Loss 52/101: Loss of life for a cardiac surgeon: Mark Field

#104. What's it like to handle a human heart? Or to operate in that small space between life and death? And is there grief for a surgeon when a patient dies during, or after, surgery?

This is The Silent Why, a podcast on a mission to open up conversations around grief, to see if hope can be found in 101 different types of loss.

Loss #52 of 101: Loss of a life for a heart surgeon

Meet Mark Field, a cardiac surgeon from Liverpool (in the north of England) who joined me (Claire), in-between commitments at work, to talk about life, death and loss in heart surgery.

Now, this isn't a subject that's discussed much with surgeons, and you'll hear Mark say that even he had reservations talking about it, but it's such an important area to highlight. Just because you work in a career that encounters death, doesn't that mean you find it any easier to face than people in other jobs. And, like many other careers we've covered on the podcast, it's once again surprising how little training is provided to medical professionals when it comes to delivering the news of a patient’s death. Especially when people's responses to bad news are so varied.

I was introduced to Mark through the Aortic Dissection Charitable Trust, and knew this was a man I wanted to speak to when he sent me the best excuse for being late to a Zoom call ever. I received an email just after the start time had passed that simply said: “Sorry Claire. 5 minutes! Trying to prevent death!!”

In this conversation you'll hear about how hard it is when major operations don't end with a healthy recovery, how surgeons control (or don’t control) human emotions, the privilege of working with such a valuable organ, and why hope plays such an important role in Mark's job.

And because trying to co-ordinate the diaries of a journalist and a heart surgeon got really tricky, Chris wasn't able to join me in this episode, so I was flying solo for the first time in 53 losses.

If you want to hear how other careers handle dealing with death, visit www.thesilentwhy.com/letschat and scroll down to 'Jobs working with loss, grief and death' for a full list.

Transcript

Mark Field: 0:02

Hi, my name is Mark Field. I'm a cardiac surgeon, and I'm here to talk about loss in heart surgery.

Claire : 0:10

Welcome to The Silent Why, a podcast on a mission to find out if hope can exist in 101 different types of loss, and to hear from those who have experienced them. I'm Claire.

Chris: 0:20

And I'm Chris. And in this episode, well, I'm pretty silent.

Claire : 0:23

Yeah, sadly, Chris had to sit this one out. It turns out the diaries of journalists and heart surgeons are just really tricky to coordinate. So I was solo on this joint mission for the first time.

Chris: 0:33

So in this episode, Claire meets Mark Field, a cardiac surgeon from Liverpool in the north of England, who joined her in between commitments at work to talk about operating in that very small space between life and death in surgery, especially around such a vital organ.

Claire : 0:50

I connected with Mark through the Aortic Dissection Charitable Trust, and I knew this was a man I wanted to speak to when he sent me the best excuse for being late to a zoom call ever. I received an email just after the start time had passed, that simply said,'Sorry, Claire. Five minutes. Trying to prevent death.'

Chris: 1:07

Brilliant, I might try that one myself some time. I've already heard this conversation and you're in for a real treat. It's so rare you hear surgeons speaking like this.

Mark Field: 1:16

As I've said to you before, I've had some hesitancy in talking about this, because mostly surgeons do not talk about these things, it's a sort of unspoken truth.

Claire : 1:27

We'll hear how hard it is when one of those major operations doesn't end with a healthy recovery.

Mark Field: 1:32

I'm not sure if it's a morbid thing. But I have a list of patients who have died. And every single one of them, I can look at their names. And remember every single detail about what happened

Chris: 1:43

And how surgeons control or don't control their human emotions.

Mark Field: 1:46

The patient did die, and I remember that surgeon crying tears rolling down his eyes. And at the time, I didn't really understand it. Why would he cry in front of the whole team once I became a consultant. I always regretted that because I personally have had many occasions where it's happened to me.

Claire : 2:03

Mark also tells me about what it's like working with such a valuable organ in our bodies, and what a privilege his job is.

Mark Field: 2:10

Having the heart in your hand is very special every time you did it. And somehow it's so beautiful and atomically beautiful. I'm sure every cardiac surgeon will tell you every time you hold a patient's heart in your hands, you do acknowledge to yourself that it is a privilege.

Chris: 2:27

And it's really surprising how little training is provided for delivering the news of a patient's death, especially when the reactions to bad news vary so widely,

Mark Field: 2:35

You can witness the relative crumbling in front of you short of shouting and screaming and people may run out of the room. And sometimes it can be quite aggressive. And sometimes the response is so deep and so visceral that it is almost shocking to you.

Claire : 2:51

It was a real privilege to interview Mark. And I think this might be one of the best loss interviews we've ever done.

Chris: 2:58

Because I wasn't there?!

Claire : 2:59

Not at all!

Chris: 3:00

We did wonder if this had happened occasionally, my work being what it is, and now it has- the loss of a co host.

Claire : 3:06

Although one out of 53 episodes isn't really that bad.

Chris: 3:09

Hm I'm still going to grieve.

Claire : 3:10

You'll get over it.

Chris: 3:11

What happened to 'feel the feelings'?

Claire : 3:13

Okay, well, you crack on with that. And we'll head into the episode. Annoyingly, when we recorded this I had a weird dry throat coughing going on after our holiday. So probably something I got off the plane. But if you're thinking my voice sounds a bit weird. That's why. So here we go. I began by asking Mark to describe an average week.

Mark Field: 3:35

So my name is Mark Field. I live and work in Liverpool. I'm a heart surgeon with an interest in aortic surgery. I guess my typical week starts on a Monday with a clinic on Tuesday. I have an operating list on Wednesday, I have a clinic Thursday have another operating list. And then Friday is meetings. I also have an encore commitment as well for emergencies.

Claire : 4:01

So is it quite a tricky job to balance like the home life work life? It sounds like it's one of those ones that would be tricky.

Mark Field: 4:05

Yes, it is. There is a commitment to the job and a commitment to the patients. And I guess I'm on call really 24/7. So I will get called on any day at any time whether I'm on call or not about my particular patients and and quite often I need to drop things and come in. And quite often that extends to holidays as well. And sometimes even when you're outside the country, you may get a call in the middle of the night because at the time, the time differences but yeah, it is it's a huge commitment, but I guess it's hugely rewarding as well. You have the opportunity to save a patient's life and you know sometimes quite frequently particularly when I was a registrar I had a really a drove a bit of a jalopy and I used to drive drive to work and stuck in a traffic jam and I'd look across at the guy in his Porsche next door and think well, that's fine. You know, I don't know what you do, but I'm going to work and I'm going to open someone's chest I'm going to stop their heart and operate on them and save someone's life. And that's enough and that's that's very rewarding.

