Hospital beds do not cure cancer.

One of the first hospital beds from 1874 . . . a lot has changed but a bed is still just a bed. Read why I think we should stop using the term “hospital bed” here. Beds are “simply a surrogate for the people, the skills, and the care that can be delivered to the passengers who ride through the health system. Neither the mattress nor the wheels can cure cancer”.

Happy covid Christmas…it’s a dog’s life

We have likely spent too much of 2020 believing our own thoughts, and striving to prove ourselves right. This unscientific tik was also on display when one of our family members pleaded for a pandemic puppy. The parent (who shall remain nameless) thought too much about how the dog would upset their manicured life and not enough about why their child craved a companion. The nay-sayer in question (alright it was Peter) was tone-deaf, and, when we finally did get a puppy, he was also delightfully wrong. This end-of-year report is about how a pet, and not a publication or presentation, was the unexpected highlight of a forgettable and unforgettable year. It is a seasonal reminder of how doctors don’t have all the answers, or even all the right questions.

Moose, the Magnificent

Our respective families both recently acquired family dogs, and both of us had doubts beforehand. However, Moose (the magnificent) and Chester (the cuddler) will undoubtedly make our Christmases warmer, and our houses more like homes. It no longer matters that our residences contain doggy hair and dodgy smells: it is a small price for 2020 joy. The literature suggests that dog owners live longer and experience greater wellbeing, cardiovascular health, mental health, and less loneliness. [1,2] Dogs may also strengthen communities and keep the vulnerable safe (“we should check in on her, she normally walks the dog every day”). In hospitals and care homes, pets help patients and staff to feel less institutionalized. However, let’s face it, the literature says lots of things. This annus horribilis has shown how easily ideas can be twisted and mangled. This is why we need to remain vigilant to bias and blinkers, including our own.

Chester, the cuddler

This year we didn’t just became dog owners, we recommitted to the scientific method. During covid-19 it is worth remembering that science is not a fixed set of facts. Instead it is one of humanity’s best strategies for ensuring data shouts louder than politics. Science is the best single way forward, but it isn’t tailor-made for questions of happiness and contentment. Therefore, brace yourself this holiday season, as we dare to discuss our feelings and our pets in a medical journal. Scheduled programmes will resume after these important messages. We shall temporarily relax our quest for immutable biomedical truth, and not “draw your attention to the Y-axis”—or whatever else we say during turgid lectures. In the n=2 study of Moose and Chester, let’s simply acknowledge that rational adults can learn lots from irrational fur balls. 

Being a dog owner has not only been a delight, it’s been an eye-opening experiment. For example, we thought we knew our neighbours. Turns out, we had never even met half of the street. The reason is because they, and we, previously rushed by with our heads elsewhere. We now stop to say “hi” and to compare pooch stories. People who we previously assumed standoffish, are often quite happy to stop so that dogs can meet and sniff bums (do we look, do we look away?). You then have your excuse to converse and share a smile. Social awkwardness is overcome with “what’s his/her name?” “how old, and what breed?” If we’re not careful we might start to care about each other. 

By the second walk you tip your hat and offer a grin. By meeting-three you contemplate an invite to tea, but only, of course, “to allow the dogs to play”. Before becoming dog-people we thought many owners were indulgent and misguided. We now appreciate that many are hardy and selfless. After all, they venture out in the rain and the snow, and attend to another’s needs. The big truth is that most people are nice if you just give them the time of day. Strange that it took a dog to help us understand humans. 

Walking the dog started out as an inconvenience. It is still an imperative, but it is also a therapeutic leg stretch and brain rest. It is too easy to be busy and self-obsessed. In contrast, “doing little” is an artform whose time has come. Having a dog has made it easier to receive the gift of an ordinary day and to find time for others: not a bad thing during covid-19. As outlined in Christopher Ryan’s bestseller “Civilized to Death” the modern world is impressive, but it has also perverted how we live, feel, work, play, and interact. [3] It may be easier to rectify these faults using a dog’s eye view.

Pets reconnect us to simple pleasures. So many cultures have words for this deficit that it must be part of what humans crave. The Danish and Norwegian talk of hygge and lykke (coziness, conviviality, well-being). The Dutch have niksen (doing something just for the fun of it). The Swedes have lagom (moderation), the Bulgarians aylyak (idleness), and the French have their flâneur (or wanderers). These are innate needs that we might otherwise dismiss. Even if doctors don’t formally prescribe pets (“take two dog-walks and call me in the morning”), they might just counter what the Finnish call kalsarikänni or päntsdrunk, namely, the tendency to stay home in your underwear and drink alcohol. Fortunately, pets don’t judge or post pictures. [4]

Science matters mightily, especially in 2020. However, this year pets were fundamental to keeping people in nature, caring about our communities, and simply able to “chill”. Philosophers such as Cicero and Voltaire argued centuries ago that if you have a garden and a library then you likely have all you really need. Like good science, that advice has endured because it stands the test of time, and tells us who we really are. Regardless, while in Voltaire’s garden, it could be even more fun to throw a stick. In Cicero’s library it would be extra special with an animal lying at your feet. We accept that our pets will not last our whole lives but, especially this year, they have made our lives more whole. Also, this Christmas we want to thank our kids for proving us “know-it-alls” wrong—but no, you can’t have a cat.   

Peter Brindley, Department of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. Scholar, Peter Wall Institute for Advanced Studies. Twitter @docpgb

Matt Morgan, honorary senior research fellow at Cardiff University, consultant in intensive care medicine, research and development lead in critical care at University Hospital of Wales, and an editor of BMJ OnExamination. Twitter: @dr_mattmorgan

References:

  1. https://www.cdc.gov/healthypets/health-benefits/index.html
  2. https://www.bmj.com/content/331/7527/1252
  3. https://www.simonandschuster.com/books/Civilized-to-Death/Christopher-Ryan/9781451659115
  4. https://en.wikipedia.org/wiki/Pantsdrunk

 

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Working from home during covid—whose TEAM(S)™ are you on?

We have all been living La Vida Lockdown, but let’s face it, we have never seen more of our co-workers’ homes. Those who might never invite us in now have no choice, courtesy of online video conferencing. Voyeurs have now inspected your shelves, your cushions, your dishes, and your beloved art: Ikea is it? Because of covid-19, online communication has never been more important. However, you don’t just see the inside of each other’s homes, you get a window into their souls, and they get a window into yours.

Firstly, like our overpaid, underplayed sport heroes, each of us has our favourite online format. In fact, the mere suggestion that you prefer Zoom™ over Teams™, or vice-versa, is like insulting someone’s mum: you just don’t do that even if mine clearly is the best. A few of you even favour Skype, in the same way that, presumably, some people still like steam trains. Regardless, don’t forget to update that display name you chose as a student in 1998: right, funkystargirl?

The covid reality is that we have to get inline to get online. First, you download the software, and then “upload” your computer onto several sturdy books. Next, you establish a reliable signal and then you lose it and swear. Next you start with headphones, but end up bellowing into your computer’s built-in mic. This is followed by telling the kids to shut up, locking the dog in the pantry, and locating a shirt without a food stain; well, without a BIG stain at least. 

