Category Archives: #WILTW

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Peri-Shift Mindfulness #WILTW

This is the 179th #WILTW

Mindfulness, compassion and burnout

Three words which have only recently become accepted as legitimate terminology in medicine.

We need to work towards tighter universal definitions to ensure the terms are not mis-used, or become consigned to leadership “buzz-word bingo” status. There is something inherent in the word ‘burnout’ that implies the driving factor is the individual themselves. While clearly some people could improve their own coping strategies or mindsets, it shouldn’t be a process where resilience (itself a term that implies some may be weaker than others) is the sole responsibility of the individual.  It’s good to see organisations are already introducing initiatives to help staff, and one might hope that there is a shared strategy between individuals, departments and hospitals in the future.

One of things I’ve become increasingly conscious of is “of the moment‘ personal awareness.

Clearly long term strategies to ensure that you remain healthy and engaged in work are vital. However the concept that an individual shift can challenge your resolve is familiar to all, regardless of speciality or profession. As winter arrives I realise there are a number of approaches to consider (acknowledging very easy to promote “do as I say not as I do” thinking)

Pre-Shift Preparation

I aim to have a quiet ‘period’ 15 minutes before the beginning of any clinical shift. Trying to avoid last minute e-mail replies or phone calls stops you coming on shift distracted about events you then can’t control or respond to. The ideal is listening to music (easier when driving into work on a late shift) as this tends to clear my head. The team at St. Emlyn’s have suggested some tracks to listen to.

In-Shift Awareness

This is the most difficult to prepare for as the more challenging the clinical environment becomes, the more it feels you are less able to take care of yourself when it in fact is increasingly important that you do so. Even 5 minutes of head space is vital if you have been constantly focused for a prolonged period.

Take other’s hints about this, if someone asks you (especially the nurse in charge) whether you have had something to eat or drink, it’s not just your stomach they are inquiring about. They may well be noticing your behaviour is changing and giving you a gentle nudge.

Another important insight is knowing the difference between when you are truly processing information and when you are procrastinating. The former is the natural passage of time used to maximise available information and determine treatment plans appropriate to the patient’s trajectory of illness. The latter is not acknowledging either cognitive overload or tiredness (both normal issue regardless of your experience) and delaying inevitable interventions as you work out what to do.

Post-Shift Practices

Your reflections on your shift will have consequences for your attitude to future shifts. An emotionally demanding shift will will be remembered more negatively  if you finish late and are rushing home or to another appointment. The stress that this causes combines with the stress of the shift. This isn’t the easiest thing to counter-act but it’s important to separate the two. One may cause the other obviously but the resultant emotional impact it has on you is multifaceted and needs to be acknowledged as such.

Cold debrief with a hot drink (a chat with a colleague over coffee in the canteen days afterwards) may alter your internal perceptions about what went wrong or was frustrating to you. This is vital to avoid long term build up of resentment about a particular situation.

I am sure there are other things that are important to consider, react to or reflect on. The key is awareness of your own awareness as it were…

What have you learnt this week? #WILTW

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Resuscitation Communication: Text or Twitter? #WILTW

This is the 178th #WILTW

One of the joys of being involved in our simulation programme is the constant stimulus to improve your own practice, especially in the grey area of leadership and communication

The critically ill child poses a logistical dilemma. There are various body systems that simultaneously need attention: the airway, the circulation, the neurological system etc. Life threatening illness is unstable and this means those systems may respond to treatment, or they might not. Either way it is possible they may require further intervention at a future point. The systems also interact with each other; sometimes in series (only by tacking one problem can you solve another) and sometimes in parallel (simultaneous collapse requiring completely different management approaches).

Imagine different members of staff, both medical and nursing, needing to interact with each other in a co-ordinated fashion, delivering medications which are dose dependant (you need to make sure you give the right amount or the patient will come to harm) but also time critical (take too long drawing them up and the patient will come to harm).

The ability to orchestrate a team around a child is an art. There are some skills you can be introduced to, and some common approaches to take, but when the manure hits the proverbial fan, especially if you are working with people you may have never met before, there is not a textbook to rely on.

Ensuring the patient is receiving enough oxygen,

and that they are breathing effectively,

and that someone is drawing up some fluids while someone else is drawing up some antibiotics,

and that you’ve not missed the fact they are low on glucose,

and that you can’t hear yourself think because a monitor is alerting you to the fact that the heart rate is dangerously low

and that two phones are ringing to let you know that the CT scan is ready but that theatre won’t be ready just yet,

and someone curses because they’ve not been able to get a cannula into the child for the third time,

And then you realise you’ve not even updated a terrified parent let alone your team.

