Emergency Medicine at 50: reflections on our progress

The Royal College of Emergency Medicine (RCEM) is celebrating a landmark in is history: the 50th birthday of UK Emergency Medicine. To mark this event, RCEM has been doing a number of things. There was a CPR event, engaging with the public.

On 12th October RCEM held a celebration at its new headquarters in London, which ended by lighting the fountains in Trafalgar Square in RCEM colours.

Simon, Laura and I were also asked to write pieces to mark the occasion. I was asked to write some reflections on the progress of EM research. With RCEM’s permission, I’m now publishing that for free below. My contribution is one of 50 special chapters, each written by a different author. There are some real gems in there! You can buy a copy at this link.

My reflections on 50 years of EM research

My passion for Emergency Medicine began as a fourth year medical student in 1998, during my first placement in the Emergency Department (ED) at Stepping Hill Hospital, Stockport. One of the first things I noticed was how quickly the working days passed by. There is something about the unpredictability, the fast pace, the opportunity to work as part of such a close knit and multidisciplinary team, and the satisfaction of knowing that our interventions and human to human interactions can make a huge difference to patients during some of the worst (and occasionally final) moments of their lives.

I was in awe of those who worked in that environment, whose expertise made them ready to calmly and effectively deal with any medical emergency that should arrive without warning. The consultants I worked with inspired me. As a first year Senior House Officer in 2001, I still fondly remember the huge amount of time and effort they invested in my training. Pertinently, I remember the day that Dr. June Edhouse observed one of my consultations and was aghast that I had introduced myself as a “casualty doctor”. Her subsequent lesson about the history of our specialty and the compelling reasons behind our drive to rename it as “Emergency Medicine” made me feel like part of a ‘movement’ pursuing a worthwhile cause. Our specialty is still relatively small and (even at 50) relatively young. Each of us as individuals has the potential to heavily influence its future.

Through my early career, I had absolutely no intention of ‘going into research’. Research seemed to be almost the antithesis of Emergency Medicine, as it required such attention to detail. I wanted to work “at the coalface”, making a difference to patients’ lives. I didn’t want to be detached from real life practice in a laboratory. However, my day to day practice raised a tsunami of questions, which I realised could only be robustly answered through research.

This led me to write a number of Best BETs, which are an incredible resource for emergency physicians, and to design my first prospective clinical research study. In 2004, I was the sole applicant shortlisted for a registrar job in Lancaster: my ticket to a consultant job within 4 years. In advance of the interview, I met with Professor Kevin Mackway-Jones, an immense figure in the history of our specialty. He glanced through my CV and immediately advised me not to take the registrar job but to instead apply for a PhD. I instantly rejected what I thought was an absurd suggestion! It did, however, only take me a few hours of reflection to realise that he was completely right. Clinical research is the only way to advance the frontiers of what is possible in Emergency Medicine. Here was a huge opportunity to be involved in that. With a heavy heart, I withdrew from the interview. I was, therefore, probably quite a dejected convert to academic Emergency Medicine. It turned out, however, to be one of the best decisions of my life: the start of an incredible journey and a mission to improve emergency care guided by evidence and good science. It is hard to argue that there is anything more fulfilling.

Academic Emergency Medicine has made almost unthinkable progress since I started my PhD in 2005. Back then, there was no infrastructure to help with the delivery of my research. Recruiting patients to a prospective clinical study required my own personal effort for screening, consent, data collection, sample processing, follow up and data entry. We had no research nurses. Perhaps the biggest change came with the birth of the National Institute for Health Research (NIHR) in 2006, an institution that I would argue is now as important as the NHS itself.

The NIHR Clinical Research Network (CRN) and its Injuries & Emergencies specialty group (which I now have the privilege of being the deputy chair for) has revolutionised what we can achieve.

In 2015, we achieved our high level objective to ensure that every single Major Trauma Centre (MTC) in the country is recruiting to NIHR portfolio research. In 2016, we achieved another high level objective, to ensure that more than 50% of all type 1 EDs are recruiting to NIHR portfolio research. By achieving these objectives the NIHR CRN has ensured that the majority of EDs in this country have the necessary infrastructure (provided by the NIHR CRN) to deliver research without relying only on the blood, sweat and tears of full time clinicians in their own time. These advances now mean that conducting multi-centre research across the country is now straight forward, and there have been some great success stories leading to clear improvements in patient care. The CRASH-2 trial, for example, demonstrated that tranexamic acid reduces mortality for patients with major trauma and suspected haemorrhage. Not only has this treatment saved thousands of lives since the clinical trial, but we can calculate that even during the trial itself, the lives of 300 patients who participated in the trial were saved. This is a terrific testament to the potential benefits of participating in clinical research for patients.