After clearing your bookshelf of the Viz annuals and One Direction fanzines, you are ready for your digital summit. You click to start only to enter the purgatory of the online waiting room. After texting the host to let you in, you are finally admitted to “The Call”, and what a anthropologic treat it is. So, who are you colleagues? And who are you? And who belongs to which of the key (Microsoft) Teams™

Team decapitation

For the first half of the call we only see the top of your head and your Italian ceiling tiles. Someone finally plucks up the courage to recommend a change of perspective. For a split second, your glorious face flashes into view. Alas, soon after we have to endure the pimples on each of your impressive chins.

Team buffet 

In retrospect, Crunchy Nut Cornflakes followed by a pulled pork sandwich was not the best choice for your online snack. Muting your microphone did lower the group’s collective blood pressure, but the sight of congealed food on every tooth will stay with us forever. You know how there’s a video-off tab: feel free to give that a try. 

Team distraction

The occasional glance at the camera doesn’t fool anyone. You are furiously typing an urgent email, while looking for Christmas gifts, and scanning the latest news. We know this because you nod your head and laugh even when nobody is saying a thing. We know this because we often do the same.

Team silhouette

The laws of physics have passed you by. A well-lit room was a strong start, but raising the blinds means you are now, quite literally, a shadow of your former self. Perhaps a nice background picture: the Golden Gate Bridge? Or the earth from space? It doesn’t really matter as most people are not listening; they are merely waiting to interrupt your interruptions. 

Team multitask

You have a busy day ahead: shopping, walk the dog, pick-up the kids. After all, why not if you’re only “working from home.” The issue is that you also couldn’t resist joining the call, after all, they need your inestimable wisdom. Starting in the kitchen, you kill the video and leave the house with earphones in. Shopping done, you’re thrilled to be getting away with it. It’s only as you bend down to pick up your dog’s poo that a question is lobbed your way. As you fumble to put the video back on, your secret life is revealed. The group is now really curious what is in that small plastic bag in your outstretched arm.

Team ear nose and throat

In your hurry to get on-line the camera ended up pointing straight up your nose. Clearly those polyps should be investigated. Moreover, would it kill you to pluck a few of the longer hairs. Dear Lord, why did the screen have to freeze at that moment?

Team mute 

“Turn off the mute, turn off the mute, we can’t hear you.” Actually, on second thoughts, turn the mute back on. You said the same thing last week and it wasn’t relevant then either. 

Team future

The serious point is that communication is central to the human experience. It is how we share meaning, and how we either forge ahead, or fall behind. Communication is experiencing a revolution and covid-19 fired the first shot. We need to work out how best to digitally leverage the online experience for education, for conferencing, for doctor’s visits, and for simply getting stuff done. This will need to be discussed if we want to be on the same team, and that discussion is as likely to occur in pixels as it is in person. The revolution is upon us, and you don’t even need to wear trousers.  

Peter Brindley, Department of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. Scholar, Peter Wall Institute for Advanced Studies. Twitter @docpgb

Matt Morgan, honorary senior research fellow at Cardiff University, consultant in intensive care medicine, research and development lead in critical care at University Hospital of Wales, and an editor of BMJ OnExamination. Twitter: @dr_mattmorgan

Disclosures: MM has eaten Weetabix Crunch during a Zoom call, and nobody knows what PB does when he turns off the video.

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Peter Brindley and Matt Morgan: So, doctor, what about the vaccine?

Doctoring is not that difficult: it requires a lot of patience and a dusting of skill. Regrettably, at the time of writing (November 2020) we might be about to lose our…sang froid. Every year, as the clocks fall back, people will phone the house, stop us in the hallway, or tug on our scrub tops. Normally that’s just fine. In other years it wouldn’t matter that it’s the same old pre-Christmas song, and we know what’s coming well before the tedious chorus. Perhaps you know it, it’s a seasonal classic, and it goes like this: “so should I bother getting this year’s vaccine?” We thought covid-19 would quarantine this silliness, but had forgotten how persistent a bad tune can be. To put it mildly, we’re a tad exasperated. 

In previous years we would listen attentively and only when it was our turn would we politely give our recommendation: “yes you absolutely should.” However, in the year of covid-19 we have just about had it up to here. Sure, the erstwhile flu shot was never perfect, but we have always recommended it as a way to protect yourself, and to show others that you’re neither selfish, nor above everyone else. Even if the boffins don’t get the cocktail exactly right, let yourself be exposed to low doses of influenza’s H (hemagglutinin) and Ns (neuraminidase) well ahead of the next nasty HN combination. Well this year it’s less about the flu and all about corona, but the procrastination song remains the same. Seriously, folks, what is it gonna take? 

We assumed back in March that a worldwide pandemic would silence anti-vaxxers and procrastinators alike, but no. Instead, in late 2020 we are hearing twice as much song, and witnessing twice as much dancing around the issue. The Christmas playlist is now flu refusal on side A, and corona procrastination on side B. As intensive care clinicians, we are truly at a loss to understand what hasn’t registered during nine excruciating months of lockdown. There is even a second wave underway to bring the issue home, and surely enough folks have already lost their livelihoods and futures. We appear to have a light at the end of this tunnel that many just don’t want to plug in. 

If you are merely a vaccine doubter then you may take umbrage being lumped in tin-foil hat wearing conspiracy theorists. Ultimately this vaccine-no-vaccine highway has two lanes and each of us will need to pick one soon. Obviously, any vaccine needs full peer-review, rather than science by press-release, however cautious optimism is warranted that Santa may deliver a safe efficacious present soon. Whoever produces the vaccine, it could save countless lives, keep businesses afloat, permit patient visitation, allow travel, retain children in school, and combat crippling (deadly) social isolation…but only if enough of us take it. There are times when “uhms and arrs” are appropriate, but this is not one of them: seriously, folks, lives are at stake. Whether to get the covid vaccine simply isn’t a tough decision. Melodrama aside, who to give your last ICU bed to if people don’t, now that’s a tough question. 

The other problem with procrastination is that doctors and nurses need your vocal support now. Some of us have already received nasty messages and others have been subjected to ludicrous accusations. Apparently, rather than being dispassionate advocates for scientific truth, we are “owned” by the vaccine manufacturers. As such, we are reportedly beholden to their nefarious ends: you mean preventing unnecessary deaths? Using this same logic, we must be in bed with the plastics companies because we sure have inserted a lot of endotracheal tubes. No doubt we are in cahoots with big-mattress, big-saline, and big-ventilation because of all the aggressive resuscitation, and from turning patients on their fronts to keep them alive. As Richard Dawkins once said, “By all means let’s be open-minded, but not so open-minded that our brains drop out”.

We have long argued that Intensive Care is nothing special and nor are its doctors. Much of the time we just maintain homeostasis while nature decides whether the patient will live or die. Giving yourself the best chance is also simple, even if keeping Modern Healthcare simple is most assuredly not. You can’t change your parents, so wear a seatbelt, put down those ciggies, eat right, exercise, sleep, wash your hands….and line up for your jabs. If you hate doctors and big pharma then put us/them out of business with your common sense. We all presumably agree that ICUs are best avoided and Christmas miracles should come down the chimney, not through ventilator tubing. Let’s also hope they don’t run out, like the oxygen very nearly did. The ICU may be our happy place, but we doubt it will be yours. 

