This is the 156th #WILTW

Improved digital accessibility via smartphones has transformed access to information for health care professionals. A variety of apps exist, some accredited by national organisations such as the National Institute for Health and Care Excellence  (e.g. NICE National Formulary for Children: iOS or Android) and some approved by extremely stringent regulators such as the Medicine and Healthcare products regulatory authority (MHRA). Mersey Burns (iOS or Android), an award winning programme for calculating burn area percentages,  was the first app approved by the MHRA and such is its ease of use it’s downloaded much further afield than the North-West.

For direction on your own institutions’s preferred approach to managing certain conditions you need to look things up on local servers. Sadly, and I have never been given an adequate legal explanation for this, hospitals rarely allow their guidance to be made public. This means if staff don’t have quick access to a computer they need to find an old guidelines folder hidden away in the recess of a desk. The Royal Children’s Hospital Melbourne have taken a far more pragmatic approach and allow anyone access to their clinical practice guidelines. It’s no surprise then to see the format (content!) of their guidelines emulated around the UK.

Huge amounts of resource are used in trying to get doctors and nurses to deliver evidence based treatments and care. Easier access to guidelines should result in more patients receiving the most clinically appropriate and effective treatment (which may often be no treatment in paediatrics). However clearly laid down ‘best practice’ is often ignored and poor practice can persist simply because it has been heard on the ‘grapevine’. This ghost guidance, which can’t be found on any website, manuscript or protocol can be pervasive throughout an organisation. The speed at which it becomes known to new-starters is incredible given it can take up to 17 years for some practices to be adopted.

But need to understand house rules before spinning roulette wheel https://t.co/dvbU55hiEW

— Andrew Tagg (@andrewjtagg) March 15, 2017

House rules are not just about treatments but often relate to cultures and behaviours and can be incredibly stifling. This latter type of ghost guidance is often applied inequitably and inconsistently making it divisive but also difficult to remove. Conversely some ghost guidance is behind the emergence of positive deviance and may well be an informal method of spreading learning from excellence. It’s certainly not a new phenomena and forms of house rules were first defined by Stephen Bergman, writing as Samuel Shem, in “The House of God“.

In researching for this blog I discovered that Stephen had added to the original house rules first published in the 1978.

Law 14 : Connection comes first. This applies not only in medicine, but in any of your significant relationships. If you are connected, you can talk about anything, and deal with anything; if you’re not connected, you can’t talk about anything, or deal with anything. Isolation is deadly, connection heals.

Law 15 : Learn empathy. Put yourself in the other person’s shoes, feelingly. When you find someone who shows empathy, follow, watch, and learn.

Law 16 : Speak up. If you see a wrong in the medical system, speak out and up. It is not only important to call attention the wrongs in the system, it is essential for your survival as a human being.

These seem like the types of ghost guidance that should be written down and shared…

What have you learnt this week? #WILTW

This is the 155th #WILTW

Co-inciding with the opening of our new Emergency Department was the release of “Emergency hospital care for children and young people“. Produced by the Health Foundation and Nuffield Trust the report analysed Hospital Episode Statistics (basic data relating to a patients’ admission to hospital) over a 10 year period. It is a sobering read with a headline figure that, although attendances in the under 25s increased by 14% (compared to 20% in all ages), in the under 1s the figure was 30%. These increases over time are no surprise to us with the figure below our own local data from the last 4 years (thanks to Dr. Gareth Lewis for this)

The reasons for this persistent upward spiral are not clear. It is important to note that a large amount of the total change is actually due to population growth and an increasing birth rate. However the birth rate has slowed in the last few years whereas admissions haven’t. Increasing parental anxiety, poor or inequitable access to local health care services and a risk averse medical culture have all been suggested as causes, but whatever the underlying problem is, it’s definitely going to need more than one solution.

