Tuesday, October 14, 2003

Learning How to Learn for ABEM’s Lifelong Learning and Self-Assessment (LLSA) <em>and</em> Then the Lights Went Out

How are you and your colleagues in your practice addressing preparation for the Emergency Medicine Continuous Certification (EMCC) program? I’ve heard that some groups are trying a journal club approach for learning the content of these articles. Many commercial CME opportunities based on the LLSA articles are in development or already advertised. Taking advantage of our residency program and incorporating the LLSA articles into the formally presented content will teach our residents important content and help them improve critical literature review skills, but it may also draw more attending staff to these conferences. This past week’s resident conference session included an hour devoted to analyzing and discussing one of the 20 articles in the 2004 LLSA reading list (http://www.abem.org/faculty/index.htm) as part of our formal presentation of diagnosis and management of pulmonary embolism. It was the first time we directly incorporated this content into our conference and we plan to do work our way through all 20 articles this year.

So, I read the article in preparation for the conference and went as scheduled—and quickly discovered that I had read the words, but not applied critical reading and interpretation skills. I’m learning to read the emergency medicine literature all over again because of LLSA. Doctor Amy Church, our residency director, led off the discussion with a review of concepts: sensitivity, specificity, likelihood ratios negative and positive, etc. I disengaged a bit and then realized that Dr. Church was defining the negative likelihood ratio in a way I’d never heard it described previously. Now, she had my attention.

Things went downhill from there . . . at least for my ego. I’ve read a lot over the past 28 years, for many years I reviewed manuscripts for several emergency medicine journals. Clearly the standards have risen and I’ve obviously slipped in my critical reading skills for the medical literature. So not only do I need to learn the content of these 20 articles, I need to pay attention to the core concepts of evidence-based medicine if I truly wish to grasp the important content. Thus the ABEM EMCC process reminds me that learning never stops at many different levels. This LLSA program is going to be challenging, but I’m certain I’ll learn what I need to learn; I’m not giving up my ABEM certification anytime soon!

But, applying the evidence based principles in the article on diagnostic tests for pulmonary embolism will surely challenge my practice. Fortunately, today we work from practice guidelines more often than not and though our electronic record won’t be implementing decision support for some time yet, the selection of laboratory tests for pulmonary embolism this paper speaks to is something we can mostly work out with our chair of pathology and laboratory director. For surely that’s part of the purpose of the LLSA component of ABEM’s: integration of the important new knowledge into our practice.

And then the lights went out. I was writing this piece, trying to get it in on time (which would have surprised my editor) when the lights went out, in Brooklyn and in much of the Northeast. Once more we activated our emergency response plan as did many of you. We fortunately only operated on emergency power for 12 hours and then the lights came back on, but I learned an important lesson. We have no guidelines, no policies addressing the likely reliability of our generator power and our electronic medical records under these circumstances. Moving to paper or staying with the electronic medical record wasn’t addressed. Perhaps I shouldn’t have even considered the question, but past experiences with hospital generators was not confidence inspiring that the ~24 hours of generator capacity required would be available—in fact though other hospitals needed more than 24 hours of capacity, we needed only 12 hours and our system of five generators performed reliably throughout. Still, we nearly lost our electronic record 7-8 hours into the blackout because the air-conditioning in the computer command center had not been properly connected to generator power and thus didn’t fully function. New cabling installed by flashlight solved the problem, but not until the command center reached 102°F and several of our redundant servers went down.

We’re in the process of moving to the Hospital Emergency Incident Command System (HEICS) a version of the incident command system pioneered by fire services across the nation. A planning function is a specifically defined component of HEICS and would have been helpful during the blackout in addressing questions such as reliability of on-site power generation and consequent implications for continuing use of electronic medical records.

The JCAHO has through its standards essentially mandated the move to HEICS, but I saw the effectiveness of ICS generally during my many years in fire service EMS during the 1980’s. Part of the attraction of HEICS for me is that it allows a calibrated response rather than the all-or-none response of traditional hospital “disaster plans” for once the ICS command structure is in place, the incident commander can decide how much and what components of the plan should be activated. The Saturday following Thursday’s blackout provided a perfect example: we lost our internal telephone system for four hours.

The particular details don’t matter, but the hospital’s senior executive in charge convened the command structure in the telecommunications department rather than in the usual emergency operations center, a conference room. She also did not bring in workers from home—except for telecommunications staff and technicians. On-site staff activated the emergency telephone and walkie-talkie system which met the needs of effective response.

Yes, some imperfect decisions were made in responding to both events; just as in the clinical practice of emergency medicine where clinicians make decisions in the face of uncertainty, so too in potentially injury creating events[1] hospital managers can’t wait to make decisions and must make their decisions in the face of uncertainty. Implementation of HEICS supports both the decision-making process and the decision-maker.

[1]Koenig KL, Dinerman N, Kuehl AE: Disaster nomenclature--a functional impact approach: the PICE system. Acad Emerg Med. 1996 Jul;3(7):723-7.