A book had been on one of our bedside tables for a while, and it was time to break the emergency glass. Authored by Will Storr it is called “The Unpersuadables: Adventures with the Enemies of Science”. Elsewhere on this apparently flat earth it is called “the Heretics.” Regardless, it emphasizes that while we are entitled to our opinions, too many have decided to have their own facts. Storr uses extreme examples of alternate thinking, but patiently illustrates how the stories we tell ourselves cement who we become. We have an insatiable “hero maker” inside us who can take delight in promoting partisanship and denial. That hero maker can also be used to bring people together, and despite our apparent vitriol, that’s really all we hope to do. Clearly, we two doctors have work to do in order to reclaim our patience. We promise to roll up our sleeves if you will please just do the same. 

Peter Brindley, Department of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. Scholar, Peter Wall Institute for Advanced Studies. Twitter @docpgb

Matt Morgan, honorary senior research fellow at Cardiff University, consultant in intensive care medicine, research and development lead in critical care at University Hospital of Wales, and an editor of BMJ OnExamination. Twitter: @dr_mattmorgan

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BMJ: Why Dylan Thomas was wrong—and right

Writing the poem after his dad’s untimely death, Thomas was both right and wrong. As I turned 40, a surprise trip to a spa hotel sent me driving past his boathouse, where he wrote such powerful poetry. Being new to the art of words, I had to stop. I went in, past the gift shop selling fudge and Welsh cakes. In front of me were those words: “Do not go gentle into that good night; Old age should burn and rage at close of day; Rage, rage against the dying of the light.”

Read the full article here.

I wish I didn’t need to write this second letter.

https://blogs.bmj.com/bmj/2020/09/21/matt-morgan-another-letter-from-icu/

I wish I didn’t need to write again, but the seas may be getting darker once more. Yet in their depths, there are glimmers of hope that break to the surface. I want to tell you that hope remains and is stronger now than ever.

To patients and their families, I say, it’s been the longest six months of mine and my colleagues’ life. But we are still here. If you become ill with covid-19, we now have more tools to help keep you safe at home. If you come to hospital, we have treatments that help you from needing our breathing machines. If you come to the intensive care unit, we know which drugs may work and will help you survive. You are now more likely to survive with covid-19 than ever before. Not everyone, but more than before. We also know illness doesn’t stop with covid-19. We are also here if your heart needs us, or if your brain needs us, or if your cancer needs us.

Read the full letter here.

Matt Morgan: Another letter from ICU 

I wish I didn’t need to write again, but the seas may be getting darker once more. Yet in their depths, there are glimmers of hope that break to the surface. I want to tell you that hope remains and is stronger now than ever.

To patients and their families, I say, it’s been the longest six months of mine and my colleagues’ life. But we are still here. If you become ill with covid-19, we now have more tools to help keep you safe at home. If you come to hospital, we have treatments that help you from needing our breathing machines. If you come to the intensive care unit, we know which drugs may work and will help you survive. You are now more likely to survive with covid-19 than ever before. Not everyone, but more than before. We also know illness doesn’t stop with covid-19. We are also here if your heart needs us, or if your brain needs us, or if your cancer needs us.

We are still here. We still care. But we still need your help.

To the public, I say, it’s been so hard for all of us to live through constant change. We have all, at times, felt overwhelmed by it. In the face of another covid wave and changing guidance, it’s easy to lose faith in “the science.” But constant change is a sign that this process is working rather than it being broken. Science learns, adapts, improves, and is honest about its mistakes. Other beliefs are different. Dogma and conspiracy are straight paths that do not deviate. Yet they lead you nowhere. Change is hard but important.

And to governments and policy makers, I say, now is the time to really look after your staff. Feed them when they are hungryno matter what time it is. Give them somewhere to park their car or lock their bike when the nightshifts are long and dark. Care for them so they can care for others. Provide them with the tools they need to do their job, not free yoga sessions. Remember to be open with the public about the balancing act that must be struck. Covid-19 kills, but so too can some policies aimed at its control. Even when there are no simple answers, you must make difficult choices with trust and honesty on your side.  

We are still here. We still care.

Signed,

Many people, from many intensive care units, in many places.

Matt Morgan, honorary senior research fellow at Cardiff University, consultant in intensive care medicine, research and development lead in critical care at University Hospital of Wales, and an editor of BMJ OnExamination. 

Twitter: @dr_mattmorgan.

Competing interests: None declared.

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Matt Morgan: Changing global medical practice through a press release has put EBM into ICU

Releasing the results of the Recovery trial quickly, may have saved lives. But without the data available yet, the results cannot be scrutinised. Matt Morgan considers this complex decision

The authors were left with an impossible choice. Staring at the bold statistics showing that a simple, cheap drug may save tens of thousands of lives, what else could they do? One day of hesitation could translate into actual lives lost. A dad, a mum, a son. 

The response to the news that dexamethasone may reduce covid-19 deaths by as much as a third was as predictable as the rain when lockdown was eased. A chorus of cheer was followed by delicate, tentative questions about “the data”, then a loud roar of criticism. As yet, there is no pre-print of the findings and the researchers have said that the full results will be published shortly. 

Although the statistics are clear, that is all that we have. Until the results are posted on a pre-print server, or published in a peer reviewed journal, we cannot scrutinise the findings more closely. Instead, potentially the biggest medical discovery of our generation was announced by email in just 234 words, and that included “Yours sincerely.” Some say that covid-19 has murdered evidence based medicine. 

History is written by the winners and it’s too early to count the casualties. Yet nuance is still needed, even in a crisis. It is possible to be right in the moment, yet wrong in time. Many decisions in the pandemic may prove “right for covid” but “wrong for all”. Our prolonged lockdown in Wales is undoubtedly “right for covid”, by preventing more covid related deaths. But the dead don’t care why they died and longer lockdown may have many other consequences, such as undiagnosed cancers, or delays to treatment. This may even be the cause of more deaths overall when the accountancy is complete. Changing global medical practice through a press release may be “right for covid”, potentially saving tens of thousands of lives, by expediting what could be a life saving treatment. But putting the frail process of evidence based medicine into intensive care, with uncertain chances of survival, may ultimately prove “wrong for all”. Future standards may crumble, public belief in press-release medicine grows, transparency and peer review die. 

Covid-19 has shaken up life’s snow globe. The scene left when the flakes have fallen will be different from before. Different in many ways, and some will be good. Perhaps now is the time to resuscitate the ageing body of evidence based medicine. Resection of the maligned peer review process may give room for a life saving transplant. Bayesian platform adaptive trials have arrived, throwing p values under the bus. The discovery of the Higgs boson was announced globally through iterative, collaborative, mathematical automated process rather than by a man wearing a tie on an expensive podium to a bunch of his friends. Medical publishing is already learning from our colleagues in the STEM world by adopting pre-print servers. But the manner of this announcement shows there is still some way to go. 

Matt Morgan, Honorary senior research fellow at Cardiff University, consultant in intensive care medicine, research and development lead in critical care at University Hospital of Wales, and an editor of BMJ OnExamination. 

