After my recent Resus Room Readiness post, my buddy James got in touch with me wanting to do this episode. I said frack that, we can't do an episode, there is too much goodness in the French brain, we need a series. This is the first episode in a new series with an amazing Emergency Medicine Doc and Innovator, James French.

James French, MD

Dr. James French was born to a father that was an incredible engineer and tenacious inventor. James’ earliest memories were working with his dad restoring vintage motorcycles which sparked his fascination with fixing things. When James was 5 years old he went to watch the film “Superman” with his dad. It turned out they knew Christopher Reeves from the flying club that they went to, so they actually knew superman while he was learning to fly. James attended many Emergency Departments in the years after as it turns out that no matter how hard he believe you can fly or whatever machine he invented, gravity always won.

Whilst studying for a science degree he realised that training in martial arts was a partial antidote to not being able to sit still or focus on one task and has trained in martial arts throughout the majority of his life.

In 1995 James started medical school in Southampton, England. In 1997 at a local kung-fu club he met a guy called Dr. Cliff Reid who was a resident or registrar in Emergency Medicine. They immediately became friends. Whilst at medical school James would shadow Dr. Reid when he worked in the ED, particularly at weekends . They constantly exchanged ideas about resuscitation, psychology, meditation and of course martial arts. Cliff later stated openly on social media that James saved him from a residency system that was breaking him.  To outsiders it was obvious that the “saving” was a two way street. James’ passion for resuscitation and education comes from Cliff.

James graduated medical school in 1999. Whilst driving to work as an intern in 2000 he was first on scene at a fatal road traffic collision. Trying to render aid to multiple trapped and dying casualties, with no formal training in prehospital care was a formative experience. He started working with the Magpas Air Ambulance System (www.magpas.org.uk)  as a volunteer in 2003. The training course featured multiple days of simulation based medical education, a competency based curriculum and was probably a decade ahead of its time and was lead by the legend that is Dr. Rod Mackenzie. Influenced heavily by the aviation industry and the military Rod and James invented the first RSI kit dump and RSI checklist in about 2006. James continued to work with Magpas in PHEM until 2012.

In 2009 James started working as an attending in Addenbrookes Hospital, Cambridge and was given the task of selecting and purchasing all of the clinical equipment and for a new Trauma Center. Influenced heavily by a very strong department of clinical engineers lead by Prof Paul White, James realised the necessity of applying principles of from EMS, ergonomics, lean and clinical engineering to resuscitation practice.

In 2012 James moved to Canada to work in Saint John, New Brunswick. Whilst in New Brunswick he chaired the trauma research subcommittee and lead an interprofessional team to establish a province wide simulation system for trauma education. In 2017 James met Dr. David Elias, who is an Emergency Physician and highly successful medical entrepreneur,  whilst competing for simulation equipment at Medical Lion’s Den competition.  James started working with Dr. Elias and his  healthcare innovations company in 2018. James describes Dr. Elias as the “Elon Musk of medicine” and is without doubt the smartest guy he has ever met.

Currently James works as an Emergency Physician and in Saint John Regional Hospital, and is the lead for Operations Design and disaster management. He is a faculty member of the simulation and ultrasound group in the department of emergency medicine. James is the co-owner of a growing Medical Education and medical retail company with the uber keen ACP, George Scott (www.aemts.ca) . He also works in applied R&D with Dr. David Elias for Canadian Health Solutions in cognitive technologies.

• ?s for James

Intro for the Series from James:

INNOVATE OR DIE

“If I had asked the public what they wanted, they would have said a faster horse”

–Henry Ford (1863 – 1947), Founder of Ford Motor Company

A physician called Dr. Frank Pantridge, the godfather of Emergency Medicine, working with NASA engineers in the 1957, using telemetry equipment designed for space vehicle monitoring discovered Ventricular Fibrillation was the arresting rhythm in a large proportion of out of hospital cardiac arrests. Using capacitors from NASA, he also developed the first portable defibrillator. Then EMS and ACLS happened (albeit 40 years later). He had no formal training in design or electronics. He was by all accounts incredibly driven to understand how he could resuscitate people, which for Dr. Pantridge was personally relevant.  He developed cardiac Beri Beri after starving as a POW working on the Burma Railway and lived most of his life knowing his heart would fail.

What a total badass. Other notable medical innovators in our history are Sir Ivan Whiteside Magill and Sir Robert Macintosh – guess what they invented?

Innovation is part of our history – we need to make sure it is part of our future.

