The Climate Emergency—And the Emergency Physicians Fighting It: Experts Are Preparing Departments and the Next Generation of Physicians for This Emerging Threat

Abstract

This summer at Northern Colorado Medical Center in Greeley, CO, emergency physician Cecilia Sorensen, MD, treated a construction worker in his early 30s who collapsed on the job shortly before 4 pm. The patient, a construction worker who was slightly overweight but otherwise had no health problems, had worked outside all day in hundred-degree heat with no access to water—during the hottest August ever recorded in Colorado.1Bateman J. Summer 2020 ranked as one of the hottest on record for US. September 9, 2020.https://www.noaa.gov/news/summer-2020-ranked-as-one-of-hottest-on-record-for-usDate accessed: February 10, 2021Google Scholar By the time Dr. Sorensen saw him, his core temperature was over 103°F; he was in an altered mental state, not sure where he was or how he got to the hospital. Dr. Sorensen and her team immediately began cooling him with ice packs to the groin, axilla, and neck while they hung 3 L of chilled fluids. Within a couple hours, they’d lowered his temperature to a normal range and his mental status returned to normal. “Early recognition contributed to his great outcome,” said Dr. Sorensen, a clinical instructor in the emergency department (ED) at the University of Colorado Anschutz Medical Campus in Aurora, CO. In the coming years, Dr. Sorensen pointed out, extreme heat caused by climate change will drive up the number of patients nationwide seeking emergency medical attention, affecting not just the elderly and medically vulnerable but also the young and healthy, particularly those who work outdoors. To help equip EDs for these changes, Dr. Sorensen assisted in developing an evidenced-based pathway that would guide emergency physicians and first responders to recognize heat illness faster and treat it earlier. Although intensifying summer temperatures are a focus for emergency physicians who study climate change—heat-related illnesses have been the leading cause of weather-related death in the United States during the last 30 years2Congress.govS.4280 - Preventing HEAT Illness and Deaths Act of 2020. 116th Congress (2019-2020).https://www.congress.gov/bill/116th-congress/senate-bill/4280/textDate accessed: February 10, 2021Google Scholar—they’re far from the only concern. Wildfires and floods are also creating a growing number of medical emergencies, and because natural disasters often degrade air, food, and water supplies, they can contribute to other health problems down the line, too. (Water damage to houses, for instance, encourages the growth of respiratory irritants such as mold.) Moreover, climate change is contributing to the distribution of vector-borne diseases such as those spread by insects that survive longer in more humid environments: A 2018 study by the Centers for Disease Control and Prevention (CDC) declared that novel vector-borne agents will be “a continuing threat,” after finding that 9 vector-borne human diseases had been reported for the first time in the United States between 2004 and 2016, a period during which the number of tick-borne bacterial and protozoan diseases more than doubled.3Rosenberg R. Lindsey N.P. Fischer M. et al.Vital signs: trends in reported vectorborne disease cases—United States and Territories, 2004–2016.MMWR. 2018; 67: 496-501Crossref PubMed Scopus (428) Google Scholar Climate change is “the biggest global health threat of the 21st century,” according to a November 2018 piece by the Lancet Commission, and emergency physicians are poised to bear the brunt of it.4Watts N. Amann M. Arnell N. et al.The 2018 report of the Lancet Countdown on health and climate change: shaping the health of nations for centuries to come.Lancet. 2018; 392: P2479-2514Abstract Full Text Full Text PDF PubMed Scopus (442) Google Scholar “Emergency medicine will own this whether we want to or not,” said Jay Lemery, MD, professor of emergency medicine at University of Colorado School of Medicine in Aurora, CO. He, Dr. Sorensen, and their peers are seeking ways to arm themselves and their colleagues for the coming onslaught. But their battle is often an uphill one. “That climate change will disproportionately impact our specialty is clear,” said Jeremy Hess, MD, MPH, an emergency physician who directs the Center for Health and the Global Environment at the University of Washington in Seattle. Emergency medicine already manages almost 30% of acute care in the United States.5Pitts S.R. Carrier E.R. Rich E.C. Kellerman A.L. Where Americans get acute care: increasingly, it’s not at their doctor’s office.Health Aff (Millwood). 2010; 29: 1620-1629Crossref PubMed Scopus (228) Google Scholar “We provide frontline care delivery for a very wide range of complaints, do surveillance for new and reemerging diseases, and already play a key role in environmental emergencies, prehospital, and disaster care, as well as safety net care for displaced people and highly vulnerable populations,” said Dr. Hess, who is also a professor of emergency medicine at the University of Washington, and director of its emergency medicine department’s Population Health Research Fellowship. “Climate change is likely to affect a wide range of the presentations we commonly see.” The changing climate will also have a greater effect on individuals who rely on the ED for care: low-income US residents, the uninsured, and the underinsured. Despite compelling reasons why medicine in general and emergency medicine in particular should be preparing for the growing climate threat, individuals leading the way haven’t had an easy time of it. “It’s a small field and there are major headwinds to engaging with this issue, from nearly nonexistent funding to frequent allegations of politicization,” said Dr. Hess. “Medicine