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

This is the 44th #WILTW

“I couldn’t see my next patient after we had stopped resuscitating a dead-on-arrival four month old. It wasn’t because I was too upset, too emotionally drained or too busy. It wasn’t even because I had to clean up the resus room; persistently re-tidying the cannula tray because it gives you something to do to switch off from the parents crying. 

It was because I was angry.

I had actually been seeing the fourteen year old with “appendicitis” before the priority one call came over the Emergency Department loudspeaker. I’d taken a history and examined the boy brought in by his worried mother. I had explained he didn’t have a compatible history, didn’t have a fever and didn’t have any right iliac fossa tenderness. I had been patient when mum explained that he had a huge pain threshold. I had been sympathetic that he had ‘always’ only ever opened his bowels every four days. I had compassionately discussed that the mass of stool in the left side of his abdomen showed he needed some kind of laxative. His Mother got angry with me saying that he ‘must’ have appendicitis and what kind of Doctor was I to diagnose constipation in a teenager! I demand to see a surgeon, she said, “They know what they are talking about.”

The priority call went off then and I made my apologies. 

The unfortunate child arrived moments later in the resus room. Found in his cot he was white, pulseless but not yet stiff. In front of his hysterical mother we performed the necessary resuscitative measures. The room was silent save for the voices of those asking how long the child had been in the department? How many rounds of adrenaline had we used? And a whispered, “ When are we going to stop?”. With mother’s consent we ceased resuscitating and left the parents, father only arriving from work seconds earlier, to grieve an unimaginable loss.

I am not sure if I felt their pain, I hope I never will, but I did feel sick. All I could see was a furious mother looking as if I had cursed her child with the words, “constipation”. I was angry that she wanted her child to have a severe illness not just a socially unacceptable inconvenience. Who is she to want her child to have the risk of anaesthetic, surgery, infective complications when the parents of the other child would have given anything that morning to have a child, albeit one with constipation?

The mother of the the child said thank you too me. Whether the mother of the teenager said thank you to the surgeon who discharged him with a diagnosis of constipation, I am not sure. Am I too harsh on a parent who probably devotedly cares for her son or justifiably perturbed at a society that doesn’t see the real picture? In the cold light of day I see the overreaction in my thinking but hope I will never wish a diagnosis on anyone ever again.

I wrote the above as part of a reflection in 2005. The experience, subtly altered to protect confidentiality has always remained with me. This week as part of a Consultant CPD session we discussed a paper by Alys Cole-King on Compassion. Compassion has become a buzzword in the NHS. I hope that this doesn’t devalue its meaning – the paper I think brilliantly explains how compassion is more than than just a singular approach but a set values which go beyond simply being kind. The paper discusses the attributes of compassion: Sensitivity, Sympathy, Distress Tolerance, Empathy, Care for Wellbeing and Non-judgment. The last, Non-judgment, defined as:

Not judging a persons pain or distress, but simply validating their experience. Compassion involves also being non-judgemental in the sense of not condemning. 

I have always considered myself compassionate but do I deliver of compassion? Since those events in 2005 I have endeavoured to question my emotional responses to the families that I see. This paper reminded me of the constant need, however busy, whatever circumstance, to continue to do this.

What have you learnt this week? #WILTW

This is the 43rd #WILTW

The Nuffield trust have recently produced a report on “Whats behind the A&E crisis“. Something clearly not changing fast enough is the use of the term of Emergency Department rather than A&E but one of the key points is:

Many answers to the problems facing urgent care already exist. But the complexity of the system and the highly politicised nature of A&E have impeded progress. Problems will not be solved if policy-makers, political leaders and regulators continue to micro-manage A&E. With change so urgently needed, it is imperative that there is a cross-party consensus on how to move forward and that action is not postponed or delayed for political reasons.

