Past, Present and a Possible Future – Help or Hinder

Published in Sanguine, journal of the ECSSA June 2015

Technology in Medicine, a topic many in EMS chat about, and if we have been in service for 20 years plus, we have then been privileged (or cursed) to see significant changes across the board with regard to equipment, patient care, protocols and drug therapies. Many of us have actively pushed for change and new equipment; be it with regard to fluid therapy, bleeding control, pain management and airway management. As one who has been active in certain areas pushing for change, we sometimes miss the most crucial approach to patient care; neatly summed up by Hippocrates (400-ish BC)

Cure Sometimes. Treat Often. Comfort Always

The classic approach to patient care has always been underpinned by the following:

  • Arrive at a diagnosis by patient consultation and physical hands on examination

  • Confirm ones diagnosis via various diagnostic devices

  • Reaffirm ones diagnosis by means of special investigations

Will technology change this approach for better or the worse?

If we look back at history, we see that not all new technologies have been readily accepted by the medical community. Many were viewed (are viewed) with suspicion. In the 1930’s some doctors doubted an X-ray image of the chest was as reliable as a physical examination. Devices threatened to replace the diagnostic expertise of the traditional doctor. Many doctors have valued their clinical experience over machine-produced information. Other technologies initially failed because doctors or patients found them impractical. The ECG was only useful when it became portable and reliable enough to be used at the patient’s bedside.

We need to also seriously review our progress in Medical Technology with regard to changes that offer only incremental benefits but at much higher patient care cost. The focus must be on evidence-based product development, manufacturers have to be able to show their products and new technologies will add value to their customers. Does new technology automatically translate into better patient care and most importantly improved patient outcomes.Plus we need to ask the question; who is their customer, the patient or the medical practitioner? If we as practitioners treat our patients as customers, they will act like customers, we need to be very careful of venturing into a quagmire such as this.

The entire patient/medical practitioner relationship is also changing, as the patient has access to a wider range of medical information, our patients are possibly smarter (maybe). Patients have access to more medical information, with the end result, that at times, they might be less trusting and prone to ask more questions of their medical practitioner. As practitioners we must be open to this new questioning patient and be willing to answer more questions than we did in the past.

Taking cognisance of all of the above: what is the health care practitioner to do?

There is an acknowledged gap in the “bench to bedside” cycle of medical discovery and its implementation in clinical practice, which can mean a gap of years changing “what we know to what we practice”.Hence the treatment of patients in an emergency setting should not only be concentrated on developing new technologies, but must also involve proper training and skills development; medical talents needs to be honed. New technologies MUST always mandate new skill sets, protocols and procedures.

An area of import in my opinion in medical development is patient information. The more information we have on the patient at hand, will allow us to render more appropriate patient care. Information and knowledge management is critical in helping with the decision making process and thereby improving patient care. Many medical practitioners believe that patients should take an active role in managing their own health information, because it fosters personal responsibility and ownership and enables both the patient and practitioner to track progress outside scheduled appointments and at times of a medical emergency. Patient smart cards is one way to grapple with this issue of information. It will allow patients to upload their health records via a flash drive and carry their information with them in their wallet. Information may be accessed through cloud-based storage and encrypted systems anywhere in the world, or plugged into medical smart readers. Medical practitioners can update to cloud technology in real time and the patients own medical doctor can be alerted to changes in the cloud files.

Another key area where technology can aid us in having more information at our fingertips is via a “differential” diagnosis or problem list, which is accessed via the cloud and links to our patient file and further information we input. After we have reviewed the patient “history” and examination. (e.g. is this appendicitis? a urinary tract infection? constipation? inflammatory bowel disease?) The practitioner must then troll his memory banks and innate knowledge base, or one may need to consult texts/online sources to check up/confirm their thinking. Cloud based technology could aid us and speed up the confirmatory differential diagnosis. As their is no doubt much room for improvement in the current approach, with many practitioners currently relying on their tacit knowledge base at the frontline which, while mostly effective, is subject to human error. Once the differential diagnosis or problem list is drawn up, then a related treatment plan could be formulated, and treatments in the form of procedures and/or prescriptions for medications may be suggested by our cloud database.

Emergency Medicine must continue its current academic trajectory, to keep pace with the challenges that technology brings to our patient care. If academic training lags behind the technology curve our practitioners and therefore our patients will be the poorer. We must ensure that there is now technology/practitioner gap as we continue to push the boundaries in improving our patient care. The danger of technology, is that it has the ability to make us lazy and self reliant. It has become noticeable in certain areas of emergency medicine how our reliance on technology has allowed us to forget the three cornerstones of good medicine, diagnosis, confirmation and reaffirmation; of which the diagnosis and confirmation are reliant on us having a hands on approach to our patients (which is becoming a dying art). Good solid diagnostic skills will always be an essential tool of medicine, especially emergency medicine, we forget this at our and our patients peril.

The Fading of the Day

Inspired by the song On the Turning Away by Pink Floyd; I paused to write this poem

Light is changing to shadow

And casting it’s shroud

as the day fades to gray

and then shifts from gray to dark

before we long for the promise of a new day

we need to cling to the dark

even when it is dark, it's not dark yet

as it is always darkest, just before the dawn

as a new day beckons with promise, on the morn

the shadow shroud enfolds the world in gray

and teases with a promise, as the gray flickers to dark

with the dark is a promise of a new day

when the morning slivers slice back the dark

that sense of expectation, that it is never dark

there is always a new beginning

no matter how dark yesterday felt

today can be the brightest day yet

as we continually move through the cycle of life

light dark light dark …. light

© 2015 Michael D Emmerich

The Sonnet of Silent Conversations

I’m there, you’re there

We are silent in each others presence

A comment made to my wife, Tania, when we were sitting on the sofa at home each engaged in our own thoughts/activities, but still at one; it inspired me to pen the following poem.

the beautiful silence between lovers

the solace in the silence

where words are not needed to uncover 

the hidden messages of compliance

the beauty of the silent bonds

that tie two stars into the same orbit

an orbit that does not require one to respond

other than in a soft touch or knowing look

as a means of expressing ones love

intimate hushed companionship, as such

reinforces the strength of silent conversation

the intimacy of conversing by touch

heightens the silent smiles and wink of flirtation

unity in our silent separateness leads to stronger ties that bind

© 2015 Michael D Emmerich