This is the 117th #WILTW

John has been admitted to hospital with pneumonia. He is on a bed near the nursing station on ward 22A. Around the station are a couple of doctors and nurses looking through the notes trolley. He watches the ward clerk stand up and walk off the ward to find some stationery. 

The phone at the desk starts to ring. The doctors and nurses on the ward round continue their discussions.

The phone continues to ring. John watches a doctor walk past the station, look at the phone, look around the room and then continue to walk up the corridor.

The phone continues to ring. A nurse arrives at the station. She looks stressed. She sits next to the ringing phone, pulls out a diary, opens it, rolls her eyes and then walks away. 

The phone continues to ring. Through the doors to the ward a consultant arrives with some medical students. They all look at the ringing phone. They look at doctors and nurses around the notes trolley and look back at the phone. They then move off to examine the patient next to John. 

One of the doctors at the notes trolley then moves round to sit next to the ringing phone. He starts writing in the notes. He looks at the phone. The phone keeps ringing. He looks up at the remaining team around the notes trolley. He then continues to write in the notes.

The stressed nurse comes back to the nursing station, mutters something under her breath and then leaves the ward. The doctors and nurses around the notes trolley push it towards the patient opposite John. They are joined by the note writing doctor. 

The phone continues to ring .

The ward clerk returns to the ward.

The phone stops ringing.  

I had to call out our staff this week for leaving the phone ringing despite a number of people being quite capable of answering it. The act of picking up a phone seems an inherently simple task. Certainly to an external observer like John there seems no reason for someone not to do it. The assumption is staff are lazy, rude or completely uncompassionate. Imagine if John had been waiting for a phone call from a loved one with some important family news or maybe about his transfer home.

Some of the reasons are more complex than the assumptions though. A honest junior said to me once, “The problem with answering the phone is that the majority of the time you can’t help at all and get dragged into a situation where you become responsible for the problems/issues/concerns of the person on the other end of the line.” This doesn’t excuse not answering the phone but if you knew you could always respond with a yes or no I suspect answering times would decrease significantly.

The prompt for this muse comes from a powerful article by Dr. Ranjana Srivastava on professionalism and responsibilities in medicine. She questions why health care professionals ‘overlook’ potential poor or harmful practice by colleagues or in systems:

“So, while professional integrity is necessary, I think the question we ought to periodically ask all doctors is actually a far simpler one. “What kind of a person do you want to be?”

I want to be the consultant that sets a good example to the medical students. I want my juniors to understand how to prioritise tasks and I want nurses and doctors to realise that some jobs can be done by either professional.

This is really easy to say but much more difficult to put into practice. Maybe answering the phone is one place to start.

What have you learnt this week? #WILTW

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Post release note:

#WILTW rarely produces responses and it is even less common for people to disagree (please see comments below). The topic of discussion is definitely in the grey zone though and I think it was a justified challenge. The tweet below perhaps was something I should have included within the blog.

Is the message here: never walk past an unanswered phone?

— Mat (@MatSilk) August 11, 2016

Fair Question

Answer: No e.g. emergency

But if you, or someone else could. Why don’t you? https://t.co/6YLNIitUST https://t.co/IsFEolOMDn

— Damian Roland (@Damian_Roland) August 11, 2016

This is the 115th #WILTW

I am currently out of the country on holiday with no phone and an intention to very much ‘look up‘

A perfect opportunity for a break from What I learnt this Week. But if you are keen for a fix here are some of the most popular posts from 2016 🙂

Let’s consider ‘appropriateness’ inappropriate 

Is your powerpoint slide teaching or are you? 

As calm as you are is as calm as she’ll be

What have you learnt this week? #WILTW

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This is the 114th #WILTW

Watch young children playing together and you will observe emotions at their most primitive. Intense joy and laughter suddenly replaced by anger when a toy is not given back and utter despair when playtime is over.

I’ve been watching my daughters playing in the unexpected heatwave we had this week in the UK. It was amazing to see emotional gear changes. Moving from low to high at a speed a Tour-de-France yellow  jersey holder would be proud of.

This grid therefore caught my eye this week

It’s an intriguing (a mix of disgust and joy) idea and while psychologists might despair (a double dose of sadness) at the over-simplification, for those that have seen Inside Out this really is a very clever representation. Even if you haven’t seen the film (and I suggest you do – I was in tears of both laughter and sadness at various points) there is an obvious face validity to the combination of emotions. The next time you are revulsed by something, stop and think, are you disgusted or afraid?

