Rory Spiegel

Dispatches from the Free Open Access Meducation frontier

No doubt, this section seems a strange one to find in a medical journal. We assure you that it is stranger than you think! Let us begin with a brief explanation. By now you have hopefully either discovered FOAM (Free Open Access Med(ical ed)ucation) for yourself, or perhaps encountered a recent article on the subject in Emergency Medicine Australasia. FOAM is a relatively new movement of slightly odd collaborators sharing knowledge via blogs, podcasts and other social media with an unbridled passion and enthusiasm. What will it amount to? Only time will tell, but imagine that FOAM, or something quite like it, actually becomes the norm. Imagine that some seemingly ephemeral FOAM creations actually change the world. Imagine that our successors cannot even imagine what things were like before FOAM. Finally, imagine that we had a window in time that allowed us to read an emergency medicine journal of the future. . . Great! You can do all of that. Now, strap yourselves in, because this ride is about to get a little crazy. . .

The uncertainty of truth

We live in a world where uncertainty has been eliminated. The publication of the Doctrine of Certitude meant that uncertainty was officially forbidden for the first time in history. The passage of this law rendered the phrases ‘I don’t know’, ‘I’m not sure’ and even ‘Huh . . .’ illegal and punishable by life imprisonment. Neoastrophysicists, using chaos theory, have modelled intergalactic maps that predict even the smallest particle of space dust’s coordinates within a half millimeter of its actual location. Cosmometeorologists have derived atmospheric models that predict a planet’s weather patterns with a five-sigma level of confidence. Even in the field of medicine, the uncertainty we once operated under has all but vanished. The latest validation from the Framingham group can predict your death within a month of your passing. And yet the human race cannot help but spit in the face of this certainty. Let us use Mr Wigan as a case in point. He was given a certified Framingham score of 689.27. Simply put, Mr Wigan’s death had been verified with 99.99999% accuracy to occur at the age of 68 years from the restrictive lung disease known as astropneumoconiosis (or as the miners on Gamma colony jovially call it ‘kettle lung’). His predicted lifespan was actually 5 years beyond the average life expectancy of a standard Gamma Colonist (whose main occupation is the mining of the colony’s one natural resource Detroleum). Mr Wigan was aware of this certified, validated destiny and wanted nothing to do with it. As he lay in front of me on our trauma bay’s hover stretcher, Mr Wigan was trying incredibly hard to die 41 years before his scheduled date. My name is REDACTED. Before the occurrence of the following events, I worked as an emergency physician on the 12th Spoke’s most distant medical hub. We are the only Trauma Center for 100 clicks, which means we see all major space trauma that occurs beyond the reach of the Mallemat Foundation. It was not long ago that the vast majority of space trauma victims perished before reaching medical attention as the unforgiving cold hand of space finished off whatever the initial insult had not taken care of. Since the development of self-insulating body armor and self-expanding short-term ecosystems known as body pods (or bodpods for short), we have experienced an influx in the amount of critically ill space trauma patients reaching our medical port in desperate need of care. Mr Wigan was such a patient, arriving at our facility following a deep space collision involving his Space Duster and a rare uncharted piece of space junk. He was thrown from his makeshift spacecraft and if not for his recently purchased self-deploying bodpod, which on sensing the decompression of his standard suit inflated to protect his body from further injury, we would not be discussing this matter today. The bodpods distress signal was picked up within 5 min of the initial event, and a medijet was deployed. Mr Wigan arrived at my spaceport 20 min later. Though much has changed in medicine over the centuries, initial trauma resuscitation has remained surprisingly consistent. Most of us follow the Damage Control Doctrine that supplanted the antiquated ATLS system of the early 21st century. The original principles can be accessed in the early FOAM archives. Following the primary survey, our ability to identify critically ill patients has changed drastically since the institution of the Doctrine of Certitude. Not surprising, the Framingham Formula holds little predictive value in acute insults, such as intergalactic space trauma and thus we are forced to turn to other modalities to fully stratify these patients. One could argue that no device has changed the management of lifethreatening emergencies more than Schrodinger’s Box, the only piece of time travel technology ever to be Correspondence: Dr Christopher P Nickson, Intensive Care Unit, The Alfred Hospital, Commercial Road, Melbourne, VIC 3004, Australia. Email: precordial.thump@ gmail.com

