Dr David Cox worked as an A&E registrar at Charing Cross, and was also at Beacon Health Strategies, trying to improve mental healthcare in the NHS, before becoming the Chief Medical Officer of the digital health platform Headspace. Rich was looking for ways to deal with the stress of the lifestyle involved in the ad industry that he was working in.
And they started off actually as an events company with Andy teaching a one-day course to a small group of people. It’s one of those kind of random stories… I was working in a company called Beacon Health Strategies, which was trying to introduce a new model of mental healthcare into the NHS. I had been aware that meditation was one of those things that supposedly has lots of benefits, but I had tried meditation a couple of times previously, and it was all a bit, sort of tree-huggy and crystal healing – not my kind of thing.
And I thought, it’s only 10 minutes, and this is clearly aiming at people like me who are deeply skeptical. I was like, “wow, they've found a way to present meditation in a way that doesn't, kind of, make your skin crawl, or activate all my mumbo jumbo senses”, coming from a medical background. He introduced me to Andy, and so for a few months I just used to meet up socially with them, and chat.
Can you tell me more about the challenges that you’ve come up against, both personally and as a company? I had mapped out for myself a path that I thought I wanted to be a hospital chief executive, and I was trying to make career moves that were basically ticking the boxes to build a CV towards that. I always had an idea of what I thought the next job should be, and possibly even the job after that. But I kept coming back to the same thought: “If I don’t give this a shot, I’m going to spend the rest of my life wondering what if”.
It’s the sort of perfect synthesis or perfect union between Andy, the monk who founded it, and Rich, the ad man. Andy’s an English guy, who spent 10 years in monasteries learning meditation, and learning how to teach meditation. It’s a very nice presentation of something that has a lot of authenticity and therefore actually just really works. Headspace is a training in meditation, and so there are hundreds of meditations that are sequential, that Andy talks you through, so you're not repeating yourself, and actually every day he's introducing new concepts or new practices or new ideas, so it's literally like having a personal teacher that's in your pocket. However, in order to pay the salaries of the genius designers and other staff that work at Headspace, there is a subscription that gives you access to the rest of the training system, which is like a kind of library of contents.
First and foremost being the skill of being able to learn, which means that you can learn other skills, and you can learn new stuff, you can learn to do new things.
You might not know what your safety net is, or how to have one, but that’s when I come back to saying, “realise the value in the skills that you have, and your ability to acquire new skills”. Regular meditation has been shown to reduce the amount of cortisol present in the brain thus leading to all kinds of beneficial effects, including an increase in libido. You just touched on it lightly just now, but do you think that doctors should continue with clinical practice when they are involved in start-ups, particularly in the early stages? Whereas if you could say, no, I still practice, that definitely buys you credibility with those within the profession. But from my perspective, I think the future of healthcare is going to be less and less about curing viruses and bacteria, and more and more about driving behaviour change in human beings….
Hopefully, with, you know three hundred million users, or three billion users, or something like that!
If you could change one thing about your career trajectory, or your move into this entrepreneurial area, what would it be? I think I was fortunate enough to have the confidence to grab the opportunity when I saw it.
We convinced her to stay until at least her blood tests came back though I was debating letting her go and letting her GP reduce her BP meds a bit. A chap in his 50s presented after, excuse the metaphor from the wrong sport, scoring an own goal with a toy rugby ball.
Crispin used a vaginal speculum to access the ball, then used a scalpel to pop the ball, he was then able to grab one of the cut edges with a fine sponge forceps and remove the ball.
AF with RVR a fairly common problem, there are many potential treatments and it can cause a lot of confusion.  Every boss has his or her way of managing it.
A fundamental principle is to find and treat any underlying condition that has caused the AF or made chronic AF faster (eg sepsis, volume depletion, heart failure, hyperthyroidism). Phenylephrine 100µg to attempt to improve the diastolic BP to improve coronary perfusion (see Phenylephrine refresher if you are not familiar with this drug).
