The second morning started with a head to head debate: “This house believes that presumed consent will lead to an increased number of organ donations without an uplift in critical care resources”. Next spring the UK law is changing to an opt-out system, which seems a reasonable answer to the challenge of an ongoing shortage of organs, having some evidence of benefits to donation rates in Spain, and with Wales having also recently implemented this system. After a strong coffee to shake off the mild after effects of last night’s dinner (+/- beverages), we got underway.
Dr Eryl Davies started with the pro perspective. There is little doubt about the benefits of transplant to patients, with longer and better quality lives, but the focus in this particular debate was more on the cost of this. The ‘pro’ financial argument is that this will actually also provide an economic advantage, with the costs of transplant being (eventually) offset by the reduced costs of caring for pre-transplant disease (with dialysis costs being the most well described). As well as being cheaper to provide care for, these patients have to potential to return to the workforce and (of greatest interest to the treasury) pay taxes. There is just that front-loading cost of delivering the surgery and perioperative care, which is actually not excessively different from the annual cost of dialysis care.
Dr John Weeks argued for the ‘con’ side, in that this is actually a big financial challenge for critical care. He accepts that the donation rates will increase, and that this has a clear ethical advantages; saving lives and improving the quality of those lives. However, this needs to be funded. Critical care is already under significant pressure, with scarce beds providing challenges to deliver current care levels. This increase in transplant numbers also won’t result in the transfer of excess funding from dialysis units to the ICU. Indeed, some of these patients in their subsequent care may actually have a higher burden on ICU rather than any other resources (money would be spent managing these patients who are sick with sepsis related to their immunocompromised state). The silo nature of the NHS is unlikely to allow funding reallocation to automatically happen, and this will need active anticipation and intervention. On voting at the end of the debate, it seems that the majority of the ANWICU group have similar worries. If you would like to read more about the concept of presumed consent that was the trigger for this debate, this document provides a detailed analysis.- https://www.ncbi.nlm.nih.gov/books/NBK56888/
Dr John Weeks argued for the ‘con’ side, in that this is actually a big financial challenge for critical care. He accepts that the donation rates will increase, and that this has a clear ethical advantages; saving lives and improving the quality of those lives. However, this needs to be funded. Critical care is already under significant pressure, with scarce beds providing challenges to deliver current care levels. This increase in transplant numbers also won’t result in the transfer of excess funding from dialysis units to the ICU. Indeed, some of these patients in their subsequent care may actually have a higher burden on ICU rather than any other resources (money would be spent managing these patients who are sick with sepsis related to their immunocompromised state). The silo nature of the NHS is unlikely to allow funding reallocation to automatically happen, and this will need active anticipation and intervention. On voting at the end of the debate, it seems that the majority of the ANWICU group have similar worries. If you would like to read more about the concept of presumed consent that was the trigger for this debate, this document provides a detailed analysis.- https://www.ncbi.nlm.nih.gov/books/NBK56888/
Spice
Dr Craig Mckenzie was back next to revisit the drug crisis, with the focus of this morning’s talk being on ‘Spice’. Cannabis is the natural source of cannabinoids, with THC and CBD being the well recognised compounds. ‘Spice’ refers to the synthetic cannabinoid receptor agonists (SCRAs), first being synthesised in 1988 and the initial research being published around that time. These patents are freely available online and provide the key features of a number of these compounds, such as their chemical structure. It was fascinating to discover that THC is only a partial agonist at the CB1 receptor, whilst SCRAs are full agonists (love a bit of primary FRCA stuff!). Indeed, when comparing the potency, SCRAs can be hundreds of times more potent, with wide variation between the different compounds.
