UNC Health Talk

The Nature of Emergency Medicine

The girl was dying. Desperate, her father wanted Tim Platts-Mills to help. But the 22-year-old Harvard graduate had only been in Papua New Guinea for a month and wasn’t a doctor. He wasn’t even a medical student. But Platts-Mills ran to the bedside of the man’s 8-year-old daughter anyway.

As she labored to breathe and coughed hard, Platts-Mills thought the girl was dying. Then she grabbed his hand, and her look told him that she, too, thought the end was near. From his backpack he pulled a book titled, “Where There is No Doctor.” As he referenced the book, the problem didn’t seem like malaria. Platts-Mills thought she had pneumonia.

“She needs antibiotics, right away,” Platts-Mills said, and the father made the four-hour trek through the jungle to fetch medications at the aid post. He returned that evening, and the girl swallowed the pills as her breathing quickened. Within a few days, she was on the mend. And Platts-Mills, half a world away from home, had found his calling.

Ten years later, Platts-Mills joined the emergency medicine department at the UNC School of Medicine, where he has made a name for himself as a dedicated doctor, teacher, mentor, and researcher. This week, the UNC School of Medicine recognized his work with the Jefferson-Pilot Fellowship, given annually to two junior faculty members who show great promise in their chosen fields.

We sat down with Tim Platts-Mills, MD, for a Five Questions feature to discuss his inspiration to become a doctor, his research, and what it takes to teach future doctors in the emergency department.

How did you wind up in that Papua New Guinea village and how did your experience lead you to pursue medicine?

“When I was a senior in college, I didn’t know what I wanted to do.”

When I was a senior in college, I didn’t know what I wanted to do. I had majored in environmental sciences, but I knew I didn’t want to go straight to graduate school. So I applied for one job – to be an environmental consultant at a coal mining company in Montana. I wrote them a letter and never heard back.

Fortunately, there was a PhD student, George Weiblen, who taught my biology section. He asked me what my plans were after college, and when I told him I wanted to see the world, he told me I should go to Papua New Guinea. George had spent time on the north coast of Papua New Guinea studying fig wasps. He described the warmth of the people, the ruggedness of the terrain, and the biological and human diversity –700 language groups in a population of 3.5 million – with most of the population living in very rural areas where there aren’t even roads. I was sold.

I applied and got a Rockefeller Fellowship to go there for 13 months. The Rockefeller Foundation started the program a few years after Michael Rockefeller died mysteriously in New Guinea in the 1960s. Every year since, three to five Harvard graduates get a fellowship, but none of them had been to New Guinea. Regardless of the merits of the other parts of my application, I think my proposal to do an ethno-botany project there was appealing to them.

I spent most of my time there living in a village of about 100 people in the Adelbert Mountains, doing what everyone else was doing: gardening, hunting, fishing, and rebuilding houses. (Houses are made entirely from plants and start to fall apart after about seven years.) A few afternoons a week I’d meet with the older men and walk around the forest collecting samples. They’d tell me the name of plants and how they used them. We put together a book describing about 200 plants called “Useful Plants of Salemben Village.”

“When I helped the girl get well, I felt the [urgent] nature of medicine. And I saw her recover and do well the rest of my time there.”

Not long after arriving there, a father asked me to help his daughter, who I really thought was on the verge of dying. When I helped the girl get well, I felt the [urgent] nature of medicine. And I saw her recover and do well the rest of my time there. Although environmental science is fascinating and important, it didn’t have the same kind of urgency as that dying 8-year-old girl. This prompted me to think about medicine as a career.

The truth is, my father is a physician. So my knee-jerk reaction to the profession – when I was younger – was to not do what my dad did. But when I was far away from my roots, on the other side of the world, I realized that this profession was calling me.

Why did you choose emergency medicine, and how did you come to join the UNC School of Medicine?

