This is the 35th #WILTW

At my recent appraisal I was constructively challenged about #WILTW

“It’s a pretty unique method of reflection but does it really need to be public?”

It is definitely a fair question. Not everything that I can reflect on can be published online and there is no real inherent value in sharing them. I explained the very process of having to think through a regular blog is extremely helpful to me for making sense of, what can often be, very chaotic weeks. The fact that not everything I learnt can be reflected on is irrelevant as I still take time reflecting on those events. In fact, I argue more so, as I have to make value judgements not only on what I have learnt, but what value it has had to me and whether it is appropriate to share with others i.e. the time spent contemplating what the key learning is; is valuable in itself.

I did add that the sharing of #WILTW sometimes prompts learning and its sharing in others. And so was nice to see the response to last weeks piece:

@Damian_Roland Another nice example of The 3Cs of Communucation (cite names, clear instruction, close the loop).http://t.co/3FehM78yfN

— Pro Mukherjee (@ProMukherjee) January 16, 2015

Pro and I must have some obsession with C’s (Pro and I have a vodcast on “coffee and compassion” and I have blogs on the 6Cs of creating FOAM and the 6Cs of rhizomy  [written with Daniel Cabrera])

What this tweet highlights is that communication is critical in Emergency Care. It is also very difficult to do consistently well. Conversing and interacting with patients is clearly one aspect of your job. But working with colleagues is another.  Over time you learn the best methods of communicating effectively with the people you work with on a regular basis. However in Emergency Medicine you spend time speaking to other professionals you may never have met. The art of ‘referral’ is a skill that the Emergency Medicine practioner must master. I recommend Iain Beardsell’s post “Making a referral” in this regard.

In the referral process, especially during the busy winter period, it is easy for those working in emergency care to lose site of the patient, so we mush be vigiliant of this and also remind our in-patient colleagues that it is not bombs were are referring!

The rush to move people around the system, either to assist in flow, meet targets, or reduce your work load results in some patients being hot potatoes – being bounced backwards and fowards with no-one taking overall responsibility or control. Countering this involves the referrer being positive, succinct and reasoned in the referral and those accepting embracing the challenge regardless of the heart sink that ‘another’ admission may bring. While this may pay lip service to the pressure the health service is currently under, acute services internally falling out with themselves is no help to anyone, especially the patients we are caring for.

What did you learn this week #WILTW

(the analogy used in this piece was prompted following a reunion of my university friends last weekend where we played ‘pass the bomb’)

Due to an number of issues this posting never quite made it last week – this is the 34th #WILTW

A recurring theme in my #WILTW series is learning from, or failing to learn from, previous experiences.

Just before Christmas our department ran a simulation day with one of the learning points:

Teams often work really well together but

"Can somebody…?"
"Can we….?”

Doesn’t assign a person to a job#TeamPaedSim

— Damian Roland (@Damian_Roland) December 18, 2014

Following this event I was involved in a case where a number of physiological observations (Heart Rate, Breathing rate etc) needed to be performed on a child. The child had been brought in by ambulance and, although features of their presenting complaint indicated they may be at risk of hypovolaemia (a significant reduction in the circulating volume of blood), on arrival in the department visual inspection revealed an alert, happy child interested in their surroundings.

I wasn’t directly involved in the initial assessment of the child but had asked for confirmation their ‘obs’ were normal. The answer was in affirmative and after a period of observation and investigation the child was admitted to the children’s hospital assessment unit.

I have had pause to reflect on this case as it transpired, at the time of asking, all the observations had been normal but not all observations that could have been performed were. My question had been open-ended, and so, therefore, was the response i.e. I had assumed I was thinking about the same observations as the person I was directing the question to. In this situation no harm was done but when managing critically ill patients in resuscitation scenarios, “closed loop communication” becomes very important.

Taken from Resuscitation Team Concept

There are many quotes about making assumptions and not all are suitable for an open posting. I leave you with the following:

What did you learn this week? #WILTW

Other useful articles on communication include Human Factors and Quality in Resuscitation and Resuscitation Team Organization for Emergency Departments: A Conceptual Review and Discussion

This is the 33rd #WILTW

A few weeks ago we ran a simulation day for the doctors and nurses in our department. It was successful (in terms of perceived value) and hopefully over time we will be able to demonstrate “outcome” based improvement.

