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Emergency Medicine Australasia (2014) 26, 84–88
doi: 10.1111/1742-6723.12190
EDUCATION AND TRAINING
Brave new world of emergency medicine education Mel Herbert,1 Aaron Bright,1 Paul Jhun1 and Dan James2 Department of Emergency Medicine, LAC+USC Medical Center, Keck School of Medicine of University of Southern California, Los Angeles, California, USA; and 2Silverorange Inc, Charlottetown, Prince Edward Island, Canada
1
‘Any teacher that can be replaced with a computer, deserves to be.’ – attributed to David Thornburg
Background To say that the past 25 years has seen unprecedented change in medicine, education and information technologies is to be redundant, stale and absolutely right! In 1989, the modern Internet did not exist. There was no Amazon®, Wikipedia or online textbooks. Most people used corded phones to make calls for goodness’ sake! If an emergency physician needed to look up the best therapy for asthma exacerbations, he or she headed to the book rack in the back of the emergency room and flipped through the index of some giant tome to find information that was often several years outdated. The present paper is being written on Google® Docs, shared internationally among four authors separated by over 5000 miles and group-edited in real time. Google® did not exist in 1989. Most people had never heard of a laptop let alone the idea of having most of the world’s information accessible immediately on a slick beautiful device in their pocket. The change has been so fast, so radical and so complete, that it is almost impossible for us to fathom it, let alone try and describe it to people who have not lived it. It has changed EVERYTHING and EVERYONE, and emergency medicine is no exception! We will attempt to explain how far information technology in emergency medicine education has come, where we are now and perhaps where we might go soon.
An illustrative case The year is 1989. A 20-year-old female patient presents to the ED with shortness of breath and pleuritic chest
pain. She is in minor distress, her pulse oximeter reads 99% and the rest of her vital signs are normal. A CXR radiograph reveals a 30% pneumothorax. The registrar instructs the registered medical officer (RMO) to place an intercostal catheter chest tube and admit the patient to the surgical service. The RMO has seen a chest tube insertion in the past but is desperately in need of a refresher. Indeed, the RMO wonders about the actual indications for chest tube insertion, about alternative techniques and how she could screw it up! The only available resource to the RMO is a registrar who ‘has no time to mess around’ and points to a hard copy of the first edition of Clinical Procedures in Emergency Medicine by Roberts and Hedges.1 This textbook is one of the best ever written, but the chapter on chest tubes does not discuss Heimlich valves, small catheter aspiration, US guidance or alternative therapy in the stable patient. Giving it her best shot, the RMO places a 40 French chest tube and lacerates the liver. The patient bleeds down to a haemoglobin of 4 g/dL and is taken emergently to the operating room in a critical condition. Fast forward 25 years: same situation, but new information technology. The registrar is still busy, the instructions are the same and the RMO has the same lack of experience and questions. The RMO remembers hearing a discussion regarding options for pneumothorax on the audio podcast, Emergency Medicine: Reviews and Perspectives (EM:RAP).2 On the programme, a discussion had ensued about small catheter techniques for pneumothorax and the utility of US guidance. The RMO cannot remember the details, so she uses her smartphone to quickly pull up the EM:RAP mobile website and download the written summary. She notes that the experts agreed that the indications for chest tube insertion for a simple pneumothorax have
Mel Herbert, MD, Professor of Clinical Emergency Medicine; Aaron Bright, MD, Assistant Professor of Clinical Emergency Medicine; Paul Jhun, MD, Clinical Assistant Professor of Emergency Medicine; Dan James, Web Technologist, Owner and CEO © 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
Education and Training
undergone radical changes in recent years and that, in many cases, no treatment might be preferred. Wanting more information, she uses her smartphone to pull up Emergency Medical Abstracts3 and does a literature search on small catheter Heimlich valves. She finds four recent papers and reads the abstracts. She is convinced that her patient would be better served by this less invasive and apparently simple procedure that could allow her patient to go home. She has never seen the procedure performed, so she goes to Google® and searches for videos on Heimlich valve insertion. A number of videos are available via YouTube®, and she reviews the steps of the procedure. Feeling reassured now, but wanting a second opinion, she sends out a tweet to her 1000 Twitter® followers who are emergency physicians and gives a brief description of the patient presentation, with an attached picture of a redacted version of the CXR radiograph. She receives eight tweets in response within 60 s. Her followers agree that a small catheter Heimlich valve sounds like the best option, including one from none other than Dr Jim Roberts, the author of the famous procedure textbook. She is also forwarded a number of animations and a link to the device manufacturer site that clearly outlines the steps of the procedure for the exact kit that is available in her department. She again goes to her smartphone and logs into the website UpToDate®4 to review the treatment complications of pneumothoraces and the clinical features of re-expansion pulmonary oedema. She notes that the online textbook chapter was just revised 