journey with emergency medicine

Emergency Medicine

(2001)

13

, 1–4

Blackwell Science Asia

Tom Hamilton Lecture

Tom Hamilton Lecture 2000: Journey with emergency medicine

Chris Curry

Emergency Department, Fremantle Hospital, Perth, Western Australia, Australia

This is not a scientific paper. It is a journey of a sort. Myidiosyncrasy has been a tendency to wander. I like goingto places I haven’t been. I have enjoyed mountains and nowI enjoy polar regions. Travels provide a unique perspectiveon life and on the place of

Homo sapiens

in the world.

Homo sapiens

means ‘the thinking hominid’.Our planet is about 4600 million years old. It has

supported life forms for more than 3000 million years.Most of the planet’s surface is covered by oceans. Most ofthe uptake of carbon dioxide from the atmosphere is intothe oceans, and most of the production of oxygen into theatmosphere is by the oceans. Life originated in the oceansand most of the world’s life forms live there. The future ofour planet is in her oceans.

Mammals have been evolving for about 60 millionyears. Hominids started their journey to

Homo sapiens

about 5 million years ago. Human history spans onlythousands of years.

Homo sapiens

has been recording hisimpact on the planet for less than one second in the24 hour day of life on earth. Western medical history spansonly hundreds of years; emergency medicine fewer than20 Antarctic breeding seasons.

Predictions made from current understanding of thesun is that our planet is about half way through its capa-city to support life forms. Many life forms have emerged,had their time in the sun, and gone. And so will manymore. Species that become plagues can extinguishthemselves.

Homo sapiens

is on an accelerating journey. The rateof rise of this species to dominance is unprecedented. Itsimpact on the planet is increasing exponentially. Our spe-cies has reason to be awed by its own progress, but mustalso take responsibility for it and be responsible with it.Unless we are to go the way of plagues.

We in emergency medicine, we of the subspecies ‘homoemergencus’, are also on a rapid journey. Our rate of riseis unprecedented. Our impact is increasing. So we inemergency medicine can be awed by our progress — butwe must also take responsibility for it, and be responsiblewith it.

Emergency medicine is a wonderful journey of whichto be a part. Like journeys in mountains or to remoteplaces, there is much to be learned. There is a new lessonto be had from each journey and there are common lessonsthat can be had from any journey.

We widen our perspectives. As we climb higher our viewexpands. We appreciate the bigger picture. Bad weathercan come through but if one is prepared one survives itand the climb resumes. With time and changing conditionswe see the world differently. A view seen in the harshmidday sun is very different when seen in the warm glowof evening light. The same view through the eyes of anaturalist, an atmospheric physicist, an artist, a philosopher,contains different sources of wonder. The world is notblack or white, but a multitude of colours which vary withtime and perspective.

One hears talk of ‘the balance of nature’, but there hasnever been a ‘balance’ in nature. A species succeeds, itmay dominate, it is superseded. Nature has been a processof constant change, and will continue to be.

We too change, and seek to change. I remember YuriGagarin, 39 summers ago the first man to orbit the earthin space, whose journey was the culmination of so much— and the beginning of so much. Last summer I stood onthe eastern most point of the former USSR and gazedacross the narrow ocean divide to the first early warningstation on a mountain in Alaska. On this side, and on thatside, men had watched the other evil empire for the first

Chris Curry, BMedSc(Hons), FACEM, Emergency Physician.

EMM199.fm Wednesday, February 21, 2001 9:36 AM

C Curry

2

intercontinental ballistic missiles. I stood with Russiansand Americans as companions.

In emergency medicine there is much that was rightonly 10 summers ago that is wrong today. Routine gastriclavage; MAST for hypotension of any cause; ACLSdrugs; steroids for sepsis, for head injury, for spinal cordinjury. We can be sure that some of what we regard as righttoday will be proven to be wrong within 10 summers.

