Lessons from Camels. EMJ Blog.

EMJ Blog

Life long learning and developing is vital for the good ED practitioner,  treatments change, pathologies change and even opinions change over months and years, and we on the front line must continually adapt and change with them.

To highlight the importance of this I would like to tell you a story. It is a story about a camel.

In 2006 palaeontologist Natalia Rybczynski was tramping through the artic wastes in the far North of Canada (as you do) as she came across some unusual grey rocks. Now personally I would have stubbed my toe on these rocks, cursed and wandered off in search of a hot chocolate, but being a shrewd and observant palaeontologist Natalia saw that these were fossils of a type she had not encountered before. She collected these, and returned over the next few years, managing to find around 30 fragments of what appeared to be a fossilised tibia(1).

Subsequent super clever collagen fingerprinting techniques revealed that these remains amazingly were from a hitherto undiscovered giant camel. Now this raised some interesting questions.  Camels are sublimely adapted to the hot and dry desserts, with their large spoon-like feet for walking on sand, and large fat filled hump meaning they can survive for longer without food. The function of having all your fat reserve in a single hump also means that you can do without the surrounding layer of adipose tissue, allowing these animals to dissipate heat easily in their hot climates.

So how could these hot weather specialists have survived in the arctic, where temperatures often plummet deep into the negative figures. (I promise I am getting to the medicine!)

To get the answer we need to re-examine what we think we know about camel’s adaptations, and take them out of the context we always find them in (the desert). For example, those wide flat feet could easily be adapted to snow, as well as sand, in fact it is likely they initial evolved to walk in soft snow and then subsequently were found to be of an advantage in the desert sands. That hump with the fat reserves would be vital when trying to survive in a place were for 6 months of the year there is darkness and nothing grows.

We have thought of camels as hot weather beasts for hundreds of years, and then all of a sudden someone finds a few lumps of rock in the arctic that causes us to completely reconsider what we think we know, and to have to think in new ways to explain things we thought we had sorted.

The recent example from the field of medicine is the FEAST trial (2) We have believed for many years that fluids were the mainstay in the treatment of severe sepsis and septic shock, and then someone comes along with a brilliant study that casts doubt on this assumption and causes us to have to rethink what we thought we knew. The FEAST trial shows us that we do not understand pathophysiology of septic shock as well as we think we do. As good clinicians we should accept this and try to explain the apparent paradoxical findings. The authors to their credit, offer the explanation that fluid boluses may cause damage through reperfusion injury, effecting pulmonary compliance or myocardial function. The FISH (Fluid In SHock) trial is currently running in hospitals across the UK to follow-up FEAST and see if we should be changing our practice.

As clinicians we have a duty to continually question what we think we know, and to search for better and more efficient ways of treating our patients. The doctor who clings to dogma and does things a certain way, because they have always been done that way is doing his patients a disservice and indeed could be putting them in harms way.

We will never know everything, and what we believe we know now will change over the course of our careers and even our lives, so I would urge everyone to learn the lessons of the giant camels, and never stop questioning what we think we know, to enable us to always do the best possible for our patients.

Thanks
Chris Arrowsmith

ST4 Emergency Medicine
Current Paediatric Intensive Care and Acute Retrieval Clinical Fellow, Bristol

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References

1. Rybczynski N, et al. 2013. Mid-Pliocene warm-period depostis in the High Arctic yield insight into camel evolution. Nature Communications, 4:1550

2. Maitland K, et al and the FEAST Trial Group. Mortality after Fluid Bolus in African Children with Severe Infection. N Engl J Med. 2011 May 26.