Playing by the rules – and getting it wrong

Cite this article as:
Tony Long. Playing by the rules – and getting it wrong, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29840

Ethics is based in philosophy – the critical evaluation of arguments and assumptions – and therefore is the activity of philosophical reflection about norms and values; right and wrong; good and bad; what ought and ought not to be done. Bluffer’s Guide tip: ethics is Greek and moral is Latin. Talking about ethics and morals is like referring to renal kidneys or cardiac hearts.

Theoretical positions

Two main theories guide ethical behaviour. The most commonly espoused is that of deontology: a principles – or rules-based approach. This has nothing to do with gods (Latin “deus”). It is from the Greek “deon” for duty. Immanuel Kant (1724-1804)not-a-recent-reference defined the Categorical Imperative, a supreme over-riding principle that is never context-dependent, which rules humans absolutely, and which is felt even when defied. It’s like Pinocchio’s Jiminy Cricket. For Kant, the foundation of morality was duty. Acts should be considered good or bad of their own right, regardless of the outcome.

Following the rules

The Beauchamp and Childress schema of respect for autonomy, beneficence, non-maleficence and justice is often adopted. Patients should not smoke (no-one should): it’s hazardous to their health and 50% of smokers will die from a smoking-related illnessinsert-reference-of-your-choice. (This includes the fictitious lady who smoked only 19 a day.) Beneficence requires that we act in patients’ best interests and stop them smoking: confiscating cigarettes and frisking visitors for contraband. At the same time, non-maleficence requires us to prevent the effects of withdrawal that we enforce. If patients refuse to use them, we might have to sneak nicotine patches in under the dressings. Justice requires that we treat all patients equally, not spending too much time stopping the smoking because obese patients need to get on the treadmills and time must be allocated to preventing cake-smuggling. Then respect for autonomy requires that patients decide for themselves whether or not to smoke (or eat too much). There’s the rub.Hamlet, nd.

Rules-based approaches are difficult because the rules or principles conflict. Increasingly more conditions (formally known as “ifs and buts”) have to be introduced to make it work. Ifs and buts bring with judgements based on circumstances, so the rules are no longer universal and rigid. Judging what action to take based on guidance (rules that have to be interpreted) and on circumstances is more often known as a consequentialist stance. Discworld fans might recognise this as Commander Vimes’ “dealing with what is in front of you” approach:try “Night Watch” something that will be familiar to all senior clinicians.

Considering the outcome

An alternative, also not without its critics, justifies actions by expected outcomes. Jeremy Bentham (1748-1832) and John Stuart Mill (1806-1873) were the classic sources of consequentialist or utilitarian theory: that to act morally, we should try to bring about the best consequences. Sometimes, telling lies is right (“Is this spot really noticeable?”), and sometimes, judgement is needed to decide between opposing actions. In health care, possible outcomes are often not clear-cut. Complexity and differing viewpoints make judgements difficult.


Ethical decisions in research

Ethical decision-making in research is just as difficult. When to stop a trial because of side effects or because the results are obviously fabulous, whether we can deceive participants for the greater good, and how informed participants need to be can all be problematic. The opt-out article is a discussion of a decision made about informing potential participants and ensuring that they have given valid consent for data to be collected in a research study in paediatric urgent care departments. 

Since the bureaucracy never retreats, the content of participant information sheets (PIS) continues to grow. Required items are added, but nothing is ever removed. A 20-page PIS is perfectly normal for a drug trial. Four pages will often be required even for an innocuous survey. GDPR regulations have added one or two pages of the densest and opaque text for those of standard (ie: low) reading age. You don’t read two pages of small print before signing a new mobile phone contract.No-you-don’t! There is evidence that participants don’t read PIS, either, so they are not informed before signing up. There is something odd, too, about requiring the person who is to be protected to sign the researcher’s consent form. The participant’s signature actually protects the researcher by evidencing that consent was sought.

In the study, we adopted opt-out consent in which brief information (one side of A4 in large print and low reading age) was provided, and parents or young people would sign only to indicate a refusal to participate. (This last sentence has a Gunning-Fog readability index of 21.5. Anything above 12 is hard for most people to read!)Years of experience in research with young people has taught us that they will not read more than a paragraph before making a decision, and they will decide immediately, refusing a cooling-off period.

Since that study, incorporation of GDPR into English law has led (in good faith and with appropriate professional concern) to the banning of opt-out consent in NHS research by the Health Research Authority and therefore by the National Institute for Health Research, applying the rule that “active consent” is compulsory. We argue that this is based on the false assumption that opt-out consent implies a lack of information and lack of a decision by participants. The brief information that we supplied had a better chance of being read than a standard PIS, so participants may have been better informed than usual. Parents made a decision for their child’s clinical data to be included and did so by not completing the contact details on the reverse of the form. 


