Category Archives: #WILTW

Blogs relating to What I learnt this week

Statistically, the thing most likely to kill me, is me #WILTW

This is the 157th #WILTW

During, and since leaving school, three of my fellow pupils have died by suicide. I can not claim to have been best friends with them but sudden loss of life puts into perspective even the most briefest contact or interaction.

Suicide remains one of the last taboos. While public awareness of mental health issues has hugely improved it remains a difficult topic of conversation to have with others. What are you more likely to bring up over a coffee: your fleeting dyspepsia or the fact for the last week you’ve just not been able to see the positive in anything? Neither of these things mean you definitely have serious illness, and both may well be transient conditions, but the latter is often perceived to carry an implication about you.

Mental Health Organisations and individuals dedicated to improving outcomes have had a huge part to play in reducing the stigma of mental health. But the sharing of honest stories, sometimes from unexpected sources, probably has had a sizeable impact on cultural perceptions.

Recently the wife of a doctor in Brisbane who had died by suicide wrote a short, and extremely powerful letter, to the medical community. She didn’t want it to be a secret that her husband, Andrew, had died and wanted people to know how proud she was of him. In response an ENT surgeon, Eric Levi, had some insightful perspectives on the impact that work can have on your mental health, in his words, “..through the dark seasons“.

The blog has been shared over 150000 times.

“I delivered my third child with my own hands because the obstetrician was stuck in a traffic jam. The following morning I went to work because if I didn’t 12 patients have to miss their surgeries, 2 anaesthetists and about 8 nurses will miss out on their day’s income. More importantly, admin would not be happy because a cancelled operating list is a huge financial loss to the hospital” Eric Levi – The Dark Side of Doctoring

I found Dr. Levi‘s piece quite challenging on first reading as his theme of loss of control grated with me. I entirely get the bureaucratic inertia that plagues healthcare professionals. The weight of targets, heavy handed communication and silo mentality at times a maelstrom. One that I have ranted and raved about as much as anyone else. But these are joint problems to sort. I am sure I am as much a part of the problem as I perceive others to be. But if the administration of the hospital will not let me off a clinic the day after the birth of my new born child the system is so rotten as in my mind to not be tenable.

But that attitude makes me as guilty as the system itself.

Andrew Tabner writing powerfully on physician suicide reminds us:

We need to abandon the macho persona that is often evident amongst doctors, especially those in acute specialties, and embrace well-being initiatives, wellness drives, career sustainability interventions, psychological tool-kits and anything else designed to help us cope with the inevitable stresses and strains that come when your job involves seeing birth, death and every facet of human existence in between, within a single shift

I am not immune from being in dark places but am lucky, through no action on my part, not to have ever been so low as to consider harming myself.  If we are to impact on the rate of suicide it is going to take continued dialogue within, and between, employees and employers to ensure that early signs of distress are recognised and can be acted on in the most appropriate and facilitative fashion.

What have you learnt this week? #WILTW

You can now follow WILTW on Facebook by liking this page . Browse previous posts here or insert your e-mail address in the box on the right hand side to receive future posts

I have taken a slight liberty with the title of this blog. The actual statistics relate to the 20-34 year old group. The title itself inspired by Christoper Young’s comments in Soul Music: A review of Waterloo Sunset 

Post Release Note:

I was contacted by Alys Cole-King (who I had linked to as an individual with a passion for improving outcomes in Mental Health ) post the blog to correct some of my language regarding suicide. Died by suicide has replaced committed suicide.

The following provides information and support on the issues raised above:

Resources for people in distress and those supporting them Staying safe if you’re not sure life’s worth living on line resource for anyone struggling to offer hope, compassion and practical ideas and suggestions on how to find a way forward connectingwithpeople.org/StayingSafe

U Can Cope film and resources The U Can Cope 22min film shares the three inspirational stories of Matt, Anthony and Cathy for whom life had become unbearable but who, after seeking help, are now leading fulfilling lives connectingwithpeople.org/ucancope

U Can Cope was designed to help young people develop resilience and cope with any current/future difficulties in their life but is just as helpful for adults. If Feeling overwhelmed and staying safe and for anybody struggling to cope when bad things happen in their life and includes advice on how to make a ‘Safety Plan’

Feeling on the edge helping you get through it:  for people in distress attending the Emergency Department following self harm or with suicidal thoughts connectingwithpeople.org/ucancope

Dear Distressed: Poignant and compelling letters of hope and recovery written by people with lived experience to reach and help others who are struggling with some much needed hope connectingwithpeople.org/wspd16

Tips on self-care connectingwithpeople.org/content/mhaw17

The Ghost Guideline #WILTW

This is the 156th #WILTW

Improved digital accessibility via smartphones has transformed access to information for health care professionals. A variety of apps exist, some accredited by national organisations such as the National Institute for Health and Care Excellence  (e.g. NICE National Formulary for Children: iOS or Android) and some approved by extremely stringent regulators such as the Medicine and Healthcare products regulatory authority (MHRA). Mersey Burns (iOS or Android), an award winning programme for calculating burn area percentages,  was the first app approved by the MHRA and such is its ease of use it’s downloaded much further afield than the North-West.

