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.

This is the 26^th #WILTW

So this week marks the six-month anniversary of #WILTW (full list here). I get a chance to reflect on reflections I suppose!

It’s been a really interesting process which I think has definitely been worthwhile for me although recent feedback varying in its utility for others  🙂

#WILTW came from a blog I wrote in the first week of being consultant. It spoke to the time honoured quote: “You never stop learning”. I thought that formalising my (perceived) learning in the form of a blog may encapsulate it. Firstly in a way that I could easily document (useful for continuing professional development) but also to help me not waste it. As a result I have discovered a few interesting things…

• I have realised on a week-by-week basis it’s actually quite difficult to learn something completely new. Most of #WILTW is about validating what I know rather than develop any entirely new skill or mindset.
• As a result I have sometimes struggled because reflection shouldn’t be forced. If I am honest there are a few posts which started as: “I have no idea what I am going to say this week….”
• But being disciplined about having a regular time (usually Friday afternoon) has been incredibly useful in not letting things drift completely. Just the time to sit and think about the last week is valuable.
• Finally when you do truly learn something new in a clinical context it can be quite difficult to discuss it in a open forum without breaching confidentiality. This was an unexpected challenge, although with some imaginative story telling, not an impossible hurdle to overcome.

For me the process has been a valuable one and something I will persist with. I am neither a Jane Austen nor a J.K.Rowling but I hope these short records will stand the test of time and at the very least give me a record of the direction my time as a consultant has taken me.

What have you learnt this week? #WILTW

This is the 25th #WILTW

I spent an evening at my old school this week for a careers fair. I was hosting a stand on a ‘Career in Medicine’ and had a very enjoyable couple of hours speaking to students about admission criteria, specialty choices and whether the work is ‘really hard.’ A common question was, “Why did you choose Paediatric Emergency Medicine?”. It’s good to reflect on this as I have no idea what I said at my medical school interview about why I wanted to be a doctor and my interview to get into Paediatric Emergency Medicine Specialty Training was a car crash from the first question; so not quite sure what I said then either.

It was easy to speak about the nature of the job: I enjoy the frenetic pace, the practical element and the fact that sick kids get ill quickly but well again even faster. I was also honest about how out-patient clinics frustrated me and I tended to see them as something to ‘get through’. Given this attitude probably isn’t conducive to a great patient experience I realised it wasn’t for me.

But I had a nagging suspicion that there was something else as well. It’s rewarding working in Emergency Care. The feedback is very visceral and immediate. Whether it is ameliorating pain, correcting a deformity or relieving an anxiety “don’t worry, I can see why you are worried but this rash isn’t serious” a lot of what happens in urgent and emergency care is positive reinforcement of your skills. Even in the most desperate of tragedies you can avoid breaking bad news badly (I am uncomfortable about saying you can be good at breaking bad news). I ponder whether this is a benefit of Emergency Care or something that I need to happen to enjoy working there? This was a bit unsettling. Is there something about Emergency Care that satisfies an inner lack of confidence that positive feedback partially corrects? Am I rejecting in- (or out-)patient care not because I find the medicine unexciting but because I don’t find the potential feedback as fulfilling….

On a related vein do we see more emergency and critical care physicians on social media as this also provides a great deal of positive reinforcement of our self worth or place in the community? I am sure the situation is not as binary as this, but it is a thought I have not been able to shake. It is a good chance to be open about my intrinsic motivations although I am pretty sure I am not going to be leaving emergency care anytime soon 🙂

What did you learn this week? #WILTW

This is the 24th WILTW

The inspiration for my learning this week came from a tweet and a road sign..

I have been thinking a lot about gut feeling and gestalt (we had a consultant CPD session on it this week).

@broomedocs @EMManchester I describe gut feeling as making a decision that goes against the available clinical information…

— Damian Roland (@Damian_Roland) October 29, 2014

I thoroughly recommend you watch Prof. Carley’s talk on risk factors. I had this partly in mind while driving on the motorway to see some friends. We were advised to slow down due to an ‘obstruction’ in the road.

Clearly the traffic slowed, although to be honest not all to the required speed limit. We waited for the ‘obstruction’ to appear while passing through three further signs, a reduction to 50 and another two miles. There was still no obstruction. You could see slowly people deciding there was no obstruction and speeding up again.