The initiative and creativity of the drug producers was once again fascinating to listen to, with small alterations to drug structure initially being used to get around the legislation (creating ‘legal highs’). This was part of the driver for increasing potency, with some of the newer molecules proving to be even stronger than the ones just banned, just through this chemical exploration (for example the simple addition of a fluorine atom). These ‘market forces’ are also contributing to toxicity. Their toxicity is related to a number of factors: the type of SCRA (often a mixture), concentration of SCRA, dosage taken, residual solvents/carriers, method of ingestion (there can be unknown products of pyrolysis from smoking them) and other pharmacy ingestion. The amateur chemistry of these manufacturers results in wide variation in these toxic effects, with great uncertainty around many of these contributing factors. This unpredictability has impacted on drug users in the past, such as the effects in Manchester recently when a change in the dose of the dealt spice lead to an epidemic of severely affected users in the town centre. These patterns are important to be aware of as critical care clinicians, as we are likely to be involved in their care if they require hospital admission, due to the potential severity of the drug effects. The changes in the drug market, such as the introduction of a new molecule, may result is a spate of presentations, and it may be useful to bear this in mind following an isolated presentation - there may be more on the way soon. Again, there are some very helpful resources on the topic, particularly from the Neptune group, which are listed at the end.
The initiative and creativity of the drug producers was once again fascinating to listen to, with small alterations to drug structure initially being used to get around the legislation (creating ‘legal highs’). This was part of the driver for increasing potency, with some of the newer molecules proving to be even stronger than the ones just banned, just through this chemical exploration (for example the simple addition of a fluorine atom). These ‘market forces’ are also contributing to toxicity. Their toxicity is related to a number of factors: the type of SCRA (often a mixture), concentration of SCRA, dosage taken, residual solvents/carriers, method of ingestion (there can be unknown products of pyrolysis from smoking them) and other pharmacy ingestion. The amateur chemistry of these manufacturers results in wide variation in these toxic effects, with great uncertainty around many of these contributing factors. This unpredictability has impacted on drug users in the past, such as the effects in Manchester recently when a change in the dose of the dealt spice lead to an epidemic of severely affected users in the town centre. These patterns are important to be aware of as critical care clinicians, as we are likely to be involved in their care if they require hospital admission, due to the potential severity of the drug effects. The changes in the drug market, such as the introduction of a new molecule, may result is a spate of presentations, and it may be useful to bear this in mind following an isolated presentation - there may be more on the way soon. Again, there are some very helpful resources on the topic, particularly from the Neptune group, which are listed at the end.
The Fallacy of the Last Bed
Dr Mike Charlesworth was next discussing “The fallacy of ‘the last bed’”. The main theme of his talk was to review the importance and advantages of qualitative research methods, using his own research experience as an example. The background to this project was the ever present problem around the capacity issues with ICU. The UK has about 4000 beds, one of the lowest ratios to total population in the developed world, and with capacity over 80% much of the time. This leads to the cancelling of operations, transfers out and early discharges, putting pressure on delivering optimal patient care. Quantitative research has so far really failed to give answers to the important questions around admission or provide useful guidance to us as critical care clinicians. There aren’t that many great tools that can translate objective values into clear management decisions (e.g. ICU admission is definitely futile). Now qualitative research has a bit of a bad rep in research terms, and this is not new. There has been some good combination of the contrasting qualitative and quantitative methods, such as the recent paper on burnout, but it still seems to play second fiddle to the data of quantitative studies. However, Mike felt that this was the best approach to answer the question he had about discussions with critical care. His study involved following the referral-taker for critical care in a large teaching hospital, simply listening to the discussions that happen and following up with an interview with the clinicians afterwards. The results of the study are available here.
He discussed some of the challenges of applying similar levels of quality to such studies as are well described in the quantitative world, such as credibility, transferability and confirmability. Similarly, the analysis sounds particularly hard (an approach called grounded theory) but the results sound fascinating. Some themes that emerged included those of negotiation, consensus and the impact of tacitly held practices. These are some of the aspects of our job that I find most interesting, and yet also those which we seem to have fairly little teaching on, or even a very strong understanding of. The efforts to understand these concepts better is definitely very worthwhile, and there are few more useful links listed below if you would like to read a bit more.
He discussed some of the challenges of applying similar levels of quality to such studies as are well described in the quantitative world, such as credibility, transferability and confirmability. Similarly, the analysis sounds particularly hard (an approach called grounded theory) but the results sound fascinating. Some themes that emerged included those of negotiation, consensus and the impact of tacitly held practices. These are some of the aspects of our job that I find most interesting, and yet also those which we seem to have fairly little teaching on, or even a very strong understanding of. The efforts to understand these concepts better is definitely very worthwhile, and there are few more useful links listed below if you would like to read a bit more.
