuss what your thought process will be if plan A does not work.  Roles are assigned.  Equipment is gathered.  When your patient is rolled into the trauma bay, your team is ready and springs into action.  Certainly, those next few minutes to hours of the patient’s stay in the ED are part of what marks an excellent EM physician.  Yet imagine what might be possible if we took similar diligence to prepare for our interactions with patients accessing our EDs who are most vulnerable—those with homelessness, substance abuse, sexual abuse, firearm misuse, frailty, and countless other preventable morbidities. 

There may be some of you thinking, “There’s a reason I went into EM, and it’s not public health.”  Consider that in Canada, ED use is inversely associated with household income.^​5​  One third of visits to the ED for seniors in long-term care are potentially preventable.^​6​   The number of ED visits attributable to alcohol is increasing.^​7​  Frequent ED users account for nearly 30% of ED visits.^​8​  As an EM physician, you regularly witness the consequences of a lack of “upstream” interventions and the impact of environments on humans.  The COVID-19 pandemic is a clear example of why it is so essential that EM physicians take seriously their role in primary prevention.  Prior to COVID-19, seemingly simple measures like hand hygiene were not habitual for many people.^​9​  Around the globe, stories from critical care and EM physicians caring for sick and dying patients with COVID-19 influenced public perceptions of hand hygiene, masking, and physical distancing rules.  EM providers carry the weight of having seen first-hand the severity of COVID-19.  It is a weight that carries influence.  It is an influence that our world, and our healthcare system, needs.

So, what does this mean for an EM physician practically?  Of course, I’m not arguing that emergency departments should start offering Pap tests (one department in the USA trialed this but it didn’t take off).^​10​  I am, however, advocating that we practice medicine with a social emergency medicine mindset.  The pandemic reminded us as a global community that everyday actions can influence critical outcomes.  We also know that the ED will be disproportionately seeing vulnerable patients who may interact and react differently to mainstream health promotion messaging.  It is all too easy as clinicians to think that patients have “heard this before” and to feel that these preventative health conversations are reserved for family doctors who “have more time” (do they?).  A randomized controlled trial from 2018 demonstrated a significant improvement in the 3-month abstinence rate for smokers who were engaged by their ED provider in a multi-component intervention including motivational interviewing, six weeks of nicotine patches and gum, referral to a smokers’ quit-line, and a follow-up phone call.^​11​  Given the morbidity that we see daily in the ED from smoking tobacco alone, imagine the downstream effects years from now if every patient who smokes was offered the opportunity to engage with a similar intervention. 

This is not an article to suggest that EM docs, in-between trying to disposition chronic abdominal pain, remove a corneal foreign body, and reduce a toddler’s dislocated elbow, are going to change public health as we know it.  However, since experts project that COVID-19 is here to stay for the foreseeable future in our communities, it seems reasonable that we incorporate education and discharge planning with communicable disease prevention in mind into our regular shift routines.  It is possible that if respiratory etiquette, physical distancing, and hand hygiene become endemic, the spread of non-COVID-19 pathogens such as influenza may also be curbed.^​12​  Many disease entities such as heart failure, acute coronary syndrome, and diabetic ketoacidosis are also known to be triggered by infectious agents.^{​13–15​}  If EM clinicians adopt an upstream holistic mindset to our work, perhaps we might play a role in seeing a reduction in some of these diseases in the future.

As an EM provider, you knew you were a front-line worker, but you may never have pictured yourself on the front lines of public health.  I ask you to reimagine. 

This post was edited by Daniel Ting and copy-edited by @alexsenger.

References

Reviewing With the Staff

Rachel Lipp is a medical student at the University of Calgary with a keen interest in Emergency Medicine and Public Health. In her insightful commentary she provides great insight on the crucial role that emergency departments play as the safety net for society and the logical home for a myriad of public health initiatives. Her focus on a proactive approach is a call to action for current and future emergency practitioners to build and leverage expertise in what underlies so much of what leads to crises in the vulnerable members of our society. COVID has moved these issues to the front burner and provides an unprecedented opportunity to reimagine what should constitute emergency care.

Dr. Eddy Lang

Department Head for Emergency Medicine, Cumming School of Medicine, University of Calgary

@EddyLang1

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Rachel Lipp

Rachel Lipp is a senior medical student at the University of Calgary. Her interests include emergency medicine, children's health, and public health. She loves spending time outdoors with her husband and daughter, especially when it involves trail running or paddleboarding.

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• Emergency Medicine as Social Emergency Medicine - August 25, 2020