Climate Change and Emergency Medicine: A Specialty on the Frontline

Emergency medicine (EM) is on the frontlines of climate change, which the Lancet Commission declared “the biggest global health threat of the 21st century” with “potentially catastrophic risk to human health.”1,2 Climate change is having broad and profound negative impacts on the health of our patients, especially for the vulnerable populations. It is also affecting our healthcare systems and mandating the creation of climate-resilient emergency departments (ED) with robust disaster preparedness. EM needs to engage climate change advocacy efforts for 2 key reasons. It has a profound impact on our specialty, and it is built into the moral fiber of our practice. As this threat continues to grow, EM is perfectly situated to lead the charge.

climate change on human health CDC graphic

Impacts of Climate Change on the Practice of Emergency Medicine

There is consensus among scientists that climate change is happening.3 We know that the driving factor is increased greenhouse gases, such as carbon dioxide (CO2), which has led to increasing global temperatures, rising sea levels, and more frequent and severe extreme weather.4 The downstream health effects, as demonstrated in the Center for Disease Control diagram below, bring patients to already crowded EDs.5–10

Examples:

  • An elderly heat stroke patient during one of the increasingly frequent heat waves.
  • A pediatric patient with an asthma exacerbation secondary to the increased allergen production from higher CO2 levels.
  • A middle-aged woman with Lyme disease, a climate-sensitive vector borne illness, in a location where it previously hasn’t been endemic as climate change alters vector ecology.

While the specialty of EM prides itself on resilience, the current practice structures and infrastructure can only bend so far, for so long, until it breaks.

Disasters: A Matter of WHEN and not IF

EM is the expert in disaster management. In 2017, the United States had a record-tying year of 16 billion-dollar weather and climate disasters.11 Wildfires in Northern California caused Kaiser Permanente’s Santa Rosa hospital to evacuate nearly 130 patients in under 3 hours.12 The incidence and frequency of wildfires is increasing secondary to higher temperatures, extremes in precipitations (e.g. droughts), and changes in insect outbreaks.6

Emergency medical staff at St. Joseph Medical Center in Houston literally worked a full-week, some without going home, after Hurricane Harvey devastated their community and brought droves of patients to the ED. Extreme precipitation and flooding events are increasing with climate change.6

Each geographic region has respective extreme weather vulnerabilities. In fact, every state has had a billion-dollar weather and climate disaster.11 Thus it is not a question of if – but when. This mandates that EM create climate-resilient infrastructures and supply chains for emergency preparedness.12

Action on Climate Change is Embedded in EM’s Moral Fiber

While more work needs to be done to quantify the health outcomes and impacts on healthcare utilization and costs, the evidence to act is clear. The precautionary principle mandates this. We pride ourselves on our ability to make decisions with inherent uncertainty, and the uncertainty surrounding the impacts of climate change is far less than many of our daily practice decisions.

Caring for our Vulnerable Populations

The ED proudly sits at the hospital front door as the healthcare system safety net. It is the vulnerable populations that are most affected by climate change and these patients are already a clear focus of our practice.6 These vulnerable populations are the “canaries in the coal mine,” as the impacts are increasingly touching us all. The Hippocratic oath mandates that we must inform our patients about everything that threatens their health.

Being Proactive Rather Than Reactive: Anticipating Threats

All of those working within an ED pride themselves on being able to anticipate a patient’s “crash” by detecting the slightest alterations in physical exam or physiology. These signs are clearly present for climate change and mandate that we anticipate the coming threats through clinical adaptation and climate-resilient infrastructure.

Taking Charge and Leading

As natural communicators and collaborators, EM providers must take a leading role in mobilizing the healthcare community as climate change is reframed as the public health threat that it is. The existing gaps will only be filled through teamwork, something we exhibit daily in our trauma bays. We are the specialty that creates calm within the chaos.