Ethics
Next was Dr Dan Harvey again, today discussing ethical decision making for anaesthesia and ICU. He opened by reiterating that ICU is approaching a bit of a crisis currently. Some of this is external, such as the funding issues already discussed, but some of the problems can be considered as internal. One component of this internal aspect that may be amenable to improvement is our ethical decision making. As just touched on by Mike in the preceding talk, this component of our practice is pretty poorly taught or studied. We are taught physiology, we are taught pharmacology, and we are taught how to construct management plans through history, examination, and applying the wealth of clinical trials to deliver effective therapy. But we aren’t really taught about the ethical or philosophical concepts that are actually an essential and major part of our everyday practice; nor the skills to implement them to deliver effective care.
The challenge that we have is to make ‘good decisions’. This is a challenging definition, but should include being justifiable, provide satisfaction (for patient, family and clinical team), and reduce fallout and stress. In the biomedical context the application of such a definition is better understood - we use the history, examination and investigations to reach reasoned hypotheses from which we can recommend treatments based on the latest evidence. With ethics there is none of this. Even our curriculum describes only ‘basic applied ethics’, and with a correspondingly smaller proportion of our training directed towards this, despite it probably making up half of the medicine we actually practice. The result is a trend towards heuristics and defaults; at risk of being highly influenced by our biases and preferences (many of which may be unconscious). Dan argues that this domain is essentially no different from the other skills we require. We need to acquire the relevant knowledge, training and practice in them to become appropriately competent. He argues that the use of frameworks can be a starting point here, and he has helped put together one that is a useful starting point for understanding these issues (see here). The classic ethical pillars of Beachamp and Childress are perhaps the best known of such ideas (autonomy, non-maleficence…), but their implementation is unclear. I do find this a particularly fascinating and important topic, although much of my reading is not specifically medically orientated. This is definitely an area I want to understand deeper, especially given the increasing importance of them as we ultimately move to working as consultants. The MORAL balance framework seems like an excellent starting point.
The challenge that we have is to make ‘good decisions’. This is a challenging definition, but should include being justifiable, provide satisfaction (for patient, family and clinical team), and reduce fallout and stress. In the biomedical context the application of such a definition is better understood - we use the history, examination and investigations to reach reasoned hypotheses from which we can recommend treatments based on the latest evidence. With ethics there is none of this. Even our curriculum describes only ‘basic applied ethics’, and with a correspondingly smaller proportion of our training directed towards this, despite it probably making up half of the medicine we actually practice. The result is a trend towards heuristics and defaults; at risk of being highly influenced by our biases and preferences (many of which may be unconscious). Dan argues that this domain is essentially no different from the other skills we require. We need to acquire the relevant knowledge, training and practice in them to become appropriately competent. He argues that the use of frameworks can be a starting point here, and he has helped put together one that is a useful starting point for understanding these issues (see here). The classic ethical pillars of Beachamp and Childress are perhaps the best known of such ideas (autonomy, non-maleficence…), but their implementation is unclear. I do find this a particularly fascinating and important topic, although much of my reading is not specifically medically orientated. This is definitely an area I want to understand deeper, especially given the increasing importance of them as we ultimately move to working as consultants. The MORAL balance framework seems like an excellent starting point.
Leadership
Dr Liz Thomas was next, speaking about her experience of medical leadership in her talk ‘leadership, it’s not for me’. She covered her journey through to becoming a clinical director, with a slightly different path than the one some might tread. Despite being a recognised important skill set, highlighted in a number of documents (GMC, FMLM/The King’s Fund), a recent FMLM survey suggests that trainees have no real experience of leadership or management within their training. Indeed, we can often find that we are drawing our impressions of what makes a good leader from the contrast with the bad examples we see, with laziness, poor communication and rudeness being frequently cited as very negative. In contrast, appearing friendly and approachable, having time for people, and being confident yet humble, are described as some of the most admired traits of leaders. Some of these things are potentially the easiest to get good at, being the personal factors that can be improved by establishing connections with people - simply getting to know them. Other features of the role are recognisably harder to simply get on with. There are a number of skills and specific knowledge that relate to aspects of budgets, money, and strategy; and the prevalence of politics in every human environment can be a challenge as a leader. It’s important to know that you’re never alone here. Peers, colleagues, unions and mentors can all provide invaluable support and advice. However, you will still have a finite amount of time and money, and there will still be a need to have difficult conversations. Overall though, there are leadership roles everyone, and everyone has skills that they can bring to such a role.
