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Don’t let your intervention define the diagnosis #WILTW

This is the 174th #WILTW

Summer is over.

Winter is coming.

The waiting room of our emergency department has altered, from being a collection of broken bones and abrasions, to one of hot and coughing children.

In particular we have seen a spate of children with croup.

Croup, on the whole, is a satisfying condition to treat. It comes with a very clear set of reproducible symptoms (such as a barking or seal like cough) and signs (noisy inspiration and breathing difficulty).

Generally parents are very good at recognising key features, especially if siblings have had croup previously, although for some reason they also seem to like posting videos of their croupy children online.

The satisfying part of treatment is the prompt response to a single dose of steroid (although the dose itself is amazingly still a matter of debate).

The challenge comes at the more severe end of the spectrum where adrenaline is required to temporarily reverse impending respiratory collapse (although in no way treat the underlying cause which clinicians often forget to tell parents and carers).

I am very protective of my staff giving adrenaline to children with croup when I am in charge of the department. I want to vet the decision, regardless of who makes it, not because I am a control freak (although I am) but because the use of adrenaline defines the disease process.

The child who receives adrenaline is then labelled ‘severe’ rather than vice-versa.

Of course many children do need this urgent treatment (and the close observation that it subsequently requires). But in my experience some don’t. It’s not that the child isn’t unwell, it’s just that they are unlikely to get worse without treatment. Patience, combined with good communication to the parents, are the key elements of management.

via http://www.mydr.com.au/

Once a child has received adrenaline however it is very difficult to pull back. Adrenaline is a powerful drug. Whether they have had mild, moderate or severe croup the child is likely to look better.  It will be impossible to know what they were previously like so, as the benefit of the doubt must be given the professionals treating the child, it is assumed they were severe. The child will need a prolonged period of observation; the very fact they have been judged severe often creating anxieties about the most appropriate place to do this.

Interventions defining severity are not unusual. This effect could be applied to the use of intravenous salbutamol in asthma and fluid boluses in presumed sepsis.

While no assessment is entirely objective it is important patients are managed based on the acuity of their illness; not always the treatments they have received for that illness.

What have you learnt this week? #WILTW

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(Other winter respiratory conditions reviewed here)

 

The Star Wars guide to decision making #WILTW

This is the 173rd #WILTW

I suspect the following rings true for many in medicine.

It inspired this movie related response…

… which then spawned an inevitable flurry of similar Star Wars inspired decision making analogies:

“It’s a trap!” – Admiral Ackbar

Learning it is very easy to make mistakes is a lifelong endeavour. The frantic pace of acute and emergency care makes it all too simple to follow a line of thinking that may directly result in patient harm. In fact St. Emyln’s, and in particular Richard Carden, are well ahead of me with this quote. A great summary of failures of thinking and cognitive biases can be found here, including anchoring and availability biases. While it might appear being aware that you may be ‘trapped‘ by your own cognition, will stop you being trapped, there is some evidence to suggest this isn’t the case!

“Never tell me the odds!” — Han Solo

There is a slight dichotomy for those experienced in emergency care who practice using some form of Bayesian Probability. When a patient presents they have a certain risk of disease. For example, over the course of a year, of all the children who present with a head injury, 5% perhaps may have a problem that needs an intervention. When I see children I will take a history, do an examination and sometimes perform some investigations. All these things will change the probability that the child in front of me does have a serious injury. Sometimes it will increase the risk (positive test result) and sometimes it will decrease it (child looks very well and is running around the waiting room). However this very process  creates an immediate bias as there is a real danger you won’t properly adjust the odds. If the incidence of a disease is really low then you can develop a mindset that it’s unlikely you will see that particular disease; so even if your history and examination reveal positive features you may ignore them.

Han Solo is telling us: Be aware of how to use odds but don’t necessarily depend on them.

 “Your eyes can deceive you. Don’t trust them.” – Obi-Wan Kenobi

While I have previously extolled the virtue of not just looking at a patient, but truly seeing what is in front of you, it is important to be aware of the concept of In-attentional Blindness.

Increasingly there is evidence to suggest that external distractions can cause such a loss of focus, you literally become blind to things you are looking for. The impact of this in medicine is unknown, but needless to say, its important you sense check what you are seeing is actually what you were expecting to see.

“In my experience there is no such thing as luck.” – Obi-Wan Kenobi

Star Wars IV: A New Hope
..this quote is also told to junior staff by wise old consultants. At the heart of this is understanding how intuition is not a form of magic but a collection of heuristics accumulated over time by experienced clinicians. Some conscious, some not, but all invaluable to collating the vast amount of information that can be derived from patients and putting them together to create one picture. Understanding the use of gut feeling and gestalt, much like the demonstration of the Force itself by Jedi knights to their padawans, is impossible by didactic teaching alone.  But it is a fundamental part of the path to mastery.