Twitter: @dr_mattmorgan

Competing interests: None declared

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Lockdown book launch

Paperback book launch

Explaining what intensive care can and cannot do is more important now than ever. So I’d love you to join me on Facebook for a live 20 minute Q&A at 8.05pm after the clap for carers on Thursday 30th April 2020, the day CRITICAL is launched in paperback

There will also be a book giveaway with 5 copies of the new paperback and a very special 1st edition signed hardback copy. All you have to do is to share the post on Twitter or Facebook and make sure you are on my mailing list here.

Send in any questions by commenting on the Facebook or Twitter post. See you on Thursday!

Covid-19: Intensive care and caring intensely

When we get through covid-19, and rest assured we will, these Intensive Care Unit (ICU) doctors, will march lockstep with others and argue for more beds, staff, and kit. We are not casting blame, but hospitals were full-to-the-brim well before covid-19. Minimal redundancy means decreased ability to surge. We need a grown-up chat about what we now understand to be our healthcare, especially given the likelihood of future viral waves. Let us garner support for that project by offering insights from the ICU covid-19 here-and-now. 

As we say when delivering unwanted prognoses, we hope to be wrong. Unfortunately, we suspect no single pill nor potion will swoop in and save the covid-day. Remdesevir (originally developed for Ebola) showed promise but attempts to obtain it via compassionate release are often soul-crushingly unsuccessful (“the patient is too sick”), just as they were for non-ICU colleagues (“patient not sick enough”). Alternatively, it’s a case of “cometh the virus, cometh the vaccine”, but again don’t hold your breath: not the best metaphor, we grant you. Over 70 vaccines are under development, with many targeting the virus’s spike protein: those crowns (coronas) from which it got its deceptively benign name. Before you throw up your mask in celebration, no vaccine is expected in 2020, even though the peddle has been pushed to the metal.

Unfortunately, viruses are as fascinating as they are awful. They are so sneaky that they highjack our cellular machinery to their nefarious ends. They are so submicroscopic that even bacteria wouldn’t see them if those bacteria magically developed the gift of sight. They are so minimalist—they contain nothing more than genetic material (the plasmid) plus a protective coat (a capsid) plus enzymes (proteases)—that microbiologists still debate whether they are “alive.” This all means it’s a tad difficult to make them “dead.” Just as Dawkins’ argued that lifeforms are the carriers of “selfish genes,” viruses are an even more effective means of getting around.

We have grown accustomed to “I want it now, safe and cheap.” But, even 2021 seems ambitious for a bespoke vaccine, given that the process usually takes a decade. It’s uncertain work, as illustrated by our zero-for-four result against the coronaviruses that cause the common cold. Next, we face the realisation that few companies make vaccines: all hail those that do. Presumably, we will also require an (im)modest 7 billion doses: herd immunity n’all. Which segues into another awkward issue. 

We suggest we use this pre-vaccine wait for a fulsome chat with influential anti-vaxxers. Measles was declared eliminated from the US in 2000 by the World Health Organization (WHO). Fast forward to 2019 and New York City declared a public health emergency because of 100s of measles cases resulting from 1000s of unvaccinated kids. Nowhere needs a covid-vaccine more than NYC, but one year later the president ceased funding the aforementioned WHO. It’s a substantial one-two punch. 

But there’s more, dear reader. Just as there is insufficient slack in healthcare, we have hardly funded our bioscientists to the max. We now expect studies on drugs and vaccines to be fast tracked and rigorous. However, these boffins are not borne overnight, and they require specialized labs. It is not enough to hope something works. Sorry, but currently, no antiviral, antiretroviral, antimalarial or antirheumatoid should be used until specialists have studied long and hard. Indiscriminate use has already caused deaths. In other words, yes, you do have something to lose.

Instead let’s pivot to what should make a difference right now, and what we can control. Doctors often preach from the pulpit of biochemisty, pharmacology and physiology, but we expect covid-19 to be managed as much by society’s humanity, kindness, and grace. If that sounds twee coming from biomedical physicians, we would argue ‘twas ever thus. While our medical industrial complex has a mighty part to play, 20 years of “ICUing” has shown us that our “life support” (machines and tubes) needs your ‘life support’ (the ability to look after yourself and others). So, how do we leverage our best during the worst of times?

Start by accepting that those scientists providing national recommendations are decent and sensible and open to change. As such they need your support. Next, understand that the scientific method is not perfect but it’s better than conspiracy theories and partisan rhetoric. Then let’s focus on caring “intensively” about each other. Fortunately, this also means you don’t need a medical or nursing degree to help. We simply need to decide to cope, much like Canadians do during cold winters, and Brits do during wet summers. 

Too many of us have been inwardly focused (how does this affect me) rather than outward (what do others need from me). You may have tried drinking from a fire hose (of information), but found it didn’t quench your thirst (for usable knowledge or peace of mind). You may have gone through those stages of grief (denial, anger, detachment, bargaining and acceptance) at break neck speed. Regardless it took one of us (PB) weeks to accept that covid-19 should not consume every waking moment.

If we are not careful then we will burnout sooner than this pandemic. I (PB) had to be reminded by my wife to enjoy sunsets and to get my recommended daily dose of joy. This non-medical maven reminded me that most of the world’s best brains—whether medical, political, or logistical—are leaning into this fight. I suggested that the same is true of the world’s best people: parents, teachers, and volunteers. We concluded that while none of us should be complacent, nor should we lean in so far that we collapse. 

Instead of chasing every rumour or tweet, we should find ways to connect. Seriously: do it now and do it properly. It isn’t morbid to let people know what matters to you. We have had “the chat” with family many times. Our weekly zoom catch-up with mates is now the highlight of our covid-week. While we never underestimate the power of community, we are very aware of the limits of Intensive Care. Doctors and nurses deliver excellent multidisciplinary supportive care but no machine can make you (or us) stronger than baseline, and our individual (previously hidden) genetic response will impact how we fare. We don’t like it any more than you, but life is too precious to candy-coat the truth. We will commit to building an ICU fit for the fight. Others will search for magic bullets and dispel magic beans. Regardless, let’s mobilize the very best antiviral yet known: the clever brain alongside the compassionate heart. 

Peter BrindleyDepartment of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. Twitter: @docpgb

Matt Morgan, honorary senior research fellow at Cardiff University, consultant in intensive care medicine, research and development lead in critical care at University Hospital of Wales, and an editor of BMJ OnExamination. Twitter: @dr_mattmorgan

Competing interests: None declared

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The Red Thread

In a strange coincidence, my BMJ column this month is about the same topic that I’m trying to teach my daughter in home schooling . . . Do you have a grasp on your own red thread right now?

Read it here.

A letter to the President

Here is a letter I have written to President Trump inspired by the writing of Nye Bevan and the song by Martin Joseph. If you enjoyed reading this, have a look at the other free articles and my book.

A letter to President Trump from an intensive care doctor

Dear Mr President,

As a viral pandemic rages in your country, as it does in mine, I ask you for one simple thing. It is the same thing that intensive care units are now offering to the sickest patients across your country – time.

We use machines in intensive care to give patients time to find out what is wrong, time for them to hopefully get better and sadly time for them to sometimes say goodbye. But one minute of your time could change the world.

I want to fill that time with three simple sentences from the founder of the British National Health System, Nye Bevan. Written under the sweat-filled brow of the Welsh coal industry from where he came, they mean more today than ever.