Conclusion

Our specialty was bred out of necessity, and this necessity to address climate change falls on us. We have never shied away from a challenge, and we must rise to meet this one – perhaps our greatest yet.

To learn more about engaging with the mobilization of emergency medicine around climate change, join the Society of Academic Emergency Medicine Climate Change and Health Interest Group and attend SAEM18 events including the advanced pre-meeting workshop and didactic.

 

1.
Costello A, Abbas M, Allen A, et al. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet. 2009;373(9676):1693-1733. [PubMed]
2.
Cook J, Nuccitelli D, Green SA, et al. Quantifying the consensus on anthropogenic global warming in the scientific literature. E. 2013;8(2):024024. doi:10.1088/1748-9326/8/2/024024
3.
Watts N, Adger W, Ayeb-Karlsson S, et al. The Lancet Countdown: tracking progress on health and climate change. Lancet. 2017;389(10074):1151-1164. [PubMed]
4.
Climate Change 2014: Synthesis Report. Contribution of Working Groups I, II and III to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge University Press; 2014:151pp. http://www.ipcc.ch/report/ar5/syr/. Accessed May 12, 2018.
5.
Climate Change and Public Health – Climate Effects on Health. Center for Disease Control and Prevention. http://www.cdc.gov/climateandhealth/effects/default.htm. Published 2016. Accessed May 12, 2018.
6.
Crimmins A, Balbus J, Gamble C. The Impacts of Climate Change on Human Health in the United States: A Scientific Assessment. Washington DC; 2016:332pp. https://health2016.globalchange.gov/downloads. Accessed May 12, 2018.
7.
Chen T, Sarnat S, Grundstein A, Winquist A, Chang H. Time-series Analysis of Heat Waves and Emergency Department Visits in Atlanta, 1993 to 2012. Environ Health Perspect. 2017;125(5):057009. [PubMed]
8.
Rosenheim N, Grabich S, Horney J. Disaster impacts on cost and utilization of Medicare. BMC Health Serv Res. 2018;18(1):89. [PubMed]
9.
Dohrenwend P, Le M, Bush J, Thomas C. The impact on emergency department visits for respiratory illness during the southern california wildfires. West J Emerg Med. 2013;14(2):79-84. [PubMed]
10.
Gotanda H, Fogel J, Husk G, et al. Hurricane Sandy: Impact on Emergency Department and Hospital Utilization by Older Adults in Lower Manhattan, New York (USA). Prehosp Disaster Med. 2015;30(5):496-502. [PubMed]
11.
Smith A. Billion-Dollar Weather and Climate Disasters: Overview. National Centers for Environmental Information. https://www.ncdc.noaa.gov/billions/. Published 2018. Accessed May 12, 2018.
12.
Safe Haven in the Storm. Health Care Without Harm. https://noharm-uscanada.org/sites/default/files/documents-files/5146/Safe%20Haven.pdf. Published 2017. Accessed May 12, 2018.

Author information

Renee Salas, MD MPH MS

Renee Salas, MD MPH MS

Clinical Instructor
Department of EM, Division of Wilderness Medicine
Harvard Medical School / Massachusetts General Hospital
Affiliated Faculty, Harvard Global Health Institute
Chair, SAEM Climate Change and Health Interest Group

The post Climate Change and Emergency Medicine: A Specialty on the Frontline appeared first on ALiEM.

Ketamine for Severe Ethanol Withdrawal: A New Hope?

Ketamine for severe ethanol withdrawalEthanol withdrawal is a complex disease state. Two of the main players are GABA (an inhibitory neurotransmitter) and glutamate (an excitatory transmitter that can act on NMDA receptors). Simplistically, chronic ethanol use leads to a down-regulation of GABA receptors and an up-regulation in glutaminergic receptors, such as NMDA. When ethanol is abruptly discontinued, we are left with a largely excitatory state with less ability for GABA-mediated inhibition and more capacity for NMDA/glutamate-mediated excitation. While much of the treatment of severe ethanol withdrawal is focused on GABA, there are agents, such as phenobarbital and propofol, that can suppress the glutaminergic response. Ketamine seems like it should confer benefit, as well, due to its NMDA antagonist properties. Until recently there was only one clinical study using ketamine for severe ethanol withdrawal.1 Now there are two.2

In this post, we will review the body of evidence for ketamine in severe ethanol withdrawal and explain its potential application to clinical practice.