2 weeks earlier. Dr Roberts, who is not faculty in her department, offers to watch the procedure via a private Google® Hangout5 in real time as the procedure is being performed. The procedure is completed successfully without complications, and the patient is given instructions to return in 2 days for potential removal. The RMO sends a text message to her patient with links to patient education material and aftercare information regarding spontaneous pneumothorax and care of the Heimlich valve. She also dictates a short audio clip summary of the condition, the CXR radiograph and the treatment that has been performed all on her phone and sends these to the patient and primary care physician, after receiving consent to do so. A text message is also scheduled to remind the patient of her appointment with a link to a Google® map with directions to the clinic. The above scenario, although created for this article, highlights just a few of the advances in technology that allow clinicians to access an enormous wealth of
information and resources that did not exist 25 years ago. Appropriate use of this information allows clinicians to confidently address the limitless scenarios that can walk through the door of an ED at any time of the day or night. It also helps to address the ongoing problem of poor communication between ED physicians, patients, families and follow-up care using smartphone technology.
Can we ‘trust’ information 2.0 In 1989, information for most clinicians came in the form of hard copy textbooks, published review articles and original research articles. Today, medical advances are still carried on the shoulders of basic research, but information dissemination and refinement for clinical practice is now not only distributed through traditional paper-based textbooks but also via a wide range of easily accessible digital technologies. Could we ‘trust’ the textbooks of 1989? This was not a question we often asked, because we assumed that the textbook authors were smart, experienced, had done research in the area and had done a thorough analysis of the available literature – we trusted them. However, it has only become recent knowledge to the average clinician that textbook chapters lag behind the most recent literature by an average of 10 years and that these ‘reviews’ often did not accurately reflect published research.6 It still might not be general knowledge that author selection for textbook chapters has less to do with experience and more to do with who you know (Amal Mattu, personal communication). Today, within hours of a major research paper being published, blogs, tweets and podcasts can and do disseminate the information to millions of healthcare providers. Implementation of this information often occurs the same day the paper is published. The upside to this rapid turnaround is that life-saving therapies can be given to a maximal number of people without the years of publication lag via the 1985 style textbook.6,7 The downside is that lack of expert reporting or thoughtful interpretation and criticism can result in overextension of concepts and extrapolation of data beyond the studied groups, into situations and patient scenarios where therapies might, in fact, be harmful (‘bracket creep’). In the world of rapid access to all information, brands become increasingly important. Original research and reviews in the New England Journal of Medicine (NEJM) are generally thought to be of high quality and have
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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M Herbert et al.
been well reviewed, as the NEJM ’s reputation for high quality is at stake. In the same way, high quality, frequently accessed blogs and podcasts have a reputation to uphold too.8 Dissemination of inaccurate or erroneous information spells death to the brand and acts as a counterbalance to the desire to simply be first to publish. In addition, most modern blogs and podcasts have comment sections that act as open forums to allow thousands of critical readers to call ‘nonsense’ or reiterate at a frequency and speed not at all possible in 1989. This type of crowdsourcing and peer review has allowed Wikipedia to become as accurate as the once untouchable Encyclopedia Britannica®.9 Of course, there is little scientific research comparing the accuracy and relevancy of old world technologies with web 2.0 technologies. Despite that, the power of social media and advances in information technology are clearly undeniable, when you take a closer look at recent advances, such as the evolution of apneic oxygenation and its eventual integration into everyday emergency medicine practice. Although the seminal article on this concept was published in the 1946,10 the use of apneic oxygenation via nasal cannula during intubation in appropriate patients became popularised in emergency medicine practice in December 2010.11–13 Around that time, a review of several core emergency medicine textbooks, including Rosen’s 7th edition 2009, Harwood-Nuss’s 5th edition 2009 and Tintinalli’s 7th edition 2010,14–16 demonstrated no mention of this adjunctive technique. Meanwhile, social media and several prominent emergency medicine blogs were bursting with references to this new technique throughout 2011 and 2012, with innumerable user comments and critiques, including EMCrit, Academic Life in Emergency Medicine, Resus.ME, EM:RAP and ERcast.17–21 Recommendations for the use of this technique were published and widely disseminated in the emergency medicine community in November 2011.22 Only with the recent publication of Rosen’s 8th edition in August 2013 was apneic oxygenation via nasal cannula mentioned in a major textbook.23 As of the writing of this article, Harwood-Nuss’s and Tintinalli’s textbooks are still awaiting update.
