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

 

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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

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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

The post I’m dreaming of a green Christmas appeared first on The BMJ.

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.

Matt Morgan and Peter Brindley: Meetings⁠—where minutes are kept and hours lost

It is estimated that meetings add less than 5% to productivity, are mostly about status management, and contribute to 70% of workers feeling disengaged. [1] Oh well, no time for such thoughts: it’s off to the monthly medical meeting. You’re not working clinically, but are dragged back to the hospital. At least you can sport your latest hipster t-shirt rather than those crumpled scrubs. Others dress in Lycra bike shorts that leave nothing to the imagination. Regardless, it’s time to ingest stale coffee, squint at a blurry screen, and balance on a wipeable chair: Let the predictable pantomime begin! But will everyone remember their lines?

Act one

Scene one: The mandatory IT delay

The organiser fumbles with a broken remote control, and cycles through countless menus: “VGA1,” “VGA2,” “AUX,” “Laptop,” “HDMI”. The screen stays as black as the coffee. Attendees mutter awkwardly as wires are un-plugged, blown on, and returned to the same hole. The organiser becomes increasingly red-faced; enter the IT saviour. You worked in Dixons at age 16 and know the dark arts of video projection. You move in, pop a battery in the remote control, and, voila, the screen is resuscitated to a bright white light. You believe you are a hero. Others silently disagree; after all this meeting was close to being cancelled. Ten minutes in, nothing yet achieved.

Scene two: For those calling in from home

An iPhone is balanced on the table and its volume turned to max. Battery power might be at 5%, but let’s give it a go. Multiple passwords are tried, before a picture of a dog eventually appears. At this point the script is as familiar and it is farcical:

“We see you but can’t hear you” 

“Try logging out and logging back in”

“Is the Wifi better in the kitchen?”

Finally, the video becomes clear, and the sound becomes ear-shatteringly loud. An important point is made right as the video connection dies. Twenty minutes in; surely there is more to life than this. 

Scene three: This will never work

It’s time to hear from “the voice.” Namely, that person who has worked more shifts that you have had hot lunches, has saved lives using nothing but a rusty spoon, and even remembers life before flat whites. With both eyes on retirement, he has little time for new initiatives that are really just recycled old ones. Nowadays, he takes delight in saying things that would get new hires struck off yet he receives admiration and the odd bottle of wine in return. 

Act two

Scene one: Why is he even here?

Our next protagonist cares more about the Wifi code and little about the agenda. His power cord is stretched across the entire floor and he has commandeered the room’s only socket. He noisily taps computer keys, and repeatedly checks his beloved phone. He might be studiously taking notes, but is likely just shopping on Amazon. Forty minutes in: if only we had arranged to be paged out. 

Act three

Scene one: Not so fast

Discussion about the clinical rota has concluded, and that contentious checklist has been okayed. A détente is reached that would impress the UN security council. “Onto the second agenda item” says the organizer at which point several actors burst into song: “uhm, just returning to the last topic, am I right in thinking that . . .?” No, dear colleague, you’re wrong, dead wrong, and you would know that if you had been listening. “Perhaps we’ll move on” states the frazzled organizer, “well I think this needs more discussion” the others reply. Fifty minutes in; thank goodness there are no sharp objects nearby. 

Scene two: Crisis averted 

Near the end of our play a villain enters in a cloud of paper and to a cacophony of pages. He collapses into the last empty seat, and is passed the agenda that he has clearly not pre-read. He tries unsuccessfully to obtain a few drips of coffee, and is just about to bite into the last stale muffin when he remembers another meeting he needs to be at. Everyone breathes a sigh of relief that they will be spared his attempt to highjack the agenda. He leaves and likely won’t be heard from for months. The meeting has now reached its allotted 60 minutes: time to conclude the performance.

Closing scene

 “Right, the next meeting is during half term, shall we meet anyway?”

“YES!” is the unanimous reply.

“Any future agenda items?”

