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What’s your target BP for ruptured abdominal aortic aneurysm?

29 Jun, 14 | by scarley

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A couple of years ago I was very (very, very) peripherally involved in an RCT investigating the management of ruptured abdominal aortic aneurysm. The IMPROVE trial was well designed and reported it’s results in 2014. The abstract is shown below, and I must admit that to my surprise there did not appear to be a definable advantage to endovascular repair.

Anyway, this post is not about the trials results per se, rather we received a comment from Prof. Janet Powell on behalf of the trial investigators that may have relevance for those of us in emergency and critical care medicine. One of the great advantages of large trials is the ability to look through data to see whether other themes and associations become apparent and this is what the trial team have done. Such data analysis has risks, but it can be an excellent way of generating hypotheses for future research, and observational data can also help us stop and think about current practice.

I digress. Read the letter from Janet below and then share your thoughts. As an emergency physician this observation raises a myriad of questions about data, analysis, resuscitation targets, association vs causality etc. and whenever I start thinking I know I’m getting better. So please, read, think, learn and please debate. Janet asks how we can work together to resolve and explore these results and surely that’s an offer that the EM and surgical communities should grasp.

vb

S

 

Blood pressure targets for the elderly with bleeding and vascular emergencies

The IMPROVE trial is the largest randomised trial of a strategy of endovascular repair versus open repair for ruptured abdominal aortic aneurysm, with over 600 patients [1]. Nearly all these patients started their care pathway in the emergency department and detailed evaluation of this large cohort of patients has raised some discussion points relevant for those in emergency care.

When we started this trial, we recommended that patients were managed with fluid restriction and hypotensive haemostasis, with systolic blood pressure targets of 70-80 mm Hg, to prevent further bleeding and optimise outcomes. These recommendations were based on emergency care guidelines for patients with abdominal trauma and the opinions of some leading vascular surgeons [2,3]. Hindsight is a wonderful thing. The patients we enrolled had an average age of 76.7 years: were these blood pressure targets far too low for this age group who were likely to have other cardiovascular disease and high cardiovascular resistance?

Cohort analysis has shown that there was a linear relationship between lowest systolic blood pressure and mortality (Table 1) and suggests that in these patients a blood pressure target of 100 mm Hg might save more lives. Lowest systolic blood pressure was directly related to outcome in a linear fashion, with each 10 mm Hg increase translating into a 13% relative improvement in the odds of survival to 30-days [4]. 30-day mortality rates of <30% were only achieved in those in whom the lowest blood pressure was 100 mm Hg or more.

Screenshot 2014-06-29 07.25.24

Management of other aortic conditions, particularly aortic dissection, may similarly be disadvantaged by unrealistic blood pressure targets. For aortic dissection the rapid blood pressure lowering to <100mm Hg, which is recommended [5], comes mainly from evidence in turkeys.

How can we work together to get the evidence for appropriate blood pressure targets for the elderly population with bleeding and other vascular emergencies? The current observational evidence is not sufficient and the question needs to be addressed in one or more randomised trials.

Janet Powell for the IMPROVE trial investigators

 

References
1 Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial IMPROVE trial investigators BMJ 2014;348:f6771
2 Joint Royal colleges Ambulance Liaison Committee. Ambulance Service Clinical Practice Guidelines; 2006. www.jrcalc.org.uk/guidelines.html‎ [accessed 1 September 2013].
3 Mayer D, Pfammatter T, Rancic Z, Hechelhammer L, Wilhelm M, Veith FJ et al. 10 years of emergency endovascular aneurysm repair for ruptured abdominal aortoiliac aneurysms: lessons learned. Ann Surg 2009; 249: 510–515
4 Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm. IMPROVE trial investigators Br J Surg 2014
5 The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. Accessed March, 2014 at www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf

 

So you have your invitation. Get in touch with the IMPROVE team to discuss, share and explore this observation.

 

vb

 

S

Predatory Journals – Enemies or Inspiration?

21 Jun, 14 | by rradecki

Science – unlike deranged, furious cursing – is not best cloistered behind closed doors, in the dark, with no audience. Dissemination of medical evidence is critical to refinement of practice and the generation of future research hypotheses. Yet, most evidence resides behind electronic publisher paywalls, accessible only for a fee, or to those with specific institutional access.

