Guest blog: Dr Charles Murphy

A guest blog this week from a wise and reflective soul in California. Dr Charles Murphy reflects on change, belief and progress in medicine following the publication of the ProCESS trial in the New England Journal of Medicine. The trial itself is open access and well worth a read. You can find it here, then read on and reflect with Charles.

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Editor,

The ProCESS study [1] brings to mind the observation by Sir William Osler that (to paraphrase) one should use a new therapy as often a s possible while it still works. I have used Swan Ganz catheters, aminophylline, bretyllium, MAST trousers, nasal intubation, ipecac and neonatal suction bulbs while they worked and abandoned them when they no longer worked. I told parents to put children on their stomachs so they wouldn’t aspirate and later to put them on their backs so they wouldn’t suffocate. I breathed for patients during basic CPR and now wouldn’t because they do better without respiratory support. In asthma, I have used magnesium because it worked. I stopped using it because it no longer worked and now occasionally use it because it now sometimes works. I still use sorbitol even though it never has worked because too many people believe it works. I smile benignly at all those who regard orthostatic vital signs as highly useful and, with apologies to Robert Knopp who demonstrated their frequent misuse [2], say nothing because there are too many “true believers.” I complied with the 4-hour pneumonia guidelines while they worked. I am complying with the sepsis guidelines while they still work? The biggest improvement in patient care in the ED in my 32 years on the UCSF emergency medicine faculty has been the low-tech addition of the Discharge Coordinator in our ED to help patients arrange follow-up. The Lancet chose the development of the oral rehydrating solution for children as the single most important medical therapy of the 20 century with an estimated 40 million lives saved. [3] In Medicine, skepticism and humility will always work.

1. The ProCESS investigators. A randomized trial of protocol-based care for early septic shock. 2014, New Eng J Med, March 18.

2. Knopp R, Claypool R, Leonardi D. Use of the Tilt Test in Measuring Acute Blood Loss. Ann Emerg Med 9:72-75.

3. Editorial. “Water with sugar and salt”. Lancet 2, August 5, 1978, pp. 300–301.

Life Behind the Scenes. Life as a TV medical advisor with Iain Beardsell.

Casualty logoLike many of life’s opportunities it all started by accident.  I was having a corridor conversation with a past CEM President, John Heyworth, who was relating his previous day’s activities – “I had a meeting with the Academy of Royal Colleges, caught a bit of the Lords’ Test and then met a researcher from Casualty”. We chatted a bit about the medical politics and England’s batting order and as we finished up to head to the shopfloor,  I tried to subtly ask about the BBC meeting (JH is one of the coolest people I’ve met and I didn’t really want to seem too starstruck – after all it’s telly. And I really love telly). He gave me the email address of one of their researchers and there began my relationship with Saturday evening medical drama.

Casualty is the longest running emergency medical drama on television and is broadcast every Saturday night in the UK with only the occasional break for special events and a summer break. It regularly has over five million viewers, or put another way is watched by 1 in 10 people in the UK. (Those of you who haven’t seen the show can watch a highlights reel from the most recent series here)

My role on the show is as a “Medical Advisor”. This isn’t, as it turns out, in anyway glamorous and only rarely involves trips to the studio in Cardiff, but is a mainly telephone and email based job. I work with the writer to try to help them add medical stories into their story arcs. The show works to a strict, tried and tested, formula, usually two “guest” storyline with some ongoing background serial for the regular characters. Stunts are a major feature and so major trauma represents a disproportionate number of cases (it’s hard to make ankle sprains dramatic, although we have tried). The process begins with “commissioning”, where a writer presents their ideas and is engaged to work on a particular episode. My involvement usually begins after this, with a series of telephone calls and emails trying to sort out the medicine for each character. Many of the writers will have ideas about this, but occasionally there is a need to try to “retrofit” a suitable diagnosis into the drama and may involve trying to find suitable responses to an, entirely genuine, email like this one.

“What I’m looking for dramatically is something like this:

His vital signs have crashed. There is massive internal trauma from the car crash. What do they do to try to save him?

They try one thing. It doesn’t work.

They try something else. It doesn’t work.

They try something else. It appears to work – and then it doesn’t.

They try shocking him. It doesn’t work.

