As Earth Day approaches, Clinician Reviews would like to shine a spotlight on clinicians who work hard to protect patients from environmental hazards, such as lead poisoning and pesticides. Other PAs and NPs work at the national and global level to track and prevent public health threats such as West Nile virus, HIV/AIDS, and pediatric asthma.
As more people recognize the intricate link between the environment and human health, interest in public health programs is increasing, according to a recent article in the Washington Post. At least one PA program, at George Washington University, offers a joint PA/public health degree.
For clinicians who are analytical and interested in health policy and who want to “do good” for the world, getting involved in public health may be an excellent career move. Perhaps the talented colleagues profiled below will inspire others to get involved and make a difference.
How a Single Question Saved Lives
Iowa emergency department (ED) PA Mark S. Johnson, PA-C, MPAS, MT (ASCP), saved nearly 100 lives when he discovered carbon monoxide poisoning in a local apartment complex.
It all started when two Bosnian immigrants, a mother and her 20-year-old son, walked into the ED at Ottumwa Regional Medical Center with a roster of vague complaints: headache, congestion, and earache. Johnson began to treat this as a routine upper respiratory case. He had the prescription in hand, and was about to send the patients home, when something stopped him. And he is glad he paid attention to that gut feeling.
“I thought to myself, ‘Well, it’s winter in Iowa,’ and they did have headaches,” Johnson said. So, he asked a few more questions. He learned that the mother’s apartment was located right next to the furnace room. The patients also told Johnson that workers had just been repairing the furnace. This information prompted Johnson to order a carbon monoxide test for both of them.
That testing revealed slightly elevated carbon monoxide levels for both the mother and son. Johnson then asked the woman’s younger son and her boyfriend to get tested. Their CO levels were also elevated. What had started as a seemingly routine case became a more clear-cut instance of carbon monoxide exposure.
“The levels were not toxic,” Johnson recalls. “But they were high enough to cause the headaches.”
Johnson called the maintenance man at the patients’ apartment complex. He, in turn, called the gas company. Their tests revealed—sure enough—that the furnace was not working properly. Carbon monoxide levels were high throughout the three-story building.
At that point, the local fire department evacuated the building. Paramedics checked carbon monoxide levels and told residents to stay away for several hours until the building had been aired out.
For a brief while, it looked as if all 100 of the apartment building residents might be headed to the Ottumwa Regional Medical Center’s 11-bed ED for testing; Johnson was glad the fire department handled that situation in the field. “The nurses I work with would never have let me live that down,” Johnson jokes.
Johnson hopes other clinicians will hear his story and stop to consider environmental causes of illness more carefully. “Before you dismiss something, go through your differential—just as you’re taught in school,” he says. “Go through that list of things you don’t want to miss.”
For example, if a patient has already seen 20 specialists and still complains of migraines, it could be a case of carbon monoxide exposure. It makes sense to ask about his/her furnace and whether there is a carbon monoxide detector in the home.
Johnson tends to dismiss the praise and attention he’s been getting from reporters who call him a hero. “I was kind of humbled by it,” he says. “Since this happened, I appreciate my work more, and I try to take the time to really listen carefully, because it might save somebody later on. You never know.”
Recognizing The Perils of Pesticide Exposure
A few years ago, a group of clinicians was eating lunch in a small health center near Tampa, Florida. Suddenly, a steady stream of farm workers started coming in with nausea, vomiting, chest pain, and respiratory problems.
The ED snapped into triage mode, separating the sickest from the less severely ill patients, who lined the hallways. The clinicians later learned the 84 farm workers they treated were working in a cauliflower field that had recently been sprayed with the chemical Phosdrin. Thirteen of the workers who had the greatest exposure to the pesticide stayed in the hospital for a week before recovering.
While PAs and NPs are often on the front lines of care for farm workers in rural clinics across the country, they receive very little formal training about how to handle pesticide poisoning. Amy Liebman, MPA, MA, hopes to change that through her work with the Austin, Texas–based Migrant Clinicians Network (www.migrantclinician.org).
Liebman, director of the network’s occupational and environmental health initiatives, coordinates continuing education and mentorship programs for 160 different migrant health centers in the United States.
“We’re all about trying to figure out ways clinicians can better recognize, better understand, and better treat occupational and environmental exposures,” Liebman says. “It’s about working strong, and working small, to make significant changes.”
Liebman’s group encourages clinicians, when they are taking a health history, to ask migrant farm workers about their occupation, particularly whether they are exposed to any substances at work or at home that might be harmful to them.
Migrant Clinicians Network CME programs cover such topics as how to document occupational exposure for workers’ compensation claims, the long-term health effects of pesticides, and what protective gear to recommend for farm workers. The organization also helps rural providers prepare for a large emergency, such as the one in Tampa, and set up decontamination areas.
