This is the 56th #WILTW

During my medical training I sat in many outpatient clinics. The vast majority I don’t remember specific details about but there is one that has always stood out for me. I was in a clinic with a Professor of Paediatric Cardiology. The Professor was nearing retirement, in fact, this may have been his last ever clinic. I has been asked to listen to a child’s heart and describe what I found. I remember not really being able to either describe the heart murmur or diagnose the problem. The Professor kindly explained to the family what the sound he was hearing was and that he would send the child for a scan to confirm his diagnosis. As the parent left the room he confidently explained the key features of this heart condition and what the plan would be to treat the patient.

“You see, Damian, it is not always possible to hear the fixed splitting characteristic of an Atrial Septal Defect but this child has all the other obvious presenting features”

The patient returned from the echo-cardiography suite with scan findings completely different heart problem than that suspected by the Professor. He was surprised and a little perplexed. You could see a range of emotions briefly come over his face before he professionally explained to the family the next steps.

After the clinic the Professor was clearly still mulling over the patient. What was troubling him seemed to be the unexpected nature of this error. As a clinician on the edge of retirement I got the sense that his confidence had been rocked. I think the reason I remember this case so clearly amongst the hundreds of other clinic cases I have seen was his disbelief and palpable disappointment.

16 years later I was asked to review a child with breathing difficulty. His parents were concerned about him and the junior wasn’t sure what was causing the problem. The child looked moderately unwell but on listening to his chest and reviewing the history it seemed they needed treatment with inhalers.

“You see, John, it’s not always possible to hear wheeze, but if you notice he is having difficuly breathing out and the history of persistent cough despite regular antibiotics is consistent with viral wheeze”

I was subsequently called into the resuscitation room but on returning found that the child had had an X-ray taken. While I had been away the child had detriorated and had started grunting. The X-ray is below:

This took me somewhat by suprise as it isn’t the typical X-ray of a child with viral wheeze and is consistent with a severe chest infection.

Every clinical shift brings a new opportunity to learn and develop skills in medicine. Sometimes you need a reminder of biases inherent in decision making. I had fallen victim to confirmation bias 

Constantly re-evaluating decision making is not something that should dissipate with experience. I hope I am open to the possibility of making mistakes right up to retirement.

What have you learnt this week? #WILTW

For medical readers the Echo-cardiogram revealed a VSD. 

Many thanks to the family of the child in question who were happy for me to discuss this story but I have also made some subtle alterations to the clinical events. 

This is the 55th #WILTW

Most mornings I have a cycle-train-cycle journey to work. The train is generally busy, as it’s on a commuter line to London. I am constantly bemused, and sometimes irritated, by the desire of my fellow commuters to get off the train as soon as possible. It is actually quite frustrating if you are sitting by the train door to have a whole line of people ready to disembark 10 minutes before you arrive. There is some unconscious sense that you should be getting ready to get off as well. Even with my fold-up bike it takes me less than 15s to stand up and put my bag on. Why would I chose to stand up far in advance of needing to?

The ‘hurry’ of life is an ever present force and I am often victim to it sweeping me away. I suppose my train stance is one way of avoiding this. I am not so great in others. I admit to being dreadful at turning off e-mail alerts – an instant fix to unnecessary stress and interruption. I am also bad at working ‘to‘ deadlines rather than ‘for‘ them i.e if it doesn’t have to be done until that date, I won’t do it until that date. This works well unless you have mis-categorised your Eisenhower box or the task takes much longer than you think it should.

(The Eisenhower box via JulienRio.com)

But the ‘hurry’ of life can also be outside your control. A nice little abstract in this months Emergency Medicine Journal describes the affect of  noise on performance. In this study from South Africa it was found that loud ambient noise didn’t affect performance but it did impact on reported stress. Your environment affects your senses and your perceptions. Generally a busy Emergency Department is a noisy one but a noisy Emergency Department isn’t necessarily a busy one. On some shifts I’ve found myself thinking: Why do I feel so stressed there are hardly an patients? It’s because noise levels increase your stress directly or remind you of previous associations between noise and stress.

Conversely a silent Emergency Department, or any place of work, feels like a controlled one. Unfortunately silence isn’t always in our control.

What have you learnt this week? #WILTW

This is the 54th #WILTW

A little chap who presented with a rash this week allowed me to capture some video footage I’ve wanted to obtain for some time. In lots of paediatric consultations it’s important to look in the throat of the child. This, as most junior doctors and parents will attest to, can be challenging. The secret is more in the technique of the parents than the doctors though and for some reason this isn’t well shared. This is a shame as Paediatricians can be quite judgemental of the poor quality throat exam performed by other specialties but never explain how they managed to visualise the tonsils.

A good opportunity arose when we had a little guy who wasn’t too fussed about opening his mouth but was still realisticially fidgety! Mum also had natural experience and huge thanks to her for consenting to demonstrate this video.

The key point is that the child’s back should be parallel to the chest of the parent (to be fair in this video this hasn’t quite happened). The parent then puts one arm around the child’s chest AND both the child’s arms and the other arm around their forhead. This should be quite a comfortable position at rest but as you can imagine you do need a decent grip for the squirming toddler.

This position is basically dependant on the confidence of the parent and the knowledge of the doctor to set them up in this position. I therefore share this as it constantly suprises me how often not knowing this results in a failure to visualise the throat properly.

For the child who won’t open their mouth levering the tongue depressor between the almost universal cross-bite that exists between the molars towards the back of the mouth often does the job.

A few viewings and a comment “oh – that’s how you hold…” proved it’s not all common knowledge but apologies to those for whom this is bread-and-butter clinical practice.

Many thanks to David for volunteering to examine and to the family for consenting to share the film in this way.

What did you learn this week?

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