Claire : 5:10

I mean, I think people hear heart surgery brain surgery you know the the vital organs like you said, huge amount of risk, life and death stuff, you know, mistakes cost lives. So what on earth made you want to specialise in hearts?

Mark Field: 5:21

I guess it's different for every person. And I guess for me, I did a I did some research and a PhD before going into medicine. So I was a mature student in medicine. And so that the time I did research in Oxford was it was all about hearts that I always wanted to be a doctor was a bit of a sort of failed medic didn't quite get the A levels to get into medical school went and did a degree and then the PhD and then finally, after the third or fourth attempt got into into medical school, and then it just, I went through medical school and kept coming back to two hearts and cardiac surgery and and the more I saw it, the more that I just said, Yeah, that's what I wanted to do. I was funnily enough I do remember when I was a medical student listening to two orthopaedic surgeons talk about cardiac surgery. And the basically said, you know, what, why would anyone want to be a cardiac surgeon, your patients die. And I guess it struck me at the time, and I didn't really understand it at the time, all I knew was that, you know, I was interested in hearts and I was interested in in fixing things back in the day, you know, you did house jobs, and your first six months was in medicine, six months in surgery. And I remember doing six months in health care, the elderly, which was difficult, difficult specialty, and then my second six months was in urology. And I just thought I was in my element here, because it's like, you have a blockage, and you unblock it. And I thought, you know, even though I was research orientated, so this is great. You're literally unblock things, patient gets better, it's very rewarding. It's sort of very defined. And so I thought, well, I like to unblock things. I'm interested in the heart, I'll put the two together. And despite many people telling me not to do it, I eventually found my way here.

Claire : 7:08

Wow. Because the heart is, you know, it's there's something romantic about the heart almost, it's got this symbolic thing from so many lovely aspects of life. You know, it's in art, literature, love pain, it's so integral to a lot of what we say even but seeing an actual human heart is not something that many of us get to do in life, I suspect a lot of people wouldn't want to, but I think it must be fascinating to be so close to something that's just the centre of life. Is there something special about the heart to you in that way? Or is it more just that this is a part of the body I work on, and it's kind of a bit more technical? No,

Mark Field: 7:38

it's really very special. Like, you know, although I do it twice a week, it's every single time you open up someone's breastbone, and you open up the sack, the pericardium that surrounds the heart, and you suddenly faced with a heart, it's very special, you know, sometimes you you put your hand around the heart and have to lift it up to do various things. Because there are various bits on the operation where you pause to give fluids to protect the heart when it stopped. And so you have two or three minutes every 20 minutes to stop. And mostly that time you just reflect sometimes I look at myself and you know, just stood around waiting for this fluid to go in. And you I just think you know, how on earth did I get to this point, what a privileged position it is. And you're having the heart in your hand is very special every time you do it. And some hearts are beautiful, anatomically beautiful. You just look at the structure, because obviously, we spent a lot of time learning anatomy and you just look at them. They're absolutely beautiful. And then sometimes you look at them, and they're not so beautiful. No reflection on the patient. But they've suffered a life's worth of things abuses, events. And obviously, those are the hearts that need fixing. But yeah, every single time I'm sure every cardiac surgeon will tell you every time you hold a patient's heart in your hands, you do acknowledge to yourself that it is a privilege. Wow,

Claire : 9:01

I love that some of them are beautiful. I love the idea. I hope my heart. I'd like to think I haven't got it. But yeah, obviously you're handling something that could just end someone's life. And when you do something wrong with that it's literally life and death. So like you said, you can't avoid patients dying. That's people's first opinion when you want it to go into it. So I assume that this can happen, maybe during an operation. But I know there's not just one way for a patient to die in your kind of line of work. So what are the types of things that can go wrong? The kinds of circumstances where a patient might die? And at what stage? Does that tend to happen the most?

Mark Field: 9:33

Yeah, I mean, that's the circumstances. I mean, for a patient and their family. It's obviously the circumstances may be quite irrelevant. And obviously they've suffered a death. But I think for a surgeon and the team, the justice and the team around because there are a group of probably eight people involved in every heart operation. And so I think the circumstances do have an effect on how it's managed or the impact it has for certain The we have a group of patients who come in as elective so that you know that they're at home they've been seen in the clinic, and you've agreed to do after, after various discussions and consent, you've agreed to do a particular operation, you've explained to them what the risks are. And then, and then that patient comes in from home relatively well, usually, some patients have no symptoms at all, yet, they're having a life threatening operation to make them live longer. Other patients have really bad symptoms of breathlessness and chest pain. And it's more obvious to them that they're coming in for an operation. And they will accept the risks to get rid of those symptoms. But those are a particular cohort of patients, which are different to patients who come in as emergencies. And those patients have bad diseases, acute diseases, which are life threatening, and, you know, the suddenly out of the blue, something has happened to them on any given day, and they come in for an emergency operation and, and they are going to die without an operation. And so effectively, those patients have no choice. And I think as a surgeon, and as a team, you may feel that in all you can do is good in that situation. And if it doesn't work out, then it is sad. And you will still reflect on how you manage things. But you know, that's a different circumstance, those two groups of patients, I guess, like you say, it's interesting the perception that some patients or family have about the risks of heart surgery. So quite often, when you see patients in the clinic, and you say, Well, you know, your risk of dying from this operation is three or 4%, or your chances of survival aren't 97 98%. They're very happy with that. And sometimes we tell patients that they are they're going to have high risk surgery, which maybe 10 or 20% risk of survival. But and quite often in in the lay public's mind, heart surgery is still 5050, you know, whether you're going to come through it, whether it's elective or emergency, so that quite often the risks that we perceive as high risk are not the same as what patients perceive as high risk. So it's, it's not often that a patient will die in the operating room, it does happen. And it happens to probably every surgeon a couple of times a year. And those are particularly difficult things to deal with. Because usually, either the patient has come in and extremists, and really death's door and you draw your can or there's been some difficulty in the operation of possibly a technical issue, possibly something that could have been different with different decision making. And those although they're rare, those hit the team the hardest. And having a patient die on the table at the end of an operation is very difficult. Mostly the deaths that we face, patients that we have got through surgery, and then they go to intensive care, a typical patient would just spend one night on intensive care and go to a normal Ward afterwards. Some patients spent weeks some patients spend months and have a tracheostomy in their, in their windpipe to help them breathe. And they may end up with other organ support like dialysis, things like that. And those, those patients may die many weeks or months down the line of a complication such as a stroke or or some issue with their bowels or their liver or kidneys. And quite often with those patients as there's a lot of warning, and there's there's an expectation that things are going in a particular direction. And sometimes it's time to talk to the patient about what's going on. And but often, it's a conversation with the relatives. And then I guess the third group is a patient who's gone through itu through the intensive care unit and no particular issues and they've gone to a normal Ward, and they usually stay in hospital for about a week recuperating. And then once when we once or twice a month in a unit of Liverpool size, there will be somebody who who has a sudden cardiac arrest on the ward and dies. And again, those those are difficult to take because the patient's survived the operation got through intensive care gone to the ward is really just sort of waiting to go home and and then it just seems even more of a tragedy that they were so close. So I guess it definitely the circumstances of the patient presentation and the circumstances of the surgery and the circumstances of of the post operative period or impact on on how deeply a surgeon and the team because I must emphasise that it's the team, you know, everyone's impacted by it. But it impacts differently. And as I said before, I think from a patient or relatives perspective, whatever happened to the patient has happened and their relative has died and the circumstances may not be that important to them as it is to the surgical team. So yeah, it's it's very different.