Those of us in academics take such access for granted – yet, the other 7 billion on Earth, many of whom toil in conditions with a lower standard of living, have a much higher barrier to entry. Many journals offer free access to visitors from certain countries, a generous, but incomplete, solution to the free flow of information. A growing alternative, however, to traditional publishing are “Open Access” journals. Such electronically published journals are free to access for all, and in lieu of the typical advertising + reprint business model used to support editorial and typesetting functions, the authors pay fees to support the costs of publication.

Some of these, such as PLOS ONE, have grown to become the largest journals in the world – publishing 31,000 articles in 2013 alone. At USD$1,350 per publication, the revenue associated with such a model is substantial. And therein lay the critical issue – the promise of such riches has attracted the usual unsavory crowd.

Now, we have the phenomenon of the “Predatory Publisher”, a faux journal whose primary function is profit. These publications, masquerading as legitimate science, have grown from 18 in 2011 to at least 477 in 2014. Most academics are likely familiar with the near-daily spam e-mails soliciting article submission, editorial positions, or conference speaking roles. In many cases, the journals are indistinguishable from reliable publishers, and well-meaning authors, hoping simply to increase the audience for an article, are sucked in.

Despite the shoddy or non-existent peer-review – in which nonsense articles by such renowned authors as Ocorrafoo Cobange pass through with nary a critical eye – these articles are entering the scientific ecosystem in ever-increasing numbers. One of the largest for-profit open-access publishers, MedKnow, from Mumbai, India, claimed over 2 million article downloads each month. In an academic professional reality where publication means promotion, and open-access publishing means unfettered distribution – it is no wonder such journals are thriving.

This phenomenon, of course, massively dilutes the scientific literature with a locust swarm of substandard evidence. Traditional journals, with strong reputations and robust Impact Factors, are holding strong for now. But, at the fringes – if funds are available, why would one risk rejection in a more rigorous, but low-impact journal, where the study would lay hidden behind a paywall?

While these journals are certainly the enemy of reliable evidence, and transitively, the public good, they represent an interesting lesson – and possible inspiration – for how traditional academic publishing might evolve.

What are we doing in EM?

12 Jun, 14 | by ibeardsell

Screenshot 2014-06-12 08.46.02It’s been a tough few months in UK Emergency Departments and has caused me recently to do a bit of thinking, as I knew I was losing a bit of my zeal and enthusiasm for our specialty. Yes, there’s the constant unrelenting pressure over targets and working under very trying circumstances with overcrowding and understaffing on an almost daily basis. It remains an enigma to me that for a lot of aspects of our work aviation is taken to be a shining example of how CRM should be done, yet a pilot would not take to the sky with 170% capacity and half the crew missing but we do, carrying on with a”Dunkirk spirit” to the best of our abilities.

So much appears to be put in our way, when trying to care for our patients.  We are drowning under the mass of bureaucracy and paperwork, it reduces time available for patient care. Common sense and practicality have gone out of the window, you can’t admit a patient to the short stay ward for a few hours without completing a host of paperwork required by outside agencies. Cannulation forms, an assessment of VTE risk, estimation of alcohol intake and smoking habit, consideration of hidden harm, a falls assessment, etc etc. A folder bulges with Standard Operating Procedures (SOPs), some about important clinical topics, but others seem appear to be bureaucratic ticks in boxes.  We even had to write an SOP  and subsequently approved in numerous places to allow a patient to sit on a chair in a clinical area rather than a trolley, but only after consulting the SOP on how to write SOPs!

Unlike colleagues in other specialties, where patients appear more grateful for their care, those attending the ED seem rather less so and referrals for inpatient admission are rarely greeted with thanks.  As much as we all try to persuade ourselves we don’t need external validation to feel valued I for one will openly admit I feel a whole lot better about myself and the job I do if just occasionally someone says thank you, well done or good job.

The final straw came when I did a brief online questionnaire which revealed I’m at very high risk of burnout. Whoa! I’ve only been an EM consultant for 6 years, part time at that. So the rethink began and I’ve come to the conclusion that what I personally, and I believe we as a speciality, need, as corny as it sounds, is  to get back to basics. To do the fundamentals really well as part of team working.

burnout

I’ve distilled this down to three areas: self; patients and environment. For myself I will try to always be a role model to others: to smile, think positively and value myself and others. My patients I will keep informed, take away their pain and encourage regular observations. The environment we work in should be professional, clean, tidy and quiet. Most importantly of all I will never forget that at the heart of all of this is care and compassion for our patients.