“Can we talk about whether these meetings are truly useful” says a quiet voice in the back.

“Sorry, there’s simply no time”. 

Curtain drops, exit stage left. 

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

References:
[1]  Bruce Daisley is the European VP for Twitter. He hosts the podcast Eat Sleep Work Repeat ad has authored the book “The Joy of Work”.

The post Matt Morgan and Peter Brindley: Meetings⁠—where minutes are kept and hours lost appeared first on The BMJ.

Hospital doctors should step outside BMJ 2019

https://doi.org/10.1136/bmj.l4914 (Published 06 August 2019) Cite this as: BMJ 2019;366:l4914

Last year I did something I found difficult, unsettling, and risky. Yet, in many ways, it was a simple act that community health workers do every day. It didn’t involve a complex procedure or a new treatment. I even wore a pair of jeans while I did it.

Last year I stepped into the home of a patient I’d cared for while he was critically ill many years before. I left the safe neon confines of “my” hospital and entered “his” softly lit world of home. I was the visitor, the guest in his life rather than he in mine. That experience changed me. It was a powerful way to navigate the fog of medicine that surrounds us in hospitals.

Until then, my “patient follow-up” had involved seeing an empty bed in the intensive care unit. This meant that the patient had either died or got better. Occasionally I’d expand this window further, by visiting people on the ward after leaving intensive care or by looking at their date of discharge on the hospital computer. To my colleagues, a “did not attend” at an outpatient clinic may represent something similar: the patient didn’t come, presumably having got better or perhaps worse.

This binary view of the future is, of course, not real life. While survival is good, it’s not always good enough, and we should strive towards what’s important to patients. What better way to frame these hopes than to see patients living their own life? Before I saw the other side of that journey I was ill prepared to advise on what route to take. This form of follow-up may be a rare concept in hospital medicine, but it’s one we need to learn about from our community colleagues, who have known this for decades.

As I stood in that person’s home—seeing the adapted shower, hearing the children playing in the garden, smelling the home cooked food—I was reminded of what medicine’s really about. Not a ward discharge, not a hospital discharge, but life returning.

I’ve come to think of this as “deep follow-up,” and I believe that it may help combat nihilism when treating conditions such as traumatic brain injury or cardiac arrest. I later visited a family where life could not return, where the patient had died. But this, too, may give us the humanity to have difficult conversations about survivorship earlier and may help shared decision making about life sustaining treatments.

Of course, this kind of follow-up needs to be done safely, with support for all parties. It may not be suitable for all patients, all families, or all staff. It isn’t practical for every encounter. But perhaps we can occasionally flip the narrative and, instead of patients booking an outpatient appointment with us, book a walk in the park with them.

Matt Morgan and Peter Brindley: Why it’s time we all woke up to the importance of sleep

For too long, medicine has been a cult that deifies workaholism and mocks those who “fuss” about sleep, say Matt Morgan and Peter Brindley

Lauren Connelly was delighted when she landed her ideal job. After years of proving her mettle through hard study she stepped enthusiastically onto the medical ladder. She was now a doctor, and would hone her craft at a rural Scottish hospital. Fast forward a few weeks and Lauren was exhausted, both physically and mentally, after yet another 100 hour-week. Undaunted she readied herself for seven consecutive night shifts. This may have been her dream job, but the truth is that the rota rarely allowed for adequate sleep. Her death occurred on 17 September 2011 on Scotland’s busiest motorway, after falling asleep at the wheel. 

Following Lauren’s death, her dad, Brian [1], suffered his own insomnia, albeit for different reasons. Alongside grief, Brian Connelly was angry and in disbelief. After all, we—the supposedly sensible and all knowing medical profession—had blithely ignored decades of its own research. We know that lack of sleep kills. Data have consistently shown how it kills slowly and silently by increasing the likelihood of cancer, heart disease, immunosuppression, and weight gain. Poor sleep also kills suddenly and loudly through motor vehicle crashes and workplace trauma. If insomnia was a drug we would ban it immediately. If sleep was a drug we would prescribe it to all. Brian is right to speak up, is right to ask questions, and deserves our full support. The answer is seemingly simple: more and better sleep for all. The question remains: do we care enough to do the right thing? 