The data presented gives an indication of where research and improvement work needs to focus as long as we are aware of some of the challenges in interpreting the figures. Large scale data analysis projects like this are very dependant on the quality of data entered. Healthcare has not had a brilliant track record in recording, or more precisely ‘coding’,  information about patients effectively. This is generally because doctors aren’t trained in how important this is and are therefore quite ambiguous in their clinical records. Hospitals employ teams of clinical coders to read notes (and decipher handwriting) so they can record the key outcomes related to a patient’s stay. To make the coders job either they collate conditions into particular predefined and agreed categories. The most common of these are shown in figure 3.6 from the report.

Notwithstanding the complexity of being able to extract information about the underlying condition there are some interesting trends here. I am most taken by the huge increase in numbers of children diagnosed with a viral infection. The authors note:

This is the 154th #WILTW

As you are ambling around a shopping centre you spy an escalator to take you to the level you need. It’s not working but hasn’t been cordoned off so you use it as stairs to climb to the floor above.

You know the escalator isn’t moving.

You have audio-visually confirmed this.

And yet as you walk onto it it starts moving forward so you overstep slightly before re-adjusting yourself.  You then realise it’s not actually moved forward at all.

This unnerving sensation has a scientific explanation although it wasn’t fully explained until the beginning of this century

Julie Beck wrote an article on the paper and coined the term “gebrochenrolltreppe” ( In German Google Translate “escalator” is “rolltreppe” and broken” is “gebrochen”)

One thing about our new Emergency Department, which opened this week, is that it’s not broken. Yes there are some snags, and lots of new processes to learn, but there is far more space, purpose built cubicles and a design that facilitates flow. These combine to create a department that is far quieter and more functional.

However this has created an unusual side effect.

You don’t need to be a experienced health care professional to notice when things are busy in a department or ward. There is a slightly distracting ambient noise level, a characteristic ‘hurry’ in people’s movements and a subtle but  inescapable increase in the atmospheric pressure that creates tension. These sensations often correlate to the number and acuity of patients on the electronic information systems. So much so, that if there are only a few patients in the department and it feels busy, you know something is wrong.

In our new building the converse of this is playing out. The information on the computer screen may tell you that patients are arriving at a seemingly exponential rate, you have a large mix of illnesses and injuries to deal with and there are two ambulances waiting to handover patients.

But the department feels calm.

(or certainly far less stressful that it previously would have done)

This cognitive dissonance was predicted by some but the reality of it has come as a shock to me. Situational awareness is a skill you can learn but there is an intuitive, almost reflexive, nature to it that definitely improves with experience.  I, and I think others, have had their situational awareness compass unbalanced with a discrepancy between what they are seeing (on the computer screens) and feeling (around them). This feeling will undoubtedly pass as we re-adjust and find new methods of abstracting clues from the environment about how the department is functioning. But it is reminder of the powerful influence the lived experience has on us and how many cues and reactions are based on our tacit knowledge of our environment rather than numbers on screens.

What have you learnt this week? #WILTW

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This is the 153rd #WILTW

This week my youngest daughter has been suffering from intermittent tummy aches. There is no condition that is more difficult to investigate, diagnose and treat than children’s abdominal pain. I say that as a Paediatrician and a Parent.

There are lots of resources that list the multitude of causes of, and treatments for, abdominal pain. These are important for clinical staff who work with children to understand and apply. However, abdominal pain is hugely context dependent and I have realised there is a fragile balance between being prudent and perturbed, regardless of your knowledge base.

I’d like to suggest four co-dependent factors that are likely to impact on getting to the bottom of the problem and successfully treating it:

I’m a big fan of alliterative lists but in this case it’s important not to see any domain as distinct from the others. All the features impact on each other, sometimes simultaneously, making separating them in some respects almost illogical (but illogical is what I will do)

The Nature of Pain is a challenge in children. I am minded of Dr. Edward Snelson’s wise words.

Internal pain is translated into external distress. The outward display of symptoms can often bear no resemblance to what the observer perceives the pain must feel like. While pain scales can be used to quantify an individual’s particular rating of their own discomfort, the dissonance between an observer’s judgement often invalidates them. This is a huge challenge in paediatric practice where the child, parent and professional may all have substantially different interpretations. It is vital though that the child or young persons perceptions are acknowledged and managed.