in the US has been slow to the ball. [Emergency medicine] has done a worse job than other specialties, though the majority of clinically active health professionals working on climate and health in the US and several other places are in [emergency medicine].” Direct effects, such as heat-related illness, are only part of the story. Indirect effects are also cropping up already. Take Lyme disease, which has spread to areas where it was previously uncommon or nonexistent. “We used to largely just see Lyme disease here in the Northeast,” said Renee Salas, MD, MPH, a Boston-based emergency physician at Massachusetts General Hospital and Harvard Medical School who is a Yerby Fellow at the Center for Climate, Health, and the Global Environment at the Harvard T.H. Chan School of Public Health. “Now it is spreading to new regions with longer seasons, and as emergency physicians we have to start thinking every rash could potentially be Lyme.” The CDC would agree: as noted on its Web site, the number of reported cases of Lyme disease in the United States has tripled since the late 1990s; and the number of counties considered high risk for the disease increased by more than 300% between 1993 and 2012. Drs. Salas and Hess work together on The Lancet Countdown, a global effort that tracks progress on more than 40 climate and health indicators and is published each year in The Lancet. As part of their initiative, they released 2 publications on December 2, 2020: one looks at the effect of climate change on health worldwide6The LancetThe 2020 Report.https://www.lancetcountdown.org/2020-reportDate accessed: February 10, 2021Google Scholar; the other, at the climate situation in the United States.7The LancetLancet Countdown: Tracking Progress on Health and Climate Change & Companion US Policy Brief.https://www.lancetcountdownus.orgDate accessed: February 10, 2021Google Scholar “The Lancet Countdown global report highlights that the world is already experiencing several health impacts from climate change, particularly related to heat exposure in elders, limitations in crop productivity, and wildfire exposure, and that adaptation efforts in the health sector are not keeping pace with the growing impacts,” said Dr. Hess. “The US Brief echoes these findings and also highlights that the structural inequities in the US are worsening impacts from climate-sensitive extreme events.” Both articles also suggested ways to address these issues as the recovery from coronavirus disease 2019 begins to occur. To produce the US report, which is coproduced with the American Public Health Association, Drs. Salas and Hess assembled a wide-ranging coalition for the US Brief Working Group, which currently includes academic public health and medical institutions such as the Harvard Global Health Institute, University of Washington Center for Health and the Global Environment, Emory, University of Nebraska Medical Center, and the University of California San Francisco Institute for Global Health Sciences. Professional societies are also participating, including the American Lung Association, National Environmental Health Association, American Geophysical Union, and the National Association of County and City Health Officials. For Dr. Salas in particular, a focus on climate change was an unexpected career turn. She was inspired to change directions professionally in 2013 when, as a first-year attending physician at Massachusetts General Hospital in Boston, she attended a talk about climate change and emergency medicine. The speaker, citing a 2009 Lancet Commission report, “described climate change as the greatest public health emergency but similarly also the greatest opportunity,” said Dr. Salas. “I was taken aback because I had not heard about how climate change was harming health during medical school or residency.” She realized climate change would not only make it increasingly harder for her to protect her patients but also would also affect her health and that of her loved ones. The lecture, she said, “completely changed my career path.” She went back to school at the Harvard T.H. Chan School of Public Health for a master’s degree in public health, with a concentration in environmental health. Subsequently, she has worked to ensure that practicing physicians and trainees hear about climate change and the ways in which it harms health and disrupts our health care systems. She has also played a part in making sure today’s medical students and residents don’t have the same knowledge gap on graduation. In early March, before the pandemic hit, she returned to the University of Cincinnati College of Medicine, where she completed her residency, to talk to the ED there about her work. She also advises her alma mater—the Cleveland Clinic Learner College of Medicine in Cleveland, OH, where she was part of the first graduating class—about how to integrate climate change education into medical school curricula. The speaker who so influenced Dr. Salas was, it turns out, University of Colorado’s Dr. Lemery, chief of its Wilderness and Environmental Medicine Section. Dr. Lemery is inspiring and guiding a new generation of emergency physicians concerned about climate and health. At the University of Colorado School of Medicine’s ED, he built a program about climate change and medicine, and under his leadership, the University of Colorado team has produced what Dr. Hess describes as “excellent scholarship,” helping to create training protocols concerning climate change and health policy. “They have done a great job of documenting that work in the literature and of working with others in the field to update early scholarship with more recent data,” Dr. Hess added. More recently, Dr. Lemery and his group, at the behest of the University of Colorado School of Medicine’s dean, also launched a campuswide climate and