For direction on your own institutions’s preferred approach to managing certain conditions you need to look things up on local servers. Sadly, and I have never been given an adequate legal explanation for this, hospitals rarely allow their guidance to be made public. This means if staff don’t have quick access to a computer they need to find an old guidelines folder hidden away in the recess of a desk. The Royal Children’s Hospital Melbourne have taken a far more pragmatic approach and allow anyone access to their clinical practice guidelines. It’s no surprise then to see the format (content!) of their guidelines emulated around the UK.

Huge amounts of resource are used in trying to get doctors and nurses to deliver evidence based treatments and care. Easier access to guidelines should result in more patients receiving the most clinically appropriate and effective treatment (which may often be no treatment in paediatrics). However clearly laid down ‘best practice’ is often ignored and poor practice can persist simply because it has been heard on the ‘grapevine’. This ghost guidance, which can’t be found on any website, manuscript or protocol can be pervasive throughout an organisation. The speed at which it becomes known to new-starters is incredible given it can take up to 17 years for some practices to be adopted.

House rules are not just about treatments but often relate to cultures and behaviours and can be incredibly stifling. This latter type of ghost guidance is often applied inequitably and inconsistently making it divisive but also difficult to remove. Conversely some ghost guidance is behind the emergence of positive deviance and may well be an informal method of spreading learning from excellence. It’s certainly not a new phenomena and forms of house rules were first defined by Stephen Bergman, writing as Samuel Shem, in “The House of God“.

Some of the house rules from Samuel Shem’s “The House of God”

In researching for this blog I discovered that Stephen had added to the original house rules first published in the 1978.

Law 14 : Connection comes first. This applies not only in medicine, but in any of your significant relationships. If you are connected, you can talk about anything, and deal with anything; if you’re not connected, you can’t talk about anything, or deal with anything. Isolation is deadly, connection heals.

Law 15 : Learn empathy. Put yourself in the other person’s shoes, feelingly. When you find someone who shows empathy, follow, watch, and learn.

Law 16 : Speak up. If you see a wrong in the medical system, speak out and up. It is not only important to call attention the wrongs in the system, it is essential for your survival as a human being.

These seem like the types of ghost guidance that should be written down and shared…

What have you learnt this week? #WILTW

You can now follow WILTW on Facebook by liking this page . Browse previous posts here or insert your e-mail address in the box on the right hand side to receive future posts

Why are so many children ill? #WILTW

This is the 155th #WILTW

Co-inciding with the opening of our new Emergency Department was the release of “Emergency hospital care for children and young people“. Produced by the Health Foundation and Nuffield Trust the report analysed Hospital Episode Statistics (basic data relating to a patients’ admission to hospital) over a 10 year period. It is a sobering read with a headline figure that, although attendances in the under 25s increased by 14% (compared to 20% in all ages), in the under 1s the figure was 30%. These increases over time are no surprise to us with the figure below our own local data from the last 4 years (thanks to Dr. Gareth Lewis for this)

The reasons for this persistent upward spiral are not clear. It is important to note that a large amount of the total change is actually due to population growth and an increasing birth rate. However the birth rate has slowed in the last few years whereas admissions haven’t. Increasing parental anxiety, poor or inequitable access to local health care services and a risk averse medical culture have all been suggested as causes, but whatever the underlying problem is, it’s definitely going to need more than one solution.

http://www.qualitywatch.org.uk/sites/files/qualitywatch/field/field_document/QualityWatch%20CYP%20report.pdf
via Health Foundation/Nuffield Trust 2017

The data presented gives an indication of where research and improvement work needs to focus as long as we are aware of some of the challenges in interpreting the figures. Large scale data analysis projects like this are very dependant on the quality of data entered. Healthcare has not had a brilliant track record in recording, or more precisely ‘coding’,  information about patients effectively. This is generally because doctors aren’t trained in how important this is and are therefore quite ambiguous in their clinical records. Hospitals employ teams of clinical coders to read notes (and decipher handwriting) so they can record the key outcomes related to a patient’s stay. To make the coders job either they collate conditions into particular predefined and agreed categories. The most common of these are shown in figure 3.6 from the report.

