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The Intersection of Public Health and EMS
It's been a typical Monday evening shift for you on All-City EMS, a third service EMS agency handling BLS and ALS for a large urban area, and you're about to turn your patient care reports in to your supervisor when you see a bulletin on the wall from the local health department about a series of flu vaccination clinics coming up. You roll your eyes and say, "Is that all those public health folks are good for? Flu vaccinations?"
Introduction
Chances are you don't really know or understand the function and structure of your local health department. Many of us work for EMS agencies that literally have nothing to do with the overarching health department that serves the same municipality, county or region. Health departments come in all shapes and sizes, serving both large and small communities and areas. Traditionally, these entities organize themselves around functional operational divisions or units. These divisions usually include, but are not limited to, such specialized fields as maternal and child health, epidemiology/disease control, administration, environmental health, community health and behavioral health. But these same public health entities have been planning and preparing for, and responding to, various emergences for many years, including environmental emergencies, food borne and sanitation issues, and water supply safety.
Since the 2001 anthrax attacks, considerable funding has been provided to local, state and federal public health agencies and organizations to orient them toward the more comprehensive state of preparedness needed to cope with the dangerous realities of today's world. These realities include the possibility of public health entities needing to plan for and respond to the full spectrum of WMD threats (specifically the C-B-R-N-E threats) as well as other threats, such as pandemic influenza. As EMS providers, and a part of the larger healthcare structure, it's in our best interests to understand the capabilities of our local and state health departments; any lack of knowledge has the potential to work against us in cases of large-scale emergencies or when we’re faced with an emerging threat.
I had the opportunity to examine the recently released National Association of County and City Health Officials (NACCHO) 2010 National Profile of Local Health Departments (LHDs) and was pleasantly surprised to find an entire chapter of this text devoted to emergency preparedness (chapter 6). NACCHO is the organization that represents all governmental local health departments, including counties, cities, city/counties, districts, townships and tribal public health agencies. Today, active membership in NACCHO continues to grow, with about 1,300 local health departments represented. The aforementioned chapter contained useful information on things like the number of health departments employing dedicated emergency preparedness staff; the types of events health departments typically consider emergencies requiring an emergency response; as well as other information (funding streams specific to emergency preparedness, etc.).
Overview
Some of the facts included in the report shouldn't come as a surprise—for example, 61% of LHDs responded to the 2009-10 H1N1 influenza outbreak—while others are certainly are surprising, such as the fact that, on average, LHDs use 30% of their staff to respond to natural disasters; this is a large percentage and has the potential to impact other functions of the health department, lowering the priority of some public health services during emergencies. Traditionally, the emergency response staff has a solid background in public health through both education and experience, and a working knowledge of ICS and NIMS principles. Additional reported emergency response activities for the LHDs during this time period included infectious disease (26%), natural disaster (23%), foodborne outbreak (21%), chemical spills or releases (9%), and exposure to a potential biological agent (5%). Most of these reported responses have the potential to call on EMS and public health to interact, even if not on an emergency scene. Although not specifically mentioned in the NACCHO report, these responses also call for pre-established plans that have been researched and written based on realistic capabilities as well as exercised in advance.
Another interesting element brought out in this chapter is the actual number of staffers dedicated to emergency preparedness employed by LHDs. LHDs serving jurisdictions with a population numbering between 100,000 and 499,999 had an average of two dedicated staffers for emergency preparedness while those LHDs serving an area with 500,000 or more people had a median of four dedicated employees. What this translates into are resources for EMS agencies to call upon in regard to information on naturally occurring events, (i.e. pandemics), man-made incidents (chemical or biological attacks) or even an additional perspective on large-scale event readiness. An additional area where your LHD can add to the EMS arsenal is in regard to stockpiling of both personal protective equipment (including gloves and N-95 masks) and antiviral medication—both of which are resources providers may have to utilize during a pandemic situation or other public health emergency when EMS will be on the front line of patient care. Clearly, this means interaction between public health authorities and EMS personnel prior to an emergency situation, which can include joint training, drills and exercises. A good example of this would be a tabletop exercise for public health officials and EMS agencies to test sharing resources.
EMS agencies and personnel need to realize that good working relationships with their health department partners (this can be local, county or regional) make sense in regard to disaster/emergency preparedness. One of the elements of the report that stood out was the amount of funding LHDs receive to support their emergency preparedness efforts, with the vast majority receiving funds through various federal initiatives, including the Public Health Emergency Preparedness (PHEP) cooperative agreement, Cities Readiness Initiative (CRI) or Hospital Preparedness Program (HPP) grants. A much smaller amount received funding through state or local governments. Just to give the readership some idea of the total figure we are speaking of, in fiscal year 2011 the federal government funded state and local preparedness and response capabilities to the tune of nearly $664.3 million. No matter the funding stream, some of this money goes toward various training, drills and exercises to assure the healthcare system is ready—and EMS is an element of the healthcare system. Clearly, that means EMS should be participating in these trainings, drills and exercises.
