In search of the ‘good anaesthetic’ for hip fracture repair:Difference, uncertainty and ideology in an age of evidence-based medicine

Hip fracture is a common life-threatening injury amongst frail elderly people and early surgical fixation under anaesthesia is advocated. It has long been suspected that mode of anaesthesia (general anaesthesia, induced unconsciousness; regional anaesthesia, interruption of sensation using local anaesthetic) influences outcome, however ‘conventional’ studies have consistently failed to demonstrate if this is the case. A similar proportion of patients receive regional and general anaesthesia; apparently decided more by institutional culture rather than clinical requirements. This variation is perceived by many as a scandal, and efforts are underway to ‘standardise’ anaesthesia. Standardisation is controversial however; anaesthetists seemingly cannot agree on what a ‘good anaesthetic’ actually is. In this ethnography I work with anaesthesia’s ‘scandalous’ variation in three contrasting hospitals. I ask how patients, anaesthetists and others understand, experience and enact the good anaesthetic. By adopting this approach, I have radically reconceptualised how hip fracture anaesthesia is described, what it consists of, and what is important about it. Blending a science and technology studies approach with my own perspective as a practicing anaesthetist, and drawing on sociological theory about boundaries, uncertainty and standardisation, I propose that a ‘good anaesthetic’ is not regional or general. These classifications fail to recognise the nuance and complexity that define ‘good’. I contend that, to patients, anaesthetists and their colleagues, a good anaesthetic: gets done today, withstands uncertainty, treads lightly and is easily forgotten. Hip fracture anaesthesia is not as it first appears. Though evidence-based medicine makes divisions along ‘obvious’ lines, it fails to consider the goals and ideologies that underpin practice. In this thesis I explain why we must reconsider how hip fracture anaesthesia is understood. By asking ‘how, why and when?’ rather than simply ‘what?’, I offer a vital and different approach to evidence and practice for researchers, clinicians and patients

Who cares where the doctors are?:The expectation of mobility and its effect on health outcomes

Doctors are typically portrayed as active agents in their work lives. However, this paper argues that this construction of agency ignores the effects of the healthcare structures that constrain choice, which in turn affects population health outcomes. Medical training pathways, regional boundaries, and rationalisation all have a long‐lasting impact on the provision of healthcare. Using a mobilities lens to examine the movement of doctors, this paper examines how the expectation of movement built into training programmes perpetuates unequal access to healthcare. Long waiting times, poor care quality and lack of preventative care all perpetuate health inequalities; as one of the socio‐economic determinants, access to healthcare affects health outcomes

The 'haves' and 'have-nots' of personal protective equipment during the COVID-19 pandemic:the ethics of emerging inequalities amongst healthcare workers

The COVID-19 pandemic has exacerbated inequalities, including among the healthcare workforce. Based on recent literature and drawing on our experiences of working in operating theatres and critical care in the UK’s National Health Service during the pandemic, we review the role of personal protective equipment and consider the ethical implications of its design, availability and provision at a time of unprecedented demand. Several important inequalities have emerged, driven by factors such as individuals purchasing their own personal protective equipment (either out of choice or to address a lack of provision), inconsistencies between guidelines issued by different agencies and organisations, and the standardised design and procurement of equipment required to protect a diverse healthcare workforce. These, we suggest, have resulted largely because of a lack of appropriate pandemic planning and coordination, as well as insufficient appreciation of the significance of equipment design for the healthcare setting. As with many aspects of the pandemic, personal protective equipment has created and revealed inequalities driven by economics, gender, ethnicity and professional influence, creating a division between the ‘haves’ and ‘have-nots’ of personal protective equipment. As the healthcare workforce continues to cope with ongoing waves of COVID-19, and with the prospect of more pandemics in the future, it is vital that these inequalities are urgently addressed, both through academic analysis and practical action

How should institutions help clinicians to practise greener anaesthesia : first-order and second-order responsibilities to practice sustainably

