I, V, M. We can't show you, I can't show you, because I'm, I'm a really nice guy. I'm partners with my youth at University of Ontario. Where we discuss various parts of the working of the working of ICUs as well as the life of an intensive is we continue the conversation today with a bit more about how medical oxygen is used how it works, how it applied, all the details about that.
So thank you, doctor. Yeah, actually we have only, you know, on the rare occasion that we miss these cheap to hope we agonize for days and then for losing the opportunity to do that. So yeah, so what we'd like to talk about is we've got the, now we've got the oxygen to the hospital. How do you get it into the lungs of the patient?
So that's basically what this is. So basically if you've talked about oxygen's got to the wall or the cylinders now make the patients bad and we can come back to cylinders later. So then what you're looking at is what does the patient need. So you have obviously done oxygen saturation on the patient, but you also have to think about why there's a patient need oxygen.
Is it an ammonia? Is it heart failure? Or is something else going on? Have they just had carbon monoxide poisoning?
Have they had cyanide poisoning? Something? Who knows what? So you have to, what you need to know is why you're giving oxygen rather than the knee jerk reflexes of oxygen saturation so low let's get more oxygen.
Then you have to decide on a target and I think everyone's heard now that the target for oxygen for a sick patient typically is around 1992, such as if you and I are walking around people have possibly 98, 99% and then I've heard on social media people saying, oh, we are just doing to this this may harm patients, but we are doing this to conserve oxygen. Actually, there is a lot of evidence to suggest that these saturation targets are better when I was starting out patient would come in with a heart attack. We would give them 15,000,000. Now we give them sometimes no oxygen at all.
Sometimes just a bit of oxygen. Just enough to get the saturation up about 93, 94. And there is a lot of evidence to suggest that any more than that is harmful and we can come back to why harmful because we don't know for short but there are theories. It's the same with ventilated patients about 24 years ago.
There was a big study in America where they tried to do two different things. They tried to compare two arms. This was called the ARM study or the ARDS, the ventilated volume study. What they did was they ventilated one group with 10 meals per kilo of tight volume.
Ventilated, not 12 meals. The other group is 6 meals per kilo. The 6 meals per kilo group was so what they found was over two days, the first two days and they did regular analysis of the gas. They found in the first two to three days the patients who were ventilated with high tidal volumes and unrestricted pressures versus low tidal volumes and pressure restricted at a reasonable level.
The high tidal volume group, they had much better gases. They were getting much better oxygen. They were clearing their CO2. They were looking a lot better by day three.
By day six, the situation had reversed by day 21 twice as many people in the high tidal volume group had died. Why? Because that is where the concept came to the forefront. The people that talked about it for years, the concept had never come into the forefront, which is your lungs are composed of about a million small sacks, thin walled sacks called alveolar, which is where gas exchange happens.
What is pneumonia or the ideas? Some of these alveolar get inflamed, they get filled with inflammatory current pass, if you will, and so they can not participate in gas exchange. You have half of the lung is not working at the moment, the other half is working. Then you try and stretch these alveolar by giving them high tidal volumes and high pressure so you get what we call the volume trauma and barot trauma.
The easiest way to describe it is take a balloon. You inflate it a little bit, let it go. You can do that 20 times. You inflate it full, over-inflated.
Then it comes back, it doesn't come back to its relationship. It's elasticity. Now it has plastic changes rather than elastic changes. Does that make sense?
Yes. That's a beautiful analogy. That's a beautiful analogy. Once you overcome the elasticity of these alveolar, these are living structures, they will also get insane.
So essentially, if you are causing trauma to your lungs and we started calling this one, it's so non-intuitive. It is so non-intuitive. It is so non-intuitive. It is absolutely.
Which is the same thing, which is what I was saying, what we learned over the last 25 years is less is more. So whatever you try to do to correct the numbers in the short term, we have unforeseen lockdown effects. Wow. The concept of a patient who looks better after four days but may end up dead after 21 days is absolutely, I mean, that requires experience to understand.
