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smaccGOLD and the rise of the Synthetics

2014; Wiley; Volume: 26; Issue: 3 Linguagem: Inglês

10.1111/1742-6723.12239

1742-6731

Rory Spiegel, Michelle Johnston, Tor Ercleve, Christopher P Nickson,

Space Science and Extraterrestrial Life

Time sure flies when you're having fun. It seems just a month or two ago that the first edition of ‘Dispatches from the FOAM Frontier’ was rushed into print. You will recall that this series announces discoveries material to the lost origins of the Federation of Outer-rim Allegorical Migrants (FOAM, or The Federation for short), a primordial chaos of which all records were lost during The Dogmalysis Wars. Of course, investigations into the past are complexified by the tense rivalry between the Time TravelTM Guild and the Astro-Archeological Society. Despite claims that reports from Time Travellers are (at best) unreliable – we have dared to present to you one traveller's account of the smaccGOLD Singularity event. First we must give you this disclaimer: the Time TravelTM program has once again been shut down due to serious breaches in Temporal Security Agency (TSA) protocols. Such breaches threaten to destabilise the entirety of the space–time complex and accounts of such journeys must be taken with a large grain of sodium iodide. After all, how can we be sure that they have gone to our past, and not that of a nearly identical, but parallel universe? There was no need to advertise. The reverberations of an event as colossal as the #smaccGOLD Singularity are felt throughout the strata of time and across the layers of space, and individuals will make their way there via any means possible. Indeed it was to enable people to attend events like this in person that Time Travel™ licences were once released to the general public. This particular conference (which occurred in 2 AF – a time long ago, in the gurgling infancy of the FOAM paradigm) shone brightly through the universe, sending out signals across the galaxies. It was attended by many of our kind, from various eras and planets, all eager to experience this event in person. It is generally agreed that #smaccGOLD was a pivotal point in the history of FOAM. The momentum of this neoteric and global critical care communication had taken on a new veracity, spreading like synapses across Old Earth. Everybody had heard about this meeting, and many individuals across the universal time and space complex took the opportunity to drop in unnoticed (in accordance with TSA rule number 2*). There were, sadly, a few transgressions recorded. We were fortunate that several alien sightings were overlooked in the general excitement and furore of the meeting, and were not mentioned except for the odd passing comment over drinks in the smaccLounge). There have been detractors throughout subsequent history, criticising this meeting as having an overabundance of enthusiasm – as being heavy on the rhetoric and hero worship, and somewhat light on slides packed with cut-and-pasted excerpts from the peer-reviewed literature (the gold standard of the time). It also clogged the Internet with over 25 million #smaccGOLD ‘impressions’ on Twitter. However, it must be remarked, that this meeting was pioneering in a number of ways; it brought together all types of critical care practitioners, including many medical specialties, nurses and paramedics, and encouraged a more interactive and engaging style of presentation, far removed from the conservative conferences of old. Those that attended returned to their own time and their own planets, imbued with the same enthusiasm that suffused the Earthlings from the early 21st century who signed up all those millennia ago – an impressive feat for such an ancient event. The overarching themes of the meeting were: (i) an examination of the dogma and pseudoaxioms that had been blindly propagated throughout medical history to date; (ii) the re-examination of the human side of critical care; (iii) the outing of new and embryonic ideas of the time; and (iv) encouraging everybody in critical care to break down the barriers between medical ‘tribes’ in order to provide the best care for patients. Each of the talks at this meeting were recorded and stored for posterity.3 They were released in stepwise fashion on each of the affiliated websites in the months following the conclusion of the meeting, and we would recommend that anyone wanting a fascinating historical review of this meeting to visit these (now somewhat archaic) websites. Special note needs to be made of a rather peculiar line that was trotted out several times during the meeting. ‘Half of what you know today is wrong, but we don't know which half.’ Although used to illustrate the concept of trusting nothing that one is taught, it became dogma itself, and thus a self-referential statement of irony. The true paradox here, is that we now know which of the concepts discussed at #smaccGOLD went onto be proved incorrect, but in accordance with TSA Rule Number 5**, we are unable to disclose which they are. Without a flagrant disregard of the rules, however, we can assure you that the percentage of ‘wrong facts’ at this meeting was well under the 50% quoted in this statement. Temporal Security Agency. Rule Number 2: When travelling outside one's own Time Era, it is forbidden to have any interaction with the natives of that time period. Any breach will result in Time Travel™ License cancellation. Temporal Security Agency. Rule Number 5. There can be no written information which allows data from the future to be accessed by the past, particularly if it involves education, thus allowing an unfair advantage for the data recipient. While the time travel apologists slathered over fanciful accounts of the smaccGOLD Singularity event, the skeptical Astro-Archeological Society continued to send agents to the Federation's Outer-Rim in a quest to find more tangible truths. An enticing dispatch from one such unnamed agent relates the forgotten story of ‘The Rise of the Synthetics’… For those of you who have spent entire lives in the CORE, your knowledge of Neurologists stems only from fairy tales and ghost stories. The fact is since the end of The Great Lytic Wars, neurologists have secluded themselves away in the Dendritic Towers of The Academy. Even before The Time of Seclusion, the majority of patient interactions was performed by the Synthetics. As my superiors were unable to gain official access to the Dendritic Towers, they have sent me to the Outer-Rim to pursue one of the few remaining non-secluded Neurologists. Banished from the fold, a few enigmatic indiviudals make their livings on the Rim in academic purgatory. After months of searching, nearly completely depleting my discretionary funds on bribes and alcoholic persuasions, I finally obtained a promising lead. On a small outpost far beyond the ruined moon colonies of Seres Mu, just past the Reynold's Shipping Colonies, is a rest stop called Korsakoff's Poison. It was rumoured that at this establishment a flesh and bone Neurologist (his name redacted to preserve anonymity) spent his leisurely hours. It was here that I spent 18 h amid a haze of jimson weed smoke learning of the fall of the Neurologist overlords and the rise of the Synthetics. Thrombolytics, in their nascent form, were first introduced as a viable treatment for ischaemic stroke toward the end of the 20th century on Old Earth. Although there was resistance from the Emergency Physicians required to facilitate this would-be therapy (deemed The Hoffmanites after the founder of the movement), their stance was severely weakened when almost a decade after tPA's FDA approval, the American College of Emergency Physicians (ACEP) published their policy recommendations supporting thrombolytics in the management of stroke. Most historians cite this document as the first shot of the The Great Lytic Wars, but the conflict came into its own when a probing editorial in the BMJ by Jerry Hoffman and Jamie Lenzer questioned the financial backing of this guideline.4 A storm of rapid-fire responses erupted and war was officially declared,5 with the Fatovich–Webbians6, 7 joining forces with the Hoffmanites as the tumult spread to encompass all of Old Earth. The Great Lytic Wars went on for centuries. Peace was not achieved until the eventual publication of NINDS 3 when tPA was finally discredited and lost its FDA approval. It was during the early years of the Lytic Wars that we saw the arrival of the Synthetics. When ACEP's clinical policy on thrombolytics was published, the only thing holding the Neurologists back was their overt avoidance of the ED (particularly at night when most medical emergencies seemed to occur). To combat this obstacle the Neurologists developed the Stroke Bot. The early version of this technology amounted to an LED screen on wheels with a high definition camera that the Emergency Physician would wheel to the patient's bedside. This device allowed the Neurologist to examine and consent for tPA administration remotely. Though the Stroke Bot solved the logistic problem of having to be physically present, patients found the experience lacking and the neurologists quickly discovered that patients were less apt to agree to tPA therapy when consented by the Stroke Bot. Genecorp, avid supporters of stroke research, could not bear to think of potential patients missing out on this ‘lifesaving intervention’ and immediately began working on a solution to this problem, the Genecorp Synthetic Neurologist. Borrowing technology from their new line of synthetic pharmaceutical representatives, Genecorp created a life-like cybernetic organism designed to examine and consent stroke patients for tPA. Numerous models were developed. Designed after famous