None of these are revolutionary requiring a policy or SOP, they are common sense, low cost, communication based basics that everyone, medical, nursing and support staff can fully participate in. So no-one can change my enthusiasm and zeal for the job except me, I’m trying to get the fundamentals spot on and encouraging others to do likewise, will you?

Dr Sarah Robinson

Consultant in Emergency Medicine

ROBINSONSarah

Patients, are they the silent contributor to case reports?

2 Jun, 14 | by scarley

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Patient participation (wikipedia CC)

We are in currently in the process of putting together a case report following a toxicological emergency in the ED. It’s an interesting case, deals with new street drugs and has some great lessons for emergency management…., well we would say that wouldn’t we, every case report author from the dawn of time has said the same…., but that’s not the point today.

Rather, as part of the writing process it is important to gain consent for publication. This is a routine requirement for any case report in the literature and here within the BMJ group you can visit the BMJ case reports website where the absolute and explicit requirement for patient consent is stated. The consent form is available in an impressive 13 languages so we obviously take this very seriously. Similarly there are explicit and clear(ish) instructions for authorship and contribution within the group as we clearly want those with their names at the top of the paper to have made a substantial and important contribution to the work. Authorship is defined differently to contributorship and it would be rare for patients to meet the following 4 criteria as lead out by ICMJE.

Screenshot 2014-05-02 07.06.39

Requirements for authorship.

I don’t think you need to be too clever to see where this is going. In a case report it is surely the patient who makes the most substantial contribution to the paper as without their involvement there is no case. Should we therefore offer patients the opportunity for acknowledgement on case reports?

Now you may argue that we need to protect patient confidentiality and that’s true so this could only ever function as an opt in rather than as an opt out, but should we at least offer the possibility of opting in? Those with paternalistic tendancies may argue that there are risks in patient identification. Coercion, willingness to please and the possibility that initial enthusiasm may subsequently turn in to a regret from sharing are clearly possible although the current trends in social media suggest that many patients share their injuries and illnesses in public forums already. My experience is that many patients are delighted to share their cases and some have expressed a wish to be acknowledged in publication, but as things currently stand it is unclear how to deliver this.

Patient involvement in publication is increasing. Examples exist such as the Patient Perspective series in journals such as the BMJ, but these are written contriubtions from patients with the time, talent and inclination to write. That is not typical of patients in case reports and in some cases it may not be possible for them to do so.

The ICMJE defines contributorship as non-authorship listing a number characteristics and ways of defining what constitutes authorship. Interestingly and perhaps disappointingly the contribution of the patient (the case of the case report) is missing. Examples include ‘caring for the patient’ but not ‘being the patient’ which I find a little strange and again somewhat paternalistic.

So, I ask the question of the readers, the editors and any patients who might be out there. If a patient wishes to be acknowledged as a contributor to the education of clinicians, should we make it happen, and if so how?

vb

S

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Gallows humour at the hanging committee

24 May, 14 | by scarley

Have you ever submitted to the EMJ or to any other journal for that matter? If so then you will know the fear and trepidation that results as you wait for the answer from the editor. Will your paper be accepted (hurrah) or rejected (boo). I’ve experienced much pain at the hands of editors and reviewers over the years and I’m doing my best not to give any pain back, but to be honest being part of an editorial team is not a popularity contest. A key part of our role is to decide what’s in and what’s out, and it will ever be thus.

The editorial decision process will vary from journal to journal but here at the EMJ all papers initially go to the editor in chief, and then are disseminated to handling editors who recruit and then manage the peer review process. Once complete the handling editors advise the editor in chief on their decisions and opinions. Ultimately the buck stops with the boss, but the handling editors clearly play a key role. That’s my position in this organisation and in the most part the acceptance/rejection decision is fairly straightforward after careful reading of the manuscript in conjunction with the reviewer comments.

However, it’s not always straightforward. There are many circumstances where it’s just really difficult to make a decision on whether to recommend publication. Here are some examples.

