This is the 53rd #WILTW

This week I spent time at two conferences with a theme of spotting ‘sickness’ in patients. The first was the Rapid Responses Conference, dedicated to developing new systems to identify deteriorating patients in hospital, and the second Sepsis Unplugged highlighting the importance of recognising sepsis.

There is a challenge of being able to decide which patients, child or adult, need further investigation and treatment, and which don’t. In the Rapid Reponse Conference (#METConf15) Paediatric Early Warning Systems (PEWS) were an area of discussion.

The challenge of amalgamating these issues can be summarised by pic.twitter.com/8fr5fA8i48#metconf2015

— Damian Roland (@Damian_Roland) May 18, 2015

Throughout the world parents bring their children to Emergency Departments with a variety of illnesses and injuries. In the majority of cases advice or simple treatments can be given and the family can be discharged. In some the child is so unwell urgent intervention is needed and the patient will be admitted for ongoing assessment. The challenge comes in the group where the decisions are not clear cut i.e there is not an obvious infection or the source of the illness is not clear. Quite rightly junior medical and nursing staff, having been trained not to miss the sick child, will admit these infants or children to a paediatric admssions unit or ward for further observation. Furthermore there are a number of protocols and national guidance supporting this approach. A recent paper in pediatrics published this week should give all health services pause for thought though.

The study used data from six academic hospitals in the United States. The results may not be directly applicable to the UK but trends between the two countries are often very similar. The work highlighted 40 ‘harms’ for every 100 patients admitted. Harm in the study was defined as an

“unintended physical injury (resulting from or contributed to) by medical care that required additional monitoring, treatment, or hospitalization, or that resulted in death.” (Adverse Events in Hospitals: Methods for Indentifying Events”

Harm is not an infrequent event in hospitals. There then becomes an uncomfortable consequence of admitting a patient ‘just’ because you can. The risk of potential for harm in hospital maybe greater than the risk of harm occuring because they weren’t admitted i.e. you are making the situation worse rather than better. There are many other reasons of course why unncessary admission results in a poor experience. Parents don’t want their children to be admitted to hospital but this is more than just simply not wanting to see their loved ones unwell. There are not inconsiderable social and financial implications to missing work or providing child care if you are in hospital.

A great deal of time is spent on spotting the sick child. This is something we remain poor at doing. The harrowing story from Sam Morrish’s mother at Sepsis Unplugged highlights how we need to considerably improve our communication and understanding of parental concern. But this comes with a secondary challenge. We can not, and should not, put more children into a healthcare system which is overburdened and continually stressed. We need to be able to determine which children are safe to go home and I would argue being mindful of this challenge will improve the recognistion of serious illness in children, not diminish it.

I will always contend that observation is the bed-rock of paediatric practice. This paper does not change my views on that.  I am also mindful of the #FOAMed communities large number of resources on highighting key conditions with the sub-text: “you don’t want to miss this!” I now find a reponsibility to deliver materials that encourage “you don’t want to admit this”. Certainly I am inspired to improve our recognition of the most sick, and most well, with even more fervour.

What have you learnt this week? #WILTW

This is the 52nd #WILTW

Nearly every evening when I tuck my eldest daughter into bed the following happens:

Me: So what did you learn at school today?

Isla: [thinks, screws up face, looks blank]

Me: Did you do reading? maths?

Isla: [looks bored]

Me: Did you do anything in school?

Isla: [laughs]

Isla: Daddy?

Me: Yes

Isla: Can I put my Elsa dress on?

Isla definitely is learning things. Even with the grommets, being the youngest in the class and the simple fact that her parents are probably over anxious it’s clear that Isla does digest what she learns at school and applies it to every day life. Whether she, now in her second year at school and not yet 6, has any idea that she is learning is not clear though.

A year ago I set on on a task to record my ‘learning’ from the previous week. It was a simple experiment that I tried for a few weeks and realised it was possible to achieve from a practical “time-based” point of view. I then set myself a non-publicised target of reaching a year’s worth of postings. It’s been an interesting jouney, one in which others have shared but not yet joined in. Apart from a splattering of initial first followers (thanks to @polythenia who does still use it) and a company who seem keen on copyrighting the phrase, promises of guest contributions have never materialised.