One of the things that someone decided to do a study, is not intuitive. Yes. Someone said this and decided to do a study. Absolutely.
A lot of things that we are doing in the last 20 years are non-intuitive. But we know this works because we've done these large studies. I mean, in a typical year, in my issue, we admit about 2,300 patients. If we do not enroll at least six or seven hundred of them into various research trials, we have failed.
Right. Because there's so much that we do not understand, so we have to try and get more knowledge. Actually, this could so easily become an episode on evidence-based medicine because you take nothing for granted and you just keep testing all your theories all the time. Obviously, there is no other way to do it.
And also on that note about how that concept of less is more about whether it is oxygen, whether it is antibiotics, whether it's about any kind of... The whole thing about, I was just seeing another video about how a lot of privileged people who have oxygen saturation at 99 or 98 are getting medications or whatever, and then just taking indiscriminately and then that is leading them to either too many steroids or leading to whatever the black fungus infections or high spiking blood sugar and all the other ailments that are coming accordingly, which has become a major thing. Understanding when certain medication is required and not everything can be prophylactic. Right.
Yeah, absolutely. And again, if I can make a tangential point here, when I started doing this, there was a move to move away from calling this intensive care unit and to call them intensive treatment units. And 10 years ago, we changed the name back because it's not the treatment. It's the care.
There are no magic bullets. It is the care. It is attention to the day. It's such a sweet and different.
Yeah. Yeah. We have a lot of patients who will get during COVID times, they'll get phone calls, but earlier they would be have open visiting. So families can visit two people at a website 24 seven whenever they want.
And if someone is predicted to die in the next 24 hours or so, we move them into a site room and then they can have five or six family members in there as well. So we have a very open visiting and every day that the families get to ask as many questions as they want and we give them a detailed update every day. So the care doesn't just extend to the patients. I have to just add one point here.
So then my dad was in the ICU. We were allowed because I knew the people most relative had to wait outside and do get their information only from the staff. So that was one second one of my close friends got go. He went to a, you know, he saw that.
So he did an excellent job. They saved him. They can buy he went into a crisis. They took him to a municipal facility and he's like sort of half a family and his family in Canada is easier and they weren't able to find out what was happening to him because he was in the ICU in this facility locked up.
So he reached out to us, his friends, he went there and they told us that you can't obviously can't get him. You can't see him being the only information we can tell you whether he's alive or dead. It was brutal. I tell you every morning you go and he's still alive.
That's it. That is unfortunate. That is unfortunate. Exactly.
Yeah. Just don't know. So I have a difference between treatment and care, right? And how there are no magic bullets.
What we see constantly on social media is like requests from, you know, relatives who are trying for the best for the patient, requesting things like plasma or remdesivir or any of these other patients. How does that come into being? Does that get passed on from the doctor or is it just, you know, like, we don't know. We have we used remdesivir plasma.
We used hydroxychloroquine on 100 patients in my unit. But we used all of these medications, all of these therapies only as parts of a research study. So, you know, all the evidence that we have from in the UK, we were part of the recovery trial, which everyone's heard of now. And we were also part of remac app.
So every single co-opitation that came to us. We're trying to enroll them in the study and 90% of the families agreed to enroll them into studies or if the patients were still conscious, they agreed. So it was humbling to see that families when you told them we do not know what works, but we are going to try and find out this may not help you outpatient. But then again, if you are not in the study, we're not going to give you this drug anyway.
But there is a 50% chance because you may be randomized and it is a double line study. So I don't know what I'm giving the patient. So they might be getting the drug or they might be getting the saline injections. I don't know.
No, no, no. The blinding is open only at the end of the study. So we don't know. So it but it was humbling that very, very few patients and families said no.
And if you are actually open and honest and say we are not sure, but we are trying to find out and this may not help you, but this may help other people in the future. Yeah. Most people just say yes. Yeah.
I think I think in India, it's on the opposite side of the spectrum where, you know, you feel compelled to try something because not trying something feels like, you know, this is a certain type involved in people having to source their own medication seems a little crazy. Yeah. Unfortunately it does. And actually, when I was brand new resident, my boss in intensive care, he had his favorite saying.