The First Ketamine Study in 2015

Annals of Pharmacotherapy journal 1

  • Methodology: Retrospective study
  • Study population: 23 adult patients administered ketamine specifically for ethanol withdrawal
  • Mean time to initiation of ketamine from first treatment of alcohol withdrawal syndrome: 33.6 hours
  • Total duration of ketamine treatment: 55.8 hours
  • Median ketamine infusion rate: 0.20 mg/kg/hr
  • Results:
    • No change in sedation or alcohol withdrawal scores within 6 hours of ketamine initiation
    • Less benzodiazepines: Median change in benzodiazepine requirements at 12 and 24 hours post-ketamine initiation were -40.0 and -13.3 mg, respectively
  • Complications: One documented adverse reaction of oversedation, requiring dose reduction
  • Author conclusion: Ketamine appears to reduce benzodiazepine requirements and is well tolerated at low doses

The Second Ketamine Study in 2018

Critical Care Medicine journal 2

  • Methodology: Retrospective observational cohort study where a guideline was instituted incorporating ketamine with benzodiazepines (or phenobarbital) for severe ethanol withdrawal
  • Study population: 63 ICU patients with delirium tremens (DTs) diagnosed by a board-certified medical toxicologist (29 patients pre-guideline, 34 patients post-guideline)
  • Median duration of ketamine treatment: 47 hours
  • Mean ketamine infusion rate: 0.19 mg/kg/hr (19 patients received a loading dose)
  • Results: Ketamine associated with –
    • Decreased ICU length of stay by 3 days (95% CI, -5.58 to -0.089)
    • Decreased likelihood of intubation compared to pre-guideline (odds ratio, 0.14, p < 0.01)
    • Less benzodiazepines: Mean dose (diazepam equivalent): 2,525 mg pre-guideline vs. 1,508 mg post-guideline (p = 0.02)
      • More pronounced difference in the subgroup of 32 intubated patients: 3,016 mg vs. 833 mg (p = 0.01)
  • Complications: One documented adverse reaction of oversedation, requiring dose reduction

Application to Clinical Practice

  1. Ketamine has the potential to serve as a great partner to our GABA agents in the management of severe ethanol withdrawal. Unlike dexmedetomidine, which does not target the underlying pathophysiology (and has been extensively covered on the ALiEM blog), ketamine does attack part of the root cause. Therefore, a reduction in benzodiazepines may be an appropriate endpoint with ketamine (but not for dexmedetomidine).
  2. Both published studies were retrospective and not controlled. This needs to be taken into account when considering ketamine. However, the 2018 study reported on meaningful, patient-oriented outcomes like ICU length of stay and intubations. While well-designed trials are needed, ketamine seemed to be effective with few reported adverse effects in both studies.
  3. The infusion rate used in both studies was approximately 0.2 mg/kg/hr and seems to be a good place to start if considering ketamine for this indication. A bolus up to 0.3 mg/kg may be considered for some patients.

I am excited to see more ketamine literature coming out for severe ethanol withdrawal. The mechanism makes sense, the results thus far look promising, and this clinical entity can present a significant management challenge. More options in the armamentarium are always welcome. For now, ketamine may be considered as an adjunct to GABA agents in the management of severe ethanol withdrawal and DTs.

Teaching Point (and a plea from toxicologists): The term ‘DTs’ is often incorrectly used interchangeably with ‘ethanol withdrawal.’ While DTs is a severe manifestation of ethanol withdrawal, not all ethanol withdrawal is DTs (think ‘every square is a rectangle, but not every rectangle is a square’).

