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

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