“Great, kid. Don’t get cocky.” – Han Solo

Han Solo may have come across as arrogant, but his own awareness of his arrogance, is what kept him alive.

“In all fields of medicine, but especially emergency and intensive care, the junior doctor does not need close supervision because of what they do not know, but because of what they do not know they do not know” [Spotting the Black Swan].

‘Do. Or do not. There is no try.” — Yoda

Is it possible to make a half a decision? It is definitely very easy not to make a decision at all and hedge-your bets to avoid being burnt. This may appear to be in a patient’s best interests but the burden of over-diagnosis and unnecessary admission are not insignificant. The facilitation of junior staff’s decision making by their seniors is vital but it is often simply not possible due to capacity issues in healthcare. We owe it to the next generation of clinicians to invest in delivering services which also deliver reliable education.

Similar to my posting on the Star Wars guide to Quality Improvement please do send me further suggestions which I will happily post here and credit!

What have you learnt this week? #WILTW

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The ingredients of a great conference #WILTW

This is the 172nd #WILTW

I am returning from the inaugural “Don’t Forget the Bubbles” conference (#DFTB17). Devised by the team who host the website of the same name, this three day paediatric conference held in Brisbane delivered humour, tears and great education in equal measure. There is always a danger of eulogising the impact of an event you’ve recently enjoyed. The metaphorical social media ‘bubble’ re-inforcing a perhaps rose-tinted view of events. There’s also a bias in that it is much easier to share thoughts on events you have enjoyed than it is to publically criticise something you haven’t. Because of this I wanted to reflect on the core elements that made it special. Are there common themes of all great conferences, regardless of their underlying content?

So here are my suggested ingredients of a great conference. The recipe itself (i.e. the amounts and the way they are mixed together) is more elusive but I suspect influenced, perhaps in intangible ways, by the organising committee.

Consolidate knowledge 

I used to believe that conferences should always focus on new innovations but there is value in looking at common practice in new ways. Certainly no-one wants to listen to someone explaining their job to them, especially if they do it in a boring and non-engaging fashion. There is real benefit though in having personal practices challenged or affirmed. This may include ‘labelling’ the components of a particular approach or procedure in a way you may not have considered before. This aids understanding and also the ability to explain your own work to others in a more objective fashion.

While analogies can be over used, and sometimes simply contrived, they are a powerful way of changing the lens in which you see your own, or others, work. An example used at the conference was the instagram filter or facebook bias. When implementing change or delivering a project there are many things that happen that don’t go to plan or go disastrously wrong. These are often essential to the projects and are an important area of learning but like the blood and meconium staining of the freshly delivered baby they are often not the pictures the wider world see. We have a tendency to share the end product and its success, not the tears of frustration in the middle.

Educate

The audience probably should leave feeling they have new knowledge to apply. They don’t have to remember all the detail (a skill in the digital age is for presenters to provide sources of information for delegates to refer post event) but should leave feeling there is something in their practice they could change. For example the session on medical simulation provided a whole host of new techniques and approaches to try:

Experiment

Put a speaker on a stage and let them talk.

While centuries of pedagogical practice are unlikely to change any time soon, there are other things that can be done at conference. The conference team experimented with an on-stage panel, led by a chair, who performed a review of 4 recent papers. As a panel member I really enjoyed the debate and it was nice seeing how the spontaneous nature of the session allowed unexpected variations in practice to emerge. I’ll be honest and say I think there is work to be done on how we can prepare and engage the audience more effectively. But you don’t know these things until you try. I hope the audience will constructively support, with their feedback, improvements and will be willing to try new presentation formats in the future.

Utilise a range of subject experts

In the case of this conference it was the use of children themselves. This is a potentially risky strategy but was handled with sensitivity and extensive parent engagement. As Liz Crowe highlighted in a lecture during the conference we are sheltering children too much from the real world, and as parents, too often make decision for them rather than with them. The use of patients is not without problems but led by #MedX, patient and public involvement in medical conferences will become increasingly common.

Provide a safe platform for difficult conversations

Some of the themes at DFTB17 were honest, raw and personal. Although it wasn’t explicitly acknowledged a culture was definitely present to allow a space for these difficult subjects to be discussed. There are very few medical specialties where ethics, morals or communication are not a fundamental part of clinical practice so facilitating this space should be considered at all events.