The patient moaned a little during the cardioversion but had no recollection of the shocks and felt great afterwards. CXR showed a RUL pneumonia and it turned out she had a lung abscess, but no sign of TB.  She was treated with a very long course of IV antibiotics.

The other common situation is the patient with chronic AF who is tachycardic and unstable (eg hypotensive,  chest pain or CCF). As mentioned above we don’t want to cardiovert for fear of throwing of a clot from the quivering atria, and also there is less chance of successfully cardioverting someone who is in chronic AF. The hypotensive ones we give fluids and pressors (eg phenylephrine) then rate control (eg IV diltiazem) once the BP is respectable.
Canadians love procainamide to chemically cardiovert AF.  Unfortunately procainamide is no longer available in NZ, but I never used in to cardiovert AF as electricity is a lot quicker.
A shout out for the Health Professionals’ Health Conference in Brisbane in October 2013. The legendary Victoria Brazil will be speaking and I will be running one workshop on preventing burn out in ourselves and our colleagues and another on mindfulness. The idea makes sense.  Release the excess intrathoracic pressure, you can manually deflate the lungs, you can manually cause the heart to pump. One of the arguments against ED thoracotomy in smaller centres that unless it is a very straight forward right ventricular laceration, we probably wont have anyone with the skills to repair anything we find once we open the patient up.  But in the asthmatic there is no lacerated pulmonary artery or similar wound to repair (other than the thoracotomy, of course) so we could potentially transfer the patient with an open chest. Other pearls: Metered dose inhalers are every bit as effective as nebulizers as long as you are using 4-8 puffs and using correctly.
Not responding to all of the above measures with increasing ventilatory failure, hypoxic, hypercarbic, and altered mental status. Remember, they are highly likely to have components of both obstructive and hypovolemic shock. Magnesium: Looks like it works for kids, looks like it doesn’t work for severe asthma in adults ? Considered magnesium, but there is recent evidence against it – and we had enough to do.
I take over the BVM, still easy to ventilate, I don’t think we have over inflated her. The mantra is when an intubated patient crashes disconnect them from the ventilator or bag as they may have breath stacking = intrathoracic pressure too high from excess bagging or incorrect ventilator settings.
Anaesthetist notices the bulging external jugular vein that we hadn’t noticed and places a huge IV line in it to give us excellent IV access. Following on from my post on PALM EM just a quick review of MD on Call.  This is an app which is probably more useful to the new ED doc in their first few months in ED, or for the first year or two on the wards. It is more focused on the challenges for new docs: how to approach a patient with chest pain, abdominal pain, the agitated patient, the patient with a decreased level of consciousness, hypotension, seizures, how to declare someone dead etc. It does have a few weaknesses eg still considering a new LBBB is a sign of an MI, recommending morphine rather than fentanyl for everything and telling us how to recognise a dissecting thoracic dissection – but not how to manage it.
Headspace is an app and a website that was founded by a monk and an adman, that aims to teach people the skill of mindfulness through daily practices in mindful meditation. He went to Andy and really thought it was incredible what Andy was teaching and how he was teaching it. Over time, the demand outstripped Andy's bandwidth to give courses, and what started off as take-home materials intended for people who attended the courses, actually ended up furnishing the material for the first version of the app.
The thing about this article was that it basically said Headspace is meditation for people who don’t do meditation.
There's quite a lot of scientific research and literature into the benefits of mindfulness meditation.
I was at a technology in mental health conference, in the audience, and somebody sat down next to me in an empty seat.