Variable speed limit signs are a funny beast. They are no different than any other traffic sign on the road in terms of the penalty for disregarding them.  However their deployment is usually in conjunction with prophylactic traffic calming measures. Therefore when travelling on a motorway you often see the sign to slow down but no sign of the associated queue. Although the slowing down prevents the queue getting worse (or even happening at all) there is a perceptual deficit created in not seeing the end result of an inaction (i.e a large traffic jam).  I’m sure people would be honest in admitting they don’t always slow immediately to the required speed. This is risky behaviour as you are technically taking a chance with your own licence and potentially other peoples lives. However the learnt experience is that the final outcome is never bad so a rather negative attitude is employed.

What other signs or advice do you feel the outcome is worth taking a chance over? I think most people would follow the sign below:

So what about this?

So while the management of a sick patient may be a million miles away from a motor way traffic sign it got me thinking about how often we dismiss an obvious clinical warning sign as we think, “We know best…?”

What have you learnt this week? #WILTW

This is the 23rd #WILTW

I have to admit that this isn’t really new learning, more of a confirmation of something I have suspected for a long time. The trigger for this blog has been seeing a few small projects come to fruition, which I have initiated, but not really been part of the process or eventual outcome. It’s very satisfying seeing this happen despite the fact that you get no credit for it. In fact it is interesting; the things that I am probably most proud of having delivered are things in which I get virtually no recognition at all.

This is a timely observation given the Health Service Journals hunt for the next “Rising Star”. I am conflicted as I was an inaugural winner. I’ll be honest, I was quite chuffed to have been nominated and it was nice to go to an event in London. It was at the event itself that I become uneasy. I sat with a number of very impressive characters, some of whom who have had significant impact at a national level, and thought to myself “What have I really delivered to be here?” I don’t doubt I have been part of a few projects which have had a larger-than-life profile but what can I say that I’ve individually done that has really inspired others to deliver significant change? I realised then that true leadership is really about fostering others to deliver on important initiatives. The fact that you are recognised probably means that you are still required to guide the process. What you really need to happen is for you to trigger a sequence of events that becomes independent of you. Now that is something that is truly fulfilling..

What have you learnt this week? #WILTW

This is the 22nd #WILTW (and a little delayed due to my attendance at #EAPS2014)

This week I took our family car into be serviced and have an MOT. I dropped it at the garage just before work and was told it would be ready later in the afternoon. However  I had an answer-phone message at about 4pm to say that the service had been done but they hadn’t got around to doing the MOT so could I please leave the car with them overnight or come back the next morning.  I was a bit frustrated by this assumption as I either

i) I couldn’t get home or

ii) would be without an appropriate car for the school run.

I suspect, in fact know, I am a bit soft in these situations and although I was frustrated I tend not to let emotions get the better of me. So surprisingly, and probably because I missed the call and didn’t get put through to the person who had initially made it, I was able to be a little more ‘robust’ in my annoyance. I felt a little uncomfortable when I put the phone down having expressed my disappointment at the service I had received. However 5 minutes later I got a phone call back saying that manager had found someone to do the MOT…

There are often times when parents, carers or relatives of children become frustrated by hospital processes. Often they are scared and emotional and outbursts can be tolerated in the context of the situation they see their children in. But sometimes it does appear the smallest thing can be blown out of all proportion and you find yourself expending energy ameliorating the parents anger at the expense of care to other patients. Conversely in my experience parents are often very humble about things they could and should be annoyed about!.

My learning last week was reflecting on whether bad behaviour gains you rewards? My small outburst with the garage sorted a problem (which probably shouldn’t have occurred in the first place). What of the families or patients we see? When is strongly challenging the care they feel their child has received appropriate? and when is it simply a method of gamesmanship?

I hope I am never in a place where I assume the latter and will always do my utmost to facilitate the former.

What did you learn this week? #WILTW

This is the twenty-first #WILTW

This tweet dropped into my timeline:

@elinlowri I've had the same idea. Keep intending to talk to the MD at our local Trust about it. I think is a good idea.

— Jonathan Griffiths (@DrJonGriffiths) October 10, 2014

It was timely as I had only yesterday spoken to a local GP about a concern he had with a patient discharged from our Emergency Department. I had seen the patient on arrival and had been responsible for their care. Review of the notes by colleagues indicated that my decision making was entirely appropriate and my documentation was coherent. However, in retrospect, my discharge letter did not contain adequate information for the GP to not need to clarify some further details. The conversation was amicable, and useful for both of us I think (direct communication between health care professionals cuts through layers of bureaucracy that a written notification often piles high). Given the increasing attention paid to service pressures being placed on our primary care colleagues adequately explaining decisions we make at the urgent/secondary care interface is vital to maintain communication. This will both foster good relationships and maintain patient safety. I’m mindful that systems don’t always facilitate the production of timely and adequately detailed information between health care professionals. It’s therefore imperative we maximise all opportunities these improve systems regardless of dependance on human or technology factors.

