Are medical students in prehospital care at risk of moral injury?

Background The term 'moral injury' may be useful in conceptualising the negative psychological effects of delivering emergency and prehospital medicine as it provides a non-pathological framework for understanding these effects. This is in contrast to concepts such as burnout and post-Traumatic stress disorder which suggest practitioners have reached a crisis point. We conducted an exploratory, pilot study to determine whether the concept of moral injury resonated with medical students working in emergency medicine and what might mitigate that injury for them. Methods Structured interviews and focus groups were carried out with medical students involved in the delivery of prehospital and emergency medicine. The study was carried out at Barts and the London School of Medicine and Dentistry in May and June 2017. The data were analysed using theoretically driven thematic analysis. Results Concepts of moral injury such as witnessing events which contravene one's moral code, especially those involving children, or acts of violence, resonated with the experiences of medical students in this study. Participants stated that having more medical knowledge and a clear sense of a job to do on scene helped reduce their distress at the time. While social support was a protective factor, not all students found the process of debrief easy to access or undergo, those with more established relationships with colleagues fared better in this regard. Conclusions The term moral injury is useful in exploring the experience of medical students in emergency medicine. More effort should be made to ensure that students effectively access debrief and other support opportunities. It is hoped that future work will be undertaken with different professional groups and explore the potential psychological and neuropsychological impact of witnessing trauma

Tree defence and bark beetles in a drying world: carbon partitioning, functioning and modelling

Drought has promoted large‐scale, insect‐induced tree mortality in recent years, with severe consequences for ecosystem function, atmospheric processes, sustainable resources and global biogeochemical cycles. However, the physiological linkages among drought, tree defences, and insect outbreaks are still uncertain, hindering our ability to accurately predict tree mortality under on‐going climate change. Here we propose an interdisciplinary research agenda for addressing these crucial knowledge gaps. Our framework includes field manipulations, laboratory experiments, and modelling of insect and vegetation dynamics, and focuses on how drought affects interactions between conifer trees and bark beetles. We build upon existing theory and examine several key assumptions: 1) there is a trade‐off in tree carbon investment between primary and secondary metabolites (e.g. growth vs. defence); 2) secondary metabolites are one of the main component of tree defence against bark beetles and associated microbes; and 3) implementing conifer‐bark beetle interactions in current models improves predictions of forest disturbance in a changing climate. Our framework provides guidance for addressing a major shortcoming in current implementations of large‐scale vegetation models, the under‐representation of insect‐induced tree mortality

Are medical students in prehospital care at risk of moral injury?

BACKGROUND: The term 'moral injury' may be useful in conceptualising the negative psychological effects of delivering emergency and prehospital medicine as it provides a non-pathological framework for understanding these effects. This is in contrast to concepts such as burnout and post-traumatic stress disorder which suggest practitioners have reached a crisis point. We conducted an exploratory, pilot study to determine whether the concept of moral injury resonated with medical students working in emergency medicine and what might mitigate that injury for them. METHODS: Structured interviews and focus groups were carried out with medical students involved in the delivery of prehospital and emergency medicine. The study was carried out at Barts and the London School of Medicine and Dentistry in May and June 2017. The data were analysed using theoretically driven thematic analysis. RESULTS: Concepts of moral injury such as witnessing events which contravene one's moral code, especially those involving children, or acts of violence, resonated with the experiences of medical students in this study. Participants stated that having more medical knowledge and a clear sense of a job to do on scene helped reduce their distress at the time. While social support was a protective factor, not all students found the process of debrief easy to access or undergo, those with more established relationships with colleagues fared better in this regard. CONCLUSIONS: The term moral injury is useful in exploring the experience of medical students in emergency medicine. More effort should be made to ensure that students effectively access debrief and other support opportunities. It is hoped that future work will be undertaken with different professional groups and explore the potential psychological and neuropsychological impact of witnessing trauma

Drivers and mechanisms of tree mortality in moist tropical forests

Tree mortality rates appear to be increasing in moist tropical forests (MTFs) with significant carbon cycle consequences. Here, we review the state of knowledge regarding MTF tree mortality, create a conceptual framework with testable hypotheses regarding the drivers, mechanisms and interactions that may underlie increasing MTF mortality rates, and identify the next steps for improved understanding and reduced prediction. Increasing mortality rates are associated with rising temperature and vapor pressure deficit, liana abundance, drought, wind events, fire and, possibly, CO2 fertilization‐induced increases in stand thinning or acceleration of trees reaching larger, more vulnerable heights. The majority of these mortality drivers may kill trees in part through carbon starvation and hydraulic failure. The relative importance of each driver is unknown. High species diversity may buffer MTFs against large‐scale mortality events, but recent and expected trends in mortality drivers give reason for concern regarding increasing mortality within MTFs. Models of tropical tree mortality are advancing the representation of hydraulics, carbon and demography, but require more empirical knowledge regarding the most common drivers and their subsequent mechanisms. We outline critical datasets and model developments required to test hypotheses regarding the underlying causes of increasing MTF mortality rates, and improve prediction of future mortality under climate change

Drivers and mechanisms of tree mortality in moist tropical forests.