He used to say, don't run and do something. Just stand there, which is the opposite of what most people try and do. Because most people that say don't stand there could run into something. Yeah.
The rule of intensive care is don't run into something. Stand there and think first. Unless it's a genuine emergency, yes. This is almost Zen life in its wisdom because it applies to real life things.
Sometimes it oftentimes you just need to reflect for a little bit and then decide a lot. Is that true and fasting? Absolutely. Absolutely.
And a lot of my intensive care friends, they are huge fans of that book. Everyone has that book. Everyone has that book. And again, there is an intensiveist on Twitter, Matt Schubert, who runs a website, which is called the Zen Intensivist.
And a lot of us have contributed to it. I was around the world giving talks on how to be a Zen Intensivist. So I found it interesting that you just said that there is no. It's life.
And one of the things that an Intensivist will see rather more often than other doctors is death. And it does affect you. And I see my father is a doctor. And he was a pretty strong guy.
He was a family physician and he had a lot of other huge practice. So every now and then, when a patient died, he would just come home and he knew that he was upset. And he would just sit and not say a word. And he was a very garrulous kind of person.
So it was unusual to see him like that. So that was most doctors I know. They never let on what's going inside their head. So here I'm going to ask you, how does death affect you in general and in particular when someone you care.
Particularly sad kids. Yeah. So when I was a medical student in India, this is what we've talked about. What I have learned over the last 15, 20 years, so about in an average year, about 20% of my patients will die.
It really somewhere between 18 and 22% a year to call it 20%. So one in five or four locations will die. But what will happen is half of my admissions are surgical elective surgical. So, and there, most of them don't die and most of them only stay for two days.
So the people. And so you are not going to remember the names and faces of people that have only stayed for two days. Now you're thinking, okay, of the other half, probably 40%. So of the others, about 40% of them are going to die.
And these are the people that are going to stay in hospital for a few days. You're going to talk to them. You're going to talk to the families every day. And so you will remember the faces.
So sometimes it's easy to forget that only 20% of patients die and the other 80% survived. Whereas in the 1970s, they would have all died. Yes. You've I hate saying you've saved lives.
What you've done is you've extended people's lives by, you know, two years, five years, possibly even 50 years. No one has ever saved a life because everyone's going to die. So, but you've done what you've done is you've postponed death for a bit. However, the names and faces that you will remember will all be dead.
And what I found and what a lot of us have found is actually the if you can feel true empathy and if you can talk to the family and about personally when I'm discussing death with families, I cry with them about one in four times. And instead of locking the emotion out, you let it in and let it pass through you and then it passes through you and then you piss it out later in the evening. Then as if you try and block it, it sits in your throat and jokes you for the next few days. That wasn't meant to be profane, but this is how I thought.
It was a profound. So medicine is that very unusual profession. Most of us, we do not see more than one or two deaths in our lifetime. And here, absolutely the same, you know, same species is seeing that every single day, it does, you know, and like PTSD, there must be so they do have a little difference mechanism.
They tend to be able to profane about it and to be, you know, they tend to make jokes about this. Like, it's like, I have a surgeon friend who actually did a trauma-interest in surgery and then went and ate spaghetti a year after that. Pretty much the same you were like operating on. Okay, you eat the same thing like 15 minutes later.
So yeah, it sort of hardens you in some ways. Yeah, there must be some very interesting dark jokes that have passed in some ICU doctor WhatsApp groups. I'm guessing, but let me take a nalene's question and it was, and thank you for sharing that because that seemed like a very personal thing. So let me take the sunshine of that, which is when the lives are saved, the 80% as it were.
That's the flip side of that happened was a joy. Do you share the joy as well? One of my hobbies is I do, I run, actually I haven't for the last 18 months, but before that I used to run an ICU for the clinic. So patients come back, families come back.
And one of the joys of my life is seeing these patients that were completely broken. Oh, well, coming back. It takes time. About 20% of our distillations have some sort of PTSD, which is very similar to military veterans.
