The Journal of Emergency Medicine, Vol. 36, No. 2, pp. 188 –189, 2009 Copyright © 2009 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/09 $–see front matter
STILL CRASHING AFTER ALL THESE YEARS Fred Leonard,
you don’t know what model aircraft you’re flying, just use 100 knots as the takeoff speed. Fortunately for us and a limited pool of aircraft accident investigators, airline pilots hold themselves to a somewhat higher standard. Why has there been so little progress? It’s not for lack of activity and attention. There have been several highly publicized Institute of Medicine (IOM) reports that directly addressed medical error and our dysfunctional medical care system. The more recent reports specifically considered the mounting problems we face providing emergency care, but these have been largely ignored by policymakers and by those outside the emergency medicine community. But the earlier IOM report, “To Err is Human: Building a Safer Health System,” attracted enormous and ongoing attention by speculating just how many people our medical errors kill. The somewhat questionable but shocking numbers they came up with launched the bureaucrats and policymakers at full-warp dither to form study groups, umbrella organizations, and task forces. Among others, we now have the Leapfrog Group, the National Quality Forum, the Agency for Healthcare Research and Quality (AHRQ) and, of course, The Joint Commission (TJC—shortened from JCAHO, previously changed from JCAH) all issuing suggestions, directives, policies, standards, and edicts intended to improve the quality and safety of our patient care. The IOM report also spawned a continuing stream of articles on patient safety and medical error in everything from supermarket tabloids to scholarly publications, including those in our own specialty. Yet, almost a decade after that first IOM report and repeated observations that we need to standardize and simplify our practices, equip-
It would be nice, in this 25-year retrospective, to note the remarkable progress we have made since “Of Crashes, Catheters, and Confusion” was written. It would be nice, but it would be fiction. To be fair, there have been some changes. In aviation, flight engineers are no longer part of a contemporary cockpit crew, and the airlines have continued to improve their already excellent safety record. Unfortunately, neither airline customer service nor the safety of air medical transport has followed suit. In emergency medicine, we have come to accept the term “ER” as firmly ingrained in our television culture, and the alternative and previously preferred term “ED” has instead become irreversibly associated with older males taking little blue pills. The term “M&M” (morbidity and mortality) has also given way to “CQI” (continuous quality improvement), a change that may again have more to do with culture than content. But despite our switch from M&M to CQI, we still have the same appalling lack of standardization and the same unnecessarily muddled and confusing system of nomenclature and measurement that we had 25 years ago. In fact, some things may have changed for the worse. Twenty-five years ago our defibrillators lacked standardization, but at least they used the same energy levels. Now we have machines with differing waveforms and differing recommended energy levels. This is despite any evidence that one waveform results in any better clinical outcomes than any other. The American Heart Association suggests that if you don’t know which biphasic defibrillator you have (rectilinear or truncated), just use 200 joules. Don’t know? That would be like saying if
RECEIVED: 21 April 2008; ACCEPTED: 22 April 2008 188
ment, and processes, overall conditions in most emergency departments have gotten worse. So why have we seen so few tangible results? One reason is that many of the people telling us how we should reform the house of medicine seem to know very little about it, and they may have agendas that don’t always serve our patients. The recent TJC standard regarding pharmacists’ prospective review of medications administered in the emergency department is just one example. In aviation, this would be like requiring flight crews to wear bulky parachutes after discovering that a mechanical defect was causing airliners to crash. These solutions often not only don’t solve our problems, they create new ones. But a more compelling reason that we are still in this mess is that we have not taken the initiative to improve our own practices. In some ways we fit the description variously applied to both the navy and the fire service, “200 years of tradition unimpeded by progress.” Although we do embrace technological change, we cling to traditional practices that impede our care. Why do we continue to use incompatible and arcane 19th-century systems of measurement for our tubes and needles? Do we really need to be identified as the only medical care system outside of Liberia and Myanmar that doesn’t use SI units? Further, is there any value added (except in taking a board examination or talking to an orthopedist) in knowing for which dead Italian physician a particular forearm fracture-dislocation is named? Medicine is rife with eponyms that not only don’t help us care for our patients, they make it more difficult. And no specialty is immune. The pediatricians, hyphen-lovers that they are, have brought us such edifying eponyms as Hand-SchullerChristian disease and Chediak-Steinbrinck-Higashi syn-
drome. Even worse, these eponymous conditions are sometimes referred to by just one or two of their eponymous components, and the components are arranged in varying orders. Imagine if the devices or instruments in an aircraft cockpit were identified with one or more eponyms instead of descriptive names. What would that do for crew coordination and flight safety? We have enough to remember without having to use a system of nomenclature that adds nothing useful in identifying or describing the conditions we diagnose and treat. Useless information displaces useful information. It is time to leave the eponyms and archaic systems of measurement to the medical historians along with the miasma theory of disease. It is also past time to do what we should have done 25 years ago. We should take the lead in reforming this area of medicine. If we don’t, people who don’t understand what we do for a living may do it for us, and we have seen the questionable solutions that can produce. We don’t need randomized clinical trials and meta-metaanalyses to confirm that needless complexity and a lack of standardization interfere with our ability to effectively and efficiently deliver patient care. In emergency medicine, more than in any other medical specialty, we have to make critical decisions with limited information in a limited amount of time. We need to get rid of systems that regularly result in error unless something active is done to prevent it. Getting this right, and getting it right soon, should be something on which the American Academy of Emergency Medicine, the American College of Emergency Physicians, the Society for Academic Emergency Medicine, and our other professional organizations can agree and take action. For the sake of our patients, we should not wait another 25 years.