Date: July 24th, 2021

Guest Skeptic: Dr. Brain Goldman is an Emergency Medicine physician who works at Mount Sinai hospital in Toronto. He is the host of CBC radio show White Coat Black Art and the podcast The Dose. He is also the author of the bestselling books The Night Shift, Secret language of Doctors, and the Power of Kindness.

This is a SGEM Xtra. Brain and I went on an away mission by shuttle craft to Ticonderoga, NY for the weekend. This was to join Mr. William Shatner to celebrate his 90th birthday. We took the opportunity during part of the road trip to record an SGEM episode about how Star Trek made us better physicians. Some of you may love this episode while others may not.

William Shatner 90th Birthday Party Celebration Away Mission 2021

There were a number of challenges that needed to be overcome to make this epic trip happen. First, it was difficult to get VIP tickets to this sold out event hosted by James Cowley.

James created the Star Trek: Original Series Set Tour. This is an amazing recreation of the sets from the original series. James is also an executive film producer, actor and famous Elvis impersonator. He graced us with a performance as Elvis as part of the birthday celebration weekend (link to video).

After obtaining a couple of VIP tickets to the event, the next concern was: what colour of shirt to wear? There is the gold command tunic worn by Captain James T. Kirk, the blue science/medical tunic worn by Mr. Spock and Dr. McCoy, or the infamous red shirt. Please note that the red shirt characters were not statistically more likely die.

Another challenge was traveling to the USA. The border restrictions were supposed to have been eased on July 21st to allow crossing by ground. However, it was announced on July 20th that the restrictions would remain in place until August 9th. People were allowed to cross by air if fully vaccinated and had negative COVID19 test within three days of departure. This allowed us to fly over the border, rent a car and drive to Ticonderoga.

The final challenge was what to get Mr. Shatner for his 90th birthday. I called the Stratford Festival a few months before the event and asked for their assistance. They kindly searched their archives for the three seasons he was part of the company (1954-1956). There were no pictures that featured him on stage because he was not a famous actor at the time. They did find two photos of Mr. Shatner receiving the Festival’s Guthrie Award from Governor General Vincent Massey in 1956. There were also some newspaper clippings describing how Mr. Christopher Plummer was admitted to hospital for a kidney stone and his understudy, William Shatner, took over the lead role in Henry the V.

The Stratford Festival Archivist did find one amazing photo of Mr. Shanter from 1954. It is a picture of him sitting in a chair surrounded by a few other individuals checking out the masks for the 1954 production of Oedipus Rex. It looked like he was getting ready to sit in the captain’s chair aboard the USS Enterprise NCC 1701. It’s this photo that I had printed, framed and presented to him as a birthday present. He was very gracious and appreciative of receiving this special birthday gift.

For those of you not familiar with Star Trek it started with a TV series that had 79 episodes and was broadcasted over three seasons from 1966-1969. It is a science fiction franchise created by Gene Roddenberry. Star Trek The Original Series (TOS) launched many other TV series and movies. This SGEM Xtra will discuss some of the lessons learned from Star Trek and how it has applied to our practice of emergency medicine.

Brian and I had a wonderful away mission. Some of the highlights included the private tour of the Enterprise by Mr. Shatner. I had the chutzpah to ask a question of during the bridge chat about what Mr. Shatner learned from his time at the Stratford festival that he applied to his career in TV and movies. His answer was he learned excellence from the best directors and actors in the world.

It was also wonderful to go on a couple of hikes with Brian around Ticonderoga and see the natural beauty of this historic town. It is located in New York state on the north end of Lake George and a southern portion of Lake Champlain. There is also fort in Ticonderoga build by the French in the 18th century that played an important role during the American revolution.

Mr. Daren Dochterman

Another super experience was meeting the talented Mr. Daren Dochterman. He is a set designer who has worked on many movies. Daren won an award for his work on the visual effects for the movie Star Trek: The Motion Picture Director’s Cut. He informed us that the Director’s Cut is being remastered for 4K release and he is part of the team.

Daren also co-hosts the best Star Trek podcast called the Inglorious Treksperts with Mark A. Altman. After Brian and I met him and discussed our love of Star Trek TOS he made us honorary treksperts.

Our private tour of the Star Trek TOS set was fantastic. Seeing everything from the transporter room, sick bay, engineering, and Captain Kirk’s quarters. The biggest thrill was to sit in the command chair on the bridge of the Enterprise. It was a surreal moment to be in such a detailed replica and is very hard to describe. If you are a Star Trek fan I would highly suggest you make the trip to Ticonderoga and sit in the Captain’s chair yourself.

Star Trek and Evidence-Based Medicine

Listeners to the SGEM know this knowledge translation project promotes evidence-based medicine (EBM). The definition we use for EBM is the one provided by Dr. David Sackett in the BMJ 1996.

“Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”

There are three components to EBM that can be represented in a Venn diagram:

  1. Relevant Scientific Evidence The literature should inform our care as clinicians but not necessarily dictate our care. Many people make the mistake of thinking that EBM is just about the scientific literature. This is not true. It is important to know about the relevant scientific information and how to critically appraise the evidence.
  2. Patients’ Values/Preferences – We need to ask patients what they value and prefer. This may be different that what we as clinicians think and we should not assume to know. Each patient will be an expert at their own personal experience. They have agency and we can engage with them on using a shared decision model.
  3. Clinical Judgment – Often the available evidence will not be very strong or will not specifically apply to the individual patient we are caring for in the emergency department. Also the patient may not be able or want to participate in the decision. We need to use our good clinical judgement to apply the best evidence while honouring what patients prefer.

This model of EBM can be illustrated by the three main characters of Star Trek TOS.

  1. Mr. Spock – He represents logical thinking and provides evidence to the situation. However, decisions are made in a context and do not reduce to just numbers, p-values, or confidence intervals around a point estimate of an observed effect size. The evidence can inform our care and guide our care but it should not dictate our care.
  2. Dr. McCoy (Bones) – He represents the patients in the EBM Venn diagram. Dr. McCoy advocates for humanity in Star Trek. He speaks passionately about the emotional aspect of challenging situations faced.
  3. Captain James T. Kirk – He represents the clinical judgment. Captain Kirk listens to the logic and evidence that Mr. Spock provides and to the emotional arguments made by Dr. McCoy. This dialog helps him make decisions. These are often life and death decisions based on incomplete information and is similar to what emergency physicians must do in the emergency department.

Lessons Learned from Star Trek that Apply to Emergency Medicine

Brian and I discussed a number of things we learned from Star Trek that we think informs our practice of emergency medicine and makes us better physicians. Listen to the SGEM podcast to hear the details of this discussion. This was recorded while we drove from our hotel in Burlington, Vermont to Ticonderoga, NY.

Risk Is Our Business: We risk stratify patients all the time considering potential benefits vs potential harms. This has been discussed multiple times on the SGEM.

  • SGEM#118: I Hope you Had a Negative D-dimer (ADJUST PE Study)
  • SGEM#282: It’s All ‘bout that Bayes, ‘Bout that Bayes- No Trouble – In Diagnosing Pulmonary Embolism
  • SGEM#212: Holding Back the Years – Risk Factors for Adverse Outcomes in Older Adults with Blunt Chest Trauma
  • SGEM#252: Blue Monday- Screening Adult ED Patients for Risk of Future Suicidality
  • SGEM#170: Don’t Go Breaking My Heart – Ottawa Heart Failure Risk Scale

Anyone, Anytime, for Anything: The emergency department is the light in the house of medicine that is on to assess and treat anyone, at anytime for anything. This includes people with substance use disorder and mental illness. It should not matter a patients gender, age, or race.

  • SGEM#313: Here Comes A Regular to the ED
  • SGEM#280: This Old Heart of Mine and Troponin Testing
  • SGEM#266: Old Man Take a Look at the Canadian CT Head Rule I’m a Lot Like You Were
  • SGEM#248: She Works Hard for the Money – Time’s Up in Healthcare
  • SGEM Xtra: I’m in a FIX State of Mind

No Win Scenario: Every patient who presents to the emergency department is an opportunity. We can have a number needed to treat (NNT) of one to help. It all depends on how we define “win”. Even if we do everything correctly patients will die. However, how we deal with death is also important. The NNT concept has been discussed on the SGEM.

  • SGEM Xtra: NNT – WET or DRI
  • SGEM Xtra: The NNT is Mellow Yellow for tPA in Acute Ischemic Stroke

Prime Directive: This is also called General Order 1 and it is a guiding principle of Starfleet in the Star Trek universe. This directive prohibits its members from interfering with the internal and natural development of alien civilizations which are below a certain threshold of technological, scientific and cultural development. It has been said many times on the SGEM that there can be only one…primary outcome.

Pain: There is a distinction between pain and suffering. Getting pain to zero out of ten can lead to more harm. We need to set expectations and discuss the potential benefits and harms of various therapies (pharmacological and non-pharmacological) to address patients’ pain.

  • SGEM#55: Drugs in My Pocket (Opioids in the Emergency Department)
  • SGEM#240: I Can’t Get No Satisfaction for My Chronic Non-Cancer Pain
  • SGEM#242: Pain, Pain, Go Away – IN Ketamine vs. IN Fentanyl for Pediatric Pain Management
  • SGEM#264: Hooked On A Feeling? Opioid Use and Misuse Three Months After Emergency Department Visit for Acute Pain
  • SGEM#304: Treating Acute Low Back Pain – It’s Tricky, Tricky, Tricky

There are many other lessons we have learned from Star Trek. These were just a few discussed on the road trip. Listen to the SGEM Xtra podcast to hear Brain and I talk about this in greater detail.

The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. So, patients get the best care, based on the best evidence.