They try chest decompressions. They don’t work.

The team is Zoe, Sam, Tess, Fletch, Linda, Charlie. What do they each do and say during this resus attempt?

I just want it to be exciting and dramatic with the patient dying in the end.“

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The early days

 

Each episode has five “Acts” with one of the key features being the “Act 4 Crisis”. This is probably the most tricky part – trying to find something medically that can happen about half way through an episode that puts the patient in danger, makes the team look heroic, yet often requiring the character to not only survive, but to have their moment of redemption before the credits role. There is a constant battle to find scenarios where the patient is not intubated, as this lessens even the best actor’s ability to communicate, and those with severe injuries cannot rush off to theatre as all the action needs to happen in the ED.

Each script goes through five drafts before a “Shooting Script” can be issued. Medical Advisors read all but one of these and we make notes trying to keep the medicine on the right track, occasionally suggesting medical dialogue. All of this is done in close collaboration with Pete Salt – the show’s long term nursing advisor who has been involved since the very beginning and was the original inspiration for the iconic character that is Charlie and has experienced every twist and turn that the process can throw up. The whole writing process takes approximately three months and there is then often a long gap before broadcast, so discussions about Christmas storylines often start in the heat of summer.

Once the final script has been issued that is usually the end of my involvement in any particular episode and it is the then in the hands of the director, editor and actors. Despite the script being polished and checked what you see on the telly can sometimes, frustratingly, be different to the written word. There are advisors on set, often ED nurses who live locally, who try to ensure medical accuracy, but, with so many episodes to make, in the rush to get it shot, mistakes do slip through, although many of these would not be spotted by the “lay” viewer.

I enjoy my work with the show greatly. It has allowed me to glimpse into the strange and mysterious world of television, and provides a balance to the sometimes unrelenting real life pressure of the ED. I know that many of my colleagues, both in the ED and outside, scoff at the programme (often not having seen it for years), but I take my involvement incredibly seriously. I am a vocal advocate for Emergency Medicine and everything it has to offer both as a career and a service to our patients. I still struggle to fathom the numbers who watch and do believe that if we get it right, it can have important messages about the specialty and what it is that we do. One of my proudest recent achievements is the team winning a “Mind in Media” award for an episode that discussed anorexia and the complicated issue of capacity and consent in mental illness. Yes, in the real world there are fewer thoracotomies, cars hanging off bridges, explosions and hostage situations, but I hope that in amongst the drama (and after all at its heart that is what the programme is all about) it gives a honest portrayal of what it is we all do.

Iain Beardsell

Consultant in Emergency Medicine

Associate Social Media editor EMJ

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Choosing Well vs. Choosing Wisely

In the United Kingdom, the NHS and Manchester publish “Choose Well” – a guide for patients in need, to help them find the healthcare resources correct for them.  The resources described include self-care, local general practitioner services, and advice regarding when to choose Urgent Care or Accident & Emergency services.  In a system where resources are Screenshot 2014-03-10 18.19.29understood to be finite, in order for all to have access to a reasonable level of healthcare, this is a prudent consumer-oriented approach.

The United States has a similarly-named system of choice – “Choosing Wisely”.  Published by the American Board of Internal Medicine Foundation, this initiative also focuses on making choices in healthcare.  However, rather than focusing primarily on helping patients make better choices, the true target of this initiative is an entirely different problem beguiling U.S. healthcare:  physicians behaving badly.  Screenshot 2014-03-10 18.19.49These initial lists, containing 5 or more items each, describe diagnostic tests and treatment modalities that ought to be re-examined – essentially, low-value candidates for expensive, harmful overuse that go further towards fattening physician and executive wallets, while providing uncertain patient-oriented benefit.

For Emergency Medicine in the U.S., the published list is prudent medicine – but hardly reflects the most costly & wasteful utilization of resources.  Several prominent academics and educators have critiqued this list informally, while others have systematically attempted to derive their own.  The important independent recommendations range from decreasing CT utilization, to mitigating over testing of low-risk chest pain, to avoiding costly hemostatic medications without clear indications.

Regardless, the point of distinction is clear – Choosing Well vs. Choosing Wisely.  Patients ought to be expected to benefit from educational programs to help improve their decision-making.  Physicians ought to be making high-value decisions every day – and we should be embarrassed our choices are so poor at baseline that an initiative such as Choosing Wisely even exists.