Meanwhile, Liebman’s counterpart, Helen Murphy, MHS, DrPH(c), who practiced as a family nurse practitioner before entering the public health realm, is launching a similar effort in Seattle. Instead of reaching clinicians already in the field, Murphy’s program through the Pacific Northwest Agricultural Safety and Health Center targets PAs and NPs who are still in school. A pilot project is under way at the University of Washington’s PA program and Seattle Pacific University’s NP program, among others.
Murphy’s program offers a Web site loaded with real case studies, photos, videos, and details from medical charts to give clinicians more practice in identifying pesticide-related illness before they enter the workplace. “The instructors can just go into this database,” Murphy says, “and all of the class materials will be there.”
Both projects receive funding from the US Environmental Protection Agency’s Office of Pesticides. For more information on these programs, contact Liebman at firstname.lastname@example.org or Murphy at email@example.com.
Tracking Environmental Health Threats
Nurse practitioner Frances Medaglia doesn’t work in a traditional primary care setting. In fact, she doesn’t work in a traditional setting at all. But she does have a positive impact on the health of children in Massachusetts every day. In her position with the Massachusetts Department of Public Health’s Bureau of Environmental Health, Medaglia’s work has touched on everything from preventing prenatal exposure to chemicals to reducing childhood asthma rates and making indoor air safer for school children.
Medaglia recently became the state’s clinical coordinator for an exciting new program, funded by the CDC, that will help health care providers monitor local environmental health issues, such as cancer, lead poisoning, and air and water pollution. The program, known as the Massachusetts National Environmental Public Health Tracking Network, currently has data from 26 states. The CDC hopes eventually to include all states in the US.
“With this tool, you can see how prevalent asthma is in your county,” Medaglia says. “Maybe even down to the zip code level.”
Medaglia says she drew on her clinical background while entering all of the pediatric asthma information into the database for the entire state of Massachusetts. She gathered the data by working closely with school nurses across the state.
Medaglia’s medical training has come into play before, such as when she worked with public health staff members to analyze developmental delays in babies born near the Housatonic River. The river had been contaminated with polychlorinated biphenyls (PCBs) years earlier, so most of the staff believed that was the cause of the defects. But Medaglia found epidemiologic studies that showed pregnant women in the area had a very low rate of prenatal care. The town (Pittsfield, Massachusetts) also had a high number of women who smoked during pregnancy. Many of the homes in the area were old and had lead contamination.
“I bring something to the table that might not be thought of by the other folks,” Medaglia says. “That’s the contribution nurses can have in public health.”
From 60s Activism to the CDC
Like the current US president, Geoff Beckett, PA-C, MPH, used to be a community organizer. During the 1960s, Beckett was involved in the antiwar effort. He also encouraged people to support Cesar Chavez’s workers and boycott grapes.
Since community organizing didn’t pay well back then, Beckett took a side job as an orderly at a New Mexico hospital. That’s when he got hooked on medicine and joined one of the first PA training programs in the 1970s.
As a high-energy person, Beckett was attracted to the action-oriented pace of emergency medicine. He landed his first job at an ED in central Maine. In the 1980s, while working in a campus health center at Bowdoin College in Brunswick, Maine, Beckett set up an HIV testing program.
Around that time, some colleagues at a national PA meeting encouraged him to pursue his interest in public health. He was accepted to a master of public health program at Johns Hopkins University and found a job with the Maine Department of Public Health. Beckett stayed there for 20 happy years, tracking such health threats as Lyme disease, West Nile virus, and SARS. “I got to be involved at the local level,” he says, “kind of on the front line of these things.”
Beckett feels his medical background helped him to interact better with the physicians, nursing home directors, and ED staff members who called in with mysterious symptoms and diseases. “I’d like to say one of my major contributions was to improve those communications,” he says. “In an emergency, they could call me 24/7 and talk with someone who understands the clinical nuances.” In fact, Beckett continued to practice in a local ED while working for the department, just to keep his clinical skills fresh.
Returning to his roots as a community organizer, Beckett worked with citizen groups and elected officials to increase awareness about and promote prevention measures for Lyme disease. “I’ve been very lucky to combine my interest in clinical issues with policy,” he says.
Recently, Beckett took his career to the next level. After enrolling in a doctor of public health program at Boston University, he was offered a position as chief of the Prevention Branch for the Division of Viral Hepatitis at the CDC in Atlanta. “I got interested in international aspects of disease control,” Beckett explains, “and I decided I would like to do something that involved policy on a more national level.” Now, he travels around the country—and the world—perfecting programs that educate patients about preventing HIV and hepatitis B and evaluating ways to use vaccines most effectively.
Beckett doesn’t bump into many other PAs in the hallway at the CDC, but he thinks that day is coming. “I hope to be involved from the CDC end to promote collaboration between PA schools and public health programs,” he says. “It’s critical that they have people in health departments who can communicate with clinicians.”
To be successful at both, you need to enjoy the clinical aspects plus politics and policy, Beckett says. It helps to be motivated by a sense of social responsibility. Writing ability and feeling comfortable with public speaking also are key. “It’s great for somebody who’s been practicing for a while,” Beckett adds, “and might be looking for a new challenge.”