Here is a piece in Esquire magazine helping to support the Intensive Care Society’s wellbeing campaign.

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!

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.

Thanks to Dr Dean Burnett for asking me to talk on his new podcast. recorded before COVID19. Sorry about the ridiculous look on my face.

Thanks to CNN for interviewing me about my letter to President Trump. Listen to the interview here.

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

Sorry this is behind a paywall but here is a free trial with The Telegraph. The most important bit for me is the last paragraph about Nye Bevan.

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.

The Channel 4 journalist Andy Davies visited us in Cardiff to see for himself the extraordinary efforts staff are going to. View the report here.

Thanks to the BBC for carrying this, full story here.

Read the full piece here.

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.

Here is a BMJ blog about science and “truth” https://blogs.bmj.com/bmj/category/columnists/matt-morgan/

Here is a podcast I did on “resilience” whether you believe in the concept or not . . . https://ficmlearning.org/podcast-resilience/#more-914

“As I fly home from another overseas conference it’s embarrassing that my talk about respiratory disease was powered by jet fuel, while the calories provided by the conference were through meat.” Read more here – https://www.bmj.com/content/368/bmj.m239

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

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

 

 

The post Moral distress—easier said than solved appeared first on The BMJ.

I was very pleased to have this article published in the Guardian newspaper in early January.

https://www.theguardian.com/society/2020/jan/09/who-do-i-treat-first-a-cancer-patient-or-the-woman-with-a-bleed-on-her-brain?CMP=share_btn_tw

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.

A massive thanks to Ger Gilroy and Stuart Lancaster for inviting me onto Episode Three of the second season of Leader’s Questions.

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.

It was a pleasure to speka with Dr Andrew Davies on his podcast Mastering Intensive Care. Have a listen here https://masteringintensivecare.libsyn.com/episode-47-matt-morgan-mixing-science-history-emotion-and-humanity-in-telling-critical-stories

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.

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.

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

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.

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 Holmes, Consultant 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_mattmorgan. Matt’s first book, Critical—science and stories from the brink of life is available to order now www.drmattmorgan.com.

Competing interests: None declared

If you missed it, have a listen to this BBC Radio London interview with the lovely Jo Good https://www.bbc.co.uk/sounds/play/p07bhgym.

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.

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_mattmorgan. Matt’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

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_mattmorgan. Matt’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.

What a day – I am so grateful to everyone who helped make this events so special.

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.

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.

The audiobook of Critical is now available including through Audible here https://amzn.to/2EMzRzO. A short clip is below:

Have a listen here to the BBC Radio Wales interview with Claire Summers. The full programme is here.

I’d be delighted if you wanted to read this Huffington Post article.

Thanks to Bill Padley for this interview. Click on the play button below.

Why you should #SqueezeTheSponge

As I come to the end of a busy run of shifts in the intensive care unit, I manage to get home in time to bath my children. My special skill is to make up silly games often resulting in a lot of bath water on the floor and a late bedtime. On this occasion, we play the “Would you rather?” game.

“Would you rather be a toothbrush for a smelly giant or a sponge for a dirty ogre?” I ask my two daughters. After the debate results in a tie, they redirect the question at me. I then realise that I am a sponge to a dirty ogre most days.

The role of senior healthcare providers is often less medical than they anticipate during training. Instead, we often act as a sink for stress, uncertainty, and conflict between the patient and the system in which we work. Those who absorb this stress most effectively can make brilliant intensive care doctors. Bringing a sense of calm in the fog of medicine when a patient suddenly deteriorates is a valuable skill. We must absorb the stress from the family, the pressure from limited beds, and the uncertainty of survival. We must be an absorbent sponge, eager to clean up the water on the floor of the hospital, and hold it tight.

However, a sponge cannot absorb forever. When saturated we face two choices. We can let the sponge slowly drip as others hold out their hands underneath to catch the excess. After that busy week, you may drink one extra glass of wine, be short with your family, or shout at your dog. Your sponge is dripping and they are catching the drops.

I prefer to squeeze the sponge. I selfishly go for breakfast alone on my way home from that last night shift. I let my parents care for my children on their regular day even when I have a compensatory day off. I go the gym when I should clean the car. I have a night out and stay in bed the next morning. I squeeze the sponge.

There are dangers to both approaches. Just as when you wash that dirty car, the water that comes out when you squeeze the sponge looks very different from when it went in. It runs cloudy and pulls with it the dirt and grime that it absorbed. So too you risk damaging the sponge if you squeeze it too tightly. Still, I much prefer to squeeze than to drip. How about you?