Applying a blanket rule like this can damage recruitment to very large studies, may lead to participation without effective information, and places a greater burden of time on participants which is not commensurate with the risks of participation. The law must be obeyed, but what if the law has been misinterpreted? What if the rule brings about worse outcomes? See what you think.

Emotional Contagion: Andrew Tagg at DFTB19

Cite this article as:
Andrew Tagg. Emotional Contagion: Andrew Tagg at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22095

I’ve always had an affinity for John Carter, as played by Noah Wyle, from the TV series ER. The night ER premiered on UK television happened to be my very first ED shift as a medical student at the Chelsea and Westminster Hospital.  I remember sneaking away to the lounge to watch it. My first ED experience was nothing like Carters but I was hooked.

I went to Chicago to do my elective and saw them filming in the snow in between shifts at Northwestern and when I returned to England to prepare for finals we would gather around the TV trying to make the diagnosis before the medicos on the television. We called it revising, but really it was escaping from the textbooks for a short time.

My interest wained nearer the end of the run. Carter had been through many trials, as had I, but one thing has stuck with me more than anything else. It was something passed down from David Morgenstern (William H. Macy) to Mark Greene (Anthony Edwards), and then more importantly from Greene to Carter. That is the basis for this talk. You can read the background here.

 

 

 

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal.

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Culture Cataclysm in modern medicine: Helen Bevan at DFTB19

Cite this article as:
Team DFTB. Culture Cataclysm in modern medicine: Helen Bevan at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22588
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Helen Bevan is the Director of Service Transformation for the National Health Service Institute for Innovation and Improvement. The NHS is one of the biggest employers in the world. When it was established in 1948 the average life expectancy for men was 66 and 71 for women. As science has advanced and the population becomes more medically complex so the challenges of meeting increased demand have become more apparent.

As Chief Change Office Helen talks about the clash between old and new power and the ability of super-connectors to drive change.

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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COVID anxiety

Cite this article as:
Ana Waddington. COVID anxiety, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24478

Working in healthcare is never easy, but working through the COVID-19 pandemic takes all the usual stresses, strains, and anxieties, and amplifies them by a factor of ten.

The mood in my A&E department is very emotional. Above all, we’re worried about the impact of the coming (or already arrived) tsunami of COVID-19 patients, which feels like it’s been looming for months now. But we’re also affected by the uncertainty and the deferral of plans and hopes which had been the only things keeping us going in the ever-strained atmosphere of A&E. Two weeks ago, a nurse I’d never met before broke down in the changing room, after having a much-needed break canceled by an airline. “I really needed this holiday”, she said. “I’ve been saving up for a whole year”. All I could do was hug her, which didn’t feel like enough. Our most used methods of coping have been stripped from us, and we’re having to find different ways to manage.

Many people are worried about spreading the virus to others, and these fears are particularly acute for healthcare workers. A friend texted me to say that she’s so scared that she will kill people in her household. She’s constantly disinfecting surfaces and feels like she spends most of her free time cleaning. And she’s not the only one – I’m not looking forward to receiving my next water bill, given the amount of time I now spend washing my clothes and showering. There’s also the feeling that we should be constantly working, permanently manning the barricades. A colleague told me she feels “helpless” on her days off: she wants to come into the hospital to support. I feel the same way, but I know, if I’m able to think clearly about it, that preserving myself and taking the time to recharge is more important. We can’t afford to burn ourselves out. I’ve just canceled my bank shifts.

 

One positive thing that I hope comes out of this is a tightening of the bonds of solidarity that hold the NHS workforce together. Watching how the entire workforce is uniting to help patients during this time is inspiring. Every time I walk through our ‘clean area’ and see groups of people gathered together, teaching one another new skills, reminds me how much we are doing to ensure we are prepared for what is to come – or what has already come, depending on when you read this.

 

I’ve written in the past about the issue of night shift anxiety, and the sense of isolation and disconnect from the wider society that comes with working nights. Over the past few weeks, I’ve found these feelings are more acute than ever. And it’s not just night shifts that are causing this: as healthcare workers, we are now living totally different lives to most. The patterns of working life continue as normal for us, even as the world around us dramatically alters. The experience is jarring: it feels like I’m living in a different timezone to everybody else, or like I’m a ghost of the world we inhabited a couple of weeks ago. Some colleagues have even said that they feel guilty that they get to go to work, and that we should consider ourselves lucky that we’re able to get out of the house. And they’re right to an extent, we are lucky to be able to see our colleagues and friends face-to-face – but it’s small consolation for having to face this pandemic as frontline staff.

