The presumed love of a parent: an uncomfortable cognitive bias #WILTW

This is the 110th #WILTW

On Tuesday (21st June 2016) Ben Butler was sentenced to life in prison for murdering his daughter, Ellie. His partner was sentenced to 42 months for child cruelty and both found to have covered up her death by faking a 999 call two hours after she had died.

Ben Butler had previously been convicted in 2009 for shaking Ellie when she was a baby although on appeal this decision was overturned. The couple then won a High Court ruling to have Ellie returned to  them. Ellie was murdered 11 months later.

The video of Ellie’s Grandfather talking on the BBC is uncomfortable viewing

This is a tragic case which leaves you feeling sad with the world. That family members can harm each other, whether it be emotionally, physically or otherwise, is difficult to understand.

It is an uncomfortable part of paediatric practice that a small proportion of the injuries you see in children will have been caused by a person well known to that child. This adds complexity to the already challenging task of learning how to identify when injuries are children protection issues. The unique context of child abuse distinguishes it from more traditional medical education pedagogical approaches. For example I have blogged not infrequently on how important it is to listen to, and more importantly hear, parents’ worries. Sadly, despite the focus on the risks of serious bacterial illness in children, we know health care professionals still miss sepsis even when parents do everything in their power to highlight their concerns. Imagine the challenge then, when a parent or carer is deliberately concealing information or fabricating stories about their child. Those working in acute paediatrics must be aware of these polar opposites; sensitively sifting through nuances in language to identify legitimate concern or illegitimate explanation.

Child Protection Blog

I must admit I am not sure my child protection training ever really prepared me for the actual reality. Experience making me increasingly more aware of my limitations rather than less. But in this area I wonder if we can work harder at raising awareness of a cognitive bias inherent in believing the person who should have the child’s best interest at heart always does. Ultimately truly hearing the parent or carer’s story and evaluating that with the clinical  information from the child or young person you are seeing is the best way of keeping all children safe – whatever the cause of their illness or injury.

What did you learn this week? #WILTW

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Child Protection Publications from the RCPCH

Failure Fatigue #WILTW

This is the 109th #WILTW

On a daily basis there is a post on how the most successful people have always experienced a great deal of failure:

Failure

This week the BBC reminded us of J.K.Rowling’s Harvard Commencement speech

“I had failed on an epic scale. An exceptionally short-lived marriage had imploded, and I was jobless, a lone parent, and as poor as it is possible to be in modern Britain, without being homeless.

They shared her famous tweet about the rejection of her initial books:

J K Rowling Tweet

It is reassuring to know that success isn’t an easy path but not everyone wants to be rich, a sporting superstar or part of the financial elite. However most of us have projects and ideas we would like to put into practice. So how long can you fail for before you decide what you are doing is never going to work?

What made Thomas “I’ve not failed I’ve just learnt a thousand ways that don’t work‘ Edison have that 1001st attempt? What is it that keeps you going when an new innovation spreads but yours just dissipates into the wind? What is that people have that enables them to climb out of the icy waters onto the top of the iceberg?

A close friend this week suddenly dropped into conversation, “Don’t give up on #WILTW. It might be hard work but keep it at.” I’d been reflecting on the numerous projects I’ve had that have nose dived without a trace. It has challenged me to draw out the things you need to do to protect yourself from failure fatigue.

Review – can you get an honest opinion. Does anyone else connect with your vision?

Reevaluate – what is the purpose of your project? Will it really deliver the outcomes you hope?

Revise – can you break down the project into smaller chunks and make the next steps more tangible or manageable?

Reenergise – do you have time for what you are doing or are you spending too much time on it. Is it time for a break?

What have you learnt this week? #WILTW

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Failure Fatigue

Learning from, rather than on, patients #WILTW

This is the 108th #WILTW

What have you learnt

It is an unintentional medical education paradigm that you tend to learn on patients rather than from them. This is especially true in the early years of training. As you gain in experience you start to encounter, or recognise situations, where a patient’s action itself can teach you something.

This happened to me during my neonatal intensive care placement. I had a few years behind me as a doctor and was in that dangerous phase where I didn’t know enough to know what I didn’t know…

During Kruger

I was covering the labour wards when I was fast bleeped to obstetric theatres. A mother was having an emergency caesarean section. I can’t remember the reason why but it was serious enough that she needed a general anaesthetic to expedite the procedure. As the baby, a boy, was delivered it was clear they had been struggling. He was limp, blue and making no effort to breathe. As he was placed on the resuscitaire I ran through the sequence of interventions to get oxygen into the babies lungs. This was the first time I had done this on my own. I’d been deemed competent to attend these situations independently; a senior only minutes away if needed. Having dried and stimulated him I felt a sense of relief as the air and oxygen delivered via a face mask caused his lungs to rise and fall in a rhythmical pattern. Shortly afterwards a pulse became obvious in the umbilical cord, and then suddenly, that precious cry of child who suddenly realises they have entered the world.