As I come to the end of a busy run of shifts in the intensive care unit, I manage to get home in time to bath my children. My special skill is to make up silly games often resulting in a lot of bath water on the floor and a late bedtime. On this occasion, we play the “Would you rather?” game.

“Would you rather be a toothbrush for a smelly giant or a sponge for a dirty ogre?” I ask my two daughters. After the debate results in a tie, they redirect the question at me. I then realise that I am a sponge to a dirty ogre most days.

The role of senior healthcare providers is often less medical than they anticipate during training. Instead, we often act as a sink for stress, uncertainty, and conflict between the patient and the system in which we work. Those who absorb this stress most effectively can make brilliant intensive care doctors. Bringing a sense of calm in the fog of medicine when a patient suddenly deteriorates is a valuable skill. We must absorb the stress from the family, the pressure from limited beds, and the uncertainty of survival. We must be an absorbent sponge, eager to clean up the water on the floor of the hospital, and hold it tight.

However, a sponge cannot absorb forever. When saturated we face two choices. We can let the sponge slowly drip as others hold out their hands underneath to catch the excess. After that busy week, you may drink one extra glass of wine, be short with your family, or shout at your dog. Your sponge is dripping and they are catching the drops.

I prefer to squeeze the sponge. I selfishly go for breakfast alone on my way home from that last night shift. I let my parents care for my children on their regular day even when I have a compensatory day off. I go the gym when I should clean the car. I have a night out and stay in bed the next morning. I squeeze the sponge.

There are dangers to both approaches. Just as when you wash that dirty car, the water that comes out when you squeeze the sponge looks very different from when it went in. It runs cloudy and pulls with it the dirt and grime that it absorbed. So too you risk damaging the sponge if you squeeze it too tightly. Still, I much prefer to squeeze than to drip. How about you?

#SqueezeTheSponge

The BMJ is calling for doctors to be able to take the breaks that they need for their wellbeing and for patient safety. You can follow our work at https://www.bmj.com/wellbeing and take part in the campaign by sharing your examples of where things are changing for the better or where more work needs to be done through social media using #giveusabreak.

 

Matt Morgan is honorary senior research fellow at Cardiff University, consultant in intensive care medicine, Research and Development lead for Critical Care at University Hospital of Wales, and an editor of OnExamination. He is on twitter: @dr_mattmorgan

Competing interests: None declared 

Read more in Matt’s first book, Critical – science and stories from the brink of life

The post Matt Morgan: Why you should #SqueezeTheSponge appeared first on The BMJ.

It has never been a better time to peer into the gritty insides of medicine through writing. There are a huge selection of medical non-fiction books out there, here are 10 to get you started!

Here are the books linked to Amazon via an affiliate link to make it easier if you want to buy them!

It’s that strangely timed phone call while you are at work. Too early in the day to be a simple hello, too late to be telling you that you have forgotten your lunch. You answer expecting something to be wrong, and you are right. Your partner’s voice is shaking and upset. They need your help. 

I’ve been on the other side of the doctor-patient relationship a few times in my professional life. My mum having cancer, my dad having emergency surgery, as well as the unfortunate incident during my stag-do that is not for these pages. This time was different. This time the phone call from my wife told me that her brother was critically ill, being cared for in a hospital I know well, by people I know well, by a specialty that I am a part of. This seemed the closest yet.

During the short drive to the hospital, I mentally rehearsed how I should behave. I was there as a supportive husband, a brother in law, a friend. I would act as a translator between the medical speak of the team and my family’s worries. I wasn’t there as an intensive care consultant. All I wanted for him was the best care that the NHS should be providing to all of its patients, not special care. 

As I walked onto the familiar intensive care unit, it felt different. I felt different. It was as if I walked through a set of sliding doors, leaving Dr Matt Morgan on one side and stepping forward in the shoes of the other me. I wasn’t fully a relative yet neither was I fully a doctor. This surprised me. I expected to care most about the facts of medicine. Was he easy to intubate? Is he on the correct ventilator settings? Does he have broad-spectrum antibiotics prescribed? What is the diagnosis? Yet these were not the things at the front of my mind.

Instead, I cared about the greeting that the receptionist gave, how clean the toilets were, whether the doctors pronounced his name correctly. And when I was asked what advice I had for my in-laws, my response also surprised me. I didn’t advise on what tests should be done next, or what procedures he needs to have. Instead, I simply said “Make sure you bring in a photo of him with his son and put it on the end of his bed.” I wanted to short circuit the disease-identity mentality that we are all guilty of in the intensive care unit. I wanted to bring back humanity to counteract the bright digital physiology of critical illness. When you say hello from the other side, it is often the things that you think about the least during a busy clinical shift that you really care about. And so, I think, do patients.

