JellyBean 049 with Julian Savulescu FOAMethics

I have a dilemma. It is this; almost all of my ethics are a bunch of poorly thought out lies and assumptions. What am I going to do about it? Perhaps I should ask the Uehiro Chair of Practical Ethics from Oxford, Professor Julian Savulescu
My ethics are crap. Your ethics are probably crap too. If you think your ethics are definitely not crap then the aforementioned probability just shot up to somewhere very near 1.

If you think Ethics in Medicine are very simple, or even dull, you haven’t thought about them enough. The more you think about them the harder they get.

When I was taught ethics as a student it wasn’t too inspiring. As I butted up against ethical issues as a clinician it was inspiring. How can I not care about a right to life or a right to death, a right to choose or the lack thereof?Lets think about how we learn medicine.Traditionally we learn medicine from great big textbooks, lectures by established experts and by an apprenticeship model as a clinical student and continuing as a junior doctor/nurse/paramedic. That means that if you didn’t love ethics as a student you would have learned most of it on the job as an apprentice. The person who taught you may well have learned it the same way. My favourite teacher from my early days as a doctor was my boss, Professor Robert Cohen.Prof Cohen was a hero of mine. He was a calm and diplomatic genius. I certainly learned ethics and more from him. He would have learned from his teachers. He was a junior doctor in London in the 1950’s.

Too often I use intuition. Too often I use vague rule based ethics (deontological ethics) without a true understanding of where that rule came from. I am the product of educational and cultural systems that are almost exclusively based on Judaeo-Christian dogma. I work in Australia, a country where 8 out of 21 million inhabitants do not even identify as Judaeo-Christian.

I am Irish so lets take Roman Catholicism as an example. The biggest religion in Australia by far at the last useful census (2011) was Roman Catholicism with 5.4million. By the Roman Catholic churches own estimate only 662 thousand people regularly attend mass. (The Catholic Church base this on the Catholic National Count of Attendance, which is a count of attendees on a preset and well publicised weekend and includes services with or without priests, it includes services in gaols, boarding schools, migrant centres.) So being generous let us say 1 in 30 Australians goes to mass each week. How many of that fraction believe all Catholic Dogma? If my ideas of ‘rights’ and ‘wrongs’ are derived from Roman Catholicism, or Judaeo-Christian dogma more generally, does that equip me to deliberate on modern ethical problems, the ones that are current for my multicultural patients and my multicultural colleagues?

How about reading the mainstream media? Don’t laugh just yet, they do publish articles about serious medical ethical issues. The Murdoch owned media published on Saturday 24.9.16 a two page spread on Euthanasia in the Herald Sun. (The Herald Sun is read by 1.3 million Victorians every weekday, that’s twice the weekly attendance at Roman Catholic mass.) There were two articles, both by Kathryn Powley. The second is a personal account reprinted from 2012 about the death of the authors mother. The first article was interestingly titled “The Right to Choose”. It was largely built on the opinions of Assoc. Prof Natasha Michael, who is director of palliative care at the Cabrini Health. Cabrini Health is owned and operated by the Missionary Sisters of the Sacred Heart of Jesus, a Roman Catholic order. I do not know if A. Prof. Michael is a woman of faith. There were also quotes from the Victorian Premier and the widow of Mr Bob Dent who availed of the euthanasia laws in the Northern Territory before they were effectively over turned by the Commonwealth in what is often called the “Kevin Andrews Bill’. I do know that Kevin Andrews is a man of faith. He has a lot of faith. The Herald Sun article ended with several quotes from Margaret Tighe, President of Right to Life Australia and a formidable pro-life campaigner.

People that have listened to my podcasts will know that I have huge respect for Palliative Care as a specialty. The most interesting thing that the above article illustrates to me is that when we do move towards some form of legal Voluntary Medically Assisted Death we should not assume that most Palliative Care Physicians would be supportive of such a thing. Neither would I assume that Palliative Care Physicians would be the professionals best placed to deliver Voluntary Medically Assisted Death. I do not know what proportion of Palliative Care Physicians are persons of Faith. It may have to fall to another group of clinicians to deliver this kind of medical assistance to people who request it.

I have become aware that I need to learn more. It is a conclusion that almost everyone interested in #FOAMed has reached. But where to start.

I have spent the last week in the Melbourne University School of Law studying Medical Ethics with one of the worlds most conspicuous experts in Bioethics, Prof. Julian Savulescu. I have been trying to keep up with a room full of very smart women and men, lawyers and doctors, academics and policy makers, local and international.

