This is the 89th #WILTW

This week we learned about the tragic death of William Mead, a young boy who had sepsis. His mother writes extremely powerfully in her blog  and I was struck by this quote she used in a posting in early January

“The days will always be brighter,
because you existed.
The nights will always be darker,
because you are gone.”

Last year I reflected on the case of Sam Morrish where again the system failed to adequately respond to ‘red flag’ signs and symptoms. I have heard Sam Morrish’s mother speak and it is humbling to listen to the eloquence with which she describes her concerns at the time and how we (the healthcare system) didn’t hear her.

It appears, although the full report into William’s death isn’t available at the time of writing, that in both cases there was a dissonance between the features of serious illness the children had and the response to them.

Sepsis is not a simple, or indeed, binary condition. To die of sepsis infers you have an infection in your body that has overwhelmed your bodies abilities to fight it. However a human’s response to infection is not predictable. The same two children could have exactly the same bug and while one might actually clear the infection by themselves the other may become critically unwell [1].

The vast majority of children presenting to their GPs, urgent care centres or emergency departments don’t need any treatment. That is not saying their presentation is not necessary, parental concern is a vital component of the diagnostic process that clinicians use, but unwell children generally have simple viral illnesses that self-resolve. There is though a cross over between some features of illness such as an increased heart rate, looking a little pale, feeling miserable that may be present with either a virus or sepsis i.e it is not the case a child with a virus only has some features of illness and a child with sepsis has different ones. To compound the problem there is evidence that having a virus may increase your risk of catching a more serious bug that could cause sepsis. This means you could present to your GP (Family Doctor) on one day and have a virus but in a couple of days become increasingly unwell and be seen in a hospital with sepsis. It may be that the GP did nothing wrong to send you home in the first instance.

This is why safety-netting is of vital importance. The delivery of information to patients, parents and carers that lets them now what to expect if the health care professional is right with their diagnosis and what to do if the situation changes. Many organisations including the UK Sepsis Trust, NICE, individual hospital trusts and academic groups are working hard at creating systems that ensure we recognise and respond to sepsis in a prompt and timely fashion to reduce the number of children dying from it each year.

There are things we can do now though to potentially turn Sepsis into a eucatastrophe; a term apparently first coined by J.R.R.Tolkien to describe a turn of events which saves someone from meeting a predictably nasty outcome.

1. Health care professionals instead of asking simply what’s wrong should enquire: “what are you particularly concerned about in your child“. The question is the same but there is an important inference on determining whether it is the behaviour of the child the parent is worried about or a symptom. Parents of child with serious illness often describe knowing their child just isn’t right.
2. Health care professionals need to consider sepsis in every encounter with an unwell child however minor the symptoms seem to be. Documentation of the features which make sepsis unlikely are important. The restricted rule-out method is a great way of doing this.
3. We need to be more confident at discharging children who are well. There is a dichotomy at present. In the same day the #NHS is under pressure to be hyper-vigilant for sepsis but reduce the number of children presenting to Emergency Departments or being admitted to paediatric wards. This can only be squared if we don’t overload the system with children who have no features of illness. Starting from tomorrow senior medical staff, whether GPs, Consultants or clinical commissioners need to ensure their staff are sepsis aware but also know the features supporting discharge and how to give good safety net advice.

There will always be children who succumb to sepsis regardless of what health care professionals do. However we must be sure that we can have a eucatastrophe in all cases where it is possible to do so.

What have you learnt this week? #WILTW

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[1] I appreciate this is an old paper. I would be grateful for more up to date versions as I couldn’t find any in my quick medline review.

This is the 88th #WILTW

Health care professionals values’ are usually pretty similar. However when it comes to their vision of how to improve services things can vary widely.

This dichotomy causes great challenges for health care organisations. Take a group of clinicians and ask them why we should treat condition ‘X’ well and you’ll get consensus. Ask the same group to agree on a guideline to treat ‘X’ and you will be there all day.

One of the challenges I face as a consultant in their early years’ of practice is not allowing practicality to get in the way of purpose. Experience brings with it a potential belief that the way you do things is the best way to do things. It is a fact of life that there will always be two different ways of doing things, and both will be ‘right’ in the eyes of those promoting them. Once entrenched, and this is where I sincerely hope reflection will always keep me open minded, it can be difficult to see another person’s view point.