This is why the Personality of the Child is important. Differing development, family circumstance and chronic health issues mean that individual age is not a good basis for making judgements of how a child will respond in a given situation. I have seen stoical toddlers to blubbing teenagers and vice-versa. In practice most children can be distracted enough to make confident decisions that the pain is not of a serious nature:

“The easiest way of engaging with a child is to tell them you can guess what they had for breakfast. Feel their tummy and shout out random cereals. If you guess correctly after a couple of goes you are considered a genius, but it’s better if you continually get it wrong as the child thinks they are cleverer that you are. Either way you get a good feel of the tummy..”

Working out how a child, and especially a young person, is interpreting their pain is a challenge and when they are very distressed this is definitely impacted by the Response of the Parents.

Addressing the concerns of agitated and anxious parents is as important as those of the children. In some cases more so. There are times when a treatment will take time to take effect and the observation period is vital to understand the nature of the disease process. Leaving a child who is perceived to be in great distress without adequate explanation instantly breaks trust. Parents provide an analgesic effect themselves when calm and engaged to the child’s needs. Conversely they can unintentionally exacerbate situations as agitation raises stress levels in the whole family.

Understanding, and predicting, the Path of the Illness is clearly important to be able to adequately treat pain in a fashion in which the child or young person responds to and the parents or carers understand. The spasmodic but persistent griping pain of constipation is different from the fluctuating but self-limiting non-specific of mesenteric adenitis; despite the fact on paper the presenting complaint is exactly the same. Children of the same age and same disease entitity may have markedly different ways of expressing their discomfort and parents may have very different approaches to seeking help. Context is key to devising an adequate management plan.

What have I learnt this week? Understanding the interplay of illness, individual and their environment is vital. Whichever side of the parent/professional divide you are on…

What have you learnt this week? #WILTW

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Useful Resources:

Don’t forget the Bubbles Tummy Pain

PEM Playbook Paediatric Pain

FOAM EM RSS Abdominal Pain

This is the 152nd #WILTW

In just under 2 weeks time we will move into a brand new Emergency Department (ED).

Although daunting we’re really looking forward to it.  It’s an exciting prospect for our patients as we are optimising the ‘front door‘ of the patient pathway to improve clinical input and patient experience. We will further improve access of children and young people to an appropriate healthcare professional following an initial assessment in a common triage area. The co-location of services is a recommendation of the Royal College of Emergency Medicine and in the new build we will have General Practitioners, working along side ED staff (many who initially trained as Paediatricians), both having easy access to the Children’s Hospital admitting teams.  (Annotation: https://practicepath.com/news/)

One of the consequences will be the need for senior staff to recognise the challenge of being able to stratify risk appropriately between patients assigned to different clinical staff. Why? Well, whether they realise it or not, all clinical staff who make diagnostic decisions apply a form of Bayesian statistics (Great summaries by St.Emlyn’s and Casey Parker) in nearly everything they do.

Patients arrive with a ‘pre-test‘ probability of disease. This is essentially the total  number of patients who have a specific diagnosis over a given time period i.e. it might be that 10% of children who present to the ED have a chest infection. After taking a history and examining the child, and maybe preforming some investigations, a clinician will make a decision on whether they think a chest infection is present or not. Those with a high ‘post-test‘ probability of disease will be more likely to get treated (‘test‘ in Bayesian Statistics doesn’t necessarily mean a blood test but could be any number of interventions including simply what the person’s gut feeling is about the presence of disease).

For example if you work somewhere where very few children have urinary tract infection (let’s say 2%) and you see a child with no relevant history or symptoms at all it’s really unlikely this child has an urinary infection. Their post-test probability will be even less than 2%. Conversely if a urine dipstick comes back positive this will increase their post-test probability of having an infection. But remember this is just probability. The mistake made by many is that a positive test means a positive diagnosis. No! It just increases the probability of having a disease – there are few absolutes in medicine.

