Wood and Trees do journal club

There was a spiritual funk over the ICU. Both Wood and Trees had been prevented from teaching as they had used strong language and “working man’s talk” during the “Train the Trainers” day and no, delegates swearing at the faculty doesn’t count as Training the Trainers. No, not even if that was how you trained your dog. So, all that experience and knowledge of how things had been in the 70 s and 80 s was now locked away in their brains never to see the light of day. Informal teaching was acceptable, but apparently expecting trainees to know lab results and clinical details was not on their module so off the menu. There was very limited mileage in Wood asking them what they thought of the colour scheme on the ventilator screen, although one of the more introverted trainees had an epiphany and left medicine immediately to do interior design. And Trees sailed very close to the wind when he asked what the trainees made of the CORTICUS study when one of them replied they had no knowledge of old films.

Wood and Trees had not sat idle when faced with these challenges. They had engaged with the trainees and sought methods to impart a comprehensive, robust, competency-based etc. etc. training programme. This involved team building in the Peak District walking over big hills and drinking beer (oddly enough hobbies they pursued most weekends), but while the Trust were supportive they were also firm. No. So they built some fitness and endurance training in and dabbled with a 10-minute Pilates station after bed 5 on the ward round, but this had to be stopped at Wood’s request as Trees’ leotard disappearing into the unknown during lunges was putting him off lunch. It was felt unhelpful to have delirious intubated patients winking and mouthing coarse suggestions so the leotard was hung up for the second time. What was needed was a Journal Club. Minimal expense, abuse a trainee with the work, invite everyone along and tease them. Great sport.

Then Wood and Trees faced the real work – which paper? Something negative that undermines decades of tradition? Something positive which suggests we should do things that Wood and Trees have been doing for decades because they don’t work? Something so ambiguous that it might work if you liked it before or be dangerous if you didn’t? Wood showed Trees some “other” types of papers featuring things like communication, quality improvement and dealing with death but Trees descended into Train the Trainers style swearing suggesting this was to be a testosterone-fuelled journal club featuring testosterone-fuelled research. Trees was touchy as he had tried some of this quality improvement before having part funded the coffee machine in the staff room.

So, they took a step back and realised lots of these papers required further reading to tease out a very weak signal form all the noise, and they both felt they had read quite enough. In a more philosophical moment, they asked the librarian to type “review” into the search and there they found the gold! An article from the grandfather of the speciality – Prof JL Vincent, assisted by Jaques Creteur, and “Paradigm shifts”. Wood shouted “yippee!” and Trees looked up what a paradigm was. This sounded good – a summary of where we are and where we might end up. Lots of opinion, so less prospect of being shown up by a trainee. No doubt reflecting their majestic status the authors had been afforded a certain latitude and consequently got away with exclamation marks and unsupported opinions. “No one would want to work in the ICU for fear of taking resistant organisms home!” Good job the relatives and visitors can do so unimpeded remarked Trees. Wood had just been hauled across the coals by the Infection Control Kangaroo Court and he was confused; it appears “… resistant microorganisms are already present inside the ICU and do not really represent a threat outside …” which seemed at odds to the efforts put into collecting MRSA and C. diff rates and the inability to discharge because Mr Smith needs a side room because of the ESBL in his urine.

Wood and Trees were at the head of the table, judge like, as if they were hosting their own Infection Control review. The trainee started to present the paper and awaited the onslaught of questions and non-evidence-based comments triggered by an attempt at evidence-based analysis of the evidence itself. They tackled a number of the changing paradigms.

From small ICU’s to larger open units. Monster units with 60 beds and move towards level 2 care. No longer rows of beds of patients melting with multiple organ failure with APC infusions and a CRRT machine clicking away and bits falling off. Far more a bit of fluid, triggered by a lactate and some oxygen. Best not to mention antibiotics after the last Infection Control probing because apparently they must be given “STAT” but with the full realisation Wood would be in the wrong if there was ever a complication. Wood and Trees both agreed this was not a man’s world any more and … a bit rubbish for them who enjoyed a bit more excitement.