So there is uncertainty in our journey, and there arerisks. Risk-taking is integral, indeed is necessary, forprogress on our journeys. In emergency medicine we mustpractise prudent risk-taking. Risk-taking causes arousal.There is a continuum of arousal from boredom to excite-ment. There is also a continuum of arousal from relaxationto anxiety. Where arousal is experienced with excitement,risks are taken with confidence. Where arousal generatesanxiety, lack of confidence may result in poor performance.Then the individual may respond with avoidance, and itmay be time to put skills and energies to use elsewhere.

On journeys crises occur unexpectedly. Ecuador isplunged into rioting at a doubling of the price of fuel andI get my first dose of tear gas and of bullets smacking intonearby walls. China closes the border between Nepal andTibet as the team arrives there. Come back to Everestanother time. The Canadian Coast Guard decides theRussian icebreaker cannot proceed. A helicopter crasheson the deck a thousand nautical miles from a hospital.

In emergency medicine our business is to respondto crises. Often, harm is continuing. The anxious mightrespond with ‘first, do no harm’. The excited will respondwith ‘allow no further harm’. With myocardial infarction,for example, harm is continuing. ‘First do no harm’responders may move the patient on for someone else todecide and so delay treatment. ‘Allow no further harm’responders will know how to intervene and will not permitdelay.

Where risks are taken one meets fear. My companionhas fallen into a crevasse. The edge of the crevasse isdangerous. I know he is alive, I fear he is seriously injured,I fear I won’t be able to deal with it. I wish vehementlythat there was another way to solve the dilemma. I knowthere isn’t. I lower myself over the edge into a darkeningblue void. My friend now lives.

Fear could control, and inhibit. The thinking person,

Homo sapiens

, acknowledges fear, but is not dictated toby it. The thinking person pursues the rational solution.In emergency medicine there is a rising fear of litigation.We must ensure that it does not lead to irrational solu-tions. We must not be dictated to. We must have confidencethat we can persuade other thinking people. It is we, theexperts, who must make the right decisions and be able

to explain them. Failure to communicate is the singlefactor that precipitates most litigation.

In daring to make journeys we will inevitably meetsetbacks. Some setbacks may seem like failures. In tryingdifferent paths we may come to dead ends and have towithdraw and change direction. But it is surprising in lifehow a setback or a change of direction can prove to be avery good thing. There is something to be learned fromevery adversity. And there are things that then happenthat would not, had there been no setback.

In daring, we will also encounter stress. Whether stressis stimulating or disabling is dependent upon motivation.Mountaineers challenge stress. Explorers take it instride. Athletes deliberately induce it to improve theirperformance.

For emergency physicians I believe the key to a healthyresponse to stress is enthusiasm. We must create theopportunities to do the things that we have enthusiasmfor. We should be careful about our involvement in thingswe have limited or no enthusiasm for. And so in our workpractices we must evolve sufficient flexibility and diversityto maintain and even to cultivate enthusiasm.

A key to this is time. In advising about strengtheningrelationships, the poet Khalil Gibran wrote, ‘Make spacesin your togetherness’. The advice applies as well to yourrelationship with your vocation. Take time out. Go do some-thing else.

We must guard against evolving a training programthat places too much emphasis on pace and intense involve-ment. There is great diversity among the individuals ofour subspecies, and diversity must be fostered. After myown first attempt at the fellowship examination I wentclimbing, and to Mount Everest. I returned to the examtwo years later. I was then more knowledgeable certainlybut more importantly and less definably I had taken afew steps along the rocky trail towards wisdom.

On the first circumnavigation of the Arctic ocean,I wrote:

I seek solitude. On the stern of the icebreaker I watchthe churn of the ocean pushed up by the three sets ofblades. It is mesmerizing. Never the same, but neverchanging. Always changing but essentially the same.Like the shapes and forms of water in a big waterfall.It takes me away. I seek it, to have it take me away. Iwant to disconnect from all this for a while. The wakeextending away from me over the horizon goes out tothe infinite. And yet as we keep our journey onwardswe would meet it again. There is a permanencedespite change. There is a recycling and revisitingdespite the ongoing of things. I feel a separation fromthis little vessel in its tiny pocket of time and space,


Tom Hamilton Lecture 2000

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and a connection with a wider thing. Another dimen-sion of being. There are times for the mysterious, forthe spiritual, to contemplate God perhaps.