As well as providing the infrastructure to deliver clinical research, the NIHR has been instrumental in providing invaluable funding for research studies (including, for example, the REVERT trial run by Andy Appelboam, which showed the effectiveness of a simple modified Valsalva manoeuvre for treating patients with SVT). It has also invested in individuals. I was extremely lucky that the NIHR funded 50% of my time during my final years as a Specialist Registrar and has funded 60% of my time for the past 5 years, at the start of my consultant career. The impact of that investment is difficult to overstate. More than we need money, to really make a difference with research, we need time. The NIHR gave me that time and it has given time to many others too, particularly through Integrated Academic Training. We should remember how lucky we are to have the NIHR: it’s revolutionised what we can achieve in clinical research.

RCEM, too, has played a huge part in growing our research capacity in Emergency Medicine. Two years ago, I was honoured to become an RCEM Professor. The title is honorary, lasts for a fixed term of 4 years and comes with no payment or extra time for research, although there is a professorial medal and gown held at RCEM to be used for special occasions! The title is, however, very prestigious and has a hugely positive impact on the career potential of an individual. It is probably no coincidence that within two years of taking up this post I was offered a Visiting Professorship at Manchester Metropolitan University, followed soon after by a tenured Professorship at The University of Manchester. The RCEM Professors, in return, must make a valuable contribution to RCEM. Our outgoing Professor, Jason Smith, has made an immeasurable contribution in this regard by running the James Lind Alliance Priority Setting Partnership, which will set research priorities in our specialty for years to come.

I’ve also been privileged to chair this year’s RCEM Clinical Studies Group, which was founded by Alasdair Gray (during his RCEM Professorship). This group creates a national network of emergency physicians interested in research, allowing us to feed off each other’s ideas and build fruitful collaborations. It also appropriately recognises the contributions of outstanding individuals through the Young Investigator and Principal Investigator of the year awards. Again, in making such awards and formally recognising the efforts of those individuals, we encourage more people to be research active and give academic careers an important boost.

In the last few years we’ve seen the RCEM Annual Scientific Conference really grow. I had the honour of chairing the organising committee for the Manchester conference in 2015. Thanks to the incredible contributions of so many internationally renowned speakers, the conference sold out months in advance. We could probably have sold twice the number of tickets if we had the capacity to do so!

#RCEM15: 24 HOUR EM PEOPLE

And this trend has continued, with the Bournemouth conference also selling out: a sure sign that, despite all the pressures and challenges of our day to day working lives, Emergency Medicine has a very bright future.

Next year we will have a joint conference between RCEM and EUSEM in Glasgow, which is a very exciting prospect. I’ve been the Scientific Chair for the EUSEM Annual Congress since 2014 and we’ve seen similar growth in the popularity of that conference, perhaps reflecting the growth of Emergency Medicine in Europe. The relationship between RCEM and EUSEM is so important: our European friends will rely on us for help, support and advice as they fight the same hard battles that our colleagues fought in setting up Emergency Medicine in the UK 50 years ago. Building these relationships will open up fantastic opportunities for collaboration. The European Dyspnoea in Emergency Medicine (EURODEM) study, for example, was an exemplar project for pan-European collaboration in Emergency Medicine. The study recruited over 2,500 patients in just nine days and the UK played a huge part in delivering that, with 15 recruiting sites.

As we celebrate the 50th anniversary of Emergency Medicine, we should think about the future. Our specialty is almost unrecognisable from the specialty that Maurice Ellis and colleagues worked so hard to found in 1967. What will it look like in another 50 years? It’s impossible to predict the future, but it seems to me that collaboration will be pivotal. With established national and international networks, were surely likely to see larger studies, delivered rapidly and efficiently to achieve clinical impact as soon as possible. I think we will also see increasing collaboration across ‘acute care’ specialties like Critical Care, Acute Medicine and Pre-Hospital Care. We will hopefully build more effective collaborations with industry. Of course, that has to be achieved with the highest ethical standards, but we live in a world where the best innovations are rapidly commercialised. By working with industry, we can make sure that those innovations really do put patients and the NHS first to maximise real life benefit.

Lastly, we need to create a culture whereby participation in research is the norm for emergency physicians and our patients. In Manchester, we have one of the largest cancer hospitals in the world: The Christie. There, an amazing 20% of all patients participate in clinical trials. If we could achieve something similar in Emergency Medicine, just think about the progress we could make. Crucially, just as it was Maurice Ellis and his colleagues who drove the formation of our great specialty 50 years ago, it’s us (as emergency physicians) who need to be driving that change in culture.

There are huge pressures in Emergency Medicine, and they’re unlikely to go away any time soon. But let’s remember just how far we’ve come, and how far we’ll go if we continue as we are. These are exciting times, and the future of Emergency Medicine is very bright.

Rick

Thanks so much for following. Viva la #FOAMed

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