Speaking six years after his daughter’s death, you can still hear gritty determination mixed through his Scottish accent. He intends to wake up the government and the medical profession, and like all good parents, he just won’t quit. There is legislation to limit working hours, but Brian will tell you how it is commonly exploited and stretched. For example, we often tabulate average working hours. This sleight of hand allows 100 grueling hour weeks to be hidden within a rota, as long as that rota includes less hours over subsequent months. Brian is clearly smarter than the lot of us when he reminds us that: “Sleep cannot simply be banked and averaged over time.” We simply don’t believe that any doctor should be worked to death. 

For too long, medicine has been a cult that deifies workaholism and mocks those who “fuss” about sleep. Regardless of whether insomnia is limited to medicine or is, instead, a society wide issue, we can likely all agree that we need a cultural shift. This starts by senior folks speaking up and standing side by side with junior colleagues. 

We should not, cannot, and need not stand by as doctors work hours that we would never condone for pilots or bus drivers. Lessons must be heeded. Fortunately, these are lessons that we have known for decades, and lessons that Lauren and her dad are shouting on our behalf. Patient safety matters, and so does practitioner safety. 

Brian is a professional working in the information technology industry. As such, both his advocacy and his day job could save more lives than any single doctor. This is because many of the greatest patient safety initiatives have been spearheaded not by highly qualified doctors, but rather by remarkable and tenacious people who had to respond to tragedy and refused to wait for us to do the right thing. Brian’s campaign mirrors another magnificent non-medical professional, the airline pilot Martin Bromiley, whose wife Elaine died unexpectedly after a minor operation. Inability to manage her airway should not have ended her life, but it did. Elaine died because while the doctors and nurses had all of the individual skills they had insufficient team skills. She died because of her team’s spiral of indecision, deferred responsibility, and its collective failure to act. She died because a team of experts is not the same thing as an expert team. This death was no one person’s fault, instead it was everybody’s fault. Accordingly, making things better is everyone’s responsibility. [2]

Like Brian, Martin Bromiley threw his energy into improving the system even while battling grief. They simply could not just stand by and let it happen again. Using decades old lessons learnt from the aviation industry, Bromiley’s Clinical Human Factors Group may well save more lives than you and I ever will. We suspect Brian’s campaign to reduce deaths from medical tiredness will be equally revolutionary and necessary and therapeutic. We medical practitioners have a lot of work to do. We need to wake up, and this starts by ensuring everyone is properly rested. We owe it to Lauren, Brian, Martin and Elaine…and many many others.

Matt and Peter would like to thank Brian Connelly for his bravery and time.

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

Peter Brindley is a professor of critical care medicine, medical ethics, anesthesiology at the University of Alberta, Canada. 
Twitter: @docpgb
Competing interests: None declared

References

[1]https://www.dailyrecord.co.uk/news/scottish-news/worked-to-death—exhausted-young-1084348

[2] https://qualitysafety.bmj.com/content/24/7/425

Critical thinking Matt Morgan: Fixing our broken wards BMJ 2019; 366 doi:

As I reach the top of the staircase a faded sign reads, “Block A, Tower 3, Wards 7F and 6G.” Nobody really knows what these characters mean or how they help to navigate the twists of an ever changing, expanding hospital. A patient looks up and down at a clutched paper letter, wondering if they’re going the right way. A hospital porter senses their disorientation and points them back towards the way they’ve already come.

As I approach the door of the ward, I see a line of relatives huddled around a buzzer with “ONLY PRESS ONCE” taped over its scratched buttons. Once a minute, once an hour, once a day? A busy nurse, looking after patients and supporting families, hears the buzzer’s call but can’t answer it. As I open the door with my access card, the opportunity is seized and families flow in. Through that one door come meals, x ray machines, dirty linen, nurses, doctors, patients, and dead bodies.