One of the issues mentioned in the chapter on emergency preparedness is utilizing volunteers in emergency response. Nearly all LHDs (93%) reported engaging volunteers for preparedness activities. This includes Medical Reserve Corps (MRC), Community Emergency Response Teams (CERT) or even Red Cross volunteers. This becomes an area of concern for EMS agencies, as many utilize volunteers as primary first responders; some of these responders may have other duties volunteering for the local and/or state health department in the capacities mentioned above.
Another statistic that caught my eye was from chapter 7 of the report—LHD Activities—which reported that 4% of the LHDs surveyed provide EMS to their communities. This section gave no additional breakdown regarding the level of service provided (ALS or BLS) as well as any other services associated with EMS (medical control, dispatch, etc.). What's interesting to note is two of the larger, more well-established EMS systems in the U.S.—Boston EMS and Denver Paramedics—are both departments of their local public health agency.
Collaboration
"More so today than at any other time, communities are relying on strong partnerships to ensure the health and safety of the country. No one entity—whether it's public or private—can do it alone," says Jack Herrmann, senior advisor and chief of public health preparedness at NACCHO. Herrmann adds, "Many local health departments have long been working from a position of having to do more with less, but unfortunately, the time has come where less means less. Critical public health services will not be available due to recurrent budget cuts and the elimination of key workforce positions. The only way we can beat this is for everyone to come together, pitch in and help."
In many communities across the country, the public health and EMS sectors have already begun to team up to ensure people will be protected and cared for during a disaster. But there's more work to be done.
Some interesting areas of collaboration between public health authorities and EMS agencies can serve as examples of what was mentioned above. These include:
- Mass fatality planning, where the LHD is the entity responsible for Emergency Support Function (ESF) #8 (public health and medical) but the local EMS agency will be the first responder with significant operational responsibilities and the medical examiner/coroner may have overall responsibility for the fatality management. Health departments may have to be the entity putting planning elements in motion—this planning needs to include agency capabilities, response realities, public expectations and other critical elements. Additionally, this intricate planning effort also needs to include additional response partners, both traditional and non-traditional (law enforcement, emergency management, etc.).
- Pandemic influenza planning and response where LHDs will be the entity entrusted with vaccinations and other broad public health responsibilities (such as general information dissemination to both the public and medical providers, distribution of stockpiled N-95 and other PPE, strategic national stockpile requests to state health departments and/or the CDC, etc.) but EMS agencies will be on the front lines, seeing patients with influenza-like illnesses, as well as possibly assisting with vaccinations and dealing with the possibility of alternate treatment and transport protocols.
- One of the critical elements of EMS terrorism preparation is establishing collaboration with public health. Both EMS agencies and public health entities can benefit from robust syndromic surveillance programs such as those being implemented in New York City (as a joint project of the NYC Department of Health and the Fire Department of New York) and Seattle/Kings County (where the fire department uses a dispatch monitoring and analysis program). Public health authorities are primarily responsible for bioterrorism events. During these and other potential incidents where emergency departments are overcrowded, EMS systems are running at peak capacity and the primary care system is strained, cooperation will be mandatory.
Conclusion
In the weeks after reading the NACCHO paper, I had the opportunity to read another, much more sobering report released by the Trust for America's Health and the Robert Wood Johnson Foundation. This second report, entitled Ready or Not? Protecting the Public's Health from Diseases, Disasters and Bioterrorism was released in November 2011 and states that, although we are better prepared to respond to public health emergencies since the Sept. 11, 2001 terrorist attacks and subsequent anthrax mailings, Federal budget cuts are chipping away at those gains. The cuts will impact critical public health preparedness areas, including the distribution of vaccines and antibiotics to large populations during a crisis, and the public health laboratories capable of testing for threatening chemicals. This level of cuts would leave the Centers for Disease Control and Prevention (CDC) as the only public health lab able to test a full range of toxic chemicals and nerve agents.
As an example of the applicability of this issue, as well as how detrimental these cuts will be to emergency response, many state and local public health entities credit federal funding for the overall success in managing H1N1 influenza during the 2009-10 outbreak. Without federally funded labs at the state level, samples would have had to travel all the way to Atlanta in order to find out whether or not people were infected with bird flu, significantly slowing response time. Additionally, previous funding had been spent on stockpiling PPE and anti-virals, both credited with slowing the progress of the pandemic.
Whether you read the NACCHO report to better understand the structure of public health entities, their emergency responsibilities or how you can better interact with them, or you read the Trust for America's Health report to gain knowledge of public health preparedness, expected funding cuts and how these may impact you, it is incumbent on EMS decision makers to review these documents and plan appropriately. If you have not already done so, it behooves you to reach out to the LHD in your response area—this small investment of time will pay off during a public health emergency.
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