One of my favourite quotes from the day was:

“I’ve learnt a lesson here. But I won’t go home + beat myself up (well, not too much) as at end of the day no patients harmed”
#TeamPaedED

— Damian Roland (@Damian_Roland) December 18, 2014

Simulation (whether high or low fidelity) has a great deal to offer medical education. Those critical of an increasing reliance on simulation to balance deficits in experience would highlight that demonstrated behaviours may not match those in the clinical workplace. They argue there is nothing like the real thing.

This was really brought to life over the holiday period when I drove off a junction on a busy motorway to be confronted by this

We were the fourth car on the scene. There were no emergency services present but a number of cars had followed us off the motorway so we did not appear to be in immenint danger of being hit from behind (although this was a potential risk as more cars came off the slip road). I got out of the car to get a closer look at the lorry. The passengers of the first car that had stopped were on the phone to the police. The passenger of the second car had got out of his car and was trying to ascertain if there was anyone in the lorry. I told this person I was a doctor and he appeared visibily relieved. I probably didn’t feel as nervous as I should have done as there then followed a sequence of events in which I learnt a great deal about pre-hospital care (my thanks to Dr. Ben Teasdale, the clinical director of our department who has a special interest in pre-hospital medicine, for gently pointing out some of the mistakes I made.)

A summary of my key learning:

1. Hospitals are safe places.

2. Roadside vehicle accidents are not.

3. Inadequate experience of (2) and too much experience of (1) leaves you cognitively disadvantaged.

4. Point 3 is a polite way of saying unconsciously incompetent.

5. Because of point 4, and not being able to ascertain how unwell driver of the vehicle may have been, led me to climbing up onto the lorry to see into the cockpit.

6. It is very, very, difficult to set diesel alight. This was a good thing for me as there was diesel spilling out of the diesel tank (1).

7.  If you sound like you know what you are talking about, but potentially don’t, either people humour you or believe you. I am still unsure as to what the ambulance and fire services made of me 😉

While I can’t share all that happened for reasons of confidentiality I certainly learnt from the experience without anyone coming to harm. InitiallyI was going to title this post: “Nothing beats the real thing”. While that may be true had I encountered a scenario like this in any of my pre-hospital or hospital training I may well have done things differently. You need no clinical training to realise getting on top of a crashed lorry is potentially a dangerous thing to do, but if you are unsure of the how well a person is, at the time just waiting is not easy. Simulation provides a great way of demonstrating many things, the pros and cons of action versus inaction for one, in a way that no-one will get hurt.

What have you learnt this week? #WILTW

(1) Please see comment below about my original school boy error on this post which has now been corrected!

This is a automated publication as I am taking a ‘digital holiday‘ during the festive period. For this 32nd #WILTW I have had a quick look through previous postings and highlighted a few notable ones:

The post that kicked off the whole idea: 13 years of training and tomorrow it all begins again…

The most popular post (probably thanks to a Kate Granger RT!): Some uncomfortable truths about insight

On reflection the post I have learnt most from: Am I narcissistic in my enjoyment of Emergency Care?

An honest admission of the the most ‘forced’ (coming up with a learning point every week can be challenging):

The justification of risky behaviour with public or patient safety 

and my personal favourite: It’s not what you say it’s how you say it

#WILTW has, and always will be, first and foremost a tool for personal reflection. The fact that some people enjoy reading them is a bonus. I often get offers of guest postings but these tend never to be realised. The door is always open though, If you have a story to tell please do get in touch.

What did you learn this week? #WILTW

Have a great festive period – wherever you are and whatever you are doing…

This is the 31st #WILTW

There is a great deal written and discussed about the ‘art’ of teaching. Numerous theories, articles, strategies and anecdotes are available but often teachers (of whatever discipline) will follow their own path and practice. This is not due to arrogance or cynicism (although this exists) but generally because teachers are lone practitioners. Whether it be by lecture or workshop the teacher educates alone nearly all of the time. Of course feedback is available from the learners themselves, but this is an infrequent exercise, steeped in issues of hierarchy and lack of objective mechanisms to determine poor practice. In Medical Education there is also a third arm, the patient, who witnesses the interplay between doctor and student but often has even less of an opportunity to have their observations taken into account.

There are events where peer observation of your teaching is available though. The Advanced Life Support Group run a number of courses for health care proffessionals to teach core skills in managing the most ill adults and children. The courses involve a number of faculty who teach via a variety of formats but often with 2-4 faculty members in a room simultaneously. This week colleagues and I were teaching on the Advanced Paediatric Life Support (APLS) course. This is an intensive 2 days in which candidates must demonstrate a uniform approach to the initial management of ill and injured children. Having your teaching observed is a very useful process. It makes you concentrate on a whole spectrum of issues which are easy to let slip in day-to-day un-observed activity. Timing is key, if you over-run, the course over-runs which will be clearly apparent to the other faculty members. If you don’t know core knowledge, the students will suffer, and again it will be obvious to other faculty this is the case.