There are many challenges in the NHS at present. Some are going to require long term policy and strategies to resolve which are clearly not in the remit of any one individual. In fact the problems facing the health system seem so great there is a temptation to fall into the trap that no-one can do anything about it at all. #NHSchangeday demonstrated there are many people keen and willing to get involved in bringing about improvement in their own localities. But it would be foolish to think that campaigns such as this are going to transform cultures or reduce deficits overnight. It is clearly important that this individual endeavour persists regardless of its cause.

@dr_fiona @Damian_Roland @DrUmeshPrabhu Lots of us make small changes every day but don't sign up to "change day". Still doing it though.

— Tim Underwood (@TimTheSurgeon) March 7, 2015

Making those small challenges  is something that anyone can do. The simulation that we ran in the canteen of Leicester Hospital as part of a Change Day action came about, not because we had a clever piece of equipment, or that our emergency department is full of people with education certificates. It came about because of few of my colleagues have found the time to set in place a regular training programme.

It’s not alway easy and there are times when things don’t go to plan. But the persistence of individuals finding a way to make things happen has resulted in an initiative risking being a fad becoming a fixture. It is starting to show results and we are hopeful after this public demonstration that other areas of the hospital will look at how they can bring simulation into their own work place.

No-one is going to change healthcare overnight. But there is still much that an individual can do to make a difference.

What have you learnt this week? #WILTW

(I am grateful to my consultant friends Gareth, Mark and Jonny for making in-situ simulation a reality in the Emergency Department. I am also massively appreciative of Amy, Rami and Paul for volunteering to take part in the live demo!)

This is the 41st #WILTW

There is some irony to the fact this #WILTW is a little late. It’s been a long term ambition of mine to use a video of a patient, with consent to be shown to anyone, as a #FOAMed resource. The project has finally come to fruition but obtaining the footage, editing, formatting, reconfiguring this website etc. has meant it has been a lengthy process. Given it’s needed to happen with other projects with clear timelines has meant it was never going to be a priority. I was hoping it would be a novel and unique contribution to the FOAM concept. Last year however the reeldx team started doing something very similar, with greater quality and much greater scale. It’s not a race or a competition but I’ll be honest in admitting I thought, “wish I had prioritised that.”

This week also sees the launch of my REMIT project, the educational ‘outcome’ of my PhD. This has also been a long term endeavour, fitted around finishing training, starting a new consultant job and trying to create a research strategy. When first imagined, I had hoped it would be cutting edge. Having spent years breaking down barriers of resistant video technologies and obtaining endorsements the rest of the online educational community has definitely caught up.

I feel perhaps patience hasn’t really paid off. Waiting for things to fall into place and thinking, “it’ll get there in the end” has allowed so much time to pass that more iterations of work are needed. Have I just demonstrated poor time management? Although I am not sure what else I could have substituted so perhaps it is just bad prioritisation!  I suppose it is more the frustrating as patience is something I have been trying to develop. Rather than a shot-gun approach to tasks and overwhelming frustration that nothing gets done taking the long view has been a personal development aim of mine.

I then reflect on the only person who is really frustrated is me. No system or process has been affected. It is only my personal ambition that has been bruised. And it’s not really a big bruise at that. While researching this blog I found the following anonymous quote:

Patience is both the love of action and inaction

Not quite sure this quite fits for me yet but maybe something to aspire to.

What have you learnt this week? #WILTW

 

 

This is the 40th #WILTW

This week we were guzumped on a house. It was pretty frustrating as we’d already started planning what our new home might look like and made provisional financial and legal arrangements.

The estate agents started with, “..we have bad news..” rather than “..we are sorry.” This may seem incredibly petty to dwell on but the ramifications of the phraseology have become more obvious as time has gone on. The estate agents said they had technically done nothing wrong and were under a legal obligation to the sellers to inform them of all offers. They seemed affronted when we didn’t appear very charitable about this.

I suspect others have been in similar situations. I feel Estate Agents are failing to recognise that it is not the legal aspect people get frustrated about, it is the principle. Its about doing something which is, and this may be overstating it, morally right. Yes you can gazump, yes your estate agent has technically done no wrong, yes they will get a slightly bigger commission, but no they have demonstrated little in the way of a shared value of respect.