  • A survey paper tackles a highly controversial and politically charged subject but has a less than perfect response rate. The information will be popular, interesting and controversial. This paper will be widely read by your subscribers, may attract media interest and (hopefully) some social media activity, but it’s not great science. Would you publish it?
  • A randomised controlled trial of a new drug fabulon is submitted. It is highly effective in treating madeupitis disease in South East Somewhere. It’s a great trial, but as far as you are aware this disease would rarely be encountered by your readership. Great science, but poor applicability. Would you publish?
  • An observational study of sedation in the ED is submitted and 4 reviews are returned. 2 reviewers recommend acceptance without correction, the other 2 recommend instant rejection. Both recognise flaws but the reviewer judgements are so distant that you wonder if they read the same paper. Would you publish?

So what next? As an author you may experience a pause in proceedings. It’s quite likely that the editorial team have referred you to a special place. It’s not somewhere where we flip coins to decide who gets in, nor do we throw darts at manuscripts on the wall, nor throw papers down the stairs and publish the ones on the top steps (honestly all of these accusations have been made by the disgruntled). No. Flipping coins or other arbitary methods of choice are considered very bad practice in the editorial world. It would be highly unfair to the authors so there must be another way and it’s entirely possible that you may have experienced a referral to THE HANGING COMMITTEE!!!

wikimedia

wikimedia

When I was first referred to a hanging committee I was rather shocked as I imagined my work and toil being led to the gallows. Should it pass the committee it might receive a pardon and be passed on to production for publication. Should it be found wanting then it would be hanged there and then, despatched, killed and never seen again.

In truth my perception of the hanging committee was quite wrong, the origin of the term not being the gallows, but the rather more enticing, pleasant and appreciative world of art. I was surprised to learn that the hanging committee term originates from the art world where decisions are made on which paintings will be shown to the public. A judgement is made in committee on what to hang for public consumption and of course at this point it all makes sense. In publishing as in art there are judgements to be made on what to present and how it should be presented. The analogy fits and so the EMJ team meets to hang papers on a regular basis. The hanging committee sits not to sentence and murder, but to view, read, appreciate and try to select the best for the hard pressed pages of the journal.

So, if you get a referral to the hanging committee it’s not a death sentence and there may well be a reprieve. Hold tight and wait to see what the decision is, you might just catch the eye of the committee and find yourself hung rather than hanged.

Hanging Committee, Royal Academy, 1892 by Reginald Cleaver Wikimedia

Hanging Committee, Royal Academy, 1892 by Reginald Cleaver
Wikimedia

vb

 

S

@EMManchester

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An Unexpected Discussion; How to Close the Loop?

21 May, 14 | by rradecki

Screenshot 2014-05-21 17.44.47A few weeks ago, on one of my other digital knowledge translation projects, I wrote about an article published in the Emergency Medicine Journal: “Prehospital use of furosemide for the treatment of heart failure”. The content of the article – making an accurate diagnosis of dyspnea is difficult in the prehospital setting, and that many patients given furosemide prehospital failed to be ultimately diagnosed with heart failure – surprisingly resonated with an unexpected cohort of readers.

In fact, with over 4,000 views in just a few weeks, this post and subsequent discussion ranks among the most popular ever hosted on the site.

Yet, as hosted on the EMJ site, there are three “likes”, an Altmetric score of 30 based on mention in 37 tweets, and zero posted responses.

This article will certainly have some reach in print. But, as far as its digital life – the entire post-publication peer review and discussion is taking place entirely disjoint from the article. Visitors to the EMJ site have no indication of the critical appraisal, nor the discussion among physicians and paramedics, nor does it appear there is any mechanism through which the authors might alerted to these comments unless made happenstance aware.

This is a serious challenge and opportunity for those engaged in knowledge translation – how to transform scholarly publiciation from a static end-product, to truly just the beginning of discussion and discourse as part of a living body of evidence. How should traditional journals embrace and incorporate post-publication peer review and critical appraisal? What sort of editorial process ought be in place to moderate ongoing discussion?  How much difference does Open Access make?

The knowledge engines of medicine are changing. The newly minted digitally facile learner is consuming and connecting with experts and authors through online tools – Twitter, blogs, social media sites – in a way past generations were unable. As I’ve noted before, you can read at least 18 experts’ comments on Targeted Temperature Management – yet all these ideas live in their separate bubbles, with disconnected discussion, and disjoint from the digital home of the original publication.