What did you learn this week? #WILTW

This is the nineteenth #WILTW

A significant proportion of patients in health care services are seen by multiple health care professionals (excepting primary care and out-patients). Acknowledging some patients do deteriorate rapidly, generally there are the same clinical signs and symptoms to be observed regardless of the different staff seeing them. It is well recognised however that patients can have many clinical encounters before someone finally recognises they are seriously ill [1].  The fact that some clinicians see different ‘things’ in patients is not unsuprising. There are some clinical signs which are very subtle, such as work of breathing and fine movements, which require training and repeated exposure to be able to put into a context which makes pattern recognition obvious.

However others are more clear; physiological features such as heart rate and breathing rate being fixed signs which should not differ when examined by different individuals. To be clear I am not pondering over gut feeling here. The literature on the use of ‘gestalt‘ by experienced clinicians to recognise serious illness is substantial but this is not about subtle signs or intuition. How is it that in the same time span a patient who has clear features of illness may be recognised by one person but not by another? Experience and knowledge play a role but continued failure to recognise significant illness even by experienced  professionals represents a significant challenge for the health care community.

I have a research interest in the educational use of clinical video cases. This hat often collides with my clinical practice hat when system errors occur in the recoginition of illness in children. This dilemma of why a particular patient isn’t recognised as being ill (or the converse – when someone is overtreated as being very unwell when in fact they weren’t) is an important issue as is often the root cause of communication problems between departments in hospitals.

The video below was consented for general viewing by the patients’ mother (appropriate hospital and national guidance was followed). I use it (hopefully!) as a potential grey case to highlight how the same clinical features can be interpreted differently . I’m hypothesising there maybe differences in determining which are the salient clinical signs in this case. Please feel free to leave your thoughts in the comments section (appreciating previous comments may bias you so try not to look!). Regardless of whether I’m right or wrong I hopefully will learn something I can feed back on in the future!

[Oxygen Saturations 96% – Heart Rate 170 – Temperature 36.4]

What have you learnt this week? #WILTW

[1] RCP NEWS standardising assessment of acute illness severity 

This is the eighteenth #WILTW (and a little delayed due to working the weekend!)

How many times do you need to experience something for you to learn from that experience? In medicine health care professionals will often refer to ‘sentinel’ events. A clinical incident which has forever changed their practice:

“I will never forget the patient who…. ”

These events often have a patient safety element to them, with harm or near harm, unfortunately occuring. It is the seriousness of the outcome making the event the more memorable. A catalogue of these stories by senior health care professionals can be found in the handbook  “Medical Error“. It is shame that these sometimes tragic events need to occur to ingrain key actions and principles in people. But how do you make sure you don’t repeat mistakes when there isn’t a significant outcome to an error you have made? Take this example; males presenting with abdominal pain could actually have a problem with their testes. Failure to examine the scrotum may miss a testicular torsion (twisting of the testicle) resulting in the patient having to have it removed. However it would be possible to examine hundreds of patients with abdominal pain – never examining the testes – and no one ever coming to any harm because none of them had testicular torsion as the cause of their pain. If no-one ever audited your notes and fed back to you may never realise you were missing out this important part of the examination.

I am reminded of this as my second ever post on #WILTW was about the importance of clinical guidelines and how sometimes guidelines may trump gestalt. Last week I was involved in a similar case demonstrating following  a tried and tested pathway was probably better that thinking ‘I know best”. Although ultimately it wasn’t a black and white issue, and there was no harm to the patient, I was left with a real sense I hadn’t learnt my lesson. In some respects cognitive errors that involve the interplay between guidelines and gut instinct are not great examples of sentinel events.  I am though left with the feeling that despite blogging publicly about “what I had learnt this week” a couple of months ago maybe I had not learnt anything at all? Or maybe the event opened my mind to note when I am making similar errors. Maybe this post was only possible because of that previous experience? Learning might not be so concrete as to ensure when this event happens you will always do this. It’s probably a little more subtle than that. At the end of the day I hope this catalogue of reflections will always inspire me to think that little bit harder about the consequences of my actions.

What have you learnt this week? #WILTW