I had a friend in medical school who had been an EMT in Atlanta. He came into medical school knowing he wanted to be an emergency physician. He’d always quiz me while we studied. He’d say things like, “So, when should you X-ray someone’s neck if they’d been in an accident?” He taught me the bread and butter of emergency medicine.

Fortunately, I was able to do an emergency medicine rotation early in my 4th year. I quickly saw the value of emergency medicine, but I also think the newness of it appealed to me. It’s a young specialty: the first full-time emergency medicine practice was started in 1961; the first residency was started in 1970. Over the past 40 years a lot of knowledge has been generated to make it possible to provide outstanding emergency care. If you sprain your ankle, it probably doesn’t matter who takes care of you. But there are many other situations in which it’s really good to have a doctor trained in emergency medicine taking care of you.

We care for people who have a broad range of complaints, who run the whole range of ages, and who often have social issues that complicate their care. It’s a huge challenge to provide good health care for all these different people. I don’t think anyone thinks someone could do this without formal, specific training.

As for how I wound up at UNC: in 2007, Judy Tintinalli was the chair of emergency medicine here and was and is still the biggest name in emergency medicine. I had done some writing with someone who knew Judy, and he put in a good word for me. I enjoyed my interview with Judy, and then met Chris Howarth, who was working in the ED. Chris and I discussed whether or not it was okay to discharge a particular patient with pyelonephritis [inflammation of the kidney]. Chris was his usually self – calm, thoughtful, and unpretentious – the type of clinician that I aspire to be. I was sold.

When I took the job, I knew I wanted to do clinical research, but I wasn’t aware of the size of the research mission here or the training opportunities, the culture of collaboration, and the outstanding school of public health. As it turns out, I couldn’t have picked a better place to learn clinical research.

What are some of your key research findings that inform treatment of pain?

To date, a lot of our work has focused on describing the problem. We looked at a sample of older patients discharged from the ED after car accidents. They didn’t have serious injuries and were released from the ED. Six months later more than a quarter of those patients had daily moderate or severe pain related to the car accident, and the majority of these patients with persistent pain experienced functional decline. About 10 percent of the patients became new daily opioid users.

“As a result, these patients tend to be left to their own resources to figure out how to manage their pain; and once the pain becomes persistent it’s very difficult to treat.”

I think emergency doctors are good at identifying injuries that might not be easy to diagnose – internal bleeding, etc. – but I don’t think we do a great job of recognizing the patient’s risk of persistent pain or helping support their recovery. As a result, these patients tend to be left to their own resources to figure out how to manage their pain; and once the pain becomes persistent it’s very difficult to treat.

We think that if we are pro-active about managing pain, and encourage physical activity during the first few weeks after the injury, we can help patients get on the right track to recovery.

Our group has also researched pain medication usage. We found that older adults have poor overall knowledge of pain medication. For example, if you ask them about ibuprofen, they know what it is and say they shouldn’t take it because, for instance, they have stomach ulcers. But when we checked their medication list, we found that many of them were taking Aleve or Advil, which are in the same class of medication as ibuprofen. One of our current efforts directly addresses this problem by providing some focused education regarding pain management for older adults in the emergency department. It’s exciting to be moving from observational research towards interventions. We have the potential to identify actions that physicians can take to improve outcomes for patients.

In 2013, you received an NIH career-development award to examine risk factors for persistent pain and functional decline in older adults after a motor vehicle collision. Can you describe this further?

Today’s older adults are an active and independent bunch. They drive cars and 4-wheelers, they hike, they work in gardens, they play tennis, they go up on ladders to clean their gutters. They want to keep going, which is great. One unfortunate consequence is that they get injured and are at risk for persistent pain. The NIH recognizes the need to develop a deeper understanding of the mechanisms that influence the transition from acute to persistent pain among older adults; and that’s the goal of this work. Our most recent analyses look at behavioral factors that influence outcomes.