Claire : 14:50

He mentioned that you might have to go through this a couple of times a year maybe on the table. So you know it follows that there must be somebody somewhere keeping a close eye on the stats and when people Die and how they die and how often they die. So how is success measured in your job? Because I'm guessing on paper, it's very different from what you're actually making decisions for in real life. How does that work?

Mark Field: 15:11

So I Yes, this is a difficult one, because I mean, it's important that surgeons are monitored in all specialties. And so that was, we've all seen on the media that some rogue doctors, rogue surgeons, and it's important that the patients are kept safe from such deviations in activity or in performance. And in heart surgery, it's easier than then probably any other surgical specialty to measure quality, because the frequency with which patients die following heart surgery means that the performance measure for a heart surgeon is the number of patients who die. So over a three year period were monitored nationally. And it's a very stark and that simple graph that they present to us, which is essentially the number of patients which you've operated on over that three year period, versus the number of patients who have died. And that's quite stark, and you can't, you can't argue with that as an endpoint. Because other endpoints such as quality of life, you can, you can argue with, but for a cardiac surgeon, you really can't can't argue it against measuring a death, because it's obviously just black and white. And it's not something to be interpreted. And there are some scores that allow for risk. So if I operate on calm, very complex patients, those patients will be scored according to their age and other other things. And I will have have a certain allowance for that in how they measure my performance. But if after a three year cycle, it's found that my mortality as it as we call it, is more than a certain percentage, then I will be challenged by the medical director of my hospital, and then I'll be challenged by, by our society who monitor performance. And so that is difficult because it it does affect the way you behave. And although as a doctor, you want to give every patient the best chance and, and the best option, and you want to be consistent in that it can be difficult, because we're all human. And if somebody's measuring your outcomes, and you're in a situation where your outcomes are borderline, difficult to, to separate that in your head, and but you have to at the end of the day, but it's difficult, because once you once you become sort of performance managed, as we call it, then that's it's a guess as a source of professional embarrassment, that you're being performance managed, it has an impact on everything in your life. Because you know, that is what you've trained to do this job for 20 odd years, you've been practising for, whatever, 10 or 20 years, and there is a risk that you may lose your job and your livelihood, and there's not much else you can do. Highly trained cardiac surgeons don't really have much else to do. But that affects, you know, that just it clouds clouds your mind a little bit, but you have to very consciously think, you know, I'm making decisions based on what I think is right and what I think is wrong, and what my opinion is. And so performance management comes with a package of measures, and it comes with that you're told that you you may have to operate within other surgeons for safety, or you may have to only do patients with a certain risk profile. And there are various other supportive sort of wraparound things that are put in place. So you hope that it doesn't affect the patient outcome. And that's keeping patients safe. And so, I mean, all these measures are designed to keep patients safe. And it all came out of the Bristol children's inquiry that went on some decades ago now where perhaps the mortality was higher than expected for a certain operation. And that led on to measuring surgical performance. But you would hope that measuring performance keep keeps patients safe. On the other hand, on the other side of it, you need to be careful that it doesn't prevent patients from having an opportunity. And it's important for us as leaders that if you have a surgeon that's in difficulty, and has been performance managed, that the temptation I guess maybe to not offer patients high risk operation, and those are the patients that actually benefit most from it. So it's for us as an institution as as as leaders to take that away from them. Let the more senior surgeons or the surgeons with better outcomes manage those patients. And in the end, the patients and relatives don't suffer from that. And the institution managers that risk so it's really a balance. They do measure us, but it's a balance between keeping patients safe and giving patients opportunity and not letting all those things In this cloud, your judgement in what you do is difficult. And it's probably, I don't think it's like that for any other surgical specialty because it's not so black and white in terms of measuring outcomes. Yeah,

Claire : 20:12

I can see how that would be difficult just by, you know, human nature and just normal workplaces. Or you can see how there would be some people who would naturally think, Well, I'm not going to take on any high risk cases, because that's going to affect my stats. And then you can see other people who'd be like, well, I want the high risk cases, because actually, that's where the interest is. For me, that's where the opportunity is, that's where I could potentially do something amazing. But if I only take on those kinds of cases, then I'm risking my stats being bad. So yeah, I can see that it'd be very difficult to balance.

Mark Field: 20:38

Our last Society president was Richard Paige who was a thoracic surgeon, actually, but he, I think he had the the insight and the foresight to see that patients were perhaps losing out because of the way we measure things. And, and so he introduced a system where we call it it's called a Nightcore exclusion. Essentially, it means that if you if you have a very high risk patient who is going to die without an operation within a couple of weeks, and not an emergency emergencies are excluded from all these measurements, which is good. But if you have a patient that needs a third or a fourth time operation and infection, and the risks are very high, we can go to an MDT a multidisciplinary team meeting and providing the the surgeons all agree that this should be excluded from the statistics, then you can have an exclusion, it's a great benefit. That means that two surgeons are mandated to scrub and operate. So you got two senior surgeons at the table during the case. And that doesn't count on anyone's statistics as it were. So it allows it we're trust to prevent all those things coming in to stop patients having opportunity.

Claire : 21:43

That's really good. And I think, I'm guessing, going into something like this where you know, someone's gonna die one day, you probably didn't come into this thinking, I'm going to be the first cardiac surgeon that's never going to have a death. What happens when you have that first death? Do you remember that first death? And are you prepared in your training for that?