In emergency medicine, as with travelling, it is thejourney more than a destination that provides the oppor-tunity for growth. And thereby we expand our capacity forcompassion.

Compassion is about caring without attachment. Onmy first journey into the Himalaya I was caught out bya fierce storm. I was taken in by a clutch of Nepalis ina broken down yak herder’s shelter. They made a littlefire, and offered me the best nibbles of some old yak meat.In the dismal shelter in the bleak storm they took it inrotation, one blowing on the reluctant wet wood, anothertelling stories, the rest of us huddled in a damp heap —all night, non-stop. When the storm had passed we wentour ways laughing.

Compassion is the basis of our humanity. It takescommitment and training to develop it. Like wisdom, it isnot a given, and it is not something that comes withouteffort. A Tibetan refugee named Tensin Gyatso has said:

Compassion can be roughly defined in terms of a stateof mind that is non-violent, non-harming, and non-aggressive. It is a mental attitude based on the wishfor others to be free of their suffering and is associatedwith a sense of commitment, responsibility, and respecttowards the other. Genuine compassion is based onthe rationale that all human beings have an innatedesire to be happy and overcome suffering, like myself.And, just like myself, they have the natural right tofulfil this natural aspiration. On the basis of the recogni-tion of this equality and commonality, you develop asense of affinity and closeness with others. (Tensin Gyatso is also known as the Dalai Lama.)

We must be compassionate with the people who, notof their choice, have become our patients. I believe thatlearning this is enhanced by being at times the first andonly doctor to offer care.

We must also be compassionate with everyone wework with, all our colleagues. Particularly our colleaguesin other medical disciplines. We are now inarguably theirpeers. Some of them see their subspecies on the descendantas the result of ours being on the ascendant. In some wayeveryone is beset. So we must be compassionate too withadministrators, and with politicians. They too have theirburdens. But that does not mean we must be compliant,kow-towing, or cowering. And we must be compassionatewith our trainees.

Emergency medicine is not solely a science. With over-indulgence in science, and in the pseudo science of overuseof investigations, we risk losing sight of the principles of

caring. Small ship medicine is very refreshing in this regard.On a small ship one cannot escape into investigations.There are none.

Expedition and ship medicine is as much if not moreabout prevention of illness and injury as it is about pro-viding a response to emergencies. What we are doing inresponding to emergencies in emergency departments isimportant. But we must begin to do more. We see all theills of society in a unique way. So far we have evolvedprimarily as a reactive specialty. Now we must becomeproactive as well. We must get into prevention

Our colleagues in other disciplines have evolved aheadof us. Dentists are leading fighters against tooth decay.Cardiologists are leading fighters against the causes ofvascular disease. Respiratory physicians, against smoking.Neurosurgeons, for head protection on cyclists and riders.

In the emergency department we react to a majortrauma resuscitation with excitement. There is the adren-aline rush. But at some time we need to recognize thatmost such resuscitations are a tragedy. The huge major-ity should never have happened.

What can we do about it?

When I was in New Zealand the rate of road killing therewas twice that in Australia. I had the opportunity toaddress the launching of several road trauma initiativesand campaigns. I addressed town and city councils, Auto-mobile Association meetings, police, bureaucrats andpoliticians. I went on TV. Real stories from the front line,real tragedies involving real people, the killed, the maimed,the dependants are very powerful. They affect people, andinspire action.

And people realise, perhaps for the first time, howmisleading the euphemism ‘accident’ is.

The use of the right language is important. And wecan change our language. We have changed from asylumto mental health services, cancer ward to oncology, TBward to respiratory medicine, handicapped to disabled,casualty (indeed we were) to emergency medicine.

We know that the overwhelming majority of roadcrashes are a direct consequence of driver misbehaviour.Drivers going too fast, drivers intoxicated, drivers failingto give way, drivers over-taking without adequate visibility.While we collude with people to allow them the comfortof the delusion that road crashes are acts of God, ‘accidents’,we will make less progress than we should. It is time wecalled a spade a spade, a department that sees emergenciesan emergency department, and a collision involving avehicle a crash.