Matt Morgan is 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. He is on twitter: @dr_mattmorgan

Competing interests: None declared.

Read more in Matt’s first book, “Critical – science and stories from the brink of life.” Available to order now www.drmattmorgan.com.

Like the 1930’s comedy brothers Groucho, Chicho and Harpo, the political theorist Karl Marx was a funny old chap. The man who penned Das Kapital and the Communist Manifesto actually longed to be a drama critic. [1] Regardless, of how much you like or loathe his ideals, 200 years after his birth, you likely know his most famous quote: “Religion is the opium of the masses”. It’s an insightful head-scratcher and likely refers to any overly simplistic belief system, not exclusively religion. Regardless, after a sorrow-filled clinical week, we don’t need to be so figurative: It seems to us that opium is the opium of the masses. 

In 2016 in Canada alone, there were almost 3000 opioid related deaths. Year on year these numbers are increasing at an alarming rate; so clearly we need to keep sounding the loudest alarm. For once, the word “epidemic” applies, but unless you work in a hospital you might not be aware of the extent. [2,3] Our emergency departments are grim places, and social workers are at their wits end. In Canada, it is common to have hallways containing intubated patients, tearful parents, and ashen paramedics as a result of opioid overuse. 

In Canada, the anti-drug campaigns, well intentioned as they are, tend towards the self-righteous and simplistic. The narrative seems to be of a mustachioed villain called Fentanyl and a squared-jawed sheriff named Naloxone. But opiate addiction is so much more than just a battle between good and evil, agonist and antagonist. Real life is really hard and lots of people feel they have nothing to lose. A comatose patient awakening following naloxone is a remarkable thing to behold. Despite this Lazarus power, let’s face some sobering truths. 

Naloxone cannot work once the heart has arrested. This means that the more potent the synthetic opiate the more likely we will be too late. In other words, medical practitioners are losing this battle to chemists, and more dangerous analogues are appearing all the time. We also need a more mature discussion about Naloxone. It cannot actually reduce population wide overdose rates. The sad inescapable logic is that it will almost certainly be associated with increased rates of opioid use because patients can overdose again. [4] Naloxone is a band-aid, and no amount of polemicizing changes that. Paramedics are even being called to the same addict several times per day. In North America, we are seeing “Narcan parties” (Narcan is the brand name for naloxone) where people congregate at malls because they assume the antidote is stocked. There are stories of people bringing Naloxone to a party in the same way we used to bring wine in a box.

Worst still, opiate publicity may not be scaring people away, but rather sucking them in. We hear stories of people seeking out dealers who sold to those that died. Perhaps this is because they assume that product must be the “real thing”, because they actually wish to die, or because they simply no longer care. In other words, this is as complex a problem as you will find anywhere in medicine. Moreover, opiates are a symptom as much as a disease. Johann Hari presents compelling arguments in his book, Lost Connections: Uncovering the Real Causes of Depression—and the Unexpected Solutions, that society needs to accept its role as a “drug mule”, smuggling opioids to dull the pain left by lost connections between families, friends and communities. In short, to varying degrees many of us are somewhat complicit, just as none of us is entirely immune. 

Despite, the Who arguing otherwise, the kids are not alright, and nor are the adults. Let’s go upstairs from the emergency room where patients are asking for enough codeine to fell an elephant. Elsewhere, successful business men are negotiating alcoholic delirium tremens. Millions are taking antidepressants. Moreover, on our campuses, more and more students are just saying “yes” to stimulants, and those that refuse to eat meat on ethical grounds care far less where Friday night’s cocaine came from. The search for endorphins and dopamine lies at the route of most human endeavors, and likely even explains ubiquitous mobile phone addiction. Regardless, in an impatient world, drugs are increasingly seen as a modern life hack. 

When one of these authors (@docpgb) worked in Africa, he was forbidden from using the word AIDS. The argument was that shame would drive people away. We are no different now that we talk of “recreational drug use” rather than “drug abuse.” We will kill with euphemism if we suggest that there is a safe amount of street fentanyl, or that opiates are merely a lifestyle choice. Elsewhere, in suburbia, everything other than unmitigated joy is a medical condition for which we have a pill or purchase. There is always somebody willing to supply and somebody eager to buy. Compassion is in short supply, and straight talk even more so. 

