Fragmentation of the QRS Complex Is Associated with Right Ventricular Dilatation and Mortality in Critically Unwell Coronavirus Disease 2019 Patients.

Background: QRS fragmentation (fQRS) is a depolarization disorder that can be detected on routine electrocardiography (ECG). Current evidence suggests that fQRS is a prognosticator of adverse cardiovascular events. This study aimed to assess the relationship between fQRS and all-cause mortality in critically unwell coronavirus disease 2019 (COVID-19) patients and to investigate the significance of associated abnormalities on echocardiography.

Pandemic and the human factor.

As the staffing crisis in the UK deepens, it is time for the policy-makers and professional bodies to rethink the approach to the most vital and yet most fragile component of the healthcare system-the human beings. The austerity measures, combined with pandemic and more recently the vision of a backlog with attached unrealistic expectations of tackling it, have brought the NHS and many other healthcare systems to the brink of a crisis. It is a human factors approach, which emphasises clinician's well-being as the core aspect of optimising performance that should become our goal.

Elevated procalcitonin concentrations in severe Covid-19 may not reflect bacterial co-infection.

Background: The variability of Covid-19 severity between patients has driven efforts to identify prognosticating laboratory markers that could aid clinical decision-making. Procalcitonin is classically used as a diagnostic marker in bacterial infections, but its role in predicting Covid-19 disease severity is emerging. We aimed to identify the association between procalcitonin and Covid-19 disease severity in a critical care setting and whether bacterial co-infection is implicated.

Human factors and ergonomics to improve performance in intensive care units during the COVID-19 pandemic.

The COVID-19 pandemic has tested the very elements of human factors and ergonomics (HFE) to their maximum. HFE is an established scientific discipline that studies the interrelationship between humans, equipment, and the work environment. HFE includes situation awareness, decision making, communication, team working, leadership, managing stress, and coping with fatigue, empathy, and resilience.

Classic cases revisited - Tony Nicklinson and the question of dignity.

Dignity is a concept we often evoke in healthcare when caring for patients and attending to their basic needs. It is a very human concept, unique perhaps. Yet, though instinctively we think we know what it means, we rarely pause to reflect on it.

Classic cases revisited: Of hurricanes, cyanide and moral courage.

All decisions made by doctors have a moral dimension. When a moral judgement demands a different course of action to one that represents the usual practice, many doctors do struggle. The inability to embrace such decisions can represent moral negligence, as often the consequence is greater suffering for the individual in question or loss of utility for the population.

Classic cases revisited: Mr Miura and the delusion of immortality.

Death continues to be viewed as a failure by many clinicians and society. For now however, it remains a biological certainty and to think otherwise is to delude oneself. Nevertheless, the society is becoming older and many individuals enjoy fulfilling life in spite of advancing years.

Classic cases revisited - Death of a nurse and the anatomy of error.

The tragic case of Mayra Cabrera who died as a result of wrong route drug administration is notable as it was the first time a verdict of unlawful killing was recorded against an NHS Trust. Error within medicine is a significant cause of patient morbidity and mortality. We explore the costs of error, the dynamics of error causation, the role of both the individual and institution in accountability for error, as well as transferrable lessons from other industries to reduce error.

Doctor won't see you now: changing paradigms in mountain medicine.

The evolution in communication and digital technologies is revolutionising the practice of medicine. A physician is now able to oversee provision of healthcare at a distance. In this paper, we argue that practice of telemedicine is an essential and evolving aspect of high altitude and expedition medicine.

Classic cases revisited - Oxygen in court and the problem of therapeutic illusion.

Medical science attempts to inform clinical practice. Law is concerned with causality. Intersection of law and medicine at times highlights the shortcomings in the medical approach to causality.

Classic cases revisited: Oscar the cat and predicting death.

Uncertainty, although inherent in medicine, is rarely discussed in spite of being ubiquitous. Communication of uncertainty is poor due to anxiety associated with it, yet one could argue that lack of such disclosure could undermine trust, lead to perception of deceit, alter decision making and in some cases could invalidate the consent process. Predictions concerning end of life are particularly difficult and may lead to excessive or insufficient medical interventions.

Fulminant high altitude blindness.

Prolonged altitude exposure even with acclimatization continues to present a physiological challenge to all organ systems including the central nervous system. We describe a case of a 41-year-old Caucasian female climber who suffered severe visual loss that was due to possible optic nerve pathology occurring during a high altitude expedition in the Himalayas. This case is atypical of classic high altitude cerebral oedema and highlights yet another danger of prolonged sojourn at extreme altitudes.

Classic cases revisited: Mr David James, futile interventions and conflict in the ICU.

The technology so prevalent in the modern healthcare setting often creates an illusion that the biological certainty of death can somehow be evaded. Increasing number of deaths worldwide occurs in hospitals, and doctors by necessity inherit the role traditionally owned by priests, in overseeing the dying process. Unrealistic expectations concerning cure or indeed different perceptions of patient's interests on a background of deficient communication can lead to conflict.

Patient-centred mountain medicine.

Venturing into the mountains, doctors have accompanied expeditions to provide routine care to the teams, undertake research and occasionally take on a rescue role. The role of doctors practicing mountain medicine is evolving. Public health issues involving concepts of health and safety have become necessary with the coming of commercial and youth expeditions.

Classic cases revisited: Baby Theresa and the definition of death.

As our medical knowledge grows the criteria for the diagnosis of death continue to evolve. The criteria tend to be pragmatic, and are designed to serve the needs of the society. They are however, only a set of tools and as such they fail to address the question of what death actually is.

Classic cases revisited: Mrs Janet Tracey, resuscitation and the importance of good communication.

The prevalence of inappropriate care, defined as actions contrary to personal and professional beliefs, is high. This is a reflection of the reluctance of the society at large to acknowledge the biological certainty that is death. The case of Mrs Janet Tracey illustrates importance of good communication at the end of life, and the difficulties associated with making of DNACPR decisions.