Flipping the classroom It is 1989 again and an emergency medicine RMO has settled into his seat to hear a lecture on electrolyte emergencies by a faculty member. As it turns out, the faculty member has no real interest in the topic and, 86
although she is a spectacular bedside clinician, she has severely limited presentation skills. Despite the actual lecture content containing useful and relevant clinical pearls, the RMO, tired from a recent bout of night shifts, falls asleep during the hyperkalemia portion of the talk. The next night, the RMO fails to recognise that the patient in room 2 is bradycardic because of hyperkalemia and the patient arrests and dies. Fast forward to 2014 and an emergency medicine RMO is instructed that the next day a small group session on electrolyte emergencies will be held at the hospital. In preparation for the small group session, a link is sent to all the RMO’s to HIPPOEM.com,24 an online education website with hundreds of hours of video and audio lectures. The selected lecture is by Dr Corey Slovis of Vanderbilt University and his presentation on how to approach and treat electrolytes emergencies is considered world class. The RMO logs in with her Apple® iPad in one hand and a cup of coffee in the other. The presentation is broken into easily digestible 15-minute segments. The video is a mix of the speaker and slides in high definition. A friend has come over to watch it with her and she sends it to her 80-inch big screen TV via Apple®’s Airplay.25 During the presentation, real-time subtitles of the audio are displayed for further emphasis.26 The RMO friend’s first language is Spanish, so they change the subtitles to Spanish and leave the audio in English. Because of the conceptual complexity and density of the lecture, they frequently pause and rewind the presentation to make sure they have understood the key concepts. At the end of each section, they take an online multiple-choice quiz modelled after standardised national examinations to determine if they have understood the material. The results of these quizzes are monitored by the residency programme director using an online dashboard to confirm that all of the RMOs have viewed and understood the material. Driving to work the next day, the RMO plays a summary audio version of the talk as a refresher. Unclear on the criteria for outpatient care, she poses the question to the board-certified ER doctors/editor of the program via the feedback forum on the site. While at breakfast, she even reviews the key pearls pushed to her smartphone, based on a pre-programmed schedule she had set up while watching the lecture the day before. She also notes her specific clinical question regarding outpatient therapy has been answered on the website. At the hospital, the small group meets to discuss the programme and share clinical stories of how the
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
Education and Training
material could help their practice. For additional review, the RMO competes with fellow HIPPOEM subscribers using the educational gaming features embedded in the programme. That night, while on shift, the RMO encounters a patient with bradycardia. She remembers the mantra ‘in bradycardia, think: drugs, electrolytes, ischemia’. She immediately performs a point-of-care chemistry panel and determines that the patient has a serum potassium of 7.2 mEq/dL. An ECG shows a wide QRS and she administers calcium gluconate intravenously. The ECG narrows and the patient is admitted to the renal service for emergent dialysis. The patient is discharged 2 days later and eventually manages to beat cancer before dying at a ripe old age surrounded by her grandchildren. This hypothetical scenario presented again demonstrates the enormous advances made in education for emergency medicine in the past 25 years. Today’s residents have quick access to the best speakers around the world in a format that allows them to pace their learning, focus on their personal areas of weakness, reinforce and test their knowledge, and have the information