Matt Morgan's Blog, page 2

Audiobook download

[image error]

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

BBC Radio Wales interview

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

[image error]

Huffington Post article

[image error]

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

TRE – Talk Radio Europe interview

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

[image error]

Why you should #SqueezeTheSponge

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?

10 great books

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!

[image error]

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

Amazon.co.uk Widgets

Matt Morgan: Hello from the other side

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.

Peter Brindley and Matt Morgan: On the frontlines of the opiate crisis—no easy answers

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:

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

Matt Morgan: Life and how to live it

I still remember the first time I heard the haunting American sound of Michael Stipe, the lead singer of the band R.E.M. I was 10 years old when my dad tried to sing their confusing lyrics from “The Sidewinder Sleeps Tonight.” R.E.M.’s bittersweet combination of melancholy notes with lyrical storytelling spoke to me and has left me helpless ever since. Twenty-five years later, as I was driving back from the hospital, their song “Life and How to Live It” spoke to me again.

This 1985 song describes the bizarre life Brev Mekis, a resident from R.E.M.’s hometown Atlanta, Georgia. Brev lived in a large house divided in two by an internal wall with a single door allowing him to move from one side to the other. He would spend a few weeks living on one side of the wall, wearing certain clothes, reading certain books and eating certain food. He would then move to the other side, eat different food, wear different clothes and watch the television. He flip-flopped back and forth every few weeks until he died. After he died, the housing department cleared out his house and found hundreds of identical books, all neatly stacked in a large, tall cupboard. None of these had been read or even opened. Brev had written and published these books himself. The book was called ‘Life and How to Live it’.

Every time I step through the automatic sliding doors at my hospital entrance, I walk between two sides of my life. I wear different clothes, I eat different food, I read different books. I even wear different aftershave. Unlike Brev, each time I move back to the other side, I take a little baggage with me. When I started as a junior doctor, the two sides of my house were very different. The small amount of baggage I have been bringing back with me ever since has now left the two sides of my life more similar than different. Sometimes this is a good thing, sometimes not. How thick are the walls between your lives?

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 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.

 

The post Matt Morgan: Life and how to live it appeared first on The BMJ.

from Matt Morgan – The BMJ https://ift.tt/2XE3HhR

The robot needs a human heart—why AI in medicine brings moral choices into focus

In a crisp, white building deep in the heart of California’s Silicon Valley, teams of people make moral choices on your behalf. The development of self-driving cars may improve global road safety and efficiency, but for individuals, they also transform purely philosophical questions of the past into a harsh reality of today. When self-driving cars need to choose between a head-on collision into a child or swerving into an adult, what should they do? What impact will these dilemmas have for artificial intelligence in medicine?

Described as the “Trolley problem,” a modern version can be traced back to the British philosopher Philippa Foot. [1] She described a runaway trolley heading toward five people who will be killed by the collision. The trolley could be steered onto a different track on which there is only one person by pulling a lever. Intuitively, it seems permissible to turn the trolley to kill one person compared with five. Yet it also doesn’t seem permissible to kill one person to save five in other cases such as organ donation.

Fast forward to 2018, with the first self-driving car fatality, AI collision avoidance systems need a steer on how they should react. Vehicles cannot escape from moral value judgements implicit in their pre-programmed decision rules. What should the humans with hearts tell these inanimate machines to do? Maybe these robots need a human heart?

One way to inform these decisions is to simply ask people. The Massachusetts Institute of Technology ran an online global experiment called the “Moral Machine” where millions of people from over 200 countries took a quiz, resulting in 40 million ethical decisions. The study’s authors describe consistent global preferences in collision avoidance for sparing humans over animals, saving more lives rather than fewer and saving children over adults.

While variation is expected, they also described large shifts in choices made across social, geographic, and demographic groups. In China, Japan, and Saudi Arabia for example, the preference to spare younger rather than older people was far less pronounced.

With AI in medicine consistently described as one of the most important advances in healthcare, the “Trolley problem” is soon coming to a hospital near you. AI models are increasingly promoted for use in diagnostic imaging, risk prediction, and even treating sepsis. Up-front ethical decisions may need to be an integral part of AI modules in healthcare.

When providing care for critically ill patients, predictive AI may help guide who should be admitted to the last critical care bed. This is a close comparator to whether healthcare professionals should “pull the trolley lever” to admit the sick child with leukaemia or else the elderly adult with pneumonia. What should we do?

The first step in managing this problem is appreciating that it exists. Although the hype around AI suggests it is a panacea for improving healthcare, equal focus now needs to be placed on the inherent challenges to humanity as well as the challenges in computing. Social scientists need to be let back into the room, sharing a table with computer scientists, healthcare professionals, politicians and, importantly, patients. Perhaps a medical version of the “Moral Machine” may help gauge the public’s attitude to these ethical dilemmas. We should also consider if healthcare decisions should echo views of people from different geographical areas or simply act as a universal moral compass. Finally, perhaps we should give the owners of self-driving cars the autonomy to make difficult ethical choices themselves in advance as individuals. Some may choose to swerve, some may not. If so, AI in medicine could also be uniquely tuned by individuals to best suit their personal choices and values around health and disease. These decisions could be made in advance before mental capacity was lost as is done through systems of opt-in and opt-out to organ donation. This way, silicone derived artificial intelligence could adjust to the needs of complex organic life.

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine, Research & Development lead for Critical Care at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @Matrix_Mania His first book Critical will be published in May 2019.

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

Competing interests: none declared.

References:

1] Philippa Foot, The Problem of Abortion and the Doctrine of the Double Effect in Virtues and Vices Oxford: Basil Blackwell, 1978, originally appeared in the Oxford Review, Number 5, 1967.

The post The robot needs a human heart—why AI in medicine brings moral choices into focus appeared first on The BMJ.

from Matt Morgan – The BMJ http://bit.ly/2Wmcx3n