 

I have struggled with my own rollercoaster of emotions. Some of my non-healthcare friends haven’t been taking the precautions they should, insisting they have nothing to worry about. I know that I should be more understanding – the advice provided by the government has been confusing and ambiguous, so it’s no wonder that people have different opinions on what’s appropriate – but I find it hard to understand their mindset. A friend of mine feels the same way: “my ability to cope with other [non-NHS] people’s emotions is low”, she tells me, adding: “I feel extremely guilty about this”. For healthcare workers at present, it feels a bit like the world is a Rorschach test, and we’re seeing and experiencing things differently to everybody else.

 

Nevertheless, the generosity of others is extremely precious in these times – the organized clap last Thursday moved me to tears. But I feel guilty receiving such kindness: I don’t feel like I’ve earned it yet. The worst, we are constantly being told, is yet to come. The looming doom is hard to handle. Colleagues are also concerned that we’re letting our normal responsibilities slide, forgetting about our other duties as nurses and doctors. “What happens to everyone who doesn’t have COVID?”, a colleague asks, “I’m worried about all the social cases that are being missed”.

 

We also know that, as healthcare professionals, we’ll have to make difficult decisions that we haven’t had to make before. Horror stories from Italy, or from our own ITU wards, are spreading across hospitals. As recently discussed in the New York Times, we may be forced to take actions that go against our moral judgment, such as breaking bad news without present family or making agonizing calls on access to ventilators. As a result, we run the risk of ‘moral injury’ – harm to the conscience due to being forced to violate our own moral values. The kinds of decisions we’ll have to make are similar to those faced by soldiers/aid workers in warzones, and there are likely to be cases of post-traumatic stress when this is all over. I’m already all too aware of such scenarios playing out – just yesterday, faced with an adult COVID-19 patient crying because she was too scared to die alone, I could only smile behind my facemask and offer her a gloved hand to calm her down: giving her a hug was not an option, even though it felt like the right thing to do.

 

What can we do to keep ourselves functioning and healthy in these trying times? Many of the normal tricks, used to confront the usual anxieties associated with healthcare work, can’t be applied to COVID-related anxiety. Eating well, for instance: it’s hard to do when the only dried food left in the shop when you finish your shift is bulgur wheat. Seeing friends in anything but a virtual context is ruled out for now. And suddenly every film you watch has an unexpected pandemic-related subtext.

 

My sister Dr. Emma Waddington, a clinical psychologist, says that teaching your mind not to become preoccupied with “wandering” thoughts is important. She recommends making a concerted effort not to focus on the negatives, absences, and perceived failings: not to let your mind drift to the things you aren’t doing, the social bonds you aren’t able to maintain, the news and information you aren’t keeping up with. Instead, try to focus on what you are doing, which is, as she and many others insist, amazing. She has a simple message which she wants us to keep in mind: “You are doing enough. You are enough.

Of course, focusing on our achievements and positive contribution to the fight against COVID-19 is easier said than done. One mechanism that Emma recommends to help with this is “thought stopping techniques”. These techniques help us to “pause, reappraise, and reframe”, to stop our minds becoming preoccupied with negative thoughts.

 

At work, finding new methods of coping has become key. We now cover our faces with masks and mostly work in cubicles on our own. Ensuring we take time to ask each other if we are okay is crucial. With expressions obscured by masks, it’s become a vital new healthcare skill to be able to tell what emotions people are going through solely by looking at their eyes. I’ve found out that no one can tell if I am smiling or not, I’m trying to achieve more expressions with my eyebrows now. Checking up on each other has been really important, and I’m particularly enjoying the new ways of being affectionate at work – elbow tap here, toe tap there.

 

With the help of friends and colleagues, I’ve added a few other techniques to the toolkit I’m using to help deal with COVID-19 anxiety. Firstly, I’ve bought an alarm clock so that when I go to sleep, I can leave my phone in a different room. That way I’m more fully disconnected from the world when I’m resting, and less tempted to catch up on things if I wake up in the middle of the night. And when I do get up, I don’t open my eyes to a bombardment of push-up notifications, emails, and frenzied messages. Secondly, I make sure I do some form of exercise once a day – even if this means following a pre-recorded boxing class via a choppy video stream. And finally, I make sure to properly relax during my time off by penciling in some time for indulging in my greatest passion (besides nursing): sprawling on the sofa and watching rubbish TV. Just make sure that the new Netflix series doesn’t have a pandemic-related sub-plot before you get stuck into it.