The grid goes someway to explaining why children sometimes burst into tears when they are surprised and why anger can be such a dreadful core emotion. However it is a shame it misses out on other important core components to our psyche. Where do excitement and curiosity sit? I presume we need a love character to be able to produce passion, shyness and jealousy?

Something to think about the next time you well up with ecstasy, rage or something in between…

What have you learnt this week? #WILTW

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This is the 113th #WITLW

Simon is 18 months old. He has had a cold for a couple of days but on waking his mother finds him to be pale, clingy and not his usual self. He refuses any food and while nestled in his mothers arms appears to become very listless. An ambulance is called and Simon is brought to the Emergency Department. 

He is seen on arrival and noted to be flushed and quiet with a raised respiratory rate (42 breaths per minute) and a high heart rate (165 beats per minute). There is no rash but his hands and feet feel cold. His temperature is 40.1 degrees centigrade. He’d spat out the paracetamol his mother had tried to give him in the morning. 

This child has some  features consistent with being high risk for sepsis. Sepsis is a devastating disease which can rob families of their loved ones in a matter of hours. It makes little differentiation between young and old, and can be as subtle as it is obvious in its presentation. Too often patients are let down because it is not considered, or acted on, promptly.

This week saw the release of the NICE (National Institute for Health and Care Excellence) Sepsis guidance. It is a detailed guide to recognition and initial management, stratified across different age ranges, both in and out of hospital. Families who have lost their children to sepsis , especially those in whom it appears that opportunities were missed to intervene, should welcome the advice it offers. However not treating for sepsis may well be one of the biggest challenges I face in Paediatric Emergency Medicine.

The vast majority of children I see do not have sepsis. It is very important to emphasise that in an era of wide spread vaccination, the rate of serious infection, not even the more serious sequelae of sepsis, in those over 3 months will be less than 7%. Given that febrile illness is the second most common presentation to Emergency Departments (after breathing difficulty) it is easy to see why finding the ‘sepsis’ needle in the ’emergency department’ haystack is an often used phrase.

What of Simon and his need for urgent blood tests and antibiotics for his potential sepsis? Simon also has a snotty nose, his throat is red and his ears inflamed. I see in his eyes an awareness of his surroundings. There is a bloody mindedness to the way he tries to push away the paracetamol he is offered and eventually takes. While his peripheries are cool his head and body are very hot and the perfusion of blood to the skin here is normal. While his mother entirely appropriately worries about him,  my instinct is that he does not have a serious infection.

But is my instinct sufficient to fulfil a duty of care to my patients and provide them with the most evidenced based treatment? This is the dilemma I face on an almost daily basis. It is simply not possible to treat all the patients I see who fit some form of criteria as having sepsis. So I remain plagued by self-doubt in my decision making. Will this be the case where I drop the ball and destroy a families life because my gut instinct felt it was just a virus?

My hope it is this self-doubt that keeps patients safe. Guidance like that produced by NICE is essential to provide a framework we can all work to. Awareness raising for professionals and the public like that performed by the UK Sepsis Trust is also vital to ensure knowledge translation occurs at scale. But underpinning everything will be individual health care professionals who must continue to doubt and reflect on their decisions to ensure Simon remains a healthy child and not another preventable tragedy.

Think: Could this be Sepsis? 

What have you learnt this week? #WILTW

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This is the 112th #WILTW

It is currently July but for many hospitals it feels like January. We are seeing a wave of respiratory and febrile illness normally associated with the winter months and in our Children’s Emergency Department 10% more patients presented than the same time period last year.

“The NHS won’t survive another bad winter‘ is a term that’s been frequently used in the press. However we are now in a situation where both presentation and admission rates indicate seasonal variation is disappearing and the health system is in a constant state of over capacity. This clearly affects staff and at the moment, undoubtedly influenced by other political issues, I sense a general fatigue in the acute and emergency care communities.

Healthcare professionals can be quite cynical about attempts to motivate them. Many initiatives considered no better than a collective ‘group hug’ which overlooks the underlying challenges.  Inspiration and motivation are very personal attributes. To re-energise some simply need a break, some need a change of environment, others need to work on different projects and some may actually just need a hug.

So what do we do to turn around an increasing malaise? If the current level of pressure is the new normal how will staff maintain the compassion and dedication that the #NHS, generally without exception, provides?

