Metajournal on Ketamine, Checklists and Social Media with ice-cream

As I read articles this week, three very different papers created a nexus of interest and push-back against mildly dogmatic thinking in the critical care specialities. Two challenge existing anaesthesia dogma, while the third highlights the potential for missteps when incorporating new media into our practice and education.

Although critical care specialties like anaesthesia and emergency medicine are often seen from the outside as embracing change and being unafraid of dipping our collective toes into the rivers of progress, there are still many strongly held views that persist even in the face of contrary evidence.

Ketamine and persistent pain

Chumbley, Thompson, Swatman and Urch report in the European Journal of Pain the results of their double-blind, randomised, placebo-controlled trial of a 96-hour perioperative ketamine infusion to reduce persistent post-surgical pain after thoracotomy. Notably they found that this significant-duration ketamine infusion did not reduce post-thoracotomy chronic pain.

This paper is the first quality RCT to follow thoracotomy patients for a year after surgery in the setting of perioperative ketamine. It adds to existing evidence suggesting a lack of effect of ketamine for mitigating persistent surgical pain – even though this has been a popular opinion (hope?) among anaesthetists and pain specialists in the past. The results of the ROCKet trial will provide us with more confidence in answering this question.1

Computerised checklists

Jelacic and team describe in Anaesthesia the use of an aviation-style computerised pre-induction anaesthesia checklist, and the positive effects they observed for this reducing pre-anaesthetic setup errors and non-routine events. Although an observational trial with associated short-comings (explored in the summary), they found an absolute risk reduction of almost 4% of failure-to-perform critical pre-induction steps!

The pro-checklist crowd will point to this as further evidence of our need to set aside cultural resistance to routinely use cognitive aids and embrace checklist use. The anti-checker cowboys 🏁🤠 will see a threat to their autonomy and individualism, and rightly highlight the lack of real outcome evidence.

The truth will probably fall somewhere in between, although it is clear that to be effectively used any checklist system must be contextualised to both the situation and the user of the tool. This is often lacking when checklist requirements are pushed from the top down. One way of framing is to prioritise the targets of a checklist so as to empower the clinician, leveraging their agency and autonomy to improve patient outcomes, rather than a disempowering, lowest-common denominator approach that is often the default.2

FOAMed & social media mistakes

Finally in the EMJ, Edwards and Roland from EM3 (East Midlands Emergency Medicine Educational Media) analysed two inadvertent FOAMed social media incidents where educational resources containing factual errors were shared from EM3 social accounts. Although the errors were quickly identified and corrected, the incorrect posts continued to be shared, reaching some 15,000 people.

This is not a new problem for medical education and research translation, with Tatsioni, Bonitsis and Ioannidis (JAMA 2007; 2005) showing how incorrect and disproven medical information is often shared and cited for decades even after it is known to be false.

Edwards and Roland’s careful description of the events, their efforts to rapidly correct the record and EM3’s additional peer review steps make for an interesting read. Between the lines however, this SoMe situation provides a lens to consider how we assess the credibility and accuracy of medical communication. In fact, there are more similarities than differences between traditional medical publishing and FOAMed – the primary difference is the scope and velocity of publishing. While SoMe widens distribution and speeds dissemination of information and misinformation alike, it then provides equally fast peer review and correction.

This is likely a net positive...

  1. A collection of related articles can be found here: Does ketamine reduce persistent post-surgical pain? 

  2. A collection of articles regarding the WHO surgical safety checklist and its consequences is also worth a deeper read.