This is no more evident than in the gun ownership debate as demonstrated in a medical education discussion group I am part of. The mostly American participants were discussing the responsibilities of the medical profession to promote gun safety. I’d suspected the debate would have centred around public health responsibilities but it quickly became apparent that some in the group are passionate advocates for very liberal gun control. The prospect of not having guns at home seemed abhorrent to some. While this is a view I can not understand, I’d believed, arrogantly as it appears, it was from an angry, poorly educated part of society. I was wrong. Adam Goplik, writing 3 years ago, described the underlying challenge well

Given how differently the same situation is viewed by different groups, and the incredulity with which they view each others positions, leads me to wonder if I have ever been on the ‘wrong’ side. Unfortunately that very reflection infers a value judgement that there is a right way. While different negotiation styles are clearly necessary to relieve severe impasses I think it is also beholden on all of us to think – Why does my vision of what is ‘right’ make your vision ‘wrong’?

What have you learnt this week? #WILTW

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This is the 87th #WILTW

Pain is an interesting phenomenon. Last weekend I aggravated an old, but not particularly serious, back injury. I  came into work on Monday and hobbled around the department feeling pretty stupid as intermittently the spasms would go away and I would be completely pain free. Not quite sure what my colleagues made of me.

It is very easy to be judgemental about pain. Even with no medical training the inconsistencies between reported pain, and its actual physical manifestation, are obvious to spot. Conversely I have yet to treat a child who has had a very serious limb fracture who even moans about it. They tend to be extremely quiet; the only sign of severe pain is their frightened face.

Despite the prevalence of pain we are still relatively information poor on how best to treat it, especially in children. There was a time when open heart surgery in neonates was performed with minimal anaesthetic.  Public health doctor and avid information sharer Ash Paul posted a link from the Canadian Institute of Health Research this week. Published in September it describes an initiative to improve awareness of pain management strategies in children.

(click here if the video doesn’t automatically appear)

The techniques described in the video should not be new to any health care professional who deals with children. Parents though aren’t always aware of some of the easy things that can be done. Distraction is a very powerful technique and rather than feeling and looking anxious it is helpful to the treating team for the parent to engage with their child. One of our play specialists reinforces this important role by saying to parents:

“As calm as you are, is as calm as she’ll be”

(or he obviously)

Anxiety about your child often promotes supra-rational responses. Not irrational because you are rightly worried about your child but often the profusely bleeding finger or the large bump to the head provoke near hysteria. Children are never helped by seeing their parents crying more than they are. “As calm as you are, is as calm as she’ll be” is sound advice.

It is also sound advice for health care professionals. No one likes someone who panics, especially in emergency care. In fact it is pretty sound advice generally. Start ranting at a meeting and it’s likely you will start getting other people raising their voices as well. Get frustrated with someone you are referring a patient to and they will get frustrated to.

As calm as you are, is as calm as they’ll be

What did you learn this week? #WILTW

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This is the 86th #WILTW

I delivered a workshop on Quality Improvement this week for our regional trainee leadership development programme. The background and links to it can be found here.

I start the session by exploring the participant’s experiences of good and bad care in the NHS. There is a sad recurring theme. A splattering of good experiences and a forest of hands for the bad. Minimal examples of poor clinical decision making or technical problems but lots of stories of long waits without explanation, having to push, push, push to find out answers and depressing tales of nonchalant and dismissive staff.  My observation is there has been little change over the two years I have been doing this.

We then move on to a definition of quality. I deliberately bias the group by discussing experiences first as I think this is an important reflection. We have a group discussion about what the group have suggested and then go on to review the Institute of Medicine’s Six Domains and the institute for Healthcare Improvement’s version of it:

One suggestion for a definition of quality was presented which I hadn’t had before:

“Quality is when something occurs that is better than you expected to happen”

There are many holes you can pick in this statement if you wish. But what I like about it is it explains those times when a family seem unduly grateful for the care you given them. It can be something very minor like checking on a patient you have admitted the day before, taking that extra 20-30s to comment on a game a child is playing with or providing a shoulder to cry on for the distressed parent. These are things that are normal ‘clinical’ tasks but may be perceived as being an unexpected addition to care by some.

