SGEM Xtra: Change the World – Honoring Dr. Rakesh Engineer - The Skeptics Guide to Emergency Medicine

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Date: December 10th, 2021

Guest Skeptic: Dr. Carly Eastin is an Associate Professor, Division of Research and Evidence Based Medicine, Department of Emergency Medicine, University of Arkansas for Medical Sciences. She is also the Chair of the SAEM Evidence Based Healthcare and Implementation (EBHI) Interest Group.

Carly was a guest skeptic on the SGEM two years ago. That was in the BC Times- (Before Covid). We had the pleasure of recording a live episode of the SGEM at the University of Arkansas. Back in 2019 we were talking about Vitamin C for sepsis (SGEM#268).

SGEM Bottom Line: “There is not enough evidence to support the routine use of vitamin C in critically ill patients.”

Not much has changed over the last two years. There have been at least two randomized control trials published that do not support the use of Vitamin C in sepsis.

Fujii et al (VITAMINS RCT) JAMA 2020: n=216 patients with septic shock. No statistical difference in their primary outcome for duration of time alive and free of vasopressor administration up to day 7 or the secondary outcome of 90-day mortality.
Moskowits et al (ACTS RCT) JAMA 2020: n=205 patients with septic shock. no statistical difference in primary outcome of SOFA scores at 72 hours or the secondary outcome of 30-day mortality.

It was Dr. Paul Marik who has been a big advocate for Vitamin C sepsis. We did an SGEM episode on his before-after study (SGEM#174: Don’t Believe the Hype) with a dozen skeptics expressing their concern the results were too good to be true.

Dr. Marik has also been promoting the use of Vitamin C for COVID19. However, there is insufficient evidence to support the routine use of Vitamin C in the treatment of critically ill or non-critically ill COVID19 patients (NIH COVID19 Treatment Guidelines and Thomas et al JAMA 2021).

There is also no high-quality evidence that Vitamin C can prevent COVID19. There is a Phase II interventional randomized placebo-controlled trial testing whether treatment with Vitamin C can prevent symptoms of COVID19 (ClinicalTrials.gov).

This SGEM Xtra episode is not to talk about Vitamin C, COVID19 or even do a structured critical appraisal of a recent publication. This is an SGEM Xtra episode to pay tribute to a friend and champion of the EBM community, Dr. Rakesh Engineer.

Dr. Rakesh Engineer

Rakesh died suddenly in 2019 and the Society of Academic Emergency Medicine (SAEM) reflected upon how best to honour him. SAEM decided to name an award after Rakesh, focusing on his passion for implementation science.

Dr. Chris Carpenter knew Rakesh well and was asked to give a brief introduction to those who did not know him. You can listen to his introduction at this LINK.

Chris Carpenter: “[Rakesh] was a devoted husband and dedicated father to three sons. He was born in Cleveland, Ohio and attended Ohio State University where he earned both his Bachelors and MD. After his internship at Barnes Jewish Hospital at Washington University St. Louis. He trained in Emergency Medicine at Spectrum Health in Grand Rapid Michigan. After that, he joined the Cleveland Clinic to be with his family, to educate the next generation of emergency physicians and launch his own clinical research career. Rakesh’s vision epitomized implementation science, in which knowing is not enough: we must apply. As an emergency medicine clnical researcher, Rakesh thrived at the interface between published evidence and pragmatic application at the bedside. He was a friend and I miss him dearly.”

Carly: “I did not have the privilege of knowing Rakesh personally very well, but was following him because I was a member of the SAEM Evidence-Based Healthcare and Implementation group when he was active and I was still trying to find my way in the EBM world. He was such a good speaker and was really funny. I also remember that it was Rakesh that gave me my first real understanding of implementation science, and I’ve been hooked ever since.”

Ken: “I remember running into Rakesh at an SAEM meeting in Indiana. To be more accurate, he almost ran into Chris and me outside the hotel. We were heading out to get something to eat or something and Rakesh pulled up in a big sedan. I want to remember that it was a convertible. We pretended to be almost run over by him. Rakesh quickly jumped out of the car, usual big smile on his face and we had a quick nerdy chat. That is the last memory I have of Rakesh. Chris sent me a goofy picture of Rakesh”.

Carly: “It’s hard to look at that picture without smiling. I can’t tell you how many stories just like yours I’ve heard about his laughter and fun personality. He was clearly highly respected and loved by many.”

Rakesh published a lot of peer reviewed articles during his career. This included biomarkers, gun safety and diagnostic imaging studies.

Rakesh had just been elected Chair of the Evidence Based Healthcare and Implementation (EBHI) Interest Group for SAEM. He had been an active member of the interest group for many years.

The mission of the EBHI Interest Group is the applied concept of merging healthcare professional expertise, research, and patient priorities and circumstances through a defined process of finding, appraising, and employing clinical science at the bedside.

This mission aligns with the three pillars of EBM. There is the literature which informs our care, our clinical judgment and the patients’ preferences and values. This is what Dr. Davide Sackett said EBM is and what it isn’t (BMJ 1996). Rakesh believed in integrating these three important aspects of EBM into practice.

The EBHI Interest Group provides a network of expertise from the emergency medicine resident to the seasoned investigator, which serves as a forum for research, education, and clinical practice.

Objectives of the EBHI Interest Group

Engage the membership regularly and broaden the active core group through mentorship and collaboration for junior members.
Increase use of social media and internet platforms to improve the visibility of the interest group and its members as well as to disseminate best practices.
Continue focus on inter-institutional collaboration on journal clubs and scholarly projects, including original research or systematic reviews.
Sponsor high-quality didactic submissions to the SAEM annual meeting.

The Rakesh Engineer Award

The Dr. Rakesh Engineer award will be given to an outstanding presentation related to Implementation Science at the SAEM annual meeting. Quality improvement projects can be considered if the implementation methods, effectiveness, and outcomes are reported. De-implementation studies are also eligible.

More information on the Rakesh Engineer Award can be found at this LINK. If you are interested in nominating someone or yourself for this award you can click on this LINK. You can also click on the QR Code.

The award will be given out for the first time at the conclusion of SAEM 2022 which will be held in New Orleans, May 10-13. The award committee will consider abstracts accepted to SAEM’s annual meeting and grade them based a list of criteria related to knowledge translation. The top three abstracts will be judged live at the meeting, a winner chosen and the Rakesh Engineer Award presented.

Implementation Science

The journal Implementation Science defines this as “the scientific study of methods to promote the uptake of research findings into routine healthcare in clinical, organizational, and policy contexts.” In other words, implementation science programs use the available evidence to achieve measurable improvements in the quality of clinical care.

It is easy to think that once something is determined to be the standard of care, people will just start doing it. But there are a lot of factors that influence the success of implementing a new practice to improve care or removing an old, outdated practice that might be harmful. Implementation science methods allow you to move through this process in a way that will be effective, sustainable over time, and lead to your desired outcomes.

For those who would like to learn more, we suggest you read the manuscript titled, “Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science,” by Laura Damschroder and her colleagues published in Implementation Science 2009.

You can also find a wealth of information at the NIH’s Implementation Science website. For those in academic or university settings, you may have an implementation science group locally who can provide additional resources. We would suggest exploring your institution’s website for implementation science experts.

The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the KT 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.