And actually, there's some research work now going on which shows that intensive care doctors and nurses have similar amounts of PTSD as well. That is it feels really good. And we encourage the families and patients that are coming back, we encourage them to visit the unit and talk to the members of staff that looked after them because we found that it is incredibly great for morale. You see your results and it feels amazingly good.
And then obviously, patients tell you stories and then you remember the stories and I think, okay, maybe we could do something different next time. On the topic of death, I've actually in the chat box, I've just shared a blog I wrote a few years ago. At some point, have a little look. I will link it out as well.
And that was something that you said recently with me. So while I've been fortunate enough not to be in an ICU myself, I wasn't a very bad car accident almost exactly 10 years ago and I had a hit with him so it's already done. And I made the point to go back to my surgeon every few years just to have a look at how the X-ray is doing. And the last time I went, which is about a year or so back, he was having a look at my femur's x-ray.
And you could see the sprite in his face. It's like, this is a look of art which I did. And he was like, wow, because one is very rare for him to have done a surgery on such a young person. I was 26 when I had that surgery, but it's a pretty bad crush.
So he put it in the only way to go. And he was like, oh, the thing has the body has accepted the implant. And he was like, you could see the joy in his face. And I just kept my eye on him to revel in his own art sometimes.
So I can totally understand what you say. When you say it's amazing when patients are survivors in some way. On the flip side, it's almost like my father a few years ago actually had a well before COVID. A few years ago had swine flu.
And he's in the 70s, he has asthma. So swine flu is pretty dangerous for him as such. And the thing being, so we have a family doctor. And he's an amazing doctor.
He's also a family doctor. He's been the coldest doctor we've ever had. He's just, we go to him. He sees us.
He says how you're doing. And then he checks you out. And he's clinically the medication. And we're done.
We've seen him for 20 years. And we've never gotten a word out of him. He's like, good. He makes time for us.
He's a great doctor. Nothing beyond that. And we've gotten used to that. Like, okay, that's how a doctor gives you five minutes.
And then you're out of the door. And my dad was, again, he had a bit of breathing problem and all that. And the doctor said, okay, the test was done done yet. And he said, the season's happening.
So might as well start taking time if you were ahead of before your result comes up. You better start taking time if you. And then 24 hours later the test came in and he actually did have swine flu. And when the doctor came to visit, and I was very conscious of my doctor coming, because again, I knew that he was always seen.
And he does five minutes and leaves. And that was the hospital. So I was ready with all my facts down. I was like, okay, any questions.
And then comes and asks, how is your dad doing? I'm like, that's not powerful because I'm not used to this. And then he's shaking, he got his gloves on. This is a patient he's seen for 20 years.
And the first time I thought emotion in his doctor, because he thought that he prescribed something out of his medical knowledge, but it's actually come to him. He faces the prospect of using a patient. He's over 20 years. And that's why I thought that he's a human being.
He's not just a doctor. So that's that's that's that's something that really struck me about how doctors like me, they're watching on some level, but they're actually like, actually, I'm going to be in the mood unexpected ways sometimes. Absolutely. Absolutely.
One more related questions for you, you know, you know, practice medicine on both sides. Like I was, I was touched to know that you share in the grief, or you express your grief, even though you're a medical professional. And it is, you know, you are you are a human being at that point of time. And that's fine.
In India, you are practicing, and you would have seen very, very little of this. Is that the thing or would it be seen as weak of the doctor to break down? Is that a cultural thing? Would you be like, you know, it's okay for you to express your grief, the grief that you feel as a human being, and all of us feel that it depends on the experience of grief.
And you express it and that's generally therapeutic because then you're really express grief. It sort of suits you somewhere inside. And then you move on because that's life. But in India, it is usually a scene of the sign of weakness.
And I would assume, I don't know, but within his work on both sides. So he probably has a better idea. Would it be seen as a weakness to express grief? I've seen very few doctors express.