I know this because I learn as much from these courses as I think the candidates do. You watch others demonstrating core material material (the ALSG have a prescribed format) but in subtlely different ways. There are great demonstrations of using examples, memorable cases, twists of context etc. to clear effect. You see how experienced faculty deal with candidates who are struggling or not engaging, and you learn the critical importance of well delivered feedback. Being able to witness good, and bad practice, stops complacency and helps you realise there are always things still to learn. On this course I mis-interpreted a candidates nervousness for over-confidence and appreciated I still have work to do on the pace of my delivery.

Taking pride in your teaching is important but there is only so much you can learn from theory and irregular feedback from participants. In an ever isolated world of clinical practice the observation of others’ delivering education, and your own, will be vital for patients and the profession.

What did you learn this week? #WILTW

This is the 30th #WILTW

I was at a development meeting for LIIPS (pronounced leaps) today. LIIPS is a collaboration between academia and the NHS with the aim to connect and share expertise, knowledge and support in service improvement across Leicestershire. Unfortunately the need to re-inforce a culture of patient safety and quality improvement persists in health care. This is in part due to some concepts being ‘relatively’ new so that there isn’t the infrastructure of knowledge out there in individuals to embed good practice in trainees, students and juniors. LIIPS hopes to assist in resolving some of these issues. There was a lot of expertise in the room, and therefore a variety of different approaches and suggestions on how LIIPS should evolve and deliver. One commonality shared by virtually everyone was the desire to move from traditional mechanisms of improvement, a reliance on audit alone, to more focused interventions which rapidly audit, review, revise and re-audit using measurements focused on patient outcomes.

There is nothing new about why ‘change’ is difficult but I have hit upon maybe something new to try. On the way home from work I stopped to buy some drinks from a local supermarket. As well as some bits and pieces I also picked up a bottle of wine. Try as I might I find it very difficult to move away from tried and tested regions and varietals. In fact that’s a lie: one particular region and one particular varietal.

This compulsion to stick with the familiar has been present since about 2005¹ and only really gets challenged when a new wine I try is unexpectedly pleasant on the palate (while there is no editor for my blogs I self-reflect the middle-class nature this train of thought is taking). It would have to be by an almost accidental wine tasting to prompt a change in tradition.

Moving improvement science from a new-fangled ‘thing’ into the ethos of healthcare culture is going to be long and arduous task. I wonder then if accidental “change tasting” is a realistic possibility within current system dynamics. While this seems implausible, with a generation of medical students and trainees hopefully being exposed to improvement principles at a much earlier stage, perhaps weaning a generation of professionals off their current vintage isn’t an impossible task.

What have you learnt this week? #WILTW

1. Following a year in Perth, Western Australia, Chardonnay’s from Margaret River have become a firm favourite

This is the 29th #WILTW

“You can’t see the wood from the trees“

This is a funny expression and one that makes little sense if you spend too long looking at the phrase’s actual construction. It does seem to ring true though. This week our Children’s Emergency Medicine Research group (PEMLA) reviewed its progress over the last year. It has not been ground-breaking: we can’t list Lancet publications, multi-million pound grants or a host of awards. But we have clearly moved fowards. Academic output has increased, we have establishing greater networks and there is an enthusiasm to continue and complete our current projects.

Creating space to review things over a set time period is incredibly useful. On a day-to-day basis I seem to be more likely to receive negative, rather than positive, news. Another grant application rejected, paper needing significant alterations, further delay with governance approval etc. I feel sometimes as if there is no movement forward. Everything is like wading through treacle – my steam roller analogy for NHS Change Day springs to mind. The NHS gets there in the end but is does so really slowly, squashing things along the way and seeming unable to change to direction.

We live ‘in the minute’ at the moment. The instant connection with mobile technology makes everthing happen ‘now’. Always busy and always something to do, and often hearing about others peoples success. Social Media creating a paradigm where you see everyone ‘else’ achieving something without realising you are probably doing exactly the same – except you aren’t taking the time to think about. As we reach the years end and the inevitable reflection on what 2015 might bring it is worth taking some time to think about 2014. Not in comparison to what others have done, but with yourself and what your personal objectives may have been. It’s likely to be time well spent.