To be fair though the blog is about my learning and reflection and unlike a Sunday magazine correspondent I am not writing to entertain. I am (and should be) writing for myself. This does make it a little hit or miss in terms of content. A side effect of this blog has been the concealed, and sometimes blunt, honesty from those who think I have written utter rubbish. I concede early posts and some of my more flamboyant analogies don’t really represent true learning.

But what is true learning? This is has been a real challenge for me as I reflect on a year’s reflections. Without a shadow of doubt the fact that I find time (usually on a Friday) to sit and consider the previous week does me a world of good. Irrespective of what I do or don’t write the mindfulness of the moment enables me to take stock of what I am doing in a way that I would not have done if I wasn’t writing this blog. People forever promise themselves time without actually taking it. The real tipping point was when a couple of people said they looked forward to #WILTW. While the blog isn’t written for others the expectation of an output has solidified the need to find the time to reflect and write it.

Sometimes writing #WILTW is really difficult though. I can’t think of anything I’ve learnt. But I can almost always think of things I should have done. I have come close on many occassions to writing: Why didn’t I do that this week?

I have been a consultant for a year now. It is inconceivable that I haven’t learnt things. But perhaps like my daughter I don’t see learning at the time. It is only by looking back you can see where you have come from. I do now have a tangible record of events to make sure that I’m not repeating the same mistakes. #WILTW will continue – a way of finding space to think in an increasingly crowded world. When and where true learning occurs though will be something I continue to look out for.

Now – where is that Elsa dress?

What did you learn this week #WILTW

This is the 51st #WILTW

Last year Prof. Meirion Thomas wrote an article entitled “Why having so many women doctors is hurting the NHS“. It was not well received by the medical community and I wrote, with colleagues, this formal response. I had hoped that this demonstrated the absence of any prejudice I may have about gender equality. Having previously been heavily involved in the Royal College of Paediatrics of Child Health workforce and training strategies I also felt I had worked hard to redress any imbalances there may have been in the perception of women in the workplace. If you encounter situations where gender bias persists despite your efforts, it’s important to address them effectively. Seek legal advice before filing a discrimination complaint to ensure you understand your rights and the best course of action to take.

My specialty, Paediatrics, has a higher proportion of females than males in training and although surveys have demonstrated concerns with work-life balance, gender inequality is not an issue that has been particular prominent. That is not to say it is not an issue and concerns about equality, especially in academic medicine, persist.

However I was surprised to find myself in an uncomfortable situation this week:

@M_Lin @Brent_Thoma @BenAzan @Akutdok probably more representative of gender imbalance in medicine as a whole, not failure of @ALiEMteam

— Seth Trueger (@MDaware) May 3, 2015

I had kindly been invited by the Academic Life in Emergency Medicine team to write a piece on “How I work smarter“. This is a great series (and probably just as relevant to those outside of medicine to those in it!) asking people to discuss their little tricks and tips to be more productive and less stressed at work. Each author is asked to suggest another three people whose ideas they would like to see as part of the series. An observer on twitter noted that virtually all the men had chose men whereas the women had chosen an equal mix.

The raw data on how men and women invite each other to "How I work smarter" on @ALiEMteam. pic.twitter.com/iOAB19BUnF

— Katrin Hruska (@Akutdok) May 4, 2015

An uncomfortable truth? It is easy to fall into the trap of protesting too much but my first defence would be that two of the women I would have chosen had already done or were doing pieces. As was pointed out to me on twitter it is not about defending actions – this is simply a sequence of events that has occurred. The bigger question is what are we to make of it, and what should I do, if anything about it?

The easy thing to do is get into a debate about how the numbers of participants in this online community stack up to make this less about gender bias and more about raw statistics. This is probably not useful as

1) It’s not an easy thing to do to work out the proportions of men and women working in emergency and critical care at an international level.

2) It is also moving away from the question of why it might be that men are more likely to choose other men.

3) Finally the question then remains is this truly gender bias and reflective of in-work place attitudes and behaviours?

On reflection I did see the question through a ‘technology’ lens. In some ways I was expecting ‘app’ based solutions or suggestions to purchase clever little devices from the persons I recommended. If I am being brutally honest I do see ‘tech’ as a slightly more male area of interest. It’s quite uncomfortable revealing this as I can cite many female colleagues who use technology extremely efficiently and now many men who are still back in the 20th century.