Mark Field: 22:00

So I guess, and I haven't been to medical school for some time, because my age may have changed a little bit. But when I went to medical school, there was no training around how you manage a patient dying. And I think it's obviously probably different for different doctors, because of the level of investment in possibly, maybe a GP, say, as a patient in the community, in a care home that dies, and they may have seen once or twice over a period of 10 years that may have a different impact to a surgeon. It's just one single patient that you have done something to. And so I guess in medical school, they never really taught us because I guess medical school is General Training, certainly where I went to medical school, they never taught us about or gave us any tools for managing a patient who dies, or how to how to process it, and how to how to reflect and how to be able to continue practising after a patient dies, I guess. I mean, I know, you know, over the course of my career, there probably have probably had 30 patients who have died. And I, I mean, I'm not sure if it's a morbid thing. But I'm sure every surgeon is the same because every every cardiac surgeon keeps a very close eye on their own data and their own outcomes. And so I have a list of patients who have died. And I, every single one of them, I can look at their names and remember every single detail about what happened. And and I guess partly, you know, that's personally for me to reflect on whether whether I could have done something different whether the decisions that were made could have been different whether and I guess every every death that happens in in I guess in any hospital and particularly cardiac surgery gets a review called on mortality review. And so, so your case gets scrutinised by another doctor, surgeon or an East test, and it's rated as avoidable or unavoidable and you get various feedbacks. And if there are particular issues, then it's discussed on an audit day where all sorts of the hospital are in a third lecture theatre and, and there's open discussion. Sometimes obviously, that can be difficult. Sometimes you have to take criticism, sometimes you have to accept that you could have done things differently. Perhaps the outcome would have been different. Quite often. It's just it's grey, really. It's never really very rarely is it? Is it clear cut that there has been a technical issue or there's been something you made a bad decision much more. It's usually much more grey, thankfully. But yeah, there isn't a lot of preparation for it. And in terms of how it's managed I've seen as a junior doctor, I've seen it managed very well. I've seen it managed very, very poorly. And when I say that I mean about personally how you how you process that information. And I remember particularly vividly one consultant surgeon who patient had had a cardiac arrest following a heart operation on the following day. And as it is with cardiac surgery, you know, once if a patient has a cardiac arrest after they've had an operation, and usually it ends in the chest been reopened to make sure there's not a collection of blood around the heart, and that can easily be fixed. And, and quite often, sometimes that can be on a normal Ward, which is quite extreme. Sometimes it's in intensive care. And but I remember vividly watching a patient just been reopened in a consultant surgeon had done the operation the day before appearing, and did all he could, there was no obvious cause as to why the patient had a cardiac arrest and what the patient did die in intensive care. And I remember that patient that surgeon crying. And I can remember, it tears rolling down his eyes. And at the time, I didn't really understand it and have to be honest, because I was a surgical trainee, and you don't really have as much insight, or you don't have as much understanding of the personal investment you have when you operate on someone. So as a little bit dismissive. I just, you know, why would he cry? Like, you know, why would he cry in front of the whole team, like I remember, but I always regretted once I became a consultant, I always regretted that because I personally, I've had many occasions where it's happened to me. And you know, tears come to your eyes, either, either at the operating table, or wherever you are on the ward, or when you're speaking to relatives, because can be very, very difficult, just the rawness of the emotion speaking to relatives, and, and it's just about how you process that. what's just happened and how you gather your thoughts and how you how you manage yourself, the team, the family, and then how you come in the next day. And so quite often, it's, you just have to muddle your way through. And I know from my observation of younger surgeons coming through the system, I don't especially think they've been trained in a different way to manage these things. Because it's just hugely, hugely personal. When you've seen a patient that clinic, you've talked to them, you've chatted with a family and know them, you've agreed to do an operation, the expectation is they're going to get through the operation. And so it's a massive investment. It's a bond between two humans, I guess. And then when it goes wrong, that leaves you, it just leaves you with with a massive sense of you failed that patient. And sometimes it's sometimes you genuinely feel you have and on other occasions, it's you know, it's just circumstance and the disease that has just been too extreme, and yet you haven't been able to, and no, probably no one, you know, no surgeon anywhere would have been able to get that patient through and, but it's trying to process all that information, to try and understand what's happened, how it happened, you know, whether there was any learning or reflection, anything, you can share anything, and then managing the family, but then going on there, and then quite often, you may have an operating list the next day. That's difficult. But I mean, I'm hoping something like this may help patients and relatives and hopefully other professionals as well, because mostly we don't talk about these things. And as I've said before, I've had some hesitancy in talking about this podcast, because mostly, surgeons do not talk about these things. There are that sort of unspoken truth, I would

Claire : 28:46

say. There seems to be this assumption, with a few different areas of work where we've spoken to people who deal with death, especially on a daily or weekly basis. Like whether it's, you know, murder detectives or paediatric intensive care. Now, as we spoke to a funeral directors, there's this assumption that you're a certain kind of person that can deal with that kind of thing a lot easier than other people. Which is a shame because it's got nothing to do really, with a human dealing with death and dealing with loss. It's all about your skill sets, and you've got skill sets and all these different areas. But that doesn't mean you're any harder, cordoned off, when it comes to dealing with loss and grief and relatives of people. And it was similar. When we spoke to the funeral directors, they said, you know, people don't really talk about it much. And they you know, they admitted we've we've got PTSD from some of the stuff we've seen, it doesn't mean we were any stronger at dealing with these things. And that does seem to be a shame, because it doesn't impact the training that you go through. And I think you're probably right, and assuming the training hasn't got a lot better in helping people deal with that side of it. How do you deal with the degree from the loss? It's a bit more sort of technical and education based and this is what happens and maybe here's some practical steps, maybe you need to debrief, maybe you need to talk to someone else. Maybe you need some counselling, but there isn't that kind of maybe setting people up for saying you know what, you're human. You might cry when one of your patient dies and that's okay, you might had a week to reflect on it at home, or it might impact your personal life. That's okay, you're human. And I think that would help a lot of people. I think that's why this is an important conversation because I want other people in these sorts of professions to hear it, that it's okay. If you struggle with human emotions connected to your job. And I know you've mentioned there are a lot of different human emotions, when it comes to surgeons and responses to stuff and they vary a lot. What are the sort of different ones you've seen? And what's your what's your go to? Or you're kind of to get angry, do you get upset,

