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Emergency medicine: we can be heroes, just for a few days

2020; Lippincott Williams & Wilkins; Volume: 27; Issue: 5 Linguagem: Inglês

10.1097/mej.0000000000000748

1473-5695

Yonathan Freund, Damien Barraud,

Clinical Reasoning and Diagnostic Skills

We thought that the annually winter surge was one of our main challenges [1]. The COVID-19 crisis revealed the good, the bad and the ugly. Let us start with the good. There is no need to insist on how healthcare workers across the world, especially those in emergency medicine and intensive care medicine, had to adapt very quickly to the tremendous surge of severe patients. No healthcare system was ready to absorb this amount of sick patients in such a narrow time frame [2]. However, something came to our mind: we are used to dealing with great variations in emergency department (ED) visits. The winter surges or regular heat waves are known to put a regular pressure on us [3–6]. We adapt. Even during acute one-time dramatic events such as massive shootings, we adapt [7]. We are emergency medicine and we are used to work under pressure. We can be nothing but grateful and proud that we succeeded in treating all patients that we needed to (with rare exceptions). However, I cannot help but wonder: was it the case every time we needed it? We must ask ourselves why it was acceptable to have several patients in the corridors in our overcrowded EDs, sometimes for hours or even days, and why this was not the case during COVID-19 crisis? We can question why fragile patients with respiratory infection or flu-like symptoms may have suffered from suboptimal care every year with reported worse outcomes, while during this crisis the whole health system did everything they can to avoid any preventable loss from SARS-COV2? We need to remind our colleagues, institutions, stakeholders, and so on that something can be done to ensure that the best care is delivered to all patients, even if they are fragile, and even if they suffer from non-COVID19 infection. When looking at the good, we can see the bad that may be back sooner than we think. Will the afterworld be different for us, emergency physicians and our patients? Let us hope – a new hope, again [8]. Finally, this crisis also showed strikingly the very ugly face of research, publication processes, communication, and its consequences [9]. As soon as March, a famous French researcher decided that treating patients was more important than doing research – this can be a valid argument when anticipating a very short crisis with high mortality. However, we can wonder why no effort was made to follow a sound methodology even in the absence of a randomized controlled trial. The publication process also failed dramatically. This process is well established: submission, reviews, revisions, and then publication after peers are satisfied. The whole process needs independent experts, reviewers, and even editors. As an editor-in-chief, I would not tolerate to be the editor of my own work. The ethics would also recommend that I pass to a deputy editor the assignment of submissions from colleagues of my institution [9–11]. However, we saw that this was not the case for some researches during the COVID crisis. The publication of flawed research by a team of editors working in the same institution as the main authors, within 2 days after submission, should be a red flag. Unfortunately, during such crisis with so many lives at stake, some politicians or institutions decided to play experts and made their own recommendations, before thorough evaluation. This is not only true for hydroxochloroquine (although the main and probably most devastating example) but also for nonsteroidal anti-inflammatory or new expensive monoclonal antibody with limited benefit. We saw the advent of preprint publication, which is a well established process in disciplines like biophysics, mathematics, etc. But since clinical research may be conducted and reported with huge flaws that limits their intepretation, MedRxiv may not be the best way to promote research. In less than 6 months, the insane number of 6772 COVID-19-related articles was posted on MedRxiv. To fight this, we need to keep our head cold, hope that we could reduce the administrative duties to start a clinical trial, and maintain the same standard for publication. Here at EJEM, at our modest level, this is what we tried to do. We are not immune to be wrong, some journals with the best standards had to retract published papers with suspicious data, and may have published too preliminary reports with no control groups, and a methodologic standard that we were not used to see [12,13]. Acknowledgement Conflicts of interest There are no conflicts of interest.