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Ryan Radecki

@emlitofnote

Ryan Radecki

From Over The Horizon

heyworth.f1_defaultJohn Heyworth, former President of the College of Emergency Medicine, provides his perspective looking back at a career in Emergency Medicine.

Herewith summary reflections from the further end of the career spectrum.  I left my post as a Consultant in Emergency Medicine in Southampton (UK) 18 months or so ago to enter my career “next phase” and absolutely clear that this is not retirement, a concept far too senior and implication laden.  In this capacity I diverted from my GP friends who have embraced retirement fully, committing themselves commendably to even more bridge, tennis and travel.  I also joined a number of my peers from Emergency Medicine who, as befits the EM personality trait, remain restless and jolly active with a range of medical interests, often including some continuing part time ED work.  The key difference in all our lives is that we now have control over our diaries (mostly) and we sign up for activities largely voluntarily.  A good place to be.  I have no idea when the basic physiological need of any EM doc to be busy changes, but not just yet.

So what are the key learning points from a career in Emergency Medicine?  First of all my evidence base is categorically certain that Emergency Medicine is THE most important specialty in Medicine.  We know that the public (22 million patients a year in England alone can’t all be wrong) and gradually those in power of influence around us are having individual and collective damascene moments.  It is undoubtedly tough, physically and emotionally draining, but no other specialty offers the fulfillment, satisfaction, and reward that Emergency Medicine provides every single day. Choosing EM was a good idea at the time  and, unusually for that portfolio, remains so on completion.

Obviously there are daily challenges.  The four hour standard (love it or loath it but without some time related incentive Emergency Departments would rapidly regress to the warehousing of patients for several days function which was extant in the early 00’s) can be hassly ++, and yes I know that some docs from other specialties aren’t always fully appreciative of the quality of our referrals as they should be, and we are constantly provided with advice by those in positions of power or influence who may not have been in an Emergency Department either at all or this century……but it’s worth it and time after time we are shown to be right.

The public – our patients and their relatives – put their wellbeing in our hands at their time of greatest need.  This trust and confidence puts us in a position of immense privilege and responsibility.  It also allows us the opportunity to do great good on a spectacularly frequent basis.  Every single shift – no matter what incoming hassle there may be – provides the opportunity to do something fabulous for patients in our care.  This may not be chest unzipping heroics every day, and may be significantly below the general radar, but it happens consistently throughout our career.  Compare and contrast with most other specialties (conflict of interest and bias declared).

When the ED is completely heaving and you are bombarded, it is tempting to believe that the grass may be greener elsewhere.  My lifetime experience is that this may be true from a distance but closer inspection often reveals muddy brown bits.  The simple fact is that Emergency Medicine in ingrained in our DNA and soul; resistance is futile.  Having said that, it is essential to work hard to develop one’s career and diversify; a portfolio of activities continues to make it even more interesting and fun throughout your career.  Emergency Medicine is a particularly suitable specialty to allow such variety and have a truly organic career.

Would I do it all again? Indubitably!  Having left the ED, there are a number of things which I miss (not in order); patients (who would have thought it?); the ED team (obviously); the Emergency Medicine family (we have a unique common bond); cake (and more cake). Have fun!

 

John Heyworth,

Former President of the College of Emergency Medicine

Spotlight Interview: DevelopingEM

image007Today, we virtually interview Lee Fineberg and Mark Newcombe, the hearts and brains behind DevelopingEM.  They are emergency physicians who have returned from Havana, Cuba, after the second edition of their conference concept providing resources and support to medical education in the developing world.

Tell us a little bit about visiting Cuba, a place that’s traditionally been closed off to many in the Western world.

Mark: Cuba is an absolutely fascinating country. A combination of Madrid and Moscow in the middle of the Caribbean.
Crumbling colonial buildings, 1950s American cars, revolutionary murals, rum and cigars, with an integrated multicultural population which makes Cuba an incredibly romantic place to visit.