“This is my truth, tell me yours”

Although politically alternative facts exist, in science and medicine we instead strive for truth. Transparent data, honest answers and brave truths are the only way to cradle real hope that things can get better. The world has shown their truths, please continue to tell us yours.

“The purpose of power is to give it away”

Intensive care can save thousands of lives, yet the true power in this global health threat lies not with doctors but with the people. Simply staying at home, socially distancing and reducing transmission will save far more. So too in politics. Giving your power to the people around you, the experts in truth, the experts in science and the experts in health, is how you too can save millions.

“No society can call itself civilised if the sick are denied through lack of means”

The dust will eventually settle on this period. And then is the time to confront the biggest challenge your country will face; to stand in the mirror and stare back at the future choices in your own healthcare system. Ours is not perfect. Yours is amazing for the rich, can work for the workers but fails the poor. Disease is an illness of the poor, which is what Nye Bevan, all those years ago, was shouting from the top of his lungs. Now is your time to confront his challenge and provide safe healthcare for all.

Thank you for listening, thank you for your time, From an intensive care doctor,

Dr Matt Morgan, Cardiff, UK, @dr_mattmorgan

“We have not forgotten about you.”

I read out the letter that I wrote to people in those vulnerable groups. I really wrote this thinking about close members of my own family who fall into all of these groups. I’m pretty humbled by the response, being viewed by over 2 million people so far. Thanks for listening to it here.

COVID-19: A letter from the ICU

The reason I wrote my book “Critical” was to talk with the public about intensive care. Yet, I have been completely humbled by the kind words in response to my short letter. I hoped to send a message of hope yet honesty to the millions living through COVID-19 who are elderly, frail or vulnerable. Read the full piece here.

Matt Morgan: A letter from ICU

To those who are elderly, frail, vulnerable or with serious underlying health conditions,

We have not forgotten about you. 

It must be so hard listening to endless news reports that end with “don’t worry, this illness mainly affects the elderly, frail, vulnerable or with serious underlying health conditions,”. What if that is you?

Our passion as an intensive care community is fixing problems that can be fixed. Yet we often meet patients like you who have problems that cannot simply be fixed. As this virus continues to impact on the world, we will meet many more of you. Although we have fancy machines, powerful drugs and talented staff, none of these things cure every disease. All they do is give us time – time to work out what is wrong, time to hopefully treat it and time for people to get better. But sometimes we already know what is wrong, we already know that there is no effective treatment. And so sometimes the machines offer little, intensive care offers no fix. But hope is not lost. We have not forgotten about you. 

As difficult as this is, we will be honest. We will continue to use all of the treatments that may work and may get you back to being you again. We will use oxygen, fluid into your veins, antibiotics, all of the things that may work. But we won’t use the things that won’t work. We won’t use machines that can cause harm. We won’t press on your chest should your heart stop beating. Because these things won’t work. They won’t get you back to being you. 

And If these things are still not enough, we will sit with you and with your family. We will be honest, we will hold your hand, we will be there. We will change our focus from cure but most importantly we will continue to care. We have not forgotten about you. 

Signed,

The Intensive Care Unit

Matt Morgan, honorary senior research fellow at Cardiff University, consultant in intensive care medicine, research and development lead in critical care at University Hospital of Wales, and an editor of BMJ OnExamination. 

Twitter: @dr_mattmorgan

 Competing interests: none declared

 

The post Matt Morgan: A letter from ICU appeared first on The BMJ.

New large print edition of “Critical”

I’d love to show you the new cover of “Critical” for the large print edition. It makes me want to open up those theatre doors and feel the pulse! Large prints are generally available in public libraries as well as to order through most book shops.

Peter Brindley and Matt Morgan: It’s time to be super heroes for scientific truth 

Don’t get frustrated, get involved, say Peter Brindley and Matt Morgan

Earlier this week, Simon Stevens, the NHS chief executive criticised celebrities and wellness companies for promoting unproven and potentially harmful therapies. He spoke about the impact that fake health news has on our lives and criticised Gwyneth Paltrow’s wellness and lifestyle company GOOP. Paltrow has previously famously suggested that women are so “unclean” that the only solution is to vaginally insert a jade egg. No doubt many clinicians and scientists have, at some point, likely thrown up their arms and considered giving in. However, rather than despairing about the apparent elasticity of inelastic facts, we are issuing a rallying call: it’s time to fight back. It’s time to be super heroes for scientific truth. 

Step one is to engage the public and stat. Get out there and mingle because grumbling at conferences surrounded by like-minded others will not save the day. This is why medical caped-crusaders such as US obstetrician Jennifer Gunter deserve high praise. She started the popular podcast “Jensplaining” and wrote the Vagina Bible. Her noble, simple, and profound goal is to empower the average person/patient. Ask yourself, is there anything that matters more? Others have initiated a “Pint of Science”, where scientists communicate their ideas with the public in pubs, cafés, and anywhere else where people will listen. Another strategy is for our universities (and professional societies) to support more professorships (and sabbaticals) that focus on the public understanding of science. The point is that public opinion matters, not just published opinion. 

After publication, the average scientific paper is read by just 10 people, and half are not read at all; not even by the author’s mum. Accordingly, we need to spread the truth more than ever. Brandolini’s law states that: The amount of energy needed to refute nonsense is an order of magnitude bigger than to produce it. Hyperbole aside, we are facing something of a culture war. A century ago, Mark Twain argued that “a lie travels around the globe while the truth is putting on its shoes”.  Nowadays lies, and truths, do that travelling at warp speed via social media. Short of hiring Cambridge Analytica, we also need to understand the taxonomy of truth, half-truth, and untruths. Our challenge will be how to encourage broad discussion while resisting non-evidence-based piffle (we are trying to be charitable here). No doctor wants to, nor should, get embroiled in twitter wars, but if you don’t stand for something there is a danger that we could fall for anything. 

Every human has bias so let us declare ours loud and proud: proper science is proper wonderful. Moreover, if you want good science then it needs to be funded and defended. However, to date, conventional medical science has not done an adequate job at arguing its case. Traditional science’s cautious and iterative style is also important, but can fall short when it comes to packaging messages that suit the many. Empirical science’s timeline also seems better suited to another age. First, you apply for research funding: 20% of projects are successful; 80% are rejected. Next you have to overcome the vicissitudes of the ethics board, and divine a question that is simultaneously precise, but generalizable. Years later, you hope your results were “positive” because it’s time to publish or perish. It’s hardly surprising, but largely inexcusable, if scientists don’t have energy left over to ensure that anyone actually still cares, let alone changes their behaviour. 

Let us state our bias even clearer: Good science delivers just as bad science hurts. Good science keeps planes in the air and infections out of wounds. However, ironically scientific advancement has also helped life become so comfortable that, at times, we tolerate ideas that don’t pass the rational sniff test. While we point smug fingers at celebrities and wellness experts we academic allopaths should accept where we have erred. Firstly, we forget that our patients don’t read our medical journals, and nor do most of our colleagues. We have also allowed a ludicrous world of 5,000 journals on Pubmed alone, so it’s difficult to separate signal from noise. And don’t get us started on predatory journals. We don’t have the time to understand why so many even exist, unless, as we fear it is to expand reputations and bank balances. 