In health care patients want to hear you are sorry, not that the mistake was a long term system issue which has yet to be resolved. While it is virtually impossible to compare a public funded health care system with a financially motivated real estate trading model, honest apologies and a value-based operational system are important in both. The increasing privatisation of  health care in the UK comes with the danger of the health system doing things ‘by the book’ rather than for the best. I hate to think patients would ever be ‘guzumped’ for a more financially profitable one.

What did you learn this week? #WILTW

 

This is the 39th #WILTW

The health system in the UK remains in a perpetually fine balance. In acute care the constant inflow of ill patients requiring care is only just met by the availability of hospital beds for them. The winter crisis of 2015 demonstrates what happens when the system becomes utterly overloaded and capacity is breached resulting in patients spending prolonged times in Emergency Departments.

It is often argued that hospitals need to run at 85% capacity in order to function efficiently (although trying to find the facts behind this is hard). This means that there must always be a good excess of empty beds at any given time (with available staff to care for patients  who may be placed in them). Without this whenever the system is faced by increasing inflow i.e. lots of patients requiring admission in a short space of time it just grinds to a halt because there is no where for patients to go. Often hospitals in the UK run at 95% capacity or more meaning there is absolutely no flexibility in the system. The challenge of keeping beds empty is a difficult one and one which NHS England have been trying to plan for. For managers or clinicians wanting to utilise spaces for surgical procedures or other non-urgent tasks it can be frustrating but failure to maintain adequate capacity can cause problems with the quality of care.

Having ‘capacity’ is not just a concept that can be applied to health systems. This week I completely ran out of capacity. This wasn’t an inability to do things – I’d hadn’t lost enthusiasm or suffered from acute writers block – I had simply not allowed any extra space to deal with a couple of unexpected tasks. I think for a couple of months I have been trading an ever dwindling capacity to accommodate what appeared to be an ever increasing work load. In hindsight I am now not actually so sure my workload was actually increasing; I was just failing to protect anytime to deal with ‘acute inflow’ as it were. This gradually weaned down the capacity I did have until suddenly everything ground to a halt.

So along with being research resilient, insightful, avoiding narcissism, and not being as busy as a Backson I now have a new #WILTW behaviour to add to weekly reflections. Will it be possible though to create space, which might not be used, within any given week? This I think will be a personal challenge that may take many winters to solve….

What have you learnt this week? #WILTW

 

This, the 38th #WILTW, comes in response to call out from Andy Bradley. Andy is a pretty inspirational guy and if you are ever dis-enfranchised with some of the efforts the NHS makes to motivate/engage staff I would recommend you watch his TED talk.

Andy has recently been promoting #wisdomofkindess and asks the question

“In your minds eye what does our future health and happiness look like, sound like, feel like?

How would you love it to be?”

In my initial response to the blog Andy replied with:

https://twitter.com/wwwframeworks4c/status/559360023227555840

I sometimes feel I live between worlds. There is a the clinical world I inhabit; being physically present on the “shop-floor’ of a busy Children’s Emergency Department or as part of a clinical leadership team improving the quality of care we provide. I try to be constantly aware of the effect my emotions and biases have on other staff, parents and especially the children and young people I meet. Simply put: it’s not easy. While #hellomynameis is a reflex, other aspects of compassionate care sometimes aren’t. It’s not simple to challenge others behaviours when you have witnessed a professional interaction that is not acceptable. Maintaining persistent empathetic engagement with families can be one of the most draining aspects of my job. Do I sometimes resent it. Yes, I’ll be honest I do. I don’t think that makes my unprofessional, callous or dispassionate. I hope it makes me aware of when I do need to take a break, re-group and re-energise.