neurologists, each generation of synthetic were stringently tested against real-life physicians to discern which would have the highest consent rate. After countless failures (the Sacks-Bot was too tangential, the Babinski-Bot too blunt) the manufacturers settled upon the likeness of David Newman-Toker a neurologist renowned for his work on the diagnosis of posterior fossa strokes. Dr Newman-Toker was not only well spoken and intelligent, he was also a caring physician who spent time addressing his patients’ concerns. It was these very qualities Genecorp hoped to exploit when they built his synthetic. And thus the High Intel Newman-Toker Synthetic, HINTS for short, was born. For centuries stroke patients throughout the CORE were consented for tPA using the likeness of Dr Newman-Toker. The fact that these misdemeanours were committed under the likeness of one of Neurology's great minds was a heartless twist lost on many. It wasn't until after the Lytic Wars came to an end and thousands of HINTSynthetics lay idle without a purpose that someone thought of using this technology for a task worthy of their inspiration. Not only were the Synthetics trustworthy and comforting but they also performed a flawless neurological exam. So well in fact that, like Newman-Toker himself, they were able to discern the subtlest neurological findings and differentiate central causes of vertigo from benign peripheral pathologies. The HINTSynthetics were reborn. Physicians of the CORE were now able to utilise a Synthetic, who in minutes of examining a patient could safely discharge them home certain that their symptoms were of peripheral origin. No villain has been so completely redeemed since Jamie Lannister lost the hand that slew the Mad King. As with most news from the CORE, stories of the HINTS rebirth reached the Outer-Rim through hearsay and gossip. Nonetheless, FOAM practitioners were quietly overcome by a slow and steady stream of rumors. A bedside test that could safely and accurately differentiate central from peripheral vertigo. For a group of medical practitioners who lacked the vast array of resources their counterparts in the CORE possessed, this news seemed too good to be true. The HINTS exam, which consisted of the head impulse test, test for skew and examining for multidirectional nystagmus, as performed by a HINTSynthetic was close to perfect. It was originally introduced to the FOAM world by @emcrit in his 33rd podcast8 and given the influential status he deservedly held, many FOAM practitioners looked to integrate the HINTS exam into their everyday practice. Others had concerns. Was the HINTS exam, when performed by a human practitioner blessed with our own wonderful imperfections, as accurate as that conducted by a Synthetic? Debate erupted about this very topic. On the original post by @emcrit the comments section seethed with discussion of the potential for misclassifying the subtle findings of the Head Impulse Test, the first of the three tests in the HINTS battery. @DrSenthi astutely pointed out that in the original HINTS manuscript the exam was performed on high risk individuals (70% had vertigo of central origin) by two highly experienced examiners. How well this test would perform when utilised by novice users in a more generalised ED population remained unknown.8 @EmLitofNote addressed similar concerns in a blogpost entitled HINTS vs ABCD2 in Dizziness.9 @EMLitofNote noted that though the HINTS exam has near perfect test characteristics, a sensitivity and specificity of 96.8% and 98.5%, respectively, its performance may suffer when it is applied to a more generalised, low-risk cohort. Finally, @emjclub produced archived audio of Dr David Newman-Toker himself discussing the diagnostic capabilities of the HINTS exam.10 Dr Newman-Toker argued that in the hands of an expert user the HINTS exam is a powerful tool. He also went on to say there is no reason why Emergency Physicians could not become experts in interpreting the subtle ocular findings utilised in the HINTS exam, but cautioned that novice users tend to overcall a positive head impulse test leading to possible false negative results. The utility of the HINTS exam in the hands non-synthetic practitioners remains uncertain. Regardless, the work done by David Newman-Toker in the diagnosis of posterior fossa stroke in both his original and synthetic forms is immensely valuable. Though the HINTSynthetics were built for less than noble purposes, their rebirth realised the benefit of a simple yet powerful tool for the diagnosis of posterior fossa strokes. Redemption is indeed a fine thing. Dispatch complete. Special thanks to Dr Newman-Toker for his generosity in allowing us to use his likeness both in fictional and synthetic forms. CPN is one of the organisers of smaccGOLD. The section on smaccGOLD was written by MJ. CPN did his best to temper her attempt at hagiography.