smaccGOLD and the rise of the Synthetics

Time sure flies when you’re having fun. It seems just a month or two ago that the first edition of ‘Dispatches from the FOAM Frontier’ was rushed into print. You will recall that this series announces discoveries material to the lost origins of the Federation of Outerrim Allegorical Migrants (FOAM, or The Federation for short), a primordial chaos of which all records were lost during The Dogmalysis Wars. Of course, investigations into the past are complexified by the tense rivalry between the Time Travel Guild and the Astro-Archeological Society. Despite claims that reports from Time Travellers are (at best) unreliable – we have dared to present to you one traveller’s account of the smaccGOLD Singularity event. First we must give you this disclaimer: the Time Travel program has once again been shut down due to serious breaches in Temporal Security Agency (TSA) protocols. Such breaches threaten to destabilise the entirety of the space–time complex and accounts of such journeys must be taken with a large grain of sodium iodide. After all, how can we be sure that they have gone to our past, and not that of a nearly identical, but parallel universe?

How Might Procalcitonin Testing and Bougies Affect Your Clinical Practice? A Review of These Emergency Department–Based Investigations

Editor’s Note: You are reading the 65th installment of Annals of Emergency Medicine Journal Club. As the Journal Club enters its second decade of publication, we are making a number of changes to the format. Dr. David Schriger, the originator of the Annals of Emergency Medicine Journal Club and its first editor, has retired from his Journal Club editorial role. The journal and his fellow editor are indebted to Dr. Schriger for his outstanding contributions and the success of this educational section. The Journal Club section welcomes Dr. Ryan Radecki and Dr. Rory Spiegel to the editorial staff. The Journal Club format has been revised and will focus on succinct review of high-impact articles from this journal and other premier medical journals relevant to emergency medicine. The reviews are followed by questions demonstrating principles by which readers—be they clinicians, academics, residents, or medical students—may critically appraise the literature. We are interested in receiving feedback about this feature. Please e-mail journalclub@acep.org with your comments.

Final frontier: Final Frontier

Although there has mostly been an uneasy truce between the ways of the CORE and those practicing out on the Outer Rim, some feel that there is a Nirvana waiting to be discovered. Such a Nirvana would embrace the benefits of both systems, creating a plexus of integrity characterised by free thought, academic rigour and the rapid dissemination of knowledge. The resulting cosmos would be welcomed by the Old Guard of the CORE and migrants to the Outer Rim alike. So, when whisperings emerged of activities on the distant planet of Twangier, a purported galactic oasis of rigorous yet progressive medical practice, we knew we must search out this Holy Grail. We are pleased to say that this last ‘Dispatch from the FOAM Frontier’ suggests that our Final Frontiersman, tasked with this daunting astro-investigative quest, seems to have succeeded (but at what cost to herself?).

Laboring under the stone: answers to the January 2015 Annals of Emergency Medicine Journal Club.

Editor’s Note: You are reading the 43rd installment of Annals of Emergency Medicine Journal Club. This Journal Club refers to the article by Smith-Bindman et al published in the September 18, 2014, edition of the New England Medical Journal. Information about journal club can be found at http://www.annemergmed. com/content/journalclub. Readers should recognize that these are suggested answers. We hope they are accurate; we know that they are not comprehensive. There are many other points that could be made about these questions or about the article in general. Questions are rated “novice,” ( ) “intermediate,” ( ) and “advanced ( ) so that individuals planning a journal club can assign the right question to the right student. The “novice” rating does not imply that a novice should be able to spontaneously answer the question. “Novice” means we expect that someone with little background should be able to do a bit of reading, formulate an answer, and teach the material to others. Intermediate and advanced questions also will likely require some reading and research, and that reading will be sufficiently difficult that some background in clinical epidemiology will be helpful in understanding the reading and concepts. We are interested in receiving feedback about this feature. Please e-mail journalclub@ acep.org with your comments.