I was chuffed to bits and with the neonatal nurse we wrapped and swaddled him. The mother was still attached to an anaesthetic machine so I left the room to see the father. He looked stressed, anxious and upset all at once. I presented him with his son explaining what I had done. I was proud to have been able to provide what I thought had been expert care. I didn’t expect him to look annoyed:”How is my wife? Is she ok

“But I’ve just saved your child’s life!” I thought. I muttered something about her needing to wake up from the anaesthetic. He took his son and rocked him in his arms. He looked worried. I felt disappointed.

I learnt a great deal from that interaction. This father was concerned about the most important person in his life and at that time it was his wife. I had not even considered that being a possibility. Not only understanding, but also predicting, what matters to patients and their family is vital. I also learnt humility. I had probably not done anything life saving. Just being able to do something independently does not make the act itself any more great. It may well have been the baby would have started breathing for itself anyway. We won’t know and it doesn’t matter.

Increasingly I learn new things not about patients’ clinical signs and symptoms but about their beliefs and expectations. I am of the mind that managing these well is far more important.

What have you learnt this week? #WILTW

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Is our response to failure misplaced in medicine? #WILTW

This is the 107th WILTW

The impact of a child dying in hospital on their family and friends is unimaginable. Whether expected or not there will be a void created in many peoples lives.

There is also an effect on the staff, especially when the child has been an inpatient for a while. Annabel Smith, a paediatric trainee from Australia, blogged this week on how to make sense of death in paediatrics. She writes eloquently on how staff deal with their own grieving processes and is honest about how difficult it can be to admit to peers how you are feeling. She notes:

Doctors – medicine is brutal. It’s also wonderful, mysterious, joyful, and an absolute privilege to practise. A success can bring us to dizzying heights of elation, but every failure rocks us to our core.

Failure is not a concept that sits well with the medical profession. There is an intrinsic desire to do good. To benefit patients with your actions and practice to a high, evidence based, standard. Whether it be through poor exams results or difficulty learning new procedures not performing well is uncomfortable.

There is also a natural tendency to equate patient outcomes with a direct result of your interventions. This is obviously a false premise. There are things that medicine, however well applied, cannot fix. And there is even a speciality,  palliative care, that has inevitable results for patients. Its patient centered outcomes being that death is as dignified and pain free as possible.

You still feel like you have failed when tragedy has occurred. I suppose it is human nature and perhaps a mechanism of demonstrating you retain the empathy that medicine could so easily remove from you.

There are other more definite failures in medicine though…

Failing to wash your hands.

Failing to introduce yourself.

Failing to be compassionate in your approach.

These seem so self evident that is it is difficult to understand how they don’t occur. Yet evidence suggests they continually don’t. I wonder if they are seen as failure though? What if the visceral response to these events were as powerful as those created when a patient dies. Would they occur as frequently?

What have you learn this week? #WILTW

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Don’t cause unnecessary distress! P.R.E.D.I.C.T before your paediatric procedure #WILTW

This is the 106th #WILTW

For those working with acutely ill and injured children there aren’t many more important things we can do than relieve distress and pain. Sadly though there are times when procedures need to be performed in Emergency Departments which will not be completely pain free.

Screaming Child

Clearly every effort is made to ensure that the management of fractures, insertion of sutures or removal of foreign bodies is as comfortable for the child as possible. Standard text books will list some analgesic agents and those with any experience will ensure they have a repository of distraction techniques and preferably a play specialist[1] with them. The real life situation is a little more complex and, as with any task, a little preparation can go a long way to improving everyone’s satisfaction with the process. One of my recommended follows in Paediatric Emergency Medicine is Brad Sobolewski (@pemtweets). This week Brad wrote on draining abscesses in children.

Abscess Tweet

His post started with the factors that will impact on a child’s tolerance of the procedure. The list was actually relevant to many procedures and it got me thinking about the unconscious processes that I go through performing them.

The sequence can neatly be described by P.R.E.D.I.C.T

Personality – maybe the most important component. What is the child like? What makes them tick? What are their fears? Do they know what is going to happen? This may be obvious but sometimes it does take some unpicking (and why play specialists are worth their weight in gold). Some children and young people are very rational, and others less so, especially when they have been through a traumatic event to bring them to the Emergency Department in the first place. From 18 month onwards you can get a sense of how children may react; this information is invaluable

Relatives (or carers) – I’m always mindful of one of our play therapists quotes “as calm as you are is as calm as she’ll be“. Anxious parents can make for anxious children.

Experiences of the child –  If one thing is going to change your approach it will be the parent saying ‘the last time this happened we had to…’ Children remember like elephants. This is why it is so vital any procedure is as pain free as possible. One poorly performed blood test makes all subsequent blood tests 100 times more difficult. Make sure you are aware of past history.

Duration of the procedure – Some manipulations may take seconds whereas an embedded earring may take much longer (and why a good nerve block sometimes essential!). A schoolboy error is not to plan for a long procedure because you are overconfident (see below)

Interruption – while sometimes procedures have a time critical element; not all do. Ensuring you are aware of other potential distractions in the department is important (there may be lots of procedures happening simultaneously at any given time on a busy evening!)