It wasn’t set in stone, but I had an idea of how to navigate my way towards that goal. And until then, I’d always known what my next step would be, so that was really scary. He has a depth of experience and authenticity that is impossible to rival – unless you yourself have spent 10 years in monasteries. So if you put it in a way that means people are willing to give it a go, and then when they give it a go, it starts working, it just takes off on its own. You can get access to the first 10 days of meditation for free, and actually you can just do those 10 days over and over and over again, if you wanted to, so there’s no instance in which people would ever be unable to have access to Headspace. The beginning few meditations teach you some basic techniques, but then the other stuff that’s in the library is about specifics on how to use those techniques to focus on particular problem areas you might have. You can actually just keep doing the 10 days over and over, it’s not a once only thing.
As I understand, there was seed funding from an early group of angel investors, who were particularly focused on making investments that were philanthropic.
So for me, that meant choosing your GCSEs and then your A Levels in order to get into medical school, in order to become a doctor.

One, you have a really good interesting skills set, and you’ve proven that you can do academic stuff, and you can do the tough slog, and pass all those exams and all that kind of stuff.
When I was getting into medical school, it was clear that the people ahead of me were able to take like a kind of career break for a couple of years and go and do something else, and it was easy enough to come back in. Certainly within medicine and within medically related start-ups, there is a huge amount of credibility. NICE already recognises mindfulness therapy with respect to depression, and I think that’s going to expand. Now they’re looking at changing the EU advice to the regulatory authorities, and the process to update the EU advice takes five years! We are literally not going to stop until people think the same way about meditating as you do about brushing your teeth, or eating fruit and veg, or knowing you’re supposed to go the gym.
Some recommend ketamine because it is a bronchodilator and helps loosen up the inspissated mucus in combination with pulmonary toilet. 200mg IO ketamine (debatable if this was needed but it is a bronchodilator and she might be aware, or become aware) and 100mg rocuronium IO. A patient loses output but they are already purple, they have a heart rate on the monitor, so no one notices they have stopped pumping blood. After about two and a half years, they had the idea, and they said, “well let's make an app”, and the app was a roaring success. I was doing all the things that I would have advised a patient to do, and nothing was really making much difference. The more I looked at that, the more I thought, “wow, there's something here that really has the power to help a lot of people”. We shook hands and exchanged business cards, and – it was Rich, the founder of Headspace. I know you spoke about some of your personal experiences, but do you have any other ideas as to why it’s been so successful? Are you able to tell me a little bit about the early funding for the app, what happened and how it was secured, between Andy and Rich?
Then it’s just having the courage to leap off the cliff and actually do it, which is a big moment. I thought there was a huge amount of credibility that came from saying, “yes, I am a doctor, and I have done what you do”. But the phones are unrecognisable in two, so that’s kind of a tough thing to navigate. You know, it’s scary as hell, but, you know, honestly, what’s the worst that can happen? Need to know FiO2 of oxygen in the heliox mixture because if it is too low, the patient can become hypoxic. So much so that they stopped doing the live events, and it's all just based around the app and the website now.
I was looking for something to help support myself, and I read a magazine article about Headspace.
And now it's been packaged in a way that actually is able to get it to a lot of people, so there's a huge potential there. And I whipped out my phone and said, “what, this Headspace?” And he said, “yes, that Headspace”.
So I think it takes quite a lot of courage to say, okay, this is what I’m going to do. I found that actually there is definitely a distinction made about those who stop practising and can say, you know, yes I have done what you’ve done, to which people say, right, but do you really know what it’s like now?
Still in the clinical arena, do you see that Headspace might impact on clinical practice, and if so, how? There’s lots of difficulty with that, just around the fact that (and this is something that’s true of a lot of apps), the speed with which apps develop, and technology develops is on a whole different cadence than the speed at which the system does things like regulatory authority approval.
You can debate the merits of adrenaline in an arrest – but probably asthma and anaphylaxis is two cases in which it probably is still helpful. And that becomes more and more of a distinction the longer it’s been since you stopped practising. Anaesthetist has arrived and reassures me that ETT probably in right place – just tight lungs.
Bagging at 11 per minute (get this figure from the capnography) – probably should have been even slower.

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