Mark Field: 30:29

so I've seen a range of things, you, and it's depends on people's personalities. And, you know, the classic range of responses. I mean, some people get very surgeons, I would say, can get very angry, they get very crossed, they start shouting, they're frustrated, things are not happening. And, and you know, they have a life in front of them, which is slipping away. And it's understandable that if things if the team around them doing things before they're even asked, and they get frustrated and start shouting, that's probably the worst response. Because what you need in that circumstance is you need your team, you need you need help, you need an East US to supportive you need a perfusionist, the person who runs the heart lung machine to be supportive. You need everyone to be on on their A game at that moment. And quite often, you need surgeons to come into your theatre and to and to look at things afresh and offer advice. And so at that moment, you need your team around you, if you can get the patient through and you need to work through the problems, and forget about everything else. It doesn't always happen. Other people go completely introvert. And I guess that's me. my niece's would tell you, I have been a lifelong project for my Anaesthetist, Justin, who I think has worked on me to try and get me to communicate during those episodes, because in my mind when I get into those situations, and it's wrong, but you can't see like a day in those circumstances. But in my mind, the only way to get this patient through is something surgical. And in my mind, the only person who can do that is me. And it's wrong. But in that moment, it's all going through my head. And it's you know, what are my options, sometimes doing something can make things worse, sometimes, sometimes you can get a patient out of the operating room alive, that perhaps in some way harmed by that I mean, you know, possibly a heart attack during the operation and but you can get the patient out alive and you can live to fight another day as it were. And if you have to something you haven't done or something you in terms of operation that you that you're leaving terms of the disease to decision, shall I accept the situation I'm in, get the patient out of theatre alive, and then come back to theatre down the line to address the issue? Or can I not get this patient out of theatre and I have to do something and but doing something may actually you may lose that position you're in and it may be a worse position. And in my mind in that moment, it's you know, it's just a decision for me. And so I just go quiet. And I think normally, we have music playing. So usually asked for the music to go off. That's when usually people know something's wrong. And then I stopped talking because usually we're talking a bit and then and then I think everyone's hit the marks gone quiet, something's wrong. And then usually just another sort of, okay, what's the problem, and then we'll try and work through it together. Another surgeon who used to play music, I remember one of the surgeons who trained me, he used to turn up the music when bad things were happening. I don't know if that was to drown out the bad thoughts on. But mostly, I would say people are in the middle. So people used to get a bit frustrated because things aren't happening quickly. They go a bit quiet because they are actually thinking about what all the problems are. But then they're able to dispassionately and I think those are the probably the surgeons who handle it best. They're actually very matter of fact, and they go okay, I've done this, it didn't work. I've got options. ABCDE what are we going to do? And then there's a discussion and then it happens on from the outside on the face of it, you may think well, that person doesn't really seem to care. You know, they're not shouting, they've not gone quiet. They really seem completely detached from the whole situation that just got some options. And you may look at that and go Well, they didn't really seem to care what the outcome is here. But I think that's misunderstanding what's going on. I think those are probably managing the situation best then managing it objectively. And then all the other issues like cloud your head around the death that surgeon will process on another day. I think so. Yeah. There's there's a huge range and room for improvement on for all of us, I think. Yeah.

Claire : 34:58

And ultimately, when someone's offered Hang on your heart, you don't really want them? Well, I don't know, if people think about this, I wouldn't want them thinking about, you know, the situation of oh, this is a young man with three kids, and who am I going to do and you know, all those sorts of things, bringing in the actual personal circumstances of that person, it's not going to help you. It's just going to cloud things and make it more emotional. So ultimately, you do want somebody that's not really well, they're caring. But like you said, it probably looks like they're not caring, but you kind of want you want them to be able to compartmentalise all that for the right time, because there must be a lot of other things that you're having to deal with. And there must be some fear that starts to come in at this point. And I know I've heard you talk about how that fear helps you focus the mind, but sometimes it can be misconstrued as arrogance. In your professional, I can see how that would happen. Do you actually, do you find that hard? Do you have to try and convince people in any way that you're not arrogant? And that you do care at times? Or do you just have to let that go? What other people might think and just get on with your job?

Mark Field: 35:52

Yeah, I think you'd have to let it go people, I mean, people around, you know who you are. And you can't hide it. I mean, one thing about this specialty is you can't hide your personality, because you're, you're quite often functioning in extremes of a situation where you can't control the narrative about who you are and what you are. And so people over a course of many years, because obviously, we're, we're a close knit team, and there isn't a huge turnover of staff. And so we you know, we all know each other, we socialise a lot together. And so you can't hide that aspect of yourself and the team around you know, generally know who you are, know what support you need, they know your skill set, and they know what you can do what you can't do, they'll know how you're going to react. And quite often the needs just is pivotal in that because their needs just, even though the surgeon may be in denial and go, I don't need any help, I'll sort this out, I'm fine. The ministers will office to be on their phone texting a friend so and so who's got a problem? Can you come into theatre? And and even though you may, you may not think that you need help, someone will appear? It's usually because someone has texted someone say there's a problem here. And we have a very supportive Hospital. I'm not it's not the same in every hospital, I would say but certainly Liverpool, you know, once you have a problem, two or three surgeons will appear in your theatre. And that's really important that there are a couple of people because, as you say, you may I often you know, these patients well, and you've met the family, and it Yes, it is hard if if the patient has you know, three children, and you've met the children, sometimes I think it's difficult to meet the children of someone you're gonna operate on because it, it's nice, but it also affects you. And it makes it very difficult to be objective and to be dispassionate and to do what you need to do. Because you're right, when when you see something going wrong in front of you, your thoughts will automatically go to well, he can't die, he's got or she you know, they've got three children and they've got this and they've got that and and there's all this history and and then that feeds into clouding up all the issues and making it difficult. Like you say the the best thing is to compartmentalise everything, and just work through the problem and get the patient out. And then speak to the relatives along the way. Even though we're cardiac surgeons, we are human. And people, I think sometimes forget that. And but it does affect us enormously, even surgeons who it may appear are not connected or in some way detached from from it, or often it's just their way of processing the tragedy.