“I left the conference wanting to go back to work” An unusual comment in the current climate but this is what Adrian Plunkett said when he was describing #SMACCDub. The Social Media and Critical Care conference is now in its fourth year (this year’s event was held in Dublin). Its founders have been passionate about delivering an event with a universally high standard of speaker and content ranging from the highly scientific to the incredibly emotive and sometimes a bit of both.  Adrian is a Paediatric Intensive Care Consultant who is behind the learning from excellence initiative. We were discussing the ‘positivity’ from an event this week organised by the RCPCH on patient safety and quality improvement. I’d been musing on how I think there has been a subtle shift in the tone of conferences I’ve attended recently.  The best example I think is SMACC (Ex- BMJ editor Richard Smith describing  it as one of the most energetic conferences he has been to) but others do exist (EMEC for example). This is not just about an increased use of social media but presenters perhaps being more honest with their audiences, topics inclusive of the challenge of work-life balance and more involvement of the public and patients in providing an important dose of realism.

It has always been the case the conferences and workshops allowed an exchange of ideas and knowledge. It might just be that they will need to have a more holistic energising role in the future. This is not just about positivism but about connecting with an audience and dealing with the challenges they face now rather than the past or future.

What have you learnt this week? #WILTW

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This is the 111th #WILTW

It has been an interesting week.

To be honest as a supporter of both Europe and the England Football team it’s actually been quite a painful one. England’s performance was so abject you wonder if we need a referendum on whether they should play in football championships in the future.

With the widespread negativity resulting from the political events you may have thought a discussion on “Paediatric end of life care in the ED” would not have been something to lift spirits. However this thoughtfully delivered teaching session by one of our Paediatric Intensive Care Consultants, Dr. Peter Barry, provided a great deal of food for thought. Judgements on  quality of life always cause a great deal of introspection. The outcomes of this weeks events put into some context when compared with the dilemmas  parents, carers and health care professionals face when making decisions about children with severe life limiting or modifying conditions.

Peter shared a piece of writing which I had not seen before. “The Median isn’t the Message” is the personal story of how Stephen Jay Gould makes sense of being diagnosed with cancer.

“Mesothelioma is incurable, with a median mortality of only eight months after discovery”

It is an eloquent description of how statistics can potentially be used inappropriately if just presented at face value. What does a median mortality mean to you? It isn’t a mean, so the average time isn’t 8 months, it is the central, or half-way point time that is 8 months.

A politician in power might say with pride, “The mean income of our citizens is $15,000 per year.” The leader of the opposition might retort, “But half our citizens make less than $10,000 per year.” Both are right, but neither cites a statistic with impassive objectivity. The first invokes a mean, the second a median. (Means are higher than medians in such cases because one millionaire may outweigh hundreds of poor people in setting a mean; but he can balance only one mendicant in calculating a median).

While in many scenarios the median and mean are close numerically the choice of measurement can result in considerable variation around that value. In Stephen’s case there is a very large right skewed distribution around the 8 month point i.e. people can live for far longer than 8 months than less than it. Furthermore as a young man, diagnosed relatively early and having access to the best care he was much more likely to be on the right side of skew.

Having analysed what the variation around the median might be Stephen adopts a very proactive and positive attitude to his situation and lives for a further 20 years. The impact of his attitude on his survival a discussion, and controversial, point in itself. Stephen felt his optimism as someone who tends to see the doughnut instead of the hole allowed him to look at the the statistics of his cancer differently and as a result look at his cancer differently. Clearly this situation is specific to the individual and difficult to generalise a whole cancer population.

However while a thorough evaluation of the economic impact of Brexit is unlikely to find us a surplus of cash, and analysing the England match will not reveal hidden talents in our players, there are times when taking a deeper look at uncomfortable news may have a more positive impact than you might think.

What did you learn this week? #WILTW

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This is the 110th #WILTW

On Tuesday (21st June 2016) Ben Butler was sentenced to life in prison for murdering his daughter, Ellie. His partner was sentenced to 42 months for child cruelty and both found to have covered up her death by faking a 999 call two hours after she had died.

Ben Butler had previously been convicted in 2009 for shaking Ellie when she was a baby although on appeal this decision was overturned. The couple then won a High Court ruling to have Ellie returned to  them. Ellie was murdered 11 months later.

The video of Ellie’s Grandfather talking on the BBC is uncomfortable viewing

This is a tragic case which leaves you feeling sad with the world. That family members can harm each other, whether it be emotionally, physically or otherwise, is difficult to understand.

It is an uncomfortable part of paediatric practice that a small proportion of the injuries you see in children will have been caused by a person well known to that child. This adds complexity to the already challenging task of learning how to identify when injuries are children protection issues. The unique context of child abuse distinguishes it from more traditional medical education pedagogical approaches. For example I have blogged not infrequently on how important it is to listen to, and more importantly hear, parents’ worries. Sadly, despite the focus on the risks of serious bacterial illness in children, we know health care professionals still miss sepsis even when parents do everything in their power to highlight their concerns. Imagine the challenge then, when a parent or carer is deliberately concealing information or fabricating stories about their child. Those working in acute paediatrics must be aware of these polar opposites; sensitively sifting through nuances in language to identify legitimate concern or illegitimate explanation.