There is a need for all industries, including healthcare, to reduce their greenhouse gas emissions. In anaesthetic practice, this not only requires a reduction in resource use and waste, but also a shift away from inhaled anaesthetic gases and towards alternatives with a lower carbon footprint. As inhalational anaesthesia produces greenhouse gas emissions at the point of use, achieving sustainable anaesthetic practice involves individual practitioner behaviour change. However, changing the practice of healthcare professionals raises potential ethical issues. The purpose of this paper is twofold. First, we discuss what moral duties anaesthetic practitioners have when it comes to practices that impact the environment. We argue that behaviour change among practitioners to align with certain moral responsibilities must be supplemented with an account of institutional duties to support this. In other words, we argue that institutions and those in power have second-order responsibilities to ensure that practitioners can fulfil their first-order responsibilities to practice more sustainably. The second goal of the paper is to consider not just the nature of second-order responsibilities but the content. We assess four different ways that second-order responsibilities might be fulfilled within healthcare systems: removing certain anaesthetic agents, seeking consensus, education and methods from behavioural economics. We argue that, while each of these are a necessary part of the picture, some interventions like nudges have considerable advantages

Lateral flow test performance in children for SARS-CoV-2 using anterior nasal and buccal swabbing: sensitivity, specificity, negative and positive predictive values

ObjectiveTo determine if the sensitivity of the lateral flow test is dependent on the viral load and on the location of swabbing in the respiratory tract in children.DesignPhase 1: Routinely performed reverse transcriptase PCR (RT-PCR) using nose and throat (NT) swabs or endotracheal (ET) aspirates were compared with Innova lateral flow tests (LFTs) using anterior nasal (AN) swabs. Phase 2: RT-PCR-positive children underwent paired AN RT-PCR and LFT and/or paired AN RT-PCR and buccal LFT.SettingTertiary paediatric hospitals.PatientsChildren under the age of 18 years. Phase 1: undergoing routine testing, phase 2: known SARS-CoV-2 positive.ResultsPhase 1: 435 paired swabs taken in 431 asymptomatic patients resulted in 8 positive RT-PCRs, 9 PCR test failures and 418 negative RT-PCRs from NT or ET swabs. The test performance of AN LFT demonstrated sensitivity: 25% (4%-59%), specificity: 100% (99%-100%), positive predictive value (PPV): 100% (18%-100%) and negative predictive value (NPV): 99% (97%-99%).Phase 2: 14 AN RT-PCR-positive results demonstrated a sensitivity of 77% (50%-92%) of LFTs performed on AN swabs. 15/16 paired buccal LFT swabs were negative.ConclusionThe NPV, PPV and specificity of LFTs are excellent. The sensitivity of LFTs compared with RT-PCR is good when the samples are colocated but may be reduced when the LFT swab is taken from the AN. Buccal swabs are not appropriate for LFT testing. Careful consideration of the swabbing reason, the tolerance of the child and the requirements for test processing (eg, rapidity of results) should be undertaken within hospital settings.Trial registration numberNCT04629157

How to plan and report a qualitative study

Qualitative research describes a suite of techniques that deal with unstructured data that cannot be summarised numerically. It typically approaches problems from a constructivist approach (i.e. there are multiple ‘truths’ which are socially constructed and dependent on context), whilst quantitative research adopts positivist standpoint (i.e. there is a definitive ‘truth’ that can be observed). The research methods involved in qualitative research, often based on discussion or observation, can generate vast quantities of data, and these can be challenging to summarise in a way that fits with journal guidelines for authors and is accessible for the reader. Furthermore, the processes involved in qualitative research are heavily reliant on the researchers themselves ; researchers must, therefore, strike a balance between a rigorous application of methods and an acknowledgement of their own influence on the work. This open acceptance that the researcher is a fundamental part of the research is known as ‘reflexivity’ . As part of the ‘Reviewer Recommendations’ series, we draw on our experience of qualitative research in patient safety and peri-operative practice to suggest effective ways to conduct and report qualitative work. We begin by briefly outlining the types of questions that are commonly answered in qualitative research and the methods that are used to investigate them. We then focus on describing the key components of a qualitative report, consider the hallmarks of high-quality qualitative research, suggest methods for demonstrating rigour and emphasise the importance of maintaining a reflexive approach throughout