Claire : 38:39

What have you sort of seen when it comes to things like coping strategies, because again, speaking to different kinds of areas of work, like the police, they've got quite a dark sense of humour. That's part of how they cope with a lot of what they see. For other industries. They're quite famous for maybe people drinking too much or getting into other addictions that are very unhealthy. If you've seen good coping strategies in your line of work, I feel like I want to say I want to assume that you haven't. I don't know why. I don't know if it's because my mum was a theatre nurse just having seen bits and bobs and heard them talking and I don't feel like the medical world is is brilliant with great coping strategies for how to deal with what they deal with. But that might be a huge generalisation. I've got wrong. No,

Mark Field: 39:16

I think you're absolutely right. I mean, I don't think anyone has specific coping strategies. I mean, there there are issues around your performance, which we discussed, and those are all managed and, you know, hopefully managed well, but and then maybe if you have a run of deaths in a short period of time, I guess I can't say that I've ever seen or heard about sort of surgeon, you know, taking to substance misuse or anything like that to cope. I've seen them become a bit withdrawn and I've seen them become detached from the department. I've seen them start to become accusatory maybe perhaps a little paranoid. You know all or human traits. But more acute when you're in a situation where you, you need to keep working. And you need to be convinced that the reason one or two or three patients died is not because of you, or anything you've done. You need to rationalise it in your mind and come to some decision whether you whether you think this is something you've done wrong, and you need some retraining or some support or whether you think no, this is just three things that have happened in short space of time. But I just hesitate because I don't think I've seen a surgeon go off the rails as it were, I think there is support there particularly, I think in Liverpool anyway, we have a, we have an early warning system, it means that we will intervene, there are various points that the national body may intervene on your performance. In our hospital, we try to trigger that sooner so that we can, we can correct things before it becomes a national issue. I mean, I didn't mention it. But your outcomes, as it were, are published in the internet, like, you know, you can log into the society and you can see what my outcomes are. There's no hiding from that. So hopefully, things are corrected. And Liverpool, certainly before you get to that point. So I guess when you ask about coping strategies, a lot of it's very personal, a lot of it is hidden away, you may get some hint of it, you know, a surgeon may say, Well, I've had a death today, I'd rather not do the list for the for tomorrow, I'd rather not operate for the rest of the week, or can I not do this case, because I just don't feel up to. And those are subtle, subtle things that you know that someone isn't coping that well with what's going on and said, that is asking for a bit of space. But apart from that, I don't have a good answer for you, other than you're right, it's probably not well managed. There are no good strategies, and it's sort of hidden away. And people are left in a dark room as it were to cope with whatever they need to cope with, and then come back when they're ready.

Claire : 41:59

So you obviously deal with the losses of life and death. But are there other losses that come with a job like this, that maybe other people aren't aware of other kind of secondary losses maybe or things that you've faced or others have faced around you? Absolutely.

Mark Field: 42:11

And as we talked about earlier, patients dying are actually quite rare. They're also traumatic when they happen. But you know, overall, heart surgery is quite safe, mostly what happens, other complications. And that is quite often a form of loss, because it's a loss of, it's a loss of quality of life. And sometimes it can be a loss of function. So one of the main issues, although we operate on the heart, the main issues are around the brain, or around the spinal cord, or around other organs in the body, the lungs, the kidneys, the bowel, the liver. And so cardiac surgery is quite unique in that, although we're very focused on fixing the heart, to fix the heart, you have to stop it mostly, not always. But mostly, you have to stop the heart. And it's the heart lung machine, that you connect to the patient. And that will keep the patient alive. While you've stopped the heart. The consequences of that is that you will affect lots of the other organs of the body. And that's why these patients go to intensive care afterwards. Mostly, it's not, sometimes it's full support of their heart with various drugs and various devices. But also, it's to support the kidneys sport delivered about the brain, spinal cord, all the other organs of the body. So quite often we are when we talked about patients dying down the line after a couple of weeks on intensive care, it's quite often as to what we call multi organ support, or multi organ failure. And so other organs start to shut down. And other things are required to try and support them. And so it's it's the complications of, of operating on the heart that lead to loss. And one of the, I guess one of the biggest issues is of stroke, it can be very, very hard to go and see a patient postoperatively on day one, because quite often, they're kept asleep for a few hours, and then they're woken up and they're taken off the ventilator. And then they're awakened. And surgeon traditionally comes around in the morning on a ward round to see the patient and then you go and speak to the patient, and they can't move one side of their body because they've had a stroke. And sometimes patients with particular operations can get paraplegia and they can't move their legs and these are permanent things paraplegia if it's there, it doesn't get better stroke can get better, sometimes it doesn't. But you feel personally responsible again, and those circuits could have done the operation in different ways such that they couldn't have they wouldn't have had a stroke and it's a devastating thing because they just look at you from their bed and they can't move their their arm or their leg and and they're like What to do now and and there is very little you can do apart from get them into stroke rehabilitation and get as much function back as you can. But I think for cardiac surgeons, it's stroke, that is the biggest thing really, because it's much more common than death. It really affects the quality of life. And it affects the outcome of the whole operation. You know, I remember One patient in particular, who was in his 80s. And he was quite fit and active. He was loved his garden, he had a huge garden. But he had this big aortic aneurysm, which is the aorta is the main blood vessel that comes out of the heart. And it was quite big, but seven centimetres from memory. Normally, we would operate when they were about five and a half just to prevent them rupturing. So he was in his 80s. And the suggestion was that he should have an operation to get rid of this aneurysm, he had no symptoms from it, patients have this idea, it's a ticking time bomb, that it's going to rupture. And he couldn't really live with that knowledge that he had this aneurysm in his body that could disrupt your anytime he decided you want to have an operation, I think between us, we met each other a couple of times, and I had some reservations for patients in their 80s, the outcomes are difficult for heart surgery. And you have to be very clear that you're doing the right thing for the right reasons in someone's in their 80s. And essentially, this is an operation to make him live longer, or to treat some of the issues he had when coping psychologically coping with the knowledge of this aneurysm, the average life expectancy in UK maybe around 83. And so doing an operation on someone at 83, to make them live longer. It doesn't make a whole lot of sense, unless there are good reasons. And he just couldn't live with this. So we took him to theatre and the operation went perfectly well and came in to see him in the morning. And he'd had a stroke, and he couldn't move his left side. And you just think, Gosh, I always remember that patient because he had a good quality of life. He was in his garden, you know, operation to make him live longer. Yes, he may live longer, but he's lost his quality of life, he did make a good recovery. Actually, in the end, he went back to driving me he wasn't perfectly normal again. But it is sort of one of those patients that affects you during your whole career in terms of decision making. And whenever I come across an octogenarian and the proposal is that they're going to have an operation don't always think back to that particular patient, don't you know, really, is this the right thing to do. And those are the sort of difficult decisions that you have to live with. It's definitely a form of loss. And it's quite often with the type of operations we do, which are very large, there is a trade off sometimes between you're doing an operation to make someone live longer, particularly in the younger age group. You know, in the 50s, and 60s, you can do an operation to make them live longer for prognosis, but the operation is so large, that they never fully recover from it. So they lose some of their long term quality of life in exchange for prognosis for living longer. You never quite know what that trade off is, in essence, COVID we have this term new normal. And I think that it was some of the operations that we do that are so huge, that is a real thing that you, yes, we can do this operation to get rid of your aneurysm that will make you live longer, but in return, you're going to lose some of the great quality of life that you have. And those are very difficult, difficult conversations.