In more innocent times, doctors were taught to fear testosterone, alcohol, gunpowder, and gasoline. People haven’t changed, but clearly the poisons have. Clearly, we cannot use legal classifications and judicial sentences to solve the problem, and life shows no signs of slowing down. Nothing that we can emblazon on the side of a train, or shout through a megaphone, or like on Twitter will change the ubiquity of human despair, nor the eagerness to make a quick buck. If we could accept that awkward truth then it would be truly revolutionary. Instead, and like Karl Marx, we all prefer to be critics.

Peter Brindley, professor in the department of critical care medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. He is on Twitter @docpgb

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine, R&D lead for Critical Care at University Hospital of Wales, and an editor of BMJ OnExamination. He is on Twitter: @dr_mattmorgan

Competing interests: None declared. 

References:

1. https://www.newyorker.com/magazine/2016/10/10/karl-marx-yesterday-and-today
2. http://www.cbc.ca/news/health/opioid-deaths-canada-4000-projected-2017-1.4455518
3. https://globalnews.ca/news/4110583/opioid-deaths-canada-2017/
4. https://www.cnbc.com/2018/03/14/study-suggests-anti-overdose-med-narcan-increases-reckless-opioid-use.html

In the seasonal spirit of giving, Matt Morgan and Peter Brindley share what they’ve learnt from their time in medicine

When these authors were medical students—several millennia ago—we faced the difficult challenge of finding a quote to accompany our graduation photos. On the one hand, we had received a marvellous state subsidised education. We had learnt from the best informed teachers and we were truly thankful and humbled and excited for more. But medical school had also been a multi-year arse kicking that included some moody supervisors, persnickety colleagues, and patients who didn’t make it. Accordingly, we were exhausted and bruised and scared.

One of these authors eventually landed on the first line of a Tale of Two Cities as his quote: “It was the best of times, it was the worst of times.” Given that he didn’t have a “Dickens” what to write, it seemed as good—or as bad—as any one liner. Twenty years on, that quote still causes a wince. It was trite, self-congratulatory, and pretentious. Fortunately, that same doctor had no “great expectations” of being anything else.

As these aging medics move from Christmas past to Christmas present, we still struggle to dispense wisdom to the latest recruits. This is a problem as our trainees are just as bewildered as us. Likely it is selective memory, but, as junior doctors, we recall being given a hard time left and right. The instructors are gentler now but the students are no less hard on themselves. Their hours are less sadistic but the world sure is not. We were unsure what kind of  doctors we wanted to be but this rarely found purchase in our sleep deprived brains. We simply assumed that “when we grew up” people would tire of reprimanding us, and we would emerge somewhat clinically competent and moderately valued. Contrast this with today’s medical student: up to their necks in worry.

Instead of focusing on teaching young doctors life saving clinical pearls of wisdom, academic instruction seems to veer more and more into “how you can maximise your future.” Students feel pressured to regard university as little more than time to buff the CV and outflank the competition. In this solipsistic pursuit they are robbed of the opportunity to expand horizons, nourish neurons, meet soulmates, quaff pints, and cut parental cords. Both because it’s the holiday season, and because it truly sucks, we want to say “sorry.” We still have time, and so do you.

The talk that welcomed our classes to medical school focused less on “you are the chosen ones,” and more on “I hope you weren’t a mistake.” Just in case we weren’t “motivated” enough, we were introduced to classmates who had won Olympic medals, sung in major choirs, and run successful companies. However, as a coda, we later learnt that if we hadn’t been singled out that they still saw something in us: our job was to discover it and nourish it. We graduated bruised but ready to go.

We fell into intensive care—or maybe it chose us instead—because we wanted to think and to do. More latterly, we understand that above all we wanted to communicate. We felt confident that regardless of our hours or the cash, we would never work more than our parents or earn less. We didn’t know that workaholism would likely increase our risk of premature death, and that our dark humour could reach a point of no return. Hopefully, today’s graduates will navigate this better.

We now know that we want our days to include not only “head and hands” but also “hearts.” For these two doctors, true happiness has become about “making connections” whether with patients, colleagues, or even academic ideas. It means that we stop to talk and listen far more than we used to. We just wish we had known and believed this years ago.

Back to Charlie Dickens for a sec. He also wrote that we should maintain “a heart that never hardens, a temper that never tires, and a touch that never hurts.” A much more useful quote for doctors, but equally likely to make eyes roll in this best and worst of times. Fortunately, it’s Christmas so we don’t have to worry how corny it sounds: “God bless us all, everyone.”

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

Peter Brindley, professor in the department of critical care medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. He is on Twitter @docpgb

Competing interests: None declared. 

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