At the same time that we implore lay people to dial back the pseudoscience, let’s accept the potential for sins and transgressions from medics and scientists. As outlined, there are enough predatory journals that if you have the funds and persistence you can probably get your work displayed somewhere. Moreover, even if a scientific publication is eventually discredited, it presumably once passed our lauded peer review process. “Dodgy academics”—again we’re trying to be charitable here—have shown that the pen is as mighty as the syringe, as demonstrated by the antivax movement. In our medical specialty of intensive care, Joachim Boldt published 90 fraudulent articles in 16 prominent journals before he was found out. [5] 

There is a small but necessary cadre of doctors and scientists doing the tough forensic work required to expose academic fraud. They deserve huge praise. They also need fearless support from our universities. The point is that, in the battle for hearts and minds, we each have a part to play. It may be as small as putting aside a few hours each month to review manuscripts. It may be that in the midst of a busy clinic you smile your way through your 20th debunk. It may be that you teach learners how to critically appraise the literature. For us it includes writing opinion pieces that simultaneously challenge and chastise. 

There is so much important knowledge still to discover. As such, it’s a crying shame that we can’t just focus on novel research; but needs must. Whether patient or provider, we are all being bombarded by pseudoscience masquerading as fact. We know you feel overwhelmed and frustrated, because we do too. However, steel yourself: nothing matters more than the truth. Become a myth buster for science. Alternatively imagine that your lab coat is a super hero cape, and then accept that with great power comes great responsibility.

Peter Brindley, Professor of Critical Care Medicine, Medical Ethics, Anesthesiology at University of Alberta, Canada.
Twitter: @docpgb
Competing interests: None declared

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Research and Development lead in Critical Care at University Hospital of Wales, and an editor of BMJ OnExamination.
Twitter @dr_mattmorgan
Competing interests: None declared

The post Peter Brindley and Matt Morgan: It’s time to be super heroes for scientific truth  appeared first on The BMJ.

Cardiff hospital trials cooling patients after cardiac arrest

A year ago, Andrew Barnett collapsed and his heart stopped beating, as he played football with his young son.

Luckily, it was at on a pitch at a Cardiff leisure centre – which had a defibrillator – and the manager knew CPR techniques.

Andrew, 46, was revived and became part of a hospital trial to see if cooling the body in intensive care helps recovery.

The event was a complete blank but he realises how close to death he came. 

The cooling trial, involving nine UK hospitals, is being led by researchers at the University Hospital of Wales, Cardiff.

Altogether, 1,900 patients worldwide are part of the trial, called TTM2.

Read the full story here

Moral distress—easier said than solved

To quote Woody Allen: “Life is full of misery, loneliness and suffering, and it’s over much too soon.” The point, presumably, is that everyone is living their struggles, alongside their joys. In fact, it is one thing that unites us. Obviously, being a patient is usually the tougher gig compared to being the practitioner. However, that doesn’t mean it’s always easy to be a doctor or a nurse: especially when you have nagging concerns about the state of the medical industrial complex, but feel little choice but to soldier on. Whether recipient or provider, we should all expect our fair share distress, doubt, even despair. It’s simply part of the deal. When these nagging emotions rear up we also need time and bandwidth to contemplate what it all means. Distress could be a foe that needs to be chased away, and or a friend that needs to be invited in. After all, adversity can be a terrible thing to waste. 

Emotions are difficult to pinpoint and cannot just be wished away. Regardless, “distress” likely sits in the same unpleasant waiting room as anxiety, sorrow, and pain. Because healthcare workers are witness to all that life and death throws at us, this means that doctors and nurses and administrators—privileged as we are—may get a double dose of distress: one from ourselves and one from our work. If we receive still more from our employers, or even from the general public, then there is a real and present danger that we could become less humane. It takes strength to ask for help, and step one, whether patient or provider or politician, is to cut yourself some slack. [1,2] However, we feel the need to dig deeper, and to understand what we mean when we claim “workplace distress”. After all, if you want to re-find your happiness you may have to look in the very place you lost it. 

Other terms such as “burnout” and “resilience” are relatively new in healthcare, but already, they risk becoming old. Despite a laudable call to arms (“it’s time we did something”), and a call to alms (it’s time we focused on humans in need), there are times when resilience is fallaciously portrayed as a personal failing, something you must address alone, or something that just needs a commercial fix. This state of affairs is neatly summarized by Ronald Purser in his 2019 book, McMindfulness. [3] It is also why new expressions such as “moral distress” and “moral injury” are gaining momentum. [4] Being content at work, or at least not being toxic, matters because there are substantial implications for recruitment, innovation, safety, and quality. The solution is not to merely download the problem from organizations to individuals. Instead, we should share responsibility and prioritize practical action.  

“Moral distress” is usually defined as the reaction of any sane human if they feel responsible, but disempowered. In other words, we know what to do, but do not believe we have the authority or agency to do it. It can be extremely unpleasant because you feel compromised instead of empowered, and pressured into acting against your code. This makes us all feel inauthentic and conflicted and disconnected. In other words, we lose the humanity that our vulnerable patients need, and we “burnout” in order to self-preserve. Like so many people, healthcare workers are finding the world a tough place to navigate. We are being asked to do more with less, our expertise is both challenged and ignored, and each day still only contains 24 hours. 

This issue of moral injury in healthcare is encompassed in a powerful viral video. [6] Its proponent, Zuban Damania, rightly points out, we are forced to simultaneously serve three task masters: ourselves, our patients, and our employers. Worse still, these three are often at odds. For example, we want to deliver our A-game to every patient, but by hour-70 something has to give. We want to ensure our patient is 100% safe, but perhaps the next patient needs their bed even more. We want to be present, but what about endless meetings and inexhaustible bureaucracy. 

In the past we would not have talked about distress in “moral” terms. Stoicism, and even denial, would have ruled the day. We would have highlighted the need to work harder and longer, and would have accepted that this is why we receive salary and benefits. However, we would still have emphasized a shared responsibility and mutual aid. We would have briefly acknowledged that this job challenges our emotions, but then reminded ourselves that we knew that when we signed up. The mantra of old would have been that personal growth often comes from finding a way to carry on nevertheless, not in squabbling over who is more virtuous. Like most things in medicine, the way forward is about balance and shared responsibility.

Morals encompass personal characteristics whereas ethics stress the social system in which morals are applied. In other words, ethics point to standards or group expectations. As such, while a person’s moral compass should not change, the way we act will be modulated by larger forces. To borrow from the legal profession, a criminal defence lawyer should always find murder morally abhorrent. However, their ethics demand that they vigorously defend the accused, even at the risk of setting them free. Just as in medicine, this is how we create a system from which we can all benefit. To those in distress, this may seem like semantics but it matters mightily. We have all had times when working in healthcare was difficult and distressing, and it feels good sometimes to admit it. We need to share responsibility and look out for one another. With that said we now wish to get back to work.  