The other world is the network of individuals and groups I belong to who are championing change, within and outside of the health service. Generally via social media, but also through conferences, projects and campaigns. There is a steady flow of what some might call ‘positive energy’ but others see as mis-informed and ill-placed conjecture and eulogising. My efforts with #nhschangeday are on the public record. As it reaches its 3rd year I am proud to have been part of a movement which I do feel has engaged people in understanding how and why change can occur in any health or social care setting. The networks I have developed from this and other initiatives are supportive, inspiring and positive. I have developed insights and skills which clearly have benefited me and hopefully the patients I treat.

And yet despite this latter point it feels sometimes as if these worlds are in contradiction with each other. If you watch Andy’s videos you think – why isn’t every clinical encounter like this? Why is it that the energy I can have from one phone call on developing a new social movement can be utterly deflated during a clinical meeting a mere hour later. Idealism often crushed by the reality of some of the things that need to be overcome. So how would I like our future health and happiness to look like? For me it would be to live in just one world. One in which there doesn’t need to be a jump from what we think we should be doing to what we are doing. But I appreciate that mostly starts with me. It’s my mindset and my beliefs that predilict the energy and compassion reserves I possess. I encapsulated this a while back without realising it:

And while I realise the very thought of this matrix will turn off many, I hope one day to create in both worlds the possibility that: “Today can always be a good day”

What have you learnt this week? #WILTW

This is the 37th WILTW

A while ago I was surprised to find an unusual dose of paracetamol written on an anaesthetic° friend’s kitchen wipeboard (1.2ml). On closer questioning it transpired that his son had developed a viral illness while on holiday in Spain.  The anaesthetist was frustrated as he could only buy a small volume of paracetamol and spent a long time negotiating for a 90ml bottle. On returning to his holiday residence he realised the reason for the pharmacist’s reluctance – in Spain a 100mg/ml concentration is used.  Although this is a standard European dose, in the UK it is more common to have 250mg/5ml which is half the amount per mililitre.

The wipeboard contained relevant values for the son’s age but had such diligence not be applied to reviewing the actual dosage it is possible that an un-intentional overdose may have been given. I had thought of submitting this as a case report to alert Paediatricians, GPs, Pharmacists and Parents to the potential problems that buying medications in countries outside of their country of origin may bring (and also a weight rather than volume based syringe may be helpful as parents sometimes find dosing difficult [1]).

This case sprang to mind as I have recently reviewed some literature on liver injury secondary to paracetamol overdose [2]. The study based on data from Australia and New Zealand revealed the majority were in small children (< 5) as a result of parental medication errors. An (unrelated) discussion on twitter this week therefore caught me eye. It related to the use of 30mg/kg of paracetamol as a loading dose to aid discharge of chidren from Emergency Departments

@PEMEDpodcast Love it! But my nurses freak if I go over 15/kg. Any citations so I can prove safety? (Though I don't often treat fever)

— Justin Morgenstern (@First10EM) January 29, 2015

I’m going to try to steer clear of the ‘fever’ treatment debate in this blog but I think this is a salient reminder of the dangers of variable medication volumes in children. While I can see the pharcomological rational behind the loading dose, the potential for confusion does exist, especially if parents mis-interpret its use. While I have previously highlighted the medical profession are a little paternalistic about parental decision making (thoughts here) there is evidence children have come to harm as a result medical errors. The work mentioned in the tweet only suggested an improved reduction in temperature, rather than other clinical outcomes, so for me currently there is no a clear reason to use the larger dose. If this was proven to reduce distress in children to the extent disposition decisions could be more safely and effeciently made then I suspect the whole fever debate will be re-ignited!

Until then we know medication errors occur as a result of health care professional and parental/carer mistakes. We should continue to do all we can to ensure we work towards them being never events.

What did you learn this week? #WILTW

°Many thanks to Richard Eve for being so thorough with his dosing calculations!

1. Marlow R, Lo D, Walton L. Accurate paediatric weight estimation by age: mission impossible? Arch Dis Child 2011;96:A1-A2
2. Rajanayagam J, Bishop JR, Lewindon PJ, Evans HM. Paracetamol-associated acute liver failure in Australian and New Zealand children: high rate of medication errors. Arch Dis Child. 2015 Jan;100(1):77-80