Tree mortality rates appear to be increasing in moist tropical forests (MTFs) with significant carbon cycle consequences. Here, we review the state of knowledge regarding MTF tree mortality, create a conceptual framework with testable hypotheses regarding the drivers, mechanisms and interactions that may underlie increasing MTF mortality rates, and identify the next steps for improved understanding and reduced prediction. Increasing mortality rates are associated with rising temperature and vapor pressure deficit, liana abundance, drought, wind events, fire and, possibly, CO2 fertilization-induced increases in stand thinning or acceleration of trees reaching larger, more vulnerable heights. The majority of these mortality drivers may kill trees in part through carbon starvation and hydraulic failure. The relative importance of each driver is unknown. High species diversity may buffer MTFs against large-scale mortality events, but recent and expected trends in mortality drivers give reason for concern regarding increasing mortality within MTFs. Models of tropical tree mortality are advancing the representation of hydraulics, carbon and demography, but require more empirical knowledge regarding the most common drivers and their subsequent mechanisms. We outline critical datasets and model developments required to test hypotheses regarding the underlying causes of increasing MTF mortality rates, and improve prediction of future mortality under climate change

Long-distance dispersal suppresses introgression of local alleles during range expansions

During range expansions, even low levels of interbreeding can lead to massive introgression of local alleles into an invader's genome. Nonetheless, this pattern is not always observed in human populations. For instance, European Americans in North America are barely introgressed by Amerindian genes in spite of known contact and admixture. With coalescent spatially explicit simulations, we examined the impact of long-distance dispersal (LDD) events on introgression of local alleles into the invading population using a set of different demographic scenarios applicable to a diverse range of natural populations and species. More specifically, we consider two distinct LDD models: one where LDD events originate in the range core and targets only the expansion front and a second one where LDD events can occur from any area to any other. We find that LDD generally prevents introgression, but that LDD events specifically targeting the expansion front are most efficient in suppressing introgression. This is likely due to the fact that LDD allows for the presence of a larger number of invader alleles at the wave front, where effective population size is thus increased and local introgressed alleles are rapidly outnumbered. We postulate that the documented settlement of pioneers directly on the wave front in North America has contributed to low levels of Amerindian admixture observed in European Americans and that this phenomenon may well explain the lack of introgression after a range expansion in natural populations without the need to evoke other mechanisms such as natural selection

Can liberal education make a comeback? The case of "relational touch" at Summerhill School

This article draws on data from a single element of a larger project which focused on the issue of "touching" between education and child care professionals and children in a number of settings. This case study looks at a school once internationally renowned as the exemplar of "free" schooling. The authors consider how the school works as a community, how it impacts on its students, and how it copes with the strictures of the audit culture in relation to "risk" and "safety." The authors’ experiences led them to the realization that physical "touch" was an irrelevant focus in this school, and they developed the notion of "relational touch." Summerhill works in ways that approximate an inversion of the audit culture. The authors argue that progressive and critical conceptions of education continue to have much to learn from concrete examples like Summerhill and conclude that a revival of such values in education is long overdue

Effect of a Nurse-Led Preventive Psychological Intervention on Symptoms of Posttraumatic Stress Disorder Among Critically Ill Patients A Randomized Clinical Trial

Importance: A meta-analysis of outcomes during the 6 months after intensive care unit (ICU) discharge indicate a prevalence for clinically important posttraumatic stress disorder (PTSD) symptoms of 25%. Objective: To determine whether a nurse-led preventive, complex psychological intervention, initiated in the ICU, reduces patient-reported PTSD symptom severity at 6 months. Design, Setting, and Participants: A multicenter, parallel-group, cluster-randomized clinical trial with integrated economic and process evaluations conducted in 24 ICUs in the United Kingdom. Participants were critically ill patients who regained mental capacity following receipt of level 3 (intensive) care. A total of 2961 eligible patients were identified from September 2015 to January 2017. A total of 2048 were approached for participation in the ICU, of which 1458 provided informed consent. Follow-up was completed December 2017. Interventions: Twenty four ICUs were randomized 1:1 to the intervention or control group. Intervention ICUs (n = 12; 669 participants) delivered usual care during a baseline period followed by an intervention period. The preventive, complex psychological intervention comprised promotion of a therapeutic ICU environment plus 3 stress support sessions and a relaxation and recovery program delivered by trained ICU nurses to high-risk (acutely stressed) patients. Control ICUs (n = 12; 789 participants) delivered usual care in both baseline and intervention periods. Main Outcomes and Measures: The primary clinical outcome was PTSD symptom severity among survivors at 6 months measured using the PTSD Symptom Scale–Self-Report questionnaire (score range, 0-51, with higher scores indicating greater symptom severity; the minimal clinically important difference was considered to be 4.2 points). Results: Among 1458 enrolled patients (mean [SD] age, 58 [16] years; 599 women [41%]), 1353 (93%) completed the study and were included in the final analysis. At 6 months, the mean PTSD Symptom Scale–Self-Report questionnaire score in intervention ICUs was 11.8 (baseline period) compared with 11.5 (intervention period) (difference, −0.40 [95% CI, −2.46 to 1.67]) and in control ICUs, 10.1 (baseline period) compared with 10.2 (intervention period) (difference, 0.06 [95% CI, −1.74 to 1.85]) between periods. There was no significant difference in PTSD symptom severity at 6 months (treatment effect estimate [difference in differences] of −0.03 [95% CI, −2.58 to 2.52]; P = .98). Conclusions and Relevance: Among critically ill patients in the ICU, a nurse-led preventive, complex psychological intervention did not significantly reduce patient-reported PTSD symptom severity at 6 months. These findings do not support the use of this psychological intervention