presented in multiple formats that cater to different learning styles and locations (asynchronous learning). In addition to this, the technologies they use in their nonmedicine lives (social networks, short message service, smartphones, digital tablets etc.) can be leveraged to reinforce learning, provide timely reminders and provide social aspects to learning that, until now, have not been possible. This is the true ‘flipping’ of the classroom and it is just the beginning! Mobile devices are useful tools in a variety of clinical settings that provide quick access to reference materials and medical applications. For instance, all third-year medical students at the University of Virginia School of Medicine are now required to own one of the recommended mobile devices.27 We no longer have to accept poorly presented material from sub-par educators. Increasingly, anyone can see, hear, and review the best speakers delivering the best education. The concept of having the best educators present the best information and allowing it to be viewed by the greatest number of people is the driving force behind The Bill Gates Foundation granting millions of dollars to the Khan Academy.28 This is perhaps the best example of the flipped classroom to date. As of September 2013, the Khan academy has 280 million video views and 1.3 million subscribers. Their lessons are now being implemented as standard teaching material in many school programmes.29
Final thoughts Emergency medicine requires an enormous breadth of knowledge. The tools used to learn this knowledge have exploded in number and kind in the past 25 years. The tools to maintain that knowledge are more robust and ‘peer-reviewed’ than ever before. Only a portion of the art and practice of emergency medicine can be acquired from memorising facts or watching lectures. In the end, this art must be perfected at the bedside. The tools we have now facilitate real bedside teaching and learning, as they can free up the clinician to learn the ‘bread and butter’ at their own pace, in their own time. The ability for peers to discuss and critique research data and its application to clinical practice is almost instant and international. In 1989, the average clinician never had a voice in what the specialty journals and textbooks disseminated. Not so today. In the end, the creation of a more knowledgeable and thoughtful clinician is the goal of training and education. All the parts are in place. In 2014, there is no longer an excuse for clinicians not to have the best and most up-to-date information in their heads and in their hands, 24 h a day, 365 days a year.
Competing interests MH is an owner of EMRAP.org and HIPPOEDUCATION.com. AB is an owner of HIPPOEDUCATION .com. PJ is content director of HIPPOEDUCATION.com. DJ is owner and CEO of Silverorange Inc.
References 1.
Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. Philadelphia: Saunders, 1985.
2.
EM:RAP. Emergency medicine: reviews and perspectives. [Cited 18 Sep 2013.] Available from URL: http://www.emrap.org/
3.
The Center for Medical Education. Emergency medical abstracts. [Cited 18 Sep 2013.] Available from URL: http://www.ccme.org/ EMA/
4.
UpToDate®. [Cited 18 Sep 2013.] Available from URL: http:// www.uptodate.com/home
5.
Google® Hangouts. [Cited 18 Sep 2013.] Available from URL: http://www.google.com/+/learnmore/hangouts/
6.
Antman EM, Lau J, Kupelnick B, Mosteller F, Chalmers TC. A comparison of results of meta-analyses of randomized control trials and recommendations of clinical experts. Treatments for myocardial infarction. JAMA 1992; 268: 240–8.
7.
Morris ZA, Wooding S, Grant J. The answer is 17 years, what is
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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the question: understanding time lags in translational research. J. R. Soc. Med. 2011; 104: 510–20. 8.
Academic Life in Emergency Medicine (ALiEM). [Cited 18 Sep 2013.] Available from URL: http://academiclifeinem.com/
9.
Giles J. Internet encyclopedias go head to head. Nature 2005; 438: 900–1.