So what I think what I would say to that is when I was training in India, it was, and from what I hear, even people of a similar age in this country, it was seen as a sign of weakness in the doctor. However, I think I like to think that things have changed. If things probably a little bit faster over here, they've changed slightly slower in India. But the guys, because as I said, every year we get two or three clinical fellows coming from India who stayed with us for two or three years and they've trained in India for eight, nine years.
So they're pretty experienced doctors and they finish their intensive care specialization. And I think things are changing in India. Now, what, and I'll tell you why I say, I think things are changing a little bit in India is because when this COVID thing started, the second wave in India, when we had subsided. So I spoke together a group of 16, 10, seven, Indian origin, they had to speak in Indian language, they had to understand Indian conditions across the US, Australia and the UK.
And then, the Indian society of critical care to set up a headline, partly for patients with nearly four doctors. And we went through all of these countries just to cover all the time zones, just like we were talking about this morning. So we could cover all the time zones and most of us have been spending two three hours every day on this headline for last month. So it's like working the second job.
And half of the phone calls have been from doctors and they have talked about repeat the raw stuff. So I think that is changing in India as well. I suspect that so far where we've got this, they're expressing their grief, they're expressing their raw emotion, perhaps to a stranger at the end of the phone line. I suspect they may not be as comfortable discussing this directly with their boss, but they might discuss this with their friends, especially after a beer.
And I am almost sure that we haven't got to stage where it is acceptable to discuss this to display emotional grief. You definitely, you never dream of loading a patient with your kid or with your grief, but expressing grief with the patient or their family. I suspect is getting more acceptable, but I suspect we're not going there yet, but we will get there. At least we've taken a few steps down the road.
When I was training, you wouldn't discuss this with a colleague, you wouldn't phone a headline, you wouldn't ask for your support. So things have definitely started changing. They're not aware if you would like them to be, but nothing is what we would like it to be. But it's better than it used to be.
Is there a function of the times that you're obviously seeing way more, I would say more morbid stuff than you used to before? Or is it a cultural shift in itself? I think it's everything. But I suspect that this was changing before COVID because the guys that we are seeing over the last few years, they are more open to expressing their emotions and discussing stuff.
So I think this is a cultural shift in society in that we're talking more about our emotional health. I had to say it's incredibly kind of your group to run a helpline for this first to recognize that it is a need and then providing, taking the trouble and are, you know, time and effort to provide for that, you know, something. We are very grateful to the Indians as an educator because they looked up to the IT solution. They set it up.
We offered. So first we asked them, what do you need? Do you need money, resources? And they said, donate to food charities.
We don't need more equipment. And because equipment distribution is a major problem. There are no commercial flights. So you have to go through the government channels and distribution, getting the equipment to the right place would be a major problem.
So they said, don't need to food charities because these patients that are coming in from distant areas to big cities, their families are sitting outside because they're not allowed in the room and they are struggling for food. So we have been donating to food and then the only other thing they said was, yes, can you do a peer support or a network headline and we put this group together. It happened very quickly and in within 72 hours, they set up an IT solution. So you can log in.
You can indicate your availability for, you know, 30 minutes to three hours, whatever you want. And anyone that goes to the website and it's they're tweeting it out regularly. We'll see who is available. So you just click on it and you get connected.
Wow. That was amazing. I have, I have sort of like, I mean, taken way more of your time that we should have and definitely the longest that I've enjoyed. I've enjoyed talking.
Yeah. And I'm pretty sure we can go on talking for much, much longer as well. I have two sort of final questions to from my side anyway to sort of like that. One is very specific to intensive care and one slightly broader.
So first one, I was doing a little bit of reading up for another episode, which involves the brain in some way. I was just reading about New York, Arkansas, then I came across this quote from a Harvard professor of biology called Jeff Lickman, who was talking about how much humans actually know about food. How much humans actually know about the brain right now. We think that we know a lot, but the core to end is beautiful.
So he starts off his courses by asking the students the question, if everything you need to know about the brain is a mile. How far have you walked in this journey and students would say like three quarters half a mile and he said the real answer is three inches, which shows how much you know about the brain. How much, how much, what are the distance be for intensive care right now. And I thought of this question when you were talking about the balloon analogy that he was using saying that we still have so much more to go in this.