Source: Quality Watch report 2017 (Emergency care for children and young people). Data via HES

Notwithstanding the complexity of being able to extract information about the underlying condition there are some interesting trends here. I am most taken by the huge increase in numbers of children diagnosed with a viral infection. The authors note:

“– in particular, the large increase in emergency admissions for viral infection and acute bronchitis, as well as the increase in admissions for other perinatal conditions (feeding and respiratory problems) and haemolytic and perinatal jaundice in infants. These may be related to more children surviving with complex disabilities and requiring more intensive healthcare support”

Children with chronic illness are more susceptible to the adverse effects of even the most simple viral illnesses so it is very plausible that an increase in children with complex needs will result in greater presentations with viral infections. The increase in number of viral illness cases seems so large though, especially given that other upper respiratory infections and acute bronchitis* are also predominantly caused by viruses, that either we are in the middle of some unrecognised ‘viral’ epidemic or there are some cultural issues at play. There is no evidence that viruses are being more virulent (length of stay is actually decreasing) and we have been using vaccines for flu and rotavirus (the bug that causes gastroenteritis) for a while.

So we have a challenge. A challenge that is not for any one individual organisation, committee, institute or group to solve. It is not sustainable to have a continued 4% rise in presentations to emergency care year on year so systems need to start talking to each other and the public. They need to discuss not only how to continue to provide quality care given the increasing pressures but to really start to look at the underlying reasons behind these trends so we can continue to give children and young people the most effective care when they most need it.

*note acute bronchitis is not a term I use or really recognise. It is used here to describe a number of different types of short lived chest infections

You can now follow WILTW on Facebook by liking this page . Browse previous posts here or insert your e-mail address in the box on the right hand side to receive future posts

An Emergency Department “gebrochenrolltreppe” phenomenon #WILTW

This is the 154th #WILTW

As you are ambling around a shopping centre you spy an escalator to take you to the level you need. It’s not working but hasn’t been cordoned off so you use it as stairs to climb to the floor above.

You know the escalator isn’t moving.

You have audio-visually confirmed this.

And yet as you walk onto it it starts moving forward so you overstep slightly before re-adjusting yourself.  You then realise it’s not actually moved forward at all.

This unnerving sensation has a scientific explanation although it wasn’t fully explained until the beginning of this century

Julie Beck wrote an article on the paper and coined the term “gebrochenrolltreppe” ( In German Google Translate “escalator” is “rolltreppe” and broken” is “gebrochen”)

One thing about our new Emergency Department, which opened this week, is that it’s not broken. Yes there are some snags, and lots of new processes to learn, but there is far more space, purpose built cubicles and a design that facilitates flow. These combine to create a department that is far quieter and more functional.

However this has created an unusual side effect.

You don’t need to be a experienced health care professional to notice when things are busy in a department or ward. There is a slightly distracting ambient noise level, a characteristic ‘hurry’ in people’s movements and a subtle but  inescapable increase in the atmospheric pressure that creates tension. These sensations often correlate to the number and acuity of patients on the electronic information systems. So much so, that if there are only a few patients in the department and it feels busy, you know something is wrong.

In our new building the converse of this is playing out. The information on the computer screen may tell you that patients are arriving at a seemingly exponential rate, you have a large mix of illnesses and injuries to deal with and there are two ambulances waiting to handover patients.

But the department feels calm.

(or certainly far less stressful that it previously would have done)

This cognitive dissonance was predicted by some but the reality of it has come as a shock to me. Situational awareness is a skill you can learn but there is an intuitive, almost reflexive, nature to it that definitely improves with experience.  I, and I think others, have had their situational awareness compass unbalanced with a discrepancy between what they are seeing (on the computer screens) and feeling (around them). This feeling will undoubtedly pass as we re-adjust and find new methods of abstracting clues from the environment about how the department is functioning. But it is reminder of the powerful influence the lived experience has on us and how many cues and reactions are based on our tacit knowledge of our environment rather than numbers on screens.

What have you learnt this week? #WILTW

You can now follow WILTW on Facebook by liking this page . Browse previous posts here or insert your e-mail address in the box on the right hand side to receive future posts

Abdominal pain in Children: illness vs individual #WILTW

This is the 153rd #WILTW

This week my youngest daughter has been suffering from intermittent tummy aches. There is no condition that is more difficult to investigate, diagnose and treat than children’s abdominal pain. I say that as a Paediatrician and a Parent.