What ideas do you have for tying all this knowledge together? How would you go about effecting change?  Should the independent bloggers band together to centralize their resources, or ought the journals take the lead on seeking out and collating the unsolicited post-publication peer review?

 

Ryan

Ryan Radecki

Are you a good EM educator?

5 May, 14 | by scarley

IMG_3422Should I even ask the question? Of course you are, you’re awesome just like the rest of us, but are you really?

Education is a cornerstone of our role as emergency physicians, be it patients, colleagues, juniors or specialities a day never goes by without some form of educational experience. Every day, every hour involves transmission of knowledge and or skills to those around us and I would argue that nearly everything we do involves teaching and learning. For anyone working in an academic institution with undergraduate or postgraduate students then it’s even more important.

So are you any good at it?

What if I were to ask about your abilities as a driver? Data suggests that the vast majority of you will rate yourself as above average (and presumably then rate the rest of us as below average). This illusory delusion suggests that most people will overestimate their positive qualities and underestimate their negative qualities across many aspects of their lives. I wonder if teaching in the ED suffers a similar effect? Presumably we all exist on a spectrum of abilities and some amongst us will be great educators others not so much, but how would you know?

Knowing where you are is not the same as simply defining the characteristics of good educators. That’s rather easy, looking back at yourself and seeing the positives and the flaws is much harder.

In preparation for a talk I gave recently I asked twitter and got some great replies. There were several themes about how you would know if you were good.

Intuition – you know it when you see it, a gestalt approach to knowing if something is good. I can understand this when observing others, but how would this work for oneself?

Sparks – many people were under the impression that our students possess intrinsic electrical activity as words such as energy, spark flash were used as a marker of something you may see in students as the learned and understood. Again, this is interesting, but hardly objective and there are reasons why staring into the eyes of students for feedback may turn nasty.

Outcome – one could argue that the best education results in positive patient outcomes and some tweets alluded to this suggesting that when we see patient care change and improve as a result of teaching that’s evidence of good teaching…, but is it? It’s evidence of learning, but that’s not a marker of whether you are a good educator.

Feedback – well feedback pervades medical education these days. End of lecture forms, or ‘happy sheets’ as I call them are a must have for portfolio and ego massaging as they inevitably score everyone as above average, or at least that’s my experience in reviewing them anyway. Routine feedback after individual sessions rarely delivers the depth required to improve nor allows teachers to benchmark themselves against others. Similarly departmental feedback as occurs in the UK through surveys such as the GMC trainee’s survey almost never delivers the fidelity to inform your personal practice. Obviously the positive comments will apply to you, but the negative comments must surely be to someone else in the department as you are…, of course…, above average at this sort of thing…., or are you?

The question remains and one might ask about the purpose of the question itself. Is ‘good’ an absolute? A measure that you reach a standard, or is it a relative measure that you are indeed above average? The former is easier to answer through standard feedback mechanisms, but the latter? I’m not so sure. For many of us the question is really rather difficult to answer and I ask you to consider it for yourself now.

and then?

It would be rude of me to ask the question with no hope of answer. I might suggest that in order to find out whether you are indeed a ‘good educator’ you need to expend some effort. By all means carry on and collect the happy sheets and national feedback scores, they are quick, easy and available, but also consider how you might learn more about yourself through one or all of the following.

  • Keep a reflective teaching diary
  • Ask an experienced educator to observe and peer review your teaching sessions.
  • Offer to peer review someone else’s session (this is often more helpful than being observed in my opinion)
  • Take part in a personal educational 360/MSF

Think about it and let me know how you’re getting on. I’d really like to know and to be honest I might join you, although to be honest I might not bother as I know I’m above average, just like you ;-)

 

Perhaps I should leave the final words to Martin Duffy, a UK anasesthetist.

I did think this was a tad ambitious…….

…but you can’t derail an optimist like Martin….

vb

S

Dengue in Fiji, lessons for home.

1 May, 14 | by rradecki

It was a Saturday night during festival season and we were the only Emergency Department in town. When I walked in we were completely full, with three-fourths of the patients waiting for a bed in the wards. There were only two nurses and two physicians. At 4 AM, the triage nurse left her post. With no one guarding the waiting room, checking vital signs, and explaining the process, we were bombarded.

