When FOAM Doesn’t Wash

The following scenario is completely fictional although it is used to represent a real-life incident. All details have been changed.

 

“Hey – you’ll want to know about this – you’re into that twitter thing, aren’t you?” your consultant colleague Dan asks as you stroll, coffee in hand, into the office on Monday morning. There’s something about his tone; it’s more of a challenge than a question. But you’re interested. “Know what?” you reply, looking up from your smartphone screen.

 

Image courtesy of stockphotos / FreeDigitalPhotos.net
Image courtesy of stockphotos / FreeDigitalPhotos.net

“James, the ST4. He got a needlestick from a drug user. You’ll never guess what he was doing.” He pauses for effect. “He was using the ultrasound – and another needle – to remove a snapped off needle from the IVDU’s arm.”

 

“What? Had he x-rayed the arm?”

 

“Yep – he knew it was in there. He’d found it with the ultrasound too. Only, instead of referring to orthopaedics to remove it under the image intensifier like any normal doctor, he decided to fish around with another sharp to try to remove the thing himself! And he was going to use a scalpel afterwards to cut down, he says! Read it on the internet somewhere. Bloody dangerous if you ask me.”

 

Image courtesy of imagerymajestic / FreeDigitalPhotos.net
Image courtesy of imagerymajestic / FreeDigitalPhotos.net

“And how’s James?” you ask, with a sinking feeling, remembering a post you’d seen on a FOAM blog.

 

“He’s crazy! But he’s fine. He’s over in occupational health having his bloods taken now. IVDU thinks she’s HIV negative, which is lucky. It was a real job trying to get samples from her too. Why is it the ones who are covered in tattoos are always the ones who are needlephobic? Anyway, he’s learned his lesson now. You can’t believe any of that stuff you read online.”

 

You take a slow mouthful of your coffee as you think about what you are going to say next.

 

Where do we stand when FOAM goes wrong? How can we present the advice of our international colleagues – people we feel we know and interact with on a regular (maybe even daily) basis – to our peers who do not engage in social media? How can we hold up to scrutiny the practice of clinicians we respect but have never met?

I have found myself in a situation similar in principle (but entirely different in practice) to the one above, and struggled to rationalise my belief in the knowledge and wisdom of the people who seem to outsiders to be little more than “invisible internet friends”. What would you say to the colleague, eager to discredit all of the fantastic experience the FOAM movement brings because of one misunderstanding or misapplication?

I don’t know what the answer is – but I really hope this provokes some debate.

 

Disclaimer: it took quite some time (and a lot of discussion!) to find a plausible alternative example of something which might be adopted into practice from a FOAM blog but provoke a significantly negative reaction among UK clinicians when something went wrong. I do not mean to suggest that the tip alluded to in the example above is dangerous practice; it merely served to illustrate the point.

20 thoughts on “When FOAM Doesn’t Wash”

    1. The simple answer:
      It’s different because if I show some new technique on my blog, that’s just 1 person behind it. If a new technique is published in PR lit, it has at least an editor, reviewers, and (theoretically at least) the weight of the editorial board behind it.

      Which is why every management tool in the top journals is always the right thing to do…

  1. Natalie,

    Thanks for the thought provoking post.

    My perspective on FOAM going wrong is not a whole lot different than when thing goes wrong in general. Because FOAM is a new medium, I would agree that it is important to be somewhat hyper-vigilant in terms of how we apply things we learn from it. However, I’d be interested in hearing why, for example, someone would point to FOAM as the problem when something goes wrong if they wouldn’t point to a lecture or a course as the problem when something learned there results in a bad outcome. In both cases the recommendation is the result of an individual interpreting the evidence in light of their practical experience. We need to judge how credible the combination of those two things is for application in our practice.

    My bottom line: we are each responsible for how we choose to practice. A well-referenced FOAM post written on a site and by a source that I deem credible is as relevant to me as a well-referenced presentation. Whether I choose to apply a tip or not is going to be based on my collective experience and comfort with it.

    I look forward to hearing from others!