There are lots of resources that list the multitude of causes of, and treatments for, abdominal pain. These are important for clinical staff who work with children to understand and apply. However, abdominal pain is hugely context dependent and I have realised there is a fragile balance between being prudent and perturbed, regardless of your knowledge base.

I’d like to suggest four co-dependent factors that are likely to impact on getting to the bottom of the problem and successfully treating it:

I’m a big fan of alliterative lists but in this case it’s important not to see any domain as distinct from the others. All the features impact on each other, sometimes simultaneously, making separating them in some respects almost illogical (but illogical is what I will do)

The Nature of Pain is a challenge in children. I am minded of Dr. Edward Snelson’s wise words.

Internal pain is translated into external distress. The outward display of symptoms can often bear no resemblance to what the observer perceives the pain must feel like. While pain scales can be used to quantify an individual’s particular rating of their own discomfort, the dissonance between an observer’s judgement often invalidates them. This is a huge challenge in paediatric practice where the child, parent and professional may all have substantially different interpretations. It is vital though that the child or young persons perceptions are acknowledged and managed.

This is why the Personality of the Child is important. Differing development, family circumstance and chronic health issues mean that individual age is not a good basis for making judgements of how a child will respond in a given situation. I have seen stoical toddlers to blubbing teenagers and vice-versa. In practice most children can be distracted enough to make confident decisions that the pain is not of a serious nature:

“The easiest way of engaging with a child is to tell them you can guess what they had for breakfast. Feel their tummy and shout out random cereals. If you guess correctly after a couple of goes you are considered a genius, but it’s better if you continually get it wrong as the child thinks they are cleverer that you are. Either way you get a good feel of the tummy..”

Working out how a child, and especially a young person, is interpreting their pain is a challenge and when they are very distressed this is definitely impacted by the Response of the Parents.

Addressing the concerns of agitated and anxious parents is as important as those of the children. In some cases more so. There are times when a treatment will take time to take effect and the observation period is vital to understand the nature of the disease process. Leaving a child who is perceived to be in great distress without adequate explanation instantly breaks trust. Parents provide an analgesic effect themselves when calm and engaged to the child’s needs. Conversely they can unintentionally exacerbate situations as agitation raises stress levels in the whole family.

Understanding, and predicting, the Path of the Illness is clearly important to be able to adequately treat pain in a fashion in which the child or young person responds to and the parents or carers understand. The spasmodic but persistent griping pain of constipation is different from the fluctuating but self-limiting non-specific of mesenteric adenitis; despite the fact on paper the presenting complaint is exactly the same. Children of the same age and same disease entitity may have markedly different ways of expressing their discomfort and parents may have very different approaches to seeking help. Context is key to devising an adequate management plan.

What have I learnt this week? Understanding the interplay of illness, individual and their environment is vital. Whichever side of the parent/professional divide you are on…

What have you learnt this week? #WILTW

You can now follow WILTW on Facebook by liking this page . Browse previous posts here or insert your e-mail address in the box on the right hand side to receive future posts

Useful Resources:

Don’t forget the Bubbles Tummy Pain

PEM Playbook Paediatric Pain

FOAM EM RSS Abdominal Pain

Same Child, Different Room, More Risk? #WILTW

This is the 152nd #WILTW

In just under 2 weeks time we will move into a brand new Emergency Department (ED).

Picture via @LeicChildHosp

Although daunting we’re really looking forward to it.  It’s an exciting prospect for our patients as we are optimising the ‘front door‘ of the patient pathway to improve clinical input and patient experience. We will further improve access of children and young people to an appropriate healthcare professional following an initial assessment in a common triage area. The co-location of services is a recommendation of the Royal College of Emergency Medicine and in the new build we will have General Practitioners, working along side ED staff (many who initially trained as Paediatricians), both having easy access to the Children’s Hospital admitting teams.

One of the consequences will be the need for senior staff to recognise the challenge of being able to stratify risk appropriately between patients assigned to to different clinical staff. Why? Well, whether they realise it or not, all clinical staff who make diagnostic decisions apply a form of Bayesian statistics (Great summaries by St.Emlyn’s and Casey Parker) in nearly everything they do.

