Letter From America #3

Essentials kicked off for real today, and it did so with a bang.

The bang was provided by the force of nature otherwise known as William “Billy” Mallon, M.D. perhaps the most natural candidate for F.UCEM status alive today. His keynote consisted of a few trademark rants…

Lamentation on the ‘teaching to the tort‘ approach that seems to dominate residency teaching in the US. The very notion of teaching medicine in a way that is centered on keeping lawyers happy seems abhorrent to me. The main focus of medical education should be on keeping doctors and patients happy, not our damnable brethren in the court-room. To my eyes the medicolegal climate in the US looks frankly oppressive — I’m glad this particular climate crisis is not (yet) my problem.

Billy also decried the ‘medicinification‘ of emergency medicine. He claims that our specialty is becoming dominated by a physician mindset and is losing it’s surgical roots. According to Billy, This is not a good thing as emergency medicine is primarily about action, not being a ‘geek‘. I disagree with him a little on this – I prefer to think of us as  ‘action geeks‘ as it is our particular cognitive skills that define us… Nevertheless I do suspect that modern trainees know less about anatomy, procedures and core surgical skills than our predecessors.This is a shame.

Finally, It was great meet the BIG man in person briefly — he is truly larger than life — and I may look to test his hypothesis about altitude sickness contributing in part to jet lag in the very near future…

A large portion of today’s talks were on critical care in the ED — staple stuff for a dual ED/ICU trainee like myself, though perhaps not everyone’s cup of tea. The debate about etomidate raged on — bottom line is adrenal suppression is real, though of uncertain clinical significance. Again this particular furore seems like a teacup storm to doctors in Australia — as we dont have access to the drug, and I don’t think we miss it either. After all, ketamine is called special K for a reason. Other topics included the emerging roles of dexmedetomidine for ER sedation; why VBG means an ABG is not needed (that old chestnut), and how to improve oxygenation in acute lung injury.

Scott Weingart MD presents at USC Essentials

Scott Weingart MD presents at USC Essentials

There was also a great talk by Michael Winters, M.D. of EM:RAP Critical Care fame on extubation in the ED — it’s well worth hunting down some of his previous talks on EM:RAP, his talk on the post-tracheostomy bleed will scare the crap out of you. It was also good to see a fair amount of skepticism about tranexamic acid in trauma and the crash-2 trial, though I think we’ll hear lots more about drug. Jeff Tabas’s point that we’d all be using tranexamic acid if it was an expensive drug backed by Big Pharma is a chilling indictment on what modern medicine has become.

LITFL takes center stage...sort of

LITFL (t-shirt) takes center stage...sort of

Away from the lecture hall, Egerton Y Davis IV was on hand to induct even more Fellows to the Utopian College (F.UCEM). The new inductees include:

Egerton had a great time meeting all these fucems. Today Egerton is on the look out for some Aussies… You have been warned.

Finally congratulations to Big Jim on winning the USC iPad…

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  1. Jim Cooper says

    The “medicinifation” of EM is real and must be resisted.It is in the patients interest to have a not yet diagnosible condition that needs admission for observation. To spoon feed the med/surg admission stream in the buffed rather than unbuffed stream stops thought. The diagnosis of x ? cause is in the patients interest.

      • Jarrad Hall says

        It ties in with so many social ills and underlying human psychology. Increasingly people are looking for unsupported certainty, over reasonable uncertainty. Dangerously, leading them to quacks who’ll feed off that emotional need to know (no matter how wrong their “knowing” is).

        Further, administrators always think things can be done faster usually factoring out the set of vital core steps central to the proper conduct of any profession. Add to that the economic maximisation of assets argument (where 100% usage to them means you’re not wasting any unnecessary resources) and we know where medicine has gone wrong… the people who are responsible for policy have no idea of anything other than management or legalities. Essentially, trying to run hospitals closer to 100% capacity to prevent “waste”, rather than viewing the hospital as a public asset acting as a form of medical insurance against unforeseen emergencies for which we need extra capacity. Rather than tackle the problem with correct procedures, set quotas and rush people through, almost the fast food approach to medicine. Diagnosis ready made speed it up, high throughput, decreased time of asset utilisation on any individual. Dangerous precedent.

    • says

      As one of the ameritus fondling members of the College and now a fully fledged Fellow of the UCEM we appreciate your enthusiasm for the cause. We look forward to more erudite and learned proclamations at a later date…I trust you are sporting the official Fellows T-gown