Pre-test probability varies between clinical settings. The risk of sepsis in children who go to a General Practitioner is very very low. There are 11 million children in the UK and in 2012/13 only 1000 were admitted to intensive care as a result of severe sepsis (100 died as a result). This clearly makes it vital we have systems to recognise sepsis promptly and avoid the tragedies that have occurred in the last 5 years. But the challenge is that a General Practitioner may go through their entire career and never see a child with sepsis. The risk of having sepsis increases if you are seen in an ED (this isn’t because an ED makes you ill but because parents are a good judge of their children’s health so are more likely take them straight to the ED when they perceive them to be very unwell). Finally because the ED screens and discharges a number of patients with more simple illness your pre-test probability of having sepsis will be highest if admitted into hospital.

So back to our new department. The same child, with the same signs and symptoms if seen by a General Practitioner, ED doctor or Paediatrician will be perceived as having a potentially different risk of illness by the 3 doctors. This is because they are consciously, or unconsciously, aware of what the pre-test probability is for their normal working environment. If the GP asks a question of the Emergency Department Consultant (as is likely to happen in a co-located department) that Consultant will need to acknowledge their different frame of reference of risk. While the phenomenon of differential risk assessment is not new (GP colleagues often phone for advice) this is going to be at at a very different scale and pace. Something everyone is going to need to be mindful of to protect patients from both over- and under- investigation.

What have you learnt this week? #WILTW

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This is the 151st #WILTW

There appears to be a genetic hangover from the evolution of mankind which resists change. Shortly after the invention of the wheel came the invention of the ‘form’ (probably to describe the correct use of the wheel and situations it couldn’t be used). The ‘form’ seems to be embeded in the consciousness of many institutions and its dangers were brilliantly encapsulated by Prof. Davina Allen in a recent editorial.

“Checklists, pathways, algorithms are a tempting way for organisations and healthcare professionals to signal to the outside world that they are making a good faith effort to ensure service quality. Yet the popularity of these everyday tools has not been matched by their systematic and critical analysis, leading to concern about the potential impact of a growing epidemic of ‘polyformacy’ on healthcare systems.” Allen D From polyformacy to formacology BMJ Qual Saf doi: 10.1136/bmjqs-2017-006677

Prof. Allen calls for us to take stock of these simple but often very powerful tools and views them as ‘actors’ that do things rather than simple inorganic material. These ‘actors’ also require ‘scripts’ of the necessary information needed to make a tool work. Many assumptions are made about how easy these scripts are to read or enact. The example cited, one that is close to my heart, is the reliance on Early Warning Scores to be used by staff  who must adequately, and appropriately, collect the right vital signs at the right time. If this script isn’t followed correctly, the actor i.e. the score performs poorly.

A mis-understanding of actors and their interaction with scripts makes formophilia a dangerous pre-occupation. In his powerful book, the Seventh Sense, Joshua Ramo highlights the amazing ability for younger generations to develop powerful algorithms that connect the world in ever more intricate ways. But while they are immensely technologically proficient, do they have the context, insight and life experience to know the impact they are having? He quotes Joseph Weizenbaum (a MIT computer scientist) as saying: “Programming appeals most to precisely those who do not yet have sufficient maturity to tolerate long delays between an effort to achieve something and the appearance of concrete evidence of success”

In the same way that simple programming is easy to learn, it is a very simple thing to produce a form. It is much more challenging to take time to decide whether the form is even necessary and a whole different endeavour to work out whether it actually works.

What have you learnt this week? #WILTW

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This is the 150th #WILTW

I think so; Experience/reflection can be powerful, just need to make sure they're tethered to substantive learning points @choo_ek @MDaware

— Christopher Hicks (@HumanFact0rz) March 28, 2017

Grace Hopper apparently was behind the quote:

..the most dangerous phrase in the language is, “We’ve always done it this way”

It’s usually used to describe the persistence of organisational blindness to repeated but ineffecient processes. However there are individual practices, especially in medicine, that despite evidence to contrary persist throughout a clinicians whole career. Some of this is pure bloody mindedness, and some ignorance, but a small proportion is related to personal experience, often a result of being burnt.