Experience brings with it the ability to determine courses of action swiftly, delegate tasks effectively and decisively communicate multiple instructions without needing to raise your voice. But there are still times when you wish time would just stop and you could Matrix style weave yourself through the scene checking each system in sequence and collating information in a non hurried fashion.

Via http://resus.me/learning-to-speak-resuscitese/

There is no one best way to manage the communication cascades that develop but there definitely patterns that emerge and as a thought experiment the digital era has offered us some comparisons..

For real control you could adopt a text messaging approach with each individual submitting questions and receiving answers only from you. This  means no mixed messages and would make sure people don’t get overloaded with tasks i.e. deliver blood transfusion before sending/receiving next message. The problem is that the team leader is left with a list of messages to answer and the rest of the team don’t know what has and hasn’t been actioned.

Straight line communication can only be seen by those at the ends of the line

It might be that e-mail would facilitate more than one individual knowing what was happening at any given time. A reply to all function would allow everyone to see the questions and the answer. Email makes it difficult to scroll through though conversations quickly though..

Arrows indicating these communications can be seen by all participants

Conversely a WhatsApp communication channel would keep everyone up to speed in a visually accessible way and allow team members to delegate tasks amongst themselves. However leadership of a this group would be challenging especially with messages flying in every direction…

All communications can be seen by all participants.

You could try a Twitter approach with the team members only allowed to follow the team leader and not each other, using #patient to allow for global updates. This would enable short pithy communications but runs the risk of errors when complex decisions are required.

Arrows indicate communications seen by all, Straight lines only by those at the end of the lines.

While clearly we are not about to see teams, face down, looking at their phones during resuscitations, the analogy demonstrates the complexity of communication management required.

What have you learnt this week? #WILTW

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#helloyournameis Mum? #WILTW

This is the 177th #WILTW

Future generations of healthcare professionals may well look back at the #hellomynameis campaign and wonder why anyone would need reminding to introduce themselves. Having had over 1,500 million impressions, and 80,000 contributors through twitter alone, it clearly is an important topic.

In the same way I probably make about 80% of my management decisions within 15s of walking into the cubicle (child’s appearance, combined with clues from monitoring devices and body language of parents) it is very likely children, parents and carers make similar rapid judgements of my professionalism and skill as a doctor. Clearly if you fail to introduce yourself then you have already started off on the wrong foot.

via http://blog.sfgate.com/sfmoms/2014/05/16/most-ridiculous-baby-names-from-2013/

Interestingly research highlighted in this week’s Bubble Wrap (please do follow this monthly journal round up!) examined parental preferences of greetings by medical staff. 137 parents were sent a questionnaire to determine what clinical staff had previously called them and what they would like to be called. Nearly 80% recalled being called Mum or Dad. The authors made the odd decision to not have “my own name” in a list of what parents would like to be called but from the remaining options it appears parents would prefer to be called Mum or Dad (as opposed to Mummy or Daddy). Personally, calling anyone Mummy or Daddy would make me very uncomfortable, so I am glad this didn’t emerge as a winning salutation!

Hidden behind the etiquette of how someone should be addressed is the even more important point of who the person actually is. Regardless of how often you are told at medical school, you only truly learn to definitely establish who is Mum and Dad when you have assumed that someone else is. The outcome of this error ranges from embarrassment to a potential safe-guarding issue. While the simplest way round this is to just ask; there are more subtle ways as well:

Would love to hear from parents and carers about what they would prefer to be called!

What have you learnt this week? #WILTW

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Tighten up your safety net #WILTW

This is the 176th #WILTW

Assume = to make an ‘ass’ out of ‘u’ and ‘me’.

Assumption is my enemy.

I can’t assume in a hectic resuscitation that an instruction has been heard unless it is confirmed back to me. I can’t assume relevant clinical signs have been identified when a patient is discussed with me and I can’t assume I always make the right diagnosis.

A further challenge when you become an autonomous practitioner is that it’s much more difficult to determine how your colleagues practice. The assumption is you do things in a similar way but you never really know this. It’s part of the reason why I enjoy immersing myself in Social Media. It’s a great way of determining and sense-checking what other people do.