The hospital and outlying health centers were full, and we were the final stop. Patients, each accompanied by at least three family members, stormed the ED hall, demanding to be seen. We were forced to use benches and makeshift wheelchairs to evaluate a range of complaints – an open boxers fracture, abdominal pain, febrile illness, chest pain, car accidents. This is an all too familiar scene, but this time it was different. The entire emergency department was already jam-packed with men and women, young and old, Indian and Fijian, each one in seemingly a different stage of an identical illness.

I have just returned from a global health elective in Fiji, where I worked as a physician in the Accident & Emergency (A&E) Department of the capital’s Colonial War Memorial (CWM) Hospital. My time there coincided with an unprecedented dengue outbreak, and the health care system was quickly overwhelmed. The situation required an improvised “Dengue Contingency Plan.”

Screen Shot 2014-04-30 at 17.58.51As critical saturation was reached at CWM, the physicians and hospital administrators were challenged with implementing a literature-based strategy to help direct management of dengue patients. Though there is no approved vaccine and treatment is largely supportive, organizations such as the W.H.O. and the Sri Lankan Ministry of Health have published guidelines on patient monitoring and admission criteria. A literature review revealed clinical predictors of poor outcomes. Nearly all of the patients we saw in the ED met admission criteria based on clinical status, lab values, and expected course. Keeping all of these patients in the hospital, however, would saturate the hospital’s ability to care for the ill and functionally shut it down. As is often the case back home, clinical guidelines cannot always be applied to individual patients. Policies adopted from foreign countries with their unique pathologies, resources, and practice patters may not adequately address local problems.

While the recent arc of global health has concentrated on non-communicable disease, emerging tropical diseases continue to surprise us back home. I imagine most of these diseases will be misdiagnosed in the early stages.

I work in a hospital with a large immigrant population near an international airport, where every headache could be neurocysticercosis, every pneumonia could be tuberculosis, and every biliary colic could be amoebic liver abscess. Last year alone, southern Texas saw dozens of confirmed dengue cases. I wonder how many of these were initially diagnosed with acute viral illness or aseptic meningitis after lumbar puncture. Identifying emerging threats requires a high index of suspicion, yet physicians may have filed away diseases learned in medical school as pathologies we never thought were going to happen in our backyard.

Dr. Sarah Dendy is an Emergency Medicine trainee writing about her work in Fiji with the University of Texas Medical School at Houston Department of Emergency Medicine Global Health Program.

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Saying I’m sorry. Iain Beardsell for EMJ

26 Apr, 14 | by ibeardsell

Screenshot 2014-04-26 13.42.08Like many of you, I suspect, many of my most “educational” experiences haven’t come from sitting in lectures, reading textbooks or even listening to podcasts. They have come simply from living life and all of the ups and downs that can be thrown at you. From witnessing the birth of your children, to a close family member, 0r yourself, being unwell, these events shape who we are as people and how we react in certain situations, whether at home or when working in the Emergency Department.

Much of our training is based on doing all we can to save lives. To investigate potential life threatening diagnoses, and then do all we can to treat these when we find them. Medical technology has advanced so far that we often persist in our aim to achieve this, regardless of the costs involved both to the healthcare system and the patient themselves. Online education is awash we adrenalized procedures, such as the advent of “extracorporeal cardiopulmonary resuscitation”, that would’ve only a few years ago been unheard of and high profile speakers at conferences talk of how we must do all we can to save life, going that one step further, pushing the boundaries. That we must be heroes.

Yet in amongst all of this emergency medicine erotica, one bare fact faces us all. That one day we, and those we care about, will die. If we are lucky this will be a planned, peaceful death, with our loved ones around us, after fulfilling all of our potential and saying our eternal goodbyes. The deaths that we intimately observe in the ED, however, aren’t like this. They are sudden, sometimes violent and often unexpected. We stand at the periphery, unable to explain why someone’s father, mother, brother, or child has died. Families look to us to help, but there is little we can do to lessen their grief. We try to find the words, with a simple “I’m sorry” often being the best we can muster, before leaving them and moving on to our next patient.