For some extra resources:

Watch out Clinician Care webinar

Managing mental health injury during pandemic

Podcast on moral injury

Good Netflix binges (not sponsored) that aren’t pandemic related:

  • Stranger things
  • The Stranger
  • Sinner
  • Sex education
  • Good girls
  • Frankie and grace
  • Working moms
  • The Fyre festival
  • Russian Doll
  • Ozark
  • Call the midwife

Good Instagram workouts

  • kobox
  • The jab
  • Melissawoodhealth
  • Joewicks

Taking your trauma team to the next level: Anna Dobbie at DFTB19

Cite this article as:
Team DFTB. Taking your trauma team to the next level: Anna Dobbie at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22066

Anna Dobbie works in HEMS, PEM, and Adult ED and is a badass at all of them. She is the person you’d want leading your trauma team. Want to be just a little more like Anna? Then watch her talk and find out how to step up.

As we are so fond of saying, “You set the tone.” That first two minutes of any resus is critical – and not just because of the decisions you make. If you can appear calm and in control, your teams’ actions will reflect that. Running every trauma call the same allows for cognitive off-loading as some behaviours become automatic. Whether they are ‘real’ calls or not so serious ones the team is expected to act the same either way.

 

 
 
DoodleMedicine sketch by @char_durand 
 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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Top 10 Tips for Consultant Interviews

Cite this article as:
Tessa Davis. Top 10 Tips for Consultant Interviews, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.21861

I’m finally settling into some job security after 16 years of changing jobs every six months. One advantage of not being in run-through training has been the frequency of job interviews (and the consequent interview experience I’ve gained). The consultant interview involved another level of preparation. Facing this is a challenge, particularly for trainees who will not have had an interview for 6-8 years.

Be productive and indistractible

Cite this article as:
Tessa Davis. Be productive and indistractible, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.21430

I love my phone (iPhone X) and I love my laptop (MacBook Pro 13″). But their aim is to enhance my productivity and not to detract from it. As apps, tech, and the way we communicate have evolved over the last 5 years, have we (or have I) evolved to handle them?

Change against the grain: Shweta Gidwani at DFTB19

Cite this article as:
Team DFTB. Change against the grain: Shweta Gidwani at DFTB19, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20875

Shweta Gidwani graduated from Seth G.S. Medical College, Mumbai, India in 2002. S. She has been involved in the development of emergency care service delivery and training programs in India for several years and was invited to join the International Emergency Medicine section at George Washington University as Adjunct Asst Professor in 2013 where she works on the India programs.

This talk, the opening talk proper after Mary set the scene, is a stark reminder of just how the world really works.

 

©Ian Summers

 

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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Blowing the whistle: Kim Holt at DFTB19

Cite this article as:
Team DFTB. Blowing the whistle: Kim Holt at DFTB19, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20736

You may recall the headlines surrounding the case of Baby P. Back in 2007 a 17 month old boy died as a result of injuries suffered over months of abuse. During that ordeal he had been seen by the London Borough of Haringey Children’s services and multiple concerns were raised. But nothing happened. Not until it was too late. Eight years earlier the same council had failed to intervene possibly leading to the death of eight year old Victoria Climbie.

Compassion to the Core: Mary Freer at DFTB19

Cite this article as:
Team DFTB. Compassion to the Core: Mary Freer at DFTB19, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20653

Mary Freer has been with us from the start. After a heartfelt keynote at our first conference we knew we had to keep in touch. In London we set her a challenge. We asked her to set the intention for the day for us, to frame our conversations around care.

The Medicines Handbook: Simon Craig at DFTB18

Cite this article as:
Team DFTB. The Medicines Handbook: Simon Craig at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20590

Ask any paediatrician what the hardest, tricksiest procedure that you might ever have to perform and they would all be in agreement – calculating drug doses in the middle of a paediatric resuscitation. In this talk Simon Craig, from Monash, takes us through the how we can do better than scratching out rough calculations on the whiteboard at 6am. He asked the key question…

 

 

 

 

 

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story‘ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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*Lori was once one of Andy Tagg’s trainees but he is quick to point out that none of the situations depicted are about him.

 

Mentoring in Medicine: Melanie Rule at DFTB18

Cite this article as:
Team DFTB. Mentoring in Medicine: Melanie Rule at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20557

Mel Rule is one of the founding members of the extraordinary WRaPEM group. They are a group of passionate educators and clinicians waim to bring back Wellness, Resilience and Performance coaching for the everyday doctor.