Confidence of success – Plastering a child with a deformed forearm is unlikely to go wrong. But if you don’t fish out the small plastic ball from the ear canal at the first attempt its not always a simple next step. I always tend to think about will happen if things don’t go to plan. What are your get out strategies and what other techniques or pain relief might be needed?

Team – My final thoughts revolve around who I have available to achieve the best outcomes. A play specialist is always invaluable, as are nursing and associated staff experienced in minor procedures in children. Sometimes less is more for the frightened child, conversely a couple of ‘holders’ (noting that brutacaine is not an acceptable approach) are necessary.

So P.R.E.D.I.C.T’ing your procedure is important and I think relevant to all children including those with development delay or a neuro-disability.

PREDICT Slide

What have you learnt this week #WILTW

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[1] In the United State Play Specialists are called Child Life Specialists I think

 

Risk and Change: Useful in an Emergency? #WILTW

This is the 105th #WILTW

A past president of the Royal College of General Practitioners and the Chief Transformation Officer of NHS England briefly debated change on twitter this week:

The imposition of change is a concept that everyone is not only familiar with but also probably weary of.

Change energises risk takers?

This statement stuck with me. Change has been a  dirty word in the past and to some it still is. Currently many health care systems around the world are at breaking point. Something must give. Is it more change that is needed?

or is it something else? There is an innate desire in health care to improve; but improvement tends not to happen by chance alone. Either with something, by someone or just somehow, a change will need occur.

Emergency Medicine is a dynamic and exciting career. The demand and pace of our work dictates that change is not an infrequent occurrence. This is a result of external influences (such as hugely increasing demand) and the impact this has on organisations to respond to them. Emergency Medicine is not a specialty that sits still. It is therefore not surprising that those in Emergency and Critical Care were the early adopters of the social media revolution that has transformed the delivery of education around the world. And while we never expose our patients to unnecessary risk we must live with risk all the time. Not every patient with a headache can be admitted, not every patient with a fever receive antibiotics.

Do we therefore potentially enjoy change? Is it in the blood of the emergency physician to relish trying different things in exactly the same way there’s something appealing about not knowing what is going to be wrong with the next patient who comes through the department doors? I think many in the UK may baulk at this analogy. At present the sheer number of patients coming through the doors is reducing the excitement somewhat.

Regardless I think it is worth noting there will always be those looking for something different and those who need time in the status quo. As Helen states a shared purpose is vital and as Clare alludes to energy is not limitless.

What have you learnt this week? #WILTW

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Filter Failure – not just knowledge overload #WILTW

This is the 104th #WILTW

The videos from the “Health of the Nation” TedX Leicester event were released this week. A colleague, Pro Mukherjee, spoke on “Another Way”

Click here if the video doesn’t play

Pro starts his talk with the parable of the wise master and the eager, but over confident, student. The student is keen to learn but incredulous as the the master keeps pouring water into a cup until it overflows. The student shouts for him to stop and the master smiles:

You are like this tea cup, so full that nothing more can be added. Come back to me when the cup is empty. Come back to me with an empty mind

This is one of those stories you sit there and listen to thinking “I get that!” but subsequently forget to action anything about it as it’s displaced 15 minutes later by another interesting meme.

Cup

The parable is not just about factual knowledge but emotional and spiritual capacity as well. Knowledge is much more easy to encapsulate though.

“Knowledge is learning something every day. Wisdom is letting something go every day” – Zen Proverb

Letting go of overbearing emotions much harder than forgetting an old definition of sepsis or the causes of erythema nodosum. I suspect I spend a lot of time with a full, but very dynamic cup, the contents of which fluctuate on a regular basis. Choosing what, and when to let go, is probably an unconscious task and I think we generally learn to manage what comes in, rather than what comes out.

Filter Failure’ is a term coined by Clay Shirkey to describe the fact that information overload isn’t the problem – it is our inability to filter what we need the real issue. He argues you don’t get a cold sweat when you walk into a bookstore or library despite the volume of information in them being immense. It is so well catalogued you can go straight to what you need. Sadly 21st century life is not ordered in this way…

http://informationcuration.wikispaces.com/The+Current+Status+of+Information+on+the+Web
http://informationcuration.wikispaces.com/The+Current+Status+of+Information+on+the+Web

I wonder if filter failure can also apply beyond being overwhelmed by the core knowledge needed for work but also to sensory and emotional inputs. There are no easy solutions to keeping your cup at a balanced level, whether it be for professional or personal aspects of your life. Being aware that you might be near tipping point probably a good place to start! And perhaps we all empty our cups metaphorically, as well as practically,  everytime time we share a ‘drink’ with friends or family….

What have you learnt this week? #WILTW

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During the writing of this blog I asked twitter for its best sources of advice in regard to information overload (list below) fully aware that this ‘knowledge’ based approached is only part of the answer.

Drinking from the Firehose 

The path to insanity

The mind palace

Information Overload

Five strategies to effectively use online resources in Emergency Medicine

Thanks Simon Carley, Olusegun Olusanya, Seth Trueger, Janos Baombe

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