My father died ten years ago. He was a “good age” and a lifelong smoker, so it wasn’t really a surprise when I received the call in the middle of the night in Australia to say my mother had found him dead in his favourite chair, early on a Sunday morning, a final cigarette burnt out on the ashtray delicately balanced beside him. I’d had a feeling something like that could happen, I’d even tried to prepare myself, but what happened over the next days, weeks and years shaped me as a doctor more than any other educational experience I’d had before or since. Every time I “break bad news” (a curious phrase we use to mean “change people’s lives forever”) I remember those times. The sleepless night, followed by the dash to the airport to try to get home, the longest plane flight I’ve ever taken, the funeral arrangements, singing his favourite hymn “Dear Lord and Father of Mankind” at the service, clearing his cupboards, the endless paperwork and calls to solicitors. And telling my brother.

NW-amboMy mother doesn’t remember much about that wintery weekend morning, except one thing the call handler said to her when she called 999. After giving his name and address they asked her several “clinical” details, presumably to ascertain the urgency of the call. She vividly remembers being asked “Is he stiff?” and, being of a certain generation, obediently following the request to lift his arm to find out. I don’t ask her about it now, but I know that moment still haunts her.

This very personal experience taught me many things. That the grief, and sheer organisational burden, for families goes on long after we have left that small room and more than anything that what we say really does matter. That many of us won’t be afforded the luxury of a “good death” and as the clinicians we must do all we can to lessen the emotional distress for the families and friends left behind. These patients aren’t the focus of a government enforced target, but if forced to choose between spending an extra few minutes with a dying patient or a grieving relative or preventing a “breach” on majors, I know where I’ll be.

I love my job: trauma calls; high tech resuscitation; diagnostic challenges and the high five from a cheery child, but the time when I feel like I am truly helping isn’t when I save lives, but when I do everything I can to ease the pain of an inevitable or unexpected death. The simple things like holding a relative’s hand or making sure a patient is on a proper bed and painfree (I have a deep seated belief that no one should ever, if at all possible, die on a trolley). Giving families time together and offering whatever support we can.

I know it doesn’t always feel like it, on a busy shift with staff shortages, too many patients, no in patient hospital beds and fighting metaphorical fires at every turn, but doing our job is a privilege. We can take away people’s pain and cure illness, but more than that when the time does come that we can do no more, we can do so much more. We can, and must, be kind ; surely there is no more valuable attribute in anyone who works in an ED. And that when we say “I’m sorry” we couldn’t mean it more.

vb

Iain Beardsell

@docib

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How Are We Accelerating Knowledge Translation?

21 Apr, 14 | by rradecki

In contemporary medicine, the first exposure to new evidence comes first in abstracts and conference presentations, filters through peer-review into journal publication, and, finally, into textbooks. Then, the process of translating knowledge into practice change takes place, slowly percolating into the current physician base through guidelines and expert recommendation, followed by trainees indoctrinated into the latest evidence during graduate medical education. Efforts to speed this process have improved markedly in the decades since the advent of the internet, but remains an ongoing challenge.

However, the rise over the past few years of prominent FOAM resources is leading to a revolution in this process, resulting in sea change to traditional means of dissemination and scholarship. A fantastic recent example can be found in a recent post on Academic Life in Emergency Medicine. As part of a recurring Global Journal Club series, the moderator Brent Thoma compiled a list of prior FOAM discussion of a recent publication regarding therapeutic hypothermia.

Within a handful of days of publication, no fewer than 18 experts in emergency medicine and resuscitation had provided commentary, whether through blog posts or podcasts. A sampling:

All this expert commentary is disseminated freely through the internet – and these experts are universally available through their blogs for further critique, discussion, and debate.

This is accelerated knowledge translation. No more waiting for professional societies and committees to process & regurgitate – nor must authors’ conclusions be taken at face value. Any healthcare worker willing to put the effort into keeping up to date has any number of excellent resources from which to draw. All of this expert commentary is, however, essentially, opinion. The peer-review and vetting process is crowdsourced and not evenly applied to all content – and may be non-existent. The reliability of each contributor is left to the individual read to discern, with few resources available to validate.

Regardless, it’s a leap forward in how practice change is influenced – and one we can all participate in, globally.

Latest from Emergency Medicine Journal

Latest from EMJ