C Curry

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Another area for prevention that is perplexing andthat we must involve ourselves in is the problem of suicideand self-harm. Emergency medicine is now the disciplinethat cares for the majority of the survivors of self-harmattempts. Self-harm is not the illness, but the expressionof dis-ease. Recently Tom Hamilton and Hugh Cook havemade an initial engagement with this problem. You maybe aware of the ‘happy link in suicide theory’, in whichvictims despair because of the well-being of their colleagues.This finding has ramifications and requires a response.We are the recipients of the dis-eases of society. We areresponsible members of our society. We must start tellingsociety what we know, and we must contribute to thesolutions.

So, where are we going? Just two breeding seasonsago Captain Petr Golikov took his icebreaker into a veryremote part of Antarctica where no man had venturedbefore. Petr feared entrapment in the ice and damage tohis vessel. But he thought it through and then he dared.He discovered an emperor penguin rookery of thousandsof individuals previously unknown. Now we know moreabout a species that we dearly seek to do no harm.

Emergency medicine needs explorers, people pre-pared to go into unknown waters. Every job advertisementseeks ‘team players’. Of course, colleagues of like mindand purpose are support in difficult endeavours. But thisdoes not mean that team players are passive compliantpeople. We must also be individuals, and leaders, andpeople who dare to innovate.

The specialty we now enjoy, which didn’t exist whenI was first searching for a purpose in medicine, is becauseindividuals have dared to innovate. They have challengedthe collegiate ‘group-think’, have departed from the

statusquo

, have dared to take a new direction.One of the strengths of the training program that

these individuals conceived is that the progeny is relativelyhomogeneous. We are well founded in hospital-basedemergency department medicine. The College examinationprocess is rigorous. More rigorous than any otheremergency medicine training program. That is good. Butwhile we pursue a uniformity of standard, individualitymust also be nourished. Every new generation must dare.Individuality is the progenitor of diversification. Diversityis the progenitor of growth.

As the cliché goes, ‘Go west, young emergencyphysician’. And east and south and north. And skyward.And to the oceans.

What is there beyond these horizons? We are alreadyparticipating in air medical transport, critical care medicine,informatics, practice management, research, EMS, ultra-sound, hyperbaric medicine, paediatrics, toxicology. Wehave begun the journey in disaster medicine, injury pre-vention and control, rural EM and maritime medicine.All of these could become special interest groups of theAustralasian College for Emergency Medicine. They arealready sections of the American College of EmergencyPhysicians.

There is much new territory to be explored: in refugeeand developing world medicine; in travel medicine andpublic health; in providing services to remote locationson the ground, water or ice; and at a distance by tele-medicine. Emergency physicians have been making con-tributions in trouble spots like Bosnia, Timor, Myanmar,the Kenya/Sudan border, Afghanistan. We are joiningwith developing neighbours like New Guinea and thePacific Islands. We are going to the outback, we are goingto sea, we are developing emergency medicine links withChina, South-East Asia, the Middle East.

And we will do more, if we dare. We will do things thatcannot now be imagined. When

Homo erectus

first startedthinking and became

Homo sapiens

he would have hadlittle inkling of where his progeny would journey to. Todayhomo emergencus is as limited as

Homo sapiens

was then,and can only speculate. And from the view point of thefuture our progeny will look back and amuse themselvesat the paucity of our vision. Our musings around thePower Point projector will be as primitive as

Homo sapiens

’earliest musings around the camp fire must have been.

But through all changes the characteristic that homoemergencus must develop beyond all others is compassion.We must care. This must be the ballast in the vessel of all ourjourneys. It is the characteristic that maintains harmonywithin the community of a small ship at sea, and withinthe community of an emergency department. ‘The secretof the care of the patient is caring for the patient’. As truetoday as it was for readers of the British Medical Journal

in 1927, and as true for 2027 and beyond.


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