Lee: Yes its certainly an amazing place. Scenically incredible as Mark says but also culturally impressive. With a rich history and a revolutionary ideology that continues to infuse through peoples’ values, it is a welcoming, fair and safe place for visitors. We were both certainly made to feel welcome by both medical and non medical Cubanos.

What challenges did you witness in the delivery of medical care in Cuba?

Mark: As you probably know Cuba has a healthcare system that provides its citizens with healthcare indices equivalent to the United States. This healthcare is free for all Cubanos and is achieved despite a 50 year old economic embargo that prevents delivery of advanced pharmaceuticals and medical devices to Cuba.  We have called upon President Obama in an open letter to end this embargo, an immoral policy whose stated goal is to “bring about hunger, desperation and the overthrow of government”.

 

Jerry Hoffman in 2013

Jerry Hoffman in 2013

Lee: Yes, Cuba despite having limited economic resources has made health care a priority and as Mark has said despite spending 1/25 the spending per capita of the USA on health Cuba has approximately the same figues regarding overall life expectancy, as well as infant and maternal mortality. Cuba also has an impressive and largely unheralded program of international medical education, through the Latin American School Of Medicine (ELAM), and international medical aid. ELAM has been described as the largest medical school in the world with approximately 15,000 students from 50 countries. Cuba’s medical internationalism currently also sees 20,000 doctors working in multiple countries around the world.

Mark: So whilst there are challenges Cuba has an impressive national and international healthcare system that has many lessons for our own systems.

How is emergency care supported – or neglected – in their healthcare system?

Lee: Cuba has a different model of critical care delivery than the Anglo-American model we are used to. The core of the health care system in Cuba has revolved around the community based polyclinic with more advanced investigation and management occurring in specialty based hospitals. Critical care has been delivered primarily from an intensive care setting.Final Logo-01

Mark: Yes emergency departments have increasingly become integrated into both the polyclinic and hospital setting with the realization that unwell patients can present to either setting. The bulk of critical care continues however to be centred in the intensive care. Whilst a different system it works well within the Cuban setting.

Many folks may not have heard enough about DevelopingEM. In a nutshell, what’s your core mission?

Lee: DevelopingEM is a new direction in medical education, combining cutting edge training in critical care medicine, with a focus on providing a meaningful contribution to medical professionals in developing regions through an inclusive and philanthropic approach.

Mark: We’re a not-for-profit conference organising agency specialising in providing a practical clinical approach to the delivery of emergency medicine and critical care education to senior practitioners in the fields of emergency medicine, intensive and critical care medicine, anaesthetics, and prehospital and retrieval medicine.

 

Lee Fineberg

Lee Fineberg

Lee: With short sharp, polished presentations focusing on evidence based best practice we hope to provide a clinically relevant educational experience aimed at the senior critical care practitioner.

Mark: Yes in fact this year we’re looking at 20 minute, 20 slide presentations, more audience participation, panel discussions and demonstrative scenarios.

Lee: As with the past two conferences in Sydney and Havana the core topics will include adult critical care medicine, pediatric critical care medicine, and trauma medicine, with optional sessions covering the Brazilian experience of emergency medicine, global health and emergency medicine, prehospital medicine and ultrasonography.

Mark: As well as the education provided during the conference we also aim to follow up on our efforts in Cuba and the Caribbean by hosting satellite workshops in the region and also donating computer workstations preloaded with FOAMed resources to centres in the region

Lee: Yes in 2013 we hosted an ultrasound course in St Lucia performed by the Ultrasound Podcast guys, and also an ATLS course in the Bahamas.

Mark: And we provided 4 Mac mini based computer workstations for health centres in the region. These were preloaded with EM courses and resources. We’re hoping to repeat the effort in Brazil.

Lee: As Mark mentioned earlier central to the philosophy of our concept is the not for profit model. We have avoided industry sponsorship in order to prevent content conflict of interest.

Mark: Yes conference registration fees and donations alone will be used to fund the ongoing costs of the annual conference and utilised to subsidise the attendance of regional delegates, the establishment of future conferences, and ongoing continuing education projects.

Lee: This model has been a successful financial model for the last two conferences with costs covered and enough credit to cover start up costs of the subsequent conference.

Mark: Our annual conference this year will be held in Salvador da Bahia, Brazil between September 8th and 12th and as with our model in Cuba, DevelopingEM is forging ties with local Brazilian critical care specialists and organizations in order to secure Brazilian involvement in both attending and presenting at the conference.