I also think there is a role for reminding trainees not to learn TOO much from a single, aberrant case.

— Esther Choo, MD MPH (@choo_ek) March 28, 2017

I’m generally not an over-cautious doctor but children I see with a history of abdominal trauma definitely get over-observed. I can’t help it. I am completely aware of the cognitive bias my experience with a single patient has placed in my diagnostic armoury but its difficult to shake. While I have always tried to explain this to students and juniors I can’t be sure I always do so.

It is only now I understand some of the odd habits of senior doctors who have taught me in the past. These probably weren’t eccentric foibles but more likely the product of the one instance, in a very specific but probably un-reproducible case,  when a sign was missed or an investigation not ordered which unfortunately had a bad outcome. The learning for the individual obvious and profound. But perhaps this context may have been lost on all the doctors subsequently taught by them…

What have you learnt this week? #WILTW

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This is the 149th #WILTW

-“Stop being a helicopter consultant..”

-“What?”

-“..just standing around and hovering”

I’d been called out by a colleague for something I’d never heard of but which made perfect sense.

There is a perception that Emergency Medicine is a dynamic, all action job in which you are constantly on the go with no time to think or reflect. This can certainly be true but while there are periods of high intensity the reality is not always as shown in popular television series. There are also times when a particular patient or situation can take up a disproportionate amount of time. You might be heavily involved in delivering a treatment or intervention, you might be having difficult discussions with other specialties, or you might be closely supervising a junior member of staff.

But sometimes you’ll find yourself ‘hovering’. This can be an almost subconscious endeavour, perhaps noticed more by other staff than yourself. A sign perhaps of not quite wanting to leave at the end of a handover leaving you just standing at the end of the bed drumming your fingers against the bed rail. The cause of this ‘action in inaction’ is multifactorial (and inconsistent) but there are some common themes:

• Active Thinking

This is typified by a difficult clinical case. You are creating space to weigh up available evidence so that you can make the most informed decision.

• Passive Thinking

This is essentially procrastination. You are not sure what the best course of action is or perhaps feel there is not one best approach. If enough time passes it’s likely the correct management will become clear. While it might appear to others you are deep in thought you are actually just killing minutes.

• Counterfeiting

This is the least easy hover to admit to. Although it may look like you are focused on one patient you are actually listening into a conversation about another. Or another method involves excessive tidying up, or record keeping, allowing you stay and see what happens to a patient you are keen to see the outcome of. Perhaps you feel like you’ve dropped a ball earlier in their care? You don’t need to stay but find a reason to.

The counterfeit hover is not always a bad thing and passive thinking may well be in the patient’s best interest. It is an interesting behaviour though. One I will be watching out for in others, and certainly in myself.

What have you learnt this week? #WILTW

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This is the 148th #WILTW

Some people appear to be inherently efficient. With no more hours in the day than anyone else they have extensive outputs, meet deadlines and never seem flustered. Pre-internet this was, in large part, due to hard work, dedication and perhaps cognitive skills suited to rapid processing of large amounts of information. Post-internet workloads are dominated by electronic communication and technology which has now become a blessing and a curse. The tools to deal with e-mails, documents and knowledge translation (whether that be from an academic or managerial perspective) are ubiquitous and you can spend hours organising information on how to organise information.

Key influencers in my personal learning networks are often asked to share how they stay so productive while simultaneously staying sane. Some examples below:

Getting sh*t done by @emcrit

How I work smarter from @ALiEMteam 

I come no where near achieving half of what is suggested in these blogs. However I have noticed in my role as a clinical supervisor a few indicators which demonstrate someone has considered how they manage their time. The absence or poor use of them is not a damning indictment of their organisational skills but helpful for framing conversations.

1) Folder Organisation

How quickly can you find a document you wrote 3 months ago? Is it pasted somewhere on the 112 items you have on your desktop or in a sub-folder labelled well enough to find via a search or side-bar?