health program, with the goal of educating the entire school’s community about climate change and health. In Dr. Lemery’s view, an interdisciplinary approach is essential. To that end, he and his colleagues have established relationships with the University of Colorado School of Public Health, as well as the university’s faculty credentialed by top earth science laboratories, such as the National Oceanic and Atmospheric Administration and the CDC. He also developed a novel fellowship for emergency physicians, offered by the University of Colorado School of Medicine in collaboration with the National Institutes of Environmental Health Sciences, CDC, and the Medical Society Consortium of Climate and Health. Launched in 2017, The Climate and Health Foundation ∗On January 1, 2021, the organization changed its name from The Living Closer Foundation to The Climate and Health Foundation.∗On January 1, 2021, the organization changed its name from The Living Closer Foundation to The Climate and Health Foundation. Physician Fellowship in Climate & Health Science Policy supports “knowledgeable, credible, and effective physician leaders on issues of climate and health [who will]…engage with policymakers, government agencies, NGO's, academia, and the public,” as Dr. Lemery put it.8Living Closer Foundationhttps://www.livingcloser.comDate accessed: February 11, 2021Google Scholar Dr. Lemery subsequently collaborated with Satchit Balsari, MD, an assistant professor in emergency medicine at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston, MA, to establish a similar fellowship there. The Colorado program’s inaugural scholar was Dr. Sorensen, who began to develop the heat-illness protocol during her fellowship term. She also studied how wildfires strain hospitals, particularly ICUs. “ICUs care for the most seriously ill patients and require copious resources, uniquely trained staff, and use of specialized equipment,” said Dr. Sorensen. “Unexpected surges in demand for these limited resources can cause a cascade of stresses on hospital operations by diverting resources from other critically ill patients and inducing shortages of essential personnel, supplies, and equipment, all of which can affect the quality of patient care.” Such surges are likely to increase as conditions get hotter and drier in the West9Union of Concerned ScientistsThe Connection Between Climate Change and Wildfires. September 9, 2011.https://www.ucsusa.org/resources/climate-change-and-wildfiresDate accessed: February 11, 2021Google Scholar; “the frequency and acreage burned by large wildfires in the western United States and Alaska has increased steadily since the 1980s and is projected to further increase under the influence of climate change,” said Dr. Sorensen. That’s why she and researcher James Crooks, PhD, MS, at National Jewish Hospital are currently looking into how wildfires add to the ED patient population,10Casey C. Climate change: ‘Physicians need to be involved’. March 12, 2019.https://news.cuanschutz.edu/news-stories/climate-change-physicians-need-to-be-involvedDate accessed: February 11, 2021Google Scholar and how hospitals can alternatively deploy resources to cope with sudden changes in demand. Despite all of the progress—despite, too, the increasing recognition among the general population that climate change is a problem—emergency physicians leading the11Funk C. Kennedy B. How Americans see climate change and the environment in 7 charts. April 21, 2020.https://www.pewresearch.org/fact-tank/2020/04/21/how-americans-see-climate-change-and-the-environment-in-7-chartsDate accessed: February 11, 2021Google Scholar way on climate change and health still have trouble finding financial support for their work. “The research funding has not changed at all in the US, though it has improved elsewhere,” said Dr. Hess. “Overall, I think there is a big generational divide on this.” Younger emergency physicians, he noted, are more concerned about the ecologic situation and have been pushing the field to do research and preparation. Not everyone is convinced that this topic11Funk C. Kennedy B. How Americans see climate change and the environment in 7 charts. April 21, 2020.https://www.pewresearch.org/fact-tank/2020/04/21/how-americans-see-climate-change-and-the-environment-in-7-chartsDate accessed: February 11, 2021Google Scholar belongs in the emergency medicine portfolio, though. One veteran emergency physician who takes issue with the growing specialty is Todd B. Taylor, MD, an independent consultant based in Phoenix, AZ, who has more than 20 years of clinical experience in the field. Dr. Taylor doesn’t think emergency physicians should talk to students or patients about climate change. “The reason climate change is not appropriate for formal ED education is the same reason politics, religion, immigration, and a host of other societal hot button topics [aren’t appropriate],” Dr. Taylor told Annals in an e-mail. “We have more (important) things directly related to emergency medicine than we often have time for. Why would we take up bandwidth with something that does not directly relate to the practice of [emergency medicine]?” He added that in the examination room, climate change could be a touchy subject. “You may not know a patient’s views,” he said, so that discussing climate change “could offend or alienate them, interrupting the very important doctor-patient relationship.” But the medical students who contact Dr. Lemery to ask about his work don’t see climate change and health as separate issues. “There's no politicization from their perspective,” said Dr. Lemery. “They foresee a health threat that will pervade their careers, one that not many schools of medicine address in their curricula, and a national response that has been anemic to date. They're asking for the knowledge and skills to address it.”