    -brent

  2. Research in a journal or textbook methods have been subject to peer review…and the authors are generally ‘experts’ with established credibility. You wouldn’t (?shouldn’t?) change practice based on a single case report. Anecdote expressed online cannot (?should not?) be treated as practice changing without critical review of the evidence.

    1. It may be different because of the direction of information flow. When Mr X tells you I presume that is senior to junior. Are we concerned with FOAM because it is easier to reverse the flow so that information might be differentially found in a more junior population of clinicians. No evidence for this, just anecdote but interested in what you think.

      S

      1. Now I’m going to be really provocative – what is the evidence that senior – junior info flow is necessarily of higher quality than junior – junior peer-to-peer review? 😉 (Generally I think the information I have received/witnessed from seniors is good, but it’s not a given…..)

        More seriously, most FOAMeders are attendings/consultants or relatively senior trainees, no? Certainly the ones with the widely subscribed blogs. Add to that the real-time peer review on blogs, I think you can argue that it has potential to be better quality.

        Anyone who takes an idea just from an unsupported Youtube video is as daft as the one who acts on the statements of their mate over a brew in the mess without engaging brain – I don’t think the virtual nature of the interaction makes that much different.

  3. Hey there,

    I’m really glad that i’m not the only person who thinks that FOAM is merely a medium, but it is the audience members/consumers of the knowledge that are, ultimately, responsible for uptake and decisions.

    Should probably think about the role of the patient and issues around consent if you’re gonna try something ‘new’. Patients might want the ‘traditional’ method… esp, if you’re supported by evidence…

    If I were a patient, I would want to know if my doctor was trying some experimental, new technique…. And as an attending, I have actually started explaining this to patients – when they are unique or require some innovative methodology. I also explain alternatives and sometimes they choose that (e.g. expert consult).

    T

  4. Great discussion piece. I think this issue is the elephant in the room when FOAM content is discussed in the clinical setting. How trustworthy or blameworthy is FOAM content? I agree with Brent in that social media content on blogs and podcasts are more easily targeted just because they are free, and digital natives are gravitating to this medium for learning. We should be more thinking — how trust or blameworthy is ANY content that we learn from?

    As a textbook author and editor as well as a peer-reviewer in some journals, I think people would be surprised to hear how the vetting and “peer review” process” really works… Essentially it’s not as hallowed as many make out the process to be. I’ll leave it at that.

    That being said, I indeed would be hesitant to accept uncited anecdotal stories as truth whether they be digital or print resources. They are interesting to know about because they may eventually end up being standard of care in the future. However, many things we do will never be robustly studied (approaches for foreign body removal, as in this case). On a case by case basis, we should make our own careful judgment whether to adopt slightly new variations, in light of all the other factors involved such as — level of provider training, availability of auxillary resources to help with technique, technical proficiency (e.g. ultrasonography), and patient compliance. I agree with Kristy, this is often no different than a “this was how I was taught” or “Dr. X said to do it this way.”

    FYI, for this case above, Roberts and Hedges reported a 2-needle approach on this technique without providing a citation. In the end, a scalpel would have been involved with the case and a needlestick/sharp injury may still have occurred.

    Great idea to have this discussion and looking forward to hearing what others’ opinions.

    1. Hi Michelle,

      Absolutely agree with your comments about peer review. It’s a system with evidence that it does not work well, yet we still hold it as a gold standard in journals.

      If you are interested in that sort of thing then Richard Smith’s ‘The trouble with medical journals’ is a great read and summarises peer review nicely as ‘the least worst system we have’.

      A jolly clever chap, and I love the related piece on ALiEM.
      http://academiclifeinem.com/is-foam-to-blame-when-a-medical-error-occurs/

      S

  5. Agree with the rest. Regardless of where they got the information, it’s only quizzical if they are drastically different from the norm.
    Nothing about peer review makes it perfect, and nothing about FOAM makes it always wrong. The people who dislike FOAM due to the essence of it are the same “you kids get off my lawn” types. All FOAM does is tries to shorten the time between discovery and implementation, which still takes decades.

  6. thanks for the provocative post Natalie. As you know this is something we started to tackle at SMACC2013. Since then its been an ongoing unaddressed issue. Nickson tried to get it being discussed on LITFL with his charter piece and now this article by you revisits it.