Further Reading

Handout from my 2018 American Academy of Emergency Medicine Scientific Assembly talk on Beyond Benzos for Severe Ethanol Withdrawal [PDF] and my general treatment algorithm

1.
Wong A, Benedict N, Armahizer M, Kane-Gill S. Evaluation of adjunctive ketamine to benzodiazepines for management of alcohol withdrawal syndrome. Ann Pharmacother. 2015;49(1):14-19. [PubMed]
2.
Pizon A, Lynch M, Benedict N, et al. Adjunct Ketamine Use in the Management of Severe Ethanol Withdrawal. Crit Care Med. May 2018. [PubMed]

Author information

Bryan D. Hayes, PharmD, FAACT, FASHP

Bryan D. Hayes, PharmD, FAACT, FASHP

Leadership Team, ALiEM
Creator and Lead Editor, Capsules series, ALiEMU
Attending Pharmacist, EM and Toxicology, MGH
Assistant Professor of EM, Harvard Medical School

The post Ketamine for Severe Ethanol Withdrawal: A New Hope? appeared first on ALiEM.

MEdIC Series: The Case of the Orphaned Patient – Expert Review and Curated Community Commentary

Our seventh case of season 5, The Case of the Orphaned Patient, presented the scenario of a junior orthopedic surgery resident rotating in the ED and receiving significant pushback when trying to transfer the care of a clinically deteriorating patient to a more appropriate service. The outcome of this pushback was a patient without a service feeling primarily responsible for further care, leaving the patient “orphaned” in the ED. If you haven’t had a chance yet, we urge you to check out the case and share your thoughts on this important topic!

The MEdIC team (Drs. Tamara McColl, Teresa Chan, Sarah Luckett-Gatopoulos, Eve Purdy, John Eicken, Alkarim Velji, and Brent Thoma) hosted an online discussion around the case over the last 2 weeks with insights from the ALiEM community. We are proud to present to you the curated commentary and our expert opinions. Than you to all participants for contributing to the very rich discussions surrounding this case!

This follow-up post includes:

  • Responses from our solicited experts:
    • Dr. Aikta Verma (@aiktaverma) completed both her FRCPC Emergency Medicine residency training and a Masters of Health Sciences in Health Administration at the University of Toronto. She works as an emergency physician and holds the position of Director of Clinical Operations at Sunnybrook Hospital. She is an Assistant Professor as well as the Assistant Program Director and Competence Committee Chair for the FRCPC Emergency Medicine residency training program at the University of Toronto.
    • Dr. Colm McCarthy (@colmjmccarthy) is a PGY-4 orthopedic surgery resident at McMaster University. He is completing his Masters in Health Science Education at McMaster while in residency. He has an interest in patient, medical student, and resident teaching as well as lower extremity reconstruction and trauma. He is passionate about patient and physician advocacy and strives to make learning a fun, humorous, and memorable experience.
  • A summary of insights from the ALiEM community derived from the Twitter and blog discussions.
  • Freely downloadable PDF versions of the case and expert responses for use in continuing medical education activities.
Expert Response 1: Who's Patient Am I? (Dr. Aikta Verma)
Expert Response 2: Orphaned Patients: A Complex Administrative Dilemma (Dr. Colm McCarthy)
Curated from the Community (Dr. John Eicken)

Case and Responses for Download

Click here (or on the picture below) to download the case and responses as a PDF (169 kb).

Author information

Tamara McColl, MD FRCPC

Tamara McColl, MD FRCPC

Associate Editor, ALiEM MEdIC Series
Emergency Physician, St. Boniface Hospital, WRHA
Academic Lead, Educational Scholarship
Department of Emergency Medicine
University of Manitoba

The post MEdIC Series: The Case of the Orphaned Patient – Expert Review and Curated Community Commentary appeared first on ALiEM.