On the ward the relatives peer into different wings, looking for “bed 9 in the 4 bedder,” without knowing what that means. As an overflowing catheter bag is quickly carried to the sluice, the dinner trolley is manoeuvred to make room. The height of the desk at the nurses’ station is an awkward compromise—too low for my knees to fit underneath and too narrow to house a set of paper notes. As I squeeze in, the computer mouse falls to the floor, hanging helplessly by the wire and swinging like a pendulum. I feel the same.

I want to speak to the patient and her family. I think that the patient is going to die. The cloth curtains around the bed are too thin to contain this news from the well wishers next door, so I look for a more private area. (“Just use the office, it should be empty.”) I don’t want to use the office. This is a hospital ward. It should be the perfect environment to do all of this—for conversations to be spoken, for food to be eaten, for patient care to happen, and for medicine to work.

Yet the many hospital wards I’ve visited all over the world have a design that’s changed little since the late 18th century. It’s time to reimagine it. The general ward should have as much consideration as a shiny new operating theatre or boardroom.

Wards need separate entrances for utilities and families—even a circular design with dividing walls. Natural light and noise reduction technology would aid sleep, and communal areas would encourage socialising, rather than eating in a chair next to the bed. We need separate areas where intimate examinations, treatments, and even difficult conversations can happen. These should be large enough to house a hospital bed and a supportive family. We should replace faded signs and use floor maps, with directions to toilets and exits, that are shown to nudge human behaviour.

Think too about staff. Central workspaces should encourage thoughtful work with additional areas close to patients, for individualised care. Zoned areas could indicate different levels of need and safe “wander paths,” allowing movement even when patients are unwell. And ageing posters that fail to change behaviour could be replaced with art that encourages reflection and has been shown to aid recovery. Hospital needs to be a place that promotes healing, not one that simply delivers it.

Read the full article here.

Expanding neverland —applying never events management to hospital infrastructure

It had been a tough weekend for our colleagues. They had to deal with a complex patient in cardiac arrest. Yet the response team took days to get to them. This decline was hardly a surprise, the warning signs were there in the notes months before. Chronic ill health, previous missed opportunities to intervene with a failure to engage with difficult palliative care conversations. Had the case been examined in detail, a DNAR decision would probably have been in their best interests. Yet instead, there was a mad scramble to treat all reversible causes while the team tried to keep blood flowing through the system at short notice.

This may sound a sadly familiar story, but we are not talking about a patient. We are not even talking about a human. We are talking about a sudden break in the critical physical infrastructure of a hospital that was predictable, should have been prevented and responded to without the necessary skills nor urgency. As the NHS creaks into its 71st year, hospitals up and down the country will echo these events. Cables will break, pipes will burst, and lifts will stop. These are all predictable events. The important thing is that prevention can work and a rapid response should be rehearsed. The day of the week, the time of night or the hospital manager on duty should not matter just as it does not for patients when they are sick. A sick hospital means that all patients are at risk and a proportionate response should be elicited.

In 2009 the NHS implemented a “never events” policy to improve patient safety. The list of never events included wrong site surgery, in-patient suicide, and wrong route medications. It was hoped that this list would allow focus on detection, investigation and action with reports shared with care commissioners. It has long been taught that before offering help, you should first “check the scene is safe”. The physical structure of a system is a core component of safety for both patients and staff. It is about time that never events are extended to organisational events and non-clinical staff. 

We propose that the never events list should include:

  • Malfunctioning safety systems during an event such as fire detectors, sprinklers and circuit breakers.
  • An inadequate or untimely response to critical infrastructure systems failure including water, electricity and transport.
  • Serious injury to staff from known, predictable risks including asbestos exposure, non-compliant building regulations or structural damage.
  • Failure to address staffing gaps that are known about that result in patient or staffing harm.