When was the last time you felt you have experienced a quality service? Not necessarily in a healthcare setting, maybe a hotel visit or buying a car. What it really something that was above and beyond what should have happened? Or just that you didn’t expect that it to  happen in that environment…

Ultimately it poses a deeper challenge of if you have to think about delivering quality care, you are probably not delivering it. The best care is probably truly unconsciousness in you.

What have you learnt this week? #WILTW

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This is the 85th #WILTW

A new day, a new year. The archetypal period for reflection in many peoples lives. For #WILTW a chance to reflect on reflection even if this runs the risk of being a little twee.

My server tells me the following have been the most popular postings* of the year

5 Things specialties don’t understand about Ed

5 referral tips that won’t annoy a paediatrician

The signs of burnout

Not everyone knows how to hold a child

The impact of i-phones on doctor’s decision making

The original purpose of #WILTW was a record of my own learning though and a couple of posts stand out on reviewing the year. Aside from the blog on burnout, one of the posts I still muse on as being uncomfortable was that of the impact of missed diagnosis. The spectre of being a #secondvictim looms over everyone who works in emergency care. I was struck by my gut reaction of sympathy for the doctor involved in missing a case of serious illness in a child before empathy for the child themselves. It is a reminder to keep a patient focus in the real world of not being able to  achieve 100% perfection in our decision making.

Decision making was a common theme and I didn’t realise I essentially duplicated a post from June “Confirmation bias – the cousin of over confidence” only last week “Avoid a confirmation cock-up this Christmas“. I can only presume this represents the constant potential of this cognitive error on my practice rather than a failure to learn from it!

Finally there was a persistent subtext of trying to maintain enthusiasm and focus in the face of increasing demand on the health care system. My post on burnout touched a nerve with many and I have already made changes which I think have been beneficial to my own resilience. I aim for 2016 then, not to have new resolutions, but the resolve to continue to put into practice what I have learned.

What have you learnt this week (year!) #WILTW

• A number counter that works in powerpoint and Not just a ‘fever’ are non #WILTW blogs that are also in my top five most read postings

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This is the 84th #WILTW

This week Steve Harvey made a mistake. It was a pretty simple mistake.

He looked at a piece of paper to see who had a won a competition. He saw “1st”, saw a name next to it and so read out who he thought the winner was….

The problem was that he didn’t see “runner up” and his error took place in front of 10 million viewers.

In retrospect it is easy to judge and wonder how he made such an error? But confirmation bias, like other forms of cognitive bias, is a subtle beast. I suspect, although I don’t know, that he was expecting to see ‘winner’ or ‘1st’  on the card. While in the cold light of day it is easy to see that Miss Universe is in bold on the right side it is possible that he never moved past seeing ‘1st‘ on the left.

In this case only Miss Colombia’s dreams were broken. In healthcare the consequences of confirmation, and other, biases can be far more serious. There are many great summaries of cognitive biases – this from a business perspective is one of my favourites.

And the below video contains a talk from  Pat Croskerry – somewhat of a international guru on the subject.

So whenever, or wherever, you are working this holiday period don’t let the amount of chocolate you have eaten lower your threshold for a cognitive error. You want to eat the turkey rather than be one…

What have you learnt this week? #WILTW

Thanks to a couple of my colleagues for highlighting this #WILTW.

Have a great holiday period and see you in the new year!

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This is the 83rd #WILTW

If you are fan of space travel, astronauts or Prof. Brian Cox this week’s Star Gazing Live may have had you in more of a frenzy than the opening of Star Wars: The Force Awakens. Live footage of British Astronaut Tim Peake taking off towards, and then docking with, the International Space Station was pretty difficult to avoid. It was an exciting spectacle but what really peaked my interest was the level of detail and intensity of training that Tim has undergone.

By no means I am trying to make a direct comparison between spaceflight and medicine. Analogies between the safety culture of airline industry and healthcare can become tired and the environment, risks and variables are different. However two particular facets of astronaut training I think have direct relevance to health care professionals.

Time: Not the total length of training but the length of their training missions. As part of his instruction Tim undertook a six hour underwater exercise.

This was to practice laying cables on the international space station in conditions similar to outer space. It is interesting that although junior doctors do very long shifts, and are technically in ‘training’, we don’t, to my knowledge, run long complex simulation exercises over hours which are similar to actual shifts. High fidelity simulation excels at 30-60minute scenarios but these are then commonly followed by a debrief and a cup of coffee. Should we run prolonged, and tiring scenarios, with medical students and junior doctors to examine the impact of fatigue on performance and communication? Do we owe it to patients to have done this?

