Dr. Damian Roland

What I learnt this week: Safe checklists versus speedy check-ins #WILTW

In Uncategorized on March 28, 2015 at 10:22 am

This is the 45th WILTW

The tragic events surrounding the crash of 4U 9425 demonstrate the difficulty in counter-acting every possible cause of harm or safety failure. There are processes though, both in the airline and health care industries, which are designed to mitigate the chance of injury and death. Checklists are an example common to both sectors (appreciating in healthcare checklists have both supporters and detractors). Most other mechanisms are unique to each industry. I personally find it odd there appears to be variation about the different security checks employed at different airports (shoes on or off, pressure versus x-ray scanners etc.) but the need for such a check has inherent face validity.

I flew to Belfast this week to give a talk as part of the “Berwick” series so my mind was already on processes and cultures. I had arrived at the airport later than I had intended but still with reasonable time to pass through security and get to my gate. However the delay, even with an express security pass, was considerable and I must admit I was getting increasingly nervous even before my bag was picked out as having a problem. The delays were not due to volume of people. They were due, dependant on your view point, to either the diligence of the staff or the absence of any haste. There was absolutely no urgency at all. It was painstaking to watch. You could see people becoming increasingly frustrated as the pre-scan person would carefully manoeuvre items around the boxes before pushing them through the machine. The person reading the x-rays would move backwards and forwards on each and every item. The man handling those which flagged as at risk would ponderously remove each and every item from the bags he was reviewing. It was painful to experience with the frustration clearly exacerbated by my being in a rush.


Emergency departments also have to process lots of people but equally need to make sure each person has a thorough assessment. I take on board the fact that in the medical environment people may suffer harm if they aren’t ‘processed’ quickly enough and one patients actions are unlikely to affect any others if that process is inadequate. I was discussing the potential analogy with Gavin Lavery on the drive to the conference venue. He raised an interesting point about how in healthcare, in order to meet an ever increasing demand, the staff just ‘find a way’. Going beyond capacity to find beds or being able to review more patients in less time during peak periods. The benefits of this are obvious but it creates a paradigm where you don’t always follow the ‘manual’ at all times. The checklist connudrum persists in part because staff want flexibility in the way they work. The challenge in healthcare is maintaining safety during flexible approaches.

I wouldn’t be able to work a security officer in an airport. I am not sure I would be able to maintain the air of someone whose desire for safety completely override any patient experience, day in day out, regardless of queues and the relentless stares of the public. But perhaps on a busy shift I’ll remember that just working that bit harder, or cutting that small corner, is not really what a ‘safe’ system should do.

What have you learnt this week #WILTW

What I learnt this week: Understanding the patients who may make you angry #WILTW

In #WILTW on March 22, 2015 at 10:59 pm

This is the 44th #WILTW

“I couldn’t see my next patient after we had stopped resuscitating a dead-on-arrival four month old. It wasn’t because I was too upset, too emotionally drained or too busy. It wasn’t even because I had to clean up the resus room; persistently re-tidying the cannula tray because it gives you something to do to switch off from the parents crying. 

It was because I was angry.

I had actually been seeing the fourteen year old with “appendicitis” before the priority one call came over the Emergency Department loudspeaker. I’d taken a history and examined the boy brought in by his worried mother. I had explained he didn’t have a compatible history, didn’t have a fever and didn’t have any right iliac fossa tenderness. I had been patient when mum explained that he had a huge pain threshold. I had been sympathetic that he had ‘always’ only ever opened his bowels every four days. I had compassionately discussed that the mass of stool in the left side of his abdomen showed he needed some kind of laxative. His Mother got angry with me saying that he ‘must’ have appendicitis and what kind of Doctor was I to diagnose constipation in a teenager! I demand to see a surgeon, she said, “They know what they are talking about.”

The priority call went off then and I made my apologies. 