Claire : 48:15

Yeah. And, again, do you get any preparation or training to have conversations like that? Because I'm guessing there's times when you have to tell people someone's died as well, I'm guessing it depends on what stage they died as maybe two is involved there. But you're facing a lot of very raw grief, even if it was, you know, that people thought, well, it might be a little bit expected, you're still facing that initial response. And those sorts of skills for those sorts of conversations almost couldn't be further away from the technical surgery that you're doing on the other side. So do you get help with how to do that?

Mark Field: 48:47

No. There's a theme here. But it's it's very, I can tell you it is very traumatic to go and tell someone that their relative has died is very traumatic, some of their reactions are so visceral, I remember again, I just go back to my training because I remember a particular example of where it was done really, really poorly. And that a patient had died following surgery, and the surgeon sort of appeared and in his backpack on jeans and sort of pushing the relatives room, the door open and sort of said, well, sorry, if I just died, and there's nothing I could do. And and then, you know, almost immediately just left him with with a nurse. And I remember thinking at the time, it was just, I mean, probably he'd had no training in it, or no guidance or how to do it well. And, and it was it just always stuck with me that was so bad in terms of how you can go and speak to relatives. In cardiac surgery as a little bit unique in that quite often you have warning and even when a patient is going to die on the table in the operating room that Heartland machine will keep them alive, and it may keep them alive while you're trying to fix things. But deep down, you know that there is a problem that you may not be able to get out of. And quite often we know in intensive care patients are kept alive artificially. So quite often, there is some warning of things, but families just like surgeons react differently, although we only have to go and speak to families, you know, probably most five times a year to give them that news, it can be extremely dramatic. And I guess it depends on the family dynamics, and how close the relatives are, and all those human things. And sometimes, it's quite sort of dislike some surgeons a bit detached and, and because people react differently, and they may not react in that moment, they may go away and react later on down the line. But in some, you can witness the relative crumbling in front of you. And they may be short of shouting and screaming, and people may run out of the room. And sometimes it can be quite aggressive as well, because, you know, they may think you're personally responsible. And sometimes the responses stay deep, and so visceral that it is almost shocking to you, and you're almost like you just don't know what to do, you definitely need a mechanism to manage that situation you need, you need some sorts of tools, which unfortunately, you learn through experience some sort of tools as to how to how to prepare or, or to have the thought to prepare someone for that if you can, if you have time, and in some way, in part that information. And I've seen again, just another example, I've seen a doctor, when I was a junior watching, and the doctor went through, spent about 15 minutes going through what had happened, what had happened, what had happened, and the end stopped and looked at the relatives. And then the relatives sort of said well, as he did. And, you know, it's like the doctors tried to go through the pathway tried to explain it all, but not got the key information out at the front. So that's certainly one thing I've learned is that, you know, you you can't go in and blurt out that, but you need to get to that point very quickly. You know, it's, it's a matter of luck. I'm really sorry, we've tried everything, but they've not survived. And you need to get that thing out really quickly. And you need to be very clear about it can't leave any ambiguity there. There will be questions, and they may have questions immediately. But those questions, even if you give the answers, they're probably not going to take it in. Another thing I've learned is to write to them, I think it's really important that as a surgeon, you write to the relatives in a couple of weeks, and just offer them an open appointment to come whenever they like at any point in the future. And quite often, some relatives will will take you up on that, and they'll come to clinical to see you in sometimes six months, when they've had time to process it and they've got questions, some people will find it very traumatic and never want to come into the hospital again and can't really face it. Some people were happy to do it on teams, and some people will, will come in face to face and their, their entire family as well. And, and sometimes that can be a rewarding experience. You can explain to them quite often relatives may not know how poorly the patient was, or they may not have understood the risks the operation, or what exactly it happened. Because sometimes patients will just not really tell their family what the risks are and tried to hide it from them. And sometimes those meetings are played out in a Coroner's Court. And it's difficult, but there is no training for it. You learn through observing it being done badly. And it's been done well, and through learning what works for you. Because every every one is very different in terms of in that moment. It's one of those things that we discussed earlier, you may think that the more of it that happens, the better you get at it, but probably the more of it that happens, you just become more traumatised by and you don't get better at it really. It's just cumulative trauma that you need to somehow process or channel away in a different way. I don't think you can ever get used to or you don't want to become good at it getting away. But you can you're never desensitised to it. Because all the time just human nature, again is that you reflect on your own family. And you know, how would you react if you're in that situation so, and all the investment you've had with the patient and the family, it becomes very personal. So it's it's really very, very difficult, but it's definitely something I would suggest is never delegated to a junior doctor, take one along with you so that they can see. Never delegate it and you should always find all nurses are compassionate, but you should find especially compassionate nurse to go with you because surgeons are surgeons and they can do what they can. Some are good at it. Some are not so good at it. Some may have more of a human touch than others. But one thing that I've found consistently is that the nurse that you take along quite often That's correct thing to say. But quite often they just have more of a human touch, they have more ability to relate. And then quite often, when the news has been given, the surgeon can leave. And usually the nurse will stay and do all those other things that are important in managing what's going

Claire : 55:16

on. They've got that bedside manner. Surgery sometimes. Yeah, and hopefully, that's really encouraging to people that are, you know, sort of behind you earlier in the, in their career that are really struggling with doing those first few and thinking, Oh, my word is this me and we're not cut out for this, why can't I do this part of the job to hear that you still struggle with that, and it's something you never really get used to. But that's okay. Because there are other people that you can put around you to help with that. I think that's, that's really important for people to know, one of the questions we ask all our guests is around the question, why? Just to find out? Is that something that people battled with? Have you ever questioned why you got into this kind of work? Or why you're doing this? Or is that never really been something that you've thought about?

Mark Field: 55:56

I mean, I think, to me, it's, it's clear, like, actually, it's extremely rewarding specialty. And as I say, mostly, these things don't happen in 97 98% of the time, the outcomes are excellent. You know, you you meet up with a patient at a particular point in their life, they've suddenly got heart disease, they think they're going to die, usually, they're convinced they're going to die, and you're able to offer them options to treatment, and then agree with them, and then take them, take them to theatre and fix their heart. And from a technical point of view, that's an amazing thing to do, as we discussed, it's an amazing thing to be allowed to take someone to an operating room and open their chest and fix their heart, that is an amazing thing on a daily basis. And then it's very rewarding, because, you know, there's patients you meet them postoperatively, and you meet them in, in clinic, and some of them, you, some of them quite often, in the type of operations I do in aortic surgery, they need repeat interventions over the course of their lifetime. And, and you get to know them, and you get to know their families. And, and so it's extremely rewarding, technically. And it's extremely rewarding on a personal perspective in, you know, the relationship you have with these patients and how you're able to help them and, you know, I think, I can't sink when I think you know, what, if I hadn't done cardiac surgery, what would I have done? I mean, the answer I often give my children as I would have been a farmer. I can't think of any other, like medical specialty, that would give me what I get. And if I wasn't going to be doing this, then I'm happily chase a few pigs around the farm.