That's question number one really and question of two is maybe on a slightly more optimistic note to sort of end this is, do you have you seen in your entire Soviet doctors nurses and across geography, I'm guessing also do you think that this entire that COVID while we are living through a very, very bad time right now and none of us really should have happened. Do you think that the medical profession has sort of will benefit from this, not just from a knowledge point of view, but from will it be like what science itself was after the moon landing in the 1960s, I had a generation of kids wanting to take up science and engineering and seeing what's going on. I want to get into this profession and get into helping my fellow human beings so one very specific question one slightly broad, maybe philosophical question for you to end I guess. Okay, so can I answer the first one first so you said a mile three inches, what I mean to say is to know how far you have to go or how far you have come you first have to have some idea of scale, we have no idea.
We have no idea. I know we've worked three inches but I don't know whether the total journey is half a mile, 25 miles, I have no idea. I don't think anyone does someone really smarter than me, you know, one of my colleagues who's the smartest person, but one of the smartest people I know. Professor David Menon, who's interesting me from Chennai, who's a professor of neuro-intensive care at Cambridge, he says that he has no idea how far we have to go either.
So I definitely can't take it, how far we have to go. The second one, which is actually easier for me, I think, is where are we going with healthcare, I think there's going to be a number of advantages, a number of things that come out of this, and I think that I am going to compare this to the second world war rather than the moon landing of the peaceful mission. This was a deadly problem, an emergency, and there are a few things that have come out of it. One is, I think the importance of research has been doubly highlighted.
It's been easier to recruit with clinical trials and I'm hoping that, and what's happened is with social media and with the whole world getting affected by this whole thing altogether, we've built up lots of worldwide networks, so we are currently doing a survey, a study on visiting practices in intensive care across all of Asia, across 32 countries, and the difference between pre-COVID times and COVID times. And five years ago, how would I build a network of 32 people in 32 different countries? It's just not possible. It's just because in the last year, the way we learned the way we interact, the way we network has changed, and just because I've been on Zoom webinars teaching at different places with a lot of these people.
Suddenly, you know, and a lot of people, you have their emails in your inbox, and you can then email all of them and say, guys, are you interested in this? It will be quick, and I think it will be informative, and then we can decide what is best practice here. You can build up a research network, you can do what you want, you can build a support network. Recruitment, already this year, we got three times more young doctors applying to intensive care than we've ever had before in the UK than I think, at least.
So I hope that that will continue in a lot of places, so I suspect, yes, recruitment will work. I think we've learned new ways of doing things like the mRNA technology vaccine. You know, it was developing three days, I think, was it three days or something? Yeah, so these two days were a lot, the DNA was for central move on, the modern idea.
Yeah, so they had done a computer model after that. Yeah, so it's a revolutionized how we do things. And even with the amino virus vaccines, previous vaccines to ten years, this vaccine took very short time, obviously, because there were so many patients, so they were able to do thousands of patients in the clinical trial very, very quickly. So I think, and if there is one thing that I would like to come out of this is two things actually.
One, we need to persuade governments, and I hope governments across the world will be persuaded that a lot of places in the world need more healthcare resources. On the other hand, as an intensivist, this will sound very perverse, but the biggest bang for buck is in primary care and in preventive care, rather than in a care. When drunk, I call, I tell people that I work in expensive care. Yeah.
It's not expensive for the patients, but it's the bed for bed. It costs ten times more to run an ICV. Yeah, absolutely. This is not the bang for buck.
This is where you go to your in trouble, so you need it. So this is like having special forces, special forces, so just need more training. They need a lot more work. And as you know, in special forces, that within their own teams, they have less hierarchy of the rank and they tend to be more informal.
I like to think of intensive care as special forces, but they are expensive. You don't want too many of them. What you want is you want diplomacy to prevent wash and you want public health and primary care, rather than an outside focus on intensive care. And this, we've noticed in the media in this country.