If it is right to call proximal patient harms events that should never happen, then surely it is right to apply these same standards to the wider hospital structures that endanger the many as well as the few.

Tom HolmesConsultant in Intensive Care Medicine.

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. He is on twitter: @dr_mattmorganMatt’s first book, Critical—science and stories from the brink of life is available to order now www.drmattmorgan.com.

Competing interests: None declared

Whose choice is equipoise in clinical trials

Doctors constantly strive towards what is best for patients. Good doctors try to make accountable decisions based on integration of clinical experience, medical evidence and patient preferences – a stable three legged stool that is safe to sit on. Great doctors do the same but realise that such decisions can only ever be based on the best evidence at that time. Ultimately such decisions may in the future be shown to have been wrong.

With less than one in ten interventions in critical care being based upon high quality evidence(1), we must be honest with ourselves and our patients. Although public awareness programs and quality improvement initiatives are common, these should be based upon best evidence driving knowledge translation for patient benefit. It may come as a surprise that these uncertain treatments include even simple concepts such as how much oxygen we should use when people are critically ill(2). Admitting this uncertainty about fundamental treatments can be hard.

In order to improve the care of our patients, we need to advance the evidential basis for our own practice. This involves addressing the remaining nine out of ten interventions that lack evidence head-on, challenging assumed, potentially outdated, or frankly wrong knowledge. This comes from a position of equipoise.

Even when trials are based on acknowledged evidence gaps, then funded, designed and delivered, we stumble against a new barrier – equipoise. Whilst the trial committees, funders, ethical committees and collaborators all maintain equipoise, individual treating doctors will sometimes prevent trials from being conducted in their own institutions. Their reasons are noble – they want to do what they feel is right for patients and be early adopters. The problem is that feelings do not save lives

Things that we have felt to be right in the past have a regular habit of actually causing harm(3-5). Some people feel best in the safe, understandable and predictable world of demonstrable physiology at the bedside as an end in itself. Understand and correct the physiology and you can deliver treatments that feel right. However, whilst physiology is important, adaptive physiology in critical illness is complex and instead we need to strive towards meaningful patient outcomes as the stick by which to judge our feelings.

Getting the right balance is hard. How should “equipoise” be decided (5)? Should it be by country, by hospital, by department or by an individual? We worry that an individual’s feelings about what works and what doesn’t may negatively impact on clinical trials. They may restrict sites from contributing towards important research, reduce recruitment rates, increases the costs of research, waste public money and ultimately be bad for patients. More than 30 years ago Benjamin Freedman writing on ‘equipoise and the ethics of clinical research’ suggested that the concept of ‘clinical equipoise’ should refer to genuine uncertainty in the expert medical community rather than on the part of individual investigators(5). Despite the passage of time researchers still find themselves encountering the same issues today.

As most trials in critical care are funded from the public purse, we need an agreed solution. There should be a social responsibility for equipoise as we strive to create new evidence for patient benefit. Too often the lack of generalisable medical evidence means that complex decisions are based only on clinical experience and patient preference. The original stable, three legged stool becomes too unsteady to safely sit upon. The development of clinical research networks both in the UK and internationally can help, outsourcing difficult evidential challenges to those best placed to balance them. This allows individual clinicians to focus on the job of integrating their outputs with clinical experience and patient preference whilst allowing equipoise to answer the questions for which uncertainty presides.

Matt Morgan is an Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Research and Development lead for critical care at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @dr_mattmorgan. His first book “Critical – Science and stories from the brink of life” published in May 2019.

Matt Wise is a Consultant in Intensive Care Medicine and Research and Development lead for Specialist Services at University Hospital of Wales.

Paul Dark,Consultant in Critical Care Medicine, NIHR Clinical Research Network National Specialty Lead for Critical Care and Chair in Critical Care Medicine, University of Manchester. He is on twitter: @DarkNatter

Disclosures/conflicts: none. This work is original.