See also: Autonomy, mastery, respect, and fulfillment are key to avoiding moral injury in physicians

Peter Brindley, Professor of Critical Care Medicine, Medical Ethics, Anesthesiology at University of Alberta, Canada.
Twitter @docpgb
Competing interests: None declared

Matt Morgan, honorary senior research fellow at Cardiff University, consultant in intensive care medicine and research and development lead in critical care at University Hospital of Wales, and an editor of BMJ OnExamination.
Twitter @dr_mattmorgan
Competing interests: None declared

Jeffrey P Kerrie, General Internal Medicine and Medical Ethics, Island Health, Victoria, Canada
Competing interests: None declared

References:

  1. Sara Gray. Voices in My Head. https://vimeo.com/262918114
  2. Kristin Neff. Self Compassion. https://self-compassion.org
  3. Ronald Purser. McMindfulness: How mindfulness became the new capitalist spirituality Penguin Randon House 2019. 
  4. Zubin Damania. It’s Not Burnout, It’s Moral Injury. https://www.youtube.com/watch?v=L_1PNZdHq6Q

 

 

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I’m dreaming of a green Christmas

Most of us see the Christmas holiday season as an opportunity to slow down, take stock, and “just be.” Accordingly, we had planned a predictable article about recommitting to old-fashioned values and taking time off. However, these are not predictable times. We are just a few short sunrises from a new decade and we have had the Xmas stuffing knocked out of us by a three-punch combination: a must-hear podcast, a should-read book, and the announcement of a don’t-miss conference. These brought home compelling arguments that climate change and pollution matter far more than us front liners may wish to know. Moreover, this decade may be our last chance to avert a major disaster. Before you roll your weary eyes, let us be clear: we don’t like it any more than you.

More and more voices are pleading that we get greener and cleaner, and STAT! As Beth Gardiner outlines in her new book, air pollution is already associated with at least 7 million excess annual deaths (roughly one-in-ten of all world deaths). Whatever the exact toll, air pollution—principally nitrogen oxides and tiny particulate matters called PM2.5—are associated with more human deaths than smoking, AIDS, diabetes, and vehicle crashes combined. Both pollution and climate change will be especially cruel to the poorest in our communities, and are therefore social justice issues, not just inconvenient truths. 

Although 40% of Americans breathe polluted air daily, worldwide it is over 80%. Hundreds of millions already struggle with pollution’s myriad of consequences to their lungs, their hearts or their brains. Pollution is even linked to poor educational and behavioural outcomes. As CO2 builds, extreme weather is expected to increasingly injure, kill, and displace populations. Disease patterns will change, and so too will microbiomes that previously protected us. Increased patient numbers mean we will struggle to squeeze yet more from our overstretched healthcare system. Anyway, Merry Christmas one and all. 

In short, and without any delight, our New Year’s resolutions likely need to be bigger and bolder. Hugh Montgomery and colleagues have set up a new conference—CODA—are unequivocal with their recommendations: change your energy source, get out of your vehicle, forego that trip, put down that steak, and measure and mitigate your carbon footprint. Gardiner is no less Cassandra: clean air acts matter to your patients as much as any machine or pill, and as much as smoking cessation. If we healthcare professionals truly care, rather than just tweeting, we need to speak up and take the side of our current and future patients. This starts by accepting that it is later than you think.

In contrast, we blithely spent the 2010s living large and thinking of carbon dioxide as a gas that pulmonary patients need our help to get rid of. It is now our cities and environment that cannot adequately exhale, but we have yet to make a PEEP (an ICU pun for those in the know). The 2020’s will be an anthropocene: an era where human actions and our population size matters most. We hominids may be saddled with prehistoric brains, and manipulated by medieval institutions, but we have the power of gods. Much like medicine, respectful debates about cause and effect are perfectly fine; inaction and outright denial are not.

If we support the scientific method, and the collective labours of our scientific brethren, then we must accept a clear and present danger to our most important patient and greatest life support: mother earth. Like you, we would rather ignore this, or worry about just one patient at a time. Moreover, when our medical day is done we quite like driving our single-occupant car, consuming a mighty feast, planning our next conference junket, and having as many kids as we please. Beyond the workplace, we don’t really want to contemplate yet more thorny issues. For example, medicine measures success by lives extended, even as the approximate world population balloons by an eye-watering 150,000 each day. Moreover, healthcare funding comes from companies that pollute. These are critical issues to resolve, but much like a gasping patient we can’t just put this off. Unlike that hypothetical patient, we also need to accept our share of the blame. 

The first global estimate of health care related emissions was completed in August 2019. It may not be on your holiday reading list, so we will offer some lowlights. Healthcare was associated with 2 gigatons of carbon dioxide in 2014. This is over 4% of all global greenhouse gas emissions, and as much as 10% of a developed nation’s total. If healthcare were a country we, collectively, would be the planet’s 5th largest emitter, and in-hospital healthcare would be our largest polluter. Few of us have thought about the carbon consequences of the care we offer. However, this complexity is exactly why we need to get informed and involved. Healthcare workers are used to moving in when conversations are needed that others run away from. We are not experts in population growth or urban planning, but we will face their consequences.

Climate science and pollution science is complex and nuanced, obviously. However, International Commissions were unequivocal when they concluded that climate change is the “greatest threat to human health” and stated that “climate change threatens to undo the last 50 years of global health gains.” As doctors, we know that quoting scary statistics is rarely enough. It doesn’t always help being told that global temperatures have already risen by 1 degree, glaciers have lost trillions of tonnes of ice, or that sea levels are rising by a cm every three years. Healthcare professionals are extremely good at speaking up when it suits our bottom line. We also need similar eloquence on behalf of our communities. This Christmas we will take comfort in the fact the we still have a voice. After a quick holiday rest, we will look to mobilize it. 

Peter Brindley, Professor of Critical Care Medicine, Medical Ethics, Anesthesiology at University of Alberta, Canada.
Twitter @docpgb
Competing interests: None declared

Matt Morgan, honorary senior research fellow at Cardiff University, consultant in intensive care medicine and research and development lead in critical care at University Hospital of Wales, and an editor of BMJ OnExamination.
Twitter @dr_mattmorgan
Competing interests: None declared

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Please don’t reply all—why we need to learn e-tiquette

The aeroplane touches down and your holiday begins. “This time I’ll relax” you promise yourself while nervously pacing around the luggage carousal. You finally check-in to your modestly priced hotel room, and you even open an immodestly priced drink from the minibar. Your partner then fixes you with a familiar stare and delivers THE TALK: “Right you, no work for a week”. Before words have left lips, your phone pings to announce that you now have wifi service. You make an excuse, sneak to the toilet, and feel an endorphin rush as you enter your password. Gosh, this many emails after such a short flight: these must be important, after all they know that you are away…

Email #1

Subject:    Fwd:Fwd:Fwd:Fwd:Fwd:Fwd:

It’s Monday, but it’s already been a long week for your clinical director. Yet another three page safety notice about that piece of equipment that hasn’t been used since the 1970s. But if others have to read it then so do you. This email has been passed along like the chain letters of old. You feel dumb as soon as you open it. However, this does not stop you forwarding it to a few more folks: you know, just to keep them in the loop.

Email #2;

Subject:     FYI

FYI presumably means “For Your Irritation.” You develop carpel tunnel syndrome by the time you have swiped through this James Joyce novel. You still can’t establish the point of this dirge. Moreover, the contents are copyrighted and yet simultaneously not the responsibility of the sender the novella length signature tells you. The archaeologist in you is compelled to unearth the original missive. “Goodness me” is not the expression you mutter when you discover it concerns maintenance work that started weeks ago, in a building you never visit and can’t even pronounce.