Repeated Critical Event Training: Spaceflight is very checklist orientated.  System failures are rare but they are very well practiced with a clear plan for all participants should they occur. Having just this week taught on an Advanced Paediatric Life Support course I am very aware of the clear algorithms that exist for treating children (and adults) with critical illness and injury. The application of this guidance is variable, in part, because teams of health care professionals come together having never worked together before. Analogies here are challenging as the three astronauts who have just arrived at the international space centre practiced, again and again, knowing they will be working with each other, again and again, for the next six months. It begs the question though how much effort we should put into ensuring that teams work together repeatedly in simulations. In practice this would come with huge resource implications but is this not worth the potentially better outcomes? Locally we work extremely hard to run regular in-situ simulations but we’re not yet at a stage of having regular inter-specialty simulations that ensure all teams are comprised of members who have worked with each other before.

Flying into space is not the same a treating a two year old with severe meningococcal septicaemia. Yet our investment into the training of the professionals involved in both is vital to safe outcomes: whether you are on the moon or in the resuscitation room.

What have you learnt this week? #WILTW

(Do you have what it takes to be an astronaut – click here to find out!)

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This is the 82nd #WILTW

Hugh Pym, the BBC’s Health editor, wrote this week on “The NHS in Winter – an alphabet soup of stats” . The article explores the reasons behind publishing the national Accident & Emergency 4 hour target results monthly instead of weekly. There are pragmatic, and cynical, explanations with incongruous data on waiting times rates only confusing the current picture. What caught my attention was the penultimate paragraph

“..Twas ever thus and the NHS has got through previous winters despite forecasts of doom and gloom..”

It is a potentially dangerous precedent to rely on the fact that we’ve done it before so we will do it again. Conversely it is testament to the hard work and perseverance of NHS staff that despite steadily increasing demand the whole system hasn’t completely collapsed. There is a point where it becomes too easy to eulogise about the ‘spirit’ of the NHS; as if it is just the dedication of staff that keeps the whole thing afloat. I’d argue though there is sense of fraternity, especially in acute and emergency specialities, that is synergistic in bringing the best out of people.

This was clearly apparent at our Emergency Department Christmas party. The event itself probably no different than any of the other festive events occurring up and down the country. But there was a spirit that was weaving its way through everyone there.

It is the spirit which provides energy through a simple knowing look when the queue of patients to be triaged doubles. It is the spirit that provides resolve when a doctor and nurse go together to break bad news. It is the spirit that acknowledges gallows humour, not as demeaning to patients, but as a way to deal with the shared pain of some of life’s tragedies. It is a spirit that says, “I’ve got your back, because you’ve got mine.”

I’m not sure how long the NHS spirit will keep us afloat. But for the moment it is very much alive and kicking.

What have you learnt this week? #WILTW

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This is the 81st #WILTW

Winter pressures are right on top of emergency and urgent care services at present with hospitals and community practices throughout the UK  experiencing high demand and high acuity in a system that is already working at capacity.  Clearly maintaining patient safety in this stressed system is vitally important. I chanced upon an interesting view point from Charles Vincent in a Health Foundation blog this week:

“Very few safety strategies are aimed at managing risk in the often complex and adverse daily working conditions of health care”

He argues that current strategies are often designed in ideal environments working in optimum conditions and explores the need to identify and respond to risk in the ‘real world’.

This struck a chord as often health care providers develop specific escalation polices for adverse times only during, or after, these events have taken place. This, on reflection, is a little binary. The ‘real’ world isn’t split between normal practice vs extreme events.  While we might aim to grade our response to avoid this dichotomy (in terms of when to contact seniors, where to re-direct flow and who to move into different areas etc.)  the ‘real’ world is a variable and dynamic place.

Furthermore Vincent argued that sometimes the actions clinicians and managers take to avoid risk are not always seen under the umbrella of patient safety (and vice-versa). To explore some of the differences the Health Foundation have created a checklist for safety solutions. While it is not immediately obvious how some of the points are directly applicable to a winter crisis the checklist is food for thought in looking at risk and improving safety in any situation.

What have you learnt this week? #WILTW