Lee: As well as Central America and the Caribbean, and South America, DevelopingEM hopes to take its educational concept to Sub Saharan Africa and South East Asia. Possible conference settings to follow Salvador include Gaborone in Botswana and Siem Reap in Cambodia.

What inspired you to initiate this program?

Lee: Primarily the inspiration grew from a desire for us to share in the experiences of our colleagues working in under resourced regions around the globe.

Mark: Yes we’ve met some truly inspiring people doing incredible work around the world. Unfortunately they often have a very limited ability to attend international meetings and interact with multi national

Joe Lex in 2013

Joe Lex in 2013

critical care colleagues.

Lee: So I guess within a conference format we hoped to introduce our delegates and faculty to amazing clinicians from developing regions so that we can learn from each other.

Mark: And I think in Cuba we really were able to achieve this goal, and hopefully we’ll be able to repeat the process in Brazil.

How can interested folks support the initiative or become involved?

Mark: Registrations are the key for DevelopingEM. Without our delegates the whole concept doesn’t work. So we’d encourage everyone to take a look at the evolving program on our website and if it appeals join us in Salvador.

Lee: They can find us online, on Facebook, on Twitter, and on Instagram and spread the word to their colleagues. Not only will we be advertising the conference through these sources but also hosting an educational blog based around the presentations from Havana.

Mark: Even if your readers can’t make it to Brazil there will be options for virtual registration and delegate sponsorship to allow anyone to contribute.

 

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Ryan Radecki

@emlitofnote

Ryan Radecki

Ryan Radecki

 

Lauren Waterman on the value of an ED doctor.

Social media allows the journal to communicate with our readership in a way that is more rapid than in print, or even on our online first pages. A good example is a letter received this week. Lauren Waterman asks us what the true value of an EM consultation is following suggestions that patients should be charged for their attendance.

We think the best way to answer this is to share with the readership and to ask for your comments via twitter using our twitter address @EmergencyMedBMJ

So, read on and tell us what you think.

 

Simon Carley

Social media editor EMJ

 

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So, Doctor, was I worth £10?

Dear Editor,

I am writing this letter in response to the recent survey which showed a third of general practitioners to support patient fees for ‘unnecessary’ A&E visits1. The idea is that patients would be charged £5-£10 and this refunded if doctors deemed the visit appropriate. I propose three key reasons why this charge would be impractical, unethical and dangerous.

Firstly, A&E doctors would have to get into discussions with patients as to why their payment cannot be refunded. These discussions will be awkward for the doctors to have, impact upon the doctor-patient relationship and also take up the doctors’ time, where resources are what we are trying to save in the first place.

Secondly, it stops the NHS being ‘free at the point of care’ which is a fundamental feature of its constitution. This may defer certain lower-economic patient groups (those groups that may have less education about heath and illness in the first place) from presenting to A&E when something may actually be wrong.

photoThirdly, when a patient presents to A&E they do not wait in a busy waiting room for fun! They believe that something needs urgent medical attention. This intervention would not educate patients, as it is unlikely that doctors would have time to fully explain why a patient’s visit was justified or not. There would be discrepancy between different doctors in what they believe to be a ‘legitimate visit’, with some willing to refund for certain presentations that others believe to be ‘not warranting a visit’. This would confuse patients further and not help them to make ‘better decisions’ the next time.

To conclude, although vast costs are incurred by patients that attend A&E without requiring urgent treatment2, charging patients is not the answer. Patients who are without extensive medical knowledge are not trained to know when symptoms signify something sinister. However, perhaps further educational intervention that teaches the public more about the different options available to them would help to direct them to the right place.

Yours sincerely,

Lauren Waterman

 

 

References

 

  1. 1.       ‘Third of GPs back charging £10 to keep timewasters away from A&E units.’ http://www.independent.co.uk/life-style/health-and-families/health-news/charge-10-to-keep-timewasters-away-from-ae-units-say-gps-9035741.html
  2. 2.       ‘A&E timewasters cost NHS £27m’. http://www.express.co.uk/news/uk/208944/A-E-time-wasters-cost-NHS-27m