2) Out of office notification

Not sure this counts as being a method of improving productivity but it is a common courtesy to highlight you won’t be responding to e-mails for a set period. Responding to e-mails when you have the notification active is a different issue…

3) Number of e-mails waiting to be triaged

This is controversial I know.  However I’m not convinced it is possible to say you are on top of things if you have 1324 e-mails in your inbox. Smarts phone often show the total number waiting to be read so a glance at someone’s front screen (aside from potentially being an invasion of privacy) can tell you a lot.

4) How you record your jobs and/or to-do list 

I’m not convinced there is a right or wrong way of doing it but you should have some way. Watching someone trying to find a scrap of paper to start scribbling a list of jobs on doesn’t inspire confidence (which is why I’m gutted when I end up doing it!)

5) Ability to share documents 

This is the least discriminatory of the indicators but I’ve seen a definite increase in the last couple of years of using Google Docs/Dropbox etc as a means of avoiding file version hell. At least three colloborations I am part of will say this is a bit rich as I am not a paragon of virtue in this regard. However suggesting, “How shall I share this?” says a lot about underlying mindset and experience in my humble opinion.

Be interested in thoughts and very happy to take criticisms!

What have you learnt this week? #WILTW

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This is the 147th #WILTW

I was first introduced to the idea of dogmalysis by Cliff Reid. It’s the break down (-lysis) of a widely held belief (dogma-). As Cliff points out numerous cognitive biases “prevent us from conducting an impartial analysis of objective clinical data“.  Essentially some of the things we do in clinical practice have no real foundation and persist despite evidence to the contrary. When I started in paediatrics all children with wheeze received a dose of steroid and a nebuliser regardless of age or severity of illness. This practice has altered significantly in my career but dogmaphiles still do exist.  Whether Cliff truly invented the term might need to  be subject to some dogmalysis itself but it’s a wonderful concept to consider in medicine.

I reviewed a recent publication with two registrars this week.

Wilson et al. Is Tachycardia at Discharge From the Pediatric Emergency Department a Cause for Concern? A Nonconcurrent Cohort Study. Ann Emerg Med 2017 doi: 10.1016/j.annemergmed.2016.12.010.

This concise paper takes on a very common issue which has been surprisingly under explored. The last decade has seen a huge increase in the value placed on observations as markers of severity of disease. This is in part driven by the increase in Early Warning Systems but also repeated demonstration that physiological changes which may predict death often occur in patients hours before they deteriorate.

It’s a relatively well designed study in which, although the disposition and treatments of patients in North America may be different from the UK and Europe, the number of patients and granularity of the reported data make the study findings externally valid.  While there was a slight increase in return rates for children discharged with high heart rates; overall outcomes were not different i.e. in isolation a high heart rate at discharge was not predictive of patient harm.

Admittedly it’s retrospective study (A non concurrent cohort study sounds a little more sexy), we don’t know the interplay of a high heart rate with other physiological features and the overall incidence of serious negative outcomes was low. This for me means that the dogma you should never discharge a child with a tachycardia can not be ‘lysed’ just yet. But even before reading this paper I’d not had a high heart rate and do not pass go attitude myself. There are rarely absolutes and contextualising each case you see is vital.

the key is the question. “still’ tachycardic is different from tachycardic

— Damian Roland (@Damian_Roland) February 27, 2017

Pragmatism is really important. When you realise that admission is not always the safe option basing your judgements on one clinical finding doesn’t seem to be in the patients’ best interest. This study supports a balanced approach to the care of the acutely unwell child and should help aid decision making around the discharge process. Why am I sending this child home with these observations?  In the absence of other identified risks, and appropriate experienced review, then it’s probably safe to send the child home.

I’m looking forward to reading some more pragmatogenic papers in the future.

What have you learnt this week? #WILTW

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Related Reading:

A Pre-mortem to prevent a post-mortem 

Sepsis and Self-Doubt

Have we forgotten to teach doctors how to think?