From paternal dictatorship to democratic teamwork. Everyone should now gather round the bed and have a say and an opinion and somehow, using the powers of shared and non-verbal communication, the best outcomes are secured for the patient. Trees was reminded of the EU Referendum and the fact that democracy is herding the proverbial cats. While everyone is having a say round the bed space, however well or ill informed, Wood noted that you can now hold an opinion with almost no come back or responsibility. Much like voting itself. The authors suggest “working together symbiotically”; except this is not referenced and Trees doubts this is a human trait. Several trainees identified discrimination as despite most medical schools having a 70–80% female intake. “… presence of a full-time intensivist as team leader is also important and associated with improved outcomes.” Wood and Trees became hippyish. Why is the team-leader an Intensivist? Let us share this out, reject the paternal dictatorship (interesting upbringing Wood observed) and let the family decide. Including the babbling baby in a nappy. The patient’s spouse could step up and offer their view on how the ventilator works? Both Wood and Trees had gone white at the scene just created which made a great form of words but a ridiculous reality. A multi-disciplinary team where everyone offers their ten penneth on their little bit and then it’s all co-ordinated by the intensivists. One of the trainees piped up “But isn’t the Intensivist meant to know all this anyway – that’s why we stopped being Anaesthetists?” to which Wood and Trees felt sick from all the revolutions and re-inventions. “Benevolent dictator” muttered Trees.

Expanding beyond the physical ICU structure. The most contentious. So, Wood and Trees have done the ward round, got everything in order, and then you get the 5 pm “stepped in a dog poo in sandals” moment and someone refers an absolute disaster, three days in the making, beautifully charted and recorded during their demise. In the spirit of “ICU without walls” Wood welcomes this patient in, Trees doesn’t shout at the referring team as we are all mates now, and ICU is saving people from the wards. Critical illness is now part of a “disease trajectory” so Wood and Trees could not help but be puzzled why society hadn’t embraced the “hospital without walls” concept. Knowing the NHS is being overwhelmed by age and the chronically unwell obese, hypertensive, diabetic baby boomers then one would presume Society had made sufficient plans and had an open debate around what should happen when life’s excesses start to kill you … rather like the democratic teamwork on the ward round. It appears not.

Death can be a good outcome. And finally, ICU or no ICU, Outreach, early antibiotics, fluids and whatever else. Patients die; we all die, even Wood and certainly Trees. As long as no one dies on the Liverpool Care Pathway then we are in the clear. Everyone went a little quiet and a thoughtful hush descended over the journal club as everyone agreed, if they became critically ill, they wouldn’t want half of the things they got paid to do. Wood already had the fare to Switzerland and Trees would be climbing somewhere high and jumping. Despite not living in a paternal dictatorship-assisted suicide remains taboo so if Trees drives Wood to the airport he might be in big trouble, even if he is too mean to pay for a one way taxi. Death may be a good or a bad outcome, but it is the outcome and yet when the real, final test comes, Society, the Government, the Law and the symbiotic professions line up to pass judgment and paradoxically the dying individual loses their control. If a patient received industrial doses of opioids and sedation in response to begging “kill me”, we have a problem. If it is in response to a perceived (dare we say paternalistic?) perception of distress, then we are OK. Wood and Trees were perplexed and sought guidance from all the stakeholders who were equally perplexed and oddly enough no symbiotic direction or decisions were forthcoming.

2016 was a bad year for celebrity deaths and many of us will have been touched by someone’s passing. Wood noticed his CD collection from living artists was thinning down considerably. Several trainees didn’t know what CDs were and Trees couldn’t believe you didn’t go to Woolworths any more to buy singles. Most of the names were unknown to the trainees from Lemmy or Glenn Frey to David Bowie. Lou Reed avoided the rush and died peacefully practicing Tai Chi, ravaged by cancer, the focus of his Magic and Consolation album.

“There are ashes split through collective guilt

People rest at sea forever

Since they burnt you up

Collect you in a cup

For you the coal black sea has no terror”

Fair enough thought Wood and Trees who were probably facing this prospect sooner than most round the table and, on this particular topic, they agreed they would be operating a parental dictatorship because it was their absolute right.

The views expressed in this column are those of the authors and do not necessarily represent, and should not be attributed to the Journal of the Intensive Care Society, the Intensive Care Society, the Editors, or the Publisher, SAGE.