Safety-netting, the provision of information to help patients or carers identify the need to consult a healthcare professional if a health concern arises or changes, is an important intervention where there are probably many different ways of saying the same thing.

https://www.pinterest.co.uk/pin/427560558347927388/

The assumption is that there is a common approach but recent conversations lead me to believe this may not be the case. If only to start a debate, I’ve determined the 5 principles I use to structure my safety netting advice.

Avoid enacted criticism – Your advice is about the future trajectory of illness not implying what the parents or carers could have done to have avoided seeing you in the first place.

Establish the process of making a diagnosis is a partnership – This is what you have told me and this is how I have interpreted it, so this is the suggestion for what we are going to do. I often quote a comment a parent/carer has made about their child’s illness. This demonstrates I have been listening and am interested in addressing concerns. This phase is important as this sets the scene for the key component of safety net advice..

Explain the natural history of the disease process if your diagnosis is correct – one of the worst things to do is suggest that typical symptoms of the illness you have diagnosed could be worrying. A child with gastroenteritis will vomit and have diarrhoea.

If he vomits bring him back” is NOT safety net advice.

“…your little guy is likely to continue to have vomitting and diarrhoea. If he remains well in himself, is drinking the amount of fluid we have discussed and is having wet nappies then he is unlikely to become dehydrated” is more useful.

Explain what the features of illness will be if your diagnosis is incorrect or the disease process worsens – I am very clear to parents  that 24 hours is a long time in a small child’s life, the decision to discharge is based on the features of illness now. These may change.

Openly ensure shared understanding. I directly ask if the parents or carers are happy with the decision that is being made. It is rare to be caught out at this stage, but I still find some clinicians seem unable to read parental body language, so I always suggest my juniors do this.

I don’t assume that this is a perfect approach, and certainly there will be individual nuances at a patient level. Would love to hear from others about their approaches.

What have you learn this week? #WILTW

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Can you “over-reach” your care? #WILTW

This is the 175th #WILTW

The concept of ‘in-reach’ is an inflammatory nidus of debate between hospital teams. If a patient is admitted from an Emergency Department, but no ward bed is available for them, who is responsible for their care? Is it the Emergency Department, as they have initially assessed the patient and will be their physical ‘home’, or the accepting team as they have specialist skills and oversight for the pathway of care needed?

We can’t do our job if we are looking after your patients as well!” is an argument used by both sides. And as Emergency Department crowding increases, from poor flow through a hospital unable to discharge patients at the rate they are admitted, the tension surrounding “in-reach” increases.

In the UK, emergency medicine is based around providing the first 4 hours of care. This is a wide range of activity from providing critical interventions (management of cardiac arrest) to the simplest of advice (re-direction to a dentist). The aim is to sift and sort, from a large group of undifferentiated patients, those who can safely go home and admit those who require ongoing care.  For the latter group, regardless of capacity, the process is initially theoretical (the patient is ‘admitted’) rather than physical (the patient is still in the ‘Emergency Department’). This exposes another issue, that of ‘over-reach’

Emergency Medicine as a specialty excels at “prompt differentiation and initial treatment of the unwell” in the same way that cardiac surgeons excel at operating on hearts and dermatologists excel at managing skin conditions. By definition though it is just the early phases of treatment and interventions, so direct patient contact, the art of medicine, is therefore often time limited. Occasionally I miss the ongoing relationship you develop with patients and their families if you work in hospital and community based specialties. While I often follow up patients on wards you don’t develop a sustained relationship with them in the same way as in-patient teams do. To compensate for this an occasional ‘stay and play’ mentality develops, co-rdinating the second phase of treatments within the Emergency Department.  This may be essential if hospital teams are unable to attend the patient themselves but may occur just because I can, rather than I need to.

It is easy to understand why the public and patients would be confused by over-reach. What is the problem with doing this? Isn’t this just good medical practice?

Over-reach in itself reduces the need for in-reach. This promotes behaviour and cultures which may not be beneficial for either ‘side’. Certainly it is vital I don’t over-reach for one patient at the detriment of others. Also as a specialist who merges skills (Paediatric & Emergency) I need to balance the delivery of both.

Do you need to be delivering the care you are giving? This is a question often asked of evidence based practice – are you giving the most effective treatment? However there is a efficiency and equitably component as well. Because you can be delivering something, does it mean you should be?

What have you learnt this week? #WILTW

[Thanks to those at this week’s consultant meeting for inspiring this blog]

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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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