But I do reveal a gender bias…..

What does that mean for me? Have I become a Prof. Thomas of the world? Do I wonder round the Emergency Department floor carrying a club and grunting (or does this view itself re-inforce a negative stereotype of men!) I sincerely hope not but the worst trap you can fall into is one of assumption. Being reminded of subtle biases in all areas of practice can only help you avoid them. I hope therefore I am more gender aware than gender biased.

What have you learnt this week? #WILTW

This is the 50th #WILTW

A year ago I became a consultant and I wrote a blog, the forerunner of #WILTW, entitled: “13 years of training and tomorrow it begins again“.

The post started:

The art of medicine was to be properly learned only from its practice and its exercise.
Thomas Sydenham

The year has gone incredible quickly, too fast in fact. The consultant I was going to be, the mistakes I wouldn’t make, the things I would definitely achieve have not come to pass. The over zealous interpretation of what you can change and deliver, I hope, is not unique to me but the desire to claw back time and revise strategies and approaches very real. One thing that has caught me a little by surprise is the extent to which non-technical clinical skills are so poorly utilised in healthcare and how challenging it is to deliver training in them. These are the clinical skills of communication, compassion and emotional intelligence. I am by no means perfect in any of these areas, far from it in fact, but I am overtly aware that the large majority of the issues that I come across as a consultant are as a result of health care professional’s sub-optimal understanding and utilisation of them. Last week’s post on listening and learning an example.

This was very much brought home to me during this week’s RCPCH ‘spring’ meeting. A national conference for Paediatricians, and increasingly Children’s nurses, to discuss research, health policy and current practice. It can be a mixed bag – certainly this year there was a greater acknowledgement of quality improvement and patient collaboration which was good to see. At the conference, Kath Evans, the NHS England lead for patient experience shared this video:

While I have fortunately not been directly involved in a similar case the video certainly makes you think about your own practices. What I am deliberating at the moment is how to ensure Jayme-Leigh’s experience does not happen in my own hospital, or anyone else’s for that matter. Sharing the video widely is one way of doing this but I am forced to reflect on my own medical training and am shocked to be unable to recall more than one lecture on patient experience. I suppose, given the nature of being a medical student, this doesn’t mean it didn’t happen but certainly the emphasis was on detecting disease not on the patients themselves.

The frantic pace of health care means it is very easy to let things drift. Have I really delivered anything in regard to improving patient experience in the last year? I am ashamed to say probably not but this video has given me new impetus to find ways of role-modelling, teaching and improving behaviours which will benefit the children and young people who visit our department. If the art of medicine is best learnt by its practice then we must find ways of making this learning apparent to health care professionals. I still have much to learn in this regard.

What did you learn this week? #WILTW

This is the 49th #WILTW

I met an inspirational couple this week who lost their son, Oscar, to a very rare complication of a viral infection. Oscar had come to hospital with a infection in his bone but at some stage during his illness caught rotavirus (a virus which commonly causes diarrhoea and vomiting in children). Unusually the virus spread to his brain and he was not able to recover from this.

During their time in hospital they both eloquently describe how they knew that there was something wrong with Oscar but felt no-one was really appreciating their concern. You hear this story all too often after tragedies, regardless of whether medical error has occurred. I have written previously on engaging parents in the identification of ill children and the great work Cincinnati’s children’s hospital have done on this. Their narrative really hit home as during a clinical shift earlier in the week I had been humbled by a mother’s comments to me, “Thank you for listening“. From my perspective that was the least I had done but for her the ‘medical’ interventions less relevant than the validation of concerns following numerous consultations.

A friend from the ASK SNIFF research group uses the term enacted criticism in the relationship between parents/carers and health care professionals which is described in this video.

One thing that stood out for me in talking to Oscar’s parents was Hannah’s comment, “isn’t there a difference between being unconscious and sleeping?” There certainly is but that difference may only be appreciated by someone who knows their child well or is very experienced. The term ‘lethargy’ is a ill-defined dangerous word. I will always review a child if someone describes them as lethargic. The divide between being tired and obtunded (a medical description of someone who is very unwell) is wide in principle but sometimes not so in practice.