10. Comroe JH, Dripps RD. Artificial respiration. JAMA 1946; 130: 381–3. 11. Levitan R. NO DESAT! Emergency physicians monthly. [Cited 18 Sep 2013.] Available from URL: http://www.epmonthly.com/ archives/features/no-desat-/ 12. Roppolo LP, Wigginton JG. Preventing severe hypoxia during emergent intubation: is nasopharyngeal oxygenation the answer? Crit. Care 2010; 14: 1005. 13. Ramachandran SK, Cosnowski A, Shanks A, Turner CR. Apneic oxygenation during prolonged laryngoscopy in obese patients: a randomized, controlled trial of nasal oxygen administration. J. Clin. Anesth. 2010; 22: 164–8. 14. Marx JA, Hockberger R, Walls R, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 7th edn. Philadelphia: Mosby-Elsevier, 2009. 15. Wolfson AB, Hendey G, Ling L et al., eds. Harwood-nuss’ Clinical Practice of Emergency Medicine, 5th edn. Philadelphia: Lippincott Williams & Wilkins, 2009. 16. Tintinalli JE, Stapczynski J, Ma O et al., eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th edn. New York: McGraw-Hill, 2010. 17. Weingart S, Levitan R. Preoxygenation, reoxygenation, and deoxygenation. EMCrit Blog: a discussion of the practice of ED critical care. [Cited 18 Sep 2013.] Available from URL: http:// emcrit.org/preoxygenation/ 18. Lin M. Trick of the trade: nasal cannula oxygenation during endotracheal intubation. ALiEM: Academic Life in Emergency Medicine (ALiEM). [Cited 18 Sep 2013.] Available from URL:
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http://academiclifeinem.com / trick - of - the - trade - nasal-cannula -oxygenation-during-endotracheal-intubation/ 19. Brian (author) ResusMe. Preoxygenation and prevention of desaturation. Resus.ME: Resuscitation Medicine Education. [Cited 18 Sep 2013.] Available from URL: http://resus.me/ preoxygenation-and-prevention-of-desaturation/ 20. EMRAP. Airway corner: management of the emergency airway. EMRAP: Emergency Medicine Reviews and Perspectives. [Cited 18 Sep 2013.] Available from URL: https://www.emrap.org/ episode/2012/march/airwaycorner?link=search 21. Orman R. Explain it: preoxygenation. ERcast: Emergency Medicine Podcast. [Cited 18 Sep 2013.] Available from URL: http:// blog.ercast.org/tag/apneic-oxygenation/ 22. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann. Emerg. Med. 2012; 59: 165–75. 23. Marx JA, Hockberger R, Walls R, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 8th edn. Philadelphia: Elsevier Saunders, 2013. 24. HIPPOEM. LLSA prep, maintenance of certification, and specialized CME. [Cited 18 Sep 2013.] Available from URL: http:// www.hippoem.com/ 25. Apple® AirPlay. [Cited 18 Sep 2013.] Available from URL: http:// www.apple.com/airplay/ 26. Amara: Caption, translate, subtitle, and transcribe video. [Cited 18 Sep 2013.] Available from URL: http://www.amara.org/en/ 27. University of Virginia School of Medicine. Third year medical student mobile device requirement. [Cited 18 Sep 2013.] Available from URL: http://www.medicine.virginia.edu/education/ medical-students/ome/edtech/pda_recom-page 28. Khan Academy. [Cited 18 Sep 2013.] Available from URL: https://www.khanacademy.org/ 29. Khan Academy Classrooms. School implementations. [Cited 18 Sep 2013.] Available from URL: http://schools.khanacademy.org/
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
Emergency Medicine Australasia (2014) 26, 84–88
doi: 10.1111/1742-6723.12190
EDUCATION AND TRAINING
Brave new world of emergency medicine education Mel Herbert,1 Aaron Bright,1 Paul Jhun1 and Dan James2 Department of Emergency Medicine, LAC+USC Medical Center, Keck School of Medicine of University of Southern California, Los Angeles, California, USA; and 2Silverorange Inc, Charlottetown, Prince Edward Island, Canada
1
‘Any teacher that can be replaced with a computer, deserves to be.’ – attributed to David Thornburg
Background To say that the past 25 years has seen unprecedented change in medicine, education and information technologies is to be redundant, stale and absolutely right! In 1989, the modern Internet did not exist. There was no Amazon®, Wikipedia or online textbooks. Most people used corded phones to make calls for goodness’ sake! If an emergency physician needed to look up the best therapy for asthma exacerbations, he or she headed to the book rack in the back of the emergency room and flipped through the index of some giant tome to find information that was often several years outdated. The present paper is being written on Google® Docs, shared internationally among four authors separated by over 5000 miles and group-edited in real time. Google® did not exist in 1989. Most people had never heard of a laptop let alone the idea of having most of the world’s information accessible immediately on a slick beautiful device in their pocket. The change has been so fast, so radical and so complete, that it is almost impossible for us to fathom it, let alone try and describe it to people who have not lived it. It has changed EVERYTHING and EVERYONE, and emergency medicine is no exception! We will attempt to explain how far information technology in emergency medicine education has come, where we are now and perhaps where we might go soon.