I must admit I am not sure my child protection training ever really prepared me for the actual reality. Experience making me increasingly more aware of my limitations rather than less. But in this area I wonder if we can work harder at raising awareness of a cognitive bias inherent in believing the person who should have the child’s best interest at heart always does. Ultimately truly hearing the parent or carer’s story and evaluating that with the clinical  information from the child or young person you are seeing is the best way of keeping all children safe – whatever the cause of their illness or injury.

What did you learn this week? #WILTW

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Child Protection Publications from the RCPCH

This is the 109th #WILTW

On a daily basis there is a post on how the most successful people have always experienced a great deal of failure:

This week the BBC reminded us of J.K.Rowling’s Harvard Commencement speech

“I had failed on an epic scale. An exceptionally short-lived marriage had imploded, and I was jobless, a lone parent, and as poor as it is possible to be in modern Britain, without being homeless.

They shared her famous tweet about the rejection of her initial books:

It is reassuring to know that success isn’t an easy path but not everyone wants to be rich, a sporting superstar or part of the financial elite. However most of us have projects and ideas we would like to put into practice. So how long can you fail for before you decide what you are doing is never going to work?

What made Thomas “I’ve not failed I’ve just learnt a thousand ways that don’t work‘ Edison have that 1001st attempt? What is it that keeps you going when an new innovation spreads but yours just dissipates into the wind? What is that people have that enables them to climb out of the icy waters onto the top of the iceberg?

A close friend this week suddenly dropped into conversation, “Don’t give up on #WILTW. It might be hard work but keep it at.” I’d been reflecting on the numerous projects I’ve had that have nose dived without a trace. It has challenged me to draw out the things you need to do to protect yourself from failure fatigue.

Review – can you get an honest opinion. Does anyone else connect with your vision?

Reevaluate – what is the purpose of your project? Will it really deliver the outcomes you hope?

Revise – can you break down the project into smaller chunks and make the next steps more tangible or manageable?

Reenergise – do you have time for what you are doing or are you spending too much time on it. Is it time for a break?

What have you learnt this week? #WILTW

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This is the 108th #WILTW

It is an unintentional medical education paradigm that you tend to learn on patients rather than from them. This is especially true in the early years of training. As you gain in experience you start to encounter, or recognise situations, where a patient’s action itself can teach you something.

This happened to me during my neonatal intensive care placement. I had a few years behind me as a doctor and was in that dangerous phase where I didn’t know enough to know what I didn’t know…

I was covering the labour wards when I was fast bleeped to obstetric theatres. A mother was having an emergency caesarean section. I can’t remember the reason why but it was serious enough that she needed a general anaesthetic to expedite the procedure. As the baby, a boy, was delivered it was clear they had been struggling. He was limp, blue and making no effort to breathe. As he was placed on the resuscitaire I ran through the sequence of interventions to get oxygen into the babies lungs. This was the first time I had done this on my own. I’d been deemed competent to attend these situations independently; a senior only minutes away if needed. Having dried and stimulated him I felt a sense of relief as the air and oxygen delivered via a face mask caused his lungs to rise and fall in a rhythmical pattern. Shortly afterwards a pulse became obvious in the umbilical cord, and then suddenly, that precious cry of child who suddenly realises they have entered the world.

I was chuffed to bits and with the neonatal nurse we wrapped and swaddled him. The mother was still attached to an anaesthetic machine so I left the room to see the father. He looked stressed, anxious and upset all at once. I presented him with his son explaining what I had done. I was proud to have been able to provide what I thought had been expert care. I didn’t expect him to look annoyed:”How is my wife? Is she ok”

“But I’ve just saved your child’s life!” I thought. I muttered something about her needing to wake up from the anaesthetic. He took his son and rocked him in his arms. He looked worried. I felt disappointed.

I learnt a great deal from that interaction. This father was concerned about the most important person in his life and at that time it was his wife. I had not even considered that being a possibility. Not only understanding, but also predicting, what matters to patients and their family is vital. I also learnt humility. I had probably not done anything life saving. Just being able to do something independently does not make the act itself any more great. It may well have been the baby would have started breathing for itself anyway. We won’t know and it doesn’t matter.

Increasingly I learn new things not about patients’ clinical signs and symptoms but about their beliefs and expectations. I am of the mind that managing these well is far more important.

What have you learnt this week? #WILTW

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