There is then a double dilemma. The ability to listen well, by truly hearing what you are being told, but also have a common language, by using words which are understood by all. In a world of increasingly reliant on technology and protocol there will always remain the need to teach all health care professionals these simple, but vital, communication skills.

What have you learnt this week? #WILTW

Oscar’s parents have set up a charity Thinking of Oscar 

This is the 47th #WILTW

A week of annual leave and moving house (still no broadband!) has significantly reduced the amount of time I spend on Twitter.

https://twitter.com/hootsuite/status/568594700107706370

While the hierarchy of needs diagram is fun the last fortnight has enabled an honest look at my relationship with Twitter. I am keen to point out in lectures it is a form of social media, not the social media.  I find the use of different social mediums is very specific to the individual. What one person hates about one, is why another person really enjoys it.

Social Media consists of different beasts, each having their own potential strengths and weaknesses.

I’m focusing on Twitter as it is the medium I chiefly use and taking a step back has highlighted the following:

• I am guilty of sometimes being more concerned about my absence of involvement in twitter conversations rather than the twitter conversations themselves.
• I suffer from  ‘I need to say that first’ syndrome.
• Its real time nature sometimes makes me uncomfortable about responding or interacting for fear of being noticed of being online.

Some difficult truths which say more about me rather than Twitter itself. But what to do about these ‘complaints’? There is an additional paradigm which came to light in some revealing feedback I received which is Twitter users tend to support Twitter users. There is a potential overall inflation of quality, especially of lectures, if twitter is the only vehicle for comment. This partly stems from Twitter being an immersive, generally positive, but intermittently hostile, environment which doesn’t always reflect the real world. It is a bit of escapism, but in which you receive validation not present in other environments. My ‘complaints’ a reflection of my ego acknowledging its own faults perhaps and projecting them onto twitter? An uncomfortable conclusion so while I find Twitter immensely powerful the break has been useful. Commentaries on the adverse affects of social media are not new but as I experiment with #WILTW I am taking a gamble that this acknowledgement will be helpful perhaps not to me but others as well.

What did you learn this week? #WILTW

This is the 46th #WILTW

Moving home can be a stressful business. Although there are greater life-changing events, it isn’t often you uproot everything you own to a new location. This stress can be amplified when you’re dealing with long distance movers, even if that new location is less than a mile away.4o

Home (re)movers have a tough job. Early starts, late finishes, a lot of manual labour and the pressure of being in charge of others’ cherished possessions. There is also the added stress of some homes being brand new. When pristine carpets are at stake it just adds to the pressure. Ensuring proper drainage with seamless gutter services in North Wilkesboro can alleviate some of these concerns.

The day before our removal company came to us they were moving someone else’s family. At 8am the next day, they were moving another. All three families with large amounts of furniture, heavy white-goods and copious amounts of ‘stuff’ (a common byproduct of having children). A large amount of patience, enthusiasm and energy is required. But I suppose it is their job. They are paid to deliver a service which ensures that your goods are moved safely and you are happy with the way your possessions are handled. In order to achieve this the removal lead deployed some very familiar management techniques. He assembled regular tea breaks for the team. Not so many so it felt too frequent, but enough it became apparent what they were being used for. He regularly touched based with us, sometimes for no obvious reason. I think to get a feel for how we were ‘feeling’. There was a lot of joking amongst the team, I wonder sometimes at my expense, but there were definitely no long periods of team silence. Transform your space with the unique beauty of 1 of a Kind Live Edge Slabs, offering a distinctive and natural touch to any room.

I’d suggest leading with the intention of maintaining moral isn’t something that features on many curriculum. Simon Carley from St.Emlyn’s has previously highlighted it is subtleties like this that aspirant leaders need. And while I’ve been party to Prof. Tim Coats thoughts on Leading an Emergency Department the following are now my own humble additions.

• Your team need breaks. And you do to.
• Touch base with the patients you are treating. If only just to see how they are getting on.
• There are many sad moments in medicine. Respect these. But when appropriate have fun with your colleagues. Watch out for those who appear to be down in the dumps.

So while the removal process was stressful, it was better than it could have been….

What have you learnt this week? #WILTW

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This is the 45^th WILTW

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

https://twitter.com/lavery_gg/status/581461158969905152

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

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

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

What have you learnt this week #WILTW