An illustrative case The year is 1989. A 20-year-old female patient presents to the ED with shortness of breath and pleuritic chest
pain. She is in minor distress, her pulse oximeter reads 99% and the rest of her vital signs are normal. A CXR radiograph reveals a 30% pneumothorax. The registrar instructs the registered medical officer (RMO) to place an intercostal catheter chest tube and admit the patient to the surgical service. The RMO has seen a chest tube insertion in the past but is desperately in need of a refresher. Indeed, the RMO wonders about the actual indications for chest tube insertion, about alternative techniques and how she could screw it up! The only available resource to the RMO is a registrar who ‘has no time to mess around’ and points to a hard copy of the first edition of Clinical Procedures in Emergency Medicine by Roberts and Hedges.1 This textbook is one of the best ever written, but the chapter on chest tubes does not discuss Heimlich valves, small catheter aspiration, US guidance or alternative therapy in the stable patient. Giving it her best shot, the RMO places a 40 French chest tube and lacerates the liver. The patient bleeds down to a haemoglobin of 4 g/dL and is taken emergently to the operating room in a critical condition. Fast forward 25 years: same situation, but new information technology. The registrar is still busy, the instructions are the same and the RMO has the same lack of experience and questions. The RMO remembers hearing a discussion regarding options for pneumothorax on the audio podcast, Emergency Medicine: Reviews and Perspectives (EM:RAP).2 On the programme, a discussion had ensued about small catheter techniques for pneumothorax and the utility of US guidance. The RMO cannot remember the details, so she uses her smartphone to quickly pull up the EM:RAP mobile website and download the written summary. She notes that the experts agreed that the indications for chest tube insertion for a simple pneumothorax have
Mel Herbert, MD, Professor of Clinical Emergency Medicine; Aaron Bright, MD, Assistant Professor of Clinical Emergency Medicine; Paul Jhun, MD, Clinical Assistant Professor of Emergency Medicine; Dan James, Web Technologist, Owner and CEO © 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
Education and Training
undergone radical changes in recent years and that, in many cases, no treatment might be preferred. Wanting more information, she uses her smartphone to pull up Emergency Medical Abstracts3 and does a literature search on small catheter Heimlich valves. She finds four recent papers and reads the abstracts. She is convinced that her patient would be better served by this less invasive and apparently simple procedure that could allow her patient to go home. She has never seen the procedure performed, so she goes to Google® and searches for videos on Heimlich valve insertion. A number of videos are available via YouTube®, and she reviews the steps of the procedure. Feeling reassured now, but wanting a second opinion, she sends out a tweet to her 1000 Twitter® followers who are emergency physicians and gives a brief description of the patient presentation, with an attached picture of a redacted version of the CXR radiograph. She receives eight tweets in response within 60 s. Her followers agree that a small catheter Heimlich valve sounds like the best option, including one from none other than Dr Jim Roberts, the author of the famous procedure textbook. She is also forwarded a number of animations and a link to the device manufacturer site that clearly outlines the steps of the procedure for the exact kit that is available in her department. She again goes to her smartphone and logs into the website UpToDate®4 to review the treatment complications of pneumothoraces and the clinical features of re-expansion pulmonary oedema. She notes that the online textbook chapter was just revised 2 weeks earlier. Dr Roberts, who is not faculty in her department, offers to watch the procedure via a private Google® Hangout5 in real time as the procedure is being performed. The procedure is completed successfully without complications, and the patient is given instructions to return in 2 days for potential removal. The RMO sends a text message to her patient with links to patient education material and aftercare information regarding spontaneous pneumothorax and care of the Heimlich valve. She also dictates a short audio clip summary of the condition, the CXR radiograph and the treatment that has been performed all on her phone and sends these to the patient and primary care physician, after receiving consent to do so. A text message is also scheduled to remind the patient of her appointment with a link to a Google® map with directions to the clinic. The above scenario, although created for this article, highlights just a few of the advances in technology that allow clinicians to access an enormous wealth of
information and resources that did not exist 25 years ago. Appropriate use of this information allows clinicians to confidently address the limitless scenarios that can walk through the door of an ED at any time of the day or night. It also helps to address the ongoing problem of poor communication between ED physicians, patients, families and follow-up care using smartphone technology.