We found that people who reduce their physical activity or rest in bed during the day face a higher risk of experiencing persistent pain than do people with similar injury histories and do not reduce their physical activity as much or spend as much time in bed during the day. We think we can promote activity to help them. We think it’s similar to therapy after a hip replacement. We now know it’s best for patients to get up and walk in the first few days after a hip operation. We hypothesize that’s probably true after car accidents. We need to be better about identifying patients at higher risk of persistent pain and mobilizing them.

At UNC, I was really fortunate because the UNC KL2 program [through NC TraCS] provided me with the protected time, formal education, and the academic community necessary to learn research methods to do these sorts of projects.

Since joining the UNC School of Medicine in 2007, you’ve received numerous teaching and mentoring awards? What advice can you give aspiring doctors who also want to become great teachers and mentors?

The emergency department is a fantastic place to learn medicine because there’s a lot of material and a high density of decision-making. There could be a patient with belly pain. As the doctor, I have a lot of choices. Do I run labs? Should I order a CT scan? What about prescribing pain meds? Do I need to talk to a surgeon? Should the person be admitted into the hospital? That’s a fair number of decisions that have a lot of important consequences both for health outcomes and cost of care. So it’s an important place to work and a great place to teach.

One of the things I try to do in teaching is not immediately answer a resident’s questions. It’s really easy for residents, early in their training, to default to presenting a case and wanting me to say what we should do. I try not to let them escape like that. Instead, I ask them what we should do. And if they don’t know, then I tell them to assume I’m not here. They can say they don’t know but then they still have to come up with a plan. Unless I push them to make a statement of what to do, then they’re not telling me how they think or what they don’t understand. And I need to know what they don’t understand.

When I was a resident, I had this very sad case of a patient with perforated appendicitis who waited far too long to receive medical care and became systemically ill from the infection. In the emergency department, the patient went into cardiac arrest. We did everything we could to save him. But after about 10 minutes, I had this sense that further efforts would be futile, that we weren’t going to be able to bring him back. So I said to the attending physician, “Can we call the code, can we stop treating the patient?” And he didn’t hesitate when he said, “I’m not deciding that; you have to decide that.”

It was the first time in my training I had been in that situation. The attending didn’t give me a hint of whether I was right to stop or not. Since I wasn’t sure, we did another 20 minutes of chest compressions and giving medication and everything we could think of. And finally, with the support of other team members – but not the attending – I called the code. It was the first time I really felt a weighty decision falling completely on me. The case itself was a terrible situation. But how we worked the case was educational, and it wound up being liberating and empowering. I really got it. I realized I was training to become the person who makes these decisions.

I like to translate this kind of lesson into my teaching. Of course, if there’s a medical student or resident who makes a decision that I don’t agree with, then I’ll redirect them. But I want them to at least come up with a plan. That’s how they’ll learn. That’s how we all become good doctors.

In terms of mentoring, I try to take what my mentors Sam McLean [MD] and Phil Sloane [MD] have taught me. Sam is an extremely talented and dedicated researcher who is incredibly careful with his writing. With both grants and papers, Sam pays attention to every word. As a young investigator there are lots of opportunities to contribute but not all of them are equally valuable for one’s career; Sam has been really good at both encouraging me to focus but letting me make my own choices. Phil is also a gifted writer, and both of them have a strong desire to learn and help patients. They stand out as inspiring examples to me as I pursue an independent research career.

I’d say our group is good at picking outstanding young people to work with. Because of the nature of our research, which involves calling patients, we need extra people. Every year we recruit undergraduates from the pre-med listserv, and out of about 40 applicants, we interview two or three and ask one or two to join our research team. Fortunately, we’ve had really outstanding mentees. It’s easier to be a good mentor when you have great, dedicated mentees.

The people who’ve worked with me have tons of energy and enthusiasm, so I enjoy feeding them projects and letting them work on them as much as possible. I also encourage them to learn from each other and collaborate with each other. We have a non-competitive, collaborative environment where people will be supported. They’ll be challenged, too. Their papers will be shredded, but we make clear that everything is a learning process with the common goal of advancing our understanding of how best to provide emergency care for older adults.