    In that time since Chris’s article, I note the North American FOAM community in at least two groups has proceeded with a couple of strategies to address trust/credibility of FOAMEd: prepublication peer review and branding of posts as being expert peer reviewed.

    I believe your hypothetical case is as you point out something all of us have witnessed in one form or another throughout our careers. Its nothing in fact unique to FOAMEd. Its just FOAMEd in some ways makes the opportunity for such a case to be more likely.

    I recall the first case of stroke thrombolysis in ED I was involved in, when a new medical registrar who had just worked at a stroke centre, came to see my patient and then all of sudden was getting the nurses to administer the lysis! our ED at time had no formal stroke lysis protocol and when I notified our ED consultant he questioned the registrar. BUt there was no stopping this registrar! He counselled the NOK and lysis was given within the accepted time frames and…did absolutely nothing!

    My point is even in areas where we think the evidence is on safe ground, we can still have divergence of clinical opinion and doctors making decisions based on a range of factors, least of which might even be peer reviewed EBM!

    In fact if it werent for FOAMed I would have been none the wiser of the controversy in stroke lysis!

    Whether you read /listen/watch something about a novel or experimental technique via FOAMED, journal, conference, you must decide what to do with the idea/information.

    FOAMEd cannot replace clinical experience. It may supplement it but for now it cannot replace it.

    I believe it is our duty as physicians/nurses/paramedics/RTs/PAs, to continually strive to improve what we do in clinical care. This means remaining open to new ideas and thinking about their potential benefits in our daily work.

    Of course, there is a spectrum of risk /benefit when dealing with novel new concepts! NODESAT/nasal cannula oxygenation is safe and offers potential significant increase in safety in RSI
    Using Well’s score <2 to rule out PE completely..may offer benefit but increased safety is yet unproven and so ratio of risk/benefit is uncertain at best!

    Both are examples of new concepts propogated almost solely via FOAMEd but demonstrate the spectrum of risk/benefit.

    I think the only way to navigate this spectrum is with sufficient clinical experience.

    There is a paradox that has not been mentioned yet. A lot of feedback I receive is that by using FOAMEd, many clinicians have found renewed or new motivation to digest the traditional medical literature/research base. The conversations within FOAMEd have stimulated a greater yearning to know more and more importantly understand more.

    this must be a good thing.

    everyone cites DSI concept by Weingart as being a prime example of the benefit ofr FOAMed. The deeper aspect to DSI is not that you use ketamine or whatever but the concept

    1. I think a lot of the use of FOAM also comes down to risk benefit to both clinician and patient. With any article that is published we take into account its credibility and apply with caution. The same should apply to information gathered from any other medium including teaching from seniors.
      For example a new technique in shoulder reduction if wrongly applied is unlikely (although I accept plausible) to have any serious consequences.
      However, a new unvalidated technique to rule out AAA could have huge consequences.
      In this case the predominant risk was to the clinician and as ED clinicians we take risks everyday.
      Where guidance is available I accept that going off track could be negligent. But where there is low risk of harm we need to develop new strategies to improve ourselves.
      Clinicians using foam should always consider other more accepted techniques but modification is what makes us 21st century clinicians.
      Excellent post Nat – thanks

  7. I saw a reshared tweet from (the late and great) John Hinds saying that #foamed should never be trusted per se and that the original literature should always be looked at. I asked Rick Body if anything had ever gone wrong by following #foamed and he pointed me at this post – different in that it is about a practical technique rather than something research based. The real pity is that the true example could not be used. We could then have looked at the original post sharing the practice and see if limitations were stated. We could also see what the response of the community was to the original post too. I think these are the things that would help me to decide whether to follow a practice I had ‘read about on the Internet’. We are a community,

    1. While the details of the original incident cannot be shared, the fictional example is accurate in representing real-life colleagues’ responses to another clinician using a practical tip gleaned from a FOAM blog. For the tip cited in the example above, the original blog post is here.
      You can see the original comments in support of the technique there too.
      Of course, peer-reviewed published articles – including case reports – share similar risks and the question of when to change practice was addressed by Simon at SMACC Gold: link here.

Thanks so much for following. Viva la #FOAMed