Can we ‘trust’ information 2.0 In 1989, information for most clinicians came in the form of hard copy textbooks, published review articles and original research articles. Today, medical advances are still carried on the shoulders of basic research, but information dissemination and refinement for clinical practice is now not only distributed through traditional paper-based textbooks but also via a wide range of easily accessible digital technologies. Could we ‘trust’ the textbooks of 1989? This was not a question we often asked, because we assumed that the textbook authors were smart, experienced, had done research in the area and had done a thorough analysis of the available literature – we trusted them. However, it has only become recent knowledge to the average clinician that textbook chapters lag behind the most recent literature by an average of 10 years and that these ‘reviews’ often did not accurately reflect published research.6 It still might not be general knowledge that author selection for textbook chapters has less to do with experience and more to do with who you know (Amal Mattu, personal communication). Today, within hours of a major research paper being published, blogs, tweets and podcasts can and do disseminate the information to millions of healthcare providers. Implementation of this information often occurs the same day the paper is published. The upside to this rapid turnaround is that life-saving therapies can be given to a maximal number of people without the years of publication lag via the 1985 style textbook.6,7 The downside is that lack of expert reporting or thoughtful interpretation and criticism can result in overextension of concepts and extrapolation of data beyond the studied groups, into situations and patient scenarios where therapies might, in fact, be harmful (‘bracket creep’). In the world of rapid access to all information, brands become increasingly important. Original research and reviews in the New England Journal of Medicine (NEJM) are generally thought to be of high quality and have
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
85
M Herbert et al.
been well reviewed, as the NEJM ’s reputation for high quality is at stake. In the same way, high quality, frequently accessed blogs and podcasts have a reputation to uphold too.8 Dissemination of inaccurate or erroneous information spells death to the brand and acts as a counterbalance to the desire to simply be first to publish. In addition, most modern blogs and podcasts have comment sections that act as open forums to allow thousands of critical readers to call ‘nonsense’ or reiterate at a frequency and speed not at all possible in 1989. This type of crowdsourcing and peer review has allowed Wikipedia to become as accurate as the once untouchable Encyclopedia Britannica®.9 Of course, there is little scientific research comparing the accuracy and relevancy of old world technologies with web 2.0 technologies. Despite that, the power of social media and advances in information technology are clearly undeniable, when you take a closer look at recent advances, such as the evolution of apneic oxygenation and its eventual integration into everyday emergency medicine practice. Although the seminal article on this concept was published in the 1946,10 the use of apneic oxygenation via nasal cannula during intubation in appropriate patients became popularised in emergency medicine practice in December 2010.11–13 Around that time, a review of several core emergency medicine textbooks, including Rosen’s 7th edition 2009, Harwood-Nuss’s 5th edition 2009 and Tintinalli’s 7th edition 2010,14–16 demonstrated no mention of this adjunctive technique. Meanwhile, social media and several prominent emergency medicine blogs were bursting with references to this new technique throughout 2011 and 2012, with innumerable user comments and critiques, including EMCrit, Academic Life in Emergency Medicine, Resus.ME, EM:RAP and ERcast.17–21 Recommendations for the use of this technique were published and widely disseminated in the emergency medicine community in November 2011.22 Only with the recent publication of Rosen’s 8th edition in August 2013 was apneic oxygenation via nasal cannula mentioned in a major textbook.23 As of the writing of this article, Harwood-Nuss’s and Tintinalli’s textbooks are still awaiting update.