Claire : 57:35

And I guess what you're talking, people play so much hope in you, they come to you with the hope that you can make somebody better, or you can keep them alive, which is quite a pressure in a lot of ways. But there's obviously a lot of hope in other ways, because like I said, the statistics are really good for what you do. So is there any other ways that hope plays a part in what you do?

Mark Field: 57:57

Well, you know, I often have this banter with my nieces. Because I sort of have a bit of an academic background, I often say, you know, everything I do is, is based on science and research. And they just go off and laugh at me, because most of it pseudo science, and it's not based on any science at all. So, I mean, it's not quite at the stage where we keep our fingers crossed, hope for the best. But there is hope in all aspects of it, I guess there is, you know, there is hope that you can from the patient perspective that something can be done for them. And it's hoped from, from a surgeon's perspective that you can do something from the outcomes, as we've discussed, can be along a broad range of things from success to failure. And some of those things you can control as much as you can. And the more experienced you are, the more things you can control, because you've been stopped yourself getting into trouble rather than trying to get yourself out of trouble. And it's not just about delegating, or just imparting that information. So you can say I told them, I told them, I told them, it's also about giving them some hope and, and saying to them, Look, this is a situation, it really doesn't look that good. However, there are certain things we can try certain things we can do. We're going to do that and see if we can change things around. However, we may not be able to give them some time to think it gives them some time to process and gives them some hope. But yes, there is hope. You know, every day, I drive into work to do an operation. I mean, I do still imagine myself driving home at the end of the day, and I don't know what the outcome was going to be, you know, I, I often think I really, really, really hope that I'm driving home reflecting on on every single aspect of the operation and how well it went and how the patient's done so well. And that's like so, so pleasing. Sometimes you can't really sleep that night is just focused on replaying the operation and then you're and then when the patient does well, you're so happy with the outcome. Other times it's not like that and you're driving home thinking what the hell just happened. And you wake up the following day going Was it a dream Was it a nightmare? You know? No, it's real it happened and having to live with, with what happened. And, and so when you go to work, definitely there is there is hope that the outcome is going to be good from the surgeon and the patient and the family. And and there's, there's hope as well, I guess in the team, because the team, we've not talked much about the team, but the team are really important. And they're all obviously, humans as well. And they all like to work with successful surgeons and in operating theatres, where the outcome is good, because when it's not good, it's so traumatic for everybody. There is hope from everyone at every point in the pathway that things are going to go well, and mostly they do go well.

Claire : 1:00:46

Okay, so our last question is, what's your Herman? Which is what kind of what things would you want to give to others to kind of help them in these kinds of situations? And I know, with a scientific brain, it's a bit trickier for you. So yeah, looking back over everything you've done, and you know, everything you've accumulated, what sort of things would you want to share with others about what you do? So what's your Herman?

Mark Field: 1:01:10

So I thought a lot about this, tried to understand it and try to come up with a, with a good answer. And, and I think it is around how we manage death, but not around a patient. A patient dying is a tragedy for everyone. But one thing that I've learned is that if you manage that death badly, you can affect the quality of the life of the entire family, for a generation. If you manage it incorrectly, there can be so much bitterness, and so much resentment in the family, for their entire lives. And it's so important to get that right, and to avoid not just the patient dying, but in a way the family dying, or the family suffering that loss for an entire generation. So if I if I was to give advice to someone coming behind me, it was yes, the death is tragic, and and there be all sorts of things and issues to cope with around that. But your focus has to be on the family. You know, certainly if it's if it's during during an operation, and you have an opportunity to get out when you know things are going wrong, and go and speak to the relatives, or if it's on the intensive care on a ward and then speak to voters give them for wanting but also gives them some hope. I think hope is really important.

Claire : 1:02:39

I've heard it said that'if you have nothing to be grateful for, check your pulse'. And I suspect this has an extra special meaning for those who have survived life saving surgery at the hands of surgeons like Mark. So thank you to all surgeons who are taking on the risks and duties of dealing with human lives every day. I'm sure you don't get half the thanks. You deserve all that are probably said behind your backs.

Chris: 1:03:00

And a big thank you to Mark for being willing to venture into a subject that other surgical professionals might not know how to broach. It's such a brilliant and insightful conversation that we know will help many others in similar vocations. Know that they're not alone in having to handle loss and grief on a regular basis. And of course, it's okay to not find it easy. To hear more of our episodes into other careers. Visit our website, www.thesilentwhy.com/letschat.

Claire : 1:03:25

Yep, on that page, I've got a list of all the conversations we've had with people who have jobs that involve working with death and grief on a regular basis. This includes a Scotland Yard murder detective who's everywhere at the moment is even on TV, a paediatric intensive care nurse, funeral directors, police chaplains funeral celebrant, an end of life coach and many more.

Chris: 1:03:44

And for more on Claire and myself, visit www.thesilentwhy.com or follow us on social media@thesilentwhypod for more about Herman you can go to the www.theHermancompany.com Or follow him on Instagram@TheHermanCompany. He's even been travelling recently.

Claire : 1:03:58

If you know someone that just needs a boost at the moment, maybe they're going through hospital treatments, chemo exams grief loss or a tough time. Why not send them a Herman he's the perfect handmade by me companion to help people know they're not alone in whatever tough situation they're going through. If you have no idea what we're talking about when we mentioned a Herman, just head over to the website in the show notes. UK shipping is free, but I can ship him anywhere in the world for you. I know that you know somebody right now that just needs a smile.

Chris: 1:04:25

We're finishing this episode with a quote from Christiaan Barnard who is a South African cardiac surgeon who performed the world's first human to human heart transplant.

Claire : 1:04:35

"I realised all of a sudden that life is the joy of living. That is what it is. It is really a celebration of being alive. You see, what they taught me was that it's not what you've lost. That's important. It's what you have left. That's important, but I qualify this. There must be a joy in living. There must be still enough left so there can be a celebration. You can't celebrate nothing in There must be something to celebrate. So I think one must realise that as a doctor, if you value life, your goal must not be to prolong life. Your goal must be always to provide something for that patient that he can celebrate. Provide something so that life can be the joy of living."