Laboring under the stone: January 2015 Annals of Emergency Medicine Journal Club.

Editor’s Note: You are reading the 43rd installment of Annals of Emergency Medicine Journal Club. This Journal Club refers to the Smith-Bindman et al article published in the September 18, 2014, edition of the New England Journal of Medicine. This bimonthly feature seeks to improve the critical appraisal skills of emergency physicians and other interested readers through a guided critique of actual Annals of Emergency Medicine articles. Each Journal Club will pose questions that encourage readers—be they clinicians, academics, residents, or medical students—to critically appraise the literature. During a 2to 3-year cycle, we plan to ask questions that cover the main topics in research methodology and critical appraisal of the literature. To do this, we will select articles that use a variety of study designs and analytic techniques. These may or may not be the most clinically important articles in a specific issue, but they are articles that serve the mission of covering the clinical epidemiology curriculum. Journal Club entries are published in 2 phases. In the first phase, a list of questions about the article is published in the issue in which the article appears. Questions are rated “novice,” ( ) “intermediate,” ( ), and “advanced” ( ) so that individuals planning a journal club can assign the right question to the right student. The answers to this journal club will be published in the June 2015 issue. US residency directors will have immediate access to the answers through the Council of Emergency Medicine Residency Directors Share Point Web site. International residency directors can gain access to the answers by emailing journalclub@acep.org. Thus, if a program conducts its journal club within 5 months of the publication of the questions, no one will have access to the published answers except the residency director. The purpose of delaying the publication of the answers is to promote discussion and critical review of the literature by residents and medical students and discourage regurgitation of the published answers. It is our hope that the Journal Club will broaden Annals of Emergency Medicine’s appeal to residents and medical students. We are interested in receiving feedback about this feature. Please e-mail journalclub@acep.org with your comments.

The dry season is coming

‘Two litres of normal saline stat!’ was the battle cry of early 21st century resuscitation. However, this Dispatch from the FOAM Frontier suggests that it was sadly misguided. In a missive examining the early history of FOAM, Professor Rimak, Head of the Federation’s Aquatic Conservation Unit, confirms that the inklings seeping through in those early days were more important than could have ever been imagined. The consequences would prove to be galactic.

All doctors are jackasses.

This Dispatch from the FOAM Frontier features excerpts from the recently discovered journal of the unfortunate Dr Daniel P Crossman. They cast new light on Crossman’s mysterious disappearance while working at the Brohi Humanoid Biorepair Facility. Crossman was a promising young doctor well regarded by his instructors at the CORE, yet his burgeoning career came to an abrupt end. By all accounts an able, dedicated practitioner, Crossman’s sudden disappearance left those who knew him flummoxed. Some observers highlight his decision to leave the CORE’s renowned psychosurgery training programme as a clear indication that he was becoming erratic. Certainly, his decision to migrate to the Reynold’s Shipping Colonies to work at what insiders call ‘The Facility’ was one that few would advise. Yet our profession has a long, noble history of rejecting appealing yet commonplace incentives in favour of the challenge of fighting disease in harsh environments. We should remember, too, that The Facility was once the Federation’s most effective incubator for nascent physicians, staffed by the CORE’s most skilled and admired graduates. Yet when Crossman took up his posting, he was the first new recruit for over a decade and The Facility had already slid down a steep gradient of dysfunction. Indeed, other than disturbing rumours of an acquired disfiguring disease affecting the staff, the fading of The Facility as the Outer Rim’s beacon of medical excellence is an even deeper mystery that few have dared explore. The discovery of Crossman’s journal helps unravel the threads that intertwine his own personal enigma with The Facility’s inexplicable decline. Although interpretations may diverge, tracing these threads provides lessons for us all.

The loneliest doctor.