There is a lot more to Medical Ethics than being able to define the 4 basic concepts of Autonomy, Beneficence, Non-Maleficence and Justice. Julian has become famous for a his position on doping in sport. When you actually listen to his reasons it is hard to argue against. If you just listen to the way an opponent of his might frame his reasons then its easy to argue against. I would suggest that understanding what a given person is saying is a minimum requirement in most ‘grown-up’ discussions.

The good news is that Julian is already a #FOAMethics hero and he didn’t even know it. A huge amount of his work is available through blogs, podcasts, vodcasts and more. In fact quite a few of the leading lights in Medical Ethics, both Faith Based and Secular, can be found through the Uehiro Centre for Practical Ethics website. iTunes U also hosts plenty of Uehiro Centre content. If you still appreciate good old fashioned journals he is also the editor of the Journal of Medical Ethics, which is the pre-eminent journal for the subject. I have no problem with Ethics based on belief systems that don’t mirror mine. I do have a problem with fundamentalism in all its forms.

Of course if you are going to say something controversial you should expect a debate. The debates come thick and fast when you are arguing against someones ethics, they come thicker and faster when you are arguing against someones faith based ethics. This is okay. The “ad hominem” attacks are not okay. We have already had a few #FOAMed controversies related to this sort of tactic. An ad hominem attack is analogous to a ‘low punch’. Prof Savulescu has had to deal with more ad hominem attacks than anyone else I have ever met.

Sometimes I know what the right thing to do is.
Sometimes I just think I know.
Sometimes I just haven’t thought enough.

I am not trying to be rude.
I am trying to suggest you might want to figure out your own ethics.

I know I do.

Further reading:

JellyBean Large

Last update: Sep 29, 2016 @ 2:11 pm

The post JellyBean 049 with Julian Savulescu FOAMethics appeared first on LITFL: Life in the Fast Lane Medical Blog.

Research and Reviews in the Fastlane 153

Research and Reviews in the Fastlane

Welcome to the 153rd edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 5 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Justin Morgenstern and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Airway

R&R Hall of Famer - You simply MUST READ this!
Duggan LV. Transtracheal jet ventilation in the ‘can’t intubate can’t oxygenate’ emergency: a systematic review. Br J Anaesth. 2016.PMID 27566790

  • All major guidelines for emergency airway management include the use of transtracheal jet ventilation as a mean of oxygenation. The NAP 4 study documented a high failure rate when used in the CICO setting. After a very comprehensive literature review the authors of this paper the authors identified 44 studies of both emergency and elective use of transtracheal jet ventilation and found a similar high failure rate of 42% (device failure 38%, barotrauma 39% and miscellaneous complications 9%) of transtracheal jet ventilation in emergency settings. They boldly but justifiably question the recommendation of transtracheal jet ventilation in the CICO situation
  • Recommended by Soren Rudolph

The Best of the Rest

Quirky, weird and wonderful
Thomas L. Schlenk et al. Electric Fans Don’t Cool Elders Exposed to Extreme Heat and Humidity. JAMA 2016. PMID 27599335

  • An interesting paper (‘m sure with many variables difficult to control for) about simple recommendations that probably don’t help, and living in a climate in Brisbane in summer like this, circulating hot wet air doesn’t help evaporative cooling occur.
  • Recommended by Daman Langguth

Critical care
R&R Hot Stuff - Everyone’s going to be talking about this
Sharifi M et al. Pulseless electrical activity in pulmonary embolism treated with thrombolysis (from the “PEAPETT” study). The American journal of emergency medicine. 2016. PMID 27422214

  • This is a retrospective study looking at a group of 23 patients who had all been referred to a specialist cardiovascular team after a PEA cardiovascular arrest secondary to PE (20 diagnosed by CT and 3 by right heart strain on bedside echo) and who received tPA. 4 of the 20 CTs were done after the arrest and tPA had been given. The patients all received 50mg of tPA followed by heparin. Return of spontaneous circulation and hemodynamic stability was achieved within 15 minutes for 22 of the 23 patients. At 22 month follow-up, 20 of 23 patients were still alive. There were no major or minor bleeding events recorded. This group was relatively sick, with a mean age of 72, lots of comorbidities, and 22% having a cancer history. Of course, there is no comparison group and this is a select group of patients that was actually referred, so I wouldn’t pay too much attention to the specific numbers, but these outcomes are way better than normal PEA.
  • Recommended by Justin Morgenstern

Emergency medicine
R&R Game Changer? Might change your clinical practice
Smith JD et al. Effectiveness of N95 respirators versus surgical masks in protecting healthcare workers from acute respiratory infection: a systematic review and meta-analysis. CMAJ : Canadian Medical Association journal. 2016. PMID 26952529