Flipping the classroom It is 1989 again and an emergency medicine RMO has settled into his seat to hear a lecture on electrolyte emergencies by a faculty member. As it turns out, the faculty member has no real interest in the topic and, 86
although she is a spectacular bedside clinician, she has severely limited presentation skills. Despite the actual lecture content containing useful and relevant clinical pearls, the RMO, tired from a recent bout of night shifts, falls asleep during the hyperkalemia portion of the talk. The next night, the RMO fails to recognise that the patient in room 2 is bradycardic because of hyperkalemia and the patient arrests and dies. Fast forward to 2014 and an emergency medicine RMO is instructed that the next day a small group session on electrolyte emergencies will be held at the hospital. In preparation for the small group session, a link is sent to all the RMO’s to HIPPOEM.com,24 an online education website with hundreds of hours of video and audio lectures. The selected lecture is by Dr Corey Slovis of Vanderbilt University and his presentation on how to approach and treat electrolytes emergencies is considered world class. The RMO logs in with her Apple® iPad in one hand and a cup of coffee in the other. The presentation is broken into easily digestible 15-minute segments. The video is a mix of the speaker and slides in high definition. A friend has come over to watch it with her and she sends it to her 80-inch big screen TV via Apple®’s Airplay.25 During the presentation, real-time subtitles of the audio are displayed for further emphasis.26 The RMO friend’s first language is Spanish, so they change the subtitles to Spanish and leave the audio in English. Because of the conceptual complexity and density of the lecture, they frequently pause and rewind the presentation to make sure they have understood the key concepts. At the end of each section, they take an online multiple-choice quiz modelled after standardised national examinations to determine if they have understood the material. The results of these quizzes are monitored by the residency programme director using an online dashboard to confirm that all of the RMOs have viewed and understood the material. Driving to work the next day, the RMO plays a summary audio version of the talk as a refresher. Unclear on the criteria for outpatient care, she poses the question to the board-certified ER doctors/editor of the program via the feedback forum on the site. While at breakfast, she even reviews the key pearls pushed to her smartphone, based on a pre-programmed schedule she had set up while watching the lecture the day before. She also notes her specific clinical question regarding outpatient therapy has been answered on the website. At the hospital, the small group meets to discuss the programme and share clinical stories of how the
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
Education and Training
material could help their practice. For additional review, the RMO competes with fellow HIPPOEM subscribers using the educational gaming features embedded in the programme. That night, while on shift, the RMO encounters a patient with bradycardia. She remembers the mantra ‘in bradycardia, think: drugs, electrolytes, ischemia’. She immediately performs a point-of-care chemistry panel and determines that the patient has a serum potassium of 7.2 mEq/dL. An ECG shows a wide QRS and she administers calcium gluconate intravenously. The ECG narrows and the patient is admitted to the renal service for emergent dialysis. The patient is discharged 2 days later and eventually manages to beat cancer before dying at a ripe old age surrounded by her grandchildren. This hypothetical scenario presented again demonstrates the enormous advances made in education for emergency medicine in the past 25 years. Today’s residents have quick access to the best speakers around the world in a format that allows them to pace their learning, focus on their personal areas of weakness, reinforce and test their knowledge, and have the information presented in multiple formats that cater to different learning styles and locations (asynchronous learning). In addition to this, the technologies they use in their nonmedicine lives (social networks, short message service, smartphones, digital tablets etc.) can be leveraged to reinforce learning, provide timely reminders and provide social aspects to learning that, until now, have not been possible. This is the true ‘flipping’ of the classroom and it is just the beginning! Mobile devices are useful tools in a variety of clinical settings that provide quick access to reference materials and medical applications. For instance, all third-year medical students at the University of Virginia School of Medicine are now required to own one of the recommended mobile devices.27 We no longer have to accept poorly presented material from sub-par educators. Increasingly, anyone can see, hear, and review the best speakers delivering the best education. The concept of having the best educators present the best information and allowing it to be viewed by the greatest number of people is the driving force behind The Bill Gates Foundation granting millions of dollars to the Khan Academy.28 This is perhaps the best example of the flipped classroom to date. As of September 2013, the Khan academy has 280 million video views and 1.3 million subscribers. Their lessons are now being implemented as standard teaching material in many school programmes.29
Final thoughts Emergency medicine requires an enormous breadth of knowledge. The tools used to learn this knowledge have exploded in number and kind in the past 25 years. The tools to maintain that knowledge are more robust and ‘peer-reviewed’ than ever before. Only a portion of the art and practice of emergency medicine can be acquired from memorising facts or watching lectures. In the end, this art must be perfected at the bedside. The tools we have now facilitate real bedside teaching and learning, as they can free up the clinician to learn the ‘bread and butter’ at their own pace, in their own time. The ability for peers to discuss and critique research data and its application to clinical practice is almost instant and international. In 1989, the average clinician never had a voice in what the specialty journals and textbooks disseminated. Not so today. In the end, the creation of a more knowledgeable and thoughtful clinician is the goal of training and education. All the parts are in place. In 2014, there is no longer an excuse for clinicians not to have the best and most up-to-date information in their heads and in their hands, 24 h a day, 365 days a year.
Competing interests MH is an owner of EMRAP.org and HIPPOEDUCATION.com. AB is an owner of HIPPOEDUCATION .com. PJ is content director of HIPPOEDUCATION.com. DJ is owner and CEO of Silverorange Inc.
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