The Robbie McKendrick Prize
The afternoon was time for the Robbie McKendrick Prize; a chance for trainees across the region to present projects and interesting cases that they had been involved in. Indeed, such was the quality and range of the presentations this year, that two prizes were awarded; one for the best case report, and one for the best audit or QI project. Dr Pete Alexander opened the session with an eloquent reminder of the concept of the prize, celebrating Robbie’s memory. https://www.rcoa.ac.uk/obituaries/dr-robert-duncan-mckendrick.
The case presentations themselves involved a case of myxoedema coma, a real diagnostic challenge of Guillain-Barre syndrome developing subsequent to a high cervical spine injury, and the winning presentation from Dr April Lu about a case of diffuse TB infection. Similarly, the audit/QI project category was of very high quality and included an audit into end of life planning, an investigation into CVC insertion lengths, a review of the support for managing metabolic disease outside a specialist centre, and the winning presentation from Dr Mercer looking at exactly what a ‘liver panel’ means, and how it can be easily used in a general ITU.
The case presentations themselves involved a case of myxoedema coma, a real diagnostic challenge of Guillain-Barre syndrome developing subsequent to a high cervical spine injury, and the winning presentation from Dr April Lu about a case of diffuse TB infection. Similarly, the audit/QI project category was of very high quality and included an audit into end of life planning, an investigation into CVC insertion lengths, a review of the support for managing metabolic disease outside a specialist centre, and the winning presentation from Dr Mercer looking at exactly what a ‘liver panel’ means, and how it can be easily used in a general ITU.
Final Thoughts
And with that the meeting was brought to a close. It had been a packed and enjoyable 2 days, with the weather putting in an especially strong performance. After some discussion at the AGM about future meetings, it was good to hear that, at least for one more year, we would be returning to the Burnside again next year. Before that though would be the ANWICU winter meeting, to be held at Royal Bolton Hospital on 11th Feb 2020 (put it in your diaries). If you would like to keep up to date with these events then the ANWICU website (currently undergoing some upgrading) is probably the best destination, and following them on Twitter is also well worthwhile. Until the next time though, thanks for reading and I hope that the blog posts have provided some interesting reading.
Tom
Tom
Links & References
- ANWICU. http://www.anwicu.org/
- Rithalia, A. et al. A systematic review of presumed consent for deceased organ donation. 2009. https://www.ncbi.nlm.nih.gov/books/NBK56888/
- NEPTUNE. http://neptune-clinical-guidance.co.uk/
- UNODC. https://www.unodc.org/unodc/index.html?ref=menutop
- European Drug Report. http://www.emcdda.europa.eu/edr2019
- Charlesworth, M. Foex, B. Qualitative research in critical care: has its time finally come? JICS. 2016. 17(2):146-153. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5606391/
- Charlesworth, M. An observational study of critical care physicians’ assessment and decision-making practices in response to patient referrals. Anaesthesia. 2017. 72(1):80-92. https://onlinelibrary.wiley.com/doi/full/10.1111/anae.13667
- James, F. et al. Decision-making in intensive care medicine - a review. JICS. 2018. 19(3):247-258. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6110024/
- Harvey, D. Gardiner, D. ‘MORAL balance’ decision-making in critical care. BJA Education. 19(3):68-73. https://bjaed.org/article/S2058-5349(18)30145-8/abstract
- GMC. Leadership and management for all doctors. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/leadership-and-management-for-all-doctors
- West, M. et al. Leadership and leadership development in healthcare. https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/leadership-leadership-development-health-care-feb-2015.pdf
- FMLM. The state of medical leadership and management training for doctors: FMLM 2017 junior doctor survey. https://www.fmlm.ac.uk/sites/default/files/content/news/attachments/The%20state%20of%20medical%20leadership%20and%20management%20training%20for%20junior%20doctors.pdf
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