  • This systematic review identified 29 studies, 6 of which were appropriate for the quantitative meta-analysis. N95 masks did not appear to be protective in any of the clinical outcomes: influenza like illness, lab confirmed respiratory infection, or days off work. However, the masks do seem to work in laboratory settings, so perhaps the reason that they don’t work in the real world is that we don’t wear them properly? Also, the confidence intervals here are relatively large and all the point estimates come down on the side of N95s being better. Given the extra expense and annoyance, this probably warrants a high quality large RCT, but for now the best answer is simply: we don’t know. Bottom line: N95 masks might not be any better than surgical masks, but we really can’t be sure at this point.
  • Recommended by Justin Morgenstern

Education
R&R Game Changer? Might change your clinical practice
Stratta EC, et al. Ethical erosion in newly qualified doctors: perceptions of empathy decline. Int J Med Educ. 2016. PMID 27608488

  • A heart-wrenching open access paper looking at the changing attitudes of junior doctors towards patients and their reflections of the care they see role-modelled by seniors. 9 doctors consented to semi-structured interviews in which they described their perceptions of empathy, its value in clinical practice and its erosion with increasing exposure to the working world of medicine. Even with the possibility of a selection bias in the respondents, the paper still leaves us with important questions; who are we, as doctors? Is this part of the medical professional’s journey essential – if not, how can we avoid it? And how can we prevent it in the first place?
  • Recommended by Natalie May

The R&R iconoclastic sneak peek icon key

Research and Reviews The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of Famer R&R Hall of famer You simply MUST READ this! R&R Hot Stuff 64 R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark Paper R&R Landmark paper A paper that made a difference R&R Game Changer 64 R&R Game Changer? Might change your clinical practice
R&R Eureka 64 R&R Eureka! Revolutionary idea or concept R&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality research R&R in the FASTLANE RR Trash 64 R&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

Last update: Sep 29, 2016 @ 9:57 pm

The post Research and Reviews in the Fastlane 153 appeared first on LITFL: Life in the Fast Lane Medical Blog.

LITFL Review 250

LITFL review

Welcome to the 250th LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.

The Most Fair Dinkum Ripper Beauts of the Week

Nick CumminsProne ventilation has a myriad of potential beneficial effects in respiratory failure. So why not try it in patients who are not intubated but hypoxic? Great and thoughtful stuff from Josh Farkas. [SO]

The Best of #FOAMed Emergency Medicine

  • Core EM features a great video this week on performing an incision and drainage of a cutaneous abscess. [AS]
  • Why randomize a trial? Rory Spiegel discusses the issues that arise when we look at data that was non-randomized. [AS]

The Best of #FOAMcc Critical Care

The Best of #FOAMed Resuscitation

The Best of #FOAMtox Toxicology

The Best of #FOAMus Ultrasound

The Best of #FOAMped Paediatrics

  • Think Upper GI bleeding is all drinkers and cirrhotics?  DFTB explore the subject in kids.  Bloody great overview. [CC]
  • US is the gift that keeps on giving. Here’s a great video and short blog piece on ALIEM on the use of US in paediatric LP. [CC]

The Best of #FOAMim Internal Medicine

The Best of Medical Education and Social Media

  • It’s conference season in Europe and the good, bad and the ugly are being demonstrated to eager learners.  Ross Fisher reminds us that less can be, and probably is, more.  [CC]

News from the Fast Lane

Reference Sources and Reading List

Brought to you by:

Last update: Sep 27, 2016 @ 12:34 am

The post LITFL Review 250 appeared first on LITFL: Life in the Fast Lane Medical Blog.

Research and Reviews in the Fastlane 152

Research and Reviews in the Fastlane

Welcome to the 152nd edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 5 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Justin Morgenstern and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Critical CareR&R Hall of Famer - You simply MUST READ this!                               

 

Bernard SA et al. Induction of Therapeutic Hypothermia During Out-of-Hospital Cardiac Arrest Using a Rapid Infusion of Cold Saline (The RINSE Trial). Circulation. 2016. PMID: 27562972

  • This multi-centre randomised control trial just added another nail in hypothermia’s coffin. Adults with out of hospital cardiac arrest undergoing CPR were randomised to either a rapid intravenous infusion of up to two-litres cold saline or standard care. Due to changes in temperature management at receiving hospitals the trial was ceased early. Patients who received cold saline with an initial shockable rhythm had a decreased rate of ROSC compared to standard care and did not display a trend to improved outcome at hospital discharge.
  • Recommended by: Nudrat Rashid