Patients arrive with a ‘pre-test‘ probability of disease. This is essentially the total  number of patients who have a specific diagnosis over a given time period i.e. it might be that 10% of children who present to the ED have a chest infection. After taking a history and examining the child, and maybe preforming some investigations, a clinician will make a decision on whether they think a chest infection is present or not. Those with a high ‘post-test‘ probability of disease will be more likely to get treated (‘test‘ in Bayesian Statistics doesn’t necessarily mean a blood test but could be any number of interventions including simply what the person’s gut feeling is about the presence of disease).

For example if you work somewhere where very few children have urinary tract infection (let’s say 2%) and you see a child with no relevant history or symptoms  at all it’s really unlikely this child has an urinary infection. Their post-test probability will be even less than 2%. Conversely if a urine dipstick comes back positive this will increase their post-test probability of having an infection. But remember this is just probability. The mistake made by many is that a positive test means a positive diagnosis. No! It just increases the probability of having a disease – there are few absolutes in medicine.

Pre-test probability varies between clinical settings. The risk of sepsis in children who go to a General Practitioner is very very low. There are 11 million children in the UK and in 2012/13 only 1000 were admitted to intensive care as a result of severe sepsis (100 died as a result). This clearly makes it vital we have systems to recognise sepsis promptly and avoid the tragedies that have occurred in the last 5 years. But the challenge is that a General Practitioner may go through their entire career and never see a child with sepsis. The risk of having sepsis increases if you are seen in an ED (this isn’t because an ED makes you ill but because parents are a good judge of their children’s health so are more likely take them straight to the ED when they perceive them to be very unwell). Finally because the ED screens and discharges a number of patients with more simple illness your pre-test probability of having sepsis will be highest if admitted into hospital.

So back to our new department. The same child, with the same signs and symptoms seen by a General Practitioner, ED doctor or Paediatricians will be perceived as having a potentially different risk of illness by the 3 doctors. This is because they are consciously, or unconsciously, aware of what the pre-test probability is for their normal working environment. If the GP asks a question of the Emergency Department Consultant (as is likely to happen in a co-located department) that Consultant will need to acknowledge their different frame of reference of risk. While the phenomenon of differential risk assessment is not new (GP colleagues often phone for advice) this is going to be at at a very different scale and pace. Something everyone is going to need to be mindful of to protect patients from both over- and under- investigation.

What have you learnt this week? #WILTW

You can now follow WILTW on Facebook by liking this page . Browse previous posts here or insert your e-mail address in the box on the right hand side to receive future posts

The dangers of Formophilia #WILTW

This is the 151st #WILTW

There appears to be a genetic hangover from the evolution of mankind which resists change. Shortly after the invention of the wheel came the invention of the ‘form’ (probably to describe the correct use of the wheel and situations it couldn’t be used). The ‘form’ seems to be embeded in the consciousness of many institutions and its dangers were brilliantly encapsulated by Prof. Davina Allen in a recent editorial.

“Checklists, pathways, algorithms are a tempting way for organisations and healthcare professionals to signal to the outside world that they are making a good faith effort to ensure service quality. Yet the popularity of these everyday tools has not been matched by their systematic and critical analysis, leading to concern about the potential impact of a growing epidemic of ‘polyformacy’ on healthcare systems.” AllenFrom polyformacy to formacology 

Prof. Allen calls for us to take stock of these simple but often very powerful tools and views them as ‘actors’ that do things rather than simple inorganic material. These ‘actors’ also require ‘scripts’ of the necessary information needed to make a tool work. Many assumptions are made about how easy these scripts are to read or enact. The example cited, one that is close to my heart, is the reliance on Early Warning Scores to be used by staff  who must adequately, and appropriately, collect the right vital signs at the right time. If this script isn’t followed correctly, the actor i.e. the score performs poorly.

A mis-understanding of actors and their interaction with scripts makes formophilia a dangerous pre-occupation. In his powerful book, the Seventh Sense, Joshua Ramo highlights the amazing ability for younger generations to develop powerful algorithms that connect the world in ever more intricate ways. But while they are immensely technologically proficient, do they have the context, insight and life experience to know the impact they are having? He quotes Joseph Weizenbaum (a MIT computer scientist) as saying: “Programming appeals most to precisely those who do not yet have sufficient maturity to tolerate long delays between an effort to achieve something and the appearance of concrete evidence of success

In the same way that simple programming is easy to learn, it is a very simple thing to produce a form. It is much more challenging to take time to decide whether the form is even necessary and a whole different endeavour to work out whether it actually works.

What have you learnt this week? #WILTW

You can now follow WILTW on Facebook by liking this page . Browse previous posts here or insert your e-mail address in the box on the right hand side to receive future posts