What have you learnt this week? #WILTW

This is the 28th #WILTW

Insight is a gift. If you have no insight into your behaviours and how they affect others it will have a profound impact on the way others respond to you. However it is quite possible to achieve a significant amount, professionally and personally, with minimal insight into the way you affect other people. This may because you have positioned yourself in a hierarchical leadership position and over time lost the ability to self-reflect. Sometimes, but not always, you may then be in a status quo of affecting others to the extent organisational performance doesn’t flourish but not enough the organisation fails.

“The first thing you have to know is yourself. A man who knows himself can step outside himself and watch his own reactions like an observer.”
― Adam Smith, The Money Game

It is a nice maxim but in practice I am beginning to see that it might not be so easy to to move from knowing yourself to changing yourself. At my hospitals’ new consultants forum (a group of consulants in the first five years of practice) we had talks this week on leadership and task orientation. We discussed positions you unconsciously adopt in negotiation. One example was taking on a victim persona (“this always happens to me“) which hugely decreases the chance of reaching a positive outcome. Having always thought of myself as someone who reads body language and feelings well it was somewhat of a surprise when the facilitator picked me up as adopting a ‘blame’ stance in my response to another consultant’s concerns. I’d merely pointed out that assuming that ‘nothing can be done’ will result in ‘nothing being done’. Hadn’t I….?

While my logic to me may seem impeccable, my outward stance was more passive-aggressive than perhaps I had realised. This came as a bit of a shock. More embarrassing given I had just told the group how much a problem it was that some consultants seem unable to present themselves in a way that doesn’t cause others to become confrontational.

Insight is a gift. A gift that you must not assume is a perfect skill and one which maybe everyone thinks they have and very few people do…

What have you learnt this week? #WILTW

This is the 27th #WILTW

While it might be ‘trash’ I am quite a big fan of the American TV series ‘Arrow‘. It is pretty typical rich vigilante with very troubled past trying to right wrongs kind of stuff. A previous love interest of the hero died recently; an event which hit all of Arrow’s team (including their technology specialist Felicity Smoak) hard: 

Felicity: How can you stand there being so cold and rational?

Arrow (Oliver Queen):    ‘Cause I don’t have the luxury of falling to pieces. Everyone’s looking to me to handle things, to make the right decisions. Everyone is looking to me to lead.

If I grieve, nobody else gets to…

Felicity: You’re still a human being, Oliver. You’re allowed to have feelings. I know sometimes that it’s easier to live under that hood.

Arrow: I’m not.

(From Arrow Series 3 Episode 2 “ Sara“)

Comparing a TV series to Emergency Medicine may be one of my most dire conceptual leaps so far in #WILTW but there is a similarity between a team leader needing to stay in control during stressful and emotional resuscitations and Arrow’s dilemma. I am not promoting the emotionless doctor who remains un-empathic with a grieving family (in fact I have written previously on how I have been deeply moved by another consultant bearing all with a patient). I acknowledge though the team need someone they know will continue to function however upset/challenging they are findings things. Where does this strength come from?

The death of someone known to us inevitably highlights our own mortality. When that death is unexpected it can be very challenging, and the grief reaction can be powerful, regardless of how well you know the person. In making sense of acute loss I am reminded of the poignant words of a consultant colleague, Dr. Pro Mukerjee, speaking of that moment when you hear that someone has passed away.

“At first there is a pause, a look of sadness and then almost always a smile as a powerful familiar memory of the good about that person surfaces”

I find this reaction invariably true and I reflect that at times of deepest sadness there is some memory we can hang on to that which provides a modicum of positivity. Unfortunately in Emergency and Acute Care there is no connection with the person who has passed away. Although health care professionals deal with death regularly, so you might expect a certain amount of tolerance and resilience, the loss of the child or unexpected collapse of a person before their time is always upsetting. How do senior staff compose themselves to ensure both families and staff receive the time, compassion and information they need? I am not sure there is a universal method but certainly experience plays a significant role. What I am sure about is that the  reaction is still there, just placed somewhere else for a temporary period, so others can have the time they need.

What have you learnt this week? #WILTW

After writing this post I thought I would highlight Saying Goodbye. The Saying Goodbye Services are the first national set of remembrance services for people who have lost a child at any stage of pregnancy, at birth or in infancy, whether last week or 80-years ago. There is a very good video on children and grief by Dr. Ranj Singh on their website.