The Best of the Rest

Emergency Medicine
R&R Game Changer? Might change your clinical practiceR&R Hot Stuff - Everyone’s going to be talking about thisHermann LK, et al. The limited utility of routine cardiac stress testing in emergency department chest pain patients younger than 40 years. Ann Emerg Med. 2009. PMID: 19231025

  • Another great paper from SinaiEM: they looked at all stress tests in ED patients under 40 years old (220 patients from 2004-2007) and only 6 had a positive stress; only 4 went on to get cathed, and 2 of those were negative. More evidence suggesting stress tests are useless in younger patients.
  • Recommended by: Seth Trueger

Airway                                    R&R Hot Stuff - Everyone’s going to be talking about thisTeoh WH, Kristensen MS. Prediction in airway management: what is worthwhile, what is a waste of time and what about the future? Br J Anaesth. 2016. PMID: 27317701

  •  Very nice editorial on prediction of difficult airway management with thoughts on how to be become better prepared in a future of ever expanding airway devices.
  • Recommended by: Daniel Cabrera

Resuscitation
R&R Hot Stuff - Everyone’s going to be talking about thisR&R Hot Stuff - Everyone’s going to be talking about thisSemler MW, Rice TW. Saline Is Not the First Choice for Crystalloid Resuscitation Fluids. Crit Care Med. 2016. PMID: 27428117

  •  While there’s nothing new here in the age old debate between “normal” saline and balanced electrolyte solutions in resuscitation, the authors of these pro/con articles summarize the available literature on both sides of the debate succinctly. These review articles act as a succinct repository of our current understanding of the debate. A must add to any library.
  • Recommended by: Anand Swaminathan

Pediatrics                                       R&R Eureka - Revolutionary idea or conceptShavit I, et al. Sedation for children with intraoral injuries in the emergency department: a case-control study. Pediatr Emerg Care. 2014. PMID: 25343735

  •  Procedural sedation & analgesia for intra oral procedures (IOP) such as lacerations, I&D and aspirations is generally considered with a higher risk of Serious Adverse Events During Sedation (SAEDS). This papers compares 38 cases (sedation for IOP) with 41 controls (sedation for forearm fracture reduction) in terms of SAEDS (apnea, hypoxemia (oximetry <93%), hypoventilation, laryngospasmand other upper airway obstruction). Both groups have similar sedation strategies and events; 5 hypoxic/2 apneas in cases vs. 4 hypoxic/2 apneas in control. This papers appears to show that IOP have similar risk of SAEDS compared to sedation for non IOP procedures.
  • Recommended by: Daniel Cabrera

 

The R&R iconoclastic sneak peek icon key

Research and Reviews The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of Famer R&R Hall of famer You simply MUST READ this! R&R Hot Stuff 64 R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark Paper R&R Landmark paper A paper that made a difference R&R Game Changer 64 R&R Game Changer? Might change your clinical practice
R&R Eureka 64 R&R Eureka! Revolutionary idea or concept R&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality research R&R in the FASTLANE RR Trash 64 R&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

Last update: Sep 22, 2016 @ 2:50 am

The post Research and Reviews in the Fastlane 152 appeared first on LITFL: Life in the Fast Lane Medical Blog.

LITFL Review 249

LITFL review

Welcome to the 249th LITFL Review! Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.

The Most Fair Dinkum Ripper Beauts of the Week

Nick Cummins

Swami discusses the process of thin-slicing in the ED: “the pathophysiology and relative illness of patients on the spectrum are different; [not] apply[ing] the concepts of management of one of the spectrum to the other end…allows us to tailor our management to our patients and maximize good outcomes”:. This SMACCDUB talk also saw the inception of the soon to be (in)famous term, BFC. [JS]

 

The Best of #FOAMed Emergency Medicine

The Best of #FOAMcc Critical Care

  • Extubate overnight or wait till morning? Josh Farkas discusses a recent observational paper and provides some insights. [SO]
  • Are nurses non-inferior to physicians when it comes to inter-hospital transport of patients? A recent paper on this topic is reviewed by the Bottom Line this week. [SO]
  • The Maryland Critical Care Project has a wonderful podcast on Family Intensive Care Syndrome. A real eye opener. [SO]
  • A lot of us will be performing echo’s to look for the presence of pericardial effusion, this post from Cliff Reid will help structure your management once you’ve found the effusion. [SL]

The Best of #FOAMed Resuscitation

The Best of #FOAMtox Toxicology

The Best of #FOAMus Ultrasound

The Best of #FOAMim Internal Medicine

The Best of Medical Education and Social Media

News from the Fast Lane

Reference Sources and Reading List

Brought to you by:

Last update: Sep 19, 2016 @ 4:37 am

The post LITFL Review 249 appeared first on LITFL: Life in the Fast Lane Medical Blog.