The unfortunate child arrived moments later in the resus room. Found in his cot he was white, pulseless but not yet stiff. In front of his hysterical mother we performed the necessary resuscitative measures. The room was silent save for the voices of those asking how long the child had been in the department? How many rounds of adrenaline had we used? And a whispered, “ When are we going to stop?”. With mother’s consent we ceased resuscitating and left the parents, father only arriving from work seconds earlier, to grieve an unimaginable loss.

I am not sure if I felt their pain, I hope I never will, but I did feel sick. All I could see was a furious mother looking as if I had cursed her child with the words, “constipation”. I was angry that she wanted her child to have a severe illness not just a socially unacceptable inconvenience. Who is she to want her child to have the risk of anaesthetic, surgery, infective complications when the parents of the other child would have given anything that morning to have a child, albeit one with constipation?

The mother of the the child said thank you too me. Whether the mother of the teenager said thank you to the surgeon who discharged him with a diagnosis of constipation, I am not sure. Am I too harsh on a parent who probably devotedly cares for her son or justifiably perturbed at a society that doesn’t see the real picture? In the cold light of day I see the overreaction in my thinking but hope I will never wish a diagnosis on anyone ever again.

I wrote the above as part of a reflection in 2005. The experience, subtly altered to protect confidentiality has always remained with me. This week as part of a Consultant CPD session we discussed a paper by Alys Cole-King on Compassion. Compassion has become a buzzword in the NHS. I hope that this doesn’t devalue its meaning – the paper I think brilliantly explains how compassion is more than than just a singular approach but a set values which go beyond simply being kind. The paper discusses the attributes of compassion: Sensitivity, Sympathy, Distress Tolerance, Empathy, Care for Wellbeing and Non-judgment. The last, Non-judgment, defined as:

Not judging a persons pain or distress, but simply validating their experience. Compassion involves also being non-judgemental in the sense of not condemning. 

I have always considered myself compassionate but do I deliver of compassion? Since those events in 2005 I have endeavoured to question my emotional responses to the families that I see. This paper reminded me of the constant need, however busy, whatever circumstance, to continue to do this.

What have you learnt this week? #WILTW

What I learnt this week: You can make a little effort go a long way #WILTW

In #WILTW on March 13, 2015 at 10:16 pm

This is the 43rd #WILTW

The Nuffield trust have recently produced a report on “Whats behind the A&E crisis“. Something clearly not changing fast enough is the use of the term of Emergency Department rather than A&E but one of the key points is:

Many answers to the problems facing urgent care already exist. But the complexity of the system and the highly politicised nature of A&E have impeded progress. Problems will not be solved if policy-makers, political leaders and regulators continue to micro-manage A&E. With change so urgently needed, it is imperative that there is a cross-party consensus on how to move forward and that action is not postponed or delayed for political reasons.

There are many challenges in the NHS at present. Some are going to require long term policy and strategies to resolve which are clearly not in the remit of any one individual. In fact the problems facing the health system seem so great there is a temptation to fall into the trap that no-one can do anything about it at all. #NHSchangeday demonstrated there are many people keen and willing to get involved in bringing about improvement in their own localities. But it would be foolish to think that campaigns such as this are going to transform cultures or reduce deficits overnight. It is clearly important that this individual endeavour persists regardless of its cause.

Making those small challenges  is something that anyone can do. The simulation that we ran in the canteen of Leicester Hospital as part of a Change Day action came about, not because we had a clever piece of equipment, or that our emergency department is full of people with education certificates. It came about because of few of my colleagues have found the time to set in place a regular training programme.

Change Day Simulation

It’s not alway easy and there are times when things don’t go to plan. But the persistence of individuals finding a way to make things happen has resulted in an initiative risking being a fad becoming a fixture. It is starting to show results and we are hopeful after this public demonstration that other areas of the hospital will look at how they can bring simulation into their own work place.

No-one is going to change healthcare overnight. But there is still much that an individual can do to make a difference.

What have you learnt this week? #WILTW

(I am grateful to my consultant friends Gareth, Mark and Jonny for making in-situ simulation a reality in the Emergency Department. I am also massively appreciative of Amy, Rami and Paul for volunteering to take part in the live demo!)

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