  1. Zhang Z, Hong Y, Liu N. Scientific evidence underlying the recommendations of critical care clinical practice guidelines: a lack of high level evidence. Intensive Care Med. Springer Berlin Heidelberg; 2018 Jul;44(7):1189–91.
  2. Schjørring OL, Perner A, Wetterslev J, Lange T, Keus F, Laake JH, et al. Handling Oxygenation Targets in the Intensive Care Unit (HOT-ICU)-Protocol for a randomised clinical trial comparing a lower vs a higher oxygenation target in adults with acute hypoxaemic respiratory failure. Acta Anaesthesiologica Scandinavica. 2019 Mar 18;18(15):711.
  3. Chohan SS, McArdle F, McClelland DBL, Mackenzie SJ, Walsh TS. Red cell transfusion practice following the transfusion requirements in critical care (TRICC) study: prospective observational cohort study in a large UK intensive care unit. Vox Sang. 2003 Apr;84(3):211–8.
  4. Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D’Urso P, et al. Decompressive Craniectomy in Diffuse Traumatic Brain Injury. N Engl J Med. 2011 Apr 21;364(16):1493–502.
  5. Freedman B. Equipoise and the ethics of clinical research. N Engl J Med. 1987 Jul 16;317(3):141–5.

The car seat of life

While stuck in an angry snarl of traffic during another grey morning commute, I had time to contemplate the view from the car’s rear-view mirror. If this was the “family car” then the back seat would be decorated with children’s toys and crayons. It might be messy, but would reflect adventure and discovery and excitement. Instead, my commuter vehicle had two neglected child seats. In contrast, on the front passenger seat there was a horror show of adult mess and misgivings. I couldn’t help but think the universe was trying to tell me something. Welcome to lessons from the car seat of life. 

I had ricocheted through a busy run of clinical shifts. The faces of the many patients I had cared for still occupying my mind. Over the past week I felt I had done my bit for humanity. However, while you can largely leave the patients at the hospital, it is the “curse of extra tasks” that follows you home. We want to help the greater mission and therefore we volunteer left and right. However, every “sorry to bother you but…” and “can you just help out for a sec” adds up and takes away. So I covered a locum shift here, attended a meeting there, tried to co-write a paper, delivered extra teaching, and squeezed in a conference call or two, or three. The resulting early arrivals and late departures could be tallied in the lines under my eyes. We might recognize the toll of overwork in our morning mirror, but this time it was writ large in the passenger seat to my right. 

Instead of a lovely conversant human sitting next to me on my drive, let me describe the detritus of my week and the self-recrimination that followed:

–      Fast food wrappers: one for every meal and beverage shoved or guzzled. Was I reduced to such low-grade fuel just to keep my engine going?  

–      A mobile phone charger and cable: my lifeline to the world which I scrambled to recharge after my phone died. How long had I lived with the spectre of being called back at all hours and never really getting away.

–      A mouldy apple core: a vain attempt to reach my five-a-month let alone five-a-day. What does it say when you don’t eat right and don’t clean up compost? 

–      A chocolate bar wrapper: a “pick me up” because of missed meals and lousy sleep. Can you really make up for lost sleep and time?

Some of your car seats may look like this all the time—and perhaps that is fine. I am not here to moralize only to reflect. The point is that mine is normally empty and clean and as uncluttered as my mind. This state of affairs was not normal. It could just as easily have been a blinking light on the dash. I really shouldn’t ignore this, but who has the time? Perhaps it is more accurate to admit that I had temporarily forgotten my priorities.

There may be other areas of your own life screaming out a warning. My polite suggestion is that you dedicate time and space to listen. For example, does your refrigerator routinely contain food well past its sell by date? Are you wardrobe hangers empty because your clothes are conducting a protest on the bedroom floor? Do you climb over unopened mail by your front door? Do you routinely forward yourself emails because you can’t bring yourself to deal with them now. This is not piety, and I am not suggesting that cleanliness is next to godliness. Instead the issue is that modern life may leave you feeling that you no longer have time for general maintenance or self-care. When you get so distracted that you fail to do what is now known as “adulting”. These routine chores used to be the cornerstone of everyday life. Clean your shoes, brush your hair, and tidy your room. Get the little things right and the rest will follow. 