Creativity is conceiving new ideas. Innovation is turning those ideas into a solution. Medical research in a traditional sense is testing the solution to see if it works. Medical academia is currently some form of education or some form of medical research. That is what we get tenured for. That is what you can publish and get grants for. We have universities that support this activity, and that is utterly essential.

However what structures exist to energize the creativity and innovation in frontline healthcare workers?  In my experience very few.

Nobody would argue with the importance of performing high quality research. It seems a significant part of what we do now is debunking many of the things we have accepted as dogma which was often based on the poorest quality research.  Performing research according to STROBE, CONSORT and the like is clearly beneficial for everyone, but I worry that the uniformity needed to get published and get grants has created an environment that may stifle innovation.

Right now, I think, most of our patients don’t need another randomised control trial. What is becoming increasingly obvious is they need to be able to access equitable healthcare whether they have hypertension or septic shock. They need to be able to access healthcare regardless of their background or geography. We know unequivocally that unfortunately this is not the case.

As Friedrich Nietzsche wrote “A vocation is the backbone of life”.  The vocations that drive us, or the “why” hasn’t really changed in healthcare. The “why” is we want, or need, to provide the best possible care for people. The “what” has changed at an exponential rate however; the “what” being increasing case comorbidity, the number and complexity of treatments, and which tests to perform and how to interpret them. The know-do-gap, which is the difference between what is known in the literature and what is actually delivered to patients is rapidly increasing. (Webber, S., 2015).

The “how” in this equation is how we are educated and do our jobs which really hasn’t changed that much in the last 50 years. There have neen significant and notable improvements, but remove EHRs, bedside ultrasound, simulation, social media and online learning and I am told that the way we learn and work looks very similar to how it was before I was born.

So, this is my frame, just so you know. I find it harder and harder to keep up to date.  I see my colleagues burning out. We all see older people waiting longer to have ever more complex cases managed. l see people suffering, needlessly, and it each time I see it I am driven more to find the best formula to “fix it”. I definitely do not have all the answers, but there are things that we can learn from other industries that can go a long way to filling the gap.

If we think, as a profession we are going to achieve health equity, using our current medical paradigm, or by just stretching the existing system further than we already have, then we and our patients are only going to continue to suffer

We need to do things differently. We need to innovate.

JF

So there you go…

Today, in Part 1, we discuss a topic near & dear to my heart:

Part I – Resus Geography, Logistics, & Ergonomics

The need for these approaches in resuscitation and critical care 

• • Talk about a cric case i did where there was nearly 200% mortality
    • Millers Law (The average person can only keep 7 (plus or minus 2) items in their working memory) – Loss of PPE.
    • Hicks Snail Trail

Resuscitation ergonomics 

• • • Lean Methodology – What plays together stays together
    • Process mapping, swim lane, how to do it.
      • GOPRO video skills training
      • Pen. Eyeball,Post It notes
      • Who does each stage?
        • Swim Lane Process Map
          • each horizontal column is a different user
          • 
      • Work as imagined vs. Work as Done – what you think you need is not what you actually need. We eliminate steps when our mental simulator is low resolution when we have move to unconscious competence.
    • Break Need Items into Packs (Hicks' law – every extra thing added to a visual field leads to exponentially increased complexity)
      • Can be broken down by…
        • by color-yellow = ppe
        • by user green for go, “own shit kit”
        • by stage- everything else in another bag, blue

Resuscitation  Geography  

• • • • • Hospital design
          • 1 entrance/exit for various streams (patient, staff, logistics)
          • Immediate Items vs. Just Outside vs. Further Away
        • COVID made us think about these issues
        • Staging – ECMO example. Jason McCLure
        • Geography by Stage

Logistics

• • Getting it to the user
  • Getting it to the warehouse
  • Nominative vs functional checking
    • Checking each other—is it there vs. is it there and can we use it
    • Currency and refresher system
      • Changing case mix
      • Increasing less emergent demand
      • rural vs urban level 1, 2, 3.
      • The patients chest and the bedside table.
    • innovation vs. optimization. In healthcare, we often concentrate on the former at the expense of the latter

Now on to the Podcast…

• Author
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Scott Weingart, MD FCCM

Editor-in-Chief, at EMCrit.org

An ED Intensivist from NY.
Professor
Chief, Division of Emergency Critical Care
Director, Resuscitation and Acute Critical Care Unit
Stony Brook Medicine
Stony Brook, NY, USA
No conflicts of interest (coi).

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