Allow people to laugh and cry

Related to the above is the importance of bringing the audience with you and extracting an emotional response from them. While 20 sessions of comedy followed by 20 tear jerkers is probably a bit much there is something powerful about shared emotion, both with the presenter but also with your fellow delegates. If nothing else I left #DFTB17 feeling part of a community, many of whom I didn’t get a chance to speak to, but with whom I felt I had a shared experience.

Listen, acknowledge (and respond where appropriate) to feedback in realtime

The organizing team sent out online feedback forms after each day. Obviously only a certain percentage of delegates responded but the team (having previously vowed not to look at them during the event!) were able to pick up immediate issues. They made themselves open and approachable and used twitter feeds effectively to respond to real time issues of capacity in break out sessions.

So thank you to the team. I look forward to #DFTB18 and perhaps a more complete recipe for the instructions.

What have you learnt this week? #WILTW

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What would you tell your younger self? #WILTW

This is the 171st #WILTW

Radio 4 Women’s hour ran a show recently on what you would tell your younger self. 

Thanks to Nish Manek for tagging me into the thread. My initial response avoided the question.

But it was a very honest response. My younger self would be appalled at how boring I have become!

I am pretty sure my younger self wouldn’t really listen to what my older self had to say. I remember all the life advice I was given by the regulars in the pub I worked in during my gap year. It all seemed a little irrelevant at the time but actually some of it would have been very helpful to follow!

via http://livingcivil.com/

What would I (try and) say:

  1. Don’t be the person you think other people want you to be. Facades can be maintained, but only for so long. You have to learn to accept yourself for who you actually are.
  2. Be loyal to those who are loyal to you. The strength of some friendships is inversely proportional to the amount of time you actually see each other.
  3. Life does not go according to plan. You will make mistakes and you will have regrets. The biggest cliche, and hardest truth  of life, is that you will rise and fall in your response to these events rather than the events themselves.

What have you learnt this week? #WILTW

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F.E.V.E.R #WILTW

This is the 170th #WILTW

As a result of a recent twitter mediated discussion (and resulting project), along with an influx of new doctors into our Children’s Emergency Department, I’ve had cause to dwell on ‘fever‘. Having been asked to solidify the key practice points to consider when managing the child with a raised temperature I couldn’t resist the opportunity to formalise an appropriate mnemonic.

Focus

The challenge with fever is that both professionals, and parents, forget that fever is a body’s response to an infection, not the infection’s response to the body. A fever, apart from in infants less than 3 months old or lasting longer than 5 days, is essentially irrelevant. You are worried about the cause of the infection not the fever.  Fever often causes distress, which you should treat, but in, and of itself, isn’t really an issue. This can be a difficult to comprehend but should focus your attention on the really key issues. Could this child have sepsis and is there an investigation or intervention I need to perform? This is only determined by a thorough..

Examination

There is a two fold process here. The first to make a global assessment – is this child unwell? And the second to ensure you have ticked off potential sources with a thorough systems review. Make sure the child is undressed to look for relevant rashes and that an Ear, Nose and Throat examination has occurred. (Ear drums can appear red secondary to temperature induce vasodilation – this isn’t otitis media). A fundamental part of the  process is…

Verification

Forehead thermometers cause far more anxiety than they are worth and I think should be banned. Sadly, while not always cheap to purchase, an electronic or chemical dot thermometer in the axilla or infra-red tympanic thermometer are the only devices that should be used. Parental concern should always be considered valid (see later) but this involves exploring with them why they thought there was a temperature not just accepting there must have been one. Once a source has been found there is always an opportunity for…

Education

A fundamental part of all emergency care consultations with children and young people, and especially those which concern fever, should be safety net advice. This process allows for education, not just for the current illness episode, but for future episodes as well. The core construct of safety net advice is to explain what the parents should expect to happen if your diagnosis is correct and what they need to seek further help for if the situation should change. Personally I aim to ensure the parents understand I’m far more concerned about the behaviour of their child than the temperature they have. It’s also important to de-mystify appropriate use of anti-pyretics, namely paracetamol and ibuprofen do not need to be given together. Families should not leave consultations thinking fever on its own is causing harm. Having said this it is important to…

Respect

The nature of illness. You don’t need to respect fever, you do need to respect its cause.

The concerns of parents. Judging parents for having fever phobia is a sure fire way to get burnt. While the outward manifestation of concern may appear to be the fever, active listening may reveal other far more dangerous symptoms the parents may not be as concerned about.