The following week, I tidied up my car seat of shame. I also tried to hit reroute. I cancelled a meeting, I turned down a locum shift, I excused myself from a conference call, and I got a half decent sleep. Small steps but at least I felt a little more in control. My car seat was clean and my life was a little manageable. I then borrowed the family car and threw the kids in the back seats. We headed out for a quick adventure that coincided with the route that I cover on my morning commute. The kids made a shocking mess of the back of the car. In contrast to feeling distress, it felt like a clean start and a fresh perspective. I have a way to go but am getting better at enjoying the journey.   

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. He is on twitter: @dr_mattmorganMatt’s first book, Critical—science and stories from the brink of life is available to order now www.drmattmorgan.com.

Peter Brindley, Professor of Critical Care Medicine, Medical Ethics, Anesthesiology at University of Alberta, Canada. He is on twitter @docpgb

Disclosures/conflicts: none. This work is original

Matt Morgan and Peter Brindley: The car seat of life

While stuck in an angry snarl of traffic during another grey morning commute, I had time to contemplate the view from the car’s rear-view mirror. If this was the “family car” then the back seat would be decorated with children’s toys and crayons. It might be messy, but would reflect adventure and discovery and excitement. Instead, my commuter vehicle had two neglected child seats. In contrast, on the front passenger seat there was a horror show of adult mess and misgivings. I couldn’t help but think the universe was trying to tell me something. Welcome to lessons from the car seat of life.

I had ricocheted through a busy run of clinical shifts. The faces of the many patients I had cared for still occupying my mind. Over the past week I felt I had done my bit for humanity. However, while you can largely leave the patients at the hospital, it is the “curse of extra tasks” that follows you home. We want to help the greater mission and therefore we volunteer left and right. However, every “sorry to bother you but…” and “can you just help out for a sec” adds up and takes away. So I covered a locum shift here, attended a meeting there, tried to co-write a paper, delivered extra teaching, and squeezed in a conference call or two, or three. The resulting early arrivals and late departures could be tallied in the lines under my eyes. We might recognize the toll of overwork in our morning mirror, but this time it was writ large in the passenger seat to my right.

Instead of a lovely conversant human sitting next to me on my drive, let me describe the detritus of my week and the self-recrimination that followed:

     Fast food wrappers: one for every meal and beverage shoved or guzzled. Was I reduced to such low-grade fuel just to keep my engine going?  

     A mobile phone charger and cable: my lifeline to the world which I scrambled to recharge after my phone died. How long had I lived with the spectre of being called back at all hours and never really getting away.

     A mouldy apple core: a vain attempt to reach my five-a-month let alone five-a-day. What does it say when you don’t eat right and don’t clean up compost?

     A chocolate bar wrapper: a “pick me up” because of missed meals and lousy sleep. Can you really make up for lost sleep and time?

Some of your car seats may look like this all the time—and perhaps that is fine. I am not here to moralize only to reflect. The point is that mine is normally empty and clean and as uncluttered as my mind. This state of affairs was not normal. It could just as easily have been a blinking light on the dash. I really shouldn’t ignore this, but who has the time? Perhaps it is more accurate to admit that I had temporarily forgotten my priorities.

There may be other areas of your own life screaming out a warning. My polite suggestion is that you dedicate time and space to listen. For example, does your refrigerator routinely contain food well past its sell by date? Are you wardrobe hangers empty because your clothes are conducting a protest on the bedroom floor? Do you climb over unopened mail by your front door? Do you routinely forward yourself emails because you can’t bring yourself to deal with them now. This is not piety, and I am not suggesting that cleanliness is next to godliness. Instead the issue is that modern life may leave you feeling that you no longer have time for general maintenance or self-care. When you get so distracted that you fail to do what is now known as “adulting”. These routine chores used to be the cornerstone of everyday life. Clean your shoes, brush your hair, and tidy your room. Get the little things right and the rest will follow.