So I was in three different BBC documentaries and lots of radio programs. Lots of my colleagues actually got more exposure than we did, but actually, I've made colleagues in medicine and I've colleagues in emergency medicine, probably so ten times as many COVID patients as we did, because you know, you know, we've been in the pandemic. And I think that's because we did, because you know, only a tenth of patients admitted to hospital would need to come to ICU, but they never really got any acknowledgement. So somehow the media made heroes out of intensive care just because it looks bright, shiny and the machines go deep.
So I think what we need is a much bigger focus on primary care and public health and preventive stuff. Well said, I can't think of any way to, you know, you can't better, there's no way to follow up on that really. So actually, I mean, I feel that one thing is, you know, exactly what is happening here, everyone is bemoaning the lack of intensive care in India. And believing that for the damage that the pandemic pandemic is causing, but you know, it is really an enormous lack of primary health care infrastructure.
It is probably more worthy of it. Yeah, I mean, that's what, like you mentioned, the machines that go deep and the problems are easier than washing your hands and wearing a mask. Yes, absolutely, absolutely. And India has to be more careful than the bigger economies or the more developed economies in their spend money.
So we need to bang for back. Absolutely. Yeah. Not not.
Not. Not. Not expensive care, not expensive care. That's incredible.
Wow. That was incredible. So this has been genuinely one of the five episodes we've done on the other side. I'm so glad it arrived from a bad episode.
Yeah. I was thinking about it. It was a great episode. I just felt it was an incomplete episode in the left of hanging out the climax.
No, no, no. The problem was we walked three inches. We didn't know how far we had. I mean, I should have because my dad spent time in an ICU and I got to see all this upfront and all I could think about was oxygen.
Not that it's not. Don't be too hard on yourself because what happens is, when you are there, your cognitive load is so high anyway. So your emotional load impairs your cognitive ability and your cognitive loads already high enough. You're getting sensory overload.
You're not used to all of this. So it is normal. Don't be hard on yourself. I think I asked one last question.
Sorry for bringing it up with the last minute. Do you think that, I mean, you've spent so much time with us. You spend so much time with other doctors and, you know, teaching them and stuff. This is practically like spending time with backbenches for you.
But is there a limit to empathy or do you see that the more empathy that you get the farther you can go on being empathetic? Okay. So can I say two things? One is actually part of my role is public engagement with intensive care.
So actually I'm loving this and I go with our organization leads to good as well as and temples regularly and we talk to people. And we have a good, I think, that is what I think is a little bit different. So I love talking to non-medics actually in some ways. It's non-medics.
I know I shouldn't define a group by a non, but you know what I mean. You've got to engineer such people. You have a different point of view. And honestly, when I start already, I can think a few things, but when I start reflecting on this and I've been listening to that episode, I think I've learned just as much from you because it's a different point of view and it is the diversity in the team.
People have different points of view that actually gives you brain waves later. You may not realize it there, but three months later. So I have loved this. The second bit, which is also about empathy, I would honestly say there isn't a limit.
And if you feel you're getting to your limit, take a break. It is the most important, one of the most important challenges is for people to recognize the limits of their own resilience and the limits of their mental health and make sure they look after them. Because what you don't want is the doctor who has a bottle of vodka under the back seat and takes a slug before they can, you know, Steve themselves to work into work. Yeah, I think I've heard it referred to as the empathy gym, which means that you can train your muscles, but also you need the rest day, which is even more important.
So, I mean, you're, it's great for us to have this video chat with you because, I mean, you just put it as so much comfort and the empathy just shines through. So I thought it was important to ask that question. Thank you so much for spending. Thank you all this time.
Yeah, it was a two hours. Thank you. Yeah, thank you. Yeah, I want to just say once again, like totally thank you and we usually sign off our simplified with some silly stay safe slogan.
I was slogan today is and I make it up and everyone politely love. So the my slogan for today is stay safe, stay intensive and say intense and stay simplified. Thank you. Thank you.
Thank you. Thank you. Fantastic. Thank you.
Thank you so much. Thank you.