What have you learnt this week? #WILTW

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Feel the fear #WILTW

This is the 169th #WILTW

Luke has just started a new job in the Emergency Department. As a foundation trainee he is at the beginning of his medical career. Enthusiastic and conscientious at medical school, he’d spent 5 years excitedly waiting for the moment he’d be able to call himself a doctor. His training in lectures, workshops, simulations and on the wards has prepared him to manage a variety of presentations and conditions. This morning he’d woken up with a spring in his step, inwardly chuffed that he’d be able to relate the same stories he’d seen on ‘24 hours in A&E‘. He picks up the notes for the next patient. It’s a screaming four-year-old, with an arm the triage nurse has described as ‘bendy’.

The colour drains from his face…. 

Alice is a four-year-old girl. She’d been playing in the local park and was very chuffed with herself that she’d scrambled up all the steps on the boat-shaped climbing frame. Mummy didn’t normally let her do this but she’d been talking with Sasha’s mummy and wasn’t watching. Alice thought it would be fun to try and swing around in a big circle on one of the metal poles (like she’d seen her older brother do). She slipped and fell onto the hard ground below.

Her arm hurt a lot. Mummy was very upset which worried Alice as she’d never see her like this before. Lots of people had come running over. She’d been carried into a car. Her arm still really hurt. They’d gone to a strange building where there were lots of other children. A person dressed in blue had looked at her arm and given her a funny look. Alice didn’t like that. She’d been taken into a little room with bright lights. Mummy was on the phone and still crying. Alice’s arm hurt a lot. She could hear lots of other children crying.

Alice started crying too. 

Who is the more scared? Alice or Luke? 

The first week of August is a scary time for our new doctors. Despite what the media might say it’s not a dangerous time for patients and shouldn’t be a frightening one. But there is often a sense of trepidation in those joining departments for the first time about what they might experience.

This fear is good. It keeps you alert and insightful. It will stop you making mistakes. But it must be acknowledged. For a child who is scared, experiencing your fear as well is not helpful!

Be cognisant of how you appear. Remember children have a different view of the world (click here if video doesn’t play).

Concentrate on the parents at first to begin with if that helps. As calm as they are is as calm as the child will be.

But above all remember the child or young person, adolescents get frightened too, will likely be more scared than you.

Take a deep breath – feel your fear – so you can deal with your patients’ fear.

What have you learnt this week? #WILTW

Related #WILTW: A parents view of the world is also knee high

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Close to certainty and far from agreement #WILTW

This is the 168th #WILTW

An entire generation’s knowledge of  chaos theory was based on a short clip in a Hollywood blockbuster (click here if video doesn’t play)

Some mathematicians have been relatively generous of this description although I suspect others view it in the same way marine biologists observe that clown fish are now called Nemo fish. What was being described was probably more akin to a complex adaptive system, a term which is being used increasingly frequently to describe healthcare environments. Thinking around complexity challenges the assumptions [1] that

  • Every observed effect has an observable
    cause
  • Even the most complicated things can be
    understood by breaking down the whole into
    pieces and analysing it
  • That if we analyse past events sufficiently, this
    will help to predict future events.

The final point merges into Black Swan theory but is also a cause of a great deal of tension between commissioners, policy-makers and providers of healthcare services. These challenges are encapsulated in the Stacey Matrix

Complexity Matrix (Stacey 2007)

The Stacey Matrix is a management tool designed to help guide the approach to a particular challenge. Just the insight that there are relationships between the certainty of outcomes following an intervention and agreement about what that intervention should be may be helpful. For example if the solution is obvious and all parties agree on it, the intervention is self-evident. Groups also may be agreed on what to do but no-one is certain on what the results may be. All too often there is little agreement on a path forward, even when the problem is very discrete and objective (close to certainty and far from agreement) .

These issues apply at micro (doctor-patient) and macro (health services-public) level. The former described by the treatment of a large inguinal hernia (likely to be agreement between doctor and patient that intervention is required) and the latter by the recent debate about the treatment of Charlie Gard.

There is nothing intrinsically clever about the way the matrix classifies complexity. However it is clear that it is often not recognised that systems are complex and so dis-agreements escalate. The below a list of interventions to improve flow in Emergency Departments.

Those who work in Emergency Care are likely to feel this is ‘close to certainty’ in terms of its impact and are often surprised at the ‘lack of agreement’ around its implementation. I offer no solution to this impasse other than an insightful response to this complex problem.

What have you learnt this week? #WILTW

(Thanks to Dr. Ben Teasdale for sharing the Stacey Matrix this week)

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Further Reading:

Complex Consultations and the edge of chaos

Lessons from Jurassic Park: Patients as complex adaptive systems

[1] Taken from Complex Adaptive Systems by the Health Foundation