The following week, I tidied up my car seat of shame. I also tried to hit reroute. I cancelled a meeting, I turned down a locum shift, I excused myself from a conference call, and I got a half decent sleep. Small steps but at least I felt a little more in control. My car seat was clean and my life was a little manageable. I then borrowed the family car and threw the kids in the back seats. We headed out for a quick adventure that coincided with the route that I cover on my morning commute. The kids made a shocking mess of the back of the car. In contrast to feeling distress, it felt like a clean start and a fresh perspective. I have a way to go but am getting better at enjoying the journey.   

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. He is on twitter: @dr_mattmorganMatt’s first book, Critical—science and stories from the brink of life is available to order now www.drmattmorgan.com.

Peter Brindley, Professor of Critical Care Medicine, Medical Ethics, Anesthesiology at University of Alberta, Canada. He is on twitter @docpgb

Disclosures/conflicts: none. This work is original

The post Matt Morgan and Peter Brindley: The car seat of life appeared first on The BMJ.

Hay Festival 2019

We had a great time at the Hay Festival this year. I am so grateful to The Baroness Finlay of Llandaff who chaired my event fantastically.

For those who were not able to come, the talk can be seen here.

10 Questions from the Hay Festival

Here is a quick interview that I did at the Hay Book festival the original link is here.

Matt Morgan’s Critical is an intelligent, compelling and profoundly insightful journey into the world of intensive care medicine and the lives of people who have forever been changed by it. We asked him our 10 questions and here is what he had to say.

1. What are you in Hay to talk about?

My new book Critical which is all about the most terrifying, the most wonderful, the most complex, yet the most simple place in the hospital – the intensive care unit (ICU). 

I say simple because we use complex technology and cutting-edge science to give patients just one thing – time. Time for us to discover what is wrong with them, time for them to get better, and sometimes, sadly, time for them to say goodbye. 

2. What do you want the audience to take away?

That the privilege of life is all around us. Exploring survival at the brink of life allows us to glimpse at something powerful, to cut through the crap of everyday life and gaze at the glimmer of time on this earth. 

3. What’s the best question you’ve been asked in an event and how did you answer?

The question was: “Why do some patients in ICU die yet other live?”

I responded with “I don’t know”.  If, “I love you” are the most important three words in life, then “I don’t know” are the most important words in medicine. They are also the most underused and honest. 

4. Which events, other than your own, have you seen and what stayed with you?

I’ve been coming to the Hay Festival for many years with my family – it is the highlight of our year. I remember crying with laughter listening to the children’s author Andy Stanton and finding inspiration for my own books after hearing Noel Fitzpatrick (The Supervet).

5. If you could sum Hay Festival up in one sentence, it would be… 

Listening, reading, thinking, eating, drinking and laughing.

6. What is so special about Hay-on-Wye?

It is that perfect mix of a beautiful rural location yet great facilities and the mix of diverse talent all around you. Plus, the ice cream is great.

7. What was the last book you read and loved?

I am normally a non-fiction fanatic, but I have tried to read more fiction this year as I’ve been finishing my own book. I loved The Seven Deaths of Evelyn Hardcastle by Stuart Turton.

8. What is the book you’ve most often given as a gift?

Guns, Germs and Steel by Jared Diamond – I’m distraught I can’t see him speak this year.

9. Which book has most inspired you?

The Diving Bell and the Butterfly by Jean-Dominique Bauby closely followed by Oliver Sacks’ The Man Who Mistook His Wife for a Hat.

10. Which piece of advice do you wish you could give your 16-year-old self?

There is no such thing as a “temporary” tattoo.