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

This is the seventeenth #WILTW

This week Alys Cole-King went on a 24 hour tweetathon in aid of world suicide prevention day. She used the hashtag #connectedwith aiming to “raise awareness that strong relationships, connectedness and a sense of belonging are powerful protective factors against suicide. “

She also wrote a great blog on the importance of friends and family and how easy it is to sacrifice this in trying to be supportive to the patients and colleagues you work with. It is a theme that has run since her NHS Change Day pledge. It is very well timed as on the other side of the planet Mike Cadogan has written on very similar themes as part of a personal reflection on the challenges he has faced in delivering the #FOAMed movement. “Family comes first” his first of 5 lesson learnt.

Being connected with people is a very easy thing to think you are doing when in fact you are not. It has been a painful process but I am now all too aware of times when I haven’t actually been truly engaged with people close to me.  At times this may have led to active antagonism with no insight at all on my behalf that this was happening. I do my best to always be utterly honest with the problems or issues I may be bringing to a discussion. Unfortunately too often there is little time to sit down with people, catch up and actually listen to the issues at stake. We work in health care environments in which time spent in the cafeteria may be seen as being work shy as opposed to being engaged. Its clearly not an easy think to balance but true connection is something I really hope to work on.

What did you learn this week? #WILTW

This is the sixteenth #WILTW

The following tweet raises a number of interesting questions:

Seriously. Medical tweeps and FOAMites. Why are we so miserable, and why can’t we change it? #musings

— Olusegun Olusanya (@iceman_ex) August 30, 2014

Are we really that miserable? My immediate response was surely not! I think, by and large, my day-to-day interactions and social media output concurs with that. I admit a tendency to look a little more stressed than I actually am (although this has advantages in not being given a deluge of additional tasks…) but think/hope my outlook is generally positive.

But if I look a little deeper then there is something to reflect on. Going back through blog posts I can honestly say that my view of the world is not “wow – isn’t everything great!”. There is a slight negative aspect to a number of them and an underlying theme that change is a very long and laboured process. I look at my recent timeline and, although there are a fair sprinkling of supportive #nhschangeday and #FOAMed tweets, there are also not an inconsiderable number on difficult situations and challenging world events. On further reflection I must be honest that actually my interaction with social media (twitter in particular) is not always a “smiley-happy” experience. All too often I can be rankled by editorials or upset by the black-and-white nature of peoples thinking. I must also admit, and this is slightly painful, occasionally it is a little frustrating to see others comments and material go quasi-viral when you have had the same idea (or even previously released the same content).

Am I more miserable than I actually think…! It is a sobering thought.

I think this is good wake up call to the importance of mindset. Earlier this week, my wife and I, without our kids(!) watched the Lego Movie. I personally highly recommend this film. It runs out of ideas towards the end but basically nearly 90% of the jokes are adult orientated (or I am just a big kid perhaps). The signature tune is “Everything is awesome”

Once you have heard this tune you are destined to hum it for the rest of the week; so beware!

It’s likely there will remain times that content flowing in-and-out of social media is frustrating and incites a feeling of dejection and depression. But there are many other times when collaboration and support are clearly demonstrated to be intrinsic to the motivations of many FOAMites and Medical tweeps. And while Mike Cadogan’s frank review of his learning over the last 5 years is not a litany of joy  – the nature of the comments on this post and the learning from it leads me to believe we will all be the better, and more positive, as a result.

Everything is awesome.

What have you learnt this week #WILTW

This is the fifteenth #WILTW

The new series of #DoctorWho started in the UK last weekend. For those who aren’t aware, every so often the Doctor re-generates, taking on a new appearance and personality although keeping previous memories and skills. It’s a brilliant concept which in some part is the reason for the shows continued success.

(photo via copyright free site http://www.fanpop.com/clubs/doctor-who/images/37459545/title/coleman-capaldi-photo)

In this series a new doctor is with us and more time than most is spent on the doctor reflecting on his new body:

“You know I never know where the faces come from, they just pop up. It’s covered in lines. But I didn’t do the frowning… Who frowned with this face?”

For the doctor’s companion the change can be hard to take, especially when a fanciable young man is replaced by a somewhat older model. The Doctor is the same person inside and pleads at the end of the episode to be considered no different from his predecessor:

“You can’t see me can you? You look at me and you can’t see me. Have you any idea what that is like. I’m right here. Please just see me…”

So what does this have to do with healthcare I hear you ask? Well at any given moment there will be a professional somewhere adopting a new role. Maybe involving more managerial or leadership responsibility, perhaps a step up a band level, or a move off a clinical rota. Often this person will be working with their peers, perhaps in exactly the same environment, but now have a ‘hierarchical’ responsibility for them. The person they are is no different, same skills and memories, but perhaps they might have to adopt a different personality. The buck, in management terms, now stops with them. This new ‘face’ is not always an easy mantle to take on. Whereas the doctor’s face changes completely – it is easy to think of them as a different person – for us non-Gallifreyans this isn’t an option. We should remember however the doctor finds the transition just as challenging.

It is worth both the doctor, and the newly promoted staff member, contemplating at the end of the day you are still the same person. It’s the characteristics of YOU that got you into this position and that will be your greatest strength.

“Have you seen this face before? No? Are you sure? It’s funny because I’m sure that I have…”

What have you learnt this week? #WILTW