The following ‘Dispatch from the FOAM Frontier’ is from the medical crew, known as ‘Lifers’, of the deep space vessel Odysseus. It concerns the perils of inducing a state of mental and physiological stasis in human beings, the psychosis of sleep and the psychosis of awakening. The reality of space travel is far more mundane than what was promised to us by the science fiction writers of Old Earth. In fact, over the millenia since the first primate (a monkey named Albert II) thrust free from Old Earth’s gravitational embrace and orbited its single moon, innovations in space travel have stagnated. Our attempts to coerce spacecrafts to reach speeds that outpace light never advanced beyond the minds of our brightest, and most impractical, physicists. Of course, the Time Travel programme developed by Kairos Inc claims to have utilised time travel technology with success, though it continues to run foul of Temporal Security Agency (TSA) protocols. Even if their technologies for manipulating the space–time continuum were widely adopted, applying this technology to deep space travel would require a ‘blind jump’ to a geographic point yet unknown, perhaps situated in a parallel universe or, even worse, within a star. Consequently, most space travel is achieved simply by traversing the vast distances of empty space at sub-light speed velocities. What this amounts to is century-long marathons through deep space. During the Time of Exodus early migrants left their homes on Old Earth on massive barges intended to deliver not their original cargo, but rather their cargo’s future lineage. This type of intergenerational travel entailed a massive utilisation of resources and an extreme degree of foresight that most humans (palliative care physicians aside) are incapable of possessing. In fact if it wasn’t for the threat of extinction due to the imminent demise of Old Earth (a particularly high-stakes ‘four hour rule’), it is doubtful these types of voyages would have ever filled their travel rosters. Centuries after Old Earth met its toxic, boiling, suffocating end, the human race has now established colonies across the many planets and moons of the CORE. Thus intergenerational voyages lack the incentive that global annihilation once provided. As always economic advancement is the strongest motivator of progress. The mining industries, motivated by the planetary-sized resources available for plunder throughout the Outer Rim, required novel methods for transporting and establishing potential mining colonies hundreds of light years away. Though all their attempts at light speed or warp jump technology failed, MineCor, the largest of the galactic energy companies, solved this dilemma with stasis pod technology. This system, derived from the rudimentary suspended animation technologies of Old Earth, placed settlers in an induced coma-like state known as stasis. Only upon reaching their final destination hundreds of years in the future would they be awakened. The care of these passengers while they are in stasis is far from trivial. Attempts at using synthetics were unsuccessful, with modified StrokeBots proving to be too dogmatic and inflexible for the complexities of dealing with stasis physiology. These complexities gave birth to Deep Space Medicine practiced by physicians trained in the management and care of the physiologically suspended patient. Of course, it is impossible for a single physician to fulfill the role of flight medic over the centuries these voyages span. Thus the mining companies took to conscripting a group of Deep Space Medics (jovially nicknamed ‘Lifers’), usually 10 physicians for every century the voyage is predicted to take. Each Lifer would spend 10 years of the voyage awake caring for the passengers while their colleagues remained in stasis. At the end of their 10 year sentence they awaken the Lifer next in line and spend the remainder of the journey getting a well-earned rest. As you can imagine the years of solitude Lifers spend in practice is incredibly difficult and tends to take its toll on even the hardiest of these practitioners. Typically a Lifer will only fulfill one term of duty, though they are paid generously for their decade of internment and the centuries lost to stasis travel. One of the extreme challenges faced by Lifers is stasis psychosis. This dreadful condition has two components, the psychosis of awakening and the psychosis of sleep. This state is reminiscent of that induced by the circadian dysrhythmia and sleep deprivation ‘experiments’ performed on emergency physicians in the early 21st century (in old money). Like their predecessors, Lifers put up with these extreme hardships as they know that their colleagues, and indeed civilisation, depend on them. Indeed, many a good thing has come from ‘paying it forward’. Rory Spiegel, MD, Emergency Medicine Resident; Michelle Johnston, FACEM, Emergency Physician; Tor Ercleve, FACEM, Emergency Physician; Christopher P Nickson, FACEM, Intensive Care Fellow. bs_bs_banner