Email #3

Subject:    URGENT

Not urgent.

Email #4

Subject:    Complaint

You heart sinks while your mind runs through a rolodex of frustrated patients, angry relatives, and huffy colleagues. What did I do; what didn’t I do? You recall something about someone, but the notes are on your desk and a response is expected pronto. You don’t tell your family, but, for you, the idea of you relaxing on this holiday is now stuffed. You promise not to check your email tomorrow, but who are you kidding. In the meantime, it seems best just to stew. 

Email #5

Subject:    Newsletter

A 30Mb attachment takes an eternity to download. Finally you can behold all of its colourful Comic Sans glory. Even though you don’t know the people, you now know that mum and baby are doing well. Another person you didn’t know had arrived is apparently leaving, and someone who you thought had never left is now back. You also learn that hand hygiene is less than 70%. You are so distracted you forget to wash your hands on the way out of the toilet.

Email #6

Subject:     Special invitation

Not special. 

Apparently, your glorious work is revered the world over. So much so that all you have to do is click the email link and share your personal details. You and only 5000 others can then pay to present at a conference in a place that may still be under a travel advisory. You ought to send this one tumbling into the spam folder stat, but hey, at least somebody recognizes your genius. 

Email #7

Subject:   Let me know your availability 

Oh god, the five most dreaded words in the email lexicon have just been typed. There is now no way to escape 50 separate emails whereby everybody feels obligated to cc all. You will soon be informed of such breaking news as “Tuesdays aren’t great for me” and “I’ll try my best to be there but can’t promise”. You wish you could send a pleading email that asks folks only to respond to all if they really must. This presents you with an interesting catch-22, can I really cc all asking people not to cc all?   

Subject:  Cake!

Now we’re talking: you love cake. Instead, this image of gluten-free diabetic-friendly vegan beetroot surprise sends your finger straight to the trashcan icon. Time to head to the pool before Happy Hour ends. After all, your family appears to be having a great time without you. 

Postscript: 

You send yourself one last reminder message. After all, you’ve been meaning to talk to the kids about not overusing their smartphones on this trip. You worry where they get such ideas. Maybe you will Google that. In fact, you could even write an article about digital detox; maybe tonight when everyone else is asleep.

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Research and Development lead in Critical Care at University Hospital of Wales, and an editor of BMJ OnExamination.
Twitter @dr_mattmorgan
Competing interests: None declared

Peter Brindley, Professor of Critical Care Medicine, Medical Ethics, Anesthesiology at University of Alberta, Canada.
Twitter: @docpgb
Competing interests: None declared

The post Please don’t reply all—why we need to learn e-tiquette appeared first on The BMJ.

Matt Morgan: We should encourage short service awards

BMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6372 (Published 12 November 2019) Cite this as: BMJ 2019;367:l6372

Follow Matt on Twitter: @dr_mattmorgan

As I walk towards the sound of 1970s music, coloured disco lights spill out from the window. I clutch a quickly wrapped bottle of cold wine, snatched from the fridge as I left the house. But an early start the next day means that the only drinks I’ll be having tonight will contain caffeine rather than the alcohol that sustains the bad dancing.

As I enter the social club, a line of hungry people talk about the weather, football, and Brexit while balancing beige, pastry based snacks on unstable cardboard plates. A silver banner, too small for the huge white wall it’s stuck on, exclaims the reason for tonight’s celebrations: “HAPPY RETIREMENT!”

For the doctor retiring, it’s been 30 years of sick patients, grateful families, and endless mandatory training—interspersed with times that made you smile, times that made you cry, times that you will remember forever, and times that you would rather forget.

The hospital’s medical director shuffles on to the dance floor, tapping the microphone to try to be heard above the sounds of “Dancing Queen.” The speech contains all of the right words: commitment, treasure, grateful, missed, dedication, thanks. The big moment arrives when an oversized card, signed by hundreds of people, is carried in from the sidelines, and they present you with that special gift that will soon feature on your mantelpiece. You deserve it, and we all applaud loudly.

Other people, other places

While the private sector embraces frequent moves, job shuffles, and the multi-hyphen method of people’s portfolio careers, healthcare still celebrates staff who show dedication, through long service awards. But, although this is only right and proper, we should celebrate short service too.

By reducing the number of geographical rotations that doctors experience to just a small cluster of hospitals—and by implementing more prescriptive, inflexible local guidelines, which are often based on politics as much as their worth—we risk losing the learning and experience that come from working with other people, in other places. “This is how we do it here” is fine, as long as you also experience “how they do it there.”

Run-through training schemes, based around a small number of hospitals—in one country, one county, even one city—can put the breadth of medicine at risk. A narrow focus can be powerful in healthcare, as long as you gaze at the horizon now and then. To help doctors obtain such long-sightedness, the process of moving between hospitals and experiencing different environments should be easy, seamless, and even encouraged.

So, perhaps we need short service awards as well as long service ones.

BMJ: Those three little words

https://www.bmj.com/content/367/bmj.l5918

I still remember the first time I said those three little words. Growing up in a loving Welsh family, I’d heard them said many times. But the first time they roll off your tongue will always be different. You try to choose your moment, but sometimes the words take you, and the listener, by surprise.

If “I love you” are the three most important words in life, then “I don’t know” are the three most important in medicine. They’re also the most underused. Their power comes from admitting that doctors don’t, and can’t, know everything.

For me, the first time I admitted to a patient’s family that I didn’t know the answer was after caring for a young man who died from sepsis. I was a doctor on the intensive care unit, surrounded by fancy blood tests and scans. Yet I couldn’t answer his family’s most basic, most important question. Trying to comprehend what had just happened, his mum asked, “Why him? Why has he died?”

All medical encounters revolve around things we don’t know. Patients and families often challenge us to predict the future, asking, “Will she survive?” or, “When can I go home?” Like the best meteorologists we must integrate science, history, and our gut instinct to make a stab at an elusive possibility that we hope clings to a truth.

Consider a weather forecast of a 90% chance of rain. If the sky stays blue the prediction wasn’t wrong—truth just happened to be found in that smaller 10%. Openness about uncertainty can lead to more understanding: a 90% chance of rain may tell you to take an umbrella, but “I don’t know” is the start of longer, more nuanced conversations.

Looking a patient or relative in the eye while saying “I don’t know” is hard. They’re difficult words to say. It’s hard to admit the limits of our knowledge, and sometimes it means hinting at the boundaries of medical understanding. Patients and families often expect doctors to have solid answers, or they assume that modern medicine can cure them. It can come as a surprise when we don’t and can’t.

They’re also risky words. When you’re standing on the solid ice of reason it can easily get slippery when that ice begins to melt. You can fall, become unsteady, and have little to grip on to. It’s a disorientating and unnerving experience for doctors to say, “I don’t know,” and once you admit the limits of your knowledge it can make you question more and more.

Yet these words also carry immense power: the power of hope, because there may be that chance to recover. They also carry the power to inspire people to strive for a better understanding of what’s not yet known. Even when these things don’t follow and hope is lost, perhaps honesty with yourself and those you care for is good in itself—although I’m not sure about that either. I don’t know.